Abstract
Within a medical context, rehabilitation can be defined as a process by which the patient strives to achieve his or her full physical, social, and vocational potential. A formal medical rehabilitation program is most commonly used after an individual has experienced a loss of function due to an injury or disease process or as a side effect of necessary medical treatment (e.g., surgery). For rehabilitation to be successful, it is crucial that the patient, physician, and therapist(s) involved in the case share the same clearly defined functional goals; treatment will be directed toward the achievement of these goals. The patient should give frequent feedback regarding effectiveness of interventions and any detrimental effects of treatment so that the rehabilitation plan and functional goals can be modified as needed throughout the rehabilitation process. Therapeutic exercise, physical modalities, and orthotic devices are the main components of a medical rehabilitation program for patients with musculoskeletal dysfunction. Physical therapists are trained to identify, assess, and work with the patient to alleviate acute or prolonged movement dysfunction. Most physical therapists use a combination of therapeutic exercise, physical modalities, manual manipulation, and massage to achieve the treatment goals. Occupational therapists are trained to identify, assess, and work with the patient to alleviate functional deficits in the areas of self-care, vocational, and avocational activities. Although medical professionals provide direction and guidance during rehabilitation, the patient plays the most important active role in the rehabilitation program.
Keywords
Modalities, therapeutic exercise, orthoses, electrotherapy, traction, rehabilitation
Key Concepts
- •
Within a medical context, rehabilitation can be defined as a process by which the patient strives to achieve his or her full physical, social, and vocational potential.
- •
A formal medical rehabilitation program is most commonly used after an individual has experienced a loss of function due to an injury or disease process or as a side effect of necessary medical treatment (e.g., surgery).
- •
For rehabilitation to be successful, it is crucial that the patient, physician, and therapist(s) involved in the case share the same clearly defined functional goals; treatment will be directed toward the achievement of these goals.
- •
Although medical professionals provide direction and guidance during rehabilitation, the patient plays the most important active role in the program.
- •
The patient should give frequent feedback regarding effectiveness of interventions and any detrimental effects of treatment so that the rehabilitation plan and functional goals can be modified as needed throughout the rehabilitation process.
- •
Therapeutic exercise, physical modalities, and orthotic devices are the main components of a medical rehabilitation program for patients with musculoskeletal dysfunction.
- •
Physical therapists are trained to identify, assess, and work with the patient to alleviate acute or prolonged movement dysfunction. Most physical therapists use a combination of therapeutic exercise, physical modalities, manual manipulation, and massage to achieve the treatment goals.
- •
Occupational therapists are trained to identify, assess, and work with the patient to alleviate functional deficits in the areas of self-care, vocational, and avocational activities.
Therapeutic Exercise ( Fig. 4.1 )
- •
In most cases, therapeutic exercise should be taught and supervised, particularly during early stages, by a physical therapist.
- •
Occupational therapists are specifically trained to supervise exercises directly related to self-care, vocational, and avocational activities and are appropriate to refer to in these cases.
- •
Major categories of exercise include muscle strengthening (strength training), range of motion (flexibility), and neuromuscular facilitation.
Strength Training
- •
Both high-resistance/low-repetition and low-resistance/high-repetition techniques exist and can be effective.
- •
High-resistance techniques are generally considered more effective and efficient in building strength.
- •
Low-resistance techniques are useful during injury or as training for highly repetitive tasks.
- •
The most important factor in increasing strength in either case is to exercise the muscle to the point of fatigue.
- •
Observed effects of strength training occur primarily due to neuromuscular adaptations, specifically improvement in the efficiency of neural recruitment of large motor units.
- •
Additional increases in muscle strength result from muscle hypertrophy, via the enlargement of total muscle mass and cross-sectional area.
Flexibility Training
- •
Flexibility generally describes the range of motion present in a joint or group of joints that allows normal and unimpaired function.
- •
Flexibility can be defined as the total achievable excursion (within the limits of pain) of a body part through its range of motion.
- •
Flexibility training is an important aspect of most therapeutic exercise regimens.
- •
Flexibility training seeks to achieve a maximal functional range of motion and is most typically accomplished by stretching.
- •
Three categories of stretching exercises have been used.
- •
Passive stretching:
- •
Uses a therapist or other partner who applies a stretch to a relaxed joint or limb
- •
Requires excellent communication and slow, sensitive application of force
- •
Very efficient means of flexibility training
- •
Should be performed in the training room or in a physical or occupational therapy context
- •
Potentially increases risk of injury when performed without due caution
- •
- •
Static stretching
- •
A steady force for a period of 15 to 60 seconds is applied.
- •
Easiest and safest type of stretching
- •
Associated with decreased muscle soreness after exercise
- •
- •
Ballistic stretching
- •
Uses the repetitive, rapid application of force in a bouncing or jerking maneuver
- •
Momentum carries the body part through the range of motion until muscles are stretched to their limits.
- •
Less efficient than other techniques because muscles contract during these conditions to protect from overstretching
- •
A rapid increase in force can cause injury.
- •
This type of stretching has been largely abandoned as a training technique.
- •
Neuromuscular Facilitation
- •
Seeks to improve function through improved efficiency of the interplay between the nervous and musculoskeletal systems
- •
Neuromuscular facilitation techniques in flexibility training:
- •
Isometric or concentric contraction of the musculotendinous unit followed by a passive or static stretch
- •
Prestretch contraction of muscle facilitates relaxation and flexibility.
- •
Examples include hold-relax and contract-relax techniques
- •
Plyometrics
- •
Performance of brief explosive maneuvers consisting of an eccentric muscle contraction followed immediately by a concentric contraction
- •
This technique is primarily employed in the training of athletes.
- •
Should be approached with caution under the supervision of a trained therapist and begun at an elementary level
- •
Some studies demonstrate a decreased risk of serious injury during sports activity among athletes who receive plyometric training (e.g., reduction in the incidence of knee injuries in female athletes participating in a jump training program).
Proprioceptive Training
- •
Background:
- •
Proprioceptive deficits have been shown to result from and predispose to injury.
- •
Impairment of joint proprioception is believed to influence progressive joint deterioration associated with both rheumatoid arthritis and osteoarthritis.
- •
Proprioceptive exercises seek to improve joint position sense and thereby prevent injury.
- •
For example, a tilt or wobble board is commonly used after ankle ligamentous injury to reduce the incidence of recurrence.
- •
Exercise Prescription
- •
A prescription for therapeutic exercise with a therapist should always include the following components:
- •
Diagnosis
- •
Frequency of treatment (i.e., number of sessions per week)
- •
Specific exercises required
- •
Precautions (includes restrictions on weight bearing and limb movement, as well as identification of significant tissue damage or other factors that may interfere with performance of specific exercises)
- •
Contraindicated exercises or modalities (should include any specific motions, positions, or modalities that should be avoided to ensure appropriate tissue healing and patient safety without incurring further injury)
- •
- •
Ideally, individual exercises are further defined by:
- •
Mode: specific type of exercise (e.g., closed chain quadriceps strengthening)
- •
Intensity: relative physiologic difficulty of the exercise (this is often best described in terms of the patient’s rating of perceived exertion, ranging from very light to very hard)
- •
Duration: length of an exercise session
- •
Frequency: number of sessions per day/week
- •
Progression: increase in activity expected over the course of training
- •
Modalities: Heat, Cold, Pressure, Electrotherapy
- •
Physical agents: use of physical forces to produce beneficial therapeutic effects (see Fig. 4.1 )
Heat
Superficial Heat Application
- •
Hot packs (hydrocollator)
- •
Transfer of heat energy by conduction
- •
Application: silicate gel in a canvas cover
- •
When not in use, packs are kept in thermostatically controlled water baths at 70 to 80°C.
- •
Used in terry cloth insulating covers or with towels placed between the pack and the patient for periods of 15 to 20 minutes
- •
Advantages: low cost, easy use, long life, and patient acceptance
- •
Disadvantages: difficult to apply to curved surfaces
- •
Safety: One should never lie on top on the pack because it is more likely to cause burns.
- •
Towels should be applied between the skin and the hydrocollator pack.
- •
- •
Paraffin baths
- •
Heat primarily by conduction: liquid mixture of paraffin wax and mineral oil
- •
Helpful in the treatment of scars and hand contractures
- •
Temperatures (52 to 54°C) are higher than hydrotherapy (40 to 45°C) but are tolerated well due to the low heat capacity of the paraffin/mineral oil mixture and lack of convection.
- •
Treatments may include dipping, immersion, or, occasionally, brushing onto the area of treatment for periods of 20 to 30 minutes.
- •
Safety: Burns are the main safety concern with paraffin treatment.
- •
Visual inspection is important: The paraffin bath should have a thin film of white paraffin on its surface or an edging around the reservoir.
- •
Diathermy (Deep Heating)
- •
Deep heating agents (diathermies) raise tissue to therapeutic temperatures at a depth of 3.5 to 7 cm.
- •
Used for analgesic effects, decreasing muscle spasms, enhancing local blood flow, and increasing collagen extensibility
- •
- •
Deep heating modality: therapeutic ultrasound (US)
- •
US is defined as sound waves at a frequency greater than the threshold of human hearing (frequencies >20 kHz). Therapeutic US uses sound waves to heat tissues. A wide range of frequencies are potentially useful, but in the United States, most machines operate between 0.8 and 1 MHz.
- •
US penetrates soft tissue well and bone poorly; the most intense heating occurs at the bone–soft tissue interface.
- •
Treatments are relatively brief (5 to 10 minutes) and require constant operator attention.
- •
Indications for therapeutic US:
- •
Tendonitis, bursitis, muscle pain and overuse, contractures, inflammation, trauma, scars, and keloids
- •
Fractures: low-intensity US (e.g., 30 mW/cm 2 ) accelerates bone healing and is approved by the U.S. Food and Drug Administration for the treatment of some fractures.
- •
- •
Therapeutic US is typically avoided in the acute stages of an injury due to concerns that it may aggravate bleeding, tissue damage, and swelling.
- •
Therapeutic US contraindications:
- •
Fluid-filled areas (i.e., eye and the pregnant uterus), growth plates, inflamed joints, acute hemorrhages, ischemic tissue, tumor, laminectomy site, infection, and implanted devices such as pacemakers and pumps
- •
US is relatively contraindicated near metal plates or cemented artificial joints because the effects of localized heating or mechanical forces on prosthesis-cement interfaces are not well known.
- •
- •
Phonophoresis
- •
US may be used to deliver medication into tissues. The medication is mixed into a coupling medium, and US is used to drive (phonophorese) the material through the skin.
- •
Corticosteroids and local anesthetics are most frequently used in the treatment of musculoskeletal conditions.
- •
- •
Therapeutic Cold or Cryotherapy
- •
Superficial only
- •
Used for analgesic effects, reduction of muscle spasm, decreasing inflammation, decreasing muscle spasticity/hyperactivity, vasoconstriction (reduction in local blood flow and associated edema)
- •
Ice massage used for treatment of localized, intense musculoskeletal pain (e.g., lateral epicondylitis)
- •
General indications:
- •
Acute musculoskeletal trauma
- •
Pain
- •
Muscle spasm
- •
Spasticity
- •
Reduction of metabolic activity
- •
- •
General contraindications and precautions:
- •
Impaired circulation (i.e., ischemia, Raynaud phenomenon, peripheral vascular disease), hypersensitivity to cold, skin anesthesia, local infection
- •
- •
Methods of application:
- •
Ice packs and compression wraps are most common.
- •
Sessions typically last 20 minutes.
- •
Ice massage is a vigorous approach suitable for limited portions of the body. A piece of ice is rubbed over the painful area for 15 to 20 minutes.
- •
Iced whirlpools cool large areas vigorously.
- •
Vapocoolant and liquid nitrogen sprays produce large (as much as 20°C), rapid decreases in skin temperature and are used at times to produce superficial analgesia as well as in spray and stretch treatments.
- •
- •
Trauma application:
- •
Cooling applied soon after trauma may decrease edema, metabolic activity, blood flow, compartmental pressures, and tissue damage, and accelerate healing.
- •
Rest, ice, compression, and elevation are the mainstays of treatment.
- •
Cyclic ice application is often recommended (e.g., 20 minutes on, 10 minutes off) for 6 to 24 hours.
- •
- •
Contrast baths
- •
Two water-filled reservoirs, warm (43°C) and cool (16°C); alternate soaks; duration varies according to treatment protocol
- •
Used for desensitization and vasogenic reflex effects
- •
Mostly used on hands or feet; typical indications include rheumatoid arthritis and sympathetically mediated pain (reflex sympathetic dystrophy)
- •
Traction
- •
Technique used to stretch soft tissues and to separate joint surfaces or bone fragments by the use of a pulling force.
- •
Based on available medical evidence, therapeutic use of spinal traction is generally limited to the cervical spine.
- •
The efficacy of lumbar traction is controversial.
- •
Traction has been shown to lengthen the intervertebral space up to 1 to 2 mm, but the lengthening is transient.
- •
Decreases muscle spasm, possibly by inducing fatigue in the paravertebral musculature
- •
May decrease neuroforaminal narrowing and associated radicular pain
- •
The patient should be positioned in 20 to 30 degrees of cervical flexion during traction to optimize the effect on the neural foramina.
- •
Therapeutic benefit is usually obtained with 25 pounds of traction (this includes the 10 pounds required to counterbalance the weight of the head).
- •
The duration of a treatment session is typically 20 minutes.
- •
The best results are obtained when a trained therapist administers manual traction in a controlled setting.
- •
Home cervical traction devices can be used (these typically use a pulley system over a door, and a bag filled with 20 pounds of sand or water).
- •
Home cervical traction devices should not be used without previous training and observation by a trained therapist or physician.
- •
Heat (hot packs) is helpful in decreasing muscle contraction and maximizing the benefit of treatment.
- •
Contraindications:
- •
Cervical ligamentous instability resulting from conditions such as rheumatoid arthritis, achondroplastic dwarfism, Marfan syndrome, or previous trauma
- •
Documented or suspected tumor in the vicinity of the spine
- •
Infectious process in the spine
- •
Spinal osteopenia
- •
Pregnancy
- •
- •
Cervical spinal traction should not be administered with the neck in extension, particularly in patients with a history of vertebrobasilar insufficiency.
Therapeutic Massage
- •
Causes therapeutic soft-tissue changes as a direct result of the manual forces exerted on the patient by a trained therapist
- •
Specific techniques can be helpful for musculoskeletal patients:
- •
Deep friction massage
- •
Used to prevent and break up adhesions after muscle injury
- •
Friction is applied transversely across muscle fibers or tendons.
- •
- •
Soft-tissue mobilization
- •
Forceful massage performed with the fascia and muscle in a lengthened position
- •
Effective as an adjunct to passive stretching in the treatment and prevention of contractures
- •
- •
Myofascial release
- •
Applies prolonged light pressure specifically oriented with regard to fascial planes
- •
Typically combined with passive range of motion techniques to stretch focal areas of muscle or fascial tightness
- •
- •
Contraindications:
- •
Should not be performed in patients with known malignancies, open wounds, thrombophlebitis, or infected tissues
- •
Electrotherapy
- •
Transcutaneous electrical nerve stimulation (TENS)
- •
Most common direct therapeutic application of electrical current
- •
Used for its analgesic properties
- •
The unit uses superficial skin electrodes to apply small electrical currents to the body.
- •
Theorized to provide analgesia via the gate control theory of pain, in which stimulation of large myelinated afferent nerve fibers block the transmission of pain signals by small, unmyelinated fibers (C, A delta) at the spinal cord level
- •
Signal amplitudes generally do not exceed 100 mA.
- •
With initiation of treatment, TENS use is typically taught and monitored by a physical therapist. Once the patient is competent and confident in using the device (electrode placement, stimulator settings, duration of treatments), the unit can be used independently, outside the medical or therapy setting.
- •
Common indications include posttraumatic/postsurgical pain, diabetic neuropathic pain, chronic musculoskeletal pain, peripheral nerve injury, sympathetically mediated pain/reflex sympathetic dystrophy, and phantom limb pain.
- •
- •
Iontophoresis
- •
Uses electrical fields to drive therapeutic agents through the skin into underlying soft tissue
- •
Treatments in the musculoskeletal patient population typically use antiinflammatory agents and/or local anesthetics.
- •
Conditions commonly treated include plantar fasciitis, tendinitis, and bursitis.
- •
Most physical therapists are trained in this technique, although not all have access to the necessary equipment.
- •
It is worth noting that, in most cases, injection enables a more efficient delivery of a greater concentration of the therapeutic agent in question.
- •
- •
Electrical stimulation (E-stim)
- •
At higher intensities than those used in TENS, E-stim can be used to maintain muscle bulk and strength.
- •
Useful for immobilized limbs and for paretic muscles after nerve injury.
- •
Evidence does not suggest that E-stim can strengthen otherwise healthy muscle.
- •
Relative contraindications to E-stim include implanted or temporary stimulators (pacemakers, intrathecal pumps, spinal cord stimulators, etc.), congestive heart failure, pregnancy, skin sensitivity to electrodes, and actively healing wounds near the stimulation site. Stimulation over the carotid sinus is also highly discouraged due to the propensity for vagal response.
- •
Orthoses
- •
An orthosis is an external device that is worn to restrict or assist movement. Examples include braces and splints.
- •
Orthoses are typically prescribed and used for one or more of the following reasons:
- •
To rest or immobilize the body part: reduce inflammation, prevent further injury
- •
To prevent contracture: minimize loss of range of motion in a joint or limb
- •
To correct deformity: typically in conjunction with therapy or surgery
- •
To promote exercise: encourage strengthening of certain muscles and/or correct muscle imbalances
- •
To improve function
- •
Orthoses can be subdivided into static and dynamic devices.
- •
Static orthoses keep underlying body parts from moving, thereby encouraging rest and healing via immobilization while preventing or minimizing deformity.
- •
Dynamic orthoses have internal or external power sources that encourage restoration and/or control of joint movements.
- •
- •
Orthoses are often named for the body parts that they incorporate (e.g., ankle-foot orthosis and wrist-hand orthosis).
- •
Prescriptions for orthotics should include the type (defined by incorporated limb segments/body parts) and a static/dynamic classification. If a dynamic orthosis is to be used, the prescription should specifically identify the motion(s) to be assisted or inhibited.
- •
Prefabricated, off-the-shelf orthotics can be effectively used in the treatment of most orthopedic injuries. Frequently encountered examples include knee and ankle braces prescribed for ligamentous injury or wrist splints for carpal tunnel syndrome.
- •
In special populations (e.g., hand trauma, nerve injury, partial limb loss, severe deformity), orthoses should be custom fitted by an orthotist or an appropriately trained occupational therapist.
- •
Orthotic use should generally be restricted to injured or dysfunctional limbs. Prophylactic bracing of joints is controversial.
- •
Indications for orthoses include:
- •
Trauma (e.g., fracture, joint sprain)
- •
Surgery (e.g., tendon repair, joint reconstruction)
- •
Central or peripheral nervous system pathology (e.g., weakness, spasticity)
- •
Painful disorders (e.g., rheumatoid arthritis, carpal tunnel syndrome)
- •
- •
Orthoses and sports
- •
There is no compelling evidence in the literature to support the use of prophylactic knee bracing in football players. In fact, both the American Academy of Pediatrics and the American Academy of Orthopaedic Surgeons have advised against the routine use of prophylactic knee bracing in football, in part due to data that actually showed an increase in anterior cruciate ligament injuries in brace wearers.
- •
There is some evidence that use of a semirigid ankle orthosis can decrease the risk of ligamentous injury in athletes, particularly those with a history of sprain.
- •
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
