1.Introduction of Rehabilitation Medicine

Rehabilitation Medicine: General Introduction

Rehabilitation Medicine is a branch of medicine supporting people living with disablement or disease.

In aged societies, more elderly people are experiencing issues in daily life due to illness; in other words, more elderly people are living with disablement. Living longer in itself doesn't necessarily make us happy-we also want to live the final stage of life in comfort and with dignity. For example, elderly people with dysphagia who are being fed via a nasogastric tube over the long term may need to be restrained to prevent them from removing the tubing. This isn't suitable for living with dignity. Rather, a suitable way to manage disablement is the key to living a long and happy life.

Rehabilitation Medicine is almost the only area that treats disablement, and it is essential to provide in aged societies. This module explains the basic principles behind Rehabilitation Medicine. Here, the term "Rehabilitation Medicine" is used as a collective term with no distinction between medical science and clinical practice.

Explanation

We start with an outline of Rehabilitation Medicine, a characteristic of which is to take a systemic approach to solving problems. We then look at the characteristic ways we practice Rehabilitation Medicine.

What Rehabilitation Medicine means

The word "rehabilitation" is derived from "re" meaning "again" and term "habilis" meaning "to be able". Putting these together, we can see that "rehabilitation" means to "become able again". In Japan, the term "rehabilitation" is mainly used in the fields of medical science and therapeutics, whereas in the West, "Rehabilitation Medicine" is terminology also used in social rehabilitation.

Explanation

The focus of Rehabilitation Medicine is not lifesaving or life-prolonging (eg, in life-or-death approaches, homeostasis, or keeping people alive in a vegetative state) but is on improving activity disorders [1]. The activity to improve cover daily conscious and subconscious behavior, actions, mobility, cognition, and judgement, which really represent "living". Also, Rehabilitation Medicine characteristically follows a practical systemic approach to solving problems and is not focused solely on pathological solutions.

Explanation

These activities can be understood by dividing them into 5 central domains; specifically, the first 3 are the motor domains of selfcare, transfers, and excretion and the remaining 2 are the cognitive domains of communication and judgment. These domains are evaluated with the Functional Independence Measures (FIMs), which are widely used worldwide (2).

Explanation

The principal organ systems involved in supporting these activities are as follows: 1) the nervous and muscular systems and the organs of sensory perception; 2) the musculoskeletal system and the skin; 3) the cardiovascular and pulmonary systems; and 4) the digestive and urinary systems (feeding and excretion). Coordination between these organ systems is clinically very important. The link between rehabilitation and each of these fields is easier to conceptualize if we think of them as the weft and warp in fabric. Also, Rehabilitation Medicine is closely linked with pediatric and geriatric medicine because the problems of aging and growth can each have a major impact on daily life activities.

Explanation

Understanding hierarchies of disablement is essential when considering problems in activities from the perspective of daily life. These hierarchies are the International Classification of Impairments, Disabilities, and Handicaps (ICIDH) [3] and the International Classification of Functioning, Disability and Health (ICF) [4] published by the World Health Organization in 1980 and 2001, respectively. Both of these classifications have their advantages and disadvantages, but let's start with the easy-to-understand ICIDH.

The ICIDH has 3 hierarchical levels for issues in daily life: impairment, disability, and handicap. Impairment represents disablement at the organ level; for example, patients with hemorrhage in the left brain may have right hemiplegia. Disability results from impairment and represents disablement at the level of the individual and includes dysgraphia, gait abnormalities, and impairment of activities of daily living (ADL). Handicap results from disability and represents difficulties at the level of society or the patient's environment, such as difficulties returning to work or navigating stairs.

The 3 hierarchical levels are connected by causal relationships as shown in the example of hemorrhage in the left brain above. However, because there is no perfect one-to-one correspondence between the levels, it is important to keep in mind interventions appropriate for the level. For example, severe right hemiplegia (the impairment) produces dysgraphia (the disability), but this disability may be overcome without needing to address the severe hemiplegia (cause), by training to switch the dominant right hand for writing to the non-dominant left hand. The potential to provide focused interventions at each level of the hierarchy makes Rehabilitation Medicine very useful.

Causal relationships can work in the opposite direction. One example is disability causing impairment, as with the muscle weakness that develops in disuse syndrome occurring secondary to a decrease in ADL. Another example is handicap that aggravates disability, as with being housebound due to difficulty in participating in wider society that results in decreased walking ability outside.

Explanation

If we compare the ICF and ICIDH hierarchies, we can see that the later ICF is not a simple revision of the earlier ICIDH. The ICF is characterized by (1) not using negative terminology such as "physical function and structure" and "activity and participation" as the components of disablement and functions in daily life, (2) separating contextual factors, and (3) distinguishing between "performance" and "capacity" in evaluations of activity and participation. In particular, factors whose use caused some confusion in the ICIDH (eg, environmental factors) were appropriately separated as background factors in the ICF. On the other hand, activity (corresponding to impairment) and participation (corresponding to handicap), which were different hierarchies in the ICIDH, are considered as a broadly the same or identical in the ICF, and this was less suitable even though "performance" and for "capacity " were separated in the ICF.

Systemic Solution

One feature of dealing with activity disorders is a perspective differing from the pathology-oriented solutions conventional in medical science. Rehabilitation Medicine is not limited to determining the pathological solutions; it also involves a flexible and highly practical approach to finding solutions as part of a whole system, even with continual disablement (5).

The system here has a certain number of interrelating major components In other words, the patient living with disablement is regarded as a system with healthy parts as well as disabled parts of the body, existing in the human and material environments. With this approach, even though a pathological condition or functional issue will remain after receiving conventional medical treatment, the patient learns activities that utilize the healthy parts of the body and supporting devices with the notion that some activities are replaceable, in order to make some actual improvements within himself or herself and also in his or her life including the environment.

For example, the aim of rehabilitation can be achieved in paraplegics when the hands take on the role of the feet, more precisely, when the hands functions to replace the legs (eg, when operating a wheelchair and pushing up the body) in walking and shifting positions. The photograph shows a paraplegic physician actively providing medical care from his wheelchair.

Explanation

First, let's look at the meaning of solutions in the systemic approach using the allegory of a coach in a grass-lot baseball team.

Imagine that you are the coach of a grass-lot baseball team. Your team has a really bad shortstop who insists that the only position he wants to play is the shortstop. There are only 9 players in the team and you can't make a substitution. So, what can you do? Of course, if you could replace the shortstop with another competent player, you could strengthen the team, but you don't have that option.

Firstly, you give the shortstop some special training (addressing a disability). Improvement may not great because of his innate ability.

The next step is shifting the positions of the first and second bases to cover the shortstop (addressing impaired ability: utilizing the healthy parts of the body and setting a type of activity commensurate with the impairment).

Actually practicing with the altered pattern is important. This training heightens the coordination between all the players in the team and then, for the first time, the team becomes capable of competing to a certain extent (addressing impaired ability: learning the new style of activity).

Players' families are involved as cheering supporters on match days and put pressure on the opposing team (dealing with the handicap).

In this way, the team can overcome the problem and start to anticipate winning.

Explanation

Let's use a similar approach to dysphagia rehabilitation for a patient with Wallenberg syndrome.

Balloon dilatation is applied to the upper esophageal sphincter, which has been prevented from opening wide by the disablement (addressing a disability).

To make greater use of the healthy parts of the pharynx than before, a shift in position-head rotation- is adjusted at the time of swallowing (addressing impaired ability: utilizing the healthy parts of the body and setting a type of activity commensurate with the impairment).

The patient then directly and indirectly practices the new form of swallowing (addressing impaired ability: learning the new style of activity).

The most suitable foods are determined, and family members are asked to learn how to prepare the relevant dysphagia diet (dealing with the handicap).

In this way, the patient becomes able to do oral intake, and this is the solution in the system. Naturally, this procedure needs to be accompanied with concomitant treatment of the primary disease, prevention of complications, and medical management based on the relevant pathophysiology.

Explanation

Rehabilitation Medicine is based on a team approach; this multifaceted therapeutic approach requires a range of health professionals. One profession that has emerged with a vitally important role is the therapist who is responsible for coaching the patient in the new exercises (the therapeutic practice).

Rehabilitation Medicine normally includes contributions from physiatrists, rehabilitation nurses, physical therapists, occupational therapists, speech therapists, rehabilitation engineers, prosthetists and orthotists, clinical psychologists, and social workers. Dysphagia rehabilitation involves additional participation from dentists, dental hygienists, and dietitians.

Explanation

Let's look now at the form of the team [1]. The names of a team (especially when translated into Japanese) and what they mean vary in the teams, but at this point, let's initially distinguish between 3 categories: multidisciplinary, interdisciplinary, and transdisciplinary teams. The word "discipline" indicates a particular specialization or scientific field, and the word "disciplinary" indicates something pertaining to a specialization or scientific field.

In a multidisciplinary or interdisciplinary team, the roles and functions of each health professional have been determined to a certain degree. These two terms differ in relation to functional communication: a multidisciplinary team involves little functional communication between the health professions; whereas an interdisciplinary team involves close functional communication. Collaboration in a multidisciplinary team is similar to that of departments of a general hospital. This contrasts with an interdisciplinary team that does not function if professionals in various fields simply gather together and instead requires a clear indication of individual responsibilities and good communication to maintain the structure and function of the team: a rehabilitation team is formed as an interdisciplinary team where there is clarity among its members about their roles in advance and when members periodically communicate with each other.

A transdisciplinary team differs slightly from multidisciplinary and interdisciplinary teams in terms of the roles of the professionals. The starting point is the needs of the patient, and these needs are broken down into "units" which are then dealt with by the relevant health professionals. (The relevant professionals dealing with the case shown here are a dentist, a dental hygienist, and a nurse as well as family members.) In this way, the actual role of each professional may vary with differences in the team's configuration. For example, when dealing with a patient who has dysphagia, the roles of the dental hygienist and the nurse will change whether the speech therapist is present or not. So, individual team members must have broad and basic competences in addition to the core knowledge and skills of their own specialty.

The idea behind transdisciplinary teams is that medical professionals must adapt their roles according to circumstances. This idea is relatively new and corresponds with the basic tenets of Rehabilitation Medicine designed based on the disabilities of patients (the needs), not the specialty (the seeds). This point does not deny the specializations or limitations in medicine by field; rather, it emphasizes that adapting medical specialties to the patient's needs is an extremely important and challenging task. The Japanese Society for Dysphagia Rehabilitation is a scientific society dedicated to realizing effective transdisciplinary teamwork for patients with dysphagia, and the society's wide scope extends from acute-stage hospitalization to institutional and home care.

Explanation

Let's move now to the 4 characteristic multifaceted approaches in Rehabilitation Medicine (5). The first aspect is medical management of patients, where medical problems that commonly occur in patients with disabilities are comprehensively addressed. The second aspect is the focus on the activity-function-structure relationship, where activity is strongly related to the function and structure. The third aspect is therapeutic learning that utilizes the great learning potential of the individual to improve the capability for the activity. The fourth aspect is assistive system that offers a suitable environment and tools through engineering and social approaches, thereby combating activity disorders [5].

Explanation

We need to deal with the medical issues to which patients with activity disorders are prone. Naturally this covers general management of the organ disease causing the activity disorder, and it also covers medical management for paralysis, spasticity, contracture, deformation, pain, urination and defecation disorders, and dysphagia. Thus, Rehabilitation Medicine offers comprehensive medical management, not that focused solely on the organ affected, for patients with disablement.

Let's take an example for patients with dysphagia. Such cases naturally involve medical management for dehydration, malnutrition, aspiration, and suffocation, as well as ascertaining the relevant pathophysiology, improving swallowing function, and taking a comprehensive approach to rehabilitating eating activity.

Explanation

Activities have strong relationships with function and structure. This principle is called the activity-function-structure relationship. Activity has a major effect on structure and function in humans. Rehabilitation Medicine is focused on activity.

Explanation

We describe a state of being unable to move as "immobilization". Because the human body functions on the premise of movement, a bedridden state and immobility cause a range of difficulties. The main cause of deep vein thrombosis, a serious post-surgical complication, is venous congestion resulting from loss of leg muscle activity. Hypostatic pneumonia is another complication and occurs in patients who spend a long time in a supine position. Physical movements of the body are needed from the acute stage as preventive measures against these complications.

Explanation

Abnormal conditions arising from insufficient activity are termed "disuse". Let's take muscle strength as an example. Muscle strength can be adapted to a maximum at 3- to 4-fold the mean muscle strength for individuals carrying out daily activities. To elaborate, when the intensity of daily activity reaches exceeds 20%-30% of the maximal level (maximum voluntary contraction), muscle strength is increased by the activity, and activity status below that level leads to decreased muscle strength. This phenomenon arises, and is then sustained, through changes in the motor neuron firing threshold and through the modulation of muscle fiber synthesis and degradation brought about due to muscle contraction activity. Accordingly, maximum muscle strength decreases when daily activity is limited. This is called disuse muscle weakness. On the other hand, muscle strength is increased when a greater load is born than for normal activity intensity. This is called the overload principle. For example, bearing loads corresponding to at least 60% of maximum muscle contraction increases maximum muscle strength. Muscle strengthening exercises are a form of therapy that exploit this association.

Explanation

Muscles that are not used will initially show fiber atrophy and contraction, then contraction of the perimysium, and loss of sarcomeres with loss of muscle strength, and spasticity is the result. Confinement to bed for just 1 week produces a loss in muscle strength of between 10% and 20%.

Explanation

There are many factors involved in activity-dependent change and these include muscle strength, muscle stamina, articular range of motion, coordination, physical strength, durability, and perception.

Explanation

Bedrest leads to immobilization and disuse, and compromises much of the patient's biological function, independent of the primary disease. These secondary complications are referred to as immobilization and disuse syndrome. These start with reduced muscle strength and muscle atrophy and progress to produce a range of symptoms.

Explanation

Disuse leaves the patient prone to a vicious circle. A considerable period is needed to treat disuse that emerges at a point in time. We should be fully aware of the hazards of rest, and it is appropriate to restrict rest in terms of quantity, time, and space. For example, in the case of a bone fracture, the need for localized rest of the region with the broken bone must be clearly distinguished from whole-body rest.

Explanation

There are 2 types of preventive measures against immobilization and disuse: passive measures including changes of posture, choosing good leg positions, leg pressure, and training across the range of motion; and active measures including muscle-strengthening exercises, muscle activity exercises (eg, sitting up, standing, and walking).

Let's look at what happens to patients with dysphagia. As a result of tube feeding, the numbers of mastication and swallowing movements decrease, resulting in disuse. This may include poorer oral hygiene and reduced muscle strength in the oral cavity and pharynx, and poorer UES opening (particularly pseudobulbar palsy).

Explanation

The most distinctive characteristic of Rehabilitation Medicine is the utilization of learning as a part of treatment. This therapeutic learning directly changes the capacity of individual patients and ameliorates their disability, through a process of training (exercise).

Explanation

For paraplegics, becoming able to walk with the aid of some equipment exploits the same mechanism that tennis players and pianists use to get better through practice.

Explanation

Therapeutic learning includes cognitive learning, but to simplify matters at this point, let's focus the explanation chiefly on motor learning. Each unit of action acquired is called a skill and consists of the various exercises for achieving the purpose of the action. This skill is a capacity that patients develop through training rather than an action they were originally capable of doing. Through the acquisition of skills, patients become able to do a variety of things.

Explanation

Many skills can be acquired through rehabilitation. Typical skills are shown here. The point is that these skills are matched to the disablement, so we can't call them normal skills. A swallowing technique used in dysphagia rehabilitation are also examples of a new skill.

Explanation

To give you some understanding of therapeutic learning, let's take the case of training for patients with aspiration due to decreased triggering of the swallowing reflex. The aim of the training is that patients with this disablement acquire the ability to swallow safely (the target task).

Based on the principle that practice will lead to achieving the target task-and more precisely here, swallowing skills will be best acquired by practicing swallowing-the simple focus is on triggering the swallowing reflex. Thermal tactile stimulation (TTS) is needed to stimulate the swallowing reflex in patients with impaired swallowing reflex. A large number of studies have demonstrated that TSS can indeed trigger the swallowing reflex.

By stimulating the swallowing reflex with TTS, patients can learn a new swallowing technique appropriate to their condition. Let's look next at the supraglottic swallow (SGS). The SGS technique involves taking and holding a breath, then swallowing, and coughing immediately after that. Holding a deep breath creates positive pressure in the thoracic cavity and prevents food from entering the respiratory tract. Coughing immediately after swallowing expels any food that may have entered the larynx. These two actions reduce the possibility of aspiration. With normal swallowing, entry of food into the respiratory tract is prevented by swallowing apnea, and we can think of SGS as strengthening that coordination. In other words, SGS may involve a slightly awkward maneuver, but this safer new swallowing technique can be mastered by patients. They perform exercises repeatedly and master the SGS technique to a certain extent, and then move on to a training step where actual food is used in the swallowing exercises. In this way, patients approach the target task gradually. When using actual food, the swallowing reflex becomes better able to be elicited, so SGS may then no longer be necessary.

Explanation

Rehabilitation Medicine is designed to achieve solutions in the system, and it leverages equipment and the environment.

Explanation

The support system rests on 2 pillars. The first is engineering support and the second is social support.

People are animals that use tools. We use about 20,000 tools in normal activities. Issues that prove insurmountable with therapeutic learning can be dealt with using equipment; in other words, by adopting an engineering approach. Such an approach can cover artificial limbs, fittings, wheelchairs, sitting-position retention apparatus, walking sticks and walking frames, self-help devices, environmental control devices, and functional electronic stimulation. Artificial limbs and fittings are widely used clinically as auxiliary equipment. It is also vital to establish a barrier-free environment. Other methods include biofeedback and glasses, which work at the level of the sensory system, and mental bracing, such as note-taking for memorization, which works at the level of cognition.

The engineering approach we use in dysphagia rehabilitation naturally includes intermittent intubation and a dysphagia diet as well as the obvious dental devices such as a palatal augmentation prosthesis (PAP).

One pillar of the support system involves the crucial procedures for coordinating family members and medical and support staff, promoting use of the social system, and making important environmental adjustments.

Explanation

Rehabilitation Medicine is a branch of medicine dedicated to supporting people living with disablement and disease.

Rehabilitation Medicine aims for solutions in the system as a form of treatment dealing with activity disorders.

It deals with these disorders through the following characteristic methodologies: 1) medical management of the patient with disablement, 2) the activity-function-structure relationship, 3) therapeutic learning, and 4) a support system.

Rehabilitation Medicine is unique and universal. Understanding this concept leads to an even greater appreciation of the value of dysphagia rehabilitation.

References

1. Saito E.: Essays on Rehabilitation Medicine. in Saito, E. and Mukai Y. (ed) Swallowing and Dysphagia Rehabilitation, 2nd edition, Pp 2-12 (in Japanese). Ishiyaku Publishers Inc., Tokyo, 2007.
2. Chino N.: (translator). Guide for use of the uniform data set for medical rehabilitation (Japanese edition). Medical Book Center. Tokyo, 1991.
3. World Health Organization: International Classification of Impairments, Disabilities, and Handicaps. WHO, Genova, 1980.
4. Japanese Ministry of Health, Labour and Welfare: International Classification of Functioning, Disability and Health (Japanese edition). Published on the ministry web site http://www.mhlw.go.jp/houdou/2002/08/h0805-1.html
5. Saito E.: Rehabilitation Medicine and the Essence of Therapy (in Japanese) in Saito E. and Sonoda S. (ed.): Full-time Integrated Treatment Program - Toward an Implementation of Comprehensive High-intensity Rehabilitation in the Hospital Ward, pp 73-85. Igaku -Shoin, Ltd. 2003.
6. Schmidt RA, Wrisberg CA: Motor Learning and Performance. 4th edition, Human Kinetics, Champaign, IL, 2008.