Customized heel pads and soft orthotics to treat heel pain and plantar fasciitis11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated

We describe the design of a new cost-effective, comfortable orthotic designed to treat heel pain associated with plantar fasciitis. The heel pad is fabricated from a 4 degrees Sorbothane medial wedge with a customized insertion of low-density Plastazote. The orthotic is medium-density Plastazote reinforced with cork in the medial longitudinal arch. One pair of orthotics takes less than 1 hour to make. Pilot data were collected retrospectively to evaluate the efficacy of the orthotic for reducing pain. Ten clients at a hand and foot orthotic clinic with a mean age of 71+/-9.1 years and with unilateral or bilateral heel pain associated with plantar fasciitis were provided with customized heel pads and soft, molded orthotics at their initial visit. Pain levels were recorded with verbal and Likert-type scales. After 5 weeks of heel pad and orthotic use, all patients showed a reduction in pain, with the overall reduction being highly significant (P</=.0001). Customized heel pads and soft molded orthotics are an effective first-line treatment for the heel pain and loss of function associated with plantar fasciitis.

Nonoperative management of functional hallux limitus in a patient with rheumatoid arthritis

BACKGROUND AND PURPOSE

Functional hallux limitus (FHL) is a condition that affects motion at the first metatarsophalangeal joint and may lead to abnormal forefoot plantar pressures, pain, and difficulty with ambulation. The purpose of this case report is to describe a patient with rheumatoid arthritis (RA) and FHL who was managed with foot orthoses, footwear, shoe modifications, and patient education.

CASE DESCRIPTION

The patient was a 55-year-old woman diagnosed with seropositive RA 10 years previously. Her chief complaint was bilateral foot pain, particularly under the left great toe. Her foot pain had been present for several years, but during the past 5 months it had intensified and interfered with her work performance, activities of daily living, and social life.

OUTCOMES

Following 4 sessions of physical therapy over a 6-week time period, the patient reported complete relief of forefoot pain despite no change in medication use or RA disease pathophysiology. She was able to continuously walk for up to 4 hours. Left hallux peak plantar pressures were reduced from 43 N/cm2 to 18 N/cm2 with the foot orthoses.

DISCUSSION

Patients with RA who develop FHL may benefit from physical therapist management using semirigid foot orthoses, footwear, shoe modifications, and patient education.

Randomized clinical trial of conservative treatment for patients with whiplash-associated disorders: considerations for the design and dynamic treatment protocol

BACKGROUND

Whiplash concerns a considerable problem to health care. Available evidence from systematic reviews indicates beneficial effects of active interventions for patients with whiplash injury. In order to evaluate whether a general practitioner or a physiotherapist should provide these active interventions, we have designed a randomized clinical trial.

OBJECTIVE

The purpose of this article is to present the design of the trial and to provide transparency into the dynamic treatment protocol used.

PATIENTS

Patients with whiplash-associated disorders grade I and II who still have symptoms and disabilities 4 weeks after the accident.

INTERVENTIONS

A dynamic treatment protocol consisting of 4 different subprotocols. The primary aim is to increase their activities and to improve their quality of life. Content and intensity of treatment are described. Outcome measures The primary outcome measures are pain and disability. The short-term effects are measured at 12 weeks and long-term effects at 1 year after the trauma.

CONCLUSION

To date, generally the effect of one intervention compared to another intervention has been examined. In our opinion, this cannot be considered as usual care for physiotherapy or general practice. Therefore, a dynamic treatment protocol has been developed to structure the black box of usual physiotherapy and general practice treatment. The results of this trial will be available in 0.5 year.

Maintenance of exercise participation in individuals with spinal cord injury: effects on quality of life, stress and pain

STUDY DESIGN

Follow-up study of seven individuals with spinal cord injury (SCI) who completed a 9-month randomized control trial (RCT) of exercise training.

OBJECTIVE

In a 9-month RCT conducted in our lab, individuals with SCI who participated in a twice-weekly supervised exercise training reported greater perceived quality of life (PQOL), and less stress and pain than a nonexercising control cohort. The present follow-up study examined the voluntary continuation of exercise training after the study ended and the persistence of the accrued psychosocial benefits.

SETTING

Centre for Health Promotion and Rehabilitation, McMaster University, Hamilton, Ontario, Canada.

METHODS

Five men and two women (age 42.3+/-3.6 years) with SCI (C5-T12; ASIA A-D 12.7+/-8.2 years postinjury) were invited to continue supervised exercise training twice weekly at the completion of the 9-month RCT. Exercise adherence, PQOL, stress and bodily pain were measured at a 3-month follow-up and were compared to values obtained at baseline, and at 3, 6 and 9 months during the intervention.

RESULTS

There was a significant decrease in adherence at the 3-month follow-up compared to the overall 9-month adherence rate (42.7 versus 80.6%, respectively; P<0.01). There was also a significant decrease in PQOL (P<0.05) and a trend for increased pain (P=0.07) and stress (P=0.12), at follow-up compared to the end of the 9-month trial. Finally, there was a significant negative correlation between pain at the conclusion of the RCT and exercise adherence over the 3-month follow-up period (r=-0.91; P<0.01).

CONCLUSIONS

These findings emphasize the importance of continued exercise adherence to the maintenance of exercise-related increases in psychological well-being among individuals with SCI.

Rehabilitation of head and neck injuries in the athlete

This article has given a general overview of a specific and reproducible physical therapy evaluation that can be used to assess progress toward and achievement of goals of treatment. General descriptions of types of presentations that can be seen clinically were also delineated. General treatment goals were discussed and some specific exercises were introduced to help in developing a comprehensive program for the athlete. The main emphasis of the treatment of the athlete requires application of clinical reasoning to the evaluation, treatment, and reassessment process in order to achieve the athlete's goal of full return to sport.

Comments on "the Feldenkrais Method: a dynamic approach to changing motor behavior"

The Feldenkrais Method has recently been discussed to fit within a dynamic systems model of human movement. One basis for this discussion is that small changes in one system--for example, enhanced body awareness--has far reaching implications across the whole of human performance. An alternative view on the Feldenkrais Method is argued here. It is argued that the clinical data do not support the Feldenkrais Method as being an effective way to improve motor performance. Further, it is argued that positive outcomes in pain and other wellness measures following Feldenkrais interventions can be ascribed to self-regulation. As part of this discussion, the role of body awareness, attentional focus, and kinesthesia in motor leaning and control are explored.

Theory and rationale for surface EMG-assisted stretching as an adjunct to chronic musculoskeletal pain rehabilitation

A clinical protocol is reviewed, which utilizes supportive intervention, education, and surface EMG biofeedback to facilitate movement and to maximize effective stretching with chronic musculoskeletal pain patients. Support for this clinical protocol is provided with an overview of the physiological basis of stretching, surface EMG patterns associated with stretching, and the effects of pain and emotional factors on stretching and movement inhibition.

A clinical guide to surface-EMG-assisted stretching as an adjunct to chronic musculoskeletal pain rehabilitation

Therapeutic stretching is a vital component of chronic musculoskeletal pain rehabilitation for increasing range of motion and counteracting the effects of physical deconditioning. Surface EMG biofeedback is currently being used to facilitate movement and to maximize effective stretching with patients in an interdisciplinary chronic pain rehabilitation program for disabled workers. A clinical protocol with case examples is presented.

What affects return to work for graduates of a pain management program with chronic upper limb pain?

Chronic upper limb pain often causes work loss, and return to work after pain management is disappointingly low. This study aimed to identify patient characteristics and beliefs contributing to return to work or nonreturn. A total of 103 (66%) ex-patients with CULP, who had completed a pain management program, agreed to telephone interview. Participants were predominantly female and in middle years; 53.4% were working part- or full-time. Their responses were related to pre- and posttreatment psychological and disability variables. Those patients who had returned to work, compared to those who had not, were more likely to have been working shortly before treatment (chi 2 = 36.77, p < 0.00001). They were more psychologically robust and were more confident of managing pain (t = 4.55, p < 0.001), and catastrophized less (t = 2.21, p = 0.029). They were also more optimistic about being capable of work (u = 566, p < 0.0001) and of overcoming obstacles to work (u = 889, p = 0.0103). Workers and nonworkers were not differentiated by expectations of support from their immediate line manager, although nonworkers doubted support available from colleagues. Overall, despite generalization of pain management strategies in nonwork activity, return to work depended on specific beliefs concerning work-relevant strategies.

Chronic pain and whiplash associated disorders: rehabilitation and secondary prevention

One fundamental concept common to the rehabilitation of chronic pain patients is the understanding that patients with complex pain problems are best served by a team of specialists with different health care backgrounds. This approach to the management of chronic pain, especially as the result of a motor vehicle accident and associated whiplash, is addressed. Also described is a anxiety-based model and the potential of this model to prevent chronicity.

Restrained rehabilitation: an approach to children and adolescents with unexplained signs and symptoms

The validation of treatment approaches for children and adolescents diagnosed with unexplained signs and symptoms is made difficult by the variety of clinical presentations and the different developmental levels of different patients. There is little evidence about what combination of approaches is most successful. This article uses what evidence is available to develop a coordinated multidisciplinary rehabilitation package that ensures consistency and can be evaluated. The package is organised around a psychologically informed physical rehabilitation programme. The need for coordination and a common approach between medical, allied health and psychological staff, and family is formally addressed. The approach is illustrated with a case study.

Lateral epicondylalgia: a musculoskeletal physiotherapy perspective

Tennis elbow or lateral epicondylalgia (LE) is a challenging musculoskeletal condition to treat. This is largely due to the lack of research-based evidence of the clinical efficacy of the myriad of treatment approaches espoused in the literature. In view of this, successful rehabilitation of LE is based on choosing treatments that address the physical impairments found during clinical examination. The primary physical impairment in LE is a deficit in grip strength predominately due to pain and its consequences on motor function. Hence the mainstay of successful management of this condition is therapeutic exercise, providing it is not pain provocative. Adjunctive procedures such as manipulative therapy and sports taping techniques have recently been shown to provide substantial initial pain relief. Early relief of pain in the rehabilitation program helps accelerate recovery and most importantly motivates the client to persist with the therapeutic exercise program. The manipulative therapy and taping treatments presented in this masterclass warrant consideration in the clinical best practice management of LE, and serve as a model for other similar musculoskeletal conditions.

Simultaneous feedforward recruitment of the vasti in untrained postural tasks can be restored by physical therapy

BACKGROUND AND PURPOSE

Physical therapy rehabilitation strategies are commonly directed at the alteration of muscle recruitment in functional movements. The aim of this study was to investigate whether feedforward strategies of the vasti in people with patellofemoral pain syndrome can be changed by a physical therapy treatment program in a randomised, double blind, placebo controlled trial.

SUBJECTS

Forty (25 female, 15 male) subjects aged 40 yrs or less (27.2+/-7.8 yrs).

METHODS

Subjects were allocated to either a placebo treatment or a physical therapy intervention program. The postural challenge used as the outcome measure was not included in the training program. Electromyography (EMG) onsets of vastus medialis obliquus (VMO), vastus lateralis (VL), tibialis anterior and soleus were assessed before and after the six week standardised treatment programs.

RESULTS

At baseline the EMG onset of VL occurred prior to that of VMO in both subject groups. Following physical therapy intervention there was a significant change in the time of onset of EMG of VMO compared to VL with the onsets occurring simultaneously. This change was associated with a reduction in symptoms. In contrast, following placebo intervention the EMG onset of VL still occurred prior to that of VMO.

CONCLUSION AND DISCUSSION

The results indicate that the feedforward strategy used by the central nervous system to control the patella can be restored. Importantly, the data suggest that this intervention produced a change that was transferred to a task that was not specifically included in the training program. Furthermore, the change in motor control was associated with clinical improvement in symptoms.

Lifetime physical and sexual abuse in chronic pain patients: psychosocial correlates and treatment outcomes

PURPOSE

This study describes a subgroup of diagnostically heterogeneous chronic pain patients, with a lifetime history of physical and/or sexual abuse, who underwent a pain management programme. A battery of psychosocial and pain measures were assessed, as well as 1-year post-treatment socio economic outcomes.

METHOD

The prevalence of a history of abuse was assessed via a semi-structured interview of 162 consecutive patients (112 females and 50 males) presenting for 4-8 weeks of treatment in an interdisciplinary, outpatient rehabilitation programme. Treatment outcome data were gathered immediately, 6 months and 1 year following discharge. The chronic pain patients with a history of abuse were compared to those without a history of abuse on several pre-treatment psychosocial variables--pain severity, psychological distress, DSM-IV Axis I comorbidity and health care utilization. Patient groups were matched on age, race, primary pain diagnosis, time in pain prior to treatment and gender.

RESULTS

Results indicated that 61% of patients had a history of lifetime physical and/or sexual abuse. Rates of sexual, and combined sexual and physical, abuse across the lifespan were higher for women than for men. Abused patients had a greater number of psychiatric diagnoses than nonabused patients. Abused patients also reported greater affective distress, less perceived life control, and a greater number of ER visits in the 6 months prior to treatment than their nonabused counterparts. A model consisting of gender (female), a higher number of psychiatric diagnoses, and higher affective distress was found to be a sensitive and relatively accurate predictor of abuse history. Finally, analyses indicated that, despite having greater psychosocial risk factors during the pre-treatment period, chronic pain patients with a history of abuse benefited from treatment and maintained treatment gains to a degree similar to nonabused chronic pain patients.

CONCLUSIONS

Chronic patients with an abuse history can successfully complete a rehabilitation programme if the programme is designed to treat their psychosocial distress. Moreover, this also carries over to treatment outcome. A history of abuse does not have to negatively impact long-term treatment outcomes in this population of chronic pain patients.

Initial development and validation of a multidimensional pain readiness to change questionnaire

Psychometric instruments that assess patient readiness to adopt pain management skills taught in multidisciplinary pain management programs have the potential to clarify interindividual responses to treatment. To date, however, such questionnaires have examined overall readiness to self-manage pain in general rather than readiness to adopt the various specific skills that are taught in multidisciplinary pain treatment. The present study describes the initial construction and evaluation of a Multidimensional Pain Readiness to Change Questionnaire (MPRCQ) that measures readiness to adopt adaptive and avoid maladaptive pain coping strategies. The MPRCQ was initially administered to patients with fibromyalgia syndrome (n = 93) and then to a replication sample of persons with acquired amputations and spinal cord injuries who have chronic pain (n = 88). The results provide preliminary support for the reliability and validity of this instrument. Further research is needed to clarify the construct validity of the MPRCQ and its clinical utility.

Encountering the continuing challenges for women with chronic pain: recovery through recognition

This work is based on experiences from a group treatment for women with chronic musculoskeletal pain. The authors explored the nature and consequences of the reported benefits from being met with recognition in the groups, focusing the potential usefulness in everyday life. In-depth interviews of six participants of various age and backgrounds were conducted. The women's answers reflected how recognition had enhanced strength, confidence, and awareness expressed as increased bodily, emotional, and social competence. This competence provided tools to handle their pain and illness. Achieving the sense of a better life with chronic pain represents an important recovery process. Because of the normative and gendered way the term "coping(ability)" has been used, the authors introduce recovery competence as a more fruitful concept.

Rehabilitation after two-part fractures of the neck of the humerus

We undertook a prospective, controlled trial which compared two rehabilitation programmes for 86 patients who sustained two-part fractures of the proximal humerus. Patients were randomised either to receive immediate physiotherapy within one week (group A) or delayed physiotherapy after three weeks of immobilisation in a collar and cuff sling (group B). At 16 weeks after the fracture, patients in group A had less pain (p < 0.01) and had greater shoulder function (p < 0.001) than those in group B. At 52 weeks, the differences between the groups had reduced. Although group A still had greater shoulder function and less pain, there was no statistical difference when compared with group B. By analysis of the area under the curve, an overall measure up to the 52-week period, group A experienced less pain as measured by the SF36 general health questionnaire and had improved shoulder function. Our results show that patients with two-part fractures of the proximal humerus who begin immediate physiotherapy, experience less pain. The gains in shoulder function persist at 52 weeks which suggests that patients do not benefit from immobilisation before beginning physiotherapy.

Reliability of detecting 'onset of pain' and 'submaximal pain' during neural provocation testing of the upper quadrant

BACKGROUND AND PURPOSE

Conflicting results have been reported with regard to the reliability of neural tissue provocation tests and it is unclear whether repeated testing affects the test results. In the present study, the stability and reliability of the occurrence of 'onset of pain' and 'submaximal pain' throughout the range of motion during neurodynamic testing was analysed, in both a laboratory and a clinical setting.

METHOD

A repeated-measures study design within and between sessions was used. In the laboratory and clinical settings, the base neurodynamic test for the median nerve was performed during a single session on a total of 27 patients with neurogenic cervico-brachial pain. In addition, the base test and three common variations were performed on two occasions by two examiners on 10 asymptomatic subjects in laboratory conditions only. Patients indicated the moment of 'submaximal pain' occurrence, whereas asymptomatic subjects indicated 'onset of pain' and 'submaximal pain'. Corresponding angles at the elbow were recorded by use of an electrogoniometer.

RESULTS

In the asymptomatic group, the intra- and inter-tester reliability within the same session was excellent (intraclass correlation coefficient (ICC2.1 > or = 0.95; standard error of measurement (SEM) < or = 4.9 degrees). Reliability after a 48-hour interval was moderate (ICC2.1 > or = 0.69; SEM < or = 9.9 degrees). The reliability coefficients for the symptomatic group within the same session were comparable with the excellent results of the asymptomatic group, for both the laboratory (ICC2.1 = 0.98; SEM = 2.8 degrees) and clinical settings (ICC2.1 > or = 0.98; SEM < or = 3.4 degrees). Consequently, from a statistical perspective, improvements in range of motion as small as approximately 7.5 degrees may be interpreted meaningfully. No significant trend due to repeated testing could be observed when three consecutive repetitions were analysed.

CONCLUSIONS

Pain provocation during neurodynamic testing is a stable phenomenon and the range of elbow extension corresponding with the moment of 'pain onset' and 'submaximal pain' may be measured reliably, both in laboratory and clinical conditions.

Can pain-related fear be reduced? The application of cognitive-behavioural exposure in vivo

Although cognitive-behavioural treatments of patients with chronic pain generally are reported to be effective, customization might increase their effectiveness. One possible way to customize treatment is to focus the intervention on the supposed mechanism underlying the transition from acute to chronic pain disability. Evidence is accumulating in support of the conjecture that pain-related fear and associated avoidance behaviours are crucial in the development and maintenance of chronic pain disability. It seems timely to apply this knowledge to the cognitive-behavioural management of chronic pain. Two studies are presented here. Study 1 concerns a secondary analysis of data gathered in a clinical trial that was aimed at the examination of the supplementary value of coping skills training when added to an operant-behavioural treatment in patients with chronic back pain. The results show that, compared with a waiting list control, an operant-behavioural treatment with or without pain-coping skills training produced very modest and clinically negligible decreases in pain-related fear. Study 2 presents the effects of more systematic exposure in vivo treatment with behavioural experiments in two single patients reporting substantial pain-related fear. Randomization tests for AB designs revealed dramatic changes in pain-related fear and pain catastrophizing. In both cases, pain intensity also decreased significantly, but at a slower pace. Differences before and after treatment revealed clinically significant improvements in pain vigilance and pain disability.

The role of health anxiety among patients with chronic pain in determining response to therapy

Considerable research suggests that health anxiety (HA) influences the response of patients with chronic pain to pain and treatment. The present investigation extends the current understanding of HA and explores whether it affects how patients respond to a common therapeutic intervention, namely instructions to reduce pain behaviour. Sixty-five patients with chronic pain completed measures of pain, anxiety and cognition following an active occupational therapy session in which they were specifically instructed either to inhibit or reduce pain behaviour, or to carry out the session as they normally would. Regression analyses revealed that those with higher levels of HA experienced greater anxiety, somatic sensations and catastrophic cognitions during therapy than those with lower levels of HA. The regression analyses also revealed a consistent trend for an interaction between HA and instructional set; when those with higher HA reduced their pain behaviour, they subsequently reported greater anxiety, and more somatic sensations and catastrophic thoughts than when they carried out the session as they normally would. In contrast, only those with lower HA had a tendency to benefit from reducing pain behaviour, reporting lower state anxiety and fewer somatic sensations during the session than those who did not reduce their pain behaviour. The results suggest that HA should be taken into consideration during treatment.

Coping strategies and life satisfaction in subgrouped fibromyalgia patients

The present study describes pain- and stress-coping strategies and life satisfaction in subgroups of fibromyalgia patients. Thirty-two females with fibromyalgia syndrome (FMS) and 21 healthy pain-free women were studied. Those with FMS were classified as thermal (both heat and cold) pain sensitive or slightly cold pain sensitive based on pain thresholds determined using a Thermotest device. Global stress-coping styles, life satisfaction, and specific pain-coping strategies were measured. Patients classified as thermal pain sensitive were affected by physical symptoms to a greater extent than were those classified as slightly cold pain sensitive. The thermal pain sensitive group used more diverting attention coping strategies than the slightly cold pain sensitive group did. Separating fibromyalgia patients into subgroups might increase the potential for improving nursing care of these patients. Through the use of effective coping strategies in dealing with stress and pain, life satisfaction may also be enhanced.