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Rehabilitation of Common Rehabilitation of Common Musculoskeletal DisordersMusculoskeletal Disorders

新光醫院 復健新光醫院 復健科科

謝霖芬 醫師謝霖芬 醫師

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Classification of Common Musculoskeletal Disorders Soft tissue lesionSoft tissue lesion

– Muscle: strain, myofacial pain sydrome

– Tendon: tendinitis, tear

– Ligament: sprain, rupture

– Bursa: bursitis

– Cartilage: degeneration, herniation, injury

Bone and joint lesionBone and joint lesion– Arthritis

– Fracture and/or dislocation

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Muscle strain

Damage to the musle fibersDamage to the musle fibers Due to overstretch or too much Due to overstretch or too much

contractioncontraction Classification: 1st, 2nd, and 3rd Classification: 1st, 2nd, and 3rd

degreedegree

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Myofacial pain syndrome

Local and referred pain patternsLocal and referred pain patterns Muscle stiffness and shorteningMuscle stiffness and shortening Taut bands in muscleTaut bands in muscle Presence of trigger pointsPresence of trigger points Local twitch response or jump signLocal twitch response or jump sign Autonomic dysfunctionAutonomic dysfunction

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Tendinitis or tendosynovitis

Local pain & tendernessLocal pain & tenderness Resisted isometric contraction Resisted isometric contraction

induces paininduces pain Tendon stretch induces painTendon stretch induces pain May have local swelling or crepitusMay have local swelling or crepitus May have tendon shortening or May have tendon shortening or

adherence (triggering)adherence (triggering)

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Bursitis

Pain on motion and at restPain on motion and at rest Local tenderness and/or swellingLocal tenderness and/or swelling Regional loss of active movementRegional loss of active movement

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Arthritis: joint inflammation Local findingsLocal findings

– redness, swelling, heat, tenderness

Impairment of joint functionImpairment of joint function– ROM restriction

– Impairment of force transmission

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Major Problems of Musculoskeletal Disorders

PainPain ContractureContracture Muscle weakness, atrophyMuscle weakness, atrophy InstabilityInstability Functional impairmentFunctional impairment

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Definition of Pain (IASP)

““An unpleasant sensory and An unpleasant sensory and emotional experience associated emotional experience associated with actual or potential tissue with actual or potential tissue damage, or described in terms of damage, or described in terms of such damage.”such damage.”– Acute pain vs chronic pain

– Individual variations

– Psychological factors

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Quantitation of Pain

Visual Visual analogue scale analogue scale (VAS)(VAS)

– 10cm line Likert scaleLikert scale

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Pain Generator

BoneBone JointJoint MuscleMuscle TendonTendon LigamentLigament NerveNerve VesselVessel

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Contracture Arthrogenic: arthritis, capsular fibrosisArthrogenic: arthritis, capsular fibrosis Myogenic: trauma, inflammation, Myogenic: trauma, inflammation,

degenerationdegeneration Other soft tissue: tendinitis, Other soft tissue: tendinitis, ligamentous ligamentous

teartear MixedMixed

Most common cause: lack of joint Most common cause: lack of joint mobilization throught full alowable rangemobilization throught full alowable range

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Muscle weakness or atrophy

DisuseDisuse Pain inhibitionPain inhibition Muscle or tendon lesionsMuscle or tendon lesions NeuropathyNeuropathy Side effect of drugsSide effect of drugs

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Instability

Bone and cartilage damageBone and cartilage damage Muscle atrophyMuscle atrophy Relative lengthening of tendon, Relative lengthening of tendon,

ligamentligament

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Evaluation of Musculoskeletal Disorders

History takingHistory taking Physical examinationPhysical examination Special examinationsSpecial examinations

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History Taking

LocationLocation Disease durationDisease duration CauseCause CourseCourse SeveritySeverity Factors relieving or worsening the Factors relieving or worsening the

symptomsymptom Other sensory complaintsOther sensory complaints

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Physical Examination Inspection: redness, swelling, atrophy, Inspection: redness, swelling, atrophy,

ecchymosis, discoloration, deformity, ecchymosis, discoloration, deformity, physical defectphysical defect

Palpation: tenderness, local heat or coldness, Palpation: tenderness, local heat or coldness, swelling, atrophy, mass, local defectswelling, atrophy, mass, local defect

Neurological examination: sensory, motor, Neurological examination: sensory, motor, DTRsDTRs

Check ROM, joint stability, soft tissue Check ROM, joint stability, soft tissue flexibilityflexibility

Special tests:Special tests:

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Special Examinations Conventional radiographyConventional radiography UltrasoundUltrasound Computed tomographyComputed tomography Magnetic resonance imagingMagnetic resonance imaging Bone scanBone scan ArthrographyArthrography ArthroscopyArthroscopy EMG & NCSEMG & NCS Motion analysis (gait laboratory)Motion analysis (gait laboratory)

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Goals of Rehabilitation

Symptom relief Mobility and strength Sense of self-worth Maximal functional ability Maximal independence

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Therapeutic Exercise

Mobility exerciseMobility exercise Strengthening exerciseStrengthening exercise Aerobic exerciseAerobic exercise Recreational exerciseRecreational exercise

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Mobility Exercise Range of motionRange of motion

– active – active-assistive– passive

StretchingStretching– ballistic– PNF (proprioceptive neuromuscular

facilitation)– static

Joint mobilizationJoint mobilization

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Strengthening Exercise

Isometric - same lengthIsometric - same length Isotonic - same loadIsotonic - same load Isokinetic -same speedIsokinetic -same speed

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Aerobic Exercise

Mode: swimming, bicycle, walkingMode: swimming, bicycle, walking Frequency: 3-5 times/weekFrequency: 3-5 times/week Duration: 20-60 minDuration: 20-60 min Intensity:Intensity:

– 55-90% maximal HR

– 40-85% HR reserve

– 40-85% VO2 reserve

– 12-16 RPE (rate of perceived exertion)

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Purposes of Orthoses (splints)

Unweigh jointsUnweigh joints Stabilize jointsStabilize joints Decrease joint motionDecrease joint motion Improve joint functionImprove joint function

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Basic function of assistive devices

Compensate for lost functionCompensate for lost function Alleviate joint stressAlleviate joint stress Decrease energy demandsDecrease energy demands Increase safety Increase safety

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Treatment and Rehabilitation of Common Musculoskeletal Disorders

Acute stageAcute stage Subacute stageSubacute stage Chronic stageChronic stage

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Acute Stage PRICEPRICE Physical agents: TENS, low power laserPhysical agents: TENS, low power laser Medications: NSAIDs, analgesicsMedications: NSAIDs, analgesics Local steroid injection (c or s xylocain)Local steroid injection (c or s xylocain) Local xylocain injectionLocal xylocain injection Acupuncture`Acupuncture` ManipulationManipulation Therapeutic exercise: Therapeutic exercise:

–ROM exercise –Isometric exercise

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Hyperstimulation Analgesia

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Subacute Stage

Heat or cold therapyHeat or cold therapy Hydrotherapy(contrast bath)Hydrotherapy(contrast bath) Local massageLocal massage ROM exerciseROM exercise Strengthening exerciseStrengthening exercise

–isometric, isotonic, isokinetic Other physical agentsOther physical agents

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Chronic Stage

Heat therapyHeat therapy Hydrotherapy (Spa therapy)Hydrotherapy (Spa therapy) Stretch exerciseStretch exercise Strengthening exerciseStrengthening exercise Aerobic exerciseAerobic exercise Mobilization and manipulationMobilization and manipulation Other physical agents (USD, SWD, Other physical agents (USD, SWD,

TENS)TENS)

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Patient

PhysicianNurse

Orthotist

OT

PT

Bioengineer

Family

Social worker

Psychologist

Pedorthist