Dott Salvatore Denaro

Pain Management

Dott Salvatore Denaro Direttore UOC Medicina Fisica e Riabilitazione

PO Umberto Ideg e Rizza ASP SIRACUSA

ldquoDivinum est sedare doloremrdquo

(Ippocrate)

Definition

ldquoPain is an unpleasant sensory and emotional experience associated with tissue damage (real or perceived) or described in terms of such damagerdquo

IASP (International Association for the Study of Pain - 1986) Dott Salvatore Denaro

Neuropathic

Visceral Somatic

The 4 components of pain

Dott Salvatore Denaro

Pain is interpreted by the individual

ndash there is no biological

measure or marker for pain

ndash the most reliable indicator

of the existence and intensity of pain is the patientrsquos description

hellipPainhellip

Dott Salvatore Denaro

La douleur nest ni plus ni moins quun systegraveme dalarme dont la seule fonction est de signaler une leacutesion corporelle Descartes 1664

Dott Salvatore Denaro

Nociceptive pain (physiological)

without tissue lesion)

Inflammatory pain

Neuropathic pain

Functional pain

PAIN

somatic peripheral central visceral

high threshold low threshold

physiological pain pathological pain

Self-assessment scale Verbal scale absent slight moderate strong very strong

Visual analogue scale (VAS)

No pain Maximum pain 10 cm

Colour (chromatic) scale

Maximum pain

No pain

Numerical scale NRS no pain 1 2 3 4 5 6 7 8 9 10 extreme pain

Dott Salvatore Denaro

Scott Huskisson 1976

Downie 1978 Grossi 1983

The measurement of subjective pain its usefulness

As far as chronic pain is concerned the measurement of pain does not allow a correct evaluation of the progress of the clinical picture

It is advisable to use measurement to evaluate episodes of acute conditions or to analyse in the short term the efficacy of a therapeutic choice

In acute episodes the intensity of pain may indicate the drug to be used and its dosage (OMS scale)

Dott Salvatore Denaro

Evaluation of pain to reach a diagnosis where illness includes pain (requiring

investigation into how the illness arose) it involves a specific therapeutic plan for the illness (illness related)

in the case of a pathogenetic mechanism (a true algological diagnosis) it involves a therapeutic plan targeted at the mechanism (mechanism related)

Dott Salvatore Denaro

Classification of pain

ACUTE PAIN serves to alert the

body to the presence of dangerous stimuli

NOCICEPTIVEPAIN

(SOMATIC AND

VISCERAL)

TEMPORAL PHYSIOPATHOLOGICAL

CHRONIC PAIN

not just extended in time but with different qualitative characteristics

NEUROPATHICPAIN (CENTRAL PERIPHERAL)

IDEOPATHIC OR FUNCTIONALPAIN

Dott Salvatore Denaro

Key points and guidelines for the treatment of pain - Joint Commission on Accreditation

of Health Care Organizations - 1 The patientrsquos right to be treated for pain

2 Evaluate and document the presence nature and intensity of pain in all patients (5th vital indication in conjunction with blood pressure pulse temperature and respiratory rate)

3 Ensure staff competence in the evaluation and treatment of pain

4 Establish protocols for adequate treatment of pain

5 Educate patients and their families for effective control of pain 6 Satisfy the patientrsquos needs for effective treatment of symptoms after

discharge

Legge 15 marzo 2010 n 38 concernente ldquoDisposizioni per garantire laccesso alle cure palliative e alla terapia del dolorerdquo (Gazzetta Ufficiale n 65 del 19 marzo 2010)

Who takes responsibility for each type of pain - the Physiatrist the

Rheumatologist or the Orthopedist

bull Muscolotendinous (including tendon sheaths and synovial bursa)

bull Articulate and capsuloligamentous bull Bone bull Neurological peripheral and central bull Oncological supporting the Oncologist

Dott Salvatore Denaro

Overview of therapy the vicious circle of untreated pain

Limiting behaviour Pain

Altered functional status

Decreased autonomy

Social limitations Reduced mobility

Dott Salvatore Denaro

Dott Salvatore Denaro Dott Salvatore Denaro

Some painful forms of musculoskeletal origin

Post-traumatic pain Fracture Dislocation Distortion

Inflammatory joint pain (acute or chronic) Arthritis Rheumatoid arthritis Gout

Periarticular inflammatory pain (acute or chronic) Pathology from functional overload in muscles tendons or ligaments

Neuropathic or mixed pain

Compressive nerve syndromes Rachialgia Radiculopathy Osteoporosis pain

Oncological pain

Dott Salvatore Denaro

NEURAL PATHS FOR THE TRANSMISSION

OF PAIN

1st neuron

2nd neuron from the spinal chord to the thalamus

3rd neuron from the thalamus to the cerebral cortex

Opioids Alpha 2 agonists

Local anesthetics

Opioids

Alpha 2 agonists

Local anesthetics

Local anesthetics

Anti-inflammatory drugs

Routes of management

Intra-articular

transmucosal

Dott Salvatore Denaro

Dott Salvatore Denaro

But also in Orthopedic Medicinehelliphelliphellip

Dott Salvatore Denaro

Infiltration therapy

Acupuncture (ancient Chinese approach outlined by Huangdi Neijing

between 305 and 204 BC) This subject is only briefly mentioned here as it deserves its own separate conference There are however very few evidence based medical (EBM) studies of this ancient approach

Mesotherapy and Prolotherapy

Mesotherapy (MPistor) is an excellent analgesic therapy which uses a single needle or multi-injector as detailed by colleagues in the SFM (Socieacuteteacute Franccedilaise de Meacutesotheacuterapie)

Neuroprolotherapy (NPT) is a method of treatment which is distinct and separate from Prolotherapy from which it was evolved Developed since 2002 by New Zealander Dr John Lyftogt it targets the superficial sensory nerves of the body with micro-injections of low concentration glucose (5)

Dott Salvatore Denaro

Dry needling Annals of the Rheumatic Diseases 74(Suppl 2)624 middot June 2015 RV Bubnov

bull Very similar to acupuncture but treats the trigger points and myalgic intramuscular cords

bull It provides pinpoint mechanical stimulation

bull It provides both intramuscular and superficial stimulation

bull Precise laquoPain pointsraquo can be treated

Hyuk Ga Ji-Ho Choi Chang-Hae Park Hyun-Jung Yoon Acupuncture needling versus lidocaine injection of trigger points in myofascial pain syndrome in elderly patients ndash a randomised trial Acupuncture in Medicine Dec 2007

Dott Salvatore Denaro

TREATMENT OF PAIN in Orthopaedic Medicine

Dott Salvatore Denaro

ELECTROANALGESIA Based on Melzack and Wallrsquos theory of gate control which

describes two types of intervention for pain control

the first consists of reinforcing the the inhibitory power of large fibers the second aims selectively to interrupt the communication of small calibre fibers near the posterior horns (where the peripheral terminations are connected to the main neural pathways of communication to the brain)

Dott Salvatore Denaro

ELECTROANALGESIA TENS

ldquoTranscutaneous Electrical Nerve Stimulationrdquo is characterised by the fact that the electrodes are applied directly to the skin above the path of the

nerve trunk causing paresthesia in the area of the stimulated nerve distribution

Low frequency currents are used rectangular in shape which have an analgesic effect with

modalities that are not perfectly defined

Using TENS for pain control the state of the evidence Vance CG1 Dailey DL Rakel BA Sluka KA Pain Manag 2014 May4(3)197-209

Dott Salvatore Denaro

Non surgical laser therapy In analgesic therapy the ideal laser emission

instrument is one which uses a semiconductor diode as its active medium emitting invisible bursts of

radiation delivered in extremely short pulses typically within the infrared (IR) band with a

wavelength of approximately 904 nanometres ie the IR laser Other options include He-Ne CO2

Neodimio Yag and HILT

low levels of evidence

Eur J Phys Rehabil Med 2017 Aug53(4)603-610 Epub 2017 Jan 30 Effects of low-level laser therapy on pain in patients with musculoskeletal disorders a systematic review and meta-analysis Clijsen R123 Brunner A4 Barbero M4 Clarys P5 Taeymans J56

MOJ Orthop Rheumatol 20152(5) Epub 2015 Jun 9 The Use of Low Level Laser Therapy (LLLT) For Musculoskeletal Pain Cotler HB1 Chow RT2 Hamblin MR3 Carroll J4

Dott Salvatore Denaro

Biological Effects of LASER THERAPY an increase in the speed of mitosis temporary and reversible tissue dehydration denaturation of proteins thermolysis

carbonization for focal CO2 tissue evaporation

Physiotherapeutic lasers essentially produce two effects analgesic anti edema and biostimulant

Heat Therapy (Thermotherapy)

bull Heat action on the gate-control of MampW There is limited overall evidence to support the general use of localized heat however randomised clinical trials (RCTs) have shown that heat therapy provides short-term reductions in pain and disability in patients with acute lower back pain and provides significantly greater pain relief from DOMS than cold therapy (Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury Gerard A Malanga Ning Yan amp Jill Stark Oct 2014) PubMedgov

bull Cold reduction of tissue temperature which subsequently exerts local effects on blood flow on cell swelling and on metabolism and speed of neural conduction (Cold-water immersion and other forms of cryotherapy physiological changes potentially affecting recovery from high-intensity exercise Gillian E White and Greg D Wells Email author Extreme Physiology amp Medicine 2013 )

Dott Salvatore Denaro

KRYO TECAR

Mechanotherapy vibration

bull CONTROL OF MUSCULAR STIFFNESS (tonic reflex from vibration)

bull STIMULATION OF BLOOD LYMPHATIC CIRCULATION

bull PAIN RELIEF (gate control)

bull INCREASED SENSITIVITY

Bibliographic details Wang P Yang X Yang Y Yang L Zhou Y Liu C Reinhardt JD He C Effects of whole body vibration on pain stiffness and physical functions in patients with knee osteoarthritis a systematic review and meta-analysis Clinical Rehabilitation 2014 epub [PubMed] Dott Salvatore Denaro

Impact Waves bull 1 direct effect of the impulse on the tissue

in the target area and in conjunction with the reflection phenomena more accentuated in the points of transition between soft tissue (tendons muscles) and more compact tissues (bones and calcification formations)

bull 2 indirect effect of ldquocavitationrdquo caused by the subsequent depression of the impulse which exceeds the elastic characteristics of the tissue

NO DIRECT EFFECT ON PAIN MODULATORS OF BIOLOGICAL FUNCTIONS IN HUMAN MUSCLE CELLS (J Orthop Surg Res 2018 Apr 613(1)75 Exposure to radial extracorporeal shock waves modulates viability and gene expression of human skeletal muscle cells a controlled in vitro study Mattyasovszky SG1 Langendorf EK2 Ritz U2 Schmitz C3 Schmidtmann I4 Nowak TE2 Wagner D2 Hofmann A2 Rommens PM2 Drees P2)

RADIALI

FOCALI

Dott Salvatore Denaro

Ion Cyclotron Resonance Quantum Molecular Resonance

bull Stimulates the biological functions of cells bull Rebalances the correct membrane potential bull Activates enzymatic processes bull Restores the correct ion exchange for cell metabolism bull Promotes intra-extra cellular ion balance

Operating principle based on Quantum Molecular Resonance with the application of high-frequency and low-power micro-currents Induces the regeneration of damaged tissues especially muscular tissues without thermal effects

Dott Salvatore Denaro

Dott Salvatore Denaro

KINESIOTHERAPY IS NECESSARY

bull WITH REGARD TO ARTICULAR LINKS ndash JOINT PLAY ndash STRUCTURAL INTEGRITY OF THE CARTILAGE CAPSULE

AND LIGAMENTS ndash CORRECT MUSCLE SYNERGY ndash ELIMINATION OF FUNCTIONAL COMPENSATIONS

bull PAIN CONTROL bull NO CONTRAINDICATION

Dott Salvatore Denaro

KINESIOTHERAPY

bull POSTURAL Aims to correct any negative issues of posture (often secondary to analgesic compensatory attitudes) to detect alterations in the knee and calcaneal axis and of the plantar support visual disturbance dental malocclusion dysmetria of the pelvis etc

Dott Salvatore Denaro

KINESIOTHERAPY

bull HYDRO-KINESIOTHERAPY Very useful in cases of rheumatic diseases Therapeutic exercise in water is facilitated by the option to regulate water temperature and by the reduction in gravitational force which this medium allows

Dott Salvatore Denaro

VERTEBRAL MANIPULATION Robert Maignersquos ldquoManu Medicardquo

bull SEMIOTICS NATURE OF ILLNESS OR PATHOLOGY (clinical examination

imaging laboratory etc) ANALYSIS OF MINOR INTERVERTEBRAL DISTURBANCE

(ROM DDIM SCTM according to R Maignersquos research into signs of functional limitations)

bull THERAPY Principles RULE OF NO PAIN AND OF CONTRARY MOVEMENT VERIFICATION OF EVERY MANIPULATION BEFORE

PERFORMING THE NEXT

Dott Salvatore Denaro

TECHNIQUES

bull TREATMENT OF SOFT PARTS bull MUSCULAR STRETCHING bull REPEATED INTERVENTIONS bull MANIPULATION (3 STAGES)

Place in position Apply tension Manipulative thrust (low amplitude high velocity)

ldquoIT IS A NON-SYMPTOMATIC CAUSAL THERAPYrdquo

Mechanism of action of Vertebral Manipulation

bull Stretching and distension of the posterior joint capsule has a powerful inhibitory effect on muscle contraction (analgesic contraction) The hypotonic Gamma is determined by the stimulation of the periarticular receptors activated by the manipulative manoeuvre and results in a rapid and powerful ldquoINHIBITORY REFLEXrdquo through the contraction of the intervertebral musculature (DDIM)

bull With Vertebral Manipulation abruptly stretching structures such as ligaments discs joint capsules or muscles activates the descending system of nociceptive inhibition of pain in cases where this originates at the level of the grey matter

J Electromyogr Kinesiol 2012 Oct 22(5) 785ndash794Published online 2012 Feb 19 doi Spinal Manipulative Therapy and Somatosensory Activation Joel G Pickar DC PhD1 and Philip S Bolton DC PhD2 Dott Salvatore Denaro

Neuropathic

Visceral Somatic

The 4 components of pain

Dott Salvatore Denaro

Pain is interpreted by the individual

ndash there is no biological

measure or marker for pain

ndash the most reliable indicator

of the existence and intensity of pain is the patientrsquos description

hellipPainhellip

Dott Salvatore Denaro

La douleur nest ni plus ni moins quun systegraveme dalarme dont la seule fonction est de signaler une leacutesion corporelle Descartes 1664

Dott Salvatore Denaro

Nociceptive pain (physiological)

without tissue lesion)

Inflammatory pain

Neuropathic pain

Functional pain

PAIN

somatic peripheral central visceral

high threshold low threshold

physiological pain pathological pain

Self-assessment scale Verbal scale absent slight moderate strong very strong

Visual analogue scale (VAS)

No pain Maximum pain 10 cm

Colour (chromatic) scale

Maximum pain

No pain

Numerical scale NRS no pain 1 2 3 4 5 6 7 8 9 10 extreme pain

Dott Salvatore Denaro

Scott Huskisson 1976

Downie 1978 Grossi 1983

The measurement of subjective pain its usefulness

As far as chronic pain is concerned the measurement of pain does not allow a correct evaluation of the progress of the clinical picture

It is advisable to use measurement to evaluate episodes of acute conditions or to analyse in the short term the efficacy of a therapeutic choice

In acute episodes the intensity of pain may indicate the drug to be used and its dosage (OMS scale)

Dott Salvatore Denaro

Evaluation of pain to reach a diagnosis where illness includes pain (requiring

investigation into how the illness arose) it involves a specific therapeutic plan for the illness (illness related)

in the case of a pathogenetic mechanism (a true algological diagnosis) it involves a therapeutic plan targeted at the mechanism (mechanism related)

Dott Salvatore Denaro

Classification of pain

ACUTE PAIN serves to alert the

body to the presence of dangerous stimuli

NOCICEPTIVEPAIN

(SOMATIC AND

VISCERAL)

TEMPORAL PHYSIOPATHOLOGICAL

CHRONIC PAIN

not just extended in time but with different qualitative characteristics

NEUROPATHICPAIN (CENTRAL PERIPHERAL)

IDEOPATHIC OR FUNCTIONALPAIN

Dott Salvatore Denaro

Key points and guidelines for the treatment of pain - Joint Commission on Accreditation

of Health Care Organizations - 1 The patientrsquos right to be treated for pain

2 Evaluate and document the presence nature and intensity of pain in all patients (5th vital indication in conjunction with blood pressure pulse temperature and respiratory rate)

3 Ensure staff competence in the evaluation and treatment of pain

4 Establish protocols for adequate treatment of pain

5 Educate patients and their families for effective control of pain 6 Satisfy the patientrsquos needs for effective treatment of symptoms after

discharge

Legge 15 marzo 2010 n 38 concernente ldquoDisposizioni per garantire laccesso alle cure palliative e alla terapia del dolorerdquo (Gazzetta Ufficiale n 65 del 19 marzo 2010)

Who takes responsibility for each type of pain - the Physiatrist the

Rheumatologist or the Orthopedist

bull Muscolotendinous (including tendon sheaths and synovial bursa)

bull Articulate and capsuloligamentous bull Bone bull Neurological peripheral and central bull Oncological supporting the Oncologist

Dott Salvatore Denaro

Overview of therapy the vicious circle of untreated pain

Limiting behaviour Pain

Altered functional status

Decreased autonomy

Social limitations Reduced mobility

Dott Salvatore Denaro

Dott Salvatore Denaro Dott Salvatore Denaro

Some painful forms of musculoskeletal origin

Post-traumatic pain Fracture Dislocation Distortion

Inflammatory joint pain (acute or chronic) Arthritis Rheumatoid arthritis Gout

Periarticular inflammatory pain (acute or chronic) Pathology from functional overload in muscles tendons or ligaments

Neuropathic or mixed pain

Compressive nerve syndromes Rachialgia Radiculopathy Osteoporosis pain

Oncological pain

Dott Salvatore Denaro

NEURAL PATHS FOR THE TRANSMISSION

OF PAIN

1st neuron

2nd neuron from the spinal chord to the thalamus

3rd neuron from the thalamus to the cerebral cortex

Opioids Alpha 2 agonists

Local anesthetics

Opioids

Alpha 2 agonists

Local anesthetics

Local anesthetics

Anti-inflammatory drugs

Routes of management

Intra-articular

transmucosal

Dott Salvatore Denaro

Dott Salvatore Denaro

But also in Orthopedic Medicinehelliphelliphellip

Dott Salvatore Denaro

Infiltration therapy

Acupuncture (ancient Chinese approach outlined by Huangdi Neijing

between 305 and 204 BC) This subject is only briefly mentioned here as it deserves its own separate conference There are however very few evidence based medical (EBM) studies of this ancient approach

Mesotherapy and Prolotherapy

Mesotherapy (MPistor) is an excellent analgesic therapy which uses a single needle or multi-injector as detailed by colleagues in the SFM (Socieacuteteacute Franccedilaise de Meacutesotheacuterapie)

Neuroprolotherapy (NPT) is a method of treatment which is distinct and separate from Prolotherapy from which it was evolved Developed since 2002 by New Zealander Dr John Lyftogt it targets the superficial sensory nerves of the body with micro-injections of low concentration glucose (5)

Dott Salvatore Denaro

Dry needling Annals of the Rheumatic Diseases 74(Suppl 2)624 middot June 2015 RV Bubnov

bull Very similar to acupuncture but treats the trigger points and myalgic intramuscular cords

bull It provides pinpoint mechanical stimulation

bull It provides both intramuscular and superficial stimulation

bull Precise laquoPain pointsraquo can be treated

Hyuk Ga Ji-Ho Choi Chang-Hae Park Hyun-Jung Yoon Acupuncture needling versus lidocaine injection of trigger points in myofascial pain syndrome in elderly patients ndash a randomised trial Acupuncture in Medicine Dec 2007

Dott Salvatore Denaro

TREATMENT OF PAIN in Orthopaedic Medicine

Dott Salvatore Denaro

ELECTROANALGESIA Based on Melzack and Wallrsquos theory of gate control which

describes two types of intervention for pain control

the first consists of reinforcing the the inhibitory power of large fibers the second aims selectively to interrupt the communication of small calibre fibers near the posterior horns (where the peripheral terminations are connected to the main neural pathways of communication to the brain)

Dott Salvatore Denaro

ELECTROANALGESIA TENS

ldquoTranscutaneous Electrical Nerve Stimulationrdquo is characterised by the fact that the electrodes are applied directly to the skin above the path of the

nerve trunk causing paresthesia in the area of the stimulated nerve distribution

Low frequency currents are used rectangular in shape which have an analgesic effect with

modalities that are not perfectly defined

Using TENS for pain control the state of the evidence Vance CG1 Dailey DL Rakel BA Sluka KA Pain Manag 2014 May4(3)197-209

Dott Salvatore Denaro

Non surgical laser therapy In analgesic therapy the ideal laser emission

instrument is one which uses a semiconductor diode as its active medium emitting invisible bursts of

radiation delivered in extremely short pulses typically within the infrared (IR) band with a

wavelength of approximately 904 nanometres ie the IR laser Other options include He-Ne CO2

Neodimio Yag and HILT

low levels of evidence

Eur J Phys Rehabil Med 2017 Aug53(4)603-610 Epub 2017 Jan 30 Effects of low-level laser therapy on pain in patients with musculoskeletal disorders a systematic review and meta-analysis Clijsen R123 Brunner A4 Barbero M4 Clarys P5 Taeymans J56

MOJ Orthop Rheumatol 20152(5) Epub 2015 Jun 9 The Use of Low Level Laser Therapy (LLLT) For Musculoskeletal Pain Cotler HB1 Chow RT2 Hamblin MR3 Carroll J4

Dott Salvatore Denaro

Biological Effects of LASER THERAPY an increase in the speed of mitosis temporary and reversible tissue dehydration denaturation of proteins thermolysis

carbonization for focal CO2 tissue evaporation

Physiotherapeutic lasers essentially produce two effects analgesic anti edema and biostimulant

Heat Therapy (Thermotherapy)

bull Heat action on the gate-control of MampW There is limited overall evidence to support the general use of localized heat however randomised clinical trials (RCTs) have shown that heat therapy provides short-term reductions in pain and disability in patients with acute lower back pain and provides significantly greater pain relief from DOMS than cold therapy (Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury Gerard A Malanga Ning Yan amp Jill Stark Oct 2014) PubMedgov

bull Cold reduction of tissue temperature which subsequently exerts local effects on blood flow on cell swelling and on metabolism and speed of neural conduction (Cold-water immersion and other forms of cryotherapy physiological changes potentially affecting recovery from high-intensity exercise Gillian E White and Greg D Wells Email author Extreme Physiology amp Medicine 2013 )

Dott Salvatore Denaro

KRYO TECAR

Mechanotherapy vibration

bull CONTROL OF MUSCULAR STIFFNESS (tonic reflex from vibration)

bull STIMULATION OF BLOOD LYMPHATIC CIRCULATION

bull PAIN RELIEF (gate control)

bull INCREASED SENSITIVITY

Bibliographic details Wang P Yang X Yang Y Yang L Zhou Y Liu C Reinhardt JD He C Effects of whole body vibration on pain stiffness and physical functions in patients with knee osteoarthritis a systematic review and meta-analysis Clinical Rehabilitation 2014 epub [PubMed] Dott Salvatore Denaro

Impact Waves bull 1 direct effect of the impulse on the tissue

in the target area and in conjunction with the reflection phenomena more accentuated in the points of transition between soft tissue (tendons muscles) and more compact tissues (bones and calcification formations)

bull 2 indirect effect of ldquocavitationrdquo caused by the subsequent depression of the impulse which exceeds the elastic characteristics of the tissue

NO DIRECT EFFECT ON PAIN MODULATORS OF BIOLOGICAL FUNCTIONS IN HUMAN MUSCLE CELLS (J Orthop Surg Res 2018 Apr 613(1)75 Exposure to radial extracorporeal shock waves modulates viability and gene expression of human skeletal muscle cells a controlled in vitro study Mattyasovszky SG1 Langendorf EK2 Ritz U2 Schmitz C3 Schmidtmann I4 Nowak TE2 Wagner D2 Hofmann A2 Rommens PM2 Drees P2)

RADIALI

FOCALI

Dott Salvatore Denaro

Ion Cyclotron Resonance Quantum Molecular Resonance

bull Stimulates the biological functions of cells bull Rebalances the correct membrane potential bull Activates enzymatic processes bull Restores the correct ion exchange for cell metabolism bull Promotes intra-extra cellular ion balance

Operating principle based on Quantum Molecular Resonance with the application of high-frequency and low-power micro-currents Induces the regeneration of damaged tissues especially muscular tissues without thermal effects

Dott Salvatore Denaro

Dott Salvatore Denaro

KINESIOTHERAPY IS NECESSARY

bull WITH REGARD TO ARTICULAR LINKS ndash JOINT PLAY ndash STRUCTURAL INTEGRITY OF THE CARTILAGE CAPSULE

AND LIGAMENTS ndash CORRECT MUSCLE SYNERGY ndash ELIMINATION OF FUNCTIONAL COMPENSATIONS

bull PAIN CONTROL bull NO CONTRAINDICATION

Dott Salvatore Denaro

KINESIOTHERAPY

bull POSTURAL Aims to correct any negative issues of posture (often secondary to analgesic compensatory attitudes) to detect alterations in the knee and calcaneal axis and of the plantar support visual disturbance dental malocclusion dysmetria of the pelvis etc

Dott Salvatore Denaro

KINESIOTHERAPY

bull HYDRO-KINESIOTHERAPY Very useful in cases of rheumatic diseases Therapeutic exercise in water is facilitated by the option to regulate water temperature and by the reduction in gravitational force which this medium allows

Dott Salvatore Denaro

VERTEBRAL MANIPULATION Robert Maignersquos ldquoManu Medicardquo

bull SEMIOTICS NATURE OF ILLNESS OR PATHOLOGY (clinical examination

imaging laboratory etc) ANALYSIS OF MINOR INTERVERTEBRAL DISTURBANCE

(ROM DDIM SCTM according to R Maignersquos research into signs of functional limitations)

bull THERAPY Principles RULE OF NO PAIN AND OF CONTRARY MOVEMENT VERIFICATION OF EVERY MANIPULATION BEFORE

PERFORMING THE NEXT

Dott Salvatore Denaro

TECHNIQUES

bull TREATMENT OF SOFT PARTS bull MUSCULAR STRETCHING bull REPEATED INTERVENTIONS bull MANIPULATION (3 STAGES)

Place in position Apply tension Manipulative thrust (low amplitude high velocity)

ldquoIT IS A NON-SYMPTOMATIC CAUSAL THERAPYrdquo

Mechanism of action of Vertebral Manipulation

bull Stretching and distension of the posterior joint capsule has a powerful inhibitory effect on muscle contraction (analgesic contraction) The hypotonic Gamma is determined by the stimulation of the periarticular receptors activated by the manipulative manoeuvre and results in a rapid and powerful ldquoINHIBITORY REFLEXrdquo through the contraction of the intervertebral musculature (DDIM)

bull With Vertebral Manipulation abruptly stretching structures such as ligaments discs joint capsules or muscles activates the descending system of nociceptive inhibition of pain in cases where this originates at the level of the grey matter

J Electromyogr Kinesiol 2012 Oct 22(5) 785ndash794Published online 2012 Feb 19 doi Spinal Manipulative Therapy and Somatosensory Activation Joel G Pickar DC PhD1 and Philip S Bolton DC PhD2 Dott Salvatore Denaro

Pain is interpreted by the individual

ndash there is no biological

measure or marker for pain

ndash the most reliable indicator

of the existence and intensity of pain is the patientrsquos description

hellipPainhellip

Dott Salvatore Denaro

La douleur nest ni plus ni moins quun systegraveme dalarme dont la seule fonction est de signaler une leacutesion corporelle Descartes 1664

Dott Salvatore Denaro

Nociceptive pain (physiological)

without tissue lesion)

Inflammatory pain

Neuropathic pain

Functional pain

PAIN

somatic peripheral central visceral

high threshold low threshold

physiological pain pathological pain

Self-assessment scale Verbal scale absent slight moderate strong very strong

Visual analogue scale (VAS)

No pain Maximum pain 10 cm

Colour (chromatic) scale

Maximum pain

No pain

Numerical scale NRS no pain 1 2 3 4 5 6 7 8 9 10 extreme pain

Dott Salvatore Denaro

Scott Huskisson 1976

Downie 1978 Grossi 1983

The measurement of subjective pain its usefulness

As far as chronic pain is concerned the measurement of pain does not allow a correct evaluation of the progress of the clinical picture

It is advisable to use measurement to evaluate episodes of acute conditions or to analyse in the short term the efficacy of a therapeutic choice

In acute episodes the intensity of pain may indicate the drug to be used and its dosage (OMS scale)

Dott Salvatore Denaro

Evaluation of pain to reach a diagnosis where illness includes pain (requiring

investigation into how the illness arose) it involves a specific therapeutic plan for the illness (illness related)

in the case of a pathogenetic mechanism (a true algological diagnosis) it involves a therapeutic plan targeted at the mechanism (mechanism related)

Dott Salvatore Denaro

Classification of pain

ACUTE PAIN serves to alert the

body to the presence of dangerous stimuli

NOCICEPTIVEPAIN

(SOMATIC AND

VISCERAL)

TEMPORAL PHYSIOPATHOLOGICAL

CHRONIC PAIN

not just extended in time but with different qualitative characteristics

NEUROPATHICPAIN (CENTRAL PERIPHERAL)

IDEOPATHIC OR FUNCTIONALPAIN

Dott Salvatore Denaro

Key points and guidelines for the treatment of pain - Joint Commission on Accreditation

of Health Care Organizations - 1 The patientrsquos right to be treated for pain

2 Evaluate and document the presence nature and intensity of pain in all patients (5th vital indication in conjunction with blood pressure pulse temperature and respiratory rate)

3 Ensure staff competence in the evaluation and treatment of pain

4 Establish protocols for adequate treatment of pain

5 Educate patients and their families for effective control of pain 6 Satisfy the patientrsquos needs for effective treatment of symptoms after

discharge

Legge 15 marzo 2010 n 38 concernente ldquoDisposizioni per garantire laccesso alle cure palliative e alla terapia del dolorerdquo (Gazzetta Ufficiale n 65 del 19 marzo 2010)

Who takes responsibility for each type of pain - the Physiatrist the

Rheumatologist or the Orthopedist

bull Muscolotendinous (including tendon sheaths and synovial bursa)

bull Articulate and capsuloligamentous bull Bone bull Neurological peripheral and central bull Oncological supporting the Oncologist

Dott Salvatore Denaro

Overview of therapy the vicious circle of untreated pain

Limiting behaviour Pain

Altered functional status

Decreased autonomy

Social limitations Reduced mobility

Dott Salvatore Denaro

Dott Salvatore Denaro Dott Salvatore Denaro

Some painful forms of musculoskeletal origin

Post-traumatic pain Fracture Dislocation Distortion

Inflammatory joint pain (acute or chronic) Arthritis Rheumatoid arthritis Gout

Periarticular inflammatory pain (acute or chronic) Pathology from functional overload in muscles tendons or ligaments

Neuropathic or mixed pain

Compressive nerve syndromes Rachialgia Radiculopathy Osteoporosis pain

Oncological pain

Dott Salvatore Denaro

NEURAL PATHS FOR THE TRANSMISSION

OF PAIN

1st neuron

2nd neuron from the spinal chord to the thalamus

3rd neuron from the thalamus to the cerebral cortex

Opioids Alpha 2 agonists

Local anesthetics

Opioids

Alpha 2 agonists

Local anesthetics

Local anesthetics

Anti-inflammatory drugs

Routes of management

Intra-articular

transmucosal

Dott Salvatore Denaro

Dott Salvatore Denaro

But also in Orthopedic Medicinehelliphelliphellip

Dott Salvatore Denaro

Infiltration therapy

Acupuncture (ancient Chinese approach outlined by Huangdi Neijing

between 305 and 204 BC) This subject is only briefly mentioned here as it deserves its own separate conference There are however very few evidence based medical (EBM) studies of this ancient approach

Mesotherapy and Prolotherapy

Mesotherapy (MPistor) is an excellent analgesic therapy which uses a single needle or multi-injector as detailed by colleagues in the SFM (Socieacuteteacute Franccedilaise de Meacutesotheacuterapie)

Neuroprolotherapy (NPT) is a method of treatment which is distinct and separate from Prolotherapy from which it was evolved Developed since 2002 by New Zealander Dr John Lyftogt it targets the superficial sensory nerves of the body with micro-injections of low concentration glucose (5)

Dott Salvatore Denaro

Dry needling Annals of the Rheumatic Diseases 74(Suppl 2)624 middot June 2015 RV Bubnov

bull Very similar to acupuncture but treats the trigger points and myalgic intramuscular cords

bull It provides pinpoint mechanical stimulation

bull It provides both intramuscular and superficial stimulation

bull Precise laquoPain pointsraquo can be treated

Hyuk Ga Ji-Ho Choi Chang-Hae Park Hyun-Jung Yoon Acupuncture needling versus lidocaine injection of trigger points in myofascial pain syndrome in elderly patients ndash a randomised trial Acupuncture in Medicine Dec 2007

Dott Salvatore Denaro

TREATMENT OF PAIN in Orthopaedic Medicine

Dott Salvatore Denaro

ELECTROANALGESIA Based on Melzack and Wallrsquos theory of gate control which

describes two types of intervention for pain control

the first consists of reinforcing the the inhibitory power of large fibers the second aims selectively to interrupt the communication of small calibre fibers near the posterior horns (where the peripheral terminations are connected to the main neural pathways of communication to the brain)

Dott Salvatore Denaro

ELECTROANALGESIA TENS

ldquoTranscutaneous Electrical Nerve Stimulationrdquo is characterised by the fact that the electrodes are applied directly to the skin above the path of the

nerve trunk causing paresthesia in the area of the stimulated nerve distribution

Low frequency currents are used rectangular in shape which have an analgesic effect with

modalities that are not perfectly defined

Using TENS for pain control the state of the evidence Vance CG1 Dailey DL Rakel BA Sluka KA Pain Manag 2014 May4(3)197-209

Dott Salvatore Denaro

Non surgical laser therapy In analgesic therapy the ideal laser emission

instrument is one which uses a semiconductor diode as its active medium emitting invisible bursts of

radiation delivered in extremely short pulses typically within the infrared (IR) band with a

wavelength of approximately 904 nanometres ie the IR laser Other options include He-Ne CO2

Neodimio Yag and HILT

low levels of evidence

Eur J Phys Rehabil Med 2017 Aug53(4)603-610 Epub 2017 Jan 30 Effects of low-level laser therapy on pain in patients with musculoskeletal disorders a systematic review and meta-analysis Clijsen R123 Brunner A4 Barbero M4 Clarys P5 Taeymans J56

MOJ Orthop Rheumatol 20152(5) Epub 2015 Jun 9 The Use of Low Level Laser Therapy (LLLT) For Musculoskeletal Pain Cotler HB1 Chow RT2 Hamblin MR3 Carroll J4

Dott Salvatore Denaro

Biological Effects of LASER THERAPY an increase in the speed of mitosis temporary and reversible tissue dehydration denaturation of proteins thermolysis

carbonization for focal CO2 tissue evaporation

Physiotherapeutic lasers essentially produce two effects analgesic anti edema and biostimulant

Heat Therapy (Thermotherapy)

bull Heat action on the gate-control of MampW There is limited overall evidence to support the general use of localized heat however randomised clinical trials (RCTs) have shown that heat therapy provides short-term reductions in pain and disability in patients with acute lower back pain and provides significantly greater pain relief from DOMS than cold therapy (Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury Gerard A Malanga Ning Yan amp Jill Stark Oct 2014) PubMedgov

bull Cold reduction of tissue temperature which subsequently exerts local effects on blood flow on cell swelling and on metabolism and speed of neural conduction (Cold-water immersion and other forms of cryotherapy physiological changes potentially affecting recovery from high-intensity exercise Gillian E White and Greg D Wells Email author Extreme Physiology amp Medicine 2013 )

Dott Salvatore Denaro

KRYO TECAR

Mechanotherapy vibration

bull CONTROL OF MUSCULAR STIFFNESS (tonic reflex from vibration)

bull STIMULATION OF BLOOD LYMPHATIC CIRCULATION

bull PAIN RELIEF (gate control)

bull INCREASED SENSITIVITY

Bibliographic details Wang P Yang X Yang Y Yang L Zhou Y Liu C Reinhardt JD He C Effects of whole body vibration on pain stiffness and physical functions in patients with knee osteoarthritis a systematic review and meta-analysis Clinical Rehabilitation 2014 epub [PubMed] Dott Salvatore Denaro

Impact Waves bull 1 direct effect of the impulse on the tissue

in the target area and in conjunction with the reflection phenomena more accentuated in the points of transition between soft tissue (tendons muscles) and more compact tissues (bones and calcification formations)

bull 2 indirect effect of ldquocavitationrdquo caused by the subsequent depression of the impulse which exceeds the elastic characteristics of the tissue

NO DIRECT EFFECT ON PAIN MODULATORS OF BIOLOGICAL FUNCTIONS IN HUMAN MUSCLE CELLS (J Orthop Surg Res 2018 Apr 613(1)75 Exposure to radial extracorporeal shock waves modulates viability and gene expression of human skeletal muscle cells a controlled in vitro study Mattyasovszky SG1 Langendorf EK2 Ritz U2 Schmitz C3 Schmidtmann I4 Nowak TE2 Wagner D2 Hofmann A2 Rommens PM2 Drees P2)

RADIALI

FOCALI

Dott Salvatore Denaro

Ion Cyclotron Resonance Quantum Molecular Resonance

bull Stimulates the biological functions of cells bull Rebalances the correct membrane potential bull Activates enzymatic processes bull Restores the correct ion exchange for cell metabolism bull Promotes intra-extra cellular ion balance

Operating principle based on Quantum Molecular Resonance with the application of high-frequency and low-power micro-currents Induces the regeneration of damaged tissues especially muscular tissues without thermal effects

Dott Salvatore Denaro

Dott Salvatore Denaro

KINESIOTHERAPY IS NECESSARY

bull WITH REGARD TO ARTICULAR LINKS ndash JOINT PLAY ndash STRUCTURAL INTEGRITY OF THE CARTILAGE CAPSULE

AND LIGAMENTS ndash CORRECT MUSCLE SYNERGY ndash ELIMINATION OF FUNCTIONAL COMPENSATIONS

bull PAIN CONTROL bull NO CONTRAINDICATION

Dott Salvatore Denaro

KINESIOTHERAPY

bull POSTURAL Aims to correct any negative issues of posture (often secondary to analgesic compensatory attitudes) to detect alterations in the knee and calcaneal axis and of the plantar support visual disturbance dental malocclusion dysmetria of the pelvis etc

Dott Salvatore Denaro

KINESIOTHERAPY

bull HYDRO-KINESIOTHERAPY Very useful in cases of rheumatic diseases Therapeutic exercise in water is facilitated by the option to regulate water temperature and by the reduction in gravitational force which this medium allows

Dott Salvatore Denaro

VERTEBRAL MANIPULATION Robert Maignersquos ldquoManu Medicardquo

bull SEMIOTICS NATURE OF ILLNESS OR PATHOLOGY (clinical examination

imaging laboratory etc) ANALYSIS OF MINOR INTERVERTEBRAL DISTURBANCE

(ROM DDIM SCTM according to R Maignersquos research into signs of functional limitations)

bull THERAPY Principles RULE OF NO PAIN AND OF CONTRARY MOVEMENT VERIFICATION OF EVERY MANIPULATION BEFORE

PERFORMING THE NEXT

Dott Salvatore Denaro

TECHNIQUES

bull TREATMENT OF SOFT PARTS bull MUSCULAR STRETCHING bull REPEATED INTERVENTIONS bull MANIPULATION (3 STAGES)

Place in position Apply tension Manipulative thrust (low amplitude high velocity)

ldquoIT IS A NON-SYMPTOMATIC CAUSAL THERAPYrdquo

Mechanism of action of Vertebral Manipulation

bull Stretching and distension of the posterior joint capsule has a powerful inhibitory effect on muscle contraction (analgesic contraction) The hypotonic Gamma is determined by the stimulation of the periarticular receptors activated by the manipulative manoeuvre and results in a rapid and powerful ldquoINHIBITORY REFLEXrdquo through the contraction of the intervertebral musculature (DDIM)

bull With Vertebral Manipulation abruptly stretching structures such as ligaments discs joint capsules or muscles activates the descending system of nociceptive inhibition of pain in cases where this originates at the level of the grey matter

J Electromyogr Kinesiol 2012 Oct 22(5) 785ndash794Published online 2012 Feb 19 doi Spinal Manipulative Therapy and Somatosensory Activation Joel G Pickar DC PhD1 and Philip S Bolton DC PhD2 Dott Salvatore Denaro

La douleur nest ni plus ni moins quun systegraveme dalarme dont la seule fonction est de signaler une leacutesion corporelle Descartes 1664

Dott Salvatore Denaro

Nociceptive pain (physiological)

without tissue lesion)

Inflammatory pain

Neuropathic pain

Functional pain

PAIN

somatic peripheral central visceral

high threshold low threshold

physiological pain pathological pain

Self-assessment scale Verbal scale absent slight moderate strong very strong

Visual analogue scale (VAS)

No pain Maximum pain 10 cm

Colour (chromatic) scale

Maximum pain

No pain

Numerical scale NRS no pain 1 2 3 4 5 6 7 8 9 10 extreme pain

Dott Salvatore Denaro

Scott Huskisson 1976

Downie 1978 Grossi 1983

The measurement of subjective pain its usefulness

As far as chronic pain is concerned the measurement of pain does not allow a correct evaluation of the progress of the clinical picture

It is advisable to use measurement to evaluate episodes of acute conditions or to analyse in the short term the efficacy of a therapeutic choice

In acute episodes the intensity of pain may indicate the drug to be used and its dosage (OMS scale)

Dott Salvatore Denaro

Evaluation of pain to reach a diagnosis where illness includes pain (requiring

investigation into how the illness arose) it involves a specific therapeutic plan for the illness (illness related)

in the case of a pathogenetic mechanism (a true algological diagnosis) it involves a therapeutic plan targeted at the mechanism (mechanism related)

Dott Salvatore Denaro

Classification of pain

ACUTE PAIN serves to alert the

body to the presence of dangerous stimuli

NOCICEPTIVEPAIN

(SOMATIC AND

VISCERAL)

TEMPORAL PHYSIOPATHOLOGICAL

CHRONIC PAIN

not just extended in time but with different qualitative characteristics

NEUROPATHICPAIN (CENTRAL PERIPHERAL)

IDEOPATHIC OR FUNCTIONALPAIN

Dott Salvatore Denaro

Key points and guidelines for the treatment of pain - Joint Commission on Accreditation

of Health Care Organizations - 1 The patientrsquos right to be treated for pain

2 Evaluate and document the presence nature and intensity of pain in all patients (5th vital indication in conjunction with blood pressure pulse temperature and respiratory rate)

3 Ensure staff competence in the evaluation and treatment of pain

4 Establish protocols for adequate treatment of pain

5 Educate patients and their families for effective control of pain 6 Satisfy the patientrsquos needs for effective treatment of symptoms after

discharge

Legge 15 marzo 2010 n 38 concernente ldquoDisposizioni per garantire laccesso alle cure palliative e alla terapia del dolorerdquo (Gazzetta Ufficiale n 65 del 19 marzo 2010)

Who takes responsibility for each type of pain - the Physiatrist the

Rheumatologist or the Orthopedist

bull Muscolotendinous (including tendon sheaths and synovial bursa)

bull Articulate and capsuloligamentous bull Bone bull Neurological peripheral and central bull Oncological supporting the Oncologist

Dott Salvatore Denaro

Overview of therapy the vicious circle of untreated pain

Limiting behaviour Pain

Altered functional status

Decreased autonomy

Social limitations Reduced mobility

Dott Salvatore Denaro

Dott Salvatore Denaro Dott Salvatore Denaro

Some painful forms of musculoskeletal origin

Post-traumatic pain Fracture Dislocation Distortion

Inflammatory joint pain (acute or chronic) Arthritis Rheumatoid arthritis Gout

Periarticular inflammatory pain (acute or chronic) Pathology from functional overload in muscles tendons or ligaments

Neuropathic or mixed pain

Compressive nerve syndromes Rachialgia Radiculopathy Osteoporosis pain

Oncological pain

Dott Salvatore Denaro

NEURAL PATHS FOR THE TRANSMISSION

OF PAIN

1st neuron

2nd neuron from the spinal chord to the thalamus

3rd neuron from the thalamus to the cerebral cortex

Opioids Alpha 2 agonists

Local anesthetics

Opioids

Alpha 2 agonists

Local anesthetics

Local anesthetics

Anti-inflammatory drugs

Routes of management

Intra-articular

transmucosal

Dott Salvatore Denaro

Dott Salvatore Denaro

But also in Orthopedic Medicinehelliphelliphellip

Dott Salvatore Denaro

Infiltration therapy

Acupuncture (ancient Chinese approach outlined by Huangdi Neijing

between 305 and 204 BC) This subject is only briefly mentioned here as it deserves its own separate conference There are however very few evidence based medical (EBM) studies of this ancient approach

Mesotherapy and Prolotherapy

Mesotherapy (MPistor) is an excellent analgesic therapy which uses a single needle or multi-injector as detailed by colleagues in the SFM (Socieacuteteacute Franccedilaise de Meacutesotheacuterapie)

Neuroprolotherapy (NPT) is a method of treatment which is distinct and separate from Prolotherapy from which it was evolved Developed since 2002 by New Zealander Dr John Lyftogt it targets the superficial sensory nerves of the body with micro-injections of low concentration glucose (5)

Dott Salvatore Denaro

Dry needling Annals of the Rheumatic Diseases 74(Suppl 2)624 middot June 2015 RV Bubnov

bull Very similar to acupuncture but treats the trigger points and myalgic intramuscular cords

bull It provides pinpoint mechanical stimulation

bull It provides both intramuscular and superficial stimulation

bull Precise laquoPain pointsraquo can be treated

Hyuk Ga Ji-Ho Choi Chang-Hae Park Hyun-Jung Yoon Acupuncture needling versus lidocaine injection of trigger points in myofascial pain syndrome in elderly patients ndash a randomised trial Acupuncture in Medicine Dec 2007

Dott Salvatore Denaro

TREATMENT OF PAIN in Orthopaedic Medicine

Dott Salvatore Denaro

ELECTROANALGESIA Based on Melzack and Wallrsquos theory of gate control which

describes two types of intervention for pain control

the first consists of reinforcing the the inhibitory power of large fibers the second aims selectively to interrupt the communication of small calibre fibers near the posterior horns (where the peripheral terminations are connected to the main neural pathways of communication to the brain)

Dott Salvatore Denaro

ELECTROANALGESIA TENS

ldquoTranscutaneous Electrical Nerve Stimulationrdquo is characterised by the fact that the electrodes are applied directly to the skin above the path of the

nerve trunk causing paresthesia in the area of the stimulated nerve distribution

Low frequency currents are used rectangular in shape which have an analgesic effect with

modalities that are not perfectly defined

Using TENS for pain control the state of the evidence Vance CG1 Dailey DL Rakel BA Sluka KA Pain Manag 2014 May4(3)197-209

Dott Salvatore Denaro

Non surgical laser therapy In analgesic therapy the ideal laser emission

instrument is one which uses a semiconductor diode as its active medium emitting invisible bursts of

radiation delivered in extremely short pulses typically within the infrared (IR) band with a

wavelength of approximately 904 nanometres ie the IR laser Other options include He-Ne CO2

Neodimio Yag and HILT

low levels of evidence

Eur J Phys Rehabil Med 2017 Aug53(4)603-610 Epub 2017 Jan 30 Effects of low-level laser therapy on pain in patients with musculoskeletal disorders a systematic review and meta-analysis Clijsen R123 Brunner A4 Barbero M4 Clarys P5 Taeymans J56

MOJ Orthop Rheumatol 20152(5) Epub 2015 Jun 9 The Use of Low Level Laser Therapy (LLLT) For Musculoskeletal Pain Cotler HB1 Chow RT2 Hamblin MR3 Carroll J4

Dott Salvatore Denaro

Biological Effects of LASER THERAPY an increase in the speed of mitosis temporary and reversible tissue dehydration denaturation of proteins thermolysis

carbonization for focal CO2 tissue evaporation

Physiotherapeutic lasers essentially produce two effects analgesic anti edema and biostimulant

Heat Therapy (Thermotherapy)

bull Heat action on the gate-control of MampW There is limited overall evidence to support the general use of localized heat however randomised clinical trials (RCTs) have shown that heat therapy provides short-term reductions in pain and disability in patients with acute lower back pain and provides significantly greater pain relief from DOMS than cold therapy (Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury Gerard A Malanga Ning Yan amp Jill Stark Oct 2014) PubMedgov

bull Cold reduction of tissue temperature which subsequently exerts local effects on blood flow on cell swelling and on metabolism and speed of neural conduction (Cold-water immersion and other forms of cryotherapy physiological changes potentially affecting recovery from high-intensity exercise Gillian E White and Greg D Wells Email author Extreme Physiology amp Medicine 2013 )

Dott Salvatore Denaro

KRYO TECAR

Mechanotherapy vibration

bull CONTROL OF MUSCULAR STIFFNESS (tonic reflex from vibration)

bull STIMULATION OF BLOOD LYMPHATIC CIRCULATION

bull PAIN RELIEF (gate control)

bull INCREASED SENSITIVITY

Bibliographic details Wang P Yang X Yang Y Yang L Zhou Y Liu C Reinhardt JD He C Effects of whole body vibration on pain stiffness and physical functions in patients with knee osteoarthritis a systematic review and meta-analysis Clinical Rehabilitation 2014 epub [PubMed] Dott Salvatore Denaro

Impact Waves bull 1 direct effect of the impulse on the tissue

in the target area and in conjunction with the reflection phenomena more accentuated in the points of transition between soft tissue (tendons muscles) and more compact tissues (bones and calcification formations)

bull 2 indirect effect of ldquocavitationrdquo caused by the subsequent depression of the impulse which exceeds the elastic characteristics of the tissue

NO DIRECT EFFECT ON PAIN MODULATORS OF BIOLOGICAL FUNCTIONS IN HUMAN MUSCLE CELLS (J Orthop Surg Res 2018 Apr 613(1)75 Exposure to radial extracorporeal shock waves modulates viability and gene expression of human skeletal muscle cells a controlled in vitro study Mattyasovszky SG1 Langendorf EK2 Ritz U2 Schmitz C3 Schmidtmann I4 Nowak TE2 Wagner D2 Hofmann A2 Rommens PM2 Drees P2)

RADIALI

FOCALI

Dott Salvatore Denaro

Ion Cyclotron Resonance Quantum Molecular Resonance

bull Stimulates the biological functions of cells bull Rebalances the correct membrane potential bull Activates enzymatic processes bull Restores the correct ion exchange for cell metabolism bull Promotes intra-extra cellular ion balance

Operating principle based on Quantum Molecular Resonance with the application of high-frequency and low-power micro-currents Induces the regeneration of damaged tissues especially muscular tissues without thermal effects

Dott Salvatore Denaro

Dott Salvatore Denaro

KINESIOTHERAPY IS NECESSARY

bull WITH REGARD TO ARTICULAR LINKS ndash JOINT PLAY ndash STRUCTURAL INTEGRITY OF THE CARTILAGE CAPSULE

AND LIGAMENTS ndash CORRECT MUSCLE SYNERGY ndash ELIMINATION OF FUNCTIONAL COMPENSATIONS

bull PAIN CONTROL bull NO CONTRAINDICATION

Dott Salvatore Denaro

KINESIOTHERAPY

bull POSTURAL Aims to correct any negative issues of posture (often secondary to analgesic compensatory attitudes) to detect alterations in the knee and calcaneal axis and of the plantar support visual disturbance dental malocclusion dysmetria of the pelvis etc

Dott Salvatore Denaro

KINESIOTHERAPY

bull HYDRO-KINESIOTHERAPY Very useful in cases of rheumatic diseases Therapeutic exercise in water is facilitated by the option to regulate water temperature and by the reduction in gravitational force which this medium allows

Dott Salvatore Denaro

VERTEBRAL MANIPULATION Robert Maignersquos ldquoManu Medicardquo

bull SEMIOTICS NATURE OF ILLNESS OR PATHOLOGY (clinical examination

imaging laboratory etc) ANALYSIS OF MINOR INTERVERTEBRAL DISTURBANCE

(ROM DDIM SCTM according to R Maignersquos research into signs of functional limitations)

bull THERAPY Principles RULE OF NO PAIN AND OF CONTRARY MOVEMENT VERIFICATION OF EVERY MANIPULATION BEFORE

PERFORMING THE NEXT

Dott Salvatore Denaro

TECHNIQUES

bull TREATMENT OF SOFT PARTS bull MUSCULAR STRETCHING bull REPEATED INTERVENTIONS bull MANIPULATION (3 STAGES)

Place in position Apply tension Manipulative thrust (low amplitude high velocity)

ldquoIT IS A NON-SYMPTOMATIC CAUSAL THERAPYrdquo

Mechanism of action of Vertebral Manipulation

bull Stretching and distension of the posterior joint capsule has a powerful inhibitory effect on muscle contraction (analgesic contraction) The hypotonic Gamma is determined by the stimulation of the periarticular receptors activated by the manipulative manoeuvre and results in a rapid and powerful ldquoINHIBITORY REFLEXrdquo through the contraction of the intervertebral musculature (DDIM)

bull With Vertebral Manipulation abruptly stretching structures such as ligaments discs joint capsules or muscles activates the descending system of nociceptive inhibition of pain in cases where this originates at the level of the grey matter

J Electromyogr Kinesiol 2012 Oct 22(5) 785ndash794Published online 2012 Feb 19 doi Spinal Manipulative Therapy and Somatosensory Activation Joel G Pickar DC PhD1 and Philip S Bolton DC PhD2 Dott Salvatore Denaro

Self-assessment scale Verbal scale absent slight moderate strong very strong

Visual analogue scale (VAS)

No pain Maximum pain 10 cm

Colour (chromatic) scale

Maximum pain

No pain

Numerical scale NRS no pain 1 2 3 4 5 6 7 8 9 10 extreme pain

Dott Salvatore Denaro

Scott Huskisson 1976

Downie 1978 Grossi 1983

The measurement of subjective pain its usefulness

As far as chronic pain is concerned the measurement of pain does not allow a correct evaluation of the progress of the clinical picture

It is advisable to use measurement to evaluate episodes of acute conditions or to analyse in the short term the efficacy of a therapeutic choice

In acute episodes the intensity of pain may indicate the drug to be used and its dosage (OMS scale)

Dott Salvatore Denaro

Evaluation of pain to reach a diagnosis where illness includes pain (requiring

investigation into how the illness arose) it involves a specific therapeutic plan for the illness (illness related)

in the case of a pathogenetic mechanism (a true algological diagnosis) it involves a therapeutic plan targeted at the mechanism (mechanism related)

Dott Salvatore Denaro

Classification of pain

ACUTE PAIN serves to alert the

body to the presence of dangerous stimuli

NOCICEPTIVEPAIN

(SOMATIC AND

VISCERAL)

TEMPORAL PHYSIOPATHOLOGICAL

CHRONIC PAIN

not just extended in time but with different qualitative characteristics

NEUROPATHICPAIN (CENTRAL PERIPHERAL)

IDEOPATHIC OR FUNCTIONALPAIN

Dott Salvatore Denaro

Key points and guidelines for the treatment of pain - Joint Commission on Accreditation

of Health Care Organizations - 1 The patientrsquos right to be treated for pain

2 Evaluate and document the presence nature and intensity of pain in all patients (5th vital indication in conjunction with blood pressure pulse temperature and respiratory rate)

3 Ensure staff competence in the evaluation and treatment of pain

4 Establish protocols for adequate treatment of pain

5 Educate patients and their families for effective control of pain 6 Satisfy the patientrsquos needs for effective treatment of symptoms after

discharge

Legge 15 marzo 2010 n 38 concernente ldquoDisposizioni per garantire laccesso alle cure palliative e alla terapia del dolorerdquo (Gazzetta Ufficiale n 65 del 19 marzo 2010)

Who takes responsibility for each type of pain - the Physiatrist the

Rheumatologist or the Orthopedist

bull Muscolotendinous (including tendon sheaths and synovial bursa)

bull Articulate and capsuloligamentous bull Bone bull Neurological peripheral and central bull Oncological supporting the Oncologist

Dott Salvatore Denaro

Overview of therapy the vicious circle of untreated pain

Limiting behaviour Pain

Altered functional status

Decreased autonomy

Social limitations Reduced mobility

Dott Salvatore Denaro

Dott Salvatore Denaro Dott Salvatore Denaro

Some painful forms of musculoskeletal origin

Post-traumatic pain Fracture Dislocation Distortion

Inflammatory joint pain (acute or chronic) Arthritis Rheumatoid arthritis Gout

Periarticular inflammatory pain (acute or chronic) Pathology from functional overload in muscles tendons or ligaments

Neuropathic or mixed pain

Compressive nerve syndromes Rachialgia Radiculopathy Osteoporosis pain

Oncological pain

Dott Salvatore Denaro

NEURAL PATHS FOR THE TRANSMISSION

OF PAIN

1st neuron

2nd neuron from the spinal chord to the thalamus

3rd neuron from the thalamus to the cerebral cortex

Opioids Alpha 2 agonists

Local anesthetics

Opioids

Alpha 2 agonists

Local anesthetics

Local anesthetics

Anti-inflammatory drugs

Routes of management

Intra-articular

transmucosal

Dott Salvatore Denaro

Dott Salvatore Denaro

But also in Orthopedic Medicinehelliphelliphellip

Dott Salvatore Denaro

Infiltration therapy

Acupuncture (ancient Chinese approach outlined by Huangdi Neijing

between 305 and 204 BC) This subject is only briefly mentioned here as it deserves its own separate conference There are however very few evidence based medical (EBM) studies of this ancient approach

Mesotherapy and Prolotherapy

Mesotherapy (MPistor) is an excellent analgesic therapy which uses a single needle or multi-injector as detailed by colleagues in the SFM (Socieacuteteacute Franccedilaise de Meacutesotheacuterapie)

Neuroprolotherapy (NPT) is a method of treatment which is distinct and separate from Prolotherapy from which it was evolved Developed since 2002 by New Zealander Dr John Lyftogt it targets the superficial sensory nerves of the body with micro-injections of low concentration glucose (5)

Dott Salvatore Denaro

Dry needling Annals of the Rheumatic Diseases 74(Suppl 2)624 middot June 2015 RV Bubnov

bull Very similar to acupuncture but treats the trigger points and myalgic intramuscular cords

bull It provides pinpoint mechanical stimulation

bull It provides both intramuscular and superficial stimulation

bull Precise laquoPain pointsraquo can be treated

Hyuk Ga Ji-Ho Choi Chang-Hae Park Hyun-Jung Yoon Acupuncture needling versus lidocaine injection of trigger points in myofascial pain syndrome in elderly patients ndash a randomised trial Acupuncture in Medicine Dec 2007

Dott Salvatore Denaro

TREATMENT OF PAIN in Orthopaedic Medicine

Dott Salvatore Denaro

ELECTROANALGESIA Based on Melzack and Wallrsquos theory of gate control which

describes two types of intervention for pain control

the first consists of reinforcing the the inhibitory power of large fibers the second aims selectively to interrupt the communication of small calibre fibers near the posterior horns (where the peripheral terminations are connected to the main neural pathways of communication to the brain)

Dott Salvatore Denaro

ELECTROANALGESIA TENS

ldquoTranscutaneous Electrical Nerve Stimulationrdquo is characterised by the fact that the electrodes are applied directly to the skin above the path of the

nerve trunk causing paresthesia in the area of the stimulated nerve distribution

Low frequency currents are used rectangular in shape which have an analgesic effect with

modalities that are not perfectly defined

Using TENS for pain control the state of the evidence Vance CG1 Dailey DL Rakel BA Sluka KA Pain Manag 2014 May4(3)197-209

Dott Salvatore Denaro

Non surgical laser therapy In analgesic therapy the ideal laser emission

instrument is one which uses a semiconductor diode as its active medium emitting invisible bursts of

radiation delivered in extremely short pulses typically within the infrared (IR) band with a

wavelength of approximately 904 nanometres ie the IR laser Other options include He-Ne CO2

Neodimio Yag and HILT

low levels of evidence

Eur J Phys Rehabil Med 2017 Aug53(4)603-610 Epub 2017 Jan 30 Effects of low-level laser therapy on pain in patients with musculoskeletal disorders a systematic review and meta-analysis Clijsen R123 Brunner A4 Barbero M4 Clarys P5 Taeymans J56

MOJ Orthop Rheumatol 20152(5) Epub 2015 Jun 9 The Use of Low Level Laser Therapy (LLLT) For Musculoskeletal Pain Cotler HB1 Chow RT2 Hamblin MR3 Carroll J4

Dott Salvatore Denaro

Biological Effects of LASER THERAPY an increase in the speed of mitosis temporary and reversible tissue dehydration denaturation of proteins thermolysis

carbonization for focal CO2 tissue evaporation

Physiotherapeutic lasers essentially produce two effects analgesic anti edema and biostimulant

Heat Therapy (Thermotherapy)

bull Heat action on the gate-control of MampW There is limited overall evidence to support the general use of localized heat however randomised clinical trials (RCTs) have shown that heat therapy provides short-term reductions in pain and disability in patients with acute lower back pain and provides significantly greater pain relief from DOMS than cold therapy (Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury Gerard A Malanga Ning Yan amp Jill Stark Oct 2014) PubMedgov

bull Cold reduction of tissue temperature which subsequently exerts local effects on blood flow on cell swelling and on metabolism and speed of neural conduction (Cold-water immersion and other forms of cryotherapy physiological changes potentially affecting recovery from high-intensity exercise Gillian E White and Greg D Wells Email author Extreme Physiology amp Medicine 2013 )

Dott Salvatore Denaro

KRYO TECAR

Mechanotherapy vibration

bull CONTROL OF MUSCULAR STIFFNESS (tonic reflex from vibration)

bull STIMULATION OF BLOOD LYMPHATIC CIRCULATION

bull PAIN RELIEF (gate control)

bull INCREASED SENSITIVITY

Bibliographic details Wang P Yang X Yang Y Yang L Zhou Y Liu C Reinhardt JD He C Effects of whole body vibration on pain stiffness and physical functions in patients with knee osteoarthritis a systematic review and meta-analysis Clinical Rehabilitation 2014 epub [PubMed] Dott Salvatore Denaro

Impact Waves bull 1 direct effect of the impulse on the tissue

in the target area and in conjunction with the reflection phenomena more accentuated in the points of transition between soft tissue (tendons muscles) and more compact tissues (bones and calcification formations)

bull 2 indirect effect of ldquocavitationrdquo caused by the subsequent depression of the impulse which exceeds the elastic characteristics of the tissue

NO DIRECT EFFECT ON PAIN MODULATORS OF BIOLOGICAL FUNCTIONS IN HUMAN MUSCLE CELLS (J Orthop Surg Res 2018 Apr 613(1)75 Exposure to radial extracorporeal shock waves modulates viability and gene expression of human skeletal muscle cells a controlled in vitro study Mattyasovszky SG1 Langendorf EK2 Ritz U2 Schmitz C3 Schmidtmann I4 Nowak TE2 Wagner D2 Hofmann A2 Rommens PM2 Drees P2)

RADIALI

FOCALI

Dott Salvatore Denaro

Ion Cyclotron Resonance Quantum Molecular Resonance

bull Stimulates the biological functions of cells bull Rebalances the correct membrane potential bull Activates enzymatic processes bull Restores the correct ion exchange for cell metabolism bull Promotes intra-extra cellular ion balance

Operating principle based on Quantum Molecular Resonance with the application of high-frequency and low-power micro-currents Induces the regeneration of damaged tissues especially muscular tissues without thermal effects

Dott Salvatore Denaro

Dott Salvatore Denaro

KINESIOTHERAPY IS NECESSARY

bull WITH REGARD TO ARTICULAR LINKS ndash JOINT PLAY ndash STRUCTURAL INTEGRITY OF THE CARTILAGE CAPSULE

AND LIGAMENTS ndash CORRECT MUSCLE SYNERGY ndash ELIMINATION OF FUNCTIONAL COMPENSATIONS

bull PAIN CONTROL bull NO CONTRAINDICATION

Dott Salvatore Denaro

KINESIOTHERAPY

bull POSTURAL Aims to correct any negative issues of posture (often secondary to analgesic compensatory attitudes) to detect alterations in the knee and calcaneal axis and of the plantar support visual disturbance dental malocclusion dysmetria of the pelvis etc

Dott Salvatore Denaro

KINESIOTHERAPY

bull HYDRO-KINESIOTHERAPY Very useful in cases of rheumatic diseases Therapeutic exercise in water is facilitated by the option to regulate water temperature and by the reduction in gravitational force which this medium allows

Dott Salvatore Denaro

VERTEBRAL MANIPULATION Robert Maignersquos ldquoManu Medicardquo

bull SEMIOTICS NATURE OF ILLNESS OR PATHOLOGY (clinical examination

imaging laboratory etc) ANALYSIS OF MINOR INTERVERTEBRAL DISTURBANCE

(ROM DDIM SCTM according to R Maignersquos research into signs of functional limitations)

bull THERAPY Principles RULE OF NO PAIN AND OF CONTRARY MOVEMENT VERIFICATION OF EVERY MANIPULATION BEFORE

PERFORMING THE NEXT

Dott Salvatore Denaro

TECHNIQUES

bull TREATMENT OF SOFT PARTS bull MUSCULAR STRETCHING bull REPEATED INTERVENTIONS bull MANIPULATION (3 STAGES)

Place in position Apply tension Manipulative thrust (low amplitude high velocity)

ldquoIT IS A NON-SYMPTOMATIC CAUSAL THERAPYrdquo

Mechanism of action of Vertebral Manipulation

bull Stretching and distension of the posterior joint capsule has a powerful inhibitory effect on muscle contraction (analgesic contraction) The hypotonic Gamma is determined by the stimulation of the periarticular receptors activated by the manipulative manoeuvre and results in a rapid and powerful ldquoINHIBITORY REFLEXrdquo through the contraction of the intervertebral musculature (DDIM)

bull With Vertebral Manipulation abruptly stretching structures such as ligaments discs joint capsules or muscles activates the descending system of nociceptive inhibition of pain in cases where this originates at the level of the grey matter

J Electromyogr Kinesiol 2012 Oct 22(5) 785ndash794Published online 2012 Feb 19 doi Spinal Manipulative Therapy and Somatosensory Activation Joel G Pickar DC PhD1 and Philip S Bolton DC PhD2 Dott Salvatore Denaro

The measurement of subjective pain its usefulness

As far as chronic pain is concerned the measurement of pain does not allow a correct evaluation of the progress of the clinical picture

It is advisable to use measurement to evaluate episodes of acute conditions or to analyse in the short term the efficacy of a therapeutic choice

In acute episodes the intensity of pain may indicate the drug to be used and its dosage (OMS scale)

Dott Salvatore Denaro

Evaluation of pain to reach a diagnosis where illness includes pain (requiring

investigation into how the illness arose) it involves a specific therapeutic plan for the illness (illness related)

in the case of a pathogenetic mechanism (a true algological diagnosis) it involves a therapeutic plan targeted at the mechanism (mechanism related)

Dott Salvatore Denaro

Classification of pain

ACUTE PAIN serves to alert the

body to the presence of dangerous stimuli

NOCICEPTIVEPAIN

(SOMATIC AND

VISCERAL)

TEMPORAL PHYSIOPATHOLOGICAL

CHRONIC PAIN

not just extended in time but with different qualitative characteristics

NEUROPATHICPAIN (CENTRAL PERIPHERAL)

IDEOPATHIC OR FUNCTIONALPAIN

Dott Salvatore Denaro

Key points and guidelines for the treatment of pain - Joint Commission on Accreditation

of Health Care Organizations - 1 The patientrsquos right to be treated for pain

2 Evaluate and document the presence nature and intensity of pain in all patients (5th vital indication in conjunction with blood pressure pulse temperature and respiratory rate)

3 Ensure staff competence in the evaluation and treatment of pain

4 Establish protocols for adequate treatment of pain

5 Educate patients and their families for effective control of pain 6 Satisfy the patientrsquos needs for effective treatment of symptoms after

discharge

Legge 15 marzo 2010 n 38 concernente ldquoDisposizioni per garantire laccesso alle cure palliative e alla terapia del dolorerdquo (Gazzetta Ufficiale n 65 del 19 marzo 2010)

Who takes responsibility for each type of pain - the Physiatrist the

Rheumatologist or the Orthopedist

bull Muscolotendinous (including tendon sheaths and synovial bursa)

bull Articulate and capsuloligamentous bull Bone bull Neurological peripheral and central bull Oncological supporting the Oncologist

Dott Salvatore Denaro

Overview of therapy the vicious circle of untreated pain

Limiting behaviour Pain

Altered functional status

Decreased autonomy

Social limitations Reduced mobility

Dott Salvatore Denaro

Dott Salvatore Denaro Dott Salvatore Denaro

Some painful forms of musculoskeletal origin

Post-traumatic pain Fracture Dislocation Distortion

Inflammatory joint pain (acute or chronic) Arthritis Rheumatoid arthritis Gout

Periarticular inflammatory pain (acute or chronic) Pathology from functional overload in muscles tendons or ligaments

Neuropathic or mixed pain

Compressive nerve syndromes Rachialgia Radiculopathy Osteoporosis pain

Oncological pain

Dott Salvatore Denaro

NEURAL PATHS FOR THE TRANSMISSION

OF PAIN

1st neuron

2nd neuron from the spinal chord to the thalamus

3rd neuron from the thalamus to the cerebral cortex

Opioids Alpha 2 agonists

Local anesthetics

Opioids

Alpha 2 agonists

Local anesthetics

Local anesthetics

Anti-inflammatory drugs

Routes of management

Intra-articular

transmucosal

Dott Salvatore Denaro

Dott Salvatore Denaro

But also in Orthopedic Medicinehelliphelliphellip

Dott Salvatore Denaro

Infiltration therapy

Acupuncture (ancient Chinese approach outlined by Huangdi Neijing

between 305 and 204 BC) This subject is only briefly mentioned here as it deserves its own separate conference There are however very few evidence based medical (EBM) studies of this ancient approach

Mesotherapy and Prolotherapy

Mesotherapy (MPistor) is an excellent analgesic therapy which uses a single needle or multi-injector as detailed by colleagues in the SFM (Socieacuteteacute Franccedilaise de Meacutesotheacuterapie)

Neuroprolotherapy (NPT) is a method of treatment which is distinct and separate from Prolotherapy from which it was evolved Developed since 2002 by New Zealander Dr John Lyftogt it targets the superficial sensory nerves of the body with micro-injections of low concentration glucose (5)

Dott Salvatore Denaro

Dry needling Annals of the Rheumatic Diseases 74(Suppl 2)624 middot June 2015 RV Bubnov

bull Very similar to acupuncture but treats the trigger points and myalgic intramuscular cords

bull It provides pinpoint mechanical stimulation

bull It provides both intramuscular and superficial stimulation

bull Precise laquoPain pointsraquo can be treated

Hyuk Ga Ji-Ho Choi Chang-Hae Park Hyun-Jung Yoon Acupuncture needling versus lidocaine injection of trigger points in myofascial pain syndrome in elderly patients ndash a randomised trial Acupuncture in Medicine Dec 2007

Dott Salvatore Denaro

TREATMENT OF PAIN in Orthopaedic Medicine

Dott Salvatore Denaro

ELECTROANALGESIA Based on Melzack and Wallrsquos theory of gate control which

describes two types of intervention for pain control

the first consists of reinforcing the the inhibitory power of large fibers the second aims selectively to interrupt the communication of small calibre fibers near the posterior horns (where the peripheral terminations are connected to the main neural pathways of communication to the brain)

Dott Salvatore Denaro

ELECTROANALGESIA TENS

ldquoTranscutaneous Electrical Nerve Stimulationrdquo is characterised by the fact that the electrodes are applied directly to the skin above the path of the

nerve trunk causing paresthesia in the area of the stimulated nerve distribution

Low frequency currents are used rectangular in shape which have an analgesic effect with

modalities that are not perfectly defined

Using TENS for pain control the state of the evidence Vance CG1 Dailey DL Rakel BA Sluka KA Pain Manag 2014 May4(3)197-209

Dott Salvatore Denaro

Non surgical laser therapy In analgesic therapy the ideal laser emission

instrument is one which uses a semiconductor diode as its active medium emitting invisible bursts of

radiation delivered in extremely short pulses typically within the infrared (IR) band with a

wavelength of approximately 904 nanometres ie the IR laser Other options include He-Ne CO2

Neodimio Yag and HILT

low levels of evidence

Eur J Phys Rehabil Med 2017 Aug53(4)603-610 Epub 2017 Jan 30 Effects of low-level laser therapy on pain in patients with musculoskeletal disorders a systematic review and meta-analysis Clijsen R123 Brunner A4 Barbero M4 Clarys P5 Taeymans J56

MOJ Orthop Rheumatol 20152(5) Epub 2015 Jun 9 The Use of Low Level Laser Therapy (LLLT) For Musculoskeletal Pain Cotler HB1 Chow RT2 Hamblin MR3 Carroll J4

Dott Salvatore Denaro

Biological Effects of LASER THERAPY an increase in the speed of mitosis temporary and reversible tissue dehydration denaturation of proteins thermolysis

carbonization for focal CO2 tissue evaporation

Physiotherapeutic lasers essentially produce two effects analgesic anti edema and biostimulant

Heat Therapy (Thermotherapy)

bull Heat action on the gate-control of MampW There is limited overall evidence to support the general use of localized heat however randomised clinical trials (RCTs) have shown that heat therapy provides short-term reductions in pain and disability in patients with acute lower back pain and provides significantly greater pain relief from DOMS than cold therapy (Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury Gerard A Malanga Ning Yan amp Jill Stark Oct 2014) PubMedgov

bull Cold reduction of tissue temperature which subsequently exerts local effects on blood flow on cell swelling and on metabolism and speed of neural conduction (Cold-water immersion and other forms of cryotherapy physiological changes potentially affecting recovery from high-intensity exercise Gillian E White and Greg D Wells Email author Extreme Physiology amp Medicine 2013 )

Dott Salvatore Denaro

KRYO TECAR

Mechanotherapy vibration

bull CONTROL OF MUSCULAR STIFFNESS (tonic reflex from vibration)

bull STIMULATION OF BLOOD LYMPHATIC CIRCULATION

bull PAIN RELIEF (gate control)

bull INCREASED SENSITIVITY

Bibliographic details Wang P Yang X Yang Y Yang L Zhou Y Liu C Reinhardt JD He C Effects of whole body vibration on pain stiffness and physical functions in patients with knee osteoarthritis a systematic review and meta-analysis Clinical Rehabilitation 2014 epub [PubMed] Dott Salvatore Denaro

Impact Waves bull 1 direct effect of the impulse on the tissue

in the target area and in conjunction with the reflection phenomena more accentuated in the points of transition between soft tissue (tendons muscles) and more compact tissues (bones and calcification formations)

bull 2 indirect effect of ldquocavitationrdquo caused by the subsequent depression of the impulse which exceeds the elastic characteristics of the tissue

NO DIRECT EFFECT ON PAIN MODULATORS OF BIOLOGICAL FUNCTIONS IN HUMAN MUSCLE CELLS (J Orthop Surg Res 2018 Apr 613(1)75 Exposure to radial extracorporeal shock waves modulates viability and gene expression of human skeletal muscle cells a controlled in vitro study Mattyasovszky SG1 Langendorf EK2 Ritz U2 Schmitz C3 Schmidtmann I4 Nowak TE2 Wagner D2 Hofmann A2 Rommens PM2 Drees P2)

RADIALI

FOCALI

Dott Salvatore Denaro

Ion Cyclotron Resonance Quantum Molecular Resonance

bull Stimulates the biological functions of cells bull Rebalances the correct membrane potential bull Activates enzymatic processes bull Restores the correct ion exchange for cell metabolism bull Promotes intra-extra cellular ion balance

Operating principle based on Quantum Molecular Resonance with the application of high-frequency and low-power micro-currents Induces the regeneration of damaged tissues especially muscular tissues without thermal effects

Dott Salvatore Denaro

Dott Salvatore Denaro

KINESIOTHERAPY IS NECESSARY

bull WITH REGARD TO ARTICULAR LINKS ndash JOINT PLAY ndash STRUCTURAL INTEGRITY OF THE CARTILAGE CAPSULE

AND LIGAMENTS ndash CORRECT MUSCLE SYNERGY ndash ELIMINATION OF FUNCTIONAL COMPENSATIONS

bull PAIN CONTROL bull NO CONTRAINDICATION

Dott Salvatore Denaro

KINESIOTHERAPY

bull POSTURAL Aims to correct any negative issues of posture (often secondary to analgesic compensatory attitudes) to detect alterations in the knee and calcaneal axis and of the plantar support visual disturbance dental malocclusion dysmetria of the pelvis etc

Dott Salvatore Denaro

KINESIOTHERAPY

bull HYDRO-KINESIOTHERAPY Very useful in cases of rheumatic diseases Therapeutic exercise in water is facilitated by the option to regulate water temperature and by the reduction in gravitational force which this medium allows

Dott Salvatore Denaro

VERTEBRAL MANIPULATION Robert Maignersquos ldquoManu Medicardquo

bull SEMIOTICS NATURE OF ILLNESS OR PATHOLOGY (clinical examination

imaging laboratory etc) ANALYSIS OF MINOR INTERVERTEBRAL DISTURBANCE

(ROM DDIM SCTM according to R Maignersquos research into signs of functional limitations)

bull THERAPY Principles RULE OF NO PAIN AND OF CONTRARY MOVEMENT VERIFICATION OF EVERY MANIPULATION BEFORE

PERFORMING THE NEXT

Dott Salvatore Denaro

TECHNIQUES

bull TREATMENT OF SOFT PARTS bull MUSCULAR STRETCHING bull REPEATED INTERVENTIONS bull MANIPULATION (3 STAGES)

Place in position Apply tension Manipulative thrust (low amplitude high velocity)

ldquoIT IS A NON-SYMPTOMATIC CAUSAL THERAPYrdquo

Mechanism of action of Vertebral Manipulation

bull Stretching and distension of the posterior joint capsule has a powerful inhibitory effect on muscle contraction (analgesic contraction) The hypotonic Gamma is determined by the stimulation of the periarticular receptors activated by the manipulative manoeuvre and results in a rapid and powerful ldquoINHIBITORY REFLEXrdquo through the contraction of the intervertebral musculature (DDIM)

bull With Vertebral Manipulation abruptly stretching structures such as ligaments discs joint capsules or muscles activates the descending system of nociceptive inhibition of pain in cases where this originates at the level of the grey matter

J Electromyogr Kinesiol 2012 Oct 22(5) 785ndash794Published online 2012 Feb 19 doi Spinal Manipulative Therapy and Somatosensory Activation Joel G Pickar DC PhD1 and Philip S Bolton DC PhD2 Dott Salvatore Denaro

Evaluation of pain to reach a diagnosis where illness includes pain (requiring

investigation into how the illness arose) it involves a specific therapeutic plan for the illness (illness related)

in the case of a pathogenetic mechanism (a true algological diagnosis) it involves a therapeutic plan targeted at the mechanism (mechanism related)

Dott Salvatore Denaro

Classification of pain

ACUTE PAIN serves to alert the

body to the presence of dangerous stimuli

NOCICEPTIVEPAIN

(SOMATIC AND

VISCERAL)

TEMPORAL PHYSIOPATHOLOGICAL

CHRONIC PAIN

not just extended in time but with different qualitative characteristics

NEUROPATHICPAIN (CENTRAL PERIPHERAL)

IDEOPATHIC OR FUNCTIONALPAIN

Dott Salvatore Denaro

Key points and guidelines for the treatment of pain - Joint Commission on Accreditation

of Health Care Organizations - 1 The patientrsquos right to be treated for pain

2 Evaluate and document the presence nature and intensity of pain in all patients (5th vital indication in conjunction with blood pressure pulse temperature and respiratory rate)

3 Ensure staff competence in the evaluation and treatment of pain

4 Establish protocols for adequate treatment of pain

5 Educate patients and their families for effective control of pain 6 Satisfy the patientrsquos needs for effective treatment of symptoms after

discharge

Legge 15 marzo 2010 n 38 concernente ldquoDisposizioni per garantire laccesso alle cure palliative e alla terapia del dolorerdquo (Gazzetta Ufficiale n 65 del 19 marzo 2010)

Who takes responsibility for each type of pain - the Physiatrist the

Rheumatologist or the Orthopedist

bull Muscolotendinous (including tendon sheaths and synovial bursa)

bull Articulate and capsuloligamentous bull Bone bull Neurological peripheral and central bull Oncological supporting the Oncologist

Dott Salvatore Denaro

Overview of therapy the vicious circle of untreated pain

Limiting behaviour Pain

Altered functional status

Decreased autonomy

Social limitations Reduced mobility

Dott Salvatore Denaro

Dott Salvatore Denaro Dott Salvatore Denaro

Some painful forms of musculoskeletal origin

Post-traumatic pain Fracture Dislocation Distortion

Inflammatory joint pain (acute or chronic) Arthritis Rheumatoid arthritis Gout

Periarticular inflammatory pain (acute or chronic) Pathology from functional overload in muscles tendons or ligaments

Neuropathic or mixed pain

Compressive nerve syndromes Rachialgia Radiculopathy Osteoporosis pain

Oncological pain

Dott Salvatore Denaro

NEURAL PATHS FOR THE TRANSMISSION

OF PAIN

1st neuron

2nd neuron from the spinal chord to the thalamus

3rd neuron from the thalamus to the cerebral cortex

Opioids Alpha 2 agonists

Local anesthetics

Opioids

Alpha 2 agonists

Local anesthetics

Local anesthetics

Anti-inflammatory drugs

Routes of management

Intra-articular

transmucosal

Dott Salvatore Denaro

Dott Salvatore Denaro

But also in Orthopedic Medicinehelliphelliphellip

Dott Salvatore Denaro

Infiltration therapy

Acupuncture (ancient Chinese approach outlined by Huangdi Neijing

between 305 and 204 BC) This subject is only briefly mentioned here as it deserves its own separate conference There are however very few evidence based medical (EBM) studies of this ancient approach

Mesotherapy and Prolotherapy

Mesotherapy (MPistor) is an excellent analgesic therapy which uses a single needle or multi-injector as detailed by colleagues in the SFM (Socieacuteteacute Franccedilaise de Meacutesotheacuterapie)

Neuroprolotherapy (NPT) is a method of treatment which is distinct and separate from Prolotherapy from which it was evolved Developed since 2002 by New Zealander Dr John Lyftogt it targets the superficial sensory nerves of the body with micro-injections of low concentration glucose (5)

Dott Salvatore Denaro

Dry needling Annals of the Rheumatic Diseases 74(Suppl 2)624 middot June 2015 RV Bubnov

bull Very similar to acupuncture but treats the trigger points and myalgic intramuscular cords

bull It provides pinpoint mechanical stimulation

bull It provides both intramuscular and superficial stimulation

bull Precise laquoPain pointsraquo can be treated

Hyuk Ga Ji-Ho Choi Chang-Hae Park Hyun-Jung Yoon Acupuncture needling versus lidocaine injection of trigger points in myofascial pain syndrome in elderly patients ndash a randomised trial Acupuncture in Medicine Dec 2007

Dott Salvatore Denaro

TREATMENT OF PAIN in Orthopaedic Medicine

Dott Salvatore Denaro

ELECTROANALGESIA Based on Melzack and Wallrsquos theory of gate control which

describes two types of intervention for pain control

the first consists of reinforcing the the inhibitory power of large fibers the second aims selectively to interrupt the communication of small calibre fibers near the posterior horns (where the peripheral terminations are connected to the main neural pathways of communication to the brain)

Dott Salvatore Denaro

ELECTROANALGESIA TENS

ldquoTranscutaneous Electrical Nerve Stimulationrdquo is characterised by the fact that the electrodes are applied directly to the skin above the path of the

nerve trunk causing paresthesia in the area of the stimulated nerve distribution

Low frequency currents are used rectangular in shape which have an analgesic effect with

modalities that are not perfectly defined

Using TENS for pain control the state of the evidence Vance CG1 Dailey DL Rakel BA Sluka KA Pain Manag 2014 May4(3)197-209

Dott Salvatore Denaro

Non surgical laser therapy In analgesic therapy the ideal laser emission

instrument is one which uses a semiconductor diode as its active medium emitting invisible bursts of

radiation delivered in extremely short pulses typically within the infrared (IR) band with a

wavelength of approximately 904 nanometres ie the IR laser Other options include He-Ne CO2

Neodimio Yag and HILT

low levels of evidence

Eur J Phys Rehabil Med 2017 Aug53(4)603-610 Epub 2017 Jan 30 Effects of low-level laser therapy on pain in patients with musculoskeletal disorders a systematic review and meta-analysis Clijsen R123 Brunner A4 Barbero M4 Clarys P5 Taeymans J56

MOJ Orthop Rheumatol 20152(5) Epub 2015 Jun 9 The Use of Low Level Laser Therapy (LLLT) For Musculoskeletal Pain Cotler HB1 Chow RT2 Hamblin MR3 Carroll J4

Dott Salvatore Denaro

Biological Effects of LASER THERAPY an increase in the speed of mitosis temporary and reversible tissue dehydration denaturation of proteins thermolysis

carbonization for focal CO2 tissue evaporation

Physiotherapeutic lasers essentially produce two effects analgesic anti edema and biostimulant

Heat Therapy (Thermotherapy)

bull Heat action on the gate-control of MampW There is limited overall evidence to support the general use of localized heat however randomised clinical trials (RCTs) have shown that heat therapy provides short-term reductions in pain and disability in patients with acute lower back pain and provides significantly greater pain relief from DOMS than cold therapy (Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury Gerard A Malanga Ning Yan amp Jill Stark Oct 2014) PubMedgov

bull Cold reduction of tissue temperature which subsequently exerts local effects on blood flow on cell swelling and on metabolism and speed of neural conduction (Cold-water immersion and other forms of cryotherapy physiological changes potentially affecting recovery from high-intensity exercise Gillian E White and Greg D Wells Email author Extreme Physiology amp Medicine 2013 )

Dott Salvatore Denaro

KRYO TECAR

Mechanotherapy vibration

bull CONTROL OF MUSCULAR STIFFNESS (tonic reflex from vibration)

bull STIMULATION OF BLOOD LYMPHATIC CIRCULATION

bull PAIN RELIEF (gate control)

bull INCREASED SENSITIVITY

Bibliographic details Wang P Yang X Yang Y Yang L Zhou Y Liu C Reinhardt JD He C Effects of whole body vibration on pain stiffness and physical functions in patients with knee osteoarthritis a systematic review and meta-analysis Clinical Rehabilitation 2014 epub [PubMed] Dott Salvatore Denaro

Impact Waves bull 1 direct effect of the impulse on the tissue

in the target area and in conjunction with the reflection phenomena more accentuated in the points of transition between soft tissue (tendons muscles) and more compact tissues (bones and calcification formations)

bull 2 indirect effect of ldquocavitationrdquo caused by the subsequent depression of the impulse which exceeds the elastic characteristics of the tissue

NO DIRECT EFFECT ON PAIN MODULATORS OF BIOLOGICAL FUNCTIONS IN HUMAN MUSCLE CELLS (J Orthop Surg Res 2018 Apr 613(1)75 Exposure to radial extracorporeal shock waves modulates viability and gene expression of human skeletal muscle cells a controlled in vitro study Mattyasovszky SG1 Langendorf EK2 Ritz U2 Schmitz C3 Schmidtmann I4 Nowak TE2 Wagner D2 Hofmann A2 Rommens PM2 Drees P2)

RADIALI

FOCALI

Dott Salvatore Denaro

Ion Cyclotron Resonance Quantum Molecular Resonance

bull Stimulates the biological functions of cells bull Rebalances the correct membrane potential bull Activates enzymatic processes bull Restores the correct ion exchange for cell metabolism bull Promotes intra-extra cellular ion balance

Operating principle based on Quantum Molecular Resonance with the application of high-frequency and low-power micro-currents Induces the regeneration of damaged tissues especially muscular tissues without thermal effects

Dott Salvatore Denaro

Dott Salvatore Denaro

KINESIOTHERAPY IS NECESSARY

bull WITH REGARD TO ARTICULAR LINKS ndash JOINT PLAY ndash STRUCTURAL INTEGRITY OF THE CARTILAGE CAPSULE

AND LIGAMENTS ndash CORRECT MUSCLE SYNERGY ndash ELIMINATION OF FUNCTIONAL COMPENSATIONS

bull PAIN CONTROL bull NO CONTRAINDICATION

Dott Salvatore Denaro

KINESIOTHERAPY

bull POSTURAL Aims to correct any negative issues of posture (often secondary to analgesic compensatory attitudes) to detect alterations in the knee and calcaneal axis and of the plantar support visual disturbance dental malocclusion dysmetria of the pelvis etc

Dott Salvatore Denaro

KINESIOTHERAPY

bull HYDRO-KINESIOTHERAPY Very useful in cases of rheumatic diseases Therapeutic exercise in water is facilitated by the option to regulate water temperature and by the reduction in gravitational force which this medium allows

Dott Salvatore Denaro

VERTEBRAL MANIPULATION Robert Maignersquos ldquoManu Medicardquo

bull SEMIOTICS NATURE OF ILLNESS OR PATHOLOGY (clinical examination

imaging laboratory etc) ANALYSIS OF MINOR INTERVERTEBRAL DISTURBANCE

(ROM DDIM SCTM according to R Maignersquos research into signs of functional limitations)

bull THERAPY Principles RULE OF NO PAIN AND OF CONTRARY MOVEMENT VERIFICATION OF EVERY MANIPULATION BEFORE

PERFORMING THE NEXT

Dott Salvatore Denaro

TECHNIQUES

bull TREATMENT OF SOFT PARTS bull MUSCULAR STRETCHING bull REPEATED INTERVENTIONS bull MANIPULATION (3 STAGES)

Place in position Apply tension Manipulative thrust (low amplitude high velocity)

ldquoIT IS A NON-SYMPTOMATIC CAUSAL THERAPYrdquo

Mechanism of action of Vertebral Manipulation

bull Stretching and distension of the posterior joint capsule has a powerful inhibitory effect on muscle contraction (analgesic contraction) The hypotonic Gamma is determined by the stimulation of the periarticular receptors activated by the manipulative manoeuvre and results in a rapid and powerful ldquoINHIBITORY REFLEXrdquo through the contraction of the intervertebral musculature (DDIM)

bull With Vertebral Manipulation abruptly stretching structures such as ligaments discs joint capsules or muscles activates the descending system of nociceptive inhibition of pain in cases where this originates at the level of the grey matter

J Electromyogr Kinesiol 2012 Oct 22(5) 785ndash794Published online 2012 Feb 19 doi Spinal Manipulative Therapy and Somatosensory Activation Joel G Pickar DC PhD1 and Philip S Bolton DC PhD2 Dott Salvatore Denaro

Classification of pain

ACUTE PAIN serves to alert the

body to the presence of dangerous stimuli

NOCICEPTIVEPAIN

(SOMATIC AND

VISCERAL)

TEMPORAL PHYSIOPATHOLOGICAL

CHRONIC PAIN

not just extended in time but with different qualitative characteristics

NEUROPATHICPAIN (CENTRAL PERIPHERAL)

IDEOPATHIC OR FUNCTIONALPAIN

Dott Salvatore Denaro

Key points and guidelines for the treatment of pain - Joint Commission on Accreditation

of Health Care Organizations - 1 The patientrsquos right to be treated for pain

2 Evaluate and document the presence nature and intensity of pain in all patients (5th vital indication in conjunction with blood pressure pulse temperature and respiratory rate)

3 Ensure staff competence in the evaluation and treatment of pain

4 Establish protocols for adequate treatment of pain

5 Educate patients and their families for effective control of pain 6 Satisfy the patientrsquos needs for effective treatment of symptoms after

discharge

Legge 15 marzo 2010 n 38 concernente ldquoDisposizioni per garantire laccesso alle cure palliative e alla terapia del dolorerdquo (Gazzetta Ufficiale n 65 del 19 marzo 2010)

Who takes responsibility for each type of pain - the Physiatrist the

Rheumatologist or the Orthopedist

bull Muscolotendinous (including tendon sheaths and synovial bursa)

bull Articulate and capsuloligamentous bull Bone bull Neurological peripheral and central bull Oncological supporting the Oncologist

Dott Salvatore Denaro

Overview of therapy the vicious circle of untreated pain

Limiting behaviour Pain

Altered functional status

Decreased autonomy

Social limitations Reduced mobility

Dott Salvatore Denaro

Dott Salvatore Denaro Dott Salvatore Denaro

Some painful forms of musculoskeletal origin

Post-traumatic pain Fracture Dislocation Distortion

Inflammatory joint pain (acute or chronic) Arthritis Rheumatoid arthritis Gout

Periarticular inflammatory pain (acute or chronic) Pathology from functional overload in muscles tendons or ligaments

Neuropathic or mixed pain

Compressive nerve syndromes Rachialgia Radiculopathy Osteoporosis pain

Oncological pain

Dott Salvatore Denaro

NEURAL PATHS FOR THE TRANSMISSION

OF PAIN

1st neuron

2nd neuron from the spinal chord to the thalamus

3rd neuron from the thalamus to the cerebral cortex

Opioids Alpha 2 agonists

Local anesthetics

Opioids

Alpha 2 agonists

Local anesthetics

Local anesthetics

Anti-inflammatory drugs

Routes of management

Intra-articular

transmucosal

Dott Salvatore Denaro

Dott Salvatore Denaro

But also in Orthopedic Medicinehelliphelliphellip

Dott Salvatore Denaro

Infiltration therapy

Acupuncture (ancient Chinese approach outlined by Huangdi Neijing

between 305 and 204 BC) This subject is only briefly mentioned here as it deserves its own separate conference There are however very few evidence based medical (EBM) studies of this ancient approach

Mesotherapy and Prolotherapy

Mesotherapy (MPistor) is an excellent analgesic therapy which uses a single needle or multi-injector as detailed by colleagues in the SFM (Socieacuteteacute Franccedilaise de Meacutesotheacuterapie)

Neuroprolotherapy (NPT) is a method of treatment which is distinct and separate from Prolotherapy from which it was evolved Developed since 2002 by New Zealander Dr John Lyftogt it targets the superficial sensory nerves of the body with micro-injections of low concentration glucose (5)

Dott Salvatore Denaro

Dry needling Annals of the Rheumatic Diseases 74(Suppl 2)624 middot June 2015 RV Bubnov

bull Very similar to acupuncture but treats the trigger points and myalgic intramuscular cords

bull It provides pinpoint mechanical stimulation

bull It provides both intramuscular and superficial stimulation

bull Precise laquoPain pointsraquo can be treated

Hyuk Ga Ji-Ho Choi Chang-Hae Park Hyun-Jung Yoon Acupuncture needling versus lidocaine injection of trigger points in myofascial pain syndrome in elderly patients ndash a randomised trial Acupuncture in Medicine Dec 2007

Dott Salvatore Denaro

TREATMENT OF PAIN in Orthopaedic Medicine

Dott Salvatore Denaro

ELECTROANALGESIA Based on Melzack and Wallrsquos theory of gate control which

describes two types of intervention for pain control

the first consists of reinforcing the the inhibitory power of large fibers the second aims selectively to interrupt the communication of small calibre fibers near the posterior horns (where the peripheral terminations are connected to the main neural pathways of communication to the brain)

Dott Salvatore Denaro

ELECTROANALGESIA TENS

ldquoTranscutaneous Electrical Nerve Stimulationrdquo is characterised by the fact that the electrodes are applied directly to the skin above the path of the

nerve trunk causing paresthesia in the area of the stimulated nerve distribution

Low frequency currents are used rectangular in shape which have an analgesic effect with

modalities that are not perfectly defined

Using TENS for pain control the state of the evidence Vance CG1 Dailey DL Rakel BA Sluka KA Pain Manag 2014 May4(3)197-209

Dott Salvatore Denaro

Non surgical laser therapy In analgesic therapy the ideal laser emission

instrument is one which uses a semiconductor diode as its active medium emitting invisible bursts of

radiation delivered in extremely short pulses typically within the infrared (IR) band with a

wavelength of approximately 904 nanometres ie the IR laser Other options include He-Ne CO2

Neodimio Yag and HILT

low levels of evidence

Eur J Phys Rehabil Med 2017 Aug53(4)603-610 Epub 2017 Jan 30 Effects of low-level laser therapy on pain in patients with musculoskeletal disorders a systematic review and meta-analysis Clijsen R123 Brunner A4 Barbero M4 Clarys P5 Taeymans J56

MOJ Orthop Rheumatol 20152(5) Epub 2015 Jun 9 The Use of Low Level Laser Therapy (LLLT) For Musculoskeletal Pain Cotler HB1 Chow RT2 Hamblin MR3 Carroll J4

Dott Salvatore Denaro

Biological Effects of LASER THERAPY an increase in the speed of mitosis temporary and reversible tissue dehydration denaturation of proteins thermolysis

carbonization for focal CO2 tissue evaporation

Physiotherapeutic lasers essentially produce two effects analgesic anti edema and biostimulant

Heat Therapy (Thermotherapy)

bull Heat action on the gate-control of MampW There is limited overall evidence to support the general use of localized heat however randomised clinical trials (RCTs) have shown that heat therapy provides short-term reductions in pain and disability in patients with acute lower back pain and provides significantly greater pain relief from DOMS than cold therapy (Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury Gerard A Malanga Ning Yan amp Jill Stark Oct 2014) PubMedgov

bull Cold reduction of tissue temperature which subsequently exerts local effects on blood flow on cell swelling and on metabolism and speed of neural conduction (Cold-water immersion and other forms of cryotherapy physiological changes potentially affecting recovery from high-intensity exercise Gillian E White and Greg D Wells Email author Extreme Physiology amp Medicine 2013 )

Dott Salvatore Denaro

KRYO TECAR

Mechanotherapy vibration

bull CONTROL OF MUSCULAR STIFFNESS (tonic reflex from vibration)

bull STIMULATION OF BLOOD LYMPHATIC CIRCULATION

bull PAIN RELIEF (gate control)

bull INCREASED SENSITIVITY

Bibliographic details Wang P Yang X Yang Y Yang L Zhou Y Liu C Reinhardt JD He C Effects of whole body vibration on pain stiffness and physical functions in patients with knee osteoarthritis a systematic review and meta-analysis Clinical Rehabilitation 2014 epub [PubMed] Dott Salvatore Denaro

Impact Waves bull 1 direct effect of the impulse on the tissue

in the target area and in conjunction with the reflection phenomena more accentuated in the points of transition between soft tissue (tendons muscles) and more compact tissues (bones and calcification formations)

bull 2 indirect effect of ldquocavitationrdquo caused by the subsequent depression of the impulse which exceeds the elastic characteristics of the tissue

NO DIRECT EFFECT ON PAIN MODULATORS OF BIOLOGICAL FUNCTIONS IN HUMAN MUSCLE CELLS (J Orthop Surg Res 2018 Apr 613(1)75 Exposure to radial extracorporeal shock waves modulates viability and gene expression of human skeletal muscle cells a controlled in vitro study Mattyasovszky SG1 Langendorf EK2 Ritz U2 Schmitz C3 Schmidtmann I4 Nowak TE2 Wagner D2 Hofmann A2 Rommens PM2 Drees P2)

RADIALI

FOCALI

Dott Salvatore Denaro

Ion Cyclotron Resonance Quantum Molecular Resonance

bull Stimulates the biological functions of cells bull Rebalances the correct membrane potential bull Activates enzymatic processes bull Restores the correct ion exchange for cell metabolism bull Promotes intra-extra cellular ion balance

Operating principle based on Quantum Molecular Resonance with the application of high-frequency and low-power micro-currents Induces the regeneration of damaged tissues especially muscular tissues without thermal effects

Dott Salvatore Denaro

Dott Salvatore Denaro

KINESIOTHERAPY IS NECESSARY

bull WITH REGARD TO ARTICULAR LINKS ndash JOINT PLAY ndash STRUCTURAL INTEGRITY OF THE CARTILAGE CAPSULE

AND LIGAMENTS ndash CORRECT MUSCLE SYNERGY ndash ELIMINATION OF FUNCTIONAL COMPENSATIONS

bull PAIN CONTROL bull NO CONTRAINDICATION

Dott Salvatore Denaro

KINESIOTHERAPY

bull POSTURAL Aims to correct any negative issues of posture (often secondary to analgesic compensatory attitudes) to detect alterations in the knee and calcaneal axis and of the plantar support visual disturbance dental malocclusion dysmetria of the pelvis etc

Dott Salvatore Denaro

KINESIOTHERAPY

bull HYDRO-KINESIOTHERAPY Very useful in cases of rheumatic diseases Therapeutic exercise in water is facilitated by the option to regulate water temperature and by the reduction in gravitational force which this medium allows

Dott Salvatore Denaro

VERTEBRAL MANIPULATION Robert Maignersquos ldquoManu Medicardquo

bull SEMIOTICS NATURE OF ILLNESS OR PATHOLOGY (clinical examination

imaging laboratory etc) ANALYSIS OF MINOR INTERVERTEBRAL DISTURBANCE

(ROM DDIM SCTM according to R Maignersquos research into signs of functional limitations)

bull THERAPY Principles RULE OF NO PAIN AND OF CONTRARY MOVEMENT VERIFICATION OF EVERY MANIPULATION BEFORE

PERFORMING THE NEXT

Dott Salvatore Denaro

TECHNIQUES

bull TREATMENT OF SOFT PARTS bull MUSCULAR STRETCHING bull REPEATED INTERVENTIONS bull MANIPULATION (3 STAGES)

Place in position Apply tension Manipulative thrust (low amplitude high velocity)

ldquoIT IS A NON-SYMPTOMATIC CAUSAL THERAPYrdquo

Mechanism of action of Vertebral Manipulation

bull Stretching and distension of the posterior joint capsule has a powerful inhibitory effect on muscle contraction (analgesic contraction) The hypotonic Gamma is determined by the stimulation of the periarticular receptors activated by the manipulative manoeuvre and results in a rapid and powerful ldquoINHIBITORY REFLEXrdquo through the contraction of the intervertebral musculature (DDIM)

bull With Vertebral Manipulation abruptly stretching structures such as ligaments discs joint capsules or muscles activates the descending system of nociceptive inhibition of pain in cases where this originates at the level of the grey matter

J Electromyogr Kinesiol 2012 Oct 22(5) 785ndash794Published online 2012 Feb 19 doi Spinal Manipulative Therapy and Somatosensory Activation Joel G Pickar DC PhD1 and Philip S Bolton DC PhD2 Dott Salvatore Denaro

Key points and guidelines for the treatment of pain - Joint Commission on Accreditation

of Health Care Organizations - 1 The patientrsquos right to be treated for pain

2 Evaluate and document the presence nature and intensity of pain in all patients (5th vital indication in conjunction with blood pressure pulse temperature and respiratory rate)

3 Ensure staff competence in the evaluation and treatment of pain

4 Establish protocols for adequate treatment of pain

5 Educate patients and their families for effective control of pain 6 Satisfy the patientrsquos needs for effective treatment of symptoms after

discharge

Legge 15 marzo 2010 n 38 concernente ldquoDisposizioni per garantire laccesso alle cure palliative e alla terapia del dolorerdquo (Gazzetta Ufficiale n 65 del 19 marzo 2010)

Who takes responsibility for each type of pain - the Physiatrist the

Rheumatologist or the Orthopedist

bull Muscolotendinous (including tendon sheaths and synovial bursa)

bull Articulate and capsuloligamentous bull Bone bull Neurological peripheral and central bull Oncological supporting the Oncologist

Dott Salvatore Denaro

Overview of therapy the vicious circle of untreated pain

Limiting behaviour Pain

Altered functional status

Decreased autonomy

Social limitations Reduced mobility

Dott Salvatore Denaro

Dott Salvatore Denaro Dott Salvatore Denaro

Some painful forms of musculoskeletal origin

Post-traumatic pain Fracture Dislocation Distortion

Inflammatory joint pain (acute or chronic) Arthritis Rheumatoid arthritis Gout

Periarticular inflammatory pain (acute or chronic) Pathology from functional overload in muscles tendons or ligaments

Neuropathic or mixed pain

Compressive nerve syndromes Rachialgia Radiculopathy Osteoporosis pain

Oncological pain

Dott Salvatore Denaro

NEURAL PATHS FOR THE TRANSMISSION

OF PAIN

1st neuron

2nd neuron from the spinal chord to the thalamus

3rd neuron from the thalamus to the cerebral cortex

Opioids Alpha 2 agonists

Local anesthetics

Opioids

Alpha 2 agonists

Local anesthetics

Local anesthetics

Anti-inflammatory drugs

Routes of management

Intra-articular

transmucosal

Dott Salvatore Denaro

Dott Salvatore Denaro

But also in Orthopedic Medicinehelliphelliphellip

Dott Salvatore Denaro

Infiltration therapy

Acupuncture (ancient Chinese approach outlined by Huangdi Neijing

between 305 and 204 BC) This subject is only briefly mentioned here as it deserves its own separate conference There are however very few evidence based medical (EBM) studies of this ancient approach

Mesotherapy and Prolotherapy

Mesotherapy (MPistor) is an excellent analgesic therapy which uses a single needle or multi-injector as detailed by colleagues in the SFM (Socieacuteteacute Franccedilaise de Meacutesotheacuterapie)

Neuroprolotherapy (NPT) is a method of treatment which is distinct and separate from Prolotherapy from which it was evolved Developed since 2002 by New Zealander Dr John Lyftogt it targets the superficial sensory nerves of the body with micro-injections of low concentration glucose (5)

Dott Salvatore Denaro

Dry needling Annals of the Rheumatic Diseases 74(Suppl 2)624 middot June 2015 RV Bubnov

bull Very similar to acupuncture but treats the trigger points and myalgic intramuscular cords

bull It provides pinpoint mechanical stimulation

bull It provides both intramuscular and superficial stimulation

bull Precise laquoPain pointsraquo can be treated

Hyuk Ga Ji-Ho Choi Chang-Hae Park Hyun-Jung Yoon Acupuncture needling versus lidocaine injection of trigger points in myofascial pain syndrome in elderly patients ndash a randomised trial Acupuncture in Medicine Dec 2007

Dott Salvatore Denaro

TREATMENT OF PAIN in Orthopaedic Medicine

Dott Salvatore Denaro

ELECTROANALGESIA Based on Melzack and Wallrsquos theory of gate control which

describes two types of intervention for pain control

the first consists of reinforcing the the inhibitory power of large fibers the second aims selectively to interrupt the communication of small calibre fibers near the posterior horns (where the peripheral terminations are connected to the main neural pathways of communication to the brain)

Dott Salvatore Denaro

ELECTROANALGESIA TENS

ldquoTranscutaneous Electrical Nerve Stimulationrdquo is characterised by the fact that the electrodes are applied directly to the skin above the path of the

nerve trunk causing paresthesia in the area of the stimulated nerve distribution

Low frequency currents are used rectangular in shape which have an analgesic effect with

modalities that are not perfectly defined

Using TENS for pain control the state of the evidence Vance CG1 Dailey DL Rakel BA Sluka KA Pain Manag 2014 May4(3)197-209

Dott Salvatore Denaro

Non surgical laser therapy In analgesic therapy the ideal laser emission

instrument is one which uses a semiconductor diode as its active medium emitting invisible bursts of

radiation delivered in extremely short pulses typically within the infrared (IR) band with a

wavelength of approximately 904 nanometres ie the IR laser Other options include He-Ne CO2

Neodimio Yag and HILT

low levels of evidence

Eur J Phys Rehabil Med 2017 Aug53(4)603-610 Epub 2017 Jan 30 Effects of low-level laser therapy on pain in patients with musculoskeletal disorders a systematic review and meta-analysis Clijsen R123 Brunner A4 Barbero M4 Clarys P5 Taeymans J56

MOJ Orthop Rheumatol 20152(5) Epub 2015 Jun 9 The Use of Low Level Laser Therapy (LLLT) For Musculoskeletal Pain Cotler HB1 Chow RT2 Hamblin MR3 Carroll J4

Dott Salvatore Denaro

Biological Effects of LASER THERAPY an increase in the speed of mitosis temporary and reversible tissue dehydration denaturation of proteins thermolysis

carbonization for focal CO2 tissue evaporation

Physiotherapeutic lasers essentially produce two effects analgesic anti edema and biostimulant

Heat Therapy (Thermotherapy)

bull Heat action on the gate-control of MampW There is limited overall evidence to support the general use of localized heat however randomised clinical trials (RCTs) have shown that heat therapy provides short-term reductions in pain and disability in patients with acute lower back pain and provides significantly greater pain relief from DOMS than cold therapy (Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury Gerard A Malanga Ning Yan amp Jill Stark Oct 2014) PubMedgov

bull Cold reduction of tissue temperature which subsequently exerts local effects on blood flow on cell swelling and on metabolism and speed of neural conduction (Cold-water immersion and other forms of cryotherapy physiological changes potentially affecting recovery from high-intensity exercise Gillian E White and Greg D Wells Email author Extreme Physiology amp Medicine 2013 )

Dott Salvatore Denaro

KRYO TECAR

Mechanotherapy vibration

bull CONTROL OF MUSCULAR STIFFNESS (tonic reflex from vibration)

bull STIMULATION OF BLOOD LYMPHATIC CIRCULATION

bull PAIN RELIEF (gate control)

bull INCREASED SENSITIVITY

Bibliographic details Wang P Yang X Yang Y Yang L Zhou Y Liu C Reinhardt JD He C Effects of whole body vibration on pain stiffness and physical functions in patients with knee osteoarthritis a systematic review and meta-analysis Clinical Rehabilitation 2014 epub [PubMed] Dott Salvatore Denaro

Impact Waves bull 1 direct effect of the impulse on the tissue

in the target area and in conjunction with the reflection phenomena more accentuated in the points of transition between soft tissue (tendons muscles) and more compact tissues (bones and calcification formations)

bull 2 indirect effect of ldquocavitationrdquo caused by the subsequent depression of the impulse which exceeds the elastic characteristics of the tissue

NO DIRECT EFFECT ON PAIN MODULATORS OF BIOLOGICAL FUNCTIONS IN HUMAN MUSCLE CELLS (J Orthop Surg Res 2018 Apr 613(1)75 Exposure to radial extracorporeal shock waves modulates viability and gene expression of human skeletal muscle cells a controlled in vitro study Mattyasovszky SG1 Langendorf EK2 Ritz U2 Schmitz C3 Schmidtmann I4 Nowak TE2 Wagner D2 Hofmann A2 Rommens PM2 Drees P2)

RADIALI

FOCALI

Dott Salvatore Denaro

Ion Cyclotron Resonance Quantum Molecular Resonance

bull Stimulates the biological functions of cells bull Rebalances the correct membrane potential bull Activates enzymatic processes bull Restores the correct ion exchange for cell metabolism bull Promotes intra-extra cellular ion balance

Operating principle based on Quantum Molecular Resonance with the application of high-frequency and low-power micro-currents Induces the regeneration of damaged tissues especially muscular tissues without thermal effects

Dott Salvatore Denaro

Dott Salvatore Denaro

KINESIOTHERAPY IS NECESSARY

bull WITH REGARD TO ARTICULAR LINKS ndash JOINT PLAY ndash STRUCTURAL INTEGRITY OF THE CARTILAGE CAPSULE

AND LIGAMENTS ndash CORRECT MUSCLE SYNERGY ndash ELIMINATION OF FUNCTIONAL COMPENSATIONS

bull PAIN CONTROL bull NO CONTRAINDICATION

Dott Salvatore Denaro

KINESIOTHERAPY

bull POSTURAL Aims to correct any negative issues of posture (often secondary to analgesic compensatory attitudes) to detect alterations in the knee and calcaneal axis and of the plantar support visual disturbance dental malocclusion dysmetria of the pelvis etc

Dott Salvatore Denaro

KINESIOTHERAPY

bull HYDRO-KINESIOTHERAPY Very useful in cases of rheumatic diseases Therapeutic exercise in water is facilitated by the option to regulate water temperature and by the reduction in gravitational force which this medium allows

Dott Salvatore Denaro

VERTEBRAL MANIPULATION Robert Maignersquos ldquoManu Medicardquo

bull SEMIOTICS NATURE OF ILLNESS OR PATHOLOGY (clinical examination

imaging laboratory etc) ANALYSIS OF MINOR INTERVERTEBRAL DISTURBANCE

(ROM DDIM SCTM according to R Maignersquos research into signs of functional limitations)

bull THERAPY Principles RULE OF NO PAIN AND OF CONTRARY MOVEMENT VERIFICATION OF EVERY MANIPULATION BEFORE

PERFORMING THE NEXT

Dott Salvatore Denaro

TECHNIQUES

bull TREATMENT OF SOFT PARTS bull MUSCULAR STRETCHING bull REPEATED INTERVENTIONS bull MANIPULATION (3 STAGES)

Place in position Apply tension Manipulative thrust (low amplitude high velocity)

ldquoIT IS A NON-SYMPTOMATIC CAUSAL THERAPYrdquo

Mechanism of action of Vertebral Manipulation

bull Stretching and distension of the posterior joint capsule has a powerful inhibitory effect on muscle contraction (analgesic contraction) The hypotonic Gamma is determined by the stimulation of the periarticular receptors activated by the manipulative manoeuvre and results in a rapid and powerful ldquoINHIBITORY REFLEXrdquo through the contraction of the intervertebral musculature (DDIM)

bull With Vertebral Manipulation abruptly stretching structures such as ligaments discs joint capsules or muscles activates the descending system of nociceptive inhibition of pain in cases where this originates at the level of the grey matter

J Electromyogr Kinesiol 2012 Oct 22(5) 785ndash794Published online 2012 Feb 19 doi Spinal Manipulative Therapy and Somatosensory Activation Joel G Pickar DC PhD1 and Philip S Bolton DC PhD2 Dott Salvatore Denaro

Who takes responsibility for each type of pain - the Physiatrist the

Rheumatologist or the Orthopedist

bull Muscolotendinous (including tendon sheaths and synovial bursa)

bull Articulate and capsuloligamentous bull Bone bull Neurological peripheral and central bull Oncological supporting the Oncologist

Dott Salvatore Denaro

Overview of therapy the vicious circle of untreated pain

Limiting behaviour Pain

Altered functional status

Decreased autonomy

Social limitations Reduced mobility

Dott Salvatore Denaro

Dott Salvatore Denaro Dott Salvatore Denaro

Some painful forms of musculoskeletal origin

Post-traumatic pain Fracture Dislocation Distortion

Inflammatory joint pain (acute or chronic) Arthritis Rheumatoid arthritis Gout

Periarticular inflammatory pain (acute or chronic) Pathology from functional overload in muscles tendons or ligaments

Neuropathic or mixed pain

Compressive nerve syndromes Rachialgia Radiculopathy Osteoporosis pain

Oncological pain

Dott Salvatore Denaro

NEURAL PATHS FOR THE TRANSMISSION

OF PAIN

1st neuron

2nd neuron from the spinal chord to the thalamus

3rd neuron from the thalamus to the cerebral cortex

Opioids Alpha 2 agonists

Local anesthetics

Opioids

Alpha 2 agonists

Local anesthetics

Local anesthetics

Anti-inflammatory drugs

Routes of management

Intra-articular

transmucosal

Dott Salvatore Denaro

Dott Salvatore Denaro

But also in Orthopedic Medicinehelliphelliphellip

Dott Salvatore Denaro

Infiltration therapy

Acupuncture (ancient Chinese approach outlined by Huangdi Neijing

between 305 and 204 BC) This subject is only briefly mentioned here as it deserves its own separate conference There are however very few evidence based medical (EBM) studies of this ancient approach

Mesotherapy and Prolotherapy

Mesotherapy (MPistor) is an excellent analgesic therapy which uses a single needle or multi-injector as detailed by colleagues in the SFM (Socieacuteteacute Franccedilaise de Meacutesotheacuterapie)

Neuroprolotherapy (NPT) is a method of treatment which is distinct and separate from Prolotherapy from which it was evolved Developed since 2002 by New Zealander Dr John Lyftogt it targets the superficial sensory nerves of the body with micro-injections of low concentration glucose (5)

Dott Salvatore Denaro

Dry needling Annals of the Rheumatic Diseases 74(Suppl 2)624 middot June 2015 RV Bubnov

bull Very similar to acupuncture but treats the trigger points and myalgic intramuscular cords

bull It provides pinpoint mechanical stimulation

bull It provides both intramuscular and superficial stimulation

bull Precise laquoPain pointsraquo can be treated

Hyuk Ga Ji-Ho Choi Chang-Hae Park Hyun-Jung Yoon Acupuncture needling versus lidocaine injection of trigger points in myofascial pain syndrome in elderly patients ndash a randomised trial Acupuncture in Medicine Dec 2007

Dott Salvatore Denaro

TREATMENT OF PAIN in Orthopaedic Medicine

Dott Salvatore Denaro

ELECTROANALGESIA Based on Melzack and Wallrsquos theory of gate control which

describes two types of intervention for pain control

the first consists of reinforcing the the inhibitory power of large fibers the second aims selectively to interrupt the communication of small calibre fibers near the posterior horns (where the peripheral terminations are connected to the main neural pathways of communication to the brain)

Dott Salvatore Denaro

ELECTROANALGESIA TENS

ldquoTranscutaneous Electrical Nerve Stimulationrdquo is characterised by the fact that the electrodes are applied directly to the skin above the path of the

nerve trunk causing paresthesia in the area of the stimulated nerve distribution

Low frequency currents are used rectangular in shape which have an analgesic effect with

modalities that are not perfectly defined

Using TENS for pain control the state of the evidence Vance CG1 Dailey DL Rakel BA Sluka KA Pain Manag 2014 May4(3)197-209

Dott Salvatore Denaro

Non surgical laser therapy In analgesic therapy the ideal laser emission

instrument is one which uses a semiconductor diode as its active medium emitting invisible bursts of

radiation delivered in extremely short pulses typically within the infrared (IR) band with a

wavelength of approximately 904 nanometres ie the IR laser Other options include He-Ne CO2

Neodimio Yag and HILT

low levels of evidence

Eur J Phys Rehabil Med 2017 Aug53(4)603-610 Epub 2017 Jan 30 Effects of low-level laser therapy on pain in patients with musculoskeletal disorders a systematic review and meta-analysis Clijsen R123 Brunner A4 Barbero M4 Clarys P5 Taeymans J56

MOJ Orthop Rheumatol 20152(5) Epub 2015 Jun 9 The Use of Low Level Laser Therapy (LLLT) For Musculoskeletal Pain Cotler HB1 Chow RT2 Hamblin MR3 Carroll J4

Dott Salvatore Denaro

Biological Effects of LASER THERAPY an increase in the speed of mitosis temporary and reversible tissue dehydration denaturation of proteins thermolysis

carbonization for focal CO2 tissue evaporation

Physiotherapeutic lasers essentially produce two effects analgesic anti edema and biostimulant

Heat Therapy (Thermotherapy)

bull Heat action on the gate-control of MampW There is limited overall evidence to support the general use of localized heat however randomised clinical trials (RCTs) have shown that heat therapy provides short-term reductions in pain and disability in patients with acute lower back pain and provides significantly greater pain relief from DOMS than cold therapy (Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury Gerard A Malanga Ning Yan amp Jill Stark Oct 2014) PubMedgov

bull Cold reduction of tissue temperature which subsequently exerts local effects on blood flow on cell swelling and on metabolism and speed of neural conduction (Cold-water immersion and other forms of cryotherapy physiological changes potentially affecting recovery from high-intensity exercise Gillian E White and Greg D Wells Email author Extreme Physiology amp Medicine 2013 )

Dott Salvatore Denaro

KRYO TECAR

Mechanotherapy vibration

bull CONTROL OF MUSCULAR STIFFNESS (tonic reflex from vibration)

bull STIMULATION OF BLOOD LYMPHATIC CIRCULATION

bull PAIN RELIEF (gate control)

bull INCREASED SENSITIVITY

Bibliographic details Wang P Yang X Yang Y Yang L Zhou Y Liu C Reinhardt JD He C Effects of whole body vibration on pain stiffness and physical functions in patients with knee osteoarthritis a systematic review and meta-analysis Clinical Rehabilitation 2014 epub [PubMed] Dott Salvatore Denaro

Impact Waves bull 1 direct effect of the impulse on the tissue

in the target area and in conjunction with the reflection phenomena more accentuated in the points of transition between soft tissue (tendons muscles) and more compact tissues (bones and calcification formations)

bull 2 indirect effect of ldquocavitationrdquo caused by the subsequent depression of the impulse which exceeds the elastic characteristics of the tissue

NO DIRECT EFFECT ON PAIN MODULATORS OF BIOLOGICAL FUNCTIONS IN HUMAN MUSCLE CELLS (J Orthop Surg Res 2018 Apr 613(1)75 Exposure to radial extracorporeal shock waves modulates viability and gene expression of human skeletal muscle cells a controlled in vitro study Mattyasovszky SG1 Langendorf EK2 Ritz U2 Schmitz C3 Schmidtmann I4 Nowak TE2 Wagner D2 Hofmann A2 Rommens PM2 Drees P2)

RADIALI

FOCALI

Dott Salvatore Denaro

Ion Cyclotron Resonance Quantum Molecular Resonance

bull Stimulates the biological functions of cells bull Rebalances the correct membrane potential bull Activates enzymatic processes bull Restores the correct ion exchange for cell metabolism bull Promotes intra-extra cellular ion balance

Operating principle based on Quantum Molecular Resonance with the application of high-frequency and low-power micro-currents Induces the regeneration of damaged tissues especially muscular tissues without thermal effects

Dott Salvatore Denaro

Dott Salvatore Denaro

KINESIOTHERAPY IS NECESSARY

bull WITH REGARD TO ARTICULAR LINKS ndash JOINT PLAY ndash STRUCTURAL INTEGRITY OF THE CARTILAGE CAPSULE

AND LIGAMENTS ndash CORRECT MUSCLE SYNERGY ndash ELIMINATION OF FUNCTIONAL COMPENSATIONS

bull PAIN CONTROL bull NO CONTRAINDICATION

Dott Salvatore Denaro

KINESIOTHERAPY

bull POSTURAL Aims to correct any negative issues of posture (often secondary to analgesic compensatory attitudes) to detect alterations in the knee and calcaneal axis and of the plantar support visual disturbance dental malocclusion dysmetria of the pelvis etc

Dott Salvatore Denaro

KINESIOTHERAPY

bull HYDRO-KINESIOTHERAPY Very useful in cases of rheumatic diseases Therapeutic exercise in water is facilitated by the option to regulate water temperature and by the reduction in gravitational force which this medium allows

Dott Salvatore Denaro

VERTEBRAL MANIPULATION Robert Maignersquos ldquoManu Medicardquo

bull SEMIOTICS NATURE OF ILLNESS OR PATHOLOGY (clinical examination

imaging laboratory etc) ANALYSIS OF MINOR INTERVERTEBRAL DISTURBANCE

(ROM DDIM SCTM according to R Maignersquos research into signs of functional limitations)

bull THERAPY Principles RULE OF NO PAIN AND OF CONTRARY MOVEMENT VERIFICATION OF EVERY MANIPULATION BEFORE

PERFORMING THE NEXT

Dott Salvatore Denaro

TECHNIQUES

bull TREATMENT OF SOFT PARTS bull MUSCULAR STRETCHING bull REPEATED INTERVENTIONS bull MANIPULATION (3 STAGES)

Place in position Apply tension Manipulative thrust (low amplitude high velocity)

ldquoIT IS A NON-SYMPTOMATIC CAUSAL THERAPYrdquo

Mechanism of action of Vertebral Manipulation

bull Stretching and distension of the posterior joint capsule has a powerful inhibitory effect on muscle contraction (analgesic contraction) The hypotonic Gamma is determined by the stimulation of the periarticular receptors activated by the manipulative manoeuvre and results in a rapid and powerful ldquoINHIBITORY REFLEXrdquo through the contraction of the intervertebral musculature (DDIM)

bull With Vertebral Manipulation abruptly stretching structures such as ligaments discs joint capsules or muscles activates the descending system of nociceptive inhibition of pain in cases where this originates at the level of the grey matter

J Electromyogr Kinesiol 2012 Oct 22(5) 785ndash794Published online 2012 Feb 19 doi Spinal Manipulative Therapy and Somatosensory Activation Joel G Pickar DC PhD1 and Philip S Bolton DC PhD2 Dott Salvatore Denaro

Overview of therapy the vicious circle of untreated pain

Limiting behaviour Pain

Altered functional status

Decreased autonomy

Social limitations Reduced mobility

Dott Salvatore Denaro

Dott Salvatore Denaro Dott Salvatore Denaro

Some painful forms of musculoskeletal origin

Post-traumatic pain Fracture Dislocation Distortion

Inflammatory joint pain (acute or chronic) Arthritis Rheumatoid arthritis Gout

Periarticular inflammatory pain (acute or chronic) Pathology from functional overload in muscles tendons or ligaments

Neuropathic or mixed pain

Compressive nerve syndromes Rachialgia Radiculopathy Osteoporosis pain

Oncological pain

Dott Salvatore Denaro

NEURAL PATHS FOR THE TRANSMISSION

OF PAIN

1st neuron

2nd neuron from the spinal chord to the thalamus

3rd neuron from the thalamus to the cerebral cortex

Opioids Alpha 2 agonists

Local anesthetics

Opioids

Alpha 2 agonists

Local anesthetics

Local anesthetics

Anti-inflammatory drugs

Routes of management

Intra-articular

transmucosal

Dott Salvatore Denaro

Dott Salvatore Denaro

But also in Orthopedic Medicinehelliphelliphellip

Dott Salvatore Denaro

Infiltration therapy

Acupuncture (ancient Chinese approach outlined by Huangdi Neijing

between 305 and 204 BC) This subject is only briefly mentioned here as it deserves its own separate conference There are however very few evidence based medical (EBM) studies of this ancient approach

Mesotherapy and Prolotherapy

Mesotherapy (MPistor) is an excellent analgesic therapy which uses a single needle or multi-injector as detailed by colleagues in the SFM (Socieacuteteacute Franccedilaise de Meacutesotheacuterapie)

Neuroprolotherapy (NPT) is a method of treatment which is distinct and separate from Prolotherapy from which it was evolved Developed since 2002 by New Zealander Dr John Lyftogt it targets the superficial sensory nerves of the body with micro-injections of low concentration glucose (5)

Dott Salvatore Denaro

Dry needling Annals of the Rheumatic Diseases 74(Suppl 2)624 middot June 2015 RV Bubnov

bull Very similar to acupuncture but treats the trigger points and myalgic intramuscular cords

bull It provides pinpoint mechanical stimulation

bull It provides both intramuscular and superficial stimulation

bull Precise laquoPain pointsraquo can be treated

Hyuk Ga Ji-Ho Choi Chang-Hae Park Hyun-Jung Yoon Acupuncture needling versus lidocaine injection of trigger points in myofascial pain syndrome in elderly patients ndash a randomised trial Acupuncture in Medicine Dec 2007

Dott Salvatore Denaro

TREATMENT OF PAIN in Orthopaedic Medicine

Dott Salvatore Denaro

ELECTROANALGESIA Based on Melzack and Wallrsquos theory of gate control which

describes two types of intervention for pain control

the first consists of reinforcing the the inhibitory power of large fibers the second aims selectively to interrupt the communication of small calibre fibers near the posterior horns (where the peripheral terminations are connected to the main neural pathways of communication to the brain)

Dott Salvatore Denaro

ELECTROANALGESIA TENS

ldquoTranscutaneous Electrical Nerve Stimulationrdquo is characterised by the fact that the electrodes are applied directly to the skin above the path of the

nerve trunk causing paresthesia in the area of the stimulated nerve distribution

Low frequency currents are used rectangular in shape which have an analgesic effect with

modalities that are not perfectly defined

Using TENS for pain control the state of the evidence Vance CG1 Dailey DL Rakel BA Sluka KA Pain Manag 2014 May4(3)197-209

Dott Salvatore Denaro

Non surgical laser therapy In analgesic therapy the ideal laser emission

instrument is one which uses a semiconductor diode as its active medium emitting invisible bursts of

radiation delivered in extremely short pulses typically within the infrared (IR) band with a

wavelength of approximately 904 nanometres ie the IR laser Other options include He-Ne CO2

Neodimio Yag and HILT

low levels of evidence

Eur J Phys Rehabil Med 2017 Aug53(4)603-610 Epub 2017 Jan 30 Effects of low-level laser therapy on pain in patients with musculoskeletal disorders a systematic review and meta-analysis Clijsen R123 Brunner A4 Barbero M4 Clarys P5 Taeymans J56

MOJ Orthop Rheumatol 20152(5) Epub 2015 Jun 9 The Use of Low Level Laser Therapy (LLLT) For Musculoskeletal Pain Cotler HB1 Chow RT2 Hamblin MR3 Carroll J4

Dott Salvatore Denaro

Biological Effects of LASER THERAPY an increase in the speed of mitosis temporary and reversible tissue dehydration denaturation of proteins thermolysis

carbonization for focal CO2 tissue evaporation

Physiotherapeutic lasers essentially produce two effects analgesic anti edema and biostimulant

Heat Therapy (Thermotherapy)

bull Heat action on the gate-control of MampW There is limited overall evidence to support the general use of localized heat however randomised clinical trials (RCTs) have shown that heat therapy provides short-term reductions in pain and disability in patients with acute lower back pain and provides significantly greater pain relief from DOMS than cold therapy (Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury Gerard A Malanga Ning Yan amp Jill Stark Oct 2014) PubMedgov

bull Cold reduction of tissue temperature which subsequently exerts local effects on blood flow on cell swelling and on metabolism and speed of neural conduction (Cold-water immersion and other forms of cryotherapy physiological changes potentially affecting recovery from high-intensity exercise Gillian E White and Greg D Wells Email author Extreme Physiology amp Medicine 2013 )

Dott Salvatore Denaro

KRYO TECAR

Mechanotherapy vibration

bull CONTROL OF MUSCULAR STIFFNESS (tonic reflex from vibration)

bull STIMULATION OF BLOOD LYMPHATIC CIRCULATION

bull PAIN RELIEF (gate control)

bull INCREASED SENSITIVITY

Bibliographic details Wang P Yang X Yang Y Yang L Zhou Y Liu C Reinhardt JD He C Effects of whole body vibration on pain stiffness and physical functions in patients with knee osteoarthritis a systematic review and meta-analysis Clinical Rehabilitation 2014 epub [PubMed] Dott Salvatore Denaro

Impact Waves bull 1 direct effect of the impulse on the tissue

in the target area and in conjunction with the reflection phenomena more accentuated in the points of transition between soft tissue (tendons muscles) and more compact tissues (bones and calcification formations)

bull 2 indirect effect of ldquocavitationrdquo caused by the subsequent depression of the impulse which exceeds the elastic characteristics of the tissue

NO DIRECT EFFECT ON PAIN MODULATORS OF BIOLOGICAL FUNCTIONS IN HUMAN MUSCLE CELLS (J Orthop Surg Res 2018 Apr 613(1)75 Exposure to radial extracorporeal shock waves modulates viability and gene expression of human skeletal muscle cells a controlled in vitro study Mattyasovszky SG1 Langendorf EK2 Ritz U2 Schmitz C3 Schmidtmann I4 Nowak TE2 Wagner D2 Hofmann A2 Rommens PM2 Drees P2)

RADIALI

FOCALI

Dott Salvatore Denaro

Ion Cyclotron Resonance Quantum Molecular Resonance

bull Stimulates the biological functions of cells bull Rebalances the correct membrane potential bull Activates enzymatic processes bull Restores the correct ion exchange for cell metabolism bull Promotes intra-extra cellular ion balance

Operating principle based on Quantum Molecular Resonance with the application of high-frequency and low-power micro-currents Induces the regeneration of damaged tissues especially muscular tissues without thermal effects

Dott Salvatore Denaro

Dott Salvatore Denaro

KINESIOTHERAPY IS NECESSARY

bull WITH REGARD TO ARTICULAR LINKS ndash JOINT PLAY ndash STRUCTURAL INTEGRITY OF THE CARTILAGE CAPSULE

AND LIGAMENTS ndash CORRECT MUSCLE SYNERGY ndash ELIMINATION OF FUNCTIONAL COMPENSATIONS

bull PAIN CONTROL bull NO CONTRAINDICATION

Dott Salvatore Denaro

KINESIOTHERAPY

bull POSTURAL Aims to correct any negative issues of posture (often secondary to analgesic compensatory attitudes) to detect alterations in the knee and calcaneal axis and of the plantar support visual disturbance dental malocclusion dysmetria of the pelvis etc

Dott Salvatore Denaro

KINESIOTHERAPY

bull HYDRO-KINESIOTHERAPY Very useful in cases of rheumatic diseases Therapeutic exercise in water is facilitated by the option to regulate water temperature and by the reduction in gravitational force which this medium allows

Dott Salvatore Denaro

VERTEBRAL MANIPULATION Robert Maignersquos ldquoManu Medicardquo

bull SEMIOTICS NATURE OF ILLNESS OR PATHOLOGY (clinical examination

imaging laboratory etc) ANALYSIS OF MINOR INTERVERTEBRAL DISTURBANCE

(ROM DDIM SCTM according to R Maignersquos research into signs of functional limitations)

bull THERAPY Principles RULE OF NO PAIN AND OF CONTRARY MOVEMENT VERIFICATION OF EVERY MANIPULATION BEFORE

PERFORMING THE NEXT

Dott Salvatore Denaro

TECHNIQUES

bull TREATMENT OF SOFT PARTS bull MUSCULAR STRETCHING bull REPEATED INTERVENTIONS bull MANIPULATION (3 STAGES)

Place in position Apply tension Manipulative thrust (low amplitude high velocity)

ldquoIT IS A NON-SYMPTOMATIC CAUSAL THERAPYrdquo

Mechanism of action of Vertebral Manipulation

bull Stretching and distension of the posterior joint capsule has a powerful inhibitory effect on muscle contraction (analgesic contraction) The hypotonic Gamma is determined by the stimulation of the periarticular receptors activated by the manipulative manoeuvre and results in a rapid and powerful ldquoINHIBITORY REFLEXrdquo through the contraction of the intervertebral musculature (DDIM)

bull With Vertebral Manipulation abruptly stretching structures such as ligaments discs joint capsules or muscles activates the descending system of nociceptive inhibition of pain in cases where this originates at the level of the grey matter

J Electromyogr Kinesiol 2012 Oct 22(5) 785ndash794Published online 2012 Feb 19 doi Spinal Manipulative Therapy and Somatosensory Activation Joel G Pickar DC PhD1 and Philip S Bolton DC PhD2 Dott Salvatore Denaro

Dott Salvatore Denaro Dott Salvatore Denaro

Some painful forms of musculoskeletal origin

Post-traumatic pain Fracture Dislocation Distortion

Inflammatory joint pain (acute or chronic) Arthritis Rheumatoid arthritis Gout

Periarticular inflammatory pain (acute or chronic) Pathology from functional overload in muscles tendons or ligaments

Neuropathic or mixed pain

Compressive nerve syndromes Rachialgia Radiculopathy Osteoporosis pain

Oncological pain

Dott Salvatore Denaro

NEURAL PATHS FOR THE TRANSMISSION

OF PAIN

1st neuron

2nd neuron from the spinal chord to the thalamus

3rd neuron from the thalamus to the cerebral cortex

Opioids Alpha 2 agonists

Local anesthetics

Opioids

Alpha 2 agonists

Local anesthetics

Local anesthetics

Anti-inflammatory drugs

Routes of management

Intra-articular

transmucosal

Dott Salvatore Denaro

Dott Salvatore Denaro

But also in Orthopedic Medicinehelliphelliphellip

Dott Salvatore Denaro

Infiltration therapy

Acupuncture (ancient Chinese approach outlined by Huangdi Neijing

between 305 and 204 BC) This subject is only briefly mentioned here as it deserves its own separate conference There are however very few evidence based medical (EBM) studies of this ancient approach

Mesotherapy and Prolotherapy

Mesotherapy (MPistor) is an excellent analgesic therapy which uses a single needle or multi-injector as detailed by colleagues in the SFM (Socieacuteteacute Franccedilaise de Meacutesotheacuterapie)

Neuroprolotherapy (NPT) is a method of treatment which is distinct and separate from Prolotherapy from which it was evolved Developed since 2002 by New Zealander Dr John Lyftogt it targets the superficial sensory nerves of the body with micro-injections of low concentration glucose (5)

Dott Salvatore Denaro

Dry needling Annals of the Rheumatic Diseases 74(Suppl 2)624 middot June 2015 RV Bubnov

bull Very similar to acupuncture but treats the trigger points and myalgic intramuscular cords

bull It provides pinpoint mechanical stimulation

bull It provides both intramuscular and superficial stimulation

bull Precise laquoPain pointsraquo can be treated

Hyuk Ga Ji-Ho Choi Chang-Hae Park Hyun-Jung Yoon Acupuncture needling versus lidocaine injection of trigger points in myofascial pain syndrome in elderly patients ndash a randomised trial Acupuncture in Medicine Dec 2007

Dott Salvatore Denaro

TREATMENT OF PAIN in Orthopaedic Medicine

Dott Salvatore Denaro

ELECTROANALGESIA Based on Melzack and Wallrsquos theory of gate control which

describes two types of intervention for pain control

the first consists of reinforcing the the inhibitory power of large fibers the second aims selectively to interrupt the communication of small calibre fibers near the posterior horns (where the peripheral terminations are connected to the main neural pathways of communication to the brain)

Dott Salvatore Denaro

ELECTROANALGESIA TENS

ldquoTranscutaneous Electrical Nerve Stimulationrdquo is characterised by the fact that the electrodes are applied directly to the skin above the path of the

nerve trunk causing paresthesia in the area of the stimulated nerve distribution

Low frequency currents are used rectangular in shape which have an analgesic effect with

modalities that are not perfectly defined

Using TENS for pain control the state of the evidence Vance CG1 Dailey DL Rakel BA Sluka KA Pain Manag 2014 May4(3)197-209

Dott Salvatore Denaro

Non surgical laser therapy In analgesic therapy the ideal laser emission

instrument is one which uses a semiconductor diode as its active medium emitting invisible bursts of

radiation delivered in extremely short pulses typically within the infrared (IR) band with a

wavelength of approximately 904 nanometres ie the IR laser Other options include He-Ne CO2

Neodimio Yag and HILT

low levels of evidence

Eur J Phys Rehabil Med 2017 Aug53(4)603-610 Epub 2017 Jan 30 Effects of low-level laser therapy on pain in patients with musculoskeletal disorders a systematic review and meta-analysis Clijsen R123 Brunner A4 Barbero M4 Clarys P5 Taeymans J56

MOJ Orthop Rheumatol 20152(5) Epub 2015 Jun 9 The Use of Low Level Laser Therapy (LLLT) For Musculoskeletal Pain Cotler HB1 Chow RT2 Hamblin MR3 Carroll J4

Dott Salvatore Denaro

Biological Effects of LASER THERAPY an increase in the speed of mitosis temporary and reversible tissue dehydration denaturation of proteins thermolysis

carbonization for focal CO2 tissue evaporation

Physiotherapeutic lasers essentially produce two effects analgesic anti edema and biostimulant

Heat Therapy (Thermotherapy)

bull Heat action on the gate-control of MampW There is limited overall evidence to support the general use of localized heat however randomised clinical trials (RCTs) have shown that heat therapy provides short-term reductions in pain and disability in patients with acute lower back pain and provides significantly greater pain relief from DOMS than cold therapy (Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury Gerard A Malanga Ning Yan amp Jill Stark Oct 2014) PubMedgov

bull Cold reduction of tissue temperature which subsequently exerts local effects on blood flow on cell swelling and on metabolism and speed of neural conduction (Cold-water immersion and other forms of cryotherapy physiological changes potentially affecting recovery from high-intensity exercise Gillian E White and Greg D Wells Email author Extreme Physiology amp Medicine 2013 )

Dott Salvatore Denaro

KRYO TECAR

Mechanotherapy vibration

bull CONTROL OF MUSCULAR STIFFNESS (tonic reflex from vibration)

bull STIMULATION OF BLOOD LYMPHATIC CIRCULATION

bull PAIN RELIEF (gate control)

bull INCREASED SENSITIVITY

Bibliographic details Wang P Yang X Yang Y Yang L Zhou Y Liu C Reinhardt JD He C Effects of whole body vibration on pain stiffness and physical functions in patients with knee osteoarthritis a systematic review and meta-analysis Clinical Rehabilitation 2014 epub [PubMed] Dott Salvatore Denaro

Impact Waves bull 1 direct effect of the impulse on the tissue

in the target area and in conjunction with the reflection phenomena more accentuated in the points of transition between soft tissue (tendons muscles) and more compact tissues (bones and calcification formations)

bull 2 indirect effect of ldquocavitationrdquo caused by the subsequent depression of the impulse which exceeds the elastic characteristics of the tissue

NO DIRECT EFFECT ON PAIN MODULATORS OF BIOLOGICAL FUNCTIONS IN HUMAN MUSCLE CELLS (J Orthop Surg Res 2018 Apr 613(1)75 Exposure to radial extracorporeal shock waves modulates viability and gene expression of human skeletal muscle cells a controlled in vitro study Mattyasovszky SG1 Langendorf EK2 Ritz U2 Schmitz C3 Schmidtmann I4 Nowak TE2 Wagner D2 Hofmann A2 Rommens PM2 Drees P2)

RADIALI

FOCALI

Dott Salvatore Denaro

Ion Cyclotron Resonance Quantum Molecular Resonance

bull Stimulates the biological functions of cells bull Rebalances the correct membrane potential bull Activates enzymatic processes bull Restores the correct ion exchange for cell metabolism bull Promotes intra-extra cellular ion balance

Operating principle based on Quantum Molecular Resonance with the application of high-frequency and low-power micro-currents Induces the regeneration of damaged tissues especially muscular tissues without thermal effects

Dott Salvatore Denaro

Dott Salvatore Denaro

KINESIOTHERAPY IS NECESSARY

bull WITH REGARD TO ARTICULAR LINKS ndash JOINT PLAY ndash STRUCTURAL INTEGRITY OF THE CARTILAGE CAPSULE

AND LIGAMENTS ndash CORRECT MUSCLE SYNERGY ndash ELIMINATION OF FUNCTIONAL COMPENSATIONS

bull PAIN CONTROL bull NO CONTRAINDICATION

Dott Salvatore Denaro

KINESIOTHERAPY

bull POSTURAL Aims to correct any negative issues of posture (often secondary to analgesic compensatory attitudes) to detect alterations in the knee and calcaneal axis and of the plantar support visual disturbance dental malocclusion dysmetria of the pelvis etc

Dott Salvatore Denaro

KINESIOTHERAPY

bull HYDRO-KINESIOTHERAPY Very useful in cases of rheumatic diseases Therapeutic exercise in water is facilitated by the option to regulate water temperature and by the reduction in gravitational force which this medium allows

Dott Salvatore Denaro

VERTEBRAL MANIPULATION Robert Maignersquos ldquoManu Medicardquo

bull SEMIOTICS NATURE OF ILLNESS OR PATHOLOGY (clinical examination

imaging laboratory etc) ANALYSIS OF MINOR INTERVERTEBRAL DISTURBANCE

(ROM DDIM SCTM according to R Maignersquos research into signs of functional limitations)

bull THERAPY Principles RULE OF NO PAIN AND OF CONTRARY MOVEMENT VERIFICATION OF EVERY MANIPULATION BEFORE

PERFORMING THE NEXT

Dott Salvatore Denaro

TECHNIQUES

bull TREATMENT OF SOFT PARTS bull MUSCULAR STRETCHING bull REPEATED INTERVENTIONS bull MANIPULATION (3 STAGES)

Place in position Apply tension Manipulative thrust (low amplitude high velocity)

ldquoIT IS A NON-SYMPTOMATIC CAUSAL THERAPYrdquo

Mechanism of action of Vertebral Manipulation

bull Stretching and distension of the posterior joint capsule has a powerful inhibitory effect on muscle contraction (analgesic contraction) The hypotonic Gamma is determined by the stimulation of the periarticular receptors activated by the manipulative manoeuvre and results in a rapid and powerful ldquoINHIBITORY REFLEXrdquo through the contraction of the intervertebral musculature (DDIM)

bull With Vertebral Manipulation abruptly stretching structures such as ligaments discs joint capsules or muscles activates the descending system of nociceptive inhibition of pain in cases where this originates at the level of the grey matter

J Electromyogr Kinesiol 2012 Oct 22(5) 785ndash794Published online 2012 Feb 19 doi Spinal Manipulative Therapy and Somatosensory Activation Joel G Pickar DC PhD1 and Philip S Bolton DC PhD2 Dott Salvatore Denaro

Dott Salvatore Denaro

NEURAL PATHS FOR THE TRANSMISSION

OF PAIN

1st neuron

2nd neuron from the spinal chord to the thalamus

3rd neuron from the thalamus to the cerebral cortex

Opioids Alpha 2 agonists

Local anesthetics

Opioids

Alpha 2 agonists

Local anesthetics

Local anesthetics

Anti-inflammatory drugs

Routes of management

Intra-articular

transmucosal

Dott Salvatore Denaro

Dott Salvatore Denaro

But also in Orthopedic Medicinehelliphelliphellip

Dott Salvatore Denaro

Infiltration therapy

Acupuncture (ancient Chinese approach outlined by Huangdi Neijing

between 305 and 204 BC) This subject is only briefly mentioned here as it deserves its own separate conference There are however very few evidence based medical (EBM) studies of this ancient approach

Mesotherapy and Prolotherapy

Mesotherapy (MPistor) is an excellent analgesic therapy which uses a single needle or multi-injector as detailed by colleagues in the SFM (Socieacuteteacute Franccedilaise de Meacutesotheacuterapie)

Neuroprolotherapy (NPT) is a method of treatment which is distinct and separate from Prolotherapy from which it was evolved Developed since 2002 by New Zealander Dr John Lyftogt it targets the superficial sensory nerves of the body with micro-injections of low concentration glucose (5)

Dott Salvatore Denaro

Dry needling Annals of the Rheumatic Diseases 74(Suppl 2)624 middot June 2015 RV Bubnov

bull Very similar to acupuncture but treats the trigger points and myalgic intramuscular cords

bull It provides pinpoint mechanical stimulation

bull It provides both intramuscular and superficial stimulation

bull Precise laquoPain pointsraquo can be treated

Hyuk Ga Ji-Ho Choi Chang-Hae Park Hyun-Jung Yoon Acupuncture needling versus lidocaine injection of trigger points in myofascial pain syndrome in elderly patients ndash a randomised trial Acupuncture in Medicine Dec 2007

Dott Salvatore Denaro

TREATMENT OF PAIN in Orthopaedic Medicine

Dott Salvatore Denaro

ELECTROANALGESIA Based on Melzack and Wallrsquos theory of gate control which

describes two types of intervention for pain control

the first consists of reinforcing the the inhibitory power of large fibers the second aims selectively to interrupt the communication of small calibre fibers near the posterior horns (where the peripheral terminations are connected to the main neural pathways of communication to the brain)

Dott Salvatore Denaro

ELECTROANALGESIA TENS

ldquoTranscutaneous Electrical Nerve Stimulationrdquo is characterised by the fact that the electrodes are applied directly to the skin above the path of the

nerve trunk causing paresthesia in the area of the stimulated nerve distribution

Low frequency currents are used rectangular in shape which have an analgesic effect with

modalities that are not perfectly defined

Using TENS for pain control the state of the evidence Vance CG1 Dailey DL Rakel BA Sluka KA Pain Manag 2014 May4(3)197-209

Dott Salvatore Denaro

Non surgical laser therapy In analgesic therapy the ideal laser emission

instrument is one which uses a semiconductor diode as its active medium emitting invisible bursts of

radiation delivered in extremely short pulses typically within the infrared (IR) band with a

wavelength of approximately 904 nanometres ie the IR laser Other options include He-Ne CO2

Neodimio Yag and HILT

low levels of evidence

Eur J Phys Rehabil Med 2017 Aug53(4)603-610 Epub 2017 Jan 30 Effects of low-level laser therapy on pain in patients with musculoskeletal disorders a systematic review and meta-analysis Clijsen R123 Brunner A4 Barbero M4 Clarys P5 Taeymans J56

MOJ Orthop Rheumatol 20152(5) Epub 2015 Jun 9 The Use of Low Level Laser Therapy (LLLT) For Musculoskeletal Pain Cotler HB1 Chow RT2 Hamblin MR3 Carroll J4

Dott Salvatore Denaro

Biological Effects of LASER THERAPY an increase in the speed of mitosis temporary and reversible tissue dehydration denaturation of proteins thermolysis

carbonization for focal CO2 tissue evaporation

Physiotherapeutic lasers essentially produce two effects analgesic anti edema and biostimulant

Heat Therapy (Thermotherapy)

bull Heat action on the gate-control of MampW There is limited overall evidence to support the general use of localized heat however randomised clinical trials (RCTs) have shown that heat therapy provides short-term reductions in pain and disability in patients with acute lower back pain and provides significantly greater pain relief from DOMS than cold therapy (Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury Gerard A Malanga Ning Yan amp Jill Stark Oct 2014) PubMedgov

bull Cold reduction of tissue temperature which subsequently exerts local effects on blood flow on cell swelling and on metabolism and speed of neural conduction (Cold-water immersion and other forms of cryotherapy physiological changes potentially affecting recovery from high-intensity exercise Gillian E White and Greg D Wells Email author Extreme Physiology amp Medicine 2013 )

Dott Salvatore Denaro

KRYO TECAR

Mechanotherapy vibration

bull CONTROL OF MUSCULAR STIFFNESS (tonic reflex from vibration)

bull STIMULATION OF BLOOD LYMPHATIC CIRCULATION

bull PAIN RELIEF (gate control)

bull INCREASED SENSITIVITY

Bibliographic details Wang P Yang X Yang Y Yang L Zhou Y Liu C Reinhardt JD He C Effects of whole body vibration on pain stiffness and physical functions in patients with knee osteoarthritis a systematic review and meta-analysis Clinical Rehabilitation 2014 epub [PubMed] Dott Salvatore Denaro

Impact Waves bull 1 direct effect of the impulse on the tissue

in the target area and in conjunction with the reflection phenomena more accentuated in the points of transition between soft tissue (tendons muscles) and more compact tissues (bones and calcification formations)

bull 2 indirect effect of ldquocavitationrdquo caused by the subsequent depression of the impulse which exceeds the elastic characteristics of the tissue

NO DIRECT EFFECT ON PAIN MODULATORS OF BIOLOGICAL FUNCTIONS IN HUMAN MUSCLE CELLS (J Orthop Surg Res 2018 Apr 613(1)75 Exposure to radial extracorporeal shock waves modulates viability and gene expression of human skeletal muscle cells a controlled in vitro study Mattyasovszky SG1 Langendorf EK2 Ritz U2 Schmitz C3 Schmidtmann I4 Nowak TE2 Wagner D2 Hofmann A2 Rommens PM2 Drees P2)

RADIALI

FOCALI

Dott Salvatore Denaro

Ion Cyclotron Resonance Quantum Molecular Resonance

bull Stimulates the biological functions of cells bull Rebalances the correct membrane potential bull Activates enzymatic processes bull Restores the correct ion exchange for cell metabolism bull Promotes intra-extra cellular ion balance

Operating principle based on Quantum Molecular Resonance with the application of high-frequency and low-power micro-currents Induces the regeneration of damaged tissues especially muscular tissues without thermal effects

Dott Salvatore Denaro

Dott Salvatore Denaro

KINESIOTHERAPY IS NECESSARY

bull WITH REGARD TO ARTICULAR LINKS ndash JOINT PLAY ndash STRUCTURAL INTEGRITY OF THE CARTILAGE CAPSULE

AND LIGAMENTS ndash CORRECT MUSCLE SYNERGY ndash ELIMINATION OF FUNCTIONAL COMPENSATIONS

bull PAIN CONTROL bull NO CONTRAINDICATION

Dott Salvatore Denaro

KINESIOTHERAPY

bull POSTURAL Aims to correct any negative issues of posture (often secondary to analgesic compensatory attitudes) to detect alterations in the knee and calcaneal axis and of the plantar support visual disturbance dental malocclusion dysmetria of the pelvis etc

Dott Salvatore Denaro

KINESIOTHERAPY

bull HYDRO-KINESIOTHERAPY Very useful in cases of rheumatic diseases Therapeutic exercise in water is facilitated by the option to regulate water temperature and by the reduction in gravitational force which this medium allows

Dott Salvatore Denaro

VERTEBRAL MANIPULATION Robert Maignersquos ldquoManu Medicardquo

bull SEMIOTICS NATURE OF ILLNESS OR PATHOLOGY (clinical examination

imaging laboratory etc) ANALYSIS OF MINOR INTERVERTEBRAL DISTURBANCE

(ROM DDIM SCTM according to R Maignersquos research into signs of functional limitations)

bull THERAPY Principles RULE OF NO PAIN AND OF CONTRARY MOVEMENT VERIFICATION OF EVERY MANIPULATION BEFORE

PERFORMING THE NEXT

Dott Salvatore Denaro

TECHNIQUES

bull TREATMENT OF SOFT PARTS bull MUSCULAR STRETCHING bull REPEATED INTERVENTIONS bull MANIPULATION (3 STAGES)

Place in position Apply tension Manipulative thrust (low amplitude high velocity)

ldquoIT IS A NON-SYMPTOMATIC CAUSAL THERAPYrdquo

Mechanism of action of Vertebral Manipulation

bull Stretching and distension of the posterior joint capsule has a powerful inhibitory effect on muscle contraction (analgesic contraction) The hypotonic Gamma is determined by the stimulation of the periarticular receptors activated by the manipulative manoeuvre and results in a rapid and powerful ldquoINHIBITORY REFLEXrdquo through the contraction of the intervertebral musculature (DDIM)

bull With Vertebral Manipulation abruptly stretching structures such as ligaments discs joint capsules or muscles activates the descending system of nociceptive inhibition of pain in cases where this originates at the level of the grey matter

J Electromyogr Kinesiol 2012 Oct 22(5) 785ndash794Published online 2012 Feb 19 doi Spinal Manipulative Therapy and Somatosensory Activation Joel G Pickar DC PhD1 and Philip S Bolton DC PhD2 Dott Salvatore Denaro

Routes of management

Intra-articular

transmucosal

Dott Salvatore Denaro

Dott Salvatore Denaro

But also in Orthopedic Medicinehelliphelliphellip

Dott Salvatore Denaro

Infiltration therapy

Acupuncture (ancient Chinese approach outlined by Huangdi Neijing

between 305 and 204 BC) This subject is only briefly mentioned here as it deserves its own separate conference There are however very few evidence based medical (EBM) studies of this ancient approach

Mesotherapy and Prolotherapy

Mesotherapy (MPistor) is an excellent analgesic therapy which uses a single needle or multi-injector as detailed by colleagues in the SFM (Socieacuteteacute Franccedilaise de Meacutesotheacuterapie)

Neuroprolotherapy (NPT) is a method of treatment which is distinct and separate from Prolotherapy from which it was evolved Developed since 2002 by New Zealander Dr John Lyftogt it targets the superficial sensory nerves of the body with micro-injections of low concentration glucose (5)

Dott Salvatore Denaro

Dry needling Annals of the Rheumatic Diseases 74(Suppl 2)624 middot June 2015 RV Bubnov

bull Very similar to acupuncture but treats the trigger points and myalgic intramuscular cords

bull It provides pinpoint mechanical stimulation

bull It provides both intramuscular and superficial stimulation

bull Precise laquoPain pointsraquo can be treated

Hyuk Ga Ji-Ho Choi Chang-Hae Park Hyun-Jung Yoon Acupuncture needling versus lidocaine injection of trigger points in myofascial pain syndrome in elderly patients ndash a randomised trial Acupuncture in Medicine Dec 2007

Dott Salvatore Denaro

TREATMENT OF PAIN in Orthopaedic Medicine

Dott Salvatore Denaro

ELECTROANALGESIA Based on Melzack and Wallrsquos theory of gate control which

describes two types of intervention for pain control

the first consists of reinforcing the the inhibitory power of large fibers the second aims selectively to interrupt the communication of small calibre fibers near the posterior horns (where the peripheral terminations are connected to the main neural pathways of communication to the brain)

Dott Salvatore Denaro

ELECTROANALGESIA TENS

ldquoTranscutaneous Electrical Nerve Stimulationrdquo is characterised by the fact that the electrodes are applied directly to the skin above the path of the

nerve trunk causing paresthesia in the area of the stimulated nerve distribution

Low frequency currents are used rectangular in shape which have an analgesic effect with

modalities that are not perfectly defined

Using TENS for pain control the state of the evidence Vance CG1 Dailey DL Rakel BA Sluka KA Pain Manag 2014 May4(3)197-209

Dott Salvatore Denaro

Non surgical laser therapy In analgesic therapy the ideal laser emission

instrument is one which uses a semiconductor diode as its active medium emitting invisible bursts of

radiation delivered in extremely short pulses typically within the infrared (IR) band with a

wavelength of approximately 904 nanometres ie the IR laser Other options include He-Ne CO2

Neodimio Yag and HILT

low levels of evidence

Eur J Phys Rehabil Med 2017 Aug53(4)603-610 Epub 2017 Jan 30 Effects of low-level laser therapy on pain in patients with musculoskeletal disorders a systematic review and meta-analysis Clijsen R123 Brunner A4 Barbero M4 Clarys P5 Taeymans J56

MOJ Orthop Rheumatol 20152(5) Epub 2015 Jun 9 The Use of Low Level Laser Therapy (LLLT) For Musculoskeletal Pain Cotler HB1 Chow RT2 Hamblin MR3 Carroll J4

Dott Salvatore Denaro

Biological Effects of LASER THERAPY an increase in the speed of mitosis temporary and reversible tissue dehydration denaturation of proteins thermolysis

carbonization for focal CO2 tissue evaporation

Physiotherapeutic lasers essentially produce two effects analgesic anti edema and biostimulant

Heat Therapy (Thermotherapy)

bull Heat action on the gate-control of MampW There is limited overall evidence to support the general use of localized heat however randomised clinical trials (RCTs) have shown that heat therapy provides short-term reductions in pain and disability in patients with acute lower back pain and provides significantly greater pain relief from DOMS than cold therapy (Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury Gerard A Malanga Ning Yan amp Jill Stark Oct 2014) PubMedgov

bull Cold reduction of tissue temperature which subsequently exerts local effects on blood flow on cell swelling and on metabolism and speed of neural conduction (Cold-water immersion and other forms of cryotherapy physiological changes potentially affecting recovery from high-intensity exercise Gillian E White and Greg D Wells Email author Extreme Physiology amp Medicine 2013 )

Dott Salvatore Denaro

KRYO TECAR

Mechanotherapy vibration

bull CONTROL OF MUSCULAR STIFFNESS (tonic reflex from vibration)

bull STIMULATION OF BLOOD LYMPHATIC CIRCULATION

bull PAIN RELIEF (gate control)

bull INCREASED SENSITIVITY

Bibliographic details Wang P Yang X Yang Y Yang L Zhou Y Liu C Reinhardt JD He C Effects of whole body vibration on pain stiffness and physical functions in patients with knee osteoarthritis a systematic review and meta-analysis Clinical Rehabilitation 2014 epub [PubMed] Dott Salvatore Denaro

Impact Waves bull 1 direct effect of the impulse on the tissue

in the target area and in conjunction with the reflection phenomena more accentuated in the points of transition between soft tissue (tendons muscles) and more compact tissues (bones and calcification formations)

bull 2 indirect effect of ldquocavitationrdquo caused by the subsequent depression of the impulse which exceeds the elastic characteristics of the tissue

NO DIRECT EFFECT ON PAIN MODULATORS OF BIOLOGICAL FUNCTIONS IN HUMAN MUSCLE CELLS (J Orthop Surg Res 2018 Apr 613(1)75 Exposure to radial extracorporeal shock waves modulates viability and gene expression of human skeletal muscle cells a controlled in vitro study Mattyasovszky SG1 Langendorf EK2 Ritz U2 Schmitz C3 Schmidtmann I4 Nowak TE2 Wagner D2 Hofmann A2 Rommens PM2 Drees P2)

RADIALI

FOCALI

Dott Salvatore Denaro

Ion Cyclotron Resonance Quantum Molecular Resonance

bull Stimulates the biological functions of cells bull Rebalances the correct membrane potential bull Activates enzymatic processes bull Restores the correct ion exchange for cell metabolism bull Promotes intra-extra cellular ion balance

Operating principle based on Quantum Molecular Resonance with the application of high-frequency and low-power micro-currents Induces the regeneration of damaged tissues especially muscular tissues without thermal effects

Dott Salvatore Denaro

Dott Salvatore Denaro

KINESIOTHERAPY IS NECESSARY

bull WITH REGARD TO ARTICULAR LINKS ndash JOINT PLAY ndash STRUCTURAL INTEGRITY OF THE CARTILAGE CAPSULE

AND LIGAMENTS ndash CORRECT MUSCLE SYNERGY ndash ELIMINATION OF FUNCTIONAL COMPENSATIONS

bull PAIN CONTROL bull NO CONTRAINDICATION

Dott Salvatore Denaro

KINESIOTHERAPY

bull POSTURAL Aims to correct any negative issues of posture (often secondary to analgesic compensatory attitudes) to detect alterations in the knee and calcaneal axis and of the plantar support visual disturbance dental malocclusion dysmetria of the pelvis etc

Dott Salvatore Denaro

KINESIOTHERAPY

bull HYDRO-KINESIOTHERAPY Very useful in cases of rheumatic diseases Therapeutic exercise in water is facilitated by the option to regulate water temperature and by the reduction in gravitational force which this medium allows

Dott Salvatore Denaro

VERTEBRAL MANIPULATION Robert Maignersquos ldquoManu Medicardquo

bull SEMIOTICS NATURE OF ILLNESS OR PATHOLOGY (clinical examination

imaging laboratory etc) ANALYSIS OF MINOR INTERVERTEBRAL DISTURBANCE

(ROM DDIM SCTM according to R Maignersquos research into signs of functional limitations)

bull THERAPY Principles RULE OF NO PAIN AND OF CONTRARY MOVEMENT VERIFICATION OF EVERY MANIPULATION BEFORE

PERFORMING THE NEXT

Dott Salvatore Denaro

TECHNIQUES

bull TREATMENT OF SOFT PARTS bull MUSCULAR STRETCHING bull REPEATED INTERVENTIONS bull MANIPULATION (3 STAGES)

Place in position Apply tension Manipulative thrust (low amplitude high velocity)

ldquoIT IS A NON-SYMPTOMATIC CAUSAL THERAPYrdquo

Mechanism of action of Vertebral Manipulation

bull Stretching and distension of the posterior joint capsule has a powerful inhibitory effect on muscle contraction (analgesic contraction) The hypotonic Gamma is determined by the stimulation of the periarticular receptors activated by the manipulative manoeuvre and results in a rapid and powerful ldquoINHIBITORY REFLEXrdquo through the contraction of the intervertebral musculature (DDIM)

bull With Vertebral Manipulation abruptly stretching structures such as ligaments discs joint capsules or muscles activates the descending system of nociceptive inhibition of pain in cases where this originates at the level of the grey matter

J Electromyogr Kinesiol 2012 Oct 22(5) 785ndash794Published online 2012 Feb 19 doi Spinal Manipulative Therapy and Somatosensory Activation Joel G Pickar DC PhD1 and Philip S Bolton DC PhD2 Dott Salvatore Denaro

Dott Salvatore Denaro

But also in Orthopedic Medicinehelliphelliphellip

Dott Salvatore Denaro

Infiltration therapy

Acupuncture (ancient Chinese approach outlined by Huangdi Neijing

between 305 and 204 BC) This subject is only briefly mentioned here as it deserves its own separate conference There are however very few evidence based medical (EBM) studies of this ancient approach

Mesotherapy and Prolotherapy

Mesotherapy (MPistor) is an excellent analgesic therapy which uses a single needle or multi-injector as detailed by colleagues in the SFM (Socieacuteteacute Franccedilaise de Meacutesotheacuterapie)

Neuroprolotherapy (NPT) is a method of treatment which is distinct and separate from Prolotherapy from which it was evolved Developed since 2002 by New Zealander Dr John Lyftogt it targets the superficial sensory nerves of the body with micro-injections of low concentration glucose (5)

Dott Salvatore Denaro

Dry needling Annals of the Rheumatic Diseases 74(Suppl 2)624 middot June 2015 RV Bubnov

bull Very similar to acupuncture but treats the trigger points and myalgic intramuscular cords

bull It provides pinpoint mechanical stimulation

bull It provides both intramuscular and superficial stimulation

bull Precise laquoPain pointsraquo can be treated

Hyuk Ga Ji-Ho Choi Chang-Hae Park Hyun-Jung Yoon Acupuncture needling versus lidocaine injection of trigger points in myofascial pain syndrome in elderly patients ndash a randomised trial Acupuncture in Medicine Dec 2007

Dott Salvatore Denaro

TREATMENT OF PAIN in Orthopaedic Medicine

Dott Salvatore Denaro

ELECTROANALGESIA Based on Melzack and Wallrsquos theory of gate control which

describes two types of intervention for pain control

the first consists of reinforcing the the inhibitory power of large fibers the second aims selectively to interrupt the communication of small calibre fibers near the posterior horns (where the peripheral terminations are connected to the main neural pathways of communication to the brain)

Dott Salvatore Denaro

ELECTROANALGESIA TENS

ldquoTranscutaneous Electrical Nerve Stimulationrdquo is characterised by the fact that the electrodes are applied directly to the skin above the path of the

nerve trunk causing paresthesia in the area of the stimulated nerve distribution

Low frequency currents are used rectangular in shape which have an analgesic effect with

modalities that are not perfectly defined

Using TENS for pain control the state of the evidence Vance CG1 Dailey DL Rakel BA Sluka KA Pain Manag 2014 May4(3)197-209

Dott Salvatore Denaro

Non surgical laser therapy In analgesic therapy the ideal laser emission

instrument is one which uses a semiconductor diode as its active medium emitting invisible bursts of

radiation delivered in extremely short pulses typically within the infrared (IR) band with a

wavelength of approximately 904 nanometres ie the IR laser Other options include He-Ne CO2

Neodimio Yag and HILT

low levels of evidence

Eur J Phys Rehabil Med 2017 Aug53(4)603-610 Epub 2017 Jan 30 Effects of low-level laser therapy on pain in patients with musculoskeletal disorders a systematic review and meta-analysis Clijsen R123 Brunner A4 Barbero M4 Clarys P5 Taeymans J56

MOJ Orthop Rheumatol 20152(5) Epub 2015 Jun 9 The Use of Low Level Laser Therapy (LLLT) For Musculoskeletal Pain Cotler HB1 Chow RT2 Hamblin MR3 Carroll J4

Dott Salvatore Denaro

Biological Effects of LASER THERAPY an increase in the speed of mitosis temporary and reversible tissue dehydration denaturation of proteins thermolysis

carbonization for focal CO2 tissue evaporation

Physiotherapeutic lasers essentially produce two effects analgesic anti edema and biostimulant

Heat Therapy (Thermotherapy)

bull Heat action on the gate-control of MampW There is limited overall evidence to support the general use of localized heat however randomised clinical trials (RCTs) have shown that heat therapy provides short-term reductions in pain and disability in patients with acute lower back pain and provides significantly greater pain relief from DOMS than cold therapy (Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury Gerard A Malanga Ning Yan amp Jill Stark Oct 2014) PubMedgov

bull Cold reduction of tissue temperature which subsequently exerts local effects on blood flow on cell swelling and on metabolism and speed of neural conduction (Cold-water immersion and other forms of cryotherapy physiological changes potentially affecting recovery from high-intensity exercise Gillian E White and Greg D Wells Email author Extreme Physiology amp Medicine 2013 )

Dott Salvatore Denaro

KRYO TECAR

Mechanotherapy vibration

bull CONTROL OF MUSCULAR STIFFNESS (tonic reflex from vibration)

bull STIMULATION OF BLOOD LYMPHATIC CIRCULATION

bull PAIN RELIEF (gate control)

bull INCREASED SENSITIVITY

Bibliographic details Wang P Yang X Yang Y Yang L Zhou Y Liu C Reinhardt JD He C Effects of whole body vibration on pain stiffness and physical functions in patients with knee osteoarthritis a systematic review and meta-analysis Clinical Rehabilitation 2014 epub [PubMed] Dott Salvatore Denaro

Impact Waves bull 1 direct effect of the impulse on the tissue

in the target area and in conjunction with the reflection phenomena more accentuated in the points of transition between soft tissue (tendons muscles) and more compact tissues (bones and calcification formations)

bull 2 indirect effect of ldquocavitationrdquo caused by the subsequent depression of the impulse which exceeds the elastic characteristics of the tissue

NO DIRECT EFFECT ON PAIN MODULATORS OF BIOLOGICAL FUNCTIONS IN HUMAN MUSCLE CELLS (J Orthop Surg Res 2018 Apr 613(1)75 Exposure to radial extracorporeal shock waves modulates viability and gene expression of human skeletal muscle cells a controlled in vitro study Mattyasovszky SG1 Langendorf EK2 Ritz U2 Schmitz C3 Schmidtmann I4 Nowak TE2 Wagner D2 Hofmann A2 Rommens PM2 Drees P2)

RADIALI

FOCALI

Dott Salvatore Denaro

Ion Cyclotron Resonance Quantum Molecular Resonance

bull Stimulates the biological functions of cells bull Rebalances the correct membrane potential bull Activates enzymatic processes bull Restores the correct ion exchange for cell metabolism bull Promotes intra-extra cellular ion balance

Operating principle based on Quantum Molecular Resonance with the application of high-frequency and low-power micro-currents Induces the regeneration of damaged tissues especially muscular tissues without thermal effects

Dott Salvatore Denaro

Dott Salvatore Denaro

KINESIOTHERAPY IS NECESSARY

bull WITH REGARD TO ARTICULAR LINKS ndash JOINT PLAY ndash STRUCTURAL INTEGRITY OF THE CARTILAGE CAPSULE

AND LIGAMENTS ndash CORRECT MUSCLE SYNERGY ndash ELIMINATION OF FUNCTIONAL COMPENSATIONS

bull PAIN CONTROL bull NO CONTRAINDICATION

Dott Salvatore Denaro

KINESIOTHERAPY

bull POSTURAL Aims to correct any negative issues of posture (often secondary to analgesic compensatory attitudes) to detect alterations in the knee and calcaneal axis and of the plantar support visual disturbance dental malocclusion dysmetria of the pelvis etc

Dott Salvatore Denaro

KINESIOTHERAPY

bull HYDRO-KINESIOTHERAPY Very useful in cases of rheumatic diseases Therapeutic exercise in water is facilitated by the option to regulate water temperature and by the reduction in gravitational force which this medium allows

Dott Salvatore Denaro

VERTEBRAL MANIPULATION Robert Maignersquos ldquoManu Medicardquo

bull SEMIOTICS NATURE OF ILLNESS OR PATHOLOGY (clinical examination

imaging laboratory etc) ANALYSIS OF MINOR INTERVERTEBRAL DISTURBANCE

(ROM DDIM SCTM according to R Maignersquos research into signs of functional limitations)

bull THERAPY Principles RULE OF NO PAIN AND OF CONTRARY MOVEMENT VERIFICATION OF EVERY MANIPULATION BEFORE

PERFORMING THE NEXT

Dott Salvatore Denaro

TECHNIQUES

bull TREATMENT OF SOFT PARTS bull MUSCULAR STRETCHING bull REPEATED INTERVENTIONS bull MANIPULATION (3 STAGES)

Place in position Apply tension Manipulative thrust (low amplitude high velocity)

ldquoIT IS A NON-SYMPTOMATIC CAUSAL THERAPYrdquo

Mechanism of action of Vertebral Manipulation

bull Stretching and distension of the posterior joint capsule has a powerful inhibitory effect on muscle contraction (analgesic contraction) The hypotonic Gamma is determined by the stimulation of the periarticular receptors activated by the manipulative manoeuvre and results in a rapid and powerful ldquoINHIBITORY REFLEXrdquo through the contraction of the intervertebral musculature (DDIM)

bull With Vertebral Manipulation abruptly stretching structures such as ligaments discs joint capsules or muscles activates the descending system of nociceptive inhibition of pain in cases where this originates at the level of the grey matter

J Electromyogr Kinesiol 2012 Oct 22(5) 785ndash794Published online 2012 Feb 19 doi Spinal Manipulative Therapy and Somatosensory Activation Joel G Pickar DC PhD1 and Philip S Bolton DC PhD2 Dott Salvatore Denaro

Dott Salvatore Denaro

Infiltration therapy

Acupuncture (ancient Chinese approach outlined by Huangdi Neijing

between 305 and 204 BC) This subject is only briefly mentioned here as it deserves its own separate conference There are however very few evidence based medical (EBM) studies of this ancient approach

Mesotherapy and Prolotherapy

Mesotherapy (MPistor) is an excellent analgesic therapy which uses a single needle or multi-injector as detailed by colleagues in the SFM (Socieacuteteacute Franccedilaise de Meacutesotheacuterapie)

Neuroprolotherapy (NPT) is a method of treatment which is distinct and separate from Prolotherapy from which it was evolved Developed since 2002 by New Zealander Dr John Lyftogt it targets the superficial sensory nerves of the body with micro-injections of low concentration glucose (5)

Dott Salvatore Denaro

Dry needling Annals of the Rheumatic Diseases 74(Suppl 2)624 middot June 2015 RV Bubnov

bull Very similar to acupuncture but treats the trigger points and myalgic intramuscular cords

bull It provides pinpoint mechanical stimulation

bull It provides both intramuscular and superficial stimulation

bull Precise laquoPain pointsraquo can be treated

Hyuk Ga Ji-Ho Choi Chang-Hae Park Hyun-Jung Yoon Acupuncture needling versus lidocaine injection of trigger points in myofascial pain syndrome in elderly patients ndash a randomised trial Acupuncture in Medicine Dec 2007

Dott Salvatore Denaro

TREATMENT OF PAIN in Orthopaedic Medicine

Dott Salvatore Denaro

ELECTROANALGESIA Based on Melzack and Wallrsquos theory of gate control which

describes two types of intervention for pain control

the first consists of reinforcing the the inhibitory power of large fibers the second aims selectively to interrupt the communication of small calibre fibers near the posterior horns (where the peripheral terminations are connected to the main neural pathways of communication to the brain)

Dott Salvatore Denaro

ELECTROANALGESIA TENS

ldquoTranscutaneous Electrical Nerve Stimulationrdquo is characterised by the fact that the electrodes are applied directly to the skin above the path of the

nerve trunk causing paresthesia in the area of the stimulated nerve distribution

Low frequency currents are used rectangular in shape which have an analgesic effect with

modalities that are not perfectly defined

Using TENS for pain control the state of the evidence Vance CG1 Dailey DL Rakel BA Sluka KA Pain Manag 2014 May4(3)197-209

Dott Salvatore Denaro

Non surgical laser therapy In analgesic therapy the ideal laser emission

instrument is one which uses a semiconductor diode as its active medium emitting invisible bursts of

radiation delivered in extremely short pulses typically within the infrared (IR) band with a

wavelength of approximately 904 nanometres ie the IR laser Other options include He-Ne CO2

Neodimio Yag and HILT

low levels of evidence

Eur J Phys Rehabil Med 2017 Aug53(4)603-610 Epub 2017 Jan 30 Effects of low-level laser therapy on pain in patients with musculoskeletal disorders a systematic review and meta-analysis Clijsen R123 Brunner A4 Barbero M4 Clarys P5 Taeymans J56

MOJ Orthop Rheumatol 20152(5) Epub 2015 Jun 9 The Use of Low Level Laser Therapy (LLLT) For Musculoskeletal Pain Cotler HB1 Chow RT2 Hamblin MR3 Carroll J4

Dott Salvatore Denaro

Biological Effects of LASER THERAPY an increase in the speed of mitosis temporary and reversible tissue dehydration denaturation of proteins thermolysis

carbonization for focal CO2 tissue evaporation

Physiotherapeutic lasers essentially produce two effects analgesic anti edema and biostimulant

Heat Therapy (Thermotherapy)

bull Heat action on the gate-control of MampW There is limited overall evidence to support the general use of localized heat however randomised clinical trials (RCTs) have shown that heat therapy provides short-term reductions in pain and disability in patients with acute lower back pain and provides significantly greater pain relief from DOMS than cold therapy (Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury Gerard A Malanga Ning Yan amp Jill Stark Oct 2014) PubMedgov

bull Cold reduction of tissue temperature which subsequently exerts local effects on blood flow on cell swelling and on metabolism and speed of neural conduction (Cold-water immersion and other forms of cryotherapy physiological changes potentially affecting recovery from high-intensity exercise Gillian E White and Greg D Wells Email author Extreme Physiology amp Medicine 2013 )

Dott Salvatore Denaro

KRYO TECAR

Mechanotherapy vibration

bull CONTROL OF MUSCULAR STIFFNESS (tonic reflex from vibration)

bull STIMULATION OF BLOOD LYMPHATIC CIRCULATION

bull PAIN RELIEF (gate control)

bull INCREASED SENSITIVITY

Bibliographic details Wang P Yang X Yang Y Yang L Zhou Y Liu C Reinhardt JD He C Effects of whole body vibration on pain stiffness and physical functions in patients with knee osteoarthritis a systematic review and meta-analysis Clinical Rehabilitation 2014 epub [PubMed] Dott Salvatore Denaro

Impact Waves bull 1 direct effect of the impulse on the tissue

in the target area and in conjunction with the reflection phenomena more accentuated in the points of transition between soft tissue (tendons muscles) and more compact tissues (bones and calcification formations)

bull 2 indirect effect of ldquocavitationrdquo caused by the subsequent depression of the impulse which exceeds the elastic characteristics of the tissue

NO DIRECT EFFECT ON PAIN MODULATORS OF BIOLOGICAL FUNCTIONS IN HUMAN MUSCLE CELLS (J Orthop Surg Res 2018 Apr 613(1)75 Exposure to radial extracorporeal shock waves modulates viability and gene expression of human skeletal muscle cells a controlled in vitro study Mattyasovszky SG1 Langendorf EK2 Ritz U2 Schmitz C3 Schmidtmann I4 Nowak TE2 Wagner D2 Hofmann A2 Rommens PM2 Drees P2)

RADIALI

FOCALI

Dott Salvatore Denaro

Ion Cyclotron Resonance Quantum Molecular Resonance

bull Stimulates the biological functions of cells bull Rebalances the correct membrane potential bull Activates enzymatic processes bull Restores the correct ion exchange for cell metabolism bull Promotes intra-extra cellular ion balance

Operating principle based on Quantum Molecular Resonance with the application of high-frequency and low-power micro-currents Induces the regeneration of damaged tissues especially muscular tissues without thermal effects

Dott Salvatore Denaro

Dott Salvatore Denaro

KINESIOTHERAPY IS NECESSARY

bull WITH REGARD TO ARTICULAR LINKS ndash JOINT PLAY ndash STRUCTURAL INTEGRITY OF THE CARTILAGE CAPSULE

AND LIGAMENTS ndash CORRECT MUSCLE SYNERGY ndash ELIMINATION OF FUNCTIONAL COMPENSATIONS

bull PAIN CONTROL bull NO CONTRAINDICATION

Dott Salvatore Denaro

KINESIOTHERAPY

bull POSTURAL Aims to correct any negative issues of posture (often secondary to analgesic compensatory attitudes) to detect alterations in the knee and calcaneal axis and of the plantar support visual disturbance dental malocclusion dysmetria of the pelvis etc

Dott Salvatore Denaro

KINESIOTHERAPY

bull HYDRO-KINESIOTHERAPY Very useful in cases of rheumatic diseases Therapeutic exercise in water is facilitated by the option to regulate water temperature and by the reduction in gravitational force which this medium allows

Dott Salvatore Denaro

VERTEBRAL MANIPULATION Robert Maignersquos ldquoManu Medicardquo

bull SEMIOTICS NATURE OF ILLNESS OR PATHOLOGY (clinical examination

imaging laboratory etc) ANALYSIS OF MINOR INTERVERTEBRAL DISTURBANCE

(ROM DDIM SCTM according to R Maignersquos research into signs of functional limitations)

bull THERAPY Principles RULE OF NO PAIN AND OF CONTRARY MOVEMENT VERIFICATION OF EVERY MANIPULATION BEFORE

PERFORMING THE NEXT

Dott Salvatore Denaro

TECHNIQUES

bull TREATMENT OF SOFT PARTS bull MUSCULAR STRETCHING bull REPEATED INTERVENTIONS bull MANIPULATION (3 STAGES)

Place in position Apply tension Manipulative thrust (low amplitude high velocity)

ldquoIT IS A NON-SYMPTOMATIC CAUSAL THERAPYrdquo

Mechanism of action of Vertebral Manipulation

bull Stretching and distension of the posterior joint capsule has a powerful inhibitory effect on muscle contraction (analgesic contraction) The hypotonic Gamma is determined by the stimulation of the periarticular receptors activated by the manipulative manoeuvre and results in a rapid and powerful ldquoINHIBITORY REFLEXrdquo through the contraction of the intervertebral musculature (DDIM)

bull With Vertebral Manipulation abruptly stretching structures such as ligaments discs joint capsules or muscles activates the descending system of nociceptive inhibition of pain in cases where this originates at the level of the grey matter

J Electromyogr Kinesiol 2012 Oct 22(5) 785ndash794Published online 2012 Feb 19 doi Spinal Manipulative Therapy and Somatosensory Activation Joel G Pickar DC PhD1 and Philip S Bolton DC PhD2 Dott Salvatore Denaro

Acupuncture (ancient Chinese approach outlined by Huangdi Neijing

between 305 and 204 BC) This subject is only briefly mentioned here as it deserves its own separate conference There are however very few evidence based medical (EBM) studies of this ancient approach

Mesotherapy and Prolotherapy

Mesotherapy (MPistor) is an excellent analgesic therapy which uses a single needle or multi-injector as detailed by colleagues in the SFM (Socieacuteteacute Franccedilaise de Meacutesotheacuterapie)

Neuroprolotherapy (NPT) is a method of treatment which is distinct and separate from Prolotherapy from which it was evolved Developed since 2002 by New Zealander Dr John Lyftogt it targets the superficial sensory nerves of the body with micro-injections of low concentration glucose (5)

Dott Salvatore Denaro

Dry needling Annals of the Rheumatic Diseases 74(Suppl 2)624 middot June 2015 RV Bubnov

bull Very similar to acupuncture but treats the trigger points and myalgic intramuscular cords

bull It provides pinpoint mechanical stimulation

bull It provides both intramuscular and superficial stimulation

bull Precise laquoPain pointsraquo can be treated

Hyuk Ga Ji-Ho Choi Chang-Hae Park Hyun-Jung Yoon Acupuncture needling versus lidocaine injection of trigger points in myofascial pain syndrome in elderly patients ndash a randomised trial Acupuncture in Medicine Dec 2007

Dott Salvatore Denaro

TREATMENT OF PAIN in Orthopaedic Medicine

Dott Salvatore Denaro

ELECTROANALGESIA Based on Melzack and Wallrsquos theory of gate control which

describes two types of intervention for pain control

the first consists of reinforcing the the inhibitory power of large fibers the second aims selectively to interrupt the communication of small calibre fibers near the posterior horns (where the peripheral terminations are connected to the main neural pathways of communication to the brain)

Dott Salvatore Denaro

ELECTROANALGESIA TENS

ldquoTranscutaneous Electrical Nerve Stimulationrdquo is characterised by the fact that the electrodes are applied directly to the skin above the path of the

nerve trunk causing paresthesia in the area of the stimulated nerve distribution

Low frequency currents are used rectangular in shape which have an analgesic effect with

modalities that are not perfectly defined

Using TENS for pain control the state of the evidence Vance CG1 Dailey DL Rakel BA Sluka KA Pain Manag 2014 May4(3)197-209

Dott Salvatore Denaro

Non surgical laser therapy In analgesic therapy the ideal laser emission

instrument is one which uses a semiconductor diode as its active medium emitting invisible bursts of

radiation delivered in extremely short pulses typically within the infrared (IR) band with a

wavelength of approximately 904 nanometres ie the IR laser Other options include He-Ne CO2

Neodimio Yag and HILT

low levels of evidence

Eur J Phys Rehabil Med 2017 Aug53(4)603-610 Epub 2017 Jan 30 Effects of low-level laser therapy on pain in patients with musculoskeletal disorders a systematic review and meta-analysis Clijsen R123 Brunner A4 Barbero M4 Clarys P5 Taeymans J56

MOJ Orthop Rheumatol 20152(5) Epub 2015 Jun 9 The Use of Low Level Laser Therapy (LLLT) For Musculoskeletal Pain Cotler HB1 Chow RT2 Hamblin MR3 Carroll J4

Dott Salvatore Denaro

Biological Effects of LASER THERAPY an increase in the speed of mitosis temporary and reversible tissue dehydration denaturation of proteins thermolysis

carbonization for focal CO2 tissue evaporation

Physiotherapeutic lasers essentially produce two effects analgesic anti edema and biostimulant

Heat Therapy (Thermotherapy)

bull Heat action on the gate-control of MampW There is limited overall evidence to support the general use of localized heat however randomised clinical trials (RCTs) have shown that heat therapy provides short-term reductions in pain and disability in patients with acute lower back pain and provides significantly greater pain relief from DOMS than cold therapy (Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury Gerard A Malanga Ning Yan amp Jill Stark Oct 2014) PubMedgov

bull Cold reduction of tissue temperature which subsequently exerts local effects on blood flow on cell swelling and on metabolism and speed of neural conduction (Cold-water immersion and other forms of cryotherapy physiological changes potentially affecting recovery from high-intensity exercise Gillian E White and Greg D Wells Email author Extreme Physiology amp Medicine 2013 )

Dott Salvatore Denaro

KRYO TECAR

Mechanotherapy vibration

bull CONTROL OF MUSCULAR STIFFNESS (tonic reflex from vibration)

bull STIMULATION OF BLOOD LYMPHATIC CIRCULATION

bull PAIN RELIEF (gate control)

bull INCREASED SENSITIVITY

Bibliographic details Wang P Yang X Yang Y Yang L Zhou Y Liu C Reinhardt JD He C Effects of whole body vibration on pain stiffness and physical functions in patients with knee osteoarthritis a systematic review and meta-analysis Clinical Rehabilitation 2014 epub [PubMed] Dott Salvatore Denaro

Impact Waves bull 1 direct effect of the impulse on the tissue

in the target area and in conjunction with the reflection phenomena more accentuated in the points of transition between soft tissue (tendons muscles) and more compact tissues (bones and calcification formations)

bull 2 indirect effect of ldquocavitationrdquo caused by the subsequent depression of the impulse which exceeds the elastic characteristics of the tissue

NO DIRECT EFFECT ON PAIN MODULATORS OF BIOLOGICAL FUNCTIONS IN HUMAN MUSCLE CELLS (J Orthop Surg Res 2018 Apr 613(1)75 Exposure to radial extracorporeal shock waves modulates viability and gene expression of human skeletal muscle cells a controlled in vitro study Mattyasovszky SG1 Langendorf EK2 Ritz U2 Schmitz C3 Schmidtmann I4 Nowak TE2 Wagner D2 Hofmann A2 Rommens PM2 Drees P2)

RADIALI

FOCALI

Dott Salvatore Denaro

Ion Cyclotron Resonance Quantum Molecular Resonance

bull Stimulates the biological functions of cells bull Rebalances the correct membrane potential bull Activates enzymatic processes bull Restores the correct ion exchange for cell metabolism bull Promotes intra-extra cellular ion balance

Operating principle based on Quantum Molecular Resonance with the application of high-frequency and low-power micro-currents Induces the regeneration of damaged tissues especially muscular tissues without thermal effects

Dott Salvatore Denaro

Dott Salvatore Denaro

KINESIOTHERAPY IS NECESSARY

bull WITH REGARD TO ARTICULAR LINKS ndash JOINT PLAY ndash STRUCTURAL INTEGRITY OF THE CARTILAGE CAPSULE

AND LIGAMENTS ndash CORRECT MUSCLE SYNERGY ndash ELIMINATION OF FUNCTIONAL COMPENSATIONS

bull PAIN CONTROL bull NO CONTRAINDICATION

Dott Salvatore Denaro

KINESIOTHERAPY

bull POSTURAL Aims to correct any negative issues of posture (often secondary to analgesic compensatory attitudes) to detect alterations in the knee and calcaneal axis and of the plantar support visual disturbance dental malocclusion dysmetria of the pelvis etc

Dott Salvatore Denaro

KINESIOTHERAPY

bull HYDRO-KINESIOTHERAPY Very useful in cases of rheumatic diseases Therapeutic exercise in water is facilitated by the option to regulate water temperature and by the reduction in gravitational force which this medium allows

Dott Salvatore Denaro

VERTEBRAL MANIPULATION Robert Maignersquos ldquoManu Medicardquo

bull SEMIOTICS NATURE OF ILLNESS OR PATHOLOGY (clinical examination

imaging laboratory etc) ANALYSIS OF MINOR INTERVERTEBRAL DISTURBANCE

(ROM DDIM SCTM according to R Maignersquos research into signs of functional limitations)

bull THERAPY Principles RULE OF NO PAIN AND OF CONTRARY MOVEMENT VERIFICATION OF EVERY MANIPULATION BEFORE

PERFORMING THE NEXT

Dott Salvatore Denaro

TECHNIQUES

bull TREATMENT OF SOFT PARTS bull MUSCULAR STRETCHING bull REPEATED INTERVENTIONS bull MANIPULATION (3 STAGES)

Place in position Apply tension Manipulative thrust (low amplitude high velocity)

ldquoIT IS A NON-SYMPTOMATIC CAUSAL THERAPYrdquo

Mechanism of action of Vertebral Manipulation

bull Stretching and distension of the posterior joint capsule has a powerful inhibitory effect on muscle contraction (analgesic contraction) The hypotonic Gamma is determined by the stimulation of the periarticular receptors activated by the manipulative manoeuvre and results in a rapid and powerful ldquoINHIBITORY REFLEXrdquo through the contraction of the intervertebral musculature (DDIM)

bull With Vertebral Manipulation abruptly stretching structures such as ligaments discs joint capsules or muscles activates the descending system of nociceptive inhibition of pain in cases where this originates at the level of the grey matter

J Electromyogr Kinesiol 2012 Oct 22(5) 785ndash794Published online 2012 Feb 19 doi Spinal Manipulative Therapy and Somatosensory Activation Joel G Pickar DC PhD1 and Philip S Bolton DC PhD2 Dott Salvatore Denaro

Mesotherapy and Prolotherapy

Mesotherapy (MPistor) is an excellent analgesic therapy which uses a single needle or multi-injector as detailed by colleagues in the SFM (Socieacuteteacute Franccedilaise de Meacutesotheacuterapie)

Neuroprolotherapy (NPT) is a method of treatment which is distinct and separate from Prolotherapy from which it was evolved Developed since 2002 by New Zealander Dr John Lyftogt it targets the superficial sensory nerves of the body with micro-injections of low concentration glucose (5)

Dott Salvatore Denaro

Dry needling Annals of the Rheumatic Diseases 74(Suppl 2)624 middot June 2015 RV Bubnov

bull Very similar to acupuncture but treats the trigger points and myalgic intramuscular cords

bull It provides pinpoint mechanical stimulation

bull It provides both intramuscular and superficial stimulation

bull Precise laquoPain pointsraquo can be treated

Hyuk Ga Ji-Ho Choi Chang-Hae Park Hyun-Jung Yoon Acupuncture needling versus lidocaine injection of trigger points in myofascial pain syndrome in elderly patients ndash a randomised trial Acupuncture in Medicine Dec 2007

Dott Salvatore Denaro

TREATMENT OF PAIN in Orthopaedic Medicine

Dott Salvatore Denaro

ELECTROANALGESIA Based on Melzack and Wallrsquos theory of gate control which

describes two types of intervention for pain control

the first consists of reinforcing the the inhibitory power of large fibers the second aims selectively to interrupt the communication of small calibre fibers near the posterior horns (where the peripheral terminations are connected to the main neural pathways of communication to the brain)

Dott Salvatore Denaro

ELECTROANALGESIA TENS

ldquoTranscutaneous Electrical Nerve Stimulationrdquo is characterised by the fact that the electrodes are applied directly to the skin above the path of the

nerve trunk causing paresthesia in the area of the stimulated nerve distribution

Low frequency currents are used rectangular in shape which have an analgesic effect with

modalities that are not perfectly defined

Using TENS for pain control the state of the evidence Vance CG1 Dailey DL Rakel BA Sluka KA Pain Manag 2014 May4(3)197-209

Dott Salvatore Denaro

Non surgical laser therapy In analgesic therapy the ideal laser emission

instrument is one which uses a semiconductor diode as its active medium emitting invisible bursts of

radiation delivered in extremely short pulses typically within the infrared (IR) band with a

wavelength of approximately 904 nanometres ie the IR laser Other options include He-Ne CO2

Neodimio Yag and HILT

low levels of evidence

Eur J Phys Rehabil Med 2017 Aug53(4)603-610 Epub 2017 Jan 30 Effects of low-level laser therapy on pain in patients with musculoskeletal disorders a systematic review and meta-analysis Clijsen R123 Brunner A4 Barbero M4 Clarys P5 Taeymans J56

MOJ Orthop Rheumatol 20152(5) Epub 2015 Jun 9 The Use of Low Level Laser Therapy (LLLT) For Musculoskeletal Pain Cotler HB1 Chow RT2 Hamblin MR3 Carroll J4

Dott Salvatore Denaro

Biological Effects of LASER THERAPY an increase in the speed of mitosis temporary and reversible tissue dehydration denaturation of proteins thermolysis

carbonization for focal CO2 tissue evaporation

Physiotherapeutic lasers essentially produce two effects analgesic anti edema and biostimulant

Heat Therapy (Thermotherapy)

bull Heat action on the gate-control of MampW There is limited overall evidence to support the general use of localized heat however randomised clinical trials (RCTs) have shown that heat therapy provides short-term reductions in pain and disability in patients with acute lower back pain and provides significantly greater pain relief from DOMS than cold therapy (Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury Gerard A Malanga Ning Yan amp Jill Stark Oct 2014) PubMedgov

bull Cold reduction of tissue temperature which subsequently exerts local effects on blood flow on cell swelling and on metabolism and speed of neural conduction (Cold-water immersion and other forms of cryotherapy physiological changes potentially affecting recovery from high-intensity exercise Gillian E White and Greg D Wells Email author Extreme Physiology amp Medicine 2013 )

Dott Salvatore Denaro

KRYO TECAR

Mechanotherapy vibration

bull CONTROL OF MUSCULAR STIFFNESS (tonic reflex from vibration)

bull STIMULATION OF BLOOD LYMPHATIC CIRCULATION

bull PAIN RELIEF (gate control)

bull INCREASED SENSITIVITY

Bibliographic details Wang P Yang X Yang Y Yang L Zhou Y Liu C Reinhardt JD He C Effects of whole body vibration on pain stiffness and physical functions in patients with knee osteoarthritis a systematic review and meta-analysis Clinical Rehabilitation 2014 epub [PubMed] Dott Salvatore Denaro

Impact Waves bull 1 direct effect of the impulse on the tissue

in the target area and in conjunction with the reflection phenomena more accentuated in the points of transition between soft tissue (tendons muscles) and more compact tissues (bones and calcification formations)

bull 2 indirect effect of ldquocavitationrdquo caused by the subsequent depression of the impulse which exceeds the elastic characteristics of the tissue

NO DIRECT EFFECT ON PAIN MODULATORS OF BIOLOGICAL FUNCTIONS IN HUMAN MUSCLE CELLS (J Orthop Surg Res 2018 Apr 613(1)75 Exposure to radial extracorporeal shock waves modulates viability and gene expression of human skeletal muscle cells a controlled in vitro study Mattyasovszky SG1 Langendorf EK2 Ritz U2 Schmitz C3 Schmidtmann I4 Nowak TE2 Wagner D2 Hofmann A2 Rommens PM2 Drees P2)

RADIALI

FOCALI

Dott Salvatore Denaro

Ion Cyclotron Resonance Quantum Molecular Resonance

bull Stimulates the biological functions of cells bull Rebalances the correct membrane potential bull Activates enzymatic processes bull Restores the correct ion exchange for cell metabolism bull Promotes intra-extra cellular ion balance

Operating principle based on Quantum Molecular Resonance with the application of high-frequency and low-power micro-currents Induces the regeneration of damaged tissues especially muscular tissues without thermal effects

Dott Salvatore Denaro

Dott Salvatore Denaro

KINESIOTHERAPY IS NECESSARY

bull WITH REGARD TO ARTICULAR LINKS ndash JOINT PLAY ndash STRUCTURAL INTEGRITY OF THE CARTILAGE CAPSULE

AND LIGAMENTS ndash CORRECT MUSCLE SYNERGY ndash ELIMINATION OF FUNCTIONAL COMPENSATIONS

bull PAIN CONTROL bull NO CONTRAINDICATION

Dott Salvatore Denaro

KINESIOTHERAPY

bull POSTURAL Aims to correct any negative issues of posture (often secondary to analgesic compensatory attitudes) to detect alterations in the knee and calcaneal axis and of the plantar support visual disturbance dental malocclusion dysmetria of the pelvis etc

Dott Salvatore Denaro

KINESIOTHERAPY

bull HYDRO-KINESIOTHERAPY Very useful in cases of rheumatic diseases Therapeutic exercise in water is facilitated by the option to regulate water temperature and by the reduction in gravitational force which this medium allows

Dott Salvatore Denaro

VERTEBRAL MANIPULATION Robert Maignersquos ldquoManu Medicardquo

bull SEMIOTICS NATURE OF ILLNESS OR PATHOLOGY (clinical examination

imaging laboratory etc) ANALYSIS OF MINOR INTERVERTEBRAL DISTURBANCE

(ROM DDIM SCTM according to R Maignersquos research into signs of functional limitations)

bull THERAPY Principles RULE OF NO PAIN AND OF CONTRARY MOVEMENT VERIFICATION OF EVERY MANIPULATION BEFORE

PERFORMING THE NEXT

Dott Salvatore Denaro

TECHNIQUES

bull TREATMENT OF SOFT PARTS bull MUSCULAR STRETCHING bull REPEATED INTERVENTIONS bull MANIPULATION (3 STAGES)

Place in position Apply tension Manipulative thrust (low amplitude high velocity)

ldquoIT IS A NON-SYMPTOMATIC CAUSAL THERAPYrdquo

Mechanism of action of Vertebral Manipulation

bull Stretching and distension of the posterior joint capsule has a powerful inhibitory effect on muscle contraction (analgesic contraction) The hypotonic Gamma is determined by the stimulation of the periarticular receptors activated by the manipulative manoeuvre and results in a rapid and powerful ldquoINHIBITORY REFLEXrdquo through the contraction of the intervertebral musculature (DDIM)

bull With Vertebral Manipulation abruptly stretching structures such as ligaments discs joint capsules or muscles activates the descending system of nociceptive inhibition of pain in cases where this originates at the level of the grey matter

J Electromyogr Kinesiol 2012 Oct 22(5) 785ndash794Published online 2012 Feb 19 doi Spinal Manipulative Therapy and Somatosensory Activation Joel G Pickar DC PhD1 and Philip S Bolton DC PhD2 Dott Salvatore Denaro

Dry needling Annals of the Rheumatic Diseases 74(Suppl 2)624 middot June 2015 RV Bubnov

bull Very similar to acupuncture but treats the trigger points and myalgic intramuscular cords

bull It provides pinpoint mechanical stimulation

bull It provides both intramuscular and superficial stimulation

bull Precise laquoPain pointsraquo can be treated

Hyuk Ga Ji-Ho Choi Chang-Hae Park Hyun-Jung Yoon Acupuncture needling versus lidocaine injection of trigger points in myofascial pain syndrome in elderly patients ndash a randomised trial Acupuncture in Medicine Dec 2007

Dott Salvatore Denaro

TREATMENT OF PAIN in Orthopaedic Medicine

Dott Salvatore Denaro

ELECTROANALGESIA Based on Melzack and Wallrsquos theory of gate control which

describes two types of intervention for pain control

the first consists of reinforcing the the inhibitory power of large fibers the second aims selectively to interrupt the communication of small calibre fibers near the posterior horns (where the peripheral terminations are connected to the main neural pathways of communication to the brain)

Dott Salvatore Denaro

ELECTROANALGESIA TENS

ldquoTranscutaneous Electrical Nerve Stimulationrdquo is characterised by the fact that the electrodes are applied directly to the skin above the path of the

nerve trunk causing paresthesia in the area of the stimulated nerve distribution

Low frequency currents are used rectangular in shape which have an analgesic effect with

modalities that are not perfectly defined

Using TENS for pain control the state of the evidence Vance CG1 Dailey DL Rakel BA Sluka KA Pain Manag 2014 May4(3)197-209

Dott Salvatore Denaro

Non surgical laser therapy In analgesic therapy the ideal laser emission

instrument is one which uses a semiconductor diode as its active medium emitting invisible bursts of

radiation delivered in extremely short pulses typically within the infrared (IR) band with a

wavelength of approximately 904 nanometres ie the IR laser Other options include He-Ne CO2

Neodimio Yag and HILT

low levels of evidence

Eur J Phys Rehabil Med 2017 Aug53(4)603-610 Epub 2017 Jan 30 Effects of low-level laser therapy on pain in patients with musculoskeletal disorders a systematic review and meta-analysis Clijsen R123 Brunner A4 Barbero M4 Clarys P5 Taeymans J56

MOJ Orthop Rheumatol 20152(5) Epub 2015 Jun 9 The Use of Low Level Laser Therapy (LLLT) For Musculoskeletal Pain Cotler HB1 Chow RT2 Hamblin MR3 Carroll J4

Dott Salvatore Denaro

Biological Effects of LASER THERAPY an increase in the speed of mitosis temporary and reversible tissue dehydration denaturation of proteins thermolysis

carbonization for focal CO2 tissue evaporation

Physiotherapeutic lasers essentially produce two effects analgesic anti edema and biostimulant

Heat Therapy (Thermotherapy)

bull Heat action on the gate-control of MampW There is limited overall evidence to support the general use of localized heat however randomised clinical trials (RCTs) have shown that heat therapy provides short-term reductions in pain and disability in patients with acute lower back pain and provides significantly greater pain relief from DOMS than cold therapy (Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury Gerard A Malanga Ning Yan amp Jill Stark Oct 2014) PubMedgov

bull Cold reduction of tissue temperature which subsequently exerts local effects on blood flow on cell swelling and on metabolism and speed of neural conduction (Cold-water immersion and other forms of cryotherapy physiological changes potentially affecting recovery from high-intensity exercise Gillian E White and Greg D Wells Email author Extreme Physiology amp Medicine 2013 )

Dott Salvatore Denaro

KRYO TECAR

Mechanotherapy vibration

bull CONTROL OF MUSCULAR STIFFNESS (tonic reflex from vibration)

bull STIMULATION OF BLOOD LYMPHATIC CIRCULATION

bull PAIN RELIEF (gate control)

bull INCREASED SENSITIVITY

Bibliographic details Wang P Yang X Yang Y Yang L Zhou Y Liu C Reinhardt JD He C Effects of whole body vibration on pain stiffness and physical functions in patients with knee osteoarthritis a systematic review and meta-analysis Clinical Rehabilitation 2014 epub [PubMed] Dott Salvatore Denaro

Impact Waves bull 1 direct effect of the impulse on the tissue

in the target area and in conjunction with the reflection phenomena more accentuated in the points of transition between soft tissue (tendons muscles) and more compact tissues (bones and calcification formations)

bull 2 indirect effect of ldquocavitationrdquo caused by the subsequent depression of the impulse which exceeds the elastic characteristics of the tissue

NO DIRECT EFFECT ON PAIN MODULATORS OF BIOLOGICAL FUNCTIONS IN HUMAN MUSCLE CELLS (J Orthop Surg Res 2018 Apr 613(1)75 Exposure to radial extracorporeal shock waves modulates viability and gene expression of human skeletal muscle cells a controlled in vitro study Mattyasovszky SG1 Langendorf EK2 Ritz U2 Schmitz C3 Schmidtmann I4 Nowak TE2 Wagner D2 Hofmann A2 Rommens PM2 Drees P2)

RADIALI

FOCALI

Dott Salvatore Denaro

Ion Cyclotron Resonance Quantum Molecular Resonance

bull Stimulates the biological functions of cells bull Rebalances the correct membrane potential bull Activates enzymatic processes bull Restores the correct ion exchange for cell metabolism bull Promotes intra-extra cellular ion balance

Operating principle based on Quantum Molecular Resonance with the application of high-frequency and low-power micro-currents Induces the regeneration of damaged tissues especially muscular tissues without thermal effects

Dott Salvatore Denaro

Dott Salvatore Denaro

KINESIOTHERAPY IS NECESSARY

bull WITH REGARD TO ARTICULAR LINKS ndash JOINT PLAY ndash STRUCTURAL INTEGRITY OF THE CARTILAGE CAPSULE

AND LIGAMENTS ndash CORRECT MUSCLE SYNERGY ndash ELIMINATION OF FUNCTIONAL COMPENSATIONS

bull PAIN CONTROL bull NO CONTRAINDICATION

Dott Salvatore Denaro

KINESIOTHERAPY

bull POSTURAL Aims to correct any negative issues of posture (often secondary to analgesic compensatory attitudes) to detect alterations in the knee and calcaneal axis and of the plantar support visual disturbance dental malocclusion dysmetria of the pelvis etc

Dott Salvatore Denaro

KINESIOTHERAPY

bull HYDRO-KINESIOTHERAPY Very useful in cases of rheumatic diseases Therapeutic exercise in water is facilitated by the option to regulate water temperature and by the reduction in gravitational force which this medium allows

Dott Salvatore Denaro

VERTEBRAL MANIPULATION Robert Maignersquos ldquoManu Medicardquo

bull SEMIOTICS NATURE OF ILLNESS OR PATHOLOGY (clinical examination

imaging laboratory etc) ANALYSIS OF MINOR INTERVERTEBRAL DISTURBANCE

(ROM DDIM SCTM according to R Maignersquos research into signs of functional limitations)

bull THERAPY Principles RULE OF NO PAIN AND OF CONTRARY MOVEMENT VERIFICATION OF EVERY MANIPULATION BEFORE

PERFORMING THE NEXT

Dott Salvatore Denaro

TECHNIQUES

bull TREATMENT OF SOFT PARTS bull MUSCULAR STRETCHING bull REPEATED INTERVENTIONS bull MANIPULATION (3 STAGES)

Place in position Apply tension Manipulative thrust (low amplitude high velocity)

ldquoIT IS A NON-SYMPTOMATIC CAUSAL THERAPYrdquo

Mechanism of action of Vertebral Manipulation

bull Stretching and distension of the posterior joint capsule has a powerful inhibitory effect on muscle contraction (analgesic contraction) The hypotonic Gamma is determined by the stimulation of the periarticular receptors activated by the manipulative manoeuvre and results in a rapid and powerful ldquoINHIBITORY REFLEXrdquo through the contraction of the intervertebral musculature (DDIM)

bull With Vertebral Manipulation abruptly stretching structures such as ligaments discs joint capsules or muscles activates the descending system of nociceptive inhibition of pain in cases where this originates at the level of the grey matter

J Electromyogr Kinesiol 2012 Oct 22(5) 785ndash794Published online 2012 Feb 19 doi Spinal Manipulative Therapy and Somatosensory Activation Joel G Pickar DC PhD1 and Philip S Bolton DC PhD2 Dott Salvatore Denaro

Dott Salvatore Denaro

TREATMENT OF PAIN in Orthopaedic Medicine

Dott Salvatore Denaro

ELECTROANALGESIA Based on Melzack and Wallrsquos theory of gate control which

describes two types of intervention for pain control

the first consists of reinforcing the the inhibitory power of large fibers the second aims selectively to interrupt the communication of small calibre fibers near the posterior horns (where the peripheral terminations are connected to the main neural pathways of communication to the brain)

Dott Salvatore Denaro

ELECTROANALGESIA TENS

ldquoTranscutaneous Electrical Nerve Stimulationrdquo is characterised by the fact that the electrodes are applied directly to the skin above the path of the

nerve trunk causing paresthesia in the area of the stimulated nerve distribution

Low frequency currents are used rectangular in shape which have an analgesic effect with

modalities that are not perfectly defined

Using TENS for pain control the state of the evidence Vance CG1 Dailey DL Rakel BA Sluka KA Pain Manag 2014 May4(3)197-209

Dott Salvatore Denaro

Non surgical laser therapy In analgesic therapy the ideal laser emission

instrument is one which uses a semiconductor diode as its active medium emitting invisible bursts of

radiation delivered in extremely short pulses typically within the infrared (IR) band with a

wavelength of approximately 904 nanometres ie the IR laser Other options include He-Ne CO2

Neodimio Yag and HILT

low levels of evidence

Eur J Phys Rehabil Med 2017 Aug53(4)603-610 Epub 2017 Jan 30 Effects of low-level laser therapy on pain in patients with musculoskeletal disorders a systematic review and meta-analysis Clijsen R123 Brunner A4 Barbero M4 Clarys P5 Taeymans J56

MOJ Orthop Rheumatol 20152(5) Epub 2015 Jun 9 The Use of Low Level Laser Therapy (LLLT) For Musculoskeletal Pain Cotler HB1 Chow RT2 Hamblin MR3 Carroll J4

Dott Salvatore Denaro

Biological Effects of LASER THERAPY an increase in the speed of mitosis temporary and reversible tissue dehydration denaturation of proteins thermolysis

carbonization for focal CO2 tissue evaporation

Physiotherapeutic lasers essentially produce two effects analgesic anti edema and biostimulant

Heat Therapy (Thermotherapy)

bull Heat action on the gate-control of MampW There is limited overall evidence to support the general use of localized heat however randomised clinical trials (RCTs) have shown that heat therapy provides short-term reductions in pain and disability in patients with acute lower back pain and provides significantly greater pain relief from DOMS than cold therapy (Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury Gerard A Malanga Ning Yan amp Jill Stark Oct 2014) PubMedgov

bull Cold reduction of tissue temperature which subsequently exerts local effects on blood flow on cell swelling and on metabolism and speed of neural conduction (Cold-water immersion and other forms of cryotherapy physiological changes potentially affecting recovery from high-intensity exercise Gillian E White and Greg D Wells Email author Extreme Physiology amp Medicine 2013 )

Dott Salvatore Denaro

KRYO TECAR

Mechanotherapy vibration

bull CONTROL OF MUSCULAR STIFFNESS (tonic reflex from vibration)

bull STIMULATION OF BLOOD LYMPHATIC CIRCULATION

bull PAIN RELIEF (gate control)

bull INCREASED SENSITIVITY

Bibliographic details Wang P Yang X Yang Y Yang L Zhou Y Liu C Reinhardt JD He C Effects of whole body vibration on pain stiffness and physical functions in patients with knee osteoarthritis a systematic review and meta-analysis Clinical Rehabilitation 2014 epub [PubMed] Dott Salvatore Denaro

Impact Waves bull 1 direct effect of the impulse on the tissue

in the target area and in conjunction with the reflection phenomena more accentuated in the points of transition between soft tissue (tendons muscles) and more compact tissues (bones and calcification formations)

bull 2 indirect effect of ldquocavitationrdquo caused by the subsequent depression of the impulse which exceeds the elastic characteristics of the tissue

NO DIRECT EFFECT ON PAIN MODULATORS OF BIOLOGICAL FUNCTIONS IN HUMAN MUSCLE CELLS (J Orthop Surg Res 2018 Apr 613(1)75 Exposure to radial extracorporeal shock waves modulates viability and gene expression of human skeletal muscle cells a controlled in vitro study Mattyasovszky SG1 Langendorf EK2 Ritz U2 Schmitz C3 Schmidtmann I4 Nowak TE2 Wagner D2 Hofmann A2 Rommens PM2 Drees P2)

RADIALI

FOCALI

Dott Salvatore Denaro

Ion Cyclotron Resonance Quantum Molecular Resonance

bull Stimulates the biological functions of cells bull Rebalances the correct membrane potential bull Activates enzymatic processes bull Restores the correct ion exchange for cell metabolism bull Promotes intra-extra cellular ion balance

Operating principle based on Quantum Molecular Resonance with the application of high-frequency and low-power micro-currents Induces the regeneration of damaged tissues especially muscular tissues without thermal effects

Dott Salvatore Denaro

Dott Salvatore Denaro

KINESIOTHERAPY IS NECESSARY

bull WITH REGARD TO ARTICULAR LINKS ndash JOINT PLAY ndash STRUCTURAL INTEGRITY OF THE CARTILAGE CAPSULE

AND LIGAMENTS ndash CORRECT MUSCLE SYNERGY ndash ELIMINATION OF FUNCTIONAL COMPENSATIONS

bull PAIN CONTROL bull NO CONTRAINDICATION

Dott Salvatore Denaro

KINESIOTHERAPY

bull POSTURAL Aims to correct any negative issues of posture (often secondary to analgesic compensatory attitudes) to detect alterations in the knee and calcaneal axis and of the plantar support visual disturbance dental malocclusion dysmetria of the pelvis etc

Dott Salvatore Denaro

KINESIOTHERAPY

bull HYDRO-KINESIOTHERAPY Very useful in cases of rheumatic diseases Therapeutic exercise in water is facilitated by the option to regulate water temperature and by the reduction in gravitational force which this medium allows

Dott Salvatore Denaro

VERTEBRAL MANIPULATION Robert Maignersquos ldquoManu Medicardquo

bull SEMIOTICS NATURE OF ILLNESS OR PATHOLOGY (clinical examination

imaging laboratory etc) ANALYSIS OF MINOR INTERVERTEBRAL DISTURBANCE

(ROM DDIM SCTM according to R Maignersquos research into signs of functional limitations)

bull THERAPY Principles RULE OF NO PAIN AND OF CONTRARY MOVEMENT VERIFICATION OF EVERY MANIPULATION BEFORE

PERFORMING THE NEXT

Dott Salvatore Denaro

TECHNIQUES

bull TREATMENT OF SOFT PARTS bull MUSCULAR STRETCHING bull REPEATED INTERVENTIONS bull MANIPULATION (3 STAGES)

Place in position Apply tension Manipulative thrust (low amplitude high velocity)

ldquoIT IS A NON-SYMPTOMATIC CAUSAL THERAPYrdquo

Mechanism of action of Vertebral Manipulation

bull Stretching and distension of the posterior joint capsule has a powerful inhibitory effect on muscle contraction (analgesic contraction) The hypotonic Gamma is determined by the stimulation of the periarticular receptors activated by the manipulative manoeuvre and results in a rapid and powerful ldquoINHIBITORY REFLEXrdquo through the contraction of the intervertebral musculature (DDIM)

bull With Vertebral Manipulation abruptly stretching structures such as ligaments discs joint capsules or muscles activates the descending system of nociceptive inhibition of pain in cases where this originates at the level of the grey matter

J Electromyogr Kinesiol 2012 Oct 22(5) 785ndash794Published online 2012 Feb 19 doi Spinal Manipulative Therapy and Somatosensory Activation Joel G Pickar DC PhD1 and Philip S Bolton DC PhD2 Dott Salvatore Denaro

Dott Salvatore Denaro

ELECTROANALGESIA Based on Melzack and Wallrsquos theory of gate control which

describes two types of intervention for pain control

the first consists of reinforcing the the inhibitory power of large fibers the second aims selectively to interrupt the communication of small calibre fibers near the posterior horns (where the peripheral terminations are connected to the main neural pathways of communication to the brain)

Dott Salvatore Denaro

ELECTROANALGESIA TENS

ldquoTranscutaneous Electrical Nerve Stimulationrdquo is characterised by the fact that the electrodes are applied directly to the skin above the path of the

nerve trunk causing paresthesia in the area of the stimulated nerve distribution

Low frequency currents are used rectangular in shape which have an analgesic effect with

modalities that are not perfectly defined

Using TENS for pain control the state of the evidence Vance CG1 Dailey DL Rakel BA Sluka KA Pain Manag 2014 May4(3)197-209

Dott Salvatore Denaro

Non surgical laser therapy In analgesic therapy the ideal laser emission

instrument is one which uses a semiconductor diode as its active medium emitting invisible bursts of

radiation delivered in extremely short pulses typically within the infrared (IR) band with a

wavelength of approximately 904 nanometres ie the IR laser Other options include He-Ne CO2

Neodimio Yag and HILT

low levels of evidence

Eur J Phys Rehabil Med 2017 Aug53(4)603-610 Epub 2017 Jan 30 Effects of low-level laser therapy on pain in patients with musculoskeletal disorders a systematic review and meta-analysis Clijsen R123 Brunner A4 Barbero M4 Clarys P5 Taeymans J56

MOJ Orthop Rheumatol 20152(5) Epub 2015 Jun 9 The Use of Low Level Laser Therapy (LLLT) For Musculoskeletal Pain Cotler HB1 Chow RT2 Hamblin MR3 Carroll J4

Dott Salvatore Denaro

Biological Effects of LASER THERAPY an increase in the speed of mitosis temporary and reversible tissue dehydration denaturation of proteins thermolysis

carbonization for focal CO2 tissue evaporation

Physiotherapeutic lasers essentially produce two effects analgesic anti edema and biostimulant

Heat Therapy (Thermotherapy)

bull Heat action on the gate-control of MampW There is limited overall evidence to support the general use of localized heat however randomised clinical trials (RCTs) have shown that heat therapy provides short-term reductions in pain and disability in patients with acute lower back pain and provides significantly greater pain relief from DOMS than cold therapy (Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury Gerard A Malanga Ning Yan amp Jill Stark Oct 2014) PubMedgov

bull Cold reduction of tissue temperature which subsequently exerts local effects on blood flow on cell swelling and on metabolism and speed of neural conduction (Cold-water immersion and other forms of cryotherapy physiological changes potentially affecting recovery from high-intensity exercise Gillian E White and Greg D Wells Email author Extreme Physiology amp Medicine 2013 )

Dott Salvatore Denaro

KRYO TECAR

Mechanotherapy vibration

bull CONTROL OF MUSCULAR STIFFNESS (tonic reflex from vibration)

bull STIMULATION OF BLOOD LYMPHATIC CIRCULATION

bull PAIN RELIEF (gate control)

bull INCREASED SENSITIVITY

Bibliographic details Wang P Yang X Yang Y Yang L Zhou Y Liu C Reinhardt JD He C Effects of whole body vibration on pain stiffness and physical functions in patients with knee osteoarthritis a systematic review and meta-analysis Clinical Rehabilitation 2014 epub [PubMed] Dott Salvatore Denaro

Impact Waves bull 1 direct effect of the impulse on the tissue

in the target area and in conjunction with the reflection phenomena more accentuated in the points of transition between soft tissue (tendons muscles) and more compact tissues (bones and calcification formations)

bull 2 indirect effect of ldquocavitationrdquo caused by the subsequent depression of the impulse which exceeds the elastic characteristics of the tissue

NO DIRECT EFFECT ON PAIN MODULATORS OF BIOLOGICAL FUNCTIONS IN HUMAN MUSCLE CELLS (J Orthop Surg Res 2018 Apr 613(1)75 Exposure to radial extracorporeal shock waves modulates viability and gene expression of human skeletal muscle cells a controlled in vitro study Mattyasovszky SG1 Langendorf EK2 Ritz U2 Schmitz C3 Schmidtmann I4 Nowak TE2 Wagner D2 Hofmann A2 Rommens PM2 Drees P2)

RADIALI

FOCALI

Dott Salvatore Denaro

Ion Cyclotron Resonance Quantum Molecular Resonance

bull Stimulates the biological functions of cells bull Rebalances the correct membrane potential bull Activates enzymatic processes bull Restores the correct ion exchange for cell metabolism bull Promotes intra-extra cellular ion balance

Operating principle based on Quantum Molecular Resonance with the application of high-frequency and low-power micro-currents Induces the regeneration of damaged tissues especially muscular tissues without thermal effects

Dott Salvatore Denaro

Dott Salvatore Denaro

KINESIOTHERAPY IS NECESSARY

bull WITH REGARD TO ARTICULAR LINKS ndash JOINT PLAY ndash STRUCTURAL INTEGRITY OF THE CARTILAGE CAPSULE

AND LIGAMENTS ndash CORRECT MUSCLE SYNERGY ndash ELIMINATION OF FUNCTIONAL COMPENSATIONS

bull PAIN CONTROL bull NO CONTRAINDICATION

Dott Salvatore Denaro

KINESIOTHERAPY

bull POSTURAL Aims to correct any negative issues of posture (often secondary to analgesic compensatory attitudes) to detect alterations in the knee and calcaneal axis and of the plantar support visual disturbance dental malocclusion dysmetria of the pelvis etc

Dott Salvatore Denaro

KINESIOTHERAPY

bull HYDRO-KINESIOTHERAPY Very useful in cases of rheumatic diseases Therapeutic exercise in water is facilitated by the option to regulate water temperature and by the reduction in gravitational force which this medium allows

Dott Salvatore Denaro

VERTEBRAL MANIPULATION Robert Maignersquos ldquoManu Medicardquo

bull SEMIOTICS NATURE OF ILLNESS OR PATHOLOGY (clinical examination

imaging laboratory etc) ANALYSIS OF MINOR INTERVERTEBRAL DISTURBANCE

(ROM DDIM SCTM according to R Maignersquos research into signs of functional limitations)

bull THERAPY Principles RULE OF NO PAIN AND OF CONTRARY MOVEMENT VERIFICATION OF EVERY MANIPULATION BEFORE

PERFORMING THE NEXT

Dott Salvatore Denaro

TECHNIQUES

bull TREATMENT OF SOFT PARTS bull MUSCULAR STRETCHING bull REPEATED INTERVENTIONS bull MANIPULATION (3 STAGES)

Place in position Apply tension Manipulative thrust (low amplitude high velocity)

ldquoIT IS A NON-SYMPTOMATIC CAUSAL THERAPYrdquo

Mechanism of action of Vertebral Manipulation

bull Stretching and distension of the posterior joint capsule has a powerful inhibitory effect on muscle contraction (analgesic contraction) The hypotonic Gamma is determined by the stimulation of the periarticular receptors activated by the manipulative manoeuvre and results in a rapid and powerful ldquoINHIBITORY REFLEXrdquo through the contraction of the intervertebral musculature (DDIM)

bull With Vertebral Manipulation abruptly stretching structures such as ligaments discs joint capsules or muscles activates the descending system of nociceptive inhibition of pain in cases where this originates at the level of the grey matter

J Electromyogr Kinesiol 2012 Oct 22(5) 785ndash794Published online 2012 Feb 19 doi Spinal Manipulative Therapy and Somatosensory Activation Joel G Pickar DC PhD1 and Philip S Bolton DC PhD2 Dott Salvatore Denaro

Dott Salvatore Denaro

ELECTROANALGESIA TENS

ldquoTranscutaneous Electrical Nerve Stimulationrdquo is characterised by the fact that the electrodes are applied directly to the skin above the path of the

nerve trunk causing paresthesia in the area of the stimulated nerve distribution

Low frequency currents are used rectangular in shape which have an analgesic effect with

modalities that are not perfectly defined

Using TENS for pain control the state of the evidence Vance CG1 Dailey DL Rakel BA Sluka KA Pain Manag 2014 May4(3)197-209

Dott Salvatore Denaro

Non surgical laser therapy In analgesic therapy the ideal laser emission

instrument is one which uses a semiconductor diode as its active medium emitting invisible bursts of

radiation delivered in extremely short pulses typically within the infrared (IR) band with a

wavelength of approximately 904 nanometres ie the IR laser Other options include He-Ne CO2

Neodimio Yag and HILT

low levels of evidence

Eur J Phys Rehabil Med 2017 Aug53(4)603-610 Epub 2017 Jan 30 Effects of low-level laser therapy on pain in patients with musculoskeletal disorders a systematic review and meta-analysis Clijsen R123 Brunner A4 Barbero M4 Clarys P5 Taeymans J56

MOJ Orthop Rheumatol 20152(5) Epub 2015 Jun 9 The Use of Low Level Laser Therapy (LLLT) For Musculoskeletal Pain Cotler HB1 Chow RT2 Hamblin MR3 Carroll J4

Dott Salvatore Denaro

Biological Effects of LASER THERAPY an increase in the speed of mitosis temporary and reversible tissue dehydration denaturation of proteins thermolysis

carbonization for focal CO2 tissue evaporation

Physiotherapeutic lasers essentially produce two effects analgesic anti edema and biostimulant

Heat Therapy (Thermotherapy)

bull Heat action on the gate-control of MampW There is limited overall evidence to support the general use of localized heat however randomised clinical trials (RCTs) have shown that heat therapy provides short-term reductions in pain and disability in patients with acute lower back pain and provides significantly greater pain relief from DOMS than cold therapy (Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury Gerard A Malanga Ning Yan amp Jill Stark Oct 2014) PubMedgov

bull Cold reduction of tissue temperature which subsequently exerts local effects on blood flow on cell swelling and on metabolism and speed of neural conduction (Cold-water immersion and other forms of cryotherapy physiological changes potentially affecting recovery from high-intensity exercise Gillian E White and Greg D Wells Email author Extreme Physiology amp Medicine 2013 )

Dott Salvatore Denaro

KRYO TECAR

Mechanotherapy vibration

bull CONTROL OF MUSCULAR STIFFNESS (tonic reflex from vibration)

bull STIMULATION OF BLOOD LYMPHATIC CIRCULATION

bull PAIN RELIEF (gate control)

bull INCREASED SENSITIVITY

Bibliographic details Wang P Yang X Yang Y Yang L Zhou Y Liu C Reinhardt JD He C Effects of whole body vibration on pain stiffness and physical functions in patients with knee osteoarthritis a systematic review and meta-analysis Clinical Rehabilitation 2014 epub [PubMed] Dott Salvatore Denaro

Impact Waves bull 1 direct effect of the impulse on the tissue

in the target area and in conjunction with the reflection phenomena more accentuated in the points of transition between soft tissue (tendons muscles) and more compact tissues (bones and calcification formations)

bull 2 indirect effect of ldquocavitationrdquo caused by the subsequent depression of the impulse which exceeds the elastic characteristics of the tissue

NO DIRECT EFFECT ON PAIN MODULATORS OF BIOLOGICAL FUNCTIONS IN HUMAN MUSCLE CELLS (J Orthop Surg Res 2018 Apr 613(1)75 Exposure to radial extracorporeal shock waves modulates viability and gene expression of human skeletal muscle cells a controlled in vitro study Mattyasovszky SG1 Langendorf EK2 Ritz U2 Schmitz C3 Schmidtmann I4 Nowak TE2 Wagner D2 Hofmann A2 Rommens PM2 Drees P2)

RADIALI

FOCALI

Dott Salvatore Denaro

Ion Cyclotron Resonance Quantum Molecular Resonance

bull Stimulates the biological functions of cells bull Rebalances the correct membrane potential bull Activates enzymatic processes bull Restores the correct ion exchange for cell metabolism bull Promotes intra-extra cellular ion balance

Operating principle based on Quantum Molecular Resonance with the application of high-frequency and low-power micro-currents Induces the regeneration of damaged tissues especially muscular tissues without thermal effects

Dott Salvatore Denaro

Dott Salvatore Denaro

KINESIOTHERAPY IS NECESSARY

bull WITH REGARD TO ARTICULAR LINKS ndash JOINT PLAY ndash STRUCTURAL INTEGRITY OF THE CARTILAGE CAPSULE

AND LIGAMENTS ndash CORRECT MUSCLE SYNERGY ndash ELIMINATION OF FUNCTIONAL COMPENSATIONS

bull PAIN CONTROL bull NO CONTRAINDICATION

Dott Salvatore Denaro

KINESIOTHERAPY

bull POSTURAL Aims to correct any negative issues of posture (often secondary to analgesic compensatory attitudes) to detect alterations in the knee and calcaneal axis and of the plantar support visual disturbance dental malocclusion dysmetria of the pelvis etc

Dott Salvatore Denaro

KINESIOTHERAPY

bull HYDRO-KINESIOTHERAPY Very useful in cases of rheumatic diseases Therapeutic exercise in water is facilitated by the option to regulate water temperature and by the reduction in gravitational force which this medium allows

Dott Salvatore Denaro

VERTEBRAL MANIPULATION Robert Maignersquos ldquoManu Medicardquo

bull SEMIOTICS NATURE OF ILLNESS OR PATHOLOGY (clinical examination

imaging laboratory etc) ANALYSIS OF MINOR INTERVERTEBRAL DISTURBANCE

(ROM DDIM SCTM according to R Maignersquos research into signs of functional limitations)

bull THERAPY Principles RULE OF NO PAIN AND OF CONTRARY MOVEMENT VERIFICATION OF EVERY MANIPULATION BEFORE

PERFORMING THE NEXT

Dott Salvatore Denaro

TECHNIQUES

bull TREATMENT OF SOFT PARTS bull MUSCULAR STRETCHING bull REPEATED INTERVENTIONS bull MANIPULATION (3 STAGES)

Place in position Apply tension Manipulative thrust (low amplitude high velocity)

ldquoIT IS A NON-SYMPTOMATIC CAUSAL THERAPYrdquo

Mechanism of action of Vertebral Manipulation

bull Stretching and distension of the posterior joint capsule has a powerful inhibitory effect on muscle contraction (analgesic contraction) The hypotonic Gamma is determined by the stimulation of the periarticular receptors activated by the manipulative manoeuvre and results in a rapid and powerful ldquoINHIBITORY REFLEXrdquo through the contraction of the intervertebral musculature (DDIM)

bull With Vertebral Manipulation abruptly stretching structures such as ligaments discs joint capsules or muscles activates the descending system of nociceptive inhibition of pain in cases where this originates at the level of the grey matter

J Electromyogr Kinesiol 2012 Oct 22(5) 785ndash794Published online 2012 Feb 19 doi Spinal Manipulative Therapy and Somatosensory Activation Joel G Pickar DC PhD1 and Philip S Bolton DC PhD2 Dott Salvatore Denaro

Dott Salvatore Denaro

Non surgical laser therapy In analgesic therapy the ideal laser emission

instrument is one which uses a semiconductor diode as its active medium emitting invisible bursts of

radiation delivered in extremely short pulses typically within the infrared (IR) band with a

wavelength of approximately 904 nanometres ie the IR laser Other options include He-Ne CO2

Neodimio Yag and HILT

low levels of evidence

Eur J Phys Rehabil Med 2017 Aug53(4)603-610 Epub 2017 Jan 30 Effects of low-level laser therapy on pain in patients with musculoskeletal disorders a systematic review and meta-analysis Clijsen R123 Brunner A4 Barbero M4 Clarys P5 Taeymans J56

MOJ Orthop Rheumatol 20152(5) Epub 2015 Jun 9 The Use of Low Level Laser Therapy (LLLT) For Musculoskeletal Pain Cotler HB1 Chow RT2 Hamblin MR3 Carroll J4

Dott Salvatore Denaro

Biological Effects of LASER THERAPY an increase in the speed of mitosis temporary and reversible tissue dehydration denaturation of proteins thermolysis

carbonization for focal CO2 tissue evaporation

Physiotherapeutic lasers essentially produce two effects analgesic anti edema and biostimulant

Heat Therapy (Thermotherapy)

bull Heat action on the gate-control of MampW There is limited overall evidence to support the general use of localized heat however randomised clinical trials (RCTs) have shown that heat therapy provides short-term reductions in pain and disability in patients with acute lower back pain and provides significantly greater pain relief from DOMS than cold therapy (Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury Gerard A Malanga Ning Yan amp Jill Stark Oct 2014) PubMedgov

bull Cold reduction of tissue temperature which subsequently exerts local effects on blood flow on cell swelling and on metabolism and speed of neural conduction (Cold-water immersion and other forms of cryotherapy physiological changes potentially affecting recovery from high-intensity exercise Gillian E White and Greg D Wells Email author Extreme Physiology amp Medicine 2013 )

Dott Salvatore Denaro

KRYO TECAR

Mechanotherapy vibration

bull CONTROL OF MUSCULAR STIFFNESS (tonic reflex from vibration)

bull STIMULATION OF BLOOD LYMPHATIC CIRCULATION

bull PAIN RELIEF (gate control)

bull INCREASED SENSITIVITY

Bibliographic details Wang P Yang X Yang Y Yang L Zhou Y Liu C Reinhardt JD He C Effects of whole body vibration on pain stiffness and physical functions in patients with knee osteoarthritis a systematic review and meta-analysis Clinical Rehabilitation 2014 epub [PubMed] Dott Salvatore Denaro

Impact Waves bull 1 direct effect of the impulse on the tissue

in the target area and in conjunction with the reflection phenomena more accentuated in the points of transition between soft tissue (tendons muscles) and more compact tissues (bones and calcification formations)

bull 2 indirect effect of ldquocavitationrdquo caused by the subsequent depression of the impulse which exceeds the elastic characteristics of the tissue

NO DIRECT EFFECT ON PAIN MODULATORS OF BIOLOGICAL FUNCTIONS IN HUMAN MUSCLE CELLS (J Orthop Surg Res 2018 Apr 613(1)75 Exposure to radial extracorporeal shock waves modulates viability and gene expression of human skeletal muscle cells a controlled in vitro study Mattyasovszky SG1 Langendorf EK2 Ritz U2 Schmitz C3 Schmidtmann I4 Nowak TE2 Wagner D2 Hofmann A2 Rommens PM2 Drees P2)

RADIALI

FOCALI

Dott Salvatore Denaro

Ion Cyclotron Resonance Quantum Molecular Resonance

bull Stimulates the biological functions of cells bull Rebalances the correct membrane potential bull Activates enzymatic processes bull Restores the correct ion exchange for cell metabolism bull Promotes intra-extra cellular ion balance

Operating principle based on Quantum Molecular Resonance with the application of high-frequency and low-power micro-currents Induces the regeneration of damaged tissues especially muscular tissues without thermal effects

Dott Salvatore Denaro

Dott Salvatore Denaro

KINESIOTHERAPY IS NECESSARY

bull WITH REGARD TO ARTICULAR LINKS ndash JOINT PLAY ndash STRUCTURAL INTEGRITY OF THE CARTILAGE CAPSULE

AND LIGAMENTS ndash CORRECT MUSCLE SYNERGY ndash ELIMINATION OF FUNCTIONAL COMPENSATIONS

bull PAIN CONTROL bull NO CONTRAINDICATION

Dott Salvatore Denaro

KINESIOTHERAPY

bull POSTURAL Aims to correct any negative issues of posture (often secondary to analgesic compensatory attitudes) to detect alterations in the knee and calcaneal axis and of the plantar support visual disturbance dental malocclusion dysmetria of the pelvis etc

Dott Salvatore Denaro

KINESIOTHERAPY

bull HYDRO-KINESIOTHERAPY Very useful in cases of rheumatic diseases Therapeutic exercise in water is facilitated by the option to regulate water temperature and by the reduction in gravitational force which this medium allows

Dott Salvatore Denaro

VERTEBRAL MANIPULATION Robert Maignersquos ldquoManu Medicardquo

bull SEMIOTICS NATURE OF ILLNESS OR PATHOLOGY (clinical examination

imaging laboratory etc) ANALYSIS OF MINOR INTERVERTEBRAL DISTURBANCE

(ROM DDIM SCTM according to R Maignersquos research into signs of functional limitations)

bull THERAPY Principles RULE OF NO PAIN AND OF CONTRARY MOVEMENT VERIFICATION OF EVERY MANIPULATION BEFORE

PERFORMING THE NEXT

Dott Salvatore Denaro

TECHNIQUES

bull TREATMENT OF SOFT PARTS bull MUSCULAR STRETCHING bull REPEATED INTERVENTIONS bull MANIPULATION (3 STAGES)

Place in position Apply tension Manipulative thrust (low amplitude high velocity)

ldquoIT IS A NON-SYMPTOMATIC CAUSAL THERAPYrdquo

Mechanism of action of Vertebral Manipulation

bull Stretching and distension of the posterior joint capsule has a powerful inhibitory effect on muscle contraction (analgesic contraction) The hypotonic Gamma is determined by the stimulation of the periarticular receptors activated by the manipulative manoeuvre and results in a rapid and powerful ldquoINHIBITORY REFLEXrdquo through the contraction of the intervertebral musculature (DDIM)

bull With Vertebral Manipulation abruptly stretching structures such as ligaments discs joint capsules or muscles activates the descending system of nociceptive inhibition of pain in cases where this originates at the level of the grey matter

J Electromyogr Kinesiol 2012 Oct 22(5) 785ndash794Published online 2012 Feb 19 doi Spinal Manipulative Therapy and Somatosensory Activation Joel G Pickar DC PhD1 and Philip S Bolton DC PhD2 Dott Salvatore Denaro

Dott Salvatore Denaro

Biological Effects of LASER THERAPY an increase in the speed of mitosis temporary and reversible tissue dehydration denaturation of proteins thermolysis

carbonization for focal CO2 tissue evaporation

Physiotherapeutic lasers essentially produce two effects analgesic anti edema and biostimulant

Heat Therapy (Thermotherapy)

bull Heat action on the gate-control of MampW There is limited overall evidence to support the general use of localized heat however randomised clinical trials (RCTs) have shown that heat therapy provides short-term reductions in pain and disability in patients with acute lower back pain and provides significantly greater pain relief from DOMS than cold therapy (Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury Gerard A Malanga Ning Yan amp Jill Stark Oct 2014) PubMedgov

bull Cold reduction of tissue temperature which subsequently exerts local effects on blood flow on cell swelling and on metabolism and speed of neural conduction (Cold-water immersion and other forms of cryotherapy physiological changes potentially affecting recovery from high-intensity exercise Gillian E White and Greg D Wells Email author Extreme Physiology amp Medicine 2013 )

Dott Salvatore Denaro

KRYO TECAR

Mechanotherapy vibration

bull CONTROL OF MUSCULAR STIFFNESS (tonic reflex from vibration)

bull STIMULATION OF BLOOD LYMPHATIC CIRCULATION

bull PAIN RELIEF (gate control)

bull INCREASED SENSITIVITY

Bibliographic details Wang P Yang X Yang Y Yang L Zhou Y Liu C Reinhardt JD He C Effects of whole body vibration on pain stiffness and physical functions in patients with knee osteoarthritis a systematic review and meta-analysis Clinical Rehabilitation 2014 epub [PubMed] Dott Salvatore Denaro

Impact Waves bull 1 direct effect of the impulse on the tissue

in the target area and in conjunction with the reflection phenomena more accentuated in the points of transition between soft tissue (tendons muscles) and more compact tissues (bones and calcification formations)

bull 2 indirect effect of ldquocavitationrdquo caused by the subsequent depression of the impulse which exceeds the elastic characteristics of the tissue

NO DIRECT EFFECT ON PAIN MODULATORS OF BIOLOGICAL FUNCTIONS IN HUMAN MUSCLE CELLS (J Orthop Surg Res 2018 Apr 613(1)75 Exposure to radial extracorporeal shock waves modulates viability and gene expression of human skeletal muscle cells a controlled in vitro study Mattyasovszky SG1 Langendorf EK2 Ritz U2 Schmitz C3 Schmidtmann I4 Nowak TE2 Wagner D2 Hofmann A2 Rommens PM2 Drees P2)

RADIALI

FOCALI

Dott Salvatore Denaro

Ion Cyclotron Resonance Quantum Molecular Resonance

bull Stimulates the biological functions of cells bull Rebalances the correct membrane potential bull Activates enzymatic processes bull Restores the correct ion exchange for cell metabolism bull Promotes intra-extra cellular ion balance

Operating principle based on Quantum Molecular Resonance with the application of high-frequency and low-power micro-currents Induces the regeneration of damaged tissues especially muscular tissues without thermal effects

Dott Salvatore Denaro

Dott Salvatore Denaro

KINESIOTHERAPY IS NECESSARY

bull WITH REGARD TO ARTICULAR LINKS ndash JOINT PLAY ndash STRUCTURAL INTEGRITY OF THE CARTILAGE CAPSULE

AND LIGAMENTS ndash CORRECT MUSCLE SYNERGY ndash ELIMINATION OF FUNCTIONAL COMPENSATIONS

bull PAIN CONTROL bull NO CONTRAINDICATION

Dott Salvatore Denaro

KINESIOTHERAPY

bull POSTURAL Aims to correct any negative issues of posture (often secondary to analgesic compensatory attitudes) to detect alterations in the knee and calcaneal axis and of the plantar support visual disturbance dental malocclusion dysmetria of the pelvis etc

Dott Salvatore Denaro

KINESIOTHERAPY

bull HYDRO-KINESIOTHERAPY Very useful in cases of rheumatic diseases Therapeutic exercise in water is facilitated by the option to regulate water temperature and by the reduction in gravitational force which this medium allows

Dott Salvatore Denaro

VERTEBRAL MANIPULATION Robert Maignersquos ldquoManu Medicardquo

bull SEMIOTICS NATURE OF ILLNESS OR PATHOLOGY (clinical examination

imaging laboratory etc) ANALYSIS OF MINOR INTERVERTEBRAL DISTURBANCE

(ROM DDIM SCTM according to R Maignersquos research into signs of functional limitations)

bull THERAPY Principles RULE OF NO PAIN AND OF CONTRARY MOVEMENT VERIFICATION OF EVERY MANIPULATION BEFORE

PERFORMING THE NEXT

Dott Salvatore Denaro

TECHNIQUES

bull TREATMENT OF SOFT PARTS bull MUSCULAR STRETCHING bull REPEATED INTERVENTIONS bull MANIPULATION (3 STAGES)

Place in position Apply tension Manipulative thrust (low amplitude high velocity)

ldquoIT IS A NON-SYMPTOMATIC CAUSAL THERAPYrdquo

Mechanism of action of Vertebral Manipulation

bull Stretching and distension of the posterior joint capsule has a powerful inhibitory effect on muscle contraction (analgesic contraction) The hypotonic Gamma is determined by the stimulation of the periarticular receptors activated by the manipulative manoeuvre and results in a rapid and powerful ldquoINHIBITORY REFLEXrdquo through the contraction of the intervertebral musculature (DDIM)

bull With Vertebral Manipulation abruptly stretching structures such as ligaments discs joint capsules or muscles activates the descending system of nociceptive inhibition of pain in cases where this originates at the level of the grey matter

J Electromyogr Kinesiol 2012 Oct 22(5) 785ndash794Published online 2012 Feb 19 doi Spinal Manipulative Therapy and Somatosensory Activation Joel G Pickar DC PhD1 and Philip S Bolton DC PhD2 Dott Salvatore Denaro

Heat Therapy (Thermotherapy)

bull Heat action on the gate-control of MampW There is limited overall evidence to support the general use of localized heat however randomised clinical trials (RCTs) have shown that heat therapy provides short-term reductions in pain and disability in patients with acute lower back pain and provides significantly greater pain relief from DOMS than cold therapy (Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury Gerard A Malanga Ning Yan amp Jill Stark Oct 2014) PubMedgov

bull Cold reduction of tissue temperature which subsequently exerts local effects on blood flow on cell swelling and on metabolism and speed of neural conduction (Cold-water immersion and other forms of cryotherapy physiological changes potentially affecting recovery from high-intensity exercise Gillian E White and Greg D Wells Email author Extreme Physiology amp Medicine 2013 )

Dott Salvatore Denaro

KRYO TECAR

Mechanotherapy vibration

bull CONTROL OF MUSCULAR STIFFNESS (tonic reflex from vibration)

bull STIMULATION OF BLOOD LYMPHATIC CIRCULATION

bull PAIN RELIEF (gate control)

bull INCREASED SENSITIVITY

Bibliographic details Wang P Yang X Yang Y Yang L Zhou Y Liu C Reinhardt JD He C Effects of whole body vibration on pain stiffness and physical functions in patients with knee osteoarthritis a systematic review and meta-analysis Clinical Rehabilitation 2014 epub [PubMed] Dott Salvatore Denaro

Impact Waves bull 1 direct effect of the impulse on the tissue

in the target area and in conjunction with the reflection phenomena more accentuated in the points of transition between soft tissue (tendons muscles) and more compact tissues (bones and calcification formations)

bull 2 indirect effect of ldquocavitationrdquo caused by the subsequent depression of the impulse which exceeds the elastic characteristics of the tissue

NO DIRECT EFFECT ON PAIN MODULATORS OF BIOLOGICAL FUNCTIONS IN HUMAN MUSCLE CELLS (J Orthop Surg Res 2018 Apr 613(1)75 Exposure to radial extracorporeal shock waves modulates viability and gene expression of human skeletal muscle cells a controlled in vitro study Mattyasovszky SG1 Langendorf EK2 Ritz U2 Schmitz C3 Schmidtmann I4 Nowak TE2 Wagner D2 Hofmann A2 Rommens PM2 Drees P2)

RADIALI

FOCALI

Dott Salvatore Denaro

Ion Cyclotron Resonance Quantum Molecular Resonance

bull Stimulates the biological functions of cells bull Rebalances the correct membrane potential bull Activates enzymatic processes bull Restores the correct ion exchange for cell metabolism bull Promotes intra-extra cellular ion balance

Operating principle based on Quantum Molecular Resonance with the application of high-frequency and low-power micro-currents Induces the regeneration of damaged tissues especially muscular tissues without thermal effects

Dott Salvatore Denaro

Dott Salvatore Denaro

KINESIOTHERAPY IS NECESSARY

bull WITH REGARD TO ARTICULAR LINKS ndash JOINT PLAY ndash STRUCTURAL INTEGRITY OF THE CARTILAGE CAPSULE

AND LIGAMENTS ndash CORRECT MUSCLE SYNERGY ndash ELIMINATION OF FUNCTIONAL COMPENSATIONS

bull PAIN CONTROL bull NO CONTRAINDICATION

Dott Salvatore Denaro

KINESIOTHERAPY

bull POSTURAL Aims to correct any negative issues of posture (often secondary to analgesic compensatory attitudes) to detect alterations in the knee and calcaneal axis and of the plantar support visual disturbance dental malocclusion dysmetria of the pelvis etc

Dott Salvatore Denaro

KINESIOTHERAPY

bull HYDRO-KINESIOTHERAPY Very useful in cases of rheumatic diseases Therapeutic exercise in water is facilitated by the option to regulate water temperature and by the reduction in gravitational force which this medium allows

Dott Salvatore Denaro

VERTEBRAL MANIPULATION Robert Maignersquos ldquoManu Medicardquo

bull SEMIOTICS NATURE OF ILLNESS OR PATHOLOGY (clinical examination

imaging laboratory etc) ANALYSIS OF MINOR INTERVERTEBRAL DISTURBANCE

(ROM DDIM SCTM according to R Maignersquos research into signs of functional limitations)

bull THERAPY Principles RULE OF NO PAIN AND OF CONTRARY MOVEMENT VERIFICATION OF EVERY MANIPULATION BEFORE

PERFORMING THE NEXT

Dott Salvatore Denaro

TECHNIQUES

bull TREATMENT OF SOFT PARTS bull MUSCULAR STRETCHING bull REPEATED INTERVENTIONS bull MANIPULATION (3 STAGES)

Place in position Apply tension Manipulative thrust (low amplitude high velocity)

ldquoIT IS A NON-SYMPTOMATIC CAUSAL THERAPYrdquo

Mechanism of action of Vertebral Manipulation

bull Stretching and distension of the posterior joint capsule has a powerful inhibitory effect on muscle contraction (analgesic contraction) The hypotonic Gamma is determined by the stimulation of the periarticular receptors activated by the manipulative manoeuvre and results in a rapid and powerful ldquoINHIBITORY REFLEXrdquo through the contraction of the intervertebral musculature (DDIM)

bull With Vertebral Manipulation abruptly stretching structures such as ligaments discs joint capsules or muscles activates the descending system of nociceptive inhibition of pain in cases where this originates at the level of the grey matter

J Electromyogr Kinesiol 2012 Oct 22(5) 785ndash794Published online 2012 Feb 19 doi Spinal Manipulative Therapy and Somatosensory Activation Joel G Pickar DC PhD1 and Philip S Bolton DC PhD2 Dott Salvatore Denaro

Mechanotherapy vibration

bull CONTROL OF MUSCULAR STIFFNESS (tonic reflex from vibration)

bull STIMULATION OF BLOOD LYMPHATIC CIRCULATION

bull PAIN RELIEF (gate control)

bull INCREASED SENSITIVITY

Bibliographic details Wang P Yang X Yang Y Yang L Zhou Y Liu C Reinhardt JD He C Effects of whole body vibration on pain stiffness and physical functions in patients with knee osteoarthritis a systematic review and meta-analysis Clinical Rehabilitation 2014 epub [PubMed] Dott Salvatore Denaro

Impact Waves bull 1 direct effect of the impulse on the tissue

in the target area and in conjunction with the reflection phenomena more accentuated in the points of transition between soft tissue (tendons muscles) and more compact tissues (bones and calcification formations)

bull 2 indirect effect of ldquocavitationrdquo caused by the subsequent depression of the impulse which exceeds the elastic characteristics of the tissue

NO DIRECT EFFECT ON PAIN MODULATORS OF BIOLOGICAL FUNCTIONS IN HUMAN MUSCLE CELLS (J Orthop Surg Res 2018 Apr 613(1)75 Exposure to radial extracorporeal shock waves modulates viability and gene expression of human skeletal muscle cells a controlled in vitro study Mattyasovszky SG1 Langendorf EK2 Ritz U2 Schmitz C3 Schmidtmann I4 Nowak TE2 Wagner D2 Hofmann A2 Rommens PM2 Drees P2)

RADIALI

FOCALI

Dott Salvatore Denaro

Ion Cyclotron Resonance Quantum Molecular Resonance

bull Stimulates the biological functions of cells bull Rebalances the correct membrane potential bull Activates enzymatic processes bull Restores the correct ion exchange for cell metabolism bull Promotes intra-extra cellular ion balance

Operating principle based on Quantum Molecular Resonance with the application of high-frequency and low-power micro-currents Induces the regeneration of damaged tissues especially muscular tissues without thermal effects

Dott Salvatore Denaro

Dott Salvatore Denaro

KINESIOTHERAPY IS NECESSARY

bull WITH REGARD TO ARTICULAR LINKS ndash JOINT PLAY ndash STRUCTURAL INTEGRITY OF THE CARTILAGE CAPSULE

AND LIGAMENTS ndash CORRECT MUSCLE SYNERGY ndash ELIMINATION OF FUNCTIONAL COMPENSATIONS

bull PAIN CONTROL bull NO CONTRAINDICATION

Dott Salvatore Denaro

KINESIOTHERAPY

bull POSTURAL Aims to correct any negative issues of posture (often secondary to analgesic compensatory attitudes) to detect alterations in the knee and calcaneal axis and of the plantar support visual disturbance dental malocclusion dysmetria of the pelvis etc

Dott Salvatore Denaro

KINESIOTHERAPY

bull HYDRO-KINESIOTHERAPY Very useful in cases of rheumatic diseases Therapeutic exercise in water is facilitated by the option to regulate water temperature and by the reduction in gravitational force which this medium allows

Dott Salvatore Denaro

VERTEBRAL MANIPULATION Robert Maignersquos ldquoManu Medicardquo

bull SEMIOTICS NATURE OF ILLNESS OR PATHOLOGY (clinical examination

imaging laboratory etc) ANALYSIS OF MINOR INTERVERTEBRAL DISTURBANCE

(ROM DDIM SCTM according to R Maignersquos research into signs of functional limitations)

bull THERAPY Principles RULE OF NO PAIN AND OF CONTRARY MOVEMENT VERIFICATION OF EVERY MANIPULATION BEFORE

PERFORMING THE NEXT

Dott Salvatore Denaro

TECHNIQUES

bull TREATMENT OF SOFT PARTS bull MUSCULAR STRETCHING bull REPEATED INTERVENTIONS bull MANIPULATION (3 STAGES)

Place in position Apply tension Manipulative thrust (low amplitude high velocity)

ldquoIT IS A NON-SYMPTOMATIC CAUSAL THERAPYrdquo

Mechanism of action of Vertebral Manipulation

bull Stretching and distension of the posterior joint capsule has a powerful inhibitory effect on muscle contraction (analgesic contraction) The hypotonic Gamma is determined by the stimulation of the periarticular receptors activated by the manipulative manoeuvre and results in a rapid and powerful ldquoINHIBITORY REFLEXrdquo through the contraction of the intervertebral musculature (DDIM)

bull With Vertebral Manipulation abruptly stretching structures such as ligaments discs joint capsules or muscles activates the descending system of nociceptive inhibition of pain in cases where this originates at the level of the grey matter

J Electromyogr Kinesiol 2012 Oct 22(5) 785ndash794Published online 2012 Feb 19 doi Spinal Manipulative Therapy and Somatosensory Activation Joel G Pickar DC PhD1 and Philip S Bolton DC PhD2 Dott Salvatore Denaro

Impact Waves bull 1 direct effect of the impulse on the tissue

in the target area and in conjunction with the reflection phenomena more accentuated in the points of transition between soft tissue (tendons muscles) and more compact tissues (bones and calcification formations)

bull 2 indirect effect of ldquocavitationrdquo caused by the subsequent depression of the impulse which exceeds the elastic characteristics of the tissue

NO DIRECT EFFECT ON PAIN MODULATORS OF BIOLOGICAL FUNCTIONS IN HUMAN MUSCLE CELLS (J Orthop Surg Res 2018 Apr 613(1)75 Exposure to radial extracorporeal shock waves modulates viability and gene expression of human skeletal muscle cells a controlled in vitro study Mattyasovszky SG1 Langendorf EK2 Ritz U2 Schmitz C3 Schmidtmann I4 Nowak TE2 Wagner D2 Hofmann A2 Rommens PM2 Drees P2)

RADIALI

FOCALI

Dott Salvatore Denaro

Ion Cyclotron Resonance Quantum Molecular Resonance

bull Stimulates the biological functions of cells bull Rebalances the correct membrane potential bull Activates enzymatic processes bull Restores the correct ion exchange for cell metabolism bull Promotes intra-extra cellular ion balance

Operating principle based on Quantum Molecular Resonance with the application of high-frequency and low-power micro-currents Induces the regeneration of damaged tissues especially muscular tissues without thermal effects

Dott Salvatore Denaro

Dott Salvatore Denaro

KINESIOTHERAPY IS NECESSARY

bull WITH REGARD TO ARTICULAR LINKS ndash JOINT PLAY ndash STRUCTURAL INTEGRITY OF THE CARTILAGE CAPSULE

AND LIGAMENTS ndash CORRECT MUSCLE SYNERGY ndash ELIMINATION OF FUNCTIONAL COMPENSATIONS

bull PAIN CONTROL bull NO CONTRAINDICATION

Dott Salvatore Denaro

KINESIOTHERAPY

bull POSTURAL Aims to correct any negative issues of posture (often secondary to analgesic compensatory attitudes) to detect alterations in the knee and calcaneal axis and of the plantar support visual disturbance dental malocclusion dysmetria of the pelvis etc

Dott Salvatore Denaro

KINESIOTHERAPY

bull HYDRO-KINESIOTHERAPY Very useful in cases of rheumatic diseases Therapeutic exercise in water is facilitated by the option to regulate water temperature and by the reduction in gravitational force which this medium allows

Dott Salvatore Denaro

VERTEBRAL MANIPULATION Robert Maignersquos ldquoManu Medicardquo

bull SEMIOTICS NATURE OF ILLNESS OR PATHOLOGY (clinical examination

imaging laboratory etc) ANALYSIS OF MINOR INTERVERTEBRAL DISTURBANCE

(ROM DDIM SCTM according to R Maignersquos research into signs of functional limitations)

bull THERAPY Principles RULE OF NO PAIN AND OF CONTRARY MOVEMENT VERIFICATION OF EVERY MANIPULATION BEFORE

PERFORMING THE NEXT

Dott Salvatore Denaro

TECHNIQUES

bull TREATMENT OF SOFT PARTS bull MUSCULAR STRETCHING bull REPEATED INTERVENTIONS bull MANIPULATION (3 STAGES)

Place in position Apply tension Manipulative thrust (low amplitude high velocity)

ldquoIT IS A NON-SYMPTOMATIC CAUSAL THERAPYrdquo

Mechanism of action of Vertebral Manipulation

bull Stretching and distension of the posterior joint capsule has a powerful inhibitory effect on muscle contraction (analgesic contraction) The hypotonic Gamma is determined by the stimulation of the periarticular receptors activated by the manipulative manoeuvre and results in a rapid and powerful ldquoINHIBITORY REFLEXrdquo through the contraction of the intervertebral musculature (DDIM)

bull With Vertebral Manipulation abruptly stretching structures such as ligaments discs joint capsules or muscles activates the descending system of nociceptive inhibition of pain in cases where this originates at the level of the grey matter

J Electromyogr Kinesiol 2012 Oct 22(5) 785ndash794Published online 2012 Feb 19 doi Spinal Manipulative Therapy and Somatosensory Activation Joel G Pickar DC PhD1 and Philip S Bolton DC PhD2 Dott Salvatore Denaro

Ion Cyclotron Resonance Quantum Molecular Resonance

bull Stimulates the biological functions of cells bull Rebalances the correct membrane potential bull Activates enzymatic processes bull Restores the correct ion exchange for cell metabolism bull Promotes intra-extra cellular ion balance

Operating principle based on Quantum Molecular Resonance with the application of high-frequency and low-power micro-currents Induces the regeneration of damaged tissues especially muscular tissues without thermal effects

Dott Salvatore Denaro

Dott Salvatore Denaro

KINESIOTHERAPY IS NECESSARY

bull WITH REGARD TO ARTICULAR LINKS ndash JOINT PLAY ndash STRUCTURAL INTEGRITY OF THE CARTILAGE CAPSULE

AND LIGAMENTS ndash CORRECT MUSCLE SYNERGY ndash ELIMINATION OF FUNCTIONAL COMPENSATIONS

bull PAIN CONTROL bull NO CONTRAINDICATION

Dott Salvatore Denaro

KINESIOTHERAPY

bull POSTURAL Aims to correct any negative issues of posture (often secondary to analgesic compensatory attitudes) to detect alterations in the knee and calcaneal axis and of the plantar support visual disturbance dental malocclusion dysmetria of the pelvis etc

Dott Salvatore Denaro

KINESIOTHERAPY

bull HYDRO-KINESIOTHERAPY Very useful in cases of rheumatic diseases Therapeutic exercise in water is facilitated by the option to regulate water temperature and by the reduction in gravitational force which this medium allows

Dott Salvatore Denaro

VERTEBRAL MANIPULATION Robert Maignersquos ldquoManu Medicardquo

bull SEMIOTICS NATURE OF ILLNESS OR PATHOLOGY (clinical examination

imaging laboratory etc) ANALYSIS OF MINOR INTERVERTEBRAL DISTURBANCE

(ROM DDIM SCTM according to R Maignersquos research into signs of functional limitations)

bull THERAPY Principles RULE OF NO PAIN AND OF CONTRARY MOVEMENT VERIFICATION OF EVERY MANIPULATION BEFORE

PERFORMING THE NEXT

Dott Salvatore Denaro

TECHNIQUES

bull TREATMENT OF SOFT PARTS bull MUSCULAR STRETCHING bull REPEATED INTERVENTIONS bull MANIPULATION (3 STAGES)

Place in position Apply tension Manipulative thrust (low amplitude high velocity)

ldquoIT IS A NON-SYMPTOMATIC CAUSAL THERAPYrdquo

Mechanism of action of Vertebral Manipulation

bull Stretching and distension of the posterior joint capsule has a powerful inhibitory effect on muscle contraction (analgesic contraction) The hypotonic Gamma is determined by the stimulation of the periarticular receptors activated by the manipulative manoeuvre and results in a rapid and powerful ldquoINHIBITORY REFLEXrdquo through the contraction of the intervertebral musculature (DDIM)

bull With Vertebral Manipulation abruptly stretching structures such as ligaments discs joint capsules or muscles activates the descending system of nociceptive inhibition of pain in cases where this originates at the level of the grey matter

J Electromyogr Kinesiol 2012 Oct 22(5) 785ndash794Published online 2012 Feb 19 doi Spinal Manipulative Therapy and Somatosensory Activation Joel G Pickar DC PhD1 and Philip S Bolton DC PhD2 Dott Salvatore Denaro

Dott Salvatore Denaro

KINESIOTHERAPY IS NECESSARY

bull WITH REGARD TO ARTICULAR LINKS ndash JOINT PLAY ndash STRUCTURAL INTEGRITY OF THE CARTILAGE CAPSULE

AND LIGAMENTS ndash CORRECT MUSCLE SYNERGY ndash ELIMINATION OF FUNCTIONAL COMPENSATIONS

bull PAIN CONTROL bull NO CONTRAINDICATION

Dott Salvatore Denaro

KINESIOTHERAPY

bull POSTURAL Aims to correct any negative issues of posture (often secondary to analgesic compensatory attitudes) to detect alterations in the knee and calcaneal axis and of the plantar support visual disturbance dental malocclusion dysmetria of the pelvis etc

Dott Salvatore Denaro

KINESIOTHERAPY

bull HYDRO-KINESIOTHERAPY Very useful in cases of rheumatic diseases Therapeutic exercise in water is facilitated by the option to regulate water temperature and by the reduction in gravitational force which this medium allows

Dott Salvatore Denaro

VERTEBRAL MANIPULATION Robert Maignersquos ldquoManu Medicardquo

bull SEMIOTICS NATURE OF ILLNESS OR PATHOLOGY (clinical examination

imaging laboratory etc) ANALYSIS OF MINOR INTERVERTEBRAL DISTURBANCE

(ROM DDIM SCTM according to R Maignersquos research into signs of functional limitations)

bull THERAPY Principles RULE OF NO PAIN AND OF CONTRARY MOVEMENT VERIFICATION OF EVERY MANIPULATION BEFORE

PERFORMING THE NEXT

Dott Salvatore Denaro

TECHNIQUES

bull TREATMENT OF SOFT PARTS bull MUSCULAR STRETCHING bull REPEATED INTERVENTIONS bull MANIPULATION (3 STAGES)

Place in position Apply tension Manipulative thrust (low amplitude high velocity)

ldquoIT IS A NON-SYMPTOMATIC CAUSAL THERAPYrdquo

Mechanism of action of Vertebral Manipulation

bull Stretching and distension of the posterior joint capsule has a powerful inhibitory effect on muscle contraction (analgesic contraction) The hypotonic Gamma is determined by the stimulation of the periarticular receptors activated by the manipulative manoeuvre and results in a rapid and powerful ldquoINHIBITORY REFLEXrdquo through the contraction of the intervertebral musculature (DDIM)

bull With Vertebral Manipulation abruptly stretching structures such as ligaments discs joint capsules or muscles activates the descending system of nociceptive inhibition of pain in cases where this originates at the level of the grey matter

J Electromyogr Kinesiol 2012 Oct 22(5) 785ndash794Published online 2012 Feb 19 doi Spinal Manipulative Therapy and Somatosensory Activation Joel G Pickar DC PhD1 and Philip S Bolton DC PhD2 Dott Salvatore Denaro

Dott Salvatore Denaro

KINESIOTHERAPY

bull POSTURAL Aims to correct any negative issues of posture (often secondary to analgesic compensatory attitudes) to detect alterations in the knee and calcaneal axis and of the plantar support visual disturbance dental malocclusion dysmetria of the pelvis etc

Dott Salvatore Denaro

KINESIOTHERAPY

bull HYDRO-KINESIOTHERAPY Very useful in cases of rheumatic diseases Therapeutic exercise in water is facilitated by the option to regulate water temperature and by the reduction in gravitational force which this medium allows

Dott Salvatore Denaro

VERTEBRAL MANIPULATION Robert Maignersquos ldquoManu Medicardquo

bull SEMIOTICS NATURE OF ILLNESS OR PATHOLOGY (clinical examination

imaging laboratory etc) ANALYSIS OF MINOR INTERVERTEBRAL DISTURBANCE

(ROM DDIM SCTM according to R Maignersquos research into signs of functional limitations)

bull THERAPY Principles RULE OF NO PAIN AND OF CONTRARY MOVEMENT VERIFICATION OF EVERY MANIPULATION BEFORE

PERFORMING THE NEXT

Dott Salvatore Denaro

TECHNIQUES

bull TREATMENT OF SOFT PARTS bull MUSCULAR STRETCHING bull REPEATED INTERVENTIONS bull MANIPULATION (3 STAGES)

Place in position Apply tension Manipulative thrust (low amplitude high velocity)

ldquoIT IS A NON-SYMPTOMATIC CAUSAL THERAPYrdquo

Mechanism of action of Vertebral Manipulation

bull Stretching and distension of the posterior joint capsule has a powerful inhibitory effect on muscle contraction (analgesic contraction) The hypotonic Gamma is determined by the stimulation of the periarticular receptors activated by the manipulative manoeuvre and results in a rapid and powerful ldquoINHIBITORY REFLEXrdquo through the contraction of the intervertebral musculature (DDIM)

bull With Vertebral Manipulation abruptly stretching structures such as ligaments discs joint capsules or muscles activates the descending system of nociceptive inhibition of pain in cases where this originates at the level of the grey matter

J Electromyogr Kinesiol 2012 Oct 22(5) 785ndash794Published online 2012 Feb 19 doi Spinal Manipulative Therapy and Somatosensory Activation Joel G Pickar DC PhD1 and Philip S Bolton DC PhD2 Dott Salvatore Denaro

Dott Salvatore Denaro

KINESIOTHERAPY

bull HYDRO-KINESIOTHERAPY Very useful in cases of rheumatic diseases Therapeutic exercise in water is facilitated by the option to regulate water temperature and by the reduction in gravitational force which this medium allows

Dott Salvatore Denaro

VERTEBRAL MANIPULATION Robert Maignersquos ldquoManu Medicardquo

bull SEMIOTICS NATURE OF ILLNESS OR PATHOLOGY (clinical examination

imaging laboratory etc) ANALYSIS OF MINOR INTERVERTEBRAL DISTURBANCE

(ROM DDIM SCTM according to R Maignersquos research into signs of functional limitations)

bull THERAPY Principles RULE OF NO PAIN AND OF CONTRARY MOVEMENT VERIFICATION OF EVERY MANIPULATION BEFORE

PERFORMING THE NEXT

Dott Salvatore Denaro

TECHNIQUES

bull TREATMENT OF SOFT PARTS bull MUSCULAR STRETCHING bull REPEATED INTERVENTIONS bull MANIPULATION (3 STAGES)

Place in position Apply tension Manipulative thrust (low amplitude high velocity)

ldquoIT IS A NON-SYMPTOMATIC CAUSAL THERAPYrdquo

Mechanism of action of Vertebral Manipulation

bull Stretching and distension of the posterior joint capsule has a powerful inhibitory effect on muscle contraction (analgesic contraction) The hypotonic Gamma is determined by the stimulation of the periarticular receptors activated by the manipulative manoeuvre and results in a rapid and powerful ldquoINHIBITORY REFLEXrdquo through the contraction of the intervertebral musculature (DDIM)

bull With Vertebral Manipulation abruptly stretching structures such as ligaments discs joint capsules or muscles activates the descending system of nociceptive inhibition of pain in cases where this originates at the level of the grey matter

J Electromyogr Kinesiol 2012 Oct 22(5) 785ndash794Published online 2012 Feb 19 doi Spinal Manipulative Therapy and Somatosensory Activation Joel G Pickar DC PhD1 and Philip S Bolton DC PhD2 Dott Salvatore Denaro

Dott Salvatore Denaro

VERTEBRAL MANIPULATION Robert Maignersquos ldquoManu Medicardquo

bull SEMIOTICS NATURE OF ILLNESS OR PATHOLOGY (clinical examination

imaging laboratory etc) ANALYSIS OF MINOR INTERVERTEBRAL DISTURBANCE

(ROM DDIM SCTM according to R Maignersquos research into signs of functional limitations)

bull THERAPY Principles RULE OF NO PAIN AND OF CONTRARY MOVEMENT VERIFICATION OF EVERY MANIPULATION BEFORE

PERFORMING THE NEXT

Dott Salvatore Denaro

TECHNIQUES

bull TREATMENT OF SOFT PARTS bull MUSCULAR STRETCHING bull REPEATED INTERVENTIONS bull MANIPULATION (3 STAGES)

Place in position Apply tension Manipulative thrust (low amplitude high velocity)

ldquoIT IS A NON-SYMPTOMATIC CAUSAL THERAPYrdquo

Mechanism of action of Vertebral Manipulation

bull Stretching and distension of the posterior joint capsule has a powerful inhibitory effect on muscle contraction (analgesic contraction) The hypotonic Gamma is determined by the stimulation of the periarticular receptors activated by the manipulative manoeuvre and results in a rapid and powerful ldquoINHIBITORY REFLEXrdquo through the contraction of the intervertebral musculature (DDIM)

bull With Vertebral Manipulation abruptly stretching structures such as ligaments discs joint capsules or muscles activates the descending system of nociceptive inhibition of pain in cases where this originates at the level of the grey matter

J Electromyogr Kinesiol 2012 Oct 22(5) 785ndash794Published online 2012 Feb 19 doi Spinal Manipulative Therapy and Somatosensory Activation Joel G Pickar DC PhD1 and Philip S Bolton DC PhD2 Dott Salvatore Denaro

Dott Salvatore Denaro

TECHNIQUES

bull TREATMENT OF SOFT PARTS bull MUSCULAR STRETCHING bull REPEATED INTERVENTIONS bull MANIPULATION (3 STAGES)

Place in position Apply tension Manipulative thrust (low amplitude high velocity)

ldquoIT IS A NON-SYMPTOMATIC CAUSAL THERAPYrdquo

Mechanism of action of Vertebral Manipulation

bull Stretching and distension of the posterior joint capsule has a powerful inhibitory effect on muscle contraction (analgesic contraction) The hypotonic Gamma is determined by the stimulation of the periarticular receptors activated by the manipulative manoeuvre and results in a rapid and powerful ldquoINHIBITORY REFLEXrdquo through the contraction of the intervertebral musculature (DDIM)

bull With Vertebral Manipulation abruptly stretching structures such as ligaments discs joint capsules or muscles activates the descending system of nociceptive inhibition of pain in cases where this originates at the level of the grey matter

J Electromyogr Kinesiol 2012 Oct 22(5) 785ndash794Published online 2012 Feb 19 doi Spinal Manipulative Therapy and Somatosensory Activation Joel G Pickar DC PhD1 and Philip S Bolton DC PhD2 Dott Salvatore Denaro

Mechanism of action of Vertebral Manipulation

bull Stretching and distension of the posterior joint capsule has a powerful inhibitory effect on muscle contraction (analgesic contraction) The hypotonic Gamma is determined by the stimulation of the periarticular receptors activated by the manipulative manoeuvre and results in a rapid and powerful ldquoINHIBITORY REFLEXrdquo through the contraction of the intervertebral musculature (DDIM)

bull With Vertebral Manipulation abruptly stretching structures such as ligaments discs joint capsules or muscles activates the descending system of nociceptive inhibition of pain in cases where this originates at the level of the grey matter

J Electromyogr Kinesiol 2012 Oct 22(5) 785ndash794Published online 2012 Feb 19 doi Spinal Manipulative Therapy and Somatosensory Activation Joel G Pickar DC PhD1 and Philip S Bolton DC PhD2 Dott Salvatore Denaro

Dott Salvatore Denaro

ORTHESES AND AUXILIARIES

bull ORTHESIS Apparatus applied to the body or a part of it to allow an improvement to functionality or adaptation to particular pathologies (eg orthotics adapted shoes splints braces etc)

bull AUXILIARY Instrument to enable greater autonomy where this would not otherwise be possible (eg walking stick zimmer frame wheelchair etc)

Functional bandages (preventative or post-trauma)

Dott Salvatore Denaro

KINESIO TAPING

bull Muscular to relax or heal the muscle

bull Corrective for joints

Pain is subjective

Dott Salvatore Denaro

Salvatore Denaro

• Pain Management
• Definition
• Diapositive numeacutero 3
• Diapositive numeacutero 4
• Diapositive numeacutero 5
• Self-assessment scale
• The measurement of subjective pain its usefulness
• Evaluation of pain to reach a diagnosis
• Classification of pain
• Key points and guidelines for the treatment of pain - Joint Commission on Accreditation of Health Care Organizations -
• Who takes responsibility for each type of pain - the Physiatrist the Rheumatologist or the Orthopedist
• Overview of therapy the vicious circle of untreated pain
• Diapositive numeacutero 13
• NEURAL PATHS FOR THE TRANSMISSION OF PAIN
• Routes of management
• But also in Orthopedic Medicinehelliphelliphellip
• Infiltration therapy
• Acupuncture (ancient Chinese approach outlined by Huangdi Neijing between 305 and 204 BC)
• Mesotherapy and Prolotherapy
• Dry needlingenspAnnals of the Rheumatic Diseases 74(Suppl 2)624 middot June 2015 RV Bubnov
• TREATMENT OF PAIN 13in Orthopaedic Medicine
• Diapositive numeacutero 22
• Diapositive numeacutero 23
• Diapositive numeacutero 24
• Diapositive numeacutero 25
• Heat Therapy13(Thermotherapy)
• Mechanotherapy vibration
• Impact Waves
• Ion Cyclotron Resonance
• KINESIOTHERAPYIS NECESSARY
• KINESIOTHERAPY
• Diapositive numeacutero 32
• VERTEBRAL MANIPULATION 13Robert Maignersquos ldquoManu Medicardquo
• TECHNIQUES
• Mechanism of action of Vertebral Manipulation
• ORTHESES AND AUXILIARIES
• Functional bandages(preventative or post-trauma)
• KINESIO TAPING
• Pain is subjective
• Diapositive numeacutero 40
• Diapositive numeacutero 41

Functional bandages (preventative or post-trauma)

Dott Salvatore Denaro

KINESIO TAPING

bull Muscular to relax or heal the muscle

bull Corrective for joints

Pain is subjective

Dott Salvatore Denaro

Salvatore Denaro

• Pain Management
• Definition
• Diapositive numeacutero 3
• Diapositive numeacutero 4
• Diapositive numeacutero 5
• Self-assessment scale
• The measurement of subjective pain its usefulness
• Evaluation of pain to reach a diagnosis
• Classification of pain
• Key points and guidelines for the treatment of pain - Joint Commission on Accreditation of Health Care Organizations -
• Who takes responsibility for each type of pain - the Physiatrist the Rheumatologist or the Orthopedist
• Overview of therapy the vicious circle of untreated pain
• Diapositive numeacutero 13
• NEURAL PATHS FOR THE TRANSMISSION OF PAIN
• Routes of management
• But also in Orthopedic Medicinehelliphelliphellip
• Infiltration therapy
• Acupuncture (ancient Chinese approach outlined by Huangdi Neijing between 305 and 204 BC)
• Mesotherapy and Prolotherapy
• Dry needlingenspAnnals of the Rheumatic Diseases 74(Suppl 2)624 middot June 2015 RV Bubnov
• TREATMENT OF PAIN 13in Orthopaedic Medicine
• Diapositive numeacutero 22
• Diapositive numeacutero 23
• Diapositive numeacutero 24
• Diapositive numeacutero 25
• Heat Therapy13(Thermotherapy)
• Mechanotherapy vibration
• Impact Waves
• Ion Cyclotron Resonance
• KINESIOTHERAPYIS NECESSARY
• KINESIOTHERAPY
• Diapositive numeacutero 32
• VERTEBRAL MANIPULATION 13Robert Maignersquos ldquoManu Medicardquo
• TECHNIQUES
• Mechanism of action of Vertebral Manipulation
• ORTHESES AND AUXILIARIES
• Functional bandages(preventative or post-trauma)
• KINESIO TAPING
• Pain is subjective
• Diapositive numeacutero 40
• Diapositive numeacutero 41

KINESIO TAPING

bull Muscular to relax or heal the muscle

bull Corrective for joints

Pain is subjective

Dott Salvatore Denaro

Salvatore Denaro

• Pain Management
• Definition
• Diapositive numeacutero 3
• Diapositive numeacutero 4
• Diapositive numeacutero 5
• Self-assessment scale
• The measurement of subjective pain its usefulness
• Evaluation of pain to reach a diagnosis
• Classification of pain
• Key points and guidelines for the treatment of pain - Joint Commission on Accreditation of Health Care Organizations -
• Who takes responsibility for each type of pain - the Physiatrist the Rheumatologist or the Orthopedist
• Overview of therapy the vicious circle of untreated pain
• Diapositive numeacutero 13
• NEURAL PATHS FOR THE TRANSMISSION OF PAIN
• Routes of management
• But also in Orthopedic Medicinehelliphelliphellip
• Infiltration therapy
• Acupuncture (ancient Chinese approach outlined by Huangdi Neijing between 305 and 204 BC)
• Mesotherapy and Prolotherapy
• Dry needlingenspAnnals of the Rheumatic Diseases 74(Suppl 2)624 middot June 2015 RV Bubnov
• TREATMENT OF PAIN 13in Orthopaedic Medicine
• Diapositive numeacutero 22
• Diapositive numeacutero 23
• Diapositive numeacutero 24
• Diapositive numeacutero 25
• Heat Therapy13(Thermotherapy)
• Mechanotherapy vibration
• Impact Waves
• Ion Cyclotron Resonance
• KINESIOTHERAPYIS NECESSARY
• KINESIOTHERAPY
• Diapositive numeacutero 32
• VERTEBRAL MANIPULATION 13Robert Maignersquos ldquoManu Medicardquo
• TECHNIQUES
• Mechanism of action of Vertebral Manipulation
• ORTHESES AND AUXILIARIES
• Functional bandages(preventative or post-trauma)
• KINESIO TAPING
• Pain is subjective
• Diapositive numeacutero 40
• Diapositive numeacutero 41

Pain is subjective

Dott Salvatore Denaro

Salvatore Denaro

• Pain Management
• Definition
• Diapositive numeacutero 3
• Diapositive numeacutero 4
• Diapositive numeacutero 5
• Self-assessment scale
• The measurement of subjective pain its usefulness
• Evaluation of pain to reach a diagnosis
• Classification of pain
• Key points and guidelines for the treatment of pain - Joint Commission on Accreditation of Health Care Organizations -
• Who takes responsibility for each type of pain - the Physiatrist the Rheumatologist or the Orthopedist
• Overview of therapy the vicious circle of untreated pain
• Diapositive numeacutero 13
• NEURAL PATHS FOR THE TRANSMISSION OF PAIN
• Routes of management
• But also in Orthopedic Medicinehelliphelliphellip
• Infiltration therapy
• Acupuncture (ancient Chinese approach outlined by Huangdi Neijing between 305 and 204 BC)
• Mesotherapy and Prolotherapy
• Dry needlingenspAnnals of the Rheumatic Diseases 74(Suppl 2)624 middot June 2015 RV Bubnov
• TREATMENT OF PAIN 13in Orthopaedic Medicine
• Diapositive numeacutero 22
• Diapositive numeacutero 23
• Diapositive numeacutero 24
• Diapositive numeacutero 25
• Heat Therapy13(Thermotherapy)
• Mechanotherapy vibration
• Impact Waves
• Ion Cyclotron Resonance
• KINESIOTHERAPYIS NECESSARY
• KINESIOTHERAPY
• Diapositive numeacutero 32
• VERTEBRAL MANIPULATION 13Robert Maignersquos ldquoManu Medicardquo
• TECHNIQUES
• Mechanism of action of Vertebral Manipulation
• ORTHESES AND AUXILIARIES
• Functional bandages(preventative or post-trauma)
• KINESIO TAPING
• Pain is subjective
• Diapositive numeacutero 40
• Diapositive numeacutero 41

Salvatore Denaro

• Pain Management
• Definition
• Diapositive numeacutero 3
• Diapositive numeacutero 4
• Diapositive numeacutero 5
• Self-assessment scale
• The measurement of subjective pain its usefulness
• Evaluation of pain to reach a diagnosis
• Classification of pain
• Key points and guidelines for the treatment of pain - Joint Commission on Accreditation of Health Care Organizations -
• Who takes responsibility for each type of pain - the Physiatrist the Rheumatologist or the Orthopedist
• Overview of therapy the vicious circle of untreated pain
• Diapositive numeacutero 13
• NEURAL PATHS FOR THE TRANSMISSION OF PAIN
• Routes of management
• But also in Orthopedic Medicinehelliphelliphellip
• Infiltration therapy
• Acupuncture (ancient Chinese approach outlined by Huangdi Neijing between 305 and 204 BC)
• Mesotherapy and Prolotherapy
• Dry needlingenspAnnals of the Rheumatic Diseases 74(Suppl 2)624 middot June 2015 RV Bubnov
• TREATMENT OF PAIN 13in Orthopaedic Medicine
• Diapositive numeacutero 22
• Diapositive numeacutero 23
• Diapositive numeacutero 24
• Diapositive numeacutero 25
• Heat Therapy13(Thermotherapy)
• Mechanotherapy vibration
• Impact Waves
• Ion Cyclotron Resonance
• KINESIOTHERAPYIS NECESSARY
• KINESIOTHERAPY
• Diapositive numeacutero 32
• VERTEBRAL MANIPULATION 13Robert Maignersquos ldquoManu Medicardquo
• TECHNIQUES
• Mechanism of action of Vertebral Manipulation
• ORTHESES AND AUXILIARIES
• Functional bandages(preventative or post-trauma)
• KINESIO TAPING
• Pain is subjective
• Diapositive numeacutero 40
• Diapositive numeacutero 41