Physical Therapy

Sandy B. Ganz

Louis L. Harris

INTRODUCTION

Management of the physical therapy for patients with musculoskeletal and rheumatic diseases is a challenging task, even for the most astute clinician.

I. The goals of physical therapy

in the treatment of patients with rheumatic diseases are fourfold:

Preventing disability.
Restoring function.
Relieving pain.
Educating the patient.

II. EVALUATION

Before these goals can be achieved, a thorough evaluation of the patient for physical therapy is performed, which includes the following:

Functional assessment
- Bed mobility. Observe the patient performing functional movements.
  - Turning over from a supine position to the side and then to a prone position.
  - Moving up and down in bed.
  - Moving from a supine to a sitting position.
- Transfer status. Observe the patient transfer to and from various surfaces (i.e., bed, chair, and toilet).
- Gait analysis
  - Observational. Watch the patient ambulate with or without assistive devices on level surfaces and stairs.
  - Instrumented gait analysis with a foot switch stride analyzer or computerized video analysis.
Range of motion (ROM) assessment of all joints
Strength assessment
- Manual muscle test of trunk, neck, and proximal and distal muscles to determine weak musculature.
- Instrumental biomechanical muscle test.
- Isometric/isokinetic objective strength measurement, recorded of select muscle groups, performed with an isokinetic dynamometer (i.e., Cybex¹, Lido²).
Posture assessment. Observe the patient in both standing and ambulating postures during functional activities.
Respiratory status. Chest evaluation consists of the following:
- Auscultation.
- Chest expansion.
- Description of cough.
- Inspirometry.

III. COMPONENTS OF TREATMENT

After the physical therapy evaluation has been performed, the clinician has baseline data for future comparison and a basis for determining treatment goals. These specific goals are achieved through therapeutic exercise, other modalities, functional activities, and perhaps the most important aspect of treatment, patient education (Table 61-1).

Table 61-1 Components of Treatment in Musculoskeletal and Rheumatic Disorders

Therapeutic exercise	Modalities
Range of motion	Heat
Strengthening	Cold
Endurance	Relaxation
Breathing	Electrotherapy
Massage and mobilization	Hydrotherapy, traction
Functional activities	Patient education
Gait training	Joint protection
Transfer and bed mobility	Home program
Activities of daily living	Body mechanics

IV. THERAPEUTIC EXERCISE

Goals of exercise
- Maintain or improve ROM.
- Strengthen weak muscles.
- Increase endurance.
- Enhance respiratory efficiency through breathing exercises.
- Improve balance and coordination.
- Enable joints to function better biomechanically (Table 61-2).

Therapeutic exercises used in the treatment of musculoskeletal and arthritic conditions are as follows:

ROM. Excursion of a joint through its available range.
Passive range of motion (PROM). Without active muscle contraction around the joint, the joint is moved through available ROM by another individual, object, or by the use of the other extremity.
Active assisted range of motion (AAROM). The patient performs ROM exercises with the assistance of another individual, object, or the use of another extremity.
Active range of motion (AROM). The patient performs ROM exercises without assistance.

Active resisted range of motion (ARROM). The patient performs ROM exercises with some form of resistance (manual or mechanical resistance, elastic bands, or weights).

Table 61-2 Treatment Goals

Stages of disease	Treatment goals	Exercise
Acute	Control inflammation Maintain ROM Minimize loss of function	Passive range of motion AAROM
Subacute	Increase ROM Maintain strength	AROM Isometric
Chronic	Increase ROM Increase strength Increase endurance	AROM AAROM Isokinetic Aerobic
AAROM, active assisted range of motion; AROM, active range of motion; ROM, range of motion

Strengthening exercises
- Static. Isometric exercises in which the patient contracts or tightens the muscle around the joint without producing any joint motion.
- Dynamic. Some form of resistance is used for the patient to work against, either manually or with an externally applied load (i.e., weight).
  - Isotonic. Concentric or eccentric contractions of variable speed with use of a set weight or resistance throughout the full ROM.
  - Isokinetic. A concentric or eccentric contraction at a set speed with use of a set weight or resistance throughout the full ROM.

General instructions to patients
- Use pain as your guide. Pain or discomfort should not last longer than one hour after exercise.
- Make the exercise a part of your daily routine.
- Try to do a complete set of exercises at least twice a day at a time convenient to you.
- Prescribed medication and heat or cold applications may precede exercise to enhance relaxation and decrease pain.
- Perform only those exercises prescribed for you by your physician or therapist.
- Perform exercises on a firm surface.
- Exercise slowly with a smooth motion. Do not rush.
- Avoid holding your breath while exercising.
- Modify the exercise regimen during an acute attack of the disease, and contact your physician or physical therapist if you have any complaints or problems with the exercises.

V. PHYSICAL AGENTS (MODALITIES)

Various modalities/treatments are employed by the physical therapist, including the application of heat, cold, electrical stimulation, mechanical traction, and mobilization/massage. These are generally provided as an adjunct to a total rehabilitative program.

Superficial heating
- Hot packs contain a silica gel that absorbs water. These packs are kept in thermostatically controlled water at 175°F (79.4°C). The literature demonstrates that hot-pack effectiveness reached at a depth of 1 cm increases skin temperature by 10°C.
  - Indications. Relief of pain, muscle spasm, and decreased ROM.
  - Contraindications. Sensory involvement, open lesions, and malignancy.
- Paraffin bath. Paraffin wax is mixed with mineral oil and maintained at 118°F (48°C) to 126°F (52°C). It is most useful in the treatment of hands. The wax mold conforms to the hand and provides heat to all joint surfaces. The heating benefits are similar to those obtained with hot packs.
  - Indications. Relief of pain, muscle spasm, and decreased ROM.
  - Contraindications. Sensory involvement and open lesions.
- Hydrotherapy (whirlpool, therapeutic pool). Water is maintained at 94°F (34°C) to 96°F (36°C). Coupled with its ability to partially eliminate the effect of gravity (buoyancy), heated water can provide excellent moist heat and exercise, simultaneously. Whirlpools are also beneficial to promote wound cleaning and healing. Hydrotherapy is a related form of heat treatment.
  - Indications
    - Muscle spasms, relief of pain, and decreased ROM.
    - Whirlpool. Open lesions.
  - Contraindications
    - Patients with decreased heat tolerance.
    - Therapeutic pool. Open lesions, urinary tract infection, diarrhea; extreme care should be taken in patients with cardiopulmonary involvement.
- Fluidotherapy is a dry application of heat. A bed of finely ground solids (e.g., glass beads with an average diameter of 0.0165 in.) are blown with thermostatically controlled warm air. This creates a warm, semifluid mixture
  for treatment of the hand or foot. The temperatures are within the same ranges as the paraffin wax.
  - Indications. Relief of pain, muscle spasm, and decreased ROM.
  - Contraindications. Sensory involvement and open lesions.
Deep-heating ultrasound. The application of high-frequency sound waves to the musculoskeletal system causes a deep-heating response. This response is deeper than that induced by other physical agents, and it has been demonstrated that the intra-articular temperature of the hip joint rises by 1.43°C after a properly applied therapeutic dose. Typical patient exposure is 1 to 2 W/cm² for 5 to 10 minutes. Ultrasound can also be combined with electrical stimulation.
- Indications. Pain relief, muscle spasm, and decreased ROM.
- Contraindications. Local malignancy, unstable vertebrae (after laminectomy), pregnancy, and spinal cord disease; ultrasound should not be applied directly over the eyes, brain, or spinal cord.
Cold. Cryotherapy is very effective in promoting vasoconstriction, thereby decreasing restricted joint ROM resulting from an inflammatory process and aiding pain relief. Cold modalities include ice packs, frozen gel packs (cold packs), and ice massage.
- Indications. Swelling and inflammatory reactions, spasms, contusions, and traumatic arthritis.
- Contraindications. Decreased sensation, sensitivity to cold, and Raynaud’s phenomenon.
Mobilization generally means moving the joints, including spinal joints, through an ROM designed to stretch the joint capsule and, in some instances, to move the joint beyond the norm of its associated muscles. The technique is primarily used in patients with musculoskeletal pain.
- Indications. Joint hypomobility, decreased proprioception, restriction of accessory joint motion, ligamentous tightness, adhesions, and joint dysfunction.
- Contraindications. Ligamentous laxity and unstable joints.
Massage is a widely practiced modality. It is intended to relieve pain, soft-tissue tightness, and muscle spasm. It is often used in conjunction with heat or cold applications. Other forms of massage include acupressure, connective tissue massage, postural integration (rolling), and deep friction massage.
- Indications. Muscle spasm and decreased extensibility of soft tissues.
- Contraindications. Cellulitis, malignancy, and phlebitis.
Electrical stimulation is one of the oldest and most effective physical agents. Its purpose is to contract or re-educate muscle, relax muscle spasms, stimulate nerves to promote motion and pain relief, and generally improve circulation. A wide range of gadgets using different current types (AC and DC) and a wide variety of electrical generators [low-volt, high-volt, biofeedback, transcutaneous electrical nerve stimulation (TENS)] are available. No individual system or model is ideal for all clinical situations, and the therapist’s choice depends on the desired therapeutic response.
- Indications. Muscle re-education, denervated muscles, pain relief, decreased general circulation, decreased muscle strength during immobilization, and decreased ROM.
- Contraindications. Phlebitis, demand pacemakers, hemorrhage, and recent fractures.
Mechanical traction. Intermittent traction is utilized for spinal disorders, generally in conjunction with other modalities. The amount of traction prescribed depends on the area being treated and on the patient’s tolerance. Its effectiveness in promoting relaxation through muscle stretching, relieving nerve compression, and relieving pain has been demonstrated. Patients receive intermittent traction two to three times/week on average for 20 minutes.
- Indications. Muscle spasm, mild nerve compression, and vertebral osteoarthritis.
- Contraindications. Unstable vertebrae, local malignancy, spinal cord disease, osteoporosis, osteomyelitis, and pregnancy.

GENERAL GUIDELINES FOR REHABILITATION OF SPECIFIC RHEUMATOLOGIC DISORDERS AND AREAS OF THE BODY

I. Systemic rheumatic diseases

including rheumatoid arthritis, juvenile idiopathic arthritis, progressive systemic sclerosis, and systemic lupus erythematosus are characterized by multisystem involvement. All are chronic, remitting, and relapsing with variable clinical courses that result in myriad clinical manifestations. Comprehensive rehabilitative management is necessary in the treatment of such systemic inflammatory diseases. Rest is essential in the management of active inflammatory joint or soft-tissue disease, and the amount of rest versus activity is the subject of extensive debate. Peripheral joint involvement in psoriatic arthritis, reactive arthritis, and colitic arthropathies should be treated in a similar manner to that in rheumatoid arthritis and juvenile idiopathic arthritis, as noted in the subsequent text. The proper balance between rest and exercise is the key to successful treatment.

Aims of treatment
- Preserve or increase functional level.
- Decrease pain.
- Improve joint mechanics.
- Decrease joint inflammation.
- Improve ROM, strength, and endurance.
Therapy
- Active inflammatory disease
  - Rest
    - Systemic (body) rest.
    - Articular (joint) rest.
    - Emotional rest.
  - Joint protection
    - Splinting.
    - Assistive devices.
    - Ambulatory aids.
  - Techniques for relaxation and stress reduction.
  - Education of the patient.
- Pain
  - Superficial heat.
  - Cryotherapy.
  - TENS.
- Decreased ROM
  - PROM.
  - AAROM.
  - Stretching.
- Weakness. Muscle strengthening with the following:
  - Isometric.
  - Isotonic.
  - Isokinetic.
- Ambulation
  - Ambulatory aid.
  - Orthotic.
- Decreased endurance techniques
  - Energy conservation.
  - Aerobic exercise program.
- Difficulty with activities of daily living (ADL)
  - Adaptive equipment.
  - Assistive devices.