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Thread: Interesting excercise modality used in Italy

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    Interesting excercise modality used in Italy

    AL CORD INJURIES : INTENSIVE , CONSTANT , PERSONALIZED MOTORY REHABILITATION - ( R. I .C. )

    Arcangeli C.A. 1 ; Lazzeri G. 2 ; Arcangeli M.E. 2

    Private Institute of Physical Therapy and Rehabilitation Centro Giusti
    Via G. Giusti n. 6 / r - Florence ( ITALY )
    Tel. 055/24.79.027 Fax 055/ 24.50.77 E - mail cngiusti@dada.it http - www.centrogiusti.it

    1 - Specialist in Physical Therapy and Rehabilitation and Orthopedics and Traumatology 2 - Kinesiology
    ------------------------------------------------------------------------------------------------------------------------------------------------
    This rehabilitation technique that ascribes to a specific philosophy, finds its roots in the so called , Russian school of Rehabilitation' .
    That which sets R.I.C. apart from common therapeutic programs is constituted by its 3 primary principals: intensity , continuity and personalized programs-hence its name .
    Intensive : the rehabilitation treatment has patient and therapist working 4 to 6 hours a day Monday through Friday .
    Constant ( continuity ) : the duration of the rehabilitation treatment cannot be established a priori - the span of the therapy is always long term ( year/s ) and its exact length is determined by the goal set and the results obtained .
    Personalized : the rehabilitation program is tailored so as to focus on each individual patients' reality, structured to suit the specific type of lesion that constitutes each patients' lesion. The therapist and patient work on a one to one basis which allows for this type of coherence .

    The indications of RIC methodology refer to all pathologies pertinent to central nervous system lesions , including peripheral type , prevalently Spinal cord injury and cerebral childhood paralyses .
    For all illnesses in acute phase, fractures that have not yet set or consolidated and for lesions cause by pressure ( ulcers ) RIC method is absolutely not advisable .
    In regard to other pathologies such as convulsive syndromes and ailments with progressive evolutions our method is not entirely inadvisable .
    The complications involve the possibility of damage to lesions associated with muscular mass and those of the osteo - ligament apparatus .

    A separate expostulation ought to be made specific to the spasticity factor ; the latter normally increases at the outset of initial treatment phases but gradually recedes over time. It is occasionally advisable to combine the physical rehabilitation therapy with pharmacological therapy such as anti - spastic drugs ( ex. Baclophene ) or with central myo - relaxant drugs ( ex. Tizanidine hydrochloride )

    The RIC method revolves around the stunning resourcefulness found when human physiology is correctly stimulated through intensive encouragement as an incentive to motivation " nature finds ingenious solutions which our engineers are unable to duplicate " ( from How the mind works by Steven Pinker ) .
    Intensive stimulation is engendered by the choice of therapeutic methods employed such as stretching , articulation movements , exercises that are ALWAYS - active - , electro - stimulation , walking , etc . The patient is stimulated 'globally' i. e. above and below the lesion site itself . The patient must be driven by strong motivation , he/she must not be mislead regarding the achievements he/she may attain , nonetheless , the patient must never be made to feel incapable of overcoming their predicament nor should their drive ever be undermined .
    No diagnostic test , either clinical or technical l , currently exists able to determine how many and which spinal marrow fibers have specifically actually been damaged . Furthermore , given our limited knowledge regarding the physiognomy of the central nervous system , we are currently unable to formulate initial diagnoses or prognoses with mathematical exactitude . Patients with marrow lesions must be considered capable of partially or entirely recuperating those functional abilities they have lost or that have been seriously compromised . The symptoms and expression of marrow lesions must never be synonymous to irreversibility of motory functions and as such , rehabilitation and reeducation programs must be constantly updated and applied according to the most recent scientific discoveries . Furthermore , rehabilitation programs must never be limited to the minimum value of either intensity or schedule duration within time restrictions, as is equally true of other motory pathology treatments . The therapy must always be constant and intensive throughout the totality of its duration .
    Therefore , nerve damage patients should be envisioned as though they were professional athletes , who after muscular - tendon injuries , are placed under treatment in order to reacquire their full abilities . Nerve damage patients obviously suffer a more ponderous and composite set of symptoms. For this reason , the concise method and duration of the treatment to be followed must be regulated and designed accordingly . Basing ourselves on our experience , the subjects , under appropriate rehabilitation treatment , will be able to partially or completely reacquire what capacities they had lost . The achievement of this goal will occur through the abidance to a spectrum of therapeutic techniques :
    Reactivation ( recovery and strengthening ) of a vast range of muscles situated above the lesion site and the use of these muscles applied to movement other than strictly function specific . This is attained by performing alternative movement exercise schemes .
    Activation of structures below the marrow lesion site .
    Addressing the unexplored resourcefulness inherent to the human body . The patient is viewed as a unification of composite components constituted by mind and body and as such furnished with immense inner resources . Contemporary science only discloses a minimal fraction pertinent to human potential . It is of common domain that patients subjected to conditions of extreme stress and augmented motivation reveal the presence of unsuspected resources that can bring surprising results .

    RIC constantly stimulates the patient regardless of the level and depth of the lesions while always abiding by the individual's clinical and technical reality .
    We wish to reiterate our firm belief born out of our clinical experience , that each patient willing to make sacrifices and is sufficiently determined can obtain striking and at times unimagined results . These outstanding results are not to be attributed to miraculous events but to the natural vast wealth of hidden resources that normally lay dormant in daily circumstances but are activated and operative in situations of need. In such cases the only real obstacle responsible for a lack of incentive and will are to be attributed to of poignant absence of support on the patient's and his/her relatives behalf . The patient who wishes to improve his/her functional situation must be propelled by a firm belief in the validity of the therapy followed . Furthermore, the patient must maintain his/her adamant desire to endure and to overcome the many moments of psychological as well as physical hardship he/she will have to confront throughout the rehabilitative therapy .
    In the initial draft of RIC its protocol and rehabilitation program are not conditioned by either medical diagnoses or the first neurological test result to which the patient is subjected as precocious prognostic indexes have often proven to be inaccurate . The main goal ultimately is WALKING . By this we intend : attaining the closest possible reality to independent movement , one with least possible need of external auxiliary supportive equipment , in other words , attaining the most akin to natural, normal walking as can be obtained . The concise practical significance of this ambitious goal is always and must always be discussed by therapist and patient and the latter must be concordant with the reality of what the program will mean so as to avoid detrimental illusions and disappointments . This decisional involvement on the patients behalf also acts as a powerful incentive toward the perpetuation of the latter's drive in attaining the goals established .

    The type of movement that is initially addressed does not have the characteristics of 'functional walking' but is set toward 3 goals :
    stimulation neuromuscular stimulation of the area below the lesion through the exploitation of gravity
    reestablishment reestablishing a new motory scheme from a central nervous system standpoint and to adjust posture so as to have it correspond with a proper erect position ; reestablishing sense of balance as well as a time-space relationship .
    reacquisition psychological re-appropriation of physical self awareness when in standing position in terms of interaction with others as well as readjusting to moving through space with out the aid of a wheelchair .

    Walking will subsequently become more fluent once the patient autonomously begins to use equipment such as low boots , and /or Codivilla spring devices or through the use of other similar tools with exclusion of tripod walking sticks and /or walkers . This is carried on till the point when the patient is autonomously capable of standing upright and effectively fulfilling daily required activities . While working on attaining the above described results, many other goals will also be achieved - long as short term such as muscular recovery and strengthening, reacquisition of lost capacities such as balance , co - ordination , control of many positions and posture ( in orthostatic position while in wheelchair as well as during walking exercises ) . This is essential in terms of avoiding the possibility for secondary pathologies to incur due to long term immobility such as osteoporosis and subsequently reducing the risk for pathological fractures to occur as well as cases of reversible left ventricle hypotrophy .
    In social integration and psychological terms , the patient's intensive rehabilitation work enhances his/her emotional sphere, their 'joy de vivre', and hence stimulates toward new social readjustment. We can therefore assert that by working on the patients' physical self , therapy causes productive perpetuation both psychologically as emotionally and vice versa.

    From a neuro-psychological stance RIC's scientific basis can be traced to some of the concepts found in the Cognitive School as well as in the Ecological School .
    All rehabilitative programs elaborated by RIC take into account cognitive functions such as :
    memory ( the patient has to reprogram each movement he/she will be performing ) .
    language ( the therapist's language must be simple and symbolic ) .
    attention ( the patient must be attentive and active ) .
    perception ( the patient is taught to listen to his/her body and to be receptive to the responses his/her body emits ) .
    time-space awareness ( during any given exercise, but more so with balance exercises and walking , it is essential for the patient to be constantly made aware of the relationship between body time and space in terms of his/her own physical self awareness ) .
    reaction times etc ( the patient's reflexes, the level of alertness must be dynamic as he/she cannot afford for vacillation or uncertainty ) .

    These cognitive functions introduced into the patients' surroundings through the insertion of information derived from sensory structures ( sight , hearing , tact , self-awareness receptors etc ) , prove initially essential to muscular recovery and subsequently in order to repeat each exercise . The repetition in itself represents a form of constant self awareness stimulus enhances motory reprogramming which is vital in order to recover lost functions such as walking . In turn in order to repeat the exercises, the patient's musculature must have optimum muscle tone which usually requires preliminary muscular strengthening .
    In terms of this we wish to reinforce what we previously asserted in emphasising the pivotal role of muscle strength reacquisition on the patients' behalf . This means: firstly to refurbish a muscle or group there of , to as to reach its/their normal strength capacity ; secondly , to augment those same muscles to reach sufficient potency in order to withstand the particular efforts necessary to properly fulfil therapeutic routine . The passage from step one to step two is not as automatic as it might sound by definition ; attaining normal strength inadvertently leads to the augmentation of the latter . RIC work programs offer many therapeutic options ( stretching , passive articulation mobilisation , massage motory re - instruction , electrotherapy , magnetic therapy etc ) all scientifically proven as efficient as can be seen in many scientific publications. The originality and specificity of the methods is exemplified by the multifaceted nature of the system in the therapeutic application being tailored so as to meet the needs of each particular case with personalised programs addressing the many realities to be found in a full range of marrow lesions .

    In order to maximise patient stimulus RIC elaborates rehabilitation programs that can be incorporated with athletic programs and therefore highly personalised ( as every lesion is different from any other ) , intensive ( with 4-6 hours of training per day , 5 days a week ) and executed by specialised therapists ( method therapists ) that follow the patient individually ( 1 to 1 basis , sometimes 2 to 1) . Another element specific to RIC is the rehabilitation equipment such as RIC boots and the so called R.I.C. bed . Although they might seem reminiscent of archaic and long discarded gadgets , the above mentioned tools accomplish their goals better than any alternative found to date . The rehabilitation treatment structured as described above does not have a predetermined duration as it is self-evident that with the vast majority of cases , the treatment will need a long time expanse ( several years ) and its duration will depend upon the results obtained and the goals established. The actual results are conditioned by the severity of the lesion, the patient's will-power and the time lapse since the marrow damage occurred . If the patient does not follow any sort of rehabilitation program , as shown by our studies, secondary pathologies caused by immobility will set in such as muscular contractions , articulation rigidity and ankylosis , severe osteoporosis , muscular hypotrophy , obesity , bedsores . The above list summing up as being terribly detrimental to the patient under all aspects-physical and consequently intellectual .

    Each RIC rehabilitation session normally allows for 3 stages scheduled within each daily program
    ( every application will be elaborated to suit each individual patient's specific needs ) :
    osteo - articulation kinestherapy : articulation stretching and movement exercises
    physiokinesistherapy : massage , electro - massage , electro - therapy , magnetic therapy
    motory rehabilitation : method exercises

    Stretching ( passive forced muscle extension ) acts as preparation to achieve maximum muscular exertion so as to support the patient's effort while performing particular method exercises. It takes place at the beginning of the rehabilitation session and varies depending upon the specific location of the lesion site ( tetra or paraplegic ) . The duration of the exercise also is variable (30 / 60 / 90 minutes ) and is determined by where the lesion is posited as well as its level of damage and the degree of spasticity .
    Massage is performed on all muscles: on spastic muscles for relaxation purposes and on flaccid muscles for stimulation purposes .
    Stimulating electro - therapy that adopts voltage akin to that used by Kotz , follows concise programs and is performed on all muscles including spastic muscles . When the patient follows an advanced program work out , electro - stimulation can occur simultaneously with the actuation of some exercises so as to achieve a more thorough muscular response .
    Electro - massage newly introduced in the RIC methodology , is used as a non specific stimulant working on the superficial layer of muscle tissue .
    Magnetic therapy , low frequency , is used for its bio - stimulant effects on the central nervous system as well as on the urinary system .
    Motory rehabilitation employs RIC method specific exercises .


    RIC Method Exercises

    Before we can discuss the actual exercises it is essential to remember that marrow lesions are linked not solely to loss of mobility and sensitivity etc , but also to the partial or total loss of physical self awareness and consequently , cause an inevitable distortion of the patient's perception of his/her temporal/spatial relationship . In normal conditions the formulation of physicality patterns is engendered by afferration receptors , in terms of dynamic 3D interaction . Seen as these pathologies cause a loss of that type of sensorial feed back , we are forced to recreate physical sensorial paragons through vigorous high density stimulation , physical , verbal and visual . Through intensive rehabilitation work the patient is to learn to 'listen' and to ' hear ' his/her body which will then allow him/her to recreate the temporarily absent perceptions . This 'reprogramming' always begins with a set of clearly delineated goals with a predetermined list of causes and effects which will assist the patient as guide lines to attain the desired results .
    The patient must always be motivated and mentally prepared to receive and assimilate the required stimulus . For this reason RIC method exercises are always and only active . From an athletic point of view Dr. H. Gardener - Harvard University - proved that the cerebral regions activated when an individual partakes in a competition are identical to when an individual engages in a competition only mentally . This proves the importance of the patient's mental engagement . RIC exercises have been created through a global observation and consequent assessment of the effects of these exercises performed by a healthy individual . The routine consisted of moving from reclining position to seated position then proceeding to an upright standing position followed by walking and consequently returning to the initial position through the inverse process . This sequence in then broken down further :
    standing upright from reclining or supine position to then proceed to
    seated position followed by
    standing erect and adding movement (walking) to then
    return to the initial position
    Every individual movement exercise is subdivided into analytical sections , each corresponding to muscular clusters and designed to cover the daily schedule . The first phase of the program revolves around the work outs that focus on obtaining motory capacities and are designed in accordance with each singular exercise that will be accomplished .
    In the second phase the rehabilitation program evolves to reach a coalescence of several exercises that are product , as mentioned earlier , of an analytical break down of all main movements . In the third phase the focus is set to capture and assess the degree of capacities that have become automatic and thereby completely assimilated . The transitions between phases occur over time and cannot be pre - programmed a priori seen as the intrinsic variables involved are infinite ( type and location of the lesion , patient's character and motivation etc...). Hence the three stages are hypothetical as throughout the training progress they may overlap .

    Thanks to this data approximately 120 exercises have been designed ; each exercise can have many variations and be applied from a gamut of different positions ( laying down , supine , leaning forward , stationary seated position , upright seated position etc ) , furthermore the exercises may be utilised for many moments of the rehabilitative treatment - reacquisition of many capacities , muscular development , co - ordination , balance , as well as combining more than one goal at a time . The variations of the exercises therefore , can be infinite and are equitable to the number of possibilities we offer for the patient to perform each exercise and in turn depend upon the level of the patient's abilities and the specific goals set out to attain .

    In order to create and perform the exercises the following material is necessary :
    R.I.C. bed : made up of a rigid bed surface ( 2 by 1.20 meters ) and a steel device made up of poles with holes 6 cm apart from each other and one hole with a diameter of 1.6. It is also furnished with pulleys, fixed chest plate revolving chest plate , knee rests and pedals . The machinery is all very easy to assemble so that each exercise can be swiftly made to fit the needs of each individual patient with fast and simple adjustments .
    Low boots : particular and original they serve as short yet rigid support tools ( approximately 15 cm below the knee )and quite resistant ( made of rigid aluminium) . They are composed by a vertical portion that is to be wrapped around the calf and a horizontal portion to fit the foot . The vertical part has a device in order to adjust the degree of inclination of the tibia -tarsal articulation . The boot is strapped onto the leg with a simple bandage .
    Chains made of plastic and steal , hooks , snap hooks , rope , bandages .
    Belt , wrist supports , wrist supports with hooks , padded ankle support .
    Positioning cushions , upright padded support plate .
    Sets of weights .
    Electro - stimulator with two phase current with a maximum exit capacity for 120 mA .
    Portable magnetic therapy device .

    RIC rehabilitation protocol administrative details :

    Admission specialist's check-up possibly to occur in correlation with the patients' own doctor . During the check-up a neurological test will take place to be followed by the compilation of an internationally validated table ( A.S.I.A / F.I.M ) as well as an RIC table ( Giusti table ) . The patient is carefully instructed regarding all details pertinent to RIC treatments and all they entail. After which the patient fills in and signs a document of consent .
    Health institution compilation for personalised rehabilitative treatment programs the latter are to be compiled on a daily basis , Mondays to Fridays with information relative to the entire duration of the sessions , on average 4 / 6 hours and cover :
    Articulation-osteo Kinetic therapy : articulation stretching and mobilisation exercises
    Motory rehabilitation : combination of active exercises
    Physiotherapy : massage , electro - massage , electro - therapy , magnetic therapy
    Given the vast gamut of lesion differentiation all therapeutic programs are personalised and are subject to constant adaptation and adjustment according to the patient's response . The day hospital re - educational cycle may sway between 3 , 6 and 9 months depending upon the severity of the lesions . This period functions as a means of adaptation for the patient to grow accustom to the new intensive therapy and so as to furnish technical data necessary to formulate a concise therapeutic program that will subsequently take place at the patient's own home .
    Appointing a specialised therapist who will follow the patient throughout therapeutic treatment individualised treatment , not group sessions , given by the diversification between types of lesions and thereby requiring therapist tailor designed therapeutic program. Patient / Therapist relationship is usually on a 1 to 1 basis occasionally 1 to 2.
    Daily physician/therapist meetings
    Daily and/or periodical medical check-ups on the patient throughout entire therapeutic program : recording of data collected relative to the patient's state of progress according to the previously mentioned internationally validated tables such as A.S.I.A and F.I.M as well as our table ( Giusti table ) .
    Therapist divulges home rehabilitation program to a relative or to the patient's personal Therapist .
    Patient's purchase of equipment required for home therapy treatment
    Discharge from rehabilitation centre for pre-established period :
    Specific daily schedule to be followed at home
    Medical and physiological documentation
    During the period the patient will be following therapeutic program at home,he/she may contact the Centre by phone and /or fax regarding any problem regarding the therapeutic progression .
    Complete medical check-up after a 3 month period of home rehabilitation treatment (see discharge) this allows for a verification of the patient's progress and the necessary updating of the exercises that may need to be modified .
    After about 10 months from the beginning of home therapy it is generally
    necessary for the patient to re enter the therapeutic centre for a period of approximately one or more months in order to verify and update the entire program so as to assure the therapy is progressively still improving the patient's situation .

    RIC's organisational route envisions :

    Once the patient has passed the acute stage of his/her ailment, RIC ( after about 3 months since the trauma occurred with paraplegic patients , 5 months with tetraplegic patients ) will begin the intensive , constant and personalised rehabilitation program phase . The patient may opt for RIC also through national Spine Centres , as the institution of their choice regardless of where in Italy they come from and other countries.
    During the patient's chronic stage his/her rehabilitation program should abide by a routine whereby he/she frequents the day hospital for an average period of 3 / 6 months for paraplegics and of 6 / 9 months for tetraplegics .
    Once the three month therapy period is over patients are sent back home where they are to proceed their rehabilitation program following very concise indications provided by RIC. In order to adequately carryout the rehabilitation exercises at home, the patient must have all necessary equipment including electro-stimulation kits and must be assisted by a therapist who has successfully undergone RIC centre training . This later portion of the program may take place at the patient's home or at appropriately equipped locations .
    During the rehabilitation therapy period of about 3 months, the patient and therapist may contact the Centre regarding any rehabilitative need they may have .
    After the 3 month home therapy session has been fulfilled, the patient and his/her therapist will need to attend a daily check-up and monitoring session at the Centre's day hospital .
    After yet another 3 months of home therapy the patient MUST follow a 2 month therapeutic session at the Centre .
    The patient will then resume home therapy sessions following an updated schedule then proceeding onto the above described program until he/she has attained the predetermined goals .

    "Life is about how you
    respond to not only the
    challenges you're dealt but
    the challenges you seek...If
    you have no goals, no
    mountains to climb, your
    soul dies".~Liz Fordred

  2. #2
    Interesting info. Will pass on to our PT's here. Thanks for sharing. PLG

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