Koleva OT - Reh 2010 2017 PDF

POTENTIAL OF REHABILITATION FOR ACCELERATION OF
FUNCTIONAL RECOVERY AND AMELIORATION OF THE

QUALITY OF LIFE OF PATIENTS IN THE CLINICAL
PRACTICE OF ORTHOPEDICS AND TRAUMATOLOGY
prof. Ivet Koleva, MD, PhD, DMedSc *

* Medical University of Sofia; BULGARIA
Prof. Yvette Koleva, DM, PhD, DMSc Sofia, 2010-2017

INTRODUCTION:
Orthopedic Traumatologic Rehabilitation

Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
is an interdiscipline:
between Orthopedics & Traumatology (OT),
and Physical & Rehabilitation Medicine (PRM).

Sofia, 2010-2017
Traditions of Bg OT rehab school
MD with both specialties:

PRM & Rheumatology, OT:
Prof. Stefan BANKOV, MD. PhD, DMSc - PRM & Orthopedics & Traumatology
Prof. Yanka DAFINOVA, MD. PhD, DMSc - PRM & Rheumatology

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Prof. Yavor VAJAROV, MD. PhD, DMSc - PRM & OT

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OBLIGATORY
CONDITION
!!!
COMPETENCIES IN BOTH
THEMATIC FILDS:
PRM & OT
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Necessary COMPETENCES
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for working in
OT rehabilitation clinical practice:
Competences
Theoretical Practical Moral & Ethical

competences;
knowledge skills Capacity for Team work
Prof. Yvette Koleva, DM, PhD, DMSc
Georges Mialaret, 1973
WHAT ? FOR WHOM ?

Content, programmes Psychological problems
HOW ?
Methods, techniques
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RESULTS (Evaluation)
Quality of Care
!!!
The problem:
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The Quality of Life
!!!
The tragedy
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The OT Rehabilitations opinion
From the point of view of OT rehabilitation

the objective must be to assure the
quality of life and the dignity of these
patients.
The problem is to define the approach and
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the care .
Protocol for registration of patients data
Clinical data: somatic examination, OT & neurological exam (pyramidal signs,

paralysis / paresis, muscle tone, coordination, balance), kinesiological

assessment, manual muscle test, assessment of muscle tone & muscle dysbalance,
balance, grip & gait; functional exam /incl. functional muscle test/; algesic
diagnostics /Visual analogue scale VAS 0-20/; Performance Status Scales;
vibratory sensibility, thermo-sensibility, autonomy in ADL (activities of daily living);
ICF evaluation; neuro-psychological battery /tests of Zung for depression and
anxiety/;
Instumental data: excitomotory electrodiagnostics, electroneurography,
electromyography, neuro-imagery (X-ray graphy, CT, MRI); doppler sonometry,
PET, SPECT.
Oxford Textbook of Palliative Medicine, Oxford University Press. 1993;109.

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.
ASSESSMENT & EVALUATION
Functional Assessment Scales ,

different for every pathology
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OT exam + Kinesiological exam
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Anterior pelvic tilt

*

Flexion and extension

Abduction and adduction
Elevation and depression
Rotation
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GONIOMETRY
active & passive

External rotation
The LOTUS POSTURE of Yoga,

demonstrating external rotation of the leg
at the hip.
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Internal rotation
Circumduction
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Special motion
Plantar flexion
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PALMAR FLEXION & DORSAL FLEXION OF THE HAND
Praying Hands by Albrecht Drer, demonstrating

dorsiflexion of the hands.
Flexion and extension of the hand
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Pronation and supination of the foot & arm
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Inversion and eversion
Eversion of the right foot
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Inversion of the right foot
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Opposition
Scapulo-humeral rhythm
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Scapulo-humeral rhythm
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FUNCTIONAL ANALYSIS OF ACTIVITIES
Assessment of the stature
???

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Assessment of ADL
Functional evaluation of the patient in PRM must be based on
INTERNATIONAL CLASSIFICATION OF
FUNCTIONNING, DISABILITY AND HEALTH
(ICF, WHO, 2001)
HEALTH CONDITION
(alteration / disease)
ICF
Body functions Activities Participation
(and structures) (limitations) (disability)
Environmental factors Personal factors

ICF Options
balancing expectations and risks in OT cases
A wide range of ICF options

with an increasing need for activities and participations
PERSONAL
BODY FACTORS ACTI
FUNCTIONS Technical Age, sex, VITIES
PAIN assistance Poly morbidity, Operating Management PARTICI
Health culture contact contact PATION
Range Verticalization
of Motion Family
ENVIRONMENT
MUSCLE
Home Mobility
FORCE/ Leisure
WEAKNESS Transport
Employment Locomotion Social life
COORDI
Health (rates
NATION (performance Political
Services based) Transport
BALANCE (time related) activities
based) Assurance
GAIT
Family Grasp
Sensibility ADL
Friends
and a need for adaptation to individual circumstances

FUNCTIONAL EVALUATION OF OT PATIENTS,
BASED ON ICF
The holistic approach to the patient must be obligatory the complex evaluation must
include:
COGNITIVE CAPACITIES (orientation, memory, attention, compliance during rehabilitation,
conscience of necessity of preventive measures due to the principal disease);
PAIN (localization, type, intensity /verbal or visual analogue scale/; activities increasing
pain);
RANGE OF MOTION (active and passive);
MUSCLE FORCE OR MUSCLE WEAKNESS, motor deficiency;
COORDINATION (neuro-muscular coordination; static, locomotor or dynamic ataxia);
MOBILITY (necessity of technical aids, gadgets; instruments, etc.);
ENDURANCE (capacity to support extreme changes, necessity of pauses during
investigations and functional activity);
INDEPENDENCE IN ACTIVITIES OF DAILY LIVING (bathing, dressing, eating, hygiene,
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necessity of assistance in the self-care).

The final complex evaluation,
based on ICF, have to include :
BODY FUNCTIONS (pain, range of motion, motor weakness,

dyscoordination syndromes - ataxia);
ACTIVITIES (verticalization, mobility, standing up, walking,
transport, grasping, ADL);
PARTICIPATION (family life, leisure, social life, participation in
political activities);
ENVIRONMENTAL FACTORS (environment at home & at work,
family & friends, health insurance, health assurance, social
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contacts);
PERSONAL FACTORS (health culture, polimorbidity, age, sex).
***
FUNCTIONAL EVALUATION of patients with neurological

conditions, with sensory, motor, autonomic dysfunctions

and deficiencies must be effectuated before and after every
rehabilitation course.
The evaluation have to be based on the holistic approach to

the patient, including :
specialized OT examination, &

Sofia, 2010-2017
Functional examination.
In clinical practice we apply the
COMPLEX REHABILITATION PRINCIPLE
Physiotherapy, electrotherapy,
massages, ergotherapy
In different groups of diseases
Or
Synergic combination of different
physical modalities and techniques:
Complex rehabilitation programme for
every health condition
Prof. Ivet Koleva, DM, PhD, DMSc

In OT Rehab we apply the
PHYSICAL-THERAPEUTIC AND
REHABILITATION PUZZLE
KINESI PREFORMED
(physio) MODALITIES
(electro/magneto/light/th)
therapy
ERGO
ES (occupational)
therapy
The found is always adapted diet and strict medication of the basic disease
Modalites physiques / PHYSICAL MODALITIES Lego style
ES MAGNETO-Therapy
KINESI-Th IONTOPHORESIS
ERGO-Th TENS
LASER DEEP
OSCILLATION
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10-2017
OT REHABILITATION ALGORITHM :
TRAINING OF THE FUNCTION -
KINESIOTHERAPY (PHYSIOTHERAPY) & ERGOTHERAPY
PREFORMED MODALITIES
Electro-stimulation, pain relief, reduction of oedema, stimulation of

regeneration, stimulation of peripheral nerves and muscles, etc.

KINESITHERAPY:
ANALYTIC
EXERCICES Sofia, 2010-2017
MS & MI
augmentation du
mouvement de base
Pour les muscles
paravertebraux
PIR
strech techniques
Massages

MANUAL THERAPY
L5, S1 --- tractions & mobilisations
PNF
Sacro-iliac blockage MANIPULATIONS;
Patellar Mobilisations
Post-isometric relaxation for soleus muscle

Vue anterieure
Vue posterieure

Proprioceptive neuro-muscular facilitation
(PNF)
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Activities of daily living
(ADL)
Sitting in bed
Verticalization
Balance training
Gait education & training up-stairs and down-stairs

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OCCUPATIONAL THERAPY:
Mirror box
therapy
A diagram of a mirror box.

A patient inserts their hand into one hole,
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and their "phantom" into the other.

When viewed from an angle, the brain is
tricked into seeing two complete hands
phantom limb / phantom pain
Mirror therapy for
in amputees
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Occupational therapy
Mechanotherapy
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Passive Mechanotherapy
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM Sofia, 2010-2017
PASSIVE ACTIVE MECHANO-Therapy
STRETCHING
MECHANO-THERAPY
ACCESSORIES
ctive Mechanotherapy
ctive Mechanotherapy
Medical
(LPG device)
Hubert
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xtension therapy
CERVICAL TRACTIONS

xtension therapy
CERVICAL TRACTIONS

xtension therapy
LUMBAR TRACTIONS

Extension vertebrotherapy
Lumbar tractions

PREFORMED PHYSICAL
MODALITIES
FUNCTIONAL
ELECTROSTIMULATIONS
PHYSICAL ANALGESIA
PREFORMED PHYSICAL FACTORS
- ELECTROSTIMULATIONS
(exponential form of pulses, ti=200 msec, tp=1000 msec, Fr=0,25-0,5 Hz,
3 min. for every muscle

15-20 procedures

(low and middle frequency)
Devices for electro-therapy
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ELECTRODES
for electrotherapy with
low frequency and middle frequency currents

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DEVICES
portable
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: .
INTELLECT Chattanooga Intelect Legend XT 2 Channel

Combo (stim and ultrasound) Unit Without Cart

by INTELLECT
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Vectra Genesys Therapy System
Vectra Genisys is the first modular

therapy system that consolidates

up to six therapeutic modalities in
one system, at a fraction of what
these modalities would cost alone.
Unique modular design lets you
choose what fits best in your
clinical setting now or easily add to
later without the replacement of
products. - See more at:
http://www.djoglobal.com/products/
chattanooga/vectra-genisys-
therapy-
system#sthash.1qRPTm8V.dpuf
Sofia, 2010-2017

Different forms of
low & middle frequency
electric currents
Rectangular, triangular, trapezius,

sinusoidal, semi-sinusoidal,
tiratronic,
exponential (positive or negative)
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Low and middle frequency electric currents
BIPOLAR periodic sinusoidal and faradic;
- aperiodic.
MONOPOLAR currents.
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Preformed physical modalities
for anti-pain effect
PHYSICAL
ANALGESIA
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TENS
-TRANSCUTANEOUS ELECTRICAL NERVE

STIMULATION (TENS):
-BTL-06, programme 1617, 10-20 m, 10-20 min., XIV proc.
- Intelect 340 Combo Electrotherapy Unit (Intelect, Chattanooga group, 2004), programme
TENS ( , 40%,
20-400 msec., 1-250 Hz), 15-20 m,
15 - 20 min., XV e.

MAGNETIC FIELD
(CHAMP MAGNETIQUE)
LOW FREQUENCY PULSED MAGNETIC FIELD
- Low frequency low intensity magnetic field

-204 , 10-20 minutes, V procedures pro cursu

Devices
Low frequency pulsed magnetic field

Light therapy
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LASER - acronym of
Light
Amplification
by
Stimulated
Emission Intense
highly directional
of
beam of light
Radiation
- LASER - He-Ne, 5-10 mW/cm2, D = 1,5 cm, 3 min. , 6 fields per die, XV procedures

Devices
Physiolaser in any configuration between 635 to 904 nm:
from 50 mW/ 785 nm up to terrific 500 mW/810 nm or 90 W/904 nm.
New: 200 mW/685 nm (red).
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DEEP
OSCILLATION
The influence of the method DEEP OSCILLATION is based on pulsed

electrostatic field, generated in a zone of the patients body.
BASIC INDICATIONS:
SN & SM conditions,
Pain relief;
TRAUMATOLOGY,
SURGERY.

FFECTS OF
DEEP OSCILLATION
Anti-inflammatory effect;
Stimulation of micro-circulation;
Oedema reduction;
Tissue regeneration;
Pain relief;
Contra fibrosis .
DEEP OSCILLATION
DEEP OSCILLATION
Evident
,
,

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(
)
DEEP OSCILLATION

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DEEP OSCILLATION

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DEEP OSCILLATION
( )
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Shock wave therapy
Shockwave is an acoustic wave which carries high energy to painful spots and
myoskeletal tissues with subacute, subchronic and chronic conditions.
The energy promotes regeneration and reparative processes of the
bones, tendons and other soft tissues.

Shockwaves are characterized by jump change in pressure, high
amplitude and non-periodicity.
The kinetic energy of the projectile, created by compressed air, is
transferred to the transmitter at the end of the applicator and further into
the tissue.
Acoustic waves with high energy peak used in Shockwave therapy interact with
tissue causing overall medical effects of accelerated tissue repair and cell
growth, analgesia and mobility restoration. All the processes mentioned in this
section are typically employed simultaneously and are used to treat chronic,
sub-acute and acute (advanced users only) conditions.
New Blood Vessel Formation Reversal of Chronic Inflammation
Nutrient blood flow is necessary to start and maintain the repair processes Chronic inflammation occurs when the inflammatory response is not completely halted. It can
of damaged tissue structure. The application of acoustic waves creates damage healthy tissue and results in chronic pain. Mast cells are one of the key components of
capillary microruptures in tendon and bone. Due to microruptures the the inflammatory process. Their activity may be increased by using pervasive acoustic waves.
expression of growth factors such as eNOS, VEGF, PCNS and BMP is Mast cell activation is followed by the production of chemokines and cytokines. These pro-
significantly increased. inflammatory compounds first enhance the inflammatory process and in the next step help
As a result of these processes arterioles are remodeled, stimulated to grow restore normal healing and regenerative processes.
and new ones are formed. The new blood vessels improve blood supply
and oxygenation of the treated area and support faster healing of both the
tendon and the bone.
Scientific support Stimulation of Collagen Production
Biological Mechanism of Musculoskeletal Shockwaves The production of a sufficient amount of collagen is a necessary precondition for the
repair processes of the damaged myoskeletal and ligamentous structures. Shockwave
therapy accelerates procollagen synthesis. The therapy forces the newly created collagen
fibers into a longitudinal structure which makes the newly formed tendon fibers more
dense and stiff and creates a firmer structure.
Shock wave therapy
Dissolution of Calcified Fibroblasts

Calcium build-up is most often a result of micro-tears
or other trauma to a tendon. Acoustic waves
break up the existing calcifications. Shockwave
therapy starts the biochemical decalcification of
the calcium build-up of a toothpaste-like
consistency and treats the tendon. The granular
particles of calcium are then removed by the
lymphatic system.
Dispersion of Pain Mediator Substance P Release of Trigger Points

Substance P is a neurotransmitter that mediates pain Trigger points are the principal cause of pain in the back, neck, shoulder and
information through C-fibers. This neuropeptide is generally limbs. They are associated with palpable nodules in taut bands of muscle
associated with intense, persistent and chronic pain. It relays fibers and have extremely contracted sarcomeres. The dysfunctional
pain messages to the central nervous system. Lowering the sarcomeres contract so tightly that they begin to cut off their own blood
concentration of Substance P reduces the stimulation of supply. This causes the waste products to build up. Waste product build-
afferent nociceptive fibers and thus reduces the pain. up irritates the sensory nerve endings which then causes even more
Decreasing Substance P, histamines and other nociceptive contraction. This vicious cycle is referred to as metabolic crisis. The
metabolites also helps inhibit development of inflammatory assumed mechanism of action is that the delivered acoustic energy
oedema. Acoustic waves generated by Shockwave therapy unblocks the calcium pump and thus reverses the metabolic crisis in the
lower the Substance P concentration and trigger pain relief. myofilaments and releases the trigger points.
Shockwave Therapy in OT pathology
Highly effective treatment of tendon-related pain
INDICATIONS in OT practice:
tennis elbow
shoulder tendonitis
heel, achilles and knee trauma
degenerative disorders
SOURCE: http://www.shockwave-therapy.co.uk
In some cases
Drug therapy
Infiltration therapy
etc.
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Meso therapy
Michel Pistor (19242003) performed clinical research and founded the
field of mesotherapy. Multi-national research in intradermal therapy culminated with Pistor's work from 1948 to
1952 in human mesotherapy treatments.
The French press coined the term Mesotherapy in 1958.
The French Acadmie Nationale de Mdecine recognized Mesotherapy as a Specialty of Medicine in 1987.
Popular throughout European countries and South America, mesotherapy is practiced by approximately 18,000
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physicians worldwide
http://mi-medicalinnovation.com/img/cms/20_MIMedicalInnovation_schematechniquemesotherapieAng.jpg
mesotherapy
before the procedure (respective pre-formed modality )
in loco doloris, or segmental application
before the application of physical modalities (electrotherapy, magnetic field, vibration,etc.)
REDUCTION OF PAIN
Padua L, I Aprile, F Cecchi, et al.
Pain in postsurgical Orthopedic Rehabilitation: A multicenter study.
Pain Medicine, 13, 2012, 769-776.
Mesotherapy & Pain
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Prof. Yvette Koleva, DM, PhD,

DMSc
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Meso therapy
Prolo therapy
Nerve blocks
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Environment adaptations
HOME ADAPTATION
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OCCUPATIONAL THERAPY
Adapting the environment for ADL
ADL
ADL
TECHNICAL AIDS
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Brace
Walker boot
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Shoulder brace
Arm sling
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Prof. Yvette Koleva, DM, PhD, DM
Universal arm sling

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Shoulder wrap - Cryotherapy
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Lumbar spine - Volare
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Modular system

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REHABILITATION OF THE
GRASP & GAIT
-
CONTEMPORANEOUS METHODS

Typical locations of the surface stimulation electrodes that
are used to retrain reaching and grasping functions
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Controlled active
flexor splint
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Synergistic splint
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Differential tendon-
gliding splints
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Controlled passive extensor splint
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Immediate controlled active motion splint
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Buddy splint and proximal Phalangeal fracture resting splint

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A REFLEX MODEL OF MOTOR CONTROL
STIMULUS BLACK BOX RESPONSE
CNS
SENSORY INPUT
MOTOR OUTPUT
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Centre of gravity
Using the gravity
wheelchair with tilting possibility
oxygen transport
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"Light Operated Mouse And Keyboard
LOMAK
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SPECIAL KEYBOARDS
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You can think about a lot of things, that one can do with
computers.
Nearly everything, that works with electricity, can be done

with a kind of roboticals, doors, curtains, television,
computers...
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PROSTHESIS
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Pre-history
Ancient Egypt
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Otto-bock
C-leg
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PARALYMPICS
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MYO-ELECTRIC ROBOTIZED PROSTHESIS
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Fig. 3. Rolled dielectric elastomer acting as a bicep on a full-size human skeletal
muscle. Field-activated polymers operate at high voltage and low current. Further
development of lightweight and efficient voltage conversion and driving circuitry is
required for operation off of batteries. High voltage must be isolated from the user.
However, the potential danger of high voltage can be greatly reduced by limiting the
available current. For example, operation of 100 W actuators at 5000 V (a typical
maximum for dielectric elastomers) would require just 20 mA a nonlethal amount.
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prosthetic hand
yo electric
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Michelangelo Hands of God (Creation)
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Otto-bock
MICHELANGELO HAND Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
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Michelangelo hand
the grip types
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MICHELANGELO NEW PROSTHETIC HAND

BY OTTO BOCK
http://www.youtube.com/watch?v=pOgfuDrtZyc
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for gait rehabilitation
EMG Biofeedback
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Exoskeleton
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Modern exoskeletons

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010-2017
Exoskeletons in industry
FORTIS exoskeleton
http://www.lockheedmartin.com/us/pr
oducts/exoskeleton/fortis.html

010-2017
US Navy
U.S. Navy to Test and Evaluate Lockheed Martin Industrial Exoskeletons
http://aerospace.firetrench.com/2014/08/u-s-navy-to-test-and-evaluate-lockheed-martin-industrial-exoskeletons/

010-2017
Exoskeletons in Rehab

010-2017
http://designyoutrust.com/2011/10/robotic-exoskeletons-help-the-paralyzed-walk-again/

TELE-REHABILITATION
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EFFECTS OF OT REHABILITATION
Pain relief;
Increase of range of motion;
Prevention of complications;
Increase of muscle force;
Decrease of muscle weakness;
Training of neuro-muscular coordination;
Restoration of scapulo-humeral and pelvi-femoral rhythm;
Balance and gait training;
Psycho-emotional effects;
Amelioration of autonomy of patients in every day activities;
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Resocialization of patients;
Amelioration of quality of life of patients.
OT Rehabilitation
PROs & CONTRAs
PROs
Natural treatment (We must respect the experience of God)

No contra-indications
Without side-effects
Cheap treatment (No expensive drugs)
CONTRAs
Lack of sufficient evidence (we are in the era of EB medicine & EB rehabilitation);
Necessity of interdisciplinary team (OT surgeon, radiologist, PRM specialist, etc).
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GROUPS OF REFLECTORY CONNECTIONS
PROPRIO-VISCERAL
(zones of Mackenzie)
CUTANEOUS-
VISCERAL
(zones of Head) MOTOR-VISCERAL
(zones of Mackenzie)
PERIOSTAL-VISCERAL
(zones of Vogler-Krauss)
REFLECTORY
CONNECTIONS
SUBCUTANEOUS-
CONNECTIVE TISSUE-
VISCERAL
(zones of Leube-Dicke)
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Conclusions
Prof. Yvette Koleva,

DM, PhD, DMSc
Algorithm of OT Rehab management
The rehabilitation have evolved from

Diagnose and Adios to a comprehensive care of
the patients problems.
We consider that the emphasis on early diagnosis
and management is obligatory.
Actually PRM in Bulgaria is not yet viewed with skepticism.
Rehabilitation procedures are well accepted like a first line therapy
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with proven safety and benefit profile.

Our proposal
for
COMPLEX ALGORITHM OF
OT MANAGEMENT
The complex algorithm must include:

systematic drugs,
OT care;
PRM complex,
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patient education.
Physical modalities:
one or two pre-formed modalities;
one cryo- agent.;
one or two kinesitherapeutic procedures
/incl. passive & active exercises, mechano-therapy, stretching
techniques, post isometric relaxation, analytic exercises.
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Rehabilitation a la carte
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The Rationale:
We could recommend our
rehabilitation strategy
for complex treatment of OT conditions.

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Home message
OT rehabilitation is obligatory
in these cases.
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La reeducation fonctionnelle est obligatoire pour les patients

In clinical rehabilitation practice -

CHOLISTIC APPROACH
to the OT patient
REHABILITATION TEAM
for OT patients
General practitioner
Specialists in OT, Radiology; PRM
Ergotherapist
Phisiotherapist
Kinesitherapist
Nutricioniste
Psychologist,
Sociologist
Nurse.

In clinical practice -
PATIENT CENTERED APPROACH
PRM doctor
PATIENT
Physiotherapist
Ergo therapist

QUALITY OF
OT REHABILITATION
in OT cases
FUNCTIONAL EVALUATION & NEW ASSESSMENT METHODS
ICF
MODERN THERAPEUTIC METHODS
MODERN DEVICES
QUALIFICATION OF THE STAFF

Quality of OT rehab
Quality of life of OT patients

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POTENTIAL OF REHABILITATION FOR ACCELERATION OF

FUNCTIONAL RECOVERY AND AMELIORATION OF THE

prof. Ivet Koleva, MD, PhD, DMedSc *

Prof. Yvette Koleva, DM, PhD, DMSc Sofia, 2010-2017

Orthopedic Traumatologic Rehabilitation

and Physical & Rehabilitation Medicine (PRM).

MD with both specialties:

Prof. Yanka DAFINOVA, MD. PhD, DMSc - PRM & Rheumatology

Prof. Yavor VAJAROV, MD. PhD, DMSc - PRM & OT

OT rehabilitation clinical practice:

Theoretical Practical Moral & Ethical

WHAT ? FOR WHOM ?

Content, programmes Psychological problems

From the point of view of OT rehabilitation

Clinical data: somatic examination, OT & neurological exam (pyramidal signs,

paralysis / paresis, muscle tone, coordination, balance), kinesiological

Oxford Textbook of Palliative Medicine, Oxford University Press. 1993;109.

Functional Assessment Scales ,

Prof. Yvette Koleva, DM, PhD, DMSc

Flexion and extension

Prof. Yvette Koleva, DM, PhD, DMSc

The LOTUS POSTURE of Yoga,

Praying Hands by Albrecht Drer, demonstrating

Flexion and extension of the hand

Pronation and supination of the foot & arm

Eversion of the right foot

Prof. Yvette Koleva, DM, PhD, DMSc

Environmental factors Personal factors

A wide range of ICF options

and a need for adaptation to individual circumstances

necessity of assistance in the self-care).

BODY FUNCTIONS (pain, range of motion, motor weakness,

FUNCTIONAL EVALUATION of patients with neurological

conditions, with sensory, motor, autonomic dysfunctions

The evaluation have to be based on the holistic approach to

specialized OT examination, &

Prof. Ivet Koleva, DM, PhD, DMSc

TRAINING OF THE FUNCTION -

KINESIOTHERAPY (PHYSIOTHERAPY) & ERGOTHERAPY

Electro-stimulation, pain relief, reduction of oedema, stimulation of

Prof. Yvette Koleva, DM, PhD, DMSc

Prof. Yvette Koleva, DM, PhD, DMSc

L5, S1 --- tractions & mobilisations

Sacro-iliac blockage MANIPULATIONS;

Post-isometric relaxation for soleus muscle

Prof. Yvette Koleva, DM, PhD, DMSc Sofia, 2010-2017

Prof. Yvette Koleva, DM, PhD, DMSc Sofia, 2010-2017

Gait education & training up-stairs and down-stairs

A diagram of a mirror box.

and their "phantom" into the other.

Prof. Yvette Koleva, DM, PhD, DMSc Sofia, 2010-2017

Prof. Yvette Koleva, DM, PhD, DMSc Sofia, 2010-2017

Prof. Yvette Koleva, DM, PhD, DMSc Sofia, 2010-2017

Prof. Yvette Koleva, DM, PhD, DMSc Sofia, 2010-2017

3 min. for every muscle

Prof. Yvette Koleva, DM, PhD, DMSc Sofia, 2010-2017

low frequency and middle frequency currents

INTELLECT Chattanooga Intelect Legend XT 2 Channel

Combo (stim and ultrasound) Unit Without Cart

Prof. Yvette Koleva, DM, PhD, DMSc

Vectra Genisys is the first modular

therapy system that consolidates

Prof. Yvette Koleva, DM, PhD, DMSc