How to manage bilateral pain causing reduced range of motion?

Managing Bilateral Pain Causing Reduced Range of Motion

The most effective approach to managing bilateral pain causing reduced range of motion is a combination of pain management strategies, relaxation techniques, and gradual activity progression that promotes normal movement patterns while avoiding splinting or immobilization. 1

Assessment of Pain-Limited ROM

When evaluating bilateral pain causing reduced ROM, it's crucial to:

• Differentiate between pain-limited ROM and true mechanical restriction
  • Pain-limited ROM typically has a softer end-feel with patient resistance
  • True mechanical restrictions have a firm end-feel 1
• Compare active versus passive ROM (passive movement may exceed active movement if the clinician can work through patient guarding) 1
• Assess pain patterns (throughout range or only at end-range) 1
• Evaluate muscle strength, as people with pain-related ROM limitations often demonstrate lower strength in multiple planes 1

Treatment Algorithm

Step 1: Pain Management First

1. Pharmacological options:

   • If no contraindications exist, use analgesics such as acetaminophen or ibuprofen for pain relief 2
   • For muscle spasm associated with acute, painful musculoskeletal conditions, cyclobenzaprine may be used as an adjunct to rest and physical therapy for short periods (up to 2-3 weeks) 3
   • For elderly patients, initiate cyclobenzaprine at 5mg and titrate slowly upward due to higher plasma concentrations 3

2. Non-pharmacological pain management:

   • Apply superficial moist heat before exercises 2
   • Consider relaxation techniques before beginning stretching exercises 2

Step 2: Movement Restoration Techniques

1. Static stretching exercises:

   • Perform daily when pain and stiffness are minimal (e.g., prior to bedtime) 2
   • Move slowly and extend range of motion to produce a slight sensation of resistance 2
   • Hold terminal stretch position for 10-30 seconds before slowly returning to resting position 2
   • Modify stretching to avoid pain when joints are inflamed 2

2. Structured exercise sessions:

   • Begin with 5-10 minute warm-up using repetitive low-intensity range-of-motion exercises 2
   • Progress to training period that provides overload stimulus to increase joint ROM 2
   • End with 5-minute cool-down involving static stretching 2

3. Specific techniques for different conditions:

   • For shoulder pain: Gentle stretching and mobilization techniques, gradually increasing external rotation and abduction 2
   • For functional neurological disorders: Use gross rather than fine movements and discourage cocontraction or tensing of muscles 2

Step 3: Activity Progression

1. Functional retraining:

   • Engage in tasks that promote normal movement, good alignment, and even weight-bearing 2
   • For upper limbs: Use hands to stabilize objects to avoid learned non-use 2
   • For lower limbs: Practice transfers, sit-to-stand, and standing activities 2

2. Distraction techniques:

   • Employ anxiety management and distraction techniques when undertaking tasks 2
   • Consider sensory grounding strategies (noticing environmental details, feeling textured items) 2
   • Use cognitive distractors such as counting backwards or singing 2

Special Considerations

Avoid Common Pitfalls

1. Avoid splinting or immobilization:

   • Splinting may prevent restoration of normal movement and function 2
   • Potential problems include increased attention to the area, accessory muscle use, compensatory movements, muscle deconditioning, and increased pain 2
   • Try strategies that encourage normal movement patterns and resting postures before considering splinting 2

2. Prevent Complex Regional Pain Syndrome (CRPS):

   • Use active, active-assisted, or passive range of motion exercises 2
   • For established CRPS, an early course of oral corticosteroids may be considered (30-50mg daily for 3-5 days, tapering over 1-2 weeks) 2

Specific Patient Populations

1. Post-stroke patients:

   • For hemiplegic shoulder pain, focus on gentle stretching and mobilization techniques 2
   • Increase active ROM gradually while restoring alignment and strengthening weak muscles 2
   • Consider botulinum toxin injections for pain related to spasticity 2

2. Cancer survivors:

   • Assess for musculoskeletal symptoms at each clinical encounter 2
   • Consider acupuncture, physical activity, or referral for physical therapy based on clinical indication 2
   • For aromatase inhibitor-associated musculoskeletal symptoms, consider changing from one antiestrogen therapy to another if pain is severe 2

By following this structured approach to managing bilateral pain causing reduced ROM, clinicians can effectively address both pain and movement limitations, improving patients' functional abilities and quality of life.