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PHYSIOLOGICAL THERAPEUTICS CRYOTHERAPY

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      

HOT MOIST HEAT
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.

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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 THERAPY
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

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

acute and chronic  Bursitis. alternating so that the "on time" or duty cycle is approximately 5-50% of the total time. 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 . scars. then off. musculoskeletal disorders  Sprains and strains. ULTRASOUND EFFECTS  Tissue temperature rise  Decreased nerve conduction velocity  Increased circulation  Increased tendon extensibility  Reduced adhesion formation  Decreased pain  Muscle relaxation ULTRASOUND INDICATIONS  Neuromuscular. 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.  Pulsating US is advantageous when the thermal effect may be detrimental. including calcific tendinitis  Neuromas. adhesive capsulitis  Arthritic conditions .  The "off time" allow the tissues to disperse the heat created. there is virtually no heating  With the 50% duty cycle.  Proliferative—fibroblast and myofibroblast may have ca++ ions driven to them by US. Fibroblast are stimulated to produce collagen fibres to from scar and myofibroblast contract to pull the edges together.PULSED ULTRASOUND  The energy is on for a short period of time.  Remodeling--. tendinitis. PULSED ULTRASOUND  With the 5% duty cycle. some heating occurs.increase tensile strength of scar by affecting the directions. strength and elasticity of fibres. thereby minimizing or eliminating the thermal effect.

jewelry. PRECAUTIONS  Remove metallic pins. The patient's sensation is an important guide as the regulation of dosage.CONTRAINDICATIONS  Epiphysis of growing bones  Over reproductive organs  Over a gravid uterus  Over the heart  Over the eye. 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.  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. keys. over anesthetic areas  Over ischemic areas. watches and buckles. buttons. hemophilia. as they will concentrate the heat and could cause burns. 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. 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. the wattage should be reduced to a tolerable level  Treat for the desired time US IMMERSION METHOD  Good for treating hands. wrists.  Duration: acute 3-4 minutes. or uncomfortable. TEN MAJOR EFFECTS  Thermal  Stimulation  Increased Blood flow  Hypotonicity 5 . If the patient gets too hot. 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. The unit should never be turned on without coupling medium because the crystal may over heat. and hair  Metallic objects must not contact the patient. directly over the spinal column or brain  Over a fracture (until well healed)  Deep vein thrombosis  Arterial disease.  Pins.

the temperature is increased to a point just below the level of Dosage I. The smaller heat output of a microwave unit warms tissues in a much more local area. 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. The power output of the microwave unit is adjusted in accordance with the size and shape of the body part treated. the less temperature elevation and the shorter the treatment duration. 6 . Dosage Level II  For patients who have pain.      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. the greater should be the electrode -skin distance.  The patient should perceive no detectable sensation of warmth GENERAL RULE  The more acute the condition to be treated. gradually increase temperature to where the patient just perceives a comfortable yet distinct sensation of “velvety" warmth. ELECTRODE POSITIONS  The three common electrode positions are:  Transverse  Longitudinal  CO-planar GENERAL RULE The thicker the body part to be treated.

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

 In the pre-modulated mode however. Two such medium frequency currents. I.effect occurs. alternating currents. six to ten sessions of I F together with other measures should produce considerable improvement in the patient.F. INTERFERENTIAL THERAPY TREATMENT DURATION  The average treatment time for most applications being 20 to 30 minutes. in order to ensure that there is no abnormal response from the patient. for example. it is wiser to halve this.F. the 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.  There is no point in continuing with a technique which appears to be having no effect 8 . one at 4.  INTERFERENTIAL THERAPY PRE-MODULATED  It is possible to deliver I. like other forms of electrotherapy is meant to be used as an adjunct to other forms of treatment. the two currents are “'mixed" in the machine and delivered to the patient via two electrodes. This "beating" is the actual "interferential effect"  The beat frequency relates solely to the number of times per second the intensity increases and decreases.  There have never been a set number of treatment sessions for any particular clinical problem since all patients and problems are different  However. other than the obvious ease of application of the premodulated method. currents are produced by the interfering of the two medium frequency.  The medium frequency (4.  For many situations. in muscle stimulation. 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. instead of the conventional four electrodes. the premodulated mode is probably the method of choice. if the overall treatment program has been carefully designed and delivered then good results should be expected fairly quickly.000 Hz) is called the carrier frequency  The current flowing in the tissues is approximately 4.  The intensity of the current rises and falls.  There is a significant difference between this technique and the standard method using four electrodes. this is described as a "beating "of the two frequencies.000Hz and the other at 4.1 to 200 times per second. 100 Hz  When these two currents are superimposed on one another. currents to a patient using two.F.F. current is produced endogenously.F.  On the first treatment session.  In this system.  In the conventional method.000 Hz but its intensity is increasing and decreasing (beating) within the range of about 0.  In most cases. the actual I.  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.  I.

then poor results should indicate possible change in electrode position and/or a change in frequency/intensity. If the patient's condition is unchanged after one or two treatments. 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.F. Stimulation and improvement of circulation General facilitation of healing INTERFERENTIAL THERAPY  I.  Combining treatments implies giving two different but complimentary treatments at different times or in some instances at the same time (ice. SUSTAINED (STATIC) TRACTION  Sustained traction applies a constant amount of force. CONTINUOUS TRACTION  An example of continuous spinal traction is the halo type device used following a fracture of the cervical spine. INDICATIONS  Pain relief both acute and chronic     Reduction of edema Re-education and strengthening of muscle.  It is generally accepted that this form is ineffective at producing separation because of the slight force used. 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.  It may also be used after certain surgical procedures such as spinal fusions. then the situation needs re-assessing.  Assuming that the machine is working correctly and is applied properly.  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 .

 The traction forces usually are applied for a few seconds at a time and. it is often employed prior to other mechanical forms of traction in order to assess the patient's tolerance. headaches.  Although manual traction may often be beneficial by itself.  It can be used for disc protrusions with longer hold/'rest periods (60 seconds hold 20 seconds rest).  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. depending upon the patient’s condition. typically. joint separation and inhibition of the disc. 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. and other conditions. Home cervical traction units (over-the-door) devices are examples of sustained traction. but also some degree of movement.  The application of different traction forces that are alternately applied and released (hold/rest). and the strength of the doctor.  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 . 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.  The amount of traction applied may vary. or an acute or chronic herniated disc.the “rest period"  The traction device alternates between the two different forces for the treatment duration. which can be beneficial for the treatment of soft tissue injuries. MANUAL TRACTION  Traction applied manually by the doctor.  It is most often used for joint dysfunction and degenerative disc disease. thereby producing not only traction and separation.  In this form of traction a moderate force is applied for a period of time usually from 30 to 60 seconds. in a rhythmic nature. 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. nerve root compression. degenerative disc disease. 10 . joint fixation.  This allows intermittent stretch of soft tissues. disc problems. As the patient's condition improves. intermittent traction may prove to be more helpful.      seen with continuous traction. the part of the spine being tractioned.

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

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

and other musculoskeletal inflammatory processes.  Pregnancy  Instability  Osteoporosis and other bone-weakening conditions  Hiatal hernia  Ankle.  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.  Research has shown that supine traction is superior to sitting traction. and a history of stroke or transient ischemic attack. consequently less force is necessary when the upper cervical spine is the target area. CONTRAINDICATIONS  Structural disease secondary to tumor or infection  Vascular compromise.  Acute sprains. CERVICAL TRACTION 13 . phlebitis.  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. atherosclerosis. 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.  It is suggested that the patient should be gradually returned to the upright position to maintain relief. hypertension.  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. angina. continue at the same poundage or increase poundage by 5-pound increments to a maximum of 45 pounds.to have the relief disappear at tile end of tile treatment session. which should be tractioned with a 0 degrees angle of pull. strains.

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

 Disc protrusions usually are treated more effectively with sustained traction or with longer hold-rest periods of intermittent traction (60 seconds hold. and the amount of flexion or extension used depend on the disorder being treated. on the experience of the doctor.  The lower in the lumbar spine the traction is intended. whether prone or supine. sodium chloride.30 degrees.  A galvanic current is a unidirectional (monophasic) current flowing for an indefinite duration.  The patient position. 20 seconds rest). continue at the same poundage or increase poundage by 10-pound increments to a maximum of 125 pounds. and on the type of equipment being used. lidocaine and a corticosteroid LOW VOLTAGE THERAPY 15 LOW VOLTAGE GALVANIC . 10 seconds rest) LUMBAR TRACTION PROPER POUNDAGE  Begin with approximately 50 pounds  If the patient improves.  Hypolordosis of the lumbar spine should be treated with an angle of pull from 15 .  Hyperlordosis should be treated with an angle of pull from 30 to 50 degrees.  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. ions of various substances are placed under their similar polarity electrode and driven through tissues by currents usually less than 5 mA. the angle of pull must be 15 to 30 degrees  To affect the lower lumbar segments (L3 -L5).  Copper sulphate. LOW VOLTAGE THERAPY IONTOPHORESIS  On the principle that like charges repel and opposites attract. 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. 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).  Low frequency alternating current: a current in which the direction of electron flow changes at a rate between l and 2000 Hz.  Galvanic current allows stimulation of deinervated muscle as well as the possibility of driving ions into the tissues called iontophoresis.  Joint dysfunction and degenerative disc disease usually respond to shorter hold-rest periods of intermittent traction (30 seconds hold. the angle of pull must be 30-50 degrees.  Low frequency alternating currents are utilized because of the continued need for electrical stimulation of atrophied muscle. the greater the angle of pull. especially for patients with CNS lesions.

50 sec.  Treatment duration depends on the effect desired and the integrity of the muscle being stimulated LOW VOLTAGE THERAPY  Dr. and/or "off ramp time. to avoid further trauma or to disperse fluid.  A probe may be used for specific stimulation of motor points.g. "on ramp" time. and velocity: 10 sec. for muscle reeducation)  Set mode to: Tetanize. if a gentle treatment is desired. on. if a tetanic contraction is desired to fatigue the muscle (e. if a series of muscle contractions is desired (e.  Set mode to: Surge. Kots of the Soviet Union has suggested the following times:  To increase circulation: 2 sec on.  Set the timer to desired time  Increase the intensity slowly to patient tolerance or until the desired muscle contraction is achieved.g. endurance. can use hot packs. off 16 . the smaller pad will produce a greater effect.  Set mode to: Pulse.  Quadrapolar or bipolar technique may be used. cold packs. for muscle spasm or muscle tension)  Choose the pulse width. for combination therapy. 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.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. 2 sec off  To reduce spasm and pain: 12 sec on.  If unequal sized pads are used. S sec off  For strength..

noninvasive. chronic and psychogenic pain of innumerable origins. however. "Low" TENS. TENS INDICATIONS  Chronic pain  Acute pain  Intractable pain (TENS can provide adequate relief of pain secondary to malignancy.  In general the primary effect of TENS is the relief of pain. as "Low TENS" causes muscle contraction and may cause soreness if used for longer periods. SOFT TISSUE MANIPULATION 17 . these manipulations are most effectively performed with the hands. TENS Certain manipulations of the soft tissues of the body. and cost effective method of treating acute. safe. 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.  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.  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. Results are best with trunk and extremity pain and worst with pelvic and perineal pain.  Electrodes should be removed every day or two to clean the skin and inspect the area. TENS should apply to any form of electrical stimulation that is applied via surface electrodes.  There are no contraindications to 24-hour use of "high TENS". 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. should be used only 30-40 minutes at a time.  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.

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

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