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Chapter 56 Physical Therapy

Manual of Rheumatology and Outpatient Orthopedic Disorders


Chapter 56 Physical Therapy

Sandy B. Ganz and Louis L. Harris

Goals of physical therapy
Evaluation
Components of treatment
Therapeutic exercise
Physical agents (modalities)
General guidelines for rehabilitation of specific rheumatologic disorders and areas of the body
Appendix 56-1

Management of the physical therapy of 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:

  1. Preventing disability.
  2. Restoring function.
  3. Relieving pain.
  4. Educating the patient.

II. Evaluation. Before these goals can be achieved, a thorough physical therapy evaluation is performed, which includes the following:

  1. Functional assessment
    1. Bed mobility. Observe the patient
      1. Turn over from a supine position to the side and then to a prone position.
      2. Move up and down in bed.
      3. Move from a supine to a sitting position.
    2. Transfer status. Observe the patient transfer to and from various surfaces (i.e., bed, chair , and toilet ).
    3. Gait analysis
      1. Observational. Watch the patient ambulate with or without assistive devices on level surfaces and stairs.
      2. Instrumented, with a foot switch stride analyzer or computerized video analysis.
  2. Range of motion (ROM) assessment of all joints
  3. Strength assessment
    1. Manual muscle test of trunk, neck, and proximal and distal muscles to determine weak musculature.
    2. Instrumental biomechanical muscle test.
    3. Isometric/isokinetic objective strength measurement recorded to selected muscle groups performed with an isokinetic dynamometer (i.e., Cybex, 1 Lido 2 ).
  4. Posture assessment. Observe the patient both standing and ambulating during functional activities.
  5. Respiratory status. Chest evaluation consists of the following:
    1. Auscultation.
    2. Chest expansion.
    3. Description of cough.
    4. Inspirometry.

III. Components of treatment. Once 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, modalities, functional activities, and perhaps the most important aspect of treatment, patient education (Table 56-1).



Table 56-1. Components of treatment in musculoskeletal and rheumatic disorders



IV. Therapeutic exercise

  1. Goals of exercise
    1. Maintain or improve ROM.
    2. Strengthen weak muscles.
    3. Increase endurance .
    4. Enhance respiratory efficiency through breathing exercises.
    5. Improve balance and coordination.
    6. Enable joints to function better biomechanically (Table 56-2).


      Table 56-2. Treatment goals



  2. Therapeutic exercises used in the treatment of musculoskeletal and arthritic conditions are as follows :
    1. Range of motion. Excursion of a joint through available range.
    2. Passive range of motion (PROM). Without active muscle contraction about the joint. The joint is moved through available ROM by another person, object, or other extremity .
    3. Active assisted ROM (AAROM). The patient performs ROM exercises with the assistance of another person, object, or extremity.
    4. Active ROM (AROM). The patient performs ROM exercises without assistance.
    5. Active resisted ROM (ARROM). The patient performs ROM exercises with some form of resistance (manual or mechanical resistance, elastic bands, or weights).
    6. Strengthening exercises
      1. Static. Isometric exercises in which the patient contracts or tightens the muscle around the joint without producing any joint motion.
      2. Dynamic. Some form of resistance is used, either manually or with an externally applied load (i.e., weight).
        1. Isotonic. Concentric or eccentric contractions of variable speed with use of a set weight or resistance throughout the full ROM.
        2. Isokinetic. A concentric or eccentric contraction at a set speed with use of a set weight or resistance throughout the full ROM.
  3. General instructions to patients
    1. Use pain as your guide. Pain or discomfort should not last longer than 1 hour after exercise.
    2. Make the exercise part of your daily routine.
    3. Try to do a complete set of exercises at least twice a day at a time convenient to you.
    4. Prescribed medication and applications of heat or cold may precede exercises to enhance relaxation and decrease pain.
    5. Perform only those exercises given to you by your physician or therapist.
    6. Perform exercises on a firm surface.
    7. Exercise slowly with a smooth motion. Do not rush.
    8. Avoid holding your breath while exercising.
    9. Modify the exercise regimen during an acute attack, 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.

  1. Superficial heating
    1. Hot packs contain a silica gel that absorbs water. These packs are kept in thermostatically controlled water at 175F. The literature demonstrates that hot-pack effectiveness reached at a depth of 1 cm increases skin temperature by 10C.
      1. Indications . Relief of pain, muscle spasm, decreased ROM.
      2. Contraindications. Sensory involvement, open lesions, malignancy.
    2. Paraffin bath. Paraffin wax is mixed with mineral oil and maintained at 118 to 126F. 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.
      1. Indications. Relief of pain, muscle spasm, decreased ROM.
      2. Contraindications. Sensory involvement, open lesions.
    3. Hydrotherapy ( whirlpool , therapeutic pool). Water is maintained at 94 to 96F. Coupled with its ability to eliminate the effect of gravity (buoyancy), heated water can provide excellent moist heat and exercise simultaneously . Whirlpools for individual limbs are also beneficial to promote wound cleaning and healing. Hydrotherapy is a related form of heat treatment.
      1. Indications
        1. Muscle spasms, relief of pain, decreased ROM.
        2. Whirlpool. Open lesions.
      2. Contraindications
        1. Patients with decreased heat tolerance.
        2. Therapeutic pool. Open lesions, urinary tract infection, diarrhea; extreme care should be taken in patients with cardiopulmonary involvement.
    4. 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.
      1. Indications. Relief of pain, muscle spasm, decreased ROM.
      2. Contraindications. Sensory involvement, open lesions.
  2. 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 intraarticular temperature of the hip joint rises by 1.43C after a properly applied therapeutic dose. Typical patient exposure is 1 to 2 W/cm 2 for 5 to 10 minutes. Ultrasound can also be combined with electrical stimulation.
    1. Indications. Pain relief, muscle spasm, and decreased ROM.
    2. Contraindications. Local malignancy, unstable vertebrae (after laminectomy), pregnancy , spinal cord disease; ultrasound should not be applied directly over the eyes, brain, or spinal cord.
  3. Cold. Cryotherapy is very effective in promoting vasoconstriction, thus decreasing restricted joint ROM resulting from an inflammatory process and aiding with pain relief. Cold modalities include ice packs, frozen gel packs (cold packs), and ice massage.
    1. Indications. Swelling and inflammatory reactions , spasms, contusions, traumatic arthritis.
    2. Contraindications. Decreased sensation , sensitivity to cold, Raynaud's phenomenon .
  4. Mobilization generally means moving joints, including spinal joints, through an ROM designed to stretch the joint capsule and, in some instances, move the joint beyond the norm of its associated muscles. The technique is primarily used in patients with musculoskeletal pain.
    1. Indications. Joint hypomobility, decreased proprioception, restriction of accessory joint motion, ligamentous tightness, adhesions, joint dysfunction.
    2. Contraindications. Ligamentous laxity, unstable joints.
  5. 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.
    1. Indications. Muscle spasm, decreased extensibility of soft tissues.
    2. Contraindications. Cellulitis, malignancy, phlebitis.
  6. Electrical stimulation is one of the oldest and most effective physical agents. Its purpose is to contract or reeducate muscle, relax muscle spasms, stimulate nerves to promote motion and pain relief, and generally improve circulation. A wide range of 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.
    1. Indications. Muscle reeducation, denervated muscles, pain relief, decreased general circulation, decreased muscle strength during immobilization, decreased ROM.
    2. Contraindications. Phlebitis, demand pacemakers, hemorrhage, recent fractures.
  7. 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 per week on average for 20 minutes.
    1. Indications. Muscle spasm, mild nerve compression, vertebral osteoarthritis .
    2. Contraindications. Unstable vertebrae, local malignancy, spinal cord disease, osteoporosis, osteomyelitis, pregnancy.

VI. General guidelines for rehabilitation of specific rheumatologic disorders and areas of the body

  1. The systemic rheumatic diseases, including rheumatoid arthritis, juvenile rheumatoid 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, Reiter's syndrome, and colitic arthropathies should be treated in a similar manner to that in rheumatoid arthritis and juvenile rheumatoid arthritis, as noted below. The proper balance between rest and exercise is the key for successful treatment.
    1. Aims of treatment
      1. Preserve or increase functional level.
      2. Decrease pain.
      3. Improve joint mechanics.
      4. Decrease joint inflammation .
      5. Improve ROM, strength, and endurance.
    2. Therapy
      1. Active inflammatory disease
        1. Rest
          1. Systemic (body) rest.
          2. Articular (joint) rest.
          3. Emotional rest.
        2. Joint protection
          1. Splinting.
          2. Assistive devices.
          3. Ambulatory aids.
        3. Techniques for relaxation and stress reduction.
        4. Patient education.
      2. Pain
        1. Superficial heat.
        2. Cryotherapy.
        3. TENS.
      3. Decreased range of motion
        1. PROM.
        2. AAROM.
        3. Stretching.
      4. Weakness. Muscle strengthening with the following:
        1. Isometric.
        2. Isotonic.
        3. Isokinetic.
      5. Ambulation
        1. Ambulatory aid.
        2. Orthotic.
      6. Decreased endurance techniques
        1. Energy conservation.
        2. Aerobic exercise program.
      7. Difficulty with activities of daily living (ADL)
        1. Adaptive equipment.
        2. Assistive devices.
  2. Spinal and sacroiliac disease in ankylosing spondylitis and other seronegative spondyloarthropathies. Maintenance of an erect posture is critical for all ADL, including sitting, standing, walking, and sleeping. Patients should sleep in a prone or supine position on a firm mattress with one small pillow or no pillow. (Pillows under the knees should be avoided at all times to prevent flexion deformities.) Breathing and chest expansion exercises are extremely important. In addition, stretching exercises that facilitate extension of the neck, spine, and peripheral joints should be taught and diligently followed.
    1. Aims of treatment
      1. Facilitate skeletal mobility.
      2. Prevent contractures.
    2. Exercises. Figure 56-1, Figure 56-2, Figure 56-3, Figure 56-4, Figure 56-5, Figure 56-6 and Figure 56-7 are examples of appropriate exercises used in the treatment of patients with back involvement in ankylosing spondylitis and other seronegative spondyloarthropathies.


      FIG. 56-1. Chest mobilization (inspiration). Bend away from right side during inspiration.




      FIG. 56-2. Chest mobilization (expiration). Bend toward right side during expiration. Push fisted hand into the lateral aspect of chest as you bend toward the right side.




      FIG. 56-3. Belt exercises for lateral costal expansion. Reinforce lateral costal expansion during inspiration. Assist with pressure along the rib cage during expiration. (Reprinted from the Saunders Group , Inc. 1996.)




      FIG. 56-4. Deep breathing with an incentive inspirometer. For inspiration, use right side up and breathe in. For expiration, use upside down and breathe out.




      FIG. 56-5. Pectoral stretching (shoulder blade pinch ). Stand or sit straight and tall. Pull your shoulders back, squeezing your shoulder blades together.




      FIG. 56-6. Pectoral stretching (hands behind head). Stand or sit. Place your hands behind your head with elbows in front. Move your elbows back as far as possible.




      FIG. 56-7. Pectoral stretching (standing). Stand facing a corner. Put the palms of your hands on the wall. Slowly lean your chest into the corner. (Reprinted from the Saunders Group, Inc. 1996.)



  3. Osteoporosis. Weight- bearing activities such as brisk walking, biking, jogging, and working with a selected group of exercise machines can be an effective way to maintain and strengthen muscles while stimulating bone formation. These types of exercises and activities are referred to as impact-loading or weight-bearing exercises. An exercise program should consist of postural retraining , education in proper body mechanics, deep breathing, stretching, strengthening, and impact-loading activities. Extreme caution should be taken during forward flexion exercises of the spine because of the longer lever arm produced with increased flexion. An osteoporotic vertebral body may not be able to tolerate this load, and compression fracture with wedging may occur.
    1. Aims of treatment
      1. Strengthen abdominal muscles and extensor musculature of the spine.
      2. Pectoral stretching.
      3. Increase weight-bearing activities of lower extremities.
    2. Exercises. See Fig. 56-18, Fig. 56-19 and Fig. 56-20 for appropriate exercises used in the treatment of patients with osteoporosis.


      FIG. 56-18. Lying on your back with knees bent, press the small of your back into the bed. Tighten your abdominal and buttock muscles.




      FIG. 56-19. Knees to chest. Lying on your back, slowly bring both knees up to your chest.




      FIG. 56-20. Partial sit-ups. Lie on your back with knees bent and arms crossed. With chin tucked, slowly lift your head and shoulders toward your knees.



  4. Polymyositis and dermatomyositis. The degree of muscle weakness can be quite variable because muscle destruction during the acute inflammatory phase is variable, as is muscle regeneration during the recovery phase. Patients exhibit difficulty climbing stairs, rising from low surfaces, and performing various aspects of ADL. The emphasis of rehabilitation is on progressive proximal muscle-strengthening exercises. Vigorous and injudicious exercise of any type may be associated with a rise in serum enzyme levels, increased fatigue, and a decrease in function and strength. Therefore, a balance between rest and exercise must be achieved. Overall, disease assessment involves a myositis functional assessment (Appendix 56-1), a biomechanical muscle test with isokinetics (Cybex or Lido), and monitoring of creatinine kinase. Physical therapy management and type of exercise are determined from the results of the above tests. It remains controversial whether exercise should be avoided during an increase in creatine kinase levels or overall disease activity.
    1. Aims of treatment
      1. Increase proximal muscle strength.
      2. Improve function.
      3. Decrease pain.
    2. Exercises. See Fig. 56-10, Fig. 56-11, Fig. 56-12, Fig. 56-13, Fig. 56-14, Fig. 56-15, Fig. 56-16, Fig. 56-17 and Fig. 56-23, Fig. 56-24, Fig. 56-25, Fig. 56-26, Fig. 56-27, Fig. 56-28, Fig. 56-29, Fig. 56-30, Fig. 56-31, Fig. 56-32 for appropriate exercises used in the treatment of patients with polymyositis and dermatomyositis.


      FIG. 56-10. Neck flexion. Sitting or standing with your back straight, bend your head forward and tuck your chin in toward your chest.




      FIG. 56-11. Neck rotation. Sitting or standing with your back straight, tuck your chin in toward your chest. Look over your right shoulder, then over your left shoulder.




      FIG. 56-12. Neck lateral flexion. Sitting or standing with your back straight, tuck your chin in. Bend your head so that your ear is moving toward your shoulder.




      FIG. 56-13. Shoulder flexion. Lie on your back while holding a rod, with one hand at the top and the other near the bottom. Pull the rod back toward your head until your arm holding onto the top is straight. Return to starting position. Switch hands and repeat. (Reprinted from the Saunders Group, Inc. 1996.)




      FIG. 56-14. Diagonal shoulder flexion. Keeping your elbow straight, bring your left arm down across your body with your thumb pointing toward your right hip. (Reprinted from the Saunders Group, Inc. 1996.)




      FIG. 56-15. Pendulum exercises. Stand holding onto a sturdy chair with your uninvolved arm. Bend forward at the waist and bend your knees to help protect your back. Let your involved arm hang limp. Keep your shoulder relaxed , and use your body motion to swing your arm in a circle. (Reprinted from the Saunders Group, Inc. 1996.)




      FIG. 56-16. Shoulder rotation exercise. While standing, hold a stick or towel as illustrated , with the uninvolved arm over your shoulder and holding the top and the involved arm holding the bottom. Slowly pull the top of the stick or towel with your uninvolved arm as shown. (Reprinted from the Saunders Group, Inc. 1996.)




      FIG. 56-17. Stand with your arm at your side and palm facing forward. (This can also be done while lying on your back with palm up.) Raise your weak arm out to the side and up toward your ear. Keep your elbow straight and palm facing forward.




      FIG. 56-23. Leg lifts while lying on side. Lie on your side, weak leg on top. The lower leg should be bent to help balance. Keep the top leg straight and in line with your body. Stay on your side and lift your leg up toward the ceiling. Do not bring your leg forward. Slowly lower it.




      FIG. 56-24. Hip external rotation. Lying on your back with entire leg straight, roll entire leg outward.




      FIG. 56-25. Hip internal rotation. Lying on your back with your leg straight, roll entire leg inward.




      FIG. 56-26. Prone hip extension. Lie on your stomach with both legs straight. Lift one leg up toward the ceiling, keeping your knee straight. Slowly lower it. (Reprinted from the Saunders Group, Inc. 1996.)




      FIG. 56-27. Hip flexion. Sitting on stairs or a chair with both feet flat on the floor, raise one knee up toward your chest as high as possible. Slowly lower it. (Reprinted from the Saunders Group, Inc. 1996.)




      FIG. 56-28. Bridging exercise. Lie on back with knees bent and arms straight. Pull toes up toward the ceiling and push heels into the floor. Tighten buttocks and slowly lift up until hips are fully extended. Return to the starting position and repeat. (Reprinted from the Saunders Group, Inc. 1996.)




      FIG. 56-29. Gluteal contraction. Lying prone, with pillow under abdomen, bend one knee and lift toward ceiling. Slowly lower to starting position and repeat. (Reprinted from the Saunders Group, Inc. 1996.)




      FIG. 56-30. Lie on your back with your weak leg as straight as possible. Bend the other leg as illustrated to protect your back. Tighten your thigh muscle. Raise your leg while keeping it straight. Keep your thigh muscles tight and leg straight as you slowly lower it.




      FIG. 56-31. Quad set. Half sitting with your involved leg straight, bend your other leg as illustrated. Tighten the muscles on the top of your thigh. This will make your knee cap move toward your hip. (Reprinted from the Saunders Group, Inc. 1996.)




      FIG. 56-32. Terminal knee extension. Lying on your back with a firm pillow under your involved knee, slowly lift your foot up. Your knee should remain on the pillow. Try to keep your leg as straight as possible. (Reprinted from the Saunders Group, Inc. 1996.)



  5. Scleroderma (progressive systemic sclerosis). Prevention of joint contractures is the primary goal in the physical therapy management of patients with progressive systemic sclerosis. An ROM program designed to stretch soft-tissue contractures should be instituted immediately. Passive stretching of all joints, soft-tissue mobilization, and massage are highly recommended. In addition, paraffin is used on the hands in an effort to decrease pain and increase finger ROM. Skin tightness around the jaw is extremely common. A series of temporomandibular joint exercises are routinely performed to increase jaw excursion. Deep breathing, use of incentive inspirometer, and mobilization of the chest wall to increase chest expansion should be incorporated into the physical therapy program. To assist with feeding and chewing activities, speech therapy is often instituted.
    1. Aims of treatment
      1. Increase ROM.
      2. Prevent contractures.
      3. Improve chest expansion.
    2. Exercises. Figure 56-1, Figure 56-2, Figure 56-3, Figure 56-4, Figure 56-8, and Figure 56-9 are appropriate exercises used in the treatment of progressive systemic sclerosis, in addition to PROM for all joints.


      FIG. 56-8. Jaw excursion. Hold an apple in front of your mouth. Gradually open your mouth, sliding your top and bottom teeth on the apple and increasing the jaw's range of motion.




      FIG. 56-9. Lateral jaw excursion. Smile so that your top and bottom teeth are touching. Move your mouth from right to left.



  6. Neck pain
    1. Aims of treatment
      1. Promote a decrease in pain.
      2. Increase muscle relaxation.
      3. Improve head and neck posture.
    2. Therapy
      1. The modalities available to the physical therapist include heat and electrical stimulation.
      2. Specific manual mobilization techniques include manual and motorized intermittent cervical traction, which provide muscle and soft-tissue stretching to promote relaxation of the neck and upper back and pain relief.
      3. An exercise program consisting of gentle active exercises progressing to isometric exercises in the supine position, or with the head supported, are generally beneficial in increasing circulation, decreasing muscular tension, and improving posture. Figure 56-10, Figure 56-11 and Figure 56-12 are examples of exercises used in the treatment of neck pain.
      4. An educational component should also be provided to ensure the following:
        1. Proper postural awareness.
        2. Body mechanics.
        3. Preventive measures, which include an explanation of home or work activities to be avoided or that may contribute to the patient's complaints (e.g., driving, computer terminal/typewriter operation, sleeping postures).
  7. Shoulder
    1. Aims of treatment
      1. Improve joint ROM.
      2. Increase muscle strength.
      3. Promote a decrease in pain.
    2. Therapy
      1. Exercise program. An ROM program initially consisting of manual joint mobilization and passive ROM should be instituted. As ROM increases, the patient is instructed in active exercise progressing to a strengthening program as tolerated. As the patient progresses, an individual program can be guided by the needs of the patient. Figure 56-13, Figure 56-14, Figure 56-15, Figure 56-16 and Figure 56-17 are examples of exercises used in the treatment of shoulder pain.
      2. Physical agents that can be an adjunct to the exercise program are various heat modalities and electrical stimulation to promote a decrease in pain. Cryotherapy may also be utilized following an exercise session to decrease any physiologic response to treatment.
      3. Patient education. It is essential that the patient be educated regarding the goals of physical therapy and be given a daily home exercise program. A pulley system is an excellent device to include in this program.
  8. Low back pain
    1. Aims of treatment
      1. Promote a decrease in pain.
      2. Increase muscle relaxation.
      3. Strengthen abdominal muscles.
      4. Normalize low back joint motion and posture.
    2. Therapy
      1. Physical agents (modalities) are available that can be incorporated to promote a decrease in pain. These include hot packs, ultrasound, and electrical stimulation. When indicated, passive joint and soft-tissue mobilization are also effective manual techniques to promote further decrease in pain, increase circulation, and aid in restoring normal joint motion.
      2. An exercise program consists of exercises designed to stretch the pelvis, low back, and hamstrings and to strengthen the abdominal muscles. As the patient progresses, an individualized program can be guided by the patient's tolerance and need. Figure 56-18, Figure 56-19, Figure 56-20, Figure 56-21, Figure 56-22, Figure 56-23, Figure 56-24, Figure 56-25, Figure 56-26, Figure 56-27 and Figure 56-28 are examples of exercises used in the treatment of low back pain.


        FIG. 56-21. Bobath exercise. Assume position as illustrated. While keeping your back level, raise one arm and opposite leg as shown. Repeat with opposite arm and leg. (Reprinted from the Saunders Group, Inc. 1996.)




        FIG. 56-22. Lower back strengthening. Lie on belly with forehead resting on floor or small towel roll. Raise head, shoulders, chest, belly, and hands off floor as shown. Return to starting position and repeat. (Reprinted from the Saunders Group, Inc. 1996.)



      3. Patient education. To restore function fully, the patient must be educated in preventive measures, including proper body mechanics, posture, and ADL.
  9. Hip
    1. Aims of treatment
      1. Increase muscle strength.
      2. Maintain ROM.
      3. Promote a decrease in pain. A painful hip usually results in limited motions , which can further produce joint contractures and gait deviations.
    2. Therapy
      1. Exercise program. The primary emphasis with muscle strengthening is to optimize the extensor and abductor groups. These muscles help to stabilize the joint and normalize gait. ROM activities associated with this strengthening program should concentrate on stretching the hip flexors and adductors and ensuring functional rotational ROM. See Fig. 56-23, Fig. 56-24, Fig. 56-25, Fig. 56-26, Fig. 56-27 and Fig. 56-28 for examples of exercises used in the treatment of hip pain.
      2. Heat modalities such as hot packs and ultrasound can be employed to complement the exercise program and promote pain relief.
  10. Knee
    1. Aims of treatment
      1. Increase ROM.
      2. Improve muscle strength of the quadriceps and hamstrings.
      3. Normalize ambulation and function.
      4. Promote a decrease in pain.
    2. Therapy
      1. A therapeutic exercise program should be established that concentrates on AROM and AAROM and progresses to muscle strengthening as tolerated. Many resistive exercise programs are available that utilize free weights and various types of exercise equipment. Isometric quadriceps sets and straight leg raising are excellent exercises to initiate quadriceps control, followed by an individualized program to meet the patient's specific needs. Figure 56-29, Figure 56-30, Figure 56-31 and Figure 56-32 are examples of exercises used in the treatment of knee pain.
      2. Physical agents. Various heat modalities and forms of electrical stimulation can be employed to complement the exercise program by promoting a decrease in pain before an exercise session. Cryotherapy can also be an essential part of a total program, depending on the patient's needs and response to treatment.
  11. Ankle. Treatment of the ankle during the acute stage focuses on the initial control of swelling. This is accomplished with rest, ice, compression, and elevation. If no severe instability is present, the patient may be referred to physical therapy.
    1. Aims of treatment
      1. Increase muscle strength and function.
      2. Increase and maintain ROM.
      3. Promote a decrease in pain.
      4. Normalize gait.
    2. Therapy. An isometric program progressing to active resistive exercises encompassing functional and weight-bearing activities is important. These help to improve balance and coordination, and aid in preparing the patient for gait training and normalizing the ankle motion during ambulation. Figure 56-33, Figure 56-34 and Figure 56-35 are examples of exercises used in the treatment of ankle pain.


      FIG. 56-33. Ankle plantar flexion and dorsiflexion, eversion and inversion. For plantar flexion and dorsiflexion, bring your toes down and then up toward your head. Also, try drawing an imaginary A. For eversion and inversion, push sole inward and then outward. Now, try drawing an imaginary B and C. (Reprinted from the Saunders Group, Inc. 1996.)




      FIG. 56-34. Heel cord stretching. Stand with the ball of your foot on a book. Hold onto a firm chair or surface. Try to place your heel on the floor. Gently lean forward, keeping your knee straight. Hold, then stand on your toes, and return to starting position. (Reprinted from the Saunders Group, Inc. 1996.)




      FIG. 56-35. Gastrocnemius (calf) stretch. Stand in front of a wall and bend one leg while keeping the other leg back. Lean forward and push against the wall and you will feel the stretch in your calf muscle, or gastrocnemius. (Reprinted from the Saunders Group, Inc. 1996.)




1 Cybex, Ronkonkoma, NY.
2 Loredan, Davis, CA.

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Suggested Readings

Banwell BF. Exercise and mobility in arthritis. Nurs Clin North Am 1984;19:605.

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Hicks JE. Exercise for patients with inflammatory arthritis. J Musculoskel Med 1989;6:40.

Hicks JE. Syllabus update for joint and connective tissue disease: scientific basis for the use of exercise for rheumatoid disease. In: Course supplements, Annual Meeting of the American Academy of Physical Medicine and Rehabilitation, 1988:39 (vol 1).

Kreindler H, et al. Effects of three exercise protocols on strength of persons with osteoarthritis of the knee. Top Geriatr Rehabilitation 1989;4:32.

Minor MA, et al. Efficacy of physical conditioning exercise in patients with rheumatoid arthritis and osteoarthritis. Arthritis Rheum 1989;32:1396.

Semble EL, Loeser RF, Wise CM. Therapeutic exercise for rheumatoid arthritis and osteoarthritis. Semin Arthritis Rheum 1990;20:32.

Stenstrom CH. Therapeutic exercise in rheumatoid arthritis. Arthritis Care Res 1994; 7:190.

Wegener ST, Belza BL, Gall EP, eds. Clinical care in the rheumatic diseases. Atlanta: American College of Rheumatology, 1996.

Yelen E, et al. The impact of rheumatoid arthritis and osteoarthritis: the activities of patients with rheumatoid arthritis and osteoarthritis compared to controls. J Rheumatol 1987;14:710.

Resources: Arthritis Self-Help Products

  1. Adaptability
    P.O. Box 515
    Colchester, CT
    1-800-243-9232
  2. Aids for Arthritis, Inc.
    3 Little Knoll Court
    Medford, NJ 08055
  3. American College of Rheumatology/Association of Rheumatology Health Professionals
    1998 Membership Directory
    Phone: 1-404-633-3777
    Fax: 1-404-633-1870
  4. Guide to Independent Living for People with Arthritis
    Arthritis Foundation
    1314 Spring Street, N.W.
    Atlanta, GA 30309
  5. Comfortably Yours
    61 West Hunter Avenue
    Maywood, NJ 07607
    1-201-368-0400
  6. Enrichments for Better Living
    145 Tower Drive
    P.O. Box 579
    Hinsdale, IL 60521
    1-800-323-5547
  7. Maddak, Inc.
    Pequannock, NJ 07440-19932
    1-201-628-7600
    1-800-443-4926
  8. The Osteoporosis Book 1993
    (life-style tips for healthy bones)
    Gwen Ellert. Trelle Enterprises
    305-1775 W. 10th Avenue
    Vancouver, British Columbia V6J 2A4, Canada
  9. Sammons-Preston
    P.O. Box 32
    Brookfield, IL 60513
    1-800-323-5547

Appendix 56-1

MYOSITIS FUNCTIONAL ASSESSMENT
NAME ____________________ DATE ____________________
THIS FORM IS DESIGNED TO EVALUATE LOWER EXTREMITY FUNCTION IN PATIENTS WITH MYOSITIS. ALL ACTIVITIES SHOULD BE RATED ON THE PATIENT'S ABILITY TO PERFORM A GIVEN TASK WITHOUT THE ASSISTANCE OF THE EXAMINER.

TRANSFER FROM SUPINE TO SITTING (5)

A. (5) Spontaneously, normal; on request, use of upper extremity is not required.
B. (4) Spontaneously, but use of upper extremity is required.
C. (3) Tentatively; use of upper extremity is required.
D. (2) Laboriously; props up on both elbows.
E. (1) Laboriously; rolls to side while lying and pushes to sitting with arms.
F. (0) Unable to assume sitting position.

TRANSFER FROM SITTING TO STANDING (4)

A. (4) Rises from low chair (knees 2 in. higher than hips) without use of arms or compensatory movements.
B. (3) Rises from standard chair (knees level with hips) spontaneously, without use of arms or compensatory movements.
C. (2) Rises from standard chair tentatively; must use arms.
D. (1) Rises from standard chair laboriously; use of upper extremity, compensatory movements, or both are required for transfers.
E. (0) Unable to assume standing posture from a standard chair.

RISING FROM A LOW BENCH (9 in.); to be evaluated only if scored A or B on transfers from sitting to standing (2)

A. (2) Able to sit and rise without difficulty; normal.
B. (1) Able to sit and rise, but with effort or difficulty.
C. (0) Unable to rise from a low bench.

STAIR CLIMBINGfour 6-in. steps (14) UP/DOWN

A. (7) (7) Reciprocal (step over step), normal; on request, no use of arms.
B. (6) (6) Reciprocal; on request, no use of arms, but deviations present.
C. (5) (5) Nonreciprocal; on request, no use of arms.
D. (4) (4) Reciprocal; use of one arm is required.
E. (3) (3) Reciprocal; use of two arms is required.
F. (2) (2) Nonreciprocal; use of one arm is required.
G. (1) (1) Nonreciprocal; use of two arms is required.
H. (0) (0) Unable to negotiate stairs.

COMMENTS

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Books@Ovid
Copyright 2000 by Lippincott Williams & Wilkins
Stephen A. Paget, M.D., Allan Gibofsky, M.D., J.D. and John F. Beary, III, M.D.
Manual of Rheumatology and Outpatient Orthopedic Disorders



Manual of Rheumatology and Outpatient Orthopedic Disorders (LB Spiral Manuals)
Manual of Rheumatology and Outpatient Orthopedic Disorders (LB Spiral Manuals)
ISBN: N/A
EAN: N/A
Year: 2000
Pages: 315

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