Conservative Orthopedics: Pain Management, Manual Medicine, and Modern Treatment at the Clinic or Without Surgery for Medical Conditions

Physical therapy uses active and passive exercises to

• restore or maintain motor functions,
• relax or strengthen muscles, and
• improve coordination.

The patient performs active exercises independently, gradually increasing the level of difficulty. During these movements, the patient may also be supported by the therapist’s hand (guided movements). The difficulty is increased by the weight of the limbs themselves and, later, by additional (controlled) resistance. Active exercises are primarily used to improve mobility in cases of functional limitations caused mainly by muscular factors.

Passive exercises are used for stiffness primarily caused by passive structures. These include

• capsules,
• ligaments,
• intra-articular adhesions, and
• scar contractures.

These exercises consist mainly of stretching and traction. The patient can use mechanical aids for this, such as

• weight-bearing exercises,
• pendulums, and
• motor movement splints.

Isometric, isotonic, and isokinetic exercises promote muscle activity:

• Isometric exercises: Increase in tension without shortening (exercises against resistance).
• Isotonic exercises: The muscle shortens while maintaining constant tension.
• Isokinetic exercises: A constant contraction is maintained throughout the entire range of motion, from full flexion to full extension.

Isokinetic exercises yield the greatest performance gains (strength and endurance training in sports, “bodybuilding”) when weights or sophisticated exercise equipment are used that also allow the speed of movement to be adjusted (Cybex training machines).

Static muscle work, on the other hand, quickly leads to poor blood circulation with an oxygen deficit and thus to fatigue. It is therefore unphysiological.

Physiotherapy methods based on neurophysiology require special attention. They focus on specific techniques for proprioceptive and developmental kinesiological control of movement sequences. They are used, for example, with young children who have motor impairments. They are also used for dynamic contractures resulting from impaired coordination (using the Voita or Bobath methods).

Exercise programs are carried out in the form of individual and group exercises in the exercise room or in the therapeutic pool. The therapist provides instructions on how to use exercise equipment and creates home exercise programs for the patient to perform individually at home.

General physical development is intended to be promoted through school physical education, gymnastics, sports, etc., and generally does not require targeted physical therapy.

Specialist medical treatment as part of physical therapy is, however, indicated for conditions such as

• scoliosis,
• fixed kyphosis,
• growth disorders

.

Special forms of care include special physical education classes at school for children with poor posture and sports for people with disabilities.

Certain techniques, such as

• stroking,
• rubbing,
• kneading,
• tapping, or
• vibrating

promote increased local blood flow by dilating blood vessels and accelerating blood flow in capillaries and lymphatic vessels. This results in

• improved tissue perfusion, which stimulates local metabolism,
• an improved oxygen supply, and
• the removal of metabolic waste products.

This is associated with relaxation, relief from muscle spasms, and an indirect reduction in pain.

Trigger points are areas of muscle tension with hardened, pressure-sensitive pain points. Trigger point massage can be very effective here. Trigger points typically cause not only localized tenderness but also radiate pain to more distant areas of the body. The principle of trigger point treatment is clearly demonstrated in the video:

Massage can have a positive effect extending from the skin to the internal organs. This activation of cutivisceral reflex mechanisms also affects

• pain transmission (afferent pathways) and
• the function of the vasomotor nerves of the arteries.

Specific techniques for this include connective tissue massage and reflexology, such as foot reflexology.

Lymphatic drainage is suitable for

• a tendency toward congestion,
• edema, and
• impaired tissue perfusion, for example, following prolonged immobilization. 

In general, massage improves well-being and promotes overall relaxation and calm (parasympathetic stimulation). Massage cannot be used to increase muscle strength! Special techniques make use of equipment such as underwater jet, suction, and vibration massage.

Chirotherapy is also known as manual therapy or chiropractic. It involves medical procedures to mobilize fibrously stiffened joints through

• manual stretching (under anesthesia under certain conditions) and
• manual redressement (orthopedic correction) of deformities, e.g., in cases of congenital clubfoot.

Chiropractic therapy employs specific manual techniques to treat functional structural disorders of the limbs and vertebral joints. These manipulations are limited

• either to the natural range of motion of the affected joint, or
• they controlledly exceed the physiological limit of mobility, usually accompanied by an audible cracking sound.

In doing so, they release mechanical locking mechanisms (blockages). In addition, they mobilize the local reflex mechanism by stretching the capsular and ligamentous structures.

This therapy requires specialized knowledge and a subtle mastery of its indications and techniques. Strict contraindications include

• inflammatory diseases,
• tumors,
• osteoporosis, and
• possible nerve entrapments and herniated discs.

Manual therapy also includes passive range-of-motion exercises performed by a physical therapist. These improve joint mobility and relieve chronic pain associated with muscle tension.

Occupational therapy serves as a functional extension and complement to physical therapy. It employs a variety of effective methods that can restore impaired arm and finger functions in a quasi-playful manner. These methods are based on activities performed at home, at work, or during leisure time.

If necessary, irreversible loss of movement can be addressed by

• practicing compensatory movements or
• by providing individualized assistive devices

. These assistive devices range from simple adaptations of eating utensils to complex splints and work tools.

Thermotherapy (hyperthermia treatment) and hydrotherapy (water therapy) utilize the effects of, among other things,

• water,
• heating pads, and
• ice packs

on the body.

Thermotherapy uses either heat or cold. Heat immediately leads to vasodilation, hyperemia, and an acceleration of metabolic processes. Cold initially causes vasoconstriction (narrowing of blood vessels). After exposure to cold, the capillaries also dilate, resulting in “reactive” hyperemia.

In principle, heat and cold thus produce the same biological effects, although these depend on the intensity and duration of their application.

Holistic thermotherapeutic combinations of stimuli include, for example,

• compresses,
• baths,
• hot steam,
• cold (cold showers).

The therapy harnesses their circulation-promoting, metabolism-stimulating, and relaxing effects. These positive effects were already described in the hydrotherapy founded by Sebastian Kneipp and have proven effective time and again. They also serve to prepare for and support other types of treatment, such as massage and physical therapy.

Local heat application, for example with

• heating pads,
• hot water bottles,
• mud packs,
• hot-air chambers,
• infrared radiation, or
• high-frequency therapy

are primarily used for chronic, non-inflammatory pain conditions (e.g., osteoarthritis).

Local cold exposure (cryotherapy) in the form of

• ice packs,
• cold gel,
• cold air, etc.

is, by contrast, more appropriate for acute inflammatory processes or recent blunt injuries.

Water is of great therapeutic importance due to its physical and chemical properties. Thermal effects are enhanced in the bath. At the same time, water serves as a vehicle for transdermally effective pharmaceuticals (mud baths, sulfur baths, etc.). The buoyancy of the water reduces the body’s weight and facilitates all movements. Exercise therapy in a therapeutic pool is therefore a significant enhancement to physical therapy.

Rest and relief are used in the treatment of musculoskeletal disorders. A painful, overloaded, inflamed, or infected body part usually requires rest. Often, simply reducing the usual level of activity or bed rest is sufficient. Immobilization is achieved locally using splints or bandages, and for the spine using back braces or corsets.

Immobility is always accompanied by a stagnation of local circulation and metabolism. Therefore, after some time, it leads to tissue damage characterized by

• atrophy,
• shrinkage,
• adhesions (so-called “rest damage”).

It should therefore always be used only as a means to an end—that is, not for longer than necessary.

Relief of pressure is not the same as immobilization. For example, an affected limb segment can be relieved of pressure using a bandage or orthosis while still maintaining mobility.

Positioning therapy is used to maintain a specific position for the purpose of

• relieve pain,
• relaxation, and
• preventing contractures.

Aids for this include, among others,

• pillows,
• mattress inserts (e.g., stepped positioning for sciatica, herniated discs, or lumbago),
• splints, and
• plaster casts.

Bandages are necessary to support limbs or the torso

• ,
• immobilize,
• relieve pressure,
• to compress,
• extend them, or to
• maintain achieved positional corrections.

Bandaging techniques therefore play a major role, particularly in orthopedics.

Compression bandages are primarily used

• on the extremities for swelling and varicose veins,
• on the joints in cases of joint effusions,
• and after sprains and contusions

.

Tape bandages support a joint by applying strips in an overlapping, roof-tile-like pattern and in the appropriate direction, thereby preventing painful movements. They are particularly useful in sports settings. The materials typically used are elastic bandages, Elastoplast, or zinc paste. Pre-made bandages and support stockings made of elastic textiles are also well-suited.

For rigid casts, the plaster cast has been unsurpassed for 150 years due to its properties. It is breathable and easy to work with. Today, however, it is often replaced by lighter and waterproof plastic casts.

To immobilize fractures or as a positioning splint, the bandage is usually applied without padding. Cotton or cellulose padding protects protruding bone fragments and superficially running nerves (e.g., at the head of the fibula!).

Some swelling is to be expected after certain surgeries and postural corrections. To immobilize the limb, the bandage must then be more heavily padded or cut open (split). Alternatively, circular bandages can be dispensed with entirely during the swelling period (shell bandage).

In any case, it is essential to

• proper shaping of the bandage,
• the prevention of pressure points, and
• careful monitoring of vascular and nerve function after the cast has hardened.

In addition, there are special plaster casts or walking casts with a rubber, plastic, or wooden cushion attached to the sole.

The weight-bearing cast is designed to relieve certain parts of the limb of body weight. This can reduce the load, for example,

• on the ischial tuberosity (Tuber ischiadicum) or
• on the tibial condyles (bony projections of the upper shinbone)

.

Other possible casts include:

• Rotational casts: These can correct joint contractures using subtle rotational stimuli. Due to the associated risks, they are rarely used today.
• Corrective plaster casts: These are now rarely used. They are used to correct axial deformities in long diaphyses or to realign joints.
• Special spinal correction casts: These treat spinal deformities.
• Extension casts: Extension can be achieved using simple traction cuffs on the ankles or wrists (cuff extension) or a twisted strip of bandage wrapped in a U-shape around the limb. The latter has a foam rubber lining on its underside to prevent slipping and is tightly wrapped with elastic bandages (“elastic band extension”).
• Zinc paste-plaster cast: A plaster cast is applied over a fresh zinc paste bandage that encircles the entire leg, with a traction strap incorporated into the cast. This has proven particularly effective for young children as a skin-friendly, secure traction cast.
• Wire or nail extension: Provides the strongest and most secure traction: A Kirschner wire or Steinmann nail is drilled through the femoral condyles (bony projections at the lower end of the thigh bone), the tibial head, the calcaneus, or the olecranon (elbow bone), and connected to the traction cable via a specific bracket.

Extension can also be applied to the spine:

• using a pelvic belt with the traction directed toward the feet, or
• for the cervical and upper thoracic spine using Crutchfield clamps or a calotte ring (“Halo”) attached to the skull.

Orthoses are external devices designed to be worn and applied. They range from bandages,

• for example, on the elbow joint,
• the wrist, and
• the ankle

and extend to braces that provide support and allow for controlled mobility.

The wide variety of knee braces available is particularly worth mentioning here. They are used especially after surgical procedures such as ligament reconstruction.

Some of these orthoses must be worn for a very long period of time. They are also frequently used for preventive purposes, especially during intense athletic activity. However, it is not the mechanical stabilization that provides protection in these cases.

Instead, proprioception triggers the muscles’ protective response. This means that the pressure from the brace stimulates the muscles to contract accordingly. As a result, they directly stabilize the affected joint.

Orthotic treatment options are also available

• following shoulder injuries,
• for spinal problems, and
• for injuries to the fingers and hands.

In orthopedics, medications are primarily used

• to treat pain, inflammation, and infections,
• to influence bone and cartilage metabolism,
• to prevent thrombosis, and
• as a chemotherapeutic agent for tumors.

Medications for Pain Management

The primary goal here is to eliminate or reduce peripheral pain symptoms. Centrally acting pain relievers are

• only in exceptional cases—postoperatively,
• in the terminal stages of cancer, or
• in cases of severe neurogenic pain (e.g., causalgia)

.

In most cases, nonsteroidal anti-inflammatory drugs (NSAIDs) are used, which have analgesic and anti-inflammatory effects. The dosage and duration of systemic treatment depend on the specific condition. The rule of thumb is: as effective as necessary, for as short a time as possible.

In principle, the following groups of medications are suitable for pain management:

• simple pain relievers (analgesics), such as acetaminophen,
• pain-relieving anti-inflammatory drugs (nonsteroidal anti-inflammatory drugs—NSAIDs), such as diclofenac or ibuprofen,
• antispasmodic and muscle-relaxing agents (myotonolytics), such as methocarbamol or baclofen, as well as
• sedatives.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

Nonsteroidal anti-inflammatory drugs are medications that can both relieve pain and reduce inflammation. These medications are sometimes also called nonsteroidal anti-inflammatory drugs, meaning they are corticosteroid-free anti-inflammatory medications. Most medical professionals simply refer to them by the abbreviation “NSAIDs.”

Anti-rheumatic drugs are not only prescribed for rheumatic diseases. They are also used to treat many other painful conditions.

How do antirheumatic drugs work?

Anti-rheumatic drugs inhibit the production of prostaglandins. Prostaglandins are signaling molecules that perform various functions in the body. Certain prostaglandins, for example, play a role in the development of

• pain,
• inflammation, and
• swelling

. Other prostaglandins have important protective functions. For example, they protect the mucous membranes of the stomach and duodenum from aggressive stomach acid.

Two enzymes are responsible for the formation of prostaglandins: cyclooxygenases 1 and 2, or COX-1 and COX-2 for short. There is a crucial difference between the two enzymes:

• COX-1 helps produce the stomach-protective prostaglandins,
• while COX-2 is responsible for the formation of prostaglandins that trigger pain and inflammation.

Development of Stomach-Friendly Pain Relievers

Researchers used this knowledge to develop a new generation of anti-rheumatic drugs. Until then, only conventional anti-rheumatic drugs were available, which inhibit both COX-1 and COX-2. While conventional anti-rheumatic drugs relieve joint pain, they can also lead to severe stomach problems. Now, medications have been developed that suppress only the production of COX-2. These medications specifically inhibit only the prostaglandins responsible for pain and inflammation.

Injections, Punctures, and Infiltrations

Local administration of medications is performed either by targeted injection of an anesthetic (Scandicain® 0.5–1%). It is usually combined with a corticosteroid preparation (prednisolone crystal suspension).

Indications include

• ligament, tendon, and capsular insertions,
• the joints themselves (intra-articular injection), as well as
• infiltration of painful muscle nodules.

Joint aspiration is performed under strict aseptic conditions to prevent the introduction of bacteria into the joint capsule.

In cases of spinal disorders, such as spondylosis, nerve root blocks are possible. Treatment involving the suppression of autonomic functions in the area of the stellate ganglion can also be performed. This interrupts the transmission of pain originating from a nerve node in the thoracic spine.

Systemic administration of steroid-containing preparations (cortisone) is generally not necessary in orthopedics. Furthermore, prolonged use would carry risks, such as

• osteoporosis,
• bone necrosis,
• fatigue, and weakness.

Exceptions include, among others, chronic polyarthritis and stage 1 of Sudeck’s disease (Morbus Sudeck or CRPS) under strict medical supervision.

Centrally Acting Pain Relievers: Opioids

Some people believe that pain must simply be endured. But that is wrong! Modern pain management offers effective treatments even for the most severe pain. Opioids are among the most important treatments for severe pain.

They mimic the body’s own endorphins and block pain in the brain and along the nerve pathways. They act via specific binding sites called opioid receptors. These are primarily located in the spinal cord and at pain-processing centers in the brain, but are also found in nearly all organs as well as on tumor and inflammatory cells. Opioids can prevent the sensation of pain from becoming entrenched in the brain and thus prevent the formation of a “pain memory.” In doing so, they normalize hypersensitivity to pain stimuli.

Opioids are prescribed for severe and very severe pain, such as

• all forms of nerve pain and chronic pain,
• severe back pain,
• severe joint pain,
• acute pain, or
• cancer pain.

They are used in particular when pain cannot be adequately managed with simple pain relievers.

Important: Opioids differ in terms of

• the duration and intensity of their effects,
• their dosage form, and
• side effects.

If a particular medication fails to relieve the pain, your doctor will try a different one. In this way, even pain that initially seems untreatable can sometimes be successfully managed.

Side Effects—Not Equally Common Across All Medications

When it comes to side effects, unwanted constipation is often the main problem. Other side effects, especially at the start of treatment, include nausea and drowsiness. However, these usually go away on their own after three to four days, or at most a week.

Unlike simple pain relievers, opioids do not damage the stomach, intestines, kidneys, or liver, even with long-term use. If an opioid rapidly reaches high levels of activity in the blood—that is, if it “floods” the system quickly—psychological dependence can develop. This is the case with some opioids that are, for example, injected into the bloodstream by drug addicts.

For sustained-release formulations, which are administered orally and release the drug gradually, this risk no longer exists. Fears of psychological dependence are therefore unfounded when the medications are taken according to medical recommendations.

Medications that affect bone and cartilage metabolism

Medications that affect skeletal metabolism include

• various vitamin D preparations,
• estrogens and androgens,
• calcitonin,
• magnesium, calcium, and fluoride supplements,
• bisphosphonates, etc.

Chondroprotective agents (from “chondro” – cartilage) are intended to

• support the metabolism and lubrication of cartilage surfaces,
• protect them from wear and tear (such as chondromalacia, a softening of the cartilage), and
• promote their regenerative capacity.

For oral and intra-articular administration,

• cartilage extracts,
• preparations of glucosamine sulfate,
• sulfated polyglycans, and
• hyaluronic acid

are commercially available. However, the effectiveness of such “anti-arthritic agents” is not always scientifically proven.

Medications for Treating Infections

Infection of joints and bones resulting from medical treatment (iatrogenic injury) can have catastrophic consequences. Therefore, maintaining a sterile environment during treatment with syringes and needles through careful aseptic technique is mandatory.

Prophylactic administration of antibiotics during surgery may be advisable in high-risk cases. Otherwise, their use is generally targeted

• based on bacteriological identification of the pathogens and
• their susceptibility to the drug of choice.

The medication can be administered orally, parenterally via injection or continuous infusion, or locally via irrigation or irrigation-drainage.

Long-term oral administration of multiple medications with the broadest possible, overlapping spectra of activity may be indicated in cases of

• chronic infections where specific identification of the pathogen is not possible and
• in protracted specific infections (tuberculosis)

 .

Medications for Thrombosis Prophylaxis

Controlling blood clotting processes is important during prolonged bed rest and surgeries on the lower extremities. It is particularly necessary for hip and knee joint surgeries.

Older adults and women taking contraceptives are particularly at risk. In these cases, thrombosis prophylaxis with heparin and coumarin preparations, based on laboratory test results, is of particular importance.

Electrotherapy encompasses all applications of electrical current for therapeutic purposes. Various types of electrical current with different biological effects are used in electrotherapy. On the one hand, the electrical current causes an ion exchange in the tissue and changes in the charge of the cell membrane, stimulating the flow of interstitial fluid. On the other hand, depending on the type of current, it induces contraction stimuli in muscle cells. It can either amplify or attenuate action potentials in nerve cells. A thermal effect is always associated with the flow of current.

Various types of electrical current with different biological effects are used in electrotherapy:

Direct current: Its continuous flow primarily has a soothing effect on pain receptors and promotes metabolism. The most common forms of application are galvanic baths (Stanger bath),

• as a full-body bath with current flowing through the entire body, or
• as a partial bath with current flowing through one or more extremities.

Iontophoresis refers to the delivery of medications through the skin using galvanic current. Histamine is frequently used for this purpose to induce strong hyperemia and relieve pain in muscles and joints. Low-frequency alternating currents (faradization, up to 1 kHz) have proven effective as so-called stimulation current therapy, among other things, for stimulating nerve and muscle activity. They can be applied in a wide variety of forms for both therapeutic and diagnostic purposes.

The so-called exponential current technique is very well suited for stimulating atrophic or paralyzed muscles. Healthy muscle has the ability to adapt to a slow increase in current. No stimulation occurs as long as the current levels are too high.