CHICAGO—Clinicians need to know when and how to provide rehabilitation services for their patients, either within the clinic or office setting or by referral to physical or occupational therapists. Understanding rehabilitation principles and the basic exercises for common rheumatic and orthopedic conditions can help improve patient management.
Working with physical and occupational therapy professionals is an integral part of the job of a healthcare provider in a rheumatology practice. Many providers, however, want clarification about when a patient should be referred to a physical therapist and when the patient could be helped with rehabilitation therapy in the clinic setting.
Another factor influencing services recommended is access to physical or occupational therapy. Many patients are unable to undergo professional therapy because of time, cost, or other impediments to access. For example, some insurance policies will not cover physical therapy services until a patient has finished a treatment program of medications or home exercises. In these situations, rehabilitative help in the clinic may be the only option for those who need immediate therapy for a common condition.
Clinicians must make key decisions about the types and duration of physical and occupational therapy recommended. For this reason, rheumatologists should know how to write a prescription for rehabilitation therapy, how to explain precautions to patients doing physical therapy at home, how to demonstrate specific exercises that can be performed in the clinician’s office, and when to refer the patient to a specialist.
These and other issues about rehabilitation services were addressed in the ARHP Concurrent Session, Rehabilitation for the Clinician, at the 2011 ACR/ARHP Annual Scientific Meeting on November 6, 2011. [Editor’s Note: This session was recorded and is available via ACR SessionSelect at www.rheumatology.org.] The session’s presenters, Donna K. Everix, MPA, BS, PT, a physical therapist and electronic health record physician liaison at Mills-Peninsula Health Services in Burlingame, Calif., and Victoria A. Merrell, PA-C, MPT, a physician assistant and former physical therapist from Encinitas, Calif., outline their goals at the beginning:
- Understand when to refer a patient to formal rehabilitation therapy;
- Recognize and explain precautions for home exercising;
- Demonstrate specific exercises, including red flags for specific conditions;
- Examine concerns about patient compliance; and
- Review appropriate progress in exercise programs.
Writing a Therapy Order
A clinician’s therapy order often instructs a therapist to evaluate a patient’s condition and then begin appropriate treatment. In some cases, the clinician may prescribe specific treatments. A typical order can include the following directions:
- Evaluate and treat; and
- Specific treatment recommendations:
- Modalities (ice, heat, ultrasound, electrical stimulation, iontophoresis, phonophoresis);
- Joint or soft tissue mobilization;
- Patient education (posture, body mechanics, joint protection, activities of daily living modification);
- Therapeutic exercises (range of motion, stretching, strengthening, aerobic conditioning, balance training);
- Aquatic therapy;
- Gait training, fitting with assistive device;
- Splinting, bracing orthotics;
- Ergonomics; and
- Exercises specific to preparing for work or sports activities.
Identify Conditions that Warrant Referral to Therapy
There are certain diagnoses that require an order for therapy:
- Adhesive capsulitis;
- Partial rotator cuff tear;
- Meniscal/ligamentous knee injury;
- Postsurgery situation;
- Osteoporosis; and
- Complex regional pain syndrome.
Patients with these conditions benefit from ongoing physical therapy and evaluation.
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.
The clinician’s role in rehabilitation begins with evaluating a patient’s therapy needs and then deciding what type of therapy meets those needs. Certain conditions require referral to a physical or occupational therapist while others need attention from a medical specialist. However, many conditions can be treated within the clinician’s office, and it is vital that rheumatologists know how to demonstrate exercise techniques to patients for home programs.
Rheumatologists can also be instrumental in encouraging patients who have not been exercising to begin a conditioning program to improve their general health as well as to alleviate symptoms specific to their conditions. Clinical providers have several treatment options, and by becoming familiar with the requirements for each, they can select the best one to fit their patients’ individual needs.
Ann Kepler is a medical journalist based in Chicago.