Physical Therapy for the Lower Extremity: What You and Your Patient Should Expect from Rehab

Transcription

1 1 Physical Therapy for the Lower Extremity: What You and Your Patient Should Expect from Rehab Thomas Clennell, PT, DPT, SCS Physical Therapist UCSF Benioff Children s Hospital Oakland Sports Medicine Center for Young Athletes 2 Disclosures I have nothing to disclose. 1

2 3 Goals Importance of expectation What to expect from Rehab Common interventions in Physical Therapy Top Sports Cases Anterior knee pain Ankle injury Why is Expectation Important? Factors relating to patient expectations are associated with both clinical outcomes, satisfaction with treatment, and influence of behavior. 1 Health care expectations can be positive or negative Most commonly defined as the general belief a clinical outcome will occur

3 5 Relationship Between Expectation and Musculoskeletal Pain Clinical studies have demonstrated an association between predicted expectation and outcomes related to the management of musculoskeletal pain conditions for: total joint arthroplasty 2 chronic pain 3 neck pain 4 shoulder pain 5 low back pain 6,7,8 These studies demonstrate that outcomes don t depend solely on the type of treatment provided, but also on individual attitudes and beliefs regarding the treatment. 1 6 So What Should the MD Expect? Good initial evaluation Detailed subjective Key physical exam components that are hands on and objectively measured A timely report back Treatments that address key areas Improving mobility of injured area and surround areas Movement retraining Strength and flexibility training Outcome measures that are functional for the individual with normative data. 3

4 7 What Your Patient Should Expect? Listening to their story, how they were injured, what their limitations are, what they can still do and what they want to get back to EXPECTATIONS. Hands on Evaluation, even over or at areas of pain. They should not expect to be pushed into pain. Functional assessment, how do they walk/move? How is their balance? What is their range? Goals that take into account what the patient wants! 8 What Your Patient Should Expect? Treatments addressing all of the deficits found, this includes: Soft tissue mobility, joint mobility Strength and power training Movement retraining Functional training Sport specific training Education and homework designed specifically for them 4

5 Common Treatments in Rehab Joint mobilization Soft tissue mobilization Strength training Proprioceptive training Functional/Movement training 9 10 Joint Mobility 9 What is it? A skilled passive movement of the articular surfaces to decrease pain and increased joint movement Why do it? Attempting to: Turn off nociceptors and decrease pain through Pain Gate Theory Improve joint hypomobility of capsular origin 5

6 11 Soft Tissue Mobility 10 What is it and why do it? Skilled hand movement intended to produce any or all of the following effects: Improve tissue extensibility Increase range of motion of the joint complex Mobilize or manipulate soft tissues and joints Induce relaxation Change muscle function Modulate pain Reduce soft tissue swelling, inflammation or movement restriction 12 Instrument Assisted Soft Tissue Mobility What is it and why do it? Skilled treatment using a tool to detect and treat fascial restrictions, encourage rapid localization and effectively treat areas exhibiting soft tissue fibrosis, chronic inflammation or degeneration. Can be performed with handheld tool or cups to perform Myofascial Decompression. These instruments break down fascial restrictions and scar tissue Promotes fully functional tissue. 6

7 13 Strength Training 11 What is it? Isolated strength training for injured muscles or general major muscle exercise programs. Why do it? Addresses injuries to the musculoskeletal system that results in skeletal muscle hypotrophy and weakness, loss of aerobic capacity and fatigability. 14 Proprioceptive Training What is it? A special type of training targeting the sensations of the deep organs and of the relationship between muscles and joints. 11 Why do it? Loss of proprioception occurs with injuries to ligaments, tendons, or joints, and also with immobilization. 12 7

8 Functional/Movement Training What is it? Movements based on real-world situational biomechanics. Involves multi-planar, multi-joint movements which place demand on the body s musculature and innervation. Why do it? Rehab must take into account and reproduce the activities and movements required when the patient returns to all their previous activities. 11 Optimize movement efficiency Stages of Rehab Stage 1 Protection, Mobilization, Walking Typically lasts 4-6 days Goals in this phase are to: Limit tissue damage Pain relief Control inflammatory response to injury Protection of injured area 8

9 17 Stages of Rehab Stage 2 Open/closed kinetic chain exercises and Proprioceptive training Lasts from day 5 to 8-10 weeks Goals of this phase: Joint range of motion and muscle conditioning Early motion promotes optimal alignment of collagen fibers Promotes tissue mobility 18 Stages of Rehab Stage 3 Sport specific drills and reconditioning Lasts from about day 21 to 6-12 months Goals for this phase: The start of conditioning process needed to return to full function. Identify and correct risk factors Reduce the possibility of re-injury 9

10 19 Stages of Rehab Stage 4 Maintenance and prevention of re-injury Relevant for athletes Goals in this phase: Transition of strengthening exercises to sport specific activity Return to Sport Top Sports Cases How it Really Works Anterior Knee Pain Initial Phase: Restore motion and reduce swelling Soft tissue mobilization and patellofemoral joint mobilization as required effleurage Remote strengthening, glutes and core Gentle Stretching Taping 20 10

11 21 Top Sports Cases How it Really Works Anterior Knee Pain Intermediate Phase: Local strengthening: Quadriceps and hamstrings to address any atrophy Advance core and gluteal strengthening Soft tissue to maintain mobility of joint and remodeling soft tissue; deep tissue and MFD Proprioceptive training to enhance neuromuscular control Functional training Squat progression Gait training 22 Top Sports Cases How it Really Works Anterior Knee Pain Advanced Stage Initiate conditioning program Advanced strengthening and movement training to remodel and create resiliency in new tissue and address mechanical/positional faults Plyometric training Agility training Soft tissue and joint mobilization to maintain proper functioning. Sport specific training 11

12 23 Top Sports Cases How it Really Works Ankle Sprain Initial Phase: Restore motion and reduce swelling at ankle Soft tissue mobilization, effleurage ROM Remote strengthening, glutes and core Glutes are secondary supporter of ankle position Gentle Stretching Taping Brace wear 24 Top Sports Cases How it Really Works Ankle Sprain Intermediate Phase: Local strengthening to Ankle stabilizers to address any atrophy Advance core and gluteal strengthening Soft tissue to maintain mobility of joint and remodeling soft tissue; deep tissue and MFD for limited tissues Joint mobilization to improve dorsiflexion and dynamic balance Proprioceptive training to enhance neuromuscular control Functional training Squat progression addressing WB issues Gait training 12

13 25 Top Sports Cases How it Really Works Ankle Sprain Advanced Stage: Advanced strengthening and movement training to remodel and create resiliency in new tissue and address mechanical/positional faults Plyometric training Agility training Soft tissue and joint mobilization to maintain proper functioning. Sport specific training 26 How to Set-up Success Find a physical therapist you trust and understand how they treat. Communicate with the physical therapist Prepare for Physical Therapy Help set expectations for those who have never been to Physical Therapy before Help reset expectations for patients who have been disappointed with Physical Therapy before. This way, you and the patient Expect the Expected. 13

14 References 1 Bialosky JE, Bishop MD, Cleland JA. Individual Expectation: An Overlooked, but Pertinent, Factor in the Treatment of Individuals Experiencing Musculoskeletal Pain. Phys Ther Sep; 90(9) Ghandi R, Davey JR, Mahomed N. Patient expectations predict greater pain relief with joint arthroplasty. J Arthroplasty August 11 3 Goossens ME, Vlaeyen JW, Hidding A, et al. Treatment expectancy affects the outcome of cognitive behavioral interventions in chronic pain. Clin J Pain. 2005;21: Hill JC, Lewis M, Sim J, et al. Predictors of poor outcome in patients with neck pain treated by physical therapy. Clin J Pain. 2007;23: O Malley KJ, Roddey TS, Gartsman GM, Cook KF. Outcome expectancies, functional outcomes, and expectancy fulfillment for patients with shoulder problems. Med Care. 2004;42: Kalauokalani D, Cherkin DC, Sherman KJ, et al. Lessons from a trial of acupuncture and massage for low back pain: patient expectations and treatment effects. Spine. 2001;26: Myers SS, Phillips RS, Davis RB, et al. Patient expectations as predictors of outcome in patients with acute low back pain. J Gen Intern Med. 2008;23: Heyamns MW, de Vet HC, Knol DL, et al. Workers belief and expectations affect return to work over 12 months. J Occup Rehabil. 2006;16: Mulligan EP. Principles of Joint Mobilization. Physiopedia. Found at 10 International Federation of Manual Physical Therapy Frontera WR. Rehabilitation of Sports Injuries: Scientific Basis. Vol X of Encyclopedia of Sports Medicine. Blackwell Science Ltd Bushbacher R, Prahlow N, Dave SJ. Sports and Medicine Rehabilitation A Sport Specific Approach. 2 nd ed. Philadelphia: Lippincott Williams and Wilkins 2009.