Clinical Rehabilitation 9788090543812

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Translated from Rehabilitace v klinické praxi, Galén, 2009 by Vanda Andělová, DPT, Tampa, Florida Main author and editor Pavel Kolář, PT, PhD Professor Department of Rehabilitation and Sports Medicine, 2nd School of Medicine, Charles University and University Hospital Motol, Prague Reviewers Miroslav Kučera, MD, DSc Professor Department of Rehabilitation and Sports Medicine, 2nd School of Medicine, Charles University and University Hospital Motol, Prague Karel Lewit, MD, DSc Professor Department of Rehabilitation and Sports Medicine, 2nd School of Medicine, Charles University and University Hospital Motol, Prague Jan Petrášek, MD, DSc Professor IIIrd Department of Internal Medicine – Department of Endocrinology and Metabolism 1st School of Medicine, Charles University and General University Hospital, Prague Pavel Kolář et al. CLINICAL REHABILITATION First edition Documentation from the authors’ archives Published by Alena Kobesová, K Vápence 16, Praha 5

www.rehabps.com All rights reserved. No part of this book may be reproduced in any form by any electronic or mechanical means (including photocopying or recording) without permission in writing by publisher. Authors, organizers and publisher have made every effort to ensure that information about medical products correspond to the latest knowledge available at the time of preparing the work. The publisher is not responsible for the use of these products and recommends to follow the manufacturers’ products information and package inserts, including contraindications, dosages and precautions. This applies particularly to rarely used or manufacturer’s marketed medical products. The text contains trademarks of medical and other products. Absence of trademark symbols (®, ™ etc.) does not mean that the trademarks are not protected. © Pavel Kolář, 2013 Translation © Vanda Andelova, 2013 English edition © Alena Kobesová, 2013 ISBN 978-80-905438-1-2

CONTENTS LIST CONTENTS LIST LIST OF AUTHORS MAIN AUTHOR AND EDITOR AUTHORS FOREWORD INTRODUCTORY SECTION REHABILITATION CONCEPT AND DEFINITION Current State of Providing Rehabilitation TREATMENT (MEDICAL) REHABILITATION Phasic Model of Treatment Rehabilitation Individual Specialties of Treatment Rehabilitation SOCIAL REHABILITATION TOOLS OF School-based REHABILITATION TOOLS OF VOCATIONAL REHABILITATION PREVENTATIVE ROLE OF REHABILITATION FUNDAMENTAL PRINCIPLES OF REHABILITATION INDIVIDUAL TYPES OF REHABILITATION SETTINGS Outpatient Settings Providing Rehabilitation Inpatient Settings Providing Rehabilitation CLASSIFICATION OF FUNCTIONAL CAPABILITY, DISABILITY AND HEALTH Impairment, Disability, Handicap – Explanation of Terms Model of International Classification of Impairment, Disability and Handicaps (ICIDH) REFERENCES

TREATMENT REHABILITATION – DIAGNOSTIC AND THERAPEUTIC APPROACHES REHABILITATIVE CARE REPOSITIONING Indications for Repositioning Principles of Repositioning Goals of Repositioning Types of Repositioning VERTICALIZATION PATIENT MOBILIZATION Mobilization goals Prevention of Muscle Atrophy Types of Mobilization REFERENCES TREATMENT REHABILITATION FOCUSED ON RESTORATION OF A FUNCTIONAL DEFICIT REFERENCES A DIAGNOSTIC PROCEDURES 1 ASSESSMENT APPROACHES FOCUSED ON THE FUNCTION OF THE MOVEMENT SYSTEM FUNDAMENTALS OF A CLINICAL ASSESSMENT PATIENT PRELIMINARY CASE HISTORY (ANAMNESIS) Components of a Complete Preliminary Patient History (Anamnesis) Radicular Pain OBSERVATION (ASPECTION) PALPATION The Most Important Palpation Techniques AUSCULTATION

REFERENCES 1.1 NEUROMUSCULAR FUNCTIONS AND THEIR CLINICAL EXAMINATION Clinical Manifestations and Examination of Neuromuscular Dysfunctions I FUNCTIONAL AND NEUROLOGIC SYMPTOMATOLOGY 1.1.1 Examination of Postural Functions POSTURE Postural Function – Normal Development of Posture Reflex Model of Posture and Locomotion Circumscription of the Term Posture Postural Stability Postural Stabilization Postural Reactibility Postural Disturbances STANDING Examination of Individual Body Regions Modified Examination of Standing Assessment of Standing in Neurologic Disorders GAIT Phases of the Gait Cycle Types of gait according to V. Janda Examination of Gait in a Clinical Setting Laboratory Examination of Gait Typology of Gait Dysfunctions from a Neurological Perspective Examination of Postural Stabilization and Postural Reactibility 1.1.2 Examination of Muscle Tone Reflex Regulation of Muscle Tone Connective Tissue Component of Muscle Tone Deficits in Muscle Tone Hypertonia and Spasm

Contracture Local Hypertonic Changes in Muscle Tissue Spasticity Rigidity Paratonia Hypotonia MUSCLE TONE DISTRUBANCES AND THEIR POSTURAL LAYOUT Upper Crossed Syndrome Lower Crossed Syndrome Layer Syndrome Assessment of Shortened Muscles 1.1.3 Examination of Sensory Functions Sensory Testing Examination of Individual Sensory Modalities 1.1.4 Assessment of Reflexes MYOTATIC REFLEXES Upper Extremities Myotatic Reflexes Myotatic Reflexes of the Lower Extremities EXTEROCEPTIVE REFLEXES IDIOMUSCULAR RESPONSE PATHOLOGICAL REFLEXES Pathological Reflexes Elicited in the Upper Extremity Pathological Reflexes Elicited in the Lower Extremity Clonus Mediopubic Reflex 1.1.5 Examination of Involuntary Movements Tremor Spasms Myoclonus Fibrillar and Fascicular Twitches Choreic and Athetoid Hyperkineses Athetosis

Chorea TICS 1.1.6 Examination of Muscle Strength MUSCLE WEAKNESS MUSCLE STRENGTH Assessment of Muscle Strength Assessment of Muscle Strength II NEUROLOGIC SYNDROMOLOGY 1.1.7 Primary Myogenic Lesion Weakness in Myopathies Pseudohypertrophy and Muscle Contractures in Myopathies 1.1.8 Deficits at the Neuromuscular Junction Myasthenia Gravis Lambert-Eaton Myasthenic Syndrome 1.1.9 Peripheral Nerve Deficits Examination of Deficits in the Sensory Fibers of the Peripheral Nerve Examination of Deficits in Motor Fibers of a Peripheral Nerve 1.1.10 Spinal Cord Syndromology GRADUAL TRANSVERSE SPINAL CORD LESION SUDDEN TRANSVERSE SPINAL CORD LESION PSEUDOPARETIC SPINAL CORD LESION SPASTIC SPINAL CORD LESION MIXED SPINAL CORD LESION CONUS MEDULLARIS SYNDROME CAUDA EQUINA SYNDROME POSTERIOR CORD SYNDROME BROWN-SEQUARD SYNDROME INTRAMEDULLARY SYNDROME 1.1.11 Cerebellar Syndromology FLACCIDITY HYPERMETRIA ASYNERGY

DIADOCHOKINESIA OTHER CEREBELLAR SIGNS 1.1.12 Extrapyramidal Syndrome 1.1.13 Thalamic Syndrome 1.1.14 Brain Stem Syndromes MEDIAL SYNDROMES LATERAL SYNDROMES 1.1.15 Syndromes of Meningeal Irritation, Intracranial Hypotension, Hypertension and Ventricular Syndromes SYNDROME OF MENINGEAL IRRITATION INTRACRANIAL HYPOTENSION SYNDROME INCREASED CRANIAL PRESSURE SYNDROME VENTRICULAR SYNDROMES 1.1.16 Cortical Syndromes and their Examination FRONTAL LOBE Primary Motor Cortex (MI) Premotor Cortex Frontal Eye Field Broca’s Speech Area Prefrontal Cortex Signs of an Injury to the Frontal Lobes of the Motor Cortex Other Disturbances with Lesions to the Frontal Cortex Assessment Tests for Frontal Lobes Deficits TEMPORAL LOBE OCCIPITAL LOBE PARIETAL LOBE Deficits in Phatic Functions Deficits in Gnostic Functions Deficits in Practical Functions LIMBIC SYSTEM Examination of Motor Functions from the Perspective of Cortical Plasticity III NEUROMOTOR DEVELOPMENT AND ITS EXAMINATION

CLINICAL EXAMINATION VIA MOTOR PROGRAMS SCREENING OF NEUROMOTOR DEVELOPMENT Central Coordination Disturbance (CCD) Developmental Kinesiology as an Assessment Method – the Examination of an Infant in the First Year of Life Postural Activity Postural Activity in Individual Phases of Development (0–15 Months) Postural Reactivity Primitive Reflexology Functional Relationship between Postural Activity, Postural Reactivity and Primitive Reflexology PSYCHOMOTOR DEVELOPMENT IN EARLY CHILDHOOD 2–3 Years 4–6 years CENTRAL COORDINATION DISTURBANCE IN PRESCHOOL AND SCHOOL AGE Monitored Areas in a Neurodevelopmental Examination Physiotherapy in Central Coordination Disturbance REFERENCES 1.2 KINESIOLOGY AND CLINICAL EXAMINATION OF THE JOINT SYSTEM Joint Motions Joint Categories Based on the Number of Axes and the Shape of Articular Surfaces Classification of Joints according to the Number of Articulating Bones within the Joint Joint Innervation Assessment of Joint Range of Motion 1.2.1 Kinesiology of the Spine, Pelvis and the Thorax SPINE PELVIS Thorax

ANATOMICAL PARAMETERS INFLUENCING SPINAL FUNCTION Regional Anatomical Parameters Global Anatomical Parameters EXAMINATION OF THE SPINE, PELVIS AND THE THORAX Patient History (Anamnesis) and Physical Assessment Neurological Assessment Assessment of Motor Functions Functional Assessment 1.2.2 Kinesiology of the Shoulder Girdle (Plexus) BONES OF THE SHOULDER GIRDLE JOINTS OF THE SHOULDER GIRDLE MOVEMENTS IN THE JOINTS OF THE SHOULDER GIRDLE SHOULDER GIRDLE EXAMINATION Anamnesis Aspection Palpation Joint Play Passive Movements Active Movements Special Tests for the Shoulder Girdle 1.2.3 Kinesiology of the Elbow Joint ELBOW JOINT MOVEMENTS ASSESSMENT OF THE ELBOW JOINT Anamnesis Aspection Palpation Passive Movements Active Movements Functional Tests 1.2.4 Kinesiology of the Wrist and the Hand WRIST MOVEMENTS OF THE CARPAL COMPLEX CARPOMETACARPAL JOINTS

HAND MAIN TYPES OF GRIP ASSESSMENT OF THE WRIST AND THE HAND Anamnesis Aspection Palpation Passive Movements Active Movements Functional Tests 1.2.5 Kinesiology of the Hip Joint HIP JOINT ASSESSMENT Anamnesis Aspection Palpation Passive Movements Active Movements PEDIATRIC HIP JOINT ASSESSMENT 1.2.6 Kinesiology of the Knee Joint MOVEMENTS OF THE KNEE JOINT KNEE JOINT ASSESSMENT Anamnesis Aspection Palpation Passive Movements Active Movements Functional Assessment 1.2.7 Kinesiology of the Lower Leg and the Foot ANKLE AND FOOT JOINTS MOVEMENTS IN THE ANKLE AND FOOT JOINTS FUNCTIONAL RELATIONSHIPS BETWEEN THE ANKLE AND THE FOOT JOINTS ASSESSMENT OF THE ANKLE AND THE FOOT Anamnesis

Aspection Palpation Passive Movements Active Movements Functional Assessment REFERENCES 1.3 SOFT TISSUES 1.3.1 Skin Anatomy Neurophysiology Pathological Processes Examination Treatment 1.3.2 Subcutaneous Tissues (Hypodermis) Examination and Therapy 1.3.3 Fasciae Pathological Processes Treatment REFERENCES 2 VISCEROMOTOR RELATIONSHIPS AND THE AUTONOMIC NERVOUS SYSTEM 2.1 VISCEROSOMATIC AND SOMATOVISCERAL RELATIONSHIPS 2.1.1 Viscerosomatic (Visceromotor) Relationships Visceral Pattern 2.1.2 Somatovisceral Relationships Movement System and Visceral Pain Movement System and Functional Deficits of the Internal Organs Movement System as a Trigger Factor for a Latent Internal Illness Movement System as a Tool for the Treatment of Internal Illnesses 2.1.3 Overview of Basic Visceral Patterns 2.2 EXAMINATION OF THE AUTONOMIC NERVOUS SYSTEM

2.2.1 Anatomy and Physiology of the ANS 2.2.2 Function of the ANS within the Movement Apparatus Vasomotricity Somatosensory System and the ANS ANS and Muscle Function 2.2.3 Anatomical Vegetative Syndromes CENTRAL AUTONOMIC SYNDROMES PERIPHERAL AUTONOMIC SYNDROMES GROSS VEGETATIVE SYNDROMES REFLEXIVE VEGETATIVE SYNDROMES REFERENCES 3 PSYCHOLOGICAL FUNCTIONS AND PAIN 3.1 PSYCHOLOGICAL DIAGNOSTICS IN REHABILITATION 3.2 ASSESSED PROCESSES AND METHODS OF THEIR TESTING Reactivity to Painful Stimuli Pain in the Pathological Process Beginning Phase of Psychological Pain Processing Cognitive Processes Affection Behavior Interpersonal Communication REFERENCES 4 Examinations by functional laboratory methods 4.1 LABORATORY EXAMINATION OF MOVEMENT 4.1.1 Kinematic Analysis 4.1.2 Kinetic Analysis (Posturography) Physics Basis of the Examination Posturography in a Clinical Setting Factors Influencing Postural Stability 4.1.3 Electromyographic Analysis in Biomechanics Examination of Muscle Coordination Examination of Force

Assessment of Muscle Fatigue 4.2 SUPPLEMENTAL NEUROLOGICAL EXAMINATIONS 4.2.1 Electromyography Basic Types of Examinations Primary Abnormalities of an EMG 4.2.2 Electroencephalography 4.2.3 Evoked Potentials Somatosensory Evoked Potentials Visual Evoked Potentials (VEPs) Auditory Evoked Potentials Motor Evoked Potentials (MEPs) 4.3 EXAMINATIONS BY IMAGING METHODS 4.3.1 Radiologic Methods X-RAY EXAMINATION Shoulder Joint Wrist Hip Joint Knee Joint Ankle Joint Spine COMPUTED TOMOGRAPHY (CT) MAGNETIC RESONANCE IMAGING Functional Magnetic Resonance TRACTOGRAPHY SCINTIGRAPHIC EXAMINATION POSITRON EMISSION TOMOGRAPHY SINGLE PHOTON EMISSION COMPUTED TOMOGRAPHY NEAR-INFRARED SPECTROSCOPY (NIRS) 4.3.2 Examination by Ultrasound REFERENCES 5ASSESSMENT OF THE SEVERITY OF MOTOR INVOLVEMENT AND LIMITATIONS IN THE ACTIVITIES OF DAILY LIVING

5.1 METHODS USED FOR MEASUREMENT AND ASSESSMENT IN REHABILITATION 5.2 ASSESSMENT OF THE EXTENT OF MOTOR INVOLVEMENT 5.2.1 Gross Motor Skills Assessment by the Gross Motor Function Measure 5.2.2 Developmental Kinesiology as an Assessment Method of a Motor Deficit Locomotion Stages According to Vojta Adjusted Age 5.2.3 Additional Tests to Assess Motor Deficits Tests Used for Adult Patients Tests Used in Children 5.3 TESTING AND ASSESSMENT OF RESTRICTED ACTIVITIES OF DAILY LIVING 5.3.1 Functional Independence Measure 5.3.2 Barthel Index 5.3.3 Katz Index of Activities of Daily Living 5.3.4 Activity Index 5.3.5 Frenchay Activities Index 5.3.6 Factor Assessment according to Tardieu Assessed Factors Treatment Strategy 5.3.7 Other Tests REFERENCES B THERAPEUTIC METHODS 1 PHYSICAL THERAPY METHODS AND CONCEPTS 1.1 GENERAL PHYSICAL THERAPY (MUSCULOSKELETAL) APPROACHES 1.1.1 Passive Movements 1.1.2 Active Assistive Exercise 1.1.3 Muscle Strength Exercises Kinesiologic Notes

Input-Adaptation Relationship during Strengthening Exercises 1.1.4 Dynamic Neuromuscular Stabilization General Principles of Practice Techniques Practice of Postural Stabilization of the Spine, Chest and the Pelvis Influence on Tightness and Improvement of Chest Wall Dynamics Influence on Spinal Straightening Training of the Postural Breathing Pattern and the Stabilization Function of the Diaphragm Postural Stabilization Training of the Spine Using Reflex Locomotion Training of Deep Postural Stabilization of the Spine in Modified Positions Exercising Postural Functions in Developmental Lines (Sequences) Movement Assistance during Exercise Facilitative Elements of Training Techniques Exercise Examples 1.1.5 Soft Tissue Mobilization Post-Isometric Relaxation Examples of Other Techniques 1.1.6 Dry Needling for Muscle Trigger Points 1.1.7 Traction 1.1.8 Relaxation Techniques 1.1.9 Exercises Aimed at the Restoration of Sensation (Somatesthesia) 1.2 METHODS AND APPORACHES USED IN REHABILItATION OF PATIENTS WITH CHRONIC RESPIRATORY SYSTEM INVOLVEMENT 1.2.1 Methods of Pulmonary Physical Therapy 1.2.2 Corrective Physical Therapy for the Postural System Correction of the Pelvic and Lumbar Spine Alignment and Movement Correcting Thoracic Spine Alignment and Movement Correcting Cervical and Cranial Alignment and Movement

1.2.3 Respiratory Physical Therapy Approaches Utilizing Postural Respiratory Function of the Diaphragm Role of the Diaphragm during the Physiological Breathing Cycle Breathing Biomechanics in a Pathological State Posturally Locomotor Function of the Diaphragm Respiratory Physical Therapy Techniques Utilizing Postural Locomotor Functions Positional Influence on the Postural Respiratory Function of the Diaphragm 1.2.4 Respiratory Physical Therapy – Methods and Techniques for Respiratory Pathway Hygiene Active Cycle of Breathing Techniques Autogenic Drainage PEP System of Breathing Oscillatory PEP System Respiratory Physical Therapy and Breathing Muscle Training Devices Intrapulmonary Percussive Ventilation Inhalation Therapy – A Component of Respiratory Physical Therapy Respiratory Physical Therapy for Patients in Intensive Care Units Control Mechanisms of Respiratory Physical Therapy 1.2.5 Breathing Exercises (Breathing Gymnastics) 1.2.6 Fitness Physical Therapy and Pulmonary Illnesses 1.3 SELECTED PHYSICAL THERAPY CONCEPTS 1.3.1 Vojta’s Principle: Reflex Locomotion THERAPEUTIC SYSTEM Activation of Reflex Locomotion Reflex Creeping Activation System Positions 1–6 Reflex Rolling TREATMENT EFFECTS PRINCIPLES AND FUNDAMENTALS OF THERAPY

INDICATIONS AND CONTRAINDICATIONS 1.3.2 Sensorimotor Stimulation Patient Preparation The Method Guidelines Applied to All Exercises 1.3.3 Feldenkrais Method Indications and Contraindications 1.3.4 Proprioceptive Neuromuscular Facilitation Facilitative Approaches in PNF Strengthening and Relaxation PNF Techniques Ontogenetic and Other Principles in the PNF Concept PNF Indications and Contraindications 1.3.5 Brunkow’s Method Indications and Contraindications 1.3.6 Brügger’s Concept The Principle Diagnosis Treatment Indication 1.3.7 Sling Exercise Therapy 1.3.8 Exercise with a Therapy Ball REFERENCES 2 Modalities 2.1 CLASSIFICATION OF MODALITIES BASED ON THE TYPE OF APPLIED ENERGY 2.1.1 Mechanotherapy 2.1.2 Thermotherapy and Hydrotherapy 2.1.3 Electrotherapy 2.1.4 Phototherapy 2.1.5 Combined Therapy and Combination of Modalities 2.2 CLASSIFICATION OF MODALITIES BASED ON THEIR PRIMARY EFFECT

2.2.1 Modalities with an Analgesic Effect Modalities with Primary Analgesic Effect Modalities with a Secondary Analgesic Effect 2.2.2 Modalities with Dominantly a Myorelaxation Effect Ultrasound Therapy Combined Ultrasound and Electrotherapy Electrotherapy 2.2.3 Modalities with Anti-Inflammatory and Trophic Effects Vasopneumatic Therapy Electrotherapy Ultrasound Therapy Phototherapy Galvanotherapy Contrast Baths Cryotherapy 2.2.4 Electrodiagnostic Testing and Electrical Stimulation of Skeletal Muscles Electrodiagnostic Testing Electrical Stimulation (Neuromuscular Electrical Stimulation) Electrical Stimulation (Electrogymnastics) 2.3 GENERAL CONTRAINDICATIONS OF MODALITIES REFERENCES 3 BALNEOLOGY 3.1 CLASSIFICATION OF MEDICINAL SOURCES 3.1.1 Waters 3.1.2 Peloids 3.1.3 Gases 3.1.4 Climate 3.2 USE OF NATURAL HEALING SOURCES IN BALNEOLOGY 3.2.1 Use of Water 3.2.2 Use of Peloids 3.2.3 Use of Gas

3.3 SPAS IN THE CZECH REPUBLIC AND INDICATIONS FOR A SPA TREATMENT REFERENCES 4 OCCUPATIONAL THERAPY 4.1 AREAS OF FUNCTION IN OCCUPATIONAL THERAPY 4.2 SPECIALIZATIONS 4.3 OCCUPATIONAL THERAPY PROCESS 4.4 AREAS OF OCCUPATIONAL THERAPY INTERVENTIONS REFERENCES SPECIAL SECTION 1 TREATMENT REHABILITATION IN NEUROLOGY GENERAL SECTION 1.1 NEUROPHYSIOLOGICAL FOUNDATION OF PHYSICAL THERAPY APPROACHES NEUROPLASTICITY Evolutionary Plasticity Repair Plasticity Neuroplasticity and Sensorimotor Programs SENSORY FUNCTIONS IN NEUROREHABILITATION 1.2 OVERVIEW OF PHYSICAL THERAPY METHODS Sensory Training Exercising with Conscious Awareness as a Component of Sensorimotor Practice Sensory Stimulation Method Based on Affolter Perfetti’s Method Rood’s Method Movement Rehabilitation of Patients with Hemiplegia Based on Brunnström Sensory Integration Based on Ayres

Neurodevelopmental Treatment Concept Based on Bobath Movement Therapy According to Petö Vojta’s Method Sensorimotor Stimulation Proprioceptive Neuromuscular Facilitation 1.3 NEUROPSYCHOLOGY 1.3.1 Neuropsychological Approaches Neurobehavioral Approach American Neuropsychological Approach Neuropsychology in the Czech Republic 1.3.2 Neuropsychological Assessment Most Commonly Used Neuropsychological Tests 1.3.3 Utilization of Neuropsychological Approaches in Rehabilitation 1.4 SPEECH THERAPY DEVELOPMENTAL DYSARTHRIA APHASIAS DYSARTHRIA Therapeutic Approaches in Aphasias and Dysarthrias Deficits in Swallowing and Management Options Orofacial Therapy 1.5 ORTHOTIC CARE IN NEUROLOGICAL DISEASES 1.5.1 Orthotic Management for Patients with Cerebral Palsy 1.5.2 Orthotic Interventions for Patients with Charcot-Marie-Tooth Disease 1.5.3 Orthotics for Patients Following Poliomyelitis 1.5.4 Orthotics for Patients Following CVA 1.6 OCCUPATIONAL THERAPY

SPECIAL SECTION 1.7 DYSFUNCTIONS IN NEUROMUSCULAR TRANSMISSION AND MUSCLE DISEASES 1.7.1 Dysfunction in Neuromuscular Transmission – Myasthenia Gravis Rehabilitation in Myasthenia Gravis 1.7.2 Muscle Diseases MUSCULAR DYSTROPHIES DUCHENNE AND BECKER MUSCULAR DYSTROPHY FACIOSCAPULOHUMERAL FORM OF DYSTROPHY GIRDLE FORMS OF MUSCULAR DYSTROPHY OTHER FORMS OF MUSCULAR DYSTROPHY MYOTONIC DYSTROPHY Rehabilitation in Muscular Dystrophies CONGENITAL, METABOLIC, INFLAMMATORY AND TOXIC MYOPATHIES ION CHANNEL DYSFUNCTIONS PERIODIC PARALYSES Hyperkalemic Periodic Paralysis Hypokalemic Periodic Paralysis Paramyotonia Congenita MYOTONIC SYNDROMES Myotonia Congenita Atypical Myotonic Syndromes Rehabilitation for Myotonic Syndromes and Periodic Paralyses 1.8 PERIPHERAL PARALYSIS 1.8.1 Causes, Degrees and Diagnosis of Peripheral Paralyses 1.8.2 Rehabilitation of Peripheral Paralyses

1.8.3 An Overview of Peripheral Pareses Based on Location PERIPHERAL PARESES OF THE UPPER EXTREMITIES BRACHIAL PLEXUS PALSY (C5-T1) RADIAL NERVE PALSY (C5-C7) MEDIAN NERVE PALSY (C5-T1) ULNAR NERVE PALSY (C8-T1) LONG THORACIC NERVE PALSY (C5-C7) SUPRASCAPULAR NERVE PALSY (C5-C6) AXILLARY NERVE PALSY (C5-C6) MUSCULOCUTANEOUS NERVE PALSY (C5-C7) PERIPHERAL PARESES OF THE LOWER EXTREMITIES LUMBOSACRAL PLEXUS PARESIS FEMORAL NERVE PALSY (L2-L4) SCIATIC NERVE PALSY (L4-S3) PERONEAL NERVE PALSY (L4-S1) TIBIAL NERVE PALSY (L4-S3) FACIAL NERVE PALSY (C.N. VII) 1.8.4 Peripheral Pareses in Diseases Involving Motor Neurons of the Anterior Spinal Horns 1.8.5 Rehabilitation Following Peripheral Nerve Surgery 1.9 ENTRAPMENT SYNDROMES 1.9.1 Etiology, Pathogenesis, Clinical Manifestations and Diagnosis Etiology and Pathogenesis Clinical manifestations Diagnosis 1.9.2 Overview of the Most Common Entrapment Syndromes ENTRAPMENT SYNDROMES OF THE UPPER THORACIC APERTURE

SCALENUS SYNDROME COSTOCLAVICULAR AND HYPERABDUCTION SYNDROME ENTRAPMENT SYNDROMES OF THE UPPER EXTREMITY AND THE SHOULDER GIRDLE SUPRASCAPULAR NERVE MEDIAN NERVE ULNAR NERVE RADIAL NERVE ENTRAPMENT SYNDROMES OF THE LOWER EXTREMITY AND THE PELVIC GIRDLE FEMORAL NERVE SCIATIC NERVE PERONEAL NERVE TIBIAL NERVE 1.9.3 Treatment Rehabilitation 1.10 POLYNEUROPATHIC SYNDROMES 1.10.1 Hereditary Motor and Sensory Polyneuropathies Therapy for Hereditary Motor and Sensory Polyneuropathies 1.10.2 Diabetic Neuropathy DIABETIC FOOT SYNDROME Rehabilitation in Diabetic Neuropathy 1.10.3 Inflammatory Polyneuropathies GUILLAIN-BARRE SYNDROME CHRONIC INFLAMMATORY DEMYELINATING POLYNEUROPATHY Rehabilitation in Inflammatory Polyneuropathies 1.11 POLIOMYELITIS AND POST-POLIOMYELITIC SYNDROME 1.11.1 Poliomyelitis

Etiology and Pathogenesis Disease Course Rehabilitation 1.11.2 Post-Poliomyelitic Syndrome Causes of Development Diagnostic Criteria Clinical Picture Rehabilitation 1.12 SPINAL CORD INJURY Spinal Program 1.12.1 Etiology, Neurological Presentation Methods of Clinical Assessment 1.12.2 Systematic Approach to Treatment 1.12.3 Medical Consequences of a Spinal Cord Lesion and Possible Complications AUTONOMIC DYSREFLEXIA ORTHOSTATIC HYPOTENSION DEEP VEIN THROMBOSIS (THROMBOEMBOLISM) URINARY DYSFUNCTION BOWEL DYSFUNCTION SEXUAL DYSFUNCTION INTEGUMENTARY DYSFUNCTIONS SEPTIC CONDITIONS PAINFUL CONDITIONS SPASTICITY PARA-ARTICULAR OSSIFICATION OSTEOPOROSIS 1.12.4 Rehabilitation for Patients with Spinal Cord Injury

1.13 DEFICITS IN CEREBELLAR FUNCTIONS 1.13.1 Functional Anatomy of the Cerebellum 1.13.2 Basic Clinical Manifestations of a Cerebellar Lesion ATAXIA HYPERMETRIA ADIADOCHOKINESIA ASYNERGY FLACCIDITY CEREBELLAR TREMOR EYE MOVEMENT DISTURBANCES PALEOCEREBELLAR AND NEOCEREBELLAR SYNDROME PALEOCEREBELLAR SYNDROME NEOCEREBELLAR SYNDROME PSEUDOCEREBELLAR SYNDROME 1.13.3 Rehabilitation in Cerebellar Dysfunctions 1.13.4 Prognosis of Cerebellar Dysfunctions 1.14 BALANCE DEFICITS 1.14.1 Balance Control VERTIGO AND ITS MOST COMMON CAUSES 1.14.2 Clinical Presentation of a Patient with a Vestibular System Disturbance EXAMINATION 1.14.3 Theoretical Bases for Rehabilitation 1.14.4 Rehabilitation of Individual Clinical Presentations UNILATERAL VESTIBULAR LESION BENIGN PAROXYSMAL POSITIONAL VERTIGO Diagnosis Treatment

BILATERAL VESTIBULAR DEFICIT BALANCE DEFICITS ASSOCIATED WITH CHANGES IN THE CERVICAL SPINE CENTRAL BALANCE DEFICITS VERTEBRAL ARTERY SYNDROME PSYCHOGENIC VERTIGO 1.14.5 Biological Feedback in Rehabilitation of Patients with Balance Deficits 1.15 EXTRAPYRAMIDAL DEFICITS 1.15.1 Basic Characteristics, Classification HYPOKINETIC DEFICITS HYPERKINETIC DEFICITS 1.15.2 Parkinson’s Disease OBJECTIVE NEUROLOGICAL FINDINGS HYPOKINESIA, BRADYKINESIA, AKINESIA RIGIDITY TREMOR POSTURAL DEFICITS Rehabilitation in Parkinson’s Disease 1.16 NEURODEGENERATIVE DISEASES 1.16.1 Basic Characteristics of Neurodegenerative Illnesses 1.16.2 Amyotrophic Lateral Sclerosis General Characteristics Classification Diagnosis Functional Stages of ALS Pharmacotherapy Rehabilitation in Amyotrophic Lateral Sclerosis

Specific Problem Areas in Patients with ALS and Treatment Options 1.16.3 Friedreich’s Ataxia Clinical Picture Diagnosis Therapy Basics 1.16.4 Autosomal Dominant Spinocerebellar Ataxia 1.17 MULTIPLE SCLEROSIS 1.17.1 Diseases Characteristics 1.17.2 Rehabilitation in Multiple Sclerosis 1.18 DEFICITS IN CONSCIOUSNESS 1.18.1 Causes LEVELS OF QUANTITATIVELLY LIMITED CONSCIOUSNESS SOMNOLENCE SOPOR COMA ASSESSMENT OF LEVELS OF CONSCIOUSNESS 1.18.2 Neurorehabilitation Approaches for Unconscious Patients 1.19 CRANIOCEREBRAL (BRAIN) INJURIES 1.19.1 Causes and Clinical Picture APALLIC SYNDROME 1.19.2 Rehabilitation for a Brain Injury 1.20 VASCULAR DISEASES OF THE BRAIN 1.20.1 Ischemic Cerebrovascular Accidents ISCHEMIA IN CAROTID CIRCULATION ISCHEMIA IN VERTEBROBASILAR CIRCULATION CLASSIFICATION BASED ON DISEASE PROGRESSION 1.20.2 Hemorrhagic Cerebrovascular Accidents

DIFFUSE HEMORRHAGES FOCAL SUBCORTICAL HEMORRHAGES CEREBELLAR HEMORRHAGE BLEEDING INTO THE BRAIN STEM SUBARACHNOID HEMORRHAGE 1.20.3 Rehabilitation for a CVA 1.21 CEREBRAL PALSY Epidemiology Causes of Onset Etiology and Pathogenesis 1.21.1 Screening for Risk of CP 1.21.2 Types of Cerebral Palsy and their Clinical Presentation SPASTIC DIPLEGIA SPASTIC HEMIPLEGIA CEREBELLAR FORM Clinical Picture Cerebellar Diplegia DYSKINETIC FORM OF CEREBRAL PALSY MIXED TETRAPLEGIA ATONIC DIPLEGIA 1.21.3 Rehabilitation in Cerebral Palsy DESIRED OUTCOME AND COPING PROCESS DESIRED OUTCOME COPING PROCESS Rehabilitation in Cerebral Palsy 1.21.4 Cerebral Palsy from the View of an Orthopedic Physician INDICATIONS FOR SURGERY INDICATIONS FOR SURGICAL PROCEDURES IN THE HIP JOINT

AREA INDICATIONS FOR SURGICAL PROCEDURES IN THE KNEE JOINT AREA INDICATION FOR SURGICAL INTERVENTIONS IN THE ANKLE AND FOOT AREAS INDICATIONS FOR SPINAL SURGICAL PROCEDURES INDICATIONS FOR UPPER EXTREMITY SURGICAL PROCEDURES 1.21.5 Neurosurgical Treatment INDICATIONS AND CONTRAINDICATIONS OF SURGICAL INTERVENTION 1.21.6 Botulotoxin in the Treatment of CP REFERENCES 2 TREATMENT REHABILITATION IN ORTHOPEDICS AND TRAUMATOLOGY GENERAL SECTION 2.1 INFLUENCE OF FUNCTION ON MORPHOLOGICAL TISSUE RESTRUCTURING 2.2 CLASSIFICATION ACCORDING TO SYMPTOMATOLOGY 2.2.1 Edema CAUSES TREATMENT STRATEGIES 2.2.2 Functional Changes in Soft Tissues TREATMENT REHABILITATION STRATEGIES 2.2.3 Range of Motion Restrictions in a Movement Segment CAUSES TREATMENT REHABILITATION STRATEGIES 2.2.4 Hypermobility CAUSES

COMPENSATORY HYPERMOBILITY HYPERMOBILITY IN NEUROLOGICAL DISEASES STRUCTURAL HYPERMOBILITY LOCALIZED PATHOLOGICAL (POSTRAUMATIC) HYPERMOBILITY TREATMENT REHABILITATION STRATEGIES 2.2.5 Deficit in the Nervous System Regulatory Mechanisms CHANGE IN AFFERENTATION FROM THE RECEPTORS MOTOR LEARNING DEFICIT AT THE LEVEL OF THE CENTRAL REGULATORY MECHANISMS TREATMENT REHABILITATION STRATEGY 2.3 CLASIFFICATION ACCORDING TO ETIOLOGY AND PATHOGENESIS 2.3.1 Congenital Developmental Defects ETIOLOGY REHABILITATION TREATMENT PRINCIPLES IN CONGENITAL DEVELOPMENTAL DEFECTS POST-SURGICAL REHABILITATION CLASSIFICATION OF CONGENITAL DEVELOPMENTAL DEFECTS CONGENITAL DEVELOPMENTAL DEFECTS OF THE UPPER EXTREMITIES Congenital Developmental Defects of the Shoulder Girdle Congenital Developmental Defects of the Elbow Joint Congenital Developmental Defects of the Wrist Congenital Developmental Defects of the Fingers CONGENITAL DEVELOPMENTAL DEFECTS OF THE LOWER EXTREMITES Congenital Developmental Defects of the Hip Joint Congenital Developmental Defects of the Knee Joint

Congenital Developmental Defects of the Lower Leg and Foot Congenital Deformities of the Toes CONGENITAL DEVELOPMENTAL DEFECTS OF THE THORAX Pectus Excavatum (Infundibuliform) Pectus Carinatum Rehabilitation in Congenital Developmental Defects of the Thorax CONGENITAL DEVELOPMENTAL DEFECTS OF THE SPINE Diastematomyelia Meningomyelocele Klippel-Feil Syndrome Spina Bifida 2.3.2 SOFT TISSUE INJURIES CAUSED BY OVERLOADING TENDON INJURIES ETIOLOGY AND PATHOGENESIS DIAGNOSTICS Clinical Picture Imaging Methods Differential Diagnosis LOCALIZATION Upper Extremity Lower Extremity Therapy Acute Form Chronic Form REHABILITATION General Principles Therapeutic Approaches

2.3.3 Degenerative Joint Diseases OSTEOARTHRITIS ETIOLOGY AND PATHOGENESIS Primary (Idiopathic) OA Secondary OA DIAGNOSIS Clinical Picture Imaging Methods LOCATION Coxarthrosis Gonarthrosis TREATMENT Pharmacotherapy Surgical Procedures Rehabilitation Arthroplasty 2.3.4 Inflammatory Diseases ETIOLOGY AND PATHOGENESIS STERILE INFLAMMATION INFECTIOUS INFLAMMATION Classification Based on Etiology Classification Based on Location PRINCIPLES OF REHABILITATION STERILE INFLAMMATION INFECTIOUS INFLAMMATION 2.3.5 Traumatology of the Movement System HEALING PHASES

Inflammation Repair Restoration of Function WOUNDS CONTUSION Treatment for a Detachment Type Injury TENDON INJURIES THERAPY MUSCLE INJURIES DIAGNOSIS CLASSIFICATION Muscle Cramp Muscle Soreness Muscle Strain Muscle Tear JOINT INJURIES TREATMENT BONE INJURIES – FRACTURES FRACTURE CLASSIFICATION BONE HEALING Secondary Primary FRACTURE HEALING TIMES TREATMENT Conservative Surgical REHABILITATION

Rehabilitation during Healing Rehabilitation in Healed Fractures SPECIAL SECTION 2.4 CLASSIFICATION ACCORDING TO LOCATION 2.4.1 Spine CONGENITAL DEVELOPMENTAL DEFECTS DEFORMITY SCOLIOSIS Classification According to Etiology and Pathogenesis Rehabilitation Surgical Treatment HYPERKYPHOSIS Juvenile Kyphosis (Scheuermann’s Disease) LUMBAR HYPERLORDOSIS TORTICOLLIS Congenital Muscular Torticollis Muscular Torticollis in Adults Acquired Muscular Torticollis Post-Traumatic Torticollis Spastic Torticollis Acute Torticollis VERTEBROGENIC PAIN SYNDROME ETIOLOGY AND PATHOGENESIS CLASSIFICATION ACCORDING TO ETIOLOGY AND PATHOGENESIS STRUCTURAL CAUSES FUNCTIONAL CAUSES Intervertebral Disc Involvement

Intervertebral Joint Degeneration Spinal Stenosis Abnormality of the Spinal Canal Spondylolisthesis Osteoporosis Ankylosing Spondylitis Infections Tumors Deficit in the CNS Control Function Deficit in Processing Nociception Psychological Disturbance CONSEQUENCES OF STRUCTURAL AND FUNCTIONAL DEFICITS Discogenic Pain Radicular Syndrome Pseudoradicular Syndrome SPECIFIC TREATMENT Rehabilitation Pharmaceutical Treatment Invasive Procedures Surgical Treatment 2.4.2 Shoulder Girdle CONGENITAL DEVELOPMENTAL DEFECTS OF THE SHOULDER GIRDLE SOFT TISSUE INJURIES IMPINGEMENT SYNDROME Etiology and Pathogenesis Clinical Presentation

Neer Classification Treatment Rehabilitation Following Shoulder Joint Arthroscopy (Subacromial Decompression, Debridement, Capsular Release, Acromioplasty) CALCIFIC TENDINITIS Clinical Presentation Rehabilitation SUBACROMIAL BURSITIS Clinical Presentation Rehabilitation ROTATOR CUFF TEARS Clinical Picture Rehabilitation SYNDROME OF THE LONG HEAD OF THE BICEPS TENDON Tendinosis of the Long Head of the Biceps Subluxation of the Long Head of the Biceps Tendon Biceps Tendon Rupture FROZEN SHOULDER SYNDROME Etiology and Pathogenesis Clinical Presentation Rehabilitation DEGENERATIVE DISEASES GLENOHUMERAL ARTHRITIS Etiology and Pathogenesis Clinical Picture Rehabilitation ACROMIOCLAVICULAR ARTHRITIS Etiology and Pathogenesis

Clinical Presentation Rehabilitation TRAUMATIC LESIONS GLENOHUMERAL DISLOCATION Etiology and Pathogenesis Clinical Picture Treatment Rehabilitation ACROMIOCLAVICULAR DISLOCATION Clinical Presentation Treatment Rehabilitation STERNOCLAVICULAR DISLOCATION Clinical Picture Treatment Rehabilitation PROXIMAL HUMERAL FRACTURES Rehabilitation INSTABILITY GLENOHUMERAL INSTABILITY Post-traumatic Instability (Recurring Dislocations) Multidirectional Non-traumatic Instability (Habitual Dislocation) DIFFERENTIAL DIAGNOSIS OF SHOULDER GIRDLE PAIN GENERAL PRINCIPLES OF REHABILITATION OF SHOUDLER GIRDLE DYSFUNCTIONS 2.4.3 Elbow Joint CONGENITAL DEVELOPMENTAL DEFECTS OVERUSE SOFT TISSUE INJURIES

ENTHESOPATHY Lateral Epicondylitis (Epicondylitis Radialis Humeri) Medial Epicondylitis (Epicondylitis Ulnaris Humeri) Triceps Brachii Enthesopathy Rehabilitation in Enthesopathies Olecranon Bursitis DEGENERATIVE DISEASES OF THE ELBOW JOINT ELBOW JOINT ARTHRITIS Etiology and Pathogenesis Clinical Presentation Rehabilitation TRAUMATIC LESIONS DISLOCATIONS Treatment FRACTURES IN THE ELBOW JOINT REGION Pediatric Fractures at the Elbow Region Adult Fractures at the Elbow Region REHABILITATION IN TRAUMATIC LESIONS POST-TRAUMATIC COMPLICATIONS ELBOW FLEXION CONTRACTURE Rehabilitation AXIAL DEFORMITIES OF THE ELBOW Cubitus Varus Cubitus Valgus Treatment of Axial Deformities VOLKMANN’S CONTRACTURE Rehabilitation

2.4.4 Wrist and Hand CONGENITAL DEVELOPMENTAL DEFECTS OVERUSE SOFT TISSUE INJURIES TENOSYNOVITIS Trigger Thumb, Finger (Digitus Saltans) De Quervain’s Disease Rehabilitation for Tenosynovitis DUPUYTREN’S CONTRACTURE Treatment Rehabilitation DEGENERATIVE JOINT INJURIES RHIZARTHROSIS Treatment ARTHRITIS OF THE INTERPHALANGEAL JOINTS OF THE HAND TRAUMATIC LESIONS SOFT TISSUE INJURIES Tendon Injuries of the Wrist and the Hand (Flexors, Extensors) Injuries of the Neurovascular Bundle Treatment of Tendon and Neurovascular Bundle Injuries Rehabilitation in Tendon Injuries DISLOCATIONS FRACTURES Distal Forearm Fractures Navicular Fracture Treatment of Dislocations and Fractures of the Wrist and Fingers Rehabilitation in Dislocations and Fractures POST-TRAUMATIC CONDITIONS

WRIST INSTABILITY Treatment Rehabilitation for Wrist Instability NAVICULAR NON-UNION GENERAL REHABILITATION PRINCIPLES FOR WRIST AND HAND INJURIES 2.4.5 Hip Joint PEDIATRIC DISEASES Congenital hip dysplasia Clinical Assessment of Newborns and Infants Examination by Imaging Methods Classification according to Radiological Findings Treatment Rehabilitation SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE) Etiology and Pathogenesis Classification Diagnosis Treatment Rehabilitation LEGG-CALVE-PERTHES DISEASE Etiology and Pathogenesis Classification Based on Radiologic Findings Diagnosis Treatment Rehabilitation TRANSIENT SYNOVITIS OF THE HIP Etiology and Pathogenesis

Diagnosis Treatment ADULTHOOD DISEASES OVERUSE SOFT TISSUE INJURIES Hip Adductor Enthesopathy Rectus Femoris Enthesopathy Hamstring Enthesopathy Rehabilitation of Hip Joint Enthesopathies DEGENERATIVE DISEASES Osteoarthritis of the Hip (Coxarthrosis) TRAUMATIC LESIONS Groin Injuries Hip Joint Dislocation Proximal Femoral Fractures Rehabilitation in Traumatic Injuries REFERRED PAIN TO THE HIP JOINT FROM OTHER SITES 2.4.6 Knee Joint> CONGENITAL DEVELOPMENTAL DEFECTS OF THE KNEE JOINT OVERUSE SOFT TISSUE INJURIES TENDINOPATHIES Patellar Tendonitis (Jumper’s Knee) Rectus Femoris Enthesopathy Hip Adductor Enthesopathy Enthesopathy of the Biceps Femoris Tendon ASEPTIC NECROSIS OF THE KNEE Osgood-Schlatter Disease (Aseptic Necrosis of the Tibial Tuberosity) Sinding-Larsen-Johansson Syndrome (Osteochondrosis of the

Patellar Apex) Osteochondritis Dissecans DEGENERATIVE DISEASES PATELLOFEMORAL JOINT DISORDERS Rehabilitation GONARTHROSIS TRAUMATIC LESIONS SOFT TISSUE INJURIES OF THE KNEE Physiology of Healing of the Knee Structures Physiology of Soft Tissue Healing Physiology of Ligamentous Healing Physiology of Autogenous Graft Healing Rehabilitation Following Meniscal Injuries and Repairs Rehabilitation following Medial Collateral Ligament (MCL) Injury Rehabilitation following Anterior Cruciate Ligament Injury and Reconstruction Actual Rehabilitation Program 2.4.7 Ankle and Foot CONGENTIAL DEVELOPMENTAL DEFECTS TREATMENT OF CONGENITAL DEVELOPMENTAL DEFECTS IN GENERAL ALIGNMENT DEFORMITIES FLAT FOOT Classification of flat foot HALLUX VALGUS Treatment HALLUX RIGIDUS Treatment

METATARSALGIA Rehabilitation in Transverse Flat Foot Surgical Interventions for Transverse Flat Foot TOE DEFORMITIES Hammer Toe (Digitus Hamatus) Club Toe (Digitus Malleus) OVERUSE SOFT TISSUE INJURIES PERITENDINITIS (TENOSYNOVITIS), ACHILLES TENDON TENDINOSIS TENOSYNOVITIS, POSTERIOR TIBIALIS TENDINOSIS ENTHESOPATHY OF THE SHORT MUSCLES OF THE SOLE OF THE FOOT, CALCANEAL SPUR (CALCAR CALCANEI) Rehabilitation of Tendon Injuries TIBIALIS ANTERIOR SYNDROME Rehabilitation for Anterior Tibialis Syndrome TRAUMATIC LESIONS ACHILLES TENDON RUPTURE Clinical Presentation Treatment INJURY TO THE ANKLE LIGAMENTOUS APPARATUS Acute Ankle Instability Chronic Lateral Ankle Instability Rehabilitation Treatment Following Injuries and Surgeries of the Ligamentous Apparatus of the Ankle and Foot 2.5 ORTHOTICS 2.5.1 Classification and Technical Overview of Orthoses OVER-THE-COUNTER ORTHOSES CUSTOM-MADE ORTHOTICS

2.5.2 Functional Indications for Orthoses FUNCTIONAL DEMANDS OF ORTHOSES ACTION PRINCIPLES OF ORTHOSES 2.5.3 Contraindications 2.5.4 Upper Extremity Orthoses SCS CLASSIFICATION DESCRITPION OF ORTHOSIS FUNCTION ACCORDING TO SCS CLASSIFICATION BASIC OVERVIEW OF UPPER EXTREMITY ORTHOSES Hand Orthosis – HO Wrist Orthosis, Wrist Hand Orthosis – WO, WHO Elbow Orthosis, Elbow Wrist Hand Orthosis – EO, EWHO Shoulder Orthosis, Shoulder Elbow Orthosis, Shoulder Elbow Wrist Hand Orthosis – SO, SEO, SEWHO 2.5.5 Lower Extremity Orthoses BASIC CLASSIFICATION OF LOWER EXTREMITY ORTHOSES Foot Orthosis – FO Ankle-Foot Orthosis – AFO Knee Orthosis – KO Knee-Ankle-Foot Orthosis – KAFO Hip-Knee-Ankle-Foot Orthosis – HKAFO 2.5.6 Trunk Orthoses BASIC CLASSIFICATION OF TRUNK ORTHOSES Cervicothoracic Orthoses – CTO Thoracic Orthoses – TO Thoracolumbar Orthoses – TLO Thoracolumbosacral Orthosis – TLSO Cervicothoracolumbosacral Orthoses – CTLSO

2.5.7 Most Commonly Applied Orthoses in Pediatric Orthopedics Congenital Pes Equinovarus (Club Foot) Metatarsus Adductus Pes Calcaneovalgus Foot Deformities in Arthrogryposis Flat Foot Osgood-Schlatter Disease (Patellar Ligament Tendinopathy) Patellar Dislocation Genu Varum, Genu Valgum, Genu Recurvatum Congenital Developmental Hip Dysplasia Legg-Calve-Perthes Disease Limb Reduction Defects Scoliosis 2.5.8 Most Commonly Applied Orthoses in Orthopedics for Adult Patients ORTHOTIC OPTIONS IN COMPLICATIONS DURING APPLICATION OF TOTAL ENDOPROSTHESIS OF THE KNEE AND HIP JOINTS ORTHOSES APPLICATION IN RHEUMATOID ARTHRITIS LEG LENGTH DISCREPANCY ORTHOTIC CARE FOR THE TREATMENT OF FOOT DEFECTS NOTES TO APPLICATION OF TRUNK ORTHOSES IN LOW BACK PAIN ORTHOTIC DEVICES FOR FOOT DEFORMITIES IN ADULTHOOD ORTHOTIC OPTIONS FOR ACUTE AND CHRONIC JOINT INSTABILITIES OF THE LOWER AND UPPER EXTREMITES ORTHOSES IN SPINAL TRAUMA ORTHOTIC OPTIONS IN TENDON INJURIES OF THE HAND

FUNCTIONAL TREATMENT OF TENDON INJURIES IN THE LOWER EXTREMITY FUNCTIONAL TREATMENT OF LOWER EXTREMITY FRACTURES ORTHOTIC CARE IN PATIENTS AFTER CRANIALTRAUMA ORTHOTIC MANAGEMENT FOR PATIENTS FOLLOWING BURN INJURIES 2.6 REHABILITATION OF PATIENTS AFTER EXTREMITY AMPUTATION 2.6.1 Reasons for Amputations 2.6.2 Prosthetics Structure of a Prosthesis Gait with a Prosthesis Indication Criteria Residual Limb Care Gait Training Prosthesis Prescription Categories of Amputees According to Insurance Companies Regulations 2.6.3 Complications in Amputations 2.7 REHABILITATION TOOLS REFERENCES 3 TREATMENT REHABILITATION FOR SELECTED INTERNAL AND OTHER DISEASES GENERAL SECTION 3.1 PHYSIOLOGICAL MECHANISMS UTILIZED IN REHABILITATION INCLUDING ADAPTATION TO PHYSICAL ACTIVITY 3.1.1 Cardiac System Adaptation

3.1.2 Pulmonary System Adaptation 3.1.3 Metabolic Adaptation 3.1.4 Immunity Adaptation 3.2 FUNCTIONAL STRESS TEST IN PATIENTS WITH CARDIOPULMONARY DYSFUNCTION 3.2.1 Laboratory Stress Test 3.2.2 Basic Terminology of a Functional Stress Test 3.2.3 Fitness Testing in Less Fit Individuals 3.2.4 Fitness Assessment Based on Submaximal Stress Tests 3.2.5 Assessment of Stress Test 3.2.6 Assessment of Activity Including Assessment of the Functional Ability of an Elderly Patient 3.2.7 Specific Stress Test Adaptations for Patients with Ischemic Heart Disease (IHD) 3.3 FUNCTIONAL LUNG ASSESSMENT 3.3.1 Causes of the Onset of Pulmonary Dysfunctions in Patients with Deficits in the Movement System and in Certain Organ Systems 3.3.2 Diagnostic Approaches Methods in Pulmonary Function Testing Description of Pulmonary Function Parameters 3.3.3 Interpretation and Implementation of Conclusions from a Pulmonary Function Test Restrictive Lung Dysfunction Lung Hyperinflation Obstructive Deficits Changes in Lung Elastic Properties IMPLEMENTATION INTO CLINICAL PRACTICE SPECIAL SECTION

3.4 RESPIRATORY DISEASES 3.4.1 Rehabilitation for Bronchial Asthma Rehabilitation Options and the Goal of Exercise Therapy EXERCISE-INDUCED BRONCHOSPASM Prevention and Treatment of Asthma and Exercise-Induced Bronchospasm 3.4.2 Rehabilitation in Chronic Obstructive Pulmonary Disease (COPD) PERIPHERAL MUSCLE DYSFUNCTION Rehabilitation of Patients with COPD 3.4.3 Implementation of Rehabilitation in Other Respiratory Dysfunctions Respiratory Insufficiency in Neuromuscular Disturbances and Thoracic Deformities Rehabilitation of Patients Following Spinal Cord Injury: Effect on Lung Function Rehabilitation of Patients on Breathing Support 3.4.4 Methods and Approaches Used in the Rehabilitation of Patients with Chronic Pulmonary System Dysfunction 3.5 SURGICAL PROCEDURES IN THE THORACIC REGION 3.5.1 Rehabilitation following Pulmonary Surgery Breathing Preparation 3.5.2 Rehabilitation following Cardiac Surgery Pre-Operative Fitness Improvement and Correction of Musculoskeletal System Dysfunctions Post-Operative Rehabilitation Approaches Exercise therapy Post-Operative Complications 3.6 ISCHEMIC HEART DISEASE (IHD)

KEY COMPONENTS OF A COMPLEX REHABILITATION PLAN Patient Assessment Nutritional Consultation Weight Management Physical Activity Exercise Training 3.7 METABOLIC DISTURBANCES 3.7.1 Diabetes Mellitus – Type 2 3.7.2 Diabetes Mellitus – Type 1 3.8 RHEUMATIC DISEASES 3.8.1 Rheumatoid Arthritis CLINICAL PRESENTATION FUNCTIONAL DIAGNOSIS TREATMENT Rehabilitation Treatment Surgical Intervention Pharmacological Interventions PROGNOSIS 3.8.2 Juvenile Rheumatoid Arthritis (Juvenile Idiopathic Arthritis) CLINICAL PICTURE TREATMENT Rehabilitation Treatment Pharmacotherapy PROGNOSIS 3.8.3 Ankylosing Spondylitis CLINICAL PRESENTATION DIAGNOSIS

TREATMENT Rehabilitation Treatment Pharmacotherapy Rheumatologic Surgery DISEASE COURSE AND PROGNOSIS 3.8.4 Osteoporosis ETIOLOGY EPIDEMIOLOGY CLINICAL MANIFESTATIONS DIAGNOSIS TREATMENT Pharmaceutical Treatment Rehabilitation Treatment PROGNOSIS 3.8.5 Fibromyalgia Syndrome CLINICAL MANIFESTATIONS AND DIAGNOSIS Differential Diagnosis Biological Aspects of FMS Psychological Aspects of FMS TREATMENT Rehabilitation Treatment Modalities Pharmacotherapy Psychotherapy Education Support Groups 3.9 OTHER DYSFUNCTIONS AND DISEASES

3.9.1 Lymphedema and Treatment ANATOMY OF THE LYMPHATIC SYSTEM MECHANISM OF LYMPHATIC FLUID FORMATION LYMPHEDEMA CLASSIFICATION DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS TREATMENT Manual Lymphatic Drainage Pharmacotherapy Treatment Frequency EDEMA PREVENTION PROGNOSIS 3.9.2 Treatment Rehabilitation of Bowel Incontinence ETIOLOGY TREATMENT Physical Therapy Approaches 3.10 GERIATRICS 3.10.1 Aging Phenotype and Involution Deterioration 3.10.2 Geriatric Frailty and Geriatric Syndromes GERIATRIC SYNDROMES OF HYPOMOBILITY, DECONDITIONING AND MUSCLE WEAKNESS HYPOMOBILITY DECONDITIONING SARCOPENIA GERIATRIC MODIFICATIONS AND CONTINUITY OF REHABILITATION ACTIVITIES 3.10.3 Principles of Movement Activity Selection in the Aging Population Assessment Prior to Exercise Program Initiation

Exercise Programs Reconditioning Stays REFERENCES 4 TREATMENT REHABILITATION IN ONCOLOGY REHABILITATION SPECIFICS FOR PATIENTS WITH ONCOLOGIC CONDITIONS BASIC GOALS AND ASSESSMENT OF REHABILITATION TREATMENT REHABILITATION TREATMENT COMPLICATIONS GENERAL SECTION 4.1 PAIN PATTERNS IN PATIENTS WITH ONCOLOGICAL DISEASES 4.1.1 Pain Pattern and Its Treatment 4.1.2 Classification of Oncologic Pain 4.2 PARAMETERS FOR THE INTERRUPTION OR MODIFICATION OF A REHABILITATION PROGRAM 4.2.1 Laboratory Values 4.2.2 Long Bone Metastases 4.2.3 Other Parameters Modifying Rehabilitation Treatment 4.3 REHABILITATION APPROACHES 4.3.1 Modalities 4.3.2 Physical Therapy Techniques 4.3.3 Contraindications 4.4 SPECIFIC FACTORS INFLUENCING REHABILITATION TREATMENT SPECIAL SECTION 4.5 METASTATIC INVOLVEMENT 4.5.1 Metastatic Involvement of the Skeleton ONCOLOGICAL DISEASES OF THE SPINE

ONCOLOGICAL DISEASES AND SURGICAL APPROACHES FOR THE EXTREMITIES Surgical Treatment Approaches Rehabilitation Goals Following Surgical Procedures 4.5.2 Metastatic Involvement of the Brain and the Spinal Cord Brain Involvement Spinal Cord Involvement 4.6 PARANEOPLASTIC SYNDROMES 4.7 SIDE EFFECTS OF ONCOLOGIC TREATMENT NEUROLOGICAL SYMPTOMS 4.7.1 Cerebellar Syndrome 4.7.2 Peripheral Polyneuropathy NEUROPATHOLOGICAL CAUSES OF POLYNEUROPATHIES TREATMENT FOR PERIPHERAL NEUROPATHY Treatment Rehabilitation in Peripheral Neuropathy 4.7.3 Hormone Therapy 4.7.4 Immunotherapy 4.8 SOFT TISSUES AND MUSCLE TISSUE 4.9 RADIATION THERAPY 4.10 LYMPHEDEMA REFERRENCES 5 TREATMENT REHABILITATION IN GYNECOLOGY AND OBSTETRICS 5.1 OVERVIEW OF GYNECOLOGICAL SYNDROMES WITH CONTRIBUTION OF FUNCTIONAL DEFICITS DYSFUNCTIONS OF THE MENSTRUAL CYCLE AND FUNCTIONAL STERILITY AMENORRHEA

DYSMENORRHEA STERILITY Rehabilitation in Gynecological Syndromes with Contribution from Functional Deficits Rehabilitation in Functional Gynecological Dysfunctions 5.2 PREMENSTRUAL SYNDROME AND MENOPAUSE PREMENSTRUAL SYNDROME MENOPAUSE MENOPAUSE, PREMENOPAUSE, POSTMENOPAUSE Menopausal Syndrome Treatment Rehabilitation of Premenstrual Syndrome and during Menopause SYNDROMES THAT CAN BE AFFECTED BY REHABILITATION 5.3 PELVIC INFLAMMATORY DISEASE Rehabilitation Following Pelvic Inflammatory Disease 5.4 ANATOMICAL DEFICITS IN GYNECOLOGY Rehabilitation in Anatomical Deficits in Gynecology 5.5 GYNECOLOGICAL SURGICAL PROCEDURES Pre- and Post-Surgical Rehabilitation 5.6 URINARY INCONTINENCE Diagnosis Treatment Rehabilitation 5.7 PREGNANCY, BIRTH AND THE POSTPARTUM (POSTNATAL) PERIOD PREGNANCY BIRTH POSTPARTUM

Rehabilitation during Pregnancy Rehabilitation during Postpartum REFERENCES 6 TREATMENT REHABILITATION IN PAIN MANAGEMENT 6.1 CLASSIFICATION OF PAIN Acute Pain Chronic pain 6.2 FOUNDATIONS OF NEUROPHYSIOLOGIC PAIN 6.3 PAIN MANAGEMENT Rehabilitation Non-Pharmaceutical Treatment Other Non-Pharmaceutical Treatment Methods Pharmacotherapy Invasive Techniques 6.4 COMPLEX REGIONAL PAIN SYNDROME (CRPS) Types of KRBS Etiology and Pathophysiology Clinical Presentation Diagnosis Treatment REFERENCES 7 TREATMENT REHABILITATION IN PSYCHOSOMATIC DISEASES 7.1 MODERN PSYCHOSOMATICS 7.1.1 Psychosomatics and Current Science 7.1.2 Psychosomatics and Irrationality 7.1.3 Biological, Psychological and Social Approach Psychosomatic Integrity

Normality Psychobiology and Sociocultural Norms Cognitive Processes and Adaptation 7.1.4 Placebo and Nocebo 7.1.5 Charisma 7.1.6 Physical Manifestations as Signs and Symptoms 7.1.7 Deficits and Signs 7.2 TREATMENT 7.2.1 Biological, Psychological and Social Context: Non-Specific Rehabilitation Factors 7.2.2 Treatment Rehabilitation 7.2.3 Psychotherapy 7.2.4 Psychopharmacotherapy REFERENCES 8 REHABILITATION IN PSYCHIATRY 8.1 REHABILITATION IN THE AREAS OF SOCIAL AND VOCATIONAL FUNCTIONS Development of Psychiatric Rehabilitation in the World and in the Czech Republic 8.1.1 General Aspects of Psychiatric Rehabilitation Current Schools of Psychiatric Rehabilitation Target Group of Psychiatric Rehabilitation Principles of Psychiatric Rehabilitation Recovery 8.1.2 Process of Psychiatric Rehabilitation and Possible Approaches Process of Psychiatric Rehabilitation According to the Boston School Process of Psychosocial Rehabilitation According to the Netherlands’ School STORM

8.1.3 Specific Levels of Psychiatric Rehabilitation Vocational rehabilitation Assisted Education Rehabilitation and Housing Rehabilitation in the Areas of Social Interaction and Leisure Time 8.1.4 Psychiatric Rehabilitation Assessment 8.2 PSYCHOMOTOR THERAPY 8.2.1 General Aspects of Psychomotor Therapy Research in Kinesiotherapy Physical Self-Concept Role of Movement Activity in Stress Coping Somatic State and Movement Abilities of Patients with Mental Illness Why Movement Therapy? 8.2.2 Kinesiotherapy Circumscription of the term Kinesiotherapy Actions of Kinesiotherapy Types of Kinesiotherapy in the Treatment of Psychiatric Patients Suggested Forms of Kinesiotherapy for the Treatment of Psychological Illnesses Principles of Kinesiotherapy Administration in the Mentally Ill REFERENCES BIOGRAPHIES of influential figures Professor Vaclav Vojta, MD, DrSc. Professor Karel Lewit, MD, DrSc. Professor Vladimir Janda, MD, DrSc. Associate Professor Karel Obrda, MD, CSc. Associate Professor Frantisek Vele, MD, CSc.

Professor Jan Pfeiffer, MD, DrSc. Professor Jan Jirout, MD, DrSc. Professor Milos Macek, MD, DrSc. Professor Miroslav Kucera, MD, DrSc. Associate Professor Jan Javurek, MD, DrSc. Ludmila Mojzisova ABBREVIATIONS

LIST OF AUTHORS MAIN AUTHOR AND EDITOR Pavel Kolář, PT, PhD Professor Department of Rehabilitation and Sports Medicine 2nd School of Medicine, Charles University and University Hospital Motol, Prague

AUTHORS Petr Bitnar, MPT Department of Rehabilitation and Sports Medicine 2nd School of Medicine, Charles University and University Hospital Motol, Prague Olga Dyrhonová, MD Department of Rehabilitation and Sports Medicine 2nd School of Medicine, Charles University and University Hospital Motol, Prague Ondřej Horáček, MD, PhD Department of Rehabilitation and Sports Medicine 2nd School of Medicine, Charles University University Hospital Motol, Prague Jiří Kříž, MD, PhD Department of Rehabilitation and Sports Medicine 2nd School of Medicine, Charles University and University Hospital Motol, Prague Milena Adámková, MPT Department of Psychology

College of Education University of J.E. Purkinje, Usti nad Labem Lenka Babková, MPT Department of Rehabilitation and Sports Medicine 2nd School of Medicine, Charles University and University Hospital Motol, Prague Jan Calta, MD Department of Rehabilitation Medicine University Hospital Kralovske Vinohrady, Prague Věra Cikánková Rheumatology Institute, Prague Ondřej Čakrt, MPT Department of Rehabilitation and Sports Medicine 2nd School of Medicine, Charles University and University Hospital Motol, Prague Zdeněk Čech, MPT Department of Rehabilitation and Sports Medicine 2nd School of Medicine, Charles University and University Hospital Motol, Prague Rudolf Černý, MD Department of Neurology 2nd School of Medicine, Charles University and University Hospital Motol, Prague Jiří Čumpelík, MPT, PhD National Theater, Prague; Music and Dance Academy of the Performing Arts (HAMU), Prague Barbora Danielová, MD

Department of Rehabilitation Malvazinky, Prague Miroslav Dobeš, MPT, PhD DJK Physical Therapy Ostrava-Vitkovice Rastislav Druga, MD, DSc Professor Department of Anatomy 2nd School of Medicine, Charles University, Prague Alice Hamáčková, MPT S-E-T Clinic, Hradec Kralove Běla Hátlová, PhD Associate Professor Department of Psychology College of Education University of J.E. Purkinje, Usti nad Labem Martina Hoskovcová, MD Department of Neurology 1st School of Medicine, Charles University and General University Hospital, Prague Vítězslav Hradil, MD Rehabilitation Department Hospital Beroun Jessenia, Inc. Zdeněk Hříbal, MD Department of Imaging Methods 2nd School of Medicine, Charles University and University Hospital Motol, Prague

Veronika Hyšperská, MD Spinal Unit Department of Rehabilitation and Sports Medicine 2nd School of Medicine, Charles University and University Hospital Motol, Prague Kateřina Chamoutová, PhD Department of Psychology College of Business and Economics Czech Agricultural University, Prague Jaroslav Jeřábek, MD Associate Professor Department of Neurology 2nd School of Medicine, Charles University and University Hospital Motol, Prague Martina Ježková, MPT Department of Rehabilitation and Sports Medicine 2nd School of Medicine, Charles University and University Hospital Motol, Prague Jan Kálal, MD Associate Professor Department of Rehabilitation and Sports Medicine 2nd School of Medicine, Charles University and University Hospital Motol, Prague Zdeněk Kalvach, MD Prague Petr Knotek, PhD Center for Treatment and Research of Pain Conditions Department of Clinical Psychology University Hospital Motol, Prague

Alena Kobesová, MD, PhD Department of Rehabilitation and Sports Medicine 2nd School of Medicine, Charles University and University Hospital Motol, Prague Vladimír Komárek, MD Professor Department of Pediatric Neurology 2nd School of Medicine, Charles University and University Hospital Motol, Prague Irena Koudelková, MD Department of Rehabilitation and Physical Medicine Hospital Na Frantisku, Prague Jiří Kozák, MD, PhD Center for Treatment and Research of Pain Conditions University Hospital Motol, Prague Josef Kraus, MD Associate Professor Department of Pediatric Neurology 2nd School of Medicine, Charles University and University Hospital Motol, Prague Petr Krawczyk, MD Private Medical Facility Technical Orthopedics Ostrava – PROTEOR, Inc. Department of Rehabilitation School of Health Studies, Ostrava University, Ostrava Veronika Kubů, MPT Department of Rehabilitation and Sports Medicine 2nd School of Medicine, Charles University and University Hospital Motol, Prague

Martin Kynčl, MD Department of Imaging Methods 2nd School of Medicine, Charles University and University Hospital Motol, Prague Magdaléna Lepšíková, MPT Department of Rehabilitation and Sports Medicine 2nd School of Medicine, Charles University and University Hospital Motol, Prague Karel Lewit, MD, DSc Professor Department of Rehabilitation and Sports Medicine 2nd School of Medicine, Charles University and University Hospital Motol, Prague Miloš Máček, MD, DSc Professor Department of Rehabilitation and Sports Medicine 2nd School of Medicine, Charles University and University Hospital Motol, Prague Michaela Málková, MPT Department of Rehabilitation and Sports Medicine 2nd School of Medicine, Charles University and University Hospital Motol, Prague Hana Marčišová, MPT Department of Rehabilitation and Sports Medicine 2nd School of Medicine, Charles University and University Hospital Motol, Prague Miloš Matouš, MD Department of Rehabilitation and Sports Medicine 2nd School of Medicine, Charles University and University Hospital Motol, Prague

Jan Mužík Fokus Praha Dagmar Pavlů, MPT Associate Professor Department of Physical Therapy College of Physical Education and Sports, Charles University, Prague Ondřej Pěč, MD ESET, Psychotherapeutic and Psychosomatic Clinic, Prague Jiří Radvanský, MD Associate Professor Department of Rehabilitation and Sports Medicine 2nd School of Medicine, Charles University and University Hospital Motol, Prague Alena Schejbalová, MD, PhD Department of Orthopedics – Pediatric and Adult Orthopedics and Traumatology 2nd School of Medicine, Charles University and University Hospital Motol, Prague Veronika Schönová, PT Department of Rehabilitation and Sports Medicine 2nd School of Medicine, Charles University and University Hospital Motol, Prague Bronislav Schreier, MPT Department of Rehabilitation and Sports Medicine 2nd School of Medicine, Charles University and University Hospital Motol, Prague David Smékal, PhD Department of Physical Therapy

School of Physical Culture, Palacky University, Olomouc Libuše Smolíková, MPT, PhD Department of Rehabilitation and Sports Medicine 2nd School of Medicine, Charles University and University Hospital Motol, Prague Ondřej Suchánek Prague Marcela Šafářová, MPT, PhD Department of Rehabilitation and Sports Medicine 2nd School of Medicine, Charles University and University Hospital Motol, Prague Jan Štulík, MD, PhD Professor Department of Surgery IIIrd Surgical Department 1st School of Medicine, Charles University and University Hospital Motol, Prague Jan Šulc, MD, FCCP Department of Rehabilitation and Sports Medicine 2nd School of Medicine, Charles University and University Hospital Motol, Prague Department of Pediatrics 2nd School of Medicine, Charles University and University Hospital Motol, Prague Martin Švehlík, MD Department of Orthopedics – Pediatric and Adult Orthopedics and Traumatology 2nd School of Medicine, Charles University and University Hospital Motol, Prague

Michaela Tomanová, MD Rehabilitation Institute, Brandys nad Orlici Ctirad Tomis, MPT S-E-T Clinic, Hradec Kralove Dagmar Tomisová, MPT S-E-T Clinic, Hradec Kralove Michal Truc, MPT Department of Rehabilitation and Sports Medicine 2nd School of Medicine, Charles University and University Hospital Motol, Prague Lenka Vachková, MD Psychiatric Clinic Brno-Cernovice Hana Váchová Department of Rehabilitation and Sports Medicine 2nd School of Medicine, Charles University and University Hospital Motol, Prague Petra Valouchová, MPT, PhD Department of Rehabilitation and Sports Medicine 2nd School of Medicine, Charles University and University Hospital Motol, Prague Ivan Vařeka, MD, PhD Department of Physical Therapy School of Physical Culture, Palacky University, Olomouc Marie Vávrová Prague Michaela Veverková, MPT

Department of Rehabilitation Medicine 3rd School of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague; Department of Physiatry, Balneology and Rehabilitation Medicine IPVZ, Prague Martina Votavová Rheumatology Institute, Prague Martin Wald, MD Department of Surgery 2nd School of Medicine, Charles University and University Hospital Motol, Prague Ivana Wurstová, MD Balneology Center Velke Losiny Milan Zedka, MD, PhD Department of Pediatric Neurology 2nd School of Medicine, Charles University and University Hospital Motol, Prague Irena Zounková, MPT Department of Rehabilitation and Sports Medicine 2nd School of Medicine, Charles University and University Hospital Motol, Prague Alena Zumrová, MD, PhD Department of Pediatric Neurology 2nd School of Medicine, Charles University and University Hospital Motol, Prague

FOREWORD The main motivation for me to begin work on this textbook was an effort to refine knowledge of the qualified public about rehabilitation and provide a framework regarding the true objectives of this field. Our profession is sometimes misconceived as massage therapy, exercising after orthopedic procedures, rehabilitation and sometimes it is reduced to only the use of therapeutic agents (modalities). I have also encountered the opinion that it is linked to or even directly considered some kind of an alternative treatment. Another important motivation for me was the lack of current study materials for physicians undergoing residencies, for graduate and post-graduate physical therapy students, as well as for physicians of other clinical specialties who want to be introduced to the methods of treatment rehabilitation used in their specialization. In my view, I consider it essential that the foundation for rehabilitation treatment approaches be neither a trend nor a school of thought (chiropractics, osteopathy, musculoskeletal medicine), but rather a wide, general foundation in the fields of clinical physiology and neurophysiology. It also needs to be appreciated that rehabilitation is not only limited to diagnostic and treatment methods, but it also attempts to limit the extent of psychological, behavioral and social changes related to the consequences of an injury or illness. Therefore, rehabilitation should not be perceived as strictly a medical field but a field that overreaches these boundaries and extends into the social, academic and work arenas. Comprehensive (integrated) rehabilitation applies to individuals whose health was compromised to a varied extent as a result of an illness, injury or a congenital defect and who require special assistance to achieve the highest possible level of independence. A person with a disability perceives limitations that they are unable to overcome while performing certain activities but they feel able and healthy in a number of other activities. Removing and solving these limiting problems is one of the particularly important tasks of rehabilitation. Therefore, the concept of

rehabilitation must complement not only the treatment process but also the subsequent rehabilitation process. From this point of view, rehabilitation is a very broad field which cannot be covered in detail in one book. Similarly, it is not possible to cover this extensive subject by one specialist. Success is based on a coordinated effort of various specialists. In this book, I focused on the treatment component of rehabilitation and devoted more space to it than the educational, social and occupational areas. Given the fact that the diagnostic and treatment approaches of rehabilitation are focused primarily on the movement system, this field reaches into practically all clinical fields (neurology, orthopedics, internal medicine, oncology, immunology, psychiatry, etc.). Movement function plays an important role in all of these clinical fields. This is because physical activity and its repeated action manifest themselves by a change in function in a number of systems (cardiorespiratory, immune, central nervous system and metabolic changes), which allows for influencing these systems through modulation of its intensity, frequency and form. Another reason why rehabilitation reaches into several medical fields is the fact that the sensory afferent inputs from the entire body are always processed not only within its own sensory modality (visual, acoustic, proprioceptive, integumentary, etc.), but also within an integrated motor function. Our eyes, respiratory muscles, tongue, etc. serve not only the function they are dominantly selected for, but they also participate in postural and locomotive functions. This is well observed in athletic performances in which maximal force or a precisely accurate movement needs to be accomplished. For example, to strike a ball with required force, a tennis player makes a movement with their extremity, which is linked to a face expression, movement of the tongue in the direction of the stroke, eye movement in the direction of the stroke, modification of breathing by diaphragm activity (a grunt, Valsalva) to facilitate trunk stabilization, position of the contralateral extremity into the opposite (reciprocal) position etc. It is an overall involuntary movement pattern that interlinks individual sensory modalities and, thus, it is related to the majority of medical fields.

This principle of modality integration within postural locomotor functions is a component of CNS development and it was established based on this principle. The fact that the described integration occurs at higher levels of control than the spinal cord and the brain stem is significant. This can also provide hypotheses regarding the effects of a number of alternative approaches whose justification of spinal cord and brain reflexology is not sufficient and is therefore substituted in clinical practice by alternative explanations. These central programs are organized above the brain stem level and can explain why functional pathologies become chained in predetermined sequences; why needle application in a single point has functional consequences in a completely distant area of the body including the visceral region; why an internal dysfunction does not only show reflexive response in the corresponding segment but in quite distant areas and in various afferent modalities (skin hyperalgic zones, changes in dermographism, muscle trigger points, joint restrictions, etc.); why respiratory function can be influenced through eye movement (eye movement automatically causes change in the breathing pattern); why breathing pattern changes with a change in hand position, and a number of other phenomena. The control system of the postural locomotor functions then provides us with a program that offers a completely new approach in the understanding of rehabilitation approaches. Clinical diagnosis focused on symptomatology organized within postural locomotor functions should not be considered an exclusive component of treatment rehabilitation but also a component of the remaining clinical specialties. I based the structuring of the General and Special Sections of the textbook on the function of the movement system in relation to individual clinical specialties. Therefore, I did not base them on diagnoses but rather on the functional manifestations of the disease. The General section of the textbook includes functional symptomatology and syndromology in dysfunctions of the nervous, musculoskeletal and internal systems and their clinical and laboratory examinations. The majority of treatment approaches are also presented in this context meaning that the treatment based on

symptomatology and syndromology dominates. In the Special Section of the textbook, treatment rehabilitation is presented in individual clinical specialties – neurology, orthopedics, internal medicine, oncology, gynecology and psychiatry. I purposely devoted less attention to occupational therapy, balneology and therapeutic agents (modalities) than these treatment approaches deserve. The reason is not to underestimate their value, but rather them already being reasonably available and sufficiently described elsewhere. In clinical approaches of the General Section of the textbook, I have extensively drawn from and expanded on a trend known worldwide as the “Prague School.” In rehabilitation, the roots of this school of rehabilitation can be found in the Neurology Clinic of Professor Henner whose concept of neurology was very broad and therefore included even vascular diseases and movement system diseases within neurological symptomatology. Treatment rehabilitation was promoted by K. Obrda who, together with J. Karpisek, wrote the first rehabilitation textbook for neurological diseases and organized an international congress in 1965. On the theoretical level, F. Vele and O. Stary played an important role. Stary and K. Lewit demonstrated the significance of painful functional deficits of the movement system. In this aspect, the large contribution of Professor J. Jirout who was the founder of functional radiology of the spine, needs to be remembered. Thanks to the work of Professor V. Janda, the basic significance of movement patterns was gradually underwood and the term “functional pathology of the movement system” was established. This presentation was even further strengthened by the influence of scientific studies and personal contact with D.G. Simons and J.G. Travell to whom we are grateful for providing detailed knowledge of muscle trigger points that also cause a limitation in joint mobility, so called joint restrictions. To understand the function of the movement system, individual dysfunctions, such as trigger points and joint restrictions, need to be understood in the context of the entire movement system, i.e. the laws of chaining of functional dysfunctions. The key to this understanding

was a better knowledge of the control function of motor skills. The new approach of treatment rehabilitation during movement reeducation is based on utilization of knowledge about human motor development. This new trend enriches the current empirical and physical approaches by findings originating from the control processes of the CNS that mature during motor development. Dr. Vaclav Vojta, whose work we are currently trying to continue, has a significant role in this approach. Professor Vojta also came from Henner’s department and his conceptualization is an inherent component of contemporary clinical rehabilitation practice. Unfortunately, the neurophysiological principle of the entire approach to developmental kinesiology is still not fully appreciated due to disagreements about indication and the type of application of the Vojta method. However, not many critics understand the true basis of the Vojta approach. What is essential and substantial is not only the way that rehabilitation of movement dysfunction is utilized, but also the fact that the concept of developmental kinesiology is combined with the neurophysiological view relying on the findings of neurosciences associated with the currently predominant physical mechanical views. In this book, I was also trying to respect and emphasize more certain general principles that condition the treatment effect, however, to convey the information in a written form is significantly limited for some of them. The respect for a comprehensive patient perspective is one such principle. The fact that human life occurs under specific biological, psychological, social-psychological, materialistically economic and ecological conditions needs to be implanted within the diagnostic, treatment and preventative approaches. Diseases and injuries cannot be viewed in isolation but rather need to be integrated within the context of such relationships because the treatment processes and rehabilitation are significantly affected by them. I also aspired to prevent this textbook from becoming a proponent of only one method but rather support a variety of rehabilitation approaches based on a person’s individual needs. The problem is that this does not allow for providing a clear-cut treatment approach for

movement dysfunctions because these approaches need to also be modified to the patient’s, and sometimes even the therapist’s, personality. In this context, protocols based on one uniform foundation outlining what and how much needs to be done cannot be implemented. These approaches are a method of choice, offering the option of finding individual solutions to how to effectively proceed and how to best modify the approach for a specific individual. It is almost impossible to express in written form some principles that significantly affect the results of a rehabilitation treatment. This, for example, includes the mutual trust between the patient and the rehabilitation specialist, which cannot be substituted by a client-expert relationship or by a work performance contract. The importance of effective communication, charismatic approach, suggestive appeal and one’s own experience developed by sensory perceptions are additional examples. Despite these limited options, I believe that this book will assist in better orientation in the broad field that rehabilitation truly is and thus will help fulfill the purpose for which it was written.

Pavel Kolar

INTRODUCTORY SECTION Pavel Kolář The term rehabilitation was first used in the United States during World War I. At that time, many soldiers with injuries with severe consequences were returning home from the war. An effort was made to assist them in returning to active life. For this reason, the Soldiers Rehabilitation Act was established in 1918 – a law about rehabilitation of soldiers. In continuation of this act, the Civilian Rehabilitation Act was established two years later – a law involving all citizens. In the Czech Republic, Professor Jedlicka pursued the care for soldiers returning from World War I. In contrast to the US, this care was not called rehabilitation and it was also not enforced by any law. In Europe, rehabilitation began to be promoted only after World War II. The occurrence of poliomyelitis served as a significant event in the 1940’s. During this time, an Australian nun E. Kenny substantially influenced the rehabilitation process of this illness from the acute and painful phase to the final stages. Back then, her methods were novel and quite controversial in Australia. They had a significant empirical influence on rehabilitation in the Czech Republic regarding a functional approach. Rehabilitation for poliomyelitis later became the main focus of treatment centers in Janske Lazne, where Dr. Frantisek Vele practiced, and significantly contributed to the development of treatment rehabilitation in the Czech Republic. A school for occupational therapy was also established at that time. Therefore, the first concepts of neurological rehabilitation focused on poliomyelitis and, for this reason, a pediatric rehabilitation department was established in the School of Neurology at the Charles University under the leadership of Professor Ivan Lesny. From a historical perspective, it is important to mention Professor Vaclav Vojta, the founder of developmental kinesiology, who paved the way for his original method and later a school at the same facility. His

neurostimulation method was originally developed mainly for patients with cerebral palsy; however, it has later shown much greater application. When the Neurology Department was established under the leadership of Professor Kamil Henner after World War II, Dr. Karel Obrda was delegated to head the first independent rehabilitation department. With the help of his friend, Dr. J. Karpisek, he had written the first, today referred to as “classic”, neurorehabilitation textbook. Shortly after World War I ended, a large rehabilitation institute in Kladruby was established by Dr. B. Karpin and based on the model of Dr. G. Gutmann from Stoke Mendeville in England. This rehabilitation institute provided rehabilitation for patients with quadriplegia. Important work was spearheaded by the head physician Z. Budinova who established a department for patients with hemiplegia in Prague–Krc with the goal of rigorous rehabilitation treatment starting in the acute stage. This department, however, later ceased to exist. In the 1960’s, the question of establishing an independent rehabilitation association came to the forefront. Considering the fact that rehabilitation is, at its core an interdisciplinary specialty, it was considered wise to establish it as a section of a neurological association, which would agree with this action. Therefore, Professor K. Obrda and Professor K. Lewit turned to the physiatry association, which was headed by Professor K. Prerovsky with a suggestion to jointly establish an association for physical therapy and rehabilitation. They intended to form a section for manipulation treatment within this association. This proposal was rejected and, in 1964, the Czechoslovak Medical Association of J. E. Purkinje permitted the formation of the Czechoslovak Rehabilitation Asso​ciation within the Czechoslovak Medical Association of J. E. Purkinje. The merger of rehabilitation and physiatrist associations occurred in 1992 and, currently, the Association for Rehabilitation and Physical Medicine

functions within the Czech Medical Association of J. E. Purkinje. In 1965, the International Rehabilitation Congress was held in Prague and organized by Dr. K. Obrda. The Institute for Continuing Education of Physicians, which was originally part of the School of Neurology, also played an important role in further development of rehabilitation. Professor Z. Macek, who was in charge of the Department of Neurology, appointed Professor Vladimir Janda to teach rehabilitation. Given his extensive academic and scientific skills, Professor Janda became the leading person in Czechoslovakian rehabilitation. In the 1960’s, the first rehabilitation department was established as a continuation of the Institute for Continuing Education for Physicians and Pharmacists at the Teaching Hospital in Vinohrady under his guidance. In the Czech Republic, rehabilitation is treatment-preventative in nature, which differs from other countries where rehabilitation is sought for mainly societal integration of persons with a physical disability. Professor Jan Pfeiffer and the Department of Rehabilitation Medicine at the School of Medicine at the Charles University are the pioneers and main proponents of this concept in the Czech Republic.

REHABILITATION CONCEPT AND DEFINITION Jan Calta, Pavel Kolář Rehabilitation is historically a term used with a broad meaning. It involves a coordinated and continuous effort of a society with the goal of a person’s social integration. This process involves healthcare, academic, vocational, social, technical, cultural, legislative, economical, organizational and political issues. Currently, rehabilitation of persons with a physical disability is referred to as comprehensive rehabilitation. It is defined as a mutually interlinked, coordinated and specific process whose main objective is to minimize the direct and indirect consequences of permanent or long-term physical disability of an individual with the goal of their optimal integration within the society.

Definition of Rehabilitation According to the World Health Organization (WHO) In 1969, the WHO defined rehabilitation as a “combined and coordinated utilization of medical, social, educational and vocational means for training or restoration of the highest degree of functional capability.” This definition specifically does not include that rehabilitation should be divided into treatment, social, academic or vocational, but it is a coordinated utilization of given means based on the need. In 1981, the WHO expanded this definition: “rehabilitation contains all means directed at decreasing the pressure that a disability and subsequent handicap cause and attempts a social integration of the involved individual”. Physical Medicine and Rehabilitation Rehabilitation and physical medicine is a specialty that addresses treatment rehabilitation of persons with a health disability to the full extent with a special focus on continuity in vocational (educational) and social rehabilitation with the goal of such improvement of their health condition that would allow integration of the involved individual back into an active social life. Rehabilitation and physical medicine is an independent scientific medical specialty interdisciplinary in nature whose concept was developed in 2001 and modified to a proposed concept in 2005. The Target Group of Comprehensive Rehabilitation The target group of comprehensive rehabilitation is formed by individuals with a health disability without an age limitation who possess or develop a limitation in either activity or integration within the society as a result of a congenital defect, disease or an injury. These are individuals whose health problems limit or even prevent them from reaching an optimal level of independence or education and who, as a result of their medical condition, are limited in their ability to work. These are individuals with permanent residency in the Czech Republic or individuals whose stay in the Czech Republic is based on their level of permanent residency. The conditions and

extent of availability of individual areas of comprehensive rehabilitation is guided by the corresponding laws and regulations, depending on the level and severity of the person’s health involvement. Current State of Providing Rehabilitation Based on the type of utilized means and rehabilitation actions, rehabilitation can be classified across the following areas: Treatment (medical) rehabilitation; Social rehabilitation; Rehabilitation in the school system; Vocational rehabilitation. This classification of rehabilitation is only done for didactic reasons. In a practical setting, the applied form of rehabilitation cannot be divided into individual areas because it must always involve combined, mutually interconnected and coordinated utilization of all given means based on the need.

TREATMENT (MEDICAL) REHABILITATION Treatment rehabilitation is an integral part of healthcare and includes a complex of rehabilitative, diagnostic, therapeutic and organizational actions directed toward reaching an individual’s maximum functional potential and establishing conditions for its achievement. Treatment rehabilitation can be provided in the form of inpatient care, outpatient care and specialized care in treatment institutions, including balneologic centers. It should be initiated in all areas of clinical specialties, including an intensive care unit (ICU) during the period of acute inpatient medical care. When treatment rehabilitation is administered in a timely manner, up to one third of individuals after a severe injury or illness utilize only treatment rehabilitation and do not even enter the comprehensive rehabilitation system (social, vocational, educational). They return back to the original environment and occupation, thus to the original

quality of life. If the patient’s condition is so involved that the rehabilitation methods comprise the majority of their medical care, then the patient is transferred from an inpatient acute care to an inpatient rehabilitation department if such a department exists in their hospital. The inpatient department of early rehabilitation care allows the patient to undergo additional needed therapy that the original department was unable to provide, which includes treatment rehabilitation with continuation to other areas of rehabilitation. Rehabilitation and its approaches (a short and long-term rehabilitation plan) is provided by a team of individuals – rehabilitation physicians, nurses, physical therapists, occupational therapists, psychologists, social workers, speech therapists and special education teachers based on the need. Most procedures of treatment rehabilitation are covered by public health insurance. However, complete statistical data is not available, only partial statistics about the costs related to treatment rehabilitation are available. The rehabilitation treatment plan is based on the short and longterm rehabilitation goals. The short-term treatment rehabilitation plan of care establishes specific treatment approaches and their coordination in a time-limited period whose duration depends on the health condition and its acuteness, or ondisease progression. Usually, treatment duration does not exceed 3 months or the designated treatment time in a specific facility. The long-term rehabilitation plan of care establishes additional medical approaches necessary to successfully fulfill the process of treatment rehabilitation. It also establishes conditions for transitioning to other components of comprehensive rehabilitation. A rehabilitation team conference consisting of the above mentioned members establishes a short-term plan of care. Their conclusions are based on objective testing, present course and all other findings

relevant to the determination of a long-term prognosis. The main shortcomings in treatment rehabilitation can be seen especially in its narrow focus (persistent focus mainly on modalities), in its often insufficient extent of treatment as well as in the lack of interconnection of its components. Early inpatient treatment rehabilitation is very often initiated late and, because of thelack of inpatient departments, early treatment rehabilitation is performed mostly through physical therapy in an acute inpatient setting in clinical departments. Also, the continuity of administration of treatment rehabilitation is insufficient in an outpatient setting as well as in an institutional setting (beds in subsequent care). For such reasons, a strict application of the phasic model would be beneficial for the organization of a rehabilitation process, which has been successfully applied in Germany for patients with neurological diseases. This model covers rehabilitation care from the acute stage to the integration phase. The phasic model guarantees (and this is its main benefit) an early initiation of rehabilitation (already during the acute phase of the disease), ensuring continuity and adequate quality of the rehabilitation process. It also allows not only the much needed interconnection of the individual rehabilitation areas but also of the individual facilities. It can be stated that, in the Czech Republic, this model functions well for patients with a spinal cord injury, although until recently, phase B was not completely addressed (see below). With the establishment of spinal cord units, a significant qualitative shift in the care of such patients occurred. This model is insufficiently utilized for patients following craniocerebral injuries and cerebrovascular accidents. Phasic Model of Treatment Rehabilitation Phase A – acute phase of an illness, this phase occurs in the acute inpatient setting, including the intensive care unit. Phase B – early rehabilitation phase (in this phase, intensive care needs to be administered if needed; spinal cord units are an example of well-organized care in this phase in the Czech Republic).

Phase C – rehabilitation phase in which collaboration with a patient occurs (in the Czech Republic, this care is provided in acute rehabilitation settings and in rehabilitation treatment centers). This phase is defined as a phase of early rehabilitation (post-primary rehabilitation). In this phase, the patient requires treatment as well as rehabilitation care. However, they no longer need intensive care and artificial ventilation. In this phase, next to neurorehabilitation treatment, the focus is on achieving the highest level of independence in activities of daily living. Phase D – rehabilitation following the completion of phase C (the main goal of this phase includes reduction of care taking and allowing social re-integration; in this phase, the extent of residual functional deficits needs to be identified). Mental deficits are at the forefront of therapeutic goals. Phase E – rehabilitation phase following the completion of intensive treatment and vocational rehabilitation (in this phase, various forms of prophylaxis are used that emphasize the maintenance of the achieved state and prevention of onset of secondary complications). Phase F – rehabilitation phase in which such an approach is implemented that can maintain the patient’s state from a long-term perspective (this phase pertains to patients who continue to exhibit severe functional deficits despite all care, for example, patients with apallic syndrome). From the perspective of the phasic rehabilitation model, the utilized approaches can be classified into two basic areas that have their methods. These are approaches that focus on the following: Influencing a functional deficit; Eliminating the effects of a functional deficit. Approaches Aimed at Influencing a Functional Deficit The goal is to assist with the patient’s maximum possible recovery and prevent early and late complications through rehabilitation care. Here, the ability of nerve tissue regeneration and neuroplasticity is utilized. The following are the main means to achieve the maximum reduction

in a functional deficit: Physical therapy; Speech therapy; Neuropsychology; Occupational therapy. Approaches Aimed at the Elimination of the Effects of a Functional Deficit These include approaches that attempt to eliminate the effects of a functional deficit on the patient and their social support, or achieving such a state that allows the patient to become as independent as possible or be employed and live with their family. A number of conditions need to be ensured for this to occur – barrier free living, the possibility of requalification, assistance services, etc. The treatment rehabilitation process is limited by time. Its completion is based on the conclusions from ongoing and final assessments, establishing and determining the dynamics of the patient’s functional potential. A patient’s active cooperation is the main prerequisite for the administration and success of treatment rehabilitation. In some cases, when the etiology of the disease is not known or the options of causative treatment are limited, the purpose of the specialty fields is to maintain functional abilities and to slow down the progression of the disease or prevent worsening of the current condition. Individual Specialties of Treatment Rehabilitation Physical Therapy Physiotherapia – (from Greek fysis – force of nature and therapeia – treatment as providing a service) treatment care with a therapeutic approach utilizing various forms of energy (including movement energy) for a treatment influence on pathological states. It mainly deals with the movement system and its analysis by specific diagnostic approaches and the options of how to influence its deficits and deficits in other organ systems. The basic methods include kinesiotherapeutic methods. As a methodical-therapeutic specialty, it is utilized in all

fields of medicine similarly to pharmacotherapy, surgical interventions, dietary therapy and psychotherapy. Occupational Therapy It is a therapeutic specialty and is a vital part of a comprehensive multidisciplinary treatment approach for many diagnoses. Rehabilitation Engineering It is a technical, interdisciplinary field that is concerned with providing the patient with technical aids with the goal to allow for a more complete integration into the society with maximum possible satisfaction of living needs and direction toward the most valuable and satisfying lifestyle. Rehabilitation engineering is a term that integrates within itself fields dealing with individual options of application of technical tools for all types of health injury and interrelated context. Physiatry Physiatry or physical medicine is a medical field that studies physical stimuli and utilizes them in healthcare practice for prevention, diagnosis and treatment. The physical stimuli used include movement, mechanical, thermal, chemical, electric, light or acoustic energy and their combination. Physical Agents (Modalities) Physical agents utilize these physical stimuli for treatment. It is utilized in all specialties of medicine as a methodical-therapeutic field similarly to pharmacology, surgical treatments, dietary therapy and psychotherapy. Balneology Balneology is a specialized field characterized by utilization mainly of natural resources of physical stimuli usually associated with a certain area. Balneotherapy Balneotherapy uses natural resources of physical stimuli for spa treatments. These include natural medicinal and mineral waters, peloids, hot-spring gases, climatic and meteorological elements.

Musculoskeletal Medicine It deals with the diagnosis and treatment of functional limitations within the movement system, which either occur individually or in connection with structural diseases. For this purpose, it uses its own diagnostic and therapeutic approaches. It ensures differential diagnosis of all diseases that manifest with functional limitations and involvement in the movement system. During a patient’s rehabilitation, therapeutic approaches that fall within the specialty of psychology (most often neuropsychology) and speech therapy cannot be neglected.

SOCIAL REHABILITATION Social rehabilitation is a process, in which a patient with a long-term or permanent health disability undergoes training of skills needed to achieve maximal independence and self-care while taking into consideration their health condition with the purpose of the highest level of social integration. After 1989, in the Czech Republic a significant development in social rehabilitation occurred even without the existence of the needed legal environment. Non-federal, non-profit organizations contributed to this development, specifically civic associations of individuals with a disability, certain medical facilities (specialized treatment institutions) and foundations that began to operate centers, in which individuals with various handicaps had the option to learn basic skills of self-care, independence, orientation, etc. These centers also provide such individuals with specialized counseling services. Social rehabilitation for patients with a disability is provided generally on an outpatient basis; however, if the patient’s condition requires an intensive course, it can also occur in an inpatient form.

TOOLS OF School-based REHABILITATION Education of children and students with disability occurs through various assistive means. These are provided beyond the framework of

educational and organizational arrangements given for the education of children and students without a disability. Assistive arrangements help decrease the disadvantage of individuals with disability in the approach to and administration of education. The new curriculum allows for differentiation and individualization of the education process, taking into consideration the educational needs of individuals with disability. The goal is to achieve the highest degree of education while respecting the children’s individual needs and capabilities, encourage their independence and engagement in all common activities of social life. Currently, the area of education of individuals with disability ensures adequate conditions to satisfy the special educational needs of preschool children, school-age children, high school students as well as students of higher specialized education. Education of individuals with disability occurs with consideration of their educational needs and preferences in several different organizational forms. There are indepen​dent schools for children or students with disability, or separate classrooms for such children and students. The main tendency is to integrate the individuals with disability into mainstream schools.

TOOLS OF VOCATIONAL REHABILITATION Vocational rehabilitation deals with acquiring and maintaining appropriate employment for a person with a disability and it is usually provided through an employment agency. Vocational rehabilitation serves as a means of an active employment strategy to increase opportunities of persons with a disability in the job market. The inclusion of a person with a disability into the process of vocational rehabilitation is based on the assessment of their health condition, work appropriateness, achieved education, acquired skills and the current job market environment. The assessment of work integration of patients with a disability and patients with temporary disability who are referred to vocational rehabilitation by their treating physician is one of the conditions for

beginning vocational rehabilitation. To accomplish this, employment agencies cooperate with vocational rehabilitation centers or, based on a written agreement, can appoint any other legal or physical person, meaning they can also utilize cooperation with centers of treatment rehabilitation. The aforementioned centers are part of healthcare facilities. Based on the report from a specialized group established within every employment agency, an individual vocational rehabilitation plan is designed for each applicant. Essentially, it is a time line to complete the established approach leading to vocational placement. Each individual portion can contain the following activities: counseling activities, theoretical and practical preparation for employment or other money earning activity – preparation for future occupation, work, specialized requalification courses, arranging and maintaining employment, changingan occupation, establishing appropriate conditions for job performance or other money earning activity.

PREVENTATIVE ROLE OF REHABILITATION Rehabilitation plays a significant role in the prevention of a number of diseases (primary prevention). The goal of rehabilitation is to make all active persons active who are temporarily, long-term or permanently physically, mentally or psychologically disabled and cannot overcome this health disability or its consequences, or possibly are at risk from such a disability and need help from a specialized environment. In this case, it is secondary and tertiary prevention of the consequences from these diseases, injuries and congenital defects. Prevention in the rehabilitation process involves three phases – primary, secondary and tertiary (Tab. 1). 1. Primary phase – prevents disease onset; 2. Secondary phase – the disease develops, focus is on prevention of secondary (side) effects of the primary disease; 3. Tertiary phase – impairment develops, it leaves more or less permanent consequences (disability) that cannot be decreased through economic, social and technical arrangements (handicap).

Tab. 1 Phases of prevention in the rehabilitation process

FUNDAMENTAL PRINCIPLES OF REHABILITATION Establishing optimal conditions for integration of persons with a physical disability into normal social and economic life or overcoming or removing barriers causing exclusion of such individuals from the society is the main goal of the comprehensive rehabilitation system. The comprehensiveness in rehabilitation means mainly the timeliness and continuity of the individual areas (treatment rehabilitation, social rehabilitation, rehabilitation in the school system and vocational rehabilitation). Providing rehabilitation in its entirety is important not only for the individual with the disability themselves, but also for the entire society. By effective utilization of all available means of rehabilitation and by practice of needed skills, the individual with a disability becomes less dependent on assistance from others and, in many cases, is able to adequately join the work force, which means not only a greater extent of economic independence but also facilitating their social involvement. Providing rehabilitation must follow universal and important principles in all areas, including the following: Timeliness – early initiation of rehabilitation is a basic prerequisite for successfully reaching its purpose and leads to the needed activation and motivation of a person with a disability when

addressing their situation and their social integration. Comprehensiveness, continuity and coordination – basic attributes of an effective rehabilitation. An absence of any of them can lead to system dysfunction and non-purposeful or duplicate financial spending. Availability – the rehabilitation system must ensure the widest availability of information about rehabilitation and approximate its mediation and administration to individuals in need. The basic tasks in this area should be fulfilled by individual providers. Individual approach – the delivery of rehabilitation or the administered rehabilitation procedures must be adequate to the specific needs of a person with a disability. Multidisciplinary assessment – in certain cases, mainly in individuals with more severe disability, the individual approach needs to be based on the results of a multidisciplinary assessment, which is a significant means for establishing the corresponding rehabilitation procedures. Cooperation – during rehabilitation, all rehabilitation providers need to collaborate closely. A component of effective organization of the entire complex of services and procedures within rehabilitation includes the fastest and widest inclusion of persons with disability (people who suffered an injury, disease, congenital or acquired defect) into all normal social and economic activities. At the same time, maximum emphasis is placed on their independence and work integration. White Book on Physical and Rehabilitation Medicine in Europe This book outlines the position of physical and rehabilitation medicine in Europe. It defines the specialty, its functions, qualification of the specialists and the relationship toward other medical disciplines and allied health professions. The book should also ensure that physical and rehabilitation medicine is viewed as a European specialty that can be practiced by highly qualified specialists adhering to correct standards based on scientific findings and within the context of different national practices. In this context, the education and skills of the specialists in physical and rehabilitation

medicine are described in more detail. Also presented are fundamental principles of specialized rehabilitation that allow for easier comprehension of the mechanisms of function of physical and rehabilitation medicine to politicians, healthcare managers, physicians and other non-medical specialties. Finally, it outlines a way in which they could assist in the pro​cess of complete integration of people with a physical disability into society. The book was prepared by the Section of Physical and Rehabilitation Medicine UEMS (Union Européenne des Médecins Spécialists) and its authors include the President of the Section and the Chair of the Committee for Professional Practice and the President of the European Academy of Rehabilitation Medicine. The book was approved by four organizations representing the specialty as a whole in Europe: the Section of Physical and Rehabilitation Medicine, the European Union of Specialized Physicians, the European Academy for Rehabilitation Medicine and the European Society for Physical and Rehabilitation Medicine whose participation adds authority to the book. The White book is available at the website of the Section at www.euro-prm.org or through the general secretariat of UEMS Section as well as at the website of the Journal of Rehabilitation Medicine (www.medicaljournals.se/jrm).

INDIVIDUAL TYPES OF REHABILITATION SETTINGS Outpatient Settings Providing Rehabilitation Outpatient treatment is provided in physical medicine rehabilitation clinics and in outpatient rehabilitation departments. Other independent facilities include private practices providing physical therapy based on their clinic specialty and on the qualifications of the healthcare providers. These clinics function based on referrals from physicians, and on an ongoing interaction with a physician. All-day outpatient rehabilitation is provided by a rehabilitation daycare. It can function in both settings of rehabilitation (outpatient

or inpatient) or can work independently. A rehabilitation daycare is used to ensure rehabilitation of patients whose health condition requires regular medical care without the need of hospitalization. It can also provide medical care associated with a short-term inpatient stay. Rehabilitation centers are outpatient facilities serving more than 100,000 patients, providing the full extent of treatment rehabilitation – including functional ability testing, psychological assessment and social inquiry with the ultimate goal to address all other rehabilitation components. The centers provide care to all patients with a health deficit or disability (regardless of etiology) who require rehabilitation. Rehabilitation centers also ensure continuity of other components of comprehensive rehabilitation for persons with permanent disability. The center can also be established as part of an inpatient rehabilitation facility. All outpatient facilities also provide and coordinate rehabilitation in a home setting. Inpatient Settings Providing Rehabilitation Inpatient settings providing treatment rehabilitation can be divided into acute inpatient and subacute (rehabilitation) inpatient. Acute Care Inpatient Rehabilitation Setting Acute care inpatient rehabilitation settings are established at hospitals. They provide early rehabilitation to patients whose majority of treatment requires rehabilitative approaches, usually immediately following an intensive and acute care in the hospital. The inpatient rehabilitation department ensures rehabilitation in a patient’s own bed, beds in other departments or on an outpatient basis. These include: Rehabilitation clinic. Provides rehabilitation within a teaching hospital, theoretical and practical education in rehabilitation, methodological leadership in the field and research within the field. It is part of a teaching hospital and the School of Medicine. Inpatient rehabilitation departments in acute care hospitals. It is

recommended that they have 30 beds per 100,000 residents. Inpatient Subacute Care Rehabilitation Facilities They provide subacute and long-term care for patients whose rehabilitation approaches are the dominant part of the treatment program. The patients can be expected to actively cooperate during treatments in individual clinical specialties regardless of their disease. It is recommended that they have 200 beds per 100,000 people. The following facilities belong to this category. Specialized Treatment Facilities This is a treatment-rehabilitative facility (such as a department in a hospital or a specialized treatment institute) that falls within the complex of inpatient subacute care for prolonged rehabilitation (approximately up to 3 months) for all medically stable health conditions with long-term (longer than 3 months) or permanent functional limitation (loss of function). A subacute and long-term rehabilitation facility should be estimated at 70 beds per 100,000 people and are divided into two types of facilities: Specialized treatment institute for general rehabilitation is a treatment facility for institutionalized rehabilitation of patients from surrounding areas. A specialized treatment institute is a treatment facility for a defined number of actual diagnoses, which this facility is specifically equipped for. Specialized balneologic treatment institutions. For balneologic rehabilitation care, it is recommended that they have 130 beds for adults and children per 100,000 residents. In contrast to the previously mentioned facilities, these facilities also use natural medicinal resources or traditional treatment approaches linked to a certain specialty. EMPLOYEE EDUCATION AND FIELD OVERSIGHT Oversight of the rehabilitation field is ensured through a specialized Association for Rehabilitation and Physical Medicine. Physicians become board certified in Rehabilitation and Physical Medicine after a 5-year preparation. Physical therapists and occupational therapists are graduates of a 3-year Bachelor’s degree and a subsequent 2-year

Master’s degree. Currently, only graduate education exists; however, some phys​ical and occupational therapists are graduates of secondary schools or vocational graduate schools who have been working in the rehabilitation field prior to the current requirements.

CLASSIFICATION OF FUNCTIONAL CAPABILITY, DISABILITY AND HEALTH In the majority of diseases or injuries, establishing the diagnosis is not difficult. However, the limitations and consequences that accompany the established diagnoses pose a larger problem. Many diseases or post-injury states can have various consequences and, in contrast, the same consequences can be caused by various diagnoses. For example, in a cerebrovascular accident, mobility deficits can be either mild and temporary or severe and permanent. A similar situation occurs in other diagnoses (multiple sclerosis, brain injury, etc.). To overcome this issue, a classification was developed that is a continuation of the etiology-pathology-manifestation line, as in the International Classification of Diseases (ICD). Impairment, Disability, Handicap – Explanation of Terms An essential step in establishing the classification of functional abilities was the development of the follow​ing chain: disease – impairment – disability – handicap. Disease manifests itself morphologically and functionally by impairment. Impairment (health) is a loss or abnormality of an anatomical structure or psychological and physiological functions. Of course, it can be permanent or temporary. To a certain extent, impairment begins to limit a person in their activities. A person cannot perform a certain common daily activity or activities; that is, their performance and activity decrease and become limited – disability. The performance can be decreased in its foundation, duration or quality. Therefore, limitation based on health impairment reflects to the external environment in regards to the abilities to move and orient within it. The societal consequences of this limitation

depend on the surrounding society and to what extent the society itself and the external environment are willing and able to accommodate the individual(s) with disability. The effect on their function within society is known as a handicap, or a disadvantage – a societal disadvantage. Lately, this term was replaced in international classification by the term participation. Participation expresses the way and extent to which a person is integrated into various life situations regarding their limitation, activities, medical problems and other factors. Participation can be, once again, limited in its foundation, duration or quality. Model of International Classification of Impairment, Disability and Handicaps (ICIDH) The above mentioned terms were used in the International Classification of Impairment, Disability and Handicaps. The first version of ICIDH was published by the World Health Organization in 1980 with a subtitle “A Manual of Classification Relating to the Consequences of Disease”. This classification is a continuation of the International Classification of Diseases by the WHO (International Statistical Classification of Diseases and Related Health Problems), whose 10th edition (ICD-10) is currently being used. To understand the entire problem, the three aforementioned basic terms (impairment, disability, and handicap) were defined, which are a continuation of a disease or injury identification. In this way, the first working version was drafted in 1980. The publication received significant attention worldwide. However, the terms were criticized, especially by organizations dealing with individuals with disabilities or handicaps. The term rehabilitation was faulted for its excessive medical view. Also, the terminology was not agreeable to the individuals with disability. For example, the term disability gradually gained a derogatory meaning. Unfortunately, this is an old semantics problem in which terms denoting disease can also be used in name-calling (cripple, stupid, idiot, etc.). Despite the criticism, this classification was used in several European Union Countries (for example, France, Germany, Sweden) for various

purposes. For example, in the healthcare insurance system for assessment of health disability and from it, implicated disability or social security claims, social services, assistance with employment placement, etc. Based on expert suggestions from the entire world and based on the changes toward neutral terminology, the next working version of the International Classification of Impairments, Activities and Participation (ICIDH-2) was published in 1997. The term disability was replaced by the term activity and the term handicap by the term participation. A new dimension of environment was established that assesses in greater detail, the societal environment as either facilitative or restrictive. In 1999, another version was published (ICIDH-2 Beta-2 DRAFT) – International Classification. In this version, one of the last definitions of rehabilitation according to the WHO is listed. “Rehabilitation includes organizational procedures and services directed toward improvement, maintenance and prevention of worsening physical, psychological, social and work activities and assisting persons in achieving their full potential andoptimal degree of independence.” Then, the WHO came up with the International Classification of Functioning, Disability and Health – Prefinal Draft Full Version in December 2000. The final version was being processed until April 2001 and it is called the “International Classification of Functioning, Disability and Health” (ICF). This last version was discussed in May 2001 at the World Health Assembly in Geneva and was then accepted as final by the member countries of the WHO. In Florence in 2000, the European Union agreed with the WHO and accepted this classification as a foundation for rehabilitation politics. The International Classification of Functioning, Disability and Health became the fundamental, ideal and leading tool for implementation of rehabilitation. Changes in titles of individual versions are the result of a strenuous search for the most objective and clear concept, and thus also the most comprehensible definition of individual terms. The ICF also uses an alphanumeric system but, in contrast to the ICD, lower case letters are used to denote the main terms. Further, it utilizes up to

a four-number numeric order in the form of a detailed list of values with well formulated definitions. In the Czech Republic, the first version was translated and published in a supplement of the Rehabilitation journal in 1984, the second version in 1998 and the last version in 2008. The classification terminology was accepted by the United Nations Organization and it has been integrated into “The Standard Rules of the Equalization of Opportunities for Persons with Disabilities”, which was approved by the General Assembly of the United Nations Organization at their 48th session on December 20th, 1993. The International Classification of Impairments, Disability and Handicaps provides a suitable tool for integration of internationally accepted human rights in national legislatures. ICIDH-2, ICF are usable for a wide spectrum of various applications, for example, in social security, healthcare management and operations and epidemiological studies of populations at local, national and international levels. It provides a framework for information that can be applied in healthcare including prevention, health assistance, improving participation by removing or decreasing social barriers and dependence in arrangements in the area of social support and assistance. It can also be utilized for studying health care systems for evaluation as well as the formation of politics. The aforementioned classification understands health care services and programs at a local, community, state and national level that determines interventions and provides assistance for an individual based on their physical, psychological and social well-being through the following: Support of health and services during disease prevention; Primary and acute care; Rehabilitation; Long-term care and services. The services are financed from public or private sources and are provided ona short-term, long-term, periodical or one-time basis. They are provided in various facilities, including community, home, school, work, hospital, clinics and residential facilities for individuals with a

health disability. The International Classification of Functioning, Disability and Health was developed to register and organize a wide amount of information about health and conditions that relate to health. It became the underlying concept and a leading tool for the implementation of rehabilitation. The classification is organized based on components, domains and qualifiers. Components 1. Body functions: They are denoted by a lower case letter b; they are physiological functions of body systems including psychological functions. 2. Body structures: They are denoted by a lower case letter s; they include anatomical body parts – organs, extremities and their parts. If a body function or a body structure is atypical and presents with significant deviation or a loss, the term impairment or phrase impairment of given function or structure is used. 3. Activity and participation: They are together denoted by a lower case letter d because if the activity is limited or participation is restricted, it is a disability. Activity is performing a task or an activity by a person. Participation is inclusion of a given activity into life or social situation. Activity has its limitations – it is limited by the problems that a person can have when performing an activity. However, this does not make the person disabled, but rather their health (health condition) is limited in the given domain (see below). Participation can be limited or they can have restrictions that the person can often experience when participating in life situations. The term “handicapped” has been abandoned. For example, an evaluated person XY is in a given situation restricted in a certain domain. The entire classification does not assess the person, but various situations within their health condition. Classification does not intend to establish predetermined outlining of schematic categories that would devalue the given individual. Every person can have various health issues in various domains but other domains can be problem-free or above average. Thus, this is not an evaluation of a

disease but rather of health. 4. Environmental factors: They are denoted by a lower case letter e (environmental) and include physical and social factors, people’s attitudes and locations where people live. Environmental factors can be facilitative or restrictive. 5. Personal factors: These include internal factors affecting a person’s functional abilities, personal qualities independent of impairments and the possibility of overcoming them. They denote the individual’s characteristics. This component has so far not been completely outlined and will require a number of scientific studies. Domains Domains are defined units pertaining to anatomical structures, physiological functions, actions, tasks (activities and participations) or areas of life. Domains are formed by units inside each component and across individual components (b3- function of voice and language, d1 – learning and knowledge application, s7 – structures pertaining to movement, etc.). Qualifiers Qualifiers specify the extent and quality of individual values, components, and domains and their scale is the same for all components. Qualifiers are coded as one or more numbers with a period in each code. The first qualifier determines the severity of involvement. Behind each period, a number between 0 and 4 is listed, which provides qualification according to the effects of the involvement. 0 – no problem (absent, negligent), 0–4%; 1 – mild problem (small, slight, low), 5–24%; 2 – moderate problem (slight, bearable), 25–49%; 3 – severe problem (high, extreme), 50–95%; 4 – complete problem (total), 96–100%. Based on the domains, the degree of involvement is listed, for example, no impairment, moderately decreased activity or severe

restriction in participation. If it involves an environmental factor e, the values that in this case denote the degree of the barriers, also include + or – according to whether the environment is facilitative (completely barrier-free) or restrictive (involves barriers). If an impairment of a certain structure s is being coded, the second and third qualifier also needs to be included. The second qualifier determines the character and extent of the body structure changes: 0 – structure is not altered; 1 – complete absence; 2 – partial loss; 3 – added part (something more) 4 – inadequate size; 5 – disrupted continuity; 6 – positional deviation (position, alignment); 7 – qualitative changes in structure including accumulation of fluid(s); 8 – other; 9 – non-specified. The third qualifier is topographical and serves for determining location. It can also have more numbers, for example, left, distally – 27, for example: 0 – more than one organ; 1 – right; 2 – left; 3 – bilateral; 4 – frontal; 5 – dorsal; 6 – proximal; 7 – distal; 8 – other; 9 – non-specified (non-applicable). Topographical determination can sometimes lack detail. Then, a

fourth degree of coding detail needs to be used, in which the individual structures are divided into relatively small anatomical segments or formations. The entire classification can be used in four degrees of coding detail. Each component always begins with a corresponding lower case b, s, d, or e. Then, only the number of the section describing a given component can follow: s7 – structures related to movement, e2 – natural environment and environmental changes developed by age, b1 – mental functions, s2 – eye, ear and corresponding structures, etc. Also, the term first degree item can be used. It is always followed (after a period) by a qualifier number. For example, b1.0 means mental functions are normal, without problems. Other, more detailed assessment according to a decimal classification consists of three numbers. Examples: Mental function b1 is superior to a lower term that includes, for example, awareness functions b110, b134 sleep functions, psychosocial functions, etc. In this context, the term second degree unit is also used. It is followed by a number or numbers of qualifiers. Even a more detailed level according to the decimal classification is a four number classification. Examples: b1142 – orientation in regards to persons, e1251 assistive products and technologies for communication. The third degree unit is not listed for all values but the user can form it after detailed assessment. The qualifier values always need to be at the end. A fourth degree unit also exists, which contains five numbers and is developed only for certain values.

REFERENCES Calta J. Obor FBLR po pěti letech změn v českém zdravotnictví. Rehab Fyz Med 1994; 1: 33– 36 a 2: 68–75.

Calta J, Kadlec M. Postavení rehabilitace v rámci zdravotní péče koncem 20. století. Eurorehab 1993; 3(2): 86–92. Calta J, Machálek Z, Vacek J. Základy fyzikální terapie pro praxi.Praha: REFOR 1994. Jankovský J. Ucelená rehabilitace dětí s tělesným a kombinovaným postižením. Praha: Triton 2001. MKF – Mezinárodní klasifikace funkčních schopností, disability a zdraví. Praha: Grada Publishing 2008. Obrda K, Karpíšek J. Rehabilitace nervově nemocných. Praha: Avicenum 1968. Pfeiffer J. Ergoterapie II. Učebnice pro zdravotnické školy. Praha: Avicenum 1990. Reed KL, Sanderson N. Concepts of Occupational Therapy. 3rd ed. Baltimore: Williams and Wilkins 1992. Turner A, Foster M, Johnson SE. Occupational Therapy and Physical Dysfunction: Principles, Skills and Practice. 4th ed. New York: Churchill Livingstone 1996. Votava J, et al. Ucelená rehabilitace osob se zdravotním postižením.Praha: Karolinum 2005. Votava J, et al. Základy rehabilitace. Praha: Karolinum 1997. Welter FL, Schönle PW. Neurologische Rehabilitation. Stuttgart: Gustav Fischer 1997. WHO International Classification of Functioning and Disability ICIDH-2. Beta-2 draft, 1999. WHO International Classification of Functioning, Disability and Health (ICF). Geneva: WHO 2001; 322: 1115–1117. WHO International Classification of Functioning, Disability and Health, Prefinal Draft Full Version, December 2000. WHO International Classification of Impairments, Activities and Participations. A manual of Dimensions of Disablement and Functioning. ICIDH-2. Beta-1 Draft for Field Trials, June 1997.

TREATMENT REHABILITATION – DIAGNOSTIC AND THERAPEUTIC APPROACHES Treatment rehabilitation is focused on symptomatology of an illness. The basis for various treatment approaches are not diagnoses, but rather the functional signs of an illness, such as changes in movement patterns, muscle tone, balance dysfunction, muscle weakness, decreased coordination, poor stereognosis, athetoid movements, etc. Physical therapy, occupational therapy, speech therapy, neuropsychology and prosthetics are the primary professional areas focused on influencing functional deficits. The goal is to achieve a patient’s maximum medical improvement while avoiding early and late complications. Treatment rehabilitation needs to be started as soon as possible, i.e., during the acute phase of an illness. In the acute phase, the timely and smooth initiation of therapy is very important for the patient. From the perspective of treatment, therapeutic concepts can be categorized into two main fields: 1. Rehabilitative care – treatment focused on pro​phylaxis of secondary complications (pneumonia, pressure ulcers, contractures, heterotypic ossifications, etc.) that affect a patient during their illness. 2. Treatment rehabilitation focused on restoration of a functional (frequently motor) deficit – applies various physical therapy approaches based on neurophysiology principles. Each of these approaches uses various forms of facilitation and/or inhibition techniques. Other disciplines include occupational therapy, speech therapy, neuropsychology and rehabilitation engineering.

REHABILITATIVE CARE Pavel Kolář The focus of rehabilitative care is to prevent secondary complications as much as possible. In the absence of physical therapy treatments focused on prevention of secondary changes, the outcomes of therapy are considerably worse and the consequences from secondary complications are often more taxing on a patient than the primary illness. In an effort to prevent secondary complications, the initiation of an individual, functionally-based treatment protocol is often delayed. The main therapeutic approaches include patient repositioning, gradual verticalization and mobilization.

REPOSITIONING Indications for Repositioning Regular and intensive repositioning is performed with patients who exhibit, for various reasons, limitations or a complete loss of mobility or a decrease in sensation in certain body parts. Lack of sensory function, which often accompanies motor loss, can be further exacerbated if a patient is immobilized in bed without changing position for several hours. A mere change in position gives rise to diverse stimuli that might assist in the return of sensory function, and subsequently motor function. Correct repositioning has a vital impact on the patient’s further functional recovery. The focus of repositioning is on segments with either a complete loss of active movement, segments with partially limited mobility displaying a tendency of staying in one position, or when the position of a given segment can be considered pathological. Repositioning is performed into precisely defined positions (see section on Types of Repositioning). Repositioning helps with relief of pressure on the skin and with improving circulation in different body parts. Therefore, repositioning acts in both the prevention and treatment of pressure ulcers. Furthermore, it prevents muscle atrophy, contractures and

joint deformations, eliminates pain and improves psychological wellbeing. Repositioning should not only be the main focus of the physical therapist, but rather all personnel involved in the care of a patient should participate in correct repositioning strategies. Principles of Repositioning The position of all segments must be comfortable, pain free and it needs to allow for possible residual movement. During repositioning, it is important to adhere to precisely defined procedures. A patient’s position must be adjusted and corrected every 2–3 hours, even at night. During repositioning, potential areas at risk should be examined, such as areas with a thin layer of muscles or subcutaneous fat tissue such as the areas of skin over bony prominences (i.e., occiput, spine of scapulae, sacrum, anterior superior iliac spine, greater trochanters, ankles, elbows). The patient needs to lie in a moisture-free bed. Correct positioning of a permanent bladder catheter or epicystostomy and IV lines must be checked. A transfer sheet is used during patient transfers to help the personnel with moving the patient. The use of a roll-board is convenient when transferring the patient to a shower bed or onto a rehabilitation table. Not even the most modern mattresses designed to reduce pressure ulcers will prevent the formation of pressure ulcers if the patient’s position is not regularly adjusted. Goals of Repositioning The type of repositioning depends on the goal we are trying to achieve. The main objectives of correct repositioning include: Control (regulation) of muscle tone Prevention of contractures Prevention of pneumonia Prevention of pressure ulcers Improvement in circulatory functions Prevention of damage to peripheral nerves Improvement in alertness and attention Prevention of formation of joint deformations

Decrease in intracranial pressure Control of Muscle Tone Certain positions have a direct effect on the magnitude and layout of muscle tone in various body parts. Certain positions might be used to increase muscle tone and others to decrease it or to influence the development of spastic patterns (Fig. 1). Apart from choosing desirable positions and movements that decrease spasticity, it is important to eliminate all factors that might contribute to an increased muscle tone, such as pain, cold temperature in the room, excessive noise, bright light and, most importantly, negative emotional factors.

Fig. 1 It is possible to influence the layout of muscle tone by various positions given the conditions of pre-positioning and maintenance of centration in key joints).

Prevention of Contractures Leaving a patient in the same position for several hours can lead to a painful restriction of joint movement and a subsequent development of contractures. Patients with a neurological illness, especially those with spasticity, are particularly prone to developing contractures. For

such patients, repositioning needs to be administered according to an anti-spastic pattern. This means positioning against the direction of the developing muscle shortening. Occasionally, additional positioning devices must be utilized. Prevention of Pneumonia Desirable repositioning and pulmonary physical therapy techniques influence stagnation and accumulation of mucus in the respiratory tract and therefore prevent the development of infections. Stagnant mucus is a source of nutrients for many pathogens, which contributes to an increased risk for growth of anaerobic microorganisms behind the mucus plug. Mobilization and expectoration of mucus will prevent the development of infection and the formation of atelectasis. Prevention of Pressure Ulcers Repositioning aids in pressure relief on the skin and it improves blood circulation in individual body parts. Therefore, it functions in prevention or treatment of pressure ulcers. Individual repositioning of a patient is determined based on areas of risk (sacrum, trochanter, heels, ankles, calves, knees, occipital bone, and elbows). Special mattresses designed to prevent pressure ulcers and fluid beds are utilized to prevent the development of pressure ulcers. Therapy for pressure ulcers is also primarily focused on reduction of pressure exerted on a specific area. In some instances, surgical management of pressure ulcers is necessary (Fig. 2).

Fig. 2 Pressure ulcers and their condition after a surgical intervention

Improvement in Circulatory Functions During motor dysfunction, there can also be a change in vasomotor function. Every form of therapy (e.g. correct and frequent repositioning, passive movement, maximal mobilization of a patient, gradual lifting of upper quarter) that improves circulation, leads to a decreased risk of embolism, thrombosis, edema, pressure ulcers and improves wound healing. Prevention of Damage to Peripheral Nerves Compression is one of the most common reasons for damage to a peripheral nerve. Repositioning protects the nerve from the pressure

that is exerted on the nerve by the weight of the body segment itself. Improvement in Alertness and Attention Improvement in alertness and attention allows for an active form of therapy and therefore is the primary goal of rehabilitation. For example, when we speak to a patient who suffered a cerebrovascular accident (CVA) on the affected side (the involved side of the brain) in order to stimulate his hearing and vision. If the patient has a left hemiparesis, then we will activate the left hemisphere by talking into his right ear. Repositioning may influence a motor neglect syndrome in which the patient does not use their limbs even though muscle strength is not affected, but the patient perceives them as foreign or dead, not belonging to their body. Our goal is to achieve an increase in the patient’s awareness of this body part (“pushed out” from the physical/body scheme) and concentrate most on their conscious awareness of the neglected body part. Prevention of Joint Deformations Joint deformations occur due to the pull of spastic musculature as seen in the subluxation or dislocation of hip joints (Fig. 3), pes equinovarus and scoliosis. Purposeful repositioning, usually with the help of orthotic devices or braces, can lessen the likelihood of such deformations. Fig. 3 Subluxation of a hip joint in a child with cerebral palsy

Decrease in Intracranial Pressure In a patient with an increased intracranial pressure, the preferred position is supine with the head aligned with the axis of the body and a slight elevation of the upper quarter (approximately 30 degrees). The head must not be below the rest of the body and must not be rotated. If the patient underwent a lumbar puncture, it is documented that the patient should lie flat for at least 12 hours. However, it has been shown that headaches (as negative side effects of lumbar puncture) are not necessarily related to whether the patient was supine or not. Types of Repositioning Pavel Kolář, Jiří Kříž Individual patient repositioning is determined by considering all areas at risk and the physiological position of the joints. Supine Position Supine positioning is generally the most tolerated. On the other hand, supine positioning brings an increased risk for pneumonia and the formation of pressure ulcers on a patient’s heels and sacrum. Incorrect padding under the head can often lead to hyperextension of the cervical spine, which in turn may lead to headaches and facial pain. Therefore, it is important to not just position the head, but also the shoulders (Fig. 4).

Head is in slight flexion; At the shoulder joints, the emphasis is on abduction and alternating internal and external rotation; Elbow joint is positioned into slight flexion alternating with extension (be careful to avoid hyperextension); Forearm is alternately placed in pronation and supination (for a patient who suffered a cerebrovascular accident, positioning into supination must outbalance pronation); Hand is placed alternately into physiological and functional positions; Lower extremities are supported with a pillow in slight flexion at the hip and knee joints; Heels are unweighted in pressure-reducing boots. Fig. 4 Positioning in a supine position

Semisupinated Position

This is a mid-position between sidelying and supine positions, in which the compression of the bottom shoulder is carefully avoided. Trunk must be rotated back and supported by a pillow along its entire length (Fig. 5). Bottom upper extremity – shoulder is abducted and externally rotated, elbow in slightly flexed, forearm supinated, hand alternates between physiological and functional positions; Top upper extremity – positioned on the body or placed slightly behind and supported, shoulder in mid-position, elbow slightly flexed, forearm pronated, hand alternates between physiological and functional positions; Bottom lower extremity – hip joint in slight flexion and external rotation, knee in 60 degrees of flexion, foot in neutral position; Top lower extremity – hip joint also in slight flexion and slight internal rotation, knee in 60 degrees of flexion, pillow between knees and ankles.

Fig. 5 Semisupinated position

Fig. 7 Semiprone position

Fig. 6 Sidelying position

Fig. 8 Semireclined position

Sidelying Position In this position, the patient is lying on their side with their trunk perpendicular to the mat and their head supported in alignment with the midline of the body. The sidelying position reduces spasticity and prevents the formation of pressure ulcers in the sacral region. This position also influences the drainage of brachio-pulmonary mucus; therefore, suction needs to be performed before and immediately after each change of position (Fig. 6). Bottom upper extremity – shoulder flexed to 90 degrees, elbow slightly flexed, forearm supinated, hand alternates between physiological and functional positions; Top upper extremity – rests freely on a pillow, shoulder slightly flexed and adducted, elbow slightly flexed, forearm pronated, hand alternates between physiological and functional positions; Bottom lower extremity – hip and knee joints slightly flexed; Top lower extremity – supported by a pillow, hip flexed to 90

degrees, externally rotated, knee flexed to 90 degrees, feet in neutral position. Semiprone Position This is a mid-position between sidelying and prone positions with the chest supported using a pillow and the head slightly rotated and supported with a small pillow (Fig. 7). Bottom upper extremity – shoulder abducted and internally rotated, elbow extended, hand alternates between physiological and functional positions; Top upper extremity – hugs a pillow which is placed under the trunk, shoulder abducted and flexed, elbow slightly flexed, forearm pronated, hand alternates between physiological and functional positions; Bottom lower extremity – hip joint extended, knee slightly flexed; Top lower extremity – supported with a pillow, hip flexed to 90 degrees, externally rotated, knee flexed to 90 degrees, feet in neutral position. Semireclined Position Trunk flexion occurs with a 30–40 degree flexion of hip joints. The semireclined position can be set up in a bed (Fig. 8) or in a wheelchair with a backward tilted back and head support, elevated foot rests and calf support. The ability to be out of bed, even for just a short period of time, is priceless for the patient. This aids with stimulation and motivation of the patient. If sitting in a wheelchair is expected, the wheelchair needs to be customized to meet the patient’s needs. During the first few days, the patient can spend only a short period of time out of bed (approximately one hour). Gradually, this period of time can be extended and active sitting practice can be initiated. Head and neck must be supported by a pillow, which will also provide support for the posterior upper part of shoulders; neck and shoulder pain can be prevented by using pillows under the forearms and elbows; Shoulders slightly flexed, slightly abducted and externally rotated; Elbow flexed to 90 degrees;

Wrist and hand in mid-position; Trunk in 30–45 degrees of flexion with gradual increase in flexion. Prone Position The prone position can be initiated when the patient is not dependent on a ventilator. Tracheotomy is not a contraindication. It is suitable to opt for a prone position at least once a day for every patient (Fig. 9). Head is rotated to the side; Chest may be supported by a pillow; Abdomen and pelvis unobstructed; Support of shins and feet by a pillow is done in such a fashion that it prevents the toes from contacting the mat when the ankle is in a neutral position; Another option for lower extremity positioning is to place one lower extremity in a step fashion (Fig. 10).

Fig. 9 Prone position with padding under the shin bones

Fig. 10 Prone position with a step fashion of lower extremity

VERTICALIZATION If the patient is able (with respect to intracranial pressure and cardiopulmonary capacity) to tolerate a more upright position, we can begin gradual transition into upright (vertical) position. At first, we elevate the position of the upper half of the body and later we begin a gradual verticalization on a tilt table (Fig. 11) or with the help of a standing frame (Fig. 12). The patient is tightly strapped to the table/frame and then brought into an upright position while heart rate and blood pressure are monitored. The degree of verticalization is increased until standing is achieved. Early verticalization is important not only for vestibular stimulation and activation of the ascending reticular activating system in reticular formation, but also for preventative reasons (pneumonia, pressure ulcers, contractures, etc.). Importantly, the diaphragm is engaged more easily in standing, which allows for improved ventilatory function and assistance in mucus drainage. Fig. 11 Verticalization on a tilt table

Fig. 12 Verticalization with the help of a Wind standing frame

PATIENT MOBILIZATION Prolonged immobilization can substantially accelerate progression of an illness. The main goal of movement activation is to prevent muscle atrophy, degenerative changes in the hyaline cartilage, ligaments and joint capsules, osteoporosis and formation of heterotopic ossifications. Early mobilization of a patient must be initiated as soon as possible due to the risk of an increased cardiopulmonary strain. Mobilization goals Prevention of Muscle Atrophy During immobilization, the extensor muscle group is particularly susceptible to muscle atrophy and, within one month, muscle loss may reach up to 60%. The amount of muscle atrophy is influenced by muscle tone. Spastic and shortened muscles succumb to atrophy at a much faster rate. After immobilization, muscle tissue recovery is probable; however, it tends to take 2–4 times longer. Prevention of Osteoporosis In the absence of movement load, osteoporosis develops within just a

few weeks. Clinical studies with patients with spinal cord injury have demonstrated that a one-hour long daily axial loading via verticalization may decrease the risk of the onset of osteoporosis. Given that patients with a central lesion are at a greater risk for falls, osteoporosis is a serious complication and a risk factor for fractures. Therefore, it is important to prevent it by early mobilization and repositioning. Prevention of Degenerative Changes in Cartilage, Ligaments and Joint Capsules Early patient mobilization has a significant effect on reduction of degenerative changes in cartilage. After a short immobilization (3–4 weeks), there is a decrease in the volume of synovial fluid of hyaline cartilage and breakdown in the structure of the collagen fibers. Furthermore, shortening of ligaments, which is correlated with contracture formation, occurs. Individual joint capsules shorten based on their characteristic joint pattern. Prevention of Heterotopic Ossifications Development of heterotopic ossifications is considered to be a serious complication in the rehabilitation process because the ossifications significantly restrict a patient’s mobility and self-sufficiency. Therefore, this problem is given special attention in this section. Neurogenic heterotopic ossification (NHO) is the formation of an ectopic bone in the soft tissues around proximal or peripheral joints in patients with a neurological deficit (Fig. 13). Most commonly, NHO develops after an injury to the brain or the spinal cord, but also after burns and various orthopedic injuries. The average occurrence of NHO is 10–20% in relevant diseases, 70–80% in patients in a prolonged comatose state and 30% in patients with a spinal cord injury. In cases of spinal cord injury, the ossification always occurs in the region below the level of the injury. In 70–97% of cases, it occurs in the hip region. Knees, elbows and shoulders are more rarely affected. NHOs most frequently form within two months after an injury, but they can appear even after a period of several years. Fig. 13 Heterotopic

ossification of hip joint and periarticular region on an x-ray film

The etiology of NHO is multifactorial. One of the factors is a trauma to the soft tissues surrounding a joint, which may be an important initial factor in the development of NHO. As a result, small muscle tears, bleeding into the muscles and soft tissue inflammation arise. These changes evoke an inflammatory process in the involved tissue accompanied by the release of anti-inflammatory mediators. Other factors contributing to the formation of NHO include local infections, venous thrombosis or pressure ulcers. All these factors lead to tissue damage and the progression of the inflammatory response. During the inflammatory response, the infiltration of a cellular exudate occurs followed by fibroblast proliferation and transformation of fibroblasts into osteoblasts which produce amorphous bone matrix. It is important to recognize through examination the forming ectopic bone and, at the same time, establish the rate of the mineralization process. Apart from clinical examination, laboratory and imaging methods are utilized. The clinical picture is dominated by range of motion restrictions in

the involved joints, surrounding soft tissue edema, periarticular hemorrhaging, increased temperature, and pain in patients with preserved sensation. Spasticity worsens with the growth of NHO. Extensive ossifications may contribute to the compression of neurovascular bundles, which may lead to the development of deep vein thrombosis. The level of serum alkaline phosphatase can be measured in laboratory tests. This level indicates the activity of osteoblasts. An increase in the level of alkaline phosphatase can be noted as early as 7 weeks prior to NHO manifestation. The examination, however, is not specific and the level may also be elevated due to associated fractures, after surgical procedures, etc. Creatine phosphokinase (CPK) is another cited marker of NHO. Its level can be elevated after a trauma to a muscle tissue or during an infection. Elevated values of proteins (CRP, IL-1) in the acute phase correlate with an extent of infection in an organism. Therefore, they might be elevated when NHO is manifested. However, it is also important to recognize these tests as less specific. Useful imaging methods include ultrasonography, skeletal scintigraphy, radiography, computed tomo​graphy, and magnetic resonance imaging. Ultrasono​graphy and skeletal scintigraphy are recommended for an early diagnosis of NHO. Primary Therapy for NHO (Prevention of NHO Formation) Rehabilitative care: The goal is to prevent complications that increase the risk of NHO formation. This type of care includes prevention of pressure ulcers, deep vein thrombosis, and attempting to decrease the incidence of urinary tract infections. Correct repositioning is important. Physical therapy: With an inappropriate physical therapy treatment, soft tissues may become traumatized. It is necessary to perform passive range of motion of the involved limbs to a minimum of into

2/3rds of their normal joint range of motion. The surrounding joints may be mobilized within their full range. Excessive caution during therapy must not lead to restriction of movement. After the acute phase of an illness has subsided, movement can be carried out to full range of motion. Physical therapy should be administered several times per day in short bouts. Patient repositioning plays an important role in prevention. Secondary Therapy for NHO Secondary therapy is focused on the management of an already formed NHO. Properly administered physical therapy is supported by pharmacotherapy, or eventually by radiation. For mature ossifications, which significantly worsen the individual’s quality of life, surgical intervention may be considered. From the pharmacological viewpoint, two basic types of medication are used – biphosphonates and nonsteroidal antiphlogistics. Radiation of ossifications is used as well, in part, for primary treatment of early stages of NHO (5.5 Gy total effective dosage), or as an adjunct after surgical resection. Complications from radiation include slower healing times of wounds and bones, osteonecrosis, as well as the risk of growth in the radiation – induced sarcoma. Indications for surgical intervention include a significant limitation with activities of daily living, decreased mobility of a patient, pressure ulcer complications as a result of ossification, and neurovascular complications. Surgical intervention is carried out after the ossification is fully matured, usually 12-24 months after their formation. Most often a simple resection of an ossification is carried out, rarely an implantation of a TEP is performed. Types of Mobilization Patient mobilization is among the most important objectives of rehabilitation. It can be divided into 3 phases: Passive movement Active-assistive movement (exercise with help)

Active exercise

Fig. 14 Standing with a trunk brace and platform walker

Fig. 17 Assisted ambulation – pelvic facilitation

Fig. 15 Sidelying to sit transfer

Fig. 16 Sit to stand transfer with platform walker

Passive Movement Performing passive motion may allow for slower onset of spasticity, help maintain a full range of motion of joints, and prevent the development of contractures. Passive movements have a preventative role during the formation of heterotopic ossifications. The goal of early passive mobilization is also “preservation of movement in memory”. Active-Assistive Movement Assisted movement is thought of as an active movement of a patient with some help by another person. It is used for patients who are not able to move completely independently or for patients who exhibit spasticity where an excessive effort of a patient to achieve an independent movement might provoke so called “associated

reactions”. In rehabilitative care, assisted movement is most commonly used when mobilizing a patient while maximally utilizing the movement capability of the patient himself. The goal is to achieve the greatest self-sufficiency. At first, only simple isolated movements of the upper and lower extremities or trunk are implemented. Later, with the assistance of a therapist, common activities of daily living can be practiced, such as bed mobility, rolling, sitting and standing, ambulation with assistance, etc. The amount and type of assistance can be chosen based on the quality with which the patient can carry out the assisted movement. Muscle tone, range of motion in individual joints, fluency of movement, pain, inadequate synkinesis, etc. can be monitored. During transfer training, which can be considered part of functional training, the therapist’s responsibility is to teach the patient to actively participate during all individual phases of movement. The following can be practiced during functional training with a patient: Bed mobility (movement toward either side of the bed or up and down in bed); Rolling to the side (in a patient with hemiparesis, practice rolling toward the involved and uninvolved side); Transition from sidelying to arm supported lateral sitting position (propped up on the forearm on one side); Sitting at the edge of the bed, legs in contact with the floor; Balance training in sitting; Practice weight shifting of body in sitting (body weight shifting from side to side and pelvic shifting forward and back); Training transition from sit to stand; Training in standing; Gait training on level surfaces; Gait training in frontal plane; Gait training in sagittal plane (forward,backward); Stair negotiation training (ascending, descending). Active Movement

During active movement, the patient carries out all the exercises under the supervision and direction of a physical therapist who determines the intensity of therapy based on the demand and chooses the type of intervention based on a functional goal. The functional goal is meant to influence conditioning, balance function, increase range of motion, and muscle strength, etc.

REFERENCES Bobathová B. Hemiplégia dospelých. Bratislava: Liečreh Gúth1997. Drábková J. Medicína naléhavých a kritických stavů. Vádemékum pro sestry. 2. vyd. Brno: Institut pro další vzdělávání pracovníků ve zdravotnictví 1992. Feigin V. Cévní mozková příhoda. Prevence a léčba mozkového iktu. Praha: Galén 2007. Chou R, Atlas SJ, Stanos SP, Rosenquist RW. Nonsurgical Interventional Therapies for Low Back Pain: A Review of the Evidence for an American Pain Society Clinical Practice Guideline. Spine 2009; 34(10): 1078–1093. Jones KB, et al. Bone and Brain: A Review of Neural, Hormonal, and Musculoskeletal Connections. Iowa Orthop J 2004; 24: 123–132. Pfeiffer J. Neurologie v rehabilitaci. Pro studium a praxi. Praha: Grada Publishing 2007. Rehabilitace po cévní mozkové příhodě. Průvodce nejen pro rehabilitační pracovníky. Praha: Grada Publishing 2004. Šeclová S. Rehabilitace po cévní mozkové příhodě: včetně nácviku soběstačnosti: průvodce nejen pro rehabilitační pracovníky. Praha: Grada Publishing 2004. Trachtová E, Mastiliaková D, Fojtová G. Potřeby nemocného v ošetřovatelském procesu. 2. vyd. Brno: Institut pro další vzdělávání pracovníků ve zdravotnictví 2001. Vaňásková E. Testování v rehabilitační praxi – cévní mozkové příhody. Brno: Národní centrum ošetřovatelství a nelékařských zdravotnických oborů 2004. Wendsche P, et al. Poranění páteře a míchy. Komplexní ošetřovatelská péče u para- a kvadruplegiků. Brno: Institut pro další vzdělávání pracovníků ve zdravotnictví 1993.

TREATMENT REHABILITATION FOCUSED ON RESTORATION OF A FUNCTIONAL DEFICIT Pavel Kolář Treatment rehabilitation includes a collection of rehabilitative, diagnostic, therapeutic and organizational measures used to achieve an individual’s maximal functional capability. Motor system dysfunctions and their analysis through the use of specific diagnostic methods and rehabilitation approaches designed to influence or eliminate these dysfunctions are at the center of interest. To examine a motor dysfunction, specific maneuvers, scales and tests are utilized in addition to visual observation (aspection), tactile assessment (palpation), hearing assessment (auscultation), and measurement of one’s body and its individual parts (anthropometric assessment). In some instances, clinical pharmacologic tests are utilized. After anam​nesis is obtained, the clinical examination is completed by clinical imaging and laboratory testing. The most common laboratory tests used to establish rehabilitation procedures include kinematic analysis (describes body position in space and time), kinetic analysis (describes forces acting on body during movement), electromyographic analysis (describes muscle activity combined with movement), assistive neurologic examination (EMG, PEMG, EEG, evoked potentials – SEP, VEP, AEP, MEP), radiological testing (functional examinations are mainly used for rehabilitation purposes), and examination of pulmonary functions and ergometric examination. The described process leads to determination of physical therapy (symptomatologic/treatment) diagnosis and establishment of a short- and long-term physical therapy plan of care. Diagnosis emphasizing limitations in activities of daily living is very significant in physical therapy. This assessment serves as the basis for social integration, vocation, and school setting

aspects of physical therapy. Treatment rehabilitation attempts to utilize therapeutic approaches to alleviate dysfunctions in a motor system, whereby it also influences dysfunctions in other organ systems. Physiotherapy is the primary discipline in treatment rehabilitation. Physiotherapy treatments utilize various manual procedures and physical therapy concepts that are based mainly on the foundations of clinical neurophysiology. Other methods used in treatment rehabilitation are physical therapy and balneotherapy. Physical therapy implements physical stimuli into treatments, balneotherapy deals with utilization of natural curative sources and their effect on human organism. Occupational therapy is also utilized to influence a patient’s functional deficits. Speech therapy and neuropsychology are focused on examination and treatment of expressive functions. During therapy, rehabilitation has the greatest impact on the movement system, but it also indirectly impacts internal, neurologic and other disease processes, including psychiatric illnesses. Functional Emphasis of Methods in Treatment Rehabilitation Karel Lewit, Pavel Kolář Methods of treatment rehabilitation are primarily aimed at function, which in part determines their effectiveness. The question remains, to what extent the function of a patient with paresis can be improved by the patient’s own activity primarily through the help of their movement system. Corresponding rehabilitation approaches are described in the chapters devoted to rehabilitation of internal, neurologic, orthopedic, and rheumatologic conditions. Pain and Movement System Dysfunction Karel Lewit, Pavel Kolář The movement system is the most common source of pain in an organism and, in turn, pain is also the most common sign of a movement system dysfunction. The reason is obvious: the movement

system is the largest system in the body, and moreover, it is the effector of our willpower. It does not possess any means of “defense” other than to cause pain. Functional Impairment in a Movement System Functional impairment is often caused by (excessive) loading. The loading increases pathogen tension which corresponds to the following clinical signs and symptoms: increased tissue tone (especially in muscles), increased resistance to movement, and trigger points (TrPs) in particular because of their inherent increased tone and pain. If no inflammation, trauma, morphologic findings, or gross mechanical pressure can be observed other than pain or a painful dysfunction, then this pain or painful dysfunction is called “nonspecific” or without a diagnosis and hence without specific therapy, or more precisely, rehabilitation. Often these cases present as the majority of painful conditions in the movement system. The goal of differential diagnosis is to distinguish between the pain caused by a pathological (structural) process and a functional impairment (functional pathology) and more often to determine whether the pathological or functional deficit is more relevant to the pain symptoms in a given patient. Although functional impairments are most frequent, pathological (morphological) impairments are more serious and, therefore, it is necessary to take a careful approach to differential diagnostics. In structural pathological impairment, a progressive course is typical. In case of relapse, the time period between the episodes shortens and the periods between the episodes might not be completely without problems. Also, the location of the impairment does not change. Accurate clinical examination can reveal the organic origin of the disorder. With functional pathological impairment, there is a chronic, intermittent course with intervals without any problems. During recurrent episodes, problems can develop in other areas of the motor system over time giving a systemic character to the disorder. This fact is essential and makes more careful delineation of the source of the

functional limitations necessary. Unlike structural impairments, which are precisely localized and for which location and substrate are to be diagnostically identified, functional limitations cannot be defined by a particular structure; only located by its manifestations. These include, for example, trigger points, movement restrictions (blockage), changes in soft tissues (changes in mobility of soft tissues, especially fasciae), static or movement pattern deficits, changes in the sympathetic system, such as perspiration, tissue temperature, dermo​graphism, etc. These changes undergo dynamic development and with appropriate therapy they can very quickly and suddenly disappear (as well as re-appear). By detecting the dysfunction, we can identify a symptom at best, but not the diagnosis itself. The function of the movement system cannot be accomplished by one structure (muscle, joint or fascia), but rather by a teamwork of many structures controlled by a nervous system (at various levels). In scientific literature, some symptoms (retraction of soft tissues, range of motion limitations, etc.) are often labeled “mechanical dysfunctions”. Here, the advocates of manual therapy implicate that mechanical function (movement) is restricted. However, this simplification is indefensible for organisms with a nervous system because each mechanical input is processed by the nervous system and becomes a piece of information. The result is always a functional impairment, which does not limit itself to the area of mechanical dysfunction. Function is as important as the structure and, if pathological physiology exists, then we must recognize functional physiology as well. Not even the notion that functional impairments consist primarily of “reflexive” changes accurately depicts the nature of the problem. In reality, these are programs in which a large amount of the movement system participates. The brain is the unattainable model for all informational and control systems working with a series of programs, i.e., the movement system; the brain must learn the functions, store them in memory and recall and modify them based on need.

Function as a program that encompasses a large portion of the movement system in its entirety, requires a wholesome approach. Within the whole unit, it is important to find certain patterns, or chain reactions, which help identify the key link in the chain and allow for more rational therapy. Postural locomotor functions and their control are the cause of the most significant chains. Impairment in function is often caused or accompanied by a structural impairment. Then, it is necessary to answer the question of relevance regarding a given component to therapy and prognosis. New imaging techniques have gradually demonstrated a series of sources causing movement dysfunctions and pain in the musculoskeletal system. Also, the concept of etiology and pathogenesis of movement dysfunctions has been continuously evolving thanks to modern diagnostic methods. Despite this significant progress, it is still impossible to determine a definite diagnosis for a large number of patients because of the insufficiencies in understanding the relationship between symptoms, pathological changes, and imaging results. Diagnostic imaging results often identify vast structural findings that produce no subjective complaints because the movement system, under the influence of functional reactions, possesses adaptative capabilities. A large number of people examined by various techniques show structural changes (disc herniations, meniscal or anterior cruciate ligaments lesions, narrowing of spinal canal, spondylolisthesis, etc.), which are later shown to have low relevance because they do not cause acute or chronic problems. Adaptative processes of movement dysfunctions are not only linked to the involved location, but occur in the whole system. During proper function of the movement system, the system additionally possesses significant self-repairing abilities (Fig. 1, 2).

Fig. 1 An image of a herniated intervertebral disc (sagittal plane) before and after rehabilitative treatment. A – An MRI picture of L5-S1 herniated disc; B – MRI film of the same patient after rehabilitative treatment

Fig. 2 Image of herniated intervertebral disc (horizontal plane) before and after rehabilitative treatment. A – MRI film in horizontal slice of lumbar spine with a significant disc herniation at L5-S1 segment; B – MRI film of the same patient 3 months after specifically targeted rehabilitation

Methods of treatment rehabilitation are focused predominantly on function. This closely relates to a clinical practice – the pain that

patients complain of is related much more to the functional changes than the actual structural changes. Generally, structural changes are (excluding inflammation) clinically demonstrated only after they cause a change in function. Principles of Therapy In general, when examining the most common painful disorders, it is necessary to evaluate the patient undressed to their underwear during the initial examination before the analysis of clinical findings is made. First, the key link in the pathological chain(s) must be identified and then the physical therapist will select the subsequent examinations and therapeutic approaches.

REFERENCES Jirout J. Das Gelenkspiel der Halswirbelsäule. In: Gutmann G, Biedermann H. Funktionelle Pathologie und Klinik der Wirbelsäule. Band 1. Die Halswirbelsäule, Teil 3. Stuttgart/New York: Gustav Fischer 1990. Kolář P. Senzomotorická podstata posturálních funkcí jako základ pro nové přístupy ve fyzioterapii. Rehabil Fyz Lék 1998; 5: 8–13. Kolář P. Systematizace svalových dysbalancí z pohledu vývojové kineziologie. Rehabil Fyz Lék 2001; 8: 139–151. Kolář P. Význam vývojové kineziologie pro manuální medicínu. Rehabil Fyz Lék 1996; 4: 152–155. Lewit K. Manipulační léčba v myoskeletální medicíně. 5. vyd. Praha: Sdělovací technika ve spolupráci s ČLS JEP 2003. Lewit K. Rehabilitace bolestivých poruch pohybové soustavy. Rehabil Fyz Lék 2001; 8(1): 4–17 a 139–151. Lewit K. The Functional Approach. J Orthop Med 1994; 16(3): 73–74. Richardson C, Jull G, Hodges P, et al. Therapeutic Exercise for Spinal Segmental Stabilization in Low Back Pain. Edinburgh: Churchill Livingstone 1999. Travell JG, Simons DG. Myofascial Pain and Dysfunction. The Trigger Point Manual. 2nd ed. Baltimore: Williams and Wilkins 1999.

A DIAGNOSTIC PROCEDURES The fundamental premise of a correctly chosen and controlled treatment approach is the evaluation of clinical findings. Next to clinical examinations, physical therapists lean on results from available methods that evaluate function (EMG, posturography, evoked potentials, etc). Physical therapy assessment is focused primarily on the symptomatology of a disease, which can be treated by rehabilitation methods, or compensated for by other means. In this context, the assessment is focused on the following: 1. Function of the locomotor system 2. 1. Neuromuscular system 2. Joint system 3. Soft tissues (skin, fascia, etc.) 3. Autonomic nervous system and function disorders of internal organs 4. Cognitive function and pain 5. Function-specific laboratory and imaging methods 6. Tests and assessments of motor handicap and limitations in the activities of daily living

1 ASSESSMENT APPROACHES FOCUSED ON THE FUNCTION OF THE MOVEMENT SYSTEM Pavel Kolář, Karel Lewit, Olga Dyrhonová

FUNDAMENTALS OF A CLINICAL ASSESSMENT Prior to the description of the actual specialized assessment of the movement system, it is necessary at this time to present an overview of the fundamental and conventional examination sections, which include preliminary history (anamnesis), palpation, observation (aspection), auscultation examination, and an anthropometric assessment.

PATIENT PRELIMINARY CASE HISTORY (ANAMNESIS) Pertinent patient preliminary history information, which we obtain directly from the patient’s interview, is an integral part of clinical assessment. With the evolution of diagnostic options for determination of diagnosis and therapeutic procedures, patient history is becoming nonessential. At the same time, the literature cites that correct diagnosis can be established in up to 50% of patients. To determine the cause of pain in the movement system, the information obtained is particularly meaningful. Anamnesis aims at the circumstances at the onset of the condition (such as lifting an object, sudden movement, gradual onset of symptoms, etc.) and the course of the symptoms, especially the information pertaining to pain (night pain, relationship between pain and movement, type of pain, radiation of pain, etc). Injuries are also important. Patient often thinks of an injury as an event that causes an immediate pain reaction. “Minor” or micro injuries and past injuries are underestimated. During the patient interview, we may also collect social information about family, relationships within family, employment, living conditions,

construction barriers, etc. The questions are asked so that we obtain the most information. However, the questions should not be leading. In some cases, we may ask questions pertinent to patient history during treatment or may even contact relatives. Sometimes, the evaluation of all history findings is carried out over several days. The data collected during patient interview (anamnestic data) is evaluated and judged always in the context of clinical assessment. Components of a Complete Preliminary Patient History (Anamnesis) Patient Personal History (Personal Anamnesis) When collecting information about a patient’s personal history, we are collecting information about illnesses which the patient suffered and the ones they are currently being treated for under the direction of a family physician or a specialist. Part of the patient history also includes information about injuries and operations. Family History (Family Anamnesis) Family history includes the medical conditions of close relatives and blood relatives. We ask questions about parent and sibling injuries. For children, we find out the number of siblings in the family. Occupation and Social History First, we conduct occupation history interview in which the patient is asked to describe the demands of their job and the work conditions in greatest possible detail. It is important to find out whether the occupation is stereotypical or diverse in nature, what the patient’s most frequent position is at work, whether they work primarily in standing or sitting, and which stereotypical movements they most frequently perform. Patients who perform physically demanding occupations are asked whether their work is predominantly lifting objects or whether they work in static or constrained positions, etc. We ask about stressful moments related to work performance, as well as lighting and temperature conditions in which the patient performs

their job. The patient is asked whether they are satisfied with their work situation or whether they are considering a change in profession and, if they are, then for what reasons. Information about family relationships and their relationship with a spouse/partner is particularly important. We collect information about partner relationships and family, number of children, financial situation, material security of the patient, and the family as a whole. It is advisable to find out satisfaction with intimate (sexual) life. Furthermore, we are interested in the patient’s leisure activities, especially participation in sports. During sports, there is not only a potential for various injuries, but also for long standing strain on the musculoskeletal system, which may lead to chronic health problems in some athletes. Allergy History (Allergy Anamnesis) When collecting allergy information, allergies to medication and contrast media are most important. The type of allergic reaction – skin reaction, breathing difficulties or even anaphylactic shock – is of interest. Pharmacologic History (Pharmacologic Anamnesis) When obtaining pharmacology-related information, medications that the patient has been taking for a long period of time are the most relevant. It is important to obtain the name of the medication, dosage, whether it is taken regularly or as needed, and if the dosage has been changed recently as well as who prescribed the medication. History of Current Illness (Current Illness Anamnesis) The following data is most frequently found in the history portion pertaining to the current condition: Pain The movement system is the most frequent source of pain in a human organism and, in turn, pain is the most frequent symptom of movement system dysfunction. Ask about the onset of pain, whether it was sudden, gradual, first

occurrence, or a recurrence. If the pain is recurring, then inquire about the circumstances under which it presented itself initially, the rate of recurrence, duration, length of time between recurrences and whether the pain-free periods are getting shorter. Furthermore, ask when the pain appears, whether it is present early in the movement, during or after loading, at rest at night, whether it disturbs sleep. Ask the type of pain (sharp, dull, constant, colic) and projection of pain. Also seek to know the positions of relief and circumstances that bring relief (heat, cold).

Radicular Pain In the acute stage, the pain is sharp, intense, worsening with movement and with increased intra-abdominal pressure (with coughing, sneezing, intrathecal pressure). True (nerve) root pain suggests: a. projection of pain in a typical dermatomal nerve root pattern, tingling; b. changes in sensation – diminished sensation; c. patient complains that his extremity “feels as if it were foreign and does not listen well”. Rest provides relief and the patient seeks a pain-free position. Pseudoradicular Pain (Referred Pain) Referred pain has a similar character as radicular pain. The projection of pain is not in the typical dermatomal pattern and its projection to the distal end (periphery) is absent. Pain with Spinal Canal Stenosis Pain is in the back and refers to both lower extremities and does not present with root characteristics. It occurs during ambulation over a certain distance and it forces the patient to stop and attain a painalleviating position (forward bend, sit, mini-squat). When the pain subsides, the patient is able to continue walking. This type of pain is

called neurogenic intermittent claudication. The distance that the patient can manage without complications is called the claudication interval. The patient exhibits no pain with bicycle riding. Pain during Inflammation Pain is present at rest, especially at night and it can wake the patient from sleeping. We ask about elevated temperature, increased fatigue, whether or not the symptoms were preceded by a general inflammatory illness. We explore possible focal regions including inflammation in the oral cavity, inner ear infection, respiratory tract infections, and infection in the abdominal internal organs. Pain with Ankylosing Spondylitis For ankylosis spondylitis, it is characteristic that the pain starts at a young age around 20 years and the patients in whom the pain starts at a young age are never going to be without pain. Another very characteristic symptom is that they regularly wake up during the night at a specific time, more likely toward the morning because of their need to leave the bed to walk a little before they can lie down again. In addition, ask about painful eye infections (iridocyclitis) and tendon pain. Pain during Myopathy or Neuritis Patient reports muscle pain in conjunction with worsening muscle strength. Pain with Osteoporosis Osteoporosis itself usually does not exhibit pain. Pain most often appears only after a pathological fracture. In connection with osteoporosis, ask about menopause, gynecological procedures, hormone supplements, and corticosteroid use. Pain with Tumors Pain depends on the stage of the disease. In a more progressed stage, the pain is extensive even relentless, constant, with activity and at rest, wakes from sleep, does not have positional relief, and does not

respond to common pain medication (analgesics). Pain with Functional Impairments The locomotor system is one of the most common sources of pain in the human body. The course of onset of this pain is mainly impairments in function or so called functional impairments. With functional limitations, we generally do not find a structural basis for the source of pain (i.e. degenerative joint diseases, damage to an intervertebral disc, etc.), but rather a change in function of the movement system, which usually presents itself by a change in muscle tone or decreased joint mobility. In regards to the functional impairments of muscle tone, the most common type seen is the increase of muscle tone or hypertonicity, while the greatest source of nociception, in the same case is a local micro-spasm or a trigger point. In a large number of cases, any pathological findings which we could objectively demonstrate by the use of instrumentation – based follow-up are absent. This is the reason why such pain is referred to as non-specific, meaning pain without a diagnosis after organic pathological changes are excluded. In reality, these are patients with abundant clinical findings. However, the control functions of the neuromuscular system tend to be disturbed in such patients. Functional impairments have a typical anamnesis and set of clinical symptoms that should not be overlooked or downplayed because an impairment in function will in time evolve into a structural impairment (for “function forms an organ”). Functional impairments and pain have a characteristic chronicintermittent course (if it is not an acute case). During patient history, it is important to find out the periods during which the patient exhibits difficulties, as well as, periods when they are completely symptom-free. Also during the history, seek details about frequency of painful attacks, their duration, periods of remission, the onset of the last attack, and whether the condition is worsening or improving. Based on the collected data, establish the rate of progression for this condition. For women, routinely ask about painful menstruation and pain specifically in the lower back, which, during a normal

gynecological exam, is suggestive of a functional impairment in the area of lumbar spine and pelvis. Moreover, functional impairments typically display a systemic nature of pain, which means that with a chronic-intermittent course of a disease, specific parts of the movement system are being affected alternately. That is why it is always important to attempt to determine whether the patient presenting to the clinic with pain in the lumbar spine is not suffering from pain in a different area because it is likely that even this is “merely” a sign of functional impairment. Functional impairments also emerge after most traumas. If the local injury healed itself completely (ad integrum), but the pain is persisting, it is likely that a functional impairment is already involved. The example may be an acceleration-deceleration trauma (whiplash) of the head and cervical spine, when an unexpected blow from behind initially seems (to a patient) as of little importance, it may leave long term functional consequences. Also, after a healed shoulder injury there is often a lingering limitation at the end ranges of motion. During patient history, we put a particular emphasis on indentifying aggravating and alleviating factors of the patient’s symptoms. Fundamentally, we do not ask “what” caused the patient’s problem because after such question the patient tends to name different theories which they believe (or which they have heard of) caused their problem. Always insist that the patient describe the circumstances under which the symptoms occur (i.e. getting up in the morning, prolonged sitting at a computer, standing, walking, etc.), whether the pain occurs at rest or whether it worsens with movement or with strain. If the pain is worsening with ambulation, it is necessary to know whether the patient needs to stop and get into a so called symptom-alleviating position – root claudication cannot be overlooked. Pain with ascending stairs more likely suggests a dysfunction in the hip joint, whereas pain with descending stairs suggests a dysfunction in the knee joint. Further, we ask the location of the pain, meaning on which side the patient feels the pain more: functional impairments are often

asymmetrical and never exactly “follow” the course of a nerve (in a chain of impairments, chains of trigger points and blockages prevail) on the same side. Pain in the movement system is often accompanied by autonomic symptoms. This is especially true for functional impairments. They may also exhibit paroxysmal disposition, especially with headaches and dizziness. It is also important to inquire about nausea. Pain in the thoracic spine has a similar character as pain in disorders of internal organs, which elicit diagnostic concerns that include heart disease, especially if the pain is felt on the left side of the chest with radiation into the upper extremity or under the scapula. Therefore, inquire about the length of the episode. For a vertebral condition, episodes tend to be much longer than that of angina pectoris (stenocardia) and are independent of fast walking or climbing, but often dependent on a certain position. Furthermore, the pain does not react to nitroglycerin. During patient history, it is important to assess the patient’s psychological condition. Pain always has a psychological reaction and the movement system is the effector of our psyche. The posture and movement of a patient under a psychological stress differs from a person who is at psychological ease, which is directly reflected in the function or dysfunction of the locomotor system. Psyche, especially emotions, is also affecting the autonomic system. By modifying central control, muscle tone, and autonomic reactions, the psychological component significantly influences the process of formation of functional impairments. Other Subjective Symptoms Paretic Impairment (Paresis) vs. Muscle Weakness Although it is necessary to distinguish central from peripheral paresis from the viewpoint of pathophysiology, it is not important from the aspect of patient history (anamnesis). During patient history, the information about the origin of weakness is the most important. Sudden weakness occurs most often as a result of an injury or a cerebrovascular accident. Gradually developing muscle weakness

occurs with degenerative neurologic illnesses (motor neuron disease, demyelinating disease), or with compression of neural structures (root syndrome, tumor). Inquire about fatigue, feeling of weakness and ataxia of extremities. For upper extremities, ask about dropping objects from hands and for lower extremities, inquire about tripping and falls. Furthermore, search for changes in sensation and proprioception. Purposefully ask about the dysfunction of the sphincters (incontinence). With cranial nerve lesions, the patient complains of visual disturbances (double vision, visual field loss), loss of taste, smell, and swallowing difficulties. Rigidity The feeling of muscle rigidity pertains to spasticity. Rigidity is associated with the clinical picture of Parkinson’s disease and it is accompanied by tremor. The first signs of this disease may be vertebral pain, increased salivation, perspiration, difficulty speaking, writing, ambulation, and falls. Dizziness During patient history, the patient reveals everything that affects his balance and can result in a fall such as “dizziness”, fear of heights and feeling of fainting. A patient who complains of dizziness must be thoroughly cross-examined to identify what exactly they mean by this word. Their first response tends to be that their “head is spinning”. This allows for a follow up: there are only two ways of spinning and that is clockwise and counter clockwise. Furthermore, ask if the perception is more like swinging or a pull in one direction and whether the dizziness is accompanied by nausea or vomiting. Explore whether the dizziness is linked to a whole body change in position or a change in head position in relation to the trunk. Dizziness might be connected to insecurity, weakness in the legs, or a feeling of drunkenness. Ataxia (Lack of Coordination) Ataxia belongs within the framework of cerebellar syndromes. The more rare paleo cerebral syndrome involves the coordination of the trunk with the lower extremities and, therefore, standing and walking

are disturbed. Visual control influences this dysfunction, but to a relatively small extent. Another cause of ataxia is a dysfunction of deep sensation. In contrast to cerebellar dysfunction, visual control plays an important part. Thus, it is necessary to ask the patient how they are moving in the darkness. Since neuropathy is currently considered the most common cause of ataxia, inquire about pain and numbness or tingling in the extremities.

OBSERVATION (ASPECTION) Visual assessment allows accumulation of helpful findings about the patient’s condition within a short period of time and helps create a complex picture about the patient’s personality and disease. Visual assessment already starts in the waiting room by observing the patient’s natural and uncorrected movement pattern. Valuable information can be gathered this way about posture, gait, pain behaviors, etc. During the description of their subjective complaints and when carrying out individual tasks, the patient’s facial expressions, eye movements, and innate behaviors can be observed during examination and compared to their behavior when not under formal examination. Observation is focused on the main manifestations of the given movement dysfunction.

PALPATION Karel Lewit While vision is being used for observation (aspection) and is mediated by the receptor in the retina, hearing is utilized for auscultation and is mediated by inner ear receptors (the organ of Corti). Palpation is incomparably more difficult. What we see can be photographed or filmed; what we hear can be recorded – in other words “objectified”; however, what we feel can only be conveyed verbally (in some cases non-verbally) and that is always a subjectively biased process to a

certain extent. The moment the palpating hand (fingers) touches an object, it senses its resistance, roughness or smoothness, pliability, elasticity, moisture or temperature. This means it encounters a large variety of receptors for very diverse characteristics of the object being palpated. Even if we focused only on the mechanical properties of an object during palpation, the palpating finger cannot be replaced by a firm device that measures only pressure. The palpating hand never uses only pressure; it “touches” everything, meaning it makes complex movements to “recognize”. By increasing pressure we do not penetrate into the depth of the tissues, but merely shift one layer after another. This means that if we are interested only in the mechanical aspect of palpation, the information is provided by receptors for touch, pressure, movement and position. To develop an instrument that would “objectify” this has so far been impossible. And there is yet another, crucial element. Whenever we place our hand on the patient’s body, the patient reacts and the palpating therapist registers this reaction. A feedback between the two systems (individuals) forms, which is irreproducible because each therapist palpates differently and every patient reacts differently. This fact is best illustrated during palpation of trigger points (TrPs). Considering the number of receptors on a palpating hand and due to the feedback from the patient, the information obtained by palpation is more valuable than by an examination using any other device. The amount of experience the therapist has gained is an important variable. With the help of palpation, we locate increased tension in soft tissues and muscle trigger points and, in doing so, we recognize where and what exactly hurts the patient. This is practically impossible to achieve with any instrument. Language, which is the expression of a long standing human experience, teaches us that if we understand something, then we comprehend it. If evidence is credible, it is “palpable”. If we govern something we “master” it. But according to modern science, palpation is irreproducible – and, therefore, subjective and its conclusions are

non-scientific. Consequently, our statements about changes in tone, muscle trigger points and pain are questionable, even though we convince ourselves daily that whenever the tension in the tissues normalizes itself and TrP’s disappear, the pain subsides. The fundamental technical rule of palpation is that the less pressure used for palpation, the better the perception. If we press too much, we will feel our own fingers and not what we are supposed to feel. The barrier phenomenon – soft tissues and joints during dysfunction of a certain part of the movement system show tendency toward decreased mobility – serves as a more accurate comparison of results in palpating diagnostics. Prior to reaching an anatomical barrier, the examined (stretched) soft tissue begins to exhibit a first, small resistance when just a very slight pressure is exerted. It is at that moment that the examiner “hit” a functional barrier. Further examination consists of a slight increase in pressure into the barrier (the examiner does not exit the barrier) and if the barrier is flexible (springy), then it is a physiological state. However, if it is not possible to elicit the give in the area of the barrier (soft tissue does not spring) then the barrier is pathological and demonstrating a dysfunction in the given segment. Pathological barriers are also achieved sooner and this barrier meaningfully and quantitatively limits movement. This is also demonstrated in the following picture – barrier phenomenon (Fig. 11). This schematic shows the barrier for joint mobility, but it applies to all mobile structures. Letter “A” denotes an anatomical barrier, which is never clinically attainable. “Ph” signifies physiological barrier, which for us is the most meaningful. It indicates the range of motion from a neutral point where we encounter the first slight resistance; this can be seen once a sustained minimal force (waiting) is exceeded. “P” designates a pathological barrier, which defines a normal range of motion. The resistance is sharply increasing so that the pathological barrier springs minimally. “No” signifies the neutral point, which is marked as “N1” if a pathological barrier exists.

Fig. 1-1 Graphic representation of the barrier phenomenon

The Most Important Palpation Techniques Skin Drag To examine superficial hyperalgic skin zones (HAZ), it is advantageous to begin by assessment using a skin drag. At the location of HAZ, the skin perspires more and therefore, even a slight touch causes increased friction. This technique is not only very quick and gentle, but it also allows for easy identification of the entire area of autonomic changes. With the following techniques the barrier phenomenon is applied. Tissue Stretch The technique of tissue stretch is selected and carried out based on the extent of the skin area treated – for example, two fingers, eventually only between the finger tips or even between the palms of crossed hands. Every time we reach the barrier through a slight pull or overstrain, it is sprung. In pathological barriers, the overstrained tissue is reached very quickly and immediately and a hard resistance is encountered. When the barrier is reached, it is sufficient to wait in overstrain and a release occurs after a short latent period, after which the therapist follows by palpation to the limit, meaning until the physiological barrier is reached (Fig. 1-2; also see Fig. 1-1) Fig. 1-2 Tissue stretch

Stretch of Soft Tissues in a Fold Stretch of a skin fold, which very often involves subcutaneous tissue or a muscle, is most frequently performed between two fingers (thumbs), with large muscles between palms so that the tissue is stretched and not compressed (Fig. 1-3). The barrier is reached by a gentle pull, which under normal circumstances gently springs. With pathological changes, the fold is thicker and, with its stretch, a pathological barrier is soon reached. After a while, the release phenomenon occurs in a pathological barrier, during which it is necessary to wait until a complete normalization of the barrier is achieved, or the method needs to be repeated. Fig. 1-3 Stretch of soft tissues in a fold

Using Pure Pressure A finger or a thumb can be pressed into the soft tissues until a minimal resistance is felt (Fig. 1-4). In the areas in which painful changes are found (most commonly within muscle TrPs and with functional resistance in the abdominal cavity), an early resistance is located while the patient is feeling pain (especially with springing in the direction of pressure). Once again, the phenomenon of release will occur without pain by merely maintaining a sustained pressure at the barrier. This type of palpation is especially important for the abdominal cavity: if the phenomenon of release does not occur and the pain with pressure persists, then pathological changes are diagnosed, which in most cases lack a functional cause. Fig. 1-4 Caption: Using purposeful pressure

Fascial Stretch This entails the shifting of deep fasciae against bones, especially in the patient’s back in a craniocaudal direction and in the chest, neck and extremities around a longitudinal axis. The scalp is a very important fascial element, functionally linking muscles of mastication with the region of cranial joints. The palpation technique is similar to the previous ones: in the direction of an assessment, a minimal force reaches the barrier (pre-strain) and springs. In functional impairments, the shifting of soft tissues is significantly limited (against a symmetrically laid down structure). Therapy is carried out by stretching the soft tissue into the pathological barrier where the release is reached and during the release, we wait to encounter the natural barrier (Fig. 1-5). Fig. 1-5 Assessment of shifting of stretched fasciae

The Assessment of Active Incisions Since scars (especially after surgeries) penetrate all levels, the pathological barriers need to be gradually assessed at all levels. Based on the findings, it is possible to reach the release for all pathological barriers. Individual layers are acting with each other, hence, when one layer releases, all other layers adjust. Diagnostics of deep post-surgical scars are more difficult after laparoscopic procedures since the superficial incision is missing. The Assessment of Muscle Trigger Points For assessment, it is critical to palpate the tight muscle band by “strumming” (Fig. 1-6). If the muscle can be grasped between two fingers, we can let it slide between the fingers. In cases where this is not possible, such as with erector spinae, it can be “strummed” across. This applies to superficial muscles, in which we initiate a contraction by strumming across them. For deep muscle layers (e.g. subscapularis, psoas, iliacus and pterygoids), a trigger point is recognized by a hard resistance as well as an acutely painful sensation after a slight touch. Fig. 1-6 Palpation of trigger points by Travell and Simons

Assessment of Joint Mobility The barrier phenomenon was first described by P.E. Kimberly specifically for joints. It is of fundamental importance for diagnosis of joint restriction and it pertains to actual functional mobility as well as joint play. Joint play can be defined as joint mobility which can be induced only passively – for example, movement in which the joint surfaces are approximated or distracted. The barriers in both scenarios are reached the moment the first resistance with passive movement is encountered. This resistance is quite giving or soft. With blockages, it develops quickly and there is not much spring to it. In time, the phenomenon of release and normalization of the barrier occur. This joint release can only be a muscular phenomenon and joint blockage in itself is closely linked with muscular TrPs. Palpatory Illusion An excessive emphasis on the significance of palpation cannot lead to

the lack of judiciousness and the feeling of infallibility. It is important to pay attention to a less known, but at the same time, common occurrence – the so called palpatory illusion. The “shear dysfunction” syndrome has most frequently been mentioned, by P.E. Greenman and it also known as an “upslip” or “downslip”. This is a relatively frequent finding in the area of pelvis, in which the symphysis and ischial tubercle are palpated on one side higher or lower. The ischial tubercles might show several centimeters of difference, especially when lying down, but often equalize while standing. They are also corrected after various maneuvers that can hardly influence the above mentioned structures. However, our palpation does not perceive this adequately. In figure 1-7 it is obvious that after a therapeutic maneuver, the alignment of the examined structures did not change on an X-ray film – however, the position of the palpating fingers has changed.

Fig. 1-7 Palpatory illusion on x-ray films. A – position of examiner’s fingers prior to therapeutic intervention; B – position of examiner’s fingers after the intervention; position of structures has not changed),

Palpation illusion is a very frequent occurrence that corresponds to what amateurs and chiropractors call an adjustment or repair/readjustment. The findings from palpation reach symmetry after a successful intervention because the tension in the soft tissues surrounding bony structures reaches symmetry. Painful functional disturbances affect soft tissues at the corresponding segment and thus cause palpation illusions. Optical illusion, which can routinely be achieved with the help of lenses, became the foundation of a scientific

field, and palpation illusion should play a similar role, which we can always accomplish if we place a sponge of unequal thickness at the corners of a match box. Therefore, we should not speak of changes in “muscle tone” during palpation because a muscle is always covered by soft tissues which react in the same segment. It is a pity that a science about palpation, “palpatorics or palpatomy”, practically does not yet exist. Thus, palpation appears as a complex culmination of the clinical assessment providing feedback during the closest contact with the patient, which in modern medicine is often lacking. The absurdity lies in the fact that we often trust instruments, mostly modern computers, which imitate the functions of a nervous system, but the original, the human brain, is underappreciated (Fig. 1-8). Fig. 1-8 Are we still at all clinicians?

AUSCULTATION Petr Bitnar Auscultation has been less frequently used as an examination technique in treatment rehabilitation. In fact, it is used only during joint assessment, joint relaxation techniques and during therapy aimed at the function of internal organs. Auscultation is one of the key examinations in respiratory therapy.

During the assessment of joint system, auscultation is used to listen to the movement in the joint. If crepitation or other jangled sounds are heard, it indicates a certain deficit in the joint. Most often, crepitus in the joint is heard in arthritic joints, deficits in synovial supply to a joint, and even in chronic inflammations. Rattling and popping sounds can be found in more serious instabilities of the joint system. Popping phenomenon may be invoked by dysfunctions of musculotendinous junction surrounding the joint during motion (due to the change in pull of short interarticular structures – ligaments, tendons, muscles), a major decentration occurs even up to a small subluxation of the joint. Popping sounds may be caused by a “jump” of a tendon over a bony prominence (e.g. trochanter), most commonly in shoulder and hip joints, or with a diagnosis of a trigger finger (digitus saltans). Joint relaxation techniques, especially manipulation and partially mobilization techniques, are accompanied by so called popping phenomenon (cavitation). This phenomenon has never been fully satisfactorily explained, but it surely indicates a sudden movement in a joint and mutual separation of joint surfaces. In the majority of cases, the popping phenomenon is followed by (during well administered therapy) a relaxation of surrounding muscles, perhaps even more distant muscles, which are “chain-linked” into the joint dysfunction. With therapy aimed at internal organs of the abdominal cavity, the auscultation is used for feedback. Peristaltic sounds are indicative of motility in a certain section of the hollow organs of the abdominal cavity, most frequently stomach or large intestine. Since motility is one of the basic functions of hollow organs, then, for correct therapeutic strategy, auscultation is one of the fundamental feedback methods used to provide feedback about goal-adherence and effectiveness of therapy. “Growling” sounds of motility heard during examination of internal organs gives information regarding the reactivity of organs and autonomic condition. Most often, auscultation is used during examination and treatment of the respiratory system, as seen in pulmonary rehabilitation,

especially respiratory physical therapy. During the assessment of the respiratory system, any wheezing, crackling, squeaking, bubbling and other sounds inform us of the amount, location and type of disorder (for example: wheezing sounds indicate an obstruction in the respiratory tract; bubbling sounds indicate the location and amount of mucus, sounds of “steps in the snow” inform of current pneumonia, etc.). Listening to a cough can also be used in differential diagnosis. There are many types of cough; “moist/productive” and “dry/nonproductive” are the most basic classifications. Auscultation provides information about the changing diameter of the respiratory tract and the movement of mucus. Auscultation is further used during work with respiratory tools (flutter, Acapella, etc.). Here, the accompanied sound phenomenon gives information about correct or incorrect usage of a given respiratory tool.

REFERENCES Andersson GBJ. The Epidemiology of Spinal Disorders. In: Frymoyer JW, et al. The Adult Spine: Principles and Practice. 2nd ed. Philadelphia: Lippincot-Raven Publishers 1997; 93– 142. Bednařík J. Akutní bolesti v lumbosakrální oblasti pro praktické lékaře z pohledu neurologa. Česká neurologická společnost, ČLS JEP 2005. Castro WHM, Jerosch J, Grossman TW. Examination and Diagnosis of Musculoskeletal Disorders. Stuttgart/New York: Thieme 2001. Ernst A, Meyer-Holz J, Weller E. Manuelle Medizin an der Halswirbelsäule Chiropraktik und Therapie. Stuttgart/New York: Thieme 1998. Greenman PE. Clinical Aspects of Sacroiliac Function in Walking. J Man Med 1990; 5: 125. Greenman PE, Tait B. Structural Diagnosis in Chronic Back Pain. J Man Med 1988; 3: 114. Hrbek J. Neurologie 3. Praha: SPN 1982. Kimberly PE. Bewegung – Bewegungseinschrankung und Anschlag. Man Med 1980; 18: 53– 55. Magee DJ. Orthopedic Physical Assessment. 5th ed. St. Louis: Saunders Elsevier 2008. Mečíř P. Radikulární a pseudoradikulární bolesti dolních končetin – praktické zkušenosti z diagnostiky a léčby. Medicína pro praxi 2006; 5: 236–240. Vondráček V. Úvahy psychologicko-psychiatrické Praha: Avicenum 1975. Zeman M, et al. Chirurgická propedeutika. Praha: Grada Publish​ing 2000.

1.1 NEUROMUSCULAR FUNCTIONS AND THEIR CLINICAL EXAMINATION Pavel Kolář Mechanical movement is the result of muscle activity. The muscular system is also important for metabolic processes in the organism and it plays an important role as an information and adaptation component of the central nervous system (CNS). Through CNS, which controls it, a muscle system is functionally linked with the joint system, internal organ system and the skin. Understanding muscle function in connection with control processes is essential for treatment rehabilitation. Every muscle is an anatomical unit, from which muscle function may be deduced. Muscle origin and insertion predetermine muscle function, ensuring movement in a joint. This means that, for example, biceps brachii is a forearm supinator and elbow and shoulder flexor. For functional diagnosis and treatment, it is more important that, with a few exceptions, the majority of CNS activity is manifested in its outcomes as muscle action. A muscle, which is an anatomical unit, does not need to be, and usually is not, a functional unit. Although the result of muscle activity is a mechanical movement, the function of individual muscles cannot be judged based only on its strength or on the location of its origin and insertion, but rather strictly by the rules of mechanics. For understanding muscle function and for deliberation about disorders of its function, including their influence, we must understand the organization of the CNS. It is necessary to define a muscle partly in terms of classical kinesiology (meaning from the viewpoint of being a flexor, extensor, rotator, agonist, antagonist, synergist, etc.), for which the core definition of function is the muscle as an anatomical unit. On the other hand, there is also the viewpoint of functional kinesiology, for which a muscle is practically a “mirror” of the CNS, such that the global muscle synergy, quality and distribution of muscle tone are the best evidence of its function. The

muscular system lies at the intersection where the effects from the central system (brain, spinal cord) and from the periphery (skin, subcutaneous tissue, joints, etc.) are merging both the internal and external effects. In its final form, all nerve influences during muscle contraction are carried out through an α-motor neuron. This means that the influences from the higher centers of the CNS as well as from proprioreceptors, exteroceptors, interoreceptors, etc. are coordinated on the level of the spinal cord and primarily via the work of spinal interneurons. They reach their final output form via the function of αmotor neurons. The surface of each motor neuron is on average 5,500 synapses. All these influences converge and determine the function of α-motor neurons. The interplay of the aforementioned influences ensures both voluntary and involuntary movements. Alpha-motor neurons thus present the final pathway for the many systems that are related to movement. The next pathway that influences movement is the pathway utilized by γ-motor neurons which transmit fibers toward muscle spindles. Their stimulation increases the excitability of muscle spindles, which multiplies the extent of arousal formed in the spindle. These inputs act via a reflex pathway on α-motor neuron synapses and elicit either a direct contraction or contribute to it in conjunction with other synaptic inputs. This indirect influence on motor neurons mediated by the fibers from peripheral nerves which innervate a muscle spindle is called a γ-loop. The gamma system is controlled by reticular formation (mainly by descending facilitative region) which mediates the regulatory influences of the cerebellum from the basal ganglia and the brain cortex. Muscle function may be understood as some expression of CNS function. In this context, the muscle is not considered the chief effector organ of the motor system, but a motor unit. The motor unit is a complex consisting of a motor neuron and the muscle fibers that are linked to this motor neuron. A motor neuron, which is directly linked with muscle fibers, relates simultaneously with the spinal interneural network by the way of its dendrites. Here, it

comes in direct contact with pathways that carry signals from both, the center and the periphery. These signals end on the facilitation or inhibition synapses of a motor neuron. A motor unit is thus the main coordination center of nervous inputs that converge on the motor neuron from peripheral systems, other spinal segments, and higher levels of the CNS. Therefore, the function of a muscle needs to be understood in such context. A muscle is functionally perceived as a continuation of a nerve and as part of the nervous system, not as an isolated unit. Given the dependence of the motor unit function on the inputs that converge on a particular motor neuron, the afferent signalization is considered quite important for the exiting motor function. The influence on the sensory system (proprioception, exteroception, vestibular apparatus, etc.) in various forms is the main focus of physiotherapy techniques used in reflexive treatments of motor dysfunctions. The afferent signalization has such an enormous significance for realization of movement that a coordinated movement, cannot be carried out without it. For example, a patient with syphilitic myelopathy (tabes dorsalis) can have functioning spinal motor neurons in the full quantity, but nevertheless cannot produce a coordinated movement during ambulation even though their muscle strength for this task is sufficient. Equally, we can notice, for example, a decreased strength in the calf muscle with a lesion in the posterior S1 nerve root without clinical demonstration of denervation of the calf muscle. Given the number of spinal pathways, we can see that the ascending pathways outnumber the descending ones, which agrees with the above mentioned assumption. In addition to the previously mentioned functional relationship that exists between motor neuron and muscle fibers, there is also a close structural relationship. A motor neuron innervating muscle fibers is not only a source of guiding processes, but also the producer of substances that maintain the muscle fibers’ contractile structure. Not only has the flow of various substances in axoplasma of a neuron been demonstrated, but it has also been shown how these substances are transferred to the periphery, which is similar to peristalsis. These

findings demonstrate not only functional, but also structural connections between nerve and muscle fibers. Disruption of the nerve supplying a muscle or motor neuron destruction lead to muscle atrophy and cessation of motor function. Should a muscle not work for a longer time period, disuse atrophy will take place. Motor units differ in the number of muscle fibers. Each motor neuron governs a different amount of muscle fibers: the least in the eye-moving muscles, the most in the large muscles of the trunk and proximal muscles of the extremities (up to two thousand). This corresponds to the fineness and precision of movement; muscles of the eye ball perform the most precise work. In addition to the number of muscle fibers, motor units also differ based on function. In this context, motor units are distinguished into phasic and tonic. Tonic motor neurons demarcate longer lasting twitch and de-contraction. It is interesting that by transposition of an axon of tonic motor neuron on presently phasic muscle fibers, these fibers become tonic fibers after a period of time, and this includes not only their function but also structure. This fact only underscores the tight linkage between nervous and muscle systems and between structure and function. Muscle in Reflexive Context as Part of the Movement System As a part of control systems, muscle is involved in more complex reflexive action. Now it may be better to talk about programs instead of a reflexive relationship since the guidance and processing of information is incorporated into a complex and, in essence, until now unrecognized physiological schemas. Therefore, when we are using the term reflexive, we mean a delineated relationship between a receptor and an effector. In this new concept, this relationship is no longer defined by a loop, but rather by a central program, i.e. movement stereotypes and motor patterns. Besides the incorporation of a muscle into mutual bonds with other muscles, the muscle can also work in isolation. It is even possible with practice to achieve independently controlled activity of individual motor units. For this reason, it is necessary to examine and manipulate the muscle. In the

context of motor programs, we talk about reflexes, motor patterns and movement stereotypes. Motor Patterns The manifestation of movement is also determined, along with volitional movement, by genetically determined components operating along consistent preformed pathways that appear in the same form across generations. This part of the motor system is labeled as reflexes in its simplest form and as motor patterns in its most complex form. In physical therapy, stimulation of motor patterns is used for targeted facilitation or, conversely, for inhibition of impaired motor function; these patterns also have a diagnostic significance. Thus, motor patterns are understood to be “standardized” movement reactions (motor responses) of the CNS to a precisely defined stimulus. This is a predetermined movement response to a stimulated/excited receptor. Motor patterns act as stabilizing factors, whereas movement stereotypes (learned and automatic movements – see below) act as factors that are unrestrained, variable, and conditioned by individual motor performance. Motor patterns include simple reflexes organized at a spinal and root level, but also complex sensorimotor functional relations organized at higher levels of control and implemented throughout the maturation of the CNS. R. Magnus found a number of lower reflexes and reactions in animals and G. Schaltebrand observed similar phenomena on small groups of children. He showed that some reflexes displayed in adult animals are also commonly present in newborns. He pointed out that even though these reflexes are originally mediated by red nucleus (nucleus ruber), they are being inhibited throughout the anatomical maturation of the CNS. As a consequence, they are unattainable at a later age. The concept of a newborn with a greater portion of reflexive functions with a hierarchical organization of functional levels has been included in the works of many authors – Milani-Comparetti and Gidoni (1967), Fiorentino (1973), Capute et al. (1978), Vojta (1974), and Bobath (1980). Reflexes are viewed as basic units superimposed

by a complex of coordinated mobility. Maturation of the CNS leads to their inhibition. These reflexes can also appear when the higher CNS centers are inactive, such as after vascular accidents, brain traumas, etc. During central paresis (differentiated movements), isolated movements are dysfunctional and, when linked to a desired activity, so called dystonic attacks appear. When an effort is made to accomplish a targeted movement, movement patterns that are seen in the patterns of primitive reflexology (asymmetric tonic neck reflex, symmetric tonic neck reflex, triflexion, etc.) appear and thus block selective movement. Our goal is to inhibit such reflexes via stimulation of higher central functions (Vojta method, NDT method, exercising cerebral functions – exercises with conscious effort, etc.) and via cerebral movement. This means that the reflexes available in an early phase of development are gradually inhibited and superimposed during brain maturation, but they do not disappear. Neurophysiologic hierarchical concept, according to which the gradual influence of cerebral cortex function (volitional activity) begins during child development and which suppresses the manifestations of spinal and subcortical reflexes, is reflected in the experimental works of a number of other authors – McCraw (1945), Paine (1960), Cohen and Taft (1967), Zelazo (1976), Gallahue (1982), Ernst (1983). Some authors discredit this concept. The notion that a newborn is not a reflexive mechanism is supported by Eccles (1977), Prechtl (1967) and Touwen (1976). The fact is that the CNS of a child is so mature and complex after birth, its function, therefore, cannot be described merely on the basis of reflexes and reactions. Thanks to clinical experiences and experimental works, it is also indisputable that maturation of higher central functions leads to an inhibition of lower functions that are demonstrated by these reflexes. “Primitive reflexes”, what we sometimes call simple forms of reflexive responses, cannot be viewed as isolated systems in the development of the CNS, but always in the context of development of higher control centers. Clinically, we can

observe the maturation of the CNS via postural activity, postural reactions or by the development of stereognosis. For example, when a child first begins to exhibit postural reactions connected to the development of co-activation or the synergistic activation of antagonist muscles (seen 4–6 weeks after birth when the infant starts lifting their head while prone and while supine lifting their legs). While at the same time, reflexes organized at the spinal level – suprapubic reflex, cross extension reflex and walking automatism, etc. – disappear, in other words are superimposed or inhibited (more in Chapter 3 Neuromotor Development and its Examination). Some reflexes are only present during pathological conditions (e.g. asymmetric and symmetric tonic neck reflexes), while others are present from birth and disappear during a very specific phase of motor development (e.g. Galant’s reflex, cross extension reflex, walking automatism, suprapubic reflex, etc.). Additionally, same reflexes appear later and can be elicited throughout the whole life (e.g. opticofacial reflex). In a child, the examination of “primitive reflexes” comprises an integral part of motor development screening. Elicitation of these reflexes, or more accurately the lack of their elicitation, shows the maturity of the central nervous system and its pathological abnormality. Examination of reflexes is a part of neurological and rehabilitation assessments. Besides simple reflexes at the spinal cord or brain stem levels, our movement presentation is also conditioned by complex sensorimotor functional relationships organized at higher levels of control, including older cortex regions. These motor patterns condition the development of body posture (including morphologic development) and basic functions of locomotion – stepping, grasping, and support function of the extremities. Movement Stereotypes Movement stereotype represents a temporarily unchanged system of conditioned and unconditioned reflexes, which arise from the basis of motor learning (stereotypically repeated stimuli). Practiced (trained)

movement, or externally stimulated stereotype, leads to the development of an internal stereotype of nervous processes. The individual targeted movement (phasic movement) and, in particular, postural stability (stabilization of movement) are automated. It can be assumed that movement stereotype (movement and its posture) ease the function of the CNS in more complex and frequently repeated situations. Our routine movements are performed automatically and unconsciously, which often leads to the inadequate use of certain muscles while other muscles are over used daily without us even realizing it. Certain muscles are involuntarily contracting isometrically during the entire day (sometimes even during sleep). This leads to a chronic overexertion of certain regions, with structural repercussions.

Clinical Manifestations and Examination of Neuromuscular Dysfunctions Clinical manifestations of neuromuscular system dysfunctions are very extensive because, through muscle function or its reactivity, we not only assess muscle function, but, as mentioned above, also control functional deficits. These manifestations are dependent on within which part of the regulatory loop the dysfunction is located. In cortex dysfunctions, along with the motor functions, the symbolic functions are also disrupted (phatic, gnostic and practical). In the examination approaches, we use palpation, aspection (observation) and functional tests, which include the assessment of activities of daily living (see chapter 5: Testing the Extent of Motor Impairment and Limitation of Activities of Daily Living). Clinical assessment of the muscular system cannot be separated from the assessment of functions of the whole body (joints, bones, soft tissues, internal organs) and, therefore, it is necessary to distinguish between these connections for the analysis of muscle function or functional pathology of the neuromuscular system (see chapter 1: Assessment Approaches Focused on the Function of the Movement System, Fundamentals of Clinical Assessment).

During clinical examination, we focus on functional and neurological symptomatology and syndromology. In children, the examination of motor functions is carried out within the framework of screening for a potential neurological handicap. I FUNCTIONAL AND NEUROLOGIC SYMPTOMATOLOGY 1.1.1 Postural function 1.1.2 Muscle tone 1.1.3 Sensory functions 1.1.4 Reflexes 1.1.5 Involuntary movements 1.1.6 Muscle strength, or decreased strength II FUNCTIONAL AND NEUROLOGIC SYNDROMOLOGY 1.1.7 Primary muscular lesion 1.1.8 Deficits in neuromuscular transition 1.1.9 Impairment of peripheral nerves 1.1.10 Spinal syndromology 1.1.11 Cerebellar syndromology 1.1.12 Extrapyramidal syndrome 1.1.13 Thalamic syndrome 1.1.14 Brain stem syndromes 1.1.15 Syndromes of meningeal stimulation, intracranial hypotension and hypertension and ventricular syndromes 1.1.16 Cortex syndromes – motor and symbolic III NEUROMOTOR DEVELOPMENT AND EXAMINATION • Clinical assessment via motor programs • Screening of neuromotor development • Motor development in early childhood • Psychomotor development in preschool age • Central coordination deficit in preschool and school age • Physical therapy for central coordination impairment

I FUNCTIONAL AND NEUROLOGIC SYMPTOMATOLOGY 1.1.1 Examination of Postural Functions Pavel Kolář Postural assessment dictates our assumption about the patient’s tendency toward overexertion or injury and allows for visualization of the relationship between structure and movement function. Good body posture is projected into the muscle tone (muscle balance or imbalance) and central control mechanisms including psychological state, ligament conditions, and anatomical relationships are all reflected in posture. Posture also reflects reactions to pathological states within the organism. We are interested in the position of individual segments, distribution and degree of muscle tone. During a physiological situation, individual movement segments are centered so that the postural tone in the muscles (especially the superficial muscles) is minimal. All excessive (whether globally or locally) muscle tone has a significant outcome value. It is practically impossible for increased resting postural tone not to be a source or a consequence of a patient’s complications (including internal dysfunctions). Muscle tone in standing also speaks to the overall relaxation capabilities of a patient. When assessing posture, we base our observations on so called “ideal posture”, which we derive from central programs of postural ontogenesis. To be able to define ideal posture, we must draw on biomechanical and neurophysiologic functions. The biomechanical function is meant to describe the nature of loading, while neurophysiologic function describes control processes of muscles that allow for integration of stabilizing or postural muscle function (even during movement) so that the loading in the joint system is optimal. Their interconnection is part of postural development. Ideal posture is determined by a central program. Therefore, postural assessment during static and locomotor functions needs to be understood within

the ontogenetic context. Supporting this concept is the fact that postural development is synchronized with the development of our anatomy, which even, to a certain extent, predetermines this development.

POSTURE Postural Function – Normal When evaluating postural functions, or determining the degree of dysfunction, the main problem is the lack of normative values due to the varied views of individual authors who have tried to define such norms. Brűgger’s concept assesses and teaches posture (body posture) differently than Pilates. Different criteria of ideal posture can be found in the works of B. Frejka (Tab. 1.1.1-1), F. P. Kendall (Tab. 1.1.1-2), M. Lomicek and M. Jaros or T. Kaperczyk, B. Mensendieck and others who extensively pursued this topic. Frantisek Vele states that the establishment of one standard for correct body posture is impossible because everybody’s correct postural alignment is varied. Most authors judge postural functions only in standing, which can be considered insufficient.

Tab. 1.1.1-1 An ideal standing alignment by Frejka (Chvatalova, 1991; Srdecny, 1982)

Tab. 1.1.1-2 Ideal positioning in standing according to Kendall (Kendall, McCreary, Provance, 1993)

To define an “ideal posture”, we must, in our own approach, identify the biomechanical, anatomical, and neurophysiologic functions and the interconnection of these functions in the context of motor or morphological development. With postural functions, it is also possible to discuss the influences of anthropometric characteristics given by a body type. However, no study exists that would confirm the presumption of somatotype influence on posture; to the contrary, it has not been successfully statistically confirmed. Development of Posture The linkage of anatomical and biomechanical principles with the principles of neurophysiology is the most distinct in the view of posture, or morphological ontogenesis. Here, the principles are mutually conditioned and can never be viewed separately. One of the main principles of motor ontogenesis is the development of body posture, or the ability to qualitatively attain joint positions with their reinforcement via coordinated muscle activity and the development of stepping and supporting function. Holding the body’s axis in a lordo-kyphotic curvature, and setting the pelvic and chest alignment (the shape of chest is changing due to this), are all developing during the first part of motor development in postural ontogenesis. This is allowed by a balanced synergy between the spinal extensors and neck flexors and intra-abdominal pressure (i.e. this is the interplay of the diaphragm, abdominal muscles and pelvic floor

muscles). (Fig. 1.1.1-1). This is followed by the development of targeted phasic movement, or locomotion. This means the development of stepping (grasping) or support (push-off) functions evolves in a dual functional manifestation:

Fig. 1.1.1-1 The maturation of an axial organ’s stability in the sagittal plane at 4 months. A – Supine; B – Prone. The support areas are symmetrically becoming elbow epicondyles of the upper extremities and the symphysis.

1. Ipsilateral pattern (rolling) – step and push happen on the same upper and lower extremity (Fig. 1.1.1-2); 2. Contralateral pattern (crawling, creeping) – step and push happen on the contralateral upper and lower extremity (Fig. 1.1.13). Fig. 1.1.1-2 Rolling is an ipsilateral motor pattern

Fig. 1.1.1-3 Step is a contralateral

motor pattern, during which the support areas become opposite lower and upper extremities

Stepping and support functions are dependent on the ability to stabilize the spine, pelvis and chest, therefore, purposeful movement of the extremities occurs as stabilizing functions mature. This is ensured by the cooperation of the antagonistic muscle groups. These functions develop with time. At 3 months of life, in supine, a reach, or step of upper extremity from the lateral side, appears. At 4.5 months, the ability to reach from mid-line gradually develops and during the 5th–6th month, the reach across midline follows. The opposite extremity provides support, or push-off function. While prone, the differentiation of stepping and support appears after the 4th month. The active ability of attaining a posture can be derived not only from the development of basic positions (prone with support on elbows, oblique sitting, quadruped position, etc.), but also from a body posture, or rather individual joints during movement of a child. Orofacial motor aspect is incorporated into the whole locomotor complex. Both the eyes and the tongue are pointed towards the stepping forward upper extremity. During the physiological development of a child, balance appears between muscles with antagonistic function, which allows for holding joint positions in a so called neutral position (centrated position). This occurs only in a healthy central nervous system. We speak of an

ideal posture. In postural developmental dysfunctions, a deficit in the functional joint position always occurs – anteversion of pelvis, forward head, inspiratory chest position, etc.

Fig. 1.1.1-4 Sequence of rolling during reflex stimulation

Reflex Model of Posture and Locomotion The developmental model of stabilization of the spine, chest and pelvis together with the stepping and support function of the extremities forms a program that originates in the central nervous system (innate motor pattern – similar to “primitive reflexes” – it is a function of higher level control centers). This system may be aroused reflexively via stimulation of so called trigger zones. Induced locomotor movement corresponds to motor patterns that we see during physiological development of the CNS. Through afferentation by pressure stimulation of trigger zones, the thoracolumbar and pelvic stabilization is facilitated (provoked) in the CNS as well as stepping and support functions, including orofacial functions (eyes and tongue

are moving toward the stepping forward upper extremity). (Fig.1.1.14). This reflexively evoked reaction (involving similar movement functions that are observed during the development of postural locomotion) takes place in a balanced teamwork of muscles with antagonistic function and allows for a neutral joint positioning (centrated position) during locomotion (stepping and support). This implies that joints are from a biomechanical aspect physiologically loaded. These global patterns of reflex locomotion can be elicited repeatedly and it is always with the same coordination and movement purpose. Once again, the interconnection of biomechanical and physiological principles is asserted here. Postural muscle functions (patterns of motor development – stabilization function of the spine, chest, pelvis and purposeful movement of the upper and lower extremities) matured during physiological postural development, or activated during reflex stimulation, are the ideal models of posture (postural stabilization) and locomotor movement, against which we compare our examination results. During postural assessment, we are interested in the deviations from this ideal postural model and their etiopathogenetic consequences. Circumscription of the Term Posture In the context of posture, individual authors limit their view only to righting (balancing) functions, while others only to assessment in standing or sitting, etc. But the term posture is much broader. Posture is understood to be an active holding of the body’s movement segments against the acting of external forces from which, in everyday life, gravitational force seems to have the greatest significance. Posture is not just a synonym to erect standing on two extremities or to sitting, which is how it has most frequently been presented, but it is a part of any position (for example, in an infant, the erect head position while laying in prone or lifting lower extremities against gravity while in supine) and, most of all, of every movement. Posture is the main component required for movement and not vice versa. Even R. Magnus wrote “posture follows movement like a shadow”.

If we divide any movement into phases, we get short time periods of a given movement, some “frozen phases”, from which it is possible to derive positioning. It pertains to the position of joints during a “period of non-movement” during an actual movement. From the aspect of postural functions, we distinguish the following: Postural stability Postural stabilization Postural reactibility Postural Stability In a static position, the body as a whole does not change its position in space. However, every static position (erect standing, sitting, etc.) implicitly contains dynamic processes. Attaining a steady position is not a static occurrence, but rather a certain course or a process that “resists” the natural volatility of the movement system, which is a necessary premise for movement. Therefore, it is not a single attempt at attaining a static position, but a continuous “attaining” of a static position. The ability to attain a body posture that does not allow for unintentional or uncontrolled falling is called postural stability. Stability is influenced by both biomechanical and neurophysiologic factors. The area of support belongs to the biomechanical factors. The basic condition of stability in a static position is that the center of mass in every moment must reflect into the support base (but it need not reflect into the base of support). Base of support is the part of surface that is in a direct contact with body. Support base is the whole area bordered by the farthest margins of the area or support area (“support areas and everything in between”). Thus, support base is commonly larger that base of support. Stability is directly proportional to the size of the support base and weight, and indirectly proportional to the height of the center of gravity above the support base, distance between projection of the center of gravity into the support base and the center of support base and the angle of base of support from the horizontal plane. On the other hand, during locomotion, the vector of gravitational force does

not need to point directly toward the support base, but the resultant vector of external forces, including outside gravitational force, momentum, friction force, reaction force, etc., must point to it. If, during static loading, the vector of gravitational force does not project into the support base (as we stated, it does not need to point to the base of support), this principle is violated. In such a case, the ligaments and muscles must maintain rotational moment or a significant muscle force in order to maintain balance. Unbalanced standing is at first corrected for by higher muscle activity with accompanied hypertonia of corresponding muscles and later by pain and even later by the development of deformity. Postural Stabilization Postural stabilization is understood to be an active (muscular) holding of body segments against the activity of external forces controlled by the CNS. This muscle activity holds body segments (active segment holding) against the action of external forces (especially gravitational force). During static conditions (in standing, sitting, etc.), a relative tightness of joints is achieved via muscular activity, which is coordinated by the activity of agonists and antagonists (co-activation activity). This activity also allows for resisting gravitational force in a given position. The tightening of body segments enables the achievement of an erect posture and locomotion of the body as a whole (an analogy can be seen in an experiment where we are trying to erect a wooden wand and a chain or a board and a net). Without coordinated muscle activity our skeleton would collapse – hence postural stabilization. Postural stabilization does not only act against gravity, but it participates in all movements, even movements involving only the lower or upper extremities. Postural Reactibility With each movement of a body segment during a demanding activity (i.e. lifting and carrying a heavy object, movement of an extremity against resistance and without resistance, push-off/rebound effort, ball throw, etc.), a muscle contraction is necessary to overcome the

resistance generated. This is transferred into force moments in the lever segment system of the human body and elicits reactionary muscle forces in the whole movement system. This reaction stabilization function is called postural reactibility. The biological purpose of this force is to increase firmness of individual movement segments (joints) to obtain the most stable punctum fixum and allow joint segments to overcome the effects of external forces. Punctum fixum thus means that one of the insertional muscle parts is tightened (by the influence of the tightening activity of other muscles), so that the other insertional part of the muscle can carry out movement in a joint. This we then call a punctum mobile. The tautness in connected segments can be, to a certain extent, altered and it is possible to link together several anatomically given segments into one unit. The necessary tautness of connected links is achieved by the coordinated activity of agonists, antagonists, and other muscle groups. It is clear, that with movement of the trunk through the help of the extremities, a certain degree of freedom in the joints of the extremities is necessary. On the other hand, the thorax cannot be formed by a number of loosely linked segments; it must form a relatively firm unit. This can be illustrated again by the chain analogy: if we pull a string attached to one of its links, the whole chain will be distorted (Fig. 1.1.1-5A).

Fig. 1.1.1-5A Stabilization of the spine during activation of extremity musculature. A

– during muscle activity, no deviation of a segment from the neutral position must occur, which is demonstrated by the chain model; B – during the movement of lower (upper) extremities, the musculature stabilizing the spine is activated (F – force); C – muscle interplay between autochthonal musculature, the diaphragm, the pelvic muscles and the abdominal muscles during a physiological situation

No purposeful movement (including movement of the extremities) can be carried out without insertional muscle stabilization, meaning securing tightness in the joint segment at the insertional region. For example, it is not possible to achieve flexion in the hips without the stabilization of the spine and pelvis; the insertional origins of the hip flexors – rectus femoris, iliopsoas, sartorius (Fig. 1.1.1-5B). With movement in a segment (for now in the hip joint), the spinal extensors and their antagonists are linked. These antagonists are not only the abdominal muscles, as it is usually noted, but primarily intraabdominal pressure regulated by the muscles of the abdominal cavity (abdominal muscles, diaphragm, pelvic floor). The interplay between the spinal extensors and intra-abdominal pressure forms a fixed point in the region of lumbar spine and pelvis (Fig. 1.1.1-5C). Under physiological conditions, the joints of the lumbar spine are in a centrated position during the action of the hip flexors, meaning that during hip flexion, there must be no movement and decentration at the insertional region. Muscle activity in the stabilizing segment generates activity in other muscles in which the insertions are connected. These then allow stability in other joint segments and that is how muscle activity in the movement system is “chained”. Repeatedly, it has been experimentally observed that the activation of the diaphragm, pelvic floor, abdominal and back muscles (thus muscles that ensure trunk stability to allow for movement of extremities) precede movement activity of the upper and lower extremities. In studies, joint activation of the diaphragm, transversus abdominis, pelvic floor and multifidi during postural activity is cited. Every movement in the segment is transferred in this way into the whole posture. Every movement maneuver includes transfer of stabilization into the insertionally roped regions and, therefore, into the whole body. For example, not even swallowing can be carried out

without tongue stabilization, specifically without its support against the palate and without stabilization function of other muscles (especially muscles stabilizing the hyoid). Chest wall, abdomen, brachial and lumbosacral plexuses and, naturally, the spine form a mutual “firm frame”, which is the requirement for all movement activity. The fact that the stabilization function is integrated into almost all movements underscores the significance of the activity of internal forces (i.e. forces acting on a joint via musculature and optimized for ideal stabilization of segments) not only in their quality, but also in their substantial stereotypical repeating, or quantity. Under the assumption that the so called internal forces elicit non-physiological loading of a segment, it is then only a question of time when the impediments begin to occur, including morphological changes (osteophytes, arthritic changes, etc.). It is also essential that while purposeful movement is freely controlled, reactive stabilization functions occur automatically and subconsciously (see below for assessment of postural stabilization and postural reactibility). Postural Disturbances Postural disharmony occurs as a result of the following deficits: Anatomical – femoral anteversion, sacral dysplasia, post-injury morphological changes – for example, the condition post vertebral compression fracture, etc.; Neurological – cerebellar, vestibular, extrapyramidal, etc.; Functional – impairment of the stabilizing function of postural muscles during movement and static positions, which is most commonly examined via tests and assessment of an impaired distribution of muscle tone, which is most significantly projected into the body posture. Anatomical dysfunctions are innate or acquired and neurological consequences arise from a neurological syndromology. Now, we will focus in more detail on functional deficits of the movement system. Functional Postural Disturbances

Main reasons for functional muscle disturbances with postural consequences are as follows: 1. Central coordination disturbances (CCD) during postural development; 2. The way in which our stereotypical movements have been evolved, strengthened and modified, often in the context of individual’s psychological state; 3. Dysfunction in nociceptive control. Ad 1. Central coordination disturbances (CCD) during postural development Abnormal motor development is one of the main reasons for disturbances of postural functions. There does not need to be a disturbance in which the postural development is delaying biological age in comparison to chronological age (quantitative component of movement). The dysfunction might be in the quality of postural functions. This means that, for example, a child lifts their head, turns from their back onto their stomach or attains a quadruped position according to their corresponding age, but the execution of the movement is not physiological. Typical deviation includes lifting of the head in prone during the first 3 months with a dysfunction in the support of the upper extremities. In such an infant, adduction of the upper extremities persists and support on the forearms is lacking; shoulders are in protraction and scapulae elevated. This positioning is compensated for by cervical extension and pelvic anteversion – the interplay between the serratus anterior, abdominal muscles and the diaphragm is not secured. The same position of segments is then observed in supine. Children with such presentation are called “children with wings” (Fig. 1.1.1-6).

Fig. 1.1.1-6 Central coordination disturbance

Other typical signs of CCD include, for example, a persistent predilection position of the head after the 6th week of life, displaying an extensor pattern during turning with the pelvis in anteversion, etc. These postural disturbances are fixated and become the foundation for postural behavior in later age. These functional (in this case postural) disturbances most commonly are among the etiopathogenetic factors of chronic movement dysfunctions. Ad 2. The way, in which our stereotypical movements have been evolved, strengthened and modified, often in the context of individual’s psychological state During motor learning, it is important for a posturally correct and secured movement to evolve. The movement should be so efficiently developed that truly only the muscles that execute and posturally stabilize this movement participate in such movement. Under such ideal assumptions, the movement occurs during the correct positioning of a joint, which we denote as centrated (neutral). This leads to an optimal loading of the joint and ligamentous structures. This principle can be observed during postural development under the presumption of physiological development of the brain and during reflex locomotion – i.e. an “ideal postural pattern”. An example is the breathing stereotype. During physiological breathing, expansion of the lower part of the chest occurs and the sternum is moving in the anterior-posterior direction. Breathing under this

circumstance involves the diaphragm and the intervertebral muscles without the help of the accessory breathing muscles. In reality, however, most of the time, a stereo​type persists in which the accessory breathing muscles function primarily (pectoral muscles, scalenes). These muscles activate additional muscles that must stabilize these accessory muscles, such as the suboccipital muscles. Therefore, muscles that lack any mechanical connection with the breathing movement become associated with breathing. A strong bond is formed between the muscles that are activated during a corresponding movement so that, eventually, all involved muscles form a functional unit. An individual then constantly activates these muscles as a whole, which leads to a non-purposeful loading of soft tissues and joint structures. Unilateral or incorrectly performed movement loading, most commonly caused by occupations, is one of the reasons for evoked changes in the muscle tone and thus the formation of faulty postural behavior. Therefore, muscle tightness and muscle inhibition occurs. This is typical in athletes who begin unilateral loading prematurely or are routinely incorrectly directed in practices. Cultural and esthetic influences also markedly determine our postural presentation. For example, women are ashamed of a protruding stomach and, therefore, they draw it in or how it is fashionable to wear high heels. In the Czech Republic, a sokol view of correct body posture dominates and so, from school age, we are instructed to keep the shoulder blades together, bring the chest out and pull the stomach in. We consider this completely contradictory to an “ideal” posture, which is defined by a central program. In addition, psychological states such as fear, anxiety and aggression, have a non-negligible influence on postural behavior. Based on body posture, it is possible to determine the psychological state of mind even though postural functions are not always under volitional control (they can be concealed only to a limited extent). In a number of psychologically demanding situations, primarily via the influence of the limbic system, changes occur in muscle tone and thus one’s own motor presentation This is well noted from one’s body

posture during various emotional situations. We can see how the muscle tone and, subsequently, body posture change when we are focused, nervous, or sad. Non-physiologic hypertonus linked to the formation of muscle imbalances occurs primarily during a longstanding stressful demand. The characteristics for this hypertonus include: Limited to a given region, but not to a muscle group; Ease of transition between hypertonic and normal tonic regions (the transition is difficult to detect via palpation) Localized primarily in the neck musculature and shoulder girdle and into the lumbosacral plexus and pelvic region; Manifestation of changes in the muscle tone in the method of a breathing stereotype (breathing is more costal, accessory muscles are more involved and expiration is not fully completed). Vegetative manifestations are present (perspiration, dermography, cold distal appendages). Ad 3. Dysfunction in Nociceptive Control The next cause of changes in postural functions is related to nociceptive stimulation and the subsequent reaction. When a pathological situation develops in an organism, nociceptive information is formed. Information about damage is not a mere interpretation of a state, but acts as a “trigger” of defense mechanisms. As a reaction, activities develop with the purpose to prevent damage to a structure or at least to minimize the injury. The motor system’s own part in the control of nociception lies in reflex reprogramming, meaning in influencing the output of motor information. An emergency saving program is formed. Automatically, changes in muscle function develop – muscle hypertonus and inhibition – which are components of autoregulatory process. Changes in tone related to this peripheral (reflex) cause may affect the whole muscle group, a single muscle, or, more frequently, only a part of a muscle – in such case, the trigger point. Unilateral overloading is the result of all sources leading to the changes in postural functions, which during long term duration leads

to the formation of morphological impairments (acquired spondylolisthesis, degenerative joint changes, etc.). For the stated reasons, the clinical examination must be aimed not only at morphological or neurological findings, but also at functional findings focused on the quality of postural functions. Postural Functions in Children and the Principles of their Examination When examining postural functions in children, it is difficult to decide which deviation should be actively treated or corrected and which could possibly be categorized as physiological developmental deviations that disappear with age and without therapy. In children, the distinction between normal and abnormal is difficult and this includes structural as well as functional findings. Typical “physiological” developmental deviations include, for example, the following: Unequal growth of the lower extremities; Varied position of pelvis in childhood – pelvis is in anteversion and lumbar lordosis is more pronounced; Children between the ages of 11–14, in long sitting with lower extremities extended cannot reach the tips of their toes because of anthropometric relations, which arise from their growth period; Genu valgum and flat feet, which in a typically developing child disappear around 6–7 years of age; Postural genu varum; Femoral anteversion, for which inward patellar rotation and foot pronation are typical; Hyperextension of knee joints, etc. Thus, when examining children, it is not appropriate to use the same tests and assessments used for adults or adolescents without making certain modifications. In children, it is normal to see certain inconsistencies and stage-based development, which, of course, does not occur proportionately. This disproportion is especially significant during growth spurts and, during this time, it is important to closely monitor the type of structure applying a training load to the body.

During an evaluation of functional anatomical relationships, it is necessary to take into account the age of the probands. These parameters should be considered constant only after growth has been completed. Gradual maturation of various tissues and disproportionate growth of individual segments are the underlying reasons where lack of knowledge or incorrect assessment can lead to incorrect diagnosis and introduction of a therapy that may be pointless or harmful. It is particularly important to take into account disproportion, instability and gradual development in the extent and, especially, in the content of physical loading of children and adolescents. In children, we must also take into account interindividual variability of physical and psychological development. Among children of the same calendar (chronological) age, it is possible to observe a different level of morphologic and functional signs. A difference exists between an arbitrarily set expected level and an actual level corresponding to a concrete biological age.

STANDING During standing postural examination, we first concentrate on the extent and distribution of muscle tone and the balance of positions between individual segments. In faulty body posture, the distribution of pressure acting on joint surfaces is not balanced, which negatively influences their function. Anatomical disharmony (sacral dysplasia, femoral anteversion or valgus, kyphotization of vertebral bodies after a course of Scheuermann’s disease, etc.), whether neurological or functional (abnormal postural development, cultural and esthetic factors that influence body posture, etc.), leads to the disruption of stability and complications. Examination of Individual Body Regions Spine During the examination of the spine, we focus primarily on its symmetry and that applies to the frontal (Fig. 1.1.1-7) as well as sagittal

plane (Fig. 1.1.1-8). The principle of optimal or complete symmetry in the sagittal plane during standing (and during walking) is the projection of the center of mass into the ground in the region of the support base. Relaxed standing is characterized by minimal muscle activity and optimal loading of static and dynamic structures of the movement system. Fig. 1.1.1-7 Vertical axis in the frontal plane during physiological scenario

Fig. 1.1.1-8 Vertical axis in sagittal plane during physiological situation

Different situations result from instability. Changes in the curvature in one segment elicit a reaction in the entire spine. Symmetry in a curved spine is best determined by a vertical plumb line – and line of gravity (see chapter 1.2.1 Kinesiology of the Spine, Pelvis, and Chest, Global Anatomical Parameters). The vertical axis is arbitrarily determined and certainly does not represent an actual projection of the center of mass. The position of the center of mass is individualized and it is related not only to posture, but also to each person’s habits. In a physiological scenario, the line of gravity passes behind the center of the femoral heads into the lower extremities. In reality, the line of gravity in healthy individuals is usually found near the center of mass of the trunk at approximately T9 and very close to the posterior edge of the sacrum. Deviations from this position lead to a balance deficit. To achieve

such balance, co-activation of the extensor and flexor muscle systems is needed. On one side, there are spinal extensors (primarily deep extensors), on the other side, there are deep cervical flexors and muscles that form and regulate intra-abdominal pressure (diaphragm, abdominal and pelvic floor muscles). Unbalanced standing is at first corrected by higher muscle activity accompanied by hypertonia, then pain appears and, later, a deformity forms. The necessity of excessive muscle activity occurs not only in standing, but also during any other movement (for example, when lifting a heavy object).The balance deficit is corrected not only structurally, but also centrally (sensory postural presentation) and so the patient perceives any postural correction as unnatural and, in the corrected posture, feels as if not standing straight. When observing from behind, we focus on the deviations of the spinal position in the frontal plane, including chest rotation marked by the prominent posterior angles of ribs and contralateral concavity under the chest wall. Evaluating symmetry in the frontal plane is significant for scoliosis. We also assess the position of the head and neck, where we primarily focus on forward positioning. If we observe in a patient unilateral flattening of the back of the head and rotated position of the head during observation of an object that is placed directly in front of the patient, we consider a deficit in the development of head position. Predilection (predetermined) positioning of the head, which is physiological only in the newborn developmental stage, can persist into later months, which leads to an abnormal postural development. In individuals with these postural deficits in childhood, at a later age, we observe a deficit in the assessment of sensory input – especially the assessment of proprioceptive and vestibular information, in which a patient with a tilted head position perceives, for example, that their head is straight and displays a limited range of visual field, including perception. We observe the tone and symmetry of the upper trapezius and sternocleidomastoid muscles. Further, we focus on the proportion

between sternocleidomastoid and scalene muscles. With incorrect body posture, the neck is prominently slender, but with significantly visible flexors. The head is held in a slightly forward position with increased cervical lordosis and extension at the cervicocranial transition. From the front, we focus on the assessment of muscle tone of the abdominal musculature, which should be symmetrical. Typical dysfunction is an increased activity of upper abdominal muscles accompanied by drawing in of the abdominal wall (Fig. 1.1.1-9). This posture is called an hourglass syndrome. With such body posture, during a postural reaction, the inverse (paradoxical) diaphragm function is present, thus punctum fixum of the diaphragm is on the centrum tendineum and, during diaphragm function the lower ribs are pulled in and move cranially with the sternum. Through the sternum, cranial movement is transferred into the upper ribs, which are further elevated by the activity of accessory breathing muscles which leads to the expansion of the upper part of the chest wall, specifically in the anterior-posterior direction. In such individuals, we can also observe paravertebral hypertonia, or hypertrophy of paravertebral muscles in the region of lower thoracic and upper lumbar spine related to the significant activity of the lumbar portion of the diaphragm. These muscles stabilize only the insertions of the diaphragm. This stabilization (of posture) is evidenced by a weakened function of the diaphragm with postural stabilization and a non-physiological type of breathing. Fig. 1.1.1-9 Imbalanced muscle tone of abdominal musculature. The shape of the abdominal wall resembles an hourglass.

Further, we observe the position of the shoulders. Their protraction is the expression of dominance and often also shortening of the pectoral muscles. The chest wall is elevated during an effort of the scapular adductors to position the shoulders into midline. Pelvis The pelvis plays an essential role in physiological balance of body posture. The position of the pelvis reflects deviations from extremities as well as the trunk. Deviations in pelvic alignment might be in the anterior-posterior direction (anteversion, retroversion), or the pelvis might also be shifted in a lateral, oblique or a rotated position or be in torsion. Pelvic anteversion and retroversion present the most common disturbances. The position of the pelvis in the anterior-posterior direction is dependent on the balance between the paravertebral

muscles and the muscles that influence intra-abdominal pressure – the abdominal muscles, pelvic floor muscles, and also the diaphragm. Particularly important is muscle balance of the muscles with attachments to the pelvis that influence the lower extremities – ischiocrural muscles and hip flexors (iliacus, rectus femoris, sartorius, tensor fascia latae). In a normal scenario, the posterior-anterior angle between the posterior iliac spine and the pubic ramus is 30°. During a faulty angle of the pelvis (especially during pelvic anteversion), the pelvic floor muscles do not react adequately to the increased intraabdominal pressure elicited by the contraction of the diaphragm during inspiration and postural stabilization. The result is an increased activity of the paravertebral musculature. Physiological Obliquity of the Pelvis, or its deficits, mainly determines pelvic tilt (PT), version pelvine and sacral slope, pente sacree (sacral alignment) and the pelvic radius angle (PRA) – the angle of the pelvic lordosis. For explanation and closer description of these terms see chapter 1.2.1 Kinesiology of the Spine, Pelvis and Chest, Regional Anatomical Parameters. If the pelvic tilt is greater, even substantially larger shearing forces in the lower segments of the lumbar spine can be expected. Steep pelvic position (pelvic incidence angle, PT – pelvic incidence presents the angle between the femoral heads and a vertical axis leading through the center of the sacral ledge) above 63° results in a compensatory lumbar hyperlordosis. When the hip flexors are shortened, the hyperlordosis is secondary and, in such case, the hyperlordosis is deep and limited only to the segments of the lumbar spine. If it forms during childhood or at a young age, it is accompanied by a relatively noticeable but short thoracic kyphosis. One of the main reasons is a dysfunction in the anterior stabilization of lumbar spine that is secured by the joint effort of the abdominal muscles, the diaphragm and the pelvic floor. Because of a functional insufficiency of this synergy, pelvic anteversion is more of a secondary consequence during primary hyperlordosis of a lumbar spine that is lengthened and reaches all the way to the mid-thoracic spine. This alignment is always accompanied by weakening of the scapular

stabilizers. Pelvic retroversion (PI smaller than 43°) also presents an unstable situation that leads to lordotic flattening (“flat back”) with subsequent negative consequences. Sometimes this may be a compensatory mechanism for the spinal canal narrowing. Laterally tilted position of the pelvis is most commonly the result of asymmetrical length of the lower extremities (functional and anatomical). Leg length discrepancy leads to a slight lateral pelvic shift that serves as a compensatory strategy to even out a tilted pelvis. Lateral shift of the pelvis is a frequent compensatory mechanism for a disc lesion in the lower segments of the lumbar spine. Pelvic torsion is related to the term sacroiliac shift, or SI block. In most cases, this dysfunction (which is always linked to an increased tone in the iliacus muscle and hip external rotators) is more of a secondary reaction than a primarily established deficit. It requires a thorough functional differential diagnosis. Pelvic rotation is often linked to an asymmetrical development that does not always have a causative explanation. Outflare, or inflare, is a significant pathological deficit in the pelvic alignment. The deficit lies in the fact that on one side, usually the right, the superior inferior iliac spine (ASIS) is flattened and farther from the umbilicus (outflare); and on the other side, usually the left, it is more prominent and closer to the umbilicus (inflare). Thorax A correct alignment of the thorax is essential for muscle balance in order to eliminate disadvantageous forces acting during body posture and movement (Fig. 1.1.1-10). Only a few biomechanical studies have been devoted to the shape of the thorax and its alignment in relation to postural functions. The role of the thorax is primarily studied in relation to breathing. With symmetrical muscle activation, the thorax is positioned so that the anterior-posterior axis between the insertion of the diaphragm pars sternalis and the posterior costophrenic angle is angled nearly horizontal.

Upper and lower stabilizers of the thorax, that is the pectoral muscles on one side and the abdominal muscles on the other, are in balance. A very common deficit from this aspect is an inspiratory position of the thorax with a movement dysfunction at the costovertebral joints. This dysfunction is compensated for by spinal movement, seen during breathing. With inspiration, the spine is moving into extension and with expiration into flexion. During straightening of the thoracic spine, the whole thorax automatically positions itself into an inspiratory position. Inspiratory position of the thorax is being coupled with pelvic anteversion – a so called open scissors syndrome (Fig. 1.1.1-11). For correct balance of acting forces in the thorax area, it is also important for the thorax to be “positioned” above the pelvis. The most common deficit is a forward shift of the thorax as a result of faulty spinal curvature in the sagittal plane – called forward-shifted thorax (Fig. 1.1.1-12). During faulty spinal curvature, it is possible to observe positioning of the tip of the thoracic kyphosis at a point behind the lumbosacral junction (Fig. 1.1.1-13). For physiological stabilization function of the spine, the shape of the thorax is important. Common deviations of the shape of the thorax are linked mainly to the angle of the ribs. Fig. 1.1.1-10 Physiological alignment of the thorax

Fig. 1.1.1-11 Open scissors syndrome

Fig. 1.1.1-12 Forward-shifted thorax

Fig. 1.1.1-13 Backward shifted (inserted) thorax

A narrow thorax (so called asthenic thorax) is flat in the anteriorposterior direction with the ribs markedly hanging and narrow intercostal spaces. An asthenic chest is characterized by a relatively marked difference in the circumference of the thorax during inspiration and expiration, meaning significant breathing excursion and a relatively good ventilatory efficiency. The opposite of an asthenic chest is a barrel chest for which horizontally running ribs and wide intercostal spaces are typical. The chest appears to be in a persistent inspiratory position and has a small ventilatory efficiency. It is often linked to an abnormal postural development and it is anatomically unfavorable with respect to a stabilization function. The most marked deviation in shape is the position of the posterior angles of the lower ribs in relation to the spine. If the position is excessively ventral, meaning in front of the spine, the function between the spinal

extensors and intra-abdominal pressure cannot be balanced. An accompanying phenomenon with this shape deficit is an over activity of the paravertebral muscles and more pronounced susceptibility toward vertebrogenic complications (including discogenic). The shape of the chest is linked to the position and the shape of the diaphragm. With a barrel chest, it is positioned higher and it is less arched. This position is associated with weakening of the postural potential of the diaphragm. For metric and functional assessments, the circumference of the chest is measured (at the nipple level or just above them in women) during inspiration and expiration. The arithmetic mean of the two values is the so called middle circumference of the thorax. The difference between the circumferential values of inspiration and expiration should be approximately 10% of the calculated average circumference. We also assess the asymmetry of the chest wall, unilateral prominence, the degree of rotation; and we also pay attention to pigeon or funnel (hollow) chest deformity. Scapulae The topic of dysfunctions related to the deviation in the alignment of the scapulae is quite varied and, therefore, we will only focus on some of these dysfunctions. For scapular alignment, it is important to primarily evaluate the position of the vertebral (medial) border in relation to the spine and the position of the scapular inferior angle. The medial border of the scapula is positioned parallel to the spine. External rotation of the scapula is indicative of the prominence of the shoulder adductors, upper trapezius and pectoralis major and weakness of the lower scapular stabilizers, esp. serratus anterior. The stabilization activity of the scapular musculature is dependent on the position of the thorax and the interplay of the diaphragm and the abdominal muscles, which form a punctum fixum (fixed end) for the function of the chest. During an inspiratory position of the chest, this stabilizing function is not achievable. A neutral position of the scapulae is not achieved by the pulling of the scapular muscles toward the spine, or adduction, which is often

recommended for correction of a rounded back posture. This position markedly overstresses the spine by extensive isometric activity of the scapular adductors. Dominance of the scapular adductors versus the serratus anterior leads to flattening of the thoracic spine. In the neck region, we focus our attention on the tone of the upper and middle parts of the trapezius. Increased tone in these muscles limits the rotational function of the upper thoracic spine and, thus it leads to the overstressing of the lower cervical spine (Fig. 1.1.1-14). Fig. 1.1.1-14 A patient with increased tone in the upper part of the trapezius on the right. This condition leads to an overload of the lower cervical spine.

The connection between the thorax and the shoulder blade is secured mainly by the serratus anterior, which participates in shoulder abduction. During abduction, it stabilizes and rotates the scapula via the inferior angle laterally. The upper part lifts the superior angle of the shoulder blade, the middle part is an antagonist (during stabilization it acts as a synergist) to the transverse fibers of the trapezius and the lower part allows for abduction. When the stabilizing function of this muscle is impaired, the inferior angle of the scapula is rotating medially, protruding from the spine along the medial border (margo vertebralis), and an abduction above the horizontal plane is also stagnating. This dysfunction in the stabilizing action is evident by a protruding scapula and it is called scapula alata. The correction of the scapular misalignment (scapulae alatae) must come first from changing the stabilizing function of the thorax.

Lower Extremities The lower extremities are evaluated, on the one hand, individually and, on the other hand, as a comparison of the differences between the two sides. In the lower extremities, we evaluate the presence of flat feet (pes planus) or increased foot arches (pes cavus). We check the alignment of the calcaneus and the degree of valgus or varus (Fig. 1.1.1-15). The entire picture comes not only from the alignment, but also from the configuration of the calcaneus. The configuration is more quadratic (it should have a spheric shape) on the side that is stressed more and the patient’s foot contact on the mat consists of a wider area. Fig. 1.1.1-15 Position of the calcaneus in standing. a – balanced physiological stance; b – calcaneal varus; c – calcaneal valgus

We are noting hammer toes and hallux valgus. We observe genu valgum, varum or recurvatum at the knee joints. During assessment of the symmetry of the lower extremities, we observe the corresponding levels of the heads of the fibula and popliteal crease; we assess the height of the corresponding greater trochanters. With regard to the hip joints, it is important to assess the inner contour of the thigh. If it is more pronounced in its distal half, it is indicative of shortening of one-jointed (short) hip adductors and relative weakness in the double-jointed (long) hip adductors. According to V. Janda, this state is typical for two clinical scenarios: a lesion in the hip joint and a proximal type of ambulation. One can suspect certain overloading of the hip joint during a stride. In conjunction with the hip joint, we note prospective excessive internal or external femoral rotation. Increased tone in the ischiocrural

musculature accompanied by a slight flexion in the knee joint in standing often presents as a compensatory consequence to narrow of the spinal canal (not only primary, but mainly one developed secondarily). In the region of the lower leg, we observe the configuration of the tibialis anterior, in which slight atrophy or decreased tone (hypotonia) in the proximal part is a frequent sign of a radicular syndrome of L5. From the front view, we focus on the configuration of the quadriceps femoris and patellar alignment. We are interested in the resting muscle tone and trophic balance in all individual heads. Simply said, hypotrophy in the region of vastus medialis, or the prominence of rectus femoris, generally suggests a predisposition for an onset of orthopedic dysfunctions of the knee joint or it is caused by their consequences. An increased tone in the quadriceps femoris is also considered to be non-physiological in standing. In a physiological case, the knees are positioned inward (valgus) at an angle of 13–18° (normal Q angle) with the patella facing straight forward and not shifted to the side. If the patient is sitting on the table with knees bent over the edge, the inferior angle of the patella should be leveled with the groove of the tibiofemoral joint. Patellae can so called “squint” when they are positioned medially or look like the eyes of a bullfrog, fish or a grasshopper. Medial or lateral patellar tilt can result in abnormal wear and tear of the joint surface and may become a cause of a patellofemoral maltracking syndrome. A patella may be positioned cranially, so called patella alta, or caudally, patella baja. Femoral medial torsion or tibial lateral torsion may lead to medial patellar dislocation (Fig. 1.1.1-16.

Fig. 1.1.1.-16 Various possibilities in patellar alignment in relation to the knee joint. a – patella baja; b – normal patella; c – patella alta; d – “squinting” patella; e – bullfrog patella

Modified Examination of Standing Following the inspection of normal standing, we assess the following modifications: Assessment in relaxed standing and in standing with feet together and eyes closed (Romberg II and III). Uncertainty during standing serves as an indication for subtle deficits in afferentation. Toe play, or rather its weakening, is often associated with radicular symptomatology of S1. Assessment in single limb stance (Trendelenburg test) gives information about stabilization of the pelvis by the hip abductors of the weight bearing extremity. The patient stands on one foot; the other is bent at the knee and hip. The test is positive if the pelvis drops on the side of the bent extremity. Assessment of Standing in Neurologic Disorders Standing is affected by peripheral and central vestibular apparatus, the cerebellum (especially its paleocerebelar part), and also by afferentation from the lower extremities. A deficit in any of these systems can reflect in a dysfunction of erect standing. We note the difference between open and closed eyes, whether a possible deviation is always in one direction, and whether it is

dependent on head position. If there is a significant worsening of the standing position with eyes closed, with deviation from the vertical as far as falling, it is known as Romberg sign (it is positive in deficits of proprioception and, in contrast, negative in cerebellar dysfunctions). Cerebellar deviation is observed in the backward direction with slight tendency toward one side. It is the sign of a more serious condition. For detection of more subtle deficits in equilibrium, the modified Romberg standing II test is used with narrowing of the base of support, meaning standing in a heel-to-toe position or on one foot. With swaying or falling, standing should also be accompanied by a head rotation right and left to detect a possible dependency of deviation on head position, which is found with peripheral vestibular syndromes. With an acute vestibular deficit or when a unilateral nystagmus is observed, the deviation in standing is in the opposite direction than the quick component of the nystagmus. The deviation in standing is further accentuated by closing the eyes and it changes its direction based on head rotation. In central (so called brain stem) vestibular disorders, which may be present without other neurological symptomatology because the region of the vestibular nuclei is the most sensitive to the changes in blood supply, deviations in both directions alternately are found. In serious brain stem syndromes with other neurological symptomatology, the vestibular deviation can be unilateral, but then we also find bilateral pontine nystagmus.

GAIT Petra Valouchová, Pavel Kolář Ambulation is the foundational locomotor stereotype created during ontogenesis and based on phylogenetically given principles characteristic for each individual. It is a complex movement function in which impairments of movement or the nervous system may manifest themselves. The observation (aspection) of walking is the simplest form of a qualitative gait analysis. The basic prerequisite for a correct gait assessment via observation is the knowledge of step phases and

kinesiology of movement segments of the body in the individual phases of gait (Fig. 1.1.1-17).

Fig. 1.1.1-17 Individual phases of gait of the right lower extremity: 1 – initial contact of the right lower extremity, 2 – loading response (weight bearing phase), 3 – mid stance, 4 – terminal stance, 5 – preswing phase, 6 – initial swing phase, 7 – midswing, 8 – terminal swing phase

Phases of the Gait Cycle Terminology by Vaughan (1992) Heel strike, HS; Foot flat, FF; Midstance, MS; Heel off, HO; Toe off, TO; Acceleration; Midswing, MSW; Deceleration. Terminology according to Perry (1992) Initial contact, IC; Loading response, LR, 0–10%; Midstance, MS, 10–30%; Terminal stance, TS, 30–50%; Preswing phase, PSW, 50–60%; Initial swing, ISW, 60–79%; Midswing, MSW, 70–85%; Terminal swing, TSW, 85–100%. Types of gait according to V. Janda

Proximal (hip) – main movement of the lower extremities is carried out in the hip joints, during which time the foot minimally unwinds. Dominant muscles are the hip flexors, which tend to be overloaded and shortened. Distal – this type includes distinct unwinding of the foot and increased plantarflexion during the final phases of stance during gait. Plantarflexors of the foot and the toes are the dominant muscle groups. Hip movement is minimal. A person with this type of gait displays a noticeably greater shift in the center of gravity in a vertical direction. Peroneal – this type of gait is characterized by more pronounced knee flexion, hip internal rotation and foot eversion. Considering the great variability of anatomical-morphological structures of each individual and the individuality in individual ontogenetic development, these types of gait are only for orientation. In the clinical setting, we encounter a wider range of various qualities and stereotypes of ambulation. Examination of Gait in a Clinical Setting Observation of Normal Gait During clinical evaluation, the patient is bare foot wearing a swim suit or underwear. Gait is observed from front, back, and side views. Observation of individual body parts is carried out from bottom to top. At first, we note the type of foot contact (including the loudness of foot contact), unwinding of the foot and the dynamics of the foot instep. Symmetry as well as length and width of a step are assessed (Fig. 1.1.1-18). At the end of stance phase (the preswing phase), we note whether terminal knee extension is achieved as well as the angle of extension at the hip joint. If there is a problem with hip extension, then, as a compensatory strategy, anteversion and pelvic rotation as well as lumbar lordosis will increase. Limited extension in the hip might be caused by weakening or shortening of the hip extensors (gluteus maximus), or by reflexive changes in the hip flexors. Further, we observe the mutual alignment of the lumbosacral and

thoracolumbar junctions, which are positioned, in an ideal situation, directly above one another.

Fig. 1.1.1-18 Gait cycle – stance and swing phases, step length and width. A – stance phase (comprises 60% of gait cycle) starts with heel strike and ends with peeling off of the big toe. Swing phase (comprises 40% of gait cycle) starts with big toe off and ends with heel strike. 100% = one gait cycle, which is the period between two heel strikes of the same leg; B – contact area of loading of the sole of the foot during stance phase of the gait cycle (marked in red). From left to right: at heel strike, loading phase, midstance, terminal stance and at toe off; C – width of the step is examined from the back. Generally, it is narrower than the distance between the centers of the hip joints. Step length is assessed from the side view and it equals approximately 2–3 lengths of the sole of the foot.

From the back, movement of the spine and the pelvis are observed. The spine, which rotates during ambulation, should not significantly bend or increase in lordosis. A distinct bend of the trunk toward one side may be a compensatory mechanism for weakening hip abductors. Increased lordosis of the lower thoracic spine (thoracolumbar) is a sign of a less than perfect co-activation of the deep abdominal musculature, diaphragm and pelvic floor with subsequent hyperactivity of the paravertebral muscles. Movements of the spine are evaluated according to lateral shifting, angulation during single limb stance phase of gait, and pelvic rotation in the transverse plane. During ambulation, the pelvis shifts slightly to the side and it is always to the side of the weightbearing lower extremity. Physiologic lowering of the pelvis during single limb stance on the side of the swinging lower extremity is 5 degrees. Greater pelvic drop is a sign of weak pelvic abductors. From the frontal view, we assess symmetrical involvement of all abdominal muscles and observe whether there is any excessive activation of rectus abdominis during walking. At the thorax, the position of the shoulders, rotation of the upper thorax, and, with it, any co-movement of the upper extremities are all noted. The shoulder complex should be freely lowered with the shoulder blades in a midposition without any protraction or retraction. In an ideal situation, upper extremity movements originate from the shoulder joint and are a natural continuation of a spinal rotation. The extent of movement in the shoulder joint is approximately 45° during ambulation with greatest participation from arm extension. Given pelvic rotation, the shoulder complex and the thorax always administer counter rotation with the apex of rotation at the T7 region. Head position and potential head movements are also noted. Examination of Modified Ambulation By examination of modified ambulation, disorders that do not always manifest themselves during normal gait can be identified or deficits that have already been identified during the observation of normal gait can be confirmed:

Ambulation with a narrow base – walking on a line may reveal a deficit in dynamic balance caused by a lesion in the central nervous system (cerebellum, basal ganglia); Ambulation on a soft surface – gives information about the quality of proprioceptive input processing; Backward ambulation – reveals limitation in hip joint extension, which can be caused by weakening of hip extensors or by shortening of the flexors; Ambulation with elevation of the upper extremities while carrying a leveled board – confirms lateral instability of the pelvis (weakening of hip abductors), which was observed during normal ambulation; Ambulation with a simultaneous cognitive task (counting, singing, names of closest family relatives) – eliminates conscious control of ambulation so that the otherwise undetected deviations during normal ambulation can manifest themselves. Ambulation at various speeds – greater speed accentuates gait deviations. Ambulation with outside support (assistive device) – ambulation with a brace, bandaging, orthopedic footwear – can assess whether the quality of gait changes when prosthetic devices are used. Laboratory Examination of Gait Kinematic analysis is an analysis of changes in the position and orientation of body segments in space and the degree of changes in the angle between segments which correspond to linear and angular speed and acceleration of body segments. Kinematic measurements may be carried out in 2D (two-dimensional) and 3D (threedimensional) space. Three-dimensional measurement requires scanning a moving subject by two or more video cameras. Kinetic analysis utilizes tensometric platforms that measure the magnitude and direction of reaction force vectors on the bottom of the foot during stance phase of gait. Measurement of pressure forces uses a contact carpet for measuring the layout of pressure forces during loading on the bottom of the foot.

Typology of Gait Dysfunctions from a Neurological Perspective Gait is a result of a complex controlled mechanism in which the spinal cord, brain stem, cerebellum, basal ganglia, thalamus and cerebral cortex are involved. Feedback is formed practically by all proprioreceptors and exteroreceptors of the movement system. Interoreceptors are also activated (for example receptors that are involved in regulation of breathing). Even a completely miniscule movement of a lower extremity elicits an immediate reaction in the stabilizing musculature of the axial system. A normal gait cycle depends on an integrated activity of all the mentioned regulatory loops. Regulatory loops of the cerebellum and basal ganglia possess a significant importance for gait control. Some regions of the basal ganglia and cerebellum are thought to be systems that integrate automatic movement stereotypes (for example, gait with synkinesis of the upper extremities). Cerebellar regulatory loops process information from a wide, afferent excitable area. The cerebellum in this function can be pictured as a computer with a goal to optimize muscle activity so that it is maximally efficient and, at the same time, accurate. Activity in the cerebellum appears even prior to the movement initiation. The fact that the cerebral cortex participates in the control and regulation of gait testifies to the existence of optical righting reflexes (an animal can stand up with their eyes open, but cannot do it with eyes closed even after the removal of vestibular receptors in the labyrinth and denervation of the neck musculature), which are very important in a human, even more important than in animals. Gait dysfunctions occur due to a loss or a limitation in function of certain regulatory loops. In central paralysis, gait dysfunctions are not always caused by only increased and unregulated muscle tone, but almost always also by deficits in perception or balance. Spastic Gait Spastic gait is caused by a lesion in the descending nerve tracts which act to inhibit muscle tone. It is characterized by a toe-touch foot contact, by the inability to achieve a foot flat position, or by

hyperextension of the knee joint. The reason for this is pes equinus. Given the lack of selective movement, heel strike and support function occur as a whole (“en bloc”) without sufficient differentiation in individual joints. The swing phase is coupled with pelvic rotation without the necessary bend in the knee. Spasticity with lesions in a central motor neuron is often accompanied by noticeable weakness, which is also manifested in gait. Based on the localization and extent of a dysfunction, we can distinguish the following types of gait: Gait in spastic paraparesis – both lower extremities are affected. This type of gait pattern is observed, for example, with extramedullary tumors, multiple sclerosis, etc.; Gait with spastic hemiparesis – absent are co-movements of the upper extremity on the affected side. The upper extremity is positioned in elbow flexion and pronation and it is weakened. The lower extremity shows limited knee and ankle flexion, foot is in plantarflexion and inversion. During gait, the patient circumducts the affected extremity and drags the lateral border of the foot on the ground. Hemiparetic gait is present in patients who suffered a cerebrovascular accident, brain injury, etc.; Gait with spastic diparesis or triparesis (infantile cerebral palsy) – child ambulates on their toes with knees together, sometimes as far as scissoring (this is a sign of contracture of hip adductors) and moves via trunk rotation around the body axis. The pelvis and hips are moving as a whole. Flaccid Gait with a Disorder of the Spinal Motor Loop Spinal motor loops include, on the one hand, efferent and afferent tracts with receptors in muscles, tendons and joints and, on the other hand, a central part, meaning nerve cells in the spinal cord. Gait dysfunction depends on the extent and location of the damage of a given part of the spinal loop. The main reasons include pressure, injury, inflammatory illnesses (polyneuritis, poliomyelitis) or toxic harm. Based on the extent of the damage and the location, we distinguish

the following: Monoparesis or paraparesis of the lower extremities with damage to the lumbosacral plexus. Most frequently, the distal part of a lower extremity is affected. Clinically, this deficit is manifested by the lower extremities being dragged behind, foot drop, and taking shorter steps. Ambulation is practically impossible without support or crutches. Peroneal gait, also called rooster gait, appears with damage to the peroneal nerve. During ambulation, the patient lifts the lower extremities high because they cannot perform ankle dorsiflexion and, therefore, step on the toes first and then onto the heel. Ataxic Gait It develops with damage to the posterior spinal tracts or cerebellum, thus muscle coordination is affected. This includes either tabetic gait or cerebellar gait. Tabetic gait – the posterior spinal roots and tracts are damaged (tabes dorsalis, neuroanemic syndrome). Decreased or lost proprioceptive signalization (as a result of a lesion in the posterior spinal tracts) from the periphery, muscles, bones and joints that give positional information of individual body segments is the pathophysiologic foundation for a functional disturbance. The loss of sense of position leads to the patient’s decreased balance, inability to correctly weight shift from one extremity to the other, and falling easily. Disturbance of movement and coordination often worsens the fear of falling. Cerebellar gait – results from an injury to the cerebellum. Gait has a wider base, the patient walks as if “drunk”, upper extremity comovements are increased and the trunk is leaning backwards. Sometimes ambulation is not possible. The signs are based on a probable dysfunction of mechanisms that evaluate feedback information in which regulation by the cerebellum participates. Parkinsonian Gait Gait disturbance develops because of a disruption in the integral systems of movement automation. Parkinsonian gait occurs with

damage to the pallidum. It is characterized by short, shuffling steps and slow steps (bradykinesia). Also, co-movements of the upper extremities are limited or absent. During gait, the whole body, including the extremities, is in slight flexion. The patient has difficulty with step initiation and stops in front of an unexpected obstacle. As a result of slight flexion of the whole body, the center of mass is shifted forward, which increases the propensity of falling forward. The patient does not possess the correct coordination between antagonistic muscle groups and lacks smooth volitional movement. Ambulation requires more control from the cortex, which leads to increased fatigue. Hyperkinetic Gait Hyperkinetic gait appears with damage to the striated system. Ambulation is accompanied by non-volitional movements. This is particularly significant with chorea minor and athetosis. Vestibular Gait Vestibular gait develops with damage to the vestibular apparatus. It is characterized by the inability to ambulate straight and a tendency toward falling. It is a result of a disturbance in muscle spindles transposed from a damaged vestibular apparatus via Gamma (γ) fibers. This results in a dysfunction in coordination of muscle tone and balance. This might be instigated by a disorder in an afferent signalization with lesions in the inner ear, by damage to the vestibular nerve or vestibular nuclei in the brain stem, or by a supranuclear lesion. Waddling (“duck”) Gait This type of gait is characterized by shifting of the trunk above the support extremity with every step. Trunk shifting is caused by a dysfunction in pelvic stabilization by the hip abductors during gait or when standing on one extremity. Therefore, the Trendelenburg test is positive in this dysfunction. Duck walk is a sign of primary muscle palsies – myopathy found with hip joint impairment or a neurogenic involvement of the hip abductors (in some cases, weakness of hip abductors is a sign of L5 radicular syndrome).

Hysterical (functional) Gait It is characterized by dramatization and randomness of symptoms without organic damage. The patient walks with a narrow base (rope line walking) or scissors the lower extremities. They always fall cautiously and in the direction of expected safety so that they do not hurt themselves. It is a symptom of hysteria. Antalgic Gait Antalgic gait develops with pain, for example, in the lumbosacral region, hip or knee joints. The type of antalgic gait indicates the cause of problems. Examination of Postural Stabilization and Postural Reactibility Pavel Kolář When evaluating postural (stabilizing) muscle insufficiency, muscle assessment based on manual muscle testing is not sufficient. During manual muscle testing, that is testing based on the anatomical muscle function, the muscle can achieve maximal values, but its involvement in a concrete postural situation may be insufficient. Therefore, postural (stabilizing) muscle function must be examined via tests that assess the quality of muscle engagement and must also consider muscle function during stabilization. The following is assessed: Whether the joint deviates or maintains its neutral alignment during stabilization; During stabilization, into what extent are the deep and superficial muscles involved and whether their activity corresponds to the required force or whether it is excessive; During stabilization, whether over excessive muscle activation occurs, or whether muscles that are not mechanically related to a given movement are activated, in other words, to what extent is the stabilization activity referred into other segments; Symmetry, or rather asymmetry, in the involvement of stabilizing muscles and timing (succession) of their activation. The basis of this evaluation is the assessment of muscle

coordination that ensures the stabilization of the spine, the pelvis and the trunk as the basic framework for movement of extremities. During stabilization (reinforcement) of the spine and trunk, spinal extensors are always involved. At first, the deep extensors are engaged and the superficial muscles only become engaged during greater force demands. Their function is balanced by a flexor synergy which is formed by the deep neck flexors, and an interplay between the diaphragm, the abdominal musculature and the pelvic floor muscles. During stabilization of the spine, the diaphragm is contracted, its contour is flattened (descent of the dome); this occurs independently of the breathing pattern. The contraction of the diaphragm, or rather its flattening, occurs even without breathing (Fig. 1.1.1-19). The flattened diaphragm puts pressure on the contents of the abdominal cavity, which acts as a viscous-elastic column, therefore increasing intra-abdominal pressure. The lower aperture of the thorax and the abdominal cavity are widened. From a functional and biomechanical perspective, the position of the anterior-posterior axis of the diaphragm, respectively the centrum tendineum, is significant. This is the axis between the insertion of the pars sternalis and the costophrenic angle. The position of the axis arises from the initial positioning of the thorax during a contraction. During a physiologic scenario, it is positioned almost horizontally (see Fig. 1.1.1-10). An angled position of the diaphragm axis in the sagittal plane and insufficient expansion of the lower aperture of the thorax during stabilization are linked to an increased activity, or rather over activity, of the spinal extensors (Fig. 1.1.1-20 and Fig. 1.1.1-21). To maintain a caudal position of the thorax during diaphragm activation, activity of the abdominal muscles (lower stabilizers of the thorax) must be balanced with the pectoral muscles, scalenes, and sternocleidomastoid (upper stabilizers of the thorax). The synchronized activity of the pelvic floor contributes to a change in the intra-abdominal pressure; for the resultant force vector, the pelvic inclination is, therefore, also important. During the influence of external forces, the abdominal muscles are functioning as lower stabilizers of the thorax. The role of the abdominal muscles is to prevent cranial co-movement of the

thorax during stabilization and to ensure that the thorax occupies a constant position in the transverse plane (neutral position). The thorax forms a punctum fixum, which allows for the contraction of the diaphragm. Insufficient flattening during activation is a typical pathological picture in the function of the diaphragm. The diaphragm is contracted inversely, which means that its costal part activates in the direction of the central tendon (centrum tendineum). This leads to the ribs, to which the diaphragm is inserted, being pulled in. Consequently, the diaphragm flattens more in the lumbar section with a distinct participation of paravertebral muscles stabilizing its insertional region (see Fig. 1.2.1-27).

Fig. 1.1.1-19 Caudal shift of the diaphragm may be noticed even during its nonrespiratory activity that is during its postural function. Upper blue line marks the resting expiratory position of the diaphragm in a sagittal plane; lower blue line marks the position of the diaphragm after activation of the upper extremities against resistance without accompanied breathing activity. Fig. 1.1.1-20 Schema of the syndrome of open scissors.

Fig. 1.1.1-21 Syndrome of open scissors in a patient with chronic vertebrogenic problems

Following the diaphragm flattening, the abdominal muscles, by their concentric or isometric activity, help increase the intraabdominal pressure – thus the stabilization phase begins. The degree of the diaphragm contraction (basal flattening) and the activity of the abdominal muscles acting against the lower thoracic and abdominal cavities are dependent on the magnitude of external forces. During the action of the external forces, respiratory movements occur with a flattened convex contour of the diaphragm, meaning during increased basal tension. During the action phase, the cooperation between the diaphragm and the abdominal muscles is absolutely essential; during an increased tonic tension, the abdominal muscles eccentrically retract the inspiratory contraction of the diaphragm. Should this cooperation be disrupted, the upper stabilizers of the thorax will become engaged in respiration, which again leads to an insufficient frontal stabilization of the spine and an overload of the spinal extensors. If the recruitment of the spinal and thoracic muscles during a reaction to outside stimuli is disrupted, disproportional loading and postural instability occur. Under the influence of stereotypical overloading, the disrupted function then becomes its own etiological factor of an anatomical finding and the source of difficulties. In a majority of patients with movement deficits, characteristic

deviations in the stabilizing muscle function is observed. Their detection allows for an assessment of provoked postural activity. Extension Test (Fig. 1.1.1-22) Starting position: Patient is prone. The test might be administered in two modified positions of the arms: Fig. 1.1.1-22 Extension test

1. Arms along the body in mid-position 2. Arms are flexed and supported on hands Test administration: patient lifts the head above the mat and proceeds with a movement into slight spinal extension, where the movement is stopped. The following is observed: Coordination of the involved back and lateral group of abdominal muscles; Involvement of ischiocrural musculature and the triceps surae; Position and co-movement of the shoulder blades; Pelvic reaction. Physiological coordination: during extension, following the spinal extensors, the lateral group of abdominal muscles is activated. Assessed is the balance between the spinal extensors, the lateral group of abdominal muscles, and the activity in the ischiocrural muscles.

The pelvis stays in mid-position; it does not move into anteversion and support is at the level of pubic symphysis. The signs of disturbance in stabilization: during extension, there is a significant activation of the paravertebral musculature with maximal activation in the lower thoracic and upper lumbar spine regions. The lateral group of abdominal muscles is not activated (or only minimally activated). The sign is a convex arching of the lateral group of abdominal muscles, primarily in their lower part. The region of the thin aponeurosis of the transversus abdominis origin is pulled and becomes concave. The pelvis tips forward into anteversion and support is transferred to the level of the umbilicus – this sign is characteristic for patients with pain in the lumbar spine (typical finding with this sign is spondylolysis, or acquired spondylolisthesis). Inferior scapular angles rotate externally as a result of the increased activity of the shoulder adductors. Excessive activity of the ischiocrural muscles is a significant pathological manifestation, sometimes even linked with activity in the triceps surae. Under normal circumstances, these muscles are activated only to a minimal extent, and the patient is able to relax these muscles during spinal extension. With a pathological finding in the lower lumbar spine, a reflexive and premature activity occurs in the ischiocrural muscles on the side of irritation (projective pattern). Increased activity in the mid-part of the ischiocrural muscles and the mid-region of the calf is indicative of irritation in the S1 region; with L5 nerve root involvement, the lateral part of thigh muscles typically shows increased activity. During extension, an increased contraction of the gluteus maximus is observed on the side of nerve root involvement. Trunk Flexion Test (Fig. 1.1.1-23) Starting position: patient supine. Fig. 1.1.1-23 Trunk flexion test

Test administration: the patient slowly flexes the neck followed by the trunk. The lower false ribs are being palpated at the mid-clavicular line and their co-movement is assessed. The following is observed: the action of the thorax during flexion movement. Correct pattern of recruitment: during neck flexion, the abdominal muscles become activated and the chest remains in a caudal position. During trunk flexion, there is balanced activation of the abdominal muscles. The signs of disturbance in stabilization: With head flexion, cranial synkinesis of the chest and the clavicles occurs, the chest is positioned into an inspiratory alignment and its shifting occurs as a result of increased extension at the thoracolumbar junction. Under the assumption of insufficient stabilization of the spine, during trunk flexion a lateral movement of the ribs and convex arching of the lateral group of abdominal muscles occurs; trunk flexion occurs with the chest in an inspiratory position; With flexion > 20 degrees, two pathological scenarios emerge: The lateral group of abdominal muscles arches, and often simultaneously, a diastasis recti becomes visible.

The upper part of the rectus abdominis and the lateral group of abdominal muscles are activated, which is manifested by an indentation (concavity) in the inguinal canal, the area above the femoral heads of the hips. This stereotype corresponds to the inverse function of the diaphragm (punctum fixum is located on the centrum tendineum). The Diaphragm Test (Fig. 1.1.1-24) Starting position: sitting with an upright posture of the spine. The chest is in a caudal, or expiratory position. Fig. 1.1.1-24 The Diaphragm Test

Test administration: dorsolateral palpation underneath the lower ribs and slightly against abdominal muscles in this region. Through palpation, the alignment and actions of the lower ribs are simultaneously checked. The patient is asked to create counter resistance with the lower part of the chest expanding (the anteriorposterior axis connecting pars lumbalis (vertebral/crural portion) and pars sternalis (costal portion) of the diaphragm is positioned almost horizontally) while the chest maintains a caudal alignment. During examination, the spine maintains an erect posture, i.e. it must not flex in the thoracic region. The following is observed: the way in which the patient is able to activate the diaphragm together with tightening of the abdominals

and of the pelvic floor. During activation, the symmetry, or asymmetry, of muscle activation is being observed. Correct pattern: the patient is trying to push the abdominal cavity and the lower part of the chest against the therapist’s palpating fingers. The lower part of the chest is expanding laterally and dorsally, the intercostal spaces are widening. The position of the lower ribs in the transverse plane does not change with activation; therefore, only lateral (not cranial) movement of the ribs appears. The signs of insufficient activation: The patient is unable to activate muscles against resistance, or activates only with a small force; During activation, the ribs migrate cranially. The patient is unable to maintain their caudal, or expiratory, position During activation, lateral chest expansion does not occur and, thus, an insufficient expansion of the intercostal spaces takes place; hence the stabilization of the lower segments of the spine is not achievable. Hip Extension Test (Fig. 1.1.1-25) Starting position: patient is prone, upper extremities placed alongside the body. Fig. 1.1.1-25 Test of Hip Extension

Test administration: The patient extends their hips against resistance. The movement is not performed by a maximal force. The following is observed: the contribution of muscle activity into hip extension by ischiocrural, gluteal, spinal extensors, and the lateral abdominal muscles. The signs of disturbance in stabilization: the gluteal muscles and the lateral group of abdominal muscles are not engaging. Lumbar lordosis deepens and the pelvis tilts into anteversion. The thoracolumbar junction and the thoracic spine become more kyphotic, spinal extensors are excessively activated with a maximum at the thoracolumbar junction. Support is transferred cranially. The region under the ribs lateral to the paravertebral muscles is drawn in concavely. The lateral group of abdominal muscles is drawn out convexly. Hip Flexion Test Sitting version (Fig. 1.1.1-26) Starting position: the patient sits at the edge of a table. The upper extremities are relaxed on the table, the patient does not lean on their arms during the test. The examiner’s upper extremities lean on the patient’s thighs and apply resistance against hip flexion. The inguinal region below inguinal canals above the femoral heads of the hip joints is palpated. Fig. 1.1.1-26 Hip flexion test – sitting version

Test administration: 1. The patient flexes the lower extremities alternately against resistance; 2. The patient slowly flexes their hip joints alternately without resistance, only against gravity; 3. The patient widens the pelvic cavity by increasing intra-abdominal pressure. The following is observed: Arching in the inguinal region of the abdominal cavity; Co-movement of the spine and pelvis; Coordinated activity of the abdominal muscles. The signs of insufficiency: During hip flexion against resistance, neither arching nor pressure against palpation in the inguinal region increase, which is indicative of an over activity of spinal extensors during stabilization and activity of the abdominal muscles above the area being palpated is insufficient; Superior anterior iliac spines, or pelvis, is tilting into anteversion or is drawn cranially by the activation of quadratus lumborum; In the thoracolumbar junction, lateralization or slight extension

occurs. The chest is moving ventrally and cranially; Upper part of the abdominal muscles is overactivated, umbilicus deviates laterally. Supine Version Starting position: patient is supine. Test administration: during expiration, via a tangential pressure on the lateral part of ribs, the patient’s chest is positioned into a caudal alignment. During this maneuver, it is important for the patient to relax their abdominal wall. In this position, the patient flexes their hip against resistance. The force they produce against the resistance corresponds to a grade 4 of manual muscle testing. The following is observed: Coordination of activity of the abdominal muscles and activity of muscles that insert to the upper aperture of the thorax; Chest stabilization. Correct stereotype: During flexion, the patient activates the abdominal wall; The chest remains in a caudal position; does not attain an inspiratory position; During resisted flexion, the pectoral (and possibly other) muscles are not activated Signs of insufficiency: During activation of the hip flexors, the chest attains an inspiratory position. The sternum shifts cranially and ventrally; In the region of the abdominal muscles, the upper regions of the rectus abdominis and the external abdominals are activated so that the umbilicus is moving slightly cranially. Activation of the extensors predominates; During lower extremity flexion, the lateral group of abdominal muscles does not get involved. During stabilization, the pectoral muscles are activated; activity is also observed in the muscles inserting into the upper aperture of

the thorax. Intra-Abdominal Pressure (IAP) Test (Fig. 1.1.1-27) Starting position: The patient sits at the edge of a table. The upper extremities are relaxed on the table; the patient does not lean on their arms during the test. The inguinal region is palpated medially from the anterior superior iliac spine and the femoral heads of hip joints. Fig. 1.1.1-27 Intra-Abdominal Pressure Test

Test administration: The patient activates the abdominal wall against the therapist’s pressure/resistance. The following is observed: The response of the abdominal wall to the increased intra-abdominal pressure. Correct pattern of recruitment: With diaphragm activation, first the abdominal wall bows out in the lower abdominal area followed by activation of the abdominal muscles. The signs of insufficiency: The pressure created against resistance is weakened; during activation, the upper parts of the rectus abdominis and the external obliques dominate. The upper half of the abdominal wall is drawn in and the umbilicus moves cranially. Activation of muscles in the palpated region without the bowing out of the lower abdomen is considered pathological. Examination of Breathing Pattern

Assessment of the breathing pattern is a very significant and “sensitive” gateway for assessment of the stabilization function of the spine. It allows for assessment of diaphragm activation and its cooperation, or its functional relation, to the abdominal muscles. From the aspect of kinesiology, we can divide breathing into diaphragmatic and costal. Starting position: The examination can be done in various positions – supine, sitting, or standing. The lower chest and one of the ancillary muscles are palpated. The following is observed: Motion of the ribs, respectively the chest. Diaphragmatic Breathing With diaphragmatic breathing (see Fig. 1.2.1-8), the diaphragm is activated (flattens) with inspiration, thus the internal organs are pushed caudally (for example, with inspiration, the kidney moves several centimeters caudally and with expiration cranially). The lower chest cavity and the abdominal cavity are evenly expanding. With physiological diaphragmatic breathing, the lower aperture of the chest expands along with the abdominal cavity. The sternum moves ventrally. During rib palpation, the intercostal spaces widen and the lower part of the thorax expands in its width and anterior-posterior dimension. The sternum does not change its position in the transverse plane. The accessory breathing muscles (for example, the scalenes, pectorals, and upper trapezius) are relaxed. Costal Breathing (Upper Breathing Type) During costal type of breathing (see Fig. 1.2.1-9), the sternum is moving cranio-caudally and the chest is expanding minimally. The intercostal spaces do not widen. The accessory muscles are engaged during inspiration. The quality of the breathing pattern and its control correlate with the results of clinical tests focused on the stabilization function of the spine. If a patient is unable to accomplish diaphragmatic breathing, it indicates an insufficient, or an interrupted, cooperation between the

diaphragm and the abdominal muscles. A frequent reason for this is the inability to relax the abdominal wall (especially its upper part). Test in the All-Fours Position (Fig. 1.1.1-28) Starting position: Patient stands with support on their palms and the front part of their feet (on metatarsal heads 1–5). The feet are shoulderwidth apart. Fig. 1.1.1-28 Test in the all-fours position

The following is observed: The alignment of individual segments and the manner of support with a non-amended assumption of a desired position. In a physiological scenario, the wrist, elbow, shoulder and scapulae are in a centrated position. Given this, the palms make full and equal contact with the mat for support. The scapulae are in a caudal position and stabilized on the chest, the spine is erect and the head is positioned as an extension of the spine. The ankle, knee and hip joints are in a centrated position along one axis. The middle of the knees point towards the middle of the feet, meaning they are positioned above the 3rd toe. Support is equally distributed between the metatarsal heads 1–3. Signs of insufficiency: Increased kyphosis in the lumbar and thoracic spine, reclination in the cervical spine (the individual is unable to straighten the spine); Lateral and inferior borders of the scapulae stand away from the rib

cage; Scapulae are elevated; Inferior scapular angles are externally rotated; Shoulders are in internal rotation; Hand support is shifted toward the hypothenar region; Femurs are in internal rotation; The alignment of the knees is outside the middle of the foot; The support on the front of the foot is not balanced. Insufficiency becomes more apparent with the body leaning more over the upper extremities. Variations for Administration Gradual unweighting of the extremities can be seen in Fig. 1.1.1-29).

Fig. 1.1.1-29 Test in an all-fours position. A – with unweighting of a lower extremity; B – unweighting an upper extremity

With correct performance, the unweighting of an extremity is isolated and without pelvic co-movement or changes in the alignment of the spine or in the position of the support extremities. During insufficiency of the stabilizing system of the spine, the following can be observed: Lateral flexion at the thoracolumbar junction; Increased kyphosis in the lumbar and thoracic spine, reclination in the cervical spine; Changes in the alignment of the segments of the supporting

extremities; Changes in the support of extremities; Concurrent movement of the pelvis – elevation and rotation on the side of the unweighted extremity. Deep Squat Test (Fig. 1.1.1-30) Starting position: The individual stands with lower extremities shoulder-width apart. Fig. 1.1.1-30 Deep squat test

Test administration: The patient slowly squats deep down from standing. During the squat, the shoulders and knees must not extend into the plane formed by the front part of the foot. Correct pattern: With squatting, the spine stays erect, meaning there is no increase in kyphosis or lordosis. The lumbosacral junction is in a centrated position – the pelvis is not tilted into anteversion, respectively retroversion. During the whole process of squatting, the center of the knee points above the longitudinal axis of the 3rd metatarsal. Foot support is equally distributed along the entire bottom of the foot and the toes. Signs of insufficiency: With more significant manifestations of an insufficiency, the individual is not able to attain a deep squat position under the

above described conditions; During the movement, increased lordosis or kyphosis of the spine occurs; Pelvis is tilting into anteversion, respectively retroversion; In the cervical spine, extension occurs and it increases the tension in the cervical extensors; Shoulders become elevated and increase the tension in the upper trapezia; Centers of the knee joints point medially from the 3rd metatarsal; Support is transferred onto the medial border of the foot.

1.1.2 Examination of Muscle Tone Pavel Kolář During assessment of disturbances in muscle function, the focus is on muscle tone (although, there is no single definition and its assessment is very complex and, to a certain extent, subjective). Muscle tone is the stipulation for all movement. From a clinical view, muscle tone is most frequently assessed as a degree of resistance and as the extent of passive movement in a joint, given that the examined segment is relaxed and the joint is not damaged. This is consistent with the definition by the American Association of Electrodiagnostic Medicine (AAEM), which defines muscle tone as a resistance during passive lengthening of the muscle. Through palpation, muscle texture can be assessed (for example, whether the muscle is weak or gives resistance to pressure). With the assessment of muscle tone, it is very important to compare both sides – a minimal increase in muscle tone may be considered normal if it is not different on either side. Nevertheless, even bilateral differences may not indicate anything significant; their causes may lie only in the dominant use of one extremity, or one side of the body, which happens in some sports (tennis, archery, etc.). With examination of muscle tone, it can be seen that its assessment via palpation does not have an outcome value and its deficits cannot

be regarded as a clinical unit (hypertonic and hypotonic syndrome). During an assessment, in addition to palpation, we also focus on the assessment of postural and locomotor functions, and reflexes, which reflect muscle tone more objectively than palpation. Two types of muscle tone can be distinguished: Muscle tone provided by the contractile structures of a muscle; Muscle tone provided by the connective tissue component, which is an innate part of the muscle. Reflex Regulation of Muscle Tone Muscle tone is the result of a complex regulatory mechanism. Regulatory loops pass through the spinal cord, brain stem, reticular formation, cerebellum, basal ganglia, thalamus and cerebral cortex. The proprioceptors, exteroceptors, and interceptors are activated in these reflex actions. Muscle tone is determined through the activity of the central and the peripheral sensory nervous systems on a spinal α- and γ-motor neuron. The simplest type of muscle tone control is at the segmental level. Here, it is ensured by a combination of functions of several feedback loops. Supraspinal control of muscle tone, which under normal circumstances is crucial, is mediated by motor pathways acting on α-motor neurons, γ-motor neurons and spinal interneurons. The cerebellum is a significant modulatory center for maintenance of muscle tone. A number of transmitters participate in the regulation of muscle tone. Among the most significant are the following: Glutamate – excitatory transmitter (it is released in the corticospinal tract and primary spinal Ia afferent fibers); Gamma Aminobutyric Acid (GABA) – modulates presynaptic inhibition and it is present in the lateral interneurons of the posterior spinal horns. Presynaptic inhibition decreases the afferent signalization from the muscle and skin and decreases the amount of released glutamate; Catecholamines and serotonin – are part of the descending pathways that regulate spinal reflexes.

Disturbances in muscle tone occur with a decrease in any of the regulatory loops or are a reaction to an afferent signal. The pathways regulating muscle tone are similar to the pathways that influence volitional and non-volitional movement. Deficits in muscle tone are exhibited during an examination of movement functions (for example, during assessment of locomotion, positional reactions in children, a test of isolated movements or an assessment of body posture). Connective Tissue Component of Muscle Tone Connective tissue reinforces a muscle and, at the same time, defines the boundaries of its mobility. The elasticity of connective tissue is maintained by its rhythmical loading, which maintains the length and the elasticity of the tissue. By retraction of the connective tissue stroma of a muscle, a limitation in the needed freedom of its fibers occurs as well as a limitation in the vascular flow through the muscle. Thus, the muscle is not able to achieve maximal activity and its work performance significantly declines. With increased tone in the contractile region, it is called a muscle spasm and, with connective tissue retraction, it is called a muscle contracture. Muscle tone deficits always alter the biomechanics of a joint and thus change the afferent signalization from the joint necessary for the control function of the central nervous system. Similarly, the joint system is influenced by deficits in the connective tissue system; these include shortening (retraction) as well as increased laxity (clinically manifested by joint hypermobility). Both deficits increase a mechanical demand on the joint and also the proprioceptive afferentation from it, this is the basis from which tonic changes in the corresponding muscles occur. The most frequent cause of deficits in muscle tone is one-sided loading often seen in a certain profession (i.e. static loading during computer work or by incorrect and uncompensated training). Thus, muscle tightness and muscle inhibition develop. Muscle tightness occurs based on the changes in connective tissue stroma. This encompasses a change in the elasticity based on morphologic and

cellular remodeling, therefore, the muscle shortens. This leads to a change in muscle force. In the first phase, the muscle is relatively stronger, but in the next phase, because of the compression influence on the contractile elements, the muscle weakens – muscle force declines.

Deficits in Muscle Tone Deficits in muscle tone are caused and influenced by a number of factors and are one of the most typical manifestations during CNS dysfunctions. A disturbance may manifest itself as either increased tone called spasticity and rigidity, or decreased muscle tone called hypotonia (typical, for example, during the damage to the peripheral nerve fibers – centripetal and centrifugal – and also with a cerebellar injury.) Muscle tone, or posture and movement, also change with deficits that cause nociceptive afferentation. It is a defense against movementelicited additional stimulation; at the same time it is a prerequisite for healing. In this case, the increased tone immobilizes a given region. Muscle tone is also closely linked to psychological stress. It was experimentally shown that our body posture and frequency of movements change during various emotional situations. Unilateral loading or muscle overload are often the cause of the deficit in muscle tone. Thus, muscle tone is “the language” or “the mirror” of the function of the CNS. The state of the CNS in which the internal influences reflect (almost all pathological situations ongoing in the organism), as well as external influences (i.e. long-lasting stressful demands), are on the surface manifested, among other things, via changes in muscle tone. Muscle tone is not only a manifestation of a static function, but it always manifests itself dynamically. Tone deficit = postural deficit (including postural reactibility) and locomotion deficit

In this scenario, we do not mean posture and locomotion only as synonyms to standing and walking. In clinical practice, muscle tone is a very commonly used term; however, its assessment is not simple because it is not definable in measurable units. For now, no means of an objective measurement of muscle tone exist and to objectify various functional situations is almost impossible. During an assessment, we base our findings on palpation, which is strictly a subjective factor, although crucial and underestimated. Considering the parallel between muscle tone and movement function, it is also necessary, during the examination to utilize the assessment of movement functions, where we have the ability to better objectify muscle tone and, at the same time, find out whether it is a harmful component. For example, for patients with spinal cord injuries or cerebral palsy, it is not always appropriate to therapeutically correct spasticity because, under certain circumstances, it poses as a benefit to a functional movement. With its relaxation (via botulotoxin or a surgery), we can cause a de-compensation in the movement system. Deficits in muscle tone are related to various causes, thus they also exhibit various forms – hypertonicity, spasm, contracture, trigger points, tender points, spasticity, rigidity, paratonia, hypotonia, or atonia. Hypertonia and Spasm Hypertonia is understood to be increased muscle tone, primarily in the reflex component of muscle tone. Hypertonia may be, under certain circumstances, physiological. Hypertonia needs to be distinguished from spasm. Spasm is a reflexive muscle contraction elicited by nociception or other pathological processes (for example, an infection). Contracture A contracture denotes all states of fixed muscle shortening. It involves a change in the connective tissue component of muscle tone, meaning it is fibrotic remodeling of a muscle. Unlike ankylosis, the resistance by a muscle is springy with a simultaneous increase in muscle tone.

Local Hypertonic Changes in Muscle Tissue Zdeněk Čech Muscle trigger points are the most widespread functional changes in pain deficits, and may even be the source of pain. These changes do not affect the whole muscle or muscle group, but only a certain part of a striated muscle, or only a bundle of muscle fibers. These fibers present during palpation as a variably painful spot within a stiff muscle bundle. Various terms are being used for this phenomenon, such as tendomyosis, myotendinosis, myogelosis, or fibrositis. In recent years, however, the most frequently used terms are myofascial trigger point (MTrP) – muscle trigger point, or trigger point (TrP) for short. Under certain circumstances, the trigger points (TrPs) can exhibit spontaneous myofascial pain. The myofascial pain syndrome is the most common painful muscle disease. In a number of studies, TrPs are viewed primarily as a local pathological phenomenon eliciting myofascial pain. However, trigger points need to be viewed in a wider context because clinical practice demonstrates the significance of these changes in the mechanisms of reaction of the CNS to nociceptive afferentation. Their significance also lies in a compensatory function leading to a limitation in mobility, or a defensive stabilization under pathological situations. Trigger Points – Clinical Characteristics During an assessment, a classic myofascial trigger point is identified via palpation as a well-defined painful knot in a tight muscle bundle (taut band). By quick strumming with a palpating finger across the fibers, a local muscle twitch (twitch response) can be elicited (see Fig. 1-6 in Chapter “The Most Important Palpation Techniques”). Sometimes, a patient can demonstrate a greater pull-away reaction that is not adequate to the applied palpation pressure (jump sign). Pressure in the TrPs area can evoke not only local but often referred pain, and additional abnormal sensory and autonomic symptoms that manifest themselves in zones at various distances from the point of irritation. The reference or target zone locations often do

not need to correspond to dermatomes or area nervina of the stimulus location (for example, trigger points in the subscapularis may manifest themselves as “bracelet-type” pain in the region of the wrist). The pain elicited by palpatory pressure in the region of the TrPs is often recognized by the patient as “the pain” that they suffer from (i.e. pain recognition). From the viewpoint of clinical manifestations, there are two types of TrPs – active and latent. Active is characterized by spontaneous myofascial pain or pain with movement. Latent TrPs manifest themselves by pain or a feeling of discomfort only during compression. From the perspective of kinesiology, it is quite significant that the presence of trigger points in a muscle corresponds with a change in the muscle dynamics of a corresponding joint-muscle unit. A tight bundle of contracted muscle fibers limits the joint range of motion in a certain direction. During muscle activation, these fibers preferentially and inefficiently contract, during which time the corresponding part of muscle simultaneously demonstrates a certain weakening in muscle force. Histological Findings in the Area of a Trigger Point Elements identified via palpation that form the structure of a TrP, i.e. a stiff muscle bundle and a knot forming the TrP itself, correspond with the histological findings. These show that some muscle fibers contain contractile knots in the location of a TrP. The knot consists of significantly contracted sarcomeres. Z-lines in this location are compressed closely together, which increases the fibers’ cross-section. In contrast, the sarcomeres of the same fiber outside the knot are stretched, therefore, the Z-lines are significantly further apart than normal fibers and the fibers’ cross-section is reduced. This finding is correlates with the palpatory perception of a taut band (Fig. 1.1.2-1).

Fig. 1.1.2-1 Histological scheme of a trigger point. The central trigger point is formed by contracted knots; the rest of the sarcomere is significantly elongated.

Localization of Trigger Points Trigger points are found in individual muscles according to their typical localization, which was mapped by J.G. Travell and D.G. Simons. Every trigger point pertains to its typical reference zone with respect to the transposed pain. A classic myofascial trigger point can be found most often in approximately the middle of the fiber length forming a tight bundle. The insertional parts of the bundle are strained by an increased pull, which is the source of a local mechanical overload of the connective tissue of the insertional structures. This tone releases substances that excite local nociceptors. The result is an onset of enthesopathy, or an insertional TrP. A “trigger point complex” forms within one tight bundle. This is formed by one central TrP and usually two insertional TrPs. Foundation of Trigger Point Formation in Muscle Tissue Currently, the fundamental abnormality in the pathogenesis of TrPs is considered to be neuromuscular dysfunction at the level of a neuromuscular plate of extrafusal muscle fibers linked to a continuous, excessive release of acetylcholine in a certain number of

neuromuscular plates at rest. This causes the formation of a sustained local contraction of the sarcomeres (contracted knots). The whole process of sustained shortening increases the demands for an energy supply. Also, local contraction compresses local blood vessels, which leads to a reduction in nutrient and oxygen supply. The increased energy demand during reduced supply causes an energy crisis. This leads to a release of substances that excite autonomic and sensory nerves in a given region. These neuroactive substances may consequently contribute to the excessive release of acetylcholine from a neuromuscular plate, which completes the “vicious cycle”. The given model allows for a good explanation of all key attributes of TrPs. However, the primary causes of changes in the neuromuscular plates which lead to their formation are unclear. The results of some studies point to a strong influence of the autonomous nervous system, especially the sympathetic portion, on modulation of an abnormal release of acetylcholine at the neuromuscular plate. A substantial influence can also be attributed to the change in the hemodynamics of a hypertonic muscle bundle – a necessary precursor to the TrPs. According to Travell, TrPs are formed by an accumulation of bodily responses to traumas, which might have a physical, emotional or chemical character. This presumption fully supports clinical experiences. These suggest that the distribution of TrPs is in a strictly defined context linked to the location of the source of nociceptive irritability. Trigger Points versus Tender Points Myofascial TrPs are to be distinguished from other painful spots – tender points (TPs), which are found in a systemic painful illness called fibromyalgia syndrome (see Special Section of the textbook, chapter 3.8.5 Fibromyalgia Syndrome). These points are found in anatomically variably defined soft tissues, including the muscle tissue. In muscles where the TP is found, the tight band is lacking and its strumming does not elicit a local twitch response. The compression of TPs only elicits local pain and not transferred pain.

It seems that the underlying cause of pain in muscle TPs in fibromyalgia is not the change in muscle tissue, but rather the CNS and biochemical changes. The therapeutic approaches used in the treatment of myofascial TrPs are, therefore, not effective in the treatment of fibromyalgia TPs. The frequent coexistence of fibromyalgia and myofascial TrPs somewhat complicates this situation. Local Muscle Twitch Local muscle twitch is thought to be the most valuable sign in validating the clinical diagnosis of TrPs. During assessment, a tight band of fibers is found which contains a palpable, painful knot. Strumming across this we know will elicit a local response in the form of a quick, transient contraction of a tight muscle band. This is a clear evidence of a TrP. This reaction can be elicited by different forms of mechanical stimulation, for example, by striking a TrP (on the skin above it) or by a needle insertion into the TrP. The ability to elicit a local muscle twitch via palpation may be complicated by adipose tissue or muscles which can cover the TrPs. Therefore, a dependable clinical diagnosis of TrPs requires, first and foremost, a high level of manual skills, as well as, sufficient experience in palpation and training of the examiner. The insertion of a needle in a TrP is not used diagnostically due to its painfulness. It is, however, used as one of the available forms of therapy. Clinical experiences indicate that with effective therapeutic usage of a needle, the insertion of the needle will elicit a muscle twitch during which the patient often experiences sharp pain. This implies that a local muscle twitch forms by irritation of the sensitized nociceptors in the area of the TrPs. It seems that the strong sensory inputs coming from these receptors into the spinal cord cause a response by α-motor neurons along with neuromuscular plates to exhibit excessive release of acetylcholine. The result is a twitch in the hyperactive motor units. The results of studies on a local muscle twitch in animals and humans indicate that this reaction is a local spinal reflex which is not

dependent on supraspinal influences. Trigger Points as a Source of a Spontaneous Myofascial Pain Numerous latent TrPs are a common finding in many asymptomatic people without any significant pathology within their anamnesis. These individuals are not aware of their presence and are often surprised when a palpatory assessment identifies their presence. Also, small deficits in motor functions attributable to TrPs often escape the patient’s attention or are simply tolerated. The presence, or formation, of latent TrPs is explained in various ways. A repeated mechanical microtrauma to a muscle or a nerve is the most frequently mentioned possible cause. This, however, corresponds with neither experimentally nor clinically identified facts. Assuming that a reflex-based or a reaction-based formation of TrPs is the result of nociceptive stimulation, it is then easy to imagine its origin, for example, in poor body posture where ligamentous tension can be a significant source of a nociception. The overload and maintenance of a muscle in a shortened position and, especially, the combination of both mentioned factors can lead to the increased activity of an originally latent TrP and its conversion into an active TrP. However, clinical experiences also suggest that with mild normal movement activity, the activity of an active TrP can be lessened unless irreversible changes have already occurred. As suggested by the results of some studies, with significant activation of TrPs, structural changes linked to the local contraction of sarcomeres occur at the level of contractile elements leading eventually to the disruption of the integrity of myofibrils, followed by an inflammatory reaction. A patient with active TrPs perceives spontaneous pain with a diffuse character which is difficult to localize. Sometimes, the patient perceives paresthesias or hypesthesias, or some other abnormal sensory signs more than the pain. These symptoms can even imitate symptoms of various illnesses (for example, a cardiac problem, appendicitis, etc.). Thus, adequate therapy is dependent on highquality differential diagnostics.

Examination of Trigger Points with the Help of Instrumentative Examination Methods Specific Needle Electromyography With specific electromyographic examination, a monopolar or a concentric needle electrode is used to identify characteristic spontaneous electric activity linked to some parts of TrPs. These sites are labeled “active loci”. It has been shown that functionally disrupted neuromuscular plates are the source of such activity. This corresponds with the fact that a classic (central) myofascial trigger point can be found in areas where a tight muscle bundle crosses with a zone of occurrence in neuromuscular plates (an endplate zone) (Fig. 1.1.2-2).

Fig. 1.1.2-2 A central trigger point is always localized at the crossing of a tight bundle with an endplate zone. The endplate zone, in a majority of muscles, is located at the center of the muscle fiber’s length.

Diagnostics by Sonography Ultrasound imaging method is used for visualization of a local muscle twitch, which makes it useful as a supplement to clinical diagnostics.

So far, its other uses are questionable. Surface Electromyography The presence of TrPs in a muscle disrupts its normal function. Surface electromyography shows increased irritability, latent relaxation and increased fatigue. This causes overload and a decrease in the loading tolerance of an injured muscle. Some studies show that TrPs may influence motor function not only in the muscle in which it is located, but also that they can manifest themselves in the function of other muscles via reactions of the CNS. The result can then be transferred muscle spasms or, conversely, inhibition of some muscles, which leads to a so called chaining of these functional deficits and their spread within the movement system. Algometry The threshold for pressure-induced pain can be measured by a pain threshold algometer. By applying pressure with an algometer in the region of a TrP through the skin, three threshold pressures can be measured: The pressure needed to evoke local pain The pressure needed to evoke transferred pain The pressure needed to evoke intolerable pain Some algometric studies explored the three listed types of threshold pressures: 1. always in the area of TrP; 2. within the course of a contracted taut band site; 3. outside of the TrP itself in normal tissue. The results indicated that the more active the TrP, the lower the pressure needed to elicit local, transferred or intolerable pain. The difference between the thresholds for local versus referred pain is smaller in an active TrP compared to a latent one. With a latent TrP, this difference is still significantly greater than in normal muscle tissue.

Although this method says very little about the origin and nature of elicited pain, it can contribute to research and to objectifying changes after therapy. Thermography Thermography allows measuring skin temperature to the depth of several millimeters. This way, skin reflex changes linked to TrPs can be visualized. Changes in skin temperature correspond with changes in skin circulation. Usually, activity of the sympathetic system is their endogenous cause. Thus, the thermographic record of changes in skin temperature is, in essence, comparable to the changes in skin resistance and perspiration. The sole finding of a warmer region on a thermogram does not suffice for the identification of TrPs. Similar changes in skin temperature seen in context with TrPs can also be seen with radiculopathy, joint dysfunction, enthesopathy, or it may be a result of local and subcutaneous inflammation. A mere thermographic examination also does not identify TrPs, which are not thermographically active. Microdialysis – Local Biochemical Environment Via microdialysis, in the areas of active TrPs, there were locally identified elevated levels of bradykinin, CGRP, substance P, TNF-α, IL-1β, serotonin and nor​epinephrine when compared to latent TrPs and normal tissues (without TrPs). The levels of these substances corresponded with the level of activation of the TrPs. Magnetic Resonance Elastography Magnetic resonance elastography (MRE) is a modification of classic magnetic resonance, which allows for the identification and quantification of different degrees of tissue stiffness. This can be useful in the assessment of TrPs because a taut band in a trigger point is noticeably stiffer compared to the surrounding tissue. In a study by Chena et al. (2007), the MRE of the TrPs in fibers of the upper trapezius showed 50% greater stiffness in the muscle bundle of the TrP when compared to the surrounding tissue.

Spasticity Pavel Kolář Spasticity is present in neurological disorders such as cerebral palsy, CVA, cranio-cerebral and spinal cord trauma, and degenerative inflammatory illnesses of the brain and spinal cord. With these diseases, various structures of the CNS suffer an injury. Spasticity needs to be distinguished from other conditions demonstrating increased muscle tone such as rigidity or muscle spasm. Spasticity is defined as an increase in a tonic stretch reflex dependent on the speed of passive movement with increased tendon reflexes, which arise from hyperexcitability of the stretch reflex. The quicker the stretch occurs, the more the muscle resists (“velocity dependent”) and hypertonus of the antagonist dominates. The phenomenon of the closing knife may (or may not) be present, during which at the peak of increased resistance a sudden relaxation occurs. With spasticity, besides increased muscle tone, hyperreflexia and spastic flexion and extension synergies, are present (Babinski, Mister, Vitek, Rossolimo, etc.). The main signs of spasticity include the following: Decreased muscle strength and amplitude of purposeful motor skills Deficit in purposeful and coordinated motor skills Deficit in selective motor skills, meaning isolated movement, and with this related occurrence of dystonic attacks in the patterns of “primitive reflexology” Increased reflexes Abnormal posturing of extremities Associated movements Clonus With spasticity, the distribution of muscle tone is important. In some scenarios, primarily with spinal spasticity, the tone is so high that it does not allow for elicitation of myotatic reflexes and clonus. Certain substances decrease spasticity and thus, were gradually

introduced to the treatment of central pareses. Untreated or insufficiently treated spasticity gradually leads within a few years to the development of connective tissue contractures. In children, joint and bone deformities occur, which in many cases require orthopedic intervention. By far not for all individuals spasticity becomes such a hurdle that it requires pharmacological or surgical intervention. The mechanisms of spasticity is not unequivocally understood. There are several theories about the development of spasticity. Theory of an Increased Activation of-motor Neurons According to this theory, spasticity occurs as a result of the loss of an inhibitive function of the brain, which leads to an increase in a the stretch reflex. Imbalance Theory With cortex lesions, there is a predominance of tonic-excitory descending pathways and a consequent increased excitability of spinal α-motor neurons that causes an increased muscle tone. Theory of Reorganization of a Synaptic Entrance Impulses coming from the brain into the spinal cord by descending pathways have an inhibitory effect. With a deficit at the CNS level, the inhibitory effect is lost with a subsequent spasticity. If certain fibers are disrupted, their endings degenerate and the neurons, or synapses, lack the presynaptic endings. Some synapses on the motor neurons and interneurons in the spinal cord region are thus not occupied. It is presumed that certain regeneration occurs, sprouting of branches of preserved nerve fibers, which begin to occupy the unoccupied synapses. This explains why, after a period of several days or weeks, the reflexes recover and their response is heightened. “Sprouting” Theory The outage of descending pathways (axons), which is caused by a CNS lesion, vacates on the α-motor neuron synaptic regions, which are later occupied by segmental excitatory afferents. According to this theory, increased muscle tone occurs because of the shift in balance toward the excitation. Some recent studies however, discredit this

theory. On the basis of various pathophysiologic mechanisms, spasticity can be differentiated into three elements: Afferent Efferent Muscle tone Afferent Component The allotment of the afferent component of spasticity is dependent on the integrity of the spinal and peripheral structures (muscle spindle, dorsal and ventral horns) and unlike efferent component, it disappears with a disruption of the posterior horns. The symptoms of the afferent components of spasticity include an increased central excitability, flexor spasms, which are facilitated and, in contrast, the inhibition of the extensors. Efferent Component The allotment of the efferent component of spasticity is not dependent on the stimuli arising via afferent fibers (tone, speed, nociception). This component does not disappear with a disruption of the dorsal horns. Among the symptoms of efferent component belong spastic dystonia, occurrence of movements in locations other than the targeted area (pathological synkinesis), presence of a co-contraction, deficit in reciprocal inhibition, and an efferent motor hyperactivity. Muscle Tone Muscle tone contains a neural component (especially the tonic and phasic stretch reflexes) and a biomechanical component. Biomechanical component is the basis for resting tone of a muscle and it is formed not only by contractile and connective tissue components of a muscle but also by tendons, joints and ligaments. On the basis of the so far known findings, spasticity is a result of a deficit in the brain inhibitory functions. To a varied extent, the increased excitability of γ-motor neurons partakes in it, which changes the sensitivity of the muscle spindle, and to a lesser degree the direct influence on α-motor neurons. Spasticity thus may be of diverse types,

either more dynamic as a reaction to a quick stretch or sustained, which gives resistance to any stretch of a muscle. A concept exists suggesting that α-spasticity originates in the cortex (freedom from the influence of suppressive areas) whereas γ-spasticity originates in the spinal cord (freedom from the descending reticular formation). Clinically, spasticity is distinguished based on whether the motor cortex or internal capsule (capsula interna) are injured and whether it is a complete or an incomplete spinal cord lesion. With a lesion in motor cortex or capsula interna (for example with CVA), a partial loss of influence of the inhibitory structures in the brain stem occurs. As a result of a lesion in the pyramidal pathway and a reduction in inhibition, spastic hemiparesis with anti-gravity type of posturing spreads and with this form of spasticity, flexion spasms usually do not occur. With an incomplete spinal lesion, the situation differs. Here, paresis in the corticospinal pathway develops, while the lesion in the dorsal reticulospinal pathway leads to the weakening or loss of inhibitory influence on the spinal stretch reflex; however, facilitation (provided by reticulospinal and vestibulospinal pathways) continues. This condition then leads to the development of significant spasticity with dominant involvement of anti-gravity muscles, which manifests itself in a patient as an extension type paraparesis of the lower extremities. With this type of spasticity, extensor and flexor synergies occur, with the extension spasms being more frequent. With severe or complete spinal cord lesion, in which complete loss of influence on the supraspinal structures of the spinal cord occurs, spasticity does not seem as distinct as with incomplete lesions. In such cases, flexion spasms are frequent and paraplegia can develop, in which the flexion type spasticity is typical. In lesions of motor pathways, other than various forms of spasticity, we find a number of other neurological signs. In particular, a central paresis develops (weakness, increased myotatic reflexes, pyramidal signs), but more complex symptoms can also occur, such as dystonia, i.e. dystonic manifestations of the extremities during verticalization or walking, further loss of agility, delayed movement initiation (inability to initiate or accelerate movement) as well as increased fatigue.

In the upper and the lower extremities, we can find certain basic types of spasticity, which primarily involve certain muscle groups. Main Types of Spasticity in the Upper and Lower Extremities Types of spasticity in the upper extremities: Adductor spasticity of the upper arm (patient struggles with dressing, pain in the shoulder) Flexor spasticity at the elbow (flexed elbow interferes with dressing and personal hygiene) Pronation spasticity of the forearm (supination is difficult, hand cannot be positioned for grasping of objects) Flexion spasticity of the hand (often carpal tunnel syndrome appears) Spastic hand with clenched fingers (grasping is impossible) “Intrinsic plus posture” (flexion in the metacarpophalangeal (MCP) and extension in the proximal interphalangeal (PIP) joints – grasp as well as fine movements of the fingers and hand are blocked) Spasticity of the hand with adduction and flexion of the thumb (interferes with hand and finger grasping) Types of spasticity in the lower extremities: Spasticity of the lower leg muscles leading to the development of pes equinovarus (patient is toe walking; locomotion is difficult) Spasticity of the lower leg muscles leading to the development of pes valgus (foot deformity is present and genu valgum is developing) So called striated big toe with spasticity of the extensor hallucis longus (patient has difficulty with footwear) Extension spasticity in the knee joint (patient makes small steps, falls are frequent) Flexion spasticity in the knee joint (ambulation with small steps is difficult, patient needs to compensate by contralateral knee and hip flexion) Adduction spasticity of the thighs (patient demonstrates scissor-like gait, problems with dressing and ambulation)

Flexion spasticity in the hip (patient has difficulties with ambulation and standing, problems with hygiene, flexion deformity in the knee joint is induced) Pathological Synergies In patients with spasticity, selective movements (differentiated movements) are disrupted and dystonic attacks occur during a desired activity. This means that during an effort to accomplish a desired movement, movement patterns occur instead of isolated movements. The movement patterns correspond to the interplay observed in the patterns of primitive reflexology (for example, asymmetrical tonic neck reflexes – ATNR, symmetrical tonic neck reflexes – STNR, triflexion) and block the selective mobility. The Assessment of Spasticity The Ashworth Scale or its modification are two methods used to evaluate muscle tone deficit, or the extent of spasticity. This scale grades spasticity based on the resistance that a spastic muscle exhibits during a passive movement. The difference between the Ashworth scale and its modification lies in the number of individual grades, in which every grade corresponds to a certain characteristic a muscle manifest during movement. The Modified Ashworth scale has one more grade and it is more specific. Ashworth Scale Scoring and clinical demonstration: 1 – no increase in muscle tone 2 – a slight increase in tone when affected part is moved passively 3 – a more apparent increase in muscle tone, but passive movement can be executed 4 – a significant increase in muscle tone, passive movement is difficult 5 – the affected extremity is rigid with flexion and extension Modified Ashworth Scale Scoring and clinical demonstration: 0 – no increase in muscle tone 1 – a slight increase in muscle tone, manifested by a catch and release, followed by minimal resistance at the end of the range of motion

1+ – a slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the remainder of the range of motion 2 – a more apparent increase in muscle tone during movement, the affected body part is easily moved 3 – a considerable increase in muscle tone, passive movement is difficult 4 – the affected body part is rigid in a certain position, passive movement is not attainable A great disadvantage of the Ashworth scale is its subjectivity. At the same time, it is an assessment that has not been validated. Another problem also lies in the fact that it judges a passive movement component and not an active one. Spasticity always manifests itself in a motor form, which allows for a better assessment than examination via the Ashworth scale. Therefore, the methods which assess posture, motor presentation (for example, assessing gross motor skills, activities of daily living), and reflex reaction (for example, pro​prioceptive and exteroceptive reflexes, postural reactions during an infant examination) are regarded for their objective assessment of muscle tone (and thus the assessment of the patient’s condition) as much more valuable. These methods assess a desired motor behavior, which does not judge the deficit of muscle tone passively, but during a purposeful function. The Oswestry Scale This numeric scale assesses the grade and distribution of muscle tone and the quality of isolated movements. The scale takes into account the influence of body posture and the descending brain stem and spinal reflexes on muscle tone. The Koman Scale This scale evaluates spasticity of the lower extremities in children (“The Physician Rating Scale”). It is used to assess the effectiveness of botulotoxin A (BTX-A) on spasticity in cerebral palsy (Tab. 1.1.2-1). In literature, some other modifications are cited, such as those by Bohannon and Smithe. Further, the “frequency of spasms” is assessed

using the so called ”Spasm Frequency Scale”. Also, pain with spasticity is quantified by the Global Pain Scale. Sometimes, a combination of the scales is utilized to assess more parameters.

Tab. 1.1.2-1 Koman scale for assessment of infant spasticity of the lower extremity (Physician Rating Scale)

Rigidity The increased muscle tone seen with rigidity is similar to the resistance seen when bending a pipe made out of soft metal (the so called phenomenon of a lead pipe). During the assessment of active and passive movement, there is resistance throughout the entire range. The patient feels muscle stiffness. The examined movement is performed slowly and never in saccades (short, abrupt movements). The examination is performed not only at the elbow, but preferably also at the wrist, shoulder, ankle, and knee. During passive extension of the patient’s extremity (for example, of the wrist or ankle joints), intermittent resistance formed from reflexive contractions of the stretched flexors is palpable (the cog-wheel phenomenon). Also, with passive muscle shortening, definition in the tendons stabilizing the segment of the extremities in the newly attained positions is palpable. These are manifestations of the higher or so called elementary postural reflexes (EPR). Rigidity is accentuated by movement of the contralateral extremity (the Froment maneuver) and recedes during sleep. Paratonia Bilaterally and symmetrically generalized increases in muscle tone, which resembles a meningeal excitation, is called paratonia. Resistance during passive movement (stretch) increases with movement velocity and is sustained throughout the entire range of motion. This distinguishes it from spasticity, which exhibits a sudden inhibition at a certain point during the movement (“the clasp-knife phenomenon”). Paratonia is a sign of diffuse hemispheral dysfunction, which is usually accompanied by a quantitative deficit in consciousness. It usually accompanies metabolic encephalopathies. With paratonia, stereotypical reactions of the extremities are common (into flexion or extension) in relation to the exteroceptive stimulation, but especially common are reactions to painful (algic)

stimuli. In some cases, the signs of paratonia can arise during rest, without external stimulation. Paratonia is a part of decerebral syndrome and has the following basic phases: 1. Decorticate rigidity – abnormal tonic reaction of the flexors in the upper extremities, which may be unilateral, is typical. 2. Decerebrate rigidity – is characterized by an increased extension tonic reaction of the extensors in the upper and lower extremities. The tone in paravertebral muscles is increased, especially in the neck muscles, leading to opisthotonus (severe hyperextension). 3. Mixed decerebrate rigidity – marked by extensor posturing of the upper extremities, and flexion or a paresis of one or both lower extremities which are abducted in hip joints. 4. Generalized atonia with postural non-reactivity – develops with lesions in the reticular formation in the lower third of the pons of the medulla oblongata. Hypotonia Muscle hypotonia means decreased muscle tone. Through palpation, the texture of the muscle (softer muscle) and the decreased resistance that the muscle can exert are evaluated. Hypotonia can also be visible from postural stability and reactibility. With an external force, the muscle does not get sufficiently activated during the stabilization of posture and thus the body posture, as well as, loading of the joints change. Any hypotonia (even partial) is going to be reflected in posture. Hypotonia develops for various reasons, which leads either to a dysfunction in some sections of the spinal reflex loop or in the supraspinal regulatory loops of muscle tone. The following are the most common reasons for hypotonia: 1. A disruption in the peripheral nerve or only its efferent (motor) or afferent (proprioceptive) fibers. Hypotonia manifests itself to the highest degree (plegia) at the innervation region of the peripheral nerve.

2. A disruption in the ventral or dorsal roots of the spinal cord. It will manifest itself in the corresponding segment – for example, with partial damage to the L5-S1 nerve root, hypotonia develops in the calf musculature. 3. Lesions in the ventral horns of the spinal cord. This will manifest itself by significant hypotonia, especially in the distal part of the extremities. Poliomyelitis anterior acuta is a typical disease of this type. 4. Damage of the posterior tracts of the spinal cord. Hypotonia arises with a disruption to proprioceptive afferentation. This is found with tabes dorsalis, neuroanemic syndrome and with some degenerative illnesses. 5. A cerebellar lesion. Damage is manifested by an increased inactivity of either half of the body or bilaterally. This is a different type of hypotonia than a muscle hypotonia caused, for example, by a peripheral nerve lesion. The reasons may include tumors in the region of the posterior fossa, cerebellar ischemia or hemorrhage, trauma, and cerebellar inflammatory conditions. For a clinical examination of hypotonia, the following tests are appropriate – ressaut test and the trunk succussion test (the patient is standing relaxed, the examiner holds their shoulders and shifts the trunk from side to side; the arm swing and its amplitude are observed – it will be more pronounced on the side of the lesion), a pendulum-like character of the patellar and triceps reflexes. 6. A lesion in the striatum with which the resting tonus is decreasing. With damage to the putamen, the chorea syndrome develops in which muscle tone is almost always decreased. With an injury to the caudate nucleus, athetoid syndrome occurs in which muscle tone in some muscles can be increased. 7. A lesion in the postcentral gyrus in the parietal region. The most common cause is a sudden development of focal ischemia in this part of the brain. 8. Reflex causes and hypoactivity. Hypertonia occurs with nociceptive stimulation or with a unilateral postural loading.

However, some muscles exhibit reflex inhibition along with hypoactivity or even muscle atrophy. This scenario is called functional pseudoparesis.

MUSCLE TONE DISTRUBANCES AND THEIR POSTURAL LAYOUT Pavel Kolář A number of clinical and experimental studies suggest that, for postural functions, certain muscles have a distinct tendency toward inhibitory signs (hypotonia, weakness, hypoactivation), whereas other muscles, in turn, demonstrate a tendency toward hypertonia and muscle shortening. The fact that some muscles are posturally inclined toward inhibition while others toward hypertonia, shortening or even contractures has been known for a long time, but these predispositions for muscular imbalance were not systematically organized until Vladimir Janda. The layout of muscle tone deficits is so characteristic that Janda describes them as syndromes – the upper and lower crossed syndromes and the layer syndrome. There is a number of various pathological states, which in certain muscles, predilectively lead to hypertonia or even contractures and, in other muscles toward inhibition and gradually even toward atrophies. This is the case with organic disorders of the central nervous system. As an example: the muscles that display a tendency toward spasm during the acute phase of infantile cerebral palsy are identical to the ones that most frequently form contractures in the chronic state of poliomyelitis and in patients with infantile cerebral palsy (spastic type) incline toward spastic contractures. In contrast, muscles that act as their antagonists are being inhibited. The same muscles that are inclined toward contractures or inhibition with CNS lesions are observed to become hypertonic or inhibited with postural dysfunctions as well, such as a faulty body posture. With fatigue and painful conditions, inhibitory and hypertonic reactions in the same muscles are observed. This occurrence can be justified by phylogenetic, or ontogenetic development of postural muscle function and also by phylogenetic

development of the muscle itself. Muscles that have a tendency toward inhibition are in their postural functions (from a viewpoint of maintaining posture) from a phylogenetic, or ontogenetic aspect younger than muscles that display a tendency toward contractures. By their postural function they are also tied to a developmentally younger morphology of the skeleton, in which they at the same time facilitate development. This portrays a very young, and hence a very fragile, unit in the movement system. Upper Crossed Syndrome In the shoulder girdle, a muscle imbalance develops that is characterized by shortening of the upper fibers of the trapezius and the levator scapulae, the sternocleidomastoid and the pectoralis major. In contrast, the deep neck flexors and the lower scapular stabilizers are inhibited. This leads to the two following scenarios in the dynamics of the cervical spine as a result of a forward head posture: 1. The upper cervical lordosis is increased with the apex at the C4 level and a flexed position is displayed at the T4 level. As a result, there is an overexertion at the cervicocranial junction, the C4-5, and the T4 spinal segments. 2. The lordosis of an entire spine is increased, or the upper thoracic spine is flattened (clinically observed as lordotic), subsequently, the cervicocranial junction and the segments C4-5 and T4-5 are overexerted. A dysfunction in these segments leads to irritation in the region of the cervical sympathetic plexus. Changes in the C4-5 segment lead to complications in the region of the shoulder joint via the axillary nerve and breathing mechanics can be influenced via the phrenic nerve. Dysfunction in the T4-5 segment is related to vertebrocardiac syndrome. In the shoulder girdle region, the lower scapular stabilizers are weakened, which leads to the verticalization of the glenohumeral joint via the alignment of the scapulae. Shoulder protraction develops. This dysfunction leads to overloading of the supraspinatus muscle and,

ultimately, to its degeneration. At the same time, the levator scapula also contributes to the overloading. Lower Crossed Syndrome This syndrome is characterized by shortening of the rectus femoris, tensor fascia latae, iliopsoas and the erector spinae in the lumbosacral segments. The gluteal and abdominal musculature are inhibited. As a result, the pelvis is anteverted (anterior pelvic tilt) with an increased lordosis at the lumbosacral junction. As a consequence, insufficient hip extension is observed during gait, which leads to an even greater pelvic anteversion. This results in a significant overexertion of the lumbosacral junction and uneven loading of the hip joints leading to subsequent adaptive changes. At the same time, the posterior edges of the intervertebral discs are overloaded. Due to the joint irritation caused by this alignment, contractures in the paravertebral muscles develop. With the lower crossed syndrome, the thoracolumbar junction becomes the stabilization region during gait. Subsequently, instability occurs in the lumbosacral junction. This state is denoted as an unstable cross. With therapeutic treatment, the muscle imbalance needs to be addressed as a whole unit. Layer Syndrome This syndrome involves shifting of muscular hypertonia, or hypertrophy, with hypotonia, or hypotrophy. On the dorsal side, alternating in the layers are hypertrophic and hypertonic hamstring muscles, further hypotrophic gluteal muscles and lumbosacral segments of the erector spinae, followed by a layer of hypertrophic erector spinae in the thoracolumbar junction, then a layer of weakened intrascapular muscles and, finally, a hypertrophic upper trapezius. On the ventral side, weakened abdominal muscle tone and increased tone in pectoralis major and sternocleidomastoid can be observed. In addition, hypertonia in the iliopsoas and rectus femoris are observed. Assessment of Shortened Muscles

The term muscle shortening describes the condition in which shortening at rest occurs for various reasons. With a passive stretch, the muscle does not allow for the full extent of joint motion. This state is not accompanied by electric activity and, thus, it is not based on an active muscle contraction or increased activity of the nervous system. Thus, the examined muscle shortening cannot be interchanged with reflexively developed contractures or spasms which accompany, for example, acute lumbago, joint injuries or neural infections. With assessment of a shortened muscle group, we must maintain a standardized approach. During the examination, the range of passive joint movement is measured in such a position and direction so as to target the isolated muscle group. The following muscles are primarily assessed: triceps surae, hip flexors, knee flexors, hip adductors, quadratus lumborum, paravertebral muscles, pectoralis major, upper trapezius, levator scapulae, elbow flexors, muscles of mastication, and scalenes.

1.1.3 Examination of Sensory Functions Alena Kobesová Sensory and motor functions are very closely interrelated. Correct sensation is the foundation for good quality of any desired movement and support motor function. Therefore, the assessment of sensory function is very significant in rehabilitation and should be the routine part of a complete examination of a patient. Receptors receive stimuli of a various quality. In the skin, the receptors for touch (Meissner and Pacini corpuscles) and for pressure (Merkel discs and Ruffini corpuscles) are found. Free nerve endings register common temperature stimuli and potentially harmful stimuli, including mechanical, as well as, chemical and thermal. The deep receptors (proprioreceptors) include muscle spindles which register muscle stretch, Golgi tendon organs which register muscle contraction and a change in muscle tone, Pacini corpuscle which register phasic joint movement, and a number of nociceptors (pain receptors) that are sensitive to heavy deformation, an extreme change in joint position or

infection. From the receptors, the stimuli travel via various types of nerve fibers (fibers α, δ, C). All peripheral sensory neurons have their bodies stored in the ganglions of the posterior spinal roots (for the orofacial region, in the sensory ganglia of the cranial nerves). Central processes of the primary sensory neurons enter the spine via the posterior roots. There are three basic sensory tracts within the spinal cord: The posterior lemniscal system contains heavily myelinated, fast conducting fibers which mediate the perception of pressure, vibration, kinesthetics (perception of movement of a segment), joint position sense (the perception of a position of a segment). The posterior lemniscus also includes a portion of the fibers for tactile perception which participate in stereognosis (the perception of various qualities of an object via touch and without visual control). The fibers of the posterior lemniscus run in the spinal cord without crossing to the nucleus gracilis and nucleus cuneatus located at the junction of the cervical spine and medulla oblongata. At these nuclei, they project into the contralateral side as the secondary portion of the tract develops here, travels via the medial lemniscus (lemniscus medialis) and terminates in the contralateral thalamus. The spinothalamic system is comprised of slower conducting, lightly myelinated and non-myelinated fibers that mediate information primarily from deep pressure and superficial skin receptors, i.e. gross skin perception, touch, pain and temperature stimuli. After the transfer in the neurons of the posterior horns, the fibers of this tract project to the contralateral side at the level of the medulla (or a few segments above and below), continue running contralaterally and ascend as the anteriolateral spinothalamic tract into the thalamus. The spinoreticular system is developmentally older than the spinothalamic system and conducts a number of various sensory signals, including nociceptive signals. Among other roles, it participates in motor control on a subcortical level, facilitates the ascending reticular activating system (ARAS) and conducts and processes dull, diffuse and chronic pain.

From the thalamus, the final part of all sensory tracts continues as the thalamocortical system and terminates in the postcentral cortex (postcentral gyrus of parietal lobe, Brodmann Areas 1, 2, 3). If a deficit is identified during examination of the sensory system, negative or positive signs and symptoms can be identified. Negative Phenomena: Hypesthesia: the variably decreased perception of a stimulus. Anesthesia: the complete loss of a certain type of sensation. Negative symptomatology, i.e. loss of sensation, is a relatively late sign of a sensory system dysfunction. At the beginning of a pathological process, stimulation (or irritation) of sensitive nerve fibers and tracts occurs, which manifests itself as positive symptoms. Thus, the positive symptoms are more sensitive and more often serve as indicators of a sensory deficit. Positive Phenomena: Hyperesthesia refers to increased sensitivity to a certain stimulus. Paresthesia occurs when sensory information is perceived inadequately but not painfully. It can occur spontaneously, or without an elicited stimulus, or it can be elicited by a stimulus, which the patient does not perceive correctly. Paresthesia is often described by the patient as burning, tingling or numbness. Dysesthesia is also an abnormal sensory perception, which arises either spontaneously or as a reaction to a normally non-painful stimulus which the patient interprets as unpleasant or approaching painful. Hyperpathia marks an increased threshold for sensation of a certain nature of stimulus (tactile, temperature or pain). However, if the stimulus exceeds the threshold, the patient perceives it unpleasantly or even painfully. Allodynia means that the pain is elicited by a non-painful stimulus. Spontaneous pain develops without an obvious source and it is a sign of peripheral or central sensory system involvement (most frequently a neuropathic pain).

Sensory Testing Deficits in the sensory system can be detected to a great extent from the patient history (anamnesis). The patient often describes the character and the onset of the sensory symptoms (autodemography) with such accuracy that it may be possible to hypothesize the location and the etiology of their problems. Usually, the patient will spontaneously describe positive sensory symptoms, such as tingling, pins and needles and particularly pain; while on the other hand, they may not be aware of sensory loss or other accompanied deficits, e.g., in motor function. For example, with a herniated disc, the patient will describe shooting pain and a sensory deficit in the corresponding dermatome, but they might not be aware of the weakness of the muscles supplied by the corresponding nerve root until the examination. Not all types of modalities of perception are perceived subjectively with the same intensity. Pain, tingling, and deficits in touch are perceived quickly; whereas, a deficit in proprioception (vibration) can stay hidden for a long time without clinical examination even if the patient sometimes perceives the consequence to this disturbance via a sensory ataxia, which is manifested as a balance disturbance in standing or ambulating with the visual component eliminated (i.e., in the dark). Since sensation is a subjective perception, good cooperation from the patient is necessary during the evaluation. It is a subjective assessment (assessed by the patient), which can only be verified to a certain extent by the consistency of the patient’s responses. Beforehand, the nature of the examination and what the patient should perceive is explained to the patient and the actual examination is carried out without a visual component. To evaluate whether the patient perceives the stimulus adequately, the same sensation is compared at the corresponding regions bilaterally both dorsal and ventral, and proximal and distal parts of the segment or at other locations. The location, type and degree of deficit are determined as accurately as possible. The acquired distribution of the sensory deficit is then compared with the anatomical distribution. If peripheral nerve

damage is suspected, the sensory deficit should correspond to the region affected by the corresponding nerve; with root lesions, the deficit should be identified in the corresponding dermatome. With brain stem or brain lesions, the deficit should manifest itself in the corresponding body part. With sensory deficits of organic nature that are manifested only on one side of the body, the sensory threshold is not located exactly at the midline; it is shifted 2–3 cm toward the affected side because the innervation from both sides is physiologically overlapping. If the patient is reporting a sensory deficit directly at the midline, it is abnormal and, thus, a conversion or a psychogenic sensory deficit is suspected. It is necessary to administer the examination repeatedly and compare the patient’s responses, which should show consistency. Examination of Individual Sensory Modalities Touch Touch or tactile sensation is best examined by the Semmes-Weinstein monofilament (Fig. 1.1.3-1). It is a filament of defined weight, thickness and tautness so that a standard force is necessary for its bending. The filament is pressed to the examined area just enough so that bending is achieved. It is possible to purchase a set of commercially made filaments of various weights. Most frequently, a 10-gram filament is used. At the examined area, for example on the bottom of the foot, different places are touched step by step while the patient’s eyes are closed. The patient reports each contact that they feel. The result is presented as a fraction based on the number of perceived contacts by the patient (i.e., 6 out of 8). This type of assessment is quantitative and can be used for comparison of sensations in a given region across patients with a certain type of diagnosis (i.e., sensation on the plantar and dorsal aspects of the foot in patients with diabetic polyneuropathy). The results can also be compared for each individual patient in time or after a course of some type of therapy. Fig. 1.1.3-1 Sensory examination by Semmes – Weinstein monofilament

Temperature Temperature sensation is mediated by the receptors and free nerve endings that react to thermal stimuli. The examination is carried out with the help of two test tubes filled with water. The perception of a cold stimuli is tested by a temperature above 10 °C; the perception of a warm stimulus by a temperature below 45 °C, not lower or higher in order to avoid painful stimulation. The temperature of the water filled test tube is initially tested on the examiner’s own skin to ensure that the difference in temperatures is both sufficient enough so that the patient can distinguish warm and cold temperature and that the stimulus is not unpleasant. The test tubes are alternately placed on the examined region and the patient is asked whether they are able to differentiate the stimulus as warm or cold. The assessment of temperature is more time consuming when compared with other types of sensation and, therefore, the patient should not feel rushed. If the stimulus is applied for a brief period of time, the information obtained from the patient might not be accurate. Prior to the examination, the patient should be in a temperature controlled environment and be adapted to the room temperature. It is recommended that the examined region is uncovered (undressed) for a short period prior to the evaluation. Special thermosounds exist for more accurate testing. Pain Pain is assessed with a sharp object, but the patient obviously must not be hurt. Painful pricking is alternated with a dull touch to

evaluate whether the patient is able to distinguish between painful and tactile stimuli. An algesimeter can be used for more accurate examination for the purpose of quantification of the intensity of the stimulus when the patient perceives it as painful. With the help of a thermosound, the pain threshold for temperature sensation can be examined. Pain perception occurs when the temperatures below 10 °C and above 45 °C are applied and the polymodal nociceptors are stimulated. Joint Position Sense Joint position sense is examined by a passive change in the position of a segment (Fig. 1.1.3-2). While the patient’s eyes are closed, the examined segment is passively moved to a certain position and the patient is instructed to remember this position. Then, the position of the segment is altered and the patient is asked, while keeping their eyes closed, to bring the segment into the original position, which they were instructed to remember. Alternatively, they can be asked to position the contralateral extremity to the same position. Fig. 1.1.3-2 Clinical examination of joint position sense

Kinesthesia Kinesthesia is most frequently assessed at the distal portion of an extremity, usually in the toes. While the patient’s eyes are closed, the examiner slowly changes the position of the segment in a certain direction and the patient is asked to describe the direction of the motion. Perception of Vibration Pallesthesia is the ability to perceive a rhythmic vibratory stimulation. It is examined by a graduated C128 Hz tuning fork (Fig. 1.1.3-3). A vibrating tuning fork is placed on an area with the greatest proximity to the bone, meaning at the point of minimal thickness of subcutaneous and soft tissues (the interphalangeal joints, ankles, knee, ASIS, or the styloid process of the radius). It is assessed whether or not and how long it takes the patient to perceive vibration. During the examination, the patient’s eyes are closed and the patient reports the moment when they stop feeling the vibration. Using the graduated tuning fork, this time can be subtracted on an eight-point scale and described as a proportion, i.e. 6/8. The higher the numerator the longer the individual perceived the vibration and ultimately the quality of sensation is better (ideally 8/8). Physiological ability to perceive vibration declines with age (especially in the distal aspects of the lower extremities). Pallhypesthesia is described as the decreased perception of vibration sensation and pallanesthesia as the complete loss of vibration sensation. The perception of vibration is most commonly disrupted in polyneuropathies, meaning with concurrent involvement of more peripheral nerves, or with a lesion in the posterior tracts, and less often with central lesions in the thalamus or the medial lemniscus (lemniscus medialis). The perception of vibration, joint position and kinesthesia are often impaired simultaneously. All proprioceptive data from receptors located in the muscles, fasciae, tendons, joints, periosteum and bones comprise so called deep sensation. Deep sensation is conducted via the posterior

spinal tracts and ensures a very important feedback, or controlled loop, about the course of movement in the movement segment. This information is an essential prerequisite for controlled and smooth coordinated movements. During clinical examination, a deficit in upper extremity proprioception is manifested as the presence of involuntary movements during shoulder flexion with the eyes closed. A deficit in deep sensation is found more frequently and earlier in the lower extremities when sensory ataxia (unsteady standing and gait with a wide base of support which significantly worsens with the elimination of visual control) is present with a positive Romberg sign. With a substantial proprioceptive deficit, the ataxia can be so significant that standing and gait are impossible, especially in the dark and on uneven surfaces. Fig. 1.1.3-3 Examination of vibration using tuning fork

Two-point Discrimination Two-point discrimination is the ability to distinguish two concurrent tactile stimuli from one stimulus (Fig. 1.1.3-4). The Weber aesthesiometer is used for testing with two dull points. Both points contact the examined area simultaneously and their distance can be modified. The smallest distance when two simultaneous contacts are recognized from just one, is extremely variable on different body parts, the smallest being on the tongue (1mm), lips and finger tips (3–5 mm), while on the back, it is physiologically several centimeters (4–7 cm). This corresponds to the density of the corresponding receptors. Two-point discrimination assessment places high demands on a

patient’s ability to focus, and thus, the results may be different with repeated measurements. Fig. 1.1.3-4 Examination of twopoint discrimination

Topognosis, Graphesthesia Topognosis is the ability to recognize tactile or painful stimuli on the skin. It is usually tested as graphesthesia, or reading numbers and letters on the skin with detection of their direction. Stereognosis The ability to recognize the characteristics of a certain object is being tested (size, temperature, hardness, shape, weight) while placed on the skin (in the palm of the hand) without visual control. With a deficit in this sensation, stereoanesthesia can occur during which the patient does not recognize the object’s characteristics due to deficits in the function of the receptors and the primary sensory pathways. Stereoanesthesia needs to be distinguished from astereognosia during which the deficit of perception is located at the cortical level. This is most frequently part of a neglect syndrome with involvement of the right parietal lobe. Clinical Sensory Syndromes A deficit in various forms of sensation can be identified by a disturbance of the receptors themselves or any other part of the primary sensory pathways at the level of the peripheral nerve, posterior spinal root, ascending spinal tracts, nuclei, thalamus, thalamocortical tract and at the level of the sensory cortex itself. The

identified pattern of deficits can significantly assist in the identification of the location and etiology of the deficit. Most frequently, sensory deficits develop with the following pathological conditions: Peripheral Nerve Involvement Usually, there is a sensory deficit of all types of receptors in the corresponding innervated region. Polyneuropathy With polyneuropathy, the fibers of the long peripheral nerves are affected first, thus the signs are first seen in the distal segments of the lower extremities and then later in the upper extremities. The so called “sock” and “glove” distribution of a sensory deficit is observed in either all or some of the receptors depending on whether the pathological process primarily involves thick myelinated fibers (deficit in vibration, proprioception, significant sensory ataxia) or thin and less myelinated fibers that involve pain perception, temperature and autonomic disturbances. Root Lesion A root lesion is most commonly present with a herniated disc, which presses on the nerve root. During assessment, a segmental deficit in the corresponding dermatome (area radicularis) is present. In the extremities, the dermatomal distribution is vertical, while it is horizontal in the trunk. At the same time, a weakness in the corresponding myotome, a segmental lack of reflexes and nerve root pain can often be found. Complete (transverse) Spinal Cord Injury With a complete spinal lesion, complete loss of sensory perception (for all types of receptors) is found below the level of the lesion. At the upper border of anesthesia, there may be a narrow area of hyperesthesia. At the same time, a change in motor function, trophic changes, a deficit in reflexes, ataxia and other deficits can be present. Incomplete Spinal Cord Injury Brown-Sequard syndrome develops with an incomplete spinal cord

lesion caused by a lateral hemisection. At the level of the injury, anesthesia for all sensory receptors on the ipsilateral side occurs and pain and temperature sensations are affected on the contralateral side, but it begins approximately two segments caudally. Deep sensation (palanesthesia, deficit in kinesthesis) is affected below the lesion on the ipsilateral side. Tactile sensation is not significantly affected because the tracts carrying tactile information from one side project to both ipsilateral and contralateral sides. Also, selective impairment of certain pathways is seen with partial spinal cord lesions. For example, this includes syndrome of the posterior tracts (tabic dissociation) in which proprioception and vibration sensations are involved whereas superficial tactile, pain and temperature sensations are preserved. In contrast, only a deficit in the spinothalamic tract involves a deficit in temperature and pain sensations (syringomyelic dissociation) while the deep sensation is intact. Brain Stem Disorders Predominantly temperature and pain sensations on the contralateral side of the body are affected with pathological processes in the lower region of the brain stem (i.e., ischemia). If the lesion is at the level of the upper brain stem, not only contralateral temperature and pain sensations, but also deep sensation can be affected. Thalamic Syndrome Thalamic syndrome manifests itself as deficits in all qualities of sensation on the contralateral side of the body and often presents with thalamic pain that is difficult to reduce, most commonly the result of an in​farction or possibly a tumor. Internal Capsule (internae capsulae) Syndrome Internal capsular syndrome most frequently occurs during a cerebrovascular accident in this region. Among other structures, the thalamocortical pathways are damaged, which manifests as a deficit in all qualities of sensation on the contralateral side (so called hemitype). Parietal Lobe Lesion Parietal lobe lesions (also mainly the result of cerebrovascular accident) are responsible primarily for a deficit in discriminatory

sensations, such as joint position, kinesthesia, topognosis and stereognosis, on the contralateral side. With involvement of the right parietal lobe, a neglect syndrome occurs; it is a syndrome of left-sided neglect; simultaneously, a loss of sensation and often a paresis of this side are present.

1.1.4 Assessment of Reflexes Pavel Kolář Inseparably, the assessment of reflexes is necessary for examination of the control functions of motion. In general, a reflex can be described as an involuntary motor response to a stimulus. In clinical practice, proprioceptive reflexes are known as myotatic or tendoperiosteal. However, this terminology is not correct because there are no receptors or free nerve endings located in the tendon or periosteum by which stimulation of the reflex response can be elicited. Myotatic reflexes are increased with lesions of the upper motor neurons (central neurons) and decreased with peripheral lesions involving a reflex loop of the examined spinal cord segment or brain stem region; as well as, in conditions with decreased muscle tone including lesions of the posterior tracts and neocerebellum. Reflexes are decreased or even absent in muscle dystrophies. A significant number of reflexes (exteroceptive reflexes) are elicited by stimulation of the skin. They respond to touch, warmth, cold, and pain. Reflexes are to be assessed in context with other findings, never in isolation. Elicitation of reflexes, or a lack there of, is also related to a postural situation. In other words, the position in which the reflexes are examined is not unimportant. To be able to elicit reflexes, for example, the extent of excitability of the muscle system is important; this may be increased, for example, by a prolonged isometric contraction of a muscle group. During examination, this can be used for facilitation of less excitable reflexes. It is known that the pressure applied at the upper extremities via the palms of the hands pushing against each other or, in contrast, significant pulling of interlocked fingers increases the level of elicitation of the lower extremity reflexes. This may allow the

examiner to elicit a requested reflex with more ease – this is the so called Jendrassik maneuver.

MYOTATIC REFLEXES Upper Extremities Myotatic Reflexes Bicipital Reflex Tapping the biceps tendon in the cubital fossa elicits forearm flexion. This reflex corresponds to the C5 spinal segment. Brachioradial Reflex Tapping the edge of the distal portion of the radius elicits elbow pronation and flexion. This reflex corresponds to the C6 spinal segment. Triceps Reflex Tapping the insertion of the triceps brachii elicits extension of the elbow – segment C7. Finger Flexor Reflex Tapping the flexor tendons on the volar side of the wrist elicits finger flexion. This reflex loop passes through C8. Brachioradial (Styloradial) Reflex It is elicited by tapping on the styloid process of the radius. The forearm is in slight flexion. The response is elbow flexion and this reflex loop passes through C5 and C6. Myotatic Reflexes of the Lower Extremities Patellar Reflex Tapping the patellar ligament (ligamentum patellae) elicits extension of the lower leg via the contraction of the quadriceps femoris. The patellar reflex is a pure segmental reflex of L4 and does not change with any other nerve root syndrome. For this reason, it is necessary to slightly correct the conventional way of describing this reflex as from segments L2-L4. Achilles Tendon Reflex Tapping of the Achilles tendon elicits plantar flexion of the foot.

Once again, this is a pure segmental reflex for the S1 level and not for segments L5-S2. With an L5 nerve root syndrome, this reflex does not change. Tibio-femoral-posterior Reflex (TFP) In supine with a slightly flexed lower extremity, the examiner’s fingers tap over the tendons of the semimembranosus and the semitendinosus muscles. The response is a palpable activation of the tendons – segments L4-S2. Peroneal-femoral-posterior Reflex (PFP) Testing for this reflex is carried out in the same manner as TFP, but the biceps femoris tendon is tapped – segment L5-S2. Adductor Reflex The patient is supine with the lower extremity in flexion and abduction (approx. 30°). Tapping on the medial femoral condyle elicits adduction of the thigh – segment L3-4 and also partially L2. With hyperreflexia, a response can be seen simultaneously in both extremities.

EXTEROCEPTIVE REFLEXES For assessment of movement functions, there are important number of skin reflexes that are elicited by the stimulation of skin receptors. Physiological abdominal reflexes are elicited by a gentle scratch of the abdominal wall, which elicits a contraction of the abdominal muscles. According to the localization of the stimulus, we can assess epigastric (T7-8), meccogastric (T9-10) and hypogastric (T11-12) reflexes. Physiologically, skin abdominal reflexes are decreased or absent in people with a weak abdominal wall. More difficult elicitation of skin reflexes is seen in obese people. Reflexes often disappear with pyramidal tract lesions and their absence is also typical in multiple sclerosis (sclerosis multiplex). Increased elicitation is seen in athetosis. Physiologically, the majority of producible skin reflexes primarily possess a defensive function.

With a painful stimulus to the bottom of the foot, a defensive triflexion of the lower extremity occurs. The muscles that flex the ankle, knee and hip joints are simultaneously activated. In addition, the contralateral lower extremity exhibits a response with a lower intensity in which extension is activated and flexion is inhibited. Centripetal afferentation is conducted via thin fibers which carry nociceptive stimuli and are denoted as “flexor reflex afferents” (FRA). In the examination, the following can also be utilized: Cremasteric reflex (segment L1-L2) – elicited by scratching the upper inner side of the thigh or by squeezing the distal part of the adductors above the knee in which an elevation of the testes is elicited on the ipsilateral side. Anal reflex (segment S2-S4) – skin stimulation with a sharper object in the area of the anus or the perineum elicits a contraction of the anal sphincter. This is examined especially in patients with incontinence or spinal cord involvement. In rehabilitation, exteroceptive skin afferentation is used for purposeful influence of motor functions. It is an important way of facilitating muscle activation. In the past, elicitation of defensive triflexion and other skin defensive reflexes were used for facilitating motion. Currently, the use of pathological defensive reflexes is not recommended. Mainly tactile stimuli (not painful) that influence muscle tone, for example, brushing, stroking, and tapping are used for facilitation and inhibition. The disadvantage of facilitation via skin afferentation is a high degree of adaptation to the acting stimuli and, thus, a relatively short effectiveness.

IDIOMUSCULAR RESPONSE Idiomuscular response is a physiological phenomenon that occurs with direct mechanical stimulation of the muscle tissue. Idiomuscular response is assessed by tapping a hammer directly on the muscle belly (i.e., biceps, ischiocrural muscles). During tapping, the contraction

and the speed of release are assessed. Increased idiomuscular response is found in patients with spasmophilia or with Thomsen’s and dystrophic myotonias, where the de-contraction may take up to several seconds. Increased response with formation of striated muscle rolls and a prolonged response are observed with peripheral neurogenic lesion with denervation and, in contrast, it is decreased or absent with myopathies and severe muscle atrophies. Similarly to skin reflexes, the idiomuscular response is more difficult to elicit in obese people. Increasing muscle reactions and widening of their reflexogennic zones are manifested as a presence of pathological reflexes, for example, the mediosternal reflex (adduction of slightly flexed arms after striking the sternum or a one sided elbow flexion after striking the acromion).

PATHOLOGICAL REFLEXES Pathological reflexes elicited on the upper and lower extremities tend to be positive in upper (central) motor neuron lesions. They signal spasticity and thus, are referred to as spastic phenomena. They can be elicited by stimulation of proprioceptors or skin receptors. Pathological Reflexes Elicited in the Upper Extremity Certain reflexes elicited in the upper extremities belong to the so called deliberate phenomena, which is not only linked to a pyramidal injury, but also to the involvement of a more extensive area of the corticosubkortical structures. According to a number of authors, these reflexes are not considered pathological in the true sense of the word, but rather are the result of hyperreflexia of the finger flexors. These reflexes are never elicited without a simultaneous increase in the elicitation of the stretch reflexes and their intensity correlates with the intensity of the hyperreflexia. The importance of these reflexes is, therefore, not as significant as the importance of reflexes in the lower extremities. Juster Sign The palm of the hand from the wrist across hypo​thenar eminence in a

direction below the fingers and above the metacarpal heads is stimulated by a sharp object. Adduction and opposition of an extended thumb is a pathological response (Fig. 1.1.4-1). Fig. 1.1.4-1 Caption: Juster reflex

Hoffmann Sign By strumming across the third digit on the dorsal side, thumb flexion and slight opposition are elicited. Trömner Sign The third digit is tapped across the muscle belly on the ventral side of the distal phalanx. The response is flexion of all fingers, including the thumb. Mayer Sign The examiner uses their thumb to press the first phalanx of the third finger into maximal flexion. The response is thumb opposition and adduction. Janisevski Grasp During its elicitation, an object is placed into a patient’s hand. A reflexive grasp is observed with the object’s attempted removal. Palm-chin Reflex (Marinesco-Radovici Reflex)

When pricking the skin of the thenar region, a contraction of the ipsilateral chin musculature occurs. Thumb-chin Reflex (Vitek phenomenon) This reflex is elicited by a slight turning of the thumb, which elicits a contraction of the chin musculature in the same way as the preceding reflex. Pathological Reflexes Elicited in the Lower Extremity Two basic types of spastic phenomena are recognized: extension and flexion spastic phenomena. Extension Spastic Processes The response to all of these reflexes is tonic extension of the big toe. Babinski Reflex It is elicited by stimulation of the bottom of the foot by a sharp object from the lateral aspect of the heel toward the big toe (Fig. 1.1.4-2). In healthy people, movement of the big toe is in the direction of the bottom of the foot while big toe extension occurs with a CNS injury. The Babinski reflex is positive when the pyramidal tract is not yet myelinated and, thus, the influence of the pyramidal pathway on the spinal reflexes cannot be fully manifested. During the first year of life, this reflex is lost and it later appears only as a pathological sign.

Fig. 1.1.4-2 Babinski reflex elicited by the stimulation of the bottom of the foot by a sharp object in the process marked by a red arrow. The response is pathological extension of the big toe instead of physiologic plantar flexion.

Roche Reflex (phenomenon) The skin is stimulated by a sharp object from the heel along the outside aspect of the foot to the little toe. Brissaud’s Reflex During the Babinski reflex, clonic contraction of the tensor fascia latae is observed. Sicard’s Sign Persistent big toe extension without the stimulation of the bottom of the foot. Vitek’s Bridge Phenomenon A patient in the supine position attempts to lift their pelvis while supported on their heels and shoulder blades. With this maneuver, once again, the big toe is extended. Chaddock’s Reflex The skin around the lateral ankle is stimulated by a sharp object. Again, the response is big toe extension. Oppenheim’s Sign The examiner presses and slides their hand on the anterior aspect of the tibia. Gordon Sign Pressure is applied to the triceps surae and the response of the big toe is observed. Flexion Spastic Processes With all of the following tests, the pathological response is flexion of the toes at the metatarsophalangeal joints with fan-like positioning.

The interphalangeal joints are typically in extension. Rossolimo’s Reflex A pathological response occurs with strumming of the pads of the toes or by tapping a reflex hammer at the level of the metatarsal heads (Fig. 1.1.4-3). Zukovsky-Kornilov Phenomenon A response is evoked by tapping a reflex hammer at the center of the sole of the foot (Fig. 1.1.4-4) Mendel-Bechterew phenomenon A response is obtained by tapping the cuboid bone (os cuboideum) on the dorsum of the foot (Fig. 1.1.4-5). Fig. 1.1.4-3 Rossolimo’s reflex

Fig. 1.1.4-4 ZukovskyKornilov phenomenon

Fig. 1.1.4-5 MendelBechterew phenomenon

Weingrow’s Phenomenon It is elicited by striking the center of the heel. Clonus The elicitation of clonus of the patella and the foot is another test focused on hyperreflexia and spasticity. Ocassionally, foot clonus occurs spontaneously in patients with spasticity. It is examined while the patient is lying down with the hip and knee in flexion. A quick

ankle dorsiflexion stretch is applied and clonus of the triceps surae is elicited. The test for clonus of the patella is performed with the lower extremity extended, the patella is pushed inferiorly by an abrupt movement, which stretches the quadriceps and clonic contractions are elicited. If the clonus stops, we speak of pseudoclonus. Mediopubic Reflex It is elicited by tapping a reflex hammer on the symphysis pubis with the lower extremities in flexion and abduction. The reflex has two responses. The upper response is characterized by contraction of the rectus abdominis (T9-12), the lower response is demonstrated by contraction of the adductors of the lower extremities. With CNS paresis, dissociation of this reflex is observed. The upper response is weaker or even vanished completely and the lower is increased in the form of hyperreflexia. With hemiparesis the dissociation can be onesided.

1.1.5 Examination of Involuntary Movements Pavel Kolář Involuntary movements, which disturb volitional movement, are one of the signs of movement dysfunction. Various reasons and different manifestations are recognized. Involuntary movements include: tremor, spasms, myoclonus, fibrillar and fascicular twitches, manifestation of spinal cord automatism, choreic and athetoid movements, ballistic hyperkinesis, and tics.

Tremor It is the involuntary movement of a certain body part. Resting tremor is found at rest without volitional contraction. With movement, it either disappears completely or decreases. It is absent during sleep and belongs among slow tremors with a frequency of 4–8 Hz. It is localized primarily in the hands where it has a character of “counting coins”. Moreover, it is found in the neck muscles, lips, tongue, and the chin.

Static tremor is found during a period when muscles are performing a stabilization function. Identical to a resting tremor, it develops with the disorders of the basal ganglia. Intentional tremor is linked to movement and its intensity increases with movement completion. It has a frequency of about 10 Hz and is a manifestation of cerebellar dysfunction as a result of a failure in the feedback mechanisms. Functional tremor is linked to a neurosis and it is characterized by high frequency and irregularity. Often, it is found in the eye lids and outspread fingers. It is easier to palpate than observe. Essential tremor is an innate disorder and it has the same character as a Parkinsonian tremor. It only differs in that the patient does not display other signs like rigidity, increased elementary postural reflexes or hypokinesis. We also distinguish between a tremor with thyrotoxicosis, an ethylic tremor and a cold-related tremor, which are physiological.

Spasms Spasms are involuntary contractions of striated or smooth muscles. They can be localized or generalized. They are either tonic, which is demonstrated by a longer lasting spasm, or clonic, which is seen as an interrupted spasm. Localized muscle spasms include intense spasms which are localized to excessively loaded muscles. They are often accompanied by a tremor. For example, graphospasm is accompanied by dyskinesis of not only the muscles used for writing, but also the shoulder girdle muscles. The following are also considered localized muscle spasms: fascial hemispasm, trismus, blepharospasm, glossospasm, pharyngospasm, spasms of the abdominal and back muscles with meningeal syndrome, and colics. Spasms developed with tetanus are also considered localized spasms. They are caused by an insufficiency in the parathyroid glands and lack of calcium. The demarcated spasm of the diaphragm is called singultus (hiccups). Generalized spasms develop due to irritation of motor neurons for

various reasons, i.e., with brain tumors, ischemic and hemorrhagic lesions, meningocerebral scars after injuries or infections. In epilepsy, generalized tonic-clonic spasms are accompanied by unconsciousness.

Myoclonus Myoclonus is a short-duration clonic spasm. It affects individual muscles or part of the extremities and trunk with an occasional kinetic effect seen with small excursions. They are similar to choreic involuntary movements. Myoclonus can be seen in various forms depending on whether the injured structure is the striatum, the thalamus or the cerebellum. With striatal involvement, myoclonus can be found even in the facial muscles, eyes (nystagmus), pharynx, and larynx. With involvement of a dentate nucleus (nucleus dentatus) or a contralateral olivary nucleus (nucleus olivarius), associated myoclonus of the palate-pharyngeal muscles or even the facial and laryngeal musculature is found. They are observed on one side only with a lesion in the dentate nucleus or the contralateral nucleus olivaris.

Fibrillar and Fascicular Twitches The fibrillar and fascicular twitches are contractions that do not produce movement. Fibrillations occur with muscle denervation. They are found 2–3 weeks after nerve damage occurs. The mechanism of onset of fibrillation is explained as an increased excitability of the post-synaptic membrane of the muscle fiber to the released acetylcholine during depolarization. Its occurrence is indicative of a gradual, but not quite complete, denervation and their cessation indicates further progression of denervation. Fasciculations are also a sign of a peripheral neurogenic lesion. Their development is linked to dysfunction in the motor neurons of the ventral horns of the spinal cord and unlike atrophies, which are mostly expressed peripherally, they are found more proximally and most often in the plexuses.

Choreic and Athetoid Hyperkineses Chorea develops with an injury to the putamen. The involvement of the caudate nucleus (nucleus caudatus) is linked to athetoid syndrome. Like the majority of extrapyramidal hyperkineses, they disappear with sleep. Athetosis It presents as involuntary, slow, twirl-like, sinuous, and snake-like movements. If it is accompanied by trunk torsion, we speak of torsal dystonia. Chorea These are involuntary movements that are present at rest and primarily with isometric muscle activity. Chorea, unlike athetosis, presents with a higher frequency of involuntary movements.

TICS Tics develop with damage to the extrapyramidal system and in neurotic patients. In neurotic patients, they have a compulsive character. Most frequently, they are found in a small muscle group either individually or in more groups simultaneously. An effort to stop tics elicits an unpleasant feeling or even anxiety, and often causes an increase in the intensity of the tics. Equally so, their intensity increases with arousal.

1.1.6 Examination of Muscle Strength David Smékal, Magdaléna Lepšíková

MUSCLE WEAKNESS The onset of muscle weakness has many causes and can be divided into organic and functional. Among the most frequent organic causes of muscle weakness are deficits in the motor pathways with volitional movement (i.e., the corticospinal tract) and of a peripheral motor

neuron, the neuromuscular junction and the skeletal muscle. Paresis develops, which demonstrates itself as a decrease in muscle strength, sometimes with a partial limitation in the range of motion. A complete loss of active movement is called plegia (paralysis). Paresis is found by a gross assessment of movements in the individual movement segments. Most frequently, the paretic muscle examination is carried out by assessing contractile endurance of the muscle. The patient is asked to close their eyes and hold both extremities in a certain position, for example, the upper extremities in a forward flexion in front of the body or the lower extremities with the lower leg in 90° of flexion while lying in prone or supine positions. Paresis is manifested by lowering of an extremity, which for the upper extremities, is referred to as the Mingazzini sign (Fig. 1.1.6-1). For the lower extremities, it is known as Barre’s sign and it has two modifications – Barre’s sign I (Fig. 1.1.6-2) and Barre’s sign II (Fig. 1.1.6-3). Paresis can be manifested when simultaneous lifting of both extremities to a certain position shows a delay on the affected extremity with lifting. These signs are considered to be a result of a pyramidal tract injury. A very sensitive test of fine motor skills is the finger dexterity test. The assessment is carried out by alternate tapping of individual fingers to the thumb. Fig. 1.1.6-1 Mingazzini sign

Fig. 1.1.6-2 Positive Barre’s sign I – lowering of a flexed lower extremity on the side of the paresis

Fig. 1.1.6-3 Positive Barre’s sign II – less knee flexion on the side of the paresis

Reflexive processes are functional causes of muscle weakness. Paresis often develops because of a functional inhibition that is dependent on reactions linked to a nociceptive stimulation. Reflexive muscle inhibition is referred to as functional pseudoparesis. Muscle weakness also develops as a result of hypoactivity.

MUSCLE STRENGTH Assessment of Muscle Strength The term dynamometry is used to describe the assessment of muscle strength. Isometric and isokinetic dynamometry are the basic methods of muscle strength assessment. These assessments are most commonly used in a laboratory setting while in clinical practice muscle testing or a simple measurement via portable tensiometers and hand held dynamometers are used. Whether examining muscle strength with

instruments or by muscle testing, a correct assessment is sometimes difficult because often just one individual muscle cannot be accurately clinically evaluated, but all the muscles that carry out that particular movement need to be assessed. This assessment also does not capture muscle coordination. Isometric Dynamometry Isometric dynamometry is based on measuring isometric muscle contraction. With an isometric muscle contraction, muscle tone increases without a change in muscle length. In a practical setting, piezoelectric tension meters are used, which are able to scan the muscle strength of individual muscle groups, as well as the muscle strength of larger muscle groups. For measurements, portable tension meters or special tension-metric units built into chairs and other equipment are used. Isokinetic Dynamometry Isokinetic dynamometry is based on the assessment of maximal muscle force within muscle groups throughout a full range of motion while the velocity of movement is constant. Current equipment allows for muscle testing at various speeds of movement. Assessment of Muscle Strength When testing muscle strength, the active movement performed by a group of muscles (in which the majority of the muscles cooperate in the same function) is always assessed, not the individual muscles themselves. For example, when assessing shoulder flexion, not only is the biceps brachii tested, but also the shoulder flexors. Muscles can be divided into the functions they perform during the movement: Agonists (primary muscles participating in the movement) Synergists (accessory muscles) Antagonists (muscles opposing the performed movement) Stabilization muscles (muscles ensuring stabilization of the primary muscle origin or insertion)

Example: The iliopsoas is the primary muscle performing hip flexion. The accessory muscles are rectus femoris, sartorius, tensor fascia latae, etc. To ensure that only contraction of the hip joint into flexion and not simultaneous pelvic anteversion and lumbar lordosis occur, activity of the stabilization musculature is necessary. In this case, it is the interplay between the abdominal muscles and the lumbar erector muscles. The antagonists of the hip flexors are the hip extensors, including biceps femoris, semi​tendinosus, semimembranosus and gluteus maximus. When categorizing muscles as agonists, antagonists, synergists and stabilizers it is necessary to realize the position from which the movement occurs. In the above example, in the supine position, without question, iliopsoas is the main hip flexor, whereas it is rectus femoris in sitting. Muscle Test In the clinical setting, a muscle test is most commonly used for the assessment of muscle strength. In the Czech Republic, the functional muscle test according to V. Janda is the most widely used. In foreign countries, testing according to Kendall et al. is often used. The beginnings of muscle testing are linked to R. Lovett who used the 20th century method of muscle strength assessment in the 40’s in children with ce​rebral palsy. Examination of muscle strength via muscle testing underwent dynamic development, but the principles of assessment stayed the same. The fundamental principle is the ability of the movement segment to overcome resistance against gravity. According to Janda, this equates to the 3rd grade of muscle strength. The assessment of muscle strength is an analytical method of identifying actual strength of individual muscle groups. We are not only interested in the quantitative aspect of movement (whether the movement is carried out within a full range of motion), but also in the qualitative aspect of movement (how it is performed). The basic grading of muscle

strength is documented in table 1.1.6-1. Janda uses grading of muscle strength of the trunk musculature (neck, torso, and pelvis) and extremities across six grades (0–5). For the assessment of mimic and mastication muscles, the muscle test according to V. Janda is used, in which the patient is examined in a supine position and the extent of individual movements is assessed. For example, when examining the orbicularis muscle of the eye (orbicularis oculi), the patient is instructed to close their eyes as much as they can or when assessing the frontalis muscle, the patient is asked to raise their eyebrows. When examining muscles of the orofacial region, resistance is never applied against the performed movement; only the extent of movement is observed and, if possible, the affected side is compared to the non-affected side. Six grades are recognized (0–5). For grade 5, the contraction is normal and no asymmetry is observed when compared to the non-involved side; with grade 4, a slight asymmetry is observed; with grade 3, the movement is carried out in approximately half of the full range of motion; grade 2 denotes that the patient carried out approximately 1/4 of the full range of motion, grade 1 denotes that with attempted movement there is a distinct muscle twitch and, finally, with grade 0, there is no contraction when movement is attempted.

Tab. 1.1.6-1 Options in muscle strength assessment (modified and supplemented by Kendall et al., 1971)

The Principles of Muscle Testing Vladimir Janda recommends the following principles be followed when testing muscle strength: Test the entire range of motion, if possible Perform the movement within a full range of motion with a slow, constant speed (“isokinetically”), but also “isotonically”, meaning with the same force, if possible Firmly stabilize; and with stabilization do not compress the belly or tendon of the tested muscle Resistance is given throughout a full range of motion perpendicular to the direction of the movement with a constant force. Resistance is not to be applied across two joints Ask for the movement to be performed in a fashion that the patient is used to and only after identifying the quality of that movement, instruct the patient in the movement or practice the movement with the patient Muscle testing is hampered by the error associated with subjective assessment. In this method, it is necessary to adhere to the principles of correct administration and to assess the patient by one examiner. It is also recommended that a standard environment is maintained during the examination. Insufficient information about muscle endurance is a potential shortcoming. Involvement of a peripheral neuron due to any cause is the main indication for performing muscle testing. Functional Tests Used for Assessment of Muscle Strength So called functional tests can be used to assess muscle strength. In contrast to muscle testing, it is not the individual muscle groups, but rather the ability to perform the skills used in daily activities, such as dressing, eating, hygiene, locomotion, transfers, etc. that are tested. Among the most frequently used tests are the Barthel Index (BI) or Functional Independence Measure (FIM) which are used for

assessment of functional ability and self-sufficiency, for example, in patients after CVA. Some tests were specifically developed to assess functional involvement in certain diagnoses. For children with infantile cerebral palsy, muscle activity can be assessed by Gross Motor Function Measure (GMFM). Also, special tests for patients with myopathy or multiple sclerosis have been designed and for patients with spinal cord injury, the Spinal Cord Independence Measure (SCIM) has been developed.

II NEUROLOGIC SYNDROMOLOGY In the previous chapters, the individual symptoms (reflexes, involuntary movements, disturbances of muscle tone, etc.) and their assessment were described. In the following chapters, the focus will be on the individual syndromes and their clinical manifestations. In Chapter “Treatment Rehabilitation in Neurology”, primarily rehabilitation treatment will be described. The clinical manifestations of individual syndromes correspond to the locations of the disturbances and they will be presented in such context. A disturbance can develop at the following levels: Muscle Neuromuscular junction Peripheral nerve Spinal cord Brain stem Cerebellum Thalamus Basal ganglia Ventricles Cerebral cortex From the perspective of differential diagnosis, it is important to also include clinical manifestations, which develop with meningeal involvement and with intracranial hypotension and hypertension.

1.1.7 Primary Myogenic Lesion Petr Bitnar, Pavel Kolář Deficits in which the primary cause is a myogenic lesion are generally called myopathies. Myopathic disorders primarily demonstrate themselves symptomatically by decreased muscle strength and no sensory deficit. If a sensory deficit is present, it is necessary to consider a different nosologic unit, such as a neuropathy. Sometimes (but rarely) myogenic lesions present with muscle pain –

myalgias. Weakness in Myopathies Based on the location (topography) of the muscle weakness, many forms of myopathic syndromes can be distinguished. Most forms of myopathies primarily involve the proximal musculature (plexuses) and less frequently distal musculature. Sometimes the facial musculature (facioscapulohumeral form) or the extraocular muscles (mitochondrial myopathy, oculopharyngeal dystrophy) are affected. In advanced stages of disease, the muscles of the pharynx (limitation of swallowing) are affected, as well as, respiratory and cardiac muscles, which subsequently are the most frequent cause of an early death in patients with myopathy. During clinical examination of the deficits in muscle function and strength, the following are most frequently observed: Waddling gait developed based on weakness of the hip joint stabilizers; Difficulty transitioning from sitting and supine to standing. When transitioning to standing, the patient helps themselves with the upper extremities against the thighs or furniture – so called “walking”. Myopathic “walking” is also known as Gower’s sign and it is one of the first manifestations of an illness, especially in children (Fig. 1.1.7-1); Significant lumbar lordosis (hyperlordosis) developed due to weakness of the abdominal and axial musculature and shortening of posturally older musculature in the region of the pelvic plexus (especially hip joint flexors); Deficit in the shoulder girdle (proximal) musculature of the upper extremity, which is demonstrated primarily by winging scapula (scapula alata), shoulder configuration (shoulders are “small”, protracted) and movement limitation in the extremities – especially above the horizontal; Disturbance in the mimetic musculature (dominant in facioscapulohumeral form and myo​tonic dystrophy) is manifested by hypomimia and a change in facial expression (for example, a sad

expression, a “tapir” mouth). For example, the patient is unable to whistle, fully close their eyes, etc.

Fig. 1.1.7-1 Gower’s sign, so called climbing

For partial classification and validation of the disease progression, a muscle test or functional tests can be utilized (Trendelenburg test, test of transitioning from supine to standing, standing from sitting in a chair, test of modified gait, etc.). Pseudohypertrophy and Muscle Contractures in Myopathies For some myopathic syndromes (dystrophinopathies), so called pseudohypertrophies are typical, primarily in the calf musculature. During observation (aspectation), pseudohypertrophy is manifested as a classic muscular hypertrophy; however, during palpation it shows pseudohypertrophic musculature of rubbery consistency with changes in shape and size (decreased) of the muscle bellies and an overall

change in muscle contour. Pseudohypertrophy is not caused by hypertrophy of the muscle fibers, but in contrast, by their decrease and replacement by fat-binding tissues. In myogenic lesions, a gradual fibrotization of the muscle occurs and contractures develop, leading to a state of permanent (fixed) muscle shortening. Achilles tendon contractures lead to toe walking; flexion contractures lead to changes in body posture and limited ranges of motion, and spinal contractures and axial musculature weakness lead to the development of scoliosis.

1.1.8 Deficits at the Neuromuscular Junction Petr Bitnar Myasthenia gravis (develops due to a postsynaptic dysfunction based on an autoimmune destruction of acetylcholine receptors) and Lambert-Eaton myasthenic syndrome (autoimmune inflammation of presynaptic calcific channels) are typical examples of deficits at the neuromuscular junction. Clinically, a fluctuating muscle weakness is observed, which significantly worsens after physical exertion (even short-lasting) and diminishes after rest. Myasthenia Gravis Most frequently, myasthenia begins to manifest itself as a deficit in the extraocular muscles, which is demonstrated by ptosis, diplopia and blurred vision. The disease further affects the muscles of mastication (deficits in chewing, chin falling), mimetic muscles (facial expression changes – tired expression) and the muscles participating in verbal communication (mumbling, slurred speech). Myasthenia gravis can further involve the neck musculature (head falling) and swallowing muscles. With myasthenia, the proximal musculature (plexuses) is affected to a lesser degree and usually in later stages. If involvement occurs, the shoulder plexus is more often affected. When the respiratory muscles become involved, the stage of

myasthenic crisis has begun. Lambert-Eaton Myasthenic Syndrome Lambert-Eaton myasthenic syndrome has a similar presentation to myasthenia gravis. Fluctuating fatigue is a typical characteristic; it worsens with movement repetition and improves with rest. In contrast to myasthenia gravis, the muscle plexus of the lower extremities is more significantly involved. Lambert-Eaton syndrome almost never begins in extraocular or facial musculature.

1.1.9 Peripheral Nerve Deficits Petr Bitnar The peripheral nerves are most frequently affected by polyneuropathies, entrapment lesions or traumas. During clinical examination of a peripheral nerve involvement, the subjective symptoms and objective findings are assessed. These findings should be confirmed by electro-diagnostics. Examination of a peripheral nerve deficit involves identification of the extent of deficits in the sensory and motor components. Examination of Deficits in the Sensory Fibers of the Peripheral Nerve Sensory fibers of the peripheral nerve are more prone to being affected than motor fibers. Therefore, in many cases, a deficit in sensory fibers precedes motor loss. However, it should be emphasized that when there is a loss in sensory afferentation, many times, there is also a simultaneous deficit in motor function. Subjective signs: Positive (irritable) signs: Algia (pain) including neuralgia (burning) pain localized in the area innervated by the involved nerve Paresthesia – spontaneous abnormal sensations (pins and needles, itching, tingling)

Dysesthesia – elicitation of abnormal phenomena (by touch, pressure); for example, touch is perceived as pain, etc.) Negative (diminishing) signs: Decreased skin sensitivity (hypesthesia) Deficit in tactile functions (a combination of deficits in exteroceptive and proprioceptive sensory afferentation) and, from them, the derived deficits in fine motor skills of the fingers Decreased perception of warmth, cold and pain Objective signs: During the objective assessment of sensory deficits, the following changes are observed: Hyperesthesias – abnormally increased perceptions in sensation that are defined by a previous examination (examination by a neurologic needle, brush, etc.); Hypesthesia up to anesthesia – decreased tactile perception based on the type and extent of the peripheral nerve deficit; Pallhypesthesia – decreased perception of vibration (assessed by a calibrated tuning fork); Changes in joint position and kinesthesia – assessing joint proprioceptive fibers. The deficit in proprioception is further demonstrated by unsteadiness in standing and walking, which can be objectively assessed by stability-metric examinations. Examination of Deficits in Motor Fibers of a Peripheral Nerve Subjective signs Subjective feeling depends on the extent of involvement (paresis vs. plegia) and the location of the deficit (proximal vs. distal muscles). The patient often complains of: Difficulties in mobility, decreased range of motion or an inability to complete a movement A decrease or loss of muscle strength Ataxia Increased muscle fatigue Limitation in activities of daily living

Increased unsteadiness and risk of falling (for example, foot drop and tripping) Objective signs: The following can be observed during an objective examination of motor deficits: Hyporeflexia or areflexia (decrease or absence of tendon reflexes, skin reflexes, etc.) Various degrees of tone deficits based on the type and an extent of the involvement (hypotonia or atonia) A decrease in or complete loss of muscle strength which can be assessed by muscle testing or functional tests (standing on toes, heels, etc.) Hypotrophy or atrophy (based on the type and extent of nerve involvement) which can be partially confirmed by anthropometric examination Range of motion limitations Fasciculations and fibrillations. Fasciculations are a sign of a partial denervation. They are small contractions of several muscle bundles, which are observed on the skin, overlying the corresponding muscle. Fibrillations are a sign of complete muscle denervation, they are not visible by the naked eye, but they are seen during electromyographic testing and they are caused by a spontaneous release of acetylcholine at the neuromuscular junction. With a peripheral nerve involvement, in many instances, the fibers of the autonomic nervous system can be involved as well (for example, in diabetic polyneuropathy or with traumas to the neck and pelvic regions). Changes in tissue blood flow (deficits in the vasomotor component), skin trophicity (dry, “paper-like”), and perspiration (deficits in sudomotor component) can occur.

1.1.10 Spinal Cord Syndromology Jiří Kříž, Veronika Hyšperská

GRADUAL TRANSVERSE SPINAL CORD LESION Occurs with gradual pressure on the spinal cord in the spinal canal, most frequently with a space-occupying process (tumor, herniated disc), less frequently with degenerative spinal diseases. Generally begins with deficits in the sensory system based on the level of involvement, either by signs of irritation or inhibition. Gradually, various serious deficits in motor and autonomic functions develop.

SUDDEN TRANSVERSE SPINAL CORD LESION Develops suddenly, most frequently as a result of an accident, after vertebral fractures or subluxations, by pressure of the fragments directly onto the spinal cord (primary) and by subsequent bleeding and inflammation (secondary). Clinically, it is manifested as deficits in movement, sensory and autonomic functions. It begins as a pseudoparetic spinal cord lesion and develops into a spastic lesion when the spinal shock subsides.

PSEUDOPARETIC SPINAL CORD LESION It is found in a patient with a spinal cord injury during the spinal shock phase, which is characterized by an inhibition of spinal cord function. The clinical picture is characterized by a decrease in or a loss of muscle tone, a loss of muscle strength, and a decrease in or a loss of tendon reflexes.

SPASTIC SPINAL CORD LESION Develops in patients with spinal cord injury after the spinal shock subsides. It is manifested as hyperreflexia, spasticity, presence of pyramidal irritability processes, persistent and variably manifested motor deficits,

and deficits in sensory and autonomic functions.

MIXED SPINAL CORD LESION Develops in patients with spinal cord involvement in the area of cervical or lumbar spinal intumescences. The clinical picture presents with a combination of disturbances in the central motor pathways and spinal motorneuron of the spinal ventral horns.

CONUS MEDULLARIS SYNDROME Occurs with a lesion in spinal segments S3-5. Muscle strength may not be significantly decreased, except for the pelvic floor muscles and small muscles of the feet. Sensory loss is present in the perianal and perigenital regions and involves the inner thighs symmetrically. Sphincter deficits (urinary retention or incontinence and bowel incontinence) and sexual dysfunction are also present. Bulbospongiosus (bulbocavernosus) and anal reflexes are absent.

CAUDA EQUINA SYNDROME It is found in lesions distal to the conus medullaris. Typically, the lesion is asymmetrical, the strength of the lower extremities is decreased based on the involvement of individual nerve roots, and muscle tone is decreased. Sensation is decreased for all types of receptors in the dermatomes corresponding to the involved nerve roots, including perianal and perigenital regions. Often, burning nerve root pain can be present. Urinary incontinence or retention, bowel incontinence and sexual dysfunction are present. Bulbospongiosus (bulbocavernosus) and anal reflexes are absent.

POSTERIOR CORD SYNDROME

A diffuse deficit of deep and discriminatory sensation and spinal ataxia are present, superficial sensation is not disturbed. A decrease in muscle tone and a decrease in or a complete loss of tendon reflexes can occur.

BROWN-SEQUARD SYNDROME It is characterized by a lesion to only half of the spinal cord. On the side of the lesion, a central paresis and deep sensory deficit develop caudally; nerve root pain can be present at the level of the lesion. A diffuse deficit of pain and temperature sensations occurs on the side opposite of the lesion.

INTRAMEDULLARY SYNDROME At the level of the lesion, a peripheral motor deficit is present; spastic paresis develops below the level of the lesion. Often, in the case of cervical spinal cord involvement, motor involvement of the upper extremities is greater than that of the lower extremities.

1.1.11 Cerebellar Syndromology Cerebellar syndrome is manifested primarily as a disturbance in the regulation of muscle tone and movement coordination. In contrast to the deficits in the pyramidal tracts, cerebellar lesions are unilateral. For humans, cerebellar syndrome is characterized by the following basic signs:

FLACCIDITY In cerebellar lesions, muscle hypotonia manifests itself as flaccidity. With passivity, the muscle does not give sufficient resistance against the movement and the joint range of motion is increased (joints are hypermobile). In the knee joint, recurvatum occurs; rotations and abduction are greater in the hip joints (Patrick’s test). Passivity can

also be assessed by ressaut test and the trunk succession test. In trunk succession test, the patient’s shoulders are pushed into an alternate rotation, which initiates passive movement of the upper extremities. The extent and number of swings of the arms around the trunk are noted. As a result of decreased muscle tone, the tendon reflexes display a greater excursion and are pendular in nature, meaning they demonstrate an increased number of responses to one stimulus.

HYPERMETRIA Hypermetria is a deficit in the ability to judge range of movement, or an accurate, purposeful movement. Movement coordination and its cessation are difficult. The patient is asked to put an index finger on the tip of their nose (see Special Section of the textbook, Fig. 1.13.2-1 in Chapter 1 Treatment Rehabilitation in Neurology) or to touch the outer edge of the contralateral ear lobe with the tip of their index finger with eyes open and later closed. For lower extremities, contact by the heel to a predetermined area on the body (i.e., the contralateral knee or ankle) is assessed (see Special Section of the textbook, Fig. 1.13.2-2 in Chapter 1 Treatment Rehabilitation in Neurology). A patient with a cerebellar lesion will “overshoot” the target. Judgment of the range of movement is also disturbed in other neurologic syndromes. With extrapyramidal syndromes, hypometria is present – movements are slowed, unsure, and the examined body segment sometimes does not even reach the desired target. An inaccurate judgment of range of movement is also present with a sensory system deficit (especially with proprioceptive deficits – “deep sensation”) and with central or peripheral pareses.

ASYNERGY Asynergy is a type of muscle coordination deficit. A so called large asynergy manifests itself as a lack of coordination during standing and ambulation. Thus, it is a coordination deficit of mainly the axial muscles. A small asynergy is manifested as a deficit in the interplay of smaller muscle groups. It is tested by a supine to sitting transition

with the arms crossed across the chest. The patient excessively lifts their lower extremity on the side of the deficit (see Special Section of the textbook, Fig. 1.13.2-4 in Chapter 1 Treatment Rehabilitation in Neurology).

DIADOCHOKINESIA Upon examination, rapid alternating movements are observed. Under normal conditions, these should be performed in a rhythmical, smooth and symmetrical fashion. For example, a rapid alternating movement of the tongue from side to side or protruding of the tongue in and out of the mouth can be tested. A typical examination is rapid alternating hand pronation and supination (see Special Section of the textbook, Fig. 1.13.2-3 in Chapter 1 Treatment Rehabilitation in Neurology). With cerebellar dysfunctions, the patient is unable to execute these movements with good coordination and movement synchronization of both extremities simultaneously (for example, one hand is delayed when compared to the other) and the movements are not performed in a rhythmical fashion. A deficit in rapidly alternating, repetitive movement is called adiadochokinesia (dysdiadochokinesia).

OTHER CEREBELLAR SIGNS Intention tremor – a tremor that is present, especially toward the end of a movement (during the final stage of targeting a movement) with a frequency of 10 Hz. Hyporeflexia or areflexia of elementary postural reflexes (EPR) – this deficit manifests itself as an inability to ensure segment fixation/stabilization in each newly attained position and, thus, guarantee an equal movement. Nystagmus and dizziness – are not signs of direct cerebellar involvement; they develop indirectly with simultaneous deficit in the vestibular pathways or nuclei, most frequently as a result of a CVA. Professor K. Henner described hyperfunctional cerebellar syndrome, which presents with opposite signs, similar to an

extrapyramidal Parkinsonian syndrome. It is quite rare in the clinical setting.

1.1.12 Extrapyramidal Syndrome Pavel Kolář Typical manifestations of an extrapyramidal or Parkinsonian or also known as hypertonic-hypokinetic syndrome are hypokinesia, rigidity, tremor and postural instability. During patient observation (aspection), the patient can show the following signs: Hypomimia Mask-like face expression Flexion posturing of the trunk and extremities (see Special Section of the textbook, Fig. 1.15.2-1 in Chapter 1 Treatment Rehabilitation in Neurology) Hypokinesis A wide-based gait with small, shuffling steps and decreased or absent synkinesis of the upper extremities. Frequently, movement “freezing” is present during which the patient is unable to continue walking, especially if they need to change direction Resting tremor Small repertoire of spontaneous mobility Inefficient breathing strategies Autonomous system deficits – hyperhydrosis, hypersalivation, oily face (facies oleosa) Other signs include slow, monotonous speech without melodiousness (aprosodia); perseveration, or persistent repetition of certain words is also frequently observed. Rigidity is manifested as increased muscle tone linked to increased elementary postural reflexes (EPR). The judgment of movement excursion is hypometric and bradykinetic, and the desired movement is slow and does not reach its target.

With assessment of rhythmic movements, a distinct slowness or absence of rhythm is observed; the movements are not followed through to the end. Thus, dysdiadochokinesia (adiadochokinesia) is different in character than other cerebellar dysfunctions where the movements are “overshooting” the intended target. Micrography, or diminished script, is also typical. The patient is not able to draw a picture (e.g. a spiral or the symbol for infinity) without a movement interruption.

1.1.13 Thalamic Syndrome Pavel Kolář Clinical signs are always manifested on the contralateral side. There are six typical signs, which may not present all at once: Hemihypestesia – with a majority of the deficit in deep sensation and stereognosis, which may manifest as apraxia Hemiataxia Hemiparesis – usually to a lesser degree Hemialgia – strong, even unbearable, pain in one half of the body, which is difficult to control by medical treatment Chorea and athetoid hyperkinesis Homonymal contralateral hemianopsia (with involvement of the lateral geniculate body – corpus geniculatum laterale) With symptoms of thalamic involvement, deficits in consciousness may appear such as epileptic seizures or narcolepsy (cataplexy), which is a sudden loss of muscle tone without a deficit in consciousness.

1.1.14 Brain Stem Syndromes Pavel Kolář The assessment of a brain stem injury is based primarily on clinical signs, which display distinct characteristics for all individual locations. Of significance are the level of the lesion and the location of injury, meaning whether lateral or medial brain stem structures are involved.

Alternate or crossed syndromes present with specific symptoms. On the side of the lesion we can observe a nuclear or intracerebral fascicular deficit of a specific cranial nerve, gaze paresis (horizontal, usually on the side of the lesion), Horner’s syndrome or cerebellar signs. On the contralateral side, a tract deficit can be seen characterized by hemiparesis or hemianesthesia. Individual syndromes are named after their authors. For example, Claude’s (tegmental) syndrome (ipsilateral lesion of Cranial Nerve III with contralateral ataxia and tremor) or Benedikt’s (tegmental and ventral) syndrome (ipsilateral lesion of Cranial Nerve III with contralateral ataxia, tremor and contralateral hemiparesis). Since brain stem syndromes present more frequently with vascular etiology, this typical symptomatology is currently not well respected. Rather, the symptoms correspond to the involvement of individual arteries and are often not found in the form described above. Eponymous designations are gradually receding and arterial syndromes serve as the bases. Arterial syndromes can be divided into: Medial syndromes – develop with the involvement of branches of the basilar artery (arteria basilaris), supplying the medial portion of the brain stem; Lateral syndromes – develop with the involvement of primarily the cerebellar arteries and their branches.

MEDIAL SYNDROMES Medulla Oblongata Artery involved: paramedian branch of the basilar artery Clinical presentation: contralateral hemiparesis, ipsilateral lesion of Cranial Nerve XII, deficit in proprioception and discriminatory sensation. Lower Pons Artery involved: paramedian branch of the basilar artery

Clinical presentation: contralateral hemiparesis, horizontal gaze paresis in ipsilateral direction, deficit in proprioception and discriminatory sensation. Upper Pons Artery involved: paramedian branch of the basilar artery Clinical presentation: contralateral hemiparesis (including CNS type mimetic paresis), frontal internuclear ophthalmoplegia (horizontal or vertical diplopia accompanied by oscillation [oscilopsia] of one of the double images). Lower Mesencephalon Artery involved: paramedian branch of basilar artery Clinical presentation: contralateral hemiparesis, contralateral deficit in proprioception and discriminatory sensation in one half of the body, ipsilateral Horner’s syndrome, contralateral lesion of Cranial Nerve IV, frontal internuclear ophthalmoplegia, ipsilateral or contralateral ataxia. Mid-Mesencephalon Artery involved: paramedian branch of the basilar artery or mesencephalic artery. Clinical presentation: contralateral hemiparesis, contralateral deficit in proprioception and discriminatory sensation in half of the body, lesion in Cranial Nerve III, frontal internuclear ophthalmoplegia, ipsilateral or contralateral ataxia.

LATERAL SYNDROMES Medulla Oblongata Artery involved: vertebral artery (arteria vertebralis), anterior inferior cerebellar artery (arteria cerebella inferior anterior) Clinical picture: Wallenberg’s syndrome – dysphasia, dysphonia and paresis of the soft palate, deficits in pain and temperature sensation of half of the face, hypogeusia or ageusia of half of the tongue, Horner’s syndrome, hemiataxia, singultus (hiccup).

Upper Pons Artery involved: superior cerebellar artery (arteria cerebella superior) Clinical picture: mimetic muscle paresis of half of the face, hypogeusia or ageusia of half of the tongue, Horner’s syndrome, hemiataxia – all ipsilateral; contralateral deficits of pain and temperature sensation of the face. Lower Pons Artery involved: anterior inferior cerebellar artery (AICA) Clinical picture: deficit in sensations of all types on the ipsilateral half of the face and temperature and pain sensation deficits on the contralateral side of the body, hemiataxia, Horner’s syndrome and weakness of the ipsilateral muscles of mastication. Lower Mesencephalon Artery involved: superior cerebellar artery Clinical presentation: contralateral deficits in temperature and pain sensation on half of the body and face; ipsilateral Horner’s syndrome. Mid-Mesencephalon Artery involved: superior cerebellar artery Clinical picture: contralateral deficits in temperature and pain sensation on half of the body and face; ipsilateral Horner’s syndrome. Upper Mesencephalon Artery involved: superior cerebellar artery Clinical picture: vertical gaze paresis (specifically in the cephalic direction), pupil areflexia, convergence and retractory nystagmus, upper lid retraction.

1.1.15 Syndromes of Meningeal Irritation, Intracranial Hypotension, Hypertension and Ventricular Syndromes Pavel Kolář Rehabilitation is CONTRAINDICATED in all of these syndromes! Subjective and objective signs are listed only for the purposes of

differential diagnosis because it is not unusual, especially at the onset of disease, that the signs are similar to the ones of an acute vertebrogennic syndrome. This causes a delay in the determination of a correct diagnosis and a selection of an inappropriate treatment strategy.

SYNDROME OF MENINGEAL IRRITATION It is a cluster of signs, which develop by irritation of the brain meninges and the roots of the cranial nerves such as sharp headache, vomiting, bradycardia, changes in higher nerve function, deficits in consciousness and oversensitivity to all stimuli – light, noise, pain, etc. Tension Maneuvers of the Meninges of the CNS Positive tension maneuvers characteristic for meningeal syndromes: Head flexion with meningeal irritation is difficult and painful Kernig’s sign (assessed in supine or sitting) – elevation of extended lower extremities causes lumbar pain and flexion in knee joints; in sitting, the patient flexes the lower extremities at the knees and hips Brudzinski sign – with passive head flexion, knee and hip flexion occur Amos maneuver – a patient sits while leaning on their upper extremities

INTRACRANIAL HYPOTENSION SYNDROME Clinically, a common sign of intracranial hypotension is its dependency on body position. The symptoms worsen in standing; on the contrary, they disappear or show decreased intensity when lying down. Subjective symptoms include headache (cephalea), dizziness, and nausea. Psychological symptoms include depression, but conditions such as delirium may also appear. Intracranial hypotension can be accompanied by deficits in consciousness. The symptoms also correspond to those resulting from a lesion in the hypothalamus. In this context, hyperthermia, hyperhydrosis, or diabetes insipidus can be present. Frequently, it occurs after a lumbar puncture and it is

reversible.

INCREASED CRANIAL PRESSURE SYNDROME The symptoms can be caused, for example, by the growth of an intracranial tumor, relative or absolute increase in the amount of cerebrospinal fluid, subdural hematoma and so on. Headache is the main subjective symptom. The headache is brought about by changes in head position. The pain increases when laying down and with all activities linked to the Valsalva maneuver (coughing, sneezing, pressure on bowels, etc.). A decrease in pain can be accomplished by applying pressure to the cervical arteries. Other subjective symptoms include nausea, dizziness, blurred vision and deficits in ventricular functions (i.e., problems with memory and spontaneity). Objective clinical signs include forced antalgic head position with a marked increase in the tension of the superficial neck musculature and increased blood pressure, which appears in the early stages (gradually, blood pressure decreases). Other signs include bradycardia and oliguria. Neurological focal signs (i.e. cerebellar syndrome, central paresis) are linked more to common illnesses.

VENTRICULAR SYNDROMES The secretion, circulation and resorption of spinal fluid occur in the brain. If one of these functions is affected, various clinical presentations develop – increased or decreased intracranial pressure syndrome or meningeal syndrome. The localized ventricular syndromes are distinguished by the ventricle where the pathological process is occurring and/or based on which part of the ventricular pathway is blocked by the aforementioned process. Tumors are the most common reason for the localized ventricular syndromes. Tumors of the third ventricle are manifested as deficits in awareness, bitemporal hemianopsia, and endocrine and cardiovascular deficits. Tumors of the fourth ventricle are manifested as titubations or falls, tonic spasms of the neck musculature (opistotonus) and paroxysmally developed headache (cephalea) with an antalgic head positioning.

1.1.16 Cortical Syndromes and their Examination Pavel Kolář, Rastislav Druga Cortical functions are the result of an integrated activity of cortices. Projection regions of individual cortices are not distinctly divided, but they functionally overlap to a certain extent. The neocortex forms the largest part of the cerebral cortex (approximately 95%), which is phylogenetically the youngest. The rest of the cortex is formed by the alocortex, which is divided into the paleocortex and archicortex. The neocortex consists of six layers, while the alocortex only consists of three layers of cells. The paleocortex, also known as the “olphactory brain” (striae olfactoriae, bulbus olfactorius, trigonum, uncus gyri parahippocampalis), belongs to the limbic system along with the archicortex of the temporal lobe (cornu ammonis, gyrus dentatus, subiculum). Nerve pathways are divided into associated pathways which connect the individual cortex fields of the same hemisphere (ipsilaterally) and, commissural pathways which connect the cortex regions of the left and right hemisphere, and projections fibers leading from the cerebral cortex to subcortical structures (basal ganglia, thalamus, brain stem, spinal cord) or from the peripheral receptors to the cerebral cortex. A cerebral cortex injury is demonstrated by the following: 1. Symptoms that are related to the function of a corresponding cortex (see below) 2. Deficit in a certain symbolic function. Cortices (functional cortical regions) which ensure specific functions (visual, auditory, motor, etc.) are common in the human cortex, as well as, in the cortex of other mammals. However, a human, unlike other mammals (including primates), possesses developed phatic, gnostic and practical functions. Phatic functions – allow for speaking, writing, counting, communicating via spoken and written forms, abstract thinking, etc.

Gnostic functions – the ability to recognize objects by vision, hearing and touch Practical functions – allow for the ability to perform complex daily activities and creative activities The extent and type of deficit in symbolic functions correspond to an existence of hemispheral dominance that is being right-handed or left-handed. These are primarily phatic functions, which are linked to the dominant hemisphere (right-handed people to the left hemisphere and left-handed to the right hemisphere). With gnostic functions, this dependency is not as important and practical functions are the least dependent on hemispheric dominance. Dominance is more developed in right-handed people. In left-handed people, some deficits (for example phatic) may develop with a lesion in the left hemisphere. Some deficits in cortex functions present similarly to deficits of a psychological origin and, therefore, their distinction is sometimes difficult. Disruption in cortical function can sometimes be observed objectively by the people surrounding the patient or during clinical examination. However, some manifestations are more subtle or completely subjective in nature. During examination, patient report and the ability to ask targeted questions are the only means. Correct recognition of these signs and symptoms and their distinction from psychiatric deficits speeds up the establishment of a correct diagnosis. Hemispheres are topographically divided into brain lobes, which are responsible for different functions (Fig. 1.1.16-1 and Fig. 1.1.16-2): Frontal Parietal Occipital Temporal Limbic system Fig. 1.1.16-1 Side view of the lobes of the cerebral cortex

Fig. 1.1.16-2 View of the medial part of the brain

Based on a specific manifestation of functional deficits, it is possible to establish a probable location of the cortical lesion. From anamnestic data, based on the course of the disease and laboratory results, it is possible to deduce the etiology of the lesion.

FRONTAL LOBE In humans, the frontal lobe (lobus frontalis) is the most developed and its surface represents 32% of the total surface of the hemisphere. The central sulcus (sulcus centralis Rolandi) divides the frontal lobe from the parietal lobe and lateral sulcus (Sylvian fissure, sulcus Sylvii) from the temporal lobe. The frontal lobe houses several important functional cortical regions. The primary motor cortex (MI) is found in the posterior portion, premotor cortex (PM), frontal eye field and Broca’s speech

area. A large prefrontal region is located in the anterior portion of the frontal lobe. Primary Motor Cortex (MI) The primary motor cortex corresponds by its size to Area 4. With electric stimulation of this region, a very low intensity of electricity is needed to elicit movement. With electrical stimulation of the MI area, muscle contractions and, subsequently, movements in the contralateral side of the body occur. The area is somatotopicaly organized (motor homunculus). The neurons controlling muscles of a particular body part are found here. Neurons in the MI region controlling spinal motorneurons of one muscle are diffused in a relatively extensive cortical area. For example, within the cortical area representing the hand and forearm muscles, neurons controlling movement in various joints of the hand and the forearm are mixed. It is in the motor areas, not the muscles, that movements are distinguished. In the cortical mechanism, the muscle is not considered a functional unit; rather, the functional unit is the movement in one individual joint. The size of the area dedicated to individual muscle groups in the cortical homunculus corresponds to the copiousness and accuracy of their movements and not to the size of the muscle or muscle groups. Thus, the largest area of this cortical region is occupied by the musculature of the hand and tongue. In contrast, the cortical representation of the trunk and lower extremity musculature is small. Simple movements on the contralateral side of the body occur with a short-term superficial stimulation of the precentral gyrus (gyrus praecentralis). More complex, coordinated movements occur with longer stimulation (500 ms) and with intracortical stimulation. With stronger stimulation, tonic-clonic spasms occur on the contralateral side of the body and the face. This is called “Jackson’s epilepsy” during which the patient maintains consciousness. With a lesion in the precentral gyrus, frequently a contralateral paresis of one extremity occurs. Paresis may be facial, brachial or distal in nature. In case the affected area is located close to midline

like in a benign tumor (falx cerebri), a pseudoparesis of the lower extremities without a sensory deficit may occur. The primary motor cortex receives fibers from SI (areas 1, 2, 3a, 3b) cortical regions and also from the premotor region (Area 6) and Area 5. This region is further influenced by the cerebellum via the thalamus (nucleus ventralis lateralis). Approximately 30–40% of the fibers project into the pyramidal tracts from Area 4, which is the only source of direct corticomotorneuron connection. Premotor Cortex The premotor cortex (PM, SMA) corresponds by its size to Area 6. It is located in front of area 4 on the convex side of the hemisphere, but also extends to the medial portion. Part of Area 6 on the convex side of the hemisphere is marked as the premotor region (PM) and the part located on the medial aspect is known as the supplementary motor area, MII. Both premotor regions are somatotopicaly organized, but their zoning is less distinct than the MI region. The premotor region receives afferent fibers from the visual cortical areas (Areas 18, 19) and from the parietal cortex (Area 7) and it is influenced by the basal ganglia. The efferent connections are significantly different to MI. It projects few fibers into the pyramidal tracts, but strong projections have been shown into the brain stem (red nucleus, reticular formation) and pontine nucleus (nucleus pontis). The premotor and supplementary motor areas are connected bidirectionally. The primary motor and premotor regions are part of several loops of the basal ganglia (cortex-striatum-palladiumthalamus-cortex). The movement program evolves and is modified in the premotor areas. The response to electric stimulation of this area is a slow, tonic movement of the ipsilateral or contralateral extremities. These movements can be coordinated. Prior to movement initiation, the premotor areas show activity earlier than the MI region. It has been shown that the premotor cortex contains many neurons.

Their activity changes based on visual stimuli and is seen prior to movement initiation. It is thought that the PM cortex is important in the control of movements guided by vision. A lesion in motor Area 4 leads to a contralateral CNS (rather pseudoparesis) paresis. Only one extremity or a portion of it can be affected or only the facial musculature. With involvement of the premotor cortex (Area 6) and the supplemental motor area, a lesser degree of paresis occurs, but it is accompanied, in contrast to involvement of Area 4, by spasticity. Quadriparesis occurs with bilateral involvement, affecting mobility of the cranial nerves (pseudobulbar paresis). Some clinical findings suggest that the PM regulates the activity of the proximal muscles of the extremities, including the plexuses. Isolated lesions in the supplementary motor area can lead to movement hypokinesis or even akinesis. The premotor areas (PM, SMA) are activated prior to the MI region. Thus, it is thought that they are superior to the primary motor cortex area. Frontal Eye Field Frontal eye field corresponds to Brodmann Area 8. It is also called the visual field or the frontal aversive field. With stimulation of this region, the eyes and the head deviate to the opposite side. In contrast, with its dysfunction, the eyes deviate toward the affected side and a volitional eye movement paresis toward the opposite side develops. Afferent connections are obtained from the visual cortex (Areas 17, 18, 19) and from the thalamic mediodorsal nucleus (nucleus mediodorsalis). Efferent projections terminate in the pretectal region, in the superior colliculus and in the reticular formation. Thus, pathways that mediate the fast component of an optomotor response arise from this cortical field. Broca’s Speech Area Broca’s motor center for speech is located in the posterior third of the inferior frontal gyrus and corresponds to Areas 44 and 45. In righthanded people, it is located in the left hemisphere. The region is

closely neighbors the precentral cortex, which controls the motor neurons needed for speech. This is a center for the spoken (expressive) component of speech and for written expression. The area is anatomically and functionally interconnected with cortical areas controlling movement of the lips, tongue, larynx, and pharynx and with Wernicke’s area. With a lesion to this cortical region in the dominant hemisphere, phatic function deficits develop, i.e., motor (expressive) aphasia. Speech is not fluent, reduced into individual syllables or into small amounts of words. Mistakes in grammar and in sentence composition arise. With more extensive lesions affecting subcortical structures, the patient cannot speak at all. Generally, the patient is not aware of their deficit. Functional brain assessments show that Broca’s center is activated with many tasks focused on word creation, word search, and the analysis of meaning. Prefrontal Cortex The anterior parts of the frontal lobe (areas 9-12 and 45-47) are known as the prefrontal cortex. In primates and especially in the human brain, these areas are quite developed. This cortical region receives strong association and commissural connections from all lobes of the hemisphere, the amygdala and the thalamus (medial dorsal nucleus). Efferent connections lead to the basal ganglia (caudate nucleus), the thalamus (medial dorsal nucleus, posterior thalamic nuclei) and the brain stem (superior colliculus, reticular formation). Functionally, the prefrontal cortex is divided into orbital, medial and lateral sections. The orbital and medial sections are part of a system that controls emotional behaviors. The lateral portion, located in the convex region of the frontal lobe, ensures control of cognitive functions. These include primarily sequencing of individual components of behaviors, speech and reasoning. The lateral part also contains memory mechanisms for individual components of behavior and for their planning. Finally, it is involved in the initiation of

planned volitional movements and in the executive control of psychological function. With an injury to the prefrontal cortex, motor deficits are more difficult to identify. The patient lacks initiation and spontaneity of movement, is apathetic, and shows a compulsive need to manipulate objects and constantly repeat certain movements. From a motor perspective, increased tone in the flexors and extensors (paratonia) is also a sign. With a prefrontal cortex injury, psychological and emotional problems arise initially. It is possible, with the help of neuropsychological testing, to distinguish between the slowing down of learning processes and certain deficits in symbolic functions in the prefrontal cortex. The extent of the deficit is dependent on the area affected. If a polar part of a non-dominant frontal lobe (the area of so called ethical functions) is involved, the effect is minimal. Bilateral deficit in the polar region leads to a personality disorder, lack of initiation, spontaneity, and a disinterest in the surroundings. The patient becomes apathetic or even abulic. With deficits in the prefrontal cortex, memory and intellect are affected. Sometimes, this condition ends in dementia. As far as a psychological deficit, the following can dominate: lack of critique toward self or the disease, which manifests itself as disproportionate joking about one’s impediment. This condition is called moria. Inappropriate or even vulgar responses, which seem to be done out of spite, are called Ganser Syndrome. The lack of a sense of appropriateness of expression leads to neglect in personal hygiene and appearance and a lack of interest in bowel and bladder control (gatism). In the end, a frontal coma (coma frontale) occurs, manifested as sleepiness or even coma. Signs of an Injury to the Frontal Lobes of the Motor Cortex A typical clinical sign of an injury to the motor areas of the frontal cortex is the presence of primitive reflexes (deliberation phenomena). They are also known as the axial and paraxial phenomena.

Axial phenomena Nasopalpebral reflex – elicited by tapping the base of the nose or the glabella region. This reflex is present in a physiological situation. In a pathological scenario, an excessive response is observed in the form of tonic eye lid closure and widening of the reflex elicitation zone. Labial reflex – elicited by tapping the upper or lower lip. Sucking reflex – elicited by touching the lips. In response, the lips move into a sucking position. With elicitation of this reflex, chewing and smacking movements can occur. Paraxial phenomena Grasp reflex (Janisevski reflex) – elicited by placing a finger (or an object) into a patient’s hand, the patient reflexively closes their fist. The grip gets stronger the harder the object is being pulled out. Palm-chin (palmomental) reflex – elicited by scratching the thenar area. The response is a twitch of the mentalis muscle (musculus mentalis) on the ipsilateral side of the chin. Thumb-chin reflex – elicited by passive twisting of the distal phalanx of the thumb. The response is similar to the palmomental reflex. Deliberative phenomena are usually indicators of a late stage of the disorder. Frontal ataxia is one of the signs of a motor deficit in the frontal cortex. It is manifested as deficits in walking and sometimes standing. With a frontal lesion, disturbances in walking are a result of a loss in the integration of feedback loops (gait apraxia). Gait is characterized by short steps, wide base of support, and an overall flexed body posture. Sometimes, an increased gait retropulsion can be observed, in which the patient is not able to stand in place and takes small backward steps until they fall. With frontal lobe deficits, pseudocerebellar signs (hypermetria, dysdiadochokinesia) can occur on the contralateral side of the body. Deficits in the supplementary motor area and possibly other parts of

the frontal motor cortex of the dominant hemisphere can lead to motor neglect syndrome, which “imitates” paresis of the contralateral extremities. With this deficit, defensive motor reflexes, as well as other reflexes associated with sensation, are not altered by a nociceptive stimulus. However, volitional movement is significantly limited. Moreover, with frontal lesions, apraxia in bilateral extremities and verbal apraxia can occur. Sometimes, with a white matter lesion of the anterior portion of the corpus callosum (corporis callosi), a so called “alien hand” deficit occurs. The patient does not consider their hand as their own (belonging to a stranger). Other Disturbances with Lesions to the Frontal Cortex Medial frontal (cingular) syndrome is characterized by significant apathy or akinetic mutism. Similar syndromes can develop with deficits in the basal ganglia, which are interconnected with this region. Lesions in the base of the frontal lobes present with unilateral or bilateral hyposmia and anosmia. With tumors in the base of the frontal lobe, an atrophy of the optic nerve papilla can develop or a space-occupying papilla on the opposite side. This pressure may also involve the olphactory nerve. Assessment Tests for Frontal Lobes Deficits The following tests can be used to screen psychological disturbances when prefrontal areas are involved: “Contrasting Programs” The patient is given commands and asked to repeat the activities demonstrated to them. For example: “open your hand and show your palm the same way as me. When I bend one finger, you bend two fingers and later, when I extend my finger, you extend two”. A patient with frontal lobe involvement demonstrates difficulty with response inhibition and repeats the demonstrated movement in a mirror-like fashion (echopraxia). Test Go/No-Go This test is based on the same principle as “contrasting programs”.

The patient is asked to repeat demonstrated movements, but instead of imitating them, they are asked to change some features. For example, the patient is instructed as follows – “when you see that I raise one finger, then you raise two fingers, but if I raise two fingers, you do nothing.” The patient, once again, has a tendency to repeat movements in a mirror-like fashion. Luria’s Test This test consists of three sequential hand gestures: Slapping one hand across the other with the palm open A strike of the fist into the palm A strike of the lateral side of an open hand into the opposite palm The patient’s goal is to repeat these gestures as quickly as possible following the examiner and then, in the same order, perform them by themselves. The patient has difficulty performing the required movements in the order required. The patient performs redundant movements and perseveres. Verbal Fluency Tests The patient is asked to say as many words as possible starting with a certain letter in one minute. The patient cannot use proper nouns and cannot gradate the words. With frontal involvement, the patient usually says two to three words quickly, but they do not know how to continue. A long pause follows or they do not continue at all. Analysis of the test results needs to take into consideration the patient’s attained educational degree. Perseveration Test Perseveration is typical with frontal lobe injuries and the patient has a tendency to cling. This can be assessed, for example, by having the patient alternately draw an outline of an arch and a square. The deficit manifests itself as a decreased ability to alternate between the drawings of these shapes. Other tests include sequential organization of pictures of a certain activity. The patient is unable to complete this task.

TEMPORAL LOBE The temporal lobe (lobus temporalis) smoothly crosses from the occipital lobe and it is separated from the frontal and parietal lobes by the Sylvian fissure. The temporal lobe is host to several important cortices. The primary auditory cortex (Area 41) and associated areas (Areas 42 and 22) are found in the superior temporal gyrus region. One of the vestibular cortexes is also located in this gyrus. The temporal lobe is a center of hearing function. Bilateral destruction of the primary auditory cortex (projection region of a hearing pathway) leads to so called cortical deafness; this only happens in rare cases. Unilateral lesions decrease the intensity of auditory perception and can be objectively assessed by so called dichotomic hearing. One of the first signs of a temporal lobe deficit is hearing agnosia, which is manifested as a poor ability to name and express sounds in words (breaking of glass, a child’s cry, etc.), or amusia, which is a loss of the ability to recognize and reproduce melody, rhythm, etc. The above described deficit rarely occurs. Irritation or lesion in the upper temporal gyri can lead to the development of vestibular deficits, which are manifested mainly as dizziness and vestibular ataxias. Visual association areas of the temporal lobe are found in the inferior and medial temporal gyri and in the occipitotemporal gyrus (Areas 20 and 21). These areas are activated with tasks focused on recognition of faces, shapes, colors and other superficial characteristics of objects. In the posterior portion of Area 22 (probably with an overlap into Areas 39 and 40), Wernicke’s language area is found. With a deficit in Wernicke’s area, perceptual or sensory aphasia (Wernicke’s aphasia) occurs. A perceptual language deficit is the inability to comprehend spoken speech. A patient is unable to repeat the words they hear. Their speech is fluent, but unintelligible. The sounds are made into senseless words without any relationship (Gibberish). Cortical regions are located on the medial side of the temporal lobe

and are part of the limbic system (parahippocampal gyrus, hippocampal formation). The function of the hippocampus is to transfer information from short-term into long-term memory. The hippocampus is one of the key structures participating in the formation of memories. A deficit in the hippocampus or a disruption in its connection to surrounding structures (entorhinal region, association cortices) leads to memory deficits. With a deficit or irritation of the frontal portion of the parahippocampal gyrus (uncus), a dreamy state can occur. The patient feels that they have already experienced a certain situation in the past and considers it closely familiar. Objects that they see and hear for the first time appear familiar to them. These are illusions that are observed, heard, and experienced (illusions du déjà vu, entendu, vécu). On the other hand, the patient does not recognize familiar objects; they perceive that they see everything for the first time (illusions du jamais vu). Also, episodes of olfactory parosmia can occur. Behavioral deficits include rage, anger and aggression. These, together with feelings of fear and anxiety, are components of temporal epileptic episodes. These emotional states can be elicited experimentally by stimulation of the corticomedial amygdaloid nuclei. A partial (quadrant) homonymous deficit in the visual field occurs with involvement of optic radiation (radio optica/geniculostriate pathways) as it passes deep within the temporal lobe. A lesion in the temporal lobe can also result in a time recognition deficit.

OCCIPITAL LOBE The primary visual cortex (Area 17, calcarine fissure and its surroundings) and visual association areas (Area 18 and 19) are located in the cortex of the occipital lobe (lobus occipitalis) and extend into the hemispheral convexity. Area 17 is the final destination for the visual tract. The primary analysis of visual signals occurs here. With stimulation of these visual regions, the following can occur: various visual perceptions (false), flickers (phosphenes), or even visual hallucinations, in which the patient sees persons or entire scenery,

various scenes, etc. Visual illusions or hallucinations can also be elicited by pharmaceutical agents (mescaline, atropine, L-dopa, antidepressives, LSD). Negative signs include scotomas or contralateral homonymous hemianopsia. With a lesion to the language dominant hemisphere, hemianopsia is accompanied by alexia or by visual agnosia in which the patient does not visually recognize objects. However, they recognize them, for example, via hearing or touch. Cortical blindness is also a negative manifestation. In this case, cortical blindness presents with an absence of optokinetic nystagmus, but photoreaction is fully preserved.

PARIETAL LOBE Anatomically, the parietal lobe (lobus parietalis) is separated from the frontal lobe by the Rolando fissure and from the temporal lobe by the Sylvian fissure. It is not distinctly separated from the occipital lobe, but rather, the two lobes merge smoothly. The somatosensory cortex (S I, postcentral gyrus) is the front part of the parietal lobe and it is divided into areas 1, 2, 3a, and 3b. Through strong connections with the thalamus (ventral posterolateral nucleus, ventral posteromedial nucleus), this region is supplied by somatosensory signals from the skin receptors and contralateral proprioceptors. Afferentation from the thalamic nuclei is somatotopically and analogically organized similar to the precentral cortex (sensory homunculus). The areas of the dermis with the highest density of receptors (lips, tongue, thumb, palm) have the largest representation in the S I region. The posterior portion of the parietal lobe contains Areas 5 and 7. Area 5 is the somatosensory association area and Area 7 is the polymodal association area. Areas 39 and 40 are found in the inferior portion of the parietal lobe and are thought to be part of Wernicke’s cortical area. During maturation of the parietal lobe centers, one’s body awareness (somatesthesia) is formed, as well as, its relation to the surroundings.

A deficit in the primary somatosensory cortex and primary somatosensory association areas leads to a deficit in sensory discrimination. The majority of deficits related to the parietal lobe belong in the category of phatic (amnestic aphasia, alexia, agrafia, and acalculia), gnostic and practical deficits. Deficits in phatic functions develop with damage to the posterior portion of the parietal lobe in the dominant hemisphere and clinical pictures of gnostic functions are not strictly related to the dominant hemisphere. Deficits in Phatic Functions Amnestic aphasia – patient presents with an apparent lack of vocabulary. They cannot recall certain words, but rather describe them. For example, instead of “pants” they say “the thing that’s for dressing”, etc. Acalculia – manifests itself as an isolated deficit. For example, a patient complains of early fatigue with successive math tasks involving longer addition. The first few items are added correctly, but the patient shows increasingly greater problems remembering the previous result. Alexia – a reading deficit, which may be accompanied by agraphia (see below). With a milder deficit, a patient does not understand text in a similar way as when we read inattentively when fatigued. With a more significant degree of involvement, a patient is not able to read a given text; some words are read by syllables or spelled. Hints of this deficit are frequent in children with dyslexia. The child cannot distinguish letters that are similar or mirror images of one another: b-d, p-q, etc. Agraphia – a writing deficit. Most frequently, during dictation, a patient makes small mistakes, like omitting punctuation, commas, or individual letters. With more significant involvement, a patient omits entire groups of letters, especially in less common words. In severe cases, they are not able to write the most commonly said words, name of their town or their own signature. The presentation is similar to ideomotor apraxia.

Deficits in Gnostic Functions The parietal lobe (specifically its posterior portion) is interconnected with the reticular formation, limbic system, and visual and hearing cortices. This important interconnection allows for the parietal lobe to serve as an integration system of cognitive functions. Various types of agnosias belong among the deficits of gnostic functions linked to the parietal lobe: Autotopagnosia – a person is unable to recognize their own body parts Anosognosia – marked by the lack of ability to recognize one’ s own deficit Asomatognosia – the patient is unaware of an entire part of their body Astereognosis – the inability to recognize shape or type of surface by skin and proprioceptive receptors (without visual control) Hemihypesthesia – a deficit in tactile sensation on one side of the body, but not affecting the entire side; thus, it is a slight deficit. If the hemihypesthesia is accompanied by hemiparesis and homonymous hemianopsia, then the deficit is severe. One of the signs of a parietal lobe lesion, but only in the dominant hemisphere (gyrus angularis), is the inability to recognize the right and left sides. At the same time, a patient usually cannot distinguish and name fingers. This is, in combination with acalculia and agraphia, called Gerstmann’s syndrome Pain asymbolia – a syndrome in which the patient distinguishes the quality of pain (i.e., sharp, burning), but they do not react to these stimuli emotionally or motorically. Gnostic deficits can also involve color recognition, perception of sound, recognition of objects (the patient sees the object, but does not register it) and faces, perception of movement (akinetopsia) and, last, but not least, tactile functions (stereognosis) Deficits in Practical Functions Another significant sign of a lesion is apraxia which is a deficit in the performance of a learned task. The patient is not able to perform

certain activities or a number of activities that were completely automatic before their deficit. At the same time, the patient does not have any motor limitations, which, of course, leads to the perception of being confused or behaviorally disturbed. As a result, the patient is often registered as mentally ill. Motor apraxia – in this deficit, the plan is preserved, but the execution is disrupted. If a patient is given a certain task, for example, to open a door with a key, they know what they are supposed to do; however, they approach the task without purpose. Ideomotor apraxia – the movement plan is absent. The movements are clumsy (in contrast to motor apraxia) and the patient is unable to complete the task. The patient has the tools, but does not know how to use them (for example, they want to unlock the door, but attempt to put the key in with the wrong end or are unable to comb their hair). Ideational apraxia – the patient does not understand what task is asked of them as if they have never heard of this type of task, much less seen it carried out, thus, the patient cannot perform any part from a given command. For rehabilitation, it is important that PET studies had shown activity in the postcentral gyrus not only with volitional movements, but also with passive movement and with somatosensory stimulation. This strongly demonstrates that cognitive functions may be significantly influenced by movement functions.

LIMBIC SYSTEM The limbic system is a complex collection of cortical regions and subcortical structures. Limbic cortical regions are located in the medial aspect of the hemisphere. They include the cingular gyrus (gyrus cinguli), parahippocampal gyrus (gyrus parahippocampalis), hippocampal formation and olfactory cortical areas. Some of these regions belong among developmentally old cortical formations (for example, olphactory cortical region or hippocampal formation). The subcortical structures that are part of the limbic system include a

complex of the amygdalar nuclei, nuclei of the septal region, the ventral portion of the striatum (nucleus accumbens), certain nuclei of the hypothalamus and the thalamus. Some authors include the prefrontal cortex and some brain stem structures within the limbic system. The limbic system is characterized by rich afferent and efferent connections of its individual structures which often form circuits. A two-way connection of the hippocampal formation with association cortices is significant for limbic system function. Efferent connections of the hippocampal formation are part of the so called Papez circuit: hippocampus – fornix - mammillary nuclei of the hypothalamus – mammillothalamic bundle – frontal thalamic nuclei – cingular gyrus – parahippocampal gyrus – hippocampus. Other circuits that deserve to be mentioned are the amygdalar circuit (amygdala – thalamus – prefrontal cortex – amygdala) and the entorhinal circuit cortex – hippocampus – entorhinal cortex. The limbic system regulates visceral and vegetative activity and has a significant role in memory mechanisms, regulating emotional behavior and emotional motor skills and, lately, it has also been mentioned in relation to immune processes. The limbic system is superior to the hypothalamus and the autonomic nervous system. Memory functions of the limbic system are stored in the hippocampus. The action of the hippocampus lies in the transformation of short-term and mid-term memory into long-term memory (memory consolidation). With damage to the hippocampus, short-term memory deficits occur (especially in declarative memory – memory about facts, events, words, and numbers). Within the hippocampus, there are also located neurons that react to change in the surrounding environment. The hippocampus is extraordinarily sensitive to hypoxia. Hypoxic states lead to destruction of the hippocampal neurons. The hippocampus is also one of the more significantly involved structures during an epileptic shock (temporal epilepsy). Stimulation of the amygdala can elicit feelings of anxiety, fear or

aggression. Destruction of the amygdala is manifested as an overall quiescence of behavior, decreased aggressiveness and decreased or lost emotional responses. Thus, the involvement of the hippocampus leads toward deficits in memory, amygdalar disturbances, and deficits in emotional experiences. The front part of the cingular gyrus and certain areas of the prefrontal cortex (for example, the orbital gyrus) are involved in the control of respiration, blood pressure, peristalsis and other autonomic functions. These areas include extensive connections with other limbic structures and their electric stimulation influences autonomic functions. The limbic system is a co-partner in the generation and initiation of motor programs. It adds the affectionate-emotional component (movement accompanying aggression, fear, happiness, etc.) to the motor programs and their context. The limbic system also participates in the initiation and planning of movements. It is movement activity that is facilitated by the needs of the organism and influenced by the changes in its internal environment. Dissociation Syndromes Dissociation syndromes include deficits that arise during the disconnection of hemispheres. One of the manifestations is alexia without agraphia. This deficit occurs with a disturbance in the connection between the primary visual center and the contralateral speech center. With a disruption of the entire corpus callosum, individuals cannot name objects in their left hand, read a text on the left side of the visual field, or carry out a task with their left hand (apraxia of the left upper extremity). Examination of Motor Functions from the Perspective of Cortical Plasticity Pavel Kolář, Magdaléna Lepšíková

Movement assimilation or motor adaptation is significantly dependent on the plasticity of the cerebral cortex. The quality of movement coordination and the degree of its adaptation, meaning the possibility of their modification, is dependent on a number of factors. The most important is undoubtedly the characteristics of the CNS component of the movement system as well as the method by which the stereotypical movements and their postural assurance are and were developed, strengthened and revised. During formation of the movement pattern, it is important to develop a truly economical pattern. This means that only the muscles that mechanically participate in or facilitate the movement are activated. This leads to an optimal loading of the joint and ligamentous structures. An example could be accessory breathing, in which the accessory respiratory muscles are involved, leading to the activation of additional muscles that must stabilize these accessory muscles. In a similar way, the pattern assuring stabilization of the spine is often incorrectly developed. Whether an individual is able to freely alter this pattern or whether this pattern is firmly fixed without the possibility of modification is an important fact to consider. The ability to form adjusted and programmed movement, modify fixed postural functions and perform a movement under various postural situations is also dependent on the quality of the CNS structures. The formation and fixation of continuously new postural variants is dependent on the quality of the control structures without the disappearance of the earlier developed variants. This ability is significant, for example, in the understanding of recurrences of painful movement syndromes and unsuccessful movement reeducation of post-injury musculoskeletal conditions. In general, the quality of the CNS components delineated by their plasticity is clinically manifested as the ability to carry out selective movement (movement differentiation), or the ability to perform a movement without additional co-movements and with the smallest recruitment of accessory muscles (without synkineses). This is not possible without quality relaxation ability. A very common

manifestation of such dysfunction is observed when working at a computer. With computer mouse use, it is necessary to relax the wrist and perform the movement with the greatest possible relaxation in other muscles. It is usually observed that the movement is transferred into another joint (for example, it arises from the shoulder with the wrist being fixed) and movement stabilization is performed to a great extent by the upper trapezius, levator scapulae, and pectoral muscles, or rather by the muscles that should be relaxed. Also, the change in the gaze from the monitor to another object is accompanied by compensatory head movement (it is not an isolated movement of the eyes) and, once again, an excessive number of muscles participate in such movement. The individual is not able to separate the movements, meaning to separate the individual segments during motion. In addition, they lack alternative movements. These movement dysfunctions become fixed and difficult to change. This type of dysfunction poses problems in all professions with unilateral loading, including athletes. Dysfunction in selective movement and the inability to relax are narrowly linked to the level of somatognosis and stereognosis (the ability to distinguish the position, movement and stimuli via skin and proprioceptive afferentation). A given function narrowly correlates with the image of one’s own body. The concrete picture of one’s own body varies greatly for each individual. The imperfection of this picture testifies to the insufficient compensatory options in pathological conditions. Patients with a deficit in spatial body awareness, i.e., deficits in somatognosis and stereognosis, also adapt poorly to an orthopedic or spine surgery. They represent the main group of patients in which surgical procedures have failed. Therefore, the diagnosis of these functions is very important. During the examination, the following functions are emphasized: Examination of Selective Movement Examination of Isolated Movements The ability to perform an isolated movement is assessed. For example, the patient in supine with the lower extremity flexed at the hip and knee. The patient is asked to perform a very small circular movement in the hip joint. It is assessed whether the patient is able to perform

the movement in isolation without synkinesis and excessive irradiation of muscle activity, for example, without the co-movement of the pelvis and without the activation of the muscles of the contralateral extremity (Fig. 1.1.16-3). The ability of isolated movements of the eyes is assessed, meaning the movement of the eyes independent of head movement (Fig. 1.1.16-4). Similarly, for example, the isolated movement of the tongue is assessed.

Fig. 1.1.16-3 The assessment of an isolated circular movement in the hip joint. The ability of a lower extremity movement without a movement at the pelvis is observed.

Fig. 1.1.16-4 The examination of an isolated eye movement. The tracking of a moving object with the eyes without head movement (A) and with head movement (B)

Examination of Relaxation Functions During examination of the ability to relax, the therapist performs a passive movement of the upper extremity and observes the extent of muscle relaxation. With a decreased ability to relax, resistance is felt in the extremity during passive movement. During this assessment, the passive movement is performed in all directions. To increase test sensitivity, the examination can be administered in posturally more challenging positions. For example, the patient will perform a unilateral mini-squat while the ability to relax the upper extremity is assessed, meaning the isolation of this movement segment without recruitment of muscles demanded by a posturally more challenging position (Fig. 1.1.16-5).

Fig. 1.1.16-5 The examination of the ability to relax the upper extremity with posturally more challenging body positions. A – in single limb stance; B – in quadruped support

Both functions are narrowly related to the level of somatognosis and stereognosis. Somatognosis is the general feeling of the existence of one’s body. It is body awareness that determines the relationships between the person and space. A stereognostic function is characterized as space perception and contact with external space (without a visual component) in relation to one’s body schema. The ability to recognize the environment by touch is the basic prerequisite for purposeful movement. Without this function, a purposeful movement does not exist because the function of the associated cortices (especially the parieto-occipital region) is significantly disrupted. This is similarly seen with agnosias and apraxias. These abilities are narrowly related to the quality of sensory function assessed by discriminatory and deep sensation (see Fig. 1.1.34). To correctly select a treatment program for movement dysfunctions, these functions and analysis of their results need to become a consistent part of clinical assessment.

Examples of Clinical Tests The patient is asked to demonstrate, through use of their hands, their body perception and it is assessed how far this idea differs from reality. The patient, for example, is asked to close their eyes and raise their arms forward with the hands delineating the depth of their chest; or to raise their arms forward so that the hands are kept above the head and held apart in a distance that corresponds to the shoulder width (Fig. 1.1.16-6).

Fig. 1.1.16-6 Assessment of somatognosis – without visual feedback, the patient gives the bitrochanteric width of the pelvis by spreading their arms in a horizontal (A) and a vertical (B) plane

It is examined how the patient identifies their body position via proprioception. With the eyes closed, the therapist places the upper extremity in a certain position and the patient is asked to remember this position. Then, the extremity position is altered. The patient is asked to attain the original position. The difference between the two positions is assessed (Fig. 1.1.12-7).

Fig. 1.1.12-7 The examination of proprioception – the patient is standing facing (A) sideways (B) to the testing board and the upper extremity is passively placed in a certain position; then, the extremity is relaxed along the body and again actively put into the original position. Using a millimeter paper on the wall, the difference in the original and final positions is assessed.

The patient’s ability to read, or perceive contact with an external environment, is assessed. On a selected body part (bottom of foot, back, etc.) a letter or number is written and the patient is asked to identify it. The level of ability to distinguish the stimuli, so called graphesthesia, is assessed. The next test serving to examine the patient’s ability to assess standard sensory stimuli is a modified test by Petrie (Fig. 1.1.16-8). For the examination, two wooden blocks, one for test and one for assessment, are used. The test block is a cuboid of equal width and length. The assessment block is gradually slanted into a pyramidal shape. The patient feels the cuboid block for 30 seconds with one hand and then tries to find the corresponding width on the pyramidal block. The pyramidal block has a field of tolerance marked to outline the normal range of response. The patient has a minimum of three trials. If a patient is repeatedly giving dimensions within this field, they do not demonstrate a dysfunction. If the patient gives a larger dimension, then they belong in a group of over-estimating patients; if they give a smaller dimension, they belong in a group of underestimating patients. Fig. 1.1.16-8 Examination by Petrie

The described tests can be administered in various modifications and variations. In patients with deficits in cortical plasticity and the associated somatognostic and stereognostic functions, it is recommended that, next to a specific practice of stabilization functions, simple exercises focused on maximal awareness of posture and movement should also be incorporated.

III NEUROMOTOR DEVELOPMENT AND ITS EXAMINATION CLINICAL EXAMINATION VIA MOTOR PROGRAMS Pavel Kolář The examination of motor, or CNS functions in children, especially in the early stages of life, is focused primarily on the assessment of muscle tone. From the aspect of diagnosis of motor deficits in children, this examination is significant; however, it does not provide sufficient information to establish a functional treatment approach or to fully understand the etiology and pathogenesis of movement dysfunctions. Greater attention needs to be directed toward postural and locomotor functions and thus, to motor programs which reflect tone deficits more sensitively. Motor Patterns of Postural Development In the neonatal stage, the posture (body posture) and anatomy of individual joints and bones are noticeably immature. For example, the chest is barrel-like and longer in the anterior-posterior direction than in the lateral-lateral direction; the posterior rib angles are anterior to the spinal axis; the spine lacks lordotic curvatures; the tibial plateau is slanted; the colodiaphysal and torsion angles of the femur are not formed; the longitudinal axis of the calcaneus deviates laterally from the talar longitudinal axis and the heel is positioned in elevation because the calcaneus has yet to shift under the talus. Anatomical immaturity could be described similarly in other body parts. In this stage, the central nervous system is quite immature and it will take several years (approximately until the 5th or 6th year of age) before it gradually matures for all motor functions (gross and fine motor skills). During maturation of the CNS (myelinization, synaptogenesis, reorganization, etc.) which is dependent on sensory inputs, posture is maturing and is strictly defined and purposeful movement behavior occurs. This is expressed not only in the quantity (all the skills that the child at a given age performs), but also in the

quality of movement (how the movement is executed). The child begins to: Lift their head above the surface and prop-up on forearms (6 weeks) While supine, flex and lift lower extremities (6 weeks) Grasp a toy from midline (5 months) Turn from supine to prone (6 months) Creep on hands and knees (in quadruped) (8.5 months), etc. A child’s movement expression corresponds to their maturity or to the developmental age of the CNS, but it can also be observed whether CNS maturation is developing in a physiological or pathological direction. Body posture, and locomotion associated with it, are developing during postural ontogenesis. Postural muscle functions (ensuring posture) have a formative influence on the morphologic development of the spine, hip joints, the trunk, etc. At the onset of life, the interplay of these muscles influences the development of local, regional and functionally linked global and anatomical parameters (See chapter 1.2.1. Kinesiology of the spine, pelvis and the trunk; Anatomical parameters influencing spinal function) (Fig. 1). In this function, the interconnection between the biomechanical and neurophysiologic principles is the clearest. During development, both principles are mutually dependent and they cannot be viewed separately. Their mutual connection contributes to the understanding of the etiology and pathogenesis of movement dysfunctions and serves as a fundamental principle for the selected rehabilitation techniques.

Fig. 1 The development of the femoral neck in the first year of life. Postural locomotion functions linked to the individual phases of motor development are participating in anatomical development [published with agreement of Mgr. Blanka Vlckova and Mgr. Miroslav Kutin, RL-Corpus, Olomouc].

This relationship is most visible with those CNS dysfunctions during which, due to an imbalance in muscle activity acting on the growth plates, there are not only deficits in postural functions occurring, but also anatomical deficits with biomechanical consequences at a joint (for example, pelvic anteversion, shoulder protraction, winging scapulae).

SCREENING OF NEUROMOTOR DEVELOPMENT Central Coordination Disturbance (CCD) In the neonatal and infantile stages, knowledge of motor behavior during CNS development (motor patterns) and its variability are used in the assessment of motor functions. Neuromotor developmental screening is a basic stepping stone for early identification of children with a CNS dysfunction. Children who demonstrate an abnormal model of spontaneous motor behavior and positional reactions are included in a clinical category referred to as a central coordination disturbance (CCD). Based on the degree of involvement, CCD is divided into the following groups: very mild, mild, moderately severe, and severe. It needs to be mentioned that CCD does not mean that the patient will develop a CNS deficit (most frequently infantile cerebral palsy). This is observed only in a very small percentage of children in which CCD is identified. Early diagnosis of CCD and the initiation of reflex therapy are crucial in prevention of other pathologies and, in case of CNS lesion, to minimize the effects of a CNS dysfunction. CCD is thought to be mainly spontaneously selfcorrective. However, experience suggests that individuals with CCD do not exhibit gross motor deviations, but often demonstrate postural dysfunction (faulty body posture) in many forms at a later age and with all the consequences and also deficits in motor adaptation. Therefore, initiation of therapy is important even in cases where the patient does not show a clinical presentation of an infantile cerebral

palsy. In the Czech Republic, the issue of functional dysfunctions of CNS regulation in adults was pursued by Dr. Vladimir Janda who observed the following in patients with body posture dysfunction: Signs of small neurological deficits, which he identified as microspasticity, and the lack of coordination manifesting itself as ataxia Slight deficits in sensation, esp. proprioception Decreased adaptability to stress and disproportionate or “uncoordinated” behavior (emotivity). Developmental Kinesiology as an Assessment Method – the Examination of an Infant in the First Year of Life Assessment of postural development serves as the primary means for determining a central coordination dysfunction. The screening of postural development according to Vojta serves as an examination of newborns and infants at risk or suspicious of psychomotor delay. In other countries, the approaches commonly used are based on Dubowitz & Dubowitz, Prechtl in conjunction with items from Touwen, and also developmental tests called the Griffiths Developmental Scale. Prechtl and his colleagues started a new approach completing neurological examination based on observation of spontaneous motor activity. In newborns with various neurological brain lesions, the quantity of endogennically generated motor activity (spontaneous movement) does not change, but the quality changes. Movements lack elegance, fluidity and complexity. From the entire spectrum of spontaneous movement, general movements (GM) are used because of their complexity and frequency of occurrence. The quality of GM is assessed according to the Prechtl method in which “normal” movements are defined by variability in sequence, speed and amplitude. In the assessment, an entire range of abnormal signs in GM quality is described. These include: Hypokinesis Poor repertoire of GM

Abnormal or absent fidgety movements Chaotic or cramped synchronized (CS) global movements Poor movements present with a reduced sequence and are missing complexity. Cramped synchronized motions are general movements which manifest as a deficit in fluidity and smoothness. They are rigid and all extremity and trunk muscles contract and relax nearly simultaneously. Fidgety movements (restless, unsettled, impatient movements) are an example of GM. In a child, these movements are observed until 3 – 5 months of life. They are manifested as a continuous stream of small circular and graceful movements of the neck, trunk and extremities. The absence or abnormality of GM fidgety movements at the age of 6 – 20 weeks of life is thought to be a very significant factor in predicting future neurological dysfunctions. In a pathological scenario, they are manifested as jerky or completely absent and with overly excessive amplitude and speed. In children with future spastic or dyskinetic involvement, a lack of typical GMs is observed from the 1st week of life. When an abnormality in the quality of GM perseveres during 6–20 weeks of life, we speak of persistence. A transient abnormality is identified as only a temporary occurrence. If cramped synchronized GM do not disappear, this deficit is termed predominant. A reduced repertoire of GM leads to a normal prognosis in majority of children (83%). In children with an absence of fidgety movement, infantile cere​bral palsy with slight motor involvement occurs. Persistence of GM of CS character after the 1st week of life suggests a severe type of spastic diparesis. Specifically, consistent predomination of CS GM predicts infantile cerebral palsy. The sooner they appear, the more severe the involvement becomes later. A mild deficit develops with transient CS GM with the absence of fidgety movements. Next to endogenously generated movement, the assessment of functional or purpose-oriented and motivated motion is the primary focus. The assessment of deviation from physiological development is administered by the following assessments:

Postural activity Postural reactivity Primitive reflexology Postural Activity Pavel Kolář, Marcela Šafářová The following are the focus of a postural activity assessment: Erector and anti-gravity functions (support, body posture, head control, etc. – support motor skills) Purposeful phasic movements (purposeful grasp and its quality, type of locomotion, etc. – purposeful motor skills) The development of postural activity is strictly kinesiologically defined. The knowledge of postural activity in individual stages, i.e. when the child begins lifting their head, when they start rolling, when they begin reaching for objects, when side sitting and thumb opposition occur, etc., allows us to assess the relationship between the involved child’s motor development and the degree of physiological development. The assessment not only focuses on the deviation from chronological development, but also on the quality of the observed movement activity. Children with a mild degree of CNS involvement may not show a delay in postural activities, but a deviation is observed in their quality of movement. A child, for example, lifts their head with hyperextension of the cervical spine without the upper extremities providing sufficient trunk support (Fig. 2A, B). Fig. 2 A child with central coordination disturbance from a side view (A) and from the top view (B). The child presents with incorrectly developed upper extremity support; the position is held in cervical hyperextension and pelvic anteversion. The child presents with a deficit in stabilization function.

Postural Activity in Individual Phases of Development (0–15 Months) Neonatal stage (Fig. 3, 4) In the neonatal stage, the newborn demonstrates an asymmetrical body positioning during waking hours. In prone, the center of mass is found at the sternal and umbilicus regions. No support base exists (support is not differentiated; no points of support are utilized), but only some kind of laying surface. The newborn lies on half of the

body extending from the face through the chest into the region of the umbilicus. The upper and lower extremities are flexed and are not capable of a support function. The same asymmetric alignment exists in the supine position. In a given period, the newborn does not possess an optic fixation but must be able to make eye contact for a short period of time. A short visual interaction must occur between the newborn and an object that we show them. Fig. 3 Body position in supine in the newborn stage of development.

Fig. 4 Body position in prone in the newborn stage of development

The head is turned toward one side. This is known as the predilection position of the head. This position is physiological until the 6th week, but must not be permanent. In the supine position, the head must turn to the opposite side or at least to midline. This can be assessed by covering the newborn’s eyes with the examiner’s palm (Fig. 5). With this provoked head turning, a newborn not only changes their head position, but by following the light, turns their head and whole body together. An isolated movement of the head or

the eyes occurs later. If a newborn does not show this capability, we speak of a fixed predilection which is considered to be a pathological risk factor. During this test, it is also necessary to observe a newborn’s own needs and their effort to turn. A normal prognosis for mental development is expected in newborns that show a strong motivation to turn their head. Fig. 5 Covering the eyes provokes head turning to the opposite side

Next to predilection, a reclined position of the cervical spine is observed. Again, this needs to be a temporary, transitional state. A fixed reclined position is the sign for a pathological picture. In the prone position with hips and knees flexed, the lower extremities should abduct to 90°. More extensive abduction is a sign of an abnormal postural development suggestive of hypotonia. A Particular Kinesiologic Context of Posturing: Hand – finger flexion, ulnar deviation, wrist flexion, the thumb is closed in the hand (Fig. 6) Elbow – flexion and pronation (Fig. 7) Shoulder – protraction, internal rotation(see picture 7) Scapula – elevation (see picture 7) Spine – kyphotic posture (see picture 4) Pelvis – anteversion (see picture 4) Hips – flexion, abduction, external rotation (see picture 4) Knees – flexion Foot – plantar flexion (see picture 4)

Fig. 6 Hand positioning in the neonatal stage of development

Fig. 7 Upper extremity posture in the neonatal stage of development

In the neonatal stage, a specific type of posturing is set in which the tonic muscles dominate. A child in this developmental stage does not possess an equilibrium function. This means that the ability of co-activation does not exist. In other words, the ability of a synchronized activity among the antagonistic muscles is missing. Given this immaturity, this developmental period is characterized by an occurrence of certain “primitive reflexes” organized at the spinal or brain stem level of control. The reflexes elicited are, for example, a cross extension reflex, suprapubic reflex, heel reflex, erectile reaction of the lower extremities, stepping automatism, doll’s eye phenomena, Babkin reflex, etc. 4–6 Weeks of Life

Between 4 and 6 weeks of life, optical fixation (Fig. 8) usually occurs which allows for a child’s orientation. The infant begins to lift their head against gravity. The head is lifted outside the base of support and the forearm is supported on the floor (Fig. 9). Fig. 8 In the 6th week, a healthy child demonstrates an optical fixation corresponding to a change in postural functions. Hand supination emerges and the thumb is no longer closed in the palm

Fig. 9 The infant begins to support on their forearms; the head achieves mid-position and looses predilection

Support of the body begins to shift in a caudal direction toward the pubic symphysis and pelvic anteversion decreases during this time. At first, lifting of the head is not an isolated movement, but it is accompanied by a change in the overall posture. The support function of the upper extremities emerges so that the trunk can be lifted from the mat and the entire body position is altered. This global change in body position comes automatically. It is dependent on psychological development and is a regular part of motor ontogenesis. In supine, the infant is able to lift their lower extremities above the

mat for a short period of time. The predilection position of the head disappears (in prone or supine, the infant achieves symmetry). In the supine position, the fencer’s position emerges (Fig. 10, 11). Fig. 10 The fencer’s position from the side

Fig. 11 The fencer’s position from above

The head is turned to one side, the upper and lower extremities on the side of the face are in shoulder abduction and external rotation (approximately 90°), elbow extension, forearm supination, hand is open and the thumb is not closed in the hand. Contralateral extremities are in flexion or slight flexion. The child demonstrates

visual fixation. Although this position is similar to the pattern of the asymmetrical tonic neck reflexes (ATNR), it is not the same. A newborn, in contrast to these reflexes, demonstrates shoulder external rotation, elbow supination and an open hand with the thumb in slight abduction outside the palm. Thus, the kinesiologic picture is completely different. The entire postural pattern is, in contrast to the ATNR, also initiated by visual control. In contrast to the ATNR, higher control systems of the CNS are involved in this posturing and, therefore, ATNR presence at this age is considered pathological. Characteristic Signs of the Developmental Stage between 4–6 Weeks of Life: Cessation of primitive reflexes (for example, support reaction, stepping automatism), thus, spinal motor patterns are transposed by a higher level of control Co-activation emerges. Symmetrical mechanisms become evident, which are possible via coactivation, meaning the ability of synchronized activation of antagonistic muscle groups and their mutual reciprocal facilitative-inhibitive cooperation Postural activity of phasic muscles occurs. Stabilization functions ensuring body posture involve muscles or their parts that are phylogenetically or ontogenetically younger (they are more inclined toward weakness, including serratus anterior, hip abductors, shoulder external rotators, forearm supinators, etc.) The fencer’s postural pattern occurs The End of the 1st and the Beginning of the 2nd Trimester The first base of support is accomplished. In prone, the base of support is formed by the elbow – elbow-symphysis. In supine, the base of support is formed by the nuchal line (linea nuchae), the level of the inferior scapular angles and the outer quadrant of the gluteal muscles (Fig. 12 and also see Fig. 15).

Fig. 12 Postural functions of a child at the beginning of the 2nd trimester

Model of Posture Extension of the axial skeleton is ensured by a balanced co-activation of the extensors of the entire autochthonic musculature (from occiput to sacrum) and the axial flexors. These include flexors of the anterior neck and upper thoracic spine (longus coli, longus capitits, etc.) and intra-abdominal pressure. During postural function, intra-abdominal pressure is maintained by the diaphragm, abdominal muscles and pelvic floor muscles. The inclusion of the diaphragm into postural function, not only respiratory function, is key in development of the spine. This is an essential pattern seen in the entire subsequent postural ontogenesis. In peripheral joints, balanced activity between the antagonistic muscles is set. Through this balanced function among the antagonist muscles, the spine and the peripheral joints are set in a position which allows the most advantageous static joint loading. The joints are functionally centrated. In an affected child, the joints are functionally decentrated due to muscular imbalance. This phase of motor development is also linked to the development of stereognosis along the patient’s entire back. If an infant’s back is exteroceptivelly or proprioceptively stimulated, then the infant is going to react to this stimulus. This can be assessed by placing a small toy on the child’s back. In contrast to the previous phase of development, the child perceives the object placed on their back, refocuses their attention and

reacts in an effort to change position. This reaction is not a reflexive response, but rather a volitional reaction. With emergence of this function, the Galant reflex ceases to exist (Fig. 13). At this developmental stage, there is no locomotion. The ability to grasp from the lateral side is emerging and the hand is in ulnar deviation. This ability is linked to the development of stereognosis in the hypothenar region. With an object contacting the hypothenar region, a grasp reflex does not occur or it is weak. In an effort to grasp an object (for example when the infant is offered an object from midline), a generalized grasp develops, meaning the infant opens their mouth and flexes their toes (Fig. 14). Fig. 13 Galant reflex. With skin (non-nociceptive) stimulation on the back from T1 through L1, lateral flexion of the trunk and the pelvis is elicited

Fig. 14 The infant is not able to grasp the object, but reacts to it with their entire body: mouth opening, grasping reaction of the feet [generalized grasp]

In the supine position, the infant is able to touch their genitals and groin (Fig. 15). At 4 months, coordination of foot vs. foot is created, in which the feet are touching each other by the toes. Fig. 15 At the onset of the 2nd trimester, the infant displays a contact between the toes and they are able to reach to the level of the groin

Mid-point of the 2nd Trimester In the middle of the second trimester, the infant is able to grasp an object while in prone (Fig. 16). The head, upper extremity and shoulder are held against gravity. In a healthy CNS, the axial organ and the peripheral joints are found in a centrated position and support has a triangular shape – elbow to anterior inferior iliac spine of one side and medial femoral epicondyle of the contralateral side.

A specific pattern of lower extremity support occurs. In this model, radial closure of the hand emerges with grasping. This completes the development of hand stereognosis. An important part of normal hand closure is thumb flexion and finger abduction. In prone, unweighting of an upper extremity is possible only when a muscle pull of the contralateral or weighted extremity is directed distally toward a point of support. The upper extremities are supported on the proximal aspect of the hands (see Fig. 24). In the supine position at 4.5–5 months, asymmetrical trunk lengthening is attainable (Fig. 17). A transfer of support toward the shoulder occurs which, again, only occurs with a distally directed muscle pull. This position is followed by rolling with an erect axial skeleton. Fig. 16 Grasp in prone

Fig. 17 Asymmetrical trunk lengthening leading to rolling

Grasp in the supine position is achievable from midline (Fig. 18).

Fig. 18 Grasp from midline

Support is transferred to the level of the thoracolumbar junction which is simultaneously stabilized by muscle activity. An infant is able to lift their pelvis above the mat and touch their knees (Fig. 19). Coordination foot vs. foot is already between the medial aspects of the feet (Fig. 20). Fig. 19 Halfway through the second trimester, an infant is able to lift his pelvis above the mat and touch their knees

Fig. 20 Coordination of foot-foot with contact of the inner aspects of the feet

5 and 6 Months of Life At 5 and 6 months, rolling from supine to prone and grasping in prone is completed. During the 5th month, grasp across midline occurs which coincides with the infant’s rolling to the side (Fig. 21). Fig. 21 The position on the side coincides with grasping across midline

During the 6th month, the infant already rolls from supine to prone (Fig. 22). Rolling is linked to grasping across midline. The grasping upper extremity is on the side of the stepping forward lower extremity. With rolling, the supporting and stepping extremities are on the same side or ipsilateral. Rolling from prone to supine does not mature until the 7th month. In prone, similarly as in supine, the stepping forward and supporting functions begin to differentiate, but the infant in prone is still unable of locomotion. In the 5th month, the typical postural pattern for grasping while in prone is support on the

elbow as well as at the region of insertion of the quadriceps and the femoral medial condyle on the side of the grasping upper extremity (Fig. 23). In prone, an infant supports themselves on the proximal aspect of the hands and the anterior aspect of the thighs (Fig. 24). At the end of 6 months, hip flexion angle is 110–120° which is the prerequisite for transition into a quadruped position. After the 6th month, with grasping, the child is supported on the entire palm, distal aspect of the thigh and contralateral knee (Fig. 25). In the lower extremities, support is at the level of the knees (Fig. 26). In supine, an infant can lift his pelvis and touch his feet with both hands (coordination hand vs. foot) (Fig. 27). Fig. 22 A series of pictures documents the course of an infant’s rolling from supine to prone

Fig. 23 Postural pattern with

grasping position in prone in the 5th month

Fig. 24 In prone, with support on the proximal aspect of the hand and the anterior aspect of the thighs in the 5th month

Fig. 25 Postural pattern with grasping in prone in the 6th month

Fig. 26 Support on the palm and the front aspect of the knees in the 6th month

Fig. 27 Coordination hand vs. foot in the 6th month

Support is at the level of the inferior scapular angles. Coordination foot vs. foot is marked by contact at both soles of the feet (Fig. 28). Fig. 28 Coordination foot vs. foot in the 6th month. The entire soles of feet are already touching and the infant lifts their pelvis.

The development of a step forward and support leads to differentiation in the direction of the muscle’s acting force. On the supporting extremity, movement is elicited in the distal segment in the direction of the support (muscle function has an anti-gravity role) and on the side of the stepping forward extremity, the muscle function ensures movement of the proximal segment.

From a biomechanical perspective, the stepping forward extremities behave as open kinetic chains and the support extremities as closed kinetic chains. Two oblique abdominal chains emerge in function. The first oblique chain rotates the pelvis in the direction of the support upper extremity. This contraction occurs on the facial side of the internal oblique muscle via the transversus abdominis and the occipital side of the external oblique. The dorsal musculature forms the antagonistic synergy. The second oblique abdominal chain works in synergy with the pectoralis major and minor on the facial and occipital sides and ensures rotation of the upper half of the trunk and the erect position of the shoulder. During rolling from supine to prone, one lower extremity becomes supporting and the other stepping. A similar situation occurs in the upper extremities. A reciprocal pattern of stepping forward and supporting occurs in supine as well as prone positions. This means that: The supporting, or push-off, extremity in the proximal joint performs internal rotation, adduction and extension; while on the other hand, the stepping forward extremity performs external rotation, abduction and flexion. The stepping forward upper extremity performs supination and the support extremity performs pronation. The knee of the stepping forward lower extremity performs flexion and external rotation while the supporting extremity performs the opposite movement and so on. The movement is always opposite. In the supporting extremities, the muscle pull is directed distally. The muscle’s punctum fixum is found distally and the punctum mobile is found proximally. In the stepping forward extremities, it is just the opposite: punctum fixum is proximal and punctum mobile is distal. The differentiation of a muscle pull emerges this way in a given developmental stage. In the supporting extremities, the movement of the socket (for example the glenoid fossa) occurs in relation to the ball (for

example, the head of the humerus) or the proximal segment on the distal segment. In the stepping forward extremities, the opposite occurs where the distal segment moves in relation to the proximal segment. 7–9 Months of Life In an infant, the first form of locomotion in the prone position emerges in the 7th month. An infant attains a position on all fours. The extremities achieve an erect position and stepping forward. The transition to an all fours position occurs from a position that a 6month-old infant uses for grasping: support on the palms, medial femoral condyle and the anterior aspect on the femur of the contralateral lower extremity (Fig. 29A, B). Erective (supporting) and stepping forward extremities are located contralaterally. If the left upper extremity is stepping forward and the right one is supporting, then the left lower extremity is supporting and the right one is stepping forward. In the supporting lower extremity, the pelvis moves on the femur (the socket in relation to the ball). The abductors, adductors, external rotators and flexors of the hip erect the pelvis and the trunk and pull toward the direction of support (medial femoral condyle) where the punctum fixum is found. The pelvis is stabilized by the back muscles and the intra-abdominal pressure. If this interplay is disrupted, usually with an insufficient amount of intra-abdominal pressure, an infant positions himself in an anteverted pelvic alignment and with an increase in cervical extension. On the supporting extremity, the scapula or trunk move via the humerus. The prerequisite for a biomechanically optimal position is balanced scapular stabilization. In the stepping forward extremities, the movement and direction of muscle pull are opposite. The punctum fixum is on the pelvis and the spine and the punctum mobile on the extremities. The muscle of the stepping forward extremity has a punctum fixum on the pelvis and the spine. In the 8th month, in the quadruped position, an infant can grasp a toy (Fig. 30). In the 9th month, crawling on hands and knees (creeping in quadruped) and grasping with thumb opposition – pincer grip emerge (Fig. 31).

Fig. 29A, B Attaining the all fours position in the 7th month Fig. 30 Grasping in a quadruped position

Fig. 31 Grasp with thumb opposition

From the supine position, sidesitting emerges. Support is formed by

the medial gluteals and elbow (at 7 months) and at the end of the 8th and beginning of the 9th month, sidesitting matures with upper extremity support through the palm (Fig. 32). An infant uses sidesitting for grasping and also as a transitional locomotor position. An infant can achieve a quadruped position via sidesitting (Fig. 33) and into upright sitting. Also, an infant uses this position to move between sitting and quadruped positions. This locomotor movement involves the transition of an ipsilateral pattern into a contralateral one. With the development of sidesitting, thumb opposition and pincer grip occur. In an upright sitting position, an infant is developmentally able to grasp a toy at various heights of shoulder flexion. In the 8th month, it is close to 100° and at the end of 9 months to an angle of at least 120° (Fig. 34, 35). Fig. 32 Sidesitting

Fig. 33 Transition from sidesitting to quadruped

Fig. 34 Upper extremity grasping at 8 months

Fig. 35 Upper extremity grasping at 9 months

This signals the beginning of verticalization into standing. At the end of 8 months, upright kneeling with symmetrical and contralateral extremity support emerges (Fig. 36). Fig. 36 Upright kneeling with contralateral extremity support

From the 4th Trimester In the 4th trimester, an infant’s verticalization into standing emerges. It begins as early as the 8th month and by the beginning of the 9th

month as stepping forward while in quadruped and as upright standing. At first, one lower extremity steps away and extends (“tripod-like” position) (Fig. 37) and gradually moves into a flexed position with support on the foot (Fig. 38). From this position, an infant comes into an upright position while supporting through the palms and the proximal aspect of the soles of both feet. This is followed by a transition into standing via a deep squat (Fig. 39). Fig. 37 Stepping away of the lower extremity from a quadruped position – “tripod-like” position

Fig. 38 Stepping forward to support on the foot

Fig. 39 The transition from quadruped with support on

the feet into standing via a deep squat

An infant’s position on their hands and the proximal aspect of the feet can also be attained via the sidesitting position. Another way of transitioning into standing is from an upright kneeling position attained from the quadruped position (often via sidesitting). In this position, an infant steps forward with one lower extremity, which becomes the erective one, and with supporting help of the contralateral upper extremity, the child attains standing. This, once again, is an example of a contralateral locomotion model (Fig. 40). From standing, at first ambulation develops in the frontal plane

(ipsilateral locomotor model) (Fig. 41). This is followed by independent bipedal locomotion between 12–14 months (Fig. 42). Fig. 40 Verticalization into standing from upright kneeling – a contralateral locomotor pattern

Fig. 41 Ambulation in the frontal plane – ipsilateral locomotor model

Fig. 42 Bipedal ambulation

Postural Reactivity With a provoked change in position, a child exhibits methodical, whole body movement reactions. The responses are constantly repeating and are dependent on the maturity of the CNS. Positional reactions exhibit a clear kinesiologic context with distinct muscle function. Postural locomotor functions and their deficits can be deduced from the responses to a provoked change of position. Positional reactions correspond to the degree of development of postural activity. In the examination, 7 standard positional reactions are tested. Considering the escalating postural demands on an infant during the examination, the positional reactions are performed in the following order: 1. Traction test 2. Landau reaction 3. Axillary suspension

4. 5. 6. 7.

Vojta’s tilt reaction Collis horizontal suspension Peiper and Isbert vertical suspension Collis vertical suspension

1. Traction Test Administration: from a supine position, the infant is brought into a 45-degree sitting position by pulling on the distal segment of the forearms. 1st Phase: Weeks 1–6 The head is hanging back, neck flexors are not activated (Fig. 43A) Perinatal period – the lower extremities are flexed and in slight abduction Second half of the newborn phase – the lower extremities are in slight flexion Fig. 43A Traction test: 1st phase – newborn stage of development

A flexion synergy develops from this position and peaks at the end of the second trimester. 2nd Phase: Week 7 – End of the Second Trimester Head flexion with trunk and lower extremity flexion; flexion synergy in all joints to 90 degrees; ankles are in a neutral and midposition 3rd month – the head is pulled in to the level of the trunk

End of second trimester – the chin is pulled to the chest, thighs are in flexion at the abdomen and an infant slightly pulls with their upper extremities (Fig. 43B through 45). Fig. 43B Traction test: 2nd phase – 7th week

Fig. 44 Traction test: 2nd phase – 3rd month

Fig. 45 Traction test: 2nd phase – 6th month

3rd Phase: 7–9 Months Flexion synergy recedes (neck, lower extremities); greater pulling with the upper extremities and increased support on the gluteals occurs. A verticalization sign appears when flexion in the knee joint recedes (Fig. 46). Fig. 46 Traction test: 3rd phase – 7th month

4th Phase: 9–14 Months An infant pulls up, the head stays with the trunk, the lower extremities are abducted and extended and rest on the mat. Trunk flexion occurs at the lumbosacral junction (Fig. 47). Fig. 47 Traction test: 4th phase – 9th month

2. Landau Reaction Administration: An infant is held in the air in a strictly prone position with the examiner’s hand on the infant’s stomach. The infant should be calm and not crying to obtain an objective assessment. 1st Phase: Weeks 1–6 The head and pelvis are slightly bent below the horizontal, the trunk and upper extremities are in slight flexion, and the lower extremities in a static flexion. Spontaneous manifestation of this phase is characterized by an infant being placed on their sternum; the infant does not actively support himself (Fig. 48). Fig. 48 Landau Reaction: 1st phase – newborn period

2nd Phase: Week 7–3 Months Symmetrical neck extension to the level of the mid-thoracic spine is developing; cervical extension should not occur;

Slight flexion is sustained in the extremities with the pelvis below the horizontal level. Observe an infant’s spontaneous motor skills in the prone position, the prone on elbows position appears at the end of this stage (Fig. 49).

Fig. 49 Landau Reaction: 2nd phase

3rd Phase: 4–6 Months Extension to the lumbar level occurs, the lower extremities are flexed at a right angle, arms are freely flexed at the elbows. Spontaneous mobility corresponding to this phase is in the prone on hands position (esp. in the 6th month period) (Fig. 50). Fig. 50 Landau Reaction: 3rd phase

4th Phase: 8 Months The neck and trunk are extended The upper and lower extremities achieve a volitionally extended position Spontaneous motor skills are demonstrated by standing with

support (Fig. 51). Fig. 51 Landau Reaction: 4th phase

3. Axillary Suspension Administration: an infant is held by the trunk so that the lateral aspects of the hands are touching the borders of the iliac crests and the infant is lifted in the air while facing away from the examiner. The examiner’s fingers must not stimulate the paravertebral muscles or the trapezius. The reaction of the lower extremities is observed. 1st a) Phase: 0–3 Months The lower extremities are in inert flexion (Fig. 52). At the beginning of this phase, the spontaneous manifestations include an infant alternating between flexion and extension positions of the lower extremities; at the end of this phase (3 months), in the supine position, hip, knee and ankle flexion are sustained at 90 degrees. Fig. 52 Axillary Suspension: 1st a) phase from the frontal and lateral views

1st b) Phase: 4–7 Months The lower extremities manifest an active flexion toward the stomach, which characterizes the transition into the second trimester (Fig. 53); Until the 4th month, hip flexion is to 90 degrees; until the 7th month, maximal flexion at the hips is observed. In the 8th month, this flexion synergy disappears (Fig. 54). Fig. 53Axillary Suspension: 1st b) phase – flexion in the hip joint

Fig. 54 Axillary Suspension: 1st b) phase – the disappearance of the flexion synergy of the lower extremities

Maximal flexion in the hip joints is demonstrated by an infant placing his big toes into his mouth and is a manifestation of a spontaneous motor skill appropriate for this level. 2nd Phase: Starting at 8 Months The lower extremities attain volitional extension; the ankle joints are in a neutral and mid-position. In this position, the infant can be

“swung” (the swing test) and the symmetrical amplitude of both lower extremities is observed simultaneously in the same direction (Fig. 55). Fig. 55 Axillary Suspension: 2nd phase

4. Vojta’s Tilt Reaction Administration: From a vertical suspension with an infant’s back to the examiner, a quick tilt of an infant into a horizontal position is performed. Prior to the tilt, an infant’s hands are passively opened. The reaction in all extremities is observed, but the most significant assessment value lies within the extremities on the top part of the body. Vojta’s reaction has five phases, two of which are transitional. 1st Phase: Weeks 1–10 (Fig. 56) Fig. 56 Vojta’s Lateral Tilt: 1st phase

Both arms – Moro reaction, palms are open With a hugging reaction of both arms, the movement of the bottom arm occurs to a smaller extent (Fig. 57) The top lower extremity – hip and knee joint flexion, ankle dorsiflexion, foot pronation with a fan-like appearance of the toes The bottom lower extremity – hip and knee extension, ankle dorsiflexion, foot supination and toe flexion Fig. 57 Vojta’s Lateral Tilt: 1st phase – hugging arm motion

1st Transitional Phase: Weeks 11–20 Moro reaction of the upper extremities recedes, arms are abducted, palms open (Fig. 58) At the end of the 1st transitional phase, the arms are freely flexed The lower extremities – slight flexion of bilateral hips and knees,

decrease in fan-like positioning of the toes on the top leg Fig. 58 Vojta’s Lateral Tilt: 1st transitional phase

2nd Phase: End of the 5th to 6 Months All extremities are in free flexion (Fig. 59) Palms are open Lower extremities are losing the earlier differentiated posturing Feet – dorsiflexion and abduction, toes are in neutral position or flexion Fig. 59 Vojta’s Lateral Tilt: 2nd phase

2nd Transitional Phase: 7 Months – End of 9 Months Upper extremity – shoulder in slight flexion and internal rotation;

later, the arm comes into slight forward flexion Lower extremity – leg comes into forward flexion, hip and knee flexion recede, ankle joint is in neutral position, feet and toes are in neutral position (Fig. 60) Fig. 60 Vojta’s Lateral Tilt: 2nd transitional phase

At the end of this phase, the spontaneous motor skills include sitting, sidesitting with arm support, quadruped position and the transitional locomotor phases between these positions. The ipsilateral and contralateral locomotor patterns are interconnected in this way. 3rd Phase: End of 9th Month – 14 Months Both top extremities are in extension, abduction and external rotation in the proximal joints The trunk is in a horizontal position and erect, head has a tendency to maintain its vertical position, which means that with rotation it tilts opposite the direction of turning (it is a sign of verticalization) Bottom extremity – is in hip flexion and abduction and the upper extremity is in shoulder adduction and external rotation Feet – dorsiflexion (Fig. 61) Fig. 61 Vojta’s Lateral Tilt: 3rd phase

The spontaneous motor skills of this phase correspond to the upper extremity position while in sidesitting and ambulation sideways along furniture/cruising. The lower extremity position with 90-degree of ankle dorsiflexion corresponds to the function of the lower extremity when standing. 5. Collis Horizontal Suspension Administration: an infant is lifted by an arm and the ipsilateral lower extremity into a horizontal position above a table to a height equal to the length of the infant’s upper extremity. The response of the free extremities and the head are assessed. The reaction has three basic phases. 1st a) Phase: Weeks 0–6 Upper extremity: the first 6 weeks – Moro reflex (Fig. 62); Lower extremity – predominates hip adduction and 90-degree flexion of the hip and knee joint, ankle is in a zero and midposition.

Fig. 62 Collis Horizontal Suspension: 1st a) phase

1st b) Phase: Weeks 7–12 Upper extremity: in the 7th and the 8th week, the response consists of arm abduction with an open hand; into the 3rd month, additional elbow flexion is observed and a mid-position of the forearm and the sign of making a fist is seen (Fig. 63); in the 3rd month the free upper extremity is easily flexed, slight forearm supination is present The lower extremity reacts in the same manner as in 1st a) Phase The head is held against gravity Fig. 63 Collis Horizontal Suspension: 1st b) phase

2nd Phase: Beginning of the 4th Month through the 6th Month

Upper extremity: at the end of the 4th month, the forearm pronates (Fig. 64) and a gradual opening of the hand on the ulnar side with wrist extension begins; at the end of the 5th month, palm opening to the 3rd digit is observed; at the end of the 6th month, the opening of the entire palm and all digit extension is present (Fig. 65). Lower extremity: flexion in all joints, the knee slowly starts to point toward the mat and gradually changes from an adduction angle to an abduction angle. Fig. 64 Collis Horizontal Suspension: 2nd Phase

Fig. 65 Collis Horizontal Suspension: 2nd Phase – palm opening and finger extension

The spontaneous motor skills of this phase correspond to the development of upper and lower extremity differentiation.

The presence of pronation is always linked with wrist extension and finger relaxation. Support on the arms appears at a time when the grasp reflex is diminishing and the infant uses a radial grasp. 3rd Phase: From the Beginning of the 7th Month through the End of the 10th Month The upper extremity is supported on an open palm An upright erect function of the bottom lower extremity develops, hip flexion maintains 90 degrees and knee extension is increasing (Fig. 66). Hip abduction begins and at the end of the 8th month, the free lower extremity is supported through the entire sole of the foot (Fig. 67) Fig. 66 Collis Horizontal Suspension: 3rd Phase

Fig. 67 Collis Horizontal Suspension: 3rd Phase – lower extremity abduction and support with the sole of the foot on the mat

The spontaneous movement in this stage corresponds to the support of the upper and lower extremities with a model of sidesitting. The infant can sit by himself and, later, performs a step forward from tall kneeling into standing with support on the furniture. 6. Peiper-Isbert Vertical Suspension Administration: in the early months, from a supine position and later from a prone position, an infant is lifted by both lower extremities (in the knee region) with the head down. The reactions of the upper extremities and the trunk are assessed. In all phases, the upper extremities are found in a frontal plane and the hands with open fingers. Only a partially open hand is a sign of a less than ideal motor reaction. 1st Phase: Week 1 – the End of 3 Months The first 6 weeks – Moro reflex; next 6 weeks – arm abduction (90 degrees to the longitudinal body axis) The neck is extended; the head in reclination/extension (Fig. 68) The lower segment of the trunk is in flexion Fig. 68 Peiper-Isbert Vertical Suspension: 1st phase

Spontaneous movement in prone corresponds to the development of bilateral elbow support (3 months). 2nd Phase: 4–6 Months The upper extremity: half way open arms, the arm and trunk angle is 135 degrees, the palms are open, the neck and the trunk are in

symmetrical extension up to the thoracolumbar junction, slight pelvic flexion (Fig. 69). Support on hands is the corresponding spontaneous motor skill observed at the end of this phase. Fig. 69 Peiper – Isbert Vertical Suspension: 2nd phase

3rd Phase: 7–9 Months The arms are elevated (above 160 degrees) Palms open Symmetrical head and trunk extension to the lumbosacral junction (Fig. 70). The development of a sidesitting position is observed in spontaneous motor development Fig. 70 Peiper-Isbert Vertical Suspension: 3rd phase

4th Phase: From 9 Months The infant is actively trying to grasp or pull toward the therapist (Fig. 71) Arms are found in the frontal plane, deviations from the frontal plane are abnormal Fig. 71 Peiper-Isbert Vertical Suspension: 4th phase

In this phase, the spontaneous motor skill corresponding to this developmental phase is a step forward from tall kneeling into standing with support on furniture. 7. Collis Vertical Suspension Administration: from the supine position, the infant is smoothly lifted by one knee with the head down. The response of the free lower extremity is assessed. The free lower extremity should move into flexion. 1st Phase: Week 1 – the End of the 6th Month The free hanging lower extremity: hip, knee and ankle are in maximum flexion (Fig. 72).

Fig. 72 Collis Vertical Suspension: 1st phase

2nd Phase: From the 7th Month The lower extremity: hip and knee flexion is gradually relaxing into more extension (Fig. 73, 74) The response of the upper extremities is similar to the Peiper-Isbert Reaction. Fig. 73 Collis Vertical Suspension: 2nd phase

Fig. 74 Collis Vertical Suspension: 2nd phase – gradual relaxation of the knee of the free extremity into extension

In spontaneous motor development, the infant reached sitting and is able to weight bear on the gluteal region. Later, this reaction corresponds to sitting with extended lower extremities. Primitive Reflexology Pavel Kolář With immaturity of the higher centers of the CNS, it is possible to

elicit motor reactions (reflexes) integrated at a lower level of control (spinal and brain stem). The elicitation of primitive reflexes is possible for a limited time period. In a pathological situation, their elicitation is prolonged. Their active period is outlined in Tab. 1. These reflexes do not disappear immediately, but do so gradually, therefore, the time of their complete cessation is provided in parentheses.

Tab. 1 An overview of primitive reflexes

The patterns that are observed during reactions to the primitive reflexes occur instead of the desired activity or during a frightened reaction in a patient with CNS motor deficits (dystonic attacks). Our goal is to inhibit the abnormal reaction even though, in some concepts (for example, in a method by Brunnström) they are utilized for facilitation, especially in the initial stage of involvement. Functional Relationship between Postural Activity, Postural Reactivity and Primitive Reflexology There is a relationship between spontaneous motor development (postural activity), postural reactibility and primitive reflexology and their functional connection is strictly defined here. Postural activity, reactibility and primitive reflexes are a picture of CNS function that ensures posture. For illustration, here are some examples. In the supine position, if an infant lifts an arm and an ipsilateral lower extremity into a horizontal position (Collis Horizontal Suspension) then, based on this motor reaction, it is possible to deduce the infant’s spontaneous motor skills presentation (postural activity) and the reflexes that can be elicited, or rather, which ones have already ceased. For example, if the infant responds by flexion of the free lower extremity and with abduction of the free upper extremity and an open hand (it is a different response than the Moro reflex). It implies that the infant, when in prone, is already able to lift his head above the mat with forearm support and the thumb is reaching a position outside the palm. If an infant shows a smaller pelvic anteversion and degree of hip flexion than in the neonatal stage then, in this infant, it will not be possible to elicit reflexes linked to the neonatal stage of development including, for example, the support reaction, stepping automatism, cross extension reflex or suprapubic reflex). However, the Galant reflex and the upper and lower extremity grasp reflex can all still be elicited. If the infant shows a support function on the free upper extremity with the entire hand open and accompanied by all finger

extension during Collis Horizontal Suspension, then, in spontaneous motor development, this infant performs a radial grasp, can prop up on hands with the fingers abducted while in prone, can turn with good coordination from supine to prone and neither the grasp reflex of the upper extremity nor the Galant reflex can be elicited. In a pathological situation, an interrelationship among an abnormal model of postural activity, reactivity and the dynamics of primitive reflexes is demonstrated. Actually, there is a direct correlation between the degree of involvement that the severity manifested via spontaneous motor development, postural reactibility and the extent of the deficit in the primitive reflexology area.

PSYCHOMOTOR DEVELOPMENT IN EARLY CHILDHOOD Irena Zounková, Pavel Kolář This is the period between the second and the sixth year of life. During this period, the ability of coordinated movement as well as the stabilization of these patterns (stereotypes), which are more suitable for given activities, increase. Muscle strength and, even more importantly, a certain level of coordination abilities are necessary to achieve specific motor skills. Some studies show that mature patterns of control are not observed until the age of seven. Healthy children undergo physical growth and their motivation for games increases. They become more independent and attain a sense of their own functioning in the environment.

Tab. 2-1 Phases of psychomotor development (based on Brunet, Lezine 1951; Bogdanowicz and Kisiel 1999; Zebrovska 1986)

Tab. 2-2 Phases of psychomotor development (based on Brunet, Lezine 1951; Bogdanowicz and Kisiel 1999; Zebrovska 1986)

Tab. 2-3 Phases of psychomotor development (based on Brunet, Lezine 1951; Bogdanowicz and Kisiel 1999; Zebrovska 1986)

Tab. 2-4 Phases of psychomotor development (based on Brunet, Lezine 1951; Bogdanowicz and Kisiel 1999; Zebrovska 1986)

2–3 Years The child shows greater predispositions to learn new purposeful movements. Movement expression is accompanied by a desire to explore new things. At the same time, the child learns how to rationally use movement and develops a relationship toward movement. The child is able to predict the results of their own movement activities, predict the dynamic changes in the environment and use them to their benefit. The child can pre-position their posture so that the movement and its anticipated consequences are possible. During this period, postural control and stability increase. Static and dynamic balance increase and the child masters their “produced” force. Reciprocal abilities also improve. The child’s ability to imitate their environment is a characteristic for this period. In education and therapy, it is important for the parents and therapist to utilize this ability. Posture At the age of three, the lumbar hyperlordosis and protruding stomach disappear and the child is able to attain an “antagonistic” position against the neonatal posturing. This includes erect standing with arm elevation in the vertical plane, shoulder external rotation and depression, elbow extension, forearm supination, wrist radial deviation and finger extension with abduction. The force and stability of the lower extremities are gradually increasing and the standing posture becomes more erect. The child can stay in a mini-squat longer. Over time, the standing base of support becomes narrower. In the feet, the longitudinal arch is forming, allowing for more mature weight bearing in the lower extremities. Gross Motor Skills During the 2nd–3rd year, the child attains the following gross motor skills: reciprocal gait when ascending stairs, tricycle riding, climbing on the jungle gym, early running, jumping off of a step, short long

jumping, brief standing on one extremity, standing on a low balance beam, hopping on one preferred lower extremity, and ball kicking with the lower extremity in extension. Ambulation During the second year of life, the gait pattern becomes more mature and it is characterized by heel strike, knee flexion in mid-stance and the ankle – knee mechanism. The child inconsistently unwinds the big toe. Gait is accompanied by swinging arm movements and a great energy demand. The speed and rhythm of gait are still changing. Until three years of age, the child’s immature gait is characterized by the following indicators: Asymmetrical step length During swing phase, hip flexion, abduction and external rotation and knee flexion are accentuated The initial period of the standing phase is characterized by foot flat contact vs. heel contact, knee hyperextension and weight transfer with the foot in pronation Base of support is wider than the trunk The upper extremities are in an elevated and gradually mid- and low guard position; reciprocal movement of the upper extremities occurs approximately 4–5 months after the onset of walking Insufficient pelvic tilt and rotation is noted In the 3rd year of life, the muscle control in the region of the pelvic girdle is increased and balance in the standing phase and with steps is improved. Step length, height and width are already symmetrical and the big toe unwinds from the mat, but variability in energy expenditure persists. The increased energy demands are seen until the age of twelve. Running At the end of the 3rd year, the child achieves the ability to run. Many children begin to run prior to achieving a refined gait pattern. Running is distinguished from walking by a short flight phase during which the body is not in contact with the mat. The ability to

control the flight phase is a qualitative sign of the end of the infancy stage. The average age for reaching the flight phase in boys is 3.04 years, average height is 96.9 cm and weight 14.8 kg. For girls, the average age is 3.03 years, height is 96.8 cm and weight is 14.1 kg. All conditions are considered retardation when the child does not reach the flight phase by 38 months of age or by a body height of 100 cm. With the assessment of weight, it is not clear where the low end of the spectrum lies. Climbing, Stair Negotiation At 1.5 years old, a child is able to ascend stairs with help at first. When the child begins to ambulate independently up stairs, they place one lower extremity on the same stair as the ascending foot. When going down the stairs, two-year-old children climb backward on all fours. Starting at 2.5–3 years of age, children begin to ascend stairs independently and reciprocally. Independent reciprocal descending of stairs begins to emerge at 3–3.5 years. Jumping Children already attempt to jump in the simplest form before two years of age and always have support on either one or both lower extremities. The assessment of jumping provides good information about the developmental stage. A child jumps down from a 30-cmhigh step at around 22 months of age. This skill more resembles a slow step down pattern than a jump carried out by a take off with both feet simultaneously. An early jump is characterized by very slight preparatory mini-squat, the arms moving high into a defensive position and the head held in flexion. Most children begin with a high jump, although they originally wanted to jump long. With a high jump, the lower extremities are bent and tucked under the body instead of in full extension. The upper extremities do not help with take off and are held slightly behind the body. The landing is on one lower extremity. Fine Motor Skills During 2-3 years of age, a child achieves the following motor skills:

turning switches, screwing jar lids, cutting with children’s scissors, unbuttoning large buttons, and bead stringing. A child can imitate a circle or an inaccurate cross after being shown. The importance of fine motor skills and manipulative abilities can be observed in a child’s desire to build from blocks and similar materials while using their imagination, by imitating facial expressions of adults, by playing with a ball, drawing, cutting with scissors, and writing. The changes in a movement pattern, which can be observed when catching a ball, illustrate the increased control and movement dissociation, as well as an increased ability to anticipate the speed and direction of an approaching ball. In the time between the second and third year, children have a tendency to hold their upper extremities in forward flexion with elbows extended and the arms open as they are waiting for a relatively large ball to fall into their arms. After that, they start to bend the elbows and supinate the forearms, catch the ball in the angulation of the elbow, as shoulder movement persists and adapts. Gradually, a child relaxes their elbows alongside their body, but nonetheless catches the ball on their forearms. Motor skills of the hand are determined by the freeing of the arms from the support system and by improved eye-hand coordination. After 18 months, hand preference emerges, the grip is strong and the child uses the entire palm for grasping with a simultaneous firm thumb hold against the other fingers (hook grip, lateral prehension/pinch). Between the second and third year, a more precise grip develops. It is characterized by a greater use of thumb opposition (cylindrical grip, spherical grip, three-point prehension and two-point prehension). The child uses a so called static tripod grip, i.e., the hand is supported by the wrist and lateral side on the table and a pencil is held by the thumb and two digits on the radial side, the index and the middle fingers. The ability of the hand to differentiate emerges at first by vertical movement and at three years of age by horizontal movement. Form of Movement

An infant spends 70–80% of their time in active movement when they are not sleeping or eating. An infant actualizes their thought activity by movement and vice versa. Since the age of three, rhythmic ability is sharply developing. At pre-school age, the ability to execute a series of jumps emerges. Suitable movement activities include speed movement activities based on isotonic muscle contractions with frequent interchange and agility (coordination) activities. Movement activity can be elicited by capturing the child’s attention. Stimulation with other children is advisable. Already at this age, children can be differentiated based on movement needs into hypomobile, hypermobile and normal. It is not sufficient enough to teach them to walk, but it is desirable to perform various activities like throwing, climbing obstacles, etc. At an infant age, a fear of the unknown is characteristic. This fear is a limiting factor during motor learning, especially in children with developmental delay or with a neurological impairment. Educational, pedagogical and therapeutic processes need to be adapted to each child to eliminate fear. Only under such circumstances can the modified process proceed with the learning of more advanced motor skills. 4–6 years This period of pre-school age is characterized by the following physiological manifestations: myelination of the pyramidal tracts is completed, cerebellar functions are maturing (balance ability, fine motor skills, speech), and cortical functions are maturing. Another very significant aspect in this stage is the maturation of awareness and the interpretation of sensory information. Somatesthesia is particularly important for movement perception, error detection and their correction. Touch and vision also play an important role in motor control and the concept of spatial relations. This period is characterized by the development of agility and motor coordination. The qualitative and quantitative development of

movement patterns continues. Improved quality of complex movements occurs, which is demonstrated by an independent movement of the extremities without whole body co-movements. Overall dynamic coordination of cyclic and acyclic movements improves. A large range of joint mobility due to laxity of the ligamentous system is characteristic of this stage. The individual phases of psychomotor development are described in Tab. 2.

CENTRAL COORDINATION DISTURBANCE IN PRESCHOOL AND SCHOOL AGE Irena Zounková, Pavel Kolář In the Czech Republic, the term Central Coordination Disturbance is used for children during infancy who show certain deviations in their motor performance before they begin walking. If developmental deficits persist into the toddler and preschool ages, we speak of a Minor Coordination Disturbance (MCD). According to P. Watter (1996), the term is used for a heterogeneous group of problems in which the shared characteristic is impairment of motor skills without an obvious mental or physical involvement. Support is growing for the notion that children with MCD show problems with central processing, recall and storage of information, as well as, demonstrate weak intersensory integration. All of this influences motor skills. Many authors point out that clumsy children have longer reaction times and perform individual tasks slower than other children. Some state that clumsy children show worse timing or sequencing of individual movements in comparison with other children and conclude that this is caused by problems with the central mechanism for keeping (interpreting) time, so called timekeeping. Children with MCD often show problems with the perception of given information. Such child may be able to feel a touch on the skin, but is not able to locate it or attributes a different emotional content to it. For such children, the reaction to a certain stimulus can be

characterized by an unsuitable movement response pattern or an inability to inhibit motor activity or impulsivity. Monitored Areas in a Neurodevelopmental Examination Tone, Reflexes, Pseudoclonus, Associated Reactions Decreased muscle tone is observed in most children while the rest of children show normal, increased or changing muscle tone. Tendon reflexes are often normal even in children with extremely low muscle tone. If muscle tone is high, one or two jerks (pseudoclonus) are observed. In children with MCD, associated reactions and synkineses can be increased mainly in connection with an increased effort. In such children, even a minimal effort is sufficient enough for the associated reactions to occur and that is because of an inadequate suppression or inhibition of undesired movements. In such children, movement differentiation is absent and the level of selective movement is decreased. Primitive Reflexes and Immature Movement Patterns For example, a reflexive extensor thrust of the big toe, traces of asymmetric tonic neck reflexes (ATNR), traces of symmetric tonic neck reflexes (STNR), or tonic labyrinth reflexes (TLR) belong among these types of reflexes and patterns. They are easy to facilitate via passive or active (assistive) movement. If a child is older than three years traces of, these patterns often persist in MCD. They are tested in more advanced positions than the ones typical for the neonatal stage. The extensor thrust should be tested in supine with a slightly flexed knee and pressure is applied at the base of the big toe. A positive response is demonstrated by lower extremity extension and plantar flexion of the foot (against the pressure of the stimulus). It can also cause shortening of the Achilles tendon. In standing, the extensor thrust can be coupled with traces of ATNR. In a large number of children with MCD, this reflex cannot be elicited when lying down, but when the child starts walking, a strong thrust can become functionally obvious.

With assessment of the ATNR signs, the quadruped position is more suitable and should always be used in children with MCD. If these reflexes are not fully integrated, the head turn to one side elicits elbow flexion on the posterior occipital side accompanied by lateral flexion of the trunk on the same side. The extensor portion of the reflex is often present as hyperextension of the elbow on the facial side. The lower extremities in this position do not react in the same manner as in supine and, often, there is a loss of pelvic stability accompanied by trunk lateral flexion. This reaction can be so strong that the child cannot maintain the quadruped position and falls. The STNR signs should be assessed in the same position therefore, in quadruped. For children with MCD, elbow flexion with cranial flexion is frequent, as well as, a loss of pelvic stability rather than full hip extension, which can be observed with classic tests in pediatric neurological patients. Cervical extension elicits elbow extension together with hip and knee flexion and there is a tendency to sit on the heels. The ATNR and STNR partial signs can be present in both standing and sitting and, as an extensor thrust, they can be used by a child for strengthening of postural stability. These reflexes are not firmly linked with the diagnosis of MCD, but children with MCD often use them temporarily as a compensation to achieve functional stability. The tonic labyrinth reflexes should be assessed during a change in position from sitting to supine. Many children with MCD display only phasic control during this test. During testing, it is necessary to distinguish what is or is not caused by decreased muscle tone or muscle weakness. For example, in a child who shows problems with head control during this test, it is necessary to distinguish between the probable source of the low muscle tone, muscle weakness and persistence of the TLR. Postural Reactions Weight shifting, positive support, and upright, defensive and equilibrium reactions are types of postural reactions.

Normal postural responses are quick, automatic and relaxed. In children with MCD, the reactions may be either too quick or jerky, with the child appearing as if they are always “ready” to fall. At the other end of the spectrum, a child may react very slowly and with a certain clumsiness, weak orientation and ineffective movements. During weight shifting from side to side, excessive pressure is placed on the weight bearing extremity. This stimulates a positive support reaction, which allows for maintaining a position against gravity. At the same time, the lower extremity that is not weight bearing loses its co-contraction. In healthy children, this reaction goes through an adaptive phase so that it allows for a certain amount of dynamic control of the extremity throughout the movement range. This allows for prevention of a collapse of the supporting extremity once the knee or elbow moves out of full extension. In children with MCD, this positive support and reaction during weight shifting can be either overly excessive or may not be synchronized and, in certain cases, may be absent. During examination of the upright reactions, the persistence of en block responses is usually more visible than rotation among the trunk segments. This insufficiency can have an influence on the gait pattern and running style and can lead to a decreased ability to rotate the trunk around the longitudinal body axis. With an upright head reaction, a child with MCD displays gross changes of muscle tone and asymmetrical responses. With assessment of the defensive and the equilibrium reactions in children with MCD, there is a link between impaired weight shifting, positive support and equilibrium reactions. Sensorimotor Aspects Sensorimotor aspects include tactile sensation, proprioception, the vestibular system, the oculomotor system, motor planning execution, diadochokinesis, crossing midline, hearing sequence, and coordination. A child with tactile problems cannot accurately interpret various

levels of stimuli, touch or grip. On the outside, they present as aggressive. With touch, movement activity grows and a defense reaction is stimulated. Sometimes, individual tactile stimuli do not elicit any reactions, but their time and spatial summation can elicit undesirable, exaggerated reactions not only in movement, but also in behavior. In the CNS assessment of tactile inputs, either hypersensitivity or, in contrast, deficits in the registration of tactile inputs (hyposensitivity) are observed. The signs of skin hypersensitivity include: Escapes touch, primarily in the areas richly supplied by receptors (face, head, shoulders); the child cannot tolerate washing their face Does not like hair brushing Does not tolerate touch during dressing Does not like walking barefoot Resists nail cutting (preschool and school age) Does not like being approached from the back, as it is perceived as a threat Does not like physical contact with other children; they like to touch themselves, but not be touched by others Resists ball catching; holds a color pencil differently Often shows intolerance to some foods A characteristic way of avoidance is by saying “I do not like doing this” Prefers loose clothing, long sleeves Does not like to play with wet materials, playdough, sand and does not like to finger paint Prefers sweets Hypersensitivity does not need to be on the entire body, but only in certain areas Signs of skin hyposensitivity include: The child does not mind food spread all over their face The child often breaks toys (due to the lack of stimuli) Very firmly presses a color pencil on paper Often hurts themselves (self-infliction) Does not distinguish shapes drawn on the skin

The child requires strong stimuli The child presents with decreased proximal muscle tone of the trunk, but it is increased distally Problems with insufficient integration of proprioception are most frequent in children with MCD. They can manifest either as localized (i.e., decreased kinesthesia of the fingers) or across the entire body (i.e., a deficit in the perception of the body schema). With testing, motor planning and motor memory need to be assessed separately. It is assessed whether the child performs the requested position based on visual demonstration (visual perception) or based on verbal instructions (memory footprint). The child can understand the movement and physically carry it out, but, when requested, they cannot consciously demonstrate it. Thus, children with MCD may not be able to plan or organize movements that they were shown. Similarly, they may not be able to plan in response to a verbal command. During the trials needed to complete a given task, this can elicit frustration because these children are aware of what they should do and they know that in the past they have carried out such a task, but they are not able to perform it upon request. Problems with motor planning are accentuated by poor memory. In such context, motor dyspraxia is assessed when a child possesses a movement plan, but its execution is disrupted. A child performs the given movement tasks in a shuddering way, non-precisely, and often purposelessly. For many of these children, it is difficult to maintain a static body position during movement and it is also difficult to regain it. A child’s decreased proprioceptive sense is sometimes manifested as falling, usually in one direction. Further, ideomotor dyspraxia is assessed and is characterized by the absence of a motor plan. The movements are skillful, but a child is not able to perform the requested task. With ideational dyspraxia, a child does not comprehend what they are being asked to do. In many children with MCD, the vestibular response of the head is either lacking or it is only partial and occasional. It is also less functional than the visual upright reaction. The responses are

asymmetrical. In clumsy children, the head often falls in the direction of gravity. With symptoms of gravitational instability and with hypersensitivity of the vestibular system, a child avoids climbing, swinging on a swing, going on marry-go-rounds, and shows an extreme fear of heights, while avoiding jumping off or takes a long time with stair negotiation. This child fears and avoids sudden changes in body positions, fears someone will make them fall and would rather play by themselves while constantly checking their surroundings. With testing, the child begins to move unexpectedly and clings to the examiner. On the other hand, deficits in synchrony between the eyes and the vestibular system are mainly observed in children with hyposensitivity of the vestibular system. With reading and counting, the duration of the rotary nystagmus is often observed to be shorter. The muscles of the eyelids do not receive a sufficient amount of efferent stimuli. Absent or very weak compensatory movements of the eyelids are a typical sign. Postural reactions are less developed and often delayed. In children with MCD, accessory reactions to a rotary movement are frequent and loss of postural control, orientation or an increased vegetative reaction can occur. These types of reactions are often asymmetrical, as much as, they are irregular, exaggerated or completely absent. In addition, the oculomotor system shows decreased function. In children with MDC, both observation of a moving object and eye convergence are uncoordinated, slower (which leads to the loss of visual contact with an observed object) or asymmetrical. They can be well executed during one part of the movement, but very quickly fatigue can set in. Strabismus in children with MCD is not any more frequent than for any other group. A large percentage of these children have difficulty with maintaining their head steady while the eyes are moving. Instead of having the ability to dissociate selective eye movements, the child moves the head and eyes together. Deficits in the development of visual perception are observed in children with MCD. Specifically, these deficits are seen in

development of visual functions (peripheral visual pathways), ability to focus, and integrative functions (integration of information with other sensory organs). The following is considered physiological development of visual perception in children: 0–1 Month The eyes turn together with the head and the body Makes short eye contact Reacts visually only in the horizontal plane 1–3 Months Fixed eye contact is already emerging 2–3 Months Eye contact is constant Observes vertically and also “along a circle” Shows interest in movement of toys Shows interest in lip reading 3–6 Months Watches own hands Since the 4th month, isolated eye movements from the head (45 degrees) emerge 3rd–4th month, observes objects laterally from midline Since the 5th month, carries visual fixation across midline 6–7 Months Grasps hanging objects Watches falling and rotating toys The time of visual attention increases 7–10 Months Notices details (for example, small bread crumbs) The pincer grasp develops Shows interest in pictures 11–12 Months Distinguishes pictures

Looks through the window and recognizes people Possesses visual orientation in a room Deficits in visual perception are demonstrated by the following signs: The child does not like to play with blocks Does not put together puzzles as well as their peers Can be nervous with descending stairs Easily gets lost; lacks orientation in the terrain Does not like new places Refuses to draw with colored pencils Shows difficulty with looking for differences in pictures Shows difficulty with differentiation of a person from a less distinct background When writing, is unable to keep the letters on the line, does not maintain the spaces between the letters and the words In children with MCD, deficits during alternative movements of the forearm without visual control (diadochokinesis) can be observed. The movement is not smooth and it is combined with simultaneous movement of other body parts. These are much more distinct if the child is trying to perform the forearm movement faster. If a child with MCD shows a problem with crossing midline, often this inability projects itself into more systems. It can be the inability to reach an object on the side opposite the hand performing a given task or a difficulty with making an eye movement across midline. The first mentioned problem has an impact on postural rotation, overall coordination and the development of hand dominance. The problem of tracking in the contralateral visual field adversely influences reading and writing ability. A decreased ability of “crossing” the midline can then be projected as a weight shifting deficit or as inadequate postural control. Children with MCD often show movement poverty and a deficit in rhythmic movement in reaction to auditory stimuli. This is often seen in connection with poor short-term memory as a sequencing deficit and during rhythmic movement pattern execution. In many children, this is manifested at school by poorer spelling and syllabifying or as a

decreased ability to remember numbers and facts. In a group of children with MCD, it is common for each individual to have their own “pattern of dysfunction”, in which it is possible to observe certain similarities. Not all such children are “clumsy”. Some children can show problems that do not have any influence on gross motor skills, but rather fine motor skills are involved or vice versa. Musculoskeletal Aspects Range of motion, muscle length and deformity are types of musculoskeletal aspects. At first glance, structural deformities can be observed in children with MCD, such as a postural scoliosis, foot deformity or, more commonly as a postural dysfunction which might accentuate a kyphosis, hyperlordosis or poor sitting posture. These are often exacerbated in those children who show a limited range of motion secondary to shortening in the muscles, fasciae or joint capsules. It is fairly common that children with MCD show such shortening in the hamstrings (ischiocrural muscles) and they are not able to sit with their legs extended in front of them without discomfort. In children between the ages of 11–14, it is physiologically normal that in sitting with the lower extremities extended, they are not able to reach their tip toes due to anthropometric relations, seen during their growth period. Clinically, this finding is often accompanied by a shortening of the hip internal rotators and adductors. As a compensatory strategy, an increased thoracic kyphosis can develop, accompanied by increased lumbar flexion visible primarily in sitting. The line of gravity projects into the support base, which results in increased demands on the hip flexors with the purpose of maintaining stability. All of this contributes to increased restlessness and “fidgeting” when sitting in the classroom and inattentiveness during learning. During therapy, it is necessary to be considerate of poor overall health. Often, intestinal problems, epilepsy, asthma or other pulmonary problems are present. With rehabilitation, it is necessary to take all of these situations into consideration, including medication being taken (Watter, 1996).

In children diagnosed with a Central Coordination Disturbance at an early age, the following deficits in postural alignment during static standing can be observed at a preschool age (children older than three): Non-stabilized cervical spine lordosis Non-stabilized lumbar lordosis Increased non-stabilized kyphosis of the thoracic spine, thoracolumbar junction, and lumbar spine Asymmetrical body silhouette Shoulder protraction Scapular elevation Scapulae alatae Cavernous chest in the region of the ribs 5–8 Relaxed positioning of the lower rib arches laterally and sagitally Diastasis of the abdominal muscles Pes planus Some of the aforementioned deviations manifest themselves not only in static standing, but also in supine on a mat during a clinical test of trunk flexion or extension. They can also be observed in static sitting with the lower extremities extended and when an active correction with a goal of straightening the spine is compensated for by the children with flexion in the knees. With changes in position during natural movement activity, the above mentioned symptoms are not constantly observed. In such children, gross and fine motor skills correspond to the quantity of the desired motor patterns of the corresponding age. Nonetheless, there are deficits in the quality of execution, for example, decreased static balance during the test of unilateral stance, in which children compensate by associating movements of the upper extremities or the trunk. Often they terminate the test sooner than the requested timed endurance – 10 seconds for four year old children. In some children while writing or tracing a picture, a very firm grip and strong pressure on the pencil is observed and the picture is drawn such that it is clear that the child understood the task, but the picture contains inaccuracies, for example, at the beginning and end of the lines. Another qualitative

deficit that can be observed is the lack of speed modification with jumping, jumping up or jumping from one foot to the other. For example, “clumsiness, awkwardness”, stilted execution and hard, loud stomping can be seen. Inaccurate and decreased force modification is obvious with activities, such as throwing a ball. When alerted, most of the children can consciously modify a given deficit, concentrate and control the quality of the movement. This can be considered as proof that movement therapy at an early age and family support has a positive influence, even though movement therapy was terminated usually after quality ambulation was achieved. All the observed children continued the all-round movement activity and showed a positive relation to it. Besides the listed deviations from the ideal psychomotor development, usually seen in the form of faulty body posture or as a certain degree of uncoordination, a more frequent incidence of respiratory illnesses was documented. Therefore, it is further recommended that these children be followed by a pediatrician, rehabilitation doctor and implement the needed therapy and education. An improvement in overall function is the main goal of rehabilitation. The goal of therapy should be to provide normal sensory stimuli, as well as, facilitate of expected responses to such sensory stimuli. To improve the processing of sensory input and the quality of its exit, a practice of more complex activities requiring a higher degree of cortical activity needs to be included. This leads to a child’s improved functional motor skills. Physiotherapy in Central Coordination Disturbance Physiotherapy approaches in the treatment of CCD need to be initiated as soon as possible and at the latest by 3 months of age. Reflex locomotion by Professor Vojta is the most commonly used and successful therapeutic treatment at an early stage of development (see section B. Therapeutic Approaches, Chapter 1.3.1. Vojta Principle: Reflex Locomotion).

It is focused on: Quality physiological stability of a position Quality physiological coordination of a movement The balance between chronological and developmental ages The prevention of faulty body posture The correction of an abnormal morphologic development: it influences the development of local and regional anatomic relationships Selected techniques of facilitative proprioceptive stimulation (handling) support the influence of reflex therapy. They are utilized during all common activities such as carrying a baby, undressing, dressing, etc. (Fig. 75).

Fig. 75 Carrying a baby. A – stimulation of upright and equilibrium reactions of the upper body provoked from key points on the lower extremities; B – facilitation of the perception of the lower extremities being held in their different functions, step forward and supporting; simultaneously, facilitation of the perception of symmetrical body posture in its longitudinal axis. The position facilitates the child’s communication with the environment and relaxation of the upper extremities for their basic function – grasping; C – the practice of weight shifting and body rotation. The manual contact of the mother’s hand on the child’s body controls and assists in movement execution, the other hand offers the child a toy in the direction of the requested movement.

By repeated handling during the entire 24 hours, a child acquires:

The spatial perception of their body The control over their position and movement The ability to modify position and movement At a time when the baby begins to cooperate, occupational therapy treatments are desirable. The choice of occupational therapy treatments is based on an accurate diagnosis of MCD symptomatology. The Duration, Frequency and Intensity of Exercise in Children with CCD Exercise duration is dictated by the age and complexion of the child and the signs of fatigue. In a newborn, it lasts 5 minutes and is repeated 4–6 times per day; in infants and toddlers it lasts 10–20 minutes and it is performed 2–3 times per day. Accurate execution of an exercise is the prerequisite for “triggering” physiological CNS control of the position and movement. In school-age children, exercise time increases, frequency decreases and it is adapted to the child’s daily regime, their school and extracurricular activities, and is guided by their ability to control the performed motor activity. Exercise intensity cannot cause fatigue. Alertness during and after exercise is a reason for adopting the motor skills that were automatically elicited by the reflex models.

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1.2 KINESIOLOGY AND CLINICAL EXAMINATION OF THE JOINT SYSTEM Pavel Kolář In this chapter, kinesiology and clinical examination of the joint system are described in general terms and also specifically according to location (i.e. spine, shoulder, knee, etc.). In the Special Section of the textbook, Chapter 2: Treatment Rehabilitation in Orthopedics and Traumatology, each individual location lists an overview of the most common pathological findings and the treatment indicated for such conditions. Joint Motions Basic joint movements can be divided into active movements executed by the muscle apparatus and passive movements elicited by an external cause (i.e., a therapist, gravity, etc.). One of the components of passive movement is “joint play”. J. Mennell suggests that these are small movements within the joint in different directions than the ones typical for its function. Joint play is limited by joint capsule elasticity and by the pull of short periarticular muscles. Joint play is assessed with distraction, anterior-posterior glide, lateral-lateral glide, rotational movements and angulations (Fig. 1.2-1).

Fig. 1.2-1 The assessment of joint play using slight traction

Every movement of the human body occurs between two segments. These two segments are referred to as a movement segment. The movement of a movement segment can be categorized based on whether the movement of the proximal segment occurs against the distal segment or whether it is movement of the distal segment in relation to the proximal segment (Fig. 1.2-2). In the upper extremity, the movement of the distal segment in relation to the proximal is common. These movements are related to the need for object manipulation and work activities during which the proximal segment needs to be stabilized to allow for movement in the distal segment. In the lower extremities, we can observe regular alternating of both types of movement during gait. During the stance phase, the movement of the proximal segment in regards to the distal segment occurs; during the swing phase of gait, the distal segment is moving in relation to the

proximal segment. In physical therapy, the term “open kinetic chain” is often used, which is a synonym for the movement of the distal segment in relation to the proximal segment. Stabilization of the proximal segment is needed for the distal segment to move in isolation. The term “closed kinetic chain” describes the movement of the proximal segment in relation to the distal segment. In a closed kinematic chain, the distal segment is stabilized (referred to as punctum fixum), body weight is usually shifted onto it and the movement is possible only with co-activation from other movement segments.

Fig. 1.2-2 Open and closed kinetic chain. A – joint movement in an open kinetic chain, or the punctum fixum is proximal and the punctum mobile is distal; B – joint movement in a closed kinetic chain, or punctum fixum is distal and the punctum mobile is proximal

Arthrokinematics include three basic movements that occur between the joint surfaces. These include: glide, spin and roll. The direction of these movements depends on whether the convex segment of the joint surfaces is moving in relation to the concave segment or whether the concave segment is moving in relation to the convex joint surface (Fig. 1.2-3). These three basic components of movement occur simultaneously during joint motion and differ only in the proportion

of the occurrence during a given movement. For example, in the knee joint, gliding motion dominates in the first 15–20 degrees of flexion; spinning motion dominates at the end range of flexion. The connectivity and continuity of these movements allow for utilization of the full range of motion and for greater effectiveness and smoothness of the motion.

Fig. 1.2-3 The movement in the knee joint, which consists of a combined motion of rolling, gliding, and spinning

Classification of Joint Movements Classification of joint movements is based on the geometrical shape of the articulating surfaces. These are linked with a number of axes around which a joint movement occurs. The number of bones participating in the joint movement is also significant. In a clinical setting, movement around the x-axis is abduction – adduction, a rotary movement around the y-axis is flexion -extension and a movement around the z-axis is internal and external rotation. The combination of such movements presents circumduction. Passive movements are additional possible movements. These include translatory movements that can be performed during joint distraction.

A painful joint is stabilized in a resting position. Thus, the knowledge of resting positions is important during stabilization of affected joints. Centrated (Neutral) Position of a Joint This is a position in which the forces acting on the joint are evenly distributed among the joint surfaces. In this position, the joint capsule is the least taut and the joint ligaments are relaxed. In a given joint position, we can speak of a mid, or neutral, position, which allows for an ideal static loading of the joint. Mid, or centrated, position of the joint is tied to the entire range of motion. These are “frozen” phases of movement. For example, with hip flexion, the centrated position in the individual phases of movement is linked to external rotation and abduction. With extension, it is internal rotation and adduction. These circumstances provide an ideal static loading and an optimal condition for muscle function from the perspective of the tendons and pennation (muscle fiber orientation). Note, for example, the starting position of a power lifter: their joint position corresponds to a position that is optimal from the aspect of loading but also from the aspect of the ability to generate maximal force. In a centrated joint position, movement is carried out most economically. In this context, Pool – Goudzwaard et. al. (1998) mention locking by force and shape. The shape lock is ensured by the mutual congruency of the bones and cartilage of the neighboring joint surfaces. Stabilization via ligaments contributes to the force lock where the tension in the ligaments is the source of the force moments. However, direct manipulation of these ligamentous structures cannot influence this tension. The force lock is generated almost exclusively by the activity of the stabilizing muscles. It can be said that the result of these two mechanisms, if they are sufficiently participating, is correct positioning of the segments in relation to each other during given postural and movement tasks. Joint Categories Based on the Number of Axes and the Shape of Articular Surfaces Triplanar Joints (Multiaxial)

The movement occurs along three axes: flexion-extension, abductionadduction, rotation, and circumduction, which is a combination of all three. Spheroidal joint (articulation sphaeroidea) is formed by a ball and a socket with a spherical surface. This joint exists in two basic subtypes (based on the ratio of the size of the socket and the ball): – Free spheroidal joint (arthrodia) with the socket surface smaller than the ball, which allows for a large range of motion. An example is the shoulder joint. – Limited spheroidal joint (enarthrosis) with a deep socket. An example is the hip joint. Biplanar Joints The movement occurs along two axes: flexion-extension and abduction-adduction. Ellipsoid joint (articulatio ellipsoidea) has surfaces similar to a rotary ellipsoid. The movements of an asymmetrical range occur around two axes: flexion-extension (longer axis) and abductionadduction (shorter axis). An example is the radiocarpal joint. Saddle joint (articulatio sellaris) is a joint with joint surfaces in the shape of a saddle. Movements are possible in two perpendicular planes. The combination results in circumduction. An example is the carpometacarpal joint of the thumb. Uniplanar joints The movement occurs along one axis: flexion-extension or rotation. Cylindrical joint (articulatio cylindroidea) has articulating surfaces in the shape of a cylinder and the following subtypes are distinguished: – A hinge joint (ginglymus) with a movement axis oriented perpendicular to the longitudinal axis of the bone – flexion and extension are stabilized by strong lateral ligaments (ligament collateralia); – Pivot (trochoid) joint (articulatio trochoidea) with an axis of

rotation identical to the longitudinal axis of the bone. An example is the radioulnar joint that allows rotation of the radius around the ulna (supination, pronation movements); Trochlear joint (articulatio trochlearis) has shape of a cylindrical joint with a guiding edge fitting into a guiding groove on the other bone. This configuration limits movement to only flexion and extension. An example is the humeroulnar joint of the elbow. Other Joint Types Plane joint (articulatio plana) is a joint with flat surfaces allowing gliding in various directions such as the intervertebral joints. Amphiarthrosis is similar to the plane joint but with irregular surfaces limiting the range of motion. An example is the sacroiliac joint. Classification of Joints according to the Number of Articulating Bones within the Joint Simple joints (articulationes simplices) in which there is contact between only two bones. An example is the glenohumeral joint. Combined joints (articulationes compositae) in which more than two bones connect (for example the ankle joint), two bones and a cartilagenous disc (for example the jaw joint), or more bones and more cartilagenous intraarticular structures (for example the knee joint with two menisci). Joint Innervation All joints are richly innervated. The richest nerve supply is found in the ligaments and the fibrotic layer of the joint capsule. The synovial layer is supplied to a lesser degree. The nerve branches do not reach the joint cartilage (however, the subchondral bone is supplied). There are two types of nerve fibers: 1. Sensory fibers in a joint capsule and ligament conduct pain and pressure stimuli as well as information about joint position, tension in the joint capsule and ligaments, and direction of movement (proprioception). Myelinated fibers terminate as free

nerve endings. 2. Autonomous fibers (unmyelinated) innervate the smooth muscle of the blood vessel walls (regulation of blood flow). Assessment of Joint Range of Motion David Smékal Joint movement can be characterized by a change in the angle between neighboring movement segments. Joint movement occurs around three basic axes. The first axis is the sagittal axis, which lies in the sagittal plane and around which movement in the frontal plane occurs (abduction and adduction). The second axis is the frontal axis which lies in the frontal plane and around which movement in the sagittal plane occurs (flexion and extension). The third axis is the longitudinal vertical axis. With movement around a longitudinal axis, no change in the angle of the given articulating segments occurs; rotation movements are performed. The standard anatomical position is used to assess a joint range of motion in the human body. This position was defined by Vladimir Janda and D. Pavlů as an erect body position in which the head is held up, eyes are looking straight forward, upper extremities rest along the body, palms are facing forward and fingers are extended. The lower extremities are close together, knee joints are extended and the feet are parallel. Joint range of motion is determined primarily by anatomical and kinesiological parameters, or the proportion between the surface of the ball and the socket, bony processes, tension in soft tissues in the joint proximity, the individual’s age, gender, etc. Joint range of motion can be estimated during observation (aspection), but this is highly prone to subjectivity. Currently, a photographic method appears to be a suitable option, which provides an image of the initial and final positions on photograph and allows for subtraction of the range of motion with a goniometer on the developed photographs. This method is advantageous for both documentation and publication purposes.

In clinical research, a kinematic method can be used to assess joint motion. However, this method is affected by laboratory conditions and is relatively demanding with respect to processing times. The planimetric method of joint range assessment is most commonly used in the clinical setting. It always measures and registers the angle between the segments in one plane of movement. It is also known as goniometric assessment. The SFTR method is used for documentation of joint movement. Planimetric Method To assess joint movement by the planimetric method, a goniometer is used to measure the joint angles. There are many types of goniometers – from manual to electronic. In physical therapy clinics, the two-arm goniometers are most frequently used. This goniometer consists of a body and two arms and allows for computing a measured value on one of three scales based on the starting position of the arms at the beginning of the motion. The first scale assesses a movement of 0–360 degrees, the second scale of 0–180 degrees and the third scale of 0–90 degrees. Goniometer scales are marked in two-degree increments. For the most accurate and reproducible measurements of joint movement, basic rules need to be followed: consistent starting position, quality stabilization and correct placement of the goniometer. A position of the joint in the above described standard anatomical position denotes a zero position in goniometry. From the zero position, movement in a given plane occurs. During a joint range of motion assessment, it is essential for the motion to occur only in one joint as much as possible. Thus, it is necessary to ensure stabilization of the proximal segment and allow for an isolated movement of the distal, assessed segment. Stabilization can be performed by the examiner, or with the help of another examiner. In some cases, volitional stabilization by the patient or stabilization with a belt can be used. An important component of the planimetric method is the placement of the goniometer during measurement. The goniometer is placed on the lateral side of the measured joint. The center of the

goniometer is placed at the point of the suspected axis of rotation for the measured movement. The stable arm of the goniometer, which follows the proximal stabilized segment, is placed parallel to this segment. The mobile arm of the goniometer is placed along the distal movement segment. The arms of the goniometer should be pointing toward the given anatomical and/or anthropometric landmarks. This will lower the risk of error during measurement of the subsequent movement. When measuring joint range of motion, active and passive movements are measured. Active movements are always measured first. Dislocated joints, fractures or areas immediately post- surgical intervention of soft tissues where a dehiscence of the incision could occur are absolute contraindications for measuring active and passive joint ranges of motion. During a joint range of motion assessment, special caution must be paid in the following scenarios: joints affected by inflammation, patients with advanced osteoporosis, individuals with hemophilia, regions with soft tissue injuries and with significant hypermobility. In patients who are taking analgesics or muscle relaxants, caution needs to be paid to avoid exacerbation of pain during the assessment. SFTR Method The SFTR method combines the method of registering joint motion or the “neutral zero method” (E. F. Cave and S. M. Roberts) and the record of measurement in the three basic planes, which was suggested by J. Schlaaff et al. in 1962. The SFTR method was accepted by the expert orthopedic community in 1964. This method is based on the standard anatomical position, which is accepted to be a zero position. Joint movements are measured in four planes (sagittal plane – S, frontal plane – F, transverse plane – T, and rotation plane – R). All movements can be documented by three numbers. The movements that occur away from the body (dorsiflexion, abduction, radial deviation, external rotation, supination, eversion, horizontal

abduction) and into extension are documented first. Flexion and the movements toward the body (volar and plantar flexion, ulnar deviation, adduction, pronation, internal rotation, inversion and horizontal adduction) are documented last. For the head and trunk, the following are used: head sidebending and head and trunk rotation to the left are documented first. Bending and rotation to the right are documented last. The middle number is usually zero, which denotes a zero (starting) position of the joint. In the case of pathologies, however, the mid value may not be zero and represents a starting position from which the patient is able to perform a movement. If a joint is in an immobilized position, only two numbers are documented. Below are examples of the SFTR documentation method. Left hip joint Sa: 15-0-120 Fp: 45-0-15 Ra (S 90degrees): 45-0-45 Verbal description: In the left hip joint, the patient is able to perform 15 degrees of active extension and 120 degrees of active flexion. The passive range of motion into abduction in the left hip joint is 45 degrees, 15 degrees of adduction. Active external rotation of the left hip joint at 90 degrees of flexion is 45 degrees and active internal rotation under the same conditions is 45 degrees. Right knee joint Sp: 0-20-115 Verbal description: The patient is not able to reach zero starting position in the right knee. With passive motion, starting position of 20 degrees of right knee flexion is achieved. From this position, 115 degrees of right knee flexion can be achieved. Left elbow joint Sa: 0-70 Verbal description: There is no active motion in the left elbow. The left elbow is positioned at 70 degrees of flexion. With the help of the SFTR method, muscle strength with

movement can easily be documented. Right wrist

Verbal description: For the right wrist, the patient is able to actively demonstrate 70 degrees of wrist extension and 90 degrees of wrist flexion. Muscle strength of the right wrist palmar flexors (both from the maximum wrist extension and zero positions) corresponds to grade five; the muscle strength of the dorsal flexors of the right wrist with movement from a maximal volar flexion into zero position also corresponds to grade five. The right wrist extensor muscle strength for movement from a zero position to maximum wrist extension corresponds to grade four. The planimetric method and documentation by the SFTR method are used primarily for the assessment of joint range of motion. Smekal et al. also recommend using the planimetric method and documentation of SFTR for the functional assessment of shortened muscles. It is necessary to adhere strictly to the methodical principles of the planimetric method. Despite using quality methods, using the same goniometer, measuring at the same time of the day and by the same individual, a subjective error can still occur. Given the possibility of a subjective error, it was agreed that when using a mechanical, twoarm goniometer, the joint range of motion will be documented in 5 degree increments.

1.2.1 Kinesiology of the Spine, Pelvis and the Thorax Pavel Kolář

SPINE Spinal Orientation Most spinous processes can be palpated. The orientation point is the spinous process of the vertebra prominens (C7). Since the C7 spinous process may not always be the most prominent protruding process at

the cervicothoracic junction, we can orient ourselves by palpation during spinal motion. C6 is the first process that does not translate anteriorly under the palpating finger with backward bending of the head. From there, we can count the processes in both directions. Deep to the ligamentum nuchae, a longer spinous process of C2 is palpable cranially. Anterolateral of the mastoid process, the C2 transverse process is found caudally. The spinous process of L5 is the last moving process with forward and backward bending. Spinal Connections The vertebral bodies are mutually connected by the intervertebral discs (disci intervertebrales) which are made of cartilaginous connective tissue. The intervertebral joints (articulations intervertebrales) between the joint articular processes (processi articulares) serve as another means of linkage. The joint surfaces have various shapes depending on the spinal segment. The shape dictates both the type of motion and the range of motion in a given segment. The alignment and shape of the joint surfaces varies in each individual joint. The joint capsules (capsulae articulares) of the intervertebral joints are free and are loosest in the cervical spine and firmest in the thoracic spine. In almost all intervertebral joints, the meniscoid formations of the synovial membrane (in the center richly supplied by blood vessels and innervated) protrude from the capsule in the front and in the back. These help align potential incongruencies of joint surfaces and maintain the joint cavity in the form of a capillary slit in all positions. The specific group of joints and ligaments that links the occipital bone, atlas and axis is referred to as the craniovertebral junction. This junction involves joints between the occipital bone and the atlas – a paired joint (atlantooccipital joint, or articulatio atlantooccipitalis) – and a joint connection between the atlas and the axis, which is formed by three joints: an unpaired joint (median atlantoaxial joint, or atlanto-odontoid, or articulario atlantoaxialis mediana) and a paired joint (lateral atlantoaxial joint or articulatio atlantoaxialis lateralis). Other vertebral connections are formed by the spinal ligaments,

which can be classified as long (anterior longitudinal ligament and posterior longitudinal ligament, anterior sacrococcygeal ligament, superficial and deep posterior sacrococcygeal ligaments) and short (ligamentum flavum, intertransverse ligaments, and interspinous ligaments). Given the freedom of the joint capsules, the joint surfaces of the intervertebral joints are in contact only during spinal extension and only then do the guiding grooves play a role. Only this can explain why with very frequent and multiple asymmetries, as shown by M. Med, movement into bending and rotation is still surprisingly symmetrical. That is also why the lumbar spine does not rotate only with backward bending. It has been documented that the muscle fibers from the deep layers of the erector spinae encroach into the joint capsules. A sudden pinching of such fibers between the intervertebral joints is prevented by the meniscoids, which level out the incongruencies in the joint surfaces during a movement. Because of the small size of the vertebral bodies, the height of the intervertebral discs is relatively greatest in the cervical spine. This corresponds to its greatest mobility, especially in the sagittal plane. Lateral flexion and rotation are somewhat limited at the level of the intervertebral bodies by the uncinate processes (processi uncinati), where the intervertebral disc also narrows at the lateral aspect. In the thoracic region, the discs are the narrowest and mobility is also limited by the ribs (chest wall). In the lumbar region, the vertebral discs again are relatively wide and mobility is greater. On average, the largest segment is L4-L5 where the disc is typically the widest (the largest in the sagittal plane). Mobility is also significant with lateral flexion and rotation if the vertebrae are not in close contact or backward bending. Spinal Stability In the context of spinal stabilization, Panjabi’s concept of the neutral zone needs to be mentioned. Neutral zone relates to the movement of one vertebra to the next. It represents a very small range of motion of the vertebra that is given minimal resistance from the bony,

ligamentous and muscle structures. Within the context of the barrier principle, the neutral zone is the region prior to reaching a physiological barrier. This only applies to passive segmental examination when the patient fully relaxes. Thus, the situation will be different for active and passive movements. The position of the neutral zone is defined as a position of two adjacent vertebrae (one spinal motion segment) during which the vector sum of all forces acting on the segment equals zero. This position maximally protects the segment from overloading. Segmental instability is then characterized by widening of the neutral zone, or a loss of passive support, which corresponds to a shifting or loss of the physiological barrier and a possible impact with an anatomical barrier. If this loss is not compensated for by adequate muscle stability, then the corresponding segment of the spine is prone to injury and repeated microtraumas to the intervertebral joint cartilage, intervertebral joints and other soft tissues. The goal of physical therapy is to decrease the size of the neutral zone (and its maintenance within the physiological range, which prevents clinical instability) by using active support, thus, the above mentioned muscle stabilization. A decrease in the size of the neutral zone also occurs after surgical fixation of the corresponding segment(s). A reduction in the size of the neutral zone does not correspond to an overall decrease in range of motion. Panjabi’s theoretical model of the neutral zone (1992) is suitable especially from a didactic perspective for the understanding of barriers in manual medicine. If we imagine the state of the neutral zone with movement (its range must be constantly maintained by the CNS control function), we are approaching, once again, the aforementioned term of dynamic centration of a segment. In other words, a centrated position is an ideally maintained neutral zone. The neutral zone can also be understood as being a result of active muscle stabilization or dynamic centration. Anatomical thinking intersects here with neurophy​siologic thinking (Fig. 1.2.1-1).

Fig. 1.2.1-1 MRI picture of the lumbosacral junction during flexion of the lower extremities against resistance (the resistance corresponded to grade 4 of manual muscle test). A – examination of lumbar spine at rest without activity of the lower extremities; B – an examination during an activity (flexion) of the lower extremities before practice; C – an examination with lower extremity activity (flexion) after practice

Spinal Mobility – Basic Movements Spinal mobility in the pre-sacral segments is defined as the sum of motion between the individual vertebrae. Intervertebral movements allow for compression of the interarticular discs and are limited by intervertebral joints. The range of motion is directly proportional to the height of the intervertebral discs, which is the relative height in terms of the surface of the disc. It is also influenced by the shape and the angle of the spinous processes and by the shape of the joint surfaces. Spinal movements include: 1. Forward and backward flexion (anteflexion = flexion, retroflexion = extension) 2. Side bending (lateral flexion) 3. Rotation (torsion) 4. Circular movement as a combination of flexion, extension and lateral flexion (cervical and lumbar spine) The range of motion between individual vertebrae is small. The resulting mobility of the spine in a certain segment is given by the sum of the individual segmental movements, which is enabled by the geometry of the joint surfaces, and the give in the intervertebral discs and joint capsules. Under physiological conditions, movement begins

with an eye movement toward a certain stimulus, which is later followed by the head, neck, trunk and the extremities. Differences in alignment and the shape of the joint surfaces of the cervical, thoracic and lumbar spine indicate that the individual segments differ in mobility. 1. Forward bending, backward bending (anteflexion, retroflexion) (Fig. 1.2.1-2) is the greatest in the cervical spine (flexion 30–35 degrees, extension 80–90 degrees). Forward and backward bending are also present at the atlantooccipital junction. In the lumbar region, extension is 30–35 degrees and flexion is 55–60 degrees. In extension, the joint surfaces glide on each other together at first, then they firmly approximate, which terminates the movement. Also, the spinous processes touch each other. The spinal canal elongates in the cervical spine with flexion and it shortens and narrows in the anterior-posterior aspect with extension. These changes also influence the intervertebral foramina. In the cervical spine, the vertebrae slightly shift forward during flexion (between C2 and C3 up to 2–3 mm); they shift backward with extension – a translatory motion occurs. In the cervical spine, it is necessary to distinguish between nodding and forward bending. With nodding, the head moves at the atlantooccipital joints and the atlas simultaneously tilts forward in relation to the axis. During forward bending of the entire cervical spine, the atlas also tilts forward but, during the motion, the head tilts backward in relation to the atlas. From backward bending to forward bending, motion occurs so that, initially, the head forward bends at the atlantooccipital joints, then the head together with the atlas bend forward in relation to the axis and, finally, the head during backward bending of the spine bends backward in relation to the atlas. Thus, nodding and forward flexion are two mechanisms during which one or the other mechanism occurs in a given moment. With backward bending, there are three regions that are the most strained and injury prone: the lower cervical vertebrae, region T11-L2 and the L4-S1 region. In the thoracic spine, the range of motion is significantly limited

by rib articulations. 2. Side bending primarily occurs in the cervical and lumbar regions (cervical 35–40 degrees, lumbar 25–30 degrees to each side); it is substantially smaller in the thoracic region. In the cervical region, side bending is coupled with rotation due to the tilted position of the joint surfaces. Given the shape of the joint surfaces, the lumbar spine does not rotate but, during side bending, a lateral rotation of the spinous processes occurs. It is not a joint movement but a result of a different bending deviation in the posterior and anterior portions of the vertebra (the deviation is greater in the front). The spinous process (presuming that normal lumbar lordosis is present) deviates laterally toward the bending side (into the concavity of the side bended spine). 3. Spinal rotation occurs in the cervical spine bilaterally to 45–50 degrees (of which approximately 30–35 degrees occurs between the atlas and the axis) and in the thoracic spine 25–30 degrees, whereas the joint surfaces of the lumbar spine essentially eliminate the possibility of rotation (it may be up to 5 degrees) because the articulating surfaces on the right and the left sides are not part of a common rotation surface. Spinal joints may be in two positions, which allow rotation. In the first case, the axis of rotation passes anteriorly to the vertebral bodies; in the second case, it passes posteriorly to the spinous process. With the axis of rotation passing posteriorly, the vertebral body mostly glides to the side rather than truly rotates. The geometry of these two types of joints, their axes and the direction along the spine are fundamental and must be taken into consideration during the assessment of spinal mobility. In general, in the kyphotic part of the spine, the joint spaces are oriented with their concavity ventrally, while in the lordotic segments the concavity is found dorsally (Fig. 1.2.1-3). Fig. 1.2.1-2 Movement of the spine into forward and backward bending

Fig. 1.2.1-3 Two types of position of the axis of curvature of the right and the left intervertebral joints. A – anterior axis, within the body of the vertebra or in front of it; B – posterior axis, behind the spinous process

The range of motion is listed systematically in Tab. 1.2.1-1.

Tab. 1.2.1-1 Range of motion of individual spinal segments (in degrees)

Spinal Curvatures The spine is curved in the sagittal and frontal planes (see below). In the sagittal plane, it is curved twice in an S-shape: Convexity forward – cervical lordosis (with an apex between C3 and C4) and lumbar lordosis (with an apex at L5); Convexity backward – thoracic kyphosis (with the apex between T5 and T6). Significant angular change at the L5 and S1 junction (with a prominent intervertebral disc) is called the promontorium. Spinal curvatures develop gradually (Fig. 1.2.1-4). In utero, the spine is bent in a kyphotic arc (primary curvature). A similar situation is seen in a newborn (in whom, however, the spine mimics the shape of the mat when in a supine position). Lordoses (secondary curvatures) develop later. At first, the lordoses are not stable and stabilize after the age of five. The S-shaped curvature increases spinal flexibility and allows for springing movements during landing and gait. Fig. 1.2.1-4 Ontogenetic development of the spinal curvature

The development of spinal curvatures can be attributed to the pull of the cervical and trunk muscles (especially with lordoses). Also, the weight of the internal organs and the differences in the height between the anterior and posterior edges of the intervertebral discs play a role. In the sagittal plane, spinal curvatures play a significant role in postural functions. From a functional perspective, symmetry is the most important aspect, meaning that the maintenance of an erect posture demands minimal muscle activity. Postural balance with minimal muscle activity depends on the quality of control mechanisms and on the regional and global anatomical parameters.

PELVIS Pelvic Influence on the Statics of the Spine The function of the pelvis and its influence on the statics of the human body depend, to a certain extent, on the type of the pelvis

(Fig. 1.2.1-5) see Table 1.2.1-2.

Fig. 1.2.1-5 Types of pelvis. A – assimilation pelvis; B – normal pelvis; C – pelvis prone to overloading

1. Assimilation pelvis – pelvis with a long sacrum and high positioned promontorium. This type of pelvis is prone to hypermobility 2. Normal pelvis – pelvis susceptible to restrictions 3. Overloaded pelvis – pelvis with a low positioned promontorium; the pelvis and the sacrum show a typical marked angulation

Tab. 1.2.1-2 Types of pelvis and their influence on spinal statics

Thorax Thorax Influence on Spinal Alignment The skeleton of the thorax consists of twelve thoracic vertebrae, twelve pairs of ribs connected to the vertebrae, and a non-paired, flat, anteriorly placed sternum. The thorax forms an elastic and firm envelope for the heart, lungs, large arteries, esophagus and other thoracic organs. It also forms the punctum fixum for muscles that contribute to the function of the upper and lower extremities. Under physiological conditions, the mobile elements of the thorax ensure respiratory movements without thoracic spine co-movements. Articulations of the Thorax 1. Costovertebral joints (articulationes costovertebrales) – posteriorly adjoin ribs with the spine. There are two types of articulations: Costovertebral joints (articulationes capitum costarum) –

connect the head of the ribs with the vertebral body Costotransverse joints (articulationes costo​transversariae) – connect the costal tubercle of the ribs with the costal facets of the vertebral transverse processes. 2. Sternocostal joints (articulationes sternocostales) – connections between the ribs and the sternum. 3. Interchondral joints (articulationes interchondrales) – mutual connection of the costal cartilages of ribs 7–10 (Fig. 1.2.1-6). Fig. 1.2.1-6 Joint and connective tissue connections of the thorax and the spine

Mobility of the thorax plays a fundamental role in respiratory and stabilization functions of the spine. The thorax exhibits two types of movements. They are (a) tied to the movements of the spine and (b) in the costovertebral joints occurring independently of spinal motion. Correct clinical identification of these movements plays an important role in the

assessment of the quality of respiratory and stabilization functions. The movements depend on coordination during muscle activation. With thoracic forward flexion, the ribs descend and the intervertebral spaces narrow. When returning to the upright position, the opposite action occurs and the thorax moves cranially. With thoracic rotation, the thorax is moving as well. For physiological movement of the thorax, the thorax needs to move independently of the thoracic spine. Or, conversely, the thoracic spine segments need to extend without co-contractions of the thorax (a deficit in this function is kinesiologically, or pathokinesiologically, significant). This movement is linked to the costovertebral joints and, thus, the movement of the ribs. Rib Movements The angulation of the ribs significantly influences rib movement. The ribs are curved in three places/ways: Flat along the circumference of the thorax; Along the lower edge (a rib placed on its edge contacts the mat only at two points); Rib torsion (the outer surface of the rib is posteriorly positioned vertically while anteriorly it turns obliquely upward and forward). During movement of the thorax, the ribs ascend and descend with breathing. They descend along the axis running from the center of the head of the rib obliquely and dorsolaterally into the costotransverse joint (Fig. 1.2.1-7). Similarly, the ribs move with muscle activation during trunk stabilization that is independent of breathing. Since the ribs are anteriorly connected to the sternum, their movement is always connected with the movement of the sternum. With physiological movement, the sternum moves anteriorly (Fig. 1.2.1-8), not cranially as it is seen in an accessory breathing pattern (Fig. 1.2.1-9). During physiological movement, the main respiratory muscles are engaged (the diaphragm and the intercostal muscles without the help from any accessory breathing muscles). With activation of the diaphragm and the intercostal muscles, the thoracic cavity expands anteriorly and, due to the influence of the rib angulations, laterally. In the region of

the manubrium and the first ribs, breathing and stabilization movements are small and are greatest with the longest ribs (pairs 7 and 8). Anterior-posterior movement of the sternum occurs at the sternoclavicular joint. With breathing and stabilization, the diaphragm is activated during such movement excursion without the participation of the accessory inspiratory muscles. During nonphysiological vertical movement of the sternum (thorax), movement at the acromioclavicular joint occurs with breathing and during stabili​zation. Fig. 1.2.1-7 Rib movements in the costovertebral joints. With rib elevation, the anterior-posterior diameter of the thorax increases.

Fig. 1.2.1-8 Diaphragmatic breathing. The sternum moves ventrally (BB’) without the vertical co-movement (AA’). Movement occurs at the sternoclavicular joint.

Fig. 1.2.1-9 Costal breathing. The sternum moves cranially (AA’, BB’). Movement occurs at the acromioclavicular joint.

ANATOMICAL PARAMETERS INFLUENCING SPINAL FUNCTION Regional Anatomical Parameters Regional anatomical parameters are landmarks defined by multiple anatomical segments, for example, the first lumbar vertebra and femoral heads. Imaging and measurement of regional parameters is related to posture and allows for better assessment of biomechanical relations. The anatomical relations observed are position dependent (lying, standing, sitting) during radiologic examination (for example, PT, OH, PL, PR), as well as independent of the position during radiologic imaging (PSA, PI, PRA).Thus, x-ray images can be compared and examined retrospectively. During assessment of these anatomical relations, it is necessary to indicate the age of the

probands. It is known that during childhood, the pelvis has a different shape and it is positioned more horizontally. Furthermore, the lumbar lordosis is also more accentuated. These parameters can be considered constant only when growth is completed. As an example, we list some regional parameters used to assess a static lumbar spine, which can be seen with a lateral view of the lumbosacral junction and the pelvis: Pelvic Tilt (PT), Version Pelvienne This is the angle formed by the vertical axis and the line connecting the center of the cranial surface of S1 to the center of the bilateral femoral heads. The norm is thought to be 12±6 degrees (Fig. 1.2.1-10). Fig. 1.2.1-10 Regional anatomical parameters of the spine. PT – the pelvic tilt, OH – pelvic overhang

Sacral Slope, Pente Sacree Sacral slope is the angle between the cranial surface of S1 and the

horizontal line. The norm is 41±8 degrees (see Fig. 1.2.1-10). Overhang (OH), Pelvic Width, Porte à Faux Pelvic width is the distance between the verticals led through the femoral heads and the center of the cranial surface of S1. The norm is thought to be 23±14mm in a dorsal direction (see Fig. 1.2.1-10). Pelvic Length (PL) R.P. Jackson obtained the above mentioned values by adding a line between the centers of the femoral heads (hip axis, HA) and the posterior upper edge of S1 and named it the “pelvic radius” (PR). Pelvic length (PL) is defined as the distance between the HA and S1. Pelvisacral Angle (PSA) Pelvisacral angle is the angle connecting the center of the sacral surface of S1 and the center of the femoral heads with a parallel axis leading through the center of the sacral surface (Fig. 1.2.1-11). It is a position independent parameter. Fig. 1.2.1-11 Pelvisacral angle, PSA

Pelvic Incidence (PI) Pelvic incidence is the angle between the femoral heads and a parallel line led through the center of the sacral surface of S1 (Fig. 1.2.1-12). Fig. 1.2.1-12 PI – Pelvic incidence angle

Based on an analysis of a group of volunteers, 53±10 degrees has been established as the norm. If the angle is larger, the pelvis has a greater slope and markedly greater shearing forces in the lower segments of the lumbar spine can be assumed. Steep pelvic alignment (PI>63 degrees) causes a compensatory lumbar hyperlordosis. If the PI angle is smaller than 43 degrees, it also denotes an unstable situation, which elicits lordotic flattening (“flat back”) with characteristic negative consequences. When using standardized standing for imaging, the PI equals the sum of the pelvic slope and the sacral slope and, simultaneously, the sum of PI and PSA equals 90 degrees. Pelvic Radius Angle (PRA)

The angle of pelvic lordosis is formed by the line of the dorsal edge of SI and the center of the femoral heads and the line that is tangential to the superior endplate of the S1 vertebral body. Jackson related pelvic radius angularly to various planes, primarily to lines tangential to end plates, for example, the upper end plate of T12 – lumbopelvic lordosis. The PRA angle is considered to be of greater practical use than the PI (Fig. 1.2.1-13). Fig. 1.2.1-13 PRA – Pelvic radius angle

This angle is cited in the context of indicatory and prognostic criteria. It is formed between the lower endplate of L5 and the sacral surface of S1. D. Boxall called it a “slip angle” and established 10-0 degrees as the norm. In the literature, numerous methods of measuring this angle are listed (Fig. 1.2.1-14).

Fig. 1.2.1-14 Lumbosacral angle (SA – slip angle)

Global Anatomical Parameters Some morphological findings in the spine must be assessed from the perspective of total body posture because changes in curvature or deficits in stability elicit reactions in the entire spine. The principle of optimal global balance in the sagittal plane during standing and gait is the projection of the center of mass into the base of support. Relaxed standing demonstrates balance by minimal loading of static structures and minimal muscle activity. Any other situation is inadequate and is the result of postural instability (White and Panjabi). Adaptive mechanisms can lead to accentuation of unfavorable forces. The pelvis plays a key role during the assessment of spinal symmetry in the sagittal plane. The pelvis, or the sacrum, is an immobile part of the axial skeleton and its position is given by the orientation of the lumbosacral junction and the hip joints. During bipedal standing, the preservation of the center of mass in the vertical projection to the base of support is necessary. With localized spinal deficits, the assessment of the sagittal contour of the spine as a whole is most important. Curvatures in the Sagittal Plane – Vertical Examination of spinal symmetry in the sagittal plane is carried out by dropping down a vertical line. The vertical is usually dropped down

from the center of C7 (plumb line vertical). The distance in which this vertical intersects the horizontal line intersecting the posterior upper edge of S1 is assessed. Under physiological circumstances, the intersection should project to the dorsocranial edge of S1 with a maximum variability of 5 cm to either side (Fig. 1.2.1-15; Fig. 1.2.1-16). The plumb line does not involve cervical spine alignment, or the head; however, their positions play a significant role in the statics and dynamics of the spine. For this reason, the vertical can also be dropped down from the external acoustic meatus and its projection is assessed similarly. The vertical is difficult to examine clinically. Therefore, standardized large format x-ray images are used for assessment (see Chapter 4.3.1 Radiologic Methods, Functional Diagnostics of Static Spine). Fig. 1.2.1-15 Vertical in a healthy individual

Fig. 1.2.1-16 The assessment of sagittal symmetry. A – symmetrical state; B – positive sagittal symmetry; C – negative sagittal symmetry

The Line of Gravity The vertical line dropped from the center of C7 is not a true representative projection of the center of mass, although in a clinical setting and in healthy individuals it can be observed that the C7 vertical is not far from the center of mass and is very close to the posterior edge of the sacrum. The true center of gravity is found only a few centimeters anterior to the T9 vertebra. In a physiological situation, the line of gravity runs through the centers of the femoral heads into the lower extremities. Curvatures in the Frontal Plane Curvature in the frontal plane, or scoliosis, occurs with all asymmetrical loading of the spine (for example, a weight in one hand). It is functional (physiological) even with static standing. The thoracic spine in the T3–T5 region is slightly deviated to the side (most frequently to the right) with a simultaneous compensation of the curvature in the cervical and lumbar spine. The explanation may be found mainly in a crossed asymmetry of the extremities (the left lower extremity and the right upper extremity are slightly longer,

therefore, the pelvis is slightly inclined) and an asymmetrical positioning of the internal organs within the body. De-compensation of a scoliotic curve in the frontal plane is determined by a slight deviation of the plumb line from the intergluteal groove. During clinical assessment, the plumb line is dropped from the external occipital protuberance. With a scoliosis, de-compensation is a negative prognostic factor.

EXAMINATION OF THE SPINE, PELVIS AND THE THORAX Patient History (Anamnesis) and Physical Assessment In the context of planning subsequent diagnostic approaches and establishing the plan of care, the initial clinical examination needs to be focused on answering the following three questions: 1. Is the cause a systemic disease or tumor? 2. Is there a localized deficit present with neurological signs that warrant a surgical intervention? Is this an acute or chronic deficit? 3. Is social or psychological stress present that exacerbates or prolongs the pathological state? Generally, these questions can be answered based on the patient history (anamnesis) and physical assessment. The individual anamnestic data (for example, onset of pain, injury, pain localization, projection of pain, symptom behavior in response to loading or position, alleviating position, etc.) and the physical examination influence not only the treatment approach but also the decision regarding imaging and laboratory testing and examination by a specialist (for example, a rheumatologist, neurosurgeon, etc.). Under the presumption that the answers to the above mentioned questions are negative, the examination focuses on the assessment of functional deficits which can then be significantly influenced by therapy. Neurological Assessment

With nerve root syndromes, the neurological assessment focuses on the hypotrophied muscle groups with decreased muscle strength, deficits in active movement, diminished or absent reflexes, and a sensory deficit in the corresponding dermatomes. The examination strategies are accompanied by nerve tension maneuvers. Assessment of Sensory Functions During this assessment, the difference in sensation to a nociceptive stimulus (pin prick) and the touch in the corresponding dermatome are observed (Fig. 1.2.1-17). Fig. 1.2.1-17 Dermatomal map

Assessment of Stretch Reflexes Symmetry, quality and intensity of reflexes are observed. In nerve root syndromes, myotatic reflexes are diminished or absent. Paradoxically, at the onset of radicular symptoms, reflexes may be increased. Upper Extremities In the upper extremities, the examined reflexes are generally referred to as C5-C8 reflexes:

1. Bicipital reflex (C5-6 segmental innervation) – tapping the biceps tendon in the cubital fossa elicits forearm flexion 2. Brachioradial reflex (C5-6 segmental innervation) – tapping the edge of the distal radius elicits elbow pronation and flexion 3. Triceps reflex (C7 segment) – tapping the triceps brachii tendon elicits forearm extension 4. Finger flexor reflex (C8 segment) – tapping the flexor tendons on the volar aspect of the wrist elicits finger flexion. Lower Extremities In the lower extremities, the examined reflexes are generally referred to as L2-S2 reflexes: 1. Patellar reflex (L2-L4 segments) – tapping the patellar tendon (ligamentum patellae) elicits quadriceps femoris contraction and, thus, lower leg extension 2. Adductor reflex (L2-L4 segments) – tapping the medial femoral condyle in an abducted position of the thigh (approximately 30 degrees) elicits adduction 3. Achilles tendon reflex (L5-S2 segments) – tapping of the Achilles tendon elicits plantarflexion of the foot 4. Tibio-femoral-posterior reflex (TFP, L4-S2 segments) – in supine and slight flexion, the tendons of the semimembranosus and semitendinosus are tapped through the examiner’s fingers. The response is palpable tendons. 5. Peroneo-femoral-posterior reflex (PFP, L5-S2 reflexes) – performed similarly to TFP except the biceps femoris tendon is tapped. Assessment Using Tension Maneuvers Nerve tension maneuvers are part of the neurological assessment. They provide information regarding peripheral nerve irritation within the context of spinal involvement and help distinguish between neurological and primary joint involvement. Next to nerve tension maneuvers, non-specific tests exist with which nerve root pain is provoked by an increased intra-thoracic and intraabdominal pressure – for example, the Valsalva maneuver, Milgram’s

test, Naffzinger’s test, etc. Tension Maneuvers to Assess Cervical Nerve Root Lesions 1. Upper extremity median nerve tension test – gradually and passively performed elbow extension with shoulder abduction to 90 degrees and simultaneous maximum wrist extension elicits tension which is carried through the median nerve and the brachial plexus to the spinal nerve root (Fig. 1.2.1-18). 2. Upper extremity ulnar nerve tensions test – gradual elbow flexion with shoulder abduction to 90 degrees and simultaneous radial deviation elicits nerve root pain (Fig. 1.2.1-19). 3. Head rotation to the contralateral side and spinal lateral flexion accentuate the pain. 4. Spurling’s test – axial pressure on the cervical spine with combined movement into extension and rotation provoke nerve root pain. Fig. 1.2.1-18 Median nerve tension test of the upper extremity

Fig. 1.2.1-19 Ulnar nerve tension test of the upper extremity

Maneuvers Alleviating Nerve Root Pain 1. Passive shoulder abduction test – decreases nerve root pain in more than two thirds of patients. 2. Cervical distraction test – gradual traction of the cervical spine leads to decompression of the facet joints, widening of the foramens and, thus, alleviates nerve root pain. Tension Maneuvers for Diagnosis of Lumbar Nerve Root Lesions 1. Lasègue’s maneuver – in supine, passive hip flexion with slight adduction and internal rotation provokes nerve root pain. The sensitivity of this examination suggesting herniated disc lesion is 0.80. If Lasègue’s test is positive, trunk forward bending with the

lower extremities extended is often limited (Thomayer’s sign). In some patients, atypical findings may be observed. During lower extremity elevation, a painful stop may appear – the patient experiences pain very early, which subsides with further elevation of the extremity. Additionally, the patient reports pain with extended lower extremity elevation but they can still continue to lift it (Fig. 1.2.1-20). 2. “Reverse” Lasègue’s maneuver – administered in prone. Knee flexion and hip hyperextension with the pelvis fixed provokes pain in the L4 dermatome. Examination is positive mainly for L4 nerve root syndrome. This test is often positive in a blocked SI joint (Fig. 1.2.1-21). 3. Crossed Lasègue’s maneuver – administered in supine. Hip flexion with knee extension elicits contralateral nerve root pain. A positive finding with this test leads to the suspicion of medial herniation or a loose fragment (sequester). 4. Bragard’s test – decrease in hip flexion by 10% during a positive Lasègue’s maneuver leads to alleviation of pain but subsequent dorsiflexion of the foot again provokes nerve root pain. Fig. 1.2.1-20 Lasègue’s maneuver

Fig. 1.2.1-21 “Reverse” Lasègue’s maneuver

Assessment of Motor Functions Decreased muscle strength consistent with a corresponding segment is listed in Tab. 1.2.1-3.

Tab. 1.2.1-3 Motor function assessment

Functional Assessment Anatomical and neurological findings do not have a full outcome value if they are not related to functional assessment. From the viewpoint of determining the appropriate therapeutic approach (for example, indication of physical therapy methods, caudal or epidural injections, infusions, periradicular injections, surgical intervention) and for the prevention of vertebrogenic problems, the functional finding is fundamental because it points out those symptoms that can be changed and clearly indicate the sources of problems. The

assessment is always begun in standing using observation. Lastly, the following fundamental functional changes are assessed: Spinal mobility assessment Functional assessment of individual spinal segments Muscle function assessment Soft tissue assessment Spinal Mobility Assessment Various tests are used to assess spinal mobility. During these tests, the ranges of individual spinal segments are measured and, subsequently, the changes in the distances during the movement of the spine are assessed. Otto’s Distance Otto’s distance is used to assess thoracic spine mobility. From the spinous process of C7, 30 cm is measured distally. During maximum forward flexion, this distance should increase by at least 3cm. Cepojevov’s Distance Cepojevov’s distance shows cervical spine range of motion into flexion. It is measured from the spinous process of the last cervical vertebra – the first mark is made here and the second mark is made 8cm cranially. With maximum flexion, the distance between the two marks should increase by at least 2.5–3cm. Schober’s Distance Schober’s distance (Fig. 1.2.1-22) shows lumbar spine mobility. Spinal extension is measured from the spinous process of S1 10cm proximally. The patient is asked to bend forward. The distance should increase by at least 5cm with forward flexion.

Fig. 1.2.1-22 Schober’s distance, Stibor’s distance, Thomayer’s test

Stibor’s Distance Stibor’s distance (see Fig. 1.2.1-22) shows thoracic and lumbar spine mobility. The starting point is the spinous process of L5 and the ending point is the spinous process of the last cervical vertebra (C7). The distance between both points is measured. With relaxed forward bending, this distance should increase by 7– 10cm. Forestier Fleche Forestier fleche is the perpendicular distance of the occipital protuberance (protuberantia occipitalis externa) from the wall. It is most frequently measured in standing. If the patient is standing with knees extended and the back of the head in contact with the wall,

Forestier fleche equals zero. It is used to measure a rigid thoracic kyphosis and the extent of a forward head position. Thomayer’s Test Thomayer’s test (see Fig. 1.2.1-22) – a so called test of simple forward bending – non-specifically assesses mobility of the entire spine. It is a very simple test with a good clinical outcome because it can assess both spinal hypomobility and hypermobility. Assessment of Hypomobility In standing, the patient bends forward while keeping their knees extended. The distance between the tip of the third finger to the floor is measured. The normal is given relative to contact of the tip of the finger to the floor. A 10 cm distance between the tip of the finger and the floor is considered physiological. A distance of 30 cm is considered unequivocally pathological. During this test, it is important to determine whether forward flexion was limited due to a true limitation in the spine or due to tightness in the knee flexors (very common in males). If motion is limited by the knee flexors, the patient begins to bend their knees during the test and pain is not experienced in the lower back but rather behind the knees. Assessment of Hypermobility The examination is the same as above, but the patient contacts the floor with their entire palm. In such a scenario, most frequently, the test demonstrates a generalized hypermobility. If the examined individual contacts the floor with their entire forearm, it then suggests a very significant deficit in the ligamentous tissues. This test is most often positive in females. Functional Assessment of Individual Spinal Segments Pelvis At first, the crests of the pelvic bones are palpated. Most importantly, the index fingers on both sides slide laterally from the last ribs to literally “sit” on the crests of the hip bones. Never “climb” on the buttocks in an upward direction! Then, the edge of the index fingers slide on the crests on both sides medially until the posterior superior iliac spine (PSIS) is found. Also, the symmetry of this part of the

crest, and thus the PSIS, is assessed. Also, the alignment of the pelvis relative to the relaxed upper extremities is always noted. If we see a shift in the pelvis, we need to realize that the pelvis and its crests were moved to the side and therefore, on the side to which the pelvis is shifted toward, the crest is palpated laterally while on the opposite side it is palpated more medially. Otherwise, an incorrect observation can occur suggesting that the pelvis is elevated on the side toward which it is deviated. Assessment of the Sacroiliac Joint With sacroiliac joint deficits, the patient limits loading on the affected side, which can reflect in a pendulum gait. During assessment, the SI joints and muscles that react to SI joint involvement by reflexive changes are palpated. The assessment of tender points within the hip external rotators and in the iliopsoas muscle is the most sensitive. During assessment, it is necessary to distinguish between deficits stemming from the hip joint and the spine, primarily from the L5-S1 segment. The S1 pseudoradicular syndrome often manifests itself by pain in the gluteals without any sign of back problems. Yergason’s test has a high specificity. During the test, the patient tries to step up on a chair. Pain and weakness is perceived on the involved side (Fig. 1.2.1-23). Fig. 1.2.1-23 Yergason’s test

Stepping forward test – in a sidelying position, the patient bends the top lower extremity into flexion. The knee is leaned against the examiner’s side who pulls down distally and stabilizes the upper part of the pelvis with one hand and with the other hand stabilizes the thorax. In this position, a slight step forward is performed passively while springing in the SI joint is observed (Fig. 1.2.1-24). Fig. 1.2.1-24 Stepping forward test – modification in a prone position

Patrick’s test is performed in supine. The patient performs hip flexion and external rotation with the heel placed on the contralateral knee. The test is considered positive when passive movement into maximum abduction is limited and painful. This test can also be positive with coxalgias or shortening of the hip adductors (Fig. 1.2.125). Fig. 1.2.1-25 Patrick’s test

Gaenslen’s test and a reverse Lasègue’s test (see above) are also used to examine the SI joint. Gaenslen’s test – in sidelying, the bottom lower extremity is flexed and the patient holds the leg with both hands behind the knee. In this position, passive hip extension of the top lower extremity is performed. A dysfunction is present when the patient reports pain in the SI joint at first on the same side and, with continued passive extension, perceived on the contralateral side. Greater specificity of this test being positive is seen with L4 involvement. Certain diagnostic techniques attempt to assess the movement between the pelvis and the sacrum by palpation. Because of the small excursion of only passive movement in this joint, such examination requires significant skills, especially in obese patients, whose numbers are growing. That is the reason why Dr. Karel Lewitt recommends a

technique based on Rosina. He found that if he palpates the “anterior spines” (ASIS) and the patient turns their head, then the ASIS on the side toward which the head is being turned drops after a short latent period. In a sacroiliac shift, the PSIS on the ipsilateral side raises. Since the palpation of bony prominences is difficult especially in obese patients and therefore unreliable, the crests of the pelvic bones are palpated with fingers moving along the crests medially above the PSISs and the patient turns their head. After a short latent period, it can be sensed that the finger on the side toward which the patient turns their head rises. The examiner needs to be patient and not press the hand forcefully on the crests. A blockage is present when this reaction is absent. Assessment of Pelvic Inflare Outflare or inflare are additional significant pathological scenarios in pelvic alignment. This abnormal change in pelvic alignment was first described by P.E. Greenman and Tait in 1988. In such a scenario, on one side, usually the right, the ASIS is flat and a greater distance from the umbilicus is noted (outflare). Contralaterally, the ASIS is more prominent and closer to the umbilicus (inflare) so that an isosceles triangle (under normal circumstances), which is formed by the lines connecting both ASISs with the umbilicus, is distorted. On the side of the outflare, the lower abdominal wall is usually hypotonic. On the side of the inflare, the tone is increased. Later, it was found that on the side of the inflare, hip internal rotation is often significantly limited (by 20 degrees or more). In slender patients, this asymmetry tends to be easily visible while in obese patients it needs to be considered and further palpated. This deficit is frequent in patients who experienced an especially difficult course of lumboischial pain. In their patient history they report may falling on their buttocks (tail bone) and often also a corresponding sport history. Sometimes while standing, they turn their right foot outward or the left one inward. When this particular dysfunction is diagnosed, it always needs to be

corrected. This opinion is truly justified because, following a very simple relaxation technique, it always is corrected. On the side of the inflare, the left lower extremity is positioned in the same position as Patrick’s test of abduction with a prestretch. A very slight isometric resistance is exerted against adduction followed by the patient’s relaxation into abduction for at least 10 seconds. Then, the patient, in contrast, abducts the knee against the examiner’s small but repetitive resistance into abduction. On the opposite side, the knee is flexed and the lower extremity is adducted into prestretch similarly to a ligamentous test and a slight isometric resistance is applied against abduction. Then, the patient relaxes into adduction for approximately 10 seconds, repeats it 2–3 times and then gives small pressure against the examiner’s repetitive resistance into adduction. After this maneuver, reposition always occurs, the lower abdominal tone evens out and the limited hip internal rotation on the side of the inflare is corrected. In contrast to Greenman, the authors’ experience is that this dysfunction does not seem to be linked to a sacroiliac blockage. On the other hand, Greenman and other authors describe an “upslip” and “downslip”, meaning on one side the symphysis and the ischial tuberosity appear to be positioned higher with the other side lower. We believe this finding is a palpation illusion brought about by an increased tension in the soft tissues of the symphysis and the ischial tuberosity. This can be seen on x-ray films of the symphysis and the ischial tuberosities with symmetry seen before and after therapy (see Fig. 1-7 in Chapter: Palpation). Lumbar Spine Following observation, lumbar spine examination begins with active movement, initially into backward bending, which is most frequently limited and painful. The greatest amount of extension is seen at the lumbosacral junction and to a lesser degree at the thoracolumbar junction. Side bending can be painful on the side of the sidebend (compression) or on the opposite side (distraction). Other than range, a rotation synkinesis is noted. Under normal conditions, the pelvis rotates during sidebending which manifests itself as a slight

movement of the ASIS on the side of the bending in a forward direction. With forward bending and the knees extended, the extent of pelvic horizontal alignment and lumbar spine flexion (kyphosis) are observed. With forward flexion, a structural scoliosis can best be observed, specifically its rotation due to the prominent transverse processes. A postural scoliosis becomes symmetrical with forward bending. Springing the individual segments in sidelying is the most reliable method for evaluation of hypomobility at individual segments. The patient’s knees and hips are bent so that the knees overhang the edge of the table. The therapist supports the patient’s knees against their own thighs and stabilizes the spinous process of the upper vertebra of the examined segment with the fingers of both hands placed on top of each other. Prestretch is achieved by pressure applied against the patient’s knees and the stabilizing fingers. The actual springing is achieved by a gentle push through the knees which is felt by the palpating fingers. Since a gentle push through the knees must be completely simultaneous with the resistance from the stabilizing fingers, the movement from the examiner must come from their trunk so that as the examiner straightens up, the patient pushes their thighs forward and, at the same time, the examiner increases the upward pull of the upper extremity. The pressure of the stabilizing fingers on the spinous process is felt. Springing is absent in a restricted segment. Similarly, limited mobility of the lumbar spine can be assessed in sidelying, in which the patient bends the top of the lower extremity at the knee and hip. The patient’s flexed knee is placed against the therapist’s side and, with simultaneous traction, the pelvis is stabilized. The opposite extremity stabilizes the lower thorax. Then, passive hip flexion with simultaneous gentle trunk rotation is performed. In a restricted position, movement is limited and the pelvis moves laterally. Limited flexion can also be examined in sidelying with both knees pulled in front of the stomach. The trunk is stabilized with the forearm on the thorax and the other hand flexes the pelvis against the trunk while at the same time the knees are pressed toward the patient’s

stomach with the examiner’s trunk to create prestretch. A localized blockage of individual segments with this technique is quite difficult. However, the shortening of the trunk extensors can be well assessed. This is manifested by an early resistance and the fact that a kyphosis cannot be achieved. Thoracic Spine With the patient sitting, the examination begins by having the patient slowly slouch and then straighten up again. Sitting straddle sits on a table, the patient rotates their trunk, which should be symmetrical to both sides. Normal range is 45–60 degrees bilaterally. Trunk rotation, however, includes both the thoracic and lumbar spine. Springing of individual segments is assessed in prone. The easiest approach is to place the palm of the hand on the lower vertebra of the examined segment so that the spinous process lies in the depression between the thenar and hypothenar regions which prevents eliciting pain in a spinous process. Prestretch is achieved by applying slight pressure followed by a non-forceful but quick spring of the segment. Diagnostically, it is not only the quality, but also the resistance and the pain elicited during springing that are significant. In sitting, passive extension and flexion are assessed. With extension, the patient sits with their hands placed behind their neck. The elbows are grasped from underneath. Trunk extension is performed while the other hand palpates the movement between the spinous processes. For flexion, the elbows are grasped from the top and, through pressure applied cranially, a kyphosis is achieved. The other hand can palpate for an increased tension between the processes, which is technically difficult. However, it is important to know that with restrictions in flexion, the resistance is sensed well by the hand that assists with the patient’s trunk flexion. Ribs The ribs are most frequently painful dorsally at the level of the costal angle (angulus costae) and at the sternocostal joints. They can hurt with inspiration or expiration. According to E. Kubis, the ribs are most frequently assessed in sitting. The patient elevates their arm bent

at the elbow on the involved side. The therapist stands on the opposite side and, with one hand, grasps the elevated elbow from the ventral side. The fingers of the opposite hand give resistance at the level of the costal angle. Pressure on the elbow in dorsal direction achieves a prestretch followed by the therapist´s gentle springing in a backward direction. The fingers at the costal angle sense increased resistance with limited mobility. The scapula overlying the costal angle does not stand in the way of the assessment. The first rib forms the upper contour of the thorax and, at its apex, it is sprung by the radial aspect of the index finger. After prestretch is achieved by a minimal pressure of the index finger, a quick but nonforceful pressure in a caudal direction springs the rib. Thorax The thorax or respectively its function, significantly influences breathing and postural activity. The thorax is a region of numerous muscle attachments. It serves as a transition for forces between the shoulder and the pelvic plexi. Stabilization of the thorax allows for the function of the upper and lower extremities and it forms the “framework” for their movement. The position of the thorax significantly influences the posturally stabilizing function of the muscles. Especially significant is the interplay between the serratus anterior, abdominal muscles, the diaphragm and the pectoral muscles. Not only is balanced coordination of these muscles essential, but their concentric, isometric and eccentric activity is interlinked in this region. It is a very complex function from the aspect of coordination. The alignment of the thorax is especially important in the function of the diaphragm. Its contractile activity acts by applying pressure on the internal organs and eliciting a counter-reaction of the pelvic floor. Thus, the position of the lower aperture of the thorax in relation to the pelvis is important. For symmetrical coordination of the muscles inserting at the thorax during stabilization, the thorax needs to be in a neutral position. The inspiratory alignment of the thorax is most frequently impaired. This is caused by shortened pectoral muscles, which pull

the thorax into inspiration. This position is common in athletes who weight train in inspiration. Contributing to this non-physiologic position are myths about correct body posture recommending an aesthetically pleasing posture of bringing forward the anterior chest and pulling the shoulder blades together. The result of such a body posture is an unbalanced activity of the diaphragm (the lumbar portion is activated excessively) and excessive lumbar muscle activity, especially in the superficial muscles during static or dynamic conditions. This also results in overactivity of the upper scapular stabilizers. Thus, this body posture is a consequence of overactivity and asymmetrical muscle activity that overloads the spine and shoulder joints. The physiological or unbalanced stabilization muscle function is not only dependent on the thorax itself, including the position of the costovertebral joints, but also on the curved character of the spine, which determines the alignment of the thorax in relation to the pelvis and respectively the lumbosacral junction. From this perspective, it is considered quite crucial to assess the regional parameters defining the relationship of the thoracolumbar and lumbosacral junctions. Two pathological situations can be distinguished: The thorax is found in a forward position because of a deficit in spinal curvature (see Fig. 1.1.1-12 in Chapter 1.1.1 Assessment of Postural Functions). This situation most frequently occurs in individuals with more significant pelvic anteversion and an elongated lumbar hyperlordosis. The position of the thoracolumbar junction is located dorsally behind the lumbosacral junction (see Fig. 1.1.1-13 in Chapter 1.1.1 Assessment of Postural Functions). This is most frequently found in individuals with a short lumbar lordosis and hyperkyphosis. Both situations lead to asymmetrical activity of the muscles of the stabilization system and, thus, to overloading of the spine. The position of the thorax determines the balance and respectively the excessive or insufficient activity of other muscles during its postural function. During assessment of the global anatomical parameters of

spinal symmetry in the sagittal and frontal planes, the position of the thorax must be assessed simultaneously. During assessment of the thorax, the focus is on assessment of its position, including the character of the spinal curvatures and rib movement. With movements of the thorax during breathing and stabilization (the diaphragm contracts with both situations), the ribs ascend and descend around the axis leading from the center of the head of the rib obliquely and dorsolaterally into the costotransverse joint. During physiological movement, the breast bone moves anteriorly not cranially, which is the case in accessory breathing. The thorax widens, mostly in its inferior portion. A flattened diaphragm is a prerequisite for correct biomechanics of the thorax. Muscle pull is directed toward the ribs and, in the pars lumbalis, toward the spine (Fig. 1.2.1-26). This leads to a caudal movement of the centrum tendineum and the muscle pull is outward (centrifugal). Fig. 1.2.1-26 Contraction of the diaphragm and the muscles of the abdominal cavity under physiological condition

In a pathological situation, a postural reaction is observed. During trunk stabilization, significant activity of the upper segments of abdominal muscles is noted and with it, a flattening or even drawing in of the lateral part of the thorax (at the level of ribs 7-10) is observed. This picture demonstrates an inverse direction of pull during

diaphragmatic contraction. This implies that the punctum fixum is formed by the centrum tendineum and the pull of the muscle fibers is reversed, or centripetal (Fig. 1.2.1-27). Fig. 1.2.1-27 The inverse way of the diaphragm contraction

Individuals with chronic respiratory problems typically show an underdeveloped chest in the superior portion. Physiological function of the thorax consists of movement in the costovertebral joints that occurs independently of spinal movement. In a pathological situation, this movement is limited and breathing is linked to flexion and extension co-movements of the spine. In an effort to erect the spine, the thorax elevates. In contrast, the ribs descend and the intercostal spaces narrow with spinal forward flexion. During assessment of the thorax, its flexibility or stiffness, needs to be observed. This is especially important in the lower segments. With stiffness of the thorax, the spine is overloaded. With more significant rigidity of the thorax, especially in younger indivi​duals, the therapist needs to be mindful of a possible diagnosis of Bechterew disease. Cervical Spine Following observation, the assessment proceeds to active movement in all three planes of motion. Forward flexion or nodding (during which flexion occurs mainly in the atlanto-occipital joints) needs to be

distinguished from cervical bending which occurs in the entire cervical and also upper thoracic spine. On the contrary, extension occurs in the atlanto-occipital joints. With passive assessment, movement needs to be carried out only around the chosen axis, which is vertical with rotation and sagittal with lateral flexion. With maximum forward bending, only rotation between the atlas and the axis is assessed. With a slightly kyphotic alignment, the cervical spine only rotates up to the C7 level. In a completely straight alignment, and especially during extension at the cervicothoracic junction, it occurs all the way to the T3 level. This assessment can also be more accurate by stabilizing the lower vertebra with fingers placed on the transverse processes of the inferior vertebra. Examination into lateral flexion is most frequently performed in sitting or supine. Resistance can be felt by stabilizing the lower vertebra of the examined segment with the radial edge of the index finger. Only with lateral flexion between the atlas and axis is the best form of assessment in supine with a mere nod of the head toward the tested side. A restriction between the occiput and the atlas is clinically very significant and its diagnosis requires the mastering of techniques of manipulative therapy described in specialized textbooks. For a screening assessment, joint play assessment is recommended. The patient is seated, the examiner grasps the patient’s head with one hand between the forearm and the arm so that the patient’s nose is placed in the bend of the elbow. The other hand stabilizes the examined posterior arc of C2 between the thumb and the index finger so that the large spinous process of the axis lies between the fingers. Slight pressure through the forehead in a backward direction achieves a prestretch followed by springing in the posterior direction against the stabilizing fingers. Since there is no joint play between C1 and C2 due to the position of the anterior arc of the atlas in relation to the axis, the entire joint play takes places strictly between the occipital condyles and the atlas where a backward shift occurs. The diagnosis is confirmed by the presence of TrPs in the suboccipital region and pain

at the transverse process of the atlas. Examination of Muscle Function Deficits in muscle function or their functional purpose, which is postural stabilization, are the main symptoms and often an etiopathogenetic factor in the development of spinal pain and the beginning of structural changes and neurological deficits. In chronic vertebrogenic disturbances and with progressive development of pathological morphological findings, the inner forces must be remembered. These act on the lumbosacral junction and therefore the entire spine through incorrectly coordinated muscle activity within postural stabilization or postural reactibility. Postural assessment (standing and walking) is important for the understanding of etiology and pathogenesis of vertebrogenic findings. The deviations from physiological stabilization are assessed by tests (see Chapter 1.1.1 Assessment of Postural Functions). By correct muscle recruitment and training, it is possible even for significantly extensive morphological findings to be compensated for to such an extent that a progression does not occur and the patient shows minimal or no problems. Fixed function is incorrect muscle recruitment during stabilization, which is automatically and unconsciously engaged in all exercises that the individual is performing. Muscles also show postural changes in muscle function not with respect to etiology, but with respect to the outcome of reactions to a developed deficit. These are called protective postural patterns. Muscle trigger points are a source of pain and the most symptomatic changes in painful spinal disorders (see Chapter 1.1.2 Assessment of Muscle Tone, Local Hypertonic Changes in Muscle Tissue). These are local changes in muscle tone which are tender with firmer palpation. A twitch may be observed in the superficial muscles with palpation. In the deep muscles, a touch is enough for the patient to feel “the” pain. A trigger point limits motion and can be the main reason for a change in the joint pattern or a specific functional limitation in joint mobility (especially into rotation and lateral flexion). Treating trigger points (see Section B. Therapeutic

Approaches, Chapter 1.1.6 Therapy with “Dry Needle” with Emphasis on Muscle Trigger Points) is meaningful especially in acute vertebrogenic syndromes. In vertebrogenic deficits, muscle strengthening is not the main approach, but rather it is exercises that influence muscle recruitment and their balance. This approach is essential especially for chronic vertebrogenic deficits. Assessment of soft tissues In soft tissues, resistance is palpated during stretching and during skin and subcutaneous tissue folding. Further, an increased resistance is palpated when the tissues are shifting against one another, especially in the deep fasciae (see more in Chapter 1.3 Soft Tissues).

1.2.2 Kinesiology of the Shoulder Girdle (Plexus) Petra Valouchová, Pavel Kolář The proximal joint of the upper extremity – the shoulder joint - is the most mobile joint of the body. The shoulder girdle is an incomplete bony ringlet, which is anteriorly completed by the sternum. The bony segments of the shoulder girdle are linked by two “true” joints (the glenohumeral and acromioclavicular joints), but a specific adaptation of the shoulder blade to the chest wall and the subacromial connection give rise to other mobile linkages within the shoulder girdle (scapulothoracic and subdeltoid linkage). These are not true joints, but rather connections further increasing the mobility of the entire extremity. At the same time, this modification of the shoulder girdle predisposes the entire appendage to overloading by placing greater demands on the muscles of the girdle.

BONES OF THE SHOULDER GIRDLE Clavicle The clavicle is S-shaped and in adulthood reaches 12 to 15 cm in length. With movement in the shoulder joint, the clavicle traces a shape similar to a cone with its apex at the sternoclavicular joint. With

movement, the clavicle also rotates around its own axis, especially during shoulder girdle elevation. The S-shape of the clavicle then significantly increases the extent of elevation of the shoulder plexus. The range of clavicular rotation is approximately 45 degrees which allows for movement of the sternoclavicular joint within three degrees of freedom (Fig. 1.2.2-1). Fig. 1.2.2-1 The movement and range of motion of the clavicle at the sternoclavicular joint with shoulder movement

Scapula With the transition to bipedal locomotion, the human shoulder blade (scapula) shifted from a more lateral position in quadrupeds into a dorsal position. Also now, the scapula is located more cranially on the chest wall, it is narrower, and longitudinally longer then in quadruped mammals. In scaption, the scapula forms a 30-degree angle with the frontal plane. This means that the scapula is tilted ventrally so that the joint socket is pointed obliquely forward. The scapula and the clavicle form an angle of approximately 60 degrees. Because of this positioning, both joints are oriented slightly forward. This orientation allows visual control of upper extremity manipulative movements.

The scapula lies in a neutral position between ribs 2 and 7. The lower angle of the scapula is found at the level of the T7 spinous process and the spine of the scapula is found at the T3 level. In neutral, the longitudinal axis of the scapula is laterally tilted whereas the medial border forms a 3 to 5-degree angle with the sagittal plane. The acromion can present in various shapes. Three types of acromion have been defined: Type I (flat) - found in 17% of the population Type II (curved) – found in 43% of the population Type III (hooked) – found in 40% of the population The type of acromion affects the likelihood of a rotator cuff injury. The incidence of a rotator cuff rupture with a type III acromion nearly 70% (Fig. 1.2.2-2).

Fig. 1.2.2-2 Individual types of acromion. A – flat; B – curved; C – hooked

The sternoclavicular and acromioclavicular joints are mechanically linked in such a way that all movements of the clavicle are accompanied by scapular movement. The scapula moves by “gliding” on the chest wall. Scapular Movements: Elevation (40 degrees) and depression (10 degrees) (Fig. 1.2.2-3); Abduction and adduction – with active protraction (30 degrees) and retraction (25 degrees) of the shoulder girdle it is referred to as horizontal translation of the scapula from a posteromedial to anterolateral position (Fig. 1.2.2-4); Lateral rotation of the inferior angle (around a transverse anteriorposterior axis) – with active arm abduction or elevation and with 60

degrees of scapular rotation, the inferior angle moves approximately 10 cm laterally while the superior angle 2–3 cm inferior-medial (Fig. 1.2.2-5); Rotation around a transverse axis – during abduction, the superior scapular border tilts dorsally up to 23 degrees (with 145 degrees of abduction). Fig. 1.2.2-3 Scapular movements: in blue – scapular depression, in red – scapular elevation

Fig. 1.2.2-4 Scapular movements: in blue – scapular retraction, in red – scapular protraction

Fig. 1.2.2-5 Scapular rotation with abduction, or arm flexion above the horizontal

Humerus The humerus of an adult shows a certain degree of torsion in which the distal end is externally rotated in relation to the proximal end. The humerus of a newborn has a torsional angle of up to 60 degrees. In adulthood, this angle decreases to 16 degrees. The decrease in the angle of torsion is given by the change in the position of the scapula during development. The joint socket, which is directed anteriorly in a newborn, is later oriented more laterally in adulthood. During ontogenesis, the gradual change in the position of the scapula decreases the angle of torsion of the humerus so as to secure that the position of the upper extremity is secured within the visual field. The head of the humerus corresponds to 1/3rd of a ball with a 3-cm radius. The axis of the humeral head is pointed cranially, medially and dorsally. The head of the humerus and the diaphysis form a 130degree angle (capital diaphyseal angle).

JOINTS OF THE SHOULDER GIRDLE Glenohumeral Joint (Articulatio Glenohumeralis) The glenohumeral joint is a ball-shaped free joint. It allows movement in three degrees of freedom and hence, six directions of movement. In neutral, the axis of the joint socket is oriented laterally, ventrally and slightly cranially. The surface of the socket forms a 30-degree angle with the sagittal plane (Fig. 1.2.2-6). Fig. 1.2.2-6 The angle of the glenoid fossa in relation to the sagittal plane

During abduction to 90 degrees, the joint socket rotates by 10 degrees in a dorsal direction. With abduction above 90 degrees, the socket rotates ventrally by approximately 6 degrees. Acromioclavicular Joint (Articulatio Acromioclavicularis) The acromioclavicular joint is a stiff joint and the joint surfaces are a flat oval shape. Movements in the acromioclavicular joint are small

and complement the movements of the sternoclavicular joint. Sometimes, an articular disc (discus articularis) is found within the joint. The acromioclavicular joint is a frequent source of shoulder pain, especially following a trauma because every impact to the shoulder affects the acromion and immediately transfers to the AC joint. Sternoclavicular Joint (Articulatio Sternoclavicularis) The sternoclavicular joint is a combined joint and contains a fibrocartilagenous disc. Because disc placement is between the articulating surfaces, the joint can move along three axes as in a balland-socket joint, but to a lesser extent. This joint is the only true joint that links the shoulder girdle and the entire upper extremity to the trunk. Scapulothoracic Joint (a false joint) The “joint” is formed by a thin connective tissue that fills the gaps between the muscles on the ventral side of the scapula and the chest wall. Gliding, made possible by this connective tissue, is a prerequisite for scapular movement. Subacromial Connection (a false joint) The subacromial connection is the clinical name for the thin connective tissue and bursae filling the narrow space between the lower side of the acromion, the tendons of the rotator cuff, the joint capsule and the inner surface of the deltoid muscle. The subacromial bursa is important for movement in the subacromial connection.

MOVEMENTS IN THE JOINTS OF THE SHOULDER GIRDLE In the shoulder joint, movements occur along three axes: vertical, horizontal and transverse. Simultaneous movement in all of the joints of the shoulder girdle allows for maximum range of motion. Flexion (150–170 degrees)/extension (40 degrees) – movements around the horizontal axis (Fig. 1.2.2-7A).

Horizontal adduction (130–160 degrees)/horizontal abduction (40– 50 degrees) – movements of the arm in 90 degrees of abduction (Fig. 1.2.2-7B). Abduction (180 degrees)/adduction (20–40 degrees) – movement along the sagittal axis. Abduction above 90 degrees is automatically linked to external rotation of the arm so that the greater tubercle (tuberculum majus) does not compress the coracoacromial space. The abduction range accompanied by internal rotation of the arm decreases to 160 degrees (Fig. 1.2.2-7C).

Fig. 1.2.2-7 Shoulder girdle movements. A – range of motion for flexion and extension; B – horizontal adduction and abduction; C – abduction and adduction; D – external and internal rotation with arm along the body; E – external and internal rotation at 90 degrees of abduction

The range of rotational movements, which occur along the longitudinal axis of the humerus, depends on the degree of abduction in the shoulder joint. In a zero position (the arm is along the body, elbow flexed), the range of rotation is approximately 60 degrees (Fig. 1.2.2-7D). At 90 degrees of abduction, the external rotation range is greater (90 degrees) than the internal rotation range (70 degrees) (Fig. 1.2.2-7E).

During everyday activities, all shoulder girdle movements tend to occur simultaneously. The position of the trunk and pelvic girdle is also crucial for optimal movement execution and establishment of the starting position of the shoulder complex (Fig. 1.2.2-7A-E). Scapulohumeral Rhythm (Fig. 1.2.2-8) Fig. 1.2.2-8 Scapulohumeral rhythm

The humerus and the scapula move in a 2 :1 ratio during abduction. This implies that for 90 degrees of abduction, 60 degrees is attributed to the glenohumeral joint and 30 degrees to scapular rotation. With deficits in shoulder girdle function, change in the scapulohumeral rhythm occurs. Generally, quicker scapular rotation occurs relative to the extent of humeral movement.

SHOULDER GIRDLE EXAMINATION Michaela Tomanová

Clinical examination of the shoulder joint consists of anamnesis, palpation assessment of simple structures and muscle tone of the shoulder girdle, and observation of the shoulder contour and alignment of individual segments of the shoulder joint (scapula, humerus, and clavicle) at rest and during movement. Anamnesis The patient is asked about any operations, injuries (mechanism of injury) to the joints and the surrounding areas (for example, the cervical spine and elbow joint), neurological illnesses (including the involvement of peripheral nervous system), vascular diseases, pain (for example, with movement, at rest, during the day, at night, pain duration, whether the pain is localized or radiating, its character, during what part of the motion it occurs, etc.). An acute intense pain is common when the subacromial bursa is involved, rotator cuff ruptures or empyema. Further, we inquire about the course of current illness, treatment, rehabilitation and the patient’s sensations during movement, i.e. a feeling of laxity, creaking, etc. Pain from other regions and organs, not only from the components of the shoulder girdle, can manifest itself at the shoulder. Therefore, shoulder examination and differential diagnosis can be sometimes difficult. Thus, it is very important to pay attention to detailed patient history. Cervical or thoracic spine involvement (even C5,6 radiculopathy) as well as problems with the ribs, gallbladder, heart (myocardial infarction, angina pectoris), pancreas, lungs (for example, Pancoast tumor), pleura, thyroid, spleen, esophagus, stomach, and liver can manifest themselves as shoulder pain. The shoulder can be painful with tumors of the neck or the mediastinum, intra-abdominal processes involving diaphragmatic irritation, or with herpes zoster. Aspection The shoulder joint region needs to be observed from all sides and compared to the opposite side. The cervical spine, shoulder blades, clavicle, and the entire upper extremities are also observed.

Abnormal Contour Abnormal contour can be the result of edema caused by the filling of the bursa during bursitis or joint exudate with arthritis. Sometimes the joint contour can be altered by a hematoma or hemarthrosis, fracture, dislocation, subluxation (hemiplegic shoulder), swelling and deformation during dislocation and disruption or even acromioclavicular joint arthrosis. Muscles With rupture of the long head of the biceps, a change in the contour of the biceps brachii can be observed, in which the lower and anterior portion of the muscle displays a soft bunching with a hollowing above it. Atrophy of the deltoid occurs with a lesion in the upper part of the brachial plexus, often with fracture or from pressure on the axillary nerve from axillary crutches. It can also be a result of a rotator cuff rupture. Shoulder Alignment An abnormal shoulder alignment into protraction is the result of increased tone in the clavicular portion of the pectoralis major. Scapular Alignment With decreased strength of rhomboid major and minor, the scapula abducts (moves lateral) and moves caudally. Decreased strength or denervation of the serratus anterior manifests itself by winging of the scapula (especially the inferior angle) and by its shifting closer to the spine. Palpation Prior to palpation, the patient is asked whether they feel pain. If they do, the painful location is assessed last. The patient is asked whether anything is painful during actual palpation. Painful areas and points in the muscles, subcutaneous and periosteal tissues (primarily in the area of muscle and ligamentous insertions) are palpated. Besides sensitivity and pain, palpation also assesses edema, increased temperature in the surrounding tissues, crepitus, scars, trigger points

and muscle tone of the shoulder girdle. The cervical and thoracic spines are also assessed. Head of the humerus – pain in the region of the greater tubercle (tuberculum majus) is found with an involvement of the insertions of the posterior part of the rotator cuff – the supraspinatus, infraspinatus, teres minor. They are easier to palpate with the shoulder in adduction. On the anterior part of the humeral head, tenderness in the sulcus intertubercularis can be palpated when the long tendon of the biceps brachii is involved. If the sulcus cannot be palpated through the deltoid muscle, then an alternative is to find the mid distance between the medial and lateral epicondyles of the humerus in the frontal plane. At this mid-distance and with the arm extended, the bicipital groove can be palpated on the humeral head. The region of the lesser tubercle (tuberculum minus) is often painful with an injury to the subscapularis tendon. It is best assessed with the shoulder positioned in extension and internal rotation. Sometimes, crepitus with movement can be palpated. Acromioclavicular joint – palpation is performed with the shoulder positioned in extension. Palpation is painful if blockage is present, in acute and chronic instability, and with degenerative changes and inflammation. Coracoid process (processus coracoideus) – can be painful when the short head of the biceps brachii, pectoralis minor tendon and coracobrachialis are involved. Sternoclavicular joint – in this joint, the patient can present with swelling imitating subluxation or dislocation. The swelling can persist long term. Joint dysfunction can be the result of a microtrauma or changes in the lymphatic activity of the subclavicular region. Joint Play Joint play assessment evaluates the range and limitations of the joint’s degrees of freedom. Joint play allows for the head of the humerus to descend from the upper portion of the glenoid fossa which is required for abduction. With joint play assessment, restriction in one or more

directions can be found and immediately mobilized. In a restricted shoulder, mobilization of the acromioclavicular and sternoclavicular joints as well as scapular mobilization can be performed. With glenohumeral joint mobilization, the head of the humerus can be moved in an anterior, posterior, inferior and superior direction and into traction (lateral distraction). Specialized literature describes this subject in greater detail. Passive Movements To assess passive movements, the patient needs to fully relax their muscles. If an active movement is painful, the same movements are always assessed passively. Often, passive movement assessment is carried out from behind the sitting or standing patient, or it can be performed while lying down. During assessment, one hand stabilizes the scapula on top of the shoulder or at its lateral border and the other hand moves the arm. With a limitation in passive movements, noncontractile structures (joint capsule, ligaments, cartilage, bone) need to be considered. If passive range of motion is limited, it needs to be determined whether it corresponds to a specific capsular pattern by Cyriax. In such a pattern, the external rotation followed by abduction and internal rotation are limited in the shoulder. A capsular pattern by Cyriax pertains to the freedom of movement within the shoulder, and thus includes the movement of the scapula. Therefore, more accurate is the assessment by J. Sachs because it involves scapular stabilization. In this case, abduction is limited first followed by external rotation. Also, with passive movement assessment, the pain that limits motion as well as any crepitus under the hand placed on top of the shoulder are noted. Furthermore, during passive movement assessment, painful restriction or a painful arc of motion (the pain occurs at certain angle of motion) are noted. After the restriction is surpassed, pain is eliminated and the patient demonstrates full range of motion. At the end of the passive movement, a barrier or an end-feel should be noted. Based on the feel at the end of the range of motion, physiological or pathological quality of the structures is assessed. Active Movements

The patient performs movement simultaneously with both upper extremities so that the difference between range of motion (limitation, hypermobility) and pain in both shoulder joints can be observed. This is followed by movement of one upper extremity. If movement is limited, it is than determined whether the cause may be pain or muscle weakness. With a limitation in active range of motion, the muscles are either primarily or secondarily involved. Range of motion and the smoothness of transitioning into abduction, flexion, external/internal rotation, adduction and extension are noted. Adduction and Internal Rotation (Apley’s Scratch Test) The patient is asked to place their hand on the spine in the area between their shoulder blades. The patient is instructed to reach as far as they can up their spine. The level of their reach between the shoulder blades on the thoracic spine is noted. The patient should be able to reach the lower border of the opposite scapula. Abduction and External Rotation The patient is asked to place their hand behind their head and is instructed to reach as far down the spine as possible in the area between the shoulder blades. The level on the cervical or thoracic spine they can reach is noted. The patient should be able to reach the upper border of the opposite scapula. Special Tests for the Shoulder Girdle Assessment of Movements against Resistance – Resistive Tests Pain with such tests suggests involvement of tendons and muscles that participate in a given movement. To assess the rotator cuff, the assessment of isometric contraction against small resistance into abduction, external and internal rotation is important. The scapula needs to be controlled or stabilized if the assessment is performed unilaterally. When assessing movement against resistance, all movements of the scapula can be assessed – elevation, protraction, and retraction. Overall, pain with movement and muscle strength are evaluated. The examination is performed in sitting or standing. Abduction

The patient performs abduction against the therapist’s resistance. The lateral side of the arm is in contact with the examiner’s hand, the elbow straight or flexed to 90 degrees. For unilateral assessment, the scapula is stabilized. The test is positive with a supraspinatus lesion. External Rotation The patient keeps their arm by their body (another test position is at 90 degrees of abduction) with the elbow flexed to 90 degrees as they perform external rotation against resistance. The resistance is applied by the palm against the outer side of the wrist at the lower portion of the forearm. The test is positive with infraspinatus and teres minor involvement. Internal Rotation The assessment is similar to the one for external rotation but resistance is applied against the inner aspect of the wrist at the lower aspect of the forearm (Fig. 1.2.2-9). The test is positive with lesions to the subscapularis or teres major.

Fig. 1.2.2-9 Resistive tests. A – upper extremity external rotators test (mainly the infraspinatus and teres minor); B – upper extremity abductor test (mainly the supraspinatus and deltoid); C – arm internal rotator test (mostly the subscapularis and teres major

Scapular Elevation The patient is asked to elevate and shrug their shoulders against resistance from the examiner’s palms.

Scapular Protraction The patient’s shoulder and elbow are flexed to 90 degrees. The examiner stabilizes the inferior angle of the scapula, while the other hand cups the patient’s elbow and applies resistance after instructing the patient to “push against me”. The test is positive when the scapula wings from the thorax (scapula alata) or when the medial border in the region of the inferior angle stands away from the thorax more as the rhomboids and the middle portion of the trapezius pull it closer to the spine. The test is positive in serratus anterior muscle insufficiency. A positive finding is present with a lesion of the long thoracic nerve (nervus thoracicus longus). Scapular Retraction The patient holds the arm in a combined position of slight extension and adduction with the elbow flexed to 90 degrees. The examiner standing behind the patient cups the patient’s elbow and applies resistance while instructing the patient to “push against me”. The test is positive with rhomboid insufficiency and the patient will show weakness in shoulder extension and adduction. Instability Tests Numerous tests were designed to assess anterior-posterior, superiorinferior and multidirectional instability (the inability to maintain the head of the humerus centrated in the glenoid fossa). An instability can manifest itself as a dislocation (separation of joint surfaces) or subluxation (incomplete separation occurs, the contact between the head of the humerus and the socket is not disrupted; translation occurs; the patient can feel brief pop or clunk). Anterior dislocation occurs in the majority of cases (95%). During assessment, these tests are performed unilaterally and the scapula should be stabilized (for example, assessing in supine with the other hand stabilizing the scapula from the top so that the thumb is in contact with the coracoid process and the fingers are on the spine of the scapula). The patient’s age by itself can lead toward a diagnosis and subsequent approach. Patients who suffered a traumatic shoulder

dislocation around the age of twenty show a greater risk of recurrence than patients with dislocation around the age of thirty. In patients over 40 years of age, rotator cuff lesions are more common. Drawer Test It is advantageous to perform this test in supine so that the patient’s shoulder is positioned over the edge of the bed. In sitting, the examiner’s one hand needs to stabilize the scapula while the other hand performs an anterior-posterior and posterior-anterior movement of the humeral head. Anterior Instability Testing These tests are based on a mechanism of injury in which an anterior dislocation occurs with abduction and external rotation. Apprehension Test The test is performed with the involved arm in 90 degrees of elbow flexion with one of the examiner’s hands holding the shoulder while the other carefully performs abduction and external rotation to 90 degrees (Fig. 1.2.2-10). The test is positive for anterior instability when the examiner feels a clunk or a pop or if the patient shows apprehension and resists movement even prior to the end of testing. If this test is positive, other tests are performed (see below). Fig. 1.2.2-10 Apprehention test

Relocation Test

This test allows the therapist to assess the degree of subluxation from the previous test. The patient is supine and the examiner pushes the humerus posteriorly. The head of the humerus returns to its position followed by an increase in external rotation range. Rockwood Test This test is performed similarly as the previous tests with passive shoulder external rotation – but the degree of abduction is gradually increased from 45 to 90 and to 120 degrees. At each degree of abduction, the state of the anterior joint capsule and the glenoid labrum are assessed. Anterior Drawer Test The patient is supine and the examiner’s one hand (same side) holds the arm by the elbow in 80–120 degrees of abduction, 0–30 degrees of horizontal adduction and 0–30 degrees of external rotation. The other hand stabilizes the scapula. The same hand performs an anterior shift of the patient’s entire upper extremity. Apprehension due to dislocation, popping sensation or a clunk may be elicited. Posterior Instability Testing The tests are based on the mechanism of injury involving a posterior dislocation, which occurs with flexion, adduction and internal rotation. Posterior Drawer Test The patient is supine, the examiner’s one hand stabilizes the scapula from the top so that the thumb points forward and the other hand (same side) grasps the upper extremity by the proximal portion of the forearm and performs 120 degrees of elbow flexion and 100 degrees of shoulder abduction with slight horizontal adduction. Gradually, the examiner moves the arm to 80 degrees of horizontal adduction and internal rotation of the forearm while the thumb is simultaneously moved above the head of the humerus and pushed posteriorly while the index finger palpates the humeral head posteriorly. The test is positive either when the patient shows apprehension due to dislocation or when greater posterior mobility of the humeral head is present.

Jerk Test The patient’s arm is brought to 90 degrees of abduction with internal rotation and then transitioned to a sagittal plane while increasing axial pressure on the head of the humerus. The test is positive when a posterior subluxation or dislocation occur. When the arm is transitioned back to the frontal plane (with repositioning), a pop or a clunk may be sensed. Clunk Test This test is used to assess a tear in the glenoid labrum. The patient is supine with the affected arm in maximal elevation. The examiner’s one hand is placed under the shoulder joint and pushes anteriorly while the other hand grasps the distal third of the arm and performs external rotation. The test is positive when a screeching sound, clunk or click is present. Inferior (Caudal) Instability This is tested in sitting with the examiner’s one hand stabilizing the superior aspect of the scapula and the other hand applying traction to the arm in an inferior direction. In a positive test, the space between the acromion and the humeral head increases. Sometimes, for example in a hemiplegic shoulder, a depression (“sulcus sign”) under the acromion can be observed. Multidirectional Instability This typically presents in hypermobility syndromes and can be observed in various directions. Tests for Long Head of the Biceps Brachii Tendon Pathology Yergason’s Test This assesses the pathology of the long head of the bicep tendon at the bicipital groove (sulcus intertubercularis). The test is performed with the elbow flexed to 90 degrees. The patient is asked to perform simultaneous forearm supination and elbow flexion against resistance. The test is positive when the patient feels pain, muscle strength is decreased, or the tendon is displaced from the groove (sensation of jumping over or popping out). The test is usually positive with tendonitis, tendon subluxation, or an impingement syndrome (Fig.

1.2.2-11). Fig. 1.2.2-11 Yergason’s test

Speed’s Test The patient’s arm is in 90 degrees of flexion and full elbow extension with the forearm supinated. The patient is asked to flex their shoulder in supination against resistance and, for more scrutiny, also in pronation. The test is positive with tendonitis or a partial tendon rupture. During this test, the tendon can be simultaneously palpated to examine its possible subluxation (Fig. 1.2.2-12). Fig. 1.2.2-12 Speed’s test

Rotator Cuff and Impingement Syndrome Tests Rotator cuff tests are designed to diagnose lesions in the rotator cuff including inflammation due to a degenerative injury, and a partial or complete rupture. The tests in this category include resistive tests of individual rotator cuff muscles (see above in Chapter Examination of Resistive Movements). Other specific tests include the assessment of the Cyriax arc and drop arm tests. Cyriax Painful Arc The patient performs maximal shoulder abduction. Under normal conditions, the freedom of movement is 180 degrees and it is pain-free. If pain occurs, it suggests various pathologies in the shoulder region. Pain to 30 degrees of abduction can be a manifestation of a supraspinatus muscle injury. Pain between 30–60 degrees often suggests involvement of the subacromial bursa.

Pain between 60–120 degrees is typical for rotator cuff involvement. Pain occurring at 180 degrees of abduction when maximum rotation of the lateral portion of the clavicle occurs suggests acromioclavicular joint involvement. Drop Arm Tests This test is used to assess the integrity of the rotator cuff. The shoulder is passively abducted to 90 degrees with elbow extended. In a complete rupture of the rotator cuff, the arm falls down and the patient is unable to hold it up. If they can hold the arm up, they are asked to slowly lower their arm down toward the body. The test is positive if the patient is unable to lower their upper extremity slowly, the extremity quickly drops or the movement is painful. Partial rupture of the rotator cuff is then suspected. Impingement tests are used to assess an impingement syndrome. This is a painful involvement in the region of the subacromial space caused by an irritation of the rotator cuff and the subacromial bursa under the acromion and the coracoacromial ligament (fornix humeri). Degenerative (for example, osteophytes on the inferior surface of the acromion) post-injury changes, changes in the acromion’s shape and a rotator cuff pathology lead to narrowing of the rotator cuff and the fornix humeri interval. The rotator cuff, specifically the supraspinatus, and the bursa run into the coracoacromial ligament (fornix) friction develops leading to bursitis, tendonitis, or ruptures. With this syndrome, pain at mid-range often occurs (for example, during swimming, reaching up to a shelf, arm position when sleeping). With the following two tests, passive shoulder maneuvers are performed to elicit tissue compression and, subsequently, increase irritation in the subacromial space. These tests are specific to a supraspinatus impingement syndrome. Neer Impingement Test Examiner’s one hand stabilizes the superior aspect of the scapula while the other hand brings the arm into shoulder internal rotation and flexion (above the head if possible), (Fig. 1.2.2-13).

Fig. 1.2.2-13 Neer impingement test

Hawkins Impingement Test The patient’s arm is elevated to 90 degrees of flexion followed by internal rotation while the elbow is flexed to 90 degrees. The test is positive if pain is elicited (Fig. 1.2.2-14). Fig. 1.2.2-14 Hawkins impingement test

The Neer infiltration test that follows is a diagnostic-therapeutic test. Neer Infiltration Test A local anesthetic is applied to the subacromial bursa. If the pain is decreased or eliminated, involvement in this location is diagnostically confirmed. If the pain persists, it usually suggests a partial rupture of the rotator cuff or tendonitis. Acromioclavicular Joint Tests Cross Flexion Test The examiner abducts the shoulder to 90 degrees followed by horizontal adduction across the chest toward the opposite shoulder. Applied overpressure in this position can elicit pain in the acromioclavicular joint. If the test is not spontaneously painful, the positivity can be ascertained by AC joint palpation (Fig. 1.2.2-15). A positive finding suggests a restriction, inflammation or degenerative involvement of the AC joint. Fig. 1.2.2-15 Cross flexion test

Shear Test During this test, it is advantageous to interlace the fingers of both hands so that one palm is placed on the back at the spine of the scapula and the other palm in front on the clavicle. Then, both palms press against each other to compress the AC joint. The test is positive if pain is elicited. Also, if joint instability is present, pathological movement can be sensed.

1.2.3 Kinesiology of the Elbow Joint Pavel Kolář The elbow joint is a compound joint formed by three bones (humerus, radius, and ulna). Flexion and extension are the basic movements at the humeroulnar and radiohumeral joints. Physiological extension is completed by the olecranon resting on the humerus. Besides movements into flexion and extension, the elbow joint complex allows for important movements enabling forearm rotation: supination and pronation, in which the wrist and hand rotate along the longitudinal axis of the forearm. These movements occur in the radiohumeral, proximal radioulnar and distal radioulnar joints (the last located outside the elbow region). They are important for manipulation, fine motor skills, self-sufficiency and feeding. Pronation and supination movements show a total range of 150 degrees. With this movement, the mutual position between the radius and the ulna changes so that the radius moves around the stable ulna. The mutual position of the bones changes from an initially parallel alignment of both bones in supination to their crossing during pronation (see Fig. 1.2.3-3). In the anatomical position and in full extension, the axis of the humerus and the axis of the ulna form an obtuse angle open laterally with an average of 170 degrees – called the carrying angle (Fig. 1.2.31). Thus, in the anatomical position of the upper extremity, the elbow shows certain physiological valgosity. Non-physiological elbow valgosity or varosity is assessed especially in children to observe possible deviations from physiological development of the elbow joint according to the Baumann angle. This angle is formed by the axis of the humeral diaphysis and a transverse axis extending through the radial portion of the distal metaphysis of the humerus. If the angle is greater than 90 degrees, it is a non-physiological varosity of the elbow joint. Fig. 1.2.3-1 Anatomical position of the elbow – carrying angle

Palpatory orientation: In the elbow region, the olecranon, epicondyles and the joint space between the capitulum of the humerus and the radial head are palpated. The most prominent structure of the elbow is the posteriorly located olecranon, which continues distally into a well accessible ulnar ridge. The medial condyle is the more prominent of the two humeral condyles. For assessment of correct elbow alignment, the mutual position of both epicondyles and the olecranon is utilized. They should be in one line with elbow extension,

while with flexion, they form an equilateral triangle.

ELBOW JOINT MOVEMENTS Flexion and Extension Flexion and extension are the only movements in the humeroulnar joint. These movements also occur in the humeroradial joint. Flexion is possible in the range of 130-150 degrees and, in muscular individuals, it is completed by the forearm resting against the biceps brachii muscle belly. Extension is completed by the olecranon’s bony contact in the olecranon fossa of the humerus and its physiological range is up to 10 degrees. Hypermobility occurs if the angle of elbow extension is greater. The most common cause of hyperextension is a deficit in connective tissue laxity or a small sized olecranon. Thus, the size of the olecranon, to a certain extent, influences the range of extension. A smaller olecranon allows for hyperextension which is quite frequent in hypermobile females (Fig. 1.2.3-2). Fig. 1.2.3-2 Elbow joint range of motion into flexion and extension

Pronation and Supination Movement into pronation consists of movement of the forearm bones, during which the ulna remains stationary and the radius rotates at the proximal radioulnar joint around its long axis and circles around the head of the ulna in the distal radioulnar joint so that it obliquely crosses the ulna in the front. The lower portion of the forearm rotates the dorsal side forward. With movement into supination, the forearm bones become parallel to one another and the lower portion of the forearm turns the volar aspect forward. Pronation and supination are possible due to the laxity of the joint capsule that allows movement of the radial end around the ulna (Fig. 1.2.3-3). Fig. 1.2.3-3 Movement of the forearm bones

during pronation and supination

Resting Position The resting position of the elbow joint is slight flexion and slight pronation.

ASSESSMENT OF THE ELBOW JOINT Anamnesis During the anamnesis of the elbow joint, information about pain is important. For most typical disturbances of the elbow joint including overuse soft tissue injuries (epicondylitis), pain with loading, lifting, carrying heavy objects, hand gripping, or forearm rotation is common. Important information is obtained regarding the type of loading. Earlier, the most frequent reason for epicondylitis was an excessive loading during sport activities, currently, it is computer work. Furthermore, information about previous therapy for epicondylitis is sought, primarily whether the patient was given a corticosteroid injection and how long its effect lasted. Using this information, it can be established whether it is an acute or chronic epicondylitis. Aspection

Resting position of the elbow is observed. From a functional view, its movement during gait needs to be assessed. In chronic tendon injuries, the coordination function of the elbow musculature needs to be assessed. Also, the ability of selective movement of the wrist, elbow and shoulder is observed. A deficit in movement coordination (for example, when using a computer mouse, a certain type of tennis stroke, etc.) is often the main reason for an overuse injury of the soft tissue. Palpation During palpation, first, the condition of the soft tissues is assessed. We observe their turgor (tone caused by perfusion), resistance (its location, range and quality), as well as temperature and painful areas. When suspecting epicondylitis, muscle tone of the forearm is assessed, it is noted whether it is hypertonic or hypotonic or whether reflex changes in the muscle bellies are present. Pain to palpation at the origin of the muscles at the humeral condyles is assessed. Similarly to the knee, the elbow is an area of referred pain from other structures of the musculoskeletal system or even internal organs. During elbow assessment, it is necessary to assess the shoulder, hand, cervical and thoracic spine and the corresponding muscles. Often, pain manifesting itself in the tendons of the elbow can originate from a shoulder instability or disc pathology of the lower cervical segments. Assessment must include examination of the forearm, arm and shoulder girdle musculature with the goal of identifying local muscle spasms, or trigger points, because pain radiating into distant areas is one of their characteristics. The assessment of TrPs is important primarily in epicondylitis. During assessment, the course and condition of the radial and ulnar nerves need to be observed. Especially the ulnar nerve, which lies very close to the bone and skin in the sulcus of the ulnar nerve on the humerus (sulcus nervi ulnaris humeri). Because of its position, it is quite injury-prone and repeated trauma (even microtrauma) can lead to fibrotic changes of the nerve

and its surroundings. This worsens the mobility and gliding of the nerve and leads to its irritation. Neurodynamic tests are used for functional assessment of peripheral nerves. For example, if the ulnar nerve is under greatest tension in shoulder abduction and external rotation with simultaneous maximal elbow flexion and forearm pronation, then pain often arises in the area where the nerve is “stretched” because of its pathological immobility within its surroundings. Passive Movements During passive movement assessment, pain with movement is assessed as well as crepitus, the relationship between the epicondyles and the olecranon during individual phases of movement and its quality and range of motion. Not only are elbow flexion and extension assessed, but also pronation and supination of the entire forearm. Wrist mobility assessment is a necessary part of the assessment of forearm passive movements. With range of motion limitations, it is assessed whether the end feel is hard or springy. The limitation with a springy end feel can occur due to increased muscle tone and, after muscle relaxation, the movement occurs within the full range. Part of the passive range of motion assessment includes joint play. A medial-lateral springing in the elbow joint and a springing of the head of the radius are assessed. Active Movements During an active movement assessment, the quality and smoothness of motion are observed. With limited range of motion, it is assessed whether the limitation is due to a structural or functional change in the elbow joint or wrist or due to a muscle deficit. Restriction in active range of motion can be seen both with muscle weakness and joint structural changes. Functional Tests

Instability Tests Varus Stress Test This test is designed to assess the lateral collateral ligament. Administration: The patient is sitting with the examined elbow flexed 20–30 degrees and the forearm supinated. The examiner’s one hand stabilizes the wrist and the other hand, from the medial side, exerts pressure on the joint space. Positive test: pain at the lateral joint space or excessive varosity without a barrier. Posterior-Lateral Instability Test This test is utilized to assess posterior instability of the elbow joint. Administration: The arm is positioned in abduction and stabilized. The forearm is supinated and subsequently transitioned to a valgus position and 20–30 degrees of flexion. After this positioning, a lateral (tangential) pressure is exerted on the joint. Positive test: Elbow joint posterior subluxation, which can be observed or palpated. Lateral Epicondylitis Tests Cozen’s Test This test is utilized to assess extensor carpi radialis strain. Administration: The patient is sitting and the examined elbow is in 90 degrees of flexion, supination and the hand is held in a fist. The examiner’s one hand stabilizes the elbow joint where they palpate the lateral epicondyle while the other hand gives resistance against forearm pronation, extension and radial deviation of the wrist. This maneuver pulls the tendinous origin of the extensor carpi radialis brevis and longus at the lateral epicondyle. Positive test: Pain in the muscle origin at the lateral epicondyle (Fig. 1.2.3-4). Fig. 1.2.3-4 Cozen’s test

Resistive Test for Finger Extensors This test is used to assess finger extensors strain. Administration: Patient performs extension of digits 2-5 in order against resistance. Positive test: Pain at the origin of the muscle at the lateral epicondyle of the humerus. Resistive Test for the Supinator This test is used to assess supinator muscle strain. Administration: The patient is sitting and the examined elbow joint is flexed to 90 degrees and in mid-position between supination and pronation. The examiner’s one hand stabilizes the elbow joint while the other hand gives resistance against supination. Positive test: Pain at the muscle origin on the radius.

1.2.4 Kinesiology of the Wrist and the Hand Petr Bitnar The wrist and hand allow for a great number of movements that are under direct volitional control (corticospinal pathways). The distal portion of the upper extremity begins at the radiocarpal joint and

ends at the distal phalanx. Functionally, the hand region also includes the distal radioulnar joint, which contributes to hand movements and its dysfunction causes deficits in hand movements into radial or ulnar deviation.

WRIST Radiocarpal Joint Out of all the forearm bones, only the radius (anatomically) participates in the radiocarpal joint because the ulna is separated from the joint space by an articulating disc and by the ulnotriquetral ligament complex. The radial epiphysis and the articulating disc with the ligaments (triangular fibrocartilagenous complex) form the socket of the radiocarpal joint. The head is formed by the proximal row of carpal bones – that is the scaphoid (articulates with the radius), the lunate and the triquetrum (articulate only with the disc). With wrist movements, these carpal bones move as one functional unit and form, in principle, a compact ball of the joint. The distal row of the carpal bones is linked more to movement of the fingers, or metacarpal movements. The articulating disc is a springy structure dampening jarring and friction: however, the majority of pressure is transferred to the radius (only about 20% of pressure is transferred to the disc). The disc is also a vulnerable structure and, in many patients with pain on the ulnar side of the wrist, a rupture of one of its components can be discovered. Around the age of 30, degenerative changes or even disc perforation can occur especially in the central portion of the disc. These changes are currently thought of as mainly an autoimmune process. Midcarpal Joint The midcarpal joint is the articulation between the proximal and distal rows of the carpal bones. It has an S-shaped joint space. The proximal row includes the scaphoid, lunate and triquetrum. The distal row includes the trapezium, trapezoideum, capitate and hamate. This articulation exhibits some movement rigidity due to the shape of the

joint surface and a vast ligamentous apparatus. However, there are small movements occurring that are important for the kinematics of the entire hand.

MOVEMENTS OF THE CARPAL COMPLEX The complex of the carpal bones displays a wide movement spectrum. Movements into flexion, extension, and radial and ulnar deviation are possible. The combination of these movements creates a false rotation movement – a circumduction. Functionally, pronation and supination belong here as well. Flexion and Extension These movements occur primarily in the radiocarpal articulation; however, to some extent, the distal carpal row participates in these movements. With extension, movement occurs in the articulation between the scaphoid and the radius and the lunate and the radius. Certainly, there are movements and changes in alignment occurring in the other joints as well, primarily in the articulations between the lunate and the scaphoid as well as the scaphoid and the capitate. With flexion, the lunate and capitate rotate volarly and, at the same time, the lunate shifts dorsally. Flexion occurs primarily at the radiocarpal joint and extension at the midcarpal joint. Different authors indicate differing values for the extent of flexion and extension. In principle; however, flexion movements are greater than extension moments. Flexion of the distal upper extremity reaches approximately 60-80 degrees and extension between 40-60 degrees (Fig. 1.2.4-1). Fig. 1.2.4-1 Wrist range of motion into flexion (in blue) and extension (in red)

Ulnar and Radial Deviation Radial and ulnar deviation occur primarily in the midcarpal articulation. During radial deviation, the proximal carpal row moves in an ulnar direction and the distal carpal row in a radial direction. The opposite occurs during ulnar deviation. With radial deviation, the proximal row flexes (the scaphoid shifts in a volar direction) and the capitate extends. Once again, the opposite occurs with ulnar deviation. With radial deviation, slight pronation occurs and with ulnar deviation, slight supination and also slight lengthening and shortening of the radius in regards to the ulna occurs. A deficit in this co-movement is the most frequent functional deficit (especially with radial deviation) and it is the cause of pain in the distal forearm (especially after a trauma). The range of radial deviation is 15–20 degrees: Ulnar deviation can reach as much as 45 degrees (Fig. 1.2.4-2). Fig. 1.2.4-2 Ranges of motion of lateral (in blue) and ulnar deviation (in red)

Circumduction Circumduction is a circular movement of the wrist. It is a combined motion of flexion-extension and radial and ulnar deviation. The movements of the carpals correspond to the individual phases of the combined movement. Pronation and Supination This is the movement of the radius around the ulna, which leads to rotation of the hand upward and downward. The movement truly takes place mainly in the proximal and distal radioulnar joints (this is a uniaxial joint between the convex head of the ulna and the ulnar notch of the radius). However, functionally, this movement directly participates in the mobility of the distal end of the upper extremity by allowing object manipulation and thus essentially complementing the grasping function of the hand. Pronation and supination are also closely linked to wrist radial and ulnar deviations. During radial deviation, simultaneous wrist extension and pronation occur and, with ulnar deviation, slight hand flexion and supination occur. Clinically, this implies that with a dysfunction in pronation and supination, the mobility of the distal segment of the upper extremity (the hand) becomes affected as well.

CARPOMETACARPAL JOINTS These joints connect the distal row of the carpal bones with the bases of the metacarpal bones and also include the intermetacarpal joints. From a functional view, the carpometacarpal articulations are less significant. The connections have limited mobility and movement primarily occurs in the wrist joints. However, one carpometacarpal articulation is functionally very significant – the carpometacarpal joint of the thumb. It is a saddle joint, which allows for dual, mutually perpendicular movements of the thumb in relation to the trapezium. Flexion and extension, as well as adduction and abduction, occur at this joint. It also allows for rotation. A combination of these movements allows for thumb opposition against other fingers (thumb opposition is unique in the animal world and essential for human grasp). A saddle joint is not accommodative to rotation (without rotation, however, opposition cannot occur) and so, with thumb opposition, an excessive rotation of the metacarpal base outside the saddle of the trapezium occurs and the contact areas of the joints are maximally reduced to only the tips of the saddle. Virtually, a functional joint decentration occurs with the carpometacarpal joint highly vulnerable to injuries in this position (Fig. 1.2.4-3). Fig. 1.2.4-3 Movements of the carpometacarpal articulation of the thumb during opposition

HAND Metacarpophalangeal Joints The metacarpophalangeal (MCP) joints connect the heads of the metacarpal bones with the proximal phalanges of the fingers whose bases consist of an oval socket. Thus, these are spherical joints with a relatively large head on the metacarpal bone and a shallow socket on the base of the phalanges. The metacarpal heads widen volarly so that the greatest joint stability occurs with full finger flexion. In contrast, the greatest joint laxity is in full extension. This also corresponds with movement ranges and abilities, which are greatest with extension of the MCP joints. A shallow joint socket is widened by a small cartilagenous border on the palmar rim of the socket – the palmar fibrocartilage (fibrocartilago palmaris). The joint capsule is loose and only reinforced by collateral ligaments. Flexion and extension are the basic movements at these joints (flexion to 90 degrees, extension to approximately 10 degrees), but with full extension (fingers extended) even abduction and adduction to 30 degrees are possible. With gradual combination of these

movements a combined circular movement occurs – circumduction. Interphalangeal Articulations These are hinge joints, in which the head contains a characteristic protuberance with a leading ledge and the joint socket contains an indentation or a leading notch. This mechanism stabilizes the joint and controls movement; however, it also decreases the potential movement spectrum. Again, the sockets are slightly widened by cartilagenous edges called the palmar fibrocartilage. Only flexion and extension occur in the joints. Flexion occurs to 90 degrees in the proximal joints and to 70 degrees in the distal joints. The numerous hand articulations allow for very complex and diverse movements, whose cooperation is necessary for a quality grasping function of the hand. The human upper extremity is unique within animal world and the dexterity of the distal segment allowed for a fast development of civilization. The grasping function of the hand is, of course, subject to ontogenic development. This development can serve as a diagnostic sign during the assessment of an individual’s developmental deviations. The first purposeful movement develops on the ulnar side of the hand and, with the development of stereognosis, it spreads to the radial side. At 7.5 months, a pincer grip develops in children which allows picking up and manipulation of small objects. The movements of the thumb and the little finger are very important for grasping and together with function of the other fingers and the wrist, they provide the main pillars for the gripping function on the hand (Fig. 1.2.4-4). Fig. 1.2.4-4 Physiologic grasp during which the arch of the hand is sufficiently maintained in the region of the metacarpophalangeal joints

MAIN TYPES OF GRIP Digital-Palmar Grip (Hook Grip) A digital-palmar grip (the grasp between the palm and the fingers) is, from a developmental perspective, the first purposeful grasp that a child exhibits. Its development begins on the ulnar side of the hand and gradually shifts toward the radial side. Its development is closely related to the development of stereognosis. This grip requires intact flexors and extensors. (Fig. 1.2.4-5A).

Fig. 1.2.4-5 Digital-palmar grip (A), palmar with a thumb lock (B), with less than full (subterminal) thumb and index opposition (C), with lateral thumb and index opposition (D)

Palmar Grip with a Thumb Lock A grip with the entire hand requires intact finger flexors and extensors and all muscles of the thenar group, primarily adductor pollicis and flexor pollicis longus (Fig. 1.2.4-5B). Grip with Less than Full (Subterminal) Opposition of the Thumb and Index Finger A pincer grip develops in a child at around 7.5 months with the child’s transition into side sitting. It allows for grasping of small objects between the pads of the thumb and index. It requires an intact function of the flexors of the index finger, primarily the adductor

pollicis and opponens pollicis. This grip is dysfunctional in patients with median nerve lesions (Fig. 1.2.4-5C). Grip with Terminal Opposition of the Thumb and Index This grip between the tips of the fingers allows for grasping of very small objects (for example, a pin). Lateral Opposition Grip With this type of grip, the pad of the thumb contacts the thumb edge of the fingers (known as a pincer grip). With this grip, it is possible to generate great strength, particularly with the help of the interossei and the adductor pollicis (Fig. 1.2.4-5D). Interphalangeal Grip An interphalangeal grip (known as a cigarette grip) is used for holding small objects (for example, a cigarette) and requires intact interossei.

ASSESSMENT OF THE WRIST AND THE HAND Anamnesis A hypothetical diagnosis can be established based on a well conducted patient history. One piece of the anamnestic data is finger stiffness. It needs to be established whether the stiffness occurs in the morning in which a rheumatological illness can be considered. With stiffness that arises during and after loading, CNS involvement or an injury to the peripheral nervous system are considered. Also, we inquire about hand dexterity, how the patient masters fine motor tasks (buttoning buttons), or whether the patient drops objects from their hands. Carpal tunnel syndrome presents with typical tingling in the fingers. This occurs primarily at night, wakes the patient from sleep, and is eliminated after shaking the hand. During anamnesis, it is important to identify strain at work or during athletic activities and any past injuries to the wrist or hands.

Aspection Joint configuration is observed. Deformation and wrist widening are typical for post-traumatic changes (especially after fractures of the distal forearm) and degenerative involvement. Wrist and finger deformities are found in rheumatologic conditions. Joint edema and its characteristics need to be observed along with the color and quality of the skin. Edema, redness and joint deformities are typical for rheumatologic conditions. Palpation The wrist, palm, metacarpophalangeal and interphalangeal joints are gradually assessed by palpation. Sensitivity to palpation of each individual bone of the wrist is assessed. With wrist pain, the focus should be mainly on the navicular whose nonunion joint can be a source of problems. Further, the flexor retinacula (ligamentum carpi volare) are examined, specifically for edema, increased ligamentous tension, crepitus, etc. In the palm, muscle tone (trophicity) is observed. An isolated hypotrophy of the thenar muscles is typical for carpal tunnel syndrome. Interosseous muscle atrophy is typical for a peripheral lesion in the C8 myotome or a lesion in the ulnar nerve. The aponeurosis and flexor tendons of the fingers are assessed. Passive Movements Passive movements of the individual joints are assessed and any limitations in motion are observed. It is important to assess joint play of the fingers and wrist. In the wrist, we examine the springing between the radius and the ulna, the radiocarpal joint, in the proximal and distal row of carpal bones and in the individual carpal bones with each other. The carpometacarpal joint of the thumb, which is often marked by degenerative changes and is a frequent source of pain in the hand is assessed in detail. Further, the springing of the individual MCP joints

is assessed in the ventral-dorsal direction and the interphalangeal joints in the ventral-dorsal and lateral-lateral directions. Active Movements During active movements, it is necessary to assess grip and fine motor skills. With fine motor skills, we observe a demonstration of “the pinch and the circle”, which is the contact between the tips of the fingers and the thumb and the contact between the thumb and the tip of the middle finger. The strength and quality of the movements are observed. Functional Tests Finkelstein’s Test This test is used to assess inflammation of the abductor pollicis longus and the extensor pollicis brevis tendons (de Quervain). Their common tendon sheath runs within the first dorsal compartment of the wrist. Administration: Patient holds their hand in a fist, thumb inside the palm and clasped by the fingers. The examiner stabilizes the forearm and performs ulnar deviation of the wrist of the examined extremity. Positive test: Pain and crepitus in the region of the abductor pollicis longus and the extensor pollicis brevis tendons suggesting de Quervain syndrome (Fig. 1.2.4-6). Fig. 1.2.4-6 Finkelstein’s test

Bunnel-Littler test This test is used for differential diagnosis of a limitation in flexion in the proximal interphalangeal joints of the digits. The limitation in the range of motion into flexion in the proximal interphalangeal joint (PIP) with simultaneous extension in the MCP joints can be caused by increased tone in the hand muscles themselves (the interossei and lumbricals) or, secondarily, by a contracture of the PIP joint capsule. Administration: To determine the cause of restriction, the examiner first performs MCP joint flexion causing relaxation of the hand’s own muscles. Then, the examiner performs passive flexion of the PIP joint. Positive test: Free execution of this movement confirms that the

cause of the limited flexion was increased tone in the muscles of the hand itself. If the restriction is caused by a tight joint capsule, PIP flexion would still be limited independently of the position of the MCP joint (Fig. 1.2.4-7). Fig. 1.2.4-7 Bunnel-Littler test

Test of the Flexor Digitorum Superficialis Tendon Integrity It suggests a rupture in the flexor digitorum superficialis tendon. Administration: The examiner stabilizes the metatarsophalangeal joint of the examined finger in extension and instructs the patient to actively isolate flexion in the PIP joint followed by distal interphalangeal joint flexion. Positive test: The patient is not able to perform flexion of the PIP joint and thus, a deficit in the integrity of the flexor digitorum superficialis tendon is confirmed. The inability to actively flex the distal interphalangeal joint suggests a rupture of the flexor digitorum profundus.

1.2.5 Kinesiology of the Hip Joint Magdaléna Lepšíková, Pavel Kolář Human evolution is characterized by two changes. First, upper extremity adaptation for grasping and manipulation of objects and, second, lower extremity modification for bipedal locomotion, which is

linked to verticalization of the axial system. Both changes were reflected in the anatomical-biomechanical organization, which then became specific only to a human. In erect standing, a human does not exhibit, for example, a fully enclosed femoral head by the socket, which is formed by the acetabulum (Fig. 1.2.5-1). Maximum contact of joint surfaces, which is from a biomechanical perspective most advantageous for distribution of hip joint loading, occurs in a position that corresponds to quadruped alignment, with 90 degrees of hip flexion, slight external rotation and abduction (Fit. 1.2.5-2). Fig. 1.2.5-1 Intraarticular view into the hip joint from the top

Fit. 1.2.5-2 Hip joint centration with extension and flexion

The hip joint is a spherical and restricted joint. When compared to the shoulder joint, hip range of motion is smaller in all planes (Tab. 1.2.5-1). Decreased muscle strength consistent with a corresponding segment is listed in Tab. 1.2.1-3.

Tab. 1.2.5-1 Table of planes and movement axes for the hip and shoulder joints

Two fundamental axes are recognized in the lower extremity: anatomical and mechanical (see Fig. 2.4.6-4 In a Special Section of the textbook, Chapter 2 Treatment Rehabilitation in Orthopedics and Traumato​logy). The anatomical axis of the femur runs through the femoral diaphysis and is tilted approximately 6 degrees from the mechanical axis, which is formed by a line between the center of the femoral head and the intercondylar eminence. The angle between the mechanical axis and the axis of the diaphysis is dependent on the size of the collodiaphyseal angle (CDA) (see below). The mechanical axis is almost vertical (tilted approximately 3 degrees from the vertical) and becomes perpendicular to the ground when a person stands with feet slightly apart. When the organization of the proximal femoral end and hip socket

is observed spatially it can be described in relation to individual anatomical planes. In the frontal plane, the femoral neck and the femoral diaphysis form the collodiaphyseal angle which, in a physiological scenario, is approximately 150 degrees in a newborn. During ontogenetic development, varization occurs and it reaches approximately 125 degrees in an adult individual. If the CDD angle is greater than 140 degrees in an adult, it is known as coxa valga. If the angle is smaller than 115 degrees, it is called coxa vara (see Fig. 2.4.5-5 in a Special Section of the textbook, Chapter 2 Treatment Rehabilitation in Orthopedics and Traumatology). The formation of this angle is attributed primarily to muscles (hip adductors and external rotators) and gravity. In the transverse plane (from superior view), it can be seen that the femoral head and neck are tilted ventrally from the frontal, or bicondylar, plane. This alignment describes femoral anteversion (Fig. 1.2.5-3). In a newborn, this angle is approximately 30–40 degrees. In adulthood, it gradually decreases to 7–15 degrees. Anteversion or retroversion have a great influence on the range of hip rotation. In an adult, an increase in the anteversion angle above 35 degrees is known as coxa anteverta (or also as antetorta). With gait, the lower extremity alignment is in internal rotation with significantly limited hip external rotation. It is also difficult for the patient to sit “Indian” style but, on the other hand, can sit in “W” sitting (buttocks between the heels) without any problems. An anteversion angle below 5 degrees is known as coxa retroverta. This hip joint alignment leads to restricted internal rotation.

Fig. 1.2.5-3 Angle of torsion of the femur. A – physiologic femoral anteversion; B – increased femoral anteversion; C – femoral retroversion

The Wiberg angle or CE (center edge) angle provides the amount of coverage of the femoral head by the acetabular socket. The Wiberg angle is given by the vertical line leading through the center of the head of the femur and the line running through the center of the head of the femur and upper edge of the acetabulum. This angle should not be lower than 10 degrees in children between the ages of 1–4 and, in an adult, should reach about 20 degrees. If the angle is less than 15 degrees, it is a pathological condition known as joint decentration (Fig. 1.2.5-4). Fig. 1.2.5-4 Wiberg angle (CE) of the hip

Acetabular cartilage (AC) or Hilgenreiner’s angle is the angle of the tilt of the acetabular roof. It is formed by the line between the acetabular edges and the horizontal. This angle is approximately 35 degrees in a mature newborn and it decreases to 25 degrees during the first year of life and, at 15 years of age, it should be less than 15 degrees.

HIP JOINT ASSESSMENT

Anamnesis The patient is asked about their pain characteristics. Hip joint pain usually has a specific presentation. Most frequently, the pain radiates to the groin and shoots to the medial side of the thigh and into the knee. Less frequently, it presents in the gluteal region (mainly in gluteus medius). Resting pain is characteristic of synovitis, bursitis, and tumors. Pain during loading or activity suggests hip arthritis (coxarthrosis) or dysplasia. Hip joint problems can be elicited by metabolic, blood and rheumatic diseases. In connection to the hip joint, the patient is asked about alcohol abuse (often with femoral head necrosis), corticosteroid use, activity schedule, and injuries. Aspection Standing and gait are mainly assessed during aspection with hip muscle stabilization observed in the frontal plane. The gluteus medius and minimus muscles participate in this stabilization. In unilateral stance (Trendelenburg test), the above mentioned muscles can stabilize the pelvis in the frontal plane. In standing on one lower extremity, gluteus medius muscle weakness is demonstrated by pelvic drop on the side of the flexed lower extremity (positive Trendelenburg test) or by trunk side bending toward the side of the weightbearing lower extremity (Duchen​ne’s sign) (Fig. 1.2.5-5).

Fig. 1.2.5-5 A – physiological stabilization of the pelvis in unilateral stance; B – Trendelenburg sign: weakness of the hip abductors manifests itself by pelvic drop on the side of the flexed lower extremity; C – Duchenne’s sign: weakness of the hip stabilizers manifested by a compensatory side bend toward the side of the standing extremity

Bilateral weakness of the pelvic stabilizers is primarily seen during gait and is called a Trendelenburg gait, which involves waddling and is sometimes called a “duck walk”. Another pathological picture of gait is a quadrated (hip hiking) gait. This pathology is demonstrated by a shortening of the hip flexors when no hip extension occurs during gait. The extension phase of the step is substituted for by pelvic elevation on the involved side by activation of the quadratus lumborum. Also, pelvic tilt and rotation are observed along with any asymmetry

in the lower extremities. Palpation Palpation assesses pain at the femoral head, greater trochanter, soft tissues of the groin region and at the origin of hip adductors. Part of the examination includes palpation of the pelvo-femoral muscles. With a hip joint injury, increased tone in the hip adductors is typically present as well as hypotonia, hypotrophy and sometimes weakness of the gluteal muscles. Passive Movements During the assessment of hip range of motion, flexion with internal rotation and slight adduction are performed first. Patients with coxarthrosis report pain with this maneuver in the early phase of involvement. With medial arthrosis, pain and limitation in flexion and abduction are present. During examination, referred pain needs to be recognized. Most frequently, it is referred from the lumbar area (primarily with L4 nerve root irritation). A reverse Lasègue’s test distinguishes this from true hip joint involvement with great sensitivity. With hip joint extension and palpation, tendonitis and bursitis need to be distinguished. The differential diagnosis needs to also focus on inflammation and on bone and soft tissue tumors. Active Movements A characteristic sign of hip joint involvement includes the patient’s inability to lift their extended lower extremity against gravity (Stinchfield).

PEDIATRIC HIP JOINT ASSESSMENT During clinical assessment, the skin folds are noted. Their symmetry and asymmetry of the gluteal and thigh skin folds is compared. At 90 degrees of flexion, an asymmetry in leg length is assessed. Furthermore, muscle tone (it is increased in the adductors), range of motion limitations, presence of repositioning clicks and clunks are

noted. Torticollis and congenital foot deformations (for example, pes calcaneovalgus, metatarsus adductus or positional equinovarus) are linked to hip joint dysfunctions. In certain scenarios, more serious conditions are linked to hip joint involvement. Often, they are associated with the newborn’s position during delivery (i.e. breach). For more details, see Special Section of the textbook, Chapter 2 Treatment Rehabilitation in Orthopedics and Traumatology, 2.4.5. Hip Joint).

1.2.6 Kinesiology of the Knee Joint Pavel Kolář The knee joint (articulatio genus) is the largest and most complex joint in the human body. The articulating bones include the femur, tibia, and patella and their joint surfaces are covered by cartilage. The ball of the joint is formed by the femoral condyles. The contact surfaces on the lateral and medial femoral condyles are anteriorly connected by a groove in which the patella glides. Posteriorly, they are divided by a deep intercondylar fossa. Both condyles are curved in the frontal and sagittal planes. The curvature in the sagittal plane is greater in the back than in the front. The joint socket is formed by the upper end of the shin bone. The contact surface on the tibial medial condyle is oval and slightly concave and on the lateral condyle it is circular and flat. The patella is the third articulating bone. The incongruency between the sharply curved femoral condyles and almost flat tibial condyles is evened out by the menisci. The medial meniscus (meniscus medialis) is oval and more open. The lateral meniscus (meniscus lateralis) is smaller, more enclosed and with a nearly circular contour.

MOVEMENTS OF THE KNEE JOINT The normal alignment of the knee joint is considered to be at zero degrees of flexion. From this alignment, a small movement into extension, or hyperextension, can be achieved in the range of five

degrees. In individuals with greater joint laxity, hyperextension is greater but usually no more than 15 degrees. With a position of zero flexion, the side ligaments are taut and all ligamentous structures on the posterior side of the joint, femur, menisci and tibia are in firm contact. This position is known as a “locked knee”. The geometric ratio of the joint surfaces, joint ligaments and menisci automatically allow other basic knee movements in addition to flexion and extension. Currently, it is generally accepted that during a flexion to extension movement, the combination of initial rotation, flexion, and terminal rotation at the end of extension occurs. The movement from flexion to extension and back is quite complex and occurs as follows: 1. In full extension, as a result of tension in almost all ligaments rotational movement is almost impossible. Initial rotation, during which the tibia internally rotates, is therefore combined with flexion in the first 5 degrees of movement. The initial rotation relaxes the anterior cruciate ligament (ligamentum cruciatum anterius). This movement is known as “unlocking the knee”. The axis of rotation runs from the femoral head to the center of the lateral condyle so that the lateral condyle rotates and the medial condyle translates. With the foot fixed on the floor (closed kinetic chain), the femur externally rotates. With the foot unsupported on the floor (open kinetic chain), the lower leg turns together with the foot, or tip of the toe inward. The range of rotation increases with gradual flexion and this occurs primarily during the first 30 degrees of flexion. The range of rotation after that increases minimally. The greatest range of rotational movement occurs between 45–90 degrees of flexion. 2. Rolling motion of the femoral condyles on the tibial plateau allows flexion after the initial rotation and occurs in the meniscofemoral joints as the femur rolls on the surfaces formed by the tibia and the menisci. 3. Translatory movement of the condyles on the tibial plateau completes flexion. In the terminal phase of flexion (when due to

the increasing curvature of the posterior aspects of the femoral condyles, the surface area for their contact with the tibia is decreased), the menisci around the femur change their shape and move together with the condyles posteriorly on the tibia. The terminal phase of flexion is thus linked to “translatory” movement in the menisco-tibial joint. With extension, the entire process is reversed. Extension begins by translatory movement forward, continues by rolling motion of the femur on the condyles and ends with external tibial “terminal rotation” (thus, in the opposite direction than the initial rotation), which causes “re-locking” of the knee joint. The spectrum of movement in the knee joint is shown in Fig. 1.2-3 in Chapter 1.2 Kinesiology and the clinical Examination of the Knee System. During flexion, the movement of the knee is enabled by the cruciate ligaments, which prevent unwanted translatory movements. The range of motion for knee flexion is 120–150 degrees (Fig. 1.2.6-1). Given this range, active flexion can be performed maximally to 140 degrees when the muscle bulk of the thigh and calf press into each other and movement cannot actively continue. The remaining 10 degrees of flexion can be performed passively, for example, with squatting during which the weight of the body compresses the muscle mass. The tension in both cruciate ligaments and the function of the posterior horns of both menisci limit flexion only in individuals with poorly developed musculature. Fig. 1.2.6-1 Flexion and extension in the knee joint. A – Range of motion of flexion in the knee joint (120–150 degrees) and extension (5–10 degrees); B – the center of rotation is a point at which the axes of both collateral and cruciate ligaments intersect; C,D – the center of rotation is moving upward and backward with increasing flexion; E – the course of immediate

centers of rotation with movement into flexion

Hyperextension is limited primarily by ligamentous tension, including the dorsal portion of the joint capsule, the anterior cruciate ligament, the posteromedial aspect of the posterior cruciate ligament, the firm contact of the femoral condyles with the anterior horns of the menisci, and the tone in the knee flexors (biceps femoris, semimembranosus, gastrocnemius). The patella glides distally with flexion and proximally with extension. In the knee joint, independent rotations – internal and external – are possible only with simultaneous flexion when the joint is “unlocked”. The rotations occur mainly in the menisco-tibial articulation with simultaneous translation of the menisci (Fig. 1.2.6-2). The range of translation is greater in the lateral meniscus. Therefore, with forceful movements into rotation (i.e., sport injuries), the less mobile medial

meniscus is always more prone to injury. The medial meniscus is involved in 95% of injuries. The actual rotation process is dependent primarily on organization of the ligamentous apparatus and its relation to bony structures. The range of rotational movement is not greatly influenced by the shape of the articulating surfaces. The only exception is the intercondylar prominence of the tibia, which partially determines the center of rotation. During rotational movement, the course of both cruciate ligaments poses an important moment. While the posterior cruciate ligament runs almost vertical, the angle of the anterior cruciate ligament is much greater. This is one of the conditions that allows for a greater freedom of the lateral rather than the medial condyle during rotation. Tibial external rotation range is determined primarily by tension in the collateral ligament. After its intersection, the range of external rotation doubles. A somewhat different situation occurs during internal rotation of the tibia. Here, beside the lateral capsular stabilizers, an important role is played by the anterior cruciate ligament, which is considered by majority of authors the primary stabilizer of tibial internal rotation. The stabilization function of the anterior cruciate ligament is determined by its oblique course in the frontal plane. Because of this, the origin of the ligament on the femur is significantly farther away from the center of rotation. In such fashion, the ligament acts on the lateral condyle as “reins”, which guide and, simultaneously, stabilize the condyle during internal tibial rotation. This limitation is also enforced by the lateral collateral ligament, iliotibial tract, posterior-lateral portion of the capsule, and the lateral meniscus.

Fig. 1.2.6-2 Rotation movements of the tibia in relation to the femur at 90 degrees of knee flexion. A – neutral position (zero tibial rotation); B – external rotation of the tibia (30–40 degrees); C – internal rotation of the tibia (10 degrees). The range of internal rotation is significantly lower than for external rotation, the reason being the mutual rotation of the knee cruciate ligaments during tibial internal rotation.

The range of individual rotations: Internal rotation: 10 degrees External rotation: 30–40 degrees, based on the degree of knee flexion. Knee joint resting position is 20–30 degrees of flexion. Palpable structures of the knee joint include the patella, patellar tendon (ligamentum patellae), synovial plica, (plicae alares). On the medial side, the level of the joint space is palpable (the upper border of the tibial condyle) on the lateral side, the lateral collateral ligament is palpable.

KNEE JOINT ASSESSMENT

Anamnesis Pain in the knee joint is the basic sign signaling an injury. Knee pain is also frequently referred from other movement segments and, therefore, cannot be omitted during the examination. It happens quite often, that knee pain signals a hip joint dysfunction (Legg-CalvèPerthes, coxalgias, hip joint arthritis) or it originates in the spine (typical for L4 radiculopathy). Insertional pain in the pes anserine can be the first signal of kidney involvement. During anamnesis, questions about loading ability of the involved extremity and the character of pain are very important. For example, increased pain when descending stairs is indicative of patello-femoral dysfunction. Pain early in the movement is characteristic for osteoarthritis. Resting and night pain suggest inflammation or bone metastases. Morning stiffness, which can be gradually improved by movement, usually accompanies rheumatoid arthritis. In acute injuries, we ask about the mechanism of injury, rate of edema formation and appearance of the knee joint following the injury, capability of knee joint loading shortly after the injury, and the character of the drained liquid. In a post-injury state, the patient is asked about the length of immobilization, post-injury rehabilitation, current complaints – immobility (restriction), and instability. Aspection With aspection the focus is on the following: 1. Axial alignment of the knee joint and the entire lower extremity. Knee alignment and movement are dependent on the alignment of the lumbosacral junction (horizontalization of the sacral bone leads to an internally rotated alignment of the femur), the torsional alignment of the femoral neck and, finally, the alignment and shape of the foot. Knee deviation known as genu varum with lateral deviation and genu valgum with medial deviation can be observed (Fig. 1.2.6-3). Posterior deviation of the knee joint is known as genu recurvatum;

2. Hypertrophied Hoff’s fat pad. This is a typical sign of intraarticular damage and synovitis; 3. Joint fullness, which can be observed by a decrease in normal joint contour, specifically the disappearance of the joint concavity on either side of or cephalic to the patella; 4. Swelling of one of the bursae. Frequently, the bursa is swollen in the posterior space known as a Baker’s cyst; 5. Surface of the tibial tubercle; 6. Configuration of the quadriceps and the resting tension in the ischiocrural muscles. The vastus medialis is very sensitive to knee deficits given its hypotonic and hypertrophic reaction. Fig. 1.2.6-3 A – genu varum; B – genu valgum

Palpation Palpation is used to determine joint edema or joint content. With greater joint filling, so called patellar ballottement presents. Ballottement of the patella is examined in supine by pressure on the suprapatellar pouch. When fluid gets pushed out between the patella and the femoral groove, the patella will “float” on the extruded fluid (Fig. 1.2.6-4). Fig. 1.2.6-4 The examination of the patellar ballottement

Patellar mobility and grinding with patellar movement are examined. The borders of the joint surfaces and patellar facets are palpated and patellar alignment in the femoral groove (i.e. high patellar position, patellar rotation) is evaluated. Palpation can also assess pain in the joint space, and identify the borders of the articulating surfaces and collateral ligaments. Pain with medial joint space palpation suggests meniscal injury, lesion of the collateral ligament, or pes anserine enthesopathy. Sensitivity at the lateral joint space suggests involvement of the lateral meniscus, joint cartilage, collateral ligament, fibula or the insertions of biceps femoris or tensor fascia latae. Insertional pain is assessed at the base of the patella, patellar apex, patellar ligament and tibial tuberosity. Muscle bulk and tone are assessed. Hypertonicity of the medial ischiocrural muscles can be a sign of an ACL involvement. Passive Movements During passive movement assessment, range of motion of knee flexion

and extension and patellar movement in the femoral groove are observed. With movement restriction, the end feel is assessed and determined to be rigid or springy. Restriction in knee extension with springing and pain present during an effort to complete the movement can suggest meniscal involvement (joint blockage). Active Movements Active movements are assessed during open and closed kinematic chains. The quality of the quadriceps femoris (vastus medialis) contraction is noted as well as the hip external rotators and tensor fascia latae. Functional Assessment Examination of the Menisci McMurray’s Test When assessing the right knee, the right hand grasps the heel of the examined extremity and the left hand is placed on the involved knee. The joint is brought into flexion and tibial external rotation with simultaneous slight pressure into abduction. From this position, tibial internal rotation is performed and the examiner applies pressure into adduction without changing the flexion angle of the knee. The same maneuver is performed several times with a gradually decreased angle of knee flexion up to 90 degrees. Positive signs include pain and popping palpable at the joint space (Fig. 1.2.6-5).

Fig. 1.2.6-5 McMurray’s test

Payr’s Sign The patient sits cross-legged. The examiner exerts pressure into hip abduction. Pain in the medial aspect of the joint space suggests involvement of the medial meniscus (Fig. 1.2.6-6). Fig. 1.2.6-6 Payr’s sign

Apley’s test Apley’s test is used to distinguish meniscal involvement from the involvement of the ligaments. The patient is prone, the hip in extension and the knee in full flexion. During the examination, tibial rotation with axial distraction is performed and subsequently followed by tibial rotation during compression along the lower leg axis. The test is repeated in various angles up to 90 degrees. Pain with traction suggests ligamentous involvement, whereas pain with compression suggests that meniscal involvement is more likely (Fig. 1.2.6-7). Fig. 1.2.6-7 Apley’s test with compression (A) and distraction (B) of the lower leg

Steinmann’s Sign I The patient sits at the edge of the table and both hands grasp the patient’s foot (by the forefoot and the heel). At a 90 degree angle, a maximum tibial external and internal rotation is performed. If the patient reports pain at the inner aspect of the joint space, the test is positive for medial meniscal involvement. If at maximum tibial internal rotation pain at the lateral aspect of the joint space is elicited, then the lateral meniscus is likely involved (Fig. 1.2.6-8). Fig. 1.2.6-8 Steinmann sign I

Steinmann’s Sign II If pain with palpation is elicited at the base of the medial meniscus at the anterior aspect of the knee joint space with flexion, then full extension is performed. If the painful area shifts forward, then a meniscal lesion is suspected. Walking in a Squatted Position If the meniscus is injured, primarily the medial meniscus, a patient is unable to walk in a squatted position. Another test used for meniscal assessment is performed in supine with the knee and hip flexed. Another therapist stabilizes the patient’s thigh while the examiner grasps the relaxed lower extremity by the forefoot and the heel and performs tibial rotation while applying traction force to the lower leg. Tibial rotation is performed while gradually increasing knee flexion. With a meniscal lesion, the restriction in rotation is obvious and possibly painful. This is a very sensitive test and its only disadvantage is the need for another person’s assistance. Assessment of Knee Joint Stability During the assessment of knee joint stability, the significant variability in the freedom of the ligamentous apparatus needs to be taken into consideration. Therefore, bilateral comparison of the findings and the overall condition of the soft tissues are necessary. Abduction Test (Valgus Stress Test) The patient is supine with the therapist standing on the side of the involved knee. The examiner’s hand grasps the extremity from the outside at the level of the supracondylar region while the other hand holds the lower leg. The examiner abducts the lower leg with adequate force and the patient fully relaxed. The examiner should not “wrestle” with the patient’s strength. The same maneuver is performed with the knee flexed to 30 degrees. In this position, the stabilization function of the ACL is most limited, and therefore, it is easier to assess the involvement of the collateral ligaments. Painful gapping at the medial joint space usually indicates medial collateral ligament (MCL) injury.

Adduction Test (Varus Stress Test) The examiner’s hand grasps the heel of the patient’s extended lower extremity and brings it to 30 degrees of hip flexion. The other hand is placed on the inner side of the knee’s supracondylar region and is used as a pivot point (center of rotation of a joint). Next, the examiner pulls the heel into adduction. The same maneuver is again performed in 30 degrees of knee flexion. If the lateral joint space gaps, it indicates an injury to the lateral collateral ligament (LCL). Lachman’s Test The patient is examined in supine and the patient’s extremity is grasped above and below the knee. During examination, the knee is in 15 degrees of flexion. The examiner then attempts to shift the proximal tibia ventrally against the femoral condyles. With an anterior cruciate ligament (ACL) injury, a drawer phenomenon is elicited, which, at the point of maximal shift, a soft, smooth resistance is felt. The test is once again performed using force that allows the patient to stay relaxed. The Lachman’s test is the most reliable and most appropriate for an acute injury (Fig. 1.2.6-9). Fig. 1.2.6-9 Lachman’s test

Anterior Drawer Test This test assesses anterior shift of the tibia against the femur at 90 degrees of knee flexion and neutral tibial rotation. The examiner gently sits on the patient’s toes and places both hands on the proximal end of the tibia, which is then pulled ventrally. Increased anterior shift of the tibia against the femur suggests anterior cruciate ligament injury. With an acute injury, this test will have a false negative because of defensive muscle spasms (Fig. 1.2.6-10). Fig. 1.2.6-10 Anterior drawer test

Posterior Drawer Test The posterior drawer test is used to assess the posterior cruciate ligament. A posterior shift of the proximal tibial end against the femur in 90 degrees of knee flexion and external tibial rotation are examined. In the case of a posterior cruciate ligament injury, a slight shift of the proximal end of the tibia occurs relative to the femur, especially when compared to the contralateral side. A posterior cruciate ligament deficit can also present itself in the supine position with a 90-degree triflexion (Godfrey test). The examiner holds the patient’s legs by the heel above the mat. The surface level of the proximal end of bilateral tibias against the femur is compared. With a posterior cruciate ligament rupture, the tibia “falls” dorsally and a step-like shift of the tibia is observed. Pivot Shift Test The patient is supine. One hand holds the patient’s heel while simultaneous knee extension and tibial internal rotation and abduction are performed. The test is positive if an anterior subluxation of the lateral end of the tibia against the femur is elicited. Patellofemoral Joint Examination Assessment of the patellofemoral articulation includes examination of patellar stability in the femoral groove and the quality of the patellar and femoral cartilage is noted.

Stability of the patellofemoral joint is determined by the shape and alignment of the patella, patellar retinacula, and the muscles (vastus medialis is the main dynamic stabilizer). Patellar Stability Test – Apprehension Test The patient holds the therapist’s hand during patellar palpation. The test is positive with congenital or recurrent patellar dislocation. The tests designed to assess cartilage quality are based on cartilage compression, which provokes pain in a pathologically altered cartilage. Planer Sign The patella is pressed against the patellofemoral groove and alternately shifted cephalically and caudally. Zohlen Test The examined knee is flexed and the examiner presses their finger into the apex of the patella while the patient performs active knee extension. Fairbank’s Test (Zohler’s Sign) The therapist stabilizes the base of the patella and asks the patient to contract their quadriceps femoris.

1.2.7 Kinesiology of the Lower Leg and the Foot Pavel Kolář, Ivan Vařeka The foot, as an anatomical term, includes those segments of the lower extremity located distally to the ankle joint. When the foot is divided by two lines corresponding to Chopart and Lisfranc joints, the foot is formed by three segments (Fig. 1.2.7-1): Fig. 1.2.7-1 Functional classification of the foot

1. Hindfoot (posterior tarsals) – formed by two large tarsal bones (talus and calcaneus) (Fig. 1.2.7-2); 2. Midfoot (front tarsals) – formed by five small tarsal bones (cuboid, navicular, cuneiforms) (see Fig. 1.2.7-2); 3. Forefoot (metatarsals and toes) – formed by the bones of the instep and the phalanges of the toes. Fig. 1.2.7-2 The bones of the hindfoot and the midfoot. 1 – navicular; 2 – cuboid; 3 – talus; 4 – calcaneus; 5 – cuneiforms

With simple classification, the Chopart joint divides the hindfoot (posterior tarsals) from the forefoot (frontal tarsals, metatarsals, and

toes). The majority of movement between the hind and forefoot takes place at the Chopart joint. In addition to the above mentioned proximal-distal division of the foot into two, or three, compartments, from a functional perspective, a division into two parallel rays is also significant. The medial ray is formed by the talus, navicular, cuneiforms, 1st–3rd metatarsals, and 1st– 3rd digits. The lateral ray is formed by the calcaneus, cuboid, 4th and 5th metatarsals and corresponding phalanges. While in the proximal segment (hindfoot), the talus rests above the calcaneus as a remnant of the original shape of the foot resting on the side of the little toe. In the distal portion of the foot, phylogenetically determined obligatory torsion is manifested and both rays align next to one another in the forefoot region. This is also the reason why the bones of the hindfoot (talus and calcaneus) move differently during loading and why range of motion in the Chopart joint is controlled by the subtalar joint.

ANKLE AND FOOT JOINTS Talocrural Joint (Upper Ankle Joint) The talocrural joint (ankle joint, articulatio talocruralis) is a combined joint. It is formed by the distal end of the tibia and fibula (joint socket) with the talus (the ball). Given the fact that the articulation between the tibia and fibula forms a morphological fork sitting on the head of the talus, the ankle joint is usually characterized as a uniaxial hinge joint with one degree of freedom. The trochlea of the talus is wider anteriorly. Therefore, the malleoli are pushed away from one another with foot dorsiflexion. The joint capsule is anteriorly and posteriorly weak, but enforced by collateral ligaments on both sides. The medial ligament or the medial collateral ligament is also called the deltoid ligament (ligamentum deltoideum). This ligament consists of three parts (tibiocalcaneal, tibiotalar and tibionavicular) and it is a strong joint stabilizer. The lateral collateral ligament (ligamentum collateral laterale) also consists of three parts (calcaneofibular ligament, anterior and posterior talofibular ligaments). However, overall, it is a weaker ligament than the medial

collateral ligament, which clinically predisposes the lateral malleolus to injuries (subluxation, dislocation) during inversion. The movement axis of the talocrural joint passes through the fibular and tibial malleoli, hence it runs from the inferior postero-lateral to superior antero-medial. Its projection into the transverse plane forms a 20–30 degree angle with the frontal plane and approximately an 85 degree angle with the axis of the foot. Its projection into the frontal plane forms an angle of approximately 80 degrees (medially open) with the longitudinal tibial axis and with the frontal plane, an angle of approximately 8 degrees. However, significant differences in angle degrees are reported by individual authors (Fig. 1.2.7-3). The standard alignment of the joint is attained during normal balanced stance and its mid-position corresponds with it. Movements in this joint include plantar flexion (approximately 40–50 degrees) and dorsiflexion (approximately 20–35 degrees). Fig. 1.2.7-3 The talocrural joint axis projection into the frontal and transverse plane

Lower Ankle Joint This is an articulation between the talus and other bones that allows an oblique sloping of the foot structure in relation to the talus set in a fork-like formation of the talocrural joint. The subtalar joint is divided into two compartments. The posterior compartment is the subtalar joint (articulatio talocalcanea seu subtalaris). It is an independent joint between the posterior surfaces of mutual articulation between the talus and calcaneus. The anterior compartment is further divided into a medial segment (talocalcaneonavicular articulation) connecting

the two anterior joint surfaces under the head of the talus with the calcaneus and the spherical portion of the head of the talus with the navicular bone. This complex is laterally attached to an articulation between the calcaneus and the cuboid (articulatio calcaneocuboidea). Subtalar Joint The subtalar joint (articulatio subtalaris) consists of the following joint surfaces: head of the calcaneus (facies articularis talaris posterior), and the socket on the talus (facies articularis calcanearis posterior). This is a cylindrical joint with its own joint capsule. The axis runs obliquely from the posterior lateral side medially and anteriorly and simultaneously from the lower posterior aspect anteriorly and superiorly. This axis determines the motions of the entire lower ankle joint. Given the axial orientation, the subtalar joint results primarily in foot rotation in the frontal plane, inversion and eversion (or rather supination and pronation) and partially also adduction and abduction in the transverse plane due to the fact that the movement axis also forms a certain angle with it (Fig. 1.2.7-4, 1.2.75). Fig. 1.2.7-4 Foot eversion (A) and inversion (B)

Fig. 1.2.7-5 The range of motion in the subtalar joint. A – eversion 10 degrees; B – neutral (zero) position; C – inversion to 20 degrees

All ankle joints, of course, contribute significantly to these movements. Transverse Tarsal Joint The transverse tarsal joint (Chopart joint, midtarsal joint, articulatio tarsi transversa) is the articulation between the talus and navicular and the calcaneus with the cuboid. It includes almost the entire anterior compartment of the lower hindfoot joint with the exception of the talocalcaneal portion at the medial aspect. Although the Chopart joint is anatomically formed by two joints (calcaneocuboid and talonavicular), from a kinesiology perspective, it is considered a functional unit that closely cooperates with other foot joints (Fig. 1.2.7-6). The movements in this joint are described as rotations around two axes (common to both its parts): longitudinal and oblique. The course of the longitudinal axis allows movements primarily in the frontal plane – supination and pronation, or inversion and eversion. This allows the forefoot and midfoot to maintain contact with the floor without taking into consideration the alignment of the hindfoot with subtalar joint movements. The oblique axis of the Chopart joint, in comparison to the longitudinal axis, is oriented steeper and more obliquely. Its course is similar to the talocrural joint axis and its large deviation from the transverse and sagittal planes (in the sagittal plane approximately 52 degrees from the transverse plane and in the transverse plane 57 degrees from the sagit​tal plane) allows significant movements specifically in such plane. Therefore, dorsiflexion with

simultaneous abduction or plantar flexion with simultaneous adduction (Fig. 1.2.7-7). The range and course of such movements is always accompanied and influenced by co-movements in the talocrural joint.

Fig. 1.2.7-6 Functional movement dependency of the Chopart joint on the subtalar joint alignment. A – supination; B – neutral position; C – pronation

Fig. 1.2.7-7 Caption: Range of motion in the Chopart and Lisfranc joints – pronation and supination (movement is tested while the subtalar joint is stabilized). A – range of forefoot pronation – 20 degrees; B – range of forefoot supination – 40 degrees

MOVEMENTS IN THE ANKLE AND FOOT JOINTS Movements in the Lower Ankle Joint These are combined movements based on the mutual relationship between individual joint components. The fact that the talus and

calcaneus are articulating in two areas (posteriorly at the subtalar cylindrical joint and anteriorly at an almost spherical talocalcaneonavicular joint) allows for a single oblique axis for the combined movements of these two bones and thus all the tarsals and entire foot. The axis of these movements begins on the external aspect of the posterior border of the calcaneus obliquely and moves forward and medially into the neck of the talus and above the navicular. It is angled from inferior-posterior to superior-anterior. The movement of the tarsals occurs in unison and includes the following: Foot inversion, which is accompanied by plantarflexion with adduction and supination; Foot eversion, which is accompanied by dorsiflexion with abduction and foot pronation; Small movements at the Chopart joint line, which are significant for flexibility of the foot as a whole. The standard alignment of the subtalar joint is achieved in standing. Mid position corresponds to the standard position. Complex Movements of the Upper (Talocrural) and the Lower Ankle Joints The result of movement in the subtalar joint is primarily rotation of the foot around the longitudinal axis, that is supination and pronation. Conversely, the talocrural joint allows for a full range of motion in the sagittal plane (dorsal and plantarflexion), which is linked to abduction and adduction given the oblique course of the axis. In such a manner, both joints complement one another in their functions so that they form a complex posterior portion of the foot allowing movement in three planes. Their function is closely linked to the Chopart joint function. In such context, I.A. Kapandji presents the model of a universal heterokinetic common joint of the foot which is formed by the talocrural, subtalar and Chopart joints. Movement in this joint occurs along two parallel axes – the axis of

the upper (talocrural) joint and the axis of the lower subtalar joint – Henke’s axis. With a range of motion restriction in one joint, a compensatory increase in the range of motion in the other joint occurs (Fig. 1.2.7-8). With increased external rotation of the foot, such as when walking with the toes pointing outward, range of motion in the subtalar joint is increased while it is decreased in the talocrural joint. Walking with the toes pointed inward presents the opposite situation. Fig. 1.2.7-8 Dorsal and plantarflexion in a closed (A) and open (B) kinematic chain and their influence on movement restrictions of the foot

FUNCTIONAL RELATIONSHIPS BETWEEN THE ANKLE AND THE FOOT JOINTS Foot Arches The foot skeleton is arched longitudinally and transversely. The talus in the area of the navicular fibrocartilage is the highest point on the volar side of the foot skeleton. The architecture of the spongious bone reflects the course of girders in a dome and forms arches from the distal end of the tibia via the talus back into the calcaneus and forward all the way to the metatarsal heads. The foot arches protect the soft tissue of the foot and allow for foot flexibility. Longitudinal Arch The longitudinal foot arch is higher on the tibial side and lower on the fibular side. Its structure is supported by the following:

Ligaments oriented longitudinally along the plantar side of the foot, of which the long plantar ligament is the most significant. However, the ligaments themselves would not be able to support the foot arch; Muscles that help support the foot arch span longitudinally along the sole of the foot (tibialis posterior, flexor digitorum longus, flexor hallucis longus and superficial short plantar muscles), superficial plantar aponeurosis and a tendinous band under the foot with the help of which the tibialis anterior pulls up on the tibial side of the foot. The longitudinal bony structure of the foot arch is found at birth. However, in infants, it is filled with fatty tissue leading to the impression of a flat foot. In infants, the heel is positioned in slight varus together with forefoot supination and accompanied by bilateral genu varum. Transverse Arch The transverse arch of the foot is most prominent at the level of the cuneiform and cuboid bones. It adapts according to the position of the two main rays of the foot present in the tarsal segment at various heights from the floor. The transverse arch is maintained by the transverse system of ligaments on the plantar side and a tendinous band with which they intercept the anterior tibialis and peroneus longus. The Contact Surface of the Foot The contact surface of the foot depends on the shape of the longitudinal and transverse arches of the foot. The foot contacts the mat continuously only at the lateral aspect. At rest, the body weight transfers posteriorly from the calcaneal tubercle anteriorly to the heads of the first (up to 1/3rd of loading) and second metatarsals. Loading of the metatarsal heads gradually decreases toward the lateral aspect of the foot. Muscle weakness and ligamentous laxity (stretch) in the structures supporting the foot arch lead to a drop of the medial aspect of the foot resulting in the widening of the contact surface of the foot and a

change in ligamentous and muscle tone. Therefore, a low arch is accompanied by problems and pain in the foot and muscles that support the arch during walking and standing which allows a flat foot or pes planus to develop. Dropping of the medial malleolus toward the floor and accompanied calcaneal deviation so that the heel axis runs sideways (instead of standing vertically) are characteristic of flat feet.

ASSESSMENT OF THE ANKLE AND THE FOOT During clinical assessment of the foot, both sides are examined and the findings are compared. In standing, mainly foot alignment is assessed and any deformities are noted. Foot assessment is not only important from an orthopedic aspect, but also because certain neurological diseases, such as Friedreich’s disease, Charcot-MarieTooth disease, diabetic polyneuropathy and other can first be diagnosed during foot examination. During foot examination, it is necessary to take into consideration foot mobility and physiological variations in individual age groups. In children, the foot is much more flexible with large ranges of passive motion when compared to adults. In congenital defects, positional faults need to be distinguished from structural ones. Repeated asses​sments in specific time periods can show the effectiveness of conservative therapy and utilized foot orthotics. Anamnesis Pain with loading (standing, walking) is typical for static deformities of the forefoot and for insertional pain developed by overloading. Pain at rest is the most common sign of overall illness. That is the reason why a subjective patient history is important during pathological ankle and foot conditions. These include primarily diabetes, peripheral vascular disease of the lower extremities or neurological illnesses (polyneuropathy). Aspection

An important part of observation, as in other joints of the lower extremities, is an examination in standing and walking. In standing, the alignment of the calcaneus (valgus, varus) and the foot are observed. Force distribution over the foot is observed, specifically whether or not loading is greater on the heel or the outer or inner aspect of the foot. It is observed whether the toes make contact with the floor and if the patient is able to use their toes for support – Vele’s test (Fig. 1.2.79, Fig. 1.2.7-10). Also, flatness of the feet and toe alignment, primarily with respect to the big toe, are assessed. Fig. 1.2.7-10 Caption: Detail of the reaction of the toes during Vele’s test. The reaction on the right side is a physiological reaction of toe flexion when the center of gravity shifts forward. On the left foot, a visible weakness or an absence of this reaction is seen.

Fig. 1.2.7-9 Leaning – Vele’s test

During gait assessment, we observe the tendency of the foot toward external or internal rotation, as well as which part of the foot undergoes more stress during loading response. Ambulation with foot in internal rotation is most frequently caused by increased internal tibial torsion or by increased anteversion of the femoral neck. External rotation of the hip manifests itself by the foot external rotation. Moreover, walking on the toes, heel, outer and inner aspect of the foot are assessed. This allows for a gross assessment of strength and mobility of the talocrural and subtalar joints. The contribution to stability by the big toe and individual toes is observed. Their significance lies not only in the biomechanics but also in proprioception. Palpation The muscles and tendons in close proximity to the ankle and the foot are examined with palpation. With pain in the heel region, the short plantar muscles and tibialis posterior are palpated for increased tone. Also, the Achilles tendon and the surrounding soft tissues are assessed. With metatarsalgias, the decrease in the transverse arch is assessed,

as well as whether the arch can be passively corrected or whether the correction is painful. Further, the metatarsal heads are palpated. Pain with palpation, as well as whether the pain projects to the bottom of the foot is assessed. Also important is the assessment of the foot is sensory function including irritability, graphesthesia and perception of joint position. The bottom of the foot is carefully stroked by a sharper object. An increased reaction accompanied by jerking or a completely absent response (known as a “dead foot”) are considered non-physiological responses. Graphesthesia is assessed by asking the patient to recognize a number or a letter written on the bottom of the foot by a sharp object. A slow, smooth movement of the joints is performed with the patient’s eyes closed. The patient is expected to recognize the direction of the passive movement performed. An individual with skin hypersensitivity walks as if they were walking on hot lava stones and their foot contact is increased on the front part of the foot. In patients with hyposensitivity, balance function of the foot is insufficient and it is transferred to the more proximal movement segments. To balance, the patient recruits muscles of the pelvic girdle and lower lumbar spine. This is associated with increased tone in the quadriceps femoris and ischiocrural muscles during standing and walking. Patients with deficits in sensory function are more prone to foot injuries. Passive Movements Passive range of motion is assessed in individual joints and in the foot as a unit. Ankle dorsiflexion is assessed while supine with the knee in both extended and flexed positions with the gastrocnemius muscle relaxed. In mid-position, the plane of the bottom of the foot forms a right angle with the shin. Physiological range of motion is 40–50 degrees for plantarflexion and 20–30 degrees for dorsiflexion. Slight tibial rotation occurs simultaneously with plantarflexion and, in contrast, internal rotation of the tibia occurs with dorsiflexion. This occurs because the transverse axes of the talocrural joint along which plantarflexion and dorsiflexion occur are not identical due to the different curvature of the outer and inner edge of the trochlea of the

talus in dorsiflexion and plantarflexion. During the examination, it is important to stabilize the subtalar and the Chopart joints and hold the foot in inversion. Only under such condition does a false impression of dorsiflexion not occur. Examination of the movement of the foot along the longitudinal axis occurs in the subtalar and the Chopart joints where the foot is either turning into supination or pronation. Foot mobility along the longitudinal axis is 20–30 degrees of pronation and 30–40 degrees of supination. Forefoot abduction and adduction, or forefoot medial and lateral deviation, occur in the Chopart joint along the vertical axis running through the midfoot. The physiological values are 10 degrees for abduction and 20 degrees for adduction. Furthermore, mobility of the calcaneus in relation to the talus is assessed by moving the calcaneus into valgus or varus. During examination, the tibiotalar joint is stabilized in a neutral position (not in slight dorsiflexion). The physiological value of passive inversion can reach 10–15 degrees and 5– 7 degrees for eversion. For these reasons, the foot possesses greater compensatory abilities when it deviates toward valgus. Active Movements Active movements include foot dorsiflexion and plantarflexion, inversion accompanied by plantarflexion, adduction and supination, and eversion accompanied by dorsiflexion with abduction and pronation. Active inversion should reach 35 degrees and eversion 20 degrees. Also, circumduction is assessed. We are interested in range of motion, muscle strength and movement coordination. Coordination is given by the ability to execute the movement selectively, or with minimal activity in other segments. With a coordination deficit, the patient, for example, is unable to perform an isolated movement of the foot without activity in the thigh muscles. Functional Assessment Tests for Ankle Instability Anterior Drawer Test The anterior drawer test assesses structural integrity of the anterior

talofibular ligament (ligamentum fibulotalare anterius), anterior portion of the joint capsule and the calcaneofibular ligament (ligamentum fibulocalcaneare). Administration: The patient is seated with their knee flexed over the edge of the table. The examiner’s palm stabilizes the distal third of the lower leg from the anterior side while the other hand grasps the heel. The foot is in 20 degrees of plantarflexion. The examiner exerts pressure on the calcaneus and attempts to shift the talus anteriorly from the tibiofibular fork. Positive test: The talus moves more than 3 mm, which is often accompanied by popping (cavitation). Talar Tilt Test This test determines the involvement of the calcaneo​fibular ligament with movement into inversion and the deltoid ligament (ligamentum deltoideum) with movement into eversion. Administration: The patient sits at the edge of the table or is supine. The examiner’s one hand fixes the distal third of the lower leg. The other hand grasps the heel and performs inversion and eversion in the subtalar joint. Positive test: Excessive movement into inversion or eversion. Thompson’s Test This test is performed when an Achilles tendon rupture is suspected. Administration: The patient is prone with their foot over the edge of the table. The examiner performs manual compression of the gastrocnemius muscle and observes plantarflexion of the foot. Positive test: The absence of plantarflexion. Important and additionally helpful tests include neurological, electromyographic and plantographic examinations.

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1.3 SOFT TISSUES Petr Bitnar In rehabilitation terminology, the skin, subcutaneous tissues and fasciae are known as soft tissues or, more accurately, epithelial soft tissues. In rehabilitation, musculature is not included in this category. Today, the importance of these structures and their association with locomotor function is an already generally accepted fact. The mobility and flexibility of these structures significantly influence the course and “programming” of movement. Just as the joints and muscles must correctly move during a movement, the skin, subcutaneous tissues, and the fasciae also have to move. Any limitation in their mobility, reflexively or mechanically, alters their overall mobility. The skin, subcutaneous tissue and the fasciae contain contractile structures (the skin contains a spatial network of smooth muscle cells and erector muscles of hair; fasciae contain myofibroblasts) that are sensitive to all disturbances related to a nociceptive component. Based on the extent of nociception (or the extent of pain) their tone and mobility change. The skin and fasciae fall under the autonomous nervous system control, and therefore, are sensitive to changes in the internal environment and mental state (for example, increased perspiration during stress, changes in blood perfusion, piloerection during hypothermia). With deficits in muscles, bones or internal organs, the sensory afferentation and stimuli from the skin and fasciae are altered. This is seen in the rule of the dermatomes, in which the pain is usually transferred between structures developed from the same embryonic foundation and thus innervated by the same spinal segments. Hyperalgic zones that were originally mapped by H. Head (Head’s zones) develop. Soft tissues may not react only by developing hyperalgesia; decreased perception and decreased or increased sensitivity may be present, therefore, it may be more appropriate to use the terms hypersensitive and hyposensitive zones. The skin and subcutaneous tissues as well as the fasciae react to the deficits by

changing their function, most often in a specific location based on segmental nerve innervation. The knowledge of Head’s zones (dermatomes) makes differential diagnosis easier. Similarly to the skin, the subcutaneous tissues and the fasciae react to the change in function of the musculoskeletal or visceral components. The primary deficits in these superficial structures change the function of other organs, for example, when you see muscle tone changes associated with skin defects, fascial tears and active scars (see below). As significant afferent sources (exteroceptive and proprioceptive), they even change the control of movement at the central level. The skin, subcutaneous tissues, and fasciae significantly influence movement planning and also serve as the trigger structures of central spinal and supraspinal reflexes (defensive triflexion, Galant’s reaction etc). The skin and fasciae take part in movement control because their afferentation is constantly being processed by the sensorimotor cortex and certain subcortical areas (for example, the cerebellum, the limbic system). Based on quality and the projected information, the motor programs are constantly being modified. Skin afferentation is also processed in the association cortices of the parietal lobe and, in this way, it directly participates in many gnostic functions. The most familiar representative being stereognosis and its superior function – the body scheme. Therefore, the skin, subcutaneous tissues and fasciae are important structures influencing the development and course of movement. Thus, not only is their mobility but also their sensibility is important. Their mobility can be altered by contractile structures (for example, network of smooth muscle, myofibroblasts), collagen retraction or hyperlaxity, edema, fatty infiltration, etc. The sensitivity of these structures changes based on the deficits of the peripheral nervous system and its receptors or based on the disrupted regulation and processing by the central nervous system. Every soft tissue disturbance leads to a change in movement which is most frequently a limitation seen as a change in the quality and the quantity.

1.3.1 Skin Anatomy The skin is the most superficial human organ. It forms an absolute barrier between the inner environment and the surroundings. It possesses many vital functions. The most important include: Body defense against mechanical, chemical and microbial noxious agents Sensory (exteroceptive) function Thermoregulatory function Excretive function (there are many glands in the skin that are utilized, for example, during biosignaling of the aromatic gland) Plays a role in breathing (minimal contribution in mammals) Immune function (Langerhans’ cells) Biochemical functions (for example, production of vitamin D) The skin is an organ consisting of two layers with a different embryonic foundation, but functionally and structurally interconnected enough to form one organ. The superficial layer formed by the multilayered squamous epithelium is called the epidermis and its embryonic foundation is formed by ectodermal cells. The second, deeper layer is the dermis (corium), which is formed by a layer of fibroelastic collagenous tissue developed primarily from the embryonic mesoderm. Many squamous derivatives develop from the cells of the epidermis, among them, for example, beard, hairs, hair, eyelashes, eyebrows, sinus tactile hairs (a special type of phylogenetically old hairs that are quite long, strong and individually growing with a rich nervous network found in specific areas – eyebrows, face, ulnar side of the distal end of the forearm), and nails. The skin also houses a vast amount of glands (sebaceous, sweat). In addition, the dermis contains contractile cells. These cells belong to a group of smooth muscle cells and form two basic structures: the erector muscles of hair (mm. arrectores pilorum) and a network of smooth muscle laid out parallel with the surface. These contractile structures are responsible for skin tone and its mobility (shifting,

stretching). There are two types of nerve supply to the skin. One comprised of sensory myelinated and non-myelinated fibers from specialized skin receptors and free nerve endings. The second type is fibers from the autonomic sympathetic system. Skin arteries and veins form the superficial and deep vascular networks. Both networks are interlinked by a number of anastomoses. Neurophysiology The skin is a sensory organ and thus contains a number of receptors from which the touch is the most functionally significant. In principle, there are two types of skin receptors: specific, structurally complex receptors registering primarily pulling, pressure, vibration and temperature changes (Vater-Pacini corpuscles – pressure, Meissner’s corpuscles – touch, Ruffini corpuscles – warmth, Krause corpuscles – cold) and free nerve endings mediating nociceptive sensation. Skin afferentation projects to all levels of the central nervous system – spinal, supraspinal brain stem, subcortical and cortical. In the spinal cord, the afferent stimuli are either transferred by the interneuronal network, directly connected to the neurons of the effectors, or are projected to higher levels of the CNS. The skin afferent signals travel to higher CNS levels by a system of sensory pathways, through the lemniscal (proprioception) as well as the anteriolateral systems (nociception – spinothalamic tract and spinoreticular tract, spinoparabrachial tract) for further processing. At the supraspinal level, the skin stimuli enter a diverse, number of nerve structures. They are processed mainly in the cerebellum, the somatosensory cortex in the gyrus postcentralis, parietal cortex and the limbic system. Given this connection (between the skin and the CNS structures), the information from the skin receptors significantly contributes to the formation and modification of motor programs. The quality of skin afferentation, to a certain extent, depends on the realization and quality of movement and, based on skin stimulation,

the movement can be elicited, facilitated or inhibited. Muscle tone is especially dependent on the quality and quantity of skin afferentation. Changes in skin tension and skin afferentation are related to changes in muscle tone. Motor programs and the resulting movement are constantly modified based on information from the external environment. The motor cortex revises and modifies its activity based on the exteroceptive afferentation and the afferentation from the teleceptors. Nociception modifies movement as early as at the spinal level and, subsequently, at the supraspinal level. At the spinal level, based on acute nociceptive afferentation, defensive reflexes are elicited (see below). If a nociceptive stimulus is consciously perceived, the individual perceives it as pain. Based on prolonged and chronic pain, the movements are modified to become more complex and a change in the movement behavior occurs (for example, antalgic body positioning, limping). Exteroceptive Reflexes Exteroceptive reflexes are elicited by stimulation of pain and tactile skin receptors. They are usually polysynaptic and polysynaptic plurisegmental. Simple reflexes (with a small number of participating neurons and interneurons) include, for example, abdominal reflexes used in neurological diagnostics to establish the level of a spinal cord lesion or CNS disturbance (these reflexes are no longer present in CNS palsies). Exteroceptive reflexes to which more neurons and interneurons contribute are based on their response and are divided into extensor and flexor reflexes. Extensor reflexes are elicited by non-nociceptive stimulation of skin receptors (primarily on the bottom of the foot). Since the tone in the extensors increases, they directly participate in static postural reactions. Flexor reflexes are elicited by nociceptive stimulation of skin receptors (primarily free nerve endings). Through activation of the flexor group, they act to distance the stimulated area from any biologically harmful stimulus. Sometimes they can have a

relatively complex course and include participation from various muscle groups. Defensive triflexion is the most familiar flexion reflex. In this reflex, following lower extremity stimulation, defensive flexion in the hip, knee and ankle are seen. In contrast, the other, nonstimulated extremity exhibits extension in all supporting joints; thus, coordination of defensive and postural reactions occurs. Beside the above mentioned exteroceptive reflexes, which can be physiologically elicited throughout a lifetime, more complex reflexive responses to skin stimuli exist, which are likely organized at the supraspinal level and elicited only under specific conditions (for example, immature CNS or a deficit in cortical control). These reflexes are more complex and more centrally organized. They present as reflexive movement reactions rather than simple reflexes. These exteroceptivelly elicited movement reactions include primarily reactions elicited at an early age, such as the grasp reflex or Galant’s reflex, or the so called primitive reflexes. These reactions also appear following insults to the CNS (for example irritable pyramidal processes). Therefore, skin (exteroceptive) afferentation has a great influence on motor control. Some neurophysiological studies consistently agree that, through exteroceptive skin stimulation, it is possible to elicit a change in muscle tone underneath the stimulated skin. According to these studies, it is easier to elicit a reflex-based response in flexor muscle groups than in the extensor groups. Based on exteroceptive afferentation, facilitation of a specific spinal segment and the CNS (especially the sensorimotor cortex) occurs. This also has an influence on movement planning as well as on the selection and correction of motor programs and, subsequently, an overall movement expression is formed. Beside muscle facilitation, mechano-exteroceptive stimulation can also modulate pain based on the principle of a well-known gate theory, the endorphine theory, and by distracted attention. An illustrative example of exteroceptive afferentation and its influence on movement control is an experiment performed with fish.

If the fish is blind and its equilibrium system (labyrinth) is removed, it swims in the position it is put in the water, for example, on its side. At the moment its skin surface touches the side of the aquarium, it immediately assumes correct position. The experiment implies that skin afferentation participates in the formation of body schema and its deficits are today considered to be one of the reasons for movement deficits and body posture deviations. Pathological Processes The skin is a very sensitive organ. Its reaction to changes in the internal environment is as sensitive as its reaction to external stimuli. Nociceptive afferentation even in distant regions elicits reflexive changes in the skin. The following includes clinically significant reflexive changes of the skin system: Mobility Blood perfusion Sensitivity Pseudomotor changes Skin drag Color (based on the changes in blood circulation or, in chronic conditions, changes in pigmentation) These reflexive changes can develop not only secondarily to skin deficits themselves, but also based on the nociceptive stimulation of other organ systems, primarily the musculoskeletal system and internal organs. In the integumentary system, reflexive changes first develop across segments, meaning that they develop in the area of a specific spinal (innervated) segment into which nociceptive afferentation is funneled. Later, based on the changes in the CNS control system, they have a tendency to form chains and spread according to the movement and skin systems throughout the entire body. The chaining is not random. Based on clinical findings, it follows certain principles and rules called the chain of functional deficits. Many authors and physical therapy schools still do not agree on the description of the chains of functional deficits. The disputed question remains the neurophysiologic foundation for this chain

formation. Today, we lean toward a theory based on ontogenetic principles and the concept of muscle cooperation during stabilization and kinetic functions. Along with a deficit and the change in tone of the chained muscles, the deficits in the skin and muscle fasciae also begin to form chains. Internal organ disorders reflect reflexive changes in the skin in a slightly different way. Most often, they manifest themselves by forming a visceral pattern with a specific surface manifestation and organization of these reflexive changes (for more detail see Chapter 2 Visceromotor Relations and the Autonomic Nervous System). Just as the movement system deficits can change the function of the integumentary system, integumentary system deficits can change the muscle function, and skin deficits can elicit an onset of reflexive changes in the movement system. A typical example is the formation of an active scar or deficits in skin sensitivity (allodynia, hyperesthesia, etc.), which may result in chronic movement difficulties (for example, vertebroalgia, pain in the lower abdomen, range of motion limitations). Examination Skin examination belongs among the basic clinical assessments. Skin, which during nociceptive stimulation presents with a number of reflexive changes, is really a “mirror” of internal disturbances. The more significant the nociceptive stimulation (the more “the illness hurts”), then the greater the reflexive change in the skin system and the subcutaneous tissue will manifest itself. Skin examination helps with a differential diagnosis because, for example, in illnesses of the internal organs, skin changes form according to Head’s zones and, thus, are localized according to segmental innervation. Based on this, it can be determined which organ is involved and causes pain (“funnels nociception”). This also applies to assessment of the musculoskeletal system. Changes in sensitivity, or in skin trophicity, allow for detection of illnesses of the nervous or neuromuscular systems and can assist in the determination

of their severity and progression. Changes in Mobility Changes in Stretch Changes in the skin stretch are caused mainly by a contraction of the smooth muscle of the skin (arrectores pili and network of smooth musculature). This contraction is controlled by the sympathetic nervous system based on the nociceptive afferentation in the correspondingly innervated segment. Other changes in skin tension, and therefore its stretching, are caused by tissue edema and by collagen fibers retracting during chronic progression of the disease (see Chapter 1.3.2 Subcutaneous Tissues). The changes in skin stretch are one of the first reflexive changes in the skin. Changes in Shifting Changes in skin shifting are manifested by a change in skin mobility in relation to the subcutaneous tissue, fascia or periosteum (or even perichondrium). This is a combination of a deficit in skin stretch itself and changes at the level of the subcutaneous tissue, which form the main layer that provides skin mobility in relation to other undersurface structures. Both above mentioned changes are the primary signs of disease in various structures and are well accessible with a palpatory examination. Palpation mainly focuses on the assessment of limitations in the skin folding and mobility in relation to underlying structures. Skin mobility is assessed by individual palpating fingers or by the surface of the entire hand based on the size of the area being examined. Skin folds are most frequently C or S shaped. The therapist waits for the first minimal resistance. When it is reached, the skin is sprung and the response is observed. If the skin does not spring once the resistance has been felt, then it is rigid and taut and is a functional pathology, or there is a reflexive skin change, ultimately a loss of mobility. If only a mild pressure is used during assessment, then the palpation can be done with a slightly greater force (the pressure is exerted into more depth) to assess changes in skin shifting. The assessment of skin rolling – the so called Kibler fold, is used to assess

changes in skin mobility (often done together with the assessment of soft tissue edema). Its ability or inability to form and its thickness are observed. In the area of reflexive changes, the skin fold is more difficult to form and it is thickened, immobile, or painful. Changes in Blood Perfusion Changes in blood perfusion are typical primary signs of the skin’s functional deficits. They can be manifested by increased vasoconstriction or vasodilation. In an area of an altered perfusion, skin temperature changes based on the vascular reaction. Dermographic assessment is a common test to examine changes in vascular reactibility, in which, after skin irritation by a sharper object (but also by a nail or a tip of a finger), the area shows erythema. The changes in skin perfusion can also be manifested by an increased amount of interstitial liquid transuded by blood plasma. Changes in Sensation Changes in sensation are the accompanying signs of many pathological processes. They may be present with functional deficits, diseases of the peripheral or CNS systems, systemic diseases (i.e. diabetes), etc. During clinical examination, patient cooperation is necessary and the patient is asked how they perceive the touch of our finger or touch associated with certain neurological assessment tools (for example, filaments, brush, needle). We find out whether the patient manifests hypesthesia or hyperesthesia in a given region or whether they perceive our touch as painful, unpleasant, ticklish, etc. In functional deficits, two- or more point discriminatory touch is assessed. The assessment is performed with the help of a sharp pin and it is related not only to the onset of the deficits but also to the maturation of the CNS during ontogenetic development in which the perceived two-point distance decreases. During neurologic assessment, sensation in individual dermatomes may be observed on the skin. This neurological assessment clarifies involvement of the individual spinal segments. The assessment helps determine, for example, the level of a spinal lesion, peripheral involvement of a corresponding nerve, or a visceral illness.

Hyperalgic skin zones are primarily zones with increased pain. They develop in many functional disturbances of the movement system and visceral illnesses. Their extent suggests the magnitude of the disturbance and the number of spinal segments into which the nociception streams. Within a hyperalgic skin zone, pseudomotor, vasomotor and skin mobility changes also occur. Thus, a hyperalgic skin zone is a complex reflexive change. Sudomotor Changes Sudomotor changes are a reaction of the autonomic (vegetative) system. They are manifested mainly by increased perspiration in the area of reflexive chan​ges. In the area of increased perspiration, increased skin drag (friction) is palpated, or changes in skin resistance are found. Palpation to verify changes in perspiration is best performed by a very gentle and quick touch of a finger pad or the dorsum of the hand. Changes in perspiration are very often found in hyperalgic skin zones. Examination of an Active Scar This examination should be part of the foundations of clinical diagnostics of movement system functional deficits. An active scar often causes a deficit in the movement system. An active scar develops usually as a result of poor tissue healing (post-secondary healing scars, hypertrophic and keloid scars). The rate of tissue healing depends on the individual’s skin type. An active scar manifests itself primarily by an increased sensitivity or even pain when touched or stretched. It also shows signs of decreased soft tissue mobility. Within an active scar, a pathological barrier phenomenon is always found and it is rigid and non-springy. In some cases, the scar can be “as taut as a string”. In the area of an active scar, a change in blood perfusion is almost always present – the area is often warmer, redder, and shows greater perspiration than the surrounding tissue. In most cases, decreased soft tissue mobility is present in all layers in this region, that is between the skin and the fascia, the fascia and the muscle, or even the muscle and the bone (decreased mobility of the so called deep fasciae between the muscle and the periosteum). The more the individual layers are

“stuck” together, the more the scar limits mobility. The restriction in mobility of an active scar manifests itself more in reflexive activity than in biomechanical restrictions. The examination to determine whether the scar is active should be part of the manual assessment foundation because it is frequently the cause of the pain. Sometimes, the skin in the scar area is freely mobile and non-painful but the “actively” scarred tissue is found in the deeper layers. An active scar can also only pertain to superficial layers, such as the dermis or epidermis. Treatment The skin, a highly sensitive organ given its large afferentation, serves as one of the main “informants” of the CNS. Its afferentation influences movement control at the spinal level and at the supraspinal level, including the cortical level. Stimulation of skin receptors can elicit simple reflex responses or complex reactions, changes in muscle tone or motor programs, and therefore the entire movement expression. Correct skin afferentation is essential for the function of the neuromuscular system and all skin system disturbances are also manifested by a change and deficit in this (neuromuscular) system. Neuromuscular system disturbances are reciprocally manifested by a change in the function of the skin system and by an onset of reflexive changes (for example, decreased mobility, decreased blood circulation, hyperalgic skin zones). These reflexive changes complete the “pathological circle”. Skin system therapy (for example, of the soft tissue) needs to be utilized in the treatment of the movement system. Skin afferentation, as a therapeutic approach, is utilized by many authors and therapeutic schools. It is the foundation for facilitative techniques. The most frequently used manual maneuvers include stroking with various rhythms and intensity, sweeping, brushing, icing. Skin stimulation and increasing its afferentation can also be accomplished with the help of electric stimulation, vacuum, and acupuncture. By changing skin afferentation, the α-motor neurons in the spinal cord and the central motor neurons in the cortex are stimulated. The response is movement or a change in movement

control. Skin receptor stimulation is utilized primarily in neurological rehabilitation. In classical musculoskeletal medicine, soft tissues are influenced primarily with the purpose of renewing their mobility and changing, reflexively and mechanically, the movement options – muscle tone and joint range. Influencing mobility of the skin and other soft tissues follows the fundamental principle of manual therapy, which is restoration of mobility in the manipulated tissue at the pathological barrier. That is why the tissue is sprung after reaching pre-stretch, and if no spring can be elicited, then the therapist waits in this pathological barrier and further uses pressure or gentle springing to achieve a subsequent phenomenon of tissue give, during which the pathological barrier “dissolves” and the movement is, to a greater extent, renewed.

1.3.2 Subcutaneous Tissues (Hypodermis) The subcutaneous tissue – tela subcutanea (hypodermis) – is a layer dividing the dermis from the muscle fasciae, periosteum or perichondria. It is formed primarily by a thin and unorganized collagenous connective tissue, underlying adipose tissue and a network of blood capillaries. The subcutaneous connective tissue provides a sliding surface for the skin. To a certain extent, skin shifting and mobility is dependent on proper function of the hypodermis. Connective tissue is formed by collagen fibers consisting of fibrous tropocollagen molecules in between which there are gaps allowing for their mutual movement and which contributes to springing of the collagen fibers springing. With pathological processes such as inflammation, injury, immobilization, and hypokinesis, these intermolecular spaces decrease, leading to a shortening of the entire collagen fiber called retraction. In the involved tissue, a change in the ratio of the collagen and elastin occurs to the advantage of the collagen fibers and, thus, the biomechanical parameters of the hypodermis change.

Thus, subcutaneous tissue mobility restrictions are caused by connective tissue retraction (not by contraction of the contractile structures). This is a reason why a deficit in the subcutaneous tissue suggests a chronic character of the deficit. Edema is another cause for changes in subcutaneous tissue mobility. Examination and Therapy Subcutaneous tissue examination and therapy are usually performed together during skin assessment and no specific techniques or maneuvers are used. Most frequently, it is treated by tissue stretch followed by the phenomenon of tissue give (“release”). Treatment effects on the subcutaneous tissue are slower, and thus we have to engage it for a longer period of time. The subcutaneous tissue contains primarily connective tissue components; therefore, it is advantageous to utilize positive thermal procedures (heat) during its treatment. In the case of edema, lymphatic drainage can be used (gentle pressure and movements carried out toward the heart). Prior to treatment of the involved area, the entire extent of the affected area of the lymphatic system needs to be treated.

1.3.3 Fasciae Fasciae are connective tissue structures that cover individual muscles and their bellies and separate them from each other. They decrease friction between the muscles and allow for their sliding. The fibers of the fascia are oriented according to the muscle fibers and in the direction of their pull. Fasciae are thickened (at the aponeurosis) in areas of increased muscle pull. The organization of the fasciae helps transfer the force generated by a muscle to more distant areas, structures, and, sometimes, it directly participates in force transfer between the muscle-bone, or muscle-joint, system. In other locations, the fasciae form bands which anchor the muscle in place. The bands bridging a bony groove are called retinacula. Together with the bone groove they form tunnels as a passageway for neuro-vascular bundles or other tendons (carpal tunnel being the most recognized). By holding the muscle in place, the fasciae secure its

correct position. Fasciae also form an intermuscular or osteofascial septa that enclose the osteofascial space in which neuro-vascular bundles and plexi are found. Thus, the fasciae become an important addition to the skeletal system. Fasciae are an important source of fibroblasts, which participate in muscle regeneration after an injury (however, only by forming a connective tissue scar, not a contractile tissue). Besides the connective tissue component, contractile cells including myofibroblasts, are also part of the fascial microstructure. Found at the border of the connective tissue cell and the smooth musculature, they are thus able to produce a contraction. An interest in research of myofibroblast function has been growing over the past several years. They appear to be significant components of the fasciae with the ability to change the tone and pull of the fascia and, to a certain extent, act as a stabilizer of the bone-joint apparatus. The strength of their contraction is demonstrated by their pathology, i.e. Dupuytren’s contracture. With this pathological contraction and the subsequent connective tissue changes result in an uncontrolled finger flexion. This disease progresses over a long period of time and it tends to be very serious with no curative treatment to date. Myofibroblasts and their pathology can limit mobility and function of the entire hand. Pathological Processes Fasciae are structures that directly adhere to the muscle and are crucial for its correct function. With their pathology, muscle function is significantly limited. Fasciae are, thanks to the myofibroblasts, able to generate pulling and pushing forces, but also show a tendency toward shortening. Besides a pathological contraction of the myofibroblasts, the shortening of the fascia can occur due to a “classic” retraction of the connective tissue and by an increased thickening of the fascia. Myofibroblasts are innervated by fibers from the autonomic nervous system. Therefore, their contraction can be elicited by increased nociceptive afferentation, with the sympathetics

playing an important role in its mechanism of origin (for example, during stimulation of nociceptors). Fascial retraction can occur, for example, after a trauma, infection, inadequate loading, repetitive microtrauma, or long-term immobilization. Correct fascial mobility and springing are one of the requirements for unrestricted, physiological movement. Fasciae, similarly to other soft tissue structures, can reflexively limit motion if they show restricted mobility themselves. However, they can also restrict movement through their direct mechanical activity (with their shortening). Compartment Syndrome One of the most serious consequences of fascial retraction is an increase in intramuscular pressure that can lead to blood supply insufficiency called compartment syndrome. It is caused by a posttraumatic intramuscular edema, which is treated by surgical fasciotomy. If untreated, the patient is at risk for serious ischemic contracture of the involved muscle. Advanced compartment syndrome occurs post-traumatically, although to a lesser extent. The signs can be seen following excessive loading of a muscle with a stiff fascial band. In a working muscle, the circulation increases multiple times and together with blood volume, the amount of intra- and extracellular fluid increases, hence the total volume of the muscle increases. A muscle that increases in its volume requires adequate springing of its musculoskeletal bed, including the fasciae. If the fascia is retracted and the muscle volume does not “recede”, a disproportional increase in the intramuscular pressure occurs, which proportionally decreases the arteriovenous gradient and the muscle ceases to receive nutrients. The result is intramuscular hypoxia and destruction of the muscle fibers. An example of a non-traumatic compartment syndrome can be tibialis anterior compartment syndrome, which has a strong fascia and the bottom of the muscle bed is formed by a strong interosseous membrane. Therefore, each retraction of the connective tissue of this bed significantly shortens the fasciae and the muscle has a smaller space to expand its volume during activity. Anterior tibialis compartment syndrome occurs after repetitive loading (for example,

unusually long marching, running, etc.). It is manifested by strong muscle pain and decreased muscle strength to the point there is no active foot and toe dorsiflexion. Conservative therapy includes rest, elevation of the involved extremity, icing, and nonsteroidal antiinflammatories (NSAIDs). During subsequent treatment, the tone of the fascia needs to be corrected which is accomplished by its soft tissue release and stretching. Surgical intervention involves fasciotomy. Treatment Treatment of the fasciae primarily involves the restoration of mobility and stretching of the retracted components. The same rules follow as in therapy for other parts of the movement system. After the barrier is reached, retracted portions of the fascia are stretched and the “release” phenomenon is maximally utilized. There are a multitude of maneuvers established by many therapeutic schools for engaging various parts of the fasciae, but the majority of them recommend reaching a barrier and subsequently stretching the retracted fascia. The contractile structures of the fascia formed by myofibroblasts react to therapy faster and more sensitively than individual collagen fibers. That is the reason why, in many cases, fascial therapy is surprisingly fast and effective. If it is necessary to influence the connective component of the fascia whose retraction suggests a longer persisting problem, it is suitable, prior to the stretching itself, to use the benefits of heat. Heat, as a thermal procedure, releases tropocollagen molecules (the intermolecular spaces increase) resulting in fascial softening and increased pliability during therapy. The superficial (between the hypodermis and the muscle) and deep (between the muscle and the bone) fasciae can be treated. Both types of fascia play a significant role in movement and muscle function (Fig. 1.3.3-1; Fig. 1.3.3-2).

Fig. 1.3.3-1 Restoration of mobility of the back fasciae. Stretch (shift) of the fasciae in caudal (A) and cranial (B) directions. Fig. 1.3.3-2 Self-therapy and restoration of mobility of the trunk fasciae

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Heinz G, Zavala DC. Slipping Rib Syndrome. JAMA 1977; 237: 794–795. Janda V. Ke vztahům mezi strukturálními a funkčními změnami pohybového systému. Praha: ČLS JEP 1999; 6(1): 6–8. Kibler M. Das Störungsfeld bei Gelenkerkrankungen und inneren Krankheiten. Stuttgart: Hippokrates 1958. Leek JC, Gershwin ME, Fowler WM. Principles of Physical Medicine and Rehabilitation in the Musculoskeletal Diseases. Orlando: Grune and Stratton 1986. Lewit K, Liebenson C. Palpation – Problems and Implication. J Manipulative Phys Ther 1993; 16: 586–590. Lewit K. Rehabilitace u bolestivých poruch pohybové soustavy. Rehabil a Fyz Lek 2001; 8(1): 4–17. Mennell JB. The Science and Art of Joint Manipulation. London: Churchill 1945. Paoletti S. Faszien. München: Urban und Fischer Verlag 2001. Sachse J, Schildt-Rudloff K. Wirbelsäule. Manuelle Untersuchung und Mobilisationsbehandlung der Wirbelsäule. 3. Aufl. Berlin/Wiesbaden: Ullstein Mosby 1997. Simons DG. Triggerpunkt und Myogelose. Man Med 1997; 35: 290–294. Wall PD, Melzack R. Textbook of Pain. 3rd ed. Edinburgh: Churchill Livingstone 1994. Weh L, Torklus D. Das Gleitrippensyndrom. Man Med 1984; 22: 130–132.

2 VISCEROMOTOR RELATIONSHIPS AND THE AUTONOMIC NERVOUS SYSTEM Petr Bitnar, Hana Marčišová, Pavel Kolář

2.1 VISCEROSOMATIC AND SOMATOVISCERAL RELATIONSHIPS Petr Bitnar During differential diagnostics (identification of the pain source), the sources of complications originating in the internal organs cannot be forgotten because of the close relationship between them and the skeletal system. These relationships often play a significant role in the occurrence of functional deficits in the skeletal system or, conversely, the deficits in the skeletal system can cause the onset of functional deficits of an internal character. A reciprocal functional relationship exists between the internal organs and the skeletal system, in which one system influences the other as a result of a mutual neurohumoral integration and regulation. The functional relationships between the internal organs and the skeletal system can be divided into: Viscerosomatic relationships Somatovisceral relationships

2.1.1 Viscerosomatic (Visceromotor) Relationships Internal organ disease can manifest itself in the skeletal system as the development of specific reflexive changes – called a visceral pattern. This reflexively developed pattern (specific to each organ) can assist with differential diagnosis. If the reflexively developed changes persist long-term, they can either cause chronic overloading of the musculoskeletal system (which can lead to its damage) or result in an internal organ illness which is an illness originating in the movement apparatus (an imitation of the illness occurs). Visceral Pattern Internal illnesses are often linked to nociceptive afferentation. Nociceptive signals are a source of information for the CNS about the illness. If the nociceptive afferentation surpasses the inhibitory

mechanisms of the CNS, it will reach a level of consciousness and pain is perceived. Nociceptive afferentation is derived from a certain internal organ and is referred to a specific spinal segment in which the muscle system reacts by changing the tone (hypertonia) of those muscles or muscle groups that are supplied by this segmental innervation. Most of the visceral organs’ nerve supply comes from only a few spinal segments. That is the reason why a deficit in a certain organ manifests itself only in certain muscle groups connected to the same spinal segment. The most common example can be seen in heart pains, for example, with angina pectoris that projects to the left upper extremity. It is a given fact that the heart and upper extremity have the same segmental foundation during ontogenetic development and, thus, lie within the same innervation segments. Often, reflexive changes in the movement system are “distributed” with such specificity and regularity that we can speak of visceral patterns for specific organs. Reflexive changes developed during an internal illness are most obvious at the region of the corresponding spinal segment, but, at the same time, the entire body reacts to it. These internally formed reflexive changes have a tendency to become “chained”. For these reasons, we can observe a reflex reaction at distant areas. A deficit in an organ can be signaled by functional changes in the movement system even in remote locations and the patient complains of areas with increased sensitivity, which cannot be explained merely by the level of segmental control. Often, for example, we will find a painful area on the sole of the foot that signals an internal organ illness much earlier than problems linked to a deficit of the internal organ itself. Regardless, the most significant and “active” changes of the movement system are always found in the area of segmental innervation. A visceral pattern is a mixture of reflexive changes in the movement system which reacts to the internally formed nociceptive stimulation. Reflexive changes can manifest themselves in many ways, however, most frequently formation of deficits in joint patterns develop, as do trigger/tender points, changes in soft tissue mobility and hyperalgic

skin zones which in principle correspond to the dermatomes. The reactions are also strongly influenced by the vascular system (vasoconstriction, changes in dermographism) and the integumentary system (changes in the skin and dermal components). During internal organ illness, these reflexive changes are so specific and typical to certain locations that it can be established that every organ has its own visceral pattern. It cannot be neglected that reflexive changes in the movement apparatus have a tendency to become chained and thus, in a chronic state of illness, this pattern appears somewhat “blurred”. Knowledge of the pattern assists during differential diagnosis of musculoskeletal system deficits. At least basic knowledge of the visceral patterns allows for determination of the correct origin of lesions in the movement system. If the cause is visceral in nature, then other specialized examinations are recommended for the patient. The knowledge of visceral patterns helps with the correct diagnosis of an internal illness and, in some cases, their identification allows timely initiation of treatment (i.e., tumors). Persistence and recurrence are typical for reflexive changes in the movement system. In the movement system, reflexive changes based on internal organ nociception have a tendency to resist classic manual techniques and tend to reoccur in a short period of time i.e., become recurrent. Specifically, the unusually quick and frequent recurrence is typical for reflexive changes that are internal in nature. If standard rehabilitation treatment is not effective, attention needs to be directed to the internal organs, by checking the visceral pattern or by performing a new diligent anamnesis or a series of various tests (for example, stress tests or irritability tests). The frequency of recurrences and the extent of reflexive changes also point to the seriousness and course (progression vs. regression) of the internal organ illness. At the same time, it is necessary to consider the individuality of each patient, which is manifested by their individual reaction to nociceptive stimulation. People with a higher threshold for pain show less reflexive changes even with more serious involvement of an internal organ than people with a lower pain threshold.

In the movement system, reflexive changes can persist even after successful treatment for an internal illness and they may continue to cause pain. Through referred pain, they can imitate an internal organ disease while the healthy organ actually continues to hurt. Basically, the individual is “internally” healthy, but does not experience significant subjective relief. Certain chronic illnesses of internal organs (for example, chronic pancreatitis, ulcer colitis, hemorrhoids) cause permanent stimulation of the movement system and thus, contribute to the development of a functional and structural disorder. This leads to another, sometimes “unnecessary”, increase in nociception and, consequently, to an increase in the patient’s pain and subjective feeling of sickness. With chronic illnesses of the internal organs, it is also necessary to focus therapy on the movement apparatus. Given the chronic nature of an internal illness, the treatments with greatest success include: specific compensatory exercises, self-therapy for joint mobilization and muscle relaxation (self-mobilization, anti-gravity relaxation, stretching, balneotherapy, etc.). All treatment approaches applied in the home environment must be included in the patient’s personal routine and the patient should be instructed in their use and show understanding of their practical application.

2.1.2 Somatovisceral Relationships Movement System and Visceral Pain Individual internal organs possess the same segmental innervation as certain muscle groups because the nociceptive signals from internal organs converge on the same spinal neurons that are integrated into the pain processing system of the movement apparatus. The CNS “focuses” and evaluates the source of nociception in the area of the entire innervated segment and, hence, in all organ structures connected to this innervated segment. In certain cases, it may happen that the patient localizes the pain in the movement apparatus more into a visceral region. This is a classic phenomenon of referred pain. To resolve a disputable internal diagnosis, a thorough kinesiologic

analysis is necessary. With better knowledge of somatovisceral relations, a specific kinesiological assessment can uncover the correct source of the patient’s problems. Pain and an internal organ disease can be simulated by any structure of the movement system. Most frequent are findings in the spine accompanied by tonic changes (trigger points) in muscles. In this region, the vertebrocardiac syndrome is described in most detail. In this syndrome, restriction of primarily ribs 3–5 and TrPs in the pectoral muscle can imitate angina pectoris so “perfectly” that this syndrome includes even shortness of breath and palpitations. The clinical picture of the vertebrocardiac syndrome clearly includes a number of other reflexive changes that significantly contribute to its manifestation. Of course, other conditions are described as well, including kidney and urinary tract pains with functional deficits at the thoracolumbar junction, 12th rib and psoas muscle spasm; prostatodynia elicited by spasm in the levator ani; pain in the throat due to blockage of the hyoid bone or the atlanto-occipital articulation, etc. The gamut of somatovisceral imitations is colorful and, therefore, during differential diagnosis, a kinesiologic analysis needs to be included as well as an anamnesis focused on the movement system and the recurrence of reflexive changes (reflexive changes in the movement system respond better to manual treatment than if they are a result of nociceptive irritation of the internal organs). At the same time, it is necessary to determine the visceral pattern, with which a “mere” imitation is not usually as clear and does not contain all the right components. Movement System and Functional Deficits of the Internal Organs So far, the causes of functional deficits of the internal organs developed through the involvement of the movement apparatus are among the less studied, but from a clinical perspective, have well known causes. For example, dysfunction in the female reproductive organs based on muscle imbalances and functional joint deficits was

described mainly by L. Mojzisova. Disturbances in bile production due to blockages in the lower thoracic spine was described by L. Zbojan. The recurrence of tonsillitis with restrictions in atlantooccipital range of motion was described by K. Lewit and the vertebrocardiac syndrome by E. Rych​likova. Constipation and anorgasmy caused by pelvic floor spasms, blocked coccyx and so on have also been described. Newly described are the reciprocal relationships between the upper part of the digestive system (between the pharynx, esophagus and stomach) and the movement system. With respect to the region of the upper esophageal sphincter, a close relationship between the tone of the oral cavity floor, neck and upper chest wall is apparent. With spasms of the upper esophageal sphincter, swallowing is disabled and neck muscle spasms can be observed, primarily in the scalenes, supraand infrahyoid muscles, digastric muscles, and the short capital muscles positioned between the skull and the spine. By decreasing the tone in the cervical musculature (by traction or reciprocal inhibition), there is a quick reflexive response (decreased tone) in the musculature of the esophagus and pharynx, which immediately decreases the tone in the upper esophageal sphincter. Reflexive changes (hypertonus, TrPs, TPs, etc.) in the area of the lower chest wall and the middle ribs are of some importance because these changes can lead to reflexive changes in tone of the lower esophageal sphincter (esophageal reflux involves increased tone of the esophageal sphincter). Pressure changes in the esophageal sphincter and changes in esophageal motility are measured and well objectified by esophageal manometry. Changes in motility can be seen on fMRI and dynamic scintigraphy. In regards to optimal function of the digestive system and its relationship to the movement system, besides the reciprocal reflexive relationship, a significant role is also played by the diaphragm. Its role is even more dominant in proper function of the lower esophageal sphincter. The diaphragm encircles the esophagus in the area of gastroesophageal junction (at the point of esophageal hiatus) by grasping brackets (crus dextrum et sinistrum). Its activation and contraction contribute to maintenance of a pressure barrier between

the stomach and esophagus. Therefore, the diaphragm plays the role of an external esophageal sphincter (similarly, the pelvic floor has a sphincter-like function in the rectal and urinary tract regions). The relationship between the diaphragm and the esophagus reach the humoral region through neuronal and even biomechanical relationships. With disturbances in the diaphragm, disturbances in the esophagus (esophageal reflux disease) can be seen and, in contrast, with esophageal and stomach disturbances, the function of the diaphragm is always affected. Thus, the diaphragm fulfills three basic functions: respiratory, postural and gastrointestinal. This makes the diaphragm one of the most important and complex muscles in the human body. To date, the mutual relationship between the internal organs and the movement system has not been well studied. However, based on various observations, certain conclusions can be deducted. Nociception (and its processing at the spinal and supraspinal level), proprioception, and direct mechanical influence serve as the foundation of mutual influence. A smooth muscle (the same as striated) reacts to nociceptive afferentation by changing its muscle tone (hypertonus, hypotonus). To ensure proper function, the hollow visceral organs (for example stomach, intestine, or a bladder) and the excretory ducts of glands need optimal smooth muscle tone for proper peristalsis to occur. With deficits in tone of the smooth muscle, immotility of the gastrointestinal tract, female reproductive organs and urinary tracts occurs. Nociception also has an influence on the autonomic (vegetative) system. In an innervated segment “flooded” with nociception, reflex vasoconstriction, decreased function of the endocrine glands and other sensitization of nociceptors occur a majority of the time (for more detail, see below about the autonomic system). Vasoconstriction can have a great influence on decreased function of the internal organs including decreased nutrition, impaired defense-mechanism of the affected organ and an overall change in homeostasis (decreased body

temperature below the optimal level necessary for proper enzyme activity, mineral imbalance, pH changes, etc.). Changes in proprioceptive afferentation from an affected movement system alter motor control at the supraspinal level and, at the same time, they alter visceral motor control. Serious functional and structural changes of the musculoskeletal system can affect the morphology of the internal organs (typical examples include kyphoscoliotic heart disease and a change in lung function with deformities of the thorax) or the anatomical position of individual organs (for example, a prolapse of the bladder, uterine changes with pelvic floor dysfunctions or hiatal hernia with dysfunction of the diaphragm). Movement System as a Trigger Factor for a Latent Internal Illness An organ disease can be occurring covertly as long as the compensation mechanisms keep meeting its demands. This disease can manifest itself at the moment when functional pathology from the involved movement system is added, leading to exhaustion of the remaining compensatory mechanism and the organ stops compensating. That is how, for example, an injury to the thoracic spine can worsen angina pectoris or a cranial joint restriction can contribute to tonsillitis. Movement System as a Tool for the Treatment of Internal Illnesses Treatment of the movement system can contribute to the treatment of internal illnesses. This includes an overall decrease in nociception within a given innervated segment and a decrease in the extent of nociception travelling to all levels of central control mechanisms. In this way, the activity of the sympathetic nervous system is mainly affected which, in case of an illness, is generally increased. Changes in the patient’s psychological mood are linked to it as well. Also, the activity of the sympathetic system is linked to a change in smooth muscle tone (see above) which is in direct reflexive connection with the tone of the skeletal musculature. This change can be called “tone changes tone”

which indicates that a functional-synergistic relationship between the skeletal and smooth muscle tone exists, during which a deficit in one system “projects” into the function of the other system. This has a significant influence on visceral functions during therapeutic treatment. If the reflexive changes in the movement system that correspond to a visceral pattern are specifically affected, smooth muscle tone is also affected which directly influences motility of the smooth muscles. With an illness of the abdominal cavity organs, the breathing pattern changes to a “loading type”, or accessory breathing, in which the accessory muscles are participating more than the diaphragm. The diaphragm has an important influence on the thoracic and abdominal organs. For example, it changes the pressure in both body cavities (thoracic or abdominal) which, in general, leads to a change in the position of the organs or elicits their movement within the breathing rhythm (for example, during inspiration, the kidney descends caudally and returns to its original position with expiration). It acts similarly when intra-abdominal pressure is increased, such as during bearing down or with voiding. A well-functioning diaphragm helps with the optimization of muscle tone of the abdominal wall and the pelvic floor. The pelvic floor musculature affects organ function of the small pelvis (pelvis minor; it supports the uterine neck and has a sphincterlike activity). Movement of the organs elicited by movement of the diaphragm produces mobilization of their tendon insertions. Just like the tendons in the movement system, the tendons of the internal organs have a tendency to become shortened and, thus, their movement corrects the mobility of the internal organs and their resting position. Furthermore, the movement of the diaphragm contributes to the passage of the intestinal and stomach content (helps with gastrointestinal tract motility). To a certain extent, the pressure activity of the diaphragm helps with the gastrointestinal tract peristalsis and with excretion of digestive juices from the glands with external secretion. A correct breathing pattern, or correct function of the diaphragm, is very important and its restoration with nociceptive blockage for internal reasons is equally significant.

Musculoskeletal therapy is one of the beneficial methods of treatment of internal diseases – especially in cases involving functional deficits of gastrointestinal tract. Decreasing nociception, correcting muscle tone, decreasing vasoconstriction, changing the tone of the sympathetic nervous system and breathing activity can influence homeostasis, which is crucial for optimization of the physiological and self-repair mechanisms of an organism. Physical therapy, as a non-invasive approach, is a method of first choice and contributes to reducing the number of patients indicated for surgery. A current trend of using multidisciplinary teams strives to include physical therapy in the treatment of internal diseases and functional deficits.

2.1.3 Overview of Basic Visceral Patterns An illness of each organ projects into the movement system by reflexive changes with consistent localization and, thus, visceral patterns form. In this overview, typical signs of each pattern are presented because a perfect description of visceral patterns in regards to their basic reflexive changes and topical organization is too extensive and ambiguous. This is caused by a non-unity of assessment methods and by the individuality of each patient, primarily due to the varied response to nociception. Each pattern has its basic, almost unchangeable signs, and the knowledge of these basic units is sufficient for a differential diagnosis of movement system deficits or visceral organ disturbances. Besides the “depiction” of the visceral pattern, a recurrence after physical therapy or a non-effective rehabilitation treatment is significant enough to establish the sources contributing to the development of the reflexive changes. Reflexive changes in the movement apparatus, which return quickly and regularly should always be a warning sign even if they do not form an exact visceral pattern. Heart Reflexive changes manifesting themselves in the thoracic spine region at T3-5, primarily the T4-5 segment, where these reflexive changes

involve spinal blocks as well as rib restrictions. Trigger points are found in the pectoral muscles, primarily in the pectoralis minor and in the scapular adductors. Hyperalgic skin zones are found in segment T3 trough T8. Reflexive changes in cardiac involvement are localized on the left (in contrast to the vertebrocardiac syndrome, in which the changes are usually bilateral). The heart is such a significant organ that when its dysfunction is suspected, all necessary assessments must be performed. Complex examination at a specialized cardiology department is essential. Tonsils Infection of the tonsils is often linked to reflexive changes, which persist after the infection subsides and may be a source of referred pain imitating symptoms of the actual infectious illness. Reflexive changes are found especially in the upper cervical spine, craniocervical junction, the region of the mouth floor, and anterior neck musculature. The most frequent reflexive changes include restrictions at the atlanto-occipital articulation and the C2-3 segment. These vertebrae also present with painful periosteal points on the spinous and transverse processes. Furthermore, reflexive changes (mainly localized microspasms) in the suprahyoid musculature are present, specifically in the mylohyoideus and digastric muscles as well as in a range of motion restriction of the hyoid bone. In the dorsal musculature, increased tone in the deep cervical musculature is common. Movement of the thyroid cartilage can also be painful. Reflexive changes occur on the side of the involved tonsil (with unilateral lesions). Esophagus Reflexive changes with deficits in esophageal function reflect into many segments. With deficits in the upper portion of the esophagus, functional deficits starting at the C3 segment and below are found and with deficits in the abdominal portion of the esophagus, functional deficits in the thoracic portion from segment T1 to T5 are found. Also, deficits in the breathing pattern and restrictions in ribs 4-6 can occur.

Stomach and Duodenum Reflexive changes are found in the T4-8 region with the majority in the T4-6 region. The visceral pattern includes restrictions in the spinal segments as well as the ribs, usually ribs 5-7. The pattern also includes increased tone of the upper left quadrant of the abdomen and painful points at the insertion of the rectus abdominis to the seventh rib and the external obliques to ribs 7 and 8. Often, a periosteal point and a trigger point are found in the seventh intercostal space on the anterior side of the chest wall in the proximity of the costosternal articulation. A change in the breathing pattern to the accessory breathing is also one of the dominant characteristics. Small and Large Intestine The description of a visceral pattern for the intestines is difficult given their indentation. It is very important to distinguish which part of the intestinal tract is affected by the illness. It is important to ask the patient about a recurrence of reflexive changes and a detailed anamnesis focused on digestion, stool, appetite and so on needs to be completed. A disease in the abdominal portion of the intestinal tract manifests itself by reflexive changes in the lumbar spine and abdominal muscles, in which abdominal muscle guarding occurs with increased nociception. With lesser stimulation, hypertonia occurs in the individual parts of the abdominal muscles lying above the area of the pathological changes. The sections of the intestinal tract close to the pelvis show reflexive changes mostly in the pelvic floor and in the lower quadrants of the abdominal wall. Restrictions are found in the last lumbar segment, false ribs, sacroiliac articulation, or even the coccyx. The S-reflex may be positive and painful points and trigger points form in the intercostal spaces, especially in the 9th and 11th intercostal spaces. The side of the muscle firing corresponds to the side of the involved portion of the intestine. Deficits in all parts of the intestinal tract show increased tone in the iliopsoas and quadratus lumborum with involvement corresponding to the affected section and the long erector spinae. For example, deficits in the left section of the intestine result in an increased tone in the left iliopsoas. Pain originating from the intestinal tract can be quite intense and often can

imitate nerve root irritation; however, without neurological findings or with negative provocation and alleviation tests. Pancreas Deficits in the pancreas manifest themselves primarily between segment T7-11 and most frequently at the T9 segment. Reflexive changes are found with a strong tendency on the left. Other associated reflexive changes include sacroiliac joint restriction and a spasm of the left psoas major. Hyperalgic zones are generally found bilaterally, again in the range of T7 and the thoracolumbar junction. Pain with pancreatic involvement is strong, deep and can sometimes imitate nerve root irritation. In differential diagnostics, identification of the true source of such pain is difficult. Liver and Gallbladder Pain with liver disease and in the gallbladder is relatively common and considerably intense. Colic states with gallbladder disturbances are generally accompanied by a sharp, shooting pain along rib arches to the front or the back and also by malaise and nausea. The visceral pattern is found in regions T6-8 or T7-9 with a tendency toward the right side. Restrictions in the intervertebral joints and the ribs are prevalent. In the region of the T7-9 intervertebral muscles, a reflexive development of trigger points occurs along with painful periosteal points on the corresponding ribs. A visceral pattern of these organs includes mid-cervical spine restrictions, especially segment C4-5 and again more frequently on the right side. Hyperalgic zones are multisegmental from T6-T10. The pattern usually does not include an iliopsoas spasm, but increased tone in the upper section of the rectus abdominis and the descendant section of the right trapezius are common. Kidneys With kidney involvement, a visceral pattern located mainly at the thoracolumbar junction (T10-L1) is found. Most common elements of the pattern include intervertebral joint restrictions, as well as, sacroiliac joint restrictions with a side location identical to the side of the involved kidney. The mobility of the last two ribs is very limited.

Psoas major, quadratus lumborum and erector spinae spasms at the thoracolumbar region are also common. Diaphragm function is also decreased. Further, this pattern often includes the piriformis and thigh adductors. Hyperalgic zones are found bilaterally at the thoracolumbar junction. In kidney diseases, the pain usually “shoots” along the lower ribs to the back in the direction of the thoracolumbar junction and it is harsh, sharp and intense. Quite often, they refer into the lower extremities, imitating, once again, nerve root irritation. Uterus and the Ovaries Adhesions following gynecological surgeries are a frequent source of the so called low back pain syndrome in females. In gynecological disturbances, the S-reflex is present due to increased tone in the coccygeus muscle. A detailed overview of reflexive changes in disturbances of the gynecological system was developed by L. Mojzisova who studied female functional infertility treatment extensively. The visceral pattern includes restrictions in the lower lumbar spine (from segment L3), the lumbosacral junction and the sacroiliac articulation. Also common are coccygeal restrictions. Increased muscle tone is seen in the pelvic floor muscles, which form a “chain” with the erector spinae at the thoracolumbar junction, which also exhibit increased tone (S-reflex). Generally, increased tone in the short hip adductors and weakness in the gluteal musculature are present. Pelvic nutation is a frequent reaction of the musculoskeletal system to nociceptive visceral irritation of the reproductive system. Prostate The muscles of the pelvic floor show increased tone, especially in the levator ani muscle, which forms the saddle for the prostate, “hugs” it and sensitively reacts to its deficits. Testicles The testicles descend from the abdominal cavity into the scrotum during postnatal development and innervation from the T10 segment persists. Therefore, testicular illnesses imitate kidney involvement because they refer pain to the thoracolumbar region. To a varied

extent, there is increased tone in the cremasteric muscle (which is absent in kidney involvement) so that the involved testicle can be pulled higher than the healthy testicle. Since the cremasteric muscle branches from the internal abdominal oblique muscle, its irritation can be manifested by a change in tone of the abdominal wall. In the overview presented above, only the basic elements of visceral patterns are described. In general, during an examination, other elements of these patterns are found depending on the individual characteristics of each patient. The longer the illness is “chronic” the more the functional deficits of the movement system become chained and the visceral pattern extends, or becomes more “blurred”. In the pattern overview, the pattern for the spleen is missing. So far, this pattern has not been described in detail but, to a certain extent, it can be presumed that there is an overlay between the pattern for the spleen and the pancreas. Within the viscerosomatic relationships, the iliopsoas muscle, the so called visceral muscle, is important. This muscle often and most sensitively reacts to deficits in the abdominal organs but, on the other hand, its deficits most often imitate internal involvement. That is why special attention needs to be paid to this muscle during examination.

2.2 EXAMINATION OF THE AUTONOMIC NERVOUS SYSTEM Hana Marčišová The autonomic or vegetative nervous system (ANS) is a division of the nervous system fundamental to the maintenance of homeostasis of an organism. It regulates and controls the function of smooth musculature, blood vessels, organs and the skin, exocrine and endocrine glands, myocardium and other organs. Given its influence on the internal organs, the autonomic nervous system is also known as visceromotor. With complex control of the body’s response to various stimuli, coordinated reactions occur within the somatomotor and autonomic nervous systems. The ANS is considered to be a part of the control mechanism of an organism that can ensure balance and cooperation between the internal organs and the somatic structures (musculoskeletal system). So far, it is not quite known how this cooperation occurs and to what extent it can be important for movement control.

2.2.1 Anatomy and Physiology of the ANS The autonomic nervous system is formed by central and peripheral neurons among which the reflex arch forms the basic communication channel (similarly as in the somatic nervous system) whose activity, however, can be modulated at many levels. In the ANS, the afferent input is enabled by viscerosensory fibers carrying information from the viscera and the somatic regions (afferentation from the skin, musculature, periosteum, etc.) to the CNS. This connection manifests itself by a local reaction to nociception or by a change in the skin blood perfusion in the area above the muscle’s increased tone. The efferent component of the ANS consists of the sympathetic as well as the parasympathetic systems.

From the anatomical organization of the efferent portions of the ANS, important principles arise for physical therapy. For example, the position of the thoracic ganglia of the sympathetic trunk (truncus sympathicus) in close proximity to the heads of the ribs can be linked to an overall autonomic demonstration of periosteal pain in these ribs. Connections are made between the changes in circulation with irritation of the perivascular sympathetic plexuses of the vertebral artery (a. vertebralis) secondary to functional and structural changes of the cervical spine. Similarly to the somatomotor system, the ANS is organized hierarchically. The lower level is formed by preganglionic and postganglionic neurons that ensure autonomic innervations of the targeted organs with the hypothalamus and cortical structures at the apex. An important “in-between” structure is the reticular formation of the brain stem. The participation of the cerebral cortex in the autonomic activity control is least understood. It is presumed that it integrates the somatic and vegetative activity with volitional motor activity. The cortex, next to the programming and execution of a targeted movement, also activates the responding autonomic response whose task is to prepare the inner environment of the organism for the increased metabolic demands of the skeletal muscles. Changes in breathing and circulation occur at the beginning of muscle work prior to a change in homeostasis due to muscle activity. The cerebral cortex continues to mediate the relationships between the outer environment and the visceral functions of an organism (vegetative component of emotional reactions). The Significance of Periaqueductal Gray Within the context of physical therapy, the periaqueductal gray (PAG) is an important central structure, especially its dorsal aspect. Studies of the effectiveness of mobilization and manipulation techniques consistently showed that the analgesic effect occurring after an application of mobilization and manipulation techniques can be attributed to the elicited activation of the dorsal PAG. The

analgesic effect is accompanied by simultaneous excitation of the sympathetic nervous system. Longitudinal columns of PAG are connected to loops that can coordinate autonomic, motor and sensory information. The section of PAG from which the subsequent autonomic responses are evoked have extensive, viscerotopically organized descendent projections into the sympathetic premotor neurons. Topical organization of the PAG can resemble, to some extent, somatotopic organization of the motor cortex (motor homunculus). Global and Differentiated Activity of the ANS The view of the sympathoadrenal and parasympathetic systems as two antagonistic effectors can be now considered obsolete. Although their activity in many aspects is antagonistic, overall, they act in reciprocal coordination. Recent research demonstrates the ability of the sympathoadrenal system to react at the level of the tissues and locally, that is without the need for global activation. Tissue and somatotopic specificity allow for local targeting of sympathetic activity (for example, local dermographismus, pseudomotor changes) corresponding to the regions of reflexive changes in the soft tissues.

2.2.2 Function of the ANS within the Movement Apparatus Only the sympathetics are active at the level of the movement system and the skin. They innervate the smooth muscle of the blood vessels (vasomotor component), smooth muscle around the hair, arrectores pili muscles (piloerection) and the sweat glands (pseudomotor). The sympathetic fibers for these functions run together with the somatic peripheral nerve. Autonomic functions can be involved in neuropathies or peripheral nerve lesions. More recently, the influence of sympathetic activity has been confirmed by afferentation from muscle proprioceptors or the muscle spindles. Only one study showed an autonomic innervation of extrafusal (commonly striated) muscle fibers in a cat (Barker, Saito, 1981).

Vasomotricity The distribution of blood volume and the influence of blood flow in a body part are among the tasks important for regulation of blood pressure as well as thermoregulation and assuring optimal metabolic demands for an activity by a given organ at a given moment. The maintenance of blood pressure mainly depends on sympathetic tone. Sympathetic nerves innervate all blood vessels with the exception of the capillaries. The response of the blood vessel to the transmitter differs in quantity and quality based on the type of the blood vessel, which is determined by the various types of receptors. The diversity in the mechanisms of sympathetic innervations of the vascular system can play an important role in the regional differences of regulation of blood perfusion. The sympathetic nerves play an important role not only in regulation of the cardiovascular dynamics, but also in the maintenance of the blood vessels’ wall structure. The ability of the differentiated activity of the sympathetics to control the extent of blood perfusion represents anticipation, certain pre-preparation or navigation of the intended movement by forming a metabolically advantageous environment and confirms the simultaneous influence of the CNS structures in planning and movement execution as well as its logistic autonomous support. Somatosensory System and the ANS The influence of the afferent inputs from the entire body and information from the telereceptors are vital for motor control and it is referred to as sensorimotor. Many physical therapy techniques are based on influencing the afferent inputs. Proprioception – Muscle Spindle Traditionally, a muscle spindle is considered a muscle receptor controlled by γ-motor neurons. The fact that autonomic innervation influences its function was unequivocally shown in animals. Although innervation similar to that found in animals’ can be presumed in humans, so far the evidence has been only indirect. Functional Consequences of Autonomic Innervations of the Muscle

Proprioceptors When considering the autonomic innervation of muscle proprioceptors, the influence of the sympathetic system on all functions attributed to the muscle spindle needs to be taken into consideration. The signals from the muscle spindle participate in various bodily functions, such as spinal and supraspinal motor reflexes, control and coordination of movements, and the perception of positional and body movements (kinesthesis). Changes in the activity of the muscle spindle elicited by the sympathetic system allow, together with γmotor neuron, for setting the threshold for stimulation of the α-motor neurons, which influences muscle tone. Increased tone of the sympathetic system probably influences the quality of kinesthesis and motor control. The changes in proprioceptive information elicited by increased efferent activity (outflow) could result in motor and proprioceptive dysfunction. The effect of the sympathetic system on the muscle spindle is a component of the central motor program and it is one of the mechanisms participating in the modification of a motor task in the context in which it is performed. Skin Sensation Skin sensation represents an important portion of the afferent component of information that the CNS assesses and responds to by motor manifestations and changes in the function of the movement system. The result of integration of the skin and proprioceptive sensation is the ability of stereognosis, which is a fundamental predisposition for movement. In the skin, the receptors for tactile, thermal, chemical and nonspecific nociceptors are present. Some of the low threshold mechanoreceptors (RA II – fast adapting receptors type II, so called Vater-Pacini corpuscles and SA II – slowly adapting receptors type II, called Ruffini corpuscles) contribute to proprioception. The stimulation of an efferent sympathetic system influences firing

of the skin affectors, although it is not known by what mechanism. Some studies lean toward the mechanism mediated by the changes in local blood perfusion and some toward not yet identified mechanical change in the skin and the subcutaneous tissue. Nociception, Pain and the ANS Every pain is accompanied by autonomic changes. With strong pain it is perspiration, shock, tachycardia, decreased blood flow, accelerated respiration and fear. Fear even accompanies chronic pain, which always possesses autonomic phenomena. Next to fear, anxiety and insomnia are common. These autonomic manifestations are very important because the autonomic nervous system, primarily the sympathetic system, influences pain very intensely. It has been shown that the sympathetic peripheral transmitter noradrenalin increases chronic pain and the sympathetic peripheral transmitter ATP stimulates muscle nociceptors. The sympathetic nervous system (SNS) can, under certain circumstances, modulate nociceptive information. In normal tissue, the activity of the postganglionic sympathetic efferent fiber does not elicit pain perception and it is unable to activate the nociceptive sensory neurons. Under pathological conditions in a sensitized tissue, it can contribute to the development and maintenance of pain, hyperalgesia and inflammation. In clinical experiments, stimulation at a physiological frequency of firing within the sympathetic system was sufficient enough to activate nociceptors in a sensitized tissue, which is common, for example, during work stress. The connection between the activation of the sympathetic system and pain has been confirmed by epidemiological studies. Stress of various origin, which is always linked to an activation of the sympathetic system (for example, work, psychosocial) can be a cofactor in the onset of painful syndromes and/or can negatively influence its timeline. The link between the sympathetic system and pain is significant in a complex regional pain syndrome (CRPS). It is considered a “vicious cycle” of changes in the peripheral and central somatosensory processes where positive feedback in the form of sympathetic efferent

neurons completes this “vicious cycle” by activation of sensory neurons at the periphery. ANS and Muscle Function At the level of the muscle, there are two states of functional changes. It is either increased or decreased activity of muscle fibers, which most often manifests itself by changes in muscle tone (hypertonia and hypotonia). These changes can be present in the entire muscle or in a group of muscles as well as in a localized section of muscle. The changes in muscle function are linked to changes in other soft tissues (skin, subcutaneous tissue, fasciae, etc.) and, especially, to changes in joint function (hypermobility or joint restrictions, or joint motion restriction). Also, the connection with the internal organs should not be neglected. These functional changes influence postural as well as phasic movement components and their long-term activity can lead to structural changes in tissues. Myofascial Trigger Points Myofascial trigger points (TrPs) represent a local hypertonic change in muscle function. It is one of the most frequent functional changes in muscle tissue. A trigger point is defined as a site of increased irritability in a tight muscle bundle which is painful to pressure and from which a characteristic referred pain and autonomic signs can be elicited. By “strumming” such a bundle with one’s fingers, a muscle twitch occurs. The twitch can be seen on EMG and the patient describes pain. The fibers containing TrPs show increased tension. This tight muscle band can be found in a hypotonic, hypertonic (shortened) or normotonic muscle. Spontaneous EMG activity was found in TrPs while surrounding fibers do not display this activity. Other research has shown that TrPs react by increased EMG activity to an increased sympathetic outflow during a stressful situation. With stress (elicited experimentally by attempting to solve math problems “in the head”), electrical activity in the TrP increased while the surrounding muscles stayed electrically “silent”. This can be the mechanism by which emotional factors influence muscle pain. It is common clinical

knowledge that patients with myofascial pain and local changes in muscle tone react to stressful demands (even “if only” a mental stress) by increased muscle tone and pain in the incriminated areas. It can be presumed that activation of pathways from the limbic system to the reticular formation (increased activity of γ-motor neurons) as well as increased sympathetic outflow can contribute to increased muscle tone. Myofascial Pain Syndrome The presence of active myofascial TrPs is characteristic of myofascial pain syndrome (MPS). It typically presents as increased muscle sensitivity and the presence of zones of referred pain. In the zones of referred pain from one somatic structure to the next, secondary hyperalgesia and trophic changes typically occur. The patient with MPS describes pain that is spontaneous or elicited by active movements (contractions) of the involved muscle. The pain is mostly diffuse, dull, usually not very intense, perceived inside the muscles, and chronic in nature. Often, it is elicited or worsened by work overload or infection. MPS usually manifests itself in the extent of functional segments and musculoskeletal system regions (shoulder, neck, etc.) and can include several segments or regions. Hypotheses for the Development of EMG Activity in Myofascial Pain Areas Several hypotheses exist about the development of EMG activity in myofascial pain areas (MPA). The most known is an activity whose onset is explained by the classic integrated hypothesis by Simons. As a mechanism of myofascial pain, it postulates a chain of events that begins by an abnormally increased release of acetylcholine at the neuromuscular endplate, which leads to subsequent abnormal depolarization of the postsynaptic membrane and a nonphysiologically high local increase in calcium ions. This leads to a permanent shortening of sarcomeres or permanent contraction of the involved muscle fibers. In this area, increased metabolism and subsequent energy crisis occur. Sustained contraction causes compression of blood vessels, tissue ischemia, release of substances

(bradykinin) participating at the onset of pain, excitation or sensitization of nociceptors, and pain. An alternative to this classic hypothesis is the hypothesis of intrafusal muscle fiber activation in the muscle spindle by the sympathetic nervous system. This hypothesis states that direct sympathetic stimulation of intrafusal muscle fibers leads to involuntary, weak, but eventually symptomatic, muscle contraction. This hypothesis is confirmed by the fact that a pharmacological intervention, specifically a sympathetic block, strongly decreases EMG activity in MPA. The studies that measured EMG activity in MPA showed its selective increase in the area of the so called trigger point at a certain depth of the palpated painful area in contrast to a control area within the same muscle. EMG activity in a given area also increased with an increase in muscle sympathetic efferentation (outflow), which can be elicited by an increased intra-thoracic pressure. These observations can be considered as further evidence of the influence of an increased sympathetic efferentation on muscle tone in the area of reflexive changes. The mechanism by which SNS influences MPA is not clear. It can be by influencing the hemodynamics (vasoconstriction) or by a direct influence of a muscle spindle. Défense Musculaire A close connection between the internal organs and muscle tone is substantiated by the “défense musculaire” state. It involves increased tone of the abdominal wall, which develops during an intense nociceptive stimulation leading from the afferent component of the autonomic nervous system during peritonitis. A similar example of the so called viscerosomatic reflex is a reflexive contraction of the neck muscles elicited by irritation of the brain membranes during meningitis. Therefore, viscerosensitivity is one of the inputs that can influence the final motor output or the activity of the spinal motor neuron.

2.2.3 Anatomical Vegetative Syndromes Pavel Kolář In clinical practice, we also come in contact with patients who present with a direct structural deficit in the autonomic system, which most frequently occurred as a result of serious injuries, strokes, or iatrogenic cause, etc. In such cases, the anatomical continuity of a given structure has been disrupted and, for that reason, these are known as anatomical autonomic syndromes. Based on location, they can be divided into: Central autonomic syndromes – cortical, diencephalohypothalamic, brain stem; Peripheral autonomic syndromes – Claude-Bernard-Horner syndrome, the syndrome of the posterior cervical sympathicus, syndrome of the ganglia trunci sympathici, nerve root syndromes and the syndromes of the plexi and peripheral nerves.

CENTRAL AUTONOMIC SYNDROMES With deficits in the bulbopontine and mesencephalic autonomic centers, the basic life-sustaining functions – respiratory and cardiovascular – are jeopardized. Diencephalohypothalamic illnesses cause deficits in vasomotor regulation (for example, blushing, turning pale, changes in blood pressure), deficits in respiration, endocrine and metabolic dysfunctions (for example, diabetes insipidus, obesity, disturbances in the metabolism of fats, proteins and glycids), sexual and trophic disturbances. They can be accompanied by deficits in consciousness in the context of narcolepsy, cataplexy, and hypersomnia. Cortical, subcortical and capsular deficits in the control regions of the autonomic nervous system manifest themselves as edemas, changes in microcirculation in the skin and muscles, cyanosis or changes in skin temperature.

PERIPHERAL AUTONOMIC SYNDROMES They occur with deficits in the peripheral structures of the autonomic system and can cause stimulation or cessation. They can also be combined. The clinical picture demonstrates: Vasomotor signs (blood vessel spasms, vasoparalysis and with it linked deficits in skin temperature, cyanosis or pale skin); Trophic deficits in the skin, bones and musculature (for example, nail breaking, thin or hyperkeratonic skin, deficits in hair); Secretory signs (hyper- or hypohidrosis); Causalgias (burning surges of pain poorly controlled by analgesics). Claude-Bernard-Horner Syndrome This syndrome manifests itself by ptosis, miosis and enophtalmos. On the involved side, hyperhidrosis and hyperthermia are present. The causes of onset of this symptomatology may be a lesion in the upper cervical sympathetic system, Budge’s ciliospinal center in the lateral horns of C8-T1 segments, lesion in the spinal roots, ramus communicans albus, superior cervical ganglion or carotid plexus (plexus caroticus). Not only a peripheral, but also a central lesion in the hypothalamus or brain stem can contribute to its development. Posterior Cervical Sympathetic Syndrome Posterior cervical sympathetic syndrome (also known as the BarreLieou syndrome) clinically manifests itself by dizziness, ringing in the ears or even hearing problems. Sometimes it is accompanied by a headache (cephalea). Its onset is linked to an irritation of the periarterial nervous plexi of the vertebral artery (most commonly due to arthritic changes).

GROSS VEGETATIVE SYNDROMES For the autonomic nervous system to function correctly, both components of the autonomic system, the sympathetic and parasympathetic, need to work in balance. This balance is considered

as normotonic. Increased activity of the sympathetic system leads to sympathicotonia during which catabolic processes dominate. In parasympathicotonia, with the function of the parasympathetic system dominating, the opposite occurs, thus the anabolic processes dominate. The clinical picture is varied and resembles an organ neurosis. In such patients, all organ systems are often gradually examined because they are perceived as involved/damaged. A sudden onset of sympathetic or parasympathetic imbalance is known as an autonomic crisis. With deficits in the sympathetic system, sudden vascular hypertension, headache, blood vessel spasms and tachycardia can occur. With increased activity of the parasympathetic system, Quincke’s edema, bronchial asthma and paroxysmal hyperhidrosis can be observed.

REFLEXIVE VEGETATIVE SYNDROMES The clinical picture is characterized by motor (slight paresis mainly in the distal segments of the extremities), sensory (deficits in sensation that do not demonstrate nerve root but rather peripheral character, causalgia-type pain) and vegetative changes (trophic changes in the skin, subcutaneous tissue and muscle atrophy, vasomotor changes – blood vessel spasms and vasoparalyses).

REFERENCES Barker D, Saito M. Autonomic Innervation of Receptors and Muscle Fibers in Cat Skeletal Muscle. Proceedings of the Royal Society of London. Series B. Biological Sciences 1981; 212(1188): 317–332. Bartko D. Neurológia. Bratislava: Osveta 1982. Čelko J. K liečbe vredovej choroby dvanáctorníka. Rehabilitácia 1996; 4: 250. Dejung B, Gröbli C, Colla F. Triggerpunkt-Therapie. Bern: Hans Huber 2001. Hep A, et al. Poruchy motility jícnu při vertebropatiích. Rehabil a Fyz Lék 1998; 4: 131 135. Hubbard DR, Berkoff GM. Myofascial Trigger Points Show Spontaneous Needle EMG Activity. Spine 1993; 18(13): 1803–1807. Chung JW, Ohrbach R, McCall WD. Effect of Increased Sympathetic Activity on Electrical Activity from Myofascial Painful Areas. Am J Phys Med Rehabil 2004; 83(11): 842–850. Janig W. The Sympathetic Nervous System in Pain. European Journal of Anaesthesiology 1995; 10: 53–60. Jasonovičová T. Viscerovertebrálne vzťahy pri ochorení obliček. Rehabilitácia 1998; 1: 51–53.

Králíček P. Úvod do speciální neurofysiologie. Praha: Karolinum 1997. Kunnert W. Wirbelsäule und innere Medizin. 2. Aufl. Stuttgart: Ferdinand Enke Verlag 1975. Lewit K. Manipulative Therapy. London: Butterworth Heinemann 1999. Lewit K, Kuncová Z. Anteflexní bolesti hlavy v dětském věku. Čs pediat 1971; 26: 75-81. Mikula J. Strategie, taktika a diagnostika u torakálních segmentových dysfunkcí a bolestí v oblasti hrudníku. Rehabilitácia 2002; 3: 88–94. Roatta S, Windhorst U, et al. Sympathetic Modulation of Muscle Spindle Afferent Sensitivity to Stretch in Rabbit Jaw Closing Muscles. Journal of Physiology 2002; 540: 237– 248. Rychlíková E. Reflexní změny u ischemické choroby srdeční a jejich terapeutické ovlivnění. Praktický lékař 1973; 10: 378–381. Simons DG. Symptomatologie und klinische Pathophysiologie des myofaszialen Schmerzes. Man Med 1994; 32: 92–122. Velecká M. Viscerovertebrálne vzťahy. Rehabilitácia 1995; 1: 40–43. Zbojan L. Chrbtica a vnútorné orgány. Vojenské zdravotnické listy 1970; 3: 90–93.

3 PSYCHOLOGICAL FUNCTIONS AND PAIN Petr Knotek

3.1 PSYCHOLOGICAL DIAGNOSTICS IN REHABILITATION In rehabilitation practice, changes in biological, psychological and social functions disturbed by some pathological condition are often treated. For example, a patient suffers chronic pain after a complicated musculoskeletal injury. During treatment, standard rehabilitation and long-term work disability signs may appear, for which there is no pathophysiological explanation – depression, formation of inaccurate opinions and expectations, learned pain behavior, loss of work habits or habitual abuse. These changes influence family and work function, complicate treatment and limit rehabilitation options. Limiting the rehabilitation process strictly to the patient’s essential problem, in this case rehabilitation of movement function, will not be effective and can have a paradoxical effect. The function of the movement apparatus will be renewed but the depression, the belief of one’s inability to continue normal life, learned pain behavior, habitual abuse and dependence on support can all persist as autonomous processes even after a complete recovery of the pathological process. If an injury or illness result in irreversible consequences, for example, as a result of a spinal lesion, the extent of subsequent changes in the psychological, behavioral and social communicative processes needs to be limited to a minimal level and valuable alternative forms of these processes in new environmental conditions should be established. A psychological diagnosis must include a description and explanation of psychological processes that are linked to the prognosis, course and consequences of such a complex life change. This description and explanation must serve the subsequent rehabilitation process and must be well arranged within the context of other examinations so that it can contribute to a complete perspective of the patient for the needs of complex rehabilitation.

3.2 ASSESSED PROCESSES AND METHODS OF THEIR TESTING Reactivity to Painful Stimuli The basic reactivity to painful stimuli measured in a neutral area of a body that is relatively non-influenced by a pathological state often depends little on the pain from the actual pathological condition. Under normal circumstances, a weak positive relationship is generally seen between the sensation of painful stimuli and pain intensity from a pathological process (greater sensitivity and greater intensity). In persons with depression, the relationship is reversed, or a negative link between decreased sensation to neutral painful stimuli and increased pain intensity from a pathological process (lower sensitivity, or dullness, and higher intensity of pain). This inverse relationship is found in patients with severe pain. Testing reactivity to painful stimuli is used to assess analgesia, hyperalgesias, hypoalgesias and other changes important for the distinction of pain from nociceptive pain, neuropathic pain and pain partially from both mechanisms. Some neuropathic changes include hyperalgesia to light touch (tactile hyperalgesia) or anesthesia dolorosa, and insensitivity to common nociceptive stimuli in a (hyper)algic region. The obtained value for sensitivity to painful stimuli should be independent of the type of pain stimulus (warmth, pressure, coldness, etc.). The sensitivity to painful stimuli needs to be distinguished from the sensitivity to other unpleasant stimuli (for example, very deep music tones or vibration). The ratio between the sensitivity to painful stimuli and the sensitivity to other unpleasant stimuli allows for the distinction between hyperalgesia and hyperesthesia. With hyperalgesia, the sensitivity to nociceptive stimuli is higher while the sensitivity to other unpleasant stimuli is relatively low (normal). With hyperesthesia, greater sensitivity to nociceptive stimuli as well as unpleasant stimuli is seen. (The distinction between “nociceptive” and “painful” stimulus should be made. Nociceptive stimulus stimulates

nociceptors, or free nerve endings. A stimulus becomes painful when its intensity elicits pain). The assessment of sensitivity to painful stimuli should establish accuracy of a response. For example, the degree of agreement across results from repeated measurements. It should establish the lower margin of sensitivity – (lower) pain threshold, or even the upper boundary of tolerance to painful stimuli – upper pain threshold. The assessment is supposed to capture separately the intensity of the sensory and affective component of pain. The same method should be used in both clinical and research settings, and the obtained information should be reliable and generalizable. Many devices exist to assess the reactivity to painful stimuli. A pain testing tool was developed to measure pain threshold and accuracy of perception of painful stimuli through thermal radiation. The tourniquet method uses stimulation by having the cuff of the tonometer fastened to the arm, which results in subsequent ischemia. The “cold compressor” method is used to produce ischemia by placing an extremity into very cold water. Mechanical or electronic algometers are used for exposure to pressure stimulation. The stimulation is carried out by applying pressure to a tested body part. The exerted pressure is either shown on a display or a computer reads and stores the data. Modern approaches generally use the measure of reaction time, or the time between the onset of the nociceptive stimulus of given intensity and the pain being elicited. Pain in the Pathological Process Modern pain assessments used in clinical settings begin with Melzack’s McGill Pain Questionnaire (MPQ). The original version of the MPQ includes scales for the Sensory Pain Rank Index (PRI-S), the Affective Pain Rank Index (PRI-A) and the Evaluative Pain Rank Index (PRI-E). The MPQ components include pain expressions with the same quality but different intensity. For example, the component PRI-S measures thermal pain quality and consists of terms such as hot, burning, scalding and searing. The application of the original MPQ is lengthy and the assessment is difficult, while the concept of

cognitive pain assessment via the PRI-E is outdated. The short form of the MPQ, the SF-MPQ, is the most widely used questionnaire for pain assessment. It consists of three scales: The Sensory Pain Rank Index contains 11 word descriptions denoting sensory pain qualities (for example, pulsating, shooting, stabbing); The Affective Pain Rank Index comprises 4 components that correspond to affective pain quality (tiring, exhaustive, fear producing and depressing, and relentless); The Total Pain Rank Index PRI-T is given by the summative value of the PRI-S and the PRI-A (15 components). The patient ranks the degree of intensity of a given perceived quality (0 – none, 1 – slight, 2 – mild, 3 – strong). The index score is given by the sum of the components of the corresponding scales. The PRI-T is almost never used. The SF-MPQ is often accompanied by the Visual Analog Scale (VAS) and the Present Pain Index (PPI), a word scale of current pain intensity. Both accompanied scales are outdated in their original forms. Visual Analog Scales are the most frequently used methods for the assessment of pain (Fig. 3.2.2-1). These are generally 100-mm long lines. The absence of an assessed quality is marked at the beginning point on the line on the left side; the right end point is marked by the highest degree of pain intensity. The modern VAS for pain testing uses primarily two basic scales:

Fig. 3.2.2-1 Visual Analog Scales of pain intensity (VAS-1) and Numeric Pain Intensity Scales (NS-1) and unpleasant pain (NS-U). The VAS line length is 100 mm.

The VAS-I for assessment of pain intensity – “none” on the left, “the worst possible” on the right; The VAS-U for assessment of unpleasant pain – “none” on the left, “worst possible” on the right. These VAS scales measure the basic perceived quality of pain, pain intensity, basic affective quality, and nuisance. They are standardized in various laboratory and clinical conditions, including a sample of Czech patients with chronic pain. The Visual Analog Scale is used for the assessment of other variables, for example suffering (VAS-S), negative opinions and attitudes, pain interference during daily activities and for testing negative affections, anxiety, anger, depression and frustration. Numeric Scales (NS) assess the same aspects of pain as VAS. Generally, an 11-degree horizontal scale is used – a row of integrals. Similarly to VAS, the lowest degree is marked on the left and the

highest degree of the assessed quality to the right. There are no statistically significant differences among the values measured by VAS and NS, only with repeated measures is the VAS scale slightly more sensitive. Therefore, the values obtained using NS and multiplied by ten can be considered equivalent to the VAS values in millimeters (values NS-I 0, 1, 2, etc. correspond to values VAS-I 0, 10, 20, etc.). In rehabilitation practice, the use of VAS or NS for pain assessment is more accurate and less time demanding than pain assessment by a common, non-standardized question. Upon reading or receiving standard instructions, the patient registers a mark on the corresponding VAS or a number on the NS. With repeated treatments, the patient performs this method automatically. If we are not sure whether the patient remembered the instruction, it can be verified. The instruction is adjusted to the purpose of the assessment. During the first contact with the patient, the following instruction can be used: “state the average pain intensity and nuisance in the past week”. For the assessment of changes during a series of treatments, the following instruction is used: “state the pain intensity and nuisance that you feel right now”. This way we can get a good overview of pain perception during one treatment, a course of treatment, or during a rehabilitative stay. Similarly, assigning pain intensity, pain nuisance, or other feeling qualities can be classified using tone pitch or sound intensity (pleasant deeper tone/humming – no pain; high pitch tone on the borderline of audibility/the sound of the dentist’s drill – the worst possible pain intensity or nuisance). This method is suitable for the blind. Other modes are rarely used. Iconic Scales use picture symbols corresponding to assessed aspects of pain. The scale for pain assessment in children, the absence of pain (“does not hurt”) is assigned an empty spot. In a horizontal line, the following succession is presented: poppy seed, a grain up to red beet and a pumpkin (“the worst possible pain”). Similarly, pain sensation can be assigned a picture of a face that gradually shows a smile (“no pain”), serious expression, up to a crying face with painful grimace

(“the worst possible pain”). Generally, pain intensity is more difficult to modify than pain nuisance. Greater pain nuisance over pain intensity is the first phase in the psychological chronic nature of painful conditions. Beginning Phase of Psychological Pain Processing Preoccupation with pain and fear of pain are essential to the extent of psychological changes in chronic pain. Acute pain is a signal of threat to body integrity, or possibly life threatening. The natural reaction is an immediate focus of attention to pain and fear elicited by the developed pain. These reactions determine the patient’s subsequent adaptation or maladaptation. An adequate feeling of risk supports motivation for treatment and rehabilitation and lead to recovery and adaptation. The absence of adequate fear and attention leads to treatment neglect. Strong fear and long-term preoccupation with pain complicate treatment and rehabilitation and lead to maladaptation. Many maladaptive manifestations in patients with chronic pain, including constant scrutiny of pain, are only persistive and deformed forms of processes that were originally a natural reaction to acute pain (compare preoccupation shortly after an injury with constant preoccupation during hypochondria). The above mentioned initial processes of adaptation to chronic pain are measured by the Fear and Observation of Pain Inventory (FOPI). The questionnaire consists of two scales: Fear of Pain and Observation of Pain. The processes assessed by FOPI retroactively influence the psychophysiological mechanisms of pain and thus the intensity and nuisance of pain. (A strong attention to pain and strong fear of pain increase pain.) Subsequently, these processes elicit other psychological changes, such as changes in the patient’s affection, cognitive processes and behaviors. The Fear-Avoidance Beliefs Questionnaire (FABQ) focuses on similar processes and measures cognitive aspects of fear and avoidance of pain. The Pain Anxiety Symptoms Scale (PASS) involves affective, cognitive and physiological manifestations of a fear of pain. Tampa’s

scale of kinesiophobia relates only to the pain in a movement system. The Fear of Pain Questionnaire (FPQ-III) includes the following scales: Fear of Severe Pain, Fear of Minor Pain, Fear from Medical Procedures and Total Score. These forms of fear of pain are general and do not represent the initial reaction to a painful condition. Cognitive Processes The methods for assessment of the cognitive processing of pain tests three overlapping groups of processes: opinions and attitudes towards pain, cognitive processing of present pain, and perception and presentation of changes attributed to the consequences of pain. The views of pain describe how the patient explains pain and how they assess what the pain means to them. In families and in the society, there are differences in how people view pain that are acquired by learning. These views serve as the basis for the explanation of the next occurrence of pain and determine the starting point for understanding and assessing pain. The Pain Beliefs and Perception Inventory (PBPI) is one of the most utilized methods of assessment in this area. The standardized Czech version of the PBPI measures how people view pain on the following scales: Pain persistence in the future – “pain will persist”, Mystery – “pain is an unexplainable process”, Own fault – “I am the reason for my pain”, Other’s fault – “my pain was caused by someone else”. The fifth scale of PBPI, Pain persistence at present, measures the time aspect of pain perception and belongs among the scales for pain assessment. The actual cognitive processing of pain, so called cognitive pain coping, is a cognitive strategy of the management of pain demands that the patient perceives as reaching, or overreaching, their own ability to reduce negative emotions and conflicts caused by the pain. Basically, there are two extreme forms of cognitive coping. The first form is based on skewing the perception of pain and its consequences to decrease anxiety. The second form leads to a rational interpretation focused on adaptive pain management. The first form leads to an avoidance strategy, for example, denying problems or escaping to work, alcohol or exciting activities. The other form leads to a

management strategy, for example, to rational treatment, rehabilitation or healthy lifestyle. The assessment of coping is relatively complicated. The only standardized Czech method for patients with painful conditions is the Questionnaire of Pain Coping. The published version of the questionnaire contains scales for Pain observation, Closure and Resignation. It was shown that closure and resignation sections indicate a failure when coping with pain, which leads to anxiety, anger and depression. In foreign countries, various tests for coping with pain exist. These methods sometimes also assess behavior that the patient uses to deal with pain (stretching, exercise, meditation, prayers, etc.) and communication focused on coping with pain, the so called social coping. The Chronic Pain Coping Inventory (CPCI) for patients and persons close to them is the most known method for this complex approach towards pain assessment. It includes the following scales: Readiness, Resting, Asking for help, Relaxation, Persistence (with problem solving), Exercise/Stretching, Seeking help from others and a Defense of own opinion. Cognitive changes during chronic pain cause changes in selfperception and the assessment of self (self-concept) as well as one’s own abilities to manage life demands attributed to the consequences of pain. These include statements such as: “I am not as I used to be”, “I can’t live as I used to”, “I can’t withstand what I used to”. These opinions form the so called cognitive component of suffering. Sometimes they persist even after recovery and with an additional onset of pain they support its psychological chronic nature. These changes are assessed by the Questionnaire for Adaptation to Chronic Pain, which involves the following scales: Self-perception, Perception of limitation and Perception of tolerance. Affection The excessiveness of affective components of pain over the sensory components is the beginning manifestation of unpleasant psychological changes with pain. This change supports fear associated with pain, which is further followed by generalized negative feelings,

anxiety, anger and depression. These affects form the affective component of suffering. Anxiety, anger and depression are characteristic of advanced psychological changes in chronic pain, but they may not necessarily be a consequence of pain. They may be a consequence of other problems, such as marital crisis, unemployment, legal dispute or it may be a manifestation of a psychological disorder. All these problems need to be addressed, at best, by a coordinated cooperation of specialists. The most commonly used questionnaires for the assessment of such affects are the State-Trait Anxiety Inventory (STAI), the State-Trait Anger Expression Inventory (STAXI), Beck’s Questionnaire of Depression, Zung’s Questionnaire of Depression and other tests. The newly utilized Questionnaire of State and Traits of Depression assesses strictly the affective components of depression as a present state and depression as a personality trait. It does not include somatic changes that can accompany certain somatic illnesses. These can be confusing during depression testing in painful conditions (lack of appetite, weight loss, feeling of body weakness, etc.). Less frequently, VAS are used for testing depression, anxiety, frustration, anger, or fear in connection to pain. Behavior A widely used method for the assessment of behavior is continuous daily recording of activities in the following categories: sitting, lying, standing, walking, habits formed and pain intensity. The Scale of Pain Behavior assesses mimetic, motor, paralinguistic (for example, moaning and painful voice modulation) and verbal manifestations of pain on a 10-point numeric scale. The sum of the values gives the total score of the Scale of Pain Behavior. More demanding methods of behavior assessment include an analysis of video recordings or electromechanical monitoring of the patient’s movements. The assessment of various aspects of the patient’s behavior requires simultaneous physiological, psychological and social approaches. Limping can be a reaction to pain in the lower extremity or a movement learned by operant conditioning. Operant conditioning or

instrumental learning is a process in which the learned reaction is followed by a reward. An example could be limping or moaning being repeatedly “rewarded” by some advantage, such as special considerations, medication prescription, interest of close relatives or retirement/pension. Such learned pain behavior persists after the pain heals as a freestanding and pain-independent process. Interpersonal Communication Communication with other people (especially within family) influences the patient’s affective, cognitive and behavioral processes. A significant aspect of such processes is known as social coping with pain. Social coping includes processes that renew the psychological balance in demanding or unmanageable conditions, which occur through communication with others. These processes are significant especially in painful conditions linked to a serious disability when common communication, motor, or even cognitive functions are supplemented or substituted for by another person. For example, a person who helps a paralyzed patient. Tests of such processes are an underappreciated area of psychological diagnosis. The exception is the above mentioned CPCI questionnaire by M.P. Jensen et al. It includes the following scales: Interpersonal Communication, Asking for help and Seeking support of others. There is a version for patients and close aides. It allows for the comparison of perceptions and attitudes of the patient and support persons. The Questionnaire of Social Coping with Chronic Pain includes two scales: Support requested (demands for help) and Support provided (help offered by others). It allows for establishing the relationship between the support required and the support provided for the formation of realistic support.

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4 Examinations by functional laboratory methods Milan Zedka, Pavel Kolář Clinical examination of the locomotor system can be complemented by assistive instrumentation methods that allow for an objective assessment of certain body processes associated with movement and they can be accurately expressed in a numeric form. With movement dysfunctions, the condition of the musculoskeletal system needs to be assessed in relation to its neural control. This chapter, along with an objective movement analysis, contains a description of basic electrophysiological and radiological examinations. The findings play an important role in the selection of a rehabilitation treatment and the assessment of its effectiveness. A rehabilitation physician and a physical therapist should know the instrumentation tests available to properly determine whether/which instrumentation methods are appropriate to use to benefit the patient.

4.1 LABORATORY EXAMINATION OF MOVEMENT Milan Zedka Overview of the examinations begins by a brief description of methods used for movement analysis. There are three types: 1. Kinematic analysis (describes body position in space and in time); 2. Kinetic analysis (describes forces acting during body movement); 3. Electromyographic analysis (describes muscle activity linked to movement). In this chapter, the third point, electromyographic assessment, falls in a transition between movement analysis in rehabilitation or orthopedic fields and supplemental examinations used primarily in neurology.

4.1.1 Kinematic Analysis Milan Zedka When assessing the quality of motor skills, it needs to be realized that human movement manifestation is a result of many processes occurring simultaneously not only during its execution but also during its preparation or its completion. Furthermore, in natural scenarios, these movements are usually not individual but rather are entire movement sequences or cyclical movements (e.g., locomotion or breathing). The purpose of instrumentation examination is to obtain not only the most accurate but also the most complex picture of the performed movement. The simplest movements which are linked to 1–2 bodily segments and are performed in one plane (e.g., ankle flexion-extension) can be analyzed. (Fig. 4.1.1-1). The angles between the segments are measured by goniometers. Most frequently, goniometers are electronic (potenciometer) and are observed as a continuous curve unwinding over time on the monitor screen. After calibration, the electrical output of the potenciometer can be simply recalculated into angular

degrees. Movement velocity and acceleration, two additional important values, can be calculated from an angular trajectory by a first and second derivative. Acceleration can also be measured directly by an accelerometer, which is usually a small and lightweight tool that can be attached to the measured segment (e.g., forearm, head, etc.). An accelerometer is especially convenient for measuring abrupt movement, such as a volitional ballistic movement, an impact (deceleration) or a tremor. Tremors and other periodic movements can be objectively described by the amplitude of an acceleration signal or its frequency. By more complicated computation, using the so called Fourier transform, several relatively differentially strong frequencies can be discovered in the signal that are not detected by the eye. The power spectrum is the graphic representation of a signal processed by Fourier transform, in which the individually represented frequencies correspond to the various heights of peaks (Fig. 4.1.1-2). With the help of such analysis, for example, cerebellar, Parkinsonian, or physiological tremors can be better distinguished. Clinically, a tremor cannot be distinguished from a non-epileptic action myoclonus (muscle twitches). In such a scenario, kinematic characteristics supplemented by an EMG analysis are helpful.

Fig. 4.1.1-1 Three cycles of passive ankle dorsiflexion in a patient with spasticity. A – angular trajectory (dorsiflexion corresponds to the upward deviation of the curve); B – angular velocity (calculated as a derivative from the angular trajectory); C – EMG of the triceps surae (stretch reflex elicited by dorsiflexion). The pathologically increased stretch reflex elicits ankle clonus, visible as small waves at the peaks of the curve A with maximal dorsiflexion.

Fig. 4.1.1-2 Power spectrum depicting the representation of various frequencies of movement of a patient’s hand with a Parkinson’s resting tremor. The most significant component is found in the 4Hz region.

Complex multisegmental movements such as ambulation or maintenance of postural stability can be assessed by digital video recordings. The principle of such movement analysis is a digital position capture of key parts of the moving human body. From the data about the position of these segments in time, the performed movement can be very accurately reconstructed and the main values characteristic for the movement can be calculated (e.g., the trajectory, velocity and acceleration). Individual methods are distinguished by the way they register and process the movement data. Optical systems exist that utilize passive or active markers placed on the body of the examined person. These markers are commonly adhered to the skin covering well- defined bony structures close to the main body joints; for example, the malleolar process of the fibula for the outer ankle, lateral femoral epicondyle for the knee, greater trochanter of the femur for the hip, etc. Passive markers are usually light, small balls reflecting infrared light emitted from the direction of the scanning camera. The number of cameras varies depending on the demand for accuracy of a three-dimensional reconstruction (usually 28). The advantage of passive systems lies in the fact that they can scan

a large amount of markers with a high sampling frequency. The movement of the examined person is not limited by a special suit or connected electrical cables. Active markers also exist, which do not reflect light, but emit it themselves (light emitting diode, LED). Every marker has its defined emission frequency, which makes it noninterchangeable with others. Therefore, it is not necessary to identify markers when the examination is completed as is the case when using passive markers. The advantage is the option of scanning a larger area. Next to passive and active systems, optical systems without markers exist today. Special computational algorithms can process optic input, identify shapes of certain body parts, and reliably monitor them simultaneously (computer vision). The advantage of this method is evident: without markers the examined person is moving more freely and the problem of covering the markers in certain positions is not an issue. Next to optical systems, systems utilizing other principles of physics also exist. Inertial systems use miniature gyroscopic sensors informing about the position of body segments. For scanning, no markers or cameras are needed and the data from the sensors are transferred in real time wirelessly into the computer that processes information. The advantages include portability, large scanning space and high accuracy. Mechanical systems use special tight suits comprised of a framework of poles interconnected by potenciometers. With movement, the angles between the poles are measured in real time. Finally, the magnetic measuring systems need to be mentioned. They register a magnetic stream in three orthogonal reels. The equipment consists of a transmitter attached to a stand and a certain number of sensors on the body connected to the transmitter by cables. Since the system registers not only the position but also the orientation of the sensors in space, a smaller number of markers can be used than for optical scanning (e.g., for observation of a knee angle, one sensor on the thigh and another on the tibia are sufficient).

The disadvantages include the above mentioned cables and also limited space around the stand with the transmitter ensuring signal accuracy (with increased distance from the transmitter, the signal becomes non-linear). The magnetic system absolutely cannot be used in the presence of any objects influencing the electromagnetic field (metal, computer screen, electrical lighting). For this reason, without complicated arrangements, the movement recording cannot be used simultaneously with metal EMG electrodes, treadmills or stabilometric platforms that serve for measuring kinetic (force) aspects of movement (e.g., locomotion).

4.1.2 Kinetic Analysis (Posturography) Ondřej Čakrt Physics Basis of the Examination During posturographic examination, reaction forces are measured, or their breakdown in three mutually perpendicular planes acting on a tensometric platform. The primary acting force affecting the platform is the patient’s gravitational force. The tensometric platform measures reaction force, which reacts to the patient’s gravitational force based on the law of action and reaction. The secondary reaction forces include the reaction forces of the muscles transferred to the platform. These forces constantly react to the oscillation of the center of gravity during standing. Individual components of the reaction force (anterioposterior, mediolateral, and vertical) and their moments are scanned via piezoelectric tensiometers located in the platform’s corners. From the scanned values, by a mathematical modification, the center of pressure (COP) can be calculated. COP represents a weighted average of all such pressure forces that act into the support surface. The platform registers COP’s position in time. Computer posturography is an electrophysiological examination method that allows assessing motor balance mechanisms participating in maintaining postural stability. Based on the results of

posturographic assessment, contribution of individual sensory systems on balance control can be determined. The examination is performed on a tensiometric platform or a force plate. The most utilized systems include Kistler, AMTI, Bertec and NeuroCom. Kistler force plates are used primarily in biomechanical research. The NeuroCom system is specifically designed for clinical use because it is equipped with a software application that allows for the assessment of individual test results and comparison with normative values of healthy individuals. The following represent the tensiometric platform output parameters: The amplitude of COP deviation in anterior-posterior and mediallateral directions; The length of trajectory that the COP undergoes during the measurement; The surface of the confidence ellipse. The confidence ellipse is a surface including the largest concentration of changes in COP position during the measurement. In practice, 90% or 95% of the entire surface of the COP is most commonly used. The obtained values are mathematically processed and yield additional data, such as the frequency of oscillations of COP or the rate of change of COP during balance reaction. The graphic presentation of the COP trajectory is called a stabilogram. Posturography in a Clinical Setting Posturographic examination is used mainly for objectification of balance deficits in a patient with balance dysfunction. It needs to be kept in mind that this is not a diagnostic method. The results of posturographic measurements should be carefully compared with the patient’s main diagnosis and other test results. Posturography has an important use in the observation of a developing balance dysfunction over time or for monitoring a treatment influence on a stability deficit.

The majority of posturographic systems have an integrated module allowing balance training with feedback utilization. The patient can visually control the position of the center of mass on a monitor during practice. Static posturographic examination is performed by measuring stability under conditions in which neither the patient nor the tensiometric platform are moving (standing examination). The majority of systems also allow for the examination of other modifications in standing (e.g., heel-toe standing, standing on one foot). During the assessment, individual sensory systems can be tested selectively by eliminating vision or by changing proprioceptive input from the platform (e.g., foam rubber, vibratory stimulation). Dynamic testing includes the examination of situations in which the patient is moving on the platform or the platform is moving with the patient. In the first scenario, it is an assessment of walking and its modifications. We can also assess more coordination challenging movement activities, such as turning in space or climbing over an obstacle. In the second scenario, the patient’s balance is examined while their balance is perturbed by an external stimulus. Most frequently, translatory movement of the platform in an anteriorposterior or medial-lateral direction is used. Another option is to tilt the platform along its horizontal axis. In both scenarios, specifically the reaction times of the patient’s balance reactions are assessed. These balance reactions show a delay of 70-180 ms and are automatic postural reactions that are organized at the subcortical level of the CNS. Posturography in Direct Differential Diagnosis Some neurologic illnesses display such a specific posturographic pattern that the posturographic data helps determine the differential diagnosis: Patients with atrophy of the ventral aspect of the cerebellum show typical oscillations with a dominant frequency of 3 Hz.

Patients with primary orthostatic tremor show an increased activity of oscillations in the zone of 12-19 Hz; Patients with a somatoform phobic postural vertigo show increased oscillations in the frequency zone of 3.5-8 Hz. Factors Influencing Postural Stability Stability is influenced by biomechanical and neurophysiological factors. Biomechanical factors include: the extent of the base of support, patient’s weight and the height of their center of mass above the base of support. Stability is also influenced by the quality of the contact of the lower extremities with the mat (adherence) and the position of the individual movement segments. Neurophysiological factors include flawless, multisensory integration of vestibular, visual, proprioceptive and dermal information, the level of excitability of the nervous system and the quality of the feedback mechanisms regulating balance. Postural stability is also affected by psychological aspects.

4.1.3 Electromyographic Analysis in Biomechanics Milan Zedka, Petra Valouchová Electromyography (EMG) is an electrophysiological method that allows for an assessment of the condition of the skeletal musculature and its CNS control. It is based on scanning the electrical manifestation of muscle tissue by electrodes that serve as an antenna. If the electrodes are placed on a body surface, the examination is known as surface EMG; if the electrodes are placed directly into the muscle (these most often include needle electrodes but also flexible wire electrodes, micropipettes filled with an electrolyte, etc.), it is known as intramuscular EMG. Surface electrodes adhered to the skin scan the sum of potentials of many muscle fibers underneath them and provide global information about the activity of the entire muscle or its major portion (Fig. 4.1.31). Surface EMG is used mainly in rehabilitation.

Fig. 4.1.3-1 A schema of scanning electrical potentials from muscle fibers of motor units by surface electrodes and the signal presentation on the computer screen

Needle electrodes can provide information about activity of only specific fibers (in special circumstances even a single fiber), which is advantageous during a neurological examination (see below). A signal from the electrodes from various electronic instruments (ensuring its amplification, inhibition of unwanted signals, steadiness and digitalization) is led to a computer monitor (oscilloscope) where, from the deviation of the potential, pertaining information about muscle activity can be read. At the same time, the data represented on the monitor is stored in the computer’s memory for further processing. In biomechanical studies, electromyography with telemetric signal transfer can also be used to an advantage because it does not require a cable connection with the apparatus. The only cables limiting free movement in a large space are the cables between the superficial electrodes and the transmitter attached to the examined person’s body (e.g., on the belt). The electromyographs can be equipped by up to 16

channels that allow for observation of muscle activity in more muscles at the same time. Mathematical data processing by established methods (e.g., filtration, rectification, integration, RMS and so on) will yield quantitative parameters of the EMG signal that can be further compared. An amplitude analysis (e.g., average amplitude, maximum amplitude, surface under the curve) and frequency analysis (e.g., average frequency, mid-frequency, proportional distribution of frequencies) are performed. In rehabilitation, electromyelography is used mainly for biomechanical analysis of motor skills. It is used as: 1. Indicator of muscle coordination; 2. Indicator of the force developed by a muscle contraction; 3. Indicator of the level of muscle fatigue. In all three scenarios, the preference is to use surface EMG because it is less invasive than needle EMG and the signal better depicts muscle function as a whole. Examination of Muscle Coordination In rehabilitation, EMG is primarily used for observation of intermuscular coordination during simple and complex movement activities, such as sit to stand, walking, jumping, etc. (Fig. 4.1.3-2; Fig. 4.1.3-3).

Fig. 4.1.3-2 EMG recording without rectification (erector spinae and ischiocrural muscles) with trunk extension in prone position

Fig. 4.1.3-3 A protocol of functional symmetry of linear abdominal muscles. The EMG curves and numeric values of their average and maximal amplitudes.

In more concrete terms, we perform: • An assessment of the percentage distribution of muscle activation. This means that we observe to what extent the muscle is activated under various situations and in various positions (e.g., the level of activation of individual segments of the abdominal muscles during different types of exercise). An assessment of bilateral symmetry in muscle activation (for example, the amount of symmetry during activation of the extensors or flexors of a healthy knee joint and a knee joint after an ACL rupture). An assessment of “timing” (time sequence) of activation of individual muscles (e.g., time sequence of activation of the erector

spinae, gluteals and ischiocrural muscles during spinal extension). “Biofeedback” – principle of feedback in motor learning, which is used to establish a threshold (amplitude) for a desired muscle activation or relaxation (e.g., relaxation of the upper trapezius during arm abduction into the horizontal level is required – the patient observes the extent of actual muscle relaxation or activation on the monitor). By EMG synchronization of kinematic and kinetic signals from other instruments, a record develops providing the examiner with objective data about a performed movement. Examination of Force Based on surface EMG, a force elicited by a contraction of a given muscle can be determined to a certain level of accuracy (Fig. 4.1.3-4). Fig. 4.1.3-4 An isometric muscle contraction. The force elicited by a muscle is proportional to its electric activity.

The effort to use EMG signal for determination of force comes from the observation that EMG amplitude is proportional to the force exerted by the corresponding muscle. The problem lies in the fact that the relationship is not simple. Due to technical and anatomicalphysiological reasons, no one method exists that would be applicable to all types of muscle contractions by all muscles. With good knowledge of this issue, for example, the relative contribution of individual muscles to the total moment of force (torque) acting at the articulation of two body segments can be determined quite accurately. Next to the above mentioned parameter of amplitude analysis, the force produced can be compared to the so called total power of the electromyographic signal.

Assessment of Muscle Fatigue During biomechanical studies of human movement, it is often desirable to assess muscle fatigue of the muscles participating in a given movement. Physiologists usually define muscle fatigue as the inability of the muscle to continue to produce a given force. This definition is based on the fact that there is a point in time, a so called failure point, starting from which the muscle can be described as fatigued. This definition possesses a few disadvantages: Muscle fatigue cannot be detected (measured) until the time it presents. At the same time, it is beneficial to recognize imminent muscle exhaustion and take appropriate measures to prevent it. With submaximal contraction, the total force moment acting in a joint can be maintained constant (meaning no mechanical muscle failure occurs), although the physiological and biochemical changes are already occurring on a microscopic level. The mechanisms reflecting the change in a way of force production include, for example, change in the intake and frequency of burning motor units or increasing the force of individual twitches of motor units. The overall measured force moment in a joint may not exactly reflect the condition of the examined muscle (it could be influenced by other muscles acting around the joint). The moment at which the force decrease occurs is influenced, not only by physiological, but also by psychological factors whose relative significance is difficult to measure. For the above described reasons, many authors prefer a description of fatigue that is a gradual process occurring in an examined muscle. The known characteristics of the EMG signal are used from a continuously contracted muscle, or a change in the power spectrum calculated by Fourier transform. This change related to muscle fatigue lies primarily in the shift toward a stronger presence of the lower frequencies and an overall narrowing of the spectrum (Fig. 4.1.3-5). The connection between the change in the EMG spectrum and the

force generated by a fatiguing muscle has been confirmed by many studies and validates its use in quantification of muscle fatigue, although a causal relationship between the two processes has not yet been established. The explanation for what exactly causes the shift of the spectrum toward the lower frequencies is not available. A change in frequency in firing motor units and a change in the shape of their action potential are being considered. Muscle fatigue (especially during isometric contraction) can be expressed, for example, by a fatigue index calculated from the parameters of frequency analysis.

Fig. 4.1.3-5 Setting of fatigue in an isometrically contracted muscle expressed by shifting of the power spectrum of an EMG signal toward lower frequencies

4.2 SUPPLEMENTAL NEUROLOGICAL EXAMINATIONS Milan Zedka

4.2.1 Electromyography In neurology, the purpose of EMG is not the exploration of muscle movement patterns. The examination is performed by a speciallytrained neurologist to determine whether the pathological muscle behavior (weakness, pain, etc.) originates in the muscle itself (myogenic lesion) or in the nervous system innervating the muscle (neurogennic lesion). Basic Types of Examinations Electromyographic examination usually starts by measuring the muscle’s innate activity, which is its electrical activity without an external stimulation. The intramuscular needle electrodes are mainly used. At first, the muscle is examined at rest followed by volitional contractions of various strengths. In a healthy, completely relaxed muscle, there should be no activity present at rest. With volitional contraction, the needle registers potentials of individual motor units. Normally, the space and time recruitment of various units occurs simultaneously. With an increased effort, the frequency of firing already active units increases and, simultaneously, new units are recruited until a full interferential pattern is formed (Fig. 4.2.1-1). With insufficient muscle activation due to an illness or a patient’s lack of cooperation, the interferential pattern stays incomplete.

Fig. 4.2.1-1 Gradual recruitment of motor units and a simultaneous increase in the frequency of their firing leads to an increase in muscle force. The last line shows an interferential pattern formed by the summation of electrical activities of individual motor units.

If a neurogenic lesion is suspected, nerve conduction velocity of the peripheral fibers can be assessed. During motor fiber assessment, surface electrodes placed above the muscle are usually used. Proximally, in the area of the corresponding nerve close to the surface, a stimulation electrode is placed on the skin. One short electrical impulse can elicit a change in potential in a surface electrode and its latency and amplitude can be read on the screen. By repeating the impulse at a different distance from the muscle, another potential is seen on the screen whose latency and amplitude are documented. From the difference in the distances between the stimulated areas and the difference in the latencies of both potentials, a desired conduction

velocity of an examined nerve segment can be calculated (Fig. 4.2.1-2). The examination of sensory fibers occurs similarly with the exception of the surface electrodes not being placed over the muscle but above the nerve itself. Besides the conduction velocity of the nerve trunk, the distal latency can also be measured, which is an important finding in certain types of distal neuropathies.

Fig. 4.2.1-2 Measurement of nerve conduction of an input in motor fibers of the median nerve. The nerve is stimulated by electricity at first at point 1 followed by point 2. The EMG signal is scanned by electrodes located on the abductor pollicis brevis muscle. The conduction velocity is calculated from the distance between the areas of stimulation and the difference in the latencies of the evoked potentials.

The quality of input conduction in the proximal part of the peripheral system (in spinal roots) and in the corresponding spinal segment can be examined with the help of the H-reflex and the F-wave. To understand the principle of these standard neurophysiological examinations, it is important to mention that electrical stimulation of a mixed peripheral nerve (anywhere along its course) evokes three types of responses in the EMG electrodes placed on the muscle: the M-wave, the H-wave, and the F-wave. The M-wave has the shortest latency. Its name (M-motor) suggests that it enters the muscle from the point of stimulation by motor axons

in the direction of natural activation. The H-wave (H-reflex) has a longer latency than the M-wave because the electric input is spread in a centripetal (ascending) fashion, and after its passage through the spinal cord (delay on the synapse), it continues distally toward the muscle. It is the only one of the three responses mentioned above that exhibits a reflex process. It is named after P. Hoffmann who described it at the beginning of the 20th century (Fig. 4.2.1-3). The centripetal component of the reflex arc is mediated by strong afferent fibers that originate in the muscle and enter the spinal cord via the dorsal horns (Ia fibers). The centrifugal part is led to α-motor neurons of the ventral spinal horns. Since the afferent fibers are stronger than the efferent fibers, the H-reflex has a lower threshold than the M-wave. The H-reflex has the most significance in the assessment of spinal excitability (often expressed as a H/M ratio). In peripheral involvement (neuropathy, plexopathy, radiculopathy), the H-reflex is used for assessment of the dorsal spinal roots.

Fig. 4.2.1-3 The H-reflex of the soleus muscle. By electrical stimulation of the tibial nerve in the popliteal fossa a potential is evoked that spreads in motor fibers of the muscle (the M-wave), but also by sensory fibers (Ia) in the direction toward the spinal cord where it activates an α-motor neuron. In an EMG of the soleus muscle, the activity of the α-motor neuron is manifested as the H-wave. In the schema, the course of the M-wave is shown by a black arrow; the course of the H-wave by a green arrow.

The F-wave has a similar latency as the H-wave. But in contrast to the H-wave, the potential does not lead from the point of stimulation toward the spinal cord via centripetal fibers, but it moves through a motor axon toward the body of the α-motor neuron (therefore, in the opposite direction seen during natural activation). The evoked depolarization of the body of the motorneuron results in the formation of an action potential, which spreads back distally to the area of stimulation and further toward the muscle and EMG electrodes. Thus, the F-wave does not reflect a reflexive process. It testifies about the activity of the α-motor neuron (body and the axon), not about the function of the posterior spinal roots or the synapses in the spinal cord as is the case with the H-wave. The examination of the F-wave has the most benefit when the anterior spinal roots are involved (e.g., Guillain-Barre syndrome), in which nerve conduction in the distal segments of the nerve can be normal. Next to these basic terms, a blink reflex will be mentioned for rehabilitation purposes. It is an electrical equivalent to a corneal reflex used during clinical neurological examination (Fig. 4.2.1-4). The ascending path of this reflex is formed by the sensory fibers of the trigeminal nerve (cranial nerve V); the centri​fugal part is formed by motor fibers of the fascial nerve (cranial nerve VII). A correctly executed reflex indicates the integrity, not only of the afferent and efferent pathways, but also the correct function of a substantial portion of the brain stem. Instead of contact with the cornea, the upper branch of cranial nerve V stimulates the electrical area of the supraorbital arch. There are usually two responses to the electric reaction connected to a reflex blink of an eye that are registered by electrodes located on the muscle closing the eye (R1, R2). Based on the response latencies and amplitudes, the area of deficit within the

reflex arc can be identified. The examination is beneficial when trigeminal neuropathy, multiple sclerosis, a tumor of the pontocerebellar corner, or polyradiculitis of Guillain-Barre or Bell’s palsy are suspected. With peripheral fascial palsy (damage to the nerve most frequently by an inflammation, injury or compression in a narrow bony canal of the petrous bone [os petrosum]), the facial nerve, as well as the blink reflex, is also examined by electrical stimulation at the point where it exits from the skull into the stylomastoid foramen. The examination should be performed approximately 1 week after the onset of facial paresis when degeneration of the distal nerve usually occurs. The size of the amplitude of the action potential in the facial nerves, when compared with the contralateral side, is proportional to the number of preserved motor fibers and, thus, the prognosis of further progression of facial paralysis.

Fig. 4.2.1-4 Blink reflex. A – EMG scanning from orbicularis oculi muscle, which is innervated by the ipsilateral nucleus of cranial nerve VII. Electrical stimulation of the ipsilateral cranial nerve V above the orbit (at point 1) elicits a fast response R1 and a slower response R. The contralateral stimulation (at point 2) elicits only response R2; B – The interconnection schema in the brain stem

Primary Abnormalities of an EMG The pathological process can occur at the level of the neuron (its axon, myelinated sheath or its body in the ventral spinal horns),

muscle fibers, or at the neuromuscular junction. With the help of EMG, the area and type of lesion can, to a large extent, be determined (often it allows to better target or eliminate an invasive histological examination). Neurogenic Lesion Axonal Lesion Acute, subacute and chronic lesions can occur and each one demonstrates characteristic signs. Here, for short, only the acute nerve injuries will be mentioned (Fig. 4.2.1-5). Following the first days after injury, the electrophysiologic characteristics of the distal nerve segment are normal (for example, conduction velocity, amplitude of the evoked potential) and the spontaneous volitional activity is dependent on the number of preserved axons. Starting by the fifth day, the nerve becomes less and less excitable, and between the 6th and 8th day stops conducting the potentials completely (if all axons are disrupted). After two weeks, anarchic spontaneous EMG activity occurs in the denervated muscle fibers – so called fibrillation potentials or positive sharp waves.

Fig. 4.2.1-5 Axonal injuries. A – undisturbed axon with myelinated sheath; B – axonal injury, gradual degeneration of its distal part and disintegration of the myelin sheath; C – regeneration of the axon by sprouting and growing of the processes in the direction of the muscle; D – renewal of the myelin sheath (often not functionally fully-fledged)

Subsequent reinnervation occurs by sprouting of the axonal processes of the preserved neighboring axons (it is quite fast) and growth of the disrupted axon (on average 1mm per day). The electrical

signs of nerve regeneration can usually be observed after 3–4 months as polyphasic reinnervation potentials, whose amplitude gradually grows. Nerve conduction velocity is slow at first and gradually increases, but it seldom reaches the pre-injury values. Volitional contraction with a decreased number of active motor units produces a poor interferential pattern brought about by a compensatory increase in the recruitment of the remaining units. If the entire nerve is completely disrupted (including connective tissue canal), new fibers find their way toward the muscle only after surgical re-connection of the residual ends. In such a scenario, the first EMG signs of reinnervation appear later (usually after 6 months) and the reinnervation is insufficient. Demyelinating Lesion This is a lesion of varied extent occurring with an injury to the Schwann cells or the myelin sheath. The interferential pattern with volitional contraction is not altered and there are no signs of active denervation. A demyelinating lesion mainly influences conduction velocity and distal latency. It has a small influence on the size of the amplitude, nonetheless, a conduction block can be formed, in which the transition of nerve potentials in a certain segment is slowed down or completely interrupted (Fig. 4.2.1-6). It is manifested by decreased amplitude or complete signal obliteration beyond the blocked region. However, the slowing down of a nerve fibers’ conduction velocity does not always correlate with the depth of the motor or sensory loss. The deficit is rather proportional to the size of the conduction block or the degree of the current axonal degeneration.

Fig. 4.2.1-6 A conduction block with peroneal nerve compression behind the fibular head. A – A schema of a local injury to the myelin sheath; B – normal amplitude and latency of motor action potential in the extensor digitorum brevis muscles with electrical stimulation at points 1 and 2. Extended latency and decreased amplitude of the potential with stimulation above the involved area at point 3.

Neuronopathy It includes a group of illnesses in which the neuronal body forming the peripheral nerve is injured. In motor neuronopathies, the pathological process is found in the ventral spinal horns. These diseases include amyotrophic lateral sclerosis (ALS) and various types of spinal muscular atrophy (SMA). Conduction velocity of the motor fibers is not decreased or only slightly decreased. The amplitude of

potentials is decreased proportionally to the neuronal loss. At rest, needle EMG shows significant denervation activity. With contraction, the pattern is very poor – sometimes with “giant” potentials above 10 mV. In sensory neuronopathies, the spinal ganglia are primarily involved and the motor component of the nerve is not involved. The most common diseases include: shingles, Sjögren’s syndrome or DennyBrown ganglionopathy as a component of Hu syndrome. With general validity of the above information, it needs to be mentioned that the signs of axonal and demyelinating lesions are simplified here. In reality, an axonal lesion can decrease conduction velocity, for example, in a scenario where the fast conducting fibers are preferentially involved. A demyelinating lesion can decrease the response amplitude by desynchronization of input conduction along the nerve. Myogenic Lesion This pathological process involving mainly muscle fibers can be manifested by a change in the shape of potentials of a motor unit (decreased amplitude and duration, polyphasic shape) and/or disproportionate recruitment of motor units (an ample interferential curve with a weak mechanical performance). Some muscle pathologies manifest themselves by abnormal electrical activity at rest, for example, myo​tonia (myotonic firing) or myositis (fibrillar potentials). Nerve conduction velocity is never decreased in myogenic lesions. Injury of the Neuromuscular Junction When suspecting a deficit in neuromuscular plate function, electrical stimulation of the motor nerve is repeated while simultaneously detecting muscle activity by a needle electrode. Two main pathological patterns exist. In post-synaptic involvement (for example, myasthenia gravis), with slow stimulation (3 Hz), gradual failure in the transmission of the nerve stimulus to the muscle occurs, which is manifested by a gradual decrease in the amplitude of

potentials observed on the screen (at least by 10%). In pre-synaptic involvement (for example, Lambert-Eaton syndrome), due to so called potentiation, the response amplitude gradually increases up to 50% with stimulation at 20–30 Hz.

4.2.2 Electroencephalography Electroencephalography (EEG) documents spontaneous electrical activity of the brain. The basic components of the electroencephalograph are similar to the above described electromyographic instrument. For common examinations, surface electrodes are used and placed on the skin of the head. From there the signal is lead by cables to an instrument to undergo modifications so that it can be read on a computer screen. The examination is an outpatient procedure taking approximately 30 minutes. The deviations in the electric potentials are interpreted in a wave form. Mainly the frequency, amplitude, shape, position, and side symmetry are assessed. Assessed by the naked eye, the frequency zones are most often denoted as δ (1–3 Hz), θ (4–8 Hz), α (8–12 Hz) and β (above 12Hz). Spectrum analysis detects even frequency zone γ (36–44 Hz). The electrodes can be placed on the skull in various ways. Most often, the system 10-20 is used (Fig. 4.2.2-1). Its name was developed based on dividing the distance between the nasal root (nasion) and the occiput (inion) into defined segments. Since the nasion-inion distance is different for each person, the length of the segments is given in percentages. The forehead electrodes (Fp) are placed 10% from the overall distance from the nasion, frontal (F), central (C), temporal (T), parietal (P) and occipital (O) electrodes are distanced by 20% of one another. Each electrode position is marked not only by a capital letter, but also by an index in the form of a number or a small letter (letter z denotes the placement in mid-line; p placement on the forehead). Odd numbers (1, 3, 5, 7) denote placement above the left hemisphere; even numbers (2, 4, 6, 8) placement above the right hemisphere (for example, T3 electrode is found above the left temporal lobe). The signal from each electrode can be drawn toward the signal of the neighboring electrode or a distant reference electrode

or even to the value obtained by a calculation from the signals of more electrodes. Based on this relationship between the electrodes, we describe bipolar connection (perpendicular or parallel), referenced, informant, etc. The view of the EEG signal from more connections allows for assessment of the brain activity from different angles. The essence of the EEG analysis is the observation that the occurrence of a certain type of electrical activity corresponds to a certain state of the brain. For example, it is known that when adults are awake with eyes closed, a symmetrical activity in zone α above the occipital lobes occurs and disappears with the eyes open. Thus, this maneuver is a common component of EEG examination. Other maneuvers include, for example, deep breathing (hyperventilation) and light blinking when the eyes are closed (photostimulation). They can detect pathological activity. Fig.4.2.2-1 Standard positioning of EEG electrodes – system 10-20

Without a doubt, epilepsy is the most common pathological process examined by EEG (Fig. 4.2.2-2). In the majority of cases, surface EEG detects pathological activity and is sufficient for observation of treatment effects. In cases when a surgical procedure is being considered for the treatment of epilepsy, superficial electrodes are not sufficient to accurately identify the area of epileptic activity. Electrodes are placed directly in the brain (placed under general anesthesia by a neurosurgeon). EEG recording by subdural or intracerebral electrodes occurs during several days or weeks of hospitalization followed by a decision about the patient’s candidacy for surgery. Next to epilepsy, surface EEG is also indicated for disturbances in sleep, speech, consciousness and to confirm brain

death. Since the objective interpretation with the help of computer programs is not yet sufficiently reliable, a visual assessment by a specialized neurologist is still the most practical way of EEG analysis.

Fig. 4.2.2-2 EEG presentation of brain epileptic activity. Generalized firing

From the perspective of exploring the co-activity of the nervous and muscle systems, EEG-EMG correlation is now going to be briefly mentioned. This examination is not very common in clinical practice, but it does have its importance there, for example, to distinguish epileptic myoclonus from non-epileptic one, followed by determination of whether the epileptic myoclonus originates in the cerebral cortex or lower control centers. By simultaneous EEG and EMG recordings, it can be identified whether certain events in these two recordings are time related (correlate) and to what extent. It is important to assess the time succession of the processes. It can be attempted to correlate EEG and EMG in a continuous recording, but in practice, it is more beneficial to observe only the segments of the EEG that correspond to a discrete events in the EMG, for example,

the onset of muscle activity. Mathematical averaging of an EEG segment “initiated from EMG” (EMG-triggered) allows for the development of even small but almost always present changes in the EEG that would otherwise stay hidden in a disorganized continuous EEG signal. Attention is paid not only to the short EEG segment prior to an event in the EMG but also to the segment immediately following the onset of movement. In the case of epileptic myoclonus, EEG can be observed with a prerogative of several milliseconds. The segment prior to an onset of activity is interesting also from a research perspective as to the mechanism of volitional movement in healthy people. Up to an entire second prior to the onset of a purposeful upper extremity movement (from the perspective of the CNS function this is a long time), the development of a negative “preparatory potential” (Bereitschaftspotential, readiness potential) is observed in the primary motor cortex of the contralateral hemisphere. The EEGEMG correlation method is also used by scientists to understand the relationship between the neurons of the motor cortex and the neurons of the anterior spinal horns during muscle contraction. It is possible that by comparing the results in healthy individuals and, for example, patients after a CVA with a spinal cord injury, we can draw nearer the explanation of mechanisms of processes that are characteristic for central muscle paresis (weakness, ataxia, fatigue). Magnetoencephalography (MEG) is a method similar to EEG from the perspective of brain activity scanning. It is technically more demanding than EEG and that is why it is used primarily for research purposes. This method is based on the fact that active neurons of the brain produce an electric current and, therefore, also a magnetic field registered outside the skull. Since the magnetic field is very weak, the examination must occur in a special room protected from the surrounding magnetic and radio noise. Not electrodes, but rather induction coils placed in a helmet are used for scanning. The coils are made of supraconductive materials and must be cooled by liquid helium. The electric current, which inducts a magnetic field of neurons, can be expressed as an electric potential thanks to another device and, after a computer modification, can be displayed, for

example, as a map of brain functions (MEG, similarly to EEG, examines brain function and its structure). In contrast to EEG, MEG has a much greater time delineating capability and it is often used in combination with other methods (evoked potentials, PET, functional MRI) for research of various functions of the nervous system.

4.2.3 Evoked Potentials The examination of evoked potentials (EPs) mainly contributes to the detection of subclinical disturbances and to more accurate specification of clinical neurological findings. Abnormal results suggest disruption in function of certain ascending and descending tracts. The most commonly examined ascending tracts include somatosensory pathway (somatosensory evoked potentials, SEPs), visual (visual evoked potentials, VEPs) and auditory (auditory evoked potentials, AEPs). The descending tracts that can be examined include the pyramidal motor pathway with the help of electric or magnetic stimulation of the cerebral cortex (motor evoked potentials, MEPs). Since electrical stimulation through the scalp is painful, it is only used under general anesthesia during neurosurgical and orthopedic procedures. During an outpatient examination, non-painful brain stimulation by a magnetic field is used (transcranial magnetic stimulation, TMS). This method of nervous system examination by evoked potentials is based on the fact that the stimulation at one end of the nerve tract evokes an electrical signal that advances along the given nerve pathway. Some areas along its course form an electrical potential that can be scanned from the body surface either close to the area of their formation (near field potentials) or in a distant area (far field potentials). These areas of potentials formation include synaptic transfers, changes in the direction of axonal orientation, or an axonal entry into a differently conducting environment. Near field potential represents the passageway of action potentials under scanning electrodes or the post-synaptic response in their proximity (majority of peripherally scanned responses). A typical example of far field

potentials represents auditory potentials of the brain stem in which the maximum amplitude is above the vertex. The electrodes are placed on the body so that they capture the highest amplitude from the scanned potentials, that is, into an immediate proximity of their source for near field potentials and mostly on the scalp for far field potentials. The wave of potentials passing toward the brain is chronologically captured by scalp electrodes as a series of positive or negative waves that are denoted by letters P or N and a number expressing their latency (for brain stem auditory potentials, it is customary to mark the waves by numbers I– V). Somatosensory Evoked Potentials The examination verifies the quality of conduction in the peripheral nerve, spinal cord (posterior tracts), brain stem (medial lemniscus), thalamocortical connections and the primary sensory cortex. Common somatosensory evoked potentials (SEPs) do not assess pain pathways (for this purpose, nociceptive evoked potentials are more appropriate). The most common reasons for this examination include spinal cord injuries, brachial plexus injuries, spinal root avulsions, CNS involvement due to cerebrovascular accident, tumor, or multiple sclerosis. A negative result on the examination may contribute to the diagnosis of psychosomatic problems. During assessment of the centripetal pathway, the median nerve in the upper extremities and the posterior tibial nerve in the lower extremities are most commonly stimulated. Based on the patient’s symptoms, any major nerve in the upper extremities can be stimulated (ulnar, radial, peroneal, saphenous nerves). The distal segment of the peripheral nerve is stimulated (wrist or fingers on the upper extremity, medial ankle or the toes on the lower extremity) by an intensity close to the motor threshold (for mixed nerves) or three times the sensory threshold (in strictly sensory nerves). The scanning electrodes are placed gradually at various levels of the centripetal pathway. In the upper extremity, they are placed at the level of the brachial plexus (Erb’s point), neck and both sides of the head (Fig. 4.2.3-1). In the

lower extremities, the electrodes are placed in the lumbar and cervical spinal regions and at midline on the head. In all instances, it is recommended to also place the electrodes on the peripheral nerve (antecubital and popliteal fossa) to control the adequacy of stimulation with a lack of response at higher levels. To obtain a quality resultant curve with a minimum number of artifacts, 500–2,000 curves are instrumentally averaged. Fig. 4.2.3-1 SEP examination by electrical stimulation of the median nerve. The placement of stimulation and scanning electrodes and their corresponding recording.

The examination takes several minutes. Clinically relevant components (peaks) of SEP with stimulation of the median nerve are, in order of their latencies, as follows: 9 ms – peripheral response – passage of action potentials through the brachial plexus (Erb’s point); 11 to 13 ms – spinal cord response – post-synaptic potentials formed by the neurons of the posterior horns of the cervical spinal cord and their advancement in the posterior tracts; 14 to 18 ms – response from the medulla oblongata and the brain stem – post-synaptic potentials formed by the neurons of the Burdach nuclei and their advancement via the medial lemniscus to the thalamus; 20 to 70 ms – post-synaptic responses from the cerebral cortex – sources of waves generated in this wide time range are found in the primary sensory cortex (S1) but also in the primary motor cortex (M1). Identification of individual waves is dependent on the placement of the scanning electrodes. Therefore, it is necessary for the testing laboratory to record the ways in which the curves were obtained. Most often, the SEP from the upper extremity is displayed as a sequence of positive (P) and negative (N) waves: N9, N13, P14, N18 and N20. The number in the wave denotation corresponds to its normal latency in milliseconds. With posterior tibial nerve stimulation behind the medial ankle, based on the placement of the scanning electrodes, potentials are registered for the following areas: the lumbar plexus and lumbar spinal cord (N20-25), cervical spinal cord (P31), thalamic potentials (P35/N40) and cortical potentials (P38, P60). Visual Evoked Potentials (VEPs) Stimulation of the visual organ by light can elicit an electrical potential in the retina (electroretinogram, ERG) and in the visual cortex. In practice, two types of stimuli are used – unstructured flashes and structured light stimuli (pattern reversal). Surface flash

stimulation is performed by special glasses. Structured stimulation can be administered either by glasses with a built-in system of light points (diodes) or more often by a highly contrasting, interchangeable checkerboard reflected on a screen placed in front of the patient. The checkerboard consists of black and white squares that alternate in a regular pattern (black squares change into white ones and vice versa). The task of the examinee is to gradually fix each eye separately at the center of the screen (cross). In certain scenarios, only a part of the visual field can be stimulated. For greater accuracy, structured stimulation is used more often than flash stimulation. Flash stimulation is used primarily in uncooperative patients (children, unconscious patients). It needs to be mentioned that VEPs elicited by a flash do not possess an outcome value related to visual acuity. Scanning of cortical potentials by electrodes placed on the occipital region of the head yields an averaged curve that has a typical shape of N-P-N, or rather a negative N70, positive P100 and negative N135 wave (Fig. 4.2.3-2). A deviation from the norm such as longer latencies or changes in the amplitude of such waves suggests pathological processes involving the entire visual tract. VEPs are influenced by eye diseases (refractive defects, glaucoma, retinopathy), non-compressive lesions of the optic nerve (demyelination neuritis as an isolated illness or part of a diagnosis, multiple sclerosis, ischemic optic neuritis, toxic lesion or nutritional insufficiency), compression of the optic nerve or chiasm (by tumor or aneurysm) and, of course, diffuse illnesses of the brain (degenerative involvement, leukodystrophy, etc.). Fig. 4.2.3-2 VEP recording obtained by visual stimulation via checkerboard

The electrical activity of the retina can be examined by electroretinography (ERG). It is stimulated, similarly as with VEPs, by using a checkerboard or flashes. Although, it is recommended to place the active scanning electrodes directly on the cornea or the conjunctiva (as a modified contact lens), it is less taxing to place a hook electrode on the lower lid. The response to the checkerboard stimulus is formed mainly by P50 and N95 waves in which the first represents the activity of the photoreceptors and the other the activity of ganglionic cells of the retina. The outcome value rests primarily in the amplitudes of the responses. Auditory Evoked Potentials Auditory evoked potentials are electrical potentials formed in the peripheral and central segment of the auditory tract in response to auditory organ stimulation. The simplest stimulus into the headphone is a click, but a structured burst can also be used. To avoid the influence of the contralateral hearing organ, which would also react to the click given the osseous passage, the contralateral ear is simultaneously exposed to a masking white noise. Based on the latencies, the following auditory potentials are distinguished: short (BAEP < 10 ms), middle (MLAEP 10 to 60 ms) and long latencies (LLAEP > 60 ms). In clinical practice, given its consistency, the BAEP potentials are used most often and reflect the activity of the auditory tract up to the level of the brain stem. The longer latency potentials are more difficult to examine and are used mainly in psychology and in unconscious patients where the information about the activity of higher cortical centers helps assess the severity of a brain injury (Fig. 4.2.3-3). Fig. 4.2.3-3 AEP recording. A – Waves I–V develop in the brain stem (BAEP). The following waves reflect the activity of higher centers of the hearing tract; B – places of formation of waves I–V

BAEPs (brainstem auditory evoked potentials) are formed in the cochlear nerve and the brain stem structures of the auditory tract. These are far field potentials scanned by electrodes placed superficially on the mastoid processes and the vertex. By averaging 1,000 to 2,000 responses, a typical curve with five to seven peaks develops. Only the first five peaks are clinically important; the last two are often inconsistent. Not only the amplitudes and latencies of individual waves are assessed, but also the relative inter-peak latencies: Wave I – develops in the distal part of the auditory nerve; Wave II – develops in the proximal segment of the nerve or in the cochlear nuclei; Wave III – develops in the upper olivary complex; Wave IV – develops in the nuclei and the lateral lemniscal tracts; Wave V – develops in the inferior colliculus, usually on the contralateral side to the stimulation.

BAEP is a neurological examination, but some electric responses of auditory structures are also assessed by otolaryngologists (ENT’s). For example, to determine an objective auditory threshold, BAEP is assessed during various intensities of auditory stimulation (in this case, the examination is more often known as BERA – brainstem evoked response audiometry). The examination is used for patients unable to cooperate in establishing the subjective auditory threshold. Electrocochleography (ECoG) is another examination used in otolaryngology, in which a response to a click is scanned by a transtympanic electrode or by an electrode placed in the external auditory meatus. The recorded activity originates in the basilar cochlear membrane (microphone cochlear potential), mainly from fibers of the auditory nerve. Cochlear potentials are sometimes visible as the first components of BAEP. Motor Evoked Potentials (MEPs) In contrast to all the above mentioned types of evoked potentials, MEPs assess a descending nerve tract – the pyramidal tract. They originate in the cerebral cortex where it is influenced by other brain regions via supporting interneurons. Its first neurons terminate in the spinal cord where they transfer to motorneurons innervating the skeletal muscles. Instead of an unpleasant electrical stimulation, transcranial magnetic stimulation (TMS) is used for the functional assessment of this corticospinal tract. TMS is based on the non-invasive induction of an electrical current in the cerebral cortex by a magnetic field (produced by a coil placed on the head), which passes pain-free through the tissues covering the brain. The electrical current activates superficially laid interneurons that also have, among other connections, a contact with the pyramidal tract. The effectiveness of cerebral cortex stimulation is measured by surface EMG electrodes placed on the skeletal muscles (Fig. 4.2.3-4). Based on the latency and amplitude of the deviation in the EMG signal, it is possible to assess whether the tract is involved in a pathological process. Isolating an issue with the peripheral nerve can be performed either by classical EMG testing (H-reflex, F-wave) or by

moving the magnetic coil from the head to the level of the spinal roots (cervical for the upper extremities and lumbosacral for the lower extremities) and by repeating the stimulation. The time it takes to pass through the central tracts (central motor conduction time, CMCT) can be obtained by subtracting the peripheral latency from the total latency. Central conductivity is disrupted in multiple sclerosis, tumors, infections, cerebrovascular events and, of course, in spinal cord injuries. Next to a diagnostic value, this method is suitable for monitoring progression of the injury. Fig. 4.2.3-4 Motor evoked potentials obtained by transcranial magnetic stimulation of the cerebral cortex – an integration schema

Transcranial magnetic stimulation can (next to MEPs) be used to establish the excitability of the cerebral cortex and to assess the connections between the individual cortical centers. The cortical stimulation is not performed by an individual pulse but rather by paired or multiple pulses. In combination with peripheral electrical

stimulation, TMS can also be used to examine other functions of the nervous system. The potential use of TMS in therapy should be mentioned. It was found that a repeated series of intense magnetic pulses (so called repetitive TMS) elicits plastic changes in the CNS beyond the time of stimulation. Certain success was reached in psychiatric diseases. Intense research is underway to explore the possibility of improvement in a patient’s disability with Parkinson’s disease, spinal cord injury, and cerebrovascular accidents.

4.3 EXAMINATIONS BY IMAGING METHODS Pavel Kolář, Martin Kynčl

4.3.1 Radiologic Methods X-RAY EXAMINATION Pavel Kolář, Olga Dyrhonová X-ray examination of the movement system is the basic source of information about the skeleton and joints. The bones appear as dense shadows contrasting with half-shadows or clearings of surrounding soft tissues and organs. The soft tissues of the bones and joints (bone marrow, periosteum, cartilage, ligaments, joint capsule) are not visible on x-ray films. That is why the joint spaces appear to be wider on an xray film than in reality. Soft tissues are difficult to distinguish by standard x-ray examination because of their low absorption capability. For this reason, soft scanning techniques are used, which include low tension (25–40 kV) and an increase in the absorption difference. For example, the Achilles tendon is x-rayed in this way. Insufficient absorption of xray radiation can be influenced by local application of a positive contrast media into anatomical sinuses, spaces, or the vascular and lymphatic systems. For the purpose of treatment rehabilitation, it is necessary to assess the structural changes as related to the function, or whether they are the result or the cause of functional deficits. Based on clinical examination, it needs to be exactly clear what we are looking for on a given x-ray film. The spine and even the individual joints are always examined in two projections. The standard projections include the anterioposterior and side views (for some joints, the side view is replaced by an oblique view; for example, with foot imaging).

For rehabilitation purposes, in radiologic diagnostics, special radiologic projections are important and are aimed at a certain portion of a segment and are key in differential diagnosis. Shoulder Joint Y Projection, Tangential, Scapulolateral Projection with a 10-Degree Angle The Y projection is used for the subacromial space of the shoulder girdle. It shows the shape of the acromion and the width of the subacromial space (its narrowing due to the formation of acromioclavicular joint osteophytes or a superior shift of the humeral head in a rotator cuff lesion). Wrist Projection of the Scaphoid (Navicular) Bone This projection is designed for diagnosis of a scaphoid fracture or pseudoarthrosis (false joint). Hip Joint Axial Projection The axial projection of the hip joint is used to accurately determine the degree of involvement of the femoral head in hip joint disorders in children (for example, Legg Calve Perthes disease, or slipped capital femoral epiphysis). Other indications include the suspicion of a femoral neck fracture (mainly subcapitular) with negative anterior-posterior finding. Knee Joint Axial Projection of the Patellae This is a tangential view of the knee joints capturing the patellofemoral articulation. This view can illustrate the type of patella (based on the shape and the tilt of its joint surfaces), patellar alignment in the femoral groove and the width of the joint surfaces of the patellofemoral articulation. Sunrise View

The sunrise view is a series of three tangential films of the knee joint at 30, 60, and 90 degrees of flexion. In this view, movement of the patella in the patellofemoral groove during knee flexion is observed. Sunrise view as well as the axial patellar projections should be performed bilaterally to compare findings. Ankle Joint Sustained positions These images are used to identify acute or chronic ankle instability. The examination is performed by a radiology technician who positions the ankle in adduction and inversion under a radiological view. If an external widening in the talocrural joint occurs, a comparative image of the contralateral, uninvolved extremity is performed to eliminate a false positive test. Spine For clinical purposes, it is advantageous to distinguish three basic components of spinal radiological diagnosis: a. diagnosis of structural changes; b. functional diagnosis of spinal alignment; c. functional diagnosis of movement function. Diagnosis of Structural Changes Classic radiological diagnosis is focused on the assessment of spinal structural changes. The standard for diagnosis of structural changes includes anterior-posterior and lateral projections, in certain cases also supplemented by oblique projections. On the image, the following are being assessed: the shape of the vertebral bodies (height, regularity, shape of the surface areas), the osseous structure of the vertebral body, intervertebral articulations, width of the intervertebral space, integrity of the vertebral pedicle and the alignment (shift) of the vertebral bodies in the individual spinal segments. The shape of the vertebral body can be altered in a

congenital developmental defect (hemivertebra) or after an injury (fractures). Changes in the shape of the vertebral body are common in diseases that affect the osseous structure of the vertebral body and can lead to a pathological fracture – rheumatic diseases, infections (osteomyelitis), metabolic deficits (osteoporosis), or tumors. Change in shape of the articulating surfaces and Schmorl’s nodes are typical in Scheuermann’s disease. The presence and the extent of degenerative changes in the intervertebral joints are assessed. The height of the intervertebral space is given by the height of the intervertebral disc. Disc degeneration is suspected when a decreased intervertebral space is present. A disruption in the integrity of the vertebral pedicle is known as a spondylolysis. To confirm this diagnosis, oblique spinal images are obtained and the affected pedicle is seen as a “Scottie dog head with a collar.” A shift of the vertebral bodies on each other within one segment is known as a spondylolisthesis. Spondylolysis and spondylolisthesis can be occurring simultaneously. To assess segmental stability, dynamic views can be obtained – images in maximum forward and backward bending. Functional Diagnostics of Spinal Alignment Clinical assessment is usually so accurate that for a routine treatment, x-ray movement images are not beneficial. However, they can be helpful in certain cases. For assessment of alignment, mainly longitudinal images in standing are used. By obtaining images in standing, information about the alignment and the angle of the sacrum and the last lumbar vertebrae, or the true spinal base, can be obtained. This information is necessary for assessment of the entire spinal alignment and cannot be obtained by clinical assessment. Alignment is assessed in the frontal and sagittal planes. Spinal Alignment in the Frontal Plane To assess spinal alignment in the frontal plane, an anterior-posterior projection in a longitudinal format in standing is used. This image allows for the assessment of scoliosis. On the x-ray image, the following can be observed: the extent of the curvature, the character

of the curvature (C or S curve), curvature location (cervical, thoracic or lumbar), vertebral bodies rotation, the degree of bone maturity (based on the degree of ossification of the apophysis of the ilial bone – Harris sign), and primary and secondary curvatures. Also the parameters influencing the alignment can be observed – scoliotic curvature compensation (the line between the occiput in relation to the vertical axis of the sacral bone) or leg length discrepancy (the angle of the line running through the upper borders of the ilium). During spinal alignment assessment, we are not only interested in the spine while in relaxed standing, but also in its reactibility, such as when its base is tilted. The reaction to a tilt of the base is adequate if the scoliosis is on the lower side, the rotation is to the ipsilateral side, the thoracolumbar junction is located perpendicular to the sacral bone and the pelvis deviates toward the higher side. The most important pathological findings include: 1. Tilting of the base without scoliosis or with an insufficient scoliosis, during which the thoracolumbar junction does not reach a position above the lumbosacral junction; 2. Lack of a lateral shift of the pelvis toward the higher side; 3. Lack of rotation with scoliosis in a lordotic position or contralateral rotation on the side of the scoliosis. Spinal Alignment in the Sagittal Plane Spinal alignment in the sagittal plane needs to be assessed from the perspective of overall posture because the changes in curvature or deficits in stability elicit a response in the entire spine. Pelvic alignment is a key component in the assessment of spinal symmetry in the sagittal plane. Lumbar spine curvature and its influence on alignment cannot be assessed if the patient was not x-rayed in standing and the image is lacking a simultaneous view of the pelvis, hip joints, lumbar spine and the thoracolumbar junction. For an x-ray film performed in standing: the upper extremities are flexed at the elbow joints and fingers are placed in the hollowing

above the clavicles. It is suitable to wait 1-2 minutes to allow for relaxed standing. A vertical line is dropped from the center of the C7 vertebral body and the distance, in which it intersects the horizontal line leading through the posterior superior edge of the S1 vertebral body, is assessed. The intersection should be found approximately 5 cm from the dorsocranial rim of S1. If the dimension is greater anteriorly, a positive balance in the sagittal plane is present. If the dimension is greater dorsally, it is a negative balance. Some authors allow even a greater range of normal values. A vertical plumb line does not include cervical spine alignment, or the head; however, their alignment has a key significance for spinal statics and dynamics. The vertical line running from the center of the C7 vertebral body should pass through the external auditory meatus. Functional Diagnosis of Movement Function Spinal kinematics can be assessed from a movement study. The examination is indicated based on the findings from clinical assessment. The images are taken in forward bending, backward bending and lateral flexion. The alignment of individual vertebrae, hypomobility or hypermobility in individual segments can be evaluated on the images. Examination in maximum forward and backward bending should be part of pre-operative assessment and considered when procedures for disc lesions and nerve root syndromes are indicated. Spondylolysis and spondylolisthesis are additional indications for this examination so that stability or the extent of vertebral bodies shifting on one another can be assessed.

COMPUTED TOMOGRAPHY (CT) Pavel Kolář, Martin Kynčl Computed tomography is a radiologic densitometric method in which an image is reconstructed from digital data. During testing, the patient lays in an examination tunnel with built-in detectors and an xray tube. The radiologic radiation passes through the examined layer

of the patient’s body and is absorbed based on the atomic numbers of elements. The passed radiation reaches the detectors and is transmitted into an electrical signal. Based on the information obtained from the intensity of the passed radiologic radiation to the individual senses, an image of the examined layer is reconstructed. CT allows for a diagnostic orientation in all planes. Three-dimensional images can be obtained by digital processing and reconstruction. In contrast to the usual summation image, the difference is more pronounced and the soft tissues and organs are more defined. CT can display brain structures and the integrity of the hematoencephalic (blood-brain) barrier. It distinguishes clearly between brain bleeding, injury consequences, various types of brain atrophy and hydrocephalus. The advantages also include good imaging of bone surfaces and nearly a 100% detection of bleeding. With multi-detector CT devices, the examination takes several seconds and it is suitable for patients with a metal prosthesis or with implanted electronical devices, such as a cardiac pacemaker. Another advantage over magnetic resonance is wider accessibility and lower cost, sufficient distinction of oxygenated blood, better assessment of the lungs and a more accurate assessment of calcification and the bone cortex. The disadvantage includes ionic radiation. Another variant of CT is a CT with the use of xenon. It measures brain perfusion, determines ischemic brain conditions and uses existing CT devices. The disadvantage includes the side effects from higher xenon concentration. Spiral CT angiography provides a detailed vascular and skeletal anatomy. This method involves an intravenous administration of a contrast medium is used to diagnose obstructive vascular injuries, bulging of blood vessels and arteriovenous malformations.

MAGNETIC RESONANCE IMAGING Martin Kynčl, Pavel Kolář Magnetic resonance imaging (MRI) is a non-invasive method not burdened by ionization radiation. An image is obtained based on the

signal developed by the released energy from accumulated atomic nuclei in the tissues caused by a strong magnetic field. The atomic nuclei with an odd atomic number (for example, hydrogen) possess their own magnetic moment, known as the spin. If the nuclei are placed into a strong magnetic field, they orient themselves in its direction. These spins are also affected by impulses from the radiofrequency waves of the coil that causes a deflection of the spins from their original direction. If the radiofrequency waves stop acting on the nuclei, they return to their original state and, at the same time, emit the absorbed energy. The release of electromagnetic energy can be measured during the return from the deviated to original position. In the nuclei, a weak electrical current is inducted, which is the MRI signal. Complexly, the MRI is an aggregate of techniques that provide information about the structure, biochemistry and function of the brain and other tissues. Thanks to a high differential ability of the tissue, MRI allows for a good quality of images of the brain, spine and spinal cord structures, vascular supply, concentration of certain chemical substances in tissues, course of nerve fibers and the state of the blood-brain barrier. MRI helps in the diagnosis of acute ischemia, tumors, demyelination illnesses, epileptic center, degenerative illnesses, and infections. Equally, spinal soft tissues, disc herniations, and various soft tissue and muscular involvements can be observed. Also, the condition of joint cartilage, menisci and bone marrow can be assessed (Fig. 4.3.1-1; Fig. 4.3.1-2; Fig. 4.3.1-3; Fig. 4.3.1-4). Fig. 4.3.1-1 MRI, sagittal plane, Achilles’ tendon rupture

Fig. 4.3.1-2 MRI, frontal plane, Supraspinatus tendon rupture

Fig. 4.3.1-3 MRI, sagittal plane, L45 disc herniation

Fig. 4.3.1-4 MRI, frontal plane, quadriceps muscle tear

Recently, for specification of structural diagnosis of soft tissues, not only examination in supine/prone has been used, but also in sitting and standing. Postural loading accentuates the conditions found under dynamic circumstances. MRI disadvantages include long examination times, claustrophobic feelings, and patients with implanted electronic devices, such as cardiac stimulator and metal bone implants, cannot undergo the test. Functional Magnetic Resonance Functional magnetic resonance (fMR) allows for chemical, functional and angiographic imaging. Functional magnetic resonance is a modern imaging (and also examining) method, by which the functional parts of the brain, activated during the execution of a certain task or by stimulation, are mapped. Mapping is performed based on changes in blood perfusion of a given region or by a change

in blood oxygenation (BOLD effect). Thus, based on the changes in blood oxygenation and a local blood flow, the method allows for an indirect detection of those parts of the cerebral cortex that participate in the execution of cognitive, motor or other tasks performed by the examined patient. Functional MR is used mainly in neurophysiologic research; from this perspective, the fMR and stimulation of the left hand are quite important for treatment rehabilitation (Fig. 4.3.1-5).

Fig. 4.3.1-5 Functional MRI, changes in the blood perfusion of individual parts of the cerebral cortex during stimulation of the left hand

TRACTOGRAPHY Martin Kynčl, Pavel Kolář Tractography is performed using Diffusion Tensor Imaging (DTI) and it is a method sensitive to translatory, random microscopic movement of water protons in the tissue. The measured tissue diffusion coefficient, known as the apparent diffusion coefficient (ADC), accurately describes the biophysical characteristics of a tissue

liquid and, thus, can be used for the description of cellular functions and structures. Diffusion is a three-dimensional process in which a liquid can move with more ease along one axis of a structure. The measured ADC along this axis will then be higher. The measured ADC values along the axis will be higher than in the other directions. The directiondependent diffusion is known as anisotropic diffusion and is well observed in the brain white matter – here, the diffusion movement is accelerated along the neuronal axons. To establish a full diffusion tension, multiple measurements that use various combinations of gradient pulses along various axes are obtained. This is a technique known as Diffusion Tensor Imaging (DTI). It can be used to display the course and structurization of fibers of the brain white matter under normal and pathological circumstances.

SCINTIGRAPHIC EXAMINATION Pavel Kolář, Martin Kynčl Scintigraphy is based on the detection of radiopharmaceuticals (radioisotopes) after it is applied to an organism. Two types of scintigraphy exist: static and dynamic. In static scintigraphy, the distribution of the isotopes in the observed organ is almost unchanged. With dynamic scintigraphy, the kinetics of radiopharmaceuticals in short time intervals or their change over time can be observed. Skeletal scintigraphy is mainly indicated in primary bone tumors and bone metastases, osteomyelitis, traumas, some endocrine and rheumatologic illnesses, for the diagnosis and observation of multi-focal bone diseases and for unspecific bone pain with negative radiologic finding.

POSITRON EMISSION TOMOGRAPHY Pavel Kolář, Martin Kynčl Positron emission tomography (PET) is a method used to examine the perfusion and substance exchange in brain tissues, protein

synthesis, neural transmitters, receptor bonds, or the condition of the blood-brain barrier. PET allows for the diagnosis of ischemic conditions, degenerative diseases, epilepsy, diseases of the functional movement system, affective deficits, drug dependency, and tumors. The advantages include functional imaging of hemodynamics, chemical proportions in the brain, and the ability to assess cognitive function. The results are quantifiable, spatial differentiation is uniform, and absolute physiological values can be established. The disadvantage includes exposure to ionizing radiation. The development of new tracers is a long process and, given the high cost, this method is not as available. Furthermore, the distinction in time is low.

SINGLE PHOTON EMISSION COMPUTED TOMOGRAPHY Pavel Kolář, Martin Kynčl Single photon emission computed tomography (SPECT) is used to examine perfusion of the brain, neurotransmitters, receptor bonds and the condition of the blood-brain barrier. It allows for diagnosing ischemic states, degenerative illnesses, epilepsy and deficits in the functional movement system. The advantage includes the ability to assess the functional, hemodynamic and chemical brain mapping. This method is relatively cheap and thus, quite accessible. The disadvantages include the burden of ionizing radiation, the measurements are only relative, spatial distinction is not uniform, and differentiation in time is low.

NEAR-INFRARED SPECTROSCOPY (NIRS) Pavel Kolář, Martin Kynčl Near-infrared spectroscopy is a spectroscopy in a wave length close to infrared radiation (650 to 950 nm). During examination, a light of this wavelength passes through the hairy portion of the head and skull. The light reflects into the brain. The changes in reflection

corresponding to the changes in brain nerve cell activity are registered. Currently, two forms of NIRS are used. The first, known as EROS (event-related optical signal; or literally optical signal proportional to neuronal events), measures the intensity fluctuation of the reflected signal during brain loading by a specific stimulus. As soon as the nerve cells change their activity level, it is manifested in light dispersion and reflection into the tissue in which they are located. Changes in the reflected light correspond to changes in electrical brain activity in a given area. It is probable that nerve cell activity is based on conditioned changes in ion concentrations passing through their covers. The second technique uses change in blood flow in a region of the cerebral cortex that is being activated. The changes in nerve cell activity also influence local blood flow. The active nerve cells require more energy, which can be supplied only by the blood flow with oxygen and blood glucose. When compared to other methods, the advantage of this method lies in the fact that it places almost no burden on the child. Children do not need to be restrained as is the case in fMR, which requires staying still for the duration of the test. They are not exposed to radioactive radiation as is the case with positron or single photon emission tomography. NIRS has good differentiation ability in time (0.01 seconds), which is better than fMR and it spatially differentiates in the range of 1–2 cm. The radiation only passes to a depth of 2–3 cm under the surface and, therefore, deep brain structures cannot be assessed, which is a disadvantage of this method.

4.3.2 Examination by Ultrasound Zdeněk Hříbal Ultrasound examination is a method of first choice for acute or chronic muscle lesions. Since it is a non-invasive, portable and relatively inexpensive test, it can be repeated liberally, can observe the dynamics of traumatic changes and also, during treatment, can proceed less invasively. During the assessment of a traumatized region, a linear probe of 8–

12 MHZ is best used and any gel medium is applied in a straight layer on the skin (in case of a skin lesion, a sterile gel should be used). The examination can be performed immediately after an injury to determine the extent of trauma. If a muscle injury with fluid (blood) aggregation is present, a one-time suction of the hematoma under ultrasound guidance can be performed, or a drain can be inserted. The development of a hematoma during treatment is monitored in relation to the clinical picture. Healing without complications from scarring or calcification is ideal. With prolonged lesions in which a persisting fluid component of the hematoma is seen, Doppler mapping is used to eliminate blood supply from a traumatized blood vessel or a developed pseudoaneurysm. By using an ultrasound, the following can be well assessed: joint alignment in a traumatic dislocation, periarticular soft tissue condition, possible hemorrhaging, rotator cuff condition, traumatic lesions of tendon insertions and the amount of liquid within the joint. Furthermore, ultrasound can quite reliably diagnose a Baker’s cyst and the presence of foreign bodies (even radiologically non-contrast). Typical characteristics can also be seen in tenosynovitis, muscle hernia or traumatic lesions of the fasciae (Fig. 4.3.2-1; Fig. 4.3.2-2).

Fig. 4.3.2-1A,B Acute hematoma in a muscle in two mutually perpendicular

projections

Fig. 4.3.2-2 A – regression of the hematoma, persisting small liquid component surrounded by a reactive spasm; B – healed hematoma with connective tissue scar.

Clinically, ultrasound examination for common traumas is sufficient to assess their extent and monitor healing. In controversial cases (for example, traumatic changes in pathological environment or mapping of large joint pathology), an MRI should be performed.

REFERENCES Aggarwal JK, Cai Q. Human Motion Analysis: A Review. Computer Vision and Image Understanding 1999; 73(3): 428–440. Aminoff MJ. Electrodiagnosis in Clinical Neurology. 5th ed. Philadelphia: Elsevier 2005. Bareš M, Kaňovský P, Dufek J. Transkraniální magnetická stimulace. Brno: Národní centrum ošetřovatelství a nelékařských zdravotnických oborů 2003. Bareš M. Neurofyziologické vyšetřovací metody v klinické neurologické praxi. Neurol pro Praxi 2000; 1: 8–11. Basmajian JV, De Luca CJ. Muscles Alive: Their Function Revealed by Electromyography. Baltimore: Williams and Wilkins 1985; 551–561. Binnie CD. Clinical Neurophysiology. EMG, Nerve Conduction and Evoked Potentials. 2nd ed. Amsterdam: Elsevier 2004. Cabeza R, Nyberg L. Imaging Cognition II: An Empirical Review of 275 PET and fMRI Studies. J Cogn Neurosci 2000; 12(1): 1–47. Chklovskij DB, Koukalov AA. Maps in the Brain: What Can We Learn from Them? Annu Rev Neurosci 2004; 27: 369–392. De Luca CJ. The Use of Surface Electromyography in Biomechanics. J Appl Biomechanics 1997; 13: 135–163. Dufek J. Elektromyografie. Brno: Institut pro další vzdělavaní pracovníků ve zdravotnictví

1995. Godfrey A. Direct Measurement of Human Movement by Accelerometry. Med Eng Phys 2008; 30(10): 1364–1386. Kadaňka Z, Bednařík J, Voháňka S. Praktická elektromyografie. Brno: Institut pro další vzdělávání pracovníků ve zdravotnictví 1994. Kaňovsky P, Dufek J, et al. Evokované potenciály v klinické praxi. Brno: Institut pro další vzdělávání pracovníků ve zdravotnictví 2000. Keller O. Obecná elektromyografie: fyziologické základy a elektrofyziologická vyšetření se zvláštním zřetelem k rozboru potenciálu motorické jednotky. Praha: Triton 1999. Koukolík F. Mozek a jeho duše. 3. vyd. Praha: Galén 2005. Kumar S, Mital A. Electromyography in Ergonomics. London: Taylor and Francis 1996; 297–312. Laughlin SB, Sejnowski TJ. Communication in Neuronal Networks. Science 2003; 301(5641): 1870–1874. Menache A. Understanding Motion Capture for Computer Animation and Video Games. San Diego: Academic Press 2000. Motlová L, Koukolík F. Citový mozek: neurobiologie, klinický obraz, terapie. Praha: Galén 2006. Nashner LM. Computerized Dynamic Posturography. In: Jacobson GP, et al. Handbook of Balance Function Testing. Florence: Delmar 1997; 280–307. Nashner LM. Computerized Dynamic Posturography: Clinical Applications. In: Jacobson GP, et al. Handbook of Balance Function Testing. St. Louis: Mosby-Year Book 1993; 308– 334. Peper JS, et al. Genetic Influences on Human Brain Structure: A Review of Brain Imaging Studies in Twins. Hum Brain Mapp 2007; 28: 464–473. Rektor I. Myoklonus. Čes Slov Neurol Neurochir 2000; 63(96): 3–19. Rodová D, Mayer M, Janura M. Současné možnosti využití povrchové elektromyografie. Rehabil Fyz Lék 2001; 8(4): 173–177. Vega-Riveros JF, Jabbour K. Review of Motion Analysis Techniques. IEE Proceedings I. Communications, Speech and Vision 1989; 136(6): 397–404. Winter DA. Biomechanics and Motor Control of Human Movement. 2nd ed. New York: John Wiley and Sons 1990. Winter DA. Human Balance and Posture Control during Standing and Walking. Gait Posture 1995; 3: 193–214. Wong WY, Wong MS, Lo KH. Clinical Applications of Sensors for Human Posture and Movement Analysis: A Review. Prosth Orthot Int 2007; 31(1): 62–75.

5 ASSESSMENT OF THE SEVERITY OF MOTOR INVOLVEMENT AND LIMITATIONS IN THE ACTIVITIES OF DAILY LIVING Pavel Kolář

5.1 METHODS USED FOR MEASUREMENT AND ASSESSMENT IN REHABILITATION Appropriately selected and correctly performed rehabilitation minimizes dysfunction, compensates for the limitations in activities of daily living and makes the return to regular life easier. To achieve good rehabilitation results, it is important to find parameters predicting treatment results because differences in response to therapy exist among patients. To obtain the necessary data, a number of measurements and tests are utilized that allow for quantification of the magnitude of the observed parameters. In rehabilitation, the term assessment describes the functional deficits and their effect on the patient’s functional capabilities. The selected methods must meet certain basic criteria of objectivity (standardization, reliability, validity, sensitivity and specificity). Basic Criteria of Objectivity Standardization Test standardization means that individual results can be compared with norms obtained by an assessment of a representative population sample. Reliability Reliability represents dependability with multiple uses. It implies the extent to which the test measures what it is supposed to measure, thus, the level of the test’s consistency. Validity Validity indicates the practical utility of a test given the fact that the test truly measures the corresponding function. It represents the extent to which the test measures what it purports to measure; therefore, how true to its purpose the testing is. Construct validity expresses the theoretical idea about what we would like to measure. Concurrent validity represents the agreement with other tests of the same phenomenon (for example, correlation of pain intensity test with other pain intensity tests). Predictive validity represents the relationship of a test to the test of a subsequent phenomenon, for

example, the relationship of a test of the affective components of a pain to a test for depression used one year later. The evidence that the tested phenomenon corresponds to construct validity is known as the convergent discriminatory criterion. Sensitivity Sensitivity represents the proportion of correctly identified positive results. Specificity Specificity represents the proportion of correctly identified negative test results in “healthy” individuals. Test standardization or the establishment of its reliability and validity is a complex methodologic-statistical process necessary for the correct use of a test in research and particularly in clinical practice. The literature cites a number of tests and scoring systems that differ in the above mentioned criteria. Specific tests, classifications and scales are very valuable not only in rehabilitation but also in research and treatment in a clinical setting. The Focus of Specific Tests in Rehabilitation To “function correctly”, rehabilitation needs information about the body’s physical abilities as well as psychological capabilities. That is the reason why the testing used in rehabilitation is aimed at a variety of areas including: Assessment of motor functions; Assessment of everyday activities; Assessment of consciousness (see Special Section of the textbook, Chapter 1 Treatment Rehabilitation in Neurology, 1.18 Disturbances in Consciousness); Assessment of neuropsychological functions (see Special Section of the textbook, Chapter 1 Treatment Rehabilitation in Neurology, 1.3 Neuropsychology); Assessment of communication and behavior (see Chapter 3 Psychological Functions and Pain). Given that rehabilitation addresses mainly function, the

objectification of the diagnosis or the assessment of treatment results is, in some cases, difficult. For example, certain functions of the movement system are very complex. The diagnosis is challenging and, furthermore, it cannot be placed in its entire scope into any of the medical disciplines. Currently, this is the reason why most methods aimed at movement function assessment are considered excessively subjective. Often, it is difficult to find assessment methods that would meet the basic criteria for research and, at the same time, not run into, for example, ethical problems. How can the effectiveness of rehabilitation therapy be objectively measured in patients with scoliosis, paraplegia or patients with infantile cerebral palsy? It is not possible to develop a sample of patients who do not participate in rehabilitation. For these reasons, in rehabilitation we are left with, to a great extent, clinical examinations and clinical results with selected rehabilitation approaches that do not always meet the criteria of standardization, reliability and validity. The foundation of clinical examination consists of an anamnesis, aspection and palpation.

5.2 ASSESSMENT OF THE EXTENT OF MOTOR INVOLVEMENT Methods that assess motor presentation are very important for objectification of the patient’s condition and its progression. They assess deficits in muscle tone and coordination through a specific motor behavior.

5.2.1 Gross Motor Skills Assessment by the Gross Motor Function Measure The Gross Motor Function Measure (GMFM) system can capture changes in gross motor skills most sensitively in moderate and mild severity of involvement, i.e. in patients that are upright or ambulating independently. This method is not quite appropriate for observation of gross motor skills over time in severely involved patients. The GMFM questionnaire contains 88 points or items. The items are grouped into five positions encompassing all gross motor skills: 1. 2. 3. 4. 5.

Laying down and turning; Sitting; Crawling on stomach and creeping on knees; Standing; Walking, running and jumping.

The items include gross motor skills that should be achieved by a healthy child by the age of five. They are divided into two basic types: Dynamic items characterizing movement. This includes transitions between positions or movements to sustain the same position. For the child to achieve a score greater than zero, the movement must be observed in the anticipated direction. Static items capture sustainability of a position from the starting position for a certain period of time. Some items are combined meaning they include not only attaining

of a position but also its maintenance. GMFM testing should not take longer than 45-60 minutes. If the test cannot be completed in this time, it is continued the following day. It is recommended to complete the test within one week. Testing Principles The child’s cooperation is one of the basic presumptions of a successfully administered test. Sometimes it is difficult to persuade the child to perform a specific task. Many children stop cooperating when they feel that something is purposefully being asked of them. In such children, it is recommended to observe and assess as many items as possible of spontaneous motor behavior in the testing environment. During the assessment, various toys and equipment are used that will automatically guide the child toward the desired movement. If the child’s performance during the assessment does not correspond to their typical functional abilities, the testing is rescheduled for a different day. At the beginning of testing, it is recommended to use the complete GMFM questionnaire. After that, it is possible to establish a targeted area for monitoring changes. If only targeted areas were assessed from the beginning, then, during a reassessment, any insufficient assessment of items could occur for the items for which changes were not expected. For example, a change in equilibrium functions in standing and during walking can be linked to increased function in sitting, which would be overlooked during targeted assessment. Testing must occur in an environment that ensures the most pleasant and stable conditions. The room for testing must be sufficient in size and the parents should actively participate in testing and help motivate the child. The child is examined barefoot and testing conditions must remain the same to be able to repeat the test and compare the findings. For these reasons, the examination should always be performed by the same person. Room Equipment Floor with a smooth surface with two clearly visible, straight,

parallel lines 6 meters long and 20 cm apart A drawn circle 60 cm in diameter A large exercise mat (at least 122 × 244 cm) with a maximum thickness of 2.5 cm Five stairs of standard height with rail A small bench lower than 90 cm A large bench or table of convenient height for testing in standing and during motion (the upper surface should be at a height between the patient’s shoulder blades and the waist) A small object or toy smaller than 10 cm that can be grasped into one or two hands A larger object or a toy that must be held by both hands; for example, a ball (item number 72) A 30–70 cm long club (item number 75) Stop watch A walker may be needed (item number 51) if the child is only able to ambulate forward with support Scoring of Each Item Scoring is based on a four-point scale for each item according to the following key: 0 – does not initiate 1 – initiates 2 – partially completes 3 – completes The scoring key serves as a general guide. Most items have a specific description for each score which should be followed during testing. The child is given three trials for the completion of one item. The child can also complete an item spontaneously. Calculation of the Total Score To determine the total score, the score of individual items is added for each individual position. A percentage score is calculated for each position using the following equation: Child’s score × 100

Maximum score Determination of the Total Task Score To determine the total score for a task, only certain or targeted positions are used. The targeted positions are the ones in which the greatest changes can be expected or the ones specifically targeted by the examiner. They include the specific areas of interest for the child and the family (for example, ambulation with a walker) and the skills required in the home and school environment. The GMFM questionnaire focuses on testing gross motor skills in children with infantile cerebral palsy but it does not completely assess the quality of the performed movement which is an important component in the assessment of the child’s motor skill level. The Gross Motor Performance Measure (GMPM) takes into more consideration movement quality. It is currently being tested in clinical practice and it is not yet available in clinics. The GMFM questionnaire does not assess activities of daily living related to independent function. To assess these functions, the GMFM can be complemented by an additional questionnaire that takes into consideration such functions. The Pediatric Evaluation of Disability Inventory (PEDI) is one such test; it assesses socialization and the need for help from a required caregiver and the technical equipment needed. The test of basic everyday activities (Activities of Daily Living, ADL) is another test that can supplement the examination. It focuses on the level of independence and determines the level of required assistance from others. One of the disadvantages of GMFM testing is the necessity of a patient’s cooperation. This test can only work with children of a certain age with a minimal level of intellectual deficit.

5.2.2 Developmental Kinesiology as an Assessment Method of a Motor Deficit To assess the level of pathological motor development, the assessment

of maturity of postural functions is utilized. This assessment respects the consistencies of the CNS control processes. In such a case, postural functions are assessed in relation to the time of their maturation and are organized into locomotor stages based on Vaclav Vojta. There is a total of ten locomotion stages, denoted 0 through 9. They determine the achieved level of gross motor skills (upright) taking into consideration simultaneously achieved mental capacity and fine motor skills. This scale includes the entire period of human motor development up to four years of age in a healthy child and, analogically, it is used for the assessment of developing pathological motor skills in children with cerebral palsy. Locomotion Stages According to Vojta Stage 0 – the patient lacks locomotion. The patient is unable to move forward with the help of arms and legs. They are not capable of any motor contact with the surrounding environment through object grasping. The patient does not exhibit support function and their head is in a predilected position. The body posture and upright functions correspond to the newborn stage (see Chapter 3 Neuromotor Development and its Examination, Postural Activity). Developmental age: neonatal Stage 1 – patient continues to not exhibit locomotion. The patient cannot move forward, but can turn toward an object to touch it with their fingers or grasp it. In prone, the patient is able to support themselves on elbows. In supine, the patient is able to lift their lower extremities above the surface. The patient possesses equilibrium functions. In this developmental stage, the reflexes tied to a newborn age are not elicitable. Developmental age: 3 to 4 months Stage 2 – also in this developmental stage, the locomotion is still not developed. In prone, the patient can use upper extremities as a support or grasping organ. In prone, they are able to reach for an object while the other upper extremity ensures support. The lower extremity on the side of the grasping hand supports itself on the medial condyle and the other extremity is extended. Muscle

differentiation begins to emerge. In supine, the patient is able to reach for an object from mid-line. They attempt to get closer to an object but do not know how to move forward by using their upper and lower extremities. Developmental age: end of the 4th and beginning of the 5th month (the second half of the 5th month; the sixth month is a transition period between the 2nd and 3rd locomotion stage). Stage 3 – the ability of primitive locomotion has already matured and the patient can crawl. Spontaneously, the patient moves around a room by crawling. The patient can also turn from back to stomach. A reciprocal model of stepping forward and support is available in the ipsilateral as well as in the contralateral form. During locomotion, both oblique abdominal chains are activated. Developmental age: 7 to 8 months Stage 4 – the patient performs scooting, in which the patient moves by scooting on their knees and hands. The patient is not able to shift their center of mass cyclically from the axis of the frontal plane. Support on the upper extremities is atypical, as the patient leans on the wrist or the fist. “Scooting” does not contain a crossedpattern, which is the case in creeping, meaning it is homologous. This type of locomotion is present only in pathological development and it does not occur in healthy children. If a child cannot crawl in a timely manner, they will abandon locomotion altogether. This pattern is superior to crawling. A patient in this locomotion stage still does not possess the volitional ability to perform movement in an isolated segment (for example, a segmental motion in an ankle joint), but is able to kneel upright and attain side-sitting position. Developmental age: 9 months Stage 5 – crawling is developed. This locomotor pattern is fully integrated when a patient with CNS paresis can crawl across an entire room on their own initiative. Locomotion includes crossedpattern and support is on open hands. Spinal rotation and its shifting in the frontal plane occur with crawling. Later, each crawling child can exhibit verticalization.

Developmental age: 11 months Stage 6 – the patient can pull up to standing by the use of their upper extremities and maintain standing. At first, they are able to move the upper extremities sideways. It is known as a quadruped locomotion in the frontal plane. Later, locomotion in the sagittal plane emerges with support. Locomotion needs to occur based on the child’s own motivation. Developmental age: 12 to 13 months Stage 7 – a patient ambulates independently or autonomously, including outside the room. Developmental age: 14 months to 3 years Stage 8 – the patient can stand on one foot for at least 3 seconds. The examination must originate from a stable standing position. At this time, the stride phase of a step also emerges. Developmental age: 3 years Stage 9 – the patient can stand on one foot longer than 3 seconds, including right and left foot. Developmental age: 4 years Adjusted Age To assess the development of upright ability and locomotion in children with cerebral palsy, it is necessary to establish the adjusted age (AA) based on the age corresponding to a certain locomotor stage. It is calculated by dividing the actual age of motor development (gross motor skills – upright ability and locomotion, see locomotion stages) by the chronological age: AA =

Developmental age Chronological age

Based on AA, developmental prognosis can be established. For example: (Assume a child with cerebral palsy with a chronological age of 20 months.) Based on motor development, they correspond to locomotor Stage 2. The child is not walking (apedal). However, they demonstrate first imperfect upright ability, in prone, and can use upper extremities for support. They attempt to move

toward an object but cannot move forward using the upper and lower extremities. The child demonstrates an ulnar grip. This developmental stage corresponds to a developmental age of the end of the 4th month and the beginning of the 5th month. Adjusted age can be calculated from the ratio between the developmental and chronological ages. AA =

5 months 20 months

=

1 4

Based on the calculated RQ, we know that if this child undergoes rehabilitation, they will, in another year of motor development, advance three months in biological age. Therefore, they will crawl spontaneously around a room by their own initiative. In the context of overall development, they will achieve verticalization and bipedal locomotion. In clinical practice, it is important to establish AA at least twice in a certain time period (at least every 6 months) to obtain greater accuracy and credibility in the establishment of the pace of motor development for a specific child. Also, to establish AA, it is important to know whether the child has undergone rehabilitation. That is why it is suitable for AA to be established no sooner than half a year after treatment rehabilitation was initiated. If the AA decreases in this time period, then it can be assumed that the child either did not receive rehabilitation or the rehabilitation was not effective.

5.2.3 Additional Tests to Assess Motor Deficits Tests Used for Adult Patients Rivermead Motor Assessment The test was developed in a rehabilitation center in Oxford in 1979. It is designed to assess motor functions in patients with hemiparesis. Gait Assessment Rating Scale This test assesses gait and it was developed by L. Wolfson et al. in 1990. The disadvantage is the test’s time length (approximately 60 minutes).

Frenchay Arm Test The test was developed in 1980 by de Souza et al. to assess the function of the upper extremity, specifically the hand. The test administration takes 5-20 minutes. Nine-Hole Peg Test The test was developed by V. Mathiowetz et al. in 1985 to assess the upper extremity. It is used in patients with a mild motor deficit. Tests Used in Children Peacock Scale for Assessment of Locomotion These assessments are used for children with CNS involvement and they evaluate what the child is able to achieve with the help of locomotion. Stages of locomotion: 1. Without purposeful movement 2. Minimal purposeful movement 3. Patient sits independently, crawls or stands with maximum assistance, difficulty with attaining positions 4. Purposeful, useful movement with the exception of ambulation (creeps on all fours) or ambulation with assistance 5. Ambulation with support 6. Low quality independent ambulation 7. Normal independent ambulation Overview of other tests Alberta Infant Motor Scale (AIMS) Bayley Scales of Infant and Toddler Development Dubowitz Neurological Assessment of the Preterm and Full-term Newborn Infant General Movements Assessment (GMsA) Harris Infant Neuromotor Test (HINT) Infant Motor Profile (IMP) Movement Assessment of Infants (MAI) Neurobehavioral Assessment of the Preterm Infant (NAPI) Neuro-Sensory Motor Development Assessment (NSMDA)

Peabody Developmental Motor Scales Pediatric Evaluation of Disability Inventory (PEDI) Posture and Fine Motor Assessment of Infants (PFMAI) Test of Infant Motor Performance (TIMP) Toddler and Infant Motor Evaluation (TIME)

5.3 TESTING AND ASSESSMENT OF RESTRICTED ACTIVITIES OF DAILY LIVING The following set of basic functional tests is suitable for clinical practice. They are used in some countries to assess the range of limitation of activities of daily living (disability) and quality of life (QOL). For assessment of “activity” (disability), the following tests are used most often: Functional Independence Measure, Barthel Index, Activity Index, Frenchay Activity Index, Copenhagen Stroke Scale and Scandinavian Stroke Scale. An assessment of participation is more difficult than an assessment of activity. Participation is socially driven and identifies the consequences of health problems on a social level. It indicates in what way a person has re-integrated in life after various life situations. Its assessment is difficult and although many tests exist, none of them are standardized. In the Czech Republic, to measure QOL, a standardized questionnaire SF-36 (Short Form 36) is used. This questionnaire is used in all studies of the European Organization for Research and Treatment of Cancer (EORTC).

5.3.1 Functional Independence Measure The test of functional independence (Functional Independence Measure, FIM) was developed in 1984 by the American Academy of Physical Medicine and the American Congress of Rehabilitation Medicine. It is based on the basic assessment by the Barthel Index and it is amended by observation of cognitive functions. The patient’s abilities are documented in the areas of everyday activities, mobility, communication and cognitive functions. The FIM test is used in the USA and other countries to establish an individual’s disability after an illness or injury. It is part of the Uniform Data System for Medical Rehabilitation (UDS MR). The collected data serve as a collective assessment of effectiveness of work programs. The test assesses 18 activities in six categories:

Personal hygiene Urinary continence Transfers Locomotion Communication Social aspects Every function is assessed on a seven point grade scale in which grade one denotes maximum assis​tance and seven corresponds to full independence. The overall scale range is 18–126 points (Tab. 5.3.1-1).

Tab. 5.3.1-1 Functional Independence Measure, assessment

5.3.2 Barthel Index The Barthel Index (BI) was used for patients with neuromuscular and musculoskeletal deficits. It was developed in 1955 and it focuses on basic activities of daily living. It is used in international studies. The sum total of the assessed items can be up to 100 points if the patient is considered independent. However, that does not mean that the patient is able to live independently because many areas of daily activities are not included in the test (Tab. 5.3.2-1).

Tab. 5.3.2-1Barthel Index

Modified Barthel Index In clinical practice, more often a modified Barthel Index, developed by S. Shah et al., is used (Tab. 5.3.2-2).

Tab. 5.3.2-2 Modified Barthel Index

5.3.3 Katz Index of Activities of Daily Living The Katz Index of Activities of Daily Living consists of six items that are assessed based on the patient’s ability to perform everyday activities (Tab. 5.3.3-1). Quick administration is an advantage of this test.

Tab. 5.3.3-1 Assessed items of Katz Index of Activities of Daily Living

“Independent” means without supervision, control or active help from another person, except for special cases listed below. Assessment is based on an actual condition, not on ability. If a patient objects to performing a task, they are graded as if they were unable to perform the task even if they were otherwise considered able to perform it (Tab. 5.3.3-2).

Tab. 5.3.3-2 Assessment of patient’s dependence and independence in Katz Index of Activities of Daily Living

5.3.4 Activity Index The Activity Index is used for assessment of a patient’s condition after a CVA (Tab. 5.3.4-1). Hamrin and Wohlin are the authors of this test. It was developed in 1982 and consists of three areas:

Tab. 5.3.4-1 Activity Index

Mental abilities Motor activities Daily activities

5.3.5 Frenchay Activities Index The Frenchay Activities Index was developed by M. Holbrook and C.D. Skilbeck in 1983. It assesses daily activities in three areas: household operation, leisure time and work integration with social activities. These also include social activities, contacts, trips, book reading, shopping and car driving. The test is administered in 5–15 minutes. A maximum of 24 points can be obtained, which indicates complete independence (Tab. 5.3.5-1).

Tab. 5.3.5-1 Frenchay Activities Index

5.3.6 Factor Assessment according to Tardieu A method developed by Professor Tardieu belongs among the assessment methods designed to analyze individual factors limiting a person with a CNS dysfunction. Tardieu implemented a so called factor assessment into clinical practice. Individual factors are assessed and based on the determined defects and proportional attention is paid to them in treatment. There are 26 factors that are observed from the perspective of social integration. The goal is to fully eliminate the patient’s limitations. Assessed Factors Factors influencing the prospect of social integration: 1. Etiology 2. Assessment of intelligence 3. Behavioral assessment 4. Social factor 5. Level of education 6. Functional age, degree of independence, standing and walking 7. Speech difficulties 8. Hearing 9. Visual acuity and eye movement 10. Seizures (objectified by electroencephalography) 11. Overall health condition (mainly various associated disturbances) 12. Previous treatments and medical procedures Motor Skills Assessment: 1. Basal condition at complete rest 2. Control of motor reactions to stimulus/irritation 3. Influence of intellectual strain on basal motor skills 4. Passive mobility (stretch reflexes and basic muscle flexibility) 5. Diagnosis and assessment of muscle weakness Special Assessment of Upper Extremities: 1. Extremity dominance

2. 3. 4. 5.

Postural alignment of upper extremities Assessment of mobility of upper extremities Assessment of tactile gnosis (stereognosis) Trophic condition of upper extremities

Special Assessment of Lower Extremities, Body Axis and Equilibrium Functions: 1. Orthopedic assessment 2. Assessment of influence of developmentally older reflexes on standing and equilibrium 3. Erect standing 4. Walking Treatment Strategy The approach of Tardieu demonstrates a complex method allowing for the establishment of a goal-oriented, short-term and long-term plan of care. All available means are used to reduce the strain caused by disability and a subsequent handicap, and the patient’s maximum social life integration is strived for. To achieve this goal, therapeutic means are implemented (for example, physical therapy, orthopedic approaches) as well as pedagogical, social and vocational resources. Individual factors are assessed and based on their importance; an appropriate amount of attention is paid to the factors that are the most straining to the child’s integration. It is important to carefully distinguish what needs to be more accentuated and facilitated in the child’s rehabilitation. It is a multipoint cooperation. It is always necessary to remember the main therapeutic goal, which is a maximal attempt at a patient’s social integration. In the treatment of children with cerebral palsy, a treatment is often used whose significance cannot be doubted; however, in a given time period, it is often applied at the detriment of more substantiated therapy. For example, for a school age child, how much time should be spent on reflex locomotion, how much on occupational therapy techniques focused on the practice of independent functions and how much time should be spent on special education needs to be considered. The factor method based on Tardieu is used primarily in children

who are able to cooperate. Tardieu divided the deficits in children into cerebral palsy (infirmité motrice cérébrale, IMC) and encephalopathies (EP). Based on this division, he determined the approach to treatment. Children with cerebral palsy can learn and be actively integrated into life while children with EP display combined dysfunctions and intellectual deficits. If the psychological examination determines that the child’s intelligence is so low that the potential of integration is minimal, Tardieu considers rehabilitation and orthopedic therapy ineffective and useless, often burdening the child. On the other hand, we are convinced that even for these children, therapy is meaningful. It does not concern their social integration – the therapy is supposed to prevent the onset of contractures and morphological deformities that often cause the child pain. It also influences the possibilities of the child’s treatment. Surgical interventions are primarily palliative.

5.3.7 Other Tests Copenhagen Stroke Scale This test assesses the patient’s abilities after a sudden CVA. Given its short administration time and technical ease, it can be administered within a neurological assessment. The test was developed by J. Olesen et al. in 1988. Scandinavian Stroke Scale The Scandinavian Stroke Scale was developed in 1992 by E.B. Ringelstein et al. It is used during the course of neurological diagnosis in patients with central cerebrovascular accident. The test can be administered quickly (it takes approximately 5 minutes). Mini-Mental State Examination (MMSE) Folstein, Folstein and McHugh are the authors of a cognitive assessment of patients with cerebral palsy. The test’s administration takes approximately 10 minutes. It provides a reliable estimate of cognitive ability and it is fast, simple and straight forward for the patient and the examiner. It can be used to monitor cognitive deficits and their changes. It can determine whether the tested person is able

to understand the given information and keep it in memory. Based on the International Psychogeriatric Association (IPA) guidelines, the test is recommended as a screening tool for possible dementia. It is suitable for the assessment of a patient’s potential cooperation during rehabilitation treatment. The test consists of 10 tasks and questions with the first part examining the patient’s orientation, short-term memory and attention. The second part determines the ability to name objects, and understand and follow written and verbal instruction. Pediatric Evaluation of Disability Inventory The PEDI test assesses the ability and means of executing independent functions, mobility, socialization and the extent of assistance needed by another person or medical equipment. ADL Test The test assesses the level of independence and establishes the level of assistance required of others. It is also used in a modified form based on Barthel. It is often used for an objective assessment of the effectiveness of selective dorsal rhizotomy, which demonstrated improvement primarily in self-sufficiency.

REFERENCES Boyce W, et al. The Gross Motor Performance Measure: Validity and Responsiveness of a Measure of Quality of Movement. Phys Ther 1995; 75(7): 603–613. De Souza LH, Langton HR, Miller S. Assessment of Recovery of Arm Control in Hemiplegic Stroke Patients. In: Arm Function Tests. Internal and Rehabilitation Medicine 1980; 2: 3–9. Folio MR, Fewell RR. Peabody Developmental Motor Scales and Activity Cards. Austin: DLM Teaching Resources 1983. Folstein MF, Folstein SE, McHugh PR. Mini-mental State. A Practical Method for Grading the Cognitive State of Patients for the Clinician. J Psychiatr Res 1975; 12(3): 189–198. Gowland C, et al. Reliability of the Gross Motor Performance Measure. Phys Ther 1995; 75(7): 597–602. Hamrin E, Wohlin A. Evaluation of the Functional Capacity of Stroke Patients through an Activity Index. Scand J Rehabil Med 1982; 14: 93–100. Hinderer KA, Richardson PK, Atwater SW. Clinical Implications of the Peabody Developmental Motor Scales: A Constructive Review. Physical and Occupational Therapy in Pediatrics 1989; 9(2): 81–106. Holbrook M, Skilbeck LE. An activities Index for Use with Stroke Patients. Age Ageing 1983: 12(2): 166–170. Katz S, Ford AB, Moskowitz RW, et al. Studies of Illness in the Aged. The Index of ADL: A

Standardized Measure of Biological and Psychosocial Function. JAMA 1963; 185: 914–919. Lippertová-Grünerová M. Neurorehabilitace. Praha: Galén 2005. Mahoney FI, Barthel DW. Functional Evaluation: The Barthel Index. Maryland State Medical Journal 1965; 14: 61–65. Mathiowetz V, Volland G, Kashman N, Weber K. Adult Norms for the Box and Block Test of Manual Dexterity. Am J Occupation Ther 1985; 39(6): 386–391. Olesen J, Simonsen K, Norgaard B, et al. Reproducibility and Utility of a Simple Neurological Scoring System for Stroke Patients. Copenhagen Stroke Scale. Neuro Rehabilitation and Neural Repair 1988; (2): 59–63. Peacock WJ, Staudt LA. Functional Outcomes Following Selective Posterior Rhizotomy in Children with Cerebral Palsy. J Neurosurg 1991; 74(3): 380–385. Peacock WJ, Staudt LA. Spasticity in Cerebral Palsy and the Selective Posterior Rhizotomy Procedure. J Child Neurol 1990; 5(3): 179–185. Ringelstein EB, Biniek R, Weiller C, et al. Type and Extent of Hemispheric Brain Infarctions and Clinical Outcome in Early and Delayed Middle Cerebral Artery Recanalization. Neurology 1992; 42: 289–298. Russel DJ, et al. Gross Motor Function Measure Manual. 2nd ed. Hamilton: McMaster University 1993. Shah S, Vanclay F, Cooper B. Improving the Sensitivity of the Barthel Index for Stroke Rehabilitation. J Clin Epidemiol 1989; 42(8): 703–709. Schuntermann MF. The International Classification of Impairments, Disabilities and Handicaps (ICIDH) – Results and Problems. Int J Rehabil Res 1996; 19(1): 1-11. Stucki G, et al. Application of the International Classification of Functioning, Disability and Health (ICF) in Clinical Practice. Disability and Rehabilitation 2002; 24(5): 281–282. Tardieu G, Chevrie-Muller C. Disorders of Speech and of Swallowing in Cerebral Palsy. Evaluation of Factors Involved, Therapeutic Indications and Contraindications (author’s transl). Neuropsychiatr Enfance Adolesc 1981; 29(11 12): 613–623. Tardieu G, Tardieu C. Cerebral Palsy. Mechanical Evaluation and Conservative Correction of Limb Joint Contractures. Clin Orthop Relat Res 1987; 219: 63–69. Tardieu G, Tardieu C. “Retraction”, “Hypertony”, “Hypotony”, “Hyperextensibility”, “Hypoextensibility”. Evaluation and Therapeutic Indications. The Necessity of a Factor Analysis (author’s transl). Neuropsychiatr Enfance Adolesc 1981; 29(11–12): 553–67. Vaňásková E. Testování v rehabilitační praxi – cévní mozkové příhody. Brno: Národní centrum ošetřovatelství a nelékařských zdravotnických oborů 2004. Vojta V. Mozkové hybné poruchy v kojeneckém věku. Praha: Grada Publishing 1993. Wolfson L, Whipple R, Amerman P, Tobin JN. Gait Assessment in the Elderly: A Gait Abnormality Rating Scale and its Relation to Falls. J Gerontol 1990; 45: M12–19.

B THERAPEUTIC METHODS

1 PHYSICAL THERAPY METHODS AND CONCEPTS Pavel Kolář The choice of a therapeutic approach is not based on diagnosis, but rather on the assessment of the functional symptoms. Physical therapy methods and concepts utilized across disciplines (multidisciplinary) are included in this section and they are being used by more clinical disciplines for various diagnoses. The majority of physical therapy methods arose from empiricism and the scientific explanation of their effects is not always sufficient. One of the first neurophysiologic foundations, which serves as the foundation for some earlier physiotherapeutic concepts, is the reflex theory of motor control that was introduced by a neurophysiologist, Charles Sherrington, in 1906. This theory describes movement as a combination or a sequence of reflexes. A complex movement is described as a system of subsequent (chained) compound (complex) reflexes. Receptor stimulation is necessary and leads to the effector (muscle) which executes a motor response through a neutral pathway. This structure is known as a reflex arc and, via feedback, it can elicit another stimulus for a subsequent response (chaining). This concept was referred to as the sensorimotor or the cause-and-effect system. In the 1930s and 1940s, the hierarchical theory, or the reflex/hierarchical theory of motor control became more popular. It placed more emphasis on the hierarchical system proposed by Hughlings Jackson. This theory views movement as emerging reflex patterns that are controlled by hierarchically organized levels of the CNS. In this top-down model, structures are controlled by higher centers or inhibit the activity of lower centers. In the 1960s and 1970s, findings accumulated showing that, in animals, coordinated movements can occur without an elicited stimulus or the participation from the higher centers. The results of

such studies served as the foundation for the emergence of the motor control theory, known as the motor programming theory. This theory presumes the existence of innate motor programs in the CNS that provide for an easier formation of specific motor programs in the brain designed specifically for an actual movement activity. In the 1960s, the ecological theory of motor control, which emphasizes the integration of the organisms and the environment, was developed by American psychologist James Jerome Gibson. This systems theory was developed in various versions. One of the newest theories of motor control is the task oriented theory that emphasizes the question of activity linked to movement, or movement intention, movement perception, etc. The representatives of this theory include, for example, current American theorists of physical therapy such as James Gordon, Marjorie Woollacott, Fay B. Horak, and Anne Shumway-Cook. In anatomy and physiology, three fundamental groups of findings contributed to the clarification of sensorimotor control and allowed for the utilization of cybernetics. These include: Clarification of all types of neurons in the cerebellum and their complex interconnections allowing for programming, learning and control of motor processes Detail topographic and functional organization of the cerebral cortex Clarification of mutual interrelations between the basal ganglia, thalamus, cerebellum and the cerebral cortex. This integrated system provides the emotional and psychological components of the overall behavior, preparation and execution of spontaneous, independently initiated and executed movements. From the first quarter of the 20th century, findings and hypotheses about the nervous system’s plasticity (neuroplasticity) have been gathered. These findings form the foundation of modern physical therapy approaches. Neuroplasticity is the ability of the CNS to adapt to new stimuli by

its functionally anatomical rebuilding. This plasticity and the functional neuronal reserves can be used in the treatment after any insult (e.g., cerebrovascular accident, trauma). The CNS can be constantly facilitated by optimal stimulation of the CNS (e.g., by increased number of afferent impulses), and thus initiate its functionally anatomical remodeling, as well as, repair and regeneration (e.g., motor loops). Many physical therapy methods use stimulation of various receptors (afferent inputs) and, therefore, directly deal with CNS plasticity and influence it. Physical therapy treatment approaches not only work with structure, but also primarily influence functions. Then the stimulation of these functions retroactively influences structure – mainly in the CNS – by utilizing its plasticity. More on CNS plasticity can be found in the Special Section of the textbook, Chapter 1 Treatment Rehabilitation in Neurology, Neuroplasticity. We are interested in the degree of muscle strength, range of motion, level of somesthetic functions, ability to relax, selective movement capability, mobility, or rather the resistance in the soft tissues, level of balance functions, postural activity and reactibility, extent and distribution of muscle tone, presence of involuntary movements, paresis responsive to reflexive stimulation or without a reflexive response, pain provocation and so on. Based on the described symptomatology, concrete physical therapy approaches are being chosen: soft tissue mobilization, muscle strength training, exercising postural function of a muscle, practice of somatognostic functions, selective mobility exercises, relaxation techniques, balance function training, etc. The ways, or rather the forms, that are being utilized for this purpose are general, but can also be considered specialized physical therapy methods that are focused on one of the described symptoms or influence more symptoms to a various extent – the Vojta method, neurodevelopment approach, PNF. The selected method needs to be based on a quality functional diagnosis. This section of the textbook describes several treatment methods that are utilized across disciplines and for many diagnoses due to their complexity and the techniques used for administration. The methods

specific to individual syndromes or concrete diagnoses will be described in the corresponding chapters in the Special Section of the textbook.

1.1 GENERAL PHYSICAL THERAPY (MUSCULOSKELETAL) APPROACHES 1.1.1 Passive Movements Pavel Kolář Passive joint movements are performed without the patient’s own activity. Passive movements are performed following surgical procedures in the initial post-surgical days. This treatment is indicated for patients with deficits in consciousness and for patients with joint contractures, in which the patient is not able to overcome connective tissue contractures by volitional activity. Continuous passive motion (CPM) and Motomeds play an important role in passive movement therapy. With CPM use, maximum range of motion needs to be specified for each stage.

1.1.2 Active Assistive Exercise Magdaléna Lepšíková A physical therapist assists during active assistive exercise and guides the movement so that it is performed with the highest quality, meaning in the centrated joint position. This type of exercising should also assist a patient demonstrating muscle weakness in completing a required movement (see Chapter Rehabilitative Care, subheading Assisted Movement).

1.1.3 Muscle Strength Exercises Zdeněk Čech Muscle strength can be improved by increased resistance, which can be accomplished by a wide spectrum of exercises, methods and tools (e.g., dumbbells), including exercising on equipment that is found in all basic fitness centers. During training to increase muscle strength, the individual muscle can be viewed as an independent anatomical unit and the exercises can be based only on the direction of its

contraction from the origin to the insertion. This approach corresponds to analytical thinking and the analytical perspective of the muscular system. The main problem with this “classical” exercise approach is that intermuscular coordination is not sufficiently developed. When strengthening a certain muscle, not only the muscle that is targeted by this exercise is engaged (e.g., pectoral muscles), but also muscles that ensure its insertional (postural) stabilization (abdominal muscles, back muscles, etc.) and muscles that present and ensure the dynamics of the entire movement system. The engagement of these muscles also determines the inner coordination of the muscle that is being strengthened. For example, the inspiratory chest wall position and an insufficient stabilization function of the diaphragm, abdominal muscles and the pelvic floor muscles during pectoral muscle strengthening will lead to imbalanced strengthening of this muscle and overloading of some of its segments. At the same time, with such inefficient strengthening of this muscle, joint segments are overloaded because of the influence of a deficient (imbalanced) stabilization function leading to a subsequent functional joint decentration with a less than optimal layout of acting forces and so on. This is the reason why, following exercise, new problems or worsening of the current problems may occur. Kinesiologic Notes The central nervous system is not controlled by individual muscles but by individual movements (Kralicek, 1995). Thus, with strengthening, it is not the muscle that is strengthened, but rather its corresponding movements. This fact can be partially demonstrated by a simple example. If an exercise (e.g., for elbow flexors) is being performed in a certain position, for example, biceps curls with dumbbells while seated with back supported, after a certain period an increase of strength capability will occur due to the adaptation to the muscle loading. Therefore, this movement can be executed with the same number of repetitions with an increased load. However, if a similar exercise is used in a different position (for example, in supine or prone

positions), at the beginning, it may not be possible to perform this exercise with the same load and the same number of repetitions as when exercising in sitting regardless of the fact that the elbow movement is being executed by identical muscles. Thus, the adaptation to strength loading (its neuroadaptative component) is not linked to a muscle or a muscle group, but rather to a corresponding movement and its postural stabilization. This demonstrates the principle of specificity. Other components of adaptation (mainly morphological changes) are linked to the muscle. Every movement originates with a certain amount of postural stability, which inseparably accompanies the entire movement. Motor programs ensuring the stabilization of muscle interplay also contain a “strength dimension”. This means that under normal conditions, such movement programs function physiologically and they are able to actualize themselves in a corresponding quality only to a certain extent under external (and internal) loading conditions. This is often used during assessment by adding resistance to a defined position or movement or the external conditions are made more challenging to evaluate the movement, that is its postural pathology. Input-Adaptation Relationship during Strengthening Exercises Every exercise and exercise program needs to be perceived as a stimulus from which a specific acute response, or a reaction, is expected. With repeated and adequately chosen stimulus application, longer lasting changes or adaptation to resistance exercises, can be observed. The context of this response is dependent on a number of variable factors, which are taken into consideration when establishing an exercise program. It also needs to be emphasized that every stimulus – even the application of a certain way of strength training – has a limited duration of its effectiveness. Therefore, it is necessary to change the individual variables within a certain time period or to make a more crucial change in the exercise protocol. These include, for example, the principles of loading progression, periodization, intensification approaches and so on.

Adaptation to Resistance Training Adaptation to resistance training occurs in a certain time sequence. At first, changes in movement control occur. These are changes in the intra-muscular and extra-muscular coordination, which already develop in the initial phase of resistance training and continue after repeated loading. Within hours and days, changes in the enzymatic activities and other biochemical changes in the muscle occur. Only after weeks of regular strength training do morphologic changes become apparent; demonstrated especially by muscle hypertrophy (Tlapak, 2002). Training Variables The most important variables of a resistance training program include the following: Type of muscle activity (concentric, eccentric, isometric) Number of repetitions in one set of exercises (and the amount of resistance to it linked) and an overall loading volume given by the number of sets Choice of exercise(s) that primarily activate a certain part of a muscle or area as well as the selected movement and postural strategy including the breathing pattern used Rest periods between the sets Speed of movement during exercise execution Exercise frequency (number of days in a week) (Bird et al., 2005) Type of Muscle Activity The majority of resistance exercises utilize dynamic repetition, in which the concentric and eccentric muscle activity alternates. It is always accompanied by isometric activity, which is utilized primarily in stabilization functions or when securing the postural stability for a movement (thus, securing the punctum fixum of a given movement). Within the concrete kinesiological context of a given exercise, the contribution of isometric activity within postural stability can be relative. In the classical approach and in a so called isolated and often one-joint exercise, the contribution of isometric activity is certainly higher than in exercises involving global movement patterns. This fact

has metabolic, cardiovascular and other consequences. If the purpose of the exercise is adaptation, therefore, an increase in dynamic muscle strength, or muscle hypertrophy, it is recommended that the exercise program include concentric, as well as, eccentric muscle activity (Colliander et al., 1990; Dudley et al., 1991; O’Hagan et al., 1995). Exercises with concentric and eccentric activity that are accompanied by an isometric activity can be considered as the most suitable type in the rehabilitation of motor dysfunctions based on the principle of specificity. Specifically, this type of muscle activity is naturally applied to ensure motor skills in the normal environment of a gravitational field. Number of Repetitions, Amount of Resistance and Overall Loading Volume The maximum number of exercise repetitions that can be performed with a given load is known as repetition maximum (RM). This parameter probably denotes the most important variable factor in strength training. Only this number of repetitions should be performed in which correct technique can be maintained, including muscle coordination and quality postural stabilization with movement. To a certain extent, the type of adaptation to resistance training also depends on the selected number of repetitions in a set and to it, the corresponding resistance. High resistance with a low number of repetitions (for example, RM 1-4) will develop maximum strength abilities. Submaximal resistance with a medium number of repetitions (for example, RM 6-15) will lead to muscle hypertrophy and lower resistance with a higher number of repetitions (RM>20) develop endurance strength (Bird et al., 2005; Tlapak, 2002). The given spectrum of optimal RM can vary based on the muscle segment, or the activated body area. It can vary individually and the fitness level of each individual needs to be taken into consideration. Breathing is altered to a greater extent when having to overcome a

high resistance. For a short period of time, the need for a significant increase in intra-abdominal pressure when manipulating a load is superior to the need for breathing function assurance. Therefore, it is necessary to consider the suitability of the loading intensity based on the goal of therapy. For individuals who are beginning resistance training, lower loads and RM of approximately 15 or even more should be used. The main reasons for this approach include increased safety with a lower load, the ability to control movement execution and breathing activity during the exercises, maintaining attention and fine tuning movement coordination. The overall loading of a body part is given by the number of sets (overall number of all exercises for a given part), number of repetitions in a set and the resistance used. The weekly number of exercise sessions for a given muscle group is also important. Resistance exercise programs that are aimed at muscle strength and hypertrophy are more effective when using mid- to high load (RM 615) and mid-volume (3–4 series per one exercise) (Otrowski et al., 1997; Paulsen et al., 2003). Exercise Selection and Exercise Program Design The classical approach divides exercise into one joint or multi-joint, or isolated and complex. From the perspective of kinesiology, exercises are divided into open- and closed kinetic chain. Although all mentioned types of exercises are effective, as far as the development of muscle strength and hypertrophy is concerned, they differ in many other parameters. Only some are mentioned below for demonstration. Isolated one-joint exercises (e.g., knee extension utilizing exercise equipment) lead to a greater localized strain of the intended muscle group, greater metabolic response of the muscle, and better perception of the muscle’s work. They do not demand as much movement coordination and attention focus. A lower risk of injury during exercise has also been noted (Bird et al., 2005). Multi-joint complex exercises (e.g., a squat) activate a greater

volume of muscle tissue and elicit a greater hormonal response (elevation of anabolic hormones), which potentially increases the ability of the entire muscle system to adapt to the applied load. At the same time, inter-muscular coordination is being “trained” under posturally more demanding conditions. The new approach of strength training based on the principles of developmental kinesiology divides individual exercises according to postural demand, which may not always correspond to exercise difficulty (Tlapak, 2008). Further, reflex locomotion principles are utilized (see Chapter 1.1.4 Dynamic Neuromuscular Stabilization). These are usually exercises using partial or global movement patterns known from early human ontogenesis, in which resistance is applied against verticalization, or locomotion. Exercises starting from a posturally low position (e.g., lying on back) show lower demands for attaining postural stabilization, demand a lower level of the individual’s concentration, and have a lower risk of incorrect technical performance (error in postural, movement and breathing strategies) than exercises performed in posturally high positions (e.g., standing). In contrast, well mastered exercises in high postural positions surely bring a greater therapeutic benefit. Symmetrical exercises, in which both body parts or extremities perform movement in the same direction (e.g., bilateral pulling of a high pulley with a wide grip in sitting) can easily reveal, and also correct, asymmetrical function of both sides of the body. Asymmetrical exercises bring torsional loading which enhances the activation of a certain muscle interplay or muscle systems (e.g., the multifidi and the rotators). Strengthening exercises, as part of a rehabilitation program, should have 1–3 selected exercises that specifically target a small problem (i.e., rehabilitation following an ACL reconstruction) or a more “total body” exercise program can be chosen (e.g., during treatment of structural hypermobility syndrome).

When designing a total body strengthening program, certain rules need to be followed. The “from the center to the periphery” principle is considered important (Tlapak, Mach, 1996). Based on this principle, the first exercises in the exercise protocol are focused on the activation of central (trunk) muscles and then other exercises are added, which, as “prime movers”, utilize more peripheral muscle activity (i.e., extremity muscles). When designing an exercise program, other principles can be followed, such as the energy-demand principle, in which the beginning of the exercise protocol includes exercises with high energy demands and at the end the program; it includes exercises with lower energy demands. Similarly, the beginning of the program includes more coordination challenging exercises with high demands on the individual’s concentration. The program is concluded with exercises that are technically simpler. Rest Period Duration between Exercise Sets The duration of the rest period between individual sets and exercises significantly influences the overall response to resistance training. The length of the rest period depends on the exercise goal, the relative resistance that needs to be handled and the individual’s fitness level. It changes the metabolic and hormonal exercise demands and influences the performance in the next series of exercises. During the rest period, resynthesis of fast energetic substrates occurs (ATP, creatinphosphate) (can be complete within 3–5 minutes) and the amount of increased lactate concentration in the blood depends on the length of the rest period (Kraemer et al., 2002; Kraemer et al., 1987; Kraemer et al., 1990). From a training study (Kraemer et al., 1991) and from experience in sport training, the following general recommendation for the length of rest periods is suggested: maximum strength training with a heavy load and low RM requires 3–8 minutes of rest; submaximal resistance with middle RM with the goal of muscle hypertrophy requires shorter rest periods lasting 1–2 minutes. During muscle endurance training with a low load and high RM, a rest period of 30–60 seconds is

recommended. Muscle tissue recovery, however, is not the only factor considered when establishing the duration of a rest period. During exercise, the control components often greatly fatigue and often, it is their function that limits the quality of exercise performance. Fatigue of the control components is often manifested by deficits in inter-muscular, or intramuscular coordination (tremor), and concentration. To maintain movement quality, the length of the rest period is often adapted to the individual’s ability to sufficiently restore the quality of control functions. The Speed of Movement during Exercise In classic isotonic exercises, various proportions of the concentric and eccentric exercise phases can be utilized, even an isometric hold at the end of the concentric phase can be applied. In this way, the time during which the muscle maintains its tension during exercise is affected. This parameter, together with exercise intensity, influences the extent of a strength training response (Bird et al., 2005). In practice, most often relatively fast repetitions with a 1-secondlong concentric (CON) and a 2-second-long eccentric (ECC) phase are used. Another cadence can also be utilized, for example, slow repetitions with a 2-second-long CON and a 4-second-long ECC phase, or super slow repetitions with a 10-second-long CON and a 5second-long ECC phases. When the exercise is performed fast, then the greater the hormonal response and energy expenditure than in super slow exercises. Slow speed (2 seconds CON, 4 seconds ECC) with 8-12 RM shows a greater growth in muscle strength and hypertrophy in contrast to super slow repetitions (Bird et al., 2005). Fast repetitions limit the ability of ongoing correction of movement coordination during the movement. For individuals with no prior exercise experience, a slower speed with repetitions is recommended (2 seconds CON, 4 seconds ECC) (Bird et al., 2005). More advanced individuals can gradually increase

the speed of repetitions and thus the potential for an accelerated increase in muscle strength. Increased speed of movement poses an increased risk of musculo​skeletal system injury (Westcott, 2001). Exercise Frequency Training frequency is the number of exercise sessions in a certain time period, usually in one week. The resting period between two exercise sessions must be long enough to allow adequate recovery after muscle loading. During this period, the muscles’ (and other organs’) depleted energy substrates are replenished and the re-synthesis of proteins occurs based on the theory of supercompensation; later, the original values also increase. When the next loading is timed correctly, the organism is in a better initial condition to manage it. The time in which the replenishment of depleted substances occurs is known as recovery time. Besides the intensity of the previous loading, its duration depends on a number of factors, such as psychological and nutritional factors. In individuals with no prior strength training experience, the optimal frequency is 2–3 exercise sessions per week, which can later be increased if needed. Individual muscle groups usually require 2–4 days to recover. This is the reason why, in practice, the split system is utilized with a higher frequency of “total body” exercise sessions, in which the entire body does not exercise all in one day, but rather the training of individual muscle groups is spread over several days. Exercises commonly used in treatment rehabilitation usually do not put significant strength demands on the exercising individual. Their goal is mainly inter-muscular coordination. The low intensity of such exercises generally does not cause significant exhaustion of metabolic muscle supplies and, therefore, can be repeated several times per day.

1.1.4 Dynamic Neuromuscular Stabilization Pavel Kolář, Marcela Šafářová According to techniques of dynamic neuromuscular stabilization (DNS) by Kolar, muscle function is influenced within its postural

locomotor function. This concept contains general principles and, therefore, it is included among the general physiotherapeutic methods. Common muscle strengthening is based on anatomical function. Strengthening exercises are derived from the muscle’s origin and insertion. This principle is also utilized for the majority of strength training equipment found in fitness gyms. In treatment rehabilitation, this principle is utilized for exercises based on muscle testing. However, when developing muscle strength, not just the muscle’s origins and insertions need to be considered, but also its inclusion within the biomechanical chains. However, these cannot be deduced only from anatomical connections (how they are presented by the majority of authors), but also from the aspect of CNS control processes (central programs). If, for example, the pectoral muscles are exercised, the muscles that stabilize their insertions are also always activated, i.e. the back muscles, diaphragm, abdominal muscles, etc. This function is automatic and, in many people, under very limited volitional control. In addition, the deep muscles that are especially important for postural functions (stabilization, tightening). Under static conditions (standing, sitting) and during movement (locomotion), individual movement segments are reinforced by the coordinated activity of the agonists and antagonist – co-activation activity (coactivation synergy) (Fig. 1.1.4-1a). Postural activity accompanies movement like a shadow (Magnus, 1924). Perhaps this statement could be corrected to say postural activity precedes and accompanies every purposeful movement. Even though the muscle in its anatomical function (derived from its origin and insertion) can reach maximum potential (when assessed by a muscle test), its integration into a specific postural (stabilization) function (biomechanical chain) can be quite insufficient and the muscle fails in this function. If the muscle is weak during the stabilization of a segment(s), postural instability occurs (Fig. 1.1.4-1b). Incorrect muscle recruitment

during stabilization is automatically and unconsciously incorporated by the individual into all performed movements and exercises. This results in stereotypical overloading, which is an important etiopathogenetic factor in a number of movement deficits. Fig. 1.1.4-1 Individual segments of the skeleton need to be reinforced by a balanced activity of muscle antagonists. (a) – physiological state, (b) – postural instability

It has already been described in Chapter 1.1.1 The Assessment of Postural Function in Section A of the textbook, that postural instability cannot be assessed by a muscle test, but rather by specific postural tests and several of these tests were mentioned. An example of such postural instability is the lumbosacral deviation from its neutral alignment which can be observed in a patient in prone when slowly lifting their head and the upper part of the trunk (extension test) (Fig. 1.1.4-2a,b).

Fig. 1.1.4-2a,b During trunk extension, pelvic movement into an anterior tilt occurs. (a) – starting position, (b) – trunk extension and anterior pelvic tilt and often cervical spine hyperextension. Postural instability of the lumbosacral area is manifested by an anterior tilt of the pelvis. Similarly, this postural instability is manifested during hip flexion assessment in supine and sitting, in which insufficient stabilization at the insertional region of hip flexors (inserting to the pelvis and the thoracolumbar region) leads to an anterior pelvic tilt, lateral shift of the pelvis and an extension or lateral co-movement at the thoracolumbar junction. This implies that the muscles (in some scenarios together with ligamentous structures) that should be stabilizing this segment are weak or the muscle pattern is incorrectly learned. This postural instability is not limited only to the lumbosacral region, but also significantly influences the muscle coordination of the extremities. To prevent overloading of soft tissues and the skeleton, the muscle activity, or rather the CNS and ligamentous structures, must ensure that stabilization of the segment(s) occurs in a centrated (neutral) joint position (see section A. Diagnostic Approaches, Chapter 1.2

Kinesiology and Clinical Assessment of the Joint System, Centrated Joint Position). For this to occur, a balance among the muscles in the entire biomechanical chain, as well as, between the exerted stabilization muscle force and the external force being overcome and, thus, form the basic presumptions. A deficit in segmental joint stabilization is often caused by the following: 1. Improper neuromuscular control. Its main causes include: a. Disturbance in postural ontogenesis. A deficit in muscle interplay occurs in relation to abnormal postural development. It is an incorrectly established posturally locomotor pattern (Fig. 1.1.4-3). b. Habituation of incorrect dynamic stereotypes. A deficit in muscle interplay develops by an incorrectly learned and fixated activity (incorrect practice, profession with a unilateral postural loading, cultural and esthetic factors, inability to relax and the associated deficit in selective movement and so on). c. Defensive (protective) CNS or muscle functions. CNS adaptation to a pathological situation leads to characteristic changes in muscle tone, as well as, the entire posture. 2. Insufficiency of muscles that ensure segmental joint stabilization. Motor programs ensuring stabilization of muscle interplay have a “strength dimension”. This means that, under normal conditions, the stabilization function works physiologically and it can be used in this fashion only to a certain extent under loading from external forces. This is often used in diagnosis by adding resistance to a defined position or movement or challenging the external conditions, which assist in accentuating the movement, or rather the postural pathology. The example can be a leaning test in which the individual in kneeling with hands on the floor shifts weight onto the upper extremities. The quality of the muscle synergy can determine the insufficiency of the stabilization, especially in the shoulder blade and shoulder

girdle area. Correctly performed exercises strengthen movement and muscle synergies ensuring an adequate postural stabilization for this movement. With every strengthening exercise, body posture is strengthened, including its dynamics. This is the reason why, during strength training, the principles of a functionally centrated position and the movement in it needs to be respected. Only in such a case do physiological stabilization muscle synergies strengthen together with the primary movement and, thus, the exercise will have a positive effect on the entire movement system. 3. Ligamentous insufficiency and deficits in local, regional and global anatomical parameters. The properties of mesenchymal tissues and the anatomical parameters (torsional and colodiaphysal angles of the hip joint, shape of the patella, alignment of the glenoid fossa, etc.) are important factors that influence joint stabilization during the activity of external forces. In contrast to muscle function, this situation cannot be significantly influenced by exercise but, can at least, compensate for it. In certain cases, corrective surgeries are an option. Fig. 1.1.4-3 Abnormal postural pattern in prone

General Principles of Practice Techniques 1. With a goal-oriented effect on the stabilization function, general principles are used, which are based on the programs maturing during postural ontogenesis (global patterns – ipsilateral and contralateral locomotion patterns, joint centration and its reflexive influence on stabilization function, facilitation by trigger zones,

2.

3.

4.

5.

support functions, resistance against planned motion, etc.). Exercises begin by influencing trunk stabilization, or the deep stabilization system of the spine, which is the basic prerequisite for a specific function of the extremities. The muscles are trained in developmental, posturally locomotor lines. Inclusion of these muscles into chains, or the central biomechanical programs, allows for the modulation of automatic muscle activation in its postural function. When selecting an exercise to influence (segmental) stabilization, it needs to be considered that segmental stabilization is never linked only to the muscles of the corresponding segment, but it always functions within the global muscle synergy arising from support. Postural (reinforcing) force must always correspond to the muscle strength that executes the movement (phasic motion), which means that the force executing the movement cannot be larger than the strength of the stabilizing muscles, otherwise the movement emerges from an alternate source (they are performed by compensatory, stronger muscles).

Note: The choice of an exercise is determined by the desired goal to be accomplished. Volitional control of an automatic postural muscle function is one of the main goals. A learned synergy of the stabilization muscles can gradually be included in common everyday activities. Practice of Postural Stabilization of the Spine, Chest and the Pelvis In patients with postural instability, trunk stabilization needs to be addressed at first. The influence of the deep spinal stabilization system must be preceded by exercises in developmental lines. These exercises are based on the basic postural pattern (trunk stabilization) for a specific movement of the upper and lower extremities. No movement of the extremities (locomotion) exists without stabilization (tightening) of the trunk as a whole. Every phasic movement requires trunk stabilization whose control is usually deficient in the majority of

patients demonstrating deficits in the movement apparatus and it needs to be corrected. In reflex locomotion, the stabilization activity of the trunk (linked to the breathing pattern) is the first activity that emerges during reflex stimulation regardless of starting position (supine, prone, in initial position, etc.). The chest wall, spine and pelvis form a common base for all movement activities. The stabilization function is integrated into all movements automatically and non-volitionally. The muscle synergy that ensures it needs to be viewed as the foundation for all exercises. The main prerequisite is, again, the knowledge of the physiological synergy, or the so called ideal pattern of deep spinal stabilization (see Special Section of the textbook, Chapter 2 Treatment Rehabilitation in Orthopedics and Traumatology, 2.4.1 Spine, Vertebrogennic Pain Syndrome, Rehabilitation). Within this context, we originate from a body posture that emerges as a program during postural ontogenesis and we can elicit this program (synergy) reflexively. In the majority of therapeutic concepts and preventative approaches, an erect spinal position is preferred as a starting posture. We all have heard the command “straighten up”. The individual concepts are not different. The difference is in the view of the chest, shoulder blades and pelvic alignment and, thus, the muscle synergy that ensures their stabilization. An erect spinal posture is recommended from an ergonomic perspective during common movement activities (housework, lifting objects), as well as, during specific stabilization exercises and exercises against resistance. From this perspective, for example, Brügger’s concept is well known. The so called back school is based on this concept. The initial model is Brügger’s sitting position which is called for as the basic working position (Fig. 1.1.4-4). Fig. 1.1.4-4 Brügger’s sitting position: recommended body position during work activities

To achieve the desired erect position of the spine, a slanted support surface under the buttocks is recommended to tilt the pelvis more forward (anteriorly). By tilting the pelvis anteriorly, the elicited lumbar spine curvature leads to the straightening of the spine. The shoulders are pulled backward, the lower extremities are shoulder width apart and the feet are supported with its entire surface on the mat. The lower extremity joints are at 90 degrees. The described position of the spine, pelvis, chest and shoulders is included into common movement activities and it is used when exercising against variable resistance. Sitting and exercising in this position on an unstable surface, most commonly on a ball, is popular today. In contrast to the developmental concept (Fig. 1.1.4-5a,b), in this positional model, the role of the chest during the formation and control of intra-abdominal pressure is not adequately understood (Fig. 1.1.4-5b).

Fig. 1.1.4-5a,b For correct body position, next to straightening of the spine, the caudal alignment of the chest and the neutral position at the lumbosacral and thoracolumbar junctions are important

From a biomechanical perspective, the recommended alignment of the chest or a deficit in its dynamics do not allow for the required activity of the diaphragm and the corresponding control of intraabdominal pressure via the lateral group of abdominal muscles, which predisposes the anterior stabilizers of the spine to weakness. A similar situation involves the pelvis, which is positioned in excessive anteversion in patients with an inflexible thoracic kyphosis during straightening of the spine. Also, this concept insufficiently takes into consideration the level and distribution of muscle tone in starting positions, when performing a specific exercise and during common daily activities. In patients with a disturbance in anatomical proportions (i.e., an increased pelvic tilt) accompanied by a disturbance in the control of intra-abdominal pressure, these facts are considered especially important because during stabilization, the patient uses excessive force in the superficial spinal extensors, which leads to an imbalance in the internal forces and overloading of the lumbar spinal region. During trunk stabilization, the focus is on the following:

The influence on tightness and improvement of chest wall dynamics The influence on spinal straightening Postural breathing pattern training and the stabilization function of the diaphragm (intra-abdominal pressure control) Postural spinal stabilization training using reflex locomotion Deep spinal postural stabilization training in modified positions Exercising postural functions in developmental lines Influence on Tightness and Improvement of Chest Wall Dynamics Alignment and the dynamics of the chest wall are important requirements for physiological spinal stabilization. With an erect thoracic spine, the thorax should be in an inspiratory position and should exhibit an isolated movement, meaning that the thorax should move independently of the thoracic spine. A co-movement of the thorax with the spine is pathological because an insufficient movement occurs in the costovertebral articulations and during expiratory and inspiratory movements of the chest, a flexion and extension co-movement of the spine occurs and originates mainly in the thoracolumbar junction (Fig. 1.1.4-6a, b, c).

Fig. 1.1.4-6a, b, c (a) – neutral alignment of the thorax during straightened thoracic spine; (b, c) – co-movement of the thorax and the spine

This deficit is most often linked to the shortening of the accessory

respiratory muscles (mainly pectorales and scalenes) and upper scapular stabilizers of the shoulder blades. While working on the inspiratory alignment, a release of the chest wall stiffness is performed (this is considered especially significant) primarily in the lower rib area. Only in an unrestricted thorax can the chest wall expand when the diaphragm expands, leading to widening of the intercostal spaces (mostly between the lower ribs). Practice Example Patient lies on their back, lower extremities flexed and in slight abduction (shoulder width), feet supported on the floor. The thoracic spine is straight. In this position, the soft tissues of the lateral chest wall are being released (Fig. 1.1.4-7). Fig. 1.1.4-7 Soft tissue release

In the same position, the thorax is passively positioned in the most caudal position. The pectoral and abdominal muscles must be relaxed. In this alignment, a slight pressure against the lower ribs is generated and the patient breathes in against the therapist’s resistance (Fig. 1.1.4-8a, b).

Fig. 1.1.4-8a, b. Resistance generated on the lower aperture of the thorax during inspiration. The chest is positioned into caudal alignment (a), prior to inspiration, the lower aperture of the thorax is manually compressed (b).

Full excursion of the lower part of the thorax is pursued (including posterior direction) without the thorax moving cranially and without activating the superficial spinal extensors. The abdominal muscles, as well as, the accessory breathing muscles must stay relaxed. This exercise can also be performed using resistive exercise bands (Fig. 1.1.4-9). Fig. 1.1.4-9 Inspiration with resistive band use

Influence on Spinal Straightening Training of spinal straightening is another requirement for physiological stabilization of the spine. Most often in patients with deficits in stabilization in the thoracic spine move as a rigid unit;

lacking isolated movement at individual segments. For treatment, traction mobilization techniques are used and straightening of the thoracic spine is practiced. To achieve this, correct stabilization of the shoulder blades is important. Stabilization of the shoulder blades by a muscle pull toward the spine (into adduction) does not allow for its straightening and blocks the straightening activity of the deep paravertebral muscles. For these reasons, extension training, or erection of the thoracic spine, is performed. This is performed at first with the upper extremity supported and, therefore, in a closed kinetic chain. Practice Example The patient lies on their stomach, forearms are supported on the mat, palms are placed on the mat and the head is straight. The patient leans on their medial epicondyles and by pressing them into the mat, the head is lifted with the intent of forward movement along the longitudinal body axis (Fig. 1.1.4-10a-f).

Fig. 1.1.4-10a-f Physiological (a) and pathological (b) pattern in a 4-month-old child. Spinal straightening training with upper extremity support in a physiological (c, d) and pathological (e, f) position.

The head lift originates in the mid-thoracic spine. During head lifting, the cervical spine straightens without sagging in its caudal portion. The shoulder blades adhere to the chest and have a tendency to move toward the points of support. For thoracic spine straightening, the activity of the serratus anterior is very important with respect to scapular stabilization. Its stabilization activity is only possible with activation of the lateral abdominal muscles that, together with the diaphragm, form the punctum fixum. The proper

function of the shoulder blades and shoulder adductors is important. Their direction of pull should not be toward the spine, but rather toward the support on the medial humeral epicondyles. Training of the Postural Breathing Pattern and the Stabilization Function of the Diaphragm A correct breathing pattern is another requirement for physiological stabilization of the spine. However, the opposite is true as well: posture very sensitively influences breathing, which is known as postural respiratory function of the diaphragm. The goal is to include the diaphragm into breathing and thus into stabilization functions without participation of the accessory breathing muscles. Straightening of the spine and caudal chest alignment are required for this function. During inspiration, the ribs move laterally (wing movement), the lower chest aperture expands, the sternum moves ventrally and does not elevate with breathing. The abdominal muscles serve as a support for the diaphragm. It is important for the abdominal wall to expand not just in an inferior direction, but rather in all directions (i.e., laterally and posteriorly). The umbilicus should not move cranially (its movement reflects an undesirable muscle pull in the cranial direction). Diaphragm activation has a fundamental role not only for breathing, but also for physiological stabilization of the trunk (see Fig. 1.2.3-5). The training is performed in various positions. During this exercise, the patient is taught to recruit the diaphragm, whose function during stabilization is not fully understood. After some practice time, with awareness and correction, we can indirectly distinguish its position without knowing its anatomical location. Practice Example The patient lies on their back, legs slightly apart, knees bent and feet resting on the mat. The patient moves their knees several times together and apart and then maintains them in a position that does not require a conscious effort. Another suitable position includes the lower extremities in shoulder-width abduction with the hips and knees at 90 degrees and the calves resting on a foot bench. In this position,

the patient exhales, holds their breath and, without breathing in, moves the thorax and the abdominal cavity similarly as if they were breathing. The abdominal content behaves more or less as a liquid. Through this exercise, the pressure in the abdominal cavity changes. During instruction, the pressure from the abdominal cavity needs to be distributed equally in all directions, including in the backward direction against the mat and, in particular, the lower abdominal area should expand (the increased pressure should be directed down in the direction below the umbilicus into the groin and the pelvis). The same exercise is performed during inspiration. Another version of this exercise in the above described position includes breathing training during increased intra-abdominal pressure. In this exercise, the therapist gently presses in a dorsal direction into the patient’s groin area above the femoral heads (Fig. 1.1.4-11). Fig. 1.1.4-11 The patient expands the abdominal cavity against resistance

The patient must feel that the area of the abdominal wall above the hip joints presses against the therapist’s fingers. It is important for the force the patient exerts against the palpating fingers to not cause any cranial movement of the umbilical region or narrowing of the lower aspect of the thorax. In contrast, it must expand in all directions. Then, the patient practices breathing without relaxation activity of the lower part of the abdominal wall during expiration. The patient can

also perform the exercise in sitting and in other modified positions. In the next exercise, the patient is in the supine position. At the completion of the expiratory phase, the caudal position of the thorax is held and passively – by pressure from the therapist’s hands – pressed toward the center (proximally) at its lower aspect. The patient attempts to expand the thorax laterally against the therapist’s resistance and without inspiration, that is, similarly as if they were breathing in. The movement cannot be accompanied by accessory breathing muscle activity or a co-movement of the thoracic spine into flexion. Arching of the lower thoracic and abdominal cavity without breathing is another version of this exercise. For accentuation, resistance is required and can be administered manually by a physical therapist (which allows for control of the executed movement’s quality). In the next phase, a resistive band can be used. Postural Stabilization Training of the Spine Using Reflex Locomotion In an early phase of education, a reflex stimulation model is used for the well-balanced co-activation of muscles of the abdominal brace (the diaphragm, abdominal muscles and pelvic floor) and the back muscles (Fig. 1.1.4-12). Fig. 1.1.4-12 Reflex stimulation according to Vojta – reflex rolling version

Individual components needed for physiological stabilization are integrated into this model – automatic positioning of the thorax in a caudal alignment, spinal straightening, postural diaphragmatic breathing with lower thoracic aperture expansion, based on the position also a neutral support function of the extremities, symmetrical involvement of the deep and superficial muscles and so on. The motor pattern of stabilization of the spine, thorax and pelvis precedes the stepping forward and the support functions of the extremities, that is, purposeful phasic mobility. It is a component of all versions of reflex locomotion – the first phase of reflex rolling, the second phase of reflex rolling, the first position and other positions. The goal of reflex stimulation includes eliciting muscle synergies and setting up an experience that during activation allows for somatoesthetic perception, which can later be transferred into exercises with volitional control. Practice Example In the supine position with the lower extremity in a tri-flexion position (with supported lower extremities) and slight abduction (shoulder width), the 6th and 7th intercostal spaces are stimulated in the mammillary line by a slight pressure. The stimulation can be expanded by activating the nuchal line region on the contralateral side and the anterior superior iliac spine on the ipsilateral side of the stimulated thoracic zone. The reflexive response is demonstrated by a change in the breathing pattern. Lower, or diaphragmatic, breathing occurs without participation of the accessory breathing muscles. The diaphragm flattens, meaning the punctum fixum is on the ribs, not on the centrum tendineum of the diaphragm. The thorax is positioned in a caudal alignment. At the same time, the spine straightens. The abdominal muscles are activated and act against the flattened diaphragm and pelvic floor, thus leading to an increased intraabdominal pressure. The stabilization function of the abdominal muscles together with the flattening of the diaphragm (punctum fixum in the rib region) manifest themselves by a caudal shift of the

umbilicus. The patient is aware of the activation and the therapist strives for the given pattern to come under volitional control. This can be achieved by the involvement of the abdominal brace during diaphragmatic breathing and by gradual unweighting of the lower extremities. Then, the upper extremities movement against resistance is added into the exercise. The exercise can be performed in other positions. Training of Deep Postural Stabilization of the Spine in Modified Positions As soon as the patient at least partially masters control of the stabilization function and the physiological postural breathing pattern, the exercises can be performed in modified and more challenging positions or can include resistance (Fig. 1.1.4-13a-h). During treatment, it is important to select adequate exercises to avoid muscle substitution and compensatory patterns which the patient may have been using. The exercises can be modified to place greater emphasis on various muscle groups, for example, the deep neck flexors.

Fig. 1.1.4-13a-h Modified positions for training of deep spinal stabilization

Exercising Postural Functions in Developmental Lines (Sequences) The starting position for exercises is derived from the basic locomotor positions of postural development (development of body posture and verticalization process): supine, sidelying, side sitting, on all fours with support on the knees or the feet, tall kneeling, stepping forward in tall kneeling, etc., as well as from positions derived from locomotor transitional phases allowing the transition from one position to the next, i.e. a transition from side sitting to the all fours position, from all fours to bipedal standing, from supine to side sitting and later to standing, or locomotion. Thus, the posturally locomotor development that occurs as part of CNS maturation serves as the base for the starting position (Fig. 1.1.4-14 through 17). ).

Fig. 1.1.4-14 and 15 Verticalization process from prone position – adult (left column) and a child (right column);

Fig. 1.1.4.-16 and 17 Verticalization process from supine – adult (left column) and a child (right column)

During selected locomotion (i.e., the transition from side sitting to quadruped), individual parts of muscles, or individual muscles from muscle groups, gradually participate. Positioning in individual moments of locomotor movement also allows to selectively influence the postural function of parts of individual muscles, or muscle groups. It is exercising in a somewhat “frozen” position of a locomotor phase. Later, the entire transitional phase of the locomotor movement can be practiced from the starting side sitting position to a quadruped position (Fig. 1.1.4-18 and 19). Fig. 1.1.4-18 and 19 Transitional phase from sidelying to quadruped – adult (left column) and a child (right column)

The selection of the original position is based on the patient’s individual predisposing factors. The rule is to advance from positions with lower postural demands (for example, supine position with triflexion of the lower extremities) to positions that are posturally more challenging, which can also include unstable support surfaces and resistances. The initial education requires a therapist’s assistance. The established starting locomotor position reflexively activates the deep stabilization system of the spine, ensuring trunk and spine

tightening (see above). The upper and lower extremities become involved in the support and stepping forward functions. The stepping forward and support functions are part of two basic developmental patterns – ipsilateral and contralateral. Based on the position selected, the extremities on one side are stepping forward and the contralateral extremities are supportive – the ipsilateral model – or their function is reversed, i.e. if a left upper extremity is supportive, the right lower extremity is supportive and the contralateral extremities (right upper and left lower) are stepping forward. It is a combination of open and closed kinetic chains, in which the stepping forward extremities present an open kinetic chain and the support extremities a closed kinetic chain. In a given position, a resistance against the movement of the stepping forward and the support extremities can be used. The support and stepping forward extremities perform an opposite movement in the joints; thus, if a support extremity performs internal rotation in a proximal joint, adduction and extension, then the stepping forward extremity performs external rotation, abduction and flexion. A similar scenario is found in other joints and it always involves movement in the opposite direction. In the support extremities, the muscle pull is directed distally, meaning the muscle’s punctum fixum is distal and the punctum mobile is proximal. It is the opposite for the stepping forward extremities, the punctum fixum is proximal and the punctum mobile is distal. In the support extremities, movement of the socket occurs in relation to the ball, or the movement of the proximal segment in relation to the distal segment. In the stepping forward extremities, the opposite occurs: the distal segment moves in relation to the proximal segment. Eye-movement and orofacial functions are reflexively included in this model (the eyes and tongue automatically turn toward the stepping forward extremity). The kinesiologic principles of both of these patterns are unconscious components of all our movements. These general kinesiologic principles during sport performances are more significant. If the movement of a javelin thrower is analyzed, it can be seen that the movement pattern at the time of javelin release

corresponds to the ipsilateral model. For a javelin thrower to achieve maximum performance, they must respect not only the anatomical, but also the kinesiological principles that are the content of biomechanical and CNS functions. The unilateral upper and lower extremities are found in an opposite position than the contralateral extremities. After movement completion, the positions are exchanged. The stepping forward extremities have their punctum fixum distally and the punctum mobile proximally and the distal segments are moving against the proximal segments. The opposite occurs in the support extremities. A position other than a reciprocal position of the extremities does not allow for attaining the required muscle strength. The javelin thrower’s tongue and the eyes automatically turn toward the side of the release, which is the side of the stepping forward (throwing) extremity (Fig. 1.1.4-20). Fig. 1.1.4-20 Javelin throw – an ipsilateral model of motion

If the javelin thrower wanted to turn the tongue or the eyes toward the other side, they cannot exert the required extremity force and they do not throw as far. Also, any position other than the reciprocal

position of the extremities does not allow the required utilization of muscle strength. This means that the eyes and the tongue are integrated into the movement and facilitate the corresponding movement pattern. In the developmental context, it should be kept in mind that our eyes possess not just a visual function and the tongue not just a dietary function or that the breathing muscles possess only a breathing function, but these functional systems are always integrated into posturally locomotor functions. The tongue, eyes, breathing and so on can be influenced by posturally locomotor functions and vice versa. It is a global movement (pattern), in which each muscle is integrated into a specifically defined synergy. Weakening of one part of this pattern leads to consequences in the entire pattern. The integration of the CNS developmental principles is observed not only in sports but also in traditional exercises developed in eastern cultures (for example, tai-chi, martial arts). Basic Positions and Transitional Locomotion Phases Used during Exercise 1. Individual starting positions and the transitional locomotion phase of the ipsilateral pattern (see Fig. 1.1.4-14 and 15). 2. Individual starting positions and the transitional locomotion phases of the contralateral pattern (see Fig. 1.1.4-16 and 17). Ipsilateral Pattern Supine position Locomotor phase: From supine to sidelying position Sidelying position Locomotor phase: From sidelying position into supine From sidelying position into prone From sidelying position into side-sitting position with support on the elbow Side-sitting position with elbow support Locomotor phase:

Into side-sitting position with support on the palm Side-sitting position with support on the palm Locomotor phase: Locomotor transition into sitting Locomotor transition into quadruped Locomotor transition into quadruped with support on palms and toes (“bear” position) Locomotor transition into tall kneeling Sitting position Locomotor phase: From sitting to side-sitting with support on the palm “Hurdle”-sitting position Locomotor phase: Transition into quadruped Transition into side-sitting Tall kneeling position (support: knee and ipsilateral upper extremity) Standing with ipsilateral lower and upper extremity support (contralateral extremities are used for movement) Contralateral Pattern Prone position with support on elbows Prone position with support on elbow and the contralateral knee Locomotor phase: Crawling Prone position with support on the palm and the contralateral knee Locomotor phase: Transition into quadruped Position with support on elbows and knees Position with support on hands and anterior thighs Locomotor phase: Homologous transition into quadruped Homologous transition into a plank position

Quadruped position Locomotor phase: Into side-sitting position (ipsilateral pattern) Alternate contralateral locomotion forward Position with support on the palm, knee and the foot Locomotor phase: Into quadruped position with support on hands and feet (“bear” position) Into side-sitting (ipsilateral pattern) Position on all fours with support on hands and toes (“bear” position) Tall kneeling position with support on the knee and the contralateral upper extremity Stepping forward in tall kneeling Locomotor phase: Into standing Deep squat position Stepping forward in standing Movement Assistance during Exercise During the early stages of education, most patients are not able to attain a position and perform exercises without manual correction from a physical therapist. A physical therapist guides the patient by using verbal and tactile cues. A therapist points out the patient’s errors and adjusts the alignment of individual segments, especially in a support function. The support and the segments must be in a neutral position. The manual contact also allows for any necessary resistance to movement. Facilitative Elements of Training Techniques Resistance Against Intended Mobility To accentuate the activity of the stabilization function, a resistance against the intended mobility can be used (stepping forward, support) within locomotor mobility. In a postural locomotor pattern, the stepping forward and support lower extremities possess an accurately

defined function within the global pattern. For example, if a resistance (minimal) is applied against the stepping forward action of the foot (resistance against dorsiflexion and eversion), an overall movement reaction is facilitated, which is strictly defined. The postural locomotor activity of the trunk, the upper extremities and the orofacial region are all being facilitated. The specific, overall postural locomotor reaction is being achieved by applying resistance against planned movements. Trigger Zone Stimulation Trigger zones according to Vojta can be used to facilitate the muscle’s postural reactions. A selected and strictly defined position (stance) facilitates the global movement pattern. Stimulation in the zones needs to be performed by accurately directed application of pressure. The pressure should be continuous and its intensity during stimulation should vary depending on the response obtained. The pressure in the zone should not elicit a nociceptive irritation. Centration of Support Support areas are sites that form the punctum fixum of the entire stabilization synergy. Straightening and specific movements arise from support areas. With incorrect support, spine straightening (alignment) nor a correct breathing pattern can be ensured; in other words, muscle balance cannot be achieved during stabilization. For these reasons, correct centration of support (i.e., the foot, hand, medial epicondyle) is emphasized in the selected position. This will activate a physiological stabilization pattern. This is especially important for the feet, which form the fundamental support for upright body posture. Foot support is directed toward the metatarsal heads of the 1st and 5th metatarsals and the calcaneal tubercle. All toes are supported on the floor. The tarsal bones are actively elevated and form a transverse foot arch similar to the one formed during foot grasping. This activity is mainly performed by peroneus longus and tibialis posterior. The muscle pre-stretch, support points on the bottom of the foot and the shape of the foot arch provide afferent impulses into the CNS, which activate an upright body posture. As a reaction to the foot musculature, the diaphragm and the thorax alter

their alignment and breathing pattern. The patient has to learn to perceive the muscle responses resulting from integration of the foot musculature, including more distant areas. Foot stabilization training is an important component of stabilization function practice and should not be neglected. In a selected position, attention is paid to ensuring and maintaining a centrated support. This leads to an increased afferentation and a greater activation of the physiological postural locomotor pattern (Fig. 1.1.4-21a-d). In postural functions, a rule applies that if a stabilization function is disturbed, meaning there is an imbalance in the agonist-antagonist synergy, it will reflect in the way the body supports itself on the extremities. The leaning test is an example. The opposite is also true: a balanced stabilization function of the muscles integrating individual components of the body cannot be achieved without centrated support.

Fig. 1.1.4-21a-d Support function. Hand: centrated (a), decentrated (b) positions; foot: centrated (c) and decentrated (d) positions

Joint Centration It implies a joint position in which the joint surfaces are in a maximum contact and the forces acting on the joint and the joint surfaces are symmetrically distributed. In this position, the joint capsule and the ligaments are in minimal tension. The centrated position corresponds to the mid- or neutral position that allows ideal static loading of a joint. Mid-position (neutral) or the centrated position of a joint is linked to the entire joint range of motion during a

locomotor movement. Pressure into the Joint In the support extremities, increased pressure into the joint (approximation) is applied to increase the effectiveness of a postural reaction. The joint must be in a neutral position when the pressure is applied, otherwise, the response elicits muscle imbalance. Exercise Against Resistance Next to resistance applied against an intended motion, resistances applied against phasic motion can also be utilized (Theraband, dumbbell, medicine ball, etc.). Resistance is used when a sufficient stabilization function is achieved. Resistive exercises are selected for the following purpose: To affect the postural function of a muscle in a closed kinetic chain (in support function); To affect the postural function of a muscle in an open kinetic chain (in stepping forward function). Exercise Examples Figures 1.1.4-22 show examples of exercises based on locomotor positions of postural development or positions derived from locomotor transitional phases. At the beginning, a physical therapist assists with exercises; later, an individual can exercise independently. To facilitate postural activity, centrated support is used, as well as, joint approximation in the support extremities, in centrated joint positions and with resistance against an intended motion. With goaloriented activated postural activity, it is even possible to exercise even phasic mobility against resistance. The resistance must correspond to the strength of postural muscles.

Fig. 1.1.4-22a The patient is assisted with positioning of the thorax into an expiratory alignment and with straightening of the cervical and thoracic spine. In this position, breathing and control of intra-abdominal pressure are practiced. The upper extremities are gradually included into exercises against resistance.

Fig. 1.1.4-22b Training from a sidelying position (ipsilateral pattern). The arrow points in the direction of the knee against the table. The right upper extremity leans on the posterior part of the arm and support shifts toward the elbow; the elbow slightly presses into the mat. The therapist provides resistance against the knee and in the pelvic region against the stepping forward activity of the left lower extremity. The left upper extremity works against Theraband resistance in a phasic motion.

Fig. 1.1.4-22c Training of the deep spinal stabilization system in a position of a 6month-old infant pattern. Controlling the neutral position of the proximal joints is important.

Fig. 1.1.4-22d An example of an exercise in a sidelying position (ipsilateral pattern). The free upper extremity works against Theraband resistance.

Fig. 1.1.4-22e Exercising from support: palm – knee – foot (tripod) (contralateral pattern). The therapist controls the neutral position of the support joints. The right

upper extremity exercises against resistance.

Fig. 1.1.4-22f An example of side-sitting into tall kneeling transition with stepping forward (ipsilateral pattern). The left upper extremity can be used for resistive strengthening.

Fig. 1.1.4-22g Exercises in a quadruped position with support on the palms and toes (a “bear” position) (contralateral pattern). The left lower extremity is unweighted and can perform exercises against resistance. The pelvis cannot drop or shift laterally during unweighting. Similarly, the upper extremity can be gradually unweighted. The control of the centrated joint position and support are important.

Fig. 1.1.4-22h An exercise example of transition from side-sitting into tall kneeling on all fours (a “bear” position) – in the given phase this is a contralateral pattern.

Fig. 1.1.4-22i An exercise example of transition from side-sitting into quadruped (ipsilateral pattern). During the exercise, joint approximation into the hip joint of the support lower extremity is important. Fig. 1.1.4-22j An exercise example in a contralateral pattern position in standing with upper extremity support. The knee of the support lower extremity should not pass over the toes; the center of the patella is aligned with the third toe; the toes push into the mat; the spine is erect. The stepping forward left upper extremity works against resistance.

Fig. 1.1.4-22k Training of an ipsilateral pattern in standing. During this exercise, the therapist controls the neutral position of the support lower extremity. Resistance is applied against the stepping forward action of the lower extremity.

Fig. 1.1.4-22l Training of stepping forward in tall kneeling (contralateral pattern).

Fig. 1.1.4-22m An assisted exercise involving the transition from sidelying to sidesitting with support on the elbow. The exercise is especially beneficial for scapular stabilization training.

Fig. 1.1.4-22n Assisted exercise in a contralateral pattern with support on the elbow and the contralateral lower extremity.

1.1.5 Soft Tissue Mobilization Karel Lewit Soft tissues surround the human body and thus the movement system. Therefore, they must move together in harmony and without

resistance with the movement system; this means they stretch or shift in all layers. So far, since this very complex function has not been studied much, we become aware of it primarily when it has become disrupted and causes problems. The deficit in function manifests itself during resistance against stretch or by shifting of these tissues. This resistance is never so large that the muscles would not overcome it. Despite this, a deficit in the soft tissues very often significantly disturbs movement and causes pain. However, if soft tissue mobility is successfully restored, then, generally, the function of the movement system immediately corrects itself. Soft tissues act on the movement system via a reflex path. Similarly, the internal organs behave like soft tissues (mainly in the abdominal cavity) and must participate in each movement of the trunk and the diaphragm. Wherever resistance or limited mobility (which is basically the same phenomenon) is found with stretch or shifting, a certain range or a zone can be identified. Within this zone the resistance is minimal, practically zero, until a barrier gradually emerges (pre-tension) which, under normal circumstances, is soft and giving. However, in a pathological and often painful state, the barrier soon increases and it does not give and limits motion. It is a pathological barrier (see Chapter 1 Examination Approaches Focused on the Function of the Movement System, Palpation). Also, the treatment approach is generally always the same. When the barrier is encountered, it is important to wait and not increase pressure because in a few seconds, the release phenomenon occurs. This can take 10 seconds or even longer and must be held to the end only by palpation. A faster diagnostic approach can be utilized only at the surface. By mere stroking, an increased resistance can be palpated in the area of dysfunction or skin drag can be found as a result of increased perspiration in the affected area. In general, mobilizations apply to all movable structures linked to the movement system; that is not only the joint, but also the soft tissues which include, among others, the fasciae and internal organs. The basic model is as follows. At first, the barrier (pre-stretch) needs to be reached and held. After a short latency, the release phenomenon

occurs, which needs to be held until the normal barrier is reached. This can take 10–30 seconds, in the case of fasciae perhaps even longer and the longer the better. This all depends on the therapist’s palpation ability. Most frequently, joints with limited range of motion (called functional blockage of the spine, the extremities or temporomandibular joint) are mobilized. Besides waiting for the release phenomenon, springing of the joints is often used after the barrier is reached. Springing is usually technically less challenging when compared to palpation. Its disadvantage may be seen in cases involving limited mobility, in which springing in the direction of limited mobility may be unpleasant and the patient will be defensive and inadequately relax. Finally, it is possible to perform a thrust after the barrier has been reached – a (thrust) manipulation is not a mobilization. The risk of manipulation lies in the fact that it temporarily deactivates the barrier, which has a protective function and thus a hypermobility occurs temporarily. A combination of soft tissue techniques and reflex stimulation techniques achieves more favorable results than the use of thrust techniques. Today, thrust techniques are no longer recommended. During mobilization, a functional movement is used, which is a movement that corresponds to a volitional, muscle-elicited movement or, most often in the extremities, joint play is used. However, it is also a physiological movement elicited only passively during joint distraction in the direction that is tangential to the joint surface. The mentioned schema shows that the mobilization affecting joint play is substantially more gentle. The functional limitations in joint mobility (“blockage”) are regularly linked to muscle trigger points (TrPs) in that they limit mobility and are the main reasons for blockages or the reasons for mobilizations. This fact has fundamentally influenced modern mobilization techniques in that mobilizations are performed with the help of “neuromuscular” techniques so that the muscles are relaxed at the same time. The methods of post-isometric relaxation (PIR),

reciprocal inhibition (RI), as well as, the principles of neurostimulation techniques based on Vojta can be used. The physiological aspect and the gentle nature of this approach arise from the core principle itself: the patient’s muscle activity is used, meaning that their specific muscle activation corrects the joint’s biomechanics. Post-Isometric Relaxation Simple PIR 1. Step: a pre-stretch in the direction of mobilization is achieved 2. Step: the patient resists with minimal strength against the direction of mobilization for at least 5 seconds 3. Step: the patient is instructed to relax 4. Step: the patient relaxes, a release phenomenon occurs which the therapist follows through to the end. From the gained position, the series of steps can be repeated. However, the therapist only precedes to the patient’s level of relaxation and may not stretch (“The therapist cannot “relax” the patient; that can only be done by the patient themself.”) Reciprocal inhibition generally follows PIR. In RI, the patient stretches the antagonist muscle to the muscle with TrPs against resistance. Commonly, a significant amount of resistance is applied for this purpose and this method may look like a “fight” between the therapist and the patient. This is absolutely not necessary and an excellent result is achieved by repetitive light resistance against the antagonist of the muscle with TrPs. In another version, the patient forcefully performs (based on Ivanicev) a full active movement in the direction opposite the restriction. However, post-isometric relaxation can be facilitated by other physiological stimuli that can increase its effectiveness. First, inspiration and expiration can be used, which significantly facilitates or inhibits the trunk muscles. The most significant result is seen when “breathing synkinesis” occurs. It occurs during a situation in which a movement in one direction is linked to inspiration and the opposite movement with expiration, such as in the scenario with bending forward and coming back up or when opening and closing the mouth. If the

temporomandibular joint is to be mobilized (relaxation of the muscles of mastication), the patient is instructed in the following manner: “breathe out and then take a deep breath in and open your mouth as if you were yawning”. An especially useful breathing synkinesis is seen by alternating inspiration and expiration in the cervical and thoracic spine with mobilization into lateral flexion according to Gaymans, in which even segments increase resistance during inspiration and relax during expiration; the opposite is true for odd segments. It is especially important to wait for the release to occur. Facilitation using vision. Bending forward and subsequent return to straight position is facilitated by looking up or down. Rotation movements are facilitated by looking right or left. Most are combined with inspiration and expiration. Another important component that has enriched mobilization techniques was developed by L. Zbojan. Based on its name, it involves the use of gravity and is called anti-gravity relaxation (AGR). The applied techniques fully use the patient’s muscles either via combined PIR or RI so that the treatment is performed mostly by the patient and the therapist merely directs it. Then, it is only a small step to home-based self-treatment. AGR is like that from the very beginning. These techniques are described in much detail in a separate textbook (Lewit, 1996). Other options provide stimulation methods based on Vojta and Kolar. This book describes why passive movements in regards to joint play are more gentle and effective than in functional movements. Examples of PIR Application PIR + RI With limited pronation, most often with lateral epicondylitis, the forearm is placed into pre-stretch pronation until minimal resistance is felt. Then, the patient is asked to resist with minimal strength in the opposite direction of the therapist’s isometric resistance for a period of at least five seconds. Then, the patient is asked to relax and the therapist waits for relaxation during which pronation increases or even normalizes. If the relaxation is not sufficient, then the process is

repeated. For RI, the patient is asked to exert a low level pressure into pronation by themselves and the therapist gives repetitive resistance into supination or the patient themselves performs full pronation independently. The patient can perform self-mobilization by using the other hand. Application of Breathing Synkinesia A temporomandibular joint mobilization – relaxation of the muscles of mastication serves as an example. Here, inspiration and expiration are used for facilitation because in mouth breathing, the mouth opens with inspiration (yawning). The patient is supine, their mouth opened to pre-stretch. The therapist stabilizes the head and applies resistance to the chin during expiration. Then, the patient takes a deep breath in as if yawning and actively opens their mouth (RI). During self-treatment, the patient is sitting, supporting the forehead with one hand and the other is placed on the chin or on the lower incisors. Breathing synkinesis is used during cervical spine mobilization. Gaymans’ rule is followed: in even segments (cranium, C2, C4, C6), the lower vertebra of the restricted segment is stabilized and after reaching the barrier with bending, the patient is asked: “look up (toward the forehead) and breathe in, breath in again, and then look down (toward the chin) and keep breathing out.” The looking up facilitates not only the straightening, but also breathing in and, on the other hand, looking down facilitates flexion and expiration. Waiting until the release phenomenon occurs is necessary during exhalation. After pre-stretch is reached in the odd segments (C1, C3, C5, C7), only the instruction “exhale, exhale and then slowly inhale” is given and we must wait for relaxation, which should occur during inspiration. Mobilization of the occipital region (cranium) on the atlas into forward flexion will be described as an example. The patient is supine with the subcranial region resting in one of the therapist’s hands. The

thumb of this hand stabilizes one transverse process of the atlas and the index finger on C2. The patient’s head is pushed by the therapist’s hand into pre-stretch in forward bending against the atlas, which is stabilized by the other hand. The patient is given the following instruction: “look toward the forehead and breathe in, breathe in, hold your breath, and now look toward the chin and slowly, gradually exhale”. Relaxation occurs after a short delay. After RI, the patient can be asked to gently press into forward flexion against the therapist’s repetitive resistance placed under the patient’s chin. A limitation of shoulder external rotation with TrPs present in the subscapular muscle serves as another example. During treatment, the patient is supine with their arm in abduction with the elbow over the edge of the mat. The forearm points cranially and it is parallel with the mat. The patient relaxes and, by the weight of the forearm itself, achieves a pre-stretch. From this position, the patient lifts the forearm by only about 2 cm and holds it elevated for approximately 20 seconds. Then, the patient relaxes for another 20 seconds. This is repeated 2–3 times. After RI, the patient actively presses the hand toward the floor. Anti-gravity Relaxation in Combination with Vision, Inspiration and Expiration Self-mobilization of C0-1 or AGR of the sternocleidomastoid: the patient lies with their head turned toward the side of mobilization so that the head overhangs the end of the table and it is supported at the level of the mastoid process and the lower jaw. In this position, the patient relaxes so that the weight of the head leads to a pre-stretch. The patient looks up and deeply inhales so that the nodding muscle is contracted and slightly lifts the head while holding the breath in. The patient looks down and slowly exhales. The nodding muscle relaxes and the head drops into lateral flexion of the occiput on the atlas. This process is repeated 2–3 times.

Examples of Other Techniques In the superficial skin layers presenting with increased myofascial tightness, the skin can be stretched using minimal force between the fingers or the palms of both hands depending on the extent of the altered skin area until a barrier is reached (pre-stretch) followed by gentle tissue springing. If the barrier is pathological, the springing is (almost) absent and the patient often feels slight pinching pain (under normal circumstances the patient only feels the therapist’s touch). During treatment, the therapist holds the tissue at the barrier and does not spring or increase the pull. After a short latency, the release phenomenon occurs and is held until the end. Tissue Fold Stretch In an affected area, the skin fold (with subcutaneous tissue) is thickened and painful to pressure. The fold can be put under prestretch (not squeezed) between the fingers of both hands without causing pain. Pre-tension needs to be maintained and the pull not increased. After a certain period of time, the release phenomenon occurs which is followed to the end. The skin fold is stretched in an Sshaped fashion. Fascial Shifting Pathological barriers in this region are especially pathogenic and their treatment is effective. This especially applies to: All soft tissues shifting around the back (lumbo-pelvic type pain in the caudal direction and with pain in the shoulder and the scapula in the cranial direction) Fasciae on the lateral aspect of the thorax Cervical fasciae Human scalp Shifting of all Soft Tissues of the Back During the assessment, the patient is in a prone, neutral position. In the superior region of the back, the therapist places both hands on the scapulae from the bottom and shifts soft tissues cranially into pre-stretch alternately on the right and the left sides and

springs them. Bilateral comparison determines a possible pathological barrier. During treatment to correct limited mobility in the cranial direction, the patient is prone with the head turned toward the side of the restriction with the ipsilateral upper extremity fully stretched overhead. The therapist stands on the affected side, places one hand on the shoulder and the other, stabilizing hand, on the lumbar region. The hand on the shoulder shifts soft tissues in a cranial direction into pre-stretch. Then, the patient inhales and thus increases the resistance as they hold their breath. Release occurs during expiration. The process is repeated 2–3 times. For assessment of a restriction in the caudal portion of the back, the patient is prone and in a neutral position. The therapist places their hands on the patient’s buttocks from the superior aspect and shifts the soft tissues in a caudal direction into pre-stretch, springs and compares both sides. During treatment, the patient is in the same position as during assessment and attempts to also extend the lower extremity on the same side. On that side, the therapist places one hand on the buttock from the top and the other hand stabilizes the soft tissues at the level of the scapula. The hand on the buttock shifts in a caudal direction into pre-stretch. Now, the patient deeply exhales, which significantly increases the resistance and a release occurs during a slow, deep inspiration. The process is repeated 2–3 times. In this case, the deep exhalation increases resistance and, conversely, inspiration releases tension. Fasciae on the Lateral Side of the Thorax Under normal circumstances, the soft tissues on the lateral side of the thorax display marked mobility in the anterior-medial direction. This can be assessed with a patient in supine by shifting the soft tissues in ventral and medial directions with a hand placed laterally below the nipple. On the side of the restriction, mobility is often significantly limited and the restriction is encountered quickly. During treatment, the therapist places the patient’s farthest hand laterally under the nipple and the therapist’s hand is placed over the

patient’s hand. Initially, the patient completely relaxes their hand and the therapist guides the hand in the ventromedial direction into prestretch. The patient inhales and a release occurs during expiration. The process is repeated and the patient’s hand is placed once more cranially and once more caudally and, gradually, the patient takes a more active part in the movement so that they can continue this process at home by themselves, regularly, twice a day. Restrictions in this region are especially pathogenic. They should be assessed routinely in a patient complaining of pain in the area of the scapula and the shoulder to find out whether trigger points are present in the diaphragm and in the subscapularis muscle. Cervical Fasciae The cervical fasciae are assessed by one hand which encompasses the neck from both sides and rotates the neck so that the soft tissues move into pre-stretch once in the direction of the fingers and then in the direction of the thumb. When the pre-stretch reaches a restriction, release occurs after a short latency. As far as the technique is concerned, mobilization by the thumb can be performed to the area of the cervical fascia where the resistance is the most obvious; while with the fingers, the entire cervical fascia can be influenced. At the cervicothoracic junction, both hands need to be connected to encompass the entire area. A parallel technique to the one for the cervical spine can be utilized for all extremities: arm, forearm, thigh and the lower leg. However, restrictions are most often found around the elbow and the knee. Human Scalp Clinically, the scalp is a very important piece of fascia. Restrictions are often present in this area with cervicothoracic as well as temporomandibular syndromes. Most of the time, they are located in the suboccipital region and around the ears, but can also be seen in any other area. They can also be found around the nose and above the zygomatic bone of the face. They are identified by movement of the fingers in various directions and, based on that, are released. Finger sliding on the hair presents a technical difficulty. Therefore,

mobilization can be performed by grasping a handful of hair and gently pulling. Resistance is achieved and the release phenomenon follows after a short interval. (A gentle pull on a greater cluster of hair is completely pain-free.) Similarly, the assessment and mobilization of the auricle is an inherent part of the assessment and release of the scalp. Painful Periosteal Points The soft tissues overlying the superficially located periosteal points (the epicondyles, C2 spinous process, posterior superior iliac spine, pes anserine on the tibia) are freely movable in all directions under normal circumstances. If they are painful, a restriction in at least one direction is found. A very gentle pull of one finger can identify a restriction and a release can be achieved by a pull in the same direction after a short latency. This technique is much gentler than periosteal massage. Acupressure Massage It is performed by a gradual sinking in of the finger pads into the deeper structure of the soft tissues (most often a muscle). Gradual palpation is important so that the patient does not react by reflexively increasing muscle tone. Later, a deep kneading in the area of a palpation-sensitive resistance is performed. Once again, it needs to be assured that the patient does not react with a reflex spasm but rather maintains a completely relaxed position. “Active” Pathogenic Scars Scars, most frequently post-surgical scars, involve all soft tissue layers. Pathological restrictions can form in any of these layers and cause clinical problems. If the scar is on the abdomen, restriction can also be found within the abdominal cavity and the patient will report pain during palpation. Here, after the resistance is reached, a release phenomenon will also occur after a short latency. In this case, the release phenomenon is especially important. If it does not occur, it is not a functionally reversible change, but rather a pathological state which warrants surgical consultation.

If a restriction is found in one layer of a scar, it is an active scar. This scar is often a source of painful functional changes affecting the movement system for which there is no other explanation and which will tend to reoccur if the scar is not identified and treated. It can be far from the area where it causes a problem, but more often, it is found at least on the same side. It does not matter when it was formed and could have developed as early as in childhood in an older patient. In anamnesis, it is significant whether or not the problems began or significantly worsened from the time the scar developed (surgery). Scar activity may not manifest itself the entire time. A successfully treated scar can reoccur, for example, as a result of a common infection. Besides pain in the movement system, the scar can also affect the state of the entire vegetative system. The founder of scar significance, F. Huneke, suggested that after the scar is injected with procaine, all symptoms resolve. He referred to this outcome as “Sekundenphänomen”. This concept can be confirmed when an active scar is the main factor in pathogenesis and is why it is recommended during patient treatment to examine the relevance of an active scar in any given scenario, which could determine further appropriate therapy. Based on the findings, the actual treatment implements the above described soft tissue techniques, however, only for the active layers. The effectiveness of the treatment does not depend on the amount of layers in which the pathological barriers are found; therefore, clinical success can occur only after skin stretching. Even if the immediate treatment is highly successful, the gains may not be permanent and the treatment often needs to be repeated in weekly intervals. According to Brügger, the scars can be heated by a small hot towel roll (with the exception of scars after mastectomy). Scars found in the abdominal cavity often pose diagnostic problems. If an incision was performed, generally, the scar’s activity can be identified by stroking and presents as an increased skin tightness. However, it needs to be considered that, for cosmetic reasons, the skin incision may not correspond to the procedure in the abdominal cavity or even on the thorax. Today, most procedures in the abdominal

cavity are performed laparoscopically or by a laser and thus the resistance and the release phenomena must be found strictly by palpation in the abdominal cavity. Every scar in the abdominal cavity may not be a remnant of a surgical procedure. It can develop after a serious injury and, in females, following birth with internal bleeding. This fact needs to be kept in mind and the pathological restriction needs to be assessed in the direction of the pelvis behind the pubic bone. It also needs to be distinguished from the resistance given by trigger points in the psoas or the iliacus muscles. Limited backward bending without typical restrictions and signs of disc involvement are a valuable lead. All tension in the abdomen, especially on the abdominal wall, limits backward bending and the patient will perceive it as pain in the low back. That is why even a pubic symphysis that is painful to palpation at the area of insertion of the abdominal muscles will refer pain to the low back.

1.1.6 Dry Needling for Muscle Trigger Points Pavel Kolář The therapeutic effect of a dry needle can be assessed by the use of acupuncture. Generally, the insertion of a needle has a significant analgesic effect when applied to a painful structure within the movement system if a sharp pain can be elicited by its application. The effectiveness of this therapy does not differ for some cases from treatment by other injections. Frost et al. (1980) has shown that a physiological solution is as effective as local desensitization. Most significantly, this effect can be seen as soon as the needle, which the patient otherwise does not perceive during intramuscular application, comes into contact with TrPs. Then, the patient feels sharp pain, which they identify as the pain that they suffer from (including referred pain). Generally, a muscle twitch can be palpated, followed by analgesia. In other words, the effects that used to be attributed to the injected substance are really the result of the needle. This is also true for the application of corticosteroids, which sometimes (mainly in enthesopathies) should not be applied. In other

words, when we are not convinced that the “dry needle” therapy is insufficient. For TrPs, the “dry needle” application is a question of differential diagnosis. Most often, TrPs are strictly functionally reversible and are corrected (together with joint restrictions) by reflexively based methods, such as PIR and RI. They occur in predictable chains and disappear as soon as the chain is successfully corrected, i.e. with activation of the deep spinal stabilization system. However, a different type of TrPs also exists that is not reversible in such a manner and become chronic. The patient typically always reports pain (even referred) in one location. Such TrPs are not part of a specific chain and react to reflex stimuli (i.e. PIR) either ineffectivelly or not at all. Then, a dry needle or a deep, high pressure massage to “destruct” the fibers with TrPs can be applied. Procedure: a painful point within the muscle is located by a needle. It is usually not just one point and, therefore, the application must be repeated several times in the surrounding area. At the same time, a twitch and pain are elicited, as well as, referred pain, that is the patient’s “familiar pain”. Prior to completion, the needle is gently partially pulled out and while the needle is still in situ, it is assessed whether the TrPs persist.

1.1.7 Traction Pavel Kolář To a certain extent, traction is a type of joint manipulation. It involves a distraction along a joint axis which can be performed repeatedly for short periods of time or continuously for longer time. With traction, choosing the appropriate force of the pull is important. During application of traction, reflexive muscle reaction should never occur. Usually, manual traction shows better response than mechanical traction. Within manipulation techniques, a specific role is played by traction of the lumbar and cervical spine. It is very effective for nerve root syndromes and in the lumbar spine, especially when disc

pathology is present. It can even be stated that if traction provides relief in the lumbar region, disc lesion diagnosis is confirmed. During traction, it is always important to perform a traction test in order to confirm that it truly relieves symptoms. Many patients do not tolerate traction well and, if this is the case, traction may need to be discontinued. In orthopedics, traction utilizes a pulley system and it is used for analgesic effect as well as for prevention of contractures.

1.1.8 Relaxation Techniques Pavel Kolář This includes awareness of increased tone in the striated muscles followed by relaxation. Autogenic training is among the best known techniques and it is performed under the therapist’s verbal guidance. Muscle tension decreases via mental relaxation. Regular practice of autogenic training leads to relaxation, increased self-control, and better physical and psychological self-awareness.

1.1.9 Exercises Aimed at the Restoration of Sensation (Somatesthesia) Pavel Kolář, Magdaléna Lepšíková This is accomplished by exercises in which the patient is forced to be fully aware of the way they move, which muscles exhibit increased muscle tone and wher excessive muscle activity is exerted unnecessarily. The exercises do not describe how to breathe or walk, sit or stand and their goal is to teach an accurate differentiation. The exercises are performed slowly, repeated several times and the patient attempts to fully experience the position and the movement. The patient is forced to realize their proprioception and exteroception. Simply said, the patient is asked to “hypertrophy” the areas of sensory perception and learn better movement differentiation (selective mobility). One of the exercise principles includes training of isolated movements of varied difficulty in postural situations (see section A.

Diagnostic Approaches, chapter 1.1.16 Cortical Syndromes and Their Examination; Examination of Motor Function from the Perspective of Cortical Plasticity).

1.2 METHODS AND APPORACHES USED IN REHABILItATION OF PATIENTS WITH CHRONIC RESPIRATORY SYSTEM INVOLVEMENT Pavel Kolář, Jan Šulc The correlation between physical therapy methods and the parameters of lung functional assessment are rarely mentioned in the literature. Some studies (Weisgerber, 2003; Ries 2003; Hui, 2003; Oh, 2003) did not show an apparent effect of rehabilitation on the standard indicators of lung function. Conversely, other studies are more optimistic (Ramirez-Sarmiento, 2002; Chlumský, 2002; Hodgkin 2009; Cameron, 2007, etc.). The results of individual studies suggest that the type of physical therapy approach is important in affecting functional pulmonary parameters and for the patient’s subsequent clinical condition. The diagnostic and therapeutic approaches that had been introduced into practical setting within the last decade of the last century have allowed physical therapists to more accurately work with respiration specifically, including its pathophysiological form. More perfected modifications of exercise approaches of respiratory rehabilitation serve as the basis of a new methodology known as pulmonary physical therapy (PPT). Together with exercise therapy, they form a foundation of treatment rehabilitation for individuals with cardiorespiratory system diseases, including acute and chronic forms of such illnesses. Decreased ventilation capacity elicited by an obstruction in the respiratory pathways and very often combined with loss of elastic lung properties present the main mechanism of pulmonary deficits that influence the respiratory pattern. This results in an unfavorable breathing frequency, increased resistance and respiratory volume that ventilates the dead space without a purpose. The imbalance between ventilation and perfusion also contributes to an increased breathing demand. Certain lung regions are hypoventilated and others are

hyperventilated. Therefore, for therapeutic approaches, the coexistence of a primary respiratory involvement with a dysfunction of the respiratory movement system (a deficit of respiration as a motor function) is essential. A ventilation deficit of the respiratory system influences the engagement of the respiratory muscles, which always affects postural functions. The goal of pulmonary physical therapy is the treatment of the patient’s respiratory problems in a form of modified breathing while taking into consideration the patient’s individual capabilities. Pulmonary physical therapy is a system of respiratory rehabilitation utilizing specifically performed methods that have a direct treatment effect and, at the same time, fulfill a function of secondary prevention. Respiratory physical therapy is indicated by a physician and a physical therapist is responsible for developing an adequate plan of care including exercise prescription of PPT. It is indicated as a treatment method addressing the patient’s individual problems, in which breathing occurs under pathological conditions of the respiratory system. The application of pulmonary physical therapy techniques in the form of modified breathing and in combination with inhalation, most often of an antibiotic treatment, significantly increases the intensity of the treatment process. The methodology of pulmonary physical therapy intensely deals with observation and research of new exercise methods and the development of more effective modified breathing techniques that help solve respiratory symptomatology, primarily shortness of breath, coughing and an excessive production of bronchial secretions. The PPT methods are aimed at decreasing bronchial obstruction, improving respiratory pathway clearance, improving ventilation parameters, preventing a decrease in pulmonary function, increasing physical conditioning, and reaching and maintaining optimal health. Individual breathing techniques whose effectiveness have been determined by evidence based medicine (EBM) can be applied in patients of all age categories in a form of individual physical therapy as well as in group exercise settings. The PPT methods are effective in actively participating patients as well as in patients who cannot or are unable to cooperate, for example, because

of exhaustion, disorientation or unconsciousness. Exercise therapy improves physical conditioning, increases tolerance to physical demands and helps restore correct movement habits linked to breathing. In children with chronic forms of respiratory system diseases, exercise therapy must be included at an early age. The goal of exercise activities is to increase physical conditioning. Movement activities can have various forms and the most frequently applied forms include respiratory gymnastics, conditioning breathing and movement preparation, training of physical conditioning and movement activities. Bio-psycho-social components of physical therapy motivate the patient to actively cooperate in their rehabilitation program, ensure exercise independence and, subsequently, improve the working relationship between the physician, patient and the physical therapist, as well as improve the patient’s quality of life. Respiratory physical therapy in combination with movement activities and participation in sports form the basis of treatment rehabilitation for individuals with respiratory and cardiovascular system illnesses. Physical conditioning training conditioned by unobstructed breathing pathways is the foundation for pulmonary rehabilitation programs that focus on health-oriented quality of life. Physical conditioning significantly contributes to the patients’ improved social and work participation, increasing their confidence and, primarily, improving their quality of life.

1.2.1 Methods of Pulmonary Physical Therapy Libuše Smolíková Physical therapy approach is based on kinesiological assessment and focuses on identification of undesirable respiratory manifestations, as well as, on establishing the intensity and effects of respiratory deviations affecting the patient’s movement system. Basic pulmonary physical therapy methods include the following: Corrective physical therapy of the postural system

Pulmonary physical therapy – corrective re-education of respiratory motor patterns Relaxation preparation This triad of diagnostic-therapeutic approaches to PPT serves as the basis for subsequent decision-making and recommendation for other exercise processes. From this perspective, the following individual methods and exercise approaches are included in the PPT methods: PPT – issue of pulmonary symptomatology PPT – techniques for respiratory pathway hygiene PPT and respiratory techniques for inhalation treatment Respiratory training and respiratory stimulators Respiratory gymnastics Conditioning training and movement activities Physical fitness training Special methods of PPT require the patient’s careful participation. Every exercise session is simultaneously a briefing on how to use a concrete breathing technique and when and why it should be included or omitted. Every patient should have an individual exercise program that contains elements from pulmonary therapy as well as movement preparation. In patients with cardiorespiratory illnesses, the individual deviations of both systems, postural and respiratory, are being addressed and the resulting common effect will be attained faster and with greater effectiveness. A comprehensive rehabilitation program is established while taking into consideration the patient’s respiratory and movement capabilities, especially the extent of their muscle dysfunction. A program is established based on group therapy, but also always considers an individual’s performance and their motivation toward exercise.

1.2.2 Corrective Physical Therapy for the Postural System Libuše Smolíková Influencing body posture is considered to be fundamental and the

components that are focused on muscle imbalances and joint problems are always included. The movement axis of breathing is formed by the pelvis-spine-head. Breathing movements serve for lung ventilation and, at the same time, influence postural functions and body posture. During the assessment of an alignment, co-activation of most trunk muscles with breathing is observed during simultaneous participation of the configuration of the thorax and an overall body posture and its movements. Breathing movements can be observed in three sections of the trunk: Lower – abdominal, from the diaphragm to the pelvic floor Middle – lower thoracic between the diaphragm and the 5th thoracic vertebra Upper – upper thoracic, from T5 to the lower cervical spine During breathing, different movements of the lower and upper ribs can be observed around the axis of rib rotation. The lower ribs move primarily laterally while the upper ribs are characterized by a horizontal movement. During inspiration, the thorax expands in all directions – cross-sectional (lateral-lateral), front to back (anteriorposterior) and vertical (cranio-caudal). The directional combination of thoracic movements is allowed by two functional mechanisms: upper rib movement (up to the 7th rib) with the sternum in the anteriorposterior direction (sternocostal mechanism), and lower rib movement with the diaphragm in the cross-sectional and vertical directions (costodiaphragmatic mechanism). Often, one type of mechanism dominates the other. This depends on many factors, including the following: type of thorax, body position, muscle activation and muscle tone. Respiratory movements rhythmically repeat themselves in two phases – inspiration (breathing in) and expiration (breathing out) and are divided by pre-inspiration and pre-expiration. Pre-inspiration is a short pause at the end of expiration before inspiration occurs. Expiration is linked to inhibitory muscle activity of the posturally-

locomotor system. Its effect is facilitated by an inspiratory pause (apnea at the end of inspiration). Expiration is generally linked to relaxation and release of muscle tension. Pre-expiration is a short pause at the end of inspiration and before expiration. Inspiration has an excitatory effect on muscle activity of the posturally-locomotor system and is used for facilitation of muscle activity, i.e. during intense concentration on a certain task performed “while holding breath”. Respiratory movements occur as a rhythmic activity of respiratory muscles and are linked to movement activity. In a patient with cardiorespiratory exertion, they also occur as part of the organism’s stress response. From the functional-anatomical perspective, respiratory musculature is divided into inspiratory and expiratory muscles. The primary inspiratory muscles include the diaphragm (2/3rds of gas exchange activity in the lungs depends on the diaphragm), as well as, the external intercostal muscles (intercostales externi) and the levatores costarum muscles. The accessory inspiratory muscles include the neck muscles, especially the scalenes and the sternocleidomastoid, the muscles of the thorax, for example, the pectorales, serratus anterior, serratus posterior superior and latissimus dorsi and the back muscles, such as the iliocostalis, erector spinae and others. The specificity of the diaphragm in its respiratory-postural function is described in detail in a Special Section of the textbook, Chapter 2, Treatment Rehabilitation in Orthopedics and Traumatology, Vertebrogenic Pain Syndrome, Postural Pattern of Spinal Stabilization – Summary. The primary expiratory muscles include the following: the internal intercostal muscles and the sternocostales. The accessory expiratory muscles are the abdominals, quadratus lumborum and the muscles of the pelvic floor as well as the back muscles, for example, the iliocostalis (pars inferior), erector spinae and serratus posterior inferior.

However, the anatomical division does not quite correspond to reality. During breathing phases, the inspiratory and expiratory muscles act in mutual synergy and cooperation. Even the pelvic floor muscles participate in breathing movements, affect the intraabdominal pressure and, at the same time, influence the changing configuration of the spine during breathing. Breathing movement influences the movement of the thorax and the spine and contributes to body posture. Limited range of these movements is one of the causes of painful vertebrogenic deficits. It is found most often during a postural dysfunction syndrome. Generally, the activity of breathing muscles is not intended for a single purpose despite its seemingly functionally-anatomical division. Since it depends on the circumstances under which the breathing motion occurs, it is obvious that the muscles considered as primarily respiratory also participate in postural function, change the configuration of movement segments during breathing (primarily the spine) and, thus, influence body posture. In any case, respiratory muscles should not be considered as only “respiration active”. Since they are characterized as communicatively strong, they can be nowadays called “respiratory-postural muscles”. The quality of respiration and stabilization of the spine are very closely related. A disturbance in this static and dynamic muscle synergy leads to a tension difference known as imbalance. In connection with cardio-respiratory illness, kinesiology of breathing is concerned with assessment of breathing movements in relation to lung function values within the individual movement culture of the patient. Persistent presence of an overloaded thoracic musculature syndrome and a variable faulty body posture syndrome are frequent manifestations of imbalance. Patients with respiratory pathway obstruction present with a stiff thorax in an inspiratory alignment, with non-physiological upper chest breathing and with decreased mobility of the sternocostal as well as costovertebral articulations with non-synchronized or even counterproductive synergy of the cranial, thoracic and abdominal-

pelvic segments of the trunk. The muscles of the upper aperture of the neck react with a combination of contracted hypertonia and chronic fatigue. This combination is the main reason for pseudospastic behavior of the neck muscles as well as the back muscles and, unfortunately, the muscles of the thorax. All this significantly influences overall posture of the trunk, head and the pelvis. Recent studies of Australian and other authors suggest that the deep layer muscle system plays an important role in the overall respiratory cycle. This muscle system is known as the deep spinal stabilization system. It includes the flexors, deep muscle system of the spine, pelvic floor muscles, abdominal musculature and, importantly, the diaphragm and its postural function. Corrective physical therapy for individuals with cardio-respiratory system involvement is recommended to begin in the area of the pelvis and the lumbar spine and progress in a cranial direction. Most often, it involves active, gentle, slow and accurately performed movements. The range of these movements should be approximating physiological ranges and should be conditioned by activating muscle chaining based on the principle of developmental kinesiology. Corrective positioning of the corresponding segment and its movements are performed while taking into consideration the deviations that are present as a result of primary illness of the pulmonary system. Corrective physical therapy is based on many widely published “back schools”, for example, the Brügger principle, the Bess Mensendieck school, McKenzie exercises, methods based on Klapp, exercises according to K. Schrott, Kaltenborn methodology, exercises according to Mojzisova or Kolar, Lewit back school etc. However, invariably they all follow the principle of an optimal and individually efficient corrective effectiveness. This means to design a postural correction program that yields a quick, reactive and positive response – relief from vertebrogenic pain, decrease in shortness of breath and breathing discomfort, decreased muscle tension and, especially, a decrease in fatigue of the breathing muscles. Correction of the Pelvic and Lumbar Spine Alignment and

Movement Based on the principles of straight trunk alignment in sitting, we begin with the correction of pelvic alignment and its direct influence on the mobility of the sacroiliac joints and the lumbar spine. The pelvis and the spine form a functional movement unit. The pelvis serves as the base that transfers movement from the lower extremities to the trunk. As a reaction to movement, the large pelvic ligaments and muscles maintain a balanced symmetry between the lower and the upper body segments and statically balance the dynamic deviations during all body movements. The pelvis significantly influences the function of the diaphragm not only by its innate morphologically given structure, but mainly by its shift in relation to the spine. Therefore, the pelvis influences diaphragm mobility within the scope of phylogenetically defined cooperation with the entire spine. The large musculature of the hip joint, especially the largest hip flexor, the iliopsoas, maintains a state of balanced dynamic stability with the abdominal and pelvic muscles and it has a direct influence on the structure and the curvature of the lumbar spine. The anterior and posterior mobility of the lumbar spine also ensures the mobility of the thoracic spine and the trunk and influences the individual phases of breathing. Correcting Thoracic Spine Alignment and Movement The thoracic spine is the least mobile segment of the entire spine but, at the same time, it is its most stable segment. Together with the ribs and the sternum it represents a major part of the thorax. It protects vital organs and the diaphragm and, at the same time, it is linked to respiratory function. The initial creeping and unobtrusive signs of a respiratory illness manifest themselves by decreased mobility of the thorax. The sequential, gradual movement of the ribs, characteristic for breathing and correlating to each individual’s ability of lung ventilation, starts disappearing first and it is substituted for by the chest wall moving as a whole – movement “en block”. From a kinesiology perspective, decreased mobility of the thorax is also a sign of quick onset muscle pain, which is often a manifestation of static

overloading of articulations between the spinal vertebrae with the chest and their corresponding muscles. A shield-like tight and hardly mobile thorax is the main obstruction to free breathing. The limitation in thoracic mobility and its gradual “tightening” is also caused by pathological changes in the breathing muscles, a decrease in their activity and a loss in lung tissue elasticity. Thoracic changes are the result of many negative processes but, at the same time, thoracic mobility has a reciprocal effect with thoracic changes. If a progression of the primary respiratory system illness is added, a functional motor breathing dysfunction emerges. The thorax persists in an inspiratory alignment and the duration of expiration gradually shortens. The muscles are sensitive to stretch and, as a result of their increased tension, functional deficits occur, most often seen as muscle imbalances. Next to muscle problems, pain from the internal organs can also be manifested in the thoracic spine. It can often signal a deficit in the function of a certain internal organ that is always accompanied by certain breathing deficits. If the cause of the breathing problems is an active inflammatory process within the respiratory system, a logical combination of hypokinesis and shallow, superficial breathing occurs. The resulting picture is identical to an abnormal structural alignment of thoracic hyperkyphosis with a subsequent cervical hyperlordosis and an obstructive deficit in ventilation, which is typical in overloaded thoracic muscles syndrome. Correcting Cervical and Cranial Alignment and Movement A typical highly-angulated cervical hyperlordosis with forward head posture and protruded chin is seen in most patients with chronic respiratory illness. This non-ergonomic spinal curvature very negatively influences diaphragm function and, therefore, the entire breathing cycle. The entire movement system of the cervical spine is supported by large muscle tissue at the nape of the neck. A muscle imbalance of the neck and head flexors, extensors and rotators all negatively influences breathing. Painful points linked to breathing are most sensitive, especially in this region.

To ensure optimal function of the cervical spine, the head needs to be aligned in a balanced position. In this principle, the point of rotation is between the load (weight of the skull) and the force that balances the weight of the load. In individuals with chronic respiratory illness, the area of the nape of the neck is always hypersensitive with a tendency toward hypertonia of the muscles of the nape and the face and a resulting limited mobility of the cervical spine, a loss of rotation component, and, most often, a persistent or migraine-like headache. The structural changes of the entire body schema are parallel with other changes in the movement system. The most serious include changes in the morphological structures of the muscle fiber. That is why it is always important to carefully consider the treatment approach during physical therapy and follow not only the objective parameters from the therapeutic assessment, but also carefully listen to the patient’s subjective report, observe the patient, listen to the sound manifestation of their breathing, check their movement performance by palpation and utilize all available control mechanisms to assess objectivity and reach an optimal exercise approach. Note: An incorrect and potentially harmful approach would be to increase the demand on breathing in an unprepared movement system.

1.2.3 Respiratory Physical Therapy Approaches Utilizing Postural Respiratory Function of the Diaphragm Pavel Kolář Recent studies confirm that the diaphragm not only becomes engaged as a breathing muscle, but also significantly participates in postural activity during breathing as well as during non-respiratory activity (Fig. 1.2.3-1). Thus, the diaphragm has a dual function. The proof of a correlation between postural activity of the diaphragm and the indicators of pulmonary function (dynamic lung volume, respiratory pathway clearance, and resting vital capacity, VC) has significant

implications for pulmonary physical therapy approaches.

Fig. 1.2.3-1 Dynamic sequence of MRI pictures synchronized with spirometric examination. Excursions of the diaphragm during resting breathing synchronized with a spirometric recording are shown in the upper part (A – picture of an expiratory position of the diaphragm, B – picture of an inspiratory position of the diaphragm). In the lower part, the diaphragm excursion is synchronized with a spirometric recording during pushing of the lower extremities against resistance while breath holding (demarcated by a red dotted line on the spirometric recording shows the initiation and completion of the maneuver, or the pressure of the lower extremities against resistance while holding a breath A – a picture of an expiratory position of the diaphragm C – the position of the diaphragm flattening when the individual does not breathe and presses against resistance with their lower extremities

Role of the Diaphragm during the Physiological Breathing Cycle Breathing is considered the main function of the diaphragm. It is estimated that 75% of changes in the intra-thoracic space depends on the diaphragm during breathing at rest and the activity of the diaphragm itself accounts for 2/3rds of ventilation of the vital lung capacity. The substantial contribution of the diaphragm to respiration is the reason why the diaphragm is considered to be the most

important muscle right after the heart. Considering that the pressure within the chest cavity is also transferred onto the internally located thin-walled organs, an increase in aortic blood pressure can be seen when the intra-thoracic pressure increases. At the same time, venous compression decreases venous return and cardiac output. With a pressure decrease in the thoracic cavity, the opposite phenomena occur. Therefore, movement of the diaphragm influences blood pressure and heart rate. Depression of the diaphragm together with other muscles of the abdominal wall leads to an increase in intra-abdominal pressure, the so called abdominal brace, which affects all tissues inside the abdominal and pelvic cavity and the content of hollow organs. It also has circulatory consequences such as a pressure-related influence on blood flow through the lower vena cava as well as a widening of the vena cava foramen (Basmajian, 1967). Movement of the diaphragm is important during defecation, intense urination and during labor. In principle, abdominal bracing and the Valsalva maneuver are identical to the process observed (a) from the perspective of pressure in the abdominal cavity and (b) from the perspective of pressure in the thoracic cavity. The diaphragm is a striated muscle which is why it functions via a contraction of its fibers or has a passive significance as a wall for body cavities. Due to the spatial organization of the diaphragm, the contractions of the diaphragm muscle fibers elicit an increased volume and a vacuum in the thoracic cavity. Decreased tone in the wall of the diaphragm leads to the opposite scenarios. This serves as the physical foundation for breathing mechanics. Generally, the diaphragm is considered to be the main breathing muscle and in this function it is also described and therapeutically influenced. As the main engine for air flow within the respiratory pathways, the diaphragm also relates to defensive processes that are derived from simple breathing. This includes coughing or sneezing. Functions that are more-or-less reflexively conditioned. In both scenarios, it is an explosive

contraction of the breathing muscles when the respiratory pathways become irritated – the lower pathways for coughing and the upper tract for sneezing – which, following a sudden opening of the glottis, sharply expels air out from the lungs. The airflow expels potential (pathological) content out of the respiratory tract. This rather rough coordination can be contrasted with the synchrony of diaphragmatic movement with the muscles of the larynx. This synchrony forms the foundation of phonation and a specific type of learning aimed at mastering the function of the diaphragm in addition to other respiratory muscles and it is the center of interest for singers, actors and speakers. In contrast, stammering (balbuties) is an expression used to describe a functional deficit in coordination of muscles participating in phonation. A contraction of the crural portion and the fibers of the costal segment decrease intra-pleural pressure and increase intra-abdominal pressure. If resistance to the content of the abdominal cavity does not limit the descent of the centrum tendineum to the level of the tendons of the diaphragm to the ribs, pulling in of the lower ribs occurs by activity of the crural part (Fig. 1.2.3-2). This inversion of the diaphragm muscle function was observed during laparotomy, or evisceration in experimental animals. Similarly, it was observed in rabbits and dogs during phrenic nerve electrical stimulation at the end of inspiration (see Fig. 1.2.3-4).

Fig. 1.2.3-2 The activity of the crural part of the diaphragm during flattening (the punctum fixum is on the ribs) and during pulling in of the ribs (punctum fixum is on the centrum tendineum). FRC = functional residual capacity of the lungs

The theories interlinking the diaphragm as a functionally dual system are fundamentally important (Macklem, 1987). Based on this theory, the diaphragm functionally consists of two muscles: one functional muscle component changes the shape and volume of the thorax and abdomen during inspiration, while the other component changes and affects only the abdomen itself. In other words, the costal and crural parts of the diaphragm work while mechanically connected in series, but also pneumatically (ventilatory) connected in parallel. The First Phase During the breathing function of the diaphragm, the punctum fixum is located on the rib, the sternal and the crural tendons of the diaphragm in the first phase of inspiration, which increases the volume of the chest cavity, decreases inter-pleural pressure and increases intra-abdominal pressure. However, passive inspiration

begins even before contraction of the diaphragm. The activity of the expiratory muscles at the end of the previous expiration actively decreases IRV, during which part of the work of these muscles is “stored” as elastic energy in the thoracic and abdominal structures. During relaxation of the expiratory muscles (primarily the transversus abdominis), this energy is released and causes a decrease in the intrathoracic pressure even prior to activation of the diaphragm. An active contraction of the expiratory muscles at the end of expiration also stretches the fibers of the diaphragm and, by the change in their characteristics, the length-tension improves the condition for the following contraction of the diaphragm. However, this indirect inspiratory contribution of the expiratory muscles cannot be used by patients with bronchial obstruction which primarily burdens expiration such that the work of the expiratory muscles cannot be used to overcome the increased resistance. The content of the abdominal cavity is primarily non-compressible (except maybe 100–300 ml of air) and, therefore, the organs in the abdominal cavity shift caudally and the abdominal wall moves outward during inspiration. This is visible during a laparoscopic surgery and the associated pneumoperitoneum (CO2 insufflation with an increase in the intra-abdominal pressure 10–12 mm Hg) when PImax and overall mechanical resistance of the breathing system increase and, in contrast, the compliance decreases. After a return of the intraabdominal pressure to its original value, the above mentioned parameters also return to their normal values. During breathing at rest, more significant bowing out of the abdomen is not necessary if the ribcage is sufficiently mobile. The situation is different, for example, in an advanced stage of Bechterew disease, in which marked bowing out of the abdomen occurs during inspiration with minimal or no chest movements. The Second Phase In relation to the growing resistance to the abdominal cavity content (and activity of the muscles of the abdominal wall and pelvic floor), a cessation of the caudal movement of the diaphragm occurs after a

certain period. If its contractile activity persists, the second phase occurs. In this second phase, the punctum fixum of the diaphragm is found on the centrum tendineum and the lower ribs together with the sternum move cranially. Via the sternum, the cranial movement is also transferred to the upper ribs which are elevated by the activity of accessory breathing muscles, leading to a widening of the upper part of the ribcage mainly in the anterior-posterior directions. Cranial movement of the ribs and the widening of the ribcage occur through their dual articulation with the thoracic vertebrae – the head of the rib with the vertebral body and the rib tubercle with the transverse process. The axis of movement connecting these two articulations is closer to the frontal plane for the upper ribs compared to the lower ribs. Therefore, widening mainly in the anterior-posterior direction occurs during elevation of the upper ribs while widening occurs primarily in the lateral direction during elevation of the lower ribs. The mechanism of activity of the diaphragm on the lower ribs in which, beside the insertions of the costal portion, the “zone of apposition” plays an important role, is shown in Fig. 1.2.3-3). Fig. 1.2.3-3 Zone of apposition of the diaphragm – shown in red on the picture

With high-speed anterior-posterior RTG scanning, it was found that the mid-range breathing excursions of the diaphragm are approximately 3.5 cm and about 0.5 cm smaller in females, with the right side usually moving more noticeably. Breathing Biomechanics in a Pathological State Under pathological conditions, the mechanical effectiveness of breathing is altered. In a resting state, it is usually around 1% and increases to 4–5% with more intense demand and that is later increased even more. The reason for this is an increased turbulence in the respiratory pathways and the result of activity in a disadvantageous respiratory position on a compliancy curve. With maximum ventilation of 100 liters per minute, oxygen consumption by the breathing muscles is 400–500 ml, or approximately 10% of total consumption. However, if ventilation continues to increase with increased demand, oxygen consumption increases by 5 ml for every 1 liter of air. Gradually, oxygen supply to the working muscles does not

increase and can even decrease. Changes in the function of the breathing muscles and the postural system, or more accurately in the stabilization functions of the muscles, are often a reaction to the lung ventilation disturbances. 1. The chest is positioned in an inspiratory position and the sternum is in a cranial starting position, which decreases the effectiveness of respiration. The result is an unsuitable breathing pattern with prolonged inspiration. The movement of the sternum during inspiration occurs only upward, which is accompanied by an upward movement of the clavicles and the shoulders. The ribcage does not expand laterally. The intercostal spaces do not widen, especially in the region of ribs 5-8, the chest is flattened and, by paradoxical function of the diaphragm, the ribs are pulled in. During breathing at rest, the auxiliary inspiratory muscles – the scalenes, sternocleidomastoid, pectoralis major and minor, lower trapezius and the levator scapulae – become involved. When there is a deficit in lung elasticity or when a severe obstruction is present, the accessory expiratory muscles (mainly the serratus posterior inferior) become active and the abdominal muscles become permanently contracted. 2. The diaphragm, as the main inspiratory muscle, is in an elevated position and its involvement during inspiration is insufficient. In a physiological situation, during inspiration, a bowing out of the abdominal and lower thoracic cavity should occur in all directions, that is laterally and dorsally. In a pathological situation, this region is restricted and the ribs are pulled inward during inspiration. In the onset of quadriparesis, a quick expansion of the lower part and a slower expansion of the upper part of the ribcage occurs. At the end of inspiration, the upper part sharply expands and, in contrast, the lower part slightly narrows. At the onset of inspiration, the upper part quickly shrinks. Primarily, the lower part of the ribcage contracts at the end of expiration. A transverse spinal lesion just under the separation of the phrenic

nerve leads to paralysis of all striated muscles innervated by the spinal nerve roots arising under the level of the lesion. The diaphragm can be used as the only respiratory muscle that is able to ensure sufficient pulmonary ventilation. The reserve of muscle work capacity decreases and the kinematics of the ribcage change. In a patient with quadriparesis, it can be well demonstrated how the respiratory ribcage movements change based on position. With a painful injury to the pleura, the patient attempts to limit pleural friction by stabilizing the involved side, for example, by laying down on the involved side. Bilateral paresis of the diaphragm is a life threatening condition and it is a reason for immediate initiation of artificial pulmonary ventilation. In the past, peripheral paralysis of the diaphragm and the intercostal breathing muscles was typical in poliomyelitis. It manifests itself by rapid and regular breathing, but it is superficial and without movement from the nasal wings. The patient helps themselves by intensely engaging the accessory breathing muscles, if the muscles of the shoulder girdles are not affected by the paresis. The movement of the thorax is asymmetrical, the thorax does not expand (or only minimally) and the epigastrium does not bow out but rather sinks during inspiration (because no increase in intra-abdominal pressure occurs). When the thorax is in a deep inspiratory position, the epigastrium bows out. The patient cannot hold their breath in, cannot sneeze and cannot count “in one breath”. For a limited time, glossopharyngeal (“frog”) breathing can be used if the patient can master it. In its principle, it forces extra air into the lungs by the tongue and swallowing muscles. Training is important for patients with a partial or subsiding deficit in function of the primary respiratory muscles (paralysis). Breathing problems lasting one hour or more can be overcome with the help of this training. It mainly has a psychological effect – limited dependence on a ventilator (Fig. 1.2.3-4).

Fig. 1.2.3-4 The schema of the diaphragm mechanism acting on the lower ribs

Posturally Locomotor Function of the Diaphragm Next to respiratory function, the postural function of the diaphragm is also quite fundamental and it is related to an increase in transdiaphragmatic pressure (Fig. 1.2.3-5).

Fig. 1.2.3-5 A view of the position of the diaphragm in the sagittal plane during examination by magnetic resonance imaging. The green contour shows a position of the diaphragm during breathing at rest, or the inspiratory and expiratory position. The blue contour shows the inspiratory and expiratory position when the examined subjects were pushing against resistance with their lower extremities. The yellow contour shows the position when the subject was pressing against resistance with their upper extremities.

This finding supports a clinical experience whereby to improve a patient’s respiratory parameters physical therapy techniques aimed at influencing only respiratory pattern are not sufficient and need to be enriched by techniques involving the postural activity of the diaphragm. One such technique that respects this functional correlation is a “technique of forceful expiration and huffing” (an active muscle-supported expiration with modified velocity). This supportive breathing technique applied by a special, tight-fitting PEP (positive expiratory pressure) mask generates permanent positive expiratory overpressure that supports an increased intra-bronchial

pressure during breathing against an adjustable resistance and significantly increases the activity of the diaphragm. A similar technique of supportive, instrumentally controlled breathing – BiPAP (bi-level positive airways pressure) generates positive overpressure. However, it does so on two adjustable and different pressure levels acting in different ways during inspiration and expiration. Given the fact that the activity of the diaphragm (or increasing the trans-diaphragmatic pressure) is linked to every movement of the body and the extremities, this principle can be used during respiratory techniques. The function of the diaphragm linked to spinal and trunk stabilization during postural functions can be utilized during these respiratory techniques. For physical therapy, demonstration of the correlation between the parameters of pulmonary function and postural activity of the diaphragm elicited by activity of the extremities is important. The parameters of diaphragm activity during breathing at rest during postural activity elicited by a desired resistance of the extremities significantly correlates with pulmonary function indicators (dynamic pulmonary volumes, indicators of clearance of breathing pathways, but also resting VC). These relationships are more significant during postural activity elicited by lower extremity resistance. This seeming discrepancy is explained by various conditions of activation of postural function of the diaphragm during stabilization of the pelvic vs. shoulder girdle. As shown by McKeough et al. (2003), upper extremity flexion in patients with COPD, as well as, in healthy volunteers significantly influences the amount of static pulmonary volumes (measured by a total body pletysmograph). The authors demonstrated a significant increase in FRC value for active flexion of both upper extremities above 90 degrees in comparison to a lower degree flexion (< 90 degrees). A similar conclusion was also reported by Smolikova et al. (2005), where specific rehabilitation in children with cystic fibrosis led to an improved function in the children’s accessory respiratory muscles. For physical therapy approaches, it is also important that a

ventilatory deficit in the respiratory system influences the activation of respiratory muscles in their respiratory functions. This always has direct consequences on muscle stabilization function, or postural functions. This is based on the fact that the function of the respiratory muscles affects stabilization function and vice versa. The function of the breathing muscles can be purposefully stimulated through the stabilization system. The muscle stabilization function influences the dynamic function of the muscles not just in the area where the muscles concentrically insert. This stabilization is also interconnected with the entire movement pattern (global biomechanical chain). Thus, the diaphragm is activated even during the movement of the lower or upper extremity. The neurodynamic stabilization system developed by the authors of this chapter is based on the principle of postural breathing function within respiratory physical therapy. We are not attempting to influence breathing but rather postural activity (stabilization). Even if the patient cooperates, it is often difficult or even impossible to elicit muscle activation for optimal stabilization to correctly perform respiratory function. Therefore, breathing functions are influenced by education or by reflexive approaches. Within the framework of a reflexive influence, we primarily attempt to influence postural, or muscle stabilization, function. These approaches are used for respiratory tract drainage and to influence breathing quality. The utilization of respiratory-postural techniques has a significant effect in the treatment of respiratory deficits, mostly in more involved patients or patients whose cooperation is difficult. The actual results of pulmonary physical therapy can be monitored by blood oxygen saturation, which can be measured by a pulse oximeter. A long-term effect can be assessed by spirometry. The effect of drainage can be observed by RTG, or even CT or MRI. Respiratory Physical Therapy Techniques Utilizing Postural Locomotor Functions A reflex approach that specifically influences respiratory-postural

(stabilization) muscle function is based on a neurophysiological principle that is the foundation of CNS controlled motor programs. It is a global muscle synergy that is fundamental for body posture and locomotion. These motor patterns are gradually (as particular motor patterns) put into function over the course of postural ontogenesis and can be reflexively activated by two locomotor patterns – reflex turning and reflex crawling based on Vojta. The patterns can be elicited by non-nociceptive pressure stimulation of trigger zones or by a slight isometric resistance against locomotor movement. The basic principle of a given locomotor pattern is based on the fact that they contain a specific muscle function (even a function of the diaphragm and other respiratory muscles), which is identical in all individuals: 1. Reflexively elicited muscle activation leads to a change in support. Automatically, the center of gravity shifts and support in the support zones is ensured (these are areas of the human body that enable erect posture). The system automatically chooses the support areas based on the starting position. 2. Muscle activation leads to a neutral alignment of the movement segments. For example, the autochthonic musculature of the spine gets activated this way. 3. An erect posture and stepping forward of the upper and lower extremities occur only under these conditions of stabilization (ipsilateral or contra​lateral). This type of muscle activation changes the stabilization conditions for respiration. The physiological type of breathing is built into these locomotor patterns. The chest shifts from an inspiratory to an expiratory position by the pull of the abdominal muscles. An automatic flattening of the diaphragm occurs, in which the punctum fixum is on the ribs and the line of pull of the muscle fibers changes (in the opposite way than in the inversion function). The abdominal musculature is symmetrically activated during inspiration and, together with the diaphragm, affects the resulting intra-abdominal pressure. Through the chest, the diaphragm influences the external

intercostal muscles. At the same time, the autochthonous (deep) musculature is activated, which stabilizes the spine and allows for rib movement and a subsequent lateral widening of the thorax. Vertical movement of the sternum is minimized. The direction of activation into the expiratory position of the chest stimulates activity of the smooth musculature of the bronchi and, in this way, regulates changes in resistance in the respiratory pathways. Positional respiratory techniques are used primarily in an effort to remove an excessive amount of bronchial excretion. These are also postural drainage techniques and their use is significant in patients whose type of breathing (or breathing pattern) we are trying to affect. The following is important for positional respiratory techniques which focus on respiratory pathway drainage: Starting position Manual resistance against inspiration Expectoration The starting position is based on the initial evaluation. Based on palpation and auscultation, areas within the lung with no ventilation or hypoventilation are identified. With drainage techniques, the appropriate lung region is considered primarily as a turning pattern (ipsilateral pattern). The stimulation occurs by trigger zones or by a slight resistance against a desired motion. During reflexive turning, the oblique abdominal muscle chain is activated first and runs from the internal abdominal oblique of the jaw side through the transverse abdominis to the external abdominal oblique of the occipital side and inserts at the inferior thoracic aperture on the occipital side. Here it connects to the serratus anterior. This transfer occurs in a region identical to the insertion of the diaphragm, which is connected to the thorax on the interior side. By the pull of this oblique chain, the rib angles are pulled in a downward direction, the intra-abdominal pressure increases and costal breathing intensifies. Stabilization in an expiratory position needs to occur on this side due to the caudal muscle pull. The therapist’s manual contact can assist in obtaining an expiratory position of the ribcage.

The main positions include supine, sidelying or side-sitting and the choice of the starting position is also based on the patient’s condition. To activate the diaphragm, even modified contralateral patterns can be used. When the effect of the reflex has been obtained, it is followed by a sequence of manual resistances against inspiration. During reflexively achieved maximal expiration, manual resistance against the inspiratory movement of the ribs or the diaphragm is performed. The resistance can be administered by the therapist’s hand sinking into the abdominal cavity under the rib angles. The ribcage is held in expiration and the therapist’s pressure stimulates the function of the diaphragm. This significantly magnifies the air flow into the hypoventilated regions of the respiratory pathways. Significantly higher air pressure in the respiratory pathways is achieved and can be further increased by forced expiration techniques, or huffing. The defensive cough reflex can be elicited and it can be elicited automatically or following instruction to patients with excessive mucus. It is important to pay attention to the control of the cough. More frequently, expiration with consciously controlled muscle support and correct speed of expiration are recommended. A volitional cough with expectorate needs to occur during maximal expiration. Positional Influence on the Postural Respiratory Function of the Diaphragm In pulmonary physical therapy, it is also common that the diaphragm does not contract uniformly in all its segments (as a functional unit) during postural function but its individual segments can be activated separately, mainly based on position. Kondo, Kobayashi et al. (2000) showed in young healthy adults that the angle of the middle and posterior segments of the diaphragm at rest, as well as, with deep breathing is greater than the angle of the anterior segment. This finding was confirmed by the same research group five years later in healthy older adults (Kondo, Kobayashi,

2005). The non-uniformity in the diaphragm contraction implies that pulmonary physical therapy techniques can influence not only the diaphragm’s contraction but also its coordination. For example, during the same movement, but in a different position of locomotor movement, a different segment of the diaphragm will be activated, which cannot be achieved with techniques of forced expiration or support breathing.

1.2.4 Respiratory Physical Therapy – Methods and Techniques for Respiratory Pathway Hygiene Libuše Smolíková Today’s modern methods and techniques of respiratory pathway hygiene, also known as airway clearance techniques (ACT), represent a radical change not only for performance of respiratory physical therapy itself, but also a change in the approach and thought process of the patients themselves. This involves the question of how to independently take care of one’s own health even during a chronic respiratory illness. Patients with chronic forms of respiratory illnesses undergo respiratory physical therapy throughout their entire life. The drainage techniques used with cough control are the basic methods of physical therapy for patients with sputum retention in the respiratory tracts. A group of methods and techniques of respiratory tract hygiene includes: Active cycle of breathing techniques (ACBT) Autogenic drainage (AD) Positive expiratory pressure system of breathing (PEP) Intrapulmonary percussive ventilation (IPV) Inhalation treatment – in combination with drainage techniques of respiratory physical therapy Physical exercises (PE)

The goal of the drainage techniques of respiratory physical therapy is to first achieve and subsequently maintain the best mucus reduction and thus to ensure optimal hygiene and good clearance of respiratory pathways. From a long-term perspective, respiratory physical therapy methods do not directly influence the overall physical fitness and physical condition of the respiratory muscles, but are designed for a quick and direct solution to an acute and burdensome respiratory situation from shortness of breath and removal of bronchial secretion. Most frequently, they are used with patients hospitalized in the anesthesia-resuscitation units, intensive care units and in the first hours following surgery, most often after thoracic operations. In outpatient rehabilitation, they help patients with re-education of breathing motor skills while taking into consideration the respiratorypostural function of the trunk muscles. They are an integral component of body movement because “free” body movement requires “free” breathing. Active Cycle of Breathing Techniques Active cycle of breathing techniques (ACBT) contains three independent breathing techniques. The order of all three techniques can be individually alternated based on the patient’s needs and capabilities. ACBT is performed in sitting or while laying down, wherever and whenever it is needed and necessary for the patient; in the hospital, health resort, at home, at the office, at a table, in standing, in bed or in an arm-chair. Thoracic expansion exercises are inspiratory techniques emphasizing maximum volume of slowly (through the nose or the mouth) inspired air and a short and without force passively blown out expiration through the mouth. This stimulates an improvement in the ventilatory parameters as a result of activation of collateral alveolar ventilation. Forced expiration and huffing techniques are active, muscle supported expirations with modified speed completed by huffing with an expectorate, which occurs instead of coughing. Controlled breathing is relaxed, resting and movement-centered in

the abdominal region but without purposeful expiratory activation of the abdominal muscles. Autogenic Drainage In the last 20 years, autogenic drainage (AD) gradually replaced classic percussion postural drainage. It has become a popular and often sought after drainage technique due to its high effectiveness, easy accessibility and noninvasive administration. This is the fundamental technique of respiratory physical therapy for all individuals with excessive chronic bronchial secretion. It can be performed in sitting or laying down. The basic principles of AD include the following: release, collect and evacuate the released mucus from the respiratory tracts (Fig. 1.2.4-1). Autogenic drainage is consciously controlled and patient-modified breathing. It is breathing in the form of a slow, smooth inspiration mainly through the nose with an inspiratory pause at the end of inspiration. It is followed by consciously controlled, slow and long, but mainly muscle-supported active expiration through pursed lips via the relaxed upper respiratory pathways. The patients practice autogenic drainage by themselves or with the assistance of another person, often a physical therapist. The drainage is not time limited, it takes from several minutes up to 60–90 minutes (with an acute need to expectorate). Sitting or supine are the most frequently used exercise positions. Part of the drainage includes manual contacts and maneuvers, self-massage, manual springing and gentle expiratory thoracic compressions. Breathing should be natural and AD can be completed by huffing. AD can be combined with an inhalation or flutter. An immediate effect of AD can be assessed by a pulse oximeter. Fig. 1.2.4-1 Autogenic drainage with assistance from a physical therapist

PEP System of Breathing Positive expiratory pressure with breathing against dosaged resistance increases intra-bronchial pressure. Three types of PEP exist: Low positive expiratory pressure – expiration against resistance of 10–20 cm H2O; High positive expiratory pressure – expiration against resistance of 40–120 cm H2O; Oscillatory positive expiration pressure – flutter, cornet etc. The original PEP breathing technique was introduced to physical therapy by using a PEP mask (Fig. 1.2.4-2). The mask consists of a transparent facial component with a soft latex lining and a valve component for inspiration and expiration. The work of the valves is based on a one-way function. The expiratory resistance changes are indicated by a color change with an opening from 1.5–5.0 mm. The expiratory pressures are determined by a manometer, which is put between the expiratory valve and the resistance reduction. The facial part of the mask is firmly but not forcefully placed over the nose and mouth. Fig. 1.2.4-2 PEP mask

The practical application is classified along two or three phases of physical therapy. The goal of the first part of the protocol is to improve ventilation and increase respiratory pathway clearance. The protocol calls for 10–12 breaths through the mask and expiration through the mouth against resistance of 10–20 cm H2O column. It is followed by an expectoration phase. The reduction is postponed and 2–3 accelerated expirations without resistance follow with the mask placed on the face. Then, the mask is removed and the exercise is completed by a slight cough and secretion removal. The cycle is repeated 4–6 times and the exercise time is 15–20 minutes in sitting or lying down. Oscillatory PEP System Oscillatory expiratory pressure is produced by instruments that combine PEP with vibratory effects within the respiratory pathways. In practice, the flutter, RC-Cornet and Acapella are most frequently used. Flutter A flutter is a pocket size device that resembles a special type of pipe (Fig. 1.2.4-3). It is portable and it can be quickly and easily used. It is washable with easy maintenance. Each patient at risk of chronic bronchial mucus retention has a flutter available to them upon a recommendation from a physician.

Fig. 1.2.4-3 Flutter

The actual fluttering involves both the physical therapist and the patient. The introductory instruction should be performed by a physical therapist specializing in pulmonary rehabilitation. The authors of the techniques describe a vibratory movement of the flutter’s small ball, which forms an oscillatory expiratory pressure of a modulated frequency within the respiratory pathways. The amount of expiratory resistance is given by the flutter’s position in the mouth (the angle that is formed between the corpus of the flutter and the upper or lower jaw), and the force of expiration (Fig. 1.2.4-4). Individual pressures that are concentrated within the breathing pathways have a tendency to expand and support bronchial opening for a longer period of time. The combination of vibration and bronchial opening allows for mobilization of secretions. Bronchial clearance improves even with instability and bronchial hyperreactivity. Simultaneously, the patient feels a gentle and deep vibratory quivering which mobilizes and subsequently facilitates transport of the released secretion into the upper respiratory pathways. The risks of bronchial collapse and atelectasis formation decrease due to mucus plugs. In thoracic surgery, the flutter significantly decreases the occurrence of post-operative pulmonary complications. The combination of a flutter with inhalation is therapeutically and motivationally very effective in small children. The tri-combination of inhalation + AD + flutter intensifies the

mobilization of secretions and shortens individual physical therapy treatment times. The duration of exercise is very individual, usually starting with 3–5 minutes, 3–5 times per day. Individual exercise times are gradually increased to 15–20 minutes and the exercises are not to be performed after meal time or before sleep. Experienced and adult patients can exercise as long as they desire, but it is always advisable to consult a physical therapist regarding exercise duration. Measuring blood saturation by a pulse oximeter is a dependable and objective indicator of an immediate (especially expectoratory) as well as longterm exercise effect of the flutter usage. Fig. 1.2.4-4 Flutter position in the mouth

RC-Cornet The shape of the RC-Cornet resembles the shape of a hollow horn (Fig. 1.2.4-5). Inside a curved tube with a 3-cm diameter is a small rubber pipe that is placed on a mouth piece. Expiration causes

vibration of the small rubber pipe, which, with repeated impact on the wall at the bend of the RC-Cornet, forms a resistance of 5–20 cm H2O during which gentle vibratory bronchial shaking occurs. The absolute functional independence of the patient’s exercise position is an advantage of the cornet. This is the reason why it is recommended with physical therapy of the youngest children. Fig. 1.2.4-5 RC-Cornet – exercising for the smallest children

Acapella During expiration, Acapella produces gentle vibrations within the respiratory pathways and their effect, similar to an RC-Cornet, is not dependent on the exercise position (Fig. 1.2.4-6). Acapella is one of the drainage techniques used in the majority of intubated patients hospitalized mainly in intensive care units whose breathing is dependent on an invasive form of mechanical ventilation. It is also used in other specialized medical settings. Fig. 1.2.4-6 Acapella

Acapella is designed for adult and pediatric patients and it is easily cleaned, so much that after a hygienic cleaning it can be used by another patient. It is very popular, well-tolerated by all patients for which it improves sputum mobilization within the respiratory tract, facilitates expectoration and precedes the feeling of fatigue following physical therapy. Respiratory Physical Therapy and Breathing Muscle Training Devices The devices that are used by patients with chronic forms of respiratory illnesses are called breathing muscle training devices. Based on their exercise purpose, they are divided into inspiratory and expiratory (Fig. 1.2.4-7). Their purpose is to not only perfect the breathing techniques in the respiratory physical therapy program, but also to more effectively involve the respiratory muscles into the breathing process. Fig. 1.2.4-7 Inspiratory muscle trainer

Inspiratory muscle trainers improve inspiratory breathing techniques for more effective performance of an inhalation treatment. They also facilitate respiratory movements of the chest wall in the post-operative stage and improve ventilation. Expiratory muscle trainers have wider effects. The main ones include assistance to expectorate, renewal of ventilatory function of the peripheral respiratory pathways, prevention of bronchial collapses and also improvement of respiratory flexibility of the bronchial walls. The devices allow the patients to repeatedly and independently exercise whenever they need to. Intrapulmonary Percussive Ventilation Administration of intrapulmonary percussive ventilation (IPV) requires technical equipment, most often a jet compressor. Aerosol inhalation therapy applied via a mouth piece is combined with regularly repeated pressure impulses or “compression” of air into the respiratory tract. The size/volume and the frequency of impulse repetitions can be individually set for each pressure impulse. The settings have various variable combinations which produce pressure waves within the bronchi, widening the breathing pathways and facilitating not only the access of the inhalation substance into the peripheral breathing pathways, but also improving sputum mobilization by strong vibratory shaking within the bronchi.

The patient needs to be carefully observed and their breathing monitored, especially during early physical therapy sessions. Ventilation supports expectoration and certain patients may display an overall fatigue following IPV, which is the reason why IPV is always supplemented by relieving positions, resting breathing and compensatory postural exercises. Intrapulmonary percussive ventilation can be interrupted at any time, the exercise period can be shortened, and a “lower” dosage can be set with more frequent repetitions, etc. Inhalation Therapy – A Component of Respiratory Physical Therapy The decision to initiate inhalation therapy is always in the hands of the physician. The results of an inhalation treatment are, among other issues, dependent on the patient’s human or personal makeup. That is why the actual application of the medication can be considered the weakest link in the entire inhalation treatment strategy. The physical therapist is involved with the breathing techniques during inhalation itself. The inhalation effect can be enhanced with the help of methods and techniques of respiratory physical therapy. If the techniques of respiratory physical therapy are applied during inhalation, the physical therapist utilizes the following: Mobilization tools to loosen the thorax Free breathing by the mouth and nose simultaneously Effect of body positions on breathing; Sometimes also the effect of body movements or its parts on breathing Inhalation through the mouth and its influence on inspiratory apnea Inhalation is alternated with rest in relieving positions The breathing pattern with a combination of respiratory physical therapy and inhalation: Active exhalation through the mouth → slow and deep inhalation through the mouth → inspiratory pause → active expiration through the nose or the mouth → expiratory pause → slow and deep

inhalation through the mouth. The clearance of the upper respiratory tract needs to be checked prior to initiating the training of breathing techniques for breathing during inhalation. Respiratory Physical Therapy for Patients in Intensive Care Units There are many reasons why patients need to be hospitalized in intensive care units, but they all have one thing in common: these are patients whose vital functions are endangered and their risk of pulmonary complications is increased. During intense therapy, specific techniques of respiratory physical therapy, which are designed for patients with limited ability to cooperate or even for patients who, for objective reasons (i.e. intubation, medically induced coma), are not able to actively cooperate, need to be applied. Based on the reflexive response of the movement system, the techniques stimulate movement of the thorax for inspiratory relaxation and facilitate muscles for activation of expiration. The technique of contact breathing is used most frequently. It is aimed at mobilization of bronchial secretion. The technique of reflexively modified breathing changes the motor manifestation of the thorax and thus positively influences ventilation. Neurophysiological facilitation of breathing serves as the theoretical basis for these exercises. It was defined in the 1970’s by D. Bethune and it is described as an externally and manually applied proprioceptive and tactile stimulation that produces reflexive breathing and movement responses. They are the cause of the change in the rhythm and depth of breathing. Physical therapy is indicated by the attending physician and the procedures are within the scope of a physical therapist and the practical content of exercises is based on the agreement between the physician and the physical therapist. Timeliness, consistency, continuity and team work are important for effective physical therapy of patients in the intensive care unit. Control Mechanisms of Respiratory Physical Therapy They provide an objective assessment of the achieved effect of

physical therapy. The following are regularly assessed and observed: Kinesiological analysis of breathing and movement functions Pulmonary function values – spirometric parameters Blood saturation by pulse oximeter, short-term and long-term monitoring Collection and volume or weight of the excreted sputum with an option of microbiological analysis Manual, visual and acoustic contact with breathing The feeling of unobstructed, easy breathing Tolerance to physical demands without respiratory discomfort Priorities of Respiratory Physical Therapy: Improve respiratory tract hygiene Increase respiratory tract clearance Decrease bronchial obstruction Achieve and maintain a healthy feeling All controlled data is part of the medical documentation and are regularly re-assessed and the results should, always after a consultation with a physician, be presented to the patient. Much of these data are obtained by the patient’s themselves during home therapy. Their subjective perceptions are formulated into individual categories of qualitative research and can be accurately processed by a licensed program for qualitative research.

1.2.5 Breathing Exercises (Breathing Gymnastics) Libuše Smolíková Breathing gymnastics, also known as breathing exercises, form the practical content of respiratory rehabilitation. Their purpose is to achieve optimal breathing efficiency. Based on the principles of kinesiology, physiology and other allied health approaches, the term breathing gymnastics better describes the essence of respiratory rehabilitation. In the current context, positions and movements are subordinate to breathing processes, which are accompanied by

movement of the trunk, head and extremities. The emphasis on volitional controlled breathing, its synchronization with movement (especially in patients with bronchial obstruction) and timely inspiration and expiration during movements are common especially with breathing gymnastics which is a higher degree of controlled movement controlled activity with an exact and goal-oriented approach. Never forcefully intervene with the patient’s breathing rhythm, do not command and imperatively control the elements of breathing gymnastics. Follow the principle of each patient’s individual approach to breathing and constantly emphasize the educational and instructional components of physical therapy. All forms of breathing gymnastics contribute to increasing physical fitness and to the prevention of secondary changes in the movement apparatus in patients with chronic respiratory illnesses. Breathing gymnastics forms the practical content of respiratory rehabilitation and fitness training for patients with cardiac problems, diabetes, oncological problems and other chronically ill people with multiple diagnoses. In common practice, static, dynamic and mobilization breathing gymnastics are used. Static breathing gymnastics is designed to renew the basic breathing pattern and it is based on respiratory training. It exercises the respiratory and movement functions of the mimetic muscles of the facial part of the head and maintains the upper respiratory tracts in an optimal state: clear and open. Prior to each breathing exercise, three necessary steps need to be carried out: sit comfortably (sometimes in front of a mirror), blow the nose and remove (even spit out) mucus. Prior to initiating the actual training, postural alignment should be corrected. Static breathing gymnastics is independent breathing without any accompanied comovement of other body parts, including the upper or the lower extremities. Breathing activity is directed toward the regions of the thorax, abdomen, back and the pelvis. Attention needs to be paid to the training of the basic breathing pattern and a coordinated movement of the respiratory and movement systems. The exercises are

performed in various positions, most often sitting or supine. The difficulty of individual exercises of static breathing gymnastics is given by the mutual position of the extremities in relation to the trunk. These positions and the positioning of the extremities have a direct influence on the modification of breathing and correspond to the principles of human body biomechanics in relation to breathing. Static breathing gymnastics is usually included in the first group of therapeutic exercises during physical therapy for the majority of patients. When breathing movements of the thorax and the abdominal wall are accompanied by extremity movements, it is known as dynamic breathing gymnastics. Based on the exercise goal, at first the movements of the pelvis, lower extremities, shoulder girdles and the arms are added during inspiration followed by movements of the trunk and head. These movements require energy and are the initial step in the implementation and adaptation of mechanics needed to sustain the demands of the body. Every exercise requires full concentration, slow and accurate execution in a timely movement sequence. This can be compared to a domino effect when during the course of one exercise, the patient can, through movement, stretch, strengthen and also breathe through a particular body part, for example, the thorax. Dynamic breathing gymnastics is performed as an individual physical and fitness preparation during hospitalization. Group exercise allows several patients to perform the same exercises simultaneously, but always in an individual context taking into consideration the individual needs of each patient. It is recommended that all patients continue these exercises at home. Dynamic breathing gymnastics serves as a breathing and movement preparation for the dynamic demands of physical fitness training. Mobilization breathing gymnastics is a higher form of breathing and movement exercises. It is a combination of breathing, its phases, treatment positions and segmental body movements. The simplest are static, isolated elements of positions that, through a specific movement accompanying breathing, are organized into mobilization exercise progressions. They are based on a combination of breathing

and movement sets during which large muscle groups are activated. The exercises that follow one another have a logical sequencing and their effect is based on the summation of an immediate and/or longterm effect. An immediate effect is given by the sequencing of individual exercises during one exercise session. A long-term effect is based on the principle of a greater effect with regular performance of breathing and movement exercises, in which repetition “facilitates” positive outcomes. Movement succession is given by the phases of breathing and static positional endurance is influenced by the rate of respiration. These exercise programs are focused on the overloaded or at risk, body areas and may be subjectively accompanied by unpleasant feelings. This is why they are not liked much. The exercises sometimes even hurt and some of their initial manifestation include perspiration, fatigue or face reddening and may not be pleasant. These are usually only temporary autonomic system reactions that are time limiting and without permanent consequences. The exercises involve positions and body movements that feel like an intense muscle stretch accompanied by a subsequent pleasant muscle relaxation and self-mobilization of restricted joints. They can be alternated with relaxed positions and long, relaxed breathing after which the exercises are repeated, perhaps even with greater intensity. This allows for a gradual increase in exercise loading with a positive influence on the patient’s breathing and physical state. The treatment effect depends on the patient’s active cooperation and their positive approach toward the exercises. The exercise results in a subjectively perceived pleasant feeling from movement and a greater ease and quicker adaptation of the organism to physical loading. Objectively, the exercise results in an improvement in the overall physical condition and a relaxed, elegant movement.

1.2.6 Fitness Physical Therapy and Pulmonary Illnesses Pavel Kolář Decreased tolerance to physical demands stands in the forefront as a problem associated with the choice of an appropriate fitness physical

therapy program. Studies examining the body’s adaptation to physical demands have shown that a targeted increase in the patient’s fitness, which can be objectively assessed by the comparison of results between exercising and non-exercising groups, positively influences the actual pathological process. At the same time, the patient’s movement options and their independence increase, leading to an improved quality of life. Similarly to healthy people, a general principle that elicits a desired result is a certain short-term overload that gradually causes adaptation in all participating systems of the human body, including the respiratory system. For adaptation, mainly endurance-type training is recommended. During aerobic training, the following changes occur in the individual systems: a. In muscle fibers: The mitochondria of the red fibers enlarge; capacity of enzymes that ensure oxidative phosphorylation and ATP regeneration increases Aerobic work capacity increases During higher loads, the muscles utilize sugars mainly through oxidation; lactate concentration remains low Glycogen storage is conserved Intramuscular and intermuscular coordination improves b. During energy expenditure regulation: A lower amount of catecholamines is produced with the same loading Sensitivity to insulin increases Burning of fat increases In the area of energetic coverage, glycogen is preserved c. With circulation and breathing following adaptation to the same load: Increased oxygen transport in the blood Decreased heart rate

Decreased blood pressure Decreased cardiac minute volume Increases VO2max The above presented changes were verified by a number of studies. Given changes eliciting adaptation to the load occur only if the movement activity is of sufficient intensity, frequency and duration. In this area; however, no uniform opinion exists. Richard Casaburi (1997) recommends applying 80% of a maximum tolerated load, 5 times per week, 1–2 times per day. The treatment effect is seen as early as two weeks. Other authors lean toward lower load intensities. European companies recommend increasing loading intensity from 50 to 80% of the presumed maximum cardiac demand or 50–70% of VO2max. The American Thoracic Society recommends in its guidelines an activity in the form of walking or riding an ergometer every day or at least 5 times per week for a minimum of 30 minutes. The load intensity; however, is not stated. Many authors recommend same load duration with an intensity at a level around the anaerobic threshold, but some recommend a lower intensity. Another opinion is that the adaptation effect correlates with the amount of energy exerted. Based on the prevailing current opinions, the effect can be expected after 5–10 weeks of exercise when repeated 5 times per week for a duration of 30–45 minutes. The intensity should reach a minimum of 50–60% of maximal capacity in the VO2max percentage or the same increase in heart rate. The intensity level must also be based on the patient’s condition. Paul W. Jones studies in detail the determination of load intensity and divides the patients into four groups based on the degree of shortness of breath, forced expiration recorded in one second, maximum minute ventilation, VO2max and the state of blood gases. Different load intensity is recommended for each group. As far as the issue of adaptation to physical loading, the form of loading is under discussion. Here, the critical principle seems to be the fact that large muscle groups need to be activated. The orthopedic

aspect also needs to be respected. This means that the form of loading cannot be established universally. For example, during running, the hip joints are overloaded and an arthrosis may develop; whereas with walking, the patellofemoral complex is overloaded. Prior to initiation of rehabilitation aimed at activity at a certain intensity, a stress test which objectively determines the level of cardiorespiratory fitness is recommended. The test should be repeated in 1–2 months and the results compared. This will verify the appropriateness of the determined intensity as well as methods to be used. The issue of a specific increase in a patient’s adaptation to physical loading is paradoxically not at the center of interest, although its significance in many cases overlaps with the effect of therapy aimed at respiration from the perspective of neurophysiological functions.

1.3 SELECTED PHYSICAL THERAPY CONCEPTS 1.3.1 Vojta’s Principle: Reflex Locomotion Irena Zounková, Marcela Šafářová Based on his own observations and experience, a Czech neurologist Vaclav Vojta (1917–2000) laid the foundations to this method, or a diagnostic and therapeutic principle, in the 1950’s. During his work on the concept of treatment of children with cerebral palsy, he discovered reflex locomotion (meaning forward movement). In such children, he was able to elicit non-volitional motor reactions of the trunk and the extremities through accurately defined stimuli in various body positions. Professor Vojta based his method on the concept that the basic movement patterns are programmed genetically in each individual’s central nervous system. These serve as “building blocks” for straightening and forward movement – from grasping through rolling and crawling to independent ambulation. The spontaneous connection of these innate movement patterns becomes limited due to CNS and movement system dysfunctions. Through reflex locomotion, the CNS can be activated, thereby awakening from a disturbed situation with the goal to renew the innate physiological movement patterns.

THERAPEUTIC SYSTEM Therapy is based on developmental kinesiology including individual developmental stages, such as a stable supine position. First head lifting in prone, rolling, side sitting, erect sitting, creeping, standing and walking are assessed not only in their final static state, but also how this change from one position to the next occurs and which muscles are activated in the process. There are three integral components to locomotion (forward movement): automatic control of body position, trunk verticalization against gravity and with it corresponding phasic mobility, which is manifested by a grasping and

stepping forward movement of the extremities. According to Vojta, the technique can incorporate the genetically coded human movement program into its control. A specific input from the periphery (afferentation) causes a specific motor response (efferentation). In certain starting positions of specific body areas, a manual application of pressure is applied to the trigger zones. Trigger zones serve for elicitation of automatic locomotor movements, which the author labeled reflexive crawling and turning. After a period of stimulation, summative zone stimulation can elicit a complex motor reaction. These motor responses are not random, but legitimate and consistent. Individual movement patterns resemble movement that leads the individual to an erect body posture and walking. Activation of Reflex Locomotion The method is founded on three movement processes: reflex creeping, reflex rolling and the process of verticalization (verticalization positions 1–6). The following movement processes contain basic elements for each forward movement: Automatic balance control during movement (“postural control”) Body straightening Purposeful grasping and stepping movements of the extremities (“phasic mobility”) Reflex locomotion is activated from three basic positions – prone, supine and kneeling with maximum hip and knee flexion, legs are at the edge of a bed, the upper extremities are in the same position as in reflex creeping and the head is rotated on the mat. To elicit a movement reaction, Vojta uses the following: Specific initial angular position of the trunk and the extremities Static and dynamic pressure and pull in the joint Activation (trigger) zones on the trunk, and upper and lower extremities Resistance against emerging movements The correct engagement of muscles in certain chains occurs in a

specific sequence. Muscle activity spreads to the entire body. A shift in the center of mass occurs through the support points of the extremities. The trunk is erected on the extremities and carried forward. The entire process occurs dynamically with alternating standing and stepping phases on the upper and lower extremities. The combination of trigger zones, resistances, changes in the direction of pressure and the position of the extremities in the initial position leads to many variants of the three basic positions. In this way, the therapy is accommodated to the individual diagnosis and to a specific therapeutic goal. Reflex Creeping The initial position is prone with (Fig. 1.3.1-1; Fig. 1.3.1-2), the head slightly rotated and resting on the mat. Based on head position, the side of the body to which the head is turned is denoted as the facial side and the opposite as the occipital side. The extremities on the facial side are called the facial upper extremity and the facial lower extremity. The extremities on the occipital side are called the occipital upper extremity and the occipital lower extremity. The elicited movement pattern occurs in a so called crossed pattern, in which the right lower and the left upper extremities move simultaneously and vice versa. The body is supported on one lower extremity and the contralateral arm. Muscle activity is elicited and corresponds to a position in which the trunk is unweighted above the mat and ready for movement in a forward direction. The head begins to turn to the opposite side and the therapist gives resistance to its movement; however, during movement, the head maintains its elongation with the axis of the spine. This strengthens the muscle activation of the entire body and forms predispositions for the process of straightening. It is primarily an activation of the mechanism needed for support, grasp, erect posture and ambulation.

Fig. 1.3.1-1 Initial position for reflex creeping

Fig. 1.3.1-2 The trigger zones for reflex creeping

Facial Upper Extremity Initial position: Supported on the forearm on the mat Trigger zone: Medial humeral epicondyle Anticipatory movements:

The facial upper extremity together with the shoulder plexus take over the support function for the trunk (the trunk is unweighted, straightened dorsally against gravity) The axial organ (head and trunk) is shifting laterally and cranially forward The elbow becomes a support point A “grasp” emerges in the distal extremity with simultaneous wrist extension and radial deviation (Fig. 1.3.1-3)

Fig. 1.3.1-3 Reflex creeping in the crossed pattern. Stepping cycle contains flexion, relaxation, standing and push-off phases. Different phases of the stepping cycle depend on head turning. It crosses midline between b and c and between d and a. This causes changes in the stepping phases and muscle function. Note: trigger zones on the medial humeral epicondyle on the facial side, on the radial styloid

process on the occipital side and on the lateral calcaneal tubercle on the occipital side. Applying pressure on the posterior inferior nuchal line on the occipital side slows down head turning. The b and d parts illustrate forward movement and head turning.

Occipital Upper Extremity Initial position: Neutral position of the shoulder and elbow; arm is positioned alongside the trunk Trigger zone: Radial styloid process Anticipatory movements: Stepping phase, shoulder flexion, movement into forearm supination and elbow flexion, wrist extension and radial deviation, metacarpal abduction (hand opening) Movement is completed by grasping the mat and the extremity is prepared to take on support function; head is turning and the extremity, originally occipital, becomes facial. Facial Lower Extremity Initial position: In pediatric patients, slight flexion, external rotation and abduction at the hip (only in pediatric patients), with slight knee flexion; in adult patients, the facial lower extremity is extended and placed on the mat in hip internal rotation Trigger zone: Medial femoral epicondyle Anticipatory movements: Stepping phase Hip flexion, external rotation, abduction; knee flexion, dorsiflexion and eversion in the ankle joint, toe extension with simultaneous metatarsal abduction; the stepping forward knee prepares for support function (see Fig. 1.3.1-2 and 1.3.1-3). Occipital Lower Extremity Initial position: Slight hip flexion, abduction, external rotation Trigger zone: The outside aspect of the heel, or the lateral calcaneal tubercle Anticipatory movements:

The occipital lower extremity takes over the support function with the thigh in external rotation, slight knee flexion with simultaneous posterior pelvic tilt Unweighting of the trunk, muscles work against gravity Support point: the heel Ankle dorsiflexion and inversion Movement is completed by push-off and simultaneous toe flexion Note: During this activity, a simultaneously elicited movement of the head, trunk and facial region occurs. Activation System Positions 1–6 Vojta described six therapeutic positions (Fig. 1.3.1-4) in which the body is carried from a horizontal position into vertical and standing. In position 1, the lower extremities are in maximum hip and knee flexion, the trunk is resting on the thighs, the head is supported on the mat and rotated toward one side. In position 6, the trunk is almost vertical (in standing). During therapy, positions 1 and 2 are most frequently used with the main therapeutic goal to activate lower extremity straightening and to invoke the needed muscle activity to lift the trunk up. Similarly to reflex creeping, the activation system of positions 1–6 is a contralateral model. Fig. 1.3.1-4 A scheme of the course and phases of elicited movement – verticalization of an individual in activation system positions 1-6

Initial position of position 1: Patient is kneeling on the mat with maximum hip and knee flexion, legs are resting over the edge of the mat so that the dorsal aspects of the feet are not in contact with the table. The trunk is positioned on the thighs and the head is rotated approximately 30 degrees toward one side. On this facial side, the upper extremity is placed on the mat, shoulder in 125–130 degrees of flexion, forearm in pronation and elbow at 45 degrees of flexion. The wrist and fingers are freely positioned on the mat. On the opposite side – the occipital side – the upper extremity is placed freely along the body and the dorsal aspect of the forearm rests on the mat (Fig. 1.3.15). Fig. 1.3.1-5 Initial position for activation system of position 1

Trigger zones The trigger zones are identical to the ones used for reflex creeping. They are as follows: a. Facial side: Medial humeral epicondyle Distal third of the medial scapular border Anterior superior iliac spine Medial femoral condyle b. Occipital side: Anterior-lateral aspect of the acromion Trunk zone – in the region of intercostal spaces 6–8 Posterior border of the gluteus medius Radial styloid process Lateral calcaneal tubercle on the bottom lower extremity Note: During stimulation in position 1, it is always advantageous to control and guide the movement of the head (give resistance against anticipated head turning). This allows for accumulation of activity and greater transfer to the axial organ and trunk.

Anticipatory movements During trigger zone stimulation, muscle activity is elicited that straightens the pelvis from a horizontal into a vertical position and, thus, carries the trunk into vertical alignment and into space. The pelvis is exposed to a powerful pull of the pelvic floor muscles, abdominal musculature and the muscles of the pelvic girdle. The muscles of the pelvic girdle pull in the direction of punctum fixum, which lies distally on the lower extremities. This mechanism, however, would not work without quality support and lifting (erecting) on the upper extremities. The lower extremities work against gravity and have differentiated functions. Although they are folded under the trunk and appear symmetrical, their differentiated function can be recognized based on the reaction at the periphery. In the occipital lower extremity, the support phase occurs at the center of the tibia followed by take-off. The support phase corresponds to 90 degrees of dorsiflexion with supination and toe flexion. On the facial lower extremity, a very short flexion phase occurs that is manifested in the periphery by ankle dorsiflexion accompanied by foot pronation and toe extension. Following this phase, the knee leans on the center of the tibia, pronation releases, the foot attains mid-position and free toe extension is visible. The feet attain metatarsal abduction. The movement of the upper extremities is similar to reflex creeping: the facial upper extremity becomes the support and the phasic forward movement occurs via the occipital extremity. The spine straightens and, in contrast to the creeping reflex model, the head rotates to the opposite side and has a tendency to unweigh itself into space. Reflex Rolling In therapy, reflex rolling is used in various phases of its course in supine or in sidelying. It is an ipsilateral model where ipsilateral extremities are stepping forward and become support extremities. Reflex rolling occurs from supine to sidelying and it is completed

by creeping in the quadruped position. Reflex Rolling – Phase 1 In supine, the stimulation of the intercostal space within the thoracic zone results in rolling over into a sidelying position. Reactions that occur include straightening of the spine, support on the surface aspect of the back, preparation of the upper extremities for support function, lifting of the lower extremities above the mat, and coordinated activation of the abdominal musculature. Initial position: Supine position, head is rotated toward one side (the facial and the occipital extremities are distinguished in the same manner). The extremities lie freely on the mat (Fig. 1.3.1-6).

Fig. 1.3.1-6 Supine position as the initial position for turning in the first phase of reflex turning. The thoracic zone as the facilitator of the turning process is located in the intercostal space around the sixth rib.

Trigger zone: Pressure at the intercostal spaces (most frequently between the 6th and 7th rib) in a diagonal direction against the mat. The pressure is directed toward the scapula on the occipital side; then, the nuchal line is contacted on the occipital side and this movement is resisted during head rotation. Anticipatory movements:

Trunk and spine align in a neutral position Parallel position of the shoulder and pelvic line The back becomes the base of support, the upper part of the trunk straightens The occipital upper extremity externally rotates; facial upper extremity is abducted and flexed Both lower extremities flex in the hip and knee joints, hips are externally rotated and abducted, lower extremities are above the mat, ankles in neutral position Head turns toward the opposite side Breathing deepens (Fig. 1.3.1-7, 1.3.1-8, 1.3.1-9)

Fig. 1.3.1-7 Spinal extension through iliopsoas synergy, and abdominal musculature – not pictured, with caudal trunk extensors, among others with iliocostalis lumborum. The base of support is pictured by a contracted trapezius muscle.

Fig. 1.3.1-8 Balanced supine position. The center of mass is shifted cranially by stimulation of the thoracic zone and resistance applied against the head. Extension along the longitudinal body axis occurs. The base of support is marked by the contracted trapezius muscle. The lower extremities are carried outside the base of support in hip flexion, slight abduction and external rotation. Knee is extended to 90 degrees through quadriceps contraction. A synergistic function of the distal part of the ischiocrural muscle group slows down the emerging knee extension. The ankle is in a neutral position.

Fig. 1.3.1-9 Balanced supine position. The thorax expands through activation of the serratus anterior. The spine is set into a neutral alignment through activation of the abdominal wall, autochtonnic (deep) musculature, longus coli muscle and the longus capitits muscle. The movements of the eyes, mimetic musculature, mandible, tongue and head are toward the occipital side. The thoracic zone and the resistance against movement of the head are shown in blue arrows on the picture.

Reflex Rolling – Phase 2 This is a specific “frozen” phase of the global process of reflex rolling.

Therapeutically, sidelying is an advantageous position. It contains movement processes that are present in spontaneous rolling, creeping and walking sideways. The upper and lower extremities on the bottom side are used to support the body. They shift the body upward and forward. The reactions include supporting the upper and lower extremities on the bottom side of the mat, phasic forward movement into flexion of the extremities on the top side. The support shifts from the shoulder toward the elbow and palm. The support in the pelvic region shifts distally along the outer side of the thigh toward the knee. Straightening of the spine occurs during the process of rolling while the head is held in sidelying against gravity. Initial position: Sidelying (Fig. 1.3.1-10, 1.3.1-11).

Fig. 1.3.1-10 Trigger zones of the second phase of reflex rolling found on the extremities, the thoracic zone

Fig. 1.3.1-11 Trigger zones of the second phase of reflex rolling found on the upper half of the trunk

Trigger zones: Acromion of the top upper extremity Radial styloid process of the top upper extremity Anterior superior iliac spine of the top lower extremity Medial femoral epicondyle of the top lower extremity Medial humeral epicondyle of the bottom upper extremity Lateral femoral epicondyle of the bottom lower extremity Lateral calcaneal tubercle of the bottom lower extremity Anticipatory movements: a. Top Upper Extremity: flexion phase (stepping) abduction and external rotation of the arm slight elbow flexion and supination wrist extension and radial deviation opening of the hand from the little finger b. Top Lower Extremity: flexion phase (stepping) hip and knee flexion hip external rotation ankle dorsiflexion in a neutral position c. Bottom Upper Extremity: standing phase, support on the shoulder, arm, elbow arm in external rotation, slight elbow flexion forearm pronation hand opening d. Bottom Lower Extremity: standing phase, support on the lateral side of the thigh and pelvis hip in slight external rotation slight knee flexion ankle dorsiflexion and inversion

toe flexion Besides specific activities of the trunk and muscles of the extremities, the mechanism of reflex locomotion also influences the activity of the muscles used for: motor skills of orofacial mobility (the movement of the mandible and the tongue in the direction of head turning, swallowing) motor skills of the eyes (eye movement precedes head movement) bladder and bowel functions (affecting smooth muscle function of the bladder, external sphincter of the bowel and peristalsis) mediastinum and lung expansion (strengthened costal breathing)

TREATMENT EFFECTS Timely initiation is one of the crucial elements for a positive treatment effect. Therapy can renew physiological movement processes sooner than the development of compensatory patterns can prevent it. Reflex locomotion activates muscles in physiological movement patterns or chains that so far have worked in pathological patterns or not at all. Muscles that the patient cannot volitionally engage are activated. Repeated therapy leads to straightening of the spine and more purposeful use of the arms and legs for support and grasping functions. Besides improvement in swallowing and chewing, speech emerges, pronunciation improves and voice presentation strengthens in the orofacial region. The patient can maintain better balance and shows improved orientation in space. They improve their body perception, as well as, perception of the shape and structure of objects (stereognosis). Patients with a movement deficit demonstrate improved ability in contact initiation and communication. In small children, school age children and teenagers, therapy can positively affect maturation and growth. In adults, the goal of therapy is to restore the originally healthy

movement patterns and prevent processes such as pain or limited function and strength. Therapy is effective not only for motor deficits brought on by CNS dysfunction, but also movement system deficits caused by other reasons.

PRINCIPLES AND FUNDAMENTALS OF THERAPY 1. The Vojta method does not teach, does not practice and does not train “normal” movement processes such as grasping, upright posture or walking. 2. The therapy is performed in a reflexive way, or without the patient’s volitional effort. Activation of both complex movement patterns is elicited by the initial position and by pressure at the trigger zones. 3. The Vojta method sends stimuli to the brain and in this way activates the patient’s natural and innate capabilities. The patient is able to organize the elicited activity into their spontaneous movement. Following therapy, the patient “discovers” and “utilizes” a certain function without “learning” it. 4. Reflex locomotion leads to an overall (global) change in body posture, shift in the center of mass, improvement in upright body posture, control of “balance”, and improved overall movement coordination. 5. Reflex locomotion and its movement processes are can be elicited in every individual regardless their age. Therefore, this therapy can be applied from newborn age into adulthood. 6. The effects of therapy depend mainly on the type of initial illness. In severe deficits, the therapy can last weeks, months, sometimes even years. The important conditions for therapeutic success include the therapist’s knowledge, accuracy in the administration of therapy, and its intensity and frequency. One therapeutic session can last between 5 to 20 minutes. The exercises are repeated several times per day (up to 4 times). The therapeutic program, frequency and rest periods are often modified to a patient’s condition.

7. The therapists who perform this therapy daily in a home environment play a critical role during application of the Vojta method. These include the patient’s family members. Through repeated learning sessions, they learn to administer the exercises accurately. 8. The therapist schooled in the Vojta method and the attending physician provide the family with specialized assistance and psychological support.

INDICATIONS AND CONTRAINDICATIONS The Vojta method is primarily indicated for pediatric patients with developmental motor deficits. It includes the following pathological conditions: Diseases of the central nervous system: cerebral palsy – all forms, degenerative neurological diseases, conditions after brain and spinal cord injuries and central coordination deficits Peripheral nerve damage: congenital or acquired forms Orthopedic deficits: for example, scoliosis, hip dysplasia, pes equinovarus, asymmetrical (scoliotic) body posture in a newborn, toddler, preschool age child, school age child, and torticollis General contraindications: 3–4 days following immunizations, malignant form of epilepsy, during a course of acute viral illnesses or infections, during an inflammatory illness, metastatic tumors, premedication prior to a physical, medication with high dosages of corticosteroids, specific medical check or a procedure, for example, lumbar puncture, MRI, surgical or orthopedic intervention followed by a period of healing in the area of therapeutic administration An absolute contraindication does not exist. The method disposes technical tools that a qualified therapist must modify to fit the patient’s given condition and their reaction whether the patient is in an inpatient or outpatient setting.

1.3.2 Sensorimotor Stimulation

Michaela Veverková, Marie Vávrová Around 1970, Professor Janda and his colleague M. Vavrova began working on the methodology of sensorimotor stimulation. Its name is supposed to emphasize a reciprocal relationship between the afferent and efferent information during movement control. The methodology is based on the findings of many authors who described the effects of afferentation deficits on movement. Most likely, A.D. Kurtz was the first person to clinically observe the relationship between foot injuries and muscle coordination deficits. In 1956, the fundamental empirical work was done by S. Skoglund, in clinical practice by M.A.R. Freeman with colleagues who systematically mentioned the interconnection between joint traumas and deficits in joint afferentation during the onset and development of an unstable ankle. Freeman described and assessed muscle coordination and emphasized muscle inhibition as an integral component of the patient’s clinical picture. In their book, C. Herve and L. Messean also explored the issue of proprioception. At first, the sensorimotor stimulation method was used during therapy for an unstable knee and ankle. Today, it is used during therapy to restore functional deficits of the movement apparatus, especially when involving stabilizing musculature. The techniques contain a system of balance exercises performed in various positions. Exercises performed in an upright (vertical) position are the most important because this method emphasizes facilitation of movement from the foot. The afferentation is increased through skin exteroreceptors and proprioreceptors from the muscles and joints. Activation of the deep muscles of the foot and training of an exercise element called the “small foot” contribute to the facilitation. Other areas that were described as proprioceptively important include the short neck extensors, sacral area, and the spinovestibulocerebellar circuit. The goal of this method is to individually select basic exercises given the patient’s condition and gradually increase the demands according to a detailed progression so that all options to correct a

deficit in the movement apparatus have been exhausted. The therapist attempts to progress the patient to standing exercises so that new motor programs can be integrated with basic activities of daily living. Main goals of exercises: Improved muscle coordination Faster initiation of muscle contraction through proprioceptive activation elicited by a change in joint alignment Influence on proprioceptive deficits accompanying neurological illnesses Correction of balance deficits Improved body posture and trunk stabilization in standing and during ambulation Integration of new movement programs into basic activities of daily living The method uses a two-step model of motor learning. At first, the individual repeatedly attempts to perform a new movement and thus gradually builds a basic movement program. This learning stage is cortically controlled, especially from the frontal and parietal cortical regions, and it is very tiresome. The brain attempts to simplify the entire regulation circuit and gradually shifts control subcortically. Automation, the second phase of motor learning, emerges. The movement program is controlled subcortically to allow for fast movement execution, which is important, among other things, for injury prevention. It has been shown that quality proprioception combined with balance exercises quickens the initiation of muscle contraction, which is the first prerequisite for a quick reaction during an unexpected balance perturbation. During the first learning phase of new movement, the therapist should emphasize the quality of the executed movement because once the movement programs become automatic they are difficult to change. The therapeutic use of exercises: Instability and hypermobility of the movement system Chronic back pain

Poor body posture Mild forms of idiopathic scoliosis Muscle imbalance Treatment completion of post-injury and post-surgical conditions involving the movement apparatus Sensory deficits accompanying neurological illnesses Balance deficits Fall prevention in seniors Note: This technique is not used for patients with acute pain! Patient Preparation Any sub-threshold or threshold nociceptive information elicits an adaptation process that is manifested as a change in the movement program. For these reasons, prior to the actual exercise, the patient needs to be assessed by observation and palpation and also by a functional assessment (testing movement patterns, short and weak muscles, hypermobility etc.) and a standing balance test. When testing balance, the ability to stand on both lower extremities is tested with eyes closed followed by standing on one lower extremity with eyes open and then closed. Balance is considered good when the patient can maintain the obtained position for 10–15 seconds. If the patient can perform the tests while standing on the floor, the same sequence is followed for balance testing on a soft surface. The assessment can be accompanied by walking forward and backward at first with eyes open and then closed. Based on the assessment, joint restrictions and deficits in soft tissues are treated – skin, subcutaneous tissue, fasciae and muscle trigger points. Short muscles are stretched if significant muscle imbalance is found. Following the corresponding therapeutic procedures, each exercise session begins by the facilitation of the foot. Brushing, tapping, stimulation using massage balls or walking on small flat marbles can all be used. The Method “Short Foot”

“Short foot” is a special exercise designed to increase foot afferentation during which, through activation of the deep muscles, the foot shortens and narrows, leading to stimulation and activation of proprioceptors from the short plantar muscles. Therefore, the CNS receives an increased number of proprioceptive inputs (short muscles and joints of the foot are rich in the number of proprioceptors), from which the brain selects and modifies the appropriate motor programs. During this exercise, the patient simultaneously pulls the forefoot and the heel toward one other, which increases the longitudinal arch of the foot. At the same time, the transverse foot arch forms by approximation of the metatarsal heads toward one another. The heads of the first and the fifth metatarsals remain on the floor and the toes freely lie on the mat. The training of “short foot” begins in sitting – in an unweighted position. The therapist uses both hands to passively mold the foot into the above described shape and gently stretches it when returning to the original position. The passive movement is repeated 3–5 times while the patient observes the entire movement and becomes aware of its course. The training in sitting further continues by molding “short foot” with the therapist’s additional assistance and is completed by the patient’s active formation of “short foot”. When the patient masters the exercise in sitting, they can advance to standing. Postural Correction in Standing For exercises in standing, the patient must first learn correct standing. The goals of this exercise include improved perception during contact of the sole with the mat, increased muscle activity on the bottom of the foot and improved body awareness in space. Correct stance is taught in three stages: 1st stage: The patient stands with both feet parallel and hip width apart, toes pointed forward. They slowly lean their body forward, the movement occurs only at the ankle joints, the body weight is shifted onto the forefoot. The heels remain on the mat; the lower extremities, pelvis, trunk and the head are in one line.

2nd stage: The foot position remains the same. The patient adds slight knee flexion (approximately 10 degrees) and hip external rotation, the knee joint axis shifts above the outer edge of the foot. The body shifts forward. 3rd stage: Corrected stance – the patient achieves “short foot” on both feet and the feet are parallel and hip width apart. Then, they slightly flex the knee joints (unlock) and perform hip external rotation, leaning the body slightly forward to achieve symmetrical weight distribution across the soles of the feet (the support is on the first and the fifth metatarsal heads and on the heel). Then, they push the feet into the mat and elongate the body along the longitudinal axis of the spine. The abdominal wall is flattened, the head is erect, shoulders are relaxed, widened and slightly pressed down. The spine maintains its physiological curvatures. To make it more challenging while maintaining posture in the corrected stance, the therapist can apply pressure or perturbation to the patient’s pelvic or shoulder areas attempting to disturb their balance. Corrected stance serves as the initial correction for all subsequent exercises. First of such exercises is the training of corrected stance while standing on one leg. Exercises to Train Correct Posture through Shifting of the Center of Mass Gradually, half-steps in the forward and backward directions, the step strategy and hops are practiced. When performing a half-step in the forward direction, the patient steps forward with one leg in a “short foot” position. They bend the front knee so that it points to the outer edge of the foot without coming in front of the toes. The patient elongates their trunk along the longitudinal axis of the spine and the entire body shifts forward so that the weight is shifted toward the forefoot. During a half-step backwards, the patient steps back with one of their lower extremities, with their foot in a “short foot” position, they bend the back knee so that it points toward the outer edge of the foot, elongates the trunk along the axis of the spine and, by approximating the tubercle of the flexed leg above the heel, shifts their body weight

onto the back leg. The trunk remains perpendicular to the mat. To increase exercise difficulty for both exercises, the therapist can use pressure or perturbations at the patient’s pelvis or shoulders. When the forward and backward half-steps are mastered, the step strategy can be practiced. Step strategy simulates a sudden change in the center of mass, which often occurs during falls. The exercise improves muscle reaction speed, which prevents further injuries. The step strategy begins from corrected stance by a gradual forward leaning of the trunk. The movement occurs only at the ankle joints. The weight of the body shifts forward to a point when the heels begin to lift off the mat. At that moment, the patient steps with one extremity to prevent falling. During stepping and after weight shifting onto the front extremity, the body is in the same position as when the forward half-step was used. Hops in corrected stance can be used to improve muscle coordination. Exercising on Unstable Surfaces All the above mentioned exercises can be performed on unstable surfaces if the patient’s condition allows it. The individual tools used include a BAPS board (round), rocker board (half-cylinder base) (Fig. 1.3.2-1, 1.3.2-2), foam mats, exercise (balance) sandals (Fig. 1.3.2-3), trampoline and large rehabilitation balls. Fig. 1.3.2-1 BAPS board

Fig. 1.3.2-2 Balance board

Fig. 1.3.2-3 Balance sandals

At first, balance is practiced on a rocker board. A rocker board allows practicing body balance in three directions. The patient’s position is chosen based on the strongest finding. Exercising on a BAPS board (round base) is more difficult because it moves in all directions. When the individual can maintain balance in a corrected stance well, then they can add upper extremity movement, mini squats, swinging motions, ball throws or practice walking on the boards. The therapist increases the challenge by applying pressure or perturbations at the patient’s pelvis or shoulders. Walking with Exercise (Balance) Sandals Balance sandals are cork slippers with a shaped arch and strap across the metatarsal heads. A half-ball made from sturdy rubber is glued on

the bottom, at the sandal’s center of mass. The patient gradually learns to walk in the sandals. At first, body posture and the position of the feet during walking in place is practiced with the therapist’s assistance. The feet must adhere to the surface of the sandals so that the foot arch is formed on the surface of the shoe. The feet are parallel and hip-width apart, the toes do not lift or flex during walking and the sole of the foot must remain parallel to the floor. The patient takes quick steps, knees move freely and the feet do not lift high. The movement is only performed at the knees and the hips, the rest of the body remains upright. In the second stage of the walking practice, the therapist faces the patient, holds their pelvis and the patient places their hands on the therapist’s shoulders. In this position, they practice walking forward. The third phase is a gradual transition to independent walking while maintaining all the details learned in the first two phases. It is important that the steps are short, quick and the arms are relaxed along the body. The patient can walk forward, backward and sideways while wearing the sandals. The balance sandals are suitable for home exercises. At the beginning, ambulation is challenging to coordinate and muscle overloading can easily occur. Walking should be practiced several times per day; each time approximately 1–2 minutes. Often times, only 2–3 meters are sufficient for a beginner; then rest prior to continuing. The total daily exercise period is approximately 10–15 minutes. Guidelines Applied to All Exercises Body posture correction always begins with the distal body segments and moves proximally, therefore, in that sequence, the feet, knees, pelvis, head, neck and shoulders are gradually corrected. Exercises are performed with bare feet because bare feet allow for better afferentation, improved control of movement quality and the exercises are safer. The exercises should not elicit pain or physical or mental fatigue. From the very beginning, training of correct body posture is emphasized. All exercises must first be performed on a firm surface. Then, unstable surfaces are used. There are usually

20–30 repetitions in one set and more difficult exercises, such as the step strategy, are repeated 5 times. The postures are held for 5–10 seconds. The total exercise time is adjusted based on the patient’s capabilities and the exercises are terminated when the first signs of fatigue are observed, which is usually manifested by deficits in muscle coordination or by decreased quality in maintaining correct body posture.

1.3.3 Feldenkrais Method Magdaléna Lepšíková Most movements performed during the course of a day are performed without us paying conscious attention to the actual movement. For example, if we decide to turn on the light in the room, we execute the necessary movement automatically only with the thought of the established goal. The way we get up from a chair, the number of steps taken and the way we lift our arm toward the light switch are processes that occur without our conscious effort and without our concentration on individual tasks. Often, then, during common activities of daily living, certain muscles are used excessively while other muscles are left out or, in a sense, neglected. This leads to a chronic overloading of certain areas, which can result in structural changes. Most movement stereotypes are already formed during the first years of life and are later influenced by other factors. These factors can be either internal or external. The internal factors include, for example, a deficit at the level of the nervous system. A child with cerebral palsy or a patient after a cerebrovascular accident will have an altered body posture and movement pattern based on the deficit in CNS control. In the same way, a patient with radicular symptoms can present with an antalgic posture as a result of their pain, which causes a change in movement patterns. The external factors also influence our movement behavior to some extent. These especially include cultural and occupational factors. Other factors include, for example, comparing the same daily activities or movement habits in sitting or carrying heavy loads of the

Euro-American population, Asian or certain African populations. Our body posture is equally affected by occupations or the sports we participate in. Just based on the first glance at the patient, a physical therapist can often guess if a patient is a competitive swimmer or a gymnast. The Feldenkrais method is based on an idea that we act according to an image we had formed of ourselves. This image can often be biased, causing the person to not use their true capacity, but rather their body based on the distorted image. The more the body image (body schema) resembles reality the more accurate and purposeful the movements are. A body schema can be tested, for example, by asking the patient to close their eyes and show the size of their ribcage or their waist line. We can assess how much the reality differs from the patient’s perception. Another factor that affects movement quality is the ability of kinesthetic perception, or proprioception. This ability can be assessed by having the patient repeat a movement that has been demonstrated to him or the patient attempts by themselves to repeat the same movement twice, as accurately as possible. During this test, the difference between the individual patient’s demonstrations is assessed. For a movement to be efficient, the ability to relax is important. If the patient is asked to perform isometric elbow flexion against slight resistance, the muscle activity should not recruit distant muscle groups. This means that if an elbow flexion muscle contraction elicits, for example, a contraction in the sternocleidomastoid, the patient is using inadequate muscles for the given movement and is overstressing certain body segments. Equally, with upper extremity passive movement, the patient should be able to relax enough so that no resistance is given to the movement being performed. Feldenkrais attempted to use exercise to refine kinesthetic perception, improve time-spatial coordination and teach his students to move with minimal effort and maximum effectiveness. Thus, this exercise principle includes mainly the improvement of movement quality (based on improvement of body schema) rather than quantity, meaning force or endurance.

In practice, the Feldenkrais method is performed in two ways: Body awareness through movement Functional integration Body awareness through movement occurs in a group exercise setting guided by a teacher. During individual lessons, the students learn to perceive and control positions and movements of individual body parts based on the teacher’s verbal instructions. Usually, these are slow and repetitive movements often of a rotational nature. At first, the exercise is performed in lower positions, most frequently lying down. Only simple, small range movements in individual body segments are practiced (for example, the hip, shoulder, cervical spine etc.). During follow up sessions, the exercises gradually implement movements with greater range and in higher positions, such as sitting, kneeling or standing and more complex movements involving more segments are practiced simultaneously (movements of the pelvis and the head, simultaneous movement of the upper and lower extremities). The goal of the exercises is for the student to learn to perform the movements with minimal effort and substitute old nonefficient movement patterns with new ones. All exercises are performed very slowly and smoothly. Emphasis is placed on smooth breathing, constant movement awareness throughout the entire course of a movement and elimination of excess tension. The individual can test the effectiveness of the exercise by a control position or a movement at the beginning and at the end of each exercise session during which they realize the changes that had occurred through introspection of their body. Examples of exercises: a. The patient sits comfortably on a chair, legs are slightly apart (approximately pelvic-width apart) and the feet are on the floor. In this position, the patient slowly alternates bending their head to the right and to the left several times. This movement needs to be performed strictly as a sidebend in the frontal plane, without co-movement into rotation. The patient attempts to perceive the sensations of their body and, at the same time, perceive whether

the range of the sidebend was the same to both sides or not. They perceive tension and its location. Following a short rest period, the patient performs the same exercise with the upper extremities abducted. Again, they try to perceive and compare a sidebend to the right and to the left and the difference between the exercises with the upper extremities relaxed and abducted. b. The patient is prone with one knee flexed to 90 degrees. In this position (without visual control), the patient attempts to perform an isolated movement at the ankle joint on the ipsilateral lower extremity. The patient feels which muscles are used for this movement, whether and where they feel tension and whether they are also moving segments other than the distal part of the lower extremity. Note: If the patient is well instructed, they can perform the exercises independently at home as part of their home exercise program. In contrast, functional integration is an individual, non-verbal technique during which the patient is taught the perception of varied movement situations through gentle touches and passive and active movements in order to achieve their maximum relaxation. Indications and Contraindications Indications: All age categories All conditions with a deficit in stereognosis and somatognosis Deficits in isolated movements Deficits in the ability to relax Athletes, dancers, musicians and other people who move a lot during their profession; this can decrease the risk of injury by teaching the muscles more effective control and use. Contraindications: Conditions with severe sensory deficits Mental deficits in which the patient is unable to understand the verbal instructions or concentrate on the performed movements.

1.3.4 Proprioceptive Neuromuscular Facilitation Irena Zounková, Pavel Kolář The foundations of proprioceptive neuromuscular facilitation (PNF) evolved from the work of Dr. Herman Kabat (1913–1995) between 1946–1951. Physical therapists Margaret Knott (1918–1978) and Dorothy Voss (1914–1996) also contributed to the development of this method. Since 1979, the main PNF learning center is located in Vallejo, CA and headed by Marie Louise Mangold. A specific effect on the anterior spinal horns of motor neurons through afferent impulses from the muscle, tendons and joint proprioceptors serves as the basic neurophysiological mechanism of PNF. In addition, the spinal motor neurons are simultaneously affected through efferent impulses from higher motor centers, which also react to the afferent impulses originating from the tactile, visual and auditory exteroreceptors. The needed stimulation of the proprioreceptors can be achieved by various palpation and passive or active movements, as well as, through dynamic and static work against appropriate resistance. The techniques of this method support or quicken the neuromuscular system’s responses through the mechanism of proprioceptive stimulation. The neurophysiological mechanism of PNF originates from a principle that the brain “thinks” in movements and not in individual muscles. That is why movement patterns are the basic building blocks of PNF. All movement patterns are carried out in a diagonal direction with simultaneous rotation and resemble a majority of activities of daily living. Rotational and diagonal components are aligned with the bones, joints and ligamentous apparatus of the skeleton, with a topographical placement of the muscles (their origin and insertion). For each body part (the head, neck, upper quarter, lower quarter and extremities) there are two diagonals. Each diagonal is formed by two movement patterns that are antagonistic. In addition, each movement pattern contains a main flexion or extension component and two flexion and extension movement patterns are formed for each body part.

Movement in the direction of these diagonals always contains three movement components in various combinations: Flexion or extension Adduction or abduction External or internal rotation The basic mechanism of PNF utilizes cooperation between large muscle groups because neither an individual muscle nor one of its functional components is responsible for movement. During movement, the pattern is strengthened by synergists (and must cooperate with them). Other times, in contrast, it can accept the role of a synergist in a different movement pattern. In addition, the working muscle requires muscles that stabilize a certain location (i.e. the scapula) toward which the given muscle contracts – the so called stabilizers. The principle of muscle activity irradiation is used for facilitation of weakened muscles and it is quite different from the approach of Sister Kenny who has consistently avoided synergies. Facilitative Approaches in PNF Proprioceptive and exteroceptive stimulation is used for facilitation. These tools include: Stimulation through muscle stretch – elicits or strengthens muscle contractions, can inhibit antagonists Stimulation of joint receptors – traction (distancing joint surfaces) strengthens muscle activity and eases movement; compression (approximation of joint surfaces) supports joint stability Adequate mechanical resistance – stimulates muscle contraction, improves motor control, increases strength and endurance. The therapist provides resistance when a certain movement is performed and constantly modifies it based on the patient’s strength and desired effect. It can include resistance along the entire range of motion or only in certain parts Tactile stimulation, manual contact – the touch or pressure of the therapist’s hand allows for good guidance and, thus, good

movement execution. Manual guidance of the movement is modified to the current situation and to the patient’s reaction. Based on this, the therapist performs passive movement without the patient’s active participation, active-assistive movements during which the therapist assists the patient’s active movement and active movements which the therapist guides by manual contact. Auditory stimulation – facilitates active motor skills through verbal commands Visual stimulation – the patient observes and controls the posture and movement. Strengthening and Relaxation PNF Techniques The summation of the above mentioned impulses leads to the irradiation phenomenon. The muscle activity of the stronger muscles allows for activity restoration of the weak or inactive muscles. Timing of a movement is another important element of the treatment during movement re-education which can allow for performing coordinated movements. It is a stimulation under normal conditions of a functional movement in a smooth and correct sequence. Patient – therapist coordinated work position, the therapist’s and the patient’s body mechanics and their mutual grasps allow for individualized application of resistance. They become significant tactile stimuli and are conditions for movement execution and control. Based on the combination of movement patterns and appropriate stimulation leading to various types of muscle contractions, strengthening and relaxation techniques are part of this method. There are four types of strengthening techniques (two techniques using activation of the agonist; two techniques use activation of the antagonists), two types of relaxation techniques and three types of combination techniques. The goals, indications and contraindications of individual techniques are precisely established. The general goals and main indications are listed in the following overview. Goals of Strengthening Techniques Improving the ability to initiate and learn conscious movement control

Increasing range of motion and relaxation of increased muscle tone (through reciprocal inhibition) Improved muscle strength and endurance Improved muscle coordination Decreased level of muscle fatigue Increased joint stability. Main Indications Deficits in proprioception and skin sensation Muscle hypertonia (through reciprocal inhibition) Need for movement learning and re-learning Difficulty initiating movement Muscle weakness Range of motion limitation Contractures Ataxias Insufficient joint stability Goal of relaxation techniques Reduction in increased muscle tone Increase in range of motion Elimination or attenuation of pain Main indications Spasticity and limitation in mobility Painful limitation of joint mobility caused by increased muscle tone Ontogenetic and Other Principles in the PNF Concept In the 1960’s, M. Knott and M. Voss complemented the PNF concept by an exercise set corresponding to an overview of an ontogenetic development. In contrast to similar exercises, their exercises are modified for adult patients. Exercise approaches based on the ontogenetic developmental movement sequence contain initial positions, their variations and transitions into other positions. These include, for example, supine, sidelying, prone on elbows, quadruped, different sitting positions, kneeling, standing, stretching and walking. During gait training, the following activities are mainly practiced:

standing from a chair or a wheelchair, standing, standing on one foot, step cycle, ambulation forward, backward, sideways, and ascending and descending stairs. The method also includes facilitative approaches to influence orofacial mobility and breathing. Within the PNF concept, other principles are applied: An effort to mobilize unused reserves of the central nervous system in the area of motor function control Movement re-education based on simple movements that correspond to the patient’s actual motor abilities and are part of normal movement activity The training is functional, modified to common activities of daily living; exercising of individual body parts supersedes the patient’s training; exercise intensity is adjusted to prevent patient fatigue; the therapist motivates the patient to achieve the needed level of cooperation PNF Indications and Contraindications The application of PNF spans a wide indication spectrum Central nervous system diseases: multiple sclerosis, ataxias, central pareses, spinal cord injuries – paraplegia and quadriplegia caused by injuries, tumors and inflammatory or degenerative processes Peripheral nerve damage: for example, peroneal nerve palsy, radial nerve palsy etc.; orthopedic conditions, degenerative diseases of the spine and extremity joints, post-surgical states of the spine, hip and knee joints; traumatic injuries to the movement system, postfracture conditions, injuries to ligaments, tendons and muscles, as well as, post-amputation, muscle atrophy and joint contractures following prolonged immobilization Contraindications Serious cardiovascular illnesses Metastatic malignant tumors Fevers Application of resistance distally to fracture site

1.3.5 Brunkow’s Method Pavel Kolář The therapeutic concept of Brunkow’s method is based on the specific activation of diagonal muscle chains. It is a system of upright stance exercises that allows improvement in function of weakened muscle groups, stabilization training of the spine and the extremities without undesirable joint loading and with re-education of correct movements. A German physical therapist Roswitha Brunkow (1916–1975) is the founder of this method. She began to explore this method in 1965. The development of the actual technique is based on her own experiences and observations and they were related to her accident after which she was forced to spend a long time in a wheelchair. The method is based on the principle that motor activity depends on the position of the extremities in relation to the trunk and the head. Brunkow attempted to activate muscle chains and achieve an upright trunk position through passive and later also active positions through supported arms. The establishment of support in one extremity is a necessary prerequisite for activation of pairs of antagonistic muscle chains. The point of support may be real or virtual. This method is used to affect motor skills of special, facilitatory and inhibitory techniques through telereceptors (optic, acoustic stimuli), proprioreceptors, exteroreceptors, interoreceptors (changes in position of internal organs, irritation of breathing). Conscious motor learning, awareness of the spectrum of quality perception, attention and concentration, understanding the optic and acoustic supply and their transition to kinesthetic level all play an important role. Brunkow’s therapy attempts to distinguish incorrect pathways of physiological patterns. Patient treatment is based on the perspective of motor deficit processing. In a certain way, it originates from developmental kinesiology, meaning it respects the individual stages of a child’s motor development when selecting positions of upright stance exercises (individual initial exercise positions use only partial

elements of posture or attitudes of motor development). Indications and Contraindications Indications Neurological illnesses Functional deficits of the movement system Post-injury conditions, etc. Contraindications Cardiovascular insufficiency Uncompensated arterial hypertension Pulmonary diseases in which the right side of the heart can be overloaded Unsuitable mental condition Pain

1.3.6 Brügger’s Concept Dagmar Pavlů Based on his own observations, a Swiss neurologist and psychiatrist, Dr. Alois Brügger (1920–2001) developed a diagnostic and therapeutic concept whose beginnings reach back to 1955–1958 when he had shown that pain in the movement system can be functionally based. Then, he focused his studies on a sternosymphyseal loading posture and definitions of tendomyosis, which represent reflectory changes within the musculoskeletal system. In 1989–1990, he defined the “nociceptive somatomotor blocking effect”, which represents the basic pathophysiological principle for the diagnosis and treatment of functional disorders of the movement system. The Principle The main idea of this concept is the fact that by activity of a pathologically altered afferent signalization, reflexive defensive mechanisms (nociceptive somatomotor blocking effect, NSB) develop within the movement system (musculoskeletal system); they elicit defensive reactions, so called arthro-tendo-myotic reactions within the

movement system and subsequently, a change in the physiological course of movement and postures occurs and the reactions become inefficient. The goal of therapy is to identify the pathologically altered afferent signalizations and to eliminate the pathological processes so that the physiological and efficient processes of movement and postures are restored. The achievement of upright body posture characterized by the presence of thoracolumbar lordosis extending from the sacrum to T5 is at the center of all therapeutic efforts. Note (in practice): Brügger’s concept established a specific detailed assessment and treatment approach that can be summarized in the following points. Diagnosis The goal is to assess pathological afferent influences and identify the so called “disruptive” factors. To accomplish this, the following are used: Patient History (Anamnesis) Patient history is very much emphasized. Besides the common anamnestic data, activities that the patient performs qualitatively and quantitatively are assessed in great detail while the prevailing (movement) functions are analyzed. Observation (Inspection) It includes the presence of possible disruptive factors that can originate from transient factors (clothing, footwear, furniture, lighting, noise etc.) as well as permanent factors (incisions, edema, deficits in blood perfusion, psychological disturbances etc.). Functional Assessment Functional assessment occurs in the following sequence: Assessment of a habitual posture: usually performed in a sitting position that is common for the patient (however, the assessment can be performed in standing, walking or another position that the patient is often in). The therapist assesses the deviations from normal, or assesses the extent of the patient’s faulty (loading) posture. At first, the primary movements are assessed, including the

anterior pelvic tilt, ribcage elevation and neck elongation. Then, the alignment of other body parts is assessed. A 3-point scale is used for assessment. Assessment of a corrected posture: at first, the therapist corrects the patient’s posture as best as possible. Then, the therapist observes posture and again identifies any deviations from normal. The primary movements are assessed first and followed by other segments (similarly to the assessment of habitual postures). However, now the therapist assesses the deficit that does not allow the patient to attain an upright posture. Again, the assessment uses a 3-point scale. Note: The comparison of the assessment during habitual and corrected posture demonstrates the extent of a functional deficit and serves as the first criterion for prognosis. Functional Tests T5 Spring Test In Brügger’s concept, this test is used as a standard functional test. Most often, it is performed while the patient is seated in corrected posture. It consists of manual application of rhythmical impulses in a perpendicular direction to the spine from T5 caudally. The test has three phases: 1. Assessment of spinal stability 2. Assessment of anterior pelvic tilt 3. Test of shoulder retraction In all three phases, the quality and quantity of the mentioned movement is noted, including three primary movements. The test not only serves for diagnosis, but also is performed after each therapeutic technique as an assessment tool of treatment effectiveness. Other Functional Tests Other functional tests include the test of scapulohumeral rhythm, the pelvic rotation test, pelvic roll test, shoulder external rotation test, head rotation test or hip flexion test. Determining the Source of Pathological Afferentation

Based on the patient’s history (anamnesis), observation and functional assessment, the therapist establishes a hypothetical source of pathological afferentation. Developing a Working Hypothesis Based on the determination of pathological afferentation, the therapist forms a working hypothesis, or establishes the therapeutic plan of care. This plan is flexible and if the selected treatment approach is not effective, the therapist can change their working hypothesis based on reassessment of the previous diagnosis. Treatment The goal of treatment is to influence pathological afferentation, or elimination/reduction of disruptive factors. Basic Elements of the Treatment Approach Body Posture Correction Brügger bases his method on the assumption that the deviations from an upright body posture cause an incorrect loading of the body and lead to pathological afferentation. At the beginning of the treatment, each patient is instructed in the correct body posture which they should attempt to attain. Brügger demonstrates upright body posture with a model of 3 cog-wheels that are interconnected and represent three basic (primary) movements: anterior pelvic tilt, ribcage elevation and neck elongation. Also, the so called thoracolumbar lordosis is emphasized during this posture as an ideal posture. Thoracolumbar lordosis should be smooth and extend from the sacrum to T5. Also, the patients are educated on possible influences of the upper and lower extremities on body posture. Preparatory Set Up This includes positioning in an upright body posture. It is performed in supine, always 20–30 minutes prior to each therapeutic session. Special heat applicators (fango wraps) are placed at four key regions: the sternocostal articulations, neck extensors, lumbar spine and the region of the pubic symphysis and thigh adductors. Relaxation is the primary effect of this procedure due to the temperature of the

applicator (it warms up to 65 degrees Celsius). In addition, positioning in an upright body posture also has a positive effect, especially on the three basic primary movements. If heat is contraindicated, only positioning (standard or modified) is performed with such a patient. Passive Therapeutic Approaches Heat is most commonly applied by a hot towel roll. It is most commonly used to influence the OGE (Obolenskaja-Goljanitzki effect according to Brügger), which are edemas formed most often as a result of repetitive movements. The hot towel roll application can be combined with a cross-fiber massage based on the patient’s needs. Neurological contractile approaches: are quick vibratory movements that have mainly a relaxation effect. They are performed for significantly painful conditions, but only after the correct postural alignment is attained. Active Therapeutic Approaches Agistic-eccentric contractile approaches Their goal is to improve the eccentric capability of certain muscle groups and also of the functional muscle synergism of agonistic and antagonistic muscle groups. Resistive Band Exercises These are found in a home exercise program. A resistive band allows for exercises in which alternate eccentric and concentric contractions of given muscle groups occur. The number of exercises and the frequency of a set of repetitions for resistive band exercises used for strengthening are given to the patient based on the course of active approaches (agistic-eccentric contraction) and the functional demand. The home exercises are based on the functional parameters (strength, range of motion, resistance and coordination). Activities of Daily Living Activities of daily living (ADL) indicate the highest and most significant goal of active treatment approaches. This consists of the practice of common daily activities into which upright body posture is

integrated. All these exercises must be performed with a certain goal related to the patient’s common activities (house work, occupation, sport etc.). Basic (Active) Exercises These include six simple exercises that are integrated into therapy. They are performed from an initial standing position. Through slow, smooth movements emphasizing a slight stretch of functionally dominant (or short) muscle groups, these exercises contribute to an improved eccentric contractile ability of the corresponding muscle groups, thus positively influencing the overloaded posture. Therapeutic Ambulation According to Brügger Brügger-Body-Walking belongs among complex therapeutic approaches that serve to influence global movement patterns and are performed with or without the use of resistive bands. Note: In Brügger’s concept, an important aspect of therapy – not a therapeutic component – includes the patient’s motivation and the therapist as a positive role model. Indication The main areas for indication include functional dysfunctions of the movement system. The therapeutic elements of this concept can also be utilized for the treatment of neurological illnesses (central lesion, Parkinson’s disease), orthopedic conditions (scoliosis), etc.

1.3.7 Sling Exercise Therapy Alice Hamáčková, Dagmar Tomisová, Ctirad Tomis Sling exercise therapy (S-E-T) is a comprehensive diagnostic and therapeutic system for active treatment. They are exercises with a goal of securing a permanent improvement in musculoskeletal issues. The system is applied in the Redcord (formerly TerapiMaster) apparatus. Redcord is a simple, mechanical suspension system that originated in Norway. In the Czech Republic, it has been used since 1997 in hospitals, outpatient settings and private practices, but it can also be

used in a home setting. The Redcord apparatus consists of a set of straps, firm and elastic ropes and an adjustable ceiling mechanism (Fig. 1.3.7-1). Its alternative version, Redcord Mini, became very popular for exercising at home and outside. The greatest advantages of S-E-T and Redcord for a physical therapist is its availability for individuals regardless of their gender, age, fitness level, the ease and personalized prescription of weight to be used as determined from examination (identification of the “weak link”) and therapy, immediate possibility to re-evaluate the effect of therapy and the patient’s increased interest in the therapy process itself. The greatest advantages for the patient include timely, safe and very effective therapy with elimination of pain and a long-lasting effect, as well as, the potential for secondary prevention in the form of a group or home exercise. Fig. 1.3.7-1 Examples of exercises using slings

The goal of the evaluation is to identify the “weak link”. The evaluation is based on an accurate amount (increasing or decreasing) of functional loading with a simultaneous body weight shift to a distal segment, which determines the level of the tolerated load by the movement system. The “weak link” represents a deficit within the biomechanical chain (this may include, for example, decreased neuromuscular control, decreased stability, decreased muscle strength or a fear of exercise activity) and results in a musculoskeletal system dysfunction. When using Redcord, the amount of loading can be achieved in several ways and with different combinations: Lever arm (the distance of the strap from the joint in which the

movement is occurring) Patient positions in relation to the suspension point (SP) (SP is the point from which the rope arises from the Redcord apparatus); based on SP position in relation to the joint, axial, caudal, cranial, medial, lateral and neutral suspension can be distinguished Rope length – the length of the rope influences movement trajectory and the degree of joint compression/decompression Utilization of elastic ropes (unweighting – decreased body weight shift) The clinical effect of therapy utilizing the S-E-T concept has also been supported by several years of systematic research in the following areas: non-specific low back pain, whiplash injury, the effect of specific stabilization of the lumbar region on post-partum pelvic pain, decreased sick leave time, rehabilitation of seniors, post-surgical shoulder rehabilitation, training of athletes, etc. In recent years, the Neurac therapeutic technique is starting to be utilized. Historically, it is based on the S-E-T concept and utilizes the facilitative effect of controlled vibration and an unstable environment for neuromuscular activation.

1.3.8 Exercise with a Therapy Ball Pavel Kolář This rehabilitation tool (inflatable large ball) has already been used by the Bobaths for rehabilitation of children with cerebral palsy. The child can be laid down, seated or supported on the ball. The ball was used for the training of righting and equilibrium reactions. With time, exercise routines with a therapy ball have been developed by many authors. Functional kinetics by Susanne Klein-Vogelbach from the 1960’s is one of the best known concepts. The therapy ball has three characteristics: Unstable surface Elasticity Size (diameter from 35 to 120 cm)

The unstable surface allows for ball movement at the point of patient contact with the ball, which leads to instability and elicits automatic righting reactions. The ball elasticity allows for hopping, jumping, and springing. At the same time, it absorbs possible impacts that could be transferred to the patient. The musculature works automatically. During exercise, the corrections of faulty positions of movement segments occur outside of one’s volitional control. A program within the CNS has the ability to identify the faults and correct them. Many exercises in various positions and their variations have been established (sitting, laying down, standing) with the goal to improve spinal stabilization, influence mobility of the spine and other segments (extremities), unweight the spine, and mobilize the spine in the sagittal, frontal and transverse planes. The use of the ball for home exercises is a great advantage. It can be used for any age category. As a sensorimotor tool, it increases the amount of proprioceptive afferentation, and thus contributes to the activation of specific sensory and motor areas of the CNS. Therefore, it constantly stimulates the activity of the CNS and facilitates more optimal correction of the motor program.

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2 Modalities Bronislav Schreier Utilization of the effects of various forms of physical energy has a traditional place in treatment rehabilitation. Our ancestors recognized the healing power of mineral springs, thermal sources and the sunlight. Although, they did not possess the exact biophysical and biochemical data, they developed effective treatment systems based on empiricism. Massages and other types of mechanotherapy contributed toward relaxation of people in all historical periods of civilization. Technical advances increased the expansion of modalities by instrument-applied types of energy with the option of an accurate dosage setup. Across the wide spectrum of available procedures, modalities provide supplemental therapy. In modern treatment rehabilitation, which emphasizes an active patient approach, modalities as a “passive” therapy should not exceed 5–10% of the overall treatment in a majority of diagnoses. The effect of modalities does not lie in the number of applications, but rather in the optimally selected therapeutic effectiveness on a patient’s symptoms and dysfunctions, especially within the movement system. This requires the knowledge of the underlying mechanism of the effect of individual types of modalities on an organism and the ability to diagnose functional deficits of the movement system. (A more detailed description of these mechanisms exceeds the content of this chapter. For more detailed information, please refer to the list of references.)

2.1 CLASSIFICATION OF MODALITIES BASED ON THE TYPE OF APPLIED ENERGY 2.1.1 Mechanotherapy It involves application of various forms of a mechanical energy. Basically, all techniques of manual medicine and massage techniques are based on mechanical energy transfer from the therapist to the patient. However, they are not included in the modalities. The procedures of mechanotherapy include: Instruments that are sources of suction, overpressure, traction, vibrations Instruments performing passive movement and positioning Ultrasound therapy Therapy through a pressure wave

2.1.2 Thermotherapy and Hydrotherapy These include the activity of thermopositive (heat) and thermonegative (cold) stimuli in the form of wide scale water treatment procedures or other sources of heat (cold). In the Czech Republic, which has a rich tradition in spa treatments, water treatments are common. They are used abundantly during home therapy. Today’s balneology is based mostly on the treatment systems developed by Vincenz Priessnitz (1799–1851), Sigmund Hahn and his sons or Sebastian Kneipp whose success was based on the practice of principles of a healthy lifestyle, including active movement, healthy diet and cold water exposure.

2.1.3 Electrotherapy Electrotherapy utilizes various forms of electric currents and electromagnetic fields. Two types can be distinguished: contact electrotherapy during which the treatment segment is part of an electric circuit (electrotherapy current without high frequency therapy) and non-contact electrotherapy during which the segment is

exposed to the electromagnetic field of the applicator. The treatment effect of contact electrotherapy is based on electrochemical reactibility of the tissues to the passing current and the stimulation of the neuromuscular system. In non-contact electrotherapy, the effectiveness is linked to electromagnetic induction and the characteristics of the electromagnetic field acting on the tissues. Contact electrotherapy includes: One-way (galvanic) current Low frequency current (frequency to 1,000 Hz) Mid-frequency current (1,000 Hz to 100 kHz) Electro-diagnosis and electro-stimulation – uses individual impulses of a right angle and oblique shape of up to 1,000 ms in length to stimulate muscle fibers Non-contact electrotherapy includes: High frequency current (frequencies above 100 kHz) – the energy from the current is transferred into heat in the tissue (diathermy); in the case of a capacitive applicator, the formation of heat is called dielectrothermy; if the applicator is in coil form, it is called inductothermy Distant electrotherapy – the current develops in the tissues through induction of the electromagnetic field under the applicator Magnetic therapy – uses the interaction of a treated segment with a magnetic field developed inside and around the applicators based on the principle of electromagnetic induction in the electric current of the surrounding conductors; currently, a low pulse frequency magnetic therapy is being used most frequently in therapy.

2.1.4 Phototherapy Phototherapy (light treatment) is used for photochemical and biostimulation effects of photon energy by application of electromagnetic radiation from the area of the visible section of the spectrum, ultraviolet (UV) and infrared (IR) radiation. Currently, in common rehabilitation practice, the treatment with a polarized laser light and biolamp are used for healing of the skin and superficial

structures and artificial sources of infrared radiation are used for a thermal effect. Therapeutic exposure to natural sunlight (heliotherapy) is a component of a comprehensive balneologic treatment. The use of UV radiation practically disappeared from treatment rehabilitation and dominates in dermatology and cosmetics.

2.1.5 Combined Therapy and Combination of Modalities In clinical practice, the term combined therapy is used for simultaneous application of therapeutic ultrasound and electrotherapy, most frequently TENS and mid-frequency current. To obtain a cumulative effect, other modalities are combined: Electrotherapy applied through vacuum electrodes Application of galvanic current in water (“hydrogalvan”) – electrotherapeutic bath, four-chamber galvanization Hydrotherapy and mechanotherapy – under water massage, whirlpool and bubble baths, Scottish shower, etc. Distant electrotherapy and infrared radiation

2.2 CLASSIFICATION OF MODALITIES BASED ON THEIR PRIMARY EFFECT Modalities are considered symptomatic and supportive treatments. Since the main symptoms of movement system deficits (pain, muscle tension imbalance, edema, decreased local circulation and changes in trophicity) are often manifested simultaneously, a question arises as to which procedure from the wide spectrum of modalities should be selected. Especially for procedures in which the tissue interactions and the depth of penetration are not quite clear or are based on empirical findings (in the worst case scenario on an advertisement), a wide spectrum of indications was developed. The effect from each procedure can be either direct (local influence of processes in the treated tissue with a subsequent hyperemia) or indirect and mediated through the nervous and humoral systems (inhibition and facilitation). Based on the primary effect, modalities can be classified as: Analgesic Myorelaxing Anti-edematous Trophotrophic Myostimulatory The final effect is based on established parameters that will be noted in individual procedures in the following chapters.

2.2.1 Modalities with an Analgesic Effect Modalities are often applied with the intent to eliminate or decrease pain in the movement system. Through their direct effect on sensitive nerve fibers, electrotherapeutic instruments can have a primary effect on nociceptive information. In other procedures, a secondary analgesic effect can be achieved as a result of local and indirect effects that evoke hyperemia in the involved tissue and support metabolic and repair processes resulting in a decrease in pain. This does not

apply in scenarios of acute conditions with a reactive inflammatory process combined with edema when, in contrast, procedures reducing hyperemia are selected (for example, cold pack application). An important principle is to not apply an analgesic procedure before the cause of the pain is determined. Quick application can distort the significance of the pain and make further diagnostics more difficult. Modalities with Primary Analgesic Effect Gate control in the posterior spinal horns (procedures that are not irritable, but well tolerated are selected with intensity at threshold and above) and stimulation of endogenous opiate production (irritable procedures with intensity above threshold) serve as the neurophysiological foundation of the underlying mechanism of the effect. Low Frequency Therapy Optimal frequency is about 100 Hz. Lower frequencies are more stimulatory; sensory fibers adapt faster to higher frequencies and their intensity needs to be increased more. Electrotherapy with frequencies around 300 Hz becomes apperceptive (the patient cannot feel it). Classic Currents Leduc’s (100 Hz frequency, 1 ms wavelength of a right angle impulse, above threshold intensity) Träbert’s (143 Hz, rectangular wavelength impulse at 2 ms, 5 ms interval time, intensity at threshold level, special location of electrodes in mid-line) Transcutaneous Electrical Neurostimulation Transcutaneous electrical neurostimulation (TENS) is a non-invasive application of pulsed currents through a monopolar point electrode to a corresponding branch of a sensory nerve. Impulse wavelength is shorter than 1 ms (usually 10–700 μs) and is tolerated better than classic low frequency currents. TENS can be equipped with continuous or randomized frequency (can be also applied as bipolar). However, burst TENS has the most marked analgesic effect (impulses with frequency of 100 Hz are divided into bursts of five impulses, the

burst frequency is 1–10 Hz), which, in contrast to other TENS, needs to be applied on the intensity below the level of pain tolerance (decreases also visceral pain). TENS currents in the form of portable applicators with parameters set up by a therapist are also recommended for home treatment in chronic pain conditions. Diadynamic (DD) Currents Pulsed sinusoid currents DF (100 Hz) and MF (50 Hz) and their specific combinations are supplemented by galvanic current. The procedure mostly begins by the application of an analgesic current DF, continues with a more stimulatory current CP (frequency modulated, 1 seconds DF, 1 second MF) with trophotrophic and antiedematous effects. It is completed by a modulated current LP with an analgesic effect. The abbreviations come from French names for currents (diaphasè fixe, DF; monophasè fixe, MF; courant module en courtes periodes, CP; courant module en longues periods, LP). Mid-Frequency Electrotherapy Mid-frequency electrotherapy involves application of alternating currents with the frequency most commonly between 2.5–10 kHz. These currents overcome skin resistance with more ease and are better tolerated than low frequency currents. To achieve a therapeutic effect, their amplitude modulation needs to be achieved through either interference of two circuits in the target tissue (quadpolar application) or in the device (bipolar application). For an analgesic effect, the modulation occurs at a frequency of around 100 Hz and the current intensity is at or above threshold. Modern appliances allow for a very accurate targeting even in deeper tissues. Modalities with a Secondary Analgesic Effect Distance Electrotherapy An electric current develops in a tissue through induction from an electromagnetic field from the applicator. For distance electrotherapy (DE), specific frequencies of 16 Hz, 48 Hz (efflux of Ca2+, indication of local function deficits of blood perfusion) and 72 Hz (Basset currents, influx of Ca2+, support of osteoblast and fibroblast activity and vascular proliferation) are utilized. Other frequencies are

analgesic. The procedure is gentle, non-perceptive, and also suitable for acute conditions. Considering the predicted activity to the level of the bone cells, DE is also used for deeper lying tissues. The applicator is equipped with an infrared emitter and the duration of a single application is usually 20 to 30 minutes with approximately 10–30 procedures performed. Indications: bone healing (except for the L-25 current, it can be used when a metal implant is present), soft tissue healing, functional deficits in blood perfusion and peripheral nerve lesions. Low Frequency Pulsed Magnetic Therapy It utilizes the activity of a magnetic field itself as well as an induced pulsed current in all segments and layers found within the magnetic field. The analgesic effect is a result of vasodilation, myorelaxation and the support of tissue trophicity. Magnetic therapy uses a frequency of up to 100 Hz, an induction in tenths mT, a 30 minute application time, and 10–20 procedures with ring and pad applicators. The procedure is non-perceptive. Indications: bone healing, degenerative and inflammatory illnesses of the movement system, functional deficits of the movement system, neurological illnesses (Fig. 2.2.1-1). Fig. 2.2.1-1 An instrument for magnetic therapy with a set of applicators

Shockwave Therapy

Therapy using shockwaves, originally used in urology to release kidney stones, is one of the newly used and, at the same time, aggressive methods in rehabilitative medicine. From the perspective of applied energy, it is classified as mechanotherapy. The therapeutic principle is based on an application of instrumentally generated bursts (“pressure waves”) with a significant pressure gradient. There is a tapper at the end of the applicator head, which is placed on the skin above the treated tissue (for example, a muscle trigger point, tendon, or insertion). The bursts emit a wave at the area of application, which spreads into the surrounding tissues to a depth of approximately 3.5 cm. The pressure intensity is adjustable to 6 bars and the burst frequency can be between 1–20 Hz. In certain instruments, an accurate dosage of applied mechanical energy can be set (energy flux density – EFD, measured in mJ/mm2). Documented recommended therapeutic values are up to 0.6 mJ/mm2. During shockwave application, shifting of soft tissue structures occurs. Cavitation forms at the interface of structures with different mechanical characteristics and lasts approximately 100 μs. These changes elicit a reaction in the active components of connective tissue and triggers repair processes (specific microtraumatization of treated tissue occurs). Subsequent hyperemia improves local metabolism. Also, decreased tension is observed in hypertonic muscle fibers and the surrounding soft tissues. The analgesic effect following application is explained by a release of endogenous opiates. The shockwave supports resorption of calcium deposits and osteogenesis. Shockwave therapy is prescribed on an individual basis and the number of bursts in one sitting is 1–2 thousand; more if a greater area is treated. The bursts are targeted at muscle trigger points, tight soft tissue structures and their insertions. These are chronically overloaded and hypersensitive areas and the application of intensive bursts is especially painful during the first application. The patient’s pain threshold needs to be taken into consideration. The number of applications is 2–5, most often 3, in one week intervals. After an application, a 48-hour rest period is required.

Indications: enthesopathies, heel spurs, impingement syndrome, bursitis, reflexive changes in muscles and soft tissues, retracted adhesions after surgeries and injuries limiting function of the movement system, and pseudoarthrosis. Contraindications: use in a location where corticosteroids were applied in the past 6 weeks, proximity of nerves and varicosities, application just above air-filled organs, radiation therapy in the preceding 12 weeks. General contraindications include tumors, localized inflammation, systemic inflammatory illnesses, pregnancy and deficits in blood coagulation. Local Thermo-Positive and Thermo-Negative Therapy This includes application of warm or cold procedures based on the phase of the painful condition. In acute conditions, thermo-negative (cold) procedures are selected, including cryotherapy (icing). In advanced phases, an individual patient’s reactivity needs to be taken into consideration. Generally, a cold object causes vasoconstriction and penetrates deeper through the skin than a warm stimulus, which is carried out through a dilated blood network of the skin. Also, a reactive hyperemia with a possible decrease in pain after application of a cold stimulus has a longer lasting effect. For application of thermopositive stimuli (heat), in addition to various water treatments and balneological procedures (peloid, paraffin wraps, “thermal bags”, etc.), the infrared light can also be used. It is classified as phototherapy based on the type of energy. Diathermy is most effective for the heating of deeper structures. High Frequency Therapy (Diathermy) It uses alternating current with a frequency greater than 100 kHz. It includes shortwave diathermy (13.56 MHz, 27.12 MHz and 40.63 MHz frequencies), ultrashort wave diathermy (433.92 MHz and 915 MHz) and microwave diathermy (2450 MHz). In the tissue, the current transforms into heat, which elicits improved circulation, metabolism, connective tissue elasticity and relaxation of muscle fibers followed by an analgesic effect. By changing the distance of the applicator, the effect can be targeted into deeper layers that other

forms of thermotherapy do not penetrate.

2.2.2 Modalities with Dominantly a Myorelaxation Effect Increased muscle tension is closely associated with musculoskeletal pain, especially in functional pain of the movement system (for example, enthesopathy, referred myofascial pain, etc.). Modalities can have a significant effect on the relaxation of hypertonic muscles. Procedures that elicit a specifically targeted contraction are used as well as the heating of muscle fibers followed by relaxation. Ultrasound Therapy Ultrasound therapy uses ultrasound (US) with a frequency of 1 MHz (for deeper tissues) up to 3 MHz (for more superficial tissues). Ultrasound absorption vibrates tissue structures (“micromassage”) and its dispersive effect will manifest itself by improved tissue viscoelasticity. In a continuous US, the heat formed warms the structures exposed to US and the subsequent hyperemia has a myorelaxation effect. Ultrasound is usually applied by an ultrasound head with a diameter of usually 1 and 4 cm, a 3–5 minute time of application with a maximum intensity of 2 W/cm2 for continuous US and 3 W/cm2 for pulsed US. Special contraindications include US application to superficial bony prominences, peripheral nerves, a postlaminectomy site and the epiphyses of growing bones. Combined Ultrasound and Electrotherapy Combined ultrasound and electrotherapy is one of the most effective methods to treat muscle trigger points. The effect of electrotherapy is potentiated in the ultrasound field. The ultrasound head serves as the second electrode. Most often, mid-frequency currents are combined with 1 MHz ultrasound (deeper TrPs) and TENS with 3 MHz ultrasound (superficial TrPs). Electrotherapy frequency is 100 Hz with an intensity above sensory threshold targeting TrPs and above motor threshold during therapy. Ultrasound intensity is approximately 0.5 W/cm2 with a 1–3 minute application time and 1–3 procedures; with more frequent occurrences, it is necessary to look for the source of the

problem outside the treated TrPs (Fig. 2.2.2-1). Fig. 2.2.2-1 Application of combined ultrasound and electrotherapy for trigger points in the upper trapezius muscle

Electrotherapy Muscle relaxation can be achieved by stimulating muscle fibers by a current intensity that elicits their contraction. Following this artificial contraction and relaxation, a subsequent decrease in muscle tension occurs. Often, the same types of currents seen in combined therapy are used: TENS and mid-frequency currents, but the optimal frequency to elicit muscle contraction is between 150–200 Hz. When vacuum electrodes are used, a massage-like effect occurs in the superficial layer. The application time is 5–20 minutes. To accomplish a muscle relaxation effect, practically any modality with a secondary analgesic effect can be used to therapeutically influence the “vicious” circle of increased muscle tone – decreased perfusion – pain.

2.2.3 Modalities with Anti-Inflammatory and Trophic Effects Reactive hyperemia during application of most types of modalities is accompanied by a change in vessel translucence, increased capillary permeability and increased venous return. Certain procedures can

potentiate these processes and are especially used in conditions in which local circulation and trophicity need to be encouraged. Vasopneumatic Therapy This modality is classified under mechanotherapy. It is an instrument with a cylinder made from a transparent material in which vacuum and overpressure alternate. Optimally set values for vacuum elicit extremity reddening and, in the overpressure phase, a slight pallor. To improve arterial blood supply, the vacuum value is more significant. On the other hand, greater overpressure supports venous return and lymphatic drainage. The cycle length and the pressure gradient can be set on the instrument (Fig. 2.2.3-1). Fig. 2.2.3-1 Vasopneumatic therapy instrument

Indications Functional and organic circulation deficits in the extremities, lymphedema, post-traumatic conditions, uninfected trophic skin deficits, complex regional pain syndrome. Special Contraindications Most often, contraindications include edemas of cardiac origin, acute thrombosis and thrombophlebitis, aneurysm, acute open wounds and infected areas in the treated extremity. Vasopneumatic Devices (Pneuven devices)

These are extremity garments with overpressure chambers for edema and lymphedema therapy. The filling of the chambers occurs gradually and forms a drainage wave. Electrotherapy It includes low frequency or mid-frequency currents with optimal frequency modulation between 50–100 Hz. The intensity is set so that a frequency around 50 Hz elicits a muscle contraction in the path of the current and a frequency around 100 Hz is only sensory. This alternating contraction and relaxation supports muscle micropumping. The effect is magnified if a quick change in frequencies is used. A typical example includes CP type of diadynamic currents (DD-CP), in which after 1 second jumping occurs between 50 Hz (contraction) and 100 Hz (relaxation). It is used locally for posttraumatic and post-operative conditions with subacute and chronic edemas. Ultrasound Therapy A dispersive effect is used in post-traumatic and post-surgical edemas, in which the exudate transforms into a gel form. Phototherapy It supports the healing of scars, pressure ulcers and skin lesions (polarized light of a biolamp, laser ray of 635 nm wavelength). It is utilized in the treatment of functional deficits in the movement system, post-traumatic conditions and also neuralgias (laser with 830 nm wavelength, which penetrates deeper – up to 1.5 cm). Lasers used in medicine use a wider spectrum of wavelengths, but it depends on the type of a laser (gas, ion, firm crystal). The mentioned wavelengths are found in the optical window (approximately 630–1060 nm) through which even “soft” lasers of class IIIB penetrate and are used as a modality. The dosage of the laser in one application is dependent on the efficiency of the laser head and the irradiated surface and it is reported in J/cm2. In acute stages, a dosage of up to 1 J/cm2 is used, for subacute 1–3 J/cm2 and for chronic 3–6 J/cm2 is used. The application time for a subacute scar with a total surface of 3

cm2 with a head of 30 MV efficiency is 2–6 minutes. Since this is a non-perceptive procedure and a patient can feel slight warmth at the end of the application when the laser head is heated, the recommended values may be perceived as too low. In a study exploring the effect of the amount of laser dosage on the fibroblasts in human skin in vitro, it was shown that a 5 J/cm2 dose (greater cell migration) had a greater biostimulation effect than a 16 J/cm2 dose (apoptosis and genetic damage occurred) (Fig. 2.2.3-2). Fig. 2.2.3-2 Laser therapy with a 830 nm wavelength for scar healing and deeper soft tissues following a surgical release and the elongation of a shortened plantar aponeurosis

Galvanotherapy The effect of galvanotherapy lasts considerably longer than in other procedures. This is apparently caused by a 30–40-minute application duration, as well as, by the process of tissue depolarization upon the completion of administration. The effect of decreasing nerve stimulation under the anode and the increased stimulation under the cathode are utilized. Protective solutions need to be used under the electrodes to neutralize caustic effects of the ions developing during water dissociation in the electrodes. This does not need to be done if galvonotherapy is to be combined with water therapy in the form of four chamber galvanization or an electro-therapeutic bath. In the past, direct current was used more extensively for application of medication through iontophoresis. Today, only hyaluronidase (from the anode) is transferred into the body in this way in some clinics.

Indications: post-traumatic conditions (already in pre-acute stage), functional deficits in blood perfusion, neuropathies, neuralgias, neuritis, paresis and spasticity. Contrast Baths Alternating or contrast bath procedures use the changing blood vessels permeability in the skin and subcutaneous tissue to alternate thermopositive (heat) and thermonegative (cold) stimuli (usually in 3:1 ratio). It is an effective and physiological “vascular exercise” that improves blood vessels’ reactivity to the periphery and optimizes peripheral resistance. Alternating procedures are applied as baths (for example, partial baths of the lower extremities) and showers, or washing (heavier patients). Indications: functional deficits in blood perfusion, slight angiopathy, hypotension Contraindications: more severe hypertension and angiopathy Cryotherapy Cryotherapy is mainly used to control edema in acute, post-injury and post-surgical conditions. However, reactive hyperemia is used after the application of cold is completed, which has a longer lasting effect than the hyperemia that occurs after the application of a thermopositive stimulus. Locally, bags with ice or cold packs are applied most often, or even instrumentally cooled applicators (i.e. cuff) are applied. Lately, an overall cooling in a polarium – frost therapy (–100 degrees Celsius up to –160 degrees Celsius for 2–3 minutes) followed by an active exercise (stationary bicycle) has been undergoing resurgence. Indications: acute conditions and injuries, muscle hypertonus (CNS or within the framework of a functional deficit of a movement system), regeneration of overstrained muscles, individually in chronic and rheumatic illnesses (based on the patient’s reactibility).

2.2.4 Electrodiagnostic Testing and Electrical Stimulation of Skeletal Muscles

Electrodiagnostic testing (ED) and electrical stimulation (ES) are modalities used for stimulation of denervated muscles so that muscle atrophy can be prevented during the period of peripheral nerve regeneration. Electrodiagnostic Testing Electrodiagnostic testing is based on the ability of the muscle fiber to adapt (accommodate) to an electrical impulse with a slow onset (oblique impulse). To elicit a contraction from an oblique impulse, a significantly greater intensity needs to be used than during stimulation by an impulse with a fast onset (square impulse). A denervated muscle loses adaptation ability and reacts in the same way to oblique and square impulses. An accommodation quotient (AQ) is used to determine the level of denervation and it is the fraction of the intensity needed to elicit a contraction for oblique or square impulses with an impulse length of 1000 ms. A healthy muscle shows an AQ of 2–6, partially denervated muscle 1–2, and completely denervated approximately 1. Strength-Duration Curve Hoorveg-Weiss strength-duration curve is used to establish optimal parameters for the impulses used in electrical stimulation. Its classic version includes measurements of intensities for elicitation of a contraction from impulses with a pulse duration of 0.01, 0.05, 0.1, 1, 5, 10, 50, 100, 500 and 1,000 ms. In practice, a short version of the strength-duration curve is sufficient, in which the intensities that elicit contraction are measured in a paralyzed and healthy muscle with oblique or square impulses of a duration of 100, 500 and 1,000 ms. The measured values are plotted in a semi-logarithmic graph, in which the x-axis is impulse duration and the y-axis is the intensity. Modern instruments determine the strength-duration curve and AQ automatically. The purpose of the strength-duration curve is to objectify muscle denervation and potential re-innervation. In practice, this is important in cases in which paralyzed muscle fibers that are found in close proximity to the healthy fibers need to be stimulated. By using

electrical stimulation without setting accurate parameters for the impulses, the activity could be overtaken by the healthy muscle fibers with a lower excitation threshold. This would limit the trophicsupporting effect of a stimulated contraction of the denervated muscle fibers. The fact that the impulses with a slow onset (oblique) are not well tolerated (especially longer impulses 500–1,000 ms) is a great disadvantage of these electrodiagnostic methods. In healthy muscle fibers covered by non-disrupted skin with intact sensitivity, the pain threshold rather than the motor threshold can often be reached. To establish the values on the right side of the strength-duration curve even the establishment of the AQ value can be biased, sometimes almost impossible. Therefore, a physical therapist must practice so that the patient is burdened as little as possible. For basic electrodiagnosis, rheobase (minimal current intensity to elicit a contraction) and chronaxie (the phase duration of a square impulse needed to elicit contraction by an intensity which is twice the rheobase) can also be used. They can be obtained from the measured strength-duration curves. During the denervation period, the rheobase and chronaxie values increase after an initial decrease (Fig. 2.2.4-1).

Fig. 2.2.4-1 Theoretical course of the strength-duration curves. Blue curve – stimulation of healthy muscle fibers by square impulses. Green curve – stimulation of healthy muscle fibers by oblique impulses. Red curve – stimulation of denervated muscle fibers by square impulses. Yellow curve – stimulation of denervated muscle fibers by oblique impulses. Gray color – field of selective electrical stimulation. Rheobase and chronaxie for healthy muscle fibers stimulated by square impulses.

In rehabilitation practice, surface EMG is used for examination of muscle function, as well as, for treatment in the form of EMGbiofeedback. Electrical Stimulation (Neuromuscular Electrical Stimulation) The optimal parameters for impulse duration and intensity for ES are obtained from the measured strength-duration curve. They are found on the graph in the field of selective electrical stimulation (see Fig. 2.2.4-1). This is an area in which the intensity needed to elicit a contraction by an oblique impulse is greater than the measured values of intensity for a denervated muscle, but smaller than for a healthy muscle. Only the paralyzed muscle fibers are stimulated while the non-affected fibers accommodate. A shorter impulse is selected on the left side of the graph field of ES. Electrical stimulation similarly to electrodiagnostic testing is performed monopolarly by a point electrode in the area of the muscle’s motor point. Fatigue of the muscle fibers needs to be avoided, the number of twitches is under constant monitoring based on individual contraction strength. After 2–3 weeks, the AQ and the strength-duration curve are measured again and the parameters of the impulses are updated. Electrical Stimulation (Electrogymnastics) If the AQ of a paretic muscle reaches Grade 2, selective (neuromuscular) electrical stimulation is no longer required. Electrogymnastics (EG) is a method used for further recruitment of muscle contractions. It is used for muscles exhibiting at least Grade 2 strength on manual muscle testing. It is performed bipolarly with two surface electrodes located at the proximal and distal ends of the muscle belly. Mainly mid-frequency bipolar currents (Kotz currents)

or surge TENS currents are used. An optimal frequency is around 50 Hz and muscle excitation occurs in waves. The duration of contraction is 3–6 seconds and the interval between the contractions is 2–3 times longer. For tonic muscles, the ratio between the contraction and relaxation is 1:1 to 2 and the contraction duration is 10–30 seconds. The overall length of application is selected so that the muscle does not fatigue; 15 minutes maximum for a phasic muscle and 30 minutes maximum for a tonic muscle are indicated (Fig. 2.2.4-2).

Fig. 2.2.4-2 Electrical stimulation of a denervated deltoid muscle (A) biceps brachii (B) in a patient after a traumatic lesion of the brachial plexus and after a reconstructive neurosurgical procedure with an expected reinnervation of stimulated muscles

2.3 GENERAL CONTRAINDICATIONS OF MODALITIES Feverish states of any etiology – except for negative thermotherapy Primary tumors and tuberculosis, overall cachexia – except for gentle forms of water treatments and analgesic TENS currents Pacemaker – except for phototherapy and water treatments, distant electrotherapy (however, L-25 current is contraindicated) and water treatment Hemorrhagic diathesis – except for negative thermotherapy Fresh skin injuries and scars – except for phototherapy Acute cardiorespiratory insufficiency Area of sympathetic plexi – except for phototherapy, superficiallyacting procedures and special gangliotrophic applications of electrotherapy Pregnancy – especially in early stages; does not apply to electrotherapy outside the abdominal and pelvic areas Thyroid gland area Note: The goal of this chapter was to provide basic orientation to modalities and provide a summary of procedures that are most frequently used in rehabilitation clinics and outpatient centers. A wide area of aquatic procedures, used daily mainly in spa settings and larger rehabilitation centers, has been omitted. Given the extent of the chapter, it was not possible to describe physiological mechanisms of the effect of the individual types of modalities or the detailed parameters of the procedures. Those persons interested in a more detailed study of modalities are being referred to the publications listed in the references.

REFERENCES Capko J. Základy fyziatrické léčby. Praha: Grada Publishing 1998. Ipser J, Přerovský K. Fysiatrie. Praha: Avicenum 1972. Poděbradský J, Vařeka I. Fyzikální terapie. Praha: Grada Publishing 1998. Robinson AJ, Snyder-Mackler L. Clinical Electrophysiology: Electrotherapy and Electrophysiologic Testing. 3rd ed. Baltimore: Lippincott Williams & Wilkins 2007.

Speed CA. Extracorporeal Shock-Wave Therapy in the Management of Chronic Soft-Tissue Conditions. J Bone Joint Surg (Br) 2004; 86-B: 165–171. Urban J. Úskalí elektrodiagnostiky ve fyzioterapii. In: Sborník abstraktů I. absolventské konference Katedry fyzioterapie Fakulty tělesné kultury UP. Olomouc: Vydavatelství UP 2006; 46–48. Vyskotová J. Přístrojová technika v rehabilitaci pro fyzioterapeuty. Ostrava: Vydavatelství Ostravské univerzity 2006.

3 BALNEOLOGY Jan Kálal, Ivan Vařeka Balneology (the study of bath and bathing procedures) is a medical discipline that uses natural medicinal sources and special therapeutic methods. The effects of these approaches are potentiated by climate conditions and solar radiation. Its benefits can be seen in primary and secondary prevention as well as in the treatment of acute and chronic illnesses and congenital defects. Next to treatment, balneology also has an important function in social and educational spheres. Balneology has a long tradition in Europe, including the Czech Republic. First indications of certain treatment procedures extend to B. C. Balneology achieved the greatest high point with the development of natural sciences in the 18th and 19th centuries. The natural medicinal sources include water, peloids and gases. For these substances to be marked as natural and medicinal, they must fulfill certain criteria. They emerged only by the activity of natural forces and their characteristics are constant. Their effectiveness can be demonstrated by scientific methods (for example, by a double blinded study).

3.1 CLASSIFICATION OF MEDICINAL SOURCES 3.1.1 Waters Classification Based on Physical Characteristics Waters with natural temperature greater than 25 °C are called thermal waters, lukewarm (20–25 °C), warm (25–35 °C) and hot (above 42 °C). Radon Radioactive Waters have an activity above 1.5 kBq/l caused by radon Rn-222. Based on osmotic pressure, waters are classified as hypotonic (up to 280 mOsm), isotonic (280–300 mOsm) and hypertonic (above 300 mOsm). Classification by Mineral Content Natural mineral waters are traditionally considered medicinal waters containing at least 1 g of dissolved solid hard substances in 1 liter of water (Hupka, 1988). More recently, waters with concentration below 1 g/l are considered very weak and weak mineralized mineral waters (Jandova, 2008). Older Classification of Waters Older classification of waters into categories and groups is presented in table 3.1.1.-1. When classifying water, the category (anion) is listed first followed by a group (cation), for example, hydrocarbonated calciummagnesium water.

Tab. 3.1.1-1 Older classification of waters in balneology

Newer Classification of Waters Based on the Natural Medicinal

Sources Ordinance Low-mineralized waters, called “Teplice” Natural, low-mineralized waters, called “Teplice”, are used in classic thermotherapy and hydrotherapy especially with movement system diseases. Carbonic Acid Waters Contain dissolved CO2 more than 1 g/l. With external balneation in a hypothermal bath, they cause changes in blood circulation and reflexively in muscles and internal organs, indicating their use quite often. Gastrointestinal function is influenced by internal balneation. Earthy Waters Contain primarily HCO3– , Ca2+ and Mg2+. With internal balneation, they act spasmolytically, increase dieresis and alter urine pH. They are used for treatment of the respiratory, gastrointestinal and excretory systems. Alkaline Waters Contain primarily Na+, K+ and HCO3– . With internal balneation, they change the pH of the stomach content and influence bile excretion, decrease glycemia and glycosuria and, with inhalation, decrease mucus viscosity. The above mentioned effects imply their indications. Salt waters Contain primarily Na+ and Cl–. They are used for gargling, rinsing and inhalation because they make it easier to expel mucus. In a trace amount, they may be also used for internal balneation with the exception of patients with hypertension and cardiac weakness. Magnesium Waters These waters are used during pregnancy, exercise recovery and cardiac rehabilitation. Given their ability to bond with sulfate, magnesium compounds possess significant laxative effects. Chloride-Calcium Waters These waters possess a non-specific anti-inflammatory effect and with

internal balneation, they can be a source of calcium for osteoporosis. Iodine Waters Iodine waters contain iodine concentration of 5 mg/l. They are used for external and internal balneation and have a number of positive effects. They act as an anti-inflammatory and an anti-sclerotic and can positively influence calcium metabolism and decrease mucus viscosity in the respiratory tracts. Iodine water balneation is used to treat the movement system (hyperthermic baths), gynecological conditions, atherosclerosis, hypertension, etc. When inhaled, they are used to treat respiratory tract illnesses. Sulfur Waters These waters form two subgroups. Sulfate waters have a laxative effect. External balneation is used in dermatological disorders, osteoarthritis and other illnesses of the musculoskeletal and nervous systems. Sulfur waters with hydrogen sulfide have a more significant effect because they are easier to reabsorb. Iron Waters These contain Fe2+, which is directly absorbed during internal balneation and used for hemoglobin production. Radon Waters With external balneation, they are used mainly to treat rheumatic diseases and other pathological states of the musculoskeletal system. They are also used to treat vascular diseases and peripheral nerve deficits.

3.1.2 Peloids Peloids are substances formed in nature by geological processes. Based on their chemical composition, they are classified as humolites and muds. Humolites Humolites are mainly composed of organic substances and contain more than 30% of moss and humolignin substances. They are classified as peat and moor.

Moss (sphagnosum) The base is formed by peat moss Sphagnum. It forms on the surface of ground water and is saturated by water from precipitation. In the Czech Republic, rich sources of peat moss can be found in the areas of Trebon, Sumava and Slavkovsky forest. Moor (uliginosum) It forms from reed, bulrush, sedge and other plants growing in a certain biotope. It is watered primarily by underground water. Muds (limus) Limus is a non-organic sediment from rivers, lakes and marine bays. It consists of finely degraded rocks and organic particles and is formed by dead algae and plankton. Muds are classified as simple (only siliceous particles) and composite with other chemical particles, for example, sulfur.

3.1.3 Gases Gas directly spewing from the subsoil (spring gas) or separated from carbonated mineral water is considered a natural healing source and contains at least 90% of CO2. It is used for “dry carbonated baths” with roughly the same effects as acid waters (see above). With subdermal insufflation, CO2 is applied by several 25 ml injections into the dermatomes, surrounding areas of painful joints, painful scars, above painful muscle points, etc. With a pneumothorax, 5 ml of gas is applied to a maximum of 20 acupuncture points. Insufflation of CO2 causes local hyperemia and other localized and distant biochemical and reflexive changes. Utilization of spring gas is broad and encompasses deficits spanning from blood perfusion and degenerative diseases of the musculoskeletal system through gynecological conditions.

3.1.4 Climate To a certain extent, climate is part of each spa stay. In some spas, the

climate is so extraordinarily favorable that it is considered a natural healing source; however, it must meet strict conditions for balancing preservation and irritation factors. These are given by a combination of pressure, temperature, humidity, air flow, sun irradiation, increased concentration of air anions, radioactivity, air cleanliness and other factors. In an optimal scenario, climatotherapy is combined with movement therapy. Typical indication includes respiratory tract illnesses.

3.2 USE OF NATURAL HEALING SOURCES IN BALNEOLOGY 3.2.1 Use of Water Out of all natural resources, water has the widest spectrum of use. It is used the most during hydrotherapy. The physical properties of water, including hydrostatic pressure and temperature, are factors that can affect the body. Simple water is used in this form of treatment. Based on temperature, water used for baths (spas) is divided into hypothermal, isothermal (it is identical to skin temperature and ranges between 34–35 °C) and hyperthermal. Each of them has specific effects. The founders of this form of therapy date back to the 19th century and include amateur healers Vincenz Priessnitz (1799–1851), Sebastian Kneipp (1821–1897) and Wilhelm Winternitz (1934–1912). In the Czech Republic, a number of balneologists and physiatrists have studied the effect of water (Charles University professors Eduard Cmunt and Karel Prerovsky). Today, baths are used primarily in kinesiotherapy. The most suitable are isothermal or slightly hyperthermal spas. Movements in water are easier than on land when movement system deficits are present. Underwater massages are advantageous during baths. The therapist applies water under pressure at various muscle groups of the trunk and the extremities. Alternating warm and cold water during foot baths as well as an alternating stream of water under pressure (called a Scottish shower) are also beneficial methods. A whirlpool bath is the streaming of water in a tub propelled by a pump. A sparkling bubble bath uses water saturated with carbon dioxide. It is a hypothermal bath with specific effects, mainly vasodilation. Considering that CO2 is artificially added to the water, it is an additive bath. Similarly, other elements can be added, for example,

sulfur in a preparation form Solfatan or iodine. Also popular are additive baths, in which various herbal silicas are dissolved. Some of them also have a pharmacological effect and release their characteristic scent. Sometimes aromatherapy can be used; however, its generally accepted benefits still need to be exactly established. Mineral waters are also used for so called irrigations, or lavage. These are performed in the oral cavity or in the large colon (so called enterocleaner). Mineral waters have a special place in inhalation treatment. Waters are mixed with air and, with the help of physical forces, pressure or ultrasound, and they are processed into particles of approximately 5 μ in size. These enter respiratory bronchioles and alveoli. Based on chemical composition, an inhaled aerodisperzoid has expectorate, mucolytic, adstringent, sposmolytic, vasodilation, and antiseptic effects. For this purpose, for example, Vincentka and Bilinska carbonic acid waters are available from resources in the Czech Republic. Water significantly contributes to the drinking regime. Only mineral and thermal waters are appropriate for this regime. Some mineral springs have shown the ability to dissolve kidney stones, others exhibit laxative effects or demonstrably adjust gastrointestinal tract function. An increase in diuresis has been shown. If mineral water is used to adjust the drinking regime or to attempt a lifestyle change, it acts as table water.

3.2.2 Use of Peloids Peloids possess an extraordinary physical characteristic – they maintain heat. When they are heated to a certain temperature, they will very slowly release heat. That is why they are beneficial for procedures requiring heat application. During peloid application on the skin, the body’s heat permeates into the subdermal layers. Here, it mainly causes vasodilation with all subsequent effects. During an analysis of a peloid’s composition, the humic acids were found to

possess a stringent and sometimes bactericidal effects. Peloids diluted with water and heated to a desired temperature (no more than 50˚C) are applied locally in the form of wraps or vaginal tampons. Overall, they are applied as a bath. A mixture of a peloid and paraffin is known as parafango and it is especially beneficial. Following clinical testing, peloid application was recommended specifically for inflammatory, degenerative and traumatic deficits of the movement system. It is also suitable for certain nervous, metabolic and respiratory illnesses. Heat application needs to be considered for any conditions with circulatory deficits. Sometimes, heat induced vasodilation and the hydrostatic pressure of a bath may be contraindicated.

3.2.3 Use of Gas The use of gas (gasotherapy) in balneology has only a limited indications. The so called gas bath can be used and at first, it was administered in bath tubs because the CO2 is heavier than air. This application was relinquished because of possible complications (intoxication). Today, gas envelopes are used, in which the body is in an air-tight plastic wrap filled with gas. Gas is absorbed quickly and releases vasoactive molecules in the body, encouraging vasodilation. Inhalation of CO2 is another form of emanated gas usage. These are called gas injections (pneumopuncture). In the Czech Republic, the effectiveness of this method was scientifically validated by photographing the vasodilation on the fundus oculi. This method is beneficial during the initial stages of an ischemic disease in the lower extremity arteries, with post-phlebitis syndrome, vasoneuroses, migraines and degenerative joint changes. In addition, technical gas can be used for medical purposes. An instrument is used for such application. An injection to the head and the neck can be performed only by a physician.

3.3 SPAS IN THE CZECH REPUBLIC AND INDICATIONS FOR A SPA TREATMENT A spa area is a territory where natural healing resources are found and it is declared as such by the government based on the recommendation from the Department of Public Health. The locations are protected according to valid legal norms (the Law of Natural Environment, Waters, etc.). Since the medieval times, a number of places with natural healing sources have been known in the Czech Republic (Karlovy Vary (Carlsbad), Marianske Lazne, Janske Lazne, Frantiskovy Lazne, Jachymov, etc.). Currently, there are 35 spa locations in the Czech Republic. Spa treatment is recommended by a general physician, often based on the recommendation from a specialist. Currently, the Indication Directory for Spa Care for Adults, Children and Adolescents is valid and contained in the Ordinance of the Department of Public Health number 58/1997 Sb. Here, besides indications and contraindications, all spa areas are listed as well as the diseases that are treated in the spas. The Ordinance classifies the diseases into eleven groups. A separate list with the same information is designed for the pediatric population. Basic groups of diseases that can be favorably influenced by balneological approaches are listed in Table 3.3.-1. The diagnosis for spa treatment is denoted in words and symbols according to the International Classification of Diseases. The therapy is divided into two groups: comprehensive, in which the entire treatment is covered by insurance and contributory, in which the patient is responsible for room and board expenses. For comprehensive treatment, the patient is on sick-leave from work and must abide by all provisions that are linked to this status.

Tab. 3.3-1 Indication groups for balneology

The recommendation for spa treatment is accompanied by a discharge report from the hospital, including surgical findings if applicable. Important anamnestic data (detailed especially for pediatric patients) must be included, as well as, the description of current illness, objective findings, functional status, laboratory test results and other necessary examinations. The Ordinance exactly establishes the type of examinations that the recommendation must contain. A complete listing of all the patient’s diagnoses is required. The recommendation is accompanied by special requirements for spa treatment and a justification for the stay by the patient’s caretaker. Each recommendation for spa treatment must be approved by the

overseeing physician from the corresponding insurance company. If the patient pays for all of their expenses (self-pay), only the simple form recommendation from the physician is needed. A self-paying patient can request any spa location for admission. In such a scenario, the treatment is indicated by a balneologist. Balneology, based on centuries of research and supported by scientific findings of treatment effectiveness, is an integral part of comprehensive therapy and rehabilitation.

REFERENCES Cmunt E. Almanach lázní České republiky. Poděbrady: Svaz léčebných lázní ČR 1993. Capko J. Základy fyziatrické léčby. Praha: Grada Publishing 1998. České lázně a lázeňství: CD přiložené k časopisu Tempus Medicorum 2008; XII. Hupka J, Kolesár J, Žaloudek K. Fyzikálna terapia. Martin: Osveta 1993. Hupka J, Kolesár J, Žaloudek K. Fyzikální terapie. Praha: Avicenum 1988. Jandová D. Balneologie. Praha: Grada Publishing 2008. Kočárek E. Vědy o zemi a medicína: vybrané kapitoly z lékařské geo​logie, geografické medicíny a balneografie. Praha: Karolinum 2004. Kolesár J, Burianová J, Hupka J, Pavlík I. Fyziatria. Martin: Osveta 1975.

4 OCCUPATIONAL THERAPY Pavel Kolář Occupational therapy is an independent therapeutic discipline with many specific elements. Its nature and principles are similar to the ones of physical therapy. The physical therapist and occupational therapist should be members of a multidisciplinary rehabilitation team and should cooperate closely. Occupational therapy uses specific diagnostics and therapeutic methods, approaches and activities to treat individuals of any age who are permanently or temporarily physically, psychologically, sensory or mentally impaired. In English literature, the term occupational therapy is used, while in the Czech Republic the term is “ergo​therapy”. “Occupation” means an area of activities in which the person is involved. They can be classified as activities of daily living (ADLs), work activities or leisure activities. Each occupation consists of many activities that possess personal and socio-cultural significance and are culturally based and support social participation. The theory of occupational therapy is based on the knowledge of activities, or work requirements, and their therapeutic use as a means as well as the goal of therapy. The goal of occupational therapy is to achieve and maintain an individual’s maximum self-sufficiency and independence with ADLs and work and leisure activities. The patient’s ability to perform activities that they consider important and necessary for their life and contribute toward maintaining a corresponding quality of life and a full inclusion into society as the primary goals of occupational therapy. Based on their abilities, the patients actively participate in the planning of their therapy. The patient’s personal, social, cultural and economic needs are taken into consideration as well as the abilities or needs of the environment in which the patient lives. It is appropriate to include the patient’s family members into occupational therapy.

The development of sensorimotor functions is one of the important goals of occupational therapy. A specific selection of occupational therapy methods and resources is focused on the development of stereognostic and somatognostic functions, selective movements, fine motor skills, etc. The selection of these approaches is based on kinesiologic assessment.

4.1 AREAS OF FUNCTION IN OCCUPATIONAL THERAPY Occupational therapy (individual and group) has a wide range of application not only in various healthcare fields, but more often now in social services. It can be encountered in the hospitals, adult daycare centers, non-profit organizations and special schools. In pediatrics, occupational therapy focuses on the needs of children from birth to 18 years of age. Family involvement in therapy is emphasized. Occupational therapy is administered through play and pursues a balanced child development in all aspects: gross and fine motor skills, graphomotor skills, sensory and cognitive functions, selective mobility and stereognostic functions. Based on the level of the child’s ontogenetic development, ADL training and the use of adaptive tool training are also administered. In geriatrics, occupational therapy aims to maintain the highest level of independence, select adaptive tools, maintain possible physical, cognitive and psychological functions and social roles through goal-oriented activities and to provide education in falls and injury prevention. For patients with cognitive deficits, the emphasis is placed on the achievement of the highest possible level of independence. Training of cognitive, communication and social functions is performed with the goal of the patient’s inclusion into a normal social and work environment. Creative techniques are used to accomplish these goals. For patients with neurological involvement, occupational therapy focuses on ADL training and recommendation of appropriate adaptive tools, training of gross and fine motor skills and sensory functions. In cooperation with other specialists, it focuses on the training of cognitive, communication and social skills. Occupational therapy is also useful during the patient’s home visits so that the occupational therapist can educate the patient on home modifications and the selection of adaptive equipment for the home.

It also occurs during the patient’s rehabilitation prior to returning to work with projects assisting employment and ergonomic setting.

4.2 SPECIALIZATIONS Individual fields often require certain specialization, which the occupational therapist mostly gains by attending specialization courses as part of their continuing education for rest of their career. In neurology, the neurodevelopmental treatment concept is very important and, in occupational therapy, it is used mainly to treat patients with CVA or children with cerebral palsy. However, it can be used for patients with other diagnoses. The concept is based on uprighting and equilibrium reflexes. It is administered individually based on a detailed assessment of a patient’s abilities. With the help of certain techniques, it is possible to achieve the following goals: muscle tone regulation, development of physiological movement patterns, body posture influence, facilitation of certain body parts (with the purpose of awareness of the individual body parts and support of motor skills), influence on stability and mobility and promoting independence. The concept is scheduled over 24 hours and the schedule should integrate all people who come into contact with the patient. The concept of basal stimulation is used for patients in comatose states or for patients who have been bed ridden for a long time, restless, disoriented, in an intensive care unit, children with disabilities and geriatric patients. The goal of basal stimulation is to assist and facilitate awareness so that the patients can develop their own identity, start communicating with their surroundings, improve their space and time orientation and their overall body function. In pediatric patients, the concept of sensory integration based on Ayres is used in specific cases. Its purpose is to increase the frequency and duration of an adaptive response, develop more complex adaptative responses, increase self-confidence and a feeling of security, improve gross and fine motor skills as well as ADLs and academic skills. Other educational courses include, for example, splinting, assistive technology, art therapy or courses in orofacial stimulation that focus on difficulties with food intake (problems with swallowing, sucking, biting, chewing, and

increased salivation, etc.).

4.3 OCCUPATIONAL THERAPY PROCESS 1. Assessment – the occupational therapy process is based on the initial and on-going assessments of performance during therapy. In the assessment, it is important for the occupational therapist to identify, which roles the individuals take on in their lives, which activities in a specific environment they can accomplish and which ones they struggle with. During the assessment, standardized/non-standardized tests, interviews, observations and an interview with family members are used. 2. Planning – based on the assessment, the patient’s strengths and weaknesses are identified, short- and long-term plan of care as well as specific treatment goals are established. This process should take into consideration the patient’s priorities and, in many cases, also the priorities of the patient’s family members. 3. Therapy – during therapeutic sessions, the established plan is followed. The therapy program is developed so that the patient can continuously progress toward their therapeutic goals (by activity progression, compensation, etc.) and be challenged by them. 4. Cooperation – in occupational therapy, the holistic approach is also used, meaning that the therapist perceives the patient as a whole, not just by their diagnosis. This approach allows the perception of the patient’s problems and needs at the physical, psychological, social and spiritual levels, which leads to the understanding of the need for cooperation between the individual fields and the family members within a multidisciplinary team. 5. Documentation – the documentation of assessment conclusions and regular intake of therapy performance serve as sources of good feedback for the therapist. The effectiveness of the selected therapeutic approaches and the achievement of therapeutic goals can be seen in documentation.

4.4 AREAS OF OCCUPATIONAL THERAPY INTERVENTIONS Motor Skills To assess motor function, the following needs to be assessed: range of motion (especially the upper extremities), muscle tone (spasticity, hypotonia, twitching), posture (body symmetry), movement patterns with positional changes (rotation, sit-stand, stand-sit), presence of primitive reflexes and automatic reactions (upright, defensive, equilibrium). The goal of occupational therapy is to achieve the most physiological movement patterns during a specific activity. This is the reason why the following assessments target functional skills linked to specific activities, including the following: Functional skills in the gross motor domain: mobility, locomotion, turning, crawling, sitting, standing, quadruped, stair negotiation, etc. Fine motor skills: individual types of grasp, grasping phases, isolated hand movements, crossing midline, upper extremity synergies, etc. Graphomotor skills: the ability to relax the wrist, correct pencil grip, eye-hand coordination, entire body position, etc. Sensory Skills For an occupational therapist, the patient’s sensory functions are very important because they rely on them during and treatment of motor skills and self-sufficiency training. Mainly, it is the ability to perceive exteroceptive and proprioceptive stimuli as well as stereognosis, which is the ability to recognize surfaces, sizes and shapes of objects without the use of vision. The information from individual senses (vision, hearing, taste, smell, touch as well as vestibular system stimuli) and their subsequent correct processing in the brain cortical centers have an effect on the adequate adaptative response.

Cognitive, Communicative and Subsequent Social Skills Cognitive and communicative skills are practiced in collaboration with a clinical psychologist and a speech therapist. The occupational therapist focuses the therapy on an improvement in memory, attention, orientation to place, time and space, sequence and development of body schema, which are all very important for selfperception, the ability to continue ADL training and to support sensory integration. Social skills include: social interaction, behavior, motivation, cooperation, and the ability to communicate. These functions are closely related to motor and cognitive skills and their therapy occurs simultaneously. Activities of Daily Living Basic activities of daily living (ADLs) include the following: independent eating, drinking, self-dressing, complete basic hygiene, bathing, toileting, transfers, walking and stair negotiation. Instrumental ADLs include, for example, the patient’s ability to go shopping, mail a letter, make a phone call, etc. These activities need to be practiced as soon as possible because they form the building blocks for developing independence that promotes self-confidence, motivation and significantly influences the quality of life. In children, it is important to focus on the ability to play and the ways that allow the child to play. Assistive Devices Occupational therapy specifically supports the patient’s ability to perform certain activities independently. If the patient does not have this ability, it is important to equip the patient with assistive devices. At first, the device needs to be discussed with the patient. Then, the appropriate vendors are contacted and the aids specific to each patient are provided. Pre-Return to Work Rehabilitation In pre-return to work rehabilitation, the occupational therapist sets up a plan for the patient’s return-to- work readiness, identifies their work

potential and their abilities prior to returning to their line of work or if choosing other forms of education.

REFERENCES Ayres AJ, Robbins J. Sensory Integration and the Child: Understanding Hidden Sensory Challenges. 25th ed. Los Angeles: Western Psychological Services 2005. Ayres AJ, Stallings-Sahler S. Aspects of the Somatomotor Adaptive Response and Praxis. Santa Rosa: Crestport Press 2003. Bobath B, Bobath K. Motor Development in the Different Types of Cerebral Palsy. London: Heinemann 1975. Bobath B. Abnormal Postural Reflex Activity Caused by Brain Lesions. 3rd ed. London: Heinemann 1985. Bobath B. Adult Hemiplegia: Evaluation and Treatment. 3rd ed. London: Heinemann 1990. Case-Smith J, et al. Occupational Therapy for Children. 5th ed. St. Louis: Mosby 2005. Česká asociace ergoterapeutů. Informace o ČAE [online] 2004: http://www.ergoterapie.org/modules.php?name=informace. Česká asociace ergoterapeutů. Informace o ČAE 2000: http://www.ergoterapie.org/modules.php?name=informace, accessed 30. 7. 2007. Česká asociace ergoterapeutů. Koncepce oboru ergoterapie 2008: 16. European Network of Occupational Therapy in Higher Education. Tuning and Quality: Terminology [online]. Publishing date: Thursday, 12 of March 2009. Friedlová K. Bazální stimulace v základní ošetřovatelské péči. Praha: Grada Publishing 2007. Hagedorn R. Occupational Therapy. Perspectives and Processes. Edinburgh: Churchill Livingstone 1995. Kielhofner G. Model of Human Occupation. Philadelphia: Lippincott Williams & Wilkins 2007.

SPECIAL SECTION

1 TREATMENT REHABILITATION IN NEUROLOGY Pavel Kolář, Ondřej Horáček In neurological illnesses, various components of the central or peripheral nervous system may become injured. The resulting clinical picture depends on the cause (traumatic injury, brain hemorrhaging, ische​mia of brain structures, tumor, CNS infection, etc.), location and extent of the neurological involvement. These are the main factors that determine the prognosis of the illness. Other factors also contribute, such as age, overall health condition, fitness level, secondary illnesses and, last but not least, the patient’s psychological state. Based on prognosis, diseases can be classified into three groups: 1. Diseases with good prognosis, in which a neurological deficit has been completely corrected. This group includes, for example, a mild degree of peripheral pareses (neuropraxia, often also axonotmesis), vertebrogenic problems, etc. In such cases, the main goal of treatment rehabilitation is to prevent secondary changes while we try to support and accelerate full recovery of the affected function. 2. Diseases that have various levels of long-term or permanent consequences but do not progress any further. This is the case, for example, in cerebrovascular accident, cerebral palsy, etc. In these scenarios, treatment rehabilitation aims at limiting the functional deficit and its effects on the patient’s personality and their social network. For such patients, treatment aspects of social, educational and vocational rehabilitation are later utilized. 3. Diseases with permanent progression of neurological deficits, for example, neurodegenerative diseases, certain forms of multiple sclerosis, or certain muscle diseases. In these types of diseases, the goal is to slow down their progression, control pain and maintain the patient’s independence by utilizing all treatment means.

Neurological diseases require complex treatment. It often takes months or even years (for example, in children with CP, in patients with multiple sclerosis, muscle dystrophies, CVA, etc.). As a result of severe neurological involvement, patients become less self-sufficient and they become dependent on others, either partially or completely. In many cases, they need to be permanently cared for. A significant neurological involvement can always affect many areas and can negatively influence family relationships and their partner’s life. Usually, the patient’s overall function and their ability to work significantly decrease. Treatment does not only focus on the functional deficit, but must be linked to the patient’s life situation and their social network. In severe neurological diseases, rehabilitation needs to be initiated as soon as possible, therefore, in the acute phase of the disease when the patient is hospitalized in the neurology department and later in inpatient rehabilitation. When the condition improves, rehabilitation continues on an out-patient basis until the condition is corrected or at least stabilized. Often, in a number of neurologically involved patients, this is a long-term process requiring a multidisciplinary approach and a coordinated cooperation of all participating specialists, which often include the following: physical therapist, speech pathologist, psychologist, occupational therapist, prosthetist, social worker, neurologist, orthopedist, anesthesiologist, and general practitioner.

GENERAL SECTION Rehabilitation of neurological diseases focuses on the symptoms of the disease. It is not based on diagnoses, but rather on the functional manifestations of the disease – mainly changes in muscle tone, balance deficits, muscle weakness, coordination deficits, deficits in stereognosis, involuntary movement, etc. Rehabilitation approaches must be initiated as soon as possible, thus, in the acute stage of the disease. In the beginning phase, a timely and smooth onset of therapy is very important for the patient. Rehabilitation should focus on two basic areas: Prophylaxis of secondary complications (decubital ulcers, contractures, heterotopic ossification, etc.) that can endanger the patient during their primary disease. This area is addressed in the General Section of this textbook. Influencing the functional, primarily motor, deficit, but also the cognitive deficit as well as a deficit in symbolic functions. Physical therapy concepts, occupational therapy, orthotics, speech therapy and neuropsychology are utilized to accomplish this.

1.1 NEUROPHYSIOLOGICAL FOUNDATION OF PHYSICAL THERAPY APPROACHES Pavel Kolář In physical therapy, treatment approaches for patients with neurological diseases are based on neurophysiological findings. Plasticity is an important characteristic of the nervous system utilized during physical therapy. Even in scenarios with a permanent defect of the nervous system, certain functional reserves and compensation abilities are available and need to be utilized during therapy. Lost functions are attempted to be replaced by assistive functions and preserved functions developed to their maximum potential in order to achieve the patient’s highest performance based on their abilities.

NEUROPLASTICITY Vladimír Komárek Plasticity is a term that is known from physics and also transposed from social sciences. The adjective “plastic” describes certain ductility, or changeability (in space and time). The opposite of plasticity is rigidity – stiffness or inflexibility. Plasticity possesses within itself potential dynamic changes and, in this sense, the entire nervous system can be considered plastic. Therefore, neuroplasticity can be defined as the ability of the nervous system to change depending on the following: 1. Internal or external conditions that are physiological (for example, loading or, in contrast, inactivity) as well as pathological (for example, as a result of an insult), 2. Experiences and repeated stimuli (for example, learning or habituation) Plasticity can lead to favorable or unfavorable changes during the individual’s development (evolutionary plasticity), during long-term or repeated stress (adaptive plasticity) or functional, or even

morphological, restoration of the injured neuronal circuits (repair plasticity). Evolutionary Plasticity Immature nervous tissue is highly plastic and dynamic changes take place in the nervous system from the first day of the individual’s development after conception (approximately from the 24th day of gestation when the neural tube closes). Genetically programmed and induced changes are at first structural and later also functional. They occur not only at the level of individual cells – neurons or synapses (local rebuilding of dendritic processes and synaptic receptors), but also at the higher “systemic” levels (organization of individual areas of the cerebral cortex and their reciprocal interconnections). After birth, the evolutionary, adaptive and repair plasticity gradually decrease. The greatest plasticity occurs in the first months of life in infants and toddlers, rapidly decreases after the 3rd and the 6th year and after the 12th year it reaches an adult level. It is very minimal in seniors. This is mainly given by the excess of neurons and support cells (glial cells) in the first months and years of life. It is reported that our life starts with a double amount of nerve cells (approximately 20 billion) than what is available in adulthood. Based on genetic programs and interaction with the environment, the brain “self-organizes” itself in a similar way to artificial computer networks. As soon as a certain brain area (for example, the cortex for fine motor skills of the hand or the speech centers) during development optimally “fine tunes”, the excessive neurons cease through a natural process – called programmed cell death or apoptosis (pruning). Well functioning and timely completed cell death is the prerequisite for the development of a normal nervous system and, thus, the individual. As the expression says, it can be stated “healthy death in healthy body”. Insufficient or absent apoptosis can lead to a persistence of abundant (excessive) neurons and improperly functioning interconnections. The result of such a state is a less optimal system, which is seen in patients with autism. In these patients, the excess amount of small and imperfectly functioning interlinks is a possible cause of their inability

to distinguish important information from the unimpor​tant one; therefore, there is often an increased risk of epileptic seizures. On the other hand, a genetic mistake that causes the apoptotic program to not stop can lead to the gradual cessation of all needed neurons. This is the case in spinal muscular atrophy (SMA) in which, as a result of a defect in the SMN gene (survival motor neuron), apoptosis is not terminated at the time of completion of the optimal connection between the spinal motor neurons and muscle cells. The clinical correlation is an irreversibly progressive muscle weakness caused by a loss of motor neurons in the anterior spinal horns. Within the context of evolutionary plasticity, a process that is the opposite of apoptotic loss needs to be mentioned. It is called sprouting – a dendrite growth of mainly dendritic processes (Fig. 1.11). Sprouting is a part of evolutionary plasticity, learning processes (Fig. 1.1-2) and also repair plasticity when the formation of new dendrites and synapses can significantly contribute to regeneration of a damaged area. Both opposing processes (sprouting and apoptosis) have a key significance in dynamic changes (tuning or retuning) of the nervous system and, thus, with its neuroplasticity. The above mentioned processes can be influenced physiologically by practice or therapeutically by neurorehabilitation (for example, using the methods of Vojta and Bobath). Fig. 1.1-1 Sprouting of synaptic connections on the dendrite during the course of development linked to learning

Fig. 1.1-2 Plastic remodeling – widening of cortical fields (dark areas) prior to initiation (A) and upon completion (B) of experiment in makaka

Next to neurobiological mechanisms acting on the reorganization of brain structures, neuromodulators and neurotrophic factors have a great influence on the course of brain plasticity. Repair Plasticity The first hypothesis regarding functional CNS reorganization (de facto neuroplasticity) was postulated by a Berlin physiologist

Hermann Munk in 1877. In subsequent years, his hypothesis was tested and confirmed several times, but also repeatedly disputed. However, based on the above mentioned definitions, the ability of the nervous tissue to repair its function after a disruption in the structures of the nervous system due to an insult is also a manifestation of neuroplasticity. Some experimental studies in animals confirmed that the processes of neural plasticity can be influenced by stimuli from the environment. Based on their influence, quite surprising results were shown in reorganization of the motor, somatosensory, visual and auditory cortices. Therapeutic approaches are based on the fact that targeted stimuli (proprioceptive, exteroceptive, acoustic, visual, motivational) trigger changes in the neural structure and, thus, affect or renew functions of injured brain areas. The structural foundation of the repair processes are, once again, changes in the effectiveness or the number of synapses, migration and formation of new dendrites and axons accompanied by the reconstruction of local neuronal circuits, or relations between the individual functional brain circuits. Current research trends are also looking for ways to strengthen the regenerative abilities of the nervous system. One of the options, for example, is strengthening the reactivation of the natural mechanisms through transcranial magnetic stimulation or administering medications activating the internal neuroplastic processes (i.e. nerve growth factors, etc.). Hypotheses exist that the mentioned methods could wake up a “dormant” process of regeneration and lead to the renewal of disrupted neuronal circuits. Modern rehabilitation concepts are based on these findings. Neuroplasticity and Sensorimotor Programs Mechanisms similar to evolutionary neuroplasticity are utilized in the processes of sensorimotor learning and repair. Based on Vele, the sensorimotor cortex can be perceived as a complex television studio that has a wide archive of already recorded programs (this corresponds to the varied size of the index of motor and behavioral

programs in the CNS). “Vele’s” television studio broadcasts relatively stereotypical programs, but it is able (based on the internal or external influences) to change this program so that it meets immediate needs. The potential of options for an individual’s motor system is immense; however, only a fraction tends to be used. This seemingly disadvantageous fact is a big advantage in the case of a CNS injury because a modest everyday life goal can be accomplished by means that would appear quite insufficient under normal circumstances. The ability to repair movement functions is significant if the elementary spinal functions that actualize motor behavior are at least partially preserved. Vojta’s concept is based on reflexive activation of primitive movement patterns that can be used for initiation of the voluntary motor superstructure and, more or less, renew seemingly lost functions.

SENSORY FUNCTIONS IN NEUROREHABILITATION Pavel Kolář When assessing motor deficits and selecting an appropriate form of reeducation, the sensory aspects (proprioceptive and tactile) and their processing within the context of CNS integration processes need to be assessed. This means that the focus is paid not only to the assessment of the formal sensory deficits, but also to assessment of the CNS functions that lead to an incorrect or insufficient interpretation of proprioceptive and tactile perceptions. Each specific movement needs an interaction with its surroundings. Before the movement is completed, the conditions of the surroundings need to be identified and the motor skills planned based on the characteristics of the environment. This function can be greatly affected when a so called motor neglect syndrome develops. For example, a patient with a motor neglect syndrome does not use the affected extremities even though their muscle strength is not affected. They consider the extremity foreign and dead, or not “belonging to their body”. Stereognosis and somatognosis are two functions that ensure processing of the proprioceptive and tactile stimuli with the purpose

of perceiving one’s own body and the surroundings. Stereognosis can be characterized as the ability of space perception through contact with an external environment (without visual help) in relation to one’s body schema. Tactile recognition of the surroundings through proprioception and tactile sense are the basic prerequisites for purposeful movement. Without this function, purposeful movement does not exist and selective movements are not available. This can be verified during the process of motor skill development. This function (similarly to motor function) matures gradually in an expected chronological order and is linked to a child’s motor ability. For example, the palmar aspect of the hand displays the grasping reflex until three months of age, but as soon as stereognosis of the hand emerges, an active and purposeful grasp can be observed (as well as isolated and selective movements). When upright posture of the spine is completed, the Galant reflex recedes and when the grasp reflex of the foot disappears and stereognostic function of the foot appears, the child achieves verticalization. Thus, stereognostic function is closely related to the ability to perform isolated (selective) movements. A patient with a brain injury is limited in their ability to obtain enough relevant information from their environment so that they could process a plan and execute movement activities. The greater the extent of the injury the lower the patient’s ability to perform selective movements. Currently, research in sensation and perception has reached great advances not only in the area of classic therapy of sensory deficits, but their problem areas have also been integrated into the areas of motor, coordination and independence training. The reception of sensory information is not only important for patients with a sensory deficit, but it is also important for the remediation of motor deficits. For the listed reasons, the stimulation of sensory function is one of the main goals of therapeutic strategies. In rehabilitation, stereognostic functions together with two point discrimination, graphesthesia, proprioception, kinesthesia and other sensory functions are often viewed as a so called “body image”.

Quality of sensory functions ensures a perfect image of one’s own body. Physiologically, even with the eyes closed, we have a constant image about the position of individual body segments and we know exactly whether, for example, the upper extremities are held in extension or flexion or whether we are standing or sitting, whether our back is leaning against support or not, whether we are dressed and wearing our shoes or not, etc. The quality of this perception, to a certain extent, affects the quality of our motor skills and, therefore, it is important in rehabilitation. The testing of stereognosis can, to a certain extent, help establish prognosis. For example, an object is placed into the paretic hand of a patient with CP without them seeing it. Then, the patient is asked to describe the object as accurately as possible by using tactile analysis. They should be able to identify the size, whether it is soft or hard, what shape it is, whether it is cold or warm, etc. The better the patient’s description, the better the prognosis for the training of the phasic movements of the affected extremity. In this way, it can be identified whether a certain compensation capacity for re-education of movement patterns of the patient’s paretic segment has been preserved or at least the capacity for training of compensatory movement stereotypes. If sensation is not all preserved, the prognosis is worse and physical therapy treatments need to focus on stimulation and training of both functions at once (sensory and motor). Sensation is one of the basic prerequisites for purposeful phasic as well as support motor skills. Without sensory functions, movement functions do not exist. Often, with a certain degree of sensory dysfunction and an altered body image, functional deficits can also be observed, for example, in patients with chronic musculoskeletal pain. Currently, the authors of the text lean toward an opinion that a disrupted body image perception can be the primary reason for abnormal and inefficient movement patterns that overload certain regions of the movement system and, in the end, lead to chronic back pain or pain in other areas of the musculoskeletal system. Besides the above described principles of sensory assessment, a number of tests exist that accurately assess “body image”. Rehabilitation attempts to correct such sensory functions and areas of

the movement system that showed limitations during assessment. A number of rehabilitation concepts exists that focus on sensory function training. In principle, a disrupted quality of sensation needs to be stimulated not only in the periphery, but the sensory function needs to also be integrated at the central cortical and subcortical levels. In other words, it is not sufficient enough to just stimulate the receptors at the periphery, for example, by brushing, stroking, or the use of the whirlpool. Those CNS regions need to be specifically activated, where perception and analysis of sensory perceptions and their interconnection with other functions, such as motor, vestibular, affecting muscle tone, etc. occur. The level of central integration is mainly influenced by rehabilitation techniques based on a neurophysiological principle (for example, Vojta’s principle of reflex locomotion, neurodevelopmental treatment, sensorimotor stimulation, proprioceptive neuromuscular facilitation). Conscious, active practice of one’s own body perception interconnected with the practice of repetitive, accurate, and simple movement patterns is also important. For such self-treatment exercises, elements based on Feldenkrais, Frenkel, yoga or tai-chi can be conveniently used.

1.2 OVERVIEW OF PHYSICAL THERAPY METHODS Pavel Kolář Individual approaches used in neurorehabilitation use various forms of afferent stimulation which attempt to stimulate the adaptive processes of the CNS. The individual approaches are significantly heterogeneous and, in clinical practice, we are confronted by a number of therapeutic schools. Each prefers different therapeutic methods and techniques that sometimes contradict one another. Sensory Training During sensory stimulation, all forms of tactile and proprioceptive afferentation are included. The following methods can be used: stroking, brushing, tapping, vibration, etc. The intensity of afferent stimulation is based on the patient’s individual ability to perceive what is known as the stimulation threshold. This practice facilitates the patient’s attention, provides the patient with cognitive impulses and increases motivation when compared to more stereotypical, monotonous and same intensity stimuli. In such patients, practice consists of a motor skill combined with a sensory discrimination task, for example, sorting objects of varied and identical surface quality. Exercising with Conscious Awareness as a Component of Sensorimotor Practice A deficit in conscious and specific motor skills and with it a linked deficit in coordination are one of the main deficits present in neurological illnesses. In patients with preserved signs of conscious motor skills, simple, non-demanding dexterity exercises are utilized during which the patients are “forced” to be fully aware of their movements over a number of repetitions. The exercises do not describe how to breathe or walk, sit or stand, but rather their goal is to

teach the patient an accurate distinction. The exercises are performed slowly and repeated several times with the patient’s effort to fully experience each position or movement. They are “forced” to recognize their proprioception and exteroception. Simply said, through these exercises, we want for the patient to “hypertrophy” certain areas of sensory perception and learn a better movement differentiation in this way. Sensory Stimulation Method Based on Affolter The author of this method is a Swiss pediatric psychologist and a speech pathologist. The method is used for pediatric as well as adult patients with a CNS deficit. The patient performs an activity of daily living with a therapist’s help – bread slicing, grating carrots, etc. The patient is asked to visually and auditorily experience these movements. By performing these activities, the patient not only learns them but, at the same time, attempts to gather the most information about the qualities of their environment through tactile and proprioceptive afferentation while performing the activity. It is important to modify the therapeutic approach to the patient’s current condition. Based on preference, a number of activities can be performed bilaterally at the same time which supports synergy of both sides of body. Perfetti’s Method In this method, the patient is required to identify various surfaces and objects with their paralyzed upper extremity. At first, the patient’s movements are performed passively by the therapist. Then, based on the patient’s progress and considering elimination of undesirable, associated movements, the patient gradually takes over and performs the skills by themselves. The movement function improves by these sensory experiences and the associated focus paid to the paralyzed extremity. Rood’s Method An American physical and occupational therapist Margaret Rood based her method on the utilization of specific stimuli for facilitation,

activation and inhibition of motor skills. Within her method, she integrated the newest neurophysiological findings of her time. The method is based on a detailed analysis of relationships between sensory stimuli and motor reactions. In this context, she applied the principle that any structure and function of the neuromuscular system can be classified into one of two basic biological needs including: 1. A self-defense effort by (defensive) protective movement patterns. 2. An individual’s development by persistent activity and adaptation to the environment. Two types of reactions – an autonomous and somatic – correspond to this classification. During exercise, motor responses are searched for and organized in a sequence of sensorimotor development. Autonomous, somatic and psychological functions mutually affect each other and, therefore, the stimuli can act on these systems either directly or through one system to the other. Movement Rehabilitation of Patients with Hemiplegia Based on Brunnström Dagmar Pavlů, Pavel Kolář A Swedish physical therapist Signe Brunnström (1909–1984) developed her method strictly for adult patients with hemiplegia or hemiparesis. The symptomatology of central hemiplegia is specific and, thus, its treatment methods cannot be fully utilized in other neurological conditions. Brunnström developed special scales and forms for assessment of motor skills and stages of re-education. It is based on the fact that with hemiparesis, selective movements in joints cannot occur if spasticity persists. Rather, the movement occurs in general motor patterns known as synergies. These synergies manifest themselves as reflexive responses to stimulation or when attempting a volitional movement. In remission, spasticity is reduced, synergies are inhibited

and selective movements emerge. Brunnström uses the associated movements as facilitative elements. These are synkineses that are selected so that they facilitate volitional movement. The patient performs a strenuous movement with their uninvolved body part which triggers synkineses (associated movement) and serves to facilitate volitional motion. The associated movement activity can be manifested either as a movement or only by increased tone in the associated muscles. In the upper extremity, the associated movement of the paretic extremity is of the same type as the healthy extremity, meaning extension facilitates extension. In the lower extremity, the associated movement is of the opposite type than in the healthy extremity, meaning flexion tends to facilitate extension. The improving condition of a patient with hemiplegia is categorized into six grades based on the level of sensation, volitional movement, passive mobility and the speed of movement execution. The sequence of recovery of each individual movement is stereotypical and none of the grades can be skipped. In each of these grades, the motor skills can plateau: Grade 1: The acute phase of CNS involvement begins to subside. Weakness and no extremity movements are seen in this phase. Physical therapy treatment emphasizes activation (stimulation) of movement synergies and the associated reactions with a certain contribution of conscious effort. Grade 2: Basic synergies emerge in extremities or their components as an associated reaction. All movement efforts are manifested in synergy patterns. Minimal volitional movements can emerge and spasticity increases. Grade 3: The patient achieves the ability to have volitional control of simple movements that differ from synergies. Spasticity decreases. Grade 4: The patient begins to be in control of volitional movements (even more complex ones) and synergies lose their dominance. Spasticity begins to subside. Grade 5: Spasticity is almost absent and movement control

approaches a normal condition. Grade 6: Normal movement execution is observed. This method uses gradual application of various facilitation techniques. Therapy Therapy is divided into four phases: 1. Development of large synergies through tonic reflexes and associated reactions Movement facilitation with the help of primitive synergies is the first step. It utilizes stimulation of the subcortical motor reflexes and associated reactions – asymmetrical tonic neck reflex, symmetrical tonic neck reflex, tonic labyrinthine reflex and tonic lumbar reflex. This approach significantly differs from other approaches (neurodevelopmental, Vojta’s, etc.). These concepts, in contrast, are opposed to such motor pattern fixation and, instead they focus on their inhibition. 2. Development of volitional control of reflex synergies The second phase involves the practice of independent control of reflex synergies – capturing. Repeatedly, synergistic reactions are elicited, at first reflexively, than volitionally. In the next phase, the patient’s attention (volitional effort) is guided toward certain components of the synergistic movement, at first to the proximal movement components, later to the distal ones. Even in this aspect, Brunnström’s approach is not in agreement with the current therapeutic technique strategies which instead attempt inhibition of synergistic reactions and an achievement of selective mobility. 3. Elimination of flexor and extensor synergies through selected components of such synergies Another phase involves perfecting the volitional control of movement. The author achieves this by alternating facilitation of different synergies. Movements that do not belong to the synergistic patterns are gradually activated, leading to decreased spasticity.

4. Development of volitional control of coordinated movements Brunnström considers the recovery of movement functions of the hand and the fingers as the most difficult phase of rehabilitation. The recovery of movement function of the paretic lower extremity is similar to the upper extremity, but faster. Sensory Integration Based on Ayres Veronika Schönová Jean Ayres worked as an occupational therapist and a special education teacher in Los Angeles. She worked with children with learning deficits and visual perception problems. She cooperated with the Institute for Brain Research in Los Angeles and, in 1950 initiated her own research about the causes of learning deficits. She developed tests originally indicated only for children between four to nine years of age who had no physical or mental disadvantages and their problems manifested themselves in a form of learning deficits. Now, the clinical testing is used also for children with slight mental involvement. In 1973, she remodeled the Southern California Sensory Integration Test (SCSIT) into a Standardized Sensory Integration and Practice Test (SIPT). It includes 17 subtests aimed at areas of visual perception, fine motor skills, tactile-kinesthetic function and body schema perception. If none of the above mentioned tests can be administered to a child, the Sensory Development Questionnaire is used. During her work, Ayres concluded that learning disorders are manifested most frequently by psychomotor hyperactivity, attention problems, behavioral problems, delayed language development, poor articulation, coordination deficits and incorrect body posture which are the end products of brain cortical regions. Sensory integration utilizes analysis of the causes of such deficits which are linked to subcortical brain regions. Sensory Integration Sensory integration is the ability of the brain to register, organize, integrate, filter and coordinate sensory stimuli and develop

adequate adaptative responses to them. It gives meaning to what we perceive by our senses. It includes all areas of development and ensures perception complexity which, in the end, also influences the child’s behavior. Sensory integration is based on the mutual dependence of a sensory input, motor output and also brain plasticity that occurs in a form of so called adaptation – changes at the neural level. Motor output of correctly functioning sensory integration is an adequate or so called adaptation response. Sensorimotor functions gradually develop until seven years of age. In newborns and also partially in infants, adaptation responses are demonstrated in the form of reflexes. In infant, toddler and pre-school ages, the child’s brain is exposed to many new sensory stimuli in response to which they need to form new adaptation responses that are not always adequate, but continuously improve as the sensorimotor functions develop. It could be said that it is an unconscious, but continuous development. In children older than 7, more complex adaptation (motor) responses are present that can, in case of a deficit, influence motor functions, the ability to perceive one’s own body, attention, ability to learn, speech and language development and also impact social development in the form of behavior deficits. General Signs Seen in Children with Sensory Integration Deficits These children usually have a high IQ and are very emotional. Given their problems, they quickly become frustrated and anxious. They have low confidence and can be introverted or, in contrast, aggressive to their surroundings. They can be hypersensitive or hyposensitive to touch, movement and visual and auditory perception. They show unusually increased or decreased activity. They can be impulsive, restless, and demonstrate concentration problems. Changes in muscle tone are seen. Deficits in body perception and motor planning abilities of individual body parts within a complex total body activity are often seen. These deficits occur within the context of movement timing, distance estimation or coordination. The child demonstrates

immature gross and fine motor skills, poor bilateral coordination, and shows difficulty crossing midline. Orofacial region difficulties are frequent and the child can demonstrate problems with biting and swallowing as well as in speech and language development. General groups of sensory integration disorders 1. Sensory modulation disorders, which include sensory seeking, weak sensory registration (during which the child shows a deficit in registering relevant inputs) and sensory defensiveness (in which the child is overstimulated by the incoming information leading to defensive or even aggressive reactions). Sensory defensiveness is manifested by hypersensitivity to touch (the child overreacts to regular touch, has difficulties with ADLs, is anxious and aggressive) and gravitational insecurity, in which the child shows fear to shift their center of gravity, dislikes movement activity and shows changes in muscle tone. 2. Sensory discrimination disorders can be divided into deficits in tactile discrimination and perception with the child showing problems with interpretation and location of tactile stimuli and with stereognosis. Problems with adequate feedback, fine motor skills and eye-hand coordination are also present. Another group includes proprioceptive disorders, in which the child demonstrates problems with their own body perception, which is manifested mainly in motor planning. Vestibular dysfunctions involve central vestibular processing of information. They are classified as disorders due to hyposensitivity or hypersensitivity of the vestibular system. Children with such deficits often demonstrate decreased muscle tone and can demonstrate problems in the areas of motor skills, crossing midline, bilateral activities, right-left orientation, equilibrium and defensive and postural reactions. Other groups form deficits in auditory, taste, olfactory and visual perceptions, in which the child incorrectly identifies individual perceptions. In case of deficits in visual perception, the child at a later age demonstrates learning problems (for example, problems with identification of letters or writing on the line), shows poor

orientation and can be insecure in movement activities. 3. Sensory-based motor disorders contain two categories of deficits: postural disorders and developmental dyspraxia. Dyspraxia is linked to body perception, exteroception, proprioception and the vestibular system. It manifests itself by a difficulty in learning new motor skills, construction dyspraxia, problems with sequencing, inability to imitate positions or movement, and orofacial problems. Therapy Therapy can be individual or in a group setting. It is based on the finding that it is important to return to the beginning of ontogenetic development and develop sensorimotor skills. The brain works as a whole and the functionally higher CNS structures require the lower hierarchical CNS structures for its correct function. The effect of sensory integration is then the formation of an adequate adaptation response. Treatment for sensory integration is strictly individual. It requires the child’s active participation and uses gradation (gradual habituation of the child to the “new perception” of the world) in the following areas: stimuli intensity, frequency of stimuli, rhythm and duration of therapy. Compensation strategy is used in place of classic sensory integration in children older than 10 years of age. The goal is to help the child form strategies for adequate solutions to problematic situations. Therapy occurs in rooms that are equipped with unstable surfaces, cylinders, balls, swings, incline surfaces, mats, rollers and other tools from various materials. Often, this ”playful” environment aids in improving the child’s motivation and their active cooperation. The main goals of sensory integration therapy include: increased frequency and duration of adaptation response, developing complex adaptation responses, improving self-confidence and security, improving gross and fine motor skills, ADLs and academic skills. Neurodevelopmental Treatment Concept Based on Bobath

Irena Zounková Berta Bobath (1907–1991), originally a gymnastics teacher in Berlin later working as a physical therapist in London, and Dr. Karel Bobath (1960–1991), a neuropsychiatrist of Hungarian-Slovak origin, developed in the 1940’s a therapeutic approach which they kept refining for the next fifty years. A Swiss physician, Elizabeth König, and an English physical therapist, Mary Quinton, were the pioneers of an early movement therapy for infants based on the Bobath approach. The theoretical foundation of the approach (Neurodevelopmental treatment, NDT) is a mechanism of central postural control. It contains a number of dynamic postural reactions that have a common goal: to maintain balance and postural adaptation prior to movement, during movement and after movement completion. These are automatic reactions (upright, equilibrium, defensive) that gradually develop in a child and serve for movement coordination and postural control in relation to the surroundings (space, gravity, surface and adjacent objects). These include active and diverse coordination movement patterns or only changes in tone. A deficit in the mechanism of central postural control is manifested in the following ways: Abnormal postural tone that can be high (spasticity), low (hypotonia) or fluctuating. Abnormal reciprocal muscle interaction that does not ensure automatic adaptation of muscles during unstable postural changes nor a smooth control of the agonists and antagonist to perform an efficient, correctly timed and directed movement. It leads to pathological co-contractions that result in an excessively increased stability and lack of mobility (spastic deficits); with simultaneous inhibition of agonists and antagonists leading to excessive mobility with insufficient stability (athetosis). Decreased heterogeneity of postural and movement patterns that do not ensure the necessary realization of functional skills. The patient moves within the framework of global patterns (flexion or extension, or mixed) and demonstrates reduced movement

selectivity. Presence of associated reactions with volitional movements such as undesirable synchronous movements even in more distant areas. Therapeutic Approach The NDT approach includes physician’s findings complemented by a therapist’s assessment and specifically focuses on the potential of therapeutic influence. General goals of therapy include: Inhibition of spasticity Inhibition of pathological postural and movement patterns Facilitation of physiological posture and movements leading to functional activities Change in sensory perception to improve perception of position and movement Support of motor development Prevention of contractures and deformities Assessment 1. General impression: Child’s behavior, their physical and emotional dependence including their attitude toward the examiner; associated problems such as visual and auditory deficits; manifestations during eating and drinking, for example, breathing and drooling; hand function; cognitive abilities: adaptation to the surroundings, comprehension of given tasks and the ability to accomplish them, ability to concentrate, etc. 2. Functional activities that the child can and cannot perform: The therapist observes the patient’s functional abilities and analyzes them. A thorough analysis is the basic prerequisite for successful therapy. The first step is to identify what the child can do with or without help and the way in which the positional or movement activity is performed. The second step is the analysis of what the child cannot do and why and which movement compensations are used and their consequences. 3. Postural tone and its related movement and postural patterns: At first, the therapist observes and then palpates the quality of

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postural tone and its distribution, analyzes the movement patterns and determines how they change during movement and which pattern dominates in certain situations. Reciprocal muscle interaction, meaning movement fluidity during complex activities, postural and locomotor (stability and mobility) abilities; the ability, for example, to turn with rotation between the shoulders and the pelvis; the ability to use the contralateral lower extremity during crawling and creeping (dissociation, selectivity). Heterogeneity of postural and movement patterns: The use of various movement patterns based on the demands of particular activities. Associated movements, such as, deficits in vision, hearing, eating and food processing and their association with changes in postural tone and coordination movement patterns. Complete range of motion to identify contractures and structural deformities. Based on this examination, the main problem is articulated and a therapeutic strategy is established. Last but not least, part of the assessment includes the parent’s interview, their expectations and goals, and their understanding of the disease. As soon as a particular goal of therapy is achieved, the patient’s reevaluation and an updated therapeutic program follow.

Inhibition and Facilitation According to NDT, inhibition and facilitation are two inseparable components. Therapeutic treatments allow for simultaneous facilitation and inhibition. Spasticity can be inhibited by application of TIPs (tone influencing patterns) and, at the same time, facilitate the patient’s correct execution of a movement pattern. The changes in tone are most likely occurring based on the activity of a TIP at the neural level (plastic adaptation ability of the CNS to influence the “feedback” and “feedforward” mechanisms), as well as at the nonneural level (the phenomenon of muscle stretch and the plastic characteristic of a muscle improve the biomechanical position and, thus, more effective growth in muscle strength). Therapy is administered by handling, in other words by the way the exercises are

executed or the patient is manipulated. It utilizes changing the external surroundings (manual contact on the child’s body, lighting, sound, colors, multiple tools) to motivate the child to actively perform a specific motor position and a movement within it. The therapist sets up, observes and corrects by manual contact (minimal support at the correct places and at the right time during movement) the patient’s automatic (upright, righting, defensive reactions) and active or volitional movement. The therapist guides the child’s motor presentation via the offered altered sensory input. To reduce spasticity and facilitate correct movement patterns, the therapist uses specialized handling techniques – form “key points of control” at certain body parts, such as the head, sternum, shoulder girdle, pelvic girdles, etc. Through the developed activity, the child achieves a normal sensorimotor experience with a normally executed movement. The goal of their repetition is to build the child’s ability to independently correct and control their own body posture and movement and to integrate all of it into everyday life during a particular functional situation. It is a process of motor learning built on the principle of feedback and so called feedforward formation as a preparation for movement and posture. Handling is applied for the entire 24 hours and is included in the activities of daily living (positioning, behavior, lifting, storing, bathing, feeding, dressing, undressing, basic hygiene, particular functional activities such as writing, reading, drawing, movement activity, play, etc.). The development of movement coordination is aided by the use of assistive tools. These include wedges, rolls, therapy balls, various unstable surfaces, appropriate exercise equipment, supportive functional splints, mobility assistive devices – wheelchairs, walkers, crutches, footwear, trunk orthoses, etc. Play serves as a typical tool for the development of motor skills, sensory and cognitive processes. It teaches the child to explore, plan activities, become independent, cooperate and explore the environment. Proprioceptive and Tactile Stimulation Techniques The goals of these techniques include:

Increasing postural tone Regulation of synergy between the agonists, antagonists and synergists Stimulation techniques include: weightbearing, pressure, resistance, placing and holding, tapping – (inhibitory, pressure, alternating, “sweep”). The goal of weightbearing is to elicit an automatic adaptation of the trunk and the extremities to a change. It is performed in various positions (static or mobile) through pressure and resistance. Placing is an automatic adaptation of the muscles to postural changes when performed by a therapist. The patient is guided so that they perceive the given situation and then are able to actively control the given postural situation and movement and maintain (hold) it in various functional patterns. Tapping is a proprioceptive and exteroceptive stimulation of the trunk, extremities and the orofacial region performed at a regularly modified speed and includes shaking, tapping, sweeping and pressure. The response is local as well as global. Various types of tapping serve a specific goal, for example, to improve the function of muscles that cannot contract because of an increased activity of the hypertonic antagonists or to reach a muscle contraction that will ensure postural stability or ensure gradation of a muscle contraction and relaxation of the agonist and antagonists or to stimulate specific muscle groups and activate synergists in the direction of desired movement, etc. Individual types of tapping can be combined when certain principles are followed. An important principle is to not increase spasticity and use tapping only until the patient takes over the activity and restores certain functions. Indications The main indication to use these techniques is when central movement deficits in pediatric patients and central motor neuron deficits (CVA, multiple sclerosis, etc.) in adult patients are present. Multidisciplinary Team

Teamwork is a foundational aspect of the NDT method. The child and their family are always the center of the team. All other team members (pediatrician, speech pathologist, physical therapist, occupational therapist) have to see the child’s problems the same way and have to use appropriate treatment techniques. If the therapeutic handling is used by all professionals and family members, the child has the greatest chance of moving with “more normal” tone. This is also true for movement patterns that, if adequately repeated, are integrated into the motor behavior repertoire. Movement Therapy According to Petö Irena Zounková, Pavel Kolář Andreas Petö (1893–1967), a founder of this method, was a physician and an educator. At the beginning of the 1950’s, he founded the Institute of Conductive Education in Budapest to support children with handicaps. Petö did not just study deficits in isolation, but rather looked at a person as a whole. Based on his theory, the learning and adaptation processes in children with disabilities are disrupted and the learning deficit serves as a foundation for a movement deficit. The child’s initiative and activity and their effort to transfer learned skills and movement into their activities of daily living are important. Petö did not solely work on one specific dysfunction. His approach is used around the world, not only for children with cerebral palsy, but also for other neurological diseases. At the same time, it is still being developed and modified to be used as therapy for adults with neurological involvement. Characteristics of Conductive Education Group. The work is done mainly in groups. Groups act in a stimulating and motivational way. A meaningful number of activities in which the children can participate are important for motivation. The children learn a lot from one another and social relationships and friendships develop. Equipment. Basic equipment consists of pallet tables, chairs, and

ladders. The furniture has a facilitative character and improves movement quality. It facilitates active grasping, holding and leaning. To meet stabilization needs, fingerboards and rings of different sizes are used. The equipment improves spatial orientation and allows for pulling up, standing by it or crawling underneath it. It helps the children change location more independently and assists them during daily activities. Rhythmical administration. Rhythm, in which everybody has to cooperate, contributes to a close relationship between perception – activity – speaking and the development of awareness. Movement and speech are very important. Speech helps with movement planning and regulates its temporal significance. It stimulates, mobilizes and directs attention to the task. Movement has many distinct steps and each step is simultaneously expressed by a word and performed. Particular movement segments are developed into so called basic motor exercises. Each basic motor skill corresponds to a certain rhythmical rhyme. Constant repetition of the movement and speech leads to automatization and recollection is formed in motor memory. Educational plans. They consist of monthly and daily plans and are developed in great detail. Administrator. This can be a nurse, teacher, therapist, psychologist and caretaker in one person. Therapy. It is also supported from the orthopedic side (early surgical intervention for soft tissues) and cooperates with prosthetics (administration of orthotics, appropriate footwear). Hydrotherapy can also be utilized. Rehabilitation of Cognitive Functions Rehabilitation of cognitive functions is led by physical therapists, psychotherapists and special education teachers and it forms an integral part of the patient’s care. In cognitive rehabilitation, it is very important to achieve at least partial independence. During the child’s participation, the training of activities focused on self-help functions needs to be initiated. If necessary, speech therapy

needs to be provided. Treatment rehabilitation needs to be coordinated with other important disciplines that are included in the patient’s rehabilitation treatment. Vojta’s Method Pavel Kolář Vojta’s reflex therapy method is used consistently in the treatment of neurological illnesses. This therapy plays an important role in many neurological diagnoses involving motor deficits. Since this method does not require a patient’s conscious cooperation, it is frequently used mainly in children (including newborn and infant ages) and can be used successfully in patients with deficits in consciousness or comprehension (for example, in patients with sensory aphasia). More details on Vojta’s method can be found in section 1.21.3 Rehabilitation in Cerebral Palsy as well as in the General Section of the textbook, B. Therapeutic Approaches, Chapter 1.3.1 Vojta’s Principle: Reflex Locomotion. Sensorimotor Stimulation Pavel Kolář Sensorimotor stimulation is a method whose stimulatory influence can be used for motor deficits within the context of neurological diagnoses. In neurological deficits, they are applied mainly for practice and correction of stability, especially with fall prevention. However, it can be used for a wide range of deficits, including orthopedic deficits. For more detail, see General Section of the textbook, section B. Therapeutic Approaches, Chapter 1.3.2 Sensorimotor Stimulation. Proprioceptive Neuromuscular Facilitation Pavel Kolář Proprioceptive neuromuscular facilitation has an important role in the rehabilitation of certain neurological conditions. It is a very effective

and complex facilitative method based on movement facilitation with the help of signalization from one’s own body – from muscle, joint and skin receptors. The method requires the patient’s active participation to perform strictly defined active movements of the upper or lower extremities. These movements are spiral and diagonal in nature. The method is used mainly for peripheral paralyses of the upper or lower extremities; however, it can also be used after CVA to influence mobility and correct muscle tone. For more detail, see General Section of the textbook, B. Therapeutic Approaches, Chapter 1.3.4 Proprioceptive Neuromuscular Facilitation.

1.3 NEUROPSYCHOLOGY Kateřina Chamoutová, Pavel Kolář Neuropsychology is part of the neurosciences and operates on the outskirts of neurology, neuropsychiatry, neurocybernetics, clinical and developmental psychology, rehabilitation and cognitive sciences from which it also distinguishes itself by its specifics. The general goal of neuropsychology is to determine the consistencies in the relationships between the neuropsychological brain processes and psychological manifestations, or simply said, to study relationships between brain deficits and behavior. It attempts to establish the type and extent of cognitive deficits as a result of CNS damage and their subsequent effects not only on the patient, but also on their social environment (family, occupation). Clinical neuropsychology as an applied discipline started to form slowly in the 1930’s. A significant development was seen following both World Wars that left behind a large number of patients with brain damage, leading to an increased interest in neuropsychology during this period. Based on the then available examination methods commonly used in psychology, neurology, speech therapy and other disciplines, neuropsychological assessment methods were developed. Historically, around the world, neuropsychology is based on two completely contrasting trends developing in different social and scientific societies. The eastern trend is based on the clinical practice of a physician. A strict experimental trend of western neuropsychology remindful of the tradition of laboratory experiments of the behaviorists stands in contrast. Today, the emphasis is placed on a complex analysis of processes, the transfer of behavior changes into complex systems of relationships between the behavior and brain activity and a broad context of these processes and the changes in the patient’ social environment. The opportunity to predict the expected results of cognitive function training and to a certain extent lays down the foundation for

development and implementation of effective biological, psychological and social rehabilitation is important.

1.3.1 Neuropsychological Approaches Neurobehavioral Approach Alexander R. Luria (1902–1977), the founder and promoter of this method, based his approach on clinical experience obtained by treating patients with post-war CNS injuries. He used methods and strategies of classical neurological assessment. He developed rehabilitation approaches for motor planning, visual perception, frontal function and speech therapy. He accomplished all this through a diagnostic set of tests compiled from simple tasks that allow the capture of deficits in individual areas. To this day, his method has many followers who continue to develop it based on new findings across allied fields. American Neuropsychological Approach The American method arises from a current level of cognitive function and a detailed laboratory exploration of their sides. The representatives of this trend (W. C. Halstead and R. M. Reitan) used extensive, complex sets of tests in their laboratory experiments. They captured individual abilities and skills, reaction times, memory for various types of materials, etc. by strictly standardized approaches. They obtained accurate data that was processed by a factor analysis to develop the most detailed description of cognitive functions and components that contribute to them. The results obtained by a psychological assistant in the laboratory can be assessed by a clinical neuropsychologist without any previous knowledge or information about the patient. The examination requires not only equipment facilities, but it is also demanding on the patient because it takes several hours. These tests are more appropriate for psychiatric patients or relatively improving patients, in whom lower fatigue can be expected than in patients with acute conditions. For practical needs, in 1979, R. M Reitan developed a set of

methods for cognitive rehabilitation known as REHABIT. It allows a clinical neuropsychologist to establish an extensive individual program of training for cognitive deficits. The differences between the two outside approaches lie primarily in the use of different models of brain activity, different terminology and different approaches to the psychological aspects of life. Also, they show a different approach toward the patients. In the last decade, a third approach has been developing, which is focused on detailed research of special neuropsychological processes, such as aphasia, apraxia, etc., while special experimental and diagnostic methods are constructed for these cases. In specialized workplaces, through adaptation of older, established approaches for computers, neuro​psychological computer-based sets of tests are being developed. An example can be given in the development of the FePsy method (The Iron Psyche), indicated as a very detailed assessment and observation of patients with epilepsy. Neuropsychology in the Czech Republic In the Czech Republic, neuropsychological assessment has traditional roots in the assessment and caretaking of children with learning disabilities that has been promoted from the mid-20th century by pediatric psychologists, such as professor Matejcek. Psychologists in pedagogical-psychological counseling settings that had to function in all regions at that time period, translated and developed tests indicating an “organic” basis of learning and behavioral deficits. This historic approach of identifying organic brain damage (“organicity”) has been shared across specialists and psychologists conducting neuropsychological assessment to this day. Neuropsychology evolves more in practice than in theory. Today, clinical neuropsychology studies specific changes in cognitive functions and the affectivity and behavior that are related to structural and functional brain deficits. The most frequent neuropsychological deficits developed as a result of a CNS injury affect overall orientation, concentration and attention, visual perception, memory, social behavior (for example, increased

aggressiveness, impulsive behavior, inability to adequately plan and control individual’s activities), affectivity (emotional lability, tendency toward clowning or, in contrast, toward depression), speech functions, motivation, ability to think and mental flexibility. These deficits project importantly into various aspects of the patient’s life, their emotions, social and work functions and partner and family relationships. In practice, applied neuropsychology relates closely to the focus on each individual workplace. Unified methodological approaches so far have not been developed. In clinical practice, no generally accepted approach to neuropsychological diagnosis exists. Taking into consideration the extent of neuropsychological issues and the differences between individual groups of patients, an individual patient approach needs to be maintained.

1.3.2 Neuropsychological Assessment Diagnostic approaches in clinical neuropsychology can be divided into the following: Preliminary During the patient interview (anamnesis), attention is paid to the manifestations that could be suggestive of cognitive deficits or changes in affectivity and behavior (Tab. 1.3.2-1). Luria’s clinically oriented approach also begins with the patient’s overall assessment, their orientation and consciousness.

Tab. 1.3.2-1 Manifestations of cognitive deficits, changes in affectivity and behavior during clinical assessment

In this context, the level of consciousness is the primary focus, followed by perception and coding of sensory function and cognitive processes necessary for encoding and retention of information, i.e. attention and memory. Lateral processing of information occurs at higher levels: a. Speech (primarily in the left hemisphere) b. Visual-spatial processes (primarily in the right hemisphere) c. Logical analysis and synthesis, conclusions and conceptual thinking (form the most complex level of processing) Specialized The examination is performed by a clinical neuropsychologist. This assessment contributes to the specification of the diagnosis, reestablishment of cognitive functions, development of the rehabilitation plan, recommendation of psychotherapy, etc. Various sets of tests focused on certain components of cognitive functions are available. Individual neuropsychological tests focus on the diagnosis of specific cognitive deficits (isolated cognitive deficits) and on their quantification. Based on their experience, most psychologists and neuropsychologists in the Czech Republic use various combinations of clinical psychological methods, i.e., drawing tests, different memory tests or tests assessing fluctuation of attention. The information about cognitive deficits can also be obtained by a detailed qualitative analysis of the achievement and errors in the subtests of intelligence tests. Based on availability, the neuropsychologists use neuropsychological sets of tests that they were able to purchase through various research studies and became familiar with by administering them. These mostly include more expensive methodology than seen in classic psychological tests. Some classical tests are included in the computer versions of neuropsychological tests (for example, FePsy, Vienna Test System) or the computer is used for the practice of certain cognitive functions (Train the Brain).

Cumulative scales that consist of a number of individual tasks and particular tests are used and are specifically aimed at certain components of cognitive functions. Most Commonly Used Neuropsychological Tests Wisconsin Card Sorting Test (WCST) – a test of executive functions, especially flexibility and the ability to form a concept of action and regulate the course of an activity based on external conditions. As one of few such tests, it is very sensitive to injuries involving the frontal areas of the brain, which was the reason for its inclusion in the computer set of tests (for example, FePSy). An example of the card arrangement is presented in picture 1.3.2-1. The patient is supposed to assign a card from the lower “deck” to the cards in the upper deck. The patient always receives feedback on whether they placed the card correctly and they have to themselves deduce the rule according to which cards are supposed to be sorted. If they master the rule, the computer changes the rule and the patient needs to identify the new rule. (When solving this task, a girl with epilepsy who had seizures in the frontal areas started arguing with the computer: “You are doing this to me on purpose!” During the next rule change, the test needed to be interrupted because she began to physically attack the computer.) Stroop test – tests cognitive speed, flexibility and the ability to resist an intruding incorrect answer. The test performance depends on attention and working memory and it is considered a method for testing control functions. It is not used for pediatric patients. The most frequently used memory tests are the Wechsler Memory Scale, Rey Complex Figure Test, Rey Auditory Verbal Learning Test, and Buschke Selective Reminding Test. Memory subtests form a significant portion even in the computer based sets of tests. Tests focused on language functions include the Western Aphasia Battery, Boston Diagnostic Aphasia Examination, Boston Naming Test, and Token Test (Fig. 1.3.2-2). To accommodate a patient who is immobilized, the assessment can

utilize shapes drawn on a sheet of paper in which the patient points to the shapes (for example, “Show the red circle and the green square”.). Tests assessing non-verbal and spatial functions are the Rey Complex Figure Test (Fig. 1.3.2-3), Face Recognition Test, and Line Orientation Test, in which the patient observes the lines and is asked to draw them from memory in various intervals. It is a sensitive test distinguishing deficits in the right and left hemispheres. In deficits of primarily the analytical function of the left hemisphere, the patient has a tendency to maintain the overall shape that they often can also name (house, pig). They sometimes add details based on their own imagination. In contrast, when deficits of the right hemisphere dominate, they draw the details in different arrangements or they do not relate them at all (a patient after an injury drew hearts around several triangles because she only remembered that there were more to draw. Four years later, during a follow up examination, she could reproduce it better). The Matejicek’s Test of Tracing Geometrical Shapes, Human Figure Drawing Test, Benton Drawing Test and other drawing tests are widely used, especially in pediatric patients. They are suitable because of their playful form and ease of administration even at bedside. They can be repeated and the change in results can be observed for several years. They are sensitive not only to the level of the child’s overall development and deficits in spatial orientation, but also to the level of fine motor skills. Test for children by McCarthy that consists of several scales (memory, verbal abilities, functions of spatial orientation, motor skills) is used as early as age two. Tests determining personality profile are the Minnesota Personality Inventory and Cloninger Personality Questionnaire. Tests used to distinguish depression from a neurological or symptomatically fundamental illness include the Beck Self-Rating Scale and Geriatric Depression Scale.

Tab. 1.3.2-1 Manifestations of cognitive deficits, changes in affectivity and behavior during clinical assessment

Fig. 1.3.2-2 An example from Token Test

Fig. 1.3.2-3 The test of non-verbal and spatial function – Rey Complex Figure Test

Neuropsychological Computer-Based Test Sets Computers allow for a more specific assessment in situations where the deficits are not captured by the classic testing methods (pen and paper or working with demonstrated material while being timed: Kohs cubes, Löwe’s pyramid). A large number was developed and some contain versions for children and adults. Many tests designed for assessment have versions used for cognitive rehabilitation. FePsy is a computer based neuropsychological examination. It consists of a set of computer tasks for an assessment of cognitive function. This test was developed in a neuropsychological laboratory in the Dutch Institute for Treatment of Epilepsy (Instituut voor epilepsiebestrijding). The institute owns and distributes this software to neuropsychological laboratories all over the world. An interconnection between the computer and the EEG equipment allows for observation of bioelectric brain activity during the course of an individual task and for a detailed analysis of a patient’s errors. FePsy is used within the context of medical studies where it identifies how far individual medication and its combination can influence the patient’s cognitive functions. It monitors changes in cognitive functions in individual patients during treatment, before and after

neurosurgical procedures, etc. During FePsy Examination, the patient sits 70 cm away from a tilted monitor to provide an optimal visual angle, which is important for tasks examining the differences between the halves of visual fields. It is initiated by subtests assessing simple reaction time in visual and auditory modalities, optional reaction time and it also contains a visual searching task, in which the patient searches for a pattern identical to an indicated object.

1.3.3 Utilization of Neuropsychological Approaches in Rehabilitation One of the goals of clinical neuropsychology in rehabilitation clinics is to plan, in cooperation with other specialists, the rehabilitation approach in all areas. This is done based on a detailed neuropsychological assessment that includes classical testing methods (Wechsler tests as well as other approved intelligence tests, memory tests, attention tests, writing tests, projective personality tests, etc.), special neuropsychological diagnostic methods, and last but not least, the assessment of the overall psychological condition (including coping with a changed life situation and motivation with rehabilitation). A neuropsychologist and a clinical rehabilitation psychologist have an irreplaceable role within the rehabilitation team. A clinical rehabilitation psychologist performs supportive psychotherapies and crisis interventions in patients who acutely require such care. These more or less include early relational problems, for example, delayed or prolonged reactions to the injury itself. Usually, these also include difficulties related to the adaptation to a change in physical and psychological experiences and emotional and behavioral disturbances that are part of a craniocerebral trauma, CVA and other CNS lesions. Based on clinical experience, following craniocerebral injuries, sometimes emotional problems caused by the inability to master the demands of rehabilitation care or an overall exhaustion and fatigue can also occur, at which point the patient needs to be given an opportunity to rest and the intensity of complex

rehabilitation needs to be decreased. A neuropsychologist as a member of a rehabilitation team can, but does not have to, be the same person as the clinical rehabilitation psychologist. Their task is to establish a neuropsychological diagnosis after the patient has been admitted. Based on the data obtained about cognitive functions and the level of their dysfunction, the neuropsychologist develops the patient’s rehabilitation plan. During the patient’s stay, they perform regular follow-ups and monitor the adaptation to functions based on the ongoing results, for example, practicing using special computer based rehabilitation programs. A psychologist or a neuropsychologist performs neuropsychological and psychological examinations, additional psychotherapy and cognitive rehabilitation. They are asked to see patients that demonstrate difficulty with adaptation or do not cooperate or those who can become depressed. In a number of cases, a physical therapist should not wait and presume the condition will resolve itself. Based on clinical experiences, the psychologist is asked to work with patients with behavioral and emotional deficits with more significant external symptoms than with patients who are depressed or introverted and not problematic, but show a lack of effort to improve their condition. It is important for physicians and physical therapists to know the capabilities and the limitations of the neuropsychologists and clinical psychologists. They already learned to pose questions and assign tasks during the patient’s common everyday care. The physician’s knowledge of, for example, the characteristic behavioral changes can help the physician with the diagnosis and long-term care of neurological patients. Although rehabilitation of cognitive functions has not been a common part of care at certain rehabilitation clinics so far, lately, an effort has been seen to develop certain methodological approaches within the framework of grant programs. In rehabilitation, approaches that attempt to restore everyday activities and normalize key functions, including cognitive functions,

play an important role. Neuropsychological rehabilitation is understood to be an individually set training based on each patient’s tests. Modern rehabilitation methods use computer based programs for training, such as: Train the Brain, Rehacom, CogniPlus or REHABIT, which is based on the Reitan method and results from his sets of standard tests aimed at quantification of cognitive functions. “Train the Brain” is used for rehabilitation of memory and attention deficits most often in patients with brain trauma or following a brain trauma. Together with psychotherapy and psychopharmaceutical treatment, it is also appropriate for patients in early stages of dementia, mainly for patient stimulation. Rehacom, CogniPlus and REHABIT are very extensive and complex computer programs that are financially difficult to obtain. The training programs are based on the patient’s individual needs since rehabilitation should focus on the restoration of the necessary everyday life skills. Temporary or permanent results reflect in various areas of the patient’s experiences, their emotions, changes in social or work function, changes in partner or family relations. For such reasons, the approaches need to take into consideration normal practical life to a great extent. The goal of neuropsychological therapy is restoration of cognitive function, compensation of deficits by learning new strategies and support of psychological well-being to cope with deficits as a foundation for realistic life planning. The frequency of therapy depends on the rehabilitation phase and on the type and degree of the patient’s neuropsychological deficits. The therapy is time consuming and in certain cases, it must be administered 2–3 times per day. Neuropsychological rehabilitation can be administered as individual or group therapy. Initially, strictly individual therapy is used while group therapy can be used in later phases. For patients with brain injury, however, group therapy did not show to be beneficial when administered in certain work settings. The patients respond better to individual programs continuing in the patient’s home setting. Adult patients sometimes consider themselves “completely cured”, insist on

returning to work and it is possible that they are surprised by fatigue, decreased performance and errors stemming from the failing of control functions that they are not able to predict, which is a good reason to not terminate home therapy prematurely.

1.4 SPEECH THERAPY Pavel Kolář Speech therapy has an irreplaceable role in the care of patients with neurological involvement. Speech functions that serve as the tool for human communication are dependent on auditory, visual and proprioceptive inputs and are closely linked to higher intellectual functions. An injury to any of these regions results in a speech deficit. In rehabilitation practice, children most frequently present with developmental dysarthria while adult patients present with aphasia and dysarthria.

DEVELOPMENTAL DYSARTHRIA Developmental dysarthria is a motor deficit of speech that occurs due to organic CNS damage by disruption in the muscle innervation necessary for speech production. It affects respiration, phonation, resonance, prosody, and articulation. There are several types of dysarthrias: Spastic (pyramidal, pseudobulbar, suprabulbar) dysarthria as a result of an injury to the motor pyramidal tract leading from cells in the cerebral cortex to the cranial nerve nuclei in the bulbus. Speech is produced with difficulty and with increased nasal contribution because the movement of the speech muscles is gross, labored, and hypertonic. Athetoid (extrapyramidal) dysarthria occurs as a result of an injury to the extrapyramidal motor system. The speech is slurred or even unintelligible due to involuntary movement of the speech muscles disturbing articulation, chest breathing and voice formation and stability. Ataxic (cerebellar) dysarthria is caused by an injury to the cerebellum and its pathways. Speech is formed explosively or even with saccadic demonstration. Adiadochokinesia, tongue ineptness, frequent stops in speech and stuttering in individual articulating

positions. Bulbar dysarthria is a result of an injury to the nuclei of motor nerves in the bulbus (medulla oblongata and pons) or the nerves arising from them and innervating the muscles of speech. It occurs suddenly, rather than developmentally, following injuries or surgical procedures in this area. Often, swallowing and chewing are impaired. Speech is more significantly disturbed due to deficits in execution of articulating movements. Mixed dysarthria includes any combination of the above mentioned types of dysarthria. Therapy Current clinical experiences offer opportunities for the interconnection of speech and physical therapy. The following rehabilitation methods are most commonly used: Neurodevelopmental treatment – application of so called orofacial tract therapy to facilitate food intake and swallowing; development of orofacial motor skills; speech therapy utilizing physical therapistestablished inhibitory positions. Vojta’s reflex locomotion – used to decrease spasticity or for inhibition of involuntary movement in the time period following the completion of physical therapy; provides an opportunity for increased facilitation of orofacial motor skills and breathing. Kabat method – during stimulation of the speech muscles, resistive exercises are also implemented. Orofacial regulatory therapy based on Castillo Morales – includes sensorimotor and orofacial techniques. It consists of three basic components: 1. Neurodevelopmental treatment to influence posture using sensory stimulation from the skin, connective tissue, muscles and joints through contact, pressure, touch, traction and vibration. 2. Orofacial regulatory treatment attempts to establish physiological functions in the orofacial area. Targeted sensory toning and activation of orofacial musculature is used to accomplish this task. They act on sucking, swallowing and

chewing functions, which links them to speech functions. 3. Myofunctional treatment focuses on the manifestations of muscle and functional imbalances in the orofacial region. Its focus and the types of exercise programs direct this therapy more toward populations with developmental articulation problems.

APHASIAS Aphasias (phatic deficits) are acquired deficits of intake (perception) and production (expression). The development of aphasia is most often linked to an injury to the cortex of the dominant hemisphere. The Boston classification is one of the most widely used types of aphasia classification. It is based on the assessment of spontaneous speech and its fluency or non-fluency. It assesses the ability (inability) of speech repetition, naming the observed and comprehending the spoken and it examines graphia. Types of aphasias: Broca’s aphasia – speech production is disturbed with a relatively well preserved language comprehension; repetition and naming are affected; speech is labored and agrammatical with a number of phonemic and verbal paraphasias; spontaneous speech can be limited to the production of several words. Wernicke’s aphasia – spontaneous speech is fluent, paraphatic, with many neologisms; significant deficits in language comprehension are dominant; repetition and naming are also affected. Global aphasia – found in extensive lesions, usually following an occlusion of the middle cerebral artery (arteria cerebri media); complete asymbolia or a complete loss of communication ability occur; spontaneous speech is characterized only by automatisms and stereotypes. Conduction aphasia – occurs with a lesion between the motor and sensory speech centers; spontaneous speech production and comprehension are intact; difficulties occur when repeating words

and sentences. Transcortical aphasia – characterized by the reproduction of words often without understanding their meaning (echolalia). Transcortical motor aphasia – spontaneous speech is disrupted, agrammatical; reproduction and language comprehension remain intact. Transcortical sensory aphasia – speech manifestation is fluent with good reproduction, but weak comprehension; patient reproduces a sentence well, but without comprehension. Anomic aphasia – is demonstrated by the patient’s inability to recall a known term neither quickly nor at all, but they are able to describe it in words; language comprehension and naming remain intact. In clinical practice, the following basic distinction of aphasias is found: Motor (Broca’s, expressive) Sensory (Wernicke’s, receptive) Total (global) Amnestic (anomic) Diagnosis The Western Aphasia Battery (WAB) is used for diagnosis. It consists of eight subtests that assess spontaneous speech, auditory comprehension of spoken language, repetition, targeted naming, reading, writing, praxis, calculations and construction ability (spatial vision). Mimra’s Test for the Assessment of Speech Functions is used to examine individual areas of phatic functions: 1. Spontaneous speech is assessed from a complete loss of speech in six grades from word recall through the norm 2. Repetition – repeating of vowels, words, sentences and complex sentences 3. Comprehension of spoken word – reaction to word commands, term selection from concrete to abstract and comprehension of

4. 5. 6. 7. 8. 9. 10. 11.

grammatical structures Naming – based on real objects and by sets of pictures Automatic series – arithmetic sequences, days, months, words of a song Singing – recognition of melody, rhythm, active singing Reading – letters, syllables, individual works, text and its reproduction, global reading Verbal counting – numeration, arithmetical relationships and actions Written computing – numeration, arithmetical relationships and actions Drawing – letter or sentence transcription, drawing based on an example with spontaneous demonstration, graphomotor skills Writing – signature, address, dictation of words, sentences, and a spontaneously written expression

The Token test focuses on the quantification of receptive speech deficits (speech understanding) and short-term verbal memory.

DYSARTHRIA Dysarthria is a motor dysfunction during which the language and cognitive components of verbal communication are, in principle, intact. Breathing, phonation, resonance and articulation are disturbed or affected during speech. Classification of dysarthrias: Flaccid (peripheral): present with lower motor neuron injuries; manifestations of dysarthria include monotonous and inarticulate speech; frequent signs also include disturbances in breathing, hypernasality, hoarseness and swallowing problems Spastic: occurs with upper motor neuron deficits and is part of pseudobulbar paralysis; speech is slow, labored with word elongation and unintelligibility of longer speech; breathing is weakened, articulating movements and palatopharyngeal closures are slow and weak Ataxic: develops with a cerebellar injury and the pathways linked to

its activity; speech is irregular with syllables and words being explosively forced out (saccadic speech); fluctuation is also manifested in breathing, voice intensity and resonance; difficulties occur in speech rhythm; also significant is the inaccurate execution of syllables, mainly consonants; clinging in the position of articulation is observed Extrapyramidal-hypokinetic: occurs with hypokinetic-hypertonic syndromes characterized by reduced activity in the basal ganglia, mainly seen in Parkinsonism; speech is monotonous and is frequently begun with an initial pause followed by precipitous and inaccurate speech with palilalia – repetition of syllables or words; breathing is insufficient and disrupted; voice presentation is significantly weakened almost to aphonia; speech is variable, either slowing down sometimes to a complete stop or, in contrast, speeding up into unintelligible mumbling Extrapyramidal-hyperkinetic: occurs in choreatic or athetoid syndromes; speech is loud, exclaimed and visibly uncoordinated with breathing; speech mechanisms can be interrupted by sudden movements or constantly disrupted by uncontrolled movements; the tempo of speech fluctuates and speech may even be unintelligible due to the lack of ability to control the movements of the tongue and the mouth or the inability to control speech movements Mixed: manifested by signs of peripheral and CNS pareses; it occurs in combination with more CNS lesions or with degenerative diseases Diagnosis The Dysarthric Test 3F (dysarthric profile) is used for diagnosis. The test diagnoses and differentiates the above listed six types of dysarthria. An assessment using this test contains the following components: Respiration (phonorespiration) Phonation Facial muscle activities (faciokinesis) Diadochokinesia (accuracy of repeated movements)

Reflex activity linked to swallowing, chewing and coughing Articulation Reading and speech intelligibility Speech tempo and prosody The fundamental role of diagnostics is to distinguish the manifestations of aphasia from dysarthria, dementia, or speech apraxia. Dementia is manifested as an acquired and severe loss of cognitive functions, mainly memory and intellect. Speech apraxia is manifested as deficits in the programming of speech elements, phonemes, syllables and their interchange, omission or perseveration. Speech is not linked with deficits in other oral motor activities. Apraxia does not develop secondary to lack of muscle activity (the muscles are not weakened; muscle tone and coordination are not affected; movement is not limited), but rather the programming of the speech itself is disrupted. Therapeutic Approaches in Aphasias and Dysarthrias In many patients, a complete remission of speech deficits does not occur. Speech therapy teaches the patient how to achieve a sufficient level of communication given the patient’s reduced capacity. A loss of communication abilities causes a significant psychological burden on the patient and, therefore, speech therapy belongs among the main therapeutic methods utilized in the care of such patients. Therapy is dependent on the stage of the deficit. In the initial stage, auditory, non-verbal and visual stimulation of speech are used as well as the automatic elements of speech. During therapy for aphasias, the methods of re-learning (Luria’s method), language based therapy (Anglo-American Aphasia Therapy) and Czech speech therapy methods are used. The goal of therapy for aphasia is to reach maximal communication abilities taking into consideration the given disability. Renewal of social relationships occurs as a result of communication therapy. In the acute stage, therapy is performed individually. It is focused on the restoration of a phatic deficit and the maintenance or renewal

of the patient’s mental stability. In early phases of the illness, psychotherapeutic and language stimulation is implemented. Certain non-verbal techniques, such as working with breathing techniques and the body as well as receptive and active music therapy can be used for additional facilitation. In the chronic stage of illness, therapy is aimed at the renewal of social contacts and the patient’s inclusion into their social environment. Individual and group therapy can be combined. During individual therapy, those types of communication that the patient needs the most and in which at least a slight improvement can be expected are developed. During group therapy, communication skills attained during previous stages or re-education are utilized. Therapy for dysarthrias is aimed at influencing speech through adequate body tone and muscle relaxation, breathing modification, phonation, articulation, resonance exercises, exercising prosody, rhythmization and intonation approaches, and utilization of nonverbal communication and communication tools. Deficits in Swallowing and Management Options In certain neurological diseases, swallowing deficits develop in addition to other neurological signs. This occurs mainly when the mixed lateral tract, brain stem or extrapyramidal structures are involved. Therefore, deficits in swallowing are often seen in patients with degenerative CNS processes (i.e., amyotrophic lateral sclerosis), Parkinson’s disease, CVA, multiple sclerosis, etc. Swallowing deficits can be manifested at the level of food disintegration, during the pharyngeal phase when contraction of the pharynx pushes the bolus forward and interrupts breathing or in the esophageal stage when the food is pushed by esophageal contractions into the stomach. Prior to initiation of treatment, a functional assessment, such as a modified barium swallow study (videoendoscopic) should be performed to specify the type of swallowing deficit. Evaluation of the dynamics of the swallowing process determines the therapeutic approach and allows for the

assessment of aspiration risk. Certain precautions need to be followed in patients with a swallowing dysfunction. For swallowing, the ability to cough is very important in preventing possible aspiration. At the beginning of therapy, pureed food is recommended to compensate for slower elicitation of the swallowing reflex. Liquids should be served later. Yogurts are not recommended because their aspiration is linked to an increased risk of pneumonia. Selective tongue movement training is important for swallowing activity. The tongue helps move the food inside the mouth and with it, its disintegration. It also transports food into the back of the mouth. The tongue stabilization function is absolutely vital for swallowing. Without tongue stabilization, or without the tongue’s ability to rest against the palate, swallowing is not possible. Electropalatography allows for specific tongue training. A swallowing dysfunction often occurs simultaneously with speech dysfunctions. The physiological swallowing process and the correct formation of speech require normal function and cooperation of the orofacial, pharyngeal and laryngeal musculature. If these muscle groups are disrupted, speech and swallowing deficits occur, often simultaneously. This can be seen, for example, in amyotrophic lateral sclerosis if the bulbar region is involved. This type of patient will demonstrate swallowing deficits as well as other problems that lead to a significant decrease in the patient’s quality of life. Orofacial Therapy Orofacial rehabilitation is performed by physical, speech and occupational therapists. Stimulation of this region’s sensory functions plays an important role during motor function re-education. Reduction of spasticity is one area given particular attention. Positioning the patient in sitting with the head in slight flexion and performing passive movements are important. Specific vibration and tactile stimulation allow for a decrease in mimetic muscle tone. This is complemented by passive movements of mimetic muscles within their natural functions. For orofacial function, cervical spine mobility is important, especially the atlanto-occipital joints. Therefore, orofacial

therapy includes mobilization techniques for the cervical and thoracic spine. During therapy and over the course of a day, cervical spine hyperextension is strictly prevented, although the patient shows a strong tendency toward it. Also, an attempt is made to limit the risk of sensory deprivation in the oral cavity area. Gentle intra-oral tactile stimulation, gum massage, passive movement of musculature and thermal stimulation are used for this purpose. A patient can react negatively to these intraoral stimuli. The presence of the biting reflex poses a potential complication. It occurs based on a lack of sensory impulses from the orofacial region. Development of the biting reflex is prevented by the timely initiation of orofacial therapy. In case this reflex cannot be inhibited, the application of botulotoxin is recommended. The method by Castillo Morales (previously mentioned) is one of the approaches for orofacial reeducation that is suitable for patients with speech and swallowing dysfunctions.

1.5 ORTHOTIC CARE IN NEUROLOGICAL DISEASES Petr Krawczyk Most neurological diseases manifest themselves in various forms of motor deficits, by structural changes in the soft tissues and the muscle system or even by developmental deficits of the skeletal system. The main goal of orthotic care is to compensate for the functional deficits stemming from the aforementioned changes. Various tools can be used to achieve this goal. Some neurological diseases require specific orthotic equipment, which is going to be specified for individual neurological diseases.

1.5.1 Orthotic Management for Patients with Cerebral Palsy Application of orthotics for patients with infantile cerebral palsy and, in general, for patients with spasticity, puts high demands on the interdisciplinary teamwork and experience of the individual members of the therapeutic team. Orthotic support for verticalization includes not only individual practical stabilization and joint centration during the patient’s standing and ambulation, but also needs to be correctly applied during the entire course of treatment to establish conditions for gradual verticalization, including orthotic management of contractures, post-operative splinting and subsequent assurance of correct foot position in standing and during ambulation. Extremity orthoses are applied during conservative therapy to stretch shortened muscle groups and for subsequent positioning aimed at improving muscle length as one of the main biomechanical characteristics of spasticity. Besides the already mentioned prophylactic use to correct poor alignment, extremity orthoses can be applied as part of a complex treatment approach with botulotoxin treatment. In this case, the orthoses are applied immediately following the administration of botulotoxin to maintain the achieved correction. Selection of orthotic devices is based on the initial functional assessment of the movement system of all involved body parts. The

application of the device over the course of the day is important and it is adjusted according to the course of rehabilitation care. The use of orthoses in post-operative care depends on the individual surgical procedures. In such cases, the orthoses preserve range of motion and joint centration and help achieve muscle balance between the antagonistic muscle groups. The goal is to maintain the postoperative effect achieved by corrective soft tissue or bone procedures. In multiple-stage procedures, a HKAFO proved to be beneficial to ensure abduction and derotation in the hip joints and extension positioning in the knee and ankle joints (Fig. 1.5.1-1A; Fig. 1.5.1-1B). During orthosis application that ensures multi-joint lower extremity alignment, the orthosis needs to be correctly positioned and repeatedly monitored to ensure correct alignment of the heel and the entire leg within the orthosis. This is done so that extremity shifting within the orthosis, pressure point formation and stabilization in an incorrect lower extremity alignment are all prevented during its wear. Fig. 1.5.1-1A Abduction and derotation positioning orthosis

Fig. 1.5.1-1B HKAFO – postoperative positioning orthosis

Becker orthoses have proven beneficial to correct internal rotation alignment of the lower extremities (Fig. 1.5.1-2A,B). A simple antirecurvatum functional brace for the knee joint is applied to correct undesirable knee hyperextension alignment (Fig. 1.5.1-3).

Fig. 1.5.1-2A,B Becker orthosis Fig. 1.5.1-3 Anti-recurvatum brace of the knee joint

A plastic anti-recurvatum KAFO orthosis is applied to correct simultaneous instability and talocrural joint position. To ensure adequate hip joint centration, a modified abduction hip orthosis like the Atlanta hip brace is applied with a custom made and reinforced lumbar socket that prevents an undesirable asymmetrical shift of the orthosis. A SWASH orthosis is applied to ensure abduction and to correct an undesirable flexion-adduction alignment of the hip joint (Fig 1.5.1-4, Fig. 1.5.1-5).

Fig 1.5.1-4 HO – hip orthosis to enforce abduction, SWASH orthosis

Fig. 1.5.1-5 HO – SWASH (standing, walking and sitting hip orthosis)

To correct foot alignment, mainly pronation or supination posting of the insoles and application of thermoplastic (hard-shell) orthopedic insoles are used. Correction of a rigid equinus position of the talocrural joint is emphasized for joints in which the foot cannot be positioned in a neutral alignment even when it is fully relaxed. In such a case, a heel lift is recommended, which also positively corrects for a knee’s tendency toward joint recurvatum. It is highly recommended to not apply a heel lift in a foot that can be passively positioned to 0° at the talocrural joint, which preconditions the triceps surae to shortening. For verticalization into sitting, custom made sitting trunk orthoses are used for children with hypotonic posture. When designing the orthosis, the range of deformity, the location of the apex of the spinal curvature, the degree of hypotonia and active trunk and head control need to be taken into consideration. During correction, a three-point principle is used. For progressive curvatures, a classic, plastic, and customized sitting trunk orthosis fabricated based on a plaster mold is recommended (Fig. 1.5.1-6). In cases of axial hypotonia with kyphotic posture and minimal deviation of spinal curvature in the frontal plane, a sitting trunk orthosis made from reinforced foam material is sufficient (Fig. 1.5.1-7).

Fig. 1.5.1-6 Plastic dynamic trunk orthosis for sitting Fig. 1.5.1-7 Trunk orthosis for sitting made from reinforced foam material

The collection of measurements is performed by sitting in a correct alignment on a cushion with memory foam. This method is well tolerated by children. In children with neurogenic hip dislocation, an incorrect position of 90-degrees of hip flexion in a sitting trunk orthosis can cause pain and decreased tolerance for the brace. With progressive spinal deformities, a plastic trunk orthosis for

scoliosis (TLSO, Cheneau corset) is recommended. For patients with spasticity, the application of a modified three-point plastic trunk orthosis of a “half-shell” is recommended, which is well tolerated by children. As an atypical orthosis for patient verticalization, a custom made or serial stander known as the parapodium should be considered. For the stander to be applied correctly, the body needs to be stabilized at all levels. A stabilized plantigrade stance in suitable, firm footwear and stable extension of the knee joints need to be assured. Based on the level of involvement, the patient’s pelvis and the trunk need to be adequately stabilized. Prior to verticalization in a stander, the hip joints can be fully weightbearing only if approved by a physician. The application of a custom-made or serial orthopedic-prosthetic device is based on a comprehensive examination, functional assessment, and the treatment recommendations by a multidisciplinary team of specialists.

1.5.2 Orthotic Interventions for Patients with CharcotMarie-Tooth Disease Charcot-Marie-Tooth disease (CMT) is among the most common hereditary neuropathies. A high foot arch is typically present in patients with CMT. As a result of peripheral nerve involvement, muscle hypotrophy occurs, which leads to the development of foot deformities, such as pes cavus or pes equinovarus. With a longerlasting progression, structural deformities also develop, such as pedes transversoplani and toe deformities. Given the decreased sensory function of the peripheral nerves, plantar calluses can form under the metatarsal heads. Weakening of the foot dorsiflexors leads to a foot slap during gait. Also, ankle joint instability into inversion is often seen in these patients. A more significant involvement of the peripheral nerves of the lower extremities leads to thigh muscle atrophy. The clinical picture includes knee joint instability with the development of genu recurvatum and a significant change in the gait pattern. Fine motor skills of the upper extremities may also be

affected as a result of muscle atrophy. Asymmetry in trunk musculature leads to the development of neurogenically based scolioses. During orthotic management, an emphasis is placed on the examination and diagnosis of a possible pathological distribution of loading in the plantar area. A mirror pedometer, plantogram or dynamic computer pedobarography are used for examination. Orthotic intervention is based on the assessment findings and includes the application of special, custom-made orthopedic inserts based on the loading distribution of the feet with the goal to decrease the maximum pressures exerted on the plantar surface. Orthopedic inserts are fabricated based on a plantogram, a three-dimensional step into a plastic foam matter and, in serious cases, also on fabrication of a plaster cast. By using corrective tools (for example, pronation wedges, supination wedges, various types of metatarsal rockers), the undesirable foot positioning and loading during gait can be adjusted. From this perspective, the options of orthopedic shoe modifications compared to standard footwear, mainly the corrections that can be made to the bottom of the shoe (shoe sole) have not been fully appreciated. Correctly selected modification can significantly contribute to gait stability. The application of a derotation wedge on the lateral side of the sole (a pronation wedge) has been shown to be beneficial. In patients with a unilateral limitation of foot dorsiflexion, a functional lengthening and the development of compensatory knee hyperextension or even recurvatum can occur. In some cases, a recommendation of footwear with wedging of the sole is sufficient. Application of orthopedic footwear is based on gait assessment. When foot drop and steppage gait occur, orthopedic footwear is indicated instead of an orthosis (with application of a peroneal counter with a peroneal spring, built up outsole for an inverted foot position). Sufficient room in the front part of the footwear, the so called toebox, ensures ample space when toe deformities are present. With ankle dorsiflexor weakness, a figure-eight bandage is used most frequently with adjustable peroneal straps and tape over which

the patient ties their shoes. Peroneal AFOs are applied less often because they are difficult to tolerate. An option in the application of an AFO includes dynamic carbon AFOs (see later Fig. 2.3.3-8A,B in Chapter 2 Treatment Rehabilitation in Orthopedics and Traumatology) with a built-in individual padding or an SAFO – silicone orthoses with a reinforced instep to correct incorrect plantar positioning while maintaining plantar proprioception. For orthotic correction of knee instability and recurvatum (KAFO orthoses, anti-recurvatum braces), a possible rigid equinus ankle alignment has to be simultaneously treated by orthotics because it contributes to knee hyperextension.

1.5.3 Orthotics for Patients Following Poliomyelitis The principles of orthotic application for this disease are based on the same principles that are described in the above paragraph. Patients with flaccid paresis and extremity plegia demonstrate foot dorsiflexion weakness as well as instability in the ankle and knee joints and formation of genu recurvatum. In such patients, KAFO application has been beneficial when made from plastic or carbon fibers (see Fig. 2.5.5-11B in Chapter 2. Treatment Rehabilitation in Orthopedics and Traumatology) as well as, with the application of special orthopedic footwear with a built-in correction for leg shortening, built-in outsole and other modifications based on specific findings.

1.5.4 Orthotics for Patients Following CVA To treat hemiparetic upper extremities, positioning orthoses are applied to affect the disadvantageous flexion positioning of the fingers and the radiocarpal articulation. When the orthosis is applied, the thumb should be positioned in abduction and the palm of the hand and the fingers should be placed in a soft material to avoid potential facilitation of spasticity. During gait, the upper extremity is supported in a sling-like shoulder orthosis to prevent shoulder joint protraction and the hand and the forearm are positioned in supination. The shoulder orthosis should not overload the cervical

spine (see Fig. 2.5.4-16B in Chapter 2 Treatment Rehabilitation in Orthopedics and Traumatology). With dominant peroneal paresis of the lower extremity, based on the severity and extent of ankle joint instability, light peroneal bandages and straps (Fig. 1.5.4-1A,B) or a dynamic AFO can be applied that can, with correct fabrication, help stabilize the foot if the forefoot is in an inverted position.

Fig. 1.5.4-1A,B Peroneal bandage. A – correction by tape; B – schema of the effect of a sliding splint in the footwear

1.6 OCCUPATIONAL THERAPY Veronika Schönová In a patient with neurological involvement, an occupational therapist focuses on the motor, cognitive and psychosocial areas. Together with the other multidisciplinary team specialists, they attempt to guide the patient toward maximum possible self-sufficiency in activities of daily living, gross and fine motor skills, and even graphomotor skills. Furthermore, they perform sensory function training, help the patient become re-integrated into social and work environments and adapt to changing life conditions. Part of occupational therapy intervention can also include a visit to the patient’s home or work environment to suggest appropriate modifications or compensatory tools. In a multidisciplinary team, sufficient communication and cooperation between the individual specialists are vital so that treatment and rehabilitation are the most effective and lead to the highest quality of the patient’s life. For more details, see the General Section of the textbook, Chapter 4 Occupational Therapy.

SPECIAL SECTION In neurological diseases, depending on the involved region of the central or peripheral nervous system, various dysfunctions occur. The most common include movement dysfunctions that can be manifested in the following ways: Decreased muscle strength Changes in muscle tone Disturbance in muscle coordination Balance deficit Decreased ability to perform a specific movement Other frequent manifestations include sensory deficits, involuntary extremity movements, and often also various pain syndromes. The neuromuscular system can be dysfunctional anywhere along its course from the peripheral structures up to the highest CNS centers. In some neurological dysfunctions and diseases, only a localized deficit with a certain level of peripheral or central nervous system involvement is present. The clinical presentation of such patients is very similar (for example, peripheral nerve lesions, localized spinal lesions). In such dysfunctions, similar rehabilitative treatment approaches can be implemented. In some neurological diseases; however, a more extensive multi-site injury involving nervous system structures can occur and, in such patients, a marked variability and inconsistency in the clinical presentation is observed (for example, in multiple sclerosis or neurodegenerative diseases). In such cases, a universal approach cannot be used for treatment because each patient requires a specific approach based mainly on the most dominant clinical signs. In the following text, treatment rehabilitation approaches are going to be mentioned for the most frequent neurological dysfunctions and illnesses, such as: Dysfunction in neuromuscular transmittal and muscle diseases

Peripheral nerve pareses and polyneuropathies Post-poliomyelitic syndrome Spinal cord injury Cerebellar dysfunctions and balance deficits Extrapyramidal deficits, Parkinson’s disease Neurodegenerative diseases Multiple sclerosis Deficits in consciousness Craniocerebral trauma and apallic syndrome Vascular brain injury Cerebral palsy

1.7 DYSFUNCTIONS IN NEUROMUSCULAR TRANSMISSION AND MUSCLE DISEASES Petr Bitnar, Magdaléna Lepšíková

1.7.1 Dysfunction in Neuromuscular Transmission – Myasthenia Gravis Myasthenia gravis is a typical representative of this group. It is an autoimmune disease that manifests itself mainly by muscle fatigue and weakness. The prevalence is approximately 10–15 cases per 100,000 individuals. To this day, the cause is an unexplained autoimmune disease in which specific antibodies form (especially in the thymus; hyperplasia of the thymus is one of the diagnostic factors of this disease) that block the post-synaptic acetylcholine receptors through activity of the sodium channels in the cellular membrane. Difficulties in myasthenia gravis fluctuate typically during the day. They are the mildest in the morning, increase during the day, especially after exertion and they decrease with rest. One of the first manifestations of the disease includes the involvement of an eye-moving and oropharyngeal musculature (ptosis, eye movement deficits, diplopia occur). With neck muscle weakening, the head starts dropping. The patient’s speech is slurred and often unintelligible. The disease is progressive, later causing weakness in the girdle musculature (upper and lower extremities) with respiratory musculature also possibly affected. Breathing insufficiency can lead to breathing myasthenic crisis and requires artificial ventilation. Treatment includes administration of cholinesterase inhibitors and immunosuppressive medications. Myasthenic syndromes can also develop secondarily with polyneuropathies, polymyosities, brain stem lesions, following certain antibiotics, with endocrinopathies and as a paraneoplastic manifestation in tumors, mainly in the lungs (Lambert-Eaton syndrome). Congenital myasthenic syndromes are also known.

Myasthenia gravis needs to be distinguished from temporary muscle palsies, which accompany deficits in ion channels (channelopathy). In such cases, an imbalance in ion channels that participate in the control of muscle membrane polarity occurs. These conditions are going to be discussed in more detail later. Rehabilitation in Myasthenia Gravis For a long time it was thought that physical exercise in patients with myasthenia gravis was contraindicated. However, newer studies point out that increased physical activity in the form of exercise is beneficial for such patients. Many patients themselves use exercises as selftherapy for myasthenic signs that make certain daily activities difficult. Strengthening and aerobic exercise improve the patient’s movement functions, mobility and activities of daily living. Based on many studies, patients who exercise demonstrate mainly increased muscle force (for example, quadriceps femoris showed 23% increase in strength in the exercised vs. non-exercised lower extremity). Muscle coordination also improves and muscle distribution changes to a certain extent. Also, the overall positive effects of physical activity should not be forgotten, such as improved oxygen and glucose utilization, increased number of mitochondria in working muscle cells, harmonization of sympathetic and parasympathetic activity, prevention of metabolic illnesses (diabetes mellitus) and increased production and secretion of endorphins, which generally increase the effectiveness and improve the internal environment as well as the patient’s psychological state. From a respiratory perspective, resistive respiratory exercises are important because they increase the strength and effectiveness of respiratory musculature and vital lung capacity and improve thoracic wall mobility and expandability. By optimizing the patient’s respiratory functions, the physical performance, quality of life and homeostasis of the internal environment are improved. However, physical exercise in patients with myasthenia gravis does not significantly decrease muscle fatigue (which is one of the main problems for patients with myasthenia); on the other hand, it decreases the feeling of fatigue subjectively.

Physical therapy also attempts to optimize the patient’s postural conditions and muscle tone distribution. Besides aerobic exercise, techniques aimed at improving muscle coordination and techniques facilitating or inhibiting muscle tone are implemented (for example, sensorimotor skills, exercises based on developmental kinesiology, Vojta’s method, proprioceptive neuromuscular facilitation, manual therapy techniques). A large group of patients with myasthenia gravis suffers from the involvement of the muscles needed for eye movement, mimetic and oropharyngeal muscles. Therefore, in such cases, the treatment must include these areas. With mimetic muscle exercises, the patient practices changing facial expressions in front of a mirror. When swallowing functions and the muscles of mastication are involved, therapy based on orofacial approaches can be utilized (orofacial therapy based on Anita Kittel, Castillo Morales concept, or NDT techniques). For speech impairments, speech therapy and breathing exercises are the most effective.

1.7.2 Muscle Diseases Myopathies form a diagnostically wide scale of neuromuscular diseases. A myogenic lesion is a common cause and an interlinking sign, which is why muscle diseases are referred to as myopathies. Decreased muscle tone is their main common denominator. In individual muscle diseases, different muscle groups can be involved, but the clinical presentation is similar. Most often, the patients show significantly weaker proximal musculature, especially in the lower extremities. An anterior pelvic tilt (anteversion) occurs as a result of decreased strength in the pelvic girdle, thigh and abdominal muscles and an increase in lumbar lordosis. The so called myopathic syndrome develops, which is present in the majority of muscle diseases. When weakness in the quadriceps femoris and hip extensors is present, the Gower’s sign (or myopathic climbing) can be observed. In Gower’s sign, the patient relies on the use of their upper extremities to push themselves up to standing by “walking” their hands up on

their thighs when transitioning from a squatted position. The gluteus medius, which acts as the main lateral stabilizer of the pelvis, is another muscle that subsequently shows decreased strength. When standing on one leg, the pelvis drops on the side of the swing lower extremity. Clinically, this results in a positive Trendelenburg sign and a typical myopathic waddling gait also known as “duck walk”. Generally, it can be concluded that from a functional perspective, a patient with myopathy shows difficulty mainly when ascending stairs, especially high steps into vehicles, when rising up from a squat or a low chair or when transitioning from lying down. A spinal kyphoscoliosis can develop, which worsens not only with age, but also with the loss of standing and walking ability. Often, pes equinus or pes excavatus with hammer toe deformities develop as a result of calf muscle contractures. Decreased muscle-tendon reflexes and a decrease or cessation of idiomuscular stimulation are also observed. Sensation deficits are not present. A higher level of muscle enzymes in serum is found. The diagnosis can be specified based on electromyographic examination, molecular genetic testing or muscle biopsy. Muscle diseases are classified as follows: Muscular dystrophies (Duchenne and Becker muscular dystrophy, facioscapulohumeral form of muscular dystrophy, girdle forms of muscular dystrophy, more rare forms of muscular dystrophies, myotonic dystrophy, etc.) Metabolic myopathy (glykogenoses, mitochondrial myopathies, deficits in lipid metabolism, steroid myopathies, etc.) Congenital myopathies (nemaline myopathy, myotubular myopathy, etc.) Inflammatory myopathies (autoimmune and infectious myopathies) Ion channels dysfunction (myotonic syndromes, periodic palsies)

MUSCULAR DYSTROPHIES

Muscular dystrophies are genetically based muscle diseases with primary involvement of skeletal muscle tissues based on an inherent deficit in muscle metabolism. To a certain extent, individual forms of dystrophy show different clinical signs depending on which muscle groups show decreased strength.

DUCHENNE AND BECKER MUSCULAR DYSTROPHY Duchenne muscular dystrophy is among the most frequent forms of primary muscular dystrophies. It is linked to an X chromosome whose protein product is dystrophin (a disease, in which the production of dystrophin is disrupted is called dystrophinopathy and Duchenne dystrophy includes approximately 80% of all cases of dystrophinopathies). Duchenne muscular dystrophy affects mainly boys. The prevalence is 20–30 cases in 100,000 births of boys. The first signs emerge between the ages 2–5 and quickly progress. A less progressive type is known as Becker muscular dystrophy, which begins at a later age. The disease is characterized by gradual weakness of the pelvic and thigh musculature, in which a myopathic syndrome develops. Besides muscle weakness, muscle atrophies of the affected muscle groups also progress. In the calves, however, pseudohypertrophy gradually develops and is characterized by a paradoxical increase in the volume of the calf muscle belly. This occurs based on increased interstitial adipose and connective tissues that replace the atrophying muscle fiber. This type of tissue; however, lacks contractile ability and, in contrast to a physiological hypertrophy that occurs with strengthening, the muscle tissue instead decreases. Upon palpation, a pseudohyperthrophic calf shows a rubber-like consistency. As a result of Achilles tendon shortening, toe walking emerges. During the disease progression, spinal kyphoscoliosis and flexor musculature contractures also quickly progress. Between the ages of 15–20, the patient is completely immobile and often develops cardiomyopathy and breathing difficulty. Death occurs between ages 20–30. Becker muscular dystrophy also leads to disability, but the patients

live longer. The clinical manifestation is similar to the Duchenne form, however, there is greater variability between individuals, especially slower progression. On average, the first signs do not emerge until the onset of puberty and independent locomotion is usually not impeded until middle age (approximately between ages 30–40). Some patients remain mobile until their death, which is usually caused by cardiomyopathy.

FACIOSCAPULOHUMERAL FORM OF DYSTROPHY Facioscapulohumeral form of muscular dystrophy is a more benign muscle disease in its course and the prognosis varies among individuals. Prevalence is 1–5 cases in 100,000 people. At first, the mimetic muscles gradually atrophy so that with time, the lips protrude prominently (“tapir” mouth) and chewing and eye lid closure problems develop. Since weakness of the girdle musculature develops, the patient demonstrates problems with dressing, combing, etc. Later, distal trunk and pelvic musculature also become affected. The disease progression is very slow. In the scapuloperoneal form, the lower leg and the scapular musculature are involved (Fig. 1.7.2-1). (Fig. 1.7.2-1 Facioscapulohumeral form of muscle dystrophy. Significant atrophy of the shoulder girdle musculature as well as winging scapulae are quite apparent

GIRDLE FORMS OF MUSCULAR DYSTROPHY Girdle forms of muscle dystrophy are a genetically heterogeneous group of diseases characterized by weakness of the proximal musculature and a myopathic syndrome. This form of dystrophy develops in childhood or early adulthood. In some forms, pseudohypertrophy of the calves develops.

OTHER FORMS OF MUSCULAR DYSTROPHY In Emery-Dreifuss muscle dystrophy, in addition to myopathy, contractures of the elbow, Achilles tendon, neck musculature, spine and the knee are typical. Cardiomyopathy is common. Distal muscle dystrophies begin in adulthood and manifest themselves by predominantly distal muscle involvement. Ocular myopathy is characterized by slowly progressive involvement of eye-moving musculature and an onset of external ophthalmoplegia (Fig. 1.7.2-2). Fig. 1.7.2-2 Patient with ocular form of myopathy – drooping of the upper eye lids is apparent (ptosis)

Oculopharyngeal dystrophy manifests itself by involvement of the eye-moving musculature with deficits in mobility of the eye bulbus and also by involvement of the pharyngeal muscles, which leads to swallowing problems.

MYOTONIC DYSTROPHY It is a progressive disease with a wide variety of clinical manifestations. Clinical presentations are generally seen in three forms. The classical clinical picture appears primarily in the first three

decades of life. Myotonia and mimetic, forearm and, also common, leg extensor muscle weakness are present. The congenital clinical picture is manifested as muscle hypotonia from birth. It is accompanied by slower psychomotor development or even mental retardation. A mild form appears after the age of 40 and it is manifested by a rather myopathic picture often accompanied by cataracts. Clinical findings in myotonic dystrophy also contain deficits in the cardiac conduction system, smooth muscle (decreased motility), respiratory dysfunction, CNS deficits and deficits in the glands with internal secretion (testicles, thyroid gland, pancreas). It also significantly shortens life expectancy. The diagnosis is based on EMG testing that shows a combination of myopathic changes and myotonic reactions. During rehabilitation for myotonic dystrophy, similar methods are used as in other muscle dystrophies, but the approaches listed below are especially appropriate for myotonic syndromes. Rehabilitation in Muscular Dystrophies Since etiology-based therapy for muscle dystrophy has yet to be developed, system-based rehabilitation care plays a very important role. Treatment rehabilitation focuses mainly on prevention of secondary changes (deformities and contractures) and slowing down the progression of functional limitations. If muscle weakness is present, a regularly performed physiological movement within its full range is not possible. In such a case, the antagonist of the weakened muscle group is not stretched, leading to a retraction of the connective tissue (so called muscle contractures). A contracture in a dystrophic muscle affects the tendon, ligament and the muscle fiber. It is a combination of shortening of intramuscular connective tissue and degenerative processes within the affected muscle fibers. Passive and slow manual stretching is utilized to stretch the shortened muscles and prevent contractures, or to position the shortened muscle in a way that encourages its maximum length. For

this purpose, special splints or a standing table can be used. A combination of stretching or positioning with thermal modalities (heat) is also an appropriate form of treatment because the use of hot packs increases blood perfusion in the involved muscle tissue. To preserve muscle strength, active strengthening exercises against light resistance or methods based on a neurophysiological origin, such as sensorimotor stimulation, Vojta’s reflex locomotion, proprioceptive neuromuscular facilitation, etc. are appropriate. To encourage healthy respiratory function, which becomes dysfunctional as a result of involvement of the respiratory muscles themselves as well as secondarily due to developing spinal deformities, controlled resistive breathing exercises and pulmonary physical therapy techniques are implemented. Regular aerobic training such as, for example, walking at 60–70% of maximum heart rate, can improve cardiovascular performance and, thus, help decrease fatigue. This type of short-term, mid-intensity aerobic loading is beneficial mainly in mitochondrial myopathies. However, eccentric muscle contraction exercises are contraindicated, in which muscle fiber damage has been demonstrated due to the lack of reparative capability of the involved musculature. The patient should also avoid this type of contraction during activities of daily living, such as with sit to stand, descending stairs or activities demanding prolonged forward bending of the trunk. The quadriceps femoris and the paravertebral musculature are among the most eccentrically loaded muscles on a daily basis. During occupational therapy, the patient should be instructed on how to perform individual self-care activities with minimal effort and with maximum limitation of eccentric contractions. To ease certain activities or to support upright body posture, appropriate assistive devices can be recommended to the patient. An elastic trunk orthosis or a corset can be used to assure an upright trunk position. In advanced stages of a disease, when the patient loses independent mobility, an electric wheelchair can be indicated in certain cases. Beginning in the 1990’s, the Association of Muscular Dystrophy

Patients of the Czech Republic, a national organization which functions in the Czech Republic to provide not only social and legal help and organize rehabilitation courses and seminars, but also represents specific interests and the needs of patients with this disease.

CONGENITAL, METABOLIC, INFLAMMATORY AND TOXIC MYOPATHIES These myopathies have many causes, categories and forms, which is why their clinical manifestations span a wide spectrum and are specifically dependent on the type of muscle tissue damage. From a general movement perspective, decreased muscle strength and increased fatigue are always present for all forms of congenital, metabolic and toxic myopathies. Muscle tone distribution and the muscle-connective tissue ratio change, adjusting in favor of the connective tissue component. Decreased mobility and limitation in daily activities as a result of increasing muscle dysfunction are the most significant and, from a patient perspective, the most unfavorable manifestations of myopathy (often leading to a complete immobility and inability of self-care). Congenital, metabolic and toxic myopathies very often accompany other systemic diseases and dysfunctions of vital organs (kidneys, liver, heart), including diverse CNS dysfunctions. As a result, they have fatal consequences and significantly decrease life expectancy. Rehabilitation is based on specific kinesiological findings determined by the type of the disease. In general, it needs to lead to prolonging the patient’s locomotor and manipulative functions for as long as possible, especially through the facilitation of the neuromuscular and cardiorespiratory systems and physically affecting the connective tissue component. Occupational and psychological therapy play a significant role within the overall rehabilitation treatment. In congenital structural myopathies, which among other things include retardation of psychomotor development and the presence of skeletal deformities, Vojta’s therapy is essential from a diagnostic and therapeutic perspective.

ION CHANNEL DYSFUNCTIONS Ion channel dysfunctions (channelopathies) or deficits in muscle excitation can also be a cause of muscle deficits. They develop by disruption in the ion channel balance that ensures changes in muscle membrane polarity and, thus, the onset of an action potential. Ion channel disturbances are the cause of periodic paralysis and myotonic syndromes.

PERIODIC PARALYSES Periodic paralyses manifest themselves by states of muscle weakness sometimes bordering on paralysis (myoplegia). Sometimes, they last only a few minutes, other times up to several hours and manifest themselves most often after a period of prolonged rest preceded by substantial physical work (demand). Manifestations of paralysis occur rarely during physical activity. Paralysis attacks can also be provoked by greater food intake with a significant proportion of sugars (hypokalemic periodic paralysis) or, in contrast, by starvation (hyperkalemic periodic paralysis). Between individual attacks, patients may be without problems completely. Periodic paralyses occur most frequently as a result of potassium imbalance; through a decrease and increase in potassium plasma concentration. Therefore, two forms have been identified: hyperkalemic and hypokalemic. Hyperkalemic Periodic Paralysis It is a relatively rare autosomal dominant illness. Attacks of weakness manifest themselves typically in the morning, at rest after exercise or during starvation. Overall about 2–3 times per day. The weakness lasts approximately 1 hour and typically spreads in an ascending fashion from the lower extremities. In the active stage, a high concentration of serum potassium can be seen. Hypokalemic Periodic Paralysis This autosomal dominant disease manifests itself in adolescence and it is less common than the previous form, but the period of weakness is more severe and lasts longer. The muscle weakness is more

pronounced on the upper half of the body. Mimetic and also sometimes the swallowing and respiratory musculature can be affected. Paramyotonia Congenita This congenital paramyotonia also belongs among periodic paralyses for its periodic states of weakness, but it is caused by a deficit in the sodium channels. The level of potassium is usually normal during the episodes. It is manifested by periodic paralyses and myotonia that is triggered mainly by coldness. It differs from myotonia because myotonic symptoms worsen during exercise (hence paramyotonia). Paramyotonia most often affects muscles of the face, neck and the distal parts of the upper extremities.

MYOTONIC SYNDROMES Ion channel deficits also manifest themselves as a myotonic syndrome, thus a prolonged state of muscle contraction and the inability of an immediate release of the contraction. It is a group of genetically conditioned illnesses manifested by an increased muscle fiber excitability coupled with the inability of quick relaxation following a contraction. Based on the changes in a spatial configuration of the ion channels, intracellular ion imbalances occur, which change the muscle cell membrane’s excitability, leading to developing and lengthening of repetitive action potentials. Clinical testing of myotonia is most often performed by tapping on the muscle belly while the muscle contracts after which a significantly slower relaxation is observed. Sometimes, a sustained hollowing in a muscle caused by a slow de-contraction of the mechanically stimulated fibers can be observed. This is called mechanical myotonia and its manifestation is visible especially in the thenar, tongue and forearm muscles. The hand shake test is a sensitive test in which the patient is unable to quickly release their hand and open their fingers following a hand shake because they over engage the extensors (action myotonia). Muscle stiffness is most noticeable during the first contractions

following a rest period. Repeated movement lessens the myotonic reaction – the so called warm-up phenomenon. Congenital myotonia (myotonia congenital) and atypical myotonic syndromes are also included among myotonic syndromes Myotonia Congenita Congenital myotonia is an autosomally linked disease found in two forms: The Thomsen autosomal dominant form The Becker autosomal recessive form Reduction in chloride channels, which prevents the access of the chloride ions into the cell is the primary cause in both forms. The main inhibition to depolarization of T-tubules (primarily the cell membrane) is disrupted due to this reduction. The Thomsen form appears sooner, often in early childhood – at infant age. The condition does not progress much further during life. The individuals show hypertrophic musculature, which gives them an athletic appearance. Myotonia is generalized and the muscles of the eye lids can also become affected, which can lead to transitional blepharospasms. From the perspective of locomotion, ambulation is more significantly affected because the patients demonstrate a greater tendency to fall. Overall, coordination and movement efficiency are affected the most. The “warm-up” phenomenon is typical. Muscle strength is preserved. The Becker form emerges later (can manifest itself at the end of the first decade of life) and slightly progresses over time (approximately to 30 years of age). The patient’s appearance is disproportional: hypertrophic musculature of the lower body does not correspond to the inadequately developed musculature of the neck and the upper extremities. Beside the stiffness, post-resting muscle weakness is more apparent in this form. Atypical Myotonic Syndromes They are manifested in two forms: myotonia fluctuans and myotonia

permanens. In the fluctuating form, the myotonia fluctuates daily and is not dependent on temperature. In the permanent form, myotonia is present nearly constantly and worsens when potassium is administered. Neck and shoulder girdle muscles are hypertrophic. This form manifests itself primarily by myotonia and, to a lesser degree, by muscle weakness. Rehabilitation for Myotonic Syndromes and Periodic Paralyses With the exception of paramyotonia, physical exercise is one of the treatment strategies for myotonic signs. Muscle stiffness occurs most noticeably at the beginning of exercises and disappears with exercise continuation. Therefore, the patients should perform dynamic, aerobic exercises daily. Muscle weakness can be decreased by exercising. In hyperkalemic periodic paralyses, it is possible to prevent the onset of paresis through exercise (literally “exercise the paresis away”). In paramyotonia and other categories of ion channel deficits in which exercise, in contrast, increases weakness, exercise is not contraindicated. Nonetheless, it is important to exercise to fatigue and attempt to gradually push the fatigue threshold higher. Patients with myotonia should exercise in higher temperatures to prevent getting a cold (even after exercise) because cold worsens myotonia. From physical therapy methods, sensorimotor stimulation is especially used for balance training and improved timing of muscles in their stabilization function. Exercises on balance boards and trampolines improve the patient’s feeling of security during ambulation and in other posturally more difficult situations. Classic manual therapy techniques, such as mobilizations, soft tissue techniques, etc., can be implemented because they affect joint mobility and tone of the possibly overloaded muscles. Among other methods, the Feldenkrais method and Schultz autogenic training have been found beneficial for patients with myotonia. These methods teach the patient conscious and specific muscle relaxation (the ones affected by myotonia) and, at the same time, decrease psychological stress, which generally prevents hypertonia and improves the patient’s relaxation ability. The Feldenkrais method

additionally improves body awareness and leads the patient in this way to the most fluid movements while utilizing the lowest number of necessary muscle fibers, which decreases movement requirements and improves coordination. Exercises based on developmental kinesiology, the Schrott method, etc., are appropriate when a deficit in body posture is present. In more severe deficits, respiratory physical therapy has its role by improving the pulmonary volume and helping with hygiene maintenance of the respiratory tracts. From the field of physical therapy, hyperthermal baths are often beneficial. Balneologic therapy is also very beneficial. Regular aerobic training of appropriate intensity is beneficial. Other exercise activities are also beneficial as long as they do not overload the involved muscles. Unweighted exercise has proven valuable – for example, exercise activities in the pool, hyperthermal baths, etc. Peloid wraps are also useful. Comprehensive spa treatments can be administered every 1–2 years. Based on the indication list, a neurologist prescribes balneologic treatment. An opinion by a cardiologist is also sought. Balneology treatment is not appropriate for patients with cardiac insufficiency and/or insufficient pulmonary ventilation. In the Czech Republic, balneology treatment is contraindicated for patients with myasthenia gravis and paroxysmal paralyses. Balneologic treatments for patients with muscle diseases are provided in Janske Lazne, Velke Losiny, Vraz, and Klimkovice.

1.8 PERIPHERAL PARALYSIS Ondřej Horáček

1.8.1 Causes, Degrees and Diagnosis of Peripheral Paralyses Peripheral paralyses develop when the peripheral nerves, nerve plexuses or roots are affected. Also, the anterior spinal horns can be affected; however, this is not as common. An ischemic-compressive injury or an injury to the peripheral nerves, nerve plexuses or nerve roots are the most common causes of peripheral paralyses. Peripheral nerve paralyses can also originate from metabolic, inflammatory or hereditary factors. This most frequently occurs in polyneuropathies, which are described in more detail in Chapter 1.10 The majority of peripheral nerves are mixed and, therefore, are formed by motor, sensory and autonomic (vegetative) fibers. When mixed peripheral nerves are injured, sensory deficits as well as autonomic (vegetative) signs are often present in addition to a motor deficit. With respect to the degree of involvement of the peripheral nerves, three degrees are distinguished: 1. Neurapraxia is a reversible damage of a slight degree. It is a transient disturbance in nerve function, mainly the myelin sheath. Axons are not disrupted (it is a conduction block). Repair occurs within a few days, no later than 6 weeks. 2. Axonotmesis is a disruption in axons including their distal degeneration from the injured area. The axonal coverings (endoneural tubes and myelin sheaths), however, stay preserved. Regeneration occurs spontaneously and it is functionally perfect. Axons grow into the original endoneural tubes. The deficit is corrected within 6 months. 3. Neurotmesis is the most severe degree of injury, during which the axons and their sheaths are disrupted. Waller degeneration occurs and, in this scenario, spontaneous regeneration is either more

difficult or completely impossible. Motor axon regeneration during axonotmesis progresses at a rate of 1mm/day. The time needed for the nerve to regenerate can be calculated from the distance between the area of the injury and the muscle motor point. Peripheral paresis manifests itself by typical changes, such as decreased muscle strength in the corresponding area, muscle hypotonia and hypotrophy, decreased or absent proprioceptive reflexes, various deficits in sensitivity and sometimes autonomic deficits. A sensory deficit does not occur when the anterior spinal horns or only the motor roots are affected. The diagnosis of peripheral paralysis is established based on a neurological exam. Electromyographic examination is also important to provide information about the preservation of nerve continuity and the conduction speed of the nerve fibers. Needle electromyography can determine whether it is a complete or partial denervation syndrome (Fig. 1.8.1-1). Sometimes, the I/t curve is performed, which is a complex form of muscle excitability testing. In graph form, it demonstrates the relationship between the electrical current intensity that is necessary to elicit threshold excitability with a gradual shortening of impulse time. The curvature shows characteristic changes during denervation and reinnervation. Parameters for oblique impulses are interpreted from the l/t curve and used for selective electrical stimulation of the denervated muscles (see General Section of the textbook, B. Therapeutic Approaches, Chapter 2.2.4 Electrodiagnostics and Electrostimulation of the Skeletal Muscles). Fig. 1.8.1-1 Manifestations of denervation (fibrillation and positive sharp waves) in the acute axonal lesion of the peroneal nerve – needle EMG

1.8.2 Rehabilitation of Peripheral Paralyses Rehabilitation of peripheral paralyses includes physical and occupational therapy. Physical Therapy Physical therapy methods are implemented following the preventative measures phase. Preventative Measures Preventative measures are supposed to prevent the gradual onset of secondary structural changes in a denervated and inactive muscle (for example, fibrotic changes and contractures). Preventative measures include the following: application of heat, massage, positioning, passive movements and electrical stimulation. In paralyzed muscles, electrical stimulation is important. During stimulation, electrical impulses elicit contraction in the denervated muscle and muscle trophicity is maintained until reinnervation occurs. Selective electrical stimulation is used, meaning only the denervated muscle fibers are stimulated, which is why impulses with gradual onset are used. The appropriate parameters for electrical stimulation – impulse length and intensity - are identified from the I/t curve. Electrical stimulation is usually completed when volitional muscle activity emerges. Physical Therapy Methods Analytical methods are used based on the neuro​physiological foundation. Analytical Exercises In most severe weaknesses (manual muscle test equivalent to grades 0,1 and low grade 2), analytical exercises utilize stimulation elements and the exercises are administered based on the results of manual muscle testing. For muscle strength grade 0 and 1, movement is performed passively with the patient’s awareness. For grade 2, exercises are performed in a gravity eliminated position and with active assistance. Grade 3 includes active exercise against gravity and starting with grade 4, it includes exercises against resistance. The methods based on neurophysiological foundation primarily

utilize proprioceptive neuromuscular facilitation, the Vojta method and sensorimotor stimulation. Proprioceptive Neuromuscular Facilitation Proprioceptive neuromuscular facilitation (PNF) is a complex facilitation method indispensable during therapy for peripheral paralyses. It is designed to facilitate movement through the facilitation of signalization from the muscle spindles and joint and skin receptors, during which the maximum number or motor units becomes activated. To achieve this, extremity movement in a diagonal direction against resistance is facilitated. The diagonal direction needs to be facilitated in which the affected muscles are activated. Therefore, it is important to know which muscle groups are activated during individual diagonals and their patterns. For example, the anterior tibialis (weakened by peroneal nerve paralysis) is activated in the direction 1 (D1) flexion pattern for lower extremities. Vojta Method During Vojta method application, a specific position needs to be selected in which optimal activity of a paralyzed muscle can be elicited within the framework of a global motor pattern. The ability of the individual to engage a muscle as well as the strength of the paretic muscle need to be taken into consideration so that the initial position is not too difficult to execute within the movement pattern. For example, during reflexive crawling, the tibialis anterior and the peroneals are activated in the flexion phase of the facial side lower extremity. Sensorimotor Stimulation Sensorimotor stimulation can be used mainly for lower extremity pareses by implementing exercises on various types of balance equipment. The level of instability needs to be adjusted to the degree of muscle weakness. This method is very appropriate, for example, for sciatic nerve paresis because exercising on an unstable surface quickly and alternately changes the activity of the weakened leg flexors and extensors, which leads to their co-activation. This improves the speed of muscle contraction and coordination of the mentioned muscle

groups. The components of this method are also included in the treatment of upper extremity pareses. Occupational Therapy Occupational therapy for peripheral pareses focuses on the improvement of fine motor skills. Its goal is to improve or at least maintain and compensate for the disrupted function of the affected extremity so that the patient is able to manage their activities of daily living and be as independent as possible. To accomplish this, the patients often use assistive devices, such as various orthoses and compensation devices (canes, crutches, or walkers) to ensure the correct position of an extremity or its segment for joint stabilization or for the patient’s stability during standing or ambulation. For plegias and severe pareses, physical therapy should be as intensive as possible and, in such cases, it is suitable to initially schedule it daily. However, this is not always possible, especially if the physical therapy is on an outpatient basis. Therefore, it is important to educate the patient early on about exercising during times between physical and occupational therapy sessions. In this period, it is important for the patient with an upper extremity paresis to perform facilitation of the paretic musculature by using their contralateral or unaffected extremity. Simple elements are used for facilitation (stroking, massage, vibration, passive movements). These encourage trophicity of the paretic musculature. When a lower extremity paresis is present, the patient stimulates the paretic musculature with both hands. It is important for the facilitation of the paretic musculature to occur repeatedly in sets during the course of a day (at least 6 times per day for at least 15 minutes) so that the paretic musculature could be stimulated frequently. The patient also needs to be educated on correct positioning so that they know which positions are appropriate for their paretic extremity and which positions should be avoided. For example, in a severe peroneal paresis, when the foot falls into plantarflexion, there is a risk of triceps surae shortening over time. The patient should be educated on calf self-stretching, prevention of undesirable and prolonged plantarflexion and foot positioning in an optimal alignment during a prolonged rest period, such as during

sleep. The therapists need to be prepared that patients with severe peripheral paresis exhibit anxiety, insecurity and fear regarding future progression. Usually, the patient repeatedly asks about their prognosis. For this reason, the patient needs to be educated early and appropriately about their prognosis. For example, if the peripheral nerve injury involves axonotmesis, in which the return of the paretic muscle strength can take several months, the patient should be informed that rehabilitation will most likely be long-term. Modalities Modalities are an important supplement to physical and occupational therapy for the treatment of peripheral paralyses. For preventative reasons, local heat application is utilized for its vasodilation, analgesic and muscle relaxation effects, especially prior to the initiation of treatment. However, if sensation is impaired, caution needs to be paid to avoid burning the patient. Paraffin wraps, moist heat, solar or other forms of dry heat can be used. For water treatment procedures, baths (38–40 °C) are indicated for their significant hyperemic effect. A whirlpool contributes to an increase in extremity blood perfusion, local metabolism and activation of skin receptors. Underwater massage (35–37 °C) has proven beneficial for muscle atrophies when applied in an ascending fashion. In neuritis or polyneuritis accompanied by peripheral pareses, deep galvanic current or galvanic bath of the extremities can be applied. Magnetic therapy is indicated given its vasodilation, anti-inflammatory and anti-edematous effects, as well as its ability to accelerate regeneration of the involved nerve. Thus, it is recommended in cases of traumatic injuries as well as in peripheral nerve inflammation. Laser may be used for its biostimulatory and anti-inflammatory effects, for example, in peripheral paresis in neuritis. Vasopneumatic therapy may be effective in peripheral pareses in which the distal segment of an extremity presents with edema. Vasopneumatic therapy uses alternating overpressure and underpressure in a cylindrical sleeve in which the affected extremity is positioned. Regeneration of an affected nerve can be improved by acupuncture, during which some points become

activated within the course of acupuncture pathways. The above mentioned approaches can be combined in rehabilitation for any peripheral pareses of the upper and lower extremities. The rehabilitation of peripheral pareses is based on the same principles whether the paresis involves an injury of the nerve roots, plexuses or the peripheral nerves.

1.8.3 An Overview of Peripheral Pareses Based on Location PERIPHERAL PARESES OF THE UPPER EXTREMITIES In the upper extremities, the most common palsies involve the brachial plexus and the radial, median and ulnar nerves. A paralysis of the motor nerves of the shoulder girdle (long thoracic nerve and suprascapular nerve) and the nerves found in the arm (axillary nerve and musculocutaneous nerve) occur less frequently. Physical therapy for brachial plexus palsy and radial, ulnar and median nerve palsy will be described in more detail. The approaches listed here can also be used with appropriate modifications for other peripheral pareses for which physical therapy treatment will be mentioned only briefly.

BRACHIAL PLEXUS PALSY (C5-T1) Often, this palsy is caused by a trauma in which traction and an avulsion of the spinal nerve roots can occur during an impact to the shoulder or with a pull on an extremity. Similarly, a brachial plexus palsy can occur post-delivery. Brachial plexus injuries can also occur with shoulder dislocations and fractures. Tumor infiltration (for example, carcinoma at the apex of the lungs – Pancoast syndrome) can be the source of non-traumatic damage to the plexus. Sometimes, the plexus can also be injured iatrogenically during a surgery, in which case the extremity is positioned in hyperabduction for an extended time. The lesions can be classified as either complete lesions of the entire plexus or incomplete lesions. An incomplete lesion can be classified as paresis of the upper, lower or middle type.

With a complete lesion of the entire plexus, (flaccid) palsy of the entire upper extremity occurs, but shoulder elevation is preserved. Sensation is disrupted along the entire extremity along the medial and posterior aspects of the arm. Upper braxial plexus palsy (C5, C6) is described as “good hand on a paralyzed shoulder and arm”. It includes weakness in the shoulder and partially in the arm while function of the hand is preserved. Lower brachial plexus palsy (C8-T1) presents by weakened musculature of the hand and forearm while the arm and shoulder musculature is not affected. It is characterized as a “paresis of the hand on a good shoulder and arm”. Often, Horner syndrome is present. Middle brachial plexus palsy (C7) is rarely found in isolation. It usually accompanies an upper or lower plexus palsy. Elbow, wrist and finger extension is limited in this type of palsy. Physical Therapy for Upper Braxial Plexus Palsy It is aimed at improving the strength of all affected muscles. With a severe weakness, a painful shoulder subluxation needs to be prevented. A sling, shoulder joint support in the axilla or a shoulder abduction brace are used for this reason. This will prevent subluxation, the onset of intra-articular edema and the development of a painful bursitis. As a preventative measure, electrical stimulation is used for Grade 0-1 muscle weakness (this is often necessary in the deltoid muscle region). Further, the plexus musculature and the shoulder joint itself are passively exercised, followed by exercises of the individual affected muscles in isolation based on the Kenny method and exercises based on manual muscle testing (for Grade 2 muscle weakness, the exercises occur in a gravity eliminated position and for Grade 3 they are performed against gravity). Starting with Grade 3 muscle strength, PNF diagonals are always included. For an extensive weakness, I and II diagonals are implemented (see General Section of the textbook, B. Therapeutic Approaches, Chapter 1.3.4 Proprioceptive Neuromuscular Facilitation) in a flexion and extension pattern so that all affected muscles of the plexus can be facilitated and

implemented into the correct movement pattern. To improve shoulder stabilization, rhythmic stabilization is also appropriate. This is performed with the elbow in extension which requires an isometric contraction of all shoulder joint muscles. To encourage stability of the shoulder joint and scapula and for the activation of the shoulder girdle musculature, it is appropriate to include sensorimotor stimulation, such as exercises focused on maintaining stability in more posturally challenging positions like with kneeling with upper extremities extended or in kneeling with support on elbows. In these positions, the patient shifts weight from one upper extremity to the other or performs trunk shifting alternately forward and backward while maintaining a stable position. To improve shoulder stability, the inclusion of the affected girdle muscles into an optimal pattern and improving their coordination are effective. Combined approaches using elements of sensorimotor stimulation and are based on certain positions of reflex locomotion, such as the reflex crawling position or a modification in kneeling with optimal positioning of the paretic extremity into support are also effective. In such positions, a wide variety of balance exercises can be performed. Physical Therapy for Lower Braxial Plexus Palsy It is aimed at the affected hand and forearm musculature. As a preventative measure, electrical stimulation of the hand flexors or extensors is included for muscle Grades 0-1. The joints of the fingers, hand, wrist and elbow undergo passive range of motion. Further, individual muscles are exercised in isolation based on muscle testing. For Grade 2, finger and hand flexion and extension are exercised with gravity eliminated; Grade 3 against gravity and later against resistance. From Grade 3 on, it is appropriate to implement I and II diagonals so that correct implementation of the forearm and hand musculature is encouraged and muscle coordination improves. To strengthen the ability to stabilize the distal aspect of the paretic upper extremity, which requires isometric contraction of all forearm muscles, rhythmic stabilization aimed at the entire forearm musculature is administered. To influence distal weakness, it is also possible to utilize methods of reflex locomotion with the paretic extremity optimally positioned in

support. If the extensors of the hand and fingers are predominantly affected, similar approaches are used, which are further described in the section addressing radial nerve palsy. Attention is paid to the practice of fine motor skills and for improving the hand grasping function. Here, the approaches used are described in the section detailing physical therapy for an ulnar nerve palsy (activities encouraging finger abduction-adduction, picking up and moving small objects, typing, etc.). In certain cases, autonomic deficits are found in the distal aspects, especially hand edema that requires anti-edematous techniques, vasopneumatic therapy, manual techniques, etc. Physical Therapy for a Complete Lesion of the Brachial Plexus The above listed approaches for upper and lower brachial plexus pareses are combined to treat this dysfunction. Long-term preventative measures are implemented for extensive, devastating injuries of the brachial plexus, in which the entire upper extremity is paralyzed. The deficit is irreversible and exercises cannot improve mobility. Facilitation of muscle trophicity, electrical stimulation, extremity positioning, passive range of motion of all segments, edema prevention in the distal aspect of the arm and joint stiffness of the fingers and the wrist are encouraged. The extremity can also be fitted with orthotic devices (braces, slings). For certain patients, a neurosurgical reconstructive operation of the injured plexus is indicated. In supraganglionic injuries, the first functional results can emerge sometimes as early as one year following surgery, but the final effect can only be assessed after three years. In such cases, long-term physical therapy is indicated. For irreversible conditions, special functional orthoses can be fabricated with a structure that allows for extremity unweighting as well as controlled movement. Neuralgic amyotrophy of the brachial plexus (brachial neuritis) is an independent clinical entity. Its etiology is not completely clear, but the signs appear following various potentially adverse events, such as child birth, immunizations or surgeries. This condition begins with strong pain in the shoulder, neck, arm or forearm area. In the initial

stages, the condition can be considered to be a cervicobrachial syndrome (thoracic outlet syndrome) or a primary involvement of the shoulder. Two to four weeks after the onset of pain, a motor deficit develops, usually in the innervation distribution of the suprascapular, axillary or long thoracic nerve, but other nerves originating in the brachial plexus can also be affected in isolation. In certain cases, the restoration of motor deficits can take up to two years. Physical therapy targets the affected muscle groups for which the analytical approaches, PNF elements and Vojta method are implemented. Pain can be controlled by therapeutic modalities (electric analgesia) or pharmacologically.

RADIAL NERVE PALSY (C5-C7) It occurs most frequently as a result of a trauma where the nerve is damaged either in the axilla (for example, from the pressure of axillary crutches) or, more often, in the area of the radial sulcus (sulcus nervi radialis) where the nerve is damaged as a result of compression of different origins. Sometimes, nerve damage occurs with humeral fractures. The deep branch (ramus profundus) of the nerve can be damaged in fractures or dislocations in the elbow area. A less common, non-traumatic nerve involvement can occur in brachial neuritis, which often involves additional nerves. Motor supply from the radial nerve serves all musculature of the dorsal aspect of the arm and the dorsal and inner part of the forearm. Sensory distribution includes the dorsal surface of the arm and forearm and half of the dorsal aspect of the hand. This paralysis leads to weakness of the hand extensors. Finger and thumb extension and thumb abduction are decreased. The hand typically falls volarly (Fig. 1.8.3-1). With a high lesion in the axilla or arm area, elbow extension is decreased. Simultaneous thumb extension and abduction in all joints and extension of the metacarpophalangeal joints 2–5 with full interphalangeal joint flexion are decreased. The sensory deficit may be very minimal. Fig. 1.8.3-1 Radial nerve paralysis,

the hand typically falls volarly

Physical therapy is initiated by preventative measures and electrical stimulation is used for muscle Grade 0–1 of the hand and finger extensors. With a high radial nerve lesion, the triceps brachii is also included. In severe paresis, volar falling of the hand needs to be prevented by the use of an orthosis or a splint supporting the wrist. This is also to be used during prolonged rest (at night). The therapist performs passive range of motion of the hand into extension. The patient also exercises in this manner independently by using their unaffected extremity. Further, elements from the Kenny method and exercises based on muscle testing are used. Stimulation of the extensors and reeducation of the paretic hand or forearm extensors are performed, at first passively and later with the patient’s active participation. In Grade 2 muscle weakness, hand extension and elbow extension are exercised with the weight of the arm eliminated. For example, elbow extension is strengthened while the extremity is supported on the table by pulling the forearm on the table into full elbow extension. Starting with Grade 3, strengthening is performed against the weight of the forearm and the hand. For example, in a high radial nerve lesion (with a weak triceps), the patient performs active elbow extension from a starting position in which the arm is supported on the table or the bed while the forearm freely hangs over the edge. Conversely, the patient with an extremity supported in the

same manner attempts to slow down the progression of the passively extending forearm (when an eccentric contraction of the triceps occurs), which may be even more effective. Similarly, hand extension is strengthened with the forearm supported on the table or the bed while the hand freely rests over the edge. With another gain in strength, strengthening occurs against the therapist’s graded resistance. Proprioceptive neuromuscular facilitation can be performed passively even in the most severe weakness as an effective facilitative method. Starting with Grade 3, the patient performs strengthening into the diagonals by themselves. For hand and finger extensors, it is suitable to combine the D1 Extension pattern and the D2 flexion pattern. D1 Extension pattern has the option of the elbow in extension when weak triceps with a high lesion of the radial nerve are present. Certain positions of Vojta’s reflex locomotion can be used to influence paretic extensors.

MEDIAN NERVE PALSY (C5-T1) This palsy can occur with damage caused by compression of the neuro-vascular bundle in the axilla or in the elbow region with supracondylar fractures. However, the median nerve is most often injured in the wrist area, especially by laceration injuries. The median nerve innervates almost all muscles on the volar surface of the forearm (with the exception of the ulnar aspect, including flexor digitorum profundus and flexor carpi ulnaris) and also most muscles of the thenar area (with the exception of the adductor pollicis and a portion of the flexor pollicis brevis). It supplies sensation to the area of the thenar, mid-portion of the palm and digits 2,3 and partially 4. This palsy does not seem to involve a strong motor deficit, instead sensory deficits usually dominate (dysesthesia, hyperpathia). Volar abduction of the thumb becomes affected. The sensory deficit of the last phalanx of digits 2 and 3 on the volar and dorsal aspects is present. With a high lesion of the anterior interosseous nerve, flexion of the last phalanx of the thumb and the index finger is affected and the patient is unable to make a circle using the 1st and 2nd digits (Fig.

1.8.3-2). Fig. 1.8.3-2 Median nerve palsy on the right. The right hand demonstrates dysfunction in the interplay between the 1st and 2nd digits

With median nerve compression at the wrist, carpal tunnel syndrome develops. It is the most common entrapment syndrome manifested mainly as a sensory deficit. Pain and dysesthesia of the hand and digits 1–4 dominate, especially at rest and it will often wake the patient at night. Typically, the patient experiences relief after warm-up exercises and by “shaking” the fingers (see further Chapter 1.9 Entrapment Syndromes). During physical therapy for median nerve palsy, fingers 1-3 require passive range of motion with special attention to the tone and the strength of the thenar musculature as well as the tone of the skin and the subcutaneous tissue. Also, the synergy between fingers 1–3 needs to be encouraged, mainly into thumb abduction and opposition. Needlework is a suitable activity to accomplish this. Also, grasping and fist making are practiced. Manual techniques prevent the onset of autonomic (vegetative) dysfunctions, which seem to be significant in this syndrome and sometimes dominant. In a milder form of carpal tunnel syndrome, mobilization of carpal bones may provide relief. A wrist brace has also been shown helpful in preventing wrist flexion and extension when used at night. Also,

injections to the carpal tunnel area can be administered. For a more severe form of carpal tunnel syndrome, a surgical intervention is usually necessary (median nerve release within the carpal tunnel).

ULNAR NERVE PALSY (C8-T1) The ulnar nerve is most often injured at the elbow by a fracture or dislocation. However, a chronic compressive syndrome, called cubital tunnel syndrome occurs abundantly, in which the nerve is damaged by microtrauma in the area of the elbow sulcus (see below Chapter 1.9 Entrapment Syndromes). At the wrist, the nerve is often injured by laceration injuries and occasionally by compression in the region of Guyon’s canal. The ulnar nerve supplies motor innervation mainly to the small muscles of the hand (with the exception of the opponens muscle and part of the flexor pollicis brevis, abductor pollicis and lumbricals I and II). It provides sensory innervation to the skin in the area of the dorsal and volar surface of the ulnar side of the hand, the 5th digit and the ulnar half of the 4th digit. This palsy causes claw-like positioning of the fingers in a semiflexed alignment of digits 4 and 5 with the little finger in abduction and the interosseous spaces depressed (Fig. 1.8.3-3). Fig. 1.8.3-3 Ulnar nerve palsy, so called claw hand

Little finger abduction and adduction and deviation of the third digit become affected. The patient is unable to touch the tip of the thumb to the volar aspect of the metacarpophalangeal articulation of the little finger. Sensory dysfunction depends on the level of the injury. Cubital tunnel syndrome is manifested by paresthesias on the ulnar side of the hand and digits 4 and 5. Physical therapy includes prevention and the actual re-education of the paretic muscles. Positioning is important in severe pareses in which the risk of a flexion contracture of digits 5 and even 4 can emerge over time. Therefore, it is recommended to use a night splint to keep digits 4 and 5 in extension. At the same time, passive extension of digits 4 and 5 and abduction and adduction of the fingers need to be performed. Elements of the Kenny method and exercises based on manual muscle testing are combined. At first, isolated movements of individual muscles are performed and stimulation is utilized, then re-education, at first passively and later with the patient’s participation against the therapist’s graded resistance is used. Specifically, finger abductionadduction and flexion-extension of fingers 4 and 5 are performed. Starting with Grade 3, the focus is on coordination training (fine motor skills and finger synergy). With an ulnar nerve lesion, practicing pinching, grasping and moving small objects, and exercising with a small ball placed between the fingers have proven beneficial. Starting with Grade 3, it is possible to implement variations of PNF diagonals based on a specific situation. Certain positions from Vojta’s reflex locomotion can be applied, in which the muscles of the paretic hand are activated. Mobilization of the small joints of the hand and the carpal region is important. In a severe cubital tunnel syndrome, the nerve needs to be released surgically. However, in most cases, the conservative approach using physical therapy is sufficient.

LONG THORACIC NERVE PALSY (C5-C7) A long thoracic nerve injury occurs during its compression, for

example, by the edge of an arm support or with blows to the shoulder. Damage by a traction mechanism can also occur in certain sports (tennis, rowing, etc.). The nerve can also be injured with brachial neuritis in conjunction with other nerves. The long thoracic nerve innervates the serratus anterior muscle. In this paresis, at rest, the shoulder blade is closer to the spine and its inferior angle shows winging (stands away from the ribcage). This winging is more pronounced when leaning against a wall or in shoulder flexion. Scapula alata is observed (Fig. 1.8.3-4). The patient can exhibit pain around the shoulder, decreased shoulder movement and, especially, limitation in full extremity elevation to shoulder height. Typically, the patient is unable to perform activities requiring extremity elevation above the horizontal. Fig. 1.8.3-4 Long thoracic nerve palsy on the right. As a result of right serratus anterior weakness, a significant dysfunction in scapular stabilization occurs, winging (scapula alata) occurs and extremity elevation above the horizontal is affected

Physical therapy prefers approaches involving activation of the serratus anterior within the movement patterns of the shoulder girdle, which needs to be influenced as a whole. Scapular instability is a dominant problem. Shoulder stabilization can be best improved by sensorimotor stimulation and Vojta’s method. In certain cases, the position of the scapula can be, to a certain extent, corrected by taping.

SUPRASCAPULAR NERVE PALSY (C5-C6) Paresis of this nerve can develop following a blunt trauma to the shoulder or as a result of an internal compression in the suprascapular notch (incisura scapulae), during which an entrapment syndrome develops (see further Chapter 1.9 Entrapment Syndromes). The suprascapular nerve innervates the supraspinatus and the infraspinatus muscles. A paresis of the suprascapular nerve results in shoulder abduction and external rotation weakness. Shoulder pain can also be present. An isolated injury to the suprascapular nerve is not common. During physical therapy, the weakened scapular muscles are facilitated and their synergy with other muscles of the shoulder girdle is encouraged.

AXILLARY NERVE PALSY (C5-C6) This paresis develops most frequently following shoulder subluxation or a humeral fracture, but can also occur with an external impact to the shoulder. The axillary nerve innervates the deltoid and the teres minor muscles. The paresis manifests itself as deltoid weakness leading to difficulty with arm abduction and elevation (especially above 90 degrees). Muscle atrophy develops, which contributes to the poor stabilization of the head of the humerus in the shoulder joint and with this weakness, shoulder joint subluxation can occur. With selective weakness of the deltoid, other shoulder girdle muscles can substitute its function. Physical therapy needs to encourage function and the tone of the deltoid. With more severe weakness, focus is directed toward prevention of shoulder subluxation.

MUSCULOCUTANEOUS NERVE PALSY (C5-C7) An isolated injury of this nerve is rare. With paresis of this nerve, which innervates the biceps brachii, coracobrachialis and brachialis, elbow flexion becomes weak when the forearm is supinated.

PERIPHERAL PARESES OF THE LOWER EXTREMITIES

Pareses of the peroneal, tibial, femoral and sciatic nerves are most frequently encountered in the lower extremities.

LUMBOSACRAL PLEXUS PARESIS Injury to the lumbosacral plexus often occurs simultaneously with injuries of the abdominal and pelvic organs (for example, pelvic fractures and dislocations). It can also occur during hip alloplasty. The lesion of the plexus can also be caused by tumor infiltration from the neighboring organs. With a lumbar plexus lesion, various degrees of hip flexion and adduction weakness occur. Knee extension weakness and deficits in sensation on the anterior thigh and the anterior and medial surface of the lower leg also occur. With a sacral plexus lesion, weakness develops in hip extension and abduction as well as in knee flexion and foot dorsiflexion and plantarflexion. Sensory deficits also develop at the gluteals, the posterior aspect of the thigh, lower leg and the foot. In a more severe lesion of the lumbosacral plexus, a significant deficit develops in the function of the entire lower extremity. Such a patient is usually unable to ambulate independently without bilateral support. During physical therapy, all weakened muscle groups are facilitated. The support function of the involved extremity is especially encouraged in standing and during ambulation. With a more serious injury, orthoses are usually needed to improve pelvic and knee joint stability and also for support of the paretic foot.

FEMORAL NERVE PALSY (L2-L4) The femoral nerve can be injured, for example, during pelvic fractures, hernia surgery, hip joint surgery, hysterectomy, appendectomy or during surgical removal of the varicosities, or also as a result of pressure by a tumor or enlarged inguinal nodes. Often, the nerve is affected during diabetic proximal amyotrophy. The femoral nerve innervates the quadriceps and provides sensory innervation to the anteriomedial surface of the thigh and the medial aspect of the lower leg.

Decreased strength in the quadriceps femoris is a dominant sign and is the main reason for an altered gait pattern due to knee joint instability and it giving out, especially during ambulation on uneven surfaces or with stair negotiation. Sometimes, knee joint hyperextension or recurvatum occurs during ambulation. In more severe involvement, besides weakness in the quadriceps femoris, the iliopsoas is also weak, which causes a problem with hip flexion. Decreased strength of the quadriceps femoris is also observed in a L4 nerve root lesion. Physical therapy attempts to improve strength of the quadriceps femoris and, at the same time, improve knee joint stability. With a weakened quadriceps femoris, knee joint stability can be improved by an orthosis. In more severe weakness of this muscle, unilateral or bilateral support needs to be provided to “unweight” the muscle during gait.

SCIATIC NERVE PALSY (L4-S3) Sciatic nerve arises from the sacral plexus and its damage occurs with dislocations and fractures of the pelvis, acetabular fractures and with posterior subluxations of the hip joint. Sometimes, it can be damaged during hip joint alloplasty or with an incorrectly applied injection to the gluteal region. The nerve can be compromised by benign tumors or infiltrated by malignant processes. It is rare for this nerve to be damaged along its course in the thigh. The sciatic nerve supplies motor innervation to the knee flexors and all muscles of the lower leg and the foot. It supplies sensory innervation to the lateral and posterior region of the calf and the entire foot. With this type of palsy, the knee flexors become weak and hip extension is also usually affected. Weakness of the foot flexors and extensors is often most pronounced and standing and ambulation on the toes and heels are affected. Gait is significantly affected because of distal weakness and also because of decreased step length of the unaffected lower extremity which does not receive the support needed during the swing phase. The risk of triceps surae contracture

increases. With the paresis of the small muscles of the foot, a claw deformity of the foot can later develop. Physical therapy is aimed at all of the above mentioned weak muscle groups and attention is paid to improving gait and stability during ambulation. To prevent the development of a triceps surae contracture, passive stretching is performed and a night splint is used to prevent foot plantarflexion. To support the ankle or the paretic lower extremity during ambulation, similar tools are used as in peroneal paresis.

PERONEAL NERVE PALSY (L4-S1) Most often, the peroneal nerve is injured behind the fibular head during compression while under general anesthesia, by pressure from a cast, tight brace or during prolonged work in a squatted position. The damage can also occur due to dislocation and distortion of the knee joint or lower leg or as a result of a laceration. The common peroneal nerve branches into the superficial peroneal nerve and the deep peroneal nerve. The superficial peroneal nerve innervates the peroneus longus and brevis and provides sensory innervation to the distal lateral half of the calf, dorsum of the foot and toes 1-4. The deep peroneal nerve innervates the extensors on the anterior aspect of the lower leg, small muscles of the dorsal aspect of the foot and provides sensory innervation to a small area between the first and second toe. If the injury is located proximal to the nerve branches, the anterolateral musculature of the lower leg shows decreased strength, which is a cause of significant difficulties during ambulation. Ankle dorsiflexion and eversion are weak. During ambulation, the foot drops into plantarflexion, which may be a reason for the patient’s tripping. Also, spraining of the foot occurs when the lower leg demonstrates instability and when problems are seen with the foot unwinding from the floor. Also, contractures in the calf muscles can develop. Individual injuries of the specific branches of the peroneal nerve are rare. Weakness of muscles similar to those seen in a peroneal nerve palsy occurs with an L5 nerve root lesion.

During physical therapy, it is necessary to improve the strength of the anterolateral musculature of the lower leg. It is important to prevent contractures of the triceps surae and stabilize an unstable ankle joint, for example, by using a figure eight bandage, taping or an ankle orthosis. An elastic peroneal pull is used to assist with lifting of the paretic foot preventing foot drop of the paretic foot during ambulation. Medial foot support is sometimes needed to prevent a flat foot if insufficient physiological support is present with more severe paresis. Custom made orthopedic inserts are used to create foot arch support.

TIBIAL NERVE PALSY (L4-S3) A tibial nerve injury can occur following severe injuries to the knee. However, more frequent it is due to an injury in the area behind the medial malleolus as a result of ankle fractures, compression from a cast or a laceration injury. The tibial nerve innervates the triceps surae, tibialis posterior, toe flexors and the small muscles of the foot. It supplies sensory innervation to the posterior aspect of the calf, lateral border of the foot and the plantar aspect of the foot. With this paresis, the rhythm of gait is disrupted because the pushoff phase is affected by weakness of the calf muscles. Surprisingly, patients with mild weakness of the calf muscles are often not completely aware of it. Clinically, more significant weakness of the toe flexors, mainly the big toe, is important because it decreases gait quality as the role of the big toe during the push-off phase is irreplaceable. A sensory deficit on the plantar aspect of the foot also negatively affects the gait pattern. However, the gait pattern is disrupted to a lesser degree than with a peroneal palsy. Decreased strength of the calf musculature occurs with an S1 nerve root lesion. During physical therapy, facilitation of the triceps surae and the toe flexors is performed and attention is paid to improving the push-off phase of the gait cycle. Attention needs to be paid to prevent the onset of a plantar aponeurosis contracture (with paresis of the short foot muscles) and its passive stretching needs to be included.

FACIAL NERVE PALSY (C.N. VII) This type of paresis belongs among the most common ones. Primary and secondary pareses are distinguished. In primary paresis (essential), which often develops after being cold, nerve swelling followed by nerve fiber compression, mostly in the area of the bony canal are presumed to be present. Secondary (symptomatic) paresis can develop in tumors of the ponto-cerebellar corner (for example, neuroma/Schwannoma), in polyradiculoneuritis and meningitis, with pyramidal fractures or with the progression of a middle ear infection. The facial nerve innervates the mimetic facial musculature. To a certain extent, the symptoms depend on the specific location on the facial nerve injury. A certain degree of weakness of the mimetic muscles is always present on the corresponding half of the face (Fig. 1.8.3-5). The following can be observed: depressed eyebrow, eye does not blink, eye cannot be closed (lagophtalmos), depressed corner of the mouth, patient unable to wrinkle forehead, fully close eyes, purse their lips, show teeth (grin) or whistle, blow out cheeks or shrug the chin, and the ability to articulate is decreased. Facial nerve palsy naturally poses a cosmetic problem with significant negative psychological consequences, mainly in young women. The specificity of this paresis lies in the development of pathological synkineses. For example, with blinking, an elevation of the corner of the mouth occurs. This phenomenon is not observed in other peripheral pareses. Also, contractures of the denervated muscles can develop, which accentuate the asymmetry and are also a source of unpleasant feelings. Fig. 1.8.3-5 Peripheral paresis of the facial nerve on the left

Physical therapy includes heat procedures, soft tissue mobilization and release of restricted tissues, manual stimulation and re-education, active movement, positioning, and electrical stimulation. With heat application, for example, hot wraps or infrared heat are applied to the affected side of the face twice a day for one hour. This is followed by soft tissue mobilization performed in a cranial direction so that the depression of the hypotonic muscles can be balanced. The procedure begins from the neck and gradually moves toward the forehead, followed by, a release of the shortened tissues. With Grades 0–2 of muscle strength, manual stimulation is implemented (gentle, vibratory movement in the direction of the muscle fibers). Then, individual muscle re-education is administered, in which the patient attempts to actively participate. When volitional activity occurs, an active exercise can begin. The patient performs a specific routine of active exercises in front of a mirror, during which all mimetic muscles are strengthened. At first, assistance is needed, then starting with Grade 3 without assistance and finally resistance is added with Grade 4–5, but only appropriate to not provoke pathological synergies and

development of contractures. Active movement is always followed by relaxation. A rehabilitation program can also include certain elements of proprioceptive neuromuscular facilitation or Vojta’s method. It is also important to maintain a healthy lifestyle. The patient should protect their face from getting cold and, during speaking, they should support their unaffected side to diminish the appearance of asymmetry. If voluntary contraction is not seen in three weeks, electrical stimulation based on the l/t curve is initiated. In severe pareses developed postsurgically or after an injury, electrical stimulation is initiated immediately.

1.8.4 Peripheral Pareses in Diseases Involving Motor Neurons of the Anterior Spinal Horns These peripheral pareses are usually progressive in nature. They develop as a result of degeneration of motor cells of the anterior spinal horns. This is seen, for example, in spinal muscle atrophies that present with gradual progressive weakness of distal musculature, muscle atrophy and fasciculations. Early onset types show severe course and poor prognosis. Adult forms have a benign course, progress slowly and patients do not become disabled. From the start, rehabilitation consists of methods based on neurological foundations in which it is suitable to combine mainly elements from Vojta’s method, proprioceptive neuromuscular facilitation and sensorimotor stimulation. During the disease course; however, greater attention needs to be paid to providing the patient with appropriate aides and devices that help compensate for progressive movement deficit of the extremities, ease locomotion or master common activities of daily living. An injury to the peripheral motor neurons also occurs in Amyotrophic Lateral Sclerosis, a neurodegenerative disease in which the central motor neurons and the nuclei of the distal cranial nerves are affected (see Chapter 1.16.2 Amyotrophic Lateral Sclerosis). Given the progressive nature of the diseases involving motor neurons of the anterior spinal horns, diseases

have a negative effect on the patient’s mental state. The patients monitor the adverse progression of their disease with fear, often showing anxiety and depression, which, in turn, affects the quality of their participation in physical therapy. It is important to motivate the patient and further encourage their cooperation. If even the least subtle improvement occurs during physical therapy, it is good to emphasize it when communicating with the patient because it encourages them. Pareses also occur with deficits in neuromuscular transmission, which is seen mainly in myasthenia gravis (see Chapter 1.7.1 Disturbances in Neuromuscular Transmission – Myasthenia Gravis).

1.8.5 Rehabilitation Following Peripheral Nerve Surgery A surgical intervention is necessary in certain severe peripheral nerve injuries, especially if the nerve is disrupted. Following peripheral nerve surgery, optimal functional results can be achieved if the muscle is re-innervated, at the latest, one year from the injury. The nerve connection cannot be under tension and a nerve defect needs to be bridged via autotransplantation. For patients after peripheral nerve surgery of the extremities, certain principles need to be followed. The therapist needs to know that the suture of the nerve reaches its original strength in three weeks. During this period of time, immobilization of the corresponding extremity segment is recommended in a physiological position and the involved extremity should be in elevation initially to prevent formation of distal edema. With distal plegias (especially the sciatic and peroneal nerves), the distal portion of the extremity should be positioned so as to prevent triceps surae contractures (see Chapter 1.8.3 Overview of Peripheral Pareses Based on Location, Peroneal Nerve Palsy). During rehabilitation, ischemia and pressure on the operated region need to be prevented. For three weeks, caution needs to be paid with respect to the movement routine. If the operated region is immobilized, passive range of motion can be performed in the joints that are not immobilized limited ranges to avoid stretching of the operated nerve.

Full range of motion is possible only after three weeks when the nerve suture is firm and the splint has been removed. Physical therapy can be initiated. In three weeks, it is also appropriate to initiate electrical stimulation to promote tone in the denervated muscles and, eventually, electrical stimulation to encourage muscle contraction. Physical therapy is modified based on the nerve involved and the type of operation. The protocols described above for individual pareses are followed. Balneology is an important part of a comprehensive treatment approach in peripheral pareses with more severe involvement. It encourages regeneration of peripheral nerves and tone of the paretic muscles and also contributes to muscle strength improvement as well as improvement in movement patterns. Comprehensive balneology is indicated most often upon a referral from a neurologist and a rehabilitation physician when the acute phase has subsided. If an inpatient rehabilitation stay is necessary, the comprehensive balneologic treatment can be repeated in one year. With facial nerve palsy, a comprehensive balneologic treatment can be rendered when the ambulatory form of rehabilitation is difficult to attend or its sufficient intensity cannot be ensured. In the Czech Republic, rehabilitation for patients with peripheral pareses is provided, for example, in spa Dubi, Klimkovice, Velke Losiny, Vraz and Janske Lazne.

1.9 ENTRAPMENT SYNDROMES Petr Bitnar, Ondřej Horáček Entrapment syndromes present a specific group of chronic mononeuropaties and their onset can be attributed to similar etiopathogenic factors.

1.9.1 Etiology, Pathogenesis, Clinical Manifestations and Diagnosis Etiology and Pathogenesis Many peripheral nerves run through certain anatomical entrapments, where the nerve finds itself in a very small space. Chronic traumatization of the peripheral nerve often occurs in areas of narrow contact between the nerve tissue and the rigid surroundings (bone, muscle tendon). This results in a disruption in the nerve’s vascular supply, an increase in intraneural pressure and the degradation of axonal transport, which damages the nerve itself and produces typical symptoms (motor and sensory deficits). Nerve compression usually occurs in the following scenarios: a. Increase in volume of structures (especially tendons and their sheaths) found around the nerve in a rigid bony canal or forming a “filler” in a tunnel b. Decrease in the tunnel space most often caused by connective tissue hypertrophy or calcification, bony hypertrophy from chronic microtraumatization (for example, osteophytes) or structural changes of a bone following traumas (bone callus, change in the bone axis, etc.) c. Systemic and metabolic diseases including, for example, diabetes mellitus, autoimmune infections, alcohol abuse, etc. These diseases disrupt the peripheral nerve which becomes more fragile in the exposed areas. Increased anatomical angulation of the nerve or fibrotization of its

surroundings, which decreases nerve mobility and can also contribute to the etiology and pathogenesis of nerve damage. This increases the tensile strain on the nerve, which also leads to its chronic traumatization (especially during extremity movement). Etiology and Pathogenesis from the Perspective of Treatment Rehabilitation The movement system fundamentally contributes to the etiology and pathogenesis of entrapment syndromes (dysfunctions). Its chronic overloading leads to structural changes (hypertrophy, edema, osteophytes, connective tissue retraction) and, thus, to decreasing the space in the entrapment area. This often occurs because of a deficit in the control of motor skills and manifests itself by incorrect muscle coactivation and changes in muscle tone distribution. In the end, the chronic overloading and the resultant muscle hypertonia lead to pathological muscle hypertrophy, nerve compression, fibrotization of its surrounding and, subsequently, to worsening of the nerve mobility in the given region. From this perspective, the entrapment syndrome needs to be viewed not only as a local, but also as a global problem in which the quality of muscle synergies, the alignment of key joints and posture need to be taken into consideration. Clinical manifestations The clinical manifestations of entrapment syndromes are varied with sensory symptoms being most common. Three developmental stages are recognized: Stage 1 – sensory fibers are affected. Typical symptoms include paresthesia, dysesthesia or allodynia. In many syndromes, the symptoms present mainly at night during this stage. Stage 2 – a period of persistent paresthesias. The majority of sensory fibers are affected, including nociceptive fibers. Pain can be present at night or during the day and the patient is not able to find a position of relief. Stage 3 – motor fibers are affected and motor deficits and vegetative (autonomic) symptoms develop.

Diagnosis An entrapment syndrome diagnosis is based on clinical examination and electrophysiological testing. Questions about the presence of paresthesia and motor skill deficits need to be asked. An objective deficit in sensation as well as motor, vasomotor and pseudomotor signs need to be explored. Localized findings, such as pain and nerve swelling in the entrapment area need to be examined. Nerve tapping or stronger palpation is performed to assess whether tingling occurs in the palpated area and projects to the area of the nerve’s sensory innervation (Tinel’s sign). Sensory examination includes, for example, nerve lengthening maneuvers specific for each nerve (for more detail see the General Section of the textbook, A. Diagnostic Approaches, Chapter 1.2.1 Kinesiology of the Spine, Pelvis and the Thorax). A thorough musculoskeletal examination, especially of the spine and the proximal joints is also necessary. Electromyographic assessment is an indispensable and basic objectified method that allows for the following: 1. Identification of nerve lesion in the entrapment area 2. Specification of the portion of focal demyelination and axonal lesion 3. Observation of the dynamics of changes 4. Decision regarding an optimal treatment approach, i.e., conservative vs. surgical

1.9.2 Overview of the Most Common Entrapment Syndromes ENTRAPMENT SYNDROMES OF THE UPPER THORACIC APERTURE This includes brachial plexus compression as the brachial plexus passes through the structures forming the upper thoracic aperture. Neurovascular compressive syndromes of the shoulder girdle form a vaguely defined group. Scalenus syndrome is a typical representative.

For example, the hyperabduction and costoclavicular syndrome with somewhat similar signs can also be diagnosed.

SCALENUS SYNDROME It is the most common syndrome in this region. It is caused by compression of the brachial plexus and the subclavian artery during their passage between the anterior and the middle scalene muscles and their insertion to the first rib. Usually, it is accompanied by hypertonia and shortening of the scalenes, a cervical rib and functional deficits in the cervical spine and the cervicothoracic junction. Scalenus syndrome is found especially in individuals with an incorrect breathing pattern where the accessory breathing muscles are improperly engaged. The patients report upper extremity paresthesias that worsen with carrying objects. Hypesthesia can be present on the anterior side of the arm into the fingers and later also atrophy of the small hand muscles where autonomic signs occurs. The diagnosis can be easily determined by the Adson’s test where the pulse palpated at the radial artery will be decreased or absent with deep inspiration and cervical extension with full head rotation toward the same side.

COSTOCLAVICULAR AND HYPERABDUCTION SYNDROME In the costoclavicular syndrome, the brachial plexus is compressed between the clavicle, the first rib and the superior scapular border. The patient reports similar symptoms to the scalenus syndrome. In the hyperabduction syndrome, symptoms occur with upper extremity elevation when the pectoralis minor muscle stretches and compromises the neurovascular bundle passing underneath it. Problems are often experienced during sleep if the upper extremity is positioned in the above described position.

ENTRAPMENT SYNDROMES OF THE UPPER EXTREMITY AND THE SHOULDER GIRDLE

SUPRASCAPULAR NERVE Suprascapular Syndrome. This is a compression syndrome of the suprascapular nerve in the suprascapular notch. Together with a vascular bundle, the suprascapular nerve passes through the suprascapular notch, which is bridged over by a transverse ligament. Here, the nerve can be chronically exposed to micro trauma (i.e., from various sports, mountain climbing, etc.). The syndrome manifests itself by pain in the upper scapular border region with radiculopathy into the shoulder with shoulder movement.

MEDIAN NERVE Carpal Tunnel Syndrome. This is the most common entrapment syndrome within the population. Women show a higher incidence when compared to men with approximately a 4:1 ratio. In principle, the syndrome is caused by pressure on the nerve as it passes through the carpal tunnel. The nerve can be compressed by any structure that passes through this tunnel (usually thickening of the flexor tendon sheaths) or by structures forming the tunnel (for example, hypertrophy and calcification of the flexor retinaculum, bone callus following Colle’s fracture, etc.). This syndrome is often found in patients with metabolic or systemic dysfunctions (diabetes mellitus) and with hormonal changes (e.g. pregnancy). It is brought on by wrist hyperextension with tapping at the carpal tunnel or, in contrast, prolonged wrist flexion (Phalen’s sign). Generally, the syndrome manifests itself as finger paresthesias, especially at night or early morning, which wakes the patient. The paresthesias dissipate after warm-up movements. Sometimes autonomic signs are also present. In later stages, persistent distal paresthesias and deficits in motor skills are present, including muscle hypertrophy. Anterior Interosseous Syndrome. Anterior interosseous nerve syndrome (Kiloh-Nevin syndrome) is caused by a compression of the anterior interosseous nerve, which is a motor branch of the median

nerve branching at approximately 3–6 cm below the elbow. The nerve is usually compressed here by an abnormal band of connective tissue arising from the head of the pronator teres muscle and the flexor digitorum superficialis tendon. The syndrome often occurs following injuries. Clinically, it manifests itself as a slowly developing hand paresis, weakness of the flexor pollicis longus and deep flexor of the index finger (decreased strength into flexion of the distal phalanx of the finger). Pronator Teres Syndrome. This is a compression of the median nerve as it passes through the pronator teres muscle. The nerve can be compressed by a hypertrophied muscle, connective tissue band connecting the flexor digitorum superficialis tendon and the pronator teres or by bicipital aponeurosis (lacertus fibrosus) of the short head of the bicep brachii. The syndrome develops slowly. Its main manifestations include pain at the elbow and proximal forearm as well as tingling in the hand and the fingers. In advanced stages, sensory deficit occurs. Paretic manifestations are rarely present (especially in the thenar musculature and in the flexor digitorum superficialis). Struthers Entrapment Syndrome. This is a rare syndrome of a median nerve compression that also often involves the brachial artery in the area of the distal humerus. The cause is the presence of the Struthers’ ligament, which is a connective tissue band connecting the medial epicondyle of the humerus with a growth anomaly – the supracondylar process. Patients report pain and pressure above the elbow and tingling in the hand and the fingers in the area innervated by the median nerve.

ULNAR NERVE Cubital Tunnel Syndrome. It is the second most common entrapment syndrome, affecting men more frequently than women. It is caused by an injury to the ulnar nerve either during its passage at the ulnar nerve sulcus (sulcus nervi ulnaris) or distally as it passes between the heads of the flexor carpi ulnaris. The entrance of the nerve between the heads of the flexor carpi ulnaris muscle can cause

irritation due to a tough connective tissue of the muscle’s origin or by the muscle’s hypertrophy. Degenerative changes in the elbow and post-traumatic conditions can significantly contribute to the etiology. The patient perceives paresthesias and burning pain, especially on the ulnar aspect of the hand and in digits 4 and 5. Sometimes, pareses (hypothenar, interossei, lumbricals, and flexor muscles) or clumsiness of the fingers develop. Guyon’s Canal Syndrome. The bottom side of the Guyon’s canal is formed by the flexor retinaculum and the upper fascia between the pisiform and the hook of the hamate. The syndrome manifests itself as sensory deficits in half of digits 4 and 5, weakness of the adductor pollicis, interossei, lumbricals for digits 4 and 5 and by general muscle atrophy of the hypothenar area.

RADIAL NERVE Supinator Syndrome. This is a compression syndrome of the deep radial nerve (ramus profundus nervus radialis) in the area of its entrance into the supinator muscle where the nerve can be compromised by a tight or hypertrophic muscle. The entrance to the canal narrows during pronation, which even further compromises the nerve. Clinically, palpatory sensitivity at the tunnel in the supinator muscle is present with pain under the radial epicondyle. Initially, the patients report weakness with little finger extension and, later, extension weakness of other fingers.

ENTRAPMENT SYNDROMES OF THE LOWER EXTREMITY AND THE PELVIC GIRDLE FEMORAL NERVE Lateral Femoral Cutaneous Nerve Syndrome (Meralgia Paresthetica). This nerve provides sensory innervation to the skin on the anterolateral aspect of the thigh. It is most often injured as it exits from underneath the inguinal ligament. In this region, it can be irritated by tight clothing or during work in occupations in which the

worker leans against a work counter at the groin area, in obese individuals by a pull of the overhanging abdominal tissue, in pregnant woman and when the musculature and their insertions in the groin area are being overstressed (hockey players, excessive strength training). The patient reports pain, burning and sharp sensations and decreased sensitivity in the entire area innervated by the nerve (anterolateral surface of the thigh).

SCIATIC NERVE Piriformis Syndrome. The sciatic nerve, or at least a portion of it, passes (in approximately 6-10% of the population) through the piriformis muscle and these individuals are at particular risk of nerve compression. Pain in the gluteal region occurs and radiates into the hip or even the thigh. A true paresis is rare.

PERONEAL NERVE Fibular Canal Syndrome. An entrapment syndrome of the common peroneal nerve in the fibular canal is rare. Acute external compressive syndromes are more common. Patients complain of tingling on the outer area of the lower leg and the dorsal aspect of the foot, less in the toes. Gradually, paresis of the foot dorsiflexors, toe extensors and foot evertors can develop. Anterior Tarsal Tunnel Syndrome. This syndrome develops if the terminal branch of the deep peroneal nerve on the anterior surface of the ankle joint is compromised by the cruciate ligament or the extensor hallucis longus tendon. The patients report pain and a tight feeling on the anterior side of the ankle joint and paresthesias in digits 1 and 2. The problems worsen if a patient is wearing shoes with tight and high lacing.

TIBIAL NERVE Medial Tarsal Tunnel Syndrome. It is a less frequent entrapment syndrome that develops if the tibial nerve is compromised in the tarsal

tunnel behind the medial malleolus. The patient reports a burning pain in the foot and on the bottom of the foot. Tingling in the toes can also be present. Sometimes standing, ambulation and running exacerbate symptoms, but other times, night pain and paresthesias dominate. Morton’s Neuroma (Plantar Interdigital Nerve Syndrome). It occurs with lesions in the plantar interdigital nerves, especially in their course between the 3rd and the 4th metatarsals. Poor fitting footwear and prolonged static standing are generally considered the causes of this pathogenetic development. In all patients with this syndrome, besides these “external” causes, a deficit in foot function can also be found. Without exception, the patients demonstrate a deficit in the transverse foot arch with a dysfunction in great toe inclusion into push-off during ambulation. The patients report burning pain on the bottom of the foot, mostly in the 3rd and 4th metatarsal region, and pain and paresthesias in the 3rd and 4th toes where a sensory deficit can also be found. Initially, the symptoms are present primarily in standing, later they are constant.

1.9.3 Treatment Rehabilitation Together with pharmacotherapy, treatment rehabilitation forms the foundation of conservative therapy for entrapment syndromes. Treatment rehabilitation for entrapment syndromes includes the following areas: muscle system (facilitation and inhibition of musculature), joint system (treatment of restrictions and subluxations), connective tissue system (influencing retractions), integumentary system (influencing deficits in sensation and motor skills), lymphatic and vascular system (treatment of edema and vasomotor dysfunctions), autonomic system (treatment of pain) and, finally, the peripheral nerve tissue itself (deficits in peripheral nerve mobility). Post-Isometric Relaxation, Reciprocal Inhibition and Agistic-Eccentric Contraction Based on Brügger These are highly effective techniques to facilitate a decrease in

increased muscle tone. They are used in association with palpatory findings and are always applied when pain and increased muscle tone are found. Altered muscle tension is always demonstrated with deficits in the area of tendons and insertions, most often locally – in trigger points. These techniques can be applied immediately at the beginning of a therapeutic session. Stretching Techniques Stretching techniques present the basic method for treatment of connective tissue changes of involved fasciae. Connective tissue stretching occurs based on the principles of musculoskeletal medicine, thus, when the pathological barrier is reached, a constant pressure is applied until the “release” phenomenon occurs and the corresponding structure is stretched. Methods and Approaches Based on a Neurophysiologic Foundation These are included in the treatment of an entrapment syndrome because they contribute to the correction of muscle tone and optimization of muscle activation within motor programs as a prevention of individual muscle and joint overloading. This approach can be vital in the treatment of an entrapment syndrome. The following approaches are used: proprioceptive neuromuscular facilitation (PNF), Vojta’s reflex locomotion, exercises based on developmental kinesiology, exercises using open and closed kinetic chains while maintaining a centrated joint position, Feldenkrais method, etc. Traction, Joint Mobilization and Manipulation These are basic techniques for the treatment of the joint system. They lead not only to decreased nociception in a given area, but also to improved joint mobility and optimization of proprioceptive afferentation (affecting motor control). They can also contribute to improving joint alignment and correcting the anatomical relationships in the entrapment region. Techniques to Correct Sensation These techniques are used when changes in skin sensation are present, including hypoesthesia or hypersensory states. The following

techniques are used: “stroking”, brushing, tapping, vibration, etc. The practice of stereognosis (object recognition without visual feedback) and two-point discrimination are also included. Lymphatic Drainage Lymphatic drainage is the most effective method for the treatment of edema. It is performed with a gentle pressure (20-40 mmHg) in order to prevent a mechanical obstruction of the lymphatic vessels with very thin walls. The movement is always from the periphery toward the center or from distal to proximal. Prior to the treatment of the edema itself, the lymphatic tract and its nodes need to be emptied above the involved area. In addition to manual lymphatic drainage techniques, equipment for lymphatic drainage can also be implemented. For more detail, see Chapter 3 Treatment Rehabilitation for Selected Internal and Other Diseases, subchapter 3.9.1 Lymphatic Edema and its Treatment. Nerve Mobilization Peripheral nerve mobilization and restoration of its mobility (sliding) in the region of its entrapment in the surrounding tissue is based on movement during which the nerve is mechanically stretched. For nerve mobilization, movements used during assessment and known as tension maneuvers are utilized. During therapy (mobilization) of a nerve, tension maneuvers in combination with the principles of “classic” mobilization of joints and soft tissues are used. When prestretch is reached, in this case a nerve stretch (manifested by pain), the range of motion is carefully increased and the release phenomenon occurs, followed by a spontaneous increase in the range of motion and a decrease in pain or paresthesia. The restoration of peripheral nerve mobility (including autonomic) is well described in the neurodynamics approach based on Maitland and Butler. Postural Re-Education For patients with an entrapment syndrome, postural correction and restoration of balanced activity between the tonic and phasic musculature is one of the conditions required for permanent improvement in the involved area. This can lead to decreased trauma

to the overloaded muscles and their insertions. Methods based on neurophysiological foundation are used for postural re-education, for example, closed kinetic chain exercises, sensorimotor stimulation, exercises based on developmental kinesiology (i.e. DNS according to Kolar, PNF – developmental line, Klapp’s crawl mobility exercises) or Vojta’s reflex locomotion, etc. Sports activities can also be included (swimming, stretching, yoga, tai-chi, etc.). Modalities Modalities complement mobility treatments; how​ever, they should not be the main and only type of intervention. The most commonly used modalities include the following: laser, ultrasound, electrotherapy, and pulse magnetic therapy. Vasopneumatic therapy is used if edema is present. These modalities are applied at the area of entrapment. Muscle relaxation and the analgesic effects of electrotherapy or balneotherapy can be used to treat increased muscle tone. Contrast baths (hot/cold immersion) have also proven effective in which the patient repeatedly submerges an extremity alternately into warm and cold water. Reflexive vasodilation followed by vasoconstriction positively influence tone and reactibility of the blood vessel’s wall and, at the same time, act against autonomic dystonia. Heat application softens connective tissue and it is, therefore, appropriate prior to actual connective tissue stretching. Orthotics During therapy for entrapment syndromes, night positioning splints have been used successfully. These splints stabilize a joint in a neutral alignment so that the disadvantageous position of an extremity is avoided when sleeping. For thoracic outlet syndrome, a soft neck brace can be prescribed. In the acute stage, a sling or stabilization against the ribcage can be used to unweight the upper extremity. Foam protectors are used for areas traumatized by pressure. In Morton’s metatarsalgia, orthopedic inserts and cushions (so called hearts) are used. These are placed under the metatarsal heads II-IV and contribute to transverse arch support. Ergonomics and Activity Modification

Inappropriate work activity, work position or work environment can cause or contribute to the onset of entrapment syndromes. Position and work environment modifications are one of the conditions for successful treatment. At the same time, incorrect participation in sport activities can lead to overloading and the development of an entrapment syndrome. For this reason, the analysis and correction of movement patterns during sport activities or changing the sport activity itself are necessary in such scenarios.

1.10 POLYNEUROPATHIC SYNDROMES Alena Kobesová Polyneuropathy (PNP) includes a heterogeneous group of diseases that manifest themselves as an injury to a peripheral nerve. Most often, it involves a diffuse or multifaceted deficit that can be symmetrical or asymmetrical. Usually, the long peripheral nerves of the lower extremities are affected the most and the earliest. The signs can be sensory, motor or autonomic and are often mixed. Based on etiology, the course of the disease can be acute, subacute or chronic (chronic-progressive). Polyneuropathy can be classified as axonal or demyelinating depending on whether the deficit is primarily at the level of the axonal nerve or the sheath of the peripheral nerve. Based on etiology, PNP can be divided into a number of subgroups: hereditary, metabolic, inflammatory – autoimmune, nutritional, toxic, autoimmune in systemic diseases and vasculitides, and paraneoplastic. From a rehabilitation perspective, there are three groups of polyneuropathies that need to be mentioned. They differ in their clinical picture, their course and their treatments, including rehabilitation. These are hereditary motor and sensory polyneuropathies, metabolic polyneuropathies (especially diabetic) and inflammatory polyneuropathies (AIDP, CIDP).

1.10.1 Hereditary Motor and Sensory Polyneuropathies Hereditary motor and sensory polyneuropathy (HMSN) belongs among the most common neuromuscular diseases (prevalence 1: 2,500). In the Czech Republic, it is presumed that this disease affects approximately 4,000 people. The first signs of HMSN, or Charcot-Marie-Tooth disease, usually occur in the second decade of life and affect both genders equally. The disease usually does not decrease life expectancy, but often slowly progresses and demonstrates familial occurrence. A motor deficit

dominates mainly in the lower extremities. A foot deformity and atrophy of the lower leg musculature are typical (Fig. 1.10.1-1). A foot deformity is manifested as a high instep with a collapsed transverse arch (pes cavus, transvesoplanus) and hammer toes with the foot distorted into supination and calcaneal varus. As a result of atypical loading during standing and ambulation, pressure sores (or calluses) can form, most often under the metatarsal heads and on the outer aspect of the foot. The foot becomes deformed as a result of muscle weakness and muscle pull imbalance. Since the long nerves of the lower extremities are the most and earliest affected in polyneuropathies, atrophy and weakness are first observed in the small muscles of the foot (the interossei and lumbricals) and soon the peroneal muscles become affected. Relatively stronger tibial muscles pull the foot into supination (Fig. 1.10.1-2). The gait pattern is altered and patients demonstrate a foot drop, for which they compensate by lifting their knees high during walking (stork walking). Ankle sprains are common. In nearly half the patients, the disease further progresses to calf and thigh muscle weakness and atrophy. Only a small number of patients are affected to such extent that they are not able to ambulate independently or be self-sufficient. The majority of patients demonstrate partial involvement of the small muscles of the hand (Fig. 1.10.1-3) and a deficit in fine motor skills. The disease has quite a variable course. The clinical findings can fluctuate even within one family from asymptomatic individuals in whom the disease is only identified by molecular genetics and electrophysiologic testing, to severely involved individuals. Electromyographic examination is the most important examination method. It always identifies hereditary neuropathy and, to a certain extent, can help establish disease prognosis. DNA analysis is performed to identify the affected gene. Fig. 1.10.1-1 Typical foot deformity in a patient with hereditary neuropathy (pes cavustransversoplanus, hammer toes)

Fig. 1.10.1-2 Supinated position of the foot and calcaneal varus in a patient with HMSN

Fig. 1.10.1-3 Atrophy in the upper extremity muscles in a patient with HMSN

There is no known cure for HMSN, thus, the treatment is supportive in nature and rehabilitation, orthotic and orthopedic

treatments form a necessary component. The goal of rehabilitation is to maintain the highest level of mobility and balance during standing and walking, to prevent joint and vertebrogenic pain, to maintain good fitness and function of the cardiovascular system and to provide the patient with orthotic aids. Therapy for Hereditary Motor and Sensory Polyneuropathies Physical Therapy Individually based physical therapy plays an important role. Following preparatory procedures, which can include soft tissue techniques and stretching of shortened muscles and fasciae (Achilles tendon, triceps surae, plantar aponeurosis, toe extensors), peripheral joint mobilization of the foot or tactile and proprioceptive stimulation is usually followed by therapeutic exercise combining methods based on neurophysiological principles. Sensorimotor Stimulation Sensorimotor stimulation (SMS) includes exercises on unstable surfaces that improve muscle coordination, motor programming (speed and quality of CNS control of movement), increase the speed of muscle activation and, thus, help compensate for an insufficient peripheral proprioception. It is an effective technique for the prevention of sprains and falls. At first, exercises are performed on less challenging equipment and, if the patient is able to, they gradually transition to more posturally challenging, or more unstable surfaces. For example, exercising on a foam surface is less challenging than on a cylindrical base, while exercising on a spherical base is the most difficult. Balance sandals help form and maintain correct alignment of the foot and stimulate activity of the small foot muscles. The patients can easily use them at a home for home program. Activation of the gluteal muscles, which are often functionally inhibited in patients with polyneuropathy as a result of faulty movement patterns, can be strengthened by using balls or a mini-trampoline. This equipment is appropriate for patients with an existing lower extremity paresis because they would not be able to master exercises using more challenging equipment. On unstable surfaces, patients exercise

barefooted to increase the proprioceptive and exteroceptive stimulation and to decrease the risk of injury (decreased probability of slipping). However, walking barefoot when not exercising is not recommended. When paresis is present, ambulation requires more energy, the risk of tripping increases and hard landing and juddering overload the foot joints. The exercises should not cause pain or fatigue. This is why a set of exercises for patients with polyneuropathy is usually shorter than for patients with a different diagnosis. Emphasis is placed on the patient’s active participation and “awareness” of their own posture and their body position in space. In more involved patients (severe paresis, severe deficit of the deep and tactile sensation), supine and sitting sensorimotor techniques can be implemented. Another option includes practicing stability on stabilometric platforms (for example, BalanceMaster), which are equipped with various computer programs. The patient exercises while using visual control and the computer monitor shows the position and movement of the actual center of mass thereby giving the patient feedback. The equipment also allows for stability training for heavier patients, which is performed while sitting on a ball. Standing exercises can be performed in standard or more challenging conditions, for example, on a soft surface. The equipment simultaneously numerically and graphically assesses the quality and speed of the executed movement and the reaction time. It also allows for the selection of an adequate level of exercise specific to each patient. Vojta’s Reflex Locomotion Method Nearly all patients with neuropathy demonstrate a deficit in their breathing pattern and a dysfunction in the deep spinal stabilization system, which are often the source of pain in various regions of the spine. Vojta’s reflex locomotion method has an irreplaceable role because it allows for an automatic activation of functionally inhibited muscles within the framework of innate global patterns (reflex turning and crawling). Repeated reflex exercise helps the patient learn how to correctly activate muscles and breathe. This is why reflex locomotion

is followed by exercises requiring the patient’s volitional participation. The patient attempts to control their body posture and volitionally breathe on their own, implementing the verbal and tactile cueing from a physical therapist. Fitness Exercise Fitness exercises include, for example, swimming, biking, yoga or taichi. The patients often show a tendency to strengthen the paretic muscles. It needs to be explained to them that strengthening against resistance is not indicated for muscles weakened as a result of denervation. The deficit is not in the muscle itself, but in its innervation. Therefore, intensive strengthening can lead to overloading the paretic muscles. Atrophy and weakness increase and an overuse weakness develops. Orthotic Equipment The majority of patients require orthotic equipment. Every 6 months, new orthopedic inserts are prescribed that are always fabricated based on a new casting. Correctly made orthopedic inserts correct foot alignment, improve standing stability and gait pattern and help slow down deformity progression. Built-in corrective components unweight areas predisposed to pressure. Peroneal paresis is most often corrected for by an elastic orthosis, peroneal strap or a firm orthosis, such as an ankle-foot orthosis (AFO). Other commonly prescribed orthotic aides include knee braces, canes, forearm crutches, and mechanical or electric wheelchairs for severely involved patients. For more detail, see Chapter 1.5 Orthotic Care in Neurologic Diseases. Surgical Treatment A number of patient with HMSN require surgical intervention for foot deformities. The most frequently performed soft tissue procedures include Achilles tendon lengthening and plantar aponeurosis tenotomy. In more severe deformities, bone interventions are necessary, most often a Dwyer’s wedge osteotomy of the calcaneus. In the most severe cases, joint fusion is needed. The goal of surgery is to improve ambulation and the patient’s stability, allow for rehabilitation and decrease pain. Post-surgical casting for such

patients is shortened to 3-5 weeks and rehabilitation is initiated shortly after cast removal. Balneologic Treatment For a number of reasons, balneologic treatment for this diagnosis is a vital component of a comprehensive therapeutic approach. Similarly to polyneuropathies of other origins, it contributes to muscle tone improvement of the weakened muscles, influences pain of joint-muscle and vertebrogenic origins, and leads to improved stability and physical fitness. It also positively influences the patient’s psychological well-being. In addition to exercise, aquatic procedures are appropriate. A comprehensive balneologic treatment is based on the indication list for spa treatment provided upon a recommendation from a neurologist or a rehabilitation physician if the muscle weakness is greater than a Grade 3 on the manual muscle test. For this diagnosis, balneologic treatment is provided in the following cities: Janske Lazne, Klimkovice, Velke Losiny, Vraz, Dubi, Teplice v Cechach, Jachymov and Msene.

1.10.2 Diabetic Neuropathy Diabetes mellitus (DM) is the most common source of polyneuropathy. Diabetic neuropathy is a late complication of Type I DM, but it can be present in both types of DM. The incidence has been reported as high as 80% with symptomatic neuropathy in approximately 18%. In Type I DM, the incidence of neuropathy rises according to the length of diabetes. In Type II DM, neuropathy can manifest itself very early, sometimes even being the first sign of the disease. The pathogenesis of diabetic neuropathy is complicated: oxidative stress of the nerve as a result of microangiopathy of vasa nervorum plays an important role and the actual metabolic deficit also contributes. Usually, the nerve sheath (myelin) and the axons themselves are affected, but the sensory and motor fibers can also be involved. With diabetes, any part of the peripheral nervous system can be affected. Based on the type and location of injury, DM neuropathy can be classified as symmetrical, focal or mixed.

Chronic distal symmetrical polyneuropathy is the most common and the most severe type. It comprises approximately 75% of all diabetic neuropathies. The sensory deficits predominately affect the lower extremity, but later, the upper extremities become involved. Similarly to hereditary neuropathy, the long peripheral nerves are affected the most and the earliest. This is why patients at first complain of distal paresthesias. Stocking-like pattern hypesthesias of the lower extremities, pain, fatigue and a feeling of coldness are common, although the diabetic foot is warm and dry upon assessment. Gradually, the deficit spreads proximally and shows a glove-like pattern in the upper extremities. Deregulation of microcirculation results in edema, painful skin tearing and other trophic skin deficits. If a deep sensory deficit dominates (thick fibers are involved), signs of sensory ataxia are observed, which manifests themselves as a balance deficit with ataxic gait, especially when visual control is eliminated. Clinical findings include decreased or absent tendon reflexes, decreased perception of vibration and, less often, tactile sensation, decreased proprioception and kinesthetic awareness, which are most prominent distally. If a deficit in the thin sensory fibers for pain and temperature dominates, the main symptoms include pain, which the patient describes as dull, deep and sometimes as a burning and severe, tearing pain. Examination reveals involvement of temperature and pain sensation and a slight deficit in tactile sensation. Vibration and tendon reflexes are affected only to a smaller extent or not at all. With a severe deficit in proprioception and pain sensation, neuropathic arthropathy (Charcot joint) can develop. Due to the lack of protective sensory mechanisms, joints are exposed to repeated trauma, which leads to gradual cartilage damage. In DM, the small joints of the foot and the ankle are typically affected. Motor involvement (pareses) is rare. Involvement of the autonomic nervous system is common. Treatment of diabetic neuropathy mainly consists of controlling diabetes and normalization of blood sugar.

DIABETIC FOOT SYNDROME Diabetic foot syndrome, which is often a reason for amputation, is directly linked to diabetic neuropathy and it is a severe complication of DM. The following contribute to the development of the defect: neuropathy, trauma, previous ulceration, biomechanical factors, such as limited joint mobility, deficit in peripheral vessels, a patient’s poor cooperation and lack of information or neglect. Next to controlling diabetes and administering medication for neuropathy and lower extremity ischemia, orthotic care plays an important role in the onset of diabetic foot syndrome. If the patient wears serially manufactured preventative diabetic footwear, it is recommended to place a special orthopedic insert in it that is made based on an actual foot imprint and fabricated according to the pressure zones present on the bottom of the foot. Open footwear is not appropriate because of the potential for exposure to foreign objects. Patients are warned about using regular footwear without protective components, which is a common source of formation or recurrence of ulcers. Biomechanical prevention of the involved foot lies in prevention of ulcers and often is more important than pharmacological treatment. A person with diabetes should take off their footwear several times per day and check their feet for redness, blisters and pressure sores. Rehabilitation in Diabetic Neuropathy Physical Therapy A number of approaches and methods used for treatment of diabetic neuropathies are identical to the ones mentioned for hereditary neuropathies. This especially applies to the use of sensorimotor stimulation. Once again, the patients should only exercise to fatigue and not through pain. A physical therapist should continuously supervise the patient’s movement and only those exercises that the patient master’s safely on uneven surfaces should be selected. As a result of a sensory deficit, patients with neuropathy demonstrate slower defensive reflexes and are at a greater risk of falling; thus, especially in the older and more severely involved patients, exercises on foam surfaces are preferred to exercises using balance boards. The

goal is to make movements more automatic. Physical therapy should occur outside the period of the insulin’s maximum effect (exercise decreases glycemic levels). Exercise is interrupted in the case of symptom worsening, hyperglycemia or hypoglycemia. Retinal bleeding can occur in patients with proliferative retinopathy, and for this reason, jumping and high impact activities should be avoided. Fitness exercise is appropriate at 60% of maximum heart rate. Cardiovascular complications and proteinuria pose risks with increased loading. Modalities Modalities are used to improve lower extremity circulation and trophicity, decrease compression on the nerve caused by edema (entrapment syndromes are more common in patients with diabetes than in the regular population), and affect the pathological threshold of peripheral nerve stimulation. A trophotropic effect can be attained by a resting galvanization or a four-chamber galvanization, which elicit hyperemia and improve local metabolism and tissue regeneration. An antiedematose effect can be achieved by vasopneumatic therapy. It can be implemented in the absence of gangrene or an open wound with purulent infection. During the procedure, the total blood flow increases and improves metabolism of the affected tissues. At the same time, lymphatic drainage increases. Improved lower extremity blood circulation. In this instance, a whirlpool and contrast baths for the lower extremities are appropriate to apply. For influencing pathological stimulation, four-chamber or longitudinal galvanization can be used. Balneologic Treatment In the Czech Republic, balneologic treatment for diabetes has a traditional role. The educational-treatment program is designed mainly for newly diagnosed patients. The goal of balneologic therapy is to eliminate risk factors of DM. In certain cases, it also focuses on

weight loss, improvement of overall fitness and the treatment of complications. In addition to exercises, mineral, temperature indifferent carbonated baths and hot spring gas can be applied as they result in peripheral vasodilation and improve skin and muscle circulation. A positive influence of microangiopathy and decreased hypoxia of the peripheral nerves can indirectly and positively affect the signs of neuropathy.

1.10.3 Inflammatory Polyneuropathies GUILLAIN-BARRE SYNDROME Its most common form is acute inflammatory demyelinating polyneuropathy (AIDP). It is a multifocal inflammatory demyelination deficit of the peripheral nerves and the spinal roots. As indicated by the name, a deficit in myelin dominates, but in severe cases, an axonal deficit can be seen. The beginning of the illness is acute and the course is afebrile and progressive with dominant motor involvement. After several days, symmetrical weakness of the lower extremities develops. At the same time, myalgias, paresthesias or dysesthesias can be present as a result of posterior nerve root involvement and sensory ataxia can occur as a result of proprioceptive deficits. Usually, slow ascendant progression follows with the symptoms moving proximally even in the upper extremities and affects the cranial nerves. The involvement of the diaphragm and the intercostal muscles is dangerous and can lead to respiratory failure. An acute onset is followed by 2–4 week long progression. In the next 2–4 weeks, the condition plateaus, followed by a slow improvement in clinical presentation. The final result depends on the degree of axonal degeneration and on the premorbid condition of the peripheral neurons. In milder cases, treatment is symptom-based. In severe forms with a quick and acute progression, plasmapheresis or administration of intravenous immunoglobulin (IVIG) are indicated. In severe forms, caretaking and the prevention of secondary complications are

important (deep vein thrombosis, pulmonary embolism, decubitus, contractures). In certain cases, respiratory support (ICU ward) and, in all cases, intensive rehabilitation with qualified therapists are important.

CHRONIC INFLAMMATORY DEMYELINATING POLYNEUROPATHY Chronic inflammatory demyelinating polyneuropathy (CIDP) is the second type of inflammatory polyneuropathy, which differs from AIDP by its slower progression and more severe prognosis. In therapy, in contrast to AIDP, glucocorticoids (methylprednisolone, prednisone), immunosuppressive treatment (azathioprine, cyclophosphamide) and also IVIG are utilized. This section also includes polyneuropathy of the critically ill that occurs in patients in an ICU with long-lasting artificial pulmonary ventilation, sepsis and multi-organ failure. Distal extremity muscle weakness dominates. When respiratory musculature is affected, the patients cannot be successfully disconnected from the ventilator. The cause of this polyneuropathy is multifactorial, but the rehabilitation principles are the same as for AIDP and CIDP. Rehabilitation in Inflammatory Polyneuropathies Rehabilitation (especially physical therapy approaches) differs in individual phases of polyradiculoneuritis. Physical Therapy in the Acute and Plateau Stages Respiratory Physical Therapy In the case of respiratory failure, respiratory pathway clearance needs to be maintained and attention paid to the prevention of pneumonia. Bronchial drainage is accompanied by manual techniques. Manual vibration is performed while lying down alternately on one and then the other side. Following the release of bronchial secretions, the patient is instructed to cough or the mucus is suctioned. If the patient’s cooperation is limited, reflex locomotion, specifically reflex turning positions I and II are advantageous. The positions can be

modified so that the segments that are hypoventilated or display a mucous plug and blood stasis are primarily activated. Positioning and stimulation of trigger zones activates not only the main respiratory striated muscles (intercostal muscles, the diaphragm), but also the smooth muscle of the respiratory tract, which helps with drainage and with increasing respiratory volume. At the same time, this technique encourages gastrointestinal tract peristalsis. If the patient suffers from mucus in the respiratory tract, has a cough and shortness of breath and is able to cooperate, the patient is taught drainage techniques, which include autogenic drainage, active cycle of breathing techniques and the use of a flutter. The patient is instructed in correct inspiration, expiration and effective work with an apneic pause or holding or interrupting breathing. The effort is to fully open and ventilate the peripheral respiratory tract. A physical therapist can assist during autogenic drainage and the patient can be “guided” by tactile cuing on the thorax. A cough is an important clearing mechanism for emptying the lungs. The patient is taught to cough effectively and non-effective coughing or long spastic and exhausting coughing are corrected. The exercise is accompanied by resting and relaxation breaks with regular breathing. For more detail, see the General Section of the textbook, B. Therapeutic Approaches, Chapter 1.2.4 Respiratory Physical Therapy – Methods and Techniques for Respiratory Tract Hygiene. Techniques to Maintain Physiological Joint Range of Motion To maintain physiological joint range of motion, gentle and passive range of motion exercises of all joints within their full range and muscle stretching to their physiological length are performed three times per day. It is advantageous to exercise in PNF diagonals. In the lower extremities, this exercise increases blood flow, which prevents thromboembolic complications and maintains peripheral circulation. To prevent thromboembolic complications, lower extremity bandaging and positioning or vasopneumatic therapy are used. To encourage functional positioning of the joint during a flaccid paresis, splints and positioning pillows and bolsters are used. Caution needs to be paid when plastic splints are used to avoid pressure sores.

Caretaking In the acute phase, repositioning every two hours, regular skin checks are needed to prevent pressure sores and even the smallest skin abrasions. Physical Therapy in the Recovery Stage Therapy is aimed at muscle strength recovery with gradual verticalization, improving breathing pattern and balance and gait training. Strengthening Exercises Prior to actual exercise, heat is applied in the form of warm wraps (50– 60 °C), paraffin or a hyperthermal whirlpool. Caution needs to be paid if a sensory deficit is present. Facilitation techniques follow stimulating proprioceptors and exteroreceptors. Brushing, rubbing, passive stretching and positioning based on Kenny and joint mobilizations are used. With Grade 0–2 muscle strength, passive movements in the entire range are performed and the movement is slow, smooth, gentle and pain-free. This maintains joint mobility, acts preventatively against the development of contractures and facilitates the paretic muscle. The patient fully focuses on the exercise and if the muscle is paralyzed, the patient at least imagines performing the movement. Initially, the strengthening exercises can be analytically based on muscle testing to avoid compensation (substitution). Starting at Grade 2 muscle strength, exercises are performed in gravity-eliminated positions, i.e., across the horizontal in the water or suspended (currently, active exercises using Redcord [earlier TherapiMaster] suspension are popular). A great emphasis is put on accurate movement execution. Poor coordination or compensation by a stronger muscle should not occur and exercises are performed to fatigue. Starting at Grade 3 muscle strength, techniques based on the neurophysiological principle are used. They are based on the presumption that the brain controls the movement as a whole, not the individual function of each individual muscle. The aforementioned techniques integrate motor function and afferentation. The quality of proprioception and kinesthetic sense, graphesthesia and somatognosis are essential for correct movement execution. Thus, for example,

reflex locomotion, which includes simultaneous muscle and proprioceptive training, is an advantageous preparation prior to volitional practice of the actual active movement. Similarly, PNF diagonals allow for exercising the entire movement patterns and lead to improved muscle coordination. With gradual improvement in muscle strength to a Grade 4, a combination of other methods can be implemented (neurodevelopmental treatment, sensorimotor stimulation) and the patient is educated in a home exercise program. They are instructed in strengthening against resistance (i.e., Theraband) in correct positions in short sessions several times per day. As soon as signs of muscle overload occur, such as shaking, pain or decreased muscle strength, the patient is instructed to end their exercises immediately. Verticalization and Gait Training If the patient is not capable of any verticalization, at the very least, pressure to the bottom of the feet is applied several times per day. Lifting the pelvis is practiced and the patient is verticalized passively using a standing table. As soon as their condition allows, supine – sit stand transitions are practiced. When standing is practiced, symmetrical weight distribution on both lower extremities is emphasized and the awareness of loading the bottom of the foot and the principles of sensorimotor stimulation are utilized. Gradually, active standing time is increased and weight shifting is implemented. Initially, the physical therapist guides and corrects the movement and gradually lets the patient increase their activity. Based on the patient’s ability, ambulation with assistive devices, such as a walker or forearm crutches, is initiated. Ambulation without assistive devices is first practiced with a wider base of support and gradually progressed to practicing normal ambulation followed by ambulation without visual control and then ambulation outside. Stability and Balance Training Muscle weakness and proprioceptive deficits both contribute to a stability deficit. Therefore, worsening occurs when visual control is eliminated. In therapy, exercises with visual control are used initially and later without it. For example, the system of exercises based on

Frenkel is indicated. Attention needs to be paid to the movement’s precise execution, smoothness, initiation, direction and goal. The exercise occurs from the simplest movements to the most complicated ones; from the most stable positions while lying down to the higher, more unstable and, thus, more challenging positions (exercising in sidelying, sitting, quadruped, standing). Gradually, the movement excursion increases and repetitive rhythmical movements following auditory commands are practiced. Practice of Upper Extremity Fine Motor Skills A consultation with an occupational therapist is sought when hand weakness and limitation in fine motor skills persist. The patient is provided with the needed assistive devices for home environment, orthoses may be issued to facilitate grasping. Balneology Balneology in inflammatory polyneuropathies occurs based on the same principles as those used in peripheral pareses (see above Chapter 1.8 Peripheral Pareses). The approach is similar to the one used in peripheral pareses and neuropathies of different origin.

1.11 POLIOMYELITIS AND POST-POLIOMYELITIC SYNDROME Ivana Wurstová Currently, poliomyelitis no longer occurs in the Czech Republic. In many patients who suffered from poliomyelitis in the past, postpoliomyelitis syndrome gradually (PPS) develops. Below, both conditions are discussed in more detail.

1.11.1 Poliomyelitis Poliomyelitis (poliomyelitis anterior acuta or Heine-Medin disease) is an acute inflammatory disease of the CNS that spread throughout Europe in the first half of the 20th century. The disease continues to be found in endemic regions (Nigeria, India, Pakistan, Afghanistan). Etiology and Pathogenesis The cause of infection in poliomyelitis is a neurotropic virus from a group of the smallest Picornaviridae viruses that elicits infection affecting mainly the ganglionic cells of the anterior spinal horns. Earlier, the disease occurred in the Czech Republic in the form of an epidemic, but after mandatory immunization was implemented in 1957, the last incidence was noted in 1960. Disease Course Only 1% of individuals suffer from the typical neuroinfection following exposure to the polio virus. In paralytic form, the prodromal signs phase is followed by a latent phase and later followed by the development of fevers and peripheral pareses. Asymmetrical extremity muscle weakness and variable weakness of the trunk musculature develop. Bulbar involvement with swallowing or speech deficits are less frequent. Landry’s ascending paralysis is the most severe form involving the muscles of the face, pharynx, larynx, esophagus, eyes and respiratory muscles usually requiring artificial pulmonary ventilation. Sensation is not affected. After six weeks, the

acute phase usually subsides and the condition stabilizes. With skeletal growth, secondary complications gradually emerge, such as extremity hypogenesis, muscle contractures, ankle and knee joint deformities, spinal deformities and other complications. The residual neurological deficit stabilizes for several decades, the preserved motor neurons of the anterior spinal horns take on the function of the necrotic motor neurons and even a full recovery can occur. Rehabilitation An Australian nurse Elizabeth Kenny (1880–1952) developed a comprehensive system of rehabilitation for acute onset poliomyelitis. The methods developed by Kenny influenced not only the muscles, but also other tissues. The method also integrated and improved movement coordination. Therapeutic interventions were selected based on the phase of the disease. Hot wraps and extremity splints were applied, which contributed to decreasing muscle pain and managing contractures and muscle spasms. Manual stretching of soft tissue (skin, subcutaneous tissue, fasciae, muscles) was implemented. This was followed by positioning of segments in physiological positions to prevent soft tissue shortening mainly in the muscles. During exercise, an emphasis was placed on the training of movements involving the functionally weakened muscle. The movement had to be accurate and in the direction of maximum muscle contraction. Proprioceptive neuromuscular stimulation was another frequently used method.

1.11.2 Post-Poliomyelitic Syndrome Post-poliomyelitic syndrome (PPS) occurs after many years following a case of poliomyelitis. It is characterized by muscle fatigue and weakness, fasciculations and atrophy of certain muscles. It mainly affects older people with a more severe primary deficit. In 1994, the post-poliomyelitic syndrome was officially recognized as an independent condition. Causes of Development

According to one hypothesis of PPS development, it occurs due to excessive metabolic stress on the preserved motor neurons, leading to their reduction and a dominance of denervation over reinnervation during long-term overloading of the surviving motor units. Exhaustion of overloaded motor neurons occurs due to lifelong compensation for the necrotic motor neurons. Also, the effect of chronic psychological stress, the possibility of reactivation of a latent poliovirus and also the possibility of an autoimmune reaction in the sense of an auto-aggressive disease (inflammatory hypothesis) have all been demonstrated. Diagnostic Criteria The diagnosis of PPS is mainly based on anamnesis and the patient’s subjective assessment. The basic criteria to establish diagnosis include the following: History of poliomyelitis Partial restoration of affected movement functions Minimum of 15 years of stable health (the period is usually longer) Gradual decrease in muscle strength and overall performance Symptoms cannot be explained by other diseases (significance of differential diagnosis) Post-poliomyelitic syndrome is most often developed following stressful situations, for example, injuries, surgical procedures, prolonged immobilization, stressful events, etc. Clinical Picture Often seen at the forefront of clinical findings are excessive fatigue and overall inefficiency with significant muscle pain and later joint pain. The already present pareses become more prominent, but the weakness also affects the uninvolved muscles. Muscle atrophy, fasciculations and cramps increase; joint deformities worsen and new ones develop (Fig. 1.11.2-1). The patient’s movement abilities and independence decrease. Fig. 1.11.2-2 A patient with post-poliomyelitic syndrome with lower extremity pareses and severe foot

deformities

Besides the above mentioned basic progressive PPS symptoms, the patients are often bothered by a new onset of pain or worsening of the already present pain. Non-specific pain is often accompanied by joint dysfunctions of various origins. Joint subluxations, deformities and arthroses in the large extremity joints and degenerative changes in the spine are a frequent source of pain (Fig. 1.11.2-2). Muscle contractures are often a source of pain. Insertional pain from overloading, such as epicondylitis, is also common. Joint and spinal deformities and nonphysiological loading result in the onset of compression syndromes, mainly carpal tunnel syndrome, nerve root syndromes of the upper or the lower extremities, meralgia paresthetica, etc. Specific pain occurs as a result of tears in individual muscle fibers or entire muscle groups. Fig. 1.11.2-2 A patient with post-poliomyelitic syndrome with lower extremity pareses and severe foot deformities

A patient with PPS needs to exert more and more effort to overcome difficulties and to accomplish regular daily activities. The patient is exposed to gradually increasing physical as well as psychological stress related to the loss of independence and normal performance. Patients with PPS also exhibit specific personality traits. The patients are more sensitive to critique and underestimation. They have strong studying and work ethics, hyperactivity and tendency toward being workaholics are common. A patient with poliomyelitis has a tendency to downplay their health condition and they often willingly strain themselves physically and psychologically. Also, they often reject tools available to their benefit. Rehabilitation

For PPS, the goal of rehabilitation is to decrease the disease symptoms and progression. One of the most important aspects of rehabilitation for patients with PPS is the modification of their current lifestyle, mainly reducing physical demands and stress, preventing injuries, infections, obesity and also emphasizing timely use of compensatory devices. The patient should get a sufficient amount of rest and sleep, should avoid getting a cold and should not overeat. Physical therapy needs to focus on maintaining their current muscle strength and fitness. Exercises to increase muscle strength, including resistive exercises and eccentric contractions are not recommended due to the risk of exhausting the available capacity of the affected musculature. Classic strength training is not recommended; rather, isometric contractions are most beneficial. For the majority of patients with PPS, individually-based physical therapy is the most effective approach. In certain patients, Vojta’s method is beneficial in reaching partial activation of the paralyzed musculature. Prior to initiation of a physical therapy session, administration of heat modalities is appropriate, such as hot packs and paraffin wraps. Electrical muscle stimulation has been used in the past to activate the paralyzed muscles. Now, these approaches are not recommended in order to avoid exhaustion of the remaining functional capacity not only in the affected muscles, but also in muscle groups originally thought to be healthy. Respiratory strengthening exercises also contribute significantly to the improvement of respiratory excursion of the thorax, which subsequently leads to improved ventilatory parameters. Soft tissue techniques and spinal and extremity mobilizations as well as acupuncture and various forms of electrotherapy are primarily used to control pain in the skeletal system. Aquatic therapy is quite beneficial because water provides appropriate resistance for the weakened musculature of the extremities and the trunk. Swimming and a relaxation whirlpool are recommended. Psychological and social assistance are also important for patients with PPS. These can be sought through an association for disabled or

similarly involved patients (The Polio Association). Balneologic treatment forms the most suitable form of specific rehabilitation for patients with PPS. It is important to maintain the patient’s optimal mobility, independence and quality of life. When balneologic treatment is initiated, an adaptation phase regularly occurs, which lasts up to two weeks. When this phase is overcome, the effect of rehabilitation becomes apparent. Balneologic effects last up to half a year. Balneologic treatment for patients with postpoliomyelitic syndrome is provided in Velke Losiny, Janske Lazne, Vraze and Klimkovice. A comprehensive balneologic treatment can be provided under the same criteria as for peripheral pareses (see Chapter 1.8 Peripheral Pareses).

1.12 SPINAL CORD INJURY Spinal cord injury is one of the most devastating health injuries. Individuals with a spinal cord lesion not only suffer from a loss of mobility or sensation in the trunk and extremities, but also from autonomic nervous system dysfunctions, including urinary and bowel deficits, sexual function deficits and other possible complications. Spinal Program Jiří Kříž In the 20th century, significant progress in the care of paraplegic patients occurred in both medical and social arenas. However, longterm efforts in the centralization of patient care for individuals with spinal cord injury became successful only in the 1990’s. Subsequently, the first spinal cord injury department was opened in the Czech Republic under the lead of Professor P. Wendsche in 1992. In 2002, the government of the Czech Republic issued “Methodological Guidelines”, which established a network of healthcare facilities and their areas of coverage to ensure complex care for patients with newly acquired spinal cord injuries. In 2003–2004, based on these “Methodological Guidelines”, other spinal cord injury departments were gradually opened in Ostrava, Liberec and Prague-Motol. At present, continuity of care is ensured for patients with spinal cord injuries starting from surgical facilities in acute IA Phase (approximately 1–2 weeks post-injury) through spinal care units in subacute IB Phase (approximately 2–12 weeks post-injury) to rehabilitation centers for patients in chronic II Phase (approximately 12–36 weeks).

1.12.1 Etiology, Neurological Presentation In the Czech Republic, the number of patients with spinal cord injury increases by 200–250 new cases each year. Spinal cord damage is most often caused by an injury involving a compromise of the spinal canal by a subluxated vertebra or bone fragments. Spinal injuries involving

the spinal cord are mainly caused by auto accidents, falls from a significant height and sport injuries. The average age of such injured patients is usually between 30–35 years. Another, smaller group of spinal cord injuries is from non-traumatic spinal cord lesions, including vascular myelopathies, infections or tumors. These patients are usually older, around 60–70 years of age. Paraplegia develops with a lesion distal to the T2 level and quadriplegia with a lesion at T1 and above. Pentaplegia, which includes simultaneous involvement of the diaphragm, hence a lesion above the C4 level, should also be mentioned. If the neurological picture corresponds to a complete spinal cord discontinuity, it is a complete transverse spinal cord lesion. Preservation of partial movement or sensation below the level of the lesion corresponds to an incomplete transverse spinal cord lesion. The neurological progression of a spinal cord injury involves a period of spinal shock, which begins immediately following the spinal cord lesion and lasts most often around 6 weeks. During this time, the patient can present with complete atonia, areflexia and anesthesia. Not uncommon, after the spinal shock subsides, sensitivity or movement can be renewed to a certain extent. Methods of Clinical Assessment The American Spinal Injury Association (ASIA) assessment tool is used to assess the patient’s neurological picture. It determines the level of a spinal cord lesion and its extent. The motor and sensory levels need to be established first in order to ascertain the neurological level of a spinal cord lesion. The motor level is based on the function of so called key muscles. The key muscles of the upper and lower extremities are defined for each individual spinal cord level. The strength of each muscle is examined from grade 1 through 5 in specifically defined positions. Motor level corresponds to the lowest level for which the key muscle is at least a grade 3 and the muscle above is a grade 5. For the trunk, the motor level is determined according to the level of sensation. To examine the sensory level, so called key points (one point corresponds to one spinal level – a dermatome) are used. Two types of sensory input are examined – light touch and sensory discrimination (recognition of sharp/dull

sensation). The sensory level is given by the lowest dermatome with normal sensation for both types of stimulation. The neurological level of a spinal cord lesion is determined by the lowest segment with normal bilateral motor and sensory function. The extent of the spinal lesion is established by the so called ASIA Impairment Scale (AIS). Activity in the sacral segments is important: AIS A – complete lesion – characterized by an absence of sensory and motor function at S4-5 levels; AIS B – incomplete lesion – characterized by preserved sensation below the level of the lesion including levels S4-5; AIS C – incomplete lesion – characterized by preservation of motor function of at least half of the key muscles below the level of the spinal lesion with muscle strength lower than grade 3; AIS D – incomplete lesion – motor function in more than half of the key muscles below the level of the lesion with muscle grade 3 or higher; AIS E denotes normal sensation and movement at all levels. However, a deficit in autonomic functions can be present to a varied extent. To assess the patient’s functional state following spinal cord injury, the Spinal Cord Independence Measure (SCIM) and gait tests are used. The SCIM is used to determine the patient’s level of independence, breathing, bowel and bladder function and mobility. Each area contains several questions with a point scale (for example, independence contains questions about feeding, dressing, bathing and visual appearance). Overall, a maximum of 100 points can be obtained. Tests designed for gait assessment include the Walking Index for Spinal Cord Injury (WISCI) (patient’s ability to stand and ambulate with a point assessment of 0–20) and time-based tests – the Timed Up and Go Test, the Ten-Meter Walk Test and the Six-Minute Walk Test. It is important to repeat these tests in regular intervals (at evaluation, at 3 and 6 months, at 1 year post injury) to be able to assess the patient’s progress.

1.12.2 Systematic Approach to Treatment Patients with a spinal cord injury caused by a trauma are urgently

transported to their regional spondylo-surgical facility where they undergo surgery. In most cases, the surgery consists of two parts. The first includes spinal decompression or spinal cord release by repositioning the dislocated vertebra and removing bone fragments. Next, spinal stabilization is performed. This is significant so that the injured segments can be loaded and timely, intensive and comprehensive rehabilitation can begin. The patient is also prescribed specific medications – anti-inflammatories, antiulcer, anti-depressants, analgesics and antithrombotics. Intensive rehabilitation is already initiated at the spondylo-surgical department or even in the intensive care (ICU), which will be described in more detail later. If the patient is stable (cardiac and pulmonary), they can be transferred to a spinal cord injury unit. Some spinal cord units have the capacity to accommodate patients needing ventilatory support. Such facilities provide comprehensive nursing, medical, rehabilitation and psychological care. Nursing includes mainly accommodation of basic vital needs, such as food intake, personal hygiene, sleep, urination and defecation. An important part of rehabilitation care includes prevention of pressure ulcers, thrombosis, pulmonary complications, urinary infections and spread of nosocomial infections. Medical care is focused on correct medication prescription, prevention and timely treatment of complications and the establishment of urinary and defecation schedules. Psychological intervention is a significant component of patient treatment in the spinal cord units. The psychologist communicates with all patients in the department, with their families and with all healthcare staff. Visits by a social worker are also important in order to obtain social assessment and help deal with the patient’s social situation. If the patient can tolerate verticalization into sitting, achieve a certain level of independence based on the level of their spinal cord involvement, has an established schedule for urination and defecation and all health issues are addressed, then the patient can be transferred to a rehabilitation facility (in the Czech Republic: Kladruby, LuzeKosumberk, Hrabyne) where they continue intensive rehabilitation

for another 5–6 months. After that, the patient is provided with assistive devices and aids and is discharged to a home setting or an Institute of Social Care.

1.12.3 Medical Consequences of a Spinal Cord Lesion and Possible Complications AUTONOMIC DYSREFLEXIA It is purposefully listed first because it is a serious acute condition. It is a sudden increase in blood pressure caused by inadequate autonomic reaction to an irritation below the level of the lesion. The causes usually include urinary bladder distention or overfilling of the bladder with a blocked urinary catheter or suprapubic cystostomy (epicystostomy). Other causes can include intestinal distention, a sudden abdominal accident, a burn or an infection. An increase in blood pressure, which is caused by an uncontrolled release of mediators below the spinal cord lesion and the subsequent vasoconstriction, mainly in the splanchnic area, which attempts to balance the body by reflexive bradycardia and vasodilation. This response is only seen above the level of the lesion and is therefore insufficient. The clinical picture of autonomic dysreflexia includes a sharp pulsating headache, redness in the face, perspiration and anxiety. If we do not react quickly, brain bleeding can occur. Usually, it is sufficient enough to sit the patient up and renew urinary drainage. If the cause of the problem is not immediately determined, the pressure can be temporarily lowered by administering a quick-acting hypertension medication. Autonomic dysreflexia is only found in patients with spinal cord lesion above T6 level.

ORTHOSTATIC HYPOTENSION It is caused by the patient’s prolonged horizontal position in the acute phase, especially with a lower extremity or trunk paralysis which is linked to insufficient venous blood return from the periphery. Often, such patients collapse when they are brought into a sitting position.

Therefore, gradual verticalization into sitting is important with the possibility of immediate reclining backward or verticalization using a verticalization table or a positioning bed.

DEEP VEIN THROMBOSIS (THROMBOEMBOLISM) Obstruction of the blood supply in the lower extremities exposes the patients to a higher risk of thromboembolism, which requires longterm use of Heparin or Warfarin.

URINARY DYSFUNCTION Following a spinal cord injury, a patient is unable to urinate spontaneously. Immediately following the injury, a permanent urinary catheter is implemented. However, in men, epicystostomy (a urinary catheter implemented through the abdominal wall) is recommended to prevent the risk of ulcer formation on the urethra long term. So called intermittent catheterization can be implemented when the patient’s spondylo-surgical condition is established and the patient is stabilized. It is a regime of intermittent catheterization every 3–4 hours performed by an experienced nurse. This also needs to be followed by a fluid intake regimen of approximately 2–2.5 liters daily. If the patient masters catheterization, they can begin self-catheterization. Approximately 2 months following the injury, urodynamic examination is performed. The regime can be adjusted based on the results and on the irritability and tone of the bladder and the sphincter musculature. The main goals are protection of the upper urinary tract and continence in the period between catheterizations. Patients with a spinal cord injury often show permanent bacterial colonization of the bladder. With incorrect bladder emptying, reflux of urine into the kidneys can occur, leading to the development of pyelonephritis, which can later lead to chronic kidney failure.

BOWEL DYSFUNCTION Intestine and anal sphincter dysfunctions depend on the level of the spinal lesion. Emptying is usually done by rectal stimulation

(suppository) or manually. Sometimes, diet needs to be modified (adequate fiber, appropriate serving portions). Obesity poses a problem after the injury due to decreased energy expenditure.

SEXUAL DYSFUNCTION Based on the level of the lesion, patients with a spinal cord injury display various combinations of deficits in sexual functions. In men, erection and ejaculation dysfunctions exist and in women deficits in lubrication and reaching orgasm are seen. Transient amenorrhea corrects itself a few months following the injury. Spinal cord injury is not a cause of infertility. All patients should maintain regular contact with a sexologist, andrologist or gynecologist.

INTEGUMENTARY DYSFUNCTIONS Skin complications are fairly common. The skin of paralyzed body parts receives less blood circulation. With decreased sensation, a risk of pressure ulcers or various skin abrasions and burns can occur. Skin defects do not heal well. In acute and subacute phases, all patients are systematically positioned and various anti-ulcer mattresses or supports are used. Most skin defects appear after a longer period of time, usually if the patient does not take sufficient care of their body. The treatment of developed pressure ulcers is always difficult and is accompanied by a great likelihood of complications. Often, the inflammation reaches the bone, osteomyelitis forms and can develop into a chronic septic condition known as pressure ulcer disease.

SEPTIC CONDITIONS In acute and subacute phases, the patient can develop sepsis. Generally, urinary infection is the cause, but in higher lesions that involve deficits in ventilation or expectoration, respiratory infection can also develop. In patients with polytrauma, an infection can be found in the abdominal cavity. However, the source may also be a pressure ulcer or a central venous catheter. It is always a serious, life threatening complication requiring aggressive treatment by large-scale

antibiotics.

PAINFUL CONDITIONS Patients with a spinal cord lesion often suffer from various types of pain. Neuromuscular pain is most common and linked to the constrained position or overloading of certain muscle groups. Visceral pain, or pain caused by internal organ pathology, is sometimes difficult to localize due to a lack of sensation. Neuropathic pain is the most intense. It originates from injured nerve structures, either from the spinal cord or the spinal roots themselves. In general, neuropathic pain is difficult to manage, tends to be chronic and is present in about one third of patients. Currently, various combinations of medications are available to manage this type of pain.

SPASTICITY In central lesions or injuries involving the entire spinal cord, most often up to L1, spasticity occurs to some degree once the spinal shock subsides. It is characterized by increased muscle tone, hyperreflexia and clonus. The extent of the spasticity can be influenced by rehabilitation itself. If it is managed by therapy and tolerable to the patient, then it is not necessary to implement pharmacological treatment. The treatment of spasticity with medications is initiated after consultation with a physical therapist once it begins to hinder the standard course of rehabilitation or is too traumatic for the patient. Sometimes following the injury, spasticity can increase and lead to contractures and deformities. If medication does not control spasticity to a tolerable extent, a Baclofen pump can be implanted (continuous intrathecal administration of Baclofen).

PARA-ARTICULAR OSSIFICATION Para-articular ossification (also neurogenic heterotopic ossification) causes joint movement restrictions and can possibly lead to ankylosis. For more detail, see the General Section of the textbook, Rehabilitation Care, Chapter Prevention of Heterotopic Ossifications.

OSTEOPOROSIS In the chronic phase, patients with a spinal cord lesion often develop osteoporosis due to lack of activity. This leads to increased incidence of fractures due to falls from a wheelchair or careless lower extremity manipulation. Regular verticalization to standing (standers, standing tables) is recommended when appropriate.

1.12.4 Rehabilitation for Patients with Spinal Cord Injury Physical therapy and occupational therapy dominate in the treatment of patients with a spinal cord injury. Patient’s health and the level of the spinal lesion play the main role in the selection of an appropriate physical therapy technique. Demands placed on the patient are based on their present health condition. In the spinal cord unit, the patient should undergo individual physical therapy twice a day during work days in addition to exercising on equipment, verticalization, modalities and occupational therapy. Physical Therapy Pulmonary (Respiratory) Physical Therapy Patients with a spinal cord injury always show changes in breathing mechanics. In patients with a cervical spinal cord injury, expectoration is affected. In patients with a thoracic spinal cord lesion, an injury to the thorax and the lungs often occurs simultaneously and some patients undergo artificial pulmonary ventilation or have a tracheostomy cannula. All patients are prone to an increased risk of atelectasis or bronchial pneumonia. Thus, respiratory pathway hygiene is one of the main goals of therapy. Pulmonary physical therapy utilizes passive and active techniques. Passive techniques include positional drainage, relaxation of the thorax, manual vibration during expiration, massage of the intercostal spaces and passive respiratory gymnastics. Active techniques include mainly the practice of expiration against resistance, self-drainage and deep breathing with reflex stimulation developed by Vojta. Tools used in pulmonary physical therapy that utilize resistance during expiration and vibration include Flutter and Acapella.

Passive Movements These movements are performed to prevent contractures and maintain movement in individual joints. Intervention is especially necessary for patients with quadriplegia who are at greater risk for upper extremity contractures and frequent shoulder joint pain due to the upper extremity alignment in internal rotation and scapular protraction. Movements must be slow and smooth and, in the acute phase, should not exceed two thirds of physiological range to decrease the risk of soft tissue injury and the development of periarticular ossifications. When spinal shock subsides and spasticity occurs, it can be significantly decreased by the patient’s individual passive movements. A component of passive movements is the centration of joints, particularly the shoulder and hip joints. It involves continuous pressure of the extremity in the direction of its axis into the joint socket. This causes stimulation of pressure receptors located within the joint socket and sends afferent impulses to the area of the spinal cord disruption with a potential for repair. MotoMed (Fig. 1.12.14-1) is used to exercise cyclic passive extremity movements. This equipment also allows for active exercise with an option to assess muscle strength. MotoMed can be used in sitting or in bed. Repeated passive movement significantly improves blood circulation in the extremities and increases the stimulation of muscle and joint receptors that send afferent impulses to the spinal cord. Fig. 1.12.14-1 Equipment for passive and active movements of the extremities

Active Movements During active movements, physical therapy focuses on the muscles and muscle groups that show completely or partially preserved function. Renewal of muscle strength, activation of muscles within correct muscle patterns and gradual control of certain positions are part of active movements. The goal is to achieve the most advantageous postural functions at individual levels of verticalization. During active individual exercise, various physical therapy methods and concepts are utilized, such as Vojta’s method, PNF, the neurodevelopmental treatment (Bobath), sling exercise therapy (S-ET) approach (exercising in slings with RedCord equipment formerly known as the TerapiMaster). Most commonly used physical therapy tools include resistance bands, balls, rolls and balance boards.

Soft Tissue Techniques and Mobilization In pulmonary physical therapy, skin, muscle and fascia mobilization techniques are applied most frequently in the thoracic and cervical regions. Mobilizations of distal aspects of the upper and lower extremities can significantly improve their function. Soft tissue techniques are also used for scar/incision mobilization. Verticalization As soon as the patient’s overall condition allows, verticalization into sitting and standing is initiated following the injury. Various types of verticalization beds, verticalization tables and stands can be used. Verticalization and mechanotherapy are interconnected when exercising on the Lokomat machine (Fig. 1.12.4-2). Lokomat is a new and modern piece of medical equipment that serves as a method of manually assisted gait training utilizing a moving belt (treadmill). The equipment consists of a suspension system, treadmill and robotic orthoses. Synchronization is controlled by a computer and the orthoses contain sensors that scan the actual movement activity of the lower extremities. The equipment can be set to individual specifications for each patient with respect to their demands and gait pattern. For patients with a spinal cord injury, intense and specific locomotor training increases the potential for supraspinal plasticity of the CNS motor centers linked to locomotor functions. Lokomat is used mainly by patients with an incomplete spinal cord lesion. Fig. 1.12.4-2 The Lokomat machine

Therapeutic Agents (Modalities) Modalities are mainly used to treat neuromuscular pain, tenosynovitis, arthropathies, and to improve skin defects and scars. Electrotherapy, ultrasound, magnetic therapy, biolamp, distance electrotherapy treatments are the most commonly used modalities. Various forms of aquatic therapy are also appropriate. If the patient is relatively continent, mobility exercises can be performed in the pool. Also, hot tubs with jets (jacuzzi) are recommended to improve circulation, decrease edema, and improve ease of movement. Occupational Therapy Occupational therapy occurs daily in coordination with physical therapy. Occupational therapy focuses on the practice of independent and common daily activities (dressing, transfers, personal hygiene, food intake, etc.). An important part of occupational therapy is functional grasp training for patients, with quadriplegia, which includes hand positioning in special positioning gloves. This facilitates finger flexor shortening and improves the resulting grasp function of the hand. In a rehabilitation hospital, the occupational therapist and the treating physician are responsible for appropriate selection of assistive devices for the patient to use in a home setting, such as a wheelchair, cushion, positioning bed, tools for personal

hygiene and other compensatory aids. An occupational therapist also offers consultations in regards to home, car driving and work station modifications for handicapped patients. Social Rehabilitation Social rehabilitation already occurs during hospitalization in the spinal cord injury unit and later during one’s stay in a rehabilitation hospital. The goal is to prepare the patient for life with a handicap while surrounded by family and strangers. An important factor is cooperation of the patient’s family, which should serve as a strong support system for the patient. Options are explored to address the patient’s home, modifications or changes in occupation, worksite modifications and patient’s transfers or transportation with minimal dependence on others. The patient should not be limited in social activities. The patient can become involved with various non-profit organizations that deal with their disability such as, in the Czech Republic, Centrum Paraple. Following discharge from a rehabilitation hospital, each patient should seek to be integrated into work and social activities as soon as possible. The patient should also develop long-term individual rehabilitation goals aimed at maintaining their physical condition and preventing contractures, edema, osteoporosis, etc. However, a patient should not expect to continue an intensive (multiple hours per day) rehabilitation program for several years even though some patients expect they will. In general, improvement in mobility or sensation can be achieved during the initial year after the injury.

1.13 DEFICITS IN CEREBELLAR FUNCTIONS Alena Kobesová

1.13.1 Functional Anatomy of the Cerebellum The cerebellum is an anatomical structure located together with the brain stem infratentorially in the posterior fossa of the skull. It consists of two hemispheres and a medially located section called the vermis. The cerebellum plays an important role in muscle tone regulation, maintenance of erect posture within the gravitational field and balance when standing or walking. It contributes to the accuracy of specific movements of the extremities, including the most complex, learned movement stereotypes, and ensures movement coordination in time and space. During ontogenesis, the cerebellum develops and fully matures at six years of age. This also involves full maturation of fine motor skills of the hand, thus, a function that needs to be mastered prior to the beginning elementary school attendance. Phylogenetically and functionally, the cerebellum can be classified across three sections: Archicerebellum (floculonodular lobe) is the oldest part of the cerebellum and it is functionally interconnected particularly with the vestibular system and hence it is called the vestibular cerebellum. It is a small but important part of the cerebellum which receives vestibular information regarding the position and movements of the head in space. Based on this information, it affects spinal cord motor activity and ensures balance during all postural scenarios. Paleocerebellum forms the anterior lobe, the superior and inferior segments of the vermis and adjacent parts of the cerebellar hemispheres including the cerebellar tonsils. It receives information primarily from the spinal cord, thus it is called the spinal cerebellum. The paleocerebellum participates in the optimization of muscle tone and the function of the anti-gravity musculature. The archicerebellum and paleocerebellum together ensure adequate

muscle tension and synergy of the agonists and antagonists participating in standing and walking. Neocerebellum is phylogenetically the youngest component. It forms the middle portion of the vermis and most of the surface of the hemispheres. This segment is rich in connections with motor areas of the cerebral cortex, the subcortical region and the thalamic nuclei. Based on this, it is called the cerebral or pontine cerebellum. It receives information about any planned movement and, through efferent pathways, modifies (mainly inhibits) pyramidal and extrapyramidal motor stimuli. The cerebellum has rich afferent proprioceptive and exteroceptive signalization, but also receives information about visual and auditory inputs. It essentially ensures one’s body orientation and analysis of the surrounding environment. On an ongoing basis, visual and acoustic information allow the cerebellum to assess the distance and speed of a moving object in the external environment and to adequately react to this situation as needed (safely cross the street, catch a ball, etc.). Smooth and accurate performance of all volitional and automatic movements is facilitated by quick processing of information from the peripheral receptors, in which information travels through spinocerebellar pathways. The cerebellum constantly analyzes all information about ongoing movement and immediately corrects any inaccuracy. This activity is mainly inhibitory, which means that the cerebellum prevents overshooting of movement. It acts as a brake by limiting range of motion and accurately guiding the movement to reach the target. Since the processing of information in the cerebellum is extremely fast, even quick repetitive movements or very complex movement programs, such as athletic, artistic or other specialized work stereotypes (playing musical instruments), are addressed. The cerebellum times the individual phases of movement and ensures their accurate initiation, duration and purpose. Therefore, it is not only involved in coordination of dexterity of the distal extremities, but also in gross postural motor skills. Next to the sensory cortex, the cerebellum also serves as a storage of learned movement patterns (engrams). Together with the

extrapyramidal system, it ensures the fine regulation and the resting state of muscle tone. The cerebellum can be affected by various pathological processes: ischemia, bleeding, tumors, injuries, inflammatory and neurodegenerative processes, intoxication or metabolic dysfunctions. In children, the cerebellum can be affected by cerebral palsy. A deficit of the cerebellum results in an inhibitory function, which is manifested as disproportional, uncoordinated movements, apraxia, clumsiness, tremor and deficits in stability, gait, gaze and language.

1.13.2 Basic Clinical Manifestations of a Cerebellar Lesion ATAXIA Ataxia is a basic movement deficit that occurs in the presence of a cerebellar lesion. It is a deficit in the coordination of volitional movements, their decomposition, clumsiness and inaccuracy. The movement is incorrectly timed or targeted, not smooth or efficient and shows many deviations into directions other than these intended. Based on the area or function affected by ataxia, it can be gait ataxia, postural (trunk) ataxia, extremity ataxia or language ataxia (cerebellar dysarthria). Standing ataxia is characterized by unsteady standing with a wide base of support with a tendency to fall in various directions. Gait ataxia is manifested by insecure wobbly gait with a wide base of support and a tendency toward falling (drunk walk). Step length is asymmetrical; the patient is unable to ambulate in a straight line. Patients often interpret their gait insecurity as dizziness; however, it is not a true vertigo. Hypermetria, adiadochokinesia and asynergy are also components of ataxia.

HYPERMETRIA Hypermetria denotes incorrect estimation of movement in a sense of overshooting. Movement begins and occurs too quickly, it is rushed,

without a target and is inaccurately completed as a result of delayed and insufficient activation of the antagonists. Clinically, this deficit is most often assessed as an upper extremity dysmetria via the finger-tonose test (Fig. 1.13.2-1). Fig. 1.13.2-1 Test of upper extremity coordination. A – cor​rect execution; B – dysmetria (hypermetria) and intention tremor

A patient with their arm stretched in front of them attempts to touch the index finger to the tip of their nose as accurately as possible at first with eyes open and, if accomplished successfully, with the eyes closed. The assessment can be even more accurate by having the patient touch alternately the examiner’s index finger and their nose. The movement becomes gradually faster and the examiner changes the position of their index finger. Dysmetria denotes missing the target, overshooting is called hypermetria (see Fig. 1.13.2-1). Volitional effort to compensate for hypermetria is manifested as bradyteleokinesia, which is slowing of the movement prior to reaching the target followed by several compensatory movements to the side and only after that does the patient’s finger reach the target (nose). On the lower extremity, the movement of the heel on the shin of the opposite lower extremity can be tested. Here, movement

decomposition can be observed easily. At first, the patient lifts the leg excessively, flexes the knee and only then aims and attempts to touch the heel to the contralateral knee. The patient is asked to slide the heel on the shin toward the foot. If a cerebellar dysfunction is present, the movement is uncoordinated, “zigzags” (Fig. 1.13.2-2), and protective movements are excessive. During examination, we suddenly push a patient (preferably seated) or pull on their shoulders or trunk. Excessive protective synkineses of the extremities are then observed. Hypermetria is also seen in writing as macrographia. Excessively loud speech is also a demonstration of hypermetria. The patient “thrusts” individual vowels (explosive saccadic articulation). With cerebellar dysfunction, slurred, slowed, drunken speech is also present (cerebellar dysarthria). Fig. 1.13.2-2 Test of lower extremity coordination. A, B – correct execution; C – deficit in lower extremity coordination in a patient with cerebellar dysfunction

ADIADOCHOKINESIA Adiadochokinesia is a deficit in quick, alternating or repetitive

movements. The alternating activation of agonists and antagonists is affected. The patient performs, for example, quick pronationsupination of both forearms. Movement typically lacks regular rhythm and individual phases are asymmetrical. Sometimes the movement may overshoot or undershoot and the physiological movement deceleration prior to reaching a target is absent. A certain degree of adiadochokinesia is physiological during preschool years when the cerebellum is still “maturing” and is frustratingly persistent in the nondominant upper extremity. Adiadochokinesia can also be assessed in the tongue. The patient is asked to slightly protrude their tongue and quickly move it from side to side. The movement is non-rhythmic, uncoordinated and the tongue does not reach the corners of the mouth (Fig. 1.13.2-3). Fig. 1.13.2-3 Assessment of adiadochokinesia of the tongue and the upper extremities

ASYNERGY Asynergy is a deficit in the coordination of a muscle or a group of muscles during movement. The timing of activation of individual muscles into movement is missing. The muscles work without mutual functional continuity and more complex movements lack smoothness. Movements are separated into individual phases and the movement lacks timely activation of the antagonists to appropriately decelerate the movement. This lack of coordination is typically manifested

during a test in which the therapist stands behind the patient and pulls them by the shoulders. With a cerebellar deficit, a physiological synkinesis of knee flexion is absent as the knees remain extended and, thus, the patient has a tendency to fall backward – manifestation of asynergy (Fig. 1.13.2-4). At the same time, excessive defensive synergies of the upper extremities can be observed and are manifestations of hypermetria. Asynergy can be also tested by the supine-to-sit test or sit-to-stand test, in which uncoordinated movement can be observed. A patient places their crossed arms across their chest and attempts to sit up from supine position. If cerebellar dysfunction is present, the patient excessively lifts their lower extremities above the mat. In the case of ipsilateral cerebellar hemisphere involvement, the deficit is observed on the ipsilateral lower extremity (Fig. 1.13.2-5). Fig. 1.13.2-4 Asynergy. A – With backward bending, a patient does not flex their knees and falls backward; B – Physiological reaction, with backward bending, knee flexion occurs

Fig. 1.13.2-5 Supine - to - Sit Test: asynergy of the left lower extremity

FLACCIDITY Flaccidity denotes decreased muscle tone and, therefore, it is also known as cerebellar hypotonia. Range of motion is increased as a result of decreased resistance from the antagonists which lack timely deceleration of movement. This is demonstrated by the rebound test (Fig. 1.13.2-6). Increased synkinesis of the upper extremities during ambulation is a sign of flaccidity. Deep tendon reflexes are pendular. Joint play is increased and many signs typical for hypermobility are seen. Elementary postural reflexes are decreased or absent. Hypotonia manifests itself in endurance tests, i.e., during the Mingazzini test, a slow lowering of the raised extremity occurs.

Fig. 1.13.2-6 Test to assess flaccidity: the examiner pulls on and quickly releases the patient’s raised forearm; a patient with cerebellar syndrome cannot stop forearm movement in time and it hits their chest

CEREBELLAR TREMOR A cerebellar tremor is an intention tremor which means that it is manifested during a specific movement. It is most prominent at the end of a movement and is best observed in the finger-to-nose coordination test (see Fig. 1.13.2-1) Titubation is a rhythmical, slow head or upper trunk tremor occurring mainly in the anterior-posterior direction.

EYE MOVEMENT DISTURBANCES In a cerebellar dysfunction, eye movement disturbances are manifested by non-continuous movements consisting of a series of twitches. In principle, it is an uncoordinated movement of the eyeballs with signs of asynergy, hypermetria and an intention tremor. Cerebellar nystagmus is gross, occurs toward the side of the lesion and becomes more prominent when looking toward the affected side.

PALEOCEREBELLAR AND NEOCEREBELLAR SYNDROME

To a certain extent, the phylogenetic-anatomical division of the cerebellum also possesses functional significance. The verminal (medial) part mainly coordinates movements of the eyes and the body in relation to gravity and movement of the head in space. It especially affects the trunk musculature, balance and erect body posture. With a simultaneous deficit in the archicerebellum, eye movement disturbances and gaze paretic nystagmus are present. These medial (verminal) lesion manifestations correspond to the paleocerebellar syndrome, which can be combined with archicerebellar involvement.

PALEOCEREBELLAR SYNDROME Clinically, the paleocerebellar syndrome is manifested mainly as deficits in standing and walking with staggering and a tendency of falling in various directions (trunk or axial ataxia). Paleocerebellar (previously known as large) asynergy is manifested by a coordination deficit mainly in the trunk and the proximal lower extremity muscles, incorrect judgment of movement to maintain standing, transition from sitting or from supine, backward bending or straightening. Spontaneous falls in various directions, especially backward, are common when the central part of the cerebellum (vermis) is injured.

NEOCEREBELLAR SYNDROME The neocerebellar syndrome develops when the cerebellar hemispheres are injured and it is manifested mainly as movement deficits in the ipsilateral extremities. In contrast to pyramidal pathways, cerebellar pathways cross twice and, thus, each hemisphere always affects the ipsilateral extremities. The neocerebellar syndrome displays hypermetria, dyscoordination and adiadochokinesia of movement in ipsilateral extremities. An extremity asynergy (small asynergy) is demonstrated mainly in fine motor skills of the upper extremities. Purposeful movements are disturbed by an intention tremor and increased passivity; neocerebellar ataxia occurs. Lower extremity involvement leads to deficits in standing and walking. Pathological lesions usually overreach the anatomical boundaries of

cerebellar regions and, thus, clinical symptomatology is mixed.

PSEUDOCEREBELLAR SYNDROME Pseudocerebellar syndrome develops with a frontal lobe injury. The clinical picture is similar to paleocerebellar syndrome with gait dysfunction known as frontal ataxia being the most obvious. Ambulation is wide-based, very unsteady and the patient feels like they are being pulled backward and shows a tendency toward falling. Lower extremity mobility while lying down does not show significant pathology. Usually, other symptoms affiliated with a frontal lobe injury are present, such as personality changes, cognitive deficits, etc.

1.13.3 Rehabilitation in Cerebellar Dysfunctions Rehabilitation is successful in scenarios involving simple cerebellar dysfunctions (small cerebellar dysfunction syndrome) or in small structural lesions of the cerebellar cortex or the subcortical region. The clinical picture is vague and the compensatory capacity is good with a tendency toward spontaneous recovery over time. Also, slowly expanding processes (tumors) can be ongoing for a long time with minimal signs given the significant compensatory ability and plasticity of cerebellar functions. In contrast, extensive lesions of the hemispheres, lesions in the cerebellar nuclei and the cerebellar connections are difficult to manage. Therapy in children with cerebellar involvement in cerebral palsy (previously known as a cerebellar form; currently, cerebellar involvement is classified as a mixed form because sole involvement of the cerebellum in CP practically does not occur) is also very difficult and often accompanied by mental retardation. When establishing a rehabilitation program, the patient’s increased fatigue levels need to be taken into consideration. More frequent, but shorter exercise times are preferred. The sessions are stopped when the patient is feeling tired because the quality of the already disturbed movement stereotypes decreases. A patient exercises independently under the therapist’s guidance. A group setting is usually not

appropriate for a patient with a cerebellar lesion because the physical therapist needs to continuously correct the deficits in the practiced movement pattern. Physical Therapy Physical therapy attempts to affect supportive and specific motor skills, improve movement coordination, improve dysmetria and influence the cerebellar tremor. Good trunk stability is a prerequisite for any purposeful movement. Since trunk stability is often affected in cerebellar dysfunctions, the treatment usually begins by practicing it. Vojta’s reflex locomotion can be used. By correctly positioning the patient in the starting position, the trunk musculature becomes automatically activated during stimulation, the spine becomes stabilized and a functional centration of the proximal joints occurs, which are necessary components for any other subsequent movement. During reflexive exercises, the patient fully concentrates and attempts to remember this correct trunk muscle synergy and, immediately following stimulation, the patient attempts to achieve the same quality of muscle coordination using their own volitional effort. This is followed by the training of phasic extremity movements. Frenkel exercises consist of a set of exercises designed for the reeducation of normal movements in patients with ataxia. The progression is from simple movements to more complex ones. The main goal is to overcome ataxia and uncoordinated movements. At first, the patient exercises with visual control and, when the skill is mastered, the exercises are progressed quickly to being performed without visual feedback. The patient performs the exercises at midspeed first, then at varied speeds. Slow movement is more difficult than fast. Initially, movement patterns originating from the proximal joints are practiced. At first, the movement is not practiced through a full range of motion, but rather, it is divided into two or more phases and, gradually, the individual phases are connected into one continuous specific movement. Initially, the patient is guided by manual contact and, later, they are instructed using verbal commands. Other auditory stimuli can be used as well, such as rhythmic counting, drumming or music. Exercises are initiated from stable positions,

known as lower positions (e.g., supine or prone), with gradual progression to “higher”, more challenging positions – quadruped, side sitting, tall sitting and standing. Exercises in supine, prone or kneeling are always performed on the floor so that an unsteady patient is not fearful and cannot fall. Attention is paid to accurate movements and continuous pace. The patient performs, for example, alternate lower extremity flexion and extension by sliding the heel on the mat, lifting the bottom of the foot from the mat, moving it to a marked area, etc. The patient is encouraged to become aware of not only the course of the movement, but also of the position of the individual segments. They also attempt to remember and maintain this position. To accomplish this, rhythmic stabilization (a component of the PNF concept) is used, in which the therapist randomly attempts to alter positions of a patient’s extremity and the patient is asked to resist and maintain the extremity in one position. An assessment test can be used to practice a specific phasic movement, i.e., for dysmetria. The patient alternately touches a point in space and their nose or various points in space that can even change positions. On the lower extremities and in the supine position, the patient practices heel contact on the contralateral knee, contact of the bilateral heels, alternate contact of heels and toes, etc. As soon as the patient masters these exercises, a more challenging position, i.e., quadruped, sitting or standing and more complex, repeated movements are selected. Following a short practice using visual feedback, the training quickly progresses to practice without visual feedback. Feldenkrais exercises are based on this practice of slow, repetitive, purposeful movements. This method emphasizes conscious awareness and control of movements and positions of individual body parts where the precision and the quality of movement execution is important. Gradually, various movement versions are practiced, including working with center of mass and accurate location of weight distribution to increase movement potential. Balance, stability and locomotion are often affected in patients with cerebellar dysfunction, making their training difficult. Often, steady standing and ambulation are the only focus. At first, the patient needs

to determine in which direction they are “being pulled” and attempts to permanently correct their center of mass (weight shift in the opposite direction). Visually fixating the gaze on a steady point helps with correcting balance. A patient’s reactions to sudden stimuli and to the center of mass deviations are practiced so that they can always “catch themselves” in time. Fall and injury prevention are a priority. Patients with a severe deficit in stability are taught ambulation with a walker or even locomotion sideways in quadruped (with the upper extremity supported on the wall or on furniture). If the patient is able to ambulate forward without assistance, but their gait is unstable, they are allowed to ambulate with a wider base of support. When the prognosis is good and the patient’s condition is improving, gait training implements ambulation with a normal and narrow base of support, same step length, walking on marked spots, toe/heel walking and ambulation forward and sideways. Taking the patient’s abilities into consideration, exercises on unstable surfaces are gradually implemented based on the principles of sensorimotor stimulation. Occupational Therapy In addition to ADL training and recommendations regarding assistive devices, an occupational therapist has an important role in selecting an occupation, mainly for children with cerebellar dysfunction, i.e., with cerebral palsy. Following the assessment of the child’s functional abilities, an occupational therapist assists in selecting an appropriate education or occupation that the child is capable of. Based on the degree of locomotor involvement, the patient receives recommendations regarding their assistive devices, such as a walking cane, three-point cane, forearm crutches, walker or wheelchair. The wheelchair can be mechanical and transportable, which means that it is maneuvered by another person or, a standard mechanical wheelchair if the patient is able to maneuver it by themselves. In most severe cases, if the patient meets certain criteria, an electric wheelchair can be requested. This also requires the recommendation of other specialists. Following an occupation therapy assessment, the patient can be provided with other tools to increase their independence (handles, commode, bed pan, shower or bath

chair, transfer board, pressure ulcer padding, etc.). Speech Therapy The care correcting the saccadic explosive speech and cerebellar dysarthria is also important. Balneologic Treatment In adults, balneologic treatment is indicated based on the primary etiology of the illness (MS, degenerative diseases, inflammatory illnesses of the CNS, CVA, post-injury and post-surgical states, oncologic etiology, etc.). In children, indications often include cerebral palsy, post-inflammatory etiology, degenerative and hereditary familial cerebellar diseases, post-injury and post-operative states. In the Czech Republic, balneologic centers in Janske Lazne, Teplice, Velke Losiny and Klimkovice are recommended.

1.13.4 Prognosis of Cerebellar Dysfunctions Correction of incorrect movement patterns or the practice of compensatory functional patterns is appropriate in permanent and already non-progressive states (i.e., following a minor stroke). A subtle deficit in cerebellar functions is often found in pediatric patients and teenagers with poor body posture or with scoliosis. In this population, slight trunk ataxia is present, for example, during forward bending, upon return from forward bending or when sitting up from lying down. The movement is not smooth, but rather it is saccadic and broken into phases with numerous side movements. Reciprocal (differentiated) movement of the lower extremities is also insufficient, which can be observed during rolling when the patient usually keeps both lower extremities extended and close together and turns them as one block “as if they were tied together”. The upper extremities or tongue can demonstrate slight dysdiadochokinesia (it is difficult to move the tongue up and down or to the sides, which can be related to slight dysarthria or stuttering). Also, the child is often unable to track a moving object only with their eyes, instead they turn their head or even the trunk even though the range of the moving object does not require it. All these signs are subtle, thus, very rarely expressed and

the patient and their parents are often unaware of them and are identified only during careful clinical examination. Professor Vladimir Janda referred to the signs of slight deficits in cerebellar functions as minimal cerebellar dysfunction syndrome, which he considered as one of the possible etiological factors of incorrect body posture or chronic back pain in early adulthood. It is strictly a functional, not structural deficit and its prognosis is good with regular and long-term rehabilitation protocol. In contrast, certain structural, mainly degenerative cerebellar diseases are progressive in nature. Although, they are often very slow (years or decades) with a gradual loss of the patient’s functional abilities and independence. Our priority is for the patient to retain their independence as long as possible. For such diagnoses, the rehabilitation worker invites family members to therapy sessions in order to educate them in the patient’s home exercises and the use of the recommended assistive devices. The Ataxia Rating Scale is used to assess the patient’s clinical condition over time or to assess changes as a result of physical therapy or another type of therapy. The Ataxia Rating Scale assesses standing and gait deficits, as well as, deficits in kinetic functions, speech and eye movements.

1.14 BALANCE DEFICITS Ondřej Čakrt, Michal Truc Balance deficits are among the more frequent symptoms for which patients seek rehabilitation treatment. Many patients treated in rehabilitation complain of “dizziness”. When asked to describe their dizziness in more detail they report that their head is “spinning”. If the patient uses the word “spinning”, it needs to be explained to them that there are only two types of spinning: clockwise and counterclockwise. If a patient can identify the direction of their spinning, it can be presumed that it is most likely true vestibular dizziness (vertigo). Patients often describe being pulled to the side, which is one of the signs of acute vestibular dizziness. A feeling of “drunkenness” without actual dizziness, which patients often report during walking, can be a sign of cerebellar dysfunctions, extrapyramidal diseases or peripheral neuropathies. Sometimes, patients also use the term “dizziness” to describe lower extremity unsteadiness, which contributes to their difficulty to maintain their balance. This is also true for presyncopal states with decreased blood pressure or for non-specific signs during anemia or hypoglycemia. All these signs need to be explored when obtaining the patient’s history (anamnesis) prior to proceeding to somatic examination. Rehabilitation must respect the pathophysiologic deficits. It needs to be established on an individual basis, taking into consideration the patient’s current problems. Only some causes are described further.

1.14.1 Balance Control From a functional perspective, balance control is a function of the movement system that utilizes multisensory afferentation: proprioceptive, vestibular and visual. Other important factors include anticipation of a movement program, experience and judgment of stability limitations. Based on the vestibular, proprioceptive and visual information, the

central nervous system forms a schema that provides accurate information about movement, body positions and the external environment. This schema is then used to correct head and gaze positions and for coordination of movements that ensure postural reactions. Professor Henner reported that the pathogenesis of dizziness develops when our senses signal contrasting information (i.e., when watching a flowing river from a bridge). Deficits in postural stability may not only be caused by vestibular system disorders. If the function of the vestibular system is disrupted, the function of the vestibulo-ocular reflex (VOR) and the vestibulospinal reflex (VSR) is affected. Balance disturbances can also occur due to disorders in other systems. Non-vestibular etiologies present a large component of balance deficits encountered in clinical practice.

VERTIGO AND ITS MOST COMMON CAUSES Vertigo is a term used to describe the fundamental subjective sign of vestibular system disturbance. Clinically, it needs to be determined whether it is a true vestibular dizziness caused by a vestibular system disease or a non-vestibular balance deficit. Based on the affected location, vestibular deficits are classified as a peripheral or central vestibular syndrome. A peripheral vestibular syndrome develops most often with a deficit in the receptor itself, which is found in the labyrinth, or an illness in the area of the vestibular nerve connecting the labyrinth and the vestibular nuclei. A central vestibular syndrome is a deficit caused by a lesion in the area of the vestibular nuclei of the brainstem or other CNS structures that are part of the vestibular pathway. A pure heterogeneous group is formed by balance deficits of nonvestibular etiology. Clinically, this group can include frequent incidences of orthostatic hypotension and a number of neurological illnesses manifested by disturbances in postural stability. The nonvestibular types of dizziness also involve psychogenic balance deficits and cervicogenic dizziness caused by upper cervical spine and cranial

joint dysfunction. A separate group includes physiological vertigo, which incorporates dizziness from heights and kinetosis (motion sickness). These types of vertigo are caused by a sensory conflict developed when processing information from the vestibular and visual receptors.

1.14.2 Clinical Presentation of a Patient with a Vestibular System Disturbance Objective signs of a vestibular disturbance include nystagmus, vestibular ataxia and tonic deviations of the extremities and trunk. Central vestibular syndrome presents with a typical non-rhythmic nystagmus in various directions. It is important that there is no correlation between the intensity of the nystagmus and the vertigo. Vestibular ataxia is manifested by a balance deficit during ambulation. In central vestibular syndrome, tonic deviations of the body and the extremities are not linked to the direction of the nystagmus and are not dependent of the patient’s head position. In contrast, peripheral vestibular syndrome typically shows a rhythmic nystagmus in horizontal or horizontally rotational directions. At the same time, a positive correlation between the intensity of the nystagmus and the intensity of the vertigo is present. All tonic body, head and extremity deviations display one direction identical to the slow component of the nystagmus and are directed toward the functionally weaker labyrinth. In standing, the direction of the deviations depends on the head position. In the case of acute vestibular vertigo, the patient can also complain of accompanied autonomic signs, such as perspiration, nausea or bleeding. Sometimes, a patient in the acute stage of peripheral vestibular disorder can display a head tilt in the frontal plane toward the side of the lesion. Tonic body and extremity deviations are also in the direction of the weaker vestibular apparatus.

EXAMINATION

During vestibular system assessment, the integrity of reflex loops into which the vestibular system is integrated is evaluated. In many cases, well conducted clinical examination has a high predictive value. Examination of a patient with a suspected vestibular system deficit is initiated by careful anamnesis. The anamnesis focuses on identifying the nature of the vertigo. It needs to be identified whether it is dizziness of a rotational character or a sensation of drunkenness and unsteadiness in space. Rotational vertigo is typical for peripheral involvement. A central deficit is more likely to be manifested by a nonspecific insecurity in space during movement. The patient is asked about the duration of dizziness and whether it is a paroxysmal dizziness or a constant state with no change. The mechanisms that trigger the patient’s dizziness are important anamnestic findings. Patient history is followed by an otoneurological examination, which can determine whether this is a case of a central or peripheral deficit. In the case of a peripheral deficit, the therapist searches for signs of static or dynamic imbalance between the vestibular systems. With a static imbalance, the clinical symptoms are manifested as an imbalance between the vestibular systems at rest. In a dynamic imbalance, there is an imbalance during movement. Resting nystagmus is examined, which is a basic manifestation of a static asymmetry of the vestibulo-ocular reflex. During examination, the patient’s visual fixation, which decreases nystagmus, needs to be eliminated; therefore, Frenzel goggles are used during examination. The Halmagyi impulse test is used to quantify the dynamic instability of the vestibulo-ocular reflex. Hautant’s test, the Barany Pointing Test or the UnterbergerFukuda tests are most commonly used to assess tonic vestibular deviations (Fig. 1.14.2-1). The Unterberger-Fukuda test is the most sensitive test. In this test, the patient is asked to march for 30 seconds with arms extended in front of them and the eyes closed. The patient’s deviation from the starting position is observed. Vestibular ataxia is assessed during ambulation. To increase the sensitivity of the assessment, the patient needs to ambulate as slowly as possible.

Walking can also be modified, i.e., walking in tandem or including a test of quickly turning in place. Fig. 1.14.2-1 Unterberger-Fukuda Test. The patient marches in place with eyes closed for at least 30 seconds. A deviation in the direction of the hypofunctional labyrinth indicates a positive test.

Examination should focus on the assessment of the vestibular system function by clinical and electrophysiological methods, but it also needs to include a complete neurological examination, kinesiologic analysis, and examination of the patient’s functional abilities or their limitations in daily activities and in a home setting. A posturographic assessment is used to quantify the function of the vestibulospinal reflex. Stability is assessed under static and dynamic conditions. In patients with vestibular system deficits, documentation of direction, frequency and magnitude of body deviations is the goal of a posturographic assessment. Specificity of the posturographic assessment is not sufficient to establish a differential diagnosis and, thus, it is indicated only as an ancillary examination.

1.14.3 Theoretical Bases for Rehabilitation The foundation for rehabilitation of patients with vertigo originates in the mechanisms of vestibular deficit correction, which include spontaneous correction of function, vestibular adaptation based on the nervous system plasticity and the use of compensatory strategies. Spontaneous correction of function. It is a known fact that individual manifestations of static instability of the vestibular systems caused by a peripheral lesion subside spontaneously. Vestibular adaptation especially affects the correction of the dynamic VOR functions. It is the ability of the vestibular system to adapt the neuronal response to the performed head movements. A deficit in the dynamic phase of the VOR is characterized by a decrease in gain VOR (gain is defined as the change in the eye angle divided by the change in the head angle during head turn). In time, gain corrects itself, but continues to stay decreased and asymmetrical, mainly during fast movements toward the affected side. Gaze, or the movement of the retinal picture, is the stimulus for development of vestibular adaptation. Formation of compensatory strategies. This is a third option which enables a person to deal with a loss of vestibular function. Stimuli from neck muscles and cervical joints form the core for the cervicoocular reflex (COR). This reflex is effective mainly during slow head movements. Under normal circumstances, its influence is very small and does not exceed a 15% contribution to generating compensatory eye movements. In patients with either unilateral or bilateral loss of vestibular function, the contribution increases to 25%. Correction of postural stability may be supported by the use of visual and somatosensory mechanisms. However, these strategies can only be utilized when both systems function flawlessly. Problems occur when the function of these inputs is affected, i.e., in the dark or when walking on a different terrain. At an older age, the use of such strategies is limited for pathological reasons (cataracts, polyneuropathy).

1.14.4 Rehabilitation of Individual Clinical Presentations UNILATERAL VESTIBULAR LESION During rehabilitation, it needs to be taken into consideration whether this is a state of static or dynamic imbalance. In the static imbalance stage (worsening peripheral vestibular syndrome), the period immediately following the onset of a vestibular injury, the patient demonstrates spontaneous nystagmus, tonic extremity deviations and vertigo accompanied by autonomic symptoms. In this stage, the saying “the worse, the better” is followed and patients should be verticalized as soon as possible and, in a short period of time, rehabilitation should focus on the development of spontaneous compensation. During exercise, however, stressful moments should be avoided because they could later contribute to the development of phobic postural vertigo. Approaches decreasing spontaneous nystagmus are selected, such as exercises with fixation on a stationary as well as a moving target. Improvement in standing stability and increased ambulation endurance are targeted. The dynamic imbalance stage (worsened peripheral vestibular syndrome) includes mainly rehabilitation approaches that increase gain VOR. Exercises aimed to improve visual-vestibular interactions are implemented. During these exercises, the patient fixates a stationary target containing some text (i.e., credit card information) and gradually moves their head in transverse, sagittal and frontal planes. The movement speed is individual and gradually increases during practice. The goal is for the patient to see a clear picture of the observed text during movement. Next, the cervico-ocular reflex is stimulated. During this exercise, the patient sits on a swivel stool, their head is held in a stable position by another person and the patient turns their body in the horizontal plane together with the swivel stool. Sensorimotor techniques or balance training with biological feedback are implemented for the training of the vestibulo-spinal equilibrium.

BENIGN PAROXYSMAL POSITIONAL VERTIGO

Benign paroxysmal positional vertigo (BPPV) is a common cause of dizziness in the adults and the older population. It is a peripheral positional vertigo occurring in short episodes and tied to positional changes. Pathophysiology of BPPV is explained by an inadequate stimulation of the semicircular canal when the otoconia dislodged from the membrane of the otolith organs (sacs) enter the lumina of one of the semicircular canals (most often the posterior canal). During quick head movements, they cause movement of the endolymph even after the movement has been completed and the subsequent irritation of hair cells is perceived as an acute rotational vertigo. In individual patients, a change in position elicits dizziness often experienced when transitioning from sitting to lying down or with backward bending of the head. Diagnosis BPPV diagnosis is based on thorough anamnesis and the presence of nystagmus in the Dix-Hallpike test. Dix-Hallpike Test The patient is seated on a table, legs extended in front of them, head in 10 degrees of extension and turned 45 degrees toward the side of the affected labyrinth. The examiner grasps the patient’s head and quickly transitions the patient into the supine position while maintaining the established head position. In BPPV, geotropic nystagmus with a rotational component occurs toward the affected ear with a 3–10second latency. Posterior canal BPPV is characterized by a gradual increase in the intensity of the nystagmus, reaching a maximum and then gradually subsiding to a complete cessation of the nystagmus and vertigo in several tens of seconds. When the patient is positioned on the side of the unaffected labyrinth, dizziness and nystagmus are not elicited. If the Dix-Hallpike test is positive, BPPV diagnosis is indisputable. Treatment Repositioning maneuvers are the only appropriate and effective

methods of treatment. Their goal is to reposition the otoconia back to the utricle where it can no longer interfere with the semicircular canal. The patient is educated on the fact that this is the most physiological and safe way to treat their condition. Semont Maneuver The patient is seated facing the therapist in the middle and at the edge of the examining table. The therapist firmly grasps the patient’s head and the patient firmly holds the therapist’s arm. The therapist turns the patient’s head 45 degrees away from the affected side. Subsequently, the therapist lays the patient down on the affected ear (position of symptom provocation). In this position, the patient stays without moving until the nystagmus and vertigo subside. This is followed by turning the patient by 180 degrees to the opposite position on the opposite side of the table (the head position is unchanged). In this position, a so called deliberate nystagmus may occur. When this reaction subsides, the therapist sits the patient back to the starting position. A milder reaction and the perception of unsteadiness may occur in sitting (Fig. 1.14.4-1).

Fig. 1.14.4-1 Diagram of the Semont maneuver with the posterior right semicircular canal affected. The upper section of the picture shows the movement of the patient’s body; the lower section shows the movement of the otoconial fluid in the lumina of the semicircular canal.

Epley Maneuver 1. The patient sits on a table with their lower extremities extended and the head turned to 45 degrees toward the affected side. 2. The patient is quickly brought to a supine position with the head positioned over the edge of the table and they are left in this position for 2 minutes. 3. Then, the patient’s head is turned by 90 degrees to the opposite side. 4. Finally, the patient, with their head turned to 45 degrees toward the unaffected side, slowly sits up and maintains this position for 2 minutes. The Semont maneuver is used more often than Epley maneuver.

BILATERAL VESTIBULAR DEFICIT In bilateral lesions, gain VOR is decreased, which is why patients demonstrate a deficit in stabilization of the visual field (oscillopsia) during head movements. With head movement, patients develop an illusion that the surroundings are moving and the visual field becomes blurred. During rehabilitation, the effort is to improve the stability of the retinal image, especially by practicing compensatory stabilization strategies by utilizing an increased reactivity of the cervico-ocular reflex (COR) and saccadic movements. Visual fixation combined with head stabilization is used during treatment. Some patients show difficulties when moving in a noisy environment such as shopping malls. To master this activity, they need certain practice or even assistive devices (cane). During rehabilitation, exercises facilitating the somatosensory spino-vestibular and spino-cerebellar reflex loops are included (balance exercises on unstable surfaces). Every patient develops their own balance control strategies and thus, individually-based training that teaches the

patient to master specific situations that they have difficulty with is necessary.

BALANCE DEFICITS ASSOCIATED WITH CHANGES IN THE CERVICAL SPINE These are less common, non-specific balance deficits. The patient often describes them as short-duration balance deficits with blurred vision. Uncontrolled movements to the sides are common. There is a negative relationship between head movement and the trunk, mainly the cervical spine. At the same time, the patient shows other signs of cervical dysfunction, mainly pain corresponding to a cervical syndrome. Quite similar is Costen’s (temporomandibular dysfunction) syndrome which is a type of dizziness with an etiology tied to the orofacial system. It is usually accompanied by a cervical syndrome. It should be mentioned that no cervical spine dysfunction can elicit a rotational vertigo with nystagmus. A patient examination should focus on spinal dysfunction (not only the cervical or orofacial systems). A number of patients with vestibular dysfunction use stabilization strategies that restrict head movement. Painful cervical spine syndromes can develop due to changes in the vestibulo-spinal reflexes and in muscle tone. They are not the cause of vertigo, as they are often mistakenly interpreted, but rather its consequence. These strategies are not beneficial because they prolong the time necessary to develop adaptation and compensatory mechanisms. Therapy follows treatment principles targeting functional deficits of the spine or even the orofacial system.

CENTRAL BALANCE DEFICITS Central vestibular syndromes are a heterogeneous group of deficits found in a number of diseases. Often, the structures contributing to compensatory mechanisms are affected. In a central vestibular syndrome, gain VOR can be increased or decreased. This is why

clinical and electrophysiological findings need to be carefully assessed prior to the initiation of a rehabilitation program. If gain is too high, the component of the rehabilitation program aimed at its increase is eliminated. Most patients with central vestibular involvement show oculomotor deficit involving pathology in smooth tracking movements, inaccurate saccades and persistent spontaneous nystagmus. For this reason, exercises involving smooth tracking movements, saccades and fixation are incorporated. Also, beneficial are exercises assessing the individual’s stability limitations and finding optimal strategies for the execution of problematic movements. The practice of postural and movement strategies is the main goal, taking into consideration increased movement safety, fall prevention and increased independence. Similar to a peripheral deficit, balance training with biofeedback can be used.

VERTEBRAL ARTERY SYNDROME In this dysfunction, cervical extension or cervical extension coupled with rotation elicits dizziness and a tendency to fall backward. Usually, it affects older patients with signs of atherosclerosis together with degenerative cervical spine changes. This position elicits ischemia in the vertebral artery on the side of its insufficiency. The patients report dizziness when painting the ceiling, hanging clothes, looking up at the sky, etc. Sometimes a sudden fall can occur accompanied by a short period of unconsciousness, possibly injuring the patient. During treatment, careful mobilizations with assistance of neuromuscular techniques are implemented and followed by rehabilitation focused on spinal function. Often, a positive therapeutic effect is seen. However, patients need to be cautioned to avoid activities requiring cervical extension and head rotation.

PSYCHOGENIC VERTIGO Peripheral vestibular deficits are often accompanied by anxious reactions. In contrast, approximately 20–40% of cases of unsteadiness are of psychogenic origin.

Rehabilitation treatment is based on the assessment of vestibular tests and a psychological examination, as well as, findings regarding quality of life and an overall activity level. Rehabilitation therapy should take into consideration the patient’s personality and exercise can serve as a means of psychotherapy. The goal is to change the experience of the position and the movement in space, to desensitize the patient toward feelings of required balance and to form a system of diverting attention from the feelings of unsteadiness. Safe movement in space and weight shifting to the limits of stability, known as falls to the wall, are practiced. Tai-chi can be implemented to emphasize a relaxed movement experience in space while perceiving the expressed movement. This type of exercise combines movement and meditation. The exercises improve balance, body posture, breathing and coordination. Patients need to be encouraged to gradually return to the highest possible level of activity that they were not able to perform during their illness (ADL functional training).

1.14.5 Biological Feedback in Rehabilitation of Patients with Balance Deficits Ondřej Čakrt, Rudolf Černý, Jaroslav Jeřábek Feedback during stability training for patients with balance deficits has been used for a number of years. Generally, it is presumed that biological feedback facilitates multisensory (visual, proprioceptive and vestibular) stimulation and, thus, speeds up the compensatory process consisting of reorganization of neural circles that contribute to balance control. In practice, several systems are currently used with visual feedback being one of them. A change in the patient’s body position is scanned by a stabilometric platform. The platform can measure, through tension meters placed in the platform’s corners, the individual components of forces acting on a standing individual and their moments. From the measured values, the position of the

resultant force (CoP) acting on a patient can be calculated. The position of the resultant CoP is given by the x-axis (anterior-posterior direction) and the y-axis (lateral directions). CoP movement can be shown on a monitor in real time. CoP position on the monitor in front of the patient presents a feedback signal that informs a patient of their actual body position. The patient is able to better regulate their postural reactions by using this signal and maintaining a static standing position. A different principle can be seen in a system that scans positional body changes through accelerometers. Accelerometers are most often placed on the trunk, close to the true position of the center of mass or on the patient’s head which is close to the vestibular labyrinth. These systems use feedback from vibratory stimulation of the mechanoreceptors on the surface of the body. Vibrators most often inform the patient when the sensor position exceeds a certain boundary and the risk of falling becomes eminent. Brain Port System Brain Port (BP), which uses feedback through electrotactile stimulation of the tongue, represents an innovative technology in the rehabilitation of balance deficits. This system was developed mainly for patients with a bilateral vestibular function loss and individuals suffering from chronic unsteadiness. Here, BP was also successfully used during treatment. The foundation of this tool forms a very sensitive accelerometer placed on the patient’s tongue. Information from the accelerometer is processed and transferred to low intensity electrical impulses that the patient perceives as a tactile signal on the tongue. This signal is mediated through a field of small 10×10 electrodes that are placed on the lower position of the accelerometer (Fig. 1.14.4-2). Through tactile tongue receptors, the patient can identify the position of an electrical signal or even the direction and the magnitude of its deviation from midline. The signal position corresponds to the actual head position of the patient in a given moment. During the treatment course, the patient is taught to react to this signal. During treatment, the goal is to stabilize the signal in the middle portion of the stimulation field, thus, in the central portion of

the tongue. This can be achieved through an appropriate postural reaction. The training positions become progressively more challenging from standing on a firm mat in tandem standing (heel-totoe stance) to standing on a foam surface. The brain port is also used for gait training. The training is always performed without visual feedback. Thus, during stability control, the patient is left with information from the stimulator and the somatosensory system. Electrical stimulation of the tongue applied simultaneously with somatosensory input leads to the formation of a correct spatial constant that corresponds to the physical space. Somatosensory afferentation is then used to maintain balance in real life despite the patient’s lack of correct information about their spatial position due to vestibular hypofunction. This is a compensatory, not a reparatory, support. Vestibular sense is substituted for by a different stimulus. Fig. 1.14.4-2 Brain port (BP)

1.15 EXTRAPYRAMIDAL DEFICITS Alena Kobesová

1.15.1 Basic Characteristics, Classification Extrapyramidal deficits develop with an injury to the extrapyramidal system, which includes the basal ganglia and their connections to other components of the nervous system in ascending and descending directions. From an anatomical perspective, the basal ganglia include the caudate nucleus and the lentiform nucleus (consists of the putamen and the globus pallidus). The putamen and the caudate nucleus form the corpus striatum. The basal ganglia system also includes the subthalamic nucleus, mesencephalic substantia nigra (pars compacta and pars reticularis), accumbens nucleus, and the nucleus basalis of Myenert. These central structures physiologically ensure basic postural and movement mechanisms and movement automatisms. When damaged, volitional and automatic movements are restricted, abnormal body posture develops and abnormal nonvolitional movements emerge. Extrapyramidal deficits can be divided into two basic types.

HYPOKINETIC DEFICITS The first group includes hypokinetic deficits that are manifested by hypokinesis (decreased range of movement, scarcity of movements) up to akinesis (from a deficit to an inability to initiate movement), bradykinesis (slowness of movement) and rigidity. Parkinson’s disease is a typical representative of this deficit.

HYPERKINETIC DEFICITS On the other hand, the second group is formed by hyperkinetic (dyskinetic) deficits, which are characterized by abnormal, undesirable and usually involuntary movements, such as tremor (also found in hypokinetic disorders), chorea (irregular, randomly occurring

movements of the face, trunk and extremities, often writhing in character), balism (abnormal movement of all extremities in large excursions), dystonia (persistent muscle tension in a certain body part), myoclonus (sudden muscle twitches) or tics (irregular stereotypical movement partially suppressed volitionally). The symptoms vary based on the involved area of the extrapyramidal system. From all these deficits, patients with Parkinson’s disease are the ones most often seen for treatment. Therefore, Parkinson’s disease is the focus of the next section.

1.15.2 Parkinson’s Disease The prevalence of Parkinson’s disease is 1 case in 100 people for people 60 years of age or older. It develops with degeneration of the pigment dopamine-containing cells of the pars compacta in the substantia nigra, which, under physiological conditions, produce the neurotransmitter dopamine that contributes to movement control. A deficit in dopamine is responsible for manifestations of Parkinson’s disease. It is important to realize that, in Parkinson’s disease, there is an insufficiency of the actual dopamine while the receptors for this neurotransmitter are preserved. This is why administration of a precursor to dopamine (L-DOPA) has a positive effect. After L-DOPA is absorbed, it metabolizes into dopamine, which binds to the corresponding receptors. In contrast, Parkinson’s syndrome often involves damage to the actual receptors, thus, post-synaptic involvement. If dopamine were administered, it would not be able to bind to a receptor and this oral treatment shows a significantly lower effect to no effect. Parkinson’s syndrome can develop in various pathological conditions that affect the CNS (e.g., post-pharmacological, vascular, toxic, post-injury, post-encephalic Parkinson’s syndrome). Parkinson’s disease is identified in approximately 80% of patients exhibiting Parkinson’s signs. The remaining 20% are diagnosed with Parkinson’s syndrome in addition to a primary diagnosis. Parkinson’s disease is characterized as a hypokinetic-hypertonic

syndrome manifested as a movement deficit that includes tremor, rigidity, bradykinesis, hypokinesis and postural instability. It is a chronic, progressive disease that mostly affects the older generation, but approximately 10% of the time the disease occurs prior to 40 years of age (so called early onset). The onset of clinical signs is gradual and the progression is very slow, even over several months or years. Initially, Parkinson’s disease can manifest itself as non-specific problems, such as heaviness in the extremities, decreased performance, depression, muscle pain and spasms, back pain, frozen shoulder syndrome or carpal tunnel syndrome. The first and still undiagnosed manifestations of rigidity are the primary cause of these problems. Often, the patient has been examined by a rheumatologist or an orthopedist or underwent rehabilitation treatments rather than being seen by a neurologist. Since rigidity is the primary cause of the problems, administration of only orthopedic or rehabilitation therapy without causative pharmacological treatment results in only a partial and temporary effect. Typical clinical signs emerge after several months.

OBJECTIVE NEUROLOGICAL FINDINGS Objective neurological findings include a combination of the following signs:

HYPOKINESIA, BRADYKINESIA, AKINESIA These deficits are manifested as a decreased range of motion, movement scarcity, lack of movement spontaneity, overall slowing and a deficit in movement initiation up to a complete inability to initiate movement. Out of all of these signs, hypokinesis limits the patient’s function the most. A disturbance in the initiation of motor programs forms the foundation for this deficit. Motor programs themselves are clearly not damaged in Parkinson’s disease. However, their activation and completion are affected, especially the smooth functional continuity of individual segments to form an overall movement pattern. Sudden freezing of movement is a form of akinesia.

Physiological synkineses (co-movements of the upper extremities during ambulation) are absent and gait becomes shuffling with shortened step length. The intended movement stops short and does not reach the target (bradyteleokinesia). Reactive defensive extremity co-movements are decreased and replaced by whole body movements, most often in the backward (retropulsion) or forward (propulsion) directions in an effort to prevent falling. As a result of hypometria, repetitive and alternating movements are affected and a disturbance in diadochokinesia is observed (however, it is altered in a different way than in cerebellar dysfunction in which, in contrast, the movement is exaggerated on the side of the lesion, or in paralysis, in which the movement is limited as a result of muscle weakness or spasticity).

RIGIDITY Rigidity denotes increased muscle tone that usually goes hand in hand with hypokinetic signs, but it can also occur separately. Muscle hypertonus has a plastic character and it is present during active and passive movement throughout the entire range and occurs regardless of movement speed. Constantly increased tone in the agonists and antagonist is present (lead pipe rigidity). In contrast to spasticity, flexor and extensor muscle tone is increased, although the deficit is more pronounced in the trunk flexors. The cog-wheel phenomenon is typical. During passive extension of an extremity at the wrist, elbow or an ankle, reflexive contractions of the stretched flexors can be palpated. Similarly, during passive muscle shortening, there is palpable activity of the tendons stabilizing the extremity segment in specific positions of the movement. This stabilization is necessary to perform the movement; however, in the case of rigidity, it is excessive and lasts too long because muscle relaxation is disrupted and movement continuity cannot occur. These saccadic tendon twitches are denoted as increased elementary postural reflexes. Rigidity is accentuated by contralateral extremity movement (called Froment’s maneuver). Pain in the extremities is caused by increased muscle tone. Micrography (small writing) is typical, although, it was more appropriate at a younger age. In the facial muscles, hypomimia or a

mask-like face is observed where the patient is unable to use mimetic muscles to express emotions. Affection is sometimes manifested as increased breathing. Speech is monotonous and non-melodic (aprosodia), quiet (hypophonia) and, in an advance stage, the patient’s speech is difficult to understand.

TREMOR A tremor is an involuntary, rhythmic, oscillatory movement of a body part. In Parkinson’s disease, a resting tremor is typically found especially in the distal extremities. The tremor is asymmetrical and accentuated most if the patient’s hands are resting freely. It is increased during ambulation when the extremities rest along the body, during stress, with increased cognitive demands or with fatigue. In contrast, it decreases during movement or in static loading and usually does not interfere significantly with daily activities; it disappears when sleeping. A hand tremor in Parkinson’s disease resembles counting coins. It can manifest itself on the trunk; however, it typically never affects the head (in contrast to an essential or cerebellar tremor).

POSTURAL DEFICITS Hypokinesia, rigidity, deficits in upright and postural mechanisms and defensive reactions all contribute to postural deficits. A flexed posture of the trunk and the extremities (Fig. 1.15.2-1), unsteady standing and shuffling gait with small steps are very obvious manifestations of Parkinson’s disease. Decreased upper extremity synkinesis, difficulty with movement initiation and changing direction, sudden inability to move (movement freezing), especially in narrow spaces or in stressful situations, can all be observed during gait. Stepping in place, especially at the beginning of ambulation (hesitation) is linked to an inability to move forward. Increased step cadence (festination) and decreased balance with pulling (usually forward) can lead to falls. Postural deficits may not be apparent at the beginning of the disease, but are typical for more advanced stages. Fig. 1.15.2-1 Typical flexed body posture in a patient with

Parkinson’s disease

In Parkinson’s disease, the signs are always asymmetrical. They begin on one side of the body (primarily in the distal aspects) and gradually can spread asymmetrically to the trunk musculature and the other half of the body. This typically does not occur in secondary Parkinsonian syndrome, in which the signs are rather symmetrical. Basically, it can be stated that the clinical picture of extrapyramidal syndrome is the opposite of cerebellar syndrome, which suggests a certain functional opposition of these two systems. The Unified Parkinson’s Disease Rating Scale (UPDRS) is a basic, generally used scale for clinical neurological assessment of patients with Parkinson’s disease. It assesses the patient’s clinical state in 6 basic categories (I–VI) and 42 subcategories, which are classified by grades 0–4 (0 = without signs, 4 = the most severe degree of deficit in a given domain), or grades 0–1 (0 = no, the sign is not present, 1 = yes, the sign is present). A complete

UPDRS scale is available on the internet. During the patient’s clinical assessment, or when trying to assess treatment effectiveness or patient progression, either the entire UPDRS scale or only certain categories that a given patient may demonstrate changes in can be used. Diagnosis of Parkinson’s disease is based on patient history (anamnesis) and clinical neurological examination. To establish the diagnosis, at least two signs from the basic three (hypokinesis, rigidity and tremor) need to be present. The diagnosis is also confirmed by a positive response to pharmacotherapy (oral administration of dopamine precursor, L-DOPA). Rehabilitation in Parkinson’s Disease In Parkinson’s disease, rehabilitation has as important a role as pharmacotherapy. It is appropriate to recommend rehabilitation to a patient already in the early phases of the disease so that suitable movement activities can become habitual. Physical therapy has its place in every phase of Parkinson’s disease and plays an important role in the prevention of muscle weakness, limited range of motion, decreased fitness and social isolation. It must be modified on an ongoing basis to adjust to the patient’s cognitive abilities, medication, aging process and other accompanied conditions. A rehabilitation specialist can assist in the establishment of Parkinson’s disease diagnosis by correctly assessing postural instability and identifying other movement problems. In early phases of the disease, appropriate rehabilitation programs assist in maintaining an adequate state of the cardiovascular, nervous and musculoskeletal systems and in overall fitness. They can prolong the onset of typical secondary signs, such as disuse of the more affected body parts, gait disturbances, falls, inability to change body positions, overall muscle weakness, joint stiffness, and orofacial and respiratory dysfunctions. During the course of Parkinson’s disease, the rehabilitation specialist participates in the assessment and assists with optimization of the effect of medication on the patient’s movement abilities. On an ongoing basis, they identify and correct movement dysfunctions and in cooperation

with an occupational therapist, they advise the patient regarding home and work setting modifications and recommend appropriate assistive devices. In the later stages of the disease, family participation is important and the family members are educated on the basics of rehabilitation care. Treatment rehabilitation in Parkinson’s disease includes physical therapy approaches administered either individually or in a group setting, aquatic therapy and occupational therapy. Physical Therapy Initially, physical therapy treatment focuses on improving the patient’s posture. The effort is aimed at correcting a flexed trunk and overall extremity alignment. The fasciae on the back and the thorax are stretched with soft tissue techniques, especially in the areas of the lower intercostal spaces, which are often “closed”. During a breathing cycle, the intercostal muscles do not become activated and their insufficiency is compensated for by the accessory breathing muscles. Ribs and mid-thoracic spine are mobilized into traction and extension and an effort is put into practicing active segmental mobility of the thoracic spine, which is often “locked” in rigid flexion. From the beginning, the patient is taught self-treatment. To maintain spinal flexibility and trunk rotation, individual exercises need to be done at least three times a week. Good thoracic mobility is linked to correct alignment of the thorax and correct breathing mechanics. The patient has to learn to consciously relax the accessory breathing muscles (scalenes, upper trapezius, pectoralis major and sternocleidomastoid) and activate the intercostal and abdominal muscles along with the diaphragm during breathing. The fasciae and soft tissues of the extremities are stretched. In the case of developing flexion contractures, hot packs and techniques based on E. Kenny are applied in an effort to maintain soft tissue flexibility. In the upper extremities, elbow and wrist mobilizations are used in addition to the soft tissue techniques. In the lower extremities, full range of motion in the hip and knee joints needs to be maintained. Isometric traction of the hip joints and stretching of hip adductors and knee flexors are performed. The patient is taught self-mobilization and relaxation techniques.

During exercise, the patient is asked to perform smooth, repeated movements within the full range of motion. The physical therapy treatment plan must be developed based on the patient’s dominant deficit. In the case of rigidity and akinesis, large range swing-type exercises, even with weight (dumbbells) are included in the exercise routine. The number of exercise repetitions and their difficulty are gradually increased. Conversely, if muscle weakness and overall decreased performance dominate, the patient’s subjective perception of their fatigue level needs to be respected and the exercises are done with lower repetitions, performed gradually in individual segments and without weights. Simple balance exercises in combination with lower extremity strengthening exercises improve stability and decrease the incidence of falls. The condition of patients who display a combination of tremor and muscle weakness is the most difficult to influence. Here, the therapist mostly uses neurophysiologically based techniques (Vojta’s reflex locomotion, neurodevelopmental treatment) to improve body posture and muscle coordination. The home program includes simple exercises that the patient has already safely mastered. Since the patient’s tremor can make the patient anxious, simple tricks are recommended to hide the tremor, such as putting the hand in a pocket or in a belt, weighing down the extremity, or wrapping the foot around a chair leg when sitting. Physical therapy treatment needs to also address the orofacial region. Soft tissue techniques, post-isometric relaxation of facial muscles and temporomandibular joint mobilizations help with relaxation of the mimetic musculature. Increased coordination of the muscles contributing to speech and swallowing can be achieved through certain components of reflex locomotion. Exercises can be performed in front of a mirror including having the patient deeply inhale through the nose and exhale through the mouth, recite aloud dynamically individual letters, syllables and words, vigorously close and open the eyes, practice eye movements in all directions, sing and laugh.

Under normal conditions, the individual components of movement patterns are continuously linked into complex movement patterns thanks to the appropriate function of the basal ganglia. That is why movements such as turning in standing or in lying, getting up from a chair or getting out of a car are automatic movements. A patient with Parkinson’s disease lacks this automation and continuity. Therefore, compensatory strategies need to be practiced during rehabilitation of gross motor skills. More complex movement patterns are broken into “phases” that are at first individually practiced. The practice has a logical sequence in which each phase of movement ends with a stable resting position, which becomes the starting position for the next phase. At first, the patient imagines each phase of movement and then performs it with full concentration. No additional simultaneous movement patterns or simultaneous motor and cognitive tasks are assigned until the pattern becomes completely automatic. Visual, auditory and somatosensory stimuli have been shown to be beneficial for initiation and maintenance of a movement sequence. For example, if freezing of movement becomes an issue during locomotion, the patient is taught sensory tricks. Freezing occurs mainly in narrow spaces, such as when a patient is not able to step over a doorstep. The patient is instructed to look at the doorstep and this simple visual stimulus interrupts the blocked movement program and allows them to make a long step. A cane with a stick is a tool used to address this situation in which the patient looks at the stick attached to the cane and “steps over” the stick with every step. This visual perception allows for a smoother gait pattern. Many other stimuli can be used to deal with movement freezing. For example, the patient swats their lower extremities, thus diverting attention and interrupting the freezing. Another option includes taking a step backward at first or weight shifting from one foot to the other. To maintain a smooth gait pattern, the patient is advised to focus on a particular phase of the step, i.e., heel strike or push-off from the big toe. During ambulation, the patient can rhythmically count silently. The exercise routine can also include a whole body massage to assist with muscle and soft tissue relaxation and improving blood

circulation. It also relieves pain, which is important because even minor pain worsens the already affected motor skills. Similarly, underwater massage has a beneficial value and overall warm immersion decreases rigidity. Aquatic exercises and swimming are also helpful. Procedures at high temperatures (above 38 degrees) should be avoided because they contribute to the patient’s overall fatigue. Heat can be applied locally prior to stretching. Group Exercise Following individual therapy, more adept patients at similar skill levels are transitioned to a group exercise program, which includes a combination of exercises affecting body posture, akinesis and rigidity. The program is initiated with breathing exercises that serve as an important groundwork for speech therapy. As a result of a forward flexed posture, patients with Parkinson’s disease take short and shallow breaths, activate mainly the accessory breathing muscles (sternocleidomastoid, scalenes, upper trapezius, pectoral musculature) and, in contrast, incorrectly activate certain parts of the diaphragm and the intercostal musculature. Initially, individual therapy is used to correct the patient’s breathing pattern (Vojta’s reflex locomotion automatically activates the physiological breathing pattern). Deep inhalation all the way to the lower intercostal spaces is practiced during group therapy with activation of the entire abdominal wall to the groin. The shoulders are relaxed and slow, controlled and relaxed exhalation follows. The patients can place their hand on the lower thorax or above the groin to better control the depth of inspiration. During subsequent exercises, the patients attempt to maintain correct breathing mechanics. Swinging movements mainly into extension are incorporated and since endurance movements activate more flexor musculature, they are avoided. During exercise, the patient selects an area on which to focus their gaze to prevent potential movement freezing. Swinging trunk movements assist in attaining an erect body posture and swinging upper extremity movements improve gait. Gait re-education focuses on the elimination of shuffling steps and encourages an erect body posture. The patients are encouraged to increase their step length even if it involves widening their base of

support and lifting their entire foot above the mat during the swing phase of gait. Gait training implements ambulation with denoted markers placed on the floor to maintain adequate step length. The patient is instructed to focus on upper extremity co-movements that positively influence gait rhythm and stability. During ambulation, the patient distinctly counts aloud: “one-two”. The patient can march with light weights (1/2–1 kg) that prolong momentum and upper extremity co-movements. Concentration and attention are improved by exercises involving balls, bowling pins or other equipment. Simple dance elements can also be implemented. During group exercise, the therapist uses loud verbal instructions and these exercises can be performed with the rhythmic guidance of a drum or music. Visual and auditory stimuli assist with movement initiation and rhythm maintenance, continuity and endurance. In Parkinson’s disease, practice of compensatory movement strategies in combination with an entire spectrum of visual, auditory and somatosensory stimuli is more effective in the long term than individual functional exercises based on a kinesiological analysis. Repeating the therapist’s instructions, counting during exercise, singing and laughter relax mimetic muscle tightness. Simultaneous practice of upper extremity and mimetic movements assists with normal gesticulation during speech. The length of exercise treatment must be adequate to the patient’s condition and abilities. In contrast to healthy individuals, patients with Parkinson’s disease require a conscious effort for each individual movement and especially its initiation. However, a state of so called paradoxical kinesis can emerge. This is a situation in which a patient with long lasting rigidity suddenly performs an accurate, quick and purposeful movement, i.e. they are able to run or can perfectly ride a bicycle even though they normally demonstrate difficulty with just walking. However, in most cases, this is not proof that the patient pretended to loose these movement abilities. Patients with Parkinson’s disease have been shown to benefit from group exercise. It provides motivation, ensures exercise variability and regular social interaction as the patients often show a tendency toward

decreased activity and sedentary lifestyle, which contributes to significant worsening of their symptoms. Occupational Therapy Occupational therapy is important in order to practice common daily activities including writing. At first, the patient writes large numbers and letters in the air, hence incorporating upper extremity range of motion. Then, the patient writes on a chalkboard – at first big pictures and letters while engaging the entire upper extremity and trunk. This is followed by practicing writing on paper. An occupational therapist practices common daily activities with the patient, such as dressing, personal hygiene, eating, getting out of bed and bed mobility. Rigidity poses a problem for a patient even during sleep. They cannot turn at night and their sleep is disturbed by an overall stiffness and pain. Rolling in bed can be initiated by eye movement in the direction of rolling. The effort is to maintain the patient’s highest level of independence. The patient’s ability to perform household chores needs to be assessed and the patient needs to be motivated to perform them at home. Patients are encouraged to take daily walks because prolonged sitting and inactivity are strongly discouraged. A number of patients with Parkinson’s disease also suffer from depression and this is why family needs to be included in the patient’s care and motivation. Weight shift training and home modifications are important for fall prevention. Based on recommendations from an occupational therapist, a physician can prescribe various devices that will make home activities easier for the patient (handlebars in the bathroom, elevated toilet, etc.). Balneologic Treatment Balneologic treatment is important not only to guide the patient in the appropriate regime and to improve movement performance, but also for motivating the patient to achieve an overall active approach and a more fulfilling life with Parkinson’s disease. Based on the list of indications for balneologic treatment, a patient with Parkinson’s disease can undergo comprehensive balneologic treatment one time per year when recommended by a neurologist. In the Czech Republic, balneologic treatment for patients with Parkinson’s disease is provided

in Dubi, Libverda, Klimkovice, Marianske Lazne and Vraz. Patients can also participate in rehabilitative-reconditioning stays that are regularly organized by the Parkinson Society. Athletic Activities for Patients with Parkinson’s Disease Besides regular walking and swimming, more adept patients with Parkinson’s disease can also participate in dance or golf; some individuals even master ball games surprisingly well. In patients with Parkinson’s disease who actively engaged in athletic activities prior to their disease, there is a higher probability that they will continue to participate in sports. Regardless, there is a greater tendency to limit physical activities than is seen in the regular aging population with these patients. Research suggests that regular exercise positively influences life expectancy in individuals with Parkinson’s disease, which is why it is necessary to constantly motivate them to maintain an active lifestyle. Mild and moderately affected individuals with Parkinson’s disease are capable of the same aerobic performance (swimming, biking) as their healthy peers. Treatment rehabilitation positively influences the course of the disease only if it is done regularly and continuously. In practice, the biggest challenge is posed by the fact that the patients are not compliant with their home programs after their discharge from therapy. Therefore, it is appropriate to alternate rehabilitation treatments between individual therapy, group therapy, balneologic stays and athletic activities. It is recommended that the patient plans to participate in additional organized movement programs every week. Assessment of Rehabilitation Effectiveness in Patients with Parkinson’s Disease Physical therapy has an especially noticeable effect on increased gait speed, step length and performance of daily activities. The effectiveness of the selected rehabilitation approach can be assessed by the above noted UPDRS scale or by other motor performance tests that quantify bradykinesis and comprehensive movement performance in patients with Parkinson’s disease. These are usually tasks that

measure the time necessary to perform a certain activity. Gait. The 10-Meter Walk Test is the simplest test. Some clinics have sophisticated measuring systems at hand that allow visual recording and movement assessment using cameras and software. Balance. Recording patient falls or measuring the distance between the feet are among the simple methods of stability assessment. Certain scales can be used to assess balance, these include the standing balance test by Bohannon, the Berg Balance Test, the Clinical Assessment of Postural Integration of Balance, the Functional Reach Test and others. Balance can also be assessed using stabilometric platforms that are commercially available in a number of varieties. Mobility. A simple way to assess mobility is to record how often the patient turns in bed. A timed sit from supine is another simple test. For a more comprehensive assessment, the following scales can be used: the Rivermead Motor Assessment, the Parkinson Activity Scale, the Elderly Mobility Scale, etc. Upper extremity motor skills. The Supination-Pronation Test measures the time it takes the patient to perform 20 repetitions. In the tapping test, the patient alternately presses 2 buttons placed 30 cm apart and the time it takes the patient to press the button 20 times is measured. The nine-hole peg test times how long it takes the patient to gradually place and remove 9 pins in holes on a peg board with one hand. Endurance. The 6-minute Walk Test is the most often used clinical test to assess endurance in patients with Parkinson’s disease. Quality of life. The Parkinson’s Disease Questionnaire-39 or Short Form-36 are used for this assessment. In patients with Parkinson’s disease, the assessment is more difficult due to the fluctuation of the patient’s condition during the day. Thus, it is appropriate for the patient to record the time and dosage of their medication and their “on and off” states of the day. The “on” state denotes the period of their medication’s optimal effect; the “off” state is the period of an insufficient medication effect. The importance of

an evaluation can be illustrated by the fall assessment. It has been shown that previous falls in a patient’s history, the length of Parkinson’s disease, dementia and a loss of upper extremity synkineses are independent predictors of future falls. In Parkinson’s disease, an important relationship has been confirmed between disease severity, stability deficits, depression and falls. Only when all of these aspects have been objectively assessed, can an adequate rehabilitation program be prepared, one which positively influences the risk factors and, thus, the patient’s prognosis.

1.16 NEURODEGENERATIVE DISEASES Barbora Danielová, Alena Zumrová

1.16.1 Basic Characteristics of Neurodegenerative Illnesses Ondřej Horáček Neurodegenerative diseases develop due to premature aging of certain neuronal and glial systems of the nervous system and most of them show a genetic component. In these diseases, various areas of the central and peripheral nervous systems are affected, e.g., the cerebral cortex, cerebellum, spinal cord and peripheral nerves. Sometimes, the degenerative process affects multiple systems at once. Clinical symptomatology is very wide and diverse. In such diseases, various deficits in movement, muscle tone and balance, as well as, sensory or cognitive impairments are present. All mentioned deficits can be addressed by rehabilitation treatment. The group of neurodegenerative diseases includes: 1. 2. 3. 4. 5.

Neurocutaneous diseases (phakomatoses) Cerebellar and spinocerebellar degeneration Degenerative diseases involving motor neurons Degenerative diseases of the peripheral nerves Degenerative diseases with predominant involvement of extrapyramidal structures

Slow progression is common in most neurodegenerative diseases. Curative treatment is not known, thus, comprehensive treatment addressing symptoms is usually administered. Rehabilitation plays an essential role within this comprehensive therapy and complex rehabilitation is always aimed at dominant symptoms that can vary greatly with each individual disease. From the numerous groups of neurodegenerative diseases, amyotrophic lateral sclerosis, which is a disease affecting central and peripheral motor neurons, will be mentioned along with two diseases

in the spinocerebellar degenerative category – Friedreich’s ataxia and autosomal dominant ataxia with late manifestation. Diseases developing due to degeneration of neurons in the extrapyramidal structures (Parkinson’s disease) are addressed in Chapter 1.15.2.

1.16.2 Amyotrophic Lateral Sclerosis Barbora Danielová General Characteristics The prevalence of amyotrophic lateral sclerosis (ALS) is approximately 4–6 cases in 100,000 people. It is defined as a progressive primary degeneration of the proximal and distal motor neurons in the absence of another pathological process. It involves progressive cessation of motor neurons of the anterior spinal horns, pyramidal cells of the motor cortex and motor nuclei of certain cranial nerves – primarily those found in the bulbar portion of the brain stem. Loss of motor cells is linked to the degeneration of the main motor pathway – the corticospinal tract. This is a typical picture in ALS – a combination of damage to the upper and lower motor neurons with symptoms affecting the bulbar, respiratory, extremity, trunk and neck musculature. Classification 1. “Classic” form of ALS – most cases, characterized by involvement of the upper and lower motor neurons with signs of deficits in the extremities, trunk, neck and bulbar regions. A typical onset is late middle age (50–70 years) and men are affected somewhat more often than women (1.5 : 1). The disease course most often takes 2–5 years. 2. Progressive spinal muscle atrophy – the so called spinal form of ALS with lower motor neuron signs in the extremities and less often in the bulbar region; its course can be slow and take decades. 3. Progressive bulbar palsy – bulbar symptoms dominate, gradually other muscles become affected. The progression is quicker; the

disease takes approximately 2 years on average. 4. Primary lateral sclerosis – it is accepted more in Europe than in the U.S. as a separate form of ALS. It is characterized by only upper motor neuron signs that are most visible and occur earlier in the lower extremities. Its course is slow and the disease can last decades. 5. Familial form of ALS – 5–10% of cases, mostly an autosomal dominant hereditary form. Clinically, the presentation is similar to classic ALS, but the onset occurs 10–15 years earlier; men and women are equally affected and the duration is shorter, 2 years on average. Juvenile onset of the disease has been described with an onset at 18 years of age. Etiology A large number of pathogenetic theories have been considered. Multifactorial pathogenesis has often been proposed, in which several or all influences are summed. The main hypotheses, which are the focus of research, include: Disorders of glutamate metabolism An autoimmune disorder An insufficiency of the motor neurons’ growth factors In the familial form, mutations in the gene for superoxide dismutase Clinical Signs Clinical signs depend on the type of ALS and on the location of the involved motor neurons. Classic ALS typically presents with lower and upper motor neuron signs. Involvement of the lower motor neuron is manifested as muscle weakness, atrophy, fasciculations, and spasms. Muscle atrophy is most often noticeable in the distal aspects of the upper extremities. Fasciculations are diffuse and typically involve the tongue. Upper motor neuron involvement is manifested by decreased dexterity, muscle tightness or even spasticity, hyperreflexia and the presence of pyramidal signs. During the disease course or at its onset, the bulbar muscles become

affected. The first sign is usually dysarthria, later dysphagia, weakness of the chewing or even mimetic muscles. A classic ALS picture does not include a sensory system deficit. Pain is usually not present in the early stages, but emerges with disease progression, most often as musculoskeletal pain or pain during spasticity. Sphincter and sexual functions are not affected. In typical ALS, cognitive functions remain intact, but in approximately 5% of cases, dementia is present at the same time. It is not clear whether these are two parallel diseases or a different form of ALS. In a typical course, the disease progression is constant, without episodes or remissions. Gradually, muscle weakness spreads to all the extremities, trunk, neck, respiratory and bulbar musculature. Diagnosis An ALS diagnosis is based on clinical findings, disease course and EMG findings. Results from cerebrospinal fluid tests and imaging methods of the brain and the spinal cord are negative. Functional Stages of ALS Six functional stages of ALS are being recognized based on the grade of muscle weakness in the extremities, trunk and neck. Each stage requires a different therapeutic approach. Stage 1. This is the early phase of the disease. The patient moves independently and is self-sufficient with ADL’s. Some muscle groups show mild weakness with decreased muscle strength and/or endurance. In this phase, treatment focuses on different forms of independent or assisted exercise with the goal to maintain or improve the patient’s overall condition. It also includes home and work station modifications and psychological help. Patient and family education is essential. Stage 2. The patient demonstrates moderate weakness in certain muscle groups, for example, a deficit in fine motor skills or tripping over their feet. In this phase, appropriate assistive devices need to be considered, including custom-made fabrication. Independent and

assisted exercises are continued. Stage 3. Weakness of some muscle groups is significant, but the patient continues to be independent. Fine motor skills can be significantly affected, severe paralysis of the distal lower extremities can be present, i.e. the patient is sometimes not able to stand up from a chair without assistance. From an overall perspective, this stage represents mild or moderate degree of functional limitations. The goal is to maintain the patient’s independence. Various aids should be prescribed to support the weakened muscles, improve patient’s mobility and safety and to decrease their energy expenditure. Patients begin to report fatigue and demonstrate difficulty supporting their head, for which a soft neck collar can be recommended. (Fig. 1.16.2-1). To prevent excessive fatigue, a mechanical wheelchair is selected and used for longer distances. Active and passive exercise is continued. Fig. 1.16.2-1 Stage 3 Amyotrophic Lateral Sclerosis. Weakness of the neck musculature leads to decreased head control. Trunk weakness alters spinal alignment. In the picture, the musculature of the upper extremities shows clear signs of overall atrophy, most visibly in the shoulder girdle and distal upper extremity.

Stage 4. Severe involvement of the lower extremities and mild involvement of the upper extremities are present. The patient uses a mechanical wheelchair and can be independent with respect to ADL’s.

Passive exercise is important to prevent contractures. Active exercise is continued based on the patient’s abilities. The patient’s skin needs to be monitored. Beds and seats should be adjustable and should be equipped with anti-decubital mats. Stage 5. Muscle weakness gradually progresses. Even the upper extremities are developing moderate or severe weakness. The patient uses a mechanical wheelchair when out of bed. A referral for an electric wheelchair should be considered. All transfers become problematic and various types of lifts are indicated. The patient loses their bed mobility skills and this task is performed by caretakers. Pressure ulcer prevention needs to be fully implemented and the use of a quality positioning bed should be considered. Neck muscle weakness progresses, however, maintaining the head in a neutral position is very important for breathing, food intake, communication and observation of the surroundings. Hard collars or a slit in a collar for easy anterior accessibility, which also allows for tracheostomy care, are indicated. With this degree of immobilization, pain may become a dominant problem and pain control then becomes the primary objective. Stage 6. The patient is bedridden and requires maximum assistance with ADL’s. An almost complete lack of head control poses a significant issue. Often, progressive respiratory problems and increasing pain need to be addressed. The patient needs to be repositioned because compromised body parts need to be supported and thromboembolic complications prevented. At this stage, the goals are similar to hospice care – addressing the needs of the patient and the caretakers, keeping them satisfied and providing the best quality of life. This applies to healthcare settings as well as home care. Pain or respiratory problems can emerge at any stage of the disease, but, in general, both increase with disease progression. Pharmacotherapy Currently, glutamate antagonist Riluzole is used in the treatment of ALS. It has been empirically shown that this medication prolongs a

patient’s life by 3–6 months. It is recommended that the medication be administered immediately upon diagnosis. Also administered are vitamins E, C, selenium, coenzyme Q or lipoic acid, which are presumed to have antioxidative effects with protection or even improvement in nerve cell function. Creatine monohydrate is indicated for facilitation of muscle contractions. Administration of the anti-seizure medication gabapentine is being tested, in which an effect on glutamate metabolism is presumed. Rehabilitation in Amyotrophic Lateral Sclerosis Amyotrophic lateral sclerosis remains an incurable disease at this moment. The average survival rate is 2–5 years, in some cases 10 years or more. All-round care can help utilize the patient’s health potential to the fullest at various stages of the disease and improve their quality of life and survival time. Given the heterogeneous clinical findings during the development of ALS, a multidisciplinary approach is necessary. Cooperation of an interactive team is ideal and should include a neurologist, rehabilitation physician, internal medicine physician, physical therapist, occupational therapist, prosthetist, language pathologist, psychologist, social worker and other specialists based on the need. Physical Therapy The most frequent physical therapy goals in ALS include: 1. Control of muscle strength with an effort to achieve the best movement quality 2. Maintaining range of motion 3. Spasticity management 4. Management of secondary musculoskeletal changes. The question of active exercise is being constantly discussed not only for ALS, but for neuromuscular diseases in general. This discussion includes the appropriateness of exercise itself, the difference between loading of the affected and the non-affected muscles, and the type and intensity of exercise. One hypothesis states that exercising the already affected muscles to and through fatigue can

accelerate the progression of muscle weakness. On the other hand, there is a risk of muscle atrophy from inactivity with the patient’s increased muscle weakness and decreased cardiopulmonary capacity. The positive effect of exercise on the patient’s psychological state is also significant. A compromised solution modified for each individual is usually selected. In the beginning stages, the patients are allowed endurance and strengthening exercises and aerobic conditioning exercises (walking, biking and swimming). All exercises are performed at submaximal intensity and without repetitive, challenging resistance exercises of the affected muscles. The patient is advised to divide their exercises into several short periods with rest in between and to not exceed one hour of exercise per day. The patient is educated on the importance of avoiding exercise through muscle fatigue. Muscle fatigue may become present either directly during exercise or after exercise, leading to increased difficulties with ADL’s, muscle pain and the onset or increase in fasciculations or spasms. The patient’s ability to perform these exercises decreases as the disease progresses. During physical therapy, comprehensive and analytical approaches, as well as, active and passive exercises, soft tissue techniques and joint mobilizations are implemented. Often, more therapeutic areas are affected at the same time. Physical therapy treatment can also include modalities. Prosthetic Devices During ALS progression, assistive devices are used in three areas: 1. To support weakened musculature – in the lower extremities, these most often include peroneal bands and splints, ankle and knee orthoses; in the upper extremities, hand and wrist splints or orthoses with an option to use universal cuffs to improve grasp; for a shoulder joint subluxation, a shoulder joint (roll) support, sling or positioning is appropriate. 2. To prevent and treat contractures – positioning and splints. 3. To improve the patient’s mobility – based on the progression, gradual indication includes canes, forearm crutches, walkers,

mechanical or electric wheelchairs and quality positioning beds. Occupational Therapy Occupational therapy for patients with ALS is sooner or later indispensable. Intervention usually includes the following areas: ADL independence and fine motor skills – assessment of individual activities, suggestions for options, selection of appropriate assistive devices, patient education and instruction, suggestions for home modifications, etc. Mobility and transfers – cooperation regarding indication and selection of assistive devices, especially for a wheelchair and appropriate modifications, transfer training and later bed mobility training. Methods for effective energy expenditure Pressure ulcer program Patient and family education Specific Problem Areas in Patients with ALS and Treatment Options Swallowing and Nutrition Deficits in nutrition and hydration are encountered by every patient with ALS. Chewing and swallowing problems usually occur several months following speech deterioration. The main reason is the progression of bulbar symptoms. Treatment Options Administration of anti-spastic medication can be one pharmacologic option. The problems can also be addressed by changing the consistency, taste or temperature of food; later, a pureed or liquid diet is inevitable. The patient’s positioning during feeding is important and includes erect sitting and head alignment. A neck collar is used to improve head position when neck muscles become weakened. Correct trunk position is also important. A retracted chin position is preferred for safer fluid intake and can be achieved by the use of a straw. From a physical therapy approach, elements of exercises based on a neurophysiological foundation are used for dysphagia and for

dysarthria (Vojta, NDT). Components of myofunction therapy, active exercise only to fatigue and passive assistance are also used. If feeding by mouth is no longer sufficient, a percutaneous endoscopic gastrostomy (PEG) usually becomes the method of choice. Either commercially prepared food or homemade food is administered through the tube. Nutrition balance and adequate fluid intake need to be monitored. PEG placement significantly prolongs the patient’s life when compared to those who refuse this treatment. The patients should be informed that they can continue (with certain exceptions) eating the way they were used to by partially consuming food by mouth and using the PEG tube only for supplementation of necessary energy. Respiratory Problems During the disease course, respiratory problems occur and gradually progress. Respiratory complications are most often the reason for all deaths attributed to ALS. The cause is partly the progressive weakness of the breathing muscles leading to the development of a restrictive pulmonary deficit with insufficient pulmonary ventilation and an insufficient ability of mucus expectoration and partly the weakening of the oropharyngeal muscles as a manifestation of bulbar involvement with subsequent food aspiration or mucus retention. In the late stages of the disease, the possibility of dysfunction in the respiratory center in the brain stem is likely. These causes can be combined to a varied extent. In the early stages of the disease, only nocturnal hypoventilation is present. Worsening of respiratory problems can be continuous, but significant worsening with signs of acute respiratory failure often occurs during an acute upper respiratory tract infection if the patients are not able to expel mucus. Respiratory Assessment Initial signs of respiratory insufficiency can be minor or non-specific, but need to be addressed. They include fatigue or sleepiness during the day, difficulties sleeping, i.e. difficulty falling asleep, reverse

sleeping schedule, nightmares, morning headaches, anxiety or depression, tachypnea, dyspnea – initially exertional or in supine, decreased appetite, weight loss, visible activity of accessory breathing muscles and recurrent upper respiratory tract infections. Total vital capacity in sitting or supine is assessed along with peak cough flow – spontaneously or with manual assistance. Additionally, blood gases, oxygen saturation and pCO2 saturation are tested and night monitoring of the two above mentioned parameters can be done if needed. Treatment Options Respiratory physical therapy treatments are appropriate in all phases involving respiratory problems. If those are not sufficient, non-invasive ventilatory treatments, which are based on intermittent pressure changes within the respiratory tract or on the patient’s intermittent pressure activity, can be used. When selecting non-invasive ventilatory methods, it is a known fact that non-invasive techniques are usually successful and can prevent tracheostomy long term if the etiology of respiratory problems predominantly involves muscle weakness of the respiratory over the bulbar musculature. If bulbar problems dominate, patients usually do not tolerate non-invasive techniques and respiratory complications can be prevented only by tracheostomy. The following methods are most often used: IPPV (intermittent positive-pressure ventilation) CPAP (continuous positive airway pressure) BiPAP (bi-level positive airway pressure) MI-E (mechanical insuflation-exsuflation) Vests that assist with expiration (intermittent abdominal pressure ventilator) If they fail or are not tolerated or if they are not available, the patient must decide in favor or against invasive ventilation (tracheostomy).

When the course of ALS is known, it is important to inform the patient ahead of time about various interventions that can help in certain phases of the disease to decrease their potential problems and improve their quality of life. Following the preliminary information, it is important to obtain the patient’s consent if they agree with tracheostomy and artificial ventilation should respiratory insufficiency occur. The patient’s decision regarding life-prolonging interventions may change multiple times during the course of the disease given them experience with disease progression, developed limitations, changes in understanding the quality of life and the challenge and fatigue associated with such interventions. Given these aspects, this should be an ongoing discussion. The treating team should guide the patient based on clinical experience, but also take into consideration their personal desires. Balneologic Treatment Patients with amyotrophic lateral sclerosis benefit from balneologic treatment if they are independent and capable of independent locomotion and cooperation. Exercise, especially in the pool, is appropriate along with other forms of aquatic therapy when the movement occurs under unweighted conditions. Fitness training is also beneficial. Although the disease progression cannot be influenced, balneologic treatment can contribute to the patient’s improved self-care and overall fitness. When swallowing and respiratory problems are present, balneologic treatment is no longer beneficial given its limited options. Comprehensive balneologic treatment is indicated by a neurologist and can be provided once every two years. The patient should also undergo an examination by a cardiologist prior to submitting an application for balneologic treatment.

1.16.3 Friedreich’s Ataxia Alena Zumrová Friedreich’s ataxia (FRDA) is the most common hereditary ataxia

with a reported incidence of 1–2 per 100,000 people. It was described in 1863 as a neurodegenerative disease affecting the cerebellum and the spinal cord. Later, the spectrum of signs expanded and the clinical picture was described involving a varied involvement of the brain stem, peripheral nerves and the cerebral cortex. Diagnosis based on DNA has been available since 1996. It is an autosomal recessive disease with mutation in gene X25 on chromosome 9 causing dysfunction of Frataxin protein subsequently leading to mitochondrial oxidative stress. Clinical Picture The first clinical signs of FRDA are most often manifested at the end of the second half of the first decade of life. However, exceptions exist with some patients demonstrating disease onset at around two years of age or patients with first signs in the second or third decade or even later. The earliest sign is usually a paleocerebellar symptom often interpreted by the parents as clumsiness. Symptoms usually worsen when the eyes are closed or in the dark (involvement of the posterior spinal column). Initially, the signs can be asymmetrical. Gradually, upper extremity coordination worsens. A tremor or choreic dyskinesia of the extremities or the mimetic musculature or even a head tremor can be present. Nystagmus is not an exception nor is a quickly progressing dysarthria. Upper CNS functions are usually intact during screening, special tests show cognitive dysfunctions in certain cases. Myotatic extremity reflexes become absent in the early stages of the disease and deep sensation can be preserved for a long time, especially in younger patients. In contrast to reflex cessation, the Babinski pyramidal reflex is well elicited. In adult onset Friedreich’s ataxia, reflexes can be preserved and pyramidal disruption phenomena can be absent. Tactile and pain sensation are preserved; however, a change can occur in the late stages of the disease. Deficits in the autonomic innervation of the superficial skin layers have also been described. Bony deformities include pes cavus, hammer toes, sometimes even hand deformities and joint flexion contractures including flat feet (pes

planus). Kyphoscoliosis is a frequent finding. It is reported that orthopedic operations are not beneficial because the body may not be able to compensate for the sudden change of the body’s center of mass if the posterior column and cerebellum are affected; however, timely operation involving spinal stabilization can be helpful. Other manifestations of FRDA include hypertrophic cardiomyopathy and diabetes mellitus. Hypothermia, intermittent vomiting and breathing problems have also been described. Diagnosis Similarly to other hereditary ataxias, the results of examination methods are often pathological, but non-specific. In the early stages of disease, MRI can already show atrophy of the upper segment of the cervical spinal cord. The cerebellum atrophies later. Therapy Basics In therapy, intensive rehabilitation, a multivitamin and, in indicated cases, also nootropic or cognitive therapy are important. A coenzyme Q derivative administered for cardiomyopathy has not been substantiated by any prospective study. In addition to a neurologist and a rehabilitation specialist, patients with confirmed Friedreich’s disease should also be monitored by a cardiologist, endocrinologist and an orthopedist. Physical therapy treatment implements methods affecting cerebellar symptoms and signs originating from spinal cord involvement. For patients with spinal deformities, methods affecting the spine are included (Vojta’s method, methods according to Klapp or Schrott), as well as, pulmonary physical therapy. Orthotic devices are needed for cases involving severe foot deformities.

1.16.4 Autosomal Dominant Spinocerebellar Ataxia Alena Zumrová From the perspective of molecular genetics, 29 various loci or 29 genetically different diseases have been identified that clinically show

very similar symptoms. Their cause is for the most part multiplication of cytosine-adenine-guanine (CAG) repeats, which affect the function of gene products known as ataxines. This repeats for glutamine amino acid, which is why we sometimes encounter cumulative denomination of polyglutamine diseases (polyQ). Autosomal dominant spinocerebellar ataxias (SCA) show high variability in the onset of early symptoms, as well as, in the clinical picture, including inter or intrafamilial scenarios. In principle, through a neurological exam, they are not distinguishable from the above described Friedreich’s ataxia. In addition to the involvement of the cerebellum and the posterior and lateral columns, other signs from the involvement of the central and peripheral motor neurons can be present and extrapyramidal signs can also be observed. The earlier reported fact that this is a disease of an adult age, whereas Friedreich’s ataxia is a disease of childhood years, is no longer valid. The implementation of DNA diagnostics leading to an exact determination of diagnosis has shown that all these diseases can begin at any age. Given the fact that the data regarding familial patient history are often incomplete (earlier, part of these diseases was hidden under the diagnosis of multiple sclerosis, postpoliomyelitic syndrome, infantile cerebral palsy, etc.), a detailed familial genealogy often does not help with the diagnosis. Causal treatment of the diseases does not exist at this time. The progression can only be slowed by an intensive, permanent, life-long, comprehensive rehabilitation, which, in certain patients, can be combined with orthopedic procedures. Emotional control is one of the cerebellar functions. A presence of depression or other psychological problems is a reason to include the close cooperation of a psychologist and a psychiatrist. Practice shows that patient’s cooperation and compliance with active rehabilitation can be significantly improved by psychotherapy and pharmaceutical treatment. In physical therapy, mainly approaches affecting the cerebellar signs and the spinal cord symptoms are implemented, similarly to

Friedreich’s ataxia. The main focus is on stability training in standing and during ambulation and accompanied symptoms. Frankel and Feldenkrais exercises are mainly included. Vojta’s method can also show benefits. With a certain level of involvement, assistive devices providing the patient with better stability in standing and with walking are needed (canes, crutches, walkers). Patients with more severe involvement should also be under the care of an occupational therapist whose focus is on the patient’s highest level of independence with ADL’s.

1.17 MULTIPLE SCLEROSIS Ondřej Horáček

1.17.1 Diseases Characteristics Multiple sclerosis (MS), the main representative of a group of demyelination diseases, is an autoimmune CNS disease which leads to a loss of myelin in inflamed areas and gradually to a diffuse axonal loss. In the Czech Republic, the prevalence of this disease is 50–150 in 100,000 inhabitants. The disease onset is most often between 20–30 years of age. Histologically, the white matter shows perivascular inflamed infiltrates of T-cells, B-cells and macrophages. Myelin destruction occurs in the acutely affected area and the extent of axonal loss determines clinical severity. Later, due to myelin loss, axonal atrophy of the CNS occurs. For MS diagnosis, the progression and clinical picture characteristics are important, but the results of imaging techniques are decisive: brain and spinal cord MRI, spinocerebral fluid test and evoked potentials testing. Brain and spinal cord MRI in MS shows mainly multiple areas of increased signal. A spinocerebellar fluid test in MS shows intrathecal immunoglobulin synthesis. The presence of at least two oligoclonal stripes in spinocerebral fluid that are not present in the serum is important for diagnosis. The diagnosis of MS is also supported by abnormal findings in visual and somatosensory evoked potentials. In more than 80% of patients, the disease shows a relapse and remission course in which alternating between relapses and remission is typical. In a longer lasting disease, the course is chronically progressive with a gradual increase in disability. In 15% of patients, a neurological deficit slowly increases from the onset, demonstrating mainly a steady progressive course. The most severe is a relapseprogressive course in which the disability worsens and the interval between relapses shortens.

The clinical picture depends on the location of the inflammatory areas in the CNS. The first signs include retrobulbar neuritis (optic nerve inflammation) and various types of sensory deficits are also common. Most severe are movement deficits – central spastic pareses and also cerebellar symptoms, often combined with vestibular symptoms. Sphincter dysfunctions are also common. Approximately half the patients suffer from depression and sometimes cognitive deficits develop (memory, attention problems, etc.). Fatigue is a typical sign of MS and it typically has multiple causes (see below). The level of severity of a patient with MS is measured most often by the Kurtzke scale (Expanded Disability Status Scale, EDSS), which grades the patient’s movement abilities (grades 0–10). Based on this scale, the severity of the disease can be assessed relatively simply and, at the same time, the level of patient care can be estimated (Tab. 1.17.11).

Tab. 1.17.1-1 Kurtzke Scale (EDSS)

A large number of patients with MS complain of excessive fatigue. In MS, 80–90% of patients suffer from increased fatigue and it has been shown that fatigue is among the most bothersome symptoms. The cause of excessive fatigue is not completely clear. A multifactorial etiology appears most probable. The main factors include primary CNS damage and immune system dysfunction. Also, deconditioning, respiratory muscle weakness, pain, sleep deficits and medication side effects all secondarily contribute to the onset of fatigue in MS. Fatigue sometimes emerges or worsens in increased temperatures – either tin body temperature or the environmental temperature. Concerns existed in the past that physical demands in patients with MS would lead to increased body temperature and, thus, to worsening of the neurological findings and fatigue. Based on this believe, it was recommended that patients with MS should only exercise to the first signs of fatigue. However, this led certain patients to an inadequate or passive lifestyle and inactivity. Current research shows that regular aerobic training for patients with MS is not harmful, but rather has a positive effect.

1.17.2 Rehabilitation in Multiple Sclerosis Based on the predominant problems, rehabilitation focuses in particular on spasticity, muscle strength, decreased coordination and the consequences of ataxia. Given the character of the disease and the variability of the clinical findings, a single rehabilitation program that would fit all patients cannot be recommended. In contrast, each patient requires an individual approach. When a rehabilitation program is being established, the patient’s current disease stage needs to be taken into consideration because a different approach is selected if the patient’s medical status is stable or if it involves a sudden change in condition. If the patient’s health condition is stable, the patient can undergo individual physical therapy at least once a year, including appropriate patient education. In the case of a sudden worsening of the patient’s condition, physical therapy methods and movement

activities need to be limited and attention paid especially to the prevention of complications linked to the acute state. Therefore, positioning, respiratory physical therapy and passive joint range of motion and muscle stretching are emphasized in the meantime. Treatment rehabilitation includes various combinations of methods. Analytical approaches, as well as, neurophysiologically based methods are used in practice. Analytical approaches (exercises based on muscle testing and components of Kenny’s method), which are less energy demanding are used in scenarios in which the individual muscle groups need to be exercised selectively and synergistic activation is not desired. The foundation of a rehabilitation program for patients with MS consists of neurophysiology-based methods, especially for patients with mild or moderate neurological involvement. Neurophysiological approaches utilize CNS plasticity. Thanks to this important quality, significant adaptive changes occur in CNS through neurorehabilitation. Correct and repeated stimulation through neurophysiological approaches can lead to the non-involved part of the brain functionally compensating for the affected area of the brain. Its function is then, in part, performed by brain areas that originally did not contribute to the given function. It has been shown that, in a patient with MS, neurophysiological approaches contribute to the adaptation and reorganization of CNS function. This has been confirmed by a study in which functional MRI assessed changes in brain activity in patients with MS who underwent neurorehabilitation. The shown changes in such patients were attributed to CNS plasticity and adaptability. To influence the signs and the disease course, neurophysiology-based therapy uses a physiological process that the patient needs to understand, experience and implement into their daily life. This therapy is based on the knowledge of sensorimotor learning and adaptation and uses the following elements during physical therapy for patients with MS: Dexterity motor learning, or volitional movement control, movement repetition with a goal to improve its quality,

optimization of movement execution, optimization of muscle timing, etc. Adaptive motor learning, or modification of motor output based on sensory inputs Conditioned associative motor learning involves the utilization of the relationship between the stimulus and the motor input in order to condition a response Non-associative motor learning, or the use of habituation and sensitization to repeated stimuli when facilitation techniques are combined so that optimal function can be achieved Stimulation techniques are combined with inhibitory techniques (for example, muscle stretch, resistance, tactile, vibration, visual and auditory stimulation, stimulation of postural reactions, etc.) that use anatomical and functional relationships between neurons (principle of divergence and convergence). Here, elements of various treatment methods are implemented, such as Vojta’s reflex locomotion, neurodevelopmental treatment (NDT), sensorimotor stimulation or proprioceptive neuromuscular facilitation. The aforementioned methods can be combined. From the neurophysiology-based methods mentioned above, specifically Vojta’s method has been shown beneficial for some patients with MS. This method uses stimulation of certain zones during reflex crawling or reflex turning to decrease spasticity. This reflex method can activate paralyzed muscles often better than when using volitional exercise. However, great attention needs to be paid to the selection of appropriate stimulation zones and positions. The Frenkel method is beneficial in the treatment of cerebellar ataxia. In this method, elementary components of individual movements are practiced prior to advancing to more complex movements while always utilizing visual control. Initially, the exercises are performed while lying down, followed by sitting and standing, and lastly with the eyes closed. In cerebellar involvement, other therapeutic approaches are also used and are listed in Chapter 1.13.3 Rehabilitation in Cerebellar Dysfunction.

Deficits in stability in ataxia of spinal origin and in vestibular involvement can also be affected by elements of sensorimotor stimulation. In patients with urinary deficits, exercises aimed at activation of the pelvic floor musculature should be implemented in early stages. Physical therapy principles for patients with MS are mentioned below and are based on the severity of neurological involvement. Physical Therapy Physical Therapy with a Mild Degree of Involvement With mild neurological involvement, the patient’s main problem is their overall decrease in performance and fatigue; motor deficits, spasticity and ataxia may not yet be present. Here, improving the patient’s fitness is the main focus. At this level of involvement, aerobic training is important and it is initiated by a “warm-up” phase, consisting of simple warm-up exercises, which are an appropriate preparation for increased loading during the aerobic phase. In the warm up phase, the muscular system is activated similarly as done in healthy individuals. In this phase, muscle stretching for the muscles that will be activated in the following phases is important. A preparatory warm-up phase should take 5–15 minutes. The actual aerobic training follows the warm-up phase and contributes to an improvement in pulmonary functions, increased oxygen utilization, myoglobin concentration and activity of oxidative enzymes, increased capillarization of active muscles, increased number of mitochondria, improved aerobic threshold and other changes. Also, cardiac function and physical fitness and the ability to recover after physical activity improve. For aerobic training, dynamic and endurance type activities are recommended (exercise bike, rowing machine, bicycling, swimming, running). During practice, it is important to not exceed the given intensity. Appropriate intensity is established by spiroergometric assessment using a bicycle ergometer, during which the load is gradually increased to the patient’s subjective maximum. From the measured values, heart rate and muscle

performance values corresponding to 60% of maximum oxygen consumption are calculated and are recommended to be used as the loading intensity that is controlled by heart rate. The training should occur three times a week. In patients with a mild movement deficit, the activity initially takes 5–10 minutes with a gradual increase to 20– 30 minutes based on the patient’s level of tolerance. In patients with a more severe movement deficit, it is appropriate to begin with 2 minutes and gradually increase the activity time to 10 minutes based on the patient’s level of tolerance. Adaptation changes occur usually after 6 weeks of regular exercise. If the health condition worsens (during a recurrence), the exercise program needs to be interrupted and should be resumed when the patient’s health condition stabilizes. Patients who do not tolerate the increased body temperature following exercise are recommended to spend approximately 5–15 minutes in a cooler room. Physical Therapy with a Moderate Degree of Involvement With this degree of involvement, the mobility deficits disrupt common daily activities or demand unilateral support during ambulation (degree 5–6 on Kurtzke scale). Many patients with MS who are being admitted to rehabilitation departments demonstrate this level of involvement. In such patients, a simultaneous decrease in strength, spasticity and ataxia and a further decrease in gait quality are observed. Ambulation is characterized by decreased walking distance and a slower cadence. As mentioned above, a combination of physical therapy methods are implemented at this level of involvement. Physical therapy especially addresses decreased strength, spasticity and ataxia and focuses on improved gait quality. The focus is particularly on decreasing spasticity, but only to a certain level. In some patients, a more significant decrease in spasticity can be achieved, but this could also have a negative consequence on the quality of their gait if the paretic lower extremities do not provide sufficient support during ambulation and the knees give as a result of more significant reduction in extensor spasticity. It is important to be aware of this possibility and the effect of physical therapy always needs to be closely monitored. In patients with a moderate or greater

degree of involvement, the use of assistive devices often needs to be considered to allow for improved locomotion. Often, unilateral or bilateral support is needed (canes, forearm crutches, axillary crutches, knee braces preventing the give in the paretic lower extremities during walking or ankle braces for improved stability, but also to improve support of the paretic foot). The patient also needs to be trained in using the selected assistive devices. Physical Therapy with a Severe Degree of Involvement With this degree of involvement, the objective neurological finding is usually so significant that the patient is required to use a wheelchair. This usually involves patients with grade 7 or higher on the Kurtzke scale. Usually, the lower extremities are more severely involved than the upper extremities. In such patients, the primary problem and the method used to address it need to be identified. In some patients with irreversible neurological involvement, physical therapy treatments can achieve some decrease in spasticity or even improved upper extremity mobility, however, only temporarily. But even temporary improvement in their condition has a great significance for patients with such severe involvement because it improves their activity and motivation for further active cooperation, not to mention the positive psychological effect. All patients with severe neurological involvement need to be equipped with appropriate orthotic devices, which are often the only option for improving the patient’s mobility and selfcare. Practical skill training for patients in wheelchairs is an important component of the rehabilitation program and it is usually addressed by an occupational therapist. The occupational therapist also has a dominant role in patients who are bedridden because they teach the patient self-care and different bed activities. Maintaining joint mobility and prevention of joint and muscle contractures is the focus for patients who are immobile. It is also important to educate family members in strategies assisting with the patient’s care in a home environment. Social Aspects of the Disease Multiple sclerosis often affects individuals at an early age and, in certain cases, causes early disability. Therefore, great attention needs

to be paid to the social aspects. In many patients with MS, work potential decreases as a result of the disease and they are not able to return to their original occupation. This, of course, has a very negative effect on the patient’s mental state. Recurrences or gradual progression of decreased independence can lead to the patient’s anxiety and fears that can lead to their social isolation. In more severe involvement, it may become difficult for the patient to remain in their home environment and it becomes inevitable for them to rely to a various extent on caretaking services. It may also be necessary to place the patient in a facility providing appropriate care. In the Czech Republic, it can be beneficial to cooperate with Union Roska, which tracks patients with MS and provides them with counseling. Balneologic Treatment Balneologic treatment has a significant role in MS. Among other roles, it contributes to an improved physical condition and has a positive effect on the patient’s psychological well-being. Aquatic therapy and exercise activities are implemented and aimed at improving the patient’s fitness and motor skills. According to the indication list for balneologic treatment, comprehensive balneologic treatment in MS is provided upon the recommendation from a neurologist usually following the first episode and usually two years after the completion of a previous balneologic treatment. Balneologic treatment cannot be performed during a relapse and it is also not appropriate for patients with severe ataxia or paralysis or when the relapses occur within one year. In the Czech Republic, balneologic treatments for patients with MS are provided in spa centers Vraz, Dubi and Klimkovice.

1.18 DEFICITS IN CONSCIOUSNESS Pavel Kolář Rehabilitation for a patient in a coma is difficult because the patient is unable to cooperate. Another problem is posed by the fact that they only have a limited intake of information. They are unable to receive visual information; taste and olfactory intake of information is significantly limited if the patient has an endotracheal tube and is dependent on artificial ventilation or artificial nutrition. Hearing is preserved, but the patient can have a speech or neuropsychological deficit, which implies that they are unable to comprehend. When approaching the patient, the therapist needs to account for this limited intake of information and cannot rely on the majority of the patient’s sensory perceptions. For this reason, it was believed that rehabilitation of patients in a coma was pointless and was postponed until the patient regained consciousness. Rehabilitation benefits have been established only recently and rehabilitation became a stable component of care for such patients.

1.18.1 Causes Consciousness is a state during which a person is able to correctly perceive themselves and the external environment and correctly react to stimuli from the external environment. This function mainly depends on the active state of the cerebral cortex. For its activation, an essential inflow of non-specific stimuli is important mainly through the ascending reticular activation system. In clinical practice, limited consciousness is exhibited if contact with a patient cannot be established even after painful stimulation of intact areas. The most important causes of a loss of consciousness include: exogenous and endogenous intoxication, diffuse brain ischemia, intracranial bleeding, traumatic brain injury, inflammatory processes of the CNS and intracranial tumors. These causes need to

be distinctly diagnostically distinguished from a psychogenic coma, locked-in syndrome, apallic syndrome, akinetic mutism and hypersomnia.

LEVELS OF QUANTITATIVELLY LIMITED CONSCIOUSNESS SOMNOLENCE It is the mildest level of deficit in consciousness. The patient does not immediately respond to questions. Although language can be used to establish contact, the patient does not spontaneously talk without stimulation and falls asleep.

SOPOR It is the middle level of consciousness limitation. The patient reacts to painful stimuli (pricking, pinching) by moaning. Language cannot be used to establish contact and the patient does not respond to questions.

COMA Coma is the most severe degree of deficit in consciousness. It can be superficial or deep. In a superficial coma, corneal reflex, myotatic reflex and a photoreaction are decreased, but present. A patient reacts to intensely painful stimuli by extremity movement. Pulse, pressure and breathing can be normal. In a deep coma, reflexes cannot be elicited. Deficits in breathing, pulse and blood pressure are usually present and the patient does not react to intense, painful stimuli. A coma vigil or akinetic mutism is a state of awareness with certain manifestations of alertness preserved. The patient does not talk, does not spontaneously move and does not react to being called. However, their eyes are open as if they were observing movement of people and

some other signs of alertness are also present.

ASSESSMENT OF LEVELS OF CONSCIOUSNESS Special scores to assess the patient’s state of consciousness have been developed: Brussels Coma Grade Coma Outcome Score Glasgow Coma Scale (Tab. 1.18.1-1) Coma Observation Scale Glasgow Outcome Scale

Tab. 1.18.1-1 Glasgow Coma Scale

Some scores (for example, the Glasgow Coma Scale) are insufficient

for rehabilitation purposes because they leave out important neurobehavioral findings. In clinical practice, standardized observation of a patients’ behavior, their reaction to multimodal stimuli and ongoing registration of autonomic and neurophysiological manifestations during 24-hour monitoring are recommended. Mechanical monitoring is based on electro-neurophysiological methods.

1.18.2 Neurorehabilitation Approaches for Unconscious Patients These rehabilitation approaches can be used for deficits in unconsciousness of any origin. They are also appropriate for certain patients after severe cerebrovascular accidents and especially for patients after craniocerebral injuries because deficits in awareness are common and often dominant in such scenarios. Rehabilitation principles for patients after CVA and craniocerebral injuries are described in more detail in Chapter 1.19.2 Rehabilitation in Craniocerebral (Brain) Injuries and Chapter 1.20.3 Rehabilitation after Cerebrovascular Accidents. Multisensory stimulation is the main rehabilitation method used for comatose patients. In the literature, this concept is known as “coma stimulation”. This is a therapeutic concept that principally differs from the concepts presented so far. The main goal of rehabilitation is not only prophylaxis, but early stimulation used as an active process aimed at improving perception and, thus, encouraging the patient’s communication with their surroundings. The end result shows improved awareness and the achievement of the first reproduced reaction. The first signs of reaction often occur in a hidden form – unobserved behavior. It is beneficial to use neuromonitoring of a patient’s reactions during sensory stimulation. The therapist registers autonomic parameters (hydrogalvanic skin resistance, breathing, heart rate) and reactions during EEG measurements. In clinical practice, standardized observation of a patients’ behavior and the above mentioned monitoring are recommended.

A neurorehabilitation principle states that the sensory stimulation used can never be painful, should try to be pleasant and known to the patient from the time prior to the injury. Stimulation therapy can be indicated under the following conditions: Sufficient cardiac and circulatory system stability Normalization of intracranial pressure Multimodal Sensory Stimulation This approach begins with the ritual of greeting the patient and it always occurs in the same manner and is based on acoustic and tactile perceptions. The best experience includes greeting the patient by their name with simultaneous touch on both shoulders. It is important that the patient is always addressed in the same way and the touch on the patient’s body is directed centrally (i.e., shoulder area). Forms of sensory stimulation: Pharmacological Electric Magnetic Unimodal and multimodal Basal Dialog initiation Locations for performed stimulation: Orofacial – this region, in which a large number of sensory stimuli normally occur, is significantly deprived in patients who are comatose. For this reason, its stimulation is very important. Stimulation of this region uses the quality of surface sensitivity, vibration and thermal stimulation. Olfactory – the patient is offered various pleasant scents. Gustatory – the patient is offered various types of flavors that are placed on a moist tongue. Auditory – during this stimulation, the patient is read (by a family member) their favorite texts, such as a newspaper; the patient is told current events from their home environment. The patients are called by their name, their favorite music is played, etc.

Visual – visual stimuli are performed through closed eyes or the lids can be manually lifted. Multicolored light is utilized. If the patient’s eyes are open, their positioning becomes very important. Proprioceptive, kinesthetic and vestibular – encourages the perception of position, movement, balance and spatial orientation. The patient should be verticalized depending on their options. Tactile stimulation – it includes various types of massages, extremity brushing, thermal wraps (hot or cold). Other options include vibration applied to the heels, pelvic bones and over the long bones of the extremities. A relaxation effect is also implemented. Neurostimulation is performed daily in three sessions with each approximately one hour long. During stimulation, signs of overloading need to be monitored – increased spasticity, increased heartbeat, profuse sweating, etc. Stimulation and other therapeutic care need to be firmly integrated into the patient’s regime.

1.19 CRANIOCEREBRAL (BRAIN) INJURIES Ondřej Horáček, Pavel Kolář

1.19.1 Causes and Clinical Picture Rehabilitation of individuals with a brain injury is one of the fundamental rehabilitation programs. It is estimated that in the Czech Republic, approximately 20,000 brain injuries requiring hospitalization occur annually with 15% resulting in a permanent status. Among such patients, younger and middle aged men dominate and a significant portion involves children. A brain injury can be classified as primary or secondary. Primary injuries that develop immediately as a result of a trauma include skull fractures, brain contusions, intracerebral and extracerebral hematomas, brain tissue lacerations and diffuse axonal injury. Secondary changes develop after a certain time delay and are either intracranial or extracranial in nature. From the perspective of clinical severity, brain injuries can be divided into mild, moderate and severe. A mild brain injury (brain concussion) is manifested by a short deficit in consciousness without permanent results; symptoms subside in 1–3 months. A moderate injury is accompanied by a loss of consciousness lasting minutes or hours; brain contusion or hematoma develop in this stage. Cognitive deficits can persist for several months, but the patient usually recovers completely. In a severe injury, a long loss of consciousness (days, weeks or even months) occurs, contusions form, hematomas or a diffuse axonal injury develop and, almost always, residual deficits persist. Most serious are extensive, combined and devastating brain injuries, for example, brain stem destruction, multifocal injuries to the white matter of subcortical regions, thalamic lesions or severe brain edema. These states are almost always accompanied by deep unconsciousness. These types of injuries can lead to an apallic

syndrome.

APALLIC SYNDROME Apallic syndrome (a permanent neurovegetative state) is characterized by an initial severe unconsciousness followed by the gradual emergence of alertness that alternates with periods of sleep. The patient appears to be alert (called alert unconsciousness), but it is impossible to engage the patient, they do not stabilize their gaze and affective reactions cannot be elicited. However, swallowing and chewing automatisms and gross motor skills are preserved. In apallic syndrome, muscle hypotonia or, in contrast, hypertonia or rigidity can occur, tetraparesis, oculomotor deficits, extrapyramidal signs and, later, the prefrontal syndrome often develop. Also, there is a great risk for developing para-articular ossifications. Para-articular ossifications develop in up to 14% of patients following severe brain injuries. The subsequent progression of apallic syndrome varies. Based on the experience of F. Gerstenbrand, the three most common forms include: 1. Overall persistent restlessness predominates with attempts to grasp everything, put into mouth, chew or suck, loss of bashfulness, hypersexuality and euphoria (called Kluver-Bucy syndrome) 2. Attention and memory deficits predominate, disorientation to time and place is present (the Korsakov syndrome) 3. Organic psychosyndrome develops, which involves emotional instability, deficits in affection, attention, comprehension, memory and imagination. Apallic syndrome results in 52% of the patients in death, complete recovery only occurs in 5% and 43% presents with residual combined neurological and psychological deficits. Based on the predominant residual signs, the following syndromes can be distinguished, in which: Dementia dominates

Spasticity with pseudobulbar syndrome dominate Parkinson’s syndrome dominates Hyperkinetic syndrome dominates In the above listed scenarios, complete recovery usually does not occur and deficits usually persist to a certain degree. However, even if the patient’s recovery after apallic syndrome is positive, fatigue or a slight cognitive deficit usually intermittently or even permanently persist.

1.19.2 Rehabilitation for a Brain Injury Physical therapy attempts to address the entire scope of neurological involvement. Central paralysis with spasticity, cranial nerve injuries, extrapyramidal deficits, cerebellar dysfunction, speech deficits, and especially psychological and cognitive deficits are the most common areas that need to be addressed in patients with a brain injury. Attention is also paid to complications that can generally occur, including limitations in joint range of motion, para-articular ossifications, myositis ossificans, pressure ulcers and sphincter dysfunction. Neurological symptoms develop gradually and the level of involvement (especially movement and cognitive deficits) can usually be specified with gradual improvement in the patient’s condition. From the very beginning, great attention needs to be focused on preventing joint stiffness and using exercises in anti-spastic patterns to prevent irreversible complications in the form of an extension or flexion extremity contracture later. From the beginning, joint range of motion needs to be performed in sufficient ranges and in correct directions. It not only contributes to the prevention of joint stiffness, but also encourages afferentation from the joint. In the acute stage, the nature of spasticity can change and the anti-spastic patterns need to be selected according to these changes. The nature of upper and lower extremity spasticity depends to a great extent on whether the injury resulted in decortication or decerebration. This fact plays an important role in the selection of anti-spastic positions during exercise

(Fig.1.19.2-1). For example, in extension spasticity of the upper extremities or flexion spasticity in the lower extremities, the antispastic patterns are different than in patients with hemiparesis following CVA. In addition to physical therapy, occupational therapy and modalities are an integral part of a rehabilitation program for patients with brain injuries.

Fig. 1.19.2-1 Decorticate and decerebrate rigidity. A – typical alignment of the upper extremities and the head in a patient with decorticate rigidity. The head is in slight extension, flexion rigidity dominates in the upper extremities and extension rigidity with plantarflexion in the lower extremities; B – typical alignment of the extremities and the head in a patient with decerebrate rigidity; the head is in hyperextension (opisthotonus), the upper extremities are in extension, internal rotation and pronation and the lower extremities are in extension and plantarflexion.

Physical Therapy Patients who suffered a brain injury usually go through certain developmental stages. Therefore, physical therapy is modified not only according to the nature of the neurological involvement, but also according to the patient’s stage.

Acute Stage Physical Therapy In this stage, rehabilitative care plays a dominant role, especially in pressure ulcer prevention, sphincter care and positioning. In severe injuries that involve a loss of consciousness, but also later when the patient is capable of certain reactions, physical therapy must always include passive exercises, facilitative methods and pulmonary physical therapy in addition to positioning. The area of the head and neck poses certain limitations in the first days (for example, probes, tracheostomy). Head flexion should not be performed; however, slight head traction and later also head rotation are usually possible. Stimulation massage of the facial musculature, passive eye opening and closing, etc. are beneficial. At this stage, temporomandibular joint stiffness needs to be prevented and passive mouth opening should be performed at least once a day. If the muscles of mastication are spasmed, jaw mobilization is performed followed by post-isometric muscle relaxation. If the patient can partially cooperate and respond to painful stimuli, the trigger points in the muscles of mastication are identified and treated. In the area of the thorax, care ensuring breathing pathway clearance and release of bronchial mucus is important and often administered through reflexive stimulation of breathing. If the patient is ventilator-dependent, physical therapy is combined with breathing with an ambu-Vac repeatedly during the day while simultaneously checking blood gases. In the abdominal area, deep palpation is performed in the passing direction if peristalsis is obstructed. However, certain caution needs to be paid in regards to eliciting the gastroesophageal reflex in a hypotonic stomach. Implementation of reflexive stimulation of the abdominal wall and the diaphragm can be beneficial. In the upper extremity, it needs to be considered whether this is a decorticate or a decerebrate state. In decortication, if the upper extremity presents with elbow and wrist flexion and arm adduction, the extremity is positioned as seen in a patient with a CVA (i.e., shoulder external rotation, elbow, wrist and finger extension, forearm

supination, thumb abduction). This is often accomplished by wrist and finger extension splints. Large and small joints of the upper extremities are exercised in anti-spastic patterns and passive diagonal movements are performed. Great attention is paid to the shoulder joint, which should be exercised in anti-spastic directions to prevent its stiffness. In the lower extremity, the same finding is observed in decortication and decerebration (knee extension, foot plantarflexion) and, thus, the treatment is similar for both cases and lower extremity positioning depends on whether the patient lays on the involved or uninvolved side (positioning is based on the same principles as in a CVA). Once again, joint care is very important – the goal is to maintain full range of motion. The hip joint is exercised in an antispastic pattern of flexion, extension, abduction and internal rotation with simultaneous dorsiflexion and eversion at the ankle. If joint range of motion is limited, the progression is from the most limited directions to less limited directions based on the capsular pattern. Exercises in an anti-spastic pattern are utilized. In patients in the acute stage, foot joint mobilization is essential (to prevent painful restrictions). Aggressive soft tissue mobilization of the soles of the feet is also beneficial. Physical Therapy in Subacute and Chronic Stages In this stage, an improvement in volitional motor skills is usually observed and the patient usually can cooperate. More time is spent administering neurophysiological techniques. Verticalization training is initiated along with balance training in sitting and later in standing, followed by gait training. Moreover, joint range of motion of the upper and lower extremities needs to be maintained to prevent muscle contractions and para-articular ossifications. Mobilization of the peripheral joints of the feet and the hands is also implemented. In the spine, soft tissue mobilization and release are performed in the paravertebral muscles, which generally present with contractures. In patients with a brain injury, rehabilitation of cognitive functions and speech needs to be initiated in a timely manner. Speech

rehabilitation relies on the cooperation of a neuropsychologist and a speech therapist. As soon as the patient’s condition allows and the patient is capable to participate sufficiently, self-care and activities of daily living are practiced. The patient is provided with appropriate assistive devices (to improve locomotion, independence or to prevent contractures, etc.). Most patients who suffered a brain injury require long-term, mainly outpatient care and attention from the above mentioned specialists. Outpatient care administered in a specialized center has been proven most beneficial. Such centers use a multidisciplinary team of specialists who are able to address all consequences of the injury. This comprehensive rehabilitation approach can address not only the somatic component of the injury but also the question of the ability to work and includes intervention with family members. To this extent, in the Czech Republic, care is provided to patients with a brain injury at the Clinic of Rehabilitation Medicine, 1st School of Medicine at the Charles University. Vast experience and a long tradition in the rehabilitation of such involved patients can also be found at the Military Rehabilitation Institute in Slapy nad Vltavou, as well as, at the Rehabilitation Institute in Luze-Kosumberk. Balneologic treatment is appropriate when it is expected to contribute to further improvement of the patient’s condition and the patient is able to cooperate. In addition to mobility being involved in patients with a brain injury, cognitive deficits need to be addressed. Movement therapy, aquatic procedures and specific occupational therapy methods aimed at cognitive deficits have been found beneficial. Comprehensive balneologic treatment can be administered when prescribed by a neurologist, neurosurgeon, orthopedist or a rehabilitation physician, usually as a continuation of treatment after hospitalization. Balneologic treatment for patients with brain injury is offered at Lazne Belohrad, Dubi, Janske Lazne, Jachymov, Karvina, Velke Losiny, Vraz and Klimkovice.

1.20 VASCULAR DISEASES OF THE BRAIN Ondřej Horáček, Pavel Kolář Cerebrovascular accidents are becoming the cause of a severe health disability more often and thus pose a significant medical, social and financial problem. The incidence of CVA in the Czech Republic is about 350 cases in 100,000 people each year. Therefore, in the Czech Republic, up to 35,000 people are affected by CVA. Approximately 2/3 of these patients survive, while approximately half of them exhibit a severe disability and are institutionalized or permanently depend on family care. More than 1/3 of the patients are younger than 60 years of age. Rehabilitation plays an important role in the care of these individuals. Cerebrovascular accidents occur either as a result of ischemia (entire brain or its part) or hemorrhaging into the brain tissue or the subarachnoid space.

1.20.1 Ischemic Cerebrovascular Accidents Ischemic CVAs are most common and present 80% of all CVAs. Under normal circumstances, brain perfusion is between 50– 60ml/100g of brain tissue. Ischemic CVAs develop as a result of a critical decrease in brain perfusion in a portion (or the entire) of the brain. If the blood flow decreases under 20ml/100g of brain tissue, neuronal function becomes disrupted and clinical signs develop that stem from the ischemic lesion. Hypoxic brain tissue is subject to structural changes and leads to brain infarction. The causes of brain ischemia can be either local (i.e., arteriosclerosis, cardiac causes, hematologic illnesses) or systemic (i.e., complete brain hypoxia in pulmonary problems or hypoxia for rheological causes due to increased blood viscosity).

ISCHEMIA IN CAROTID CIRCULATION During ischemia in the carotid circulation, the internal carotid artery

or only its branches can be affected. Based on the location of the injury, the signs of frontal, occipital or temporal lobe involvement or even involvement in the deep areas of a brain hemisphere (i.e., the internal capsule) can be seen. Ischemia most commonly affects the middle cerebral artery and results in a typical clinical picture (Fig. 1.20.1-1 A,B). A contralateral movement deficit dominates and affects mainly the distal upper extremity and mimetic musculature. Often, a contralateral sensory deficit and contralateral visual field deficit (homonymous hemianopsia) are present. A deficit in symbolic functions also occurs, which is a sign of injury to the dominant hemisphere. If the non-dominant hemisphere is involved (parietal lobe), it can sometimes be observed that the patient is unaware of the severity of their own injury (i.e., hemiplegia) and they act as if the deficit “does not exist” and they “ignore it” – this is known as neglect syndrome. Often, the eye deviates toward the affected side and gaze paresis toward the opposite side can be seen. The so called WernickeMann posture is present (Fig. 1.20.1-2) with a typical spastic pattern characterized by the following: Shoulder depression, adduction and internal rotation Elbow flexion with forearm pronation, wrist and finger flexion Lower extremity internal rotation, hip and knee extension Foot inversion and plantarflexion, lower extremity circumduction during gait Fig. 1.20.1-1A CT scan of ischemia in the flow of the middle cerebral artery on the right

Fig. 1.20.1-1B Thrombus in the middle cerebral artery in the same patient causing ischemia

Fig. 1.20.1-2 Wernicke-Mann posture with a typical spastic pattern on the right-side extremities

The signs of ischemic involvement of the entire trunk of the internal carotid artery are similar to ischemia in the flow of the middle cerebral artery, but additional signs can be present from the flow of other branches of the internal carotid artery. Ischemia in the flow of the anterior cerebral artery is also manifested by a contralateral hemiparesis, but the lower extremity is involved more significantly. Prefrontal syndrome may be present with significant psychological deficits. With ischemia in the flow of the perforating central arteries, lacunar infarction develops and motor and sensory signs are present along with ataxia or dysarthria. Besides isolated focal lesions, multifocal hypoxic corticosubcortical

involvement can sometimes be seen, which can lead to vascular dementia. Merging ischemic areas within the white matter of the brain hemispheres are the cause of Binswanger’s disease, which is characterized by progressive deterioration of cognitive functions.

ISCHEMIA IN VERTEBROBASILAR CIRCULATION Here, the vertebral artery, basilar artery or cerebellar and brain stem arteries can be involved. Signs of involvement of the brain stem structures, cerebellum, occipital lobe, base of the temporal lobe, posterior part of the thalamus and injury to the vestibular and auditory receptors can be seen. Ischemia in the flow of the posterior cerebral artery leads to visual impairments. Most often, contralateral homonymous hemianopsia, cortical blindness or various visual phenomena develop and, sometimes, a deficit in symbolic functions (i.e., agnosia), gaze paresis and contralateral sensory deficits, body schema and spatial orientation deficits can be present. With ischemia of the cerebellar arteries, Wallenberg syndrome develops. It is characterized by homolateral neocerebellar signs, Horner syndrome, involvement of cranial nerve V and a contralateral dissociated sensory deficit in the trunk and extremities. Vestibular signs, swallowing deficits, snoring and hiccups (singultus) are also present. With unilateral ischemic involvement of the brain stem arteries, alternating hemipareses occur, in which a contralateral hemiparesis is accompanied by unilateral involvement of a cranial nerve. With involvement of the basilar or vertebral arteries, the signs are similar to the involvement of individual branches or the clinical pictures are combined.

CLASSIFICATION BASED ON DISEASE PROGRESSION Based on the clinical signs of disease progression, several types of brain ischemia can be distinguished: 1. Transient ischemic attack (TIA) in which the signs completely resolve within 24 hours

2. Reversible Ischemic Neurologic deficit (RIND) in which the signs resolve within 2 weeks 3. Stroke in evolution in which the signs gradually progress 4. Completed stroke in which irreversible focal ischemia develops with a permanent neurological deficit

1.20.2 Hemorrhagic Cerebrovascular Accidents Hemorrhagic CVAs, in which bleeding occurs to the brain parenchymal tissue, includes 15% of all CVA’s and results in higher mortality than the ischemic CVAs. They develop as a result of a rupture in the wall of a brain artery. Bleeding can be either lacunar or defined (global). Lacunar (typical) bleeding forms 80% of parenchymal hemorrhages and develops with a rupture in a blood vessel wall affected by chronic arterial hypertension, most often in the area of the central perforating arteries. Bleeding to the basal ganglia, thalamus, and internal capsule generally occurs and the prognosis is often poor. Global (atypical) bleeding is usually caused by a rupture of a blood vessel anomaly and typically affects the subcortical region. It comprises 20% of parenchymal hemorrhages and their prognosis is more favorable. Bleeding sometimes occurs in arteriovenous malformations or during various angiopathies and coagulopathies. Around 5% of all CVAs form subarachnoid bleeding, which develops with a rupture of an aneurysm in the circle of Willis arteries or the receding of the main brain arteries. A massive hemorrhage of this type can lead to the fast destruction of the brain and can be complicated by the development of vascular spasms, which can sometimes be the cause of a brain infarction.

DIFFUSE HEMORRHAGES They are manifested by a combination of focal signs (mainly internal capsule syndrome) and signs of intracranial hypertension, usually associated with a deficit in consciousness. The entry of the hematoma into the brain ventricles (hematocephalus) poses a complication (Fig. 1.20.2-1). The prognosis is poor with high mortality.

Fig. 1.20.2-1 CT scan of central bleeding into basal ganglia and the ventricles

FOCAL SUBCORTICAL HEMORRHAGES These are similar to ischemic CVAs in the same blood circulation and, in this case, the prognosis is favorable with low mortality (Fig. 1.20.22). Fig. 1.20.2-2 CT scan of subcortical bleeding in the left occipital area

CEREBELLAR HEMORRHAGE They are less serious and often manifest themselves as a headache, nausea, vomiting, standing and gait deficits and unilateral neocerebellar and vestibular symptoms.

BLEEDING INTO THE BRAIN STEM It is manifested by brain stem symptoms and the prognosis is usually terminal.

SUBARACHNOID HEMORRHAGE It is manifested by a sudden sharp headache (often during a physical demand, defecation, etc.) and possibly accompanied by nausea and vomiting, photophobia, and psychological changes. Coma develops quickly if the bleeding is severe. Focal signs are either completely absent or are only present to a mild degree. However, if bleeding occurs into the brain tissue, the signs can be substantial. Gradually, a meningeal syndrome develops and it is manifested by nuchal rigidity

and other meningeal signs. The Hunt and Hess Stroke Scale is used to assess the severity of clinical findings in subarachnoid bleeding. It classifies clinical findings according to the severity of involvement by grades I–V (in grade I, the patient presents without clinical signs; in grade V, the patient is in a coma).

1.20.3 Rehabilitation for a CVA A rehabilitation program for patients with a CVA should be developed so that it addresses all the patient’s neurological deficits. The above mentioned clinical pictures of individual types of CVAs implies that patients after a CVA most often display the following: sensory deficits, deficits in symbolic functions, cognitive functions, extremity movement (central paresis), cranial nerve involvement (mainly paresis of the eye-moving nerves, facial nerve paresis, involvement of the lateral mixed system), deficits in superficial and deep sensation, and vestibular and cerebellar deficits. The mentioned deficits need to be specifically addressed by a comprehensive rehabilitation program. With a CVA, the clinical picture is always combined by manifestation of structural and inhibitory functions. The areas of inhibitory changes can be especially influenced through physical therapy. Mainly the areas of decreased function in the region of morphological changes are being addressed through physical therapy. It also aims at preventing secondary inhibitory changes in the superior and related far-off areas. The established rehabilitation plan is based on the assessment of postural tone, postural and movement patterns and functional skills while taking into consideration the stage of the CVA. Several developmental stages of CVA are distinguished and each stage requires a different physical therapy approach. In the acute stage, muscle hypotonia dominates (so called pseudoweakness). In the subacute stage, spasticity develops and dominates. In the stage of relative correction, favorable progress is seen, during which the condition continues to improve and, when the condition plateaus and no more improvement occurs, the so called chronic stage begins. The

above listed stages tend to overlap and thus, cannot be strictly separated. Physical therapy methods form the foundation of a rehabilitation program for the majority of patients. Therapy uses predominantly a combination of Vojta’s method, neurodevelopmental treatment and proprioceptive neuromuscular facilitation. Occupational therapy also has a significant influence. Components of these methods are implemented at all stages of a CVA and a specific approach is selected based on the patient’s current condition. In the following section, rehabilitation treatment will be described that is appropriate for a patient with hemiparesis following ischemia in the middle cerebral artery circulation, which is the most common type of CVA. However, a number of elements that are going to be mentioned can be used for patients with different types of CVA because the foundational physical therapy principles are similar. Physical Therapy Physical Therapy in the Acute Stage This stage lasts several days or weeks. The patient presents with muscle weakness, decreased muscle tone and decreased balance. Their unilateral extremities are limp and hanging freely as the patient is unable to move them or lift them against gravity. Rehabilitation has an important role here and aims at taking care of skin trophicity by preventing the development of pressure ulcers and addressing sphincter deficits. Positioning is an essential part of rehabilitation care and influences the following: Prevention of musculoskeletal deformities Prevention of pressure ulcers Prevention of circulatory problems (vascular and lymphatic) Source of physiological information for the CNS (as a result of CVA, a transient lack of adequate reactions occurs) Assistance in recognition and awareness of the involved side A sensory deficit, which often accompanies motor loss, can decrease

if the patient lies in bed without changing positions for several hours, in an environment that they can perceive negatively and where they often do not feel well. Under such circumstances, even a small change in position causes the onset of sensory stimulation that can assist in a return of sensory function. Positioning needs to be initiated as soon as possible and needs to follow several important rules. It is performed every 2–3 hours, including at night. Classic or special positioning pillows can be used. Every position must be stable because a lack of stability provokes spasticity. During positioning, it is important to set the key joints (shoulder and hip) into a functionally neutral position. The extremity position needs to be based on anti-spastic patterns. The distal parts of the extremities need to be placed in positions that facilitate their function. Positioning takes into consideration whether the patient lies supine, on the unaffected or on the affected side. If the patient is supine, the affected upper extremity needs to be supported on a pillow so that the shoulder is not protracted, and that the arm is in external rotation with the forearm in slight supination, and the elbow and wrist in extension. The affected lower extremity is supported on a pillow under the pelvis and the thigh to prevent pelvic retraction and extremity external rotation. The knee is in slight flexion. The head is not excessively supported to prevent increased spasticity. The patient should be supine for the shortest time possible because this position increases extension spasticity of the lower extremities. If the patient lies on their unaffected side, they are slightly tilted toward their stomach with the affected upper extremity supported on a pillow placed in front of their body so that the shoulder is in protraction and the elbow in extension. The lower extremity is in front of their body with a flexed hip and knee supported on a pillow so that it does not fall into hip adduction. If the patient lies on their affected side, they are slightly turned to their back (the back is supported by a pillow). The affected shoulder is positioned in protraction, elbow extension, forearm supination with the palm facing up, and wrist and finger extension. The affected lower

extremity is in hip extension and the knee is in slight flexion. The unaffected lower extremity is flexed at the hip and the knee in front of their body and supported on a pillow (Fig. 1.20.3-1). Previously used supports preventing foot plantarflexion (i.e., small boxes) are not recommended because they provoke plantarflexor spasticity. During positioning, an injury to the affected shoulder needs to be prevented, which can easily occur by rough handling (for example, pulling). The involved shoulder must also be protected from the effects of gravity, especially in sitting, to prevent its subluxation, which could later contribute to the development of a frozen shoulder, which is a feared complication following a CVA. Previously used extremity slings are generally not recommended. Given the extremity position in the sling, there is a certain risk that it could encourage a spastic flexion pattern of the extremity. When a sling is used, it also restricts shoulder girdle synkinesis during gait (see Fig. 2.5.4-16B in Chapter 2 Treatment Rehabilitation in Orthopedics and Traumatology). However, some patients can temporarily use a sling correctly and this is their best option at the time. During the verticalization phase and later on, it is more beneficial to use support in the area of the axilla to protect and unweight the shoulder joint (Fig. 1.20.3-2). In the acute stage, a pneumatic splint has been found beneficial for the involved extremities. It is indicated for the upper or lower extremities for: Distal edema control Areas with a sensory deficit and when sensory input needs to be increased Spasticity inhibition Fig. 1.20.3-1 Positioning of a patient after CVA on their affected side in an anti-spastic position

Fig. 1.20.3-2 Orthotic support of the paretic upper extremity preventing shoulder subluxation – the axillary roll

Next, postural reflexive mechanisms are practiced. In this phase, Vojta’s reflex locomotion has been found quite beneficial. Its application is important for the development of stereognostic functions and for the control of abnormal muscle tone. The exercises act in an “anti-spastic pattern”. Rolling to the affected side is practiced and followed by turning to the unaffected side. To facilitate reflexive postural mechanisms, joint approximation, tapping, active assistive movement, postural retraining and active movements are implemented. For example, a pelvic lift (bridging) is practiced in supine with the lower extremities flexed (Fig. 1.20.3-3). Bridging serves as an important preparation for getting up and sitting down while the pelvis is being mobilized, which is later a component of rhythmic gait.

Next, pelvic rotation is practiced, which is important later during gait training because a controlled movement cannot occur without rotation. In the given stage of illness, passive exercise is important and it is performed in an anti-spastic pattern.

Fig. 1.20.3-3 Caption: A bridging exercise by a patient after CVA. The patient lifts their pelvis above the table while the therapist assists by applying pressure to the knees with the affected lower extremity stable (fixated). The therapist’s other hand can assist with pelvic elevation on the affected side

Patients with hemiparesis typically show decreased resting pulmonary volume and a predominance of abdominal breathing relative to costal breathing. Pulmonary ventilation mechanics are disrupted as a result of decreased strength of the thoracic and abdominal musculature and decreased costovertebral mobility. Breathing exercises are important and Vojta’s method has been seen as especially beneficial in facilitating diaphragmatic breathing. The condition gradually improves in a majority of patients, volitional movement occurs and the patient transitions into the

subacute stage. Physical Therapy in the Subacute Stage At this stage, spasticity begins to develop (sometimes this stage is referred to as the spasticity stage). During rehabilitation, active mobility is emphasized and later followed by gradual verticalization. The verticalization process is gradual and includes a step by step continuous sequence. First, the patient learns to sit up in bed. Their back needs to be supported and the head and the trunk need to be erect (the thoracic kyphosis should not be accentuated). Balance training in sitting is especially important for the next stage. Chair transfers and standing at the side of the bed can only be practiced if the patient is capable of transferring to sidelying and sitting and demonstrates good sitting stability. Sooner or later, the majority of patients develop spasticity with a tendency to affect the upper extremity flexors and the lower extremity extensors, as was described above in the spastic pattern. To control spasticity, a sequence of gradually progressive exercises can be used in which the upper and lower extremities are exercised in supine or lying on the uninvolved side as the shoulder girdle is mobilized. Then, the exercises are performed in prone with forearm support followed by kneeling with forearm support and quadruped to practice balance. In the quadruped position, the muscle tone of the flexors in the upper extremity and the extensors in the lower extremity decreases. Quadruped is followed by tall sitting and then walking on the knees, which is important because the patient must use their lower extremity in the correct movement pattern resembling gait. Then, the patient learns to stand from sitting. Stabilization in sitting and, especially, lateral stability are practiced. Knee stability and selective (isolated) foot dorsiflexion are also important to practice. Then, sit to stand and stand to sit are practiced. During gait training, the lack of equilibrium reactions is expected because the affected lower extremities are being loaded. For this reason, practicing side to side weight shifting, correct foot placement and forward and backward ambulation are implemented.

If the patient shows favorable progress, a relative recovery occurs in certain patients. At this stage, the patients are able to control their affected arm and their gait has already significantly improved. Although the spasticity is usually only mild, the patient is not capable of selective movements of individual segments of the upper and lower extremities. The extremities continue to move as a whole. Physical therapy focuses on the finer and more isolated movements and, at the same time, suppresses the pathological movement patterns. For example, in the upper extremity, the patient should be able to move their wrist and fingers independently of their ipsilateral shoulder and elbow movements. Opening and closing of the fingers and thumb opposition need to be practiced in various upper extremity positions. The patient should master foot dorsiflexion and plantarflexion independently of lower extremity position and, thus, ankle motion is being practiced in supine with the affected lower extremity flexed and also extended. Isolated foot dorsiflexion in standing should be encouraged because the patient will not be able to master the heel-toe gait pattern without it. Focus should also be on balance training of the involved extremity during which the patient is being shifted side to side while standing on one foot. At this stage, flexion and pronation dominate in the upper extremity and movements in these directions are simple for the patient. However, supination and radial deviation continue to be a challenge. Therefore, patients find it difficult to bring a spoon to their mouth when feeding themselves. At this stage, patients are not able to dissociate a simple flexion and pronation pattern and a firm grip can only be performed with the forearm in pronation. A firm grip needs to be practiced independently of arm position. At this stage, object release from the hand is often a greater problem than is grasp. Therefore, exercises should incorporate hand relaxation. The dissociation of simple movement patterns (stereotypes) is essential at this stage. While some patients demonstrate continuous progress in their recovery, others reach a stage in which no significant improvement occurs. These are patients who demonstrate incorrectly fixated

postural and movement patterns, which is a sign of the chronic stage. Physical Therapy in the Chronic Stage In the chronic stage, poor postural and movement patterns are already fixed. The patient uses their involved lower extremity as a rigid support and leans more on their cane with their healthy hand. Pelvic elevation, lower extremity circumduction, knee hyperextension (recurvatum) and contact on the lateral aspect of the foot are observed. During gait, upper and lower extremity spasticity is accentuated. The upper extremity is held along the body with the elbow in flexion. Shoulder joint subluxation or impingement syndrome are common. The patient can perform active movement only in the context of tonic reflexive synergies. In some of these patients, the residual finding is the result of an incorrect, delayed or very brief rehabilitation. However, despite timely, correct and longterm rehabilitation, certain patients can continue to demonstrate a significant residual neurological deficit. The progression of recovery cannot usually be accurately estimated ahead of time. For certain patients in a chronic stage who start ambulating relatively well overall, but lack movements on the involved side, a methodical sequence of exercises from the very beginning is sometimes more appropriate. In such cases, the movement re-education returns back to the beginning and utilizes exercises in lower positions. If spasticity in patients with significant spasticity cannot be inhibited, even temporarily, then occupational therapy is more appropriate. It emphasizes the patients’ self-care and time is spent practicing specific activities of daily living. The goal is for the patient to be as independent as possible in their surroundings because independence gives them the much needed confidence for further cooperation. Orthotic Equipment In any phase of CVA progression, the need for certain assistive devices to ease standing or ambulation may occur (Fig. 1.20.3-4). These devices assist in support of unstable joints or prevent the onset of spasticity and secondary changes. They include various types of

orthoses and splints, canes, crutches, walkers, etc. For the upper extremities, custom made splints are used to prevent flexor contractures of the fingers and the hand if finger and hand flexor spasticity is more pronounced. In some patients, the splint is sufficient only for night use, but sometimes also needs to be used during the day. The use of assistive tools for shoulder joint support was already mentioned. On the lower extremity, orthotic devices are sometimes needed to ensure correct foot alignment during gait. The foot of the paralyzed lower extremity often demonstrates calf muscle spasticity and weakness in the anterolateral muscles of the lower leg prepositions the foot in plantarflexion, which usually affects the gait pattern. At the same time, significant ankle joint instability can be present if there is a tendency toward foot inversion. This situation can be solved in a mild degree of involvement by an elastic bandage on the ankle joint or by taping. However, with a more significant deficit, an elastic peroneal pull or an ankle joint orthosis is necessary to prevent plantarflexion and to stabilize the ankle joint during gait. It is also important to prevent the development of a flexion contracture of the calf muscles and, therefore, for patients in whom this could occur, a brace needs to be used to also prevent plantarflexion during the night. If a more significant knee joint instability is present and the knee gives out into flexion during gait or, in contrast, the knee hyperextends, it is appropriate to support the joint with a bandage or a brace and in this way assist in lower extremity support function during gait. Fig. 1.20.3-4 Example of platform walker use during gait training in a patient with left sided hemiparesis following ischemia in the right middle cerebral artery circulation

In patients after a CVA, some modalities can also be utilized to control pain, decrease spasticity, improve trophicity, reduce edema and improve proprioception. To accomplish this, certain aquatic treatment procedures are appropriate (for example, whirlpool). Electrical modalities can be used to control analgesia, such as in shoulder pain. Patients after a CVA who also show a speech deficit need long-term intervention by a speech pathologist. Speech therapy intervention is an integral component of treatment for patients after a CVA. Loss of communication ability during a symbolic function deficit can be a traumatizing experience for the patient. Such patients should undergo a stimulation program, work with breathing and undergo dysphonia, dysarthria and dysphagia re-education.

Care in the Subsequent Period, Psychosocial Aspects If the patient’s deficit is severe at the time of discharge from the hospital, the patient cannot be transferred to their home environment and continuity of care needs to be ensured for such patients (rehabilitation institutes, skilled nursing facility). When the progression is favorable and the patient has an appropriate home environment, the patient can be discharged to home care. Some patients after a CVA need to utilize caretaking services to a various extent following their discharge to a home setting. Mobility deficits, limited independence and a symbolic function deficit greatly affect the patient’s life. To accept this new reality is one of the hardest tasks that the patient and their caretakers need to deal with. Here, an important role can be played by non-profit and public organizations. In the Czech Republic, the Association for Rehabilitation of Persons after Cerebrovascular Accidents was formed from an initiative of patients after CVA and healthcare workers. Integration back into the society of patients after CVA is the main goal of this organization. The public organization “Afazie” offers programs and counseling for patients after CVA with a speech deficit. In conclusion, it needs to be emphasized that patient care during hospitalization after a CVA is provided by an entire team of collaborating specialists. No less important is the assurance of appropriate care when the patient is being transferred to a home setting. In the entire system of care for patients after CVA, the family physician has an irreplaceable role and often is the first person in contact with the patient during their transition to their home setting and ensures further follow up care. Comprehensive balneologic treatment in patients after a CVA is indicated when the acute stage subsides, especially in cases when it is presumed that the affected functions are recovering. It is mainly beneficial in assisting in the renewal of mobility, improving independence and the patient’s quality of life. A statement from an internist regarding the patient’s ability to handle physical demands from the cardiovascular perspective also needs to be provided.

Comprehensive balneologic treatment is administered based on the recommendations from a neurologist or a rehabilitation physician. It is contraindicated in patients who suffered a CVA more than twice and also in patients with a severe phatic deficit or cardiac insufficiency. In the Czech Republic, balneologic treatment for patients after a CVA is available in Dubi, Karvina, Msene, Velke Losiny, Vraze and Janske Lazne.

1.21 CEREBRAL PALSY Pavel Kolář Cerebral palsy (CP), also known as infantile cerebral palsy (ICP), was originally called Little’s disease after London physician, John Little, who was the first to describe it in 1859. It is defined as the neurodevelopmental and non-progressive involvement of the child’s motor development due to sustained (and completed) prenatal, perinatal or early postnatal brain damage. The damage, which occurs during the prenatal or postnatal period, is not stable and continues to progress. Postnatal scarring, progressive atrophy, gliosis with retraction or cavitation develop. Brain imaging methods may or may not show clear signs of disturbances – microcephaly, macrocephaly, hydrocephalus, porencephaly, agenesis of gyri, lissencephaly, etc. In patients with CP, motor deficits are regularly seen; however, in many cases other systems can be involved as well. Epidemiology Cerebral palsy affects 1.5–2.5 out of 1,000 newborn children. Its incidence has not been linked to a decrease in newborn mortality in recent years. Long-term incidence is being monitored in Australia, Denmark, the USA and, especially, in Sweden. Data about the incidence of children with cerebral palsy in the Czech Republic is quite different. In the Czech Republic, there are 16,000–20,000 children with cerebral palsy and about half of them require continuous rehabilitation. Causes of Onset The causes of brain damage can be diverse. They can be divided into three groups: 1. Prenatal – intrauterine infections are prenatal factors that most often cause brain damage. This category often includes TORCH (toxoplasmosis, rubeolla, cytomegaly, herpes infection). Other causes include developmental malformation, drugs used by the

mother, etc. A number of these factors can lead to various degrees of premature birth. Premature birth is one of the etiological factors of CP for two reasons – it involves delivery of a very fragile head of the baby through a firm birth canal and, at the same time, the child is being born without completely matured biological functions. Genetic factors are being continuously discussed, but so far they are not a proven etiological factor of CP. 2. Perinatal – abnormal childbirths are perinatal factors that most often cause the onset of CP. They result in a brain trauma, especially ischemia and hypoxia. Ischemia and hypoxia selectively damage individual brain structures based on their level of maturity and vulnerability. The key role in brain damage by hypoxia or ischemia is played by excitatory amino acids (aspartate, glutamate) and by the activation of N-methyl-Daspartate receptors with subsequent influx of calcium into the cells, which leads to cell death if cells do not show sufficient activity. In pre-term babies, hypoxia and ischemia are a result of periventricular leukomalacia. In term babies, a selective neuronal necrosis occurs in predilected areas, such as the hippocampus, cerebellum and the basal ganglia. Periventricular leukomalacia (PVL), especially its cystic form (cPVL) is considered to be the main predisposing factor for the onset of CP. Bilateral occipital PVL, identified by an ultrasound during the neonatal period, predicts occurrence of CMO with an almost 99% certainty. 3. Postnatal – these include mainly early newborn infections, most often bronchopneumonia or gastroenteritis. Etiology and Pathogenesis Etiology and pathogenesis of CP are a multifactorial interrelation of individually predicted factors of development and are a subject of constant clinical-epidemiological reassessment. It is primarily a severe prematurity (under 32 weeks of gestational age or under 1,500 grams) that predisposes the immature newborns to cerebral morbidity and severe deficits in neuromotor and mental development due to structural and functional immaturity of the CNS, circulatory instability with a tendency of pressure passive cerebral circulation,

insufficient activity of the anti-oxidative defense system or increased sensitivity in regards to toxic activity of excitatory amino acids. Occurrence of CP and its manifestations vary depending on the level of prematurity or birth weight. Jessen at al. found that over 40% of children with early cerebral mortality, without taking into consideration gestational age or birth weight, later demonstrated a severe deficit in movement functions. They also pointed out the fact that the frequency of involvement in physical abilities does not vary among individual birth categories, but the incidence of involvement of cognitive abilities increases with the infant’s decreased birth weight.

1.21.1 Screening for Risk of CP Cerebral palsy occurs in 8–10% of children born prematurely. Approximately 40% of all children with CP are born prematurely. Screening aimed at neuromotor development is an essential step in timely recognition of children with CNS involvement. Children who show abnormal models during spontaneous motor behavior and with positional reactions are included in a clinical unit known as central coordination disturbance (CCD). It is important to realize that CCD does not mean that the patient will develop CP. Cerebral palsy develops only in a very small percentage of children in whom CCD has been identified. Based on the grade of CCD (grade 3 and 4), repeated neurological assessments are performed and assistive methods are indicated (specific metabolic screening, neurophysiological examination, ultrasound or other imaging methods – CT, MRI, genetic and other testing). A differential diagnosis of motor function deficits (elimination of etiology other than CP) must be performed no later than the child’s adjusted age of nine months. However, the actual identification of CNS involvement needs to be established much earlier, no later than at two months of age. Timely identification of children with CP allows for the indication of early care and means earlier initiation of therapy. This approach can significantly decrease the functional consequences and prevent

motor and cognitive complications of a late diagnosis. During the assessment of postural functions, the question remains how to define the criteria outlining the severity of a deficit that requires the child to be included in therapy. It is important to identify the children with a non-significant central deficit in muscle function in whom spontaneous correction occurs. Vojta’s screening of postural development, as well as, other methods are used in the assessment of newborns and infants at risk who are suspected of delayed psychomotor development (see General Section of the textbook, A. Diagnostic Approaches, Chapter III Neuromotor Development and its Assessment).

1.21.2 Types of Cerebral Palsy and their Clinical Presentation Despite the overall diversity of the clinical picture of CP, usually a movement deficit is the dominant manifestation, which is usually visible in the earliest stages of the disease and poses the greatest problems to the patient. The character of the motor deficit is given by the involved CNS area. Based on the clinical picture (dominating signs), several forms of CP can be distinguished. They develop gradually during brain maturation and have different prognoses, different predispositions for development of contractures and joint deformities and also respond differently to the same therapeutic approaches.

SPASTIC DIPLEGIA It belongs among the most frequent forms of CP. Numerous incidences of diplegia are reported by various authors. The data ranges from 41% to 65%. The severity of motor involvement differs. Spastic diplegia affects patients who achieve independent bipedal locomotion without support, but also patients who are completely apedal. Even if the patient is capable of independent bipedal locomotion, gait always shows pathological features. In a classic form of spastic diplegia, the lower extremities are always more affected than

the upper extremities. Spastic diplegia usually develops as quadriplegia in which neither extremity fulfills its basic function, such as support and grasping by the upper extremity and support and stepping forward by the lower extremity. By gradually including one upper extremity into a specific motor function (even if it is a pathological motor skill) spastic diplegia develops in a stage of triplegia and, by including both upper extremities, spastic diplegia occurs. Often, the plegia is asymmetrical and, in some patients, the dysfunction can result in monoplegia, which can be observed, for example, in unilateral leukomalacia. Spastic triplegia is being reported as an independent form of CP. The number of children with spastic triplegia has increased with the increased number of children who survive significant prematurity. A half of these children demonstrate epilepsy and only a third of them present with normal intellect. It is a very severe motor deficit that is very difficult to influence with therapy. Etiologically, intraventricular bleeding with asymmetrical infarction is common. Severely involved patients who demonstrate a more significant deficit in the upper extremities or in whom all four extremities are equally affected have a bilateral hemiplegia syndrome. It is reported that the incidence of this syndrome is 27% out of all patients affected by spastic diplegia. In most cases, the patients with bilateral hemiparesis also show mental impairment. Approximately a third of children with spastic diplegia are born prior to 32 weeks of gestation, a third are born between 32–36 weeks and a third are born at term. Prematurity is linked to high incidence of perinatal factors. The first manifestations of spastic diplegia can already be observed in the early stages of development through an assessment of the child’s motor behavior. During the first months after birth, especially in congenital motor deficits, a pathological motor pattern is visible, but it is not yet defined. It is non-specific or common to a number of later developing forms of CP or other syndromes. The clinical picture becomes more distinct only during the second or the third trimester after birth.

In any case, motor development lags behind the quality of motor patterns that are typically observed during physiological motor development (see General Section of the textbook, Chapter III Neuromotor Development and its Assessment). All children with spastic diplegia present with a pathological postural foundation followed by pathological phasic mobility. The normal developmental pattern of eye-hand-mouth is not present; however, so called dystonic attacks are observed. They occur following acoustic or visual stimuli linked to an emotional component – when the child attempts to accomplish a specific task, for example, when grasping an object being passed to them. Dystonic attacks present mass generalized movements of the entire body in the patterns of tonic neck, tonic labyrinthine or other primitive postural reflexes or in their various combinations. Dysmorphic features such as a gothic palate or pseudoharrison’s ridge below the ribcage (it is present in rickets) are typical in children with spastic diparesis. In more severe forms, approximately 20% of children with spastic diplegia show some signs of rigidity (more commonly in flexion types).

SPASTIC HEMIPLEGIA Hemiplegia is a unilateral deficit in mobility most often spastic in nature. The entire half of the body is affected, including the facial and hypoglossal nerves. Spastic hemiparesis can be divided into congenital and acquired. If the acquired hemiparesis develops in infancy, it is difficult to distinguish it from congenital hemiparesis, especially if the episodes were present prior to the hemiparesis being identified. Pseudoflaccid stadium and central paresis of the facial nerve are more likely to indicate acquired hemiplegia. Acquired hemiparesis of vascular etiology requires a specific diagnostic and treatment approach. In contrast to congenital hemiparesis, aphasia also occurs in left-sided involvement. However, it is also possible that when the genotypically dominant hemisphere is affected, no developmental delay may be observed. Epilepsy poses a significant

complication in children with spastic hemiplegia. It affects more than one third of patients. The seizures are focal or secondarily generalized. Most of them can be controlled by treatment. The presence of epilepsy is significantly linked to mental retardation. More than 50% of children with epilepsy suffer from mental retardation. In patients with hemiplegia, mental retardation can be identified in almost half of patients; in children without epileptic seizures, about one third presents with mental retardation. The severity of hemiplegic involvement, which is distinguishable mainly from the upper extremity involvement, is also closely linked to mental retardation. Hemiplegic form of CP affects more boys than girls and right-sided hemipareses occur somewhat more often. Divergent strabismus may also occur. Homonymous hemianopsia can also be present (it can nearly be eliminated by treatment). The growth of the hemiplegic extremities is delayed in comparison to the healthy extremities. Hemihypogenesis is more pronounced on the upper extremity, which is almost always more affected than the lower extremity. It is measured based on the severity of involvement. The extent of the involvement can be assessed by the ability to perform an isolated movement and by the ability to assume a joint position that is developmentally typical of a younger age. In a mild form, the fingers can perform isolated movements. In a moderate form, only the entire extremity can be moved and in a severe form, no isolated movement of the hand or any other upper extremity segment is possible. Isolated movements are also linked to the ability to attain a position in a movement segment. A child with spastic hemiparesis attains newborn positioning, which includes shoulder protraction, adduction and internal rotation, elbow flexion and protraction, wrist flexion and ulnar deviation, and finger flexion. Active shoulder flexion, abduction and external rotation and elbow extension and supination are assessed. In a hand, wrist extension, thumb opposition and abduction and finger extension are being assessed. The more the child is able to attain a position close to physiological development, the lower the level of their involvement. In severe forms, the patterns typical for a newborn persist.

In children with spastic hemiplegia, not only the bones, but also the muscles are delayed in development and hemihypogenesis of the corresponding side develops (leg length discrepancy is on average 1.5 cm with 1–3 cm difference in circumference).

CEREBELLAR FORM A cerebellar form as an individual occurrence is almost never present. Prenatal factors contribute to a great extent on the onset of involvement. In the majority of children with a cerebellar syndrome, mental retardation is also observed but it usually is not severe. Sometimes, a cerebellar syndrome is accompanied by autism. A cerebellar form of CP develops in relation to brain maturation and the specific signs of cerebellar involvement appear gradually based on brain structure maturity and their inclusion within motor function. Clinical signs, which include muscle hypotonia, trunk ataxia, hypermetria, intention tremor and trunk ataxia all occur gradually during the process of CNS maturation. Clinical Picture Hypotonia Central hypotonia, and with it, related delayed locomotor development dominate the clinical picture of a cerebellar syndrome. All muscles are flaccid and the joints can be bent to large angles. Joint excursion and muscle flexibility, as criteria of muscle tone, are manifested by scarfs sign in which the patient is able to cross their arms around their neck like a scarf. It is assessed whether the elbows are away from each other, above each other or are crossed over each other. Another sign is the drawing compass during which the lower extremity can be bent at the hip joint all the way to the trunk. In sitting, a child’s trunk can be bent to their lower extremities, which is known as the armadillo sign. Next, the flexibility of the knee and elbow flexors and extensors is being assessed followed by ankle range of motion, hand, thumb and finger flexibility, arm raising test, etc. Hypotonia in childhood age is not the only manifestation of

cerebellar involvement, but often, it is a mere transitional stage of CP. Quite different syndromes may arise from hypotonic forms. The onset of hypotonia is time-dependent on CNS maturity or rather its immaturity. Hypotonia in infancy always needs to be assessed for differential diagnoses. Some level of relative hypotonia can also be considered normal between 2–5 months of age. Joint range of motion and muscle flexibility are not only dependent on the extent of the pathological process, but also on the physiological state of the nervous system and its developmental stage. Reflexes are preserved or only slightly decreased. Thirty percent of children exhibit epilepsy. Dysmetria This is the incorrect targeting of a movement. The direction of the movement is correct, but the end of the movement shows hesitation. Thus, movements become inaccurate. Intention Tremor This is a tremor observed prior to reaching the target of movement. The movement is rough, irregular, rather slow and with large amplitudes. Typically, an intension tremor subsides prior to movement completion. It is seen in the upper and lower extremities. Trunk Ataxia It is a lack of coordination of the trunk caused by a disproportion between contraction intensity and the type of movement. Asynergy Asynergy is a deficit in cooperation of various muscle groups. Adiadochokinesis Adiadochokinesis describes the patient’s inability to perform alternating movements. Cerebellar Diplegia The cerebellar form as an individual entity is rare. Often, spasticity is found along with a cerebellar syndrome. Given the extent of motor involvement, it is classified as a separate form of CP.

This form demonstrates typical symptoms. The hypotonic picture begins to show spasticity in the second half of the first year of life. Spastic flexion phenomena are observed and extension phenomena are usually not present. The increased tone begins especially distally, most often in the triceps surae, which later develop contractures. The picture of primitive reflexology lacks or shows a decreased tonic grasp of the lower extremities. Trunk lateral flexion as a response to unilateral paravertebral skin stimulation is either absent or decreased, thus, the Galant reflex is decreased. Pseudoclonus emerges with the development of distal spasticity. Motor development depends on the severity of involvement, which varies in this form, similar to spastic diplegia. In an ideal scenario, the children can ambulate at two to three years of age. More severe forms achieve verticalization between the fifth and the tenth year at the latest. Verticalization and bipedal locomotion are not achieved in the most severe forms.

DYSKINETIC FORM OF CEREBRAL PALSY A dyskinetic form of CP is characterized by abnormal movements or postures. The corresponding form of CP is classified based on whether hyperkinesis or dystonia predominate. In the hyperkinetic form, irregular, repetitive and excessive movements dominate the clinical picture. In CP, these movements are most often divided into two forms: Athetosis – the most typical; described as writhing, inconsistent, fluctuating and involuntary movements that affect proximal aspect of extremities Chorea – it is distinguished from athetosis mainly by the speed of involuntary movement; distal aspects of the extremities are primarily affected A dystonic form is characterized by abnormal changes in muscle tone resulting in typical changes in body posture. The dystonic subgroup also presents with non-volitional movements, but not nearly

to such a great extent as the hyperkinetic subgroup. An isometric contraction disturbance is one of the main problems that are characteristic for a dyskinetic syndrome. Therefore, volitional movements recruit muscle groups from the entire body. An athetoid syndrome can develop from a hypertonic, as well as, a hypotonic syndrome and it is observed in the first three months of life. Most future athetoses develop from neonatal hypotonia. Hypotonia is mainly axial (trunk) and proximal. Trunk hypotonia can be confirmed by the Landau reaction. In the third trimester, an infant’s head and pelvis almost flaccidly hang toward the mat with trunk instability, which is not seen as much in other syndromes. The trunk turns toward the jaw side. The extremities are flexed, however, a sudden opisthotonic posturing can occur with the lower extremities positioned in extension. In contrast to spastic diplegia and hemiplegia, athetoses show more diffuse involvement throughout the entire movement system. Trunk instability is clearly manifested during axillary suspension. During a traction test, no neck flexion activity is observed during the entire first year. During this test, the lower extremities remain in flexion. In the first three months of life, dyskineses have yet to manifest themselves. In this period, primitive reflexology and central acoustic deficits can be preliminarily used, which are often associated with dyskinesis. The inability to elicit the acoustic-facial reflex is a warning sign. Disrupted dynamics or the persisting presence of primitive reflexes and a differential diagnosis together predict the severity of the injury. Persistence and an exaggerated response to the Galant reflex are typical signs of dysfunction. In contrast to spastic forms of involvement, the grasp reflex of the lower extremities is accentuated and persists after the first year of life or even for several years. In contrast, reflexive grasp of the upper extremities is diminished and ceases as early as in the second trimester. The cause is a predominant

tendency toward finger extension, especially the thumb and the index. The Moro reflex persists into the third trimester and becomes a stereotypical response to various external stimuli. The heel reflex already cannot be elicited in the second trimester. The suprapubic and crossed extension reflexes become absent in the first trimester. Gait automatism persists for a long time, which is known as stepping (child moves as if to push off). The Babkin reflex persists longer than normal. Lower extremity stretch reflexes are normal or increased. The first signs of future dyskinesis can already be recognized during the second trimester. Dystonic attacks begin to emerge. Based on external and sometimes also internal stimuli, the infant reacts with a hypertonic change in muscle tone, usually in the pattern of the tonic neck reflex (TNR), the tonic labyrinthine reflex (TLR) or opisthotonus. These are present mainly in athetoses developed from hypertonic stage. In children with hypotonia, dystonic attacks are less pronounced. They are provoked by a sudden change in position. Dystonic attacks also develop as a reaction to sounds. The children struggle with head control. In addition, significant changeability in muscle tone is observed. At rest, the infant is hypotonic and suddenly as a reaction to external stimuli hypertonia accompanied by opisthotonus may occur. When it subsides, hypotonia dominates, especially in the trunk. The severity of hypotonia shows a positive correlation with the severity of involvement. In addition to dystonic attacks, athetosis of the distal lower extremities emerges in the third trimester. Swallowing poses significant problems. During swallowing, tongue support against the upper palate, which the child is unable to accomplish, is important. This results in malnutrition. Stimulation of the orofacial region elicits dystonic postures. Similarly, every attempt at movement results in grimacing. Feeding dysfunctions are most pronounced in the third trimester. In the past, many children died during this period. The children cannot chew and they constantly salivate. Their biting is homologous without lateral co-movement of the lower jaw. In some

children, protruding of the tongue occurs long-term in a similar fashion as can be observed in a newborn as a reaction to unpleasant gustatory stimuli. This phenomenon is the so called “tapir’s mouth”. Food that is moved during feeding accentuates tongue protrusion. The clinical picture also includes autonomic lability (increased perspiration) and emotional instability. Mental abilities are usually normal. Some children show above average intelligence. Scenarios in which mental involvement is present usually include athetosis combined with another type of involvement (cerebellar, spastic, etc.). Postural dysfunctions cause a vocalization deficit and a significant delay in speech development. The patient shows difficulty with pronunciation and articulation. The speech is throaty, explosive and less intelligible. When the child attempts to speak, they breathe in and the entire posture reflects co-movements. Given the normal mental development, the patient’s speech is significantly expressive, meaning that they can express a large content by using few words. The children show decreased facial expressions.

MIXED TETRAPLEGIA Mixed forms of CP include patients in whom more forms of central involvement are combined. Often, for example, spastic diplegia, ataxia and dystonia or spasticity and dyskinetic syndrome are combined. It is usually a diffuse brain injury that also includes significant mental retardation – most often at the level of oligophrenia. This can also include children whose psychological development is not as severely involved. Most of such children can only live in an institution; none of them will be able to live independently in society in the future. The patients show a decreased life span. More than 50% of the children have epileptic seizures that are mostly severe in intensity and are difficult to control by medication. Central dystrophy is typical as a result of a swallowing deficit. The neurological finding corresponds to the type of involvement. In some cases, amaurosis or mostly divergent alternating strabismus

are present. As far as kinesiologic development, upright posturing shows significant delay. For a long time, it remains at a newborn level.

ATONIC DIPLEGIA Sometimes it is referred to as an atonic-astatic type of CP according to Forster. In this type of CP, the cerebellum is not affected, but the brain’s frontal lobes are involved. Some signs are similar to a cerebellar syndrome, especially significant hypotonia. The scarf, drawing compass and armadillo signs are present. Next to hypotonia, this type of diplegia presents with a more severe degree of mental involvement, usually at the level of oligophrenia. In the first months, the children are considerably apathetic, not interested in their surroundings, do not reach for objects and do not recognize the mother. They react to external stimuli by dystonic attacks. Typically, the postural pattern practically does not include the lower extremities until the third trimester. In the first year, the child lies with the thighs abducted to 90 degrees. Plagiocephally occurs as a result of being in a supine position. Nystagmus is typically not part of the child’s clinical picture. The dive reflex is associated with forward flexion of the upper extremities with clasped hands. During axillary suspension administered in the third trimester, the lower extremities remain in flexion and muscle tone increases.

1.21.3 Rehabilitation in Cerebral Palsy DESIRED OUTCOME AND COPING PROCESS DESIRED OUTCOME Cerebral palsy includes patients with varied severity of involvement. Rehabilitation therapy depends on the extent of involvement and the “desired outcome”, which can be expressed by the term treatment

expectation. Given the extent of motor and psychological involvement, the children can be divided into several groups and each group needs to be approached in an individual and specific way: Patients with a Severe Motor Deficit and Severe Mental Retardation Verticalization should not be expected in such patients and, in the majority of cases, sitting is also not accomplished. They are fully dependent on the care from others. The main goals for such patients include prevention of contractures and joint deformities, prevention of pressure ulcers and chest wall deformities that make breathing difficult. Treatment mostly consists of rehabilitation care and prophylactic methods. Patients with a Severe Motor Deficit and only a Moderate or Mild Degree of Mental Retardation In such patients, it is especially important to begin rehabilitation treatment as soon as possible. Contractures and neurogenically developed deformities pose the main problem. Even with intensive, correctly administered and timely initiated physical therapy, the effects of spastic or hypotonic manifestations cannot be prevented. In such children, botulotoxin is administered. Surgical procedures involving the musculoskeletal system are also performed. The indication for botulotoxin and surgical interventions must be based on kinesiologic analysis and the evolving morphological findings. Rehabilitation of cognitive functions plays a significant role. Patients with a Moderate Motor Deficit and only a Mild Degree of Mental Retardation The population of children with CP also includes individuals with moderate motor involvement, but preserved mental capacity. The patient’s ability to cooperate is a great advantage. They are able to obtain standard education and their integration into regular schools is very important. However, they are sometimes denied this option due to their significant motor deficit. Patients with a Mild Motor Deficit and Mild Degree of Mental Retardation

This group of patients is not too common. Mild motor involvement in CP is usually not linked to mental retardation. However, mild mental or cognitive deficits can be identified in a certain percentage of patients. Cognitive rehabilitation is very effective and sometimes can completely improve and accelerate their mental and thus motor development. Not independence, but rather integration is the goal for this group of patients. In the majority of patients, even the motor deficit can be significantly improved. With comprehensive rehabilitation and meaningful school integration, the patients may not have to become dependent on the social system. Patients with a Mild, Isolated Motor Deficit without Signs of Mental Retardation These are patients with mild hemiplegia, spastic diplegia or monoplegia. Affected children are highly cooperative and the motor and cosmetic deficit can almost be eliminated through comprehensive rehabilitation treatment including orthopedic intervention.

COPING PROCESS Care involving a disabled child poses high demands on the family. Several principles can be followed to manage this challenging life situation: Parents should know as much as possible about their child – the nature of the child’s illness or involvement, which will help their understanding and ability to help. The child’s deficit is not a misfortune, but rather a task – an active approach toward the child is only possible if the parents accept the situation as a life challenge and a mission. The parents should be devoted, but not victimized. The parents should be realistic, including future perspective – it is important for the parents to accept the fact that the child will progress at their own pace and according to their own order. The child does not suffer from their disability; we usually assume that the affected child physically or mentally suffers. However, the child does not perceive their condition as such.

All the care for a child with a disability has to occur at the right time and in an appropriate extent. Everything that we do with a child or are planning to do is done at the right time and an appropriate extent. Rehabilitation in Cerebral Palsy Treatment rehabilitation for patients with CP represents an essential and decisive therapeutic approach. The effect of treatment rehabilitation and prevention of secondary complications are to a great extent dependent on its timely initiation. This places a high demand on timely identification of the deficits. Given the fact that the indicated physical therapy is based on symptoms, treatment is initiated at a time when the diagnosis is not fully established. The indications include more significant deviations from normal development (CCD grades III and IV). Timely initiation of treatment rehabilitation is also significant due to the very dynamically occurring processes of CNS maturation (synaptogenesis, myelination, apoptosis, etc.). At this time, the neuroplasticity of the brain tissue can be intensely utilized. Delayed initiation of physical therapy also leads to fixation of developmentally old motor patterns (ATNR, STNR, etc.), which the child uses as a means of mobility. Vojta’s reflex locomotion is most often implemented at a time when the child is still unable to cooperate. Afferent stimulation of trigger zones is used to activate the CNS and facilitate movement patterns that are part of physiological development. Handling plays a very important role during the initial phases of development (for details see the General Section of the textbook, B. Therapeutic Approaches, Chapter 1.3.1 Vojta’s Principle: Reflex Locomotion). Vojta’s Reflex Locomotion in Children with Cerebral Palsy Indication for Vojta’s reflex locomotion is linked to a number of questions that are the causes of errors during its application. Frequency and Exercise Time The frequency and duration of exercise depend on the patients’ age and must be adapted to the patient’s level of tolerance. In the first months of life, the exercise is indicated 3–4 times per day and exercise

duration is limited to no more than 10 minutes. It is important that the child does not fall asleep immediately following exercise (this means that the patient has been overexerted). After 1 year of age, the number of sessions is decreased to two and their duration increased to 10–15 minutes. Parent and Child Education The therapist’s relationship with the child’s parents and the child themselves is one of the prerequisites for a successful therapeutic outcome. Selection of the therapeutic method by the patient’s family should be deliberate. Last but not least, the therapist’s selection of an appropriate psychological approach not only toward the parents, but also toward the child, is important so that they are convinced of its importance and positive effects. Timely initiation of therapy is a decisive factor for successful therapy and it should be initiated at the newborn stage and not until after 3 months of age. The parents need to be educated on the following: What is Vojta’s method? Why it is administered. The way it is administered? Which movement reactions are desirable? Which movement reactions are incorrect? Which associated positive or negative reactions can they expect? What are the intensity and time demands of therapy? The parents need to be informed that they themselves will be regularly exercising with the child several times per day for several months and, with severely involved patients, even for several years. The therapist becomes their teacher, adviser and partner. Usually, the child’s mother exercises with the child, but assistance from other family members is desirable. The parents learn to perform the indicated program, as well, as manual and palpation skills. They learn visual skills to recognize the desired movement reaction. They attend regular check-up sessions and the children’s current condition and the parent’s learned skill are a determining factor in selecting the time between the check-ups. No less important is their confidence in

whether or not the care administered by them is performed correctly. Methodology To correctly indicate and administer Vojta’s reflex locomotion is an essential, but also quite challenging skill. The administration depends on the therapist’s skills and experience. The manipulation itself and communication with the child as well as the selection of correct positions and stimulation zones are the key areas. At a time when the child can begin to cooperate, reflex locomotion is complemented by core mobility training. Of course, this depends on the severity of involvement. It includes the following practice: Selective mobility Ability to obtain information by touching an object Self-assessment of body position and orientation within a body schema Ability to plan a movement that is adequate to the situation Ability to gather information by visual observation Development of selective attention Neurodevelopmental Treatment Approach in Children with CP A neurodevelopmental treatment is always based on a well performed evaluation. The evaluation focuses on the child’s comprehensive assessment. It is identified which activities the child masters by themselves, which activities they need help with and which activities they are unable to achieve at all. Their movement patterns, postural tone, associated reactions and accompanied issues are examined. Next, the main problem is identified and an appropriate therapeutic approach selected. The goal of therapy is to improve the child’s selfcare and independence. The exercise is implemented into activities throughout the day and the activities are modified to meet the therapeutic goal. Prevention of deformities, providing external support and facilitating the ease of an activity are accomplished with the help of assistive devices. The parents’ role is important as they perform everyday activities according to the therapist’s instructions. To reach an optimal result, the same approach needs to be adapted by all other persons who take care of the child, including hospital staff,

teachers, counselors, etc. The physical therapist performs the so called handling, which is a set of therapeutic techniques. The therapist teaches the parents how to lift the child, carry them, position them, which positions to select during the day or during play time, etc. It is important to motivate the child according to their age and developmental level. In a small child, learning spontaneous movements are a priority, while volitional control of movement is the goal for pre-school and school age children. Children up to age 1, exercise with the therapist three times a week for 20–30 minutes and additional time is spent on parent education. For preschool children, the frequency and nature of exercises is established based on individual needs. For school age children, the treatment is aimed at prevention of pathological changes as a result of limited movement activity during class time. Appropriate movement-oriented afterschool activities are selected. Petö Movement Therapy This method is widely used during therapy for children with CP but also in other neurological diseases. The founder, Andreas Petö, based this method on the idea that learning and adaptation processes are disrupted and that a deficit in learning is the foundation for movement dysfunction. It is administered mainly in groups because they have stimulatory and motivational effects and the children learn from each other while developing social relationships. The exercises are performed using furniture because of its activating character, improved quality of movement and facilitation of spatial orientation. This method also includes therapy for cognitive functions. Exercises Aimed at the Development of Somesthesis To develop somesthesis, exercises are selected based on their ability to facilitate the patient’s full awareness of their movement and on when the patient perceives increased muscle tone or exerts unnecessary muscle activity. The exercises do not prescribe how to breathe or walk, sit or stand. The goal is to learn to distinguish activities accurately. The exercises are performed slowly and repeated several times while the patient attempts to fully perceive their position and movement. The patient is encouraged to sense their proprioception and

exteroception. Simply stated, through these exercises, the patient is asked to “hypertrophy” their sensory perception and learn better movement differentiation (selective movements) in this way. For example, one of the exercise principles includes practicing isolated movements in differently challenging postural situations. Balneologic Treatment Balneologic treatment is an integral component of comprehensive therapy for patients with CP and is beneficial following certain corrective orthopedic procedures. It is indicated especially for patients who ambulate independently and do not present with significant psychological deficits. It is also beneficial when it is presumed that the treatment will contribute to maintaining the patient’s self-care or work potential. The treatment mostly includes movement activities, Vojta’s method and balneotherapy. Comprehensive balneologic treatment according to the indication list is provided based on the recommendation by a neurologist or a rehabilitation physician for patients up to 21 years of age. In the Czech Republic, balneologic treatment for patients with CP is provided in Janske Lazne, Dubi, Klimkovice and Vraz.

1.21.4 Cerebral Palsy from the View of an Orthopedic Physician Alena Schejbalová Orthopedic surgical intervention is most often indicated in the spastic form of CP and, with a great deal of caution, in mixed forms of CP in which the dyskinetic form cannot dominate over the spasticity. Patients with CP most typically show hip adduction and various presentations of flexion and internal rotation. The prevalence of hip subluxation and dislocation is 2.6–28% based on the type of CP and severity of involvement. Knee joints are typically flexed, less often extended and the ankle demonstrates pes equinus. Often, the foot is in valgus with a steep talar alignment. The goal is to allow a child’s verticalization, facilitate standing,

walking and self-care. For this reason, most surgical procedures are performed on the lower extremities. In patients with a quadriplegic form of CP who will never be able to achieve verticalization, the goal of surgical interventions is to at least allow for basic hygiene in bed, sitting or movement in a wheelchair. Erect standing is possible with plantigrade foot alignment and knee and hip extension. The spine, pelvis and hips are viewed as one unit. Since all individual areas affect each other, the ankles, knees and hips are treated as a whole. In many cases, application of Botulotoxin Type A can postpone a surgery. Especially for the hip area, it is recommended to consider simultaneous application of Botulotoxin Type A and an orthosis to maintain symmetrical alignment and improve centration with the help of a modified abduction splint with a lumbar socket. For an orthopedic surgical intervention to be successful and achieve planned verticalization, the retardation quotient needs to be followed. Orthopedic surgeries can be divided into procedures involving the following: 1. Muscles and tendons 2. Joint 3. Bones

INDICATIONS FOR SURGERY INDICATIONS FOR SURGICAL PROCEDURES IN THE HIP JOINT AREA A surgical procedure involving the muscles is indicated with positive clinical findings that include lower extremity alignment in adduction, positive Thomas test for the iliopsoas and positive Ely’s test for the rectus femoris and a presentation of lateral migration on an x-ray film. During an open adductor tenotomy, which is the most common surgical procedure involving the hip muscles, a tenotomy of the adductor longus, gracilis, or possibly a resection of the adductor magnus is performed. During a closed adductor tenotomy, the connective tissue at the origin of the adductor longus is the most

commonly resected area. A combination of surgical procedures, such as tenotomy of the adductors, the iliopsoas and even the rectus femoris is very effective in patients with a more pronounced lateral migration (percentage of the ossified part of the femoral head that is not covered by the acetabulum) until the age of six. Reposition and prevention of future lateral migration can occur. The procedures involving the hip musculature are fundamental procedures and may serve as preparatory procedures for hip joint repositioning (Fig. 1.21.41). Fig. 1.21.4-1 Neurogenic left-sided dislocation

In patients with CP, a procedure involving the bones of the hip joints is indicated based on the degree of lateral migration in the area of proximal femur, pelvis, and also possibly in combination with surgical reposition. Subtrochanteric derotation osteotomy is appropriate either as an individual surgical procedure to correct hip joint anteversion or as one of the steps in combined surgical procedures to correct hip joint geometry. Varization osteotomy should be contraindicated if the gluteal musculature is insufficient prior to surgery. Acetabuloplasty (Dega, Pemberton, Wiberg) is indicated also as an individual procedure when the muscle imbalance has been corrected following a hip joint subluxation in children with CP. The abductors, which are up to 85% insufficient in patients with CP, are not negatively influenced. It can be beneficial for children up to 10

years of age and also for older children due to the pliability of the pediatric bone without the use of internal osteosynthesis. A pelvic osteotomy (Steel, Ganz) is performed in adolescents with a tendency of hip joint lateralization. Palliative procedures are often the only solution to improve caretaking for patients with a quadriplegic form of CP with long-standing neurogenic hip dislocation. In children, we prefer the palliative Schanz abduction osteotomy to a proximal femoral resection, which is recommended by a number of international authors.

INDICATIONS FOR SURGICAL PROCEDURES IN THE KNEE JOINT AREA Flexion contractures or the lack of active extension with patellar tendon pulling are the most common problems in the knee joint area (Fig. 1.21.4-2). Surgical strategies include an elongation of the medial hamstring or a combination of the medial and lateral hamstrings and a correction of the patella’s high position by shortening of the patellar tendon or its transposition. Patellar distalization is recommended at the earliest, 6–12 months following knee flexor elongation, if the patellar tendon is elongated and passive knee extension can be accomplished. Knee flexion deformities in patients with CP significantly impede the patient’s standing and ambulation. Sitting also poses a problem because with a knee flexor contracture due to hamstring tightness, the pelvis tilts posteriorly followed by a kyphotic alignment of the back and subsequent development of a fixed thoracolumbar spinal kyphosis. During a flexion contracture, the semitendinosus and the gracilis are usually elongated in a “Z” fashion while the semimembranosus and the biceps femoris are elongated by incisions in their aponeurosis. In large contractures, the fixation should be modified after several days and the orthoses should be gradually tightened into greater knee extension to prevent possible overstretching of the nerves. Transposition of the patellar tendon possibly together with a bone block can be performed when the child’s growth has been completed to decrease the risk of genu recurvatum. During the growth period, the patellar tendon can be

shortened by plication. A supracondylar deflexion osteotomy is indicated for a rigid flexion deformity. Knee extension contractures are less frequent because the child ambulates with an extended knee joint. This is usually caused by spasticity of the quadriceps femoris. Based on the severity of the contracture and simultaneously the flexion alignment of the hip joints, a distalization of the rectus femoris proximally or a distal shift or even its transposition toward the medial flexors or biceps femoris are recommended. Genu recurvatum is addressed rather conservatively by using orthoses. Fig. 1.21.4-2 Flexion contracture of the knee joints, lack of active extension

INDICATION FOR SURGICAL INTERVENTIONS IN THE ANKLE AND FOOT AREAS Pes equinus is the basic ankle deformity in patients with CP (Fig. 1.21.4-3). The Silfverskiold (Strayer) test determines whether a triceps surae release is the correct indication. When the test is positive (pes equinus is eliminated with knee flexion) a gastrocnemius release is indicated – an operation developed by Strayer in which the soleus remains intact. With a partially positive result of this test, it is

beneficial to release at the region of the common aponeurosis of the gastrocnemius and the soleus – an operation developed by Baker, or possibly Vulpio. When the test is negative, an Achilles tendon elongation is recommended. Pes calcaneus can occur due to impetuous elongation, but also as a result of Vulpio’s surgery. This deformity can lead to a loss of the patient’s stability. An Achilles tendon shortening or possible triple arthrodesis may not completely improve this situation. Fig. 1.21.4-3 Pes equinus in spastic diplegia

A foot alignment in varus can be corrected in younger children by hemitransposition of the anterior tibialis tendon and in children older than nine by a complete transposition of the above mentioned tendon to the lateral aspect of the foot to the base of metatarsals IV or V. With a simultaneous excavation of the sole of the foot, a surgery based on Steindler is indicated, which involves the plantar aponeurosis and short foot muscle release. With equinovalgus deformity, which is the most common ankle deformity in patients with CP, the equinus foot alignment is corrected

by using the above mentioned procedures (Fig. 1.21.4-4). In children older than six years of age, Grice talocalcaneal arthrodesis is one of the essential procedures to achieve foot stability. In principle, this surgery involves implanting a graft (from the tibia or the pelvis) between the talus and the calcaneus in the area of the sinus tarsi where the alignment of the talus and the calcaneus is corrected. In older children, this stabilization surgery can be expended through Young’s dynamic procedure (anterior tibialis muscle transposition across the navicular bone). Implantation of a bone graft is possible only in a correctly controlled foot and these procedures cannot be indicated in rigid deformities. Plantigrade alignment in rigid feet can be achieved by triple arthrodesis with closing-wedge osteotomy based on the type of deformity performed when the growth has been completed. Fig. 1.21.4-4 Pes equinovalgus with collapsing at the Chopart joint

INDICATIONS FOR SPINAL SURGICAL PROCEDURES In patients with CP, the incidence of scoliosis reaches 25%. In children with severe tetraplegic form of CP, structural scoliosis occurs in 78% (Fig. 1.21.4-5). Indications for surgical intervention include the degree of scoliosis during which a restriction in respiration occurs and decreased trunk balance in sitting is seen (over 10 years of age, greater than 40 degrees). The procedure consists of a long intertransversal

fusion including the lumbar spine and transpedicular instrumentation (T2-L5). Following the surgery, the patient completes the treatment by wearing a TLSO, which can be equipped with a neck socket depending on the involved levels. A surgical option is contraindicated for patients with a severe mental deficit, with disturbances in nutrition and a vital capacity lower than 20–30%. Instead, it should be indicated when muscle balance and stabilization of hip joints has been assured. Fig. 1.21.4-5 – Scoliosis in spastic tetraplegia

INDICATIONS FOR UPPER EXTREMITY SURGICAL PROCEDURES Surgeries in the upper extremities are indicated in 3–5% of the patients with CP. The indications for surgical interventions usually include patients with a hemiparesis, between the ages 6–12 and with an IQ above 50. The decision in favor of surgical intervention is based on three categories:

1. Hygiene – with significant wrist flexion, the skin can be macerated 2. Cosmetic appearance 3. Function Dynamic transfers can be considered if at least good passive cooperation exists, i.e. the patient can hold an object in their hand and stabilize it so that it can be used by the other hand. In more severe involvement, a release and joint stabilization may be indicated. In an elbow flexion contracture, a downward shift of the muscles from the medial epicondyle is recommended (pronator teres, flexor digitorum superficialis) or a downward shift of the muscles in the area of proximal ulna and the interosseous membrane. This leads to a release of wrist extension. In the wrist area, elongation of the flexors is recommended and transposition of the flexors and extensors can be considered. Wrist arthrodesis is indicated in significant flexion deformities with minimal function when growth has been completed. Muscle and tendon surgeries in the upper extremities should be performed by six years of age. Following surgery, the patient should be provided with assistive devices (splints, orthoses, orthopedic footwear). Only correct indication, a correctly performed surgical procedure and intensive, well-guided post-operative rehabilitation can lead to successful treatment in CP. With indications for surgeries, the orthopedic perspective needs to be respected together with the neurological and developmental perspectives (Vojta’s locomotor stadium). Although rehabilitation will always be the fundamental treatment in CP, the orthopedist, while respecting all these principles, can contribute to the child’s improved integration into the society by surgical procedures. Orthopedist – surgically addresses muscle contractures and bony deformities developed by the pull of spastic muscles. Timely surgical intervention involving muscles can prevent the formation of bony deformities (hip joint dislocation, patella alta neurogenes, Chopart joint dislocation, angulation of the tibial plateau, etc.). Surgical procedures are most often performed between the ages of 4–7 and when growth has been completed. Several factors need to

be considered prior to selecting and indicating the surgical procedures – consequences for the child’s mobility, prognosis of motor development, psychological tolerance of the procedure, etc. The orthopedist, together with a physical therapist, also addresses the application of orthoses. Neurosurgeon – in certain cases, selective dorsal rhizotomy is indicated to decrease spasticity. Neurologist – prescribes Botulotoxin. It is indicated for abnormal spastic or spastic-dystonic contraction that is responsible for a significant functional limitation, it is localized to a group of muscles and presents as a dynamic functional contracture. The indication for these approaches must be coordinated, should be referred to specialized workplaces and should not be addressed haphazardly.

1.21.5 Neurosurgical Treatment Pavel Kolář In those forms of CP that show a significant regional spasticity resulting in a limited function of the upper extremities, a neurosurgical method designed to decrease spasticity known as selective dorsal rhizotomy (SDR) is performed. During this procedure, 40–50% of the fibers of the posterior spinal roots are severed, which affects the afferent component of spasticity. It is most often performed in diplegic and tetraplegic forms of CP, but also for spasticity of a different origin (for example, Wilson’s disease). It can be used only for a selective group of patients. It is an extensive and complicated surgery that poses a risk for complications. The most serious complications include sensory loss, bladder innervation dysfunction or erectile dysfunction. Abnormal sensitivity in the soles of the feet is a frequent complication and should resolve within six weeks. Similarly, temporary bladder dysfunction can occur. Other complications include hip joint dislocation, scoliosis, liquorrhea, meningitis or an infection at the incision site. Some patients can develop pneumonia or a urinary tract infection. Correct indication for

this surgical procedure is the main presumption in avoiding complications.

INDICATIONS AND CONTRAINDICATIONS OF SURGICAL INTERVENTION Selective dorsal rhizotomy should be “selective” not only in the selection of the afferent nerve fibers, but also in the selection of appropriate patients. It certainly is not a good option for every patient with spasticity. The selection of a patient for SDR must be based on teamwork. This team is formed by a neurosurgeon, neurologist, orthopedist and a rehabilitation specialist. A pediatrician should also contribute their opinion. The New York Institute for Neurology and Neurosurgery classifies patients appropriate for SDR across two categories based on the severity of involvement: a. Patients, whose spasticity functionally limits their activities of daily living and, at the same time, have enough strength to complete these tasks. These are usually patients without mental retardation or with only mild mental retardation. It is presumed that these patients will actively participate in therapy after SDR. b. Patients who are non-ambulatory, whose spasticity prevents sitting, hygiene, dressing, etc. In such patients, the options in rehabilitation treatment and rehabilitation care are limited. Selective dorsal rhizotomy is also indicated in patients who, as a result of spasticity, show painful deformities, especially in the hip joint, and these deformities are difficult to address by an orthopedic intervention. Many such patients show severe mental retardation. The goals of surgical procedures in such group of patients include decreasing pain, improving personal comfort and sitting stability, as well as, facilitation of the difficult daily rehabilitation regimen. The main reason for surgery in such patients is then palliative.

1.21.6 Botulotoxin in the Treatment of CP

Pavel Kolář, Josef Kraus Today, Botulotoxin injection is a common component of treatment for excessive muscle activity. Excessive muscle tension is a component of many diseases. The examples include diseases with focal dystonia, blepharospasm, sphincter dysfunction or spastic dystonia in CP. The treatment goals include: decreasing tone and uncontrolled contractions, improving function and mobility, preventing complications (contractures and deformities, decreasing pain and spasms), facilitating rehabilitation exercise, improving the patient’s, caretaker’s and the family’s quality of life. Botulotoxin Type A is one of the available effective medications. Botulotoxin is a protease eliciting chemodenervation. Muscle contraction occurs when acetylcholine is released from the axonal nerve ending. Botulotoxin decreases the amount of the released acetylcholine and thus prevents the transmission of a signal to the targeted muscle and allows for decreasing the excessive muscle contraction within it. It is administered in a very small amount via injection directly into the affected muscles. It eliminates the excessive muscle activity and retains volitional mobility. It effectively reduces muscle tone in carefully selected patients. Thus, its application needs to be indicated following the examination by a team of specialists including a neurologist, orthopedist, and rehabilitation physician. The effect of Botulotoxin begins to emerge 2–3 days after application. Maximum relaxation of muscle tone occurs in 2–3 weeks. Following a Botulotoxin Type A application, reduction in spasticity occurs (always) in combination with reduction in residual physiological functions (sometimes). This reaction is individually based. The best effect of Botulotoxin Type A can be achieved: a. In younger age groups b. In conditions with localized, non-generalized focal spastic dystonia c. In the presence of dynamic contractures limiting function d. Especially with multiple applications; effectiveness of a Botulotoxin Type A application is 3–9 (but can be up to 13–18)

months; the effect depends on the dosage and volume, muscle size, muscle activity, specific physical therapy, and orthoses Factors influencing the effect of Botulotoxin Type A application: a. The extent of muscle weakness b. The patient’s ability of movement coordination and their intellectual capability c. The level of orthotic devices and specific rehabilitation aimed mainly at the improvement of a gait pattern Side effects include: a flu-like syndrome, localized pain at the area of application, allergic reaction, dysphagia, dysarthria, diplopia and ptosis. These are reversible side effects. A production of antibodies anti-Botulotoxin type A can result in decreased effectiveness with repeated applications (secondary non-responders). The effectiveness of a Botulotoxin Type A application can be assessed by the parents, a physical therapist or a physician. The following clinical scales are used: a. b. c. d. e. f.

Gross Motor Function Measure (GMFM) Vojta’s locomotor stages Koman Spasticity Scale Ashworth Spasticity Scale Global Assessment Scale (GAS) Dynamic video recording

Botulotoxin gives the opportunity to utilize hidden functional abilities, corrects the growth of affected muscles and can assist in the prevention of long-term muscle contractures and permanent bony deformities. It postpones the need for orthopedic correction to a later age and, in certain patients, it can possibly prevent this correction. The benefits of this option depend solely on the patient’s functional abilities.

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2 TREATMENT REHABILITATION IN ORTHOPEDICS AND TRAUMATOLOGY Pavel Kolář, Jiří Kříž, Olga Dyrhonová Rehabilitation has an irreplaceable role in the treatment of orthopedic injuries and traumas. A number of structural orthopedic disorders begin as a functional limitation and the identified structural changes emerge as a result of a functional deficit. Thus, rehabilitation can also be used for prevention and to help avoid many orthopedic disorders by timely intervention to a functional limitation. Even in already developed orthopedic disorders, rehabilitation treatments (edema control, change in afferentation in an involved segment, correcting muscle imbalance in a segment, etc.) can help eliminate pain and improve range of motion or reach such a functional state that complete functional recovery is possible. Rehabilitation is also important after surgical procedures of the musculoskeletal system because rehabilitation treatment can help regain function of the involved body part (spine, joints) and, at the same time, improve the patient’s overall condition (fitness). Rehabilitation treatment should also be included as part of preoperative care for planned complex surgical procedures (spinal surgeries, total joint replacements). Pre-surgical rehabilitation care shortens the recovery time following surgery and accelerates the patient’s return to their normal activities.

GENERAL SECTION Similar to neurology, orthopedic treatment rehabilitation approaches are not selected according to a structural diagnosis, but according to the goals and prevalent functional signs that emerge due to either a congenital or an acquired orthopedic condition. Given the fact that rehabilitation approaches focus on the restoration of function, they play an important role, not only in treatment, but also in the prevention of orthopedic disorders, including their traumatic causes. Pathological changes within the musculoskeletal system often develop with a deficit in coordination (agility) or due to functional overloading (strain).

2.1 INFLUENCE OF FUNCTION ON MORPHOLOGICAL TISSUE RESTRUCTURING This process can be best explained by an example of the functional adaptation (restructuring) of a bone under pathological conditions. Although many, especially older, nomenclatures classify bone as an inactive component of the musculoskeletal system, it belongs among one of the most active tissues in the human body. It not only contributes to the statics and movement, but it especially contributes to the process of permanent change of its own tissue and, at the same time, also to the formation of other structures. Bone is an active organ and its activity can be observed metabolically as well as morphologically. The structure of the trabecular (cancellous) bone corresponds to the trajectories or lines connecting the areas of greatest stress and strain forces. This finding serves as the fundamental principle of bone transformation and it was first defined by Julius Wolf. His principle is part of a law regarding functional adaptation and applies to all organs. According to Wolf’s Law, bone deformation occurs as a result of functional adaptation to altered shape and altered function. The shape of a bone is thus secondary and determined mainly by function. Changes in the internal architecture and secondary changes in the external shape of the bone occur as a result of prevalent bone loading. However, bone loading needs to be distinguished as either adequate (physiological) or inadequate (pathological). Bone loading depends on the activity of the external forces with the gravitational force being the most significant one. However, the internal forces produced by muscles cannot be overlooked. It is presumed that the influence of internal forces is more significant, but it is more difficult to measure. Muscle pull shapes the axes of bones and thus their shape and, especially, their joint alignment. This process is particularly important during the growing years during which muscle forces have an important effect on the development and shape of the entire skeleton because of their action on growth zones during this time. For these

reasons, muscle balance is especially important during skeletal development and it can be disturbed by CNS dysfunction (CCD, CP, flaccid paresis, etc.) or by mechanical overloading. This formative effect of muscle imbalance is quite typical in children with CP who show characteristic changes in the development of hip and knee joints or the spine and other parts of the skeleton as a result of spasticity. In the hip joint, weakness of the external rotators and abductors (specifically their posterior aspects) and dominance of the adductors leads to the development of anteversion and orientation of the proximal femur in a valgus direction. Mechanical overloading in children and adolescents has an important role in the development of osteochondroses and deficits in epiphyseal growth. In adults, overloading leads to an increase in bone restructuring seen on an x-ray film. The bone becomes denser, which is known as Looser’s zone of remodeling. Persistent overloading results in stress fractures. Thus, function has a crucial effect on the balance between bone formation and resorption processes. It is a lifelong, permanent change. The processes of bone formation and resorption are intertwined and limited by the physiological conditions of stimulation. To achieve balance, the dynamic and static components must display a balanced relationship. Prevalence of one of the processes imitates a pathological development. In practice, this implies that all activity must be two-sided – dynamically static. In everyday practice, it can be demonstrated by muscle activity as the isometric and isotonic movement of a muscle unit. However, it is not as obvious in a bone. Dynamic stimulation is characterized by changes in body positions and its individual segments while static stimulation is characterized by maintaining these positions. Under physiological conditions, isolated dynamic and static loading do not exist. Predominance of dynamic loading occurs when the gravitational component is decreased – in a state of weightlessness and in patients who are immobile, also partially in asthenic individuals. In contrast, the predominance of static loading occurs in all scenarios where overweight, obesity or a secondary increase in body weight (i.e., various occupational or sport activities, but also regular

carrying of bags) are present. This principle certainly projects into therapy during which the static component is unilaterally increased, for example, in asthenic individuals by jogging, by increasing stress on the weightbearing extremity or by prolonged pressure on the mat, carrying heavy loads and maintaining them in a stationary position. If this component dominates, it must be decreased even outside physical therapy sessions to decrease weight and movement in spaces with decreased gravitational activity (water, staying in high elevation areas 1,500–2,000 m above sea level). The actual process of bone remodeling is triggered by static loading also as a component of a two-sided activity (thus even the seemingly clearly dynamic movement has some static component). Specifically, activation of the mesenchymal cells gradually leads to development of their functional specialization. At the same time, osteoclasts (cells that contribute to resorption of already non-functional bone cells) become activated. The activated mesenchymal cells subsequently turn into osteoprogenitor cells and then into preosteoblasts. Osteoclasts partially cease and remain in a resting phase. During parallel dynamic loading, the process continues by the preosteoblasts developing into osteoblasts. Several hormones play an important part in this transformation process (parathyroid hormone, calcitonin). Calcitonin decreases the number of osteoclasts and potentiates the transformation of the osteoblasts. Osteoblasts produce new bone tissue in an extent that corresponds to an extent of the reabsorbed old bone tissue by the osteoclasts. In this way, the already mentioned process of bone formation and parallel resorption occurs. Here, pathology manifests itself the most, for example, as a result of inadequate stimulation. From the perspective of an optimal ratio between the static and dynamic component of a mixed movement, physiological and qualitative loading is given by body mass index (BMI), ideally BMI of 18–25, and the environment. However, in addition to the already mentioned secondary influences, the contribution of the bone axis and the type of movement needs to be taken into consideration.

A loading-dependent remodeling process is often more or less underestimated or even completely overlooked. The examination of certain concurring hormonal and enzymatic factors seems to be the dominating factor. This is especially given by the fact that most problems of bone structures are connected to critical physiological life stages – growth and especially adolescence and later menopause. Certain other pathological changes during which the question of remodeling can be dominant should not be forgotten. When the rules arising from the effect of loading on bone remodeling are applied in practice, then it can be clearly implied that stimulation by varied loading is ideal, which applies to prevention as well as treatment. While both types of loading are commonly included in rehabilitation, this is not the case in everyday life (or in primary prevention). Therefore, they still are seen especially in education and advertising, however, they have not become a regular component of daily routine yet. The emergence of jogging as a form of stimulation with a higher component of static loading is typical (landing elicits three times the load in the weightbearing extremity than a step). Swimming, on the other hand, decreases the static component and can assist in the dynamic domain. However, a specific or spontaneous increase in anti-gravitational activity can negatively reflect in another area of the musculoskeletal system, i.e., straining and overloading occurs in joints, which leads to a greater risk of degenerative changes as well as to problems involving the circulatory and respiratory systems.

2.2 CLASSIFICATION ACCORDING TO SYMPTOMATOLOGY Functional signs that occur based on congenital or acquired orthopedic involvement include the following: Edema Functional changes in soft tissues Limited range of motion in a movement segment Hypermobility Dysfunction in regulatory nervous mechanisms The goal of rehabilitation treatment is to eliminate or compensate for the above mentioned functional deficits, influence postural stabilization muscle function, improve sensorimotor functions, prevent deformities, as well as, influence the patient’s psychological state.

2.2.1 Edema Olga Dyrhonová, Jiří Kříž Edema is a result of fluid accumulation within tissue. The following can contribute to the etiology and pathogenesis of edema: Increased hydrostatic pressure in the vascular system Decreased colloidal osmotic pressure of fluids Increased vascular permeability Decreased flow of the lymphatic system Edema limits movement, reflexively inhibits muscles and changes proprioception and thus, changes the perception of a given segment (perception of pressure, tension, strangeness). It can also be a source of pain. In edema, segmental circulation becomes disrupted.

CAUSES Causes of edema include:

Internal diseases Cardiac insufficiency Chronic venous insufficiency Deep vein thrombosis Renal insufficiency Liver diseases Endocrine disturbances Rheumatic diseases Lymphedema Allergic reactions Trauma Following an injury Following a surgical procedure Local inflammatory process

TREATMENT STRATEGIES Treatment of edema that is a symptom of another primary disease is based on the treatment of the primary disease. Edemas developed as a result of tissue trauma, tissue overloading and sterile inflammations are part of the following treatments: 1. Local and systemic administration of antiflogistics + antiinflammatory treatment 2. Physical therapy, modalities Treatment for localized edema utilizes physical therapy methods as well as modalities. Soft tissue techniques, especially manual lymphatic drainage, are administered. Physical therapy can also include instrumental lymphatic drainage (vasopneumatic therapy, Pneuven, Lymphoven), hydrotherapy (whirlpool, contrast baths) and ultrasound. The treated extremity should be wrapped/bandaged following treatment. Next, the segment needs to be unweighted (positioning, immobilization of the involved segment) and follow a relative resting regime. Edema treatment in complex regional pain syndrome follows the

principle of pain avoidance. Manual lymphatic drainage of the extremity is the treatment of choice in this scenario.

2.2.2 Functional Changes in Soft Tissues Olga Dyrhonová, Jiří Kříž Skin, hypodermis, fasciae, muscles (their contractile and noncontractile properties), joint capsule and ligaments comprise soft tissues of the musculoskeletal system. Functional changes demonstrate the following findings: Reflexive changes of the skin and hypodermis Changes in skin and fascial mobility Changes in muscle tone (see General Section of the textbook, A. Diagnostic Approaches, Chapter 1.1.2 Assessment of Muscle Tone); Increased tone (hypertonia) Decreased tone (hypotonia) Reflexive changes in muscles Decreased tissue mobility and its structural remodeling and retraction with subsequent movement limitation throughout the entire corresponding movement segment are the most common pathologies that affect soft tissues and subsequently change the function of the involved segment. Generally, structural changes in one tissue lead to the subsequent dysfunction in other tissues. An example can be adhesive capsulitis also known as frozen shoulder syndrome. In this condition, the joint capsule and ligaments retract, leading to limited shoulder range of motion, altered tension in the shoulder girdle musculature, increased tone in the subscapularis and the pectorales, gradual muscle shortening, limited mobility of the fascia in the shoulder girdle and the thorax, and decreased skin and hypodermal mobility in the involved shoulder girdle. Scars also comprise pathological changes in soft tissues, which can significantly limit tissue mobility and affect their function. For example, scars from abdominal surgeries (appendectomy, laparoscopy, or gynecological procedures) can be a source of pain in

the lower lumbar spine.

TREATMENT REHABILITATION STRATEGIES The goal of therapy is to restore the mobility of pathologically altered soft tissues and to treat muscles exhibiting increased tone and other reflexive changes. Manual therapy techniques as well as modalities are utilized. Physical therapy administers soft tissue techniques (see General Section of the book, A. Diagnostic Approaches, Chapter 1.3 Soft Tissues), which release individual layers of soft tissues. The skin fold technique is used, which leads to the release of the hypodermis against the fascia and a reflexive release of the corresponding muscle. The soft tissue incorporates manual release of the fascia, stretching of the noncontractile muscle structure and relaxation of the contractile muscle structure. Brügger’s hot towel roll technique can be used for muscle and fascial release (see General Section of the textbook, A. Diagnostic Approaches, Chapter 1.3 Soft Tissues). To bring about structural changes in the joint capsule and the ligaments, traction and gentle joint mobilization can be administered in addition to soft tissue techniques, but only in a centrated or neutral joint position. Exercises based on a neurophysiological foundation can also be implemented. Pathological changes in tissues can be influenced also by reflex or classical massage. Modalities that can influence structural remodeling can also be indicated. Ultrasound, mid-frequency and high-frequency electrical stimulation treatment and laser are commonly used. Combined electrical stimulation treatment can be used for muscles with increased tone. Hydrotherapy treatments include whirlpool and under water massage.

2.2.3 Range of Motion Restrictions in a Movement Segment David Smékal, Pavel Kolář

CAUSES The causes for range of motion limitations include: Structural joint deficits (pathological changes in cartilagenous and bony structures) Retraction of a joint capsule and pericapsular ligamentous structures. This is most often a result of prolonged immobilization and segment inactivity, for example, after an injury or surgery. Remodeling structural changes with a resultant range of motion limitation occur in chronic processes such as capsulitis, arthritis, etc. Pathological changes in muscles: Muscle shortening (see General Section of the textbook, A. Diagnostic Approaches, Chapter 1.1.2 Examination of Muscle Tone, Examination of Shortened Muscles) Muscle weakness (see General Section of the textbook, A. Diagnostic Approaches, Chapter 1.1.2 Examination of Muscle Tone, Deficits in Muscle Tone) Functional joint deficits (joint restrictions)

TREATMENT REHABILITATION STRATEGIES The goal of therapy in patients with limited range of motion is to achieve the same range of motion as prior to the injury or at least to ensure such range of motion so that the patient is not limited in their basic independence. Movement restriction can either occur in a sense of joint play restriction or as limited passive and active movement. Increasing the range of motion in the corresponding region cannot be achieved to the detriment of a given segment’s stability. Increasing the range of motion can be slightly painful, but should not elicit a defensive reaction in the muscles. The techniques used to increase range of motion must respect the causes for the restriction and pain. Based on the location of the movement limitation, soft tissue techniques are used that assist in the correction of a muscle imbalance

caused by local deficits in muscle tone (trigger points), muscle shortening and deficits in connective tissue (post-isometric relaxation, muscle energy techniques and stretching). In addition to these barrierbased techniques that work at the level of the available movement, techniques that result in a subsequent increase in the range of motion due to improved stabilization in the affected segment are also implemented. A technique of stabilization and subsequent dynamic reversal through the concept of proprioceptive neuromuscular facilitation (PNF) is one such technique. Specific dynamic postural stabilization (DNS) training is another option in which, for example, the practice of the lower scapular stabilizers in their postural function facilitates reflexive inhibition in their antagonists (upper scapular stabilizers), resulting in increased range of motion. Range of motion is affected by muscle activation, not by muscle relaxation. The effect is often more pronounced than when using analytical methods. In specific cases, it is possible to also utilize mobilization under anesthesia or exercise under local anesthesia or after a nerve block. The goal is to release the shortened joint capsule and ligaments during muscle relaxation and analgesia. Mobilization techniques have an irreplaceable role in affecting movement in a joint. Exercising using equipment can also be implemented – MotoMed or continuous passive motion machine (CPM). Aquatic therapy also has beneficial effects. Modalities are part of the rehabilitation treatment (hydrotherapy, electrotherapy, mechanotherapy, ultrasound).

2.2.4 Hypermobility David Smékal, Pavel Kolář The term hypermobility denotes a range of joint mobility that is greater than the physiological norm in terms of joint play and passive

and active movement.

CAUSES The classification of hypermobility based on its cause includes: Compensatory Due to a neurological disease Structural Local pathological (post-traumatic) Segmental hypermobility can result in instability. Pain is often a clinical manifestation of instability.

COMPENSATORY HYPERMOBILITY This is a localized pathological hypermobility resulting from compensatory mechanisms when a range of motion limitation is present in a different segment or joint. In this type of hypermobility, treatment focuses on the hypomobile segments. Restoration of mobility in the hypomobile segment leads to a spontaneous correction of function in the hypermobile segment.

HYPERMOBILITY IN NEUROLOGICAL DISEASES This type of hypermobility (or rather increased flaccidity) is found in a clinical presentation of certain neurological diseases, i.e., cerebellar dysfunction or peripheral paresis. This type of hypermobility also includes hypotonia, which can be seen in attention deficit hyperactivity disorders (ADHD) and hypermobility, which is present in dyskinetic and cerebellar forms of CP, Down syndrome and oligophrenia.

STRUCTURAL HYPERMOBILITY It is characterized by increased range of motion above the common norm generally occurring in all joints. The etiology is not clear. However, it is presumed that mesenchymal insufficiency clinically

manifests itself by an increased ligamentous laxity and laxity of the intramuscular supportive tissue (stroma). Hormonal changes participate in the changes of mesenchymal tissue quality. Structural hypermobility is more common in women and affects up to 40% of the female population. According to Janda, this type of hypermobility is more pronounced in young girls and its occurrence gradually decreases with increased age (around 40 years of age). Hypermobility also belongs among central coordination disturbances (minor coordination dysfunctions) and it is accompanied by minimal cerebellar symptoms, deficits in stereognosis, etc.

LOCALIZED PATHOLOGICAL (POSTRAUMATIC) HYPERMOBILITY The term instability is usually used to describe this type of hypermobility. It develops following a trauma in which the static stabilizers (joint capsule and ligaments) were damaged in a given movement segment.

TREATMENT REHABILITATION STRATEGIES The goal of rehabilitation treatment (physical therapy) is to stabilize the unstable segment through muscle function. Through exercises aimed at activation and strengthening of muscles in their stabilization function, muscles that are directly linked to the unstable movement segments as well as muscles ensuring the punctum fixum of the unstable segment are facilitated. With muscle activation in their stabilization function, the muscle chains within their postural function must be respected. General principles are used during stabilization training. These include joint approximation, rhythmic stabilization, stabilization reversal, reflex activity on the movement segment in neutral (centrated) positions, exercise in closed kinetic chains and sensori​motor training. Elastic materials are most commonly used for exercises against resistance.

2.2.5 Deficit in the Nervous System Regulatory Mechanisms Pavel Kolář A pathogenetic interpretation of orthopedic disorders and thus their treatment mainly focus on the anatomical and biomechanical areas and on the question of the influence of internal forces. When considering the cause of an orthopedic disorder (including traumas) and when selecting treatment for an orthopedic dysfunction, the influence of movement control mechanisms and the associated function of the musculoskeletal system should not be overlooked. If we accept this perspective, then certain joint lesions are not going to be viewed merely as a local joint dysfunction, but as an overall movement system dysfunction, including not only the skeletal component, but also the regulatory mechanisms of the CNS. In this perspective, a dysfunction perceived as local becomes viewed as global. The ability of the movement system to adapt comes to the forefront, which is dependent not only on joint anatomy and biomechanics, but also on control functions, particularly their plasticity. CNS function allows for the formation and stabilization of continuously new postural movement options without the earlier formed options disappearing. The central function also determines the speed of muscle reaction in the presence of joint danger, i.e., during a wrong step, fall etc. The protection of the joint and bone structures depends on the reaction speed of the muscle system and its coordination quality (i.e., the way an individual falls, how quickly and in which way they react to contact with a team player or how quickly they can relax their forearm following a tennis stroke). A disturbance in the regulatory mechanisms of the nervous system plays an important role in the development of certain traumas, degenerative disorders, enthesopathies and other orthopedic deficits developed by chronic strain, recurrence of painful conditions, but also in unsuccessful movement re-education of post-injury conditions of

the bone-joint system. From the perspective of etiology and pathogenesis of an orthopedic finding, the issue of influence of the acting forces is also important. The forces acting on joints play a decisive role in the development and progression of orthopedic disorders. Every segment is exposed to internal and external forces. During movement, the external force vectors expand by rotational and shearing forces. We accept and count on the external forces because they can be objectified (defined, measured or calculated – i.e., on cadavers). An effort to eliminate these forces as much as possible dominates in the therapeutic and preventative approaches (orthoses, position at work, schedule arrangements to prevent strain/loading, etc.) For the actual development and progression of an orthopedic disorder (i.e., progression of pain and neurological deficits in spinal dysfunction), the inner forces cannot be neglected. The inner forces are generated by muscle activity and act very substantially on the individual’s joints and bones. These forces develop during postural stabilization, thus when stabilizing body segments are affected by external forces. The main role is played by the stabilization function of muscles, which is controlled by the CNS. The stabilizing muscle activity occurs automatically and non-volitionally. The inner force vectors (muscle activity) influencing the development and progress of orthopedic disorders determine whether the organism will be able to compensate for the deficit or whether global deterioration will occur. With an imbalance in these forces, segmental stability is disturbed, pain develops and a neurological deficit can emerge if the condition involves the spine. In the majority of orthopedic conditions, the inner forces produced by muscles (the vectors of their activity, their amplitude, pattern of repetition, etc.) are considered more important than the external static forces. The impact of these forces is underappreciated because of the limited options of their quantification, as well as, because of the fact that the influence of these muscles or inner forces is not a result of only one’s own muscle mechanics, but it also depends on the control processes of the CNS.

The diagnostic analysis of the inner forces is given only minimal attention. For the above described reasons, an orthopedic disorder cannot be viewed only from the perspective of the anatomy and biomechanics, as well as, from the influence of inner forces, but always using clinical assessment of the inner forces acting on a joint, including muscle stabilization (postural) functions linked to the quality of CNS control processes.

CHANGE IN AFFERENTATION FROM THE RECEPTORS A deficit or a change in afferent input from the receptors leads to changes in regulatory mechanisms. Joint injuries (including microtrauma) involve, not only damage to the joint and ligamentous structures, but also to a change in afferent signalization from the injured segment. For example, an anterior cruciate ligament rupture is not a mere deficit in knee biomechanics, but also a deficit in control because the afferent signalization from the ligament becomes absent when the ligament is injured. It needs to be noted that approximately 2% of the entire ACL tissue is made of proprioceptors. The injured joint sends less proprioceptive information and more nociceptive information to the CNS than a healthy joint. A number of patients demonstrate a lower level of sensory (especially proprioceptive) perception. This regulatory deficit can be called “joint blindness” and it is either innate (global or segmental) or acquired (i.e., following a joint injury). Delayed muscle reaction to a joint at risk is the main consequence of this regulatory dysfunction. Individuals with this deficit show a greater predisposition to injuries and orthopedic disorders that develop from overloading.

MOTOR LEARNING DEFICIT AT THE LEVEL OF THE CENTRAL REGULATORY MECHANISMS The quality of central components and the way in which the fundamental movement patterns were learned comprise other factors that need to be addressed during therapy and during the prevention

of orthopedic and traumatic musculoskeletal injuries. Both of these determine in which way the muscles become engaged in their postural stabilization and coordination functions and which muscles work during repeated stereotypical loading during the activity of external forces. For example, during shoulder abduction, the muscle stabilization function determines how the scapulohumeral rhythm is carried out, the way the shoulder joint will be loaded and which forces are going to influence it. Similarly, when kicking a ball, the muscles (and the CNS) determine how the external forces will influence the individual’s joints via the stabilizing muscles. CNS plasticity determines to what extent we are able to change and modify the muscles engaged in postural stabilization functions.

TREATMENT REHABILITATION STRATEGY The goal of treatment rehabilitation is to influence the inner forces through reflexive methods and educational movement concepts. Correctly performed patient education serves as prophylaxis to the recurrence of orthopedic disorders or injuries. A physical therapy treatment strategy is based on affecting the joint afferentation deficit. Inclusion of the joint into a body schema and influencing the reactibility of the sensorimotor loop are the main principles of the treatment plan. The muscle is taught to react faster and with increased coordination quality to the sensory stimulus from the joint. Balance exercises utilizing various orthopedic tools that increase sensory afferentation are used to accomplish this goal. The exercises can be modified to many variations. The sensory stimulation method addresses this type of treatment globally and systematically. The training of the muscle stabilizing function is another strategically important approach. It is a non-volitional activity and thus reflex programs need to be used for education. Programs derived from postural ontogenesis (see General Section of the textbook, A. Diagnostic Approaches, Chapter 3 Neuromotor Development and Assessment) have been found beneficial.

Exercises aimed at training somatognostic functions, including segmental and general exercises with full awareness of movement and position, are designed to improve joint sensation. During movement, the patient needs to perceive its speed, muscle tone including distant muscles, body position, etc. Closed kinetic chain exercises can be used (joint compression or traction) if the joint is maintained in a centrated (neutral) position. This again increases the amount of “correct” afferent impulses from the joint surfaces (from the subchondral area of a bone), from the joint capsule and from the surrounding ligaments.

2.3 CLASIFFICATION ACCORDING TO ETIOLOGY AND PATHOGENESIS Pavel Kolář This section provides an overview of the most common nosological units in orthopedics and trauma and their rehabilitation treatment. In certain nosological units, rehabilitation is the only treatment option and plays an important role in the prevention of their formation because it can influence their etiology and pathogenesis. Other orthopedic disorders cannot be affected by rehabilitation and surgery is indicated. In such cases, subsequent and correctly indicated rehabilitation contributes to a good surgical outcome. Practicing compensatory functions plays a significant role in rehabilitation. Based on etiology and pathogenesis, the disorders can be classified as follows: Congenital developmental defects (Chapter 2.3.1) Soft tissue injuries due to overloading (Chapter 2.3.2) Degenerative joint diseases (Chapter 2.3.3) Inflammatory diseases (Chapter 2.3.4) Traumas (Chapter 2.3.5) Rheumatic illnesses – see Chapter 3 Treatment Rehabilitation in Selected Internal and other Diseases Metabolic diseases – see Chapter 3 Treatment Rehabilitation in Selected Internal and Other Diseases Tumors – see Chapter 4 Treatment Rehabilitation in Oncology

2.3.1 Congenital Developmental Defects Congenital developmental defects are localized anomalies of bones and soft tissues that develop during the prenatal stage and can already become apparent during birth.

ETIOLOGY

Factors leading to the formation of congenital developmental defects are very diverse and, in certain cases, their etiology remains unexplained. For prognosis, it is important whether the deficit occurred during embryogenesis and differentiation of the musculoskeletal and nervous systems or later during fetal development. More serious deficits result in abortion usually in the first trimester. Generally, the etiological factors for onset of developmental defects can be classified as follows: 1. Internal (genetic) 2. External (teratogens) – radiation, toxic substances, biological mutations (infectious diseases), fetal hypoxia and deficits in nutrition

REHABILITATION TREATMENT PRINCIPLES IN CONGENITAL DEVELOPMENTAL DEFECTS Rehabilitation treatment in these patients cannot affect the etiology or the pathogenesis of the defect and it mainly focuses on the following: Achieving maximum functional potential Practice of compensatory mechanisms Orthotic treatment Post-operative rehabilitation if a surgery was performed The identification and diagnosis of congenital developmental defects are performed prenatally as well as postnatally. For serious conditions, they are best performed in the neonatal stage. Immediately following birth, rehabilitation treatment is initiated. Vojta’s reflex therapy and neurodevelopmental treatment are at the core of rehabilitation. Both methods facilitate CNS functions that emerge during the child’s physiological development. In a child with a congenital developmental deficit, the affected part is integrated into the body schema and into the movement program of the CNS and thus into the correct function during movement execution. At a time when the child is unable to cooperate with the therapist, the treatment includes elements of active exercise. Mainly active

exercises in developmental positions and sequences, closed and open kinetic chain exercises and proprioceptive neuromuscular facilitation are utilized. Occupational therapy is an important component in the rehabilitation of congenital developmental defects. The occupational therapist tests the extent of functional loss, is able to use the patient’s functional reserve, and teach the patient compensatory strategies that replace the lost function of the involved part. With congenital developmental defects involving the hand, occupational therapy includes thumb opposition and fine motor skills training. The occupational therapist cooperates with an orthotist in the selection and assessment of assistive devices. In upper extremity congenital developmental defects, the goal of therapy is to achieve a functional level in which the patient is selfsufficient and not dependent on another person. In lower extremity congenital developmental defects, the goals of the therapy include the patient’s verticalization to standing and independent ambulation.

POST-SURGICAL REHABILITATION Following a surgical procedure for congenital developmental defects, classic symptoms such as pain, edema, limited mobility and muscle imbalance are addressed by therapy. Surgeries to correct congenital developmental defects are specific in that they completely or partially renew function in a segment that originally did not exist or was significantly restricted. The central nervous system does not “recognize” this function or it is substituted for by compensatory mechanisms. The goal of post-surgical rehabilitation is to not only eliminate edema, increase range of motion and correct muscle imbalance, but also to primarily implement the newly acquired function of the originally injured segment into the movement program of the CNS.

CLASSIFICATION OF CONGENITAL DEVELOPMENTAL DEFECTS Congenital developmental defects of the upper extremities Congenital developmental defects of the lower extremities Congenital developmental defects of the thorax Congenital developmental defects of the spine

CONGENITAL DEVELOPMENTAL DEFECTS OF THE UPPER EXTREMITIES Congenital Developmental Defects of the Shoulder Girdle Sprengel’s Deformity This deformity is a rare genetic autosomal dominant disease that occurs more often in girls. Scapular elevation is accompanied by clavicular deformity and shortening (Fig. 2.3.1-1). On the affected side, the neck line is shortened, shoulder mobility is limited and the scapulohumeral rhythm is disrupted. Fig. 2.3.1-1 Sprengel’s deformity

Treatment is conservative and includes rehabilitation. The goal of rehabilitation is to maintain the maximum possible range in the shoulder girdle and increase muscle strength. Rehabilitation is indicated immediately after birth. Vojta’s reflex locomotion is beneficial. Surgery is indicated in severe deformities that significantly limit shoulder girdle function. Currently, there is a tendency to perform the corrective surgery early, between 6–9 months of the child’s age. Cleidocranial Dysostosis This is a combination deformity of the clavicle and an abnormal ossification of the skull. The clavicle presents with aplasia, dysplasia or a congenital nonunion. The absence of the clavicle is sometimes accompanied by glenohumeral joint subluxation or dislocation and muscle defects most often seen in the deltoid, trapezius and sternocleidomastoid. The skull is widened in the frontal direction, the frontal suture is open and the orbital rims are prominent.

Congenital Clavicle Nonunion The clinical picture of this deformity includes non-painful widening of the mid third of the clavicle. In the first years of life, this deformity does not cause problems, but starting from 3 years of age, the anterior aspect of the shoulder girdle can become angulated and shortened, thereby resulting in limited mobility. In such a case, surgical intervention – nonunion resection, spongioplasty and osteosynthesis are warranted. Os Acromiale Os acromiale results from an incomplete ossification of the acromion. In adulthood, it can be a source of irritation in the subacromial space leading to a rotator cuff lesion. Congenital Developmental Defects of the Elbow Joint Congenital Dislocation of the Elbow, Congenital Dislocation of the Radial Head These developmental defects are rare and typically do not occur in isolation as they are often part of syndromes. Conservative therapy occurs during growth and the goal of therapy is to maintain maximum range of motion in the involved joints. Surgical intervention is performed when growth is completed. Congenital Radioulnar Synostosis This deformity develops during a disturbance in the differentiation of the mesoderm. A complete separation of the radius and the ulna does not occur at the proximal end. This results in movement restriction (pronation and supination). This deformity can also include an elbow flexion contracture. This defect often affects both upper extremities. This deformity is surgically corrected. The resection of the bony bridge and bone release does not provide a functional effect. Rotation osteotomy of the radius and ulna is performed and the osteotomied distal aspect is positioned into an alignment that allows for more favorable upper extremity function.

Congenital Shortening of the Radius This deformity involves hypoplasia or aplasia of the radius. It results in a wrist deformity known as manus vara congenita. Congenital Developmental Defects of the Wrist Manus Vara Congenita This deformity occurs with radial hypoplasia or aplasia. The forearm is angulated radially and it is shortened. The hand is in radial deviation and the wrist is unstable. The thumb ray is atrophied or it is not developed at all. In patients with this deficit, other systems need to be examined because this defect is accompanied by congenital cardiac defects, a dysfunction in blood formation, and urogenital deficits. The inability to stabilize the wrist in supination and extension and the loss of function of the 1st ray (thumb) are the main problems with respect to hand function. The goal of therapy is to renew these functions. Conservative therapy occurs until 2–3 years of age, including rehabilitation and positioning of the forearm, wrist and hand. Surgical intervention is initiated at 3 years of age and the procedures are carried out in two stages. The first stage focuses on wrist stabilization. The second stage includes the formation of a functional thumb, which is achieved by pollicization of the 2nd ray. Madelung’s Deformity This deformity involves a growth deficit of the distal radial epiphysis. It leads to subluxation of the hand from the radiocarpal articulation in ulnar and volar directions. Treatment is based on the fact that the deformity begins to manifest itself during adolescence with this growth acceleration causing the deformity to worsen. Conservative therapy is based on rehabilitation and positional casting. Surgery is indicated when growth is completed and involves a corrective radial elongation osteotomy accompanied by a distal ulnar resection. Wrist arthrodesis is indicated if osteotomy fails.

Congenital Developmental Defects of the Fingers Camptodactyly Camptodactyly is a flexion deformity of the proximal interphalangeal articulation. Clinodactyly Clinodactyly denotes finger deformity in the frontal plane (ulnar, radial deviation). The fifth finger and less often the 4th finger are affected. Treatment is difficult as conservative and surgical solutions have both failed. Syndactyly It involves fusion of the soft parts or the bones of adjacent fingers. Surgery is indicated to separate the fused fingers and it is ideally performed prior to the beginning of school attendance. Thumb Hypoplasia Given the thumb’s important function during grasping, this function needs to be addressed. Surgical intervention is indicated, the type of procedure depends on the severity of involvement. Either elongation or pollicization of the 2nd digit is performed. A microsurgical procedure provides another option – toe transfer from the foot to the hand.

CONGENITAL DEVELOPMENTAL DEFECTS OF THE LOWER EXTREMITES Congenital Developmental Defects of the Hip Joint Developmental hip dysplasia is a deformity of an originally normal hip joint. The forced abnormal position of the lower extremities or limited fetal movement during intrauterine development can contribute to its development. For more details, see Chapter 2.4.5 Hip Joint, Childhood Diseases. Congenital Developmental Defects of the Knee Joint Congenital Knee Dislocation It is characterized by knee hyperextension and quadriceps femoris

shortening. The milder form is positional and it is due to a faulty position of the fetus in the uterus. Structural dislocation is the more severe form due to shortening of the rectus femoris or hypoplasia of the cruciate ligaments, which is often part of systemic diseases (arthrogryposis). Therapy depends on the level of involvement: Type I – genu recurvatum; knee is in hyperextension, flexion is at least 90 degrees Type II – subluxation; the tibia subluxates anteriorly, it can be repositioned with the knee in flexion Type III – dislocation, the tibia is positioned anteriorly to the femur, cannot be repositioned in knee flexion Conservative therapy is initiated immediately after birth. In a positional deformity, intense rehabilitation is indicated. Physical therapy includes analytical treatments (soft tissue techniques, relaxation and stretching of the quadriceps, knee joint traction) as well as neurophysiologically-based exercises (Vojta’s reflex locomotion). In more severe deformities, rehabilitation is combined with positional casting. A surgical intervention is indicated when conservative therapy fails. Surgery is performed between 3–6 months of age. The goal of the therapy is a stable knee joint with free motion between 0–90 degrees. Congenital Patellar Subluxation This involves a hypoplastic patella that is positioned and fixated on the external femoral condyle. The knee joint presents with a flexion and valgus deformity with the tibia in external rotation in relation to the femur thus, active knee extension is limited. This defect is present in systemic diseases (Marfan’s syndrome, Ehlers-Danlos syndrome). Surgery is indicated to release lateral structures and transpose the insertion of the patellar ligament. Patella Bipartita

In this dysfunction, the patella does not ossify physiologically from one ossification center, but the upper lateral segment of the patella has its own ossification center. The individually ossified fragment has a smooth edge and it is connected to the rest of the patella by fibrocartilagenous tissue (Fig. 2.3.1-2). Patella bipartita can cause pain on the anterior aspect of the knee during increased loading. It is the cause of the more frequent onset of enthesopathies of the patellar ligament. Fig. 2.3.1-2 Patella bipartita

Conservative therapy recommends activity modification or even short-term knee joint immobilization. Relaxation and stretching of the knee extensor structures and correction of pelvic and femoral muscle imbalance are the main goals of therapy. It is important to address the intramuscular coordination of the quadriceps femoris and the co-

activation of the quadriceps femoris and the hamstrings, during which hamstring activation should not be delayed in relation to the activation of the quadriceps femoris, but rather should precede it. Surgical intervention involves the excision of the separate ossification fragment. Congenital Developmental Defects of the Lower Leg and Foot Figures 2.3.1-3 through 2.3.1-5 schematically show the most common pathological foot alignment. Individual defects are described in detail in the following text.

Fig. 2.3.1-3 Pes equinovarus congenitus

Fig. 2.3.1-4 Pes equinovalgus

Fig. 2.3.1-5 Pes excavatus

Club Foot (Talipes Equinovarus, Pes Equinovarus Congenitus) Club foot is a defect that involves the following deformities: equinus at the ankle joint, calcaneal varus, and forefoot adduction and supination. In addition to the above described deformities, the clinical picture also shows a shortened Achilles tendon and hypotrophy of the calf and foot (Fig. 2.3.1-6). Fig. 2.3.1-6 Club foot

This deformity occurs in 1–2% of newborns and it is twice as common in boys. Fifty percent of affected children show bilateral involvement. Often, it is accompanied by other congenital developmental defects. Diagnosis Club foot can easily be diagnosed from a clinical presentation. X-ray films are used to assess anatomical dimensions and to monitor treatment effectiveness. The angles between the axis of the tibia and the calcaneus in the lateral and anteroposterior directions are assessed. Summation of both angles is known as the talocalcaneal index and it is used to assess the success of the therapy. Classification 1. Rigid, true club foot

2. Postural club foot A rigid club foot deformity cannot be passively corrected back to a normal alignment. Postural club foot deformity contains all components of a rigid foot, but it can be passively corrected to physiological alignment. Rigid and postural club foot classification is important for correct treatment selection. Surgical intervention is indicated in 60–70% of rigid deformities. Therapy Treatment of a club foot is initiated immediately after the diagnosis is established. The sooner the treatment is initiated the more favorable the prognosis. In the majority of cases, the initially conservative treatment is followed by surgical intervention to correct a rigid club foot. Conservative Therapy Conservative therapy is initiated for a postural, as well as, rigid club foot. At one week of age, the child begins treatment by (corrective) serial casting. The casts are usually replaced in weekly intervals. When the corrected alignment is achieved, the cast stabilizes this alignment for 6–8 weeks. Retention tools such as positional laminated or DenisBrown bars are used to complete the treatment. Retention tools are discontinued when the child begins to ambulate. Surgical Intervention Generally, casting is applied as long as the defect is improving. If consistent conservative treatment does not achieve full correction, surgical intervention is indicated. A surgery involves either soft tissue procedures (tendon elongation, capsulotomy) or bone procedures, which are mainly performed for rigid defects and in patients whose treatment initiation was delayed. Rehabilitation Intensive corrective exercises need to be initiated immediately following the child’s birth and after establishing the diagnosis. The parents are taught exercises that passively correct individual

components of the deformity. They are also instructed in Achilles tendon stretches. In a postural club foot, Vojta’s reflex therapy can be beneficial. Pes Metatarsus Adductus (Pes Calcaneovalgus) Pes metatarsus adductus is a congenital foot deformity in which the foot is aligned in maximum ankle dorsiflexion; sometimes, the dorsal aspect of the foot can be placed all the way to the anterior part of the shin bone. The calcaneus is in valgus. The deformity affects girls more often and can occur as a component of other neuromuscular diseases (i.e., arthrogryposis multiplex congenital or neurofibromatosis). Therapy No treatment is needed if the foot can be passively brought into a neutral position. For rigid deformities, the treatment is initiated by exercising into the corrected position. Parents who were instructed in the exercises perform plantarflexion and inversion 10 times several times per day. If the treatment is not successful after 2 weeks, serial casting is initiated. Orthotic equipment becomes part of the therapy to achieve the patient’s verticalization. A special orthopedic insert is indicated based on the functional assessment of the foot. Congenital Flatfoot (Vertical Talus, Pes Planovalgus Congenitus) A congenital vertical talus, congenital steep talus and congenital convex pes valgus are rare congenital foot deformities. The talus is in maximum plantarflexion and the navicular bone is dislocated at the talonavicular joint. This alignment results in a cradle-like shape of the sole. The deformity consists of Achilles’ tendon shortening, calcaneal eversion and forefoot abduction and dorsiflexion (Fig. 2.3.1-7). Fig. 2.3.1-7 Pes planovalgus in cerebral palsy

The deformity occurs in 1:100,000 live births either isolated, which is a prognostically more favorable variation, or it is accompanied by other congenital defects or neuromuscular involvement. Therapy Treatment of a congenital vertical talus is problematic and almost always requires surgery. Therapy is initiated by serial casting of the deformity into plantarflexion and inversion for a period of three months. This is followed by surgery. In principle, the surgery releases

the soft tissues, repositions the tarsal bones and transfixes them with Kirschner’s wires. In rigid deformities, there is a high risk of recurrence. The final solution is usually a corrective surgery at an older age (talocalcaneal extraarticular arthrodesis according to Grice or triple arthrodesis sub talo). Providing the patient with orthotic equipment is part of the therapy to achieve the patient’s verticalization. A special orthopedic insert or custom made orthopedic footwear is indicated based on the results of a functional foot assessment. Metatarsus Varus (Pes Adductus) In this deformity, the foot is kidney-shaped with the forefoot in adduction and inversion and the calcaneus in neutral alignment. Metatarsus varus or pes adductus is a relatively common congenital defect. Nearly half of the affected children show bilateral involvement. Therapy Milder postural deformities correct spontaneously or with corrective exercises. Serial casting is indicated for more severe and rigid deformities. If conservative therapy fails, metatarsal osteotomy is indicated after the age of four. In the past, it was recommended to wear shoes on the wrong feet (left shoe on the right foot and vice versa) to correct the alignment. Congenital Deformities of the Toes Congenital Hallux Varus This is a rare congenital defect in which the big toe is deviated medially at the metatarsophalangeal joint. About a third of patients demonstrate bilateral involvement. Conservative treatments of this deformity have been unsuccessful. Exercise, positioning and serial casting have shown no effect. Majority of these deformities need to be surgically addressed. Digitus Quintus Supraductus It is a congenital alignment of the little toe in adduction where it is positioned across the 4th toe and externally rotated. The deformity is

visible after birth, but complications are experienced in later childhood years when donning shoes. Therapy involves deformity correction by using a bandage for stabilization. Surgical intervention is indicated if conservative therapy fails. Syndactyly Congenital fusion of the toes does not cause functional limitation. In syndactyly involving all toes, surgical separation of the big toes is recommended. Polydactyly Extra toes can be found on the side of the little toe, the big toe or centrally (duplication of one of the middle toes). Duplication can involve one phalanx or the entire toe including the metatarsal bone. Polydactyly is a common defect with a higher incidence in females. Surgical removal of the extra toes is indicated for cosmetic and functional reasons and because the deformity hinders donning and wearing shoes. Surgery is performed between 10–12 months of age. Macrodactyly Accumulation of connective and adipose tissues is the most common reason for abnormal overgrowth of the toes. Neurofibromatosis can be another cause. Treatment involves surgery and consists of surgical removal of the excess tissue. The function of the involved toes is preserved.

CONGENITAL DEVELOPMENTAL DEFECTS OF THE THORAX Pectus Excavatum (Infundibuliform) In this deformity, the lower part of the sternum and adjacent vertebral cartilages are caved in toward the spine. The deformity can be either symmetrical or asymmetrical. In an asymmetrical deformity, the sternum is rotated and scoliosis may occur.

The incidence of this deformity is 1:300 and it is more common in males. It can occur in isolation or as a symptom of another disease, such as Marfan’s syndrome, osteogenesis imperfecta or rickets (Fig. 2.3.1-8). Fig. 2.3.1-8 CT 3D reconstruction – pectus excavatum

Diagnosis Diagnosis is based on clinical examination. The clinical exam can be complemented by imaging methods and functional assessment of the heart and lungs. A thoracic x-ray is performed to assess heart position. Cardiac EKG, stress test (ergometry), echocardiography and examination of lung function (spirometry) are beneficial functional assessments. Surgical Intervention Surgery is indicated in severe deformities prior to growth completion. The goal is to improve pulmonary functions (Fig. 2.3.1-9; Fig. 2.3.110). Fig. 2.3.1-9 Fourteen-year-old female patient with pectus excavatum prior to surgery

Fig. 2.3.1-10 Same patient 6 days after a Nuss procedure

Pectus Carinatum This deformity of the thorax is characterized by the sternum protruding ventrally. This deformity does not affect pulmonary functions. Surgical Intervention Surgical intervention is indicated mainly for cosmetic reasons. The reasons for having this surgery need to be carefully considered because it is an extensive procedure which does not always address the psychological foundation of the problem.

Rehabilitation in Congenital Developmental Defects of the Thorax Pulmonary rehabilitation is the foundation of therapy for congenital developmental defects of the thorax. In the general section of this chapter (see above 2.2 Classification according to Symptomatology, subheading 2.2.2 Functional Changes in Soft Tissues), it is stated that the soft tissues and the bone have the ability to adapt to a change in function. In correctly administered pulmonary rehabilitation, respiratory function improves, but cannot change the structure of the deformity. In a child up to one year of age, pulmonary rehabilitation is performed reflexively by Vojta’s reflex locomotion. Active breathing exercises are performed to address the breathing pattern in a child who is able to actively participate in therapy. Diaphragmatic breathing and exercises with assistance of the Valsalva and Müller’s maneuvers are especially important. Focus is placed on the patient’s effort to fully expand the thorax. To accomplish this, the abdominal muscles need to work in synergy to allow for a full caudal shift of the centrum tendineum of the diaphragm during their contraction. Abdominal muscles form a punctum fixum during diaphragm contraction. During inspiration and with an increased intrathoracic pressure, the abdominal wall should not be drawn in. Synergistic activation of the pectoral muscles is important to correct the deformity when the diaphragm is fully activated. Soft tissue techniques of the thorax (especially release of the fasciae) and soft tissue techniques and spinal mobilization are important components of rehabilitation treatment. Rehabilitation does not strictly focus on the thorax; the entire posture needs to be influenced. If a child (patient) can cooperate well, Vojta’s reflex locomotion therapy is administered at the same time.

CONGENITAL DEVELOPMENTAL DEFECTS OF THE SPINE

Diastematomyelia Diastematomyelia presents a split in the spinal cord and the dural sac by a bony-cartilagenous (fibrous) septum dividing it into two asymmetrical halves. A neurological deficit below the level of the defect during accelerated growth can be the first sign of this defect. Diastematomyelia can occur in congenital scoliosis. This defect needs to be taken into consideration in patients considered for surgical intervention for congenital scoliosis because a spinal cord lesion at the site of the defect can occur. Meningomyelocele Meningomyelocele is a congenital deformity in which the neural tube does not close. A given segment of the spine is defective and a sac containing the spinal meninges and nerve structures – spinal cord and nerve roots – protrudes at the level of the defect. At this level, the spinal cord and the spinal nerve roots are structurally damaged and the clinical picture corresponds to a certain degree of a spinal cord lesion. Therapy A child with meningomyelocele undergoes an urgent surgical procedure in which the sac is resected and the nerve structures are placed back inside the spine. Rehabilitation is initiated shortly after the procedure. Vojta’s reflex locomotion presents the foundation of rehabilitation therapy. The goal of rehabilitation is not to repair the spinal cord structure, but rather to achieve maximum functional potential from the preserved nerve structures. Therapy also addresses symptoms accompanying a spinal lesion, especially incontinence that puts the patient at risk of complications from an infection. Klippel-Feil Syndrome This is a congenital synostosis of two or more cervical vertebrae. Clinically, this syndrome can imitate torticollis. Therapy

Therapy is conservative and rehabilitation is initiated shortly after birth. Vojta’s reflex locomotion plays an important role during the patient’s first year of life. At a later age when the child is able to actively cooperate, soft tissue techniques and muscle relaxation are implemented. Active therapy focuses on correcting muscle imbalance in the facial, neck and trunk muscles. Active exercises in developmental positions and sequences are used the most. Elements from Klapp’s crawling and proprioceptive neuromuscular facilitation can also be implemented. Thrust manipulation techniques are contraindicated in this congenital developmental defect. Spina Bifida This is a relatively common congenital developmental defect of the spine in which the arch of the vertebral body fails to close. It can affect any vertebrae, but it most often involves the arch of the L5 or S1 vertebral body. The defect does not affect the dural sac or the neural structures and does not limit spinal mobility.

2.3.2 SOFT TISSUE INJURIES CAUSED BY OVERLOADING Pavel Kolář, Jiří Kříž, Olga Dyrhonová This group includes injuries to the joint capsule, ligaments, tendons and bursae. The following text specifically focuses on tendon injuries.

TENDON INJURIES These injuries are the most common soft tissue problems encountered in the rehabilitation of orthopedic diagnoses. Given the etiology and nature of the injury, their treatment is very difficult and sometimes fails.

ETIOLOGY AND PATHOGENESIS

The etiology and pathogenesis of tendonosis is multifactorial. In etiology, exogenous and endogenous factors apply. The main exogenous factor is a frequently repeated loading that causes edema and subsequent ischemia of an overloaded tissue. Other exogenous factors include trauma, microtrauma, coldness and toxic tendon injury. Endogenous factors include vascular, metabolic and endocrine influences, bony dysplasia and CNS function. In some patients with chronic tendon injury, mechanical overloading is magnified by anatomical predispositions such as bony deviations within an articulation, leg length discrepancy, muscle imbalance, and deficits in joint flexibility (hypermobility as well as a restriction in segmental mobility). The so called transition period most often contributes to this overloading, which includes a change in the way the affected anatomical region is activated, for example, changing a tennis racquet, changing footwear during running, etc. The injury most often occurs in middle age. It is common in athletes and the main causes include incorrect training methods, a change in the training load or a change in the way the affected segment is loaded. Tendon inflammation is often the first manifestation of a systemic illness. This needs to be remembered during differential diagnosis.

DIAGNOSTICS Clinical Picture Pain in the tendon is a subjective sign of tendinosis while pain at the tendon insertion is a sign of enthesopathy. The pain is specifically localized, present with loading and diminished at rest. Objective findings show the following: pain upon palpation of the affected tendon or tendon insertion and increased tone and reflexive changes in the muscle belly. Resistive testing of the corresponding muscle is positive or a movement in the affected segment against resistance (activation of the corresponding muscle) provokes pain in the area of tendon insertion. The pathological clinical picture includes

limited springing in the joints of the affected segment. Tendinoses and enthesopathies can occur separately or they can be accompanied by tenosynovitis (peritendinitis). Tendinosis Tendinosis or tendinopathy is a degenerative tendon injury. Enthesopathy The term “enthesis” involves the insertional part of the tendon, the insertion part of the bone, the attached hyaline cartilage, peritoneum that smoothly transitions into perichondrium and periosteum, and additional structures (bursae, sesamoid bones). Enthesopathy is a degenerative injury to the insertion of the tendon or a tendinosis localized to the tendon insertion. Paratenonitis, Peritendinitis, Tenosynovitis This is an inflammation of the synovial two-layered tendon sheath without the actual tendon being affected by inflammation. This group includes the Achilles tendon, the long abductor and the short extensor tendon of the thumb (de Quervain’s tenosynovitis), and flexor tendons of the fingers and the thumbs (trigger finger/thumb). Imaging Methods Imaging methods used for diagnosis include ultrasound and magnetic resonance imaging. Ultrasound imaging is easily available, but magnetic resonance imaging is more accurate in diagnosing soft tissues. The goal of the imaging tests is to distinguish between an inflammatory and degenerative component of the injury, or identify a partial tendon rupture along its course of degeneration. The result of the testing is taken into consideration during treatment selection. Differential Diagnosis From the perspective of differential diagnosis, the following need to be distinguished: spinal involvement, peripheral compression neuropathy, aseptic necroses, osteochondritis dissecans, and generalized tendinoses as part of inflammatory or metabolic diseases.

At the same time, it needs to be remembered that in certain cases, a chronic compartment syndrome can occur. It occurs most often after very intense muscle activity, especially when isometric in nature. In such a case, the differential diagnosis is especially important because the signs are similar to enthesopathy; however, the treatment strategy is completely different. The same treatment as with an enthesopathy can lead to iatrogenic damage.

LOCALIZATION Upper Extremity Rotator cuff tendinosis Lateral epicondylitis (tennis elbow) Medial epicondylitis (golfer’s elbow, javelin thrower’s elbow) De Quervain’s syndrome Stenotic tenosynovitis of the finger flexors Lower Extremity Hip adductor enthesopathy Hamstring muscle enthesopathy Rectus femoris enthesopathy – at the origin on the anterior superior iliac spine or at its insertion at the base of the patella Patellar tendinosis (jumper’s knee) Paratenonitis, peritendinitis or tendinosis of the Achilles tendon Paratenonitis, peritendinitis or tendinosis of the tibialis posterior muscle Enthesopathy of the short plantar muscles

Therapy It is important to distinguish between an acute and chronic form of the injury to select the correct therapeutic treatment. Acute Form Acute tendon injuries occur following demanding repetitive work (painting, screwing etc.). In an acute form, inflammation dominates

and the clinical picture is dominated by signs that are typically seen during inflammation, such as resting pain, edema, redness, increased skin temperature and, in peritendinitis, also crepitus. Therapy includes: Rest and possible stabilization (orthoses, splints) Local and systemic anti-inflammatories Local application of corticosteroids Chronic Form A long term microtrauma due to unilateral repeated loading causes chronic injury (most commonly due to a faulty work position or athletic loading if the individual started at a later age). Degeneration dominates in the chronic form. Clinical picture includes pain with movement initiation, pain during and after loading. The tendon is painful during palpation and structural changes can be palpated in the tendons found close to the surface (Achilles tendon, patellar tendon, wrist and finger flexors and extensors). Therapy includes: Rehabilitation Surgical intervention

REHABILITATION General Principles Rehabilitation must be based on etiology and pathogenesis of the injury and has to occur in several steps and stages. During rehabilitation, the tendon is being treated – the source of pain, as well as, the cause that elicited the tendon overloading and inflammation and evoked its pain. Affecting the Painful Area or the Starting Point for the Insertion of the Muscles Treatment of edema and inflammation, which is the source of pain at the affected muscle’s insertion, is the goal of localized therapy. Physical therapy incorporates soft tissue techniques and joint

mobilization of the affected segment. Indicated modalities include procedures with an analgesic effect – electrotherapy (DD current, TENS) and procedures with antiinflammatory effects – phototherapy (biolamp, laser). Affecting Changes in the Muscle (Increased Tone and Reflexive Changes of the Corresponding Muscle), Co-contraction Training of Muscles of the Corresponding Segment Muscle relaxation and attainment of correct muscle co-contraction of the involved extremity in a neutral (centrated) joint alignment are the goals of the therapy. Physical therapy utilizes analytical techniques including post-isometric relaxation (PIR), anti-gravity relaxation (AGR) and Brügger’s hot towel roll. Neurophysiologically-based exercises are also included: Vojta’s reflex locomotion, PNF, sensorimotor exercises, and closed kinetic chain exercises. Modalities include ultrasound (as a myorelaxation procedure) or combined electrotherapy. Influence of Postural Functions Treatment of local changes in the muscle is effective only when performed simultaneously with treatment of poor posture and pathological movement stereotypes. Physical therapy includes soft tissue techniques, spinal mobilization, muscle activation of the lumbopelvic stabilization system and their activation within a correct pattern. Therapy also includes components of sensorimotor exercises. Training is done in a neutral (centrated) joint position. Modification of Movement Regime Pathological movement patterns that cause the patient’s problems are modified. Modification or elimination of loading depends on the degree of injury. The load needs to be modified if pain is present during and after exercise (during loading, the pain is minimal or disappears). If the pain is present during exercise or increases during exercise, the load needs to be completely eliminated. Orthotic Equipment The rehabilitation treatment includes orthotic tools that improve the

biomechanical ratio of the segment, ensure unweighting of the affected muscle’s insertion (epicondylar brace, infrapatellar strap, or taping) or ensures a neutral (centrated) joint alignment of the lower extremities (orthopedic inserts). Therapeutic Approaches Rehabilitation is the treatment of choice for tendon overuse injuries. The fundamental principles of therapeutic treatments generally do not differ for individual diagnoses. When selecting therapeutic approaches, the tendinoses need to be accurately identified as acute or chronic because the therapeutic approach is substantially different for the acute and chronic forms. The chronic form cannot be assessed by the length of its involvement as it is defined (in chronic forms, the problems persist longer than 6 weeks). The length of involvement of the pathological loading, rather than the time period of the subjective problems, needs to be used for assessment. Work position, incorrect training techniques, etc. lead to chronic problems even though the patient may not demonstrate any symptoms for a long time. To establish a treatment strategy for a chronic injury, the anamnesis is essential and includes inquiries about the type and means of workload or athletic loading. Next, we are interested in changes in loading and the possibility of their influence on the patient’s symptoms, whether the patient did not change training habits, sport equipment or whether they have started participating in a new sport. In chronic forms, immobilization is not beneficial because it leads to tissue atrophy; rather, the dysfunction needs to be treated actively. In chronic forms, the application of corticosteroids is contraindicated. Repeated administration of corticosteroids leads to trophic changes in the skin and hypodermis during clinical assessment. During surgery, necrosis and fibrotic muscle remodeling is present. When assessing the severity of the findings and determining the strategy for therapeutic treatment, the cortical plasticity of the CNS, or relaxation and selective movement ability need to be assessed. A

dysfunction in the control processes of the CNS is the main cause of a chronic tendon injury in many patients. This dysfunction is most pronounced in individuals whose professional interest is linked to a stereotypical unilateral loading (professional musicians, people working on computers all day, etc.). These individuals, for example, are not able to execute a movement in the wrist while relaxing the shoulder girdle muscles. Their extremity works in a “block” with excessive isometric activity in the stabilizing muscles. This also leads to significant circulatory consequences. Similarly, problems are seen in individuals who engage in a new sport and lack movement efficiency. For example, during tennis, when a patient completes a stroke and does not relax the forearm muscles prior to the next stroke, but instead, holds them constantly in an isometric contraction. An isometric contraction can have circulatory consequences that are sometimes so significant that they will cause a compartment syndrome. Such situations need to be analyzed because assessing only the subjective problems and the localized findings does not address the cause of the problem. Tendon involvement is always connected to locally increased tone or spasm or even structural remodeling changes in the muscles. These changes are not localized only to the affected muscle, but the functional deficit chains itself and to other segments within the stabilization functions of the other muscles. For example, in epicondylitis, TrPs are found in the muscles of the shoulder girdle or the hand. Release of these local spasms must be a standard component of treatment for each tendinosis. A trigger point release is performed manually by deep muscle massage and post-isometric relaxation. “Dry needle” application is also beneficial. Indicated modalities include procedures that increase circulation (contrast baths), electrotherapy, ultrasound, and combined therapy. In some cases, shockwave ultrasound is applied. During therapy for tendinoses, exercises to strengthen the muscle’s stabilization function need to be included because they are often a significant reason for their onset. This is quite typical in high level athletes. During chronic epicondylitis, attention should be focused

not only on the muscles of the forearm, but especially on the lower scapular stabilizers that significantly influence the stabilization function of the forearm. Similarly, in chronic tendon pain of the adductors, the focus is on the stabilization function of the pelvic floor, the diaphragm and the lower abdominal muscles. Training involves the stabilization function in such muscles rather than their concentric activity. The effectiveness of treatment of tendinoses is increased by eccentric exercises through stimulation of healing. If the tendon displays microtears, treatment rehabilitation needs to include strengthening that achieves the tendon’s durability against the magnitude of loading that led to its injury. Next to the actual treatment approach, the cause of tendinosis needs to be addressed. In a work environment, ergonomics (work station modifications) are important. In athletes, the type and magnitude of training load and athletic equipment are assessed and modified.

2.3.3 Degenerative Joint Diseases Pavel Kolář Degenerative joint disease generally occurs due to chronic overloading. Primarily, it affects joint cartilage, and later the subchondral bone and the surrounding soft tissues (joint capsule, ligaments). Osteoarthritis is the most common degenerative joint injury.

OSTEOARTHRITIS Osteoarthritis (OA) is the most common joint injury with a prevalence of 12–15% of the population, affecting both genders. It is found in more than 80% of the population 75 years of age or older. The term osteoarthritis is used in Anglo-Saxon literature. This term denotes a disease in which degeneration and inflammation occur simultaneously. The traditional term osteoarthrosis implies that degeneration is the primary process and inflammation only a secondary process

(complication) that can be decreased or eliminated by treatment.

ETIOLOGY AND PATHOGENESIS Osteoarthritis is a joint disease manifested by changes in the mechanical properties of the cartilage. From an etiological perspective, OA can be classified as primary or secondary. Primary (Idiopathic) OA Disruption in metabolism of the joint cartilage serves as the basis for the development of this disease. Secondary OA In this type of OA, the causes of degeneration are known: Anatomical – congenital dysplasia, Leg-Calve-Perthes’ disease, leg length discrepancy, hypermobility syndrome Traumatic – joint trauma (dislocation, dislocation and intraarticular fractures), chronic microtrauma (excessive loading during sport) Metabolic – diabetes mellitus (DM), gout, deficit in steroid metabolism Inflammatory – rheumatoid arthritis, septic arthritis The following processes can be seen in the involved joint: 1. Cartilage damage – the cartilage’s surface is rough, uneven; local defects initially occur in the cartilage; later, cartilage loss occurs 2. Remodeling activity in the subchondral bone – osteoblast activity increases, subchondral bone is sclerotic, microfractures of the sclerotic bone can develop 3. Osteophyte formation 4. Formation of pseudocysts in the bone marrow underneath the subchondral bone

DIAGNOSIS Diagnosis of osteoarthritis is based on the clinical and radiological

findings. Clinical Picture Usually, the patient seeks a physician’s help due to pain caused by local inflammatory changes and synovitis. It usually is an active type of OA. In advanced stages, pain is caused by joint disfiguration resulting in a significant limitation in function. It is known that the majority of x-ray findings do not correlate with the severity of a patient’s problems. Some patients with clearly pathological x-ray findings remain symptom free. Mainly symptoms are found in the large joints. Subjective symptoms: the cause of pain in OA is explained by an increased intra-articular pressure, inflammatory synovitis, periosteal separation, increased tension at the muscle insertion, tendons and the joint capsule, increased muscle tone, neurogenic pain, or bone hyperemia. In OA, pain typically occurs with exertion and improves with rest. Pain at the beginning of movement is typical while in advanced stages of OA; it can occur at rest. Joint stiffness is usually shorter than 30 minutes. Joint mobility decreases based on location and joint instability develops. Ambulation becomes limited if the weight bearing joints are affected and self-care is limited when the upper extremity joints or the small joints of the hand become limited. Objective findings: joint contour thickening with crepitus, soft tissue edema and exudate, knee joint deformities with a typical onset of genu varum (less often valgum), limited passive range of motion and deficits in movement patterns. Imaging Methods A radiologic picture remains the standard in the diagnosis of osteoarthritis. The signs of a degenerative joint observed on an x-ray film include: 1. Subchondral sclerosis of joint surfaces 2. Joint space narrowing 3. Osteophytes at the edges of joint surfaces, remodeling changes of

the bone adjacent to the joint surfaces (irregularities or less defined structure of the trabecular system, cystic subchondral changes) 4. Irregularity and incongruence of joint surfaces, lack of joint space

LOCATION Coxarthrosis Pain referring into the inguinal region and spreading into the inner aspect of the thigh toward the knee is the main subjective symptom. Pain in the greater trochanter area is an accompanying sign of bursitis. Lumbosacral etiology needs to be kept in mind, as well as, if the pain is present in the gluteal area. Objective findings include relative lower extremity shortening with limited mobility that leads to an anterior pelvic tilt and pelvic rotation and changes in spinal alignment. A normal gait pattern is altered where a waddling (duck) gait can be present if the hip abductors are weak. An exudate can inhibit the gluteus medius muscle. The Trendelenburg test is positive during examination and limited internal rotation, abduction and extension are accompanied by weakness of the hip abductors and extensors. The adductors show increased tone. Gonarthrosis Most often it occurs as secondary gonarthrosis unilaterally in younger men as a result of a trauma while bilateral gonarthrosis is more common in overweight older females. Subjectively, pain is perceived around the knee with weightbearing, ambulation over uneven terrain and with ascending stairs. As the disease progresses, resting pain occurs. Instability or a giving way phenomenon can be manifested (sudden, uncontrolled giving out of the lower extremity with a tendency of falling). Objective findings include poorly defined joint structure and axial deformities (valgus, varus).

Other findings include edema and joint fullness. A Baker’s pseudocyst in the posterior knee is common. Muscle imbalance is evaluated with increased tone in the hamstrings, inhibition of quadriceps femoris, especially the vastus medialis seen. Finally, limitations in joint range of motion and a knee flexion contracture are observed. Other locations for arthritis include the ankle, shoulder, elbow, and wrist joints.

TREATMENT Pharmacotherapy Global Symptomatic analgesic treatment includes analgesics, non-steroidal anti-inflammatory drugs (NSAIDS). Causative treatment consists of symptomatically slow acting medication with a long-term effect (SYSADOA – glucosamine sulfate, chondroitin sulfate, chondroitin sulfate, hyaluronic acid, diacerein, etc.). Local Non-steroidal antiflogistics in the form of a gel or an ointment are administered and corticosteroids applied intra-articularly during inflammatory joint irritation and with resting pain. SYSADOAs are applied intra-articularly. Surgical Procedures Surgical procedures can be divided into arthroscopic procedures involving joint surface treatment (cartilage debridement), surgical procedures affecting loading distribution (corrective osteotomies) and joint replacements – alloplasty. Rehabilitation Olga Dyrhonová, Pavel Kolář

Rehabilitation treatment, specifically a historically beneficial modality treatment with an emphasis on exercise therapy (see below), has an important role. The selection of a rehabilitation treatment depends on the stage and activity of the disease. In the irritable stage, joint exodus can occur as a manifestation of synovitis, especially in the knee joint. The exudate prevents volitional quadriceps contraction and contributes to the atrophy of this dynamic stabilizer leading to joint instability. In this stage, a resting regimen is followed with 2–3 days of preventative positioning; for coxarthrosis, in the prone position to affect a flexion contracture and in supine with the lower extremities in neutral in order to prevent any additional rotational positioning of the involved extremity. To prevent more atrophy from inactivity, isometric exercises of the abdominal, gluteal and thigh musculature are implemented. Passive movements in a sling or in the water are beneficial due to decreased weightbearing. Relief can be achieved by manual traction of the hip in the direction of the femoral neck or along the axis of the lower extremity. With joint irritation subsiding, the focus is on releasing the short muscles and gradually increasing active exercises. Forearm crutches are recommended for ambulation with future progression to a single point cane which the patient uses on the upper extremity contralateral to the involved lower extremity. When the lower extremity symptoms improve, active exercise is expanded to include resistive exercises and pulley-based equipment. Joint overloading, painful end ranges of movement and swinging movements should all be avoided. In the knee joint, the exudate needs to be eliminated prior to the initiation of exercises. The goal is to maintain full knee extension, which can be ensured by lower extremity positioning into knee extension, or possibly by alternating with at least 10 degrees of flexion. Patellar mobility is essential for the correct function of the quadriceps muscles and, for this reason, patellar mobilization is included in the treatment program. Surely, hamstring muscle flexibility, active quadriceps strengthening, including the vastus medialis need to be implemented. Based on the type of involvement, the patient can use various types of braces. Unstable

surfaces and sensorimotor exercises are an important component of physical therapy. Modalities Aquatic therapy in the form of individual or group exercises allows for movement under unweighted conditions. The whirlpool decreases edema and works as an analgesic. Muscle relaxation electrotherapy can be applied. In the irritability stage, analgesic electrotherapy procedures not eliciting hyperemia are beneficial. In the chronic stage, heat therapy is indicated – shortwave, microwave diathermy. Correction of a Movement Regimen In osteoarthrosis, the basic principle is to avoid overloading of the affected joint and encourage the joint’s unweighting. Weight loss is another lifestyle modification for patients who are obese. Orthotic Equipment Orthotic aids ensure unweighting of the affected joint and orthopedic shoe inserts and orthopedic footwear modifications are indicated. In the advanced stages of arthritis affecting weightbearing joints, the patient is provided with a single point cane or forearm crutches. Braces can be prescribed for patients with secondary instability and axial joint deformity. Arthroplasty Martina Votavová Joint replacement by arthroplasty is used in cases when the joint is a source of intense pain or the function of the joint significantly worsens. For many years now, the hip and knee joints have commonly been replaced, whereas the shoulder, elbow and ankle joints have started to be replaced in recent years. Surgical procedures involving the small joints of the hand, such as the metacarpophalangeal and the radiocarpal joints, are evolving. The implant is usually made from metal materials (steel, an alloy of metals or titanium) and the contact surfaces are made with metal,

polyethylene or ceramics. Two basic types exist– cemented and noncemented joint replacements; however, hybrid implants are also being used. The indications for arthroplasty differ for individual joints depending on whether the involved joint is a weightbearing joint taking part in verticalization, how significant the limitation of range of motion is in the context of preserving joint mobility for patient’s independence, and that comorbidities and other possible reasons exist for the implant to not be tolerated or to be rejected. The actual indication comes from a specialist, an orthopedist, and should ideally be an outcome of an interdisciplinary approach. Rehabilitation Following Arthroplasty Martina Votavová, Věra Cikánková Actual physical therapy occurs in two phases: pre-operative and postoperative. The success of the surgical procedure depends to a certain extent on the quality of the administered physical therapy. Pre-operative Phase The rehabilitation plan of care must be preceded by a detailed examination, which includes kinesiological analysis, goniometric assessment and the assessment of quality of everyday life using standardized questionnaires (HAQ, FIM). The pre-operative phase focuses on the following: 1. Treatment of the affected joint – the goal is to correct muscle balance in the area of the affected segment and decrease contractures 2. Gait training with decreased weightbearing on the affected lower extremity while using forearm crutches or axillary crutches, assistance with grasping 3. Self-care training by the uninvolved extremity 4. Modification of a breathing pattern 5. Improvement in overall fitness 6. Patient education – patient should be educated about the early post-operative period, the need for early verticalization and an

active rehabilitation approach Post-Operative Phase Specific physical therapy is based on the general principles of rehabilitation for joint surgery, the type of surgical procedure, type of endoprosthesis used and the physician’s recommendations – while taking into consideration each individual’s specific factors (fitness level, age, other diseases such as osteoporosis, rheumatic diseases, etc.). Successful surgery usually eliminates pain sufficiently enough to continue with basic functions. The goal of physical therapy is to train the musculature without overloading the operated joint and to attempt to eliminate any abnormalities in movement patterns. In patients after soft tissue reconstructive surgeries, the progression of physical therapy treatment is prescribed by a surgeon. Early Post-Operative Phase During the early post-operative period, breathing exercises and isometric muscle contractions are implemented. At this time, preventing thromboembolism is the main focus. The principles of rehabilitation care are followed (prevention of contractures, positioning). Modalities (especially cryotherapy) can be initiated shortly following surgery. Continuation during Hospitalization Following upper extremity surgeries, unweighting of the involved extremity is an integral component. At the same time, the cervical and thoracic spines are addressed as these areas become overstrained due to a change in movement patterns. Care of the incision site following the removal of stitches (soft tissue techniques, laser) should be implemented for all patients. After lower extremity surgeries, the fit of the crutches and the gait pattern should be assessed. Correction of extremity length should also be addressed. Treatment using modalities assists in healing and decreasing pain. A biolamp or laser can be used to decrease a hematoma. Cryotherapy is indicated during the early post-operative period. Aquatic

procedures are indicated only after the incision site completely heals. Balneologic Treatment Comprehensive balneologic therapy is prescribed by an orthopedist, rehabilitation physician or a rheumatologist starting at stage III coxarthrosis and gonarthrosis, and for arthritis in other locations if the disease causes long-term or repeated sick-leave times. Comprehensive balneologic treatment is also indicated in patients following a joint surgical procedure, including arthroplasty, up to one year post-surgery. Home Care A patient should be discharged from a medical facility in stable condition with satisfactory range of motion of the replaced joint and sufficient independence to be able to stay home without assistance of another person or with established assistance. The patient should be provided with assistive devices. During hospitalization, the patient is instructed in a home exercise program, educated on which movements should be avoided and told the weightbearing status of the involved joint. If the patient cannot be discharged to a home setting, the patient is transferred to a specialized medical setting (i.e., rehabilitation institutions, assisted living facilities, or skilled nursing facilities). Lifestyle Modifications and Limitations The patient should be educated on the expected lifetime of the endoprosthesis, the possibility of wear and tear, and appropriate loading. This relates to activity modification and often changes in body weight. Earlier, joint arthroplasty was considered a contraindication for magnetic resonance imaging or magnetic therapy. Given the fact that new materials are now used for implants, this no longer applies and the indication for MRI testing or magnetic therapy is decided by the surgeon. Hip Joint Arthroplasty This arthroplasty has two components – femoral and acetabular.

Three types of endoprostheses are used – cemented, non-cemented and hybrid. The cemented endoprostheses are usually implanted in older patients. Non-cemented endoprostheses are used more often in younger individuals. They require a longer non-weightbearing prior and full loading is allowed only after bone surface transformation with the surface of the implant, which occurs approximately 6–12 weeks after surgery. Indication Arthroplasty is indicated in damaged, uncontrolled arthritic joint pain, and in inflammatory (rheumatic) diseases. Next, it is indicated in cases of post-traumatic damage or avascular necrosis of the femoral head. Another indication includes joint reconstruction following the surgical removal of tumors in the proximal femur. Post-Surgical Rehabilitation Protocol At an early post-operative stage, breathing exercises, positioning, active upper extremity exercises, isometric lower extremity exercises and prevention of thromboembolism are implemented. The patient can stand up the second or third day after surgery. Assisted hip flexion and abduction, balanced sitting, and transfers are practiced. Standing with assistive devices and decreased weightbearing of the lower extremity is implemented based on surgery precautions. Gradually, exercises in prone (abduction and extension) are initiated and gait with assistive devices and decreased weightbearing of the involved lower extremity is assessed. Sidelying positioning on the non-involved lower extremity with a pillow between the knees is practiced. In the case of an external rotation alignment, the involved extremity needs to be aligned and an anti-rotation boot can be applied if needed. Starting week three, the patient begins stair training. Daily prone positioning is important to prevent muscle contractures. The patient should be educated on situations that can lead to the dislocation of the endoprosthesis – crossing the involved lower extremity across midline, sitting at the edge of a bed, hip flexion with knee extension (excessive long lever). The patient is instructed in

placing a pillow between their knees in sidelying (preventing undesirable adduction). External rotation is excluded. Prior to a patient’s discharge, the patient is instructed in home exercises, which should be performed 2–3 times per day, slowly, and not using momentum, each exercise should be repeated 5–10 times and synchronized with breathing. Dislocations, post-operative paralysis (femoral and sciatic nerves) and inflammatory complications are among the most common complications. The involved extremity can be gradually loaded according to the surgeon’s guidelines and gradual weaning off of the crutches depends on the type of endoprosthesis. Full loading usually occurs at 3–6 months unless indicated otherwise by the surgeon. Knee Joint Arthroplasty Indications It is indicated when the involved joint is a source of uncontrollable pain or joint function is significantly disrupted, such as in morphologically significant gonarthrosis, inflammatory rheumatic diseases, post-injury conditions (especially intra-articular fractures), systemic deficits of the movement system (Paget’s disease) and tumors. The advantage includes the possibility of correcting the axis (Fig. 2.3.3-1; Fig. 2.3.3-2A,B).

Fig. 2.3.3-1 Knees, AP projection: significant decalcification in the area of both knee joints, maximal symmetrical narrowing of joint spaces with damage in the area of the femoral and tibial condyles

Fig. 2.3.3-2A,B Juvenile idiopathic arthritis: the stage after total knee replacement of both knees without signs of release (published with the permission of the RadioDiagnostic Department of the Rheumatology Institute)

Post-Surgical Rehabilitation Protocol In the early post-operative phase, standard care includes positioning of the involved extremity, breathing exercises, fitness exercises of the non-involved extremities, and prevention of thromboembolism. Two or three days after surgery, the patient is usually in an upright position. Specific physical therapy is initiated with isometric exercises of the quadriceps and active exercises for the distal aspect of the leg. Standing and then ambulation are practiced with assistive devices and decreased weightbearing of the involved lower extremity according to the physician’s guidelines. The extremity is alternately positioned in flexion and extension at the knee joint and a large therapy ball can be used to increase this effect. Attention is paid to achieving and maintaining sufficient knee extension. The analgesic and antiinflammatory effects of cryotherapy need to be emphasized to prevent complications. Continuous passive motion (CPM) equipment and assisted exercises are initiated. The patient can attain the prone position when the incision is well healed or when the stitches have been removed. Movement into flexion is gradually increased, but not forced past 90 degrees. It is best to perform the exercises slowly two times per day with 5–10

repetitions of each exercise. If the patient demonstrates a good grip (and if not contraindicated by the surgeon), forearm crutches are recommended for decreased weightbearing right after the surgery. Gradual weaning off the crutches is done according to the surgeon’s recommendations. Optimal recovery is usually achieved 3–6 months post-surgery. In the future, the patient should avoid kneeling, deep squats and jumping. Ankle Arthroplasty Indication Arthroplasty is indicated in cases of joint damage and uncontrollable joint pain. These situations occur in rheumatic diseases (especially rheumatoid arthritis) and arthritis (most often secondary to posttraumatic comminuted intra-articular pilon fractures of the distal tibia). Post-Surgical Rehabilitation Protocol This is a quite complex surgery and the extremity is immobilized in a cast for 3–6 weeks after the surgery. This is followed by 6–12 weeks of ambulation with decreased lower extremity weightbearing. Passive and assisted movements and incision care are indicated at the beginning of rehabilitation. Full function is usually achieved 16 weeks post-surgery. Rehabilitation treatment also includes orthotic assessment and provides the patient with special orthopedic shoe inserts or orthopedic footwear. Shoulder Joint Arthroplasty Indication It is indicated if the affected joint is a source of pain that cannot be conservatively controlled or if joint function is significantly limited. Most frequent scenarios include inflammatory rheumatic diseases (rheumatoid arthritis, ankylosing spondylitis), post-injury conditions, shoulder joint degenerative disease, systemic deficits of the movement system and tumors (Fig. 2.3.3-3; Fig. 2.3.3-4).

Fig. 2.3.3-3 Extensive cystic remodeling and damage in the left humeral head. Diagnosis of rheumatoid arthritis (published with permission from the Radiodiagnostic Department of the Rheumatology Institute)

Fig. 2.3.3-4 Left shoulder joint replacement without signs of loosening (published with permission from the Radio-diagnostic Department of the Rheumatology Institute)

Post-Surgical Rehabilitation Protocol In the early post-operative phase, the upper extremity is positioned on a pillow in flexion and slight abduction and slight flexion at the elbow (so that the position approximates an anatomical alignment). Prevention of thromboembolic complications is emphasized. The following are indicated: cryotherapy of the involved joint, breathing exercises, finger and wrist exercises, passive shoulder flexion and abduction in a pain-free range, elbow exercises, extremity positioning and sling use during ambulation and at rest. A continuous passive motion machine is utilized. The intrascapular muscles are strengthened and the patient is taught positioning of the involved extremity into flexion and abduction by using their noninvolved extremity. Isometric exercises are initiated upon the surgeon’s recommendations and later expanded by assistive shoulder range of motion and incision site care. Starting at three weeks post-surgery (unless instructed otherwise by the surgeon), active shoulder exercises without scapular movements can be initiated. Pendular movements are recommended. A sling is usually used for three weeks. Occupational therapy, especially for ADL training, is also included in the treatment. Complex therapeutic concepts (most frequently PNF, Vojta’s reflex locomotion) or their components are used with great benefits in rehabilitation of postoperative shoulder conditions. Elbow Joint Arthroplasty Indication Elbow joint replacement is indicated with intense, uncontrolled pain or when a significant decrease in function is present, especially when both elbows are affected and limit the patient’s independence. Movement between 30–130 degrees is sufficient for activities of daily living.

Post-Surgical Rehabilitation Protocol Surgical procedures of the elbow often involve significant reconstruction of the periarticular soft tissues and physical therapy is administered according to the surgeon’s guidelines. In the early post-operative phase, the non-involved extremities are exercised for conditioning, breathing exercises are administered and the prevention of thromboembolism is ensured. Therapy initially implements passive, assistive and later active exercises without resistance administered in a pain-free position. Exercises involve all planes of movement (unless indicated otherwise by the surgeon).

2.3.4 Inflammatory Diseases Pavel Kolář, Olga Dyrhonová, Jiří Kříž

ETIOLOGY AND PATHOGENESIS Inflammation is a stereotypical reaction of an organism to an injury. It is an essential means of innate immunity and one of the regulatory mechanisms of homeostasis. Tissue damage may occur (autoimmune processes) during an excessive inflammatory reaction. Often it cannot be determined when the inflammatory reaction was initiated for defense and when tissue damage occurs as a result of an autoimmune reaction. The inflammatory reaction occurs in vascularized connective tissue. Blood plasma, blood cells, vessels, cellular and intercellular components of connective tissue all contribute to the inflammatory reaction.

STERILE INFLAMMATION This is a tissue reaction to acute or chronic overloading (see above Chapter 2.3.2 Soft Tissue Injuries Caused by Overloading) or develops during worsening of a degenerative process (osteochondrosis, arthrosis) (see the above Chapter 2.3.3 Degenerative Joint Diseases).

INFECTIOUS INFLAMMATION Classification Based on Etiology Bacterial, viral or parasitic agents can be the source of infectious inflammation. Based on etiology, infectious inflammation can be classified as non-specific and specific. Non-specific Staphylococcus aureus is the most common cause of non-specific purulent inflammation and it is a source of infection in 90% of the cases. This bacteria demonstrates variability in antigen structure, high metabolic activity, good adaptation to worsened metabolic conditions, easy growth and rich enzymatic content. Other causes include Streptococcus haemolyticus, Proteus, Pseudomonas, and Escherichia coli. Haemophilus influenzae type B is a source of infection found in children prior to four years of age. Currently, nosocomial infections pose the main problem. Specific Specific inflammation includes tuberculosis, syphilis, brucellosis and mycotic diseases. Tuberculosis Tuberculosis is the most common inflammation in this group. Globally, nearly 30 million people exhibit various types of involvement. In the movement system, tuberculosis affects the spongious bone, synovial joint tissue or tendon sheaths. The spine is affected in nearly 50% of the cases (Pott disease). Other diseases in this group are rare. Clinical Picture At the onset of the disease, the clinical picture may not be significant and, given its various presentations, it can imitate other diseases. The symptoms are global and local. The global symptoms include weakness, fatigue, weight loss, night sweats and slightly increased temperature. In time, local signs emerge, such as pain and limited range of motion.

Examination Initially, radiological findings are negative; later, bone thinning and formation of cavities can be seen. A microscopic or culture sample is positive for microbes (PCR – polymerase chain reaction shows mycobacteria in just a few days). Treatment Treatment is based on long-term administration of a combination of antituberculotics. Surgical treatment can be indicated. Synovectomy is performed in the affected joint and necrectomy in the affected bones. The defects are filled by autologous xenografts. Immobilization of the affected segment is a part of therapy. If the involved spinal or extremity segment is overloaded, it can disintegrate. The goal of therapy is preservation of maximum function of the affected extremities. Classification Based on Location An inflammatory reaction can affect any tissue in the movement system – muscle, tendon, joint capsule, ligaments and bone. An inflammatory infection (pyogenic arthritis, osteomyelitis, spondylodiscitis) can lead to bacteremia (agents enter blood circulation) and sepsis. Based on the affected location, the following can be distinguished: Pyogenic arthritis Pyogenic osteomyelitis Spondylodiscitis Pyogenic Arthritis This is a serious illness with purulent inflammation of the joint synovium (purulent synovitis). The purulent content of the joint leads to the destruction of the cartilage, ligaments and the joint capsule; joint dislocation can occur. Ankylosis is often the consequence of purulent arthritis. Clinical Picture High fever, shivering or even a septic state are typical presentations. The joint is swollen and very painful. Joint movement is limited by

pain and the skin is hot, swollen and red. Examination Laboratory findings show high levels of erythrocyte sediment rate (FW) and C-reactive protein (CRP). Ultrasound examination confirms joint exudate. Treatment Surgical treatment (joint capsule incision), irrigation and lavage are indicated in the acute stage. At the same time, antibiotics are administered intravenously, most often in a double combination. Intravenous administration takes approximately 1–2 weeks and is followed by oral antibiotics for 6–8 weeks together with antirheumatics. Rehabilitation is indicated on day one after surgery. Joint positioning and passive range of motion in a continuous passive motion machine is initiated. In one week, verticalization to standing is initiated and the patient is provided with an orthosis. Osteomyelitis Osteomyelitis (OM) is a non-specific bacterial bone infection. Based on the disease course, it can be classified as acute, subacute and chronic. Acute Form The acute form of osteomyelitis can be further classified based on the type of developed infection as follows: 1. Early osteomyelitis, exogenous – the infection enters the bone directly from an outside source (open fractures, surgical procedures) 2. Hematogenous osteomyelitis, endogenous – the infection originates in the patient’s body (the lungs, kidneys and urinary tract, in the ear-nose-throat region or in the teeth). The source of infection becomes dislodged from its center and enters the areas with the greatest circulation, such as metaphyses of the long bones (thigh, arm, shin) and the vertebral bodies, through a hematogenous path

Acute hematogenous OM is mainly a childhood disease due to the difference in the vascular supply of the bone in children and the adults. In children younger than one year of age, the vessels infiltrate the metaphyses and epiphyses through the growth plate. Therefore, the infection can freely spread from the bone to the joint, leading to joint arthritis. The inflammatory process causes irreversible growth plate damage and results in a growth deficit in the extremity. At the end of the first year, the growth plate between the bone metaphysis and the epiphysis forms a firm barrier that prevents the entrance of the infection from the bone to the joint. The incidence of OM is lower in adulthood and infection affects mainly the spongious bone of the vertebral bodies and the flat bones of the pelvis. Osteomyelitis in Children Clinical Picture The clinical picture includes global and local symptoms. An overall change in condition, fever and shivering occur; only rarely does the illness show a mild course. Local signs include edema, erythema and increased skin temperature. Other signs include extremity pseudoparesis in which the extremity is held in an antalgic neutral position with zero active movement. The child resists palpation or passive range of motion of the affected extremity. Local findings are often concealed by global findings. Examination Laboratory tests show high erythrocyte sedimentation rate – over 100 in the first hour. High levels of CRP and fibrinogen are also present. High neutrophil leukocytosis with shift to the left toward myelocytes is seen on a blood test. An ultrasound examination can show active changes in the surrounding soft tissues. A primary image in the first days after the onset of the illness is negative. Periosteal apposition and remodeling changes are seen at a minimum of three weeks after the onset. Treatment

For treatment, the source of the infection needs to be identified and a hemoculture is collected and a puncture at the site of the infection is performed. Treatment includes administration of antibiotics, ideally based on the results of cultivation and sensitivity of the blood and the extracted fluid. Antibiotics are administered for 6–12 weeks from the onset of infection. Therapy includes mobilization of the affected segment. Immobilization ensures rest for healing of the site of osteomyelitis and has an analgesic effect. A cast or a brace are used if a vertebral body is involved. Surgical intervention is indicated if an abscess or a sequester of the affected bone develops. Chronic Form Chronic osteomyelitis can be primary or secondary. Primary chronic OM is an infectious disease in which low microorganism virulence and a good immune state of an organism do not allow for an acute course of the disease. Primary chronic OM may not show any clinical or cultivated findings. MRI or scintigraphy may not confirm the disease. Secondary chronic OM develops from either endogenous or exogenous acute osteomyelitis. It is characterized by sclerotic bone thickening and cavities with fibrous or granulated tissue containing weakened infectious agents. In chronic OM, remission can occur and last for a short period of time or for several years. Chronic OM can worsen suddenly. Fever, recurrence of local findings (edema, erythema, increased skin temperature, movement limitation in the segment), abscess or fistula can form. A secondary exogenous infection can spread through the fistula. For these reasons, the term remission rather than cure is being used for chronic OM. When the immune system is weakened, exacerbation can occur even 20–30 years after remission. Radiologic imaging, CT scan, three-phase skeletal scintigraphy and cultivation of the source of infection from the extracted fluid confirm

the diagnosis. Treatment Treatment of chronic OM is prolonged and very difficult. Antibiotics are administered long-term. Surgical intervention is indicated to remove the source of infection. Necrectomy is performed with irrigation and lavage for 7–14 days. During chronic OM treatment, three main problems need to be addressed – a bone cavity, disruption in skin covering and deficit in blood circulation in the affected region. Spondylodiscitis Spondylodiscitis is an infectious inflammatory involvement of an intervertebral disc (Fig. 2.3.4-1)which can occur directly or indirectly. Fig. 2.3.4-1 Spondylodiscitis at L2-3 (MRI image

In the first scenario, disc infection develops most often during a surgical intervention due to degeneration or trauma. In the second scenario, it is a hematogenous transmittal of bacterial agents into the disc from another infected center in the patient’s body. During infection, disc destruction occurs at first and it is later followed by the infection spreading to the vertebral bodies of the corresponding segment and by the onset of spinal deformities. The clinical picture shows spinal pain that not only worsens during movement but also occurs at rest and at night. Treatment Administration of antibiotics based on the sensitivity of the eliciting agents forms the foundation of treatment. Segmental stabilization is part of treatment. Stabilization is performed either conservatively using a firm trunk orthosis (most often a Jewett brace) or surgically by a spondylo-surgical procedure. A surgical procedure is indicated based on clinical assessment and findings from the imaging methods (x-ray, CT, MRI).

PRINCIPLES OF REHABILITATION Rehabilitation is based on the type of infection and its activity.

STERILE INFLAMMATION Rehabilitation is identical to the one administered in cases of soft

tissue overuse (see above Chapter 2.3.2 Soft Tissue Injuries Caused by Overloading, Therapy).

INFECTIOUS INFLAMMATION In the acute phase, cryotherapy is administered for its analgesic and anti-inflammatory benefits. In the chronic phase, the goal of rehabilitation is to address the consequences – edema, muscle imbalance and limitations in range of motion. Physical therapy techniques are implemented. Modalities include hydrotherapy (whirlpool, underwater massage, aquatic therapy) and ultrasound for its anti-inflammatory effects. Local osteoporosis in the bones of the affected segment is a frequent consequence of an infectious inflammation. In this case, pulsed magnetic field and distant electrotherapy can be beneficial.

2.3.5 Traumatology of the Movement System Olga Dyrhonová, Pavel Kolář Traumatology of the movement system is a field concerned with prevention, diagnosis and treatment of musculoskeletal injuries resulting from a trauma. Movement system traumatology involves soft tissue injuries (joint capsule, ligaments, tendons, muscles and cartilage) as well as injuries to the skeleton. However, the traumatology field does not address only injuries to the movement system, but also addresses other systems. These include: CNS injury – craniocerebral trauma and spinal cord injury Peripheral nerve injury Injuries to the thorax – contusion of the heart or lungs, pneumothorax, hemothorax Abdominal injuries – liver, kidneys, spleen, pelvic organs, intestines Blood vessel injuries

The injuries occur in isolation or as a polytrauma. Generally, conjunction of connective tissue structures already occurs within three weeks and complete healing occurs in six weeks.

HEALING PHASES Tissue healing occurs in three phases. Inflammation, gradual tissue repair and soft tissue remodeling occur in the area of the trauma. Inflammation Phase I includes a reaction to the hematoma and necrotic tissue. The necrosis is taken apart by macrophages. These cells arrive at the damaged area through blood flow. This phase of healing is known as acute inflammation. It usually lasts 3 days. Repair In the repair phase, special cells from the healthy tissue arrive in the damaged areas along the capillaries (satellite) and begin to form “chains” from which new tissue develops. New capillaries gradually grow in the new tissue, ensuring good oxygenation. Fibronectin is formed. Until day 5 post-injury, the production of type III collagen increases, followed by type I collagen fibers production until week 3. After a muscle has been injured, full-fledged muscle fibers do not develop, but a scar is formed from connective tissue. Their fibers organize themselves along the lines of acting forces and are able to withstand traction. However, they are less flexible than a healthy muscle fiber. Often, especially following serious muscle injury, the original number of muscle fibers does not develop and the muscle is also not as large or as strong as prior to the injury. However, it can still contract and relax as quickly as before. Restoration of Function In stage III, muscle strength is renewed and other remodeling of the injured area occurs. This phase lasts from several days to several weeks

depending on the extent of the injury.

WOUNDS Open wounds can be classified as cuts, lacerations, lacerated contusions, shot gun and detachment injuries.

CONTUSION A contusion can involve either simple bruising, “bumping” or separation (detachment). Detachment type injuries occur by activity of a tangential force causing the tissues to move against one another resulting in the formation of a blood-filled cavity between the tissue layers.

Treatment for a Detachment Type Injury Treatment consists of puncturing the cavity and removing the hematoma. Following the puncture, it is recommended to apply a compression bandage, which prevents refilling the cavity. Compression, however, is unsuccessful in a number of cases. If the cavity fills again with blood, surgery is indicated in which an incision and drainage of the cavity is performed.

TENDON INJURIES Injuries to a tendon or a muscle can be either open (occurs during a wound injury) or closed (most often the result of a contusion). During an injury, either a complete disruption in the structure occurs resulting in a complete loss of function in the muscle or tendon or a partial disruption occurs in which the function of the tendon and the muscle is partially preserved.

THERAPY Treatment differs for a complete and partial lesion.

In a complete lesion, the tendon is surgically repaired followed by 2–6 week long immobilization. The length of immobilization depends on the injury location and the strength of the surgical sutures. The length of immobilization is indicated by the surgeon. In a partial injury, the injured segment is immobilized for 3–6 weeks.

MUSCLE INJURIES DIAGNOSIS Diagnosis is based on patient history, observation, palpation and functional assessment. Ultrasound is the most conclusive method. It is used not only to establish the diagnosis, but also to observe the healing process and to assess the potential for a return to full loading. Based on the situation, the ultrasound should be repeated in two days because a hematoma often occurs on the second day after the muscles relax and is, initially, not evident. Magnetic resonance imaging is more accurate for a muscle lesion diagnosis.

CLASSIFICATION A muscle injury can occur in many ways. Either it is a direct injury known as muscle contusion or an injury caused by an indirect influence, such as a sudden uncoordinated movement or asymmetrical loading during muscle imbalance. A muscle injury is classified based on its severity. If the injury does not damage the muscle bundle, then it is known as a contusion or a strain. If the injury causes a disruption in the integrity of the muscle bundles, then a partial or complete muscle rupture occurs. If the trauma disrupts the muscle fascia, the muscle may protrude through the defected fascia, leading to a muscle herniation. Often, it is present in the thigh or the anterior lower leg. A muscle rupture leads to the formation of a hematoma. It is located strictly intramuscularly if the fascia remains intact and is not observed on the surface or under the skin. If the fascia is disrupted,

the hematoma spreads intermuscularly and can leak down between the muscles. If the hematoma is massive or if the therapy is being incorrectly administered, the muscle may be loaded prematurely and the ideal inflammatory and reparatory phases of muscle healing do not occur, which can lead to heterotopic muscle ossification or muscle calcification. Muscle Cramp It is elicited by an inadequate loss of fluids and ions during activity. Thigh and calf muscles are the most commonly affected areas. Often, it occurs during elevated outside temperatures. For treatment, immediate interruption of athletic activity is usually sufficient followed by stretching of the affected muscles, gentle massage, and sometimes also stimulation of the antagonists or administration of an electrolyte-rich drink. Muscle Soreness It is typically manifested by intermittent muscle pain during loading, which usually occurs the next day after performance. It is characterized by pain with stretching the involved muscle and a transient decrease in muscle strength. Usually, it occurs in recreational athletes at the beginning of training at increased levels, which the muscles are not ready for. Active rest, ice massage over the affected area and also regular massage are effective treatment methods. Low level exercise that is different in nature is also beneficial. Analgesic and anti-inflammatory gels and ointments can be applied locally. Muscle Strain Muscle distension generally occurs by an indirect mechanism. During a strain, the anatomical continuity of the muscle fibers is preserved. The muscle fibers elongate beyond their capacity. A muscle strain can occur following a single excessive force action (acute strain) or it can be caused by prolonged excessive overloading (chronic strain). In both cases, a muscle strain occurs during eccentric contraction. The situation worsens by a lack of fitness, being overweight, during

lymphatic system strain and recurrent injuries. A muscle strain is manifested as spasm-like pain and increased tone with perceived tension, especially when the affected muscle is being stretched. There is a fine line between a muscle strain and soreness. Ultrasound assessment is recommended to establish a diagnosis and determine the length and type of treatment. In the first phase, a relative resting regimen is important. Ice is applied to the affected area (15 minutes). Gentle soft tissue mobilization relaxes the muscle in the strained location. Acupressure massage relaxes the areas of reflexively developed spasms in the affected muscle, as well as, in the muscles reacting to the injury through muscle chains. Dry needling can be used in the areas of reflexive spasms. Muscle Tear A muscle tear occurs more often by an indirect mechanism. The continuity of muscle fibers is disrupted and a blood hematoma forms. Classification Based on Severity: 1st degree – damage of individual muscle fibers (less than 5% of fibers), the muscle fascia is intact, it is a “slight” muscle tear with healing taking 2–3 weeks 2nd degree – more extensive injury, more muscle fibers are involved with localized hematoma and intact fascia, muscle integrity is not disrupted, healing takes 2.5–4 weeks 3rd degree – disruption in many muscle fibers with a partial rupture of the fascia and diffuse bleeding, healing takes 3–5 weeks 4th degree – complete rupture of the muscle and the fascia usually requiring surgery and prolonged rehabilitation Clinical Picture A partial or complete muscle tear is manifested as sharp pain (“pinching”) in the muscle during movement and painful movement restriction. In the early stage, a hollowing can be seen in the muscle,

which disappears in time because it fills with a hematoma. Treatment Acute Stage The extent of the injury needs to be established – based on patient history, clinical assessment and ultrasound findings. A compression wrap (elastic wrap) is applied to the injured muscle. Modalities include the local application of a cold pack (ice for 15 minutes over a single layer of elastic bandage); a longer application can elicit reactive hyperemia and greater blood perfusion of the muscle. Icing is repeated every hour. Galvanic therapy is also indicated. Pharmaceutical treatment is administered globally – antioxidants, as quickly as possible, after the injury – fibrinolytic enzymes, antiinflammatories, or analgesics – and locally – ointments and gels (to control pain and swelling). Rest is important during the acute phase (2–5 days) and it is followed by active treatment. Subacute and Chronic Stages Week 1 Modalities include resting galvanic therapy. Combined ultrasound and electrotherapy is used to relax the muscle and the trigger points (TrPs). Laser applied to the affected area 5–7 times increases metabolism in the tissues and the cells and thus decreases pain in the injured muscle. Manual and instrumental lymphatic drainage is beneficial and performed every other day for a total of 5–7 times and later 1–2 times per week. During lymphatic drainage, the lymphatic vessels and nodes are released and lymphatic fluid flow improves leading to faster absorption of the edema and the hematoma. Starting at day 3 post-injury, local application of heat with gentle muscle massage, acupressure massage or application of dry needling are implemented. Pharmacotherapy continues to be indicated globally or locally by administering anti-inflammatories and analgesics. Enzyme therapy is another option. Week 2

Modalities include distant electrotherapy, ultrasound, laser, hydrotherapy (whirlpool, aquatic exercise). Application of shock wave ultrasound to the affected area is another modality option. A shockwave ultrasound setting leads to increased microcirculation and improved tissue metabolism, which accelerates healing. Shockwave is applied 3–4 times in 7–10 day intervals. Physical therapy is initiated and includes stretching of the involved muscle. Stretching is only performed to pain. Treatment also includes other segments of the movement system, such as spinal and rib mobilization. Correction of muscle imbalances and preparation for gradual loading are the next steps. Week 3 Application of selected modalities is continued. Based on the patient’s subjective report and objective findings, muscle loading is gradually increased. Movement activity must be controlled and recommended activities include exercise bikes, swimming and light jogging on a soft surface. Prior to returning to athletic activity, clinical and ultrasound reassessment of the involved muscle must be performed. The ultrasound assesses the degree of resorption of a hematoma, size of the scar and organization of muscle fibers. In general, the closer the injury is to the muscle insertion (thus the connective tissue), the longer the healing time and return to full loading. Full loading is recommended gradually 3–5 weeks postinjury.

JOINT INJURIES Joint injuries are classified as sprains, subluxations and dislocations. In joint sprains, the physiological joint range of motion is exceeded and swelling and possibly a partial rupture of the joint capsule and the ligaments occurs. Other signs include hematoma and joint bleeding – hemarthrosis and decreased range of motion. Joint stability is

preserved. In a subluxation, the capsule and the ligaments rupture, joint congruency is disturbed and soft tissues can be deposited between the joint surfaces. Joint instability is one of the signs of a subluxation. In a dislocation, there is a complete loss of contact between the articulating surfaces. The signs include joint deformity, restrictions in range of motion and springing during passive range of motion. Joint dislocation is often associated with injuries of the bone, which is referred to as a dislocation fracture. During dislocation, nerves (paralysis) and the blood vessels (ischemia) can be injured.

TREATMENT Closed joint repositioning under general anesthesia is the first step in joint dislocations. If it is not successful, surgical joint revision is performed. This is followed by 3–6 weeks of immobilization. For the shoulder, elbow and knee joints, the extremity is immobilized for 3–4 weeks or for as long as the soft tissues require for healing. In an ankle sprain, functional treatment is currently preferred. Immobilization is used for only a minimum amount of time postinjury until the pain and swelling are under control which is when the period of immobilization is completed and physical therapy is initiated.

BONE INJURIES – FRACTURES Fracture is a forceful disruption in bone continuity. Pathological fracture occurs as a result of another disease that changes bone structure (tumors, metabolic diseases, osteoporosis, etc.) during exposure to a minimal or spontaneous force.

FRACTURE CLASSIFICATION

Fractures can be classified according to individual authors, for example, Neer – classification of proximal humeral fractures according to the number of fragments, Weber – fracture classification of the distal tibia according to the height of the fracture line on the fibula and according to the relation between the height of the fracture line to the syndesmosis. Classification of fractures shows inconsistencies. This is corrected by the AO classification, which is based on the morphological classification of fractures. A fracture is defined by a sequence of numbers with strictly defined rules. Each bone is assigned a number 1 through 8 (humerus – 1, forearm – 2, femur – 3) and every part of a bone is assigned a number 1 through 3 (proximal aspect – 1, diaphysis – 2, distal aspect – 3). The type of fracture is defined by letter A through C (simple – A, with a fragment – B, multifragmented – C). Additional classification of individual types is denoted by the 4th and 5th digit (again using numbers 1-3): 1st digit – the affected bone (1 – humerus, 2 – forearm, etc.) 2nd digit – bone segment (1 – proximal end, 2 – diaphysis, etc.) 3rd digit – basic type of fracture (A, B, C) 4th digit – groups characterizing an individual type of fracture (1, 2, 3) 5th digit – subgroups (1, 2, 3) Example: AO 2-1-A – simple displaced fracture of the distal humerus AO 1-2-B-2 – fracture of the humeral diaphysis with a wedged fragment

BONE HEALING When a bone is injured, the blood supply to the bone from the periosteum, endosteum and the Haversian system is disrupted. For

rehabilitation, general knowledge about bone healing is important because the course and length of healing guide the rehabilitation treatment. The intensity and type of loading during therapy must respect the bone healing process. Bone healing is classified as primary or secondary. Secondary Secondary bone healing is more common and stronger. The healing time is approximately six weeks. Secondary bone healing occurs in conservatively treated fractures and has three phases. In the first phase, inflammation occurs at the fracture site as a reaction to the hematoma. The second phase is a reparatory phase. Granulation tissue (mixture of fibroblasts, chondroblasts and osteoblasts) forms at the fracture site. In the third phase, bone remodeling and remineralization occur at the site of the primary bone callus. Tissue remodeling occurs in the direction of compression and pulling forces. Primary In primary bone healing, direct growth of osteons between the bone fragments occurs. Certain conditions need to be ensured for primary bone healing to occur. These include close contact and compression of the fragments. Fragments must be viable and their stability needs to be ensured. This type of healing occurs in fractures treated by stable osteosynthesis. Stable osteosynthesis fulfills all of the above mentioned criteria. An absolute or relative stability can be achieved in the system of stable osteosynthesis. Primary bone healing occurs during absolute stability. Absolute stability is ensured by screws or plates. Screws can be used in isolation (in fractures of the metacarpals, metatarsals, tibial condyles, ankles or pelvic ring) or in combination with another type of immobilization (plate). The plate ensures absolute stability and allows for early functional treatment of the fracture. The disadvantage is greater

damage of the soft tissues. In the past, osteosynthesis with a splint was used in fractures of the diaphysis of long bones, but today it has been replaced by nailing. Plate osteosynthesis is indicated in epiphyseal and intra-articular fractures. Mainly secondary bone healing occurs in relative stability. Relative stability is expected when intramedullary fixation with a nail, K-wire or an external fixator were used. These are indicated in fractures of the diaphyses and metaphyses. The advantage of an external fixator includes fragment stabilization with a minimal amount of metal material in the tissue. An external fixator is indicated in open fractures, fractures with large soft tissue damage, in pelvic ring fractures and short-term fracture stabilization after a multitrauma (Fig. 2.3.5-1). Fig. 2.3.5-1 Comminuted intra-articular fracture of the elbow joint (distal humerus); presentation after stabilization by an external fixator

FRACTURE HEALING TIMES Secondary bone healing, or healing of conservatively treated fractures or fractures treated by osteosynthesis, K-wire, nail or an external fixator take approximately six weeks.

Primary bone healing or healing in fractures treated by plate osteosynthesis takes approximately three months. Complete bone remodeling at the fracture site occurs within one year from the injury. At about that time, the osteosynthetic material is removed. It needs to be mentioned that these guidelines are not rigid and the assessment of fracture healing is based on radiological findings from which callus formation, a less visible fracture line, alignment of the fragments and whether osteosynthesis (loosening of the osteosynthetic material) is working can all be observed. Radiologic follow-ups occur six weeks post-treatment (repositioning and stabilization). Next, images are taken between 3 and 12 months from the injury (these guidelines are for orientation only; fracture type, treatment and current clinical findings need to be taken into consideration). When the fracture has healed, fixation is removed and gradual weightbearing is allowed. Rehabilitation is initiated during the process of fracture healing. Full loading is allowed after the fracture has completely healed.

TREATMENT Fracture treatment can be either conservative or surgical based on the type of bone healing. Conservative In conservatively treated fractures, secondary bone healing will occur. Conservative treatment is indicated in fractures without dislocation, fractures with favorable alignment of the fragments and dislocation fractures after closed repositioning. Fixation of the fragments (cast or orthosis) and decreased extremity weightbearing/loading (for lower extremities: crutches, forearm crutches) are necessary to ensure healing. Surgical

Surgical intervention is indicated for displaced, multi-fragmented or comminuted fractures, intra-articular fractures and dislocation fractures. Surgery is performed according to the principles of stable osteosynthesis (see above), reposition and stabilization of the fragments is performed. Based on the type of fracture and the type of stabilization, the surgeon determines whether the procedure requires additional fixation (casting, orthosis).

REHABILITATION Rehabilitation in patients with fractures can be initiated shortly after treatment (repositioning and stabilization of the fracture). Rehabilitation during Healing In this acute phase, the goals of rehabilitation include pain control, edema control and maintaining range of motion in the surrounding segments. Rehabilitation therapy depends on whether the extremity is immobilized in an orthosis or a cast. Immobilized Fracture If the extremity is immobilized, an isometric muscle contraction is performed by the immobilized body part. On the other hand, reflexive relaxation of muscles that are in a defensive spasm due to injury needs to be addressed. Next, open kinetic chain exercises are administered with the goal of maintaining range of motion in the unaffected segments. Proprioceptive neuromuscular facilitation techniques are valuable. Modalities include procedures that assist in tissue proliferation and bone healing (pulsed magnetic field). Fractures without Immobilization If the fracture is treated by stable osteosynthesis and does not require additional immobilization, rehabilitation can specifically influence the affected segment. In this case, physical therapy includes scar care and reflexive (Vojta’s reflex locomotion, PNF) or analytical range of motion release in the affected segments. Manual lymphatic drainage is indicated to reduce edema. Modalities indicated for scar treatment include phototherapy (laser,

biolamp) or distant electrotherapy (Basset currents). The ability to keep the wound covered is an advantage of distant electrotherapy. When the sutures have been removed, hydrotherapy can be initiated. A cold whirlpool is indicated as an anti-edematous and facilitative procedure. Aquatic exercises are part of therapy. Rehabilitation in Healed Fractures When the bone is healed, gradual extremity loading is permitted. In immobilized fractures, fixation is removed when the fracture has healed and intensive rehabilitation is initiated. The goal is to improve range of motion and muscle imbalance in the affected segment. Soft tissue techniques, mobilization techniques, continuation of reflex therapy (Vojta’s reflex locomotion, PNF, open kinetic chain exercises) and closed kinetic chain and resistive (Theraband) exercises are indicated. Indicated modalities include ultrasound or combined electrotherapy to relax muscles with increased tone. In addition to a whirlpool, hydrotherapy can include contrast baths, aquatic therapy and swimming.

SPECIAL SECTION

2.4 CLASSIFICATION ACCORDING TO LOCATION This chapter discusses individual orthopedic disorders based on location and their possible influence by treatment approaches. Spine Shoulder girdle Elbow joint Wrist and hand Hip joint Knee joint Ankle and foot

2.4.1 Spine Congenital Developmental Defects Diastematomyelia Meningomyelocele Klippel-Fail syndrome Spina bifida Deformities Scoliosis Hyperkyphosis Lumbar hyperlordosis Torticollis Vertebrogenic Pain Syndrome

CONGENITAL DEVELOPMENTAL DEFECTS Pavel Kolář, Marcela Šafářová Diastematomyelia, meningomyelocele, Klippel-Fail syndrome and spina bifida belong among the congenital developmental defects of the spine. For details about individual defects see above Chapter 2.3.1 Congenital Developmental Defects, Congenital Developmental

Defects of the Spine.

DEFORMITY Spinal deformities are observed either in the frontal or sagittal plane. Deformity in the frontal plane is known as scoliosis. Deformity in the sagittal plane is known as hyperkyphosis or hyperlordosis.

SCOLIOSIS The Scoliosis Research Society defines scoliosis as a side curvature of the spine of 11 or more degrees. The spine does not only curve in the frontal plane, but simultaneously, it rotates in the transverse plane. The vertebrae show a deformed shape. The greatest changes occur at the apex and the transitional vertebrae. An apex vertebra is irregularly wedge-shaped and deformed in the perpendicular as well as horizontal cross-section. The apex vertebra is higher on the convex side than on the concave side and it is flattened in an anterior-posterior direction in the sagittal plane. The further the vertebra is from the apex of the curvature, the less wedged shaped the vertebra is observed to be and the vertebral rotation and torsion are more visible. Rotation is understood to be a spiral rotation of one vertebra relative to the next so that the spinous process of one vertebra is shifted against the spinous process of the other vertebra in the direction of the spinal concavity. Torsion means twisting of the vertebra itself in the direction of the force that is acting on it. Simultaneously with changes of the spine, changes in the ribs occur and involve their course, shape and length. On the concave side of the thorax, a deep drawing inward develops and the ribs are pushed close together. On the convex side, on the other hand, the ribs are spread out and form a gibbus. The scapula on the lateral side of the thorax is shifted cranially and laterally and it is elevated when compared to the other side where the scapula is in a more retracted position. On the side of the convexity, the iliac crest is positioned lower than on the opposite side Fig. 2.4.1-1).

Fig. 2.4.1-1 Adam’s forward bending test used for assessment of paravertebral asymmetries during forward bending

Classification According to Etiology and Pathogenesis Non-structural (Functional) Scoliosis Postural Compensation (with lower extremity shortening) Hysteric With nerve root irritation Reflexive (sudden abdominal accidents) From a rehabilitation perspective, postural scoliosis is not an individual nosologic unit because a postural scoliosis includes compensatory scoliosis, reflex scoliosis and scoliosis found with a nerve root irritation. Structural Scoliosis Idiopathic scoliosis Congenital scoliosis Neuromuscular scoliosis Scoliosis in neurofibromatosis Scoliosis in trauma Scoliosis in tumor disease Scoliosis with inflammation Scoliosis in metabolic diseases Idiopathic Scoliosis Idiopathic scoliosis is the most common scenario of structural

deformities in the frontal plane. It includes approximately 65% of all cases of structural scoliosis. (Fig. 2.4.1-2; Fig. 2.4.1-3; Fig. 2.4.1-4). Curvature greater than a 20 degree Cobb angle occurs in less than 0.5% of adolescent population. Idio​pathic scoliosis endangers the patient throughout bone growth development and sometimes even after the growth has been completed. This is a disease that can develop at any during this long time period and can worsen at any time, sometimes even very quickly (malignantly). The involvement varies across patients with respect to the degree of severity and location of the curvature. Potential negative effects of scoliosis include its progressive development, unpleasant cosmetic consequences, back pain and other health complications (i.e., decreased vital lung capacity, breathing problems, development of kyphoscolioticum, etc.), social and psychological problems during childhood (negative self-assessment, social isolation) and in adulthood (limited options for occupation, lower percentage of marriages) and financial cost of treatment. The etiology of idiopathic scoliosis remains unknown. It can only be guessed which scoliosis will progress. Fig. 2.4.1-2 Clinical finding in an adult patient with idiopathic scoliosis

Fig. 2.4.1-3 An x-ray finding of a patient from the previous picture

Fig. 2.4.1-4 Cobb angle measurement: Th7–57°–L2

Classification According to Onset Infantile- until 3 years of age Juvenile – between 3 and 10 years Adolescent – beyond 10 years of age

Classification According to Size of Angle The extent of the curvature is given by the degrees measured most often by Cobb or Fergusson methods (Fig. 2.4.1-4). Based on the measured Cobb angle, scoliosis can be classified as follows: 10–20° 20–40° 40–60° Above 60° Classification According to Location (King Classification) Location is determined by the main curvature. The apex vertebra serves as the orientation point and, in the frontal and sagittal planes, the following types of curvatures are distinguished: Between C1-C6 it is known as cervical Between C7-T1 it is known as cervico-thoracic Between T2-T11 it is known as thoracic Between L2-L4 it is known as lumbar Between L5-S1 it is known as lumbo-sacral A scoliotic curvature is most commonly located in the thoracic region. It is important to distinguish between a primary and secondary curvature. A primary curvature is one that demonstrates the most structural changes. Examination and Diagnosis The examination is classified into screening and specific. The screening examination is used for the early detection of a deformity. It is done by a pediatrician or another specialist or by trained medical staff or even a non-medical person who is in frequent contact with children (a PE teacher). The sensitivity and specificity of the physical assessment depends on the skill of the examiner and on the degree of curvature. In one of the studies, specially trained nurses were able to identify all children with a Cobb angle greater than 20° during a school screening. The assessment specificity was 91%. Sensitivity and specificity of the

assessment in detection of curvatures greater than 10° was 73.9 and 77.8%, respectively. Early detection of a scoliosis is very important for the treatment strategy and its actual effectiveness. A standing examination of the trunk is key. The overall curvature, trunk compensation and the total height when compared to arm span are observed. In a healthy child up to 10 years of age, the arm span is equal to body height. In an individual with scoliosis, the trunk is shortened by the spinal deformity. The scoliotic curvature can be distorted by the alignment of the spinous processes which rotate toward the side of the curvature’s concavity. Their alignment often does not correspond to the objective extent of the deficit and during examination by an inexperienced examiner, the scoliotic curvature can be overlooked or its extent can be underestimated. During the specific assessment, two areas are mainly targeted. First, it needs to be established whether this is an idiopathic scoliosis and not a postural scoliosis or a scoliosis of different etiology. To eliminate scoliosis from other causes, light brown spots on the skin (“café au lait” spots), subcutaneous soft tumors that suggest neurofibromatosis, hair patches, pigmentation and a lipoma in the lumbar region accompanying diastematomyelia are searched for. The cornea is assessed for possible cloudiness (mucopolysacharidosis), arachnodactylia (Marfan syndrome) and the shape of the auricles (congenital scoliosis). During a clinical assessment, rigid rotation with forward bending is the main manifestation of a structural scoliosis. In a postural scoliosis, the curvature disappears when the child bends forward while in idiopathic scoliosis the curvature remains in every position. In structural scoliosis, minimal or greater vertebral rotation is present and not corrected in any position. When a structural scoliosis is suspected, clinical assessment should be accompanied by radiological imaging. The x-ray film allows for the identification of the size of the structural changes, assessment of the functional and structural components, measurement of the angle of the curvature and determination of the primary curvature. Skeletal age is given by the Risser sign (Fig. 2.4.1-5), which is an important sign indicating

whether skeletal growth has been completed and whether disease progression can be anticipated. The Risser sign is demonstrated by apophyseal fusion at the iliac bone. This sign of growth completion is not 100% reliable, but, in general, it can be said that for scoliosis, the curvature can progress until the apophysis firmly fuses with the iliac crest. A radiological image of the wrist is more accurate in determining more precise growth completion.

Fig. 2.4.1-5 Risser sign in the diagnosis of scoliotic curvature progression. The degrees denote the extent of ossification of the hip bones apophyses; the ossification is completed when the 5th degree is achieved.

Risk Factors for Curvature Progression Next to diagnosing idiopathic scoliosis, the examination focuses on the assessment of signs that can be viewed as risk factors in the context of progressive scoliotic curvature development. Progression of the disease and prediction of its severity are very difficult during the time of initial progression. Only a small number of patients with idiopathic scoliosis progress to the point of potential clinical significance. The probability of progression in patients with predisposing factors can reach up to 90%. The predisposing risk factors that influence the probability of progression include the patient’s age, gender, location of the primary curvature, soft tissue condition, minimal cerebellar signs and compensation for the curvature. a. Age. The initial age of onset of scoliosis is a very important factor for prognosis. The earlier the patient’s age at the time of diagnosis, the worse the prognosis. b. Gender. Idiopathic scoliosis has a greater incidence in girls than in boys. c. Curvature location. Primary curvature location is one of the

d.

e.

f.

g.

criteria for prognosis. Thoracic scoliosis has a less favorable prognosis than a primary scoliosis that is located more caudally. Lumbar scoliosis does not reach levels that are as severe. Scoliosis with multiple primary deformities shows good prognosis (for example, a double curve has a better prognosis than a single curve). Soft tissue condition. Skin and joint laxity is assessed. For idiopathic scoliosis, soft tissue laxity is a significant risk factor in curvature progression. Minimal cerebellar signs. Careful assessment of cerebellar functions has especially important outcome value for the development of the curvature. In patients with potential progression (often malignant), slight signs of a paleocerebellar cerebellar deficit are present. A minimal cerebellar syndrome and soft tissue laxity are considered the most significant symptoms for a potentially progressive curvature. Curvature compensation. Trunk compensation in relation to the pelvis is determined by a plumb line suspended from the middle of the posterior occiput. In a worsening curvature, the plumb line deviates from the center of the sacrum. Compensation can also be assessed by a plumb line suspended from the sacrum to between the heels. The greater the worsening, the greater the predisposition to progression. In idiopathic scoliosis, curvature worsening is not as frequent as in a neurogenic scoliosis. Genetic component. Inquiring about familial occurrence of scoliosis needs to be remembered because of its relation to possible progression. Examination of parents and grandparents should be as thorough as possible. If a positive clinical finding is identified, standing x-ray images should be obtained of parents and grandparents.

On the other hand, progression is less probable in older children with greater skeletal maturity and with a smaller curvature. The probability that a curvature less than 19° will progress is 10% for girls between 13–15 years of age and 4% in children older than 15 years. According to a different study, the probability of progression for

progressive curvatures greater than 10° is 34%, for curvature more than 20° it is 18% and for curvature above 30° it is 8%. Another study that monitored patients with non-treated curvatures identified that 25% of cases stopped progressing prior to reaching 25° and 12% stopped progressing prior to reaching 29°. Treatment Early detection of a scoliosis is among the most important factors affecting the progression of the condition. Immediate initiation of conservative therapy for smaller curvatures can prevent curvature progression and avoid complications of advanced scoliosis. From a few short-term studies it can be assumed that conservative therapy is much more likely to fail in patients with an advanced curvature (they will need to undergo surgery) than in patients with a smaller degree of curvature. A 10-year study conducted in Sweden attempted to support the effectiveness of early detection and timely treatment of this condition by indirect evidence. During an organized information campaign to support screening, the authors found a significant increase in the number of patients referred to local consultation clinics for scoliosis and a number of braces used, as well as, a decrease in the average age of the referred patients, average degree of curvature, and in the number of curvatures greater than 40°, as well as, in the number of cases requiring surgery. Similarly, a British study reported an increased number of cases of scoliosis identified by screening and a decrease in the degree of the curvatures. A Minnesota-based study, performed for eight years after an all-state school program was initiated where 210,000 children were screened each year reported a decrease in the average degree of curvature in new patients and a decrease in the number of patients requiring a brace or surgery. There is no known cure for idiopathic scoliosis. We are left with only symptomatic treatment. The goal is to stop the curvature from further progression. Physical therapy and spinal bracing are among the fundamental approaches of conservative treatment for idiopathic scoliosis. In certain cases, surgical intervention is necessary. For diagnosis and treatment, this is a condition spanning across

various disciplines. A pediatrician, orthopedist, rehabilitation physician, physical therapist and, in certain cases, also a neurologist all participate. An orthotist also plays an essential role. Regardless of the lack of sufficient evidence, the following are considered essential for maximum effectiveness with treatment: Early detection of scoliosis (in smaller curvatures) and immediate initiation of treatment (therapy in the first phase). Treatment initiated at a greater degree of curvature limits treatment effects due to the progression of the condition. Examination and assessment of risk factors of potential progression. In patients with potential progression risk factors, an intensive specific treatment rehabilitation should be initiated and it should include parent participation, including patients with smaller curvatures. Adherence to brace wear on a consistent basis is also important Establishment of cooperation between the patient, parents, physician (orthopedist, pediatrician), physical therapist and orthotist. Movement activity should not be limited in any substantial way. Congenital Scoliosis Congenital scoliosis develops in disturbances during spinal development. The first disturbance includes a deficit in vertebral body formation (most often a wedge vertebra), which becomes the apex of the curvature (Fig. 2.4.1-6). In a segmental disturbance, a separation of the individual vertebral bodies does not occur and a part of the spine is connected by a ledge. In the area of the ledge, the vertebral bodies do not grow and scoliosis develops (Fig. 2.4.1-7).

Fig. 2.4.1-6 Deficits in vertebral body formation

Fig. 2.4.1-7 Deficits in spinal segmentation

A congenital scoliosis observed immediately after birth may or may not progress during growth. Progressive deformity worsening and other problems are indications for surgical osteotomy and spondylodesis at an early age (2–4 years of age). Neuromuscular Scoliosis This occurs in deficits of the CNS in central and peripheral pareses and in primary muscle diseases (myopathies). The treatment depends

on curvature progression. In certain cases, significant curvature progression can be observed during its frontal and sagittal worsening (Fig. 2.4.1-8; Fig. 2.4.1-9; Fig. 2.4.1-10). Fig. 2.4.1-8 Clinical picture of a patient with neuromuscular scoliosis – anterior view

Fig. 2.4.1-9 Clinical picture of a patient with neuromuscular scoliosis - posterior view

Fig. 2.4.1-10 Radiological findings for a patient from figures 2.4.1-8 and 9

Scoliosis in Neurofibromatosis A neurofibroma in the spinal area elicits a short curve of the affected spinal segment. This type of scoliosis is suspected when the typical light brown (café au lait) skin spots are present. When presumed as an option, it is important to remove the neurofibroma and perform corrective fusion if the curvature progresses. Other Types of Scoliosis They are present with inflammations – i.e., tuberculosis, post-injuries, status post spinal surgeries and in certain diseases, such as various epiphyseal dysplasias, osteogenesis imperfecta, mucopolysacharidoses, and Marfan syndrome. Rehabilitation

Exercise is recommended as treatment to attempt to influence curvature progression and also to facilitate therapy to enhance the effectiveness of bracing. Scientific evidence supporting physical therapy treatment is limited. Only a few studies have been published on this topic. It is also not clear for what time period physical therapy should be carried out. It can include regular exercises or specific treatment techniques that differ in their approaches. A kinesiologic analysis serves as the foundation for the selection of a specific physical therapy approach. Treatment selection also has to respect the type of scoliosis, degree of curvature, patient’s age and patient’s and parents’ cooperation potential because certain techniques require daily assistance by a trained person (usually a parent). A specific formative influence of muscle function on skeletal development is mainly used within a physical therapy treatment. The treatment is highly individual. Despite different techniques influencing musculature, these general principles always need to be followed: Specific activation of autochthonous (deep lying) musculature that affects alignment of individual segments; its symmetry is disrupted in idiopathic scoliosis. The effort to influence a deficit in synergy between the ventral and dorsal musculature and insufficient differentiation of muscle function. Establish diaphragmatic breathing in correct pelvic alignment (pelvis is aligned in rotation) because the kinesiology of respiratory function is completely disrupted. The exercises are performed after the pelvis is corrected. Exercises are almost always performed in traction. Exercises are focused on muscle function and accompanied by mobilization techniques. The methods used most often in therapy for scoliosis include: Klapp’s crawling method, Schroth method and Vojta’s method.

Klapp’s Crawling Method This method was developed by a German orthopedist, Rudolf Klapp (1873–1949), and involves locomotion in the quadruped position. The fundamental idea of “creeping exercises” was initially indicated for pediatric patients with poor body posture. This exercise principle is based on the layout of the spine between 4 points of support with simultaneous locomotion (creeping) directly influencing rotation and spinal muscle stretching and strengthening (Fig. 2.4.1-11; Fig. 2.4.1-12). This technique uses two basic types of creeping: Kreuzgang (reciprocal crawling) and Passgang (nonreciprocal crawling). In the first type of crawling, the push-off extremities are contralateral and in the second type of crawling they are ipsilateral. Crossed crawling is indicated more in a C-shaped scoliosis and ipsilateral crawling for an S-shaped scoliosis. The exercises can be modified so that curvature correction occurs in patients with scoliosis (movement of the trunk into vertical or horizontal curvature, arching, swing movement, etc.) (Fig. 2.4.1-13). Certain principles need to be followed during the exercise: the movement is initiated from a specifically determined initial position, slow and smooth extremity pressure should be directed into the mat even in the stepping phase while maintaining external rotation and slight abduction in the key joints and erect spinal alignment, etc. In the past, this was a mechanical approach and the patients spent several hours per day doing this locomotion. In current practice, there is a tendency to apply principles from this concept that are based on the knowledge of developmental kinesiology. That is the reason why, for example, it is beneficial to progress from less challenging positions (forearm support vs. the hand) to more challenging positions (kneeling, bunny hop, spider, arch). (Fig. 2.4.1-14). The alignment is corrected in key joints, the breathing pattern is addressed and mobilization and stretching techniques are used. Overall, spinal posture improves and the core muscles are being strengthened. Exercising in scenarios that are challenging for maintenance of postural stability is also beneficial. Fig. 2.4.1-11 Elements from Klapp’s

crawling – starting position- lateral view

Fig. 2.4.1-12 Elements from Klapp’s crawling – initial position – view from the top

Fig. 2.4.1-13 Elements from Klapp’s crawling – deep crawling

Fig. 2.4.1-14 Elements from Klapp’s crawling – C arch

Indication In the presence of scolioses, poor body posture, poor postural stability, functional deficits of the movement system, muscle imbalances and core muscle weakness. Contraindications Inability to master the exercises (motorically, mentally) and situations in which loading and weightbearing of the upper and lower extremities is contraindicated. Schroth Method Katharina Schroth viewed scoliosis as a three-dimensional deformity. She divided the trunk into three right angle blocks stacked on top of each other: 1. Pelvic (starts below the abdomen and ends with the ribs)

2. Thoracic (begins at the abdomen and extends to level T6 and lower third of the ribs) 3. Shoulder (from shoulder level to the mandible) With scoliosis, these blocks shift in the frontal plane, rotate against each other and attain a wedged shape, which results in torsion. As a result of overrotation, the body collapses and shortens. Thus, the deficit involves the frontal, transverse and sagittal planes. The author’s selection of exercises is based on this state. The goals include: Active extension in the sagittal plane Lateral flexion in the frontal plane Derotation in the sagittal plane During therapy, the following exercise elements are applied: Elongation in the direction of longitudinal axis Specific pelvic correction Exercising muscles in derotation-supported position Specific breathing exercises in derotated alignment This method presumes a good motivation and cooperation from the patient. Vojta’s Method The development of an idiopathic scoliosis means a restriction in the predisposed reciprocal pattern (a crossed pattern in which extremity differentiation occurs during the support and phasic function) while lacking the organization of time and spatial developmental sequence of an autochthonous musculature. The global pattern of reflex crawling contains muscle synergies and partial patterns of motor ontogenesis that serve as a foundation for healthy motor development. Inclusion of these patterns can significantly affect disturbed functions of the autochthonous musculature, which controls the reciprocal pattern spreading from the CNS to the entire axial skeleton. Vojta’s method is indicated in the treatment of scoliosis when: Specific activation of deep musculature, which directly influences vertebral alignment; if the alignment of individual spinal segments

is disrupted, the reciprocal movement models cannot be implemented. Specific activation of muscles that are difficult to control volitionally (i.e., serratus anterior, transversus abdominis, etc.) and are key for postural function. Improving body schema, “waking up” of certain areas and inclusion of certain areas that have been excluded by the CNS. Activation of a correct respiratory pattern, inclusion of the diaphragm into respiratory and postural functions. During therapy for scoliosis using Vojta’s method, both or all three therapeutic models should be implemented (reflex crawling, reflex rolling and the initial position). In all reflexively triggered models, the muscle is activated in its function that corresponds to the given postural situation (supine, sidelying or prone) and planned mobility. In each of these movement manifestations, muscle synergies corresponding to partial patterns of physiological human ontogenesis can be found. A patient’s active participation is important; the physical therapist leads the treatment and educates the mother (or other family members). The lack of well-trained physical therapists poses a disadvantage to this technique. The therapy is challenging given the need for accuracy of administration and the time which needs to be spent with the patient. The effectiveness of this treatment relies on other factors as well (soft tissue quality, location of the primary curvature, age and cerebellar signs). Incorrectly administered therapy is ineffective and can even be harmful because it encourages muscle imbalance, which can lead to a worsening of the curvature. Modifications of Physical Activity Next to specific exercises, lifestyle modifications are very important. No agreement exists and thus, in many cases, the education of the patient and the parents is almost counterproductive. It has not been demonstrated what effect movement activity poses on the development of scoliosis. It is recommended to not limit physical activity in any substantial way. Prolonged static loading and unilateral

loading encouraging a pathological body posture are the only undesirable conditions. Orthotic Treatment The goal of treatment by orthotic supports is to improve the scoliotic curvature and especially to prevent further progression of spinal deformity. Bracing treatment is generally effective when it is immediately implemented to correct curvature. Initial radiological films of patients with an orthosis often show 50–60% curvature correction. Long-term studies (longer than a five-year observation) showed that an immediate correction is often only temporary. The years following treatment by an orthosis showed a gradual decrease in correction with an average overall improvement of 2–4 degrees when compared with values obtained prior to wearing a brace. The significance of orthoses in the prevention of curvature progression is less clear because despite this treatment, the scoliosis can continue to progress further. No prospective studies confirming the effectiveness of orthotic treatment have been published so far. Retrospective study including a control group of non-treated subjects found that the patients treated by an orthosis showed a smaller degree of curvature progression than non-treated patients. However, the differences were not statistically significant. The absence of matched controls in studies exploring the benefits of orthoses limits the interpretation of the independent effect of an orthosis on the results. In patients with a high risk of progression (joint and skin laxity, level of the primary curvature, etc.), treatment including bracing combined with physical therapy is the only option for conservative treatment. The effectiveness of treatment by a brace is very often limited by the patient’s cooperation. Generally, it is recommended to wear the brace 23 hours per day. In adolescence, it is very difficult to adhere to this time interval, which significantly influences the overall time period for brace wear. One study reported that the patients wore their brace on average only 65% of the recommended time and only 15% of patients showed a high level of cooperation. This is often related to the patient’s body image perception and the psychosocial consequences of

wearing a brace. Some studies have shown a relationship between brace wear and psychological effects, decreased self-image and disrupted relationships within the patient’s surrounding environment. Establishing the patient’s and the parents’ participation is one of the most important tasks during the treatment of idiopathic scoliosis. Especially important is the cooperation of patients with idiopathic scoliosis who demonstrate a primary curvature in the thoracic region and in whom the scoliosis manifested itself prior to 10 years of age. They are hypermobile and show minimal cerebellar signs. In such patients, the orthosis should already be applied when the curvature is smaller. Surgical Treatment The goal of surgical correction is to decrease the rib hump and pelvic rotation and ensure stability. Currently, surgical intervention is not being considered if the curvature progression is not greater than 40– 50°. Only a few clinical studies assessing the effectiveness of surgery report that a surgery can correct a curvature in the frontal plane when compared to a group of non-surgically treated patients, but it shows significant limitations in maintaining stability and achieving correction in other planes.

HYPERKYPHOSIS Pavel Kolář Hyperkyphosis is a spinal curvature into the dorsal convexity that overreaches the physiological range (Fig. 2.4.1-15A; Fig. 2.4.1-15B). Based on etiology, hyperkyphoses are classified as follows: I. II. III. IV.

Scheuermann’s disease (juvenile kyphosis) Congenital Postural Secondary kyphosis (status-post laminectomies, post-traumatic, following radiation, in osteoporosis, in tumors, in Bechterew disease)

Fig. 2.4.1-15A Hyperkyphosis in a 20-year-old girl

Fig. 2.4.1-15B Radiological picture of hyperkyphosis of the same patient

Juvenile Kyphosis (Scheuermann’s Disease)

Juvenile kyphosis is a structural spinal defect that most often occurs during a growth spurt at the end of the growing period. It needs to be distinguished from postural kyphosis which is associated with poor body posture and is not caused by structural changes of the spine. The incidence of a postural kyphosis significantly overlaps the incidence of a familial hypermobility syndrome (autosomal dominant hereditary sign of mild hypermobility of the skin and the joints, often accompanied by muscle hypotonia). The period of significant progression of a structural hyperkyphosis is known as the acute stage. The incidence of this disease is very high (some studies report up to 20%). The vertebral bodies are flattened anteriorly and are wedge shaped. Intervertebral discs are smaller in height and Schmorl’s nodes develop in 40% of the cases. A so called low level of Scheuermann’s disease has the most significant influence on spinal alignment and spinal dynamics in which the apex of the hyperkyphosis is at or below the T11 level. This state is accompanied by a more accentuated hyperlordosis. In individuals with a hyperlordosis, there is a greater predisposition to the development of degenerative changes and disc herniation at the lumbosacral junction. Treatment Modifications to the physical activity routine play an important part. At the acute stage, extensive physical activity needs to be limited. This is especially true for elite athletes. Activity does not need to be limited if the growth is not in the acute stage. In athletes, assessment of bone growth and an estimation of overall height can be performed. If less than 5% remains prior to growth completion, further progression is not a concern. The problem is that rarely is the disease identified in its acute stage. Exercise is used to achieve muscle balance. Mid-thoracic spine mobilizations are administered because the patient needs to gain segmental mobility in the thoracic spine. In this region, the spine moves as a whole (“en bloc”). The kyphotic alignment leads to the loss of the rotational component of the thoracic spine, which is compensated for by movement in the lower cervical spine. Practicing thoracic spine extension (erect posture) must occur without the activation of scapular adductors. Spinal exercises are beneficial. In

more severe forms, a modified Milwaukee brace is indicated with a pelvic socket and two longitudinal supports inferiorly close to the apex of the kyphosis.

LUMBAR HYPERLORDOSIS The most common causes of this hyperlordosis are deficits in the hip joints linked to hip flexion contractures. The pelvis is in an anterior pelvic tilt. During assessment of a pelvic tilt, the angle of sacral inclination guides the assessment (see General Section of the textbook, A. Diagnostic Approaches, Chapter 1.2.1 Kinesiology of the Spine, Pelvis and the Thorax, Regional Anatomical Parameters). Rehabilitation treatment does not center around abdominal muscle strengthening as it is usually recommended, but around the practice of co-activation of the diaphragm, the abdominal muscles and the pelvic floor muscles. Through a change in the intra-abdominal pressure, this muscle synergy ensures the anterior stability of the spine and contributes to the hyperlordotic alignment of the spine. Hip flexors are stretched if they are tight.

TORTICOLLIS Congenital Muscular Torticollis This neck and head deformity is most commonly caused by a unilateral contracture of the sternocleidomastoid and secondary shortening of the fasciae and other soft tissues. The etiology is not quite clear. Often, a trauma during child birth is considered to be the causative moment that resulted in a vascular obstruction in the lower part of the muscle. The mechanism is similar to a Volkmann’s ischemic contracture. Fibrosis in the muscle is most often located near its clavicular insertion, but can also diffusely affect the muscle. The right side is affected in 75% of cases. Girls show greater incidence. In 7–20% of children with torticollis, hip dysplasia and other defects of the movement system are found (Sprengel’s deformity, congenital anomalies of cervical vertebrae, pes

equinovarus). Clinical Picture The first signs can be observed immediately after birth or during the first 2–3 weeks of life. The head is tilted toward the side of the contracted muscle and the chin is pointed in the opposite direction. In severe cases, the shoulder girdle is elevated on the affected side and asymmetry is reflected in the entire postural behavior (Fig. 2.4.1-16). Fig. 2.4.1-16 Postural pattern asymmetry in torticollis

Palpation of the sternocleidomastoid reveals tightness. If left untreated, secondary deformities of the skull and face develop. On the affected side, the face becomes flattened due to external pressure (the child usually sleeps on their stomach and on the affected side of the face). Facial scoliosis occurs (Fig. 2.4.1-17). The occipito-frontal diameter of the skull decreases and plagiocephaly develops (Fig. 2.4.1-

18). The asymmetry becomes more accentuated with growth as the level of the eyes and ears is different. Fig. 2.4.1-17 Facial scoliosis in torticollis

Fig. 2.4.1-18 Plagiocephaly in torticollis

Treatment

Treatment needs to be initiated as soon as the diagnosis is established. The initial treatment implements Vojta’s reflex locomotion, passive stretching and mobilization of the cervical spine. The parents perform therapy at home 4–6 times per day for 10–15 minutes each session. The child is not to sleep in prone. The crib is situated so that the child needs to turn their head toward the side of limited rotation. Correct carrying of the infant is an important form of treatment. When conservative treatment is initiated early and the exercises are followed consistently, a surgical intervention of the contracture is usually not necessary. Surgery is indicated when torticollis does not respond to conservative therapy by age one or if fibrotic remodeling of the muscle and facial asymmetry are present. Muscular Torticollis in Adults Onset of this deformity in adulthood is more common than the congenital form. However, its cause is usually not known. Signs can manifest themselves at any time, most often between the third and sixth decades. Women are often more affected. Torticollis can be of various degree. Usually, it slowly progresses for 1–5 years and then it stops. In 10–20% of cases, spontaneous regression can occur. Treatment is similar to the one for a complex regional pain syndrome (see Chapter 6 Treatment Rehabilitation of Painful Conditions, subchapter 6.4 Complex Regional Pain Syndrome). Acquired Muscular Torticollis This torticollis is of a bacterial origin and interstitial myositis and fibrositis develop. Rehabilitation is indicated based on the state of infectious parameters. Post-Traumatic Torticollis Its onset is caused by distortions, dislocations, fractures and subluxations during which the patients experience sharp pain in the cervical spine after they suddenly turned their head. Muscle spasm occurs. Therapy includes mobilization, cervical traction and muscle relaxation. In children 6–12 years old, this condition can occur following an

upper respiratory infection or tonsillitis (Grisel’s syndrome). Once again, it is treated symptomatically including mobilizations, traction and relaxation of the contracted muscles by post-isometric relaxation. Spastic Torticollis This is a neurological disease. It is characterized by a twisting movement of the neck musculature usually in one direction. This movement can have varied character (athetoid, choreic, etc.) and different neck muscles can participate in it (sternocleidomastoid, splenius, scalenes). Often, the patients find a position that minimizes this unpleasant involuntary movement (leaning the head against their hand is common). Stimulation of the vestibular (equilibrium) system on the contralateral side of the hyperkineses leads to their decrease. Rehabilitation treatment is only supplemental. When selecting techniques, exercises with cortical control (exercises with volitional control) are selected in various modifications. An attempt is made to identify and use a posture that inhibits non-volitional movement. Vojta’s reflex locomotion does not seem sufficiently effective in this condition. It is attempted to correct muscle asymmetry that developed as a result of hyperkineses. Relaxation methods are also implemented. Also, Botulotoxin and surgical interventions (deficit in thalamic stereotaxy or a peripheral nerve involvement) can also be applied. The effectiveness of neurosurgical procedures is marginal. Acute Torticollis This involves the so called “kink” in the neck associated with a muscle spasm. Acute torticollis is more common in younger patients. It occurs either by sudden movement or can be of viral origin. It is not easy to distinguish between the two causes. In acute torticollis, the main treatment includes soft tissue mobilization and rest. Modalities and hydrotherapy are not recommended because their application can lead to worsening of the condition.

VERTEBROGENIC PAIN SYNDROME

Pavel Kolář Statistics show that back pain is one of the most common reasons for people to see a physician. It is also one of the most common reasons for sick leave because it affects people in their productive years (the highest incidence of such symptoms occurs in people between 30–55 years). There are approximately 70% of adults who have suffered back pain at some point in their lives. Bonetti et al. reports that lumbar pain or sciatica affect approximately 80% of the population at least once in a lifetime. Annual prevalence of back pain in the population of a productive age is approximately 30–40% and 5–10% of people from this population will need sick leave. The same percentage of patients shows signs of transition to a chronic state. Fifty percent of disabilities for medical reasons are due to back pain. Back pain has many causes, which is the main reason for such high incidence.

ETIOLOGY AND PATHOGENESIS Modern imaging methods gradually revealed many causes contributing to back pain. The most important causes of spinal problems include: Injury of the musculoskeletal system Intervertebral disc protrusion or herniation Degenerative changes in the intervertebral discs and intervertebral joints Spinal stenosis Nerve compression in the spinal canal due to bony apposition or ligament calcification Spinal or paraspinal infections Anatomical anomalies (spondylolisthesis, transitional vertebra, etc.) Systemic diseases (especially primary or metastatic tumors, autoimmune diseases) In recent years, the perspective of etiology and pathogenesis of spinal problems has been constantly evolving. However, despite significant progression in this area, a definite diagnosis cannot be established in a high percentage of patients due to an insufficiently

defined relationship between the symptoms, pathological changes and imaging results. Imaging methods often identify marked structural findings that lack neurological findings and significant subjective complaints because, due to functional reactions, the spine shows a greater adaptive ability than the peripheral joints. Today, a number of authors have shown that an intervertebral disc herniation can be observed on perimyeolography (PMG), CT or MRI in approximately 20–30% of healthy adults. In this case, it has been demonstrated in a large number of people and examined by various techniques that asymptomatic disc herniations can occur and may cause neither acute nor chronic problems. A similar situation is seen for other findings in the spinal region (spinal stenosis, spondylolisthesis, etc.). Through functional reactions, the spine has a tremendous capability to compensate. In a favorable functional situation, it also demonstrates significant self-repairing abilities (see General Section of the textbook, section Treatment Rehabilitation Focused on Influencing Functional Deficits, Chapter Functional Deficits of the Movement System and Figures 1 and 2). Also important is the fact that in a large number of patients who suffer back pain, no morphological findings can be identified by using current methods, leading to pain being denoted as “non-specific” or “idiopathic”, in other words without a diagnosis. This should also include a great amount of patients with identified morphological changes that prove to be only marginally relevant. One of the main causes of why it is difficult to diagnostically determine the insufficiently distinct relationship between the morphological and neurological findings and the extent of subjective problems lies in the inadequate knowledge of the very complex functional changes that are found during a clinical assessment. To assess the condition from a prognostic perspective and to establish a treatment strategy, the lesion needs to be assessed from a neurological and morphological perspective and always within a

functional context.

CLASSIFICATION ACCORDING TO ETIOLOGY AND PATHOGENESIS Individual causes are based on morphological findings. Localized findings in the spine can be accurately and anatomically described through modern examination techniques. Based on radiographic images (including dynamic images), CT, MRI, scintigraphy and discography, the localized anatomical finding and its biomechanical relation to other structures at the regional and global levels, need to be identified as accurately as possible. With the help of anatomical classification, the pathological significance of the finding can be better understood and, to a certain extent, the prognosis of its progression better established. Local anatomical findings may not manifest themselves clinically or may have already self-repaired. Therefore, the simultaneous occurrence of functional changes and multifactorial pathogenesis is relevant, as well as, complex and individual cases need to be addressed individually.

STRUCTURAL CAUSES Pathologic-anatomical definitions are important in order to correctly classify the localized morphological picture. The main structural (morphological) causes of vertebrogenic pain syndrome include: Involvement of the intervertebral disc Degeneration of the intervertebral (facet) joints Spinal stenosis Spinal canal abnormalities Spondylolisthesis Osteoporosis Ankylosing spondylitis Infections Tumors

FUNCTIONAL CAUSES

These include deficits that are not only anatomically defined. This group includes: Disturbance in the control function of the CNS Disturbance in nociceptive processing Psychological disturbances Intervertebral Disc Involvement Disc Degeneration This involves a change in the architecture of the disc with a typical loss in the gelatinous structure (nucleus pulposus) or a fibrotic disc with amyloid and lipofuscin deposits. The first manifestation of the degenerative process involves tears in the center of the disc, which gradually increase and progress to the annulus fibrosus. This leads to cavity formation inside the disc and a loss of its height, which can be identified on a radiologic image. The most common manifestation of degenerative involvement includes osteophytes on the adjacent vertebral bodies which are oriented primarily in a horizontal direction. Osteophytes grow first on the anterior and, later, posterior edge of the vertebral body. Disc Protrusion, Herniation In the past 40 years, a significant shift in opinions about the pathogenesis of lumbar discogenic diseases has been seen in relation to the development of diagnostic imaging techniques and surgical procedures. It is clear in the pathogenetic picture that the fibrous annulus shows a tear, usually on the posterior side, and part of the pulpose matter herniates to the spinal canal in a lateral, posterolateral or medial direction. The extent of intervertebral disc involvement differs and can be classified into four categories: 1. Bulging disc – symmetrical disc bulge beyond the vertebral body 2. Disc herniation (protrusion, prolapse) – central substance of the nucleus pulposus escapes toward the defect in the annulus fibrosus and focal protrusion of the disc beyond the perimeter of the vertebra occurs

3. Disc extrusion – nucleus pulposus penetrates through the external layer of the annulus fibrosus, but remains connected to the rest of the nucleus substance 4. Extrusion with sequestration of the disc – the posterior longitudinal ligament is perforated and one or more free fragments of the nucleus pulposus migrate within the epidural space, but not into the spinal canal It is a known fact that the clinical significance of a disc herniation can be confirmed in approximately 20–30% of examinations (CT, MRI) in healthy individuals. These herniations are neurologically asymptomatic and are not accompanied by any problems. However, they are never asymptomatic functionally, meaning they are always linked to functional reactive changes in the muscles and soft tissues. According to Allat, a disc herniation is found in 39% of individuals who report no problems. During radiculography, Allat showed a disc protrusion in 50% of cases and a disc herniation in 24% of the cases. A CT scan of the lower lumbar spine in 52 volunteers who did not demonstrate low back pain or a nerve root syndrome showed an abnormality in 35.4% of cases and, in people younger than 40 years, disc herniation was observed in almost 20% of cases. MRI of the lumbar spine in 302 women without low back pain showed that signs of disc degeneration increases linearly with increasing age. The data presented show that asymptomatic disc herniations may be present without any manifested difficulties. In the majority of cases, the condition is corrected by conservative treatment despite the persisting herniation. New MRI studies allowing examination in standing show a relationship between the pathological finding and the position in which the examination was performed. A patient in supine shows only a minimal finding, however, as soon as the patient stands up, the deficit is accentuated. In this context, a new term is introduced – a soft disc. The majority of clinically significant lumbar disc herniations at L4-5 and L5-S1 levels cause neurological deficits in motor and sensory areas on L5 and S1 spinal roots. A lateral disc herniation at L4-5 level usually causes L5 nerve root compression, less often S1 compression. It does not affect the L4 spinal root. A lateral herniation at the L5-S1

level is the main cause of S1 nerve root involvement. A combination of L5 and S1 nerve roots is the most common form of all nerve root syndromes in the lower extremities. It is usually caused by disc herniation at L5-S1 and less often by L4-L5. A medial L4-5 disc herniation can cause involvement of the L5 spinal nerve root as well as S1-4, but does not involve the L4 nerve root. As a result of compensatory mechanisms, a disc herniation may not be the source of neurological signs or even subjective findings. A demonstrated disc herniation always needs to be observed in a clinical picture and in a functional context. In a number of cases, low back pain precedes pain radiating into the lower extremities. This is also why disc herniation needs to be considered as a cause of not only spinal nerve root syndromes, but also of low back pain. At the same time, back pain develops and progresses to the lower extremities similarly to nerve root irritation but without the presence of neurological findings (Fig. 2.4.1-19; Fig. 2.4.1-20; Tab. 2.4.1-1). Fig. 2.4.1-19 Lateral disc herniation at L4-5 and L5-S1 levels

Fig. 2.4.1-20 Medial disc herniation at L4-5 level

Tab. 2.4.1-1 Sensitivity of physical assessment for herniated intervertebral disc in patients with sciatic pain (according to Kosteljanetz et al., 1984, Spangfortt, 1972)

Intervertebral Joint Degeneration Joint degeneration may not be accompanied by radiological findings. In some cases, it leads to the development of synovial cysts that migrate toward the lateral recesses and cause nerve root compression. The findings may not correspond to disc degenerative changes. They can be isolated. Spinal Stenosis Spinal stenosis includes any changes that lead to local, segmental or generalized narrowing of the spinal canal, lateral recesses or nerve root canals. Based on the development, it can be congenital or acquired. The main causes of acquired stenosis include osteophytes on the endplates, uncinate processes, intervertebral joints, a hypertrophic ligamentum flavum and joint capsule. Spinal stenosis can also be the

result of a spinal surgical procedure. Spinal stenosis can also be classified based on location as follows: Central stenosis of the spinal canal Stenosis of the lateral recess Foraminal stenosis Extraforaminal stenosis The clinical picture of lumbar stenosis is complex, but shows typical features. It includes low back pain with nerve root pain in the lower extremities that disappear in supine or sitting positions. A typical sign includes neurogenic intermittent claudication – after walking a certain distance, the patient demonstrates cramping in the calf muscles which progresses to paresthesias or numbness in the distal aspects of the extremities and forces the patient to stop and squat. Incline ambulation causes less problems than ambulation down the hill. Biking is tolerated without problems. Lumbar backward bending increases symptoms and forward bending decreases symptoms (in contrast to a disc herniation in which flexion is the most painful and the position of the herniation is important). Objective neurological findings can be normal at rest, but nerve root signs can develop following loading. Abnormality of the Spinal Canal Fused spinal nerve roots are found in 8–10% of patients. Spinal nerve roots are conjoined and found within one sheath. Perineural cysts are formations developed by a spindle-like dilatation of the sheaths covering the nerve roots. Synovial cysts are found in degenerative changes of the intervertebral joints, especially in the lumbosacral region. Spondylolisthesis Spondylolisthesis is an anterior shift of the cranial vertebra in a spinal segment. In certain types, progressive segmental kyphotization occurs in which the shifted vertebra rotates around the anterior border of the inferior vertebra. This condition involves several groups of etiologically varied types. Individual types differ by the frequency of

occurrence, pathological significance, speed of progression of the slip, prognosis and therapy. Classification according to Marchetti and Bartolozzi appears to be the most useful. Spondylolisthesis can be most often classified as developmental or acquired. Developmental Spondylolisthesis They are characterized by dysplasia. Changes described as dysplasia most likely have a genetic origin. Currently, it is very difficult to establish the portion given by an innate predisposition and the portion attributed to a bipedal way of life or degenerative changes in the spine. So far, it is not apparent which changes are primary and which develop secondary to pathological overloading. Dysplastic changes are found especially in the cranial aspect of the sacrum. Most often, it involves a change in the shape of the S1 endplate. Usually, it is cumulous in shape and in English literature it is also known as a “sacral dome”. Dysplastic changes include a change in the angle of the end plate in relation to the sacrum or the sacral table angle (STA), the change in the shape of the entire sacrum, especially its kyphotization, and also partial or complete defects in the spinal arches – spina bifida, aplasia of the vertebral arch, as well as, elongation of the pars interarticularis (isthmus) or changes in joint shape. Changes in the shape of the L5 vertebral body are also significant. Their extent can be expressed by a ratio between the size of the posterior and anterior wall. This ratio is known as the lumbar index and it is based on Laurent. A group of developmental spondylolistheses are classified into subgroups of “low grade dysplastic” and “high grade dysplastic”. Both subgroups are found in the form of either a disrupted pars interarticularis or elongated pars interarticularis. Spondylolysis (disruption in the pars interarticularis) is usually detected by a lateral image (Fig. 2.4.1-21; Fig. 2.4.1-22; Fig. 2.4.1-23). Fig. 2.4.1-21 Congenital spondylolisthesis L5-S1: “sacral dome”

Fig. 2.4.1-22 Congenital spondylolisthesis L5-S1: “sacral lip” (extension of the anterior edge of S1)

Fig. 2.4.1-23 Congenital spondylolisthesis: an ax-like change in the shape of L5 vertebral body. A – MRI image; B – radiological image

To identify the age of the defect, Tc skeletal scintigraphy is indicated. Accumulation of radioactive compound within the defect precedes the actual manifestation of a spondylolysis. The lytic defect in an oblique view resembles a dog leash and it is known as the “Scottie dog sign” in the literature. The “low dysplastic” group is characterized by the preservation of the parallel alignment of the vertebral endplates and the absence of segmental kyphosis, although the signs of dysplasia are present. If this group shows progression above 50%, it is known as “high grade dysplastic”. The vertebral body shows a typical trapezoid shape with a concavely shaped inferior end plate. It is expressed by segmental kyphosis and the size of the slippage is greater than 50% in spondyloptosis. Acquired Spondylolistheses They are classified as traumatic, post-surgical, pathological and degenerative (Fig. 2.4.1-24). The group of traumatic spondylolistheses is further divided into a subgroup due to an acute trauma, which is actually a special type of injury of the spine due to substantial force, and a group called “stress fracture” developed on the basis of spondylolysis after stress fracture of the pars interarticularis. Fig. 2.4.1-24 Degenerative

spondylolisthesis L5-S1 on an MRI

Osteoporosis Osteoporosis is a very common cause of spinal problems, especially at an older age. Osteoporosis is addressed in more detail in Chapter 3 Treatment Rehabilitation in Selected Internal and Other Diseases, subchapter 3.8.4 Osteoporosis. This section will briefly describe its relation to a vertebrogenic syndrome. Osteoporosis itself is not painful and does not cause back pain. Pain only manifests itself when structural changes develop among which compression fractures are most typical. The thoracolumbar junction is a common site of their development. Trunk stabilization is very painful because it activates muscles that insert to this area. The acute stage is characterized by cramping that radiates into the diaphragm and the paravertebral musculature during positional changes. Most patients do not report an injury in their anamnesis. The condition is three times more common in women than in men. In primary care, approximately 4% of patients with back pain demonstrate compression fractures. Caucasian women have a four times higher rate of compression fractures than American women of African or Mexican descent. Ankylosing Spondylitis This is a systemic, chronically progressive inflammatory disease of the spine that affects men more than women. Its onset is typically around

the age of twenty. Next to spinal pain, the first symptoms may include Achilles tendon pain (recurrent peritendinitis) and recurrent iridocyclitis. For more details, see Chapter 3 Treatment Rehabilitation in Selected Internal and Other Diseases, subchapter 3.8.3 Ankylosing Spondylitis. Infections Bacterial infections of the spine represent very serious conditions. They most often develop as a result of hematogenous dissemination from a different source. It is a cause of pain in .01% of patients. In up to 50% of patients, the infection is caused by Staphylococcus aureus; in drug addicts the bacteria include Pseudomonas, Escherichia coli and Proteus. In many cases, the etiologic agents cannot be identified and in half the cases, the lumbar spine is affected. A neurological lesion is most often present in the cervical spine and pain is usually the first sign. Acute infection or sepsis accompanied by high temperature, shivers, fever and overall fatigue are present only in some patients at the onset. The most significant infection is the early onset of tuberculous osteomyelitis (Pott disease) causing fused abscesses. Discitis as a postsurgical complication is not an exception. The number of postsurgical spinal infections depends on the duration and extent of the surgical procedure. Fairly often, infections appear after injections. Rheumatologic diseases are also part of infections. Destructive inflammatory centers in rheumatoid arthritis cannot be forgotten and can occasionally be found in the area of the dens of C2, which can cause a pathological fracture with subsequent spinal cord compression. To diagnose an infection, we cannot rely solely on the elevation of infectious parameters (CRP elevation, increased sedimentation of erythrocytes and leukocytosis). The examination needs to be accompanied by imaging methods. Tumors Benign Tumors

Osteoid osteoma is manifested by resting and night pain; scoliosis develops. Treatment is radical and involves a complex resection of the nidus. Hemangioma is most often asymptomatic and can be a source of pain only in some patients. There is no progression in this benign tumor. Regular radiological screenings are performed for monitoring. Osteoblastoma can cause spinal cord compression. An aggressive form can progress to osteosarcoma. It relapses after incomplete removal. Tumor-Like Presentations Eosinophilic granuloma located in the vertebral bodies belongs in this category and manifests itself as poorly defined osteolysis. An aneurysmatic bone cyst can be the reason for a pathological fracture because it is locally destructive. Vertebra plana (Calve disease) develops in childhood. A radiological finding of thoracic spine shows a compromised vertebral body with normal pedicles and an arch; only minimal or no kyphotization is present. Malignant Tumors A tumor is the source of pain in 0.7% of patients with a vertebrogenic syndrome. These can include primary malignant tumors arising from the bones or tumor metastases from a different primary tumor. Multiple myeloma or chordoma are the most common primary malignant tumors of this location. Metastases are frequent here given the rich venous network. They can be osteolytic (most often) or osteoplastic (especially in prostate tumors). In this case, for differential diagnosis, the physical assessment is less helpful than an anamnesis. A report of a progressive course is important during subjective assessment – especially in an older individual without earlier incidence of banal vertebrogenic disorders. Other important cues include a tumor in the anamnesis, resting pain, failure of a recent conservative treatment and weight loss (Tab. 2.4.12).

Tab. 2.4.1-2 Estimated reliability of anamnesis in diagnosis of a spinal disease involving cancer causing pain in the lumbar region (Deyo and Diehl, 1988)

During a physical examination, the presence of malignancy is suggested by simultaneously ceasing symptomatology in multiple nerve roots or a bilateral deficit. During joint assessment (assessment of joint motions), pain independent of soft tissue resistance is typical. This factor is very specific. The sources of spinal metastases most often include the breast, lungs, prostate, kidneys and the thyroid gland. Therefore, if any of the anamnestic information is positive, the examination focuses on further assessment of these organs. Deficit in the CNS Control Function The influence of muscle activity on the spine mainly depends on the quality of the stabilization function and on the degree of its fixation, meaning its remodeling capability. Inadequacy in this centrally conditioned function causes the patient to use non-symmetrically distributed and excessive muscle forces and to engage a greater number of muscles than is mechanically necessary. This results in a

unilateral stereotypical activity during muscle stabilization without the option for its modification. These functions are dependent on a number of factors and the most important ones include: Factor 1 Qualities of the central components of the movement system. Development of correct and programmed movements, rebuilding fixed stereotypes and performance of movement in various postural situations all depend on the quality of the central nervous structures. Plasticity of cortical functions allows for the formation and fixation of continuously new postural variants, but without the cessation of the variants formed earlier. To a certain extent, this can influence the development of a deformity and facilitate its exacerbation. Generally, the quality of the central control components defined by their plasticity is clinically demonstrated by the ability of selective movement or movement differentiation. This cannot be achieved without the ability to relax well. For example, working on the computer can be observed as a typical manifestation of this dysfunction. When working with a computer mouse, the wrist needs to be relaxed and perform the movement with the other muscles being as relaxed as possible. However, the movement is usually transferred into other segments as well. For example, it originates from the shoulder when the wrist is fixed and the stabilization of the movement is provided by the upper trapezius, levator scapulae, scalenes, etc., which are muscles that are not mechanically related to the wrist movement and should be relaxed. These movement dysfunctions become permanent and stereotypically activated during other various movement activities. Certain functions are closely associated with body image and actual body image is quite different. Imperfection of this image suggests inadequate compensatory options under pathological conditions. Patients with a spatial body awareness deficit that is with deficits in somatognosis and stereognosis, also poorly adapt to a surgical procedure. They include most patients in whom a surgical procedure

has failed. Our diagnostic orientation in the area of this function is quite significant. The above mentioned capabilities are closely linked with the quality of differentiation during the assessment of discrimination and deep sensation. These functions are also included in the assessment. The qualities of the central cortical components of the movement system are significant during interpretation of individual reactions to movement re-education and, in the case of necessary surgical intervention, affect its results. In the case of surgical indications, these functions cannot be underestimated. In patients with a local vertebrogenic finding, therapy also needs to focus on training these functions, especially if the CNS function is insufficient and if surgical intervention is being considered. Factor 2 The way in which the movement stereotypes were and are developed, trained and corrected. When developing movement patterns, it is important to form truly economical movement stereotypes. In theory, the learned movement should be efficient, which means that it includes only those muscles that mechanically accomplish or enable this movement. This leads to optimal joint and connective tissue loading. A breathing pattern serves as an example. In physiological breathing, the lower aspect of the thorax expands and the sternum moves in an anterior-posterior direction. Then, the diaphragm and the intercostal muscles participate in breathing. In patients with vertebrogenic conditions, a disturbance in this type of breathing is observed. In the majority of cases, accessory muscles are activated (pectorales, scalenes), which in turn activate other muscles that must stabilize these accessory muscles (i.e., the suboccipitals). During breathing, muscles that have no mechanical connection to breathing are being included. Similarly, the pattern ensuring spinal stabilization is usually incorrectly formed. A patient is unable to alter this stereotype volitionally.

Deficit in Processing Nociception In vertebrogenic syndromes, next to other functional deficits, so called hidden central deficits need to be mentioned. Their early identification and treatment are important. These are not obvious pathological neurological syndromes, but rather conditions that are manifested by an increased tendency toward chronic problems and are among the important causes contributing to the failure of adaptive mechanisms. Failure during stress in the psychosocial aspect is common. There are many ways in which functional brain reorganization can produce persistent pain in the absence of significant peripheral pathology. Decreased pain inhibition is one of them and causes an abnormally oversensitive state. Reactivation of memory imprints of pain or CNS generated pain as a response to sensorimotor incongruency during movement are other presumptions. These mechanisms probably exist simultaneously (co-activated). The patterns of CNS changes are identical in many studies and the extent of the CNS changes is proportional to the duration and severity of the condition. Unfortunately, it is not known to what extent these brain changes are reversible. One of the possible explanations for a tendency toward a chronic course of problems can be a certain level of hypersensitivity of the nociceptive system, which means that facilitation of pain perception occurs with a little or no peripheral nociceptive input. This can arise either from changes at the level of the periphery of the spinal cord and the brain or from changes in a combination of any of these areas. The perception of chronic vertebrogenic pain in the absence of significant peripheral pathology can also develop the presence of central memory imprints of pain. This explains how previous low back pain episodes lead to a chronic progression which occurs specifically by strengthening the memory imprints. This functional reorganization in the somatosensory and motor systems was observed in musculoskeletal pain and the extent of such changes increases with low back pain (LBP) chronicity. These central modifications can be

observed as memory imprints of pain that influence other processing of painful and non-painful inputs into the somatosensory system as well as their effects on the motor system. Wand and O’Connel mention another alternative mechanism that explains how cortical reorganization can elicit continued pain linked to movement. In their book, they suggest that altered cortical representation of somatic proprioceptive inputs can falsely signalize incongruency between the motor intent and movement. Formation of movement activity within the CNS is closely linked to the sensory feedback systems that are monitored with the purpose of identification of each deviation from a predicted reaction (response). However, if a conflict exists between the motor output and sensory feedback, it is presumed that the pain produced will function as a warning signal cautioning the subject of the abnormality in the context of information processing. According to the authors, changes in regards to the expansion of the S1 representation of the back in chronic nonspecific low back pain (CNSLBP) of patients is found in the primary somatosensory cortex (S1), which can be the foundation for abnormal proprioceptive representation of the back and thus a possible source of sensorimotor disharmony. Significant data about altered brain function in patients with chronic, non-specific low back pain also exist. One of the research studies was based on a recording of an evoked magnetic field in the brain that was the response to an electric stimulation of back muscles. Greater reactivity in the primary somatosensory cortex and expansion of S1 representation of the back in CNSLBP was seen. Another study about brain changes in patients with CNSLBP showed degeneration in the gray matter of the brainstem in the area associated with an inhibitory pain control. Psychological Disturbance Psychosocial anamnesis is important to establish the actual cause of the deficit, to assess the prognosis, and thus to establish a treatment plan. As our experiences confirm, psychological stress plays a very common role in the etiology and pathogenesis of low back pain,

including the actual radicular syndrome. As a result of stress, worsening often occurs (possibly by the influence of reflex pathogenetic mechanisms, especially in the area of vegetative reflexes) in a neurological asymptomatic disc herniation or some other mentioned deficit in the structures of the lower lumbar segments. At the same time, this deficit is a significant complication during the actual treatment, which is often prolonged by this condition. Waddle et al. suggested five categories for psychogenic or inorganic signs that correlate with other indicators of psychological stress: 1. Disproportional sensitivity either superficially or globally 2. Pain during simulated axial loading by applying pressure to the top of the head or during simulated spinal rotation – the patient is grasped by their arms and pulled to one side while the sides/hips are rotating. It needs to be ensured that the shoulders and the hips are turning simultaneously. 3. Inadequate response during the assessment of tension maneuvers – for example, the patient reports pain when lifting their extended lower extremity in supine but can fully extend the knee in a seated position at a position with an identical angle of hip flexion. 4. Local deficits in strength and sensation that do not correspond to the dermatomes of individual nerve roots. 5. Hyper-reactivity during a physical exam. Presence of just one sign has limited value, but three out of five positive signs demonstrates a psychological deficit.

CONSEQUENCES OF STRUCTURAL AND FUNCTIONAL DEFICITS Discogenic Pain Discogenic pain is typical in disc degeneration or protrusion and in disc herniation without nerve root compression. Subjective Symptoms Back pain without radiation into the extremities is the main sign. The pain is accentuated with increased intra-abdominal pressure (cough,

sneezing). Maximum symptoms are present in slight forward bending. Patients report pain during dressing, donning shoes and personal hygiene (brushing teeth). Objective Signs In the acute stage, a defensive postural pattern is typical. Forward bending is limited and the Straight Leg Test (Lasègue Test) is often positive (see General Section of the textbook, A. Diagnostic Approaches, Chapter 1.2.1 Kinesiology of the Spine, Pelvis and the Thorax, Assessment of Tension Maneuvers). All movements that do not correspond to an antalgic posture are usually very limited. If the patient can be prone, springing of lumbar segments is usually very painful, especially at the level of the deficit. Pain upon segmental springing will persist even after the joint restriction has been addressed. In chronic conditions, painful restriction according to Cyriax is an important sign (see General Section of the textbook, A. Diagnostic Approaches, Chapter 1.2.2 Kinesiology of the Shoulder Girdle, Cyriax’s Painful Arc). Differential Diagnosis of Discogenic Pain and an Acute Lumbago Acute lumbago develops due to overloading of the muscle-connective tissue apparatus or in an acute joint blockage/restriction. In discogenic pain, the severity is often the same as in radicular syndromes because they are, in essence, their improved state. For prognosis, discogenic pain in the lumbar region is often more significant than disc herniation with nerve root compression. In practice, discogenic lumbar pain needs to be diagnostically distinguished from acute lumbago. In an incorrectly administered treatment for discogenic pain, the symptoms may worsen and progress to nerve root compression. Radicular Syndrome Radicular syndrome is a result of nerve root compression by an intervertebral disc, an osteophyte due to degenerative changes of the intervertebral joints and in stenosis of the spinal canal or the

intervertebral foramen. Subjective Findings They include sharp back pain with projection into a corresponding spinal root dermatome and a deficit in the sensation of the corresponding dermatome. The pain and sensation deficit are well defined, localized. Another anamnestic symptom can be alienation or ataxia of the involved extremity, its weakness, tripping, and falling. Objective Findings A protective postural pattern and an antalgic trunk posture are found upon assessment. The dynamics of the affected spinal segment are significantly limited and movements that do not correspond to the antalgic positioning are painful. The affected segment (if it is possible to assess it) shows limited springing and it is extremely painful. Neurological assessment shows a sensory deficit (hyperesthesia) in the corresponding dermatome and muscle weakness in the corresponding nerve root myotome. Tension maneuvers involving the affected nerve root are positive. Pseudoradicular Syndrome A pseudoradicular syndrome needs to be mentioned in the context of manifestations of nerve root compression. Based on clinical experience, similarly to true nerve root syndromes, pain can be observed in a pseudoradicular L4 syndrome radiating to the anterior aspect of the thigh toward the knee and sometimes below the knee; in a L5 syndrome along the lateral aspect of the leg to the lateral malleolus; and in an S1 syndrome along the posterior aspect toward the heel. In L5 and S1 syndromes, the Lasègue Test is positive. Beside pain, dysesthesia and hyperalgesia in the corresponding segment are observed. Pain radiating distally (below the knee) suggests true radiculopathy rather than pain radiating to the posterior aspect of the thigh. These pseudoradicular manifestations can develop in various structures. For example, a pseudoradicular S1 syndrome can be caused not only by a disturbance at the L5-S1 segment, but also by sacroiliac

joint dysfunction or a chained deficit from more cranial spinal segments. Each of these syndromes exhibits muscle spasms. However, a pseudoradicular syndrome, similarly to discogenic back pain, can reflect compensation for some more significant findings in the lumbar segments. Often, it is the picture of a disc herniation with the goal to identify the source of problems. A functional diagnosis of sensorimotor relationships (see below) will assist in this process. According to Lewit, it is an “incomplete radicular syndrome” in which there is pressure on the sheath of the nerve root, but not on the nerve root itself.

SPECIFIC TREATMENT Rehabilitation Pavel Kolář, Karel Lewit, Jiří Čumpelík, Veronika Kubů Not only the anatomical, but also the functional findings (the quality of CNS components, psychological aspects, muscle stabilization function, etc.) need to be carefully considered when selecting a treatment approach. To select a conservative treatment program, it needs to be determined whether the condition is in an acute or chronic stage (from the perspective of the onset of the structural finding). A chronic stage requires a different strategy than an acute condition. In contrast to an acute finding in which taking medication and following a resting schedule are advised, conservative treatment of a chronic condition is dominated by specific exercises that affect the patient’s condition through the inner forces. Ergonomic and activity precautions are beneficial and supportive bracing also needs to be kept in mind. Despite clinical results, only a small number of prospective studies have assessed the effectiveness of physical therapy in individual morphological findings. For example, McNeely, Torrance and Magee reviewed seventy one articles assessing the effectiveness of physical therapy in spondylolisthesis with spondylolysis. From these, fifty two were presented as studies, but only two of them truly fulfilled the

criteria of a prospective study. Both of these studies suggest specific exercises either on an individual basis or in combination with other types of therapy. At the same time, both studies report significant positive effects from a specific exercise on back pain caused by spondylolisthesis. Based on the majority of published studies, strengthening of the trunk musculature leads to improved core strength and to improved clinical signs. The main focus of conservative treatment is not only exercise. The result depends on its specificity, the means and intensity of its administration and, mainly, on the integration of the practiced function into posture and common activities. Influence of Stabilization Functions Based on our clinical experience which is to a large extent in agreement with the results of some international studies, specific training of the spinal stabilization function and its inclusion into common functional activities are considered fundamental during conservative treatment of patients with spinal deficits. Influencing the stabilization function of a muscle is not as much a question of exercising as it is commonly presumed, but rather it is a learning system. In this case, muscles cannot be exercised according to their anatomically defined origin and insertion. Also, it is not sufficient to only implement exercising into flexion and extension as it is often presented and discussed in certain systems designed for the treatment of vertebrogenic deficits. Our main goal is to affect the muscle in its actual function, in this case in the stabilization function, or co-activation by reinforcing segment(s) – with other muscles. This is a question of not only actual muscle strength, but especially its recruitment, or inclusion in a synergy. Disproportionate loading occurs if recruitment of the spinal and trunk muscles is disrupted during their reaction to external stimuli. The disrupted function becomes the actual etiopathogenetic factor for the onset of the structural findings and problems. Among the muscles that are activated during a particular movement, a firm feedback (memory) is

formed so that all the participating muscles form a functional unit in the end. If this muscle synergy is integrated into all movements (during each movement of the upper and lower extremities), the individual engages these muscles as a whole practically continuously, which predisposes them to overloading, mainly as a result of a stereotypical repetition of the acting forces. The engagement of stabilization muscle activity in a similar quality as is observed in a physiologically developing child is the main therapeutic goal. The muscle activity of a physiologically developing child identically corresponds to muscle synergy that can be elicited by Vojta’s reflex locomotion. It is a basic postural pattern that is integrated into all movements (including the upper and lower extremities) and allows for optimal biomechanical joint loading. An immature kyphotic spine develops into a lordo-kyphotic curvature exactly through this pattern (the curvature differs in an abnormal postural development). All other anatomical systems develop in a similar way – shape and alignment of the thorax, pelvic angle, femoral torsion, collodiaphyseal angle, etc. For training the muscle stabilization function – see General Section of the textbook, B. Therapeutic Approaches, Chapter 1.1.4 Dynamic Neuromuscular Stabilization. Postural Pattern of Spinal Stabilization – Summary Muscle recruitment during an activity of external forces (when lifting an object, holding an object, movement of the lower or the upper extremity against resistance including the center of mass force, change in position, etc.) is always linked to spinal stabilization and exhibits a defined coordination muscle synergy under physiological conditions. Inner forces that are elicited by the stabilization force of a muscle act on the intervertebral discs and joint articulations. Coordination during muscle activation determines the vectors of such forces, respectively for the type of loading. Muscle synergy reinforcing the spine during the activity of external forces is identical in supine, sitting and in standing. It is linked to every position. The assessment and re-education of this stabilization synergy is the goal of therapy.

Stabilization Function of the Spine under Physiological Scenario Spinal extensors are always engaged during spinal stabilization (reinforcement). Their activation occurs in the following sequence (timing). At first, the deep extensors are engaged and only situations requiring greater muscle demands lead to the contraction of the superficial muscles. Their function is balanced by a flexion synergy that comprises the deep neck flexors and the synergy between the diaphragm, abdominal muscles and the pelvic floor muscles. During spinal stabilization, the diaphragm contracts and its contour flattens, which occurs independently of breathing. The flattened diaphragm presses on the contents of the abdominal cavity, which acts as a viscous elastic column and increases the intra-abdominal pressure. The lower thoracic aperture and the abdominal cavity expand. From a functional and biomechanical perspective, the alignment of the axis between the insertion of pars sternalis and the costophrenic angle is important for the stabilization function of the diaphragm. The alignment of the axis is given by the initial alignment of the thorax, shoulders and the spine during contraction. In a physiological situation, this axis is aligned almost horizontally. The oblique alignment of the axis of the diaphragm in the sagittal plane and the insufficient development of the lower thoracic aperture during stabilization are linked to increased activity, respectively to dominance of the spinal extensors. To maintain the caudal alignment of the thorax during activation, the activity of the abdominal muscles needs to be balanced (lower stabilizers of the thorax) with the pectoral muscles, scalenes and the sternocleidomastoids (the upper stabilizers of the thorax). The synchronous activity of the pelvic floor, the diaphragm and the abdominal muscles contributes to the adjustment of the intraabdominal pressure. The pelvic tilt and especially the alignment of the thorax in relation to the pelvis are very important for the resultant force vector (Fig. 2.4.1-25). Even a slight shift of the thorax forward elicits excessive activity of the superficial spinal extensors.

Fig. 2.4.1-25 Alignment of the pelvis and the thorax in standing. A – physiological posture; B, C – asymmetrical alignments

During activity of the external forces, the abdominal muscles act as lower stabilizers of the thorax. Their task is to prevent cranial comovement of the thorax during stabilization. They form punctum fixum on the ribs, which allows flattening of the diaphragm. Together with flattening of the diaphragm, the abdominal muscles help by their concentric or isometric activity to increase the intra-abdominal pressure, thus, a stabilization moment.

During activity of the external forces, thus during postural (stabilization) activity, there are respiratory movements during the flattening contraction of the diaphragm (tonic function of the diaphragm), or during its basal increase in tension (Fig. 2.4.1-26). The extent of contraction, or the basal flattening of the diaphragm, depends on the strength of the external forces. In a phase in which the intra-abdominal pressure is increased and breathing occurs, the cooperation between the diaphragm and the abdominal muscles is essential. During increased tonic tension of the diaphragm, the abdominal muscles eccentrically recede to the inspiratory contraction of the diaphragm. If this cooperation is disrupted, the upper stabilizers of the thorax become engaged into respiration, which results in insufficient anterior spinal stabilization and overloading of the spinal extensors.

Fig. 2.4.1-26 Inspiratory (B) and expiratory (A) position of the diaphragm during MRI imaging and a corresponding spirographic recording. The contour of the expiratory position during external force activity is more flattened when compared to breathing at rest. The lower line in section B denotes the expiratory position of the diaphragm during activity of the external forces, the upper line denotes the same during resting breathing.

Stabilization Function of the Spine in a Pathological Scenario In patients with weakened anterior spinal stabilization, the diaphragm does not flatten sufficiently. The lower aspect of the thorax does not expand, the content of the abdominal cavity is not pushed caudally and this insufficiency is compensated by overactivity of the superficial spinal extensors. The main causes of the weakened diaphragm

contraction include the following: Oblique alignment of the axis of the diaphragm in the sagittal plane. The thorax “hangs” on the upper stabilizers of the thorax (pectoral muscles, scalenes and the sternocleidomastoids). Thoracic rigidity, especially in the lower aspect, which decreases the ability for expansion of the intercostal spaces and the thorax in the transverse plane. Imbalance between the upper and lower stabilizers of the thorax. Shortened pectoral muscles pull the shoulders into protraction. During shoulder retraction, they pull the thorax into an inspiratory alignment. Similarly, this occurs in patients with a rigid thoracic kyphosis where the thorax and the spine move as a whole (en bloc). Then, during maximum available thoracic spine straightening, the rib cage is positioned in an inspiratory alignment. Disruption in the timing between the contraction of the diaphragm and the abdominal muscles. The activity of the abdominal muscles ensures the punctum fixum for the activation of the diaphragm and, at the same time, acts against the content of the abdominal cavity that is being compressed by the diaphragm and acts on the spine through the internal organs. Isometric, respectively concentric, activity of the abdominal muscles occurs in continuation with the flattening of the diaphragm. In a pathological scenario, the concentric activity of the superior aspect of the rectus abdominis and the external obliques precedes the activity of the diaphragm, which is a compensatory strategy. Insufficient activity is found in the internal obliques, transversus abdominis and in the inferior aspect of the rectus abdominis. Tests are used to assess deviations from physiological stabilization. Correct muscle recruitment and muscle training can lead to sufficient compensation of an extensive morphological finding so that a progression does not occur and the patient does not demonstrate any or only minimal symptoms. Therapeutic-Teaching Approach The intent is not for the patient to attend long-term therapy, but

rather to volitionally master the correct muscle stabilization synergy and incorporate it into regular daily activities. It cannot be presumed that all patients will participate in daily exercises for the rest of their life. Therefore, the goal is to influence muscle activation so that the individual could activate these muscles during all daily activities. The patient should not be a passive recipient of therapy, but rather be an active participant, which is one of the requirements for successful therapy. The therapeutic approach depends mainly on a series of visits rather than a few visits. Therapy especially focuses on the deep spinal stabilization system. It is a synergy of muscles stabilizing the spine, thorax and the pelvis. Training of the deep spinal stabilization system consists of certain principles that are similar in most patients despite an individual approach: Influencing the rigidity and the dynamics of the ribcage (see General Section of the textbook, B. Therapeutic Approaches, Chapter 1.1.4 Dynamic Neuromuscular Stabilization). Influencing the upright alignment of the thoracic spine (see General Section of the textbook, B. Therapeutic Approaches, Chapter 1.1.4 Dynamic Neuromuscular Stabilization). Training the stabilization function of the diaphragm in synergy with the abdominal muscles (see General Section of the textbook, B. Therapeutic Approaches, Chapter 1.1.4 Dynamic Neuromuscular Stabilization) The activation of the diaphragm plays a crucial role for physiological stabilization. In these exercises, the patient learns how to engage the diaphragm whose function we are practically not even aware of. After a certain training period involving the patient’s awareness and the therapist’s feedback, its position can be indirectly recognized without knowing anything about its anatomical placement. Training the breathing pattern (see General Section of the textbook, B. Therapeutic Approaches, Chapter 1.1.4 Dynamic Neuromuscular Stabilization).

The therapist practices diaphragmatic breathing with the patient. The goal is to ensure the inclusion of the diaphragm into breathing and thus into the stabilization function without the participation of accessory breathing muscles. During training, the trunk needs to be erect and the thorax positioned in its caudal alignment. The ribs move laterally (wing movement) during inspiration. The abdominal muscles serve as support for the diaphragm. The sternum moves ventrally and does not elevate during breathing. During inspiration, the lower aperture of the thorax expands. The abdominal wall should not only expand anteriorly, but rather in all directions (laterally and dorsally).The umbilicus should not move cranially (an undesirable pull of the muscles in a cranial direction). Training is performed in various positions. Facilitation by using support functions. Purposeful movement and upright posture arise from support areas. Straight alignment, a correct breathing pattern, etc. cannot be achieved with incorrect support, or in other words, muscle symmetry cannot be achieved during stabilization. For these reasons, the focus is placed on correct centration of support (foot, hand, medial epicondyle, etc.) in a selected position. The foot forms the basic support for upright body posture. Thus, the correction and training of the support function is very important. Muscle pre-stretch, support points on the sole of the foot and the shape of the foot arch send afferent signals to the CNS, which activates upright body posture. The diaphragm and the thorax both react to the muscle activity of the foot by changing their alignment and breathing. The patient has to learn to perceive muscle reactions resulting from activation of foot musculature, including distant areas. Stabilization training of the foot function is an important part of spinal stabilization training and should not be neglected. Utilization of reflex locomotion principles (see General Section of the textbook, B. Therapeutic Approaches, Chapter 1.1.4 Dynamic Neuromuscular Stabilization). In the initial phase of teaching, the model activated by Vojta’s reflex stimulation is used to achieve well balanced activation of the

muscle synergy between the muscles of the abdominal brace (the diaphragm, the abdominal and pelvic floor muscles) and the back muscles. This model integrates individual components of deep spinal stabilization. Utilization of principles of postural ontogenesis in training of the muscle stabilization function (see General Section of the textbook, B. Therapeutic Approaches, Chapter 1.1.4 Dynamic Neuromuscular Stabilization). Training of the stabilization function in developmental sequences is another approach for training spinal stabilization function. The principles of postural ontogenesis can be implemented. Other Rehabilitation Techniques Mobilization Techniques and Influencing Trigger Points The goal of mobilization treatment is restoration of physiological joint mobility including joint play. Previously, the thought of mobilization techniques in the acute stage was contraindicated, which stemmed from experiences linked to the results of adverse thrust techniques. However, if mobilization techniques are performed gently and general principles are being respected, then there is no reason to exclude them from treatment methods because they often provide a patient with relief. General Principles of Mobilization Techniques Patient’s position: The patient is placed in a position that encourages maximum relaxation and discourages holding their breath. The therapist’s position and grasp should stabilize one component of the mobilized segment. Therapist’s position: The way in which the therapist positions themselves toward the patient and how they stabilize determines their technique to a significant extent. Mainly, the therapist needs to be stable and stand relaxed. If the therapist is not relaxed themselves, then the patient cannot relax. It is important to synchronize the breathing pattern with the patient. The movement must originate from the whole body, most often from the legs and the pelvis. Stabilization: The spine is most often stabilized in the initial

position (“locking”) or by using the hands. During the actual mobilization, it is always important for the joint to be in a neutral alignment so that the joint capsule is not under tension. The joint cannot be locked. This facilitates muscle relaxation. The direction of the therapist’s touch corresponds to the limited mobility or joint play, translatory movement or distraction. Prestretch: In the spine, functional movement and joint play often cannot be accurately distinguished. Therefore, this difference is usually not distinguished even during set up into prestretch. Mobilization: During the actual mobilization, low amplitude springing is performed in a precisely given direction. Sometimes the mobilization is limited to waiting while applying minimal pressure, which achieves pretension in the joint (it is indifferent in the sense of joint play or functional movement). Mobilization using the methods of muscle facilitation or inhibition: techniques aimed at certain muscle groups are distinguished – PIR (inhibition as a result of antagonist stimulation, etc.) and techniques with an overall effectiveness (reflex stimulation of trigger zones after the prestretch has been achieved in a segment, breathing synkineses, facilitation by using eye movements, etc.). Trigger point release: TrPs release (deep massage, dry needling, etc.) as a component of reflexive influence of a joint segment must be an essential component of mobilization techniques. It is a vital prerequisite for effective therapy during non-forceful mobilization. Testing: immediately following mobilization, the effect of the therapeutic approach is assessed. Spinal mobilization differs from peripheral joint mobilization in certain technical aspects, for example, it is more difficult to move one spinal segment than an extremity joint. For the spine, it is also more difficult to distinguish functional movement from joint play. Since a single movement segment of the spine cannot be actively moved, the passive movement in a different segment is a joint play to a certain extent. Distraction techniques are the most obvious techniques in the

sense of joint play, during which joint surfaces are pulled away from each other (for example, lumbar rotation and posterior-anterior springing in the cervicothoracic region). We also distinguish direct and indirect techniques. Specific palpation can be done by several methods: ideally, although not always possible, is direct stabilization of the distal or proximal aspect of the joint, which is often the scenario during extremity manipulation. Another way is “locking”, especially when using longer levers, for example, using the head if the cervical spine is going to be treated or “locking” the lower extremities and the pelvis during lumbar spine mobilization. The therapist attempts to “lock” all movement segments with the exception of the one that is being manipulated. In principle, “locking” implies that all segments that are not being manipulated are positioned in the end position that is in prestretch. The actual mechanism of “locking” consists of a complete stop of bony structures or a ligamentous stretch. However, even in this case, it is necessary to reach prestretch prior to manipulation. “Locking” is always only relative and, if gross force is applied it is impossible to work specifically. Long levers, of course, have their advantages – very small force is needed, the technique is gentle, but still effective; however, they are specific only if the force is not excessive. Locking is achieved mainly by an appropriate combination of sidebending and rotation, and through the use of combined movements. Since forward bending and rotation occur in opposite directions in the lumbar spine (if it is in lordosis), the locking is achieved by sidebending and rotation in the same direction. Since it is the opposite for kyphosis, sidebending and rotation in the opposite direction are combined. In the thoracic spine, the spine usually rotates in the opposite direction of the sidebending, therefore, locking is achieved by a combination of sidebending and rotation in the same direction (with the exception of backward bending when the situation is reversed). In the cervical spine, rotation is accompanied by ipsilateral sidebending and locking then occurs by sidebending and rotation to the opposite side.

It is obvious that specific palpation can be achieved by direct contact. Thus, the vertebra can at least be stabilized in one direction, for example, by stabilizing the spinous process from the side if the therapist wants to prevent rotation toward the opposite side. If the therapist applies pressure, the vertebra is sprung or a thrust is performed. Subsequently, this force most certainly acts (also) on the area where it is being applied. Chiropractors also believe that a quick thrust can act like the sudden impact of a hammer on a brick that moves out of line while the others stay put. A more specific and, at the same time, highly effective technique is achieved through combination of locking and direct contact. Locking and contact, however, must be aimed at the same area. Furthermore, it needs to be emphasized that good stabilization (manual contact) is always more reliable than locking. The above given information implies that the hand that stabilizes or, in contrast, moves a vertebra, acts in the opposite direction than the other hand that acts as a lever. It is true for most cases. However, some techniques are used in which both hands act in the same direction or with common force and the lower vertebra is stabilized only by a position (for example, stabilization of the pelvis achieved by the patient’s straddle sitting, which also indirectly stabilizes the lumbar vertebrae). In such techniques, the therapist counts mainly on the locking during significant levering. Most often, the aforementioned techniques are used for traction manipulations which are risk-free and very effective. Their specificity is more controversial, especially if the technique is not quite gentle. Less specific techniques also exist that are advantageous during mobilization of a larger spinal region. Long axis traction is the most common technique. Most passive movements can be used this way for mobilization. To avoid confusion, traction along the long axis of the spine needs to be distinguished from distraction of an intervertebral segment. This difference is the most obvious in the lumbar spine in which longitudinal traction acts on the intervertebral discs while the

distraction of the small intervertebral joints occurs during rotation along the same axis (only on the side of the rotation). In the cervical spine, in contrast, long axis distraction acts on the discs as well as the joints. Exercising with Awareness In patients with deficits in cortical plasticity and the associated somatognostic and stereognostic functions, it is recommended to perform simple exercises with maximum postural and movement awareness in addition to specific training of stabilization functions. This is done with exercises in which the patient is required to be fully aware of the way they move, where the muscles demonstrate increased tension and where the muscle activation is excessive. The exercises do not train how to breathe or walk, sit or stand, but the goal is to learn the exact distinction. Exercises are performed slowly, repeated several times and the patient attempts to fully perceive the position and the movement. The patient is required to read their proprioception and exteroception. The Feldenkrais method, tai-chi or yoga seem to fit the above described context. Spinal Exercises According to Cumpelik (Posture – Breathing – Concentration) Spinal exercises according to Jiri Cumpelik are among the exercises that affect postural functions. They do not have the typical strengthening or stretching features and they are based on a change in afferentation leading to a change in motor response by the CNS. Every exercise is preceded by straightening up (position set up), which is maintained during the exercise. “Correct (ideal)” alignment of the initial position prevents vertebrogenic problems. Not only the spine, but the entire body contributes to it including coordination and integration of various muscle synergies with breathing and a foot position. The entire interlinked complex ensuring the attainment of a position for a specific movement is imprinted in the form of a “program” or rather actualizes it in the CNS from which it is later “triggered”.

The renewal of a program for upright body posture, which functioned well during childhood, but for various reasons was (during adolescence and later) modified or “clouded”, is elicited through exercises. The next paragraph outlines the individual components of upright alignment that serve as a foundation and a component for all other exercises and, without which, the effectiveness of the exercises is uncertain (for more detail see Cumpelik, 2006). Exercise Example Starting position: hooklying position, knees apart, arms in abduction, palms facing up. Exercise execution: The patient brings their foot into a grasping position. This means that the patient opens the sole of the foot. This function is ensured mainly by the peroneus longus and tibialis posterior (Fig. 2.4.1-27) and also the interosseous muscles (Fig. 2.4.128 A, B). The shape formed and the muscle prestretch of the foot (grasp) trigger afferent impulses to the CNS, which in turn activate an upright body posture. If the foot position is correct, the diaphragm automatically sets to an “ideal” breathing pattern and a change occurs in the hip and shoulder girdles. During this breathing movement, the ribs move laterally, the sternum does not elevate and the diaphragm supported against the abdominal content increases the intraabdominal pressure and stabilizes the body. Spinal straightening occurs based on these changes (the patient perceives being light, as if they grew by a few centimeters). Then, a rotational movement of the spine is performed in which the feet, knees and the pelvis move right and, at the same time, the head moves left (Fig. 2.4.1-29). This starting foot position is maintained during the entire course of the exercise; in an ideal situation, it persists even after the exercise. An important concept is for the patient to realize this grasp and the changes that occur even in the more distant areas. Then, an upright posture is not a rigid position, but rather a program that ensures cooperation between the agonists and the antagonists in any position. Fig. 2.4.1-27 Pull of the peroneus longus, tibialis

posterior and the short foot flexors influencing foot alignment

Fig. 2.4.1-28 A, B Interosseous muscles. A – dorsal interossei, B – plantar interossei

Fig. 2.4.1-29 Spinal exercise in supine

Concentration or the ability to keep attention on an activity that is currently being performed, is an important factor to make this exercise effective. This will improve muscle coordination and kinesthetic perception. With increased practice, breathing movements also become a diagnostic tool. The movement originating from the “axial skeleton” becomes smoother after its stretching and stabilization. A systematic and unhurried approach is important. Only then the exercises can have a permanent effect – improved spinal stabilization, joint mobility, movement coordination, that is, correction of incorrect postural habits. But not only that – a decrease in stress (and similar disturbances) can also occur because this type of exercise elicits the feeling of inner peace which can persist after exercising. This method is effective for the prevention and treatment of chronic back pain, especially pain arising from postural dysfunction. It can also be beneficial in recurrent overuse injuries originating from poor balance of individual spinal segments and their insufficient stabilization. The awareness process, which has already been mentioned, is a vital component of postural exercises. For example, it is known that it is not possible to directly control the individual musculature (i.e., deep back muscles). Rather, the musculature can be controlled indirectly by having the mind concentrate on the purpose of the movement, which automatically establishes the points of support. Gathering experiences from exercising gradually strengthens the awareness of these points of support and later, it is possible to become aware of changes in tension and, muscle relaxation through

proprioception even in places that are more distant from the points of support. The suggested postural exercises represent a process that is characterized by gradual advancement at each phase. At first, the patient needs to learn to attain a position according to the nature of motor skills (based on anatomy knowledge) even if the mind is not yet trained and subtle perception is insufficient. Emphasis is placed on the external presentation of the attained position. At this stage, the overall framework of the position needs to be and the details understood about the program control are not yet emphasized. It is important to master stability and relaxation in the initial position. The perception of postural certainty, which becomes more apparent and evident, allows for progression to the next stage. A change in afferentation of the CNS from the newly attained positions changes awareness of the initial position, in this case straightening up. The perception is now clearer and the earlier modified position no longer prevents attaining the new position, while the resulting movement is coordinated and natural. Awareness transitions into concentrated, or meditative, attention. Perhaps a comparison to playing the piano can be used here. A virtuoso who mastered the technique of piano playing only perceives the music while playing and mediates it to his audience through his body movements without realizing that this movement is completely automatic. Analogously, as the piano player learns to master the techniques of finger movements and their groups on the keys in the first phase, the patient searches in the first phase for the techniques of an accurate movement, recognizes muscle chaining that contributes to it and learns to control them. In the second phase, a transformation occurs. Similarly, as the piano player’s attention to correct fingering transitions to a greater focus on the music, the patient’s attention on movement transitions to their attention to body position when attaining a certain posture. The piano player’s fingers are now completely at the service of the music and, in the same way, the movement system finds itself fully at the service of the intended movement. Transformation of attention, which occurred at this level, allows volitional access to a more advanced postural control.

During exercise, attention is directed toward the posture, its character and possible changes. A correct body posture serves mainly for prevention of spinal disease, but can also indirectly affect the function of other body systems. It is always important to keep in mind that posture to which various components of the body contribute (breathing, muscle synergies, foot arch support, mind concentration), their coordination and their integration cannot be “exercised” but rather established. McKenzie Therapy Robin McKenzie developed a method focused on patients with spinal problems. The philosophy of this method includes primary, secondary and tertiary prevention. Its treatment approach is based on the principle that the basic cause of spinal pain has a mechanical component and thus can be addressed mechanically. Guiding the patient toward selfresponsibility and their own contribution to the treatment are important components of this method. The patient is not a recipient, but rather an active participant in the treatment. Treatment is selected based on the patient’s problem classification. Treatment or self-treatment is indicated after the diagnosis has been established. Based on the obtained subjective symptoms and an objective assessment, the syndromes are classified into three categories: 1. A postural syndrome – this is an incorrect body posture in a certain position. The developed pressure on the normal tissue is abnormal and causes only localized pain in the spinal region. During assessment, repeated tests of movements do not provoke any symptoms because the entire mechanical problem is based on overloading of alignment. Successful therapy is based on patient education of the correct body posture and a change in the patient’s behaviors. 2. In contrast, the second syndrome is characterized by normal pressure on an abnormal tissue. This syndrome is known as a

dysfunction and the type of dysfunction is determined during an examination. If the symptoms are provoked during movement into flexion, it is a flexion dysfunction. Similarly, a number of other dysfunctions have been described, for example, an extension dysfunction and, in the cervical spine, a rotation dysfunction. Following the assessment and identification of the type of dysfunction, treatment in the direction of the limitation is selected. In a dysfunction, symptom location is characterized by the region of the spine, with the exception of a nerve root adhesion. Treatment involves stretching the shortened tissue. The patient needs to be motivated because the effects of therapy occur slowly. Gradually, range of motion increases and pain decreases. Tissue remodeling occurs no sooner than in three weeks. Therapy, of course, includes postural correction. 3. The presence of an anatomical lesion within the spinal canal is known as a derangement syndrome. This syndrome is described most often in the cervical and lumbar spine. In both cases, it is subclassified based on symptomatology – there are seven categories. Clinically, they are distinguished based on location, type and course of pain and objectively based on limited range of motion and the type of nucleus pulposus shift inside the disc. During the examination, repeated movements tests are positive. Treatment is based on assessment outcomes. One of the eighteen principles of treatment is selected. The following are the principles for the lumbar spine (positions and exercises): 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Prone lying (Fig. 2.4.1-30) Prone extension (Fig. 2.4.1-31; Fig. 2.4.1-32) Prone extension with a stabilization belt (Fig. 2.4.1-33A) Prone extension using a tilt table (Fig. 2.4.1-33B) Prolonged extension Standing extension (Fig. 2.4.1-34) Mobilization into extension Manipulation into extension Rotation mobilization into extension Rotation manipulation into extension

11. 12. 13. 14. 15. 16. 17. 18.

Rotation mobilization into flexion Rotation manipulation into flexion Supine flexion (Fig. 2.4.1-35) Flexion while seated on a chair (Fig. 2.4.1-36) Standing flexion Flexion while standing on a step Lateral shift correction Self-correction of a lateral shift (Fig. 2.4.1-37)

Fig. 2.4.1-30 Simple prone lying used in the first acute and highly painful phase of the disease

Fig. 2.4.1-31 Exercise into partial extension in prone mostly used in highly painful states in the first phases of disc herniation

Fig. 2.4.1-32 A sample of exercise progression into extension completed by deep exhalation in full lumbar extension

Fig. 2.4.1-33 Exercise into prone extension with a stabilization belt (A) or a tilt table (B) used mainly in patients with overactivity of superficial lumbar extensors during the exercise Fig. 2.4.1-34 Self-treatment: standing extension used mainly for prevention

Fig. 2.4.1-35 Self-treatment: exercise into flexion in supine

Fig. 2.4.1-36 Flexion while seated on a chair

Fig. 2.4.1-37 Self-treatment – correction of a lateral shift of the pelvis with the upper quarter being supported against the wall

The treatment principle is based on reaction to pain. The therapist is guided by the centralization phenomenon (see below) and, for this reason, the treatment selection is very conservative to ensure that no additional tissue pathology occurs. Once again, correction of position is vital. Every syndrome requires different treatment based on an accurate diagnosis. The diagnosis is based on patient-specific assessment, which determines the treatment method in the functional context. The anamnesis is identical to other diseases and detailed information about symptom behavior during daily activities needs to be collected. Starting from the moment the patient enters the clinic, their movement is observed, including the way they sit and stand. The patient is not only assessed under static conditions and during movement. The patient is assessed in various positions, directions and repeated movements tests are performed. The quality of movement is always assessed. The cervical spine is more complicated when compared to the lumbar spine. Besides simple flexion and extension, protraction and retraction are performed, and other common movements are assessed. An example of repeated movements tests during lumbar spine assessment: A patient in supine brings their lower extremities toward their stomach one time and the therapist asks about their subjective symptoms. Then, the same movement is performed ten times in the same position and subjective symptoms are reported. A similar procedure is followed during forward bending in standing, prone extension, etc. During the assessment, subjective symptoms are documented and compared to the therapist’s objective findings. In this method, the term centralization is used. A shift of the symptoms from the periphery toward the midline and a decrease in pain as a result of repeated movements is a sign of good prognosis. In contrast, peripherization is characterized by symptom worsening, the examination needs to be repeated and the treatment altered.

The thoracic spine does not demonstrate as many problems. Problems above the superior angle of the scapula are addressed as cervical problems. Symptoms below the inferior angle of the scapula are addressed as part of the lumbar spine. Treatment is based on the principles of postural correction that utilizes the extension, flexion or lateral principle. In general, during the treatment of the most common syndrome, a derangement syndrome, the movement that causes symptom centralization (the symptoms shift from the periphery to the center) or elimination is selected. The main goal of therapy is not only the focus on individual segments, but also the correction of the patient’s condition from a functional, as well as, pain control and prevention perspective. A mobilization effect is achieved by repeated movements, hence mainly self-treatment. Correctly selected frequency, intensity of range of motion and patient education are important. The most commonly used techniques include: prone extension, relaxed extension, supine flexion, flexion on a step and lateral shift correction. Centralization of pain, change in the nature of pain (constant/intermittent), decreased pain frequency, increased range of motion, movement restoration and decreased medication are all signs of improvement with therapy. In case the treatment does not lead to improvement, it needs to be examined whether the lateral component has not been overlooked. Other reasons can include treatment that has been too short in its duration or the fact that the patient did not perform the exercises into a full range of motion or did not exercise correctly (for example, extension was performed with activation of the back extensors). Therapy is contraindicated in patients with metastases, nonmechanical problems (behavior deficits), in patients with a body structure anomaly and acute inflammatory conditions, in cases where there is no change in symptoms with any movement or position and peripherization occurs or in a severe neurological deficit. Based on data, McKenzie method is used successfully in patients status post

spinal surgery. Although the indication of McKenzie therapy is not universal, it is often the method of choice. Indication must be based on movement analysis. Based on our experiences, patients who exhibit deficits in the synergy of trunk stabilization muscles with predominance of spinal extensors do not show positive results in the long term (Fig. 2.4.1-38).

Fig. 2.4.1-38 Movement of the nucleus pulposus during basic movements (positions of the spinal segment which are the foundation of the mechanical perspective of the treatment of vertebrogenic syndromes

Pharmaceutical Treatment Pavel Kolář Antirheumatics, analgesics and muscle relaxants are the main categories of drugs indicated for the treatment of spinal root syndromes. They are often complemented by local anesthetics and corticosteroids, or anti-convulsion drugs, antidepressants and drugs affecting peripheral nerve regeneration. When muscle relaxants are indicated for patients with spinal problems, caution needs to be paid, especially in patients who display hypermobility. In such a scenario, treatment with muscle relaxants is considered contraindicated. Invasive Procedures Jan Štulík Intervention Methods Guided by Computerized Tomography Based on the diagnostic assessment, the following can be performed: CT guided facet denervation CT guided periradicular treatment An axial image of the examined spinal segment in a thin layer provides accurate control of needle inserted into the pathologically involved intervertebral joint or a nerve root and precise application of the treatment mixture. Marking the treatment mixture with a contrast substance allows observation of its distribution. Surgical Treatment In general, indications for surgery include uncontrollable pain, involvement of nerve structures and instability in which the above mentioned signs can be anticipated in the future. For traumas, the absolute indications for surgery include injuries with a neurological component and open injuries. Relative indication includes any instability, spinal canal stenosis greater than 50%, decreased anterior border of the vertebral body by more than 50%, kyphosis greater than 15–20 degrees and multiple fractures. Ligamentous instability is more severe than bony instability, especially from a long-term perspective.

In the case of degenerative spinal involvement and deformities, the general indications apply, but are modified based on the particular pathology. The situation differs for tumors for which a surgical procedure plays a fundamental role. In most cases, a solid tumor cannot be removed in any other way. In spinal infections, surgical treatment is indicated mainly for patients with an abscess and serious bone damage. Simple Resection Discectomy is the most common resection and it is practically the most common surgical procedure on the lumbar spine. Given that this surgery often does not disturb the alignment and dynamics of the spine, bed rest is recommended only until the acute pain subsides after surgery. The patient ambulates with axillary crutches one or two days after surgery. Based on the patient’s condition, crutches are gradually discontinued and the patient is allowed full weightbearing. Discectomies of the cervical spine are, for the most, part no longer performed. Single resection procedures are applied to remove peripherally localized tumors. Common procedures include a resection of necrotic substances in infections, decompression of a severely arthritic and spondylotic spine in older adults or a decompression during inoperable tumor involvement compressing on nerve structures. For all such patients, early verticalization without support is recommended if their overall condition allows it. Osteosynthesis Only three surgical procedures are performed on the spine that can be denoted as osteosynthesis: direct pinning of an odontoid fracture (Fig. 2.4.1-39; Fig. 2.4.1-40), direct osteosynthesis of C2 pedicles in an executioner fracture and repair of a pars interarticularis defect in young patients with lumbar vertebra spondylolysis. Bone healing usually takes three months. During this time, the patient wears a cervical external support, most often a Philadelphia collar. Intensive rehabilitation is postponed until after the fracture has safely healed. A patient with lumbar surgery uses axillary crutches for the same period of time.

Fig. 2.4.1-39 Fixation of an odontoid fracture in lateral projection

Fig. 2.4.1-40 Fixation of an odontoid fracture, an open mouth radiologic view

Bony Fusion (Arthrodesis) of the Surrounding Segments Bone fusion is a frequently used surgical technique in all spinal segments. It is performed either individually or as a supplement to spinal instrumentation. In the upper cervical spine, bone fusion most often complements C1-C2 fusion (Fig. 2.4.1-41) or an atlanto-occipital fixation (connection of the head to the neck) (Fig. 2.4.1-42). The patient is seated and, if possible, stands up one day post-surgery. The patients wear a Philadelphia collar or another external support for three months. Young patients with good bone quality need only a soft collar for the same duration of time or no external support at all. Early mobilization, especially in older patients, is important. In the lower cervical spine, most surgical procedures are performed using an anterior approach. The same procedure is used as for the above mentioned upper cervical spine. In some cases, anterior stabilization with fusion is combined with posterior stabilization with fusion (Fig. 2.4.1-43) with no subsequent use of an external support. This approach is especially used for patients with spinal cord involvement with a goal of more frequent rehabilitation without limitations to the spine. In the thoracic and lumbar spine, bone fusion is mostly performed using a posterior approach (Fig. 2.4.1-44). Given the greater loading in this region, it is recommended to rest one day after surgery and begin standing by the bed two days after surgery. In the following days, based on the patient’s health, the patient is progressed

to ambulation with axillary crutches. Even in this situation, we presume a three-month long healing time of the bone graft. During this time, the patient gradually discontinues the use of the crutches and fully weightbears. Specific rehabilitation is recommended after this period. In patients with spinal cord involvement, a combined posterior-anterior surgical procedure is preferred followed by immediate rehabilitation based on a protocol for paraplegics. Patients with degenerative disease treated by the so called 360-degree spinal fusion (Fig. 2.4.1-45) in one surgical procedure require crutches only during an acute post-operative painful phase. Fig. 2.4.1-41 C1-C2 fixation

Fig. 2.4.1-42 Atlanto-occipital fixation

Fig. 2.4.1-43 Combination of anterior and posterior stabilization with bone fusion

Fig. 2.4.1-44 Bone fusion and instrumentation using a posterior approach

Fig. 2.4.1-45 360-degree spinal fusion

Mobile Spinal Stabilization In principle, there are two ways of mobile spinal stabilization – replacement of the intervertebral disc by a metal mobile implant (Fig. 2.4.1-46) or posterior fixation with limited segmental spinal movement (Fig. 2.4.1-47). The first type is used in the cervical and lumbar regions, the second type only in the lumbar spine. Both techniques are used only when treating degenerative changes. In the first week, the treatment is identical to the one noted above. Given the fact that these surgeries do not involve a bone graft, there is no reason to delay rehabilitation and it should be initiated immediately. Fig. 2.4.1-46 Disc replacement by a metal mobile implant

Fig. 2.4.1-47 Posterior fixation with limited spinal segmental movement

2.4.2 Shoulder Girdle Petra Valouchová, Olga Dyrhonová, Jiří Kříž, Pavel Kolář Congenital Developmental Defects Sprengel Deformity Cleidocranial dysostosis Congenital pseudoarthrosis of the clavicle Os acromiale Soft Tissue Injuries Impingement syndrome Calcific tendonitis Subacromial bursitis Rotator cuff tears

Syndrome of the long head of the biceps tendon Frozen shoulder syndrome Degenerative Diseases Glenohumeral arthritis Acromioclavicular arthritis Traumatic Lesions Glenohumeral dislocation Acromioclavicular dislocation Sternoclavicular dislocation Proximal humeral fractures Instability Glenohumeral instability

CONGENITAL DEVELOPMENTAL DEFECTS OF THE SHOULDER GIRDLE Sprengel deformity, cleidocranial dysostosis, congenital pseudoarthrosis of the clavicle and os acromiale belong among the congenital developmental defects of the shoulder girdle. Their etiology, pathogenesis and treatment are described in Chapter 2.3.1 Congenital Developmental Defects, Congenital Developmental Defects of the Upper Extremities.

SOFT TISSUE INJURIES IMPINGEMENT SYNDROME The term “impingement” means a “pinch”. It is a painful compression of soft tissues (coracoacromial ligament, supraspinatus tendon and subacromial bursa) by impinging on the fornix humeri (comprised of the acromion and the coracoacromial ligament) during abduction between 70–120°. This condition occurs as a result of structural or functional changes in the shoulder girdle (Fig. 2.4.2-1).

Fig. 2.4.2-1 The principle of supraspinatus tendon impingement syndrome

Etiology and Pathogenesis Structural causes of an impingement syndrome include changes in the inferior surface of the acromion, anatomical anomalies of bony structures, such as a hooked type acromion, bone spur on the anterior aspect of the acromion, prominent AC articulation, post-injury and degenerative changes of the rotator cuff. The functional causes of an impingement syndrome include an internally rotated humerus, shoulder protraction with thoracic kyphosis, supraspinatus weakness, biceps brachii spasm and other deficits in muscle coordination between the abductors and external rotators and scapular stabilizers, which results in scapulo-humeral

rhythm dysfunction during shoulder abduction. Clinical Presentation Pain during loading and at rest is the main subjective symptom. Night pain is typical and the patient is unable to lie on the affected side. Objective findings include pain with supraspinatus tendon palpation and a positive painful arc (see General Section of the textbook, A. Diagnostic Approaches, Chapter 1.2.2 Kinesiology of the Shoulder Girdle). Neer Classification Based on the severity of pain and the degree of degenerative structural changes, three stages are distinguished: I. Stage – dull pain, painful arc with 90° abduction, positive resistive test, decreased strength with abduction and external rotation II. Stage – pain with movement, pain at night, limited range of motion, fibrosis, inflammation of compressed tissues III. Stage – changes in bone tissue, osteophyte formation, supraspinatus tendon calcification, greater restriction in active range of motion than passive range of motion, rotator cuff muscle atrophy Treatment Treatment selection depends on the degree of tendon involvement. Grade I Treatment is based on addressing the causes and their consequences during the development of the impingement syndrome, at first, by thorough evaluation of the joints and the muscles of the shoulder girdle, assessment and mobilization of the cervical and thoracic spine and rib restrictions and an assessment of the spinal stabilization system. This will identify the source of the scapulo-humeral rhythm dysfunction and the loss of active external rotation of the humerus. Trigger points are often found in the supraspinatus itself, upper and middle trapezius, deltoid, rhomboids, pectorales and biceps brachii. Generally, immediate relief can be felt after the treatment of TrPs in

the supraspinatus by PIR, agistic-eccentric contraction (AEC) or another soft tissue method. Trigger points in the supraspinatus often reoccur if the biomechanical relation of the shoulder girdle including the scapulo-humeral rhythm is not corrected. The scapulo-humeral rhythm is usually altered by quicker recruitment of the upper scapular stabilizers with subsequent weakness of the lower stabilizers (serratus anterior, lower trapezius). TrPs in the scapular adductors need to be treated, which are often found along the medial aspect of the scapula. TrPs in the scapular adductors often cause a secondary limitation of extension with internal rotation, which is a movement of the entire arm behind the body with the elbow flexed and a functional inability to reach between the shoulder blades. When the acute pain of the “painful arc” subsides, pain can persist at end range abduction with internal rotation. At this stage, a change in the activity of the lower and upper stabilizers is important during movement into abduction with emphasis on relaxation of the trapezius, especially in the initial 60° of abduction. This requires activation of the lower scapular stabilizers and their insertions to the trunk via the trunk stabilization muscles (diaphragm, abdominal muscles, deep core musculature). To restore this co-activation, maximum thoracic spine straightening with unrestricted mobility of the costovertebral joints is important. At this stage, laser or combined electrotherapy for trigger points are beneficial modalities. Grade II The treatment approach is similar for grade II impingement syndrome. Moreover, traction and mobilization of the glenohumeral joint and the scapula are beneficial. At this stage, when inflammation of the subacromial soft tissue occurs, application of shockwave ultrasound, analgesic current (bipolar vector field – interferential currents, laser, ultrasound) or combined electrotherapy are beneficial to relieve reflexive changes in the involved muscles. Grade III A grade III impingement is characterized by significant structural changes in the supraspinatus tendon, osteophyte formation and rotator cuff muscle atrophy. Surgery is indicated with subacromial

decompression, coracoacromial ligament resection and partial distal acromioplasty. In surgeries involving the subacromial space, which are most often decompressions or bursectomies, immobilization is not needed for tissue healing. In contrast, the effort is to prevent adhesion formation. Therefore, passive exercises are initiated one day after drainage removal. Active shoulder mobility exercises are implemented when post-surgical pain subsides. Again, aquatic therapy is beneficial. A similar treatment method is implemented after capsulotomy performed in frozen shoulder syndrome. Following the surgery and incision healing, electrical stimulation of mainly the external rotators, gentle isometric exercises, closed-kinetic chain exercises and finally open-kinetic chain exercises are initiated. During all exercises and in all positions, attention is paid to the neutral position of the scapula and its optimal position in relation to the angle of glenohumeral abduction or flexion. Rehabilitation Following Shoulder Joint Arthroscopy (Subacromial Decompression, Debridement, Capsular Release, Acromioplasty) Treatment selection is based on the time period since surgery. Phase I (0–2 weeks post-surgery) Following surgery, ice is applied for 1–2 days; later, cryotherapy is used for pain control or following over activity. A sling is recommended for patient comfort; a brace is used if recommended by the surgeon. The patient performs active movement of the wrist, elbow and begins stabilization exercises of the shoulder joint and the scapula, including pendulum-like movements. Gentle post-isometric relaxation in all planes (attention needs to be paid to end-feel), soft tissue techniques, passive range of motion and careful stretching are performed. Strengthening or active exercise is not yet included other than stabilization exercises in the permitted position. Also shoulder joint centration is performed. The patient begins to engage in regular daily activities. Movement is performed strictly to the pain threshold.

The following are performed: flexion in supination, elevation or rather supine flexion (anti-gravity elevation) with assistance, external rotation in a neutral position in supine only (for example, using a wand), and internal rotation behind the back. Abduction above 90° is avoided (the humeral head contacts the humeral fornix/shoulder roof). The patient is observed so that they do not utilize compensatory movements and correct body posture is taught. Phase II (2–6 weeks post-surgery) In this phase, active assistive movement is initiated with gradual active movement of muscles based on the grade of muscle strength. Stabilization exercises of the rotator cuff and the scapular muscles are included. Mobilization of the scapula, glenohumeral joint, AC, SC joints and the ribs are also implemented. Elevation or flexion in supine and standing with the elbow flexed and with assistance from the physical therapist or from the other arm are included. Movement into abduction and external rotation with the forearm in supination is allowed, which means that the patient places their hands with the elbows flexed behind their head followed by pulling the elbows toward the head. The patient exercises into horizontal adduction and external rotation in a neutral position in the same way as when standing sideways to a door, which is then opened by moving the upper extremity into external rotation and closed by movement into internal rotation. Resistance bands, wall ladder and active exercises in Therapi Master are used. PNF, components from Vojta’s reflex locomotion, etc. are used as well. If muscle pain emerges, exercise is limited or temporarily suspended. The patient continues to be reminded to be cautious with movement into active abduction. Phase III (6–12 weeks post-surgery) During therapy, shoulder range of motion and muscle strength are gradually increased in all planes by using dumbbells, weights and resistive exercises. Dynamic shoulder stabilization is continued, including post-isometric relaxation and passive stretching in all planes performed by a physical therapist. Next, the patient strengthens by pulling resistive bands into external rotation, internal rotation, flexion, extension and also elbow flexion by using the biceps brachii

(i.e., exercising in sidelying on the uninvolved side, elbow flexed to the side at 90° and lifting the hand in the direction of external rotation). The patient can perform flexion of the involved upper extremity up a wall ladder or on the wall. They can move their body gradually toward the wall and allow the upper extremity to slide down the wall and, at the same time, press gently against the wall (the arm is extended and its position can be altered into internal or external rotation, with contact with the wall more in the direction of abduction or adduction). The corner self-stretch is beneficial, in which the patient faces the corner with their arms abducted and externally rotated and placed on the wall with the patient leaning in and stretching the pectoral muscles. This position is also used well for post-isometric relaxation, in which the upper extremities press against the wall.

CALCIFIC TENDINITIS This disease is characterized by calcium deposits within the rotator cuff. Calcification is quite often preceded by degenerative changes of the rotator cuff tendons, mainly in the so called critical zone of the supraspinatus tendon, in which the vascular supply is disrupted as a result of chronic soft tissue compression. Clinical Presentation Calcific tendinitis is manifested as pain in the subacromial space, which is similar to the pain experienced in impingement syndrome. Pain radiates along the deltoid toward its insertion. Significant pain quickly leads to limited range of motion and shoulder muscle atrophy, especially in the rotator cuff (Fig. 2.4.2.-2. ).

Fig. 2.4.2-2 Calcification at the supraspinatus tendon insertion at the greater tubercle of the humerus

Rehabilitation Rehabilitation consists of similar exercise elements and principles as in an impingement syndrome. During the assessment, the reason for rotator cuff tendon overloading needs to be identified and therapeutic treatment focused on minimizing or compensating for these mechanisms (scapulo-humeral rhythm dysfunction, inhibition of lower scapular stabilizers, loss of thoracic rotation and segmental extension, etc.). Modalities include laser, ultrasound or shockwave ultrasound, which is beneficial only after the shoulder muscles are stronger and the correct scapulo-humeral rhythm has been mastered.

SUBACROMIAL BURSITIS Subacromial bursitis is often found as part of other shoulder

conditions, such as impingement syndrome or calcific tendinitis. The bursa is altered by inflammation and is filled with liquid. Clinical Presentation The clinical picture typically shows pain at rest, pain at night, which wakes the patient from sleep and pain with shoulder movement in all directions. Rehabilitation The goal of therapy is to decrease inflammation. Rest is recommended and the extremity is immobilized in Desault’s bandage. Manual techniques implement relaxation of spasmed muscles using post-isometric relaxation or AEC, and glenohumeral joint mobilization and traction, restoration of cervical and thoracic spinal dynamics, and rib and thoracic fasciae mobilization are utilized. Modalities include cryotherapy, analgesic currents in electrotherapy, ultrasound and a laser.

ROTATOR CUFF TEARS Rotator cuff tears are closely linked to an impingement syndrome. Most often, it occurs with chronic degenerative changes in the rotator cuff tendons, which are a result of chronic overloading and microtraumas or emerge after non-indicated and repeated local application of corticosteroids. An acute rotator cuff tear is rare. A rotator cuff tear is more often seen in men older than 60. Clinical Picture Subjective findings typically include chronic shoulder pain during activity and at rest and pain at night. Objective findings are dominated by limited active shoulder range of motion up to a seeming extremity “pseudoparesis”; passive range of motion is not restricted. The clinical presentation also includes rotator cuff atrophy, especially in the supraspinatus and the deltoid. Classification according to Gschwend

1. The tear affects the supraspinatus or the subscapularis; lesion size up to 1 cm. 2. The tear involves the supraspinatus or the subscapularis; lesion size up to 2 cm. 3. The tear involves the supraspinatus and simultaneously the subscapularis or the infraspinatus. 4. The tear affects the entire cuff, the head is “stripped off” the cuff. Treatment Rotator cuff tears are most often treated by surgery. The surgical procedure consists of suturing the tendons or their re-insertion. A subacromial decompression is often a component of this procedure. Following surgery, the extremity is immobilized for 6 weeks in an abductor immobilizer set at 60° of abduction. Following rotator cuff surgery that included sutures or re-insertion to the humeral head, active contraction of the re-inserted muscles is not allowed for at least 6 weeks post-surgery. During this period, the patient performs passive movements administered by a physical therapist or by a continuous passive motion machine. It is recommended to perform the exercises in shorter time intervals (10–15 minutes), two or three times per day. Active abduction and flexion are strictly prohibited. After 6 weeks, the patient begins active assistive exercise. Movement synkinesis of the scapula at the beginning of movement needs to be prevented. Exercises include open and closed kinetic chain. Aquatic therapy is also beneficial. Rehabilitation The selection of rehabilitation treatment following surgery depends on the extent of the original lesion. Grades I and II according to Gschwend Phase I (0–2 weeks post-surgery) – the following are recommended: sling, cryotherapy 1–2 times per day, passive range of motion limited to 90° abduction, 20° extension, and 70° internal rotation (not behind the back). Soft tissue techniques, stabilization exercises and pendulum-like exercises (Codman’s) are implemented.

Phase II (2–6 weeks post-surgery) – the use of a sling is decreased during the day; the patient is taught postural awareness; shoulder joint is stabilized; scapular stabilization should not be forgotten, as well as, soft tissue techniques and mobilizations. Phase III (6–12 weeks) – sling is only used at night; range of motion is no longer restricted. Active assistive and active movement is initiated throughout its entire range, similarly to the previous programs (resistive bands, PNF, using submaximal isometric contraction during stabilization exercise); gentle strengthening exercises of the scapular stabilizers and the rotator cuff are gradually implemented. Phase IV (12–18 weeks) – resistive exercises are incorporated, postural awareness is encouraged, movement quality is emphasized, patients have their own daily routine. Grades III and IV according to Gschwend Phase I (0–2 weeks post-surgery) – constant brace wear is recommended except for when exercising, otherwise the guidelines are the same as in rehabilitation for a small or medium rotator cuff tear. Phase II (2–6 weeks post-surgery) – the approach is again the same as after surgery for a small or medium rotator cuff tear, but the brace should be worn constantly with the exception during exercise, when bathing or sitting at rest. Phase III (6–12 weeks post-surgery) – it is recommended to discontinue using the brace; no restrictions are placed on range of motion except when lifting the arm above the head. Phase IV (12–18 weeks post-surgery) – resistance exercises are included if healing and rehabilitation are without complications. Return to athletic activities is permitted after 6 months without limitations.

SYNDROME OF THE LONG HEAD OF THE BICEPS TENDON

Tendinosis of the Long Head of the Biceps The tendon of the long head of the biceps most often presents with tendinosis. It is manifested by shoulder pain, especially in the anterior aspect with shoulder and elbow flexion. Movement of the arm behind the body is significantly affected and the Yergason’s test is positive (painful) (see General Section of the textbook, A. Diagnostic Approaches, Chapter 1.2.2. Kinesiology of the Shoulder Girdle, Special Tests of the Shoulder Girdle). Crepitus can be palpated during biceps activation. With ultrasound testing, inflammation and tenosynovitis are observed. This inflammation occurs acutely during muscle overloading with underhand ball striking (volleyball, tennis), with repeated impacts on the hands (gymnastics) or in disadvantageous work positions, in which the arm is held in slight shoulder flexion, elbow flexion and forearm supination (waiters, mine workers using a jackhammer, etc.). The quality of the lower scapular stabilizers and the trunk stabilization musculature also play an important role in the onset of long head biceps tendinosis. Treatment Treatment includes only rehabilitation. In the acute phase, trigger points in the biceps brachii are treated by AEC or post-isometric relaxation, direct release of the tendon area by soft tissue techniques and a hot towel roller (Brügger). Also, the TrPs in the pectorales, scapular adductors and the triceps brachii are treated. Scapular mobility needs to be restored. Painful tendons of the shoulder adductors need to be released, as well as, possible cervical and thoracic spine restrictions or costovertebral joint restrictions. When the acute phase and pain subside, the treatment includes methods engaging the involved muscle into muscle synergies that ensure shoulder girdle mobility and stability (Vojta’s method, PNF). Subluxation of the Long Head of the Biceps Tendon Subluxation of the long head of the biceps tendon occurs with a tear in the transverse humeral ligament. With a ligamentous tear, the tendon migrates medially above the tendon of the subscapularis

muscle (Fig. 2.4.2-3).

Fig. 2.4.2-3 Subluxation of the long head of the biceps tendon

Injury to the transverse humeral ligament occurs during forceful shoulder flexion with scapular elevation. The patient experiences a pop and a sharp pain in the anterior aspect of the shoulder. Then, anterior shoulder pain persists and the paint increases with contraction of the biceps brachii. The biceps muscle also demonstrates decreased strength. During clinical assessment, the Yergason’s test is positive. Treatment Surgical repair of the ligament is indicated if the tendon is unstable and a tear in the transverse ligament is present. After a period of immobilization, which takes approximately 2–3 weeks, gentle passive stretching and isometric exercises are initiated. Intensive post-surgical rehabilitation continues by renewing the function of the scapulothoracic and glenohumeral joints. Biceps Tendon Rupture Avulsion of the long head of the biceps occurs in the area of its proximal insertion during forceful shoulder abduction and extension and often after repeated application of local corticosteroids.

The rupture of the muscle belly or an avulsion of the short head of the biceps occurs mostly in the area of its distal insertion when lifting heavy objects in 90° of elbow flexion. Clinically, this condition is manifested by retraction of the muscle belly and a localized hematoma. Treatment Generally, surgical repair is indicated for the torn tendon or reinsertion of the torn tendons. Active exercise is initiated based on the surgeon’s guidelines (approximately 4–6 weeks post-surgery). When the sutures are removed, gentle and pain-free elbow range of motion is performed. Later, passive shoulder and elbow range of motion in all planes followed by isometric exercises, closed kinetic chain exercises and later dynamic exercises against resistance, gentle post-isometric relaxation techniques, etc. are implemented. Exercise intensity is modified based on the patient’s tolerance and the possibility of pain during shoulder or elbow movements. Modalities include aquatic therapy or electrotherapy with connective tissue healing effects (distant electrotherapy –Basset’s currents).

FROZEN SHOULDER SYNDROME Frozen shoulder syndrome denotes a painful shoulder condition with fast progression and significant movement limitations in all directions. Etiology and Pathogenesis The etiology and pathogenesis of this condition is diverse. A previous shoulder trauma, long-term immobilization, impingement syndrome, autoimmune disease, thyroid gland dysfunction or diabetes mellitus can all have an effect on the onset of the syndrome. The incidence is more common in women in the 5th or 6th decade of life. Clinical Presentation Pain is the first sign. Generally, pain is present during movement and increases with loading; later, the pain is experienced even at rest and wakes the patient at night.

Limited range of motion is another sign. Gradually, movement becomes limited above the horizontal and into extension. The patient is limited in basic self-care. Objective findings include a significant limitation in passive and active range of motion and joint play is minimally limited. Resistive tests are usually negative. Painful TrPs are found in the subscapularis, deltoid, teres major, and latissimus dorsi. TrPs are also found in the scapular adductors and secondarily in the upper trapezius and biceps brachii. The scapulo-humeral rhythm shows significant dysfunction as a result of increased tone in the muscles of the posterior axilla. Scapular and arm movement occur to the same degree, which leads to maximal scapular rotation (60°) being reached at 60° of humeral abduction. Furthermore, every movement is initiated by activation of the upper trapezius and thus, scapular elevation. During an effort to passively “dissociate” the scapula from the humerus, a restriction is encountered. Three stages are distinguished, each lasting approximately 3–4 months: 1. Acute and subacute phases – an intense pain is present 2. Progressive tightness phase – pain recedes, limited mobility dominates 3. Phase of mobility restoration Rehabilitation The rehabilitation strategy is selected according to the clinical findings and the stage of the condition. In therapy, traction and mobilization of the glenohumeral joint has been found beneficial. Soft tissue techniques include the release of the posterior axilla (latissimus dorsi, teres major) and the anterior axial fold, the scapular adductors medially to the scapula and the subscapularis on the medial and ventral aspects of the scapula. The contracted fibers of the subscapularis can also be palpated and treated by ischemic compression through the axilla after gentle arm traction in slight abduction. Post-isometric relaxation of the subscapularis provokes

shoulder pain, thus the AEC method should be used instead. Gentle dissociation between the scapula and the humerus is performed (the patient is prone with the arm off the table; the scapula is stabilized from the top and the humerus is gently moved into abduction and external rotation) until the release phenomenon occurs. Under any circumstances the patient should exercise through pain, which would lead to even greater reflexive spasm of the shoulder musculature. Thoracic spine straightening allows for optimal scapular position and thus, encourages improved engagement of the lower scapular stabilizers. Gentle mobility exercises include pendular-like extremity movement in forward bending with the trunk erect and the contralateral upper extremity supported on the elbow or hand. Similarly, movement into flexion or abduction can be performed in prone with the arm over the edge of the table and the hand on a small ball. Pushing into the ball allows facilitating the shoulder joint in its support function. The lacking phasic mobility can be improved by rolling the ball to the side or forward. In phase II, aquatic therapy is appropriate and effective. Modalities used to decrease pain in the acute phase include analgesic currents, such as Träbert’s currents or mid-frequency currents – isoplanar vector field. For muscle relaxation, combined electrotherapy or high voltage treatment can be used if at least 20° of abduction has been preserved by applying the electrodes at the medial and lateral borders of the scapula. In the absence of abduction, distant electrotherapy is recommended instead (f = 182 Hz), specifically at the posterior axilla.

DEGENERATIVE DISEASES GLENOHUMERAL ARTHRITIS Etiology and Pathogenesis Glenohumeral joint arthritis can develop due to congenital dysplasia, metabolic disorders, traumatic, post-traumatic, vascular, septic and

aseptic inflammatory processes. In degenerative arthritis, the cartilage of the posterior joint socket is damaged at first and the head develops erosions first in the middle part with subsequent development of circular osteophytes. In arthritis developed as a result of inflammatory conditions, the entire cartilage is damaged. Arthritis developed status post a rotator cuff lesion affects the spherical cap of the humerus in the subacromial space. Arthritis developed as a result of instability affects the anterior or posterior rim of the socket, and later, the humeral head. Simultaneously with arthritis, reactive changes in the soft tissues occur, such as synovitis, joint capsule retraction and retraction or contracture of the rotator cuff. Clinical Picture Pain with shoulder movement is a subjective sign occurring initially at movement initiation and later during loading and at rest. Objective findings include limited range of motion and crepitus with movement. Rehabilitation Modalities are effective in decreasing pain and inflammatory processes. In the acute phase, a Priessnitz wrap is applied (changed every 3 hours), electrotherapy (isoplanar vector field), TENS or laser. In the chronic phase, in which pain at rest is not present, SF currents are effective – dipolar vector field, DD currents or low frequency magnetic therapy. In the chronic stage, aquatic therapy is beneficial to improve restricted mobility. With manual treatment, attention is paid to the release of reflexive spasms and retracted muscles (subscapularis, pectorales, latissimus dorsi). Glenohumeral and accessory shoulder girdle joint traction and gentle mobilization provide relief. Mobility of the cervical and thoracic spine and the ribs needs to be restored. A total joint replacement by an endoprosthesis is indicated for severe shoulder arthritis.

ACROMIOCLAVICULAR ARTHRITIS

Etiology and Pathogenesis Damage to the acromioclavicular joint (AC joint) cartilage is quite common, especially after shoulder injuries caused by microtraumas to the articulation and the ligaments (Norris, 1998). As a result of repeated traumas, acromioclavicular joint instability develops, which later leads to damage of the disc and the joint cartilage and osteophyte formation. This damage is found in athletes and occupations that stress the AC joint by throwing, lifting heavy objects or impact on the hands. Clinical Presentation Painful horizontal adduction with full passive end range of movement (scarf sign) is a typical sign. Pain is also present with arm movement into elevation, abduction and/or full elevation (180°). Movement elicits crepitus. The acromioclavicular joint is distorted and painful to palpation. Rehabilitation In the acute phase, rest, elimination of painful movements and possibly a Desault’s bandage are recommended. Effective modalities include laser, distant electrotherapy, bipolar vector field or low frequency magnetic therapy. Manual distraction and joint mobilization are generally relieving and temporarily improve joint mobility and thus, the entire shoulder girdle. Other approaches involve the release of muscle spasms and reflexive changes (upper and middle trapezius, supraspinatus, anterior deltoid), activation of inhibited muscles (posterior deltoid, external rotators, serratus anterior, lower trapezius) and their engagement into movement patterns of the shoulder girdle and global movement programs.

TRAUMATIC LESIONS GLENOHUMERAL DISLOCATION

During a glenohumeral dislocation, a loss of contact occurs between the joint surfaces of the humeral head and the glenoid socket, as well as, damage to the joint capsule, lower glenohumeral ligament and the glenoid labrum. Etiology and Pathogenesis The majority of glenohumeral dislocations involve an anterior dislocation, which occurs during falls on the upper extremity while the shoulder is in abduction and external rotation and the impact results in its hyperextension. A posterior dislocation is rare and occurs during falls on an upper extremity while it is in flexion, adduction and internal rotation. Clinical Picture In an anterior dislocation, the shoulder joint is deformed, the head of the humerus is palpable on the anterior aspect of the joint, the extremity is in an antalgic alignment, active and passive range of motion cannot be performed and springing is observed during an effort to perform passive movement. Treatment The treatment for an acute traumatic dislocation of the glenohumeral joint is conservative and consists of glenohumeral joint repositioning and shoulder girdle stabilization. Following the first glenohumeral dislocation, immobilization is vital during treatment. The extremity is immobilized in adduction and internal rotation by a Desault’s bandage. The extremity is immobilized for six weeks. Recurrent dislocations occur when correct immobilization principles are not adhered to. Rehabilitation The length of immobilization needs to be respected during rehabilitation. In the acute stage, modalities include cryotherapy and resting galvanization. During immobilization, physical therapy focuses on the surrounding segments – the cervical and thoracic spine,

wrist and hand. Upon discontinuation of immobilization, rehabilitation can focus directly on the glenohumeral joint. Starting at 6 weeks, isometric exercises with joint approximation are implemented. Permitted movements include active movement into flexion, extension, internal rotation against slight resistance, and movement into abduction to 45°. Starting at 8 weeks, active movement to 90° of abduction is continued and movement into external rotation is initiated. Vojta’s method can be used for activation of the rotator cuff muscles and the lower scapular stabilizers; initially by using reflex rolling and later, if greater external rotation range is available, through reflex crawling, or position 1. The position can be modified based on the patient’s available shoulder range of motion. Up to 3 months after injury, movements into full abduction and external rotation are contraindicated. Modalities include electrical stimulation of the deltoid and the supraspinatus by using a TENS surge or mid-frequency current. Biofeedback can also be used. For 6–8 weeks, the patient should be provided with an orthosis.

ACROMIOCLAVICULAR DISLOCATION An acute dislocation or subluxation of the acromioclavicular joint occurs either by falling on the shoulder (an impact on the acromion is directed inferiorly), by an impact to the shoulder joint from the outside or by falling on the elbow. During the trauma, the ligaments and the capsule of the AC joint are torn. Chronic AC joint instability occurs during ligamentous laxity and is accompanied by crepitus. Clinical Presentation Edema, AC joint deformation and pain upon palpation are typical objective findings. Active shoulder range of motion above the horizontal is restricted. Full passive range of motion can be achieved, but it is painful. Elevation of the lateral aspect of the clavicle may be present. Three grades are distinguished ranging from distortion to joint dislocation.

Treatment A Desault’s bandage for 2–3 weeks is used if surgical correction is not indicated. Dislocation involving a complete rupture of the acromioclavicular and coracoacromial ligaments is treated operatively. In sport traumatology (especially in the USA), a complete dislocation is usually treated non-surgically (conservatively) without the use of immobilization. Rehabilitation begins immediately on the second day after injury. Rehabilitation Rehabilitation is initially limited to scapular mobilization and gentle mobilization of the cervical spine, isometric and stabilization exercises. Soft tissue techniques are used for the upper trapezius and the posterior and anterior axilla. During this time, phase I of Vojta’s reflex rolling can be used. In 2 weeks, active exercise to pain is implemented. Closed kinetic chain exercises are initiated at first on elbows and later on hands. During exercise, the caudal alignment of the scapula needs to be ensured, as well as, the descended alignment of the rib cage with an erect thoracic spine and thus, co-activation of the lower scapular stabilizers and trunk musculature. Phase II of reflex rolling can be used to improve activation of the shoulder girdle muscles and their engagement in body patterns. Based on the extent of joint range of motion, a modified position of reflex creeping or Vojta’s first position can be used. The extension component of PNF diagonal I and II can be implemented. Later, plyometric strengthening elements can be included. Modalities include electrical stimulation of functionally and reflexively weakened muscles.

STERNOCLAVICULAR DISLOCATION A sternoclavicular (SC) joint dislocation most often occurs by falling on the shoulder. With a fall on the anterior shoulder, an anterior dislocation of the medial clavicular end occurs. With a fall on the posterior side of the shoulder, a posterior dislocation of the medial end of the clavicle occurs; however, it is rare (Fig. 2.4.2-4).

Fig. 2.4.2-4 Sternoclavicular dislocation. A – posterior; B – anterior

Clinical Picture With an anterior dislocation, the joint is enlarged by the clavicular head dislocation. The patient holds the shoulder joint in antalgic protraction and movement into horizontal flexion is painful and exhibits crepitus. A posterior dislocation is dangerous because of a possible injury to the mediastinal organs (trachea, esophagus) or the brachial plexus, which can be manifested as upper extremity paresthesia. Treatment Closed repositioning of the SC joint is indicated for a dislocation. Open repositioning with joint capsule reconstruction is performed less often. Rehabilitation begins following a necessary period of sling immobilization for at least 2–3 weeks. Rehabilitation Initially, isometric exercises are implemented and later followed by closed kinetic chain exercises. With an anterior dislocation, movements into extension and internal rotation are excluded. Soft tissue techniques are used for the pectoral muscles and their fascia to prevent defensive spasms.

PROXIMAL HUMERAL FRACTURES

Rehabilitation According to Bastlova et al. (2004), the entire course of rehabilitation of proximal humeral fractures is divided into 4 phases: 1. Subacute phase rehabilitation – prevention of reflexive and dystrophic changes 2. Mobility restoration in the scapulo-thoracic articulation 3. Neuromuscular stabilization of the glenohumeral joint 4. Rehabilitation of specific motor skills of the shoulder girdle Phase I In simple fractures, phase I begins within a few days after the injury. For complex fractures, it begins in the second week (Fig. 2.4.2-5). Treatment focuses on improving cervical and thoracic segmental mobility, their straightening and the optimal alignment of the scapula.

Fig. 2.4.2-5 Examples of proximal humeral fractures

Phase II This phase is characterized by gradual discontinuation of immobilization. Restoration of correct function of the scapula and its surrounding muscles are the goals of manual therapy. These include the tendons and tendinous structures of the muscles surrounding the lower scapular angle (medially and dorsally the rhomboid major and

the teres major; medially and ventrally the serratus anterior and laterally the teres major). Focus is paid to soft tissue mobilization of muscles attaching to the spine and the superior angle of the scapula (levator scapula, upper trapezius). In this period, phase I of Vojta’s reflex rolling can be used, which decreases the tension in the above mentioned muscles through global activation and increases the tone in the muscles of the trunk, spine and scapular stabilizers. The PNF method is also beneficial either by using gentle rhythmic stabilization or slow reversal of the antagonists of the scapular muscles. According to the condition and circumstances, active arm exercises are initiated 2–3 weeks after the injury or surgery. The patient is taught pendular movements of the arm while they are in a forward bent position and leaning on the bed with the contralateral forearm. The movements can be performed into either flexion or extension or an imaginary figure “eight”, which can gradually increase in size. During the immobilization period, muscles of the anterior and posterior axilla become shortened or reflexively spasmed. A similar situation occurs in the biceps brachii. Either soft tissue techniques or neurophysiologically based methods (Vojta, PNF) are used to relax these muscles. In contrast, the triceps brachii is a muscle that is found to be hypotonic and weak following an injury. The rotator cuff muscles, especially the external rotators, are usually inhibited. Thus, attention is paid to active external rotation during phasic movement and later during practice of the arm support function. Functional taping can be used to improve shoulder girdle stability. Phase III The strategy of phase III rehabilitation following proximal humeral fractures includes neuromuscular compensation, or substitution of damaged surrounding structures that ensures passive shoulder joint stabilization (Bastlova, 2004). Movements in the open kinetic chain are continued in the form of pendular arm movements, as well as, exercises in closed kinetic chains, in which axial loading through the humerus is gradually increased. The arm can be supported through

the forearm or the hand. “Dosage” of the weight bearing is possible by adjusting the amount of body weight used when leaning. Additionally, pressure through the extremity using unstable surfaces – soft foam, ball, etc. can be used. Phase IV The last phase of intensive rehabilitation begins in non-complicated and early rehabilitated patients the end of four weeks after the injury, sometimes during the second month (Bastlova, 2004). The prerequisite to initiate this phase of rehabilitation include active elevation and abduction to at least 135° with adequate scapular range of motion (scapulo-humeral rhythm). Specific exercises of the shoulder girdle musculature include practicing the stabilization function through support and through training of the muscle’s ability to alternate its concentric and eccentric activity either through slow reversal of the antagonist or by quickly alternating accelerationdeceleration activity (plyometric exercises). This can be achieved by resistance from elastic bands or by throwing balls of various weight against the wall. In this phase, sport or occupation specific arm movements are practiced. The overall time for satisfactory resolution of shoulder girdle function following proximal humeral fracture with intensive and complete rehabilitation is usually 3–4 months. However, rehabilitation needs to be continued to the end of 6 months in the form of a home program and physical therapy visits every 2–3 weeks for follow up regarding the regular home exercise program (Fig. 2.4.2-6; Fig. 2.4.27). Fig. 2.4.2-6 Proximal humeral fracture accompanied by a fracture of the acromion

Fig. 2.4.2-7 Surgical fixation via osteosynthesis of a proximal humeral fracture

INSTABILITY

GLENOHUMERAL INSTABILITY Post-traumatic Instability (Recurring Dislocations) During a glenohumeral dislocation, a tear of the capsule, the inferior glenohumeral ligament and the labrum occurs. If these structures do not heal (as a result of insufficient immobilization time or extensive damage from the injury), joint instability occurs leading to recurrent joint dislocations. Treatment Surgical correction followed by rehabilitation to restore dynamic (muscle) joint stability is indicated in glenoid labrum tears and subsequent joint instability. Rehabilitation Following a Stabilization Procedure (Status-Post Bankart Repair) Phase I (0–2 weeks post-surgery) The extremity is immobilized in an immobilizer. The immobilizer can be removed only during physical therapy. Soft tissue techniques of the shoulder girdle are performed. Passive movement to 90° of flexion is permitted. Caution needs to be paid to external rotation, extension and internal rotation with the hand behind the back. The patient performs active exercises at the elbow, hand and fingers. Phase II (2–5 weeks post-surgery) The brace is gradually discontinued and joint range of motion is gradually increased. The patient performs pendular movements, stabilization exercises and passive movements. Around week 3, internal rotation with the arm behind the back is initiated. External rotation to 30° in a neutral position and shoulder flexion with supination are tolerated. Shoulder external rotation in abduction and extension are avoided. Phase III (5–8 weeks post-surgery) Active movements with assistance and the gradual addition of independent active movement in the shoulder to nearly its entire

range are initiated. Dynamic stabilization, PIR, stretching into flexion, internal rotation and horizontal adduction are implemented. The range of external rotation in the neutral position is gradually increased; however, external rotation in abduction should be still avoided. Phase IV (8–12 weeks post-surgery) Unrestricted range of motion and strengthening are allowed, including shoulder abduction with external rotation. Multidirectional Non-traumatic Instability (Habitual Dislocation) This type of dislocation occurs generally in congenital defects, such as glenoid dysplasia, in systemic diseases, brachial plexus palsy, hemiparesis or psychiatric illnesses. In the case of joint hypermobility, rehabilitation is usually effective with dynamic joint stability training through muscle activation, especially the rotator cuff and their integration into movement patterns. Rehabilitation Physical therapy for anterior glenohumeral joint instability focuses on possible symptoms that could develop due to the given shoulder instability (pain) and especially on the improvement of dynamic stabilization of the shoulder girdle during movement tasks and everyday activities. During physical therapy, the period of time of joint instability needs to be taken into consideration. With long-term instability, reactive changes in the fasciae are addressed, especially the clavipectoral fascia, which reflects in the protracted and internally rotated resting alignment of the upper extremity. In this case, the clavipectoral fascia is treated by shifting stretching techniques. Increased tone in the middle and upper portion of the trapezius and sensitive TrPs in the shoulder adductors are typical. The insertion of the long head of the triceps brachii is sensitive. Stabilization exercises of the shoulder girdle are an important component of therapy. Movement originates from a neutral joint position of the upper extremity and a

physiologically established base of support. To improve stabilization, it is recommended to initially implement exercises in the closed kinetic chain and progress to exercises in an open kinetic chain. For such exercise, Redcord or suspension exercises can be used and the unsteadiness of the suspension can be used to facilitate upper extremity proprioception. When using Vojta’s reflex locomotion, it is beneficial to begin with exercises, in which the upper extremity is in a support function. With increased stability of a given segment, the pain in the given area decreases. When the pain subsides and co-activation of the shoulder girdle musculature improves, the exercise routine can include Vojta’s method of stepping forward phases and exercises in the open kinetic chain while using resistive bands. Treatment can also utilize PNF techniques (stabilization reversal or rhythmic stabilization). In general, rehabilitation fails in instabilities that involve dysplasia of the glenoid fossa and, in this case, surgery is indicated (osteotomy).

DIFFERENTIAL DIAGNOSIS OF SHOULDER GIRDLE PAIN The following needs to be excluded as a source of pain in the differential diagnosis of shoulder girdle pathology: Restrictions and irritation of C3-C7 segments (for example, C5 referred pain is perceived in the lateral shoulder) Cervicothoracic junction, restriction in ribs 1–4 Restrictions in the thoracic spine, limited active segmental mobility Referred pain from the diaphragm, gallbladder, heart and spleen Referred pain from TrPs of the shoulder girdle muscles (trapezius, supraspinatus, infraspinatus, subscapularis, levator scapulae) Thoracic and dorsal fascia retraction

GENERAL PRINCIPLES OF REHABILITATION OF SHOUDLER GIRDLE DYSFUNCTIONS As described in Chapter 1.2.2 Kinesiology of the Shoulder Girdle in the General Section of the textbook, movement in the glenohumeral

joint includes flexion and extension in the sagittal plane, abduction and adduction in the frontal plane and horizontal abduction, horizontal adduction and rotations (internal and external) in the transverse plane. Movement in the shoulder girdle; however, is not limited to only movement in the glenohumeral joint itself, but other joints and articulations contribute to this movement (sternoclavicular, acromioclavicular and scapulothoracic), which all need to be respected during therapy. The synergy between the glenohumeral and scapular movements is important for physiological shoulder movement. This requires strictly defined muscle coordination that not only depends on the muscles that carry out the movement, but also on the muscles that stabilize this movement. Any small deviation from an ideal movement leads to overloading of certain aspects of the shoulder girdle, which can be manifested as pain. The function of the muscles participating in the movements and stabilization of the shoulder is closely linked to trunk stabilization. This means that weakness of the serratus anterior and overloading the lower scapular stabilizers is a result of the insufficient stabilization function of the diaphragm and the abdominal muscles that stabilize the thorax. Clinically, excessive scapular elevation and more significant rotation occur during abduction. From the perspective of shoulder rehabilitation, it is essential that the shoulder is a joint that sensitively reacts to immobilization. During shoulder immobilization, a significant movement limitation occurs very quickly, even in just a few days. This may not be the result of immobilization linked to stabilization, but it can be a result of painful states that force the patient to acquire an antalgic position. A typical antalgic position includes adduction, protraction and elevation of the scapula. Therefore, this is a position similar to, for example, one seen with the development of spasticity. The joint is positioned in an alignment that is phylogenetically or ontogenetically older. The position is linked to hypertonia and gradual shortening of the shoulder adductors and upper scapular stabilizers (the upper trapezius and the levator scapulae). In contrast, muscles with an antagonistic function are inhibited (shoulder abductors and lower scapular stabilizers).

Retracted soft tissues lock the shoulder joint in this position. In painful conditions, the defensive pattern of the joint capsule leads to a limitation in external rotation and abduction. These are movements (positions) that are ontogenetically the youngest and a human masters them only after their third year of life, which is the reason why this shoulder position is the most fragile. The patient very sensitively perceives their shoulder range restriction. The shoulder has a significant tendency to fixate on a defensive pattern even after a surgical procedure because the surgical procedure is painful in itself. That is the reason why shoulder immobilization needs to be as short as possible while still respecting the surgical procedure. In older patients, there is a greater tendency toward shoulder stiffness following long head biceps tendon tenodesis. Thus, intensive rehabilitation needs to be initiated by the second post-operative day with the exception of active elbow flexion against resistance. As far as a rehabilitation plan for patients without increased laxity, experience shows that it is beneficial to begin with simple and non-challenging stabilization exercises as soon as possible, initially perhaps only in static positions for patients prior to surgery, post-surgery or even non-surgical patients. It is important to plan and constantly modify a balanced program including early mobilization based on the joint capsular pattern and the end-feel at end range of motion. Restoration of functional stability or full shoulder mobility is the main goal of a successful rehabilitation program. This is accomplished not only by stabilization and range of motion exercises, but also by decreasing nociception. In certain cases, nerve blocks are used to decrease nociception. More extensive structural instabilities that did not improve with rehabilitation are indicated for surgery.

2.4.3 Elbow Joint Pavel Kolář, Petr Bitnar, Olga Dyrhonová Congenital Developmental Defects Congenital dislocation of the elbow joint Congenital dislocation of the radial head

Congenital radioulnar synostosis Congenital shortening of the radius and the ulna Congenital non-union of the radius and the ulna Overuse Soft Tissue Injuries Lateral epicondylitis (tennis elbow) Media epicondylitis (javelin thrower’s or golfer’s elbow) Triceps brachii enthesopathy Olecranon bursitis (student’s elbow) Degenerative Diseases Elbow joint arthritis Traumatic Lesions Dislocation Pediatric fractures Adult fractures Post-traumatic Changes Flexion contracture Axial deformities Volkmann’s contracture

CONGENITAL DEVELOPMENTAL DEFECTS Congenital developmental defects of the elbow joint include congenital elbow dislocation, congenital dislocation of the head of the humerus, congenital radioulnar synostosis, congenital shortening of the radius and the ulna and congenital nonunion of the radius and ulna. Their etiology, pathogenesis and treatment were described in Chapter 2.3.1 Congenital Developmental Defects, Congenital Developmental Defects of the Upper Extremities.

OVERUSE SOFT TISSUE INJURIES ENTHESOPATHY Lateral Epicondylitis (Epicondylitis Radialis Humeri)

Lateral (radial) epicondylitis (tennis elbow) is an injury to the origin of the wrist extensors (most notably the extensor carpi radialis brevis), finger extensors and the supinator muscle at the radial condyle of the humerus and the radial head. The clinical presentation includes pain with loading (lifting, carrying heavy objects) and with gripping. Acute epicondylitis demonstrates edema; chronic epicondylitis demonstrates soft tissue hypotrophy at the origin of the muscles. The wrist and finger extensors usually demonstrate increased tone (less often decreased tone) and the muscle bellies present with multiple reflexive changes. Resistance tests of the extensor carpi radialis, finger extensors (most often the 2nd and 3rd fingers) and the supinator are positive; hand grip is painful. Springing in the elbow joint is often limited. For differential diagnosis, the true location of the origin of the pain needs to be diligently determined because the elbow region is a frequent area of referred pain from the arm muscles (biceps brachii, triceps brachii), shoulder girdle (especially the subscapularis, infraspinatus, supraspinatus, and pectoralis major and minor), upper thoracic structures (the scalenes) and spine. Active trigger points in the corresponding muscles or their traumatization are typical signs of referred pain. Referred pain from the cervical and thoracic spine during static or dynamic dysfunction or nerve root irritation can be additional sources of referred pain. Conservative therapy for tennis elbow only fails in a small percentage of patients (approximately 10%) and surgery is then indicated in these cases. Medial Epicondylitis (Epicondylitis Ulnaris Humeri) Ulnar epicondylitis (golfer’s, javelin thrower’s elbow) is an injury to the origin of the wrist and finger flexors and the pronator teres at the medial epicondyle of the humerus. The clinical presentation is similar to lateral epicondylitis: increased tone and reflexive changes are found in the muscle bellies of the wrist and finger flexors and in the pronator teres. Resisted wrist flexion is painful and elbow springing into extension and supination is limited.

Differential diagnosis needs to examine whether or not the source of pain involves the ulnar nerve as it passes through the sulcus nervi ulnaris (cubital tunnel). However, the involvement of this nerve can accompany medial epicondylitis. In such case, neurodynamics need to be implemented to mobilize the ulnar nerve. Triceps Brachii Enthesopathy This condition involves inflammatory degenerative changes of the triceps brachii tendon in the olecranon region. Clinical presentation includes pain, especially with elbow extension. The triceps muscle belly shows increased tone with reflexive changes, the tendon insertion is painful to palpation, elbow extension against resistance is painful and the elbow flexion end-feel may also be painful. Edema and crepitus at the muscle’s insertion are present in the acute form. Rehabilitation in Enthesopathies Treatment differs for acute and chronic forms (see above Chapter 2.3.2 Overuse Soft Tissue Injuries, Treatment). Acute Form It most often develops as a result of relatively uncommon prolonged work (screwing, yard work, uncommon athletic performance). In contrast to the chronic form, the specific properties of inflammation are more visible – pain, edema, increased skin temperature and functional limitations. In the chronic form of enthesopathy, inflammation and increased skin temperature are less marked. In the acute phase of the disease, the edema also involves the surrounding tissues. The acute form requires rest and sometimes short-term immobilization until the acute pain subsides. Modalities include cryotherapy and sometimes diadynamic currents. Gentle and specific soft tissue mobilization and lymphatic drainage are indicated. Pharmacotherapy includes mainly non-steroidal anti-inflammatories that can be applied either locally (ointment, gel) or systemically (oral medication). A local injection of an anesthetic mixed with a corticosteroid is also indicated. If the acute form of enthesopathy

progresses to a chronic stage, the approaches used for chronic enthesopathy are implemented (see below). Chronic Form The chronic form is most often the result of chronic overuse of the tendinous region, usually due to muscle imbalance in the upper extremity and the upper half of the trunk (postural imbalance – especially the upper crossed syndrome). Enthesopathy can also develop in a posturally symmetrical individual as a result of chronic inadequate loading (i.e., working in a poor ergonomic setting) or based on general metabolic disturbances or intoxication. The chronic form of enthesopathy is most often unilateral and affects the dominant extremity, which significantly impacts the patient’s daily activities. In therapy, increased tone and trigger points of the corresponding muscles need to be addressed (post-isometric relaxation, compression therapy, reciprocal inhibition, soft tissue techniques). Further, joint mobility needs to be restored and preserved (traction, mobilization, active and passive range of motion) and muscle coordination and activity need to be improved (sensorimotor component, exercises based on developmental kinesiology, Vojta’s method, close kinetic chain exercises, PNF). Modalities include heat, electrotherapy, ultrasound, combined electrotherapy, laser, shockwave ultrasound and magnetic therapy. Therapeutic treatment also includes ergonomic assessment and modification with a possible change in work activity and orthotic devices (epicondylar brace). Olecranon Bursitis This injury affects the olecranon bursa (typist’s or student’s elbow), which is quite exposed between the skin and the bone (olecranon). It is the most frequently affected bursa at the elbow region. Inflammation of this bursa occurs mainly following a trauma (blunt force) or in chronic microtrauma (supporting on an elbow during work activities). Inflammation of a bursa causes increase in the serous liquid, which leads to its significant increase in size (it can increase by several centimeters). Following trauma, it fills with blood, which becomes gradually diluted by the serous liquid.

Clinical presentation includes perception of pressure and pain above the elbow joint. Above the olecranon, the palpated tissue is painful and filled with fluid. Bursa can become infected, which is known as purulent bursitis. Resting and night pain emerges as well as an overall change in condition (fever). Clinically, purulent bursitis also includes significant erythema and increased skin temperature around the bursa. The bursa is filled with brown exudate. Elbow movement is limited and painful. Treatment Conservative therapy for bursitis includes puncture and content removal. If the infection is sterile and the fluid is clear, a compression wrap is applied and local anesthetics and anti-inflammatories are used if needed. If a bacterial infection is present, the extremity is immobilized in a brace, the fluid is extracted for testing and antibiotics are prescribed based on lab results. Rehabilitation Rehabilitation includes modalities and cryotherapy is indicated following puncture. Anti-edematous therapy is beneficial in sterile inflammations – ultrasound or lymphatic drainage. Olecranon bursitis is frequently a recurrent condition. From a rehabilitation perspective, ergonomic evaluation and intervention is important in the work setting (practice of sitting, modification of work station, etc.) and during daily activities. A protective sleeve (made out of foam) has been found to be beneficial to protect the affected area. If conservative therapy fails and the condition keeps recurring, surgery is indicated – excision of the bursa.

DEGENERATIVE DISEASES OF THE ELBOW JOINT ELBOW JOINT ARTHRITIS The incidence of elbow arthritis is lower than that found in the weight bearing joints.

Etiology and Pathogenesis The etiology and pathogenesis of degenerative changes in the elbow joint is multifactorial. The following contribute to the development of arthritis: Small and large deviations in the structure of collagen and the morphology of the collagen fibers Joint instability caused most often by increased laxity of the connective tissue apparatus and by a deficit in the muscle’s stabilization function Post-traumatic changes Systemic metabolic disease and metabolic deficits of chondrocytes Excessive loading often related to work activity and the individual’s unsuitable athletic activity Post-traumatic changes (joint surface incongruency, necrosis as a result of disruption in vascular supply of the bone, chronic inflammatory processes, etc.) are the most frequent cause of elbow joint arthritis. Clinical Presentation The clinical presentation of elbow joint arthritis includes pain with movement. In advanced arthritis, one will also see resting and night pain. Progression of arthritis is accompanied by edema and joint filling. A range of motion limitation into extension, flexion and rotation occurs with a gradual elbow flexion contraction. At an advanced stage, limited range of motion of the elbow and a contracture can contribute to the individual’s decreased self-care, especially with hand –to-mouth or hand-to-head movements. Rehabilitation Physical therapy plays an irreplaceable role in the treatment of arthritis. The recommendation of appropriate movement activity and the influence of joint and muscle function both significantly affect the treatment process. In arthritic joint changes, muscle tone reflexively increases and the

muscle becomes hypertonic, which changes its function and metabolic conditions and, therefore, subsequently becomes an additional source of nociception. Distancing the articulating surfaces by traction will decrease nociception from the joint, as well as, decrease muscle tone. Traction techniques are the first step prior to other joint manipulations. The following techniques are implemented to address the increased muscle tone: soft tissue techniques, post-isometric relaxation, reciprocal inhibition, gentle mobilization, specific techniques of trigger point therapy (dry needling, compression therapy, spray and stretch, etc.) and insertional (tendinous) and painful point treatment (hot towel roll, specific soft tissue mobilization, injection). Another step in treatment includes the correction of muscle coordination and co-activation and improving the stabilization muscle function. Methods based on a neurophysiological foundation are applied: PNF (for example, rhythmic stabilization), sensorimotor elements (unstable surfaces), closed kinetic chain exercises while consistently maintaining the centrated joint position and exercises based on developmental kinesiology. Vojta and Feldenkrais methods can also be included. Practicing muscle coordination and stabilization functions leads to joint centration, which improves loading of the joint surfaces and decreases cartilage wear. At the same time, joint stability improves. This prevents increased friction of the joint surfaces and the tendency to subluxate. Modification of the patient’s activity schedule with possible elimination of movement activities that overload the joint is an important component of physical therapy treatment. Modalities are indicated based on the activity of the degenerative disease. In progressive arthritis, analgesic procedures are beneficial, especially electrotherapy (DD currents, TENS, isoplanar vector field) and anti-inflammatory procedures (ultrasound, lymphatic drainage, hydrotherapy). During remission, procedures that address and release soft tissues surrounding the joint are indicated and include the following: DD currents, TENS, dipolar vector field, pulsating

magnetic field or distant electrotherapy (VAS 07, mid-frequency currents L25). The treatment plan should also include ergonomics.

TRAUMATIC LESIONS DISLOCATIONS A dislocation is characterized by loss of contact between joint surfaces. It may be complicated by an avulsion of the joint surface’s rim, which is known as a dislocation fracture. Damage of the neurovascular bundle in the elbow area can be another complication. A dislocation occurs most often during falling on a flexed elbow joint. Treatment Closed or open repositioning of the elbow joint is performed under general anesthesia. Following the reduction, the extremity is immobilized by a splint or an orthosis. The length of immobilization is determined by the physician.

FRACTURES IN THE ELBOW JOINT REGION Pediatric Fractures at the Elbow Region Supracondylar fracture of the humerus (Fig. 2.4.3-1A,B). Fig. 2.4.3-1A Supracondylar fracture of the humerus in an 8-year old child

Fig. 2.4.3-1B Supracondylar fracture of the humerus – after repositioning and fixation with 2 Kwires

Adult Fractures at the Elbow Region Distal humeral fracture

Olecranon fracture Fracture of the head of the radius

REHABILITATION IN TRAUMATIC LESIONS It is up to the physician to determine when physical therapy should be initiated. The goals of rehabilitation treatment include edema control, increased range of motion, correction of muscle imbalance and inclusion of the extremity into total body movements. Physical therapy techniques include soft tissue techniques for the release of muscles, ligaments and the joint capsule, stretching of shortened structures and gentle elbow joint mobilization. Relaxation techniques (post-isometric relaxation, anti-gravity relaxation) are used for muscles with increased tone. To increase range of motion, exercises based on a neurophysiological foundation are implemented, such as Vojta’s reflex locomotion, PNF and closed and open kinetic chain exercises. Physical therapy also needs to address the additional segments of the affected upper extremity (wrist, hand and shoulder), ensure scapular stabilization and treat cervical and thoracic spine. The modalities used include anti-inflammatory procedures, manual or mechanical lymphatic drainage, hydrotherapy (whirlpool, contrast baths) and procedures that speed up soft tissue and bone healing (pulsating magnetic field, distant electrotherapy). Patients after traumatic elbow injuries can also undergo comprehensive balneologic treatment.

POST-TRAUMATIC COMPLICATIONS ELBOW FLEXION CONTRACTURE Post-immobilization limitation of elbow extension or even the formation of para-articular ossifications can pose complications following an elbow fracture. Post-immobilization restricted extension is caused by a flexion contracture, which develops due to remodeling changes in the connective tissue of the joint capsule, as well as,

fibrotization, shortening and increased tone in the surrounding musculature. The joint capsule tightens especially during prolonged elbow immobilization. The muscles may also shorten for different reasons (for example, post-injury or post-surgical bleeding, from longterm nociception-based hypertonia, pathological activation of the sympathetic nervous system, etc.). Rehabilitation Treatment includes gentle active movement to pain (analytical methods are sufficient) combined with slightly hyperthermic hydrotherapy procedures that relax soft tissues surrounding the involved movement segment. Soft tissue techniques and postisometric relaxation techniques are used for the surrounding muscles. The cervical and upper thoracic spine are also treated to decrease nociception and to prevent muscle imbalances of the entire upper extremity. The rehabilitation success rate is high.

AXIAL DEFORMITIES OF THE ELBOW Cubitus Varus A varus deformity of the elbow joint is the result of an insufficient repositioning of a supracondylar humeral fracture in children. A varus deformity less than 15° is only a cosmetic issue. A deformity greater than 15° involves pain with loading, joint instability, and decreased muscle strength. With time, degenerative changes in the elbow joint begin to develop. Cubitus Valgus The norm for elbow valgus is 20° for women and 10° for men; greater angle is considered a deformity. An elbow valgus deformity develops as a result of fractures in the distal humerus in children, in which the growth cartilage fuses prematurely or a nonunion forms. A valgus deformity presents with pain upon loading, joint instability, and limited elbow extension. Irritation or even paralysis of the ulnar nerve can occur.

Treatment of Axial Deformities Surgery is indicated to correct axial deformities. A distal humeral osteotomy, axial correction and stabilization are performed. In a valgus deformity involving the ulnar nerve, the procedure also includes neurolysis or nerve transposition.

VOLKMANN’S CONTRACTURE Supracondylar fractures of the humerus are typical pediatric fractures in the elbow area. In these fractures, there is a high risk of damage to the neurovascular bundle at the time of injury, during fracture reduction or from compression by edema in combination with a tight fitting cast. If the neurovascular bundle is injured, ischemic necrosis of the forearm and hand musculature can develop with subsequent development of Volkmann’s claw-like contracture. In this contracture, the forearm is pronated, wrist flexed, metacarpophalangeal joint hyperextended and the rest of the finger joints flexed. This contracture significantly limits the patient’s independence. Rehabilitation Rehabilitation is the main component of treatment for a Volkmann’s contracture. Soft tissue techniques are used to treat the musculature and the fasciae and gentle joint mobilizations address the affected and surrounding joints. Dry heat should be applied prior to stretching of the shortened structures because it relaxes the collagen. Passive and active movements maintain joint range and mobility. Exercises involving diagonal PNF planes have been found to be beneficial. Other methods based on a neurophysiological foundation normalize muscle tone of the corresponding muscles. All movements and exercises are performed only to a minimal pain threshold because increased pain activates the sympathetic system and decreases vascular supply to the already affected muscles. Modalities include analgesic and anti-inflammatory procedures. Electrotherapy (diadynamic currents), contrast baths or gentle persistent stroking of the involved extremity and manual or instrumental lymphatic drainage can also be used. At the stage of chronic changes, orthotic devices need to be

consistently utilized, specifically braces and serial casting.

2.4.4 Wrist and Hand Petr Bitnar, Pavel Kolář Congenital Developmental Defects Congenital manus vara Madelung’s deformity Camptodactyly Clinodactyly Syndactyly Thumb hypoplasia Overuse Soft Tissue Injuries Trigger thumb, finger De Quervain’s disease Dupuytren’s contracture Degenerative Joint Injuries Rhizarthrosis Arthritis of the interphalangeal joints of the hand Traumatic Lesions Soft tissue injuries Dislocations Fractures Post-Injury Wrist Conditions Wrist instability Navicular nonunion General rehabilitation principles for wrist and hand injuries

CONGENITAL DEVELOPMENTAL DEFECTS Congenital developmental defects of the wrist and the hand include congenital manus vara, Madelung’s deformity, camptodactyly, clinodactyly, syndactyly, and thumb hypoplasia. Their etiology,

pathogenesis and treatment are described in Chapter 2.3.1 Congenital Developmental Defects, Congenital Developmental Defects of the Upper Extremities.

OVERUSE SOFT TISSUE INJURIES TENOSYNOVITIS Trigger Thumb, Finger (Digitus Saltans) This is a stenosing tendovaginitis of the thumb or finger flexors. The thumb or finger flexors are affected in their passage under the A1 pulley. The injury develops due to overloading and microtrauma or can be a sign of a systemic disease (typically rheumatoid arthritis). In chronic overloading, the tendon becomes inflamed and begins fibrotic restoration. A tendon altered in this way causes relative narrowing of the passage under the pulley. The clinical picture includes a thickened structure (palpable knot) on the tendon in the area above the metacarpal head and pain with passive end range of motion of the thumb or the finger into full flexion and extension. “Popping” occurs during finger movement, in which the widened segment of the tendon overcomes the resistance when passing above the pulley. In the chronic stage, adhesions between the flexor tendons and their sheaths develop. Treatment Treatment is localized to using medication. A corticosteroid injection with a local anesthetic is indicated up to a maximum of 3 times in 4–6 week intervals. In the chronic stage, surgical intervention is indicated involving a pulley release. Post-surgery, gentle range of motion of the thumb into flexion and extension is indicated to prevent adhesions at the incision site. Rehabilitation includes physical therapy. The treatment includes soft tissue techniques and gentle pressure massage of the involved tendon, mobilization of the hand and wrist joints, and treatment of trigger points in the forearm and hand muscles. Elimination of one

possible cause of this condition – shoulder girdle instability – is also part of the treatment. Modalities include analgesic and antiinflammatory treatments. Ultrasound and laser are indicated and they are applied directly to the area of structural changes. Practicing correct ergonomics, especially training to relax one’s grasp is also a component of rehabilitation. De Quervain’s Disease This tenosynovitis affects the tendons of the abductor pollicis longus and the extensor pollicis brevis in the area of the styloid process of the radius. In this area, the tendon sheaths form a fibro-osseous canal. Clinical presentation includes pain at the radial aspect of the wrist during loading. The area of the styloid process of the radius and the tendon of the long abductor and short extensor of the thumb are puffy and painful to palpation. Resisted thumb extension and abduction is painful. Finkelstein’s test confirms de Quervain’s diagnosis. In this special test, pain is provoked in the styloid process of the radius on the radial aspect of the wrist by movement of the hand into ulnar deviation with the thumb gripped in the palm (fist), under the index finger. Treatment Once again, treatment involves the local application of corticosteroids with a local anesthetic up to a maximum of 3 times in 4–6 week intervals. Surgical intervention is indicated if conservative treatment fails and involves a release of the common tendon sheath of the long abductor and short extensor of the thumb. Post-surgery, gentle range of motion into thumb flexion and extension needs to be performed to prevent adhesions at the surgical site. Rehabilitation for Tenosynovitis Inflammation of the tendon sheaths is a typical example of diseases developed from overuse, often potentiated by the nature of specific anatomical parameters (narrow carpal tunnel and other entrapments, bony growths, etc.). Based on the development, acute and chronic forms are distinguished. Acute changes develop as a result of sudden

non-physiological strain (unusually demanding work activity, inadequate athletic performance, as a result of coldness, etc.). Chronic forms are caused by repeated trauma or microtrauma (poor work ergonomics). In the acute form, rest and immobilization in a brace or a splint for 1–2 weeks or functional taping is recommended. Cryotherapy is indicated. Gentle and localized manual lymphatic drainage and techniques to eliminate increased tone and trigger points in the forearm and hand muscles are all implemented within the therapeutic treatment. In the chronic form, the most important components involve ergonomic correction, changing the technique during an athletic activity and correcting the coordination of muscle activity (correcting muscle tone of the corresponding muscles, timing optimization, improving muscle relaxation ability, etc.). Alignment of especially the proximal joint (shoulder) and the spine needs to be improved and, therefore, techniques that lead to the improvement of poor body posture and neutral joint alignment are implemented. In the chronic form of inflammation of the tendons and their sheath, soft tissue and muscle relaxation techniques are implemented. Joint treatment is performed on the affected extremity including joint centration with approximation, mobilization and manipulation. Modalities include heat, ultrasound and contrast baths.

DUPUYTREN’S CONTRACTURE Dupuytren’s contracture is a condition involving the palmar aponeurosis. Its etiology is not clear, but one of the causes of its onset is myofibroblast dysfunction. This disease is often found in patients with diabetes and liver disease or alcoholics. During the course of the disease, the palmar aponeurosis gradually thickens and shortens and connective tissue nodes develop in the palm and the fingers. The originally fine and smooth longitudinal stripes of connective tissue of the aponeurosis change their quality and the

pathologically altered tissue manifests the characteristics and behaviors of a scar where retraction occurs leading to flexion contracture. The tendons and flexor tendon sheaths of the fingers are not usually affected in this type of condition. Treatment Since this is a condition of unknown etiology, no specific causative treatment. Surgery is indicated if the patient demonstrates pain during activity or work (for example, with pressure on the palm) or if pathologically strong bands and nodes are formed or the flexion contracture limits hand placement on the mat (table top test). The first option involves aponeurectomy, in which the surgeon attempts to remove all affected connective tissue of the aponeurosis. In another procedure, under local anesthesia, the shortened bands are resected by a needle inserted through the skin so that the contracture of the basic finger joints partially releases the contracture. Following the procedure, an overnight cast is used for one month, which prevents healing in the original flexed finger position. This type of procedure is usually a temporary solution prior to an aponeurectomy and allows for the patients’ increased comfort so that the flexed fingers do not prevent common activities, hygiene and often allows for healing of infections in the skin folds of the contractures. In older patients, this can provide a definite solution. Rehabilitation Patients who are not good candidates for surgery undergo rehabilitation treatment to maintain current finger range of motion into extension and prevent progression of finger flexion contractures. Treatment includes heat application (positive thermotherapy) and stretching exercises. Soft tissue techniques and exercises in the closed kinetic chain are performed with attention paid to stable support and an open palm. Modalities include ultrasound. Post-surgery, edema control and incision care are important components of the therapeutic treatment. Occupational therapy is also implemented in the post-operative period – specifically fine motor

skills and grasping.

DEGENERATIVE JOINT INJURIES Degenerative joint changes occur most often as a result of chronic overloading, muscle imbalance and joint decentration. Post-traumatic changes and systemic diseases are another cause of the onset of a degenerative disease. From a clinical perspective, the most significant conditions include carpometacarpal arthritis of the thumb (rhizarthrosis), carpal joints and the interphalangeal joints.

RHIZARTHROSIS Rhizarthrosis, or arthritis of the proximal joint of the thumb, is a degenerative condition involving the carpometacarpal joint of the thumb. This joint is anatomically a saddle joint; however, it functionally acts as a spherical joint and is important for the thumb’s capability to perform opposition. The carpometacarpal joint is fragile and prone to repeated microtraumas. The clinical picture includes pain during thumb movement, especially into opposition. Palpation of the proximal joint reveals poorly defined joint structures. The joint is markedly painful upon palpation and movement is limited and crepitus and popping are palpated. Thenar muscle hypotrophy is often part of the clinical presentation. Treatment The treatment of arthritis of the hand joints is identical to the treatment implemented for arthritis in general. Pharmacotherapy utilizes an injection of a local anesthetic and corticosteroid mixture. In physical therapy, increased muscle tone and trigger points are treated to restore muscle imbalance; traction is also utilized. In rhizarthrosis, the therapist attempts to modify work ergonomics. Education on the correct grasp of work tools and a pen also seems important. Grasp cannot be spastic and should require only minimal muscle activity while the proximal muscles should be

relaxed. In athletes (usually volleyball players), it is beneficial to stabilize the thumb with a brace or athletic tape. Modalities in the chronic stage include heat, electrotherapy and magnetic therapy.

ARTHRITIS OF THE INTERPHALANGEAL JOINTS OF THE HAND Arthritis of the hand joints is manifested as an onset of Heberdern’s (distal interphalangeal joints) and Bouchard’s (proximal interphalangeal joints) nodes. Differential diagnosis needs to distinguish them from other rheumatologic diseases.

TRAUMATIC LESIONS SOFT TISSUE INJURIES An indirect or blunt force can lead to injuries of the tendons or the neurovascular bundles. Tendon Injuries of the Wrist and the Hand (Flexors, Extensors) Tendon disruption can be either isolated or it can occur as a component of an associated wrist or hand injury, in which the tendon injury involves the hand bones and the neurovascular bundles. Injuries of the Neurovascular Bundle Most often, the neurovascular bundle is injured on the volar aspect of the distal forearm. Injury by a sharp object (slash or cut) usually causes this injury. During this injury, damage (cut) of the median nerve, ulnar nerve, radial artery or ulnar artery can occur. A finger flexor injury is also common. Fracture of the distal forearm with subsequent neurovascular bundle compression by a fragment or edema can be another cause of damage. An artery or nerve can be damaged in an open or closed finger injury. Treatment of Tendon and Neurovascular Bundle Injuries Surgical suture of the tendon is the foundation of treatment. In an

isolated injury, ideally a primary tendon repair is performed within 6– 12 hours of the injury. Restoration of skin coverage of the involved tendon is a prerequisite for correct tendon healing, otherwise necrosis develops. In associated wrist and hand injuries, the primary treatment involves the nerves, arteries and fracture. Tendon repair can be performed at the same time as fracture stabilization or secondarily. In a concurrent injury of the tendon and the neurovascular bundle, repair of the nerve, tendon, and at least one digital artery, all at one time, is indicated within 24 hours. Rehabilitation in Tendon Injuries In the past, the extremity was immobilized for 3–4 weeks following surgical repair. Currently, early rehabilitation is administered. The tendon repair needs to be maintained without tension during rehabilitation. This condition is fulfilled by the Kleinert method of semi-active mobilization in which the extremity is stabilized in a splint, but movement in the affected segment is preserved and allowed through a pulley system. In a flexor repair, the segment is passively ranged into flexion and active movement is administered against resistance into extension. The situation is reversed in an extensor repair. Passive mobilization of the affected segment by continuous passive motion is another possibility for early rehabilitation. Tendon healing time is 4–6 weeks and the tendon can be gradually loaded after this time period. The exercises are performed analytically based on Kenny or by using PNF. From the newest rehabilitation approaches, the pyramidal system of loading has been beneficial, which is used strictly during rehabilitation of finger flexors. It is a graduated system of exercises comprised of several steps that vary in difficulty. Modalities include anti-inflammatory therapy, ultrasound, lymphatic drainage and hydrotherapy including whirlpool and contrast baths. Rehabilitation also includes occupational therapy,

especially addressing fine motor skills and grasping.

DISLOCATIONS These include dislocations of the radiocarpal joint, carpal bones and carpometacarpal, metacarpophalangeal and interphalangeal joints.

FRACTURES Distal Forearm Fractures Distal forearm fractures are one of the most common injuries of the skeleton. Next to proximal femoral fractures and compression fractures of the vertebral bodies, they are often associated with the clinical picture of severe osteoporosis. This group also includes a Colle’s fracture as a “loco typico” (“typical location”) fracture. It occurs during a fall on the forearm in the long axis when the wrist is in dorsal extension and it is defined as a fracture of the distal radius and dislocation of the peripheral fragment in the dorsal direction (Fig. 2.4.4-1). Fig. 2.4.4-1 Colle’s fracture of the left distal forearm in a lateral (A) and anteroposterior (B) projection

Complex regional pain syndrome (CRPS) formerly known as Sudeck’s algoneurodystrophy is the most common complication of distal forearm fractures (see Chapter 6 Treatment Rehabilitation in Pain Conditions, subchapter 6.4 Complex Regional Pain Syndrome). Navicular Fracture This fracture occurs with fall onto the palm. The clinical picture includes edema and pain with palpation of the anatomical snuffbox (fossa tabatiere; a triangle in the area of dorsomedial side of the wrist, defined by the extensor pollicis longus on one side and the extensor pollicis brevis and abductor pollicis longus on the other side). Pain elicited by tapping digit 1 or 2 in the direction of the longitudinal axis is a typical sign of a navicular fracture. The diagnosis is confirmed by a radiological film taken in four projections. The examination needs to be repeated at 2 and 4 weeks after the injury because of decalcification and increased quality of the fracture line during this time period. Treatment of a Navicular Fracture A non-displaced navicular fracture is treated conservatively. Cast with fixation of digits 1 and 2 is applied for 12 weeks. Surgery involving fracture stabilization is another option. In a displaced navicular fracture, surgery is indicated. The ability to perform early functional treatment is an advantage of surgical treatment. Lack of healing and development of a nonunion are complications of navicular fractures. Treatment of Dislocations and Fractures of the Wrist and Fingers Following surgical treatment, repositioning and stabilization of a displaced fracture, a splint or a brace is applied to immobilize the affected segment. The immobilization period is usually 2–6 weeks and the length of immobilization is determined by the treating orthopedist or a traumatologist based on radiological findings and clinical assessment.

Rehabilitation in Dislocations and Fractures Even during immobilization, modalities can be applied to accelerate the healing process. Pulsed magnetic field and distant electrotherapy are most commonly applied. Physical therapy treatment is initiated following the immobilization period. The goal of therapy includes range of motion restoration in the affected segment while maintaining its stability. Occupational therapy is an important component of rehabilitation for wrist and hand injuries. It is designed to restore hand function including grasping and fine motor skills.

POST-TRAUMATIC CONDITIONS Axial deformities, range of motion limitations, wrist instability and non-unions are among the consequences of traumas to the wrist and hand.

WRIST INSTABILITY Wrist instability is defined as an abnormal alignment of the carpal bones caused by a ligamentous lesion. Instability develops as a result of wrist distortion. A fall on the extremity in the longitudinal axis with the wrist extended is the most common cause of wrist distortion involving an injury to the ligamentous structures of the wrist. A diagnosis of carpal instability is based on patient history (anamnesis) and clinical assessment and it is complemented by imaging tests. The anamnesis includes any trauma, falls on the wrist and post-injury wrist pain. A non-symptomatic period follows that can last several years. Later, wrist pain emerges, most often following loading, wrist restrictions or a sensation of “jumping’, wrist popping, limited wrist range of motion and decreased muscle strength. Degenerative changes, like arthritis, develop in the wrist as a result of wrist instability. Imaging methods include radiological exams (native image, dynamic images), computed tomography (arthrographic) and magnetic resonance.

Treatment Surgery is indicated for post-traumatic wrist instabilities and the goal of surgery is to restore and maintain the correct alignment of the carpal bones. Soft tissue procedures (ligament sutures or reinsertion, plastic surgery of the ligaments, capsulodesis) or procedures involving the bones, called limited arthrodeses of the individual carpal bones are performed (i.e., scaphoid-lunate, scaphoid-capitate). Rehabilitation for Wrist Instability The goal of therapy is to stabilize the wrist. Joint centration of the wrist and hand joints is achieved through neutral alignment of the entire upper extremity joints on a stable scapula with muscle facilitation and their activation during the stabilization function. Exercise methods based on a neurophysiological principle, i.e., Vojta’s reflex locomotion or PNF are used, as well as, practice and implementation of isolated movements in individual upper extremity joints.

NAVICULAR NON-UNION A non-union of the navicular develops when the fracture is not identified or when the fracture treatment is not administered correctly. However, a non-union of the navicular can also develop with correctly administered conservative or surgical treatment. The clinical picture of a non-union includes pain at the anatomical snuffbox (fossa radialis), especially with loading and the objective findings are identical to the findings of a fracture. With time, degenerative changes (arthritis) develop, at first in the radiocarpal region and later in the entire wrist.

GENERAL REHABILITATION PRINCIPLES FOR WRIST AND HAND INJURIES In general, it can be said that an injury to the structures of the hand has a multifactorial character. Injuries to the hand structures are often

caused by a combination of incorrect work ergonomics and an associated deficit, i.e., post-traumatic condition, muscle imbalance, movement incoordination, metabolic disease or even a psychological stress. Specific causes of hand dysfunction include orthopedic congenital developmental defects and deficits in the central nervous structures (cerebral palsy, cerebrovascular accident, etc.). For a human, the most specific and important hand function includes hand manipulation or work in an open kinetic chain, which is the reason why exercises involving optimal stability of the proximal and axial joints and occupational therapy seem as one of the pillars of hand therapy. The above mentioned correct ergonomics in the workplace play an important role. The hand area is also a common region of referred pain. Pain can also be caused by local microspasms (TrPs) of the short muscles of the hand.

2.4.5 Hip Joint Magdaléna Lepšíková, Pavel Kolář, Olga Dyrhonová Pediatric Diseases Congenital developmental hip dysplasia Slipped capital femoral epiphysis Legg-Calve-Perthes disease Transient synovitis of the hip joint Adulthood Diseases Overuse soft tissue injuries Hip adductor enthesopathy Rectus femoris enthesopathy Hamstring muscles enthesopathy Degenerative Diseases Osteoarthritis

Trauma Groin injury Hip joint dislocation Acetabular fractures Proximal femoral fractures

PEDIATRIC DISEASES Congenital hip dysplasia Congenital hip dysplasia is a deformity of a previously anatomically normal hip joint whose development is influenced by an unfavorable position of the lower extremities, limited movement of the fetus during intra-uterine development or shortly after birth. Acetabular dysplasia is genetically conditioned and causes the dislocation itself. The term developmental dysplasia of the hip (DDH) is used in foreign literature, thus it is developmental rather than congenital dysplasia of the hip joint. It does not include symptomatic hip joint dislocations (teratologic, neurogenic or pathological). This disease includes a wide spectrum of morphological deviations and related functional deficits. This leads to various degrees of hip joint instability or hip joint decentration (subluxation, dislocation). The incidence of congenital hip dysplasia includes marked differences based on a geographical location and ethnicity. Endemic regions with an increased incidence of congenital hip dysplasia exist and include countries of Central and Eastern Europe. According to ultrasound screening, the incidence of congenital hip dysplasia does not exceed 4% in Central Europe from which only .15% involves decentrated hip joints in born children. For acetabular dysplasia, the ratio for boys and girls is 1:1 while for hip subluxation and dislocation the ratio is 1:4. The basic examination of hip joints in all born children occurs within 3 weeks of birth and additional at 6–8 weeks and 12–14 weeks of life. The basic examination includes clinical assessment and

ultrasound imaging. If there is a pathological finding present in the hip, further follow up is needed. Clinical Assessment of Newborns and Infants Patient history includes information regarding the incidence of congenital hip dysplasia in the child’s parents and siblings or the incidence of other congenital developmental defects of the movement system, the course of pregnancy, type of delivery and post-partum recovery. Assessment The child undergoes comprehensive evaluation, including observation of signs of other congenital developmental defects, followed by the actual hip joint assessment, which includes the following observations: Limited range of motion into abduction, symmetry or asymmetry of hip joint abduction Muscle tone, hip adductor shortening The depth of the adductor sockets; the therapist attempts to palpate the femoral head in the fossa Genito-femoral and gluteal fold asymmetry on the back, the abdomen and buttocks Specific Tests for Diagnosis of Congenital Hip Dysplasia Bettman Sign Lower extremity length is compared at 90° of hip flexion. Excessive movement in the hip joints is a sign of pathology. Ortolani Sign When the lower extremity is brought into abduction and external rotation, there is a palpable or an audible clunk in the hip joint. This phenomenon accompanies reposition of a decentrated joint. Barlow’s Sign The Barlow’s sign is positive in an unstable, dislocatable hip. The loose joint capsule allows for increased anterior-posterior movement in the hip joint. LeDamany Sign

This sign is also a sign of a loose and dislocatable hip. During adduction, internal rotation and flexion in the hip joint, the femoral head “jumps” over the acetabular rim. Examination by Imaging Methods Ultrasound Assessment of the Hip Joints This assessment is performed by a specially trained orthopedist (sometimes by a radiologist). The child is placed on their side. A linear probe of 7.5 MHz or 5MHz is used for the assessment. The ultrasound image of the hip joint in the frontal plane assesses acetabular development and the quality of the bony and cartilagenous rim. The following are measured: Angle α – formed by the mainline (the line projected through the lateral edge of the hip bone) and the line of the bony rim Angle β – formed by the basic line and the line of the cartilaginous rim According to Graf, the findings are classified into four types: Type I – mature hip joints. A physiological hip joint if acetabular development is normal. Type II (Fig. 2.4.5-1) Fig. 2.4.5-1 Ultrasound image of acetabular dysplasia of grade I – type IIc according to Graf

a. Acetabular development is sufficient. Acetabular ossification is physiologically increased to 3 months of age. b. Acetabular development is sufficient. Acetabular ossification is delayed beyond 3 months of age. c. Hip at risk. The hip joint is centrated. The acetabulum is insufficiently developed and the edge of the bony roof is flattened. Dynamic assessment needs to be performed. If femoral head decentration occurs when pressure is applied to the joint, the finding is graded as IId. d. Decentrated hip. Type III – decentrated (subluxated) hip. It involves a severe degree of dysplasia. The acetabular development is insufficient; the edge of the bony roof is flattened; the cartilaginous roof is pushed proximally (roof eversion). Type IV – dislocated hip (Fig.2.4.5-2). The acetabular cartilaginous roof is deformed (pushed apart); the labrum interposes into the hip joint and can pose as an obstacle to repositioning. Fig. 2.4.5-2 Ultrasound image of hip dislocation – type IV according to Graf

Radiologic Examination A radiological image is indicated when there is no agreement between the clinical assessment and the ultrasound finding or when additional clarification is needed. An image of the entire pelvis and both hips is

taken (Fib. 2.4.5-3). The relationship between the proximal femur and the acetabulum is assessed on the image. The following parameters are being assessed: Fib. 2.4.5-3 Left-sided hip dislocation

AC angle – an angle that indicates the degree of the loading zone of the acetabulum. It is formed by a line connecting the center of the Y cartilage and the acetabular edge. The norm is 25–30° at 3 months of age (Fig. 2.4.5-4). CE angle – Wiberg angle – formed by a perpendicular line that runs through the center of the femoral head and the line connecting the center of the femoral head and the acetabular rim. The norm is 20°. CCD angle – an angle between the axis of the femoral diaphysis and the axis of the femoral neck that intersect at the center of the femoral head (Fig. 2.4.5-5). Fig. 2.4.5-4 AC angle

Fig. 2.4.5-5 CCD angle

Classification according to Radiological Findings 1. Acetabular dysplasia: Steep roof, AC angle greater than 30° The hip is centrated 2. Subluxation: The roof is steep, AC angle greater than 30° Head of the femur is decentrated CCD angle is greater than 130° 3. Dislocation Steep and short roof The head of the femur is not in contact with the acetabulum and it is shifted proximally

Currently, radiological diagnosis is important in the assessment of congenital developmental defects of older children (can be used from the 3rd month of the child’s age). Ultrasound examination is the method of choice for newborns and children up to 1 year of age. Treatment The goal of therapy is to develop a centrated and stable hip joint from a decentrated position. The treatment is either conservative or surgical. Treatment selection depends on the severity of pathology and can be determined based on the clinical, ultrasound or radiologic examinations. Conservative Treatment Abduction devices are utilized during conservative treatment. The decision is based on the type of hip joint according to Graf (see above for ultrasound assessment). Type I – without treatment Type IIa – without treatment or preventative abduction immobilization Type IIb – abduction tool, i.e., Frejka blanket Type IIc – abduction tool, i.e., Pavlik’s harness Type IId, III and IV – in a subluxated or dislocated hip, the patient is admitted to the hospital Treatment involves traction during which the hip joint is repositioned. This is followed by treatment with Pavlik’s harness. Immobilization in a spica cast is applied if the above mentioned treatment does not yield significant improvement in hip joint stability and the arthrographic exam does not show an obstruction to joint repositioning. Surgical intervention is indicated, i.e., open repositioning of the hip joint if traction treatment fails. Surgical Treatment It is indicated when conservative treatment fails and the hip joint cannot be repositioned back into the socket and retained. The goal of surgical treatment, as well as with conservative treatment, is to establish a centrated, stable hip joint (Fig. 2.4.5-6).

Fig. 2.4.5-6 Left-sided hip dislocation – a state following an open reposition

Prior to surgery, arthrographic assessment is performed to assess the changes in the joint capsule, soft tissues and the shape and size of the femoral head. Closed repositioning can fail in certain intra-articular obstructions, which can be identified by arthrography. The intraarticular obstructions include hypertrophy of the pulvinar (fibrofatty tissue) in the acetabulum, transverse acetabular ligament or the ligament of the head of the femur. Another obstacle to dislocated hip repositioning can be a narrowing of the joint capsule or a labrum deformed by pressure and showing histological changes. The surgical procedures for congenital hip dysplasia are classified into 3 groups: 1. Repositioning surgery – the procedure involves open repositioning of the femoral head into the socket and removal of repositioning obstructions. 2. Surgery involving the pelvis (roofing procedures) (Fig. 2.4.5-7 to 2.4.5-12) – procedures on the pelvis addressing acetabular dysplasia and ensuring retention of the femoral head in the joint socket. These include acetabuloplasties and pelvic osteo​tomies. 3. Procedures involving the femoral bone – procedures on the proximal femur to restore its ideal anatomical parameters (CCD angle and the angle of neck anteversion). These include proximal

varus and valgus femoral derotation osteotomies. Fig. 2.4.5-7 Left-sided acetabular dysplasia prior to acetabuloplasty

Fig. 2.4.5-8 Left-sided acetabular dysplasia following acetabuloplasty

Fig. 2.4.5-9 Right-sided acetabular dysplasia

Fig. 2.4.5-10 Right-sided acetabular dysplasia following Steel’s triple pelvic osteotomy

Fig. 2.4.5-11 Dysplasia of the left acetabulum

Fig. 2.4.5-12 Dysplasia of the left acetabulum following Ganz periacetabular osteotomy

Rehabilitation Rehabilitation is a crucial component in the treatment of congenital hip dysplasia and should be included in the treatment program immediately after the diagnosis has been established. The treatment utilizes combinations of various physical therapy methods. The foundation is the correct manipulation of the infant,

which is known as handling. During all handling, the physical therapist and the parents need to constantly maintain the centrated hip joint alignment, which is flexion, abduction and external rotation. The physical therapist should train the parents in correct handling techniques and educate them that adduction leads to worsening of the deformity and, in some cases, can lead to dislocation of the affected hip joint. To correct the adduction contracture, soft tissue techniques are used, such as gentle soft tissue mobilization of the adductors. For the same purpose, hip traction with passive movements in the direction of the limited mobility is implemented. Slight pressure into the joint (sometimes referred to as approximation) can also be implemented. Vojta’s reflex locomotion is an obvious component of rehabilitation in congenital hip dysplasia. Reflex rolling (position RR I) is practiced, as well as, reflex creeping, which has to be modified based on the ability of the given centrations and based on the stability of the hip joint.

SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE) In slipped capital femoral epiphysis the femoral head slips dorsally and medially. The incidence is 2–13 cases in 100,000. The condition is more common in boys and emerges between the ages 8–17. In 40% of patients, the contralateral hip joint also becomes affected approximately 1.5 years later. Etiology and Pathogenesis Epiphysiolysis is linked to a hormonal imbalance and is found in children with hypothyroidism, hypogonadism, panhypopituitarism and in obese children. In adolescence, the growth plate loses its firmness and the epiphysis slips as a result of external forces. The epiphysis remains in the joint fossa, the femoral neck rotates externally and the head is dislocated into retroversion and varum. The anterior and superior portions of the femoral neck become prominent and

limit hip abduction and internal rotation. The synovial lining becomes inflamed and the joint becomes filled with fluid. Classification According to Time Course Widening of the growth plate (preslip) is the first sign of SCFE. Hip pain emerges and a radiological film shows a widened, irregular and poorly defined growth plate. Preslip is an early sign of SCFE. 1. Acute slip: sudden sharp pain in the hip joint, which develops with minimal injury (firm stepping, jumping, gentle falls). The anamnesis includes the early onset of hip pain less than 3 weeks. 2. Primarily chronic slip: hip pain during loading. 3. Acute epiphysiolysis in the course of a chronically occurring SCFE: hip pain that has been present for longer than 3 weeks and worsens following minimal trauma. According to Stability of the Slippage 1. Stable slippage – the patient is able to load the affected hip and is able to ambulate with crutches. 2. Unstable slippage – the patient does not tolerate loading even with decreased weight bearing and is unable to ambulate with crutches. According to radiological findings on AP and lateral projections: 1. Mild: shift of the femoral head on the femoral neck is less than 1/3 of the width. The angle between the femoral head and the diaphysis is less than 30 degrees. 2. Moderate: the femoral head shifts by 1/3 to 1/2 of the width of the femoral neck. The angle between the femoral head and the diaphysis is 30–50 degrees. 3. Severe: the femoral head shifts more than ½ of the width of the femoral neck. The angle between the femoral head and the diaphysis is greater than 50 degrees. Diagnosis Clinical Presentation In primarily a chronic slippage, the first sign includes hip joint pain

during and after activity and the pain is dull. The child localizes the pain in the groin region and pain referring to the anterior and medial aspect of the thigh. Pain can refer to the knee region. Pain in the knee during loading and after loading is the first sign of hip joint pathology. Therefore, this principle needs to be followed: in patients with knee joint pain, a hip joint assessment always needs to be performed. Objective findings include a limitation in hip internal rotation and the extremity turns into external rotation and abduction during hip flexion. The clinical picture also includes shortening of the affected lower extremity. The child is not able to stand on the affected extremity and if they do accomplish standing on it, hip joint instability during single limb stance becomes visible (positive Trendelenburg sign). The gait pattern is pathological and the child unweights and favors the affected lower extremity. In an acute slippage, the pain is sharp and the patient is not able to stand on the affected lower extremity and, therefore, is unable to ambulate. Imaging Techniques Radiological films are performed in two projections: anterior-posterior and axial. A radiologic film shows a widening of the growth plate (preslip) and the position of the femoral head in relation to the axis of the neck and the axis of the femur are assessed. Ultrasound assessment of the hip joint shows joint exudate and a dorsal shift of the epiphysis. Computed tomography and MRI imaging do not seem to be needed for the diagnosis of SCFE. Treatment In a chronic slippage, shifting and positioning of the femoral head on the posterior aspect of the neck occurs and the joint’s growth space closes prematurely. The process of proximal femoral remodeling occurs. Acute epiphysiolysis can progress to a state, in which a complete loss of contact between the femoral head and the neck occurs which makes the head of the femur at risk for avascular

necrosis. Given the course and consequences of this disease, surgical intervention is always indicated. The first type of procedures involves epiphysiodesis, for example an epiphysiodesis with a screw complemented by a K-wire placement, which prevents femoral head rotation. Shortly following the procedure, the patient can stand up and ambulate with forearm crutches with decreased weight bearing on the affected lower extremity for three months. In a femoral head slippage greater than 30°, corrective intertrochanteric osteotomy is performed. In a femoral head slippage between 50°–70°, a femoral neck osteotomy is performed (Fig. 2.4.5-13 and 14; Fig. 2.4.5-15 and 16). Fig. 2.4.5-13 and 14 Bilateral slipped femoral capital epiphyses – stage I on the right, stage II on the left. AP projection (13) and inlet projection (14)

Fig. 2.4.5-15 and 16 Bilateral slipped capital femoral epiphysis – epiphysiodesis in situ on the right and corrective multiplanar femoral osteotomy with epiphysiodesis according to Immahäuser-Weber. AP projection (15) and inlet projection (16)

Rehabilitation Rehabilitation is indicated following surgery. Physical therapy implements soft tissue techniques, release of hypertonic muscles (especially hip flexors and adductors), gentle hip traction and range of motion, and activation and strengthening of pelvic and femoral musculature. Treatment includes Vojta’s therapy, PNF and exercises in open kinetic chains. When loading is allowed, sensorimotor exercises are implemented as well as exercises on unstable surfaces and in closed kinetic chains. Modalities include hydrotherapy (whirlpool, aquatic therapy), magnetic therapy or distant electrotherapy to accelerate the healing after epiphysiodesis or osteotomy. The patients are prescribed comprehensive balneologic treatment.

LEGG-CALVE-PERTHES DISEASE Perthes disease (or Legg-Calve-Perthes) or coxa plana is a necrosis and subsequent remodeling of the femoral head caused by a

disturbance in vascular supply. The process can result in femoral head deformation with a disruption in the congruency of the joint surfaces leading to prearthrosis of the hip joints. Perthes disease occurs more commonly in boys (in 4:1 ratio) between 2–12 years of age (most often between the ages of 5–8). In 10% of cases, the involvement is bilateral. Etiology and Pathogenesis Currently, the disease is being linked to discrete forms of coagulopathies. A disturbance in the arterial and venous supply, trauma, and transient hip synovitis are other factors contributing to femoral head necrosis. Classification Based on Radiologic Findings Catterall Classification 1. Necrosis affects the anterior aspect of the epiphysis 2. Necrosis affects a greater portion of the femoral head; an anterolateral sequester is developed 3. Necrosis affects the majority of the femoral head; dorsomedial aspect of the head is preserved 4. Necrosis affects the entire femoral head Herring Classification The femoral head is divided into three pillars, lateral (15–30% of head scope), central (50% of head scope), medial (20–30% of head scope). If the necrosis affects a greater part of the lateral pillar, the disease prognosis is worse and deformation (flattening) of the femoral head occurs more often. a. The lateral pillar is not affected b. Greater than 50% of lateral pillar is affected c. Less than 50% of lateral pillar height is preserved Diagnosis Clinical Presentation Pain is a subjective sign. It occurs in the hip joint, groin or in the greater trochanteric area. The pain can be referred, i.e., the child can

complain of knee pain. Pain is minimal in the morning and its intensity increases during the day as the hip joint has been loaded. It recedes at rest. Limping dominates the objective findings and is caused by pain (the patient decreases weightbearing of the hip) and hip joint instability (when weakness of the hip stabilizing muscles is present). The clinical picture includes limited range of motion into abduction and internal rotation and limited internal rotation with the lower extremity extended (roll test). The extent of the clinical findings correlates with the disease stage. 1. Early necrotic phase – period, in which the child complains of hip pain and limping, which alternates with a period without symptoms. 2. Femoral head fragmentation – onset of subchondral fragments – in this period, the symptoms become more accentuated; the head can collapse and become deformed, hip range of motion is limited. 3. Repair stage – femoral head re-ossification – symptoms gradually recede. Imaging Methods Radiologic films include two projections. The first film demonstrates the stage of the disease (necrosis, fragmentation, repair) and the extent of femoral head involvement (classification according to Catterall). MRI accurately presents the extent of the necrosis. Scintigraphy together with MRI are advantageous in the early diagnosis of femoral head remodeling changes. Treatment The goal of treatment is to achieve the centrated position of the femoral head, which implies maximum contact of the joint articulating surfaces (containment). Maintaining the ideal alignment of the femoral head in the hip joint is the focus of treatment. If the head is well covered by the acetabulum, the necrotic portion does not become overloaded and femoral head deformation does not occur. Currently,

conservative, as well as, surgical treatments are being implemented. Conservative Treatment Conservative treatment consists of the application of abduction devices – splints or braces that maintain the hip in abduction and internal rotation. An Atlanta brace is most commonly used. In the abduction brace, the patient can freely move and walk. Abduction brace treatment lasts 18 months. Surgical Treatment Two types of procedures can achieve femoral head containment: pelvic osteotomy (most often based on Salter) (Fig. 2.4.5-17; Fig. 2.4.518; Fig. 2.4.5-19) or varization osteotomy of the proximal femur. Both procedures can also be combined (Fig. 2.4.5-20; Fig. 2.4.5-21; Fig. 2.4.5-22). Fig. 2.4.5-17 Right-sided Perthes disease

Fig. 2.4.5-18 Right-sided LeggCalve-Perthes disease following pelvic Salter osteotomy

Fig. 2.4.5-19 Right-sided Perthes disease after complete remodeling of the femoral head following Slater osteotomy

Fig. 2.4.5-20 Left-sided Perthes disease

Fig. 2.4.5-21 Left-sided Perthes disease following Salter pelvic osteotomy and varization femoral osteotomy

Fig. 2.4.5-22 Left-sided Perthes disease following a complete remodeling of the femoral head – spherically congruent hip

Following the surgery, the extremity is immobilized in a spica cast for six weeks. In the following six weeks, ambulation is allowed with decreased lower extremity weight bearing while using forearm crutches. Full weightbearing is permitted three months after surgery. Rehabilitation Rehabilitation is indicated with conservative, as well as, surgical treatment of Perthes disease. The goal of physical therapy is to maintain and improve hip range of motion and restore balance of the pelvic and femoral musculature. Soft tissue techniques, traction and hip joint centration with gentle pressure into the joint, relaxation of muscles with increased tone and activation and strengthening of hip joint stabilizing musculature with their inclusion in a correct movement pattern are all being implemented. The reflexive influence of a position, support and trigger points to activate pelvic girdle muscles are implemented, as well as, active exercises in developmental positions and sequences, PNF and open chain exercises. When the patient is allowed to weightbear, exercises in closed kinetic chains, sensorimotor exercises and exercises on unstable surfaces are all implemented. To accelerate recovery, pulsed magnetic field and distant

electrotherapy are implemented. A comprehensive balneologic treatment is indicated for patients with Perthes disease.

TRANSIENT SYNOVITIS OF THE HIP Transient synovitis of the hip is an inflammatory disease of the hip joint accompanied by an exudate. Etiology and Pathogenesis Transient synovitis of the hip is the most common pathological condition of the hip joint in children and occurs between 2–12 years of age (most often between 5–6 years of age). It occurs as a reaction to different concurrent inflammatory process, a virus, upper respiratory infection or immunization. Diagnosis Clinical Presentation Subjective symptoms include an overnight onset of hip pain in which the child cannot get up from bed in the morning, limps or is not able to weight bear on the affected extremity. In the anamnesis, the patient reports an illness involving fever in the past 14 days prior to onset of symptoms. The objective findings include limited and painful hip range of motion into abduction, flexion and internal rotation. Examination Laboratory results can reveal an elevation in inflammatory values. Ultrasound imaging of the hip joint reveals edema and joint capsule expansion with joint exudate. Differential diagnosis of Perthes disease and juvenile epiphysiolysis needs to be accompanied by radiological imaging. Treatment The treatment for transient synovitis is conservative. It begins with one week of rest, decreased weightbearing of the affected lower extremity and anti-inflammatories.

Rehabilitation in the acute stage of transient synovitis is limited to gentle traction and cryotherapy to the patient’s tolerance. When the acute symptoms subside, hydrotherapy can be implemented (aquatic therapy, whirlpool).

ADULTHOOD DISEASES OVERUSE SOFT TISSUE INJURIES The hip joint includes adductor, rectus femoris and hamstring enthesopathy. The diagnosis of enthesopathy is established based on clinical examination and imaging methods, from which ultrasound and MRI are beneficial. Hip Adductor Enthesopathy The clinical presentation includes pain at the muscles’ origin at the symphysis during loading. The pain can radiate into the lower abdominal area or into the inner thigh toward the knee. The objective findings include pain with palpation at the muscle origin at the symphysis, increased tone and reflexive changes in the hip adductors. Hip external rotation can be restricted and painful. Hip adduction against resistance is painful and weakness of the internal obliques is observed. Clinical findings also include changes in postural alignment, such as an anterior pelvic tilt, knee valgus, calcaneal valgus, ankle and foot instability and flat foot. Rectus Femoris Enthesopathy Clinical presentation includes pain in the groin during loading. Pain can refer to the anterior aspect of the thigh toward the knee. The objective findings include pain with palpation immediately below the anterior superior iliac spine, at the site of the muscle’s origin, and over the upper third of the muscle. Increased tone and reflexive changes in the muscle belly, or shortening of the rectus femoris are noted. Tone

in the muscle restricts hip extension and hip flexion against resistance can be painful. Rectus femoris enthesopathy in children during a growth period can be linked to the development of aseptic necrosis in the tendinous region. Hamstring Enthesopathy Clinical presentation includes pain below the gluteals of the affected lower extremity with forward bending. This pain can project along the posterior aspect of the thigh toward the knee. The objective findings include significant pain with palpation at the muscles’ origin on the ischial tuberosity and increased tone in the muscle bellies. Stretching of the posterior side of the thigh is painful and forward bending is limited. During supine assessment, elevation of the extended affected lower extremity above the mat is limited when compared to the contralateral side and the end-feel is painful. In children, aseptic necrosis of the ischial tuberosity can occur. Rehabilitation of Hip Joint Enthesopathies Treatment is based on the etiology and pathogenesis of the disease and must occur in several steps and phases: 1. Treating the area of localized pain, or the muscle origin. Treatment of edema and inflammation, which are the source of pain at the muscle origin, are the goals of localized treatment. Kinesiotherapy utilizes soft tissue techniques and mobilization of the affected segment (hip joint traction). Indicated modalities include procedures with an analgesic effect – electrotherapy (DD currents, TENS) and procedures with anti-inflammatory effects – phototherapy (biolamp, laser). 2. Treatment of increased muscle tone and reflexive changes of the corresponding muscle. Muscle relaxation is the treatment goal. Kinesiotherapy utilizes analytical techniques (PIR, AGR) and neurophysiological techniques (PNF, Vojta’s reflex locomotion). Modalities include ultrasound (as a muscle relaxation procedure) or combined therapy.

3. Treatment of the postural function of the spine, pelvis and lower extremities and the correction of pathological movement patterns that are the source of problems. The treatment of localized changes in the muscle has an effect only with simultaneous treatment of a pathological posture and pathological movement stereotypes. Physical therapy treatments include soft tissue techniques, spinal mobilization, activation of muscles of the stabilization system of the spine and the pelvis and their activation in a correct movement pattern. The treatment also implements sensorimotor exercises and these exercises are performed in the centrated position of the foot, ankle, knee and hip joints. Treatment also includes orthotic shoe inserts for the patient.

DEGENERATIVE DISEASES Osteoarthritis of the Hip (Coxarthrosis) Hip osteoarthritis is a degenerative disease. Secondary arthritis is not a result of the body’s aging but rather a result of a disturbance in function. A functional disturbance leads to structural changes in the hip joint region. Pre-arthritic conditions include hip dysplasia, slipped capital femoral epiphysis and Legg-Calve-Perthes disease. Secondary hip osteoarthritis gradually develops from a pre-arthritic condition. Hip joint arthritis including conservative and surgical treatment is described in detail in Chapter 2.3.3. Degenerative Diseases of the Joints, Osteoarthritis.

TRAUMATIC LESIONS Traumatic lesions in the hip joint include groin injuries, hip joint dislocation, acetabular fractures and proximal femoral fractures. Groin Injuries In a groin injury, a distention or a partial rupture of the adductor muscle at the origin occurs on the pubic bone. This injury often

occurs with chronic hip adductor enthesopathy and it is common in elite athletes, especially in hockey players and soccer players. Weakness of the diaphragm, pelvic floor and abdominal muscles (especially the internal obliques) is one of the main reasons for this injury. When testing the strength of the diaphragm, the patient is supine. The patient is asked to flex their lower extremities against gravity to 90° of hip and knee flexion. Undesirable response includes anterior pelvic tilt, inspiratory alignment of the thorax and concavity in the inguinal canal. Subjective signs include suddenly developed sharp pain at the muscles’ origin on the pubic symphysis with referred pain into the abdominal muscles, the groin and the inner aspect of the thigh. The objective findings include significant pain with palpation at the muscles’ origin, reflexive changes in the muscle, and pain with resisted adduction and flexion. In differential diagnosis, a groin injury needs to be distinguished from a femoroacetabular impingement (limited and painful adduction and internal rotation in the hip joint at 90° of flexion) and iliopectineal bursitis. Hip Joint Dislocation A hip joint dislocation belongs among the so called high-energy injuries (car accidents, falls from heights). Based on the position of the dislocated head, dislocations are classified as anterior, posterior and central. A posterior dislocation is often accompanied by the breaking away of a piece of the posterior ridge of the acetabulum, which poses an injury to the sciatic nerve, a complication of this type of dislocation. In a central dislocation, the acetabular joint surface breaks through. Proximal Femoral Fractures Fractures of the proximal end of the femur are the most common fractures at a later age. They are closely linked to skeletal osteoporosis when only a minimal impact can cause fracture (most often falling on the side).

Proximal femoral fractures can be classified according to location as femoral neck fractures, trochanteric fractures and subtrochanteric fractures. This classification is important for the selection of a surgical procedure (Fig. 2.4.5-23; Fig. 2.4.5-24). Fig. 2.4.5-23 Femoral neck fracture in a 12 yearold boy – Boitzy type II

Fig. 2.4.5-24 Femoral neck fracture in the same boy following osteosynthesis with two spongiose screws

Currently, implantation of total endoprosthesis is the method of choice for some femoral neck fractures; occasionally, an implantation of cervicocapital endoprosthesis in biologically old and poorlycooperating patients is used. In trochanteric and subtrochanteric fractures, a certain type of intra-marrow osteosynthesis is indicated. Rehabilitation is initiated post-surgically and verticalization begins early (Fig. 2.4.5-25).

Fig. 2.4.5-25 Left side shows hip condition following implantation of cervicocapital endoprosthesis for a femoral neck fracture, the left side shows treatment by stable osteosynthesis after comminuted intertrochanteric fracture

Rehabilitation in Traumatic Injuries Restoration of hip range of motion while maintain hip joint stability is the goal of rehabilitation treatment. The treatment has to respect the time needed to heal the tissues and the physician’s decisions regarding the permitted loading of the affected lower extremity. Most fractures in the hip region are treated either by stabile osteosynthesis or by

endoprosthesis and early rehabilitation can be initiated following these procedures. The patient undergoes respiratory and endurance therapy for the prevention of post-operative complications (pneumonia, deep vein thrombosis) and this serves as preparation for standing. At the same time, incision care is initiated, as well as, techniques to control edema, gentle soft tissue mobilization, increasing range of motion and facilitation of weak muscles. Already 1–3 days post-surgery, verticalization is initiated, at first to sitting and, based on tolerance, to standing. In standing, the affected lower extremity follows the weightbearing precautions. Following verticalization into standing, gait training is initiated with decreased weightbearing on the affected lower extremity while using a walker or forearm crutches. This is done at first on level surfaces and later includes stairs. Following osteosynthesis and total endoprosthesis, the patient follows the decreased weightbearing status for three months. Following implantation of a cervicocapital endoprosthesis, the patient can fully weightbear when the incision heals, approximately 10–14 days postsurgery. Rehabilitation includes modalities, occupational therapy and social evaluation. Modalities include hydrotherapy (aquatic therapy, total body whirlpool, whirlpool of the affected extremity). Hydrotherapy is indicated after the incision has healed and the stitches have been removed. A pulsed magnetic therapy or distant electrotherapy are beneficial to accelerate bone healing at the injured site. Manual or instrumental lymphatic drainage is used for edema control. Occupational therapy includes practicing independence with activities of daily living (ADL) and selecting the appropriate assistive devices (elevated toilet, shower or bath chair, anti-slippage mats, handlebars). Often, patients are required to undergo a social evaluation to ensure continued therapy in a rehabilitation setting, such as in nursing homes. Another option allows for the patients to be discharged to a home setting with nursing, caregiving and rehabilitation care provided in their home.

REFERRED PAIN TO THE HIP JOINT FROM OTHER SITES The following need to be ruled out during hip differential diagnosis: 1. Functional pathology in the lumbar spine region (restrictions). Each restriction responds by a change in the muscle tone of certain muscles. This change can be a source of muscle pain or can be referred to its tendons. In a L2-L3 restriction, reflexive changes in the gluteus medius are found. With a L3-L4 restriction, there are changes in the rectus femoris. With a L4-L5 restriction, the piriformis is involved and in a L5-S1 restriction the iliopsoas is involved. Reflexive changes in the piriformis and the gluteus medius can be referred to the muscles’ insertion to the greater trochanter and imitate trochanteric bursitis. 2. Structural pathology in the lumbar spine region (nerve root compression). Nerve root projection of the L4 dermatome into the groin and the anterior and medial aspect of the thigh can imitate pain in hip joint pathology. Nerve root projection of the L5 dermatome into the lateral aspect of the thigh can imitate pain from the greater trochanter.

2.4.6 Knee Joint Pavel Kolář, Jiří Kříž Congenital Developmental Defects Congenital knee dislocation Congenital patellar dislocation Bipartite patella Overuse Soft Tissue Injuries Tendinopathies Patellar tendonitis (jumper’s knee) Rectus femoris enthesopathy Hip adductor enthesopathy Biceps femoris enthesopathy Aseptic necrosis

Osgood-Schlatter disease Sinding-Larsen-Johansson syndrome (osteochondrosis of the patellar apex) Osteochondritis dissecans Degenerative Diseases Patellofemoral joint dysfunctions Gonarthrosis Traumatic Injuries Soft tissue knee injuries and their consequences

CONGENITAL DEVELOPMENTAL DEFECTS OF THE KNEE JOINT Congenital developmental defects of the knee include congenital knee dislocation, congenital patellar dislocation, and bipartite patella. Their etiology, pathogenesis and treatment are described in Chapter 2.3.1 Congenital Developmental Defects.

OVERUSE SOFT TISSUE INJURIES TENDINOPATHIES Patellar Tendonitis (Jumper’s Knee) This condition presents as insertional pain of the patellar tendon and it is also known as jumper’s knee. The pain is located at the patellar apex, the tendon or its insertion at the tibial tuberosity. This condition occurs most often in athletes who undergo extreme loading of the extensor apparatus of the knee joint (basketball, volleyball, jumps). Clinical presentation includes anterior knee pain during loading and, later, also at rest. The objective findings include pain with palpation of the origin, course and insertion of the patellar tendon, as well as, puffiness of the tendon and the soft tissues in the affected area. Resisted knee extension is painful. Pain is also experienced during squatting and when rising up from a squat. Thigh muscle changes are also part of the objective findings including increased

tone and reflexive changes in the quadriceps and hamstring muscle tightness. Rectus Femoris Enthesopathy This injury refers to insertional pain of the rectus femoris tendon at the base of the patella. The injury is often present in cyclists or jumpers. The clinical picture includes pain at the patellar base during loading. The objective findings include pain with palpation of the base of the patella with the greatest pain at the lateral aspect of the base. Shortening of the rectus femoris is also present during assessment. Hip Adductor Enthesopathy It is demonstrated as insertional pain of the hip adductors at the medial tibial condyle (pes anserine). A pes anserine injury can be accompanied by irritation of the bursa beneath its insertion. Clinical presentation includes pain on the inner aspect of the knee joint, especially during loading. The objective findings include edema and pain with palpation of the anteromedial aspect of the tibial condyle. The hip adductors demonstrate increased tone and reflexive changes. Increased muscle tone results in a hip range of motion restriction into external rotation and end range of abduction with external rotation can provoke pain on the inner aspect of the knee. Differential diagnosis needs to include a medial meniscus lesion, medial collateral ligament lesion or gonarthrosis. Enthesopathy of the Biceps Femoris Tendon This injury is common in runners and can be present following a long walk. The clinical picture includes significant pain on the lateral aspect of the knee during walking. The objective finding includes edema and pain upon palpation of the tendon’s insertion at the fibular head. The fibular head shows limited springing and the springing is painful. The biceps femoris muscle demonstrates increased tone and reflexive changes are present in the middle and lower third of the muscle. Differential diagnosis includes a lateral meniscus lesion.

ASEPTIC NECROSIS OF THE KNEE In principle, aseptic necroses of the knee are “overuse soft tissue injuries” of the growing skeleton. Aseptic necrosis involves bone remodeling changes at the insertion of the overused muscle because during growth, the bone in this region is “softer” and, therefore, less resistant to loading than connective tissues. Osgood-Schlatter Disease (Aseptic Necrosis of the Tibial Tuberosity) This injury involves the proximal apophysis of the tibia (tibial tuberosity). This overuse condition occurs in active adolescents primarily between 8–15 years of age and, thus, during a period of maximum growth. It results from overloading of the knee extensor apparatus during weight lifting, soccer, cycling, tennis and other sports. Clinical presentation includes pain at the tibial tubercle during and following activity and after exposure to the cold. The objective findings include soft tissue edema and pain upon palpation of the tibial tubercle; resisted knee extension, mini-squat and rising from a mini-squat are painful. Clinical findings also include hamstring muscle tightness. The lateral view of a native radiologic film shows an irregular shape and fragmentation of the proximal tibial apophysis (Fig. 2.4.6-1). Fig. 2.4.6-1 Osgood-Schlatter disease

The condition can persist for 12–24 months and symptoms subside when the growth space of the proximal tibial apophysis closes. Treatment Treatment is mainly conservative and includes the following components: 1. Limiting weightbearing (by 50–75%) based on the finding; sometimes the knee joint is immobilized in extension with a knee brace. 2. Modalities to control symptoms. The indicated procedures include cryotherapy and the application of Priessnitz wraps. Ultrasound is sometimes indicated. However, it needs to be cautiously considered because high intensity ultrasound levels and its application over the growth plate can lead to its damage,

premature closure and subsequent development of knee recurvatum. Remodeling of the tibial tuberosity apophysis can be accelerated by application of pulsed magnetic field or distant electrotherapy. 3. Kinesiotherapy leading to the correction of a muscle imbalance in the lower extremities. Closed kinetic chain exercises and proprioceptive neuromuscular stimulation are implemented. Sinding-Larsen-Johansson Syndrome (Osteochondrosis of the Patellar Apex) It occurs between 10–13 years of age and the clinical picture is similar to patellar tendonitis with pain at the patellar apex during loading and especially when ascending stairs. The area around the patellar apex is puffy, painful to palpation and resisted knee extension is painful. Radiologic lateral views show remodeling changes or a fragmentation at the inferior patellar pole (Fig. 2.4.6-2). Obr. 2.4.6-2 Morbus Sinding-Larsen-Johansson

Treatment Treatment is similar to patellar tendonitis – see above subchapter Patellar Tendonitis (Jumper’s Knee).

Osteochondritis Dissecans Osteochondritis dissecans is a local aseptic subchondral necrosis that affects joint surfaces of predisposed locations. During osteochondrosis dissecans, necrosis at a well-defined area on the subchondral bone occurs. If the necrosis does not heal spontaneously, a fragment of the necrotic bone detaches. The cartilage above the bony fragment gradually degenerates. The medial femoral condyle is most commonly affected (Fig. 2.4.6-3). Fig. 2.4.6-3 Arthroscopic finding of the fragment at the medial femoral condyle during osteochondrosis

Osteochondritis dissecans occurs in athletes, most often in boys as a juvenile (5–15 years of age) or adult form (older than15 years of age). Clinical presentation includes dull knee pain during and after loading and medial femoral condyle pain with palpation. Wilson’s test is a special test for osteochondritis dissecans, in which the knee is flexed to 90° and internally rotated. When moving the knee from internal rotation into extension, pain at the medial aspect of the joint occurs at 30° and is eliminated when the knee is brought into external rotation. Imaging tests are performed to establish the diagnosis. A native radiologic film shows subchondral clearing at the site of the fragment; in the next stage, the site shows a sclerotic edge or fragment. Site location and the extent and condition of the cartilage above the site are confirmed by CT and MRI.

Treatment The prognosis for the juvenile form is good. Osteochondritis usually heals with conservative treatment, which includes limited activity and decreased weightbearing. Arthroscopic surgery is usually indicated in the adult form. If the fragment does not dislodge, drilling at the site is performed to stimulate healing. If the fragment dislodges and the cartilage is preserved, the fragment is stabilized. Fragments with damaged cartilage are excised and the defect is filled with auto​genous grafts (mosaicplasty) or by an osteochondrous autograft transfer secured in place by tissue glue.

DEGENERATIVE DISEASES PATELLOFEMORAL JOINT DISORDERS Patellofemoral dysfunction is characterized by pain (anterior and parapatellar knee pain – for this reason this dysfunction is sometimes referred to as anterior knee pain syndrome), muscle imbalance in the knee extensor apparatus, instability of certain knee extensor apparatus and, in some cases, by inflammation. According to Griffin (1995), an increased Q-angle is one of the causes. This is an angle formed by the line connecting the anterior superior iliac spine through the center of the patella and a line connecting the tibial tuberosity and the center of the patella (Fig. 2.4.6-4). Other causes include vastus medialis weakness, shortening of the myofascial structures on the lateral aspect of the thigh and patella alta. Quadriceps femoris activation in a Qangle that is greater than 20°, results in the patella being pulled in a lateral direction and the patella then becomes compressed against the lateral femoral condyle. Fig. 2.4.6-4 The Q-angle

Fig. 2.4.6-5 “Stress” test of the patella

The clinical presentation of the patellofemoral dysfunction includes retropatellar anterior knee pain when descending stairs, walking downhill, when kneeling, squatting and in prolonged knee flexion position (riding in cars, driving). Objective findings include pain upon palpation of the inner aspect of the patella (articular facets), decreased patellar mobility, painful patellar shift in the femoral groove, joint crepitus is palpable under the patella when it is being shifted. “Stress” tests of the patellofemoral articulation are positive (the principle of these tests is to apply pressure between the patellar articular surface and the articular surface of the femoral groove) (Fig. 2.4.6.-5.). The symptoms typically occur in girls between 15–18 years of age. During this time, the patellar cartilage can be 1 cm thick. The etiology and pathogenesis of this condition considers the contribution of hormonal changes. Activity can also provoke symptoms. Rehabilitation Physical therapy is the foundation of rehabilitation for patellofemoral dysfunction. The treatment can be described in six steps:

1. The first step includes removal of any possible exudate from the knee. Exudate as little as 20ml can elicit inhibition of the quadriceps femoris, especially in the vastus medialis muscle. Modalities include vasopneumatic treatment, DD-CP currents and cryotherapy. 2. Pain should be eliminated as it can be a source of muscle inhibition. Exudate or patellar compression can be sources of pain. Pain can be referred from reflexive changes in the quadriceps femoris. Physical therapy implements soft tissue techniques, patellar mobilization, gentle knee joint traction and mobilization of the fibular head. The quadriceps femoris is treated by soft tissue techniques and, at the same time, muscle relaxation is performed. Modalities include analgesic procedures – electrotherapy (DD currents, TENS), muscle relaxation procedures for the quadriceps femoris (ultrasound, combined electrotherapy) and also hydrotherapy (especially the whirlpool). Patellofemoral articulation can be specifically unloaded and stabilized by a brace or with taping. 3. Improvement in soft tissue mobility of the knee musculature is another important factor. This involves mainly the restoration of normal mobility of the medial and lateral retinacula, the superior and inferior poles of the patella and the iliotibial band. Soft tissue techniques are mainly used as well as patellar mobilization. 4. Individual exercises with a focus on improved muscle activation of, specifically the vastus medialis oblique, is a key point in the treatment. Currently, the authors of this textbook recommend closed kinetic chain exercises using developmental lines for vastus medialis facilitation. 5. To improve proprioception and neuromuscular control, elements from sensorimotor (rocker boards, Posturomed, etc.) and plyometric training are implemented. 6. The last point involves the effort to improve the biomechanical relationship in the knee region either by McConnell taping or by using orthotic devices (braces with patellar guiding, patellar strap, etc.).

GONARTHROSIS Gonarthrosis is a degenerative disease of the knee joint. It is mainly caused by chronic joint overloading. Prearthritic conditions include trauma in the knee area with an injury to the meniscus and the ligaments with subsequent knee instability. The etiology and pathogenesis, as well as, the conservative and operative treatment of gonarthrosis are described in Chapter 2.3.3 Degenerative Joint Diseases.

TRAUMATIC LESIONS Miroslav Dobeš

SOFT TISSUE INJURIES OF THE KNEE Soft tissue injuries of the knee are common athletic injuries. The most common injuries include knee joint sprain, injury to the cruciate and collateral ligaments, meniscal tears and last, but not least, combined injuries. Physical therapy is an essential component of treatment for patients with soft tissue knee injuries. Effectively performed physical therapy returns the patient to their daily activities faster and it serves as prevention from other movement system injuries. Physiology of Healing of the Knee Structures The understanding of physiology of soft tissue healing is one of the fundamental conditions for successful rehabilitation of injured and post-surgical soft tissue knee structures. Physiology of Soft Tissue Healing Soft tissue healing is a complex morphological, biochemical and physiological process. In general, it can be said that the entire process begins by formation of granulation tissue, which is rich in fibroblasts, endothelia, microphages, granulocytes, lymphocytes and plasmocytes. New capillaries form in the granulation tissue. Platelet-derived growth

factor (PDGF) and other mediators stimulate fibroblast proliferation and migration. Fibroblasts produce glycosaminoglycans that swell and deposit themselves on the collagen fibers. The newly formed collagen “contracts” and closes the edges of the wound. Collagen fibers or a scar (fibrotic tissue) are the result of the healing process. This is a reparative process. From the perspective of soft tissue assessment and treatment of the knee, the understanding of physiology of ligamentous healing is important. Physiology of Ligamentous Healing Healing of the extra-articular ligaments is analogous to the process of reparative remodeling also known from other locations. This process was observed in detail in several studies involving healing of the medial collateral ligaments in rabbits. As a result of an injury, a hematoma develops from disrupted blood vessels followed by a fibrin clot formation with subsequent tissue vascularization and repair. This process can be divided into four phases: 1. Acute inflammatory phase 2. Subacute phase with predominance of proliferation (during approximately 6 weeks) 3. Remodeling phase – healing 4. Phase of healing completion Complete healing (ad integrum) occurs approximately 12 months after injury. Physiology of Autogenous Graft Healing The understanding of healing of transplanted ligaments is important. In clinical practice, it involves mainly an anterior cruciate ligament (ACL) repair. Currently, the most commonly used grafts include patellar tendon, hamstring tendon or a cadaver. Grafts made from synthetic materials are no longer commonly used. Several experimental and clinical studies have shown that the autogenous and biological replacement of one of the cruciate ligaments undergoes physiological and biomechanical remodeling when used.

An autogenous graft is defined as a tissue that is harvested from one body part and subsequently transplanted to another body part in the same individual. An autogenous graft harvested from the patellar tendon and used as a replacement of the anterior cruciate ligament becomes avascular during transplantation. Biological processes lead to revascularization inside the joint. This fact has been demonstrated by experimental studies. Following transplantation, the patellar grafts are gradually covered by vascular synovial tissue that emerges from the soft tissues of the knee. This synovial process occurs within the first 4– 6 weeks after surgery. During this time, the avascular center of the graft demonstrates ischemic necrosis. In other words, the graft plays an innocent role in the race between the avascular necrosis and revascularization. Luckily, the soft tissue that initiates “synovialization” of the graft also ensures the revascularization process, in which the vessels from the infrapatellar branch and the synovium penetrate the graft tissue and cause its revascularization. This complete revascularization process occurs approximately 30 weeks post-surgery. Together with the process of revascularization, the transplanted patellar tendon undergoes fundamental morphological, biochemical and biomechanical changes. Experimental studies in rabbits demonstrated graft ligamentization in an intra-articular environment. The change in the patellar graft takes approximately 30 weeks and is characterized by gradual changes in the morphology of the cells, collagenous profile and the parallel alignment of the fibers. These changes in the autogenous graft in its morphological and biomechanical profile are identical to a “normal” ACL (Amiel, Kleiner, Roux, 1986). However, the biomaterial nature of the remodeled graft demonstrates less quality. According to experimental studies, this type of transplanted graft never reaches 100% strength of the original ligament. The question of loading in the post-operative phase poses an important question in the entire process of extra-articular ligamentous healing, revascularization and remodeling of an autogenous graft.

Prolonged immobilization (9 weeks) disrupts the parallel organization of the collagen fibers and decreases the number and size of the collagen bundles. These morphological changes decrease the ligament’s absorption ability and increase its tension. Changes are also manifested by weakening of the ligamentous insertions. Biochemical and morphological changes caused by immobilization in the boneligament-bone complex progress very quickly. However, these changes appear to be reversible and the healing process is very slow and can last several months. It has also been demonstrated that the ligaments loaded earlier (following an injury or a surgery) are stronger than the ones that were immobilized. Naturally, loading and the timing of exercises needs to be administered carefully. The amount needs to be established based on the repair process of the ligaments and in soft tissues in general. Rehabilitation Following Meniscal Injuries and Repairs Knee injuries involving the meniscus are quite common considering the total number of knee injuries. The reason may be the increased interest of the population in exercise activities, including relatively (in the Czech Republic) new sports such as squash, skating, snowboarding, etc. At the same time, with increased risk, need for the orthopedic-traumatological, diagnostic and treatment (especially arthroscopic) options have been increasing. A meniscal injury is quite accurately diagnosed at an early stage following a trauma and, for this reason, can also be treated with surgery sooner. This has also been inevitably linked to a change in the rehabilitation approaches. In the end, this is beneficial for the patient and timely treatment allows for a faster return to work or athletic activities (Fig. 2.4.6-6). Fig. 2.4.6-6 Arthroscopic finding of a medial meniscus lesion

Until recently, an opinion predominated that a surgical procedure with low demands on early mobilization of the involved joint was the most appropriate treatment for a meniscal injury. Rehabilitation programs were developed according to a typical protocol. Three phases were described: the phase of maximum protection, the phase of decreased protection and the phase of return to activity. According to this algorithm, the patient’s knee joint was immobilized for a prolonged period of time to protect and allow for healing of the meniscus (soft tissues) following the surgery. This practice often lead to knee joint contractures, soft tissue adhesions and decreased nutrition supply to the articular cartilages. The subsequent rehabilitation was more involved in addressing secondary problems rather than the actual knee injury. The rehabilitation was time demanding and, in many patients, patellofemoral syndrome developed because of overloading of the knee extension apparatus. The actual program did not include proprioceptive exercises and the strengthening exercises were not based on the knowledge of the forces acting on the knee joint during exercises in open and closed kinetic chains because it was developed according to principles that could not (and cannot) address the patient’s specific needs.

Currently, meniscal tears are treated orthopedically by an early arthroscopic intervention. Therefore, subsequent rehabilitation is influenced by this fact. In general, it can be stated that modern rehabilitation approaches used in patients after arthroscopic meniscal surgeries are identical and, respectively, they are based on rehabilitation principles used for patients with an ACL injury. The program most commonly used contains five functional phases. The length of the program is variable, it takes weeks or months, and it depends on the type of injury, surgical techniques and the patient’s motivation. The actual phases are not identical in duration. They smoothly transition from one phase to the next and are individually based. Establishing quality lines of communication between the physician, therapist and the patient is an important component (as well as, for other diagnoses). Phase I – Early Protective Mobilization This phase begins immediately after the arthroscopic procedure. The goal is to prevent soft tissue adhesions and maintain capsular mobility and nutrient supply to the joint structures. Attention is paid to reducing pain and edema because pain and edema inhibit muscle activity and decrease muscle strength. This especially includes reflexive weakness of the quadriceps femoris. Joint capsule tightness due to edema can reflexively decrease the activity of the entire lower extremity. In the early post-operative phase, modalities such as cryotherapy are recommended to decrease edema and pain, electrotherapy (IF, TENS) for pain modulation and magnetic therapy to enhance soft tissue healing processes. Soft tissue mobilization of the thigh and manual lymphatic drainage are important components of treatment of soft tissues surrounding the joint. Currently, non-steroidal antiinflammatories are being administered. Their application is important in patients prone to edema formation or in patients with extensive soft tissue involvement. Further, exercises to maintain joint range of motion are implemented. The exercises can be active, passive or active-assistive. The use of a CPM does not seem necessary. The distal aspect of the lower extremity is activated as soon as possible to

maintain proprioceptive signals from this area and to maintain strength. The exercise position (lying, sitting, standing) is selected based on weightbearing restrictions. Progression from partial to full weightbearing depends on the surgical procedure and the degree of protection needed. Patients after partial meniscectomy comprise the simplest situation. Immediate partial weightbearing (50%) is recommended with fast progression into full weightbearing (within 1 week). More caution needs to be paid in patients with a meniscal suture. During the healing phase, toe touch weight bearing is recommended. In approximately 4 weeks, partial weightbearing (50%) is recommended with progression to full weightbearing after 6 weeks. These guidelines need to be followed. It needs to be emphasized that early aggressive pressure loading leads to recurrent formation of joint exudate, which negatively influences the healing process. In such cases, exercises in the horizontal position are chosen. At 4 weeks, stabilization exercises in sitting and exercises in the water with decreased weightbearing are incorporated. Phase II – Neuromuscular Proprioceptive Training Neuromuscular proprioceptive training is an integral part of the rehabilitation program in patients with a meniscal injury. Studies of human meniscal patterns showed the presence of three morphologically different mechanoreceptors (Day et al., 1985) – Ruffini corpuscle, Golgi tendon organs and Paccinian corpuscles. Their presence demonstrates that menisci can play an important role in providing afferent sensory information for the CNS and consequently influence the biomechanical function of the knee joint. However, this observation has not been confirmed by scientific studies. Meniscus function is biomechanically reinforced by their relationship with the quadriceps femoris, the semimembranosus and the popliteus muscles. Kapandji states that during knee extension, the menisci are pulled by the meniscopatellar fibers anteriorly and during flexion posteriorly via the semimembranosus. They do not function in isolation from the dynamic stabilizers. That is the reason why it is important to restore soft tissue flexibility together with neuromuscular

proprioception and coordination to restore joint function and to prevent future injuries. Neuromuscular proprioceptive training in patients after meniscal injury is administered through various exercises on a firm floor, uneven surfaces (balance boards, sandals), Posturomed, minitrampoline, etc. It is recommended to initiate these exercises even prior to reaching full range of motion. The exercises cause changes in joint alignment and pressure on the intra-articular soft tissues and stimulate, in this way, the joint neuroreceptors to send afferent signals to the CNS, which subsequently provides control over the muscle contraction. The therapist stimulates the patient to maintain a constant level of quadriceps and hamstrings co-contraction during exercises in various extremity positions. The neuromuscular proprioceptive program is based on a finding that repeated micro or macrotrauma to the intra-articular structures (in this case menisci) during functional activities is minimized thanks to a controlled muscle co-contraction. As soon as the patient achieves dynamic stability during exercises on unstable surfaces, other functional activities can be included in the program. According to the authors’ experience, these exercises not only increase dynamic knee control, but also significantly motivate the patient toward further cooperation with the therapist. Phase III – Strengthening of the Dynamic Stabilizers The criteria to initiate this phase include full and pain-free knee range of motion, controlled co-contraction of the dynamic stabilizers and proficiency in the neuromuscular proprioceptive rehabilitation program. Closed-kinetic chain exercises are preferred with the elimination of full knee flexion. It is recommended to follow these principles as long as possible. However, we are aware that in active athletes it is difficult and complicated to “suddenly” change the already established way of training and the coaches’ way of thinking. However, the entire rehabilitation team needs to realize that strength training is effective only when possible damage to the soft tissues by excessive shearing

and compressive forces is eliminated and when the patello-femoral articulation is not needlessly overloaded. Phase IV – Functional Training Directed rehabilitation ends during this phase. The patients should be instructed in continuing their program, which aims to maintain or increase their strength, endurance and neuromuscular proprioceptive abilities for standard daily activities. This program is, of course, modified according to the degree of necessary protection of the intraarticular soft tissue, joint surfaces (in cases involving cartilage damage) and subchondral bone structure. In general, repetitive movements with heavy loads should be minimized. The situation is more complicated in athletes who are required to perform athletic activities at a high level of functional ability of the knee. The patients (athletes) need to meet the following criteria to transition into phase IV: Pain-free full range of motion The strength of the affected lower extremity with 20 repeated exercises in a closed kinetic chain (leg press) decreases no more than 10% from start to finish The patient demonstrates good dynamic control in full weightbearing on one lower extremity on an unstable surface Isokinetic tests during open-chain exercises are not routinely used because of the presence of large shearing forces Good cooperation among all members of the rehabilitation and athletic team needs to be maintained (physician, therapist, patient, coach). If pain or edema keep recurring, a physician needs to be consulted. Phase V – Return to Common Activities and a Maintenance Program The return to full (even competitive) level of activity is allowed when the patient achieves pre-injury (pre-surgical) condition. At the same time, the need for prevention of new injuries occurs. Knee strength, endurance and dynamic stabilization need to be maintained. The patients are educated on correct preventative body posture because

posture plays an important role in the prevention of a knee joint injury during all movement activities. In general, the patient should understand all principles of this rehabilitation phase and should independently follow these principles during daily activities. The above principle of developing a rehabilitation protocol in patients with meniscal involvement is based primarily on accurate diagnosis and a defined extent of tissue damage. A single strict outline cannot be developed because each patient needs their own rehabilitation program developed specifically according to the type of injury and their functional goals. The authors reject unrealistic demands for an accelerated return to functional activities and recommend careful consideration of transitions between individual phases of the rehabilitation program. Rehabilitation following Medial Collateral Ligament (MCL) Injury Injuries to the ligamentous structures of the knee are quite common in orthopedic and sports medicine. The ligaments belong among a group of passive stabilizers of the knee and their injury significantly affects knee stability. In general, it does not matter which treatment (conservative or surgical) the orthopedist or traumatologist selects. In any case, the following rehabilitation is very important and irreplaceable. It covers the entire treatment process and we can easily confirm that well timed rehabilitation treatment begins immediately following the injury. Mechanism of Injury Injuries to the medial structures can be caused by a direct external force directed at the lateral aspect of the thigh or the lower leg or by a non-contact activity improving a valgus force. Long term studies have shown that the majority of MCL injuries occur as a result of direct force. According to Hughston and Barrett, this occurs in 86% of patients. Often, direct MCL injury is accompanied by an ACL and medial meniscus injury. Treatment

Conservative treatment of an isolated MCL injury was previously described a quarter century ago. Based on our experience, the rehabilitation program for all grades of involvement of an isolated MCL injury (I, II, III) can be divided into three phases. The first phase focuses on pain and edema control and restoration of range of motion. The goals of the second phase include training of coordinated strength abilities and an overall postural stability. The third phase includes closed-chain strengthening exercises on equipment to restore absolute strength of the lower extremities. The same classification can be found in available literature. However, our opinion varies in the selection of therapeutic approaches in the individual phases. The duration of the individual phases is directly dependent on the degree of injury. A transition from a lesser to more advanced stage depends on the results of the rehabilitation process and it is strictly individual. Phase I In the initial phase, pain, edema and inflammation control are the main objectives. Various means of cryotherapy and, in more involved cases, cryotherapy with compression are used. Cold decreases pain and compression limits edema formation and increases the perception of stability. From the beginning, range of motion is restored (maintained), especially extension. Maintenance of soft tissue mobility surrounding the joint and patellar mobility in all directions are equally important. In the case of increased muscle tension (especially on the posterior aspect of the thigh), any technique can be selected to decrease the tension. The treatment of contractile and non-contractile soft tissues is an essential step in renewing joint mobility. Maintaining functional mobility is important as early as in the first stage. Assistive devices can be used in scenarios involving a marked degree of pain, with the perception of significant knee instability or in the presence of an antalgic gait pattern. Psychological barriers during locomotion are also common. Therefore, crutches are recommended to prevent a gait pattern disruption, but only for the time it is absolutely necessary.

Criteria to progress to the next phase include the absence of edema, active knee range of motion from 0–90° and the ability to perform a basic quadriceps contraction. Phase II Increasing lower extremity strength (especially the extensor group) is the main goal in this phase. Griffin recommends strengthening exercises in a closed kinetic chain using exercise equipment (kickbacks, leg-press, squat, etc.) Initially, he recommends sets of many repetitions with a light load. Later, the number of repetitions is decreased and the load is increased. We believe that initially, it is better to implement active strengthening exercises in sitting, standing on both and later on one lower extremity on a firm surface and then, when sufficient stability is achieved, progress to unstable surfaces and balls. The significance of these exercises lies within their proprioceptive effect and in increasing the strength and coordination abilities of the dynamic stabilizers and, with it, an increased level of co-contraction synergy of the thigh musculature. Phase III A patient’s return to functional activities prior to the injury is the goal in this phase. In principle, this period pertains only to individuals engaging in sport activities. Only now (in contrast to Griffin) do we recommend to include closed kinetic chain strengthening exercises while utilizing equipment. Rehabilitation following Anterior Cruciate Ligament Injury and Reconstruction An anterior cruciate ligament (ACL) injury is an injury that significantly affects knee function (Fig. 2.4.6-7). The injury is often linked to a sports activity – skiing, soccer, tennis, squash. Fig. 2.4.6-7 An arthroscopic finding of ACL tear

Perception of instability, joint inefficiency, repeated occurrences of the joint giving way and recurrent joint filling are among the main symptoms. The injury is often accompanied by a medial meniscus injury and an MCL tear (unhappy triad). Insufficiently treated instability leads to an early onset of gonarthrosis with all its consequences. Arthroscopy allows for accurate diagnosis as well as successful treatment. A perfect reconstruction of this ligament with flawless graft centralization is essential for correct function of the implanted ligament. Knee immobilization is not needed and the joint can be mobilized starting day one after surgery to prevent secondary damage of the connective tissue system. Today, the most commonly used grafts include a section of the patellar tendon stabilized by interferential screws or a semitendinosus or gracilis graft and its stabilization. In some scenarios, a cadaver graft is used. Early ligament reconstruction effects long-term longevity of the knee joint. Postponing surgery or the permanent lack of an ACL significantly increases the risk of other intra-articular damage, especially in active and athletic individuals. Clinically, significant instability and the condition of the knee following a meniscal repair significantly increase the incidence of secondary osteoarthritis long-

term. Actual Rehabilitation Program The rehabilitation protocol is divided into five phases. The entire program begins with the pre-operative stage. The second phase begins during the actual reconstruction and ends within 14 days of reconstruction. The third phase includes the third, fourth and fifth week following reconstruction. The fourth phase is the time period up to eight weeks post reconstruction. The final, fifth phase smoothly follows after the prior phase and it is completed by a full, functional return to (mainly) athletic activities. We are aware that this time-based classification and the suggested course of the entire rehabilitation process depend on the following: Type of surgery Technique of the surgical procedure Technical equipment that the surgeon has available Patient motivation Patient’s body healing potential Patient’s prior movement experience Degree of the patient’s intramuscular coordination Social factors Therapist personality, their knowledge and their expertize Phase I – (Pre-Operative Phase) Rehabilitation begins at the time of the injury, i.e., ACL damage with possible involvement of other knee structures. It can be divided into two parts. Rehabilitation of the Soft Tissues of the Knee Edema control and full range of motion preservation are the most important aspects. It is beneficial to combine cold application with compression in order to prevent pain and increased intra-articular bleeding. When the pain is controlled and edema is eliminated, the focus is shifted to increasing knee range of motion (if it is limited). The ability to achieve and maintain full extension is especially important. Passive range of motion, frequent positioning, relaxation

of the muscles on the dorsal aspect of the thigh and modified active exercises sitting and in standing are implemented to achieve this goal. To maintain joint flexion, the same methods and exercises are used as in post-operative phase. When the acute post-injury phase subsides, attention is paid to restoring gait and muscle function. The patient usually ambulates with an assistive device because full weightbearing is not recommended and, in the majority of cases, preventive immobilization is used, such as a brace. The brace is taken off during active exercises in standing. We recommend discontinuing crutches as soon as the patient is able to ambulate without limping. Stabilization exercises are continued; at first, on a firm surface and later on unstable surfaces. Strength training is initiated at a time when the patient shows marked improvement in stability and a normal gait pattern. In this case, we recommend progression to exercises in a closed-kinetic chain. The goal is then to prepare the patient for reconstructive surgery so that the knee has neither edema, nor other soft tissue defects and that range of motion is within normal limits and that they have a normal gait pattern. For a patient to execute a stabilization and strength program at the same time, the patient must have a set of basic movement skills that he can return to and further develop during the post-operative phases of rehabilitation. It is important to time the surgery well. We do not recommend performing the reconstruction earlier than three months after the initial trauma. Full healing of the soft tissues of the knee needs to be allowed. In some cases, when this time period was shorter, the postoperative rehabilitation was affected by various complications (frequent edema, prolonged joint mobility limitations, insufficient cocontraction activity of the thigh musculature). These complications resulted in the patient’s poor psychological well-being and led to an overall prolonging of their rehabilitation. Another advantage of postponing surgery is that it allows the patients to prepare the neuromuscular system for future demands. The patient is introduced to all methods and techniques that they will

undergo during post-operative treatment. This will actually encourage the patient with the entire process and strongly motivate them. Preparation for Surgery A patient’s good understanding of the surgical procedure and postoperative rehabilitation is one of the goals in the pre-operative period. The surgical procedure is explained to the patient by the surgeon. The therapist, however, spends much more time with the patient than the physician and must be prepared to expertly answer questions from this area. It needs to be emphasized to the patient and their surroundings that the first 14 days post-surgery are the most important from the perspective of actual rehabilitation. Work, school and daily routine must be unreservedly adjusted to the rehabilitation needs. These adaptations are important to prevent complications in the early postsurgical period. The therapist also needs to educate the patient on a complete return to full function, which depends on biological processes of the graft and other soft tissue healing. Fully informed patients are highly motivated, mentally ready for the time demands of the entire rehabilitation and do not attempt to return prematurely to daily and athletic activities and, therefore, are expected to undergo a successful rehabilitation course. Phase II (0–2 weeks post-surgery) We would like to emphasize one more time that this phase is the most important time period during the entire rehabilitation program. It begins in the operating room when the surgeon controls full range of motion in the knee. We completely agree with the use of the term accelerated rehabilitation. It includes five important parameters: Maintain full extension Control post-operative edema by rest and elevation of the lower extremities Allow surgical incision healing Preserve quadriceps activity

Achieve 90° of knee flexion at the end of this period In the early post-operative period, the patient’s overall condition needs to be respected, especially their perception of pain. Based on availability, the patient elevates the extremity and applies a cold pack or other types of cryotherapy. When the Redon drain is removed, some centers use a CPM at 0–30° of range and some at 10–90° of range. Based on our experience, however, there is no difference in patients using a CPM versus not using one. Rehabilitation in the first several days should include patellar mobilization, soft tissue mobilization around the joint, lymphatic drainage and isometric contraction of the extensors. We recommend using a large ball for positioning and performing flexion-extension range of motion. Further care depends on the patient’s discharge time to home. It usually occurs 3–4 days following surgery. At discharge, the patient receives instruction regarding home self-care and establishes contact with a physical therapist who directs further rehabilitation. Even though the overall approach is viewed as “accelerated” rehabilitation, the extremity needs to be maintained in relative rest. In the second half of phase II, “official” rehabilitation is initiated. The patient is treated daily and the treatment is focused on soft tissue mobilization of the knee and non-forceful passive movement to increase range, including extension if it is lacking. Inhibition techniques are used to decrease tension in the hamstrings and patellar mobilization is included. The patient is instructed in a home program involving isometric contractions of the knee extensors, active exercises with the knee extended through minimal ranges in all planes, soft tissue mobilization and self-massage of the thigh musculature (edema drainage). The patient continues to use assistive devices during ambulation and a short knee brace with range restricted to 30–60° to improve stability. Modalities include thigh muscle stimulation, biostimulatory phototherapy for the treatment of the incision and continued cryotherapy. The criteria for progression to the next stage include:

90° flexion Minimal edema Visible isometric activity of the knee extensors Full extension – this criterion is not absolute Phase III (3–5 weeks) During this phase, progression toward greater knee flexion is continued. This is linked to scar mobilization after graft harvesting and the constant decrease in tension in the surrounding soft tissues. Standard soft tissue techniques are used. Active exercises include stabilization exercises in sitting, standing on the floor with symmetrical bilateral lower extremity weightbearing, and exercises with balls. When 100–110° of flexion is reached, a stationary bicycle can be added. The patient has to be able to transition the involved extremity through a full revolution. Initially, a minimal load is selected (0.5–1 W/kg) with a cadence of 80–90 cycles/minute. The total time and the number of intervals are determined according to the soft tissue reaction to the cyclical movement and by the patient’s overall physical condition. Usually 10–15 minutes is selected with 2–3 ten-minute-long intervals. As far as mobility is concerned, full extension needs to be achieved in the first half of this phase. Modalities include hydrotherapy – whirlpool and aquatic therapy in a pool with warm water (36–37 °C). The relaxation effects of water are used to increase joint mobility. At the end of this phase, the knee joint should show no edema. There should be a normal gait pattern and nearly normal joint stability. Most patients feel well given the increased stability and muscle strength. This leads to a desire for greater activity. However, it needs to be remembered that, in this time period, the process of autograft revascularization continues and the graft is still at a high risk of injury when exposed to shear and compressive forces. Phase IV (6–8 weeks) In this phase, a patient with a non-complicated recovery masters coordination and strengthening exercises on unstable surfaces –

exercise sandals, rocker boards, Posturomed, balls, etc. In these positions, the patient is able to use his upper extremities independently (ball toss, catching objects). Athletes can start running on a treadmill or on a soft surface (without speed or directional changes). Only in this phase, do we recommend to include closed chain exercises (mini-squat, leg press, step ups). However, the exercises should not cause significant pain, lead to edema as a reaction to loading and nor should movement coordination decrease with repetitions. At the end of week 8 post-surgery, outpatient physical therapy is completed. Further progression depends on functional goals and on the type and intensity of everyday activities (sport). Phase V (from completed week 8) Every patient completing the outpatient part of rehabilitation is instructed in exercise principles and given a home program. Home therapy is individual and depends on the type and intensity of demands that the specific individual is exposed to. In athletes, the coaches or the team physical therapists are contacted to specify training schedules. The training has to include coordination exercises and needs to prevent repeated loading in knee flexion greater than 60°. Closed chain exercises are preferred during strength training. Increased attention needs to be paid to quality regeneration following activity and in order to prevent the development of muscle imbalances. Within the time constraints, the therapist attempts to be present in the sport arena (weight room, in-line skating, bicycling) and points out the risk factors in specific situations. If interested, the bicycle can be inspected and recommendations can be made for its frame height or length, height of the handle bars and the setting of the pedals. This, of course, requires the therapist’s knowledge and skills. In return, the patients are very grateful for the recommendations and the trust of the therapist’s abilities deepens. The significance of rehabilitation following injuries and ACL reconstruction increases because even the best performed surgical procedures do not achieve their full quality without rehabilitation.

Therefore, team work among the physician, physical therapist and the patient is quite essential.

2.4.7 Ankle and Foot Miroslav Dobeš, Pavel Kolář, Olga Dyrhonová Congenital Developmental Defects of the Ankle and the Foot Club foot (congenital pes equinovarus) Pes calcaneovalgus Congenital vertical talus (pes planovalgus congenitus) Metatarsus adductus Congenital hallux varus Digitus quintus supraductus Syndactyly Polydactyly Macrodactyly Alignment Deformities Flat foot Hallux valgus Hallux rigidus Matatarsalgia Toe deformities (hammer toes and club toes) Overuse Soft Tissue Injuries Peritendinitis, Achilles tendon tendinosis Tenosynovitis, tibialis posterior tendinosis Enthesopathy of the short plantar muscles, heel spur (calcar calcanei) Tibialis anterior syndrome Degenerative Diseases Osteochondritis dissecans Osteoarthritis Traumatic Lesions Achilles tendon rupture

Ankle ligamentous injury

CONGENTIAL DEVELOPMENTAL DEFECTS Congenital developmental defects of the ankle and the foot include club foot, pes calcaneovalgus, vertical talus (congenital pes planovalgus), metatarsus adductus, congenital hallux varus, digitus quintus supraductus, syndactyly, polydactyly, macrodactyly (their etiology, pathogenesis and treatment are described in Chapter 2.3.1 Congenital Developmental Defects, Congenital Developmental Defects of the Ankle and the Foot).

TREATMENT OF CONGENITAL DEVELOPMENTAL DEFECTS IN GENERAL Congenital developmental defects are classified as positional or structural. Rehabilitation plays an integral role in the treatment of positional defects. A combination of orthopedic and rehabilitation treatment is implemented for structural defects. Rehabilitation treatment can positively affect the development of the ankle and foot by changing their function.

ALIGNMENT DEFORMITIES FLAT FOOT Flat foot is a wide term used to describe a decreased longitudinal foot arch with calcaneal valgus. Classification of flat foot 1. Congenital flat foot a. Rigid – congenital steep talus b. Flexible – pes calcaneovalgus 2. Acquired flat foot a. With increased connective tissue laxity b. In neuromuscular diseases – pareses, myopathies

c. In rheumatic diseases d. In contractures This subchapter deals with flat foot as an acquired static deformity, e.g. deformity with increased connective tissue laxity. Flat Foot in Children (Pes Planovalgus) The foot develops until 6–7 years of age. Until this time, the lower extremity is physiologically positioned in calcaneal valgus, knee valgus and hip valgus and internal rotation. Around the age of 6, the knee joint axis straightens and the calcaneal valgus decreases. Calcaneal valgus greater than 20° is defined as pathological. Next to calcaneal valgus, this deformity also includes internal rotation of the ankle axis, lowering of the talus in a medial and plantar direction, forefoot abduction or adduction and 1st ray pronation. Clinical Presentation In children, flat foot is usually asymptomatic; problems do not emerge until adolescence. The symptoms include foot fatigue and pain on the medial aspect of the foot, which spreads to the anterior shin (anterior tibialis muscle). The objective findings include Achilles tendon shortening, which is one of the causes of foot pronation. The shortening is often unilateral with unclear etiology. The shortening is assessed by ankle dorsiflexion with full knee extension while the Chopart joint alignment is in neutral position (centrated). Treatment Opinions on the treatment of flat foot vary to a great degree. Conservative treatment is essential: 1. Wearing quality footwear with longitudinal arch support and heel guidance (firm heel counter). 2. Stimulation and facilitation of the bottom of the foot during daily activities – walking barefoot on soft, uneven surfaces (grass, sand). 3. Passive support – orthopedic inserts based on a functional assessment. 4. Active treatment – physical therapy.

The authors agree with the first two principles; however differ in opinion regarding passive correction of a flat foot with an orthopedic insert and physical therapy. Considering that a flat foot often develops as a symptom of poor posture or constitutional hypermobility, physical therapy would then, in our opinion, be indicated. Treatment occurs in the form of a game, which focuses not only on the flat foot itself, but also on influencing overall posture. Elements from sensorimotor exercises are essential – training foot support, a “short” foot in a neutral alignment at the ankle, knee and hip joints and with correct alignment of the pelvis and the trunk. Orthopedic inserts are recommended for symptomatic flat foot and in a flat foot, in which the medial border of the foot is convex. Orthopedic inserts should be custom made, include a medial wedge to correct the longitudinal arch, support the transverse arch and increase the outer edge of the insert, which allows for correct guidance of the calcaneal valgus. Acquired Flat Foot in Adults This is a static foot deformity that develops due to long-term overuse. It can develop from childhood flat foot or in a foot without any previous deformity. Next to long-term exposure to static loading, poorly fitting footwear and hormonal imbalances (pregnancy, menopause) also contribute to the development of flat foot. Clinical presentation includes ankle and subtalar joint pain with most of the pain felt inferiorly to the external malleolus. Pain can also radiate to the anterior aspect of the shin. Objective findings include calcaneal valgus, in which the lateral edge of the heel loses contact with the floor. The forefoot is in abduction and pronation. The objective findings also include edema and varicosities. During gait assessment, foot unwinding from the floor is absent, foot contact is firm and the foot loses its shock absorptive function. Flat foot is one of the factors contributing to the development of

insertional pain in the ankle and the foot region (Fig. 2.4.7-1). Fig. 2.4.7-1 Calcaneal valgus in acquired flat foot

Treatment Fitting the patient with foot orthotics is the foundation of conservative treatment. Orthopedic inserts are custom made based on a foot impression, made from the cast of a patient’s foot. The insert includes a medial wedge and transverse arch support. Another option for an orthotic solution includes footwear modifications and, in severe deformities, fabricating custom made footwear. Rehabilitation is indicated for patients with flat foot. Physical therapy includes sensorimotor exercises, foot sole facilitation, training of foot pressure distribution, the practice of three-point support and “short” foot with the lower extremity in neutral alignment. Treatment also incorporates soft tissue techniques, foot joint mobilization and mobilization and stretching of shortened muscles and muscles with increased tone. Modalities include anti-inflammatory procedures like manual and instrumental lymphatic drainage and hydrotherapy consisting of contrast and stepping baths or a cold whirlpool. Ultrasound, electrotherapy (DD currents, TENS) and combined electrotherapy can be used for muscle relaxation.

Surgical intervention is only indicated for a flat foot that causes severe pain and significantly limits common daily activities. A triple arthrodesis of the subtalar joint is performed in such a case.

HALLUX VALGUS Hallux valgus is an alignment deformity of the forefoot defined by the big toe being positioned in valgus and rotated at the metatarsophalangeal articulation (MTP) with a varus alignment of the first metatarsal and its prominent head. The following contribute to hallux valgus: 1. Congenital predisposing factors (length of the first metatarsal, hypermobility, connective tissue weakness) 2. Direct influences (incorrectly fitting footwear) 3. Indirect influences (flat foot, prolong static loading) In addition to a big toe valgus and rotation deformity and varus of the first metatarsal prominence, the objective findings include the following: Joint capsule and bursa thickening above the medial surface of the metatarsal head Lateral shift of the sesamoid bones, increased loading of the first metatarsal head Lateral subluxation of the proximal phalanges, onset of arthritis at the MTP articulation Downward shift of metatarsals II–IV toward the plantar surface; relative lowering of the longitudinal arch During a functional standing assessment, the big toe is not utilized for support, foot unwinding from the floor is affected and push off from the big toe is lacking during gait. Treatment Conservative treatment includes functional orthotic fitting based on a functional foot assessment.

A rubber corrector between the toes is used and placed between the big toe and the second toe. A night orthosis is applied on the medial side and the big toe is pulled toward it with a strap. Orthopedic insoles with a medial wedge and transverse arch support are used. Rehabilitation The goal of treatment is to improve the first ray axis and include the big toe in support and push-off functions in standing and during ambulation. Sensorimotor exercises (proprioceptive facilitation) are an essential component of therapy. The sole of the foot is facilitated, training of “small” foot and three-point foot support are practiced. Physical therapy includes soft tissue techniques, foot joint mobilization and traction of the big toe at the MTP articulation. Modalities include mainly hydrotherapy – whirlpool, contrast baths and stepping baths. Surgical Intervention Tens of various surgical procedures have been described, but the following four types of surgical interventions have been used mostly: 1. Soft tissue procedures 2. Resection arthroplasties, in which the base of the proximal phalanx is removed and movement at the MTP joint is preserved 3. First ray osteotomy 4. Arthrodesis of the big toe MTP

HALLUX RIGIDUS A rigid big toe is defined as degenerative arthritis of the metatarsophalangeal joint of the big toe without the development of an axial deformity. Clinical presentation includes pain during ambulation. Objective findings include MTP joint deformity given by the formation of osteophytes with most of them on the dorsal aspect of the joint. Movement at the MTP joint is painful and limited into extension. During the functional assessment of standing and gait, the foot is

loaded on its outer edge and foot unwinding through the big toe is lacking. Treatment Surgical intervention is indicated in this condition: 1. Metatarsal head remodeling, osteophyte removal 2. MTP joint arthrodesis 3. Resection arthroplasty of the MTP joint, or removal of the base of the proximal phalanx and the osteophytes of the metatarsal head Following a surgical procedure with preserved movement at the MTP articulation, rehabilitation is indicated with a goal of maintaining the achieved movement in the MTP joint.

METATARSALGIA Metatarsalgia is a pain in the forefoot found distally to the Lisfrank articulation. The most common reason is a transverse widening of the forefoot (“transverse flat foot”). This alignment deformity is defined by the divergence of the metatarsals, big toe valgus and little toe varus with subsequent weakness of the first metatarsal and overloading of metatarsals II–IV. A transverse flat foot develops due to long-term loading in standing, during ambulation and with poorly fitting footwear (in women, shoes with high heels and a narrow tip). Clinical presentation includes pain in the forefoot in standing and during ambulation. Pain is sometimes accompanied by paresthesia of the 2nd and 3rd digits, which is known as Morton’s neuralgia. Objective findings include widening of the front of the foot, metatarsal heads II–IV are more pronounced on the bottom of the foot, they are painful to palpate and the skin on the bottom of the foot demonstrates pressure points in the area of metatarsal heads. The big toe is in abduction, the little toe in adduction and an increased pull of

the toe extensors results in flexion deformities of the toes (hammer toes). Rehabilitation in Transverse Flat Foot Functional orthotic fitting is an essential part of conservative treatment. Individual inserts are fabricated with transverse foot support and footwear can be modified by adhering transverse foot support. Footwear with a low heel is recommended (2–3 cm). Physical therapy includes gentle soft tissue techniques of the bottom of the foot, joint mobilization and stretching and positioning to release muscle contractures. Taping is quick and effective to control pain by wrapping the widened front aspect of the forefoot (Fig. 2.4.7-2). Fig. 2.4.7-2 Taping for transverse flat foot

Surgical Interventions for Transverse Flat Foot Metatarsal osteotomy is performed. Metatarsal head excision is performed in severe deformities. The procedure can be combined with hallux valgus surgery.

TOE DEFORMITIES Hammer Toe (Digitus Hamatus)

Digitus hamatus or hammer toe is a flexion deformity of the proximal interphalangeal joint. At the metatarsophalangeal articulation, the proximal phalanx is in hyperextension and subluxation of the base of the proximal phalanx to the dorsum of the metatarsal head can occur. Club Toe (Digitus Malleus) Digitus malleus or club toe is a flexion deformity in the distal interphalangeal joint. This deformity is caused by excessive pull of the long toe flexor.

OVERUSE SOFT TISSUE INJURIES PERITENDINITIS (TENOSYNOVITIS), ACHILLES TENDON TENDINOSIS Peritendinitis is an inflammatory injury of the bi-layered synovial sheath of the Achilles tendon. Tendinosis is a degenerative injury to the Achilles tendon structures (Fig. 2.4.7-3). This injury is common in athletes and it is often related to loading on a hard surface or with a change in footwear, in which the shoe counter presses into the tendon or at its insertion. Fig. 2.4.7-3 Achilles tendon tendinosis with peritendinitis

The clinical picture includes Achilles tendon pain during and after activity; pain present at movement initiation. Objective findings

include either edema of the entire tendon or the typical spindle-like tendon thickening in its middle third and pain with palpation of the tendon and the structures beneath the tendon. During assessment, gentle crepitus can be palpated; standing on the toes is painful. The triceps surae shows increased tone and the muscle belly shows reflexive changes. Tension in the muscle limits movement into ankle dorsiflexion. With chronic inflammation, the triceps surae atrophies, especially the medial head of the gastrocnemius (Fig. 2.4.7-4). The assessment includes a functional lower extremity assessment in standing (look for calcaneal alignment, weight distribution on the bottom of the foot, toe contact with the floor) and during ambulation (observe foot unwinding from the floor). Fig. 2.4.7-4 Achilles tendon tendinitis with peritendinitis – standing on toes

TENOSYNOVITIS, POSTERIOR TIBIALIS TENDINOSIS Tenosynovitis is an inflammation of the tendon sheath of the posterior tibialis muscle. Tendinosis is a degenerative injury of the posterior tibial tendon. The injury of these structures has a similar clinical presentation to an inflammatory and degenerative injury of the Achilles tendon. Imaging methods (ultrasound or an MRI) are used for differential diagnosis of posterior tibialis tendon versus an Achilles tendon injury.

ENTHESOPATHY OF THE SHORT MUSCLES OF THE SOLE OF THE FOOT, CALCANEAL SPUR (CALCAR CALCANEI) This is insertional pain of the short muscles of the sole of the foot, which develops during overloading of the flexor digitorum brevis, the quadratus plantae and the abductor pollicis longus. Clinical presentation includes heel pain, at first during movement initiation (disappears after a few steps) and then later the pain occurs during or after activity. Objective findings include pain upon palpation and edema and crepitus can be present at the muscles’ origin at the calcaneal tubercle. The short plantar muscles and tibialis posterior show increased tone and are painful when palpated. Foot dynamics are altered. One of the possible causes of this injury includes a varus or valgus alignment of the calcaneus, which is the reason why a functional foot assessment is performed in standing and during ambulation. During this functional assessment, the axis of the calcaneus is observed, as well as, the alignment of the subtalar joint knee, hip and pelvis. Enthesopathy of the tendons of the short foot flexors is more common in a supinated foot. In a chronic state, calcification of the origin of the short plantar muscles occurs and a heel spur develops, which can be observed on an x-ray film in a lateral calcaneal view (Fig. 2.4.7-5). Fig. 2.4.7-5 Heel spur; calcar calcanei

Rehabilitation of Tendon Injuries The treatment is mainly conservative. Medications are indicated and

include: analgesics and local or systemic non-steroidal antiinflammatories. Local application of a corticosteroid injection with an anesthetic is another option. The question regards the application of the corticosteroid to the tissues surrounding the Achilles tendon. Some authors do not recommend this because of a high risk of necrotic formation of the tendon and its subsequent rupture. In rehabilitation, the painful tendon or its insertion is treated with soft tissue techniques and gentle joint mobilization is included. Treatment also includes sensorimotor training. Initially, three-point weight distribution on the sole of the foot is practiced in a neutral alignment of the entire lower extremity in a closed chain and later in an open chain. Unstable surfaces are implemented and training can include the stabilometric platform. The goal of therapy includes coactivation of the lower extremity muscles in correct neutral alignment and with correct alignment and stability of the spine. Another step in therapy includes transitioning this activity to common movements (walking) and, in athletes, to their specific movement activity. Modalities include anti-inflammation, pain-control and muscles relaxation procedures. Orthotic equipment is also necessary to ensure decreased weightbearing of the affected structures. The patient is fitted with special orthopedic insoles and athletic footwear is modified. Other options include unweighting the heel by using a heel lift or by taping the affected segment. Surgery, in which the inflammation and degeneration altered peritendineum is removed is indicated for a chronic Achilles tendon injury that does not respond to conservative treatment.

TIBIALIS ANTERIOR SYNDROME This syndrome involves an ischemia of the muscles on the anterior side of the lower leg between the tibia and the fibula in the anterior fascial compartment. The structures become damaged after being exposed to prolonged activity (long walk, long distance running), in

which edema occurs and is followed by ischemia and necrosis of the muscles and the nerves in the anterior fascial compartment. Clinical presentation demonstrates stiffness, cramping and intense pain on the anterior aspect of the lower leg. Objective findings include edema and pain upon palpation of the anterior aspect of the lower leg, the patient is unable to perform active ankle and toe dorsiflexion and hypesthesia is found on the dorsal aspect of the foot. Rehabilitation for Anterior Tibialis Syndrome An anterior tibialis muscle injury requires surgical intervention in which an anterior fascial compartment decompression is performed. Rehabilitation treatment is part of post-surgical care and the goal of rehabilitation is to restore the function of the nerves and structurally altered muscles on the anterior aspect of the tibia. During physical therapy, soft tissue techniques, mobilization of the scar, fascia and muscles and gentle foot and ankle joint mobilization techniques are implemented. Muscle facilitation, activation and strengthening are also implemented through analytical techniques (exercises based on manual muscle testing) as well as exercises based on a neurophysiological foundation (Vojta therapy, PNF, sensorimotor training), exercises in open and closed kinetic chains and prevention of contractures. Modalities can include neuromuscular electrical stimulation for muscles of muscle Grade 0–1 on the manual muscle testing scale and electrical stimulation (electrogymnastics) for muscles with muscle Grade 2–3. Procedures with anti-inflammatory effects (manual and instrumental lymphatic drainage, ultrasound, hydrotherapy – whirlpool, contrast baths) and procedures with stimulatory effects (phototherapy – biolamp, laser, pulsed magnetic field and distant electrotherapy) are used. The patient is provided with orthotic supplies, such as a figure 8 strap, peroneal strap or peroneal brace.

TRAUMATIC LESIONS

ACHILLES TENDON RUPTURE An Achilles tendon rupture occurs most often in a degeneratively altered tendon, approximately 2–5 cm from its insertion (there is minimal vascular supply to the tendon in this region). An Achilles tendon rupture is most common in middle age men. The rupture occurs during athletic activity involving a sudden acceleration, quick slowing down or sudden change in direction of movement. Typical sports include tennis, squash, soccer, basketball and volleyball. Clinical Presentation A loud pop is heard and sharp pain occurs in the area of the tear. The injured person is able to weight bear on the affected lower extremity and can perform ankle dorsiflexion; however, is unable to stand on their toes. Objective findings include edema, hematoma at the rupture site and a defect in the tendon can be palpated. Thompson’s test is a special test for an Achilles tendon rupture, in which passive pressure on the triceps surae muscle belly does not produce ankle dorsiflexion in a positive test. Treatment The injury is treated surgically by suturing the Achilles tendon. A long cast is applied following the surgery to unweight the surgical site (slight flexion at the knee and ankle plantarflexion) for 3 weeks. After 3 weeks, the cast is exchanged and the ankle is repositioned into neutral position and the cast goes below the knee. The total period of immobilization lasts 6–8 weeks. The patient uses forearm crutches for 3 months to decrease weightbearing on the affected lower extremity.

INJURY TO THE ANKLE LIGAMENTOUS APPARATUS Acute Ankle Instability Acute instability occurs in an ankle sprain. The sprain can involve distension (sprain), partial or full ligamentous tears or a joint capsule tear depending on the magnitude of force. The anterior talofibular

ligament and the anterolateral aspect of the joint capsule are the most frequently affected structures. Clinical Presentation In a sprain or partial rupture of a ligament and joint capsule, the patient can complete the movement activity without limitations. The edema, pain and limited range of motion occur later, after the activity has been completed. In a complete ligamentous tear, immediate pain is felt, massive localized edema and hematoma under the lateral ankle occur and the patient is not able to continue in the physical activity because they are not able to weightbear on the affected extremity. The diagnosis of a complete anterior talofibular ligament tear is established based on radiological film in sustained positions. This examination is performed by a traumatologist who positions the ankle in adduction and inversion during the imaging. If the tibiotalar joint gaps laterally, a comparison image is obtained on the contralateral, uninvolved extremity to rule out a false positive test. Treatment Conservative treatment is indicated in ankle sprains and partial ligamentous tears. A brace or splint is applied for 3–6 weeks after the injury. Functional treatment is another option, in which only a bandage is applied shortly after the injury. Modalities include cryotherapy and galvanic current. Rehabilitation is initiated after the pain and edema subside. Two rehabilitation approaches can be used in a complete tear. The first is radical and involves surgery, in which the torn capsule and ligament are sutured. The second involves functional treatment, in which the extremity is immobilized for 3–4 weeks by a splint or brace, which allows lower extremity weightbearing. Rehabilitation is initiated when the immobilization period is completed. Currently, conservative functional treatment is preferred for acute instability injures. Chronic Lateral Ankle Instability This condition usually occurs as a result of an acute injury of the

ligaments on the lateral aspect of the joint. Clinical presentation includes the perception of insecurity and instability when walking on uneven surfaces and recurrent sprains. Objective findings include edema, pain with palpation of the lateral ankle structures, instability and increased ankle range of motion into adduction and inversion. The diagnosis is confirmed by sustained radiologic images. Treatment Surgical intervention is indicated in young and physically active patients. A reconstructive procedure is performed by increasing the tone in the soft tissues surrounding the scars. Also, an anterior talofibular ligament plasty can be performed using a peroneus brevis tendon transfer. Rehabilitation Treatment Following Injuries and Surgeries of the Ligamentous Apparatus of the Ankle and Foot A ligamentous (generally soft tissue) injury is the most common injury in the ankle region. In conservative or surgical treatment, physical therapy care is irreplaceable. Also, certain modalities need to be used immediately after the injury. The overall process is divided into three phases: Phase I – Early Post-Injury Phase Decreasing edema, prevention of other soft tissue damage and initiation of the healing process are goals of this phase. The entire rehabilitation process is known as PRICE, which is a term comprised of the beginning letters of each approach. P

Protection

R

Rest

I

Ice

C

Compression

E

Elevation

Protection – decreased weightbearing is ensured (or a complete elimination) for 3–6 weeks. Rest –movement activities are eliminated for the prevention of further mechanical damage to the soft tissues based on the degree of involvement. Grade I = 24 hours, grade II = 3–5 days, grade III 3–7 days. Ice – cryotherapy to prevent bleeding into the tissues and decrease pain, especially in the acute phase. Compression – compression of the affected region by an elastic wrap. Elevation – elevation of the involved extremity above the heart to minimize edema in the affected region (to approximately 70 hours after the injury). All these actions are suitably complemented by a massage of the segment above the injured area (calf and the thigh) in an appropriate position or by lymphatic drainage. The intensity of the actions during the acute phase is directly proportional to the severity of the injury and it is directed by the physician. Phase II – Late Post-Injury Assistance in soft tissue healing, gradual restoration of muscle activity and proprioceptive function are the goals of this stage. In addition to modalities (ultrasound, IF current, TENS), soft tissue techniques and joint mobilizations are used and, based on our assessment, active exercises are initiated including: Isotonic exercises Proprioceptive exercises Closed-kinetic chain exercises Criteria to progress to the next stage include the following: Stability on the affected lower extremity (including unstable surfaces)

Normal gait pattern Absence of edema and pain during and after activity Phase III – Preparation for Sport Specific Activity A functional return to the previous level of activity is the goal of this phase. Only in this phase, do we recommend to include strengthening exercises with external loading (strengthening equipment), especially in closed-kinetic chain and speed-coordination exercises (training) including acceleration and changes in movement directions. In the English literature, this training is abbreviated as SAQ (Speed, Agility, Quickness). This entire phase is not part of treatment care, but rather part of sports training. Generally, these are situations that prepare the athletes for their return to their specific athletic activity and are, therefore, within the competency of the coaches or sports physical therapists. The physical therapy treatment approach is identical for patients after surgeries for ligamentous injuries or following ankle and foot fractures. Of course, the severity of the surgical procedure needs to be respected, as well as, its extent and biological timelines for healing of all affected structures. The timing of transitions between individual phases and the appropriate activity is determined by a specialized physician. As soon as possible after the surgical procedure, antiinflammatory measures, including soft tissue techniques, are implemented. A complete course of physical therapy should be implemented in the following time sequence: soft tissue and joint treatment → mobility → proprioception → stabilization exercises → strength.

2.5 ORTHOTICS Petr Krawczyk Orthotics is a part of orthopedic prosthetics and it is concerned with indication, fabrication and application of orthoses. An orthosis is an externally applied device used for the modification of structural or functional characteristics of the nervous or musculoskeletal systems. Orthotics overlap into several clinical fields. For orthotic care to be successful, the functional goal of the device within its overall treatment context needs to be accurately defined, including the timing of application, purpose, administration, and the underlying mechanism of the effect and the function of the orthosis itself. To fulfill this requirement, the communication among the individual members of the rehabilitation team is crucial. The rehabilitation team should always include an orthotist and/or prosthetist who is fully familiar with the most current technical options of orthopedic prosthetics and orthotics. Also, cooperation of an educated patient and a follow up regarding the functionality of the prescribed device by the physician and the treating physical or occupational therapist should certainly be incorporated.

2.5.1 Classification and Technical Overview of Orthoses In the literature, orthoses are described based on various criteria: Type of fabrication – over the counter or custom-made orthoses Type of material – textiles, leather, metal, low temperature and high temperature plastics, or composite materials Purpose – treatment orthoses, temporarily used orthoses or compensatory orthoses, which are usually applied permanently Function – immobilization, support, balance, corrective, stabilization and unweighting Construction of the device and its influence on individual segments – static or dynamic orthoses Patient’s body location – trunk or extremity orthoses

This classification is specified by an international classification of orthoses that strictly determines which segment of the extremity or trunk should be affected by a given orthoses (Fig. 2.5.1-1). The desired functional effect should always accompany every specified device.

Fig. 2.5.1-1 International classification of orthoses

OVER-THE-COUNTER ORTHOSES These are usually designed for immediate use for post-injury or postoperative conditions, in rheumatic and degenerative diseases and certain congenital defects (i.e., hip joints in children). They are made in standard sizes in many constructional designs. The therapeutic effects of such orthoses include ensuring rigid or elastic stabilization, correct alignment and also a temperature insulation effect. The lighter types of orthoses are made as simple wraps from elastic textile materials. More complex types of orthoses also include reinforcements and elastic straps (reinforcing orthoses). Orthoses designed for joint stabilization are equipped with plastic or metal rods that can be either rigid or have joints that allow free or specifically limited movement. More complex orthoses designed for athletic activity are made from modern composite materials. For a better overview, the over-the-counter orthoses are classified into the so called categorization groups based on their indication, patient’s body location and functional comparison. The immediate use of these orthoses is a great advantage. The low potential for modification for patients with more severe injury is their greatest disadvantage.

CUSTOM-MADE ORTHOTICS These individually made orthoses are fabricated based on each patient’s specific measurements. Based on the device, “twodimensional” outlines are formed, such as drawings, outlines of body parts, cutouts, templates, or plantograms (foot impressions). Individual orthoses can be built based on the measurements from a mold and from the building pieces of the orthoses, whose parts are shaped when applied to the patient’s body. In more complex devices, “three-dimensional” outlines are made including cast fabrications, imprints or digital computer aided design

(CAD) models. For rigid orthoses, the cast is fabricated based on these measurements and it is further modified. This modified cast model forms the basis for orthotic fabrication. The construction of the device, the material selection and the constructive design itself are based on the functional requirements of the orthotic and must be specified by a physician prior to obtaining the individual measurements. The patient’s overall health also needs to be taken into consideration. The advantages of custom-made orthoses include the ability to take into consideration the patient’s presentation, their condition and the ability to modify the device when their medical condition changes. The time and financial demands on fabricating these types of orthoses are among their disadvantages.

2.5.2 Functional Indications for Orthoses The indication for orthoses is based on the assessment of the patient’s functional deficits, muscle testing, gait pattern, grasp and assessment of their independence. At the same time, additional diseases (cardiorespiratory function, neurovascular state, skin condition and cognitive functions) and the patient’s cooperation in using the device need to be taken into consideration. To eliminate problems during orthotic wear, the patient needs to be motivated and also capable to use the device with respect to any required assistance when donning/doffing the device and its maintenance, as well as, the availability of continued care (possible device modifications with weight changes and changes in health status). Orthotic application usually fails due to inadequately defined limitations, unclear functional goals and last, but not least, due to unrealistic expectations of the final result given the device’s technical potential or its appropriateness for the patient. A correctly selected device should fulfill functional demands, ensure the patient’s comfort during application and should not cause

secondary problems, such as skin irritation, overloading the neighboring joints, increasing energy demands during gait or pain. In patients who use long-term orthoses, the cosmetic presentation and minimal alteration to the patient’s attire should be taken into consideration. The considerations for indication must contain specific functional demands that the application of the orthosis should achieve and establish the required constructive option. In the final decision, it should be considered whether the required construction design can be met by an over-the-counter or a custommade orthosis and whether it is even within the technical and material capabilities of the orthopedic orthotist to fabricate the desired orthosis. When considering the financial aspect of orthotic treatment, the overall contribution of the orthotic application needs to be considered and can include a shorter hospital stay, facilitation of rehabilitation care, a significant decrease in the patient’s need for additional assistance from another person or social services.

FUNCTIONAL DEMANDS OF ORTHOSES Immobilization – extremity fixation following trauma or inflammation Mobilization – increasing range of motion (i.e., in contractures) Stabilization – stabilization of extremity joints during acute or chronic instability Movement restriction – restriction of individual segments (i.e., tendon injuries) Corrective function – casting into specific morphological or functional alignment Retention function – maintenance of achieved functional alignment Support function – support of muscle function, segment derotation, etc. Balance function – for correction of shortening Unweighting function – compensation or support of extremity

weightbearing function

ACTION PRINCIPLES OF ORTHOSES Contact surface – immobilization of a joint, outside of a joint or of the entire extremity or trunk Three-point principle – in corrective extremity and trunk orthoses Derotation – in orthopedic inserts, in extremity and trunk orthoses Distraction – distraction action in a given body segment Reclination – straightening, extension action on the spinal column Ball principle – compression of the abdominal cavity against the lumbar lordosis in trunk orthoses Analgesic brace – elastic immobilization, thermal brace

2.5.3 Contraindications Contraindications for the use of orthoses are based on careful clinical assessment, patient history and assessment of therapeutic and technical options during orthosis application and include the following: Inadequate muscle strength for application of extremity orthoses (high energy demand) Cardiopulmonary weakness Venous system insufficiency, thrombophlebitis (for application of lower extremity orthoses) Unstable extremity circumference (fluctuating edema in the lower extremities) Skin condition Decreased tolerance to longer lasting and constant pressure on the skin Patient’s non-compliance and inability to ensure follow up care and regular check-ups

2.5.4 Upper Extremity Orthoses Orthosis specification is important for a good treatment effect with its

application. When obtaining a prescription, the extent and the segment requiring the orthosis should be described using international classification (see Fig. 2.5.1-1), as well as, the functional demands on the orthosis (in case the orthosis is used to restrict movement, it needs to include the segment and the degree of movement restriction within the segment). Material specification, from which the orthosis is to be fabricated, is important (textiles, leather, plastics, low temperature aquaplast formed directly to the patient’s body, etc.). In some cases, the physician should also specify the constructional organization pertaining to the location of the orthosis’ firm parts (location of bars and enforcements on the volar, dorsal, ulnar or radial surface of the forearm), for example, in distal extremity spasticity or when there is risk of soft tissue compression by an osteosynthetic material. The terminology and nomenclature of orthoses undergo constant changes. The individual terms for orthoses in the literature are sometimes non-uniform, leading and often based on brand names (splint, brace, orthosis, strap). In 1989, the Splint Classification System (SCS) was developed by the American Association of Hand Therapists to facilitate inter-disciplinary communication and minimize misunderstandings when prescribing upper extremity orthoses. SCS classification describes upper extremity orthoses and splints based on fabrication, location, direction of action and the functional effect of the orthosis itself (Fig. 2.5.4-1).

Fig. 2.5.4-1 SCS classification of the upper extremity orthoses

SCS CLASSIFICATION Based on construction, orthoses can be classified as articulating (with joints) or non-articulating (without joints) utilizing arm straps. The location of the orthosis is based on an internationally used classification of upper extremity orthoses (see Fig. 2.5.1-1). The priority of joint influence needs to be established. The primary joint is the one being functionally affected by the orthosis. The secondary joint is integrated into the orthosis for stabilization and comfort. This descriptive classification is important, for example, for correct fabrication of dynamic finger splints. The orthosis description has to include the direction of force (pulling, pressure) in regards to the desired joint position and in regards to the effect of movement in all planes. It should include the requirements for flexion, extension, radial and ulnar deviation, supination, pronation, adduction and abduction of individual segments.

DESCRITPION OF ORTHOSIS FUNCTION ACCORDING

TO SCS CLASSIFICATION Immobilization – maintain the extremity or its segment in an anatomical or otherwise resting position. It can include articular or non-articular orthoses. Usually, these include simple types of orthoses. Mobilization – ensure movement in a joint or stretching of soft tissue structures in contractions. Healing processes are facilitated by mechanical effort. Restriction – ensures limitation or restriction of movement in upper extremity joints. Restriction orthoses can be static or dynamic.

BASIC OVERVIEW OF UPPER EXTREMITY ORTHOSES Hand Orthosis – HO Hand and finger orthoses (HO) include rigid (Fig. 2.5.4-2), static or dynamic finger extension or flexion orthoses (Fig. 2.5.4-3; Fig. 2.5.44A,B). In addition, this group includes stabilization or reinforcing thumb orthoses (Fig. 2.5.4-5) and orthoses for correction of finger ulnar deviation in rheumatic arthritis (Fig. 2.5.4-6). Fig. 2.5.4-2 HO – rigid finger orthosis

Fig. 2.5.4-3 HO – dynamic finger flexion orthosis

Fig. 2.5.4-4A,B HO – dynamic finger extension orthosis Fig. 2.5.4-5 HO – stabilization thumb orthosis from thermoplast

Fig. 2.5.4-6 HO – correc​tive orthosis in finger ulnar deviation

Wrist Orthosis, Wrist Hand Orthosis – WO, WHO Based on the functional requirements, wrist and hand orthoses are classified as elastic braces stabilizing the wrist and rigid immobilizers (Fig. 2.5.4-7). Based on construction design, the orthoses are classified as static or dynamic (Fig. 2.5.4-8). Fig. 2.5.4-7 WHO – wrist and hand positioning orthosis

Fig. 2.5.4-8 WHO – dynamic flexion/extension orthosis for combined injury of the tendon apparatus of the hand

Elbow Orthosis, Elbow Wrist Hand Orthosis – EO, EWHO This group of elbow, wrist and hand orthoses includes more complex static or dynamic rigid orthoses with free or restricted range of motion at the elbow and wrist (Fig. 2.5.4-9A,B; Fig. 2.5.4-10) or orthoses with joint bars (Fig. 2.5.4-11), simple reinforcing elastic braces (Fig. 2.5.412) or epicondylar straps (Fig. 2.5.4-13).

Fig. 2.5.4-9A,B EWHO – dynamic forearm derotation orthosis Fig. 2.5.4-10 EO – dynamic elbow mobilization orthosis

Fig. 2.5.4-11 EWHO – dynamic orthosis with restricted range of motion at the elbow

Fig. 2.5.4-12 EO – elastic elbow brace

Fig. 2.5.4-13 EO – epicondylar brace

Shoulder Orthosis, Shoulder Elbow Orthosis, Shoulder Elbow Wrist Hand Orthosis – SO, SEO, SEWHO Shoulder orthoses include abduction braces ensuring the required

position for healing of skeletal or neuromuscular injuries and elastic reinforced immobilization tools supporting the shoulder joint during instability (Fig. 2.5.4-14, Fig. 2.5.4-15A,B). This group also includes simple arm slings (Fig. 2.5.4-16 A,B,C). Fig. 2.5.4-14 SO – elastic shoulder brace

Fig. 2.5.4-15A,B SO – shoulder stabilization orthosis made form thermoplast

Fig. 2.5.4-16 A,B,C A – SEWHO – upper extremity arm sling; B – upper extremity sling in brachial plexus paresis; C – arm sling assisting in shoulder elevation

2.5.5 Lower Extremity Orthoses Considering the weightbearing function of the lower extremity, which fulfills static and dynamic functions, the selection of an appropriate functional orthosis is extremely important for the patient. The following criteria are taken into consideration when selecting an appropriate orthosis: Assessment of the extremity’s functional state

Assessment of the extremity’s weightbearing status Range of motion and stability in individual segments Muscle strength Possible extremity shortening

BASIC CLASSIFICATION OF LOWER EXTREMITY ORTHOSES Foot Orthosis – FO Foot orthoses are applied either when correcting incorrect foot and toe alignment or to decrease the demands of weight bearing (orthopedic insert) (Fig. 2.5.5-1A,B), which can decrease the defect on the plantar surface. In severe deformities, toe correctors are applied (Fig. 2.5.5-2A,B).

Fig. 2.5.5-1A,B FO. A – foot orthosis influencing forefoot adduction; B – stabilization of a fracture at the base of the fifth metatarsal

Fig. 2.5.5-2A,B FO. A – night splint to correct hallux valgus; B – Hallux valgus strap

Ankle-Foot Orthosis – AFO Ankle orthoses are applied to correct foot and ankle deformities, to stabilize talocrural articulation and to ensure decreased lower extremity weight bearing. The overview of orthoses includes rigid ankle orthoses, those with options to preset range of motion at the TC joint (Fig. 2.5.5-3), ankle elastic reinforcing braces (Fig. 2.5.5-4) and a dorsiflexion-assist orthosis (Fig. 2.5.5-5). Fig. 2.5.5-3 AFO – an orthosis with an option to set range of motion at the talocrural joint

Fig. 2.5.5-4 AFO – leather orthosis

Fig. 2.5.5-5 AFO – dorsiflexion assist orthosis

An orthosis with a firm ankle provides maximum immobilization of the ankle and foot complex in all planes. The anterior floor reaction AFO is another type of AFO. The principle of this orthosis lies in the

slight ankle plantarflexion, which causes an extension force moment at the knee and increases its stability in the sagittal plane. An unweighting type AFO known as a patellar tendon bearing AFO (utilizing Sarmiento principles) is another modification to an AFO. Its main goal is to decrease the axial loading of the distal segment of the lower extremity during gait. It is used, for example, during functional treatment of fractures or to allow for complete healing of defects on the plantar aspect of the feet. This device, however, can only be used if the skin is intact in the areas the orthosis applies support and if the quadriceps femoris demonstrates sufficient strength to maintain knee stability. Dynamic AFOs include plastic, metal and also composite fabrication materials. In contrast to static AFOs, they allow ankle movement in the sagittal plane. The posterior leaf spring (PLS) AFO is a thermoplastic orthosis whose medial and lateral edges are positioned behind the connection of both malleoli (Fig. 2.5.5-6). This design allows for movement in the actual ankle joint and its range is given by the thickness of the material used for the orthosis fabrication. Dorsiflexion assist AFO, in contrast to the PLS, uses a mechanical ankle joint with a built-in spring mechanism (Fig. 2.5.5-7). This orthosis assists with foot dorsiflexion during the swing phase and ensures smooth transition between the initial heel strike and midstance. The plastic AFO with a joint consists of a plastic ankle joint built-in between the foot and the shin portion the orthosis made from thermoplast. For the orthosis to function effectively, the ankle needs to have at least 5º of dorsiflexion. The degree of plantarflexion can be limited by a stop. Fig. 2.5.5-6 AFO – posterior leaf spring

Fig. 2.5.5-7 AFO – with a mechanical ankle joint

An AFO made from a composite material uses the accumulated

energy in an elastic skeleton of the plantar segment of the orthosis during heel strike. These orthoses are designed for active patients (Fig. 2.5.5-8 A,B). Fig. 2.5.5-8A AFO from composite materials

Fig. 2.5.5-8B AFO – aluminum orthosis as partof footwear

The full effect of AFO wear also depends on the type and condition of the patient’s footwear. Different heel heights of footwear significantly alter the orthosis’ biomechanical function.

Knee Orthosis – KO The most simple knee orthoses include infrapatellar straps, knee elastic reinforcing braces and knee orthoses with joint bars. If more rigorous stabilization is needed, orthoses with constant rigid flexion or

orthoses with restricted movement are selected. In severe combined instabilities and knee joint deformities, orthoses with firm construction are indicated and the TC joint is used as a secondary joint to stabilize the device. Corrective KO influences the knee alignment based on a three-point principle. Most often they are equipped, similarly to other KOs, by lateral or medial bars with a joint and adjustable straps. These KOs can correct knee varus or valgus, or even a genu recurvatum deformity (Fig. 2.5.5-9 A,B).

Fig. 2.5.5-9A Schema of correction of knee valgus and varus. M = medially, L = laterally

Fig. 2.5.5-9B Schema of correction of knee flexion and extension

Knee-Ankle-Foot Orthosis – KAFO A knee, ankle, and foot orthosis is selected mainly in patients who require stabilization and movement control in the knee and ankle joints. A KAFO is an orthosis spanning from the patient’s thigh to the foot. This extent allows for function of the actual AFO and, at the same time, allows for control of the knee joint in the sagittal and frontal planes. A classic AFO is made from metal bars that connect the knee and ankle joints of the orthosis with leather or Velcro straps for attachment to the extremity. Firmness and durability are their advantage. The

durability, however, is achieved in exchange for heavier weight. Another disadvantage of this type of KAFO includes a smaller range of contact surfaces, increased demand on the insole of the footwear and a less appealing cosmetic look. A plastic KAFO is constructed from a cast of a patient’s extremity. This ensures tighter contact with the larger surface area of the extremity thereby decreasing pressure points and increasing movement control of the entire extremity. The individual components of this orthosis are connected by joints. The advantages of this orthosis include low weight and better cosmetic appeal. However, a plastic KAFO is limited by skin condition and extremity size/volume (Fig. 2.5.5-10). Fig. 2.5.5-10 KAFO – plaster-made orthosis

A special KAFO is fabricated from light construction materials (carbon, titanium) based on the patient’s individual measurements. Their light weight is the main advantage. The disadvantages include relatively lower contact area in the area of the orthosis arches, which due to possible intolerable pressure points does not allow for correction and stabilization of significant knee joint deformities. Given its light weight, it is used in patients with lower extremity paresis (Fig. 2.5.5-11 A,B).

Fig. 2.5.5-11A,B KAFO – special carbon orthosis

The function of a KAFO depends on the type of joints that are used in its construction. A singe axis knee joint allows for unlimited flexion and extension in the sagittal plane. This type of joint is suitable for patients who demonstrate sufficient muscle strength to maintain stability in the stance phase, but, at the same time, demonstrate initial deformity of the knee joint: recurvatum, valgum or varum. Single axis knee joint with a lock will lock the joint in extension and thus, provides the knee with rigid stability in all planes. This type of joint is suitable for patients with a decreased ability to control the knee joint throughout the stance phase, leading especially to sudden knee flexion with gradual loading at the beginning and during the stance phase. The orthosis’ knee joint can be utilized and locked at various degrees of knee flexion. This is utilized in patients who are unable to fully extend the knee, for example, in knee flexor contractures. Mechanical or microprocessor controlled knee joints in orthoses that affect the stance and swing phases of gait are among the more

complex mechanisms used with a KAFO knee joint. This type of joint automatically locks when loaded during the initial contact of the heel with the floor and remains locked during the entire stance phase until it is unlocked at the moment when the heel comes off the floor at the end of stance phase. The patient’s cognitive functions need to be considered when selecting this type of knee joint as the patient needs to understand this mechanism to utilize it.

Hip-Knee-Ankle-Foot Orthosis – HKAFO The indication for a HKAFO should always be preceded by careful consideration and consultation with the interdisciplinary team. This type of orthosis is a typical example of an uncomfortable device and donning and doffing can be very complicated for the patient and the treating assistant (Fig. 2.5.5-12A,B).

Fig. 2.5.5-12A,B HKAFO – an orthosis stabilizing the hip, knee and ankle joints

In contrast to the previous orthoses, these orthoses also consist of an elastic or rigid lumbar socket and hip bars with limited range of motion, which ensure stabilization of the hip joints. Some types of Reciprocal Gait Orthoses (RGO) (Fig. 2.5.5-13) are equipped with Bowden cables interconnecting the hip joints of the orthosis. When the center of mass shifts and one hip joint is in a swing phase, extension is elicited in the other hip joint, which is in stance phase. This leads to the elimination of simultaneous flexion in both hip joints and the decreased risk of the “clasp knife” phenomenon during gait.

This orthosis is indicated in children with myelomeningocele, in patients with traumatic paraplegia and in patients with muscular dystrophy. Fig. 2.5.5-13 HKAFO – reciprocal gait orthosis

The indication for this orthosis must be preceded by careful examination and assessment of all aspects important for application of this device. Simple hip orthoses are used as stabilizing orthoses in cases of instability following total hip endoprosthesis or to ensure hip abduction positioning in children. They serve as an important device in the verticalization of patients following proximal femoral traumas (Fig. 2.5.5-14) or in patients with neuromuscular involvement following trauma or in cerebral palsy. Fig. 2.5.5-14 HO – orthosis for stabilization of the proximal femur

and the hip joint

2.5.6 Trunk Orthoses Application of trunk orthoses is an integral part of treatment of many problems linked to spinal instability following traumas or for the treatment of spinal deformities. The recommendation for a trunk orthosis in patients with spinal conditions is based on an accurate assessment of spinal instability and the state of the myofascial system. Trunk orthoses are in such cases indicated to stabilize vertebral fractures or as a supplemental device after surgical stabilization. In patients with spinal pain, soft lumbar belts are often routinely issued, which enhances the patient’s passivity as they use it as a “crutch”. The treatment of spinal deformities in pediatrics is primarily with custom trunk orthoses. These devices should be indicated only by an experienced physician in clinical centers specializing in the treatment of scoliosis. Equally, the corset fabrication for scoliosis should be performed at a well-established orthotic and prosthetic center with sufficient experience, technical proficiency and trained personnel. When applying trunk orthoses, a patient’s comorbidity, which can lead to worsening of the patient’s condition, needs to be taken into consideration if simultaneous cardiopulmonary involvement is present.

During orthosis selection, the functional demands need to be considered. It needs to be defined whether the orthosis should provide firm trunk stabilization following traumas, inflammatory spinal conditions, vertebral damage or if it is supposed to serve as a supportive device in painful spinal conditions caused by muscle weakness. The patient needs to be thoroughly educated in the use of a trunk orthosis.

BASIC CLASSIFICATION OF TRUNK ORTHOSES The terminology involving trunk orthoses is not united. The terms orthosis, corset, lumbar and abdominal belts are used. When selecting a trunk orthosis, it is recommended to use the international classification of trunk orthoses that includes the location on the trunk and simultaneously describes the construction design (fixation, reclination, flexion, extension, distraction, derotation) and the material from which the orthoses should be made to meet its functional demands. Individual trunk orthoses for the treatment of spinal traumas and scoliosis require the careful collection of measurements and a cast fabrication, from which the model is further modified. The fabrication requires close cooperation between the physician and the orthotic-prosthetic technician.

Cervicothoracic Orthoses – CTO Cervicothoracic orthoses include soft or hard collars (Fig. 2.5.6-1) used for muscular and degenerative cervical spine injuries. In more severe cervical and upper thoracic instabilities, the hard or adjustable cervical orthosis with shaped support for the lower jaw and the base of the occiput are indicated (Fig. 2.5.6-2). Fig. 2.5.6-1 CO – cervical plastic collar

Fig. 2.5.6-2A CTO – Philadelphia collar

Obr. 2.5.6-2B CTO – individual bivalve orthosis (Minerva)

Thoracic Orthoses – TO Thoracic orthoses are designed as either simple elastic belts and braces for stabilization of the thoracic area or as devices for rigid stabilization of the clavicle.

Thoracolumbar Orthoses – TLO Thoracolumbar orthoses include lumbar orthoses made from flexible elastic materials, which can be supplemented with reinforcing components and other supportive elements (whole surface shells, retraction shoulder straps, etc.). A plastic trunk orthosis is fabricated if rigid stabilization is needed.

Thoracolumbosacral Orthosis – TLSO

Thoracolumbosacral orthoses are high corrective derotation trunk orthoses used to treat scoliosis or trunk orthoses that are used for extensive trunk stabilization in multilevel metastatic spinal involvement or following traumas (Fig. 2.5.6-3). Fig. 2.5.6-3 TLSO – bivalve (two-part) orthosis

Cervicothoracolumbosacral Orthoses – CTLSO Cervicothoracolumbosacral orthoses are indicated for conditions, in which high derotation trunk orthoses need to be applied for the treatment of scoliosis (Milwaukee orthosis) or for stabilization following traumas and spinal surgeries (Fig. 2.5.6-4). Fig. 2.5.6-4 CTLSO – bivalved orthosis

2.5.7 Most Commonly Applied Orthoses in Pediatric Orthopedics Congenital Pes Equinovarus (Club Foot) Orthotic treatment is indicated in conservative or post-operative treatment following serial casting upon recommendation by an orthopedist. In conservative treatment, KAFO orthoses are applied. To correct the deformity, simultaneous correction of subtalar derotation, equinus alignment and calcaneal varus need to be ensured (Fig. 2.5.7-1). During the post-surgical period, a short AFO orthosis has been shown beneficial. Positioning orthoses for sleeping during the day or night should be applied for at least three years following surgery. Anti-varum footwear needs to be worn for ambulation, which continues to be difficult. The application of anti-varum posting with corrective pressure in the area of the medial surface of the first MTP and calcaneocuboid joint has been beneficial (see Fig. 2.5.5-1).

Fig. 2.5.7-1 KAFO – positioning orthosis to complete treatment of club foot

Metatarsus Adductus As part of conservative treatment, a corrective AFO is usually indicated following a 6-week long serial casting above the knee (Fig 2.5.7-2). Fig 2.5.7-2 AFO – corrective orthosis for completion of metatarsus adductus treatment

Pes Calcaneovalgus A foot that is positioned in full dorsiflexion is placed into orthograde position through the use of an orthosis. The application of an orthosis is only indicated in rigid contractures, in which the foot alignment cannot be corrected even after intensive exercises. Foot Deformities in Arthrogryposis The treatment goals include contracture management, improving foot shape and ensuring a plantigrade foot contact. In orthotic-prosthetic care, the application of positional corrective orthoses affecting the vertical alignment of the extremities at various stages has been utilized. Flat Foot Orthotic devices are indicated in third degree pes planovalgus. For indication, the physiological changes in a growing individual need to be taken into consideration because physiological genu valgum at three years of age significantly increases calcaneal valgus and a 15º axis is considered normal at this age. A functional insert must correct foot alignment and prevent its repeated shifting into valgus alignment. This is achieved by a thermoplast heel cup or a lateral stop in the heel area. Forefoot abduction can be influenced by the supination action of an orthopedic insert. The effectiveness of an orthopedic insert in severe flat feet should always be checked by a physician so that the foot orthosis can be further modified. The rigid orthopedic insert needs to be worn in appropriate, quality and spacious footwear. The effect of the orthosis decreases if this condition is not met. Orthopedic inserts need to be regularly changed as the foot grows. The total length of application is around 2 years. The opinions on effectiveness of flat foot treatment by orthopedic inserts vary. Osgood-Schlatter Disease (Patellar Ligament Tendinopathy) Infrapatellar braces and straps are used to decrease the strain on the patellar tendon insertion. Patellar Dislocation

Orthoses and special braces are applied in recurrent patellar subluxations and dislocations or following post-surgical reconstructive procedures. Genu Varum, Genu Valgum, Genu Recurvatum The consideration of orthotic treatment for these conditions is based on the etiology of these conditions. We should never focus only on isolated orthotic solutions for knee joint pathology. Foot stabilization and vertical positioning of the heel during gait need to be ensured. Rigid plantarflexion alignment of the foot needs to be ruled out when genu recurvatum is present. Orthosis application without simultaneous calcaneal assessment by an orthotist (or pedorthist) would be a large error in this case. The three-point pressure principle is utilized for orthotic correction of genu varum or genu valgum (see picture 2.5.5-9), prestretch (Fig. 2.5.7-3). In such cases, the lower extremity orthoses are applied positionally and used at night. Walking orthoses are applied only in deformities that progress during standing and ambulation. Fig. 2.5.7-3 KO – knee orthosis with prestretch

Congenital Developmental Hip Dysplasia A number of devices were gradually developed for the treatment of congenital developmental hip dysplasia, which ensured hip joint abduction and reposition. The Czech orthotic school registered lots of success in this field. A Pavlik harness is the most frequently used

device worldwide for the treatment of developmental hip dysplasia. A Pavlik harness uses the principle of “functional treatment by restricting movement” through a correct set up of the harness. The harness is used for the treatment of hip subluxation in the absence of an abduction contracture. Frejka’s pillow splint is another well-known and still used device. The application of these devices and their set up require regular check-ups that should be performed by an experienced orthopedist. For the treatment to be successful, the parents need to be carefully educated and compliant with treatment. Legg-Calve-Perthes Disease The opinions in treatment of Legg-Calve-Perthes disease by orthotic devices vary. The variety in opinions is mirrored by the diversity of its clinical presentation and the disease course itself. Each treatment approach can have its proponents and critics. The physician’s experience and the treatment utilized in a given treatment facility always matter. The assurance of “containment” treatment through hip joint abduction serves as the basic principle for orthosis application. The Atlanta brace (Fig. 2.5.7-4) and Tachdjian brace (Fig. 2.5.7-5) are the most commonly applied devices. Fig. 2.5.7-4 HO – Atlanta brace

Fig. 2.5.7-5 HKAFO – Tachdjian brace

Limb Reduction Defects

Specialized types of individual orthoses (orthoprostheses) are applied in congenital defects of the extremities, which substitute or support the limited function of the extremity and, at the same time, address its cosmetic appearance. The morphological and functional states of the weight bearing bones and the joints need to be assessed when selecting an orthosis. The functional demands of the device require experience and good knowledge of morphological changes in congenital developmental defects. The widely accepted Swanson classification better serves orientation of a wide spectrum of extremity involvement, which classifies developmental defects based on anatomical location and type. Orthoprostheses address limb shortening, joint instabilities and cosmetic involvement (Fig. 2.5.7-6). Fig. 2.5.7-6 Orthoprosthesis in reduction defect of the lower extremity

Scoliosis Successful treatment of scoliosis is based on early detection of the

deformity. Treatment with a corset is designed to affect Cobb angles between 20–40º. The goal of corset treatment is permanent curvature correction or prevention of deformity progression. The considerations for indication are described in tables assessing the scoliosis score, which is based on the degree of the curvature, its progression and bone maturity (see Tab. 2.5.7-1 Scoliosis Score and 2.5.7-2 Orthosis indication based on a score).

Tab. 2.5.7-1 Scoliosis Score

Tab. 2.5.7-2 Orthotic indication based on score

The corset’s biomechanical action is based on the principle of a neutral pelvic alignment, which elicits active spinal extension and curvature derotation. Throughout the history of treatment for scoliosis, many corsets were developed. Corset type is selected based on the location of the apex of the curvature. The most often applied corsets include the Cheneau, Lyon (Fig. 2.5.7-7A,B) and Cheneau-Boston-Weisbaden corsets (CBW). Recently, other types of corsets have been beneficial in the treatment of scoliosis, which use the principle of hypercorrection and are used only at night (Charleston bending brace, CAEN’s corset).

Other types of corsets include dynamic trunk orthoses that allow the patient more significant movement while the curvature is being corrected by the corset (3D corset, DKTO type Cerny).

Fig. 2.5.7-7A,B TLSO. A – Cheneau corset; B – Stagnara (Lyon) corset

The corset is applied 23 hours per day along with the nightly hypercorrective orthoses. The time of wear can be shortened if the orthosis shows good results during adolescent years. However, the loss of curvature correction needs to be prevented. The opinions on treatment of scoliosis by corset application vary. Some authors recommend shortening the time of bracing in adolescents to 16 hours per day. Others recommend to merely monitor the scoliotic curvature and perform surgery for cases that progress beyond 40º. Given the statistics indicating no worsening of scoliotic curvature in 60% of patients treated with corset wear, corset treatment continues to be the method of choice. Patient and parent education are essential components of the treatment. Prohibiting movement activity while

wearing a corset is not recommended. We recommend all activities that pose no risk to the child or the environment and the child is able to master, including recreational sports.

2.5.8 Most Commonly Applied Orthoses in Orthopedics for Adult Patients ORTHOTIC OPTIONS IN COMPLICATIONS DURING APPLICATION OF TOTAL ENDOPROSTHESIS OF THE KNEE AND HIP JOINTS In dislocations of total hip replacements or in cases of total prosthesis extraction, a stabilization hip orthosis can be applied. A two sleeve KAFO ensuring knee stability during ambulation has been shown to be beneficial in cases of extraction of a total knee replacement. A shorter knee insertional portion of this orthosis is designed for patients with significant pain during transfers in sitting or during bed mobility (Fig. 2.5.8-1). Fig. 2.5.8-1 Combined knee (KO) and KAFO for instability following the extraction of a total knee endoprosthesis

ORTHOSES APPLICATION IN RHEUMATOID ARTHRITIS Night hand splints are applied for progressive ulnar deformities of the fingers (see Fig. 2.5.4-6). Thermoplastic “finger” orthoses are applied to ease grasping. Stabilization and corrective knee orthoses are used for the lower extremities to address genu varum or genu valgum arthroticum. Special orthopedic inserts or individualized posting directly in the shoes are applied to affect foot deformities and to decrease plantar pressure. In severe foot deformities, which prevent wearing regular footwear, custom orthopedic footwear usually needs to be fabricated.

LEG LENGTH DISCREPANCY Various options can be utilized to correct the short extremity. Heel lifts are used to correct 1cm shortening. To correct shortening of up to 5cm, the outersole on the regular shoes can be built up or orthopedic footwear can be made. When the outersole is modified, the metatarsal arch (fornix) needs to be preserved in order to facilitate foot unwinding. With even greater shortening, an extension sandal can be applied through which orthopedic footwear is fabricated. An orthosis that replaces footwear is indicated in limb shortening of 8cm or more. Orthoprostheses (see Fig. 2.5.7-7) are fabricated for patients with congenital developmental defects involving significant limb shortening. These special devices are known as special prostheses. With long term cast or orthosis wear, functional lengthening of an extremity occurs and the contralateral footwear needs to be corrected. Also, unilateral foot stabilization in a plantarflexed position leads to functional lengthening and proper modification requires correction under the heel on the affected side and also modification of the contralateral footwear to achieve horizontal pelvic alignment.

ORTHOTIC CARE FOR THE TREATMENT OF FOOT DEFECTS In the Czech Republic, approximately 5,000 foot amputations are

performed as a result of complications from diabetes. Early detection of increased plantar pressure on the foot and correct unweighting of the areas at risk decrease the onset of foot defects. Self-adhesive and specific devices are used to decrease pressure with superficial ulcerations. In more extensive defects on the front or back part of the foot, special footwear is used to decrease pressure in these areas (Fig. 2.5.8-2A,B). When these devices are used, careful determination needs to be used to assess whether the pressure ulcers are truly outside the areas with increased pressure.

Fig. 2.5.8-2A Post-surgical footwear to decrease pressure on either the forefoot or the hindfoot Fig. 2.5.8-2B AFO – post-surgical orthosis to decrease pressure on the back part of the foot

Older patients with dizziness and balance deficits, however, decline

footwear with decreased pressure on affected areas because of a fear of falling. This often results in decreased healing of the affected areas. In such cases, padding with an opening at the pressure ulcer area or at bony prominences is used. This type of intervention requires using shoes with ample space inside. For this reason, diabetic footwear has become popular. If pressure relieving footwear is not sufficient, removable orthoses with decreased pressure on the front aspect of the foot are used, as well as (Fig. 2.5.8-3), various types of AFOs to decrease heel pressure, Walker or VACOPED boots. A modified Algöver orthosis with a built-in stirrup for the patient’s foot and fully decreased weight bearing of the foot has been beneficial for patients with severe deformity, with a defect in the mid portion of the foot or on the medial aspect of the foot, osteomyelitis or an acute stage Charcot type neuropathy (Fig. 2.5.8-4). For these types of orthoses, the footwear on the contralateral side needs to be modified to achieve horizontal pelvic alignment. Fig. 2.5.8-3 AFO with unloading of the forefoot

Fig. 2.5.8-4 AFO – modified orthosis according to Algöver

Adequate footwear needs to be worn when the healing process has been completed to prevent recurrence of pressure ulcers.

NOTES TO APPLICATION OF TRUNK ORTHOSES IN LOW BACK PAIN Trunk orthoses for low back pain are often overrated and prescribed over the counter as a solution for patients with persistent problems that often have a multifactorial character. A lumbar brace is certainly suitable as supportive bracing that allows patient activity in situations that load the area. Sometimes, only a narrow lumbar brace crossing the ASISs has been found beneficial to assist in abdominal muscle synkinesis. A stabilization trunk orthoses – firm plastic lumbar braces – are indicated in severe instabilities, i.e., spondylolisthesis.

ORTHOTIC DEVICES FOR FOOT DEFORMITIES IN ADULTHOOD

The application of orthoses to correct toe deformities is an issue if the patient does not use, at the same time, suitable footwear that does not deform the foot. Toe or inter-toe correctors do not have any purpose if the foot is crowded in a tightly fitting shoe. Positioning orthoses to correct hallux valgus, usually from over the counter, are applied to prevent progression and relax muscle contractures. It is applied at night for positioning or in the early post-operative stage to maintain appropriate position for soft tissue healing. To correct hammer toes, (Fig. 2.5.8-5) taping or the application of a silicone slip-on or pipe-like toe correctors works well. Fig. 2.5.8-5 Taping for correction of toe deformities

During pedometric assessment on a pedobaroscope, the pathological pressure distribution on the front aspect of the foot or the pathological calcaneal axis can be observed (Fig. 2.5.8-6). The goal of application of corrective toe orthoses (orthopedic inserts) is to spread out the plantar pressure symmetrically and decrease in this way the adverse localized overpressure. Based on an accurate podologic assessment, a significant pain relieving effect can be ensured for metatarsalgia, sesamoiditis and calcaneodynia. Taping has also been beneficial when applied for enthesopathy of the plantar aponeurosis. Fig. 2.5.8-6 Pathological distribution of weight distribution on the plantar surface of the foot

during examination on a pedobaroscope

ORTHOTIC OPTIONS FOR ACUTE AND CHRONIC JOINT INSTABILITIES OF THE LOWER AND UPPER EXTREMITES For ankle joint instabilities, over the counter braces with various degrees of support based on the degree of instability have proven beneficial. Taping provides good results in milder joint injuries and in ligamentous sprains. The selection and the effect of knee orthoses are based on the type of ligamentous injury. The pictures (Fig. 2.5.8-7) outline how the type of orthosis construction affects different ligamentous lesions in the knee.

Fig. 2.5.8-7 Schema of knee orthosis action in ACL and PCL injuries

In the upper extremity, shoulder joint instability is a great challenge for orthotic management. Commonly used shoulder orthoses are made from thermoplast, leather or textiles and additional pulling mechanisms through straps. The braces allow movement and common daily activities, but limit shoulder end range of motion and prevent recurrent dislocations (see Fig. 2.5.4-14 and Fig. 2.5.4-15) (Fig.2.5.8-8), or decrease the symptoms of impingement syndrome (Fig. 2.5.8-9).

Fig.2.5.8-8 Modified shoulder orthosis based on Fitslaf – post-surgical reconstruction of brachial plexus lesion Fig. 2.5.8-9 Shoulder orthosis with distal strap

ORTHOSES IN SPINAL TRAUMA

Trunk orthoses are indicated in the conservative treatment of stable vertebral fractures or as means of spinal column stabilization following osteosynthesis. Cervical hard collars or CTOs (see Fig. 2.5.6-2) are indicated in ligamentous injuries of the cervical spine or unstable vertebral fractures. A Jewett brace (Fig. 2.5.8-10) has been found beneficial in stable vertebral fractures at the thoracolumbar junction and can be modified to allow for stabilization of T10-L3 segments. Rigid bi-valved trunk orthoses ensuring stability in all planes are used for more extensive, multilevel spinal injuries (see Fig. 2.5.6-4). Fig. 2.5.8-10 Jewett brace

A separate group includes the application of trunk orthoses in pathological vertebral lesions for patients with oncologic involvement. The main aspects for indication of trunk orthosis in this patient population include spinal stabilization, support function during verticalization, prevention of progression of possible deformities and,

mainly, improvement and facilitation of the care in a patient with high levels of pain. A patient with oncological involvement usually demonstrates decreased tolerance to activity and has difficulty adapting to any externally applied device.

ORTHOTIC OPTIONS IN TENDON INJURIES OF THE HAND Finger flexion or extension orthoses, dynamic wrist and hand orthoses (WHO) with straps affecting the movement of injured tendon structures are applied most frequently. Correct placement of the finger pulls (Fig. 2.5.8-11A,B) needs to be taken into consideration when an orthosis is being applied. It needs to be precisely specified to the orthotist, which hand and finger segments should be immobilized and which ones, on the other hand, should be mobilized and to what extent. Fig. 2.5.8-11A Schema of pulling activity in a dynamic upper extremity orthosis. The lower picture shows incorrect placement of the loop and localized pressure padding

Fig. 2.5.8-11B Schema of action of dynamic upper extremity orthoses – pulling at a-90º-degree angle,

incorrect pulling force is shown on the right

FUNCTIONAL TREATMENT OF TENDON INJURIES IN THE LOWER EXTREMITY Recently, in the treatment of tendon injuries of the lower extremity, such as Achilles tendon rupture, walking boot (Walker-type) orthoses or custom made plastic orthoses (Mortensen) have been fabricated. They allow partial mobility of the Achilles tendon with a significant decrease in healing time when compared to standard immobilization in a cast.

FUNCTIONAL TREATMENT OF LOWER EXTREMITY FRACTURES In 1981, Sarmiento and Lata described independently of each other this type of treatment for the first time. The principle of this treatment lies in immediate (early) extremity mobilization without prolonged and rigid immobilization – collagen fiber repair occurs in the direction of movement, during which loading and movement have a positive effect on the architecture of the newly formed tissues. Pain guides the person’s level of functional activity.

At the time when this method was first described, cast orthoses were used. With advances in modern technology, these devices are applied as encircling two-sleeve plastic orthoses ensuring unweighting of a given segment during full or partial extremity weightbearing. The AFO’s points of support include the tibial tuberosities, patellar tendon and femoral condyles (Fig. 2.5.8-12 A–C). Decreased weightbearing in KAFO-type orthoses is ensured by supporting on the ischial tubercle.

Fig. 2.5.8-12A,B,C AFO – Sarmiento-type orthoses

ORTHOTIC CARE IN PATIENTS AFTER CRANIALTRAUMA A patient in a prolonged coma is, among other aspects, at risk of developing contractures, especially in the distal lower extremities. Positioning tools for prevention of flexion contractures at any segment of the upper or lower extremities needs to be implemented. Development of a severe plantarflexion position is a serious shortcoming in the times of modern orthotic care. This position is difficult to correct when the patient’s brain function improves and often, it is the only residual deficit significantly limiting the patient’s mobility.

ORTHOTIC MANAGEMENT FOR PATIENTS FOLLOWING BURN INJURIES A number of extremity orthotic devices that affect developing joint contractures can be indicated for such patients across interdisciplinary care. Modern approaches include using compressive garments and burn masks with gel or silicone padding to reduce hypertrophic keloid scars (Fig. 2.5.8-13A,B,C).

Fig. 2.5.8-13A,B,C Face masks to reduce hypertrophic keloid scars in burn injuries

2.6 REHABILITATION OF PATIENTS AFTER EXTREMITY AMPUTATION Jan Kálal Treatment of patients after amputation of an extremity is an important part of medicine, in which prosthetics and physical therapy play an important and essential role. The condition of the extremity following an amputation requires a comprehensive therapeutic approach containing knowledge and methods from orthopedics, orthotics, neurology, pain management, social and vocational rehabilitation and psychology. Amputation of any extremity always has a significant impact on body integrity. Next to a somatic deficit, the loss of a limb can also have psychological consequences.

2.6.1 Reasons for Amputations Extremity amputation, most often involving the lower extremities, has varied etiology and pathogenesis. Most amputations occur for vascular reasons; in the Czech Republic, there are several thousand each year. The second reason comprises traumatic amputations; there are hundreds of them. A surgery due to osteosarcoma, often accompanied by a loss of a limb, often occurs at a young age. These procedures are not very common, maybe in the tens. Occasionally, amputation due to unmanageable osteomyelitis, severe morphological defects or with the significant shortening of one lower extremity needs to be performed. Lower extremity circulation problems are currently a large issue, not only in medical care, but also in the social and economic arenas. Artery involvement has a pandemic character. At the turn of the century, the World Health Organization committee developed guidelines, not only on how to treat these conditions, but also enumerated the economic demands of treatment. A book called The Diabetic Foot Syndrome lists the expenses that a treatment of lower

extremity vascular conditions amounts to in individual countries of the world. According to the World Health Organization, the number of diabetics will double to 300 million by 2025. From the increasing trend of diabetic macroangiopathies, the resources necessary to treat such patients can be calculated. If, in the Czech Republic, there were a total of 3,714 amputations performed in 1989 then, already in 2007, there were 7,859 amputations performed only in patients with diabetic macroangiopathy. Therefore, in the last 17 years, the number has doubled. If the number continues to rise proportionally, 13,000 amputations will be performed in the Czech Republic. Tab. 2.6.1-1 lists the number of amputations for vascular and traumatic reasons in the years 1989–2008.

Tab. 2.6.1-1 Total number of amputations and their causes in the Czech Republic

2.6.2 Prosthetics A prosthesis is a mechanical device that allows movement when an extremity has been amputated. Prosthetic fitting is an important decision given its psychological, social and economic reasons. Studies performed in the last century point out that only approximately 70– 90% of amputees effectively use their prosthesis. The rest of the patients use a wheelchair for mobility. An extremity prosthesis is a mechanical device that is controlled by the strength of the muscles of the residual limb. This applies to the upper and lower extremity. So called myoelectric prostheses, which are powered via electric motors, are used when an extremity has been amputated at the upper arm. The signal to initiate their activity is given by an impulse scanned from the area of the motor nerve. Similarly, on the lower extremity, various technical options are utilized and the movement is controlled by a computer. However, these so called intelligent prostheses are expensive and not covered by insurance. Structure of a Prosthesis A standard lower extremity prosthesis consists of 3 basic parts. They include the socket, shank and foot. The socket of the residual limb is the part that is shaped like the residual limb so that it fits well. The suction principle is used. In the past, the socket was attached to the residual limb by straps. The lower aspect of the socket contains an adapter – a device to which the next part of the orthosis, the metal shank, attaches. Today, the shank is made from a light, firm and springy metal frame. The foot is attached to the end of the metal frame. The frame construction is covered by a soft plaster shape so that the prosthesis resembles, as much as possible, the shape of the residual limb. This type of prosthesis is used only for below the knee amputations. If the amputation occurs at a higher segment, i.e., at the thigh, the device needs to be equipped with a knee joint. Otherwise, its construction is identical to the previous scenario. The knee joint

connects to the adapter. Gait with a Prosthesis The reason why some amputees with a prosthesis are not able or do not want to ambulate has yet to be clarified. In the 1990’s, the energy expenditure of ambulation with a prosthesis was studied and the results suggested that ambulation with a prosthesis is more demanding than so far expected. We observed the oxygen consumption during ambulation with a prosthesis. In a thigh amputation, the oxygen expenditure is approximately 400% greater than in bipedal locomotion of a healthy individual. In the 1970’s, EKG during ambulation with a prosthesis was studied and, even then, a prosthesis was contraindicated for patients with signs of coronary insufficiency during activity. Indication Criteria If an individual uses their prosthesis, not only as a cosmetic accessory, but for ambulation, it is known as a functional prosthesis. An amputee needs to meet certain physical, psychological and social criteria to be provided with a functional prosthesis. The physical criteria of a functional prosthesis are usually not met by patients whose diseases prevent prosthetic fitting. Next to the oxygen transport system, which can worsen during ambulation, it includes atrophied musculature especially in the area of the residual limb and hip joint stiffness (ankylosis) on the side of amputation. The length, volume and strength of the residual limb muscles are significant values that allow for effective locomotion with the prosthesis. For such reasons, the surgeon always attempts for the residual limb to have an optimal length and through myoplastic surgery ensures maximum muscle coverage of the residual limb. The flexor and extensor groups are sewn together so that muscle padding is present above the transection. Equally, the femoral nerve needs to be transected perpendicularly to the longitudinal axis so that its ending can heal with a minimal amputation neuroma. An “Amputation neuroma”, besides other mechanisms, can be a possible trigger point for eliciting phantom pain. This view is also supported by the fact that pain is elicited if the

neuroma’s surroundings are stimulated by a syringe or an electrical impulse. In contrast, if a local anesthetic is applied to its surrounding area, phantom pains are often eliminated. Certain anatomical and physiological conditions need to be met for an amputee to ambulate with a prosthesis. The shape and the length of the residual limb are the basic requirements. The residual limb must have a certain minimum length and shape for the device to attach to the body. In the lower extremity, the residual limb is the most important segment because it allows for forward stepping. Approximately 1/3rd of the length of the femur is the optimal length for the residual limb. The residual limb is the lever that provides the strength and speed of movement with the prosthesis. The longer the residual limb, the greater the strength. Optimally, the residual limb should be cylindrical and distally slightly conic in shape. Residual Limb Care Following amputation, the residual limb develops for a long time (one year or longer) and it is the physical therapist who teaches the patient how to take care of it. Bandaging with an elastic ace wrap, which contributes to shaping of the residual limb, is one of the essential components of residual limb care. Also, temperature tolerance is included – performed by alternating streams of a warm and cold shower. The process is completed by cold water. Brushing is an important procedure to help restore skin sensitivity. Also, residual limb positioning by pressure or by weighing it down with a bag of sand or gel is implemented. Positioning prevents development of a flexion contracture, which is an unpleasant complication for the prosthetist during device fabrication. At first, passive and later active movement of the residual limb stimulates the preserved musculature. Also, movement imaging is important. In this method, the patient exercises with the uninvolved extremity and imagines that he is also exercising with the involved extremity. Based on many years of experience, it appears that this approach can contribute to a limited occurrence of phantom pains.

Gait Training Immediately after amputation, as soon as the patient’s condition permits, verticalization of the patient is initiated. Various assistive devices are used, such as platform walkers, parallel bars and, in younger and muscle-ready patients, axillary and, later, forearm crutches. We do not recommend prolonged resting in sitting because of the risk for flexion contractures. As soon as the patient masters standing, balance training needs to be initiated. This is followed by gait training. In patients with an above the knee prosthesis, gait training occurs with a locked knee joint at first and, in the next phase, the knee joint is unlocked. Patients with unilateral below the knee and above the knee amputations can learn to ambulate without any assistive device given that several factors are taken into consideration, such as age, concomitant diseases and overall fitness. Some patients, however, use a single point cane or forearm crutch because of poor balance and a fear of falling, especially in more challenging and unstable terrain. It is always used on the uninvolved side. The crutch/cane moves forward together with the prosthetic limb. Prosthesis Prescription Based on current regulations, a prosthesis is prescribed by a physician contracted with an insurance company (by specialty it can be an orthopedic prosthetist, surgeon, orthopedist, rehabilitation physician or a neurologist). Prosthesis fabrication is sought as soon as possible after amputation. This initial prosthetic fitting is not definitive. Since the residual limb attains its shape over a long period of time, the socket needs to be modified to fit it. A final prosthesis is allocated when the residual limb is stable. A standard prosthesis is prescribed every 2 years. Repairs and modifications are covered by insurance. The insurance companies established five categories (patient’s psychological potential, profession, area of use, etc.) based on which device is fabricated so that it meets the patient’s needs and, at the same time, is economically effective. From a health perspective, the essential technical fabrication of the prosthesis (the selection of basic

components for prosthesis fabrication) is based on the patient’s potential functional abilities. These functional abilities are based on the expectations of the prosthetist and the treating physician and involve the following assessment: The patient’s history (including the patient’s assessment prior to amputation) The patient’s current condition (the condition of the residual limb and other health aspects) The patient’s positive motivation for the use of the prosthetic limb Categories of Amputees According to Insurance Companies Regulations The functional indication for a prosthesis is suggested by the inclusion of components for a lower extremity prosthesis based on the patient’s expected level of activity and overall health. It is based on the patient’s functional potential. Insurance companies classify amputees into the following 5 categories: 1. Degree of activity = 0. Non-ambulatory patient. Therapeutic goal: patient’s cosmetic appearance, wheelchair mobility 2. Degree of activity = 1. Household ambulation. Therapeutic goal: facilitate standing, facilitate household ambulation 3. Degree of activity = 2. Limited community ambulation. Therapeutic goal: using prosthesis for household distances and to a limited extent in the community; patient is able to ambulate with prosthesis for a limited period of time and is able to overcome only small terrain instabilities and barriers 4. Degree of activity = 3. Unlimited community ambulation. Therapeutic goal: using prosthesis for household and community ambulation without limitations; patient can overcome most terrain instabilities and barriers and is able to work in light duty positions. 5. Degree of activity = 4. Unlimited community ambulation with special needs; includes fully working individuals; this category does not include special sport prostheses, which are not covered by insurance.

The selection of the individual components of the prosthesis is based on these categories. The newest ones, for example, bionic joints are very expensive (up to 500,000 Czech crowns).

2.6.3 Complications in Amputations Although already described by Ambrois Paren in 1558, phantom pain remains a mystery to this day. The etiology of phantom pain has not yet been clearly explained. The newest literature refers to phantom pain as a body schema deficit. It is a fact that phantom pains are experienced by almost all patients early after surgery. True pain is experienced by 70% of patients. Treatment is difficult; certain analgesics including opiates and electro-neuro stimulation have proven beneficial. Surgical procedures involving ascending nerves or brain structures did not yield a desired effect. It is a sad fact that some individuals, despite all available medical treatment and neurosurgical procedures, end up committing suicide because of uncontrollable phantom pains.

2.7 REHABILITATION TOOLS Jan Kálal A wide variety of tools are used in rehabilitation. They are known as rehabilitation equipment or assistive devices (Fig. 2.7-1). They contribute to the improvement or stabilization of a patient’s medical condition, prevent its worsening, compensate or decrease the consequences of physical limitation, substitute for loss of function (for example, locomotion) and modify anatomical structures or physiological processes.

Fig. 2.7-1 Samples of rehabilitation tools

The insurance company assigns a specific code and documents it in a code book, which is regularly updated by adding new, approved equipment. It contains approximately 90,000 items. These items are divided into 17 subgroups. Rehabilitation mainly uses orthotic, prosthetic, cosmetic/aesthetic prostheses, and assistive mobility devices. Overview of subgroups: 1 Dressing material

2

Aids for incontinence

3

Wound care products Aids for orthopedic prosthetics, over the counter and custom fabrication Compression stockings and sleeves Wheelchairs and all assistive devices for movement Hearing aids Glasses and visual aids Respiratory and inhalation aids Aids for diabetics Compensatory aids for persons with handicaps Anti-decubital mats, seats, mattresses, preventive helmets and instruments for pressure massage Aids for patients with auditory and visual handicaps Prosthetics Aids for patients after laryngectomy

04 and 05 6 7 8 9 10 11 12 13 14 and 15 16 17

Rehabilitation aids included in the 4th subgroup can be prescribed by an insurance contracted physician with specialization in orthopedics, orthopedic prosthetics, rehabilitation physician, surgeon, a neurologist and, in some cases, also an oncologist. This subgroup includes over the counter orthoses, breast prostheses, residual limb coverings and guards/protectors. Rehabilitation aids included in the 5th subgroup can be prescribed by an orthopedic prosthetist, orthopedist, surgeon, rehabilitation physician or a neurologist. A supplier needs to submit a preliminary financial estimate for the devices that are especially economically demanding (their codes are specifically listed). This subgroup includes custom made orthopedic footwear, trunk orthoses for stabilization in sitting and standard and special upper and lower extremity prostheses.

Rehabilitation aids included in the 7th subgroup are once again in the scope of a rehabilitation physician, although they can also be prescribed by an orthopedist, neurologist or an internist. These include medical strollers, adult size tricycles and manual and electric wheelchairs for household and community ambulation. All these devices contain numerous accessories. A special voucher needs to be filled out for all accessories. In the introduction to subgroup 7, the diagnosis is specifically defined, as well as, the extent of functional deficit, for which a particular device can be prescribed. The device can be provided on a temporary or permanent basis. Electric wheelchairs are provided to patients who are immobile when the following criteria are met: 1. Involvement of both lower extremities preventing independent locomotion in combination with involvement of the upper extremities, which do not allow maneuvering a manual wheelchair, including one handed mechanism. 2. Involvement of both lower extremities preventing independent locomotion in combination with severe chronic illness, which does not tolerate increased physical demand. The request needs to be accompanied by a stress test performed at a specialized facility or by a specialist in the area of a given chronic disease. 3. Somatic or mental capability of the patient needs to correspond to Regulation No. 361/2000 about operation on the streets. Examination by a psychologist, ophthalmologist, internist or an orthopedist is necessary. The physical therapist performs the patient’s muscle testing. A rehabilitation physician suggests other accessories and establishes the means of manipulation (which hand or alternate ways). Rehabilitation aids from the 12th subgroup facilitate or allow mainly movement function. They are used for compensation of various locomotor deficits and increase the ability and comfort of independence. They are used most frequently in rehabilitation. They include various crutches, canes, walkers, commodes, shower chairs and bath seats. Often, the assistive devices include elevated toilet

seats, lifts, positioning devices and verticalization tables. Nowadays, electric or mechanical positioning beds are more often prescribed for facilitation of care in individuals who are significantly limited in their mobility, for example, following cerebrovascular accidents. Prior to prescribing a positioning table, the physician needs to evaluate whether the person operating the bed is capable of using it. Rehabilitation aids from the 16th subgroup include orthopedic footwear. Insurance companies established specific indications, in which the patient can be provided with simple, complex and very complicated orthopedic footwear. The repairs and modifications are also covered. This subgroup also includes standard, custom and special orthopedic insoles. Specialized footwear is available for diabetics with a diabetic foot syndrome. It is prescribed by a podiatrist from a diabetic clinic and it is approved by an audit physician. Some devices can be prescribed by a general practitioner. These devices are denoted by the letter Z in the list of medical equipment and need to be approved by an audit physician. A form explaining the type of device and its necessity needs to be submitted by a specialist. For devices that are very expensive (i.e., certain types of prostheses with bionic joints, specialized electric wheelchairs, respirators, etc.), a preliminary financial analysis needs to be submitted. Some devices can only be prescribed by certain specialists. All limitations are always provided on the list of medical equipment. A rehabilitation physician has extensive privileges in this area. Most mobility devices can be prescribed together with a neurologist, orthopedic prosthetist or an orthopedist. Special equipment (i.e., respirators, electrolarynx, hearing aids) can be prescribed only by a tuberculosis respiratory specialist or an otorhino​laryngologist. A physical therapist can also suggest a device for a patient. Often, the physical therapist needs to modify it to fit the patient. Many of the assistive devices are constructed so that they can be adjusted, especially their height. Incorrectly fitted equipment can cause the patient additional problems. The incorrectly adjusted height of

axillary crutches can serve as an example. When fitted correctly, the axillary support fits 3cm below the apex of the axilla. If the axillary crutch is too high and the support presses against the axilla, a neurovascular bundle can be compressed. Forearm crutches need to be adjusted so that elbow flexion is not greater than 30 degrees. Excessive strain on upper extremity muscles and their premature fatigue occurs if the flexion is greater than 30 degrees. The durability of most assistive mobility devices is 5 years. If it is damaged earlier, the prosthetic technician establishes the degree of damage and estimates the financial cost of a repair. An audit physician determines whether the patient’s device should be repaired or whether the patient should be issued a new device. If a disease progresses and the new condition requires a new device, the physician examines the patient and makes a recommendation about a new device (i.e., a patient is no longer capable of maneuvering a mechanical wheelchair and requires an electric one). A device that the patient no longer needs is returned to the insurance company if it is in a good condition to be refurbished and offered to another patient.

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3 TREATMENT REHABILITATION FOR SELECTED INTERNAL AND OTHER DISEASES Miloš Máček, Jiří Radvanský, Libuše Smolíková, Pavel Kolář Rehabilitation for internal diseases has only been fully developing over the past several decades. For a long time, it has been overshadowed by other specialties, in which movement dominated because it was presumed more important, especially in orthopedics, traumatic surgery and neurology. Treatment with movement can claim maybe the oldest indicated treatment previously voiced by Hippocrates who, next to medication for chronic obstructive pulmonary disease (COPD), recommended walking a daily distance of 20 stadiums during the first month. One stadium was 180m long. The next month, 10 stadiums were added and by four months, the patient should walk 80 stadiums, or 14,400m. He promised the patients that if they follow his treatment plan that they will be cured within one year. Exercise therapy then, became a component of any overall treatment. Of course, this leads to considerations on how rehabilitation can influence pharmacological treatment and, in contrast, how current treatment with medication using β-blockers of the sympathetic system can influence the result of exercise therapy, or how a patient with a pacemaker can react to it. Can rehabilitation as a whole influence other treatments? Particular requirements are, among others, lower medication dosages decreasing blood sugar in patients with diabetes during concurrent movement treatment. A question remains about how adaptation to physical activity (loading) manifests itself in the case of a decreased need to administer oxygen in more severe COPD involvement. Or, how physical activity acts on substrate metabolism or clearly the most affected bone metabolisms and on other areas? In recent years, the influence of physical activity on the human immune system has been carefully studied.

New issues emerge with gradual implementation of rehabilitation into treatment of severely involved patients. One of them is a so far little known problem of exertional desaturation in certain patients with COPD, which can be perhaps considered as a manifestation of decreased adaptation or a result of a more challenging stress test with gradually increased intensity. In the same patient, desaturation does not appear until the walking test and does not present during activity on an ergometer. Inclusion of strengthening or resistive exercises for patients with dyspnea is another new issue. It has been shown that muscle metabolism more significantly affects the reaction to physical activity, for example, in lipid metabolism and that the patient unmistakably benefits from simultaneous maintenance of muscle strength. However, are the concerns of increased arterial network pressure in patients with COPD warranted or unreasonable? And, should resistive training be implemented more since it is not as demanding on cardiac output? It is apparent that there are many topics that need to be studied. The benefits of rehabilitation are also reflected in the patient’s way of life. Their quality of life increases not only by possible participation in professional and social activities, but also in family relations. Recent meta-analyses show that for patients with a mild course of disease, rehabilitation programs lasting 2–3 months are appropriate while patients with more severe involvement should participate in long-term programs. In any case, it is desirable for the patients to be willing to accept a healthier lifestyle (for the rest of their lives). It is known that comprehensive rehabilitation is not solely a concern of medical personnel. It cannot function without necessary social and legal affairs and without relationships with the community and other areas. Correct interpretation of the rehabilitation process requires realization of the primary and secondary preventive programs and also the cooperation and support of family, close surroundings and the entire community. This includes the option of expansion of movement activities, correct nutrition, limiting smoking and the application and financial assistance of prevention programs.

Putting the described concept into action so that everyone who could benefit from rehabilitation had unlimited access to it will require a lot of effort. Nonetheless, it has already been implemented in certain countries. The concept’s primary treatment component must be based on medical services. Social, pedagogic and other components of rehabilitation in certain locations can lean on state or community associations. For now, the countries that are the most advanced in implementing the concept include, for example, Great Britain where this service is utilized by approximately 40% of patients in need (women less often than men). This concept is widely implemented in Canada (especially in Quebec province). In Germany, less structured organizations for patients with cardiovascular or pulmonary diseases exist, which with the help of athletic organizations and communal groups or insurance companies, they provide preventive rehabilitation and exercise treatment. This concept has a long standing tradition even in the Czech Republic. For example, in the 1960’s, a group was formed at the pediatric clinic in Prague-Motol that studied physical activity of pediatric patients with asthma. The results of the experiment showed that patients with asthma benefit from more challenging movement activities because they become more resistant to fatigue and thus, are able to manage the demand of regular daily life. The occurrence of bronchospasms decreases and the patient with asthma is able to manage potential dyspnea. This is the reason why then they established summer reconditioning camps for children with asthma. Rehabilitation and Secondary Prevention Reducing rehabilitation to only one of the methods of secondary prevention can limit the treatment process. This happens often during the treatment of metabolic syndrome and it has complications in patients with cardiac complications, patients with diabetes, overweight individuals and patients with COPD. It establishes disease inhibition as the first priority so that the object of prevention becomes the actual the disease in the sense of influencing some of its risk factors and not the patient. This, of course, does not mean rejecting the positive effect of exercise therapy as a secondary prevention. However, this effect is

understood only as a component of the treatment process and not as a main goal. The main goal is the true realization of rehabilitation. Another reason for the realization of the aforementioned concept to its full extent is the necessity to utilize the improved results of comprehensive treatment of the previously mentioned diseases, including surgical and other invasive procedures developed in the last two decades, which leave the patient in a considerably better physical condition than before. Therefore, a need develops to supplement or strengthen these results by other physical, psychological and social interventions. Rehabilitation cannot be a monopoly of only healthcare institutions. Although medical care becomes dominant in the critical phases of the disease, other components of rehabilitation need to develop in parallel, especially social and psychological and they can dominate in the following periods. Respiratory physical therapy and exercise therapy are methods in which the treatment success is based on the patient’s active participation in the treatment process and the patient themselves gradually becomes responsible for the overall course of treatment. This change in roles from passive subordination to active participation requires a change in thinking, as well as, in the professional approach to rehabilitation, including the traditional habits of many of the rehabilitation workers. A patient in this position will seek more information and contribute their ideas to treatment success. These need to be positively accepted and diplomatically addressed. Currently, however, this profession has a small number of medical personnel with this type of thinking. Regardless, it can be expected that time itself and the patients themselves will lead to changes in attitudes and thinking. Chronic diseases often elicit irreparable changes that have a tendency to gradually deepen and cause further complications. Therefore, there is a general effort and goal of medical care to inhibit the disease symptoms, attempt to influence its course and prolong the patient’s life. Therefore, it is an effort to increase the effectiveness of

the current treatment. In the last decades, more and more often attempts have been made to support this effort by permanently maintaining or increasing the patient’s quality of life. This means to ensure that the acquired prolonging of life by modern treatment was fulfilled by adequate physical activity leading to an enrichment of the patient’s condition and that it did not only represent a passive acceptance of a more or less successful treatment. While prolonging life is a clear term and does not need to be further explained, to define what it means to increase its quality is substantially more difficult. Many studies have been published attempting to define and unite the context of this term so that an international consensus could be reached. The term quality of life is currently used only broadly and can contain basically all positives, including health, personal, materialistic and social satisfaction. This is the reason why this term is narrowed and the term health focused quality of life is used. This implies a way of living that approximates the patient’s normal function in several basic life areas, for example, physical, emotional and social. This term also includes the achievement or maintenance of a certain functional level allowing this function. Of course, it also consists of independence in completing all common daily activities. An essential component of the assessment of this indicator is dependent on patient cooperation and compliance. For clarification, certain auxiliary objective indicators can be used, such as physical fitness, pulmonary function, etc. However, they cannot replace the patient’s actual activity. When evaluating quality of life, we can focus either on the existence of one determining indicator i.e., dyspnea or observe specific indicators typical for the course of COPD (cough, sputum formation) and the characteristics influencing the type of life, such as resistance against body fatigue, mental balance and well-functioning social relationships.

GENERAL SECTION

3.1 PHYSIOLOGICAL MECHANISMS UTILIZED IN REHABILITATION INCLUDING ADAPTATION TO PHYSICAL ACTIVITY Miloš Máček, Jiří Radvanský Adaptation is an essential demonstration of life and a response to the influence of external factors, including the action of physical activity. It is demonstrated by a change in the function of a number of systems, i.e., cardiorespiratory, immune, central nervous system and by changes in metabolism. In this chapter, these adaptive changes will be described in more detail on a general level.

3.1.1 Cardiac System Adaptation Jiří Radvanský Adaptation to physical stress as a manifestation of a reaction to repeated stress is clinically manifested after a patient’s exercise regime optimization in a weeks’ or months’ time. However, on the molecular level, changes in transcription of a number of regulatory molecules can already be observed as a result of a single, prolonged and intense load. For didactic reasons, cardiac adaptation can be divided into peripheral, vascular, central in terms of myocardial adaptation, adaptation on the subcellular level and adaptation at the control level mediated neurohumorally. In reality, all these changes occur in parallel. Cardiac system adaptation due to months of repeated adequate loading with a dominantly dynamic component can be succinctly characterized as follows: Decreasing resting pulse by increasing parasympathetic tone and decreasing spontaneous depolarization of the sinoatrial node Increasing the end-diastolic cardiac volume Improving myocardial contractility and increasing systolic cardiac volume Decreasing demands on cardiac output during light and moderate load intensities

Ability to overcome short-term ischemic episodes without damage Slowing down cardiac aging Regulatory changes of the circulatory system, especially adaptation, an increase in resting vagotonia, a change in the dynamics and the resultant effect of the sympathicus, as well as, changes in the actual cardiac muscle tissue influence the stress adaptation of the heart and overall circulation. These are elicited by several types of stimuli: External humoral factors, such as hormones (catecholamines, thyroid gland hormones, growth hormone and IGF-10), peptide growth factors and cytokines Mechanically – muscle contraction itself Changes in calcium concentration as a result of more frequent stimulation of a contraction. The result is an altered gene expression in the cardiomyocytes with a subsequent change in the synthesis of many groups of substances, most often in the area of calcium ions transmitters Hypoxia: ischemic cardiomyocyte decreases gene expression of a number of regulatory substances, i.e., atrial natriuretic peptide and also adapts to the load by different morphology – it does not elongate and loses volume An adaptive increase in cardiac chamber volume, especially in the left ventricle, with minimal symmetrical wall thickening occurs after several months as a result of intense endurance training. A healthy left ventricle reacts to appropriate endurance training by slight, symmetrical, and eccentric hypertrophy. Exclusive thickening of the cardiac muscle is only elicited by intense (usually excessive and incorrectly structured) strength training, in which resistance work of the heart dominates. In such case, the cardiac chambers become rather small, which is a similar condition to concentric hypertrophy of the left ventricle in response to pressure overloading of the left side of the heart. In contrast, well executed resistance training without excessive continuous loading of muscles that are not statically loaded for a prolonged period of time does not elicit concentric cardiac

hypertrophy. Athletic cardiac hypertrophy differs from similar pathological conditions (concentric or eccentric hypertrophy with pressure or volume overloading of the heart), especially by good diastolic function of the ventricles. On the molecular level; however, the adaptation of a healthy, overloaded or ischemic myocardium substantially differs. An extreme athletic adaptation of the left ventricle also brings about certain risk with aging. Athletic hypertrophy regresses when the athletic career is over, but only at the level of the cardiomyocytes. The connective tissue stroma from the time of athletic hypertrophy does not regress and can worsen the diastolic function of the left ventricle. Adaptation of the peripheral circulation is manifested in a number of areas. It can be briefly characterized as follows: Increasing plasma volume Favorable increase of fibrinolytic system Increased endothelial function Improved muscle capillarization Muscle adaptation and increased oxygen extraction from blood The endothelial cells of the blood vessels are the first cellular structures that can early, easily and clearly register the state of physical activity independently of nerve stimuli. In response to endothelial physical stimulation given by an increased arterial volume, the excretion of a number of regulatory substances is altered, which act on the dilation of blood vessel musculature, capillary proliferation and can also cause a change in blood properties (inhibitory effect of blood coagulation and inflammatory factors). In the endothelium, the synthesis of nitric oxide from amino acid L-arginine is an important regulatory pathway, which gradually alters its dynamics with repeated loading demands. Its availability in the vessel’s smooth muscle increases with training; this occurs more with a mildly intensive rather than a prolonged loading at a lower intensity or a short duration loading with intensity at anaerobic threshold. The adaptation depends on the extent of the working muscle groups. Following the training of the forearm muscles, the peripheral resistance changes only in the

trained muscles. After lower quarter training, changes are found in the entire arterial system of the muscles. Blood vessel dilation in the muscles is caused by nitric oxide through augmentation of acetylcholine’s effect as well as independent of anything. Loading vasodilation increases with adaptation in healthy people and in patients with increased circulatory output. As a result of decreased tone in the smooth muscle of blood vessels, peripheral resistance decreases and the stiffness of the elastic vessels decreases. The resting systolic and diastolic blood pressure falls and its rise during the same loading also decreases. A disrupted endothelial function is linked to many diseases increasing oxidative stress. Through adaptation, physical activity, although an oxidative stress in and of itself, elicits improved function of a number of antioxidative systems, which possibly improves function of the damaged endothelium. A mild and submaximal loading intensity causes faster peripheral adaptation. During the same loading intensity, the sympatheticadrenal activity decreases and, in only a few weeks, the heart rate (HR) shows lower values during loading as well as at rest. In the adapted system, blood flow does not need to be radically restricted through the active regions as in the non-adapted system because the increased capacity of the oxidative enzymes in the muscle fibers leads to a greater use of the accessible amount of oxygen. The evidence is a greater arteriovenous difference. A physiologically enlarged heart with a higher arterial volume is very efficient, capable of reaching a high minute output and increasing systolic volume even during high HR. At rest, this state, compensated for by a higher vagal tone, is demonstrated by a low HR, even lower than 40 pulses per minute. The ejection fraction of the adapted system can be due to extreme vagotonia even slightly lower than average. However, with minimal loading and with decrease in vagal tone, it increases above the values of loading in a non-adapted population of the same age. In most people, cardiac systolic volume already reaches maximum during moderate loading levels, does not increase any further and somewhat

falls at maximum levels. The adapted heart of a competitive endurance athlete increases the systolic volume until almost maximum loading. Regular physical activity increases oxygen delivery to the cardiac muscle that works more efficiently by lowering energy consumption during the same performance. This is confirmed by lower values of the byproducts [HR and blood pressure (BP)], which closely correlate with myocardial oxygen consumption during an absolutely identical loading. Electric stability improves, probably by the increased ability of the myocyte to resist short-term ischemia and increased myocardial perfusion and ejection fraction during loading. The risk of atherosclerotic involvement decreases as a result of adaptation to longterm intense training by the combination of an improved lipid profile, the positive influence on the endothelium, decreased production of inflammatory mediators and improved plasma antioxidative capacity. The adaptation also causes decreased platelet aggregation and increased fibrinolytic activity. The activity of oxidative enzymes doubles as well as the aerobic usage of lactic acid causing an increase in the Krebs cycle capacity. Aging of the enzymatic mitochondrial components slows down. The density of the capillary network in the trained muscles increases and reaches its peak after approximately 3 months of training. According to the latest data verified by catheterization, this type of training decreases or even stops the formation of atherosclerotic plaques and, in certain cases, dissolves them. Adaptation to loading also has a substantial effect on the decreased formation of inflammatory mediators in the atherosclerotic endothelium of the coronary arteries, which leads to plaque stabilization. In summary, it can be said that an individual with a highly adapted circulatory system does not have to exert as much energy on the transport system during regular activities, saves their heart by having a lower resting HR and the metabolic changes caused by adaptation slow down the atherosclerotic changes in the arteries.

3.1.2 Pulmonary System Adaptation

Miloš Máček Regular physical activity most certainly elicits adaptation in the pulmonary system because, similar to circulation, breathing is also a component of the same transport system. Increased activity of the oxidative enzymes utilizes a greater supply of oxygen for the wider utilization of this form of obtaining energy and limiting glycolysis, which significantly decreases lactate production and, thus, limits the degree of metabolic acidosis and dyspnea during strenuous activity. Increased adaptation brings about improved breathing efficiency because for each needed lower ventilation is needed for oxygen delivery; the ventilation equivalent for oxygen decrease. Breathing mechanics improve and, in patients with COPD, the onset of dynamic hyperinflation during activity decreases. The results of static spirometric testing, which confirm lower values, suggest signs of obstruction. However, as a result of adaptation and physical activity, they are basically not altered because they are dependent on the extent of irreversible lung tissue damage. However, the values of a functional stress test improve as a result of adaptation especially with peripheral circulatory and muscle factors. Pathological changes of pressure differences in patients with COPD show that their breathing work is increased when compared to healthy patients. This is validated by changes in the oxygen breathing equivalent. According to this, the patient needs to substantially increase ventilation to obtain one liter of oxygen when compared to a healthy individual (Fig. 3.1.21). During resting breathing, oxygen consumption by the breathing muscles in a healthy individual is an insignificant 3% of the overall consumption while in patients with COPD it increases up to 20% because of greater activation of additional muscle groups and greater breathing activity. During increased physical activity, the increased oxygen consumption by the breathing muscles becomes the limiting factor in the patient’s performance. Increased activity of the breathing muscles and various disturbances in their coordination also increase energy demands (Fig. 3.1.2-2). An example could be the lower efficiency of the diaphragm with a dysfunction in the coordination of

contractions of its muscle parts that contribute to the onset of hyperinflation. The disturbance in gas exchange forces the patients to exert at least twice the ventilation to maintain normal PaCO2. During common daily activities, they need to utilize higher percentage of its vital capacity (VC) because the usual 50% is not quite sufficient and thus, they are forced to overcome higher static resistances of the lungs and thorax.

Fig. 3.1.2-1 Breathing work – (Pes/Plmax) during physical activity in healthy individuals and patients with COPD in relation to increasing ventilation

Fig. 3.1.2-2 Breathing muscle performance during ergometer exercise in healthy patients (•), in patients with an obstructive deficit without hypoxia (•) and in patients with hypoxia (•)

Regular physical activity increases the deepened adaptation of respiratory functions, which in milder conditions and in younger patients partially limits the aforementioned deficits and, at the same time, teaches them to use compensatory abilities of the peripheral circulatory reserves. It also brings better respiratory muscle coordination and, thus, a decreased respiratory effort. In more severe conditions accompanied by irreparable lung tissue changes, mechanisms other than those that are pulmonary based especially on metabolic muscle function are utilized. So far, unknown causes and maybe also systemically administered corticosteroids often lead to the development of muscle dysfunction and to developing myopathy. The basic adaptive changes in a healthy individual as well as to a lesser extent, in patients with COPD include decreasing ventilatory demands during identical physical activity, increasing oxidative enzymatic capacity of the large extremity muscles by up to 100% and

therefore, increased utilization of supplied oxygen, which allows for greater movement activity and thus, improved quality of life. Long-term results of pulmonary system adaptation depend on correct methodology and indication for exercise treatment. A number of patients after a lung transplantation due to irreparable emphysematic changes did not show the expected improvement in the overall condition, especially in the ability to perform normal movement. This fact indicates that in this stage of COPD, the lung function is no longer decisive and the disease becomes primarily a disease affecting large muscle groups. Their treatment by resistive and endurance exercises becomes dominant. That is why when treatment effectiveness is evaluated, the training of large muscle groups is assessed as most effective when the optimal duration and intensity are respected while other forms of respiratory exercises fade into background (Fig. 3.1.2-3).

Fig. 3.1.2-3 Changes in respiratory indicators in percentages prior to a rehabilitation program and after a rehabilitation program in two groups of patients with COPD; in both groups the forced expiratory volume in one second (FEV1) was approximately 30-40%. The group with the greatest effect (dark columns) trained on an ergometer 5times per week for 30 minutes for 8 weeks at the intensity of 1 W  kg-1. The second group (light columns) trained for the same duration at 0.5 W  kg-1 for 40 minutes. The overall energy expenditure was identical, but the intensity differed. In the first group, all changes were significant. In the second group, only lactate decreased. The results suggest that a certain threshold exists, from which the exercise treatment becomes effective.

3.1.3 Metabolic Adaptation Jiří Radvanský Metabolic adaptation to loading has been traditionally divided into the areas of substrate metabolism and, therefore, especially fat and

glucose metabolism and the adaptation of other areas, from which bone metabolism is apparently the most important. According to the newest data, substrate adaptation is the only integrated system interconnected with the adaptation of the immune system. Adenosine monophosphate activated protein kinase is the trigger of loading reaction. It alters gene expression of many genes that affect glucose transport as well as β-oxidation of fatty acids. The adaptation also includes the ability to form carbohydrate transmitters of fatty acids into the cells. Interleukin 6 (IL-6) produced in human muscles is one of the key regulators and until recently, was described as a substance with a negative regulatory role (facilitating inflammation). Its resting value can increase up to 200% during loading. Greater production of IL-6 decreases the production of tumor necrotic factor (TNF-α), as well as, the silent inflammation contributing to acceleration of atherosclerotic process. The production and degradation of carbohydrates in the muscles is influenced by a number of substances, from which the strongest influence on their production can be seen in growth hormone (GH), testosterone and an insulin-like growth factor (IGF-1). Glucocorticoids, in contrast, have the greatest effect in shifting the balance toward protein catabolism. Shorter, intense loading elicits the dominance of protein anabolic hormones. A prolonged, low intensity loading can lead to a dominant effect of protein catabolic substances. Slight overloading by repeated muscle contractions, especially if it contains eccentric loading in addition to concentric loading, leads to IGF-1 mediated activation of satellite muscle cells, which results in the acceleration of compensatory muscle hypertrophy. Growth hormone produced by loading acts as a synergist to IGF-1. Training, especially endurance training, stimulates the metabolism toward increased utilization of fats and, therefore, limits the burning of muscle glycogen. A perfect synchronization of insulin, catecholamines and growth hormone and, at the subcellular level, improved mitochondrial function and greater utilization of intracellular fat stores forms a complex control mechanism of this system. A gradual change in the enzymatic and protein composition

of the fast fibers toward extreme “fast oxidative” fibers is significant. This type of metabolic adaptation results in decreased production of catecholamines during the same loading intensity and occurs after only several days of training. Liver muscles and adipose tissue show increased sensitivity to insulin and glucose, especially after longer and more intense endurance loading. Increased insulin receptor sensitivity in the muscles by 1/3 or 1/2 is the main effect. This results in lower plasma concentration of insulin. If the loading is not repeated in time, the response disappears after about 24-48 hours and substantially sooner in insulin resistant patients. During long-term regular exercise, insulin production decreases, which is manifested by its decreased levels. Regular endurance-type physical activity over the course of a week causes increased insulin receptor sensitivity for most of the days, helps maintain normoglycemia with a lower insulin level, and, at the same time, blocks adipose tissue lipolysis. In addition to improved glucose metabolism, a higher and faster supply of fatty acids also exists during loading. Therefore, physically active individuals show less visceral fat and less often present with type II diabetes. This metabolic adaptation occurs earlier and at lower loading intensities than is needed for increasing VO2max. It is almost certain that these positive consequences are not just the result of an increased sensitivity of the muscles and other tissues to insulin, subsequently leading to its decreased production. This is the longest known result of the adaptation processes which leads to increased muscle tissue and changes in the overall metabolism. Adaptation to physical activity – not only endurance based, but also in combination with resistance training – leads to the decreased blood level of cholesterol and triglycerides, increased HDL concentration and decreased LDL level. Together with a favorable lipid profile, oxidative stress caused by loading decreases, which further slows down the process of atherosclerosis. This is the reason why there is a clear trend in exercise therapy away from propagation of exclusively endurance dynamic loading to that of a combination of endurance

and modern forms of strength training or resistance training. Exercise therapy has been shown to be especially important in primary and secondary prevention of patients with type II diabetes who are at risk for ischemic heart disease because of the favorable influence of physical activity on the overall metabolism. The protective effect of exercise therapy decreases morbidity and mortality by approximately 40% when compared to individuals leading a sedentary lifestyle.

3.1.4 Immunity Adaptation Ondřej Suchánek, Pavel Kolář In the last decade, the number of studies examining the influence of physical activity on the immune system has significantly increased. These studies show that exercise can have either a positive or negative influence on immune functions. The final effect is given especially by the type of loading – its intensity, duration and frequency of repetitions. Based on several epidemiological studies, the model of a “J”- curve has been developed which describes the relationship between the type of physical activity and the state of the immune system in the form of post-activity inclination to infections. The curve describes that regular light physical activity in comparison with a sedentary lifestyle strengthens immune functions while prolonged, high intensity physical activity acts in the opposite manner (100–500% increase in the risk of contracting a virus). Intense, challenging and prolonged physical activity (the duration and intensity depend on the individual’s body condition and its fitness) then shows a temporary immunosuppressive effect. According to studies, sore throat and flu symptoms in elite athletes occur more often than in the regular population and upper respiratory infections also last longer in these individuals. However, only a small number of studies showed the relationship between the immunosuppressive effect of long-term intensive athletic activity and a true, clinically confirmed illness. The symptoms that the studies often use in questionnaires to assess illnesses in athletes (i.e., sore throat, congested nose, high temperature) are subjective and can be elicited

by a number of other – non-infectious causes (allergy, sterile infections induced by air condition). One of the studies in individuals actively participating in sports, in which carefully performed mucous membrane smears were tested to confirm true infection, clearly demonstrated that these “infections” of the upper respiratory pathways after challenging physical activity only rarely show an infectious origin. Immune system reactions to intense physical activity are in many aspects comparable with those that are elicited by an infection, sepsis or trauma. These especially include the following changes: 1. Substantial rise in the number of circulating leukocytes (especially lymphocytes and neutrophils) 2. Rise in inflammatory (TNF-α, IL-1β) and anti-inflammatory cytokines (IL-5, IL-10, IT-1ra), acute phase protein (including Creactive protein, CRP) – significant rise in IL-6 is, at the same time, attributed to its release from contracting muscle fibers during exercise 3. Rise in hormonal levels – adrenalin, cortisol, growth hormone, prolactin while the cortisol level is significantly influenced by IL-6 4. Based on a significant increase of level IL-6, IL-10 and IL-1ra the number of circulating type I helper T-cells decreases while type II helper T-cells level remains the same 5. Decrease in expression of toll-like receptors (TLR) 1, 2 and 4 on the surface of monocytes lasting several hours following activity 6. Neutrophil activation, but, in contrast, a decrease in their functional characteristics (degranulation, oxidative burst) after activity completion lasting several hours 7. Rise in the number of circulating HK-cells; however, a drop to less than half of the original values prior to activity 8. If the activity lasts longer than 1.5 hours, the number of circulating lymphocytes drops following activity for several hours below the original value prior to activity 9. Decrease in expression of the Major Histocompatibility Complex (MHC) class II and antigen presenting capability of the macrophages

Immune functions altered by intense physical activity gradually return to pre-activity levels in 3–24 hours. Crosssectional studies showed that leucocyte numbers, including other considered immune functions observed in athletes more than 24 hours after the last training, differ only very little from non-trained individuals or individuals with a sedentary lifestyle. Therefore, in a true resting state, the immune functions of the athletes and nonathletes do not show large differences. Stress hormones (catecholamines and glucocorticoids) are one of the main agents that mediate the effects of physical activity on the immune system. In the past, the stress hormones were considered for a long time to be pure immune-suppressors. However, current knowledge suggests that their action has a more varied character and individual components of the immune system can react quite differently to these substrates (i.e., immune-stimulatory activity is seen by facilitating phagocytic function of the neutrophils by catecholamines). Different responses can also be observed at the systemic and local levels, in which the systemic activity of these substances is generally an anti-inflammatory with an induction shift of Th2, although certain local responses can be anti-inflammatory. The arterial plasma concentration of adrenaline and noradrenaline increases linearly with duration and exponentially with intensity of physical activity and is expressed relative to the individual value of VO2max. During relatively the same activity, the adrenal glands of trained individuals generally excrete more adrenaline than the adrenal glands of non-trained persons. This is known as the sport adrenal medulla. Expression of β-adrenergic receptors (AR) differs among individual leukocytous populations (NK-cells most, CD4+ cells the least) and among various differential stages in one population. The number of these receptors on the surface of each leukocyte determines its sensitivity to catecholamines and, therefore, also the degree of mobilization during a stress response. Since the blockage of β-AR interferes with leukocytosis during physical activity, adrenaline clearly causes cell mobilization (especially NK-cells) back into circulation

from the marginal vascular field, lymphatic nodes, spleen and intestines. Following the application of catecholamines, two phases are distinguished in general: fast (up to 30 minutes) linked to lymphocyte mobilization and slow (maximum 2–4 hours after administration) characterized by granulocytosis with relative lymphopenia. Catecholamines especially affect the circulation of NKcells and neutrophils while the numbers of B- and T-lymphocytes remain relatively unchanged. Catecholamines also inhibit T-cell proliferation either directly (pathway β-AR) or indirectly through the pathway of altered cytokine production (inhibit IL-1, IL-2, IFN-γ). Taking into consideration that β2-AR are expressed only on Th1-cells and not on Th2-cells, the catecholamines do not directly affect cytokine secretion of the Th2 axis, but mainly the production of IL-4. However, using the same type of receptors, they stimulate the secretion of anti-inflammatory cytokines IL-10 and IL-6 antigens from presenting cells. The plasma concentration of cortisol increases only in relation to longer-lasting activity. In contrast to catecholamines, cortisol acts with a several hour time delay, which contributes to the hypothesis that this hormone probably does not need to elicit immediate changes linked to short-term physical activity. Glucocorticoids suppress B7 expression of human monocytes and dendritic cells and, respectively, act on the down regulation of class II MHC expression in antigen presenting cells (APC), which contributes to an inhibitory effect on APC – bound activation of T-lymphocytes. After administration of one dosage of short acting glucocorticoid, the number of circulating neutrophils increases while the number of lymphocytes, monocytes, eosinophils and basophiles drops. The increase in the number of neutrophils is given by their increased influx from the bone marrow, demarcation and decreased extravasation (diapedesis). These changes act against any possible accumulation of the cells in the area of the inflammation, which, in part, explains the anti-inflammatory effect of glucocorticoids. The decreased number of the other above listed cells is apparently caused by their migration

from the blood vessel bed into the lymphatic tissue. Glucocorticoids act synergistically together with catecholamines and cause the above mentioned Th2 shift by inhibiting production of IL-12 antigen by the presenting cells and, therefore, the subsequent TH1-cell stimulation. Similarly, they inhibit the production of IL-1, TNF and IFN-γ. However, in contrast to catecholamines, the glucocorticoids act directly on Th2-cells and, in this way, potentiate the production of IL-4 and IT-10. Dendritic cells (DC) play an important role in relation to physical activity. These cells are considered the most effective antigenpresenting cells. Some studies described early changes in the number and function of basic components of cell immunity following athletic activity; the behavior of circulating DC was studied only partially, but so far the findings show their non-negligible importance in immunology during physical activity. They complete, among other things, a mosaic of current knowledge of an increased predisposition toward infectious diseases following intensive physical activity. In the body, the dendritic cells are found in immature form as well as mature forms. Immature forms are strategically spread in tissues, which are on the outer layers of the body and its surrounding environment. The greatest number can be found in the skin and in the mucous membranes of the pulmonary and digestive systems where they form 1–25% of the overall cell count. The dendritic cells in the mucous membrane even “extend” their dendrites amongst the epithelial cells on the mucous surface and actively collect samples of food or inhaled antigens. Dendritic cells are found in a smaller amount in nearly all organs and tissues and dynamically migrate between the blood and lymph. If there is no infection present in the body, the immature dendritic cells absorb dead cells of the healthy tissues and the molecules dissolved in the intercellular fluid on an ongoing basis. During its path between the tissues and the lymphatic nodes, they process their own absorbed molecules and expose their fragments in a complex with MHC proteins on their surface. Specific T-lymphocytes that do not recognize such “normal” auto-antigens are

not activated. They are either completely inhibited or they become regulatory T cells, which suppress immune reactions toward a given antigen. The immature dendritic cells significantly contribute to the preservation of tolerance toward their own tissues. If the immature dendritic cells recognize a stimulus that can be potentially dangerous to the organism (most often these are pathogenic microorganisms or their own cells that do not die through necrosis), then they become activated and become mature dendritic cells. Such dangerous molecular structures are recognized by corresponding toll-like receptors (TLR). The activation elicited through various receptors leads to dendritic cell differentiation (maturation) and it is linked to dramatic changes in their character. Maturing DCs shift from the tissues to the lymphatic nodes and other secondary lymphatic organs and lose their ability to absorb particles from the environment and change into active antigen-presenting cells (APC). This is shown mainly by a strong increase of MHC protein expression, co-stimulating molecules (CD80, CD86), adhesive molecules and by the production of cytokines needed for optimal stimulation for differentiation of antigen specific effector Tlymphocytes (i.e., IL-1, IL-6, TNF and IL-12). Only mature DCs can activate “naïve” T-lymphocytes, meaning the ones that have not yet encountered an antigen. Dendritic cells last approximately 2–3 days, during which they activate T lymphocytes and then cease to exist through apoptosis. The supply of DCs is continuously supplemented from precursors in the bone marrow and perhaps also from blood monocytes. Acute and chronic physical activity significantly decreases expression of TLR and co-stimulating molecules on the DC surface. The above described immature and mature DCs are known as the so called myeloid DCs (mDC). In addition to these cells, morphologically and functionally different plasmacytoid DC (PDC) cells exist. Myeloid DCs express mostly TLR and their main function is to stimulate the antigen specific T-lymphocytes in the mature stage. Plasmacytoid DCs express mainly the receptors of nucleic acids TLR-7 and TLR-9. This explains a long known fact that when encountering a virus they produce a large amount of interferon α (IFN-α). TLR-7 and

TLR-9 are very effectively stimulated by viral RNA, respectively DNA. Also in DCs, following their stimulation, maturation occurs and transformation into active APC for antigen specific T lymphocytes. Production of IFN-α pDC is, among other things, important for activation of NK-cells, which also markedly contribute to the body’s defense against viruses. Increased levels of IL-6, adrenalin and cortisol and, additionally, a drop in the expression of TLR antigen-presenting cells elicited by physical activity can contribute to post-activity immunosuppression and subsequently to a higher predisposition to infections by suppressing the formation of cytokine Th1-cells and macrophages leading to the inhibition of cellular components of the immune system and, in contrast, toward a shift in the direction of Th2 response. This shift, however, clearly brings about a significant health benefit in the form of decreasing the body’s anti-inflammatory capacity. Individuals with regular physical activity truly show lower levels of inflammatory biomarkers (i.e., CRP) with a corresponding decline in the risk of certain chronic diseases (cardiovascular, metabolic, etc.). For this reason, it can be assumed that a higher predisposition to a viral infection linked to intensive physical activity (especially in elite athletes) is only a small token for its long-term anti-infectious activity.

3.2 FUNCTIONAL STRESS TEST IN PATIENTS WITH CARDIOPULMONARY DYSFUNCTION Jiří Radvanský The foundation of rehabilitation for a patient with cardiopulmonary system dysfunction lies in convincing the patient that an active attitude toward exercise within the context of changes of their overall lifestyle is a necessary component of treatment. For most rehabilitation approaches, it is desirable to know the patients’ fitness level and reaction to physical activity aimed specifically at those pathological signs that do not manifest themselves at rest.

3.2.1 Laboratory Stress Test Indications: Diagnosis of decreased coronary reserve; assessment of risk and prognosis in symptomatic patients, those with a history of ischemic heart disease or with multifaceted risk factors; in patients with myocardial infarction in early post-hospitalization phase with a goal to optimize the subsequent treatment approach; pre- and postrevascularization procedures; in patients with chronic heart failure to determine prognosis and suggest exercise treatment; for patients prior to being placed on the waiting list for heart transplant due to arrhythmia Check treatment effectiveness of symptoms dependent on activity: arrhythmia, claudication, dyspnea upon exertion, activity hypertension, change in medication Prior to return to sports, traveling and challenging activities of daily living (ADL) Prior to admission into a supervised exercise treatment program (modified by a rehabilitation physician, physical therapist, diabetologist, pulmonologist or a cardiologist) Check for the effectiveness of supervised exercise treatment, rehabilitation or physical therapy Activity assessment including assessment of the functional ability of

an elderly patient; also includes evaluating the demands placed on a patient following lower extremity amputation and their ability to undergo gait training with a prosthesis; functional diagnosis to assess the risk of early post-operative period following elective surgeries Motivation to habitually increase physical activity Contraindications: Acute infectious illness Myocardial infarction (first 4 days) Unstable angina pectoris Worsening diabetes type I and II Serious deficit in ph balance Previously detected and so far untreated stenosis of the left coronary artery trunk Electric myocardial instability Aortic dissection Acute inflammatory cardiac illness Acute pulmonary embolism Valve stenosis Heart failure NYHA III and IV Severe arterial hypoxemia, global respiratory insufficiency Following CVA (3 months) Movement system diseases restricting physical activity Significant anemia Moderate forms of thyroid and endocrine pathologies Insufficiently treated hypertension Conditions involving metabolic dysfunction Early period following pulmonary embolism

3.2.2 Basic Terminology of a Functional Stress Test Physical Fitness and Performance Physical fitness is the ability to manage physical activity and the resulting stress, including mastering the surrounding influences (external environment).

Performance is a narrower term usually defined as the ability to perform a measured activity in a certain movement domain. It is a term that is closely connected to athletic performance. Athletic performance is usually assessed from the perspective of speed, strength and endurance. Psychomotor coordination and agility are defined outside of the term performance. Strength performance is the ability to perform short-term physical activity of a high intensity (expressed as force activity over distance). It is apparent mainly in the muscle tissue, its structure (type of muscle fibers), the ability of its activation and movement coordination and less by metabolism. Endurance Endurance is substantially more difficult to measure than strength performance and, therefore, the term endurance fitness is being used. It is the ability to resist a prolonged (according to deep-seated usage it can be a number of minutes or hours) physical stress. The foundation is the ability, through regulation, to form and maintain a sufficiently long period of resistance to a physical stress in a sustainable and balanced state of loading until the defensive inhibitory reflex occurs, i.e., fatigue. Fatigue prevents the exhaustion phase. Endurance fitness is significantly multifactorial, as seen by the combination of genetics and the momentary state of a number of functions – metabolic, cardiorespiratory, mobility and psychological. Maximal Oxygen Consumption Maximum oxygen consumption (maximum aerobic capacity, VO2max) expresses the overall ability to aerobically utilize nutrients and, at the same time, it is considered the most dependable value to predict endurance fitness. It is measured as the highest achieved oxygen consumption during a graded exercise test to a maximum level. It is expressed in milliliters of consumed oxygen on a kilogram of weight in one minute. In English literature, it is also expressed in multiples of resting tabular oxygen consumption, therefore, the resting metabolic equivalent (MET). Its value is 3.5 ml per kilogram in a minute and it is known as 1 MET (METs in plural). In a scenario, in which, due to a

medical condition, the cardiopulmonary system cannot be gradually and slowly stressed to a full maximum, the peak value of achieved oxygen consumption is used (VO2peak). Ergometer and Treadmill An ergometer and a treadmill serve as the essential tools for laboratory stress tests. On a bicycle ergometer, the patient is exposed to a stress test at a pre-set value. The performance, or work over time, usually described in watts (1W = 6.12 kp · m · min–1), should be measured in relation to the patient’s weight, thus, watts per kilogram. With ergometers with the option to select the load independently of the rotation velocity, the patient can select a pedaling velocity between 55–75 rotations per minute. At a maximum, the load can be increased gradually beyond this limit. The advantage over the treadmill less artifacts during EKG scanning; it is an easier non-invasive or invasive assessment; a greater amount of safety and the easily attainable linear increase in loading (Fig. 3.2.2-1). Fig. 3.2.2-1 Stress test laboratory with an ergometer

The treadmill uses a more physiological dynamic pattern involving loading of the upper and lower body. That is its greatest advantage: during running, the patient can be stressed to a complete maximum and maximal oxygen consumption is usually 10% greater than on an ergometer. Maximum performance given by the speed and the angle of the treadmill can calculate only an approximate oxygen

consumption value (METs) while presuming that the patient did not hold on to the handle bars and that the speed of the treadmill was increased slowly. The description of the stress protocol needs to be documented. The treadmill is preferred especially by athletes. The ergometer is preferred by the European stress testing school given its higher quality of stress EKG recording and the ease in obtaining blood pressure measurements during the test.

3.2.3 Fitness Testing in Less Fit Individuals Basic Testing Domains Fitness testing in less fit individuals, mostly in chronically ill patients or the elderly, has three main domains: Functionally Metabolic Domain It can be detected only in selected patients by standard testing via a graded stress test up to the maximum, which is performed in athletes. During gradually increased loading up to the maximum, the patient is stressed so that the maximum is reached between the 8th and 16th minute from the test’s initiation. During such a test, between approximately the second and highest third of the loading intensity, the patient experiences a regulatory breaking point known as the anaerobic threshold (steep increase in blood lactate usually around 3– 5 mmol/l and non-linear increase in minute ventilation greater than the one corresponding to increased oxygen consumption). With a loading intensity above the anaerobic threshold, oxygen consumption continues to increase, but not as steeply as in an intensity below the threshold. During an additional increase in respiratory load, the exchange coefficient (expenditure of carbon dioxide divided by oxygen consumption) increases from a value close to 1.0, which is within the anaerobic threshold up to a level of 1.10–1.25. At this time, fatigue occurs due to achieving maximal aerobic stress, during which maximal oxygen consumption was obtained (VO2max). Symptomatic Domain In contrast to healthy athletes, fitness in many seniors and chronically ill patients is limited by symptoms and, thus, clearly pathological

signs linked to negative emotions (symptomatically limited load). These most often include pain originating from a musculoskeletal system dysfunction or local ischemia of working muscles, angina pectoris with ischemic heart disease, dyspnea of cardiac or pulmonary origin, pathological fatigue with low cardiac output during loading or in certain metabolic and endocrine diseases. Volitional Domain Fitness is limited by volitional characteristics. If the patient is limited by uncertainty, negative experiences with intense loading or is depressed, they perceive physical stress more unfavorably and often are not willing to tolerate the test to a complete maximum. Equivalent is the purposeful behavior and inability to tolerate unpleasant or unusual sensations even in healthy individuals with extremely low physical activity. The recognition and differentiation of symptomatically limited loading from a state of severe chronic hypokinesis involves either good experience with simple functional testing or with rather expensive equipment, i.e., fast analyzer of respiratory gas exchange showing respiratory exchange coefficient at the moment of completion of the patient’s loading and, thus, a degree of ventilator compensation of metabolic acidosis. If the patient is limited volitionally or symptomatically, one of the submaximal laboratory tests can be implemented. Selection of Loading Type Gradual stress test on a bicycle ergometer to the maximum or to a symptom-limited load remains the gold standard in stress testing of less fit patients. The vital circulatory parameters are monitored by an EKG recording and by measuring gas exchange and blood pressure (the reliability of automatic measuring tools including a 24 hour BP recording is controversial for peak values of blood pressure during loading). If possible, the test is initiated by a brief static load of a small muscle group – most often it is one third of the maximum volitional contraction of the non-dominant hand to exhaustion – and following a brief rest period (5–10 minutes is usually sufficient for BP and the

pulse to return to original values), the test is continued with dynamic loading. This initial brief strength assessment can also assist in identifying a “problematic patient”. One who is anxious, uncooperative and show low ability to overcome fatigue. In laboratory conditions, one of three alternatives is almost always selected for dynamic (isotonic) loading: ergometer – treadmill – windlass ergometer (upper body ergometer; for patients unable to ambulate or use regular bicycle ergometer). An ergometer, or bicycle ergometry, is always selected in scenarios, in which the patient spontaneously prefers it to a treadmill or in patients who, at least until recently, rode a bicycle or an ergometer. For patients with advanced lower extremity arthritis, a dif​ferent method needs to be selected: treadmill or upper body ergometer. The load on the ergometer is basically selected based on the patient’s weight. According to a classic schema of stress testing protocols with the duration of one grade for 2–4 minutes, the load is gradually increased without an interruption to the maximum. A several second interruption to obtain a quality EKG recording and blood pressure reading is acceptable. In extremely unfit patients, the intensity is increased from 0.25 W· kg–1 and it is increased by 0.25 W· kg–1. For the majority of patients who come to the clinic ambulating faster rather than very slowly, they begin at 0.5 W· kg–1 intensity. The load is increased by 0.24–0.5 W· kg–1. In highly fit patients less than 60 years of age, the first degree is selected at 1 W· kg–1 and the load is increased by 1 W· kg–1. For pulmonary reasons, the protocol sometimes suggests a continuous linear load increase to the maximum. The steepness needs to be estimated and the maximum should be achieved between 10–13 minutes. These approaches can be combined. After one to three submaximal grades (i.e., 0.5 and 1 W· kg–1), a decision needs to be made whether the test will continue in the same manner or whether the load will be completed in approximately three to seven minutes, with a continuously graded load up to the maximum, in other words to symptom-limited exertion. The length of one submaximal grade is

constant. Therefore, at the beginning, the duration of two, three or four minutes is selected. Cardiologists recommend selecting two minutes, but, from a physiological perspective, this is questionable. A balanced state occurs after approximately 3–4 minutes, especially in unfit patients or in seniors, but most of them are not motivated long enough for one grade of loading and they terminate the test prematurely. An older recommendation by World Health Organization was three minutes. A treadmill is larger, noisier and more expensive, with a higher incidence of complications, less accessible EKG and blood pressure monitoring and it is often stopped during more invasive tests. The main advantages include greater loading of the upper body muscles with a usually higher VO2max by about 10% and a greater maximal pulse rate by about 5–10 pulses when compared to ergometer testing. Loading intensity is regulated by the treadmill speed and incline level, such as in the modified Naughton protocol (Tab. 3.2.3-1). Other facilities use a protocol based on Bruce, which is more suitable for athletes (Tab. 3.2.3-2).

Tab. 3.2.3-1 Modified Naughton Protocol

Tab. 3.2.3-2 Bruce Protocol

3.2.4 Fitness Assessment Based on Submaximal Stress Tests Due to a lack of types of assessments gas exchange and from an effort to find tests that would assess performance without the necessity of stressing patients at risk to the maximum, certain tests received excessive attention, especially the Index W170 (see below). Submaximal stress tests are a reasonable solution for patients whose physical performance is limited by symptoms, low motivation and in some cases, in which a larger number of individuals needs to be divided into groups to exercise based on their fitness level. As the name of the test suggests, the tests, in principle, should not be administered with severely subjective and maximal loading and thus,

they are not suitable for an early diagnosis of disease changes. A negative result does not mean that the illness does not present itself during maximal loading. The submaximal tests are used as a primary check of medication effectiveness, but are appropriate only for patients who do not reach their subjective maximal intensity of physical activity during their regular daily activities. The outcome value of these tests can be done by special long stress test protocols lasting several tens of minutes and which are not done in clinical practice due to their high time demands. Submaximal Tests outside the Laboratory Outside of the laboratory, an individual’s overall ability to perform in specific conditions is assessed. The tests are especially appropriate for stratification of individual performance in patient groups during group exercise therapy. It can only be performed with well cooperative individuals. The test standardization requires using the same distance (track) and environment – a park, hospital hall, and premises of a treatment facility or a tourist path. There are two main alternatives to the test: 1. The given distance of a circuit and measurement of time it takes for the patient to complete it as fast as possible without feeling obvious emotionally negative or pathological signs. 2. The given time of stress test – the distance walked is measured (“walk for 20 minutes as fast as possible”). The distance, time and speed are determined based on the patient’s functional fitness level and require experience and at least, to a certain degree, a homogenous group of patients. Based on the options, the circulatory parameters are measured during the test, including pulse, blood pressure and EKG – either “off-line” by monitoring BP and EKG or by telemetry. Outside the laboratory, arterial hypoxemia can be indirectly measured by the dynamics of decreased hemoglobin saturation through pulse oximetry. To simply obtain a pulse at various levels of physical activity, it can be measured by external devices, such as a chest belt, in which the pulse can be read on a watch (they are

referred to as sport testers). A-Six-Minute-Walk Test (6 MWT) is a commonly used alternative to a submaximal test outside the laboratory with published reference values for various age groups. The patient is instructed to walk as fast as possible for 6 minutes. It is mainly used in adult patients with pulmonary diseases. Tests outside the laboratory were previously used in patients with cardiovascular diseases in the form of step ups – Master’s Two Step Test is the most known. Submaximal Laboratory Tests Today a physical therapist today selects submaximal testing directly outside the laboratory or during group exercise, while a physician usually uses a more exact laboratory assessment. Submaximal tests in patients with symptom-limited physical activity are usually based on bicycle ergometry and the relationship between performance in a stable state and their pulse’s response. They assess changes in fitness and the effectiveness of medication (and, also not forgotten, the patient’s feelings of security and safety during additional exercise treatment). In principle, submaximal tests can also include tests that are completed by symptom limited physical activity or by reaching 85% of the predicted maximum pulse rate based on age. In international literature, these standardized tests for cardiologists are known as GXT (Graded Exercise Test or Cardiac Stress Test). Since it is difficult to distinguish whether the test in the laboratory was submaximal or if it reached the patient’s true metabolic maximum, the assessment needs to state the reason for termination of the test. Performance indexes W 170, W 150, W 130 provide the intensity of physical activity on a bicycle ergometer corresponding to the pulse (standardized) in a stable state. They should always be expressed in watts per kilogram of weight; i.e., index W 170/kg states in how many watts per kilogram of weight present on an ergometer will the patients demonstrate a balanced pulse of 170 pulses per minute. They are usually determined from a graph of two or more intensities during one test. For many reasons they have a low outcome value and their

popularity does not correspond to its clinical significance; i.e., patients treated by β-blockers show inadequately high indexes.

3.2.5 Assessment of Stress Test The record of a stress test should always contain the following: 1. The reasons for stress test indication, patient’s medication, possible conditions related to relative contraindication, type of selected stress test protocol (with the intensity being expressed consistently in watts per kilogram of weight). 2. All the patient’s negative reactions linked to a physical demand. 3. Objective description of the main cardiorespiratory parameters at each individual grade of the stress test, especially pulse acceleration, increase in systolic blood pressure, occurrence of symptoms of decreased coronary reserve, dysrhythmia and other pathologies on an EKG and dynamics of hemoglobin saturation during the stress test (pulse oximetry should be a routine component of the assessment in every patient with dyspnea in their anamnesis). During the stress test, the systolic blood pressure rises as a sign of good contractibility of the myocardium. The reaction to the stress test; however, should be proportionate. For younger and middle aged individuals, an increase of 30 mm Hg for each watt per kilogram of weight is considered (as a very tolerant level) the upper threshold of systolic blood pressure rise vs. its resting value. Systolic blood pressure above 250 mm Hg is a contraindication for continuation of the stress test. 4. The reason for stress test termination in tests to a subjective maximum or in a symptom limited stress test. For differential diagnosis of causes for decreased fitness, it is also important to note whether the patient was more limited by muscles or by dyspnea during heavy physical activity. 5. Information about the relationship between blood pressure increase and the intensity of the stress test. Hypertonic reaction is at a maximum above 250 mm Hg (in young, fit individuals without any risk factors above 280 mm Hg; in patients following a

stroke or transient ischemic attack it is less). Maximum achieved physical stress is expressed to assess the rise in systolic blood pressure in watts per kilogram of weight. In maximum stress tests on the ergometer, the rise in the systolic blood pressure when compared to resting values should not exceed 30 mm Hg per 1 W· kg–1 in a younger individual and, in the elderly, slightly more at approximately 40 mm Hg per 1 W· kg–1. A pathological reaction to a stress test is also suspicious, in which the systolic blood pressure does not rise with increasing intensity when compared to the previous intensity (exception: a transition from the first “warm-up” level to a higher level). 6. In tests registering gas exchange – spiroergometry – it is documented whether the true, aerobic metabolic maximum was achieved with subsequent metabolic acidosis compensated for by hyperventilation. In such a scenario, the respiratory exchange ratio (RER), or the ratio between the exhaled CO2 and inhaled O2, needs to be above 1.1 in the last quarter of a minute of the stress test and the maximum measured oxygen consumption is denoted as VO2max. If this state was not achieved, it is denoted as VO2peak. If the patients did not reach a true metabolic maximum, it is recommended to identify the main reason why the patient terminated the stress test prematurely. 7. In tests without registration of gas exchange, oxygen consumption can be approximated from the performance in watts at a maximum intensity (on the treadmill, from the incline angle and the belt speed). RER is not available and whether the patient reached metabolic maximum can be checked only by the pulse – which is a value with a standard deviation of ten pulses. During such large population differences, it is very controversial whether “the expected pulse” value should be used. Two people with the same fitness level, one with a maximum pulse at a lower threshold and the other with an upper threshold norm can differ in maximum pulse frequency by as much as 40 pulses. Simplification in the form of deduction of VO2peak or VO2max from maximum

intensity of the ergometer can be only allowed when the stress test protocol is progressed reasonably and brings the patient to maximum performance in approximately 10–15 minutes of testing and in 8–12 minutes for non-fit patients (including the warm-up phase of the test). The estimation of whether the patient reached the true maximum is given only by the examiner’s experience and not by the percentage of the predicted maximum pulse rate. In general, it can be said that for consumption (in milliliters per kilogram of weight) derived from a slowly increased intensity expressed in watts per kilogram of weight (W· kg–1), the oxygen consumption (in milliliters per kilogram of weight) equals 12.8 times the load in watts per kilogram of weight plus the resting consumption. One MET can be used as a table value for resting oxygen consumption, thus, 3.5 ml · kg–1 · min–1. The formula is more accurate prior to reaching the anaerobic threshold intensity. Therefore, it overestimates the reality for VO2max, especially for patients with slowly progressing circulatory system diseases and especially in non-fit patients who demonstrate a stress test threshold during relatively lower intensity. Main Indications for Early Termination of a Stress Test Moderate to severe pain from angina pectoris Patient disorientation, ataxia, dizziness, feeling faint ST segment elevation on EKG above 1 mm, horizontal, quickly progressing significant depression of ST segment above 2 mm Onset of severe dysrhythmia during the stress test Blood pressure drop when compared to the previous level of intensity by more than 10–20 mm Hg Onset of cyanosis or quickly decreasing HbO2 saturation Progressive dyspnea Onset of blockage of Tawar branches on EKG that is not clearly distinguishable from ventricular tachycardia Principles of Stress Test Assessment

During stress test assessment, the basic vital parameters are compared to reference values and the identified pathologies, as well as, the patient’s subjective perception of physical loading are evaluated. A simplified stress test assessment can be acceptable as a classic diagnostic cardiology test. Positive Stress Test 1. Intensity provoked horizontal or descending ST segment depression of 80 ms or more on EKG is considered a classic positive stress test for the presence of decreased coronary reserve leading to subendocardial ischemia; suspicious are also depressions ascending 2 or more millimeters in an interval between J point to the end of QRS lasting 80 or more milliseconds. Angina pectoris provoked by a stress test increases the reliability of the stress test. 2. ST segment elevation linked to blood pressure drop. 3. Classic pain caused by angina pectoris with suspicious ST segment depression in a patient at risk. Negative Stress Test The stress test did not provoke subjective or objective signs of cardiovascular system dysfunction. Atypical (Abnormal) Stress Test Small abnormalities developed during the stress test, but did not affect in any major way the results. It is recommended to assess the abnormalities again in several months. Non-Diagnostic Result of a Stress Test This occurs in a symptom limited stress test due to locomotor system dysfunction, in patients who lack cooperation and for technical reasons. The assessment of a stress test from a cardiology perspective is so complex that we recommend consulting specialized literature on this topic. However, let’s remember that a stress test EKG when compared to a reference method (coronarography) as a standard in an ICHS diagnosis shows only 80% sensitivity and 80% specificity.

Assessment of Treatment Effectiveness The first reference test is performed and a re-assessment test is performed following pharmacological or other treatments to assess its effectiveness (by comparing stress test tolerance and the pathological findings during the same loading intensity). Prior to returning to sports, traveling and challenging activities of daily living, including exercise, the patients’ fitness level and the occurrence of pathological findings during loading need to be established. The performance is compared to the reference values and to the planned intensity of physical activity. Prior to initiation of guided exercise (including modifications by a rehabilitation physician, physical therapist, diabetologist, pulmonologist and a cardiologist), the fitness level and the pathologies of the cardiorespiratory system during physical activity are established. Following the comparison to age referenced values and the extent of risk factors, the appropriate intensity is established in the context of the selected goal of exercise and medication. If the patient was stressed to the maximum, the training intensity is derived from the percentage of pulse reserve or maximal oxygen consumption. For endurance, the usual intensity is around 50–60% of heart rate reserve or VO2max with the gradual addition of short intervals inserted several times during the training unit at an intensity close to an anaerobic threshold or just above it. If the patient reached VO2peak during the stress test, the stress test is then used as a foundation to establish individual exercise prescription based on the specialist’s empirical knowledge of exercise performance. The establishment of individual anaerobic threshold for the needs of exercise is usually used less often in the rehabilitation setting due to its excessive elaborateness and the necessity to prolong maximal loading, which can be demotivating in a practical setting.

3.2.6 Assessment of Activity Including Assessment of the Functional Ability of an Elderly Patient The New York Heart Association (NYHA) classifies patients without age consideration into four groups based on physical fitness. Patients

in NYHA categories II–III are indicated for supervised exercise therapy (patients in NYHA I category are not functionally limited and it should be sufficient to provide them with a home exercise program). Patients with chronic cardiac failure and patients with a fitness level corresponding to NYHA III and IV are candidates for specialized rehabilitation. NYHA Classification NYHA I – without functional limitation of physical fitness. The patient is able to reach 7 METs, is able to walk 7km/hr in the community, and can cycle at 19km/hr without cardiac symptoms. NYHA II – slight functional limitation, work capacity at 5–7 METs, can complete all common activities at home and in a physical nonstrenuous work setting. (Insurance companies in the United States recognize disability usually below 5 METs). NYHA III – marked functional limitation, 2–4 METs. The patient can hoe a flower bed, but cannot chop wood and does not tolerate fast walking on a slightly uneven terrain. NYHA IV – very severe functional limitation, signs of cardiac dysfunction at rest or with minimal physical demand, work capacity is below 2 METs and the patient has difficulty to be independent at home. The classification roughly suits the population up to 75 years of age. The result is more credible after spiroergometry versus simple ergometry with the recalculation to METs based on the achieved physical activity. In patients with a lower extremity amputation, the prescribed intensity for upper body ergometry is half the intensity that would correspond to bicycle ergometry. Maximum oxygen consumption; however, cannot be compared with reference values. For gait training with a prosthesis, the patient needs to tolerate an intensity above 0.5 W/kg of weight prior to amputation. The shoulder girdle muscles need to be extensively strengthened in patients who demonstrate a lower fitness level.

3.2.7 Specific Stress Test Adaptations for Patients with Ischemic Heart Disease (IHD) A meta-analysis published in 2005, which includes 48 studies focused on the results of exercise therapy in patients with IHD (with 95% interval reliability from –7 to –32%) shows convincingly that exercise decreased mortality from this disease by 26%. At the same time, it identified that the number or re-infarctions did not decrease, which can be explained by the fact that the risk of onset of sudden cardiac death has simultaneously decreased and thus, the potential for survival has increased. The mortality decreased and thus, the morbidity increased. The overall effect of exercise therapy is indisputable and the VO2max increases within a few months by 10–60% depending on the initial value; the greater the decrease or lower initial value, the greater the increase. Arterio-venous difference also increases, or greater oxygen extraction decreases the extent of the needed blood flow and increases the effectiveness of circulation. Most positive activity occurs in the first 2–3 months but a significant increase in the cardiac output gradually increases and reaches an increase during submaximal loading through the ejection fraction and the systolic (heart rate) output approximately a year after participation in rehabilitation programs. The identification of loading stress eliciting a beneficial adaptation remains an issue. The intensity can be expressed as a percentage of VO2max, which has perhaps the needed accuracy or by heart rate, which is less accurate. Other options include identification of various training load duration, which needs to be accompanied by estimated intensity level. The number of training units per week is an important information. Most controlled studies recommend training 3 times per week for approximately 20 minutes at a heart rate intensity of 70–85%. Currently, it is recommended to supplement aerobic training with resistance training. Its intensity is expressed by a percentage of 1 repetition maximum (RM). Overall training duration increases by a 5-

minute warm-up time and the same amount of cool down time, so it can reach 30 minutes. After some time and with continued improvement, the training time can somewhat increase. It is best for the patient to enter an already established rehabilitation program that most often occurs in the above described manner. A faster walk at 5–6km/hr is a beneficial form of training. The addition of other kinesthetic exercises does not show a substantial effect on the end result other than increased strength with resistive exercises. Resistance training also increases the oxidative capacity of the fast twitch oxidative fibers in people older than 60 years of age. Walking in an outside terrain without much elevation is most suitable for patients without regular check-ups who do not demonstrate any motor deficits in the lower extremities. A 2–3km long loop that the patient is the most familiar with is the easiest to select. The energy expenditure through weekly ambulation should be approximately 1,000 kcal (4,000 kJ), which is about 16 km. This value is considered very effective for prevention and for decreasing the risk of myocardial infarction (MI) by approximately 30–40%. This leads to about 3 hours of walking per week at a speed of 5 km/hr. Maximum recommended HR should be about 60–75%. The situation is more difficult for patients with orthopedic problems. They can pedal on an ergometer, swim or exercise in water. The ergometer is the easiest if it is available to the patient. Further complications with searching for other forms of physical activity make patient compliance difficult. Patients with complications or more severe conditions and with a need for regular check-ups can begin with a lower intensity of up to 65% of HRmax. A practical recommendation has also been cited: exercise slightly below the intensity that elicits dyspnea. It is recommended that patients whose exercise intensity is limited by ischemia also exercise because it has a positive effect on endothelial function, decreases the occurrence of coronary artery spasms caused

by physical activity and by the demands on the heart muscle pumping function. According to some studies, exercise is more effective than a stent placement. In patients with angina pectoris, it has been shown that exercises in provoked angina pectoris decrease ischemia and show a decrease in ST segment depression on EKG. Training principles are similar to myocardial infarction principles. Patients with claudications should also exercise; an increase in claudication distance by 100% can be expected. So far, convincing results were shown only by studies demonstrating improvement after participation in a supervised program. Exercise is not recommended if the symptoms are already increasing at low loads even if the patient attends therapy and it is recommended always following a surgical procedure.

3.3 FUNCTIONAL LUNG ASSESSMENT Jan Šulc

3.3.1 Causes of the Onset of Pulmonary Dysfunctions in Patients with Deficits in the Movement System and in Certain Organ Systems The following conditions contribute to abnormal pulmonary function findings: chronic neuromuscular diseases, thoracic deformities, compression of the respiratory tracts by intra-thoracic or intraabdominal formations, including abnormal vascular structures, frequent and recurrent respiratory infections, bronchial hyperreactivity [increased readiness of the bronchial smooth muscle toward contractions (spasms)], obesity, stiff thorax in certain diseases, diaphragm dysfunction including its unilateral paresis, vocal cord paralysis, deficits in growth and development of the lungs and thorax (including iatrogenic influences, i.e., after radiation treatment). In children, pulmonary functions (PF) are significantly affected by the natural development of the respiratory system Physiologically, pediatric lungs are an immature organ system at the time of birth. If abnormal influences act on this immature system for a certain period of time, remodeling of the pulmonary parenchymal tissue, respiratory pathways and pulmonary vascular network can occur. In addition, pulmonary development can be affected by intensive treatment for various perinatal and postnatal diseases (effects of oxygen therapy, artificial pulmonary ventilation, conditions after extensive cardiac surgeries with thoracotomy, etc.).

3.3.2 Diagnostic Approaches A pulmonary function test (PFT) is a diagnostic method used in rehabilitation. This is a set of testing methods to assess respiratory system (RS) function as a whole as well as its components. From a functional perspective, the respiratory system consists of three

components: the lungs themselves, assessing mainly the static and dynamic volumes and elasticity of the pulmonary parenchymal tissue; the respiratory pathways, assessing an obstruction or, in contrast, the “supranormal” clearance of the respiratory pathways, including its reactivity; and the thorax assessing its shape, alignment and mobility. A special section is designated for respiratory muscles, especially the diaphragm function. The fundamental methods of PFT are based on physics principles that measure flow rate, volume and pressure. Additional methods also utilize other principles, such as those for measuring partial oxygen and/or carbon dioxide pressures or the rate of transition of certain gasses (i.e., helium and carbon monoxide) through the alveolarcapillary membrane, etc. The methods of a function test include methods designed for cooperative patients (approximately starting between 3–4 years of age) and methods for non-cooperative patients (from birth to 3–4 years of age). The reason for this classification is the need for selecting special methods that were developed for patients with disabilities given by either age (i.e., low level of cooperation during testing, low level of motor coordination necessary for execution of certain breathing strategies) or because the disease limits the full administration of a pulmonary function assessment (i.e., patients after spinal cord injury who are bedridden, patients on ventilators, etc.). However, more often the pulmonary function testing methods are classified as follows: Pulmonary volumes Respiratory pathway clearance Lung elasticity Pulmonary diffusion capacity Respiratory muscle function In addition, several other principally novice methods (i.e., electronic record of thoracic respiratory bruits, thoracic vibration, assessment of expiratory condensers or exhaled nitric oxide analysis) have emerged in the past 10–15 years. Their detailed description, however, exceeds the context of this textbook.

The quality of life for patients with a movement system dysfunction or after serious injury, such as a spinal cord injury (SCI) can be influenced by the functional state of the respiratory system. Lung function in these patients is one indicator of the effect of rehabilitation and the requirement for additional treatment. Possible pulmonary function abnormalities can affect the assessment of short-term and especially long-term treatment results. The interaction between the respiratory function itself (i.e., the extent of pulmonary vital capacity) and the movement system condition (movement restrictions in the shoulder joint and/or limited diaphragm function) play an important role. The body’s adaptation ability during dysfunction of one, or both previously mentioned organ systems (respiratory and movement) also plays a certain role at rest as well as during physical activity. Therefore, the pulmonary function test together with a wide set of rehabilitation methods becomes a component of comprehensive assessment of quality of life for patients with a movement system dysfunction. The goal of this chapter is to summarize the basic information about options for the testing of pulmonary function abnormalities in patients with a movement system dysfunction and to comprehend the various clinical interpretations of pulmonary function tests in such patients. Technical Equipment Current equipment for pulmonary function testing is usually based on the original principles of measurement but utilize the ever expanding possibilities of computer data processing. An example can be body pletysmography. The original idea by Menzies (1790) was completed by DuBoise in 1956 and is used to this day in computer form, principally, without any changes. A different example is the enormous progress in data processing (by Fast Fourier Transform) describing respiratory pathway clearance by oscillometric measures (impulse oscillometry). Enormous advances in the process of digitalization of analogous variables (flow, pressure) and in computer processing (i.e., integration of flow signal into volume signal), graphic presentation (i.e., presentation of the flow-volume curve) and statistical data

processing (i.e., diurnal changes of a measured parameter and their comparison with the patient’s “best” personal value) bring to today’s offices of pulmonary, rehabilitation and sports medicine specialists a wide selection of instruments. Their choice depends on the needs of each patient (for example, a patient with tetraplegia cannot be assessed by regular pletysmograph) and on the clinical questions of the treating medical personnel or a research team (Fig. 3.3.2-1) ). Specific names and manufacturer names are not going to be mentioned in this chapter because, except for a few exceptions – thanks to strong competition, quality equipment can be easily obtained based on the specific needs of any clinical facility.

Fig. 3.3.2-1 Standard equipment for a pulmonary function testing laboratory includes a body pletysmograph and certain additional supplementary instrumental sets (i.e., impulse oscillometry module – see the lever above the computer screen, or equipment to measure pulmonary diffusing capacity. Body pletysmograph for infant patients (cylindrical chamber on the right) is considered special equipment.

The Procedure for Pulmonary Function Testing Prior to the initiation of a pulmonary function test, the patient’s accurate demographic and anamnestic data need to be obtained.

These are needed mainly for comparison of the measured (actual) values with the reference (normative) values. It is highly recommended to introduce the patient to the purpose, type and significance of PF testing because specialized teams emphasize the patient’s perfect cooperation during strenuous (forced) breathing maneuvers. Prior to initiating the test, the surrounding environmental conditions (room temperature, humidity, barometric pressure) need to be updated and calibration of the testing equipment and sensors needs to be performed and set. Full professionalism of the examining personnel (technical reliability and correctness, as well as, so called patient couching by the examiner) is ensured by a periodic continuing education training. The goal of testing is to acquire a reproducible record that allows for follow-up clinical assessment. A summative written interpretation of the results with a clinical conclusion (performed by a physician with an appropriate specialty) should also contain clinical implications that provide answers to the clinical questions initially asked. We emphasize that the digitally processed results cannot be left without a clinical conclusion. The methods used are instrumental methods (thus not for instance imaging methods) and require interpretation of all, not just the technical aspects of testing. Methods in Pulmonary Function Testing Static Lung Volumes Static lung volumes (Fig. 3.3.2-2) are measured by body pletysmograph or by dilution methods in non-cooperative patients. Special pletysmographs have been developed for patients with quadriplegia that allow for the patient to be assessed while sitting in a wheelchair.

Fig. 3.3.2-2 Spirographic recording of volume-time and static lung volumes: vital capacity (VC), tidal volume (VT), inspiratory reserve volume (IRV), expiratory reserve volume (ERV), functional residual capacity (FRC), total lung capacity (TLC) and residual volume (RV)

Dynamic Lung Volumes Dynamic lung volumes (Fig. 3.3.2-3) are obtained during forced maximum expiratory maneuver. The obtained parameters are mainly used to assess volumetric parameters of the respiratory system, especially lung size, mobilization capacity and possible lung hyperinflation (based on possible changes in the ratios of individual lung volumes). In non-cooperative pediatric patients, external pressure exerted on the patient’s thorax and abdomen can be used

(the squeeze method – quick thoraco-abdominal compression). Lung volume parameters can reach decreased as well as increased values.

Fig. 3.3.2-3 Functional parameters derived from a spirographic recording of a volume-time and a flow-volume curve (rotated by 90°): inspiratory vital capacity (VC IN), inspiratory capacity (IC), tidal volume (VT), inspiratory reserve volume (IRV), expiratory reserve volume (ERV), one second vital capacity (FEV1), forced vital capacity (FVC), maximal expiratory flow (MEF25, MEF50 and MEF75) and peak expiratory flow (PEF)

Respiratory Pathway Clearance Respiratory pathway clearance is typically measured during a forced maximum expiratory maneuver by a flow-volume curve and at rest as just slightly increased breathing through body pletysmography. A possible respiratory pathway obstruction is then ensured by two completely different methods. The results of both measurements include a number of parameters used for the detailed assessment and even identification of the location of the possible obstruction. The parameters of respiratory pathway clearance can reach decreased or increased values. In non-cooperative pediatric and adult patients, the following methods can also be selected: impulse oscillometry (IOS) utilizing the activity from a wide spectrum oscillatory signal (in the range of 5–20 Hz) that allows for the definition of resistance of the central and peripheral breathing pathways during breathing and a number of other parameters. Next, testing a resting expiratory flow limitation (EFL) by small negative pressure (–0.3 to –0.5 kPa) is

administered (negative expiratory pressure, NEP) (see below). Beside this resting EFL, the maximum expiratory limitation is also recognized (measured during a forced maximum expiration). Another method is called the interrupter technique, which measures resistance of the respiratory system as a whole (Rint). The expiratory flow is interrupted for a very short moment (100 mx) during a resting expiration measurement. Rint is calculated as the difference in the pressure and flow before and after the interruption. Bronchial Reactivity Bronchial reactivity is measured at the end of a resting test by bronchodilation and bronchoconstriction tests. Following spirometric testing, bronchodilation preparation is administered through inhalation and spirometric testing is repeated in 20–30 minutes. A positive test is assessed from the ratio between the measured and control (initial) values. Lung Elasticity Lung elasticity is measured after a balloon probe is inserted into the lower third of the esophagus (Fig. 3.3.2-4). Static pulmonary compliance as well as the values of lung recoil pressures (elastic pulmonary resistance) measured under static conditions at various volumetric levels of the lungs are calculated. Lung recoil pressures are very accurate indicators of the shrinking force of the pulmonary tissue itself while the thoracic elasticity is eliminated. In non-cooperative infants and newborns, the methods based with the Hering-Breuer deflation reflex can be used; however, they measure compliance of the entire respiratory system (the lung – thorax complex). Lung elasticity parameters can reach increased or decreased values.

Fig. 3.3.2-4 Measuring lung elasticity by esophageal balloon method. A – placement of the esophageal balloon in the lower third of the esophagus; B – the procedure of inserting the esophageal balloon through the nasopharyngeal approach

Pulmonary Diffusion Capacity Pulmonary diffusion capacity is most often measured with the singlebreath method with a mixture of low concentration helium and carbon monoxide. In non-cooperative patients, the measurement can be performed by an alternative method during resting breathing. The parameters obtained in this method serve to assess the quantity and quality of oxygen transfer though the alveolar-capillary membrane. The parameters of pulmonary functions depend on the patient’s height, age, weight, body surface area, race and gender. The patient’s position requires special attention, thus, a wide scale of positions from standing or sitting through semi-recumbent, supinated and pronated to an elevated position (with lower body elevated) are used. This influence has a non-negligible effect not only on volumetric parameters (especially functional residual capacity), respiratory pathway clearance and the strength and effectiveness of the respiratory musculature but also on the ventilation/perfusion ratio. A detailed description of the aforementioned changes exceeds the scope of this chapter. Description of Pulmonary Function Parameters A standardized set of indicators (parameters) is used to assess pulmonary function. The method of measuring these indicators, their assessment (for example, reproducibility of the test) and comparison

to the reference (normative) values are strictly defined (standardized). Picture 3.3.2-5 shows the flow-volume curve with a schematic illustration of the expiratory and inspiratory maneuver.

Fig. 3.3.2-5 Function parameters derived from the flow-volume curve: forced vital capacity (FVC), inspiratory capacity (IC), tidal volume (VT), inspiratory reserve volume (IRV), expiratory reserve volume (ERV), maximum expiratory flow (MEF25, MEF50 and MER75), peak expiratory flow (PEF)

Vital capacity (VC) is pulmonary capacity that is mobilized during a slow complete expiration preceded by a complete inspiration (expiratory VC) or, in contrast, during a complete inspiration preceded by a complete expiration (inspiratory VC). In healthy individuals, the size of VC does not differ from forced vital capacity. Forced vital capacity (FVC) is the same as VC and only differs in the fact that the inspiratory, as well as, expiratory maneuver is forced. If FVC significantly differs from VC, additional testing is

recommended to help assess the clinical origin of this difference (body pletysmography and respiratory muscle function assessment are the most appropriate). Total lung capacity (TLC) is a capacity describing the size of the lungs. It is calculated from the sum of inspiratory and functional residual capacity or from the sum of vital capacity and residual volume. Functional residual capacity (FRC) is a pulmonary capacity of lung volume at the end of resting expiration. In this position, the shrinking force of the lung tissue and the expanding (centrifugal) force of the thorax become balanced. It is sometimes called the relaxation volume. Inspiratory capacity (IC) is a lung capacity of the air volume that the patient can breathe in at the end of resting expiration. When the maximum inspiration (to the level of TLC) is reached, the pulmonary tissue demonstrates its maximum shrinking (centripetal) force also known as retractile pulmonary force. Tidal volume (VT) is a parameter of resting breathing used together with respiratory pathway flow for analysis of a breathing pattern. A simple increase or, in contrast, decrease in VT can alert to a number of important pulmonary abnormalities (respiratory pathway obstruction, lung hyperinflation, stiff lungs, etc.). Inspiratory reserve volume (IRV) is a volume of air that the patient can inhale from the end-inspiratory position at rest. Inspiration reserve volume plus VT equals IC. Expiratory reserve volume (ERV) is a volume of air that the patient can exhale after reaching the end-expiratory position at rest. This volume plus RV equals FRC. Residual volume (RV) is the residual amount of air remaining in lungs despite all expiratory efforts. Maximum expiratory flow (MEF) is the speed of gas flow passing through respiratory pathways during a forced expiratory as well as

inspiratory maneuver. It is most often measured at three volumetric levels of FVC (the resultant then being MER25, MEF50 and MEF75). The measured MEF value is used to describe respiratory pathway clearance. The volumetric level at which MEF is measured is important for the location of a possible respiratory pathway obstruction. MEF/TLC is maximum expiratory flow corrected per unit of TLC. Peak expiratory flow (PEF) is the greatest speed of gas flow passing through the respiratory pathways at the beginning of the forced expiratory or inspiratory (PIF) maneuver. This frequently utilized parameter especially describes the passage of the larger respiratory pathways and can be partially used to assess respiratory muscle function. Specific Airway Conductance (sGaw) is a parameter measured during testing by body pletysmograph and calculated from the values of the flow resistance of the respiratory pathways (Raw) and lung volume in the resting expiratory position (FRC). It is the only functional parameter describing respiratory pathway resistance, at which the volumetric level is specifically known and at which this resistance is measured. Forced expiratory volume in one second (FEV1) is the most common dynamic lung volume (corrected per unit of time) describing overall respiratory pathway clearance. The lower the FEV1 the more significant the limitation in respiratory pathway clearance. The ratio of FEV1/FVC specifies the functional diagnosis and helps to distinguish false positive obstruction findings. The significance of the FEV1 parameter in the pediatric population is uncertain. Expiratory flow limitation (EFL) is a self-regulatory function of the tracheobronchial stroma, which does not permit the exceeding of the individual flow value during expiration. The maximum expiratory flow limitation and a resting expiratory flow limitation (tidal EFL) are ensured during maximum expiration. A resting EFL measurement is performed by the NEP instrument, which brings to the patient’s

mouth a low negative pressure (usually –0.5 kPa) during resting expiration. Static lung compliance (Cst) describes volumetric change in the lungs during a unit change in the transpulmonary pressure (where the transpulmonary pressure is an actual difference between the esophageal and oral pressures). The higher the Cst value, the more supple the lungs are. Cst/TLC is a specific static lung compliance, thus, a value of static lung compliance corrected per unit of TLC. Static lung recoil pressure (Pst) is the value of the shrinking, centripetal force of the lung parenchyma leading to a minimal volume in a lung lobe measured at the level of 100%, 90% and 60% of TLC. The higher the Pst the stiffer the lungs; in other words, stiffer lungs have higher elasticity.

3.3.3 Interpretation and Implementation of Conclusions from a Pulmonary Function Test To correctly interpret the results of a pulmonary function test, the patient’s accurate anthropometric (age, gender, height, weight, etc.) and anamnestic data (i.e., active or passive smoking, past medical history, etc.) need to be known. At the same time, the appropriate reference (normal) values need to be selected. Regression formulas are often used to compare measured and reference values that, after the patient’s anthropometric data input, provide the required “normal” value of the required parameter. Today, in a time of fairly quickly changing environments (improved nutrition and changed movement habits in the regular population, etc.), the characteristics of the reference data set need to be known (number of patients, their ethnicity, age, anthropometric data, etc.) to select the appropriate reference values. An increased population migration leading to its low homogeneity also contributes here, even in a relatively small territory (for example, large city agglomeration). For this reason, a large number of narrowly specialized reference values (i.e., for all African Americans) has been developed based on anthropometric differences

in these subpopulations. The following methods are commonly used to compare the measured (actual) values with the reference (normal) values. The result is expressed in percentages of the norm with an interval of normal values (average ± 2 SD) or by using the so called Z-value, a method including the average and standard deviation of the measured parameter. This can allow for correction of the size of the used reference data set of healthy (control) volunteers and a physiological population variability of the parameter. Restrictive Lung Dysfunction In restrictive lung dysfunction, the size of the lungs according to the TLC parameter is significantly lower than the average reference value. Restrictive dysfunction can be extrathoracic (extrinsic) or intrathoracic (intrinsic) in nature. In an extrathoracic restriction caused by, for example, a dysfunction in thoracic growth, normal lung elasticity is found. A restriction of intrathoracic origin, which is often found in interstitial pulmonary processes, confirms a simultaneous finding of increased lung elasticity (increased lung stiffness). We emphasize that a mere decreased VC value is not sufficient for the detection of a restrictive lung dysfunction. Lung Hyperinflation The term lung hyperinflation describes the pathological redistribution of static lung volumes. Hyperinflation can be either static or dynamic. Static (sustainable, fixed) hyperinflation is characterized by increased residual volume to the detriment of vital capacity. From a functional perspective, the moveable lung volume is decreased and the nonmovable residual lung volume, which does not participate in gas exchange, is increased. Lower inspiratory capacity, and often a higher breathing rate with small breathing volumes and a resultant activitydependent and sometimes even resting dyspnea are the consequences of static lung hyperinflation. A long-term pathological change in functional ratios, for example, an obstruction in the peripheral respiratory pathways or a significant thoracic deformity are needed for

the onset of static hyperinflation. A subacutely increased value of functional residual capacity in relation to inspiratory capacity is typical for dynamic (changing) lung hyperinflation. This dynamic hyperinflation develops, for example, during an asthma attack or during a bronchoconstriction test (in sensitive individuals). Under normal conditions, the FRC: IC ratio is approximately 1:1. In other words: at the end of resting expiration, a healthy individual is able to inhale approximately the same amount of air that is already present in the lungs. In a patient with dynamic hyperinflation, the resting endexpiratory position is “placed” higher; therefore, the patient is at the end of resting expiration and still slightly in a state of “inspiration”. Dynamic lung hyperinflation is usually caused by increased bronchial reactivity; there may be more causes in the pediatric population. This is most often corrected by a reversal of the obstruction – either by medication or by appropriate rehabilitation, or for the best results, by implementation of both of these approaches. Obstructive Deficits An obstructed peripheral respiratory tract is a state, in which the maximal expiratory flow (MEF) is abnormally decreased to a level of 25% and 50% of vital capacity and a change in X5 (reactance measured by impulse oscillometry at a frequency of 5Hz). Some laboratories use one second vital capacity (FEV1). The severity of this obstructive deficit is interpreted based on the extent of the decrease (often up to values below 50% of the norm). A decrease in the peak expiratory flow (PEF), one second vital capacity (FEV1) and a change in R20 parameter (resistance measured by impulse oscillometry at a frequency of 20 Hz) are seen in a central respiratory pathway obstruction. However, the PEF value also depends on the strength of the respiratory muscles. A specific airway conductance (sGaw) is another parameter used to assess airway obstruction. An sGaw value below 60% of the norm corresponds to significant obstruction of the central respiratory pathways. So called specific flow values are used for a more accurate assessment of the true extent of clinical significance of an airway obstruction. They are

obtained by the measured MEF values adjusted for lung size. If a patient demonstrates a restrictive deficit with an obstruction, their functional finding is concluded to be a mixed ventilation dysfunction. However, if the values of a specific MEF (that is MEF adjusted for lung size) are within normal ranges during a basic assessment, it is an isolated restrictive lung dysfunction. The absolute clearance of smaller respiratory pathways is decreased, but given the smaller lung size, the overall caliber of these pathways is sufficient for the patient and, thus, this is not an obstructive deficit. Changes in Lung Elastic Properties Stiff, as well as, supple lungs represent pathologically altered elastic properties of the lung parenchymal tissue. Lung elasticity is assessed based on lung recoil pressures (Pst). In addition, static (Cst) or, occasionally, dynamic (Cdyn) lung compliance values are used. Increased lung elasticity is found in stiffer lungs and, in contrast, decreased lung elasticity correlates to more supple lungs (with greater lung compliance). A functional finding of small and, at the same time, stiff lungs can be interpreted as a restrictive deficit of intrapulmonary origin. In newborns and small infants, the compliance of the respiratory system (Crs) is advantageously measured and can be interpreted as an increase or decrease in the compliance of the lungs themselves. This is given physiologically by high thoracic flexibility in pediatric patients prior to the onset of ossification processes.

IMPLEMENTATION INTO CLINICAL PRACTICE In rehabilitation, pulmonary function (PF) is used to acquire the following information: 1. One-time testing of PF abnormalities in patients with movement system dysfunction prior (one-time) to rehabilitation treatment (physical therapy), during specific rehabilitation and after its completion 2. Long-term observation of PF abnormalities during the course of development of a movement system dysfunction and monitoring

the effect of a long-term rehabilitation program 3. Development of a respiratory system dysfunction in patients after spinal cord injury (SCI) throughout the course of long-term therapeutic treatment 4. Onset (physiological or pathological) of a respiratory system dysfunction in neonatal stage For the above listed purposes, modified sets of PF testing methods can be used. This approach is selected in part due to the specific requirements of rehabilitation teams and their hypothesis (their scientific question) and in part due to the specific distinction of the assessed patients (that is the necessary modification in PF testing method selection in relation to the clinical condition and/or the age of the assessed patients). Examples of appropriate method systems for the above mentioned areas: Spirometry (spirographic recording volume-time, maximal force flow-volume curve), measuring respiratory pathway clearance by other methods (i.e., interruption method assessing respiratory system resistance, NEP method), measuring the function of the respiratory muscles (by measuring PEmax, PImax, P0.1), bronchomotor tests, body pletysmography, or additional measurements of lung elasticity and lung diffusing capacity; Same tests modified based on the recommendations of a physical therapist; Spirometry, measuring airway clearance (see above), measuring respiratory muscle function (by measuring PEmax, PImax, P0.1) and bronchomotor tests; Analysis of resting breathing pattern, measurement of airway clearance by MEP, measuring respiratory system resistance by the interruption method, measuring resting function of the respiratory muscles (method P0.1), body pletysmography (a special version is needed for patients younger than 2 years of age) or additional measurements of lung elasticity by a method that does not require the patient’s cooperation.

SPECIAL SECTION An overview of individual types and groups of diseases is listed in the special section of this chapter. These diseases fall within the scope of internal medicine and treatment rehabilitation is an essential component of their comprehensive treatment and the overall treatment strategy. While mostly the reaction of the individual somatic systems to loading and their testing was described in the general section of this chapter, the following section of this chapter describes the specific application of these findings (together with approaches to treatment rehabilitation) in individual clinical nosological groups and units.

3.4 RESPIRATORY DISEASES Miloš Máček, Jiří Radvanský, Libuše Smolíková, Pavel Kolář

3.4.1 Rehabilitation for Bronchial Asthma Miloš Máček Brief Description of the Condition Bronchial asthma is a disease whose origin continues to be the subject of research studies. At this time, it is considered to be a deficit in the innate immunity and an immune-pathological state of non-purposeful defense of the organism expressed by an inadequate response to an antigen stimulus. Currently, a certain genetic predisposition to allergic manifestations also exists. For the above reasons, in clinical practice, a detailed family anamnesis is important. If neither parent demonstrates any allergic manifestations, the frequency of allergies in a non-selected population is approximately 12–15%. The incidence increases to 20 % if one parent has a history of allergies and it can be expected that approximately 40% of children will demonstrate similar manifestations if both parents demonstrate allergies. The overall number of patients with asthma is estimated at 1–13%. The differences are based on the research methods used and on location. Pollen-based allergens are most common and are followed by fungus and then mites. Common allergens are considered dust, environmental chemical substances, microbial sources, various parasites, certain foods, medications and many others. The actual diagnosis of asthma is based on clinical manifestations. These include states of expiratory dyspnea with typically wheezing elicited by bronchial obstruction, excessive mucus production in the respiratory pathways with simultaneous mucous membrane inflammation and maximum inspiratory alignment of the thorax elicited by inspiratory muscle spasm, specifically in the diaphragm. The patient is unable to breathe out.

The main signs include: hyperactivity of the bronchial mucous membrane, expiratory dyspnea during an attack and transient obstruction of expiratory pathways. Approximately 50% of all cases of asthma develop in childhood in the period prior to five years of age. Early adulthood shows another increase in the number of individuals with asthma. Asthma only rarely develops after 50 years of age. Asthma in children is often preceded by reoccurring viral obstructive bronchitis that can gradually transition into asthma after repeated occurrences. The signs of acute infection fade and infectious allergic manifestation dominate. The longer the illness lasts and the more episodes there are, then more significant are the accompanied somatic complications. Since children present with muscle weakness, decreased physical fitness and a lack of physical activity, they often demonstrate poor body posture, thoracic deformities and functional limitations in movement coordination. Often, the child demonstrates psychological complications given their perception of being isolated from a company of other children if, due to special demands, their participation in child play activities and free physical activity is limited by the parents and the physician. In principle, adult asthma differs from pediatric asthma only in certain areas. Gradually, manifestations of hyperreactivity rather than states elicited by allergens become more prevalent. More often, signs of chronic infection emerge with asthma resembling chronic bronchitis. In children, typical obstruction reversibility decreases and, at first, post-activity and, later, resting dyspnea occurs. During the functional assessment, restrictive changes and signs of chronic obstructive disease can be identified as a result of fibrotic changes. Individual degrees of involvement differ based on the frequency of attacks. Their complete absence means a full remission; sporadic emergence a partial remission. An asthma attack is another level followed by status asthmaticus (critical asthma). Based on the course and results of the function tests, asthma can be

classified as follows: Intermittent asthma (with symptoms less than 1 time per week) Mild course (with symptoms more than 1 time per week, PEF or FEV1 more than 80%) Moderate course (frequent symptoms, night symptoms less than 1 time per week, PEF or FEV1 between 60 and 80%) Severe course (permanent symptoms, frequent night symptoms, PEF or FEV1 less than 60%) Functional tests. Functional test findings often fluctuate based on the patient’s current state. To assess the degree of obstruction, the maximum expiratory flow (PEF) method, forced expiration method (FEV1), as well as, the flow-volume curve during forceful expiration and inspiration (FV curve) can be used. Bronchial hyperreactivity tests also play an important role; that is bronchial dilation tests to assess obstruction reversibility and bronchial-provocation tests. They use histamine, metacholine and physical activity. Rehabilitation Options and the Goal of Exercise Therapy Different methods and approaches are used for the rehabilitation of children and adults. While children practically do not experience any significant symptoms in the time period between attacks, adults often demonstrate chronic bronchitis or even the beginning signs of COPD. In children, breathing exercises (breathing gymnastics) and similar methods are primarily used to address only developing or persisting thoracic deformities and weakness of the corresponding muscles. If this is not the scenario than breathing exercises (breathing gymnastics) are pointless because the breathing muscles of a patient with asthma demonstrate greater strength, which is acquired during asthma attacks when they attempt to push the air through the narrowed respiratory pathways, as shown when measuring respiratory work during an asthma attack. Improving the patient’s fitness level is substantially more significant, which is to a benefit not only during overall therapy, but also in improving tolerance to cold and physical activity and in the reaction to post-activity bronchial spasm. Although,

the reaction to physical activity in patients with asthma does not differ in principle from healthy individuals, the achieved physical fitness values, especially VO2max, are quantitatively lower. The immediate cause is not the illness itself, but the decreased physical activity, excessive guarding of the child from physical activity and often the imposed sedentary lifestyle. However, the physical fitness of children with asthma can be, with sufficient consideration, approximately the same as for healthy children. A group of boys with asthma underwent the same intensity training in soccer as a group of healthy children. After several months of training, the results showed not only an improvement in their health by decreasing the number of attacks and increasing physical fitness, but also in a positive effect on their psychological well-being because they no longer had a feeling of inferiority toward other children. In a meta-analysis of 8 studies of exercise therapy, Anderson reports that in 226 children with asthma, whose majority exercised 3 times per week for 20–30 minutes for a period of at least 4 weeks, the majority of patients demonstrated an increased VO2max and showed improved performance accompanied by an increase in heart rate and ventilation. The majority of subjects did not demonstrate changes during asthma or in bronchial reactivity. Patients with asthma tend to prefer swimming as a form of exercise, which can be explained by the typical breathing against resistance during this sport, as well as, it having lowest occurrence of bronchospasms. Routinely, an increased performance in swimming and VO2max are seen in all trainees with mild to moderate asthma after pre-medication by β2-sympathomimetics. Increased adaptation exhibiting lower ventilation during identical physical activity indicates that a bronchial spasm eventually occurs only during more intense physical activity rather than prior to the initiation of a training program (see below). Some studies report that sports, especially swimming and higher physical activity levels decrease the amount of required medications and the duration of in-hospital stays. Children are less absent from school; in a group of 18 children with asthma, the number of days

absent decreased on average from 185 days to 69 days. A significantly lower number of attacks when compared with previous years was the most important fact. Earlier beliefs about the decreased physical fitness of children with asthma and limiting their physical activity were refuted many years ago. A child with asthma, if they are not right in the middle of an asthma attack can participate in the same athletic activities as a healthy child. Certain limitations eliciting exercise-induced bronchial spasm can be controlled by medication.

EXERCISE-INDUCED BRONCHOSPASM Exercise-induced bronchospasm or a less accurate, but official term, exercise-induced asthma is a fairly common phenomenon seen in patients with asthma and allergies and even in healthy individuals without any signs of asthma. For not quite clear reasons, it has been increasingly diagnosed, especially in athletes. It appears that this phenomenon belongs to the defensive physiological reactions that occur during inhalation of a certain amount of irritating substances. According to numerous data reports, the inhalation of cold air (more than –20 °C) elicits bronchospasm even in completely healthy individuals. It occurs 5–15 minutes after moderate or more intense physical activity and it is demonstrated by dyspnea, coughing, wheezing, sneezing, increased secretion and sometimes chest pressure. Easy diagnosis is performed using FEV1, which is decreased by at least 10% following physical activity during a test performed outside and by 15% during a laboratory test. If exercise-induced asthma is not treated, it ceases within 1 hour. If it occurs and disappears naturally without the administration of medication, a refractory period occurs, during which a new attack does not occur even after more intense physical activity. This time period can last several hours. McFadden expressed an opinion that the original cause of exerciseinduced asthma is the cooling down of the respiratory pathways as a

result of hyperventilation. With a ventilation volume above 30–40 liters, the exercising individual begins to breathe by mouth, which alters the quality of the inspired air whose temperature and humidity drop. This elicits higher evaporation of liquid from the surface of the mucous membrane causing its cooling by up to 18 °C. This change stimulates receptors in the respiratory tract that reflexively elicit bronchoconstriction. The mucous membrane reacts to the cooling by an effort to once again warm up by excessively increasing circulation that elicits edema and, thus, even more narrows the clearance of the small bronchi. At the same time, transient dehydration is applied that results in hyper-osmolarity leading to an exercise-induced asthma. Testing of 120 young adults prior to them enlisting in the army, 7% demonstrated exercise-induced asthma. Following intensive training with special units for 8 weeks, there was no difference in the performance of these individuals and all others. Based on the conclusion of this study, the occurrence of exercise-induced asthma is not a reason to exclude an individual from training or from a physically challenging occupation. The current occurrence of this phenomenon differs from past experiences. According to Larsson, it now occurs in 33% of Swedish cross country skiers compared to 3% of the regular population. The diagnosis was confirmed by the presence of at least two clinical findings and a metacholine test, but only about 10% had previously suspected asthmatic illness. It has been shown that exercise-induced asthma and low FEV1 values are found in very low outside temperatures as low as –20 °C and with humidity decreased between 30–50%. The occurrence was most common after maximal performances accompanied by hyperventilation reaching up to 200 l/min. According to the latest data, athletes participating in summer sports are not excluded from exercise-induced asthma. In 1984, exerciseinduced asthma occurred in 8.6% of Australian Olympic athletes. In 1996, this phenomenon was seen in 15.3% of participants in the summer Olympic Games; in 1998, it was already 21.9% for the

participants in the winter Olympic Games. New studies performed on athletes and potential participants in the Olympic Games, outside of the games themselves also show an increase in exercise-induced asthma. For example, it was 34.7% for Italian athletes in 2007 and 26.5% for Finnish athletes in 2005. According to 8 cross-sectional studies in the past 5 years, the incidence of exercise-induced asthma has increased by 25–35%. The causes for this can only be speculated. Next to external factors, such as increased occurrence of allergens and an increased number of patients with asthma, better diagnostic tools and a broader knowledge of the treating physicians also contribute to these results. The incidence of asthma and exercise-induced asthma also depends on the high pollution that is produced especially by the automobile industry. For example, in one large event, young boys and men participated in physical activity, with several thousand of them practicing on sports fields in large cities. After two years, it was shown that bronchial asthma developed in approximately 10% of the participants. Further examination showed that only those who practiced in sport fields located close to the freeways were affected. The risk was 3.3 times greater than in boys without exercise activity. The areas with low levels of pollution showed no onset of asthma in athletes and non-athletes. Prevention and Treatment of Asthma and Exercise-Induced Bronchospasm Asthma treatment is a complicated matter and, in addition to pharmacological treatment, also requires patient re-education. The main principles include complete treatment of respiratory infections, flu immunization and decreasing hyperreactivity of the bronchial mucous membrane. Experiments have shown that inhalation of corticosteroids prior to physical activity shows no significant effects when compared to a placebo. In a double blind study, it has been shown that a four-week long administration of leukotriene antagonist by mouth has not been very effective. Similarly, a combination of antihistamines, leukotriene

antagonists and Nedocromil inhalation did not show the expected result. The use of β-agonists has been shown to be beneficial. For prevention, formoterol was shown effective when compared to placebo and prevented exercise-induced asthma and thus, a decreased FEV1. Also, beneficial are albuterol, salbutamol, metaprotenerol and terbulatin; all of these act for approximately 4 hours. Recent literature shows fewer studies assessing the effect of exercise therapy in adult patients with asthma than in pediatric patients, nevertheless the results are similar. The effectiveness of exercise therapy is significantly more beneficial in certain climates/elevations. Most authors recommend a mountainous environment with moderate to high elevations. A number of studies confirm decreased bronchial reactivity and inflammatory changes after a six-month-long stay in high elevation mountains, especially in children allergic to mites. They also show a decreased need for medication, especially corticosteroids.

3.4.2 Rehabilitation in Chronic Obstructive Pulmonary Disease (COPD) Miloš Máček The official definition of COPD was developed during an important meeting of leading world specialists who agreed on the definition, classification and the treatment approaches and on a joint activity to suppress the mass incidence of this disease. This disease is characterized by limited bronchial air flow, which is not fully reversible. The obstruction progressively worsens and, at the same time, inflammatory changes develop as a result of inhalation of harmful particles and gasses. Characteristic signs include coughing, sputum expectoration and activity-induced dyspnea. Earlier definitions emphasized the presence of emphysema, which is more a result of chronic bronchitis. Emphysema together with asthma often precede the onset of COPD.

The disease can occur in stages of various intensity. The following are distinguished: Stage I: mild – shows mild airflow limitation (FEV1/FVC < 70%, but FEV1 ≥ 80% predicted) Stage II: moderate – 50% ≤ FEV1 ≤ 80% predicted; shortness of breath after exertion Stage III: severe – characterized by more severe bronchial obstruction with 30% ≤ FEV1 ≤ 50% Stage IV: very severe – 30% ≤ FEV1 predicted + chronic respiratory failure Signs of respiratory or circulatory right-sided failure occur and a drop in partial oxygen pressure below 60 mm Hg and an increase in CO2 above 50 mm Hg are seen. Studies of prevalence showed that cigarette smoking is the deciding risk factor, which, until recently, was caused by a higher frequency of the disease in men. Currently, the number of affected women has increased steeply, which is explained by the increased number of smoking women, their lower resistance and longer duration spent in an environment with gas heating (during cooking). Other factors include poor air quality at work or long-term climate effects, i.e., in farm workers. However, smoking, including second hand smoking continues to be the most decisive factor. Other important factors include so called host factors, such as genetic influences, i.e., α1antitrypsin defect, which increases the negative action of the exposed factors, such as smoking, poor air quality, etc. For COPD mortality, the age at which the patient began smoking is as important as the number of cigarettes smoked in a year. COPD, however, does not develop in every smoker and thus, the risk is determined by the already mentioned hereditary factors. Over time, pulmonary hypertension develops during the course of COPD and it is accompanied by a worsening of arterial hypoxemia and later by hypercapnea. As a cardiac complication with poor

prognosis, failure of the right side of the heart develops leading to cor pulmonale. Treatment should improve health and allow for a certain tolerance to physical activity. No medication, however, can change the decrease in pulmonary functions caused by pulmonary tissue damage. The main medications include bronchodilators that increase FEV1. This group also includes β2-agonists, anticholinergics, and theophylline. Corticosteroids are another type of medication administered either orally or by inhalation. Lately, the inhaled form has been preferred because it has been shown that when these medications were administered orally in tablet form and in much higher dosages than they cause long-term or permanent damage of the oxidative slow twitch muscle fibers in the large muscle groups of the extremities.

PERIPHERAL MUSCLE DYSFUNCTION Biopsy studies of large muscle groups in patients with COPD showed that muscle pain and weakness are not caused by hypoxia as it was claimed for a long time, but probably by decreased physical activity and a sedentary lifestyle of these patients. Muscle weakness manifests itself mainly during locomotion and pain is most often localized in the thigh muscles. The upper extremities are usually less affected than the lower extremities. The loss of muscle tissue results in decreased strength; however, the crosssection of the thigh musculature remains similar to that of a healthy individual. This decrease in strength, which correlates well with decreased movement capacity, is a reliable and independent predictor of mortality without taking into consideration the state of pulmonary function. Histochemical and morphological examinations of the vastus lateralis muscle show that, during inactivity, the number of slow twitch oxidative fibers decreases while the number of fast twitch fibers increases. At the same time, capillarization of the muscle decreases, which causes decreased oxygen supply. This finding is significant

especially in patients with more advanced stages of COPD. Morphological changes result in decreased activity of two main oxidative mitochondrial enzymes, citrate synthase (CS) and HADH. All suggest a severe dysfunction in energy release through oxidative phosphorylation and an increase in glycolytic forms producing lactic acid. A decrease in the first by approximately 30% and an increase in the latter of approximately 34% has been reported. Not all large muscle groups are affected the same. The strength of the upper extremities is usually relatively preserved more. The situation is similar for the diaphragm. So far, the etiology of this dysfunction remains unclear. Most authors consider a multifactorial origin, which includes especially chronic inactivity and deconditioning, as well as, chronic inflammation and other factors, such as hypoxemia, corticosteroid treatment and electrolyte imbalance. Most authors tend to believe that chronic inactivity is the key to the onset of this dysfunction. Many patients out of fear of shortness of breath continue to decrease their physical activity leading to decreased activity tolerance. This leads to an inability to tolerate increased physical activity and, therefore, the psychological resistance to greater muscle activity increases. Irreversible muscle damage decreases the quality of life in these patients. This fact can explain why a certain portion of patients who underwent lung transplantation and acquired hope for increased oxygen supply, continue to be unable to improve their physical activity. Rehabilitation of Patients with COPD Direct application of rehabilitation methods and exercise in such patients occurs in the form of increasing adaptation to physical activity, as well as, by repeated use of various forms of breathing exercises (breathing gymnastics). The first form is more long-term in nature – adaptation develops following exercising that lasts several weeks or months. Most programs last at least 8 weeks and the results remain somewhat longer. Nonetheless, when the training is interrupted, the acquired level of adaptation begins to gradually decrease. Therefore, it is a mistake to organize programs for these

patients that are only a few weeks long and create an impression that the acquired results are permanent. It needs to be understood that these results are an introduction to long-term exercise therapy. According to Troosters (2005), the benefits of a 6-month-long training comprised of walking, bicycle ergometer, ascending stairs and resistance training at 60% intensity of the initial maximum tests and it lasted for 18 months. Other benefits in patients with moderate involvement included decreased dynamic hyperinflation during exercise and decreased inflammatory processes accompanying the disease course and eliciting frequent acute flare-ups. Adaptation can partially substitute the limitation of certain pulmonary functions by a different mechanism and, if the exercise continues, the improvement persists. Breathing gymnastics act directly, bring immediate relief, but their action is short-term and the individual lessons need to be repeated daily or several times per week. The onset of adaptation is based on physiological findings requiring the needed loading intensity between 60 to 80% maximum and of sufficient duration. It occurs in patients in stage I and II and also in patients with more severe involvement. However, this requires not only a significant decrease in intensity, but also the simultaneous use of certain elements of endurance training, relaxation exercises and resistance exercises. It is often reported that the contraindications to exercise therapy for patients with COPD include a dangerous increase in pulmonary artery pressure during physical exertion. Experiments with direct measures, however, showed that this increase is relatively small and does not exceed values registered during sleep. The FEV1 value is an appropriate criterion for inclusion into the exercise group. In patients with more than 40% of predicted value, higher intensity is used; in patients with less than 40% the selected intensity is significantly lower. The results are assessed by standardized questionnaires determining the quality of life, degree of dyspnea and subjective perceptions of exertion according to Borg’s scale. More reliable, although technically more demanding, is determining VO2max, by which even the subjective maximum in less fit

patients with breathing deficits can be measured. If the breathing equivalent for oxygen is calculated, other valuable information about performance and breathing efficiency is acquired. Commonly, a pulse oximeter is used in clinical practice as an excellent assistant in determining the level of exertion. A pulse oximeter measures immediately and with sufficient accuracy the degree of partial respiratory weakness during exertion. A readily available chest strap and wrist watch are used to measure heart rate (after the instrument has been tested on a particular patient). The ever developing implementation of exercise therapy for COPD in a large number of patients discovered an interesting fact. Within a group of patients, approximately 40% of whom use exercise therapy and the others some alternative form of respiratory physical therapy, they show little or no change. Some experiences lead to the conclusion that the patients whose muscle strength is preserved to a greater degree, even if they show decreased respiratory functions, better respond to future exercise. Patients, who respond to exercise by improving the factors of quality of life, show smaller gains from exercise therapy. The main contraindications to exercise therapy in patients with COPD include the following: Cor pulmonale worsening Significant overloading of right-sided heart and pulmonary hypertension Severe bronchial asthma not controlled by medication Exertional hypoxemia (it is less expressed on an ergometer than during walking) Significant arrhythmias Other significant illnesses that prevent the patient’s participation in individual or group based physical activity Program for Patients with Mild and Moderate COPD This program was developed based on the following experiment. A group of patients with FEV1 43 ± 16% underwent higher intensity

exercise and the second group 50% lower intensity. The patients’ ages were 69 ± 7 years. The program lasted 8 weeks and each participant had 16 sessions. The first type of intense physical activity consisted of treadmill or ergometer exercise twice a week at approximately 80% of intensity in watts reached during the initial maximum test. The exercise session lasted 30–40 minutes and gradually became longer by adding a several-minute-long warm up and a cool down at the end of session to implement certain instructional principles. During the exercise session, the patient’s condition was checked by a 10-point Borg scale, in which the perception of exertion and shortness of breath should not pass grade 7 or drop below grade 4. Heart rate should not increase above its value at initial testing. Patients in the group with more intensive physical activity showed better results in all indicators. Exertional dyspnea decreased significantly in the first group, but not in the second group. Nonetheless, even the second group registered certain progress. Endurance walking increased in both groups, health test scores improved, and sit-stand test improved as well as other assistive indicators. This study showed the objective advantages of the more intense program, but even the second group showed beneficial changes just to a smaller extent. Although it is difficult to analyze both programs to a greater detail, it is likely that the intense program elicited the needed adaptation to exertion and thus, the expected effect that will last several months. The less intense program could not elicit adaptation, but the movement training and better mastering of daily activities brought an increased score in quality of living and walking endurance. If the patient does not follow through with persistent physical activity, the changes are likely to be short-term and transient, but nonetheless, beneficial to the patient. Most authors agreeably state that higher intensity is more beneficial and it is used especially in patients with a mild or moderate disease stage. The most beneficial are thought to be sessions lasting 30 minutes and repeated 3–5 times per week. In more involved patients

who are limited by shortness of breath, exertional partial respiratory insufficiency occurs with a drop in hemoglobin saturation in the arterial blood substantially earlier when walking than when exercising on an ergometer with elevated handle bars. Arterial hypoxemia by itself during exertion is already an indication for using oxygen supplementation while exercising. Assistive Methods with Exercise Therapy in COPD Since some of the patients do not respond sufficiently to movement treatment, certain supplementary methodical approaches are recommended that can strengthen and accelerate the effect of rehabilitation methods. A brief overview of these methods and their possible interpretation follows: 1. Deeper breathing through increasing the dead space Deeper breathing through increasing the dead space is a simple method appropriate especially in patients who are bedridden. Normocapnic hyperventilation is performed, in which the patient breathes into a 30 cm long and 3 cm wide tube. This added dead space increases ventilation by approximately 20–30 l/min. It is recommended that this method is performed under the supervision of a physical therapist. It should be performed 2–3 times per day when mastered. A manufacturer supplies the tubes with a table that is adjustable in length and is used for deepening breathing. 2. Exercise therapy assisted by long acting bronchodilation aides Bronchodilation is elicited by tiotropium, which has a long-lasting anticholinergic effect. It is administered in an 18 μg-dosage one time per day. This preparation has been shown to be beneficial in an 8week-long rehabilitation program because it allowed for an increased intensity of 80 % of the initial test. The results included decreased hyperinflation at rest and especially during exertion. A substantially longer lasting effect of the rehabilitation program after 3 months has been observed in those patients who received tiotropium while in others, the effect stopped substantially earlier, usually with the end of

the rehabilitation program. At the same time, as a side finding, the authors demonstrated that the effect of the tested medication used to decrease dyspnea and increase performance is more successful when compared to the administration of albuterol. The combination of exercise therapy with simultaneous use of inhalation aides has been shown to be a very effective approach allowing for the increased effects of exercise therapy (Casaburi, 2009). 3. Exercise therapy and simultaneous oxygen administration With increased work capacity, shortness of breath decreases and a positive effect occurs earlier. This approach is used especially in those patients who demonstrate hypoxia at rest. During exertion, the performance increases as the duration of physical activity increases. When 3 liters of oxygen per minute were administered, the time of exertion increased by 50%. The option of accelerating the course of the rehabilitation programs is an advantage of this method. Most often, a mixture of Heliox is used, which contains 28% oxygen and 72% helium. The improved results can be explained by lower resistance within the respiratory tracts and easier lung emptying. 4. Inspiratory pressure assist Inspiratory pressure assist can diffuse the conflict between poor performance or inefficient breathing accompanied by increased respiratory pathway resistance and the demands on the respiratory musculature. The activity of the inspiratory muscles can be facilitated by a pressure drop of 10cm H2O. With the help of this method, the performance of patients with a more severe form of COPD has increased with exertion up to 75% of their maximum performance despite the fact that these changes were not manifested in the assessment from the questionnaire about dyspnea levels. This method also has certain disadvantages. Its application requires continuous supervision by a physical therapist, which makes it more costly. Also, breathing in a mask or using a mouthpiece is uncomfortable for patients and limits communication.

Patients with higher hypercapnea should use this method during training because it prevents the onset of chronic alveolar hypoventilation that develops during unmet breathing requirements when the inspiratory muscles are weak. This method can also be indicated in more involved patients as a temporary treatment used intermittently during the day, i.e., for approximately 3 hours per day, 5 days a week or for 3 weeks. The patients show improvement in the Six-Minute Walk Test during this time when compared to patients from a control group (without any intervention). 5. Exercise therapy and inspiratory muscle training Routine use of this method has not been shown to be beneficial. It has only been beneficial for patients with significant inspiratory muscle weakness, which was defined as decreased intra-oral inspiratory pressure below 60%. Although the results of the training of these muscles were significant, they did not demonstrate any changes during the Six-Minute Walk Test or any other indicator of quality of life. The benefit was only manifested in patients with chronic hypercapnea, in whom PaCO2 was higher than 45 mm Hg. 6. Exercise therapy and interval training Not all patients are able to maintain the required walking speed or ride a stationary bicycle in a balanced state for a long time. In such a case, interval training is used. It is based on the principle of regularly alternating lower and higher intensity physical activity. During this type of training, 30 seconds to 1 minute is the most suitable duration of exertion. The mechanism, in which the body is able to double its performance during the same circulation and energy parameters, is still not quite clear. Most likely, the ATP and energy rich phosphates break down in the initial seconds and they quickly resynthesize during the subsequent resting period. Vogiastizis (2005) compared two groups of randomly selected patients with COPD whose forced expiration was around 50–60%. Both groups performed the same amount of work; however, one group exercised on an ergometer at 50% of maximum intensity, which was established earlier, continuously 2 times a week for 40 minutes for

12 weeks. The second group exercised at the same time intermittently at 100% intensity for 30 seconds followed by a 30-second rest period. To eliminate the effects of adaptation, the intensity was re-established each month and gradually increased. The results showed a significant increase in tolerance to exertion in both groups, but the interval training performed at a maximum intensity was accompanied by a relatively lower increase in dyspnea. This can explain why certain patients with more severe involvement can perform certain physically demanding tasks. Short intervals are energetically covered by the energy rich phosphates and do not elicit an intense activity of anaerobic glycolysis. 7. Resistance training in patients with COPD Resistance training focuses especially on exercising smaller muscle groups, in which the individual movements are repeated multiple times in sets. For example, up to 8 repetitions are recommended in one set. The intensity is determined in percentages of maximum performance, which can be performed only once (1 repetition maximum, RM). It is recommended to use an intensity of 75% of 1RM. It has been shown that this approach is very effective and well utilized, especially in older, weaker patients with COPD. Similar results can be accomplished during endurance and strength training; however, after a long time and with greater effort. A special benefit has also been seen in the change in muscle fibers. Older men showed an increased number of oxidative fibers after resistance training, which was not achieved in younger patients. The combination of resistance and endurance training has been especially beneficial. The demands on the respiratory system are lower and exercising further is not limited by shortness of breath. This type of training seems to be most appropriate for patients with advanced degrees of muscle dysfunction. 8. Neuromuscular electrical stimulation The results and application of exercise therapy based on physical activity is greatly limited by increased dyspnea and decreased

cardiovascular system performance. Therefore, a method offers itself that can, in certain aspects, substitute the cardiorespiratory functions and act directly on the muscle fibers. It substitutes the stimulation of the higher centers and elicits the same effects. It increases muscle strength and facilitates muscle tissue increase, which is especially utilized during times of a patient’s total immobilization. The action occurs without any pain or other undesirable side effects. For effective application i.e., for a patient’s bed-to-chair transfer, the time should not exceed 14 days. This treatment approach can also be used for patients in home care. 9. Examples of rehabilitation program prescription Example 1 A 53-year-old male with moderate COPD, FEV1 at 68 % and CO transfer factor of 79 %, presents with shortness of breath and muscle pain during activities of daily living. He undergoes outpatient treatment. He uses tiotropium, salbutamol, formoterol and acetylcysteine. He is overweight, BMI = 28.3. He achieved maximum loading of 90 W on the ergometer, or 60 % of predicted value and heart rate of 16 l/min. He rates his dyspnea at 9 on the Borg dyspnea scale (Fig. 3.4.2-1). During the Six-Minute-Walk Test, the patient walked 455 meters and when repeated he walked 499 meters, or 68 % of predicted value. The quadriceps strength in a rotational moment is 74 % of predicted value.

Fig. 3.4.2-1 Increased dyspnea and energy expenditure according to the Borg scale during ergometer stress test with increasing load in a patient with COPD. Increased dyspnea to the “slight” level according to Borg corresponds to 105 beats per minute and oxygen consumption of 0.7 liters. “Severe” dyspnea corresponds to 125 beats per minute and approximately 1 liter of oxygen (HR – heart rate).

Recommended exercise therapy: Endurance training: on ergometer 1 time, 20 minutes at 60 % of maximum test, or 54 Watts. Walking on treadmill: 1 time, 20 minutes at 80 % of predicted value of the Six-Minute-Walk Test, or at a speed of 4 km/hr. Resistance training: Lower extremity resistance training (leg press): 3 times, 8 repetitions at 70% of 1 Rm = 80 kg (70% of 80 kg = 56 kg); Sit-ups (abdominal crunches): 3 times, 8 repetitions at 70 % of 1 Rm = 46 kg; Lateral pull down: 3 times, 8 repetitions at 70 % of 1 Rm = 46 kg;

Chest press: 3 times, 8 repetitions at 70 % of 1 Rm = 42 kg. Note: Nutritional and pharmacological supplementation is not needed at this stage. Example 2 A 55-year-old female with severe COPD (FEV1 = 23% and CO transfer factor 43% of predicted value). She demonstrates a high degree of dyspnea and is unable to perform activities of daily living independently. She takes tiotropium, formoterol and Quar R2. She has a very low BMI = 17.3 and low adipose tissue reserves. During ergometer exercise, a very low maximum performance was identified at 25 Watts, which is 22 % of the predicted value, Six-Minute-Test at 390 meters, which is 59 % of predicted value. She also demonstrates decreased oxygen saturation during exercise on the ergometer and during the walking test. Recommended exercise therapy: Ergometer training: 10 times, 2 minutes at 60 % of initial testing = 15 Watts. Treadmill training: 4 times, 5 minutes at 80 % of Six-Minute-Walk test = 3.1km/h. Resistance training: Leg press: 3 times, 8 repetitions at 70 % of 1 Rm = 14 kg; Abdominal crunches: 3 times, 8 repetitions at 70 % 1 Rm = 14 kg; Lateral pull down: 3 times, 8 repetitions at 70 % of 1 Rm = 11 kg. Note: The listed resistance training in selected exercises is an example of exertion level. This selection of exercises is not always considered appropriate and it needs to be individually modified. Exercises with resistive bands (Therabands) are appropriate. Inspiratory muscle training, protein nutrition supplements and Nandrolone once every 2 weeks are recommended to improve respiratory muscle function, body weight and body composition.

3.4.3 Implementation of Rehabilitation in Other Respiratory Dysfunctions

Miloš Máček Respiratory Insufficiency in Neuromuscular Disturbances and Thoracic Deformities A loss or decrease in strength of the primary and accessory respiratory muscles is usually the result of mechanical overloading, such as muscle palsies, kyphoscoliosis, severe obesity or tetraplegia. Although the causes may vary, the result is alveolar hypoventilation accompanied by an increase in partial pressure of the alveolar CO2 and a decrease in O2. Since each increase in energy expenditure due to physical activity must be accompanied by increased respiration, its delay or failure to increase leads to decreased oxygen supply and CO2 retention. An increase beyond the usual 40 mm Hg immediately elicits a reflexive increase in respiration while a failure of this system leads to hypoxia and hypercapnea. Decreased muscle strength caused by various dysfunctions, a cerebrovascular accident, palsies and head traumas can lead to acute or chronic hypoventilation. These conditions also have other negative consequences, such as pulmonary hypertension, overloading the rightside of the heart, increased intracranial pressure, polycythemia, etc. A similar state can also be elicited by severe thoracic deformities, such as kyphoscoliosis. Treatment and Rehabilitation Principles In acute hypoventilation, which can occur during worsening of chronic conditions, as well as, during acute respiratory infections, post-injury or surgical stress, an oxygen enriched air mixture is applied through the face mask or by a catheter into the respiratory tract. This simple and successful treatment also has its risks because chronic hypercapnea decreases sensitivity and limits the necessary increase in respiration. This is the reason why a mechanical increase in ventilation by using a ventilator has proven beneficial in such scenarios. Patients with chronic hypoventilation use modern equipment that

automatically maintains appropriate pCO2 and pO2. Rehabilitation of Patients Following Spinal Cord Injury: Effect on Lung Function Jan Šulc Respiratory system dysfunctions are common in certain patient populations after spinal cord injury. Altered breathing mechanics are almost always present; further, expectoration is affected in cervical spinal cord lesions. In thoracic spinal cord lesions, lung and thorax contusions (chest trauma, flailed chest) are often present. During the early post-injury period, a portion of patients uses artificial pulmonary ventilation and, subsequently, a tracheotomy cannula. All patients with spinal cord injury are at risk of atelectasis development and demonstrate limited self-clearing lung ability which leads to an increased risk of onset of bronchopneumonias. Pulmonary function tests are administered to prevent respiratory complications, acquire additional valid clinical data, improve medical care and, subsequently, improve quality of life for patients with spinal cord injury. New information about pathophysiological mechanisms of onset and progression of certain concomitant respiratory signs and pulmonary dysfunctions can be acquired. For all of the listed reasons, certain “classic” methods and specifically modified methods can be used. The extent and severity of respiratory abnormalities following spinal cord injury depend on the level of spinal injury. These abnormalities can emerge during the entire post-injury period. From a clinical perspective, the results of pulmonary function tests acquired during mid-way and long-term after a SCI, or subacute phase (Ib) to chronic phase (II), are the most important. During this time, the immediate effect of specific rehabilitation can also be assessed by pulmonary function indicators (Fig. 3.4.3-1).

Fig. 3.4.3-1 Flow-volume curve measured in a patient with a spinal cord injury prior to rehabilitation (curve 1) and 20 minutes after rehabilitation (curve 2). An improvement in the indicators of respiratory tract clearance and a slight increase in forced vital lung capacity can be observed.

Some pulmonary function indicators increase based on the level of the spinal lesion; that is caudally to the T10 level. These include dynamic lung volumes (FEV1, FVC and their ratio) and inspiratory capacity (IC). FVC is pathologically decreased in a patient with quadriplegia (those with spinal cord injury located above the C8 level). In contrast, the lesions caudally from T7 through L3 (low paraplegia) show normal dynamic lung volumes. The level of the spinal cord lesion demonstrably correlates with the value of expiratory reserve volume, ERV, RV/TLC value (the ratio of residual volume

and overall lung capacity) and the value of the maximum inspiratory pressure (PImax) acquired during inspiration against resistance – the so called Müller maneuver. Similarly, minute ventilation (MV) – a parameter used to assess respiratory muscle endurance during training – depends on the level of the spinal lesion. In patients with quadriplegia, MV reaches approximately 40% of the norm while it is approximately 60% in patients with paraplegia. The assessment of PImax value and the maximum expiratory pressure (PEmax) in relation to the level of the spinal cord lesion; however, is only appropriate in cases when the motor lesions are confirmed to be complete lesions. Bronchodilation tests can also provide important clinical information. Patients with quadriplegia (in comparison to the ones with paraplegia) show – according to spirometric and body pletysmographic tests – limited respiratory tract clearance at rest. This condition causes increased cholinergic (vasomotor) tone of the respiratory tract musculature, which most likely develops as a result of disrupted sympathetic innervation (leading to a vegetative imbalance and subsequently to “vasomotor” bronchoconstriction) and the inability of the respiratory tract musculature to react during deep inspiration by the usual dilation and inhibit, in this way, bronchoconstriction. A positive response occurs after inhalation of preparations causing bronchial dilation, facilitating the inhibition of bronchoconstriction, and, therefore, normalization of the resting respiratory pathway clearance. To correctly interpret the results of a pulmonary function test and to achieve the best treatment results for patients with spinal cord injury, complete anamnestic data from the time prior to the injury (i.e., smoking, passive smoking, symptoms of chronic pulmonary diseases, increased BMI), as well as, all clinical data from the time since the injury (i.e., lung contusion, traumatic pneumothorax) and all post-injury complications (i.e., subglottic obstruction, tracheomalacia, etc.) are reviewed and assessed. Most of the above listed clinical (pneumological) units and respiratory dysfunctions can be linked to decreased dynamic

pulmonary volumes (FEV1, FVC and their ratio) and can, in this way, influence the short-term and long-term clinical course after the injury; at the same time, it was recently shown that patients with spinal cord injury with the most severe neurological involvement also demonstrate the most significant decrease in the mentioned dynamic volumes. In patients with a spinal cord injury, pulmonary function indicators can provide useful information about the effectiveness of pulmonary rehabilitation. For example, in patients with a cervical spine lesion, gradual improvement in the function of the respiratory musculature can be observed and demonstrated by increased coughing effectiveness. During testing, it is very important to monitor inspiratory muscle strength, which becomes shortened, especially with pulmonary hyperinflation (pathological redistribution of static pulmonary volumes), which is the reason why they are found in a mechanically disadvantageous position at the onset of inspiration. Measuring maximum inspiratory pressure (PImax) serves as strength testing of the inspiratory musculature (Fig. 3.4.3-2).

Fig. 3.4.3-2 Development of maximum inspiratory pressures (PImax) in a patient with a high spinal lesion (C4) during the 15th through 18th weeks (curves 1-4) and 35th week (curve 5) after the injury. The y-axis shows maximum inspiratory pressure [kPa], the x-axis shows time [s]. Gradual increase in PImax values can be observed corresponding to improved diaphragm function.

Similarly, in patients with transverse spinal cord lesions, pulmonary function testing is a useful tool for the evaluation of effectiveness of rehabilitation and the rehabilitation program. Improved breathing effectiveness (that is increased respiratory volume and a decrease in the breathing equivalent for oxygen) was shown after a 6 week long training program in patients shortly after spinal cord injury. Specific methods and their modifications are indicated for testing short-term and long-term pulmonary function in patients with spinal cord injury taking into consideration the specific health condition for each patient. These include, for example, modification of the standard methods during FVC measurement, in which the volume plateau

needs to be maintained at the level of residual volume for at least 0.5 of a second (at the end of FVC maneuver) or the so called verification of the expired volume through reverse extrapolation. Methods that do not require patient cooperation can equally be included. For example, impulse oscillometry, the interrupter technique or application of small negative pressure during expiration at rest to establish expiratory restrictions (NEP method) (Fig. 3.4.3-3).

Fig. 3.4.3-3 Pulmonary function testing by portable instrumental setup for a patient with a spinal cord injury. The shown setup allows for spirometric assessment, establishment of maximum inspiratory and expiratory pressures (PImax, PEmax), measurement of respiratory tract resistance by interrupter techniques (Rint) and establishment of expiration limitation (NEP method).

Rehabilitation of Patients on Breathing Support Libuše Smolíková Physical Therapy for Patients with Non-invasive Supplemental Breathing

Some patients use a CPAP and for some patients with permanent hypoxemia and subsequent hypercapnea, treatment by non-invasive ventilation by BiPAP needs to be considered. Not even these types of treatment are a reason for omitting physical therapy. In contrast, shorter, but more frequent sessions of gently guided physical therapy help the patient decrease the current progression of the obstructive respiratory disease and subjectively overcome a very difficult period. Restoration of good respiratory hygiene still remains the primary goal of pulmonary physical therapy. When the patient is connected to non-invasive ventilation equipment, breathing most often occurs in the form of autogenic drainage and an individually selected technique for an active breathing cycle. Modification of exercise duration and type is always individuallybased and it is adequately modified to the patient’s condition during repeated sessions and during the course of a day. Physical Therapy for Patients with Supplemental Oxygen Breathing The treating physician always determines the implementation of oxygen treatment. In patients with moderate disease and night time or daily hyposaturation, long-term home-based oxygen treatment is administered. Timely initiated long-term oxygen treatment allows the patient’s to have better rehabilitation, prevents pulmonary artery vasoconstriction and protects the myocardium. A physical therapist modifies pulmonary physical therapy techniques to each new situation that the patient may present with. In some patients, the timetable of individual sessions needs to be altered and the patient needs to be taught the use of the technical equipment for the oxygen condenser in combination with inhalation treatment and the application of expectorate drainage in pulmonary physical therapy. The practical content of pulmonary physical therapy needs to be modified to the patient’s age and their respiratory and movement capabilities and, especially, their current medical condition. Even during one exercise session, the therapist needs to be flexible in their reaction to the patient’s pulmonary system response to the breathing techniques within the context of pulmonary physical

therapy. It also needs to be remembered that the patient may be placed on the waiting list for a lung transplant. If the patient is admitted to the preparation program for transplantation, the importance of non-interrupted respiratory physical therapy and movement activity needs to be emphasized, including the time period after the patient’s discharge to a home setting. This effort is continued with the patient in the form of outpatient physical therapy consultations and with an agreement with the patient’s physicians, especially with the treating physician who coordinates and oversees the preparation for the entire transplantation process. Maintaining good physical fitness is ensured by bicycle ergometer or by hiking. The values obtained by pulse oximetry assist in fine tuning the individual training program for patients utilizing oxygen support.

3.4.4 Methods and Approaches Used in the Rehabilitation of Patients with Chronic Pulmonary System Dysfunction Libuše Smolíková, Pavel Kolář See General Section of the textbook, B. Therapeutic Approaches, Chapter 1.2.4 Pulmonary Physical Therapy – Methods and Techniques of Respiratory Tract Hygiene.

3.5 SURGICAL PROCEDURES IN THE THORACIC REGION Lenka Babková Surgical procedures in the thoracic region are currently quite common and are performed for various reasons. They include pulmonary indications, i.e., lung tumors or lung tissue reduction in COPD, as well as, cardiac indications, including surgeries from an ischemic heart disease, such as a bypass, all the way to transplantations. Rehabilitation and exercise therapy should improve the patient’s readiness prior to the surgical procedure to increase the hope of survival and recovery. Here, correctly prescribed exercise therapy is important. Training of individual methods of pulmonary physical therapy is another goal and most often includes expectoration, the improvement of respiratory coordination and reaching optimal work of breathing (WOB). To improve the coordination of extremity movements and breathing, various methodical approaches of breathing exercises (breathing gymnastics) are used and described later. For overall activation of the neuromuscular system and to improve muscle activation, timing and stabilization muscle function, certain methods based on neurophysiological foundation can be used.

3.5.1 Rehabilitation following Pulmonary Surgery Based on the extent of a lung procedure, the following are distinguished: lung segmentectomy, lobectomy, pneumonectomy and transplantation. Lateral or anterolateral thoracotomies are the most common approaches for lung surgeries. Physical therapy principles do not differ for individual procedures, only small differences exist in the context of exercise therapy. In elective surgeries (with a no-risk option of a several month delay), preconditioning is important and involves increasing endurance fitness and minimizing functional deficits of the movement system prior to surgery. Having already increased the patient’s fitness during

the pre-operative phase is an important benefit during the postoperative recovery period. Provocation of the body by optimally prescribed physical activity, its adaptation and compensatory mechanisms improve, which the body literally “draws from” during the post-operative stress period. Any strengthening prior to surgery increases and accelerates the period of post-surgical recovery. For pulmectomy, 20 ml · kg–1 · min–1 is generally considered to be an insufficient aerobic capacity and around 15 ml · kg–1 · min–1 is considered insufficient for lobectomy. However, even these values need to be individually assessed within the context of the patient’s overall health. In lower values, the surgical risk increases and the time of early post-operative recovery is prolonged. Breathing Preparation Breathing preparation is the foundation of physical therapy and should occur in two stages: pre- and post-operative. Physical therapy in the pre-surgical period includes the explanation of the significance of physical therapy before and after surgery, training of pulmonary physical therapy practical skills, incision care, breathing techniques emphasizing respiratory thoracic excursion, breathing practice with inspiratory and expiratory breathing simulators, relaxation, positioning, gentle expectoration, corrective work of the postural system, i.e., lower extremity movements, movements of the arms, trunk, trunk muscle stretching, etc. Each physical therapist should at least partially attempt to understand the patient’s mental condition and not underestimate their anxiety, which can impede good cooperation. The absence of physical therapy, especially in the first hours after the procedure, can negatively influence the post-operative course. The practice of pulmonary physical therapy practical skills prior to surgery gives patients the needed peace and certainty during the post-surgical stay in the Intensive Care Unit (ICU). Physical therapy in the post-operative period. As soon as possible

and following a consultation with the referring physician, the physical therapist initiates intensive exercises that should be repeated 2–4 times per day. The most common exercise methods include: active expiratory techniques, standard respiratory tract hygiene, restoration of spontaneous breathing through breathing excursions of the thorax, manual compression of the thorax, etc. Physical therapy should improve respiratory tract clearance, sustain the patient during maximally gentle and minimally exhaustive expectoration, decrease bronchial obstruction, improve ventilator parameters and consistently prevent post-operative pulmonary complications, and respectively contribute to their quick elimination. As soon as possible, the physical therapist instructs the patient how to independently exercise while using breathing simulators. Expiratory flutters, acapellas and inspiratory simulators are used most used. The physical therapist also recommends the training tools for the practice of inspiration. A physical therapist always closely and interactively cooperates with the staff involved in the patient’s treatment. Nurses implement elements of rehabilitation care after they have been educated by a physical therapist while taking into consideration the patient’s individual requirements. Early verticalization, mobilization exercises of the lower extremity vascular system and independence are practiced from the first hours and days after surgery. As secondary prevention, it is beneficial for patients to attend group rehabilitation exercises aimed at their given diagnosis. They will meet other patients with similar conditions and can exchange their own experiences, but most importantly, they can exercise under supervision and strengthen, in this way, their physical fitness.

3.5.2 Rehabilitation following Cardiac Surgery In the Czech Republic, the most common cardiac surgeries are performed to treat ischemic heart disease (approximately 63%); however, their frequency is falling proportionally to the increase in using percutaneous transluminal coronary angioplasty (PTCA). This

is followed by surgical heart valve repairs (23%), congenital heart defects (8%), heart transplants (around 1%) and other cardiac operations (5%). A median sternotomy is the most commonly used surgical approach. Pre-Operative Fitness Improvement and Correction of Musculoskeletal System Dysfunctions For the reasons mentioned in the previous section of the text, it is beneficial to include “pre-conditioning” in the patient’s pre-operative care, including patients with elective cardiac surgeries. The preoperative rehabilitation principles basically do not differ from the principles of rehabilitation prior to a lung surgery. Only the possibility of greater limitations with physical exertion due to the patient’s current state of their circulatory system needs to be taken into consideration. Post-Operative Rehabilitation Approaches Patients after cardiac surgery more than in pulmonary surgeries, require constant monitoring. To be able to modify treatment on an ongoing basis based on the patient’s current condition, the physical therapist needs to monitor the presence of angina pectoris (stenocardia), hemodynamic compensation of heart rate, the presence of arrhythmias, hemoglobin oxygen saturation, blood pressure, pulse, cough, body temperature circulation and the temperature of the distal aspects of the extremities. Despite the principles of post-operative physical therapy being the same as after lung surgeries, rehabilitation following a cardiac surgery follows certain specifics given by the severity and the technique of the surgical procedure itself.

Exercise therapy Cardiac rehabilitation following a cardiac surgery is divided into four phases and follows similar principles as for patients after myocardial infarction. The goal of cardiac rehabilitation is to increase the patient’s cardiopulmonary reserves.

Phase I Cardiac Rehabilitation The first phase occurs during the patient’s hospitalization. The exertion is described by grades 1–5 (Tab. 3.5.2-1) and it is determined by the treating physician based on the assessment of the patient’s current clinical condition.

Tab. 3.5.2-1 Selection of intensity of post-operative activity exertion in hospitalized patients according to their clinical condition level

If the post-surgical course occurs without complications, cardiac rehabilitation in a younger patient with good musculoskeletal system function occurs as follows: 1–2 days post-surgery: bed exercises to prevent deep vein thrombosis; the first day includes simple extremity movement with the least impact from gravity. The second day, the extremities can be elevated above the surface. These simple exercises are also performed by patients connected to mechanical lung ventilation if their current medical condition allows it. 3–4 days post-surgery: sitting in bed or standing by the bed, the patient is usually transferred to the cardiac surgery unit or a regular cardiac unit. 5–6 days post-surgery: ambulation in the room. 7–10 days post-surgery: ambulation in the hallways. 11–14 days post-surgery: ambulation around the ward at faster speeds, stair negotiation. For certain heart conditions, the surgeries are currently performed

without a sternotomy by using a mini- thoracotomy (chest tube) incision while the heart is beating. This surgical approach shows a smaller risk for developing post-surgical complications and decreases pain. The patients also do not exhibit such significant changes in their breathing mechanics and demonstrate less mucus. The degree of exertion during rehabilitation is determined by the treating physician based on the patient’s condition. In contrast to patients after extracorporeal circulation, they are allowed earlier mobilization and verticalization. Usually, these patients can already start sitting a day after surgery and can stand up two days after surgery. From the perspective of pulmonary physical therapy, identical techniques for both surgical procedures are used; however, stabilization of the sternum during coughing is, of course, not necessary. Rehabilitation in the Intensive Care Unit Rehabilitation is initiated as soon as possible and no later than 24 hours after surgery. Usually, the first physical therapy visit occurs the day of the procedure. Patients after cardiac surgeries are usually connected to mechanical lung ventilation the day of surgery and sometimes one day after the surgery. Pulmonary physical therapy is the foundation of physical therapy care. It is important for the prevention and treatment of postoperative respiratory complications. In patients connected to artificial lung ventilation, contact and reflexive breathing techniques are used, which facilitate secretion removal from the respiratory tract and assist in the restoration of an optimal breathing pattern. During the patient’s extubation, the presence of a physical therapist is advantageous for many (the patient, physician and physical therapist) because they assist the patient with effectively and gently overcoming the first moments after extubation and assist with their first expectoration. Other pulmonary physical therapy principles are identical to the principles utilized in pulmonary surgery. However, careful checks of coughing are important to prevent the onset of an unstable sternum, which becomes overloaded during uncontrolled coughing. A possible dysfunction in the diaphragm needs to be

remembered, which can occur after cardiac rehabilitation as a result of phrenic nerve damage. Unilateral paralysis of the diaphragm can have a completely asymptomatic course or can be demonstrated by shortness of breath, intolerance of physical activity or even by respiratory weakness. Diaphragm dysfunction leads to the development of atelectasis often located in the lower lobes of the lung. If diaphragm dysfunction truly occurs, respiratory physical therapy usually implements reflexive breathing and, of course, drainage techniques that help secretion removal from hypoventilated parts of the lungs. If the phrenic nerve is partially damaged, the nerve regenerates leading to improved diaphragm function in 70–90% of cases in one year and within 2 years in others. Rehabilitation in the Step-Down Unit Patients are transferred to the step-down unit if they no longer need to be continuously monitored, usually by the afternoon of the fourth day. While on this unit and under continued supervision of a physical therapist, physical therapy treatments include pulmonary physical therapy techniques, mobilization and stretching exercises and, especially, fitness exercises and walking so that the patient can negotiate one flight of stairs prior to discharge. During fitness training, the physical therapist monitors the increased heart rate caused by exercise. Similarly to pulmonary surgeries, the patient is instructed in incision care and a home exercise program prior to discharge. Nutritional and dietary recommendations are also provided. Prior to the patient’s discharge to home care, a submaximal stress test should be performed and serve as the basis for the patient’s further cardiac rehabilitation. Long-term Rehabilitation Care Rehabilitation treatment is usually based on a developed protocol. Phase II (2–6 weeks post-surgery) This is a critical phase involving the transition into a home setting and outpatient rehabilitation. Rehabilitation plans should be consulted ahead of time with the patient’s family physician, cardiologist,

physical therapist and rehabilitation physician near the patient’s residence. Besides incision care and post-operative residual issues, in principle, the rehabilitation does not differ from rehabilitation of patient’s after myocardial infarction. Continuity of care needs to be especially ensured, including pharmacological intervention. The possible timing of balneotherapy should be considered, which often directly follows early post-hospitalization care, such is the case in Germany. Given the financial pressures to have the shortest possible post-operative stay in specialized cardiac units, the opportunities arise for a specialized, outpatient team care. In patients whose musculoskeletal and cardiorespiratory systems allow for the initiation of physical fitness optimization, subjective mid-intensity physical activity is selected. Its duration is gradually increased from the original 20 minutes to one hour. A stress test is a component of the cardiologic assessment at the time of discharge and should be modified so that the maximum recommended intensity of a dynamic load can be established (i.e., using pulse rate). The extent of risk of cardiac rehabilitation needs to be established and, when needed, exercising under constant EKG monitoring is required, which has been very difficult so far in a practical setting. Phase III (7–12 weeks post-surgery) A transition to a regular recovery regime occurs at this time. The patient should master an adequate endurance load – preferably 3 times per week with a mid-intensity endurance load combined with resistance training that is adequate to the patient’s musculoskeletal and cardiovascular systems. Phase IV (13 weeks and beyond post-surgery) The foundation of successful rehabilitation lies in the modification of lifestyle risk factors. The patient continues the program that they have established during cardiac rehabilitation. If the patient is not able for any reason to attend individual or group exercise sessions, they should respect the following recommendation. The following activities are not recommended for patients after cardiac surgeries:

Lifting and carrying heavy objects Driving prior to incision healing Prolonged upper extremity activities above the head Sports that involve jumping/rebounding Strengthening in the form of resistance training (this should only be performed under the guidance/instruction of an experienced physical therapist) The following activities are recommended for patients after cardiac surgeries: Alternating appropriate activity with a sufficient rest period To prevent mucous formation, the patient should continue pulmonary physical therapy learned in the hospital, including breathing exercises Attempt to perform at least half an hour of endurance physical activity every day (walking, stationary ergometer, swimming when the incision has healed) with gradually increased duration of exertion Rest in the case of heart palpitations, dyspnea or anxiety Acclimatize during transitions from warmer to cooler areas Ensure consultations with a rehabilitation specialist for patients after cardiac surgery in several-week-long intervals. The above listed recommendations pertaining to rehabilitation approaches in thoracic surgery apply in general, but given the seriousness of thoracic surgeries and the increasing number of operations at an older age, the individual needs of each patient need to be especially respected and their current health condition and physical fitness need to be taken into consideration. Similarly to other medical fields, it is true in thoracic surgery that a patient, physician and the physical therapist are partners whose main interest is to provide the patient with the highest quality of life. Post-Operative Complications Pulmonary Complications Pulmonary complications (hypoxemia, atelectasis, pulmonary edema,

pneumonia and bronchopneumonia, pleural exudate, diaphragm dysfunction, etc.) comprise a significant cause of post-operative morbidity and mortality. Their occurrence varies and depends on the type of surgical procedure. The group at risk includes patients with COPD, chronic bronchitis (smokers), bronchiectasis, emphysema, decreased lung elasticity, increased residual volume and increased dead space. During cardiac surgeries, these complications are more frequent in patients with an arterial graft from the internal thoracic artery than in patients with a vena saphena graft. Cardiovascular Complications They develop mainly in patients who underwent a surgical procedure with an extracorporeal circulation or in patients who were functionally assessed as NYHA IV or NYHA III prior to surgery. They are especially at risk for post-operative arrhythmias or cerebrovascular accidents. Thromboembolism, however, is the most frequent cardiovascular complication linked to a patient’s post-operative immobilization. Pain Pain at the surgical site and its surroundings can have a varied intensity and duration (based on the size and location of the surgical site and the patient’s perception of pain intensity). A number of patients have difficulty tolerating pain; they are irritable, exhausted and focused only on the experienced pain. This pain is often linked to breathing deviations that reflexively slow down ventilation. In this way, pain inhibition contributes to the treatment of pulmonary complications. Although certain physical therapy techniques assist in decreasing pain, sometimes it is beneficial for the patient to take their analgesics so that they are willing and able to cooperate with the physical therapist and then the effects of rehabilitation can be as good as possible. An initiation of SSRI antidepressants (4–6 weeks ahead of time), which may increase pain threshold, needs to be consulted with the treating physician. If the incision has not yet healed and postoperative vomiting occurs frequently, antiemetics can rid the patient of enormous pain developed by reflexive abdominal bracing during vomiting.

3.6 ISCHEMIC HEART DISEASE (IHD) Jiří Radvanský In the Czech Republic, long-term rehabilitation and cardiac rehabilitation for patients with IHD is only emerging. An individual treatment plan designed for several months will only treat a fraction of patients. The latest recommendations of the Czech Cardiologic Association were made in 2006 and recommend either outpatient therapy, individual home exercise or balneologic treatment after the in-patient phase. The American Heart Association and The Association for Cardiovascular and Pulmonary Rehabilitation reached a conclusion that all cardiac rehabilitation programs and secondary prevention programs should contain specific key components with a goal to maximally limit risk factors, encourage healthy habits and compliance with these habits, decrease disability and support an active way of living in patients with cardiovascular diseases. In 2007, a supplement to the earlier recommendations was issued containing the list of key components that are considered important. The publication summarizes recommendations for testing, intervention and the expected results of all key components of rehabilitation programs for patients with cardiac involvement, including the patient’s basic assessment, nutritional counseling, influencing risk factors including dyslipidemia, hypertension, obesity, type II diabetes, smoking, psychosocial intervention, and counseling regarding physical activity and cardiac rehabilitation. When compared to earlier recommendations, it includes changes in the desired lipid profile, strategies on how to achieve these changes and emphasis on our assurance that the patients truly consume the prescribed medication, which was shown as one of the significant factors to decrease further cardiovascular incidents. The foundation of other changes in the recommendations is also the finding that modifying the risk factors and maintaining an active lifestyle is a lifelong process. Including the strategies on how to optimize the

patient’s adherence to a changed lifestyle and to the medical treatment (pharmaceutical) is an integral part in achieving the true treatment benefit. Therefore, any program of these interventions needs to occur “in harmony” with a general practitioner and the treating cardiologist. This physician will, according to mutual recommendation of the largest American Specialist Associations, oversee further interventions and modify them long-term. This trend must also be established in the Czech Republic where rehabilitation of patients with cardiac involvement is so complex that it needs to be directed by either a general practitioner or a cardiologist who cooperates with him. Without team work, including the rehabilitation specialists, the optimal result cannot be achieved. In the introduction of the recommendations, their purpose is distinctly articulated: “These recommendations should assist the workers in the rehabilitation of cardiac patients, guide the providers of medical care, and those involved in insurance and the development of health politics, as well as, to the recipients of the care itself so that they are able to distinguish to what extent the actual program is complete. Those, who finance healthcare, should adequately finance cardiac rehabilitation and secondary prevention so that comprehensive care can be ensured by a team of specialists”. The summary of the key components is so important due to its complexity that their substantial part is being listed here at this time.

KEY COMPONENTS OF A COMPLEX REHABILITATION PLAN Patient Assessment Anamnesis (Patient History) Anamnesis identifies current and previous cardiovascular diseases (including the function of the left ventricle), surgeries, comorbidities (including peripheral vascular disease, cerebrovascular diseases, diabetes, musculoskeletal and neuromuscular diseases, depression and other diseases that can be related to the current condition), symptoms

of cardiovascular diseases, medications (including dosages, frequency and the patient’s tolerance to medication), date of the last influenza immunization, presence of cardiovascular risk factors and lifestyle preferences. Also, all key components needed to complete the anamnesis. Physical Assessment Cardiopulmonary system is assessed (including pulse rate and its regularity, blood pressure, heart and lung auscultation, inspection and palpation of the lower extremities, including edema and arterial pulse presence) as well as the incision after invasive cardiovascular procedures and orthopedic and neurologic conditions. If needed, another physical assessment is performed. The examiner also includes a cognitive function assessment. Tests: take resting 12-electrode EKG, establish how the patient perceives their health condition and their quality of life; use additional tests if needed. Intervention Document that you had found information that describes the patient’s current condition and allow this to lead to the individual modification and development of: 1. The patient’s treatment plan that favors goals and lists strategies leading to risk reduction 2. Plan follow up checks for a period after discharge, during which it should be checked whether a true progression occurred given the established goals and whether it lead to long-term changes in secondary prevention Discuss the treatment plan and the schedule of regular check-ups with the patient and their family members and with their primary care physician. At the same time, based on the indication of the treating physician or the cardiologist, make sure that the patient takes an appropriate dose of aspirin or Clopidogrel, β-blockers, hypolipidemics, ACE inhibitors or Angiotensin receptor blockers. Make sure that the patient receives a

yearly influenza immunization. Expected Outcomes The patient’s treatment plan including the documented patient assessment and short-term goals (weeks or months) are outlined in the intervention strategy. It also includes a discussion of the final outline of the plan with a general physician. The discharge needs to contain a report with data that the patient truly adhered to the outlined plan, including medication, that they are immunized for influenza (and if not, include a reason why) and it must contain specific areas that require further treatment and checkups. At the time of discharge from the hospital, the plan needs to also include long-term goals and means of how to achieve them. Nutritional Consultation Assessment Ensure daily energy intake and the content of saturated fats, trans fatty acids, cholesterol, sodium and nutrients. Establish dietary habits including the intake of fruits, vegetables, cereals and fish. Establish the number of servings, frequency of servings outside the regular environment and alcohol intake. Establish goals for nutritional intervention as it is stated in the key components for weight, hypertension, diabetes, heart failure, kidney diseases and other comorbidities. Intervention Prescribe dietary modifications at least fulfilling the limits for cholesterol and trans fatty acids based on the NCEP panel of experts; modify the diet based on need in synchrony with key components for weight, hypertension, diabetes, heart failure and other comorbidities; recommendations should respect cultural preferences. Educate the patient and provide advice (as well as to other family members or partners whom they live with) about dietary goals and how to achieve them.

Include behavioral changes regarding education and recommend strategies on how to adhere to them. Expected Outcomes The patient continuously adheres to the suggested diet. The patient understands the basic dietary principles, such as nutrient energy content and concentration of fats and cholesterol. The plan was established in a way that it modifies errors in the patient’s dietary habits. Weight Management Assessment Obtain the patient’s weight, height, waist circumference and calculate their BMI. Intervention In a patient with a BMI above 25 and waist above 102 cm for men and 88 cm for women: Establish a reasonable short-term and long-term plan for weight reduction individually-based on the patient’s other risk factors; for example, reduce at least 5% or better yet, 10% of weight at a rate of 0.45–0.9 kg per week for 6 months; establish a combination of diet, movement activity/exercise and a behavioral program with the goal to reduce total caloric intake, but maintain appropriate intake of nutrients and fiber while increasing energy expenditure; the exercise portion of the plan should include daily long distance walking (60–90 minutes). The goal to obtain the described weight reduction is to decrease the caloric intake by 2,100–4,200 kJ (500–1,000 kcal) per day. Expected Outcomes Short-term: continue dietary regime and modify intervention according to whether the patient is gradually losing weight. If they are not losing weight, refer the patient to an authentic specialized program. Long-term: patient adheres to the diet and exercise/training program directed toward achieving the previously suggested final

goal weight. In the original recommendations, this is followed by management of blood pressure, dyslipidemia, diabetes, smoking cessation and psychosocial management, which are multidisciplinary problems involving team cooperation and exceed the framework of this publication. Physical Activity Assessment Establish the current level of physical activity (questionnaire, pedometer) and outline in-home, work and recreational needs. Identify activities that are age, gender and daily activity appropriate for the patient, such as driving, sexual activity, sports, yard work and house work. Establish to what extent the patient is willing to alter their behavior, their self-confidence, their barriers preventing an increase in physical activity, and their social support that would assist in making positive changes. Intervention Advise the patient on how much physical activity they need during the initial assessment as well as at check-ups. The program should emphasize the patient’s individual needs (see cardiac rehabilitation).Provide educational materials as a part of consultation and take into consideration work tolerance or simulation of work exertion for patients with heavy physical occupations. Continuously and consistently challenge the patients so that they perform at least 30–60 minutes of medium intensity physical activity daily (at least 5 days per week). Assess their daily routines to be able to suggest how to include increased physical activity into activities of daily living (i.e., parking further away from entrances, always negotiating 2 flights of stairs, walking during a lunch break). Recommend aerobic activities with low impact to minimize the risk of musculoskeletal injuries. Recommend a gradual increase in physical activity over the course of several months. Warn patients about heavy exertion that they are not used to (i.e.,

squash, badminton, shoveling snow). Re-establish the patient’s exercise program as their ability to tolerate more intense physical activity increases. Expected Outcomes The patient demonstrates: a) increased participation with in-home, work and recreational physical activities; b) improved psychosocial state, reduction in stress, progress in social independence and prevention of disability, greater independence when fulfilling established goals; c) improved aerobic fitness, decreased fat body composition and decreased cardiovascular risk (especially patients who used to have a sedentary life style and accepted an active way of life with regular physical activity). Exercise Training Assessment Prior to participation in a cardiac rehabilitation program based on supervised exercise, it is recommended to use physical exertion until the symptoms are elicited. The assessment should always be repeated when the patient’s clinical signs decrease. The tested parameters should contain an assessment of pulse rate, rhythm, signs of circulatory disease, changes in ST segment on EKG, hemodynamics, subjective perception of exertion and physical fitness. Based on the patient’s assessment and stress test results, determine the necessary level of supervision and monitoring needed during cardiac rehabilitation. Use stratification of the overall risk for cardiac rehabilitation based on the recommendations of the American Heart Association from year 2000 or 2003. Intervention Establish individualized prescription for aerobic and resistance training based on the assessment, stratification of risks, comorbidities (i.e., peripheral arterial disease, musculoskeletal conditions), the patient’s goals and the program goals. The exercise regime should be reviewed, modified and approved by the program’s lead physician or by the referring physician. The

exercise prescription should include exercise frequency, intensity, duration of each session, type of activity and the approach for its progression. For aerobic exercise, the following is recommended: frequency of 3–5 days per week, 50–80% intensity and 20–60 minute duration. Type of activity: walking, treadmill, bicycling, rowing, stair negotiation, upper body/lower body ergometer, other continuous or interval type exercises that serve the purpose. For resistance training, the following is recommended: frequency of 2–3 times per week, intensity of 10–15 repetitions to slight fatigue, 1– 3 sets, 8–10 repetitions for some muscle groups. Type of exercises: simple exercises, resistive bands, cuff weights, hand weights, dumbbells, pulleys and strengthening equipment. Expected Outcomes The patient understands safe exercise principles and recognizes warning signs. The patient adapts to the load, shows less exerciseinduced pathological symptoms, is fitter and feels better.

3.7 METABOLIC DISTURBANCES Jiří Radvanský Metabolic diseases include hundreds of congenital metabolic disturbances with a low incidence and only a few diseases with a higher prevalence. They include diabetes mellitus (DM) and most non-familial forms of dyslipidemia. This chapter will focus mainly on DM and ischemic heart disease whose complications are the most common cause of death in adult patients. For simplification, diabetes mellitus can be classified as insulin-dependent autoimmune type known as type 1 DM and type 2 DM, which is the result of a developed insulin resistant syndrome, gestational diabetes (which cannot be treated by exercise, even though exercise is its best prevention) and other types of diabetes. In the 1960’s, exercise therapy for metabolic diseases was grouped together with cardiac rehabilitation through an interdisciplinary agreement integrated within sports medicine. Today, exercise therapy of such diseases has a tendency to be integrated into the treatment of a cardiologist or diabetologist with contributions from other specialists within the medical team.

3.7.1 Diabetes Mellitus – Type 2 It is the most common metabolic disease together with dyslipidemias. Its incidence, specifically in the Czech Republic, ranks as one of the highest in the world. The onset of type 2 DM is preceded by several decades, in which patients only demonstrate insulin resistance (IR). Insulin resistance is a decreased sensitivity of the insulin receptors, especially in the muscles, so that they need more insulin to compensate for an increase in glucose after a meal. The disease is often a late manifestation of insulin resistance syndrome (same as metabolic syndrome), which, besides early onset IR, also includes an android-type obesity, hypertension, dysfunction in fat metabolism with dyslipidemia, higher blood coagulation and acceleration of atherosclerosis. If a higher level of insulin cannot even compensate for

the glucose blood level, then type 2 DM develops. During DM and sometimes even before it is fully manifested, neuropathies and microangiopathies develop at the capillary level. At first, neuropathies affect the autonomic system and later also the afferent nerve fibers and motor skills. Microangiopathies especially affect the myocardium, kidneys, retina and distal aspects of the extremities, especially the lower extremities. Diabetes is the cause of the largest number of lower extremity amputations, significantly contributing to the morbidity and mortality of ischemic heart disease and strokes and accentuates the effects of simple obesity on the movement system. It belongs among diseases, in which physical therapy and cardiac rehabilitation play a significant role. Although movement is the best known prevention of diabetes in patients with IR (there are more than one million such patients in the Czech Republic with the prevalence rising) and a substantial component of treatment in the majority of patients with manifested DM, an effective exercise therapy has not yet been integrated well into clinical practice. While an optimal exercise regime is of undoubted benefit, minimal physical activity does not help the patient and, in contrast, inappropriate, too long or too intense physical activity is ineffective. An alibistic approach with excessive movement restrictions does not benefit the patient in the same way as allowing excessive intensity loading. A patient with type 2 DM with the ability to still produce insulin demonstrates, during the early phase of a reaction to exertion, substantially higher glycemia than a healthy individual. In this phase of the disease, hyperglycemia develops by pathologically high and fast glycogenolysis in the liver and by accelerated transport from the intestines during mild exertion. Insulin resistance together with quickly increasing glycemia leads to a great strain on the β-cells of the pancreas leading to the need to significantly increase the insulin level at this stage to block lipolysis. A correctly selected response to exercise improves the patient’s basic problem. A patient with diabetes improves the sensitivity of the

insulin receptors (in the early phase of the disease, the receptor sensitivity is at its worst most commonly by 30–40% when compared to a healthy population and thus, can be eliminated by regular exercise) by half through prolonged and sustained load of moderate intensity. However, in contrast to a healthy individual, the increased receptor sensitivity does not last longer than 10–20 hours, which is the reason for regular exercise. From the perspective of increased receptor sensitivity, it is desirable for the loading to be rather continuous (short intermittent load excessively stimulates anaerobic glycolysis and lactate formation) and of adequate intensity. Excessive intensity approaching the anaerobic threshold worsens disproportionally the utilization of lactate and fats. During worsening of type 2 DM (dietary error, prodromal stadium of virosis, activation of chronic inflammation, etc.) and during physical activity at an intensity normally tolerated, the counter-regulatory stress hormone Cortisol is produced after only tens of minutes, which substantially decreases the effect of insulin. If diabetes is not sufficiently controlled, cortisol can be produced and a metabolic disruption can occur during intensities at the level of activities of daily living. The physical activity then leads to another increase in glycemia and the onset of ketoacidosis. This is the reason why the patient’s glucose level needs to be monitored before and after physical activity, especially in less stable patients, and at the onset of exercise therapy. If the glucose level during planned exercise treatment is too high, the treatment needs to be modified and the exercise needs to be initiated after the modification. During correctly established and well performed exercise therapy in combination with dietary changes in obese patients with diabetes, the diabetes itself improves significantly in many patients in 4–6 weeks. In obese patients, it significantly decreases insulin resistance and leads to a 5–10% weight reduction, which occurs independently of exercise therapy. Comorbidity linked to previous insulin resistance syndrome is common and a reason for adjusting the physical activity. Principles for developing an exercise protocol are as follows:

Stable health is brought about only by a permanent lifestyle change with a reasonable diet and guided physical activity. If the patient is sufficiently motivated – to motivate a patient with type 2 DM to make long-term changes in their dietary and activity habits is the most difficult goal of the treating team – a physician, in cooperation with a physical therapist, establishes an individual exercise program based on the patient’s health and physical fitness. In the Czech Republic, this is usually a physical medicine physician, diabetologist, weight management specialist or a primary care physician. The team should also include a dietitian and a psychologist. At first, the physician evaluates the disease state and its complications (ischemic heart disease, ischemic lower extremity disease, the state following a transient ischemic attack, condition after a stroke, the extent of diabetic nephropathy, retinopathy, mobility risks in a patient with a diabetic foot). Other symptoms of insulin resistance syndrome need to be taken into consideration, such as the presence of: obesity level and the condition of the musculoskeletal system and, with it, linked hypertension, the degree of neuropathy and proprioceptive deficits). A stress test is administered, which should provide answers to the following questions: Does the patient show signs of ischemia on a stress EKG? (Be careful since a patient with diabetic autonomic neuropathy, which after ten or more years is present in more than half of the patients with diabetes, usually does not feel a distressing state. They will stop the test for non-specific symptoms or shortness of breath. They usually do not even perceive a possible arrhythmia). Does the patient show other pathological signs that would require you to stress the patient for a longer duration with lower intensity? These are most often hypertonic reactions to exertion over 220 mm Hg of systolic pressure, progressive arrhythmias during exertion, a blood pressure drop with greater exertion, claudication difficulties, disorientation or an exertion-induced

rise in glucose above 15 mmol/L. What is the patient’s maximum pulse rate? It can be pathologically low as a result of medication, but also as a result of chronotropic incompetency of the sinoatrial node and autonomic neuropathy. What is the patient’s pulse rate during maximum stress? This can be purposefully decreased by the effect of β-blockers of the sympathetic nervous system, but also pathologically low as a result of chronotropic incompetency of the sinoatrial node or autonomic neuropathy. What is the patient’s anaerobic threshold or their maximum aerobic capacity? Does the patient show any other signs restricting physical activity? There can be a number of them including structural deficits in the musculoskeletal system, psychosomatic problems, depression or hypothyroidism. Then, the physician will consult with a specialist in exercise therapy and together they will establish an individual exercise program with the goal of achieving sufficiently long and intense physical activity to achieve over a few weeks, at a training pulse rate approaching the anaerobic threshold for ideally 45 minutes (does not include the time for warm-up or cool down). During the first stage, increasing endurance fitness is the main goal. In the later phase in a stabilized patient, it is desired to also add resistance training with the goal to increase muscle mass. In this phase, a goal intensity just slightly under the anaerobic threshold is no longer beneficial; during an endurance based exertion, an intensity of around 50–55% of pulse range is better for burning fat during prolonged physical activity. For a stabilized patient who is overweight, it is better to change the duration rather than intensity of a physical activity. Patients with type 2 DM usually show an anaerobic threshold around 65% of the pulse range for a selected movement activity, but given the number of pathological findings during a stress test, in which the intensity of exercise treatment needs to be lowered, it is not appropriate to use this formula for patients with type 2 DM. The physical activity should be repeated

at least 4 times per week, ideally every day. The training pulse rate can be obtained from the initial stress test performed by spiroergometry, during which the lower coronary reserve and a blood pressure pathological reaction can be ruled out and the patient’s maximum aerobic capacity can be established (VO2max, VO2peak). If spiroergometric testing is not available, the patient can be tested twice. At first, the circulatory reaction to physical activity is the focus. The second test is performed to establish the training pulse rate for the initial several-week-long phase of exercise therapy. A number of patients are only willing to accept exercise therapy only at an advanced stage of the disease, in which intense loading poses a risk. Therefore, the list of relative contraindications is rather detailed. Relative Contraindications to Physical Activity The relative contraindications to exercise therapy in patients with type 2 DM are not a reason to prohibit exercise therapy, but rather to significantly modify it. The list includes: Clinically severe forms of ischemic heart disease – myocardial infarction in the past 6 weeks, unstable angina pectoris (mild intensity exercise therapy is today included in the first week after myocardial infarction. However, it is within the scope of a specialist in the rehabilitation of patients with ischemic heart disease – there is a greater risk of complications in a patient with myocardial infarction and type 2 DM during exercise therapy). Chronic heart failure – priority of knowledge of cardiac issues applies here; light activity is an effective component of rehabilitation. The question of when to begin exercise therapy and medication administration in patients after a TIA remains unanswered to this day. Proliferative retinopathy – risk of retinal detachment during heavy static loading, for example, lifting heavy loads while breath holding (small muscle groups against light resistance can be exercised without holding a breath). Autonomic neuropathy with symptomatic postural hypotension –

risk of syncope, arrhythmias (exercising while lying down is very appropriate; however, it is difficult to design and prescribe its parameters). Advanced stage peripheral neuropathy with the lack of sensation in the feet – risk of foot injuries (swimming in relatively warm water at 32–35 °C is optimal). Patient’s inability to timely recognize hypoglycemia in Type 2 DM when using insulin treatment. Contraindicated are athletic activities that pose a health risk or even death with short loss of orientation, a deficit in coordination or a disturbance in consciousness, such as mountain climbing and diving. It needs to be remembered that when prescribing intensive and long exercise sessions, the patients treated with β-blockers have a decreased ability to recognize the first signs of hypoglycemia. For this reason, glucose monitoring prior and after physical activity is indicated and even repeated. (This is important especially for patients who are also being treated with insulin).

3.7.2 Diabetes Mellitus – Type 1 This type of DM is caused by an autoimmune process involving the βcells of the pancreas. Clinically, it is manifested as hyperglycemia, a metabolic disturbance with polyuria and polydipsia and ketoacidosis. The patients depend on insulin for the rest of their lives based on their current glucose level and the planned intensity of physical activity. With an insulin overdose, they are acutely at risk of hypoglycemia. Even patients with Type 1 DM can be influenced by the sensitivity of insulin receptors as a result of physical activity. Decreased insulin dosage can be accomplished by the combination of increased muscle exertion, increased receptor sensitivity and decreased glucose production in the liver during exertion. In preparation for a reaction to exercise, either the dosage of the applied insulin needs to be decreased prior to physical activity or sugar intake needs to be increased, or both. The insulin dosage needs to be decreased, especially prior to prolong exertion. If the patient has a glucose level

between 5–10 mmol/l prior to exercise, they should eat roughly 20–40 more grams of sugars approximately 60–90 minutes prior to exercise. If the initial glucose is between 10–15 mmol/l, the sugar intake does not need to be increased because the actual physical activity will cause the glucose decrease to an optimal level. If the glucose level is above15 mmol/l, the patient should not participate in physical activity because there is a risk of the diabetes worsening with ketoacidosis. If the physical activity lasts longer than one hour and the glucose level falls below 5 mmol/l, sugar can be supplied on an ongoing basis, usually about 10–20 grams of sugar per hour (20 grams of sugar corresponds to, for example, 200 ml of juice). Basic instructions for participation in sports and heavy physical activity in well stabilized young patients with Type 1 DM without clinically significant complications are as follows: Sport is not absolutely necessary, but significantly decreases the risk of complications later. Transition to a routine involving sport is difficult and that is why long-term and practical options should be considered prior to initiating sport activity and altering insulin dosage. If possible, engage in sports regularly throughout the entire year. A sport with the possibility of an occurrence of a quickly emerging deficit in movement coordination and later a deficit in consciousness or one that could put your life at risk should only be considered if the following two criteria are met: 1. Your diabetes has been under control for a long time 2. You are safely able to recognize the signs of an oncoming hypoglycemia attack Roughly 60–90 minutes prior to planned exercise, eat a small portion of food rich in carbohydrates. Decrease insulin dosage corresponding to the time of day and type of food and do not apply it to an intensely working muscle. Longer, endurance-based exertion corresponds to decreasing the insulin dosage by one quarter or one half. During irregular training, the patient will find out that they have a tendency toward

hypoglycemia early after a sport activity and that they are required to change the overall insulin dosage. Athletic habits should be altered slowly while monitoring the glycemic response more often. If the patient’s condition is stable and their performance is sufficient, the patient can consider participating in competitive sports. The patient’s performance may not be limited by performance, but their regeneration may be slower. Muscle building athletic activities are also desirable because muscle mass increases; however, they can be risky at a competitive level. The patient should not participate in a sport activity without having a spare package of sugar and they should warn those around them about the risk of hypoglycemia during heavy and prolonged exertion. Hypoglycemia can occur not only during exercise, but also several hours after exercise when the insulin receptors display their highest sensitivity elicited by exertion. An insufficient intake of sugars prior to physical activity, as well as, non-lowered dosage or an inappropriate type of administered insulin can cause hypoglycemia.

3.8 RHEUMATIC DISEASES Irena Koudelková, Pavel Kolář Rheumatic diseases include over one hundred diseases of various etiology, pathogenesis, clinical presentation and prognosis. A multidisciplinary team of specialists, including a rehabilitation physician, physical therapist, occupational therapist and a social worker are all included in the treatment and differential diagnosis of these diseases. The most severe diseases requiring disease modifying antirheumatic drugs (DMARDs) include overall (diffuse) inflammatory connective tissue diseases (i.e., rheumatoid arthritis, polymyositis, lupus erythematosus, etc.). Ankylosing spondylitis (Bechterew’s disease) is a typical representative of a group of arthritis with spondylitis (spondylarthritides). In such diseases, the inflammatory manifestation in a joint and muscle tissue are also accompanied by many interarticular systemic organ signs (i.e., deficits in the aorta, spondylytic pulmonary fibrosis, iridocyclitis, etc.). The rheumatology department also sees patients with osteoporosis, bone and cartilage diseases, and a various painful conditions, such as fibromyalgia, etc. For a detailed classification of symptoms and the treatment of individual rheumatic diseases, please see a clinical rheumatology textbook. Rehabilitation treatment together with medication and rheumatic surgery form a mainstay of the comprehensive treatment of rheumatic diseases and they significantly affect functional capability, independence, subjective symptoms and the patient’s social integration. The goal of rehabilitation treatment is to not only prevent the worsening of a functional deficit, but to also minimize the extent of symptomatic treatment by medication (analgesics, non-steroidal antirheumatic medication), or either delay or prepare the patient functionally for a rheumatologic surgery so that the surgical procedure can bring about the expected outcome.

In systemic inflammatory diseases, the selection of rehabilitation treatment (exercise and modalities) is limited because, besides the musculoskeletal system, the internal organs and other inter-articular signs are often involved. These diseases are chronic in nature, often require permanent treatment by medication and thus, the rehabilitation treatment is often long-term. When setting up a short-term rehabilitation program, it is necessary, with regard to a specific activity (meaning an acute exacerbation of a chronic disease), to select an approach from the area of exercise therapy, establish the appropriate time of day for exercising, and the frequency, intensity and duration of the individual session. The selection of modalities depends on the disease activity and the presence of local signs. Long-term rehabilitation plan includes subsequent rehabilitation treatment (balneologic treatment, rehabilitation settings), appropriate orthotic and assistive devices or home care. For patients with rheumatologic diseases, it is also important to learn strategies for overall relaxation and develops a physiological breathing pattern. Inner stress, and respectively the ability to relax, shows a significant neuro-immunological relationship. Improved somato-esthetic perception is a prerequisite to learn relaxation. The indications of treatment rehabilitation are based on an anamnesis and a basic kinesiologic assessment while taking into consideration the disease activity. Rheumatoid arthritis in adults and juvenile rheumatoid arthritis in children are examples of chronic inflammatory diseases with polyarticular involvement of primarily the peripheral joints.

3.8.1 Rheumatoid Arthritis Rheumatoid arthritis (RA) is a chronic inflammatory joint disease affecting joint synovial lining, bursae and tendons. It presents with numerous inter-articular signs and development of nodes or vasculitis. In 2/3rds of patients with RA, the serum demonstrates rheumatoid

factors with proteolytic enzyme synthesis. A genetic predisposition is suspected, as well as, the influence of exogenous factors, such as various types of bacteria and viruses, which serve as a trigger mechanism for an autoimmune process. Most patients with RA are carriers of the shared epitope, which is shared by certain alleles HLA-DR4 or HLA-DR1. The patient’s serum shows auto-antigens, the most known being the rheumatoid factor (RF); however, it may not be present in all patients. A chronic synovial inflammation leads to the formation of panus, whose invasion and synthesis of proteolytic enzymes are the reason for cartilage destruction, subchondral bone erosion and damage to the periarticular structures. Rheumatoid arthritis is the most common inflammatory rheumatic disease with a prevalence of about 1%. It is found in all age categories. The peak incidence occurs between 30–50 years of age with women being affected more than men (2–3 :1).

CLINICAL PRESENTATION Joint pain of a varied intensity is among the first subjective signs. It is worse in the morning, usually at rest, accompanied by morning stiffness and restricted joint mobility. Morning stiffness usually lasts longer than one hour. Joint signs can be preceded by systemic symptoms, such as fatigue, weakness, temperature, sleep deficits and depression. Objective evaluation reveals polyarticular symmetrical arthritis most often affecting the metacarpophalangeal (MCP), proximal interphalangeal (PIP), wrist, metatarsophalangeal (MTP) and almost always the knee joints. Knee inflammation, or the disease activity, demonstrates itself by joint edema, pain upon palpation and limited active and passive range of motion. The skin surrounding the joint may be warmer; however, erythema is not part of the clinical picture. Joint damage results in joint deformities. Characteristic deformities include MCP joint subluxation with ulnar deviation. The interphalangeal joints demonstrate typical Boutonniere deformities (buttonhole) that are formed by PIP flexion and hyperextension of

the distal interphalangeal joint and swan neck deformities with MCP flexion and DIP hyperextension. In the wrist, there tends to be a shift in the volar direction with instability, or even stiffening after ankylosis. Frequent elbow involvement can be the cause of significant limitation in independence. In the shoulder region, besides joint damage, the periarticular tissues can also be affected, such as the subacromial bursa, rotator cuff tendons and the long head of the biceps tendon, which leads to humeral head migration. Coxitis is a significant finding in RA because it causes joint damage and requires a total joint replacement. With knee joint arthritis, a Baker’s cyst in the popliteal region poses a complication. A gradual loss of cartilage and ligament damage leads to anterior-posterior instability and later to genu varum, more often genu valgum. MTP joint involvement with foot joint deformities, such as hammer toes, hallux valgus and pes planovalgus accelerate gait dysfunction resulting in a significant limitation in the patient’s mobility. Muscle atrophies are also present. Common cervical spine involvement, especially at the C1-C2 level with subluxation and transverse ligament damage, spondylodiscitis, osteoporotic fracture or basilar impression present a severe and life threatening complication. The asymptomatic course of the disease can be complicated by the onset of cervical myelopathy and vertebrobasilar insufficiency. The clinical picture of the cervical spine also includes cervicocranial and cervicobrachial symptoms. In addition to joint involvement, median nerve compression under the flexor retinaculum is also common with clinical symptoms of carpal tunnel syndrome. RA is accompanied by secondary osteoporosis, which is explained by systemic activity of the inflammatory mediators, a change in the level of the circulating hormones, changes in calcium metabolism, inactivity and the effect of medication used to treat RA. Periarticular osteoporosis is the most severe problem.

FUNCTIONAL DIAGNOSIS The Health Assessment Questionnaire (HAQ) is the most common

questionnaire that assesses health by disability index. The Arthritis Impact Measurement Scale (AIMS) is a commonly used system, which, in addition to the functional assessment, also contains psychological categories. The questionnaires assess activities of daily living related to mobility, independence, special hand functions and recreational and work related activities, thus, activities necessary for a patient’s independence. Regular assessment of function is very useful because the laboratory indicators of the disease activity or the X-ray findings may not correlate with the patient’s functional abilities. The Steinbrocker Functional Classification (class I–IV) provides screening information regarding the patient’s functional abilities whereas severe structural joint damage may not correlate with the level of restrictions in work activities if the patient was adequately treated and instructed immediately from the beginning of the disease onset and educated in functional positioning and active exercise.

TREATMENT Rehabilitation Treatment Patient education regarding the nature of the disease, its course, prognosis, type of medical treatment, and the need for compliance and adherence to condition management are considered the key to a non-pharmacological treatment strategy. Condition Management Physical rest decreases the systemic inflammatory response; however, a long lasting resting regime can cause irreversible joint stiffness with fibrotic remodeling and influence functional fitness and independence. Therefore, physical activity is a part of the patient’s everyday regime. Prevention of flexion contractures is carried out through positioning and functional splinting. Exercise and Modality Selection The choice of exercise and modalities depends on the disease activity and state, the patient’s age, influence of other organs and compliance. In the early stages, during which significant structural joint damage or joint deformities are not yet present, the exercise routine focuses on

prevention. In the more advanced stages, further development of deformities needs to be prevented and, at the stage of significant deformities, it focuses on practicing movement compensations to preserve independence. At the stage of high humoral and local activity, 2–3 days of bed rest is recommended while adhering to the principles of positioning within the scope of rehabilitation care. The strategies include positioning in a sling. Individually fabricated thermoplastic splints act not only for prevention, but also for correction. They also contribute to pain relief. At least once per day, the joints need to be passively moved within their maximum range of motion. Traction along the longitudinal extremity axis tends to decrease pain. The treatment is usually initiated by relaxation of the most painful joints and muscles. At this stage, isometric contractions of the muscles surrounding the affected joint contribute to maintaining muscle strength. As the disease activity subsides, the patient needs to gradually become more active. Special attention is paid to the muscles whose atrophy can result in deformities. In the upper extremities, these especially include the extensors of the wrist, fingers and their short muscles as well as the elbow extensors. In the lower extremities, these include knee extensors and foot arch musculature. During therapeutic exercise, the question of overcoming pain is often discussed. Today, pain is no longer considered a limiting factor. During therapy, the patient should overcome a certain degree of pain. It is important for the pain to decrease within two hours after exercise or subside completely by the next day. The afternoon is usually more convenient for the patient. During remission, or low disease activity, the emphasis is placed on active exercise to increase muscle tone, improving range of motion and muscle strength and gait training with forearm crutches, often with axillary crutches depending on the patient’s grasping hand function. The treatment also includes aerobic fitness training. Principles of Therapeutic Exercise Therapeutic exercise needs to be performed on a long-term basis and must be progressed, but not increase pain and fatigue. It is not

appropriate during the sudden onset of inflammation, severe internal organ involvement, during fever and in severe joint changes (necrosis). Therapeutic exercise methods used to maintain full range of motion include joint mobilizations (stretching, mobilization) and muscle elongation or stretching. Stretching is performed to end ranges several times per day. Techniques focused on the cervical soft tissues are utilized. A physician or an experienced physical therapist can, in certain cases, perform relieving traction with gentle mobilization. Joint mobilization brings about subjective relief in pain and joint stiffness and contributes to the improvement in fine motor skills and independence, especially in the upper extremity joints. A decrease in muscle strength is the result of inactivity, synovitis, inhibition in muscle contraction and medication side effects. Isometric activity needs to be repeated at least 2–4 times per day. The resistance is always manual; pulleys are not appropriate. Prior to exercise, a cold pack can be applied for approximately 10 minutes. Group exercises are indicated for patients in rheumatologic or balneologic facilities. Patients are placed into groups based on more severe deformities, disease activity and internal organ involvement. Modalities In the acute phase of the disease, localized analgesic and antiinflammatory effects of cryotherapy have been found beneficial. In an inpatient setting, localized cryotherapy can be administered by the use of instruments with liquid nitrogen, which is transformed into gas with an average temperature of –160 °C. In some countries, whole body application is applied by a brief stay in a cold chamber with a temperature of –170 °C. During remission, heat application including paraffin wraps, whirlpool and aquatic physical therapy is also beneficial. The treatment effects of ultrasound and laser are used as assistive treatment methods, especially for hand and foot joints. An individual approach with modifications to accommodate the patient’s current condition is always necessary for the indication of rehabilitation treatment and modalities. Comprehensive balneologic treatment is recommended by a rheumatologist. Contraindications

include high or progression inflammatory disease activity and lack of independent mobility. Occupational Therapy Occupational therapy is an important component of treatment, which also includes, in addition to various skills, education regarding joint protection, consultation regarding ergonomic modifications and utilization of assistive devices. Based on the patient’s level of involvement, the patient is fitted with crutches. Axillary crutches are indicated for patients with significant hand joint deformities and limited grasping function. Custom made footwear, raised toilet seats, shower chairs, various reaching tools, thermoplastic splints, orthoses, cervical collars, etc. are often needed. Surgical Intervention Surgical intervention includes prophylactic surgeries –synovectomies and reconstructive surgeries – osteotomies, arthrodesis, spondylodeses and joint arthroplasties. Pharmacological Interventions So called disease-modifying anti-rheumatic drugs (DMARDs) form the foundation of pharmacotherapy and objectively suppress the inflammatory reaction (observed in laboratory results) and slow down the disease progression, which improves the patient’s quality of life. Corticosteroids are a fast and intense acting anti-inflammatory medication and they are administered systemically or intra-articularly. Non-steroidal antirheumatics (NSA) as a symptomatically acting medication contribute not only to pain relief, but also to decreasing joint stiffness which helps to improve motor skills. For patients who did not respond to the conventional treatment with DMARDs, biological treatment with TNF-α-blocks can be considered.

PROGNOSIS Prognosis depends on the rate of onset of erosive changes, the success

of comprehensive treatment and the presence of inter-articular involvement. Uncontrolled polyarthritis causes disability in as many as 50% of patients after 5 years and as many as 90% of patients after 10 years. Rheumatoid arthritis shortens life expectancy (especially in women) by as much as 10 years. Limited function is improved by an appropriate regime and rehabilitation treatment.

3.8.2 Juvenile Rheumatoid Arthritis (Juvenile Idiopathic Arthritis) Juvenile rheumatoid arthritis (JRA) is a chronic inflammatory disease of unknown etiology that begins prior to 16 years of age and lasts at least 6 weeks. It is the most common rheumatic disease in childhood. Similar to the adult form, there is a hereditary predisposition, primarily in the HLA-system. The classification is based on clinical symptoms. Most often, seven types of JRA are distinguished: 1. 2. 3. 4. 5. 6. 7.

Systemic arthritis Polyarthritis with negative rheumatoid factor (RF) Polyarthritis with positive RF Oligoarthritis Extended oligoarthritis Arthritis with enthesitis Psoaritic arthritis

The disease onset is often preceded by feverish states that are accompanied by significant changes in the entire body. Pulmonary complications or liver dysfunction (hepatopathy) can also occur. Laboratory findings show the presence of high, non-specific inflammatory activity, especially an increase in the circulating antiinflammatory cytokines and their inhibitors (IL-6, IL-18, TNF-R, IL1Ra) and also increased ferritin concentration.

CLINICAL PICTURE Oligoarthritis is manifested as a monocyclic, intermittent or persistent disease. An advanced form sometimes develops into polyarthritis.

Arthritis can be preceded by chronic anterior uveitis that is independent of joint inflammatory activity. The speed and degree of progression of joint damage depends on timely diagnosis, treatment, and also occurrence of complications, such as growth retardation or osteoporosis. Only certain forms resemble RA in adult patients, but even here the clinical presentation can be modified by the fact that the inflammation affects growth plates. “Paw-like” hands with shortened “telescopic” fingers develop in the hand region due to slowed skeletal growth. The face can present with a shortened mandible with a “bird-like” face (facies avina).

TREATMENT Treatment needs to be initiated on time to prevent destructive joint changes. Treatment of JRA is similar to the treatment of RA in adult patients. Pharmacological intervention and rehabilitation always form the treatment pillars. Rehabilitation Treatment Rehabilitation treatment should be part of a multidisciplinary approach. The selection of rehabilitation approaches for patients with JRA; however, needs to respect the specifics of rehabilitation of pediatric patients that differ from the specifics of rehabilitation for adult patients, especially in methodology and the selection of a treatment algorithm. Physical Therapy Physical therapy focuses mainly on maintaining or restoring movement functions. It is important for the child’s activity to be directed toward a specific function. A beneficial therapeutic result can be achieved if the exercise is related to strong motivation. The exact prescription of physical activity needs to be established based on the patient’s age, disease stage and the possible presence of osteoporosis. For therapeutic approaches, it is beneficial to utilize kinesiologically targeted exercises in play form, occupational therapy approaches, etc.

If the child is unable to actively participate in the treatment, reflex therapy can be used. Respiratory therapy is beneficial in patients with pulmonary complications. The influence of family and parent cooperation needs to always be carefully assessed. According to the latest studies that meet evidence based medicine (EBM) criteria, it has been shown that combined movement programs, especially aerobic endurance-based exercise on a treadmill or bicycle ergometer, are the most beneficial therapeutic methods for cardiovascular fitness in the rehabilitation of patients with JRA. Endurance training is also complemented by post-facilitation stretching of those muscle groups that show a tendency toward shortening. Last but not least, specific kinesiotherapy is performed to maintain movement function at the highest possible level. Occupational therapy aimed at influencing fine motor skills is also an important component. Modalities Modalities are mainly used in the acute inflammatory stage to control pain and decrease edema. General principles are followed when selecting modalities for this patient group. During active inflammation, extremity immobilization and positioning are recommended. Cryotherapy is recommended from the application of ice packs to submerging ice baths. Pharmacotherapy Pharmacotherapy includes application of non-steroidal antiflogistics, corticosteroids and Methotrexate. Newer treatment methods include implementation of biological means, such as substances influencing the TNF soluble receptor. Medication is also administered to control osteoporosis or other complications present with the disease.

PROGNOSIS Prognosis depends on early diagnosis, pharmacotherapy and continuous rehabilitation. The fast development of flexion contractures, localized changes in the growth of an affected segment

and an overall growth deficit can affect the level of disability and handicap.

3.8.3 Ankylosing Spondylitis Ankylosing spondylitis (AS) or Bechterew’s disease belongs among the typical diseases within a group of spondyloarthroses that primarily affect the axial skeleton. Ankylosing spondylitis is a chronic, systemic inflammatory disease that affects mainly the axial skeleton, sacroiliac, apophyseal and costovertebral joints of the spine. The disease generally begins at the end of the second or third decade, more frequently in men than in women (7–10 :1 ratio in favor of men). In the adult population, its prevalence is around 0.5–1%. Spondyloarthroses are characterized by three main symptoms: 1. Arthritic, affecting preferentially mid-size and large joints of the lower extremities 2. Axial, in the sense of inflammatory involvement of the spine (spondylitis), or sacroiliac joints (sacroiliitis) 3. Extra-articular, which involves the mucous membrane and skin lesions, the eyes and the cardiovascular system In contrast to RA, in which the primary inflammation involves the joint synovial lining, the primary lesion in spondyloarthritis includes inflammation of the joint capsule, tendons and ligaments close to their insertion to the bone. The etiology of this disease is unknown so far; often, infections, genetic and immune-genetic factors are being reported. The disease has shown a high degree of association with the HLA-B27 antigen. The mere presence of HLA-B27 antigen; however, is not sufficient for the development of AS and a small percentage of patients with AS do not show HLA-B27 antigen at all. The inflammatory reaction of the joints of the axial skeleton is accompanied by subsequent new bone formation, by ossification of

the peripheral fibers of the connective tissue ring of the intervertebral disc and the formation of a syndesmotic bridge between two adjacent vertebrae and by ossification of the sacroiliac joint capsule eliciting partial ankylosis and joint synostosis.

CLINICAL PRESENTATION The first sings of AS can manifest themselves as joint pain, insertional pain or enthesitis, most often around the heel or the sitting bones. The disease rarely begins with visual signs – uveitis or iridocyclitis (15– 30%). Back pain with a primary pain location at any spinal segment is the dominant sign. Typical is the so called inflammatory type of pain at rest during the night and early waking hours with relief after warm up exercises and morning stiffness lasting longer than half an hour. Spinal movement restrictions caused by gradual stiffening of the spine, can initially affect only a certain segment, but, as the disease progresses, it can result in complete spinal rigidity. According to disease progression in the spine, the ascendant and descendant types are distinguished. From the perspective of disability, proximal joint involvement is the so called rhizomelic form. It is the most severe of any form of symmetrical coxitis with clinical manifestations of acute painful inflammation and the subsequent development of damage, deformities and ankyloses. In the peripheral form of AS, a chronic arthritis syndrome with post-arthritic joint deformations develops. Already in the early stages of the disease, painful edema can occur at the sternoclavicular, sternocostal, and less often at the acromioclavicular and mandibular joints. Spondylodiscitis with damaging changes in the intervertebral discs or an osteoporotic vertebral fracture can elicit spine and nerve root compression. When C1-C3 are unstable, an atlanto-occipital dislocation can form with simultaneous lower cervical spine ankylosis. An acute episode, similar to an acute form of disease onset, generally presents with increased temperature, pain, overall fatigue and increased laboratory inflammatory indicators; seasonal exacerbation in the spring and fall

months is typical. The course of AS can be mild and further progression can even stop; however, on the other hand, in severe forms, it can progress to ankylosis very quickly. When other organs are affected, they may include the aorta in 1–5%, spondylotic pulmonary fibrosis in 4–7% and neurological compression syndromes in 2–8%. Osteoporosis can be an associated phenomenon with the ongoing disease process. As a result of respiratory complications, pulmonary ventilation tends to be decreased and caused by decreased mechanics of the thorax due to costovertebral joint stiffness.

DIAGNOSIS Based on the modified diagnostic criteria of ankylosing spondylitis from 1984, for a definitive diagnosis of AS, an x-ray has to confirm the presence of bilateral sacroiliitis of at least stage II and one of the following clinical criteria needs to be met: Pain in the lower back with stiffness lasting more than 3 months that improves with exercise and is not relieved by rest Restricted lumbar spine mobility in the frontal and sagittal planes Limited thoracic excursion It is not difficult to identify a developed condition because the symmetrical syndesmophytic bridging of the vertebrae gives the spine the image of a “bamboo stick” (Fig. 3.8.3-1). Longer monitoring is often needed for an early diagnosis of AS because the clinical manifestations are usually intermittent and the radiological findings develop slowly. During clinical assessment, it is important to not only pay attention to the data regarding the type of pain or peripheral joint edema, but mainly to the manual assessment of the sacroiliac joints. In the early stages, the sacroiliac joints present with recurrent restrictions that can be the first signs of spondyloarthritis requiring further specialized observation. Dynamic assessment of the spine, including thoracic excursion, contributes to identifying the functional deficit of restricted breathing capacity. Further, radiological findings of the sacroiliac and spinal joints are important, as well as, a laboratory

finding of increased reactant values in the acute phase and, finally, positive HLA-B27 (Fig. 3.8.3-2). From the rheumatologic perspective, the developmental stages of AS are assessed mainly based on a radiological image of the sacroiliac and spinal joints. Prodromal signs can be diagnosed during clinical assessment of the sacroiliac joints; however, the results of this assessment are non-specific. Examination and monitoring by a rheumatologist is necessary for patients with recurrent problems and typical symptoms. Fig. 3.8.3-1 Radiological finding of spinal ankylosing spondylitis – the so called bamboo stick image

Fig. 3.8.3-2 Radiological image of sacroiliitis in ankylosing spondylitis

Functional Diagnosis During postural assessment, the characteristic findings include slight knee and hip flexion, flattened lumbar lordosis, significant thoracic hyperkyphosis with hyperlordosis, and respectively a forward head posture and protruded abdominal wall. The dynamic assessment of the spine reveals restricted spinal mobility in three planes. The following are positive: Thomayer test and Forestier fleche, Schober and Stibor distance are limited – see Fig. 1.2.1-22 in the General Section of the textbook, Section A. Diagnostic Approaches, Chapter 1.2.1 Kinesiology of the Spine, Pelvis and the Thorax, Assessment of Thoracic Mobility. During the assessment of thoracic excursion, there is a minimal difference in the circumference of the thorax at the level of the nipples with maximum expiration and maximal inspiration, vital capacity is decreased and the thorax is significantly stiff upon palpation. Thoracic stiffness during clinical assessment together with resistance at the sacroiliac joint during springing are among the most significant initial clinical sings of the disease. In morphological joint changes, the joint restriction occurs in a capsular pattern. Hip joint ankylosis in the fle​xion position completely prohibits ambulation. The Bath Ankylosing Spondylitis Functional Index (BASFI) is used to assess functional abilities. The patient answers 10 questions pertaining to accomplishing common tasks and life situations. The result of the assessment is an average value expressed on a visual analogue scale from 0 mm (activity is easily performed) to 100 mm (the activity

cannot be performed).

TREATMENT Rehabilitation Treatment Condition Management Condition management pertaining to the daily exercise program, early education about the disease course and the patient’s needed cooperation are the prerequisites to preserve at least partial work potential even in patients with significant functional involvement. Physical Therapy Physical therapy has a fundamental role in the treatment of AS. Active movement is a lifetime necessity for such patients and maintaining movement routine significantly influences the quality of life. The goal of physical therapy is to slow down spinal ankylosing and prevent kyphotic formation. Physical therapy is aimed at maintaining spinal and thoracic mobility, addressing muscle imbalance, maintaining range of motion of the proximal joints, addressing postural correction, maintaining maximum breathing capacity and improving the patient’s overall fitness. Exercise treatment selection depends on the stage of AS, disease activity, involvement of additional organs and the patient’s age. In the stage of high activity, it is important to prevent the onset of deformities by preventative positioning, passive exercise combined with traction techniques and breathing exercises. Warming the tissues up prior to the application of soft tissue techniques helps control pain. Exercises are based on the antalgic position, which contributes to the patient’s overall relaxation. Muscle atrophy is also preceded, among others, by isometric exercises. During the stage of low and moderate disease activity, the treatment focuses on postural re-education, positioning, gentle mobilization of the sacroiliac joints, neuromuscular techniques for spine and rib mobilization; thrust techniques should be avoided. Part of the treatment under the guidance of a physical therapist includes a release

of shortened muscles, spinal exercises and exercises aimed at the deep stabilization system and chest breathing. Within the neuro-immune context, training general relaxation techniques related to the practice of various modifications of a breathing pattern is important. Somatognostic training is important to develop coordination and, therefore, better compensatory control of mobility as a consequence of the disease. The goal of group exercise is, once again, preventative maintenance or restoration of optimal mobility (stretching, exercising into backward bending, visually controlled swing movements to release soft tissues, movement into full range of motion, etc.). During exercise, various tools are utilized – balls, wands, resistive bands. Wall bars are also beneficial because hanging has a corrective effect on the thoracic spine. They are recommended for home use. Group exercises provide an important psychological benefit to the patient. Exercise treatment is a necessary component in a patient’s daily routine, initially under the guidance of a physical therapist and later performed independently at least 20–30 minutes per day when the patient becomes proficient in their exercise routine. Modalities Exercising in the water including individual or group exercises, submerged massage to release muscle contractures, whirlpools and Scottish showers can all be beneficial. Magnetic field application has shown a positive response resulting in decreased pain. Based on the treatment goal, electrotherapy and ultrasound can be utilized for pain control and muscle relaxation. Comprehensive balneologic treatment is prescribed by a rheumatologist starting in stage II of the disease. Contraindications include high or progressive disease activity and more severe visceral involvement. Pharmacotherapy No specific or curative medication is available at this time. During an active disease stage, non-steroidal antirheumatics are used to control symptoms; sulfasalazine and methotrexate are used in the peripheral form of the disease. A breakthrough in the treatment of AS represents

“biological treatment” by TNF-α inhibitors; however, the indication criteria for this treatment are strictly defined. The treatment side effects need to be respected during the course of treatment. Rheumatologic Surgery Total endoprostheses are necessary after joint destructions and for ankylosing coxitis; however, the end result of surgical treatment is decreased by secondary ectopic calcifications.

DISEASE COURSE AND PROGNOSIS Functional limitations and disability depend mainly on early diagnosis, the disease course, treatment and, especially, on the patient’s compliance. Disability is increased especially when the hip and knee joints and other organs are affected and when the respiratory functions are restricted. When diagnosed early, the life and working perspective is favorable, 70–75% of patients are fully active with good working prognosis. Temporary work disability can be caused by the recurrence of the inflammatory process and by increased pain. Mild and benign forms are restricted to the sacroiliac or lumbar spine regions. In most clinically manifested cases, the spondylitic process progresses through the thoracic into the cervical spine regions. Patients with peripheral arthritic syndrome show worse prognosis. In the Czech Republic, regional civic networks exist including the Club of Individuals with Bechterew’s Disease founded by the Rheumatological Institute in Prague. The club connects patients with Bechterew’s disease, promotes and defends their interests, ensures their education in a social setting, allows for their participation in club activities and ensures their full-fledged and equal life.

3.8.4 Osteoporosis Osteoporosis (OP) is a systemic metabolic disease characterized by decreased bone density and disruption in the bone microarchitecture, which leads to increased bone fragility and, thus, an increased risk of

fractures even with minimal trauma.

ETIOLOGY Up to 60% of bone mass is genetically conditioned. The overall amount of bone mass (so called peak bone mass, PBM) is influenced by physical activity until the age of 30 with the maximum being accumulated until the age of twenty. The risk factors for the onset of osteoporosis include early menopause, hormonal disturbances with an estrogen deficit, thyroid disease, chronic renal insufficiency, diabetes mellitus, post-transplantation conditions, prolonged immobilization, etc. Osteoporosis can be classified as generalized and localized (regional). Generalized OP can be either primary or secondary. Primary OP includes postmenopausal (given the estrogen insufficiency some authors include it in the secondary OP group), senile, juvenile, young and adult individuals. Secondary generalized OP depends on endocrine influences (hyperthyroidism, hyperparathyroidism, hypogonadism, type 1 diabetes mellitus, etc.), iatrogenic influences (corticosteroids, anticonvulsives, anticoagulant, immunosuppressive, diuretics, laxatives), nutritional influences (protein and calcium insufficiency), immobilization, chronic inflammatory diseases, tumors, etc. Immobilization is the most common cause of localized osteoporosis. Juxta-articular osteoporosis occurs in chronic rheumatic diseases.

EPIDEMIOLOGY In industrial European countries, OP affects 5–6% of people. Senile osteoporosis affects women and men older than 75 in a 2:1 ratio. Symptomatic vertebral compressions are found in 20–40% of women above 75 years of age.

CLINICAL MANIFESTATIONS As many as 50% of vertebral fractures can be discovered accidentally; however, fractures often develop acutely without any significant traumatic mechanism. Osteoporotic fractures also include forearm and

proximal femoral fractures. Osteoporosis does not hurt and subjective symptoms only emerge with fractures. Most often, the first symptom is sudden, acute pain between the mid- thoracic and upper lumbar spine that worsens under static loading in sitting and standing and is relieved by lying down. Pain is linked to movement of the diaphragm, which is the reason it emerges with inspiration and spreads along the rib angles. The patient’s independence becomes limited. Objective examination reveals antalgic body posture, paravertebral reflexive muscle spasm, limited unwinding of the thoracic and lumbar spine and pain with tapping on the spinous processes. In wedged fractures, the thoracic kyphosis is accentuated, lumbar lordosis is flattened and body height gradually decreases.

DIAGNOSIS Radiological imaging shows increased translucence only when the bone mass has decreased by 30%. Therefore, patient history regarding pain between the scapulae at rest is emphasized during the prodromal stage. Fracture location and osteoporotic finding are signals for a more thorough assessment. Bone densitometry is the standard for OP diagnosis. Laboratory testing specifies the differential diagnosis and the dynamics and effectiveness of treatment (serum concentration of calcium, alkaline phosphatase, biochemical markers of bone turnover, etc.). Functional Diagnosis Restriction in the dynamics of the thoracic and lumbar spine in all directions is identified as well as thoracic excursion, increased tone of the paravertebral musculature or contractures, an incorrect breathing pattern and deficits in gait pattern.

TREATMENT Pharmaceutical Treatment Medications are indicated based on the type of OP and under the guidance of an osteologist. It includes calcium, vitamin D, hormone

substitution treatment, bisphosphonates, calcitonin, etc. Rehabilitation Treatment Physical Therapy Therapeutic exercise is crucial. An exercise program must be individualized based on the severity of the OP and the patient’s capabilities. The goal of therapeutic exercise is to not only improve body posture, but to also maintain the muscle corset to prevent further fractures. The release of muscle contractures of the iliopsoas and the pectorales with an emphasis on correcting the activity of the deep spinal stabilization system are also goals. Breathing exercises are an inseparable component of active exercise. Exercise should not cause or increase pain; exercises involving swinging movements and spinal flexion are not appropriate. For older patients, resistance exercises without maximal intensity are beneficial and individual exercises are repeated 10–15 times in a series. The rehabilitation program should also include fall recovery. Exercise treatment must be regular and long-term. Depending on the complications of OP and the patient’s individual condition, rigid or semi-rigid orthoses are beneficial. Their supporting effect should always be supplemented by an isometric activation of spinal stabilizers. During the acute stage, resting, preventative positioning, breathing exercises, specific abdominal and later thoracic breathing, pelvic and femoral isometric contractions and passive exercises are implemented. Modalities Modalities include pre-heating by infrared lamp for 20–30 minutes followed by a gentle massage 2–3 times per day and decreasing pain by low frequency analgesic electrotherapy (TENS). Hydrotherapy includes pool therapy, whirlpool and bubble baths. When the acute stage subsides, the clinical picture includes chronic pain related to the kyphotic changes of the spine, increased muscle tone and ligamentous tension. Recreational activities are recommended during the times the osteoporosis is stabilized. These include light hiking (walking) to maintain fitness and muscle

coordination (3–5 km walk at least 3 times per week), biking on level surfaces and swimming. Although swimming is not effective for improving spinal bone density, it is beneficial for maintaining overall fitness and muscle tone. Swimming in patients with osteoporosis should not be done in water that is too warm and should be dynamic in character (floating in warm water is not recommended). Also, activities involving lifting heavy objects, jumps or sudden movements are not recommended. The foundation of OP prevention lies in sufficient physical activity in the formative years to achieve maximum bone mass. During adulthood, bone loss prevention is emphasized. A comprehensive balneologic treatment can be recommended by an internal medicine physician or rheumatologist. Contraindications include acute worsening and certain states after new compression fractures of the vertebrae and other bones.

PROGNOSIS The patient’s functional potential depends on their age, type of fracture, involvement of other organs and other complications. Two thirds of patients who survive the first year after a proximal humeral fracture (typical fracture especially in women of advanced age) require assistive devices and assistance. One half becomes permanently institutionalized. Asymptomatic vertebral compressions in the lower thoracic and upper lumbar spine can cause chronic back pain and often are not linked to hospitalization or higher mortality. However, they present significant health and financial issues because of repeated examinations, work disability and, in 10% of individuals, long-term hospitalization needs. The severity of osteoporotic fractures (especially in the femoral neck) lies especially in their consequences. Following a femoral neck fracture, approximately 20–30% of patients die within one year and 30–40% become dependent on assistance of others.

3.8.5 Fibromyalgia Syndrome Petr Knotek, Pavel Kolář Fibromyalgia syndrome (FMS) is classified as a nosologic unit of rheumatologic diseases, although its etiology is not quite clear and it is the topic of disagreements. Fibromyalgia syndrome, or fibromyalgia for short, is a painful condition that in general comprehensively affects the patient’s biological, psychological, social and economic aspects of life. It is found in all ethnic groups regardless of the society’s industrial level. The occurrence is usually reported in 2–4% of the population. In the 18th century, painful conditions of the musculoskeletal soft tissues were known as muscle rheumatism. This, together with joint rheumatism falls under rheumatologic diseases. The term fibromyalgia was established by P.S. Hench in 1976 to describe painful conditions that manifested chronic muscle pain as their main symptom. In 1990, the American College of Rheumatology (ACR) developed a statistical approach for the establishment of FMS symptoms based on the controlled data collection in a number of major facilities (multicenter studies). The following were established to be the determining criteria for FMS diagnosis: (1) presence of at least 11 out of 18 tender points that are painful upon palpatory pressure of 4 kg and, (2) body-wide pain lasting a minimum of 3 months or longer. These tender points (found in the back of the neck, trapezius muscle, lower cervical spine, gluteals, greater trochanter, supraspinatus muscle, 2nd rib, lateral epicondyle and knee) serve as determining factors for FMS diagnosis (Fig. 3.8.5-1). These criteria are (given the current knowledge about the disease) crucial and vital for FMS; however, differential diagnosis to distinguish FMS from other soft tissue pain syndromes continues to be quite complicated.

Fig. 3.8.5-1 Tender points. If a 4 kg-pressure (or smaller) elicits pain in 11 of 18 points, the main diagnostic criterion of FMS has been met.

Fibromyalgia syndrome requires a specific approach to the diagnosis and treatment and also an individual approach with each patient. In the past, patients with developed FMS symptoms were often considered neurotic, persons overusing healthcare services or malingerers. People close to the patients did not understand the change in the patient’s behavior and the patients were also subjected to oversimplified approaches by healthcare providers. The patients themselves lost their credibility, at first, because of their tendency to initially deny their problems and continue participating in challenging activities. Later, their efforts to convince others about their problems

were unsuccessful. In the 1970’s, the time between the onset of FMS symptoms and the patient’s diagnosis exceeded 9 years. Currently, it is less than 3 years (in the US). In patients with FM, non-pharmacological treatment and rehabilitation are, in certain aspects, different from standard approaches and when these differences are not respected, a paradoxical effect is seen. Fig. 3.8.5-2 Shows a hypothetical causative model of FMS onset and progression.

Fig. 3.8.5-2 Onset and progression of fibromyalgia. The first line includes basic causes; the second line includes personal dispositions. The left column includes the most common trigger processes (psychological stress, illness, etc.). The right column includes gradually weakening in immunity (infection, toxins, antibiotic treatment) and typical pathological reactions and trigger processes based on the

severity of involvement: immediate reaction to stress, neurotic deficit, psychosomatic systemic diseases (for example, cardiovascular – ischemic heart disease, myocardial infarction, skin – psoriasis, etc.) and fibromyalgia syndrome (respectively another form of overall disruption to an organism, such as, deficit in immunity, chronic fatigue syndrome, autoimmune deficits, etc.) and also maladaptation of a patient with FMS to the social environment, especially the lack of understanding and disapproval of their family or the medical personnel. The arrows show the direction of causation.

CLINICAL MANIFESTATIONS AND DIAGNOSIS At least 11 active tender points out of 18 possible is the main criterion for FMS. Their activity is tested by 4 kg pressure either with palpation or by pressure algometer. A numeric scale is used for more sensitive quantification of the disease. The patient’s reaction to 4 kilograms of pressure at each tender point is given a grade: 0 = non-painful; 1 = painful but without bodily reaction, 2 = painful with strong withdrawal and 4 = painful and standard testing is not possible (the scale spans values of 0–76). Localized aching can persist for days following testing. Pain duration for 3 months or more is another criterion according to ACR classification. From a clinical perspective, it is also important to monitor other manifestations, listed in Tab. 3.8.5-1, and signs, such as a possible disruption in immunity by an infection (for example, Lyme disease), post-injury condition, exhaustion or other influences. If FMS is difficult to treat, the following rule should be followed: precede developing FMS by a treatment with less strict diagnostic criteria rather than wait for progressed FMS with all signs.

Tab. 3.8.5-1 Fibromyalgia symptoms

A patient’s anamnesis reveals body-wide pain lasting at least 3 months. The pain is present in all four body quadrants (right and left body side and above and below the waist line). In addition, axial pain needs to be present in the neck area, anterior thoracic surface area, and the level of the thoracic and lumbar spinal segments. Differential Diagnosis Differential diagnosis in FMS is quite complicated. There are several reasons; one of them is a certain unfamiliarity of its etiology, which is probably multicausal. Some describe a smooth transition between FMS and chronic fatigue syndrome, or a pathological state with

significant manifestation of chronic fatigue syndrome and less prominent signs of FMS. Chronic fatigue syndrome and FMS are quite common conclusions from a clinical assessment. The simultaneous incidence of myofascial pain syndrome and FMS is reported in approximately 70% of patients. A number of patients also display irritable bowel syndrome. It is presumed that the increased “passage” of the nociceptive input to the CNS and increased central sensitization are vital. Since the intensity of the individual manifestations of these syndromes usually continuously increases, the establishment of their presence is not clear-cut. Lately, the effect of the examiner’s experience and other influences are being admitted. Currently, the hypotheses considering myofascial pain syndrome as a causative stepping stone toward FMS have been on the decline. Rather, a general contribution of a certain pathological state to the development of FMS is being discussed. For example, the effects of undergoing neuro-infections, hepatitis C and other diseases are being considered. Certain differences in subcellular structures attest to FMS autonomy, such as electron-microscopy identified mitochondrial changes, degreased thalamic blood flow, disruption in endocrine processes, namely the axis of the hypothalamus- hypophysis- adrenals, or possibly gonads and growth hormone – or gluten intolerance. Endocrine changes imitate certain manifestations of anxiety and depression that can secondarily contribute to the patient’s negative reaction to the overall frustrating conditions resulting from FMS. The relationships between FMS and other pathological states also cause problems in diagnosis and differential diagnosis. Certain pathological states apparently trigger or accelerate FMS progression. The systemic nature of FMS also influences the course and manifestations of comorbidities, usually in a non-specific way. The signs of concurrent pathological states are then more accentuated, subjectively less tolerated and their overlap with relatively non-specific FMS manifestations can appear exaggerated or non-credible. Patients with FMS usually show higher comorbidities. Irritable bowel syndrome is 3.5 times higher than in the regular population.

Further, patients with FMS show a more frequent occurrence of dysmenorrhea, interstitial cystitis, other rheumatic diseases, myofascial pain syndrome, low back pain and temporomandibular pain. Biological Aspects of FMS Deficit in Sensory Information Processing In FMS, the mechanism processing sensory information in the CNS is specifically disrupted, which has been identified with functional imaging methods. In FMS, the thalamic nuclei and other structures show decreased localized blood flow, which contribute to nociceptive information processing. This is linked to a lower level of substance P in the spinocerebellar fluid. An increase in nociceptive stimulation activity even at the spinal cord level has been seen on fMR. Also, the neurochemical changes in FMS attest to an alteration in the transfer of nociceptive stimulation activity. The presence of pronociceptive mediators, substance P, neural growth factor, dynorphin A, glutamate and nitric oxide is increased. These substances increase the afferent signals and thus, pain perception. This fact was substantiated by a test of differences among patients with FMS and healthy individuals. In contrast, noradrenalin, serotonin and endogenous opioids inhibit the transfer of nociceptive signals and have an anti-nociceptive effect. Other causes of FMS are related to the aggregation of oxidants (metabolic, microbiologic and environmental). These influences lead to disturbed oxygen utilization at a cellular level and toward hyperacidosis. Neuroendocrine Aspects The relationships between the neuroendocrine processes and FMS are, without a doubt, supported by the difference in FMS incidence in men and women. The commonly reported ratio of occurrence of approximately 1% in men and 7–11% in women corresponds at age 50 and older. The data in children show a similar FMS incidence between boys and girls. The differences in prevalence increase during adolescence. This trend continues into old age, but there is little

validated data. In old age, the incidence of FMS for both genders somewhat approximates. Certain neuroendocrine axes point out dysfunctional changes in patients with FMS, but the etiology of such abnormalities is still uncertain. The hypothalamus-hypophysis-adrenals axis shows an increased formation of adrenocorticotropic hormone (ACTH), which can lead to, for example, glycemia during physical activity (insulininduced hypoglycemia). During increased ACTH production, the level of plasma cortisol is decreased and, in addition, fluctuates during the day. It is presumed that even this can be one of the main reasons for a generally lower tolerance to physical activity in patients with FSM. The hypothalamus-hypophysis-gonadal axis is without a doubt extraordinarily significant in the greater incidence of FMS in women. Up to 30% of FMS incidence occurs in the time following gynecological procedures (hysterectomy, ovariotomy). Although estrogen influence is presumed, apparently the differences in the CNS production of serotonin are significant in the higher occurrence of FMS in women when compared to men. The significance of the hypothalamus-hypophysis-growth hormone axis supports the influence of parenteral administration of growth hormone for a significant cessation of FMS symptoms. The change is not permanent, the approach needs to be repeated, the financial demands are high and, as a result, it is not being implemented. Muscular System Fibromyalgia syndrome is accompanied by muscle pain, fatigue and a change in tension. Some studies attest to mitochondrial abnormality, muscle fiber atrophy (type 2) and red fiber rupture. Clinically, overall muscle weakness can be observed or weakness following a one-time strength-demanding task with slow regeneration, lasting several tens of minutes. In the initial phase of FMS, this occurs in the distal upper extremity. The patient can unlock a key lock on the “first try”. However, if they do not succeed, they require help from others or have to wait for several minutes. These manifestations are often present at the onset of FMS, which is the reason why sometimes a complex regional pain syndrome is considered as the first diagnostic

hypothesis. In the later phases of progression, the symptoms may regress. If the patient’s condition is not sufficiently stabilized and the patient undergoes shorter muscle activity, the symptoms may significantly worsen, especially in a shorter time period. These manifestations of muscle weakness, pain and decreased regeneration differ among individual patients. They mostly depend on the degree of involvement and other circumstances. These include a significantly atypical pain reaction to mechanical stimulation, for example, following classic massage if the massage therapist does not take into consideration the specific FMS conditions (often, these are a reaction to strong stroking or tapping). A similar manifestation also occurs as a reaction to relatively disproportional muscle loading during physical therapy if the therapist uses the usual movement prescription (exercise intensity) without taking into consideration the specifics of FMS and without feedback, meaning without taking into consideration the patient’s response. Sometimes, increased pain occurs as a reaction to an invasive treatment, such as an injection of anesthetics in a tender point. This type of reaction is linked to an overall higher excitability, which is the foundation of FMS. It then is related to a higher excitability of free nerve endings A-δ and C-fibers, with a higher “passage” of nociceptive inputs from the periphery to the CNS and a higher overall excitability of the CNS to nociceptive and other stimuli, including affectogenic stimuli (for example, during passive hostility from the treating person). FMS displays characteristically disproportionate (abnormal) relationships between the stimuli and its response. This involves the reaction to pressure, vibration, sound, disturbance in the body’s integrity including invasive treatments, physical activity, stronger medications, affectogenic stimuli, conflicts and lower tolerance to communication demands in a presence of more people. Circulatory System In FMS, there is a decreased blood flow through the thalamic nuclei and other brain structures that contribute to the transfer and processing of nociceptive information. Clinically, manifestations of

decreased blood flow to the distal aspects of the extremities are apparent with cold hands and feet. Decreased cardiopulmonary system function can be assumed to be a secondary effect of limited movement due to muscle pain and fatigue. Psychological Aspects of FMS Psychophysiological Aspects Psychophysiological manifestations of FMS correspond to neurasthenic syndrome; thus, demonstrate an overall weakness and malaise. Increased CNS excitability, lower blood flow through brain structures that are linked to pain and affective mechanisms, higher fatigue and natural frustrations from a limited lifestyle as a result of FMS can imitate affective and neurotic disturbances. A significantly higher incidence of anxiety and, in 50% of affected individuals, also the occurrence of depression can be, especially in depression, difficult to assess given the test’s clinical criteria and items. These include the typical manifestations of a somatic illness, such as fatigue, exhaustion or sleepiness. Personality and Risk Behaviors Personality dispositions in FMS have not been studied much; however, some are clinically apparent. They are probably non-specific influences and contexts that are found in other psychosomatic disorders, but they are seen in an exacerbated form in patients with FMS. Patients with FMS often exhibit perfectionism, excessive selflessness or even submissiveness to the people that are close to them for physical and psychological exploitation, positive (self-realization) and denial and concealment of exhaustion and the early signs of FMS. These risk characteristics often and seemingly paradoxically also include initial physical endurance, psychological stability and toughness on themselves. Future patients precisely perform physically and psychologically demanding activities and willingly or even submissively accept tasks and requirements from others. They tolerate well the subsequent fatigue and exhaustion and “successfully” hide the first signs of FMS. When they approach exhaustion and after the

signs develop, they are not able to dissimulate these manifestations and the people close to them do not understand them or do not believe them. Such patients develop an expectation that they can handle “everything”. The patients themselves develop a nonsymmetrical communication, in which they “give more and receive less”. Others enjoy such “inflation at a cheap benefit”. When a patient is not able to dissimulate their problems they feel embarrassed. If these problems are noticed by the patient’s close family, they are considered biased and perceived as unexpected unwillingness, disapproval or an incomprehensible personality change. Risk characteristics and self-destructive behaviors are found substantially more often found in women. These characteristics and manifestations do not disappear as FMS progresses. The signs of FMS are manifested with fluctuating intensity, including partial remissions. During remission, patients with a frustrating need for excessive self-destructive activities, renew their behavior, or even add similarly acting “rehabilitation”, such as, an intense strengthening of painful muscles. This accelerates symptom exacerbation and their secondary intensification. This state is frustrating to the patient on many levels. They are not able to perform their regular activities and that even frustrates them socially. They feel inferior and not needed. They feel like “prisoners in their own body”. Social-Psychological Aspects The social-psychological aspects of FMS also correspond to the aforementioned personality and behavioral components. The patient is being raised toward this behavior, more accurately they are selected for it. Their childhood reveals an unbalanced communication, including an unbalanced “exchange of emotions”. To acquire and maintain love from their parents and their close family, they need to “deserve it” and “cannot ask or bother too much”. A person brought up in this way, or rather taught this personality, becomes an “easy prey” to parasitic friends or they form such an environment by themselves by their own submissive tendency of “leave it to me, I will gladly do it.”

A destruction of interpersonal relationships is a natural consequence of FMS manifestation, especially in this predisposed personality. If this person has active, powerful and social friends, they are not able to continue in the same relationships and activities. If their close friends are used to “higher demands and taking” and the patient is to able to continue in this way, they either lose their affection or retract and isolate themselves. A Note on the Psychological Aspects of FMS The described personality and psychological processes are a result of clinical observations. Therefore, they are not “evidence based” and their accurate validation is being awaited. They were found primarily in females. The described reactions of a female patient to the first manifestations of FMS are a less refined form of a natural reaction to change in performance, fatigue, muscle pain and weakness. These changes can be perceived as not understandable by the patient, as well as, by the people close to the patient so that the patient can still perceive their daily activities as routine and necessary. Besides the described individuals at risk, other patients with FMS exist in whom most of the listed psychological risks practically do not occur. In such patients, FMS developed as a result of a serious disturbance of their immunity, most often an infection (Lyme disease, mononucleosis), especially during an ongoing stressful event, an acute illness or an injury. Typical situations include constant care taking of a dying family member, building a family home with financial stress solved by side jobs, or finishing treatment for injury simultaneously with divorce proceedings and trials involving children and property issues. Under such circumstances, we often find manifestations of chronic fatigue syndrome.

TREATMENT Treatment and rehabilitation approaches must be comprehensive and include physical therapy, modalities, patient education, psychotherapy, pharmacotherapy and lifestyle changes. The treatment puts specific demands on the relationship between the patient and the

caretaker. Symptom cessation is not steady and complete recovery is not likely. Patient-Caretaker Relationship The communication between the caretakers and the patient is an important component of the overall treatment and rehabilitation. During treatment of patients with FMS, other specific conditions need to be taken into consideration. Given the increased excitability of the CNS, autonomic and neurohumoral imbalance, disruption in psychophysiological mechanisms of affections, pain and analgesia and the inconsistency in the relationship between stimulation intensity and psychological and physiological reactivity, it results in the patient being more sensitive during communication, “inconsistent” and sometimes less understood and easy to ”read”. Another problem lies in the fact that the patient is usually frustrated by a series of examinations without clear conclusions and by the doubtfulness of their problems by physicians, family and others. Under such circumstances, disagreeing opinions often occur between the medical staff and the patient’s family regarding the patient’s assessment. The patient is also frustrated by the difference in their original and current perception and self-assessment, their abilities and options. The amount of contact with such a patient at a facility that administers and coordinates their comprehensive treatment over a period of months or rather years should not have a specifically established time limit. A comprehensive physical and psychological assessment is needed, as well as, an assessment of the patient’s social, professional and financial situations. The first contact with their physician and, especially with the psychologist, should occur without tension, should be encouraging and accepting of the patient’s problems and non-judgmental. It should allow the patient to spontaneously express themselves. An experienced physician generally screens the patient’s health from an already available medical record, performs the necessary initial evaluation and possibly makes additional suggestions. The physical therapist should acquire detailed information about the patient’s individualized specifics related to tactile and nociceptive stimuli and the individual differences in motor

skill manifestations in comparison to a regular patient. The patient’s verbal communication allows for the observation of certain medical and non-medical problems in a new view when the patient has accepting, encouraging and non-judgmental contact with the medical staff. For example, referring the patient to another specialist is viewed as an attempt to get rid of the patient who is not improving. The indication for a psychiatric assessment can be viewed as punishment, or a “good effort” to help the patient “without a suitable diagnosis” as a reason for retirement “due to depression.” Also, the family efforts for new examinations can be viewed as an effort to confirm an assumption, “that the patient is exaggerating” or as a compensation of hostility toward the patient and guilt from insufficient care, i.e., “what else can we do for him/her.” The main goal of the initial assessment of a patient with FMS is to establish a good therapeutic relationship and to also restore the patient’s trust in the medical staff. The “technical details” can be addressed later. The results of the initial assessment need to be discussed by the team of all the specialists who are expected to contribute to the patient’s treatment and rehabilitation. The result should be a generally integrated, team approach to the patient and their problems. Conveyed, as well as, undisclosed conflicts in opinions complicate the treatment. Communication with the patient should be consistent and emotionally supportive, especially at the beginning of treatment. Shared decision making is an important aspect for all cooperation during treatment and rehabilitation. The patient should understand the clearly explained advantages and disadvantages and take part in treatment selection, as well as, confidently accept all treatment and rehabilitation approaches. Rehabilitation Treatment Physical Therapy When administering physical therapy, cooperation between the physical therapist and patient is important as well as the therapist’s understanding to the patient’s feedback. When the sensory

mechanisms in FMS are disrupted, there is only a small difference between a therapeutically effective intensity of a stimuli and an unpleasant or even harmful activity. In general, the following empirical rule is applied: “Lower to medium intensity stimuli have a therapeutic effect.” This effect is gradual and often occurs following a latent period. High intensity stimuli have an undesirable effect, sometimes almost immediate and sometimes after a latent period. Physical therapists without FMS experience have been known to produce a negative treatment effect. For example, an inexperienced physical therapist controls pain, which resulted from excessive stimulation and a negative reaction to treatment by manipulation. The warning signal should be the unpleasant perception or “pre-pain” and not pain itself. Gentle or moderate intensity soft tissue mobilization is effective if good feedback and tactile communication are established. Fibromyalgia syndrome includes a dysfunction in the pain mechanism. Pain, analgesic mechanisms and processes activating and releasing energy for healing are often easily “activated” and then intensely “run idle and deteriorated” and damage the body. This “idle running” is easy to start, but very difficult and time demanding to stop. Special physical therapy approaches should take into consideration the thermoregulatory deficit present in FMS. The overall deficit in feeling cold, as well as, localized poor circulation in the distal portion of the extremities can be observed. Therefore, it is beneficial to warm up the body prior to treatment, for example, with an infrared heating lamp. Exercise Routine and Physical Exercise The physical activity capabilities of patients with FMS differ greatly among individual patients and also fluctuate over time. The extreme manifestations include the inability to be independent with basic tasks. Therefore, the current status of functional mobility needs to be assessed while taking into consideration the concept of time. The fluctuations are usually circadian; generally, mornings being the worst, but large differences exist among patients. Also, fluctuations

can be found over a period of several days or even long-term. In some fluctuations, a specific cause cannot be identified. In other cases they can be linked to an error in their routine, to disproportionately localized or increased muscle loading, with interpersonal conflicts or other psychological stress or even other influences. An effort to accelerate rehabilitation by a disproportional amount of exercise activity, especially with the goal of “loosening up stiff muscles”, is a common reason for worsening in the patient’s condition. Such attempts are often followed by an exacerbation of symptoms and it takes longer for the episode to subside after each such mistake. The function of proximal muscles regenerates faster than distal muscles (mainly fine motor skills). An individually based exercise treatment program is the key. It needs to gradually progress the patient’s physical demands. The training should include postural exercises taking into consideration muscle imbalance and weakness of the deep stabilization system, passive stretching, strengthening with light resistance and a low number of repetitions and gradually include aerobic activity (biking, walking and swimming). In the acute stage, physical exercises or modalities are not recommended, only rest and heat. Aquatic therapy is appropriate when pain and muscle weakness begin to subside. Aerobic exercises should initially be excluded. The exercises should be individualized, gradually progressing while considering the fluctuations in the current fitness level and end with a feeling that “the patient could continue comfortably for a while longer”. Exercise treatment in patients with a greater degree of deconditioning should be progressed from low intensity exercise 5 minutes per day to exercising 30–40 minutes 3–4 times per week. Not exceeding the patient’s pain tolerance and performing the physical activities regularly are the main guidelines of physical therapy. The practice of relaxation is also beneficial. The day needs to be divided into active and relaxation phases (pacing the day). While cooperating with a patient, an experienced physical therapist

should be capable of selecting and prescribing exercises. The patient should modify their home exercise program based on their current condition and feeling. Activity needs to be alternated with rest, at first based on a routine of one day on, one day off (one day hard, one day easy). In general, most patients with FMS have a tendency to overdo their exercises and disproportionately shorten their rest periods. Physical therapists also have this tendency if they implement their experience from regular practice to patients with FMS. A patient with a tendency to overdo their exercise can be reminded when their symptoms first subside that “until now you suffered from what you could not do and now you have to voluntarily suffer from what you prohibit yourself from doing.” Modalities Recommended modalities include overall relaxation procedures in the form of hydrotherapy, peloids and other balneologic procedures. Heat therapy can be used for home treatment to increase localized circulation and decrease muscle tightness. Cold packs or other forms of cryotherapy can be applied to decrease pain in tender points and to disrupt “cyclic” pain mechanisms. Recommended athletic activities include swimming, bicycling, walking and Nordic walking. Pharmacotherapy Pharmacotherapy for FMS includes the administration of a wide spectrum of medication while taking into consideration the overall principle of a greater range of (non-standard) reactions by the patient to any stimuli, including paradoxical reactions during strong stimuli. To control pain, analgesics (paracetamol) and non-steroidal antirheumatics are being administered. Tricyclic antidepressants or anxiolytics are recommended for anxiety and sleep disturbances. The synergy of psychopharmatics and analgesics is more beneficial for such patients compared to the isolated use of analgesics. Chronic pain is usually controlled by co-analgesics within the group of antiepileptic medications: gabapentin and pregabalin.

Psychotherapy Psychotherapy in FMS closely follows reasonable education. It corrects risks and the patient’s “self-destructive” attitudes and tendencies and assists with appropriate coping therapy. It assists in changing the behavior proportionally to the patient’s changing physical dispositions and tolerance to gradual change with episodic deviations without an eventual chance to fully restore the lifestyle prior to the onset of FMS. It also assists in the need to change life values that can be fulfilled with limited physical abilities and, generally, in altered social relationships. Since FMS etiology is probably neurogenic in nature, cognitive behavioral therapy forms the determining psychotherapeutic approach. This generally applies to all painful conditions as a result of somato-pathological changes whose roots do not primarily lie in the patient’s psychological traumas and problems. Cognitive behavior therapy lead by a psychotherapist should work in synchrony with the overall direction of therapy. At the same time, the patient should be instructed in self-therapy methods, such as Jacobson’s progressive relaxation, Schultz’s self-training or Machac’s activation method. A psychotherapeutic method involving the combination of working with the body and manual therapy of the movement system seems to be a “broader range” perspective method. Unfortunately, its application in practice is still being awaited. In a common course of FMS, a few sessions are usually sufficient, usually 1–2 times a week. Later, less frequent sessions are possible, but the contact should not be completely eliminated because an open psychotherapeutic relationship allows for the quick option to address possible crises, i.e., when the patient suffers another symptom worsening. Psychotherapy is usually individual. Working with the family should accomplish acceptance of the patient’s real condition and corresponding strategies in social coping. If FMS manifestations lead to exacerbation of a latent neurotic or affective deficit or trigger a family crisis, specific treatment is required and exceeds the standard

scope therapy in FMS. Education The patient and their family will have a certain opinion regarding the disease, treatment, recovery, exaggeration, simulation, other cognitive schemas and what the disease is, what it means, its course and its completion. Fibromyalgia does not fit into these generally accepted schemas. FMS symptoms appear suspicious, do not have a clear cause, specific signs, such as a rash or fever, and they last unusually long with the physicians unclear early on as to what type of disease they are dealing with. As a result, the patient is at first hesitant or uncomfortable. Later, they experience frustrating disappointment that their close family does not understand them. In the beginning, therapy and rehabilitation are crucial so that the patient has information about what FMS is, what to expect during its course and what demands will be placed on the patient and the persons close to them. Often, this information is accompanied by denial. Gradual acceptance of reality, acceptance of gradual symptom improvement with sporadic fluctuations and a small change toward complete recovery is linked to the risk of a “flashback” of earlier tendencies to resolve the issues. When symptoms are subsiding, the patient interrupts their treatment routine, gives in to a tendency to try the usual athletic activity, cleans the house completely, chops a supply of wood for the winter or attempts a “miraculous” medication or treatment procedure that has not been indicated by the patient’s physician. This usually leads to symptom recurrence, often in several days. The renewed symptoms are usually more intense and less resistant leading to reduced hope in a relative cure. Thus, when the symptoms are subsiding, we need to repeatedly remind the patient of this risk by emphasizing that “you are the greatest danger to yourself.” Together with patient education, the patient’s family should be educated as well. Since typical patients with FMS often surround themselves with people emotionally, occupationally and otherwise exploitive, this tendency needs to be addressed in the closest people. Most people with such a tendency lose an interest in the patient by

themselves. Good educational literature for patients with FMS exists worldwide. However, these materials are still not available in the Czech language. Support Groups Communication and cooperation between patients with FMS in the form of support groups or online chat groups are helpful with the patient’s rehabilitation and adaptation to FMS. This communication specifically provides authentic sharing experiences for patients with similar involvement in various stages of FMS progression. It also provides the available assistance during possible psychological crises or when a care by a specialist is not available and helps with the patient’s adaptation. The patient’s integration in such a setting is advantageous to correct the perception of suffering from different problems and the lack of understanding of their problems. The risk of this type of communication is the formation of a tight knit community, one of a group of people with the same fate which can lead to the patient’s segregation from the natural social environment. This type of communication is lacking in the Czech Republic and needs to be implemented.

3.9 OTHER DYSFUNCTIONS AND DISEASES Pavel Kolář This chapter provides general information including the treatment of diseases that overlap with many specialties. These diseases usually occur as complications.

3.9.1 Lymphedema and Treatment Martin Wald, Hana Váchová The existence of lymphatic vessels was already known to Hippocrates and Galén in the 5th century B.C. The first anatomical description of lymphatics dates back to 1627 when G. Aselli published an article in Milan describing “milk vessels” entering the lymphatic nodes. Subsequently, a number of anatomists deepened the knowledge regarding the lymphatic system. In 1954, Kinmonth significantly contributed to the description of the lymphatic tracts by performing direct lymphography with an oilbased contrast medium. Today, it serves as the gold standard for lymphatic system imaging and, especially, for its function in lymphoscintigraphy (radionuclide lymphography). The treatment of lymphedema was significantly influenced by the discovery of a special manual form of drainage that was included under the term manual lymphatic drainage into the comprehensive decongestive lymphedema treatment. The manual lymphatic drainage method was implemented into practice by Dr. J. Asdonk in 1963 in Essen. In the Czech Republic, the first training in manual lymphatic drainage occurred in 1992 in Karlovy Vary and, the same year, the Czech Lymphology Association was established.

ANATOMY OF THE LYMPHATIC SYSTEM Lymphatic vessels are present in nearly all the tissues of the human

body. They begin as blind endings in the intercellular space as prelymphatic perivascular spaces. A lymphatic capillary network arises from them, in which the lymphatic fluid drains into lymphatic collectors. These collectors have valves that prevent lymphatic fluid backflow and also contain muscle tissue within the wall of the blood vessels. The ascending direction of lymphatic fluid movement is ensured by the contraction of the lymphatic collectors themselves, as well as, by filtration pressure and the speed of lymphatic fluid formation from blood capillaries, breathing movements, large venous trunk pressure, skeletal muscle contraction and pulsation of arteries surrounding the lymphatic vessels. From the collectors, the lymphatic fluid drains into the thoracic duct and then into the venous blood. Lymphatic nodes that are situated among the lymphatic vessels function as filtration units and play a significant role in the body’s defense-system.

MECHANISM OF LYMPHATIC FLUID FORMATION As soon as the lymphatic flow from the intercellular space is disrupted, a large amount of protein edema begins to form. Lymphedema that results in a growth in volume, as well as, in the chronic inflammatory process of soft tissues in the involved area. Both these factors lead to gradual soft tissue remodeling leading to its gradual fibrotization or even sclerotization.

LYMPHEDEMA CLASSIFICATION Classification based on etiology: 1. Primary (congenital dysplasia of the lymphatic system) Non-familial (Meige’s syndrome) Familial (Nonne-Milroy syndrome) 2. Secondary Benign: post-operative, post-radiation, post-inflammatory, parasitic, post-traumatic, artificial Combined edema of mixed etiology (i.e., phlebolymphedema, lipolymphedema)

Malignant: by closure of the lymphatic network as a result of primary tumor pressure or metastasis in the lymphatic nodes. Lymphedema Classification Based on Clinical Stage: Stage 0 – latent lymphedema: lymphatic drainage is decreased, but clinical manifestation of edema is not yet present Stage 1 – reversible lymphedema: more marked dysfunction in the lymphatic system with transient, clinically identifiable edema Stage 2 – irreversible lymphedema: edema, in which the ratio between soft tissue fluid resorption and transportation capacity of the lymphatic system is permanently disrupted resulting in protein build up in the interstitial space Stage 3 – elephantiasis: monstrous lymphedema based on chronic lymphatic insufficiency accompanied by deformed fibrotic-sclerotic remodeling of the skin, subcutaneous layers and other tissues found in the involved area.

DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS The patient history and clinical examination are the key points in diagnosing lymphedema of any origin. Only in perplexed differential diagnoses, are imaging methods used, especially lymphoscintigraphy and ultrasound assessment of the venous system. Other imaging methods need to be used only sparingly. Subjective complaints of edema, perceptions of tension, pressure or unspecified pain are dominant signs of a failing lymphatic system. In the latent stage and often in the reversible stage, the clinical findings are usually quite poor. Sometimes, bouts of erisipela can be the only clinical manifestation. Diagnosis in more advanced stages, in which edema is a dominant clinical sign, should not cause any problems. The cardiac and renal systems should be examined in lymphedemas that do not respond to treatment and also in the differential diagnosis of edema in general. If the diagnosis continues to be uncertain, lymphoscintigraphy is indicated. Radiologic contrast lymphography is contraindicated in most lymphedemas. A comprehensive oncological assessment is

performed for edemas of unclear origin and/or edemas in locations typical for secondary lymphedema in tumor diseases.

TREATMENT A combination of physical therapy and pharmacotherapy are considered an ideal combination. The goal of physical therapy (so called comprehensive decongestive therapy) is to primarily sustain the preserved resorption capability of the lymphatic system, its transportation function and to maintain the achieved volume reduction through compressive bandaging. Comprehensive decongestive therapy contains manual lymphatic drainage, instrumental lymphatic drainage, compressive treatment, bandaging in single and multiple layers, compressive sleeves, mobility and breathing exercises, hydrotherapy (cold whirlpool and aquatic exercise), skin hygiene and adequate lifestyle. Manual Lymphatic Drainage Basic Rules for Manual Lymphatic Drainage Manual lymphatic drainage is a gentle palpatory technique influencing the function of the lymphatic system. Its goal is to primarily assist in the drainage of the lymphatic fluid without strengthening blood flow. Manual lymphatic drainage should not hurt. The pressure on the tissue should elicit the contraction ability of the lymphatic system itself. The pressure should be graded (30–40 mm Hg). Stroke frequency should be every second and at least 5–7 types of strokes should be alternated including whole surface circular motions. All motions should be directed toward the center while the central parts need to always be carefully treated prior to the peripheral ones. Indications: Edemas of venous and mixed lymphatic origin Post-operative, post-injury and post-inflammatory edemas Pre-surgical preparation in planned orthopedic and traumatological procedures Sudeck’s syndrome Lower leg ulcer and chronic wounds

Spastic paresis in neurological disturbances Sports medicine Cosmetics Contraindications to manual (and instrumental) lymphatic drainage: Skin and soft tissue infections, including venous infection, especially in the region that is to be treated (i.e., the skin) Purulent skin wounds and ulcers Unhealed or recurrent tumor disease Increased thyroid gland function (hyperthyroid) Heart failure Uncontrolled bronchial asthma and chronic bronchitis Uncontrolled ischemic heart disease Uncontrolled high blood pressure (hypertension) Pharmacotherapy The goal of pharmacotherapy is to increase the transport capacity of the lymphatic system by reducing the interstitially accumulating lymphatic fluid with high protein content. This can be achieved by proteolysis of protein precipitates in the lymphatic vessels, proteolysis of interstitially deposited protein by the elimination of tissue fixated immune complexes and by an improvement in the rheological fluid properties. Currently, systemic enzyme therapy medication is the medication of choice. Types of Medication Systemic Enzyme Therapy The pharmacological effects of proteolytic enzymes, which are the main component of these medications, include: Increasing transport capacity of the lymphatic system Proteolysis of interstitially deposited proteins Proteolysis of precipitates in the lymphatic vessels Improving rheological properties of fluids Increasing venous return Prevention and treatment of inflammatory complications and fibrosis

Decrease in lymphatic fluid escape through intact skin (lymphorrhea) Abatement of secretion and healing of the lympha​tic leak Improving chronic wound healing Pharmaceutics for Venous System Medications influencing the venous system are also used in lymphedema treatment. Their primary effect lies in influencing the venous system. The effect on the lymphatic system is secondary. Diuretics For the treatment of lymphedema, diuretics are, except for few exceptions, contraindicated. Treatment Frequency 1. The patient’s status needs to always be considered. 2. Prevention of edema and planned orthopedic procedures – Complex decongestive therapy (CDT) 1 week prior to surgery and 1 week after stitches removal. 3. Systemic enzyme therapy should be started a week prior to the procedure – stopped 24 hours prior to the procedure and in case of edema, restarting the second day after surgery, or when oral intake is permitted. 4. Consent from an oncologist is needed for lymphedema treatment in patients with oncological conditions to initiate comprehensive decongestive therapy. 5. It would be ideal to initiate the treatment in the latent stage while respecting lymphoscintigraphic findings.

EDEMA PREVENTION Lymphatic treatment also has its role in pre-operative preparation for planned surgeries not only in orthopedic and traumatic, but also in other types of operations (i.e., plastic and reconstructive procedures, vascular surgeries, etc.) in which there is a high probability of postoperative edema or lymphedema itself. Pre-operative lymphatic therapy improves microcirculation at the surgical site, removes

residual edema after the trauma or surgery, influences latent lymphedema and decreases the risk of post-operative inflammatory and venous complications. Comprehensive treatment of edema of any etiology in patients after orthopedic and traumatologic procedures has an important role in uncomplicated tissue healing and the ability to initiate early and effective rehabilitation.

PROGNOSIS Although, lymphedema is a chronic and usually lifelong illness, its course can be significantly influenced by treatment. The goal is early diagnosis (see above stages of lymphedema) and immediate initiation of comprehensive decongestive therapy. In this case, it is possible to significantly reduce not only the edema itself, but also the chronic inflammatory changes in soft tissues, including fibrosis and sclerotization.

3.9.2 Treatment Rehabilitation of Bowel Incontinence Pavel Kolář Roman criteria for digestive tract dysfunctions define bowel incontinence as uncontrollable leakage of the bowel for a period of at least one month in individuals older than three years of age. Bowel incontinence has a very high incidence. In the Czech Republic, the prevalence of bowel incontinence in people living in retirement facilities was 63% in 1997. In Germany, the prevalence of partial incontinence was found to be 20% and 5% for complete incontinence. Children and older population comprise the most patients. It can be presumed that the average prevalence of bowel incontinence is around 5% in the normal population. This number increases to 15% in individuals older than 60 years of age. The number of people with this problem is expected to grow as the average age of the population increases. Incontinence can be partial or complete. Typical partial

incontinence is demonstrated by uncontrolled frequent passing of gas or spotting in the underwear, usually during diarrheal stool. Complete incontinence is defined as the frequent and regular loss of the ability to prevent uncontrolled passing of stool of normal consistency.

ETIOLOGY In patients with incontinence, anatomical (i.e., rectal prolapse, congenital deficits, hemorrhoids, etc.) or neurogenic deviations can be found (i.e., sensation deficits, pudendal neuropathy, multiple sclerosis, etc.). A large portion of patients have functional incontinence, in which neither structural nor neurological abnormalities can be found. Functional incontinence is often present in patients with impacted stool (encopresis in children), irritable bowel syndrome or in patients with diarrhea. The most common etiological factors for bowel incontinence are listed in Tab. 3.9.2-1.

Tab. 3.9.2-1 Overview of etiological factors in bowel incontinence. Some functional factors can lead to either anatomical ​and/or neurogenic deviation

TREATMENT Anti-diarrheal medication is the simplest solution, especially in patients with diarrhea. If constipation or obstructed fecaloma is the

reason for incontinence, then care needs to be taken regarding regular stool and fecaloma expulsion. Many studies (more than 40) were published worldwide on the topic of bowel incontinence treatment by using biofeedback in physical therapy. New, and so far not tested in the Czech Republic, is a permanent electrical stimulation of the sacral nerves. Last, but not least, surgical methods are used including graciloplasty, suture of the sphincter with extirpation of the connective tissue portion or even an artificial sphincter. It needs to be mentioned that these techniques are not prevalent in the Czech Republic.

Physical Therapy Approaches Specific exercises and physical therapy based on biofeedback are among the main treatments influencing sphincter function. Exercise focuses on the training of controlling abdominal pressure. Synergy between the diaphragm, pelvic floor and the lower section of the abdominal muscles plays an important role. In incontinence, the diaphragm is almost always weak, which is the reason why the training of its function is initiated in an effort to improve its non-respiratory function. The biofeedback treatment method plays an important role in the treatment of incontinence, which, among others, has been beneficial because of its safety and low cost. This method allows the examined person to influence their own (often autonomic) function, such as heart rate or blood pressure, based on the information provided by this function (called biological signal). With incontinence, these “signals” are pressures and perceptions in the rectal area and the anal canal region, sometimes also an electromyographic signal. Given this information, the patient is able, with the help of a physician or a physical therapist, to improve the contractile function of the sphincter, decrease or increase the basal tone or improve contraction endurance. Subsequently, this leads to an improvement in symptoms or a complete recovery. Patients who are cured after two or three treatments after several years of incontinence are not an exception.

Biofeedback shows an improvement in 57–92% of patients with incontinence.

3.10 GERIATRICS Zdeněk Kalvach A decrease in mortality is the reality of the natural development of civilization. An absolute majority of people in industrialized countries live today not only to the conventional age limit of 65 years, but often outlive this limit by many years. This, together with a low number of births and a large number of aging people during the post-war years, between 2010–2015, make up the phenomenon of an aging population – an increasing proportion of old people in the society (in 1869, there was 6.2% of people 60 or older living in the area of today’s Czech Republic while in 2050, it will be more than 50%), including their dominance in health facilities. At the same time, very old and longlived people are currently growing markedly in numbers. The progression is directed “from an aging population to a long-lived population.” In rehabilitation, functional fitness, or disability, is the key element to health during aging. In old age, the bond between functional independence and specific diseases changes and loosens. Not only are the manifestation and consequences of specific diseases (diseasespecific outcomes) important, but also the multifactorial functional deficits, functional deterioration, decrease in health potential as mutually interlinked fitness, endurance and creative adaptability of the body. Throughout aging, the health services should not only focus on prevention of diseases, diagnosis, treatment and rehabilitation of patients, but also on decreasing suffering, strengthening health, slowing down its potential decline, strengthening functional fitness, and thus, health-based quality of life in general, without being linked to a specific disease. Onset of disability in old age can be: Sudden (catastrophic disability, rapid-onset disability) – trauma, cerebrovascular accident Gradual

Mono-causal, linked to a certain disease – for example, Alzheimer’s disease, Parkinson’s syndrome, age-based macular degeneration Multi-causal – geriatric frailty For the development of somatically determined disability, involvement of the lower extremities and mobility (stability) are more significant than involvement of the upper extremities and independence. S.G.Leveille at al. suggested in their prestigious Women’s Health and Aging Study (WHAS) that we distinguish 5 types of somatically determined geriatric disability based on the dominant cause, which can include: pain, instability, muscle weakness, inefficiency (shortness of breath, fatigue) or another cause. According to all studies, although women live to a higher age (the ratio is 4:1 in the 100+ age category), they also show a higher occurrence of disability and a greater extent of dependence than surviving men. Unfit, lonely women dominate geriatric medicine. A long-term decrease in the prevalence of severe disability in old age is fundamental, although the lifespan of patients with chronic disease and slight disability is extending. It supports the reality of concepts of successful aging and healthy active aging without the expansion of disease in an advanced age, which is also anchored in the Health 21 project by the World Health Organization. During rehabilitation (physical or occupational therapy), the following specific aspects linked to an aging population need to be kept in mind: 1. Increased prevalence of age-predetermined diseases, called diseases of old age (i.e., atherosclerosis, cerebrovascular accidents, osteoarthritis and other degenerative diseases of the musculoskeletal system, musculoskeletal injuries and operations, COPD, heart failure) 2. Rarities of diseases and conditions for their treatment and rehabilitation in old age (i.e., atypical clinical picture, effect of involution changes and comorbidities, including dementia syndrome) 3. Progression of aging phenotype and functional deterioration,

fragility or even disability From a societal perspective, the priority for an aging population and young seniors is to preserve and strengthen the ability to work and limit serious disabilities, especially at an advanced age.

3.10.1 Aging Phenotype and Involution Deterioration Aging phenotype – aged appearance, including functional deficits and limitations – is determined by several factors that are manifested in various ways in each specific individual and can also be influenced to a varied degree: 1. Genotype (including disposition toward longevity) and biological involution 2. Manifestations and consequences of disease, their combination (multimorbidity) and pharmaco​therapy 3. Consequences of lifestyle, especially physical activity (deconditioning and muscle atrophy from inactivity) and nutrition (obesity, malnutrition) 4. Influences from the physical (demands, safety, accentuation or mitigation of functional deficits, barriers, handicap-inducing situations) and social environment (social role and participation, poverty) 5. Psychological state (adaptation to aging, motivation, aspiration and expectation, role actualization) The loss of functional fitness and the development of an aging phenotype can be principally determined by other and more influential factors than principal biological involution. From the perspective of rehabilitation, a contribution to successful aging and healthy aging reconditioning programs and caretaking of the musculoskeletal system with timely correction of functional deficits, and muscle weakness or joint pattern deficits play an important role. In this way, rehabilitation influences not only healing from a disease and functional fitness stand point, but also influences the senior’s phenotype including their posture, gait and, last but not least, their psychological state, adaptation to aging, self-respect and confidence.

3.10.2 Geriatric Frailty and Geriatric Syndromes The term geriatric frailty has been used to describe clinically significant, multi-causally determined loss of functional abilities at a low level of health potential (decreased fitness, endurance and adaptability). The weakness of this generally accepted concept lies in its operationalization and quantification, which is given by the spiral development of mutually influencing elements that are alternately the cause and consequence, like when hypomobility worsens muscle weakness and muscle weakness, in turn, worsens hypomobility, etc. The most accepted criteria were outlined by L. Fried at al.: 1. 2. 3. 4. 5.

Unintentional weight loss ≥5 kg in the last year Fatigue and exhaustion Muscle weakness Loss of physical activity Slow walking

In the aforementioned study, the prevalence of such defined frailty was 7% for individuals older than 65 years of age. Geriatric frailty is usually manifested as geriatric syndromes and symptoms. In contrast to the common understanding of a syndrome to be a group of symptoms of a single cause, “geriatric syndromes” are viewed as clinically significant, frequently stereotypical, multi-causally determined and causally usually unresolvable symptoms. In the 1970’s, B. Isaacs defined the most significant ones out of them as the geriatric giants with a high priority in geriatric medicine. These included instability, immobility, incontinence, intellectual deficits (delirium, dementia) accompanied by iatrogenic involvement (undesirable sideeffects of medication and geriatric hospitalization including immobilization syndrome). Today, it includes mainly the following geriatric syndromes: anorexia with weight loss, hypomobility with deconditioning and muscle weakness, instability and falls, immobility, cognitive deficits and deficits in behavior, incontinence or terminal geriatric deterioration. These syndromes can often describe clinical problems of a fragile patient substantially better and, from the perspective of coordination of interventional arrangements and

treatment continuity, much more purposefully than from a long list of diseases. From the rehabilitation perspective, the most significant syndromes include hypomobility, immobility and instability with falls (fear of falling is an important related problem that can markedly limit old people and is also an indication for rehabilitation).

GERIATRIC SYNDROMES OF HYPOMOBILITY, DECONDITIONING AND MUSCLE WEAKNESS HYPOMOBILITY In old age, hypomobility often shows a comprehensive psychosomatic nature. It often includes a lifetime aversion to physical activity (comfort), the loss of motivation to overcome movement discomfort (becoming widowed, retirement, loss of walking partner, loneliness) and the increase in its effects (pain, especially musculoskeletal, shortness of breath, fatigue, disadvantageous change in movement patterns), instability (central or peripheral vestibular syndrome, neuropathy, paresis, osteoarthritis), insecurity in space (visual deficits), fear of falling, depression, dementia with hypobulia, extrapyramidal syndrome, deficits in nutrition (malnutrition and obesity), etc. Within the realm of a downward spiral, hypomobility leads to deconditioning, muscle weakness and movement patterns worsening, which further worsens hypomobility. Multiple causes contribute to the low compliance of most seniors to reconditioning programs; therefore, it requires comprehensive approach to not just an exercise program, but also to motivation and an effort to decrease discomfort.

DECONDITIONING Movement inactivity gradually or quickly (movement restriction during illnesses, after surgery or an injury) leads to deconditioning with a significant decrease in already involutionally decreased maximal aerobic capacity (metabolic, circulatory, muscle changes) and a low tolerance to physical activity. In regular life, these activities

exceed a person’s 75% increase of a person’s maximum aerobic capacity, which is roughly the limit for discomfort (fatigue, shortness of breath).This state is so far often assessed as a manifestation of a disease (ischemic heart disease, ventilatory insufficiency), the senior receives non-effective medication and, specifically, they are recommended to follow a resting regime, which worsens their health. In contrast, a reconditioning program should be indicated whose benefits have been demonstrated in the 9th decade of life.

SARCOPENIA Sarcopenia is a serious geriatric priority in rehabilitation and in medicine in general. It is defined as muscle atrophy and weakness during aging with the loss of muscle mass, speed and contractile strength. It differs from muscle wasting during starvation and rumor cachexia. It affects phasic muscles sooner than the tonic ones and is multi-causal in nature. The most important factors of its development include involution changes, especially the influence of free radicals, the cessation of nerve endings (picture of denervation atrophy) and a change in hormonal regulation (decrease in androgens, growth hormone and IGF-1, which is the main reparatory and adaptation factor for muscle tissue). The main negative regulator of muscle growth is myostatin whose expression with age and inactivity increases. Inflammatory cytokines are also negatively utilized (influence of chronic inflammation in old age) with malnutrition with protein and vitamin D deficits and, of course, physical inactivity. Physical activity is apparently the main cause in the decrease of muscle performance until 75–80 years of age, only then do other involution changes dominate. During bed immobilization, muscle strength decreases by 40% in 4–6 weeks with the quadriceps femoris being the most affected. Therefore, rehabilitative prevention of immobilization syndrome is essential. Sarcopenia leads to hypomobility, instability with falls, disability (even to the level of lost independence) and the onset of immobilization syndrome. Gentle resistance training with anabolic assistance (testosterone is the most effective; however, nandrolone is safer) in the elimination of

malnutrition and vitamin D deficits (biologically valuable nutrition, support of a nutritionally defined diet – for example, Nutridrink or Diasip for people with diabetes, vitamin D supplements, for example cholecalciferol, ergocalciferol). An anabolic environment develops in a muscle approximately after 10 weeks of stimulation and it is manifested as an increase in IGF-1 and as an expression of myosin heavy chain gene. Sarcopenia in patients with severe obesity is a complex problem.

GERIATRIC MODIFICATIONS AND CONTINUITY OF REHABILITATION ACTIVITIES During aging, rehabilitation activities do not need to be modified to a particular age, but rather to a specific condition of the individual participating in rehabilitation. Individualization of health approaches should increase with age because the heterogeneity of the corresponding age group increases. Rehabilitation procedures indicated based on the disease states need to be modified according to comorbidities, including geriatric frailty and according to safety requirements, seen mainly with cardiovascular diseases, advanced osteoporosis and muscle weakness. Especially in reconditioning programs, stress testing should be mandatory to assess coronary reserve and myocardial electrical stability. However, as pointed out in the Czech Republic by M. Macek, reconditioning programs are safe and their risk is often grossly overestimated. In general, the need for gentle training is known. An exercise session involving resistance training should be short (in certain cases 10 minutes) and should be preceded by muscle preparation for physical loading. A significant cognitive deficit is the main limitation of rehabilitation procedures during aging. Even in such a case, the individual needs to be objectively assessed and their rehabilitation activities accommodatingly modified. Efforts that may not be effective include, for example, teaching more complex independent exercises to a patient with advanced dementia. However, this training can be

performed with the patient’s family or a caretaker (i.e., when treating pain syndromes). Many old people are also unjustly believed to have dementia and their rehabilitation program is mistakenly reduced. The reason for this error can include the use of an inappropriate method (unclear instructions, hurried approach under time pressure), prior prejudice, patient’s fatigue or other temporary indisposition, sensory deficits (heard of hearing), confusing permanent dementia with a transient state of unclearness, inhibitory effect of medication, etc. Psychotherapeutic and the ethical connectivity of rehabilitation activities are very important. Seniors are, in contrast to younger people, at a disadvantage. Within healthcare, they are at risk of discrimination and inappropriate treatment or a disruption in their social roles. Therefore, a vital part of rehabilitation activities in geriatric patients should facilitate dignity, self-respect, positive motivation, promotion of autonomy and self-realization. Common mistakes include, for example, excessively restricting the patient’s choices, denying decision making competencies (forced rehabilitation), insensitivity (painful procedures or transportation without analgesic preparation), conforming the patient’s lifestyle to healthcare facilities and doubting the meaning of the patient’s activities. For these reasons, the center of geriatric rehabilitation activities should be shifted to an outpatient setting. To ensure the effectiveness of rehabilitation care, this needs to be implemented into the patient’s overall assessment. Coordination of the patient’s complete treatment is crucial, especially for comprehensive long-term care of fragile geriatric patients with limited or lost independence. This includes the Comprehensive Geriatric Assessment (CGA) or Geriatric Evaluation and Management (GEM). It is necessary for the physicians and the nurses (i.e., in home care) within the extent of their knowledge and competencies to also assess and influence the patient’s functional aspects, but primarily for the rehabilitation specialists to be a crucial component of in-patient and outpatient geriatric teams (for example, in community-based geriatric centers). Only in this way, can the multispecialty understanding of the patient’s problems, prognosis and effective purposeful intervention be ensured.

Terminally ill and dying patients present an ethically sensitive example. With quality palliative care, the rehabilitation worker needs to be aware that their patient is dying and that rehabilitation, if it even is indicated, should not be disruptive (i.e., to sleep, often purposefully induced) and that only relieving and palliative interventions should be selected.

3.10.3 Principles of Movement Activity Selection in the Aging Population Miloš Matouš, Pavel Kolář Maintaining mobility through exercise activities leads to an improved perception of health and quality of life. A positive effect of movement on an organism depends on the appropriate selection of movement activities. The selection must take into consideration: 1. Health, 2. Age, 3. Gender, 4. Exercise experiences and the patient’s fitness level. Health The majority of older individuals manifest chronic illnesses and, based on the diagnosis, the limits of physical activity need to be respected at the initiation of physical activity. Based on patient history and subjective and objective assessments, the appropriate exercise and intensity of physical activity are selected (intensity is controlled based on the safe level of heart rate) and the limits, forms, duration and intensity of physical activity are unambiguously set. The individual is educated in monitoring their symptoms during physical activity and to possibly stop the exercise activity if they emerge. Age Testing of the individual’s fitness level and comparing it to the norms appropriate for their age is considered important. Based on this testing, the limit for safe heart rate and the training form are established. To determine the appropriate movement activity and intensity, emphasis is placed mostly on the overall fitness assessment,

mobility and musculoskeletal system function rather than on the actual age of an individual. Gender Gender differences in the organization of the human body generate different premises for physical activities that are part of everyday life and for exercise activities specifically implemented into the individual’s daily routine. In women, there is a greater percentage of osteoporosis that limits certain types of physical activity (contraindicated are jumps and activities with a risk of falling). In contrast, women benefit from resistance training and exercising at adequate levels of loading to stimulate bones. Exercise Experiences and Fitness Level Fitness, as well as, exercise experiences is best acquired at an early age. They have a longer lasting nature. Those individuals who participated in sports their entire lives can cope much better with physical activity during aging than those who began engaging in physical activity at a later age. Assessment Prior to Exercise Program Initiation Examination by an internist with detailed anamnesis, including exercise Stress test with EKG recording, blood pressure measurement and establishing the individual’s safe heart rate for exercise Basic assessment of the musculoskeletal system with emphasis on the assessment of movement patterns Basic biochemical testing to establish the risk for development of atherosclerosis: fat metabolism in blood, liver and kidney function and glucose tolerance Exercise Programs Individual programs Walking, swimming programs Individual training on an ergometer Home exercise programs Group exercise (60 minutes, 1–2 times per week)

Week-long reconditioning stays (ideally 2 times per year) A group of 15 individuals is ideal for exercise programs. A morning warm-up routine is desirable so that the entire joint system can be ready for common activities of daily living. It can last up to 20 minutes based on the individual’s needs. Exercises activating the deep spinal stabilization system, breathing exercises and exercises promoting joint mobility are usually included. Principles of Exercise Performance Educate the individual in the methodology and techniques of performed activities (especially for basic locomotion, such as walking) Everyone should know their intensity limit with physical activity (pulse, Borg dyspnea scale) Every older adult should undergo stress test in a physician’s office Create a consistent routine for the physical activity, including warm-up (emphasis on starting positions, body posture) Ensure the regenerative phase of exercise (relaxation, rest, resting pulse and blood pressure must be within the norm) An exercise session focused on symmetry can contain only balancebased exercises directed mainly at increasing joint range and muscle stretching. Subsequently, dynamic strengthening exercises and practicing movement patterns are implemented. The lowest exercise positions, which are not as demanding on the muscles maintaining an erect body posture, are preferred. Based on capabilities and physical abilities, exercises in higher exercise positions are implemented. Assisted movements are selected and performed in a slow rhythm. Attention is paid to the accurate attainment of a selected starting position and accurate exercise execution to achieve the desired effect. Special emphasis is placed on improving body posture and gait pattern as well as correct breathing. All premises for these patterns are formed in the movement system and coordinated with breathing and relaxation. The method of activation and stabilization of the deep stabilization system is utilized. Exercise can take 20–60 minutes.

Exercise Principles Starting in lower positions with gradual transition to higher positions Consistently focus on correct initial positions Prefer simple exercises without large demands on coordination Exercises may not be performed while holding one’s breath; exercise is coordinated with breathing Relaxation exercises (self-training) should be implemented at the end Activate the deep stabilization system In contrast, a traditional exercise session consists of several parts based on its purpose. The introductory part contains more demanding activities to increase blood circulation and warm up. The intensity should not be high. This part usually lasts 5–10 minutes. It involves a gradual warm up of the cardiovascular system and body preparation for more challenging activities. This is followed by a balance component. It is more demanding as far as the execution of each exercise is concerned. The exercises are selected according to a specific purpose and activities that will follow in the evolving component. Because this is a balancing process, the principles mentioned in the previous paragraph apply here. The intensity of physical activity is low and mainly slow movements are performed. The evolving part can have a varied content with various purposes. Many physical activities are applied based on the patient’s interest and need. The intensity of physical activity should not exceed a submaximal value, or 60% of the maximum. For orientation, the algorithm for establishment of recommended heart rate during physical activity can be followed, which is 170 pulses minus the patient’s age. The basic predictors of the level of physical demand and the signs of fatigue are being monitored. The limit of safe pulse rate needs to be monitored for an individual with known weakness, for example, of the cardiovascular system and in whom overexertion would put their life at risk. Usually, safe heart rate is determined by a physician based on a stress test. In the conclusion part, the organism calms down and returns to a resting state.

Reconditioning Stays They are ideal 2 times per year with reduced food intake to 1,500–1,700 kcal. Program: Morning warm-up for 30 minutes Late morning and afternoon exercise for 60 minutes Conditioning walk in the woods for 4–6 km 2 times per day Afternoon walk 30–40 minutes (everyone at their established heart rate) Afternoon relaxation Evening educational lectures 3 times during the duration of the stay Other organization forms, such as, hiking on foot, biking, swimming, etc., should be implemented into the program as additional forms of exercise because they have a specific format, activate the body in a different context and put specific demands on the movement system. Each of these activities should be preceded by faultless preparation and a balancing process so that the movement system can cope with the demands of the individual activities, is perfectly prepared for them and meets their demands. Group organized forms of physical activities can be recommended under the supervision of an experienced physical therapist. Evidencebased intervention has good results. However, attendance of organized exercise sessions is only a mere guideline to regular daily home exercise. Only in this way can the expected results be achieved.

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4 TREATMENT REHABILITATION IN ONCOLOGY Vítězslav Hradil In the Czech Republic, over 66,000 new cancer cases occur every year and approximately 29,000 people die yearly from cancer. Cancer is the cause of every fourth death in the Czech Republic. The incidence and types of cancer differ based on gender. In the Czech Republic, lung cancer ranks first in men (92.5 newly registered cases for every 100,000 men) and breast cancer ranks first in women (110.5 newly registered cases for every 100,000 of women). The ever expanding spectrum of multimodal oncological treatments prolongs the five year survival of persons with cancer. Therefore, the significance of comprehensive rehabilitation care increases in such patients. Its goals include maintenance of the maximum possible quality of life, independence, self-sufficiency and a return to normal life and work with minimal work limitations. Rehabilitation care is a vital component in prevention, as well as, treatment care in patients with oncologic conditions. According to Klener, the individual levels of cancer prevention can be classified as follows: Primary prevention – implementing measures to protect the environment. It includes taking action against smoking, promoting healthy eating and hygienic habits to decrease occupational exposure of workers in at risk environments. Secondary prevention – seeking out patients with pre-carcinogenic conditions through preventive check-ups and screenings that can contribute to the early diagnosis of cancer. Tertiary prevention- observation of patients who survived cancer with the goal of identifying early disease recurrence or relapse. Quaternary prevention – (recently considered are the past few

years) preventing the consequences of progressive and non-curable disease that can worsen the patient’s quality of life. It is based on timely administration of analgesic treatment, indication of appropriate surgical procedures, early administration of orthopedic care when the skeleton is involved, and the early implementation of psychological assistance and social support assurance.

REHABILITATION SPECIFICS FOR PATIENTS WITH ONCOLOGIC CONDITIONS Rehabilitation care for patients with neoplasms has its specifics and depends on the following: The affected anatomical area Histological type of cancer Stage of the disease Oncological treatment with undesirable side-effects Patient’s age Prognosis Patient’s psychological state Patient’s social support

BASIC GOALS AND ASSESSMENT OF REHABILITATION TREATMENT Schematically, therapeutic goals of treatment rehabilitation can be divided into 4 categories: Secondary, tertiary and quaternary prevention (preventive rehabilitation) Restoration of affected tissues (restorative rehabilitation) Supportive (prevent progression of condition) Palliative (prevent the development of complications caused by the disease progression) Comprehensive teamwork with other medical specialties related to family care or possibly social workers with some assistance in home care is the foundation of adequate rehabilitation care.

During the initial evaluation, it is appropriate to perform the patient’s functional assessment, which includes their overall condition and skills while using a certain international classification scale, for example, Karnofsky’s scale, the FIM or the WHO classification Tab. 4.1. The Facit system has been implemented to assess quality of life in patients with oncologic conditions. It includes the Functional Assessment of Cancer Therapy (FACT), Functional Assessment of Human Immunodeficiency Virus Infection (FAHI) and Functional Assessment of Multiple Sclerosis (FAMS). The Functional Assessment of Cancer Therapy questionnaire (FACT-G) is an essential component of the classification system in oncology. Oncological treatment and disease progression cause changes in the clinical condition and, thus, also a shift in the classification stage in individual patients.

Tab. 4.1 Assessment of physical performance according to the WHO point scale in comparison with assessment of performance according to Karnofsky (from Klener P, et al., 2006)

REHABILITATION TREATMENT COMPLICATIONS Rehabilitation treatment of patients with oncological conditions is often interrupted by a planned chemotherapy, radiation therapy, immunotherapy, or even because of undesirable side-effects of an oncological treatment. The most common complications include those that are: Internal in nature (anemia, cardiomyopathy with damage of cardiomyocytes as a result of cytostatic toxicity, infections as a

result of myelosupression, etc.) Neurological in nature (encephalopathy, paresis, polyneuropathy, etc.) Surgical in nature (complications of an oncological condition during compression of various anatomical structures, bowel obstructions, etc.) Orthopedic in nature (in metastases involving the skeleton, etc.) Urological in nature (cystitis, deficits in urination, etc.)

GENERAL SECTION

4.1 PAIN PATTERNS IN PATIENTS WITH ONCOLOGICAL DISEASES 4.1.1 Pain Pattern and Its Treatment Pain is present in 30–50% of patients with primary oncological diseases without metastases and up to 90% of patients with advanced cancer. The treatment strategy lies in the correct selection of pharmacological and non-pharmacological treatment. The distinction between acute and chronic pain, the type of pain, intensity, location and the effect of pain on various daily activities and sleep all contribute greatly to a successful treatment. Acute pain is a defensive mechanism with a warning function (acute abdominal/peritonitis, burns, fractures). However, if the pain does not possess a warning function, it is a chronic pain. Chronic pain occurs if the pain persists 3–6 months after the condition has been successfully treated or once the original condition has been stabilized or if it accompanies a chronic disease. Pain is a physical subjective perception meaning that even if the available evaluation does not have an organic pathophysiological origin, it is not only the result of sensorimotor perception, but also an overall complex of processes. Chronic pain can be classified as carcinogenic or non-carcinogenic. Carcinogenic pain is more clearly defined and shows a clearer pathophysiological basis. Chronic pain dominates and is the most common sign of disease in patients with oncologic conditions. Pain control is very complicated because of a fixed central pain pattern. It affects up to 90% of patients with advanced disseminated oncologic disease. It causes not only physical and emotional problems, but also negatively affects their social life and puts the patient’s existence in danger (i.e., inability to return to work). Pain and, in general, all subjectively unpleasant symptoms, travel through a path of common neuromediators (neurokinins, substance P, noradrenalin, etc.) toward depressive moods and later, a deficit in the thalamo-hypothalamic area leading to decreased function of the

autonomic nervous system and decreased immunity. In patients with an oncological condition, this physiological reaction is increased multiple times and reflected in the overall clinical state. In 65–75% of patients, the pain occurs due to the cancerous processes invading other visceral organs, soft tissues, nerve structures or even due to bone tissue infiltration. In 15–25% of patients, pain can be elicited by a surgical procedure, radiation therapy, cytostatic treatment with subsequent nerve structure damage, onset of steroidal pseudorheumatism, aseptic bone necroses, mucositis, fibrotic changes in soft tissues, granulomas, irritated scars, etc. In 5–10% of patients, the pain is not related to oncologic problems. The principles of treatment of cancer pain are established by the World Health Organization and are valid as a recommended approach.

4.1.2 Classification of Oncologic Pain Nociceptive somatic pain – occurs by stimulation of mechanoreceptors, thermoreceptors and chemoreceptors (nociceptors, peripheral pain receptors) in an affected tissue, skin, subcutaneous tissue and periosteum, for example, due to bone metastases. In patients with oncologic conditions, some authors also distinguish nociceptive visceral pain (with cancer metastasis into body cavities, in lymphatic node involvement, distention of the pleura or the liver capsule, etc.). Neuropathic pain (peripheral neuropathic pain), neurogenic peripheral – occurs by stimulation of peripheral nerves, with damage to the myelin sheath, axonal nerve cell or nerve compression. It accompanies paraneoplastic syndromes, toxic polyneuropathies, etc. Deafferentation thalamic phantom pain (neuropathic central pain, neurogenic central) – occurs in lesions and deficits involving the brain and spinal cord metabolism, i.e., when the tumor grows within a nerve root, plexus or a peripheral nerve, or as a postsurgical pain syndrome with the involvement of skin and deep

nerves or as phantom pains, post-amputation causalgia, etc. Dysautonomic pain (reactive pain) – the sympathetic nervous system plays an important role here. In an acute injury, the sympathetic nervous system has a positive role, but in chronic pain it causes certain pathological changes. The initial pain stimulus activates the sympathetic autonomic nervous system, which causes localized vasoconstriction (vessel narrowing). As a result of insufficient circulation and tissue nutrition, trophic changes occur. Complex regional pain syndrome (CRPS) Type 1 (reflex sympathetic dystrophy) and Type 2 (causalgia) are examples of dysautonomic pain. Psychogenic pain – originates in the structural changes of the CNS that are responsible for the psychological state and emotions, but also the ability to process information from the surrounding environment and the organism itself. Sometimes, none of the organic structures demonstrate any changes; however, the patient experiences pain that they are unable to always accurately describe or localize. Pain caused by the cancer itself can be classified as nociceptive somatic (bone and periosteal pain, soft tissue pain), nociceptive visceral pain (in cancer metastasis into the lymph nodes, in body cavities with distention of organ structures); neurogenic (neuropathic) peripheral pain with direct stimulation of nerve structures including pain characterized as reflex sympathetic dystrophy and neurogenic (neuropathic) pain with cancer or ischemic involvement of certain brain (thalamus) or spinal cord structures. Based on an individual’s pain threshold and their psychological state, pain has neuro-sensory, cognitive processing and emotional components.

4.2 PARAMETERS FOR THE INTERRUPTION OR MODIFICATION OF A REHABILITATION PROGRAM 4.2.1 Laboratory Values Leukocytes Leukocytes < 4.5 . 109/l (equals decreased immunity) With a low leukocyte count, individual rehabilitation treatment needs to be selected based on the patient’s clinical presentation (fevers, malaise, and fatigue). Muscle activity results in temporary leukocytosis possibly distorting the laboratory results (therefore, it is appropriate to limit the patient’s physical activity prior to blood testing even if the patient is in a stable condition). Hemoglobin Below 75 g/l: minimal physical activity in bed, passive range of motion, positioning 75–100 g/l: full active range of motion only, isometric muscle work, muscle activity up to Grade III on manual muscle testing, maintain overall mobility; aerobic loading and concentric muscle contractions are not appropriate 100–120 g/l: concentric muscle contraction can be implemented, light aerobic activity and full mobility Thrombocytes (Platelets) Thrombocytopenic states can pose an increased risk of hypertension and muscular and intra-articular bleeding. The patient’s routine should follow the following laboratory values: < 25 . 109/l: zero (!) physical activity 25–50 . 109/l: active maintenance of range of motion and overall mobility > 50 . 109/l: possible isometric or gentle concentric muscle work, aggressive stretching and more moderate concentric muscle activity are not recommended

4.2.2 Long Bone Metastases Therapeutic treatment for the femur, tibia and humerus is based on their percentage of involvement: Bone sheath involvement > 50 % – more than 50 % involvement of the compact bone leads to immobilization of the given segment and requires limited mobility with assistive devices and the need for appropriate positioning; Bone sheath involvement < 50% – 25–50% of compact bone involvement, rehabilitation assists in maintaining mobility; active movement within spontaneous joint mobility is allowed Bone sheath involvement < 25% – zero to 25% compact bone involvement or a lesion greater than 3 cm in the femoral region allows submaximal isometric muscle activity and gentle individual aerobic exercise

4.2.3 Other Parameters Modifying Rehabilitation Treatment Vital Organ, Blood Vessel or Bone Compression Rehabilitation: Passive and active while respecting the severity of the condition and cooperating with an oncologist. Pleural, Pericardial, Retroperitoneal Exudate or Ascites Exudate or ascites are accompanied by pain, shortness of breath and limited intestinal motility. Rehabilitation: Only submaximal isometric muscle activity and preservation of overall mobility are appropriate. Altered Consciousness, Coma or Increased Intracranial Pressure Rehabilitation: positioning, passive exercise (see Chapter 1 Treatment Rehabilitation in Neurology, subchapter 1.18 Deficits in Consciousness). Mineral Imbalance K+ < 3.0 mmol/l: depolarization changes with decreased transmission at the muscle cell membranes, skeletal muscle spasms

and potential risk of arrhythmias Increased K+ > 6 mmol/l: onset of bradycardia, arrhythmia or even cardiac arrest Na+ < 130 mmol/l: fatigue, muscle weakness, sleepiness or even altered consciousness Increased Ca2+: depolarization changes, decreased transmission at the muscle cell membranes, skeletal muscle spasms Increased Mg2+: depolarization changes at the muscle cell membranes, risk of cardiac arrhythmias, skeletal muscle spasms Hypoglycemia < 2 mmol/l: skeletal muscle spasms Rehabilitation: Individually-determined physical activity based on the patient’s clinical presentation. Significant Orthostatic Hypotension or Hypertension Significant hypertension occurs when the blood pressure is higher than 160 mm Hg with the pulse above 100 beats per minute. Other complications that can accompany blood pressure problems include severe disturbances in heart rhythm. Rehabilitation: Individually determined rehabilitation program based on the patient’s clinical presentation.

4.3 REHABILITATION APPROACHES Rehabilitation Principles The decision to use rehabilitation and physical therapy techniques, methods and treatment approaches, as well as, orthoses is individually based for each patient. Modalities can only be applied at areas distant to the primary tumor taking into consideration the area between the electrodes and eliminating their application within lymphatic flow locations. Cooperation with an oncologist and assessment with the Classification of Malignant Tumors (TNM) classification are important to determine the extent of the cancer, lymph node involvement and distant metastatic sites. TNM classification of tumors, developed between 1943–1952, is used by the International Union Against Cancer (UICC). The criteria, documentation and classification of tumors based on the disease stage are identical with the classification of the American Joint Committee on Cancer (AJCC). TNM classification of malignant neoplasms describes the anatomical extent of the disease based on the establishment of three components: T (tumor) – the extent of the primary tumor, N (noduli) – presence or absence and extent of metastases in regional lymph nodes, M (metastases) – presence or absence of metastases. Adding a number to the letters gives the extent of a malignant tumor (T0, T1, T2, T3, T4; N0, N1, N2, N3; M0, M1).

4.3.1 Modalities Thermotherapy Application choices: Cryotherapy/negative thermotherapy: (total, local) taking into consideration basic contraindications of thermotherapy (be careful with subsequent reactive hyperemia) Complete hydrotherapy: activity of thermal, mechanical and

movement energy; Options: complete cold bath, indifferent, warm Complete hydrotherapy with water temperature up to 37 °C (note: starting at 37 °C, increase in core temperature by 0.1°/5 min poses a risk of increased circulation). Local (partial) hydrotherapy – indifferent, positive (heat), negative (cryotherapy) and alternating. Note: with application of localized procedures with water temperature above 37 °C, the principle of consensual and cutivisceral body reaction applies. Electrotherapy Application principles: At the site of the tumor or the metastases, only transcutaneous electrical stimulation (TENS analgesic currents) can be applied according to the parameters (lege artis) to decrease painful stimuli at various levels of the nervous system. Outside the cancer or metastatic sites, it is possible to use analgesic low frequency, mid-frequency and unidirectional electrotherapy, for example, ascending or descending resting galvanization, or Amos currents, especially in post-cytostatic peripheral polyneuropathy. In the muscular system, electrotherapy is used especially for the stimulation of weak or denervated muscles. Phototherapy (Electromagnetic Radiation Using Photon Energy) Ultraviolet (UV) radiation < 400 nm wavelength causes changes in superficial skin layers (careful with skin infections: skin tumors, skin metastases). Infrared (IR) radiation of wavelength above 760 nm can be classified as thermotherapy because of its effects and the formation of hyperemia. Laser and biolamps use polarized light with thermic and photochemical effects. Note: Application of a laser or polarized light in physical therapy is only possible in areas distant from the primary tumor, metastatic sites and lymphatic sinuses (according to TNM classification).

4.3.2 Physical Therapy Techniques Physical therapy techniques are, in principle, similar to the ones used with other patients, but their application is always strictly individual because the patient’s clinical and psychological states and their ability to actively cooperate must be taken into consideration. The most commonly used principles include: Manual techniques – mobilization techniques and soft tissue techniques are commonly used while taking into consideration oncologic contraindications; however, they cannot be applied at the cancer or metastatic site. Techniques that are not recommended (fascial, pressure massages) include those causing possible stimulation of corresponding lymph nodes and sinuses. At the same time, caution needs to be paid to prevent a disruption in the skin. Manual lymphatic drainage or instrumental pressure therapy – this technique is often used while taking into consideration oncologic contraindications; the continuity of the skin needs to be essentially respected. Relaxation techniques – they focus on facilitation of muscle and psychological relaxation with a goal to correct autonomic and emotional balance, i.e., autogenic training, biofeedback, Shultz autogenic training, Jacobson’s progressive muscle relaxation. Techniques and treatment methods based on neurophysiological foundation – they are used especially in patients with oncologic involvement who demonstrate neurological complications. The options and degree of the patient’s cooperation need to always be assessed first in regards to their objective and subjective condition. Proprioceptive neuromuscular facilitation, neurodevelopmental approach (Bobath), sensorimotor stimulation and Vojta’s reflex locomotion are used most often.

4.3.3 Contraindications All methods and procedures that could disrupt the skin covering in the area of the tumors or corresponding lymph sinuses are

contraindicated. All approaches and methods that increase autonomic functions, cellular metabolism, local hyperemia and subsequent vasodilation at the tumor site are contraindicated because of their risk of higher cancerous dissemination. Contraindicated methods: Ultrasound Diathermy Application of heat (positive) thermotherapy at the primary tumor site (paraffin, peloids, hot pack) Phototherapy by infrared light Hydrotherapy procedures above 37 °C Magnetic therapy Electrotherapy close to the primary tumor (with the exception of TENS) Vojta’s reflex locomotion is contraindicated because of its subsequent increase in metabolism, influence on autonomic functions and other risk factors (common in patients with oncological involvement), i.e., corticotherapy, febrile sates Any type of stimulation and massage to the tissue area that is affected by cancerous cells, in the area of corresponding lymph nodes, or after recent tumor removal Manipulation and thrust techniques are absolutely contraindicated in the areas of metastatic involvement of the skeleton and in the neighboring segments

4.4 SPECIFIC FACTORS INFLUENCING REHABILITATION TREATMENT Specific factors affecting rehabilitation treatment in patients with oncologic diseases include the following: Cancerous tissue masses with soft tissue changes and neural tissue compression Treatment with application of corticosteroids given their pathological influence on muscle fibers and bone cells Surgical removal of cancerous masses, individual organ and lymphatic tissue resection, or procedures stabilizing the skeleton during metastatic involvement Chemotherapy application with negative side-effects: Cardiotoxicity of many preparations and the subsequent decrease in cardiovascular performance possibly leading to permanent myocardial damage characterized by dilated cardiomyopathy Neurotoxicity with development of peripheral polyneuropathies, deficit in muscle innervation with changes in muscle activity and coordination, sensory deficits, trophic changes and the onset of a pain syndrome Nutritional state; malignancy itself and oncologic treatments lead to weight reduction, loss of appetite, deficits in food intake and malabsorption. Increase in cytokines, for example, TNF-α (cachectin) with induction of anaerobic glycolysis, amino acid release from the muscles, secretion of liver lipids, reduction of albumin synthesis and increased body temperature all contribute to cachectization. These processes result in muscle atrophy and gradual cachectization; Prolonged inactivity and immobilization affecting individual organ systems: Musculoskeletal system (muscle and fascia contractures, muscle atrophies, decreased muscle strength and endurance with up to 3% loss of muscle strength per day, osteoporosis). This group

also includes the so called hypokinetic disease that is accompanied by increased activity of the sympathetic nervous system, decreased muscle tone, muscle hypotrophy, connective tissue hypotrophy, osteoporosis, catabolic reaction of the body, deficit in the body’s vasomotor and proprioceptive adaptation, decreased cardiovascular function and decreased tissue ability to utilize oxygen Cardiovascular system (increased heart rate, decreased cardiac minute volume, postural hypotension, thrombotic complications) Endocrine system (decreased tissue metabolism, increased catabolism, negative nitrogen balance, osteoporosis, glucose intolerance) Respiratory system (decreased breathing frequency and lung volume, atelectasis, respiratory insufficiency and risk of pulmonary embolism) Digestive system (decreased peristalsis, constipation, loss of appetite); Urinary system (urinary retention, lithiasis, infection) Skin and subcutaneous tissue (formation of pressure ulcers, slowed wound healing) Psychological and social aspects (depression, reality denial, fear, anxiety, fear of dying, intellectual and social isolation, loss of job, family’s financial situation worsening, effect on spouse/partner relationships) Infectious complications – viral infections are, in general, caused by DNA viruses, especially in lymphoproliferative disorders; they are less common in solid tumors. Bacterial infections represent 90% of all solid tumor infections. Infections elicited by gram-positive microbes dominate. Mycotic infections are most common in acute leukemias and after bone marrow transplantation. The selection of a rehabilitation program for patients with oncological involvement and its intensity and frequency should always be strictly individually-based taking into consideration the indications, contraindications and the patient’s current health status.

SPECIAL SECTION

4.5 METASTATIC INVOLVEMENT 4.5.1 Metastatic Involvement of the Skeleton Either a primary bone cancer or metastatic involvement can involve the skeleton. Primary cancerous involvement of the skeleton is caused mainly by sarcomas that represent around 1–2% of all malignancies in adult patients, usually of younger ages. They include a wide spectrum of mesenchymal tumors, which especially include osteosarcoma, chondrosarcoma, large cell bone sarcoma and soft tissue sarcomas (rhabdomyosarcoma, leiomyosarcoma, liposarcoma, fibrosarcoma, mesothelioma, synovial blastoma, neuroectodermal sarcoma and malignant fibrous histiocytoma). In general, bone metastases are found in advanced cancers of the breast, lung, prostate, kidney and thyroid gland. Extensive bone marrow infiltration is common in hematologic malignancies (i.e., leukemia, multisite myeloma, malignant lymphomas). The most commonly affected areas include the vertebrae, pelvic bones, femur, ribs and the skull. Clinical presentation includes pain of various intensity, local instability and variable neurological symptomatology. Definite laboratory proof of metastatic involvement has not been established yet. Metastatic process of the bone can involve either a lytic or plastic lesion, or have mixed involvement. Lytic lesions are typical in breast, lung, kidney, gastrointestinal tract (GIT), neuroblastoma, lymphoma and melanoma cancers. Plastic lesions are typical for prostate cancer. Both types of lesions can occur simultaneously in one type of cancer. The risk of fracture needs to be taken into consideration when selecting rehabilitation approaches (Fig. 4.5.1-1). It has been statistically demonstrated that the presence of an osteolytic site or the presence of mixed metastasis leads to the chance of developing pathological fractures 48% and 32% of the time, respectively. However, the presence of an osteoplastic metastatic site only leads to pathological fractures occasionally. According to international

statistics, breast cancer is responsible for 30–50% of all pathological fractures of long bones. More than half are localized to the proximal humerus. There is a higher fracture risk 6–8 weeks following analgesic radiation due to tumor necrosis and increased bone tissue fragility.

Fig. 4.5.1-1 Selection of treatment strategy in osteolytic metastatic involvement of the bones

The risk of pathological fracture in oncology is determined by the so called Mirels’ Scoring System. Mirels has statistically demonstrated that: Only 5% of metastatic sites within 1/3–2/3 of the bone width leads to a pathological fracture. Roughly 80% of metastatic sites above 2/3 of the bone width lead to pathological fracture (Fig. 4.5.1-2). Fig. 4.5.1-2 Locations of femoral lesions based on metastatic involvement in relation to the risk and onset of fracture. 1 – intertrochanteric lesion, 2 – cortical lesion including more than

50% of cortex, 3 – cortical lesion longer than 2.5 cm, 4 – medullary lesion greater than 50-60% of bone diameter, 5 – weight bearing joint surface lesion

ONCOLOGICAL DISEASES OF THE SPINE Tumors in the spine are classified as primary or secondary (metastases). Primary tumors can be further divided into benign or malignant. There are very few primary spinal tumors. The benign tumors most often include hemangioma and less frequent are osteocartilagenous exostoses, osteoid osteoma, osteoblastoma, largecell tumor, eosinophilic granuloma, aneurysmatic bone cyst and vertebra plana. Myeloma is the most common primary malignant spinal tumor followed by chordoma, malignant lymphoma, osteosarcoma, chondrosarcoma and Ewing sarcoma. Metastatic spinal tumor involvement caused by secondary tumors is much more common. Most often, primary tumors from the mammary glands, lungs, kidneys, prostate, thyroid gland and the GIT metastasize into the spine.

Clinically, spinal tumors manifest themselves especially as back pain in the affected region or by nerve root irritation or neurological involvement corresponding to the level affected by possible tumor expansion or pathological fracture or dislocation. Often, back pain or neurological signs are the first symptoms of oncological involvement. The diagnosis of spinal tumors is based on clinical exam, including neurological assessment. This is followed by radiological testing consisting of simple radiography in two projections, CT scan in transverse sections with sagittal and frontal reconstructions and a triplanar MRI. Angiography is performed to assess the tumor’s blood supply. PET, CT or scintigraphy are used to rule out other involvement. A biopsy of the pathological structure completes the diagnostic algorithm. When all the testing is completed, possible surgical treatment is planned by the oncological team. Surgical procedures are divided into curative and palliative. Curative surgery is considered only for benign lesions and for small intra-compartmental malignant tumors. Benign lesions are removed and the defects are replaced by bone grafts or metal osteosynthetic materials. The entire area is bridged over by an internal fixator. In intra-compartmental malignant tumors, a resection of the entire vertebra is performed, with an “en bloc” resection being the most beneficial. In the case of metastases, pain control, spinal canal decompression and improvement or easing of the neurological involvement are the goals of palliative surgery. The extent of the surgical procedure in this case depends on the “life expectancy” and it is strictly individual. In general, more gentle, less burdening decompression procedures are selected for patients with life expectancy of 3 months. Upon discussion with the patient, extensive resections are performed for patients with an expected life expectancy beyond 6 months. Vertebroplasty can be performed for treatment or prevention of a single pathological fracture of a vertebral body with metastatic involvement (without spinal cord compression). In this procedure, the vertebral body is filled with bone cement. This is also recommended for the treatment of benign hemangioma.

ONCOLOGICAL DISEASES AND SURGICAL APPROACHES FOR THE EXTREMITIES Preservation of the maximum possible function and length of the involved extremity are the current trends for children, as well as, for adults undergoing surgical procedures involving bony structures of the upper and lower extremities. Resection procedures are the methods of choice. A resection of the carcinogenic masses is performed with subsequent utilization of bone grafts and osteosynthetic materials. Even in an effort to preserve the greatest amount of healthy tissue, the surgeon should follow the so called principle of oncological radicality – resection procedure must be performed into the zone of uninvolved tissue. Surgical Treatment Approaches Limb Saving Surgeries Current trend in surgical and orthopedic procedures reflects an effort to preserve the extremity’s maximum length for those with a tendency toward resection procedures and utilization of bone grafts from a bone bank or an osteosynthetic material. Treatment options for the upper extremities: Scapulectomy Tickhoff-Lindberg procedure (the scapula, clavicle and the proximal humerus are removed with minimal disfiguration of the shoulder girdle; the shoulder has no function but the elbow and hand can be fully functional) Regular type of total shoulder endoprosthesis, or with application of a tumor endoprosthesis allowing for greater resection of the involved tissue Resection at the level of the forearm bones with various options of post-operative mobility in the wrist and the forearm Treatment options for the lower extremities:

Proximal femoral resection with hip joint endoprosthesis; today, hip joint endoprosthesis is a routine procedure after proximal femoral resection and usage of common endoprostheses; its implantation allows for greater resection of the involved tissue Knee area is also a possible option in metastatic involvement either by a commonly used type of endoprosthesis (or the so called tumor endoprosthesis) or by an “en bloc” resection (distal femur and proximal tibia) with subsequent arthrodesis and a slow, energy demanding gait pattern Femoral diaphysis or tibial diaphyseal resection with subsequent fixation on the femur or the tibia by osteosynthesis Fibulectomy with possible fixation by metal instrumentation Radical Amputation Procedures Amputation procedures in today’s oncological surgery are only indicated in the following scenarios: If, when adhering to the oncologic radicality principle, the primary resection cannot involve an amount of tissue that allows for other, limb salvaging surgical solutions If the tumor is so aggressive that the patient’s prognosis for survival is short-term When cancer recurs in a given location Extremity amputation means a tremendous loss to a patient and a vital change in their functional status. Selection of a surgical technique and the level of resection determine the correct prosthesis placement and a good rehabilitation outcome. Classification of individual levels of amputations in the upper and lower extremities is shown in Fig. 4.5.1-3.

Fig. 4.5.1-3 Classification of amputation levels for the upper and lower extremities in patients with oncologic diagnoses

Amputation procedures in the upper and lower extremities can be performed in the bone diaphysis extra-articularly or directly in the joint by disarticulation procedures. Types of upper extremity amputations: Amputation above the shoulder joint, called an interscapulothoracic amputation Amputation above the elbow joint in the humeral region Amputation below the elbow joint in the forearm and hand region Types of lower extremity amputations: Hemipelvectomy and hip joint amputation – rehabilitation program focuses on verticalization and gait training based on individual needs Femoral region amputation- rehabilitation program focuses on prosthetics, spinal stabilization and mobility training with ambulation assistive devices; when thigh prosthesis is used, the

patient’s increased energy demands (increased approximately 80%) during locomotion need to be taken into consideration; at the same time, the patient’s cardiovascular system performance needs to be tested Lower leg and distal leg amputation – rehabilitation program focuses on prosthesis fitting, spinal stabilization and mobility training with ambulation assistive devices When using a prosthesis, the increased energy demand (increased approximately 35%) during locomotion needs to be remembered and therefore, it is recommended to test the performance of the patient’s cardiovascular system. Extensive surgical procedures involving amputation of half of a body are very rare (translumbar hemicorporectomy). Rehabilitation Goals Following Surgical Procedures Axial system stabilization – maximal possible stabilization of the axial organ with emphasis on biomechanics of the trunk and the extremities while preserving the highest level of mobility and function in the affected area. Reduction in the patient’s immobilization time while simultaneously limiting the period of muscle inactivity in regards to their negative consequences on the body as a whole, such as the onset of muscle atrophy, subsequent hypotonia, decreased fitness with the risk of thromboembolic complications, hypercalcemia and the onset of hypokinetic syndrome. Compensation – practicing compensatory mechanisms, compensatory movement skills and providing the patient with assistive devices (adaptation tools). Ergonomics – considering options for modification of the surrounding environment including injury prevention, integration into the society (barriers, apartment, job).

4.5.2 Metastatic Involvement of the Brain and the Spinal Cord

During an oncological disease, the CNS is often affected as a result of neurological complications caused by metastases (bleeding in thrombocytopenia or infection are relatively common). Brain Involvement The following most commonly metastasize into the brain: lung and breast cancer, malignant melanoma, less often hematological malignancies and urogenital tract tumors. Up to 80% of metastases are localized intracerebrally and almost 40% in the area of the brain meninges. Spinal Cord Involvement In about 70% of cases, the metastatic process is localized to the thoracic spine, in 20% to the lumbosacral area and in 10% to the cervical spine. Approximately 5% of patients show clinical signs of spinal compression. As high as 95% of cases show the tumor spreading epidurally with clinical signs of pain provocation with increased intraabdominal pressure and pain during flexion in the cervical and lumbar spine when stretching the meninges.

4.6 PARANEOPLASTIC SYNDROMES Paraneoplastic syndromes are remote signs that accompany cancerous diseases in approximately 15% of patients; however, they are not directly linked to the primary site progression or to tumor metastasis. All these symptoms change the clinical presentation and significantly influence the intensity and course of the rehabilitation program. The principles of pathophysiological mechanisms include the production of cytokines or hormonally active derivates of cancer cells or the damage of healthy cells based on a pathologically crossed reaction. This mechanism dominates in neurological paraneoplastic syndromes – cerebellar degeneration, peripheral polyneuropathy, paraneoplastic retinal degeneration (CAR syndrome). Fever Fever is a common symptom of cancer, often as a manifestation of an infection or a breakdown of cancerous masses. It is also seen as an undesirable side effect accompanying the use of certain anti-cancer medications (cytostatics, interferons). Anorexia and Weight Loss Anorexia and weight loss are the main reasons for cancer cachexia in patients with oncologic conditions. In pathogenesis, humoral factors, which influence the hypothalamic centers regulating stomach motility and thus, appetite, are active. Endocrine Syndromes Cushing syndrome – caused by excessive production of ACTH by the carcinogenic tissue; it is most often manifested by hypertension, hyperglycemia and hypokalemia Syndrome of inadequate antidiuretic hormone secretion with signs of hyponatremia, hypochloremia with reabsorption of water, serum hypoosmolality, urine hyperosmolality, water intoxication (Na+ level is usually below 120 mmol/l or lower) Hypercalcemic syndrome – occurs in cancer metastasized to the bones, it is linked to tissue destruction by a metastatic process

Hypoglycemia – caused by cancer cells that produce hormonally active derivates Paraneoplastic Neurological Syndromes These syndromes occur in only 10–15% of patients with malignant tumors. They manifest themselves in the brain, brain stem, cerebellum, spinal cord and the peripheral nerves. The onset is attributed to the production of specific antigens. Developed antigens then react with intact neuronal antigens leading to nerve tissue damage. Brain involvement in a paraneoplastic syndrome is most often manifested in the following ways: Progressive multifocal encephalopathy – it is most common, especially in lymphoproliferative disorders; it manifests itself by mental retardation and a speech deficit Paraneoplastic retinal degeneration (CAR syndrome) – begins with color blindness, night blindness and later blindness; occurs most often with melanoma and lung carcinoma Cerebellar degeneration – it is characterized by diffuse cessation of Purkinje cells and ataxia, dysarthria and dementia; it occurs most often in cancer of the lungs, ovaries and the breast and in Hodgkin’s disease Necrotizing myelitis – most often found in Hodgkin’s disease and lung carcinoma with finding of IgG antineuronal antibodies Peripheral neuropathy – it is caused by axonal degeneration and demyelination, occurs in nearly 1% of all patients with carcinoma Eaton-Lambert myasthenic syndrome – it is caused by a deficit in the presynaptic peripheral cholinergic neurotransmission; clinically it resembles myasthenia gravis; most often occurs in lung cancer Paraneoplastic Musculoskeletal Syndromes Hypertrophic osteoarthropathy with characteristic triad: hammer toes, periostoses and arthritis – occurs especially in lung cancer, thymoma and other intrathoracic tumors including metastases Jaccoud’s arthropathy – fast developing non-painful arthropathy common for lung carcinoma Paraneoplastic polyarthritis – resembles rheumatic arthritis;

clinically it is manifested as morning joint stiffness; most often develops in breast cancer Dermatomyositis syndrome – occurs in ovarian and breast cancer; the true paraneoplastic process occurs in only a fraction of patients Hematological Changes Hematological changes include changes in the number of blood elements and coagulation deficits. They are most often manifested as anemia, erythrocytosis, leukocytosis and thrombocytosis. Coagulation deficits are manifested by migrating episodes of phlebitis or by disseminated intravascular coagulation syndrome. Skin Signs In malignant lymphomas, pruritus, herpes zoster and dermatitis herpetiformis are common. Hyperpigmentation is a manifestation of hormone production that stimulates melanocytes or lipotrophin. Acanthosis nigrans sometimes accompanies GIT cancer and it is manifested by dark pigmentation, a rough surface and verrucous growths, localized especially in the axillae, groins and under the breast. Hypertrichosis and pemphigus can also be of paraneoplastic origin.

4.7 SIDE EFFECTS OF ONCOLOGIC TREATMENT Negative side effects are very common during the treatment of cancer. They are expected after chemotherapy. Most often, they are related to the cytotoxic effect of chemotherapy in normal proliferating tissues (Tab. 4.7-1). The most significant effects of cytostatics include: Dysfunction in blood production – granulo​cytopenia Gastrointestinal toxicity – mucositis, hemorrhagic diarrhea, vomiting, dysfunction in intestinal passage Damage of the skin and skin appendages (adnexa) – changes in pigmentation, folliculitis Lung damage – interstitial pulmonary fibrosis Cardiac damage – toxic cardiomyopathy Kidney damage – nephrotoxicity Neurotoxicity

Tab. 4.7-1 Overview of cytostatic and hormone side effects (according to Klener P, et al., 2006)

NEUROLOGICAL SYMPTOMS In general, neurological signs and symptoms in patients with oncological involvement include a wide array of clinical signs and symptoms. They occur in the primary cancer disease of the CNS and in the peripheral nervous structures (i.e., due to tumor pressure or carcinogenically altered surrounding structures), as well as, in metastatic processes, paraneoplastic syndromes and overall disease

manifestations as undesirable side effects of an administered oncological treatment. The neurological manifestation of side-effects of oncological treatment include a wide array of symptoms and syndromes, such as subacute cerebellar degeneration syndrome, peripheral motor and sensory neuropathies, deficits in neuromuscular transmission, dementia and reflex sympathetic dystrophy. Inflammatory, carcinogenic, steroidal proximal myopathies and cachectic weakness are also common.

4.7.1 Cerebellar Syndrome Chemotherapy application in certain protocols can elicit an acute cerebellar toxicity with the rapid onset of clinical symptoms, sometimes within the course of several days. Usually, cerebellar syndrome is temporary and disappears when chemotherapy is completed. Severe or irreversible cerebellar syndrome has been statistically reported in 8–20% of patients after high dosages of chemotherapy. Clinically, it is manifested by trunk and extremity ataxia, dysarthria and a nystagmus. A loss of Purkinje cells in the cerebellum has been pathophysiologically demonstrated. The pathogenesis is not yet known.

4.7.2 Peripheral Polyneuropathy Peripheral polyneuropathy is the most common side effect of cytostatic treatment manifested as a symptom of paraneoplastic syndrome in a number of malignancies. It is increased by actinotherapy and nutritional deficit. A slightly reversible form of sensorimotor neuropathy almost always occurs in patients with oncological diseases who are treated by chemotherapy or radiation.

NEUROPATHOLOGICAL CAUSES OF POLYNEUROPATHIES

Individual types of nerve fibers are predetermined to be affected based on the type of chemotherapy received. This usually includes toxic involvement of the myelin of the large (strong) sensory nerve fibers resulting in deficits in proprioception, vibration and deep reflexes. Clinically, it is manifested as sensory ataxia leading to balance deficits and gait ataxia. Objectively, decreased tendon reflexes, impaired deep and also, partially, tactile sensation along with impaired proprioception and sense of motion are present. Also, significant dysesthesia can be present, especially at night. A proprioceptive deficit leads to the weakness of a joint and protective, sensitive mechanisms with the possible degeneration of joint cartilages. With myelin damage involving the small (thin) sensory nerve fibers responsible for transmitting pain and temperature sensation (fibers in the spinothalamic pathways), deep dull or burning pain is the dominating clinical symptom already experienced, with light touch viewed as similar to gentle stroking. Objectively, a deficit in temperature, touch and pain sensation is present. Vibration is affected only minimally or not at all. Tendon reflexes are not decreased. Pathogenesis of polyneuropathy onset is not clearly known, but it is presumed that the toxic damage of the axonal transport of cytostatics with an influence of the function of the axonal microtubules and subsequent metabolic changes terminating in axon cessation is the most important cause. Peripheral polyneuropathy is most often characterized by symmetrical sensorimotor involvement with primary damage to the neurites of individual axons. Electromyographic testing shows fibrillations or poly​phasic motor unit potentials. Strictly motor or strictly sensory involvement only occurs occasionally.

Motor neuropathies are accompanied by a disturbance in the transmission of stimuli in the afferent part of the reflex arc with subsequent gradual isolated loss of lower motor neurons with a varied degree of motor function involvement. Sensory neuropathies are accompanied by an inflammatory reaction and neuronal damage in the posterior ganglionic roots. This is referred to as dorsal root ganglionitis in the literature. Peripheral neuropathy is usually reversible or at least partially reversible. The clinical picture varies: pain, paresthesias, hypesthesia (stocking and glove distribution), dysesthesia, impaired temperature sensation, pseudoparetic involvement of the distal musculature, balance deficits and instability. A patient after oncotherapy (chemotherapy) often reports loss of stability during ambulation and a lack of sensation in the hands.

TREATMENT FOR PERIPHERAL NEUROPATHY Treatment Rehabilitation in Peripheral Neuropathy Vasopneumatic therapy – used to alternate overpressure and underpressure in a special cylinder acting on the upper or lower extremities. Improving lymph outflow, or lymphatic drainage are the main effects of this treatment. At the same time, venous return and blood flow are increased. Resting longitudinal galvanization – uses the stimulatory effect of cathode or the inhibitory effect of anode, or also Amos electric currents. Synthetic and analytical techniques – analytical techniques aimed at improved muscle function are rarely implemented (exercises based on manual muscle testing and exercises based on Kenny are used), all other techniques used in rehabilitation are the so called synthetic techniques and methods, during which muscle activation occurs in co-activating and synergistic patterns. Lifestyle modifications – such as comfortable footwear, nonconstrictive socks, injury prevention, skin burning prevention, and minimization of negative psychological stimuli (stress).

Rehabilitation treatment is always long-term because the patient’s clinical condition often fluctuates based on the disease progression and repeated series of oncological treatments. Almost always the rehabilitation program needs to be repeated.

4.7.3 Hormone Therapy Hormone therapy plays an important role in the comprehensive treatment of cancers of the breast, prostate, endometrium, etc. Negative side effects include fatigue, hot flashes, and headaches with autonomic symptoms including sleepiness, ataxia and arthralgia.

4.7.4 Immunotherapy In recent years, immunotherapy in oncology became an important therapeutic method for patients with side effects during interferon therapy. Its application is accompanied by many undesirable side effects, such as a flu-like syndrome, myalgia, arthralgia, headache, muscle stiffness, ataxia, paresthesia, fatigue, fever, shivers, malaise, neuropsychological deficits, mood swings, depression, hallucinations, coma and visual deficits.

4.8 SOFT TISSUES AND MUSCLE TISSUE The growth of carcinogenic tissue itself leads to significant metabolic and biochemical changes at the cellular level with pathological deviations in enzymatic chains of muscle cells with the occurrence of microangiopathy and remodeling, or possibly muscle cell atrophy. The invasion of healthy tissues by cancer together with a possible surgical procedure creates extensive damage seen in muscle fiber remodeling, contractility and the timing of muscle activation. These pathological changes are accentuated by frequent application of corticosteroids leading to the onset of steroidal myopathy, radiation therapy with emerging damage to the skin, subcutaneous tissues as well as fasciae and muscle fibers. Chemotherapy has a negative side effect on the soft tissue structures and it is accompanied by a loss of appetite, nausea, vomiting, decreased fitness, malnutrition or even the possibility of peripheral neuropathy. Oncological disease is a stressful factor and leads to a decreased pain threshold and increased muscle tone.

4.9 RADIATION THERAPY Forms of Application: Radical – used for tumor mass reduction or as protective radiation following a surgical procedure at the site of the original tumor Palliative – used to control pain symptoms in metastases to the brain, bones or as a prevention of complications, i.e., in superior vena cava syndrome and pathological bone fractures Negative Side Effects Early – leukopenia, thrombocytopenia, fatigue, desquamation of cells, mucous membrane changes (decreased salivation, mucositis, loss of taste bud sensitivity), nausea, vomiting and anorexia; postradiation esophagitis, proctitis, cystitis and amenorrhea or loss of libido are common Late – soft tissue fibrosis with contractures, skin atrophy or ulceration, osteonecrosis, lymphedema, pulmonary fibrosis, gastrointestinal strictures or chronic cystitis and nephritis; transverse myelitis, brain necrosis, xerostomia, auditory and visual deficits, endocrine insufficiency and late malignancies are not exceptions From a psychological perspective, it needs to be remembered that there is the possibility of developing impotence in men and sterility in women. Simultaneous application of chemotherapy and radiation therapy mutually accentuates toxic effects. The Time Sequence of Radiation Treatment Neurotoxicity: Early – effects are rare Subacute – radiation encephalopathy based on nerve cell demyelination following CNS radiation (in the first 8 months after radiation). Clinical manifestations are variable, usually with good response to corticosteroids. Very often, they are reversible. Chronic – delayed radiation encephalopathy based on coagulation necrosis of cortical white matter emerging 1–2 years after treatment

with minimal responsiveness to corticosteroid administration. Following CNS radiation, brain atrophy can occur and may be accompanied by memory loss and cognitive dysfunction. Note: During radiation treatment, the protective effect of corticosteroids on the nerve tissue has been demonstrated (Dexamethasone is most commonly administered). Muscle Damage by Radiation Muscle cells are considered to be relatively resistant to the effects of radiation treatment, although a higher dose application (above 50 Gy) can cause late toxicity in muscle cells. Early effects of radiation therapy on muscle cells are not common. Late effects are seen several months or a year after the completion of radiation therapy. Clinically, muscle contractions, decreased muscle strength and possible pathological fractures are seen. Spinal Cord Damage by Radiation From the perspective of radiation sensitivity, the spinal cord is more sensitive than the brain tissue. Based on the location of radiation to the spinal cord, a various amount of radiation dosage can be administered based on the anatomical parameters of the spinal cord and the spinal canal: up to approximately 40 Gy for the cervical spine, up to 45 Gy for the thoracic spine and up to 50 Gy for the lumbar spine. Corticosteroids are being preventatively administered to protect the spinal cord tissue. A classification developed by Reagan is used to express the extent of the damage: Type I – temporary form, so called Lhermitt syndrome (“electric currents” along the spine, often following radiation treatment in the ear, nose and throat areas). It occurs within 4 months after radiation, persists for weeks or months. It is characterized by extremity paresthesias and the already mentioned “electrical“ shocks along the spine into the extremities. The symptoms are provoked especially by neck flexion. Clinical manifestations are reversible and often disappear in a few months. They are caused by

demyelination and the increased sensitivity of the exposed axon. Type II – it is characterized by weak paralysis of the lower extremities and loss of sensation as a result of damage to the anterior spinal horns. Type III – fast developing signs of paraplegia and quadriplegia, sensory loss as a result of spinal cord infarction and radiation changes to the corresponding spinal cord vessels. Clinical symptoms emerge within a few hours. Type IV – it is the most common form of chronic progressive postradiation myelopathy. Clinical signs develop gradually and are characterized by fatigue, muscle weakness, sensory deficits, i.e., paresthesias, upper and lower extremity pain, gait disturbance or even complete spastic or a flaccid paresis. Also, disturbances in intestinal and urinary bladder function can be present. Prognosis is poor. Radiation damage to the spinal cord can manifest itself through various clinical presentations, such as transverse myelitis, delayed radiation myelopathy (in the 9–18 month period after radiation), clinical signs of Brown-Sequard, radicular pain, sphincter dysfunctions associated with upper motor neuron deficits and also rarely with lower motor neuron deficits. Radiation induced brachial or lumbar plexopathy can manifest itself months or years after spinal cord radiation.

4.10 LYMPHEDEMA Lymphedema is a common complication in oncologic diseases. The etiology is a blockage of lymphatic flow developing as a result of a surgical procedure, carcinogenic tissue pressure or a post-radiation fibrosis. In patients with breast cancer, a subsequent surgical procedure on the breast, including axillary exenteration followed by radiation therapy of the corresponding lymph nodes and thoracic wall form the largest group affected by lymphedema. Another common group is formed by patients with gynecological cancers after surgical procedures with subsequent radiation of the pelvic and inguinal lymph nodes. The next most common group includes patients after lymphadenectomy of a prostate carcinoma, kidney tumors, soft tissue sarcomas, or possibly after a harsh paraintravenous application of chemotherapy. From a therapeutic perspective, the following can be distinguished: Reversible edema stage (clinically – soft edema, a negative Stemmer’s sign, which means that a fold can be formed by the fingers and dimples on the skin); Irreversible edema stage (clinically – permanent edema, positive Stemmer’s sign with formation of fibrotization, sclerosis and deformities). For more information on lymphedema and its treatment, see Chapter 3 Treatment Rehabilitation in Selected Internal and Other Diseases, subchapter 3.9.1 Lymphatic Edema and its Treatment.

REFERRENCES Bechyně M. Terapie lymfedému. Praha: Phlebomedica 1993. DeLisa JA. Rehabilitatiton Medicine/Principles and Practice. 3rd ed. Philadelphia: Lippincott-Raven 1998. DeVita jr. VT, Hellman S, Rosenberg SA. Cancer, Principles and Practice of Oncology. 7th ed. Philadelphia: Lippincott 2005. Dietz JH. Rehabilitation Oncology. New York: John Wiley and Sons 1981. Goodgold J. Rehabilitation Medicine. Toronto: Mosby 1998.

Janda V. Funkční svalový test. Praha: Grada Publishing 1996. Janda V, Kraus J. Neurologie pro rehabilitační pracovníky. Praha: Avicenum 1987. Klener P. Klinická onkologie. Praha: Galén 2002. Klener P. Protinádorová chemoterapie. Praha: Galén 1996. Klener P, et al. Vnitřní lékařstvi. 3., přeprac. a dopl. vyd. Galén–Karolinum 2006. Kolář P. Facilitation of Agonist-Antagonist Co-Activation by Reflex Stimulation Methods. In: Rehabilitation of the Spine. A Practitioner’s Manual by Craig Liebenson. 2nd ed. Philadelphia: Lip​pincott, William and Wilkins 2006; 531–565. Kopecký J, Sumerová J, Kopecká P. Rehabilitace po operacích prsů. Ostrava: Zdravotněsociální fakulta Ostravské univerzity 2000. Kottke FJ, Amate EA. Clinical Advances in Physical Medicine and Rehabilitation. Washington: Pan American Health Organization 1991. Mirels H. Metastatic disease in long bones. A Proposed Scoring System for Diagnosing Impending Pathological Fractures. Clin Orthop 1989; 36(249): 256–264. Poděbradský J, Vařeka I. Fyzikální terapie I, II. Praha: Grada Publishing 1998. Reagan TJ, Thomas JE, Colby jr. MY. Chronic Progressive Radiation Myelopathy. JAMA 1968; 203(2): 106–110. Smolíková L, Horáček O, Kolář P. Plicní rehabilitace a respirační fyzioterapie. Postgrad Med 2001; 3(5): 522–532. Trávníčková Kittlerová O, Hradil V, Vacek J. Rehabilitace pacientů s onkologickou diagnózou. Praha: Triton 2004. Véle F. Kineziologie pro klinickou praxi. Praha: Grada Publishing 1997.

5 TREATMENT REHABILITATION IN GYNECOLOGY AND OBSTETRICS Martina Ježková, Pavel Kolář Treatment rehabilitation in gynecology and obstetrics plays an important role, not only as a component of the treatment itself, but also in prevention. In selected gynecological conditions, in which the movement system function is discussed as an etiopathogenic factor, its causative effect can be presumed. Various gynecological pathologies, such as infections, dysmenorrhea, post-surgical conditions and last, but not least, physiological processes, such as pregnancy and the six week postpartum period, have a direct effect on the structure of the movement system and vice versa. Clinically, it can be sometimes difficult to distinguish whether the cause is primarily gynecological or whether it is a movement system dysfunction with a visceral referral pattern. In this section, the individual gynecological syndromes and conditions are described as specific diseases (nosologic units) and include functional symptoms and rehabilitation treatments.

5.1 OVERVIEW OF GYNECOLOGICAL SYNDROMES WITH CONTRIBUTION OF FUNCTIONAL DEFICITS Martina Ježková, Pavel Kolář In general, gynecological diseases are closely linked to functional deficits of the movement system. Although this connection, or its etiopathogenetic meaning, has not been sufficiently validated, it needs to be taken into consideration that any gynecological disorder is registered by the CNS through receptors. Then, the CNS reactively, or adaptively develops protective changes in muscles (changes in muscle tone), including the smooth muscle. Muscles and other soft tissues also react sensitively to humoral actions linked to certain gynecological diseases. Their consequences are observed in relation with treatment or administration of contraceptives. Through changes in muscle tone and soft tissue tension, joint function also becomes affected (especially its limitation; on the other hand, increased soft tissue laxity resulting in functional hypermobility is seen during hormonal changes). A complete picture also includes changes in skin reaction, such as hyperalgic zones, increased dermographism, etc. Next to reflex relationships, close anatomical relationships, including innervation and vascular and lymphatic supply, participate in the functional relationships between the visceral gynecological region and the movement system. In many cases, gynecological involvement is subjectively perceived as pain in the sacral region. Pain in the lumbar region can originate from the female reproductive system during menstruation, pregnancy, delivery, in gynecological disease or following surgeries. Karel Lewit points out females with negative gynecological findings who report diffuse pain in the sacral region during menstruation as a result of ordinary functional spinal and pelvic deficits. He reports a high percentage of women (79%) with algomenorrhea who present with either lumbosacral restriction or sacroiliac shift accompanied by iliacus muscle spasm. Clinically, it is important that movement system symptoms in some

cases of gynecological dysfunctions (amenorrhea, dysmenorrhea and sometimes functional sterility) are quite alike and show similar characteristics. These are protective motor patterns. The possibility of gynecological causes needs to be considered in patients with back pain who demonstrate a chaining of functional deficits of the muscle system (pelvic nutation, pelvic floor spasm, unilateral gluteal muscle hypotonia, TrPs in the hip adductor region, etc.), (Fig. 5.1-1). In such scenarios, it is recommended to consult with the gynecologist and rule out possible gynecological etiology. However, a large number of functional spinal and pelvic dysfunctions exist that are mistakenly considered to be gynecological diseases. Fig. 5.1-1 Reflexive pelvic floor muscle spasm accompanied by pelvic nutation

Next to gynecological conditions that cause lumbago, an opposite relationship has been discussed lately regarding the role that the described functional deficits play in the movement system, or as a structural finding in the lumbar spine (disc herniation, spondylolisthesis, etc.) in the etiology and pathogenesis of gynecological deficits. These movement system deficits predetermine decreased circulation of the small pelvis, influence intra-pelvic pressure, are a source of chronic pathological afferentation, muscle

spasms, etc., which are not without functional response by the reproductive organs. Clinical experiences confirm such functional relationships; however, experimentally, this somatovisceral influence has not been sufficiently validated, especially its activity over time. Gynecological dysfunctions that are being significantly influenced by movement system function include menstrual cycle deficits, dysmenorrhea, premenstrual syndrome, certain gynecological infections, functional sterility and deficits during menopause (climacterium).

DYSFUNCTIONS OF THE MENSTRUAL CYCLE AND FUNCTIONAL STERILITY Classification of menstrual cycle disturbances: Deficits in the onset of menstruation (precocious menstruation and late menstruation) Bleeding deficits during the cycle (i.e., hyper- or hypomenorrhea) Deficits in bleeding frequency (poly- or oligo​menorrhea) Dysfunctional bleeding Amenorrhea Dysmenorrhea Amenorrhea and dysmenorrhea are among the menstrual cycle deficits most often affected by rehabilitation.

AMENORRHEA Amenorrhea is the absence of menstruation in a female during the reproductive period with the exception of pregnancy. It can have various causes and is classified by the following: 1. Based on the time of onset 1. Primary amenorrhea – menstruation bleeding has not occurred by 15 years of age. The cause is often biological. 2. Secondary amenorrhea – a female who already menstruated at least once or more. Menstruation did not occur for longer

than 4–6 months. The cause is usually functional. 2. Based on clinical significance 1. Physiological – prior to puberty, during pregnancy, lactation and post-menopause. 2. Pathological – a very long absence of menstruation due to a deficit in a certain component within the functional cycle (cerebral cortex, hypothalamus, hypophysis, ovaries, uterus). Amenorrhea is among the most frequent psychosomatic gynecological complications. Abnormal and usually insufficient blood circulation through the small pelvis often contributes to its onset.

DYSMENORRHEA Dysmenorrhea denotes menstruation accompanied by significant pain and complications that often cause the woman to be unable to work. Based on the onset of complications, it can be classified as: 1. Primary dysmenorrhea Beginning with menarche (first menstruation), bleeding with each menstruation is accompanied by pain. 2. Secondary dysmenorrhea Painful complications during menstruation occurring later in life. Causes The most common biological causes include infections, tumors, cervical stenosis, endometriosis, uterine retroversion, congenital defects of the uterus, etc. Functional deficits are often caused by autonomic dystonia. Typical findings include sympathetic tone in the uterine vessels, increased contractile ability of the uterus and incomplete endometrial expulsion during menstruation. In these functional disturbances, functional deficits of the musculoskeletal system are also always found. The functional deficits of the musculoskeletal system that can be linked to painful menstruation include spasm of the iliacus muscle that is palpated as a painful resistance in the lower abdomen or

weakness of the deep stabilization system (diaphragm dysfunction and pelvic floor synergy accompanied by a deficit in intra-abdominal pressure regulation), which leads to poor posture, not only in the lumbosacral and pelvic regions, but in the entire body. Individual segment overuse leads to the onset of functional deficits (especially functional restrictions) and therefore, an increase in nociception. In the case of dysmenorrhea, chronic overuse especially of the lumbosacral region is present. This overuse increases during the premenstrual period and in the first days of menstruation, during which ligamentous laxity is increased as a result of hormonal activity (similar to pregnancy). If the female chronically demonstrates a decreased ability with spinal stabilization, she is at risk of developing reflexive changes in the movement system (i.e., restrictions, TrPs, TPs, hyperalgic zones, etc.) during the time of increased ligamentous laxity. This contributes to increased pain in this entire region. Based on painful stimulation, reflexive changes also occur in the vascular system (especially vasoconstriction), which leads to decreased circulation. The resulting regional hypoxia leads to elimination of tissue mediators that stimulate nociceptors.

STERILITY Sterility is a state, in which a female with regular sexual intercourse at least 2 times per week does not get pregnant within 1 year. Infertility is a state, in which a female becomes pregnant but does not carry the child to term; therefore, miscarries. Based on the cause of onset, it can be classified as: Biological – ovarian, tuboperitoneal, uterine factor, endometriosis and hormonal influences Functional – causes are psychogenic in nature or functional deficits in the musculoskeletal system. Patients with functional deficits are appropriate for rehabilitation. However, the partner’s fertility also needs to be examined Sterility for any reason is always a source of stress, which, in turn, demonstrates itself in the musculoskeletal system and can secondarily

further worsen the situation. Rehabilitation in Gynecological Syndromes with Contribution from Functional Deficits The close interrelationship between gynecological function and the movement system forms the foundation for rehabilitation approaches in certain gynecological syndromes. Physical therapy treatment is always based on a carefully selected kinesiological analysis. Given the fact that the clinical presentation of the movement system in amenorrhea, dysmenorrhea and often in functional sterility is similar, this issue will be described simultaneously. Motor Pattern in Gynecological Involvement A motor pattern, or a schema, that is related to gynecological involvement contains the following movement system deficits. Rigid Pelvic Nutation with Unilateral or Bilateral Pelvic Floor Spasm Spasm has a tendency to rotate the pelvic bone in the sagittal and transverse planes. These changes are transferred through the symphysis to the contralateral pelvic bone that becomes deviated in the opposite direction. The symphysis and the other components (the sacroiliac joint, coccyx) contributing to the mechanical energy transfer are extremely strained by forces. A typical finding includes pain with palpation of the sacrococcygeal articulation and the sacrotuberal ligament, which is palpated laterally and cranially from the coccyx. Since the coccyx serves as an anchor for the pelvic floor muscles (Fig. 5.1-2), this often forgotten bone can also elicit visceral pain in the small pelvis. In standing, the patient’s anterior superior iliac spines and the posterior superior iliac spines are not level. Usually, the left posterior and the right anterior spines are positioned higher than the right posterior and the left anterior. In this pathological pelvic alignment, the coccygeus muscle shortens and affects functional movement in the sacral and hip joints (most often on the right). Fig. 5.1-2 Most common distribution of TrPs in the pelvic floor muscles

Trigger points are found at the gluteus maximus insertion at the sacrococcygeal junction, in the hip external rotators and in the hip adductors on the side of the elevated ASIS. This usually involves the right side. When the patient is seated, the gluteal fold on this side appears lower and rotated when viewed from the back. Gluteal muscle weakness and hypotonia are also typically present. A patient in the prone position is not able to sufficiently isometrically activate these muscles and they are also insufficiently activated during gait. Their dysfunction is compensated for by increased activity of the paravertebral and hamstring muscles. Characteristic presentation includes decreased tolerance to static loading, especially in standing. The patients are unable to stand in one position. After a short time in a static position, they need to immediately change their stance. They either lean on the upper extremities or change their stance to an “at ease” position, during which they frequently alternate weight bearing on their lower extremities. A rigid pelvic nutation is almost always accompanied by a thoracolumbar restriction with increased tone in the psoas and the quadratus lumborum muscles and a restriction in the atlanto-occipital joints. These patients present with frequent headaches. Deficit in Breathing Pattern and Muscle Coordination during IntraAbdominal Pressure Regulation A deficit in the breathing pattern, including a coordination deficit

during regulation of intra-abdominal or intra-pelvic pressure is a common initial symptom of the listed gynecologic syndromes. Both signs are described together because of their close relationship. During assessment, a coordination deficit in muscle synergy is found between the diaphragm, abdominal muscles and the pelvic floor muscles and therefore, the paravertebral muscles. A breathing pattern deficit typically presents with overutilization of the accessory breathing muscles. During inspiration, the lower thoracic wall, or the intercostal spaces do not expand. The sternum moves craniocaudally during breathing. During inspiration, the abdominal wall is drawn in, especially its upper portion. The patient is not able to change their breathing pattern even after they have been educated on it. Breathing dysfunction is closely related to paradoxical diaphragm function when the intra-abdominal pressure increases. In a given situation, during diaphragm contraction, the punctum fixum is on the centrum tendineum, not on the ribs. The contraction of the upper abdominal muscles, drawing-in of the abdominal wall and a simultaneous cranial movement of the umbilicus are typically found in this dysfunction. Testing The patient sits at the edge of the table with the upper extremities placed freely on the mat (does not lean on them against the table or on the thighs). The thorax is in an expiratory alignment and the spine is erect. At first, the examiner palpates the lower ribs laterally and underneath the lower ribs. The examiner gently presses against the lateral abdominal muscles. Through palpation, the examiner simultaneously checks the alignment and activity of the lower ribs. During inspiration, the examiner observes the movement of the ribs and respectively the thorax. In a physiological scenario, the thorax expands, which is registered through palpation as a lateral rather than cranial movement. Next, the patient is asked to exert counter pressure against the examiner’s fingers, or to increase their intra-abdominal pressure by expanding the lower section of the thorax. During the entire test time, the spine remains erect and the thorax in a caudal

alignment. The test assesses the ability of the patient to activate the diaphragm in synergy with abdominal bracing and pelvic floor activation. During activation, symmetry and, respectively, asymmetry in muscle activation is observed. During correct activation, the patient activates their muscles against our palpation, expands the lower part of the thorax in a lateral direction while expanding the intercostal spaces. None, insufficient or asymmetrical muscle activation against palpatory resistance, insufficient lateral expansion of the lower thoracic aperture and the intercostal spaces and also a scenario in which the patient is unable to maintain caudal alignment of the thorax are all considered non-physiological. In the same scenario or during inspiration or the Valsalva maneuver, the groin region above the femoral heads is palpated. Under physiological circumstances, the abdominal wall expands during inspiration and intra-abdominal pressure increase and this is registered by palpation. In women with a pathological finding, no resistance is palpated even when the patient is instructed in correct mechanics (Fig. 5.1-3).

Fig. 5.1-3 Most common distribution of TrPs (marked by x) within postural pattern in a patient with functional gynecological dysfunction. A – anterior view, B –

posterior view

Rehabilitation in Functional Gynecological Dysfunctions Rehabilitation treatment is based mainly on affecting functional deficits in the soft tissues, joint-muscle system, coordination of muscle synergy during intra-abdominal pressure regulation, improved circulation in the small pelvis area, etc. By correcting functional pathologies, such reflexive responses of the movement system (including the autonomic nervous system) are achieved and thereby signal correction of the gynecological problem. Treatment selection is carefully based on a kinesiologic analysis. Soft Tissue Techniques These are techniques that aim to release the soft tissues in the pelvic, lumbar and ribcage regions. Influencing Ribcage Rigidity and Dynamics Relaxation of the inspiratory alignment of the thorax and achievement of isolated movement of the ribcage independently of thoracic spine movement are the goals of achieving improved ribcage mobility (decreased stiffness). The first step is to release the skin, subcutaneous tissue, fasciae and muscles of the ribcage and practice a correct breathing pattern. Method The patient is supine with the lower extremities flexed and slightly abducted and the feet placed on the mat. The thoracic spine is straight. In this alignment, the therapist performs a release of the lateral thoracic wall to its maximal caudal alignment. If, during this maneuver, the shoulder girdle elevates, it needs to be stabilized. The patient attempts to breathe into the lower segment of the ribcage. The abdominal and accessory breathing muscles need to be relaxed. Stretching of the thoracolumbar fascia is another important maneuver for relaxation of the posterior lower segment of the ribcage. Relaxation Techniques Aimed at the Pelvic Floor Method

The patient kneels at the edge of a table. She leans on her forearms and flexes head. In this position, the second or the third digit of the right hand is inserted into the rectum. The examiner stabilizes the pelvis from the top with their left hand and then uses their right hand to stabilize the patient’s coccyx. At first, the examiner assesses by palpation from the coccyx down to the left and then to the right. Spasm is usually asymmetrical, which is why a spasm of only a few muscle fibers is palpated on one of the sides. During treatment, soft tissue techniques are used (including stretching the structures to their barriers and waiting for the release phenomenon) to release such muscle spasms. Either direct pulling or small circular motions from the coccyx in a downward direction can be used. If the spasm does not release using either one of these methods, a post-isometric muscle relaxation can be used. In post-isometric relaxation, the therapist palpates the spasm with their inserted finger. The patient attempts to selectively activate the corresponding part of the levator ani or the levator coccygeus muscle against the therapist’s inserted finger. This is followed by a relaxation phase and passive stretch of the muscle by the therapist. This treatment can also be performed with a finger inserted under the coccyx from the ventral side. The patient, then, contracts the pelvic floor muscles, inhales and holds their breath for 10 seconds. Then, they release the contraction and exhale. The therapist waits for the release phenomenon and gently stretches the coccyx in a caudal direction. Pelvic floor relaxation can also be performed as a home treatment. In supine with the lower extremities flexed, the patient pulls in the levator ani muscle, which they keep checking by placing their finger near the anal opening (which must be pulled in an inward direction). Then, they inhale and hold their breath. This is followed by relaxation, expiration and attempts at supreme relaxation. Mobilization Techniques The following are used in female reproductive organ dysfunctions:

Lumbar spine mobilization into lateral flexion and rotation Rib and mid-thoracic spinal mobilization Sacroiliac joint mobilization. Usually, this articulation does not need to be mobilized because it often corrects itself after pelvic floor muscle relaxation or after cranial joint mobilization Home treatment also utilizes methods by Ludmila Mojzisova. Activation of the Deep Spinal Stabilization System During spinal stabilization, the following muscle activation occurs: at first, the deep spinal extensors are activated, which are then subsequently balanced by the synergy of the deep cervical flexors and increased intra-abdominal pressure, which is achieved by optimal synergy of the diaphragm, abdominal muscles and the pelvic floor. Training is performed in supine with the lower extremities flexed. The lower legs are resting against the seat of a chair. Hips are flexed to 90 degrees. In this position, the patient exhales and the therapist passively and gently presses the thorax in a caudal direction. The abdomen and the lower thorax expand in all directions. The intraabdominal pressure that the patient actively increases must spread in all directions, especially dorsally and laterally (at the level of the thoracolumbar junction) and in the lower abdominal area. For better execution and specification, the therapist can use palpation pressure against which the patient pushes out the abdominal wall in all directions, not only forward. It is important that the force exerted by the patient does not cause cranial co-movements in the abdominal region. Then, the patient practices breathing (the ribs are moving laterally, the sternum ventrally and without elevation cranially) without relaxing the abdominal wall in the palpated region during expiration. In dysmenorrhea, the following is recommended: Functional belt (tape) – placing two strips between the anterior spinae. One from the right to the left and the other vice versa. The strips can overlap. With pain during menstruation, exercises based on abdominal

breathing can be implemented. They are performed in the fetal position either in sidelying or in low hands and knees position with deep forward trunk flexion. These positions are beneficial given their potential for good breathing control through contact of the abdominal wall. Method by Ludmila Mojzisova Today, the treatment of female functional sterility is inherently linked to the treatment methods by Ludmila Mojzisova despite the fact that this method has been used primarily for patients with back pain. The method contains mobilization techniques, relaxation of the levator ani through the rectum and a set of exercises for active daily exercise. The entire treatment method requires the patient’s active participation and daily exercise. The setup includes a total of 12 exercises. The exercises focus on changing the coordination of the abdominal and gluteal muscles that, together with the pelvic floor muscles, ensure correct pelvic alignment. Strengthening is performed isometrically and it is facilitated by breathing. The exercises also have mobilization and stretching effects, for example, exercises to release the sacroiliac joint or individual spinal segments. The set of exercises reflexively influences smooth muscle tone and improves circulation in the small pelvis area, which leads to functional improvement and decreased gynecological problems. This method can also be used in men. they utilize all 12 exercises and this leads to an improved spermiogram or management of constipation problems.

5.2 PREMENSTRUAL SYNDROME AND MENOPAUSE Premenstrual syndrome is a collection of psychological, somatic and autonomic symptoms that intensely accompany the second half of a cycle (5–14 days prior to menstruation and disappear with the onset of menstrual bleeding).

PREMENSTRUAL SYNDROME Causes of premenstrual syndrome are not quite clear. It can be elicited by more factors, most often the following: Psychogenic factor Hormonal factor – excessive activity of estrogens, hypofunction of the yellow body (corpus luteum) Autonomic dysfunction (hypofunction of the sympatheticergotropic system) Hyperprolactinemia The main symptoms of premenstrual syndrome include edema, headaches, nausea, bloating, feelings of fullness and heaviness, psychological changes, emotional lability, anxiety and fear, irritability, depressive states and insomnia. This state often occurs after or during a period of great psychological stress and also during anovulatory cycles.

MENOPAUSE Menopause or the climacterium (climax = apex) is a period immediately prior to the last menstruation and lasting for one year. In this time period, the production of reproductive hormones in the ovaries slowly decreases and manifestations of hormonal imbalance emerge. For clarification of terminology, other gynecological terms pertaining to this phase are listed.

MENOPAUSE, PREMENOPAUSE, POSTMENOPAUSE

Menopause is a permanent cessation of menstruation as a result of decreased production of reproductive hormones (estrogens and gestagens) by the ovaries. The levels of reproductive hormones become so low that a menstruation cycle cannot occur. The average age during menopause is 49–51 years. Prior to 45 years of age, the menopause is premature. After 55 years of age, it is delayed. Premenopause is the time preceding menopause. Perimenopause (climacterium) is a phase immediately prior to menopause and up to one year after menopause, during which the production of reproductive hormones in the ovaries stops and manifestations of hormonal imbalance occur. Postmenopause is a phase of ovary function cessation. It begins one year after menopause. In menopause, most females (70–80%) demonstrate a set of specific problems that they did not seem to have displayed so far. This is called the menopausal (climacteric) syndrome.

Menopausal Syndrome Menopausal syndrome is characterized by the following symptoms: hot flashes, perspiration, headache, tachycardia, digestive problems, irritability and depression. Given the lack of estrogens, atrophy of the vagina (infections can occur), urethra (lower urinary tract infections can occur, urge or stress incontinence), other mucosal tissues, skin and breast can occur, as well as, decreased muscle tone of the pelvic floor and atrophy of the uterine supporting and suspension systems can emerge. The occurrence of uterine prolapse or vaginal wall prolapse is quite common. Osteoporosis is another important manifestation of postmenopause. Treatment Rehabilitation of Premenstrual Syndrome and during Menopause Mechanisms of Treatment Rehabilitation Influences:

Relaxation practice can bring about and improve overall relaxation and shift autonomic balance in the direction of the parasympathetic system Endorphins are released during physical exercise, which contribute to decreasing pain and the onset of pleasant feelings Activation of a certain cortical region causes inhibition of the neurons in the rest of their section, which leads to pre-columnar inhibition, especially in the prefrontal cortex; simply said, exercises distract from an anxious self-observation Stimulation of mechanoceptors during exercise decreases pain perception – the gate theory Body shaping during regular physical activity reflects positively on the individual’s self-awareness within their surroundings

SYNDROMES THAT CAN BE AFFECTED BY REHABILITATION Neuro-autonomic signs (nausea, irritability, moodiness) are the most common findings of premenstrual tension and menopausal syndrome. These changes can be, to a certain extent, influenced by physical therapy methods through the above listed mechanisms. Besides calcium intake in a diet, osteoporosis also requires movement. During physical activity, the osteoblasts are activated and the bony framework is functionally remodeled. Also, exercises to improve muscle strength and coordination are beneficial (for example, exercises based on sensorimotor principles), which especially improve the individuals’ stability and function in fall prevention. Endurance training and jogging are also recommended as a prevention of, not only osteoporosis, but also cardiovascular and respiratory diseases. For more detail, see Chapter 3 Treatment Rehabilitation in Selected Internal and Other Diseases, subheading 3.8.4 Osteoporosis. Breast atrophy can be slowed by exercises targeting the pectoral and shoulder girdle musculature. Adequate and regular physical activity also helps maintain a reasonably balanced hormonal spectrum and autonomic balance.

Pelvic floor, urethral and vaginal atrophy. From a physical therapy perspective, the patient needs to “recognize” their pelvic floor muscles, learn to control them, strengthen them and implement them into correct movement patterns. Exercising the pelvic floor muscles effects circulation of the pelvic region and tones the autonomic system as a whole. The spinal axis and the general tone of the postural muscles are being influenced by optimization of pelvic floor muscle tone.

5.3 PELVIC INFLAMMATORY DISEASE Pelvic inflammatory disease can affect the uterus, fallopian tubes and the ovaries. If the inflammation is localized to the fallopian tubes and the ovaries, it is an adnexitis; therefore, an inflammation of the uterine appendages. Clinically, it can present as sacralgia, dysmenorrhea or non-specific pain in the lower abdomen. Based on adnexitis, connective tissue growths can form in the pelvic region, which can lead to sterility or infertility. Rehabilitation Following Pelvic Inflammatory Disease Subacute and chronic conditions are indicated for physical therapy, especially to accelerate the absorption of the exudate and prevent adhering to the surrounding tissues and thus, preventing fallopian tube blockages, which is one of the causes of female infertility. The goal is to improve circulation in the small pelvis. Following pelvic inflammatory disease, treatment rehabilitation utilizes the following: Soft tissue techniques for scars, fasciae and internal adhesions (a better result can be achieved after prior heat application – infrared, hot towel roll) Mobilization of the lumbar spine, lumbosacral, sacroiliac, hip, thoracic spine and rib joints Release and strengthening of the pelvic floor muscles Strengthening the deep stabilization system Breathing exercises

5.4 ANATOMICAL DEFICITS IN GYNECOLOGY Anatomical deficits in gynecology include congenital deficits in the female reproductive system (agenesis, hypoplasia, unilateral development, development of surplus organs, disturbances in connections and impassibility of organs) or faulty positioning of the reproductive organs (position, angle, incurvation). The causes of reproductive organ hypoplasia can include, to a certain extent, genetic influences, hypothalamohypophyseal deficits, as well as, deficits at the level of the estrogen receptors in the end (target) organs. A retroverted uterus can be classified as free or rigid. In contrast to free retroversion, the uterine body cannot be pushed out by the fingers from the Douglas’ space in rigid retroversion during gynecological exam. It is fixed to the posterior leaf of the peritoneum by adhesions that developed as a result of inflammation or endometriosis. From the perspective of etiology and pathogenesis, the retroversion can be either congenital or acquired. Clinically, it can be manifested by sacralgias, dysmenorrhea or hypermenorrhea. Retroversion can sometimes also be linked to sterility or infertility. Rehabilitation in Anatomical Deficits in Gynecology In anatomical deficits of the female reproductive system, rehabilitation plays a smaller, however, important role because of all functional changes in the movement system in the area of the pelvis and the lower spinal region that decrease the patient’s quality of life and, therefore, their treatment is important even just from this perspective. However, we cannot forget that correction of nociceptive stimulation always affects the body’s autonomic functions and, therefore, specific rehabilitation alters circulation especially in the small pelvis area. This significantly contributes to the trophic conditions of an already anatomically compromised organ. In such cases, breathing pattern correction is important because the practice of

correct diaphragmatic breathing acts preventatively against functional deficits of the musculoskeletal system (especially correcting pelvic floor muscle tone and increasing the stability of the lumbar spine). Furthermore, in diaphragmatic breathing, the pressure parameters in the abdominal and pelvic areas are regularly and often altered, which leads to the movement and mobilization of the internal organ suspension system and, therefore, improvement in their mobility and motility (this applies to hollow internal organs). Musculoskeletal techniques and breathing pattern correction contribute to improvement in physiological parameters even in anatomically compromised structures in the small pelvis. Treatment rehabilitation has the most benefit in reproductive organ hypoplasia (physical therapy focuses specifically on improving circulation in the small pelvis) and in a retroverted uterus. Exercises for a Retroverted Uterus Sometimes, the following exercises, which relax the uterine position in the sagittal plane (meaning forward and backward), can assist in correcting the uterine position: In supine, calves are placed on a chair or a large exercise ball. The patient moves their pelvis away (upward) and then toward (downward) the mat. In supine, the patient moves their lower extremities behind their head and remains in this position for some time. The movement is repeated several times. The lower extremities can be in extension or slight knee flexion.

5.5 GYNECOLOGICAL SURGICAL PROCEDURES Gynecological surgical procedures are very diverse, starting with short, procedures lasting a few minutes and ending with extensive operations several hours long, during which the gynecologist works with a surgeon or a urologist. The surgical site – the internal reproductive organs – is approached either laparoscopically or classically, by an open approach either through the abdominal wall (laparotomy) or the vagina. Some operations only provide information about the explored organ (diagnostic procedures), others have a treatment effect (for example, a cyst removal or plastic corrections in incontinence). In some operations, the entire affected organ is removed. Gynecological surgeries also include procedures performed on the vulva or the breast. Small surgical procedures in gynecology include transcervical procedures on the uterus (diagnostic or surgical hysteroscopy, curettage). These procedures are not commonly indicated for rehabilitation. Rehabilitation treatment should be a component of comprehensive treatment after extensive surgical procedures. Extensive surgical procedures are classified based on the type of access: Abdominal laparotomic surgeries – procedures on uterine appendages, the body of the uterus, procedures involving a descended uterus and deviations, urogynecological and oncogynecological procedures Abdominal laparoscopic surgeries – planned (sterility, endometriosis, adhesions) or emergency (acute pain, ectopic pregnancy, etc.) diagnostic procedures and surgical procedures (the spectrum is identical to the laparotomic surgeries) Vaginal surgeries – surgeries on the external genital organs and the perineum, at the area of the vaginal opening, surgery of the vagina, cervix and the uterus and with urinary incontinence The decision whether the procedure will be administered

laparotomically, laparoscopically or vaginally depends on individual conditions. In the case of radical surgeries by laparotomy, the incisions can reach the xiphoid process, which can significantly disrupt the function of the abdominal wall. Pre- and Post-Surgical Rehabilitation If possible, rehabilitation should be initiated prior to surgery. This preparation should include patient education about the type of operation and exercises that will be performed during their recovery. It is also beneficial to begin fitness training because increased fitness prior to surgery improves and accelerates the patient’s subsequent recovery. Types of Exercises Prolonged Expiration and Diaphragmatic Breathing These exercises improve overall spinal stabilization, which contributes to the prevention of developing subsequent functional deficits (i.e., restrictions caused by lying for a longer period of time in a required position, etc.). Optimal caudal descent of the diaphragm during diaphragmatic breathing causes a shift in the organs in the direction of this movement, hence, mostly in the caudal-cranial direction. In this way, the suspension of the organs and their tissue are constantly stretched (with each breathing cycle), which can partially prevent possible adhesions and retraction of the healing tissue. Prevention of Thromboembolism The surgical position slows down lower extremity blood circulation and therefore, predisposes a patient to the development of thromboembolic disease. This is the reason why blood circulation needs to be assisted. This can be achieved by exercises involving the distal lower extremity joints and by lower extremity isometric contractions. The recommended exercises include toe flexion and extension in supine, ankle dorsiflexion and plantarflexion, circular ankle movements or alternately pressing the popliteal fossa toward the mat. Thromboembolic prevention also includes ace bandaging the lower extremities. The ace wrap is applied from the toes all the way to the thighs while decreasing the pressure of the bandage in a cranial

direction. The lower extremity needs to be elevated during bandaging. Coughing with Incision Support Administration of general anesthesia and intubation often causes respiratory tract irritation (sore throat, cough) and nausea. The respiratory pathways need to be cleared by coughing. Patients often avoid coughing because they feel an increase in intra-abdominal pressure, sudden activation of muscles surrounding the incision site and thus, pain. However, coughing can be done quite easily while supporting the incision. In supine with the lower extremities flexed (relaxed abdominal musculature), a patient after laparotomy stabilizes the surgical site with their palms and coughs at the end of expiration. In the case of vaginal surgery, the patient slightly draws in the rectum and the vagina prior to coughing to stabilize the pelvic floor and the perineum. Bed Mobility and Transfer Training Rolling in bed. The patient turns to the side via log rolling from supine. During transition, the knees and hips are slightly flexed. Transfer from bed. The patient turns to the side and shifts toward the side of the bed. Then, slowly lowers the lower legs out of bed and, at the same time, pushes up from their elbow and later the palm and the lower aspect of the upper extremity. This way, sitting is attained with minimal activity of the abdominal muscles. In sitting, the patient performs several inspirations and expirations without closing the eyes. This is followed by moving the ankles and knees. The patient can stand up and walk if no orthostatic hypotension is present. In the case of planned surgery through the vagina, the patients are not allowed to sit for several days. They are taught to transfer out of bed while omitting sitting. Muscle Activation and Strengthening in Correct Movement Patterns This method is always assessed on an individual basis based on the patient’s condition, movement capabilities, perception, movement coordination and the extent and nature of the surgical procedure. Post-Surgery

The goal of rehabilitation mainly includes the fastest restoration of the patient’s physical fitness and prevention of secondary changes. Rehabilitation is initiated as soon as possible, at best, the day of surgery and is based on the patient’s age, psychological and physical condition, and the extent and nature of the surgical procedure. The Day of Surgery On the day of surgery, the patient is under the influence of analgesics and anesthetics. Rehabilitation indications or contraindications are determined by the physician. The exercise session is short, but can be repeated several times. Method: Perform thromboembolic prevention Coughing with incision site support Breathing exercises with prolonged expiration (in this way, the body disposes of the anesthetics with more ease) Day 1 after Surgery The first day after surgery, the exercises should take at least 15 minutes three times per day. The exercises are performed in supine and in sidelying. Method: Exercises from the previous day are repeated Dynamic breathing exercises are performed with upper extremity co-activation – for example, upper extremity flexion in supine during inspiration and a return to the starting position with arms along the body during expiration Active movement of the larger lower extremity joints – for example, knee and hip flexion via heel slides in supine Isometric exercises (gluteal and thigh muscles, etc.) Rolling to the side Out of bed transfer Day 2 and the Following Days after Vaginal Operations During this time, the patients generally have a catheter (for several days). Exercises that do not irritate the urinary tract by moving the

catheter are selected to prevent possible urinary tract infection. Method: Hip movements and pelvic floor contractions are avoided; exercises can also be performed in prone When the catheter is removed, pelvic floor strengthening exercises are appropriate. At first, the patients attempt an isolated contraction of the pelvic floor (drawing in of the vagina, urethra, rectum) and later, a coordinated activation of the deep muscle stabilization system, especially co-contraction of the diaphragm, abdominal muscles and the pelvic floor. Starting day 5, standing exercises can be performed if the catheter has been removed Day 2 after Surgeries Using the Abdominal Approach The next day after surgeries with abdominal access, exercises leading to intense abdominal muscle activation are avoided. Method: Exercises from the previous day are repeated Pelvic floor strengthening exercises Exercises improving circulation of the pelvic area Exercises with greater range of motion in the hip joints Day 3 and the Following Days after Surgeries using Abdominal Approach Exercises from the previous days are repeated Exercises and positioning in prone – designed to stretch abdominal muscles and the incision, prevention of adhesions, improving intestinal peristalsis Incision care (after suture removal) – from the very beginning, soft tissue mobilization techniques at the site of the incision and its surroundings need to be performed. Also, development of soft tissue adhesions at the surgical site needs to be prevented. Also, incisions following laparoscopy should not be overlooked. They appear to be very small on the surface of the skin, but they reach very deep and also into more distant areas from the area of the

actual incision. For this reason, from a soft tissue mobilization perspective, it is important to monitor the resistance in the subcutaneous and deep tissues, as well as, in the areas where the incision is not directly on top of the skin as the surgical procedure under the skin is more extensive. In this case, pressure massage or a skin fold stretch techniques are used. These techniques result in increased localized circulation and a stretch of the healing tissue. In an older incision, this especially involves stretching the scarred connective tissue. Ambulation with trunk flexion should be avoided After Discharge The patient should be educated on the importance of regular exercise in a home setting with emphasis on correct pelvic floor function for the next two months. Post-Operative Complications (Post-Surgical Incisions) The surgical incision in gynecological laparotomies can vary to an extent. After the surgery, the abdominal cavity is sutured in layers (a technique closing all layers at once is only rarely used for an abdominal wall closure), which include the peritoneum, muscle layer (note: today, muscles are not sutured in gynecologic laparotomies), muscle fascia, subcutaneous tissue and the skin. A scar is the end result of wound healing and of an incomplete regeneration of damaged tissue. In its nature, it is a connective tissue structure that is found at all soft tissue levels from the surface to the deep layers based on the extent of the surgical procedure. The scar tissue and the surrounding (original) tissue differ in many aspects. The scar tissue is always “less valuable” than the original tissue it has replaced. Its anatomical structure is very different and it contains only a small number of functional cells and vessels. In contrast to the skin or the muscle, it nearly does not contain nearly the number of elastic fibers, which disrupts the continuity and elasticity of the given region. With time, the scar tissue has a tendency to stiffen and shrink (with accentuates the biomechanical differences between the scar and healthy tissue). Problems linked to a scar (and its irritation of the surroundings) are often manifested after a longer time period

following a surgical procedure. If the incision has healed well (physiologically), soft tissue mobility is not significantly affected. These incisions are usually clinically irrelevant. Following abdominal surgeries, however, problematic scars often develop that do disrupt soft tissue functions. These scars are usually referred to as adhesive or active scars. Active Scar An active scar is manifested by increased skin friction and poor skin flexibility, thickened subcutaneous fold that resists stretching and decreased mobility of the deep soft tissue layers. Pain with palpation is also typical (a feeling similar to pin prickling or burning) with scar tissue stretch as well as hyposensitivity of the scar and its surroundings. An active scar in the abdominal region is diagnosed based on palpatory assessment of mobility of the individual layers of the abdominal wall (while using the release phenomenon). In postsurgical scars, the entire abdominal region needs to be assessed because changes in the deeper layers may not accurately correspond to the location of the incision on the skin. A characteristic sign of scars in the abdominal wall area includes a limitation in trunk backward bending, which patients perceive as pain in the lumbar region. An active incision becomes a source of nociception that reflexively influences the reaction of the body and directly reflects in movement system function. The activity is not only local, but systemic in nature because the sensorimotor loops are polysynaptic. Localized and disruptive afferentation can reach a motor response, not only at a corresponding segment, but also in the entire movement pattern. This reaction is completely automatic and independent of the patient’s will. Its purpose is to specifically affect the position or movement of an affected segment. This leads to reflexive pre-programming of muscle tone that results in decreased pulling in the scar area and decreased afferent irritation. An active scar in the abdominal region can cause various clinical issues. Most often, it contributes to an onset of painful conditions that are similar to a lumbar vertebrogenic pain syndrome. That is the

reason why active scars need to be addressed during clinical treatment. Treatment of post-surgical active scars is performed manually on the scar and the surrounding tissue. The extent depends on the functional finding. During treatment, a very gentle pressure from the fingers is used until the barrier is reached. Then, the therapist waits until it releases. Effective Techniques: Skin stretch – superficial layer Connective tissue fold stretch – deeper connective tissue layers Applying pressure – deeper connective tissue layers Deep tissue (fasciae) shifting against the bone Hot towel roll application

5.6 URINARY INCONTINENCE Martina Hoskovcová Urinary incontinence is a state of unintentional (non-volitional) leakage of urine. According to the International Continence Society (ICS), extra-urethral and urethral incontinence can be distinguished and classified into four categories as follows: Urge incontinence denotes non-volitional leakage of urine linked to an urgency to urinate. Every urgency; however, does not always result in urinary leakage or urge incontinence. This is why the term hyperactive bladder with incontinence or without has been used lately. Urgency can be related to two types of functional deficits. Motor urgency is caused by non-inhibited contractions of the detrusor muscle and sensory urgency by its hyperactivity; Genuine stress incontinence (GSI) is a condition of non-volitional urinary leakage during increased intra-abdominal pressure, during which the intravesical pressure passively dominates the maximal urethral pressure without a simultaneous contraction of the detrusor muscle. The patient reports urinary leakage with increased physical activity, positional changes, coughing, laughing, sneezing, etc. Mixed form of incontinence – the urge and stress components of urinary leakage are present Reflexive incontinence means urinary leakage as a result of detrusor muscle hyperreflexia due to a neurogenic disturbance in the lower urinary tract. Incontinence from overflowing means any non-volitional urinary leakage with excessive distention of the urinary bladder. Diagnosis In order to treat incontinence, the cause of the spontaneous loss of urine needs to be established and a correct treatment method selected. An accurate diagnosis is based on careful anamnesis, physical exam, urine testing, clinical stress and special tests, urogynecological and

urodynamic assessments, imaging testing and possibly cystoscopy. Also, a neurological exam of skin sensation in the perianogenital region, anal reflex assessment and volitional contraction of the anal sphincter are all necessary components. Treatment Treatment of urinary incontinence is based on the type of incontinence. This can be determined by a set of diagnostic methods, most often a urodynamic examination. Stress incontinence can be treated surgically. Surgical interventions for other types of incontinence are contraindicated. In urge and reflex incontinence, a surgical treatment is performed only in special circumstances. Surgery can be performed in a mixed form of stress and urge incontinence; however, with worse outcomes if the stress factors have a greater contribution to its onset. In severe types of stress incontinence, surgical intervention is indicated while other cases utilize physical therapy methods. Behavioral therapy (BT) or therapy directed toward changes in habits, behaviors and lifestyle is an essential component of treatment in urogynecology and requires the patient’s thorough cooperation. An educational interview is an unequivocally unique means for establishing a close relationship with a patient and gaining their trust. The factors with demonstrable effect on incontinence include body weight reduction in the case of obesity, limiting excessive physical activity (i.e., prolonged, repeated heavy object lifting), sufficient, but controlled fluid intake and regular bowel movement. Also, it includes adequate athletic activity, a home exercise program, urinary dairy, establishing suitable conditions for continence in a home setting, eliminating stress, allowing sufficient time for relaxation and optimal urination and, last but not least, correct movement patterns. Questionable effects on incontinence include smoking, methylxantine and caffeine intake, number of births for females, etc. Rehabilitation Physical therapy is based on the utilization of pelvic floor muscle

activation, the use of biological feedback and electrical stimulation to prevent a sudden decrease in urethral pressure by altered morphology, position, neuromuscular function and pelvic floor muscle coordination. In a physiological scenario, during increased intraabdominal pressure (coughing, laughing, etc.), a simultaneous reflexive contraction of the pelvic floor muscles occurs and a transfer of intra-abdominal pressure into the proximal third of the urethra. In a pathological scenario, urethral hypermobility occurs as a result of pubourethral ligament relaxation and a loss of supportive function of the pelvic floor muscles. With increased intra-abdominal pressure, the transfer of this pressure to the proximal third of the urethra does not occur and the urethral pressure is lower than the intravesical pressure, which results in involuntary urinary leakage. The first mention of physical therapy implementation in the treatment of urinary incontinence was seen in 1948 by an American gynecologist A.H. Kegel. Under his guidance, a patient performed several quick contractions of the pelvic floor. Their effectiveness was controlled intra-vaginally by an inserted finger. This gynecologist recommended a combination of exercises with biofeedback with a Kegel perineometer and the original studies reported 84% success with this method. A crucial weakness of his studies includes the fact that he did not distinguish between urge, stress and mixed types of incontinence. Currently, the following algorithm of examination and treatment of urinary incontinence is used. Following the establishment of a diagnosis by a urologist or a urogynecologist, the physical therapist performs a complete kinesiologic analysis with the focus on pelvic alignment in all three planes, assessment of the coccyx, sacroiliac joint and the ligamentous structures. Then, the abdominal wall and the soft tissues are examined by palpation. Attention is paid specifically to the examination for diastasis recti, presence of trigger points and active scars that elicit un-coordinated contraction of the abdominal wall and disrupt the co-activation of the diaphragm, deep back muscles and the pelvic floor muscles during spinal stabilization and during maneuvers that increase intra-abdominal pressure. The important component of

palpation is the assessment of active scars after episiotomy and pelvic reconstruction procedures that can cause pain, dysfunctional urination and constipation, and pain during sexual intercourse. The actual assessment of pelvic floor muscles consists of observation (aspection), palpation and muscle motor function assessment. Observation is performed in a gynecological position. The patient is asked to increase their intra-abdominal pressure, push down into the pelvis and contract the pelvic floor muscles. If there is minimal or no activity or, after the movement is initiated, perineal shaking is observed as a sign of muscle incoordination, then dysfunction and, especially, sensitivity with palpation can be expected. For this reason, palpation should be very gentle. Assessment of motor function of the pelvic floor muscles can be performed using either a vaginal or rectal approach. The assessment uses the PERFECT schema that identifies the following parameters: contraction performance and strength (Performance), duration of contraction (Endurance), Repetitions, Fast contractions, Elevation, Co-contraction and Timing of the reflexive contraction of the pelvic floor muscles. When the motor assessment is completed, the ability of the pelvic floor muscles to relax should be assessed. A perioneometer can be used to complement and objectivize the physical assessment of the pelvic floor. Modern instruments allow simultaneous administration of biofeedback through a vaginal or rectal probe in combination with electrical stimulation. Another objectification can be done by pelvic floor ultrasound or experimentally by dynamic MRI. Relaxation Techniques Relaxation techniques are the first therapeutic step if the initial evaluation reveals the presence of scars, increased muscle tone or TrPs. The techniques include scar, myofascial and TrPs release, manual therapy via the rectum and other relaxation approaches. These approaches must be comprehensive rather than localized because muscle tone is influenced by the entire nervous system, especially the limbic system. Mood swings, chronic stress activity and

fatigue cause decreased movement adjustment, limited movement variety and reduced reaction time. The overall body posture changes. The head is in protraction and appears to be pulled between the shoulders. Typical increased muscle tone in certain predilected areas can be observed, such as the mimetic, neck and pelvic floor muscles. In such scenarios, relaxation techniques that focus on affecting the limbic system (positive relationship between the therapist and the patient, psychotherapy, autogenic training, acupuncture, etc.) are implemented. Approximately 30–40% of patients cannot fully activate their pelvic floor musculature despite the absence of any apparent body deficit, such as muscle atrophy or dysfunction in innervation. Most often, they activate the abdominal, gluteal or adductor musculature with minimal or no activity of the pelvic floor muscles. In such patients, treatment focuses on isolated muscle contractions and, later, coordination and inclusion of such muscles into correct patterns to ensure urinary continence. For this training, manual biofeedback, visual imaging, EMG biofeedback and neurophysiologically based methods are used. If the patient is unable to contract the pelvic floor muscles, treatment for incontinence is initiated by electrical stimulation with gradual transition to a combined program, in which the proportionately increasing ability to control the pelvic floor muscles increases the biofeedback contribution to treatment. During electrical stimulation for stress incontinence, a frequency around 50 Hz is the most beneficial because it improves tone and contractile ability of the pelvic floor muscles. Then, a pelvic floor muscle contraction is practiced in scenarios involving increased intraabdominal pressure (coughing, laughing, positional changes, lifting heavy objects, etc.). Automatic activation of the pelvic floor muscles in the above mentioned situations is the final goal of treatment. Physical Therapy for Hyperactive Bladder and Reflex Incontinence To utilize physical therapy for the treatment of hyperactive bladder and reflex incontinence, it needs to be established that functional electrical stimulation and voluntary contraction of the pelvic floor muscles elicit inhibition of the detrusor muscle. This is most likely

occurring through a “volitional inhibition of the urinary reflex.” The reciprocal inhibition reflex passes through the cerebral control region and then activates the motor neurons in the anterior spinal horn to voluntary contract the pelvic floor muscles and, at the same time, inhibits the parasympathetic excitatory pathways, which inhibit the contraction of the hyperactive detrusor. In physical therapy treatment for a hyperactive bladder, besides the practice of isolated activation of the pelvic floor muscles, behavioral therapy is implemented. This is called bladder emptying training. This treatment method is based on the presumption of a psychosomatic etiology of the problem. Loss of inhibitory cortical stimuli developed by a behavior, which is normally present over an entire life, is considered a cause of an unstable detrusor. Prolonging the intervals between urinations serves as the basis for restoration of this inhibition. Careful documentation of urination to assess the achieved results serves as a successful foundation of treatment. Most authors recommend a 4–6 week education cycle once the basic work with the pelvic floor muscles has been completed. Another option in the treatment of a hyperactive bladder is the implementation of electrical stimulation with a 10 Hz frequency, which causes reflexive contraction of the striated pelvic floor muscles accompanied by reflexive inhibition of the detrusor muscles. Rehabilitation Phases and Timing Individual phases and timing of rehabilitation treatment for incontinence are strictly individual. In phase I, the focus is on initial evaluation, behavioral therapy, relaxation techniques, optimization of muscle imbalance and awareness. Gradually, a transition is made toward the treatment of the pelvic floor muscles. After re-assessment of the patient’s current subjective and objective condition, the treatment continues with an emphasis on integration of the pelvic floor muscles into movement patterns and their activation in challenging situations. The final treatment phase includes final reassessment and home exercise program review, which should become

a routine part of the patient’s life. An insufficient education of the general and educated public is continuously being encountered. Improper recommendations and ingrained dogmas, such as strengthening the pelvic floor muscles by interrupting the stream of urine (which is often the primary recommendation of healthcare aides) or by exercising according to handouts that cannot address the patient’s individual problems can often lead to treatment failure. Rehabilitation for urinary incontinence provides a solution to a great number of such problems and should become a vital component in the treatment of incontinence. However, a perfect knowledge of the problem and, specifically, individual physical therapy under the guidance of a qualified physical therapist are essential prerequisites for successful treatment.

5.7 PREGNANCY, BIRTH AND THE POSTPARTUM (POSTNATAL) PERIOD Martina Ježková, Pavel Kolář

PREGNANCY In humans, pregnancy lasts 280 days (10 lunar months) counted from the first day of the last menstruation. Calculated from the day of conception, pregnancy lasts 267 days (38 weeks). A due date determined in this way is approximate and fluctuates within ± 10 days. Pregnancy is divided into 3 periods: First trimester (weeks 1–12), second trimester (weeks 13–28) and the third trimester (29–40 weeks). Pregnancy presents a strain on the mother’s body primarily due to the need to provide nutrition for the developing fetus. The mother’s body adapts to this need by altering a number of physiological functions elicited by hormonal stimuli from the hypothalamus as well as stimuli from the fetoplacental unit. During pregnancy, the uterus serves as a capsule ensuring development of the egg. During child birth, it fulfills the role of an organ that propels the fetus from it into the birth canal. The uterus is anatomically and functionally structured to meet this purpose and adapts during pregnancy. It grows from 50 grams prior to pregnancy to 900–1,200 grams at the end of pregnancy and its volume increases from approximately 5 ml prior to pregnancy to 4,500–5,000 ml by the end of pregnancy. Its muscle fiber architecture changes and completes its formation by the end of the pregnancy. Muscle fibers run in the uterine wall in spirals organized in several layers. The vascular supply multiplies and blood flow increases. The urinary bladder is pulled up above the pubic symphysis due to an expanded lower uterine segment. Changes are not only found in the reproductive system, but involve the pregnant woman’s body as a whole.

BIRTH

Birth usually begins by the onset of regular and effective activity of the uterus that results in the shortening of the cervix. The intervals between the uterine contractions gradually shorten, their intensity and duration grow; they increase with movement (walking); cause pain in the lower abdominal area and sacral region and result in shortening of the cervix and, ultimately, dilation of the cervix. The actual course of birth is divided into several phases called birth periods, which are characterized by strictly defined processes: The first stage of labor – opening period begins at the onset of regular uterine contractions affecting the opening of the birth canal and ending with the dilation of the cervix. In first time mothers, it takes on average 8–12 hours. In women with previous births, it takes 4–8 hours. The beginning of birth is not always easy to determine. The second stage of labor – the pushing stage begins with full dilation of the cervix and ends with birth of the baby. In first time mothers, it can take 1–1.5 hours and in previous mothers, about 20– 30 minutes. The uterine contractions continue to strengthen and lengthen and become more frequent. The head of the baby descending into the pelvic floor is perceived by the mother as a foreign body stimulating reflexive pushing by using abdominal bracing. The third stage of labor – placenta delivery includes a sequence of three processes: 1. Separation of the placenta, 2. Delivery of the placenta, 3. Control of bleeding. Although, it only lasts about 15–20 minutes, this is a period of frequent complications (especially bleeding). When the placenta separates, bleeding occurs and the physiological blood loss is usually 100–350 ml. During an active third stage of labor (administration of uterotonic medication, such as oxytocin), the duration of blood loss shortens to 3–10 minutes and blood loss decreases to 50-100 ml. After delivery of the baby, the uterus retracts and accommodates to the decreased content. It is spherical, stiff and reaches to the umbilicus. Following a several-minute-long resting phase, the uterus begins to retract (sometimes by painful contractions), which separates

the placenta from the uterine wall as well as the superficial layer of the uterine mucous membrane.

POSTPARTUM Postpartum is a six week period after birth, during which the anatomical and functional changes of a pregnant body gradually return to its original state. During this time, uterine involution occurs as well as decreased blood circulation of the external genitals, loss of puffiness and skin pigmentation and possible varicosities decrease or completely disappear. The biomechanical properties of the movement system also gradually change. Rehabilitation during Pregnancy With growth of the fetus and uterine volume, a biomechanical and reflexive limitation of the caudal movement of the diaphragm occurs. This significantly restricts diaphragmatic breathing and the accessory breathing muscles become more engaged during breathing. There is an increased tendency toward accessory breathing. Recruitment of accessory muscles functionally strains their insertion sites (especially in the cervical and upper thoracic regions). Maintenance and facilitation of quality diaphragmatic breathing become the pillars of protective principles during pregnancy. Training and restoration of the correct diaphragmatic function are also very important for the birth itself. The diaphragm together with the abdominal muscles contributing to abdominal bracing are the basic components influencing the increase in intra-abdominal pressure. Its correct function and tone have an important effect on pushing the fetus during the second stage of labor. During pregnancy, diastasis recti either develops or enlarges in many women. This occurs mainly because of increased connective tissue laxity. The separation in the linea alba can subsequently effect the function of the abdominal muscles and the deep spinal stabilization system.

During pregnancy, the goal of rehabilitation is to maintain the body in optimal fitness physically and psychologically and prepare the pregnant woman for birth so that its course is as smooth as possible. Neurovegetative changes can be influenced similarly to premenstrual syndrome or menopause by diverting attention during exercise. Physical activity also contributes to “fine tuning” of the autonomic system because in exercising individuals, the resting activity of the parasympathetic system increases, which decreases the patient’s stress level. Gentle mobilization and treatment of muscle imbalances decrease nociceptive afferentation, which is one of the main causes of excessive autonomic reactions (increased perspiration, pulse, etc.). During pregnancy, the breast glands become enlarged. A woman’s breasts increase, not only in volume but also in weight, which can overload the thoracic spine given the increased ligamentous laxity in pregnancy. Functional deficits (especially restrictions) develop in the thoracic spine and the costovertebral joints, which can become chained within the movement system. Limitations in the thoracic wall and in thoracic spine dynamics can lead to pectoral musculature shortening, which, once again, increases pain and decreases the thoracic wall dynamics. During pregnancy, the secretion of progesterone and relaxin increases, which causes soft tissue laxity (muscle and connective tissues). This occurs to ease delivery (relaxation of pelvic floor ligaments, with the greatest effect on the ligaments of the coccyx and symphysis). However, not just the pelvic ligaments relax. Other ligaments in the body which can affect support structures, such as the foot arch, spinal axis, etc., also relax. Therefore, in a pregnant woman, flat foot can develop as a result of a combination of more factors including relaxation of the connective tissues of the foot arch, a sudden increase in body weight and a shift in the center of mass. Within physical therapy treatment, emphasis is placed on facilitation of musculature that contributes to arch formation. Also, trunk and pelvic muscles are strengthened.

A growing uterus, common abdominal muscle weakening and limited work of the abdominal brace muscles leads to slower intestinal peristalsis. A decreased ability to defecate can lead to the development of pre-delivery hemorrhoids, cause feelings of fullness, loss of appetite, etc. Activation of the transversus abdominis, the diaphragm and the pelvic floor muscles contributes to addressing such problems. Limited diaphragm function (that functions as an external lower esophageal sphincter) and pressure of the uterus on the intestines and the stomach result in an increased occurrence of gastroesophageal reflux in pregnant women. This dysfunction often persists for a long time after delivery and sometimes worsens with time. Pregnancy, in this case, acts as a trigger. Here, once again, the activation of the diaphragm is beneficial as well as careful treatment of reflexive changes in the movement system, especially in the mid-thoracic spine and ribs 4-7. During pregnancy, the uterus reaches approximately 30 cm in length and its volume presses on the venous return from the lower extremities. Blood pools in the veins leading to the development of varicosities, a feeling of heaviness in legs and sometimes also pain, especially during movement, during which the limited venous return is most pronounced. Lower extremity positioning, vascular exercises and unweighting of a pregnant stomach by a pregnancy belt are all utilized as treatment and prevention. The uterus also pushes the diaphragm upward and causes a physiologically tilted position of the heart and pregnancy dyspnea. Lung vital capacity decreases. Breathing exercises and correct diaphragm activation are used to preserve thoracic flexibility. During pregnancy, the pelvic floor needs to withstand greater pressures given the increasing weight of the uterus. For pregnancy and delivery, it is important for the pelvic floor muscles to have the correct tone and flexibility, so that they can perform their functions. During exercise, these muscles are trained to contract as well as relax.

During pregnancy, the abdominal muscles need to significantly stretch for the abdomen to adapt to the size of the uterus. At the same time, however, the baby should be maintained as close as possible to the spine so that the lumbar spine is exposed to the least amount of pulling and its stability is the least affected. During pregnancy, two types of strengthening activities of the deep stabilization system are distinguished. The first is classic, which supports correct activity and a flattening of the diaphragm in continuity with the activity of the abdominal and pelvic floor muscles. This functional synergy stabilizes the spine from the ventral side through intra-abdominal pressure and positions the diaphragm together with the pelvic floor into a horizontal position. This parallel position cannot be reached in advanced stages of pregnancy. In the last trimester (3 weeks prior to delivery), the deep spinal stabilization system is trained to be used in the second stage of labor. The same activity is practiced; however, with the different goal being that with increased intra-abdominal pressure, the pelvic floor is to be as relaxed as possible. In this way, the correctly activated diaphragm which is leaning on the punctum fixum in the form of intra-abdominal pressure, can flatten even more and act as a piston following the craniocaudal contraction of the uterus and help push the baby out through the birth canal. Time Sequence of a Rehabilitation Plan for Pregnant Women First Trimester: Continue with exercise that the female is used to Relaxation and activation of pelvic floor muscles Practice diaphragmatic breathing Activation of the deep stabilization system Activation of foot arch and sensorimotor stimulation training Pectoral muscle strengthening Pelvic stabilizer strengthening Jumping, suspension and fast running are contraindicated Caution is paid during the “menstruation period” because bleeding from the uterus can occur

Second Trimester: Repeat the exercises from the first trimester Lower extremity positioning exercises Exercises to relax hip joints Gentle strengthening of the abdominal muscles and deep stabilization system Exercises while holding in breath Prone exercises are omitted Third Trimester: Exercises from the second trimester are repeated; Exercise intensity decreases; Special exercises important for delivery are implemented In the first stage of labor, the patient practices deep breathing (performed during a contraction for greater oxygenation of the fetus) and performs unweighting maneuvers to relax the hip joints and pelvic floor, for example, through a wide stance in standing or with small hip swinging performed during walking. A wide based squat with the hands supported on the bed is also included. Transition from kneeling to sitting between the heels (W-sitting) is also included. Bouncing and circular movement of the pelvis on a large exercise ball are performed. Superficial breathing is included as well (for breathing during contractions, during which the birthing mother feels the need to push, but is not allowed to push quite yet). In the second stage of labor, it is important to practice positions and methods for delivery. The practice of inspiration, breath holding and pushing into the rectum (second activation of the deep stabilization system with pelvic floor relaxation) is practiced three weeks prior to delivery. Rehabilitation during Postpartum Exercises begin 12–24 hours after delivery. Contraindications include fever and symphysiolysis. Exercise Goals: Facilitation of blood circulation and prevention of thromboembolic

conditions Accelerate retraction and correct positioning of the uterus Strengthening of muscles that become weak during pregnancy and delivery Facilitate lactation by activation of pectoral musculature Time Sequence of the Exercises: Day 1: Breathing exercises Exercises to prevent thromboembolic conditions Pelvic floor activation Pectoral muscle activation Day 2 and 3: Previous exercises with greater intensity Gentle strengthening of abdominal musculature and the deep spinal stabilization system Day 4: Repetition of exercises Increased intensity of exercises to strengthen the abdominal musculature Practice of correct body posture Caesarian Section Rehabilitation following a C-section occurs in the same manner as for surgeries with an abdominal approach. Pectoral muscle strengthening is added. Diastasis Recti Sometimes, the abdominal muscles separate at the linea alba during delivery. The goal of rehabilitation is the correct activation of the deep stabilization system and the oblique abdominal chains. The most important appears to be activation of the transverse abdominis, which directly influences the position of the internal organs and prevents their entrance into the space between the vertical abdominal muscles. Symphysiolysis Separation of the pubic symphysis is caused by gestational relaxation

of the structural connections and ligaments in the pelvic area, sacroiliac joint relaxation, and the weakening of the ligaments and pelvic floor muscles. The goal of physical therapy is to strengthen the pelvic floor muscles, gluteals, abdominals and deep stabilization system. Exercises that stretch the pelvic floor muscles and soft tissues are contraindicated. In a complete symphysiolysis, axial loading of the pelvis (sitting, standing) is also initially contraindicated.

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Lewit K. Manipulační léčba v myoskeletální medicíně. 5. přeprac. vyd. Praha: Sdělovací technika 2003. Martan A. Novinky v léčbě inkontinence moči žen. Sestra (mimo​řádná příloha) 2005; 7: 8. Martan A, et al. Inkontinence moči u žen a její medikametózní léčba. 2. vyd. Praha: Maxdorf 2006. Melzack R. The Myth of Painless Childbirth (The John J. Bonica lecture). Pain 1984; 19: 321– 337. Melzack R. Záhada bolesti. Praha: Avicenum 1978. Poněšický J. Psychosomatika pro lékaře, psychoterapeuty i laiky. Praha: Triton 2002. Rob L, Martan, Citterbart K. Gynekologie. 2., dopl. a přeprac. vyd. Praha: Galén–Karolinum 2008. Rovner ES, Gomes CM, Trigo-Rocha FE, et al. Evaluation and Treatment of the Overactive Bladder. Rev Hosp Clin 2002; 57(1): 39–48. Shafik A, Shafik IA. Overactive Bladder Inhibition in Response to Pelvic Floor Muscle Exercises. World J Urol 2003; 20(6): 374–377. Epub 2003 Apr 4. Smolíková L, Máček M. Fyzioterapie a pohybová léčba u chronic​kých plicních onemocnění. Praha: Blue Wings 2006. Strusková O, Novotná J. Metoda Ludmily Mojžíšové – cesta k přirozenému otěhotnění. Praha: Ivo Železný 2002. Véle F. Kineziologie pro klinickou praxi. Praha: Grada Avicenum 1997. Wall PD, Melzack R. Textbook of Pain. 3rd ed. Edinburgh: Churchill Livingstone 1994. Zwinger A, et al. Porodnictví. Praha: Galén 2004.

6 TREATMENT REHABILITATION IN PAIN MANAGEMENT Jiří Kozák, Pavel Kolář Pain is a natural phenomenon protecting the body from harm or injury. Physiological pain has a protective function and ensures the individual’s integrity. As a basic phenomenon of protection against harm, pain can act extensively and the body reacts to it comprehensively. The somatic, as well as psychological, aspects react to pain and in both areas, the reactions to pain are important and cannot be ignored. Often, the origin of an uncontrolled pain lies within a person’s psyche and the person’s psychological state is highly responsible for the level of pain intensity and experience. In general, the state of “psychological well-being” substantially reflects into physical health and, as shown by psychosomatic treatment, the mental and physical processes are so closely interlinked that trying to separate them can often be misleading. For this reason, both components need to be understood as one unit hence, psychosomatic health. For this reason, an individual and their health need to always be viewed holistically (wholesome). When searching for the true causes of a disease and the patient’s complaints, looking for the origin in both of these fundamental components is important, as well as, taking into consideration the patient’s psychological well-being.

6.1 CLASSIFICATION OF PAIN Acute Pain Acute pain has a more narrow definition in a sense of body reaction signaling tissue damage. It has a physiological meaning and assists in body repair, healing and as an escape from a stressful event. This reaction is known as “fight or flight.” Acute pain is a direct consequence to a painful event. It is defined as symptoms developed based on tissue damage or disease. Nonetheless, pain lasts for a long time after it has acted as a helpful warning signal and persists even after the affected tissue has healed. Chronic pain is not directly linked to the initial injury or disease; rather, it is a consequence of secondary changes, including the ones that occur during a systemic pain reaction. Chronic pain Chronic pain is a longer lasting state, which completely lacks purposeful physiological character and acts negatively on the person’s biological, psychological and social aspects. The primarily sympathetic reactions of acute pain in the form of a flight reaction (dilated pupils, increased blood pressure, etc.) are not present here. Psychological deficits occur and are described as “pain behavior”; social problems, personality and character changes dominate. Classically, the duration of chronic pain is described as 3–6 months; however, this time is very individually based and, in some cases, pain behavior is observed over a much shorter time period and, in contrast, some “resilient” individuals do not show signs of pain behavior even many months after. Chronic pain, in contrast to acute pain, displays different physiological mechanisms and develops a comprehensive emergency state of somatic and psychosocial changes that are an integral part of the chronic pain state and contribute to the challenge of a patient suffering from pain.

6.2 FOUNDATIONS OF NEUROPHYSIOLOGIC PAIN Pain is envisioned as independent of other sensorimotor perceptions and it has its own physiological mechanisms. It needs to be understood and treated as an independent nosologic unit. Nocisensors (nociceptors) – pain receptors – are free nerve endings found in the skin (superficial pain – sharp, defined), muscles, joints and bones (deep pain – dull, diffuse). Several types of nociceptors are distinguished: Mechanoreceptors – react to a low threshold mechanical stimuli Thermoreceptors – react to increased temperature beyond physiological values Polymodal nociceptors – react to mechanical, chemical and thermal stimulation Nociceptor stimulation shows many similar features of an inflammatory process. The stimulation is primarily a result of prostaglandins, histamines, serotonin, kinines and substance P activity. Nociceptors alter their threshold and it is possible to elicit their sensitization and desensitization. Terms “silent” or “hidden” nociceptors are known, which only react to strong painful stimuli. The transmission of pain information from the nociceptors is mediated by non-myelinated C fibers or lightly myelinated Aδ fibers. Both types of fibers run into the posterior spinal horns where Rexed laminae I–X are found. Laminae I, II, III and V are important for pain transmission. Somatosensory fiber endings are found in the superficial layers and the pain fibers of visceral origin are found deeper. At the spinal cord level, the influence of pain impulses is mainly a result of the sympathetic system. Intersegmental connection of Aδ and C fibers occurs in Lissauer’s tract. In this region, a complex regulatory system with important function of the substantial gelatinosa Rolandi and the transmission cells are found. A theory respected to this day has been formatted about the transfer of pain

impulses (by Wall and Melzack – Gate control) known as the “Gate control theory of pain.” It is based on a finding that fast fibers (Aα) are thicker than slow fibers (Aδ and C). It is based on a principle that fast fibers can modulate the activity of the slower fibers through transmission cells and in this way close the “gate” for pain transfer by the slower fibers. To better understand this theory, examples from acupuncture and rehabilitation methods have been used that stimulate tactile receptors (Aα fibers) to suppress pain from the deep receptors. Although research done in the last few years did not completely confirm all “gate theory” presumptions, it has a huge didactic value to this day. Spinal cord transmission of pain is mediated by spinothalamic and spinoreticulothalamic tracts. These tracts, as suggested by their name, lead to the reticular formation of the brain stem and then into the limbic system and the medial thalamus. The thalamus is considered the most important nociceptive region of the CNS. Aδ fibers transmit fast and sharp pain into the ventrobasal thalamus and C fibers transmit prolonged and dull pain and terminate in the intralaminar nuclei of the thalamus. The cerebral cortex contributes to nociceptive signal processing and it has a vital function in the processing of pain impulses. Other CNS structures interlinked with reticular formation become important, especially in chronic pain conditions. These include the limbic system, hypothalamus and locus coeruleus, responsible for emotional and affective components of pain. Endogenic mechanisms and descending inhibitory systems influence pain in the “opposite direction” by decreasing activity of the central nociceptive system, or inhibiting pain perceptions. In the CNS, the periaqueductal gray of the diencephalon and raphe nuclei in the reticular formation are the most important regions with inhibitory activity. If electric stimulation is performed in these areas, obvious analgesia occurs. The same effect can be achieved by administration of opiates. The endogenic opiate system significantly contributes to the system of pain control by its receptors and ligands (endorphins, encephalines, dynorphines); simultaneously, these substances act as transmitters of the descending inhibitory system.

6.3 PAIN MANAGEMENT Rehabilitation Rehabilitation is an independent discipline that treats various forms of acute and chronic pain conditions by non-pharmaceutical methods and by minimal use of invasive techniques. It utilizes a wide range of rehabilitation techniques and methods based on a detailed musculoskeletal assessment. Common techniques used in rehabilitation medicine also include methods based on physical agents: electrical current, direct or acupuncture-based laser, magnetic therapy, liquid media and ultrasound. Neradilek (2000) divides the most common therapeutic rehabilitation approaches into those influenced by heat, cold and electrotherapy. Other therapeutic methods include traction, manual therapy and therapeutic exercise. Rehabilitation teams should cooperate closely with higher level pain clinics and, in turn, a pain specialist must be included in the rehabilitation team. After the patient’s assessment, pain clinics mostly use mobilization techniques, traction, movement pattern re-education and the practice of relaxation methods. Rehabilitation methods also include education and specific spine exercises even, for example, Chinese-based exercises. Pain intervention at a rehabilitation clinic is also beneficial because it can facilitate the use of rehabilitation methods with specific pain control, such as rehabilitation of a patient with low back pain under simultaneous continuous epidural analgesia or a brachial plexus block and subsequent upper extremity rehabilitation under analgesia with good muscle relaxation. Non-Pharmaceutical Treatment Modalities for Patients with Chronic Pain Patients with chronic pain require a comprehensive and team treatment approach that is provided, for example, by interdisciplinary structured Centers for Pain Management. The main goal of treatment rehabilitation is to guide the patients toward an active attitude in regards to therapy for a painful condition and toward an awareness of the need to improve their movement options and fitness.

Chronic pain is multifactorial and its manifestations are very variable among individuals. In addition, the subjective perception is significantly influenced by prolonged use of analgesics and pain centralization, which biases the feedback between the patient and the therapist. For this reason, it is difficult to recommend specific modalities. The patient’s previous experience plays an important part in selecting a specific procedure and the ability to continue long-term treatment (if the procedure is proven beneficial). In general, gentle and less stimulating types of modalities are selected. The following methods are used with electric stimulation procedures with a primarily analgesic effect: transcutaneous electrical stimulation (portable stimulators can be used for home treatment), mid-frequency currents with frequency around 100 Hz and distant electrotherapy (analgesic currents). In some patients with chronic pain, micro electric stimulation (MENS, microcurrent) has been shown to be beneficial when administered through electro-acupuncture. Laser application (830 nm wave length) has a good effect in patients with chronic neuropathic pain and dysesthesias. Other modalities (secondary analgesic effect) that are well tolerated include hydrotherapy, which can be combined (with a purpose to facilitate an active approach) with aquatic exercise therapy. Various types of heat application are used for home treatment. Short-wave diathermy is used in some facilities for specific heating of deeper tissues. Other Non-Pharmaceutical Treatment Methods Radiation therapy methods are used not only in oncology but they are also used to suppress pain of non-oncologic origin. Neurosurgical methods apply procedures to neural structures that participate in the transfer and perception of pain. Alternative medicine is another group of non-pharmaceutical methods used in pain management clinics. Acupuncture emerged 7,000 years ago in China as a preventative, diagnostic and treatment method. Written documentation about acupuncture in Europe has been found in the 17th century and this method has been utilized more

in Europe starting in the 20th century. It is apparent that the historic and social roots of this method influence the perspective of the society and the physicians in its effect on the treatment process. Its task in Asian and European medicine is inarguably significant, in contrast to the methods that had developed later and often became a source of controversial opinions by the specialists (homeopathy, aromatherapy, etc.). It is important to remember that this group of therapeutic approaches can have an important role in painful conditions if it acts positively on the patient’s health. Treatment of chronic pain would be incomplete without psychological and psychiatric treatment methods. From psychological and psychiatric aspects, it needs to be emphasized that without these methods a patient with chronic pain cannot be correctly assessed and treated. From this perspective, patients can be classified into 2 categories: the ones almost exclusively indicated for an anesthesiological procedure or another somatic treatment including rehabilitation and the ones with typical somatoform pain deficits, complicated psychological suprastructure and secondary psychological changes with minimal somatic pathology. The goal of psychophysiological assessment is to develop a fundamental screening of the patient’s psychological characteristics, including possible psychopathology and assessment of the psychophysiological pain mechanism to establish a hypothesis regarding the ratio of nociceptive, psychogenic or even neuropathic components. Psychotherapy and psychological rehabilitation are based on fundamental cognitive-behavioral methods. They can also be combined with self-training, relaxation methods, hypnosis and instrumental techniques, such as biofeedback and audiovisual stimulation. In the overview of analgesic approaches, anesthesiology methods are often overlooked. According to the WHO, they can be used at every level on the pain scale. Some are administered without the use of other medication (neurostimulation techniques), others use local anesthetics (invasive techniques, nerve blocks). Another group is formed by neuromodulation techniques that have been used for many years all over the world, including the Czech

Republic. These techniques are financially taxing and are strictly indicated in the most severe pain conditions, most often after failed back surgery syndrome (FBSS) and for complex regional pain syndrome, less often for phantom-type pain. The most common conditions include implantation of programmable subcutaneous pumps, in which the analgesic mixture is delivered into the subarachnoid space and externally controlled by computer technology. Spinal peripheral nerve stimulation is another technique, in which one or two electrodes are inserted into the epidural space or a nerve region. Nociceptive pain is the main indication for intra-spinal application of medication. Neuropathictype pain is treated by spinal and peripheral stimulation by an electrode. Pharmacotherapy Analgesics and antipyretics are the most commonly used medications that suppress and decrease pain perception typically at the peripheral level (inflammation sites, bones, joints, internal organs) with minimal effect on consciousness, although, they also affect the CNS in the areas of the thalamus and hypothalamus. Non-steroidal anti-inflammatories (anti-rheumatics) are a group of medications previously used mainly in rheumatology and for inflammatory diseases. Due to their chemical properties, they are able to focus at the site of inflammation and significantly suppress the synthesis of inflammatory substrates, mainly prostaglandins. They are also now being used more often as analgesics. Opioid analgesics are used to inhibit intense pain. Based on their origin, they can be classified as opium derivates (morphine, codeine), polysynthetic substances (oxycodone) or synthetic (pethidine, bezitramide). Their effect occurs through special receptors in the CNS. Adjuvants form a group of medications (antidepressants, neuroleptics, anxiolytics, anti-epileptics, central muscle relaxants, corticosteroids, antihistamines) that are administered as

complementary to basic analgesic medication. Given its marked analgesic effect, some groups are also used independently, especially in situations in which the classic analgesics lack significant effect (neuropathic pain). Invasive Techniques Next to rehabilitation, psychological and pharmaceutical treatment methods, invasive techniques also belong among the basic methods in the treatment of chronic pain. The ability to combine these techniques with rehabilitation methods at one facility is a great advantage, i.e., facilitation of extremity rehabilitation with analgesia or muscle relaxation through a nerve block. Invasive techniques should only be used after a patient’s careful assessment and upon establishment of an etiology of the pain condition, the cause of movement restrictions, etc. They should be applied in scenarios, in which other methods failed and in cases, in which clearly defined structures are targeted by analgesia, which can be utilized during concurrent rehabilitation treatment. Invasive techniques in combination with rehabilitation treatment are based on anesthesiologic regional techniques, but present with many differences. A lower concentration of local anesthetics is used to elicit sensory or autonomic blocks. Adequate muscle relaxation of an extremity in a well selected invasive technique can make many rehabilitation techniques easier. In addition to pain relief during rehabilitation treatment, a nerve block also significantly increases the patient’s comfort during exercise therapy. For back and extremity pain of various origins, long-term insertion of analgesic catheters can be utilized while simultaneously administering rehabilitation treatment. The mutual communication between the algesiologist (pain therapist) and a rehabilitation specialist is essential. A nerve block needs to be correctly indicated and, at the same time, appropriate rehabilitation approaches need to be selected to prevent displacement of the implanted catheter (for example, restriction at the end-range of upper extremity flexion with axillary block, restriction of sudden trunk forward bending in epidural

analgesia with a catheter, etc.). One-application techniques (blocks) have limited significance in chronic pain, but can cause significant relief in a worsened pain condition, in severe acute pain or with a specific rehabilitation procedure. In cooperation with a rehabilitation specialist, the area that is to be affected by treatment needs to be identified. The most common indications for single-application nerve blocks include the following: therapeutic blocks for a worsened condition and the need for a targeted rehabilitation procedure, prognostic blocks prior to indication of a more complex invasive technique, differential diagnostic blocks for a specific type of pain or detection of a psychological superstructure. Neuromodulation methods allow for a non-destructive and reversible treatment method for strong and otherwise unmanageable chronic pain. Neuromodulation methods include neurostimulation of nerve tissues and intraspinal and intraventricular application of medication. Radiofrequency has been newly included into these techniques. Description of these techniques exceeds the capacity of this chapter even though their application can often significantly facilitate rehabilitation methods thanks to reliable analgesia. Single-Application Invasive Techniques Peripheral Blocks Examples of administered blocks include the following: peripheral blocks in the cranial nerve region, most often in the trigeminal and occipital nerve branches. A facial nerve block is performed for facial spasms. In the neck region, a stellate ganglion block is most often used, for example, in a complex regional pain syndrome (see Chapter 6.4), with an interscalene block at the site of pain, or to facilitate shoulder and upper extremity movement. Nerve root blocks in the cervical spine are used less because of the risk of altering accessory structures (vertebral artery, spinal cord structures, mediastinum, etc.). Upper and lower extremity blocks are used often. In the arm, the brachial plexus is most often infiltrated by a supra- or infraclavicular approach. An axillary block is preferred because of improved safety

and less probability of artificial pneumothorax during the procedure. In anesthesiology, peripheral nerve blocks at the elbow and wrist are often used and several nerves can be infiltrated simultaneously. Nerve blocks are used to affect neuropathic or residual neurological deficits in the involved lower extremities and in discopathies and radicular syndromes of various etiology. The most commonly used blocks include the sciatic nerve and the “3 in 1” block (obturator, femoral and lateral cutaneous nerves). The lateral cutaneous femoral nerve block is used separately in meralgia paresthetica. Less used, but still very effective are blocks administered to the area below the knee, most often a tibial nerve block, common peroneal nerve block and the so called foot block in the ankle. All aforementioned techniques can be used independently to relieve pain or to facilitate rehabilitation approaches in a specifically defined region. Central Blocks Caudal blocks are indicated especially for degenerative etiology of lumbar spine pain or in failed back surgery syndrome. They can also be very beneficial in “borderline” discopathies that are not yet indicated for surgery. High doses (up to 60 ml) of low concentration local anesthetic with corticosteroid or opiates are used. The medication mixture is expected to not only have analgesic and anti-inflammatory effects, but also a mechanical pressure effect of a higher volume anesthetic. Single-application epidural blocks with a corticosteroid have similar indications as caudal blocks; however, they can be used at all spinal levels with an analgesic mixture specifically directed toward the affected structures. Combined blocks are most often a combination of continuous techniques with an implanted epidural or subarachnoid catheter and subsequent single application at a different level or two continuous techniques applied simultaneously. Good results have been seen with failed back surgery syndrome and implantation of an epidural catheter above the surgical incision with a subsequent series of caudal pressure blocks. This type of block is sometimes

referred to as “double decker” or a “sandwich” method. Continuous Invasive Techniques Peripheral Blocks Insertion of a catheter into a nerve or a plexus is used for repeated or continuous administration of an analgesic mixture. Continuous catheters can be implanted in almost all commonly used peripheral regional techniques. Central Blocks CNS blocks include blocks at the level of the spinal cord (intraspinal, epidural – ED and subarachnoid – SA blocks) and blocks at the level of the brain. In ED and SA blocks, the activity of the administered substance (local anesthetics) applies to the roots and the spinal nerves of the affected region, including the autonomic nerves. Epidural and SA systems and catheters can be used for short-term analgesic purposes (post-operative analgesia, temporary analgesia in a patient with chronic pain in relation to other therapeutic modalities) without tunnelization of the catheter under the subcutaneous tissue or the catheter can be tunneled and lead into the skin for more long-term analgesia. Most often, local anesthetics by themselves or in combination with other medication are applied into centrally implanted catheters as well as into peripheral catheters. Algesiologic invasive techniques are very popular, but, on the other hand, also critiqued for their unreliability and risky procedures. Their correct or respectively incorrect indication is considered to be the more important problem. Only a small amount of valid data and studies exist that objectively assess these algesiologic methods according to the principles of evidence based medicine. However, only the individually used invasive techniques and their analgesic effectiveness have been assessed. There are very few studies in the literature that would assess the analgesic effect in close relation to rehabilitation approaches of invasive analgesia. Such studies certainly pose a challenge for future research. Without a doubt, when treating pain, especially chronic pain, a multidisciplinary view of the entire problem is most effective

therapeutically. Establishment of a treatment strategy must be preceded by comprehensive assessment of the pain etiology from the aspect of neurology, algesiology and the musculoskeletal system, including the assessment of the psychological aspect of the overall complications. Combination of therapeutic methods from corresponding specialties has been shown to have greater success in the treatment of deficits and diseases accompanied by chronic pain.

6.4 COMPLEX REGIONAL PAIN SYNDROME (CRPS) Complex regional pain syndrome is a term denoted to various pain conditions that occur mainly as a result of an injury. They are localized and present with most significant clinical changes distal to the initial injury. The clinical changes do not overreach in their intensity or duration from the expected course of initial injury. They can result in significant deficits in movement function and demonstrate a various progression over time. CRPS needs to be considered as a manifestation of systemic dysregulation, characterized by an inability of autonomic mechanisms to control and gradually limit anti-regulatory mechanisms whose center is the area of microcirculation. A stasis with edema and hypoxia develops within the capillary network leading to connective tissue, muscle and bone tissue dystrophy with a severe deficit in joint function that can become irreversible. Bones show a various degree of porosity, from simple thinning of the trabecular framework to Sudeck osteoporosis. Types of KRBS Type I CRPS (reflex sympathetic dystrophy) is a syndrome that occurs after the effects of the initial harming injury. Spontaneous pain or allodynia/hyperalgesia is present that is not limited to the area of an isolated peripheral nerve and it is not proportional to the eliciting injury. During the course of the disease, edema has occurred with deficits in circulation and skin perspiration in the injured area. Diagnosis of type I CRPS is eliminated by circumstances that can explain the pain intensity and degree of involvement. Type II CRPS is linked to an injury known up until now as causalgia. It occurs much less often than type I CRPS. It is a syndrome that occurs with a nerve injury. Spontaneous pain or allodynia/hyperalgia is present and may not only be limited only to the area of the injured nerve. Other characteristics of type II CRPS are identical to type I CRPS.

Etiology and Pathophysiology The pain mechanisms found in type I and II CRPS have yet not been explained. Overview of the most common reasons for CRPS onset: External – injury (bones, soft tissues, nerves), surgery, burns, frostbite, muscle and ligament overuse, incorrect and painful types of treatment, especially a tight cast or painful rehabilitation Internal – inflammation (specific, non-specific), myocardial infarction, CVA, tumor congestion, barbiturate intoxication, antituberculosis treatment Undoubtedly, psychological changes, especially negative life events and personality traits, including autonomic stigmatization, all contribute to the onset of CRPS. However, spontaneous conditions also exist, in which no causative contexts or predispositions can be identified. These are idiopathic, or cryptogenic forms, which can mask an unidentified internal disease. Clinical Presentation Basic clinical symptoms (spontaneous pain, hyperalgia and allodynia) and other signs, such as circulation deficits, perspiration, edema, trophic changes and movement alterations are typical clinical signs that include the basic clinical criteria for correct diagnosis. Changes are most often located in the upper extremities and in a large number of cases, they develop as a result of injury and incorrect treatment. The deficit can be limited to only one extremity, especially its distal aspect. With disease progression into more advanced states, an ascending myoskeletal reaction occurs, in the context of tissue changes and an overall deficit in statodynamics – shoulder-hand syndrome in the upper extremity, muscle atrophy and thoracic spine scoliosis. Cases have also been known to include unilateral extremity involvement, in which the deficit initially begins in the upper extremity and subsequent symptom progression affects the lower extremity on the same side, or even the trunk and the head. Less often, the symptoms will progress from the lower extremity to the upper one

– in an ascending direction. In a sensory deficit, pain is the main symptom. Initially, pain is limited to the affected region, most often an extremity, but can spread until it gradually encompasses a large part of body either unilaterally or even contralaterally. Pain is often spontaneous, but can be paroxysmal in the sense of paresthesias or dysesthesias. In nerve involvement (type II CRPS), burning sensation is common and the intensity is variable and often prevents the patient from performing any activity. Pain worsens with movement, which needs to be remembered especially by the physical therapists. It worsens with visual, auditory and psychological stimuli (stress), similarly to some other pain syndromes. Autonomic dysfunction is manifested as marble-looking skin or its reddening, cyanosis and changes in skin temperature. It can be present in 75–90% of type I CRPS. It is apparent that the skin can be either warm from peripheral vasodilation or, in contrast, cold from vasoconstriction. Pseudomotor anomalies are common (hypo or hyperhidrosis) and changes are typical for individual phases of CRPS, as well as, for changes in trophicity mentioned below. Trophic deficit – commonly occurs in the later stages, usually weeks or months after the initial injury. Changes can affect skin, subcutaneous tissue as well as muscles, joints and bones. Thin skin, rough nails prone to breakage, an increase or decrease in hair growth and involvement of ligaments, aponeuroses, joints and bones are most often seen. A motor deficit is the most common. It includes muscle weakness, tremor, dystonia, etc. According to some authors, motor deficits are an integral component of CRPS. Decreased muscle strength is found in nearly all patients. The fact that range of motion and muscle strength are limited mainly by pain are clinically valuable signs of CRPS. If CRPS is not correctly treated, there is no exception that the symptoms will persist for many months or years in the form of one of

the three clinical stages, in which the course of the disease is commonly classified as follows in clinical practice: I. Acute stage – increased circulation, edema II. Dystrophic stage – decreased circulation, increased edema, range of motion restrictions III. Atrophy stage – muscle and connective tissue involvement With this classification, the time span is sometimes taken into consideration. For example, it is reported that stage II – dystrophic – occurs 3–6 months after the initial injury. It needs to be recognized that the disease, specifically in this stage, can still be reversed if treated correctly while stage III – atrophy – is irreversible. Diagnosis Diagnosis is mostly clinical. Other diagnostic tests and methods are only accessory and assist in the specification of the diagnosis. Computer processed thermography is considered the most sensitive diagnostic method to establish a type I CRPS diagnosis and can be used for reliable observation and monitoring of therapeutic success of applied interventions. In our facility in the Czech Republic, we most often use imaging techniques, such as three-phase bone scintigraphy with Technetium-99 to compare both extremities, magnetic resonance imaging to demonstrate soft tissue involvement or bone densitometry to observe Sudeck type osteoporotic changes, including their dynamics. A simple method that has proven beneficial to us involves measuring the difference in skin temperatures by a digital thermometer. Clinical symptoms of CRPS and differential diagnosis are listed in Tab. 6.4-1 and 6.4-2.

Tab. 6.4-1 Clinical symptoms of CRPS (according to Cerny R, 2000)

Tab. 6.4-2 Differential diagnosis based on functional assessment (according to Cerny R, 2000)

Treatment In CRPS, it is often encountered that not only is the diagnosis

incorrectly established and the condition classified under a different clinical unit or set of symptoms, but often, the treatment does not involve a comprehensive approach in part because the extensive symptomatology of the disease requires a multidisciplinary approach if the whole group of structures is affected (soft tissues, bones, joints, central or peripheral nervous system). The patient can also be incorrectly treated because they are assessed from only a limited perspective within a certain specialty. It is not an exception, that in the initial phases of the disease, the affected segment is immobilized because of an incorrect diagnosis. A whole spectrum of treatment approaches is used to treat CRPS. They are mainly aimed at pain and edema control, improving the vasomotor state and restoration of restricted mobility. The fundamental treatment strategy in CRPS includes restoring night sleep, decreasing pain, decreasing microcirculation deficit, influencing localized changes and restoring restricted mobility. Rehabilitation Treatment rehabilitation plays an important role in the treatment of this syndrome. Pain-free techniques and methods are the main requirement for treatment. Individual approaches and methods are selected based on the stage of CRPS. In the acute stage, isometric exercises are implemented. Passive exercises are contraindicated. In the acute stage, the patient does not tolerate any stimuli in the affected segment. Locally, non-contact and aperceptive (patient does not feel the procedure) procedures are used, especially distant electrotherapy (DE, on VAS 07 equipment analgesic currents L1-L5) and low frequency pulsed magnetic therapy. Soft tissue mobilization techniques addres​sing edema are important. Vasopneumatic therapy is implemented. The values for cycle duration and pressure gradient need to be optimally set (they are selected individually and based on tolerance). Pries​snitz’s wraps are also beneficial. Heat procedures are contraindicated. In dystrophic and atrophy stages, circulation needs to be increased and the development of dystrophic changes prevented. Most often

implemented modalities include, once again, distant electrotherapy (Basset currents I 72, assistance in bone and soft tissue healing) and magnetic therapy. Vasopneumatic therapy is indicated to improve extremity blood circulation and lymphatic drainage. In the case of chronic edema, the dispersive effect of ultrasound can be used. When blood vessel reactibility normalizes, heat hydrotherapy procedures (whirlpool, stepping baths) or dry heat can be initiated and applied locally. A consensual reaction of the vascular system can also be used, in which the application of a warm procedure to an un-involved area on the extremity leads to vasodilation and improved perfusion on the affected extremity. Early detection of the primary signs and initiation of adequate treatment can prevent irreversible dystrophic changes (third stage) and chronic pain. Heat application is also used and vibration exercises, active exercise of the affected area including large-scale exercises, in which the affected area is included into global movement, are all beneficial. Yoga and tai-chi appear to be good choices. Also, Vojta’s reflex locomotion is used with emphasis on the positions and zones that provoke the desired response in the affected segment. Gentle mobilization techniques are also performed. In all phases, the emphasis should be placed on minimizing skin sensitivity. Stroking and similar techniques can also be implemented. Mobilization techniques are combined with active exercises. Application of microcurrents was observed to provide beneficial effects. Other modality options include TENS, ultrasound and magnetic therapy. Psychological or psychotherapeutic intervention is often needed because, based on clinical experiences, CRPS most often occurs in neuroautonomically more labile individuals. Pharmacologic treatments include the so called Mikes’ mixture, which is a compound of chlorpromazine hydrochloride, dosulepin, xanthinol and dihydroergotoxine. A combination of neuroleptics, antidepressant and vasoactive substances is in many cases very effective, especially if it is

applied simultaneously with invasive sympatholytic therapeutic approaches that were listed above as effective rehabilitation techniques or modalities. However, if these medications are applied in full doses, they can cause significant inhibition and thus, it is often of benefit to replace these medications with similar preparations within the same classification (tiapride for chlorpromazine, antidepressants SSRI for dosulepin, etc.). Invasive Procedures Stellate ganglion and lumbar sympathetic blocks are most often recommended. Other methods include sympathetic regional blocks with intravenous approaches. Epidural blocks are beneficial for lower extremities. In dystrophic and atrophy stages, when the previous types of analgesia failed, we have had good experience with peripheral nerve continuous regional blocks or an epidural block with implementation of subcutaneous tunnelization of the continuous catheter for longerterm administration of a local anesthetic. Also, the technique of spinal cord stimulation needs to be mentioned (for type I CRPS) or stimulation of the peripheral nerves (type II CRPS – causalgia), especially for CRPS in the extremities. Spinal cord stimulation is primarily indicated in more advanced stages of the disease (stage II or III), when its effect is not only analgesic, but often, significant improvement in the extremity’s mobility occurs.

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7 TREATMENT REHABILITATION IN PSYCHOSOMATIC DISEASES Petr Knotek, Pavel Kolář Rehabilitation is a specialty that combines a clinical approach with pathological states and complex biological, psychological and social aspects of human life in regular daily situations. For this reason, psychosomatic problems are not described in detail in this textbook. More specifically, psychosomatics is understood as a specialty studying the diseases that demonstrate physical problems, changes and functional deficits caused by a psychological state. More broadly, it includes a comprehensive (wholesome) approach to preserving physical and mental health within the context of interpersonal relationships, life activities and the environment. Psychosomatics involves a complex, biological, psychological and social view of health, disease and human life as a whole. Causality of disease development, injuries and other changes in a human life are, in this context, multifactorial and hardly apply to only a simple causative relation to the type of injury → pathological state. The following principle applies more commonly: one cause → many possible consequences (divorce → neurotic worsening, psychosomatization, relief), more possible causes → one result (overworking, inability to rest, encephalitis, decreased immunity after antibiotic treatments → chronic fatigue syndrome), or complex chains of causes and effects with feedback. For example, pain, subsequent psychophysiological processes and cognitive pain processing alter pain perception by various feedback cycles: psychophysiologically increased CNS activation, cognitively catastrophic thinking and cognitively mediated changes in emotional affect. Psychophysiological feedback is mediated mainly on the subcortical level. The association cortex significantly contributes to cognitively mediated feedback. In some cases, it is a primary biological component (i.e., a fracture)

that elicits an affective reaction (fear), autonomic disturbance (sympathetic tone), cognitively conditioned change in affect (“catastrophization”), change in self-assessment (“I am not able to lead a normal life”) and expected future (“an injury spoiled my plans”). Overwhelming fear of pain and the subsequent inadequate sympathetic system reaction, such as in a complex regional pain syndrome, complicates and prolongs the disease course and leads to negative social consequences, such as a change in relationships with people close to the patient. This change, in turn, can trigger the patient’s social disintegration, disrupt the relationship between partners or negatively influence the patient’s position at work, exacerbate the latent neurotic deficit or latent somatic (biological) disease, such as vertebrogenic or gastrointestinal problems. For another patient, the primary role can involve a relationship or a social problem (divorce, bullying), which the patient cannot adequately nor cognitively assess and effectively process. The problem is processed neurotically, for example, in a somatized form (see Chapter 7.1.6 Bodily Manifestations as a Sign and Symptom). This can result in various pains, pareses or episodes that do not correspond to any pathophysiological condition. In such a case, we speak of a conversion from a psychological level to a somatic level. These conversion deficits, earlier known as hysterical deficits, form only a specific part of psychosomatic disturbances and cannot be regarded as applicable to the entire psychosomatics. In diagnosis, treatment and prevention, it needs to be respected that a human life occurs under specific biological (genetic influences, prenatal influences, etc.), psychological, social-psychological (especially family environment), economic (financially insecure family, unemployed parents, uncertainty of employment, etc.) and ecological consequences (noise, city, village, work conditions, etc.). Within this context, the person is born, lives, works, rests and dies. Within this context, diseases and injuries occur and vitally influence treatment and rehabilitation.

7.1 MODERN PSYCHOSOMATICS The fundamental principles of psychosomatics reach beyond common human issues. They also relate to general biological issues that were formulated at the beginning of the 20th century by J. von Uexkull, who was the first person to use the term biological feedback, and T. Seebok who used terms known as umwelt and biosemiotics. The term umwelt denotes that part of the world that is significant for an organism, thus also relevant to the person’s surroundings and the meaning that a person attributes to it. Biosemiotics deals with biological objects and processes as signs that, after their attribution to other objects and processes, become their symbols (a pear-shaped body type of Venus of Vestonice was apparently a symbol of fertility). The stepping stones to modern psychosomatic medicine also include, next to the psychological field theory (K. Lewin) and holistic medicine (studies human function from the molecular level to the interaction with the environment), a psychodynamic representation of neurotic signs as a transformed form of psychological conflicts and a behavioristic representation of these signs as a result of conditioning. The conditioning stimuli presented secondary gains from these signs. For example, jactation during a panic reaction in a fight was “rewarded” by the safety of jail. The beginning of modern psychosomatics also contributed to the approximation of the psychodynamic approach to bodily signs with psychology of personality (risk characteristics) and with somatic medicine at the end of the first half of the 20th century (F. Alexander, F. Dunbar). The extent of the problem and the challenging interdisciplinary foundation of modern psychosomatics are some of the reasons why current psychosomatic practice often does not achieve the results that would correspond to the current state of knowledge. One of the causes can be the fact that a specialist with a primary medical education does not sufficiently appreciate the patient’s psychological and social problems and, in contrast, a specialist with education in

psychology does not adequately understand the medical aspect, often even on a basic level. Further, this condition is also worsened by the remnants of the influence by psychophysical parallelism that assumes a parallel course with psychological and somatic function and their principal loss of integration and affectability. This results in a onesided presentation of a problem whether the given sign has a psychological or somatic character. According to a unilateral psychophysiological parallelism, every mental process has a corresponding physiological process. These commonalities are not connected causally. They do not elicit or act on each other and they do not influence each other. Common “intuitive’ parallelism generally acknowledges some connection between the psychological and somatic. However, it is considered as unsubstantiated or “inappropriate for the discipline.” This corresponds to an erroneously formulated question of a differential diagnosis: “Is this patient (somatically) ill or do they belong to a psychiatric unit?” Interdisciplinary cooperation is required to establish a correct diagnosis; however, this is still not a common practice. Another cause of unsuccessful psychosomatic practice is the fact that the specialists are not competent in or rather underestimate nonspecific means that affect the patient, for example, effective communication, charismatic presence, suggestive action and the placebo effect. Alternative medicine healers often used these nonspecific means better than qualified professionals. Under this circumstance, they are more successful in a number of cases, especially in influencing conversion symptoms.

7.1.1 Psychosomatics and Current Science In current science, a disproportion between the extent of often disorganized fractional findings and the slow establishment of theories that would allow for their effective organization into larger systems dominates. Thus, also the practical use of new findings with a comprehensive psychosomatic approach toward a patient is limited. An analytical means in exploring dominates over a synthetic means or

an accumulation of detailed findings above their organization into organized systems. An implicit rule practically applies “the greater the detail, the greater the science.” This trend of atomization of scientific findings has been apparent since World War II and it is not conducive to psychosomatics. The current foundation of scientific findings is served better by a highly focused expert specializing in one aspect of a psychosomatic deficit, for example, in cellular immunity. The disproportion between the analytical process of fractional information growth and its insufficient effective synthesis slows down the advancement of psychosomatics. This process is “copied” in education. A future physician learns more about the mechanisms of the onset of cellular membrane stimulation than about the activity of chronic pain on physical, psychological, behavioral and social processes.

7.1.2 Psychosomatics and Irrationality The vaguely understood unity of psychosomatics and the reduced scientific validity of such an approach is the platform for irrational theories and historical representation by terms and opinions prior to the time of modern science. As an example, let’s use the often used terms “psychological energy”, “conflict of psychological forces” and other so called psychosomatic terms that are out of context with current science because, in reality, the psychological processes pertain to information and not to energy that the person possesses. The energy is of a metabolic origin. Theory is a description and an interpretation phenomenon. It is its framework that includes the fundamental components of the phenomenon (elements, subsystems) and their relationships that are essential for the presentation of the function of the phenomenon. A model should be logically unequivocal and should correspond with reality (empirical correspondence theory), predict the process development (predictive ability) or allow for its utilization (practical function). This framework is approximate, for example, for a causal structural model of psychological changes in chronic pain that trigger

pain and cognitive processing of pain. The contrast of parallel theoretical frameworks is a representation of phenomena in untestable terms and untestable relations. For example, a symbolistic and poetic narrative representation of the principles of acupuncture, even though the treatment effects of acupuncture are, without a doubt, evident. Therefore, the value of therapy is not supported by a logically consistent theory, but rather its effect. A theory is only effective when it helps a practical diagnosis and treatment and can suggest a new or improve on the therapeutic methods used so far. In scenarios where it describes and presents their course and effectiveness, it really provides no value for therapy. In a better scenario, it can serve as a foundation to a theory that can be applied in the future. The exploration of complex problems in psychosomatics contains more inaccuracies (“noise”) than research in specialized fields, contributing to a precisely formulated and statistically tested theory. The answer to the question of whether a stress acts to decrease immunity will be easier when exploring the effect of exposure to a loud sound on a change in the white blood cells of a rat than studying the effect of a city’s environment on the immune system of its inhabitants. In the first scenario, the comparison of a group exposed to a noise and a group in a quiet environment that differs in only one controlled variable will be more exact, but the application of a given finding will be far from beneficial in its application in psychosomatics. In the second scenario, due to the need for comparing a large amount of data with complex (multivariate) statistics, the answer can be suitable from a complex perspective of a psychosomatic approach but will be adversely affected by statistical error that increases with the size of the data sample.

7.1.3 Biological, Psychological and Social Approach Disease prevention, the disease itself and injury need to always be viewed from biological, psychological and social perspectives. Rehabilitation methods can never limit themselves to just one of these

perspectives. Biological, psychological and social perspectives reflect the pathology and the norm. Manifestations of fibromyalgia (see Chapter 3 Treatment Rehabilitation in Selected Internal and Other Diseases, Subchapter 3.8.5 Fibromyalgia Syndrome) and also, partially, chronic fatigue syndrome are good examples of disrupted bio-psycho-social integrity. They include disrupted processes on subcellular and cellular levels including disrupted pain and analgesia mechanisms, slowed down regeneration of muscle tissue following a strain, sleep disturbances, feeling of fatigue, exhaustion, decreased activity and other manifestations of a so called pseudo-depression. Pseudodepression denotes a complex of symptoms of somatic diseases, such as exhaustion, sleep disturbances or a subjective perception of a change in performance or even physical appearance (“I can’t do anything; I do not look good”), which are a natural consequence of a pathophysiological state. These signs are erroneously interpreted as signs of depression even if the typical manifestations of depression are absent – dysthymia (prolonged “pathologically bad moods”) and anhedonia (lack of pleasure or the inability to experience it). Manifestations of fibromyalgia and chronic fatigue syndrome also include generalized changes in affect (anxiety, anger and depression), alteration of cognitive processes (perception of self as ailing and inferior), frustration linked to the inability to live a normal lifestyle and disruption in social integrity (closing in, loss of friends), including a position within the family (switch from a leader to an incapable family member). These changes are also associated with reduced work performance, financial difficulties and other problems. The manifestation of chronic fatigue syndrome can also be the result of the cumulative consequences of certain personality traits, such as perfectionism, exaggerated selflessness or denial and a denial of exhaustion. A similar pathological state can sometimes be caused by disrupted immunity, i.e., as a result of a neurological infection. Biological, psychological and social processes can, in different ways, contribute to the etiology, course and consequences of a certain

disease or dysfunction. Development of a stomach ulcer can serve as an example. Although, it involves an anatomical change within the stomach, its formation can be, to a varied degree, attributed to all three of the aforementioned processes. The formation of a stomach ulcer is significant. However, not necessarily, when conditioned by the presence of Helicobacter pylori. However, a genetic disposition and the body’s overall condition, as well as, current and previous diseases, lifestyle, stress, smoking, alcohol, medication irritating the stomach’s mucous membrane, affect and personality traits (suppressed anger), difficult relationships, a stress producing social environment and environmental factors all contribute to its development. Some contributing factors are only partially specific (presence of specific bacteria). They are more or less general and non-specific and are manifested only in certain diseases or are universal (poor diet, general distress). All of these influences affect each person in an individual and unique way. In some people, a stomach ulcer is a result of pain medication abuse, in another person, it is the result of stress elicited by suppressed impulsivity. It is important that the strategy of therapeutic approaches be distinguished within this etiopathogenetic view of a disease. The anatomical finding cannot be treated uniformly and it is important for the indicated treatment to always take into consideration the etiopathogenetic context. A similar approach can be used for other diseases, dysfunctions and injuries. A car accident or an injury are often not a mere chance, but rather, the driver’s personality traits can contribute to it, such as their aggressiveness, egocentrism, risk seeking and the need for a higher level of stimulation (sensation seeking), their actual state (fatigue, intoxication) and other influences. Psychosomatic Integrity A person’s biological, psychological and social unity includes basic questions of what psychological and physical entities are and where they end; where the distinction between the physical and psychological lies. The answer to these questions is not considered clear cut or practically significant given the nature of the problem.

Meaningfully, they can be defined by what no longer being psychosomatic means and an outer limit can be established. Searching for the purely psychological is impossible given the continuity between the individual’s psychological and biological existence. To a certain extent, the entire prenatal period can be considered as biological. Also, many other biological processes are not psychologically reflected and do not have an actual psychological impact. Today, the body, personality, social surroundings and (cultivated) environment are viewed as highly organized interconnected units. Their existence is linked to achieving a large amount of information and energy, which importantly interlink the biological (somatic) and psychological processes. Information processes are linked to stimulation activity of neurons, including cognitive processes, intake, processing and storing information, and affectively-motivational processes. Affectivelymotivational processes include the experience aspect and processes leading to the release and modification of energy for various forms of behaviors (motivations). Humoral processes vitally contribute to the underlying mechanisms of emotional states. Motivation mechanisms are also conditioned by an ion concentration in the plasma (thirst), sugar concentration in the plasma (hunger), humoral processes (libido) and many other biological conditions. At a certain level of assessment, biological conditions are reflected by types of affect such as pleasant or unpleasant and they arouse stress feelings and more complicated emotional responses. Cognitive processes and affectively-motivational processes affect each other. For example, adverse cognitive processing, assessing a situation as dangerous and the assessment of one’s ability to master a situation as such can elicit a feeling of threat or anxiety (affect). Anxiety is linked to motivation of flight (behavior). The difference between a human and other species lies mainly in information processing, especially in its quality or in cognitive processing (in perception and thinking) and in the affectively-motivational

processing developed as a result of “higher” cognitive operations (complex feelings, correct motives). In the listed types of processing, however, the problem of “purely psychological” and “purely biological” ends. Information input, processing and storage are linked to neuronal stimulatory activity with a neurotransmitter function and with peptide changes in brain cells. For example, a reaction to stimulation and transfer of information by afferent system or retention of information in the short-term memory are mediated by stimulation activity. Long-term memory is associated with alteration of proteins in the brain cells. Information processing elicits other nerve and humoral processes, such as increased levels of catecholamines and an “adrenaline reaction” (corresponds to associated emotional states, increases stress, “pumps up”). This is a process of increased energy release and its usage, in which a direction (motivation) is triggered, such as flight or fight (behavior). Normal and pathological minds function at the level of these and similar (even if much more complex) processes. In this way, even concurrent or antagonist information, emotional states and motivations (conflict) are processed. If we perceive something that is either wanted or unwanted, we are motivated to achieve a rejection of the pertinent object. Energy is released for its attainment or nonattainment. The situation is either solved by acceptance of one of the alternatives, called fluctuation activity, or by the inability to resolve the conflict (“process”). Remaining in the conflict leads either to a psychological discomfort (neurotization) or a disruption in somatic processes as a result of persistent distress (psychosomatization). A conflict between natural sexual motivation and motivation based on a moral code can serve as an example. Neurotic mechanisms often resemble the function of an automobile with simultaneously pressed gas and brake pedals or when we want to go left and right at the same time. Energy is needed for all bodily and psychological processes, and thus for all communication between a person and the environment. All human energy is metabolic in origin. Simply said, the Krebs cycle

in mitochondria in connection with the breathing cycle significantly affects the production of all energy that a person and other species possess. Biological, psychological and social processes occur as a whole within a certain ecological context. In reality, the course of a life presents a complex of life activities, internal – biological and psychological processes and external – behavior. It contains typical regularities, for example, phases of development and an individually specific course; a concrete “life story.” Normality A human’s biological, psychological, social and ecological purpose brings about complicated and ambiguous issues of norms and normality. If a person in a certain aspect falls into a statistical norm, i.e., into the zone of 68% occurrence on average, they may not fall into a functional norm, derived from the good and correct function of body, mind or social integration. From a functional perspective, statistical normality of a population according to BMI can be unfavorable or “abnormal” where the population is obese. A tooth cavity is an example of absurdity of a statistical norm; most of the population has a cavity; however, it is not viewed as a norm. Further, statistical and functional norms are also utilized in the context of a standard (common, adequate, correct, usual performance) and in the context of normal performance (victory, physical attraction, admired performance). The position between introversion and extroversion is the statistical norm of a usual position with the majority of people somewhere in between these zones. An extremely high IQ can also be statistically viewed as an end zone of the intellectual performance spread. From a functional perspective and when related to common psychological and social aspects of existence, this can be a risk of maladaptation, misunderstanding and problematic integration within the environment of a common population as the result of a mutual lack of understanding. A consensual norm also needs to be mentioned. The concept of

“this is how it should be”, without taking into consideration the frequency of the occurrence and a “good function” of the process. An example of a pathological consensus can be the image of a cachectic body as the ideal of beauty, leading to anorexia. Certain cultural and moral norms have a hidden biologically deterministic and genetically Darwinistic foundation. Under common life conditions, the moral code of a stable family supports a higher probability of transferring a genetic code and quality descendants. The same genetically Darwinistic foundation is also found as an “ethics failure” under conditions of vita minima. For example, during a war, when the probability of a genetic code transfer increases promiscuity given the uncertainty of survival. Promiscuity is also typical for an anxious neurotic who perceives themself as unable to face regular life situations and perceives the relevant environment as a source of uncertainty and endangerment. A similar principle also applies in primates. Psychobiology and Sociocultural Norms Psychobiological determinants are also further complicated by the determination of motives and norms based on sociocultural or religious aspects. Psychobiologically innate motivation, i.e., sexual, can conflict with a sociocultural norm (“fidelity”) either with an accepted moral norm (I must not) or with a perceived norm of relevant social environment (I could offend someone, I would cause conflict). These are conflicts between psychobiological motivation and cognitive assessment based on a moral norm. Conflicts of psychobiological and socio-culturally determined motives require constant processing to restore psychological balance (coping). Psychological normality includes a “challenging situation”, or a conflict or frustration, dealing with it, resolving it, accepting the solution and, thus, completing the original natural adaptive neurohumoral process, stressful reaction, or “adaption”. It is not normal to not adapt psychobiologically, cognitively or socially. A psychobiologically continuing stress reaction, which originally activated the body to solve a challenging situation, leads to a neurotic disturbance or possibly to an exacerbation of a chronic or “prepared”

somatic illness in an area where a certain weak link is found. This pertains to, for example, hypertension, a stomach ulcer, psoriasis, an allergy, certain skin diseases, chronic vertebrogenic conditions and oncologic diseases. If one of the listed options does not occur and a person continues to face stress and discomfort, body exhaustion can occur reaching as far as a disruption in cellular immunity and metabolism (autoimmune dysfunction, a chronic fatigue syndrome). A neurotic and psychosomatic patients then permanently live in the conditions of processes that were adaptive at the time of an acute stress but continue chronically. Cognitive Processes and Adaptation Cognitive processes are constructed and maintained mainly by perception and the assessment of common situations and events as difficult to solve or unsolvable. These characteristics and tendencies include externality or a tendency to perceive a situation as unsolvable by one’s own means; tendency toward catastrophization or selective perception and a tendency toward overanalyzing negative sides of situations; disposition pessimism or the learned negative expectation of future events and self-efficacy or the tendency to perceive oneself as able to master problems by one’s own means. Self-efficacy correlates with higher plasmatic concentration of opioid peptides. A cognitively distorted (biased) self-image and deeming relevant environmental and common situations as permanent and unmanageable form the cognitive foundation for pain chronization, unsuccessful integration into work and life maladaptation, unsuccessful social integration and decreased treatment effectiveness. Passive and unsuccessfully socially integrated patients “want to be treated”; ”they do not wish to be cured.” They prefer treatment that does not disrupt their passivity, thus they prefer orally applied medication, injections, infusions, or possibly surgical procedures. They refuse rehabilitation treatment that requires their participation or exercise. They spend more time in a horizontal position (bed). These manifestations are predictors of chronic pain, pain behavior and acknowledgment of disability. Active, confident patients have

different preferences with more positive reactions to treatment and an ultimate desire to return to their regular life. It has been empirically shown that disruption in immune functions can be conditioned or learned (Adler and Cohen, 1975). A change in immunity is then possible as a result of direct exposure to stress or as a signal of endangerment – conditioning or deformed cognitive processes, for example, a tendency toward catastrophization (perhaps following a psychological trauma) or learned helplessness. This leads to the cognitive interpretation of a situation as more challenging or unmanageable and to the interpretation of one’s own self as incapable and helpless to solve such situations. In common life circumstances, a person is more likely to succumb to their own interpretation of the world than to the direct psychophysiological stress-producing influences such as pain. Negative cognitive pain processing is a stronger predictor of negative emotions (anxiety, anger and depression) and pain behavior than the intensity and unpleasantness of pain. Positively processing pain as a challenge leads to adaptation and recovery. A subjectively accepted form of conflict resolution that is rejected and sanctioned by social environment can also have stress producing consequences. A specific disturbance in the cognitive processing of one’s own health is a factual deficit. A patient with this disturbance is constantly convinced they have illnesses and problems; however, these cannot be supported by any pathological findings. They constantly and urgently seek repeated tests and treatments. Often, they can articulate their requests in a rational and educated way. If their requests are not met, they find different health facilities and the process is repeated. This dysfunction is common in patients with a personality disorder and it is considered an atypical somatoform deficit in such people. It partially overlaps with an older term called hospital wandering (Munchausen syndrome), which includes similar characteristics for different reasons, such as the effort of a homeless person to survive the winter by being admitted to a medical facility. Failure as a Pathological Adaptation

Mental and physical health can be “bought out” by decreased performance or even by failing at work, problems with parenting children, or the psychological and somatic problems of a partner who takes on the worries and the duties. Decreased mental resilience during stress can lead to a neurotic reaction, i.e., a breakdown, which completes the corresponding stress producing situation. Extreme cases can include an escape to a disease from a demanding job or a family situation.

7.1.4 Placebo and Nocebo Placebo is a neutral substance administered as medication from which the patient expects recovery, improvement in a pathological condition or a decrease in symptoms. Under certain motivational conditions, it is effective in decreasing a number of symptoms, especially with pain, in other dysesthesias, in somatoform symptoms and in disease stress and anxiety modification. Such means used to be morally condemned, while at other times, defended as a necessity or a graceful lie. Negative side effects of common placebo treatments were also reported. If they contained sugar, they contributed to obesity. In a modern view, the term placebo effect has been better known as a psychologically mediated effect of a medication, surgical procedure, person, object, environment and situation to improve health, decrease symptoms or assist in recovery. A presumption for such an effect leads to the expectation of a positive change, trust in the person who provides the treatment and in their abilities and trust in an environment and a situation in which the patient expects the change. A placebo reaction mediates the projected expectation of a desired change. Positive emotional-motivational tuning elicited by such an expectation can also occur differently, for example, in the presence of a pleasant, renowned specialist and a charismatic person who sets such an expectation and emotional modification. The place associated with such expectations also contributes to the placebo reaction. A placebo effect is conditioned biologically, psychologically, socially and also by the relevant environment, therefore ecologically.

Pain has been a relatively well studied component and can be used to show the biopsychological and cognitive mechanisms of a placebo. The transfer of nociceptive inputs from an injured tissue by the primary afferents into the secondary (spinal) neurons depends on efferent regulation, which determines the transmittance of the inputs from the periphery into the spinal cord. The process generally occurs in the following manner: The inputs from the slow conducting systems are led from the spinal cord to the medial thalamus and further into the limbic system (cingulum) followed by the frontal cortex. At the same time, the inputs are transmitted into the reticular formation (regulation of psychological tension) and the hypophysis (influencing neurohumoral regulation). A two-way communication occurs between the reticular formation and the hypophysis. The inputs from the neurohypophysis enter the limbic system. In this way, the hypophysis communicates through the hypothalamus and the limbic system with the frontal cortex. The input activity of the fast conducing systems recedes, after a synaptic transmission in the lateral thalamus into the somatosensory cortex and from there into the association cortex (“hardware of the cognitive processes”). Here, the inputs from the frontal cortex are also processed, which is where the tracts of the slow conducting systems terminate. From the association cortex, the input activity enters the descending corticothalamic system. The effect of cognitive processes on the emotionally motivated processes is mediated in this way. The input activity from the association cortex also enters the descending corticospinal system. This activity forms a “top-down regulation” of nociceptive input entry into the spinal cord from the periphery. The presented process with determining effect of the descending (top-down) processes for pain perception and natural analgesia is known as the gate mechanism of pain control. At first, it was described by R. Melzack and P.D. Wall in 1965. The original “electrophysiological foundation” of modern pain theory was continued by the work of Wall’s students in the area of neurochemical and neurohumoral aspects of pain and analgesia mechanisms, as well as, in psychological research of the influences of cognitive processing of pain and emotional processes, thereby

continuing the work of Melzack and Casey (1968). These processes are substantially more complex and, so far, less understood. This psychological research indicates that cortical pain processing during a placebo effect is prepared ahead and, on an ongoing basis, influenced cognitively by expectations and reassessment, and also emotionally. Influencing such processes by another person, treatment (and ritual) procedure or situation is the basic mechanism of a placebo effect. Imaging techniques and other methods substantiate the changes in the input activity of the somatosensory cortex, as well as, changes in the activity of the brain structures in which the regulatory processes of emotions and motivation (thalamus) during pain occur. Placebo analgesia, pharmacological analgesia, as well as, hypnosis and, further, changes in the regulation of the neurohumoral process (hypothalamus), in certain pathological situations occur during which the pain and analgesia mechanisms are disrupted. Pain reduction as a result of a placebo is repeatedly documented by VAS and other tests. A two-way connection exists between these processes and the general neurohumoral regulation triggered by the hypothalamus (releasing hormones), neurohypophysis (accumulates and releases oxytocin and arginine vasopressin, synthetized in the thalamus) and adenohypophysis by excreting trophins. Thyreotropin controls the activity of the thyroid gland and corticotropin controls the excretion of corticosteroids from the cortex of the adrenal glands. Adenohypophysis also excretes somatotropin (growth hormone) and gonadotropin hormones that stimulate the activity of the reproductive glands and the excretion of reproductive steroid hormones. These processes are associated with emotionally-motivational processes and with pain and analgesia mechanisms. For example, the level of corticosteroids correlates with the level of opioid peptides, therefore also with a specific neurohumoral mechanism of analgesia, positive emotional being, body activation and with the corresponding psychological states of excitement, stimuli seeking, determination, depression and similar states. Learning occurs at the level of such processes. These processes can also be influenced by counseling, hypnosis, cognitive processes as well as by a placebo effect. The

general context is unclear. Testable aspects are few and the research overview would exceed the scope of this chapter. A comprehensive psychosomatic placebo theory is nowhere near being established. Therefore, a placebo effect can be, from a psychological perspective, a result of direct counseling, learning or a socially mediated attitude and expectation. In a placebo, the only treatment effect is the placebo effect. The situation is more complicated during effective medication. For example, methodologically stringent studies of the analgesic effect of non-steroidal analgesics and low and medium strength opioids are in favor of a complex interaction of a pure pharmacological effect and a placebo effect: The analgesic effect of such medication depends purely on their pharmacological effectiveness, similarly to the patient’s and physician’s expectations. A strictly analgesic effect of such medication by an intravenous application without the patient being informed that it is an analgesic medication or a placebo effect with the administration of a non-effective substance with the assurance that it is an effective analgesic, is approximately the same. An analgesic is most effective after it was administered with favorable expectation of its effects by the physician and the patient. An analgesic effect is decreased if the physician administers an effective medication in belief that it is a placebo or if the physician administers a placebo assuming that it is an effective medication. This is true for certain other medication (i.e., some psycho-pharmaceuticals) and it can also be generalized that a tired physician administers in a hurry and without an interest in pain medication or medication used to decrease an acute anxiety attack. A charismatic healer who devotes time, interest and attention to the patient administers a pharmacologically ineffective medication or performs a magical ritual and in this way develops a strong expectation of relief and comfort. The analgesic effect and the reduction in negative affect can be greater after visiting a healer. If the experienced anxiety and pain are the cause of the given phase of a psychosomatic illness, the actions of the healer can positively influence the mechanisms of stress, autonomic disposition, hormonal processes, immunity and the general regulatory physiological (homeostasis) and cognitive (optimistic expectations) mechanisms.

The actions of the healer can be, even “miraculous” (i.e., in a conversion paresis) especially for a short period of time. In this way, certain “miraculous” recoveries can be explained. If the aforementioned physician would display the same strong, nonpharmacological tools as the aforementioned healer, the same placebo effect would be expected and additionally strengthened by the pharmaco-dynamic effect of the corresponding medication. Nocebo is the opposite of placebo and a nocebo effect is the opposite of a placebo effect. The processes supporting the placebo effect also support the nocebo effect, meaning worsening of the symptoms or the pathological state. For example, after reading the side effects of a medication in an included pamphlet, its effectiveness decreases or an accurate interpretation of a finding in the spine region increases pain, etc. A clinician, without a doubt, would not use the aforementioned means for a nocebo reaction. However, the clinician should know about it and understand it. They will interpret the worsening symptoms as the result of a number of negative influences, causing undesirable information processing by the patient or a better understanding of the effect of other persons on such undesirable changes. In pessimistic people, the usual means of a placebo effect lead to the opposite effect, or a nocebo effect, and symptom worsening. A nocebo effect is common in certain personality dysfunctions and also occurs when a patient displays a negative attitude toward therapy or treatment.

7.1.5 Charisma The influences that contribute to a placebo effect also include the personality trait called charisma. Charisma is the ability to act on an individual, a group or a larger social structure (class, nation, community, mankind) in accordance with one’s own intentions or with how the intended people perceive them and how they interpret them. The influence of a charismatic person is accepted spontaneously by the persons being influenced, it is associated with their psychological representation, “picture”, image, meaning to which they

perceive and to how they interpret their opinions and efforts. Charisma can act in a direct fashion (a medical worker in a clinic, pastor in a church), as well as, through history (charisma of religion founders). A charismatic personality is perceived as more trustworthy, powerful and independent of external influences, often also as protective. Sometimes, it can be perceived as a gift by a certain higher power, with whom the charismatic person communicates or through which they mediate help and support for those who are not gifted in such a way. Such a personality facilitates the basic processes of a placebo effect more effectively and easily with an increased suggestibility, partial dissociation of cognitive processes, limiting critique toward shared information and a positive emotional state of mind. The process of influencing is generally pleasant to the patient and strengthens their feeling of security. A charismatic person’s actions narrow the cognitive context of the suggested topic, establish positive emotional well-being and increase dependence – “influence the strength” of the charismatic person. This can be used as well as misused. Increased dependence is the principal problem of a strong, long-term charismatic influence. Persons who are immature and passively dependent on a charismatic person seek, or idolize, a suitable person. Body language and specifically the manipulation of their symptoms can bind them to their idol and maintain communication with them. One of the manifestations of dependence can be seen with continuous treatment (a patient wants to be treated, but not healed). The influence of a charismatic person can be strong in a positive as well as negative direction. Charisma is also desired by narcissistic and histrionic persons who need to excel above others (a priori). In medical fields, they seek this while paying less attention to the patient. Charisma is manifested in all components of therapy. In rehabilitation, it is especially important because the patient needs to be included in the treatment and be convinced of their active role. Charisma should act in agreement with other treatment components and come to the forefront only in situations in which specific methods are not effective.

7.1.6 Physical Manifestations as Signs and Symptoms A sign can be any object or a process that does not have any meaning by itself. In fact, it does not mean anything. Assigning a sign to a different object or a process leads to a sign-object relationship. Under this condition, the sign becomes a symbol of the corresponding object. A symbol is a sign representing this object. A set of symbols and their relationships form a language. In a certain language, specific signs are attributed to specific objects of a certain area. Exclamations, laughter, moaning or squirming are psychobiological and natural components of shock, happiness, pain or spasm, and, therefore, are areas of specific psychosomatic manifestations (“primary body language, primary language, “specific language”). The patient can transform this language, or “translate” it into other meanings, use it to express remorse or request medication or pension. They do this especially when they do not presume that they would be listened to in a normal language or spoken speech. The signs persist, the meanings change and vice versa: if one symbol system fails, for example, spoken language, it is replaced by another symbol system. In a given scenario, hand gestures, grimacing or conversion signs, such as paresis or neurotic heart clutching present themselves – “the physician needs to address these.” Congruency, the unity between spoken language and body language, is a sign of the statement’s believability and convincingness. Disagreement is a manifestation of an internal conflict or non-credibility. In psychosomatics as well as in common life, however; uneasily decoded communication is often encountered on several levels, including the connotation layer of language in which communication occurs or the layers of so called external meanings. In diagnosis, treatment and rehabilitation, when communicating with a patient, comprehension, the ability to “read” and decipher such meaning and the ability to move between two or more communication layers are very important. The patient reports something using the language of somatoform signs and the therapist understands it, but the patient is not ready to accept this information. At the same time,

communication with their relatives is important, for example, to decipher their tendency to bias the patient’s presentation for their own benefit, masked by a polite concern. In terms of biological, psychological and social processes, a large number of communication processes run through a large number of channels and in many languages. Good communication is a prerequisite for good function of the systems. Loss of information or systemic bias of information disrupts a good condition (system organization) and their cooperation. This pertains to biological and psychological processes and to social communication. For example, a healthy tissue identified as a foreign protein elicits an autoimmune reaction. Failure in hormonal communication between the adenohypophysis and the adrenal cortex leads to activity intolerance and a disruption in biological functions in fibromyalgia. During communication among generations in a multi-generational family, one generation “does not understand” the other and so on. Disruption in communication can occur between psychobiological and cognitive processes. Increased heart rate during acute stress can be assessed as a manifestation of a cardiac problem. In psychosomatics, the aforementioned problems also include the communication between the systems, namely among biological, psychological and social processes and the relevant (“significant”) environment, within the context of the external and internal environment (“world”). Biological objects need to be approached in the context of relevant external processes and objects that have corresponding significance to a given object – direct and simple. For example, the significance of nutrition lies in decreasing hunger, for example, in Pavlov’s dog, the bell ringing was a sign of food. With humans, caviar can be a symbol of luxury. Under such circumstance, caviar has a greater meaning as a statutory symbol rather than a source of energy. External and observable manifestations of emotions or pathological processes are their signs. These signs form a symbol system or a language that tells of emotions and physical processes (body

language). However, this language is a relatively independent and enclosed system of symbols and their relationships also function in other communication contexts rather than only in the context of a simple, “easily read” bodily state and emotion. It reports something to the others – for example, “I have pain”, as well as, to oneself – “I can’t do it.” Such a statement occurs within the context of various motives and needs, often conflicting or socially and subjectively unacceptable. Body language then enters the general communication contexts so that the symbols remain (moaning, spasm), but their meaning changes (they mean, denote or represent something different and they are a symbol of something else). Through body language, something different is denoted and stated than what corresponds to its original function. A headache can mean “I do not want to go to school”. Nonreceding signs after an injury can mean “you are treating me incorrectly”. Relentless fatigue can be “I do not want to continue, I am embarrassed to interrupt my work and admit this aversion to myself and others.” Certain anxious uncomfortable cognitive processes are also transformed at the level of body language. For example, anxiety expressed as throat tightening is misleading in nature, both psychologically and socially. The patient is preoccupied by the symptoms that they interpret as somatic and they attempt treatment and, in this way, divert attention from the true source of anxiety, such as marital problems or problems at work. Their own disinformation reports to others. If they do not react to it, the patient expands their communication, nags, punishes or “seeks understanding.” If they succeed, this behavior becomes stronger (learned) by this conditioning and the patient can continue with such (pathological) communication even after the pathophysiological process has healed.

7.1.7 Deficits and Signs The biological-psychological-social nature of psychosomatic processes implies that all problems of a person fit together in some way. If we focus on diseases, disturbances and dysfunctions and their symptoms, we will see a wide array of manifestations from primarily psychological

all the way to pathophysiological. Most manifestations of psychosomatic disturbances lie within these boundaries. These processes are dynamic in nature. The signs change, but the problems persist in the individual’s life as well as across culture and history. In childhood, an escape toward an illness expressed, for example, by a stomach ache can be seen when a child would like to skip school. In adulthood, an analogical sign of not wanting to go to work is most often manifested by a headache. In psychosomatics, an empirical rule applies: “A neurotic stomach ache in childhood corresponds to a neurotic headache in adulthood.” Also, acute stomach aches in children exist that are equivalent to migraine headaches in adulthood. Anxious reactions during World War I differed (violent unrests in bed) from those of Gulf War Syndrome during Iraq war. An outburst of anger in Malaysia differs from an outburst of anger by a European. The following levels of signs, dysfunctions or diseases are distinguished in psychosomatics. Acute Psychological Reaction to Stress Acute reaction to stress is a transient reaction to a physical or psychological stress that usually subsides within hours or days. It can be a reaction to a wide spectrum of stress producing factors, such as biological, psychological and social, but most often combined (i.e., a reaction to a natural disaster, assault, challenging family or work situation, loss of loved ones, or even the expectation of such a situation). Usually, autonomic and psychological symptoms are present, such as tachycardia, perspiration, acute anxiety, anger, despair, decreased attention, decreased ability to perceive reality or asses a situation. Also evident are emotions that are not well thought out and demonstrate poor cognitive control manifested as angry attacks, fearful stiffness or the anxious need to escape. Sometimes, such a reaction prevents deeper and more significant consequences, for example, to a person’s psyche or through bodily harm. This reaction “frees” the person from other stressful activity (“a breakdown” at work). Other times, it can be fatal, for example, chaotic behavior during a catastrophe.

Neurotic Disturbances Neurotic disturbances are longer lasting disturbances in psychological functions and behavior. They develop as a result of mainly psychological stress and learning at various phases of a psychological development. They are marked by negative emotions, usually anxiety and depression, with a tendency toward ruminating thoughts or activities (obsessions) and the occurrence of somatic symptoms without somatopathological causes (conversion). Although these disturbances are not included in current psychiatric taxonomy, we consider their simple comprehensive concept for our purposes because the current classification criteria of MKN10 or DSM IV TR are too complicated for non-psychiatric practical usage. Some “neurotic symptoms” are learned complexes of reactions that decrease tension either motorically (i.e., compulsion in obsession) or lead to redefining (cognitive transforming) of a situation as less stressful. For example, a hypochondric disturbance can connect anxiety from a survival threat to overassessed somatic signs. Similarly, conversion manifestation can fulfill the need to attract attention or “free” oneself from a conflict or a stress producing situation. It is a pathological form of adaptation or the attempt at it. Neurotic signs are fixed by learning, especially seen with complicated adaptation and mature adulthood integration, or when they lead to the pathological integration to the detriment of others and the society (gains from a disease, manipulation, disability pension. Psychosomatic Disturbance A psychosomatic disturbance is similar to a neurotic reaction mainly because of functional somatic symptoms (conversions). Psychosomatic reactions sometimes disrupt the physiological function of an organ, usually reversibly. Globus hystericus (pharyngis) makes swallowing difficult, but does not lead to anatomical changes in the esophagus. A similar scenario can be seen in various forms of psychogenic sexual dysfunctions, for example, in frigidity, vaginismus or psychogenic impotence as a result of a dismissive attitude toward a partner. In contrast, conversion muscle spasms of the forearm during the escape to a disease by a person who avoids work can sometimes

cause irreversible changes in muscle tissue. Psychosomatic Diseases of Organs and Organ Systems Psychosomatic diseases of organs and organ systems include somatopathological states with a substantial contribution of psychological influences, conflicts and stress. Most typical psychosomatic illnesses, such as a stomach ulcer, ischemic heart disease, hypertension, psoriasis and so on, were, at the beginning of modern clinical psychosomatics, attributed to psychogenic etiology. A certain part of the pathophysiological influences in etiology generally corresponds to a modern interpretation. Certain biological factors (genetics, infections) are generally predisposing to a certain illness or such factors are at least presumed to do so, although they may not be known to yet. This includes, for example, certain gastrointestinal diseases (Crohn’s disease, stomach ulcers), skin disorders (psoriasis), etc. Psychogenic and sociogenic influences significantly contribute to the triggering and course of the process. Systemic Diseases These diseases include a pathological disruption in the regulatory and metabolic processes of the entire organism with substantial contribution of psychological influences. These include, for example, various forms of immune system failure, fibromyalgia or chronic fatigue syndrome. They often affect individuals who are somatically resistant and are perfectionists or those who are unable to reject requests from others. Their psychological resistance is paradoxical: they are hard on themselves, efficient and selfless. They dissimilate their problems and, when they are unable to dissimilate them, they become embarrassed by them. If they do not fulfill requests from their loved ones, they feel guilty and inferior. These individuals “are not able to relax in time”, disrupt the self-destructive efforts or develop one of the previously mentioned diseases that would stop the selfdestructive activity and in that way prevent systemic failure. Somatopsychological Disturbance It is a pathological psychological change without significant psychogenic causes. An example may be a person with a personality

disorder suffering from chronic pain.

7.2 TREATMENT 7.2.1 Biological, Psychological and Social Context: NonSpecific Rehabilitation Factors Rehabilitation treatment approaches are the subject of choice. The same approaches can often have a different therapeutic effect. Rehabilitation occurs within a certain real context, which includes the patient and “the external environment” or the relevant environment of the rehabilitation process. In rehabilitation, this “external context” in particular needs to be taken into consideration and actively influenced; i.e., a good, hour long physical therapy treatment of a patient with spinal problems can be wasted over the remaining 23 hours by inappropriate daily activities and in other ways. Each patient has individual characteristics and relatively constant traits that distinguish them from other patients. These traits form differences among patients. Rehabilitation treatment occurs in conditions of a particular and pertinent state of the patient’s physical and psychological processes. The differences in the patient’s actual state at a given time are expressed as the patient’s characteristics. Actual psychological well-being is influenced by a number of factors including irreversible consequences of an injury (i.e., paralysis following a spinal cord injury), pain, expectation of results or the degree of trust in a healthcare provider. A desirable effect of rehabilitation is a positive, permanent change, such as improved mobility, decreased pain, or a change in psychological processes (decreased anxiety) and behavior (decrease in a learned pain behavior). If the dysfunction cannot be restored, it can be compensated. The external context during therapy includes the healthcare provider (physician, physical therapist, nurse) and the treatment area, generally restricted to an office or other enclosed environment. Communication between the patient and the healthcare staff occurs within this treatment area. The communication process is especially

determined by the characteristics and the current state of the patient and the healthcare provider, the patient’s direct experience from this relationship and similar relationships, the experiences facilitated by other people or, for example, the media. The relationship of the patient to the person administering treatment is co-determined by the perception and assessment of the healthcare provider, from the facilitated perception and perceived expertise to the actual perception and assessment during the therapy. The determining factors for the patient’s effective motivation include a goal, goal importance, subjective perception of the probability of its achievement, perception of the abilities of the healthcare provider and the perception of one’s own chances and dispositions to achieve this goal. The estimation of one’s disposition to contribute to a positive goal depends on self-perception and selfassessment as being able to master challenging situations by one’s own strengths and self-perception as dependent or independent on the external environment. A patient, who perceives themself as able to handle challenging situations, feels less dependent on the external environment and accepts the healthcare personnel and has a greater chance to recover than a patient who passively awaits the treatment results only as a result of the healthcare provider’s efforts. For example, an effective treatment and rehabilitation of chronic pain conditions depends on the patient’s active attitude and their willingness to be treated. The passive attitude of “I want to be treated” without any active contribution negatively influences therapy and rehabilitation and it is a significant predictor of psychological and chronic pain and learned pain behavior. Patients with chronic pain and a passive attitude prefer bed rest, administration of oral medication, injections, infusions and surgical procedures and refuse active rehabilitation and activity in general. Patients with an active attitude show the opposite preferences. Spontaneous preferences and demands of invasive treatment methods are a significant predictor of psychological chronization of a pathological state. This attested conclusion can be generalized: an active attitude toward rehabilitation is a significant factor of its positive effect.

Another significant aspect of the interaction between the patient and physical therapist is the congruence between the expected rehabilitation effect by the patient and the treating personnel, with a determining influence including realistic modification of the patient’s expectations by the therapist. “Establishing” the level of aspired goals (expected results) should lead to the subjective perception of partial rehabilitation effects, but not strictly, just the successes. A complete dominance of failures or successes by setting unachievable or easily reachable goals does not motivate the patient. Predominantly, successes with occasional failures provide the strongest motivation. The optimal ratio of successes and failures depends on multiple factors. In general, the rule of concurrent action of a specific therapy effect, non-specific activity of the healthcare provider, trust in their abilities and the non-specific effect of result expectation (i.e., administration of medication) or used techniques (i.e., manipulation) applies. Expected success of therapy prepares the patient psychologically for its achievement. The charisma of the treating person acts in a similar fashion thereby increasing positive expectation. Both support the placebo effect as well as a significant component of therapy with a proven analgesic effect, the positive modification of emotions, decreased central projection of nociceptive stimulation activity, with demonstrated effects on the endocrine and biochemical stress markers (concentration of CRH, catecholamines) and analgesia (increased opioid concentration). Other changes can also occur (muscle tone, muscle relaxation, change in breathing pattern). The contact of the treating person with the patient should correspond to a relatively restricted context of a therapeutic unit and a comprehensive treatment. The healthcare worker defines this context at the beginning by “open and substantial lines of communication” through a willingness to listen to the patient and observe their nonverbal communication. They sensitively modify the exchange of information by decreasing, or tactfully rejecting, the patient’s impulses toward “invasion” of privacy. The communication is completed by a slightly formal farewell (i.e., “so this is it for today”). The emotional

context of therapy is given by the manual contact of the healthcare worker with the patient’s body, which can encourage the patient toward more relaxed communication, to release tension and encourage trust in the therapist as well as in the placebo component of therapy. Communication with a high emotional component; however, can also pose a risk. It can support the strong emotional bond with the treating person (transfer) or worsen latent neurotic disturbances. If the treating person perceives such a risk, they will conclude that the problem should be addressed by a different specialist – a psychologist or psychiatrist. For similar reasons, the therapist does not engage in communication with the patient outside the time and space spent in the treatment session. A patient’s possible attempts to continue communication is ended or its continuation can be deferred to the next rehabilitation session. The rehabilitation process can also be complicated by other concurrent events, for example, the patient’s family crises, problems at work and so on. Rehabilitation can also be used as means for other goals, such as when the patient perceives unsuccessful rehabilitation as a means to acquire disability payments. Similarly, motivation for rehabilitation can be a manifestation of an overuse of healthcare services, for example, by lonely individuals. In conclusion, it can be summarized that therapy effectiveness depends on the treatment goals, applied treatment method, the patient, the person delivering treatment, the environment and the interaction of all the above mentioned complex variables. Exact, evidence based findings for therapy are often absent because of the vast amount of influences. There are a number of typical problems, and the atypical “genuine events” are endless. Methods and approaches are available to address typical problems, or problems similar in nature, that do not differ significantly for individual patients, such as the physical therapy methods used after a total hip replacement. These can be therapeutic methods based on more or less strict principles or algorithm-based methods in strictly defined steps. Experience, skill, creativity and the ability to improvise are important in addressing unusual or unique problems. For example, there are so

many variables in vertebrogenic conditions that a universal approach can never be selected. Rehabilitation, similar to chess, applies the saying that a master knows the rules, but a grand master comes to light only where the rules no longer apply.

7.2.2 Treatment Rehabilitation Barbora Danielová, Petr Knotek, Pavel Kolář Treatment of psychosomatic patients is based on an objective clinical finding while using all common rehabilitation methods. Assistive examination methods are used; however, the testing should not be repeated or expanded unnecessarily. Medication is indicated with a tendency toward decreasing it over time. Recommendations regarding lifestyle changes, appropriate physical activities, ergonomics and good diet are important. The basic rehabilitation approaches – individual physical therapy, soft tissue mobilization, hydrotherapy and electrotherapy – also significantly influence the psychological aspect. A release in skeletal muscle tension in the entire body leads to psychological relaxation and vice versa. In addition, a release of neck tension substantially contributes to decreasing tension headaches and, in general, also other types of headaches. Soft tissue mobilization in patients with psychosomatic conditions, especially in patients with systemic muscle involvement, is performed with careful feedback control of the patient’s reaction as they often present with a decreased pain threshold. The pleasant manual contact or a charismatic therapist decreases psychological and muscle tension and decreases anxiety and negative emotions. Trust in a therapist and positive emotions facilitate therapy, assist in the placebo component of treatment and also lead to a spontaneous decrease of some negative states and reactions to unpleasant situations. Empathy and the ability to view a specific patient within the context of their life situation will facilitate rehabilitation effectiveness and allow for understanding of the potential seemingly unexplainable responses to therapy. Most rehabilitation methods are based on empirical experience

because they are empirically based. The patient benefits from a therapeutic method that is remedial, or at least the symptoms inhibit the effect. In order for a treatment method to be acknowledged, its effectiveness needs to be substantiated. Specific testing of the effectiveness of treatment methods should occur as soon as possible. Evidence provides the insurance companies with proof of objective effectiveness of reimbursed treatment approaches which is a requirement for each specialty (a requirement of evidence based approaches). The following are possible manifestations warning of probable psychosomatic involvement: Discrepancy between the level of subjective problems, clinical findings and diagnostic testing results Qualitative difference between the symptomatic presentation of the patient’s problems and symptoms of known pathological conditions Persistent problems after correctly established diagnosis and typical treatment approach or frequent recurrences Inconsistent symptoms including alternating various body systems, or polymorphic problems Psychological problems and unpleasant life events (i.e., family crisis, prosecution, loss of a loved one) Presence of personality risk traits, such as alexithymia (inability to perceive one’s own feelings); tendency to suppress negative emotions, especially anger and anxiety; inability of rest; restlessness and a need for an increased level of stimulation A patient’s difficult social surroundings and other stressful environmental influences, especially in connection with an inability to solve these situations by their means A personality disposition that perceives the environment and one’s life as processes that cannot be influenced, including the expectation of negative future (pessimism) If psychosomatic involvement is suspected, attention should mainly be focused on the following areas:

The patient’s current psychological condition, current emotional state (mood), fatigability, sleep disturbances Lifestyle, extent of physical activity and physical fitness Facilitation of the current social context, especially assessing family problems and issues at work The patient’s course of life over time, dependence or independence of the patients’ problems on life events Supplementing the anamnesis and an overview of current problems with an interview of other family members or other people close to the patient During clinical assessment, the following possible signs of psychosomatic symptoms are assessed: Manifestations of increased neuroautonomic stimulation: all tendon and skin reflexes being symmetrical and more lively, increased pupil responsiveness, increased mechanical and idioneural stimulation (i.e., a positive Chvostek sign), increased pressure sensitivity or pain at neural outputs, occurrence of trigger and tender points, spontaneous or palpatory muscle pain, sensitivity of girdle or proximal musculature, functional tremor, cardiovascular system response (i.e., presence of more significant respiratory arrhythmia and orthostatic hypotension), increased dermographism, reddening, paleness, presence of acrocyanosis and increased perspiration Muscle tension, its overall condition, changes in individual body parts and changes with function Movement stereotypes, including the breathing pattern (especially superficial breathing, in which the expiratory phase does not completely occur) Presence of active incisions Overall feeling about the patient Physical Therapy Approaches Physical therapy approaches emphasize movement and movement experience. The most known approaches include the Alexander and Feldenkrais approaches and certain types of soft tissue mobilizations

can be included here as well. The goal is to increase awareness of one’s body, the way it moves, increasing movement coordination and attaining new movement patterns.

7.2.3 Psychotherapy Minimal psychotherapy should accompany every systematic rehabilitation. The foundation is a cognitively behavioral minimum, which includes control and modification of the patient’s opinions regarding their problems and establishing realistic expectations and limits of the rehabilitation process. During rehabilitation, the patient’s lifestyle, their diet and sleep routines, and the selection and dosage of physical exercise, including appropriate aerobic activity, are checked and modified. In a number of patients, family cooperation is necessary, especially to correct possible hyperprotections leading to passivity or for a deeper understanding of a patient in some systemic diseases that substantially decrease their performance and physical abilities, usually seen when the family refuses to understand and respect. In many cases, psychotherapy administered by a specialist is necessary to affect the psychosomatic symptoms. This can be individual, group or family based psychotherapy. As already mentioned, primarily cognitive behavioral therapy and adequate patient education are important for longer lasting non-malignant pain conditions. In irreversible conditions (oncological diseases, amyotrophic lateral sclerosis, etc.), existential psychotherapy and similar approaches that assist in the restoration of finding an appropriate purpose in life under the conditions of vital existential changes (i.e., after post-injury paraplegia) or to minimalize suffering and assist in dignified life closure while facing death seem to be more suitable. The psychosomatic issues should be sensitively explained to the patient and the patient should be directed to a psychotherapist. This conversation is done at the moment when a good relationship with a patient has been established and when the patient trusts the therapist

regarding the therapist’s attempts to find the best solution. Often, the patient needs to know that we do not need to say goodbye in this way. Even for this reason, it makes sense to combine rehabilitation treatment with psychotherapy. It is beneficial to find several cooperative psychotherapists, best to find one with a psychosomatic specialty, with whom the therapist can communicate regarding their patients. A patient also most easily accepts someone whom the therapist knows or recommends. Often underappreciated are very significant psychotherapeutic approaches involving self-regulation techniques. These include selftraining approaches based on Schultz, Machac and Jacobson’s muscle relaxation. These approaches facilitate muscle relaxation with subsequent positive changes in autonomic and psychological areas. The approach based on Machac further facilitates positive neuropsychological activation and transforms negative emotional moods into positive ones. A similar effect is also seen in controlled diaphragmatic breathing. Every physical therapist should know how to apply this technique. Organizationally, it is very difficult to achieve an effective connection between specific physical therapy techniques and psychotherapeutic techniques involving work with the body. Perspectively, we expect a highly effective link between physiotherapeutic approaches (especially with manual contact) with concurrently performed psychotherapy. This approach will require qualifications both in physical therapy and psychotherapy. In the context of dynamic psychotherapy in psychosomatic disturbances, it needs to be noted that in the acute or subacute phases of psychosomatic disease, it is important to at first stabilize the psychological state and prevent exacerbation of eventual latent psychopathology and to prevent the onset of a learned pain behavior. This is accomplished by the above mentioned approaches. If the patient is treated in this aspect and the subsequent ”psychogenic chronization” is stopped, it should be considered if another psychotherapeutic activity should be utilized, including systematic

dynamic psychotherapy. This therapy then usually occurs in a “closed psychotherapeutic space” between the patient and the therapist. Close cooperation with a rehabilitation specialist no longer occurs.

7.2.4 Psychopharmacotherapy In certain cases, treatment involving the administration of medication affecting a patient’s mental condition can be appropriate. Most often, these include antidepressants, anti-anxiety medication and hypnotics. In more complicated cases, cooperation with a psychiatrist is appropriate as well. Psychological deficits can significantly influence the picture of somatic grief. A combination of such disturbances and somatic problems is usually confusing diagnostically. Pharmacotherapy of such a combination is often complicated because many medications influencing somatic symptoms, such as pain or spasms, have an effect on the psychological processes and, in contrast, psychiatric indication of medication can often neglect a possible effect on the pain mechanisms. As an example, certain antidepressants (for example, tricyclic) help with chronic pain while others do not. Insufficient coordination of psychiatric and somatic therapy can lead to polypragmasia or to unpredictable interaction, especially in systemic psychosomatic or somatopsychological disturbances, among them fibromyalgia or chronic fatigue syndrome.

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Chromý K, Honzák R, eds. Somatizace a funkční poruchy. Praha: Grada Publishing 2005. Knotková H, Dmochowská J, Sibirceva U, Flor H, Cruciani RA. Cortical Reorganization in the Complex Regional Pain Syndrome. In: Merrick J, ed. Pain Management Yearbook – 2008. New York: Nova Publishers 2009. Knotek P, Blahuš P, Knotková H. The Psychological Structure of Chronic Pain: Factor Analysis. Stud Psychol 1997; 39: 27–37. Knotek P, Knotková H. Psychological Processes in Chronic Pain: Structural Model. In: Merrick J, ed. Pain Management Yearbook – 2008. New York: Nova Publishers 2009. Kolář P. Vertebrogenní obtíže a stabilizační funkce páteře – terapie. Rehabil Fyz Lék 2007; 14(1): 3–17. Kull K. On Semiosis, Umwelt, and Semiosphere. Semiotica 1998; 120(3/4): 299–310. Melzack R, Casey KL. Sensory, Motivational and Central Control Determinants of Pain: A New Conceptual Model. In: Kenshao D, Thomas CC, eds. The Skin Senses. Illinois: Springfield 1968: 423–443. Melzack R, Wall PD. Pain Mechanisms: A New Theory. Science 1965; 150: 971–979. Penrose R. Shadows of the Mind: Search for the Missing Science of Consciousness. Oxford: Oxford University Press 1994. Poněšický J. Psychosomatika pro lékaře, psychoterapeuty i laiky. Praha: Triton 2002. Popper KR. The Logic of Scientific Discovery. London: Routledge 1994. Price DD. Psychological Mechanism of Pain and Analgesia. Seattle: IASP Press 1999. Russell IJ, Bieber CH. Myofascial Pain and Fibromyalgia Syndrome. In: McMahon SB, Koltzenburg M, eds. Wall and Melzack’s Textbook of Pain. 5th ed. London: Elsevier 2005: 669–681. Ventegodt S, Andersen NJ, Merrick J. Holistic Medicine: Scientific Challenges. Sci World 2003; 3: 1108–1116.

8 REHABILITATION IN PSYCHIATRY Barbora Danielová, Petr Knotek, Pavel Kolář Rehabilitation assistance for patients with psychiatric involvement is aimed at the treatment of their disease and presumes to view their condition along biological, psychological and social aspects. In specific approaches, it is especially important to apply and coordinate a comprehensive rehabilitation approach. The first section of this chapter focuses on the social, vocational and educational components of rehabilitation. The second section explains that therapeutic exercise is a very suitable alternative supplementation to treatment principles for a mentally ill individual.

8.1 REHABILITATION IN THE AREAS OF SOCIAL AND VOCATIONAL FUNCTIONS A discipline known in scientific literature as psychiatric rehabilitation, or psychosocial rehabilitation, is a field that deals with rehabilitation in the areas of social and vocational functions. The extent of psychiatric rehabilitation is defined by its mission and that was described in the 1980’s by William Anthony and his colleagues. According to these authors, psychiatric rehabilitation should help people with mental involvement to strengthen their ability to function so that they become successful and satisfied in their selected living environment and do so with the least amount of permanent professional support (Anthony et al., 2002). The focus of rehabilitation is then the strengthening of one’s own abilities and skills while decreasing assistance from others. Social and vocational rehabilitation dominate in psychiatric rehabilitation. The rehabilitation results should correspond to the environmental demands (success), as well as, to the person’s inner satisfaction (contentment). The living environment must be selected by the individual themselves, should not be determined only by the wishes of others and should allow for the use of various options of environmental protection. Theoretical concepts of rehabilitation are based on the fact that current psychiatric treatment can decrease or inhibit symptoms of severe psychological disturbances. However, it cannot decrease the functional deficit (disability) that arises from the disturbance (Anthony and Liberman, 1986). A number of patients with psychological involvement can live outside a hospital setting; however, their quality of life is limited by their functional deficits. Therefore, psychiatric rehabilitation is a component of community care and shares a number of common features with it. Development of Psychiatric Rehabilitation in the World and in the Czech Republic Development of modern psychiatric rehabilitation can be dated back to after World War II, when post-war federal vocational rehabilitation

programs were expanded in the USA and Great Britain from including physically handicapped individuals to individuals with mental illnesses. The first movement of psychiatric rehabilitation was implemented “from the top”, i.e., British and American federal revenue allowed for de-institutionalization (substantial decrease in the number of beds in psychiatric facilities/treatment institutions) and a formation of community centers for mental health that included rehabilitation. The principles of accessibility, complexity and continuity of services were introduced to rehabilitation, which led to new forms of care, such as, case management, advocacy, the self-help movement and assertive searching. However, later, the community centers were criticized in that they tended to be more dedicated to “healthier” patients. The second movement, “from the bottom”, was introduced by the development of activity centers that were founded by people with experiences with psychiatric treatment. These self-help centers started to hire professionals, including social workers. Mutual help and a belief in the productive potential of individuals with mental illness are the main features of the center’s activities. These centers did not deviate from the focus on severely and chronically ill patients. The centers developed certain rehabilitation programs that were later utilized outside their scope, for example, transitional employment. The development of psychiatric rehabilitation in the Czech Republic did not follow the world trend. Until 1989, rehabilitation was linked to the hospital environment and psychiatric institutions administered various forms of vocational therapy. After 1989, the first non-federal, non-profit organizations began to emerge that focused on providing psychiatric rehabilitation. These were first organizations that developed the principles of community care in mental health. Non-profit organizations providing rehabilitation are currently overseen by two organizations: the Association of Community Services (www.askos.cz) and Fokus – Association for Mental Health (www.fokus-cr.cz). Another stream after 1989 included the emergence of psychotherapeutic day cares,

from which a substantial amount is devoted to the treatment of patients with serious functional deficits. In contrast to other countries, day cares interlink psychotherapy with psychiatric rehabilitation.

8.1.1 General Aspects of Psychiatric Rehabilitation Current Schools of Psychiatric Rehabilitation Today, the term psychiatric rehabilitation encompasses many different approaches and activities. However, all of them have common elements. They attempt to give the patient hope for a better future, stress the importance of work and meaningful daily activities and the necessity of the patient’s inclusion into the rehabilitation process. Another common feature is the prolonged nature of the rehabilitation, which exceeds the limits of individual institutions (Bachrach, 2002). Three main movements in rehabilitation are distinguished based on the place of origin: 1. The Boston movement, which is represented by W. Anthony and known as the developmental model. It emphasizes skill development and the benefit of learning. A patient is mainly a student. Rehabilitation maximizes health in contrast to treatment that minimizes symptoms. It implements the concept of rehabilitation readiness (Anthony et al., 2002). 2. The Los Angeles direction whose main representative is R. P. Liberman. It develops in detail the training of social skills, develops strategies for problem solving, monitoring symptoms and functional assessment or assessment of stress factors. 3. The British model is represented by G. Shepherd and D. Bennett. British tradition prefers a carefully formed system of care and modification of the environment in which the patient – a “conscientious recipient” – lives. Bennett warns that a person’s reaction and behavior in a certain situation depend on the nature of their surroundings. Skills learned in a controlled and supportive environment do not automatically carry over to the common, uncontrolled environment (Watts et al., 1983).

Target Group of Psychiatric Rehabilitation Psychiatric rehabilitation focuses on persons with short- or long-term mental illness that results in the possibility of a significant disruption in psychological, social and work abilities and functions. A classic definition of a target group of patients with long-term mental illness is presented by Liberman. It is characterized by the three “D’s” (disease, duration, disability) schizophrenia, emotional disturbances or personality disturbances. Further, it is determined by the duration of the illness being longer than two years and, finally, by a presence of disability. Disability can be defined as a state that limits a person’s activity or function and requires securing a greater number of services over a longer period of time (“Rehabilitation Act” from 1973 according to Anthony et al., 2002). In recent years, the term chronic or long-term mentally ill has not been used as much due to its stigmatizing connotation and the term severe mental illness (SMI) has been used instead (Goldman et al., 1981). It is newly defined as severe and persistent mental illness (SPMI) (Anthony et al., 2002). Principles of Psychiatric Rehabilitation The principles of psychiatric rehabilitation were pursued by a number of authors and, although they all emphasize their various aspects, they basically agree on the principles that have been presented by Anthony et al. (2002). These principles include the emphasis on improvement of the skills and competencies of a patient with mental involvement, improvement of behavior in an environment that they need, improvement of skills in the area of living, education and work and the integration and active participation in the rehabilitation process. A temporary increase in dependence can lead to gradual independence. Two basic interventions of psychiatric rehabilitation include the development of the patient’s skills and expansion of assistive resources from the surroundings. Long-term medication treatment is often necessary but rarely a sufficient supplement of rehabilitative intervention. Psychiatric rehabilitation is versatile in using various techniques. Hope is the main component of the rehabilitation process. Psychiatric rehabilitation, from an insider’s view, is identified by key

rehabilitation values and draws from them (Farkas et al., 1989). These are orientations to a person (and the relationship between a professional and the patient undergoing rehabilitation), function (in place of symptom reduction or achieving an insight), support (only to a point when it is needed and wanted), environment specificity (rehabilitation focuses only on a specific context in which the patient with mental illness functions), integration (an individual with functional limitation is an active partner in rehabilitation), selection (emphasis on the patient’s human rights), orientation on the result and growth potential. Rehabilitation focuses on improving success and satisfaction of the rehabilitated patient without taking into consideration whether the patient currently encountered any difficulties. Every patient has the potential for growth even if they display a momentary plateau (Strauss et al., 2002). J. P. Wilken and D. Hollander highlight the following rehabilitation principles: emancipation (restoration of social roles, promoting status and rights), normalization (effort to fulfill social roles as much as possible; the patient’s behavior minimally deviates from normal society) and participation (patient’s gradual contribution in the process of decision making until complete autonomy is achieved). A person with severe mental illness requires a continuum of care from hospitalization to maintenance and long-term therapy. Rehabilitation needs to be initiated as soon as possible after disease onset (Prokupek, 1971). A team approach needs to be utilized and should include healthcare specialists (psychiatrists, nurses, social workers, vocational therapists), the patient and their family. Only in this way can optimal care be achieved (Flexer et al., 1993). The entire system of mental healthcare should provide support through hope, encouragement of the patient’s personal responsibility for their health and assistance in developing their own life beyond the limits of their illness (Torrey et al., 2000). Recovery

Rehabilitation assists an individual with psychiatric involvement in their recovery process. The term recovery is sometimes translated to Czech as recuperation. Recovery is described as a deeply personal, unique process of change in a person’s attitudes, values, emotions, goals, abilities and roles. It means experiencing a satisfying, hopeful and valuable life despite the limitation caused by the illness. It includes establishing a new sense and purpose in a person’s life (Anthony, 1993). Thus, it does not mean a complete cessation of symptoms, but successful life adaptation despite persistent symptoms, which is analogous to healing by scar formation (per secundam/secondary healing) in somatic medicine or adaptation to paralysis. Patients with mental illness often need to recover from a stigma, often internalized by the patient, from the iatrogenic effects of unemployment or unfulfilled dreams (Anthony, 1993). D. Fisher offers a comparison of different content of a 7-dimension recovery process between an individual with acute schizophrenia and an individual who has already undergone the recovery phase (Tab. 8.1.1-1).

Tab. 8.1.1-1 Comparison of individuals with schizophrenia to individuals in recovery (Fisher, 2006)

Based on research of the most important topics of recovery, individual phases of the recovery process were established during its course, including their essential context (Young and Ensing, 2002).

These include: 1. Recovery initiation – overcoming being “stuck” (realization of illness, motivation toward change) 2. Middle phase – regaining the lost and shifting forward (taking active control and responsibility for one’s own life, understanding one’s self, understanding the relationship between self and illness, understanding life in the world, ability to take care of self, ability to be active and socialize with others) 3. Late phase – improving quality of life (increasing self-respect, feeling of ”normalcy”, finding a purpose in life, improving the standard of living or increasing independence) The recovery process is possible to apply in patients with psychosis. Long-term studies following patients with schizophrenia have shown that most people suffering from schizophrenic psychosis do recover (Harding, 2003).

8.1.2 Process of Psychiatric Rehabilitation and Possible Approaches Process of Psychiatric Rehabilitation According to the Boston School The process of psychiatric rehabilitation is listed in Tab. 8.1.2-1).

Tab. 8.1.2-1 Process of psychiatric rehabilitation)

Diagnostic Phase The diagnostic phase begins with the assessment of readiness for rehabilitation, or during inadequate readiness, by planning an intervention and a support that would lead to greater readiness, called readiness development. Readiness is a necessary measure of the patient’s motivation to achieve a task and their competence to take responsibility for their own decisions. During the assessment of readiness, it is especially important to notice the so called readiness indicators, which include the following: a need for change (the level of dissatisfaction with the current condition), decision to change (to what extent the patient is determined to make changes in their life, motivation), social seclusion

(to what extent the patient is open to contact with others), realization of self or awareness of the environment (to what extent the patient is aware of the difference between the environments, awareness of a possible better environment in the future) (Farkas et al., 2000). Readiness development is suggested as a complex or combination of approaches so that they can assist the individual in increasing their awareness about recovery, rehabilitation, environments, themself or psychiatric services (visits from such services, self-help groups and psychotherapy). Forming a work alliance and relationship with the patient as a necessary means for establishing the patient’s general rehabilitation goal is another task of a rehabilitation specialist. At the same time, the specific environment is identified that the patient desires for living, learning, socialization or work in the next 6–24 months (for example, starting a job, selecting more independent living). To establish a goal, a series of interviews must be performed and they are based on the patient’s values, experiences and advantages or disadvantages of the environment that can be utilized as alternatives to the current state. In this phase, special attention needs to be paid to potential situations, in which the goal is not fully understood by the rehabilitation worker or the rehabilitating patient. If the rehabilitation goal has already been established, a functional assessment follows with focus on the selected goal. A list of critical skills is established that the patient needs to master in order to be able to achieve their goal and find out which skills need to be further practiced and developed. Functional assessment examines the frequency of using the critical skills and describes the observed behaviors and situations when these skills are used (what, where, when and with whom). It also provides a picture of the strengths and limitations of such skills. Besides skills, the critical resources of support from the environment (resource assessment), which allow for goal accomplishment, are assessed. The critical resources include people, places, activities or objects. Similarly, the observable characteristics and circumstances are accurately described. Resource

assessment should point out the need to develop interventions to achieve some particular resource (Anthony et al., 2002). Planning Based on the results of the previous assessment, the rehabilitation specialist and the patient establish a plan to develop skills that also include the specific selection of required interventions. This plan also includes a plan for resource development from the surroundings (i.e., involvement of family and coworkers) (Anthony et al., 2002). A rehabilitation specialist assigns each goal of skill development or resource establishment to a specific intervention and a specific person who is responsible to administer the intervention. The rehabilitation specialist and the patient both sign the rehabilitation plan as an indicator of agreement. More people are often included in the administration of interventions. The realization of the rehabilitation plan then becomes a team approach. Each member of the team has a strictly defined task within the plan, as well as, observable goals that should be accomplished by their interventions. Intervention Phase Psychiatric rehabilitation interventions develop the patient’s skills as well as the resources for their facilitation. The skills can be developed either by direct training in a controlled environment (direct skill teaching) or by programming (skill programming), which means their utilization in a natural environment. Skill teaching presumes that the patient does not possess the appropriate skill. Skill programming is a continuation of an already acquired skill, but the patient is not able to apply it in a specific environment. The barriers preventing the utilization of the skills are identified and overcome. Skill teaching and programming can complement one another and skill training can be a continuation of programming. Assistance in the development of support and resources from the environment are an important aspect of the rehabilitation process. Resource coordination means “to connect” the rehabilitating person with an already existing resource by:

1. Selection of the most appropriate resource that fulfills a given goal (i.e., selection of transportation means that the patient will regularly use to get to a certain activity) 2. Actual connection of the patient to the selected resource. Resource modification is a technique that adapts the existing resources so that they better meet the patient’s needs. A rehabilitation specialist then seeks changes with the resource providers within the community that would meet such needs (i.e., changing a work schedule or decreasing work hours in a temporary occupation). Process of Psychosocial Rehabilitation According to the Netherlands’ School STORM Wilken et al. (1999) describes psychosocial rehabilitation as a comprehensive and eclectic approach containing the individual, as well as, the interpersonal and refers to it as a comprehensive approach to psychosocial rehabilitation (KoPPR). This approach sets as a goal both an improved quality of life and the need to address all levels of function: the individual, their surroundings and society. A fundamental component of the comprehensive approach is the holistic concept of rehabilitation. The environment is divided into 4 domains in which an individual can develop: living, work, learning and leisure time. Personal satisfaction can be achieved in four essential aspects of life, so called personal domains: personal care, health, meaning and purpose and social relations. The concept of quality of life is another component. Desires and needs are ascertained according to the current or desired quality of life. Rehabilitation is a process that occurs in three dimensions: the relationship dimension, activity dimension and time dimension. Rehabilitation acts in a triad of the patient – the professional – the relative. The long and short cycle of KoPPR describes the phases of the rehabilitation process. The short cycle can be utilized in work oriented to solving a problem – the problem is analyzed, a goal is established and a solution to the problem is being addressed, all in a relatively short time period.

The long cycle is oriented more toward the long-term perspective and it focuses on finding the most suitable plans for the future. During this cycle, the short cycle is used to remove obstacles that stand in a way of the patient’s desires or quality of life.

8.1.3 Specific Levels of Psychiatric Rehabilitation Vocational rehabilitation Vocational rehabilitation can be defined from the perspective of a professional, as well as, from the perspective of a patient with a psychiatric illness. From the perspective of the professional, occupational rehabilitation consists of all activities that lead to recovery, toward maintenance and to further development of work competencies of the rehabilitating individual in all work situations (van Weeghel et al., 1990). These activities have two aspects: 1. Work readiness of the patient with mental illness 2. Retrieval or creation of adequate work activity, work position for the patient with mental involvement (Wilken et al., 1990) From the patient’s perspective, work rehabilitation facilitates selection, acquisition, maintenance of a suitable occupation (the so called choose, get, keep model according to Anthony) and its completion (Michon et al., 1999). The functions of vocational rehabilitation provide a picture about what kind of benefit can be expected from vocational rehabilitation. The following functions can be distinguished in vocational rehabilitation: Preparation (various forms of work orientation, pre-occupational training or education) Adaptation (i.e., mediation of vocational rehabilitation) Assistance under controlled work conditions Assistance under regular work conditions, including influencing the working environment (Michon et al., 1999) Work integration of outpatient long-term care patients with mental

illness does not exceed 10%, which is less than in individuals with a physical handicap. Despite this, 60% of people with mental health problems wish to work (van Weeghel et al., 1990). Greater work integration of patients with mental illness is limited by external barriers (unemployment, preference for the most productive workers, stereotypes and prejudices toward patients with mental illness, lack of work positions in a safe environment, preference for workers with a physical disability rather than a mental disability in positions available for workers with disabilities) as well as the patient’s internal barriers (severe symptoms of mental illness, inadequate qualification and problematic job history, deficits in social and communication skills, negative self-image) (van Weeghel et al., 1990). A patient with mental illness can encounter a number of problems during their work career. Problems already occur during the selection of an occupation (lack of desire and motivation, inadequate judiciousness toward the requirement of the occupation). Another complication occurs during the job search (not knowing how to look for work, how to present as a competent and motivated candidate; unrealistic self-assessment – too low or too high). Finally, issues occur with the ability to maintain employment (slow working pace and poor concentration, more difficult adaptation to changing requirements and conditions, recurrences of illness). Adequate skills in social and emotional areas are also important for staying employed. In this context, deficits in relationships with supervisors or colleagues and a simple inability to talk about everyday things with coworkers form a barrier. Types of Vocational Rehabilitation Types of vocational rehabilitation usually include volunteer work, controlled (or supervised) workrooms, temporary employment, supported employment and assistive educational job centers. Volunteer Work In volunteer work, the patient can select the number of work hours or the type of activity. Volunteer work is sometimes implemented at the beginning of assistive employment. It is an option for the patient and

the employer to verify whether the work or the worker meet the expected needs should a work contract be offered. Controlled Workrooms In the case of controlled workrooms, work occurs in a controlled environment. Traditional workrooms in a hospital or outside a hospital setting are often criticized for establishing dependence on a supportive workroom environment for patients with mental illness. Also, they can use non-meaningful work activities that may not always allow for the establishment of the patient’s appropriate work skills and their confidence in future direct utilization in the job market. Although only limited evidence in clinical practice exists that this type of occupational rehabilitation leads to work skill maintenance or reestablishment, it remains a sole option for many patients with mental illness. Temporary Employment Temporary employment is based on the “job center” model and this is its integral component. However, many places are structured outside this model. Patients with mental illness who engage in temporary employment work for a limited time (usually 6 months) in regular part-time work positions outside their organization (most often they include administrative work, cleaning, etc.). The positions do not require any specific work qualifications. The only criterion to be included in the program is the patient’s interest to work and any previous assessment of work functions does not necessarily apply. At first, the assistants at temporary occupations try out the work positions themselves, test them and assess them, and only then do they train the patient. Therefore, the assistants work side by side with the patients for a period of time. During work, they provide ongoing assistance. The work is paid (usually based on the number of hours worked). In case an employed patient does not report for work, another patient with mental illness or the assistant themselves can fill in. Assisted Employment Assisted employment occurs as paid work under regular work

conditions with continuous assistance from a consultant or an assistant (Bond et al., 2001). The employment training begins by an assessment of the patient’s work capability and interests and individual work selection. The patient actively participates in the selection. This is followed by searching and securing employment and an interview leading to keeping the job position. Screening of work skills or pre-employment training usually does not occur (or only to a minimal extent). Work placement depends on the identification of the patient’s strengths from the initial assessment. Active participation of the family and the relatives, as well as, contact with society are encouraged. A consultant provides assistance not only to the patient with mental illness, but also to the employer (Becker et al., 2003). The fundamental principles of supported work were formulated by Bond (1998): a) regular work force is the goal; b) quick finding of a position; c) integration of services of vocational rehabilitation with other services of mental health, including medical services; d) attention to the preferences of the services’ consumers; e) ongoing and comprehensive assessments; f) assistance not limited by time. Assistive Educational Programs during Vocational Rehabilitation (Job Centers) A job center is a comprehensive, time-limited educational program for people who need help when searching for employment due to their health or other limitations. A job center program teaches the patient theoretically and practically how and where to look for employment, introduces them to their rights and responsibilities as a job seeker and subsequently an employee. It provides practical advice about how to handle specific situations related to the employment search (i.e., resume, advertisement, interview, first day of employment). Assisted Education The onset of mental illness usually falls during a person’s educational career. Incomplete or unrealized education then further complicates a

career of such involved individuals. Assisted education includes providing permanent support and assistance to people with mental illness in the area of education and personal growth. Assisted educational programs emerged approximately 15 years ago. Three main models can be distinguished (Mowbray et al., 1993; Pettela et al., 1996): The self-contained classroom model. These programs assist those patients who are enrolled in educational programs to establish work career goals and provide assistance to employment entry or for studies. They occur directly in the educational institutions The on-site model. This model emphasizes the search for utilization of available resources for other students. It uses existing services that provide care for patients with mental illness The mobile supported education model. It is usually organized as part of a larger psychosocial rehabilitation programs. The program participants individually select what and where they want to study. The program is more flexible in using various options of education and in incorporating psychiatric rehabilitation Rehabilitation and Housing Psychiatric rehabilitation in the area of housing should allow the patients with mental illness to live independently, improve the needed skills and self-confidence, assist them in creating a stable home and an environment facilitating the recovery process, allow for the separation from the primary family, develop alternatives for long-term hospitalizations in psychiatric institutions and allow for the use of regular public services. In the first decades of deinstitutionalization, the majority of former patients were discharged from institutions and returned to their families or into homes or they were simply left to take care of themselves in the housing market (Ridgway et al., 1990). With an increase in the proportion of mentally ill among the homeless, pressure from the patient’s families grew to establish assistive and rehabilitation programs. The gradual development of a linear system

of specialized residential services arose, called the “continuum of continued care facilities.” At the end of the 1980’s, this “continuum” was criticized and a new approach developed, the so called assisted housing, directly in the patient’s own house. In the Czech Republic, the first protected housing scenarios began to develop at the beginning of the 1990’s under the patronage of nongovernment and non-profit organizations. Linear Continuum of Continued Care Facilities A linear residential continuum contains several facilities (assisted housing with varied degrees of care, houses and apartments as halfway residences in the continuum of services) that provide a patient with mental illness a varied degree of assistance or supervision. The patient advances according to the continuum from the most restricted setting with numerous personal services to less controlled options. The patient should be integrated in an environment (program intensity) that best corresponds to their level of function (Ridgway et al., 1990). The basic characteristics of a continuum model of continued care facilities include the following: integration of housing and clinical services (case management with utilization of detailed, long-term plans of care), interchangeability (admittance to the system of services at any time where the availability of specialized assistance best meets the patient’s desires and needs), flexibility (allowing “going back” and adaptation to the patient’s changing needs), perception and sensitivity (observing possible stress producing influences of rehabilitation approaches that can be a cause of worsening health) (Bebout et al., 1992). The continuum system, however, has a number of disadvantages. A complete continuum of services is not readily available and if the services are available, they only serve a fraction of the patients in need (Ridgway et al., 1990). Each step during rehabilitation in the housing aspect can be a potential crisis situation whether it is a change in the place of residence or different concepts of care or the definitive termination of residential care (Rahn et al., 1999). Given the crisis in housing politics, the system of services becomes backlogged and the

waiting times for service admittance increase. In contrast to assisted housing, the continuum system is more financially straining. Typology of Residential Services and the Principles of Their Operation Residential community programs can generally be divided into three areas: 1. Programs for management of crises as an alternative to hospitalization, i.e., when an acute patient is secluded from their home environment. The goal is to handle the crisis and minimize the symptoms, return the patient to a regular environment as soon as possible and obtain outpatient medical care. These are treatment communities, short-term acute residential care crisis centers or Soteria programs (Switzerland, Hungary and Germany) (Aebi et al., 1994). 2. Programs focused on improving social functioning in as regular an environment as possible including skill training and strengthening, independence and the ability to handle stressful situations, cooperation with the surrounding community and an environment where they find the needed resources and assistance. These are more often individuals with a longer course of illness. This group also includes halfway housing (houses, apartments), assisted apartment complexes or the so called community assisted housing. 3. Residential programs focused on allowing quality of life for patients whose illness does not allow them to live in a regular community environment. These include, for example, houses and group houses with daycare and nursing care, residential services, i.e., for old individuals with permanent mental illness (certain permanent forms of controlled housing). Housing should meet the conditions of availability, maintenance (including protection from discrimination by renters), separation (in cooperation with specialized services, but not as their only part), sensitivity (allowing social roles at work, in the family, during studies and in social relationships) and acceptability (respecting the patient’s individual values, preferences and decisions) (Peace et al., 2001).

House residents should actively contribute to the functioning of the home in order to prevent excessive dependence on residential services. The relationships between the residents and their social roles need to be developed based on the principle of neighborhood communities rather than therapeutic communities. The length of stay should be limited (motivation factor) in programs aimed at a renewal of social functions. Activities and therapeutic interventions should take place outside of the home. The principle of normalization should be implemented in an effort to facilitate the most natural conditions (own mailbox, keys, daily regime as close as possible to normal household function). The most common areas of support that the housing services focus on, include home maintenance, homemaking (house cleaning and maintaining, cooking, laundry), self-care skills (personal hygiene, daily regimen, dressing), skills to search for and utilize regular (even specialized) public services, prevention of illness relapse, communication skills, fulfilling the role of a renter and a neighbor (active participation in residential living), leisure time, shopping, mastering safety risks, and financial management or transactions with authorities (paying rent, taking care of social security benefits, etc.). Assisted Housing Assisted housing developed with a goal in shifting the center of support from “social services” to home in an effort to reduce problems with homelessness and hospitalizations. The important elements of this model include individually focused services and the ability to live in a community. Also participation in its living and flexible services based on the patient’s changing needs, the long-term care unlimited by a “program completion” and the skill of learning options in a specific environment are important (Ridgway et al., 1990). Rehabilitation in the Areas of Social Interaction and Leisure Time The onset of a mental illness shatters an individual’s social roles because only the role of the patient persists. People often lose their original network of support due to the illness. A vicious cycle develops. People with psychosocial illness often have only a few social

roles, they have a limited social network and, at the same time, a difficult time making and maintaining social contacts (Wilken et al., 1999). The goal of rehabilitation in the social area of contact is comprised. Therefore, the rehabilitation of those individuals who, as a result of mental illness, demonstrate limited social and communication skills, lack sufficient or functional social support, do not possess clearly or sufficiently defined social roles or need assistance from the environment on their way to recovery is compromised. The functions of such programs include social role training (i.e., family, parenting, partner, professional roles), facilitation and increase of self-respect, restoration of communication with the outside world together with developing a social network, handling stress and support in selfsufficiency and independence. Barriers complicating the accomplishment of such goals arise from the outside (inadequate family support, outside world only find the patient’s symptoms as barriers rather than virtues), as well as, from the perspective of the patient (disturbance in cognitive or communication functions, hypobulia or lack of motivation). Assistance in social contacts may not be solely provided by formal services, instead natural assistance can also be looked for within the family, friends, colleagues or other patients. Actual services in this area can include activities at daycare centers and community centers that provide cognitive and practical assistance (assortment of information and advice), emotional support, deepening trust, motivation and ability or support of normalcy and recommended behavior.

8.1.4 Psychiatric Rehabilitation Assessment In recent years, a number of scientific studies provided new information, especially regarding rehabilitation assessment in vocational and housing areas. The general effect of vocational rehabilitation has been shown by the findings of a meta-analysis which included results of a number of

vocational rehabilitation programs that have not changed since 1955 (Bond et al., 1999). Vocational rehabilitation programs are consistently, although only slightly, successful in assisting the patients with acquiring and maintaining employment. However, the programs’ inability to prepare the patients for further regular employment without assistance appears to be their shortcoming. Besides improving work abilities and performance, better functioning in other social roles has been found. Hospital admission and re-admission occurred less often and the quality of life increased. None or only few and far between side effects have been identified. However, clear results were achieved by the supported employment program in the form of well documented program of Individual Placement and Support (IPS) (Bond, 1999). The program was assessed by randomized studies with the result that IPS leads to greater number of employed patients in an open job market compared to other vocational rehabilitations. It is also effective in the integration of assisted employment inside other psychiatric and psychosocial services (Crowther et al., 2001; Twamley et al., 2003; Drake et al., 2003). Nevertheless, the fact that nearly half of all patients in assisted vocation do not succeed also justifies the need for other types of psychiatric rehabilitation. Some studies show that supported education could improve social function, self-confidence, cognitive abilities and decrease hospitalization (Isenwater et al., 2002) or increase the patient’s integration into education (Collins et al., 1998). Fakhoury et al. (2002) summarizes the results of housing assessment studies by saying that controlled housing can bring about improvement in social functions and support social integration because patients are more satisfied when living in a community rather than with classic hospitalization. Research studies of supported housing are fairly new. However, they have shown that assistive living programs increase the resident’s stability and independence and decrease the occurrence of homelessness while, at the same time, living at home with assistance decreases the number of hospitalizations. So

far, however, the conclusions of these studies are yet to be confirmed by randomized studies (Parkinson, 2003; Chilvers et al., 2006).

8.2 PSYCHOMOTOR THERAPY Běla Hátlová, Milena Adámková From the perspective of psychomotor therapy, improving health is possible by strengthening factors, means and forms of behavior that improve overall resistance. Learning correct movement behaviors as a possible change in perception and appreciation is another tool. In 1952, Jean Piaget warned that movement patterns, mostly based on early pre-verbal experiences, were a tool for coping with life changes. If body movement is altered, a corresponding change in the psychological aspect should be expected. The foundation of a personal path is the understanding of one’s own “self”, its integration, boundaries and limitations in regards to the environment. Active movement activity develops the individual’s personality, their self-perception and self-assessment. Its psychological influence on personal development has already been demonstrated. Since the 1930’s, various rehabilitation movements and approaches have begun to develop independently of each other utilizing physical activity as a means of treatment. Many authors and institutions pursue movement therapy in patients with mental illness from various aspects. The therapeutic methods are closely interlinked with the therapist’s personal experiences. Often, they lack theoretical basis, diagnostic methods and only a few work with the control of biological feedback and knowledge of neural mechanisms. Their broader application depends on the personal transfer of experiences, which is why their effectiveness usually decreases when administered by a different therapist. Without the ability to adequately verify their activity, they remain, despite obvious shifts in the patient’s health condition, at the level of assistive therapies despite their ambitions to become the fundamental therapy, which is not unrealistic in follow-up care. Global utilization of such experimental “unverified” methods does not have an identifiable positive quality and, in certain cases, can act negatively.

The therapeutic methods, whose positive effect has been partially experimentally and empirically demonstrated, include the following: Psychomotor therapy (PMT): works with body awareness and movement behavior. This group includes: Kinesiotherapy: a Czech form of psychomotor therapy Field therapy: psychomotor therapy utilizing as a means of change of an experience with emotionally focused movement activities Psychomotor fitness training: psychomotor therapy utilizing as a means of change an experience during the execution of sport activities Body awareness therapy (BAT, BBAT): a therapy aimed at the physical experience of bodily perceptions during movements. They are aimed at body posture, coordination, breathing, perception of emotions expressed by movement, perception of others and nonverbal communication. Konzervative Bewegungstherapie: German system of psychomotor therapy focused on the body. Dance and movement therapy: a large, heterogenic group of movement therapies using expressive dance elements as a means to express emotions. Some movements possess partially supported effectiveness by diagnostic psychological or physical therapy methods. In the Czech Republic, kinesiotherapy began to develop as an area of movement therapy for psychiatric illnesses starting in 1990. Based on European classification, kinesiotherapy is a psychomotor therapy aimed at the prevention and treatment of psychological disturbances and psychiatric illnesses. Development of psychomotor therapy within Europe is coordinated by the “European Forum of Psychomotricity”, which was established in 1996 in Marburg, Germany. Currently, it associates 17 member countries and develops within the framework of the Plan for Strategic Development of the European Forum of Psychomotricity 2006–2010.

Psychomotricity has two branches: educational and therapeutic. The therapeutic branch is coordinated by a newly formed European association known as “Physiotherapy in Psychiatry and Mental Health” and was founded in 2007 in Bergen in Norway. The Czech Republic is a member of both Associations.

8.2.1 General Aspects of Psychomotor Therapy Research in Kinesiotherapy In the last decades, very small attention has been paid to the research of non-pharmaceutical treatment in psychiatry. Kinesiotherapy is an empirical discipline. Scientific research is one of the conditions for its further development. However, the so far the published studies only partially meet the criteria of scientific research. Current research in kinesiotherapy mainly asks the question of kinesiotherapeutic effectiveness and an effort is made to compare the effects of individual approaches. The methods of kinesiotherapy can be considered effective. However, their action is not only positive. A possible negative effect also needs to be presumed. Physical Self-Concept Our self-perception and self-assessment significantly affect our behavior and experiences. Psychomotor therapy asks the question about what place a physical self-concept has within the structure of an overall self-concept. Self-concept is the study of personality psychology. Its development is studied by ontogenetic psychology while cognitive psychology studies self-concept formation. Psychotherapy deals with correction of deficits in self-concept. There is an abundance of various opinions regarding the issues of selfconcept and the related research, which makes this subject difficult to fully capture. Body self-concept is a component of the overall structure of perception of one’s own “self”. Self-concept is a structure of conscious self-reflection within the context of achieved knowledge preserved in memory. Body self-concept within the framework of self-perception

has been developed by Fox (2000) and, in the Czech Republic, by Tomesova (2005). Role of Movement Activity in Stress Coping Movement activity can act on decreasing reactivity toward psychological stress through the feedback between physical activity and the slower physiological response (as a result of adaptation). It mainly includes decreased reactivity in the form of heart rate, or decreased catecholamine response during stress and in the recovery phase (Solcova, 1994b). Besides body functions, regular exercise also strengthens emotional functions. It functions as a mental detour and as a way to release emotions or tensions. It has positive short-term and long-term effects on self-experiences, mental well-being and a positive influence especially on anxiety, depression, tension and stress perception (Solcova, 1994b). The function of physical activity is important for a distraction from stressful thoughts. According to Solcova (1994a), this mainly occurs through cognitive processes and with them associated emotions rather than through direct physiological effects. V. Hosek (1997) classified the effects of movement into psychoregulatory and stress reducing. He considers anxiety as a significant outcome of stress. Its influence on physical activity occurs by diverting the process of thinking to stimulation and a change in assessment of the symptoms that led to the anxiety. Somatic State and Movement Abilities of Patients with Mental Illness Physical fitness and physical activity of patients with mental illness are usually significantly worse when compared to a non-clinical population. Also, the extent of participation in leisure activities is decreased (Hatlova, 2003; Probst, 2006). Poor physical fitness in patients with mental illness is linked to illness pathology. It is presumed that increased or decreased irritability of such patients often elicits fears from further exertion, which is the reason why they avoid

it. According to some research (for example, Eckman, Friesen, 1997; Hatlova, 2003; Probst, 2006), poor physical condition also has other consequences. It has been observed that patients with mental illness demonstrate decreased motor and manipulative abilities from childhood age, which, together with decreased communication abilities, reflects poor attributes for integration into childhood social environment (Wedlichova, 2003). It is known that movement skills represent an important aspect in the child’s role within a group of children. Children that get to the outskirts of communication limits in a group become lonely and, therefore, it is possible that in some such individuals a full development of social skills and the formation of a social identity do not occur (Langmeier et al., 1998). Why Movement Therapy? The following can be the components of mental illnesses: Disorganization of psychological functions Biased perception Disturbance or loss of movement schemas (movement pattern behaviors) Change in body stability, change in center of mass Uncoordinated body parts Loss of boundary of “self” For patients who are losing the perception of body wholeness and its functions as well as the ability to control their body, therapy focused on body perception and work with the body is suitable. A transfer of experiences from a body area to the mental and, later, social components is presumed (Spurkova, 2003).

8.2.2 Kinesiotherapy Kinesiotherapy attempts to use movement in the broadest sense of the word to gain access to a patient and, through their personal experiences, influence their mental state from the aspect of awareness of their own psychosomatic “self” and its potential. Circumscription of the term Kinesiotherapy

The purpose of psychomotor therapy, or kinesiotherapy, is to facilitate the individual’s active participation in therapy, assist them in discovering ways to approach their problems and leave them space to explore these pathways by themselves. Nonverbal elements are emphasized and the need for communication is gradually prompted. Kinesiotherapeutic programs model situations in which the patient examines and develops their abilities that can be consequently transferred to other areas of life. Based on the patient’s limitations, the programs focus on the perception of self, its function and abilities to control it. In this way, the therapists act on a change in the patient’s experience and behavior and, through a new perspective of a new problem, they form awareness of options to cope with it. They are supposed to assist the patient in finding awareness of their “own mobility”, psychosomatic unity, restore their own positive selfacceptance, integrity, emotional spontaneity, creativity, body symbolism and the ability to communicate. Initially, the ideal situation can be perceived as unmanageable. However, under the guidance of a therapist, the patient is guided to overcome fears from unmanageable situations and then to gradually verify their abilities and competencies. They are stimulated to utilize and later further develop internal and external resources to handle stress and subsequent growth in self-control. Verification of one’s own abilities can lead to the establishment of self-trust, but also mutual trust and communication with others. Movement quality is an indicator of the patient’s actual psychosomatic state, health and illness. Kinesiotherapy offers the possibility of application of specifically focused movement programs in the prevention and treatment of mental illnesses. Based on the patient’s limitations, movement programs focus on their perception of self, their functions and options for their control, development of self-confidence by verification of their own strengths (exercises using overcoming non-traditional obstacles; exercises may be modeled outdoors or indoors), and development of mutual trust and communication (situation modeling; which solution requires mutual co-operation and communication).

Kinesiotherapeutic programs always maintain conditions for the establishment of a trusted relationship with the therapist, for forming a nonthreatening environment and adequate physical and psychological stresses that gradually rise to the upper threshold of manageability. In this way, the patient’s active approach toward themself and verification of their strengths are stimulated, thereby shifting the threshold for perception of their own abilities and competencies. Actions of Kinesiotherapy Kinesiotherapy as a somatotherapeutic activity assists the patients in regaining the following: Movement awareness. This includes awareness of one’s own body, its abilities and subsequently the ability of self-body control. Positive experience assists in developing and reinforcing a body schema Psychosomatic unity. Movement is one of connecting links between the internal and external worlds. Intentional and actively executed movement is a simultaneous physical and mental activity. It serves as a means to express the physical and the mental aspects at the same time. Positive self-acceptance. The objective body schema often differs from the subjective body image. It is formed based on one’s own experiences with the internal and external environment, including interpersonal bonds that may not be realistic in psychological deficits. To allow for self-image restructuralization in a sense of its more positive acceptance, exercises with adequate difficulty need to be selected. Overly difficult exercises could activate defensive mechanisms Self-acceptance and integrity. During physical exercises, an individual is guided to become aware of their own body, its positions, course of movement, activity of self-movement expression and its meaningful aspects. At the same time, the patient perceives the movement of others in a way that the patient perceives them. Perception of their own movement and the movements of

others allows not only for confrontation, but also stimulates intentional self-regulation of one’s own movements. (The process of developing autonomy is especially important in patients with psychoses.) Body symbolism. Movement and body positions have a symbolic meaning. Therefore, it is possible to express ourselves through movement (mainly utilized in dance therapy.) Emotional spontaneity. The patient is often forced by life conditions to suppress their expression of emotions associated with the need to express their needs and desires. During the course of movement, the emotional manifestation is not limited and, in a number of programs, it is initiated and understood as an adequate component of self-expression Creativity. During its course, movement activities programmatically initiate spontaneity and creativity Social acceptance. During movement activity, it is presumed that contact can be established with greater ease through non-verbal communication. Therapy focuses on developing the awareness of participation and cooperation and on the initiation of cognitive and communicative processes Types of Kinesiotherapy in the Treatment of Psychiatric Patients Types of kinesiotherapy are developed while taking into consideration the patient’s involvement and their current psychosomatic state and the options available within kinesiotherapy so that the preselected personality components can be affected. Integrated and Focused Kinesiotherapy Integrated and focused kinesiotherapy works with the person’s healthy components so that their own “self” can be embedded in the external world through the influence of their own body schema perceptions as non-divisible unit. Simple gymnastic movements and positions are used. The patient is guided toward constant body awareness of it as a whole and in parts and the relation of body parts to one another and within space. The patient is required to actively participate. An emphasis is placed on

the quality of execution and self-control. The feeling of wholeness is considered the most important. Later, an emphasis is placed on perceiving body parts while at rest and in motion and on the ability to select and control a part of the body and, later, the entire body. By being aware of one’s own body schema, the extent of disintegration can be decreased. Kinesiotherapeutic Activation Programs Kinesiotherapeutic activation programs focus on the initiation of cognitive processes and motor skills. The programs use manipulation exercises, elements from sports and dance that restore and develop the patient’s movement abilities. An emphasis is placed on the accuracy of the execution of a movement structure and the positive experience from mastering a movement skill. Kinesiotherapeutic Active Relaxation Programs Kinesiotherapeutic active relaxation programs focus on the initiation of cognitive and emotional processes. They implement gymnastic exercises, dance and expression sequences and sport elements. The exercises are easily mastered; no demands are placed on performance. The goal is to establish a positive perception of one’s own self and to decrease tension (in a psychoanalytical approach, this can be used in a certain treatment phase in patients with neuroses, addicts and patients with behavioral deficits, an increase in tension can occur). The person’s healthy personality components are facilitated to stimulate their self-confidence, as well as, their trust in the environment and the possibility of experiencing pleasure and happiness. A positive emotional experience is emphasized. The accuracy in the execution of a movement structure is not important. Perceptive (Attention) Focused Kinesiotherapy Perception focused kinesiotherapy leads to a conscious observation of executed movement and its effect. It regulates breathing, muscle tone, arises from the knowledge of mutual relations between the mental and motor activities and the possibility of them influencing each other. Gymnastics exercises, relaxation and breathing exercises as well as elements from hatha yoga are implemented.

It requires the patient’s active participation. An emphasis is placed on the quality of execution, experiencing self-movement and selfcontrol. Kinesiotherapeutic Programs Increasing Self-Confidence and Confidence in Others These programs focus on the initiation of cognitive and volitional processes. Through modeled exercises that include elements from sports and games, the patient can assure themselves of their own abilities and potential. Exercises occur in small groups and are designed while taking into consideration the patient’s physical and mental potential. Their difficulty gradually increases. The content is designed based on the needs of verification or practice of skills. Emphasis is placed on mastering a task (Kirchner, 2005). Kinesiotherapeutic Communication Programs Communication programs are based on the presumption of easier contact establishment through non-verbal communication. They focus on the social dimension, perception of participation and cooperation and initiation of cognitive and communication processes. Elements of games and spending time outdoors are emphasized. Emphasis is placed on experiencing harmony with the surroundings. Therapeutic Utilization of Athletic Exercises Athletics-focused exercises mainly use the rules of the executed exercises that need to be followed. The emphasis is placed on strict adherence to the commands and prohibitions to become aware of order as assurance. Further, the patient is guided toward the options of their own creative approach when solving play scenarios and movement tasks (Kirchner, 2005). These programs are especially appropriate for long-term hospitalizations. For men, we recommend activities motivated by athletic performance. For women, activities motivated by music, dance and athletic performance are recommended. Suggested Forms of Kinesiotherapy for the Treatment of

Psychological Illnesses Based on present knowledge, it is presumed that the following movement programs will be appropriate for individual illnesses: Kinesiotherapy for the Treatment of Dementia Concentration-based simple gymnastics and breathing exercises accompanied by self-massage can be used in more severe forms of dementia. The patient is guided toward the self-awareness of their body, their parts and their unity. By becoming aware of their body schema, the level of disintegration can be decreased. Exercises can be performed while seated on a chair (Sucha, 2006). In milder forms of dementia, active relaxation programs can be used with application of gymnastics and dance elements. The focus is placed on maintaining and facilitating current cognitive, manipulative, psychological and social functions and the establishment of skills, knowledge and quality of skills. Integrationrelated exercises are utilized with awareness of one’s own body schema, its integration and potentials. Exercises focus on small object manipulation, nonverbal communication programs, communication programs with a simple form of cooperation and verbal communication. For men, elements from sports and games are utilized. For women, shorter active dance motives and exercises with music are recommended. Exercises are integrated within the treatment program on a daily basis. Each exercise session is 30–60 minutes long. Kinesiotherapy for the Treatment of an Addiction Syndrome Initially, perception-focused relaxation, health, tactile or yoga type exercises are included. Then, active relaxation exercises are recommended to decrease tension and encourage integration of the mental aspect. Gender differentiation is encouraged. In women, dance step variations and rhythmic exercises are recommended while for men, exercises from rhythmic gymnastics are preferred. In the next phase, programs increasing self-confidence and

confidence in others, and the ability of cooperation have been shown beneficial. Elements from outdoor games, problem solving movement games, as well as, rope courses are utilized. This combined program contains initiation and problem games. Integrated movement motives are also incorporated to strengthen self-confidence and confidence in others with potential risk and the need to overcome it. Rope courses are used to design difficulty of activity. The program difficulty gradually increases and they are indicated 3x per week. Exercises are implemented as a mandatory component of the treatment program. Exercises are appropriate for men and women, especially the ones addicted to drugs other than alcohol (Kirchner, 2005). Subsequent treatment offers movement programs with an aerobic component allowing for the specific influence of one’s self and the option of distinguishing themselves within a group by their own will. For men, running, athletic games, weight lifting and problem solving games are recommended. For women, running, gymnastics exercises with an aerobic component, athletic games and problem solving games are recommended. Exercises are integrated into daily treatment programs. Kinesiotherapy for the Treatment of Schizophrenia Schizophrenia may be positively influenced by stimulatory as well as perception-focused exercises, which, however, require appropriate execution. It is especially important to pull the patient from their autistic world and form a trustworthy and safe environment that prepares the patient for exercise and keeps them active. Acquired skills need to be transferred to the patient’s life (Spurkova, 2003). In severe forms of schizophrenia, integration exercises are implemented in the form of non-stressful positioning of body parts, simple gymnastic and breathing exercises. Accuracy of execution is emphasized. The patient is guided toward the awareness of their own body, its parts and wholesomeness. Awareness of one’s own body schema can decrease the level of disintegration. Exercises can be performed in low positions, including lying down. In milder forms of the illness, active relaxation programs can be

used with implementation of gymnastics exercises. These include athletic elements for men and exercises with music and small dance routines for women. The focus is on maintaining and supporting current cognitive, manipulative, psychological and social functions, and restoring and developing earlier or new skills and their quality through learning. Exercises involving small object manipulation, as well as, solving tasks involving manipulation, non-verbal communication programs and communication programs with a simple form of cooperation and verbal communication are utilized. Exercises are integrated within the treatment program 2–3 times per week. The exercise session is 30–40 minutes long. Exercises should be regularly performed for the entire length of treatment and should be led mostly by one therapist. The presence of another person during exercise sessions is encouraged. This person spends time with patients who are not able to follow the program for various reasons. However, it needs to be kept in mind that the effectiveness of therapy can be observed only several months after the initiation of regular exercise. Kinesiotherapy for the Treatment of Manic Illnesses Movement therapy can be implemented into treatment only if the patient is ready for it. This means if the patient can control their current condition and can at least partially cope with the demands of self-sufficiency and has a tendency to begin actively solving their problems and planning their future. The proposed therapeutic activity is at a manageable level in the somatic, psychological and social areas. The patient can find and experience the fundamental value of their being in situations, in which they become aware of their being (Chudejova, 2007). Movement programs focus on experiencing performed movement, improving coordination and stability, utilizing relaxation and breathing exercises and movement-expressive elements that help the patient with mental illness understand somatic symptoms accompanying depressive symptoms and face them. Movement programs, such as controlled relaxation, the Feldenkrais method, Alexander’s method, hatha yoga, concentration exercises in martial arts, European health exercises, as well as, dance and

movement therapy and various types of sports, lead the patient toward deeper body perception through psychosomatic approaches. Exercise is effective if it is a part of the daily or weekly regime (4–5 times a week). Sometimes, patients feel immediate relief, but other times it can take weeks. In such cases, it is important to persevere. A patient must be aware of their limitations (on their own in a limited space that surrounds them). Gradually, based on positive experiences, they expand the environment within which they feel secure. Kinesiotherapy for the Treatment of Neuroses Based on the current condition of the neurosis and the medication, any program selected by a physician can be implemented. The goal of the program is to decrease anxiety and depression, but also to verify the patient’s own abilities and competencies. To decrease anxiety, the authors of this chapter recommend relaxation programs that decrease stimulation. Activation programs with a light aerobic component that increases overall stimulation and activation are recommended to control depression by decreasing metabolic and other processes. Concentration relaxation or active relaxation kinesiotherapy are appropriate for neurastenias. In the post-treatment stage, athletically based activities and games are appropriate for increasing mental and physical endurance. Emphasis is placed on accurate rule adherence that assists in learning awareness of an order as a rule and a gradual increase in demands toward the patient’s upper threshold. Next, the patient is guided toward options of their own creative approach when solving game situations and movement tasks (Probst, 2006). Exercise is included as a mandatory component within a treatment program. Kinesiotherapy for the Treatment of Personality and Behavioral Disorders Active relaxation exercises with a light aerobic component are applied to control anxiety and depression, which is followed by a more challenging form of concentration relaxation exercises. In a stabilized state, sport training with performance motivation is implemented.

Exercise is included as a daily mandatory component within a treatment program. Principles of Kinesiotherapy Administration in the Mentally Ill The purpose of kinesiotherapeutic work is to assist the mentally ill individuals in working independently and finding ways to approach their problems, and to give them space to discover these pathways by themselves. The kinesiotherapist’s goal is to ensure a specific, safe, and clear movement program corresponding to the patient’s current psychosomatic state and developing their mental potential in a desired direction. All other therapeutic activities are left to other specialists (Hatlova, 2002).

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BIOGRAPHIES of influential figures

Professor Vaclav Vojta, MD, DrSc. Professor Vaclav Vojta was born in Southern Bohemia in 1917. In 1937, he began medical school, which he had finished after the war in 1947. The same year, he also began to study neurology, including pediatric neurology. He worked at the Neurology Department under Professor Kamil Henner from 1948-1956. This period was very important for him. Later, he often emphasized the significant contribution by Professor Henner to Czech and European neurology. In 1954, he also worked in the Zeleznice Balneologic Health Resort with children with central movement deficits and empirically developed the reflex locomotion system. In 1956, he was in charge of pediatric neurology at the 4th Pediatric Department at the School of General Medicine at the Charles University and also had a part-time appointment at the rehabilitation department at the 1st pediatric clinic at the School of Pediatric Medicine at the Charles University. In 1961, he began working at the Charles Square Clinic in Prague as a physician in pediatric neurology. Over the next few years, he was intensively dedicated to the field of developmental kinesiology and continued this activity even after he immigrated to Germany in 1968. In Germany, he was offered a position as a research assistant with Professor Immhäuser at the Orthopedic Clinic in Cologne. Here, he was able to continue his work in the area of developmental kinesiology and diagnostics and hold courses for physicians and physical therapists. Henceforward, he maintained in contact with some Czech colleagues, sent them literature and also assisted some of them in participating in courses in Germany. In 1975, he was in charge of the rehabilitation department by Professor Hellbrugge at the Pediatric Center in Munich. Here, he continued to develop the diagnostic and therapeutic reflex locomotion system, including continuing education courses for physical therapists, physicians and instructors in the Vojta method. In 1984, Professor Vojta’s activity, in cooperation with his German colleagues, lead to the establishment of the Vojta Society and

Professor Vojta became its first chairman. This society took upon the task to not only promote the implementation of the locomotion principle in the diagnosis and treatment at the national and international levels but also research in this area and education of physicians and physical therapists. After 1989, professor Vojta returned to Prague where he participated in therapeutic and medical courses and lectured at the Department of Physical Education and Sports at the Charles University. Professor Vojta published more than 100 research articles and his book “Brain Movement Dysfunctions at an Infant Age” was translated to many languages. Professor Vojta’s work was recognized with many honors. Professor Vojta died in 2000 in Munich at the age of 83. In the same year, he was awarded a national distinction – the Medal of Achievement in memoriam.

Professor Karel Lewit, MD, DrSc. Professor Karel Lewit was born in 1916. He was forced to interrupt his studies at the Medical School because of World War II. He spent this time in the Czechoslovakian Army in England and later in France where he functioned as a member of the Czechoslovakian Armored Brigade. He completed medical school in 1946 and began working at the Neurology Department under the legendary Professor Kamil Henner in the same year. Here, Professor Lewit found a unique setting for his work, which determined the rest of his career. Between 1960–1973, he successfully continued his work at the Neurology Department in Vinohrady under the guidance of Professor Z. Macek. Then, he gradually worked at the Research Institute of Rheumatic Diseases, the Central Institute of Public Railway Health, the Institute for Treatment of Movement Dysfunctions in Trebon, at the Neurology Department at the hospital in Kralovske Vinohrady, at the rehabilitation department of the hospital in Prague-Motol and, at this time, functioned at the rehabilitation department Malvazinky and at the Center of Comprehensive Care in Dobrichovice. Professor Lewit studied neuroradiology and functional pathology of the movement system. In the Czech Republic, he is considered the founder of manipulative treatment, for which he developed new diagnostic and therapeutic approaches. For a long time, he collaborated with other members of the “Prague School”, such as Professor Vladimir Janda, Jan Jirout and Dr. Frantisek Vele, which is exemplified by their numerous joint publications. Professor Lewit refers to these colleagues as his “students”, but, at the same time, as his “teachers”, which illustrates their relationships. During his long career, he collaborated with many internationally recognized figures, including J. Sachse, M. Berger, G. Gutmann, F. Gaymans, F. Mitchell, F. Greenman, D.G. Simons and others. Professor Lewit is an author of more than 200 publications. The most significant is his memoir about manipulative treatment, which was reedited many times and translated into several foreign languages.

Professor Lewit is an exceptional educator and, in the 1960’s, began organizing courses in manual medicine, which educated several generations of physicians who fondly remember their teacher. Professor Lewit is also well recognized abroad. He is able to lecture in several languages and has had many students in Germany, France and other European countries, as well as, the USA and Australia. Professor Lewit is admirably active and is constantly open to discussions about new therapeutic approaches. He gladly shares his ample clinical experience with younger generations of physicians and physical therapists who often seek his knowledge. Professor Lewit is a big figure in Czech medicine and rehabilitation. He is a founder of modern manual medicine not only in the Czech Republic. But he also significantly influenced the development of manual medicine in Europe and overseas.

Professor Vladimir Janda, MD, DrSc. Professor Vladimir Janda was born in 1928 in Prague and graduated from high school in Kolin in 1947. At the age of 17, he contracted poliomyelitis and this experience significantly affected his further professional direction. The disease also contributed to his decision to attend medical school. He graduated from medical school in 1952. Immediately, he was interested in neurology and rehabilitation. Already during his studies, he worked part-time at the Neurology Department under Professor Henner. After his studies, he worked at the Neurology Department in Kralovske Vinohrady under the guidance of Professor Z. Macek. Later, he established an independent rehabilitation clinic at the hospital in Kralovske Vinohrady and became its first and long-term chairman. From the beginning, Professor Janda focused on the muscular system and painful spine and movement system conditions. Still as a student, he wrote “The Muscle Test”; revisions of this book are found in rehabilitation texts, not only in the Czech Republic, but also abroad and are part of fundamental rehabilitation literature. His publication “Diagnostic Foundations of Functional (Non-paretic) Movement Disturbances” has an important value. In this publication, Professor Janda describes the causes and clinical manifestations of functional movement disturbances, their diagnosis and treatment. He systematically described various manifestations of muscle imbalances that he considered a significant pathological factor in the development of functional pathology in the movement system. Another important area that Professor Janda devoted time to included “sensimotor stimulation”, which he developed and introduced to practice together with his colleagues K. Kabelikova, PhD. and M. Vavrova. He was a long-term director of the department and later the School of Treatment Rehabilitation of the Institute of Post-Graduate Education in Healthcare in Prague. He began and maintained a high level of physician education in the areas of physiatry, balneology and treatment rehabilitation. Physicians who took their board certification

exam with Professor Janda remember him as a strict tester, but thanks to this, he maintained a certain level of specialty. Professor Janda’s cooperation with Professors K. Lewit and J. Jirout and Doctor R. Vele was quite significant in the development of this specialty. Professor Janda lectured, not only in the Czech Republic, but also abroad, especially in Australia and the United States where he was highly acknowledged. He also was often sought by worldwide specialists who were honored to be his students. Thanks to Professor Janda, a number of congresses and scientific conferences with international participation were held in Czech Republic. Professor Janda is a major figure in the Czech medicine and rehabilitation and one of the founders of the “Prague School.” Professor Janda, in a fundamental way, contributed to the development of Czech rehabilitation and myoskeletal medicine and affected the development of this specialty worldwide. Professor Janda died in 2002.

Associate Professor Karel Obrda, MD, CSc. Associate professor Karel Obrda was born in 1910. He completed his studies prior to World War II and was an assistant and later an associate professor at the Neurology Department under Professor Kamil Henner from its establishment in 1945. At that time, poliomyelitis was one of the most feared diseases in young people and rehabilitation was an irreplaceable component in the comprehensive treatment of this neurological disease. Professor Henner, therefore, supported Doctor Obrda in his intention to devote himself preferentially to rehabilitation because he was aware of the significance of rehabilitation in neurologic diseases. Associate Professor Obrda, with support from Professor Henner, established and developed a rehabilitation department at the Neurology Department. At the same time, he used his experience from his earlier work at the Balneological Institute of Professor Eduard Cmunt. Obrda’s rehabilitation department was the first of its kind in what was then Czechoslovakia. What was especially important was that rehabilitation here was interconnected with neurology and, to a certain extent, it ear-marked the further direction of development. Associate Professor Obrda hired the staff for the department and developed its scientific program. The Laboratory for Pathophysiology of the Nervous System in the Neurology Department became a scientific center. Dr. Obrda led the kinesiology and polyelectromyelography sections. At this laboratory, many doctoral theses and tenure candidates worked here and were supported by Doctor Obrda. The effort of Doctor Obrda in Czech rehabilitation was also recognized at an international level when he was voted the secretary of a research group for rehabilitation in neurology by the World Federation of Neurology. Based on Dr. Obrda’s initiative, two international rehabilitation congresses were held in the Czech Republic, in 1966 and 1976, which contributed to the sound name of Czech rehabilitation in the world. Dr. Obrda together with his friend

Dr. Karpisek wrote a textbook “Rehabilitation of the Neurologically Ill”, which was the first important textbook about rehabilitation of neurological diseases in the Czech Republic. This textbook remains a firm foundation and, in many ways, a good source of information in rehabilitation, although, rehabilitation has advanced a lot since then. Dr. Obrda was the chairman of the Rehabilitation Society until he died. He exerted a lot of effort for rehabilitation to become a recognized field so that it attains as recognized a position as possible within medicine. Justly, he is among the most significant figures that contributed to the origins and development of rehabilitation. Dr. Obrda died in 1989.

Associate Professor Frantisek Vele, MD, CSc. Assistant Professor Frantisek Vele was born in 1921 and studied at the Charles University, School of Medicine in Prague between 1945–1949. After graduation, he worked at a psychiatric clinic in Plzen. During mandatory Army training, he was sentenced to two years in prison for a disagreement with the political regime. He worked as a laborer after he was released. From 1953, he worked at the rehabilitation institute in Janske Lazne as a staff physician and later as the head of the department. In the meantime, he worked part-time at the neurological clinic in Hradec Kralove and Prague. In 1961, he was employed by the Institute for Continuing Education for physicians and pharmacists where he taught electrodiagnostic methods in neurology and rehabilitation. Upon reaching retirement in 1988, he worked at Czech Railways in the motor learning laboratory. Since 1991 he has been working at the Department of Physical Therapy at the School of Physical Education of Sports at the Charles University where he was the chair of the department for three years and where he works now. From the position of department chair he began fulfilling his idea of a new teaching approach to physical therapy. He began the Master’s degree program and was the guarantor of a fundamental specialization – physical therapy for functional deficits within the movement system. Dr. Vele collaborated with Dr. A. Brügger from Switzerland and is still a member of the editorial board of the Funktionskrankheiten journal. During his stay in Vietnam, he became familiar with oriental medicine and its application for movement purposes. He was always devoted to kinesiology and currently studies the effect of respiratory movements on postural function. Together with Jiri Cumpelik, PhD, he is merited with the inclusion of preventative spinal exercises into rehabilitation. He initiated the founding of the Kinesiology Society and attempted for kinesiology to become a tenured specialty necessary for the education of movement specialists in rehabilitation as well as in sports and physical education.

Dr. Vele published a number of publications nationally and internationally, primarily about kinesiology. His most significant publication includes a memoir “Kinesiology in Clinical Practice”, which continues to be a very useful source of information. Dr. Vele is a recipient of the J.E. Purkinje medal, the Palacky University medal, the silver medal of the Charles University in Prague and a medal commemorating the anniversary of the Charles University establishment. Dr. Vele belongs among the significant figures in the fields of rehabilitation and musculoskeletal medicine. He contributed significantly to the progression of rehabilitation of movement deficits and, together with professors Janda, Lewit and Jirout, contributed to the recognition of the “Prague School.”

Professor Jan Pfeiffer, MD, DrSc. Professor Jan Pfeiffer was born in 1928, attended high school in Trebon and continued his studies at the medical school, which he completed in 1952. During his studies, he was a volunteer at Dr. Henner’s Neurology Department, which significantly affected his future professional development. After graduation, he began working at a sanatorium for tuberculosis in Dube and then at the pediatric and neuroinfectious department at the hospital in Teplice. When he returned to Prague, he worked at Jedlicka’s institute and later at Dr. Henner’s Clinic of Neurology. Soon, he began to focus on neurologic rehabilitation and also spent time in an electromyographic laboratory, which was founded by Dr. Obrda. In 1977, Dr. Pfeiffer became an associate professor and in 1986 a full professor. From1968-1969, he was a student of Professor G. Tardieu at his clinic in Paris and also spent some time in Germany. In 1970, Professor Pfeiffer became the head of the Department of Rehabilitation at the Neurology Department at the School of Comprehensive Medicine of the Charles University in Prague. Dr. Pfeiffer’s stays abroad contributed to his interests in the issues of severely involved patients, which predisposed him to his later and main career interest. Later, he also collaborated with a manufacturing company of The Union of Disabled Persons Meta where he pushed the need for ergonomic diagnostics that would allow for a capable assessment of life and work functions of patients with disabilities. In 1982, Professor Pfeiffer and his team relocated to the former Balneologic Institute where he established the Department of Rehabilitation Medicine – a workplace for comprehensive ergonomic diagnostics, occupational therapy and occupational rehabilitation. Here, he successfully continued with the integration of findings in the areas of treatment and occupational rehabilitation with comprehensive medical care for the physically disabled and chronically ill. Professor Pfeiffer was the chairman of the Rehabilitation Society for

many years. He is also a member of a number of national and international specialty associations. After 1989, he worked as an advisor to the Ministry of Health and supported the foundation of rehabilitation centers and their interconnection with other institutions. At the same time, he contributed to the 1st and 2nd editions of the ”International Classification of Functioning, Disability and Health” (ICF) by the World Health Organization and translated it to Czech in 2008. The school founded by Professor Pfeiffer has an important place in the system of education of rehabilitation physicians because it is a place for specialty stays as a part of preparation for the board examination. He was the chairman until 1992. Professor Pfeiffer belongs among the significant figures in Czech rehabilitation given his significant contribution to its development.

Professor Jan Jirout, MD, DrSc. Professor Jan Jirout was born in 1912 in Prague and graduated from the Charles University School of Medicine in 1937. After graduation, he became part of the Neurology Department of Professor Kamil Henner at the Department of Internal Medicine. Under the guidance of Professor Bastecky, he became interested in the foundations of radiology and specialized in the nervous system. In 1945, he was the head of the radiology department of Professor Henner’s Neurology Department and in 1946 became an associate professor of neurology. Professor Jirout can be credited by a tremendous contribution to the development of Czech and international neuroradiology. Starting in the 1940’s, he contributed to the development of the radiology department of Professor Henner’s Neurology Department, where he introduced contrast diagnostic methods including pneumoencephalography and pneumomyelography and, at the beginning of the 1970’s, also angiography. He was a big advocate of computed tomography and magnetic resonance imaging. He superbly mastered manipulation techniques, which he administered gently and sensitively. Professor Jirout was recognized internationally, which is furthered by the fact that he was a co-founding member of the neuroradiological section of the World Neurological Federation, the chairman of the European Neuroradiological Association, a member of the American Neuroradiological Association and the German Radiological Association. Professor Jirout was a long-term chairman of the Czech Neurological Association and the chair of its Neuroradiological Section. He was a forefront specialist in musculoskeletal medicine, as well as, one of the most significant members of the “Prague School.” He closely collaborated with its other members on various publications. Professor Jirout’s fundamental publications deal with pneumomyelography and functional radiology of the cervical spine. His most significant work is summarized in an independent memoir

“Das Gelenkspiel der Halswirbelsäule” published 1990. Studies describing joint play dynamics of the cervical spine were published in many languages. Overall, he published more than 150 original works in Czech, as well as, international journals and published nine memoirs that became the foundation of neuroradiology studies at home and abroad. Professor Jirout significantly contributed to the development of rehabilitation and musculoskeletal medicine and is among the figures who significantly promoted the recognition of this specialty internationally. Professor Jirout died in 2001.

Professor Milos Macek, MD, DrSc. Professor Milos Macek was born in 1922 and graduated from high school in 1941 in Prague and medical school in 1949. At the beginning of his career, he worked at the Pediatric Department of the hospital in Jilemnice and later in Liberec, where he worked in the Pediatric and Internal Medicine Departments. In 1951, he worked at the 1st Pediatric Department with Professor J. Svejcar who asked him to establish the Department of Rehabilitation and Physical Medicine in 1953. He had spent a lot of time developing rehabilitation programs in pediatrics. He was the first to implement rehabilitation for pediatric patients with cardiac and asthmatic involvement and initiated, at that time, also studies regarding the effects of movement on healthy children. Between 1963 -1969, he was the dean of the School of Pediatric Medicine at the Charles University. In 1963, under his leadership, the Department of Sports Medicine and Rehabilitation was established at the School of Pediatric Medicine. When the work facility was moved to the university hospital in Prague/Motol, it developed further. The facility gradually earned specialty credit in the Czech Republic and abroad and collaborated on international projects (i.e. the International Biological Program). Professor Macek was surrounded by capable colleagues, which included Professors M. Kucera, MD, J. Vavra, MD, J. Javurek, MD and later J. Radvansky, MD, PaedDr. P. Kolar, PhD and others. Professor Macek was the head of this facility until 1988. Professor Macek is a recognized specialist and, as a renowned specialist, he was named a member of the scientific commission by the International Organization of the Sports Medicine (FIMS) and was delegated to organize the V. European congress of FIMS in 1985. For two terms, he also served as the chair of the Czech Association of Sports Medicine and the chair of the health commission of the Czechoslovakian Association of Physical Education. Between 1969 – 1974, he served as the President of two symposia of the Pediatric Group of Work Physiology.

Professor Macek’s publication record is very extensive. The overall number of publications reached more than 270 titles. He was the first author on 110 publications and he published about 80 articles abroad. His most significant publications include: “Rehabilitation in Pediatrics”, “Physiology and Pathophysiology of Physical Activity” and “Exercise Treatment in Pulmonary Diseases”. He also translated numerous specialized publications. His translation of Professor’s Vaclav Vojta’s memoir “Movement Dysfunctions at an Infant Age” is especially valuable in rehabilitation. He maintained a long-standing friendship with Professor Vojta. Professor Macek was also awarded numerous awards for his achievements. He is an honorary member of the American Association for Pediatric Physiology, a recipient of the J.E. Purkinje medal and his academic record and his function as the dean was rewarded with the Gold Medal by his Alma Mater medical school. Professor Macek educated many specialists who work in sports medicine and rehabilitation theory and practice. He was always aware of the meaning of rehabilitation, which is the reason why he fully supported this specialty.

Professor Miroslav Kucera, MD, DrSc. Professor M. Kucera was born in 1932. After graduation from medical school, he worked as a staff physician at the Orthopedic Department in the hospital in Most. In1960, he interviewed for a position as an assistant at the pediatric section of the Department of Sports Medicine where a future independent department and later a school was forming. He became its second employee; the first was his then supervisor Dr. M. Macek. Gradually, well established facility was built where Professor Kucera began focusing mainly on the movement system’s reaction and adaptation to physical activity in children and youth. This topic permanently became the subject of his main interest. “Physical Fitness of Girls during Adolescence” is an important memoir devoted to this subject, which he co-wrote with Professor Macek. Professor Kucera also studied motor skills of infants and young children. As one of the first, he began to observe spontaneous activity in preschool children and found that they were much more intense than presumed. Later, he studied the relationships between Scheuermann’s disease and physical activity and presented a proposal for an apparatus that would non-invasively examine the nature and the extent of a spinal deformity. For many years, Professor Kucera chaired the commission of the medical board of the Czechoslovakian Association of Physical Education that registered and analyzed the development of sports injuries with the goal to improve their prevention. He published guidelines for youth competition and, as an organizer, he participated in many other projects and studies. He is the author or co-author of more than 200 publications, from which there are 10 memoirs. He is the author of seven specific chapters in national textbooks. He lectured at the medical school, the School of Physical Education and Sports, at the Institute of Postgraduate Education in Healthcare, at seminars of the Health Commission of the Czech Sports Association and others. He also presented the results of his scientific activity internationally.

Professor Kucera was a capable coordinator of conferences, for example, he organized symposia of Pediatric Work Physiology in 1969 and 1975 and functioned as the general secretary of the V. European FIMS Congress in 1985. In 1988, he took over a position as the chief of the Department of Sports Medicine in the School of Pediatric Medicine at the Charles University in Prague. In 1992, he became a chief of the Rehabilitation Department. For many years, he was the chairman of the Czechoslovakian and later Czech Association of Sports Medicine. He was also a member of healthcare and scientific agencies of the Czech Sports Association. He is recognized as an international authority, which is confirmed by the fact that he was invited to assess the prospects of children’s education designs as a member of a specialized commission of the European Council. Professor Kucera died in 2013.

Associate Professor Jan Javurek, MD, DrSc. Doctor Javurek was born in 1931. He graduated from Academic high school in Prague. After graduating from the School of Pediatric Medicine at the Charles University in 1957, he worked in a regional hospital in Usti nad Labem in the Pediatric Department as well as in the Rehabilitation Department. Between 1963-1976, he was the director of a treatment facility in Kyselka in Karlovy Vary and, in 1976, was named the chief of the Rehabilitation Department of the university hospital in Prague/Motol. Here, once the graduate studies in rehabilitation were established, he gradually took over the organization and teaching of a number of subjects. He became board certified in pediatrics in 1959, in sports medicine in 1963 and in physiatry, balneology and treatment rehabilitation in 1972. He became a Candidate of Medical Sciences in 1978, received the title Doctor of Medical Sciences in 1989 and was tenured in 1985. In 1988, he was named the Chief of the newly established Department of Rehabilitation Medicine. Doctor Javurek is a co-founder of graduate studies for physical therapists at the School of Physical Education and Sports at the Charles University and also developed the education programs at the 2nd Medical School at the Charles University. From the very beginning, Doctor Javurek participated in the development of the treatment rehabilitation specialty and its presence at specialized forums. This was possible thanks to his activity in specialty functions, as well as, through special national and international congresses and conferences that he organized. Dr. Javurek’s publication activity is extensive. He published more than 215 articles and contributed to 18 textbooks. He published primarily about movement system deficits, rehabilitation in athletes and pediatric patients, modalities, etc. His important publications include a memoir “Treatment Rehabilitation of Athletes”, “Small Atlas of Treatment Injections”, “Phototherapy by Biolaser”, etc. He devoted his other publications to kinesiology of gait and problems related to scoliosis and arthritis. Two of his article collections received an award from the Czechoslovak Medical

Association of J. E. Purkinje. Dr. Javurek presented more than 170 lectures, from which 20 were at international forums. In 1982, he founded a journal named Report Selection from Treatment Rehabilitation and served as its editor. He has been focusing on biostimulatory laser therapy since 1976 and has been lecturing on this topic at the Institute of Continuing Education for Physicians and Healthcare Providers.

Ludmila Mojzisova Ludmila Mojzisova was born in 1932 in Uzhrod. After graduating from family school and nursing school, she began to work as a nurse at a transfusion station in Pardubice. In 1955, she worked at the School of Physical Education and Sports at the Charles University initially as a research nurse and later as an assistant at the Rehabilitation Department in the School of Sports Education and Special Physical Education. She became more and more interested in the issues of pain in the movement system and demonstrated excellent palpation skills and a feel for movement. She had significant treatment success and was sought out especially by athletes. Between 1978-1988, she was a member of the support team in a number of athletic championships and Olympic Games, during which she assisted the athletes. Gradually, she developed her own treatment approach, which implemented specific manual approaches, including those influencing the rib region and, with it, associated chained muscular deficits. She consequently recommended a specific regime of exercises. She began to utilize her original methods for the treatment of female and male sterility, which was another important area that she had focused on and had great success with. In this area, she collaborated with a gynecologist, Professor E. Cech, MD, who referred to this method at specialty congresses. The methodical approach developed by Mojzisova was later taught at specialty courses upon the recommendation of the Ministry of Health. Several books were published about her methods (for example, “Treatment Rehabilitation Approaches by Ludmila Mojzisova”, “Ludmila Mojzisova’s Rehabilitation Method through the Eyes of a Physical Therapist”, “The Ludmila Mojzisova Method”, etc.) Ludmila Mojzisova had a number of students with whom she shared her experience. But not everyone could learn to implement the methods as successfully as her. Besides well-wishers and admirers, she also had adversaries who doubted her method and pointed out its insufficient theoretical reasoning. Ludmila Mojzisova’s specialized activity was interrupted by a severe illness that did not allow her to

realize all her plans and dreams. Ludmila Mojzisova died in 1992. Unquestionably, she contributed in an original way to the development of diagnosis and treatment of functional pathology of the movement system and her methods continue to be used today.

ABBREVIATIONS AC ACBT ACL ACRM ACT ACTH ADC ADH ADL AEP AIIS AIMS ALS ANS APC AQ ASIA ASIS ATNR ATP BAEP BERA BI BiPAP BMI BP

acromioclavicular (joint) active cycle of breathing techniques anterior cruciate ligament American Congress of Rehabilitation Medicine airway clearance techniques adrenocorticotrophic hormone apparent diffusion coefficient antidiuretic hormone activities of daily living auditory evoked potentials anterior inferior iliac spine Alberta Infant Motor Scale amyotrophic lateral sclerosis autonomic nervous system antigen presenting cells accommodation quotient American Spinal Injury Association anterior superior iliac spine asymmetric tonic neck reflex adenosine triphosphate brainstem auditory evoked potentials brainstem evoked response audiometry Barthel Index bi-level positive airway pressure body mass index blood pressure

BPPV CCD CMCT CNS COP COPD CP CPAP CPCI CPK CRH CRP CRPS Cst CT CVA DD DIP DM DMARDs DNS DTI EBM EEG EFL EKG EMG EORTC

benign paroxysmal positional vertigo central coordination disorder central motor conduction time central nervous system center of pressure chronic obstructive pulmonary disease cerebral palsy continuous positive airways pressure Chronic Pain Coping Inventory creatine phosphokinase corticotropin releasing hormone C-reactive protein complex regional pain syndrome static lung compliance computed tomography cerebrovascular accident diadynamic currents distal interphalangeal diabetes mellitus disease modifying antirheumatic drugs dynamic neuromuscular stabilization diffusion tensor imaging evidence based medicine electroencephalography expiratory flow limitation electrocardiography electromyography European Organization for Research and Treatment of

EP ERG ERV FABQ FBSS FEV1 FIM fMR FMS FOPI FPQ-III FRC FVC GH GIT GM GMFM GMPM GMsA GXT Gy HINT HKAFO HLA HMSN HR IC

Cancer evoked potentials electroretinography expiratory reserve volume Fear-Avoidance Beliefs Questionnaire failed back surgery syndrome forced expiratory volume in one second Functional Independence Measure functional magnetic resonance fibromyalgia syndrome Fear and Observation of Pain Inventory Fear of Pain Questionnaire functional residual capacity forced vital capacity growth hormone gastrointestinal tract general movements Gross Motor Function Measure Gross Motor Performance Measure General Movements Assessment Graded Exercise Test gray Harris Infant Neuromotor Test hip-knee-ankle-foot orthosis human leukocyte antigens hereditary motor sensory neuropathies heart rate inspiratory capacity

ICD ICIDH IF IGF IHD IMP IOS IPA IPV IRV JRA KAFO LCL LED MCD MCL MCP MEF MEG MEP MI MRI MS MTP MV MWT NAPI NHO

International Classification of Diseases International Classification of Impairments, Disability and Handicaps interferential currents insulin-like growth factor ischemic heart disease Infant Motor Profile impulse oscillometry International Psychogeriatric Association intrapulmonary percussive ventilation inspiratory reserve volume juvenile rheumatoid arthritis knee-ankle-foot orthosis lateral collateral ligament light emitting diode minor coordination dysfunction medial collateral ligament metacarpophalangeal maximum expiratory flow magnetoencephalography motor evoked potentials myocardial infarction magnetic resonance imaging multiple sclerosis metatarsophalangeal minute ventilation myocardial wall thickness Neurobehavioral Assessment of the Preterm Infant neurogenic heterotopic ossification

NIRS NSMDA NYHA OA OM PASS PBPI PCL PCR PDGF PEDI PEF PEG PEMG PEP PET PF PFMAI PFT PIP PIR PM PMG PNF PPI PRA PSA

near infrared spectroscopy Neuro-Sensory Motor Development Assessment New York Heart Association osteoarthritis osteomyelitis Pain Anxiety Symptoms Scale Pain Beliefs and Perception Inventory posterior cruciate ligament polymerase chain reaction platelet-derived growth factor Pediatric Evaluation of Disability Inventory peak expiratory flow percutaneous endoscopic gastrostomy perimyeolography positive expiratory pressure positron emission tomography pulmonary function Posture and Fine Motor Assessment of Infants pulmonary function test proximal interphalangeal post-isometric relaxation premotor area perimyeolography proprioceptive neuromuscular facilitation Present Pain Intensity pelvic radius angle pelvisacral angle

Pst

static lung recoil pressure

RA RER RF RV SAFO SCI SCIM SEP S-E-T SI SLE SMA SSRI STAI STAXI SWASH TC TEE TENS TIA TIME TIMP TIPs TLC TLSO TMS TNF

rheumatoid arthritis respiratory exchange ratio rheumatoid factor residual volume silicone-ankle-foot orthosis spinal cord injury Spinal Cord Independence Measure somatosensory evoked potentials sling-exercise-therapy sacroiliac systemic lupus erythematosus spinal muscular atrophy selective serotonin reuptake inhibitors State-Trait Anxiety Inventory State-Trait Anger Expression Inventory standing-walking-and-sitting-hip orthosis talocrural thoracic expansion exercises transcutaneous electrical neurostimulation transient ischemic attack Toddler and Infant Motor Evaluation Test of Infant Motor Performance tone influencing patterns total lung capacity thoracic lumbosacral orthosis transcranial magnetic stimulation tumor necrosis factor

TNM

tumor, node, metastases

TP TrP UDS MR US UV VAS VC VEP VO2max VO2peak VOR VRL VSR WHO WISCI

tender point trigger point Uniform Data System for Medical Rehabilitation ultrasound ultraviolet Visual Analog Scale vital capacity visually evoked potentials maximal oxygen consumption peak oxygen consumption vestibulo-ocular reflex Vojta reflex locomotion vestibulo-spinal reflex World Health Organization Walking Index Spinal Cord Injury