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Physical Therapy Interventions for ACL, SLE, and CVA

2249 words (9 pages) Essay in Medical

08/02/20 Medical Reference this

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There is a vast amount of research about the anterior cruciate ligament tear due to its common occurrence. The body has a set of four ligaments that keep the knee in a hinge-like position while we move. Two ligaments on either side of the knee joint, the medial collateral ligament (MCL) and lateral collateral ligament (LCL) connect to either side of the femur and tibia and limits shifting movement left or right. The other two ligaments, the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) connect from the base of the femur to the top of the tibia. They cross and prevent the knee from excessive forward and backward movement as well as twisting in either direction. An ACL can be torn in three main ways: direct contact, indirect contact, and noncontact. Direct contact is when the knee is hit by either another person or object, indirect contact is when another person or object hits another part of the body and force is applied to the knee, and noncontact is when a person is running/walking and changes direction or moves in an awkward position and tears the ACL. Noncontact injuries are the most common. If an ACL is injured, a person will most likely have a swollen knee, pain around the knee joint, sensations of buckling or giving out of the knee, knee instability, and difficulty walking. They are associated with long term conditions such as meniscal tears, chondral lesions, and development of early onset posttraumatic osteoarthritis (Filbay, 2017, Introduction section).

There is not only one treatment method in treating a torn ACL. Treatment should be individualized to the person with consideration of their age, size, activity level, and severity of the tear (partial or fully torn). Researched treatment options are either nonoperative, repair, or reconstruction. Ultimately, if a person does not have stability in their knee or a person is young and wants to get back to playing sports, surgery is recommended. Surgery on a torn ACL is typically a one-hour outpatient procedure performed successfully more than one way preferably with an autograft vs. an allograft.  Surgery alone is not the best evidence-based treatment. Physical Therapy is recommended pre and post-surgery. According to the Norwegian Research Center, “Optimal preoperative knee function will lead to better postoperative knee function. Thus, we recommend that the patient has 90% muscle strength and hopping ability on the injured leg compared to the uninjured leg prior to ACLR” (Grindem, 2014, Introduction section).  Multiple resources concluded that a patient should work on strengthening the quadriceps, restoring range of motion, and reducing inflammation prior to surgery and right after surgery, which is considered the acute phase. In the recovery phase, functional stability and continued improvement of lower limb muscle strength should be completed. During the functional stage, patients should work to return to their previous activity level.

A comparison study was completed on patients who participated in pre and postoperative physical therapy vs. patients who received usual care. The patients who participated in physical therapy had significantly higher outcomes compared to the patients in the National Knee Ligament Registry that received usual care, even after a two-year follow-up (Griffin, 2018, Results section).   The take away message is progressive preoperative and postoperative physical therapy should be considered the standard treatment protocol of patients who undergo ACLR focusing on strength training, plyometrics, and balance. Physical therapy should also include cryotherapy, gravity-assisted motion, and protective bracing. Patients can return to normal sports when they are 8-12 months post-surgery, absent of pain and swelling, comparable range of motion in both knees, and able to shift, hop, and jump.

 Systemic Lupis Erythematosus is an autoimmune disease that can affect any tissue or organ in the body including joints, kidneys, brain, skin, and lungs. The immune system attacks healthy tissues causing inflammation, pain, and damage throughout the body. There is not a clear reason why it develops, but it is a result of genetics, hormones, and the environment. Environmental triggers are stress, pregnancy, overexposure of ultraviolet light, and immunization reactions. It occurs mostly in women between the ages of 15 and 45 and the butterfly rash on the face is a commonly known symptom. Other symptoms may be pain or swelling of the joints, muscle pain, fever with no cause, red rashes often on the face, chest pain when taking a deep breath, hair loss, pale or purple fingers or toes, sensitivity to the sun, swollen glands, mouth ulcers, and fatigue. People suffering with SLE may not have all these symptoms. SLE can be mild, moderate, or severe. SLE is characterized by periods of flare ups and periods of symptoms being in remission. Treatment is geared towards preventing flare ups and limiting severity when they do happen. Unfortunately, there is not a cure for the disease, so the goal is to manage the symptoms. People with SLE can live a normal life span, but it is possible to die from the complications of this disease (Rhodes, 2016, Overview section).

SLE is complicated and a varied condition. There is not a textbook answer on what to do, except help what is affecting them. Physical therapy is very helpful to people suffering with SLE, because most people suffer from musculoskeletal system problems. Physical therapy goals, depending on the individual, are to help reduce pain, mobilize joints and increase range of motion, maximize joint stability, strengthen muscles and balance, maximize patients’ functional independence, improve exercise tolerance, decrease stiffness and inflammation, educate the patient, and motivate them. Research based ways to reach these goals are using manual therapy, massage, heat, ice, therapeutic exercise, and aquatic therapy. When choosing the appropriate exercise for each patient it is important to think about the patient’s individual symptoms and stage of the disease. Some key points to think about are the patient’s joints unstable, do they have low bone density, or active muscle inflammation? Additional physical therapy interventions that were researched in a case study to help people suffering with SLE are reflex inhibition and functional training with the combined used of Corticosteroids. “A 22-year-old male SLE patient with CNS involvement requested physical therapy due to strong spasticity of the trunk and limbs in a bedridden state” (Lee, 2014, Introduction section). He was tracked for 16 days of physical therapy. The first goal was to relieve the spasticity level with a reflex inhibition pattern, which is active and passive range of motion exercises in all four limbs and the trunk at a 90-degree angle for one hour a day. After seven days, the patient did not have spasticity of the trunk anymore. The second goal was to improve balance by working on posture, ROM exercises, and transfers. After 12 days, he was able to sit independently and assist in transfers. The third goal was gait training and he was able to independently walk on the 16th day.

A 2018 study was completed to evaluate physical inactivity and sedentary behavior with patients with SLE. More than half of people with SLE did not meet the recommended activity level. Since people with SLE have an increased risk for cardiovascular issues, it is important that we improve awareness of increasing physical activity and reducing sedentary time. Fatigue and overall aerobic capacity can improve if people suffering with SLE increased their activity level. Focusing on individual symptoms along with increasing activity levels can help manage SLE.

 If there is a loss of blood supply to the brain, it is possible to lose some or all brain function. This loss of blood supply and loss of brain function is called a cerebrovascular accident (CVA) or more commonly known as a stroke. There are two ways to disturb blood supply. The first way, which is more common, is a stop of blood flow to an area and is called an ischemic stroke. The second way is a rupture of a vessel, which is called a hemorrhagic stroke. Either way, brain cells start to malfunction in about three minutes or so due to lack of oxygen, not getting proper blood supply, and lack of glucose. The body needs oxygen and glucose in the bloodstream to function properly and carry out complicated functions. If a part of the brain starts malfunctioning, the person affected will lose abilities that that part of the brain performs. To determine how bad a stroke is, depends on where in the brain it occurred and how much brain tissue is damaged. Which blood vessels were involved determines this. Most of the time it is irreversible, because the neurons start to die after four minutes of lack of oxygen. Causes are atrial fibrillation, heart attack, and atherosclerosis. Common misconceptions are that a stroke occurs in the heart, they are unpreventable, and only happen to old people (Veerbeek, 2014)

 A common condition after a stroke is hemiplegia, which is weakness or paralysis on one side of the body. If a person has weakness on their left side it is because there was an injury to their right side of the brain and vice versa. Common side effects of hemiplegia are muscle weakness, loss of muscle strength, seizures, and pain. Physical therapy is recommended for patients that suffer from hemiplegia. Best practices of physical therapy interventions for patients suffering from hemiplegia are range of motion exercises to improve muscle stiffness, flexibility training to help with balance and improve blood circulation, electrical stimulation to strengthen muscles, modified constraint-induced therapy to increase movement, and motor imagery to mentally practice movement to get certain areas of the brain working. A 2016 study was completed to help restore function in the upper limb in a patient who experienced a chronic stroke with severe hemiplegia using EEG- triggered functional electrical stimulation therapy (FEST). FEST is a researched based treatment that has a patient try certain movements and after a few unsuccessful tries, the physical therapist will trigger electrical pulses to the affected limb, which will move the limb without help from the patient. Gradual release of electric stimulation is used as a patient gains more strength in their limb. Brain-computer interfaces were also used in this study, which uses brain signals to control electronic devices and does not require voluntary movement of the patient. The 64-year-old patient in the study went through 40 90-minute sessions to help with his reaching functions. He saw a significant increase in his reaching movements. All other interventions had failed to help him since his stroke six years prior (Marquez, 2016, Conclusion section).

 Physical therapy is a main component in rehabilitation for people who suffered from a stroke. There are many randomized controlled trials on the topic of best interventions to be performed on people who suffer from a stroke. The amount of studies and the positive results proves that physical therapy is a key to progression. The take away message for the best interventions for stroke is repetitive task-oriented and task-specific training. Since there are many new studies being done, more education should be taught to professionals and the general public to make sure the most up-to-date treatments are being performed. Warning signs should be reminded to catch a stroke quickly, so remember FAST, Face, Arms, Speech, Time.

References

  • Brahmachari, I. (2015). A Practical Guide to Hemiplegia Treatment. doi:10.5005/jp/books/12438
  • Filbay, S. R., Roos, E. M., Frobell, R. B., Roemer, F., Ranstam, J., & Lohmander, L. S. (2017). Delaying ACL reconstruction and treating with exercise therapy alone may alter prognostic factors for 5-year outcome: An exploratory analysis of the KANON trial. British Journal of Sports Medicine, 51(22), 1622-1629. doi:10.1136/bjsports-2016-097124
  • Griffin, L. Y., Kercher, J., & Rossi, N. (2018). Risk and Gender Factors for Noncontact Anterior Cruciate Ligament Injury. The Anterior Cruciate Ligament. doi:10.1016/b978-0-323-38962-4.00005-9
  • Grindem, H., Granan, L. P., Risberg, M. A., Engebretsen, L., Snyder-Mackler, L., & Eitzen, I. (2014). How does a combined preoperative and postoperative rehabilitation programme influence the outcome of ACL reconstruction 2 years after surgery? A comparison between patients in the Delaware-Oslo ACL Cohort and the Norwegian National Knee Ligament Registry. British Journal of Sports Medicine, 49(6), 385-389. doi:10.1136/bjsports-2014-093891
  • Lee, I., & Ryu, Y. U. (2014). Physical Therapy Combined with Corticosteroid Intervention for Systemic Lupus Erythematosus with Central Nervous System Involvement: A Case Report. Journal of Physical Therapy Science,26(11), 1839-1841. doi:10.1589/jpts.26.1839

References

  • Legge, A., Blanchard, C., & Hanly, J. (2017). Physical activity and sedentary behavior in patients with systemic lupus erythematosus and rheumatoid arthritis. Open Access Rheumatology: Research and Reviews, Volume 9, 191-200. doi:10.2147/oarrr.s148376
  • Marquez-Chin, C., Marquis, A., & Popovic, M. R. (2016). EEG-Triggered Functional Electrical Stimulation Therapy for Restoring Upper Limb Function in Chronic Stroke with Severe Hemiplegia. Case Reports in Neurological Medicine, 2016, 1-11. doi:10.1155/2016/9146213
  • Rhodes, B., & Gordon, C. (2016). Clinical features of systemic lupus erythematosus. Oxford Medicine Online. doi:10.1093/med/9780198739180.003.0004
  • Veerbeek, J. M., Wegen, E. V., Peppen, R. V., Wees, P. J., Hendriks, E., Rietberg, M., & Kwakkel, G. (2014). What Is the Evidence for Physical Therapy Poststroke? A Systematic Review and Meta-Analysis. PLoS ONE, 9(2). doi:10.1371/journal.pone.0087987
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