Stress loading program therapy

Watson / Carlson Protocol

Stress loading refers to a specific set of exercizes intended to improve the clinical course of patients who suffer from reflex sympathetic dystrophy. The following program has been adapted from 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. This program 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.

During the initial visit, RSD is described to the patient as an abnormal or exaggerated response to injury or surgery. The patient is told that specific stressful exercizes are necessary to remedy this problem. Light activity or active motion is not enough. The patient is also told that increased pain and swelling may occur initially, but generally will subside within a few days.

The program is performed by the patient as follows:


The patient is positioned on the floor on their hands and knees, with a coarse bristled brush in the affected hand. They are told to scrub a plywood board, applying as much pressure as possible using a back and forth motion. The patient must lean on the affected arm. If possible, the shoulder should be directly over the hand for maximum pressure. If the patient is unable to get on the floor, the program can be adpted by placing the board on a table. The average home program begins with 3 minute sessions of steady scrubbing performed three times a day. A record sheet is given to the patient to take home and record the duration of each session.


The patient is told to carry a briefcase or purse in the affected hand, with the arm extended. The amount of weight is the maximum tolerated by the patient. An initial weight is determined at the first session, generally ranging from 1 to 5 pounds. The weight should be carried throughout the day whenever the patient is walking or standing. The amount of weight carried is recorded daily on the record sheet.

Generally, no other treatment modalities are used initially. The stress loading program is the only home program given and the only treatment modality used in supervised therapy sessions until the pain begins to subside. This allows the patient to concentrate their efforts on the program and avoids posible increase in severity of symptoms from other modalities of treatment.

A followup vist is usually scheduled within a day or two of starting treatment. The frequency of followup visits is dependent on the patient's need for reinforcement, supervision, and treatment modification. The average patient is aware of improvement of symptoms in 5 days. It is usually necessary to repeat initial explanations and instructions. The program is advanced as follows:


After the first several days, the program is increased to 5 minutes three times a day and generally increased to 7 minutes after two weeks. If tolerated, an alternative is a 10 minute session twice a day. The physician or therapist should have the patient go through the program during each session to make sure that adequate force is being applied and to judge the patient's ability to increase the duration of each session.


Maximum weight carried at home is comparedwith the patient's demonstrated ability in the office. Recommended increases in weight are made. The patient is also encouraged to continue increasing the weight between sessions if possible.

Additional therapy:

Once the pain has begun to subside, splinting and other modalities may be used. Joint manipulation, passive range of motion exercizes and dynamic splinting are avoided until specifically recommended by the physician.

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