Topic: Physical Therapy (Read 534 times)

Rainbow · « **on:** July 03, 2009, 01:00:14 »

http://www.rsdhope.org/Showpage.asp?PAGE_ID=158&PGCT_ID=4054
http://www.rsdhope.org/Showpage.asp?PAGE_ID=158&PGCT_ID=4055

PHYSICAL THERAPY - HOW DO YOU FIND A THERAPIST ?

HOW DO YOU LOCATE A PHYSICAL THERAPIST KNOWLEDGEABLE ABOUT RSD/CRPS?

There have been a lot of questions recently concerning this topic so we thought we would put together some thoughts and tidbits that we have learned over the last decade or so.

The good news is that current CRPS/RSDS patients have a great head-start on those of us who came before because you have so much more knowledge about RSD/CRPS than we did a dozen years ago. Not only what you yourselves have learned but also what is available on the internet through websites and listserves, etc.

With this knowledge in hand, you can call and talk to the lead therapists in these clinics and ask them about their knowledge of CRPS/RSDS. You can find out very quickly how much they actually know about the disease and about treating it with PT by asking a few simple questions. Their answers will tell you whether or not to trust your body and health with them. In the hands of the wrong therapist your CRPS/RSDS can actually accelerate and worsen the same as in the hands of the wrong Doctor.

Here are the basic questions I would ask a Physical Therapist;

1) Are you familiar with Reflex Sympathetic Dystrophy, also known as Complex Regional Pain Syndrome?

If the answer is no then you probably should move on. There may be cases where you don't have many options in your area and you may be able to find a therapist who is willing to learn about the disease. In which case we have tapes, brochures, and of course the website to help. Your Doctor may also be able to provide guidelines for them.

I know that some people suggest just only giving them the initials RSD and seeing if they know what they stand for, or not asking about CRPS and seeing if they are up to date with the latest name change but this isn't about games. You want to determine their knowledge of actually treating the disease. They may not know the letters but may know the disease. They don't have to know everything about the disease, that is where your Doctor comes in. What is paramount here is DO THEY KNOW HOW TO TREAT YOU?

2) Have you treated RSD/CRPS patients in the past, and/or currently, and if so, how many?

Ideally the answer should be four, five or more but if you don't live in a large city that may not be feasible based on the number of patients available. However, it isn't enough for them to simply answer "None but we do treat Chronic Pain patients".

RSD therapy and CP therapy are two totally different animals due to two key components; allodynia and the adverse reaction RSD patients have to ice, or hot/cold contrast therapy. We touch on allodynia below and most everyone knows how ice causes RSD to worsen and/or spread.

3) Do you have a therapeutic or warm water pool?

This is a pool that is at least 88 degrees. It is used for patients with all sorts of injuries as well as diseases like arthritis, fibromyalgia, and of course, CRPS/RSDS. It is the BEST form of therapy for CRPS/RSDS. It is without a doubt the form of therapy CRPS/RSDS patients should be doing in our opinion. From everything we have seen, heard, and read over the years it seems to have the best results with the least impact. It also has the added benefit of reducing allodynia in many cases while at the same time increasing mobility. The end result being not only a reduction in pain but oftentimes a reduction in medication as well. We do have an article on the website about this;

AQUA THERAPY

Also an article concerning water therapy and Arthritis can be found by going to WATER WORKOUTS

Allodynia is part of the First of the Four Symptoms of CRPS/RSDS, see FOUR MAIN SYMPTOMS OF RSD

Allodynia is an extreme sensitivity to touch. Something as simple as a slight touch, clothing, sheets, even a breeze across the skin on the affected area can cause an extreme amount of pain to the patient. Pain can also be increased by sounds and vibrations, especially sharp sudden sounds and deep vibrations.

This is one of the most painful parts about RSD and this side effect can be reduced by Aqua Therapy. It takes quite a few visits but eventually you will notice a difference and it is amazing! This also seems to be the least painful way of reducing allodynia. After all, who doesn't like a nice dip in a warm pool? It is especially nice during the winter for those of us who live up north!

If you are on Medicare, this type of therapy is typically paid for by Medicare and there is no Physical Therapy cap for RSD patients. Your Doctor just has to write the prescription for it and, of course, you have to show improvement. A decrease in the allodynia is enough to show improvement and continue treatment. Being in the pool you greatly decrease the impact on your body because the water displaces your weight.

Land therapy, in contrast, whether it be massage, band therapy, exercises, or any type of stretching where they stretch your body by grabbing you and pulling, can be very painful due to the allodynia as well as the impact of the exercises themselves on RSD limbs.

4) If they took you on as a patient would they automatically put you into their "pain patient program" or would they be able to customize a program for you based on the needs of an RSD patient? Would they treat your "chronic pain" differently from "acute pain"?

Many physical therapy clinics are finally coming around on these questions but it is a slow turnaround. First, let us address the difference between acute pain and chronic pain. Doctor Tim Sams in his book called "ABC's of Pain Relief and Treatment", states "Chronic pain is not simply acute pain that doesn't go away", and " If short-term and long-term pain were not the same thing, then why would the treatments for acute pain make chronic pain go away? The answer is that they do not. The treatments for acute pain can be helpful at best and occasionally destructive at worst."

All too often the primary goal of the chronic pain patient in going into physical therapy and the goal of the Doctor/physical therapist are not the same. While the pain patient is seeking to reduce their pain, the medical professionals are simply seeking to increase the ROM (range of motion). If decreased pain is a by-product that is a bonus, but it is all about getting the patient moving again.

This can create problems in that the chronic pain patient becomes discouraged if, within the first three to four weeks they don't feel any decrease in pain, even if their ROM has changed. While the acute-pain patient can see immediate gains, the chronic pain patient needs to look long-term. They need to look 3 to 6 months and more down the road in their physical therapy plan for their first gains because they are in this for the long-haul.

However, what ends up happening in many cases, especially with certain types of insurance and in some WC cases, they are told what program to put you in and it is usually the Pain Patient Program. This is a standardized program and is fine for most types of acute pain. It is set on the principle of NO PAIN, NO GAIN! It can involve everything from classroom instruction (and many RSD patients cannot sit for very long without pain), to land therapy, sometimes very aggressive land therapy.

With CRPS/RSDS, NO PAIN is ALL THE GAIN, as a Doctor friend of mine used to say. The PT program for a CRPS/RSDS patient must be a combination of Aqua Therapy, a basic water therapy program typically based on the Arthritis Society's Water Therapy Classes, cardio therapy when possible, and ROM exercises. The Aqua Therapy is the most beneficial form of therapy for CRPS/RSDS patients. It involves stretching, walking, and even some light weights, but all done in a warm water pool. It has the added benefit of reducing allodynia (sensitivity to touch) in most cases as well.

It is important to remember that while the warm packs work very well for most patients they must never be followed by the cold or ice packs as the ice will simply further damage the already weakened myelin sheath surrounding our already damaged nerves. Even though the ice may feel good for a brief time it will end up causing severe damage and repeated use of ice packs or hot/cold contrast therapy will, in many cases, accelerate the CRPS/RSDS.

5) Where do I start to look for such a Physical Therapist?

The best place to start is in the nearest large hospital. Sometimes you may have to travel an hour or more but if you find the right therapist it is worth it. Since many of your questions can be asked over the phone, call as many places as possible. Don't be put off by the person who answers the phone either. You want to talk to the Director of the clinic if possible or, at the very least, one or more of the physical therapists.

If they can't talk to you right away then leave your name, number, and the reason why you called (looking for a therapist who treats Reflex Sympathetic Dystrophy), and a time to call you back.

There is nothing wrong with the smaller physical therapy centers but they are less likely to have a therapeutic pool so it is best to stick with the larger hospitals.

Also, talk with your Doctors; your RSD Doctor, your GP, etc. Chances are good they know of one they can recommend. 6) Should CRPS/RSDS Patients use ICE in ANY part of their Physical Therapy?

The short and long anser is ABSOLUTELY NOT! Not in ice packs, not in hot/cold contrast therapy, not cold packs, not ice in any form! For a more detailed answer read the information in the link below.

RSD AND ICE

Remember, a good Physical Therapist can be a key member of your medical team and play a very important role in helping you get your life back, and a bad one can accelerate your RSD and possibly even make it worsen and/or spread.

Hopefully this will give you a head start! If you have ideas that you would like to add, send them in to RSDHope@mail.org

Peace, Keith Orsini

Keith has had CRPS/RSDS since 1974. He has full body CRPS/RSDS. He is not a Medical Doctor. Be sure to talk over any advice with your Doctor.

Rainbow · « **Reply #1 on:** July 18, 2009, 01:17:34 »

http://www.rsdcanada.org/parc/english/therapy/alt-treatment/physio.html

What is a physiotherapist?

A physiotherapist, also known as a physical therapist, has a detailed understanding of how the body works. University educated and trained, he assesses and improves function, movement and pain relief. He listens, asks question, explains treatment techniques, goals and results. He encourages the patient to increase his independence. He helps the patient who may be feeling apprehensive about therapy.

What are the general goals of therapy?

Whatever treatment is used, the physical therapist's aims are to:

* relieve pain
* loosen stiff joints
* restore muscle tone
* improve circulation
* prevent further injury or damage
* improve range of motion.

What treatments are used?
After assessing the physical problem, the patient's age and situation, he creates a treatment program. He may use any of the following options:

* balloons and weights
* stretching
* exercises for circulation and muscles
* massage
* thermotherapy (heat treatment)
* cryotherapy (cold treatment)*
* hydrotherapy (whirlpool baths or exercises in a pool
* stationary bicycle
* walking
* joint exercises
* cardiorespiratory exercises
* biofeedback
* electro-therapeutic devices e.g. TENS or ultrasound

*Note: This treatment is not used for RSD/CRPS.

DIFFERENCES IN CHRONIC PAIN (CP) PATIENTS

The first priority of therapy is to reduce or control the patient's pain.

Without adequate pain control, the patient will not be cooperative in physical therapy.

It is possible that some CP patients may not have a reduction in pain. In this case, the goals change to reducing disability and increasing function.

Therapists treating CP patients should be aware of the following:

* Patients with pain tend to move more slowly, have less force during muscle testing, and display poor endurance during exercise.
* Persons with chronic pain may be severely impaired and physically "deconditioned". Deconditioned persons function at a level close to their maximum capacity. They have less energy available which is used up getting through the day. There is little reserve energy.
* Many CP patients have levels of activity dependent upon the amount of pain they are in. When they have overdone it, the pain increases and therapy stops.

OVERACTIVITY-REST CYCLE
The overactivity-rest cycle is staying with an activity until increasing pain prevents further participation. The person then rests completely until the pain subsides or frustration with inactivity motivates him to be active again. The person then again continues until increasing pain prevents further activity.

DECONDITIONING
Generally, CP patients are not physically fit and do not tolerate physical activity well. Deconditioned patients have less cardiorespiratory endurance and tire easily during aerobic exercise. Their heart rates are higher at rest.

PROBLEMS WITH INACTIVTY

"The main problem with inactivity is that skeletal muscles atrophy. Immobilization and bed rest result in a loss of Type 1 muscle fibers. Loss of muscle strength and endurance with inactivity is due to loss of muscle mass, decreased ability to use energy, decreased neuromuscular tramsission and decreased efficency in muscle fiber recruitment."

"Inactivity also deprives bones, joint cartilage, and connective tissue of the mechanical stress necessary to maintain tensile and compressive strength and elasticity."

"Evidence is building that motor control and proprioceptive efficiency are altered, balance is compromised, and reaction times are slower in persons who are unfit or have pain."

REHABILITATION

What are the factors in rehabilitation?

For chronic pain patients, the following rehabilitation strategies must be included:

* activity
* setting goals for activities
* pacing of the activity

With general exercise regimens, problems associated with deconditioning are reversible. For example, aerobic training improves aerobic fitness (maximal oxygen consumption). Of utmost importance in an exercise routine are:

* a regular regimen
* a gradual increase in duration
* a gradual increase in intensity.

Patient Concerns

Each patient has certain fears that may hinder progress:

* the effects of pain over time
* severity of pain
* how long the pain may last
* physical effects

HOW CAN I DO MY PART?

Two key factors will help the patient show progress and be successful:

* self pacing
* getting realistic and attainable goals

PACING

Daily activities should be structured. Gradual and controlled increase in activity is the best way to avoid a flare up in pain. Timing activities is also essential and rest periods should be included. Another activity that does not cause pain can be substituted.

SETTING GOALS

Deciding on realistic goals will contribute towards success. Making the goals unattainable or too difficult can lead to a sense of failure and the patient may discontinue therapy.

TRY IT!

If the patient attempts something he fears doing, achieves it and recognizes he did it, then self-confidence improves.

ACTIVITY GOALS

Setting goals in the following three areas will help facilitate progress:

* physical: e.g. number of exercises performed, the duration and level of difficulty
* functional: e.g. task of everyday living such as housework or hobbies
* social: e.g. visiting friends, going for a walk or other pleasurable activity

How do I manage a relapse?

A chronic pain patient will encounter an exacerbation of pain at some time during treatment. It is essential that the situation causing the pain, be identified. The therapist can then offer strategies to cope with the pain e.g. visit doctor, use pain medication, rest and relax. Having an action plan for this event is critical because it helps the patient keep a sense of control. It is important that this situation not be taken as a failure or mismanagement of the pain.

THINGS TO REMEMBER
The rehabilitation process can be long and complicated for a chronic pain patient. It involves overcoming not only physical but psychological problems. The patient and therapist need to work together as a team to set goals, recognize achievements and above all manage a relapse. With the help of an excellent, understanding, well-trained therapist, success can happen.

Adapted from: Physical Therapy for Chronic Pain Vol.6 No.3 Nov. 1999 by Vicki R. Harding, MCSP,Maureen J. Simmonds, PhD MCSP, Paul J. Watson, MSc MCSP, UK

ADVICE FROM AN RSD/CRPS PATIENT

As a longtime RSD patient, I have used many forms of physiotherapy. The following tips have served me well and I hope they help you:

*
Educate. Find a physiotherapist who is genuinely interested in helping you and educate her about RSD. A therapist who is not familiar with RSD will not be useful and her program may be too difficult. When you find the right one, encourage any questions about RSD and be specific about how RSD affects you.

Remember the four G's:

*
Goals: Set the goals within your reach even if they are small steps at first. Each step is an accomplishment.
*
Gentle: All therapy should be gentle and not cause pain. Omit exercises that cause pain and try re-introducing them later on.
*
Gradual: All progress should be very gradual e.g. riding a stationary bike for five minutes a day for several weeks then increase to six minutes etc.
*
Gab: Provide your therapist with continuous feedback during and after therapy about what is painful and what isn't. Sometimes the exercise that caused you pain a few weeks ago, can be done today with less intensity or duration. She will be able to adjust your routine.

Be flexible. What works for one RSD patient, may not work for another so flexibility is essential. Your routine may need to be adjusted continuously to find the right combination that works for you.

*
Sometimes today's routine can incorporate the same exercise done differently. e.g. instead of using the stability ball, use the floor mat.
*
Sometimes the therapy you did yesterday may be too painful today. Leave it out.
*
Sometimes you can do the same thing with less intensity or duration

A good therapist can modify or re-design the program to suit your needs.

Journal: Keep track of exactly what you do; record the intensity and duration of each exercise. Exercises that cause pain can be pinpointed at a glance. Progress can be seen instantly.Celebrate even the small victories.

Progress:.While the road may seem long, recognize that over time you will improve. Do not expect linear progress e.g. you will take two steps forward and one step back. This will happen frequently in the beginning and can be frustrating but if you persist, the steps backward become less frequent and eventually disappear. Then you will only take forward steps! Since every RSD patient is different, it is difficult to say when improvement occurs but your therapist will notice long before you do. Think of therapy as an ongoing maintenance project and as part of your wellness program.

Relapse: Be prepared; recognize that a relapse will happen. Some days you will not be able to tolerate much due to pain. If you can pinpoint what exactly caused the relapse by looking in your journal, it may just mean an adjustment in your routine e.g. less intensity, duration or elimination of that particular exercise. Be sure to tell your therapist. Sometimes, just rest and increasing painkillers will help. It is critical that you do not give up at this point. Wait it out and realize that you can resume activities once the pain level is tolerable again.

Why do it? Since the latest RSD research has now found lack of oxygen in the skeletal muscle, it is more essential than ever that we exercise. Inactivity is the enemy of RSD since it causes the "sleeping nerves" to wake up and cause more pain. Inactivity also causes muscle atrophy, can result in joint problems and loss of function of the limb. "Use it or lose it" does apply.

FURTHER INFORMATION

To find a physiotherapist near you, contact:

Canadian Physiotherapy Association National Office
2345 Yonge Street Suite 410
Toronto, Ontario M4P 2E5
Tel: 416 932 1888
Toll Free: 1 800 387 8679
Email: information@physiotherapy.ca

READINGS

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18. Fordyce WE. Behavioral methods for chronic pain and illness. St. Louis: CV Mosby, 1976.
19. Keefe FJ et al. In: Gatchel RM, Turk DC(Eds). Psychological approaches to pain management.New York: Guilford Press, 1996.
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24. Harding VR. In: Pitt-Brooke J (Ed). Rehabilitation of Movement: Theoretical Basis of Clinical Practice. London: WB Saunders, 1998.

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