Technology in Physical Medicine and Rehabilitation practice.
Technology in Physical Medicine and Rehabilitation practice
BME days 2006 ITB.
Multidisciplinary Sinergy: Towards Better Community Health Care
Bandung, 13-15 November 2006
Marina Moeliono, MD, Physiatrist
Dept of Physical Medicine and Rehabilitation
Faculty of Medicine, Padjadjaran University – Hasan Sadikin Hospital
Abstract
The higher life expectancy and advances in medical care and technology have
resulted in an increased proportion of dependent individuals, who require extensive
intervention in rehabilitative care. PM&R manages persons with impairment,
disabilities and handicaps through the use of medications, physical modalities,
assistive devices, therapeutic exercises and experential training approaches
For this purpose various technologies are developed to aid in the diagnosis of
disabilities and to find the best treatment for a certain disability.
Introduction
Physical medicine and rehabilitation (PM&R) is a branch of medicine dealing with
functional restoration of a person affected by physical disability.
Scope of Physical Medicine and Rehabilitation involves the management of
disorders that alter the function and performance. Management is focused on restoring
the health and the optimization of functional abilities of people with impairments,
disabilities and handicaps, as the result of an illness or injury, through the combined
use of medications, effective physical medicine and rehabilitation therapies including
physical modalities, and experiential training approaches.
Advances in medical care and technology have resulted in an increase in the elderly
population, mostly encumbered with chronic and degenerative diseases, survival of
babies with congenital anomalies, and the number of persons surviving an acute
illness or injury such as stroke, heart surgery, amputation, joint replacement, sports
injuries, occupational injuries, spinal cord injuries or other spinal disorders resulting
in an increasing proportion of dependent individuals, who require extensive
intervention in rehabilitative care.
For this purpose various technologies are developed to aid in the diagnosis of
disabilities and to find the best treatment for a certain disability. Technologies in
PM&R includes electrodiagnostics (EMG and NCV studies) to diagnose and provide
prognosis for various neuromuscular disorders; gait analysis for interpretation and
diagnosis of normal and pathological human locomotion and in the end to optimize
and improve performance; CPM (continuous passive movement) machines to aid in
treatment of muscles and joints; assistive devices to use in activities of daily living;
biofeedback used in diagnosis and therapeutic exercises; treatment modalities using
heat, cold and electrical current; and the technology used in making orthotics and
prosthetics
History
PM&R is a relatively young specialty. In 1936 Dr. Frank Krusen, one of the early
pioneers, developed the Department of Physical Medicine at the Mayo Clinic. PM&R
was recognized as a medical specialty by the American Board of Medical Specialties
and the American Medical Association in 1947.
This specialty expanded rapidly after World War II, when many soldiers with severe
disabilities returned and physicians were necessary to treat and manage chronic
debilitating conditions. Polio epidemic in the early 1950s and advances that allowed
longer survival from disorders as varied as spinal cord injury and stroke also helped
establish the value of physiatrists in management of neuromuscular disorders.
In Indonesia the first physiatrists, who graduated from Santo Thomas University in
Manila, Philippines, began working in 1981 but not until 1992 were PM&R
departments declared as independent departments in those hospitals. Education for
future specialists in PM&R started in 1987.
The development of PM&R is accordance with the change in current medical
services, characterized by comprehensive treatment and includes preventive, curative,
promotive and rehabilitative measures.
Rehabilitation medicine itself encompasses promotive rehabilitation, preventive
rehabilitation and curative rehabilitation,
Purpose of promotive rehabilitation is to increase or maintain functional status, and
includes education of healthy living, education to prevent and avoid disabilities and
increasing the overall condition. Preventive rehabilitation is to prevent disabilities,
includes the prevention of secondary and tertiary disabilities such as weakness,
atrophy of unused muscles, stiffness or contractures of joints, osteoporosis,
abnormalities of gait, misalignment of the spine, problems in mobilization and
performing the activities of daily life.
Curative rehabilitation is to diminish disabilities and uses medications, rehabilitative
nursing, physiotherapy, speech therapy, occupational or vocational therapy and
orthotics and prosthetics to help persons to function optimally within the limitations
placed upon them by a disease process for which there is no cure or by the disabilities
or handicaps caused by the disease. The general emphasis is not on the full restoration
to the premorbid condition, but rather the highest level of independency and
optimization of the quality of life for those who may not achieve full restoration.
Technology in Physical Medicine and Rehabilitation practice
In the USA, the science of biomechanics and biomedical/biomechanical engineering
research have developed rapidly in the last 20-25 years. Research came from the
fields of biomechanics, and established medical sciences like neurology, orthopedics
and rehabilitation medicine.
Because functional status is closely linked to movement of the body, the study of
biomechanics or the study of musculoskeletal, neuromuscular and sensory disorders
that are associated with abnormal control of posture and movement, is of particularly
importance for diagnostics and therapeutic purposes in rehabilitation medicine
The research has helped in the development of artificial limbs (prosthetics), the study
of motor control of the human body, biomechanics, computer modeling, and robotics.
The latest achievement is the first sip-and-puff wheelchair control system, enabling
quadriplegics to operate motorized wheelchairs independently
Gait analysis is one of the real success stories of biomechanics. Nowadays, gait
analysis is used routinely for investigation of various conditions, for diagnostics and
planning of surgery and in the rehabilitation department, for diagnostics and to
construct a good rehabilitation program.
The focus of gait analysis is locomotion, which is the act of moving from one point to
another, while gait is a method of locomotion, using alternative and rhythmic
movement of both legs, to provide both support and propulsion. While the gait pattern
can be very individual owing to body proportion, habits, coordination and motivation,
human gait, because of similar anatomical and physiological factors, is accomplished
in a similar manner by all healthy adults.
The study normal and pathological gait can be applied in many rehabilitation
programs. For example, gait training for persons with impairments affecting the gait
pattern like hemi paresis after stroke or traumatic brain injury, elderly persons with
impairment of balance and/or equilibrium, persons with Parkinson disease,
pathological conditions of the feet and lower extremities
Gait analysis began in the early part of 19th century, with sequential photographs and
observational studies. Later, dynamic electromyography was added to record the
internal forces (kinetics) to record the activity of muscle groups during walking.
More detailed analysis was made possible with the development of computer
technology, used in analysis of massive amounts of data obtained simultaneously
from a variety of different sources: force transducers, foot switches, EMG amplifiers,
electrogoniometers, spotting systems
These specialized transducers transform a physical variable into an electric signal that
can be converted to a digital signal. The digital signals are recorded by a computer
and displayed as dependent variables of time on a graph with a common time axis.
These data can be analyzed with the direction and level of analysis depending on the
specific questions being asked. The context in which the data are analyzed is critical
in planning, performing and interpreting the study.
In gait analysis muscle action cannot be measured directly, so EMG studies were
added to gait analysis. The electromyography (EMG) allows indirect measurement of
muscle activity. A typical kinesiological (dynamic) EMG represents the activity of
multiple motor units of various muscle groups. Single motor units are analyzed
routinely in clinical electrodiagnostic studies, but this level of analysis is not
performed as part of a routine gait analysis.
In clinical situations, electrodiagnostic testing or EMG studies of the peripheral nerve
system is done an adjunct to the history, physical examination and other additional
examinations in the overall evaluation of neuromuscular disorders.
Basically electrophysiology or electromyography is the study of the physiologic
functioning of muscle and nerve fibers which are the two basic excitable tissues in the
human body. Results are obtained through application of electrical stimulation and
recording of the responses. The practitioner must be aware of how the instrument
detects and displays the recorded physiological potentials
The EMG studies are done with needle electrodes that are inserted in the muscle cell.
Cell activities studied and analyzed are insertional activity, caused by the disruption
of the resting membrane when pierced by the needle electrode; muscle at rest; single
motor unit action potential (MUAP) generated by minimal voluntary contraction and
the recruitment pattern caused by maximal contraction.
Physiology of MUAP, all living cells have a potential difference across the cell
membrane with the intracellular region negative compared to the extracellu lar
environment. When there is no action potential present, the cell is in a resting state
and the difference in action potential is called resting membrane potential. A
mathematical statement of the potential states that this resting potential is -75 mV (-70
– 90mV), meaning that intracellular is 75 mV more negative than the extracellular
region. In this state, concentration and electrical forces are balanced and the cell will
attempt to maintain this state.
Muscle and unmyelinated nerve contain both sodium and potassium voltage gated
channels. These gates are closed at the resting membrane potential.
Application of electrical, mechanical or chemical stimulation which reaches the
threshold of the membrane, 15-20 mV less negative than the resting potential, causes
the channels to open, resulting in an increased permeability of sodium ions, a process
known as sodium activation. This massive shift in transmembrane potential is referred
to as depolarization. The process will then continue along the length of the cell.
Once the process begins, it is self sustaining as long as there are sufficient ion
channels to repeat the process of depolarization. If not, the sodium gates automatically
close with a return of the resting membrane potential, referred as repolarization
The voltage generated by the depolarization induced current flows generates all of the
potentials we observe on the instrument’s cathode ray tube screen.
Nerve conduction studies is another feature of the electrophysiology studies. Motor
nerve conduction is recorded by applying stimulation along a nerve and record the
time of conduction using a pick up electrode on the muscle innervated by that specific
nerve. Sensory nerve conduction is done the same, with the stimulus given along the
nerve with pick up electrodes on the sensory organ.
Nerve conduction velocity is calculated by dividing the time needed by the electrical
current to reach the end organ from the point of stimulation by the length of nerve
fiber.
The result of EMG studies confirms whether the impairment comes from muscle or
nerve, and in many neuromuscular disorders, can aid in the planning of management.
Based on the normal physiological process that normal muscle contraction is initiated
by propagation of depolarization from the alpha motor neuron, its axon, to the muscle
fiber it innervates, one of the modalities used in neuromuscular disorders is electrical
stimulation.
The interest in electrical stimulation began with an experiment by Galvani which
showed that placement of a metal connector between the spinal cord and muscle could
produce a twitch.
Electrical stimulation was used as a therapeutic modality throughout the 1980s. There
was great debate about the type of stimulation, galvanism, faradism and franklinism,
but the therapeutic claims were never substantiated. In the 1990s electrical stimulation
was used again with use of the alternating current generation.
Interest in electrical stimulation continued to develop and data gathered since the
1940s support the efficacy of electrical stimulation as a valuable therapeutic modality.
The first significant application of electrical stimulation to improve muscle function
dates back to 1950, with the invention of the cardiac pacemaker.
Effective application of functional electrical stimulation, a form of electrical
stimulation, in a rehabilitation setting began with the stimulation to the peroneal nerve
to produce ankle dorsiflexion.
Since the 1970s, FES or functional electrical stimulation for gait restoration after an
upper motor neuron lesion has progressed from feasibility studies to the development
of a commercially available, FDA-approved ambulation system. FES ambulation
systems range from totally external devices to more experimental systems that are
virtually completely implanted.
Typical components of the FES system include a power source plus cables, a control
mechanism, stimulator with cables and electrodes. Additionally, FES system requires
a feedback mechanism. Types of feedback mechanism include input from external
sensors, EMG of muscle, sensory areas or the brain. The most common and practical
sensors are externally mounted devices that feedback information regarding limb
position and movement. More sophisticated automatically incorporate feedback from
changes in the muscles or fatigue, directly back into the FES system
Despite considerably progress, a number of barriers remain that continue to render
this cumbersome clinical application of technology. In addition to requiring a user
friendly system, the ideal FES gait system should be safe, reliable, sufficiently
functional to provide community ambulation, inexpensive and cosmetically
acceptable. Many of these goals have not been realized.
The Physical Medicine and Rehabilitation Department in Hasan Sadikin Hospital has
a few of those technologies mentioned, although not the gait analyzer. Gait analysis is
done in the traditional observational method. Electrical stimulation is done routinely
in the management of various disorders, but FES is done only for the small muscles of
the upper extremity. EMG studies for diagnostic purposes is mainly done by the
neurologist, while in the rehabilitation setting it is used for biofeedback purposes.
We do not develop the equipment but are the user of equipment and technology from
Japan, the Netherlands and America. There are not many research programs ongoing,
primarily restricted by inadequate funding.
With what we have, our specialty aspires to spread the knowledge about what is
possible and what can be done to increase the functional capacity of persons with
disabilities and handicaps.
BME days 2006 ITB.
Multidisciplinary Sinergy: Towards Better Community Health Care
Bandung, 13-15 November 2006
Marina Moeliono, MD, Physiatrist
Dept of Physical Medicine and Rehabilitation
Faculty of Medicine, Padjadjaran University – Hasan Sadikin Hospital
Abstract
The higher life expectancy and advances in medical care and technology have
resulted in an increased proportion of dependent individuals, who require extensive
intervention in rehabilitative care. PM&R manages persons with impairment,
disabilities and handicaps through the use of medications, physical modalities,
assistive devices, therapeutic exercises and experential training approaches
For this purpose various technologies are developed to aid in the diagnosis of
disabilities and to find the best treatment for a certain disability.
Introduction
Physical medicine and rehabilitation (PM&R) is a branch of medicine dealing with
functional restoration of a person affected by physical disability.
Scope of Physical Medicine and Rehabilitation involves the management of
disorders that alter the function and performance. Management is focused on restoring
the health and the optimization of functional abilities of people with impairments,
disabilities and handicaps, as the result of an illness or injury, through the combined
use of medications, effective physical medicine and rehabilitation therapies including
physical modalities, and experiential training approaches.
Advances in medical care and technology have resulted in an increase in the elderly
population, mostly encumbered with chronic and degenerative diseases, survival of
babies with congenital anomalies, and the number of persons surviving an acute
illness or injury such as stroke, heart surgery, amputation, joint replacement, sports
injuries, occupational injuries, spinal cord injuries or other spinal disorders resulting
in an increasing proportion of dependent individuals, who require extensive
intervention in rehabilitative care.
For this purpose various technologies are developed to aid in the diagnosis of
disabilities and to find the best treatment for a certain disability. Technologies in
PM&R includes electrodiagnostics (EMG and NCV studies) to diagnose and provide
prognosis for various neuromuscular disorders; gait analysis for interpretation and
diagnosis of normal and pathological human locomotion and in the end to optimize
and improve performance; CPM (continuous passive movement) machines to aid in
treatment of muscles and joints; assistive devices to use in activities of daily living;
biofeedback used in diagnosis and therapeutic exercises; treatment modalities using
heat, cold and electrical current; and the technology used in making orthotics and
prosthetics
History
PM&R is a relatively young specialty. In 1936 Dr. Frank Krusen, one of the early
pioneers, developed the Department of Physical Medicine at the Mayo Clinic. PM&R
was recognized as a medical specialty by the American Board of Medical Specialties
and the American Medical Association in 1947.
This specialty expanded rapidly after World War II, when many soldiers with severe
disabilities returned and physicians were necessary to treat and manage chronic
debilitating conditions. Polio epidemic in the early 1950s and advances that allowed
longer survival from disorders as varied as spinal cord injury and stroke also helped
establish the value of physiatrists in management of neuromuscular disorders.
In Indonesia the first physiatrists, who graduated from Santo Thomas University in
Manila, Philippines, began working in 1981 but not until 1992 were PM&R
departments declared as independent departments in those hospitals. Education for
future specialists in PM&R started in 1987.
The development of PM&R is accordance with the change in current medical
services, characterized by comprehensive treatment and includes preventive, curative,
promotive and rehabilitative measures.
Rehabilitation medicine itself encompasses promotive rehabilitation, preventive
rehabilitation and curative rehabilitation,
Purpose of promotive rehabilitation is to increase or maintain functional status, and
includes education of healthy living, education to prevent and avoid disabilities and
increasing the overall condition. Preventive rehabilitation is to prevent disabilities,
includes the prevention of secondary and tertiary disabilities such as weakness,
atrophy of unused muscles, stiffness or contractures of joints, osteoporosis,
abnormalities of gait, misalignment of the spine, problems in mobilization and
performing the activities of daily life.
Curative rehabilitation is to diminish disabilities and uses medications, rehabilitative
nursing, physiotherapy, speech therapy, occupational or vocational therapy and
orthotics and prosthetics to help persons to function optimally within the limitations
placed upon them by a disease process for which there is no cure or by the disabilities
or handicaps caused by the disease. The general emphasis is not on the full restoration
to the premorbid condition, but rather the highest level of independency and
optimization of the quality of life for those who may not achieve full restoration.
Technology in Physical Medicine and Rehabilitation practice
In the USA, the science of biomechanics and biomedical/biomechanical engineering
research have developed rapidly in the last 20-25 years. Research came from the
fields of biomechanics, and established medical sciences like neurology, orthopedics
and rehabilitation medicine.
Because functional status is closely linked to movement of the body, the study of
biomechanics or the study of musculoskeletal, neuromuscular and sensory disorders
that are associated with abnormal control of posture and movement, is of particularly
importance for diagnostics and therapeutic purposes in rehabilitation medicine
The research has helped in the development of artificial limbs (prosthetics), the study
of motor control of the human body, biomechanics, computer modeling, and robotics.
The latest achievement is the first sip-and-puff wheelchair control system, enabling
quadriplegics to operate motorized wheelchairs independently
Gait analysis is one of the real success stories of biomechanics. Nowadays, gait
analysis is used routinely for investigation of various conditions, for diagnostics and
planning of surgery and in the rehabilitation department, for diagnostics and to
construct a good rehabilitation program.
The focus of gait analysis is locomotion, which is the act of moving from one point to
another, while gait is a method of locomotion, using alternative and rhythmic
movement of both legs, to provide both support and propulsion. While the gait pattern
can be very individual owing to body proportion, habits, coordination and motivation,
human gait, because of similar anatomical and physiological factors, is accomplished
in a similar manner by all healthy adults.
The study normal and pathological gait can be applied in many rehabilitation
programs. For example, gait training for persons with impairments affecting the gait
pattern like hemi paresis after stroke or traumatic brain injury, elderly persons with
impairment of balance and/or equilibrium, persons with Parkinson disease,
pathological conditions of the feet and lower extremities
Gait analysis began in the early part of 19th century, with sequential photographs and
observational studies. Later, dynamic electromyography was added to record the
internal forces (kinetics) to record the activity of muscle groups during walking.
More detailed analysis was made possible with the development of computer
technology, used in analysis of massive amounts of data obtained simultaneously
from a variety of different sources: force transducers, foot switches, EMG amplifiers,
electrogoniometers, spotting systems
These specialized transducers transform a physical variable into an electric signal that
can be converted to a digital signal. The digital signals are recorded by a computer
and displayed as dependent variables of time on a graph with a common time axis.
These data can be analyzed with the direction and level of analysis depending on the
specific questions being asked. The context in which the data are analyzed is critical
in planning, performing and interpreting the study.
In gait analysis muscle action cannot be measured directly, so EMG studies were
added to gait analysis. The electromyography (EMG) allows indirect measurement of
muscle activity. A typical kinesiological (dynamic) EMG represents the activity of
multiple motor units of various muscle groups. Single motor units are analyzed
routinely in clinical electrodiagnostic studies, but this level of analysis is not
performed as part of a routine gait analysis.
In clinical situations, electrodiagnostic testing or EMG studies of the peripheral nerve
system is done an adjunct to the history, physical examination and other additional
examinations in the overall evaluation of neuromuscular disorders.
Basically electrophysiology or electromyography is the study of the physiologic
functioning of muscle and nerve fibers which are the two basic excitable tissues in the
human body. Results are obtained through application of electrical stimulation and
recording of the responses. The practitioner must be aware of how the instrument
detects and displays the recorded physiological potentials
The EMG studies are done with needle electrodes that are inserted in the muscle cell.
Cell activities studied and analyzed are insertional activity, caused by the disruption
of the resting membrane when pierced by the needle electrode; muscle at rest; single
motor unit action potential (MUAP) generated by minimal voluntary contraction and
the recruitment pattern caused by maximal contraction.
Physiology of MUAP, all living cells have a potential difference across the cell
membrane with the intracellular region negative compared to the extracellu lar
environment. When there is no action potential present, the cell is in a resting state
and the difference in action potential is called resting membrane potential. A
mathematical statement of the potential states that this resting potential is -75 mV (-70
– 90mV), meaning that intracellular is 75 mV more negative than the extracellular
region. In this state, concentration and electrical forces are balanced and the cell will
attempt to maintain this state.
Muscle and unmyelinated nerve contain both sodium and potassium voltage gated
channels. These gates are closed at the resting membrane potential.
Application of electrical, mechanical or chemical stimulation which reaches the
threshold of the membrane, 15-20 mV less negative than the resting potential, causes
the channels to open, resulting in an increased permeability of sodium ions, a process
known as sodium activation. This massive shift in transmembrane potential is referred
to as depolarization. The process will then continue along the length of the cell.
Once the process begins, it is self sustaining as long as there are sufficient ion
channels to repeat the process of depolarization. If not, the sodium gates automatically
close with a return of the resting membrane potential, referred as repolarization
The voltage generated by the depolarization induced current flows generates all of the
potentials we observe on the instrument’s cathode ray tube screen.
Nerve conduction studies is another feature of the electrophysiology studies. Motor
nerve conduction is recorded by applying stimulation along a nerve and record the
time of conduction using a pick up electrode on the muscle innervated by that specific
nerve. Sensory nerve conduction is done the same, with the stimulus given along the
nerve with pick up electrodes on the sensory organ.
Nerve conduction velocity is calculated by dividing the time needed by the electrical
current to reach the end organ from the point of stimulation by the length of nerve
fiber.
The result of EMG studies confirms whether the impairment comes from muscle or
nerve, and in many neuromuscular disorders, can aid in the planning of management.
Based on the normal physiological process that normal muscle contraction is initiated
by propagation of depolarization from the alpha motor neuron, its axon, to the muscle
fiber it innervates, one of the modalities used in neuromuscular disorders is electrical
stimulation.
The interest in electrical stimulation began with an experiment by Galvani which
showed that placement of a metal connector between the spinal cord and muscle could
produce a twitch.
Electrical stimulation was used as a therapeutic modality throughout the 1980s. There
was great debate about the type of stimulation, galvanism, faradism and franklinism,
but the therapeutic claims were never substantiated. In the 1990s electrical stimulation
was used again with use of the alternating current generation.
Interest in electrical stimulation continued to develop and data gathered since the
1940s support the efficacy of electrical stimulation as a valuable therapeutic modality.
The first significant application of electrical stimulation to improve muscle function
dates back to 1950, with the invention of the cardiac pacemaker.
Effective application of functional electrical stimulation, a form of electrical
stimulation, in a rehabilitation setting began with the stimulation to the peroneal nerve
to produce ankle dorsiflexion.
Since the 1970s, FES or functional electrical stimulation for gait restoration after an
upper motor neuron lesion has progressed from feasibility studies to the development
of a commercially available, FDA-approved ambulation system. FES ambulation
systems range from totally external devices to more experimental systems that are
virtually completely implanted.
Typical components of the FES system include a power source plus cables, a control
mechanism, stimulator with cables and electrodes. Additionally, FES system requires
a feedback mechanism. Types of feedback mechanism include input from external
sensors, EMG of muscle, sensory areas or the brain. The most common and practical
sensors are externally mounted devices that feedback information regarding limb
position and movement. More sophisticated automatically incorporate feedback from
changes in the muscles or fatigue, directly back into the FES system
Despite considerably progress, a number of barriers remain that continue to render
this cumbersome clinical application of technology. In addition to requiring a user
friendly system, the ideal FES gait system should be safe, reliable, sufficiently
functional to provide community ambulation, inexpensive and cosmetically
acceptable. Many of these goals have not been realized.
The Physical Medicine and Rehabilitation Department in Hasan Sadikin Hospital has
a few of those technologies mentioned, although not the gait analyzer. Gait analysis is
done in the traditional observational method. Electrical stimulation is done routinely
in the management of various disorders, but FES is done only for the small muscles of
the upper extremity. EMG studies for diagnostic purposes is mainly done by the
neurologist, while in the rehabilitation setting it is used for biofeedback purposes.
We do not develop the equipment but are the user of equipment and technology from
Japan, the Netherlands and America. There are not many research programs ongoing,
primarily restricted by inadequate funding.
With what we have, our specialty aspires to spread the knowledge about what is
possible and what can be done to increase the functional capacity of persons with
disabilities and handicaps.