Patient education for pain management

                    Patient education for pain management

Introduction:

Pain is a complex, multi-faceted perceptual experience that demands an explanation. As a sufferer, an inability to make sense of the often worrying and persisting uncertainties of pain, forces many to retreat from life’s pleasures. As a clinician, it is therefore vital to ensure a collaborative facilitation of meaning in those who live with pain. Educational skills are merely assumed in both practice & research. In many disciplines, pain education accounts for less than 1% of undergraduate programme hours within the United Kingdom.

Patient education has been defined as, "any set of planned activities designed to improve a patient's health behaviours, health status, or both."  These activities aim to facilitate the patient's knowledge base in order to help them make sense of their pain and guide them towards effective, ongoing self-management.

To facilitate an understanding of pain’s complexities and the importance of self-determined, sustained self-management, we must first develop facilitatory skills.  Facilitation can be defined as, “A technique by which one person makes something easier for others.”. Helping & enabling are central to meaningful facilitation. Yet, the desire for practice-based educators to ensure efficient and effective learning “often leads to concentration on what they are doing rather than what the learner is doing.”

Even though patient education has been viewed and practiced as a preventive strategy majorly, it includes all the information about the disease/disorder/condition the patient is concerned with. Education is a vital part of rehabilitation from pain; a process which requires the acquisition of new knowledge and skills. This requires the ability to concentrate, understand and process information. The information must also be retained, retrieved, integrated and used in a meaningful way.

When including patient education as part of a pain management program, there are certain topics which should be covered to address the areas patients often have concerns or misunderstandings about. These topics include: the anatomy and physiology of the affected part(s), the multi-faceted nature of persistent pain, the difference between acute and chronic pain, triggers and flare up management, fear avoidance and pacing, the role of exercise, the role of physiotherapy and other treatments/interventions, realistic expectations about a diagnosis and cure, and goal setting. 

Factors which will affect patient education include physiological, psychological, sociocultural and environmental. In Pain Management, the patient is enabled to understand pain mechanisms in order to reconceptualise their pain experience. Pain is "a multiple system output activitated by the brain based on perceived threat.". Therapeutic neuroscience education aims to help people make sense of their pain and reconceptualise their understanding of the outdated and unhelpful societial view of pain being lniked to harm or damage. For example, many patients believe that degeneration is a disease and needs to be cured. The primary goal of patient education should be to facilitate understanding that degeneration is not a disease but a normal aging process and has to be treated with that view. 

Why need?

Cost containment studies show that educating patients results in significant savings. Educated patients maintain better health and have fewer complications; as a result, they require fewer hospitalizations, emergency department visits, and clinic and physician visits.  As the growth of health care continues to outpace inflation in many countries around the world, health policy makers have increasingly focused their attention on cost containment. Managed care has a major focus on reducing the supply of services. There is increasing attention to lowering health care costs through primary prevention efforts.</span>There is evidence to support patient education not just in general pain management but in specific pain conditions. A meta-analysis of patient education for migraine sufferers showed that education led to decreased disability, increased quality of life, and decreased frequency of migraine in the intermediate term. For neck pain and whiplash disorders structured patient education has some benefit (albeit small) when combined with physiotherapy.

When considering the need for patient-centred care, it is essential that we ask a fundemental question when educating people about pain: What do patients want? In a recent met-analysis, Yelland (2011) discovered that patients are seeking the following:

• Pain relief
• Functional improvement (work return)
• Acquired knowledge
• Believed/Listened to (social legitimisation)
• Accurate diagnosis (clearly & confidently explained)
• A positive shift in attitude

In addition, Gifford (2014) suggests that people in pain want to know five things:

1. What's wrong with me?
2. How long is it going to take to get better?
3. Is there anything I can do to help myself?
4. Is there anything that you can do to help me?
5. How much will it cost?

Therapeutic neuroscience education (TNE) should aim to address all of the above factors by facilitating a meaningful understanding of the contemporary evidence base related to pain neuroscience. This must be delivered with empathy and compassion for the person's lived pain experience.

However, despite our desire for patient centred care, Eccleston & Crombez (2007) argue that the delivery of contemporary helathcare all too often fails to live up to the needs of people in pain.  Rather than facilitating a helpful reframing of pain, which guides patients towards acceptance and self-efficacy, Eccleston & Crombez (2007) highlight the repeated and escalating perseverance loop of short-term, problem solving behaviours that many patients continue to experience. "Pain is an ideal habitat for worry to flourish." (Eccleston & Crombez, 2007). Unfortuantely, without an adequate and meaningful understanding of pain, many patient's worries continue to grow.

Affecting factors:

1. Inadequate assessment of pain. Assessment of the patient's symptoms should be person centred and should follow the biopsychosocial approach.In order to effectively assess pain and begin managing and educating patients, it is essential for clinicians to relinquish some of their "authority" and empower the patient to become engaged and proactive.
2. Inadequate understanding of how patient perceives his/her pain. Understanding what a patient believes about the causes or consequences of pain will allow the clinician to better inform the patient and correct any misinformation. However clinicians must approach these conversations with respect in order to earn the patient's trust. Examples of perceptions of pain common among cancer patients include: a fear of addiction to medications, concerns about side effects, discussing pain will distract the doctor from curing the disease, pain is an indication of the progress of the disease. 
3. Variations/ differences in the information received. { For example, a patient with knee pain is confused whether to do or avoid activities like cycling and walking due to the differences in the information provided even among health care providers}. Education and pain management will be less successful if information varies among clinicians, and if the care pathway is disjointed with poor communication among team members. There is no clear consensus on the ideal mode, personnel, intensity, or content of delivery. Content of patient education should address aspects of the condition that the patient may have little knowledge about. Some of these aspects will include: decreased understanding of the various therapies, poor understanding of the disease and the  consequences of poor compliance, poor understanding of clinic visits, and poor understanding of medication dosage/regimens. 
4. Life style
5. Cultural barriers. The format and content of patient education material should be appropriate and culturally sensitive for the target audience; with consideration for language, beliefs, experiences and values. Factors such as literacy, age group, and socio-economic status will impact on how well patients will learn from the materials provided. If patients do not understand the information provided then they will nto be able to self-care effectively.

The following are important in patient education for pain management:

1. Recognize the impact of, and evidence for, the use of therapeutic neuroscience education and self-management as a critical part of pain management.
2. Design and apply appropriate educational strategies based on educational science.
3. Identify the range of educational opportunities available across therapeutic domains (eg, injury, disease, medical and post surgical intervention) with consideration of age, culture and gender.
4. Consider the scope and evidence for/against various contemporary therapeutic educational styles (e.g. biomedical, psychological, neuroscience) and models (e.g stages of change theory) and service delivery modes including face to face, web-based, group education.
5. Identify key variables which may impact on knowledge outcomes for the patient (eg self efficacy, health literacy, co-morbidities, culture), the clinician (eg health professional's pain-related beliefs), the message (e.g. use of multimedia), and the context (e.g. insurance limitations; risk reduction; injury prevention)

Beware:

Patients who have in-depth knowledge of their condition encounter problems when their expertise is seen as inappropriate in standard healthcare interactions, and expertise taught to patients in one branch of medicine can be considered non-compliant by those who are not specialists in that field.Although patient education can give people confidence in their own self-management skills, it cannot solve the power imbalance that remains when a generalist healthcare professional, however well meaning, blocks access to medication and supplies needed to manage chronic diseases successfully. There is a role for those involved in primary and hospital care, including those supporting and training healthcare professionals, to recognise these problems and find ways to acknowledge and respect chronic patients’ biomedical and practical expertise.

Education skills:

Recent epidemiological data brings our need to meet the challenge of persitent pain into alarmingly sharp focus. Persistent pain affects over fourteen million people in England alone. It also accounts for 4.6 million GP appointments per year. By reframing pain as an epidemic, we may begin to draw useful comparisons with other epidemics.

Historically, epidemics from measles to cholera have been contained through education and communication.  Therefore, for clinicians to adequately meet the demands of the biopsychosocial model, it is imperative that they develop their knowledge and skills as practice-based educators. Patient education forms “a significant component of modern health care.” However, most clinicians have a limited educational toolkit.  As the pain epidemic continues to grow, we must ensure that all clinicians feel equipped to guide their patients through the complexities of therapeutic neuroscience education (TNE).

As a sufferer, an inability to make sense of the often worrying and persisting uncertainties of pain, forces many to retreat from life’s pleasures. As a clinician, it is therefore vital to ensure a collaborative facilitation of meaning in those who live with pain. Educational skills are merely assumed in both practice & research.  In many disciplines, pain education accounted for less than 1% of undergraduate programme hours within the United Kingdom. 

This persistent undervaluing of our educational role and the need for an increased awareness of facilitatory skills within healthcare places a practical dilemma at the heart of pain education. In his call for a transformative medical education system, Quintero  states, “In order to respond to the current needs of society, which is education’s main objective, the learning processes of physicians and their instruction must change.” In addition, Sir Ken Robinson urges us to move towards an educational system that embraces creativity and lessens the fear of failure when trying new things.

To facilitate an understanding of pain’s complexities and the importance of self-determined, sustained self-management, we must first develop facilitatory skills. Facilitation can be defined as, “A technique by which one person makes something easier for others.” . Helping & enabling are central to meaningful facilitation. Yet the desire for practice-based educators to ensure efficient and effective learning “often leads to concentration on what they are doing rather than what the learner is doing.” 

This traditional, copy and paste, dualistic approach to education stems from a lack of understanding regarding andragogy and a fear of losing control as an educator within learning environments. The novelist, E.M. Forster provides a striking grasp of the dilemma facing contemporary pain education by suggesting, “Spoon feeding in the long run teaches us nothing but the shape of the spoon.”

Healthcare professionals need to develop three key qualities in order to meet the facilitatory demands of practice-based education :

1. An ability to actively listen
2. Best use of peer-learning opportunities
3. An understanding of group dynamics

Whether healthcare professionals endeavor to facilitate a meaningful understanding of pain through either one-to-one clinical interactions or group settings, in order to engage patients in the process of TNE, we must embrace collaborative learning.  However, there are distinct differences between cooperation and collaboration within practice-based education. Whilst cooperation involves a superficial level of joint engagement, collaborative learning involves a wholehearted desire and active interest in collectively solving problems.

By moving from more conventional, didactic teaching methods and by embracing collaborative learning activities, both practice-based educators and sufferers sense of connection is amplified. However, many practice settings remain implicitly unconducive to collaborative engagement. When we consider the diametrically opposed seating arrangements seen within most clinic settings, it is easy to see how something so simple as where we sit in relation to our patients, can impact on our ability to facilitate a meaningful understanding of pain. Collaborative learning should involve side-by-side, close positioning, not the more traditional, dualistic stance of sitting opposite one another where the implicit, physical metaphor is one of division.

Self directed learning:

“The move to a more student-centred view of learning has required a fundamental shift in the role of the teacher. No longer is the teacher seen predominantly as a dispenser of information or walking tape recorder but rather as a facilitator or manager of the students’ learning…The more responsibility given to the student, the greater the shift in the teacher role.” Harden & Crosby (2000)

Here are ten self-directed learning skills. As practice-based educators we must embrace these skills for our own development, whilst also fostering them in our patients.

1. Ask critical questions & analyse problems;
2. Define what needs to be learnt & be able to access relevant resources;
3. Adopt appropriate learning strategies;
4. Be open-minded to other points of view;
5. Cope with ambiguity, uncertainty & change;
6. Understand your own limitations as a learner;
7. Observe & use experts as models for improving your own performance;
8. Assess your own performance & make plans for improvement;
9. Accept that facing setbacks & overcoming difficulties are essential parts of the learning process;
10. Remain positive & self-motivating.

As practice-based educators aiming to deliver patient-centered care, it is crucial that we understand the undoubted differences between how people learn. Educators must become acquainted with each individual’s learning needs in order to optimise learning. Whilst learning styles questionnaires (LSQ) provide some insight and promote discussion, research suggests that they don’t stand up to peer review.  LSQs also risk labeling learners and therefore must be viewed in context. 

Our ability to adapt our educational delivery and tailor meaningful pain education to individual needs is vital. This process must begin with a better understanding of interest. Interest is an emotion that serves two main functions: Motivation and performance. Without an ability to actively facilitate an interest in TNE, patients will likely remain disengaged and practice-based educators will miss opportunities for sustained cognitive and behavioural change towards self-efficacy.

As practice-based educators, we must understand what lies behind the emotion of interest. “Finding something understandable is the hinge between interest and confusion.” Through an appreciation of an individual learner’s coping potential and an understanding of the dynamic relationship between challenge and support, clinicians would feel better equipped to respond to the ever changing demands of contemporary pain education.

Daloz summerises our educational duties by suggesting, “Like guides, we walk at times ahead of our students, at times beside them, and at times we follow their lead. In sensing where to walk lies our art.” Whilst there is an undoubted art to practice-based education, an appreciation of the theoretical models that underpin TNE and an active and continued development of facilitatory skills will enable healthcare professionals to meet the demands of contemporary pain education. 

Physiotherapy for Neuropathies

                   Physiotherapy for Neuropathies:

Anatomy:

A neuropathy is a dysfunction of one or more peripheral nerves or peripheral nervous system. Neuropathy can involve damage to: only one nerve (called mononeuropathy); two or more nerves in different areas, called mononeuropathy multiplex; or most commonly, many nerves are affected (called polyneuropathy). The short video below illustrates the types of neuropathies and their treatment.

Pathological process:

The causes of neuropathies are manyfold and include:

• Physical injury eg pressure from disc herniation , pressure from a cast, trauma, arthritis.
• Systemic autoimmune diseases eg diabetes, Sjogren's syndrome, RA
• Autoimmune diseases that attack nerves eg Guillain-Barre syndrome, Multifocal motor neuropathy.
• Toxins eg from toxic amounts of substances in the blood associated with kidney and liver disorders, alcoholism, chemotherapy drugs
• Infections eg Varicella zoster virus (shingles), White Nile virus, AIDS, Lyme disease ( carried by ticks)
• Neuropathies may primarily affect sensory nerves, motor nerves, autonomic nerves, or multiple types. Anything that damages nerves can interfere with their ability to transmit accurate signals, which can lead to a number of signs and symptoms.

Clinical features:

Neuropathies may primarily affect sensory nerves, motor nerves, autonomic nerves, or multiple types. Anything that damages nerves can interfere with their ability to transmit accurate signals, which can lead to a number of signs and symptoms.

Dependant on the type of nerves affected

• Motor nerve damage will cause muscle weakness, painful cramps, fasciculations (uncontrolled muscle twitching visible under the skin) and muscle shrinking.

• Sensory nerve damage causes various symptoms because sensory nerves have a broad range of functions. Damage to large sensory fibers affects the ability to feel vibrations and touch. The client may feel as if you are wearing gloves and stockings. This damage may contribute to the loss of reflexes (along with motor nerve damage). Loss of position sense presenting with eg balance problems. The “small fibers”( without myelin sheaths ) damage affects transmition of pain and temperature sensations which interferes with the ability to feel pain or changes in temperature. This causes neuropathic pain which can erode a persons quality of life.

• Autonomic nerve damage affects the axons in small-fiber neuropathies. Common symptoms include excess sweating, heat intolerance, inability to expand and contract the small blood vessels that regulate blood pressure, and gastrointestinal symptoms.

Diagnosis:

A full Medical History (including client symptoms, lifestyle, exposure to toxins, drinking habits and a family history of nervous system (neurological) diseases).

Neurological examination

Other tests ordered include

• Blood tests, checking for eg toxins, vitamin deficiencies, diabetes
• Imaging test eg CT MRI for eg tumours, disc herniation.
• Nerve function tests, checking nerve conduction.
• Nerve biopsy, looking for abnormalities
• Skin biopsy, looking for reduction in nerve endings

Outcome measures:

The many different presentations of neuropathies lead to a need to client specific outcome measure. Usually related to muscle strength, pain, QOL, and activity limitations. They include

The SF-36 is a measure of health status and an abbreviated variant of it, the SF-6D, is commonly used in health economics as a variable in the quality-adjusted life year calculation to determine the cost-effectiveness of a health treatment.

INCAT (inflammatory cause and treatment) score is a measure of activity limitation

TUG; 10 metre walk test; grip strength; FUSS;PSFS; oxford muscle strength scale; ROMBERG TEST test.

Interventions:

Besides medications used to treat conditions associated with peripheral neuropathy, medications used to relieve peripheral neuropathy signs and symptoms include:

Anticonvulsants: Gabapentin; Pregabalin; Valproate

Antidepressants:Amitriptyline; Duloxetine; Venlafaxine

Opioids: Dextromethorphan; Morphine sustained release; Oxycodene; Tapentadol; Tramadol.

Others: Topical nitrate sprays; Capsaicin cream.

Physiotherapy:

The main role of physiotherapy is to

Restore, or maintain muscle strength, and prevent muscle shortening and deformity

Balance, co-ordination and functional training.

Pain relief eg provision of TENS, massage

Splints as needed, prevent deformity and contractures

Education re managing condition , preventing damage and emotional support.

Importance of Quadriceps Muscle

        Importance of Quadriceps Muscle

 

The quadriceps muscles consist of four large muscles at the front of the thigh: the rectus femoris, vastus intermedius, vastus lateralis, and vastus medialis. The "quads" are powerful muscles involved in movement and propulsion. Exercises that improve the quadriceps muscles are leg presses, Squats, and leg extensions.

Anatomy:

The quadriceps muscles are a group of muscles on the front of your thighs. As you may guess from the name, there are four distinct muscles that make up the quadriceps muscles.

The four quad muscles have individual names and are located in different positions on the front of each of your tights. These names are:

• Vastus intermedius: This is the deepest of the quad muscles, located below the other three.
• Vastus medialis: This muscle is located on the inner portion of your thigh and ends near your knee cap as the vastus medialis oblique (VMO). A weak VMO is often associated with poor kneecap position and knee pain.
• Vastus lateralis: This quad muscle is located on the lateral or outer portion of your thigh.
• Rectus femoris: The rectus femoris is the superficial muscle on top of your thigh between the vastus medialis and lateralis.

The quadriceps are also known simply as the quads, so if you hear someone speaking about the quads, this is the muscle group they are referring to.

What the Quadriceps Muscles Do:

The quadriceps all work to extend (straighten) the knee. The rectus femoris also flexes the hip, The vastus medialis adducts the thigh and also extends and externally rotates the thigh and stabilizes the kneecap.

You use the quads whenever you straighten a bent knee. In everyday life, they help you get up from a chair, walk, climb stairs and squat. They are used in walking and running at the onset of a stride and get used significantly when going downhill. They get a real workout with cycling, and cyclists have well-developed quads. The quads are used in jumping and sports like basketball that requires jumps.

The quadriceps are antagonists to the hamstring and gluteal muscles, which do more of the heavy work in running and walking. Tight quads can have an effect on those antagonistic muscles.

Functions

The quadriceps are involved in almost every movement of your legs. The primary function of the muscles is to bend and straighten your knee. The rectus femoris muscle is also is the primary muscle involved in rotating the hips. Your quads work in concert with other leg muscles, such as the hamstrings, to promote effective movement, running, squatting, cycling and balance.

Care

When the quads are damaged or overused, they can make it difficult to get around. Quads, like all other major muscle groups, require care and maintenance. Stretching is one of the most effective ways to keep the quadriceps flexible, increase their range of motion and maintain appropriate blood and oxygen circulation in them.

Warm up your quads with dynamic stretching -- for example, gentle aerobic exercise such as walking on a treadmill or marching in place -- before you begin working out. For a static stretch after your workout, stand next to a stable object and hold one foot up behind your rear end. Gently pull your foot toward your body and feel the stretch in your quad. Hold for 20 seconds, release and repeat on the other leg.

Possible Injury

Any one of the four muscles can be damaged, resulting in a small tear or total rupture. The muscles are particularly vulnerable to strain and tears when you perform strenuous activities without warming up the muscles first.

The rectus femoris is the most commonly injured muscle and often is injured while kicking, sprinting or jumping. You'll know when you've damaged one of the quadriceps muscles when you feel a twinge or spasm in your thigh or when walking becomes uncomfortable. A more serious tear results in swelling and severe and sudden pain.

 

Common Injuries to the Quadriceps

Injury to the quad muscles can and do occur. Your quadriceps are a large muscle group, and they are responsible for generating quite a bit of force to keep you walking, running, and stair climbing. Since your quads also keep your kneecap in the correct position, they may be subjected to repetitive stresses and forces that can cause injury.

Injuries to the quadriceps may include:

• Kneecap dislocation. Sometimes, your quad muscle tears off the bone just below the kneecap, resulting in a dislocated kneecap. This is almost always the result of trauma, such as a sports injury or fall. If this occurs, surgery is often performed to repair the torn quadriceps. After surgery, you may have to wear a knee brace and attend physical therapy to return to normal activity and function.
• Patellofemoral stress syndrome. If you have knee pain or swelling from an injury or if you have arthritis, the quadriceps sometimes stops working properly. This may result in a condition called Patellofemoral Stress Syndrome. This happens when the quads are unable to help keep the kneecap in its proper position, resulting in pain and difficulty walking or running.
•     Iliotibial band friction syndrome. This condition is caused          by an irregular rubbing of your iliotibial band as it crosses the lateral side of your kneecap. This may happen if your quads are weak or tight and can cause pain and limited function in your walking or running ability.

• Paresis and paralysis. Your quadriceps may become weakened due to spinal cord injury or stroke (neurological weakness in a muscle is a condition called Paresis). Low back pain may result in a pinched nerve at lumbar level 3 that may cause weakness in the quads. This is usually a severe condition, and you should see your doctor right away to assess the situation and get this taken care of.

If you are having difficulty with any part of your thigh or knee and feel your quadriceps may be the cause, a visit to your doctor or PT may be in order to get things checked out.

Loss of Function from Injured Quadriceps:

If you injure your quadriceps muscle or muscles, you may have difficulty with functional mobility. You may be surprised to learn that your quadriceps muscles help you move around in bed. They contract to help you scoot your bottom while lying down, and they can help you roll in bed.

The quadriceps muscles also are very active when rising from a chair. They help to straighten the knee, which is essential to rise up from a sitting position. The quads are also a major muscle group responsible for walking up and down stairs.

As you may have guessed, the quadriceps muscle group is also essential for walking and running. The quads help keep you moving forward while walking and running, and they prevent you from falling when standing still. Weakness in the quads may result in gait abnormalities, and you may require an assistive device like a cane or walker to help with normal walking if your quads are not working properly. Your physical therapist can help you decide which device is right for you if you need one after a quad injury.

Can I Perform Exercises for My Quadriceps?

If you suffer an injury to your quadriceps, your doctor may refer you to physical therapy to help improve functional mobility and to improve the strength and flexibility of the quadriceps. Your physical therapist can offer suggestions for the correct exercises for you to perform to help your specific condition.

Basic knee mobility exercises focus on quadriceps strength and mobility and stretching exercises for the quads help to improve the flexibility of the muscle group.

The main types of exercises that you can perform to help improve the function of your quadriceps include:

• Strength: Since the quadriceps muscles cross both the hip and the knee, exercises that involve the knee and the hip are essential to improving the strength of the quads. Simple knee strengthening exercises will target the quads, and Advanced Hip strengthening exercises will also include quite a bit of quadriceps work.
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• Flexibility: There are many easy stretches to do to improve the flexibility of your quadriceps muscles. Basic Quadriceps Stretching can be done, and the towel Quadriceps stretch is a great way to improve the flexibility of this muscle group.
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• Balance and proprioception: Balance and proprioception exercises often focus on the quadriceps since these are essential in keeping you upright and balanced. Basic balance exercises can also help to prevent falls, and advanced balance exercises may be used to help treat quad injuries and knee pain.

Be sure to check in with your doctor or physical therapist before starting any exercise for your quads.

A word from verywell:

If you feel pain in the front of your thigh after an injury, you may have done something to your quadriceps. Often, injuries to the quads are easy to rehab; a little rest and some stretching are all it takes. Other times, a quadriceps injury can be serious, so check in with your doctor  you have injured the front of your thigh. An injury to your quadriceps can be a painful experience. A visit to your physical therapist may be the key to helping you improve the function of your quadriceps to get you back to normal functional mobility quickly and safely.

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Treatment

Depending on the severity of the damage, you may be out of commission to participate in sports and strenuous exercise for up to 12 weeks. Without effective quadriceps, you cannot compete in competitive events, training and may even require surgery.

Sports massage can help relieve the discomfort of mildly strained quads, and either electrical stimulation or ultrasound can speed healing. For mild tears, you may be able to use your quads soon after following a period of rest, ice, compression and elevation, or RICE. Compression bandages may allow you to maintain mobility while the injury heals.

Exercises

Sprinting, cycling, and stair climbing will give the quads a natural workout. Compound exercises for the quadriceps include sprints, squats, lunges, deadlifts, leg press, and Smith Machine squats. Isolation exercises for the quads include leg extensions and exercise machines for the inner thigh and outer thigh.

Stretches

Tight quadriceps can cause an imbalance with the hamstrings and gluteal muscles. Runners and cyclists may experience tight quads. Warming up at an easy pace can help relieve tight quads, but using stretches is common.