Exercise and Active Physical Therapy
Exercise as a therapeutic intervention is defined as a structured, repetitive, physical activity aimed to improve or maintain physical fitness (Caspersen, 1985). Clinicians should consider the effectiveness, appropriate dose and potential adverse events when prescribing exercise or physical therapy. A patient-centered approach encourages the patient to be an active participant in the treatment program, which improves clinical outcomes (Jordan, 2010).
Active therapy is defined as strength training and/or conditioning exercise performed by patients under the direction of a licensed practitioner such as a physician, physical therapist or athletic trainer.
- All patients with chronic pain should participate in an exercise program to improve function and fitness (Malmivaara, 2006). Formal physical therapy and recreational or self-directed exercise are both beneficial for chronic pain rehabilitation.
- Exercise under expert direction of a physical therapist has demonstrable efficacy in the medical literature in improving pain symptoms and functional performance in chronic pain patients (Falla, 2013; Cuesta-Vargas, 2011; Standaert, 2011; van Middelkoop, 2011; Hall, 2008; Hurwitz, 2008; Malmivaara, 2006; Hayden, 2005).
- Since most patients with chronic pain are physically deconditioned from inactivity, graded or progressive physical therapy is recommended. This approach is better tolerated in this population, which improves patient participation and compliance. Progressive therapy focuses on motor learning principles where specific muscular contractions are first learned and mastered before moving on to a sequence of muscular movements with increasing load (Falla, 2013; Jull, 2009; Lindström, 1992).
- One type of exercise has not been shown to be definitively more effective than another. Studies have shown benefit of flexion exercises, extension exercises, isokinetic intensive machine muscle strengthening, and group aerobic low-impact exercises. Group aerobic exercise and stretching can be as beneficial as structured land-based physical therapy, suggesting this is a reasonable, low-cost alternative for patients (Mannion, 1999).
- Aquatic physical therapy, usually performed in warm water (30-35ºC/86-95ºF), is well tolerated by patients with painful chronic musculoskeletal or neurologic disease. The buoyancy and thermal comfort of warm water exercise decreases nociception via multiple physiologic mechanisms and increases ease of movement (Hall, 2008). Appropriate indications for aquatic therapy are gait instability, neuromuscular disease, inflammatory or degenerative joint disease, morbid obesity, or deconditioning secondary to acute/subacute medical illness (Dundar, 2009). Two sessions of aquatic therapy per week is equally efficacious as three sessions per week (Cuesta-Vargas, 2015).
- Active physical therapy for chronic spinal pain conditions should show clinical improvement in pain and function within 8-12 weeks of initiation. Typical physical therapy sessions are 30-90 minutes, occurring two to three times per week, often with an additional daily home exercise program of 10 minutes.
- If no clinical benefit occurs within this time frame, the appropriateness and efficacy for the prescribed physical therapy should be reconsidered (Cuesta-Vargas, 2015; Cramer, 2013; Falla, 2013; Standaert, 2011).
- Geriatric patients can benefit from a physical rehabilitation program. The American Geriatric Society Panel of Exercise and Osteoarthritis encourages light- to moderate-intensity physical activity for both prevention and possibly restoration of health and functional capacity in patients with chronic disease (American Geriatrics Society Panel on Exercise and Osteoarthritis, 2001).
Passive Physical Treatments
Passive therapies are defined as the external application of manual and physical treatments to the patient by a clinician. As part of the Choosing Wisely® campaign, the American Physical Therapy Association recommends that clinicians don't employ passive physical agents except when necessary to facilitate participation in an active treatment program. The definitions and indications for conventional passive physical modalities are detailed below.
Spinal manipulation therapy
This is a specific type of manual therapy performed directly on patients by specially trained physicians (DO, MD), chiropractors and physical therapists. It usually involves applying high-velocity low amplitude thrust movements, or slow passive muscle relaxation techniques to increase range of motion and reduce spinal pain.
- Manual therapies treating chronic non-specific axial neck pain have been demonstrated, in a systematic review of high-quality RCT's, to have moderate short-term efficacy and minimal long-term efficacy. Manual therapies included in this review were typical chiropractic or osteopathic technical procedures: manipulation, passive mobilization and myofascial relaxation techniques. There was not one particular manual therapy superior to the others. A key finding was that concurrent exercise therapy improved the efficacy of all manual therapies (Vincent, 2013).
- Spinal manipulation therapy for chronic low back pain has similar clinical improvements relative to structured exercise after two months. This was based on a rigorous systematic review, though the evidence for this conclusion is low (Standaert, 2011).
- Spinal manipulative therapy has been shown to be effective in the early intervention of low back pain (Dagenais, 2010; Walker, 2010; Jüni, 2009; Santilli, 2006; Assendelft, 2004).
Traction therapy is an applied external force to physically distract spinal facet joints and intervertebral foramina. It can be applied manually or with mechanical devices such as a home cervical traction unit.
- Cervical spine traction for radiculopathy and axial neck pain is a common practice, though high quality RCTs have not shown any significant clinical benefit over standard physical therapy (Young, 2009; Borman, 2008).
- There is a paucity of recent prospective trials for lumbar spinal traction therapy, and currently there is not any high-quality evidence showing clinical efficacy.
- It is contraindicated in patients with cervical spine instability or craniocervical junction anatomical derangement as seen in rheumatoid arthritis or advanced cervical spondylosis.
Massage therapy is the manual manipulation of musculoskeletal and connective tissue to improve relaxation and enhance physical rehabilitation.
- Massage therapy has been shown to reduce pain scores for patients with low back pain (Hsieh, 2006; Cherkin, 2001), osteoarthritis of the knee (Perlman, 2006), juvenile rheumatoid arthritis (Field, 1997), chronic neck pain (Bakar, 2014) and fibromyalgia (Brattberg, 1999).
- Yet to be determined are the optimal number, duration and frequency of sessions for treating pain.
Transcutaneous electrical nerve stimulation (TENS)
TENS therapy is the application of low-voltage electrical stimulation to the skin with contact electrodes. Conventional technique uses four electrodes placed around the painful region, delivering 10-30 mA electrical intensity at high frequency (40-150Hz) for 30-60 minutes duration once or twice daily. The proposed pain control mechanisms involve sensory modulation of the central nervous system via the Gate and Endorphin Theories (Cifu, 2016).
- Most chronic neuropathic and musculoskeletal pain syndromes can be safely treated with TENS therapy (Cifu, 2016).
- Application near or over a pacemaker/implanted defibrillator, anterior neck, anterior chest, gravid abdomen or insensate skin is contraindicated due to the potential risks (Cifu, 2016).
Ultrasound therapy is the application of high-frequency sound waves (> 20,000 Hz) to the skin for deep soft tissue heating using a piezoelectric sound generator, which is also called a transducer. Treatment goal is to increase tissue temperature to 40-45ºC (104-113ºF) for therapeutic effects of increased blood flow, decreased chronic inflammation, increased soft tissue flexibility and reduced pain (Cifu, 2016).
- Usual indications are painful musculoskeletal conditions: muscle spasm, contracture, chronic inflammation, and chronic joint and tendon pain (Cifu, 2016).
- Due to the physical properties of ultrasound, prolonged use directly over cortical bone could potentially lead to excessive heating and thermal injury (Cifu, 2016).
- Only competently trained practitioners should apply this modality (Cifu, 2016).
Lumbar spine corsets and braces
There is a multitude of available off-the-shelf (OTS) and custom-fitted (Rx), circumferential lower torso braces typically termed corsets, which are soft, or lumbosacral orthoses, which are semi-rigid or fully rigid, from integrated hard plastic or metal panels. This group of appliances exerts minimal external structural support to the lumbar spine by increasing intra-abdominal pressure and provides increased spinal proprioception to improve posture. Goals of application are to minimize painful or abnormal lumbar spinal motion and improve activity endurance by increasing paraspinal muscle tone (Rao, 2012).
- Usual indications are subacute or chronic lumbar spinal disease and injury such as disc herniation, stable vertebral compression fractures, arthritic pain, lumbar scoliosis, paraspinal muscle strain or non-specific chronic low back pain.
- Prescription lumbosacral orthoses are fit by orthotists, who are licensed practitioners with expertise in creating and applying braces.