Physical Medicine

and Rehabilitation

Kinesiotherapy, Therapeutic Massage

Lesson II

Prof. A.S. Nica

S.L. Brindusa Mitoiu
S.L. Consuela Brailescu
S.L. Florina Ojoga
 Physical Tools for Rehabilitation
 The physical therapeutic unit recommended in functional
rehabilitation is represented by:
- termotherapy: the heat or cold application
- electrotherapy (electric current, electromagnetic field)
- kinetotherapy – therapeutic physical exercise)
- the therapeutic massage.
Kinetotherapy
 Definition
 Clasification
 Therapeutical objectives
 Effects
 Indications
 Contraindications
Kinesiology

 Kinesiology - Dally in 1957.

 The science dealing with the study of the
movement of living organisms and the structures
that participate to all activities.
 Medical kinesiology - studies the neuromuscular,
joint and afferent soft tissues mechanisms that
ensure the normal motor activities of the human
being also concerned with recording, analyzing
and correcting the deficient neuromuscular
mechanisms.
 Prophylactic Kinesiology

 all the methods and means of kinesiology which

aim to maintain and improve the state of health
and prevent the disease;

 primary (has the definition above);

 secondary - applies all the necessary means to

prevent aggravation or occurrence of patho-
morpho-functional complications of a chronic
disease.
 Therapeutic and Rehabilitation
Kinesiology

 THERAPEUTIC KINESIOLOGY – its role is to correct

the deficient mechanisms of movement.

 KINESIOLOGIC REHABILITATION – the main

method in the functional rehabilitation assistance.
 Evaluation in Kinetoprofilaxis/
Kinetotherapy
 Growth and development of the body:
appreciation of the general state of the body, the
result of the attitude, the level of global growth
and development in relation to age and sex;
 Statics, posture and alignment of body segments;
 Joint mobility, range of motion (ROM);
 Muscular tonus, muscle strength and endurance;
 Balance, coordination and ability;
 Effort capacity in connection with cardiovascular
and respiratory activity and also metabolic
activity
 Somatic Functional Evaluation
Analytical tests:
 Joint functional balance;

 Muscle testing;

 Balance and coordination assessment: e.g. Tinetti test.

Global tests: synthetic assessments of the neuro-

musculoskeletal system:
 ADL and i-ADL evaluation;

 Assessment of gait, prehention;

Quality of life assessment.

Other tests and evaluation scales (FIM, FES,
ASHWORTH, etc.).
 Muscle Strength Assessment (MRC-
Medical Research Council)
 Strength 5 (normal level):
 The muscle can perform full-range motion against an
external force (resistance opposed by the clinician),
equal to the value of normal force.
 This "normality" is appreciated by comparison with
the opposite healthy segment, or if it is affected,
based on the experience of the clinician, which will
take into account the age, sex, muscle mass, the
degree of physical training of the patient etc.
 The tester should apply the resistance in the end of
the movement and on the distal segment.
 Muscle Strength Assessment (MRC-
Medical Research Council)

 Strength 4 (good level):

 Represents the ability of the muscle to perform

complete movements against gravity and against an
average resistance.
 It is the same as in the case of 5 force testing, but
with a lower resistance applied by the clinician.
 Muscle Strength Assessment
(MRC-Medical Research Council)
 Force 3 (acceptable level):
 Muscle force to completely mobilize the segment against gravity
(without another counter-resistance). On the concept of
contraction the muscle against gravity is built the whole system
of the muscle testing, because it is based on the relationship
between the pressure force of gravity and the segment’s weight.
 The value of force 3 represents a true muscular functional
threshold, which would indicate the minimum functional
capacity for a minimum work that would require the
mobilization of the segments in all directions.
 This is true for the upper limbs, but not for the lower limbs,
which also support body weight.
Muscle Strength Assessment (MRC)

 Strength 2 (mediocre level):

 Allows the muscle to mobilize the segment, but with
the elimination of gravity.
 Manual force testing requires the clinician to know
precisely how to position the patient and the
respective segment in order to highlight the
"mediocre" force, respectively it slides easily,
mobilized by force 2.
 In clinical practice there are some border situations
between the 3 and 2 degrees of force.
Muscle Strength Assessment (MRC)

 Strength 1 (outlined level):

 Represents the sensation of the contraction of the
muscle or tendon palpation or the observation of a
slight tremor of it.
 However, the strength 1 of a muscle is unable to
mobilize the segment.
 Obviously, the contraction can be noticed only for
the superficial muscles, which can be palpated.
Muscle Strength Assessment (MRC)

 Strength 0 (zero level):

 The muscle does not perform any contraction. For
deep muscles one cannot distinguish between forces 1
and 0. The application of muscle testing on this scale
is possible only for some muscles, especially for the
main muscles of the limbs and the trunk.
 It should also be remembered when accomplishing a
balance for a particular muscle, we actually get the
result of the activity of a group of muscles, of which
the main one is tested.
Assessment of the Falling Risk
 The Program of Physiotherapy/
Kinetoprophylaxy

 Objectives
 posture correction and alignment of body
segments;
 improving joint mobility;
 increasing/maintaining muscle strength and
endurance;
 improving the effort capacity; heart activity and
breathing
 improving balance and coordination;
 breathing re-education.
 General Principles of
Physiotherapy/Kinetoprophylaxis

 the principle of specificity

 the principle of progressivity
 the principle of reversibility
 the principle of initial values
Methods, Techniques in Kinesiology
 Techniques:
 Anakinetic: immobilization, posturing

 Kinetic: - dynamic - passive mobilization: assisted

passive, autopassive; active: reflex, voluntary
(free, active/passive, active resistive)
- static: isometric contraction, muscle
relaxation.
 Therapeutic physical exercise (TPE)

 Methods: a group of TPEs used for a particular

purpose, in a specific condition: Kabat, Bobath,
Williams programme, Klapp.
The role of physical exercise

• The benefits of physical activity

• The importance of physical exercises
in pain management
• General fitness items
 The benefits of physical exercise (I)

 Lowering blood pressure

 Body weight control

 Maintaining bone density

 Improvement of joint mobility

 Increased muscle strength

 Positive influence of all the body's systems:

cardiovascular, respiratory, musculoskeletal

and endocrine
The benefits of physical exercise (II)

 Improves energy levels and the capacity to relax

(in stress management)
 Offering opportunities for socialization
 It adds pleasure and enthusiasm to everyday life
 Reduction of the risk of cancer, strokes,
osteoporosis and diabetes
 Maintaining self-esteem, independence and well-
being
 The benefits of physical exercise (III)

A high level of physical

activity

is associated with:
● Improvement of cognitive
functions
● Increased mental
performance
● Protecting the brain from
some forms of decline
Exercise and chronic pain

 Exercises are essential for chronic pain

management
 A reduced level of physical activity, for long
periods, can cause functional limitations :
o joint pain (limiting joint mobility), muscle
hypotonia, pain and physical impairment
 An extended sedentary lifestyle can be associated
with increased risk of falling
Preparation for physical exercises

• The right time (eg light exercises can reduce morning sickness
and pain)
• Suitable equipment : comfortable, shoes to provide good
support
• The right place : comfortable temperature, good ventilation,
firm, non-slip surfaces, existence of support systems (if there are
balance disorders)
• Assessment from the specialist doctor and physiotherapist :
functional evaluation, identifying needs and recommendation of
the exercise program and other appropriate physical methods
• Compliance with the prescribed pharmacological treatment
(for blood pressure, balance or pain reliever)
General recommendations regarding the
exercise program (I)

 To include various activities, which

encourage regular participation
 Following the principles of the progressive
training - increasing the intensity slowly,
starting from a safe, pleasant level, to a
level with training effect
 Adapting to needs
General recommendations regarding the
exercise program (II)

 Muscle and joint discomfort and pain require

the program to stop; if they persist after
resuming the program - consult specialist
 Know your own limits - to avoid overloading
and exceeding physical abilities
 To allow normal breathing to be maintained
 Soft, rhythmic movements, not sudden or fast
General recommendations regarding the
exercise program (III)

Alarm signals :
● Chest pain
● Weakness / loss of tone
● Nausea
● Confusion
● Sudden loss of bladder or bowel control
● Aphasia
● Respiratory dyspnea
● Vertigo
● Visual disorders
● Any kind of accusations of the patient
● Irregular pulse, slow or fast
General recommendations regarding the
exercise program (IV)

Not recommended for elderly patients:

● Exercises / activities that place the head below the heart
level (can overload the heart)
● Stretching exercises, from orthostatism, with flexion of the
lumbar spine and touch of the toes (may overload the
lumbar spine)
● Activities that involve extreme positions of the arms and
spine, which overload the cervical spine, shoulders and
back
General recommendations regarding the
exercise program (V)

 Setting realistic goals

 Physical fitness = the ability to perform
comfortable daily activities (those important for
the patient), maintaining sufficient energy level to
cope with emergencies without fatigue
 Recording of the exercise program and the progress
in performing the usual activities (evaluation scales -
Functional Fitness Test - for strength, flexibility and
aerobic performance)
Posture

 = position adopted by the patient:

 in orthostatism (the least stable; assumes a good
balance); exercises in orthostatism improve the
dynamic activities (walking, climbing stairs)
 in sitting
 in decubitus (the most stable and safe)
 during physical activities
 It is recommended to change the position during the
exercise program
 Exercises in orthostatism

 Maintaining a neutral position

 Equal weight distribution on both legs
 Easy bending of the knees - prevents
overwork of structures at this level

Strengthen the trunk muscles

and facilitate physical
activities in orthostatism
Exercises in sitting position (I)

 In people with intensified joint pain in orthostatism or in

those with balance disorders
 The height of the seat should allow the soles to reach the
floor and the equal distribution of weight on the spinal
area, bilaterally
 The use of a stool / ball strengthens the abdominal and
back muscles
 Exercises in sitting position (II)

 The use of a seat with backrest

and armrests limits movement
 In prolonged sitting, it is
recommended to get up from the
chair and stretch every 20 - 30
minutes
Exercises in decubitus

 For people who stay long in decubitus, it is important to support

the head, neck, spine and extremities in neutral positions
 In the dorsal decubitus - with the knees slightly bent and with
a cushion below the entire length of the lower limb (relax the
lumbar spine and the knees and decrease the pressure in the
popliteal area)
 In the lateral decubitus - the most comfortable, it ensures a
good support, with pillows at the head, neck and shoulders
 It is recommended to change the posture frequently and
maintain a neutral position
The components of fitness

 Cardiorespiratory fitness
 Muscle strength
 Muscle resistance
 Range of Motion (ROM)
 Flexibility
 Structure / composition of the body
 Cardiorespiratory fitness

 The ability of the heart, lungs and circulatory

system to supply oxygenated blood throughout the
body
 Exercises that require the movement of large
muscle groups (such as the muscles in the thighs)
for long periods are most effective for
cardiorespiratory training.
 The most effective exercises are: walking,
swimming and cycling
 Muscle strength

 Ability of skeletal muscles to generate sufficient force to

perform a task
 Weight lifting is the most effective method of increasing
muscle strength
 Activities that involve lifting weights have the advantage
of loading the skeleton and help maintain bone density
 Increased muscle strength can provide additional support
for weak joints
Muscle resistance

 Ability of skeletal muscles to generate movement

for a long time
 In order to increase the muscular endurance it is
necessary to increase the number of repetitions
of the exercises performed to increase the
muscular strength.
Movement amplitude (ROM) (I)

 It quantifies the joint movement

 It is crucial for an independent life
 The joints have different directions and different
levels of movement
 With the passing of years, the level of the ROM
decreases
 Exercises can reduce this decrease
Range of Motion (ROM) (II)

ROM exercises:
● Aim for all possible movements of
certain joints (to prevent injury),
especially those used during normal
functions and activities
● Involve all the periarticular structures
(muscles, tendon, joint capsule, bone)
● They are made without resistance
and can proceed other types of
exercises
Flexibility (stretching)

Exercises for flexibility:

● Different from ROM exercises
● Ensure the normal length of the periarticular muscles
- they prevent shortening and shrinking
● They can intensify the pain
● They are more effective if performed after ROM
exercises (which stimulate circulation and increase
mobility of joint structures) and after warm-up
exercises
Body composition (I)

 The percentage of body mass

represented by the adipose tissue
 A high percentage of adipose
tissue is a burden for the
cardiorespiratory system and for
the musculoskeletal system
 It depends on nutrition and
physical activity
Body composition (II)

 All physical activity help burn calories

 Regular physical activity is essential for
maintaining proper body weight
Warm-up exercises / activities (I)

 5 - 10 minutes, 5 - 10 repetitions, progressively

increasing the number of exercises
 Warm-up the muscles, stimulate the peripheral
circulation, prepare the body
 Facilitate mobilization and prevent trauma
 Reduce muscle pain and improve movement
ability in patients with chronic pain
Heating exercises / activities (II)

Examples of exercises (sitting or

orthostatic):
● Flexion - elbow extension
● Leg lifts from the ground
● Rolling shoulders back and forth
● Ankle / leg rotation
Aerobic Exercises (I)

 15 - 20 - 30 minutes, initially three days / week

 There are continuous activities that use important
muscle groups
 It doesn't have to be intense
 It is recommended to select several types of aerobic
exercises (cycling, swimming, treadmill and
ergometric bicycle, walking, dancing or other daily
activities), in order to avoid overloading certain joints
and to keep the individual's interest for exercises.
Aerobic Exercises (II)

Exercise examples:
● Lifting your feet off the
ground (from sitting)
● Walking (indoors or
outdoors)
● Climbing the stairs
Exercises to increase muscle strength (I)

 Warm-up exercises
 The number of repetitions depends on the
goals and should increase progressively
 To be consistent with the objectives
 It implies lifting a weight or increasing
the strength (elastic bands)
Exercises to increase muscle strength (II)

Exercise examples:
● Elbows and extensions
● Extensions of the fist
(sitting)
● Throwing a ball (sitting)
Stretching exercises (for flexibility) (I)

 It is performed after the warm-up exercises, or after the

aerobic exercises
 Improves the range of motion (often limited to the elderly
with chronic pain)
 It is recommended to be performed when pain and redness
are minimal
 They can be modified to adapt to functional limitations
(pain or inflamed joints)
 They can be performed daily
 Must accompany aerobic or muscle building exercises
Stretching exercises (for flexibility) (II)

Examples:
● Trunk extension (sitting or orthostatic)
● Extension of the shoulder and cervical-dorsal
spine
● Extensions and flexions of the forearm / wrist
(sitting)
● Ankle / leg extension / flexion (sitting)
Relaxation activities

 It can reduce the discomfort and muscle pain felt

the day after the exercise program
 After a program of aerobic exercises, relaxation
exercises are recommended similar to those of
warm-up exercises
• examples:
Lifting the feet from the ground, as during walking
(sitting or orthostatic, with shoulders relaxed) - 5
minutes
Goals

 The exercises / activities must be selected according to the

abilities and must be adapted
 In patients with limited mobility, joint exercises and
stretching components are recommended initially.
 For people with muscular hypotonia, warm-up and muscle-
strengthening exercises are recommended
 In order to improve fitness, we recommend warm-up,
aerobic and relaxation exercises
 To obtain all these benefits, it is recommended to perform
all types of exercises
Be Careful Of!

o The performance of physical activities should not cause or

intensify pain
o Exercises reduce joint redness
o It is advisable to maintain an adequate posture during
exercises, using a mirror
o The onset of pain, erythema and the local increase of
temperature of a joint or a muscle, fatigue and insomnia
can signal overload.
o Performing the daily routine activities should not be
hindered by the exercise program
Other options regarding the exercise program

 Yoga
 Tai Chi
Therapeutic Massage
 Definition
 Clasification
 Therapeutical objectives
 Effects
 Indications
 Contraindications
 Therapeutic Massage
Definition
 Massage = set of mechanical excitations performed
manually or with the help of the devices, applied
systematically to the skin and to the underlying
tissues for therapeutic and hygienic purposes.
 Manual massage = a series of various

manipulations which happen in a certain order

depending on the region on which it is operated, the
purpose pursued and the state of the body.
Therapeutic Massage
 Therapeutic Massage

Local therapeutic effects

 Sedative-analgesic effects: neuralgic, muscular, joint pain;
 Local hyperemic action - improvement of local circulation,
followed by the increased elimination of substances
responsible for the pain persistence (P) and other algogenic
substances blocked at the level of a dermatoma;
 Functional re-harmonization : getting rid of proprioceptive
afferents disturbed by nociceptive messages: MTP;
 Regaining of correct kinesthetic engrams : passive
mobilization restores the "sleeping" neurons;
 Therapeutic Massage
General therapeutic effects
 Stimulating the functions of the circulatory and
respiratory system;
 Increased basal metabolism;
 Favorable effects on the general condition of the
patient: improvement of sleep, removal of muscle
fatigue;
 Neuro-vegetative rebalancing;
 Distant reflexogenic effects at the level of other
elements of a particular metamer (dermatome,
myotom, sclerotom, viscerotom, neurotom,
angiotom).
 Therapeutic Massage
Indications I
 disorders of the locomotor system accompanied by pain:
periarticular, tendon and periosteal tendon, muscular, joint,
disc;
 post-traumatic sequelae of the locomotor apparatus;
 peripheral and central neurological disorders accompanied by
pain, hypotonia and hypotrophy;
 dermatological disorders: bedsores, scars, cellulite infiltrates,
hematomas;
 diseases of the cardiovascular system: various heart disorders
(reflex massage techniques), in disorders accompanied by
venous-lymphatic stasis, arteritis;
 Therapeutic Massage
Indications II
 post-traumatic or post-surgical edema;

 respiratory tract diseases: COPD, bronchial asthma (outside

the seizures);
 obesity;

 pregnant women (lower back pain, circulatory disorders,

stretch marks);
 geriatrics;

 sports medicine - rehabilitation after effort and of various

diseases in sports pathology.
 Therapeutic Massage
A. Absolute contraindications
 All acute infectious diseases;
 Skin conditions: furunculosis, pyoderma, shingles, herpes simplex, mycosis,
skin cancer;
 Inflammatory rheumatism in acute stroke;
 Pulmonary and extra-pulmonary TB;
 Vascular disorders: phlebitis, thrombophlebitis (risk of thrombi mobilization);
 Hemorrhagic disorders, coagulopathies;
 Acute inflammation of the abdominal organs (gastric or duodenal ulcer in
crisis);
 Lithiasis - may be responsible for the migration of the calculus, the
abdominal massage acts both in the renal and the gall bladder;
 On spastic muscles - in neurological spasticity.
 Therapeutic Massage
B. Relative contraindications - situations in which the maneuvers are either
excessively used, or that the pathological moment prohibits their use:
 In dermatological pathology: psoriasis, eczema, pruritus;

 Skin fragility in the elderly;

 Skin fragility in children;

 In traumatology: some recent traumas of the musculoskeletal system (eg:

sprains, fractures);
 patients with spasmophilia, with polientesopathies, gentle, sedative
massage techniques with relaxation techniques are being used;
 Topographic areas where massage is relatively contraindicated:

- poplitee fossa,
- the Scarpa triangle,
- elbow pouch,
- anterior region of the neck.
Shower Massage
Shower Massage
Shower Massage
Underwater shower
Underwater shower
Jacuzzi
Manual Therapy
 Definition
 Clasification
 Therapeutical objectives
 Effects
 Indications
 Contraindications
 Manual Therapy

 The therapy consists of manipulations, pressures,

torsions and tractions, being focused in particular
on the treatment of joint disorders.
 It is also known as osteopathy, chiropractic,
osteo-articular manipulations, orthopedic
massage, etc. Any maneuver executed incorrectly
can have serious consequences.
 Spinal Manipulations

 Definition: medical manual technique consisting

of a single, short, sudden maneuver that moves
a segment over the limit of joint motion, all
remaining within the anatomical limit.
 It is usually accompanied by a crackling sound.
(Dr. Robert Maigne)
Principles

 It is indicated by the doctor, after:

- a complete general medical examination to
eliminate a non-mechanical disease (inflammatory,
infectious, tumorous)
- an orthopedic examination in order to investigate
postural and minor intervertebral disorders
- a radio-imagistic evaluation
Principles

 Clinical examination = research of unilateral

signs is important: muscle pain, joint pain,
contractures, signs of unilateral blockage,
important for determining the meaning of
the maneuver
 Spinal radiography is questionable.
 Principles

 The preparation of a manipulation includes:

1. Explanation of the maneuver;
2. Maneuvers for general and local relaxation
(SEDATIVE massage, passive mobilization, heat
applications, ice massage).
3. The proper manipulation is performed when the
patient's relaxation is sufficient.
Plan of Action

 The extent of the paravertebral musculature (mm.

Depths - transversal and spinal), whose persistent
reflex contracture is the main mechanism of the
"segmental dysfunction"; the stretched muscles
will be the ones on the symptomatic side,
 For example: if the lower back pain is on the right
side, a lateral rotation maneuver combined with
left bending will be chosen according to the "star"
scheme.
Mckenzie Star Pattern
 Plan of Action

 Removal of posterior interapophyseal joints

(responsible for "cracking" by the phenomenon of
gas cavity), capsular stretch with inhibitory effect
of muscle contracture;
 Ligament stretch: An electromyographic response
of the multiphyses muscles during the stretching of
the spinal ligament (ligament-muscular reflex) was
revealed.
Plan of Action

 A decrease of the intradiscal pressure;

 Nonspecific action on pain: activation of the
descending system of inhibition of pain originating
in the gray periaqueductal matter, by
contrastimulation effect that causes the abrupt
extension of the innervated structures.
 A placebo effect
 Classification of manipulations

 The axial manipulations (decoupling, traction)

have a more global effect, with preferential
action on the reflex stresses of the paravertebral
muscles.
 The manipulations in rotation and lateral-flexion
where the impulse is perpendicular to the spinal
axis, with more segmental action.
Indications
 Vertebral pains of mechanical origin:
lumbalgia (acute or chronic), dorsalgia,
cervicalgia;
 the benefit / risk ratio will be less obvious in
the presence of radiculalgia (sciatica,
cruralgia or cervico-brachial neuralgia)
where medical treatment is predominant
(rest, infiltrations, antiinflammatory and
analgesic medication).
 Contraindications

 Cervical level: in women < 50 years, especially if

there is a combination of tobacco + contraceptives
(vascular risk), or in persons > 50 years old, with a
vascular history;
 Lesions of tumor, traumatic, infectious, inflammatory,
congenital or metabolic origin;
 Any hyperalgic state treated with drugs;
 Pain with neuropathic or psychogenic component.
Accidents

 The most important risk is present in

cervical rotational manipulations and for
people with associated risk factors
 Possible to occur: stroke, sudden death.
Types of maneuvers

 direct
 indirect

 Half-indirect
Types of Maneuvers for the Cervical Spine
Types of Maneuvers for the Thoracic-Lumbar Spine
Maigne Maneuver
Vertebral Traction
 Definition
 Clasification
 Therapeutical objectives
 Effects
 Indications
 Contraindications
Vertebral Traction

 They consist of the application of two forces

of opposite direction along the vertebral axis;
 Indications: acute or sub-acute spinal pain,
acute phase in chronic stage;
 There is :

 active traction (self-traction),

 passive traction (manual traction, by the
weight of the body)
 traction by mechanical devices (pulleys,
weights, sandbags).
Vertebral Traction

 The intensity of the traction force must be

inversely proportional to the duration of the
session.
 Mode of action: decrease of the physiological
curves of the spine and increase of the
intervertebral spaces, putting in tension the
paravertebral muscle-ligament structures
 The effect: pain relief, muscle relaxant, placebo.
Vertebral Traction

 Indications:
 Lumbar level: lumbago, lower back pain of
degenerative origin < three months;
 Cervical level: recent cervical-brachial neuralgia with
moderate disc herniation, or localized degenerative
lesions.
Vertebral Traction

 Contraindications: cancer pain, inflammation,

infection, post-trauma or other than common
spinal pathology.
 The traction on the continuous traction table is the
most widespread in Europe, the intermittent and
short ones in the USA.
Vertebral Traction

 Cervical level: a manual traction test is performed

on the dorsal decubitus, then the intensity of the
traction must be gentle and progressive.
 The absence of improvement after 3-6 sessions
should stop this therapy.
 There is no standardization of this therapeutic
procedure and the studies have conflicting results.
 Vertebral Traction

Longissimus-Dorsi (B1),
Cervicis (B2), Capitis (B3)
Iliocostalis-Thoracis (A1),
Lumborum (A2), Cervicis
(A3)
Spinalis (C)
Multifidus (D)
Vertebral Traction
Vertebral Traction
Vertebral Traction
Vertebral Traction
Vertebral Traction