Rehabilitation in

musculoskeletal
dr. Ibrahim Agung, Sp.KFR (K)
Physical Medicine and Rehabilitation Department
Musculoskeletal Division
 Overviews
• Philosophy of physical medicine (PM&R)

• Point of views from PM&R

• Most common problems in musculoskeletal system

• Comprehensive management in musculoskeletal rehabilitation

PHILOSOPHY OF PHYSICAL
MEDICINE (PM&R)
To improve the functional ability of a person in accordance with his
potentials, to maintain or increase the quality of life through optimal
prevention or minimizing impairment, disability, and handicap
 Point Of Views FROM PM&R
• Clinicians using The International Classification of Diseases (ICD) on classifications
for the diagnosis of health conditions
• PMR practitioners using the International Classification of Functioning, Disability
and Health (ICF)
• ICF providing a coherent view of different perspectives of health, NOT ONLY body
function & structures BUT includes activities limitation, participation restriction,
environmental factors, and personal factors
International Classification Function (ICF) International Classification Disease (ICD)-10

M17-Osteoarthritis of knee
M17.0-Bilateral primary osteoarthritis of knee
M17.1-Unilateral primary osteoarthritis of knee
M17.10-Unilateral primary osteoarthritis, unspecified knee
M17.11-Unilateral primary osteoarthritis, right knee
M17.12-Unilateral primary osteoarthritis, left knee
M17.2-Bilateral post-traumatic osteoarthritis of knee
M17.3-Unilateral post-traumatic osteoarthritis of knee
M17.4-Other bilateral secondary osteoarthritis of knee
M17.5-Other unilateral secondary osteoarthritis of knee
M17.9-Osteoarthritis of knee, unspecified
 Musculoskeletal System
• Bones
• Joints
• Ligaments
• Muscles & Tendons
• Bursa
 Conditions of Musculoskeletal Disor-
Acute Compartment Syndrome
ders Chronic Fatigue Syndrome
Ankylosing Spondylitis Chronic Neck Pain
Baker’s Cyst Clavicle Fracture
Boutonniere Deformity of Finger Clubfoot
Bunion Coccydynia
Bursitis Coccyx Fracture
Calcific Tendonitis of The Shoulder Colles’ Fracture
Carpal Tunnel Syndrome Contractures
Cauda Equina Syndrome Costochondritis
Chondromalacia Patella Degenerative Disk Disease
 Conditions of Musculoskeletal Disor-
Dermatomyosis
ders Foot Pain
Dupuytren’s Fracture Forearm Fracture
Fibromyalgia Fracture
Finger Dislocation Frozen Shoulder
Finger Extensor Tendon Injury Ganglion Cyst
Finger Flexor Tendon Injury Gout
Finger Fracture Hammer Toe
Flat Foot Herniated Disc
Floating Shoulder Hip Dislocation
Foot Fracture Hip Fracture
 Conditions of Musculoskeletal Disor-
Hip Labral Tears
ders Pelvic Fracture
Juvenile Rheumatoid Arthritis Pes Cavus
Kyphosis Plantar Fasciitis
Legg-Calve-Perthes Disease Polymyalgia Rheumatica
Lordosis Polymyositis
Low Back Pain Raiter’s Syndrome
Morton’s Neuroma Rhabdomyolysis
Neck Fracture Rheumatoid Arthritis
Osgood-Schlatter Disease Rotator Cuff Injury
Osteoarthritis Sacroiliac Joint Pain
 Conditions of Musculoskeletal Disor-
Sciatica
ders Tendinopathy
Scoliosis Toe Fracture
Sesamoid Fracture Torticollis
Shoulder Tendinopathy Trauma
Skull and Facial Fracture Trigger Finger
Spinal Stenosis Vertebral Fracture
Spondylolisthesis Whiplash
Spondylolysis Wrist Fracture
Temporomandibular Disorder
Types of Musculoskeletal Injuries

Fracture Dislocation Strain Sprain

 Common Signals of Musculoskeletal
Injury
• Pain
• Swelling
• Deformity
• Discoloration of the skin (bruising)
• Inability to use the affected part normally
• Loss of sensation in the affected part.
 Sign and Symptoms of Serious In-
jury
• Deformity
• Swelling and discoloration
• Inability to move the part
• Bone protrusion
• Bones grating/ snap
• Loss of circulation in an extremity
 Most common problems in muscu-
loskeletal
• Fracture
• Degeneration  Osteoarthritis, tendinosis, low back pain
• Injury & sport injury
• Amputation
• Spinal deformity  Scoliosis
 Fractures
Goal of PMR:
1. Early mobilization
2. To prevent disabilities
3. To return to the capacity before the incident
4. Consider Healing Process
 Immobilization PHASE
Main goal : to prevent complications of prolonged immobilization
Pain management
Positioning
Isometric exercises of the Quadriceps, Hamstrings, and Gluteal muscles
Active exercises to the uninvolved extremities and the “crutch walking muscles”
General body mobilization
 mobilization PHASE
• Most important phase of vigorous effort to regain the pre-fracture state, involves :
• Inspection of non-union or infection
• Joint mobilization
• Strength and endurance therapy
• Rehabilitation includes :
• Heat Therapy
• Upper and Lower Extremities Exercises
• Bed Mobilization Exercises
• Mobility aids (crutches or walker ) at week 6-12
• Assistance during change from non-weight bearing
to partial weight bearing mobilization (week 6-12)
• Functional Training
 Osteoarthritis
• Degenerative disease of the entire joint
• Involves all tissues of the joint
• Abnormal balance of breakdown and repair

Braddom. Physical Medicine& Rehabilitation. 5th edition

 Risk Factors of Osteoarthritis
• Older adults • Obesity
• 19% >40 y.o. • Quadriceps muscle weakness
• 20-40% >75 y.o. • Joint biomechanics
• Women > Men • History of injury
• Men < 50 y.o
• Genetic factors
• Women > 50 y.o
• Occupation
• Joint Location  weight bearing joints
• Repetitive joint loading
• High physical demands

CDC (Center for disease Control and Prevention). A national public health agenda for osteoarthritis: 2020 update.
Frontera, W. R. (2012). DeLisa’s physical medicine and rehabilitation: Principles and practice: Fifth edition.
 Clinical Symptoms of Osteoarthritis

• Pain • OA knee changes periarticular structures,

not only joint structure
• Stiffness & Disability
• Most common : PATB & MCL sprain
• Swelling & Tenderness
• Causing pain and biomechanical changes
• Deformity
• Muscle spasm & weakness
• Contracture
• Deconditioning syndrome

Anestherita, F., Agung, I., Nelfidayani. (2021). Periarticular problems in knee OA. Jakarta: RSUPN Cipto Mangun Kusumo.
 Periarticular changes in Osteoarthritis
• Suprapatellar recess effusion
• MCL bulging
• Bursitis pes anserine
• Baker cyst

Anestherita, F., Agung, I., Nelfidayani. (2021). Periarticular problems in knee OA. Jakarta: RSUPN Cipto Mangun Kusumo.
 Periarticular changes in Osteoarthritis
• Suprapatellar recess effusion
• MCL bulging
• Bursitis pes anserine
• Baker cyst

Anestherita, F., Agung, I., Nelfidayani. (2021). Periarticular problems in knee OA. Jakarta: RSUPN Cipto Mangun Kusumo.
 Periarticular changes in Osteoarthritis
• Suprapatellar recess effusion
• MCL bulging
• Bursitis pes anserine
• Baker cyst

Anestherita, F., Agung, I., Nelfidayani. (2021). Periarticular problems in knee OA. Jakarta: RSUPN Cipto Mangun Kusumo.
 Periarticular changes in Osteoarthritis
• Suprapatellar recess effusion
• MCL bulging
• Bursitis pes anserine
• Baker cyst

Baker cyst

Anestherita, F., Agung, I., Nelfidayani. (2021). Periarticular problems in knee OA. Jakarta: RSUPN Cipto Mangun Kusumo.
 Treatment of osteoarthritis
Aim: to improve quality of life and diminish disability

• Pharmacology
• Non pharmacology  Comprehensive REHABILITATION
• Surgery  Arthroplasty
Frontera, W. R. (2012). DeLisa’s physical medicine and rehabilitation: Principles and practice: Fifth edition. 31: 785
 Low back pain
• Most commonly reported musculoskeletal
problem (84%)
• Low back pain is a symptoms  chronic or acute
pain in the lumbar or buttock area, between
costal margin and gluteal folds, or in the upper
leg region  major work-related disorder
• Major problem  disability, poor services,
sickness absences
• Related to  ergonomic stressors at work,
environmental, psychosocial, personal risk factors

Wami et al., Work-related risk factors and the prevalence of low back pain among low wage workers: results from a cross-sectional study. BMC Public Health. 2019. 19:1072
Braddom. Physical Medicine& Rehabilitation. 5th edition
Pain Distribution in Non-spesific Pain Distribution in Radicular
Low Back Pain Pain

L3 L4 L5 S1
Good BODY Posture
Good BODY Posture
 Structures & Biomechanical Changes

Impaired muscle support / weak back muscle  causing pain

Weak back muscles  compensated by quadratus lumborum
muscle  impaired muscle  Low Back Pain (QL Pain)

Sions et al. 2017. Trunk muscle characteristics of the multifidi, erector spinae, psoas, and quadratus lumborum in older adults with and without chronic low back pain. Journal of orthopaedic & sports physical therapy. 47(3):173-179
Asha Satish Barge, Satish Mahadeo Barge. Qudaratus lumborum: one of the many significant causes of low back pain. Indianjpain 2018 32(3): 184-186
 SPORTS INJURY (acl Rupture)
• Most commonly injured knee ligaments in athletics
• Overstretch / Tearing
• Sudden pop with posterior lateral joint line pain, tenderness

Cuccurullo, S. Physical Medicine and Rehabilitation Board Review. 3rd Ed. New York: Demos Medical. 2015
 ACL Rupture Treatment
• Initially partial weight bearing, ice, and compression are used while evaluation is ongoing
• If reconstruction is undertaken :
• Partial weight bearing is maintained initially
• ROM is instituted to regain flexion over the first 2 weeks
• Progress to closed chain kinetics is then undertaken
• Avoid open chain exercises, especially those that are performed near full extension
• Resistive exercises performed between 0° and 45° flexion are avoided during the first 3-6 months
• Lenox Hill derotation orthosis is used to control knee axial rotation as well as anterior–posterior
and medial–lateral control
• Sports-specific exercises may be started in 6 to 12 weeks
• Complete rehabilitation in 6 months to 1 year is the goal with maximum ROM, strength, and
agility

Cuccurullo, S. Physical Medicine and Rehabilitation Board Review. 3rd Ed. New York: Demos Medical. 2015
SPORTS IN-
JURY

Prentice. E William.Bob.Blake. The Basic Science Of Therapeutic Modalities.in Theraputic Modalities for Sports Medicine and Athletic Training 6th edition.McGraw Hill. 2 0 0 9
 Prevention rehabilitation
• In example, patients with osteoarthritis have high risk to go under surgery
• A six-week (5x/week, 1hour) preoperative training program is efficacious for ↓
knee pain, ↑knee function, and enhancing daily living activities
• Preoperative training program, consists of :
• 10-minute aerobic warm-up
• Bilateral lower body exercises (standing calf raise, seated leg press, leg curl,
knee extension, knee flexion, and hip abduction) on standard strength training
machines

Vasileiadis D, Drosos G, Charitoudis G, et al. The Efficacy of High-Intensity Preoperative Physiotherapy Training on Postoperative Outcomes in Greek Patients Undergoing Total Knee Arthroplasty: A Quasi-Experimental Study. 2022. Cureus 14(3): e23191
Standing Calf Raise Seated Leg Press Knee Flexion

Leg Curl Knee Extension Hip Abduction

 Modalities role in rehabilitation
• Management or reduction of pain associated
with an injury
• Return of full nonrestricted range of motion
to an injured part
• Maintenance or perhaps improvement of
strength through the full range

Therapeutic modalities play role in reducing pain and are

extremely useful as an adjunct to therapeutic exercise

Prentice. E William.Bob.Blake. The Basic Science Of Therapeutic Modalities.in Theraputic Modalities for Sports Medicine and Athletic Training 6th edition.McGraw Hill. 2 0 0 9
 Modalities in rehabilitation
• Electromagnetic Energy
 Shortwave energy, Diathermy, Infrared Lamps, Ultraviolet therapy, Low-power laser,
High-Power Laser
• Thermal Energy
 Thermotherapy, Cryotherapy
• Electrical Energy
 Electrical Stimulating currents, Biofeedback, Iontophoresis
• Sound Energy
 Ultrasound, ESWT (Extracorporal Shockwave therapy)
• Mechanical Energy Modalities
 Intermittent compression, Traction, Massage
Prentice. E William.Bob.Blake. The Basic Science Of Therapeutic Modalities.in Theraputic Modalities for Sports Medicine and Athletic Training 6th edition.McGraw Hill. 2 0 0 9
 ELECTROMAGNETIC ENERGY
MODALITIES
Arndt-Schultz Principle:
• The Purpose of using therapeutic is to stimulate
body tissue. The stimulation will occur if energy
produce is absorbed by the tissue.
• To achieve the depolarization of a motor nerve,
intensity if the current must be increased until
enough energy is made available and is absorbed
by that nerve to facilitate depolarization

Prentice. E William.Bob.Blake. The Basic Science Of Therapeutic Modalities.in Theraputic Modalities for Sports Medicine and Athletic Training 6th edition.McGraw Hill. 2 0 0 9
ELECTROMAGNETIC ENERGY
modalities

Diathermy Laser

Ultraviolet Light Infrared Lamp

Prentice. E William.Bob.Blake. The Basic Science Of Therapeutic Modalities.in Theraputic Modalities for Sports Medicine and Athletic Training 6th edition.McGraw Hill. 2 0 0 9
ELECTROMAGNETIC ENERGY
modalities

Starkey C. Therapeutic Modalities, 4th ed. USA: F.A. Davis Company; 2013
 Thermal Energy modalities
• Modalities such as hot and cold packs operate by conduction of thermal energy,
so they are better described as conductive modalities.
• Also known to have analgesic effects as a result of stimulation of sensory cutaneous
nerve ending

THERMOTHERAPY CRYOTHERAPY

Prentice. E William.Bob.Blake. The Basic Science Of Therapeutic Modalities.in Theraputic Modalities for Sports Medicine and Athletic Training 6th edition.McGraw Hill. 2 0 0 9
Thermal Energy modalities

Starkey C. Therapeutic Modalities, 4th ed. USA: F.A. Davis Company; 2013
 Electrical Energy modalities
• An electrical current applied to nerve tissue at a sufficient intensity and duration to reach
that tissue’s excitability threshold will result in a membrane depolarization or firing of
that nerve.
• Clinically used frequemcy 1 Hz – 4000 Hz

Electrical Stimulating
Electromyographic Biofeedback
Prentice. E William.Bob.Blake. The Basic Science Of Therapeutic Modalities.in Theraputic Modalities for Sports Medicine and Athletic Training 6th edition.McGraw Hill. 2 0 0 9
Electrical Energy modalities

Starkey C. Therapeutic Modalities, 4th ed. USA: F.A. Davis Company; 2013
 Mechanical Energy modalities
• Using kinetic energy (using clinician's hand moves to apply a force that can stretch, bend or
compress skin, muscles, ligament and the like.
• Intermittent compression, traction techniques & massage use mechanical energy involving
force applied to some soft tissue structure to create therapeutic effect.

Prentice. E William.Bob.Blake. The Basic Science Of Therapeutic Modalities.in Theraputic Modalities for Sports Medicine and Athletic Training 6th edition.McGraw Hill. 2 0 0 9
Braddom. Physical Medicine& Rehabilitation. 5th edition
Mechanical Energy modalities

Starkey C. Therapeutic Modalities, 4th ed. USA: F.A. Davis Company; 2013
 SOUND ENERGY MODALITIES
Sound energy consists of pressure waves due
to the mechanical vibration of particles.

Ultrasound

ESWT
Prentice. E William.Bob.Blake. The Basic Science Of Therapeutic Modalities.in Theraputic Modalities for Sports Medicine and Athletic Training 6th edition.McGraw Hill. 2 0 0 9
Starkey C. Therapeutic Modalities, 4th ed. USA: F.A. Davis Company; 2013
THERA-
PEUTIC
MODALI-
TIES

Prentice. E William.Bob.Blake. The Basic Science Of Therapeutic Modalities.in Theraputic Modalities for Sports Medicine and Athletic Training 6th edition.McGraw Hill. 2 0 0 9
 Pain intervention in musculoskeletal
• RFA (Radiofrequency Ablation)
• PLDD (Percutaneous Laser Disc Discectomy)
• Corticosteroid injection
• Hyaluronic acid Injection
 Regenerative treatment in musculoskeletal
• Prolotherapy Injection
• PRP (Platelet Rich – Plasma) Injection
• Secretome Injection
 Therapeutic exercise
• Use of activities requiring physical exertion
• Therapeutic exercise consists of passive movements, active-assistive exercises,
active exercises, stretching, and relaxing exercise
• Strengthening exercises  ↑ maximal force that a muscle can generate
• Aerobic Exercises  low intensity and high repetition
• Anaerobic Exercises  high intensity and low repetition routines
• Mobility Exercises  improve flexibility
• Aquatic Exercises
• Stretching Exercises

Frontera, W. R. (2012). DeLisa’s physical medicine and rehabilitation: Principles and practice: Fifth edition
Cuccurullo S. Physical medicine and rehabilitation board review. 1st ed. New York: Demos Medical Publishing; 2004.
 Strengthening exercise
ISOTONIC EXERCISE
• Muscle contraction with joint movement
• Consist of concentric and eccentric contractions
• Constant external resistance (constant weight through ROM)

ISOMETRIC EXERCISE
• Muscle contraction without joint movement or minimal joint movement
• For patients who cannot tolerate repetitive joint motion, for example, with painful, inflamed
joints

ISOKINETIC EXERCISE
• Constant speed of motion, visible joint movement and external resistance
• Infrequently used, due to equipment requirements and uncertain correlation to functional
activities  Cybex, Nautilus

Frontera, W. R. (2012). DeLisa’s physical medicine and rehabilitation: Principles and practice: Fifth edition
Isotonic Exercise - Hamstring

Isometric Exercise - Quadriceps

Isokinetic Exercise - Knee Joint

 AQUATIC exercise
• Pool-based therapy takes advantage of the buoyancy and viscosity of water
• Buoyancy  a patient submerged in chest-deep water ↓ weight-bearing load of 40%
of total body weight.
• Viscosity of water  ↑ resistance to movement

Pelvic Roll Hamstring Stretch Double-leg Lift

Spine Extension–flexion

Cuccurullo S. Physical medicine and rehabilitation board review. 1st ed. New York: Demos Medical Publishing; 2004
Houglum PA. Therapeutic exercise for musculoskeletal injuries. 4th ed. US. 2016
 Orthosis
• External tools that used to modified structure & function
of neuromusculoskeletal system
• Orthotic Functions :
• Immobilization or as support
• Traction
• Aiding weak muscle
• Substitution for loss motor control
• Manipulate moving path
• Assistive device attachment
• Acting as a pillar of a segment

Frontera, W. R. (2012). DeLisa’s physical medicine and rehabilitation: Principles and practice: Fifth edition
Frontera, W. R. (2012). DeLisa’s physical medicine and rehabilitation: Principles and practice: Fifth edition. 31: 785
 Prosthesis
• a device designed to replace a missing part of the body or
to make a part of the body work better

Frontera, W. R. (2012). DeLisa’s physical medicine and rehabilitation: Principles and practice: Fifth edition
Braddom. Physical Medicine& Rehabilitation. 5th edition
Silicone Restorations Myoelectric fingers

Body-powered prostheses Osseointegration Bionic Arm

Myoelectric Leg

Bionic leg

Prosthesis design for sport

 Conclusions
• Musculoskeletal disorder still become an common concern in our commu-
nity
• Beside structures impairment, musculoskeletal system disorder also caused
an function impairment that end up in lowering ADL and QoL
• An comprehensive approach are an important part in musculoskeletal re-
habilitation
• Musculoskeletal rehabilitation has an important role to maintain the struc-
ture and function of our body, which could improve the ADL and QoL
• Role in musculoskeletal rehabilitation so important not only for the struc-
tures but also the functions and ADL in patient which affect the QoL
Thank
you