THE MANAGEMENT OF MUSCULOSKELETAL

DISORDERS
A Physical Medicine and Rehabilitation Point of View

By :
Asmaun N, MD, Physiatrist, SpRM

Rehabilitasi Medik, R.S. Wahidin Sudiro Husodo

Jl. Perintis Kemerdekaan No. 11
 THE MANAGEMENT OF
MUSCULOSKELETAL DISORDERS

PART II

PART I PART III

PART IV PART V
Menu
Menu
Item Physical Medicine Drug Therapy Surgery
and Rehab (PMR)
Muscle Stiffness/
contracture (reversible)
Muscle spasm
Muscle/joint contracture
severe-long standing
Improve circulation
Management of pain
Management of
inflammation

Menu
Item Physical Medicine Drug Therapy Surgery
and Rehab (PMR)
Muscle atrophy and
weakness due to the
disuse condition
Management of swelling
Functional impairment
(non surgical)
Support of preventive
measures
Support of rehabilitation
Control of etiologi factors

Keterangan: Very Possible Impossible

Possible Menu
Menu
 Rest Superficial Heat
Manual Therapy : Deep Heat
Exercise Short Wave Diathermy
Massage Microwave Diathermy
Manipulation Ultrasound Diathermy
Relaxation Cold
Mechanical Theraphy Vapocoolant Spray
Traction : Cervical/Lumbal Ice Packs
Ice Massage
Menu
 Ultrasound-Phonophoresis
Iontophorosis
Transcutaneous Electrical
Nerve Stimulation (TENS)
Laser (Low) Therapy
Hydrotherapy
Joint Protection

Menu
 Recreational Exercises
Supports-Braches, Splints, Strapping, and
Assisitive Devices
Occupational Therapy

Menu
Menu
 Rest
Local Rest
Systemic Rest
Short Rest Periods
Exercise
Goals :
1. Increase and Maintain ROM
2. Reducate and Strengthen muscles
3. Increase static and dynamic endurance
4. Decrease the number of swollen joints
5. Enable joints to function better biomechanically

Menu
 6. Increase bone density
7. Increase the patients overall function and well-being
Techniques :
1. Passive Exercise
2. Active Exercise
3. Strengthening Exercise
4. Endurance Exercise
5. Stretching Exercise
Specific Exercise
Massage

Menu
 Manipulation
Contra Indication Therapy are :
1. Inadequate skill of manipulator
2. Vertebral malignancy
3. Infection of Inflammation
4. Cauda equina syndrome
5. Myelopathy
Traction
Cotra indications :
1. Spinal infection eg tbc, osteomyelitis

Menu
 2. Myelum compression
3. Malignancy
4. Severe osteoporosis
5. Pregnancy (pelvic traction)
6. Malignant hypertension
7. Unstable coronary heart disease
8. Very weak alderly
9. RA (cervical joint)
Phonophoresis
Iontophoresis

Menu
 Heat Therapy
Indications :
1. Tendon/muscle syndromes, regardless of etiology
2. Osteoarthritis of large and small joints
3. Chronic forms of arthritis
4. Chronic periarthropathies
5. Degrenerative disease of the spine
6. Ankylosing spondylitis (other than during flares)
Contra Indications :
1. General : edema, heat disorders, tumors, etc
2. Specific : acute arthritis, vasculitis, active osteoarthritis

Menu
 Infrared Lamp
Hydrocollator Hot Packs
Melted Paraffin/Paraffin Bath
Moist Air
Shortwave Diathermy (SWD)
Microwave Diathermy (MWD)
Ultrasound Diathermy (UWD)

Menu
 Cold Therapy
Indications :
1. Cold therapy is absolutely indicated in :
1. All acute forms of arthritis (including infections arthritis)
2. Acute gout
3. Active OA
4. Acute periarthropathy of the shoulder
5. Acute bursitis and epicondylitis
6. Acute post-trauma on muscles, joints and ligaments
7. Myalgia, especially myofascial trigger point syndrome

Menu
2. Cold Therapy is recommended in :
1. Sub acute arthritis, bursitis, epicondylitis
2. Sub acute and chronic periarthropathy of the shoulder, less
often in osteoarthritis in major joints
3. Chronic tendinitis
4. Shoulder-hand syndrome, stage I
5. Postoperative cases after joint and tendon surgery and
discoperations
6. Sub acute post-trauma
7. Joint and spinal stiffness
3. Cold Therapy is generally not recommneded in :
1. Scleroderma
2. Ankylosing spondylitis

Menu
 4. Cold Therapy is contra indicated in :
1. Raynauds disease
2. Vasculitis
3. Urticaria from exposure to cold
4. Sensitivity to cold
5. Severe cold pressure reaction
6. Paroxysmal cold hemoglobulinemia
7. Cold agglutinin disease
8. Pronounced cryoglobulinemia
9. Kidney and bladder disease
10. Severe cardiovascular disease

Aquatic Therapy / Hydrotherapy

Menu
 Laser Therapy
TENS
Indications :
1. Best Response : ~ Neurogenic pain of peripheral nature
~ Post-operative pain
2. Some Response : ~ Musculoskeletal pain
3. Poor Response : ~ Central pain
~ Psychogenic pain
Absolute contra indication : Cardiac Pacemaker
Recreational Exercise

Menu
 Assitive Devices, Brace, Splints, and Supports
Crutches
Canes
Walkers
Wheelchairs
Braces
Splints
Special Shoes
Strapping and Bandaging

Menu
 Joint Protection
Guiding principles of joint protection :
1. Avoid positions that cause deformity
2. Avoid sustained positions
3. Use the strongest joint for heavy work
4. Sufficiently frequent rest periods
5. Use joints to the greatest mechanical advantage
6. The patient must be taught to respect pain
7. The therapist teaches the patient the use of assistive
devices for self-care and homemaking activities

Menu
8. The arthritic patients home can be made safe by the addition
railings at stairways, removal of heavy managed latches on
doors and cabinets, and arrangement of furniture and work areas
for ease of movement and function
9. To maintain muscle power and prevent deformity, the patient
learns methods of using the muscle that maintain joint ROM,
strength, coordination, and body aligment.
As a rule, the following sports are contra indicated in
rheumatic disease :
Boxing, wrestling, and martial arts
Weight lifting
Sport with a high risk on injury
Sports requiring extreme stamina
Playing sports under unfavourable climatic conditions

Menu
Chief aim of sporting activities in rheumatic disease
Maintenance of function
Joint mobilization without exercise load-bearing
Reduction of muscle strength
Prevention of muscular athropy and postural defects
Prevention of osteoporosis and osteoarthritis
Maintenance of general fitness
Enjoyment of physical exercise and restoration of self-
confidence

Menu
Occupational Therapy
The goal of occupational therapy
1. To alleviate functional impairment
2. To increase the patients independence (through self-help
training and the use of aids)
3. To improve the patients fitness for work (including training for
house work and adaptation of work place)
4. Instruct patient in joint protection techniques
5. Vocational counseling
To improve the patients work prospects, occupational
may focuson the following :
1. Workplace training
2. Workplace adaptation
3. Provision of aids

Menu
Menu
A. Main goals of Physical Therapy :
A. Relief of pain
B. Suppression of inflammation
C. Prevention and correction of contracture/increasing
range of motion (ROM)
D. Maintaining or increasing muscle strength
E. Maintaining or increasing muscle endurance or
cardiopulmonary endurance
F. Improving coordination
G. Relaxation of circulation
H. Proper gait training

Menu
B. Modes of action
A. Triggering of short-term reactions (Immediate
effects)
B. Triggering of long-term regulatory processes
(adaptation)

Menu