Conservative Treatments



Conservative Treatments


Ronald Guberman

Karina Tavakalyan

Daniel Howell

Julien Adicho

Elizabet Peraj

Rock CJay Positano

Timur Davydov

Mary Ann Picone



The focus of this chapter is nonsurgical treatments for neuropathies. Nonsurgical options should always be the first line of treatment as most often the condition being treated will respond to these treatments. In situations where there is no response, further evaluation and testing should be considered, and if indicated, a surgical solution should be considered.


EXTRACORPOREAL PULSE ACTIVATION AND EXTRACORPOREAL SHOCKWAVE THERAPY

Extracorporeal shockwave therapy (ESWT) is a noninvasive treatment option that involves inducing microtrauma to the affected area by means of repeated shockwaves and thus enhancing neovascularization into the area, which in turn enhances tissue repair and healing.1 This treatment option is beneficial in treating and managing injuries and many other inflammatory and painful musculoskeletal conditions. Extracorporeal pulse activation therapy (EPAT), however, is also a noninvasive treatment option for a wide variety of orthopedic conditions and injuries but works by utilizing lower energy acoustic pressure waves to stimulate metabolism, promote blood circulation, and speed the healing process.2 It does not require local anesthesia and may be used multiple times over a short period of time. ESWT is sometimes referred to as a high-energy shockwave, and EPAT is called a low-energy shockwave.

High-energy ESWT generally requires local anesthesia or a combination of local and regional anesthesia and is performed in an office or surgical setting. Low-energy EPAT is generally performed in the outpatient department where it is easy to use and well tolerated.3

Both ESWT and EPAT have been used as effective modalities for treating a variety of foot and ankle conditions including postinjury conditions and Achilles tendonitis, plantar fasciitis, and tendonitis of the foot and ankle.4


LASER THERAPY

Laser therapy is used for persistent pain in patients complaining of rheumatologic, neurologic, and musculoskeletal disorders.5 Low-level laser therapy (660-905 nm) is commonly used to treat musculoskeletal conditions. Conditions in the foot and ankle for which laser therapy is prescribed include plantar fasciitis, peroneal tendinitis, posterior tibial tendinitis, Achilles tendinitis, and
neuropathy. Laser therapy is performed by projecting light to the skin, and upon penetration, it reaches into the deeper tissues. The duration of treatment varies with skin melanin content. Laser therapy produces both thermal and nonthermal effects. The true mechanisms by which laser therapy works to relieve pain are unknown. Laser therapy is also effective in stimulating wound healing, reducing inflammation, increasing blood flow, reducing scarring, and stimulating tissue regeneration.6 According to several studies, activation of specific photoreceptor proteins initiates secondary cascades linked to protein growth factor synthesis, cell proliferation, and expression of transcription factors.7 The percentage of reported pain reduction using laser therapy is 20% to 80%.8 Laser therapy also has an effect on serotonin release and inhibition on tumor necrosis factor alpha.9 Laser therapy has shown to be an effective method to relieve pain and, in some cases, prevent the need for oral analgesic and anti-inflammatory medications or surgery.


TAPING

Taping is commonly used for the prevention and treatment of injuries and to prevent recurrence of an injury. Taping is also used to protect, support, and limit or enhance joint function. Taping can also limit motion of a weakened muscle or ligament of an injured joint to prevent the recurrence of additional damage during repetitive exercise schemes.10 Taping can be performed by 2 methods: elastic taping (Kinesio taping [KT]) or inelastic taping (athletic taping). KT produces fewer mechanical restraints and avoids mobility restrictions. KT reduces pain by correcting muscle function, applying cutaneous stimulation, facilitating movement, and aiding in reduction of edema. Nonelastic taping differs from KT in that it provides more mechanical stability and reduces motion. Athletic taping provides pain reduction through the reduction of motion at the joint. Taping can be used for Achilles tendinitis, plantar fasciitis, peroneal tendinitis, and posterior tibial tendinitis. It can alter foot biomechanics similar to orthotics. It is sometimes used precursory to the fabrication of orthotics or braces.


COMBINATION THERAPIES

Chronic pain often poses a challenge to physicians. Many individuals who have been on narcotics for years are often recalcitrant to many treatment options and medications. Physicians commonly prescribe a combination of different physical therapy (PT) modalities to relieve pain. A different set of treatment modalities may be employed based on the chronicity of the condition. In acute conditions, a combination of ice, exercise, and bracing may be used. In chronic conditions, heat, bracing, or taping may be employed. Heat is generally contraindicated within the first 48 hours of an injury. Contrast baths are also used in post-injury conditions to reduce edema. Contrast baths may be combined with laser therapy and bracing for chronic pain and conditions such as Achilles tendinitis and plantar fasciitis. In a study by Pavone et al, 40 patients were treated for chronic insertional tendinitis using eccentric stretching and ESWT, and at 12 month follow-up, 65% of patients did not complain of pain.11,12,13,14,15 Combination therapy produces pain relief through multiple mechanisms as each modality provides pain relief and anti-inflammatory treatment differently.


NONINVASIVE THERAPIES FOR FOOT CONDITIONS

The foot is very vital to mobility and sporting activities that call for running, sudden changes in direction, and jumping. Given that the conditions cause foot and ankle pain and limited mobility, reduce an individual’s level of physical activity, and potentially side line them from engaging in sports and activities of daily living, seeking early medical diagnosis and effective treatment is important.16 The foot and ankle are complex structures. They consist of over 100 tendons, ligaments, muscles, and bones
that are intricately connected and 33 distinct joints. Treating conditions that affect these structures calls for foot and ankle specialists. Noninterventional therapies for foot conditions include PT, splints, taping, arch supports, bracing, and orthoses.


ORTHOSES

A foot orthosis (FO), or orthoses, is an external device applied and fitted to the human body and is designed to achieve a number of goals such as the following:



  • 1. Aid in rehabilitation


  • 2. Reduce pain


  • 3. Increase independence


  • 4. Increase mobility


  • 5. Correct or accommodate deformity


  • 6. Control biomechanical alignment


  • 7. Protect and support an injury

An orthosis is a single device, and 2 or more are called orthoses. Orthoses are divided into various categories depending on the body part for which they are designed. Depending on a patient’s needs and shoe gear, 1 or more orthoses can be used.14,15 The “one-size-fits-all” orthosis is a very common misconception as different types of shoe gears (athletic sneaker, loafer, dress, pump, etc.) require different biomechanical designs for the orthosis to have a maximum therapeutic and protective effect. This will often result in a less than optimal therapeutic outcome and directly affect patient compliance using these devices. Functional orthotics and accommodative orthotics are the major categories of orthoses available to assist in mobility and other foot and ankle therapies. Functional orthoses are made to assist in providing biomechanical correction, changes, and alterations in function by realigning anatomical structures to help rectify a number of deformities and conditions and promote joint and muscle use, relieve pain, and prevent further deformity.14,15 Accommodative devices are generally employed to relieve pain in the foot, reduce pressure, and evenly redistribute weight and are most effective and useful in conditions where a functional device cannot be tolerated, advisable, or feasible. Over-the-counter orthoses are accommodative in nature and not recommended or effective in treating foot and ankle conditions that require strength and stability.


TYPES OF COMMONLY PRESCRIBED ORTHOSES


Foot Orthoses

These are designed for different foot, leg, or postural complications. They were historically believed to work by correcting mechanical deformities that were visible, such as correcting a foot that was perceived to be “overpronated.”16 FOs are commonly known as inserts and are mostly positioned in shoes in order to redistribute the weight of the feet and legs and as a result minimize shock, relieve pain, and bring stress to a minimum. They can be hard or soft and can either be fitted or custom made. At times, they come in the form of a shoe.16,17 However, more modern knowledge aims at the therapeutic results being realized from internal kinetic changes. The increased understanding of biomechanics has led to a greater and wider variety of orthotic prescriptions for functional and accommodative devices. They also serve to provide an important biomechanical contact and interface for the body and supported structure and are therefore also helpful in correcting and treating a variety of foot, knee, hip and spinal problems.17


Knee-Ankle-Foot Orthoses

These aid in joint protection, reduction of pain, and support of joints after a surgery and for other acute and chronic conditions.17 These forms of orthoses are also used for individuals with various syndromes and neuromuscular conditions.


Spinal Orthoses

This type of orthoses serves to control spinal injuries and deformities and provide immobilization and support.17 This form of orthoses assists with providing relief for the foot, ankle, and leg pain that originated from the spine.



Fracture Orthoses

They are a modern version of plaster or fiberglass casts.17 They are used with the intention to treat and stabilize fractures of the foot, while also allowing for partial weight bearing.


Ankle-F oot Orthoses (AFOs)

These are designed to improve or limit movement and promote rehabilitation and biomedical targets.18 They are mostly L-shaped braces designed to stabilize the foot and ankle in order to align muscles and joints. They extend up the calf and can be made from a variety of rigid, semirigid, and flexible materials. Some devices also have an anterior component. They often have straps that connect together to hold the device in the right position and bring stability to the foot, ankle, and the lower leg. They may be solid or hinged. AFOs are often used to treat foot drop.17,18 Examples of AFOs include hemispherical AFOs, tone-reducing AFOs, posterior leaf spring AFOs, solid AFOs, spiral AFOs, rigid AFOs, and Tamarack flexure joint AFOs.17,18


Knee Orthoses

Knee orthoses are braces worn in order to support and align the knee and extend from above the knee to below the knee.17,18 Prophylactic braces are rigid and have knee hinges. They are prescribed for people with knee injuries. It is important to clearly understand the patient’s condition and effectively communicate with them in order to achieve success on the use of orthoses. If a patient has positive results with the orthoses, then their use could promote the therapeutic benefit. It is important to realize that the treatment of the knee affects the pain and functioning of the foot.19

There exist a wide range of prefabricated and custom-made orthoses designed for various musculoskeletal conditions.19 A prefabricated orthosis is an orthosis that is made prior to fitting. It is customized to meet the exact specific requirements of a patient. They are used on a short-term prescription use or for noncomplicated clinical presentations.19 It is ethical and imperative to understand that all prefabricated orthoses must be modified to suit the patient for maximum achievement and realization of treatment goals. A custom-made orthosis, however, is an orthosis with high specialization.18 The components of orthotic devices can be rigid, semisoft, or soft and are made from a variety of materials such as metal, plastics, carbon fibers, rubber, plastic polymers, and leather.


PURPOSE OF ORTHOTIC TREATMENT

Foot injuries have adverse effects on the joints, muscles, and patterns of motion and therefore make it challenging to establish a meaningful gait/posture. A successful orthotic device helps an individual develop more normal joint motion and enhance muscular function. This is achieved by providing a stable foundation for movement, establishing a correct posture, aiding in transition between sitting and standing, and reducing the potential for conditions and injuries.14,15 Orthoses also aid in strengthening weak muscles, preventing deformity and correct poor skeletal alignment. Pain relief for conditions such as posterior tibial tendon dysfunction (PTTD), plantar fasciitis, Achilles tendonitis, hallux limitus or rigidus, lateral ankle sprains, and many more conditions can be achieved through the use of proper orthotics. Orthoses are often utilized for the treatment and prevention of foot and ankle ulcerations, for Charcot and many other painful and arthritic conditions.


ORTHOSES FOR CHILDREN WITH CEREBRAL PALSY

For purposes of mobility in children with cerebral palsy (CP), orthotic devices and braces for the lower limb can be used together or separately to help a child gain and maintain balance.20 This is realized by limiting certain irregular movements so that a child can relearn how to stand and walk.21,22 Getting affected limbs into proper alignment aids in correcting deformities of flexibility and helps in transferring a child’s body weight to avoid unnecessary weight on the joints and muscles affected by injury.21,22 Children with CP experience joint deformity caused by an imbalance in muscle
tones and can be treated using orthoses.21,22 Toe walking, common in this group, is treated using AFOs, which strengthen and bring stability to the muscles and joints of the foot and ankle.21,22

Spasticity can be seen and the use of orthoses can yield positive results on the child’s body mechanics.21,22 When the child develops a stable basis for movement, they are in a position to develop better levels of functioning such as strengthened muscles, increased step length, increased control over spastic movements, better coordination, and improved endurance.21,22 In addition to CP, orthoses help children living with a variety of conditions and disabilities. They can attain a level of mobility and independence, reduce stress, and reduce the chances of an injury or a fall.21,22 As a result, a child is able to take the focus off of required mobilization and onto play time, fostering relationships and family time and pursuing their own interests. Braces are designed to decrease swelling, reduce pain, improve balance, immobilize and protect joints, and, as a result, facilitate healing of acute pain.20,21,22,23,24,25 They also serve to prevent injury, reduce pain, and change the use of a joint.24 The medial unloading knee brace is used for medial knee osteoarthritis (OA), and the patellar stabilizing brace aids in maintaining the right patellar alignment, while a patellar tendon strap is effective in treating pain resulting from patellar tendinopathy.23,26 Ideally, the use of a functional ankle brace is more efficient than immobilization or compression wrap when it comes to functional results after an acute sprain on the ankle. Braces also serve to prevent future possible ankle spra ins.20,21,22,23,24,25,26

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Sep 8, 2022 | Posted by in ORTHOPEDIC | Comments Off on Conservative Treatments
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