1. PHYSIOTHERAPY IN THE MANAGEMENT OF KNEE PAIN
Presented at the workshop of the Nigeria Society for the Study of Pain 2016
Onigbinde Ayodele Teslim BMR PT, PhD, MACAPN, LPT, MNAOMT

3. Physiotherapy: Educate the patient Rest Cryotherapy /cryoanalgesia
Acute stage
Sub-acute
Educate the patient
Rest
Cryotherapy /cryoanalgesia
Joint positioning
Splinting
Low intensity exercise programmes
Thermotherapy
Electro-analgesia
Passive movements
Moderate intensity exercise programmes
Mobilization techniques
Massage with topical medications

4. Chronic stage/ Rehabilitation
Mobilization techniques
Passive stretching
Splinting
Thermotherapy and Electro-analgesia

5. ACUTE: Cryotherapy/Cryo-analgesia
Skin temperature is reduced to 10 ° C
There is stimulation of cold receptors
The impulses arrive through large diameter nerves
Blocking other (pain) impulses attempting to access the spinal cord (pain gate theory).
This reduces the pain temporarily.
Duration of application ?

6. SUB-ACUTE & CHRONIC: Kinetic chain exercises
Open and closed kinetic chain exercises
Stimulates mechanoreceptors thus blocking the nociceptive stimulus

7. OKE
A set of three lower limb activities in supine lying (Awotidebe et al, 2011)
-Air Cycling for a period of two minutes
- Active straight leg raising 5sec/10reps /2sets
-Isometric Quads contraction 2sets/10reps

8. CK & SCOOTING EXERCISES

9. Continuous passive motion MACHINE
↓ degradation effects of immobilization
Providing a quicker return of ROM
↓ postoperative pain
1 cycle per 45 seconds per 2 minutes is well tolerated.

10. Improving muscle strength
Quadriceps weakness
Resistance/weight/strength training
-a prominent feature [David et al 2011; Jefferson, 1990; Stephanie et al, 2008].
-Functional activity limitations-
-Arthrogenic muscle inhibition (AMI)
-Lean muscle cross sectional area
Increase in muscle strength protects the knee from pain aggravation
Determine the value of 1 RM
Quads & Hams isometric contraction for 3 to 5 seconds
3 sets of 12 repetitions
Set of 1 – 5rep: develops strength
Set of 6 – 12reps: muscle balance & strength

11. Avoiding Pain aggravation
Cross training effects
Bilateral co-activation of the cortico-spinal tract
Diffusion of impulses between the cerebral hemisphere
Activation of afferent modulation at the contra-lateral limb

12. Transdermal massage: Oral Vs Topical medications
Bioavailability and plasma concentrations between 5% and 15% compared to systemic [Heyneman et al, 2000)].
Diclofenac was the most preferred topical medication (Onigbinde et al 2014).

13. Dosage specificity for topical medications
Advocacy for the use of FTU
1FTU = 0.5g
1 FTU can treat twice the size of a handprint
Leg and thigh 5.8 ±1.7cm2
Knee: approx 1 – 2FTU
Equivalent to 0.5 – 1g

14. Pain caused by muscle tension, spasm and dysfunction
Pressure on muscle tissues to manipulate
Mobilization techniques
MET

15. Muscle Energy Techniques (MET)
Using isometric and isotonic contractions
3 to 5 seconds
2 to 3 x
Neurophysiological principles
Postcontraction Inhibition
After a muscle is contracted, automatically goes into a relaxed state for a brief period
Reciprical Inhibition
When one muscle is contracted, its antagonist is automatically inhibited
Operator – Direct Method
Patient contracts agonist muscle
Chronic conditions
Operator – Indirect Method
Patient contracts antagonist muscle
Acute conditions

16. Mobilization Techniques: Distraction & Gliding techniques
Distraction techniques
Anterior gliding

17. TIBIOFIBULAR MOB
POSTERIOR GLIDING

18. Pain & thermotherapy: short wave diathermy (SWD)
Physiologic and therapeutic effects
Release of inflammatory chemical mediators and nitrous oxide [Minson et al, 2001].
Vasodilatation ↑ the rate of enzymatic biological reactions, the nerve conduction velocity, and soft tissue extensibility
Increased elasticity of connective tissues and range of motion (Cetin et al, 2008).
Aids the synthesis of glucosamine [Vaharanta , et al, 1982)].

19. COCHRANE reviews ON ULTRASOUND
EMDA:
Ultrasonophoresis
Loyola-Sánchez et al(2010)
Using VAS measured in centimeters.
Application of US resulted in decreased pain for knee OA [SMD CI  = −0.49  P = 0.002] 
US better than control (Rutjes et al, 2010)
Piroxicam phonophoresis alleviated pain more than only ulrasound (p=0.009). [KOA, 2013]
knee OA: insight for the health care professionals, 2013

20. PULSED vs cont. US 5mins US, Freq 1MHz, 2W/cm2, 5cm diameter
PI in PUS < placebo group
No superiority for CUS over placebo
CUS at 1MHz, 1W/cm2, 5mins for 10 sessions is as effective as ibuprofen phonophoresis (Kozanolu et al 2003; Ozgonenel, 2009)

21. Electro-analgesia Interferential Current therapy (IFC) TENS
Iontophoresis
EMS

22. IFC Duration of tx 15- 20 minutes 3x a week Contraindications
Pain of central origin
Pain of unknown origin
Indications
Acute pain
Chronic pain
Muscle spasm

23. TENS FOR KNEE OA Acute stage Sub acute Chronic Gate control theory
Relevance
Physiological effects
Acute stage
Sub acute
Chronic
Gate control theory
Opiate-mediated control theory
Local vasodilatation
Stimulation of acupuncture points causes a sensory analgesia effect

24. EMDA Iontophoresis
40% researches focused on transdermal delivery (Kamalet al 2007)
Multiple fold increase in penetration((Schuetz et al 2005)
NSAIDs block the actions of prostaglandin- generating enzyme (Cyclooxygenase)

25. iontophoresis GlucoSo4
↓Pain (Bassleer, ;Reginster et al, 2001, Graig 2013 ; Onigbinde et al 2008, Onigbinde et al 2009, Onigbinde et al 2016)
Dexamethazone 
Iontophoresis is more effective than placebo in relieving pain (Hasson et al and Li et al, 1996)
Diclofenac flux & sorbitan mono-oleate
1% w/v of sorbitan monooleate concentration and methylated spirit enhanced immediate ↓ in PI and ↑ in knee flexion (Onigbinde et al 2013)

26. Iontophoresis IN KN OA Tramadol PI < TENS Hot pack Ultrasound
Exercise therapy (Turhanoğlu, et al, 2010)
Ibuprofen
5% ibuprofen = TENS (Bello and Kuwornu, 2014)

27. Magnesium Sulphate + ve Dexamethasone - ve Acetic acid - ve
Drug charges
Drug charges
Piroxicam ve
Diclofenac ve
Methyl Salicylate ve
Menthol ↔
Ketoprofen ve
Ibuprofen ve
Lidocaine ve
Naproxen ve
GlucosamineSo ve
Capsaicin ↔
Magnesium Sulphate + ve
Dexamethasone ve
Acetic acid ve
Hydrocortisone ve

28. Drug transmission pathways
Intercellular (paracellular)pathway
-between the conneocytes along the lamellar lipids
Intracellular (transcellular) pathway
-through the cells
Appendageal (shunt) pathway
- hair follicles, sweat ducts and secretory glands

29. EMS: Physiologic responses to EMS:
Contraction of muscle.
Relaxation of muscle spasm.
Increase of endorphins production.
Increase of fiber recruitment.
Stimulation of circulation.
Enhancement of reticulo-endothelial response to clear waste products.

30. Pain Control Sensory-level Motor-Level Noxious Level
Target A-beta fibers Motor nerves A-delta
Tissue C fibers
Phase < 60 µsec 120 to 250 µsec 1 msec
Duration
Pulse 60 to 100 pps 2 to 4 pps Variable
Frequency 80 to 120 pps
Intensity Submotor Moderate to To tolerance
Strong contraction

31. Contraindications and Precautions
Areas of sensitivity
Carotid sinus
Esophagus
Larynx
Pharynx
Around the eyes
Temporal region
Upper thorax
Severe obesity
Epilepsy
In the presence of electronic monitoring equipment
Cardiac disability
Demand-type pacemakers
Pregnancy (over lumbar and abdominal area)
Menstruation (over lumbar and abdominal area)
Cancerous lesions (over area)
Sites of infection (over area)
Exposed metal implants

32. Pain management requires multi-disciplinary approaches but Physical Therapy is an accepted conservative means
Compliance is usually high with minimal side effects
Self management is easy
Improved QoL and physical functions when pain is less

33. Thank you