Chapter 22 Physical Medicine and Rehabilitation Approaches to Pain Management Flashcards Preview

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Flashcards in Chapter 22 Physical Medicine and Rehabilitation Approaches to Pain Management Deck (60):

Therapeutic programs often include

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


Treatment programs for acute pain focus on

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


Programs for chronic pain

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


Physical therapy

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


goals of pain treatment programs

self-efficacy, return of functional capacity, and
acceptable analgesia



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.


Passive modalities may include

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


Modalities are most useful when treating

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


Therapeutic heat transfer occurs by one or a combination of mechanism

radiation, conduction, convection, conversion,
and evaporation.



the transfer of heat through
thermal radiation at the surface



is heat exchange through direct contact



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



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



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


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

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


Mechanism ways that cold can be applied

convection, and evaporation


Applying heat causes improved

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


Nerve conduction velocity increases with

application of heat.


The heated tissues become

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


complications of heat

heat can also increase
edema and bleeding


The target temperature for these modalities is generally accepted to be

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


Indications for Therapeutic Heat

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


Contraindications for Therapeutic

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


Superficial heat

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.


Superficial heat Applications

Hydrocollator packs

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.


Superficial heat Applications

Paraffin baths

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.


Superficial heat leads to

mild analgesia and a sense of relaxation


Ultrasound diathermy

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


When ultrasound vibrations are directed into tissue

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


Tissues that heat and well poorly during a ultrasound

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.


Ultrasound may cause

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



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


Common Uses for Therapeutic Ultrasound

Degenerative arthritis
Subacute trauma


Precautions for Ultrasound

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


Applying cold through conduction, convection, or evaporation results in

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


Indications for Cryotherapy

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


Precautions and Contraindications for Cryotherapy

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



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.


How is Cold applied?

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


Cold water immersion

Vapocoolant spray

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


Cold and heat can be used together in

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



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


How does Iontophoresis work?

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.


Advantages of Iontophoresis

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).


Iontophoresis indications

overuse conditions such as epicondylitis and plantar fasciitis


transcutaneous electric
nerve stimulation (TENS)

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


Transcutaneous Electric
Nerve Stimulation (TENS)

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

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.


current therapy (ICT)

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


Comprehensive Rehabilitation Program

Phases: Theraphy Focus

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


Relative rest is important because

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


Therapeutic exercise should begin during

the acute phase


Manual techniques should focus on

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


Myofascial release improves

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


three main types of therapeutic exercise:

exercises that improve flexibility, muscle strength, and aerobic capacity


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

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


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

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


frequency, intensity, and duration of aerobic training

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


Treatment approaches for spine-related conditions

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


Stabilization exercise training

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.


Stabilization exercises indications

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

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