"If you want to improve, move!".
Physiotherapy is so very important in the treatment of RSD/CRPS. Early activity for recovery of function of the affected limb is absolutely necessary for improvement. The patient who takes part in his own recovery plan along with the therapist is destined for success. The therapist helps the patient overcome obstacles, restore function and attain personal goals. The emphasis is on positive outcomes for effective pain management.
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
- exercises for circulation and muscles
- thermotherapy (heat treatment)
- cryotherapy (cold treatment)*
- hydrotherapy (whirlpool baths or exercises in a pool
- stationary bicycle
- joint exercises
- cardiorespiratory exercises
- 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.
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.
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."
What are the factors in rehabilitation?
For chronic pain patients, the following rehabilitation strategies must be included:
- 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.
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
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.
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.
If the patient attempts something he fears doing, achieves it and recognizes he did it, then self-confidence improves.
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.
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
- Jette AM et al. Phys Ther 1994; 74:101-115.
- Waddell G. Spine 1987; 12:632-644.
- Turk DC et al. J Rheumatol 1996; 23:1255-1262.
- Nelson RM. NIOSH Low Back Atlas of Standardized Tests and Measures. Springfield VA National Technical Information Service,1988.
- Newton M et al. Spine 1993; 18:812-824.
- Simmonds MJ, Claveau Y. Physiotherapy Theory and Practice 1997; 13:53-65.
- Simmonds MJ et al. Spine 1998; 23:2412-2421.
- Harding VR et al. Pain 1994; 58:367-375.
- Bergner Met al. Med Care 1981, 19:787-805.
- Roland M, Morris R. Spine 1983; 8:141-144.
- Fordyce WE et al. In: France RD, Krishnan KRR (Eds). Chronic Pain. Washington: American
- Gil KM et al. In: France RD, Krishnan KRR(Eds). Chronic Pain. Washington: American Psychiatric Press, 1988.
- Davis V et al. Arch Phys Med Rehabil 1992,73:726-729.
- Lindstrom SJ et al. Phys Ther 1992; 72:279-290.
- Brennan GP et al. Spine 1994, 19:735-739.
- Martin L et al. J Rheumatol 1996; 23(6):1050-1053.
- Simmonds MJ et al. Disabil Rehabil 1996;18:(4):161-168.
- Fordyce WE. Behavioral methods for chronic pain and illness. St. Louis: CV Mosby, 1976.
- Keefe FJ et al. In: Gatchel RM, Turk DC(Eds). Psychological approaches to pain management.New York: Guilford Press, 1996.
- Locke EA. Organizational Behavior and Human Performance 1967; 3:157-189.
- Bandura A. Psychol Rev 1977; 84:191-215.
- Wittink H, Michel TH (Eds). Chronic pain management for physical therapists. Boston:Butterworth-Heinemann, 1997.
- Gifford L (Ed). Topical Issues in Pain:Physiotherapy Pain Association Yearbook 1998-1999.Falmouth: NOI Press, 1998.
- Harding VR. In: Pitt-Brooke J (Ed). Rehabilitation of Movement: Theoretical Basis of Clinical Practice. London: WB Saunders, 1998.