Therapeutic Exercise

Therapeutic
Exercise
Acute Therapeutic Exercise / Proliferative Therapeutic Exercise /
Remodeling Therapeutic Exercise / McKenzie Method / Aquatic
Therapy / Cryotherapy / Compression / Thermotherapy / TENS / IFC /
NMES / US / Traction / Chronic Pain / Balance / PNF / FMS / Return-to-
Sport
Acute Phase of
Healing
Therapeutic
Exercise
Dr. Keith Avin, DPT, PhD
1-27-20
Acute Ther Ex
- generalized healing timelines
 Inflammatory Phase (0-7 days)
 characterized by the rupture and
necrosis of myofibers and an
inflammatory cell reaction
 Proliferation/Repair Phase (7-21
days)
 characterized by the phagocytosis
of the necrotic muscle fibers, the
generation of new muscle fibers
and the production of a tissue scar
 Maturation/Remodeling Phase (21
days-years)
 characterized by the reorganization
of the muscle fibers, the
remodeling of the scar tissue and
the restoration of muscle function
Adapted from Cruess et al. 1975
Acute Ther Ex
- local pathology dysfunction
Pathology Clinical Conditions

 Strain  Dysfunction
 Sprain  Tissue
 Subluxation
 Joint
 Dislocation
 Contractures
 Tendinous lesions
 Synovitis
 Adhesions
 Hemarthrosis  Reflex muscle guarding
 Bursitis  Intrinsic muscle spasm
 Contusion  Weakness
 Overuse, cumulative trauma,
repetitive strain
Acute Ther Ex
-inflammation phase
 Days 0-7  Vasoconstriction

 Result of altered tissue  Blood loss is mediated
physiology by norepinephrine 5-10
mins
 3 major steps
 Vasodilation/capillary
 Limit loss permeability
 Takeout the garbage  Occurs 1 hour after
 Set the table tissue damage, leads
to edema
 Deleterious
inflammation  Clot Formation
 Wrong tissue or  Phagocytosis
overactive response
Inflammation Phase
-increased permeability
 Prostaglandins
 Prostaglandin E1:↑ vascular permeability
 Prostaglandin E2: attracts leukocytes
 Corticosteroids & NSAIDS

 Inhibit prostaglandin synthesis
Inflammation Phase
- edema
 Accumulation of fluid within

extracellular space and interstitial
tissues
 Result of:
↑ capillary hydrostatic pressure
 ↑ interstitial osmotic pressure
 ↑ venule permeability
 Overwhelmed lymphatic system
Inflammation Phase
-clot formation
 Platelet-derived
growth factor
 Fibroblasts
 Macrophages
 Monocytes
 Neutrophils Fibrin + Fibronectin

Inflammation Phase
-phagocytosis
 Leukocytes (aka white blood cells)

 Created by hematopoietic stem cells in the bone
marrow
 Leukocytosis: high count
 Leukopenia: low count
 Stagehands of healing 24-48 hrs after injury
 5 types
 Neutrophils, basophils, and eosinophils
 Lymphocytes, monocytes (i.e. macrophages)
Inflammation Phase
-debris removal
 Macrophages
 Considered most important cell for wound healing
 Produce phagocytic chemicals, factors for cell proliferation,
extracellular matrices & attract fibroblasts
 Phagocytic (M1) macrophages
 invade 24 hours
 coincides with ↑ expression of MRF (MyoD and myogenin)
 macrophages significantly ↑ transcription factor expression levels
and promote satellite cell proliferation, but not dependent
 peak ~48 hours,
 Non-phagocytic (M2) macrophages
 promote myoblast proliferation, growth and differentiation
 peak ~4 days following injury
 persist until well into the remodeling phase of skeletal muscle repair
Inflammation Phase
- edema
 Transudate
 Initial clear, fluid Muscle
hematomas
 Low cell content cause pain, limit
 Electrolytes and water motion and
increase scar
 Exudate tissue formation
 Cloudy, viscous fluid

 High cellular debris
 Pus/suppurative exudate
 Bloody exudate indicates severe injury to
microvasculature
 Hematoma: accumulation of blood in a tissue/organ
 Hemarthrosis: bloody fluid in joint
Inflammation Phase
- tendon & ligament cell types
 Fibroblasts (aka tenocytes, tendon cells)

 Capable of cell-to-cell communication
 Coordination of cellular and metabolic processes
throughout the tissue
 “Sense” loads from the extracellular matrix (ECM), and
in turn modulate the ECM
 Loading
 Maintenance of tissue
 Promote remodeling
 Promote degeneration
 Optimal Loading: want our pt’s in the maintainance
or hypertrophy phase, not the atrophy phase
Image adapted from Wagenhäuser MU, et al., 2012

Inflammation Phase
- skeletal muscle cell type
 Muscle Stem Cell

 Progenitor cell, satellite cell,
muscle-derived stem cell
 4% of muscle cells are called
satellite cells
 Repair myofibers
 Located between the myofiber
basal lamina and plasma
membrane
Adapted from Zouraq F, et al., 2013

Inflammation Phase
- injury classification
Severity Common characteristics
Grade I • Mild damage to individual muscle fibers (<5% of fibers)
• minimal loss of strength and motion
• Mild pain
• Mild edema
• Local tenderness
• Pain occurs when tissue is stressed
Grade II • More muscle fibers involved, but not completely ruptured

• significant loss of strength
• significant loss of motion
• Moderate pain
• Requires stopping activity
• Stress and palpation greatly increase pain
• If ligamentous, some increase in joint mobility
Grade III • Near-complete or complete tear/avulsion

• Severe pain
• Stress to tissue is usually painless
• Swelling and bruising are usually present
Acute Ther Ex
- common interventions
Plan of Care Intervention
Pt. Education • Inform of anticipated recovery
• Appropriate loading/wt. bear
• Appropriate functional activities
Control pain, edema, • Protection

spasm • Optimal loading
• Ice, compression, elevation
• Grade I mobilizations (in pain-free position)
Maintain soft tissue and • PROM, A-AROM, AROM

joint integrity and • Muscle setting (isometrics)
mobility
Inflammation Phase
- loading (ligament)
 Early mobilization (WBAT over NWB (cast immobilization))

 Sooner return to sport
 Sooner return to work
 Sooner return to functional activities
 Immobilization
 synovial adhesions
 ↑ collagen degradation, ↓ collagen synthesis
 greater % of disorganized collagen fibrils
 shift to a catabolic state
Inflammation Phase
- tendinopathy terminology
 Tendinopathy
 General descriptor of dysfunction in and around the tendon due to
overuse
 Tendinitis
 Tendon inflammation due to micro-tears from sudden or heavy
overload
 6-10 weeks prognosis to heal
 Treated with POLICE
 Tendinosis
 tendon degeneration due to chronic overuse
 overuse without sufficient rest time
 3-6 month prognosis to heal
 Treated with optimal loading to restore type 1 collagen fibers

Acute Ther Ex
- interventions
 POLICE
 Protection: splint, tape, cast
 Optimal Loading
 Ice: 5-30 minutes depending upon type
 Compression
 Elevation
 Soft tissue mobilization
Remember we are
 Massage (low level)
talking about the
 Joint mobilization first ~48 hours
Therapeutic Exercise
- passive range of motion (PROM)
 Definition  Goals
 unrestricted ROM for a  overall goal is to decrease
segment that is
produced entirely by an complications associated to
external force; little to immobilization (i.e. tissue degeneration,
no voluntary adhesion and contracture formation, reduced
contraction. circulation)
 Indications  Maintain tissue mobility and elasticity
 Acute, inflamed tissue  Minimize contracture formation
 Conditions where active  Assist circulation/vascular dynamics
motion is
contraindicated or  Enhance synovial movement for cartilage
patient unable to nutrition
perform  Decrease/inhibit pain
 Comatose, paralyzed,  Assist with healing process
bed rest, surgical
precautions/restrictions  Maintain patients’ movement awareness
 Perform as tolerated before P1

Acute Ther Ex
- interventions
 P1: position where

pain is initially
experience
 P2: pain that
restricts further
motion
 Acute Phase
 P0-P1
Type of Resistance Exercise
- active range of motion (AROM)
 Active-Assistive Range of Motion (A-AROM)

 Combination of active contraction of the muscles crossing
that joint and assistance provided by an external force
(mechanically or manually) to perform unrestricted ROM
for a body segment.
 Active Range of motion (AROM)

 Unrestricted ROM for a segment that is produced by an
active contraction of the muscles crossing that joint.
Type of Resistance Exercise
- AROM/A-AROM
 Indications  Goals
 If pt has limited ability to  Maintain physiologic
contract through full elasticity and
ROM>>AAROM contractility
 Slowly, steadily progress  Provide sensory

feedback from
so pt is able to actively contracting muscle(s)
contract>> AROM
 Provide stimulus for
 Once controlled motion is bone and joint tissue
achieved>> resisted ROM integrity
 AROM>>Aerobic  Increase
conditioning circulation/prevent
thrombus formation
 Following immobilization,
AROM above and below  Develop coordination
segment and motor skills for
functional activities
- resistance exercise variables
 Contraction Type- Isometric

 muscle produces force without a change in muscle
length/visible joint motion
 Examples: holding a weight at a given angle, maintaining
the plank position, pushing against wall
 Rationale
 Prevent/minimize muscle atrophy and improve muscle
strength when joint motion is contraindicated
 Facilitate appropriate neuromuscular coordination when joint
motion is contraindicated
 Develop postural or joint stability
 Develop joint-angle specific strength for a given task
 Contraction Type- Isometric

 Types of Isometric Exercises
 Muscle-setting: low-intensity against little to no resistance to
promote muscle relaxation, circulation, decrease pain and
spasm during acute phase of healing.
 Examples: Quadriceps and gluteal setting
 Stabilization: submaximal and sustained co-contractions that

can occur in antigravity, weight bearing and gravity minimized
positions to promote joint or postural stability.
 Examples: rhythmic stabilization, alternating isometrics and dynamic
stabilization
 Multiple-angle isometrics: resistance applied at multiple joint

angles to promote strength throughout a greater ROM. (called
Active resistance in E&A)
Acute Ther Ex
- post-surgical considerations
 Tissue type
 Surgeon Preference
 Extent of tissue
pathology/damage
 Size/severity of the lesion
 Type and unique
characteristics of surgical
procedure
 i.e. joint arthroplasties
(cement vs. uncemented)
 Integrity of structures
adjacent to involved tissues
Overall,
Acute Ther Ex similar to non-
- post-surgical goals surgical
management
 Minimize pain and prevent infection

 Prevent postoperative complications
 i.e. pneumonia, atelectasis, infection, DVT, PE
 Promote mobility while protecting injury
site (bed rest=adverse effects)
 Consider surgical techniques (i.e. tourniquet)
 Prevent/minimize adhesions and
contractures
 Adapt activities of daily living
Acute Ther Ex  Repair of tendon
- post-surgical goals
 Immobilization typically
longer time than for muscle
 Repair of muscle  Muscle setting can be
started immediately post-
 Muscle setting can be op
started immediately
post-op  Can remove immobilization
for brief periods during PT
 When immobilization is
removed, begin A-  PROM, muscle setting
AROM/AROM  A-AROM/AROM is not
 Stretching is initiated for several weeks,
contraindicated until surgeon dependent
tissues fully healed (8  Stretching is
to 12 weeks) contraindicated until
tissues fully healed (8 to 12
weeks)
Acute Ther Ex
- post-surgical goals
 Repair of ligament
 Early, but protected motion
 Progressive strengthening
 Progressive weight-bearing
 Type of surgery influences management
 Muscle setting can be started immediately
post-op
 Recovery is a long process of 6 months to 1
year
Acute Therapeutic Exercise
Systemic Pathology
- hospital associated deconditioning
 Acute hospitalization includes:

 prolonged periods of bed rest (therapy then right back to bed)
 relative inactivity
 sleep disturbances (those damn nurses)
 nutritional deficits (hospital food)
 Altered homeostasis >> older adults vulnerable to adverse
health events
 including re-hospitalization.
- detrimental effects of reduced use
 Mechanisms of muscle loss

 Mitochondria damage
 Increased apoptosis
 Increased proteolysis
 Decreased protein synthesis
 Autophagy/fiber loss
 Need for early mobilization
- hospital associated deconditioning
 Acute hospitalization older adults spend:

 83% of hospital stay in bed
 12% of their time in a chair
 Commonly resulting in declining:
 muscle strength
 muscle mass
 cognitive function
 muscle protein synthesis
 physical function
 activity of daily living (ADL) performance
 hospitalized older adults are 61x more likely to
develop disability in ADLs than those who are not
hospitalized
- general goals and interventions
Muscle
Strength &
Endurance
Balance
Cardiopul
Function
Stability
Flexibility
Neuro
Control/Co
ordination
THERAPEUTIC EXERCISE FOR THE
PROLIFERATION PHASE OF
HEALING
Drs. Amy Bayliss and Keith Avin,
2-24-20
PROLIFERATION PHASE THERAPEUTIC EXERCISE
- GENERALIZED HEALING TIMELINES
 Inflammatory Phase (0-7 days)
 characterized by the rupture and necrosis of
myofibers and an inflammatory cell reaction
 Proliferation/Repair Phase (7-21 days)
 characterized by the phagocytosis of the
necrotic muscle fibers, the generation of new
muscle fibers and the production of a tissue
scar
 Maturation/Remodeling Phase (21 days-
years)
 characterized by the reorganization of the
muscle fibers, the remodeling of the scar
tissue and the restoration of muscle function

 Active muscle regeneration (Ambrosi et al., 2009)

 Begins: 7–10 days
 Peak: 2 wks,
 Declines: 3–4 wks
 Fibroblasts → Collagen (zip line of tissue structures)
 Ligament/Tendon
 Type III collagen synthesis: 3-7 days
 Peaks: 2 weeks
- ROAD TO RECOVERY
 Days 3-20
Collagen
production
Neovascularization PROLIFERATION Epithelialization

PHASE
Satellite cells
Fibroblasts
Osteoblasts
Wound
contraction
 Nerves, blood vessels and muscle cells infiltrate injured area
 Scar tissue bridges gap between new & existing muscle fibers
 preserves force transduction along the muscle
 Less severe injuries

 scar tissue also acts as a conduit to promote myofiber formation
 Severe injuries (i.e. volumetric tissue loss)

 scar tissue forms a dense cap that blocks regenerating muscle fibers
 creating two muscles in series
 Granulation tissue: newly formed capillaries, fibroblasts

and myofibroblasts form delicate tissue
 Collagen becomes aligned with the long axis of the
ligament
 Newly-formed collagen fibrils are abnormal and smaller in
diameter than normal ligament tissue.
 Strength 15% of uninjured tissue
 Optimal loading
 Early mobilization vs immobilization
- EPILTHELIZATION
 Reestablish epidermis to prevent fluid loss and decrease

infection risk
 Superficial wound: within hours of injury
 Deep wound: occurs after collagen is produced and
neovascularization
 Uninjured epithelial cells from margins migrate to injured
area, cover surface
 Clingy friend cells (closer the edges of the wound are the quicker
it will heal)
- WOUND CONTRACTION
 Final step of wound healing

 Pulls edges together and shrinks injured site
 Begins 5 days after injury, peaks at 2 weeks
 Primary cell type is myofibroblasts
 “Picture Frame” theory (linear or square injuries heal faster than circle wounds)
 Angiogenesis: development of new blood supply

 Generate a new network
 Expand existing network (anastomosis)
 Coupling of vessels in injured area
 New vessels are required to deliver oxygen and nutrients to

injured and healing tissues.
 Be wary of loading as vessel formations are thin and prone
to injury.
 Clinical signs  Common Impairments

 Pain when end of available ROM is
 Decreasing inflammation reached
 Pain is synchronous with tissue  Decreasing soft tissue edema
resistance during passive  Decreasing joint effusion
stretch  Decreasing soft tissue, muscle and/or
 Be aware of signs of INFECTION joint contractures
 Developing muscle weakness from
 Clinical Goals reduced use
 Decreased functional use of the injured
 Develop mobile scar tissue and associated areas
 Loading
 electrical stimulation, mechanical
stimulation
- COMMON MANAGEMENT
Pt. Education • Recovery process ● Appropriate loading/wt. bear ● Appropriate functional
activities ● Teach HEP
Promote healing of • Monitor tissue response from exercise progression (↓ if inflammation)
injured tissues • Protect healing tissue (AD, splints, tape, etc) ● Progressive wt. bearing
Restore soft tissue, • Progress from PROM>>A-AROM>>AROM (within pain limits)
muscle and jt mobility • Gradually ↑ scar mobility ● Progressively ↑ mobility
Develop neuromuscular • Progress multiple angle isometrics (mild resistance, ↑ as tolerated)
control, muscle • Initiate AROM and protected closed-chain stabilization exercises
endurance and strength • Initiate isotonic/dynamic exercises with low load
(involved, adjacent areas) • Emphasize proper control and mechanics
• Progress resistance later in this phase
Maintain integrity and • Apply progressive strengthening and stabilizing exercises (monitor
function of associated response)
areas • Resume low intensity functional activities involving the healing tissues that
do not exacerbate symptoms
- RESISTANCE EXERCISE VARIABLES
 Contraction Type- Isometric

 muscle produces force without a change in muscle length/visible
joint motion
 Examples: holding a weight at a given angle, maintaining the plank
position, pushing against wall
 Rationale
 Prevent/minimize muscle atrophy and improve muscle strength when joint
motion is contraindicated
 Facilitate appropriate neuromuscular coordination when joint motion is
contraindicated
 Develop postural or joint stability
 Develop joint-angle specific strength for a given task
 Contraction Type- Isometric
 Types of Isometric Exercises
 Muscle-setting: low-intensity against little to no resistance to promote
muscle relaxation, circulation, decrease pain and spasm during acute
phase of healing.
 Examples: Quadriceps and gluteal setting
 Stabilization: submaximal and sustained co-contractions that can
occur in antigravity, weight bearing and gravity minimized positions to
promote joint or postural stability.
 Examples: rhythmic stabilization, alternating isometrics and dynamic
stabilization (will be discussed further in proprioceptive neuromuscular
facilitation lecture)
 Multiple-angle isometrics: resistance applied at multiple joint angles
to promote strength throughout a greater ROM.
 Contraction Type- Isotonic/Dynamic
 Rationale
 Transfer of training effects does occur albeit less than mode-specific
 Simulate home, work, sport and recreation-related activities
 Consider ecc/con, power, strength, endurance
 Dynamic Constant External Resistance
 Free weights, weight machines, manual resistance, body weight
 Dynamic Variable External Resistance
 Hydraulic/pneumatic systems, elastic resistance products
(bands/tubing), manual resistance
 Contraction Type- Isotonic/Dynamic Exercise

 Muscle contraction that causes joint motion of a body segment as the muscle shortens
(concentric) and lengthens (eccentric).
 Concentric motions: occur when provided skeletal muscle

tension produces shortening against resistance, provide
segmental acceleration.
 Eccentric motions: occur when provided skeletal muscle

tension is lengthened against resistance (controlling external
load), provide segmental deceleration and impact absorption.
 Greater loads lowered (ecc) than lifted (con)

 Contractile/non-contractile properties
 Concentric contractions activated greater number of motor units and require greater
energy stores (compared to Ecc)
 Con is les mechanically efficient as Ecc (mechanically efficient meaning that gravity helps)
 More effort required to Lift (con) than Lower (ecc)
 Eccentric exercise > Delayed Onset Muscle Soreness (DOMS)

 This may be a volume issue more so than contraction type issue
Contraction Type- DOMS DOMS- Etiology

 Sensitization of nociceptors by tissue breakdown
 Reported muscle soreness pain and products and noxious chemicals
 histamines, bradykinins, prostaglandins and free
stiffness) following an unaccustomed radicals.
bout of exercise that increases within
 Mechanoreceptors, including muscle spindle
24 h, peaks from 24-72 h, subsides in afferents are activated
few days.
 Biochemical changes due to structural
 Some report specific to Ecc, not disruption of the extracellular matrix (ECM)
supported as evidence in Con as well  Damage to myofibers facilitates the escape and
(Fitzgerald et al., 1991) entrance of intracellular and extracellular
proteins
 Symptoms can be exacerbated by swelling
within muscle fibers that exerts pressure on
nociceptors and thus increases the sensation of
pain. (Schoenfeld, 2012)
 Contraction Type- Isokinetic (aka accommodating resistance
exercise)
 velocity of muscle shortening/lengthening (and angular limb velocity) are
predetermined and held constant.
 Load is variable, but maximal
 Speed specific training
 Able to accommodate as muscle fatigues
 Limitations
 Speed specific, cost, requires constant
supervision, sport specific speeds exceed
capacity of equipment, many functional
tasks are not constant velocity
Open-Chain Exercises Closed-Chain Exercises
Distal segment moves in space Distal segment remains stationary
Independent join movement; no predictable Interdependent join movement; relatively
joint motion in adjacent joints predictable joint motion in adjacent joints
Movement of body segment only distal to Movement of body segments may occur distal
moving joint and/or proximal to moving joint
Muscle activation occurs predominately in Muscle activation occurs in multiple muscle

prime mover groups, both distal and proximal to moving
joint
Typically performed in nonweight-bearing Typically performed in weight-bearing
positions positions
Resistance is applied to the moving distal Resistance is applied simultaneously to
segment multiple moving segments
- OPEN VS. CLOSED CHAIN RATIONALE
 Isolation of Muscle Group  Coactivation/Dynamic Stabilization

 Open easier to isolate  Promote co-activation of agonist and
 Individual versus multiple muscles antagonist
 Compensation greater with closed  Easier to attain with closed-chain
exercises
 Control of Movements
 Proprioception, Neuromuscular Control
 Open easier to control via patient or with and Balance
external aids (manual contact, belt)
 Closed-chain activities thought to
 Closed chain difficult to control multiple provide greater proprioceptive feedback
joints/segments and requires greater due to greater number of receptors
patient control (multiple muscle groups)
 Joint Approximation  Balance is clearly closed-chain
 Approximating joint surfaces increases  Carry-over to Function
stability (in both Open/Closed), however
easier to perform with closed-chain  Parallel patient needs
exercises
- CONSIDERATIONS
 Severity/irritability
 Direct vs. Indirect Intervention
 Are they directly related to site of injury or contributory
 Have you identified deficits in muscle performance?

 Muscle strength
 Muscle endurance
 Balance
 Sensation
 Coordination
 Flexibility/ROM
 Can these deficits cause future impairment of function?

 Patient Goals
- RESISTANCE TRAINING CONTRAINDICATIONS
 Pain
 Severe joint/muscle pain during AROM
 Acute muscle pain during resisted isometric contraction
 Pain during resistance exercise
 Inflammation
 Inflammatory neuromuscular disease (i.e. Guillain-Barre) or inflammatory muscle disease
(polymyositis, dermatomyositis) as may cause greater muscle damage.
 Acute inflammation
 Infection
 Severe Cardiopulmonary Disease
 Associated with acute symptoms
- PRESCRIPTION
 So are 1-3 sets of 12, 3 time/day prescribed? Based

on pt. response, perform without pain and no signs
of inflammation when they come back (see notes
below)
 What is the goal of the activity? To prevent
contraindications What impairment are you
targeting? Clear joints below and above
- EXERCISE EVALUATION
1. Body Alignment
 Posture
 Base of support
 Center of gravity
 Large base of support → Small base of support

 Low center of gravity → High center of gravity
 Log rolling → segmental rolling
 Hooklying → bridging
 Prone → prone on elbows
 Quadruped → alternating limbs
 Sitting
 Kneeling → half kneeling
 Plantigrade/modified plantigrade
 Standing
2. Stabilization
 Supports (right pic)
 Challenges (left pic)
3. Compensatory Motions
 Stronger adjacent agonists
 Stabilizer muscle group
4. Direction of Resistance
 Oppose direction of muscle action
 Specific to muscle group (ie. glute med vs. TFL)
5. Placement of Resistance
Distal vs proximal
Parameters Progression
% Body Weight Partial >> Full weight-bearing >>> Resisted Motion
Base of Support Wide >> Narrow
Bilateral >> Unilateral
Fixed on support surface >> sliding on support surface
Support Surface Stable >> Unstable/moving
Hard/right >> soft
Ground level height >> Increasing height
Balance External support >> No external support
Eyes open >> Eyes closed
Excursion of Limb Small ROM >> Large ROM
Plane of Motion Uniplanar >> Multiplanar
Speed of Motion Slow/Fast dependent upon goals
 Task Type
 Discrete: recognizable beginning/end. Ex. Push-up
 Serial: a series of discrete motions that create a sequence. Ex. Push-up with side plank
 Continuous: uninterrupted movements with no distinct end or beginning. Ex. Vinyasa,
walking, running
 Task Learning (Fitts and Ponser method)
 Cognitive (explicit feedback)
 Big performance changes
 Associative (explicit and intrinsic feedback)
 Performance changes slow down
 Autonomous (intrinsic feedback)
 Skill becomes automatic
Focus on evidence based intervention for Sub-Acute Spinal
Pain/Dysfunction
 How do you know your patient is subacute??
 Signs and symptoms of the inflammation is under control
 Pain is no longer constant
 Pain may still interfere with some ADL’s
 In a derangement, symptoms are staying centralized most of the time
 Impairments/activity limitations and participation restrictions that may be present:
 Pain – only when excessive stress is placed on vulnerable tissue
 Impaired posture/postural awareness
 Impaired mobility
 Impaired muscle performance
 General deconditioning
 Inability to perform ADL’s for extended periods
 Poor body mechanics
 Emphasis is placed on:
 Postural control
And their relationship to modulating
 Stability pain
 Mobility
 General intervention plan:
 Educate the patient in self-management and how to decrease
episodes of pain (at home and work)
 Progress awareness and control of spinal alignment
 Increase mobility in restricted muscles/joint/nerve (HEP)
 Teach techniques to develop stability (at home and work)
 Develop cardiopulmonary endurance (conditioning)
 Teach techniques for stress relief prn
 Teach safe body mechanics and functional adaptations
 Precautions/contraindications
 Whiplash & instability
 Other external rapid forces (manipulation)
 Overly forceful PT (Grade IV mobilizations, mechanical traction)
 Disc herniation
 May educate on a traffic light system when introducing new activities
 Red = stop (symptoms increase after exercise, pain moves more peripherally down
limbs, mobility worse)
 Yellow = caution (symptoms are the same during/after exercise, might have pain
during)
 Green = go (symptoms are gone or lessen after exercise, pain moves centrally
from peripheral limbs, mobility gained)
Modalities are not recommended in this
stage (emphasis is on therapeutic
exercise)
Soft tissue mobilization/massage (can be
beneficial in this stage)
Mobilization/manipulation (can be beneficial in
this stage)
EXTENSION BIAS
 In the sub-acute phase the patient should
be progressed to loaded exercises for
symptom management
 Extension in standing
 Or extension at a countertop
 Dosage in the sub-acute phase is:

 At minimum 2-3 times per day, 10-20 reps –
but often still 100 reps per day
 More frequently if performed after known
provocative activities
 Correct sitting posture using a lumbar roll or a
change of chair
 Go through the ergonomics of their desk set-up
 Is a standing desk a better option?
FLEXION BIAS
 In the sub-acute phase the patient
should be progressed to loaded
exercises for symptom management
 Flexion in sitting
 Flexion in standing
 Dosage can be lower in the sub-

acute phase
 At minimum 2-3 times per day, 10-20
reps – but often still 100 reps per day
 More frequently if performed after
known provocative activities
CERVICAL
 Most cervical derangements are caused from head forward postures resulting in
protraction = lower cervical flexion
 Progress to cervical extension in a loaded position in the sub-acute stage
 May add end range rotation in a cervical extended position to get further in the range
 Posture correction
 Slouch-overcorrect is a specific
exercise
 Sit on the edge of a firm chair. Assume a
fully slouched posture. Now move into an
extreme upright sitting posture by
arching your back, increasing the
inward curve of your low back. Move
back and forth between the extreme
slumped posture to the extreme upright
posture.
 Neural glides (flossing) may be required after a
derangement if extremity symptoms were present
in the acute stage:
 An example is a lumbar derangement with posterior leg
pain
 Modified straight leg raise with ankle
dorsi/plantarflexion (flosses sciatic and tibial
branch)
TrA with arm pull
TrA with marching

TrA with knee fall out
Scapular retraction
Elastic band rows

Resisted cervical retraction (upper cervical
flexion)
EXAMPLE 2:
YOUR PATIENT HAS INCREASED LOW BACK PAIN WITH LIFTING
 Teach correct lifting technique
1. Start by standing close to the object with feet spread
apart. Bend at the knees and hips and NOT at your
spine.
2. Hold the object close to your body as you use your
legs muscles to stand back up lifting the object.
3. Walk over to the surface you want to set the object
on to and set it down. Be sure to NOT twist your
spine but to pivot your feet so that your feet are
pointed forward to where you want to set the object.
4. Slide the object on the shelf to off load your body.
Therapeutic Exercise:
remodeling phase
KEITH AVIN, DPT, PHD
P646 INTRODUCTION TO THERAPEUTIC INTERVENTIONS
MARCH 30, 2020
Therapeutic Exercise: remodeling phase
- overview
 Briefly review the phase of healing and clinical indicators of the

remodeling phase
 Management guidelines for the remodeling phase of healing
 Intervention strategies for the remodeling phase
 resistance training
 Plyometrics
 stretching
Therapeutic Interventions
- choosing wisely campaign
 The American Board of Internal Medicine (ABIM) developed a

campaign, “Choosing Wisely”
 Aims to promote conversations between providers and patients by helping

patients choose care that is:
 Supported by evidence
 Not duplicative of other tests or procedures already received
 Free from harm
 Truly necessary
- choosing wisely campaign
 Don’t employ passive physical agents except when necessary to facilitate

participation in an active treatment program.
 Don’t prescribe under-dosed strength training programs for older adults.
Instead, match the frequency, intensity and duration of exercise to the
individual’s abilities and goals.
 Don’t recommend bed rest following diagnosis of acute deep vein thrombosis
(DVT) after the initiation of anti-coagulation therapy unless significant medical
concerns are present.
 Don’t use continuous passive motion machines for the postoperative
management of patients following uncomplicated total knee replacement.
 Don’t use whirlpool for wound management.
- generalized healing timelines
 Inflammatory Phase (0-7 days)

 characterized by the rupture and necrosis of
myofibers and an inflammatory cell reaction
 Proliferation/Repair Phase (7-21 days)
 characterized by the phagocytosis of the
necrotic muscle fibers, the generation of
new muscle fibers and the production of a
tissue scar
 Maturation/Remodeling Phase (21 days-
years)
 characterized by the reorganization of the
muscle fibers, the remodeling of the scar
tissue and the restoration of muscle function
- generalized healing
 Longest healing phase  Important to safely stress tissue

 Day 9 up to 24 months to improve strength and
flexibility (based on patient
response)
 Collagen is less organized than  Stress during healing increases
surrounding tissue tensile strength; controlled forces
that replicate normal stress of
tissues
 Ligament/tendon  Immobilization reduces tensile
 Transition from type III to type I strength that takes months to
collagen reverse (often not complete)
 Continue to develop a mobile scar
- clinical keys
 Clinical Signs  Clinical Note

1. No signs of inflammation  Immobilization/reduced use
2. Pain/discomfort after tissue results in:
resistance during passive  Greater atrophy of type I (slow)
stretch fibers
 Conversion of slow to fast fiber
 Clinical Goals type
1. Restore function  Therefore, want to emphasize
endurance training following
2. Increase strength injury/surgery (endurance
targets slow fibers)
- impairments/activity limitations and participation restrictions
 Pain  Neuromuscular control &

 only when excessive stress is Endurance
placed on vulnerable tissue in  Poor during high-intensity or single
repetitive leg stance
 a sustained nature for prolonged  Muscle Imbalances
periods
 Flexibility and strength
 Stress placed on restrictive
contracture/adhesion  Generalized deconditioning
 Soreness due to increased  Inability to perform high-intensity
stress/resistance exercise (DOMS) physical demands for extended
periods of time
- general intervention plan
1. Patient Education
2. Increase Soft Tissue (Extensibility) and Joint
Mobility
3. Improve Neuromuscular Control, Strength,
Endurance
4. Improve Cardiopulmonary Endurance
5. Progress Functional Activities
- management guidelines
1. Patient Education 2. Increase Soft Tissue and Joint

 Instruct safe exercise progressions Mobility
 Monitor compliance and  Stretching techniques
understanding  Joint mobilization
 Teach ways to avoid re-injuring  Cross-fiber massage
 Safe body mechanics and  Massage

ergonomic counseling  Modalities
 Manual, mechanical or self-
stretching techniques
3. Improve neuromuscular control, strength and

endurance
 Progress exercises
 Submax >>> maximal
 Specificity using concentric/eccentric, wt. bearing, non-wt.
bearing
For high-intensity/
 Single plane >>> multiplanar motions high-level and
 Simple >>> complex motion that simulate functional needs repetitive activities
 Controlled proximal stability >>>> superimpose distal motions
 Proper form and safe biomechanics
4. Improve cardiopulmonary endurance Will cover in

Cardiopulmonary and
 Progress aerobic exercise using safe activities Health Promotion and
5. Progress Functional Activities Wellness
 Continue use of supportive/assistive devices until

ROM is functional with joint play and strength in
supporting muscles is adequate.
 Perform simulated exercises to meet functional
demands
 Protected and controlled >>> unprotected and
variable
Remodeling Phase Therapeutic Exercise
 Contraction Type  Load Type

 PROM, AAROM, AROM  Manual Resistance
 Isometric vs Isotonic/dynamic vs  Free weight
Isokinetic
 Machine
 Concentric vs Eccentric
 Body Weight
 Theraband
 Open vs Closed Chain  Electrical Stimulation
Open-Chain Exercises Closed-Chain Exercises
Distal segment moves in space Distal segment remains stationary
Independent join movement; no predictable joint motion in Interdependent join movement; relatively predictable joint
adjacent joints motion in adjacent joints
Movement of body segment only distal to moving joint Movement of body segments may occur distal and/or
proximal to moving joint
Muscle activation occurs predominately in prime mover Muscle activation occurs in multiple muscle groups, both distal
and proximal to moving joint
Typically performed in nonweight-bearing positions Typically performed in weight-bearing positions
Resistance is applied to the moving distal segment Resistance is applied simultaneously to multiple moving
segments
- interventions
 Resistance Training
 Plyometrics
 Stretching/Flexibility
- guidelines
Load Sets Reps Rest

Muscular Strength 60-70% 1 rep max 1-3 8-12 1-2 minutes
novice to intermediate
Muscular Strength 80-100% 1 rep max 2-6 1-8 2-3 minutes

advanced
Muscular 70-85% 1 rep max 1-3 8-12 1-2 minutes

Hypertrophy
novice to intermediate
Muscular 70-100% 1 rep max 3-6 1-12 2-3 minutes

Hypertrophy
advanced
Muscular Power 0-60% 1 rep max 1-3 3-6 1-2 min (low intensity)
2-3 min (high intensity)
Muscular Endurance <70% 1 rep max 2-4 10-25 30-60 seconds
- methods for estimating repetition maximum
1. Rep Estimation 2. 1 Repetition Max Prediction

a) Based upon # of repetitions a) 1RM = W/ [102.78–
achieved until fatigue 2.78(R)]/100
• W = weight used and R is the
Load Reps maximal number of repetitions
Average Untrained 90 % 1 rep 4-5 performed.
Adult max
Average Untrained 75 % 1 rep 10 3. Ratings of Perceived Exertion
Adult max
a) vary considerably from
Average Untrained 60 % 1 rep 15
Adult max
performed 1 repetition max
- guidelines
 Recovery from exercise

 3-4 minutes: time it takes to restore 90-95% of pre-exercise capacity
 Recovery occurs more rapidly if light activity is performed following
exercise (as compared to total rest)
 Balance must be struck among training, recovery and fatigue
 Overtraining is an imbalance among these components with too
much load or too little recovery resulting in performance plateaus or
deterioration
 During the earlier phases of healing the load is generally low so this is
not as much of a concern.
Isotonic Resistance Exercise Intensity
 More on Intensity…
 Start by determining “repetition max”: the amount a person can
lift, 1x or 10x, with good form and no increase in pain
 1 RM: amount of force generated in one maximal contraction
 10 RM: 10 RM = ~75% of 1 RM
 Guidelines for specific populations…

 In “trained” individuals: 90-100% of RM
 Among healthy, un-trained individuals: 70-80% of RM
 For debilitated, sedentary, untrained persons: 30-50% of RM
- exercise prescription
 DeLorme Regimen  DAPRE

 Determine 10 rep max  10 reps @ 50% 6RM
 10 reps @ 50% 10-RM  6 reps @ 75% 6-RM
 10 reps @ 75% 10-RM  Max reps @ 100% 6-RM
 10 reps @ 100% 10-RM  Max reps @ 100% 6-RM
 Oxford Regimen Set 3 reps Set 4 Set 3 Next day
 Determine 10 rep max 0-2 ↓ 5-10 lb ↓ 5-10 lb
 10 reps @ 100% 10-RM
3-4 ↓ 0-5 lb No change
 10 reps @ 75% 10-RM
5-6 No ↑ 5-10 lb
 10 reps @ 50% 10-RM
change
7-10 ↑ 5-10 lb ↑ 5-15 lb
>11 ↑ 10-15 lb ↑ 10-20 lb
- periodization
Characteristics of Periodized Training

 Systematic variation of training Period of Intensity of Volume and Frequency
program (dosing) over a specified Training Exercise of Exercise
period of time Preparation Lower loads High number of reps
and sets
 Micro-cycles- weekly
More exercises per
 Meso-cycles- 2 to 6 weeks session
More frequent exercise
 Macro-cycles- annual sessions per day and
week
 Though to optimize progression and
Competition Higher loads Decrease in reps, sets, #
reduce overtraining of exercises and
frequency
 Limited evidence
Recuperation Gradual Additional decrease in
decrease in reps, sets, # of exercises
exercise loads and frequency
- 5 steps of resistance exercise
1. Body Alignment 3. Compensatory Motions

 Posture  Stronger adjacent agonists
 Base of support  Stabilizer muscle group
 Center of gravity 4. Direction of Resistance
2. Stabilization  Oppose direction of muscle action
 Supports  Specific to muscle group (ie. glute med
vs. TFL)
 Challenges
5. Placement of Resistance
Resistance Training
- contraindications
 Pain
 Severe joint/muscle pain during AROM
 Acute muscle pain during resisted isometric contraction
 Pain during resistance exercise
 Inflammation
 Inflammatory neuromuscular disease (i.e. Guillain-Barre) or inflammatory muscle
disease (polymyositis, dermatomyositis) as may cause greater muscle damage.
 Acute inflammation
 Infection
 Severe Cardiopulmonary Disease
 Associated with acute symptoms
- early childhood and preadolescence
 1st decade (just be active)

 Focus on recreation, motor control and free play
 ~10-13 years (preadolescent)
 Balanced exercise program can improve cardiopulmonary
fitness, decrease blood lipids, improve psychological well-
being
 Demonstrate strength and endurance gains similar to young
adults
 low loads and repetitions
 Sufficient rest
 Closely supervised
- adolescence and young/middle adult
 Adolescence  Young/middle adult

 Experience muscle mass and strength  Strength may peak at 30 and
increase due to hormonal change decline 1% per year
 Demonstrate strength and endurance  Highly dependent upon training
gains similar to prepubescent children  Generally can follow ACSM or
 30-40% greater than expected from CDC exercise guidelines for
normal hormonal change increase resistance training for healthy
 Balanced exercise programs are adults (lab handout).
commonly centered around sport
season
 Periodization of Training
- older adult
 Changes in the older muscle

 15-20% loss of strength per decade (60-79)
 30% loss of strength per decade >80
 Reduced muscle mass (effects type II more so), speed of
contraction and motor units, and increased connective
tissue
 Weaker and less flexible muscle
 Loss of power (strength x velocity)
 Resistance training can mitigate these losses
 Either slowed or partially reversed
 ACSM or CDC guidelines in handout
Plyometrics
- basics
 Definition
 Employs high-velocity eccentric to concentric
muscle loading, reflexive reactions and
functional movement patterns to increase
muscle strength, power and coordination.
 Aka- stretch (eccentric phase)-shortening
(concentric phase) drills
 Aka- reactive neuromuscular training
 Amortization
 The period of time between the stretch and
shortening cycles
 Should be very rapid to capitalize on the
increased muscle tension
https://www.youtube.com/watch?v=s5jV9UK7s4E
Plyometrics
- basics
 The eccentric loading immediately followed by concentric is thought to

increase force production
 The stretch-shortening cycle may stimulate proprioceptors of muscles,
tendons, ligaments and joints
 Activates the monosynaptic stretch reflex
 Muscle spindles sense the length and velocity change of the stretch and send
to central nervous system
 CNS then actives muscle to shorten/contract
 The thought is the more rapid the stretch, the greater the stretch reflex and
subsequent activation/contraction
Plyometrics
- evidence
 Plyometric training is an effective method to improve muscle

strength and power.
 Supported by multiple systematic reviews and meta-analyses support
 Sport-specific benefits evident
 Throwing velocity in baseball pitcher significantly increased
 Strengthening and plyometric training was shown to be superior to
strengthening alone
 Performed weighted ball plyometric training
 Some limited evidence of preventing injuries, but did not involve
proper control subjects.
Plyometrics
 General Criteria  Appropriate

 Strength >80% of contralateral  Advanced stages of healing
limb  Individuals with a need to perform these
type of movements
 Pain free range of motion
 Sport
 Sufficient proximal strength to
 Recreation
maintain balance and control
 Contraindicated
 Movement should
relate/replicate to sport-  Inflammation
specific motion  Pain (during)
 i.e. match patient goals  Joint and Postural instability
Plyometric
- criteria
 Speed of drills
 Rapid yet safe and controlled motions
 Rate of stretch is more important than length
 May need to begin with small ROM
 Intensity
 Speed is more important
 Progress load gradually to not impede speed
 Weighted vest, weighted balls, elastic bands, wt. bearing (bi/uni), height
 Reps, frequency, and duration
 Generally recommended 2 sessions/week
 “Optimal” not identified, utilize resistance training principles
Plyometrics
- precautions
 Make sure appropriate for patient  Jumping activities

 Children/elderly use light resistance  Emphasize form and safe landing
techniques before progressing
 No high impact, heavy load exs.
 Progress repetitions before resistance
 Ensure proper strength and flexibility to
or height of jumps
attain/maintain position
 When progressing to high-intensity exs,
 Always perform a warm-up that
increase rest intervals between sets
includes active, dynamic trunk and
and decrease frequency of drills
extremity exs.
 Allow 48-72 hours recovery
 Stop if fatigue influences form/safety
Therapeutic Exercise: remodeling phase Applicable
- signs of excessive stress with exercise/activity to both
resistance
training and
plyometrics
1. Soreness that does not begin decrease after 4 hours
2. Soreness not resolved after 24-48 hours (After DOMS)
3. Pain that begins early on during exercise and in higher than previous session
4. Progressively increased feelings or demonstrations of stiffness or decreased
ROM over several exercise sessions.
5. Swelling, redness, warmth in healing tissues (going back to earlier phases)
6. Progressive weakness over several exercise sessions
7. Decreased functional use of involved body segment
Flexibility/Stretching
- interventions to increase mobility of soft tissues
 Stretching
 Muscle Energy Techniques
 Neuromuscular Facilitation and Inhibition Techniques
 Soft Tissue Mobilization
 Joint Mobilization/Manipulation
 Neural Tissue Mobilization
 Modalities
 Thermal: hot pack, ultrasound, paraffin
- definition
 Ability to move a joint(s)  Types of Flexibility

smoothly and easily through an 1. Dynamic flexibility
unrestricted, pain-free range of  Aka active mobility, active ROM
motion.
 Degree to which an active muscle
 Components of Flexibility contraction moves a body segment
through available ROM
1. Muscle length
2. Passive flexibility
2. Joint integrity  Aka passive mobility, passive ROM
3. Tissue extensibility  Degree to which a body segment can be
passively moved through the available
4. Muscle tone ROM and is dependent upon tissue
extensibility
 Selective stretching
 Stretching a muscle group while allowing limitation of motion to
develop in other muscles/joints
 Think about balancing hamstring length for those with spinal cord
injury
 Some ROM is needed for dressings/transfer, but too much and
sitting stability reduced
 Overstretching/hypermobility
 Stretching well beyond normal length of muscle or ROM
(necking in plastic region)
 Compare and contrast functional needs versus instability
 Range of motions exercise

 During acute and proliferative stages of healing
 Stay within the limits of tissue extensibility to maintain available length
of tissue
 Stretching
 During latter stages of healing to take soft tissue structures beyond
their available length to increase range of motion
 Once additional range of motion is achieved, it is important to
incorporate strength and functional activities in new range.
- types
 Form  Source
 Static  Manual
 Cyclic/intermittent  Mechanical
 Ballistic  Self
 Proprioceptive neuromuscular  Patient participation
facilitation
 Passive
 Assisted
 Active
- determinants/dosing of stretching intervention
 Alignment  Duration
 Limb position to target  Length of time stretch is applied
specific/appropriate muscle group  Speed
 Speed of initial application of stretch
 Stabilization  Frequency
 Fixation of one attachment site  Sessions/day, sessions/week
 Mode
 Form static, ballistic, cyclic
 Intensity
 Patient participation: passive, assisted, active
 Magnitude of applied stretch
 Source: manual, mechanical, self
- duration (and intensity)
 Static
 Cyclic/intermittent
 Tissues elongated just past the point of tissue
resistance  Low intensity, low velocity (i.e. not ballistic)
 Hold in a lengthened position sustained  Repeated short duration
over time
 More comfortable for patient
 Considered safer than ballistic (1/2 amount
of tension created)  Limited studies show equivocal results (total
time of stretch is equal)
 Low intensity considered safer and more
tolerable  5-10 second cycles reported
 Static progressive
 Similar to static
 Hold in a lengthened position, once a
degree of relaxation felt, take up slack and
hold, repeat
- duration (and intensity)
 Lack of agreement on duration  “healthy” older adult

 Time for each rep/cycle and total  4 reps of 60 seconds greatest benefit
number (compared to 15, 30 45 seconds)
 Inverse relationship between intensity  “healthy” young/middle age adult
and duration
 1 rep 30 sec, minimum 2x/week
 Low intensity (load), long duration (compared to 3 reps of 30-60 sec)
stretch is considered the safest and
yields most significant tissue  Adult with chronic contracture
deformation and long-term plastic  4-8 minutes at minimum 2x/week
changes
- speed
 Slowly Applied (static)  Ballistic

 Minimizes muscle activation  High speed, high intensity movements
that create momentum to move body
 Minimizes injury risk segment through ROM
 Easier to control  Greater trauma?
 Less likely to activate stretch reflex  Equally increases ROM in young, healthy
(compared to static)
 May be beneficial for highly trained
athletes
 NOT advised for older adult or sedentary
or patients with musculoskeletal
pathology or chronic contracture
- frequency
 Consider the following  “Optimal” unknown

 Underlying pathology  Ranges from 2-5x/week
 Quality tissue healing  Clinical decision based upon above
 Phase of tissue healing  Need to balance ROM gains with tissue
 Chronicity and severity breakdown
 Age
 Corticosteroids
- mode
 Manual  Manual and self-stretching appropriate

 External end-range stretch force applied by
for “healthy” adults
therapist beyond point of tissue resistance  Patients with chronic contractures
 Passive stretching: patient is fully relaxed benefit from mechanical stretch
 Assisted stretching: patient assists with motion  Prolonged durations are commonly
employed (i.e. 15-30 sec. not effective)
 Self-stretching
 Patient is instructed and supervised in stretch,
then:
 Performs independent stretch
 Mechanical
 Typically applies low load, long duration stretch
 Cuff weight, pulleys, automated devices, serial
casts
 Muscle Energy Technique

 Similar to positional release, evolved from osteopathic
medicine
 Intended to lengthen muscle and fascia
 A muscle contraction is performed by the patient which the
therapist employs a counter force (i.e. isometric contraction)
 Direction of force and intensity of force vary
Indications Contraindications
 Limited ROM due to limited soft tissue  Bony block that limits motion
extensibility
 Recent fracture or non-union
 Due to adhesions, contractures, scar tissue
 Acute inflammation
 Restricted motion leading to structural
deformities  Infection
 Muscle weakness and shortening of tissue  Sharp, acute pain with movement
 Component of total fitness/sport-specific  Hematoma/tissue trauma

program  Hypermobility
 Performed prior to and after vigorous exercise  Shorten tissue required for stability and/or
to potentially reduce muscle soreness function
Foam roller
 Dense foam of varying lengths and

 Self-myofascial release
shapes that may be used to improve:
 Type of Myofascial Release
 Muscle tension and stiffness
 Individuals use their own body mass to
 Muscle pain
exert pressure on the affected soft
 Fascial adhesions tissues
 Muscle length  Massage roller as an alternative
 Balance
 Strength
 Coordination
Foam Roller
- application for myofascial techniques
 Can perform before or after exercise bout

 Evidence mixed on when to implement for soft tissue/blood flow effects
 Dose
 Optimal is unknown, recommended is unknown
 20 repetitions on each muscle group at 1-minute intervals
 1 minute regardless of repetition
 3 sets of 1 minute no cadence
 3 sets of 1-minute with a cadence of 1 second to span muscle belly
 1 X 30 seconds per region no cadence
 2 sets of 1 minute foam rolling with cadence of 3 to 4 cycles per minute
 ***Pain level or load (compression) are often not considered
Massage Roller
- application for myofascial techniques
 Dose
 3 sets of 30 seconds at a cadence of one second per direction for muscle belly
 The pressure applied was equivalent to 7/10 pain on a numeric pain rating scale.
 5 repetitions of 20 seconds
 5 repetitions of 60 seconds
 30 beats per minute (BPM) or 2 second per direction for muscle belly
Focus on evidence based intervention for Acute Spinal Pain/Dysfunction
P646: 2/3/20
 Impairments/activity limitations and
participation restrictions
 Pain and/or neurological symptoms
 Inflammation
 Guarded posture
 Inability to perform ADL’s
 Educate the patient
 Decrease acute symptoms
 Initiate neuromuscular activation and control
of stabilizing muscles
 Teach awareness of cervical, lumbar and
pelvic position for correct & safe posture
 Teach safe performance of basic ADL’s
 Engage patients in all aspects of their care:
 Injury etiology & structures involved
 Healing time anticipated for inflamed tissues or
reduction of symptoms due to nerve root pressure
 Anticipated progress and outcomes
 Precautions/contraindications
 Injury etiology & structures involved
 In the case of whiplash a MVA is the cause (rapid
hyperextension & flexion occurs)
 Patients often ask “why am I so sore, imaging
shows no bone or disc damage”
▪ Overload injury to cervical muscles
▪ Forceful stretch on capsule and
ligaments
▪ Contusions of the facet joints
Tameem A et al. 2013. Whiplash Injury

 Injury etiology & structures involved
 Disc herniation
▪ Patients report an insidious onset
▪ Disc herniation is often due to repetitive poor postures or
accumulated damage overtime (lifting, compressive forces)
▪ Smoking also contributes to early disc degeneration
 Low back pain due to instability

▪ Due to lack of neuromuscular control
▪ Could be initiated after an episode of low back pain
▪ Or be the cause of the low back pain
 Prognosis
 Acute whiplash < 3 months for full recovery
▪ After whiplash some patients do not fully recover,
predictors are pain >5.5/10 on intake & high disability
 Acute lumbar disc herniation
▪ 50% recover in 2 weeks, 70% recover in 6 weeks
 Acute cervical disc herniation
▪ Little on this topic, 60-70% recover in 6-12 weeks
 Instability
▪ 4-6 weeks but some patients’ might take 12 weeks
Tameem A et al. 2013. Whiplash Injury.
Walton et al. 2013. Risk factors….
Dutton’s Orthopedic Examination, Evaluation & Intervention
Wong et al. 2014.
 Precautions/contraindications
 Whiplash & instability
▪ Other external rapid forces (manipulation)
▪ Overly forceful PT (Grade IV mobilizations, mechanical
traction)
 Disc herniation
▪ Activities that increase pain/neurological symptoms
▪ Spinal cord compression or cauda equina symptoms
 Modalities such as cryotherapy or TENS (covered in this
course)
 Soft tissue mobilization/massage (covered later in this course)
 Mobilization/manipulation (in the future in P541/P622)
 Traction (previously covered in this lecture series)
 Therapeutic exercise (this lecture’s focus)
 General exercise/positioning for trauma
patients for symptom management
 Symptom reduction/relief through the
McKenzie approach (Mechanical Diagnosis &
Therapy) for disc herniation
 Neuromuscular control exercises aka
stabilization exercises for functional
instability
 The patient will present with constant pain
due to acute inflammation and a known
mechanism of injury
 Determine a position of symptom relief
▪ Hook lying, prone, sitting, standing
 Consider mid-range exercises to maintain joint
mobility
 Consider isometrics to maintain core stability
Abdominal bracing
Mid range rotation
 The patient will present with constant pain
due to acute inflammation and have
sustained a whiplash injury
 Determine a position of symptom relief
▪ Typically with head and neck supported in neutral
 Consider mid-range exercises to maintain joint
mobility
 Consider isometrics to maintain cervical strength
Use of a cervical roll, this picture shows cervical positioning for
comfort combined with diaphragmatic breathing ( for relaxation)
Flexion Side flexion
Extension Rotation
Cervical retraction
Isometrics
 Treatments that should be routinely provided
 Active exercise (involving range of movement and
mobilising exercises, and strengthening of the
neck and scapular muscles) Grade A
 Advice to ‘act as usual’ / reassurance / education
Grade B
Clinical guidelines for best practice management of acute and chronic whiplash-
associated disorders.
Commissioned by the South Australian Centre for Trauma and Injury Recovery (TRACsa)
 Resting position changes every 30 minutes
 Short sessions frequently throughout the day
to minimize further inflammation
 10 reps, 4-5 sessions daily of mid range of motion
and isometrics
 This next slides are for patients who have not
suffered a trauma
 The suspected structure causing symptoms is
the disc, most likely due to a herniation
 In the McKenzie approach it is termed a
“derangement”
 Typically the disc is the structure involved in
all derangements
 Internal derangement will occur when the
annulus (outside ring) can no longer restrain
the nucleus pulposus (inner “gel”)
“Bulge”
With active exercise we should be able to

influence bulges, protrusions and extruded
discs.
 Each episode is typically more difficult for a
patient to recover from
 Pain with a derangement has a characteristic
presentation
 Pain is:
 Often constant
 Sudden or insidious onset
 Symptoms may be felt locally, cross midline, and are
often referred
 Patients may have difficulty finding a position of
comfort to rest, they are better on the move
 Pain experienced during movement
 There may be a gross loss of movement
 Repeated movements will alter symptoms (, )
 Centralization is a phenomenon that:
 as a result of repeated movements or position
changes causes radiating pain originating from
the spine to move away from the periphery
towards the midline
 centralization remains after the repeated
movements
 once these movements are identified, pain may
even be abolished with further repetitions
 Peripheralization is a phenomenon that:
 as a result of repeated movements or position
changes causes radiating pain originating from
the spine to move toward the periphery and
intensify
 new symptoms such as numbness and tingling
may even be produced
 peripheralization remains after the repeated
movements
 Our ultimate goal is to determine if the patient
has a directional preference
▪ Does the patient have a direction of movement that
centralizes symptoms?
▪ In this course we will consider extension and flexion bias
▪ Tested with repeated movements into extension and flexion in both
loaded and unloaded positions
 Extension in standing
 Extension in lying
We will focus here in this course
 Flexion in standing
 Flexion in lying
 Side glides in standing/ flexion/rotation in lying (variations to
detect a lateral component)
 Symptoms are lessened in positions of
extension (prone, walking, standing)
 The disc is bulging posteriorly
 Flexion such as sitting will load the anterior
disc region and cause fluid distribution and
increase posterior bulge
 Exercises should start unloaded typically
 Prone lying, prone on elbows, prone press-ups
 Progress to loaded exercises in subacute
(proliferative) phase
 Symptoms are lessened in positions of flexion
(sitting, stoop standing)
 The disc is bulging anteriorly or there is spinal
condition causing compromise of the spinal
canal (spinal stenosis, spondylosis,
spondylolisthesis)
 Exercises should start unloaded typically
 Supine knees to chest
 Progress to loaded exercises in subacute
(proliferative) phase
 Flexion in sitting, flexion in standing
Start position End position
 Our ultimate goal is to determine if the
patient has a directional preference
▪ Does the patient have a direction of movement that
centralizes symptoms?
▪ Tested with repeated movements into extension,
flexion, side flexion or rotation in both loaded and
unloaded positions
▪ Retraction in sitting
▪ Retraction/Extension in sitting We will focus here in this course
▪ Retraction in lying +/- extension
▪ Flexion in sitting
▪ Side flexion or rotation in sitting
 Most cervical derangements are caused from
head forward postures resulting in
protraction = lower cervical flexion
 Typically cervical retraction is a good starting
point along with postural education
 Progress to cervical extension in either
loaded or unloaded position depending on
centralization vs peripheralization
 Our goal with exercise is to make a
mechanical change and gain symptom relief
 Dosage must be high
 10-20 reps every 2 hours (waking hours)
 At minimum 100 reps per day
 If you are only able to perform a static
exercise such as prone on elbows, dosage is 5
minutes every 2 hours
 Whether the patient has a cervical or lumbar
problem
 As soon as able in the acute phase, we must
teach the patient to activate deep segmental
spinal stabilizers
 This is because we know when pain occurs these
muscles are inhibited
 In lumbar spine these muscle are the transversus
abdominis and multifidus
 In the cervical spine these muscles are the deep
cervical flexors
 This is about neuromuscular control not
strengthening
 The patient must learn how to contract the
deep segmental muscles without contracting
the global trunk muscles
 Educate where the muscles are & what they do
 Activate TrA using a “drawing in” maneuver in
hook lying
 Activate Multifidus in prone
 Position the patient in hook lying
 Explain that the muscle encircles the trunk and
when activated, the waistline draws inward
 Palpate the TrA just distal to the ASIS and lateral
to the rectus abdominis
 When the TrA contracts a flat tension is felt, if
the internal obliques are activated instead a
bulge of the muscle is felt
 The desired result is an isolated TrA contraction
 Have the patient assume a neutral spinal
position
 Instruct the patient to breath in and breath out,
then gently draw the belly button in toward the
spine to hollow out abdominal region
 Or contract the pelvic floor 50%, then gently
draw in
 Look out for substitute patterns
▪ No pelvis movement, flaring of ribs, bulging of belly,
increased pressure under feet, gluteal activation, breath
holding
Since this is performed in a neutral spine position, it should
be pain free in acute patients. The goal of this exercise is to
segmentally stabilize the lumbar spine.
 The patient should try in prone or side lying
 Explain that the muscles runs adjacent to the
spinous process and spans 2-4 segments
 The therapist places palpating digits just
lateral to the spinous processes (you typically
palpate one level at a time)
 Instruct the patient to “swell the muscle” out
against your digits
 To facilitate the contraction you can instruct
the patient to perform the “draw in”
maneuver for TrA and contract the pelvic
floor 50%
 Substitutions to monitor for:
 Breath holding, flaring of ribs, erector spinae
activation, gluteal activation, change in lumbar
lordosis
Since this is performed in a neutral spine position, it should
be pain free in acute patients. The goal of this exercise is to
segmentally stabilize the lumbar spine.
 This is about neuromuscular control not
strengthening
 The patient must learn how to contract the
deep segmental muscles without contracting
the global cervical muscles
 Educate where the muscles are & what they do
 Activate the deep cervical flexors by performing a
head nod in supine
▪ Primary muscles being activated are longus colli and
longus capitis
 Position the patient in supine without a pillow
 If patient has a significant forward head then
place a folded towel under the occipital region so
extension of the head does not occur
 Explain where the deep cervical flexors are
that these muscles support the cervical spinal
segments and maintain ideal cervical posture
 Instruct the patient to perform slow,
controlled nodding motions of the head
(”yes” motion)
 You may need to facilitate the motion with
manual cues
 Look for substitutions
 SCM, scalene or platysma activation, breath
holding, shoulder rounding or pectoral activation
 Our goal with exercise is to improve
neuromuscular control
 Dosage must be frequent throughout the day
 5 sessions per day
 10 reps with a 10 second hold at each exercise
session is the goal
▪ Your patient may perform less reps or hold time if they
cannot perform this dosage with correct form aka
neuromuscular control
 You must address postures that are
detrimental to recovery
 Explain positions to avoid
▪ For example in extension bias lumbar disc herniation
avoid flexion
 Teach correct postures for ADL’s and work ADL’s
▪ May include sitting, standing, sleeping (pillows), work
station (standing)
Poor posture typically has a forward head, rounded forward shoulders and a rounded forward spine.
Good posture demonstrates ears in line with the shoulders and hips. It is your tallest position with your
feet flat on the ground. Use of a lumbar roll is a good strategy.
Poor posture typically has
a forward head, rounded
forward shoulders and a
rounded forward spine.
Good posture
demonstrates ears in line
with the shoulders, hips
and ankles. It is your tallest
position with your feet flat
on the ground.
Pillow placements while
lying down can reduce pain
and pressure on the low
back.
Lying on your back: Place

pillows under your knees.
Lying on your side: Place

pillows between the knees.
GETTING IN BED:
Start by sitting on the edge of the
bed. Next, lower your self down
lying on your side using your arms.
Once fully on your side, roll onto
your back. When rolling be sure
your knees stay bent and that you
roll your whole body together as
one unit. Your shoulders, pelvis and
knees all roll as one.
GETTING OUT OF BED:
Start by bending your knees and
then roll onto your side. Reach your
arm across your body to initiate the
rolling. When rolling, be sure that
you roll your whole body together
as one unit. Your shoulders, pelvis
and knees should all roll together.
Once on our side, tip yourself up to
sitting using your arms.
Desk set up should have the
monitor set at or just below eye
level. The elbows, hips and knees
bent 90-110 degrees.
Adjustments can be made for

monitor height, keyboard height,
seat height and/or foot rest height
in order to achieve proper
alignment.
 Be able to verbalize general guidelines for
management of acute low back & cervical pain
in the protection phase
 Prescribe an initial therapeutic exercise program
for acute spinal pain due to
 Trauma
 Disc herniation
 Or instability
 Be able to educate your patient on correct and
safe postures in the acute phase of healing
Aquatic Therapy
(Hydrotherapy)
P646 Therapeutic
Interventions
April 20th, 2020
Dr. Keith Avin, DPT, PhD
Aquatic Therapy
- uses/indications
 Exercise
 Pain control
 Edema control
 Superficial heating and cooling
 Wound care (outdated)
Aquatic Therapy
- goals
 Facilitate ROM
 Resistance Training
 Facilitate weight-bearing activities
 Enhance delivery of manual techniques
 Cardiovascular Exercise
 Initiate Functional Activities
 Minimize Injury Risk
 Enhance Patient Relaxation
Aquatic Therapy
- physical properties of water
 Buoyancy
 Hydrostatic pressure
 Viscosity
 Surface tension
 Specific heat and thermal conductivity
Aquatic Therapy
- buoyancy
 A body immersed in a
liquid experiences an
upward force (opposing
gravity) equal to the
weight of the displaced
liquid (Archimedes’
principle)
Aquatic Therapy
- buoyancy
 Dependent upon the density of the body

– Example: Lean (will sink) vs. Obese (will float)
 Human body is less dense than water

– Joint unloading
 Minimize stress of joints and muscles
– Provides resistance
– Assist with exercise
– Belts, vests and armbands
Aquatic Therapy
- buoyancy
These numbers may

vary some;
specifically some
texts list 25-33% at
the xiphoid process
Aquatic Therapy
- hydrostatic pressure
 Pressure exerted by water on immersed objects

 Pascal’s Law
– Pressure exerted by fluid is equal on all surfaces of the object
(at a given depth)
 Pressure Effects
– Increased pressure limits effusion, assists venous return,
induces bradycardia, and centralizes peripheral blood flow
Aquatic Therapy
- hydrostatic pressure
 Perpendicular pressure that

is equal on all sides at a
given depth (when at rest)
– 22.4 mmHg/foot
 Magnitude of the force
exerted by the fluid
– depth
– density
 **** must be in dependent
position to have > pressure
Aquatic Therapy
- viscosity
 The friction occurring between molecules of

liquid resulting in resistance to flow
 Viscosity resistance is proportional to the
velocity of movement through liquid
– Moving faster makes activity more challenging
 Surface Area
– A greater surface area
Aquatic Therapy
- surface tension
 The surface of a fluid acts as a membrane

under tension
 Attraction of surface molecules is parallel to the
surface
 An extremity that moves through the surface
performs more work than if kept completely
under water
Aquatic Therapy
- resistance
 Provided by the viscosity of the water

 occurs against the direction of movement
Aquatic Therapy
- resistance
 increases in proportion to relative speed and

frontal area of body part
Aquatic Therapy
- specific heat and thermal conductivity
 Conduction
– High specific heat
 Amount of heat required to raise 1g of substance by
1ºC
 Retains 4x as much thermal energy than air
– High thermal conductivity
 Transfers thermal energy 25x faster than air
– Amount of conduction will be alter by body fat
composition
 body fat will decrease ability to dissipate heat
Aquatic Therapy
- specific heat and thermal conductivity
 Convection
– More rapid process of thermal exchange
than conduction
 Transfer rate is increased when fluid flow rate is
increased
– Heat transfer increases with velocity
 A patient moving through water loses body temperature
faster than an immersed patient at rest.
Aquatic Therapy
- physiological effects
 Musculoskeletal Effects
– Buoyancy unloads weight bearing joints
 Degenerative conditions, trauma, obesity
– Strengthening with resistance

 Velocity-dependent
– ½ to 1/3 speed of land same metabolic rate
 Can provide assistance or resistance depending upon the
direction in which you move water flow
Aquatic Therapy
 Cardiovascular effects
– Increased venous return
– Increase in cardiac volume (30%)
– Increase in atrial pressure
 14-18 mmHg
– Increase in cardiac output (30%)
– Decrease in heart rate & systolic blood pressure
– Effect may be altered in warmer water

Aquatic Therapy
 Respiratory effects
– Immersion increases the work of breathing 60%
 Shift of venous blood from the peripheral to the central
chest cavity and hydrostatic pressure on the chest and
diaphragm.
– Patients with respiratory or cardiovascular
impairments should be carefully monitored
– Good environment for those with Asthma
 Humidity most likely reason
Aquatic Therapy
 Renal effects
 Increased renal blood flow  Increase Hydrostatic
pressure Central
blood volume  ADH
Aldosterone 
Increase in urine productionIncreases urinary sodium and

potassium excretion.
Decreased Edema!!
Aquatic Therapy
- uses (thermal effects)
 Same as cryo/thermal therapy lectures

 Effects dependent upon water temp
– Vasodilation (heat)
– Vasoconstriction (cold)
– Muscle relaxation
– Soft tissue extensibility
– Pain control
Aquatic Therapy
- uses (thermal effects)
 Advantages
– Perfectly contoured
– Allows for movement
– Does not need to be fastened to body
 Disadvantages
– When applied to distal extremities; must be in
dependent position
Aquatic Therapy
- uses (exercise)
 Types: swimming, running,

walking, cycle ergometry
 General uses
– Increase: circulation, muscle
strength, joint viscoelasticity,
flexibility, ROM, gait,
coordination, cardiovascular
and respiratory conditioning,
psychological well-being
– Decrease: Pain, muscle spasm

and stiffness.
Aquatic Therapy
- uses (exercise)
 Body Immersion
– Musculoskeletal effects
 Balance impact
– Unloading
 Strengthening
– Resistance
 Gait training
– Upright posture
– Decrease fear of falling
– Balance training
Aquatic Therapy
- uses (pain control)
 Sensory stimulation to mechanoreceptors

– Gating of pain
 Temperature
 Agitation
 Cold water
– decrease in inflammation
 Buoyancy
– Unloads joints
Aquatic Therapy
- uses (edema control)
 Cold water
– vasoconstriction
– acute inflammation
 Disadvantage?
– Easy to get hypothermia
– Patient tolerance (painful)
– Cleaning b/w pts
– Correct temperature
Aquatic Therapy
- exercise pool
 Full body immersion

 exercise
 musculoskeletal benefits
 82-88F (28-31C) more active patients and patients with
MS
 88-92F (31-33C) less active patients (arthritis)
 92-96 (33-36) degrees for less active patients
Aquatic Therapy
- temperature regulation
 Reduced sweating  Common temps for exercise

mechanisms 26-35ºC
 Water temperature perception – Warm water 33-35C may be
greater than air temp. helpful for relaxation,
increasing pain thresholds
 Adequate core > 25ºC and decreasing muscle
 Prolonged, high intensity spasm
exercise in temps >37ºC may be
– 26-28C is appropriate for
harmful
cardiovascular training
– At rest cardiovascular output
significantly increases – If working >80% max heart
rate, temps 22-26C
Aquatic Therapy
- contraindications
 Cardiac Instability  Open wounds without

 Infectious conditions dressings
 Respiratory dysfunction
that may be spread
(vital capacity <1 liter)
by water  Severe peripheral
 Bowel Incontinence vascular disease
 Severe epilepsy  Severe kidney disease
 Suicidal patients (unable to adjust fluid
loss during immersion)
MS patients and pregnant women in warm/hot water
Aquatic Therapy
- precautions
 Full body immersion

– Precautions
 Confusion, disorientation
 After ingestion of alcohol
 Limited strength, endurance and balance (could they drown
themselves?)
 Medications
 Urinary incontinence (water immersion increases renal flow)
 Fear of water
 Respiratory problems
 Neurological disorders
– Ataxia, heat-intolerance (MS)
Aquatic/hydrotherapy
- adverse effects
 Drowning
 Burning
 Fainting- with full body immersion (decreases
BP)
 Bleeding- agitation
 Hyponatremia- with extensive wounds lose salt
 Infection
 Acute edema
 Asthma- chlorine
Cryotherapy
and
Compression
Keith G. Avin, DPT, PhD
1-13-20
- categories
Category Definition Types Clinical Examples

Thermal Energy transfer to Deep heating Diathermy
increase/decrease agents Hot pack
tissue temperature Superficial heating Ice pack
agents
Cooling agents
Mechanical Application of Traction Mechanical
mechanical forces Compression traction
to Water Elastic bandage
increase/decrease Sound Whirlpool
pressure in body Aquatic Therapy
Ultrasound
Electromagnetic Application of Electromagnetic Ultraviolet
electromagnetic fields TENS
radiation or Electric currents
electrical current
Specific Heat
• Amount of energy required to raise the temperature of a given
weight of material a given number of degrees
• Higher specific heat requires more energy
• Higher specific heat hold more energy than materials with low
specific heat when held at the same temperature
Table 6.1: Specific Heat of Various Materials

Material Specific Heat in J/gm/°C
Water 4.19
Air 1.01
Average for human 3.56
Body
Skin 3.77
Muscle 3.75
Fat 2.30
Bone 1.59
Modes of energy transfer
• Modalities will transfer energy via:
• Conduction (thermal)
• Conversion (mechanical)
• Convection (mechanical)
• Evaporation
• Radiation
Conduction
• Direct contact between materials of different temperatures
(collision of two different molecules)
• Higher to lower
• Examples
• hot packs, cold packs, contrast bath and paraffin baths
Transfer of energy
• Determining the rate of energy transfer by Conduction
= Contact Area X Thermal Conductivity X Temperature Difference

Tissue Thickness
Convection
• Heat transfer via circulation of a medium
• Result of direct contact
• Agent/medium is in motion (not stationary as in conduction)
• More heat transfer occurs by convection in the same amount

of time than conduction when using the same material at the
same temperature
• Convection
• Examples
• Oven, fluidotherapy, whirlpool, our body’s circulation
Conversion
• Non-thermal energy to heat
• Mechanical, electrical or chemical
• Heating is unaffected by the temperature of the person, it is
dependent upon the power source
• Rate of tissue increase is dependent upon the size of the area
to be treated, size of applicator, efficiency of transmission and
tissue type
• Does not require direct contact but does require a coupling
medium
• Examples
• Ultrasound
• Diathermy
Radiation
• Transfer of heat from a material of high temperature to low
temperature without an intervening material or contact
• Rate of increase is dependent upon intensity, size of the
source of radiation and area of radiation
• Examples
• Infrared lamps, the sun
Transfer of Heat
• Evaporation
• Absorption of energy as the result of conversion of a material
from liquid to a vapor state
• material must absorb energy to evaporate
• Absorbed energy is in the form of heat
• Example
• Sweating,
Cryotherapy
- modes of energy transfer
Cryotherapy
- common interventions
Pt. Education • Inform of anticipated recovery

• Appropriate loading/wt. bear
• Appropriate functional activities
Control pain, edema, spasm • Protection
• Optimal loading
• Ice, compression, elevation
• Grade I mobilizations (in pain-free position)
Maintain soft tissue and joint • PROM, A-AROM, AROM
integrity and mobility • Muscle setting
Maintain integrity and function • AROM

of associated areas • Resisted ROM
• Isometric
• Dynamic
• Functional activities as indicated
Cryotherapy
• Definition • Therapeutic Uses
• Therapeutic use of • Inflammation control
cold • Edema control
• Pain control
• Physiological effects • Spasticity
• Three general effects • Altered skeletal
• Hemodynamic muscle strength
• Vascular • Skeletal muscle
• Neuromuscular contraction facilitation
• Metabolic
Physiological Effects
- hemodynamic effects
• Vasoconstriction
• Persists with
application 15-20 mins
• Greatest in area where
cold is applied
• Why vasoconstriction?
• Protect other areas from
exposure to cold
• Stabilize core temperature
• Less blood to warm so
progressive decrease in
temp where cold is
applied.
- neuromuscular effects
• Decreased nerve
conduction velocity
• Occurs within ≥ 5 min
• Decreases proportional
to degree and duration
of temperature change
• ≥2 min to regain velocity
• Greatest effect on
myelinated, small
fibers
• A-Delta (pain-
transmitting fiber)
• Complete block possible
on superficial nerves
• Decrease pain
sensation
• Increased pain May be utilized across healing spectrum
threshold
• Mechanisms
• Counterirritant
• Reduction in muscle
spasm due to ↓ nerve
conduction velocity
(pain-spasm-pain
sycle)
• Reduced edema
• Altered muscle strength
• Brief ice massage (< 5
minutes)
• ↑ isometric strength May be utilized across healing spectrum
• Increased motor unit
excitability
• Prolonged cooling (≥30
minutes)
• Decrease in isometric
strength, nerve
conduction and blood
flow
• Increase in viscosity, and
joint and tissue stiffness
• Temporarily
decreases
spasticity
• Decreases Gamma Motor May be utilized across healing spectrum
Neuron Conduction and
afferent muscle
spindle/GTO activity
• Prolonged cooling
(10-30 mins) reduces
or eliminates
spasticity, clonus and
passive stretch
resistance for 1-1.5
hrs
- metabolic effects
• Decrease metabolic rate
and enzymatic activity
• Controls Acute
Inflammation
• NOT recommended
when healing is delayed
Cryotherapy
Physiological effects
Hemodynamics Neuromuscular Metabolic
Pain Threshold
Direct
Pain Sensation
Indirect
Strength Changes
Clinical Application
• Primary goals of cryotherapy application:
• Inflammation control
• Edema control
• Pain control
• Spasticity
• Facilitation
Cryotherapy
- clinical application (inflammation)
• Controlling inflammation is intended to accelerate

recovery/healing via:
• ↓ chemical reactions association with inflammation also
heat, redness, edema, pain and loss of function
• Apply immediately and throughout acute phase
• When applied within 2 days of ankle injury (Ogilvie-
Harris 2006) Persistent
• ↓ pain, edema and recovery time warmth
• If tissue warm >>>> cryo think
• If tissue normal >>> NO cryo Infection/
refer
Cryotherapy
• Inflammation control
• Mechanisms
• directly reduces heat
• vasoconstriction
• increased blood viscosity
• decreases neural conduction velocity
• decreases formation of new edema
• gates pain
• Discontinue when acute inflammation has
resolved to avoid impeding later stage
recovery (proliferation phase)
Cryotherapy
• acute inflammation 48 to 72 hours
• Cold has been shown to be more effective at controlling
swelling when applied with compression (Merrick, 1993)
• 10-20 mins on:1 hour off
Cryotherapy
- clinical application (edema)
• Mechanism
– Edema: extravasation of fluid
– Cryo: ↓ fluid pressure via ↓ blood flow
• Application
– RICE, PRICE, POLICE
– Immediate
– Add elevation and compression
– 10-20 minutes; repeat after 1-2 hrs
• Avoid rapid re-warming with shorter time periods
• Greater than 30 minutes and re-warming may not occur if
reapplication occurs
• Not effective for edema caused by immobility or poor
circulation
Cryotherapy
- clinical application (pain control)
• Immediate effect: vapocoolant spray, ice massage

• Prior to stretching; aware of reduced sensation
• Long-duration: apply >10 min for 1-2 hr effect
• Block A-delta fibers
• Gate pain via cutaneous thermal receptors
• Pain-spasm-pain interruption
Cryotherapy
- clinical application (spasticity)
• Temporary relief of spasticity

• Prolonged application
• Treatment application of up to 30 minutes
• Check skin every 10 minutes!
• 1 hour effect (or longer)
• Follow-up with ther ex, ADLs, etc.
Cryotherapy
- clinical application (cryokinetics)
• Cryokinetics
• Do not recommend
• Should you ice prior to sporting activity?
Cryotherapy
- contraindications
• Cold hypersensitivity • Normal response to

• Vascular skin reaction cold
to cold application • Intense Cold
• Reddish and pale patches
• Burning
• Hives
• Severe itching • Aching
• Cold Intolerance • Analgesia (no
perception of pain)
• Severe Pain
• Numbness
Cryotherapy
- contraindications
• Cryoglobulinemia • Raynaud’s disease

• Proteins aggregate and phenomenon
upon cold > impaired • Sudden pallor and
circulation > ischemia cyanosis in the digits
> gangrene
• Idiopathic or related
to multiple myeloma,
systemic lupus
erythematosus,
rheumatoid arthritis,
other
hyperglobulinemic
states
Cryotherapy
- contraindications
• Over an area of circulatory compromise or PVD

– Aggravation of impairment
• Paroxysmal Cold Hemoglobinuria
– Red blood cells in the urine in response to cold
• Over a regenerating nerve
– May delay regeneration
Cryotherapy
- precautions
• Over the superficial main branch of a nerve

• Can cause a nerve conduction block
• Peroneal nerve; radial nerve
• Be aware of distal numbness/tingling > If yes > D/C
• Over an open wound
• Delay wound healing
• Decrease circulation
• Decrease metabolic rate
Cryotherapy
- precautions
• Patient’s with poor sensation or mentation

• Unable to report abnormal responses
• Patient’s with hypertension
• Transient increases in blood pressure
• Very young and very old patients
• Impaired thermal regulation
Cryotherapy
- adverse events
• Tissue damage begins at 15ºC

• Frostbite between 4ºC and 10ºC
• Tissue death
• Nerve damage
• Pain, numbness, tingling, hyperhidrosis, nerve conduction
abnormalities
• Apply <45 mins, maintain skin >15ºC
Cryotherapy
- modality application
• Assess patient and set goals

• Determine if cryotherapy is most appropriate
treatment
• Determine whether contraindications or precautions
are present
• Select/apply the appropriate cooling agent
• Cold/ice pack, ice cup, controlled cold compression units,
vapocoolant sprays, ice water, cold whirlpools and contrast
baths
Cryotherapy
- modality application
• Explain the procedure,
reason for applying
cryotherapy, expected
sensations
• Apply the appropriate
cooling agent
• 10-30 minutes duration
• 10on-10off-10on
(Bleakley et al)
• Assess patient during
intervention
• Assess outcomes of the
treatment
• Documentation
Cryotherapy
- documentation
• Area of the body treated

• Pre-treatment assessment
• Type of cooling agent
• Treatment duration
• Patient positioning
• Response to treatment
Compression
Compression Therapy
• Purpose
• mechanical force that increases the external pressure on the
body
• Effects
• improve fluid balance & circulation
• modify tissue formation (including scar tissue)
• Clinical Applications
• Edema control
• Vascular or lymphatic etiology
• Limb shaping after amputation
• Prevention of deep vein thrombosis
• Facilitate healing of venous ulcers
Compression Therapy
- fluid balance and circulation
1. Improved Venous & Lymphatic

Circulation
• Compression limits outflow of vessel
fluid keeping it in the circulatory
system >>>> can circulate elsewhere
• This is achieved by:
• increased hydrostatic pressure in the
interstitial space outside of the blood
and lymphatic vessels
• Need to treat underlying cause of

edema (if applicable)
• i.e.- infection, malnutrition, physical
inactivity, organ dysfunction
Compression Therapy
- modify tissue growth
2. Shape and size of tissue

• Acts as a “2nd skin” that is less extensible
• Bandages, garments, devices
• Therapeutic Indications
• Amputation
• Burns
• Edema
• Also increases tissue temperatures
• Result of insulation provided by compression
device/sleeve/stocking
• Increased temps may activate enzymes that break down
collagen (possibly)
Compression Therapy
- clinical indications (edema)
• Presence of abnormal amounts of fluid in the

extracellular spaces
• Normal conditions
• Hydrostatic pressure > (slightly) Osmotic pressure
• Fluid is pushed from Veins >>>> Lymphatic capillaries >>> Venous
circulation
• Lymphatic fluid- rich in protein, water and macrophages
• Factors that affect edema

• Diet
• Vascular system
• Muscular contractions (physical activity/exercise)
Edema
- pressures
• Osmotic Pressure
• Determined by the
concentration of proteins inside
and outside of the vessel
• Intravascular Hydrostatic
Pressure
• Determined by blood pressure
and effects of gravity
• Normal Conditions
• Hydrostatic is slightly higher than
osmotic
• Slight fluid loss into interstitial
space and taken up by lymphatic
system
Edema
- causes
• Acute Inflammation
• Cellular response
• mast cells, platelets, basophils (type of white blood cell),
macrophages
• Causes vasodilation and increase vascular permeability
• Compression
• Increases extravascular hydrostatic pressure and subsequently
increases circulation
• Fluid is forced back into veins and lymphatic vessels, which is then
circulated throughout the body.
Compression Therapy
- clinical indications (edema)
• What are the most common causes?

• Older individuals
• Venous insufficiency
• Other causes
• Burns
• Lymphedema
• Infection
• Surgery
• Cancer
• Radiation treatment
• Inflammation
• Exercise
• Pregnancy (may be sign of preeclampsia)
• Air travel (>7 hour flight)
Compression therapy
- Adverse Complications of Edema
• Restriction in ROM
• May be due to swelling or fibrosis
• Limitations in function
• Disfigurement
• Pain
• ↑ Risk of Infection
• ↓ oxygenation
• Arterial obstruction
• Ulceration/amputation
• Skin changes
• Itching, pigmentation changes
Compression therapy
- Edema that should NOT be treated with compression
• Medical conditions
• Congestive Heart Failure (CHF), Cirrhosis, acute renal disease, renal
failure, diabetic glomerulonephritis, malnutrition, radiation injury,
liver failure
• Compression should not be used with these conditions
• Will not have an effect and may overload cardiovascular system
Compression therapy
- Clinical Indications (edema)
• Venous Insufficiency
• Peripheral veins transport deoxygenated blood to heart
• 90mmHg @ ankle
• Muscle contractions exerts 200mmHg on the venous system to push
blood proximally
• Falls to 10-30mmHg after contraction for refill
• Vessel valves prevent backflow
• Abnormalities
• Physical inactivity
• Venous valve degeneration
• Phlebitis
• Mechanical obstruction
• Tumor, inflammation>>> edema
Compression therapy
- Clinical Indications (lymphedema)
• Lymphedema
• Hydrostatic pressure > (slightly) Osmotic pressure
• Fluid is pushed from Veins >>>> Lymphatic capillaries >>> Subclavian
veins
• Lymphatic fluid- rich in protein, water and macrophages
• Flow is dependent upon muscle activity
• ↓ lymphatic flow leads to lymphedema
• Causes: ↓ plasma protein (albumin), mechanical obstruction of
lymphatics, abnormal distribution of lymphatics and reduced activity
• Lymphedema can be
• Primary (congenital dysfunction)
• Secondary (cancer, infection, radiation, trauma)
Compression therapy
- Clinical Indications (lymphedema)
Compression therapy
- Other clinical Indications
• Prevention of DVT
• Compression garments, intermittent pumps on inpatient wings
• Venous stasis ulcers
• Unna Boot
• Residual limb shaping
• Hypertrophic scarring
Compression therapy
- Clinical Indications (DVT prevention)
•Prevention of DVT
• Blood clots (thrombus) form in deep veins due to poor circulation
• Causes pain, swelling and skin changes
• Can lead to a pulmonary embolus
• Pulmonary embolus (PE)
• Dislodged thrombus that blocks blood supply to lungs
• Causes shortness of breath, respiratory failure or death
• Commonly seen in ICU
• Risk factors
• Age, surgery, trauma, hospital/nursing home stay, cancer, central
vein catheterization, transvenous pacemaker, prior thrombosis,
varicose veins, paralysis, oral contraceptives, pregnancy, hormone
therapy
Compression therapy
- Clinical Indications (DVT prevention)
• Compression effects
• Improves venous flow
• Reduces venous stasis
Sequential compression
devices (SCD)
Compression therapy
- Clinical Indications (venous stasis ulcers)
•Venous Stasis Ulcers

• Areas of tissue breakdown and necrosis due to
impaired venous circulation
• Exact mechanism unknown

• Endovascular and inflammatory changes lead to fibrosis,
impaired wound healing, ulceration
• Why compression (cornerstone of treatment)

• Improves venous circulation >>>> which reduces risk of ulcer
formation
• Increases rate of healing
• Multilayered > single layer compression
• High-pressure > low pressure
Compression therapy
- Clinical Indications (venous stasis ulcers)
Compression therapy
- Clinical Indications (residual limb shaping)
•Residual Limb Shaping

• Compression
• Shape and reduce edema in the residual limb following amputation
• Prepares limb for prosthetic fitting
• Creates appropriate areas of functional weight bearing
Compression therapy
- Clinical Indications (hypertrophic scarring)
•Control of Hypertrophic scarring

• Common complication of deep burns
• Potential mechanisms of compression:
• Facilitate collagen orientation
• Increased skin temperature
• Increased prostaglandin E2 release
• Tissue hypoxia
• Controlling cell apoptosis (cell death)
• Some people are predisposed to hypertrophic scarring
• Scarring results in:
• Raised and rigid skin appearance
• Limited flexibility
• Can result in loss of ROM
• Poor cosmetics
Compression therapy
- Clinical Indications (hypertrophic scarring)
•Control of Hypertrophic scarring

• Treatment
• Types
• Elastic bandages
• Self-adherent wraps
• Tubular elastic supports
• Elastic custom garments
• Static garments
• Custom fit and worn for 8-12 months or more
• 24 hours a day
• Take off in shower of course
Contraindications
Compression Therapy
• Heart failure or pulmonary edema
• Recent DVT, thrombophlebitis, pulmonary embolism
• Obstructed lymphatic or venous return
• Arterial insufficiency/ulcers
• Acute skin infection
• Hypoproteinemia (protein < 2gm/dL)
• Acute trauma or fracture***
• Arterial revascularization
***contraindication for intermittent only; static allowed

Precautions
Mechanical Compression therapy
• Impaired cognition or sensation
• Unable to recognize or communicate when pressure is too large
• Uncontrolled hypertension
• Compression can further elevate blood pressure
• Cancer
• Could potentially spread cancer
• Stroke
• Superficial nerves
• Nerve palsy
Compression therapy
- Clinical Application
•Static Compression Therapy
• Static – continuous applied force
• Alter shape and size of tissues
• Decrease formation of edema in residual limb
• Prepares limb for prosthetic fitting
• Applied with bandages or compression garments
Compression therapy
•Compression bandaging
• Long-stretch bandaging
• 60-70 mmHg
• Can extend 100-200%; use moderate tension
• Little to no working pressure
• Types: Acewrap, tubigrip
Long stretch bandage

Compression therapy
• Short-stretch
bandaging
• Can extend 30-90%
• Low resting, high
working pressure
• Useful during exercise
(pt’s w/ lymphedema)
• Types: Coban,
Comprilan
Short stretch bandage

Compression therapy
- Application
•Compression bandaging
• Figure 8 Bandage
• Distal to proximal application
• Provide moderate comfortable compression
• Specialized bandages can provide different amounts of compression
(short or long-stretch)
• Procedure
• Remove clothing and jewelry
• Inspect skin
• Dress and cover any wounds
• Apply compression bandage from distal to proximal
• Figure 8
• More tension distal than proximal
Compression therapy
- Application
•Compressive Garments
• Off the shelf and custom fit
• Moderate elasticity to create working and resting pressure
• Off the shelf
• Low compression of 16 to 18mmHg
• Used to prevent DVT in post surgical and low activity patients
• Will not aid in dependent position
• Custom Fit
• Available in different levels of pressure
• 10 to 50mmHg
• 20-30 mmHg- scar control
• 30-40 mmHg- edema control
Compression therapy
• Intermittent Compression Therapy
• Intermittent compression may be more effective; thought to milk
fluids from distal to proximal vessels
• Applied with a mechanical device (compression pump)
• Results in:
• Decreased edema
• Prevention of DVT’s
• Healing of venous stasis ulcers
Application
•Intermittent pneumatic compression pump
Problem Inflation/Deflation Inflation Pressure Treatment Time

time (secs) (mmHg) (hrs)
Edema, DVT 80-100/25-35 (3:1) 30-60 UE 2-3
prevention, venous 40-80 LE
stasis ulcer
Residual limb 40-60/10-15 (4:1) 30-60 UE 2-3
reduction 40-80 LE
Inflation pressure should never exceed diastolic pressure

Documentation
• Device
• Area of body
• Inflation and deflation
• Compression
• Total treatment time
• Patient position
• Response
Part 1
 Superficial heaters
 Hot packs CLINICAL PEARL:
 Paraffin Skeletal muscle blood
flow is less affected
 Infrared lamp by superficial heating;
 Fluidotherapy exercise or ultrasound
 Whirlpool tank* are more effective for
muscle
 Deep heaters
 Ultrasound
 Diathermy
 Radiation
 Heat transfer from a warmer object to a cooler
object by means of transmission of
electromagnetic energy without heating of an
intervening medium
 Convective modalities
▪ Infrared lamp
 Convection
 Heat transfer by movement of air or fluid from a
warmer area to a cooler body part
 Convective modalities
▪ Whirlpool tanks
▪ Fluidotherapy
 Conduction
 Heat transfer from a warmer object to a cooler
object by means of direct molecular contact of
objects in physical contact
 Conductive modalities:
▪ Hot packs
▪ Paraffin wax baths
 When large areas of the body surface are
exposed to heat modality e.g. whirlpool tank
INCREASED DECREASED
Cardiac output Blood pressure
Metabolic rate Muscle activity (sedentary effect)
Pulse rate Blood to internal organs
Respiratory rate Blood flow to resting muscle
Vasodilation Stroke volume
 Heat is applied to a discrete area of the body
e.g. low back or neck
SYSTEM/STRUCTURE MECHANISM
Blood flow Dilation of arteries & arterioles
Capillary permeability Increased capillary pressure
Elasticity of non-elastic tissues Increase extensibility of collagen tissue
Metabolism The rate of cellular oxidation increases 2-3x for
every 10° tissue temperature increase
Vasodilation Activation of axon and spinal cord reflex
through the release of vasoactive agents
Edema Increased capillary permeability
 Heat is applied to a discrete area of the body
e.g. low back or neck
SYSTEM/STRUCTURE MECHANISM
Joint stiffness Increased extensibility of collagen tissue and
decreased viscosity
Muscle strength Decreased firing of alpha (somatic) motor
neurons and function of glycolytic process
Muscle spasm Reduction of alpha (somatic) motor neuron
activity which decreases tonic extrafusal
activity
Pain (gate-control theory) Pre-synaptic inhibition of A delta and C fibers
via activation of A beta fibers (gate theory),
disruption of pain-spasm cycle.
 Modulate pain
 Increase connective tissue extensibility
 Decrease muscle spasm
 Increase range of motion and decrease joint
stiffness
 Accelerate healing
 May also be indicated prior to e-stim, soft

tissue mobilization, passive or active exercise
 Area of recent or potential hemorrhage
▪ Cause a reopening of lesion
 Area of thrombophlebitis
▪ Could create an thrombus
 Areas of impaired sensation or patients with
mental impairment
▪ Burns
 Over or near a malignant tissue
▪ Increase the growth rate
 What is this?
 Erythema ab igne = represents a skin
reaction to thermal injury
 Chronic heating pad use and warming
in front of a wood-burning stove are
common causes
 Typically, the affected area has a net-
like pattern of blue-gray discoloration,
sometimes with associated erythema
 Patients often complain of burning or
pruritus (itching) of the involved area.
 The mainstay of treatment is
avoidance of the heat source.
 The discoloration slowly resolves over
months to years; however, permanent http://www.aafp.org/afp/2006/1115
scarring and hyperpigmentation can /p1765.html
occur
 An area of acute injury or inflammation
 Can increase edema, bleeding from vasodilation
 Pregnancy
 Trigger for maternal hyperthermia  fetal
damage
 Impaired circulation or poor thermal
regulation
 Potential burn
 Edema
 Vasodilation could increase edema
 Cardiac insufficiency
 Heat increase cardiac demand
 Metal in the area
 Metal has higher thermal conductivity so it will
heat more quickly than the surrounding tissue
 Over an open wound
 Precaution for paraffin
 Demyelinated nerves (MS, CTS)
 Conduction block could occur
 Fainting
▪ Due to vasodilation and decreased blood pressure causing
inadequate cerebral flow
▪ If a patient feels faint during heat application, lower the head
and raise the feet
▪ If a patient feels faint when getting up after heat, they could
be experiencing orthostatic hypotension
▪ Remain in the treatment position for a few minutes and transition
between positions gradually
 Bleeding
▪ Avoid by screening for bleeding risks
 Burns
 Should feel
 Gentle warmth
 Should not feel

 Excessively hot
 Burning
 Increased pain
1. Treatment must be performed by a PT or
PTA
2. Check contraindications/precautions
3. Explain the treatment and expected
sensations to the patient
4. Place patient in a comfortable position
(know where a pt. has muscle spasms)
5. Expose treatment area and drape patient
properly
6. Inspect skin and complete a temperature
sensation screen (fill 2 test tubes with hot
and cold water and ask pt. to differentiate)
7. Place heating agent on the skin
8. Leave the patient with a bell or call light, set
timer
9. Dry and inspect skin at conclusion of
treatment
 Immersed in water at ~ 70-75°C [158-167°F]
 Method of heat transmission is conduction
 Method of application:
 add 6-8 layers of toweling between hot pack and
patient
 or a terry cloth cover (=2-4 layers of towel) and
one folded towel
 risk of burn is highest in first 5 minutes so check
skin in the first 5 mins
 treatment time 20-30 mins
 Paraffin bath treatment temperature is ~ 52-
57°C [126-134°F]
 Method of heat transmission is conduction
 Dip-wrap method or paint method
 Treatment time is 10-20 mins
 You should document the following:
 Area of the body being treated
 Type of heating agent used
 Treatment parameters
▪ Temperature of agent
▪ Number and type of insulation layers
▪ Patient’s position or activity during treatment
▪ Treatment duration
 Response to intervention
Effect Cryotherapy Thermotherapy
Pain Decrease Decrease
Muscle spasm Decrease Decrease
Blood flow Decrease Increase
Edema formation Decrease Increase
Nerve conduction velocity Decrease Increase
Metabolic rate Decrease Increase
Collagen extensibility Decrease Increase
Joint stiffness Increase Decrease
Spasticity Decrease No effect
Electrotherapeutic Modalities
1/20/20
 Electrical current is the movement of electrons
through a conducting medium
 Current (or amperage) is the rate of flow of
electrons
 Voltage is the force that drives electrons through
the conductive medium
 Resistance (or impedance) is the property of a
medium that opposes the flow of electrons
▪ High resistance substance is an insulator (e.g. rubber or skin,
adipose tissue)
▪ Low resistance substance is a conductor (e.g. metal or
muscle)
 The opposite of resistance is conductance
 Electrical current tends to choose the path of
least resistance to flow
 Electricity has an effect on each cell and
tissue that it passes through
 Consequently the whole body is affected
 Typically tissue highest in water content and
consequently highest in ion content is the
best conductor of electricity
 Direct current (DC)
 Continuous unidirectional flow of
charged particles with a duration of at
least one second
 One electrode is always the anode (+)
and one is always the cathode (-) for
the entire event
 Build of charge since it is moving in one
direction
 Clinical pearl – DC is most often used
with iontophoresis
 Alternating current (AC)
 Bidirectional flow of charged particles
 This type of waveform has one-half
cycle above the baseline and the
second phase below the baseline
 One complete cycle (two phases)
equals a single pulse
 AC is biphasic, symmetrical or
asymmetrical
 It has zero net charge if symmetrical
 Clinical pearl – AC is used in
Interferential or Russian stimulation
 Pulsed current (PC)
 Is an interrupted (non-continuous) flow of direct or
alternating current
 The current flows in a series of pulses separated by
periods where no current flows
 The current can flow in one direction during a pulse –
monophasic pulsed current
 Or the current can flow back and forth during a pulse
– biphasic pulsed current
 Clinical pearl – PC is used in many applications
including pain control, tissue healing and muscle
contraction
 Monophasic
 Single phase, unidirectional pulse from baseline to
either positive or negative
 Do not confuse with DC
▪ Pulsed monophasic waveforms have interruptions,
shorter duration and less strength
 Clinical pearl - monophasic pulsed current is used in
wound healing and for acute edema (high volt
pulsed current - HVPC)
 Biphasic
 Two phases, bidirectional pulse with one positive
phase and one negative phase
 Can be symmetrical (identical phases that cancel each
other out)
 Or asymmetrical (non-identical phases that can be
either balanced with no net charge or unbalanced
yielding a net charge)
 Clinical pearl - biphasic pulsed current is used in most
commercial transcutaneous electrical nerve stimulation
(TENS) and neuromuscular electrical stimulation
(NMES) units
 Polyphasic
 Bi-directional wave with three or more phases in
bursts
 Clinical pearl - polyphasic waveforms are used in
most commercial Interferential and Russian
stimulation units
 Self adhesive electrodes
 Self adhesive gel coating that decreases
resistance between the electrode and skin
 Most commonly used
 Sensitive skin electrodes are available
 Carbon- impregnated rubber electrodes
 Need a gel conduction medium or wet sponge
 Must be secured by straps/bandages
 Electrodes made of conductive fabric
 Electrodes made of
conductive fabric
 Typically it is silver
threaded into the fabric
of a glove, sock or sleeve
 They can treat the entire
area so coverage is
greater then individual
electrodes
 Current density is the concentration of
current under the electrode
 Electrode surface area is inversely
proportional to current flow
 Larger electrode – current is less dense and
distributed over a larger area
 Smaller electrode – current is more intense over a
smaller area
 So keep the electrode in proportion to the size of
the body being treated
 Electrodes must lie smoothly on the skin with no
wrinkles
 Do not place directly over bony prominences
 The distance of spacing between electrodes affects
the depth and course of the current
 General rule have the distance between electrodes greater then the
electrode size
 The closer together electrodes are the more superficial the current is
 Conversely the greater the distance the current is deeper
 The configuration can be:
 Monopolar technique
▪ The stimulating or active electrode is placed over the
target area
▪ The second dispersive electrode is placed at another site
away from the target area
▪ The active electrode is generally smaller
▪ Used in wounds, iontophoresis and the treatment of
edema (HVPC)
 Bipolar technique
▪ Two active electrodes are placed over the target area
▪ For example the quads – one electrode is placed over rectus
femoris muscle belly and one on vastus medialis motor point
▪ Typically the electrodes are equal in size
▪ This technique is used for muscle weakness,
neuromuscular facilitation, range and painful conditions
 Quadpolar technique
▪ Four active electrodes are placed around the target area
▪ Typically the electrodes are equal in size, two leads are
required
▪ This technique is used for painful conditions most often
 Try to document electrode placement with a
diagram
Monopolar
Bipolar Quadpolar
 Amplitude
 Refers to the magnitude of the current or voltage
 Amplitude controls are often labeled intensity or
voltage and can be expressed in volts, microvolts
or millivolts
 Peak amplitude must be large enough to exceed
the threshold for the nerve or muscle cell
 Clinical pearl - lower amplitudes are used for
sensory stimulation, higher amplitudes for motor
stimulation
 Pulse duration
 How long each pulse lasts
▪ The time from the beginning of the first phase of the
pulse to the end of the last phase of the pulse
 Usually measured in microseconds
 Shorter pulse durations are usually used for pain
control
 Longer pulse durations for muscle contraction
 Frequency or rate
 Represents the number of cycles or pulses per
second (rate of oscillation)
 Normally measured in the unit of Hertz (Hz)
 Also called pulses per second (pps)
 Different frequencies are chosen depending on
the goal of treatment
▪ Referred to as low rate or high rate in TENS applications
 Adaptation
 Adaptation is the decrease in the frequency of
action potentials and a decrease in the subjective
sensation of stimulation when electrical
stimulation is applied without variation in the
applied stimulus
 Demand pacemaker or unstable arrhythmias
 ES may interfere with pacemaker function,
monitoring, & heart rate
 Seizure disorders or epilepsy
 Trans cerebrally or transthoracically
 In the presence of active bleeding or infection
 Superficial metal implants
 When movement is contraindicated
 Electrode(s) over the following areas:
 over/near abdomen or low back in pregnancy
 venous or arterial thrombosis or thromboplebitis
 pharyngeal or laryngeal muscles
 carotid sinus
 eyes
 urinary bladder stimulator
 Cardiac disease
 Hypotension, hypertension, excessive edema
 Impaired sensation
 Impaired mentation
 Malignant tumors
 Irritated skin/open wound
 Excessive adipose tissue
 Potential of burns
 More common in direct current applications
 Or if incorrect electrode size is used
 Skin irritation or inflammation
 If the patient is allergic to the adhesive or gel
 Increased pain
 Change parameters and/or use larger electrodes
 TENS
 Waveform is a pulsed biphasic waveform
▪ Conventional
▪ Low rate
▪ Burst
▪ Brief intense
 Interferential current (IFC)
▪ Waveform is a produced by two interfering alternating
currents that are polyphasic
▪ A variation within IFC is a premodulated current
 Gate control theory
 Severity of pain is determined by the balance of
excitatory and inhibitory inputs to T cells in the spinal
cord
 T cells receive excitatory input from C and A-delta
nocioceptive afferents and inhibitory input from A-
beta non-nocioceptive sensory afferents and
descending neurons
 Increased activity of the non-nocioceptive sensory
afferents (A-beta) causes presynaptic inhibition of T
cells thus effectively closing the spinal gate to the
cerebral cortex and decreasing the sensation of pain
▪ Electrical stimulation can activate the sensory afferents
 Gate control theory
Increased activity –
spinal gate closes and
decreased pain
sensation
 aka high-rate TENS
 Most common type of TENS
 Uses short-duration higher frequency pulses at a
current amplitude sufficient to produce a
comfortable sensation without muscle
contraction = low intensity/high frequency TENS
 Most often pulse duration 50-80 µs, pulse
frequency 100-150 pps
 Gates pain when stimulation is “on”
 High rate TENS has been shown to involve delta
opioid receptors and reduce aspartate and
glutamate levels in the spinal cord
 May also interrupt pain-spasm-pain cycle (↓ pain
in turn ↓ spasm)
 The stimulus may be modulated to limit
adaptation (meaning it changes automatically
so the patient doesn’t get use to a pre set
stimulus)
 Electrodes are placed over the painful area
 Most patients report a mild tingling under the
electrodes
 Pain relief is experienced during use
 Most often used during painful ADL’s
 Treatment time is variable depending on the
duration of the activity and patient’s
symptoms
 This type of TENS is a low frequency TENS
delivered at a high intensity
 It requires repetitive stimulation of motor
nerves to produce brief repetitive muscle
contractions or twitches
 Low rate TENS has been shown to involve mu
opioid receptors
 Can control pain for 4-5 hours after a 20-30
minute treatment
 Treatments should not be longer than 45
minutes due to repetitive muscle contraction
which could lead to delayed-onset muscle
soreness (DOMS)
 Parameters
 Pulse duration:200-300µs
 Current amplitude: to produce contraction
 Frequency: 2-10pps
 As name implies….
 Stimulation is given in packets of bursts
 Mechanism
 Same as low-rate TENS, but may be more
effective
▪ More current delivered
▪ Better tolerated by patients
 High frequency and high intensity
application of TENS
 This mode is used to provide rapid-onset pain
relief during painful procedures
 Such as wound debridement, deep friction
massage, joint mobilization or stretching
 Parameters
 Amplitude to tolerance (strong sensation)
 Frequency: 80-150 Hz
 Pulse duration: 50-250 µs
 Time: 15-30 minutes
 Pain relief: 30-60 minutes
 Bipolar (2 electrodes) or quadpolar (4
electrodes) arrangement
 A variety of electrode placements can be
successful
 Sites of nerve roots
 Trigger points or acupuncture sites
 Around the area of pain
 Dermatomal distribution of the nerve
Parameter Pulse Frequency/ Pulse Duration Amplitude/ Treatment Time
Settings Rate Intensity
Conventional 100-150 pps 50-80µs Produce tingling As needed; can

(high) (low) be worn for 24hrs
Low-rate 2-10 pps (low) 200-300µs Visible 20-30 min

contraction
(high)
Burst-mode Generally preset Often preset. Visible 20-30 min
in unit at 10 May have max of contraction (high)
bursts (low) 100-300µs
Brief intense 80-150 pps (high) 50-250µs Intense tingling 15-30 min
(high)
 Interferential current (IFC)
 Two alternating medium-frequency currents (4,000
Hz)
 The two waveforms are delivered through 2 sets of
electrodes from 2 channels
 When the currents intersect in the body, they produce
envelopes of pulses known as beats
 This is often more comfortable for the patient
because a low amplitude is delivered through the skin
and a higher amplitude current is generated in the
deeper tissues
The electrodes from each channel
must be placed diagonally to create
the beat frequency (channels can be
designated as 1 &2, or A & B
depending on unit).
 Premodulated IFC occurs when the two
frequencies are crossed in the electrical
stimulation unit
 The interference occurs in the unit
 Then the current can be delivered in one
circuit (2 electrodes)
 This is ideal for small areas where 4
electrodes would not fit
 How long does the pain relief need to last?
 Some studies point to IFC giving longer relief
 Can patient tolerate muscle contractions

 Low-rate & burst TENS may aggravate acute soft tissue injury
 Anatomical location
 If pain is at bony prominence>>> do not use low-rate TENS
 Can the patient donn electrodes properly, IFC can be more

complicated
 Is cost an issue? TENS is a cheaper device
 Conventional TENS is often a good place to start for home use
 Edema due to inflammation
 High volt pulsed current (HVPC) with a negative
polarity applied below the threshold for motor
contraction
▪ Negative electrode placed directly over the site of injury
▪ Dispersive is placed some distance away (proximal to
edema)
▪ Can prevent the formation of new edema
▪ Decreases leakage of protein molecules and fluid from blood
▪ Reduces blood flow by reducing microvessel diameter
 Inflammation (HVPC)
 Cathode/negative electrode
placed directly over the site
of injury
▪ Cathode is typically colored
Electrode placement for a lateral
black at the end ankle sprain
 Anode/dispersive electrode
is placed some distance
away (proximal to edema)
▪ Anode is typically colored red
at the end
 Edema due to inflammation
 HVPC parameters
▪ Pulse frequency 100-120 pps
▪ Pulse duration 40-100 µs
▪ Amplitude/intensity – comfortable tingling
▪ Treatment time – 20-30 minutes
 Low-amplitude DC (continuous) for
transdermal drug delivery
 Administration requires a prescription for
the medication
 Alternative to other drug delivery
procedures
▪ Oral: GI issues, incomplete absorption
▪ Nasal: low concentration
▪ Injection: discomfort, infection risk
 Mechanism
 “Like” charges repel
 A fixed charged electrode on the skin can promote
the movement of charged ions of a drug through the
skin by “pushing” them away
 More recent studies suggest transdermal drug
penetration is by increased permeability of outermost
skin layer (stratum corneum)
 Depth of penetration ???

 3-20 mm
 Systemic distribution may occur
 Waveform
 Continuous direct current
 Current Dosage
 Therapeutic range is 40 to 80 mA-min
▪ Current amplitude dependent upon patient comfort
▪ At the 40 mA-min dosage
▪ 1mA- 40 mins
▪ 2mA- 20 mins
▪ 3mA-13.3 mins
▪ 4mA- 10 mins (Don’t start patient at 4mA due to possible adverse
effects)
 Acidic reaction  Avoid by considering
 Under the positive current density
electrode (anode)  Current amplitude divided
 Hydrochloric acid forms by the surface area of
 Alkaline reaction electrode
 Under the negative  Higher current density
electrode increases drug delivery
 Sodium hydroxide forms
velocity >>>>> increased
skin irritation****
 Both result in significant
 Do NOT exceed:
discomfort, skin ▪ 0.5mA/cm2 negative
irritation and chemical ▪ 1.0mA/cm2 positive
burns  ↓ mA or ↑ electrode size
 Unipolar/monopolar placement
 One active electrode (the medication containing pad) is
placed over the treatment site
 A second electrode (typically larger) is needed to complete
the circuit but is placed ipsilaterally several inches away
from treatment site
 The decision about which polarity the medication pad has
depends on the polarity of the drug
Active
electrode
 Most commonly used drugs for delivery
 Dexamethasone
▪ Corticosteriod (anti-inflammatory effects)
▪ Diagnoses
▪ Tendonitis, bursitis, plantar faciitis
▪ Drug polarity: Negative
▪ Electrode polarity: Negative
 Lidocaine
▪ Local anesthetic
▪ Diagnoses
▪ Painful conditions requiring analgesia for example TMJ dysfunction
▪ Drug polarity: Positive
▪ Electrode polarity: Positive
Part 3
P646: 3/2/20
 Neuromuscular electrical stimulation (NMES)
 Used in innervated muscle
 Electrical muscle stimulation (EMS)
 Used in denervated muscle
 Functional electrical stimulation (FES)
 Functional tasks are performed along with
stimulation
 Potential Benefits  Patient population:
 Increase muscle  Post-operative
strength  Injury recovery
 Increase muscle cross-  ICU
sectional area  Debilitation
(hypertrophy)
 Athletes
 Improve muscle function
 Spinal cord injury
 Muscle re-education
 Stroke
 Decrease spasticity
 Incontinence
 Control edema through
muscle pump action
 Strength-duration curve
 Duty cycle
 Ramp time
 Strength-duration curve
 The amount of electricity required to produce and
AP depends on the type of nerve and can be
represented by a strength-duration curve
 Graphic illustration of
different thresholds
of excitability of tissues
 Duty Cycle
 Ratio of on and off time
 Current flows during the “on time” and ceases
during the “off time”
 Expressed often in ratios, so if the on time is 5
seconds and off time is 20 seconds = 1:4 ratio
 Ramp time
 Ramp up is the gradual
increase in amplitude over time
from zero(at the end of the off
time) to peak amplitude during
the on time
 Ramp down is the time it takes
from the maximum amplitude
to zero during the off time
 Fixed in some machines,
ranges from 1-8 seconds
typically
 It improves comfort of
treatment and can prevent
adaption to stimulus
 Clinical pearl – 2 second ramp is
often adequate for comfort
 Normal physiological  Electrically stimulated
muscle contraction muscle contractions
 Order of recruitment  Order of recruitment
▪ Small-to-Large muscle fiber ▪ Large-to-small muscle fiber
activation activation
▪ The smaller slow-twitch ▪ Our text states this is good
type I (Fatigue/atrophy since large fast-twitch Type II
resistant) are activated first fibers atrophy rapidly with
▪ Followed then by the larger disuse and are targeted with
fast-twitch Type II muscle e-stim
fibers (Fatigue easily &
atrophy with disuse)
 Muscle contraction is  Muscle contraction is rapid
smooth and jerky
 Electrically stimulated muscle contractions
 Motor units of different types are recruited
synchronously in a non-selective manner with
spatially fixed electrodes
▪ The electrodes are on the skin and so more superficial motor
units are reached but activation of deeper motor units may be
difficult
▪ So the same motor units may be repeatedly stimulated which can led
to muscle damage
▪ Muscle fibers are stimulated simultaneously resulting in an
uncoordinated, inefficient contraction
▪ Can lead to the development of neuromuscular fatigue and possibly
muscle damage
 Employ different methods during treatment
session
 Progressive increase in intensity
▪ Increased by the subject themselves, during training session,
in order to depolarize new and deeper motor units
 Vary muscle length
▪ For example at the elbow when training biceps: greater
damage at 160 vs 90 degrees of flexion
 Move electrodes
▪ Within and between sessions
 Use in conjunction with voluntary contractions
 Waveform (2 choices)
 Pulsed biphasic waveform
▪ Most common
 Russian current (medium frequency alternating

current) with a frequency of 2500 Hz
▪ Available on some e-stimulation units
 Electrode placement for a muscle contraction
 Electrodes placed on the proximal(-) and distal(+)
ends of the muscle
 Or one electrode over the motor point of the
muscle and the other electrode placed on the
same muscle
▪ There are motor point charts posted but typically most are in the
middle of the belly
 Electrodes should be aligned relatively parallel to
each other at least two inches apart
 Patient position
 Isometric contraction - place the joint in mid
range and secure in place so a strong isometric
contraction can occur in mid-range
 Isotonic contraction – ensure the limb can move
through the full range safely
 Pulse duration
 Between 125-350µs (0.15-0.35ms) to stimulate
motor nerves
 Shorter pulse duration for smaller muscles (or
smaller people)
 Longer duration for larger muscles
 Keep in mind as pulse duration is shortened,
higher amplitude current will be needed to
achieve the same strength of contraction
produced by a longer duration
 Frequency
 Low frequency will produce muscle twitches
▪ Smaller muscles < 20Hz, larger muscles < 30Hz
 A smooth tetanic contraction typically occurs
when the frequency is between 35-50 Hz
 Common clinical ranges you will find in research
are between 25-80 Hz
 Ranges above 80 Hz result in more rapid fatigue
▪ Force increases linearly with frequency up to a force
plateau at 70-80 Hz which is why fatigue occurs
 On:Off time or Duty Cycle (expressed as a ratio)
 Off (relaxation) time is used to limit fatigue
 Generally on time is less than off time with on time
not exceeding 10 seconds
 Some variation in our text and latest evidence
 Our text recommends strengthening initial on:off
time of 1:5 ( on time in range of 6-10 seconds, off
time 50-120 seconds)
▪ To relieve muscle spasm and to pump out edema, the On:Off
time is 1:1, typically both at 2-5 seconds
 Research recommends on times of 2-10 seconds in a
1:1 or 1:2 ratio
 Ramp time
 Allows for a gradual increase and decrease in
force
 When performing repetitive exercise, a ramp time
of 1-4 seconds is recommended
 When treating spasm a longer ramp time of 4-8
seconds can prevent a rapid stretch of the agonist
and thus increased spasticity
 Current amplitude
 Should be adjusted to produce a visible
contraction of desired strength
 To strengthen in an uninjured patient, at least
50% of MVIC
 To strengthen after injury or surgery, equal or
greater than 10% of MVIC
 For motor reeducation/ to reduce spasm or
decrease edema, the lowest amplitude to
produce a visible contraction
 Treatment time and frequency
 The are a wide spectrum of training durations and
frequencies published
 Basic guidelines from our text:
▪ Muscle strengthening – 10-20 contractions, 10 mins ( 3
times per day)
▪ Muscle reeducation (neuromuscular training) - ~ 20
minutes per session to minimize fatigue ( 3 times per
week)
▪ To decrease spasm or edema - ~ 30 minutes (2-3 x per
day or as needed)
Treatment Pulse Pulse Amplitude On:Off Ramp Time Treatment Times/Day
Goal Frequency Duration Time
Muscle 35-80 pps 125-200µs To visible 6-10(on): At least 2 10-20 mins 3 times per
Strengthening (small mm) contraction 50-120(off) secs for 10-20 day
200-350µs >10% of (1:5 ratio) reps
(large mm) MVIC in Can
injured, progress to
>50% MVIC lower ratios.
in uninjured
Muscle 35-50 pps 125-200µs To visible 2-5 (on):2-5 At least 2 ~ 30 mins 3 times per
Re-education (small mm) contraction (off) secs week
200-350µs 1:1 ratio
(large mm)
Muscle Spasm 35-50 pps 125-200µs To visible 2-5 (on):2-5 At least 1 10-30 min 2-3x per day
(small mm) contraction (off) secs or as
200-350µs 1:1 ratio needed
(large mm)
 Medium frequency, polyphasic burst alternating
current
 The current is time modulated within the electrical
stimulation unit to create a pulsatile burst current
 General parameters
 Amplitude: tetanic muscle contraction
 Delivered in 50 bursts per second
 Pulse duration: 150-200 µs or 50% duty cycle
 Ramp time is 1-5 seconds
 Duty cycle: 1:5 for strengthening, 1:1 for muscle pumping
for edema
 A different stimulus is needed to contract
denervated muscle
 Typically a continuous direct current is used
 The electrical current must last longer than 10ms to
get a denervated muscle contraction
 Controversial treatment area with conflicting
evidence for benefit
 Bells’ palsy (facial paralysis due to CNVII damage),
EMS does not enhance recovery
 Spinal cord injury and cauda equina injury, EMS can
increase mean muscle mass but effect disappears
after stimulation is stopped
 Electrical muscle stimulation performed with a functional activity
 Stimulates contractions at the moment when a “functional” muscle
would contract
 May substitute static or dynamic orthotic device
 Muscle reeducation in a functional application
 Increased patient awareness through improved proprioceptive and
kinesthetic awareness
 Patient population is typically neurologically impaired patients

 CVA
 TBI
 SCI
 Cerebral Palsy
 Home ES units
 Parastep I
 Uses a walker apparatus with hand controls
to regulate standing and sitting
 FES cycling
 Therapeutic Alliances
 Restorative Therapies
 Peroneal stimulators (with heel switch)
 Bioness
▪ Post-Stroke drop foot
▪ Example parameters: amplitude 0-100mA,
duration 100-300 µs, frequency 20-45pps and
gait parameters including ramp up/down 0-2
sec)
 Contrast baths
 Hot pack and e-stim
 US/E-stim combo treatment
 Intended Application  Potential Issues
 Decrease edema  Limited research
 Increase blood flow  Varied protocols
 Reduce pain ▪ Water temp
▪ Time ratio of hot to cold
 Reduce joint stiffness
▪ Total treatment time
 Basically the effects of

heat while avoiding the
risk of increased
edema
 2 containers
 Warm container temperature is ~38°C
(100°F)
 Cold container temperature is set
between 10°-15.5°C (50°F to 60°F)
 Immerse the limb in cold for 1 minute
 Then warm for 2 minutes
 Repeat sequence 5 times, ending in cold water
 16 minutes total treatment time
 When using e-stim for muscle spasm or pain
relief
 You can combine with a hot pack, the theory is the
combination of modalities will give great relief of
symptoms
 No evidence to support
 Our units allow us to
perform ultrasound in
conjunction with
electrical stimulation
 A dispersive electrode is
placed adjacent to the
treatment site
 The ultrasound probe
emits US waves and
electrical current
 The thought is by combining modalities you
gain the benefit of both
 Thermal US and IFC for pain relief
 Thermal US and NMES/Russian for relief of trigger
points or muscle spasm
 No evidence to support any of these
application
Part 2
 What is ultrasound?
▪ It is a high frequency sound wave that transmits energy
▪ It can be applied to provide thermal or non-thermal
effects
▪ Therapeutic US is at a frequency of 1-3MHz to maximize
energy absorption at a depth of 2-5cm within the soft
tissue (not very deep)
 A high frequency alternating current is applied to the crystal in the
transducer head
 The crystal is made of material with pizoelectric properties,
causing it to expand and contract with changes in polarity
 When it expands the material, it compresses the material in front
of it and when it contracts, it rarifies the material
 This alternating compression-rarefaction is the ultrasound wave
Ultrasound propagation increases molecular motion
Increases chance for molecular collisions
Collisions generate HEAT
Greater amplitude (intensity) and frequency of motion = greater
the chance of collisions and greater heat
Alternating pressure wave
CAVITATION = ultrasound-
induced formation and/or
activation of gas-filled
(bubbles)
 It can be described by its:
 beam non-uniformity ratio (BNR)
 near field
 attenuation due to reflection, refraction,
absorption (transmission)
ISP
During continuous ultrasound,
intensity described according
to space—spatial-peak (ISP) ISA
and spatial-averaged (ISA)
intensities
Transducer
Peak acoustic power Average acoustic power

ISP = ISA =
ERA ERA
Generally occurs along central axis Reflects overall output across

of beam and is important in terms transducer and, therefore, amount
of safety of overall amount of energy being
introduced
 High energy in central part of beam and
interference of waves generates regions of
high energy in near-field (HOT-SPOTS)
 99.9% of US applications in PT are in the
near-field
 To counteract use of near-field ultrasound
and hot-spots, a moving treatment head is
advocated
 Attenuation = loss of US intensity as ultrasound
waves travel through a medium
 Occurs as result of reflection, absorption & refraction
Incident wave
Reflection
Tissue interface
Refraction
(scattering)
Transmission
(and absorption)
Attenuation and transmission
Material mm
Transmission inversely related to
Water 11,500
attenuation
Fat 50
% energy Muscle (perpendicular) 9
remaining Skin 11.1
Tendon 6.2
Cartilage 6
Bone 2.1
Tissue depth
HALF DEPTH = the depth of tissue at which the ultrasound

intensity is half its initial intensity
Attenuation and transmission Material mm
Possible to treat swollen sites Water 11,500

Fat 50
Possible to treat regions with
Muscle (perpendicular) 9
some adiposity
Skin 11.1
Difficult to treat deep muscles, Tendon 6.2

tendons and joint structures Cartilage 6
Bone 2.1
 Two major clinical implications
1. Localized bone effects
 High absorption in bone and reflection at
interface self-localizes energy to bone surface
 Can cause discomfort during treatment
(periosteal pain) and potential tissue damage
Keeping the soundhead moving and lower intensities

both decrease this negative effect.
 Two major clinical implications
2. Damage to transducer
 Air has a very low acoustic impedance
 100% reflection of ultrasound energy at the metal
endplate of the soundhead due to large
impedance difference of the soundhead and
surrounding air
Using a transmission medium minimizes the air

between the soundhead and the body.
 It can be described by
its:
 frequency
 duty cycle
 intensity & duration
 size of area to be
treated - effective
radiating area (ERA)
 Frequency is selected by depth of tissue
 Tissue up to 5cm deep (muscles)  1 MHz
 Tissue 1-2 cm deep (hand or superficial
ligaments)  3 MHz
 Depth of penetration is reduced in tissues
with high collagen content
Blood – Fat – Nerve – Muscle – Skin – Tendon – Cartilage – Bone
Protein content
Intensity 2 ms 8 ms
 Duty cycle is selected
based on the treatment goal
Time
20% duty cycle
(1:4)
 When the goal is to alter cell membrane permeability

and promote healing (non-thermal)  duty cycle is
20% or less (pulsed)
 When the goal is to increase tissue temperature aka
gain thermal effects  duty cycle is 100%
(continuous)
 The power per unit area of the soundhead,
expressed in watts per centimeter squared
(W/cm2)
Amount of acoustic energy per unit

time Acoustic power (W)
Intensity = =
the area of the transducer from Effective radiating
which the ultrasound energy area (cm2)
radiated
 Thermal (continuous) ultrasound applications
 1 MHz, intensity 1.5-3.0 W/cm2
 3 MHz, intensity 0.5-1.5 W/cm2
 You know it is the right current intensity if the patient
feels warmth in the first 2-3 minutes with no increase in
discomfort
 Non-thermal (pulsed) applications
 1 MHz or 3 MHz, intensity 0.5-1.5 W/cm2 for soft tissue
injuries
 You know it is the right current intensity if the patient
feels NO warmth
 Determined by:
 Treatment goal
 Size of area to be treated
 ERA (effective radiating area) of sound head
 Generally treatment duration for thermal and
non-thermal applications is applied 5-10 mins
for each treatment area that is twice the ERA
of the transducer
 Treatment area of 20cm2 & 10cm2 transducer
head = 5-10 minute treatment duration
 Typically a treatment equal to twice the ERA
of the transducer head
 Transducer head sizes in PT are typically 5cm2
or 10cm2
 Areas larger than 4x the ERA of the
transducer are impractical to treat
 An example is the low back because the
treatment durations would be excessive and
inconsistent heating would occur
 In most cases – a positive treatment effect
should occur in 2-3 treatments
 Non-thermal US is applied in the acute and
proliferative phases (can be daily but most
often at 2-3 times per week)
 Thermal ultrasound is applied in proliferative
and remodeling stages of healing (2-3 times
per week)
 Approx 4cm/second
 Quickly enough to maintain motion and slowly
enough to maintain contact with the skin
 Strokes overlapping by half the ERA of the
sound head are recommended
 Critical angle for ultrasound at skin appears
to be about 15°
Acute Chronic
Desired effect Non-thermal Thermal

Intensity 0.5-1.5 W/cm2 0.5-3.0 W/cm2
Duty cycle Pulsed Continuous
Frequency Depends on tissue depth
Duration 5-10 mins 5-10 mins
Patient should not Patient should feel mild to

feel anything comfortable warmth
THERMAL NON-THERMAL
 Soft tissue shortening  Accelerate tissue healing

 Use prior to stretching to  Tendon and ligament injuries
decrease pain  Carpal tunnel syndrome
 Decrease pain  Muscle strains
 Bone healing
 Decrease pain
Do not apply ultrasound
Directly over a malignant tumor
Over the abdomen, low back or pelvis of a pregnant patient
Directly over central nervous system tissue
Directly over joint cement or plastic components. Although typically

deep, best to err on side of caution as rapidly heated
Directly over pacemaker as may heat it and interfere with circuitry
Over an area of thrombophlebitis as may dislodge thrombus resulting

in a potentially life-threatening thromboemboli
Over the eyes, or male or female reproductive organs

Use caution with ultrasound
In an area of acute inflammation
Over areas of skeletal growth (growth plate, epiphyses, apophyses)
Over a non-united fracture
Over breast implants
In each case, high-intensity ultrasound is contraindicated and

heating effects should be minimized
Over implanted metal—reflects >80% of incident energy. Reduce risk
of standing waves by using dynamic treatment head and pulsed
ultrasound. (Ultrasound does not heat metal rapidly, or loosen screws
or plates)
A modality for the treatment of spinal dysfunction
P646: 2/3/20
 A mechanical force is applied to the body
 To separate joint surfaces
 And elongate the surrounding soft tissues
 The ultimate goal is symptom reduction for

the patient
 Vertebral body separation
 Distraction & gliding of facet joints
 Tensing of ligaments at spinal segments
 Straightening of spinal curves
 Stretching of spinal musculature & soft tissue
 Spinal flexion, separation of foramen
 Neutral spine, separation of disc space
 According to your
textbook
 Joint distraction
 Reduction of disc
protrusion
 Muscle relaxation
 Soft tissue stretch
 Joint mobilization
Do these mechanical effects really occur?

YES , if positioning is correct
 Back & neck pain caused by:
 Herniated disc – rules of centralization apply
 Nerve root impingement
 Degenerative disc disease
 Joint hypomobility
 Facet impingement ( subacute joint inflammation)
 Muscle spasm
 Traction is less effective for large or calcified
disc herniation
 Traction is typically most effective soon after
discal injury
 Patients who report
worsening symptom
on spinal loading are
good candidates for
traction
 Spondylolisthesis
 forward displacement of a vertebra over a lower
segment
 due to a developmental defect or fracture in the
pars interarticularis
 Any condition where movement is contraindicated
▪ Fracture
▪ Ligament insufficiency/rupture
▪ Hypermobile or unstable joint
▪ Immediately after spinal surgery
 Tumor or infection of the spine or nervous system
 Acute/Trauma injury or inflammation
 Peripheralization of symptoms (feel worse) with
traction
 Uncontrolled hypertension
 Vascular compromise
 Pregnancy (lumbar* & cervical)
 TMJ problems (cervical)
 Dentures (cervical)
 Bone Disease of Spine
 Rheumatoid arthritis , Osteoporosis, Infection, etc
 Hiatal hernia
 Claustrophobia or altered mental state
 Unable to tolerate prone/supine positions
 Orthopnea (out of breath lying flat)
 Spondylolisthesis*
 Down’s syndrome (cervical) (poor
transverse ligament)
 Displaced anular fragment
 Medial disc protrusion
 When severe pain resolves fully with
traction
 A crossed straight leg raise test is a test
where, when one leg is raised, the pain
travels down the opposite leg.
 Said to be indicative of a herniated disc
 Dependent on
 Successful trial/pretest of manual traction
 Proper equipment – belts, traction stool, split
table
 Patient must be willing to relax
 For treating a disc
 “the traction treatment is going to cause a gentle
stretch on your spine causing a vacuum/suction
effect on the disc. Which will cause your disc bulge
to decrease in size”
 For treating joint problems
 “the gentle traction will reduce pressure on your
inflamed joints, which will decrease your pain”
 Position
 Equipment
 Dosage
 mode
 force
 treatment time
 frequency
 Considerations
 Generally 90/90
position
 Use traction stool
 Posterior separation
into slight flexion with
belt set up shown
 Useful in stenosis, DJD
& joint dysfunction
 Rope angle relatively
horizontal
DJD = degenerative joint disease

 Causes an anterior separation
 Best choice if you want a normal lordosis or lumbar
extension
 Belt set-up gives anterior pull on pelvis, patient steps
through pelvic belt loops with clips posterior
 Vary rope angle to control amount of extension
 Force localized to lower vertebrae
 Used for HNP
HNP = Herniated nucleus pulposus

 Place against the skin to avoid slippage
 Hook pelvic belt first with top strap across
umbilical line & pad above iliac crest
 Thoracic belt should overlap pelvic belt
slightly and be applied below zyphoid at
approx ribs 8-10
 Arms should go through thoracic harness
straps and tightened down
 Consider padding belts with towels as needed
 Need a split table to eliminate friction
 The area of the spine to be distracted should
positioned over the split
 Static mode, allow time for slack to be taken up
then release
 Intermittent mode, release during rest phase after
2-3 progressions
 Remember to block table with hand as releasing to
avoid jerking the patient
 Choice of static or intermittent
 For HNP use sustained traction or
intermittent with long hold/rest periods
(60/20 seconds)
 For joint dysfunction/DJD use intermittent
with shorter hold/rest periods (30/10
seconds or 15/15 seconds)
 Parameters required for you to set are
different depending on the mode
 Static
▪ Maximum traction force, total traction duration +/-
progressive/regressive periods
 Intermittent
▪ Maximum & minimum traction force, hold and relax
times, total traction duration +/- progressive/regressive
periods
 Conservative approach for joint disease
 Start with 25% of the patient’s body weight
 Progress to 50% (since this is required to gain joint
distraction)
 Evidence based approach for disc herniations
 40-60% of the patient’s body weight
 For HNP, start with < 8 minutes (6-8 mins) of
sustained or < 10 minutes of intermittent
 For DJD/stenosis, start with 10 minutes
 Progressions, you may extend time up to 20

minutes
 Length of total treatment time depends on
the patient response to treatment
 In clinic
 traction typically administered 2-3x per week
 At home
 Varies from daily to as needed for symptom
control
 Always loosen belts before undoing clip
 Why?
▪ Rebound effect = resultant increase in intradiscal
pressure after removal of traction causing severe pain.
You can minimize by removing belts correctly and only
progressing one parameter at a visit.
 Have patient rest a couple of minutes on the
table before getting up
 You should teach the patient how to get up with
proper body mechanics
 May use progressive/regressive modes to act
as a warm-up and cool-down periods,
especially if using heavier poundage
 Can combine with ice or heat
 When progressing a patient, change only one
parameter at a time
 Take home points for use
 Consider this treatment in this subgroup:
▪ a disc herniation present with leg symptoms
▪ peripheralization was present with extension, therefore
an inability to centralize symptoms with active
movement testing
▪ a positive crossed straight leg raise
▪ symptoms present for less than 6 weeks
 Position
 Equipment
 Dosage
 force
 angle of pull
 mode
 treatment time
 treatment frequency
 Considerations
 Supine
 Superior because of improved soft tissue/muscle
relaxation
 Sitting
 Halter places moderate forces through the TMJ
 Difficult for the patient to relax
So why talk about sitting traction?

Cheaper equipment so you may still see it!
 Supine
 Headpiece
 must be fitted snugly to
the occiput
 Sitting
 Halter needs to fit
around the occiput and
under the chin
 Starting force at generally 10-15lbs
 Progression up to 20-30lbs required to
actually get joint distraction
 Progression depends on the level you are
treating and patient’s symptom response
 In general increase 3-5lbs at subsequent sessions
 120lbs needed to damage C5/6 disc

 Generally a 20-35 degree of flexion is
recommended
 To open foramen and posterior structures 25-
35 degrees is required
 To increase separation at the disc space 20-30
degrees
 You will need to consider the level you want to
effect and basically traction that level in neutral
for disc separation
 For HNP/acute conditions
 Static or intermittent with long hold/rest (60/20
seconds)
 For DJD/joint dysfunction
 Intermittent with shorter hold/rest (30/10 seconds
or 15/15 seconds)
 You can use progressions and regressions for

patient comfort
 For HNP/acute conditions
 Start with 5 minutes
 For DJD/joint dysfunction

 Start with 6-8 minutes
 Progress to 10-20 minutes gradually

 Frequency dependent on patient’s symptoms
 (basic guidelines same as frequency for lumbar)
 Loosen headpiece and allow patient to rest a
couple of minutes prior to getting up
 Can combine with heat or ice
 Very important in the cervical spine to only
progress one parameter at a time
 Slow progression!
 Take home points for use
 Consider this treatment in this subgroup:
▪ ?? Research does not guide us
▪ Clinical experience
▪ A herniated disc that is worse on loading the spine and has not
responded to repeated movements
▪ A cervical stenosis when surgery is not indicated
 When applying traction, document the
following:
 Type & mode of traction
 Area of the body where traction applied
 Patient’s position
 Type of halter/belt used
 Force
 Treatment time (+/- progressions/regressions)
 Response to treatment
 With intermittent traction, also document:
 Hold time
 Relax time
 Force during the relax time
PNF & Balance
P 6 4 6 I N T RO T HE R APEU TIC I N T ERVENTIO NS
APRIL 6, 2020
DR . K E I T H AV I N
PNF
Proprioceptive Neuromuscular
Facilitation
The goal is to improve neuromuscular control and
function.
◦ Develop muscular strength
◦ Increase muscular endurance
◦ Improve flexibility
◦ Facilitate stability to mobility
◦ Improve coordination and function
What determines whether you are building
strength, endurance, flexibility or mobility?
Dosage
PNF
- overview
• Multi-joint, multi-planar, diagonal and rotational
movements of the extremities, trunk and neck.
• Implemented with multiple musculoskeletal
(orthopedic and/neurologic) disorders such as
multiple sclerosis, cerebral palsy and
poliomyelitis.
•Can be used at ANY phase of healing (acute,
proliferative, and remodeling)
Proprioceptive neuromuscular facilitation
- PNF
Therapeutic exercise that combines :
◦ Functionally based Diagonal movement patterns
◦ Multisensory: Proprioception, visual, cutaneous and auditory inputs
◦ Facilitation or Inhibition
◦ PNF activities follow a progression of motor control
◦ Mobility Skill
Clinical applications
◦ Selective reeducation of individual movement patterns
◦ Patterns are experienced then practiced
PNF
- theoretical principles (therapist)
PNF requires conscious involvement of the learning
◦ Not a passive exercise
Diagonal patterns combined with somatosensory input is

critical for motor learning (proprioception, cutaneous, visual,
auditory)
◦ Patient should feel movement
◦ Patient should do movement
◦ Incorporate visual component
Appropriate resistance is applied to increase muscle activation

and strength
Therapist should decrease sensory input as patient progresses
PNF
- theoretical principles (patient)
Functional recovery must involve conscious
involvement of the learner
Patient should feel and perform movement
Repetition is critical
◦ More repetition, greater learning
Patient must have success
◦ Allows for evaluation of motor task
◦ Increases involvement of the patient
PNF
- theoretical principles (task)
Repetition is critical
Sensory facilitation is important in the early
learning stages
Complex tasks are learned in movement segments
◦ Tasks are broken into parts
◦ Rebuilt to form more complex movements
Increase task difficulty
◦ Enhances motor retention
PNF Elements
Manual Contacts
Body Mechanics
Resistance
Approximation/Traction
Stretch
Verbal Commands
Visual Input (guidance)
Overflow or Irradiation
Timing
PNF
- treatment application
Manual Contacts
◦ Open hand
◦ Guide the movement process
◦ Influence
◦ Power
◦ Direction
◦ Influence power and direction: pressure is applied in opposite direction of
movement
◦ No circle grips
PNF
Body mechanics
◦ Therapist position is within the line of movement
◦ Always move with the patient
◦ Positioned directly in line of the movement
◦ Optimize the direction of the contact and resistance
◦ Always move with the patient
◦ Proper positioning enhances the therapist’s control of movement
PNF
Resistance
◦ Applied manually and through the application of gravity
◦ Amount of resistance varies with the needs of the
individual
◦ Goal: Enough resistance to produce a smooth
coordinated movement; not to overpower the patient
(there are some exceptions)
◦ Isotonic or isometric
PNF
Approximation (Compression)
◦ Compression of the joint surfaces
◦ Facilitation of extensors and joint stabilizers (stimulates co-
contraction)
◦ Applied manually or through functional positioning through the
use of gravity (example – sitting up includes both manual
application as well as gravitation forces)
◦ Closed chain
◦ Anti-gravity stimulation
Traction (Distraction)
◦ Separation of joint surfaces to inhibit pain
◦ Facilitate motion
◦ Often applied during flexion patterns
PNF
Stretch
◦ Muscle elongation, patterns are taken to end
ranges to optimize the effects of stretch on the
muscle.
◦ Active lengthening enhances motor strength and
functional available range
◦ Stretch Facilitation or quick stretch can be applied
at the end range, to stimulate muscle contraction
(in the opposite direction).
PNF
Verbal Commands
◦ Motivational
◦ Simple and concise
Visual input
◦ Head and eyes should move with/watch pattern
PNF
Overflow/Irradiation
◦ Refers to the spread of muscle response from
stronger muscles in a synergistic pattern to
weaker muscles
◦ Maximal resistance is the main mechanism for
achieving overflow
◦ Overflow can also be used to strengthen from one extremity to
another or from extremity to trunk
PNF
Normal Timing
◦ A sequence of distal to proximal should occur with
diagonal patterns
◦ The distal component of the pattern should be completed
halfway through the pattern
PNF
Strengthening
Not an application for strengthening of specific
individual muscle actions
Gross movement patterns
◦ PNF Patterns
◦ Shoulder motions
◦ Extremity motions
◦ Trunk and extremity motions
◦ Application
◦ Rotational and diagonal
◦ More advantageous in some cases, why?
PNF
3 major components
◦ Flexion – extension (sagittal)
◦ Abduction – adduction (frontal)
◦ Internal –external rotation (transverse)
Each pattern is initiated from a lengthened or
stretched position
Muscle group is then asked to contract
◦ Moving the body part through the range
PNF
- D1 Upper Extremity Movement Pattern
D1 Flexion D1 Extension
Shoulder Flexed, Shoulder Extended,
adducted, abducted,
ext. rot internally rot.
Forearm Supinated Forearm Pronated
Wrist Flexed Wrist Extended
Fingers Flexed, Fingers Extended,

adducted abducted
PNF
- upper extremity D1 pattern
Upper Extremities
A: Flexion-
ADDuction-
External Rotation
(D1 fl)
B: Extension-
ABDuction-
Internal Rotation
(D1 ex)
PNF
- D2 upper extremity movement pattern
Shoulder Flexed, Shoulder Extended,
abducted, adducted,
Forearm Supinated Forearm Pronated
Wrist Extension Wrist Flexion
Fingers Extended, Fingers Flexed,

abducted adducted
PNF
- D2 upper extremity
Upper Extremities
A: Flexion-
ABDuction-
External Rotation
(D2 fl)
B: Extension-
ADDuction-
Internal Rotation
(D2 ex)
PNF
- D1 lower extremity movement pattern
Hip Flexed, Hip Extended,
adducted, abducted,
Knee Extended/ Knee Extended/
Flexed Flexed
Foot Dorsiflexion
Foot Plantarflexion
& inversion
Toes Extension Toes Flexion
“Swing Phase of Gait” “Toe off Phase of Gait”

PNF
- D1 lower extremity pattern
Lower Extremities
A: Flexion-
ADDuction-
External Rotation
(D1 fl)
B: Extension-
ABDuction-
Internal Rotation
(D1 ex)
PNF
- D2 lower extremity movement pattern
Hip Flexed, Hip Extended,
abducted, adducted,
internal External
rot. rotation
Knee Flexed/ Knee Extended
Extended
Foot Dorsiflexion Foot Plantarflexion
& Eversion & Inversion
Toes Extended Toes Flexed
D2 Lower Extremity Pattern
PNF
- shoulder & hip patterns
Promoting proximal control
Trunk
◦ Bilateral tasks
◦ Irradiation/overflow
Trunk Rotation
Upper Trunk
A: Flexion with
rotation to right
(D fl, R)
B: Extension with
rotation to left
(D ex, L)
PNF
◦ Techniques to initiate movement
◦ Rhythmic Initiation (RI)
◦ Progression of activities beginning with passive movements,
progressing to active-assistive, active, and active with light
resistance.
◦ Resistance is applied only in the form of tracking to enhance
muscle activation and smooth out the movement pattern.
PNF
Strength, coordination
Combination of Isotonics
◦ Combined concentric, eccentric and stabilizing
(isometric) contractions of 1 muscle group without
relaxation.
◦ Therapist resists concentric contraction, then at end of
available range a stabilizing contraction, then once
stable the patient will slowly allow movement back to
starting position.
◦ No Relaxation
◦ Therapist’s hand remains on same side
PNF
Stability techniques
◦ Stabilizing reversals (Alternating isometrics): Isometric contraction
of the agonist group in a single plane/direction.
◦ Unilateral/Bilateral
◦ Open/Closed
◦ Rhythmic Stabilization (RS): isometric contraction of the agonist and
antagonists simultaneously. The technique is performed without
relaxation. Results in co-contraction of opposing muscle groups.
PNF
Controlled Mobility and Skill Development
Dynamic Reversals/Slow Reversals
◦ Slow Reversals (SR) (Dynamic Reversals): Begins with a slow isotonic
contraction in the agonist pattern followed by contraction in the antagonist
pattern using careful grading of resistance and optimal facilitation.
◦ Slow Reversals with holds (SRH): Similar technique as above, an isometric
hold is added at the end of the range or at a point of weakness. The hold
may be added in one direction or both directions.
◦ Slow reversals and slow reversals with holds in decrements and increments
in range: The movement is performed as described in slow reversals, a hold
can be added, the range of motion is then gradually reduced in decrements
or gradually increased over the range.
PNF
Repeated Stretch (Repeated Contractions)
Repeated use of the stretch reflex to elicit active
muscle recruitment from muscles under the
tension of elongation.
Initiate movement with repeated quick stretches
followed by resistance
PNF
◦ Mobility
◦ Goal: Increase ROM; prepare patient for mobility and the
acquisition of skilled control
◦ Contract Relax: Strong, isotonic contraction of the restricting
muscles (antagonist) followed by voluntary relaxation and
movement into new range in the agonist pattern.
◦ Hold Relax: At end of pain-free motion, strong isometric
contraction of antagonist muscles is resisted, followed by voluntary
relaxation, and passive movement into new range.
◦ Contract-Relax Active Contraction (CRAC): isometric contraction of
range-limiting muscle followed by a concentric contraction of
opposite muscle.
Balance
Balance
- what is it?
Complex definition
◦ process involving the reception and integration of sensory inputs and the
planning and execution of movement to achieve a goal requiring upright
posture.
Simple definition
◦ the ability to control the center of gravity (COG) over the base of support in
a given sensory environment.
◦ generally COG at S2 level
Balance
- definition
Center of Gravity (COG)
◦ imaginary point in space where the sum total of all forces equals zero.
Base of Support
◦ is the body surface that experiences pressure as the result of body weight
and gravity.
◦ Standing: location of feet/foot
◦ Sitting: Thigh and buttocks
Balance
- limits of stability
the distance a body can move without either
falling (as COG exceeds BOS) or establishing a
new BOS by reaching or stepping (to relocate
BOS under COG).
Another way to state LOS:
◦ it is the farthest distance in any direction a
person can lean (from midline) without altering
BOS (step, reach, fall)
Balance
- balance control
Balance
- task context
Bed mobility ◦ Each activity is not the
Sitting same for a given person
Sit-to-stand
◦ Need to understand the
environment in which the
Transfers task is being performed.
Standing
Walking
Work
Sport/recreation
Balance
- environmental context
A task is performed within an Environment that is detected
by the sensory system
The sensory environment are a set of conditions that exist
or are perceived to exist.
In the body, gather information about the environment and
body position in relation to the environment.
Central sensory structures process information to
determine opportunities and limitations present.
Balance
- environmental context
Surfaces context
◦ Escalator, sandy beach, gravel driveway, icy sidewalk
Visual context
◦ Mass transit, in crowds, boats
Stability
◦ More stable is obviously easier
◦ Unstable is harder
Need to identify where along this continuum your
patient lies and which components you can challenge
to make improvement.
Are you Modifying surface or visual environment?
Balance
- sensory systems and balance control
Sensory Environment
Vision
Vestibular Somato-
System sensation
Compare, select,
combine senses
Determine Body Generate Body

Position Movement
Balance
- sensory systems (vision)
Central Vision (focal vision)
◦ Environment orientation based upon perception of verticality and object
motion, identification of hazards and opportunities.
◦ Incorporates head motions and postural sway.
Peripheral Vision
◦ Detects motion of self in relation to the environment
◦ Orientation of environment allows for feedforward or anticipatory actions.
◦ This about how you walk on ice when you know its present versus when do
you not know
Balance
- sensory systems (somatosensory)
Peripheral sensory receptors provides joints,
ligaments, muscles and skin about:
◦ muscle length, stretch, tension, contraction, pain,
temperature, pressure and joint position.
Balance
- sensory systems (vestibular)
Uniquely identifies self-motion of the head in relation to gravity
◦ Identifies self-motion as difference from motion in environment
Acts as a “referee”
◦ when visual and somatosensory inputs conflict
◦ i.e. sitting in a car at a red light and car next to you moves.
Balance
- types of balance
1) Static balance
◦ The ability to maintain stability and orientation with the center of gravity
over the BOS while at rest
2) Dynamic balance
◦ Ability to maintain stability and orientation with GOG over the BOS while
parts of the body are in motion.
3) Anticipatory Balance Control

◦ Ability to modify postural control prior to a potentially destabilizing
movement in order to avoid instability
4) Reactive (Unanticipated) Balance Control

◦ A feedback sensorimotor process where muscle activity is activated in
direct response to task-level error
Balance
- motor strategies following perturbation
Stretch Reflexes
◦ Mediated by spinal cord
◦ Fastest response
Voluntary movement
◦ Slowest
◦ Coordinated but highly variable
Automatic postural response

◦ Intermediate speed
◦ Brainstem/subcortical
◦ Anticipatory (feed forward)
◦ Missing last step
Balance
Ankle Strategy (anteroposterior plane)
◦ Quiet stance and small perturbations
◦ Loss of balance Anterior direction causes muscle activation
◦ Gastroc >>> hamstrings >>>>paraspinals
◦ Loss of balance Posterior direction causes muscle activation
◦ Anterior tibialis >>> quadriceps >>>> abdominals
Weight Shift Strategy (lateral plane)

◦ Hips control COM via
◦ Hip aBductors/aDDuctors
◦ Ankle invertors/evertors (minimal)
Ankle strategy
Balance
Suspension strategy
Suspension Strategy
◦ Occurs during balance tasks
◦ Person quickly lowers COM by:
◦ Flexing at knees causing hip and ankle flexion
◦ Can be combined with ankle or weight shift
Hip Strategy
◦ Rapid and/or large external perturbations
◦ COG near LOS
◦ Rapid hip flexion or extension to move COM within BOS
◦ Anterior body sway (support moves posterior)
◦ Abdominals >>> quadriceps
◦ Posterior body sway (support moves anterior)
◦ Paraspinals >>> hamstrings
Hip strategy
Balance
Stepping Strategy
◦ Large forces displace COM beyond LOS
◦ Step utilized to enlarge BOS and regain balance
Combined Strategies
◦ Movement patterns are presented as singular concepts
◦ In reality patient may demonstrate multiple motor strategies
Stepping strategy
Balance
- screen
Physical therapists should routinely ask older adult patients if they
have fallen in the previous 12 months (CGS Grade C: Strong recommendation
based on Level III evidence).
◦ Screening should include:
◦ History and context of falls over the previous 12 months
◦ At least one question about the patient’s perception of difficulty with balance or
walking
For each patient who reports a fall or falls or reports difficulty with
balance or walking, the physical therapist should screen by observing
for gait or balance impairment (CGS Grade C: Strong recommendation based on Level III
evidence).
◦ A screening is positive when either of the following conditions is found:
a) The patient reports multiple falls regardless of balance and gait
impairments
b) The patient reports one fall, and a balance or gait impairment is observed
Balance
- assessment
Fall Screen Reactive Postural Control Tests
◦ STEADI ◦ Push or pull test
Static Balance Tests Sensory Organization Tests

◦ Single limb stance ◦ Clinical Test of Sensory Integration
◦ Tandem Stance on Balance
◦ Rhomberg Balance During Functional
Dynamic Activities
◦ Berg Balance
◦ Five times sit-to-stand
◦ Tinetti: Performance Oriented
Anticipatory Postural Control Tests Mobility Assessment –POMA
◦ Functional Reach ◦ DGI: Dynamic Gait Index
◦ Star Excursion Test
Balance
- medications
- Older adults who take 4 or more medications
- Medications alone
◦ Hypnotics
◦ Ambien, Belsomra
◦ Tricyclic antidepressants
◦ Amitriptyline, Amoxapine, Desipramine
◦ Tranquilizers and Sedatives
◦ Benzodiazepines (Xanax), barbituates (Phenobarbital)
◦ Antihypertensive meds
◦ Angiotensin-converting enzyme (ACE) inhibitors
◦ Beta blockers
◦ Angiotensin II receptor blockers (ARBs)
◦ Calcium channel blockers
Balance
- Intervention
Holistic View
◦ Balance Training
◦ Strength Training
◦ Muscular Endurance
◦ Flexibility
◦ Aerobic Conditioning
You need to identify the impairment that in contributing to impaired

balance.
Balance
- Intervention
Physical therapists must provide individualized
interventions that address all positive risk factors
within the scope of physical therapist practice
(CGS Grade A: Strong recommendation based on
Level I evidence).
Balance
- training safety
1. Use a gait belt any time the 4. Do not perform exercises near
patient practices exercises or sharp edges of equipment or
activities that challenge or objects
destabilize balance
5. Have one person in front and
2. Stand slightly behind and to one behind when working with
the side of the patient with patients at high risk of falling
one arm holding or near the or during activities that pose a
gait belt and other arm on or high risk of injury
near the top of the shoulder
(on the trunk, not the arm) 6. Check equipment to ensure
that it is operating correctly
3. Perform exercises near a railing
or in parallel bars to allow 7. Guard patient when getting
patient to grab when necessary on/off equipment (i.e.
treadmill)
8. Ensure floor is clean and free
of debris
Balance
- progressions
Large base of support → Small base of support
Low center of gravity → High center of gravity
Log rolling → segmental rolling
Hooklying → bridging
Prone → prone on elbows
Quadruped → alternating limbs
Sitting
Kneeling → half kneeling
Plantigrade/modified plantigrade
Standing
Balance
- progressions
Alter factors below to progress your patient:
% body weight
Base of support
Support surface
Balance assist
External loads
Plane and speed of motion
Balance
- poor static balance
Begin with maintaining proper Provide resistance with handheld
posture on firm surface weights or elastic bands
◦ Sitting >> half-kneeling >> tall
kneeling >>> standing Add secondary task (dual task)
◦ Catching a ball
◦ Progress to tandem stance >>
single limb stance >>> lunge >>> ◦ Mental calculations
squat
◦ Progress to compliant/soft surface
◦ Foam, sand, grass
◦ Incorporate hand motions or
closing eyes
Balance
- poor static balance
Ankle Strategy Hip Strategy
◦ Small ROM, slow-velocity ◦ Larger ROM and faster-velocity
shifts
shifts
◦ Approach limits of stability
◦ Muscles surrounding the ◦ Require early activation of
ankle are the focus to proximal hip and trunk muscles
maintain COG with BOS ◦ Sagittal plane strategy
◦ Alter surface ◦ Anterior/posterior hip
◦ Airex pad ◦ Frontal plane strategy
◦ ½ foam roller ◦ Lateral hip
◦ Wobble board
Balance
- poor dynamic balance
Have the patient maintain equal weight distribution and upright trunk
postural alignment while on moving surfaces
◦ sitting on a therapeutic ball >>> standing on wobble board >>> bouncing on mini
trampoline
Progress activities by superimposing movements such as:
◦ Shifting body weight >>> rotating the trunk >> moving head or arms
Vary the position of the arms from out to the side to above the head
Practice stepping exercises starting with small steps >>> mini lunges >> full
lunges
Progress to hopping >>> skipping >> rope jumping >> hopping down from a
small stool while maintaining balance
Perform arm and leg exercises while standing with normal stance, tandem
stance, and single-leg stance
Balance
- poor dynamic balance
In general range of motion
◦ Small >> large
◦ However, with hyperkinetic disorders increased challenge may occur when
large >>> small motion
Same principles as with dynamic resistance training

discrete>>>serial>>>continuous
Fatigue is an indicator of when to progress
◦ Patient should be able to maintain posture
Balance
- poor dynamic balance and BOS
Balance
- further dynamic balance challenges
-Resistance
-Dual Task
-Important to make functionally applicable
- Factory worker vs. volleyball athlete
-Stepping strategy
- Lateral step vs cross-step
- Upper limb motion
-Infinite number of movement patterns

- conditions, pathology, environment
- Cannot identify 1 pattern as ideal
Balance
- anticipatory balance control
Reach in all directions to touch or grasp objects, catching a ball, or
kicking a ball
Use different postures with throwing or rolling a ball
◦ Sitting, standing, kneeling
◦ Throw at different heights and/or speeds
Use functional tasks that involve multiple body parts to increase the
challenge
◦ Have patient lift objects of varying weight
◦ In different postures
◦ Varying speeds
◦ Maneuver through obstacle course
Balance
- reactive balance control
Have the patient work to gradually increase the amount of sway when
standing in different directions while on a firm surface
Ankle strategy training
◦ Have patient practice while standing on one leg with upright trunk
Hip strategy training

◦ Have patient walk on balance beam or lines drawn on floor
◦ Perform tandem stance >>> Single leg stance with trunk bending >>> Stand
on mini-trampoline >>> Rocker balance >>> Sliding board
Stepping strategy training

◦ Have patient practice stepping onto a stool or stepping with legs crossed in
front or behind
Balance
- sensory organization
Redundant with many of the suggestions/progressions
previously described.
It is influencing sensory feedback such as:
◦ visual inputs
◦ Close eyes
◦ Move the eyes and head during activity
◦ wear prism glasses
◦ Somatosensory cues
◦ Narrow base of support
◦ Stand on foam
◦ Stand on an incline board
Balance
- balance during functional activities
Match task to functional need
◦ Reaching for a glass in a cupboard
◦ Reaching behind (jacket, belt)
Perform two or more tasks simultaneously (dual tasking)

Practice recreational tasks
◦ Golf
◦ Yoga
◦ Dancing
Chronic Pain
Dr. Amy Bayliss DPT, PT
2020
Definitions: Pain
 Pain = an unpleasant sensory and emotional experience associated
with actual or potential tissue damage
 Pain is influenced by many factors:

 Cognitive
 Emotional
 Behavioral
 Psychological
 Cultural/spiritual
 Gender
 Genetic
 Nutritional
 Mechanical
Definitions: Pain
 Acute/subacute pain = pain of less than 3 months
duration* for which an underlying pathology can be identified.
 Pain is well localized and the patient can define it
 Nocioceptive pain: inflammatory
 Nocioceptive pain: ischemia
 Peripheral neurogenic
Definitions: Pain
 Chronic pain = pain without biological value that persists beyond the normal
tissue healing time
 Brain responds to perceived not actual reality
 We must consider which system is dominating in pain generation
 Nocioceptors
 Peripheral nerve
 Spinal cord
 Brain centers (cognitive/emotional/somatosensory cortex)
 By determining the dominating pain generation site then the pain can be classified
 Classification leads to effective treatment
 Pain > 3 months duration*

 Pain less defined and localized
 Not referring to anatomical boundaries (dermatomes)
 Poor results with previous treatment
 No specific diagnosis by physicians*
 No natural recovery, pain does not decrease over time
What maintains the chronic pain?
 Ongoing pathology stimulating the nocioceptors/PNS
 Re-evaluation needed, possible involvement of other practitioners
 Red flags stimulating nocioceptors
 Fractures, tumors, and infections  immediate attention required
 Orange flags
 Signs of psychiatric symptoms – personality disorder, somatoform
disorders
 CNS Pain mechanisms (where PT’s come in)
 Central sensitization
 Affective pain mechanisms
 Autonomic/motor pain mechanisms
Central sensitivity
 Dysregulation and hyperexcitability in the central nervous
system
 “brain derangement”
 Resulting in hypersensitivity to both noxious and non-
noxious stimuli
 Associated with:
 Allodynia – Pain with stroking of the skin
 Hyperalgesia – Increased response to painful stimuli
 Expansion of the receptive field – pain has spread out from initial location
 Unusually prolonged pain after a painful stimulus has been removed
Affective pain mechanisms
 Pain descriptions are similar to central sensitization but
there is a much stronger/dominating emotional
component
 Pain easily provoked, widespread and non-anatomical distribution
 Further assessment will detect problems in any and all of the
following areas
 Social issues
 Former diagnosis/treatment conflicts
 Emotional issues
 Cognitive issues
 Behavioral issues +/- pain behaviors
Autonomic/Motor Pain Mechanism
 Pain is widespread, non-anatomical and severe
 Patients have significant disability
 Associated with abnormalities in the autonomic nervous
system
 Swelling
 Tone changes
 Trophic changes (skin and hair changes)
 Excessive sweating
 Cold sensitivity
 Allodynia
 Patients have sensorimotor deficits (laterality, 2-point discrimination)
Chronic Pain Management
 Is an evolving field
 The goal of medical and physical therapy management is to
enable someone to:
 Learn to be independent in self management
 In order to achieve maximum function for ADL’s
 While minimizing discomfort and adverse outcomes from
treatment
Chronic Pain Management
 All patients regardless of the dominant pain mechanism will
require education on:
 Non-damaging nature of the pain
 Pain mechanism education
 Coping strategies
 Activity tolerance pyramid and traffic light system guidelines
 Determining meaningful activities
 Goals of treatment – patient and therapist goals must be in
alignment
INJURY
ACTIVITY PYRAMID Behavior:
1. Severe spike in pain that stops you
from performing the activity, unable
to continue activit.
2. Pain persists for weeks.
3. Significant CHANGE in range of
motion, strength and over all ability.
Plan: Consult healthcare practitioner.
RED LIGHT
POSSIBLE HARM
FLARE
UP/INFLAMMATION
Behavior:
1. Pain may spike during the activity or not.
SLOPE OF ACTIVITY
2. Pain increases and persists by 3 numbers
for 24-72 hours.
3. No change in range of motion, strength or
ability.
Plan: rest, ice, medication as needed for 24-
72 hours, return to activity.
YELLOW LIGHT NO
HARM
TOLERANCE FOR MY
CONDITION
Behavior:
1. Pain may spike during the activity or not.
2. Pain NO worse at 2, 12, and 24 hours post-activity
3. No change in range of motion or strength.
Plan: continue activity consider adding 1-5 minutes more
daily.
GREEN LIGHT
Management: Central sensitivity
 Pacing and graded exposure to activity
 Neural flossing to decrease irritability of nerves and improve
blood flow
 Build low aerobic activity, HR 55-75% max, 2-5 hours per
week
 Build UE and LE strength with resistance training
 Spinal postural endurance – segmental core muscle training
Management: Affective pain mechanism
 Patients must have a psychological evaluation
 We must determine the patient’s willingness to engage in
change and be motivators
 Teach stress relieving activities (breathing exs etc..)
 Therapeutic exercise will be similar to central
sensitization
 Pacing and graded exposure to activity
 Build low aerobic activity, HR 55-75% max, 2-5 hours per week
 Build UE and LE strength with resistance training
 Spinal postural endurance – segmental core muscle training
Management: Autonomic pain mechanism
 Pacing and graded exposure to activity is required but we
need to incorporate sensory/motor re-training in this group
 Build low aerobic activity 55-75% of HRmax
 Desensitization
 Desensitization training
 Use of compression garments
 Graded motor imagery
 Laterality exercises
 Imagine movements
 Reflective movements
 Isometric “bracing” training
Mirror therapy
 Small range movements with feedback
 Large range movements with feedback
Where does soft tissue mobilization fit
in with chronic pain?
 Practical guidelines for hands-on manual therapy skills in
those with hypersensitive pain pathways
 Educate patient to report adverse reactions during treatment
 Do not elicit identical nociceptive stimuli > once every 3 s
 Adopt techniques to reduced sensory threshold -Do not
increase nociceptive barrage
 Initiate soft-tissue mobilization with superficial stripping
techniques
 Progress soft-tissue mobilization with deeper cross-fiber
techniques
 Careful with ischemic compression
Nijs & Houdenhove. Manual Therapy. 2009

What about modalities?
 We move away from modalities with our chronic
pain patients
 TENS
 May decrease the central sensitivity however the science of
TENS is based on the gate control theory and endorphin release
 Heat/ice
 Heat maybe used for temporary pain relief but we would be
better off using low level exercise to increase blood flow instead
 Ice maybe used in the desensitization process with autonomic
dysfunction
Overview based on Evidence
Treatment Goals Interventions
 Decrease afferent nociceptive barrage  Neural flossing + soft-tissue
of trigger points mobilization + TENS + dry needling
 Improve appropriate sensory feedback  Desensitization & motor imagery
to prevent sensory motor conflict training
 Address joint hypermobility  Motor control training + movement
advice + self-management strategies
 Improve inappropriate beliefs (e.g.  Pain neurophysiology education
catastrophizing)
 Stress management/stress reduction  Relaxation + stress self-management
Decrease fear of movement techniques + breathing exercises
 Improve exercise capacity  Exposure in vivo or low to moderate
intensity exercise below pain threshold
 Improve symptoms and daily  Low to moderate intensity exercise
functioning below pain threshold
Nijs & Houdenhove. Manual Therapy. 2009
Functional Assessment
and Return-to-Sport
Testing
MAT T GAUTHIER, PT, DPT, SCS
Functional Testing
What is functional testing?
 A test, or battery of tests, that look at a patient’s combination of range of motion, strength, control,
coordination, balance, and proprioception
Why do we use these tests?

 Patients don’t seek treatment because they have pain, they do it because pain prevents them from
performing their daily, functional activities
 ROM and MMT testing alone can’t tell us if a patient is ready to squat, lunge, climb stairs, reach
overhead, run, jump, cut, throw, swim, etc., etc., etc…
 Objective functional testing allows you to demonstrate medical necessity to physicians and insurance
companies
Functional Testing
Normal, pain-free movement patterns are the building blocks for ADLs and athletic performance
Speed
Skill Elastic/Reactive Strength
Explosive/Plyometric Strength
Performance Muscular Strength
Work Capacity
Movement Mobility/Movement
Evaluation/Testing
Credit: Al Vermeil, per Rob Panariello
We must build performance (strength, endurance, power) and skill (throwing, cutting,
swimming, etc) on top of healthy movement patterns to prevent injury.
Functional Testing
How functional is our testing?
 No test is going to perfectly mimic ADLs or sport activities, but these tests
allow us to objectively measure a patient’s integration of ROM, strength,
control, balance, coordination, and proprioception with functional tasks
The Functional Movement Screen
The Functional Movement Screen (FMS) is among the most widely used functional tests as it
uses objective scoring and is backed by considerable supporting evidence.
 Uses 7 movements to identify asymmetries and functional limitations
 Provides a simple, common language that can be used between health professionals to describe a
patient’s strengths and weaknesses
 Establishes a standardized, objective baseline of performance that can easily be reproduced
The Functional Movement Screen
It is important to remember that the FMS is a screen, and that it does not
provide specific diagnoses.
 The screen looks at the patient’s ability to perform specific movement patterns. If the patient
is unable to perform the given movement, this is a red flag that further evaluation is needed.
 Can the patient perform the movement?
 Yes – move on
 No – further assessment needed to determine why
Administering the FMS
The FMS consists of 7 movements which are scored on a 0-3 scale for a total possible score of 21
 Deep Squat
 Hurdle Step
 In-Line Lunge
 Shoulder Mobility
 Apley’s Scratch Test
 Active Straight Leg Raise
 Trunk Stability Pushup
 Lumbar extension clearing test
 Rotary Stability
 Lumbar flexion clearing test
Interpretation of Results
Scores less than or equal to 14/21 indicate increased risk of injury
0s and 1s need to be addressed
 Pain necessitates that the athlete should begin or continue PT
Hierarchy of concern
 0 – pain
 Therapy needed
 R-L asymmetry involving a 1 – poor mechanics cause microtrauma
 Therapy needed
 R-L asymmetry not involving a 1 – poor mechanics cause microtrauma, but less severe as above
 Therapy needed, possibly via HEP
 Bilateral 2s – microtrauma can occur at high intensity
 Can likely get by with comprehensive HEP
Treat mobility deficits first, stability deficits second
This is according to FMS, but think about it…
When emphasizing stability, work bilaterally
Different core control motor programs in different positions
Avoid loading painful, pathologic movement patterns
 i.e., Don’t performed weighted squat if deep squat hurts. Address mobility
and stability deficits first!
Y-Balance Test
 Tests an athlete’s combined strength, balance, and flexibility in multiple planes
 Developed to increase reliability and repeatability of the Star Excursion Balance Test
 Previously shown to be predictive of LE injury
 Plisky et al, 2006
 Can be used for lower quarter or upper quarter
 Lower quarter has more supporting evidence at this time
Administering the Y-Balance Test
Lower Quarter Y-Balance Test
 The patient reaches in 3 directions: Anterior, Posteromedial, Posterolateral
 Direction of reach is in relation to stance leg.
 3 trials are performed in each direction, taking the best score
Upper Quarter Y-Balance Test

 The patient reaches in 3 directions: Medial, Inferomedial, Superomedial
 Direction of reach is in relation to stance arm
 3 trials performed in each direction, taking the best score
Lower Quarter Y-Balance Test
 Patient is at increased risk of injury if they demonstrate:
 Right-left asymmetry of >4cm in anterior reach
 Right-left asymmetry of >6cm in posterolateral and posteromedial reach
 Composite score of <89% for either extremity
Upper Quarter Y-Balance Test

 Patient is at increased risk of injury if they demonstrate:
 Right-left asymmetry of >4cm in any direction
 Supporting evidence is growing for this, but evidence for upper quarter is not as strong as it is for the lower quarter
Hop Testing
Single leg hop testing is a great way to look at a patient’s strength, power, and control after LE
injury
For years, it was considered the gold standard of ACL return-to-sport testing but low sensitivity
of the tests allowed too many ACL-deficient knees to pass through
 Noyes et al, 1991; Barber et al, 1990
As tests have high specificity and are good objective measures of power and control, inclusion of
hop testing is highly recommended as part of return-to-sport battery
Hop Testing
Single leg hop
Triple hop
Triple crossover hop
Timed 6m hop
>90% limb symmetry needed for return to sport

 Myers et al, 2011
Return-to-Sport/Work
When can I get back on the field????
March 30, 2020
Keith Avin, DPT, PhD

Goals of Return to Play
▪ Phase 1-Restore ROM ▪ Phase 4- Increase Sport

Performance
▪ Phase 2- Establish – Develop Functional Training
Strength Base Program
– Restore Muscle Activation ▪ Remember that eccentric
and Sequencing strength is the foundation of
plyometric training
▪ Phase 3- Restore Muscular ▪ Impose Power Demands
Control & Kinesthetic
Sense
– Dynamic Warm-up
– Jogging Progression (Test
Battery for Return to
jogging)
Rehabilitation Team
Physical
Therapist
Athletic
Parents
Trainer
Athlete
Coaches Physician
Defining the return
▪ Environment/Sport
– Specifically stating where (i.e. loading dock, driver, soccer, tennis)
▪ Level
– Applies more so to sport (i.e. recreational, local club, college, professional)
▪ Timing
– Shortest possible time, or best performance
▪ Championship upcoming
▪ Contextual Factors
– Type of injury (acute/chronic)
– Age
– Sport factors (i.e. team, contact/non-contact, cutting, endurance)
Strategic Assessment of Risk and Risk
Tolerance (StARRT)
Return to sport
- loading progression
Modify Modify
Loading? Loading?
Return to Return to Return to

Participation Sport Performance
RTS Principles
- when is the athlete ready
▪ Return to sport can

begin when the
patient can
perform activities
of daily living with
pain no >2/10.
▪ Classification
schema based
upon pain during,
after and rate of
perceived exertion

Therapeutic Exercise

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Therapeutic

Pathology Clinical Conditions

 Days 0-7  Vasoconstriction

 Corticosteroids & NSAIDS

 Accumulation of fluid within

 Neutrophils Fibrin + Fibronectin

 Leukocytes (aka white blood cells)

 Cloudy, viscous fluid

 Fibroblasts (aka tenocytes, tendon cells)

Image adapted from Wagenhäuser MU, et al., 2012

 Muscle Stem Cell

Adapted from Zouraq F, et al., 2013

Grade II • More muscle fibers involved, but not completely ruptured

Grade III • Near-complete or complete tear/avulsion

Control pain, edema, • Protection

Maintain soft tissue and • PROM, A-AROM, AROM

 Early mobilization (WBAT over NWB (cast immobilization))

 Treated with POLICE

 Treated with optimal loading to restore type 1 collagen fibers

 Perform as tolerated before P1

 P1: position where

 Active-Assistive Range of Motion (A-AROM)

 Active Range of motion (AROM)

 Slowly, steadily progress  Provide sensory

 Contraction Type- Isometric

 Contraction Type- Isometric

 Stabilization: submaximal and sustained co-contractions that

 Multiple-angle isometrics: resistance applied at multiple joint

 Minimize pain and prevent infection

 Acute hospitalization includes:

 Mechanisms of muscle loss

 Acute hospitalization older adults spend:

Adapted from Cruess et al. 1975

 Active muscle regeneration (Ambrosi et al., 2009)

Neovascularization PROLIFERATION Epithelialization

 Less severe injuries

 Severe injuries (i.e. volumetric tissue loss)

 Granulation tissue: newly formed capillaries, fibroblasts

 Reestablish epidermis to prevent fluid loss and decrease

 Final step of wound healing

 Angiogenesis: development of new blood supply

 New vessels are required to deliver oxygen and nutrients to

 Clinical signs  Common Impairments

 Contraction Type- Isometric

 Contraction Type- Isotonic/Dynamic Exercise

 Concentric motions: occur when provided skeletal muscle

 Eccentric motions: occur when provided skeletal muscle

 Greater loads lowered (ecc) than lifted (con)

 Eccentric exercise > Delayed Onset Muscle Soreness (DOMS)

Contraction Type- DOMS DOMS- Etiology

Muscle activation occurs predominately in Muscle activation occurs in multiple muscle

 Isolation of Muscle Group  Coactivation/Dynamic Stabilization

 Have you identified deficits in muscle performance?

 Can these deficits cause future impairment of function?

 So are 1-3 sets of 12, 3 time/day prescribed? Based

 Large base of support → Small base of support

 Dosage in the sub-acute phase is:

 Dosage can be lower in the sub-

TrA with marching

Elastic band rows

 Briefly review the phase of healing and clinical indicators of the

 The American Board of Internal Medicine (ABIM) developed a

 Aims to promote conversations between providers and patients by helping

 Not duplicative of other tests or procedures already received