Physical Therapy

Theresa H. Michel

Harriët Wittink

Life begins on the other side of despair.

—Jean-Paul Sartre, 1905–1980

The goal of physical therapy is to restore or improve function and to prevent disability. Referral to physical therapy is appropriate when pain impairs a patient’s optimal functional ability or inhibits a patient’s independence in activities of daily living, or when physical rehabilitation is a necessary component of treating the underlying cause of pain. The physician supplies a diagnosis and communicates any precautions, thereby allowing the physical therapist to use clinical judgment in designing an appropriate treatment program. Because patients may choose to see a physical therapist first, before a medical diagnosis is made, physical therapists perform screening, as well as a comprehensive assessment and a treatment plan based on this assessment. Referrals are made to appropriate medical practitioners. Physicians who refer to the physical therapist may make an “evaluate and treat” order that is a reasonable means of requesting a physical therapist to see a patient. In all cases, the key is collaboration and integration of component therapies between the physician and the physical therapist.

Physical therapists attempt to identify the relation between pathology, impairment, functional limitation, and disability to direct treatment appropriately. In acute pain, a clear relation exists between nociception, perceived pain, and impairment; therefore, treatment will focus on the elimination of pain. As a result, impairments are diminished, functional ability is restored, and disability is prevented. In patients with chronic pain, however, the relation between pain and disability is unclear. Treatment that solely addresses elimination of pain in patients with chronic pain will likely fail to alter the illness and disability behavior. Instead, treatment addresses function in spite of pain and promotes independence at a level of tolerance.

I. PHYSICAL THERAPY EVALUATION

Physical therapists are trained to assess physical impairments such as flexibility, strength, and endurance, as well as activity limitations. Through an interview and physical examination, most of the information needed to develop an appropriate treatment plan should be obtained. Although the physical therapist’s interview and examination closely resemble those of other health care providers,
observation of the patient’s movement patterns and willingness to move are specific to the physical therapy examination. Transitional movements are observed when the patient sits, stands, walks, or climbs onto a plinth. Important diagnostic features include quality of motion, which can be distorted and erratic, and dysfunctional movement patterns including muscle guarding and pain behaviors.

Because patients’ self-report of their functional ability has been shown to be influenced by mood, evaluation is supplemented by functional tests. Functional testing helps compare the patient’s perception of what they are able to do with what they are actually capable of doing. Some functional tests that have been applied to the patients with chronic pain include the 5-minute walk test (distance in meters walked in 5 minutes), the number of stairs climbed in 1 minute, and the stand-up test (the number of times a patient can stand up from a sitting down position in 1 minute). A functional capacity evaluation (FCE) is usually performed to determine the patient’s physical capacity to perform work. The assessment includes the patient’s ability to lift weights from the floor to the waist and from the waist to overhead, carry, crawl, squat, sit, stand, walk, climb stairs, and push and pull weights. Aerobic fitness may be determined from a bicycle or treadmill test. Aerobic fitness represents the capacity to transport oxygen and generate energy and is part of the measure of a person’s work capacity. An FCE is always somewhat subjective because it can only document how much a patient is willing to do on a given day.

II. PHYSICAL THERAPY INTERVENTION

Physical therapy treatment should have an observable endpoint associated with (a) restoration of optimal physical functioning; (b) reduction of the impact of pain on the patient’s life, that is, reduced disability; (c) resolution of treatable impairments that interfere with normal function; (d) prevention of future occurrences; and (e) improvement of the patients’ knowledge of independent pain management. Components of physical therapy intervention for pain are as follows:

Education/self management techniques.
Pain treatment or management for which active modalities (i.e., exercise) or passive modalities (i.e., massage, joint mobilization, electrotherapy, heat, and cold) can be used.

1. Education and Self-Management

Perhaps the most important goal in educating patients and teaching them self-management techniques is increased self-reliance. Many patients report feeling helpless and hopeless and cannot understand why they have pain. Increased self-reliance increases patients’ participation in the intervention process and leads to better outcomes. Educating patients on their diagnosis and pathology is helpful in reducing fear and eliminating catastrophizing. It is important that the patient agrees with the goals of treatment. For example, if a patient feels that the only helpful treatment is medication, then chances of a successful outcome from physical therapy intervention are slim. When patients understand their pathology and agree with the goals of intervention, they are more likely to be compliant with the intervention offered.

It is helpful to teach patients self-massage and techniques for applying heat or cold as an active pain-control modality whether they have acute or chronic pain. For self-massage, patients can use a cane or umbrella handle to press against a trigger point and apply ischemic pressure or they can be taught to slowly rotate two tennis balls around a painful area. Heat and cold packs in all sizes are commonly available through pharmacies.

2. Pain Treatment or Management

(i) Active Modalities

Active modalities can be subdivided into three categories: (a) stretching exercise, (b) strengthening exercise, and (c) endurance exercise.

STRETCHING EXERCISE.

The purpose of stretching is to regain normal flexibility around joints to allow patients to function in their optimal position. Muscle imbalance can be a precipitating factor in the development of both trigger points (TPs) and joint pain and therefore must be addressed. Numerous observations have been made about the fact that certain muscles respond to a given situation (e.g., pain and impaired afferentation by a joint) with tightness and shortening, whereas others respond by inhibition and weakness. Muscle responses seem to follow some typical rules; therefore, development of tightness and/or weakness may be considered as a systematic and characteristic deviation to the functional performance of these muscles. The final result of this deviation is a general imbalance within the whole muscular system. With an imbalance, a changed sequence of activation of the muscle in the movement pattern occurs. This change can further spiral the patient into a continuous cycle of weakness, tightness, abnormal movement patterns, and pain. Because tight muscles are thought to inhibit their antagonists, stretching muscles indirectly helps to restore strength.

Changes in muscle function play an important role in many painful conditions of the motor system and constitute an integral part of postural defects in general. Postural adjustments are the body’s strategy in maintaining the center of gravity of the whole body. An increase in any one spinal curve must be compensated by a proportionate increase or decrease in the other curves. Fine muscle coordination is needed to prevent damage to a joint, especially during fast movement. Thus, balanced muscle coordination may be the best protection of our osteoarticular system. Treatment consists of stretching the short musculature and strengthening the weak muscles. Normal posture will be sought, resulting in normal bone alignment and normalized stresses across the joints. Restoration of normal muscle balance results in the following:

Decreased repetitive microtrauma through normalization of biomechanical forces
Normalization of reciprocal action muscles
Restoration of normal flexibility (normal range of motion)

Passive stretching exercise is used in the treatment of TPs. An active TP is associated with spontaneous pain at rest or with motion that stretches or overloads the muscle. Specific to a TP is referred pain and the “jump sign.” The pattern of referred pain from

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