Physiotherapy in dentistry - Dr Sanjana ravindra

Physiotherapy: Key to the kinetics of orofacial musculatureSodhi A, Nair PK, Hegde S J Indian Acad Oral Med Radiol 2014;26:419-24.

Dr Sanjana RavindraOral medicine and radiology Rajarajeswari dental college

DEFINITION

Kinetics The scientific study of the turnover or rate of change or specific factor in the body, commonly expressed as units of amount per unit time.Chemical kinetics the study of the rates and mechanism of chemical reactionsKinesilogy attempts to explain the manner in which movement of the body occur by considering collective areas of information from anatomy, physics and mechanics2

Oxford Textbook of Palliative Medicine

DEFINITION World Confederation for Physical Therapy (WCPT) defines Physical Therapy

History

Kumar SP, Jim A. Physical therapy in palliative care: From symptom control to quality of life: A critical review. Indian J Palliat Care 2010;16:138-46.

4

CARDIOPULMONARY DISEASES

NEUROLOGICAL DISORDRESMUSCULOSKETAL INJURIESORTHOPAEDIC

THERAPEUTIC APPLICATIONSKumar SP, Jim A. Physical therapy in palliative care: From symptom control to quality of life: A critical review. Indian J Palliat Care 2010;16:138-46.

Physiotherapy is used in various specialities like in 5

THERAPEUTIC APPLICATIONS IN OROFACIAL CONDITIONSTMDsIntracapsular joint disorders (clicking and clicking-related jaw incoordination as a result of disc displacement)Intracapsular joint disorders (acute trauma-induced joint pain)Intracapsular joint disorders (chronic closed lock and painful capsulitis)Intracapsular joint disorders (arthritic changes in TMJ)Masticatory muscle painMandibular mobility disorders (Hypermobility)Mandibular mobility disorders (Hypomobility)Post-orthognathic surgeryPost-TMJ surgeryOral submucous fibrosisBells palsy

Sodhi A, Nair PK, Hegde S. Physiotherapy: Key to the kinetics of orofacial musculature. J Indian Acad Oral Med Radiol 2014;26:419-24.

McNeely et al. conducted a systematic review on the efficacy of physical therapy interventions for TMD patients. Four of the 12 articles which met their selection criteria were dedicated to exercise and manual interventions. Jadad score of 2 was obtained for the four studies. One study did not demonstrate significant benefit from the chosen treatment strategy which was an oral exerciser device. The remaining three studies evaluated postural training, manual therapy and exercise, which demonstrated significant benefit. They concluded that active and passive oral exercises, and exercises to improve posture can reduce symptoms associated with TMD. To firmly establish the role of physical therapy in orofacial disorders, more evidencebased research is needed.[12] Table 2 shows the various physical therapies which can be employed for orofacial conditions

6

TREATMENT MODALITIES IN PHYSIOTHERAPY


PHYSICAL THERAPY Massage Deep tissue massage Trigger point therapy Myofascial release massageSpray and stretch Physical activity


Massage Deep tissue massage Trigger point therapy Myofascial release massageSpray and stretch Physical activity


PHYSICAL THERAPY

MASSAGE

Clark GT, Adachi NY, Dornan MR. Physical medicine procedures affect temporomandibular disorders: A review. J Am Dent Assoc 1990;121:151-62

BIOMECHANICAL EFFECTS

Eisensmith L. (2007). Massage therapy decreases frequency and intensity of symptoms related to temporomandibular joint syndrome in patients one case study. Journal of bodywork and movement therapies. 11: 223-230





PHYSIOLOGIC EFFECTS


Psychologic Effects


It stimulates parasympathetic activity which in turn reduces stress and anxiety.

Treatment TechniquesClinician hands should be warmPressure regulation determined by the type and amount of tissue present and patient's condition Rhythm must be steady and evenDuration depends on the pathology, size of the area being treated, speed of motion, age, size, and condition Massage should never be painful Direction of forces should parallel muscle fibers Make sure patient is warm and in a comfortable, relaxed positionSufficient lubricant should be usedBegin with superficial stroking to spread lubricantStroke should overlapPressure should be in line with venous flow followed by a return stroke All strokes should be rhythmic


Outcome of Massage

Clark GT, Adachi NY, Dornan MR. Physical medicine procedures affect temporomandibular disorders: A review. J Am Dent Assoc 1990;121:151-62

Indications

Clark GT, Adachi NY, Dornan MR. Physical medicine procedures affect temporomandibular disorders: A review. J Am Dent Assoc 1990;121:151-62Contraindications



SPRAY AND STRETCH TECHNIQUEThis technique utilizes a vapocoolant. It is thought that the vapocoolant modulates the pain so that more manipulation is possible without discomfort.


SPRAY AND STRETCH TECHNIQUE

It involves passively stretching the target muscle while Simultaneously applying ethyl chloride spray topically. Sudden drop in skin temperature is thought to produce temporary anesthesia by blocking the spinal stretch reflex and the sensation of pain at a higher center. Decreased pain sensation allows the muscle to be passively stretched toward normal length, which will help to activate trigger points relieves muscle spasm and reduce referred pain.21


A mixture of fluorocarbons delivered in form of fine stream with the calibrated nozzle.The muscle is stretched & stream is directed at an acute angle of 30 degrees.In end moist heat is applied & range of motion exercises instituted.

22

Simons and Mense (2003)


Simons and Mense (2003) advocate the use of vapocoolant spraying for the management of myofascial trigger points.

23

Indication

Spray and stretch techniques have been widely used by clinicians to treat myofascial pain due to active trigger points, musculoskeletal dysfunction, and to increase range of motion (ROM) of various joints

24



Physical activity


Soft tissue mobilizationSoft tissue therapy(STT) is theassessment,treatmentand management ofsoft tissueinjury, pain and dysfunction primarily of the neuromusculoskeletal systemAlso known as - Myofascial ReleaseGroup of stretching techniques used to relieve soft tissue from abnormal grip of tight fasciaMyofascial restrictions are unpredictable and may occur in many different planes and directionsTreatment is on localizing restriction and moving into the direction of the restriction


Joint mobilization


Muscle conditioning is a term that relates to a group of exercises that are performed in order to strengthen the muscles in the body and improve endurance.MUSCLE CONDITIONING


There are exercises that can help restore normal function and range of movement of the orofacial musculature. Four types of exercises can be instituted:

29

LIP EXERCISES

OPENPUCKERPUCKER AND MOVESIDEWAYSSMILECLOSE LIPS TIGTHLYBLOW AIR AND HOLD


TONGUE EXERCISESSTRETCH AND HOLDMOVE TO THE LEFTMOVE TO THE RIGHTPUSH CHEEK WITH TONGUEMAKE A CIRCLETOUCH UPPER LIP




ELECTRODE PLACEMENTElectrodes may be placed:On or around the painful area Over sites where peripheral nerves that innervate the painful area becomes superficial and can be easily stimulatedOver superficial vascular structuresOver trigger point locations

Bellis E, Bazin S, Kitchen S, (2009) .Electrotherapy evidence based practice. Publisher: Churchill Livingstone 11 ed: 259-281

Creating muscle contraction through nerve or muscle stimulationStimulating sensory nerves to help in treating painCreating an electrical field in biologic tissues to stimulate or alter the healing processCreating an electrical field on the skin surface to drive ions beneficial to the healing process into or through the skinIndications for Electrical Stimulation


Contraindications for Electrical StimulationPregnancyInfectionMalignancy Pacemaker


Gate Control TheoryImplies a non-painful stimulus can block the transmission of a noxious stimulus.Is based on the premise that the gate, located in the dorsal horn of the spinal cord, modulates the afferent nerve impulses.

S K Chaudhari.Concise Medical Physiology 6th edition NCBA; 2011.

Conditions that open or close the gate

Conditions that open the gate

Conditions that close the gate

Physical conditions

Extent of the injury

Medication

Inappropriate activity level

Counterstimulation, eg massage

Emotional Conditions

Anxiety or worry

Positive emotions

Tension

Relaxation

Depression

Rest

Mental conditions

Focusing on the pain

Intense concentration or distraction

Boredom

Involvement and interest in life activities

TRANSCUTANEOUS ELECTRICAL NERVE STIMULATIONTranscutaneous electrical nerve stimulation (TENS) utilizes a high frequency, but very low intensity electric current. Used to stimulate the nociceptive A-beta cutaneous afferents that activate the descending pain-inhibitory mechanism without involving the opioid peptides. Useful in acute pain, chronic intractable pain, trigeminal neuralgia, peripheral nerve injuries, myofascial pain dysfunction syndrome and causalgiaAnalgesic effect ranges from 50-70%.


ELECTROGALVANIC STIMULATION THERAPYElectrogalvanic Stimulation Therapy (EGS) uses a high-voltage, low-amperage mesomorphic current of varied frequency. A rhythmic electrical impulse is applied to the muscle, creating repeated involuntary contractions and relaxations. This causes a break-up of the myospasm as well as increases the blood flow to the muscles.


Low-intensity direct current (microampere)-Bioelectric current follow path of least resistanceInjured site increasing ATP production, assist in tissue growth and healingMicrocurrent Electrical Nerve Stimulation


41Use is not substantiated in professional literatureAnecdotal and sport personnel testimonials

ELECTROACUPUNCTURE


Diathermy


ContraindicationsIndications


44

ULTRASOUND


High frequency electrical generator connected through an oscillator circuit and a transformer via a coaxial cable to a transducer housed within an applicator

Therapeutic Ultrasound Generators


Frequency range of therapeutic ultrasound is 0.75 to 3.3 MHzFrequency is the number of wave cycles per secondMost generators produce either 1.0 or 3.0 MHzDepth of penetration is frequency dependent not intensity dependent1 MHz transmitted through superficial layer and absorbed at 3-5 cm3 MHz absorbed superficially at 1-2 cm

Therapeutic Ultrasound Generators


Thermal Effects of Ultrasound

Increased collagen extensibilityIncreased blood flowDecreased painReduction of muscle spasmDecreased joint stiffnessReduction of chronic inflammationNon-Thermal Effects of Ultrasound

Increased fibroblastic activityIncreased protein synthesisTissue regenerationReduction of edemaBone healingPain modulation


indications

49

Areas of decreased temperature sensationVascular insufficiencyEyesPregnancyPacemakerMalignancyInfectionContraindications


Laser

Light Amplification by the Stimulated Emission of Radiation

Principle - photonic energy delivered into tissue, modulate the biologic process in tissue.Cold laser ( He Neon ) stimulation at acupoints is as effective as EA and has the advantage of being practically painless


Lasers accelerate collagen synthesis ,increase vascularity of healing tissue ,decrease the number of micro-organisms and decreases pain

51

IONTOPHORESIS




Heating Agents Transfer heat to patients body, between various tissue / fluids

Cooling Agents Transfer heat away from patients body

53

HOT APPLICATIONHot application is the application of a hot agent, warmer than skin either in a moist or dry from on the surface of the body

McNeely ML, Armijo Olivo S, Magee DJ. A systematic review of the effectiveness of physical therapy interventions for temporomandibular disorders. Phys Ther 2006;86:710-25.

54

Cold applicationCold application is the application of a cold agent cooler than skin either in a moist or dry form, on the surface of the skin. Cold encourages relaxation of muscles that are in spasm and thus relieves associated pain


Temperature for hot and cold applicationsDescription Temperature Application Very coldBelow 15CIce bag Cold 15-18 CCold packs Cool 18 27 CCold compresses Tepid 27 37 CAlcohol sponge bathWarm 37 40 CWarm bath Hot 40 46 CHot soak, hot compresses Very HotAbove 46 CHot water bag for adult

PHYSIOLOGICAL EFFECTSHOT APPLICATIONCOLD APPLICATIONPeripheral VasodilatationPeripheral VasoconstrictionIncreased capillary permeabilityDecreased capillary permeabilityIncreased oxygen consumptionDecreased oxygen consumptionIncreased local metabolismDecreased local metabolismDecreased blood viscosityIncreased blood viscosityDecreased muscle toneDecreased muscle toneIncreased blood flowDecreased blood flowIncreased lymph flowDecreased lymph flowIncreased motility of leucocytesDecreased motility of leucocytes


CONTRAINDICATIONS HOT APPLICATIONS

MalignanciesAcutely inflammed areasWith paralysisOpen woundsEdema associated with venous or lymphatic diseasesHeadacheWith very high temperature

Cold APPLICATIONS State of shock & collapseEdemaimpaired circulationMuscle spasmDecreased sensationWith very low temperatureCold hypersensitivity or intoleranceRaynauds DiseaseRegenerating Nerves


COMPLICATIONS PainBurnsRedness of the skinEdemaHyperthermia

HOT APPLICATIONS PainBlisters and skin breakdownGrey or bluish discolorationThrombus formationRedness HypothermiaCOLD APPLICATIONS


HOT PACKS


PARAFFIN wax


Ice PACKS


ICE CUBE MASSAGE


COLD/ ICE SPRAYS

fomentationDefinition: The alternate application of hot and cold fomentation to a local area.Heat Induces vasodilation: drawing blood into the target tissues. Increased blood flow delivers needed oxygen and nutrients, and removes cell wastes.The warmth decreases muscle spasm, relaxes tense muscles, relieves pain, and can increase range of motion.Cold therapy produces vasoconstriction, which slows circulation reducing inflammation, muscle spasm, and pain.


Hot- cold fomentation Effects:Relieves pain through acceleration of local circulation.Stimulates healing in local injuries with contusions.Relieves muscle stiffness and pain due to trauma and strain.Stimulates healing in wound infections.Indications:Infected wound.Local injuries due to trauma and muscular contusions.Muscle stiffness.


Indications


Contraindications


ConclusionPhysiotherapy has cured various diseases without inflicting mental trauma and the pain of undergoing surgery in medical field.This novel way of medicine has been brought into practice in dentistry as an adjuvant therapy.

References Kumar SP, Jim A. Physical therapy in palliative care: From symptom control to quality of life: A critical review. Indian J Palliat Care 2010;16:138-46.Rosted P. Introduction to acupuncture in dentistry. Br Dent J 2000;189:136-40. Allen RJ. Physical agents used in the management of chronic pain by physical therapists. Phys Med Rehabil Clin N Am 2006;17:315-45. Clark GT, Adachi NY, Dornan MR. Physical medicine procedures affect temporomandibular disorders: A review. J Am Dent Assoc 1990;121:151-62. Dostalov T, Hlinakova P, Kasparova M, Rehacek A, Vavrickova L, Navrtil L. Effectiveness of physiotherapy and Gas laser in the management of temporomandibular joint disorders. Photomed Laser Surg 2012;30:275-80.Bush FM, Dolwick MF. Conservative treatment. In: Bush FM, Dolwick MF. The Temporomandibular Joint and Related Orofacial Disorders. 1st ed. Philadelphia: JB Lippincott Company; 1995. p. 303-56Fulton CL (1994).Physiotherapists in cancer care: A framework for rehabilitation of patients. Physiotherapy 80 (12): 830-34.Fulton CL, Else R (1997) Rehabilitation in palliative care: physiotherapy. in Oxford Textbook of Palliative Medicine. Doyle D, Hanks GWC, McDonald ed Oxford; Oxford University PressS K Chaudhari.Concise Medical Physiology 6th edition NCBA; 2011.How physiotherapy works - the mechanisms of physiotherapy. 2008.Karren F. (2002) Oral motor exercises in treatment of phonological disorders. Semin Speech Lang .23(1): 015-026.Khokhar V. (2000) Textbook of Helpline Electrotherapy for Physiotherapists Publisher: Bharat Bharati Prakashan & Co. 1 ed: 627. 25-39.

Wright EF, North SL. Management and treatment of temporomandibular disorders: A clinical perspective. J Man Manip Ther 2009;17:247-54.von Piekartz H, Hall T. Orofacial manual therapy improves cervical movement impairment associated with headache and features of temporomandibular dysfunction: A randomized controlled trial. Man Ther 2013;18:345-50.McNeely ML, Armijo Olivo S, Magee DJ. A systematic review of the effectiveness of physical therapy interventions for temporomandibular disorders. Phys Ther 2006;86:710-25.Okeson JP. General considerations in managing orofacial pains. In: Okeson JP. Bells Orofacial Pains: The Clinical Management of Orofacial Pain. 6th ed. Chicago: Quintessence Publishing Co Inc.; 2005. p. 197-242.Kostopoulos, D., Rizopoulos, K., Effect of topical aerosol skin refrigerant (Spray and Stretch technique) on passive and active stretching. Journal of Bodywork and Movement Therapy (2008), doi:10.1016/j.jbmt.2007.11.005Bellis E, Bazin S, Kitchen S, (2009) .Electrotherapy evidence based practice. Publisher: Churchill Livingstone 11 ed: 259-281Carolyn K, Lynn A, (2002) Therapeutic Exercise: Foundations and Techniques Publisher: F. A. Davis Company 4 ed: 55-99.Charted society of physiotherapy.The effectiveness of physiotherapy in the palliative care of older people. may 2010. Cole RP, Lucien B, Scialla SJ (2000). Functional recovery in cancer rehabilitation. Archives of Physical Medicine & Rehabilitation. 81: 623-627.Eisensmith L. (2007). Massage therapy decreases frequency and intensity of symptoms related to temporomandibular joint syndrome in patients one case study. Journal of bodywork and movement therapies. 11: 223-230McDonnell ME, Shea B.D. (1993) the role of physical therapy in intensity in patients with metastatic disease to bone. Back and Musculoskeletal Rehabilitation. 3(2): 78-84

References

THANK YOU

Health & Medicine

Physiotherapy in dentistry - Dr Sanjana ravindra