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Guidelines for Physiotherapy Modalities

Guidelines for Physiotherapy Modalities


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Published by: dramitsaini on Sep 14, 2010
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DEFINITION: The therapeutic use of cold Ice is inexpensive, readily available to both practitioner and patient and can be used in a variety of forms.  Has relatively few contraindications, and can be very effective in the treatment of pain, edema, spasm and inflammation, especially in the first 24 to 48 hrs after an injury.  In many instances in which heat is considered the modality of choice for its "soothing" qualities, cooling would probably afford longer lasting and more complete results, and therefore should be considered more often. CRYOTHERAPY EFFECTS  Anesthesia  Analgesia  Reduction of edema  Reduced Muscle spasm  Reduced Spasticity  Reduced manual Dexterity CRYOTHERAPY INDICATIONS  Acute sprains and strains  Acute inflammatory processes  Acute trauma  Acute and Chronic muscle spasm  Spasticity associated with neurological disorders CRYOTHERAPY CONTRAINDICATIONS  Caution with geriatrics, infants, and cachexics  Individuals with psychological aversion to cod  Hypersensitive individuals CRYOTHERAPY APPLICATIONS  Ice packs  Ice massage  Cold compresses  Extremity baths      

This is the most commonly used heat modality Transfers heat to the patient primarily by conduction Most common cause for malpractice in physiotherapy today is burns, and they are most frequently caused by hot packs. The moist packs should be totally submerged in water to a minimum of 30 to 40 minutes between use to regain their correct temperature (150 -180 degrees F) Hot moist heat can be used in conjunction with other therapies. Moist heat vs. dry heat: dry heat causes stiffness.


EFFECTS  Increased circulation to the area being treated.  Relaxation  Decreased pain  Decreased muscle spasm  Generalized effect (PR, BP) INDICATIONS  Non-acute sprains/strains  Sinus conditions  Menstrual cramps  Arthritis, tendinitis, bursitis, capsulitis  Decreasing pain before exercise CONTRAINDICATIONS  Acute conditions  Patients on anti-coagulants  Psychological hysteria or drug dependent  Dermatological conditions  Diabetic or alcoholic neuropathy  Severe vascular occlusions  Always have patient inform you if hot pack is too hot.  Do not use steam packs over cuts or abrasions  Do not use heat packs in conjunction with skin balm or liniments.  Do not use toweling that is moist from use.

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Paraffin is essentially hot wax that consists of seven parts paraffin and one part mineral oil Some authorities recommend a 4:1 ratio Purpose of the mineral oil is to lower the melting temperature of the wax. Without the mineral oil, the melted wax would be far too hot for therapeutic purposes. Because the paraffin-oil mixture has a low specific heat, it can be applied directly to the skin if the circulation to the part is normal. Before the application, the part to be treated should be cleaned and dried, the thermesthetic sense should be ascertained to be normal, and all jewelry on the part to be treated should be removed. Temperature of the melted wax should be checked with a thermometer, but a finger pretest by the doctor/therapist will even more assure the apprehensive patient that the mixture is not too hot. Paraffin offers the same effects and advantages as any other form of superficial heat that is transferred by conduction.

PARAFFIN THERAPY INDICATIONS  Primarily indicated for non-acute arthritic joints, especially where there is limited mobility.  Bursitis, post fractures, stiffness, sprains, strains, and indurated scar tissue or contractures that limit motion 2

 When the treatment is completed.  There is less danger of burning  It takes only 8-10 minutes  It is capable of penetrating 5 cm into the tissues. use the immersion method. keep fingers spread apart. allow time between dipping for congealing. THERAPEUTIC ULTRASOUND THERAPEUTIC ULTRASOUND  Therapeutic ultrasound is that which is used for therapeutic (rather than diagnostic) purposes and is usually produced at 1 megacycle or 1 million cycles per second  US has replaced diathermy for many types of conditions because it is less time consuming and penetrates tissues well.  Depending upon the intended duration of the treatment.  Dipping method: After washing and drying the extremity.  After removal.  When first applied. wrap the part in wax paper and insulate all around with a towel. 3 . the application of the paraffin boot.  The entire treatment usually takes about 20 to 30 minutes.  Because US is transmitted by skin and fat.  Keep the part immersed from 20 to 30 minutes. dip again.  At the end of the treatment. METHODS OF PARAFFIN THERAPY APPLICATIONS  When constant heat is required for a long period. properly insulated. or where there is diminished sensation.  Repeat several times until the glove of paraffin is of sufficient thickness to allow the part to remain in the bath with comfort. The friction caused by the vibration within the patient’s tissues will produce heat. abrasions.  Continuous US causes a thermal effect. discard the wax. gives excellent results either by direct or reflex application.  Brush on method: To apply paraffin bath heat treatment to parts of the body which cannot be immersed in the paraffin bath conveniently. the heat can be directed to the deeper muscle layers where it is needed. and keep repeating until the thickness of the paraffin is from 1/4 inch to 1/2 inch.  The part treated should now be massaged and passively exercised. dip the part in and out of the bath quickly. remove the wax and discard it. acute skin disorders. 10 to 30 minutes. keep brushing until a thick coating covers the area  Allow it to remain for twenty to thirty minutes.  The part treated should be massaged and passively exercised. remove the paraffin and discard it  When dipping hands.  Dip the part in and out of the bath quickly so that a thin coating of paraffin congeals on the skin. the paraffin will feel very warm. two or three hours.PARAFFIN THERAPY CONTRAINDICATIONS  Paraffin should not be used over open wounds. paint the surface rapidly with a soft paint brush.  Immersion method: For heat treatments of shorter duration.

Fibroblast are stimulated to produce collagen fibres to from scar and myofibroblast contract to pull the edges together.  The "off time" allow the tissues to disperse the heat created.  Remodeling--. there is virtually no heating  With the 50% duty cycle. musculoskeletal disorders  Sprains and strains. some heating occurs. tendinitis. ULTRASOUND EFFECTS  Tissue temperature rise  Decreased nerve conduction velocity  Increased circulation  Increased tendon extensibility  Reduced adhesion formation  Decreased pain  Muscle relaxation ULTRASOUND INDICATIONS  Neuromuscular. alternating so that the "on time" or duty cycle is approximately 5-50% of the total time. including calcific tendinitis  Neuromas. adhesive capsulitis  Arthritic conditions . dupuytrens contracture  Plantar warts  Hematomas  Adhesions PRECAUTIONS  Over heating of the cutaneous tissues may occur if  the intensity is set too high  Transducer is moved too slowly  Transducer surface is not kept parallel to the skin surface PRECAUTIONS  Over heating of the periosteum may occur if: ~ The transducer is held too close to the bone ~ The intensity is set too high ~ The transducer is moved too slowly 4 . PULSED ULTRASOUND  With the 5% duty cycle. strength and elasticity of fibres. thereby minimizing or eliminating the thermal effect.increase tensile strength of scar by affecting the directions. then off. BIOLOGICAL EFFECTS  Inflammatory—increase fragility of lysosome membrane nd thus enhances the release of their contained enzymes which helps to clear the debris and allow next stage to occur.  Proliferative—fibroblast and myofibroblast may have ca++ ions driven to them by US.acute and chronic  Bursitis. scars.PULSED ULTRASOUND  The energy is on for a short period of time.  Pulsating US is advantageous when the thermal effect may be detrimental.

watches and buckles. over anesthetic areas  Over ischemic areas. The patient's sensation is an important guide as the regulation of dosage. chronic 5-10 minutes    SHORT-WAVE DIATHERMY Uses high frequency currents to heat the body tissues The heat results from the resistance offered by the tissue to passage of the electric current. jewelry.  Pins.  Duration: acute 3-4 minutes. The unit should never be turned on without coupling medium because the crystal may over heat. PRECAUTIONS  Remove metallic pins. directly over the spinal column or brain  Over a fracture (until well healed)  Deep vein thrombosis  Arterial disease. wrists. buttons. keys. TEN MAJOR EFFECTS  Thermal  Stimulation  Increased Blood flow  Hypotonicity 5 . malignancy  TB of the lungs or bone  Over the thoracic region of a patient with a pace maker APPLICATION OF ULTRASOUND  Apply coupling medium to the part being treated and place the transducer against the coupling medium. as it should produce only a mild comfortable sensation of warmth and not a sensation of heat  It is imperative that the sensory perception of the patient be normal in the use of diathermy. the wattage should be reduced to a tolerable level  Treat for the desired time US IMMERSION METHOD  Good for treating hands. If the patient gets too hot.CONTRAINDICATIONS  Epiphysis of growing bones  Over reproductive organs  Over a gravid uterus  Over the heart  Over the eye. feet and elbows  Place the transducer and the treating part in a container of water  Keep the transducer moving slowly and within 1cm of the part being treated. as they will concentrate the heat and could cause burns. and hair  Metallic objects must not contact the patient. hemophilia.  Keep the transducer moving slowly  Turn the intensity up to the desired level  Avoid bony prominences and keep the transducer parallel to the skin as possible  The patient may get a mild sense of warmth. or uncomfortable.

the greater should be the electrode -skin distance. Dosage Level II  For patients who have pain. gradually increase temperature to where the patient just perceives a comfortable yet distinct sensation of “velvety" warmth.  The patient should perceive no detectable sensation of warmth GENERAL RULE  The more acute the condition to be treated. which is provided by air spacing or towels INDICATIONS  URI  Chronic osteoarthritis  Prostatitis CONTRAINDICATIONS  Over pregnant uterus  Over wet skin  Patients with pacemaker  Peptic ulcers  Rheumatoid  Malignancy    MICROWAVE DIATHERMY The configuration of a pattern is determined and controlled by the distance that it is placed from the patient and the shape of the reflector.      Increase in visceral circulation Endocrine changes Oxidation Phagocytosis Detoxification Increase in capillary pressure DOSAGE LEVEL I  For patients who have no appreciable specific pain or in the treatment of visceral conditions. 6 . The power output of the microwave unit is adjusted in accordance with the size and shape of the body part treated. The smaller heat output of a microwave unit warms tissues in a much more local area. the temperature is increased to a point just below the level of Dosage I. ELECTRODE POSITIONS  The three common electrode positions are:  Transverse  Longitudinal  CO-planar GENERAL RULE The thicker the body part to be treated. the less temperature elevation and the shorter the treatment duration.

 The heat build up occurs mainly because of the resistance offered by tissue constituents to high frequency current. the skin resistance will be low. a larger potential difference (voltage) has to be applied to the skin in order to achieve an adequate current flow in the tissues. if any effect on deep joints or viscera MICROWAVE DIATHERMY PRECAUTIONS  If vigorous heating effects are desired. however.  The field that can be heated at any one time is relatively small.  Contact is not necessary.  When the skin resistance is high. and a specific temperature distribution results within body tissues. and smaller confined areas can often be treated more effectively. two medium frequency sine waves are applied to the skin and tissues in such a way that there is a difference in frequency between the two currents. the more likely it is that the stimulus will become uncomfortable for the patient. the eyes should be shielded with special goggles. with all the advantages of a more comfortable and efficient stimulation.  During treatment near the head. then a rather interesting 7 INTERFERENTIAL THERAPY .  Most of the effects of microwave radiation are due to heating of tissues by conversion. If the skin resistance is lowered.1 and 200 Hz.  Watches must be kept away from the high frequency field.  The applicator should not be brought into contact with the skin. Normal human skin has a very high resistance to the passage of a low frequency current. There is little penetration into deeper organs. TREATMENT DURATION  Treatment duration exceeding 2O minutes is inadvisable        The name interferential therapy stems from the concept of two currents interfering with each other  The major problems with the standard low frequency currents lie with the resistance offered by the skin and the relatively long pulse duration.000 Hz.  The larger the applied voltage.  Avoid sweat droplets forming on the skin that can be selectively heated. At this medium frequency the current is well outside the usual biological range of between 0.  Hearing aids must be placed at least 4 feet from the treatment field. Little resistance is offered to a higher frequency alternating current The net result is that if the applied current has a higher frequency. that in order to gain the advantages of lowered skin resistance.  The director should be placed from 1-7 inches from the patient depending on the type that is used. the applicator must be brought close to the surface of the skin. the frequency of the current used needs to be approximately 4. In addition. the higher frequencies will mean shorter pulse durations and this will lead to a more comfortable stimulus Problems arise. then a smaller applied voltage will be required to produce a given current flow in the tissues.  Microwave has little. If however.

F.F. currents to a patient using two. six to ten sessions of I F together with other measures should produce considerable improvement in the patient.F. in order to ensure that there is no abnormal response from the patient. the two currents are “'mixed" in the machine and delivered to the patient via two electrodes. the premodulated mode is probably the method of choice.  The "beat" frequency is the number of times in each second that the current rises and in intensity to the maximum and falls away to its minimum value  The beat frequency in Hz is simply the difference in frequency between the two medium frequency currents. currents are produced by the interfering of the two medium frequency.  In most cases. alternating currents. if the overall treatment program has been carefully designed and delivered then good results should be expected fairly quickly.  On the first treatment session.F.000Hz and the other at 4.000 Hz but its intensity is increasing and decreasing (beating) within the range of about 0.  I. current is produced endogenously.  In the pre-modulated mode however.  The intensity of the current rises and falls. instead of the conventional four electrodes. this is described as a "beating "of the two frequencies. the actual I. currents are applied via electrodes to the patient's skin  It is most unlikely that there is any significant clinical difference between the two methods. it is wiser to halve this.000 Hz) is called the carrier frequency  The current flowing in the tissues is approximately 4. This "beating" is the actual "interferential effect"  The beat frequency relates solely to the number of times per second the intensity increases and decreases. it can be seen that the effect of the blending of these two medium frequency sine waves is a variable increase in amplitude (intensity) of the resultant current.  For many situations. one at 4. Two such medium frequency currents. like other forms of electrotherapy is meant to be used as an adjunct to other forms of treatment.  The medium frequency (4. INTERFERENTIAL THERAPY TREATMENT DURATION  The average treatment time for most applications being 20 to 30 minutes. I.1 to 200 times per second.effect occurs.  There have never been a set number of treatment sessions for any particular clinical problem since all patients and problems are different  However.F.  INTERFERENTIAL THERAPY PRE-MODULATED  It is possible to deliver I.  In this system. 100 Hz  When these two currents are superimposed on one another.  In the conventional method.  There is no point in continuing with a technique which appears to be having no effect 8 . for example. other than the obvious ease of application of the premodulated method. the I. in muscle stimulation.  There is a significant difference between this technique and the standard method using four electrodes.

then poor results should indicate possible change in electrode position and/or a change in frequency/intensity.  Sustained traction is used from only a few minutes to as long as 30 minutes  The shorter duration seen with static traction is coupled with a greater traction force than that 9 . INDICATIONS  Pain relief both acute and chronic     Reduction of edema Re-education and strengthening of muscle.  It may also be used after certain surgical procedures such as spinal fusions. Stimulation and improvement of circulation General facilitation of healing INTERFERENTIAL THERAPY  I. moist heat)  Spinal Traction Definition The application of a drawing or pulling force along the long axis of the spine in order to:  Stretch soft tissues  Separate joint surfaces  Separate bony fragments DISTRACTION  A form of dislocation in which joint surfaces have been separated without rupture of the binding ligaments and without displacement INVERSION  Turning upside-down or other reversal of the normal relation of a part TYPES OF TRACTION CONTINUOUS TRACTION  This particular form involves lightweight applied for prolonged periods of time.F.  Assuming that the machine is working correctly and is applied properly. CONTINUOUS TRACTION  An example of continuous spinal traction is the halo type device used following a fracture of the cervical spine.  It is generally accepted that this form is ineffective at producing separation because of the slight force used. If the patient's condition is unchanged after one or two treatments.  Combining treatments implies giving two different but complimentary treatments at different times or in some instances at the same time (ice. can and should be combined with other modalities.  This type of traction is generally used to align and stabilize adjacent body parts when there are fractures and/or dislocations. then the situation needs re-assessing. SUSTAINED (STATIC) TRACTION  Sustained traction applies a constant amount of force.

 This is referred to as the “hold time"  The moderate force is then reduced to a lesser traction force that is applied for a shorter period from 10 to 20 seconds .  Although manual traction may often be beneficial by itself. which can be beneficial for the treatment of soft tissue injuries. headaches. Home cervical traction units (over-the-door) devices are examples of sustained traction.      seen with continuous traction. typically.  It can be used for disc protrusions with longer hold/'rest periods (60 seconds hold 20 seconds rest). nerve root compression.the “rest period"  The traction device alternates between the two different forces for the treatment duration.  The amount of traction applied may vary.  This allows intermittent stretch of soft tissues. degenerative disc disease. or an acute or chronic herniated disc. many patients find these devices helpful INTERMITTENT TRACTION  Utilizes a mechanical traction device that alternately applies traction and allows relaxation for a time period of several minutes to one-half hour. depending upon the patient’s condition. MANUAL TRACTION  Traction applied manually by the doctor. the part of the spine being tractioned. it is often employed prior to other mechanical forms of traction in order to assess the patient's tolerance. As the patient's condition improves. and other conditions. intermittent traction may prove to be more helpful.  The traction forces usually are applied for a few seconds at a time and. 10 .  The application of different traction forces that are alternately applied and released (hold/rest). joint separation and inhibition of the disc. Static traction is used mostly for WD herniations and may be effectively applied in both the cervical and lumbar spine Sustained traction is probably most helpful in the early phases of treatment when there is significant guarding and muscle spasm present. but also some degree of movement. in a rhythmic nature.  It is most often used for joint dysfunction and degenerative disc disease.  Patients who may be intolerant of manual traction probably will not respond well to more aggressive forms of traction  Manual traction may often provide relief for patients with cervical stiffness. joint fixation. and the strength of the doctor. thereby producing not only traction and separation. These devices use a traction force that ranges from 5 to 15 pounds Although the forces probably are not great enough to create any significant separation. disc problems.  In this form of traction a moderate force is applied for a period of time usually from 30 to 60 seconds.

 The weight of the upper body is affected by gravity and allows traction of the spine. very specific distraction is applied to the motion segment involved  Many tables can also rotate and/or sidebend they’re lower half. especially of the lumbar segments. As they move.POSITIONAL TRACTION  Involves placing the patient in a particular position to increase motion in a specific direction at a specific segment of the spine.  This type of "traction" is more appropriately termed a form of Passive mobility rather than traction. and sandbags may be used to accentuate the position and increase traction. using the flexion-distraction technique. speed.  In addition to the application of the mechanical forces. allowing even more specifically therapeutic distraction to the segment. facet syndrome. and generally tense.  Traction is applied in an intermittent fashion. alleviating the need for surgery. tight. INTERSEGMENTAL TRACTION  Involves the application of mechanical rollers that move up and down vertically as they track longitudinally along the paraspinal structures.  The tension. retrolisthesis. creating a pumping effect.  The primary benefit of intersegmental traction is seen in patients who are stiff. Spondylolisthesis. 11 . Flexion-Distraction  This is achieved with a specialized table on which the patient is placed in a prone position with the ankles strapped to the caudal end of the table.  The table is then unlocked. anterior or posterior innominate. many of the intersegmental traction tables simultaneously incorporate the use of vibration and heat with the mobilization. blocks. discogenic spondyloarthrosis. so that the lower half of the table is allowed to flex.  By placing cephalad and anterior pressure on the vertebra above the motion segment being treated. the rollers lift and separate the vertebral units and exert a mild tractioning effect.  Pillows. 55 responded to this treatment. and sacrum inferiority. The patient is secured by the ankles or thighs and allowed to invert in some degree up to 90 degrees. found in 43 cases of medial disc protrusion that 3 responded to this treatment:  In 57 cases of lateral disc protrusion. GRAVITY LUMBAR TRACTION  This may be achieved by a variety of inversion apparatuses.  Flexion Distraction can be a very effective method for the treatment of acute and chronic intervertebral disc protrusion (medial and lateral).  Cox. and amount of travel of the rollers are modified to patient comfort.  These techniques are incorporated into many of the procedures used by McKenzie in his extension protocols for LBP patients.

consequently. EFFECTS  Suction: A subatmospheric pressure is created when two vertebrae are pulled apart.  Distraction: The distance between the articular surfaces increases with sufficient traction.  It should not be a routine part of the treatment of every patient. traction should be initiated gently. Intersegmental traction should be provided to those patients who will benefit from the procedure. causing further centripetal force on the disc. This is a very gentle form of therapy that affects whole segments of the spine. only 12 .  Ligamentous tautening: The anterior and posterior longitudinal ligaments are stretched.g.. causing a centripetal force on the disc. it should be discontinued until both the condition and the therapy have been re-evaluated PRECAUTIONS  To minimize any potential injury resulting from inappropriate use of traction (e. INTERSEGMENTAL TRACTION  Intersegmental traction meets with high patient acceptance.If treatment increases peripheral pain and/or symptoms. too much weight or improper patient position).  Following the application of traction. that traction is usually not the only therapy used. a patient should be allowed a short rest period before resuming activities. it is very comfortable and relaxing. .  In addition to any mild effect that this procedure may have on the movement of the spine.  Relaxation of the musculature: Cyriax reported EMG silence 3 minutes after continuous traction. with progressively increasing force and time as the patient condition warrants. when it is used the doctor should be alert to changes in the patient's condition that warrant modification in treatment methods. INDICATIONS  IVD protrusions  Facet syndrome  Nerve root compression  Spondylolisthesis  Retrolisthesis  Discogenic spondyloarthrosis  Muscular spasm  Anterior or posterior innominate  Sacral inferiority  Early scoliosis  It should be borne in mind.  It is not uncommon for patients to feel some pain relief during the application of traction. it is overused in many practice situations  As with all other forms of therapy.  It is particularly important to keep in mind the following rule. As with other forms of therapy.  Widening of the IVF  Straightening of the spinal curves.

and other musculoskeletal inflammatory processes. which should be tractioned with a 0 degrees angle of pull. strains. CERVICAL TRACTION 13 . phlebitis. hypertension.  Pregnancy  Instability  Osteoporosis and other bone-weakening conditions  Hiatal hernia  Ankle. CONTRAINDICATIONS  Structural disease secondary to tumor or infection  Vascular compromise.  It is suggested that the patient should be gradually returned to the upright position to maintain relief. atherosclerosis.  For the safe and effective application of traction to the cervical spine:  It is suggested that the doctor begin with a traction force of between 10 and 15 pounds  If the patient improves. knee or hip joint dysfunction  Patients with aortic aneurysms  Patients with active peptic ulcers  Patients who are claustrophobic CERVICAL TRACTION  Maximum separation of the cervical vertebrae occurs when the cervical spine is flexed to 25 to 30 degrees except for the atlantoocccipital and atlantoaxial joints.  Acute sprains. angina. consequently less force is necessary when the upper cervical spine is the target area. continue at the same poundage or increase poundage by 5-pound increments to a maximum of 45 pounds.  It is particularly important that patients are able to relax  Consideration must be given to the effect of the traction device on the TMJ  In order to produce a desired effect the traction force must be great enough to effect a structural change at the spinal segment  Much less force is required for the cervical region CERVICAL TRACTION PROPER POUNDAGE  Forces of 25 to 45 pounds are necessary to produce measurable changes in the posterior structures.to have the relief disappear at tile end of tile treatment session.  Research has shown that supine traction is superior to sitting traction.  The maximal force should not exceed 45 pounds  Forces of 120 pounds have been shown to be necessary to cause a disc rupture at the C5-C6 level CERVICAL TRACTION PROPER POUNDAGE  It has been shown that a traction force of only 10 pounds will produce a separation of the atlantoaxial joints. and a history of stroke or transient ischemic attack.

some relief should be seen within the first three to five treatments.  Daily treatment is suggested for the first 3 days. however. the patient should be positioned in such a neutral or extended position. the traction will exert its maximal effect on the posterior structures. followed by three times weekly for 2 to 3 weeks  If traction is to be helpful. CERVICAL TRACTION DURATION  Traditionally. serve as a substitute for stretching and flexibility exercises. 14 . the lower in the cervical spine is the area affected by the traction force.  This is most easily accomplished by communicating with the patient during the initial application. forward.  If the head is maintained in a flexed. CERVICAL TRACTION ANGLE OF PULL  It is suggested that an angle of 0 to 15 degrees be used for the upper cervical spine. spinal traction is applied in 20-minute increments  Treatment times may vary depending on the nature of the condition. CERVICAL TRACTION TREATMENT FREQUENCY  As with other forms of therapy.bent position.  The greater angle of flexion.  The position of the head and neck can be adjusted to ensure that separation occurs at the desired location.  When the objective is separation of the posterior articulations. such as the facet articulations and the WF.PATIENT POSITION  Positioning of the patient has a direct effect on the location of the traction effect:  If the head is allowed to lay on the table with the cervical spine in a neutral or extended position.  Unlike other forms of traction.  The best position is the one that localizes the traction force in the area of pain.  When the objective is separation of the interbody joints. nor should it be used as a standard procedure for all patients seen. intersegmental traction may be warranted on a continuing basis in some patients.  It should not. the patient should be positioned with the neck in a flexed position. LUMBAR TRACTION  There is a great variation in the methods used to apply traction to the lumbar spine. spinal traction has a specific physiologic effect and should be used when that effect is desired. the type of equipment used. and the response of the patient.  The angle should be increased by 5-degree increments for each progressively lower cervical segment  Both the angle of pull and the position of the head have a similar effect in changing the location of the traction forces. the traction will exert its maximal effect on the anterior intervertebral structures such as the IVD.  The application of sustained and intermittent traction is usually only warranted for relatively short periods of time.

especially for patients with CNS lesions.  The lower in the lumbar spine the traction is intended.30 degrees. LUMBAR TRACTION ANGLE OF PULL  To treat lumbar conditions the proper angle of pull is between 15 and 50 degrees  To affect the lower thoracic and upper lumbar segments (L1 -L3). and the amount of flexion or extension used depend on the disorder being treated.  The patient position.  Disc protrusions usually are treated more effectively with sustained traction or with longer hold-rest periods of intermittent traction (60 seconds hold. the angle of pull must be 15 to 30 degrees  To affect the lower lumbar segments (L3 -L5).  Low frequency alternating currents are utilized because of the continued need for electrical stimulation of atrophied muscle. whether prone or supine. Traction node (sustained or intermittent) depends on both the disorder being treated and on the comfort of the patient. on the comfort of the patient. ions of various substances are placed under their similar polarity electrode and driven through tissues by currents usually less than 5 mA. sodium chloride. and on the type of equipment being used. 20 seconds rest).  Hyperlordosis should be treated with an angle of pull from 30 to 50 degrees.  Joint dysfunction and degenerative disc disease usually respond to shorter hold-rest periods of intermittent traction (30 seconds hold. on the experience of the doctor. continue at the same poundage or increase poundage by 10-pound increments to a maximum of 125 pounds.  Sine wave: a low frequency alternating current that takes the shape of a sine curve  Faradic current: a low frequency alternating current with 2 unequal phases  The iontophoresis effect is not frequently used. LOW VOLTAGE THERAPY IONTOPHORESIS  On the principle that like charges repel and opposites attract.  Low frequency alternating current: a current in which the direction of electron flow changes at a rate between l and 2000 Hz. 10 seconds rest) LUMBAR TRACTION PROPER POUNDAGE  Begin with approximately 50 pounds  If the patient improves. the angle of pull must be 30-50 degrees.  Copper sulphate.  Hypolordosis of the lumbar spine should be treated with an angle of pull from 15 .  Galvanic current allows stimulation of deinervated muscle as well as the possibility of driving ions into the tissues called iontophoresis. the greater the angle of pull.  A galvanic current is a unidirectional (monophasic) current flowing for an indefinite duration. lidocaine and a corticosteroid LOW VOLTAGE THERAPY 15 LOW VOLTAGE GALVANIC .

 Set the timer to desired time  Increase the intensity slowly to patient tolerance or until the desired muscle contraction is achieved. Kots of the Soviet Union has suggested the following times:  To increase circulation: 2 sec on. cold packs. for combination therapy.g. if a tetanic contraction is desired to fatigue the muscle (e. can use hot packs. if a series of muscle contractions is desired (e. "on ramp" time. and/or "off ramp time. S sec off  For strength. 50 sec. heart or eyes  Over bony prominences  Fractures  Skin lesions  Malignancy  Anesthetic areas  Over a gravid uterus LOW VOLTAGE THERAPY APPLICATION  Place pads firmly on treating parts. endurance.EFFECTS  Contraction of innervated muscle  Pain relief  Edema reduction LOW VOLTAGE THERAPY INDICATIONS  Stimulation of weak and/or atrophied muscles  Nonsystemic edema LOW VOLTAGE THERAPY CONTRAINDICATIONS  Through the brain.  If unequal sized pads are used.  Set mode to: Pulse. the smaller pad will produce a greater effect.  Quadrapolar or bipolar technique may be used.. 2 sec off  To reduce spasm and pain: 12 sec on. and velocity: 10 sec. for muscle reeducation)  Set mode to: Tetanize. off 16 . on. to avoid further trauma or to disperse fluid.  Set mode to: Surge.g.  A probe may be used for specific stimulation of motor points. if a gentle treatment is desired.  Treatment duration depends on the effect desired and the integrity of the muscle being stimulated LOW VOLTAGE THERAPY  Dr. for muscle spasm or muscle tension)  Choose the pulse width.

and are administered for the purpose of producing effects on the nervous and muscular systems and the local and general circulation of the blood and lymph.  Electrodes should be removed every day or two to clean the skin and inspect the area. TENS INDICATIONS  Chronic pain  Acute pain  Intractable pain (TENS can provide adequate relief of pain secondary to malignancy. TENS should apply to any form of electrical stimulation that is applied via surface electrodes. Results are best with trunk and extremity pain and worst with pelvic and perineal pain. and cost effective method of treating acute. TENS Certain manipulations of the soft tissues of the body. TENS CONTRAINDICATIONS  Pacemakers  Carotid nerve stimulation  Laryngeal stimulation  During pregnancy TENS ELECTRODE PLACEMENT  Electrode placement is one of the most critical factors for the success of TENS  Directly over or around the painful site  Over trigger points  Over acupuncture points  Within a specific dermatome  At the site of the corresponding nerve root TENS  The most significant complication of TENS is local skin rashes produced by the conduction gel or tape. these manipulations are most effectively performed with the hands. noninvasive. chronic and psychogenic pain of innumerable origins. safe.  The term has been used for small portable stimulators that can be attached to the belt or clothing and used for various time periods for the relief of pain.  Care must be taken to not allow the TENS to obliterate pain to the extent that the patient loses protective cues and overstresses the part being rehabilitated.  Many health practitioners are finding TENS to be an effective.  Rehabilitation: The use of TENS for the reduction of pain during rehabilitation can increase performance and shorten disability. however. SOFT TISSUE MANIPULATION 17 .  There are no contraindications to 24-hour use of "high TENS".  In general the primary effect of TENS is the relief of pain. "Low" TENS. as "Low TENS" causes muscle contraction and may cause soreness if used for longer periods. should be used only 30-40 minutes at a time.

No lotion is used and small circular or linear strokes are used to loosen the tissue beneath the skin.Kneading or rolling motion. It is useful for increasing circulation to an area and for postural drainage to increase the release of abnormal secretions from the lungs. It is performed perpendicular to the tendon sheath.is a deep massage that strives to separate the fascia between muscles Friction . strokes are either in a centripetal direction or transverse to the muscle fibers Rolfing . Tapotement .is used to break up superficial and/or deep adhesions of muscle or other soft tissues.stroking motion and begin with light pressure and progress to heavier pressure as tolerated and terminate with light pressure. adhesions. thrombus Hyperesthesia of the skin Communicable disease SPECIFIC METHODS Effleurage . 18 . embolus.           EFFECTS Mechanically assisting the flow of blood and lymph to increase circulation and reduce edema Maintenance of muscle flexibility and viability Breaking up scar tissue. Transverse friction . slapping. causing the tendon to separate from the sheath and slide through it more easily.is a specific type of friction massage that is used to treat tendinitis or tenosynovitis. Petrissage . cupping motions. kidney disease. and fibrosis Sedation Stimulation CONTRAINDICATIONS Acute circulatory disturbances Acute inflammation Malignancy Edema secondary to heart decompensation. obstruction of lymph channels.includes tapping.

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