PDF Physical Medicine Treatments for Low Back Pain

Physical Medicine Treatment Series…. Low Back Pain Author: Dr. Iarz, ND, RMT  Learning Objectives Identify physical medicine treatments for lower back pain Understand the physiological concepts behind physical medicine treatments View demonstration of s...

Physical Medicine Treatment Series…. Low Back Pain Author: Dr. Iarz, ND, RMT  Learning Objectives Identify physical medicine treatments for lower back pain Understand the physiological concepts behind physical medicine treatments View demonstration of selected physical medicine treatments for lower back pain  Treatments that will be covered Ischemic Compression (Trigger point therapy) Cross-Fibre Frictions PNF - Contract-Relax Method Active Muscle Release (Hypertonic Muscle) What is a Myofascial Trigger Point Can be described as a spot within a hypertonic band of skeletal muscle, usually around the muscle belly, that is hyper-irritable. Although they can occur in other structures such as; ligaments, joint capsules, fascia This spot can be tender and can exhibit a predictable pain referral pattern This spot will also cause a shortening of the muscle, making it more hypertonic and less functional Clinical Massage Therapy: Page 205  Causes of Myofascial Trigger Points That is hard to say. The physiological mechanisms have never really been fully understood. Some believe these “trigger points” form due to damaged muscles fibres from trauma, that begin to contract and hold that contraction. Instead of calcium being reabsorbed and the muscle contraction releasing, a damaged sarcoplasmic reticulum would let calcium spill onto the affected sarcomeres, causing them to have a sustained, yet uncontrolled contraction. This can be a partial explanation, since eventually the calcium would have to be absorbed  Clinical Massage Therapy: Page 46  MYOFASCIAL TRIGGER POINTS What is known is that Trigger points locations show an increase in metabolism and yet a decrease in circulation Possibly the body is trying to contain the uncontrolled contraction or metabolic processes.  TYPES OF TRIGGER POINTS Active Trigger Points Latent Trigger Points Primary Trigger Points Secondary Trigger Points Satellite Trigger Points We won’t go into the definition of these types, since the point of this lecture is to show you the treatment for a trigger point.  HOW DOES ISCHEMIC COMPRESSION WORK? Through the compression of a “trigger point”, a temporary local ischemia was created and with the long awaited release, a FLUSHING effect is created and the metabolites that cause nerve irritation are removed. This breaks the pain cycle and thus the hypertonicity and spasms diminish. Slowly breaking down the “trigger point”  ISCHEMIC COMPRESSION METHODS Static Compression This is where the practitioner applies gentle focused pressure to the identified trigger point either with their thumb or elbow. The pressure is increased until the patient reaches a pain of 7/10. This is then held there, while the patient is told to focus on their breathing (In through the nose and out through the mouth) Pressure is held for 30-120 seconds. Patient should report pain is diminishing to about a 2-3 before releasing pressure. ***Caution - DO NOT HOLD LONGER THAN 120 Seconds. A reaggravation might occur.  ISCHEMIC COMPRESSION METHODS Intermittent Method This is where the practitioner applies gentle focused pressure to the identified trigger point either with their thumb or elbow. The pressure is increased until the patient reaches a pain of 7/10. This is then held there for 10 seconds, while the patient is told to focus on their breathing (In through the nose and out through the mouth) After 10 seconds, release pressure, and wait 5-10 seconds. Then apply gentle focused pressure again to reach a 7/10 pain threshold. Again the patient is instructed to focus on their breathing and this is held for 10 seconds Repeat 1 more time for a total of 3 (10 second) sessions.  ISCHEMIC COMPRESSION Clinical Massage Therapy: Pg 450 CROSS-FIBRE FRICTION This technique is employed to disrupt and breakdown and forming adhesions in muscles, tendons, and ligaments This method is not used in Acute injury, but more the late sub-acute to chronic stages. Adhesions and scar tissue forming in acute injury is needed to aid in healing the tissue. We do not want to disrupt that. This is also a painful technique, so if there is any signs of swelling or edema, please do not use it. Keep in mind the stages of healing and the presentation of the injury WHY DOES IT WORK: CROSS- FIBRE FRICTION The purpose is to help the stages of healing and increase ROM by breaking down adhesions that are preventing normal motion of the joint or muscle. These adhesions are found within muscle fibres or between ligaments and tendons. Breaking these down will help to form smaller adhesions. With multiple treatments, these smaller adhesion are thought to be component of scar tissue formation and thus they start to be realigned and scar tissue is diminished. Additional effects: minor inflammation, resulting in histamine and bradykinin release which will cause local vasodilation and thus blood flow to accelerate healing.  CROSS-FIBRE TECHNIQUE During the technique, the therapist does not use lotion or oils. If any is on the patient, please remove before employing the technique The goal is to use a thumb or tool to help move superficial tissue over the deeper tissue The direction of the technique is in the OPPOSITE direction of the fibres being worked on. Hence, cross-fibre. Since this is painful, only perform the technique for 1-2 minutes. The goal is to feel the scar tissue breaking down as well as to get the skin to show petechia. In the end, this will bruise the patient and will leave them sore. Being such an aggressive treatment, it is best to only perform it 1-2 times per week with at least 5-7 days in between treatments.  CROSS-FIBRE TECHNIQUE 1. To start, please warm up the intended area with massage (10 min) 2. Begin friction, is a cross fibre direction, without any cream or lotion 3. Continue for about 1-2 minutes. Trying to breakdown that tissue 4. When done, flush the area with massage technique (effleurage) 5. Stretch the affected area (holding for 10-30 seconds) 6. Apply Cold to the area for 5-10 min Clinical Massage Therapy: Pg 441 PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION (PNF) A stretching technique that is technically an active inhibition technique With this approach, the hypertonic muscle is reflexively inhibited and thus relaxes so that it can be lengthened There are about 4 different PNF techniques or approaches. We will be discussing the CONTRACT- RELAX technique  (PNF) CONTRACT-RELAX TECHNIQUE The practitioner identifies the hypertonic muscle, in this example we will use the Hamstrings. A tight hamstring can affect the overall pelvic angle and thus cause low back pain The practitioner begins to stretch the hamstrings in a comfortable and painfree manner. Once a good amount of resistance is felt, the practitioner holds that for about 10 seconds while the patient relaxes The practitioner then asks the patient to CONCENTRICALLY (Shortening) contract the muscle with a maximum strength. But do not over power the practitioner and the practitioner must only allow minimal movement. This is held for 10 seconds. The patient relaxes and the stretch is pushed further then before. Hold for 10 seconds, and repeat the process again for a 2nd and then 3rd time. On the 3rd time, the stretch is held for 30 seconds This should NOT CAUSE PAIN Clinical Massage Therapy: Pg 61 ACTIVE MUSCLE RELEASE A soft tissue method, where the focus is similar to friction due to the fact that we are focusing on an adhesions and hypertonic muscles. With the release of adhesions within muscles, which are formed from overloading the muscles through repetitive use, muscle tension is released and thus pain or compression type pain is relieved.  ACTIVE MUSCLE RELEASE FYI’S This technique is used in the CHRONIC Stage. It is painful and relieving at the same time The technique is implemented for about 1-2 minutes and is based on patient tolerance to the pain. Please do not cause pain that is too much for the patient, as this may further injury them. Again keep in mind the stages of healing, if there is any swelling please refrain from using this technique Patient “may” bruise. The purpose is NOT to bruise them.  ACTIVE MUSCLE RELEASE TECHNIQUE The practitioner identifies an area of hypertonicity where an adhesion can be located In that area, the practitioner applies a deep tension causing tenderness and pain, that should not exceed a 7/10 on a pain scale. Aim closer to a 4-5. With pressure maintained, the practitioner takes the muscle through a stretching, going as far into the stretch as possible. This will cause an increase in pain but will be working to releasing that adhesion. This is repeated, slowly, for about 1-2 minutes.  Active Muscle Release Example Clinical Massage Therapy: Pg 78 TREATMENT VIDEO  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