Chapter 79. Physical Medicine and Rehabilitation

This chapter focuses on physical therapeutics and their prescription to treat diagnoses with a significant symptom of pain. However, physical medicine and rehabilitation professionals attend or administer to persons with a wide variety of diagnoses, and they practice with a variety of allied health professions. To apprise professional services that the specialty of physical medicine and rehabilitation can offer a patient, this chapter opens with a synopsis of rehabilitation philosophy, methods, and goals. Antecedent to discussing this specialty as it applies to pain, the chapter references current review works that define the types of exercise and modalities. The chapter concludes by addressing specific diagnoses and referencing the current literature that guides the physical medicine and rehabilitation prescription.

The field of physical medicine and rehabilitation spans the settings of inpatient, outpatient, and home health medicine. The philosophy of physical medicine and rehabilitation embraces an intradisciplinary approach to patient care, with not only the patient and physician working toward the patient’s recovery but also a team of allied health care professionals. This team includes physical, occupational, and speech therapists, social workers, nurses, pharmacists, psychologists, recreational therapists, and vocational specialists.

The goal of physical medicine and rehabilitation interventions is the improved function of the patient, despite the presence of permanent disease or impairment. Physical medicine and rehabilitation teams treat a spectrum of diagnoses referred from medical, surgical, pediatric, and traumatic specialties. The severity and complexity of diagnoses varies from catastrophic entities such as spinal cord injury and stroke to routine soft tissue injuries, for example, shoulder impingement and shin splints. With more complex disease entities in which tissue loss or tissue death has occurred (e.g., amputation or traumatic brain injury), successful physical medicine and rehabilitation intervention compensates for impairment rather than resolves or cures the disease process.

For diagnoses with soft tissue injury (e.g., ankle sprain and shoulder impingement), physical medicine and rehabilitation interventions promote soft tissue healing. For all levels of injury, physical medicine and rehabilitation interventions aim, however, to restore function and prevent recurrent injury. Physical medicine and rehabilitation uses a team treatment approach to restore function to patients with soft tissue injury or permanent tissue loss. Tools of the field include exercise, thermal and electrical modalities, as well as education and new learning.

Except in the case of chronic pain syndrome where pain and dysfunctional behavior in response to the pain have become the impairment and disease,1 pain is a symptom of a disease process or tissue injury. This chapter discusses the physical medicine and rehabilitation interventions for diagnoses in which pain is a complaint or symptom; these interventions involve straightforward, applied progressive exercise and education.

For the treatment of the soft tissue injuries in patients who have pain, the physician prescribes physical therapeutics, which a physical or occupational therapist administers. The treatment and improvement of the symptom of pain generally cannot be separated from the treatment and improvement of the disease process. This chapter cites available literature that notes the molecular and cellular mechanisms whereby exercise and thermal and electrical modalities may relieve pain. Physical therapeutics, which lessen pain and remedy soft tissue injury, include exercise, education, and thermal and electrical applications.

The Physical Medicine and Rehabilitation Script

The physical therapeutics at the physician’s disposal for the treatment of pain and its associated soft tissue injury include stretch, range of motion, strengthening, endurance exercise, and aquatic therapy; positioning, bracing and assistive devices; transcutaneous electrical stimulation, and superficial and deep heat, and superficial cold; and learned strategies to prevent injury or simplify work (Table 79-1). When writing a prescription for soft tissue injury and pain, it is helpful to include these headings to ensure a complete script. Additional components of a prescription for physical or occupational therapy include the patient’s name and contact information, the patient’s diagnosis, precautions about comorbid disease processes, and goals of the treatment intervention (Fig. 79-1).

The components of exercise and thermal and electrical modalities have definitions and specific applications. When prescribing physical medicine interventions for painful conditions, the physician who trains himself to write specifically for stretch, strengthening, endurance activity, education, assistive devices and splints, and modalities should generate a complete and useful script. The following sections describe the techniques, physiology, and effects of physical therapeutics.

Stretch

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

Strengthening

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.

Endurance

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.

Aquatic Running

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.

Patient Education

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.

The literature supports that stretching and endurance activity relieve pain. The mechanism for stretch is not clear but the mechanism for endurance activity may be related to changes in neurohormones. The diagnoses-specific section of this chapter discusses literature that demonstrates a pain-relieving effect of strengthening activity as well. The mechanism of this pain relief is not clear.

It is important to note that the patient does not require expensive in-home equipment or private gym memberships to participate in an exercise program. By intention, the models demonstrating the exercises and stretches in this chapter were nonprofessionals, photographed in a spare noncluttered room in a home, and they had access to no specialized equipment other than a good pair of athletic shoes.

The modalities of superficial heat and cold relieve pain, as does TENS. The mechanisms are variable and include local effects on the nerves, and modulating effects in the central nervous system. Interestingly, in a meta-analysis ultrasound has not been found to relieve pain but is useful when used in combination with stretch to relieve contracture.21

Knee Osteoarthritis

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:

• Evaluation: Screen for significant contraindications to exercise; baseline ECG. The therapist is quite capable of modifying an exercise program to allow for coexistent diagnosis.

  Prescription

  • • Precautions: List comorbid diagnoses.

      Goals: Increase knee range of motion; increase knee extension strength; and improve functional mobility.

      Education: Instruction in the proper sequencing of a gait with a cane; instruction in joint conservation techniques.

      Stretching: Sustained stretch to the hamstrings (Fig. 79-5).

      Strenghtening: Isometric strengthening of the knee extensors (Fig. 79-6) initially; progress to assisted and active range of motion exercise around the knee; progress to isotonic strengthening of the knee extensors. Strengthen the arm and shoulder extensors to promote joint conservation techniques.

      Endurance exercise: Low-impact endurance activity; or walking in a pool waist to chest deep, if available.

      Modalities: Ice to muscles as needed for spasm; TENS; electrical stimulation.

      Frequency: Physical therapy 3 days a week plus home exercise twice a day, 3 days per week.

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:

• Evaluation: Screen for significant contraindications to exercise; baseline ECG.

  Prescription

  • • Precautions: List comorbid diagnoses.

      Goals: Decrease knee pain at rest and during functional activity; increase knee extension strength.

      Stretch: Exercise hamstrings and iliotibial band.

      Strengthening: Isometric quadricep sets, isometric hip adduction, Muncie-modified straight leg raise; terminal extension, progress to full knee range of motion.

      Endurance: When pain is diminished, progress to biking or swimming.

      Modalities: Ice after exercise for 20 minutes; TENS.

Fibromyalgia

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:

• Evaluation: Screen for significant contraindications to exercise; baseline ECG.

  Referral: Psychological referral for coping and stress management.

  Prescription

  • • Precautions: Contraindicated for comorbid diagnoses.

      Stretching: Generalized upper (Figs. 79-9, 79-10, 79-11) and lower limb flexibility (Figure 79-12 and see Figs. 79-2, 79-3)

      Endurance: Aerobic activity to a heart rate of >70% predicted maximum for 30 to 60 minutes.

      Education: Provide instruction about benefits of regular exercise.

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:

• Evaluation: Screen for significant contraindications to exercise; baseline ECG.

  Prescription

  • • Precautions: List comorbid diagnoses.

      Stretching: Generalized upper (see Figs. 79-9, 79-10, 79-11) and lower limb flexibility (see Fig. 79-12)

      Endurance: Aerobic activity to a heart rate of >60% predicted maximum for 20 to 30 minutes.

      Modalities: Superficial heat, spray and stretch, soft tissue massage.

      Education: Provide instruction about benefits of regular exercise.

Axial Low Back Pain

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:

• Evaluation: Screen for significant contraindications to exercise; baseline ECG.

  Prescription

  • • Precautions: List comorbid diagnoses.

      Education: Back conservation and proper body mechanics, the syndrome of low back pain, its frequency and the significance or lack of significance of radiographic findings, the importance of regular exercise, and back first aid.

      Stretching: Lumbar (see Fig. 79-2), quadratus lumborum, and lower limb flexibility, including tensor fascia lata, hamstrings (see Fig. 79-3), and gluteus (see 79-15).

      Strengthening: Lumbar crunches (Figure 79-13), pelvic tilts (Figure 79-14), lumbar extensions.

      Modalities: Superficial ice or heat for comfort.

Spondylolisthesis

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:

• Evaluation: Screen for significant contraindications to exercise; baseline ECG.

  Prescription

  • • Precautions: List comorbid diagnoses.

      Education: Back conservation and proper body mechanics, the syndrome of low back pain, and back first aid, the importance of regular exercise with a flexion bias (infrequently the patient will prefer the extended position).

      Stretching: Lumbar (see Fig. 79-3), quadratus lumborum, and lower limb flexibility, including tensor fascia lata, hamstrings (see Fig. 79-4), and gluteus (Fig. 79-15).

      Strengthening: Lumbar crunches (see Fig. 79-13), pelvic tilts (see Fig. 79-14).

      Modalities: Superficial ice or heat for comfort.

      Assistive devices: Bracing that blocks extension and promotes flexion radicular sciatic pain.

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:

• Evaluation: Screen for significant contraindications to exercise; baseline ECG.

  Prescription

  • • Precautions: List comorbid diagnoses; stop extension exercises if back pain peripheralizes or leg pain increases; stop therapy and return the patient to the physician if weakness is progressive.

      Goals: Centralize leg pain.

      Education: Provide instruction in back conservation and proper body mechanics, instruct the patient in posture maintenance, and during transitions, the importance of regular exercise, and back first aid.

      Stretching: Sustained stretch of the hamstrings (see Fig. 79-3), quadriceps, hip flexors (see Fig. 79-15), and calves (see Fig. 79-12).

      Strengthening64: Identify the neural position of minimal leg pain; lumbar crunches (see Fig. 79-13) 10 reps × 3 sets, pelvic tilts reps over 2 minutes (see Fig. 79-14), bridging slow reps over 3 minutes; quadriped with alternating arm and leg movements, slow reps held over 2 minutes; wall slide held 1 minute.

      Endurance: After leg pain is minimized and the patient can maintain standing and walking posture, treadmill walking and progress to other endurance activities.

      Modalities: Superficial ice or heat for comfort.

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:

• Evaluation: Screen for significant contraindications to exercise; baseline ECG

  Prescription

  • • Precautions: List comorbid diagnoses; stop exercises that peripheralize back pain or cause leg pain; contact the operating surgeon for any persistent postoperative limitations, specifically those restricting extension.

      Strengthening exercises: Floor exercises including prone pressups (if allowed by the surgeon) and including dynamic lumbar stabilization exercises supine and prone with supported alternating arm and leg movements; bridging exercises; quadriped exercises; lateral pull down exercises if patient has access to weight equipment.

      Education: Instructions in back conservation techniques with transitions.

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:

• Evaluation: Screen for signs and symptoms of cardiopulmonary disease; baseline ECG.

  Prescription

  • • Education: Provide instruction on back conservation; log rolling to come to sitting if needed.

      Flexibility: Advise corner stretches (see Fig. 79-10).

      Strengthening: Suggest strengthening exercises such as shoulder retractions and depressions (Fig. 79-17); prone or seated thoracic extensions (Fig. 79-18); if the patient has too much pain to mobilize from bed, supine isometric retractions and extensions (Fig. 79-19), where the patient “tries to pin the mattress with the shoulders” can be done. Patients with more skill can perform more advanced or resisted shoulder retractions with weights (Fig. 79-20).

      Endurance: Walking as briskly as tolerated for 30 minutes, 5 times per week.

      Bracing: Brace to block flexion, and hold in extension; the Jewitt brace most restricts motion. Knight, Taylor-Knight, and Cash are less restrictive braces.

      Modalities: TENS.

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:

• Evaluation: Review of systems for signs of cardiopulmonary disease; baseline ECG.

  Prescription

  • • Goals: Increase endurance for common activity, and diminish regression to display of pain behavior.

      Education: Pacing activity; resting before the onset of fatigue or pain; self-applied ice first with local ice or heat after exertion.

      Flexibility: Establish baseline range of motion around the symptomatic area over several days or sessions; the patient should be instructed to give effort to tolerance while establishing the baseline of flexibility; stretch to average range of motion for 4 to 5 days; increase range of stretch by two to three degrees every 4 to 5 days; at day 4 or 5 the increase range of motion takes place regardless of whether the patient is having a “good” pain day or a “bad” pain day.

      Endurance activity: Establish a baseline of walking activity (or other activity) to tolerance over several days or sessions of performance. Walk for the average walking time for 4 to 5 days and increase the walking time by 10% every 4 to 5 days. The increase in walking time occurs regardless of whether the patient is having a “good” pain day or a “bad” pain day on day 4 or 5. If the patient is having a particularly good day, he or she should not increase activity beyond the prescribed walking time, but perhaps enjoy some other leisure reward of limited exertion, like reading a book, relaxing outside, knitting, visiting with family or friends, eating a dessert or drinking a cup of coffee at a restaurant, or potting a small plant.

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

Physical medicine and rehabilitation can provide a spectrum of services from a variety of health care professionals to address discomfort and pain that patients experience as a result of surgical, medical, traumatic, or congenital disease. Exercise prescription, including education, stretch, strength, and endurance portions, administered by physical or occupational therapists, relieves pain, improves strength and stamina and flexibility in various musculoskeletal complaints.

Physical medicine and rehabilitation strategies and personnel may also help persons with other types of discomfort or distress or dysfunction, and the physician can consult for recommendations.