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Steven D. Feinberg, M.D.
Clinical Associate Professor
Stanford University School of Medicine
V



v Many PMR approaches

v Traditionally minimally invasive
v Useful alone & in combination with other
approaches
„
 V
  V

v RICE - is commonly invoked as the

appropriate immediate response to injury
v Rest
v Ice
v Compression
v Elevation
  

v For chronic pain states, the physical

modalities are more often used as adjuncts to
pain treatment approaches
 „  



v Thermal
v Electrotherapy
v Physical modalities
v Manual therapies
v Therapeutic exercises
v Aerobic conditioning
v Functional restoration approaches
2 2 

v A number of thermal modalities that produce

pain relief directly and indirectly
v These include
various cold applications
and heat in the forms of radiant heat, ultrasound,
shortwave diathermy, microwave and laser
2 2 

v All of these modalities may work indirectly

and through a counterirritant effect or directly
through effects on peripheral nerves and free
nerve endings
v Cold therapy tends to be used acutely to
reduce swelling and pain of acute injury and
inflammation
v Whereas heat is utilized after the acute injury
phase has subsided and for more chronic
conditions
2 
 V 



v More focused on the direct effects, but the

indirect effects can be quite therapeutic
v Heat and cold application to the skin of the
abdominal wall have a profound effect on
pain resulting from spasm of the smooth
muscle in the GI tract or uterus
There is a reduction in peristalsis and stomach
acid production with heat and an increase with
cold application
Menstrual cramps are relieved with lower
abdominal heat application
Y

v Physiologic effects that produce pain relief

direct results of the temp elevation on the tissue
and cellular functions
and through a reflex reaction
v Heat reduces pain & muscle spasm while
decreasing joint stiffness and contractures
v Produces hyperemia, speeds metabolic
processes & hematoma resolution
v Heat is useful for bursitis and tenosynovitis
along with superficial thrombophlebitis
v Causes an induction of reflex vasodilatation
 
 
 Y

v The major factors determining the number

and intensity of the physiological reactions to
heat are:
Level of tissue temperature: therapeutic range is
narrow: 43o C [109.4o F] to 45o C [113o F]
Duration of tissue temperature elevation [5 to 30
minutes]
Rate of temperature rise in tissues
Size of the area treated
?  Y

v While the physical properties differ, none of

these agents are able to overcome the
combination of skin tolerance, tissue thermal
conductivity, and the body's response to
produce localized temperature elevations of
more than a few degrees at depths of a few
centimeters
v Conduction, Conversion & Convection
 
  Y


v Hot (hydrocollator) packs

Clinically useful temperature for 30 minutes
Advantages include low cost, minimal
maintenance, long life, patient acceptance, and
ease of use
Alternatives include electric heating pads, gel
pads, hot water bottles, and circulating water
heating pads
Exposure time: 20 minutes
 
   


v Paraffin baths
Mineral oil and paraffin (1:7)
Temperatures of 52o C to 54o C are well tolerated
because the mixture has a low heat capacity and
an insulating layer of wax builds up on the treated
area
Dip method versus continuous immersion
Contraindications: open wounds, skin infections,
inadequate circulation, sensory loss
   Y
 

v Heat Lamps
Inexpensive
Versatile
An easy way to warm superficial tissues
250-watt bulb, 40 to 50 cm from the patient
 
  Y
 

v Hydrotherapy
Whirlpool baths & Hubbard tanks
Pumps agitate water and provide convective
heating, massage, and gentle debridement
Temps: 33o C to 36o C are considered neutral
Hubbard tank temps limited to 39o C
Single extremity treatments can be more rigorous
and in a healthy individual temperatures from 43o
C to 46o C are possible
 
  Y
 

Used for burn and wound treatment at neutral

temperatures
Hydrotherapy can be effective for mobilization of
joints, as an adjunct in the treatment of
rheumatoid arthritis, and for muscle spasm
Hydrotherapy allows exercise of painful joints with
reduced stress because water buoyancy reduces
the gravitational forces
Caution should be exercised with full submersion
as body temperature may rise
 
  




v Alternating immersion in hot and cold water

to produce a vascular exercise through active
vasodilatation and vasoconstriction of the
blood vessels
v Hot/cold ratios are used depending on patient
tolerance; typically ratio is 4:1
v Thought to be effective due to reflex
hyperemia produced by the alternating
exposure to heat (43o C) and cold (16o C)
 Y



v Ultrasound
v Short wave Diathermy
v Microwave
v Laser (non-surgical)
þ
 

v Arbitrarily defined as sound at frequencies

above the limits of human hearing (i.e., more
than 20,000 Hz)
v Ultrasound machines use ceramic and quartz
piezoelectric crystals to produce ultrasonic
energy
v Intensities of 0.5-2.0 Watts/cm2 are used
v Frequencies of 1 MHz (deep) or 3 MHz
(superficial)
þ
 

v Pulsed versus Continuous

v Treatment time 5-10 minutes
v Deep-seated joints and fibrous scars with soft
tissue are selectively heated by ultrasound as
are myofascial interfaces, tendon and tendon
sheath & nerve trunks
v Useful for painful amputation neuromas
v Phonophoresis includes the addition of a
steroid which is forced into the tissue to
potentiate treatment effectiveness
þ
 

v Precautions and contraindications include:

fluid-filled cavities
joint replacements containing cement/plastics
open epiphyseal plates
Cancer
the eyes, brain & testicles should be avoided
should not be used over a pregnant uterus
v Pain is used as an endpoint to avoid tissue
destruction
?
! 


v Radio waves are used to heat superficial

tissue by conversion with induction coil
applicators or condenser pads
v Most commonly used frequency: 27.12 MHz
v Treatment time: 20-30 minutes
?
! 


v Pelvic organs are selectively heated using

internal vaginal and rectal electrodes and can
be useful in pelvic inflammatory disease
v Avoid over metal implants (including
intrauterine devices) and electronic devices
such as cardiac pacemakers, spinal
stimulators, etc.
v Should not be used with a pregnant patient or
operator
"

v Electromagnetic radiation at frequencies of

915 and 2456 MHz
v Treatment time: 20-30 minutes
v Avoid near sensitive organs such as the
eyes, testicles, brain, etc.
v Precaution over bony prominences due to
reflection of the wave at the bone interface
may produce increased heat absorption in
the tissues superficial to the bone
  #  $

v A collimated (parallel waves of light) beam of

photons of the same frequency with the
waves in phase of lower level intensities
v Helium-neon, gallium-arsenide, etc.
v Usefulness anecdotal
v Utility unestablished
Y
V 
 

v Pain
v Muscle spasm
v Decreases joint stiffness and contractures
v Myofascial pain and Fibromyalgia
v Production of hyperemia
v Acceleration of metabolic processes
v Hematoma resolution
v Bursitis and tenosynovitis
v Superficial thrombophlebitis
v Induction of reflex vasodilatation
Y

 
 %
 

v Acute inflammation, abscess, trauma, edema

or hemorrhage
v Bleeding disorders
v Insensitivity
v Inability to communicate or respond
v Poor thermal regulation
v Areas of malignancy
v Ischemia (Inadequate blood supply)
v Atrophic skin & Scar tissue
?    
 

v Reduces blood flow

v Decreases metabolic activity
v Lessens muscle tone and spasm
v Decreases swelling
v Inhibits spasticity and clonus
v Increases gastrointestinal motility
v Slows nerve conduction
v Produces analgesia

 

v Restricted to superficial agents that are

inexpensive, but effective including:
ice, cold water, refrigerated units, vaporizing
liquids (Vapo-Coolant spray), and chemical packs
v Chilling causes an initial period of
vasoconstriction until subcutaneous tissues
reach 15o C

 

v Thereafter, vasodilatation occurs, however

vessels are still constricted compared to
normal
v Temperatures to 13 -15o C for 10 to 20
minutes are used
v Cold should be provided just long enough to
prevent swelling and bleeding but prolonged
use should be avoided as cold can retard
healing
 V 
 

v Musculoskeletal trauma
v Edema/hemorrhage control & analgesia
v Pain
v Muscle spasm
v Spasticity
v Adjunct in muscle re-education
v Reduction in metabolic activity
 
 
   
 

v Ischemia
v Cold intolerance/hypersensitivity
v Raynaud's
v Severe cold pressor responses
v Cold allergy
v Insensitivity


 
v Transcutaneous electrical stimulation and
interferential therapy are the two most
common forms of electrical stimulation used
for pain modulation
v By varying parameters such as frequency,
waveform, pulse duration, electrode
configuration, and duration of stimulus, a
range of therapeutic effects is possible
v Both types of electrotherapy are thought to
have similar actions through segmental
inhibition or activation of descending pain-
inhibitory systems


 

v Contraindications include pacemakers,

myocardial disease, superficial metal
implants and over pharyngeal or laryngeal
muscles
v There are many other forms of electrical
stimulation including, H-Wave, diadynamic
current and various E-Stim devices
v None of these devices have been proven
effective nor is there any evidence for a
difference in outcome between different
electrical stimulation forms
 

v General Indications
Pain Modulation: TENS, Interferential, H-wave
Muscle Spasm: Produces muscle fatigue &
relaxation
Spasticity: Fatigue of the agonist, reciprocal
inhibition
Impaired Range of Motion: Used for mechanical
stretching
Muscle Re-education: Training muscles to
respond appropriately to volitional effort
Disuse Atrophy & Strengthening: Does not
strengthen normal muscles more rapidly than
traditional approaches
 

Wound healing & Edema Reduction

For immobilized and injured muscles, electrical
stimulation maintains isometric strength and when
there is splinting and pain, it may supplement
volitional movements and speed of recovery
Functional Electrical Stimulation (FES): In the
upper motor neuron spinal cord injured patient,
may increase strength, normalize blood pressure,
allow for limited ambulation and lead to a sense of
well-being
FES also used for shoulder subluxation and
dorsiflexion assist in gait training.
 
 #2&?$
v A TENS unit produces analgesia in a wide
range of medical conditions
v It is used in a self-administered setting after
patient receives proper instructions
v TENS units are non-invasive, easy to use,
safe and inexpensive
v TENS units are small simple devices
consisting of a power source (rechargeable
battery), one or more signal generators and a
set of electrodes
 
 #2&?$
v Electrode placement and stimulation
parameter remain more art than science
v High frequency (or conventional) TENS
typically results in immediate pain relief that
lasts while the stimulus is on, but usually
abates when the stimulation stops
v In acupuncture-like (or low frequency) TENS,
the high stimulus intensity is painful and
many patients cannot tolerate it but the
benefit is longer lasting pain relief
 !"#

v Interferential therapy involves a different form

of electrical stimulation than TENS, although
the physiologic and therapeutic effects are
similar in both
v Interferential is based on the principle that the
interference between two medium frequency
(KHz) currents produces a low frequency
current that will be induced in the deep
tissues
 !"#

v Therefore, interferential therapy allows

effective stimulation of deep tissues whereas
TENS is predominantly a cutaneous or
superficial stimulus
v Unlike the TENS unit, interferential
treatments are usually provided directly by a
physical therapist
v Treatments involve the use of two pairs of
electrodes and most units allow variation in
waveform, stimulus frequency and amplitude
or intensity
 $%!"#

v The manufacturer lists H-Wave therapy as a

powered muscle stimulator that at low
frequency produces comfortable, rhythmic,
non-fatiguing muscle contractions that
increase local blood flow and lymphatic
drainage
v At high frequency, H-Wave therapy is
purported to break the pain cycle similar to
conventional TENS
V
 

v A process in which a continuous direct

current is used to drive electrically charged
molecules or atoms (ions) into the tissues
v Iontophoresis delivers high concentrates of
polar substances, or medicinal agents, into
the skin, but to questionable depths
v The amount of medicine transferred through
the skin is directly related to the duration of
treatment, current density, and concentration
of the ions in the solution
V
 

v Indications for iontophoresis include

musculoskeletal inflammatory conditions,
such as bursitis, and pain relief
v Common medications include
dexamethasone, lidocaine and
hydrocortisone
v Contraindications include impaired skin
sensation, broken skin or bruises, and metal
in or near the treatment area
Ë'


v Vibration is used for muscle facilitation and

re-education and for acute and chronic pain
conditions
'

v Biofeedback is used to measure motor unit

action potentials (MUAP)
v The signals are detected, amplified and
converted into audiovisual signals that are
used to reinforce voluntary control
v The biofeedback signals, along with the
patient's voluntary effort, are used to either
increase or decrease muscle activity
v Biofeedback has been successfully used for
headaches and muscle tension
2
 „ 
 2 (

v Manual
v Mechanical
Free weights, pulley system
v Motorized
Continuous
Intermittent
v Gravity
2
 


v Cervical (25-30 pounds)

Sitting versus supine
20-30 degrees flexion
v Lumbar (50-100 pounds)
Prone versus gravity inversion
45-90 degrees hip flexion
v Continuous versus intermittent
v Duration
5-10 minutes herniated disc
10-30 minutes other conditions
2
 V 
 

v Degenerative disc disease

v Discogenic pain
v Herniated nucleus pulposus
v Radiculopathy
v Subacute or chronic joint pain
2
 )

v Inadequate weight
v Poor positioning
v Stretching of pain sensitive tissues
2
 
 
 

v Spine instability, tumors/infections

v Vertebrobasilar disease - poor positioning
v Signs of myelopathy
v Significant osteopenia
v Lumbar traction in pregnant women
v Spondylolisthesis
v Extreme anxiety
v Restrictive lung disease
v Rheumatoid Arthritis
 

v Elevation
v String wrapping
v Ace wraps
v Garments
v Gradient pumps
v Physical activity and use
`



v Spine braces, corsets, collars, & supports

v Upper extremity slings, braces (dynamic and
passive), bands, supports
v Lower extremity braces, orthotics/braces
v Cushioning devices and pads
v Shoes, lifts & inserts
v Splints
Static & Dynamic
v Mobility aids
Canes, crutches, walkers, wheelchairs, scooters
2 
 *

v Major factor in achieving long-term benefits in

the treatment of chronic pain
v Patient may have had long period of
decreased activity, weak muscles and
contracted joints, which contribute to pain
v Exercise can decrease the pain cycle while
improving cardiac and whole body
conditioning
2 
 * `'



v Decrease pain
v Improve mobility
v Strengthen weak muscles
v Increase flexibility
v Decrease mechanical stress
v Improve posture
v Stabilize hypermobile joints
v Improve fitness to prevent future injury
2 
 *

v Aerobic exercise can slow the decrease of

functional capacity in the elderly and
recondition those that have been ill or have
chronic disease
v Exercise may have a direct effect on pain
management as evidence suggests that
exercise can activate endogenous pain
modulation systems
2 
 *

v A therapeutic home exercise program should

be started early as part as the patient's
overall therapy program
v Initially, if the symptoms are acute, an
exercise program may only include posture
and body mechanics, positioning and basic
stretching
v As the symptoms decrease the program
should progress to more aggressive ROM,
strengthening and functional activities
2 
 *

v In the case of a chronic pain, the exercise

program should begin slowly due to
deconditioning and pain compensations
v A home exercise program gives the patient a
sense of control over his or her therapy and
progress
v Emphasis should be placed on the benefits
and the lifestyle changes that must be made
to incorporate a routine exercise program
throughout life
„(
 2 

v Buoyancy allows aerobic exercise, range of

motion and weight bearing that would not be
possible out of water
v Water can be soothing and relaxing and
particularly helpful to an anxious and fearful
patient
v Short-term individual treatment should be
followed by group classes and thereafter
should be carried out independently
„(
 2 

v Therapy in warm water is beneficial for

diagnoses such as:
Fibromyalgia
Myofascial Pain Syndrome
Rheumatoid Arthritis
v Therapy in cool water is recommended for
heat sensitive disorders such as multiple
sclerosis
  ` 
  2 

v The therapist is a trained professional who

should be recognized as a team member
v Communication between physician and
therapist is key to achieving a successful
outcome for the chronic pain patient
v The therapist sees the patient much more
frequently than the physician and may be
able to provide important insights into both
physical and psychosocial factors affecting
the patient's presentation
2  


v The therapy prescription should include a

general order to evaluate and treat plus any
limitations or specifics requested by the
physician
v The prescription should include the
diagnosis, frequency and length of
recommended treatment and most
importantly, any precautions or
contraindications
) 
  `
 2 

v Therapy should be active and not passive

v Modalities may be useful early on but in
general should be discouraged in favor of
therapy that is functionally oriented and
supports patient independence
v The patient must be encouraged to take
control of their therapy program and become
an active participant
v Patient's participation in an exercise program
is an important aspect of therapy
   

v Manual therapy refers to specific skills by the

therapist in muscle, joint and somatic
dysfunction
v As with any discipline, some therapists have
exceptional skills in this area
v Manual therapy is best utilized as an
integrated part of a comprehensive treatment
program


v Reflex Effects
Stimulation of peripheral receptors in the skin
produce centrally mediated sensations of pleasure
and peripherally cause muscle relaxation
v Mechanical Effects
Consists of measures to assist return flow
circulation of blood and lymph and measures that
produce intramuscular motion to stretch
adhesions and mobilize fluid accumulation


v Techniques
Includes stroking (effleurage), compression
(pétrissage), friction/deep massage and
percussion/clapping (tapotement)
v Indications
Include any condition in which relief of pain,
reduction of swelling, or mobilizing of contracted
tissue is desired
v Contraindications
Include infections, thrombophlebitis, malignancies,
burns, and in skin diseases
   ?

 

v Myofascial release involves active or

voluntary muscle contraction along with
passive massage
v A highly interactive stretching technique that
requires feedback from the patient's body to
determine the direction, force and duration of
the stretch and to facilitate maximum
relaxation of the tight or restricted tissues
`
 ?

  2 (

v Progressive stretch mobilization

v Sustained progressive stretch
v Spray and stretch
v Muscle energy
v Strain-Counterstrain
v Rolfing
'


v Mobilization includes those manual

procedures which attempt to increase joint
range of motion beyond the resistance barrier
which limits passive range of motion or
exercise
v May involve either an accessory glide of the
joint or a physiologic movement of the joint
'


v Rhythmic repetitions with minimal force may

provide pain relief
v Differs from manipulation or adjustment by
the absence of a forceful thrust or jerking
movement
v Maitland's grades of mobilization: Grade I -
Grade IV
  


v Thrusting techniques: Application of a high-

velocity, low-amplitude thrust to a joint
v Forces the joint beyond the physiologic range
of movement to the anatomical limits of
motion
v Contraindications: osteoporosis, acute
inflammation, infection, tumor, structural
instability, Vertebrobasilar insufficiency
 

v Ergonomics is the study of how people

interact with their physical environment, and
modifications to prevent/reduce
musculoskeletal disorders
v The ergonomic system model consists of four
parts; the task, the operator, the environment
and the equipment
v The objective is to maximize system
performance while minimizing mismatches
between system elements
 

v Basic ergonomic principles include keeping

the wrists straight and the elbows down,
minimizing spine twisting and bending and
providing adjustable chairs and/or work
surfaces
v Ergonomic redesign requirements include
reduction of forces, frequency of activities,
holding time, prolonged static posturing and
extreme postural deviations
) 
  

 „ 

v Structured group physical conditioning

v Regular sessions of stretching, strengthening
,aerobic conditioning plus educational
activities & work simulation
v Dependency on the therapist is discouraged
and the program is geared towards healthy
behaviors and return to leisure and work
activities
v The group setting provides friendship and
encourages mutual support
! Y     
  

v Work hardening involves specific simulated work

activities prior to returning to employment
v Work toughening or conditioning where the
individual exercises in a gym is not work hardening
v While work hardening may include gym exercise
activities, the program is task specific for the
particular job and involves both emotional and
physical reactivation to meet job demands
    

v Multidisciplinary, coordinated pain

management is based on viewing chronic
pain treatment from a biopsychosocial model
rather than from a traditional biomedical
treatment approach
v The goal is to assist the individual in
managing pain and returning to a functional
lifestyle including re-engaging in personal
and work activities
    

v The biomedical model focuses on "fixing"

physical pathology and curing the pain
through various interventions
v The biopsychosocial model of pain
management acknowledges the role of
physical pathology while realizing that
psychological, social and cultural issues play
a major role in how individuals perceive and
react to painful stimuli
  +

v Reducing the misuse of medications and

excessive invasive medical procedures
v Maximizing & maintaining physical activity
and returning the individual to productive
activity at home, socially and/or at work
v Increasing the patient¶s ability to manage
pain and related problems while reducing
subjective pain intensity
v Strong emphasis is placed on increasing the
level of function and ability to manage pain
and related problems, even without reduction
of subjective pain intensity
  


v Medication management
v Physical and Occupational therapy
v Behavioral-psychological therapy
v Vocational and disability management
v Adjunctive treatment modalities such as
trigger point injections, nerve blocks and
various invasive interventions
)
 

v Supervised low-cost gym program at the

physical therapy center
This program is ideal as the patient can be
weaned early from one-on-one physical therapy to
independent use of the gym facility
Less costly, yet the patient is still in a protected
and supervised environment
v Private gym or fitness center
To prevent re-injury, patients should not start such
a program without specific directions from the
physician or physical therapist
Ë
  '



v For chronic pain patients who have return to

gainful employment as a reasonable goal,
vocational rehabilitation efforts should be an
integral part of pain management and such
efforts should start early in the rehabilitation
process
v Resources such as Workers' Compensation
or State Vocational Rehabilitation Services
should be identified
Ë
  '



v Employers should be encouraged to make

reasonable accommodations and consider
return to work for the patient in modified
and/or part time positions
v Volunteer activities allow many individuals to
have meaningful interactions with other
people, stay busy, get out of the home, and
make a worthwhile social contribution
„
   
  V

v Recreational activities can be pleasurable,

time filling, socially reinforcing as well as both
physically and mentally therapeutic
 +    

v Do no harm
v Biopsychosocial model
v Diagnose and then treat
v Cost-effective care
v Pain control
v Appropriate use of assistive devices
v Patient empowerment
v Functional restoration
v Return to work & leisure activities