TIS                         

CONCEPTS OF ORTHOPEDIC REHABILITATION

The therapist's primary role in musculoskeletal rehabilitation is to maximize the ideal conditions for the tissues' own healing capability and to assist the patient in resuming preinjury activities that are important to the patient.

Treatment strategies, those methods chosen by the therapist to assist the patient to recover functional skills, are driven by the occupational challenge and the physical therapy diagnosis, by the patient's desired outcome, and by scientific knowledge and rationale.

Occupational therapists and physical therapists must be able to provide sound rationale to support the interventions they choose for the rehabilitation of patients with orthopedic problems.

Guiding Principles of Rehabilitation:

• Continually Observe, Evaluate, and Critically Think
• Interventions Must Be Patient-centered
• Consider the Dimensions of Rehabilitation (Acute to long term)
• Apply Knowledge of Tissue Healing to Intervention
• Understand and Apply the Concepts of Protection, Rest, and Return to Activity
• Apply Tension to Healing Tissues
• Think Anatomically, Biomechanically and Functionally
• Perform Ongoing Patient and/or Caregiver Education
• Choose Appropriate Frequency of Treatment and Know When to Discharge
• Respect the Injury, but Don't be Intimidated by It

Continually Observe, Evaluate, and Critically Think

Continually test your Diagnosis / Occupational Performance Dysfunction.

Compare your current measurements to the baseline that you established in the initial evaluation.

Continually critique your chosen intervention(s) and ask yourself: is this the best thing for the patient at this time? Always consider the "progression" of treatment, and continue to challenge the patient, ultimately preparing the patient for return to activities.

Interventions Must Be Patient-centered

To assist a patient in resuming preinjury activities that are important to the patient, the therapist must know the patient's desired outcome(s) of treatment.

All treatment goals pertain to the patient's desired outcome(s). Any outcome will relate to one or more of the three areas of activities: self-care, work, and leisure.

Therapists should have the patient prioritize each desired outcome so that they know which activities to focus on during treatment. The majority of patients will rank the importance of their desired outcomes along a continuum similar to the following:

• Regain self-care activities
• regain ability to return to work
• return to performing leisure activities.

Patient-centered treatment should end with patients resuming all of the activities that they have determined are important.

Consider the Dimensions of Rehabilitation

As they treat the patient, therapists should ask: "What conditions are responsible for the dysfunction and are these conditions reversible? If reversible, what would be the most appropriate means of intervening therapeutically so as to affect these conditions? If the conditions at fault appear irreversible, what can be done to optimize residual function?"

It is extremely important for therapists to realize that they cannot "fix" every person who comes to them with a problem. In addition, just because a person’s problem is not "fixable", this does not mean that the problem cannot be alleviated through a therapist’s intervention.

Rehabilitation can occur in any of the following dimensions that relate to the patient's problem(s):

• From the pathophysiology perspective
• The impairment perspective
• At the dimension of functional limitation
• The disability perspective >(National Center for Medical Rehabilitation Research, 1993).

Treatment of Pathophysiologic Problems:

Therapists can employ a number of treatment strategies in the pathophysiology domain to assist tissue healing, including:

Treatment of inflammation: Pathophysiological interventions should focus on controlling the acute or chronic inflammatory responses.

Acute Inflammation of Tissue:

Protect: to reduce the chance of further injury to the tissue

Rest: to promote proper healing

Ice: to reduce blood flow, decrease perception of pain

Compression: to prevent and reduce swelling

Elevation: to prevent and reduce swelling and hyperemia
(Prentice, 1994).

Chronic Inflammation:

Identify the source of ongoing irritation and eliminate it, or alter the person's activities so that it no longer has an adverse impact on the person.

Application of Wolff's Law and Davies' Law to Tissue Healing: a balance of protecting the tissues and early mobilization; balance of rest versus exercise.

Treatment of Impairments: includes the following areas:

• Pain: use of modalities, including thermal agents, electrical stimulation, etc.
• Range of Motion: address restrictions of joint mobility, strengthening weak muscles, stretching tight ones; addressing joint capsule tightness; etc. (Goldstein, 1995, p. 55).
• Postural alignment and base of support.
• Sensory input: desensitizing areas, retraining proprioception, etc.(Goldstein, p. 59)
• Mobility and coordination/motor control: can be improved by altering some of the characteristics of the movement, including the speed of the movement, the joint ROM, the initial postural alignment, the sequence of muscle activation (Goldstein, 1995, p. 60).

Treatment Functional Limitations: The most successful treatment strategies are those that exactly simulate/duplicate the functional aspects of activities that the person wishes to resume.

Treatment of Disabilities: the therapist’s intervention is geared toward optimizing a patient's function in the various activities of self-care, work, and leisure. If the conditions causing disability are irreversible, the therapist must work to optimize the patient's residual function and help the patient to adapt performance of occupational roles.

Activity Adaptation

A primary concern in any activity adaptation is the patient’s ability to perform those activities that are part of the individual’s daily routine. There are four broad considerations for activity adaptation:

1. Positive role for the individual: the individual is actively performing the activity rather than it being done to them. Through the individual’s participation, the individual is actively adapting to the environment, the situation, or the activity and, therefore, is actively involved in the therapy process (Levine & Brayley, 1991).



2. Demand of the environment requires adaptation: if individuals want or need to do something and are obstructed by their own inabilities, then individuals must learn to adapt themselves to the environment or adapt the environment to meet their needs (Levine & Brayley, 1991).



3. Adaptation is most efficient when it is organized on the subcortical level: the focus is on the activity or the outcome, providing organization of sensory input and motor output to the subcortical centers where it is handled most efficiently and adaptively (King, 1978).



4. Adaptation is self-reinforcing: each successful adaptation serves as a stimulus for attempting the next step (King, 1978).

The adaptations used with clients are limited only by the creativity and imagination of the therapist. The most important criterion of the adaptations incorporated into activity should be their relevance to the client (Levine & Brayley, 1991).

Apply Knowledge of Tissue Healing to Intervention

Tissue healing times depend on the type of tissue, the extent of the injury, and when/how tension is applied to the tissue. The following table reflects general time frames when specific tissues may be "clinically" healed:

[healingtbl.JPG - 22573 Bytes]

Understand and Apply the Concepts of Protection, Rest, and Return to Activity

To allow tissues to heal, therapists must protect them from continued trauma by eliminating or reducing loading of the injured structures. The extent of protection is dependent on the degree of tissue injury. Low-grade injuries may not require protection, whereas tissues that are significantly injured and have a slow healing rate may require long-term protection.

Rest does not necessarily mean inactivity. Resting injured tissues can range from not allowing the patient to perform any activity, to performance of the activity with certain modifications. Therapists must be very clear to their patients what constitutes protection, rest, and return to activity for that patient.

Protect and rest tissues by:

• Immobilization: casting, splinting, internal fixation.
• Protected Mobilization: Braces, splints, strapping, taping.
• Reduced loading: use of assistive devices, adaptive equipment, etc.
• Alteration of activities: maintaining optimal levels of function while preventing unnecessary loading of the tissues, example: shortened work time, taking frequent rests, use of proper body mechanics.
• Alter environment in which activities take place.

Return the patient to activity by preparing the tissues for the activity and by gradually resuming the activity.

* Remove the mechanism of injury, guide tissue healing, prepare the tissues for return to activity (Gross, 1992, p. 255).

Apply Tension to Healing Tissues

Wolf's Law and Davies' Law:

Long-term exercises cause collagen fibrils to thicken and align themselves parallel to the direction of force, increasing their tensile strength (Liu, et al. p.268).

Optimal remodeling of initially formed collagen fibers does not occur unless the tissue is subjected to physiological loading. Tissues that do not experience tension will lay down collagen in a disorganized, nonparallel manner, decreasing their tensile strength (Gross, 1992, p. 254).

When applying Wolf's and Davies' Laws to healing tissues, therapists must consider:

• When to introduce tension to the tissues;
• The magnitude and type of tension;
• How to progress the tension such that the tissue can tolerate the demands of the patient's various activities.

Introduction of Tension

Therapists can use their knowledge of the various healing times of tissues to assist them in determining when to introduce tension. Many significantly injured soft tissues are weakest at three to four weeks post injury, due to the more-rapid absorption of type III collagen and the slower deposition of Type I collagen.

Medical imaging techniques such as MRI, CT, x-rays, etc. will provide information on the exact healing status of tissues.

The cardinal signs of inflammation will help to determine when therapists can begin to introduce tension to injured tissues. Reduction of most or all of the cardinal signs of inflammation is a good indicator of when to begin to mildly stress tissues. The recurrence of any of the signs following the introduction of tension usually indicates that the tension applied exceeded the tolerance of the tissue.

The Magnitude and Type of Tension

The degree of tension is inversely proportional to the extent of injury. Common sense would dictate that therapists introduce a small amount of tension initially, evaluate the tissue response, then proceed as indicated.

Therapists can apply tension in a variety of ways. Tension can be manual, such as with friction massage, joint mobilization, or exercise. It can also be provided mechanically by rubber bands, weights, or other methods of resistance. Regardless, the tissue will reorganize and begin to align its components in parallel with the vector(s) of the tension.

When selecting exercises/ activities to apply tension to tissues, therapists should arrange the functional activities by order of difficulty/stress to structures (begin with lower level activities, then progress).

Think Anatomically, Biomechanically, and Functionally

Occupational therapists and physical therapists must have a solid foundation in anatomy and biomechanics to develop effective interventions.

They should always consider the anatomy of a region and visualize the various structures that they are rehabilitating.

Therapists should apply biomechanical principles to their treatment. They should understand and encourage "typical" postures and movements and be able to discern and influence atypical patterns. They should consider the forces that the tissues and joints experience, and alter these as needed.

Treatment should always progress toward the patient performing the functional activities that they defined as important to them in the interview. Treatment may begin with simple planar exercises, but during the course of treatment should progress toward functional activities.

Perform Ongoing Patient and/or Caregiver Education

Patient education is an ongoing part of rehabilitation. It includes educating the patient and/or caregiver about the problem, teaching home programs to augment treatment, providing strategies for performing functional activities, etc. Therapists can augment patient education with handouts, videotapes, or other educational methods.

Because patient education is an integral part of rehabilitation, therapists must take the time to perform it properly. Teaching occurs during therapy. It should not be "tacked on" in the form of a home program handed to the patient following treatment.

Choose Appropriate Frequency of Treatment and Know When to Discharge

Frequency of treatment depends on many factors. Therapists can use the following considerations to determine number and duration of patient visits:

• The extent of the injury/length of healing time
• The degree of "skilled" service needed
• See the patient when you need to change the intervention.
• Don't be afraid to schedule a follow-up session soon after you've changed the treatment program. It is important that therapist's evaluate the patient's response to the altered treatment.
• Some reimbursors or other parties may try to dictate frequency and duration of patient visits. Don't be afraid to negotiate with these people.
• Always have the patient's best interest in mind. Work to avoid falling into a habitual frequency/duration schedule.

Part II of the Hypothesis Oriented Algorithm for Clinicians (HOAC) provides guidance for when to discharge patients (Echternach & Rothstein, 1989). Portions of part I of the HOAC are below for reference, followed by Part II.

Part I

4. Generate a working hypothesis about the problem(s). Correlate and interpret findings of the P.E. to determine a P.T Diagnosis or Occupational Challenge; refer to other practitioner (if therapist cannot generate a hypothesis)



5. Plan reevaluation methodology (schedule dates for reevaluations)



6. Plan treatment strategy based on hypothesis, obtain consultation, if needed



7. Plan tactics to implement strategy (specifics of treatment plan)



8. Implement tactics (perform treatment) and document

Part II

9. Reassess the patient: Have the goals been met?
   
   Yes. Discharge the patient.
   
   No. Are the treatment strategies being implemented correctly?
   
   
   No. Improve implementation (go back to step # 8)
   
   If Yes, are the treatment tactics appropriate?
   
   
   No. Change your strategy (go back to step # 6)
   
   If Yes, is the strategy correct?
   
   
   Yes. Are the hypotheses viable? (If testing criteria have been met and goals are not met, new hypotheses are needed.
   
   No. Generate new hypotheses (Go back to step # 4)

Respect the Injury, but Don't be Intimidated by It




Return to Table of Contents