Recovery

In some cases, patients are able to identify which movements are causing their pain. They are able to modify their activity and allow healing to occur. However, in other cases, particularly when there is latency (time delay) between their movement and the onset of pain, the patient is not able to modify the activity correctly.

Table 14.3 Original pain source varies depending on location and nature of original injury. Compensatory patterns can cause myofascial pain dependent on the specific patterns the individual patient chooses.

Types of pain

Typical region

Possible reason

Original pain source

Any area

Trauma

Repetitive use

Degeneration

Idiopathic

Myofascial pain from

Joints —one to two levels proximal or

Altered movement patterns and

compensatory patterns

distal to the affected area

postures

Other joints specific to the patients

chosen compensatory movement

pattern

In order to recover completely, the patient must be educated to recognize the current functional status. This is of critical importance. If a patient continues to keep the "best" or "pre-injury" functional level as the baseline, he/she will continue to make errors in judgment leading to increased pain. For example, if a patient has a 5-min walk tolerance, but decides to walk for 25 min, it results in a "flare up." The patient often says that "I used to walk for 60 min so 25 should be no problem." This inability to recognize current compromised level of function and the subsequent failure feed to their psychological dysfunction. In the above example, had the patient attempted to increase the time by small proportions, for example, to 7 min, this might have been a successful attempt with positive emotional/psychologic effect. It is important that the physical therapist and physician determine tolerance for activity. These include walking tolerance on level ground, hills, up/downstairs; standing tolerance; sitting tolerance; and sleep tolerance (including total hours and uninterrupted time). This establishes the intensity of the treatment plan and helps monitor functional progress for the patient, clinician, and third-party payers. It can also be used to determine alternative activities that do not cause pain (i.e., sitting desk activities versus standing activities if walk and stand tolerance is an issue). Detailed examples of activity-specific tolerance and ensuing functional limitation and secondary effect on the patient's life are presented in Table 14.4.

To establish a recovery plan, the patient and clinician must have a clear understanding of aggravating and alleviating factors. Simply stated, to improve, a patient must do more of what alleviates symptoms and less of what aggravates. Generally speaking, a patient continues to aggravate and maintain the symptoms by not only moving in a suboptimal pattern but also with "too much" movement at the injured area. In some cases, the patient is able to move appropriately, but can only do so for a short period of time or when the load is low (endurance and strength deficit). When the patient becomes fatigued, he/she switches to an altered pattern which results in pain. The physical therapist must identify these problems and educate the patient to avoid these movements and activities, adopt appropriate movement strategies (for permanent or temporary use depending on the ability to recover from disease process), rehabilitate their joint (mobility) and muscle (strength and length) deficits, and then retrain appropriate motor control. Depending on the injury, there will be a varying degree of recovery versus compensatory strategies. Ultimately, the patient's goal is to return to their baseline,

Table 14.4 Examples of specific tolerances and functional limitations.

Activity tolerance

Functional limitations

Participation in life

Sit tolerance

Cannot drive, work at desk, sit through movie,

Avoids social events, work duties, family

meeting

activities

Stand tolerance

Cannot wait in line at grocery store, socialize at

Avoids social events, stops doing own

parties, go to museum

shopping, has to carry equipment or use

wheelchair

Walk tolerance level ground

Cannot walk to activities, attend social

Avoids social events, may not be able to work,

functions, visit friends, makes shopping and

avoids activities, becomes more isolated

other activities difficult

Walk tolerance hills

Cannot access certain environments, cities,

Avoids uncertain or unusual environments

ramps, sports such as golf

Walk tolerance stairs

Cannot enter certain buildings, homes

Avoids environments, stays in home, may not

up/down

be able to leave home

Sleep tolerance

Cannot obtain restorative sleep and does not

Avoids activities, becomes more depressed,

-Total time

heal, may cause other injuries by assuming

avoids travel that may further affect sleep

-Uninterrupted time

harmful positions, decreased concentration,

strategies

-Position

increased irritability

being able to perform the activities that they want without pain. It is important, however, that the compensatory strategies do not cause injury over time by increasing stress on other body segments. Frequently, to meet this need, physical therapists will teach the patient to move in a way that optimizes body mechanics and shifts forces to stronger, larger muscle groups over multiple body segments. All treatment plans will incorporate preparation for this goal by muscle strengthening and motor control training. It should be emphasized that full recovery requires communication between the physician and the physical therapist about disease processes and treatment plan. If this is not done, the patient may lose confidence, develop fear, and may not participate fully in the program.

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