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Stress loading refers to a specific set of exercises intended to improve the clinical course of patients who suffer from Complex Regional Pain Syndrome (CRPS).
The programme has been adapted from H. Kirk Watson and Lois Carlson. Treatment of reflex sympathetic dystrophy of the hand with an active stress loading programme.[1] This programme may be incorporated into the treatment of any patient with a mechanically stable hand whose condition is clearly more painful and swollen than the average patient after surgery or trauma.
Stress loading provides inhibitory proprioceptive input to the nervous system through the use of deep pressure, loading the affected joints or extremity and enabling the nervous system to acclimate to these stimuli. The programme promotes active movement and compression of the affected joints for a minimum of 3-5 consecutive minutes, three or more times each day. Though stress loading may initially produce an increase in pain or swelling of the extremity, after several days a decrease in symptoms will begin to be evident.[2] Use of the affected extremity in daily tasks is encouraged throughout rehabilitation to inhibit muscle guarding and disuse atrophy.
Stress Loading consists of two principles: scrubbing and carrying. A stress loading programme promotes active movement and compression of the affected joints for a minimum of 3-5 consecutive minutes, three or more times each day. Though stress loading may initially produce an increase in pain or swelling of the extremity, after several days a decrease in symptoms will begin to be evident. Use of the affected extremity in daily tasks is encouraged throughout rehabilitation to inhibit muscle guarding and disuse atrophy.
Indications
CRPS is classified into two subtypes: type I, previously referred to as reflex sympathetic dystrophy, and type II, formerly called causalgia. Complex Regional Pain Syndrome is a neuropathic pain that is associated with sensorimotor and autonomic alterations, such as allodynia, hyperalgesia, vasomotor disorders and trophic changes. This pain is regional and disproportionate to the severity of the tissue injury, and It can persist even after the tissue has completely healed. It often occurs after a trauma, such as fracture, or surgery.[3]
The diagnosis is clinical based on the Budapest Criteria, a four-category diagnostic scheme assessing sensory, vasomotor, sudomotor/oedema, and motor/trophic features through both reported symptoms and observable signs, after excluding alternative diagnoses.[2]
Application
Stress Loading consists of two principles: scrubbing and carrying. Scrubbing consists of moving the affected extremity in a back/forth motion while weight bearing through the extremity. The patient scrubs against a hard surface, keeping the bristles of the brush in constant contact with the surface, while maintaining constant pressure on the brush. The amount of weight placed through the affected extremity and the duration of the activity are gradually increased. Scrubbing is performed with the patient in quadruped for upper extremity involvement and in elevated sitting or standing for lower extremity involvement. For upper extremity involvement, the patient holds a scrub brush with the affected hand. For lower extremity involvement, a long Velcro® strap can assist in fastening the brush to the bottom of the affected foot.
Modifications can be made to enhance performance or compliance. For example, upper extremity scrubbing may be done standing at a table or counter. Persons with limited wrist extension may benefit from using a handled brush. The Dystrophile® can be used to gauge reliable performance. It is a device designed to facilitate consistent weight bearing and compliance during scrubbing by activating a light when the patient has reached the pre-set load.
* Dystrophile® Ideal for treating reflex sympathetic dystrophy/complex regional pain syndrome. To begin exercise, push down on the Dystrophile® handle while sweeping the device in any direction. Feedback light and timer are activated when the pre-set resistance and duration level is reached. Force can be graded up to 12 lbs. (5.4kg). Timer records in hundredths of a minute as long as the pre-set load level is maintained. Includes instructions, programme guidelines, progress record sheet, and one 9-volt battery. Special, plastic-coated Dystrophile® Pad is used as a sliding surface for the Dystrophile® Device.
Carrying or loading - This is the second component in the stress loading protocol. Small objects are carried in the hand on the affected side, progressing to a handled bag loaded with increasingly heavier weight. Carrying should be performed throughout the day, whenever the patient is standing or walking. The lower extremity can be loaded in a variety of ways. Walking is an important loading technique if care is taken to ensure weight bearing through the affected leg during gait, especially when an assistive device is used.
Increased weight bearing can be accomplished with verbal/ physical cueing or by having the patient carry a weighted object or bag on the affected side. Loading can also be facilitated by engaging the patient in activities that promote weight shifting and balance (i.e. ball toss) or by placing the non-affected foot onto a small footstool during static standing tasks. [1][4]
Key Evidence
H. Kirk Watson and Lois Carlson: Treatment of reflex sympathetic dystrophy of the hand with an active stress loading program, J Hand Surg 1987;12A:779-785.
