Theory Into Practice

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November 2004

By Pamela Kasyan-Itzkowitz, MS, OTR/L, CHT, Mary O'Connor, OTR/L, CHT, and Martha Hartgraves, OTR/L, PhD

The pursuit of knowledge is the highway for taking research findings and transforming the data into new trends or developments in rehabilitation. The therapist who stays abreast of new research findings, translates the findings into practice, and publishes results will be the trendsetter in the field. Professional development of all practitioners should start with a dedication to reading and attending courses that support growth and development in individual areas of interest.

In two exciting areas, new research findings are coming in on a regular basis that are already setting trends in rehabilitation practices. These areas are: looking at our current understanding and hypotheses in the field of neuroscience and new evidence in the treatment of tendonitis. We hope this information will allow the clinician to better identify and understand their clients, get the clinician interested in reading research findings, and direct the manager to identify continuing education opportunities in new areas instead of signing up for the same topics again and again.

As the rehabilitation manager and the treating clinician are well aware, current constraints made by insurance companies in number of patient treatment visits make clinician ability to support treatment rationale with current research critical. How can you advocate for your client who is just not progressing as quickly or in the manner expected at evaluation? New research in neuroplasticity, dystonia, and tendonosis may help to justify how your treatment will be effective, organize and prioritize each session, as well as allow you to provide effective patient education. When it comes to patient education, it is important to teach our clients to become their own therapists. Insurance companies do not allow us enough time to follow a client with a long-term dysfunction from beginning to end. Patients need to be educated in anatomy, pathology, and tissue healing in understandable terms. Most patients will be more compliant if they fully understand the underlying causes and long-term implications of adherence to a rehabilitation plan.

NEURO VERSUS ORTHO
Frequently, the clinician makes a distinction between the "neuro" patient and the "ortho" patient and writes out goals and treatment plans accordingly. Typically, the practitioner analyzes orthopedic problems such as joint contracture, subluxations, or peripheral nerve compressions occurring secondary to increased tone as seen with CVA. Less common is this process done in reverse. Current research findings indicate a need to start looking at the ways neural changes and dysfunction may occur due to orthopedic injuries, without injury or lesion to the central nervous system.

New information from neuroscience research shows there does not need to be a pathology, injury, or lesion to create neural dysfunction. Studies on both animals and humans have reported that cortical maps change with use and disuse. Neural adaptation occurs quite rapidly at all levels of the nervous system after immobilization, orthopedic-type injuries, and repetitive injuries, and in individuals with complaints of chronic pain.

What does this mean to the practitioner? Consider alterations of the somatosensory cortex and think dystonia for clients who present with chronic pain and intermittent vague motor control problems. How long does it take for these changes to occur? Primate studies have been done mapping the somatosensory cortex before and after surgical syndactyly (webbed digits) connection and release. Human and animal studies have mapped cortical changes after amputation. Changes have been noted as early as 2 to 4 weeks. Other areas where studies in neuroplasticity have lead the rehabilitation team include:

Constraint induced therapies (CIT). This area of research is also the framework for CIT for individuals with hemiparesis. By forcing use of an affected extremity, the practitioner is able to alter the neural mechanisms in the cerebral cortex, which integrate sensory and motor functions when performing purposeful actions. We know patients with muscle weakness demonstrate abnormal movement patterns in attempts to complete basic activities of daily living. Examples include: excessive scapular elevation, shoulder flexion with reaching, protective positioning with elbow flexed shoulder abducted, and internally rotated and altered fisting. Working on body mechanics with the client and demonstrating these altered patterns require focused attention and repetition before changes can be expected at the somatosensory cortex.

Pain management: Neuroplasticity also has a role in acute and chronic pain. The extent of this impact is still up for debate. We do know that the nociceptive system is not just a system for the conduction of pain impulses from the periphery to the brain. If that were true, when you removed the noxious stimulus, the perception of pain would always stop. The process where an initial painful event can result in chronic pain is a complex one.

Initially, tissue injury causes the release of several substances at the site of the injury. These substances activate and sensitize the peripheral nociceptors. As these nociceptors are activated and reactivated, response threshold may be decreased. Then nonpainful stimuli may be perceived as noxious. This is known as peripheral stimulation. From here, there is increased input to the dorsal horn of the spinal cord, which is the point of origin of ascending pain pathways to the brain. This increased input to the spinal cord, along with continued chemical responses, further activates the dorsal horn. At this point, there is evidence pointing to neuron changes at the level of the spinal cord or central sensitization.

So what does this mean to the practitioner? Patients with chronic pain may have ongoing symptoms due to both peripheral sensitization and central sensitization. Therefore, they may need to be treated longer in order to give enough time for the plan of care to alter these pathways. According to a study by Kaas, with the majority of orthopedic patients, if there has been no peripheral denervation or amputation, the original cortical patterns persist and can be easily reactivated.¹ Again, if we are still unable to secure longer treatment times, the practitioner's most important role is to teach our patients to carry out their treatment plans.

CASE STUDY
Mason, a 40-year-old small business owner, was sent to XYZ rehabilitation because he complains about coordination in his hand when writing. As the owner of the company, it is his responsibility to keep the books, make the orders, and write the plans. He is concerned that when he picks up the pen, his hand begins to cramp, and he strongly grabs the pen, contracts his wrist, and lifts his elbow in a pattern to hold onto the pen. Without these compensatory techniques, he drops the pen. He does not complain of much pain, in two out of 10 fingers. Over the years, many theories have been used to treat the client with writer's cramp. There are reports where practitioners utilized psychoanalysis, behavior therapies, biofeedback, and injection of drugs such as botulinum. If the practitioner uses the information framework noted in the area of neuroplasticity, he or she would be looking for a way to alter the way the somatosensory cortex is registering the messages from the digits. Has the brain begun to map two fingers into one area of the homologous map? If this is the case, then it makes sense that having the digits work independently of each other will alter the somato-sensory cortex and result in improved individual functioning of the fingers, and improved writing ability.

In fact, research demonstrates this. Splinting the involved digits separately and having the patient perform individualized functions have resulted in significant improvements in coordination, sensation, and return to prior life roles. Even without splints training in altered motor patterns, allowing the cortex to relearn adaptive movement patterns results in significant improvements.

RESEARCH IN TENDONITIS
Researchers have long looked at microscopic and macroscopic changes in tissues of patients with lateral epicondylitis and Achilles tendonitis. The changes found were not consistent with inflammation; rather, they were finding degenerative changes. As we know, normal healthy tendon is white, glistening, and firm. The tissue examined from the subjects was brown and soft. When it was examined further, they found disorganized collagen, an increase in ground substance, vascularity, and cellularity, as well as an increase in fibroblasts and myofibroblasts. So what does this mean to the treating therapist? This research supports our feelings and assumptions that a 1- to 3-month recovery timeline for a chronic presentation of these common diagnoses is not long enough. It may take 6 to 12 months of follow-up and follow-through of a prescribed occupational or physical therapy program for the collagen fibers to realign and have a lasting improvement. Khan et al² outlined areas where tendon goes through fibro-osseous tunnels on the way to their insertions. He notes that misconceptions that come from the label of tendonitis result in treatment plans that are not effective. Tendonopathies such as tendonosis often take months, not weeks, to resolve. Timelines recommended for tendonopathies frequently match the "gut instinct" timelines that practitioners have been proponents of in the first place.

REIMBURSEMENT AND ETHICS
As we are all aware, the amount of time insurance companies allow for a specific diagnosis such as unexplained problems with coordination, or tendonitis, is getting shorter and shorter. This decrease in allowable treatment visits is due to either the client's managed care plan or lack of authorization from the gatekeepers. When the therapist or manager calls to extend patient visits they are usually met with noticeable conflict and a demand for more pages of documentation; after all their efforts, they still receive only a few visits. The person who is at the insurance company may be a therapist, physician, or layperson who has never laid eyes on your client.

As new research supports extended rehabilitation, therapists need to work toward providing the highest level of care. As research continues to find areas where practitioner care and services are indicated, it will be the responsibility of the rehabilitation teams to support the best actions for the clients. The exciting new findings for the areas discussed in this article are still being incorporated into routine therapy practices. It will be the clinicians who enjoy reading new literature and are flexible enough to integrate new strategies into practice who will be setting the trend.

Pamela Kasyan-Itzkowitz, MS, OTR/L, CHT, is assistant professor and fieldwork coordinator, Occupational Therapy, at Nova Southeastern University, Ft Lauderdale, Fla.
Mary O'Connor, OTR/L, CHT, is a therapist at Moss Rehabilitation Hospital, Philadelphia.
Martha Hartgraves, OTR/L, PhD, is in clinical practice for the State of New Mexico, Valencia County.

REFERENCES

Kaas JH, Collins CE. The organization of sensory cortex. Curr Opin Neurobiolol. 2001;11:498-504.
Khan KM, Cook JL, Kannus P, Maffulli N, Bonar SF. Time to abandon the “tendinitis” myth. BMJ. 2002;324:626-627

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November 2004