1. Principles of Intervention CH 10 Part II SOFT TISSUE LESIONS

2. Chronic Pain Syndrome A state that persists longer than 6 months Pain cannot be linked to a source of irritation Functional limitations and disability include – Physical – Emotional – psychosocial parameters

3. Impairments Inflammation, pain, edema, muscle spasm Impaired movement Joint effusion Decreased use of associated areas

4. Educate the patient. Anticipated recovery time How to protect the part while maintaining appropriate functional activities.

5. Control pain, edema, spasm PRICE 48 hours Grade I joint oscillations

6. Maintain soft tissue and joint integrity and mobility Passive movements Muscle setting EMS

7. Reduce joint swelling if symptoms are present Medical intervention Protection (splint, cast)

8. Maintain integrity and function of associated area. Active-assistive Free Resistive Aerobic Assistive devices

9. Precautions: Rest and movement Increased pain Increased inflammation Contraindications: Stretching and resistance exercises

10. MANAGEMENT DURING THE ACUTE STAGE/PROTECTION PHASE/CONTROLLED MOTION PHASE

11. Impairments Pain at the end of available ROM Decreasing edema Decreasing joint effusion Contractures and adhesions Muscle weakness Decreased functional use of the part and associated areas

12. Educate the patient.

13. Promote healing Assistive devices Splints Tape Wrap

14. Soft tissue, muscle, and/or joint mobility Passive Active assistive Active ROM Mobility of scar Mobility of related structures

15. Neuromuscular control, muscle endurance, and strength in involved and related muscles Multiple-angle isometric AROM Stabilization exercises Isotonic exercises Progress resistance

16. Integrity and function of associated areas Strengthening Stabilizing exercises Low-intensity functional activities

17. Precautions: Resting pain Fatigue Weakness Spasm

18. Impairments Contractures and adhesions Muscle weakness Poor endurance Poor neuromuscular control Decreased usage

19. Educate the patient. Safe progressions of exercises Monitor Avoid re-injuring the part Safe body mechanics Ergonomic counseling

20. Increase soft tissue, muscle and/or joint mobility. Stretching Joint mobilization Cross-fiber massage Neuromuscular inhibition

21. Improve neuromuscular control, strength, muscle endurance. Submaximal to maximal resistance Specificity of exercise Multiplane motions Complex motions Functional activities Safe biomechanics

22. Improve cardiovascular endurance Progress aerobic exercises using safe activities

23. Progress functional activities. Supportive and/or assistive devices Functional training Progressive strengthening exercises advanced training activities

24. CUMULATIVE TRAUMA— CHRONIC RECURRING PAIN GHURKI TRUST TEACHING HOSPITAL

25. Tissue Response—Chronic Inflammation Injured Repetitively stressed Inflammatory process New immature collagen Weakening of the tissue Limitation of motion

26. Etiology Overuse, repetitive strain Trauma Re-injury of an “old scar.” Contractures or poor mobility

27. MANAGEMENT GUIDELINES: CUMULATIVE TRAUMA GHURKI TRUST TEACHING HOSPITAL

28. Impairments Pain of varying degrees: – After doing repetitive activities – When doing repetitive activities – When attempting to do activities – Continued and unremitting Contractures or adhesions Muscle weakness Poor muscular endurance Imbalance in length and strength Decreased functional use of the region Faulty position or movement pattern

29. Acute Stage 1. Educate the patient. 2. Promote healing; decrease pain and inflammation. 3. Maintain integrity and mobility of involved tissue. 4. Develop support in related regions. 1. cause of chronic irritation and to avoid stressing the part Adapt the environment to decrease tissue stress. Home exercise program to reinforce therapeutic interventions. 2. PRICE 3. Non-stressful passive movement, massage, and muscle setting within limits of pain. 4. Posture training. Stabilization exercises

30. MANAGEMENT GUIDELINES—Chronic Inflammation/Cumulative Trauma Syndromes: Controlled Motion and Return to Function Phases 1. Educate the patient. 2. Develop strong, mobile scar. 3. Develop a balance in length and strength of the muscles. 4. Progress functional independence. 5. Analyze job/activity. 1. Ergonomic counseling in ways to prevent recurrence. Home instruction in safe progression of stretching and strengthening exercises. Instruction on signs of too much stress 2. Friction massage. Soft tissue mobilization. 3. Correct cause of faulty muscle and joint mechanics with appropriately graded stretching and strengthening exercises. 4. Train muscles to function according to demand; provide alternatives or support if it cannot. Train coordination and timing. Develop endurance. 5. Adapt home, work, sport environment/tools.

31. Precaution Progressive loss of range of motion Emphasize stabilizing the part Safe adaptive patterns of motion