Articles from prior issues of The Advocate

March/April 2001

Aches and Pains of Physical Medicine
by Ken Forbes, Oregon DDS

WHILE TECHNICAL PROBLEMS PROHIBITED THE use of the Power Point presentation, physiatrist Dr. Luis Cotto went forward with the show.

Early management for people with musculo-skeletal conditions must include an assessment of the likelihood of recovery. Dr. Cotto advocates open communication with the patient to let them know how likely it is that they will recover, to what extent they will recover, and how soon they can expect to see improvement. Today, doctors have several tools to assist patients through the recovery process. These tools include physical therapy, rest, medication and orthotic devices.

The audience was somewhat unhappy with the loss of the PowerPoint presentation when Dr. Cotto resorted to the old pop quiz approach. The question was “what is the difference between sprain and strain?” I just knew the answer had to be that strains involve lifting a lot more weight than sprains do. I was wrong. The difference is that “Strains” affect muscles and tendons while “sprains” involve ligaments.

Overuse is a very common problem for hips and knees. In the hip, trochanteric bursitis often results from overuse and it tends to be a chronic condition. Fibromialgia , pain, and chronic pain are often associated with depression and treatment plans need to consider this component. Dr. Cotto said they commonly see patients with herniated nucleous pulposis (HNP) resulting from trauma. For anyone unfamiliar with that condition, it is the bulging forth (herniation) of the jelly-like (pulp) central (nuclear) material from a spinal disc. Anatomically, the disc separates two vertebrae and provides some shock absorption.

Acute trauma to the musculo-skeletal system needs 72 hours immediate rest. Then, depending on the nature of the condition, this period of rest gets adjusted. For example HNP will require 10 days rest with traction.

In the majority of cases just following the dictates of mother nature means that you will recover and not need additional treatment.

The first four weeks is critical for rest. After the first four weeks, scar tissue has formed and that will not have the same elasticity and ability to recover. It will result in lost range of motion.. At that point, ultrasound and stretching will lengthen the muscle fibers and let the muscle recover omewhat better.

Heat and cold - cold always used first, during the first 72 hours. Cold inhibits transmission of pain and inhibits the intrafusile fibers of the muscle - relaxing the muscle. For some patients cold can be effective if used in 15-20 minute increments even beyond the first 72 hours. In other cases, heat will work better after 72 hours.

Use of transcutaneous electrical stimulation increases blood flow. This device also has some effect on the nerve tissue and may interrupt pain signals going to the brain.

All modalities must be combined with exercise. In some cases, this is just stretching . However, atrophy sets in very quickly and strength retention is much easier than to regain lost strength.

To prevent atrophy, Dr. Cotto uses isometric exercise. Isometric exercise is a sustained contraction without moving the joint - sustained for at least six seconds. While isometric exercises will prevent atrophy, to regain lost strength require progressive resistance exercises. No, that doesn’t mean getting progressively more resistant to doing exercises. It means using muscles to move through a range of motion against some sort of resistance.

In the upper extremity osteoporosis will develop if the patient does not contract the muscles of the upper arm and hand. It came as a surprise to me to learn that the bones depend on muscle contraction to prevent calcium loss.

Someone from the audience, remembering the pop quiz I’m sure, asked about the use of magnetism to treat pain. Dr. Cotto answered by pointing out the beneficial effect of placeboes. He suggests that, if magnetism was really effective in treating pain, then everyone who undegoes an MRI (Magnetic Resonance Imaging) would come out without pain because the MRI provides just about the most powerful magnetic field anyone would be exposed to. And, it is designed to realign all the molecules of the body.

Trying to determine disability is a problem not just due to the patient’s condition but also because professional treatment often reinforces disabling behaviors.