Physical Therapy Prescription

Numerous guidelines recommend physical therapy for the management of musculoskeletal conditions. However, specific recommendations are lacking concerning which exercises and adjunct modalities to use. Physical therapists use various techniques to reduce pain and improve mobility and flexibility. There is some evidence that specific exercises performed with the instruction of physical therapists improve outcomes in patients with low back pain. For most modalities, evidence of effectiveness is variable and controlled trials are lacking. Multiple modalities may be used to treat one clinical condition; decisions for the treatment of an individual patient depend on the expertise of the therapist, the equipment available, and the desire of the attending physician. A physical therapy prescription should include the diagnosis; type, frequency, and duration of the prescribed therapy; goals of therapy; and safety precautions. (Am Fam Physician 2007;76:1661-6. Copyright 2007 American Academy of Family Physicians.)

Physical therapists are an integral part of inpatient and outpatient treatment of neurologic and musculoskeletal injuries and disabilities. They also can assist with and augment the care of patients with cardiac, pulmonary, and developmental disorders. Family physicians should have some understanding of the various treatments and modalities used by physical therapists.

Physical Therapy

Modalities are adjunctive treatments to exercise and manual therapy; the use of modalities alone is not considered physical therapy. The American Physical Therapy Association states: "Without documentation which justifies the necessity of the exclusive use of physical agents/modalities, the use of physical agents/modalities in the absence of other skilled therapeutic or educational interventions should not be considered physical therapy."1 The ultimate goal of any physical therapy intervention is to improve the long-term function of the patient, which is best accomplished with the use of exercise, manual therapy, and modalities.

Research conducted during the development of several physical therapy modalities focused on how they affect inflammation. Many of the conditions that were thought to be inflammatory (e.g., patellar tendonitis) are in fact not histologically inflammatory. However, these tendinopathies (a more accurate classification) continue to be treated with modalities designed to decrease inflammation. There is some evidence that these modalities may be beneficial, but this may not be related to a true anti-inflammatory effect.

Exercise and Adjunct Modalities

A working knowledge of the uses and limitations of different modalities will assist family physicians in prescribing physical therapy. Table 1 summarizes some of the physical therapy modalities that are available. The practicality of individual modalities may vary, and physicians are encouraged to discuss the options with qualified physical therapists.

Exercises that target muscle deficiencies or that help rehabilitate patients after surgery or injury are a mainstay of many physical therapy protocols. Therapeutic exercise is used to improve strength, mobility, and function and to decrease pain and swelling.

Family physicians often prescribe simple home-based rehabilitation exercises by providing patients with brief instruction and handouts. Supervised therapeutic exercise has been shown to be more beneficial than home-based exercise in patients with low back injury,2 osteoarthritis of the knee,3 or intermittent claudication.4 Other studies, however, have found that home-based exercise is as beneficial as supervised physical therapy for postoperative recovery after anterior cruciate ligament reconstruction.5,6 Table 2 includes common therapeutic exercises.

Therapeutic ultrasound is another commonly employed technique. Modifying the application parameters (i.e., intensity, wavelength, duty cycle, and frequency) provides a variety of local effects on tissues.

Ultrasound provides therapeutic benefit via thermal (continuous ultrasound) and nonthermal (pulsed ultrasound) effects.7,8 Continuous ultrasound heats the tissue. Pulsed ultrasound is thought to accelerate tissue healing at the cellular level, primarily through alteration of membrane permeability, ionic concentration gradients, and cellular biochemical activity.7,8 Higher-frequency ultrasound waves treat superficial tissues such as patellar tendons. Lower frequencies penetrate deeper (up to 2 in 5 cm ) to treat deep muscle bruising, spasms, and strains.7 Selection of ultrasound application parameters is based on the desired effect and the location and density of the tissue to be treated. These decisions are best made by a therapist experienced in performing therapeutic ultrasound.

Common indications for ultrasound therapy include treatment of tendon injuries and short-term pain relief.7,9-11 Ultrasound has also been shown to promote healing of some acute bone fractures, venous and pressure ulcers, and surgical incisions.7,8,12,13 Therapeutic ultrasound can cause burns or endothelial damage if applied incorrectly.7,8,14

Despite the widespread use of therapeutic ultrasound in the physical therapy setting, evidence of its clinical effectiveness is lacking. Although there is limited evidence that ultrasound benefits musculoskeletal pain and soft tissue injury, more well-designed studies of its clinical effects are needed.9,15-17 In the absence of more definitive evidence, family physicians should prescribe therapeutic ultrasound only as symptomatic treatment.

phonophoresis

Phonophoresis uses high-frequency sound waves (i.e., ultrasound) to deliver therapeutic medications, usually topical analgesics or steroids, through the skin to deeper tissues. It is used for the treatment of conditions that may also be treated with local anesthetic or steroid injections. There is a risk of thermal injury, which increases with the amount and intensity of the energy applied.18

A corticosteroid or nonsteroidal anti-inflammatory drug usually is mixed with an appropriate aqueous base in a 10 percent concentration and is applied with ultrasound at 1 to 2 watts per cm2.18 One study showed an increased level of ketoprofen in tissues following phonophoresis compared with topical application alone.19 Studies of the systemic effects of phonophoresis with steroids have had contradictory results. One study demonstrated a possible systemic decrease in collagen deposition after phonophoresis with dexamethasone, but another study showed no effect on adrenal function.20,21

iontophoresis

This modality uses an electric current to deliver an ionically charged substance through the skin to deeper tissues. Iontophoresis is often used to treat arthritis, bursitis, and tendinopathy. It can also be used to treat edema, hyperhidrosis, and certain dermatophytoses.18 Hypersensitivity to direct current may cause a characteristic galvanic skin response.

Dexamethasone 0.4% solution is the most commonly prescribed medication used to treat tendinopathies and possible inflammatory conditions. Cathodes are used for negatively charged substances, and anodes are used for positively charged substances. The amperage used depends on the natural resistance provided by the skin.

Iontophoresis in conjunction with traditional modalities can shorten treatment time for plantar fasciitis.22 One small case report showed that acetic acid iontophoresis in conjunction with ultrasound was beneficial in the treatment of myositis ossificans.23 However, a small randomized controlled trial showed no difference in the clinical outcome of patients with calcific tendinopathy in the shoulder.24

electrical stimulation

There are several electrical stimulation methods used in physical therapy. Family physicians usually are most familiar with electrical muscle stimulation and transcutaneous electrical nerve stimulation. The theoretical goal of electrical stimulation is to generate an action potential in nerve tissue, causing a muscle contraction or altering sensory input.7

Muscle contraction allows for isometric activation, making electrical stimulation useful for the treatment of muscle spasm or atrophy and for strengthening muscles.7,8,25 In addition, electric currents are thought to affect ionic tissue and alter vascular membrane permeability, which promotes tissue healing, decreases edema, and improves drug penetration.7,8 Pain reduction is thought to be achieved by altering the gate mechanism and through endogenous opioid and cortisol release.7,8

Electrical stimulation may also help reduce inflammation and edema and facilitate chronic wound healing.7,8,26-28 Basic transcutaneous electrical nerve stimulation uses multiple electrodes that are impregnated with a conduction medium and applied over muscle groups. The location and spacing of the electrodes varies depending on treatment area and desired effect. Specific electrode placements are needed to create pain control, isometric muscle contraction, wound healing, and edema reduction.7,25-27

Although there are few risks with electrical therapy, potential adverse effects primarily include burns from improper parameter settings, allergic reaction to electrodes or the conduction medium, and pain during treatment.7,8,28 Expert opinion and anecdotal reports support the use of this modality; however, studies are lacking, limited, or conflicting. More evidence is needed on the long-term benefits, ideal parameters, and overall effectiveness of electrical stimulation methods.16,25,28,29

low-level laser therapy

The mechanism of low-level laser therapy is not well understood, but it appears to be related to a photochemical reaction at the cellular level rather than a thermal effect. According to one theory, cytochrome oxidase acts as an acceptor of photon radiation in the 600 to 900 nm range. This stimulation increases adenosine triphosphate production and cellular oxidative metabolism. A recent study showed a significant decrease in prostaglandin E2 concentration in peritendinous fluid in patients treated with low-level laser therapy compared with those treated with sham therapy.30 Larger studies are needed to confirm this mechanism.

Low-level laser therapy is used to treat musculoskeletal disorders, including muscle strains, epicondylitis, rheumatoid arthritis, osteoarthritis, and carpal tunnel syndrome. This therapy is approved by the U.S. Food and Drug Administration for the treatment of hand and wrist pain associated with carpal tunnel syndrome and for minor musculoskeletal pain. Although nausea has been reported with prolonged use, there are no other known adverse effects.

Differences in studies of low-level laser therapy
(e.g., device used, end points, control group) make it difficult to determine the effectiveness of this modality. A Cochrane review of low-level laser therapy in patients with osteoarthritis showed minimal improvement in pain and joint movement, but study results were conflicting.31 A similar Cochrane review of the therapy in patients with rheumatoid arthritis showed limited benefit but stated that it could be considered for short-term relief of pain and morning stiffness.32 In general, low-level laser therapy has not been shown to cause adverse effects, but a benefit has not been clearly established.

Physical Therapy Prescription

Table 3 lists the components of a physical therapy prescription.

Physical therapy clinics often provide standard forms that facilitate prescribing of therapy. These forms can improve teamwork and communication between the physician and the therapist. Usually, there is an "evaluate and treat" option that allows the therapist to use discretion in the application of therapeutic interventions.

The frequency and duration of physical therapy treatments will vary based on the patient's condition. Acute muscle strains often benefit from daily treatment over a short period, whereas chronic injuries are usually addressed less frequently over an extended period. Figure 1 is a general algorithm for prescribing physical therapy interventions to treat musculoskeletal injury; however, individual prescriptions are based on the patient's specific condition and comorbidities and on the availability of modalities.

It is important for the physical therapist to document the patient's progress so that the physician can modify the care plan, if needed. This documentation is typically given to the physician every 30 days or before the patient sees the physician for a follow-up visit.

The Authors

scott e. rand, md, is director of the Conroe Medical Education Foundation Primary Care Sports Medicine Fellowship at the Texas Sports Medicine Center in Tomball. He received his medical degree from the University of South Dakota Sanford School of Medicine in Vermillion and completed a family medicine residency at the Naval Hospital in Pensacola, Fla. Dr. Rand holds a certificate of added qualification in sports medicine.

chris goerlich, MSc, pt, is a physical therapist at the Texas Sports Medicine Center. He received his physical therapy degree from the University of Texas Medical Branch at Galveston.

kristina marchand, md, is a family physician in New Zealand. She received her medical degree from Texas A M College of Medicine, College Station, and completed the Conroe Medical Education Foundation Family Medicine Residency Program.

nathaniel jablecki, md, is chief resident in the Conroe Medical Education Foundation Family Medicine Residency Program and a sports medicine fellow at the Texas Sports Medicine Center. He received his medical degree from the University of Texas School of Medicine at San Antonio.

Address correspondence to Scott E. Rand, MD, Lone Star Sports Medicine Clinic, 605 Holderrieth Blvd., Tomball, TX 77375 (e-mail: scottrand@lonestarfamily.

Copyright 2007 by the American Academy of Family Physicians.
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Health article: Introduction of family therapy, health articles categories: mental health, structural family therapy brief introduction: Freud founded by the spirit of creating a precedent for professional psychological treatment, depending on the individual as its protagonists, no matter how the environment, always maintained a self-centered point of view. But with the depth of psychological therapy, people gradually come to realize: a person s mental disorders and psychological problems often is not isolated, but closely related to their family members, that is, family members ...n

Created in the spirit of Freud s analysis created a precedent for professional psychological treatment, depending on the individual as its protagonists, no matter how the environment has always maintained a self-centered point of view. But with the depth of psychological therapy, people gradually come to realize: a person s mental disorders and psychological problems often is not isolated, but closely related to their family members, that is to say, the interaction between family members is the result.

In practical work, and sometimes, we can heal the patient, the patient can go home will be a relapse, and doctors with the patient s family about this, not only because they are normal people. They really normal? That is not true.

Family therapy that the whole family is the real patient , and found patients But this patient s family is a symptom .n

This family therapy perspective, the resultant echoes the beginning of this century is a part of the environment, the concept of the personal impact on the family, community and families affected by this idea, and now, even the medical model also into new biological - psychological - social model, and does it mean that the views of family therapy and is not seeking a while!

Family therapy as a psychological treatment method has been through half a century, then what is family therapy?

Family therapy that: Each family has its own life cycle (that is, from one pair of married couples get married, to have children, their children have grown up away from home, the last couple elderly, widowed, the whole process until death) in this the life cycle of the various stages, especially first child in primary school children enter puberty and the two-stage, families are facing psychological problems is the biggest, most likely to family members suffering from mental illnesses period.

Family therapy is for the treatment and all members of the family regularly talks to promote the family in a state of missing functionality to make some adaptability to change, reconstruction can adapt to the new changes in the model, while members of the family illness or relieve symptoms disappear. Such a reversal of the past pattern of linear causal relationship of the argument, and replaced by circular causation perspective of the individual symptoms, the problem behavior and interpersonal conflict, the problem is that individual families lost function in a system characterized Therefore treatment the focus should be on changing the whole family members on the interaction between.

Family therapy is a broad sense of collective psychological treatment areas, the treatment group also fall into this category. The marriage treatment of some form, in fact belong to another family therapy areas. Family therapy development to the present, both the theory and concepts of the new breakthroughs, structural family therapy master Minuchin think that even if only and is a member of the family to talk, but as long as it is to see their family therapy viewpoint family problems, and promote He made changes so that the other members of the family also will be made to change, but also can be seen as family therapy, only individuals in the family as a system to the treatment only.

The family is an equal and harmonious entity, stable family structures and systems to individual mental health. Families should exchange their unique approach and process to ensure the independence and development of the individual. Chinese feudal families tend to sacrifice to protect the family, family therapy can not do so. The goal of family therapy or break some inappropriate to continue to maintain the dynamic balance of symptoms loop and establish appropriate linkages good feedback, so that symptoms eliminated or radically re-establish the family structure system, the elimination of avoiding conflicts the usual mechanism to cope with the introduction of a good way to improve inter-generational relations and mutual exchanges among members. Raising solve problems and meet challenges. The whole family therapy in the course of treatment are always take the leading position, taking advantage of their authority to guide the family to change and development.n

Health article: Introduction of family therapy, health articles categories: mental health, structural family therapy brief introduction: Freud founded by the spirit of creating a precedent for professional psychological treatment, depending on the individual as its protagonists, no matter how the environment, always maintained a self-centered point of view. But with the depth of psychological therapy, people gradually come to realize: a person s mental disorders and psychological problems often is not isolated, but closely related to their family members, that is, family members ...

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