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DEFINITION of PHYSIOTHERAPY

Physiotherapist is an individual who is trained, certified and registered as physiotherapist , responsible to analyze and make physiotherapist diagnosis , carry out physiotherapy treatment for prevention of pain or injury , habilitate or rehabilitate any form of physical condition and disabilities in order to facilitate or restore optimum movement and functional abilities as well as to promote physical health for patients and public .

(AHP Act)

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PHYSIOTHERAPY SERVICE IN PRIMARY HEALTHCARE

Promotive

Preventive

Curative

Rehabilitative

Consists of:

For all age group in the population

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PHYSIOTHERAPY ROLE IN PAIN MANAGEMENT

Assisting patients to diminish pain

Improving quality of life

Preventing acute & sub-acute painful conditions from developing into chronic pain

Assisting patients to live with chronic pain

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CONTOH RUANG RAWATAN UNIT FISIOTERAPI

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CASES TREATED BY PHYSIOTHERAPY

Consideration of multipathology by identifying actual and potential limitations to function, including pain and other problems of musculoskeletal, respiratory, circulatory etc.

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PROGRAMS OFFERED BY KLINIK KESIHATAN

COMMUNITY BASED PROGRAM

E.g:

GERIATRIC ( WARGA EMAS)PROGRAM
ANTE /POST NATAL PROGRAM
CHILDREN WITH SPECIAL NEED
SCHOOL SCREENING
KEM KESIHATAN
OUTREACH COMMUNITY
KOSPEN
WORK HEALTH PROGRAM
DOMISILIARI TREATMENT
NCD PROGRAM
Obesity
Diabetes Mellitus
Hypertension

OUTPATIENT

Based on condition :

E.g:

Neck, shoulder , elbow, back , hip , thigh, knee, calf, ankle , foot , chest, stroke, men’s health , women’s health , peads musculoskeletal, and peads neurology

*case mainly seen are to treat -pain

-correct posture

-create awareness

-prevention of future/further injury,

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REFERRAL TO PHYSIOTHERAPY

TO KLINIK KESIHATAN

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REFERRAL TO PHYSIOTHERAPY

TO HOSPITAL

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Carta Alir Pengurusan Kesakitan Di Fasiliti Kesihatan Primer ��Carta alir ini juga perlu dipamerkan di tempat yang strategik dan disimpan di dalam fail untuk rujukan

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PHYSIOTHERAPY TREATMENT APPROACH

Detail and careful history taking

Thorough physical examination

Sound clinical reasoning

Selection of suitable treatment based on patients need

flowchart

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Carta Alir Pengurusan Kesakitan Fisioterapi di Fasiliti Kesihatan Primer.

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Format Penilaian Kesakitan di Fasiliti Kesihatan Primer (Pain Assessment Format)

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EXAMPLE OF PHYSIOTHERAPY ASSESSMENT FORM

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PAIN SCALE RULER

Skala Kesakitan Kementerian Kesihatan Malaysia

IASP FACES pain scale – revised

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Skala FLACC (FLACC Observational Pain Score)

Category	Scoring
Category	0	1	2
Face	No particular expression or smile	Occasional grimace or frown, withdrawn, disintereseted	Frequent to constant quivering chin, clenced jaw
Legs	Normal position or relaxed	Uneasy, restless, tense	Kicking or legs drawn up
Activity	Lying quietly, normal position, moves easily	Squirming. Shifting back and forth, tense	Arched, rigid or jerking
Cry	No cry (awake or sleep)	Moans or whimpers; occasional complaint	Crying steadily, screams or sobs, frequent complaints
Consolability	Content, relaxed	Reassured by occasional touching, hugging or being talked to. distractable	Difficult to console

Skala FLACC (Face, Legs, Activity, Cry, Consolability) merupakan skala pemantauan (Observational scale) digunakan untuk pesakit kanak-kanak berumur satu (1) bulan hingga empat (4) tahun dan juga pesakit dewasa yang mempunyai masalah kognitif. Untuk skala FLACC, setiap kategori adalah 0-2 dan jumlah skor adalah antara 0 – 10.

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CONTOH BORANG MAKLUMBALAS KEPADA PEGAWAI PERUBATAN -� *bakal dimurnikan. Makluman secara rasmi akan diwarwarkan setelah selesai proses pemurnian

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AIM OF PHYSIOTHERAPY INTERVENTION

ON PAIN:

To beat pain & gain control

Habilitate or rehabilitate any form of physical condition and disabilities

Restore optimum movement and functional abilities

prevention of pain or injury

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Pendekatan Berperingkat bagi Fisioterapi (Non-Pharmalogical Approaches) dalam Pengurusan Kesakitan Kronik di Fasiliti Kesihatan Primer.

		UNCONTROLLED
		Sakit tidak berkurangan / bertambah teruk / tiada perubahan selepas 3 bulan intervensi Skala Sakit > 6
	MODERATE to SEVERE	Rujuk Pegawai Perubatan / Pakar Perubatan Kelaurga untuk pemeriksaan dan tindakan lanjut.
	> 4
MILD	Penggunaan Pain Modalities seperti berikut: Elektroterapi Electrical Stimulation (TENS) Ultrasound Terapi Interferential (IFT) Terapi Laser Short Wave Diathermy Terapi Shock Wave Terapi haba Terapi panas (Hotpack, Infrared, Wax) Terapi sejuk (Ice pack,Cryo Compression) Senaman Terapeutik Regangan Kekuatan Mobiliti Koordinasi Ketahanan Terapi Manual Joint Mobilization Soft Tissue Manipulation (STM) Myofasial Release (MFR) Taping/Bracing/Bandaging Muscle Energizing Techinique Proprioception Neuromuscular Facilitation (PNF)
1 - 3
Pengurusan Kendiri Kesakitan Tunjuk ajar aplikasi modaliti oleh Ahli Fisioterapi seperti Hotpack / Icepack / TENS untuk digunakan di rumah. Senaman Terapeutik Memberikan preskripsi senaman regangan, mobiliti, kekuatan, ketahanan, keseimbangan dan koordinasi serta aktiviti fizikal yang bersesuaian berdasarkan kondisi. Pendidikan Kesihatan dan Latihan Memberi pendedahan kepada pesakit dan keluarga berkenaan teknik relaksasi, konsep pacing, penilaian risiko, penjagaan postur, ergonomik dan konsep adaptasi dalam pengurusan kesakitan. Pelan Discaj Pesakit Membentuk pelan discaj pesakit yang komprehensif dalam pengurusan kesakitan kronik.

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SPECIAL PHYSIOTHERAPY TREATMENT CONSIDERATION in PAIN MANAGEMENT

Consider the safety of the patient and care taker by providing education and training on the safe movement and ways of handling patient.

Each exercise program is tailored based on individual need and does not exacerbate the pain.

Prepare a proper home exercise program or discharge care plan to prevent recurrent pain

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EXAMPLE OF AWARENESS FOR PHYSIOTHERAPY MANAGEMENT IN PAIN

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EXAMPLE OF AWARENESS FOR PHYSIOTHERAPY MANAGEMENT IN PAIN

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Three main approaches a physiotherapist use are:-�(especially for chronic cases)

Education and Advice
Movement and Exercise
Manual Therapy

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Education and Advice.

Regular exercise and maintaining a healthy weight – this is the MOST important part of any treatment.
Patient & Carer education

Information on patient condition

Anatomy
Pathophysiology
Prognosis
Pain self care management: Pacing , Posture care , positioning, Pain relief at home/work
Quality movement for functional improvement at home or work adaptation

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Education and Advice cont…

give specific advice that patients can apply to everyday activities to look after themself and reduce the risk of pain or injury.

E.g: posture, correct lifting or carrying techniques, and avoiding awkward twisting, over-stretching, or prolonged standing.

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Example of patient education

1. Head and neck to be upright, or in-line with the torso (not bent down/back). �2. Head, neck, and trunk to face forward (not twisted). �3. Trunk to be perpendicular to floor (may lean back into backrest but not forward).�4. Shoulders and upper arms to be in-line with the torso, generally about perpendicular to the floor and relaxed (not elevated or stretched forward). �5. Upper arms and elbows to be close to the body (not extended outward). �6. Forearms, wrists, and hands to be straight and in-line (forearm at about 90 degrees to the upper arm). �7. Wrists and hands to be straight (not bent up/down or sideways toward the little finger). �8. Thighs to be parallel to the floor and the lower legs to be perpendicular to floor (thighs may be slightly elevated above knees). �9. Feet rest flat on the floor or are supported by a stable footrest.

Correct working posture

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Physiotherapist’s

advice to patient

Advise are given based on patient’s need and condition especially for self treatment or general understanding of his condition through history taking .

PHYSIOTHERAPIST’S ADVISE

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Find a position of comfort that decreases / eliminate the pain.
Use a pain-relieving treatment e.g ice therapy for 10 – 15 minutes
Use an assistive device e.g crutches / walker if the leg is involved, a sling / splint for the upper extremity / a corset for the back.

Example of physiotherapist’s advise

Management of acute pain

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Improve problems such as inflexibility, loss of mobility / weakness, which contribute to the pain.
Decrease pain by inhibiting transmission of pain impulses
Prevent secondary musculoskeletal complications of pain such as further weakness, immobility, & flexibility at the other joints.

Example of physiotherapist’s advise

Exercise for chronic pain patient

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Ideally, the patient should do activities every day, at least once per day
Patient may perform several exercise. These session may be only 5 – 10 minutes long
Stretches should be intense enough to feel a gentle pulling sensation

Example of physiotherapist’s advise

General exercise regime for chronic pain patients

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4. Other exercises should be performed

slowly until slight fatigue is felt / as

instructed by the physiotherapist /doctor

The patient may feel some discomfort during / for a short time after exercise. This discomfort should not be confused with the pain that brought the patient to the clinic.
Patient may continue with to exercise with some of the discomfort

Example of physiotherapist’s advise

General exercise regime for chronic pain patients

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Home management

1. Heat treatment

- hot (warm) pack

- reduces pain by sedative effect

Example of physiotherapist’s advise

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PHYSIOTHERAPY INTERVENTIONS should be…

Graded exposure & pacing

There are often particular activities that are challenging, painful & sometimes avoided for fear of causing damage / harm.

With knowledge of pain & confidence to move, patient can gradually re-engage with these activities.

Pacing means doing activities / exercises with rest in between so that patient’s achieved set goals.

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EXAMPLES OF PHYSIOTHERAPY INTERVENTIONS

PHYSIOTHERAPY INTERVENTION

BREATHING EXERCISES

SPECIFIC EXERCISES TAILORED BASED ON PATIENT’S CONDITION

HYDROTHERAPY/ WATER THERAPY

MANUAL THERAPY

POSITIONING

GENERAL EXERCISES

ELECTROTHERAPY

PATIENT EDUCATION

HOME EXERCISE PROGRAM

PATIENT ADVISE

RELAXATION

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Movement and Exercise

Exercises designed to improve movement and strength in a specific part of the body – these usually need to be repeated regularly for a set length of time.

Providing mobility aids – such as crutches or a walking stick to help patients move around.

Type of exercises	Function
Mobilizing	To maintain or improve range of motion
Stretching	To improve flexibility To reduce muscle tightness
Strengthening	To improve muscle strength
Breathing exercise	Relaxation To control the pain

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EXAMPLES OF PHYSIOTHERAPY INTERVENTIONS

Specific exercise

To mobilize tight & stiff body regions, to develop normal control of movement; gradually progressed

Hydrotherapy/Water Therapy

For build up strength, stability , reduce stiffness & reduce pain

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Pain relief modalities

Modalities	Function
Cold therapy (ice pack / cryotherapy)	To reduce pain -To reduce swelling
Heat modalities (hotpack, infrared therapy, wax therapy)	To reduce superficial muscle pain
Ultrasound	To reduce superficial and deep pain
Electrical current (TENS)	To control pain

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EXAMPLES OF PHYSIOTHERAPY INTERVENTIONS

Therapeutic Electro modalities

For pain relief

General exercises

To progressively build up patient’s tolerance & confidence for daily activities & the chosen exercises & sports

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EXAMPLES OF PHYSIOTHERAPY INTERVENTIONS

Relaxation

For pain relief

positioning

For pain relief

Breathing exercise

For relaxation

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EXERCISES

Shoulder-neck stretch

Posterior shoulder stretch

Hip extensor stretch

Calf stretch

Hamstring stretch

Wrist stretch

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EXERCISES

MOBILIZATION

PASSIVE MOVEMENT EXERCISE

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EXERCISES

STRENGTHENING- Lower limb

(using body weight)

STRENGTHENING- Lower limb (using other exercise tools)

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STRENGTHENING- Upper limb �(using other exercise tools)

STRENGTHENING – Upper limb (Hand)

STRENGTHENING- Upper limb (using resistance band )

Using exercise putty

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Example of relaxation technique and positioning

Relaxation technique and positioning for asthmatic patient during asthmatic attack

Relaxation technique and positioning for patient with back pain

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Relaxation technique and positioning for pregnant lady

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Example of breathing exercise

Diaphragmatic breathing

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EXAMPLES OF PHYSIOTHERAPY INTERVENTIONS

Hands-on techniques to manipulate / mobilize tissues of the body, to diagnose & treat soft tissues & joint structures for the purpose of modulating pain, increasing range of motion (ROM), reducing / eliminating soft tissue inflammation, inducing relaxation, improving contractile and non-contractile tissue repair, extensibility, and/or stability, facilitating movement and improving function.

Correction of physiological impairments allows fearless , pain free movements that facilitate the relearning of pain free memories of movements.

MANUAL THERAPY

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Types of Manual Therapy

Soft tissue techniques	Joint techniques
Soft Tissue Manipulation	Joint mobilization
Myofascial Release technique	Joint Manipulation
Manual Lymphatic Drainage	Muscle energy techniques

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Soft Tissue Manipulation

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MYOFASCIAL RELEASE TECHNIQUE

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Manual Lymphatic Drainage (MLD)

Are designed to increase the movement of lymph and interstitial fluid.

The basic hand positions of MLD are adapted to follow the anatomy & physiology of the lymphatic system

Vodder Technique

GENERAL EFFECTS OF MLD

Improves the lymph capillary uptake

Increase the lymph-angio-activity

Soothing effect

Analgesic effect

Redirect the flow around blocked areas into

more centrally located healthy lymph vessels

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Joint Mobilization

Joint Manipulation

Muscle Energy Technique

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Therapeutic Electrotherapy modalities

Infrared Ray	Hot pack
Infrared ray on Knee	Hot pack for back pain

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Therapeutic Electrotherapy modalities

Cryocuff	Ice pack
Cryocuff for Ankle pain	Ice pack on the forearm and knee

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Cryotherapy	Transcutaneous Electrical Nerve Stimulation (TENS)
Cryotherapy on the right knee

Therapeutic Electrotherapy modalities

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Therapeutic Electrotherapy modalities

Ultrasound		Wax therapy
Ultrasound therapy on elbow and knee		Wax bath therapy on hand

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Extracorporeal Shockwave Therapy (ESWT )

ESWT is based on a unique set of pressure waves that stimulate the metabolism, enhance blood circulation and accelerate the healing process. Damaged tissue gradually regenerates and eventually heals. Examples of condition treated by this modality:

Rotator cuff tendonitis
Plantar fascitis
Tennis elbow
Golfers elbow

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EXAMPLES OF PHYSIOTHERAPY INTERVENTIONS

Taping

Using a more flexible kind of tape, it function to reduce pain . inflammation , swelling, promote healing, via stabilization and support , facilitate towards full range of motion and to relax overused muscle

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EXAMPLES OF PHYSIOTHERAPY INTERVENTIONS

Physiotherapy patient education

Patient education plan started with an analysis of the patient’s need from the information identified during history taking.

Public awareness on pain & Posture care

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Physiotherapy Management can be physically or via Virtual Platform depending on the patients’ condition

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Evidences

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BY CONDITIONS

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Pain management in ante and post natal pain

A study concluded patient who followed physiotherapy program after cesarean delivery have shown reduced pain perception (Citak Karakaya et al, 2012)

Breathing exercises, muscle relaxation, lumbosacral massage, and showers reported to have reduced pain as cervix dilation increased (Davim et al, 2009)

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Pain management in Cancer patients

Physiotherapy soft tissue mobilization technique for these patients may prove beneficial in limiting subsequent shoulder dysfunction among breast cancer patient with axillary web syndrome (Fourie & Robb,2009)

Sufficient levels of exercise were consistently associated fewer side effects such as chest wall pain and shoulder limitation among patient undergone breast cancer treatment (Gho et al , 2013)

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Physical exercise regime have reported significant improvements in fatigue, depression, sleep disturbances, pain, and quality of life of cancer patients. The improvements were independent of the type of cancer, extent of disease, or treatment status. Additional benefits described by participants were support, a sense of belonging, and being understood.(Van Gerpen & Becker, 2013)

Pain management in Cancer patients

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Phantom Limb Pain

Evidence has demonstrated that TENS has potential for reducing phantom pain and stump pain at rest and on movement (Mulvey et al, 2013)

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Management Post Surgical Pain

A review on TKR have stated effectiveness of physiotherapy management on post TKR pain and regaining the functional ability (Akodu et al ,2011)
Application of kinesio taping on patient post laparoscopic cholecystectomy have shown decreased level of pain and also improved functional mobility compared to controled group patients (Krajczy et al, 2012)
Relaxation technique

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Temperomandibular Joint pain

The anesthetic blockage and physical therapy(Massage and Muscular stretching), when used together, are effective in the reduction of pain among patients with TMD compared to those received anesthetic alone (Nascimento et al, 2013)

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BY TECHNIQUES

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Taping

Findings demonstrated that Kinesio taping would be an effective method for reducing neck and low back pain and improving functional performance (Keratas et al, 2012)
Kinesio taping also showed good prognosis in managing pain during the acute phase (Mostafavivar et al ,2012)

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Manual Therapy

A systemic review showed that manual therapy contribute usefully to the management of nonspecific neck pain (Vincent et. al., 2012)
Studies demonstrated analgesic effects and modulation of spinal excitability with use of manual therapy techniques, with clinical outcomes of improved gait and functional ability among patients with lower quadrant pain (Courteny et.al., 2011)

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TENS

A study using functional MRI shown TENS been effective in reducing pain among subacromial impingement patients and also induce analgesic effect through modulation of discriminative, affective, and motor aspects of central pain perception. (Kocyigit et al, 2012)

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Ultrasound:

Recent review on chronic tendon injuries have shown therapeutic ultrasound as of modalities widely used in conservative management (Chidress & Buetler , 2013)

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ESWT

Patient with chronic plantar fascitis reported more satisfaction in term of pain & functional (Krishnan et. al., 2012)
ESWT have reported success of the treatment among plantar fascitis patients at 3 months, 12 months and after 12 months. (Wong CP, 2009)

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Hydrotherapy

Have shown improvement in the mobility level (P<0.01), walking and bending ability of the trunk (P<0.05), levels of pain (P<0.01) and mood (P<0.01) among elderly patients with knee osteoarthritis (Lau et al 2013)

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Exercises

Physical exercises improves not only in term of pain but also strengthen and improves flexibility among patients with lower limb osteoarthritis (Uthman et al, 2013)
Current review on fibromylagia have stated physical exercise as one of the multidimensional approach to treat the condition (Hawkins,2013)

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THANK YOU

VIDEO PRESENTATION

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