While Everix and Merrell provided a list of disorders that require referral to therapy, they purposely did not include spinal conditions in this presentation. Spinal care is such a comprehensive topic that, “we could do a whole day on the spine…the protocols are very different based on what the pathology is,” said Everix.
On the other hand, there are certain musculoskeletal conditions that can be addressed in a clinic setting:
- Plantar fasciitis;
- Ankle sprain;
- Achilles tendonitis;
- Patellofemoral syndrome;
- Iliotibial band syndrome;
- Rotator cuff tendonitis/bursitis;
- Medial and lateral epicondylitis;
- Carpal tunnel syndrome; and
- Dequerrain’s tenosynovitis.
These conditions offer the clinician the opportunity to recommend and demonstrate exercises within the office and then monitor the progress of the patient’s at-home program (Visit ACR SessionSelect at www.rheumatology.org to watch this session and see illustrations of therapies and treatments for these conditions.) However, the provider should always evaluate the severity of an injury and its causes before making a final decision about its treatment in a clinical setting.
Red Flags
A rheumatologist must always be alert to red flags that indicate the need for referral to a another medical specialist rather than to a physical or occupational therapist. A diagnosis or suspicion of these conditions is a warning that evaluation by a specialist is recommended:
- Neurological changes, including radicular symptoms or bladder or bowel incontinence;
- Fracture;
- Tendon rupture or significant tear;
- Malignancy;
- Cardiopulmonary complications;
- Increase in pain for more than two hours after therapy; and
- Onset of new symptoms.
Prescribing Exercise
Exercise can be the basis of effective therapy for some rheumatology patients. Everix and Merrell suggested that getting and keeping patients moving is the beginning of any therapy program.
People with arthritis are often unfit, having given up leisure activities because of pain. Yet there is evidence that there are long- and short-term benefits of exercise for patients with arthritis. Active people experience improved cardiovascular function; increased muscle strength and flexibility; higher physical and social activity levels; less fatigue, pain, and depression; and a reduction of disease activity. Any type of movement helps: aerobic exercise; aquatic exercise; sports-related activities; even walking, which has the benefits of being free and accessible.
Merrell and Everix recommended that a patient starting an exercise regimen begin and progress slowly, protect joints by avoiding repetitive movements, and seek the help of a physical therapist to begin. They also suggested setting reasonable goals:
- Moderate aerobic activity at least three to four times a week for 30 minutes (cumulative)—moderate means activity well within the patient’s current capacity to sustain for 60 minutes;
- A heart rate 50% to 70% of the predicted heart rate;
- Monitoring heart rate, perceived exertion, and talk test;
- Meeting individual needs and variations in disease activity;
- Emphasizing time versus speed or distance; and
- Alternating exercises that vary between weight-bearing routines and those that protect joints.
Most important, said Merrell and Everix, is that a patient, in consultation with the clinician and the physical or occupational therapist, selects activities he or she will continue. This is the issue of self-efficacy, that is, the confidence among all of the interested parties in the patient’s ability to begin and sustain a long-term exercise program.
