physical medicine and rehabiltation

1. THERAPEUTIC
MODALITIES FOR
PAIN MANAGEMENT
- part 1
DR.R.BALAMURUGAN
FIRST YR PG MD PMR

2. PAIN ASSESSMENT
• Pain is purely a subjective phenomenon.
• Unlike range of motion(ROM), strength or tissue
extensibility, It has no objective or specific
measurement tool.
• However, measurement of pain is a vital tool for patient
examination and treatment.
• Efffective examination of chronic pain is more complex
than the visual analog scale (VAS) or numeric rating
scales(NRS) typically used for acute pain.

4. Mnemonicsin AssessingPain
•Provoking /Precipitating factors
•Quality of pain
•Region and Radiation
•Severity and Associated symptoms
•Temporal factors / Timing

5. CHARACTERISATION OFPAIN
• Site
• Onset
• Character
• Radiation
• Associations
• Time Course
• Exacerbating / Relieving factors
• Severity

6. What are therapeutic modalities
• An agent or tool used to stimulate the body tissue to
perform its normal function.
• Modalities provide an environment in tissue that is
optimal to fast and efficient healing.

7. NEEDFOR THERAPEUTICMANAGEMENT
• Create optimum environment for injury healing
• Decrease the frequency and / or severity of the pain
• General sense of feeling better
• Increased level of activity
• Return to work
• Decreased health care utilization
• Elimination or reduction in medication usage

8. • Selection of the Modality for Treatment depends on:
• Injury site, type and severity
• Modality indication and contraindication
• Physician prescription
• Patient’s willingness to accept treatment

9. TREATMENTMODALITIESTO PAIN
• Neurostimulation
• TENS
• Acupuncture
• Anesthesiology
• Nerve block
• Surgery
• Physical therapy
• Exercise
• Heat/cold
• Psychological
approaches
• Cognitive therapies
(relaxation, imagery,
hypnosis)
• Biofeedback
• Behavior therapy
• Psychotherapy
• Complementary tx
• Massage therapy
• Art therapy
• Music therapy
• Aroma therapy

10. TYPESOF NON-INVASIVEMODALITIES
• THERMOTHERAPY
Heat
Cold
• HYDROTHERAPY
• ELECTROTHERAPY
• LIGHT THERAPY
Ultraviolet Radiation
Laser
• MECHANICAL
Pressure
Manipulation
Traction
Massage
Acupuncture

11. THERMOTHERAPY

12. THERMOTHERAPY
• The goal of thermotherapy is to alter tissue temperature in a
targeted region over time for the purpose of inducing a desired
biological response.
• Thermotherapy consists of application of heat or cold for the
purpose of changing the cutaneous, intra-articular and core
temperature of soft tissue with the intention of improving the
symptoms of certain conditions.

13. • Using ice(Cryotherapy) or heat(Thermotherapy) as a
therapeutic intervention decreases pain in joint and muscle as
well as soft tissues and they have opposite effects on tissue
metabolism, blood flow, inflammation, edema and connective
tissue extensibility.
• The majority of thermotherapies are designed to deliver the
thermal therapy to a target tissue volume with minimal impact
on intervening or surrounding tissues.
• Therapeutic heat
104°F - 170°F
40°C - 70°C

14. THERMOTHERAPY(HEAT)

15. Transmissionof Thermal Energy
• Conduction
Heating through direct contact with a hot medium
(e.g., hot pack).
• Convection
Heating indirectly through another medium such as
air or liquid (e.g., whirlpool)
• Radiation
Transfer of heat through space from one object to
another (e.g.,ultraviolet therapy)
• Conversion
Heating through other forms of energy
(e.g.,ultrasound)

17. PhysiologicEffectsof Heat
• HEMODYNAMIC
INCREASE….blood flow,a/c inflmn,edema,
bleeding(vasodiln)
DECREASE….c/c inflmn
• NEUROMUSCULAR
NERVE FIBER FIRING RATES
NCV
• JOINT & CON. TISSUE
INCREASE…tendon extensibility, collagenase
activity
DECREASE…joint stiffness
• OTHER…decrease pain, relaxation

18. TYPES OF MODALITIES
• SUPERFICIAL
HOT PACKS
HEATING PADS
PARAFFIN BATHS
FLUIDOTHERAPY
WHIRLPOOL BATHS
RADIANT HEAT
• DEEP
ULTRASOUND
SHORTWAVE
MICROWAVE
MECHANISM OF HEAT
TRANSFER
CONDUCTION
CONDUCTION
CONDUCTION
CONVECTION
CONVECTION
RADIATION
CONVERSION
CONVERSION
CONVERSION

19. • Superficial tissue is a poor thermal conductor
• Temperature rises quickly on the skin surface as
compared with the underlying tissues
• There are limitations of superficial tissue
• The deeper tissues, including the musculature, are not
significantly heated because the heat transfer from the
skin surface into deeper tissues is inhibited by the
subcutaneous fat, which acts as a thermal insulator, and
by the increased skin flow, which cools and carries away
the heat externally applied.

20. SUPERFICIALHEATINGMODALITIES
Superficial
heating
modalities
INFRARED
HYDROCOLLATOR
PACKS
FLUIDOTHERAPYPARAFFIN BATH
WHIRLPOOL

21. HOTPACK/ HYDROCOLLATOR PACK
• A hydro collator pack is a fabric envelope containing silica gel
• The gel is contained in a set of separate fabric pockets
• The main property of the gel is its capability to absorb many
times its own volume of water and when heated, to give moist
heat for 30 to 40 minutes
• The packs are heated in a hydro-collator unit
• The pack is applied to the body after being wrapped adequately
in toweling or blankets. (This provides THERMAL
INSULATION, So that the pack is at above 75˚C & the skin
temperature does not rise above 42˚C or so).

23. HEATING PADS
• Electric & circulating fluid pads
Peak temp 520C

24. RADIANT HEAT (INFRA RED)
• Emitted from substance
with temp >absolute zero
• At distance 30-60 cm
• LAMPS
Luminous(770-1500nm)
Non luminous(1500-
12,500nm)
• TEMP. RISE
1.50C at 2cm depth

25. PARAFFIN BATHS
• Paraffin wax & mineral
oil 6:1/7:1
• Temp 52.2- 54.4 0C
• Method of application
-Dipping(7-12 dips)
-Brushing
- Immersion
• Time of therapy
10 – 20 mins

26. FLUIDOTHERAPY
• Fluidotherapy is a dry heat modality used to treat acute
injuries and wounds, decrease pain and swelling.
• Increase ROM and inadequate blood flow.
• The unit contains fine cellulose particles that become
suspended when a stream of dry hot air is forced between
them.
• Treatment temperature ranges from 38.8 to 47.8C (102 to
118F).
• Treatment duration ranges from 15 to 20 minutes.
• Advantage : Exercise can be performed during the treatment,
and higher treatment temperatures can be tolerated.

27. INDICATIONS
• Joint stiffness
• Muscle or tendon
tightness
• Spacticity
• Pain in the hand

28. WHIRLPOOL
• Tank with a turbine motor which regulates the movement
of water and air
• Convection and Conduction are occurring
• Reduces swelling, muscle spasm and pain and active
movement is also assisted
• Treatment time should not exceed 20 minutes
• Whirlpool unit/tank must be kept clean
• Frequent water changes and daily cleaning essential
• Open wounds and abrasions should be handled cautiously
so that contamination or spreading of the infection is
prevented

29. Hot Whirlpool
• Duration: 5 to 30 minutes
• Temp: 96°F to 104°F
Indications:
• Subacute inflammation
• Chronic inflammation
• Peripheral vascular
disease
• Peripheral nerve injuries
• Distal body parts

30. DEEPHEAT THERMOTHERAPY
Deep
Heating
modalities
MICROWAE
DIATHERMY
LASER
ULTRASOUND
SHORTWAVE
DIATHERMY

31. ULTRASOUND
• Ultrasound uses high-frequency acoustic (sound) waves,
rather than electromagnetic energy, to elicit thermal and
nonthermal effects in deep tissue to depths of 3 cm or more.
• The actual mechanism of ultrasound, produced via the reverse
piezoelectric effect, converts electrical current to mechanical
energy as it passes through a piezoelectric crystal (e.g., quartz,
barium titanate, and lead zirconate titanate) housed in the
transducer head.
• The vibration of the crystal results in organic molecules
moving in longitudinal waves that move the energy into the
deep tissues to produce temperature increases (thermal
effects), and mechanical and chemical alterations (nonthermal
effects).
• Frequencies range between 0.75 and 3.3 MHz.

32. • PHYSIOLOGICAL EFFECTS OF ULTRASOUND THERAPY
• Increase collagen tissue extensibility,
• Increase blood flow,
• Increase sensory and motor neuron velocity,
• Increase enzymatic activity,
• Decrease muscle spasm
• Decrease joint stiffness,
• Decrease inflammation,
• Decrease pain.

33. Ultrasoundcanbecontinuousorpulsed.
LOW INTENSITY PULSED
ULTRASOUND(LIPUS)
• By stimulating
Angiogenesis
Osteogenesis
Chondrogenesis
• Uses
Treatment of musculo –
skeletal disorders.
PHONOPHERESIS/
SONOPHERESIS
• Transdermal drug
delivery
• Frequency
20 – 200 KHz to 0.2 –
1MHz

35. ULTRASOUNDAPPLICATIONS

36. SHORTWAVE DIATHERMY
• Diathermy uses electromagnetic energy from the nonionizing
radio frequency (RF) part of the spectrum.
• There is no stimulation of motor or sensory nerves.
• Rapid vibration of the continuous shortwave diathermy
(CSWD) waves is absorbed by the body and converted into
heat by the resisting tissues. This elicits deep, penetrating
thermal effects.
• When these waves are interrupted at regular intervals, pulses or
bursts of RF energy are delivered to the tissues, and are
referred to as pulsed radiofrequency radiation (PRFR).
• Pulsed radiofrequency radiation may produce either thermal
or nonthermal effects on tissues; low power produces
nonthermal effects, and high power produces thermal effects

37. • Radio frequencies range
between 10 and 50
MHz.
• The most commonly
used RF is 27.12 MHz

39. DiathermyApplications

40. LASER
• L=Light
• A=Amplification by
• S=Stimulated
• E=Emission of
• R=Radiation
• Lasers are referred to by the type of active medium (gas,
liquid, solid)
• HeNe: visible red light penetrating 0.8 to 15mm
• GaAs: invisible penetrating up to 2 cm
• Energy is introduced into the active medium
• An orbiting electron briefly elevates into a higher or ‘excited’
state
• The electron spontaneously returns and releases another
photon

41. TherapeuticEffects
• Lasers alter cell membrane permeability and increase in
fibroblast, lymphocyte, and macrophage activity occurs
• Blood and lymph improve to promote the growth of
granulation tissue
• Increase collagen and tensile strength of healing wounds
• Decrease acute and chronic pain
• Reduce the rate and velocity of sensory nerve impulses
May enhance fracture healing and bone remodeling by
increasing capillary formation, calcium deposition, increase
callus formation, and reducing hematomas
Photons striking the tissue create acoustic waves that affect
bone healing similar to ultrasonic bone growth stimulators

43. Uses
• MUSCULOSKELETAL(Tendonitis,bursitis,
capsulitis,tenosynovitis)
• PAIN
• ARTHRITIS
• CONTRACTURE
• MUSCLE RELAXATION
• C/C INFLMN

44. PHYSIOLOGICALCONSIDERATIONS
REBOUND Phenomenon:
• 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

45. CRYOTHERAPY

46. What is Cryotherapy
• Cryotherapy is the local or general use of low temperatures in
medical therapy.
• Cryotherapy is widely used to relieve muscle pain, sprains
and swelling either via soft tissue damage or postoperative
swelling.
• Used in first aid treatment of trauma to the musculoskeletal
system
• When applied intermittently w/ compression, rest and elevation
it reduces many adverse conditions related to inflammation and
the reactive phase of an acute injury
• RICE (rest, ice compression, elevation) may be used for the
initial days of and injury and continue up to 2 weeks after
injury

47. • The major therapeutic value of cold is its ability to produce
anesthesia, allowing pain-free exercise.
• Wet ice is a more effective coolant because of the extent of
internal energy needed to melt the ice.
• Hunting Response : Causes a slight temperature increase
during cooling. The extent of cooling depends on the thickness
of the subcutaneous fat layer.
• Relies on conduction -- degree of cooling depends on the
medium, length of exposure and conductivity
• At a temperature of 38.3oF, muscle temperature can be reduced
as deep as 4cm
• Tissue w/ a high water content is an excellent conductor

48. PHYSIOLOGICEFFECTSOF CRYOPTHERAPY
• HEMODYNAMIC
Immediate cutn. Vasocon & delayed reactive vasodiln
DECREASE….a/c inflmn
• NEUROMUSCULAR
NERVE FIBER FIRING RATES
NCV slowing; Condn block & axonal degrneration
DECREASE,,muscle fatigue,stretch reflex,spasticity
INCREASE..Isometric strength
• JOINT & CON. TISSUE
DECREASE…tendon extensibility, collagenase activity
INCREASE…joint stiffness
• OTHER…decrease pain, relaxation

49. CRYOTHERAPEUTICMODALITIES
TYPES
• COLD PACKS
• ICE MASSAGE
• COLD WATER
IMMERSION
• CRYOTHERAPY
• VAPOCOOLANT
SPRAY
• WHIRLPOOL BATHS
MECH.OF TRANSFER
• CONDUCTION
• CONDUCTION
• CONDUCTION
• CONDUCTION
• EVAPORATION
• CONVECTION

50. • COLD PACKS…Hydrocollator,Endothermic gel,
Cold packs
20-30min applictn…2cm depth cooled by 50C
Temp….-12 0C
• ICE MASSAGE…5-10 MIN PER SITE
• COLD WATER IMMERSION…in minor burns
• CRYOTHERAPY-COMPRESSION UNITS…
Temp 7.20C & pressure 60mmHg
• VAPOCOOLANT SPRAY-FLUORI-METHANE
Myofascial & MSK pain
Along with passive stretching

51. IceMassage
Duration: 10 to 15
minutes
Indications:
• small muscle areas
• subacute injury
• subacute inflammation
• muscle strain
• Contusions
• acute pain
• chronic pain

52. Cold or Ice Water Immersion

53. Equipment
• Variety of basins or containers can be used, small whirlpool
• Temperature should be 50-60 degrees F
• Circumferential cooling of a body part
Application
• Athlete immerse body part in water and goes through four
stages of cold response
• Treatment may last 10-15 minutes
• Once numb body part can be removed from immersion and
ROM exercise can be performed
• As pain returns re-immersion should take place
• Cycle can be repeated 3 times

54. Indications:
• Distal body parts
• Acute injury
• Acute inflammation
• Acute pain
• Chronic pain post-
surgical pain
• Post-surgical edema

55. Ice Packs (Bags)
• Equipment
• Wet ice (flaked ice in wet towel)
• Crushed or chipped ice in self sealing bag
• Not as efficient, but less messy
• Useful for approximately 15-20 minutes
• Towel should be placed between skin and pack
• Chemical Cold packs
• Gel pack
• Liquid pack
• Indications
• Athlete experiences four stages of cooling and then
proceeds with ROM exercises
• Special Considerations
• Avoid excessive cold exposure; w/ any indication of
allergy or abnormal pain, treatment should be stopped

56. Vasocoolant Sprays
• Equipment
• Fluori-methane, non-flammable substance that is
released in fine spray from pressurized canister
• Indications
• Reduces muscle spasm, increases ROM, effective on
trigger point
• Application
• For spasm and ROM
• Hold can 12-18 inches from skin, treat entire length of
muscle - covering an area 4 inches/second
• Apply spray 2-3 times, while gradually applying a
stretch

58. 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

59. HYDROTHERAPY

60. 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

61. PHYSIOLOGICALPROPERTIESOF
HYDROTHERAPY
• 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

62. CLINICAL USES OF HYDROTHERAPY
• Superficial Heating and Cooling
• Advantages
• Even contact with skin
• Does not need to be fastened
• Allows movement of heat/cold
• Disadvantages
• Extremity often in dependent position
Wound Care
• Cleansing properties facilitate
• Rehydration
• Softening and debridement of necrotic tissue
• Removal of wound debris
• Hydrostatic pressure and heat increase circulation
• Provides moist environment to optimize healing

63. • Pain Control
• Increased sensory stimulation to peripheral
mechanoreceptors
• Gait Theory
• Cold water decreases inflammation
• Decreases weight-bearing, increases “ease of movement”.

64. HYDROTHERAPYMODALITIES
WHIRLPOOL BATHS HUBBARD TANK

65. CONTRASTBATH
• One unit holding hot water at 105-110 degrees F ( for
example a whirlpool)
• One unit holding cold water at 50-65 degrees F ( for
example a bucket can be used)
• The goal to alternating hot and cold is to increase local
circulation to the treated limb
• Vasodilation from hot water and Vasoconstriction from
the cold water accomplishes this.
• The limb is first placed in the warm water for 5 minutes
• Then is alternated to the cold water for 1 minute
• Hot to cold is 1 cycle, after first cycle use 4 minutes in
hot and 1 minute in cold
• Repeat 4/1 cycle for up to 30 minutes