New Treatment of the Orthopedic Patient
The Physician/Physical Therapist Relationship
Physical therapists have, historically, treated many musculoskeletal problems, particularly low back pain, using modalities such as ultrasound, heat, cold, and a range of motion exercises. These treatments were prescribed by physicians and carried out by physical therapists with varied results. The general thought regarding physical therapy seemed to be: “well, it probably won’t hurt so let’s give it a try”.
There was little change in this “give it a try” attitude. In the eighties, however, physical therapists began receiving additional training and understanding of exercise physiology. This training brought validity to the profession. With the increase in education of physical therapists, physicians began to rely more on the physical therapist’s judgement for managing their patients’ musculoskeletal problems.
By allowing the therapists to draw upon their pool of knowledge, treatments have become more precise and customised. This alliance has grown to the extent that physical therapists, having completed special orthopedic residencies, can now assist physicians in rendering a mechanical or functional diagnosis. (see “Medical Journal of Australia”, March 7 1988)
Physical therapists have developed a variety of treatment protocols which are now standards in healthcare. For example: Robin McKenzie developed back extension exercise; Clive Brewster developed an anterior cruciate ligament rehab; Jerry Lampe is known for his work in the application of transcutaneous electrical nerve stimulation; and D D Kelsey developed an exercise technique known as Unloading® Exercise Therapy. Unloading® Exercise Therapy is the newest of the methods and deserves an explanation of its origin and applicability.
Unloading® Exercise Therapy- The Basis
Unloading Exercise Therapy is defined as mechanically offsetting a portion of the patients bodyweight by a specified amount acquired by testing. This can be done through the use of a harness and a specially designed apparatus, the Zuni Exercise System, or with other equipment designed for this purpose. By removing a portion of the patient’s bodyweight, exercises can be performed in functional positions such as walking climbing stairs, squatting etc.
Why is Unloading® Exercise Therapy so important in the orthopedic patientω The answer is two-fold: tissue response to training and specificity of training.
Tissue Response and Training
Tissue responds adequately to the stresses placed upon it up to a certain point. Our bodies are amazingly adaptable and plastic, but all tissue has a point of fatigue: an amount of stress that when exceeded causes damage and evetually pain.
In rehabilitation, our goal is to stimulate tissue and to heal and gain both strength and endurance to allow maximal loading during everyday activities and recreation. The pain present with damaged tissue often prevents therapists from designing precise treatment programs for a particular injury. In terms of chronic conditions, it may be that the patient is functioning at or beyong their tissues’ point of fatigue. Thus, exercising has been difficult as it generally tends to increase pain in conditions such as osteroarthritis, tendinitis, and degenerative disc disease.
Low Back Patient
Saltin demostrated in 1976 that a large part of the improvements that follow aerobic training represent local changes in the internal structure and chemistry of working muscles (see appendix for Saltin’s study)
This is clinically relevant in the patient with uncomplicated low back pain. If the patient’s complaints relate to activities such as bending, lifting, walking etc. It may be that exercise would be helpful. But what typeω
Keeping in mind that a large part of the changes that occur with training are local events, we would want to stress the tissues of the spine (ligaments, disc, tendon, muscle, bone) that are proving troublesome. The only way to do this is to remove some of the load that those tissues are exposed to which will allow training to begin in a non-painful state. This is Unloading® Exercise Therapy. With Unloading® Exercise Therapy, exercise in functional patterns can begin early without increasing pain. By using Unloading® Exercise Therapy, you not only achieve pain relief, but you also dramatically increase the tissue capacity for the stresses of everyday activities.
This is very helpful in exercising an acute injury. In the past, these situations would have required relative inactivity until most of the pain had subsided. At that point, William’s flexion exercise, stretching, extension exercises, and pelvic tilts would begin. But if you examine the specificity of these exercises,
there is no training to improve the loading capacity of the tissue. Unloaded functional exercise solves this problem.
Unloading® Exercise Therapy and Walking for Back Patients
Holm has shown that lack of oxygenation may be an etiological factor in disk degeneration. He demonstrated that a minimum of 30 minutes of movement in a motion segment is required in order to improve the nutritional status of the disc. By oxygenating the tissue, we may be decreasing the pain experienced as well.
For years we have advocated walking for back patients for these reasons. The problem has been, how do you get 30-60 minutes of steady movement out of a patient who is in pain and refuses to moveω When discussing this with back patients, the time that they can walk without increasing their pain is often much less than 30 minutes.
Using Unloading® Exercise Therapy on the treadmill will allow walking for extended periods of time (40-90 minutes). Pain reduction occurs, but more important is the oxygenation that occurs in the disc. With Unloading® Exercise Therapy, we have provided the patient with an answer for the acute problem of pain annd the chronic problem of poor oxygenation.
How Unloading® Exercise Therapy Compares in Terms of Time and Expense
An aspect of healthcare that is of concern to all parties is the cost and length of treatment. How does Unloading® Exercise Therapy compare to other methods in these areasω
In a retrospective study performed at a physical therapy clinic of Corley & Kelsey comparing two groups of knee patients (both groups had reconstructive surgery, n = 4), the group treated using Unloading® Exercise Therapy regained active range of motion in 66% less time than the group treated with traditional methods (p=.005). In addition, the group treated with traditional methods had 58% more pain complaints than the unloaded group (p=01).
There was no difference in the two groups final active ranges. Both methods of treatment will give the same end result, but Unloading Exercise Therapy does it much faster with significantly less pain.
Specificity of Training
The challenge with specificity of training is to train the local tissue involved (ligaments, cartilage, muscle, tendon, and bone) in such a way that their capacity is increased. We know, for example, that swim training will improve one’s capacity to to swim, but it will not affect one’s capacity to walk or run. Therefore exercise programs must be geared toward stresses that the patient must face on a day to day basis. We are not only strengthening muscle but also the non-contractile structures.
Medial Collateral Strain Patient
Let’s use a patient with a medial collateral strain as an example. After appropriate rest and medication, it is decided the rehabilitation for the lower extremity is indicated because the patient still has pain with walking and climbing stairs. The patient is referred to a physical therapist.
Does it matter what types of exercises are chosen for a patientω Traditionally, quad sets, straight leg raises, and knee extensions would be included in such a lower extremity program, but knowing what we do about specificity of training, are these appropriateω Clearly, what would benefit the patient most are activities that address the specific problems – walking and climbing stairs. But the patient has pain with these activities and this option would not normally be chosen. Unloading® Exercise Therapy allows us to address both issues.
With the patient unloaded (that is in a harness with a portion of their bodyweight offset by the Zuni Exercise Therapy), we can begin a walking program on a treadmill at a controlled speed. Progression of the patient includes gradually increasing the speed of walking and gradually increasing the amount of bodyweight that the lower extremities are supporting. With Unloading® Exercise Therapy, we can reduce the load to a non-painful state and begin training in walking, preparing the tissues for eventual full bodyweight. While it is true that quad sets and straight leg raises have worked for years in reducing pain and increasing endurance, they are not specific enough. With exercise, just as it is with medication, type, dosage, and frequency are important.
Summary
The use of Unloading® Exercise Therapy offers a method of exercise that can be used early in injured patients promoting functional activities. It has been shown to provide faster gains in range of motion thereby making it less costly than traditional types of intervention, and it is less painful for the patient. It requires patients to become an active participant in their care and gives them a foundation upon which to build and maintain their improved state of health. The use of Unloading® Exercise Therapy provides an environment in which all participants gain.
Appendix
Saltin studied the effects of one – legged bicycling for six weeks on three groups of individuals.
Group 1 : trained sprinting for one leg and endurance for the other leg
Group 2 : trained sprinting for one leg and no training for the other leg
Group 3 : trained endurance for one leg and no training for the other leg
Results
- Maximum oxygen intake changed the most in the group that trained endurance for one leg and had no training for the other leg. (Group 3)
- Maximum oxygen intake improved less for the group that did sprint training for one leg and no training for the other leg. (Group 2)
- Sprint training for one leg and endurance training for the other leg caused this group to demonstate less increases in maximum oxygen uptake when compared with the groups that trained only one leg – either sprint or endurance. (Group 1)
Lawrence W. Styles, MPT, OCS, MTC
PT Today, May 29, 1995