Physical Therapy, Pain, The Brain. GOBHI May 17, 2012 Dr. Tom Watson PT MEd DAAPM Bend, Oregon. Conflict of Interest Financial Disclosure. Dr. Tom Watson DPT PT MEd Diplomate American Academy of Pain Management Rebound Physical Therapy 541-382-7875 Bend, Oregon
GOBHI May 17, 2012
Dr. Tom Watson PT MEd DAAPM
“A successful outcome in pain therapy involves more than the lowering of pain intensity scores”
Greeks, Egyptians, Chinese, Romans: Heat, sun, geodes, eels, massage, manipulation
Modalities-Thermal, Sound ,Traction, Magnets
Lasers, electrical stimulation
Therapeutic exerciseAncient Times and Today
Philadelphia Panel Evidence-Based Clinical Practice Guidelines (EBCPG) in Selected Rehabilitation Intervention for Low Back Pain
Cochrane Collaboration, and literature review using meta-analysis and observational studies
Feel Good: eels, massage, manipulation
Heat— Radiant-sun-fire-hot coals-sound
Conductive — Hot water, heated agents
Cold — Ice, chemical freezing agents
High Intensity Afferents-e-stim, TENS, IFC
Pain management in 5 minutes
Mercola & Kirsch, "microcurrent electrical therapy" (MET)
Based on the Arendt-Schultz physics principal of low intensity stimulation causing profound biophysical response, Works on the cellular level, using microamp current
Effective: reducing chronic headaches,improvingserotonin levels, depression, insomnia, chronic pain, fibromyalgia, PTSD
120 human studies and 19 animal by Daniel Kirsch, PhD, Mineral Wells, Texas
serotonergic (5-HT) raphe nuclei at brainstem.
5-HT inhibits brainstem cholinergic (ACh) and noradrenergic (NE) systems that project supratentorially. Release dopamine
Suppression thalamo-cortical activity, arousal, agitation, alters sensory processing and induces EEG alpha rhythm.
5-HT acts directly to modulate pain sensation in dorsal horn of the spinal cord, alter pain perception, cognition and emotionality within the limbic forebrain.
Light Amplification by Stimulated Emission of Radiation: 1950s
Helium neon laser, with 632.8 nm:
superficial wound healing, acute and chronic pain, with or without inflammation
Gallium Arsenide or infrared laser 830nm:
deep pain, deep wound healing, scar tissue, calcium deposits, neuropathies
Jedi squirrels of Oregon with light sabers
Decrease pain, decrease inflammation, increase healing, Krebs cycle ATP increased by 150% –1000%
Decreases bradykinins-histamine: anti-inflammatory analgesic
Regenerative: increases mitosis
No thermal effects below 500 mW
6 –12 treatments
Acute and chronic pain, TMJD
Neuropathies, FMS, Post polio syndrome
Athletic Injuries: Sprains, Strains, Hematomas
Dorland: manipulation skillful or dexterous treatment by the hand and in physical therapy, forceful pressure/movement of a joint within or beyond its active limit of motion.
Massage, mobilization, manipulation- highly effective in reducing pain and muscle guarding, increasing range of motion. Hypermobility or hypomobility
Manipulation/mobilization date back to Hippocrates in 460 BC
Basmajian documented “Laying on of hands” in the Old Testament of the Bible
Andrew Taylor Still introduced osteopathic manipulation in late 1800s, diseases were due to abnormal bony situations
Bonesetters were prominent in Mexico and famous for “stamping or trampling” techniques that are still practiced today.
Sarah Mapps, aka Crazy Sally or Cross Eyed Sally, was in high demand in London during the early 1700s for her “bone setting ability.”
Cyriax disagreed with osteopathic techniques, advocated manipulation by PT”s
“Hippocrates straightened kyphosis, Galen replaced outward dislocated vertebrae, and Pare wrote about subluxation of the spine.” ‘bone setters’ replaced out of place bones, osteopaths treated the osteopathic lesion, orthopedic surgeons manipulated the SI joint, chiropractors replaced subluxed vertebrae, and neurologist havestretched the sciatic nerve.”
Soft Tissue Therapies
manual contact, pressure, or movements primarily to myofascial(soft) tissues
myofascial release, muscle energy, traditional massage, Rolfing, movement therapies such as Feldenkrais, Traegering, PNF, classical massage
manual manipulation of soft tissue administered for producing effects on nervous, muscular, lymph, and circulatory systems
The Ultimate Goal of joint mobilization or manipulation techniques is to lower the threshold of activity at a joint or muscle via dorsal horn inhibition
manipulation/mobilization increased active range of motion and decreased muscle tone
massage/stretching demonstrated increased range of motion but increased EMG activity
The musculoskeletal system does not respond well to immobilization.
The end result is the deterioration and weakness of the body’s tissue.
Recovery is a slow process and care must be taken during activity and exercise to avoid further tissue damage.
For every 1 day in a brace or cast 2 days of mobilization and exercise
Reducing pain and increasing stability
Programs begin with exercises aimed at increasing circulation into a muscle, improving endurance, facilitating coordination - motion occurs around a normal physiological axis, increasing strength and power.
Release endorphins, improve self esteem, decrease depression
Phase 1 : coordination, mobility, and stability around a physiological axis throughout the range of motion
Phase 2: increasing tissue tolerance to levels corresponding to the demands of activities of daily living and restoring function
5000 to 6000 repetitions to regain the former coordination of the tonic or phasic muscles in a joint system following an injury
Phase 3: Stabilizing exercises combining concentric and eccentric contractions
Phase 4: Coordinate tonic and phasic throughout full AROM such as in PNF patterns to finalize strengthening and coordination. Plyometric training.
The patients are pain free and are preparing to return to their pre-injury levels of activity or sports participation at this time.
Ball Therapy, Theraband, running, swimming, skiing, weight lifting
Pool therapy, Pilates, Plyometrics
Mirror Therapy for CRPS
Dry needling for trigger points
Nutritional counseling, Anti-inflammatory Diet, Vit D3, Red Krill fish oil
Placebo up to 40%
Physical therapy is a skill and an art
Head: learns anatomy, physiology, pain symptoms, evidence based outcomes various types of modalities, exercises, and manual therapies
Hands: apply modalities, manual therapies, and exercises
Heart: empathy and understanding that pain patients need more than just modalities and exercise
Pain does not have to be a
Way of Life