NMT150 Wk9 Spotlight Physical Medicine PDF

Physical Medicine Treatment Series…. Low Back Pain Part 2 Author: Dr. Iarz, ND, RMT  Video Link https://ccnm.ca.panopto.com/Panopto/Pages/View er.aspx?id=f3c3c432-b12d-4ce4-af92-afbb013608f7  Learning Objectives Understand th...

Physical Medicine Treatment Series…. Low Back Pain Part 2 Author: Dr. Iarz, ND, RMT  Video Link https://ccnm.ca.panopto.com/Panopto/Pages/View er.aspx?id=f3c3c432-b12d-4ce4-af92-afbb013608f7  Learning Objectives Understand the steps taken for an assessment Identify physical medicine treatments for lower back pain Understand how physical medicine treatment modalities work and why they are used  Treatments that will be covered Interferential Current Ultrasound Laser Manipulation (Grade 5 Mobilization)  Case M.L , a 43yo Male, came into your clinic last week with a chief complaint of sharp pain in his low back and right gluteal area that does NOT travels down his right leg. He tells you that his pain is aggravated when he sits for long periods of time, like when he is in the car stuck in traffic. He has noticed pain in his right gluteal area for about 3 months, but it seems to be getting worse. Occupation: office worker Hobbies: Ice hockey on weekends  Extra Information for Case Inspection - No antalgic gait and posture seems normal. Nothing excessive Palpation - Revealed hypertonicity and tenderness over the right gluteal area and lumbar area PROM Of lower back (Flexion, Extension, Lateral Flexion, Rotation) - All completed without pain or restriction PROM Of Hip (Flexion, Extension, Internal/External Rotation, Abduction/Adduction) - Found restriction with internal rotation AROM Of lower back (Flexion, Extension, Lateral Flexion, Rotation) - All completed without pain or restriction AROM Of Hip (Flexion, Extension, Internal/External Rotation, Abduction/Adduction) - Found pain & restriction with external rotation. And the pain is felt specifically in the right gluteal RROM - Same findings as AROM Negative special tests = SLR, WLR, Slump Test, and valsalva , Ober’s Positive Special Tests = Pace, Piriformis Length Test, Piriformis Test, Patrick Faber’s DIAGNOSIS Right Piriformis Syndrome causing possible SI Joint Dysfunction  How to Approach Treatment With a diagnosis of Piriformis Syndrome, we need to understand what is actually happening. Hypertonicity of piriformis due to overuse? If the muscle is tight, what is the consequence of that? Would this tight muscle cause any tears in the muscle belly? Musculotendonous junction? Is there inflammation present? How long has this been going on?  How to Approach Treatment After that has been determined. Now we can get into treatment Interferential Current Tens Ultrasound Laser Manipulation (grade 5 mobilization) WHAT IS IFC AND TENS? A treatment that involves electrical current Giving us a Sensory-Level Response (higher frequencies) Motor-Level Response (lower Frequencies) Used to help relieve pain and relax muscle  FACTORS TO CONSIDER WHEN APPLYING THIS TREATMENT Electrode Setup (never on face, head, or chest) Patients Skin (Sensitive skin, body hair, rashes, etc) Distance between electrodes Further apart gets deeper into tissue Close is superficial Too close and arc might form (Not good) Burning Patient  TENS Transcutaneous Electrical Neuromuscular Stimulation Works with Pain Gate Control Theory Distraction Endorphin release Most commonly used for Controlling Pain in acute stages of injury but can be used in chronic situations Temporary relief but most comfortable compared to IFC Treatment lasts around 20 min TENS  IFC Produced by interfering 2 waveforms that differ in frequency resulting in low to medium frequency 4 pads required Will get deeper into tissues Can improve circulation via muscle pump Can help decrease pain and muscle spasm Can help decrease healing time req. IFC  THERAPEUTIC ULTRASOUND A form of mechanical energy (Sound Waves) that gets from 2-5cm into soft tissue Has thermal and non thermal effects Used for tissues that have a high collagen content (tendons, ligaments, joint capsules, fascia, connective tissue) Bone has a high absorption for it as well, but if set too high, it will strike deep hurting the periosteum. Best to avoid high settings over boney area THERAPEUTIC ULTRASOUND EFFECTS Thermal Effects Can accelerate the metabolic rate/Healing Reduces or controls pain and muscle spasms Can alter nerve conduction velocity Increase circulation Increases soft tissue extensibility THERAPEUTIC ULTRASOUND EFFECTS Non-Thermal Effects Can enhance tissue fluid interchange and mobility Affects diffusion rates and membrane permeability Thus helping with Tissue Repair via immune stimulation Can enhance the appropriate orientation of newly formed collagen fibres and the changes from type 3 to 1 collagen. More tensile strength. THERAPEUTIC ULTRASOUND CONTRAINDICATIONS Malignant Tumor Pregnancy Laminectomy Joint replacement Pacemarker Thrombophlebitis Eyes Reproductive organs ULTRASOUND  LASER Light Amplification by Stimulated Emission of Radiation Can penetrate only a few millimetres but has deeper physiological effects Used to help with Wound Healing (In the tissues, not a cut or surgical wound) Fracture Healing Bone Healing/Reducing inflammation Pain management  LASER THERAPEUTIC EFFECTS Has Cellular Effects Increases ATP Production Stimulates macrophages Stimulates fibroblasts thus increasing collagen production Can alter nerve conduction and regeneration Increases vasodilation (getting rid of cellular debris)  LASER THERAPEUTIC CONTRAINDICATIONS Eyes Malignancy Open Lesions/Skin Wounds LASER MANIPULATION (GRADE 5) A CONTROLLED ACT Used to help joints that are fixated or “Stuck” Allows for better motion of joint If joint moves better than root of problem might be helped - Stuck joint means muscles are not moving properly also Joints are fixed due to hypertonicity of muscles Once joint is mobilized, then muscle relaxation needs to be worked on MANIPULATION (GRADE 5) In this case, a different assessment of his SI joint and Lumbar Spine would be warranted The approach is more of a ROM for the bones in isolation If found to be dysfunctional, which most likely would be the case with hypertonicity throughout the glutes and lumbar area Depending on the findings, it will dictate the manipulation that you perform. The questions are: #1: Is a joint or bone not moving the way it should and as such, is this an issue? #2: Would giving this bone or joint proper movement right now, help or hurt the patient’s condition? MANIPULATION (GRADE 5)  RELATING ALL BACK TO THE CASE What do you think would be the best method of treatment? IFC Tens Ultrasound Laser Manipulation  RELATING ALL BACK TO THE CASE The overall answer is that there is NO perfect way of treatment. Each modality has it’s uses Our job is to make sure we choose the most appropriate treatments that will give the patient maximum benefit  References 1. Hertling, D.; Kessler, R. Management of Common Musculoskeletal Disorders: Physical Therapy Principles and Methods. 4th ed. Philadelphia: Lippincott Williams & Wilkins. 2005. ISBN-10: 0-7817-3626-9 2. Kisner, C., Colby, L. Therapeutic Exercise: Foundations & Techniques. 5th Ed. F.A. Davis,Publishers, 2007. ISBN-10: 0-8036-1584-1 3. Magee, David J. Orthopedic Physical Assessment, 5th Edition, Elsevier 2008,ISBN 978-1-4160-6851-8 4. Rattray, Fiona. & Ludwig, Linda., (2005). Clinical Massage Therapy. Elora, On: Talus Inc. 5. Jurch, Steven E. Clinical Massage Therapy: Assessment and Treatment of Orthopaedic Conditions, 2009, McGraw-Hill