Chapter 22 Physical Medicine and Rehabilitation Approaches to Pain Management

Question 1

Therapeutic programs often include

Answer 1

medication and exercise for flexibility, strength, and fitness,
and may use passive modalities, injections, interventional treatments and cognitive and behavioral interventions

Question 2

Treatment programs for acute pain focus on

Answer 2

addressing the pain generator, using temporary relative rest if indicated, and education for stretching, strengthening, fitness, and proper biomechanics.

Question 3

Programs for chronic pain

include

Answer 3

exercise regimens, but often require behavioral and
psychological interventions, and direct treatment of the
pain generator itself is rarely effective

Question 4

Physical therapy

Answer 4

includes therapeutic exercise, functional training in home and work activities, manual therapy, prescription and application of
devices, and passive modalities

Question 5

goals of pain treatment programs

Answer 5

self-efficacy, return of functional capacity, and

acceptable analgesia

Question 6

Modalities

Answer 6

methods used by therapists to exchange energy with tissues with the goal of creating a therapeutic response. Modalities are an adjunctive treatment included as part of a rehabilitation program, rarely used in isolation.

Question 7

Passive modalities may include

Answer 7

the application of heat, cold, sound waves, electricity, and electromagnetic waves to effect changes in tissue structures such as muscle,
fascia, ligament, tendon, capsule, and nerve

Question 8

Modalities are most useful when treating

Answer 8

acute pain where the specific underlying musculoskeletal abnormalities can be matched with an appropriate intervention. The long-term use of modalities is discouraged, since they may reinforce passive coping behavior

Question 9

Therapeutic heat transfer occurs by one or a combination of mechanism

Answer 9

radiation, conduction, convection, conversion,

and evaporation.

Question 10

Radiation

Answer 10

the transfer of heat through

thermal radiation at the surface

Question 11

Conduction

Answer 11

is heat exchange through direct contact

Question 12

Convection

Answer 12

is characterized by transfer of thermal energy through movement in a fluid medium, although the therapeutic energy exchange still occurs through conduction

Question 13

Conversion

Answer 13

occurs when a different type of energy is converted to heat energy

Question 14

Evaporation

Answer 14

results in loss of heat when a liquid on a surface undergoes a phase transition into a gas

Question 15

mechanism can be used to transfer heat to structures deeper than several centimeters beneath
the surface.

Answer 15

only conversion. Remaining mechanisms are able to provide only superficial exchange of thermal energy.

Question 16

Mechanism ways that cold can be applied

Answer 16

Conduction,

convection, and evaporation

Question 17

Applying heat causes improved

Answer 17

elasticity of soft tissue as well as increased blood flow, metabolic activity, enzymatic activity, oxygen demand, and capillary permeability

Question 18

Nerve conduction velocity increases with

Answer 18

application of heat.

Question 19

The heated tissues become

Answer 19

more supple, and there
are increases in healing cells and nutrients and decreases
in metabolic waste

Question 20

complications of heat

Answer 20

heat can also increase

edema and bleeding

Question 21

The target temperature for these modalities is generally accepted to be

Answer 21

40° to 45° C, and the thermal pain threshold is normally

about 45° C

Question 22

Indications for Therapeutic Heat

Answer 22

Muscle spasm, Pain, Contracture, Hematoma resolution, Hyperemia
Increase collagen extensibility
Accelerate metabolic processes

Question 23

Contraindications for Therapeutic

Heat

Answer 23

Acute inflammation
Hemorrhage or bleeding disorders
Decreased sensation
Poor thermal regulation
Malignancy
Edema
Peripheral vascular disease
Ischemia
Atrophic skin or scarred skin
Inability to respond to pain

Question 24

Superficial heat

Answer 24

causes the greatest increase in temperature at the surface of the skin, with less heat penetrating to the deep tissues: about 1° C at a depth of 2 to 3 cm.

Question 25

Superficial heat Applications

Hydrocollator packs

Answer 25

It is often applied using hydrocollator packs, a variety of fluid baths, and infrared lamps. Hydrocollator packs are
heated to 74.5° C. Several layers of towels are used to prevent burning of the skin and minimize loss of heat to the air.

Immersion of body parts in water around 40° C is another way to apply.

Question 26

Superficial heat Applications

Paraffin baths

Answer 26

Paraffin baths are typically used for peripheral limbs, especially the hands and arms. Temperatures around 53° C are used because paraffin transfers less heat than water does. Infrared lamps can provide similar warming to tissues if angle of incidence
and distance are optimized.

Question 27

Superficial heat leads to

Answer 27

mild analgesia and a sense of relaxation

Question 28

Ultrasound diathermy

Answer 28

can easily heat the bone-muscle interface up to 45° C, even in deep structures such as the hip. Ultrasound generators convert electrical energy
into vibratory energy through the piezoelectric properties of a crystal transducer

Question 29

When ultrasound vibrations are directed into tissue

Answer 29

they generate heat based on the water and protein content of the tissue, and in areas of transition
between tissue densities, such as at the interface between bone and muscle

Question 30

Tissues that heat and well poorly during a ultrasound

Answer 30

Tissues that heat poorly due to high water
concentration are fat and skin, and tissues that heat well due to high protein concentration are ligament, tendon,
muscle, bone, and nerve, with bone and nerve heating the most.

Question 31

Ultrasound may cause

Answer 31

gaseous cavitation and acoustic streaming effects that do not transmit
thermal energy, but may increase tissue pressures and cellular metabolism, and disrupt cell membranes

Question 32

Phonophoresis

Answer 32

A process in which ultrasound may be used to help deliver analgesics and anti-inflammatories across the skin

Question 33

Common Uses for Therapeutic Ultrasound

Answer 33

Contractures
Tendonitis
Degenerative arthritis
Subacute trauma

Question 34

Precautions for Ultrasound

Answer 34

Malignancy
Open epiphysis
Pacemaker
Laminectomy site
Radiculopathy
Near brain, eyes, or reproductive organs
Pregnant or menstruating uterus
Heat precautions in general
Caution around arthroplasties, methyacrylate, or high-density polyethylene

Question 35

Applying cold through conduction, convection, or evaporation results in

Answer 35

loss of heat from tissues; this results in vasoconstriction followed by vasodilation, decreased local metabolic activity, decreased enzymatic activity, and decreased
oxygen demand. Tissues and muscles become stiffer, nerve conduction slows, and muscle spindle and Golgi tendon organ activity decreases. Muscle isometric strength increases and rate of muscle fatigue decreases. Cold also results in
analgesia and relaxation

Question 36

Indications for Cryotherapy

Answer 36

Acute trauma, Edema
Hemorrhage, Analgesia
Pain, Muscle spasm
Spasticity, Reduction of metabolic activity

Question 37

Precautions and Contraindications for Cryotherapy

Answer 37

Ischemia, Raynaud’s disease or phenomenon
Cold intolerance
Insensitivity
Inability to report pain

Question 38

Cold

Answer 38

often used during the first 48 hr after an acute
musculoskeletal injury to decrease inflammation, edema, and pain. Cold application should not exceed 30 min and
should not be placed directly over superficial nerves to prevent neurapraxia. the surface of the skin is affected first and most, but after 20 min, tissues 2 cm deep are cooled by about 5° C.

Question 39

How is Cold applied?

Answer 39

Cold is normally applied in ice packs at –12° C with towels layered over to protect the skin

Question 40

Cold water immersion

Vapocoolant spray

Answer 40

Cold water (5 to 13° C)
immersion can be used but is generally poorly tolerated, although muscle temperatures can decrease by about 6 degrees after 30 min of immersion. Vapocoolant sprayis used for cutaneous anesthesia

Question 41

Cold and heat can be used together in

Answer 41

contrast baths with alternating warm and cold immersion to cause cyclic vasodilation and vasoconstriction, with beneficial effects
hypothesized for pain from rheumatologic and neuropathic conditions

Question 42

Iontophoresis

Answer 42

process by which various drugs (i.e., corticosteroids, lidocaine) are introduced into a joint or around periligamentous or tendinous structures via electrical current

Question 43

How does Iontophoresis work?

Answer 43

uses electromigration and
electro-osmosis to increase permeation of charged and neutral compounds. The medicine is applied to the electrode
with the same charge, and then the electrical field is
set up on the skin surface to push the medicine away from the electrode and toward the target tissue.

Question 44

Advantages of Iontophoresis

Answer 44

Iontophoresis is non-invasive, painless, and
avoids potential side effects and adverse reactions of oral
medications or injection therapies (i.e., increasing risk for bleeding, intravenous catheter infiltration, and pump malfunction).

Question 45

Iontophoresis indications

Answer 45

overuse conditions such as epicondylitis and plantar fasciitis

Question 46

transcutaneous electric
nerve stimulation (TENS)

Answer 46

mechanisms of pain relief include modulation of the gating mechanisms at the dorsal horn system to decrease pain transmission to the brain and stimulation of
endogenous neurotransmitters and opioids. Cutaneous
nerve fibers are stimulated using surface electrodes emitting a mild electrical current

Question 47

Transcutaneous Electric
Nerve Stimulation (TENS)

High-frequency low-intensity stimulation and Low frequency high-intensity stimulation

Answer 47

High-frequency low-intensity stimulation patterns are better tolerated and result in immediate analgesia, while low-frequency, high-intensity patterns cause more discomfort
and result in longer-lasting analgesia.

Question 48

Interferential
current therapy (ICT)

Answer 48

uses electrical current like TENS, but combines two different high-frequency pulses so that their interference pattern creates a low-frequency stimulation. The high-frequency stimulation penetrates skin better
than low-frequency stimulation, but the treatment results in
the longer-lasting effects of low-frequency stimulation

Question 49

Comprehensive Rehabilitation Program

Phases: Theraphy Focus

Answer 49

Acute: Education, relative rest, pain control

Recovery: Full or optimal range of motion, strength, balance, proprioception

Maintenance: Return to work and sport specific activity, aerobic conditioning

Question 50

Relative rest is important because

Answer 50

excessive immobilization results in decreased muscle strength,
endurance, and flexibility

Question 51

Therapeutic exercise should begin during

Answer 51

the acute phase

Question 52

Manual techniques should focus on

Answer 52

improving soft tissue extensibility that helps promote proper alignment of collagen fibers during healing and remodeling. These techniques may include massage, fascial stretching, traction, and joint mobilization

Question 53

Myofascial release improves

Answer 53

elasticity and motion by applying pressure in shear forces directed by fascial planes, and
assists with pain control

Question 54

three main types of therapeutic exercise:

Answer 54

exercises that improve flexibility, muscle strength, and aerobic capacity

Question 55

When implementing an exercise program, the specific adaptation to imposed demand (SAID) principle should be applied

Answer 55

The principle states that the body responds to
given demands with specific and predictable adaptations. Stronger muscles develop with strength training. Oxidative capacities of skeletal muscles increase with aerobic training.
Pliability of connective tissue increases with flexibility exercises

Question 56

In aerobic fitness Oxygen consumption (VO2) increases in proportion to the intensity of

Answer 56

the exercise. VO2 max, the highest level of oxygen consumption
achieved during exercise, is the best indicator of
aerobic fitness

Question 57

frequency, intensity, and duration of aerobic training

Answer 57

This is typically at 40% to 85% of VO2 max for
aerobic training. The duration for aerobic training is usually
greater than 15 min of continuous exercise. Frequency for aerobic training is usually 3 to 6 times per week

Question 58

Treatment approaches for spine-related conditions

Answer 58

flexion-based therapy, stabilization exercises, mechanical diagnosis and treatment (MDT), neurodynamic therapy,
and various manual therapy and soft tissue approaches, as well as activity and therapeutic exercise

Question 59

Stabilization exercise training

Answer 59

emphasizes not only strengthening muscles but motor relearning of inhibited muscles.
Patients are advanced from training in isometric and eccentric strengthening of core muscle groups to include
Swiss ball and other dynamic multiplanar exercises, and finally gradual return to work- and sport-specific activities.

Question 60

Stabilization exercises indications

Answer 60

reduce the recurrence
of low back pain from spondylolysis and spondylolisthesis. Stabilization exercises prevent recurrence and
improve pain and function of nonspecific chronic low
back pain, but do not reduce pain or disability in acute low back pain