PMR Approaches

8/8/2019 PMR Approaches

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PHYSICAL MEDICINE &REHABILITATION

APPROACHES TO PAINMANAGEMENT

Steven D. Feinberg, M.D.

Clinical Associate ProfessorStanford University School of Medicine


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Introduction

Many PMR approaches

Traditionally minimally invasive

Useful alone & in combination with otherapproaches


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Acute Injuries - RICE

RICE - is commonly invoked as the

appropriate immediate response to injury

Rest Ice

Compression

Elevation


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Chronic Pain

For chronic pain states, the physical

modalities are more often used as adjuncts to

pain treatment approaches


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PMRApproaches Categorization

Thermal

Electrotherapy

Physical modalities Manual therapies

Therapeutic exercises

Aerobic conditioning Functional restoration approaches


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Thermal Therapies

A number of thermal modalities that producepain relief directly and indirectly

These include various cold applications

and heat in the forms of radiant heat, ultrasound,shortwave diathermy, microwave and laser


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Thermal Therapies

All of these modalities may work indirectlyand through a counterirritant effect or directlythrough effects on peripheral nerves and free

nerve endings Cold therapy tends to be used acutely to

reduce swelling and pain of acute injury andinflammation

Whereas heat is utilized after the acute injuryphase has subsided and for more chronicconditions


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Thermal Direct & Indirect Effects

More focused on the direct effects, but theindirect effects can be quite therapeutic

Heat and cold application to the skin of the

abdominal wall have a profound effect onpain resulting from spasm of the smoothmuscle in the GI tract or uterus There is a reduction in peristalsis and stomach

acid production with heat and an increase with

cold application Menstrual cramps are relieved with lower

abdominal heat application


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Heat

Physiologic effects that produce pain relief direct results of the temp elevation on the tissue

and cellular functions

and through a reflex reaction Heat reduces pain & muscle spasm while

decreasing joint stiffness and contractures

Produces hyperemia, speeds metabolicprocesses & hematoma resolution

Heat is useful for bursitis and tenosynovitisalong with superficial thrombophlebitis

Causes an induction of reflex vasodilatation


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Physiological Reactions to Heat

The major factors determining the number

and intensity of the physiological reactions to

heat are:

Level of tissue temperature: therapeutic range is

narrow: 43o C [109.4o F] to 45o C [113o F]

Duration of tissue temperature elevation [5 to 30

minutes]

Rate of temperature rise in tissues

Size of the area treated


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Superficial Heat

While the physical properties differ, none of

these agents are able to overcome the

combination of skin tolerance, tissue thermal

conductivity, and the body's response to

produce localized temperature elevations of

more than a few degrees at depths of a few

centimeters Conduction, Conversion & Convection


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Conduction Hot Packs

Hot (hydrocollator) packs

Clinically useful temperature for 30 minutes

Advantages include low cost, minimal

maintenance, long life, patient acceptance, and

ease of use

Alternatives include electric heating pads, gel

pads, hot water bottles, and circulating water

heating pads

Exposure time: 20 minutes


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Conduction Paraffin Baths

Paraffin baths Mineral oil and paraffin (1:7)

Temperatures of 52o C to 54o C are well tolerated

because the mixture has a low heat capacity andan insulating layer of wax builds up on the treatedarea

Dip method versus continuous immersion

Contraindications: open wounds, skin infections,inadequate circulation, sensory loss


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Conversion Heat Lamps

Heat Lamps

Inexpensive

Versatile

An easy way to warm superficial tissues

250-watt bulb, 40 to 50 cm from the patient


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Convection - Hydrotherapy

Hydrotherapy

Whirlpool baths & Hubbard tanks

Pumps agitate water and provide convective

heating, massage, and gentle debridement

Temps: 33o C to 36o C are considered neutral

Hubbard tank temps limited to 39o C

Single extremity treatments can be more rigorousand in a healthy individual temperatures from 43o

C to 46o C are possible


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Convection - Hydrotherapy

Used for burn and wound treatment at neutral

temperatures

Hydrotherapy can be effective for mobilization of

joints, as an adjunct in the treatment ofrheumatoid arthritis, and for muscle spasm

Hydrotherapy allows exercise of painful joints with

reduced stress because water buoyancy reduces

the gravitational forces Caution should be exercised with full submersion

as body temperature may rise


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Convection Contrast Baths

Alternating immersion in hot and cold waterto produce a vascular exercise through activevasodilatation and vasoconstriction of the

blood vessels Hot/cold ratios are used depending on patient

tolerance; typically ratio is 4:1

Thought to be effective due to reflex

hyperemia produced by the alternatingexposure to heat (43o C) and cold (16o C)


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DeepHeat Modalities

Ultrasound

Short wave Diathermy

Microwave Laser (non-surgical)


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Ultrasound

Arbitrarily defined as sound at frequenciesabove the limits of human hearing (i.e., morethan 20,000 Hz)

Ultrasound machines use ceramic and quartzpiezoelectric crystals to produce ultrasonicenergy

Intensities of 0.5-2.0 Watts/cm2 are used

Frequencies of 1 MHz (deep) or 3 MHz(superficial)


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Ultrasound

Pulsed versus Continuous

Treatment time 5-10 minutes

Deep-seated joints and fibrous scars with soft

tissue are selectively heated by ultrasound asare myofascial interfaces, tendon and tendonsheath & nerve trunks

Useful for painful amputation neuromas

Phonophoresis includes the addition of asteroid which is forced into the tissue topotentiate treatment effectiveness


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Ultrasound

Precautions and contraindications include: fluid-filled cavities

joint replacements containing cement/plastics

open epiphyseal plates Cancer

the eyes, brain & testicles should be avoided

should not be used over a pregnant uterus

Pain is used as an endpoint to avoid tissuedestruction


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Short Wave Diathermy

Radio waves are used to heat superficialtissue by conversion with induction coilapplicators or condenser pads

Most commonly used frequency: 27.12 MHz Treatment time: 20-30 minutes


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Short Wave Diathermy

Pelvic organs are selectively heated usinginternal vaginal and rectal electrodes and canbe useful in pelvic inflammatory disease

Avoid over metal implants (includingintrauterine devices) and electronic devicessuch as cardiac pacemakers, spinalstimulators, etc.

Should not be used with a pregnant patient oroperator


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Microwave

Electromagnetic radiation at frequencies of

915 and 2456 MHz

Treatment time: 20-30 minutes

Avoid near sensitive organs such as the

eyes, testicles, brain, etc.

Precaution over bony prominences due to

reflection of the wave at the bone interfacemay produce increased heat absorption in

the tissues superficial to the bone


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Laser (non-surgical)

A collimated (parallel waves of light) beam of

photons of the same frequency with the

waves in phase of lower level intensities

Helium-neon, gallium-arsenide, etc.

Usefulness anecdotal

Utility unestablished


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Heat Indications

Pain

Muscle spasm

Decreases joint stiffness and contractures

Myofascial pain and Fibromyalgia Production of hyperemia

Acceleration of metabolic processes

Hematoma resolution

Bursitis and tenosynovitis

Superficial thrombophlebitis

Induction of reflex vasodilatation


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Heat Contraindications/Precautions

Acute inflammation, abscess, trauma, edemaor hemorrhage

Bleeding disorders

Insensitivity

Inability to communicate or respond

Poor thermal regulation

Areas of malignancy Ischemia (Inadequate blood supply)

Atrophic skin & Scar tissue


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Superficial Cold - Cryotherapy

Reduces blood flow

Decreases metabolic activity

Lessens muscle tone and spasm

Decreases swelling

Inhibits spasticity and clonus

Increases gastrointestinal motility

Slows nerve conduction Produces analgesia


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Cryotherapy

Restricted to superficial agents that areinexpensive, but effective including: ice, cold water, refrigerated units, vaporizing

liquids (Vapo-Coolant spray), and chemical packs Chilling causes an initial period of

vasoconstriction until subcutaneous tissuesreach 15o C


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Cryotherapy

Thereafter, vasodilatation occurs, howevervessels are still constricted compared tonormal

Temperatures to 13 -15o C for 10 to 20minutes are used

Cold should be provided just long enough toprevent swelling and bleeding but prolonged

use should be avoided as cold can retardhealing


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Cold Indications

Musculoskeletal trauma

Edema/hemorrhage control & analgesia

Pain Muscle spasm

Spasticity

Adjunct in muscle re-education Reduction in metabolic activity


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Cold Contraindications & Precautions

Ischemia

Cold intolerance/hypersensitivity

Raynaud's Severe cold pressor responses

Cold allergy

Insensitivity


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Electrotherapy

Transcutaneous electrical stimulation andinterferential therapy are the two mostcommon forms of electrical stimulation usedfor pain modulation

By varying parameters such as frequency,waveform, pulse duration, electrodeconfiguration, and duration of stimulus, arange of therapeutic effects is possible

Both types of electrotherapy are thought tohave similar actions through segmentalinhibition or activation of descending pain-inhibitory systems


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Electrotherapy

Contraindications include pacemakers,myocardial disease, superficial metalimplants and over pharyngeal or laryngealmuscles

There are many other forms of electricalstimulation including, H-Wave, diadynamiccurrent and various E-Stim devices

None of these devices have been proven

effective nor is there any evidence for adifference in outcome between differentelectrical stimulation forms


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Electrical Stimulation Indications

General Indications Pain Modulation: TENS, Interferential, H-wave

Muscle Spasm: Produces muscle fatigue &relaxation

Spasticity: Fatigue of the agonist, reciprocalinhibition

Impaired Range of Motion: Used for mechanicalstretching

Muscle Re-education: Training muscles torespond appropriately to volitional effort

Disuse Atrophy & Strengthening: Does notstrengthen normal muscles more rapidly thantraditional approaches


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Electrical Stimulation Indications

Wound healing & Edema Reduction

For immobilized and injured muscles, electricalstimulation maintains isometric strength and whenthere is splinting and pain, it may supplement

volitional movements and speed of recovery Functional Electrical Stimulation (FES): In the

upper motor neuron spinal cord injured patient,may increase strength, normalize blood pressure,allow for limited ambulation and lead to a sense of

well-being FES also used for shoulder subluxation and

dorsiflexion assist in gait training.


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Transcutaneous Electrical Nerve

Stimulation (TENS)

A TENS unit produces analgesia in a widerange of medical conditions

It is used in a self-administered setting after

patient receives proper instructions TENS units are non-invasive, easy to use,

safe and inexpensive

TENS units are small simple devicesconsisting of a power source (rechargeablebattery), one or more signal generators and aset of electrodes


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Transcutaneous Electrical Nerve

Stimulation (TENS)

Electrode placement and stimulationparameter remain more art than science

High frequency (or conventional) TENS

typically results in immediate pain relief thatlasts while the stimulus is on, but usuallyabates when the stimulation stops

In acupuncture-like (or low frequency) TENS,the high stimulus intensity is painful and

many patients cannot tolerate it but thebenefit is longer lasting pain relief


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Interferential Therapy

Interferential therapy involves a different formof electrical stimulation than TENS, althoughthe physiologic and therapeutic effects aresimilar in both

Interferential is based on the principle that theinterference between two medium frequency(KHz) currents produces a low frequencycurrent that will be induced in the deep

tissues


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Interferential Therapy

Therefore, interferential therapy allowseffective stimulation of deep tissues whereasTENS is predominantly a cutaneous orsuperficial stimulus

Unlike the TENS unit, interferentialtreatments are usually provided directly by aphysical therapist

Treatments involve the use of two pairs of

electrodes and most units allow variation inwaveform, stimulus frequency and amplitudeor intensity


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H-Wave Therapy

The manufacturer lists H-Wave therapy as apowered muscle stimulator that at lowfrequency produces comfortable, rhythmic,

non-fatiguing muscle contractions thatincrease local blood flow and lymphaticdrainage

At high frequency, H-Wave therapy is

purported to break the pain cycle similar toconventional TENS


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Iontophoresis

A process in which a continuous directcurrent is used to drive electrically chargedmolecules or atoms (ions) into the tissues

Iontophoresis delivers high concentrates ofpolar substances, or medicinal agents, intothe skin, but to questionable depths

The amount of medicine transferred throughthe skin is directly related to the duration of

treatment, current density, and concentrationof the ions in the solution


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Iontophoresis

Indications for iontophoresis includemusculoskeletal inflammatory conditions,such as bursitis, and pain relief

Common medications includedexamethasone, lidocaine andhydrocortisone

Contraindications include impaired skinsensation, broken skin or bruises, and metal

in or near the treatment area


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Vibration

Vibration is used for muscle facilitation and

re-education and for acute and chronic pain

conditions


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Biofeedback

Biofeedback is used to measure motor unitaction potentials (MUAP)

The signals are detected, amplified and

converted into audiovisual signals that areused to reinforce voluntary control

The biofeedback signals, along with thepatient's voluntary effort, are used to either

increase or decrease muscle activity Biofeedback has been successfully used for

headaches and muscle tension


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TractionApplication Techniques

Manual

Mechanical

Free weights, pulley system

Motorized

Continuous

Intermittent

Gravity


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Traction Parameters

Cervical (25-30 pounds) Sitting versus supine

20-30 degrees flexion

Lumbar (50-100 pounds) Prone versus gravity inversion

45-90 degrees hip flexion

Continuous versus intermittent

Duration 5-10 minutes herniated disc

10-30 minutes other conditions


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Traction Indications

Degenerative disc disease

Discogenic pain

Herniated nucleus pulposus Radiculopathy

Subacute or chronic joint pain


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Traction Failures

Inadequate weight

Poor positioning

Stretching of pain sensitive tissues


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Traction Contraindications

Spine instability, tumors/infections

Vertebrobasilar disease - poor positioning

Signs of myelopathy

Significant osteopenia

Lumbar traction in pregnant women

Spondylolisthesis

Extreme anxiety Restrictive lung disease

Rheumatoid Arthritis


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Compression

Elevation

String wrapping

Ace wraps Garments

Gradient pumps

Physical activity and use


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Orthotics

Spine braces, corsets, collars, & supports

Upper extremity slings, braces (dynamic andpassive), bands, supports

Lower extremity braces, orthotics/braces Cushioning devices and pads

Shoes, lifts & inserts

Splints Static & Dynamic

Mobility aids Canes, crutches, walkers, wheelchairs, scooters


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Therapeutic Exercise

Major factor in achieving long-term benefits in

the treatment of chronic pain

Patient may have had long period of

decreased activity, weak muscles and

contracted joints, which contribute to pain

Exercise can decrease the pain cycle while

improving cardiac and whole bodyconditioning


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Therapeutic Exercise Objectives

Decrease pain

Improve mobility

Strengthen weak muscles

Increase flexibility

Decrease mechanical stress

Improve posture

Stabilize hypermobile joints

Improve fitness to prevent future injury


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Aerobic exercise can slow the decrease of

functional capacity in the elderly and

recondition those that have been ill or have

chronic disease

Exercise may have a direct effect on pain

management as evidence suggests that

exercise can activate endogenous painmodulation systems


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A therapeutic home exercise program shouldbe started early as part as the patient'soverall therapy program

Initially, if the symptoms are acute, anexercise program may only include postureand body mechanics, positioning and basicstretching

As the symptoms decrease the program

should progress to more aggressive ROM,strengthening and functional activities


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In the case of a chronic pain, the exerciseprogram should begin slowly due todeconditioning and pain compensations

A home exercise program gives the patient asense of control over his or her therapy andprogress

Emphasis should be placed on the benefits

and the lifestyle changes that must be madeto incorporate a routine exercise programthroughout life


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Aquatics Therapy

Buoyancy allows aerobic exercise, range ofmotion and weight bearing that would not bepossible out of water

Water can be soothing and relaxing andparticularly helpful to an anxious and fearfulpatient

Short-term individual treatment should be

followed by group classes and thereaftershould be carried out independently


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Aquatics Therapy

Therapy in warm water is beneficial for

diagnoses such as:

Fibromyalgia

Myofascial Pain Syndrome

Rheumatoid Arthritis

Therapy in cool water is recommended for

heat sensitive disorders such as multiplesclerosis


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Physical & Occupational Therapy

The therapist is a trained professional whoshould be recognized as a team member

Communication between physician and

therapist is key to achieving a successfuloutcome for the chronic pain patient

The therapist sees the patient much morefrequently than the physician and may be

able to provide important insights into bothphysical and psychosocial factors affectingthe patient's presentation


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Therapy Prescription

The therapy prescription should include ageneral order to evaluate and treat plus anylimitations or specifics requested by the

physician The prescription should include the

diagnosis, frequency and length ofrecommended treatment and most

importantly, any precautions orcontraindications


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FunctionallyOriented Therapy

Therapy should be active and not passive

Modalities may be useful early on but ingeneral should be discouraged in favor of

therapy that is functionally oriented andsupports patient independence

The patient must be encouraged to takecontrol of their therapy program and become

an active participant Patient's participation in an exercise program

is an important aspect of therapy


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Manual Medicine

Manual therapy refers to specific skills by the

therapist in muscle, joint and somatic

dysfunction

As with any discipline, some therapists haveexceptional skills in this area

Manual therapy is best utilized as an

integrated part of a comprehensive treatmentprogram


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Massage

Reflex Effects Stimulation of peripheral receptors in the skin

produce centrally mediated sensations of pleasureand peripherally cause muscle relaxation

Mechanical Effects Consists of measures to assist return flow

circulation of blood and lymph and measures thatproduce intramuscular motion to stretchadhesions and mobilize fluid accumulation


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Massage

Techniques Includes stroking (effleurage), compression

(ptrissage), friction/deep massage andpercussion/clapping (tapotement)

Indications Include any condition in which relief of pain,

reduction of swelling, or mobilizing of contractedtissue is desired

Contraindications Include infections, thrombophlebitis, malignancies,

burns, and in skin diseases


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Myofascial Release & Stretching

Myofascial release involves active orvoluntary muscle contraction along withpassive massage

A highly interactive stretching technique thatrequires feedback from the patient's body todetermine the direction, force and duration ofthe stretch and to facilitate maximumrelaxation of the tight or restricted tissues


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Other StretchingTechniques

Progressive stretch mobilization

Sustained progressive stretch

Spray and stretch

Muscle energy

Strain-Counterstrain

Rolfing


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Mobilization

Mobilization includes those manualprocedures which attempt to increase jointrange of motion beyond the resistance barrier

which limits passive range of motion orexercise

May involve either an accessory glide of thejoint or a physiologic movement of the joint


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Mobilization

Rhythmic repetitions with minimal force mayprovide pain relief

Differs from manipulation or adjustment by

the absence of a forceful thrust or jerkingmovement

Maitland's grades of mobilization: Grade I -Grade IV


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Manipulation

Thrusting techniques: Application of a high-

velocity, low-amplitude thrust to a joint

Forces the joint beyond the physiologic range

of movement to the anatomical limits ofmotion

Contraindications: osteoporosis, acute

inflammation, infection, tumor, structuralinstability, Vertebrobasilar insufficiency


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Ergonomics

Ergonomics is the study of how peopleinteract with their physical environment, andmodifications to prevent/reduce

musculoskeletal disorders The ergonomic system model consists of four

parts; the task, the operator, the environmentand the equipment

The objective is to maximize systemperformance while minimizing mismatchesbetween system elements


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Ergonomics

Basic ergonomic principles include keepingthe wrists straight and the elbows down,minimizing spine twisting and bending and

providing adjustable chairs and/or worksurfaces

Ergonomic redesign requirements includereduction of forces, frequency of activities,

holding time, prolonged static posturing andextreme postural deviations


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Functional Restoration Approaches

Structured group physical conditioning

Regular sessions of stretching, strengthening,aerobic conditioning plus educationalactivities & work simulation

Dependency on the therapist is discouragedand the program is geared towards healthybehaviors and return to leisure and workactivities

The group setting provides friendship andencourages mutual support


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WorkHardening vs Conditioning

Work hardening involves specific simulated work

activities prior to returning to employment

Work toughening or conditioning where the

individual exercises in a gym is not work hardening While work hardening may include gym exercise

activities, the program is task specific for the

particular job and involves both emotional and

physical reactivation to meet job demands


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Comprehensive Pain Programs

Multidisciplinary, coordinated painmanagement is based on viewing chronicpain treatment from a biopsychosocial model

rather than from a traditional biomedicaltreatment approach

The goal is to assist the individual inmanaging pain and returning to a functional

lifestyle including re-engaging in personaland work activities


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Comprehensive Pain Programs

The biomedical model focuses on "fixing"physical pathology and curing the painthrough various interventions

The biopsychosocial model of painmanagement acknowledges the role ofphysical pathology while realizing thatpsychological, social and cultural issues play

a major role in how individuals perceive andreact to painful stimuli


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Pain Program Goals

Reducing the misuse of medications andexcessive invasive medical procedures

Maximizing & maintaining physical activityand returning the individual to productiveactivity at home, socially and/or at work

Increasing the patients ability to managepain and related problems while reducingsubjective pain intensity

Strong emphasis is placed on increasing thelevel of function and ability to manage painand related problems, even without reductionof subjective pain intensity


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Pain Program Modalities

Medication management

Physical and Occupational therapy

Behavioral-psychological therapy

Vocational and disability management

Adjunctive treatment modalities such as

trigger point injections, nerve blocks and

various invasive interventions


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Fitness Programs

Supervised low-cost gym program at thephysical therapy center This program is ideal as the patient can be

weaned early from one-on-one physical therapy to

independent use of the gym facility Less costly, yet the patient is still in a protected

and supervised environment

Private gym or fitness center

To prevent re-injury, patients should not start sucha program without specific directions from thephysician or physical therapist


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Vocational Rehabilitation

For chronic pain patients who have return togainful employment as a reasonable goal,vocational rehabilitation efforts should be anintegral part of pain management and such

efforts should start early in the rehabilitationprocess

Resources such as Workers' Compensationor State Vocational Rehabilitation Services

should be identified


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Vocational Rehabilitation

Employers should be encouraged to makereasonable accommodations and considerreturn to work for the patient in modifiedand/or part time positions

Volunteer activities allow many individuals tohave meaningful interactions with otherpeople, stay busy, get out of the home, andmake a worthwhile social contribution

A i l R i l I


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Avocational & Recreational Issues

Recreational activities can be pleasurable,

time filling, socially reinforcing as well as both

physically and mentally therapeutic

P G idi P i i l


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PM&R Guiding Principles

Do no harm

Biopsychosocial model

Diagnose and then treat

Cost-effective care Pain control

Appropriate use of assistive devices

Patient empowerment Functional restoration

Return to work & leisure activities

PMR Approaches

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