admin, Author at Hirofizikal


Shoulder pain can occur acutely (caused by an injury), or pain that occurs as a result of chronic conditions. In the younger population, it is most often the result of an injury, while in the elderly, it is a more common cause of chronic changes.

Pain in the shoulder can be reflected from the zone of the cervical or thoracic part of the spine, the zone under the shoulder blade, where the physiotherapist or physiatrist can feel the changes through palpation, the patient feels pain that is reflected in the shoulder, also the intercostal zone can reflect pain in the shoulder , that is why it is necessary to perform an examination and establish the exact place of origin of the pain, because only then can adequate therapy be implemented. Pain in the shoulder itself sometimes cannot be treated with therapies, because it can be caused by a cardiac condition, therefore it is necessary to take into account all aspects, as well as the complete clinical picture of the patient, if necessary, the patient is referred to imaging of the shoulder or other parts of the potential site of pain, I can work, x-ray, mr, ct, ultrasound of soft tissues, emng…

Therapy for shoulder pain:

Chiropractic (if indicated)
Manual non-invasive method
Laser therapy
Ultrasound therapy
Tecar therapy
Mesotherapy of pain

We are at your disposal for any additional information

Hirofizikal Rehabilitation Clinic.


Hip pain:

Hip pain occurs very often in the elderly as a result of changes in the hip joint itself and damage to the soft tissues around the joint.

According to the cause, place and type of pain, pain in the hip can be divided into the following diseases:

  • Osteoarthritis (joint degeneration)
  • Bursitis (inflammation of the bursa within the joint)
  • Sarcoilitis (sarcoid joint pain)
  • Iliotibial pain syndrome (pain on the outside of the upper leg)
  • Trochanteric pain syndrome (outer hip pain)

Chronic conditions that cause pain in the hip can be treated with a combination of injections, medication, as well as through the use of physical therapy, a manual non-invasive method also shows good effects, and later kinesitherapy is applied.

Knee pain:

Knee pain can be divided into knee pain during movement and knee pain during rest. Pain in the knee that occurs during rest requires immediate intervention and a trip to the doctor. Such pain is most often caused by swelling or a sprained knee.

Recreational and professional athletes, as well as the elderly, often experience knee pain that can be immediate as a result of a sprained or dislocated knee.

If the pains are temporary, it is important to rest, to put cold compresses on the place of pain. If the patient’s pain or swelling does not disappear after 2-3 days, if there is any, he should immediately contact his doctor or physiotherapist, in order to receive the necessary therapy.

Chronic knee diseases that require treatment:

  • Gonarthrosis
  • Jumper’s knee
  • Prepatellar bursitis
  • Knee arthritis

Treatment of the above-mentioned diseases requires that the patient consult a doctor or physiotherapist, who will recommend a possible examination by an orthopedist, rheumatologist or other specialist, as well as additional diagnostics in the form of CT, MR or ultrasound imaging. Therapy can be physical (electrotherapy, laser, magnet, tecar), acupuncture, pain mesotherapy, medication, injection for the knee, later application of kinesitherapy.


Pain and stiffness in the joints is very complex and has many causes and types. In young people, joint pain occurs as a result of some trauma, sports injury or everyday injury from a fall, while in the elderly, joint pain is more common, caused by chronic conditions such as rheumatoid arthritis and gout.

Rheumatoid arthritis is a condition of pain and stiffness in the joints, fingers and hands, accompanied by a feeling of discomfort, especially on cold days. Rheumatoid arthritis is aggravated in some patients, making it impossible for patients to even hold objects in their hands, which limits them in their daily functioning. Gout manifests itself through redness and swelling exclusively in the feet, resulting from the accumulation of uric acid crystals.

If you feel pain in your joints, regardless of whether it was caused by an injury or a chronic condition, consult a doctor.

Physiatrists and physiotherapists also play an important role in solving joint pain problems.

Therapy for pain in the joint or joints that is carried out in our office includes the following methods:

  • Electrotherapy
  • Chiropractic
  • Laser therapy
  • Magnetotherapy
  • Kinesitherapy
  • Manual non-invasive method
  • Acupuncture
  • Mesotherapy of pain



Neck pain occurs in almost 90% of people as a result of bad habits and inadequate body position. The causes of neck pain can be numerous, and the most common cause is stress, then excessive sitting at the computer, where the body position is unnatural, and the neck is in a non-functional position for a long time, which leads to spasms of the neck muscles, and they become less mobile.
The causes of neck pain can be numerous. One of them is sleeping on a bad mattress, a bad pillow and in an incorrect position that does not allow the body to rest. Pain in the neck often spreads to the shoulders and further to the spine, which can lead to bad posture of the whole body.

Improper sitting, stressful life in combination with poor sleep and inactivity of an individual can leave permanent consequences not only for the neck, but also for the entire spine and the entire back.
Neck pain can also occur due to certain injuries, and if neck pain is chronic, certain degenerative changes occur that can only be cured with a combination of different therapies carried out by a professional, usually a physiatrist.
The physiatrist will determine the degree and type of pain in the neck through a detailed examination and suggest adequate therapy

Therapies that can be applied depending on the type and degree of pain are:

  • Chiropractic
  • Kinesitherapy
  • Application of various forms of electrotherapy
  • Tecar therapy
  • Mesotherapy of painMassage
  • Laser therapy
  • Manual non-invasive therapy
  • Acupuncture

There is a way to prevent the spread of neck pain, and that is to provide yourself with rest in a comfortable position until they pass, as well as to use an adequate bed, mattress and pillow that will significantly improve the condition and prevent chronic pain from occurring.



Physical therapy is an indispensable part of medicine, which deals with treatment, rehabilitation, as well as improving the functionality of the entire organism. The goal of physical therapy is for the person to regain mobility, as well as to return to daily activities. Physical therapy is used to treat injuries, as well as diseases that affect the entire locomotor apparatus (bones, muscles, joints, tendons, ligaments). The therapy itself acts on bones, muscles, joints, tendons, ligaments, joints, so it has a very wide range of effects. Regardless of whether your shoulder, elbow, wrist, hip, neck, spine, knee, ankle hurts, whether it is an acute, subacute or chronic illness, physical therapy is an indispensable part of treatment. In addition to the effects on the locomotor system, physical therapy also affects the cardiovascular, respiratory, and digestive tracts.

Physical therapy has several forms of application, the most common being electrotherapy, kinesitherapy, laser therapy, magnetotherapy, ultrasound therapy, tekar therapy, various forms of massage. In addition to forms of physical therapy, the Hiro-Fizikal clinic also uses chiropractic, popularly known as chiropractic, a manual non-invasive method (for patients who are afraid of manipulation), acupuncture, pain mesotherapy, as well as a physiatrist examination service at the request of the patient.


Ankle sprain requires adequate care. Many years of experience have shown that most patients do not perceive this problem in a serious way, but think that their problem is solved when the pain stops. However, this is a mistake that can later have far-reaching consequences, such as joint instability or other chronic changes in soft structures, algodystrophic syndrome (Sudek’s disease).

When does joint distortion (sprain) occur?

• It most often occurs during sports activities
• Walks on uneven ground
• Sudden changes in the direction of movement
• Landing on the ground
• A sudden fall where the wrist twists

Why do ankle sprains occur?

When the joint is in a position that does not correspond to its physiological position, and the tendons, ligaments and muscles fail to maintain the joint, i.e. to return it to the physiological position, the joint luxates (moves from its position), and when the foot contacts the ground, due to strong pressure, an injury occurs, i.e. ankle sprains.

Symptoms that the patient has:

• Pain
• Swelling
• Limited movement
• Impaired or completely disabled movement

What the patient can do as a form of first aid:

• Ice the injured segment
• Leg elevation
• Rest
• Bandaging, compression bandage, depending on what is nearby
• Moderate leaning, if possible it is best not to lean on the injured leg

An objective examination can determine:

• Determine by palpation the most intense place of pain, or several of them, depending on the degree of injury
• Swelling
• Is the skin cyanotic
• Is there inflammation
• Range of motion test
• Assessment of joint stability
• Is it necessary to send the patient for further diagnostics (ultrasound, x-ray, magnetic resonance)
• Orthopedic examination, or another specialist

Rehabilitation program of the Chiro-Physical Outpatient Clinic for ankle joint distortions (Distorzio articulatio talocruralis)

• Chiropractic, if indicated
• Cryomassage
• A gel that has a local cooling effect
• Manual non-invasive method
• Compression bandage, longette
• Tecar therapy
• Electrotherapy set
• Magnetotherapy
• Laser therapy
• Kinesitherapy
• Patient education for performing exercises at home

We are at your disposal for any additional information
Your CHIRO-PHYSICAL Mileševska 7, Vračar.


A Discus hernia occurs when one of the intervertebral discs prolapses (bulges, leaks). It can occur in any part of the spine, and most often in the lower back area. Depending on where the prolapsed disc has occurred, numbness or weakness may occur in the neck, arm, or leg.

The most common causes of Discus hernia are continuous physical activity (carrying heavy objects, heavy physical work, standing for long periods of time…) or sitting in the same position every day (most often when working at a computer).


Discus hernia occurs most often in the lumbar spine. If the nerve is pressed, in addition to the back, the pain can be felt in the buttocks, thighs, calves, and sometimes in the feet.

With a herniated disc in the neck area, the pain is most often present in the neck, shoulder and arm, and is often described as sharp or burning.

People with a Discus hernia often describe the symptoms as sharp pain (like a knife stab), radiating numbness or tingling in the part of the body served by the affected nerves. Weakness can be felt in the muscles of the affected nerve, inability to lift or hold objects, possible tripping while walking.


A Discus hernia can be treated non-operatively, and the best results are achieved by combining chiropractic, physical and kinesi therapy.


Author: dr. Marijana Todorović, specialist in physical medicine and rehabilitation

Complex regional pain syndrome is defined as a pain syndrome in which, in addition to pain, there is loss of function and signs of autonomic dysfunction. In clinical practice, it is most often seen as a complication of a wrist fracture. Although still unexplained, the largest number of theories indicate that CRPS occurs as a result of hyperactivity of the sympathetic nervous system.

Complex regional pain syndrome (CRPS-complex regional pain syndrome), better known in our country as Sudek’s disease, refers to a painful, limited, sensitive extremity with a changed color and limited functions. It was first described under the term “causalgia” during the American Civil War as a complication of gunshot wounds.

It was first described under the term causalgia (kausós, “burning”) + (álgos, “pain”) during the American Civil War as a complication of firearm injuries in the 1950s. Evans introduced the term “reflex sympathetic dystrophy”: sympathetic hyperactivity on somehow involved in pathological activity on the periphery Paul Sudeck 1866-1945.

In 1900, Sudek described radiographically visible patchy osteopenia, while Evans introduced the term “reflex sympathetic dystrophy” (RSD) in the 1950s, believing that sympathetic hyperactivity was somehow involved in abnormal activity in the periphery. After the decision made by the International Association for the Study of Pain in 1994, the name complex regional pain syndrome is used.

The American Hand Surgery Association defines CRPS as a pain syndrome in which, in addition to pain, there is loss of function and signs of autonomic dysfunction.

Former name for complex regional pain syndrome

  • Reflex sympathetic dystrophy
  • Causalgia
  • Algodystrophy
  • Algoneurodystrophy
  • Sy shoulder jacket
  • Sudek’s dystrophy
  • Post-traumatic dystrophy
  • Post-traumatic sympathic dystrophy
  • Acute bone atrophy
  • Pseudodystrophy
  • Reflex neurovascular dystrophy
  • Sympathalgia

Forms of complex regional pain syndrome

Type I Reflex Sympathetic Dystrophy 90%

It is not associated with nerve damage (or minor damage) in the affected area
It develops with fractures, dislocations, contusions, distortions

Type II (Causalgia) 15%

Associated with nerve damage in the affected area or injury to a large peripheral nerve
These two forms of CRPS differ only in the initiating factors: minor or no trauma to the nerve in type I, and major nerve damage in type II.
They do not differ in clinical signs and symptoms as well as in treatment.
It is chronic neuropathic pain that lasts longer than three months
The disease is regional without specific points of pain, in the acute phase it is accompanied by swelling, warm skin, hyperesthesia, allodynia and vasomotor symptoms with reduced mobility.
In the chronic phase, the affected extremity may be reduced in size, thinner, with a low skin temperature, and the development of contractures is also possible.
In the acute phase, CRPS is easier to diagnose than in the chronic phase
Patients with CRPS also experience psychological changes (insomnia, depression and anxiety).


CRPS is 3-4 times more common in women (ages 61-70)
It is present 2 times more often on the upper extremities
trauma almost always precedes CRPS Type I
CRPS occurs in about 1-2% of patients who have had fractures and about 2-5% of patients after peripheral nerve injury
In 40% of patients, a bone fracture or surgical procedure precedes the development of the disease
In a certain percentage of CRPS patients, the syndrome develops spontaneously
CRPS most often occurs after trauma. A common predisposing factor in this regard is a Colles fracture – 25% of patients with this type of fracture show signs of CRPS (Atkins 1989). However, CRPS can occur as a result of many other conditions such as myocardial infarction, cerebral infarction, traumatic brain injury, spinal cord injury, and more.

The largest number of theories indicate that CRPS arises as a result of hyperactivity of the sympathetic nervous system. Namely, the physiological activation of the sympathetic nervous system that occurs after an injury leads to vasoconstriction and normally lasts from a few minutes to a few hours. For unknown reasons, in people who develop CRPS, the sympathetic nervous system does not stop its activity, maintaining spasm of the blood vessels and thus leading to additional swelling and pain, as a result of which the circulus vitiosus is established. Additionally, it is believed that there is a psychological basis for the occurrence of this disease, but it is insufficiently described in the literature.

Clinical picture

The disease usually progresses through three stages. They can be variable and vaguely limited.

Phase I (traumatic, acute phase) begins at the time of the initial injury, or within a few weeks of it, and usually lasts from a few weeks to 6 months. It is characterized by pronounced pain and increased circulation, which is manifested by doughy swelling, redness and a warm extremity. Limitation of range of motion as well as hyperhidrosis may also be noticeable at this stage. The skin may be sensitive to the touch. It is considered that osteoporosis begins to develop at this stage, but it is still not visible on radiographs.

Phase II (dystrophic phase) begins 3 to 6 months after the onset of pain and lasts an additional 3 to 6 months. The swelling is less pronounced, however, pain and limitation of range of motion are still present. Circulation is reduced and the temperature of the extremities is lower. Hair and nail growth decreases, while hyperhidrosis remains. Atrophy of muscles and subcutaneous tissue develops. Radiographs may show patchy atrophy as well as perarticular thickening. Personality by type of causalgia is described and can be manifested in this phase.

Phase III (atrophic phase) begins 6 to 12 months after the onset of pain and can last for several months. The pain is less pronounced, but there is significant atrophy of the skin and subcutaneous tissue, as well as irreversible contractures. The skin is smooth, shiny, dry and cool. Diffuse osteoporosis or osteopenia is visible radiographically.

IASP (Orlando) diagnostic criteria for CRPS

Existence of certain precipitating damage
Continuous pain, hyperalgesia, allodynia
Edema, changes in the local circulation of the skin of the affected region or vasomotor changes
Other conditions associated with this degree of pain and dysfunction exclude the diagnosis
International Association for the Study of Pain: Diagnostic Criteria for Complex Regional Pain Syndrome with 1997 ICD Codes • Merskey H, Bogduk N. Classification of Chronic Pain: Descriptions of Chronic Pain ygp Syndromes and Definitions of Pain Terms. 2nd ed. Seattle, Wash.: IASP Press; in 1994

Proposed Modified Diagnostic Criteria for CRPS (Budapest, 2003)

Continuous pain that is not proportional to the severity of the injury
At least one symptom in 3 of the 4 listed categories is present
a) Sensory hyperalgesia and/or allodynia
b) Vasomotor temperature asymmetry and/or skin color change and/or skin color asymmetry
c) Edema and/or sweating and/or asymmetry of sweating
d) Motor/Trophic: reduced range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes

Harden RN, Bruehl SP. Diagnostic criteria: the statistical derivation of the four criterion factors. In: Wilson P, Stanton-Hicks M, Harden R, editor. CRPS: Current Diagnosis and Therapy. Seattle, WA: IASP Press; 2005 pp. 45-58.

The diagnosis is usually made on the basis of the clinical picture. Radiological examination may be helpful, but changes in terms of patchy osteopenia may not be apparent until the later stages of the disease (usually after 3 or more months). Three-phase bone scintigraphy may show increased binding in the area of ​​the affected limb early in the disease, which most likely indicates increased blood flow originating from local bone metabolism due to sympathetic vasoconstriction. This is best seen in the carpal and metacarpal joints of the bones. The findings, however, do not precisely correlate with the degree of vasomotor disturbance. Thermography is a sensitive method for measuring and registering the difference in temperature of the affected and unaffected limb.

Early diagnosis of CRPS is the best therapy. Poplawski and the authors believe that the most important measure of the outcome of the treatment of this syndrome is the initiation of therapy in an interval of less than 6 months between the onset of symptoms and the initiation of therapy. Delayed diagnosis can lead to prolonged rehabilitation and physical changes characteristic of the later stages of CRPS. The therapeutic approach includes pharmacological measures with aimed at reducing the intensity of pain, sympatholytic interventions and physical medicine and rehabilitation, depending on the severity and stage of the disease


  • Treatment is multidisciplinary
  • Invasive and non-invasive methods
  • Medication
  • Physical therapy
  • Interventional forms of treatment


Medical treatment

  • Antiepileptics (gabapentin and pregabalin). They act via the NMDA receptor
  • Antidepressants
  • Opioid analgesics
  • Anesthetics (Ketamine in subanesthetic doses. Acts through NMDA receptors and reduces sensitization)
  • Corticosteroids (reduce the production of prostaglandins). Most often, Pronisone is given with doses up to 100 mg/24h or 1mg/1kg, which are gradually reduced over the next two weeks.
  • Calcitonin (analgesic effect, inhibition of osteoclasts)
  • Bisphosphonate (osteoporosis, analgesic effect)
  • Alpha adrenergic antagonists (phentolamine)
  • Ca channel blockers (in the acute phase), vasodilators
  • NSAIDs
  • Vitamin C and DMSO (antioxidants)
  • Muscle relaxants (spasmolytics) (first, oral, then intrathecal, Baclofen – reduces dystonia)



Of the surgical interventions, sympathetic blockade of the ganglion stellatum is most often used. This intervention is expected to lead to a reduction in complaints, which represents a simultaneous diagnostic and therapeutic means of treatment. Intravenous regional blockade, chemical and surgical sympathectomy as well as amputation of the affected extremity are also considered. Most authors emphasize the importance of physical therapy in the prevention and treatment of this disease. Physical therapy and rehabilitation in the early stages should lead to reduction of pain and prevention of contractures. The principles are reduced to the elimination of painful passive movements, the mobilization of adjacent joints in terms of preventing the occurrence of their contractures, while forcing controlled active and actively assisted movements to the limit of pain. The kinesitherapy program is followed by the application of appropriate agents that, depending on the stage, aim to reduce swelling, pain, increase circulation and prevent hypotrophy of the affected limb.

Goal: reduction of pain and improvement of function

  • Early mobilization (prevention of CRPS)
  • Diadynamic currents-ganglion blockade (eg Ganglion Stellatum for GE)
  • Low frequency laser
  • TENS
  • Cryotherapy
  • Hydrotherapy
  • Exercises to increase range of motion, exercises to strengthen GMS

Invasive therapy

When satisfactory results are not obtained with physical and medical therapy

  • Cute blocks
  • Spinal cord stimulation
  • Surgical sympathectomy
  • Limb amputation

The majority of authors emphasize the importance of an early, targeted multidisciplinary therapeutic approach to CRPS, a condition that, if not treated in a timely manner, can lead to long-term disability. Early recognition is important for timely initiation of therapy before the development of stage II and stage III trophic changes. Unfortunately, there is little objective evidence on which to base a reliable treatment plan. In this sense, it is certainly time for large multicenter, prospective, controlled studies that will better explain the effects of existing therapeutic options.


Paice E. Fortnightly Review: Reflex sympathetic dystrophy.BMJ 1995;310:1645-48. 2. Mitchell SW, Morehouse GR, Keen WW. Gunshot wounds and other injuries of nerves. New York: Lippincott, 1864. 3. Singh MK, Patel J.: Complex Regional Pain Syndromes. Emedicine. 2006 Jun. Available from: URL: 4. Amadio PC, Mackinnon SE, Merritt WH, Brody GS, Terzis JK.: RSDS: consensus report of an ad hoc committee of the American Association for Hand Surgery on the definition of RSDS. Plast Reconstruct Surg; 87:371-5. 55. Atkins RM, Duckworth T, Kanis JA: Algodystrophy following Colles’ fracture. J Hand Surg 1991;14B:161-64. 6. Kozin F.: Reflex sympathetic dystrophy syndrome: a review. Clin Exp Rheumatol 1992;10:401-9. 7. Poplawski ZJ, Wiley AM, Murray JF.: Post-traumatic dystrophy of the extremities: a review and trial of treatment. J Bone Joint Surg [A] 1983;65:642-54. 8. Livingston WK.: Pain mechanisms. New York: Macmillan, 1947. 9. Hooshmand H. Chronic pain: reflex sympathetic dystrophy, prevention and management. Boca Raton, FL: CRC Press, 1993:13-26. 10. Egle UT, Hoffman SO.: Psychosomatic correlations of sympathetic reflex dystrophy (Sudeck’s disease). Review of the literature and initial clinical results. Psychother Psychosom Med Psychol 1990; 40:123-35. 11. Van Houdenhove B, Vasquez G, Onghena P, Stans L, Vandeput C, Vermaut G, et al. Etiopathogenesis of RSD: a review and biopsychosocial hypothesis. Clin J Pain 1992; 8:300-6. 12. De Vilder J.: Personality of patients with Sudeck’s atrophy following tibial fracture. Acta Orhop Belg 1992; 58 (suppl 1): 252-7. 13. Gellman H, Andrew D.: Reflex Symphatetic Dystrophy. U:Brotzman BS, Wilk KE, urednici. Clinical Orthopaedic Rehabilitation. 2nd ed. Philadelphia: Mosby; 1996. p. 543-553. 14. Todorović-Tirnanić M, Obradović V, Han R, Goldner B, Stanković Đ, Sekulić D, Lazić T, Djordjević B.: Diagnostic approach to reflex symphatetic dystrophy after fracture:radiography or bone scintigraphy? Eur J Nucl Med 1995;22:1187-1193. 15. Fialka V, Wickenhauser J, Engel A, Schneider B.: Sympathetic reflex dystrophy. Effectiveness of physical therapy treatment of Sudeck’s syndrome. Fortschr Med 1992;110(9):146-8.


The rehabilitation process begins immediately after the surgery, on the same day or the next day. The patient becomes vertical, starts walking, with the help of aids (crutches, walkers) or only with the assistance of a physiotherapist, depending on the patient's condition, his muscles, general health, as well as previous activities and possible accompanying diseases.


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Copyright by Hirofizikal 2021. All rights reserved.

Copyright by Hirofizikal 2021. All rights reserved.

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