Physical rehab, also known as functional rehab, is a specialized healthcare dedicated to improving, maintaining, or restoring physical strength and mobility with maximized results. Typically, it helps patients to improve or maintain functional abilities like activities of daily living (ADL) and to gain greater independence after illness, injury, or surgery. It usually includes passive and active therapies. The distinction between these two terms essentially comes down to the movement of the patients. It is important to note that active and passive treatment techniques go hand-in-hand and may even be used in a single session: a passive therapy will help warm up muscles and reduce pain, followed by active therapeutic exercise. Patients must have a personalized recovery plan combining the two. Passive treatment focuses more on pain relief. If the patient's injury or condition creates a lot of pain and discomfort, their first few therapy sessions may consist of more passive treatment. Once their pain level starts to decrease, active therapies will be introduced. It is common to be treated with passive and active measures during the same session. While engaged in active therapy, many patients will continue to receive passive treatments at the beginning or end of their therapy sessions. The key is to get the right mix of passive and active therapies to best suit their needs.
PASSIVE THERAPIES
Treatments that do not require the patient to move their muscles and joints. This may be because the patient is still experiencing too much pain or discomfort to undertake more active exercises, or the patient’s muscles are too weak to complete specific exercises. Passive therapies thus primarily involve pain management to be able to advance to a more active approach eventually. Here are the most common passive therapies used for physical rehab:
Conductive modalities utilize the conduction of thermal energy to produce local and occasionally generalized heating or cooling of superficial tissues with a maximum penetration depth of 1 cm or less. Two primary conductive modalities are:
1) Thermotherapy refers to applying therapeutic heat, including warm whirlpool, warm hydrocollator packs, paraffin baths, and fluid therapy. Primary physiological effects of heat include increased blood flow through vasodilation (dilation of the blood vessels), increased metabolic rate, and relaxation of muscle spasm. Increasing local tissue temperature accelerated the healing process by dilating blood vessels and shifting the oxy-hemoglobin dissociation curve to increase the oxygen and nutrient supply to the tissue. Heat can relax muscle tone by reducing muscle spindle and gamma efferent firing rates. There is also the theory that muscle relaxation is assumed to occur with the disappearance of pain.
2) Cryotherapy applies therapeutic cold, including ice massage, cold hydrocollator packs, cold whirlpool, cold spray, contrast baths, ice immersion, cold compression, and cryokinetics. Primary physiological effects of cold include decreased blood flow through vasoconstriction (constriction of blood vessels), decreased metabolic rate, and decreased nerve conduction velocity. Restriction of local blood flow reduces the potential for edema (swelling) to develop. Slower metabolism releases fewer inflammatory mediators and, therefore, reduces edema formation. Decreased nerve conduction velocity, raising the threshold stimulus of muscle spindles, and depression of the excitability of free nerve endings result in an increased pain threshold and, therefore, pain relief.
Electrotherapy refers to using electrical currents such as transcutaneous electrical nerve stimulation (TENS) and interferential current (IFC) for pain relief. Electrical currents generated by a portable pulse generator are delivered across the intact surface of the skin via the self-adhesive conducting pads called electrodes. Electrical energy is used for the modulation of pain through stimulation of cutaneous sensory nerves and the following two analgesic mechanisms:
1) Gate Control Theory refers to applying an electrical current to a painful area. This stimulates the large-diameter A-beta (Aβ), fast-conducting nerve fibers, which inhibit the transmission of pain perception to the brain by closing the gate for small-diameter A-delta (Aδ) nerve fibers carrying pain messages to the brain.
2) Endorphin Release Theory refers to the production of endogenous opioids by the brain to modulate pain perception. Endorphins are endogenous transmitters with a similar effect to morphine. The stimulation of A-delta (Aδ) and C fibers causes the release of endorphins (endogenous opioids) that bind to opiate receptors and block the release of “Substance P” (a neurotransmitter involved in pain responses).
Therapeutic ultrasound is classified as a deep heating modality capable of producing a temperature increase in tissues of considerable depth because it travels well through homogenous tissue (e.g., fat tissue). It is commonly used in physical rehab to provide deep heating to soft tissues (muscles, tendons, joints, and ligaments), and it is not to be confused with diagnostic ultrasound, which is used to see the inside of the body, such as checking on a fetus during pregnancy. Mechanical vibration at increasing frequencies is known as sound energy. The normal human sound range is from 16 Hz to 15-20,000 Hz (in children and young adults). Beyond this upper limit, the mechanical vibration is known as Ultrasound. Therefore, Ultrasound is a form of mechanical energy. The frequencies used in therapy are typically between 1.0 and 3.0 MHz (1MHz = 1 million cycles per second). Pressure waves created by the mechanical vibration of particles through a medium may be delivered as an uninterrupted stream (continuous mode for chronic conditions) or delivered with periodic interruptions (pulsed mode for acute conditions). Traditionally, it has been used for its thermal effects, but it can enhance healing at the cellular level by altering all phases of tissue repair. Recent studies show that nitric oxide released by ultrasound therapy may be a potent angiogenic (blood vessel formation) agent, stimulating new blood vessel growth at the injury site. More recently, pulsed ultrasound has been shown to accelerate the healing rate of fresh fractures due to the enhancement of angiogenic, chondrogenic (cartilage formation), and osteogenic (bone formation) activity. Ultrasound also aids in pain relief, and the literature has proposed reduced conduction of pain transmission as a possible mechanism for the analgesic effects.
Laser therapy is a form of light therapy. LASER is an acronym for the Light Amplification by Stimulated Emission of Radiation. It's a light amplifier that enhances particular properties of light energy. Laser light will behave according to the fundamental laws of light, in that it travels in straight lines at a constant velocity in space. It can be transmitted, reflected, refracted, and absorbed. It can be placed within the electromagnetic spectrum according to its wavelength/frequency, which will vary according to the generator under consideration. Therapy lasers tend to fall into a particular category of laser light known as 3A or 3B & are often referred to as 'soft laser' or 'mid laser' sources. More recently, the terms Low Level Laser Therapy (LLLT) and Low Intensity Laser Therapy (LILT) have been adopted. Lasers with different wavelengths, varying from 632 to 904 nm, are used to treat musculoskeletal disorders. As with many other forms of energy delivered to the patient, the primary effects are divided into thermal and non-thermal. LLLT is generally considered a non-thermal energy application. However, one must be careful to appreciate that the delivery and absorption of any energy to the body will develop heat to some extent. Non-thermal in this context relates to thermal energy's non-accumulative nature. While some research studies show that LLLT can result in immediate pain reduction in rheumatoid arthritis (RA), osteoarthritis (OA), tendinopathies, acute and chronic neck pain, temporomandibular joint (TMJ) pain and other joint disorders there is currently a lack of consensus on the best parameters to use; i.e. power, dosage, time, pulsing, and type of laser. The therapeutic wavelength appears between 800 and 1,000 nm, and the dose is around 6-10 joules/cm2. Light at the wavelength typically employed in laser therapy is readily absorbed by enzymes, hemoglobin, fibroblasts, and neurologic tissue. Laser has been shown to stimulate cell degranulation, causing the release of potent inflammatory mediators such as growth factors, and activate fibroblast cell function to increase collagen deposition and improve tensile strength. Some reports also show a slight decrease in edema produced by inflammation following laser therapy. Absorption by hemoglobin releases nitric oxide, resulting in endothelial cell proliferation. Low dosages also significantly decrease sensory nerve conduction velocity, reducing pain. LLLT may minimize inflammation-related pain by lowering levels of COX-2 and tumor necrosis factor-alpha (enzymes associated with inflammation), oxidative stress, edema, and bleeding. It is also believed to cause cellular mitochondria to produce more ATP, a cell’s basic energy unit, increasing metabolic activity.
Passive exercises are also known as passive range of motion (ROM: how far a joint can be moved in different directions). These exercises are considered passive because the patient does not exert any effort. Instead, someone helps them move their muscles and joints through their full range of motion. Also, passive ROM can be done in conjunction with passive stretching exercises, where the therapist or another person stretches the patient's soft tissues (muscles, tendons, and ligaments). Passive ROM exercises can help prevent muscle stiffness and spasm. Along with prevention, passive ROM exercises can also be used to treat spasticity.
ACTIVE THERAPIES
Any treatment where the patients are physically involved. This might mean that they are moving a joint or a muscle, either with the assistance of a therapist or other care provider or without. If the patients are physically involved in the treatment in any way, the treatment is considered active. An active rehab program is provided for those patients who no longer require acute care treatment but have ongoing physical complaints with respect to their original injuries. These patients have typically plateaued with conventional therapies and require a more active approach to their recovery. Active therapies always involve exercise focusing on restoring and maintaining flexibility, strength, endurance, stability, and balance. Active therapeutic exercises aim to return an injured patient to a fully functional, pain-free state. Therapeutic exercises fall into four basic categories:
Flexibility exercises are stretching and ROM exercises to improve patients' flexibility. Flexibility exercises give the patients more freedom of movement for their physical and everyday activities, such as getting dressed and reaching objects on a shelf. There are different types of flexibility exercises performed by the patients based on their stage of recovery:
1) Active-assistive ROM exercises involve some assistance from the therapist. The patient can move his or her limb but cannot complete the full range of motion because of weakness or pain. This is done to slowly increase the strength of the patient's specific muscle.
2) Active ROM exercises involve the patient performing all movements without manual assistance from the therapist. The therapist may continually provide verbal cues on performing the exercises correctly.
3) Stretching exercises are for patients with limited ROM and/or flexibility who often need to begin stretching exercises. Stretching exercises can recondition muscles that have contracted due to injury or other trauma. By keeping muscles stretched and loose, the patient can maintain flexibility and lessen the chance of re-injury or losing range of motion.
Strengthening exercises are for patients with loss of muscle strength, a common problem with age, injury, and surgery. The human body is quite resilient, and muscle strength can be improved with proper exercise. By increasing muscle strength, the patient will have better balance, mobility, and the ability to enjoy a normal lifestyle. Strengthening exercises do not necessarily mean you have to lift weights or start a heavy workout program. Some simple exercises, such as toe raises, leg lifts, and arm rotations, can help improve muscle strength and endurance. Some therapists recommend using resistance bands, light weights, or other implements for advanced strengthening of muscles.
Endurance exercises, aka aerobic activities, include walking briskly, jogging, swimming, and playing sports (e.g., tennis, soccer, etc.). They increase the breathing and heart rate of the patients, and help keep them healthy, improve their fitness, and help them do the tasks they need to do every day. Endurance exercises improve the health of the heart, lungs, and circulatory system. They also delay or prevent many diseases that are common in older adults, such as diabetes, heart disease, and osteoporosis.
Balance exercises can help prevent falls and avoid the disability that may result from falling. They can also be helpful for people with issues related to balance, such as a stroke, or individuals with muscle weakness. Initially, balance exercises can be performed on parallel bars with the help of a therapist. This largely depends on the patient's level of balance. They can be transitioned to exercises without the bars as soon as the patient can perform them without the therapist's help. At this stage, the patient may proceed to more complex movements such as heel-to-toe walking and standing on one foot.
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