MEDICAL REHABILITATION AT DISEASES OF CARDIAL-VASCULAR SYSTEM, IN DISEASES OF RENAL AND IN UROLOGY, IN ENDOCRINE DISEASES AND METABOLIC DISORDERS
CARDIAC REHABILITATION
Define cardiac rehabilitation (CR).
A series of definitions should provide perspective:
The American Association of Cardiovascular and Pulmonary Rehabilitation defines CR as “the application of rehabilitative services to improve and maintain a patient’s physiologic, physical, psychosocial, and vocational functioning at an optimal level.”
The
We define CR similarly but emphasize the person as the center for rehabilitation goals and the key to success. CR is a patient-participative interdisciplinary process that seeks to enhance the patient’s personal effectiveness through education, cardiac risk prevention, cardiovascular and psychosocial adaptation and lifestyle changes, functional improvement, and reintegration into community functions.
Patients who have physiological, functional, and psychosocial deficits related to impairments of the cardiovascular system can benefit from CR. This includes patients with the following diagnoses or cardiovascular conditions: ischemic heart disease, recent myocardial infarction, post-coronary artery bypass graft (CABG) surgery, post-percutaneous transluminal coronary angioplasty (PTCA), post-cardiac transplant, post-heart valve replacement, stable angina and congestive heart failure.
The 1993 statistics indicate that CAD affects 13.5 million Americans. Seven million suffer from stable angina and could benefit from CR. One and one-half million suffer myocardial infarction each year, and almost 1 million survive. Forty-five percent of all myocardial infarctions are in persons under age
Cardiac rehabilitation is available locally for people who have had:
Heart attack (myocardial infarction / coronary)
Coronary artery bypass grafts
Valve surgery
Heart failure
Percutaneous coronary intervention (PCI / angioplasty and stenting)
Angina
During your hospital stay patient will automatically be referred to the cardiac rehab team by a member of the nursing or medical staff on your ward or department. However, if patient feel that you require cardiac rehabilitation but have not been referred to the service, please feel free to contact the Cardiac Rehabilitation Team who will provide you with advice and support.
Patients with cardio-vascular pathology to prefer a “cardiac diet” of foods that are low in cholesterol, salt, saturated fat and caffeine. These facilities offer a comprehensive program of exercise, nutrition, education, and support provided by specially educated cardiac rehabilitation specialists.
Achieve an overall healthy eating pattern.
Choose a balanced diet with food from all major food groups, emphasizing fruits, vegetables and grains
Consume a variety of fruits, vegetables and grains
At least 5 daily servings of fruits and vegetables
At least 6 daily servings of grain products, including whole grains
Include fat-free and low-fat dairy products, fish, legumes, poultry and lean meats
Eat at least 2 servings of fish per week
Achieve a Healthy Body Weight
Limit foods that are high in calories and/or low iutritional quality, including those with a high amount of added sugar
Maintain a level of physical activity that achieves fitness and balances energy
Expenditure with caloric intake
Expenditure should exceed intake for weight reduction
Achieve a Desirable Cholesterol Level
Limit foods with a high content of saturated fat and cholesterol
Substitute with grains and unsaturated fat from vegetables, fish, legumes and nuts
Limit cholesterol to 300 mg a day for the general population, and 200 mg a day for those with heart disease or it’s risk factors
Limit trans fatty acids
Trans fatty acids are found in foods containing partially hydrogenated vegetable oils such as packaged cookies, crackers, and other baked goods as well as commercially prepared fried foods and some margarines
Achieve a Desirable Blood Pressure
Limit salt intake to less than 6 grams (2,400 mg sodium) per day ? slightly more than 1 teaspoon a day
If patient drink, limit alcohol to no more than 1 drink per day
Exercise: Many people with heart problems aren’t used to regular exercise, or they feel nervous about exercising after experiencing a heart attack or chest pain. Program rehabilitation allows patients to starts exercising slowly a few times per week under the supervision of cardiac nurses and exercise physiologists. Typically, patients will start with light aerobic activity, for the first two weeks, progressing slowly and using various types of equipment such as a treadmill, stationary bike, and free weights.
Cardiac rehabilitation is a medically supervised program to help heart patients recover quickly and improve their overall physical, mental and social functioning. The main source of heart problem is often due to high blood pressure, smoking, high blood cholesterol, physical inactivity, obesity and diabetes. People should take care of their heart both before and after a heart problem starts. As per physician advice, cardiac rehabilitation is helpful to patients with congestive heart failure, chest pain due to clogged heart arteries, recent heart attack, and coronary bypass surgery, etc. Research has found that only 20 percent of patients seek cardiac rehabilitation after a heart attack or coronary bypass surgery. Rehabilitation has been found to help people reduce the risks of subsequent cardiac disease or disability by educating them about the cause and consequences of heart problem.
The rehabilitation helps patients in many ways. If someone has had a heart attack, they may be afraid to exercise because exercise training as part of cardiac rehabilitation may not be safe for all patients. For example, people who have very high blood pressure or severe heart disease may not be ready to exercise. These patients can still benefit from other parts of the cardiac rehabilitation program. Rehabilitation programs include exercise training, education on heart healthy living, and counseling to reduce stress, tension and help people return to an active life. People of all ages can benefit from cardiac rehabilitation but the lifestyle changes made during rehabilitation must be implemented. These changes can improve your overall health and prevent future heart problems. Now, rehabilitation includes helping patients with smoking cessation, diet, risk factors, and lifestyle habits. Rehabilitation best suits people who are just recovering from a heart attack or heart related illnesses as well as people who would like to regain their strength and fitness after a heart surgery. Cardiac Rehabilitation plays a vital role in bringing people to active life safely.
In particular, patient may benefit from cardiac rehabilitation if your medical history includes:
§ Heart attack
§ Coronary artery disease
§ Heart failure
§ Peripheral arterial disease
§ Angina
§ Cardiomyopathy
§ Certain congenital heart diseases
§ Coronary artery bypass surgery
§ Valve replacements
Cardiac rehabilitation team will tailor a program for patients based on your specific health situation and goals. Most cardiac rehabilitation programs last about three to six months. During that time, patients may work with cardiologists, nurse educators, dietitians, exercise rehabilitation specialists, occupational therapists, physical therapists, psychologists and psychiatrists.
Here’s what to expect, in general, during the three basic phases of cardiac rehabilitation:
§ In the hospital. Cardiac rehabilitation program starts while still in the hospital. Patients may begin with nonstrenuous activities, such as sitting up in bed, range-of-motion exercises and self-care, such as shaving. Then progress to walking and limited stair climbing.
§ Early recovery. This phase of cardiac rehabilitation begins when patient leave the hospital. It generally lasts from two to 12 weeks. During this phase, patients gradually increase his activity level, usually under the close supervision of patient cardiac rehabilitation team. Your team might suggest exercises you can safely do at home, such as walking and gentle calisthenics. You also learn about eating a healthy diet, quitting smoking, coping with your condition, resuming sexual activity and finding social support. If you don’t have a nearby medical facility with a cardiac rehabilitation center on site, your team can advise you about safely using a gym.
§ Late recovery. This is a long-term maintenance program — something to follow for the rest of your life. By this point, you probably will have developed your own exercise routine at home or at a local gym. You may also continue to exercise at a cardiac rehab center. You may remain under medical supervision during this time, particularly if you have special health concerns. Education about nutrition, lifestyle and weight loss may continue, as well as counseling. For best success, make sure your exercise and lifestyle practices become lifelong habits.
At the heart attack of miocarda there is the ischemic hearth of necrosis of cardiac to the muscle as a result of thrombosis or protracted spasm of one of coronal arteries of heart.
Value of physical rehabilitation of patients it is heavy to over-estimate by the heart attack of miocarda. Program of rehabilitation of patients by the heart attack of miocarda – it is the complex of successive stages of rehabilitation in cardiologic permanent establishment, in the separated rehabilitations of local cardiologic sanatorium and in policlinics at the place of inhabitation hvorgo.
The early beginning, complexity, continuity and sequence of all stages of rehabilitation is principles of physical rehabilitation.
Task of stationary stage of rehabilitation:
1) to attain such level of physical activity, that a patient could to serve itself;
2) to walk up one floor on shoots;
3) to carry out walks to 2-
Task of sanatorium stage of rehabilitation:
1) renewal of physical capacity;
2) psychological readaptatsion patient;
3) to prepare a patient to the independent life and production activity.
Task of clinical-policlinic stage of rehabilitation:
1) renewal of function cardio-vascular system;
2) rise of tolerance to the physical loading;
3) the second prophylaxis IDH
4) renewal of capacity, returning to professional activity;
5) partial or complete waiver of supporting medicinal therapy;
6) Improve quality of life of the patient.
A working group VOOZ recommends 3- and 5- a week’s the programs of stationary stage of rehabilitation of patients by the heart attack of miocarda. V.A. Silouyanova, E. Recommend V. Socova (1978) and 6 a week’s program of physical rehabilitation .
Forms TPE: medical gymnastics, morning hygienical gymnastics, individual tasks for independent employments.
Conduct a medical gymnastics from initial position lying on the back, from active (and sometimes passive) exercises in the distalnih departments of extremities. The rate of implementation is slow, every exercise is repeated 3-4 times. Duration of employment 3-5 minutes. In a complex include no more than 8 exercises: static respiratory exercises, motions by the brushes of hands, feet, exercises on weakening, passive exercises for the middle muscular groups of overhead and lower extremities, turns of head, not tearing away her from a pillow.
At the adequate reaction on loading in 2-3 days a complex LG needs to be extended: the quantity of reiterations of exercises is multiplied at first, and later in a complex new exercises are included for preparation of patient to the turn on a side. First the sick comes back on a right side at the help of methodist in the presence of doctor on 1 hv, then again comes back on the back and continues employment.
If a patient mastered the complex of physical exercises and turns on a side, he can before breakfast execute a morning hygienical gymnastics, using the trained exercises, and after a quiet hour can repeat this complex as independent employments.
Medical physical education on the sanatorium stage of rehabilitation:
Task:
а) renewal of physical capacity of patients;
б) psychological readaptation;
в) preparation of patient to the independent life and production activity.
Principles of rehabilitation:
1. The program of physical rehabilitation is logical continuation of previous stage of restoration medical treatment. Determining the motive mode, it is necessary to take into account all types of physical activity of patient (domestic, professional). Underestimation of these data, wrong the produced mode of motive activity, labour and rest can be entailed by worsening of coronal insufficiency or negative gemodinamic changes. Therefore after the previous stage of medical treatment it is necessary to lower the executable to the patients previous loading and get back to him only on 7 – a 10 day.
2. Gradual increase of the physical loading and stabilization of motive activity in accordance with functional possibilities of the cardio-vascular system of patient.
3. Continuity, regularity of loading. Only frequent, constantly an operating factor is instrumental in adaptation to loading.
4. Simplicity of using method, that it is necessary for the perfect process control of the proper medical treatment.
What are the overall goals of the CR process?
To reduce myocardial ischemia and the risk of infarction or sudden death
To prevent and reverse atherosclerosis
To maximize cardiovascular capacity and fitness
To maximize exercise tolerance and ADL performance
To establish a patient-controlled and safe aerobic exercise program
To provide guidelines for safe activities and work
To control risk factors for CAD
To help patients cope with perceived stressors
To utilize energy conservation and work simplification
To improve quality of life
Describe the phases of the CR process.
The CR intervention sequence integrates into the classic medical continuum of care and management of any illness: prevention, acute care (medical/surgical), and rehabilitation. The typical patient referred for CR has sustained a myocardial infarction and/or undergone CABG. CR has therefore typically been divided into three sequential phases that bring the patient out of acute care:
Phase I—Inpatient phase from hospital admission to hospital discharge.
Phase II—Outpatient training phase includes aerobic conditioning, reacquisition of full activity, risk factor management, and lifestyle changes.
Phase III—Maintenance phase, with patient-monitored continuation of the aerobic exercise program, risk-reduction strategies, and activity/work modifications.
These phases represent a timeline for the process of intervention. It is important to recognize that many interventions continue through the phases on an ongoing basis and that the application of CR interventions should be tailored to the need of each individual.
How is cardiovascular impairment estimated by the rehabilitation team ?
The history, physical examination, and review of cardiac enzymes, EKG, coronary catheteri-zation, cardiac images, and other pertinent tests may reveal the severity of CAD and help to determine the patients who are at low, moderate, or high risk for complications upon application of activity and exercise program. The following components are to be included in each evaluation.
History: angina (typical, atypical, nocturnal, progressive, as well as activity limits and intensity required), modifiable risk factors (smoking, hypertension, hyperlipidemia, diabetes mellitus, sedentary life style), dyspnea (exertional), paroxysmal nocturnal dyspnea (1-5 hr after recumbent), fatigue level (exercise tolerance), and premorbid level of physical and psychosocial functioning.
Physical exam: vital signs, orthostatics (pulses and BP while supine, sitting, and standing up, if possible), pulses, jugular venous distention, cardiac auscultation (murmurs, gallops), pulmonary assessment (rales), abdominal exam (hepatojugular reflux, bruits), edema, and tolerance of functional activities. Musculoskeletal and neurologic exams are also essential to determine any associated impairments that may affect functional and exercise training.
Functional clinical evaluations (to assess tolerance): grooming, bathing, dressing, bed mobility, transfers, ambulation, stairs, aerobic exercises, work capacity. The intensity and extent of functional testing depend on how many days the patient is after the cardiac invent. Measure heart rate and BP before and perceived rate of exertion after the functional test. This is specifically important to do during the implementation of the Phase I program.
Laboratory tests (to review): total creatine kinase-MB, hematocrit, EKG (arrhythmias,Q waves, estimate MI severity, and ST-T wave changes during subsequent testings), BUN/CR ratio,Cardiac Rehabilitation
echo/MUGA (ejection fraction), cardiac exercises stress tests, or other cardiac imaging tests or studies.
From the patient’s history and above findings, each patient is stratified as low, moderate, or high risk in order to determine the level of required supervision. The patient’s intensity of aerobic exercises for the Phase II program could be obtained from exercise tolerance test.
What are possible contraindications for entry into inpatient or outpatient exercise programs?
According to the
Unstable angina
Resting systolic BP > 200 mmHg
Resting diastolic BP > 100 mmHg
Orthostatic BP drop or drop during exercise training of > 20 mmHg
Moderate to severe aortic stenosis
Acute systemic illness or fever
Uncontrolled atrial or ventricular dysrhythmias
Uncontrolled sinus tachycardia (120 bpm)
Uncontrolled congestive heart failure
Third degree A-V block
Active pericarditis or myocarditis
Recent embolism
Thrombophlebitis
Resting ST displacement (>
Uncontrolled diabetes
Orthopedic problems that prohibit exercise
What are the foci of intervention during phase I, the inpatient phase of CR?
Early ambulation and ADL training under supervision
Alleviation of anxiety and depression
Reassurance to reestablish patient’s control of self
Patient education regarding rationale for treatment and exercises
Medical evaluation of cardiac injury, EKG and enzyme changes, imaging
Development of a team knowledge base of the patient’s previous activities and work, and life
roles as well as current personal goals that he or she wants to achieve during CR. Establish modifiable risk factor reduction strategies Assessment of cardiovascular function and impairments Establish level of the risk for development of complications; risk stratification Prescription and education with guidelines for activity and work after discharge.
Describe the relationship between heart rate, stroke volume, cardiac output, aerobic capacity, and the anginal threshold.
The maximum heart rate (HR) is defined as the maximum HR obtained on an exercise stress test. It decreases with age and can be estimated for the normal population by subtracting the patient’s age in years from 220. Stroke volume (SV) is the amount of blood ejected with each ventricular contraction and increases with exercise to become maximum at 50% over the basal HR (resting HR). Cardiac output (CO) equals HR x SV and relates directly to the total body oxygen consumption (VO2) because all O2 consumed is delivered to the body tissues via the blood. Maximum aerobic capacity (VO2 max) is the greatest rate (VO2 ml/kg body mass/min) of 02 consumption a person is capable of metabolizing, and it relates directly to maximum work output in watts. One way to understand and calculate VO2 max is to use the formula SV x HR x (arterial-venous O2 difference), which integrates the delivery and extraction of O2. Thus, an increase in CO, the product of S V x HR, and/or increase in arteriovenous O2 difference increases in V02 maximum. It decreases with age, inactivity and after MI. The anginal threshold is defined as the CO at which myocardial O2 demand exceeds O2 delivered. An ischemic myocardium is not capable of maintaining the same cardiac work load, which results in a fall in CO, VO2max, and/or BP.
The significant risk factors for developing CAD are age, male sex, elevated total cholesterol, elevated low-density lipoprotein (LDL) cholesterol, low level of high-density lipoprotein (HDL) cholesterol, elevated systolic or diastolic BP, diabetes, obesity, sedentary lifestyle, cigarette smoking, stress, family history of premature coronary disease, and EKG evidence of left ventricular hypertrophy. From the risk factors reported in the
Which types of cardiac stress tests are used to evaluate for cardiac ischemia or dys-rhythmias?
EKG stress test stratifies risk and determines exercise and work capacity in METS. The test includes EKG monitoring for heart rate, arrhythmia, ischemia (ST depression >
Nuclear medicine stress testing such as thallium-201 scintigraphy uses exercise orva- , sodilators (dipyridamole, adenosine), which increases the cardiac steal phenomenon (stiff, narrowed vessels dilate less), to evaluate CAD. Immediate perfusion studies indicate myocardia blood flow in various vessel territories. Changes in delayed images 2 to 24 hours later demonstrate viable myocardium.
Dobutamine HC1 echocardiography assesses areas of cardiac ischemia by determining regions of wall motion abnormalities. The cardiac demand is increased by dobutamine, which increases both HR and BP. Therefore, in contrast to the dipyridamole thallium tests, dobutamine stress echocardiograms not only identify coronary ischemia (sensitivity 95%, specificity 82% vs catheterization) but also reveal the ischemic anginal threshold and the maximum HR and BP, or rate-pressure product. This additional information helps prescribe the patient’s cardiac guidelines for exercises, activities, and work.
What are the major goals of phase II, the outpatient phase of CR?
Besides continuing the goals of phase I CR, the major goals of phase II are:
1. To achieve cardiovascular conditioning and fitness via an aerobic exercise training program
2. To achieve control of modifiable risk factors using psychosocial and pharmacologic interventions and lifestyle changes
3. To achieve an early return to work.
During phase II of the CR program, the patient will be educated to self-monitor for the appropriate level of exercise, work, or activities via HR monitoring and/or rating of perceived exertion and receive psychosocial support to reduce anxiety and depression. The CR phase II should result in improvements in VO2 max, lowering of HR for a given exercise or workload, and reduced systolic BP and have beneficial peripheral effects on improvement of O2 extraction/utilization by skeletal muscle. It will also result in reduction of anxiety and depression and improved coping mechanisms.
List the five major parts of a CR exercise prescription.
1. Modality—The American College of Sports Medicine recommends that the exercise modality be “any activity that uses large muscle groups, that can be maintained for a prolonged period, and is rhythmic and aerobic iature.”
2. Intensity—Either prescribed by target HR, rating of perceived exertion, or metabolic equivalents. It is usually 60-70% of VO2max for healthy patients.
3. Duration—Depends on the mode and intensity of exercise. Usually it is 20^-5 minutes initially and later may increase to 60-minute sessions.
4. Frequency— while in the hospital daily and at least three times weekly while in the aerobic training and maintenance phases, usually skipping a day between intensive sessions.
5. Rate of progression—Depends on the patient’s individual tolerance, progress, endurance, needs, and goals.
The warm-up period, usually lasting minutes, increases the intensity of exercise gradually from rest to the desired intensity level and also stretches the major muscles that will be used. This warm-up decreases the risk of cardiovascular problems (i.e., delay in onset of angina) and prevents sprain or strain injuries. Some patients, such as those with cardiac transplants and congestive heart failure, need longer periods of warm-up before proceeding to the more intensive aerobic exercises.
It allows gradual reduction of cardiac work and redistribution of blood from muscles and ex-remities to internal organs. A gradual reduction of exercise intensity with continued body movements maintains venous return; prevents pooling of blood in the lower limbs, post-exercise hypotension, and end-organ insufficiencies; and promotes continuous dissipation of heat.
What are the major interventions of phase III, the maintenance phase of CR?
Phase III has the same goals as phase II (the training phase), except that the program is monitored by the patient and/or family. The program continues outside the CR center, in a community-based setting or wherever the patient feels comfortable. The members of the CR team (i.e., physician, therapist, nutritionist, psychologist, social worker) then may be available to assist and advise the patient as needed. The patient continues the level of exercise program achieved and self-monitors his or her own exercises and activities to avoid overexertion. Periodic evaluations should be done to monitor the patient’s progress and tolerance and maintenance of previously achieved goals. Before beginning or changing the exercise program, the patient should check with his or her doctor.
Which changes in lifestyle for CAD are beneficial?
Aggressive lifestyle changes in respect to control of hypertension and smoking, dieting with < 10% of total calories from fat, combined with 3 hours of aerobic exercise per week as well as stress management have been demonstrated to produce clinically significant regression in coronary atherosclerosis as documented by coronary arteriography. In the Lifestyle Heart Trial Study, patients on the American Heart Association-recommended diet of < 30% fat showed progression of their coronary atherosclerosis on repeat catheterization. Such studies suggest that conventional recommendations for patients with CAD are not sufficient to abate or reverse the disease process.
A CR dietary program should provide the metabolites needed for muscle adaption with exercise, reduce risk factors associated with lipids and body fat content, and establish a body habitus that minimizes cardiac work, thus maximizing functional independence. In an attempt to approach this dietary ideal, the amount as well as the content of the diet need to be calculated. The incidence of myocardial infarction in depressed patients is significantly greater, and depression after myocardial infarction increases morbidity and mortality; thus, pharmacologic and psychological intervention are both important components of CR. Adequate social support enhances recovery of patients and is a buffer against stresses.
What modes of aerobic exercise training can be used in SCI patients?
Wheelchair propulsion, arm ergometry, wheelchair cycling using an arm crank, functional electrical stimulation (FES), and hybrid exercise (arm ergometry combined with lower-extremity
Should patients with congestive heart failure be excluded from CR?
No, stabilized and compensated patients with congestive heart failure are capable of achieving an increase in functional capacity up to 20%. Slow progression in the intensity and duration of each exercise session, applied at least for 3 months and thereafter continued with a maintenance program, has demonstrated a significant improvement in function capacity in these patients.
PERIPHERAL VASCULAR DISEASE REHABILITATION
What are the three organ systems most commonly affected by peripheral vascular disease?
1. Arteries and arterioles frequently are affected by atherosclerosis, especially the coronary arteries, carotid bifurcations, and aortoiliac and femoral arteries. In diabetics, the popliteal and tibial arteries and small vessels are affected more frequently than the aortoiliac arteries. Peripheral arterial disease in the lower extremities is one of the best predictors of coronary and carotid atherosclerosis.
2. The venous system is most frequently affected by lower-extremity deep vein thromboses (which can lead to fatal pulmonary emboli) and chronic venous insufficiency.
3. The lymphatic system drains high-protein lymph fluid from the interstitial space through lymphangions, lymph nodes, the lymphatic trunk, and lymphatic duct into the subclavian veins. Lymphedema is a high-protein edema, most often caused by cancer surgery involving the lymph nodes or by parasites in underdeveloped countries.
How frequent is atherosclerotic peripheral vascular disease?
The incidence, if determined by claudication and clinical examination, increases from 1 % between 40 and 44 years of age to 7.5% between 60 and 64 years of age. Of patients with claudication, 15-20% develop rest pain or gangrene and 1-2% require amputation. The incidence is higher when measurements are done using arterial Doppler test, because they are more sensitive than relying on symptoms.
What patient groups and risk factors predict atherosclerotic peripheral vascular disease?
• Lipid disorders—especially low-density lipoproteins and cholesterol.
• Smoking—the strongest predictor of peripheral atherosclerosis.
• Hypertension—exacerbates atherosclerosis by damaging endothelial cells
• Diabetes mellitus—associated with earlier, more frequent, and more rapid development of atherosclerosis
• Family history, obesity, lack of exercise, and hyperuricemia—also predictors for atherosclerosis
What causes intermittent claudication and rest pain?
Intermittent claudication is caused by atherosclerosis and mechanical muscle action preventing an adequate increase in blood supply to the calf muscles during exercise. This increases muscle metabolites and causes calf pain relieved by rest. Many other conditions can mimic these symptoms.
Rest pain occurs because the blood supply is inadequate for resting muscle. This can be exacerbated by edema, and if the leg is elevated to decrease edema, the arterial pressure may decrease further.
What are the signs of atherosclerotic peripheral vascular disease?
• Decreased peripheral pulses, even if no bruit
• Delayed capillary filling
• Rubor (rubor of dependency is a dusky red color occurring within 3 minutes)
• Pallor on elevation: Elevate the leg, and press the sole of the foot for 25 seconds, Thecaptt-] lanes should refill in < 9 seconds.
• Asymmetric temperature (cooler or warmer)
• Trophic changes or early gangrene
Noninvasive Doppler studies are now very effective at confirming the diagnosis, localiznjl the lesion, and measuring severity. It may be helpful to compare the ankle to the brachialpresaKJ (ankle-brachial index).
When should an emergency evaluation and surgery consultation be obtained?
The signs of emergency are rapid onset of the “6 Ps”: pain, pallor, paresthesia, polar (asys-1 metric cooling), paralysis, and pulselessness. These signs may indicate an acute thrombosisotl embolus needing emergency surgery. Vascular surgery also may help salvage a limb if there isi] gradual progression from intermittent claudication to rest pain and then trophic changes.
What are the components of good foot care?
• Wash in lukewarm water (<
• Apply skin cream such as Eucerin, lanolin, or Alpha Keri.
• Check for red spots, cuts, ingrown toenails, or infections.
• Cut nails straight with corners out, not digging in.
• Wear clean cotton socks each day.
• Wear well-fitted shoes, custom modified wheeeded.
• Involve a podiatrist when appropriate. Many skin breakdowns, if caught early and treated appropriately, can be healed without progression to amputation.
Can medications help?
Aspirin decreases platelet function and clotting. In acute cases, anticoagulants may be tali-1 cated. Some feel that pentoxifylline (Trental) decreases blood viscosity, improves microcinA I tion, and may increase walking distance before claudication. Controlling diabetes is impottaU, and use of a multivitamin with antioxidants seems logical.
Can exercise help?
Exercise helps many patients by improving the efficiency of muscle metabolism and walk-1 ing, improving collateral flow, increasing tolerance, and improving emotional outlook. Otte 1 benefits include improvements in lipids, diabetic control, and coronary artery disease. Becauseof I the high incidence of cardiac atherosclerosis, patient should be screened for this. Walking up to I tolerance for 30—45 minutes, three times a week, for several months may be needed before a tt j ference is seen on re-evaluation.
What are the different types of venous disease?
Venous disease is a component of peripheral vascular disease and includes a spectrum of & orders increasing in severity from varicose veins, chronic venous insufficiency, superficial ttat j bophlebitis, recurrent deep vein thrombosis, acute deep vein thrombosis, and pulmonirj j embolism.
Virchow’s triad consists of:
1. Stasis (reduced blood flow velocity)
2. Injury (venous endothelial damage)
3. Hypercoagulable state
During rehabilitation, 9.2% of cases have a thromboembolic complication. Deep veil j thrombosis is very common after spinal cord injury, brain injury with hemiparesis, total joint!*! placement, multiple trauma, cancer, and obesity. It can largely be prevented with a high index oil suspicion and prophylactic anticoagulation. Any patient with venous thrombosis without j clear cause deserves a work-up for one of the newly recognized inherited, hypercoagulable IPeripheral
states. Noninvasive venous Doppler tests can often clarify or rule out lower extremity deep vein thromboses.
Most common prophylactic treatments for deep vein thrombosis
Risk factors can be reduced by mobilizing patients early, actively moving the ankles, wearing venous compression stockings, elevating the legs, or using intermittent venous compression devices. Subcutaneous low-dose heparin, 5000 units every 12 hours, is often used. Low-dose oral warfarin and the newer low-molecular-weight heparins are also options.
Chronic venous insufficiency:
Chronic venous insufficiency occurs when there are congenital or acquired injuries to valves, obstruction of the veins, or valve obstruction and recanalization by deep vein thrombosis. As many as 67-80% of patients develop postphlebitic syndrome after deep vein thrombosis.
Chronic venous insufficiency treated:
Elevation of the leg higher than the heart and venous compression garments can be of assistance. If there is no congestive heart failure or deep vein thromboses that may be dislodged, venous compression pumps and leg wraps may be helpful. After edema stabilizes, custom compression garments of 30-40 mmHg are essential. In a few cases, venous surgery is useful. Superficial spider veins and other very superficial venous incompetence is sometimes helped with sclerotherapy.
Nonhealing ulcers treat:
In addition to prevention, it is important to determine if the ulcer is caused by nerve, arterial, small vessel, or venous insufficiency. Cultures, x-rays, and bone scan may be important when osteomyelitis is a possibility. Debridement with wet to dry dressings, enzymes, or surgery is sometimes needed. A multidisciplinary approach can sometimes heal chronic ulcers and prevent amputation. Sometimes, modified or custom shoes, extra depth shoes with Plastizote inserts, and a podiatrist consultation are very helpful.
There are many types of dressings and wound care products. An
MEDICAL REHABILITATION IN DISEASES OF RENAL AND UROLOGY
Renal
Renal circulation receives more blood flow per tissue weight at rest than any
other organ. With exercise, there is a reduction in renal cortical blood flow and an
increase in renal vascular resistance.117 An immediate decrease in blood flow after exercise is due to central command and metaboreflex.4 Further decrease in renal blood flow during exercise is thought to be due to increased metabolic demand during exercise and shunting of the blood to the exercising muscles.17 Radionuclide angiographic studies in healthy volunteers showed that renal blood flow was decreased by 53.4% immediately after exhausting exercise. Renal blood flow remained decreased by 17% 30 minutes after exercise and by 21.1% 60 minutes after exercise.1718 Similar studies on renal blood flow on healthy volunteers with static handgrip exercise showed that renal cortical blood flow decreases and renal cortical vasculature resistance increases after exercise.1718 Renal vascular constriction during exercise is not an autoregulatory mechanism because renal blood flow falls below the basal value. Normally, autoregulation helps the blood flow to remain at control levels. There are no relationships between renal blood flow and plasma angiotensin, plasma rennin/or noradrenalin. As a result of the reduced blood flow, the urine output is reduced and urine is concentrated.
Renal blood flow changes during exercise are influenced by age of the individual.
One study found that there was less reduction in blood flow to the kidney during
exercise in an older population (mean age 67 years) when compared with a younger population (mean age 24 years). During the recovery period, the renal blood flow fell below the resting value in older subjects compared with younger subjects. Renal blood flow is also influenced by nonsteroidal anti-inflammatory medications (NSAIDs). Indomethacin (Indocin) produces no change in renal blood flow or renal vascular resistance at rest compared to control values, but significant reduction in renal blood flow was noticed (p < 0.027) after exercise. Patients who routinely take NSAIDs should be warned about the effects of NSAIDs during exercise. Adequate fluid supplementation is very important in these patients and in older subjec
REHABILITATION IN CHRONIC FAILURE AND END-STAGE RENAL DISEASE
Renal failure is the loss of the kidneys’ ability to filter and eliminate metabolic waste products, to maintaiormal fluid and solute homeostasis, to regulate blood pressure, and to produce hormones that prevent anemia and bone disease. The accumulation of metabolic waste products results in uremia. Chronic renal failure results from progressive, irreversible damage to the kidney. End-stage renal disease (ESRD) requires chronic dialysis or kidney transplantation to maintain life. The incidence and causes of ESRD vary from country to country and are changing as our population ages; but in
Clearance (CI) expresses the efficiency with which the kidney removes a substance from the plasma. The clearance is a measure of glomerular filtration rate (GFR) and is an assessment of renal function. Creatinine (Cr) is used to determine GFR because it is released from muscle at a constant rate, is stable in concentration in the plasma, and is freely filtered in the glomeruli.
The following equation calculates CrCl (in mL/min), which reflects renal plasma flow.
CrCl = -£5- x V
where UCR = urine concentration of creatinine in mg/ml, PCR = plasma concentration of creatinine in mg/ml, and V = urine flow in mL/min.
Normal creatinine clearance can be estimated with the following equation (the value is 15% less in women):
CrCl = (140 – Age [yr]) x (lean body weight [in 1
Treatment of renal failure
Many patients with chronic renal failure are not referred to a nephrologist until they have developed severe uremia and its complications. However, current practice standards encourage beginning dialysis earlier, as this has been shown to result in better survival, less morbidity, and better rehabilitation.
The two types of dialysis are hemodialysis (HD) and peritoneal dialysis (PD). HD requires a permanent vascular access for external filtering of blood as it is pumped through a cellulose or synthetic filter to remove waste and water, either at an outpatient clinic or at home. The blood access for HD is usually in the forearm and may be either an arteriovenous fistula or a Gortexvascular graft. The typical HD regimen is 3-5 hours, three times weekly, and may result in an ii termittent pattern of post-dialysis fatigue and fluid gain between dialysis sessions.
PD maintains a more steady state. PD requires a permanent intraperitoneal catheter for 4 to daily manual exchanges of dialysate fluids to remove diffusible waste and excess water. PD i often supplemented by automated machine exchanges overnight at home. Both forms of dialysi require dietary management and some limitation of fluid intake.
Kidney transplantation is the optimal treatment for many ESRD patients. It requires im munosuppressive drugs, such as cyclosporine or prednisone, which have side effects such a weight gain, osteodystrophy, and mood swings.
Metabolic consequences of renal failure
ESRD and its treatment affect every organ system. The metabolic consequences of renal failim include anemia (secondary to lack of erythropoietin normally produced by the kidneys), increasec risk of heart and vascular disease, hypertension, secondary hyperparathyroidism, renal osteodystrophy, hyperuricemia, and episodes of hypotension. Related neuromuscular disturbances may include peripheral neuropathy, muscle wasting, sleep disorders, fatigue, restless legs, headache, and seizures. These problems continue and may progress, particularly if dialysis is inadequate, but are reversed with a successful kidney transplant or with more frequent and longer hemodialysis. Cardiovascular and cerebrovascular disease are the leading causes of death among ESRD patients.
Discuss the forms of renal bone disease seen with dialysis.
Secondary hyperparathyroidism is the most frequent cause of renal osteodystrophy, a generic term encompassing all skeletal disorders occurring in chronic renal failure and ESRD patients. High-turnover bone disease (osteitis fibrosa) is more common in hemodialysis (50-60%) than peritoneal dialysis patients, and low-turnover bone disease (osteomalacia) is more common in patients on peritoneal dialysis (60-70%). However, both can occur in some patients. Unmineralized adynamic (aplastic) bone lesions caused by aluminum deposition are seen less often since aluminum hydroxide phosphate binders have generally been replaced by calcium carbonate in recent years.
Secondary hyperparathyroidism causes increased bone resorption (osteopenia) and increased bone formation with unmineralized bone matrix (osteitis fibrosa). Three stages are recognized in the progression of secondary hyperparathyroidism in chronic renal failure:
(1) Compensatory—increased parathyroid hormone (PTH) levels with normal (or low) serum calcium levels and only subclinical skeletal changes
(2) Hypercalcemic—increased serum calcium levels secondary to hypersecretion of PTH
(3) Osteitis fibrosa cystica—severe symptomatic bone lesions (fractures and aching bones) that are preventable or treatable by parathyroidectomy. However, parathyroidectomy is rarely necessary today, with new vitamin D analogues and better management of serum calcium and phosphate levels.
PTH affects cortical bone more than trabecular bone, and lesions develop over many years. Most dialysis patients take calcium carbonate to bind phosphate, but excessive calcium supplementation may produce painful extraskeletal (soft-tissue) calcifications and possibly contribule to vascular calcification.
Uremia and its treatments affect every aspect of life—diet, work, recreation, sex, cognition, and sleep. Symptoms associated with uremia and dialysis include fatigue, decreased exercise tolerance, sleep disorders, headache, and muscle cramps, all of which can limit function and reduce quality of life. The time required for dialysis treatments and, for many patients, post-dialysis fatigue can limit the time and energy available for work and recreation. Recent work has shown that longer or more frequent dialysis can eliminate most of these symptoms.
Surveys show that dialysis patients, especially home hemodialysis patients, consider their subjective quality of life almost as good as that reported by the normal healthy population.However, objective measures, including employment and exercise capacity, indicate substantial quality of life deficits among these patients. Clinical attention to dialysis adequacy Kt/v > 1.2 (where K = dialyzer clearance of urea per t = dialysis time per v = volume of distribution of urea in the body), nutrition, and treatment of anemia reduces mortality and morbidity and improves rehabilitation. Unfortunately, too many patients in the
The exercise tolerance of persons on dialysis is only about 50% of normal. In dialysis patients over age 60, fatigue is the most frequent reason given for activity limitations, with dialysis patients being more limited in their ability to climb stairs, walk, and perform heavy work around the house than a control group matched for age, race, sex, and cardiac problems.
The low rate of employment, fatigue, and reduced exercise capacity in ESRD patients was long attributed to renal anemia. However, these explanations have been challenged recently, as correction of anemia does not restore normal exercise tolerance or physical activity. Exercise training also fails to increase the physical capacity of dialysis patients as much as predicted by their hematocrit increase, so other metabolic dysfunction(s) also must contribute. Early fatigue and build-up of lactic acid with mild exercise are consistent with reduced oxygen extraction, even in athletic dialysis patients, but the precise defect in muscle metabolism is not yet known. Decreased muscle mass, decreased capillary density in muscles, and lower proportion of type 2 muscle fibers are typical in dialysis patients. Extremely low oxygen extraction rates, even in exercise-trained and nonanemic renal patients, have been attributed to defective aerobic metabolism in the muscles. Recent experience with more frequent dialysis suggests that defective muscle metabolism may be related to chronic uremia resulting from inadequate dialysis. Or more simply stated, the physiologic mechanism is still unknown.
Most patients can benefit from an exercise program at any time, but early intervention prior to initiation of dialysis is optimal to prevent disability and maintain employment, relationships, and physical activity. Physical therapy is not always required but can facilitate recovery from transplantation, hospitalization, or deconditioning for any reason.
Most guidelines for aerobic exercise recommend a training heart rate, which is not useful for people taking β-adrenergic blocking drugs to control hypertension. Perceived exertion is a better guide for exercise intensity, because β-adrenergic blocking drugs blunt the normal exercise-induced increase in heart rate. Each patient should be evaluated for the specific risk factors summarized by Harter and Moore before beginning any exercise program. Contraindications include medical instability or severe comorbidities, such as uncontrolled diabetes, cardiovascular disease, osteodystrophy, and arthritis. Painter summarized the issue simply: “Once specific risks have been ruled out, the risks of not exercising are even greater than the risks of exercising.”
Almost every patient with chronic renal failure or ESRD can safely do mild stretching and strengthening exercises, and many are capable of meeting the new NIH recommendation to accumulate a daily total of 30 minutes of moderately intense physical activity. Patients should be selected more carefully for strenuous aerobic exercise. Painter’s guidelines for exercise during hemodialysisinclude prolonged warm-up and cool-down, and limiting stationary cycling to the first 2 hours of hemodialysis. Protection of the dialysis access during exercise is important for all patients. Peritoneal dialysis patients must avoid abdominal pressure when full with dialysate, but may do abdominal strengthening and stretching exercises part way through an exchange when they are only half full.
Frequent monitoring by healthcare providers is important for the early identification of medically significant changes in exercise tolerance, minor injuries that can discourage the habit of regular exercise, or the need to advance individual goals. Patients should keep an exercise diary of activity, intensity, and duration.
The benefits of exercise include all the benefits for the general population, plus additional benefits related to the special challenges of renal failure and associated comorbidity. Regular physical exercise can slow, stop, or reverse the progressive deconditioning that often characterizes the course of kidney disease, thus preventing progressive frailty, maintaining independence, reducing post-dialysis fatigue, and speeding patients’ recovery from illness and surgery (including transplantation). Aerobic conditioning improves blood pressure control, often reducing medication requirements, and reduces cardiac risks—both of which are serious problems for many of these patients. Exercise training improves glucose tolerance and insulin sensitivity in diabetics, who make up about one-third of the dialysis population. Aerobic exercise during hemodialysis may increase the ease of fluid removal, and it clearly reduces hypotensive episodes and muscle cramping. Moore and colleagues showed normal, safe cardiovascular changes with stationary cycling during the first 2 hours of hemodialysis, but some increased risk during the third hour.
UROLOGIC DISORDERS IN REHABILITATION
A neurourologic disorder is defined as a loss of voluntary control on initiation of micturition and/or an inhibition of micturition. This loss of control leads to either retention or incontinence of urine. Neurourologic disorders usually result from CNS lesions (e.g., cerebrovascular accident, head injury, intracranial tumors, spinal cord injuries [SCI], multiple sclerosis, and myelodysplasia) but may result from peripheral nerve injury as well (e.g., diabetic neuropathy). After a complete SCI lesion, there is usually a total lack of voluntary control on voiding, and as a result, there is usually retention or inadequate voiding.
The human bladder is supplied by both the parasympathetic (motor and sensory) and sympathetic nervous systems. The bladder outlet at the pelvic floor is innervated by the somatic nervous system through the pudendal nerves.
The micturition center in the spinal cord is localized primarily in the interomediolateral region of spinal cord segments S2-4, with S3 being the most important root for bladder innervation. The pelvic parasympathetic nerves (S2^t) innervate the detrusor muscle and carry both motor and sensory fibers. However, the cell bodies of the parasympathetic fibers are located in the bladder wall. In other words, preganglionic fibers originate in the spinal cord, and postganglionic fibers originate in the bladder wall and innervate the bladder through short loops.
The innervation to most striated muscles of the pelvic floor, including those of the periurethral and anal sphincter, is through the pudendal nerve arising from S1 —4.
There is ample evidence that the actual organizational center for micturition is localized in the pontine-mesencephalic reticular formation. Lesions above this level (suprapontine) are usually associated with detrusor hyper-reflexia, whereas infrapontine supraconal lesions are always associated with detrusor sphincter dyssynergia.
Describe the physiology of micturition.
When the bladder fills to about 100 mL, there is a minimum sensation of filling, but when it fills to about 300^1-00 mL, there is usually a feeling of fullness sensed by the brain (frontoparietal cortex). This sensation can be depressed and therefore micturition is inhibited. However, one can instantly initiate voiding when desired. Therefore, both initiation and inhibition are under voluntary control of the cerebral cortex, and continence is maintained. During sudden vigorous activities, such as jumping, coughing, or dancing, continence is maintained reflexively through the spinal cord, the holding reflex.
The bladder’s response during filling is to accommodate and not lead to an increase in intravesical pressure. This very high compliance is due to passive viscoelastic properties of the bladder wall and possibly to intact β-adrenergic sympathetic innervation. Any fibrotic changes due to chronic infection and/or a neurologic lesion can reduce compliance and lead to much higher pressures during bladder filling.
Role of sympathetic innervation of the bladder and bladder neck:
Efferent sympathetic nerves to the bladder and urethra originate in the intermediolateral nuclei of spinal cord segments Tl 1-L2 and promote urine storage and continence. These nerves traverse the paravertebral ganglia to the hypogastric plexus to the bladder wall, bladder neck, and posterior urethra. They carry both motor and sensory fibers.
The bladder wall (fundus or body) primarily exhibits β-adrenergic receptors and responds to norepinephrine by relaxing. There is also an abundance of β-adrenergic receptors at the bladder base, which includes the upper trigone vesicoureteral junction. This helps bladder storage by relaxing the bladder muscle.
The bladder neck (vesicoureteral junction) is predominantly supplied with α-adrenergic fibers. There is a high density of α-adrenergic receptors along the bladder neck, particularly in males. This helps to prevent retrograde ejaculation and also helps close the bladder neck during bladder filling. Since α-adrenergic activity leads to closure of the bladder neck, α-adrenergic blockers (α-antagonists) have therefore usually been used to improve voiding by relaxing the bladder neck.
Routine urodynamic evaluation:
Because flow rates are difficult to determine in completely paralyzed patients, other objective urodynamic parameters must be used, including cystometry and urethral pressure profiles. The term video urodynamics refers to the simultaneous pressure flow studies with fluoroscopic visualization of the lower urinary tract. Similar studies can also be done using transrectal ultrasonography to simultaneously visualize the lower urinary tract.
Cystometry is the recording of intravesical pressures during bladder filling. It requires introduction of a catheter through the urethra and slow filling of 24^0 mL/min of fluid at body temperature. During bladder filling, intravesical pressure usually does not rise above
It is difficult to study flow rates in patients with SCI, and therefore pressure/flow studies cannot be accomplished. Some information can be obtained by gently tapping the suprapubic area over the bladder, which can lead to voiding. Post-void residuals can then be determined either with ultrasound or by catheterizing the bladder.
Best way to provide bladder drainage in patients with acute SCI?
During the first 7-14 days, an indwelling catheter may be left in the urethra for continuous bladder drainage to prevent inadvertent bladder overdistension. A small catheter (F14 or 16) is recommended, which prevents urethral irritation and allows periurethral secretions to drain easily around it. Most patients who have severe injuries require fluid intake/output monitoring since they are on intravenous fluids.
Intermittent catheterization can be started as early as 7-15 days after injury. Fluid intake may need to be restricted to < 1500 mL/day. The bladder is drained with a straight catheter (F14) every 4 hours with a goal bladder volume of no more than 500 mL. After the establishment of reflex bladder, the patient is evaluated objectively with urodynamic monitoring of intravesical voiding pressures (leak pressure). A cystometrogram (CMG) may need to be repeated to evaluate voiding pressures following the use of anticholinergics to reduce detrusor contractions. Persistently high voiding pressures > 40-
Patients who have a reflex bladder, particularly tetraplegics, cannot catheterize themselves but can wear an external drainage condom, and they should be considered for surgical reduction of outflow obstruction. To reduce outflow resistance and to have them void at low pressure, transurethral sphincterotomy or stenting of the urethral sphincter is considered. This also helps to reduce the autonomic dysreflexia triggered by detrusor sphincter dyssynergia.
A patient with a small retractile phallus with reflex bladder may be considered for a penile implant. Other patients who cannot self-catheterize and have a small retractile phallus may need an indwelling catheter or suprapubic cystostomy.
In female patients who cannot self-catheterize and are incontinent, vesical or supravesical diversion, such as a suprapubic cystostomy or bowel pouch, may be considered. Continent reservoirs that can be catheterized through sites on the abdomen area also available. Recently, such patients are also being considered for sacral nerve root implants to accomplish an electrically controlled bladder.
Autonomic dysreflexia.
A sudden paroxysmal rise both in systolic and diastolic blood pressures with compensatory slowing of the pulse rate is observed clinically in dysreflexia. It usually happens in patients with spinal cord lesions above T5-6. Symptoms may include a pounding headache and sweating.
Autonomic dysreflexia is commonly precipitated by a full bladder and/or rectum or by other painful stimuli. To relieve the condition, the bladder is emptied by suprapubic tapping and/or immediate catheterization. Immediate blood pressure reduction can also be achieved with ni-ttopaste, nifedipine, 10 mg sublingually, or by chewing the caplets and swallowing them for rapid absorption. Long-term management includes prevention of the triggering mechanism and may require the chronic use of α-adrenergic blockers, such as prazosin, terazosin, or a ganglionic Mocker. Permanent resolution of dysreflexia (caused by voiding dysfunction) can sometimes be accomplished by transurethral sphincterotomy or following placement of a metallic stent in the posterior urethra.
Describe the usual protocol for urologic follow-up of these patients.
Patients with SCI are monitored with radionuclide renal perfusion imaging to evaluate glomerular filtration and renal plasma flow and with annual ultrasound of kidney to detect renal parenchymal loss, hydronephrosis, and stones. If hydronephrosis of the kidneys or ureters is noticed or deterioration of the renal function is found, a full work-up including intravenous urogram and voiding cystourethrogram is done. Cystoscopic examination is also done to evaluate outflow obstruction or to rule out other bladder problems such as bladder tumors. A yearly cystoscopic examination is recommended for patients who are heavy smokers or use chronic indwelling catheters.
Common urinary tract complications of neurogenic bladder. How can they be prevented?
• The earliest changes are noticed as trabeculations seen inside an irregular, thickened bladder wall and even small diverticuli seen on voiding cystographic studies.
• Vesicoureteral reflux has been recorded in 10-30% of poorly managed patients. The presence of reflux is a serious complication since it leads to pyelonephritis and renal stone disease.
• Severe bladder outflow obstruction can result in bilateral hydronephrosis and hydroureters and even an overdistended areflexic bladder.
• Repeated bladder infections can lead to bladder wall changes and marked reduction in the compliance of the bladder.
All of these bladder wall changes can be prevented to some extent by adequately draining the bladder at a pressure below
MEDICAL REHABILITATION IN ENDOCRINE DISEASES AND METABOLIC DISTURBANCES.
|
Take a look at the body-map below to see the range of problems we can treat. |
|
|
|
|
|||
|
|
|
|
|
||
|
|
|||||
Endocrine
During exercise, the whole body consumption of O2 increases as much as 20-
fold. To meet the increase in energy demand during exercise, skeletal muscle uses
its own stores of glycogen, triglyceride, and free fatty acids derived from breakdown of adipose tissue from the muscle and uses glucose derived from the liver.
Blood glucose level is well maintained during exercise in order to preserve central
nervous system function and muscle function. The metabolic adjustment that
preserves normoglycemia during exercise is hormonally mediated. There is a
decrease in plasma insulin and increase in glucagon during early part of exercise.
This helps mobilize glucose from the liver.33 During prolonged exercise, there is
increase in catecholamines, which plays an important role in mobilization of glucose. The central command and withdrawal of vagal tone are responsible for
increase in catecholamine levels in blood.
Exercise program diabetes mellitus
Exercise is an excellent adjunct to diet therapy, but it is very ineffective when used as the sole weight-reducing modality.
Exercises must be clearly planned and depend on patient’s abilities and the physical condition, exclusion of the competition’s elements.
Exercises may be valuable adjunct to the management of the DM by:
– lowering blood glucose concentration;
– decreasing insulin requirements;
– potentiation the beneficial effects of diet and other therapy.
To prevent hypoglycemia, patients should carefully monitor glucose level and taking of insulin. Mostly they need to reduce the insulin dosage by 20 – 25 % on the day that strenuous exercises is planned.
Plant’s therapy (phytotherapy).
1) hypoglycemic action;
2) treatment of chronic diabetics complications;
3) influence on the immune reactivity.
Patient’s education.
Video (link for life)
Patient education is essential to ensure the effectiveness of the prescribed therapy, to recognize indications for seeking immediate medical attention, and to carry out appropriate foot care. On each physician visit, the patient should be assessed for symptoms and signs of complications, including a check of the feet and the pulses and sensation in the feet and legs, and a urine test for albumin. The serum creatinine levels should be assessed regularly (at least yearly) and an ECG and complete ophthalmologic evaluation should be performed at least yearly. Coexistent hypertension and hypercholesterolemia increases the risks for specific late complications and requires special attention and appropriate treatment.
Principles of education (Video)
1) the nature of DM and importance of metabolic control;
2) the principles and importance of good nutrition and reasonable exercise program;
3) the principles of adequate foot, dental and skin care;
4) treatment of DM during the periods of illness;
5) techniques of insulin administration and measurement of urine and blood glucose level (if taking insulin);
6) recognition of hypoglycemia, its causes and methods of prevention;
7) the importance of general and specific measures to minimize in the best possible way diabetic complications and maintain of good overall health.
There are several specialized sanatoriums for diabetics in Truscavets, Myrgorod,
Beneficial effects of exercise on the cardiovascular system include increases in exercise tolerance, cardiac output, and maximum oxygen consumption. A regular exercise program, at least 3 days a week, increases the exercise tolerance level. An 8-week exercise program at 60% or more of the maximal heart rate achieved at baseline testing increased the subjects’ exercise tolerance on the treadmill by 30% and increased the maximum oxygen consumption by 15-20%.n The beneficial effects are more prominent in sedentary individuals.11 Higher intensity exercises are shown to have a better short-term improvement but no statistically significant difference after 1 year. Older individuals may require a prolonged period of training compared with younger individuals.3‘11
Regular exercises have been shown to reduce the severity of anginal symptoms and increase anginal threshold in subjects with chronic stable angina11 and have been shown to improve cardiac function among patients with chronic heart failure and cardiomyopathy. Dipyridamole-thallium tests in these patients have shown increased uptake of thallium suggesting increased coronary perfusion.11 The clinical improvement in patients with heart disease is also due to peripheral adaptation such as increased oxidative enzyme capacity and improved peripheral oxygen uptake.
The effect of exercise programs on the reduction of blood pressure (BP) is controversial. Some studies have shown that exercises reduce average BP by 10-13 points, but others have not found similar results. Progressive increase in blood pressure is a normal phenomenon during endurance and strengthening exercise. Strengthening exercises cause a slightly higher elevation of BP compared with endurance exercise. Short bouts of strengthening exercises are commonly associated with the Valsalva maneuver, which sometime causes dangerously high levels of BP. Meta-analysis was conducted on 15 studies in which subjects were involved in a 4-week progressive resistive exercise program. Analysis showed that progressive resistive exercise had beneficial effects in reducing systolic and dias-tolic blood pressure in hypertensive individuals. However, a well-controlled study to determine the efficacy of progressive resistive exercise as a measure to control high blood pressure is lacking.
An increase in heart rate after exercise is due to reduction in vagal tone. Similarly, recovery of heart rate is due to vagal reactivation. Cole et al. showed that the recovery of heart rate might be a powerful predictor of overall mortality due to cardiovascular disease. In this study, 2428 subjects without coronary revascular-ization or heart failure were followed for 5 years. Recovery of heat rate was defined as decrease in heart rate by 12 beats in 1 minute after stopping the exercise. The mortality rate showed that a delayed decrease in heart rate during the first minute after exercise might be a powerful predictor of overall mortality (95% confidence interval of 1.5-2.7; p< 0.001).
Renal
Renal circulation receives more blood flow per tissue weight at rest than any other organ. With exercise, there is a reduction in renal cortical blood flow and an increase in renal vascular resistance.117 An immediate decrease in blood flow after exercise is due to central command and metaboreflex.4 Further decrease in renal blood flow during exercise is thought to be due to increased metabolic demand during exercise and shunting of the blood to the exercising muscles.17 Radionu-clide angiographic studies in healthy volunteers showed that renal blood flow was decreased by 53.4% immediately after exhausting exercise. Renal blood flow remained decreased by 17% 30 minutes after exercise and by 21.1% 60 minutes after exercise.1718 Similar studies on renal blood flow on healthy volunteers with static handgrip exercise showed that renal cortical blood flow decreases and renal cortical vasculature resistance increases after exercise.1718 Renal vascular constriction during exercise is not an autoregulatory mechanism because renal blood flow
Therapeutic Exercise 125
falls below the basal value. Normally, autoregulation helps the blood flow to remain at control levels. There are no relationships between renal blood flow and plasma angiotensin, plasma rennin/or noradrenalin. As a result of the reduced blood flow, the urine output is reduced and urine is concentrated.
Renal blood flow changes during exercise are influenced by age of the individual. One study found that there was less reduction in blood flow to the kidney during exercise in an older population (mean age 67 years) when compared with a younger population (mean age 24 years). During the recovery period, the renal blood flow fell below the resting value in older subjects compared with younger subjects.19 Renal blood flow is also influenced by nonsteroidal anti-inflammatory medications (NSAIDs). Indomethacin (Indocin) produces no change in renal blood flow or renal vascular resistance at rest compared to control values, but significant reduction in renal blood flow was noticed (p < 0.027) after exercise. Patients who routinely take NSAIDs should be warned about the effects of NSAIDs during exercise. Adequate fluid supplementation is very important in these patients and in older subjects. Vascular
Nitrous oxide (NO) has been identified as a potential mediator for the vascular benefit of exercise. Elevation of shear stress on vascular endothelium causes NO production. Previous studies have postulated that NO derived from endothelium is responsible for vasodilatation of feed arteries in the muscles, which therefore permits increased vascular flow to the muscle without a decrease in perfusion pressure.23 This vasodilatation is also presumed to be responsible for reduction in blood pressure with regular exercise. A brisk walk for 30 minutes five to seven times per week was found to improve endothelial function iormotensive and hypertensive individuals. This may help to contribute to cardiovascular protective effects of exercise training. The important effect was on coronary arteries. Exercise training improved endothelial-dependent vasodilatation both in the epicardial coronary vessels and in resistance vessels in patients with coronary artery disease.24
126 Therapeutic Exercise
Psychological
Meta-analyses on the effect of regular exercise have shown that physical activity enhances self-esteem, improves mood state, reduces anxiety, and improves physical self-perception. Both aerobic and resistance exercises enhance mood state.25–26 Serum levels of norepinephrine were found to be low in depressed individuals, and mood state is thought to be improved by the high levels of norepinephrine that are present after exercise.26 In addition, aerobic exercise increases beta-endorphin levels in plasma, which may result in mild euphoria.26
Improvement in depression has been documented by significant improvement in Beck Depression Inventory scale. Improvement was more rapid in subjects who exercised in addition to taking antidepressant medication compared with those who were treated with medication alone. Weaker evidence also suggests that exercise improves cognitive function in patients with chronic fatigue syndrome.27
Hematologic
Exercise enhances thrombin-induced platelet fibrinogen binding and platelet aggregability.28 These changes were reversible with recovery 60 minutes after completion of exercise. Various intensities of exercise affect platelet function differently. For example, moderate exercise desensitizes and strenuous exercise potentiates platelet aggregability.29‘30 Severe exercise may potentiate platelet activity by elevating the norepinephrine level, which is a potent platelet-activating agent.30 These factors may explain exercise-induced acute myocardial infarction and cardiac arrest. Other hematologic effects of exercise include increased neutrophil migration from the marginated pools into circulation. This mainly occurs after exhaustive exercise.31
Endocrine
During exercise, the whole body consumption of O2 increases as much as 20-fold. To meet the increase in energy demand during exercise, skeletal muscle uses its own stores of glycogen, triglyceride, and free fatty acids derived from breakdown of adipose tissue from the muscle and uses glucose derived from the liver.32
Blood glucose level is well maintained during exercise in order to preserve central nervous system function and muscle function. The metabolic adjustment that preserves normoglycemia during exercise is hormonally mediated. There is a decrease in plasma insulin and increase in glucagon during early part of exercise. This helps mobilize glucose from the liver.33 During prolonged exercise, there is increase in catecholamines, which plays an important role in mobilization of glucose. The central command and withdrawal of vagal tone are responsible for increase in catecholamine levels in blood.33
COMPONENTS OF THERAPEUTIC EXERCISE
There are several types of therapeutic exercise, and the clinician must weigh the advantages and disadvantages of each when formulating an exercise prescription to achieve maximum benefit. Components of exercise regimens include flexibility, ROM, strengthening, and endurance. Most often, a combination of these exercise regimens leads to the most optimal results.
Therapeutic Exercise 127
Flexibility Training
Muscles produce their maximal amount of tension when fibers are at their optimal resting length.34 The resting length of a muscle may become shortened as a result of immobility from factors such as prolonged casting, soft tissue injury, restricted joint mobility, and neurologic disorders. Stretching is a key component of most exercise regimens and serves to maintain muscles at their optimal resting length to enhance muscle function. The American College of Sports Medicine (ACSM) has established guidelines for stretching prescription, which include (1) a minimum of three days per week, (2) stretch to a position of mild discomfort, (3) hold the stretch for 15-30 seconds, (4) complete three to five repetitions for each stretch, and (5) perform static stretching, that is, avoid ballistic, bouncing movements, with emphasis on the lower back and thigh area.35
Many methods for stretching include manual passive stretching, mechanical stretching, and the contract-relax technique. During manual passive stretching, the body segment is passively moved to a position just beyond the resting length of the involved tissues36 and may be held in this position from 15 to 30 seconds.36 Mechanical stretching may be accomplished by use of serial casting or a dynamic splinting device, which provide a low-intensity stretch for a prolonged period of time and are typically used to reduce joint contractures. Dynamic splinting devices may be worn 8-10 hours per day.37 The contract-relax technique is commonly used by therapists to improve muscle length.38 In this technique, the person isometrically contracts the tight muscle and then relaxes. After the relaxation is complete, the therapist passively lengthens the muscle. The type of stretching procedure that is prescribed ultimately will be based on individual ability and need.
Stretching exercise performed for lower body segments has beneficial effects for proximal body segments.39 For example, a 3-week program of daily hamstring muscle stretching, performed for 10 repetitions with 15-second hold, resulted in increased straight-leg raise range and hip motion during forward bending.40 Thus, increased flexibility of the hip may reduce the amount of lumbar spine motioecessary to complete an activity.
Stretching is commonly recommended before exercise with the belief that injuries will be prevented.35 However, some studies have found that static stretching performed exclusively before exercise had no significant difference in delayed onset of muscle soreness41–42 or preventing injury43 when compared with exercise without a stretching component. Therefore, to maintain optimal flexibility, stretching exercise should be done on a regular basis rather than only before exercise.
Studies have shown that stretching exercise, if not done properly, has potential to cause injury.41–44 Injury may be avoided through active warm-up before stretching,35 use of heat prior to stretching,36–44 and avoidance of bouncing, ballistic movements.35–36 Stretching must be prescribed individually because stretching exercises may be contraindicated for certain musculoskeletal disorders with active joint pathology, and some people may not have adequate flexibility to properly perform certain stretches.
Range-of-Motion Exercises
Each joint has an optimal ROM for performance of daily activities. Many ortho-
128 Therapeutic Exercise
pedic and neurologic conditions, such as contracture after prolonged casting or spasticity resulting from a stroke, may negatively affect joint ROM. ROM may be increased by several different methods including passive, active-assisted, and active ROM. Passive range of motion (PROM) is exercise in which there is no voluntary muscle contraction of the involved body segment as the joint is moved through its available range. PROM may be used to maintain joint ROM when active exercise is contraindicated. These exercises are helpful after recent tendon or muscle repair surgery or active inflammatory process of a joint. PROM is prescribed when a person is incapable of active muscle contraction such as in the case of paralysis or severe pain. PROM may be accomplished using gravity, another person, another body segment, or mechanical devices. A continuous passive motion (CPM) machine is commonly used to maintain knee joint ROM passively after total knee replacement.45 Similarly, Codman’s pendulum exercises use gravity to maintain flexibility in shoulder joints after surgical repair of a tendon or joint replacement.46
Active-assisted range of motion (AAROM) is a type of exercise in which the involved limb is assisted through the ROM when a person is unable to move his or her limb actively through the full available range because of pain, weakness, or poor motor control.37 It is important that as little assistance as possible is rendered so that the weaker muscles are allowed to generate their maximum force throughout the range. The involved limb may be assisted by many sources such as the unin-volved limb, use of mechanical devices, or the buoyancy of water.36
Active range of motion (AROM) is defined as the movement of a body segment through its available ROM with the person’s own effort. AROM may be performed through a limited range, in the presence of recent surgery or pain, or through full available range. The exercise program progresses to include moving the extremity through full range against resistance when indicated. The time it takes to advance a person from PROM exercise to AROM exercise depends on the nature of the disease, injury, or surgery performed.
Strength Training
Muscle strength has been defined as “the maximum force a muscle can produce during a single exertion to create joint torque.”46 Several types of muscle contractions lead to increases in muscle strength including isometric,47‘48 isotonic,36‘46 concentric,4950 eccentric,41–50 isokinetic,50–51 and plyometric.52 Human movement is composed of concentric, eccentric, and isometric contractions. Isotonic and isokinetic contractions are dependent on a fixed load or fixed velocity, respectively, that are controlled external to the body and do not often occur outside of a controlled evaluation or treatment situation.
Isometric
An isometric contraction is elicited when the external force placed on the muscle equals the force generated by the muscle and yields no net change in muscle length. For example, isometric contractions are elicited in the trunk musculature to maintain upright posture.
Isotonic Contractions
An isotonic contraction is elicited when a constant load is placed on the muscle and the length of the muscle is not fixed. The load remains the same, but the veloc-
Therapeutic Exercise 129
ity of muscle shortening changes. For example, concentric or eccentric isotonic contractions may be elicited using free weights in a typical strengthening program.
Concentric Contractions
A concentric contraction results in a net shortening of the muscle as force generated from the muscle fibers exceeds the external force applied to the muscle. Concentric contractions may be isotonic or isokinetic.
Eccentric Contractions
An eccentric contraction results in a net lengthening of the muscle as the external force applied to the muscle exceeds the force generated from muscle fibers. The potential for skeletal muscle soreness is greatest during training that emphasizes eccentric contractions as compared to isometric or concentric contractions.35–53 Eccentric contractions may be isotonic or isokinetic.
Isokinetic Contractions
An isokinetic contraction occurs under constant velocity with varying torque. Isokinetic contractions may be elicited for purposes of training or evaluation of strength, and may be concentric or eccentric iature. This type of contraction is performed with an isokinetic dynamometer, which is set at a velocity between 0 and 400°/second.54 Maximal tension is maintained throughout the ROM as the force applied by the muscle is translated to resistance.54 Bast and colleagues found that the eccentric isokinetic training group showed a greater increase in peak force and peak torque compared with the combined concentric and eccentric isokinetic training group for training of shoulder abduction in the scapular plane with the humerus internally rotated.51 This study involved 28 healthy male and female subjects who completed a protocol of 12 sets of 10 repetitions at maximum weight, three times per week for 4 weeks with 30 seconds rest between repetitions.
Plyometric Contractions
A plyometric contraction is elicited when the muscle is placed on stretch before a concentric or shortening contraction.52 For example, a person may crouch down, placing his or her gastrocnemius and soleus muscles on stretch, before bounding up to a step.
Open-Chain versus Closed-Chain Exercises
Resistance exercises may be performed in either an open-chain or closed-chain55 environment. An open-chain environment is one in which the distal end of the exercising limb is not in contact with another surface. A closed-chain environment is one in which the distal end of the exercising limb is in contact with another surface, resulting in weight bearing through the limb. Examples of open-chain exercises of the knee are hamstring curls and knee extensions, whereas examples of closed-chain exercises are standing squats or leg presses. Open-chain exercises tend to elicit contraction of a single muscle group and may or may not elicit contraction of the antagonist muscle. Closed-chain exercises tend to elicit cocontrac-tion of agonist and antagonist muscle groups.56
Strengthening protocols. The “overload principle,” in which the resistance to movement or the frequency or duration of the activity is increased to levels above those normally experienced,35‘46 guides increases in strength and endurance. Strength training may result in physiologic benefits including an increase in bone
130 Therapeutic Exercise
mass, an increase in connective tissue strength, improvement in cardiorespiratory fitness, reduction in body fat, a reduction in blood pressure, improvement in glucose tolerance, and improvement in blood lipid and lipoprotein profiles.35 Exercise intensity may be increased or decreased by varying the amount of weight used, the number of repetitions, the number of sets and the length of rest periods. Several authors have proposed protocols for increasing strength.35‘57‘58 The ACSM recommends that a minimum of 8-10 separate exercises be performed to target major muscle groups. They recommend a duration of less than 1 hour per session to increase compliance and one set of 8-12 repetitions performed through full ROM to the point of fatigue at least twice per week. Exercises should be performed both eccentrically and concentrically in a slow, controlled manner, maintaining a normal breathing pattern to prevent hyperventilation or hypoventilation.35
In 1945, DeLorme proposed that progressive resistance exercise (PRE) be performed at a certain percentage of the 10-repetition maximum (RM).57 The 10-RM is the amount of load that may be placed on the muscle to allow only 10 repetitions to be performed before muscle fatigue. The 10-RM should be determined for each muscle group being trained and must be re-established once each week. DeLorme also proposed that sessions should be performed daily, not less than three times per week, with the following protocol: 10 repetitions at 50% of the 10-RM, followed by 10 repetitions at 75% 10-RM, then 10 repetitions at 100% 10-RM. Often however, subjects are not able to perform 10 repetitions at 100% 10-RM due to fatigue from the previous submaximal contractions.
The Oxford technique is a training method in which a person performs 10 repetitions each at 100% 10-RM, then 75% 10-RM, and ending at 50% 10-RM.58 This method has been shown to elicit less fatigue than the DeLorme method. The Oxford technique may be less effective than the DeLorme method, because a certain level of fatigue has been shown to be necessary to achieve training effects.46
Circuit weight training is a method of training in which a series of exercises are performed in succession with minimal rest between exercises For example, a series of exercises are performed to strengthen upper extremity muscles, followed by series of exercises to strengthen different muscles groups in the lower body.35 Taafe and associates achieved training effects in male subjects ranging from 65 to 82 years old after performing a circuit of heavy resistance training three times per week for 14 weeks. The circuit included 10 exercises involving both upper and lower body muscle groups performed for a total of three sets of eight repetitions for each exercise at 75% of 1- RM, which is defined as the maximal load the subject could lift. The 1-RM was re-established every 2 weeks, and training weight was adjusted accordingly.59
Yarasheski and associates achieved training effects in 62- to 75-year-old men after a 16-week program of weight-lifting exercises.60 The exercises were progressed from moderate to high-intensity, including four sets of 4-10 repetitions of each exercise, four times per week at 75-90% 1-RM. The subjects used Nautilus equipment and alternated daily between upper body (biceps curls, shoulder press, deltoid lifts, bench press, latissimus pull downs, arm crosses) and lower body (leg press, knee flexion, knee extension) exercises. Thus, many strengthening regimens have proved to be beneficial, and the most optimal regimen must be determined on an individual basis.
Therapeutic Exercise 131
Endurance Training
Endurance may be defined as the ability to maintain a force or effort for a prolonged period of time. Endurance training has several beneficial effects such as improving general fitness, improving cardiovascular condition, and enabling one to sustain a particular activity for an increased period of time in order to perform daily or recreational activities. Any type of endurance training should incorporate a warm-up and a cool-down phase to prevent injury.3536
Aerobic exercise is important to maintain or improve general fitness level. The ability to achieve improved aerobic capacity through endurance training is directly related to the frequency per week, duration per session, and intensity (% VO2max) of training.61 The ACSM recommends maintaining an exercise intensity of 60-90% maximum heart rate or 50-85% of VO2max to achieve a training effect in healthy individuals. Exercises aimed at increasing endurance should last for a duration of 20-60 minutes and have a frequency of 3-5 sessions per week.61 For deconditioned individuals, a training effect may be achieved with lower exercise intensities of 50-60% maximum heart rate at a minimum exercise duration starting at < 10 minutes three times per week.35 Aerobic exercise may include use of equipment such as stationary bikes, treadmills, upper extremity ergometers, and free weights. Endurance exercise with free weights consists of lifting weights that are significandy below maximum resistance with a high number of repetitions (e.g., 8-12 repetitions).35
EXERCISE PRESCRIPTION
Before prescribing an exercise program, it is important to obtain a good history, including the risk factors for coronary artery disease. ACSM guidelines provide clear indications for exercise testing before starting exercise program.35
Intensity of exercise is based on the target heart rate (THR). THR is established usually between 70% and 90% of maximum heart rate (MHR). In patients who are deconditioned, intensity should be less than 70%, and in those who are well conditioned, the starting THR could be greater than 90%.
One method of determining maximum heart rate is 220 minus the patient’s age. This method is not recommended in cardiac patients because variability of predicted heart rate is found to be very high. Another commonly used method of determining THR is the Karvonen formula.35 This formula measures THR as maximum heart rate minus resting heart rate (RHR). The resulting value, called the heart rate reserve, is then multiplied by intensity of the exercise and added to the resting heart rate (THR = max HR – rest HR X [0.4 – 0.9] + rest HR). Intensity of the exercise is usually set at 50% of heart rate reserve in patients with known cardiac disease and gradually increased to 90%.3562
Intensity of exercise can also be determined by perceived exertion. A common method that is used is the Borg scale of perceived exertion. In asymptomatic patients, the perceived intensity should be 12-16. In cardiac patients, it should be < 13.62
Frequency of exercise should be at least three to four times a week. The duration of exercise is usually 30 minutes or more if the individual is highly trained. This is preceded by 5-10 minutes of warm-up exercises, which may include light aerobic exercise such as walking or bicycling. Following the activity session, there
132 Therapeutic Exercise
should be cool-down period, which is similar to the warm-up, and this gradually brings the heart rate down to the resting value.62
The mode of exercise is often sport related for athletes. There is no best type of exercise to improve cardiovascular fitness for nonathletes. Walking, outside or on a treadmill, and bicycling are a few of the modes commonly prescribed. Addition of resistance strength training in conjunction with aerobic training has been shown to be beneficial in young patients and in patients with heart disease in the absence of congestive heart failure.62
The prescription for a specific musculoskeletal condition or neurologic disease needs to be individualized and is based on the specific diagnosis. Some common conditions in which exercises are prescribed are briefly described in the following paragraphs.
Cardiovascular Condition
Exercise is an important part of rehabilitation in patients after any cardiac event, including myocardial infarction, coronary revascularization, valve replacement, and unstable angina. Meta-analysis of 21 randomized, control trials showed a 25% reduction in mortality in patients with known cardiac disease after cardiac rehabilitation during a 3-year follow-up. These studies included other modalities such as dietary modification, beta-blocking agents, and thrombolytic agents. There was a positive correlation between training-induced peak exercise capacity and lower mortality rate suggesting the independent effect of exercise.11 Supervised exercise training in cardiac patients was found to be extremely safe, with mortality rate of 1 death per 116,00 patients.11 Exercise in cardiac patients improves exercise tolerance and quality of life. Exercise also decreases the chance of nonfatal myocardial infarction over 5 years (28.5% to 39.9%). Previous studies examining the effect of exercise training on patients with chronic stable angina have reported an increase in anginal threshold and reduction in severity of angina compared to the control group.11 In patients with ischemic cardiomyopathy, exercise has been shown to decrease dyspnea and fatigue.1163
Immediately following an acute cardiac event, the physical or occupational therapist should see the patient to plan an early exercise program. Exercises requiring 1.2-1.5 METs should be introduced. Frequent, brief sessions, rather than a longer single session, are preferable to avoid fatigue. Patients should be started on a program with 1 minute of exercise followed by a 2-minute rest period and progress as tolerated. Patients who have just had a cardiac event should be started on a phase I exercise program during their inpatient stay. The target heart rate should not exceed 20 points above the resting value (< resting HR + 20). Each session should last 5-10 minutes and should be progressed as tolerated. After discharge, patients should be started on a more intensive phase II exercise program lasting 20 minutes to a maximum of 30 minutes at 60-70% of maximum heart rate. Even though the phase II program is monitored, all patients should undergo exercise tolerance before entering this phase to determine the maximum heart rate. Patients then can advance to a supervised but unmonitored phase III program and subsequently to a community-based unsupervised program (phase FV). It is important to obtain a stress test prior to advancing to a nonmonitored exercise setting.63a
Therapeutic Exercise 133
Chronic Obstructive Pulmonary Disease
In addition to medications, exercise plays an important part in the rehabilitation of chronic obstructive pulmonary disease (COPD). Poor exercise tolerance in COPD is due to increased flow resistance, poor gas exchange, ventilatory pump impairment, and deconditioning. Mode, frequency, and duration remain the same as for healthy individuals. An increase in resting heart rate due to inhalers is commonly seen in patients with COPD, and use of inhalers should not exclude patients from exercising to their tolerance. Despite high respiratory rate, the ventilatory response to hypoxia and hypercapnia is reduced.13 Many of these patients are deconditioned, and an exercise program to improve the cardiovascular condition has been shown to improve their functional status and psychological well-being. Many patients attain only 60-70% of the predicted maximum heart rate. Reconditioning exercises are shown to improve pO2, vital capacity, and FEVp even in patients with FEVj < 2 L. Studies have shown that presence of hypercapnia is not a contraindication to exercise and pCO2 does not increase with an intensive exercise program.15 The guideline for exercise is similar as for any deconditioned patients, but gradual increase in the exercise intensity is strongly recommended. Evaluation of pulmonary function test guides the physician to prescribe the exercise program tailored to the patient’s needs.
Diabetes
Before prescribing an exercise program, a diabetic patient should undergo a complete physical examination including heart and lung examination, peripheral pulse, and sensation and vision testing. The physical examination and history should focus on signs and symptoms affecting the heart, blood vessels, kidneys, eyes, and nervous system. It is important to check the glucose level before and after exercise in diabetic patients until the glucose levels are stable for two or three consecutive exercise sessions. Hormonally mediated mobilization of glucose is lost in diabetic individuals. In type 1 diabetics, mobilization of glucose in the absence of insulin production may produce hyperglycemia. Exogenous administration of insulin in these patients may increase insulin availability during exercise, and hypo-glycemia may ensue. Self-monitored blood glucose data and adjustment of insulin and intensity of exercise among these individuals are recommended.33 Many studies have proved the beneficial effects of exercise in type 2 diabetes in glycemic control and prevention of cardiovascular disease, hyperlipidemia, and obesity. Improvement of hemoglobin A1C was noted in diabetic patients who were involved in a exercise program three to four times a week compared with control subjects.33
Diabetic patients with known coronary artery disease should undergo an exercise stress test. Any symptoms of peripheral vascular disease need to be noted. Patients should have proper footwear to prevent skin irritation in the feet during impact exercise such as treadmill walking or jogging.
It is important to remember that presence of autonomic neuropathy may limit the individual’s capacity during exercise and increases the risk of adverse cardiovascular event during exercise. Resting tachycardia (> 100/min), orthostasis, or other disturbances of autonomic function involving skin, pupil, gastrointestinal system, and genitourinary system indicate presence of autonomic neuropathy.
134 Therapeutic Exercise
Hypotension and hypertension after vigorous exercises are more common in patients with autonomic neuropathy. Because these individuals have difficulty with thermoregulation, they should not exercise in a hot or cold environment and should be more attentive to adequate hydration. An exercise tolerance test or thallium stress test may be performed in these patients prior to exercise prescription.33
Psychiatric Conditions
Many psychiatric disorders are associated with psychomotor retardation. Exercise prescription is based on age and other comorbid conditions. Aerobic conditioning exercises are commonly prescribed for this population. Many psychiatric patients are nonexercisers. The prescription should start at 40-50% of heart rate reserve and increase gradually to 60-70%. Exercise is an important aspect of treatment in chronic fatigue syndrome. Improvement in cognitive function and sleep patterns was noted in patients with chronic fatigue syndrome.
IONTOPHORESIS
Iontophoresis has been described as a method of facilitating the transfer of ions by means of an electrical potential into soft or hard tissues of the body for therapeutic purposes.12 It is a noninvasive procedure whereby free ions are applied topically into the skin using direct current. Iontophoresis is based on Faraday’s law of electrolysis: M = nIT/ZF, where M is the number of moles of a given ion that will be released by the passage of I amperes of charge of the same polarity as the drug molecule during each second of the ejection time (T). The number of ions delivered depends on the valence of the charged ion (Z) and the Faraday constant (F). The relationship between the passage of charge and the passage of charged ions depends on the complex factor n, known as the transport number, which varies for individual compounds as an expression of their solubility, polarity, and type of media into which the molecules are ejected. Simply put, the basis of iontophoresis is that an electrically charged electrode will repel a similarly charged ion.
Historical Background
The uses of iontophoresis have been studied by professionals from different backgrounds—physicians, dentists, pharmaceutical scientists, chemical engineers, biologists, and physical dierapists. It was found to be useful not only for local conditions but also for systemic delivery of drugs, in particular proteins and peptide drugs.3
In 1747, Veratti described the application of electric current to increase penetration of drugs into surface tissues.4 The first controlled study was done in 1900 by LeDuc using strychnine and cyanide ions in rabbits.5 One of the well-known applications of iontophoresis is for treatment of hyperhidrosis based on studies done by Ichihashi in 1936.6 The sweat test used to diagnose cystic fibrosis, first used by Gibson and Cooke, is performed using iontophoresis with topically applied pilo-carpine to induce sweating.7
Mechanism of Action
Acids, bases, salts, and alkaloids are ionizable substances that dissociate into their component charged ions when dissolved in water. The resulting solution with electrolytes is capable of conducting electric current by virtue of migration of the dissociated ions. When a continuous direct galvanic current (DC) is passed between two electrodes in an electrolyte solution, the cathode (negative pole) will attract positive ions, and the anode (positive pole) will attract negative ions. Iontophoresis is the transfer of ions into the body by this method for therapeutic purposes. Membrane barriers made up of lipids and proteins are present in the skin and other surface tissues; thus, ionized compounds are less easily absorbed thaonionized compounds. The rate of membrane penetration of ionized drugs may be increased by
37
38 Iontophoresis and Phonophoresis
means of an electrical source. The process of iontophoresis provides this electrical energy source for passage across the membrane. The skin has an isoelectric point of around 3-4. When in contact with solutions with a pH of less than 3, it carries a net positive charge. When in contact with solutions with a pH of greater than 4, it carries a net negative charge.8 A negative charge on the skin during iontophoresis causes electro-osmotic movement of water from within the body toward the outer surface of the skin, anode to cathode. This water movement may result in pore shrinkage at the anode and pore swelling at the cathode.9 Thus cation transfer may occur during anodal iontophoresis in the same direction as the water flow.
Factors Affecting lontophoretic Transport
Ionic Strength
The ionic strength of a solution is related to the concentration of the various ions in the solution. Migration of a particular ion requires that an ion of the opposite charge should also be present in close proximity. The pH of the delivery medication is often controlled by the addition of buffering agents, in which the ions are usually more mobile than the ions meant for iontophoretic delivery. This has a retarding effect on the protein of the ion, which should be delivered iontophoret-ically into a tissue. Ideally, the use of a buffer system should be avoided in iontophoresis, but if that is not possible, buffers containing ions with low mobility or conductivity are preferred. The drug transport in skin always is less than unity owing to the pressure of endogenous ions, such as bicarbonate, potassium, chloride, which carry a sizable fraction of ionic current.
Vehicle pH
Vehicle pH is important for drugs whose degree of ionization is pH dependent. The optimum pH for iontophoretic delivery is where the compound exists in an ionized form. Siddiqui and colleagues studied the effect of pH on the rate and extent of lidocaine iontophoresis through the skin.10 The rate of penetration was highest at the pH where lidocaine existed in the ionized form. The pH changes become significant for protein and other drugs because the pH of the solution changes the charge on these molecules. For example, greater skin permeability has been shown at a pH below its isoelectric pH for drugs such as insulin.11
Current Strength
A linear relationship between the applied current and the movement of the compound has been observed. However, the maximum strength that can be used is limited by consideration for patient safety. The maximum tolerable current increases with the electrode area. The upper limit of current strength for clinical use has been suggested to be 0.5 mA/cm2.12
Concentration
The effect of the solute concentration may be determined by the Nerst-Planck equation. However, it is possible that at higher concentrations, the transport may become independent of concentrate owing to the saturation of the boundary layer relative to the saturation of the donor solution.13
Iontophoresis and Phonophoresis 39
Electro-osmotic Transport
An electrically driven flow of ions across a membrane with a net charge can produce a flow of solvent called electro-osmosis. Delivery of compounds through the anode has been observed to be higher than those delivered through the cathode.14
Continuous versus Pulsed Current
Use of continuous direct current may result in skin polarization, which can reduce the efficiency of the iontophoretic delivery system. A pulsed direct current delivered periodically can overcome this problem.15
Physiologic Factors
Limited studies have suggested that iontophoretic delivery may be independent of the type of skin studied. Iontophoresis using lithium and pyridostigmine through human, pig, and rabbit skin have been found to be comparable. Insulin delivery through hairless rat skin was comparable to fuzzy rat skin.16 Factors such as age, race, skin thickness, degree of hydration, and normal versus diseased skin have yet to be studied. The effect of dermal blood flow on iontophoresis has been shown in pigs using lidocaine delivery in the presence of vasoactive chemicals (epi-nephrine). There was a decrease in lidocaine flux because of lidocaine’s vasoconstrictor effect compared with use of tolazoline, which increased the iontophoretic lidocaine flux caused by its vasodilator effect.1718
Therapeutic Applications of Iontophoresis
Iontophoresis has many advantages that render it a desirable modality for drug delivery. Some of the advantages are similar to those of phonophoresis, including the noninvasive nature of the procedure, low risk of infection, systemic absorption, and enhanced drug penetration. Additionally, the iontophoresis unit is available for home use and provides a simplified therapeutic regimen, which helps with compliance. Disadvantages of the procedure are that it can be time consuming, and minor skin irritation and burning can occur with treatment.
Inflammatory conditions such as bursitis, tendinitis, strains, and sprains have been successfully treated using dexamethasone sodium phosphate combined with lidocaine (Xylocaine) iontophoresis.1920 Glass and associates demonstrated effectiveness of iontophoresis in a series of animal studies with rhesus monkeys by introducing radio-labeled dexamethasone sodium phosphate into tissues surrounding major joints including tendons and cartilage.21 Iontophoresis using acetic acid has been reported to treat successfully calcifying tendinitis of the shoulder in humans and traumatic myositis ossificans in the quadriceps femoris muscle.22–23 Banta found outstanding results with his patients with carpal tunnel syndrome using dexamethasone. In this study, more than 58% of the subjects had a positive response to iontophoresis, and he suggested that this is an excellent alternative to steroid injections.24
Other conditions found useful for treatment are skin conditions such as hyper-hidrosis,2526 small open ulcers,2728 and fungal infections.29 Iontophoresis has also been used to administer local anesthetics for dental, ear, nose, throat, and eye procedures.30“32 Edema reduction using hyaluronidase, which appears to increase absorption of fluid from skin and subcutaneous tissue, has been attempted, but as
40 Iontophoresis and Phonophoresis
________ Table 1. Commonly Used Ions with Iontophoresis
Ion Polarity Indication
Dexamthasone – Musculoskeletal inflammatory conditions
Acetate – Calcium deposits
Lidocaine + Analgesic agent
Hyaluronidase + Edema reduction
Zinc + Ischemic ulcers
Copper + Fungal infections of feet
with other edema-reduction techniques, the effect is short-lived.3334 Table 1 contains a list of the most commonly used ions and their respective polarity.35
General Principles of Application
Identification of the appropriate ion and its polarity for treating the presenting pathology is paramount for successful treatment. Some ions, such as those in iron, silver, copper, and zinc, form insoluble precipitates as they pass into the tissues and should be avoided. Other important factors that influence outcome are the (1) depth of penetration, (2) number of ions transferred, and (3) whether vascular transportation of the ions carry away from the application site. The number of ions transferred into the body is dependent on three factors: the current density, duration of the current flow, and the concentration of ions in the solution. The current density is determined by the size of the electrode used—the smaller the electrodes, the higher the density. To decrease the caustic alkaline reaction in the body tissue that occurs under the cathode, the surface area of the cathode is always at least twice that of the anode. Normal intact skin is intolerant of current densities greater that 1 mA/cm2. This impedance is further lowered in abraded or lacerated skin, fair skin, and scarred skin. The anesthetic effect produced under the electrodes poses a high risk for electrical burns. Therefore, close monitoring and caution is advised during treatment. Research on the penetration and distribution of ions with iontophoresis has demonstrated effectiveness. Several studies have indicated that ions penetrate and have therapeutic effects on deep structures.36‘37 More recently, Costello found penetration of at least 1 cm into the gluteal muscles of rabbits when using lidocaine with iontophoresis. His ideal parameters for ion penetration were current of 4 mA for 10 minutes, with a 4% lidocaine solution.38
Equipment
Three types of equipment are available for iontophoresis: line-operated units, simple battery-operated units, and rechargeable power units. Line-operated units are used mostly for the pilocarpine iontophoresis sweat test in cystic fibrosis.39 Because of the potential for electric shock from the wall outlets, battery-operated units were developed.
Battery-operated units are available for commercial and home use. A more sophisticated multipurpose unit, called the Phoresor, is popular in dentistry and physical therapy. The Phoresor runs on a 9-volt battery with a 45-volt DC transformer. It delivers a constant current and adjusts to change in resistance in the
Iontophoresis and Phonophoresis 41
external circuit during the procedure. It is equipped with safety features including a limited maximal rate of current of 2 mA/sec to prevent shock. The actual procedure entails massaging the chosen drug solution or cream into the bare skin over the area to be treated or placing a towel soaked with the drug solution on the skin to be treated. The active pad electrode made of tin, aluminum foil, or commercial metal electrode that has the same polarity as the ions is placed over the towel. Avoiding direct contact between the pad and skin is essential to prevent chemical burns. On the other hand, good contact between the electrode and towel and between the towel and skin is needed to avoid “hot spots” from increased current density. A second electrode pad, moistened with tap water or saline solution, is placed at a distance on the same side as the active electrode. The lead wires from the pads are connected to the appropriate generator terminals. The amplitude of the current is set to achieve current density between 0.1 and 0.5 mA/cm2. The duration of treatment can be up to 15 minutes, depending on die patient’s comfort.
Today, several brands of electrodes are available that allow for simple drug delivery. With these modern electrode systems, the ion solution is simply injected onto the drug delivery electrode, saturating it. The pads come in various sizes, each with their respective drug fill volume. This pad is placed over the treatment area, and a separate dispersive pad is placed over a muscle group at least 6 inches away. The lead clips are attached to the appropriate electrodes, and the unit is turned on. For inflammatory musculoskeletal conditions, these authors typically use dexametha-sone with the following settings:
Dose: 40 mA-min
Current: 2 mA
Treatment time: 20 minutes
|
|
|
Figure 1. A typical electrode placement for treatment of lateral epicondylitis using the Iomed Phoresor II. |
The newer Phoresor units automatically calculate the treatment time once the dose and current variables have been selected. These units sound an audible alarm and shut down once the treatment time is complete. Figure 1 shows a Phoresor in use with electrode placement for treatment of lateral epicondylitis.
42 Iontophoresis and Phonophoresis
Summary
Iontophoresis has enjoyed considerable success in the treatment of muscu-loskeletal and dermatologic conditions. With use of appropriate parameters, it has proven to be a safe and effective modality. As knowledge of the mechanism and physiology of the iontophoretic process increases, the potential for its use for drug delivery in the treatment of musculoskeletal conditions expands.
PHONOPHORESLS
Phonophoresis may be defined as ultrasonic energy used to enhance skin permeability, allowing uncharged or charged molecules of drugs into dermal tissues. Ultrasound refers to sound waves with frequencies beyond the human audible range of 20 kHz. High-frequency waves in the 800-1000-kHz range are generated by applying alternating current to a crystal, usually quartz or silicone dioxide. Through a phenomenon known as the piezoelectric effect, the electric current causes the crystal to undergo rhythmic deformation producing ultrasonic vibrations. The vibrations are then transferred through a coupling medium to tissue surface.4041 In phonophoresis, the coupling agent (water or gel) is replaced with the drug to be delivered. Phonophoresis can thus be used as a transdermal drug delivery system.
Historical Background
In 1954, Fellinger and Schmid first reported use of phonophoresis to enhance drug delivery in treatment of arthritis using hydrocortisone ointment.42 In 1963, Griffin and Touchstone used cortisol to demonstrate percutaneous penetration into paravertebral nerve and skeletal muscle.43‘44 Hydrocortisone has been used successfully for treatment of sprains, strains, tendinitis, bursitis, and epicondylitis.45
Mechanism of Action
Phonophoresis is different from simple ultrasound therapy in that the drug is delivered to deep tissue by ultrasound energy and the clinical effect is associated with the pharmacologic effect of the drug. The exact mechanism of action of phonophoresis is still unknown, but several theories hold that ultrasound may cause intracellular diffusion from high-speed vibration of drug molecules along with vibration of the cell membrane and its components.46 Other theories involve the cavitation effect of ultrasound. Cavitation may cause mechanical stress. Temperature elevation or enhanced chemical reactivity causes drug transport.4748 Brown suggested that ultrasound increased cell permeability and drug absorption by raising skin temperature.49 Increased tissue permeability has been attributed to mechanical “stirring” and increased pore size.50 Other studies suggest that changes in stratum corneum lipid structure enhance percutaneous absorption.51
Applications of Phonophoresis
Transcutaneous drug delivery through use of topically applied agents is a well-known treatment for conditions such as angina, hypertension, motion sickness, and local musculoskeletal injuries. Anti-inflammatory agents and local anesthetics
Iontophoresis and Phonophoresis 43
have been used to treat pain and inflammation. Steroid phonophoresis generally has been used in conditions for which steroid injection is considered. Advantages of using phonophoresis over injections include:
1. The method of delivery is noninvasive.
2. There is little or no systemic absorption, minimizing the risk of hepatic and
renal injury from drug elimination. Studies that substantiate this finding doc
ument absence of dexamethasone, hydrocortisone, and salicylates after
phonophoresis in humans.52“54
3. Patient comfort is increased.
4. Drug delivery can be terminated rapidly through termination of ultrasound.
5. There is a low risk of infection when used on intact skin.
6. Delivery of selected drugs is enhanced.
Phonophoresis should be limited or is contraindicated in the following conditions:
1. Broken skin surface and skin infections
2. Allergy to the drug used for phonophoresis
3. Conditions with reduced temperature and light touch sensation
4. Peripheral vascular diseases
5. Malignancies
6. Pregnancy
7. Presence of cemented prosthesis
8. Weak and unstable joints
9. Presence of keloid or exuberant scar formation
Equipment
Performance of phonophoresis requires an ultrasound machine that is AC powered, has two or more frequencies of operation, and has outputs that are easily adjusted. The treatment head is sized to treat irregular body surfaces and has a transducer that senses poor coupling. There is total contact between the gel and transducer that is constantly moved at a rate of 1 inch per second. The pulsed mode of ultrasound is preferred to minimize thermal injury. The usual treatment dose is 1.0-1.5 watts/cm2 for 5 minutes.
Review of Drugs Used for Treatment of Musculoskeletal Conditions
The most frequendy used and most studied drug for phonophoresis in musculoskeletal conditions is hydrocortisone. Ten percent hydrocortisone has been shown to be more effective than 1 % hydrocortisone in the treatment of humeral epicondylitis, subdeltoid bursitis, and bicipital tendinitis.55 Byl and associates studied the effects of phonophoresis with corticosteroids on collagen deposition in pigs under controlled conditions.56 Collagen activity, as measured by level of hydrox-yproline, showed decreased levels in the subcutaneous tissues but not in the sub-muscular or tendinous tissue. This highlights the limitations of phonophoresis for conditions deeper than subcutaneous tissue. This observation was substantiated by Muir and colleagues, who studied phonophoresis of hydrocortisone in canine knees.57 Compared with intra-articular steroid injection, phonophoresis was shown to be ineffective in delivering the hydrocortisone into the knees. However, phonophoresis has been shown to be superior to ultrasound alone using 10% cor-
tisol solution in the hind leg joints of dogs.58 Because of the potential for adverse effects, systemic effects of hydrocortisone phonophoresis have been studied. Ten percent hydrocortisone did not appear to suppress adrenal function in patients who received phonophoresis with dexamethasone every other day for 2 weeks over the shoulder area.59 Similarly, no increase in blood levels of cortisol was found in a blinded study of healthy human volunteers who received 1.0 watts/cm2 ultrasound treatment using either 10% hydrocortisone gel or Aquasonic gel for a total of two treatments, 1 week apart.60 Many PT clinics use dexamethasone in Aquasonic V3% gel. There are many anecdotal reports of benefits in using this for treating lateral epicondylitis. To date, there is no clear scientific data available to verify which medication or dose of medication works best and how much of the active ingredient is actually absorbed. Oziomek and associates, who studied effects of phonophoresis on serum salicylate level, suggest that phonophoresis is substrate specific. Topical application of salicylates with and without use of ultrasound resulted io increase in serum salicylate level. Thus, they concluded that perhaps no appreciable absorption of salicylates occurred in subdermal tissues.54 A double-blind study by Benson et al. using benzydamine, a nonsteroidal anti-inflammatory drug for phonophoresis, also found no percutaneous absorption.
Cryotherapy_____________________
Kirstin Young, MD, MPH, and Eugenie Atherton, MSPT
Cryotherapy, or cold therapy, has been used for centuries to treat many ailments. Superficial cooling is a basic tool for all rehabilitation practitioners owing to its simplicity, low cost, safety, and effectiveness. Most forms of cryotherapy are based on superficial cooling agents, with energy transfer occurring through conduction. Conduction involves the transfer of energy through direct contact. The cold surface (usually ice or other cold modality) extracts energy or heat from the warmer surface (usually skin). The larger the temperature difference between the two surfaces, the larger the drop in tissue temperature.1–4
Although conduction is the primary mechanism of energy transfer in most cryotherapy techniques, exceptions to this rule exist. Vapocoolant spray extracts energy or heat through evaporation. As the liquid spray is emitted and comes in contact with the skin, it vaporizes, which requires heat or energy. The skin temperature drops as the spray is applied due to energy loss in the evaporative process.
Hydrotherapy is another exception to the conduction rule. The transfer of energy or heat through convection occurs during hydrotherapy. The temperature of the skin and underlying tissue drops as the cool water current passes by the warm skin extracting heat in an attempt to equalize the two temperatures.
MECHANISMS OF ACTION
Cold acts through several mechanisms to produce the desired therapeutic effects. First, cold results in immediate arteriole vasoconstriction, which decreases the delivery of blood to the cooled area. This occurs through sympathetic fibers and by a direct effect on the blood vessels.18‘31 In addition, the use of cold can decrease the delivery of substances carried in the blood. Some of these agents may be undesirable vasoactive agents such as histamine. Without the delivery of large amounts of histamine, inflammation and fluid filtration are kept to a minimum.27
Another substance that is retarded by cooling is cytochrome oxidase. This can cause mitochondrial damage; therefore, its decrease as a result of cooling can be beneficial in retarding secondary injury.25 The hunting response has been described as a delayed vasodilation of arterioles after cooling. This protects the peripheral tissues from cold induced damage.19
Neuromuscular effects of cooling are well documented. The cooler the muscle, the slower the rate of firing. The site of the thermal effect is the sensory terminal itself.10 With cooling, the tendon jerk is diminished. This is due to the decreased tone of the muscle at the spindle level.14>17>26 The motor nerve fibers display prolonged twitch in both contraction and relaxation. The nerves demonstrate conduction slowing with cooling and effectively become blocked at the neuromuscular junction. As temperature decreases, the amplitude and duration of the motor unit end plate potentials increase, and the frequency of their firing decreases.20
The peripheral nerves are affected by cryotherapy as well. The duration of action potential recovery is increased after cooling,7 and the action potential dura-
47
48 Cryotherapy
tion itself increases inversely as the temperature decreases.20 The rate of stimulation required to obtain fusion of the twitches to complete tetanus drops as the temperature decreases.33 The cooling effect on spasticity lasts long after application of ice (up to at least 30 minutes) .32
The threshold at which patients experience pain has been found to be decreased with the use of cryotherapy. This is thought to be due to a direct effect of temperature reduction oerve fibers and receptors.18 The diminished sensitivity of the muscle-spindle afferent fibers to discharge may contribute to this decrease in pain and also to muscle spasms.
However, cryotherapy also causes some effects that may be less desirable, such as increased tissue and blood viscosity, which can result in decreased elasticity of the tissue and increased resistance to motion. This could hamper therapeutic efforts,27 because it becomes progressively more difficult to perform skilled motor tasks as cooling takes effect.11‘12
As cold compresses are applied, skin temperature drops first, then the subcutaneous adipose tissue temperature slowly decreases, the intra-articular region (syn-ovium) is cooled, and finally the rectal (core) temperature drops. As little as 5 minutes of cooling can produce a decrease in intra-articular temperature, and the decrease is linear until 30 minutes. Rewarming takes longer than 1 hour, perhaps because of vasoconstriction.2–34 Compared with compresses, ice baths cool superficial tissues faster and have a more dramatic cooling effect, but they exert a lesser effect in the deep tissues.35
INDICATIONS
The most common indications for cryotherapy are:
• To decrease muscle tone
• To decrease spasticity in upper motor neuron lesions
• To facilitate muscle contraction and muscle reeducation
• To decrease bleeding
• To decrease edema
• To alleviate thermal burns
• To increase pain threshold
• To decrease inflammation
• To decrease joint pain and edema
• To decrease collagenolysis
• To decrease synovial inflammation
In patients with increased muscle tone, application of cryotherapeutic agents have been shown to decrease tone and spasticity through reflex decreases in motor neuron activity and muscle spindle discharge.14–28 Not only does abnormal muscle tone diminish through the application of cryotherapy, but muscle strength and endurance increase, facilitating muscle re-education and contraction.18
In an acute musculoskeletal injury, cold has been found to decrease bleeding, edema, and delivery of inflammatory cells.15‘18–24–27‘31 In addition, cryotherapy is believed to increase the pain threshold in both chronic and acute conditions through direct and indirect mechanisms.6–18–24 The pain receptors are impaired by
Cryotherapy 49
cold directly, and the reduction of spasticity, edema, and inflammation contribute to the relief of pain.
The use of cold has been shown to inhibit the development of burns, shorten healing time, and decrease severity of the burn. The more quickly the cold is applied after the initial burn, the better the therapeutic effects.836
Cryotherapy may also decrease collagenolysis and synovial inflammation and, therefore, slow joint destruction in patients with rheumatoid arthritis.1330
PRECAUTIONS
Cryotherapy is contraindicated:
• In areas with absence of sensation
• In patients with cold hypersensitivity
• In patients with arterial insufficiency
• In patients with cryopathies, such cryoglobulinemia, paroxysmal cold hemo-
globinuria, and Raynaud’s phenomenon
Prolonged joint cooling with topical ice can lead to nerve palsy and extensive axonotmesis. Ulnar and peroneal nerve damage have been reported in the literature.59129 To prevent these complications, avoid compression of nerves that lie relatively superficially, avoid the use of gel packs, which produce temperatures below freezing, and do not ice areas where patients may be insensate and unable to feel a cold “burn.”
The nerve injury thought to be caused by cold is likely a result of direct injury to the nerve membrane as well as secondary injury due to neural ischemia, edema, and suspension of axoplasmic transport.5 Some patients have been reported to have “hypersensitivity” to cold. The release of histamine or histamine-like substances causes cold urticaria. Symptoms include erythema, itching, and sweating. These cases are rare but do constitute a contraindication to cold therapy.16
Additionally, patients with arterial insufficiency should not receive prolonged cold therapy because of the already compromised delivery of blood.
Additional precautions for the use of cold include cryopathies such as cryoglobulinemia, paroxysmal cold hemoglobinuria, and Raynaud’s phenomenon.
SPECIAL CONSIDERATIONS
The major component of vapocoolant spray, fluoromethane, is made of dichlorodifluoromethane and trichlorofluoromethane, both of which harm the environment by destroying ozone in the upper atmosphere. This product is still used in some locations and is still sold in the United States. However, it does require a medical prescription by a physician for use.
The amount of subcutaneous adipose tissue directly relates to the rate of temperature decrease when ice is applied and rewarming when ice is removed due to the depth of the tissue, poor conductivity, and insulatory characteristic. In practice, a client who has little adipose tissue will benefit from a 10-minute ice pack application, whereas a client with a greater adipose layer may require as much as a 30-minute cold pack application to receive benefit.18‘21
Cryotherapy can alter a client’s true range of motion (ROM) and strength. This
50 Cryotherapy
can result in a skewed evaluation or re-evaluation. Ice increases the viscosity and decreases the elasticity of muscle and, therefore, can decrease the potential ROM for a given muscle.27 Clinically, measurements taken after cryotherapy is applied can appear more restricted than their actual values. Therefore, measurements should always be made before the application of cryotherapy. Performance can be diminished as well, and fine motor skills or activity involving full ROM may be impaired by the application of cryotherapy techniques.
Additional confounding occurs with strength measurements. Strength of a given muscle group appears to increase temporarily after cryotherapy.23 Thus, true strength measurements should be taken before cryotherapy. In addition, greater work can be accomplished after cryotherapy because the client may be able to perform therapeutic exercise with greater weight than without cryotherapy. This factor needs to be taken into consideration when prescribing or directing therapeutic exercises.
Ice is used to prevent inflammation in the first 24-48 hours after an acute injury. After that time, if swelling has been prevented, ice is to be discontinued because it can delay the healing process.1822
Ice immersion, chipped ice in a bag, ice massage, and applying frozen vegetables to the involved site are inexpensive and easy for the client to perform as part of his or her home exercise program.
CHOOSING A TYPE OF CRYOTHERAPY
The size and type of the area to be treated and time constraints are factors to consider when selecting a cryotherapeutic agent. A large treatment site requires a larger agent; therefore, a large commercial ice pack, chipped ice, or iced towel would be appropriate. Ice massage is used if a small region, such as a small muscle, tendon, or joint, is involved. If a distal extremity is involved, ice immersion is the treatment of choice. If time is limited and a muscle region is small, ice massage provides quicker results for cooling than an ice bag.35
METHOD OF ADMINISTRATION
|
|
|
Figure 1. Commercial gel ice pack applied to the knee. |
Commercial Gel Ice Packs. Commercial gel ice packs are applied to the entire region with a layer of towels placed between the client’s skin and the pack (Fig. 1).
Cryo therapy 51
Figure 2. Ice massage applied to wrist extensors.
For increased cooling effect, the towel is moistened with water and then placed on the treatment area and secured with a strap. The treatment time is 10-15 minutes, depending on the amount of adipose tissue.
Chipped Ice Bag. Scoop chipped ice into a plastic bag. To decrease the temperature more significantly, add one part water to three parts ice. Secure opening, and place on treatment site for 10-15 minutes.
Ice Massage. Water is frozen in paper cups, and the paper is partially peeled back to expose the ice. The therapist grasps the cup and rubs the ice in quick sweeping circular movements over the target area for 5-10 minutes (Fig. 2).3M The patient should report analgesia of the region after the session.
|
|
|
Figure 3. Iced towel applied to the elbow. |
Iced Towels. A towel that has been submerged in ice water or chipped ice is placed over the joint or muscle and secured with a strap (Fig. 3). This is beneficial when performing the contract/relax method during therapeutic exercise. The
52 Cryotherapy
Figure 4. Iced bath immersion of the left hand.
towels will need to be reapplied throughout the session because the iced towels warm quickly. The duration of application is the duration of the exercise session.
Iced Bath Immersion. The muscle or joint to be treated is placed in a basin or a whirlpool filled with crushed ice and water at a temperature around 13(C-27°C for 10-20 minutes (Fig. 4). The duration is dependent on the temperature: the lower the temperature, the shorter the duration of treatment. Immersion is beneficial when treating an extremity and circumferential cooling is needed.
|
|
|
Figure 5. Vapocoolant spray applied to wrist extensors. |
Vapocoolant Spray (Fluoromethane). The glass bottle of vapocoolant spray is held with the nozzle down approximately 12-18 inches above the treatment site, so that the stream will directly contact the skin (Fig. 5). Spray the site at a rate of 4 inches/second in one direction. Perform PROM while spraying and have the client
perform active ROM immediately afterwards. The entire process can be repeated three to four times. Rewarm the skin manually or with a hot pack, if necessary.
