Section 1. Fundamentals

Chapter 7. Rehabilitation

Topics: Introduction | Treatment of Pain and Inflammation | Physical Therapy | Occupational Therapy | Rehabilitation for Specific Problems

Physical Therapy

Physical therapy involves exercising and manipulating the body. Techniques include range-of-motion exercises, muscle-strengthening exercises, coordination exercises, ambulation (walking) exercises, general conditioning exercises, transfer training, and use of a tilt table.

Range-of-Motion Exercises: Range of motion commonly becomes restricted after a stroke or prolonged bed rest. Restricted range of motion can cause pain, reduce a person's functional level, and predispose a person to bedsores.

Range of motion is evaluated with an instrument, called a goniometer, that measures angles of joint motion. Range of motion typically declines with age; even so, the decrease in range of motion does not usually prevent healthy older people from being able to perform self-care activities.

See the figure Increasing the Shoulder's Range of Motion.

Range-of-motion exercises may be active, for people who can exercise a muscle or joint without assistance; active-assistive, for people whose muscles are too weak to exercise without assistance or for people who experience pain during joint movement; or passive, for people who cannot actively participate. Active-assistive and passive range-of-motion exercises are performed very gently to avoid injury, although some discomfort may be unavoidable.

Before beginning therapy, the physical therapist determines if restricted motion is the result of tight ligaments and tendons or of tight muscles. If tight muscles are the cause, a joint may be stretched more vigorously. If tight ligaments or tendons are the cause, gentle stretching is attempted, but surgery is sometimes needed before progress can be made with range-of-motion exercises. An affected joint is moved beyond the point of pain, but the movement should not cause residual pain (pain that continues once the movement is stopped). Sustained moderate stretching is more effective than momentary forceful stretching. For sustained stretching, weights with pulleys are applied for about 20 minutes per day.

Muscle-Strengthening Exercises: Many forms of exercise increase muscle strength; all involve progressively increased resistance. When a muscle is very weak, gravity alone is sufficient. As muscle strength increases, resistance is gradually increased, either with stretchy bands or weight training. In this way, muscle mass and strength are increased, and endurance improves.

Coordination Exercises: These task-oriented exercises are for people who have problems with coordination and balance, usually as a result of a stroke or brain injury. The exercises involve repeating a meaningful movement that works more than one joint and muscle, such as picking up an object or touching a body part.

Ambulation Exercises: The purpose of these exercises is to improve a person's ability to walk independently or to walk with assistance. Before starting ambulation exercises, some people need to improve a joint's range of motion or muscle strength. Some people need an orthotic device such as a brace. Training may begin on parallel bars, especially if the person's balance is impaired, and progress to walking with mechanical aids, such as a walker, crutches, or a cane. Some people must wear an assistive belt, which the therapist uses to prevent the person from falling.

As soon as a person can walk safely on a level surface, training to step over curbs or to climb stairs may be initiated. A person being taught to climb up stairs is instructed to step up with the uninjured leg first. To climb down stairs, the person is instructed to step down with the injured leg first. These instructions can be memorized with the phrase "good is up, bad is down."

General Conditioning Exercises: A combination of range-of-motion, muscle-strengthening, and ambulation exercises is used to counter the effects of prolonged bed rest or immobilization. General conditioning exercises help restore proper blood flow and increase heart and lung function.

Transfer Training: Transfer training is often a critical goal of rehabilitation, because people who cannot transfer safely and independently from bed to chair, chair to toilet, or chair to a standing position generally require 24-hour assistance. The techniques used in transfer training depend on whether the person can bear weight on one or both legs, has sound balance, or is paralyzed on one side of the body. Assistive devices can sometimes help. For example, people who have difficulty standing from a seated position may benefit from a self-lifting chair, a chair with a raised seat, or another assistive device.

Tilt Table: For people who have low blood pressure and who get dizzy when they stand up (orthostatic hypotension (see Section 3, Chapter 23)), a tilt table may help. The person lies face up on a padded table with a footboard and is held in place with a safety belt. The table is tilted so that the angle is very slowly increased until the person is nearly upright. By slowly increasing the angle, the person's blood vessels regain the ability to constrict. How long the position is maintained depends on the person's tolerance, but it should not exceed 45 minutes. The tilt-table procedure is performed once or twice a day; its effectiveness varies depending on the person's disability.