++
Stretch and flexibility are the first steps in an exercise program.
Flexibility is “the ability to move a joint smoothly throughout
a full range of motion.”2 Muscles, fascia,
tendons, ligaments, adipose tissue, and the joint capsule affect
flexibility.3 Under normal conditions muscles and
tendons and the joint capsule are the structures that most limit
flexibility, but neurologic conditions with hypertonicity, and excessive
adipose, when present, can also limit flexibility.2,3
++
Patients take flexibility for granted; however, stretches should
comprise the initial activity in an exercise program. Participation
in regular exercise without stretching does not imply that the individual
is limber. It is noted that long-distance runners who do not regularly
stretch have poor flexibility3 and stretching prevents
soft tissue injury.2
++
The therapist instructs clients in two types of stretch techniques:
static stretch or contract-and-relax techniques.2 The
individual performs static stretch by slowly stretching the muscle
to the point of discomfort and holding that position for 60 seconds.2 Therapists
utilize this technique of stretch in the first few days after injury.2 Individuals
without acute soft tissue injuries can perform contract-and-relax
techniques, in which the individual maximally contracts the muscle
for 10 seconds and then releases the contraction into a slow stretch
while contracting the antagonist muscle group.2 Slow,
mild stretching over minutes is more beneficial than short, rapid
stretches.4 The application of heat to a joint
before stretching, via ultrasound for large joints, and paraffin
dips for small foot and hand joints, increases soft tissue distensibility
and may be part of a script for flexibility.3 A
good review of stretches with pictured demonstrations are noted
in Tollison’s review article.5
++
There are special patient populations to consider when prescribing
flexibility exercises. The immobile individual should receive daily
range-of-motion exercises with sustained stretch at end range from
a trained caregiver.4 Range should be done over
all joint groups and may conveniently accompany bathing activity.
Splinting provides prolonged mild stretch and should be used on joints
at high risk for functional restriction, for example, the hands,
wrist, and forefoot and ankles.4 Patients at particular
risk include those with upper motor neuron lesions that result in
spasticity (e.g., stroke and spinal cord injury) and patients with
burns.
++
Caregivers and individuals should perform stretching and range
of motion with caution in osteoporotic individuals since inadvertent
fractures are possible. The presence of fracture, new skin grafts,
and new subcutaneous lines or wires preclude stretch and range of
motion. The adjuvent use of deep and superficial heat is contraindicated
in the presence of low or absent sensation because burns occur.
Fixed-joint contractures or heterotopic bone and myositis ossificans
also preclude stretch, and orthopedic remedies should be investigated.
An individual using a splint or the caregiver should, after 30 minutes
of use, inspect the underlying skin for pressure areas, that is,
areas of blanching redness; if redness is found, discontinue splint
use until the splint can be adjusted.
++
Assisted range of motion, another form of stretching, is when
the individual or a caregiver helps move a weakened limb through
its full range of motion. The individual may use the strong contralateral
limb to assist movement of the weak or painful ipsilateral limb
as in stroke, where a patient interlaces the fingers and raises
the weak and strong limbs overhead. After knee replacement, therapists
teach patients to assist extension of the operated knee by crossing
the intact ankle under the ankle of the operated side, and straightening
the strong and operated knee together. Devices may assist range
of motion. For example, in bicipital tendonitis, the patient learns
to use an overhead pully to extend the range of the painful shoulder.
++
Physiologically, stretching has many effects. In animal models,
cyclic stretching of animal muscle–tendon units demonstrates
decreased peak muscle tension and increased muscle relaxation and
increased muscle length.6 During a cycle of 10
stretches, performed over 30 seconds, decreased muscle tension and
increased length occurred primarily within the first four stretch cycles
and most muscle relaxation occurred during the first 12 to 18 seconds
of the 30-second cycle.6 By contrast, in human
models with a diagnosis of short or “tight” hamstrings,
Halbertsma demonstrates no change in the length or elasticity of
hamstrings with applied stretch, but rather increased tolerance
of stretching applications.7 Extrapolating these
results to human patients, the prescriber will recommend that regional stretches
occur over 20 to 30 seconds and for four to five repetitions (Fig.
79-4). Another benefit of the slowly performed stretch is that a
technique which slowly stretches a muscle imposes less force on
the muscle than a rapidly performed stretch.
++
++
As regards human subjects, the literature describes pain relief
as well as physiologic benefit of stretching. Khalil et al describe
systematic stretching applied to low back pain patients by a physical
therapist.8 These stretches include the regions
of the lumbar paraspinals (Figure 79-2), the quadratus lumborum,
the tensor fascia lata, the hamstrings (Figure 79-3), and the obliques.
Significant benefits to the patient with low back pain included
increased strength of muscle, increased maximal effort exerted,
and decreased regional pain. These benefits, including pain relief,
occurred in 2 weeks with the application of stretch twice a week.
++
++
++
Lewit studied 244 patients with over 300 myalgic areas in a prospective
but uncontrolled study.9 Applied immediately after
isometric contractions of the sore muscle, stretch provided immediate pain
relief for 95% of patients.9 To perform
this technique Lewit describes first stretching the muscle passively
to the point of pain and then contracting the muscle isometrically
for 10 seconds and then releasing the contraction.9 The
patient is instructed to deep breathe and exhale during the release,
at which time the therapist further stretches the muscle; however,
the muscle is only stretched at the rate that is felt to relax and
the therapist does not apply force.9
++
Often when the physician proposes an exercise program, the patient
will state that he or she is busy all day and gets plenty of exercise.
The literature supports intensified exercise efforts and makes clear
that mundane activity does not result in adequate flexibility,3 strength,
endurance, or bone density.10 Pollock writes that “strength
refers to the ability of the muscle or muscle group to apply force. Typically,
strength is defined relative to the maximal force–producing
capability of a muscle.”3
++
Scientists define strength as the maximal force a muscle group
can generate in a single isometric contraction of unlimited duration.3 There
are three types of muscle contractions and three types of strength
training: isometric, isotonic, and isokinetic. Isometric contraction,
that is, where the length of the muscle does not change but is set
at one length, does not have as many applications in daily activity
as isotonic contraction and strength. During an isotonic contraction
the muscle contracts through all or part of its normal range of
motion while lifting a constant amount of weight. The classic biceps
curl with a dumbbell is an isotonic example. There are two types
of isotonic contractions: shortening (i.e., concentric, contractions)
and lengthening (i.e., eccentric, contractions). Lastly, there are
isokinetic contractions, in which the muscle contracts against a
fixed torque. Many of the fixed-axis machines in exercise clubs
strengthen isokinetically.
++
Practical examples help illustrate the difference between isometric,
isotonic, and isokinetic contractions. We use isometric contractions
of the finger flexors to grasp and hold a can of soda, but then
we use an isotonic contraction of the biceps to lift the soda to
the mouth. When lifting the can of soda to the mouth, a concentric,
or shortening, isotonic contraction of the bicep occurs; when we
return the can of soda to the table, it is not a passive activity
of the bicep, but actually the biceps contracts eccentrically, or
in a lengthening fashion, to slowly lower the can of soda in a controlled
fashion to the table. If the biceps did not eccentrically control
the descent of the can, it would simply slam to the table because
of gravity. Isokinetic contractions do not have many practical examples.
We perform an isokinetic contraction when trying to push closed
a door that is on a hydraulic governor.
++
Strength training improves the force production of a group of
muscles by any of the following mechanisms: an increase in the number
of motor units activated, an increase in the rate of activation,
an increase in the synchronization of motor units firing, or the
hypertrophy of muscle fibers.3,11 In the first
2 to 3 weeks of a strength-training program, strength improvements
result from the synchronization of neural firing.11 With
continued strength training after 3 weeks, hypertrophy of muscle
fibers causes increased force production by the muscle.
++
Progressive resistive training, performed to fatigue, strengthens
muscles. DeLorme described progressive resistive training based
on a 10 repetition maximum (RM), that is, the maximal amount of
weight that a trainee could move 10 times through a muscle’s
full range of motion.11 Following DeLorme’s
method, the trainee perform 10 repetitions of 10% of the
10 RM weight, followed by 10 repetitions of 20% of the
10 RM weight, followed by 10 repetitions of 30% of the 10
RM weight, and so forth, up to 10 repetitions of the full 10 RM
weight. The trainee performed this regimen three to five times per
week. Once a week, the new 10-repetition maximum weight for each
muscle group is determined. This training method requires a large
amount of time if multiple muscle groups are to be trained, and
revisions of this original progressive resistive-training method
exist.
++
Braddom’s test describes an effective strength training
technique in which the trainee finds a relatively high weight, one
that can be lifted three to five times before fatigue or muscle
failure ensues.11 The trainee exercises each muscle
group with its three to five maximal repetition weight two to three
times per week; in each session the trainee lifts weights to the
point of fatigue for each muscle group trained. When the trainee
can lift a maximal weight 15 or more times, the weight is increased
10% (see Fig. 79-4). Usually a weight increase is indicated
about every 7 to 14 days. The most important concept in strengthening
is that the amount of weight lifted, very high or only moderate,
is not important as long as the muscle group is exercised to the
point of fatigue.11 Using relatively lower weights
to train will require more repetitions to achieve fatigue. Hickson
writes that weight training of the legs to fatigue 5 days per week
increased strength 40% in ten weeks.12
++
Contraindications and precautions for strength training do exist.
Strengthening exercise is contraindicated in the presence of fracture;
the orthopedic surgeon should prescribe the permitted activity and
denote prohibited activity for a fractured limb and the contiguous
joints. Strengthening exercise acutely increases blood pressure,
and this vital sign needs to be monitored in patients with significant
hypertension. Persons should have a “spotter” or
partner when performing strengthening exercises, especially with
free weights. Strengthening exercises are contraindicated in the
presence of acute or unstable cardiopulmonary disease.
++
As noted earlier, muscle contracts in isometric, isotonic, or
isokinetic fashion. Likewise, strength training, using free weights
or weight machines, may be isometric, isotonic, or isokinetic. Strengthening
occurs initially by neuromuscular integration and then by muscle
hypertrophy. Strengthening occurs as long as exercise continues
to the point of fatigue.
++
The DeLorme axion states that “high weight, low repetition
exercise programs build strength and low weight, high repetition
exercise programs build endurance.”11 Endurance
is the time that a person can maintain either a static force or
a power level involving a combination of concentric and eccentric
muscle actions.2 Endurance is also defined as “the
ability to continue a prescribed task in the desired manner.”11 Endurance
(i.e., aerobic) exercise involves the rapidly alternating contraction
of large muscle groups at low resistance for a sustained period.
Examples of endurance exercises include jogging, rope skipping,
skating, cross-country skiing, swimming, stair-stepping, and bicycling;
strengthening exercises include weight lifting with free weights
and fixed-axis machines.
++
While strengthening exercises increase muscle force, endurance
exercises increase aerobic capacity, or maximal oxygen uptake (V ˙O2).
As a result of endurance training, the number and size of mitochondria
in muscle increase, the activity of mitochondrial enzymes increase,
and blood flow to muscles increases because of increased numbers
of capillaries and improved efficiency of blood flow shunting.12 Adaptations in
the heart and vasculature include increased stroke volume, expand
blood volume, decreased resting heart rate, and decreased resting
systolic and diastolic blood pressure.12 To achieve
an endurance effect, the trainee needs to participate in 15 to 60
minutes of continuous aerobic activity three to five times per week
at sufficient intensity to raise heart rate to 60% to 90% of maximum13 (see
Fig. 79-4). A maximal exertion exercise treadmill test can determine
maximal heart rate; however, an easy approximation of maximal heart
rate for a given age is arrived at by subtraction the patient’s
age from 220. This level of participation, that is, increasing heart
rate to 60% to 85% of maximum, will increase maximal
oxygen uptake 15% to 30%.13 However,
endurance training more often than five times per week can lead
to an increase in the occurrence of orthopedic injuries.13
++
As regards pain, endurance activity has been shown to increase
endorphin levels. McCain summarizes these works writing that “exercise
leads to a predictable increase in serum levels of beta-endorphin
like immunoreactivity, ACTH, prolactin and growth hormone.”14 He
continues that a state of decreased pain sensitivity, called post-run
hypoalgesia, which is naloxone reversible, is associated with these
neurohormonal and endocrinologic changes.14 Studying
elite athletes running at a submaximal level after naloxone or placebo
injection, Surbey found that the athletes receiving naloxone had
reduced exercise time and increased affective component of pain.15
++
Considerations for special populations of patients include short,
frequent sessions of endurance exercise for markedly deconditioned
patients; because frequent, short sessions of endurance activity
have been shown to be as effective as equal amounts of sustained
endurance activity.13 Patients with osteoarthritis
benefit from endurance exercise but require modifications including
a low impact or an aquatic program. The physician should consider
exercise test screening for patients who plan to participate in
a moderate- to high-intensity exercise program, who are male and
older than 45 years old, or female and older than 55 years old,
and who have two or more risk factors for cardiac disease.16 The
risk factors for cardiac disease include positive family history of
coronary disease or sudden death before age 55 years, cigarette
use within the past 6 months, blood pressure elevation over 140/90
mm Hg, hypercholesterolemia with total cholesterol >200
or LDL >130, impaired fasting glucose over 110
mg/dL, or obesity with a body mass index >30
kg/m2. Persons with known cardiovascular,
pulmonary, or metabolic disease should have an exercise treadmill
test prior to exercise participation. Absolute contraindications
to endurance or strength training include acute and unstable cardiopulmonary,
metabolic, and vascular conditions: acute electrocardiogram (ECG)
changes, unstable angina, uncontrolled cardiac arrhythmias, severe symptomatic
aortic stenosis, symptomatic or uncontrolled heart failure, acute
pulmonary embolus of deep venous thrombosis, acute infection, suspected
or known dissecting aneurysm, and acute pericarditis or myocarditis.17
++
Some additional adverse effects of endurance activity are predictable.
It is possible to sustain sprains, falls, overuse injuries, or blunt
injuries if exercising on busy thoroughfares. The exerciser can
become dehydrated. However, one of the adverse effects of aerobic
participation is not the promotion of osteoarthritis. Lane followed
30 runners with age-matched controls for 5 years to evaluate for
the acceleration of arthritis due to running activity. Running did
not accelerate the development of radiographic or clinical osteoarthritis
of the knees.18
++
Familiarity with the types of exercise, the goals of each type,
and its proper performance improve the ability of the physician
to educate the patient about treatment options, and improve the
ability of the physician to estimate the quality of the exercise
program the patient receives from community therapy settings.
++
Wilder and Brennan wrote a succinct review of the techniques
and benefits of aqua-running.19 Deep water running
is accomplished by floating the participant, tethered in place,
in the deep end of a pool. The participant does not touch the pool
bottom. Maximal heart rate and maximal oxygen carrying capacity
are about 90 of those values obtained from on-land running. Maximal
perceived exertion is similar for both on-land and aqua running,
and both forms of training lead to increased maximal oxygen carrying
capacity. Unlike on-land running there is no weight bearing but
the addition of resistance from the water. The arms work harder,
but the legs work less. Hydrostatic pressure may assist venous return.
Body temperature during exercise is slightly lower in the aquatic
setting. Aqua-running may be an alternative endurance activity for
certain populations where weight-bearing exercises are painful or
harmful.
++
The physician can prescribe or instruct the patient in strategies
to prevent injury and promote health, such as energy and back and
joint conservation; the therapist can reinforce and demonstrate
these strategies. Studies discussed in reference to the specific
diagnoses suggest that education may be as useful as exercise at
relieving painful symptomatology.
++
Common sense comprises most patient education strategies. For
example, patients with hip and knee arthritis are instructed to
sit in higher chairs with firm seats and with arms so that the upper limbs
may assist transitions to and from sitting. By contrast, plush,
deep, low seating without arms make it difficult for the patient
with hip and knee pain to rise from the seated position. Back conservation
techniques include lifting with the arms and legs, and keeping the
object lifted close to the body. Work simplification techniques,
like carrying smaller packages, dressing in bed or while sitting,
resting between tasks, are strategies that persons with discomfort
due to dyspnea can use make activities of daily living more comfortable.
Planning ahead and organizing, avoiding unnecessary trips, having
all equipment available prior to starting a task, combining tasks,
using lightweight tools, and resting before fatigue onsets are work
simplification guidelines.20
+++
Assistive Devices
for Mobility and Activities of Daily Living
++
Assistive devices include those for mobility and those for activities
of daily living (ADLs). Canes, walkers, and crutches increase balance
by increasing points of contact, and thereby surface area over which
the center of gravity is supported; or they function to relieve
the weight from a painful or immobilized limb. A walker is the most
stable among these devices, and can be self-supporting if the patient
must lean on it to rest. A cane is useful because it leaves one
hand free for other tasks. A properly fitting cane should be adjusted
to a height so that, when used, the hook of the cane approximates
the patient’s trochanter. Crutches are unstable devices,
and difficult to use correctly. Indications for mobility aids include
lumbar and lower limb osteoarthritis, sprains, and fractures, as
well as situations of weakness including stroke and lower motor
neuron disease, like polio and neuropathy, and myopathic processes.
++
A wheelchair is also a mobility aid. It is maximally useful when
the patient can propel it independently. It is useful for persons
with severe lower limb weakness, knee, thigh and pelvis trauma,
or dyspnea due to muscle, lung or cardiac disease. However, the
chronic use of a wheelchair can predispose to muscle tightness and
contracture. The prescribing of wheelchairs for persons who can otherwise
ambulate but prefer to be pushed should be avoided.
++
Trombley catalogues devices for ADLs (Table 79-2) and other techniques
to simplify ADL work.20 Simplification techniques
include dressing the affected limb first, and undressing it last.
Using spray deodorant is easier than using stick varieties. Using
implements with short handles to feed is easier than using those
with long handles. The reader treating patients with stroke, spinal
cord injury, or weakness from peripheral nerve lesions can access
this reference for other recommendations. Mobility and ADL devices
and simplification techniques exist to make activity less painful
and maximally efficient.
++
+++
Electrical and
Thermal Modalities
++
Thermal and electrical modalities are passive therapeutic interventions.
Modalities that patients can apply independently at home, namely
hot packs, ice packs, and transcutaneous electrical stimulation
(TENS), are particularly useful. This section presents the forms,
physiologic effects, contraindications, and precautions of thermal
modalities and then of TENS. The proposed mechanisms of pain relief
for the various physical modalities are also discussed.
++
Common forms of thermal therapies include superficial ice and
heat and deep applications of heat (see Table 79-1). Superficial
ice applications include ice packs and ice massage. Superficial
forms of heat include heat lamps, hot packs, heating pads, paraffin,
and hydrotherapy. Deep heat includes ultrasound and short- and long-wave
diathermy.
++
The physiologic effects of heat are local, regional,and distant.
Local physiologic effects include increased tissue histamine and
prostaglandin and bradykinin release that relax vascular smooth muscle
and contribute to vasodilation. At a spinal level, due to afferent
thermoreceptor stimulation, decreased sympathetic tone results and
further relaxes vascular muscle tone. Sufficiently warmed blood
reaches the thermoregulatory hypothalamus and causes increased metabolism
and preparation. At the tissue level local heating results in increased
tissue elasticity and decreased viscosity.
++
The physiologic effects of cold include vasoconstriction, decreased
edema, decreased pain possibly due to slowed nerve conduction, and
decreased spasticity due to effects on the muscle spindle.22 Ice
application in the first 24 to 48 hours after acute injury is recommended
to control swelling and edema. Contraindications to cold applications
include cold-agglutinins, Raynaud’s phenomenon, and peripheral
vascular disease.
++
There are cognitive impairments as well as disease states that
preclude the use of heat. Cognitive contraindications to hot applications
include obtundation, confusion, or an infantile state. Medical contraindications
to therapeutic heat include insensate skin, peripheral vascular
disease, acute inflammation, tumor, and proximity to growth plates.
Whirlpool immersion is contraindicated for patients while congestive
heart failure.
++
If the patient cannot feel heat or express the perception of
being burned because of inattention or peripheral nerve disorder,
burns will occur. Burns can occur at home or in the therapy gym.
The following examples of inadvertent burns observed over more than
a decade of rehabilitation practices illustrate these concerns:
++
- 1. A paraplegic spinal-cord-injured patient with deep
partial thickness to the flank after a hydrocollator pack was applied
to partially cover the area below the level of injury and insensate
skin.
- 2. A patient with traumatic brachial plexopathy who sustained
full-thickness burns to the tips of the fingers when the fingers
came to rest on the bottom of a paraffin unit.
- 3. An osteoporotic patient who sustained blisters to the
back when laid on a hot pack at a therapy gym.
- 4. A 50-year-old woman with diabetes who sustained full-thickness
burns and a subsequent below the knee amputation when she fastened
an electric heating pad to her leg and fell asleep.
- 5. A spinal-cord-injured patient who sustained superficial
to deep partial-thickness burns when the patient fell asleep on
a heating pad and it slipped below the level of injury.
- 6. A paraplegic spinal-cord-injured person who sustained
deep partial-thickness wounds to the foot when placed under a stream
of hot water at home.
- 7. An elderly arthritic person burned on the arms and torso
by flame when attempting to heat paraffin in an ordinary pan on
a gas stove.
++
The threat of burns from external heating devices is real. Electric
heating pads should be avoided or used very carefully. Absolutely
never sleep with an electric heating pad. Thus, the physician should
write precautions to monitor for burns when thermal modalities are
prescribed.
++
The different types of external heating devices have various
temperatures and techniques of use.22 Hydrocollator
hot packs are 71°C, and must be wrapped in six to eight layers of
toweling before being applied to a patient.22 The
patient should never lay on a hot pack because the body weight and
pressure on the skin impairs adequate circulation to dissipate the
heat. The skin under the pack should be checked at 5 minutes; if
there is excessive redness, the pack should probably be removed,
or at least extra towel layers added.22 The skin
reaches maximal temperature in 8 to 10 minutes.22
++
Paraffin dips consist of paraffin wax and mineral oil; this mixture
comes premixed and is heated to 47° to 54°C.22 The
hands or feet may be dipped in the mixture for eight to ten dips,
or the mixture may be brushed on. Then layers of toweling are applied
around the extremity for 10 to 15 minutes.22 Common
uses include various hand arthritides. To maximize the risk of flame
burns, only a paraffin unit should be used to heat the paraffin-mineral
oil mixture; these units can be obtained inexpensively at many department
stores.
++
Water bottles are useful self-limited heating units but can scald
if they accidentally open. Heating lamps are external heating devices
prescribed by specifying the angle and distance of the unit from
the patient and the minutes of use.
++
Heat over 45°C permanently injures living tissues and denatures
proteins. At temperatures below 45°, the normal vascular response
to heat with increased vasodilation limits the depth of penetration
of superficial heat. The average depth of heating with superficial
modalities is 0.5 cm.22
++
Ultrasound is a mode of deep heat in common use. A meta-analysis
of 22 controlled studies published on the use of ultrasound for
the treatment of musculoskeletal pain in human subjects found that
there is no indication that ultrasound can relieve pain.21 The
technology has value, however, in the treatment of tissue distensibility,
which may be a therapeutic goal.
++
The technology of ultrasound is passage of electric current through
crystals to cause vibration and sound waves; this phenomenon is
called the piezo-electric effect. Ultrasound penetrates to a depth of
1 to 5 cm depending on the frequency used. The most commonly used
frequencies are 1 MHz, which penetrates to depth of 5 cm, and 3
MHz, which penetrates to a depth of 1 cm.22 Ultrasound
waves pass through, are absorbed, or are reflected depending on
the composition of the tissue that they encounter. Tissue interfaces,
such as muscle in proximity to bone, absorb more ultrasound energy
and generate higher tissue temperatures.
++
Ultrasound requires a liquid medium to pass through because it
travels poorly through air. The therapist applies ultrasound gel
between the ultrasound wand and the patient, and moves the wand continuously
to avoid creating hot spots.22 Ultrasound may also
be used on smaller joints, like the hand, by placing the extremity
and the wand in water and moving the wand through the water about
1 cm from the extremity.22 The prescription for
ultrasound includes specifying the duration of treatment and the
watts per centimeter squared, and the anatomic area of application.
The desired clinical effect is the sensation of warmth in the area
treated. The treatment should be discontinued immediately if the patient
perceives burning. Ultrasound should not be used over artificial
joints fixed by methylmethacrylate.
++
Superficial hot and cold and deep heat using ultrasound are common
forms of thermal modalities. The patient can independently apply
superficial heat and cold treatments at home, and the therapist
and physician should encourage the patient to use these mediums
as sprain–strain first aid to control symptoms. Cold is
applied to an injury, and when swelling subsides, heat may be used. The
physician should explain to the patient how to observe for burns.
Patients often request ultrasound treatment, but the patient cannot
utilize this modality independently, and Gam’s work suggests
that it has no pain-relieving effect. Prescribing ultrasound in
conjunction with a stretching program under therapy management probably
best serves the patient.
++
Transcutaneous electrical nerve stimulation is an electrically
powered neuromodulating technology. A TENS unit consists of a pulse
generator, an amplifier, and two to four carbon-impregnated silicone
electrodes. The unit is about the size of a deck of playing cards.
The pulse generated has characteristics that include configuration
(for example, rectangular), pulse width in milliseconds, and frequency
in hertz. The most common settings, those of conventional TENS,
are a rectangular waveform of 40 to 70 Hz frequency and 0.1 to 0.5
ms pulse width, with constant current. The electrodes are placed
4 or more centimeters apart to avoid skin irritation.23 Conventional
TENS feels like vibrations; the therapist modifies the settings
of the pulse to gain a deeper, broader sensation of vibration, not
a stronger one. The electrodes can be placed at the area of pain
or along the nerve root innervating the area.24 TENS
is not helpful in poorly localized or psychogenic pain.25 Conventional
and brief-intense TENS are not naloxone reversible, but acupuncture-like TENS
is.26
++
Mannheimer reviewed the diagnoses in which TENS was helpful,
including peripheral nerve injury, causaglia and reflex sympathetic
dystrophy, intercostals neuritis, postherpetic neuralgia, radiculopathy,
and arachnoiditis.27 Subsequent to the publication
of Mannheimer’s text, the efficacy of TENS in the treatment
of pain in other diagnoses has been studied. For rheumatoid arthritis,
Abelson showed that TENS at 70 Hz significantly relieved hand pain
and increased grip strength better than placebo, but only while
the unit was on.28 Langley studied acupuncture-like
TENS in a placebo-controlled, double-blinded design and found that
neither modality was significantly better than the other but that
both decreased pain and increased grip strength.29 The
efficacy of TENS to relieve pain in other diagnoses is discussed
in the diagnoses-specific section of this chapter.
++
Knee osteoarthritis affects 10% of the elderly and limits
the ability to use stairs, rise from a chair, and stand comfortably.30 The
literature demonstrates that patients with osteoarthritis have reduced
strength, endurance, and functional performance.30 Fisher
summarizes the literature, writing that aerobic exercise for the
patients with osteoarthritis increases endurance and decreases fatigue,
but does not have an impact on functional capacity.30 As
regards pain, Fisher summarizes the available literature and notes
that quadricep setting exercises, a form of isometric strengthening,
reduce pain associated with arthritis and improves function.30
++
TENS used biweekly relieves knee pain due to arthritis.31 Neuromuscular
electrical stimulation in patients with knee arthritis increases
strength, decreases swelling, increases range of motion, and decreases
muscle wasting.32,33
++
A possible prescription for subacute and chronic knee osteoarthritis
is as follows:
+
++
++
+++
Anterior Knee
Pain and Patellofemoral Syndrome
++
Roush describes a simple home program of modified (Muncie) straight
leg arises that a randomized, controlled study showed to be significantly
effective at relieving pain and improving functional impairment
ratings.34 The trainee performs the modified straight
leg raise (Fig. 79-7) by sitting on the floor with the legs straight.
The exercised knee is rotated out about 45 degrees, and the quadriceps
muscle is set. Then the ipsilateral heel is raised 1 to 2 in. off
the floor and the contraction is held for 5 seconds. This exercise
is repeated 20 times twice a day.
++
++
A review article by Bourne describes phases of treatment for
anterior knee pain and patellofemoral syndrome.35 In
the acute stage of pain, ice packs, massage, and patella-stabilizing
bracing are the recommended modalities along with nonsteroidal anti-inflammatory
medication. Stretching of the hamstrings (see Figs. 79-4 or 79-5)
and the iliotibial band and isometric strengthening of the quadriceps
and hip adductors (see Fig. 79-6 or 79-7, more difficult), and toe
raises are recommended. Certain activities are proscribed, including
jumping, squatting, hill running, cycling, and sitting with the
knee flexed more than 40 degrees. TENS may be used for pain if ice
is ineffective.
++
In the subacute phase, Bourne recommends exercise for 30 minutes
per day consisting of multiangle isometrics quadriceps strengthening,
and terminal knee extensions from 0 to 30 degrees (Fig. 79-8). In
the chronic stages, one can increase the amount of weight used during
the terminal extension exercises and increase the flexion moment
in increments of 10 degrees until full knee range is achieved. Endurance
exercises like biking, or swimming become appropriate. The trainee applies
ice after activity.
++
++
A possible script for anterior knee pain (subacute and chronic)
is as follows:
+
++
In the treatment of primary fibromyalgia syndrome, a randomized,
controlled trial demonstrates the efficacy of both exercise and
education to reduce pain in tender points, physical dysfunction, and
feelings of helplessness.36 Education included
information about the disease, coping and stress management, relaxation techniques,
and the importance of physical activity. Physical activity included
stretching and range-of-motion exercises plus walking, swimming,
or cycling.
++
A controlled trial by McCain supported that a three times per
week, 60-minute participation in cycling activity to achieve a sustained
elevated heart rate resulted in improved pain thresholds of tender
points and improved cardiovascular fitness.37 Study
subjects participated for 20 weeks. There was also a trend toward
improvement in pain scores. The control group participated in flexibility
activity only.37 In a controlled study, Nichols showed
that a less vigorous aerobic exercise program only trended toward
lowered pain ratings in fibromyalgia patients. The patients walked
three times per week for 8 weeks, and attempted to raise heart rate
to 60% to 70% of predicted maximum.38 Flexibility
and endurance activity of vigorous to moderate intensity benefit
persons with fibromyalgia.
++
A possible script for fibromyalgia is as follows:
+
++
++
++
++
+++
Myofascial Pain
Syndrome
++
Myofascial pain has seven clinical features: exquisite local
tenderness, referred pain pattern, electrically quiet palpable band,
perpetuation by metabolic distress, weakness and fatigability, local twitch
response, and relief by stretch.39 Thompson notes
that these criteria are supported by clinical observation but have
not been validated.39 The literature does not support
the utility of TENS in decreasing pain in myofascial pain syndromes.40 Treatments
that are commonly used but supported primarily by convention include
spray-and-stretch techniques and trigger-point injections or dry
needling followed by stretching.39,42 Other conventional
treatments include galvanic stimulation and hot pack application,
massage and soft tissue mobilization techniques.39 Aerobic exercise
is probably more beneficial than stretching alone.41 Kraus
and Fischer note that in the acute state the patient may need to
stretch the affected muscle group hourly.41,42 Lewit
studied 351 muscle groups in 244 patients to evaluate the effect
of post-isometric relaxation techniques on pain relief and found
that 94% of locations received immediate pain relief, whereas
63% of persons receiving lasting relief.9 The
study lacks control and blinding.
++
A possible script for myofascial pain is as follows:
+
++
Axial low back pain includes diagnoses of muscular, tendonous,
articular, and bony origin. The value of patient education to treat
pain related to this diagnosis should not be overlooked. In a randomized,
controlled study of patients admitted 3 weeks for the intradisciplinary
treatment of low back pain, the researchers found that patients
ranked education significantly higher than electrotherapy for overall
benefit from the program. The patients ranked exercise second and
electrotherapy third.43 Sikorski prospectively
studied 142 patients with low back pain, subcategorizing them into
acute and chronic, and further subdividing the chronic complainants
into anterior element, posterior element, movement-related, and
unclassified groups.44 He found that the patients
in the chronic groups judged education to be the most valuable intervention,
closely followed by exercise.44 The acute group
judged exercise to be the most valuable intervention, closely followed
by education.44 Although statistics were not compiled,
all groups judged the interventions of education and exercise to
be more useful than manipulation, bracing, or medication.44
++
Of interest, education and the use lumbar supports prior to experiencing
low back pain were not found to decrease the incidence of low back
pain.45 A study by Walsh and Schwartz led to similar conclusions,
but lost time from work was lower for workers who used a brace and
received education46; this decrease in time lost
was not true of the experimental group that received only education.
The use of lumbar supports does not increase isokinetic endurance
during lifting,47 nor isometric lumbar strength
and dynamic lifting capacity.48 Bracing does not
affect strength or prevent injury, but their use may decrease lost
man hours.
++
Stretching has been shown to contribute to pain reduction in
low back pain patients. Khalil studied 28 patients with myofascial
low back pain in a controlled trial with stretching plus a multimodal
rehabilitation program versus only the multimodal program.8 The
stretch group demonstrated improved measures of muscle function,
and after 2 weeks, low back pain was significantly lowered.
++
Kendall and Jenkins studied the effects of three different types
of strengthening exercise on patients with chronic low back pain:
The regimens were lumbar extension, isometric flexion, and isotonic
flexion.49 Although all patients improved, the
isotonic flexion group improved the most, but statistics were not
done.49 Davies also compared the effects of two
different types of exercise of patients with back pain.49 A
control group received diathermy only, whereas the two experimental
groups received diathermy plus isometric flexion exercises, or diathermy
plus lumbar extension exercises.50 All three treatment
groups improved, but the extension group did better than the flexion
group, who both did better than the diathermy only group.50 However,
no differences were statistically significant. A more recent randomized,
controlled study showed that 149 patients with acute low back pain
receiving either flexion or extension exercises did not differ in amount
of improvement in reduction of disability scores or return to work;
however, both groups did better than control subjects receiving
no exercise.51 There were no statistical differences.
A controlled study of 123 patients with low back pain compared with
126 normal controls showed that patients with low back pain had
low flexor and extensor trunk strength than normal patients, and,
in addition, that extensor strength was disproportionately weaker
than flexor strength in back pain patients.52 The
patients were exercised using situps (Fig. 79-13), prone trunk extensions, pelvic
tilts (Fig. 79-14), and knee to chest (Fig. 79-15) stretches, and
back pain decreased as strength increased.52 The
patients exercised daily for an average of about 3 months. Patients
with low back pain and no identified organic lesions did better
on strength gains and pain relief than patients with back pain and
organic lesions (herniated disk, spondylolysis, and spondylolisthesis).52
++
++
++
++
The literature explores the effect of modalities on low back
pain. Thorstiensson studied the placebo effect of TENS on low back
pain and found that the placebo effect was similar to that noted in
other double-blinded studies of medications, about 32%.53 Marchand
restudied the placebo effect of TENS in a controlled prospective
study of 42 patients with low back pain.54 He found that
TENS reduced the intensity of pain more than sham-TENS but that
there was no significant difference for the reduction of the unpleasantness
of pain.54 Additionally, TENS only had a significant
effect in the first week but no long-term effect, and, from this
observation, Marchand posited a placebo action of TENS.54 Melzack
and Jeans studied the effect of ice massage and TENS on chronic
low back pain on 44 patients with chronic low back pain in a crossover,
prospective study. The researchers applied TENS and ice massage
to the back and the lateral malleolar area. TENS and ice massage
were both reported to reduce pain levels more than 33% in
about 68% of the patients, and neither modality was significantly
superior to the other treatment.55 Melzack also
compared TENS to automated soft tissue massage in a double-blind
study and found that TENS reduces pain significantly better than
massage in low back pain patients.56 Of the various settings
for TENS, Lehmann studied conventional TENS versus electroacupuncture
and found that electroacupuncture tended to improve pain better
than conventional TENS or dead battery (control) TENS, but not significantly.43 Deyo
et al, in a randomized, controlled trial of TENS versus exercise
and exercise plus TENS for the treatment of chronic non-operated
low back pain in 144 patients, found no benefit of TENS over exercise
and there was no added benefit of TENS added to exercise.57 The
exercise group improved more than the electrotherapy group, but
at 2 months patients had discontinued exercises and the initial
benefits were gone.
++
In summary, the value of education in the improvement of low
back pain is considerable if not significant. Exercise, including
pelvis and lumbar flexibility, and strengthening exercise including lumbar
exercise with flexion and extension bias are helpful. The physician
can screen for the patient’s more comfortable position
in the office by simply making the pelvic tilt position, crunch and
prone pressup (Fig. 79-16) position part of the exam. An improved,
or no-change-in pain response, is desired. Positions that increase
pain should be avoided or delayed. Back bracing, except for traumatic
or postoperative indications, has limited value. TENS may benefit
some sufferers of low back pain, but education, flexibility, and
exercise are the core components of the physical medicine and rehabilitation
script.
++
++
A possible prescription for axial low back pain is as follows:
+
++
Sinaki retrospectively studied the conservative treatment of
spondylolisthesis.58 Forty-eight patients participated
in flexion or extension exercises for the treatment of spondylolisthesis.58 After
3 months only 27% of the flexion troup had severe pain,
but 67% of the extension group continued to have pain.58 In
the same period, 58% of the flexion group had recovered but
only 6% of the extension group at recovered.58 Exercise
with flexion bias achieves pain reduction as a primary end point.
++
A possible prescription for spondylolisthesis:
+
+++
Radicular Sciatic
Pain
++
The goal of physical therapy, surgery, or medicinal treatment
for sciatica is the resolution of leg pain. On therapy prescriptions,
physiatrists write that the goal of the exercises is the centralization of
leg pain. Bed rest does not improve the patient’s outcome.59 In
a randomized, controlled study Vromen evaluated 180 patients with
clinical signs and symptoms of lumbar radicular disease. At 2 weeks
slightly more patients in the bed rest group had less pain, but
at 12 weeks 87% of patients in both groups were improved.
There was no difference between the groups for functional status, medication
use, absenteeism from work, or occurrence of surgery.59 Saal
and Saal completed a prospective cohort study of 64 patients with
herniated lumbar disks, sciatic pain, positive electromyograms,
and positive straight leg raise using the intervention of dynamic
lumbar stabilization.60 The patient could participate
in the study design even if they had weakness as long as they did
not have progressive weakness. Measuring a self-assessment of pain,
self-assessed outcome and return to work, 85% of patients
had good to excellent outcomes; 92% of patients returned
to work.60 Six patients failed to improve with
the exercise regimen alone and had surgery; four of these patients
had stenosis.60 Extension exercises of lumbar stabilization
were discontinued if they peripheralized or increased leg pain.60 The
appendix of the referenced article describes the exercise used in
lumbar stabilization,60 and a second reference
by the one of the authors pictures the exercises.61 Following
this protocol, flexibility is the initial activity; when the strengthening
exercises commence, attention to correct performance of the exercises
is tantamount.
++
The classic McKenzie approach to evaluating and treating low
back and radiating back pain first proposed the goal of exercise
being the centralization of leg pain.62 A therapist
or physician, trained in the McKenzie method of spine treatment,
can rapidly reduce and centralize pain of acute or chronic duration.63 One
of the interesting clinical caveats derived from McKenzie is the
idea that exercises that cause centralization of the pain are to
be continued and those that peripheralize or increase leg pain should
cease.
++
A possible prescription for axial low back pain is as follows:
+
+++
Low Back Pain
after Laminectomy
++
The literature contains few well-designed studies that assess
the utility of physical therapy with chronic low back pain after
laminectomy. A randomized, controlled study by Timm of 250 patients
with chronic low back pain showed that patients exercised three
times a week for 8 weeks using floor set exercises and the patient
group using weight-lifting equipment gained significant pain relief
and lumbar range of motion compared with the patients treated with
manipulation alone or those treated with modalities alone.65 The
patients all had lumbar laminectomies and were over 1 year out from
surgery.65 The floor set exercises consisted of
three sets of 10 of prone pressups and of lumbar stabilization exercises
including alternating arm and leg raises in the supine and prone
positions and bridging and alternating arm and leg raises in the
quadruped position.65 The patients in the exercise
equipment group performed endurance and strengthening exercises;
they completed 10 minutes of bicycle ergometry and then used machines
to exercise the spinal flexors and extensors and rotators, and the
latissimus dorsi muscle with lateral pulldowns.65 Although
these two programs were equally effective, the floor set application
was less expensive to administer.65 The modalities
treatment was not effective and was the most expensive form of treatment
for low back pain after laminectomy.65
++
A possible prescription for low back pain after laminectomy,
1 year out:
+
+++
Exercises Considerations
after Discectomy
++
Surgeons often restrict the motion and movement of patients after
spinal surgery. There is a small body of literature that supports
cautious mobilization and re-examines this convention.
++
A small study by Kitteringham evaluated the efficacy of stretching
exercises beginning in the second day after discectomy.66 Twelve
patients were studied for the effects of pulley-assisted straight
leg raises after discectomy: A low-repetition group with 10 repetitions
per day was compared with a high-repetition group with eight sets
of 10 repetitions.66 Compliance was poor in the high-repetition
group and no significant differences were found between groups for
pain or disability level or straight leg raise range in the 6-week
study period.66 There was no zero-straight-leg-raise
control group because the practicing physicians believed and had
demonstrated that some straight leg raises were beneficial.66
++
Carragee prospectively observed 50 patients after open discectomy
for herniated lumbar who were given no postoperative restrictions,
except those regarding wound healing.67 The available literature
cited by Carragee noted that patients return to work 4 to 16 weeks
after back surgery.67 In his study group, average
time to return to work was 1.4 weeks. Average time to return to
full duty was 3.4 weeks.67 There were only five
complications: a transient foot drop, a dural tear, one prolonged
wound drainage, one antibiotic allergy, and one suprascapular nerve
palsy.67 Three reherniations (6%) occurred
after 14 months.67 The literature cited notes reherniation
rates of 6% to 20%.67 Although
this study has neither control group nor randomization, the authors
propose that postoperative restrictions, if unnecessary, only promote
avoidance behavior and limit normal and routine spinal motion.67 This
topic merits further consideration in a randomized, controlled design.
++
Kjellby-Wendt studied active exercise after discectomy in a randomized,
controlled study.68 The authors note that the literature
only describes therapy programs that begin more than 4 weeks after discectomy.68 The
experimental group sat the second day after surgery and were encouraged
to walk.68 The experimental group performed passive
extension while lying down 5 days after surgery and flexion while
lying down 3 weeks after surgery. The patient did active knee extension while
lying supine with the hip flexed to 90 degrees the first day after
surgery.68 The patients in the experimental group
were encouraged to do these exercises 5 to 6 times per day for the
first 6 weeks.68 In the second 6 weeks muscular
strengthening exercise and spinal stabilization exercises were added
and done once per day, and endurance activity like jogging and swimming
was encouraged.68 The control group only did a
partial situp with the hips and knees bent once a day in the first
6 weeks; in the second 6 weeks, the control group added range-of-motion
exercises for flexion and lateral flexion of the lumbar spine.68
++
Results showed that 12 weeks after surgery lumbar range of motion,
especially in the extension and hamstring distension.68 At
the 6-week mark, but at no other time, more patients in the experimental
group were pain-free than in the control group.68 However,
the early mobilization group had significantly less pain at 6 and
12 months than the control group.68 Compliance
for range-of-motion exercises was higher than for the strengthening
exercise. At the 1 year only 11.5% of the experimental
group had residual predominating leg pain, but 19% of the
control group had residual predominating leg pain.68
++
These studies have difficulties including lack of control group67 and
small study size,66 and no discussion of complication
rates between groups.68 These studies all involve
the immediate postoperative period, and merit study on a larger
scale with controlled design and comparison of complication rates
before being implemented into conventional practice.
+++
Prescription
for Vertebral Compression Fracture in Osteoporosis
++
The goals of medical and exercise intervention in osteoporosis
are the increase of bone mineral density, the prevention of fracture
occurrence, and the relief of pain. The literature supports that exercise
for osteoporosis and for vertebral compression fracture achieve
these goals. Patients counseled to engage in regular exercise activity
often reply that they are busy all day and get plenty of exercise.
Coupland, reporting on the EPIC cohort study, noted that neither
household activity (11 hours per week) nor sporting activity less
than 2.5 hours per week had an effect on bone mineral density.10 Both
endurance and strengthening exercise increase bone mineral density
and decrease the rate of fracture occurrence in persons with osteoporosis.
++
As regards endurance activity, Bemden reports that athletes have
significantly higher bone mineral density than less active controls.69 The
EPIC cohort showed a significant increase in the bone mineral density
of the trochanter of women who walk at a rapid pace or stair climb.10 The duration
of walking if slower did not affect bone mineral density. Other
studies have shown an effect of walking duration. Smith70 and
Dalsky71 demonstrated that walking 5 miles per
week, or 30 to 60 minutes three to five times per week, increased
bone mineral density. Bemden reported that women who jog, stair
climb, or walk have increases of bone mineral density at the wrist
hip and spine.69 Coupland11 cited
one study that demonstrated that regular weight-bearing activity
reduced fracture risk over 1 year, although the walking activity
may affect balance and rates of falling, making the effect on fractures
indirect.
++
Strengthening exercises also increase bone mineral density. Pruitt
found that 9-month program for early postmenopausal women resulted
in a 1.6% increase in lumbar bone mineral density but controls
declines 3.6%.72 Kerr reported that high-weight,
low-repetition exercises increase bone mineral density, whereas
low-load, low-repetition activity did not.73 Sinaki
in a case study demonstrated that spinal flexion bias exercises
increased the rate of spinal compression fracture and increased
related spinal pain, whereas extension bias exercises decreased
the rate of fracture and decreased spinal pain.74
++
Precautions for women with osteoporosis, noted by Bemden69 and
Sinaki,74 include avoiding jarring exercises like
high-impact aerobics and horseback riding, abdominal flexion moments
like situps and rowing, and activity that increases the risk of
falling like skiing.
++
A possible prescription for a patient with osteoporosis alone
or with spinal compression fractures:
+
++
++
++
++
+++
Prescription
for Neck Pain
++
Sweeney provides instruction and review for the treatment of
neck pain by cervicothoracic stabilization training.75 The
author draws initial attention to the correction of “spectator” position
posture with the chin thrust forward and the head anterior to rounded
shoulders. The head and neck posture, which reduces translational
stress and compression of the facets and stress on ligamentous structures,
is the chin-tucked position.75 The preferred position
is with the thoracic spine straight, the shoulders gently back,
and the chin gently tucked toward the chest.
++
The thoracic extensors and lumbar spine stabilizers may need
to be strengthened to adequately support this head and neck posture.75 Corner
stretches (see Fig. 79-10) help stretch the rounded shoulders and
thoracic spine. Patient education about posture and body mechanics,
pacing activity, flexibility and strengthening, and self-applied
first aid for aches and strains occurs first, followed by postural
re-education using mirrors.75 The patient learns
flexibility, including range of motion in flexion, extension, and
lateral flexion and rotation. Isometric strengthening in lateral and
forward flexion and extension in the chin-tucked position are taught
and corrected by the therapist.75 Maintaining optimal
head and neck posture through positional transitions and then during
exercise round out the instruction.75 An increase
in pain, either axial or radicular, should result in reexamination
of the exercise program or the technique of the participant.75 Poor
technique during exercise performance can increase pain.75
++
A possible prescription for cervical pain is as follows:
+
Precautions: List other comorbid
diagnoses; screening for signs of cardiopulmonary disease.
Goals: Improved flexibility; corrected
head and neck posture; maintained posture during activities; decreased
pain.
Education: Provide instructions
on optimal head and neck posture; importance of strength and flexibility; strain
and sprain first aid.
Flexibility: Neck and shoulder
rolls (“clocks”); corner stretches; range of motion
to extension, flexion, rotation, rotation with flexion and with
extension.
Strengthening: Thoracic extensions
and lumbar stabilization; chin tucks in the flexed, neutral, laterally
flexed, and extended positions.
Endurance: Transition, treadmill
training with attention to maintaining correct posture.
+++
Reflex Sympathetic
Dystrophy
++
The physiatric treatment of reflex sympathetic dystrophy remains
anecdotal or weakly supported by the literature. Contrast baths
of alternating hot and cold immersions of the involved limb have been
suggested for “vascular exercise,” but without
supporting literature as one writer notes.22 Another
author advises against this treatment altogether.76 Splinting
in a functional position if tolerated may hinder contracture formation.
Anecdotally, paraffin helps range of motion of nonedematous hands
but should be stopped if edema occurs; heat is contraindicated if
the patient has an insensate limb or sensation is diminished. Range
of motion is conventionally recommended but may incite vasomotor
and sudomotor instability, at which time these activities are held
until medical or injection therapies can calm the syndrome. Therapy
to maintain range of motion and strength at ipsilateral joints proximal
to the painful extremity and in contralateral limbs as well as the
cervical, thoracic, and lumbar spine should not be overlooked. By
observation, these patients have weak and stiff limbs proximal to
the active reflex sympathetic dystrophy. Not focusing on the patient’s
painful extremity and exercising other body parts may help the patient
gain confidence in the treatment plan and diminish fear of pain
inflicted. The contralateral limb can become overused and the physician
should be vigilant for this possibility.
++
A possible prescription for reflex sympathetic dystrophy (based
on convention):
+
Prescription
Precautions: Hold range of motion
if sudomotor/vasomotor symptoms destabilize.
Goals: Improve or maintain range
of motion of the involved portion of the extremity; decreased edema; maintain
strength and range of motion in the proximal extremity and contralateral
limb; maintain spine posture and flexibility.
Education: Pace activity; avoid “overdoing
it.”
Flexibility: Gentle passive range
of motion and active assisted range of motion of the involved extremity; passive
splinting to maintain functional positioning (monitor skin for pressure
areas); active range of motion and stretch of the proximal limb
girdle, contralateral limb, and spine.
Strengthening: Contralateral limb
(Fig. 79-21) and spine.
++
+++
Prescription
for Chronic Pain Syndrome
++
Physical medicine prescription is only a portion of a multidisciplinary
effort to treat chronic pain syndrome, in which pain or its report
is the given reason for inactivity and withdrawal from normal social
roles and functions. Persons with chronic pain syndrome are deconditioned
and the focus of their treatment is conditioning or endurance activity,
for example, biking, walking, or swimming.77 Because
behavior modification is the foundation of this treatment program,
to reinforce desired behavior, the exercise must be relevant to
the person, his or her limitations, and to the pain.77 The
activity must also be quantifiable to gauge improvement and accessible.77 Initially,
the patient and physician establish baseline activity by having
the patient exercise to tolerance several days in a row.76 When
the baseline of activity is established, the therapist and physician
develop a program of regular activity for the patient at or just
below the baseline, and increase the activity every few days in
small increments.77,78 The patient is rewarded
and reinforced for achieving goals without the display of pain behaviors.77
++
It is important that the therapist not ask the patient about
pain, and that the therapist not indulge or respond to complaints
of pain by the patient. These concerns should be referred to the
physician, and should not affect the progression of therapy. Obviously
new and different pains, which might be indicative of cardiac or
other significant illness, should be evaluated in a timely fashion.
++
By contrast, when the patient is having a particularly good day,
the patient should be instructed to pace activity and avoid overexertion
that reactivates the chronic pain cycle.77 Patients
with a preponderance of psychosocial stress, secondary gain, or
psychiatric diagnoses will do less well than persons without these
features.77
++
A possible prescription for chronic pain syndrome:
+
+++
Limiting Exercise
and Rehabilitation Assistance Apart from Exercise Activity
++
Certain disease processes like multiple sclerosis worsen with
overexertion. Patients with multiple sclerosis become weaker and
more symptomatic in warm weather and if they overexert while exercising
or in therapy. Precautions for this population include resting the
patient frequently, and avoiding exercising in a hot environment
or warmed pool or whirlpool.
++
Up to 72% of patients with Guillain-Barré syndrome
experience pain.79 These pains include paresthesias
and radicular pain, but also myalgia and arthralgia in particular
shoulder pain and lumbago.80 Movement aggravates
the pain. Other rehabilitation considerations like mattress support, turning
and positioning, bed cages to keep the sheets off allodynic limb,
and passive range of motion may provide comfort to this population.79 While
these patients do participate in mobility therapies, moderation
diminishes over exertional pain.
++
Forty to 64 percent of sufferers of amyotrophic lateral sclerosis
(ALS) may experience pain, including skin pressure, musculoskeletal
pain, and cramps.81 Again, other considerations
from the realm of physical medicine may provide comfort to this
population. The caregiver can learn turning and positioning and
passive range of motion. These patients also have distress and discomfort
that do not fulfill the definition of pain but that rehabilitation
intervention can lessen.81 For example, a speech
therapist may alleviate feeding problems and choking sensations
with evaluation of swallowing, instruction in head and body positioning
to facilitate swallowing, and recommendation for the appropriate
consistency of the diet, for example, pureed.81