physical medicine and rehabiltation

1. PHYSICAL
MODALITIES-2
MYOFASCIAL PAIN
SYNDROME&ITS
MANAGEMENT
-DR.R.BALAMURUGAN M.D
PMR,FIRST YEAR

2. • REBOUND PHENOMENON:-
THERMOTHERAPY
• Occurs at the time that maximum therapeutic effect of hot or
cold application is achieved .
• Heat produces maximum vasodilatation in 20-30 minutes.
• Continuation beyond 30-45 minutes causes tissue congestion,
the blood vessels constrict
• The opposite effect is occurring because of reflex vascular
constriction.
• Recovery time of one hour is advised before reapplication

3. Cold or Ice Water Immersion

4. Skin Response to Cold
 Stage 1
 Response
 Cold sensation
 Estimated Time after Initiation
 0 to 3 minutes

5. Skin Response to Cold
 Stage 2
 Response
 Mild burning, aching
 Estimated Time after Initiation
 2 to 7 minutes

6.  Stage 3
 Response
 Relative cutaneous anesthesia
 Estimated Time after Initiation
 5 to 12 minutes

7. CRYOKINETICS
Technique that combines cryotherapy
with exercise
Goal is to numb region and work towards
completion of rehab program
(ROM….etc)
Treat area with ice pack, massage or
immersion
When analgesia is experienced, exercises
should be performed (window will last
4-5 minutes)
As pain returns, process may be repeated

9. WHAT IS HYDROTHERAPY
 Application of water, internally or externally, for the
treatment of physical or psychological dysfunction
 TYPES OF HYDROTHERAPY
Immersion
Non-Immersion
USES
 Treatment of Wounds
 Enhanced Environment for exercise
 Pain
 Edema
 Health maintenance /disease prevention

10. Cleansing
Pressure (Force = Rate of Flow)
Dissolved antimicrobial agents,
etc. (Wounds)
Musculoskeletal Effects
Decreases weight-bearing
(Arthritis)
Increases blood flow to muscles
Strengthening
Decreased bone density loss
Decreased fat loss
Compared to other forms of
exercise
Good for obese secondary to non-
weight bearing exercise
Not good for general weight
loss

11. ELECTROTHERAPY

12. ELECTRICAL STIMULATION
 Electrical stimulation uses an electrical current to
cause a single muscle or a group of muscles to
contract.
 By placing electrodes on the skin in various
locations , it can recruit the appropriate muscle
fibers.

13.  Contracting the muscle via electrical stimulation
helps strengthen the affected muscle.
 can change the current setting to allow for a
forceful or gentle muscle contraction.
 Along with increasing muscle strength, the
contraction of the muscle also promotes blood
supply to the area that assists in healing.

14. Mechanism how electrical therapy
alleviates pain.
 1 electrical stimulation blocks the transmission
of pain signals along nerves.
2 electrical stimulation promotes the release of
endorphins (hormones in the brain that reduce pain
sensations and affect emotions).
 .

15. Types and differences of electrical
therapy
Transcutaneous electrical nerve
stimulation (TENS).
 A small, battery-operated device sends low-voltage
electrical current through the skin, with electrodes
(small, flat adhesive discs) placed near the source of
the pain.
 The electricity stimulates the nerves in the affected
area and sends signals to the brain that distort normal
pain signals. TENS, the most common type of electrical
therapy

16.  Traditional or Conventional TENS : >50Hz
 Low frequency / Acupuncture like TENS : 1-10
HZ

17.  Percutaneous neuromodulation therapy
(PNT).
 Also known as percutaneous electrical nerve
stimulation (PENS)
 PNT is similar to TENS except that needles are
inserted in the area where pain is being experienced
before stimulation occurs.


18.  ELECTROACUPUNCTURE
 This treatment is sometimes described as a
variation of PNT and sometimes as a separate
therapy.
 It incorporates techniques of acupuncture with
needles that are inserted on specific points in the
body. The needles are then attached to a device
that generates electrical pulses.

19. MICROCURRENT ELECTRICAL
THERAPY (MET).
 Electrodes are placed on opposite sides of the body
so that the electrical current flows through the
injured or diseased part of the body and speeds
healing.

20.  IONTOPHORESIS
 Electrical current delivers medication through the
skin using a Direct Current of 10-30mA.
 This method is sometimes used to treat conditions
such as neck pain, back pain, arthritic conditions,
rotator cuff injuries, bursitis, tendonitis and other
joint pain.

21. INTRADISCAL
ELECTROTHERMAL
THERAPY (IDET).
 A wire is placed into an injured intervertebral disc.
The wire is then electrically heated to seal and
toughen the tissue. It is often used to treat lower
back pain.

22. USES
 PAIN MANAGEMENT
 Treatment of Muscle Weakness
 Reduce Spasticity
 Motor Reeducation
 Alter Vascular Response and Improve Wound
Healing
 Enhance Bone Growth/Fusion
 Influence Bowel, Bladder, and Sexual Function
 Enhance Peripheral Nerve Growth

23. CONTRAINDICATIONS
1 Pregnant women.
2 Patients with implanted devices such
as pacemakers, defibrillators, pain pumps, artificial
joints and bone screws.
3 Patients with hemophilia or thrombosis cause
vasodilation (widening of the blood vessels),
which could aggravate these conditions.
4 Others include epilepsy, other seizure disorders
and certain heart conditions.

24.  Some devices can raise or lower blood pressure or
cause headaches, vertigo or nausea.
 Some devices may cause vasodilation (widening
of blood vessels), which can worsen conditions
such as blood clots and hemophilia.

25.  Excessive stimulation can cause muscle soreness
or spasm.
 Patients may become tolerant to the therapy,
meaning more treatment is needed over time to
produce the same level of pain relief.

26. Transcutaneous Electrical Nerve
Stimulation
 TENS device delivers stimulation above the
sensory threshold to produce pain relief.
 TENS units act by depolarizing the peripheral
sensory nerves. Muscle contraction is a side
effect and not a primary action.

27. EQUIPMENTS
 Small
 One or more signal generator
 Set of electrodes
 Output : 100mA
 Fq: 0.5 – 200 Hz
 Technique : placed over painful area,
paravertevral, nerve , Trigger points

28.  Gate mechanism
 Presynaptic inhibition in the dorsal horn of the
spinal cord
 Endogenous pain control (via endorphins,
enkephalins, and dynorphins)
 Direct inhibition of an abnormally excited nerve
 Restoration of afferent input
 Low frequency TENS raises the pain threshold

29.  Neuralgic pain: Deaffrentation pain , phantom
pain, pain from SCI , post herpetic pain
 Musculoskeletal pain : post operative (mild to
moderate ) , RA , OA,
 Visceral pain
 Angina pectoris

30. CONTRAINDICATIONS
 patients with a pacemaker
 during pregnancy because it may induce premature
labor.
 over the carotid sinuses due to the risk of acute
hypotension through a vasovagal reflex.
 over the anterior neck because of possible
laryngospasm due to laryngeal muscle contraction.

31. FES
 FES systems are meant to deliver pulses of
electrical currents at predetermined frequencies
and amplitudes to nerves or myoneural junctions.
 The first application of electrical stimulation to
improve muscle function was the invention of the
cardiac pacemaker in 1950.

32.  Application of FES in a rehabilitation system is
credited to Liberson.
 He applied electrical stimulation to the peroneal
nerve to produce ankle dorsiflexion in hemiplegic
patients during the swing phase of gait.

33.  The gate theory of Melzack and Wall described in
1965, provided the rational basis for the use of
electrical stimulation in
- Transcutaneous Electrical Nerve Stimulation
- Dorsal column and
- Conus medullaris root stimulation
in the management of neuropathic pain and neurogenic
bladder dysfunction.

34. Components
 A portable power source
 A control mechanism
 Lead wires
 Electrodes
 Sensors and microprocessor for preprogrammed
or automatic control

35. USES
1. Pain relief (analgesia)
2. Muscle weakness
3. Reduce spasticity
4. Motor reeducation
5. Alter vascular response and wound healing
6. Enhance bone growth and healing
7. Enhance bowel bladder and sexual function
8. Peripheral nerve growth
9. Iontophoresis

36.  All therapeutic electrical generators are
transcutaneous electrical stimulators.
 The majority of these generators are used to
stimulate peripheral nerves and are correctly called
transcutaneous electrical nerve stimulators
(TENS).
 Occassionally the terms neuromuscular electrical
stimulator (NMES) or electrical muscle stimulator
(EMS) are used; however, these terms are only
appropriate when the electrical current is being
used to stimulate muscle directly, as would be the
case with denervated muscle in which peripheral
nerves are not functioning.

37. Direct Current (DC current)
 Flows in one direction only from the positive pole
to the negative pole.
 Direct current may be used for pain modulation or
muscle contraction or to produce ion movement.

38. Alternating Current (AC current)
 The direction of current flow reverses itself once
during each cycle.
 Alternating current may be used for pain
modulation or muscle contraction.

39. Pulsed Current
 Pulsed currents usually contain three or more
pulses grouped together.
 These groups of pulses are interrupted for short
periods of time and repeat themselves at regular
interval.
 Pulsed currents are used in interferential and so-
called Russian currents (currents interfere with
each other).

40.  Duration: 10 to 30 minutes
 Can be used with ice or heat

41. High Voltage or Pulsed Indications
Peripheral nerve injuries,
 Delaying denervation
 delaying disuse atrophy
 Post-traumatic edema reduction
 Increase local blood circulation
 Joint contracture prevention
 Maintenance of range of motion
 Muscle strengthening
 Muscle spasm reduction
 Inhibitation of spasticity
 Muscle re-education
 Assist voluntary muscle function

42. Contraindications
 Demand-type pacemakers
 Over pelvic or lumbar areas
 During pregnancy
 Pain of central or unknown origin

43. IFT
 Interferential Current
Therapy
 Crossing two slightly
different medium
frequency alternating
currents within the tissue,
a third frequency current
of greater intensity is
created in the deeper
tissue
 4 electrodes total
 Allows for centralized
concentration of current
 Maximized by electrode
placement so that
intensity is perceived in
area of pain
 “Carryover Effect”

44.  IFT uses alternating medium- frequency electric
current of 4000Hz.
 GALVANIC STIMULATION
 High voltage galvanic stimulation uses intensities
of 50-75 Volts at frequency of 100 pulses/sec

45. MASSAGE THERAPY
 Sports massage causes mechanical, physiological,
and psychological responses.
Mechanical Response
Encourages venous and lymphatic drainage, mildly
stretch superficial and scar tissue
Physiological Response
Reflex effects, relaxation, stimulation, and increased
circulation

46. Massage Strokes
 Effleurage
 Petrissage
 Tapotement
 Vibration
 Deep Friction

47. Effleurage
 Stroking; divided into light and deep methods.
 Light stroking is designed primarily to be sedative.
 It is also used in the early stages of injury
treatment.
 Deep stroking is therapeutic compression of soft
tissue, which encourages venous and lymphatic
drainage.

48. Petrissage
 Kneading; a technique adaptable primarily to
loosen heavy tissue areas such as the trapezius,
latissimus dorsi, or the triceps.
 Friction heat producing
 Often used around joints and other areas where
tissue is thin and is used on tissues that are
especially unyielding such as scars, adhesions,
muscle spasms, and fascia.

49. Tapotement
 Percussion; produces an invigorating and
stimulating sensation.

50. TWO TYPES OF INTERFERENCE
 CONSTRUCTIVE INTERFERENCE
 DESTRUCTIVE INTERFERENCE
 ADV OF IFC-DECREASE SKIN IMPENDANCE
 AMPLITUDE MODULATION
 High voltage galvanic stimulation-
wounds,weakness,fatigue
 Electrical myostimulation-MPS
 Electrical twitch obtaining intramuscular
stimulation-Myofascial pain syndrome

51.  Microcurrent-depression,anxiety
 Low level laser therapy-musculoskeletal
conditions

52. ACUPRESSURE
 Definition
 Acupressure involves the application of
manual pressure usually with fingertips on specific
points on the body.

53.  Use firm pressure
 Acupressure points are very sensitive areas
 Massage until numbness is felt
 No limit in the number of exercises per day.
 Increase the massage in intensity slowly.
 During massage ,client can sit or lie down and
breathe deeply.
 Client need not massage on his own.

54. Mechanism of action
 Energy flows through the various channels irrigating
and nourishing the tissues
 An obstruction in movement causes diseases and
ailments
 Needling unblocks the obstructions and reestablish
flow through merdians
 Acupuncture helps internal organs to correct
imbalances in digestion,absorption and energy
production.
 Stimulation of endorphins and hormones

55. Precautions
 Acupressure should never be painful
 Pressure should be gentle
 AVOID : Osteoporosis, Bruising ,bleeding
disorders,Circulatory problems – Diabetes
 Anticoagulant therapy/Antiplatelet
medications(Warfarin)
 Else can be done under supervision of a qualified
therapist.

56. ACUPUNCTURE
 Definition
It is the treatment of various diseases of the
body ,carried out by inserting very fine filiform
needles or giving heat to specific points on the
body.
Latin ‘Acus’ - needle & ‘pungus’ - prick

57. Modalities
 Electro-Acupuncture - Diabetes ,asthma,slip
disc,sciatica,migraine,addictions,
deafness,menstrual disorders,azoospermia etc
 He-Ne Laser Therapy – Children,elderly
,debilitated and Hi-Fi patient
 Moxibustion – Asthma,Rhinitis etc
 Cupping/Fire cupping/Bekam Therapy
 Catgut Embedding Therapy
 Plum blossom Therapy.

58. TRACTION
 ABSOLUTE CONTRAINDICATIONS
 MALIGNANCY
 INFECTIONS(Osteomyelitis,Discitis)
 OSTEOPOROSIS
 ARTHRITIS
 FRACTURE

59. SPECIAL PRECAUTION
CERVICAL TRACTION
 VERTIBRO BASILAR INSUFFICIENCY
 C.V .D viz R.A d/t risk of atlanto-axial
dislocation
 Midline herniated Nucleus pulposus or acute
torticollis

60. SPECIAL PRECAUTION
LUMBAR TRACTION
 RESTRICTIVE LUNG Ds
 Pregnancy
 HERNIAS
 Aortic aneurysm, gross hemorrhoids
 cauda equina compromise

61. Thankyou