Paget disease is a common disorder in middle-aged and elderly patients that is characterized by excessive and abnormal remodeling of bone. The excessive remodeling gives rise to bones that are extensively vascularized, weak, enlarged, and deformed, with subsequent complications. As a result, affected individuals may suffer pain, fractures, and bone deformities. [1, 2, 3]
This disease can be managed in an outpatient setting with physical, occupational, and/or speech therapy. In addition, home exercise with physical therapy is important in maintaining skeletal health, avoiding weight gain, and maintaining joint mobility. However, inpatient rehabilitation may be appropriate for patients with Paget disease who have become deconditioned and are unable to be independent or care for themselves at home.
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Physical therapy (PT) can play an important role in the treatment process and rehabilitation of patients with Paget disease by helping to maintain or improve muscle strength, maintain joint range of motion (ROM) and flexibility, increase endurance, and avoid deconditioning.
Rehabilitation is required after total joint replacement, fracture repair, laminectomy, or other major surgery. Pain management and education regarding proper bracing are important. Gait and balance training also is necessary for ataxic and weak patients. [4, 5]
Correcting leg-length discrepancies
Patients may have leg-length discrepancies as a result of fracture or deformity. The physical therapist can aid in correcting this problem by providing inserts or making appropriate shoe modifications. Functional fracture bracing may be useful with open reduction and internal fixation (ORIF) limb surgeries. The physical therapist typically completes gait and transfer training with the patient to ensure safety in using the assistive device. Ambulatory assistive devices, such as a cane or walker, can reduce the weight-bearing load and pain following these surgeries.
Treatment modalities, supportive devices, and exercise
Modalities, such as superficial heat, transcutaneous electrical nerve stimulation (TENS), and massage, may be helpful for muscle pain, tenderness, and tightness. Proper bracing and spinal immobilization and support should be provided when warranted to decrease pain or in cases of spinal instability. Spinal orthoses can decrease pain associated with weight bearing, thus improving the patient's ability to participate in ambulatory activities and reducing effects related to immobility, such as muscle atrophy, bone loss, and cardiovascular deconditioning. Increased activity also decreases the patient's risk for developing skin breakdown or decubitus ulcers. Equally important, the patient's feeling of well-being often is improved with participation in physical activities.
Efforts to support and protect malaligned limbs, such as functional prosthetic bracing, are important. Aerobic exercise should be incorporated into physical therapy or a home exercise program.
Functional ROM measurements
Functional ROM should be maintained in major joints. Examples of joint-specific measurements for functional ROM include the following:
ROM of the shoulder should allow for abduction of at least 90°, with adequate external rotation to touch the back of the head and internal rotation to touch the low back
Forearm ROM should be adequate to allow a minimum of 45° of supination and pronation, with wrist flexion of 45° and extension of 30°
Finger flexion should be within 1 inch of the palm
Hip flexion should be at least 90°, with hip extension to at least neutral
Knee flexion should be to 110°, with knee extension to at least neutral
Ankle dorsiflexion should be to neutral
Arthritic joint involvement with limited ROM may require modification of the therapy program. Spinal flexion exercises should be avoided to decrease the risk of anterior wedge compression fractures.
Occupational and Speech Therapy
Occupational therapy (OT) may be indicated for patients with Paget disease who need training in activities of daily living (ADLs), especially those who undergo surgery for various pagetic-related conditions. The occupational therapist can advise patients in home modifications when necessary, to increase the patient's independence and safety with mobility.
Patients may also require the use of adaptive equipment to perform their ADL. Occupational therapy can work in conjunction with physical therapy to maintain or improve muscle strength of the upper extremities, maintain flexibility and range of motion (ROM), and prevent deconditioning.
Speech therapy may be indicated for patients who acquire speech and hearing deficits as a result of Paget disease.