Understanding the Application and Landscape of Physiotherapy for Patient Referral, Benefits and Outcome – Dr. Shivali Thakore

Abstract

Physiotherapy or Physical Therapy (PT) is considered a supportive field to the practice of medicine and though most well known in the arena of musculoskeletal disorders, it also has diverse applications and benefits in other conditions. It is important for General Practitioners (GPs) as well as practitioners of various medical and surgical specialties and super specialties to be well acquainted with the application, role, types and benefits of physiotherapy, so that physiotherapy can be integrated and well-coordinated as part of the all-round care and long-term rehabilitation of the patient.

Keywords: Physiotherapy, Musculoskeletal, Rehabilitation, Physical Therapy, All-round Patient Care.

Introduction

Physiotherapy is a diverse field offering benefits and treatment to patients with different medical conditions. It is important for physicians to be aware of the various physiotherapy techniques and types to enable appropriate and timely referral, to improve patient outcomes.

World Physiotherapy or Physical Therapy (PT) day is celebrated on 8^th September, as an opportunity to raise awareness about the vital role that physiotherapists play in promoting health and well-being.

Evaluation

• Grading Pain

VAS (Visual Analogue Scale of Pain) is used to grade pain on a scale of 0 to 10 (0 is no pain and 10 is maximum pain).

Recording all presenting complaints meticulously is important.

• Observation of Different Types of Postures
  • Kyphosis
  • Scoliosis
  • Lordosis
  • Flat Spine
• Palpation: Tenderness on the surface of pain.
• Examining Range of Motion (ROM): The device which is used to measure this is the Goniometer, where the ROM of various joints of the body which are measured (Shoulder, Elbow, Ankle, Wrist, Knee)
• Manual Muscle Testing: This is done by assessing and grading resistance and comparing it to the other or normal side. It is graded as poor (0), passive assistance (1), active but requires assistance (2), good with active movement possible (3), active with mild resistance (4), active with full resistance (5).

Types And Application Of Physiotherapy

Physiotherapy techniques encompass a wide range of approaches aimed at restoring and improving movement and function ^1,2. These can be broadly categorized into:

1. Manual therapy

The physiotherapist performs skilled manoeuvres on the patient like:

• Joint mobilization (skilled, hands-on techniques to move joints, improving range of motion and reducing pain) Maitland, Mulligan and McKenzie.
• Soft tissue mobilization (techniques like massage, myofascial release and cyriax trigger point therapy to address muscle tension, scar tissue and restrictions in soft tissues).
• Muscle function techniques (involve the patient actively using their muscles against resistance provided by the therapist to improve joint mobility and muscle function).

2. Exercise therapy

The physiotherapist teaches and trains the patient to perform exercises like:

• Active Range of Motion Exercises (to improve the movement of joints and muscles, enhancing flexibility and reducing stiffness).
• Strengthening Exercises (focus on building muscle strength and endurance, often using Theraband exercises).

Theraband, when used by the physiotherapist for strengthening any particular muscle of a particular joint requires the therapist to explain to the patient that there is a colour code which the patient has to follow strictly^3,4. The colour code is decided by the physiotherapist depending on the strength of the muscle. The Theraband is used only as a resistive form of exercise after the person’s muscle strength is more than power 4 (graded according to Manual muscle testing on the scale of 0 to 5). There is a specific colour code of the Theraband – Yellow, Red, Green, Blue and Black (This colour code is according to Theraband Academy USA). When the physiotherapist starts giving exercises to the patient with the Theraband, the patient should start the exercise with the Yellow Theraband followed by the Red Theraband depending on the strength of the particular muscle. For a general sedentary person, Yellow should be followed by Red and Green. For a person whose main occupation is sports and for those wanting to regain their particular sport fitness in a short time, the physiotherapist should train a particular muscle, progressing with Blue and Black Theraband or bodyweight exercises.

• Core Stability Exercises (designed to improve posture and strengthen the muscles that support the spine and the core abdominal muscles which are essential for overall stability and function).
• Functional Exercises (mimic real-life movements and activities to help patients regain the ability to perform daily tasks).
• Neuromuscular Re-education Exercises (to reduce stiffness, tremors and improve coordination, balance and proprioception – awareness of body position in space, useful in patients of Parkinson’s, post-stroke and other neurological conditions)⁵.
• Hydrotherapy involves ‘Aqua therapy’ by exercising in water, to reduce weight-bearing stress on joints and improve muscle relaxation.

3. Electrotherapy

The physiotherapist utilizes electrical stimulation to manage pain and improve muscle function. These techniques include:

Transcutaneous Electrical Nerve Stimulation – TENS (uses electrical currents to stimulate nerves and reduce pain). TENS is a low-frequency current. There are 3 modes of TENS: Continuous (which delivers constant stimulation), Burst (which groups pulses into bursts) and Modulation (parameters like frequency or pulse width change cyclically to prevent nerve adaptation).

Neuromuscular Electrical Stimulation – NMES (uses electrical currents to stimulate muscles, promoting muscle contraction and strength). They have 2 types of currents:  galvanic and faradic.

Interferential Therapy: They are medium frequency currents (a deeper form of electrical stimulation used to reduce pain and inflammation).

4. Ultrasound Therapy

This uses a high-frequency deep heating modality.

5. Low-Level Laser Therapy (LLLT)

This uses low-intensity lasers to stimulate tissue repair and reduce inflammation.

6. Other Forms of Physiotherapy

Other techniques include acupuncture, taping and heat-cold therapy.

The perception is that since physiotherapy mainly addresses musculoskeletal and nerve conditions, physiotherapists most commonly work with specialists in orthopaedics, spine, neurology and pain management.

However, physiotherapists can also be of immense benefit to other specialties as seen with:

• Vestibular Rehabilitation (technique used to treat dizziness and balance problems by retraining the vestibular system)⁶.
• Respiratory Physiotherapy (focuses on improving breathing mechanisms and clearing airways in patients with respiratory conditions like COPD, asthma and other chronic lung diseases)⁷.
• Cardiovascular Rehabilitation (improves cardiovascular health through exercise programs, cardiac rehabilitation and lifestyle modifications)⁸.
• Fibromyalgia and Chronic Fatigue Syndrome (to manage pain and improve function in these conditions and some types of headaches)⁹.

7. Virtual Reality Rehabilitation (VRR)

VR physiotherapy utilizes immersive VR environments to enhance rehabilitation for various conditions ^10,11. By engaging patients in interactive and personalized exercises, VR can improve motivation, engagement and ultimately, outcomes in physical therapy. It also helps distract patients from pain through immersive environments, reducing pain perception and enabling more effective participation in exercises. VR provides opportunities for repetitive, task-oriented movements, which can help rewire neural pathways and improve motor skills, especially in neurological rehabilitation.

Therefore, VRR has diverse applications in musculoskeletal injuries, neurological rehabilitation, chronic pain management and post-surgical rehabilitation¹². VRR can be an immense asset in paediatric practice making therapy more engaging and fun for children, helping them overcome challenges related to conditions like cerebral palsy or developmental delays.

8. Augmented Reality is a method of projecting visual instructions and focal points to guide patients during home exercises.

Newer advances like wearables and robotics herald the future.

Conclusion

While collaborative treatment with physiotherapy is often seen with specialists of orthopedics and neurology, knowledge of types and benefits of physiotherapy techniques can also help general practitioners and family physicians refer and follow up cases for a long-term holistic approach for motor rehabilitation as well as management of chronic cardiorespiratory and lifestyle conditions.

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