Physical Therapy in Spondyloarthritis PT Management: What the Rheumatology Trainee Needs to Know Angelo Papachristos BSc, BScPT,CAFCI, MBA Advanced Practice Physiotherapist St. Michael s Hospital Toronto, Canada Boston, May 3, 2018 Disclosures Nothing to disclose related to topic and discussion material Objectives To better appreciate the common rehabilitation therapies and treatment modalities utilized in the treatment of spondyloarthritis in ambulatory care practice To appreciate the current rehabilitation landscape when referring clients for therapy Have basic understanding of treatment protocols and care plans implemented by PT 1
Strong recommendation: Physical therapy over no physical therapy Supervised exercise over passive interventions (massage, ultrasound, heat) Land based over aquatic therapy What does a rheum trainee need to know about PT and SpA management 1. Provide Education 2. Stretch/Strengthen/Postural 3. Cardiovascular conditioning programs 4. Mobilize / Manipulation 5. prescribe assistive devices / bracing / splinting / orthotics 6. Use of Therapeutic Modalities [electrotherapy and non-electrotherapeutics] 7. Ergonomic and functional abilities evaluation Common Modalities Interferential Current (IFC) TENS Transcutaneous Electrical Nerve Stimulation 2
Therapeutic Ultrasound Therapeutic Ultrasound Actually NOT a form of sound or electrical energy.. Mechanical Energy Piezoelectric crystal vibration at high frequency producing sound energy Typically humans hearing 16 Hz-20000Hz Ultrasound typically 1-3 Million cycles per second It is Pro-inflammatory 1 MHz vs. 3MHz Half Value Depths Blood Fat Nerve Muscle Skin Tendon Cartilage, Bone To some degree operator dependent [settings, dose, duration, proper application] Reflection of almost all US at metal/air interface (>99.99%) Refraction if beam does not strike surface at 90. ie the path of beam will be angled. If treatment head is at angle >15 beam will just travel via the dermal tissue /parallel to skin surface. Increased Protein content RESULTS in Increasing absorption Pulsed vs. Thermal Low Level Laser Therapy [LLLT] Thermal essentially continuous wave, generates deep heating in tissue. Can raise internal temp to 40-45 and cause tissue hyperemia. Possible use in chronic inflammatory state Pulsed (Athermal): interrupted pulse, combination of cavitation and acoustic streaming. Most effective in proliferative stage, early remodeling stage Superficial application of laser at wavelengths of 632-904 nm The penetration of both He-Ne and infra-red lasers was observed for only a few millimeters. The most important absorption was observed at the depth level of 0.4 and 0.5 mm. 3
Acupuncture /Dry needling Graston Technique Changing the way soft tissue injuries are treated. Graston Technique is an evidence-based form of instrument-assisted soft tissue mobilization that enables clinicians to effectively address scar tissue and fascial restrictions through comprehensive training, resulting in improved patient outcomes 12 Standard Meridians, 8 extraordinary channels 400 standard acupuncture body points Knee acupuncture /electroacupuncture Yes TAPE because we can. Shoulder Impingement /RC Cupping 4
Acupuncture/ Moxa Exercise Benefits ACSM RECOMMENDATIONS Increased cardiovascular endurance Reduced blood pressure and stress Increased good cholesterol (HDL) Maintains muscle mass Maintaining bone density Maintain or reduction in weight Psychological improves well being, depression Improves fatigue Pain reduction / pain modification Exercise Benefits Recommendations - Guidelines Osteoporosis Guidelines Exercise (30 min 5X /week, stretch 2X/ week), quit smoking, ETOH, Caffeine, Vit. D. Diabetes Guidelines Osteoarthritis Guidelines Cardiac Guidelines Chronic Fatigue, Depression, Fibromyalgia 5
% grade 9-12 students watching >3 hours TV /school night 6
Get Started Home Exercise www.wegotyourbacktwh.ca 7
iphone App 8
Neck Retraction 1 2 9
140 1 2 3 1.5-2 feet 10
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Supine to Sit -Bed Rise from Chair 12
Lumbosacral Rotation Core rotation with weighted ball Summary 150 minutes per week of physical activity is magic number! Passive modalities not indicated in SpA exception rather than rule Link with physiotherapist /facility in community that has interest in SpA Physiotherapy intervention for most part is to develop, monitor and alter physical fitness and wellness program for SpA over time. Program must be patient specific /setting specific 13
Core with weighted ball - BOSU Questions? 14
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