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PHYSIOLOGICAL THERAPEUTICSCRYOTHERAPY

DEFINITION: The therapeutic use of cold Ice is inexpensive, readily available to both practitioner and patient and can be used in a

variety of forms. Has relatively few contraindications, and can be very effective in the treatment of pain,

edema, spasm and inflammation, especially in the first 24 to 48 hrs after an injury. In many instances in which heat is considered the modality of choice for its "soothing"

qualities, cooling would probably afford longer lasting and more complete results, andtherefore should be considered more often.

CRYOTHERAPYEFFECTS Anesthesia Analgesia Reduction of edema Reduced Muscle spasm Reduced Spasticity Reduced manual DexterityCRYOTHERAPYINDICATIONS Acute sprains and strains Acute inflammatory processes Acute trauma Acute and Chronic muscle spasm Spasticity associated with neurological disordersCRYOTHERAPY CONTRAINDICATIONS Caution with geriatrics, infants, and cachexics Individuals with psychological aversion to cod Hypersensitive individualsCRYOTHERAPY APPLICATIONS Ice packs Ice massage Cold compresses Extremity baths

HOT MOIST HEAT This is the most commonly used heat modality Transfers heat to the patient primarily by conduction Most common cause for malpractice in physiotherapy today is burns, and they are most

frequently caused by hot packs. The moist packs should be totally submerged in water to a minimum of 30 to 40 minutes

between use to regain their correct temperature (150 -180 degrees F) Hot moist heat can be used in conjunction with other therapies. Moist heat vs. dry heat: dry heat causes stiffness.

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EFFECTS Increased circulation to the area being treated. Relaxation Decreased pain Decreased muscle spasm Generalized effect (PR, BP)INDICATIONS Non-acute sprains/strains Sinus conditions Menstrual cramps Arthritis, tendinitis, bursitis, capsulitis Decreasing pain before exerciseCONTRAINDICATIONS Acute conditions

Patients on anti-coagulants Psychological hysteria or drug dependent Dermatological conditions Diabetic or alcoholic neuropathy Severe vascular occlusions Always have patient inform you if hot pack is too hot. Do not use steam packs over cuts or abrasions Do not use heat packs in conjunction with skin balm or liniments. Do not use toweling that is moist from use.

PARAFFIN THERAPY Paraffin is essentially hot wax that consists of seven parts paraffin and one part mineral oil Some authorities recommend a 4:1 ratio Purpose of the mineral oil is to lower the melting temperature of the wax. Without the mineral oil, the melted wax would be far too hot for therapeutic purposes. Because the paraffin-oil mixture has a low specific heat, it can be applied directly to the skin

if the circulation to the part is normal. Before the application, the part to be treated should be cleaned and dried, the thermesthetic

sense should be ascertained to be normal, and all jewelry on the part to be treated should beremoved.

Temperature of the melted wax should be checked with a thermometer, but a finger pretestby the doctor/therapist will even more assure the apprehensive patient that the mixture is nottoo hot.

Paraffin offers the same effects and advantages as any other form of superficial heat that istransferred by conduction.

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

that limit motion

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PARAFFIN THERAPYCONTRAINDICATIONS Paraffin should not be used over open wounds, abrasions, acute skin disorders, or where

there is diminished sensation.METHODS OF PARAFFIN THERAPY APPLICATIONS When constant heat is required for a long period, two or three hours, the application of the

paraffin boot, properly insulated, gives excellent results either by direct or reflex application. Dipping method: After washing and drying the extremity, dip the part in and out of the bath

quickly, allow time between dipping for congealing, dip again, and keep repeating until thethickness of the paraffin is from 1/4 inch to 1/2 inch.

Depending upon the intended duration of the treatment, wrap the part in wax paper andinsulate all around with a towel.

When the treatment is completed, remove the paraffin and discard it When dipping hands, keep fingers spread apart. The part treated should now be massaged and passively exercised. The entire treatment usually takes about 20 to 30 minutes. Immersion method: For heat treatments of shorter duration, 10 to 30 minutes, use the

immersion method. Dip the part in and out of the bath quickly so that a thin coating of paraffin congeals on the

skin. Repeat several times until the glove of paraffin is of sufficient thickness to allow the part to

remain in the bath with comfort. Keep the part immersed from 20 to 30 minutes. At the end of the treatment, remove the wax and discard it. Brush on method: To apply paraffin bath heat treatment to parts of the body which cannot be

immersed in the paraffin bath conveniently, paint the surface rapidly with a soft paint brush. When first applied, the paraffin will feel very warm, keep brushing until a thick coating

covers the area Allow it to remain for twenty to thirty minutes. After removal, discard the wax. The part treated should be massaged and passively exercised.

THERAPEUTIC ULTRASOUNDTHERAPEUTIC ULTRASOUND Therapeutic ultrasound is that which is used for therapeutic (rather than diagnostic) purposes

and is usually produced at 1 megacycle or 1 million cycles per second US has replaced diathermy for many types of conditions because it is less time consuming

and penetrates tissues well. There is less danger of burning It takes only 8-10 minutes It is capable of penetrating 5 cm into the tissues. Continuous US causes a thermal effect. The friction caused by the vibration within thepatient’s tissues will produce heat. Because US is transmitted by skin and fat, the heat can be directed to the deeper muscle layers

where it is needed.

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PULSED ULTRASOUND The energy is on for a short period of time, then off; alternating so that the "on time" or duty

cycle is approximately 5-50% of the total time. The "off time" allow the tissues to disperse the heat created, thereby minimizing or

eliminating the thermal effect.PULSED ULTRASOUND With the 5% duty cycle, there is virtually no heating With the 50% duty cycle, some heating occurs. Pulsating US is advantageous when the thermal effect may be detrimental.BIOLOGICAL EFFECTS Inflammatory—increase fragility of lysosome membrane nd thus enhances the release of

their contained enzymes which helps to clear the debris and allow next stage to occur. Proliferative—fibroblast and myofibroblast may have ca++ ions driven to them by US.

Fibroblast are stimulated to produce collagen fibres to from scar and myofibroblast contractto pull the edges together.

Remodeling--- increase tensile strength of scar by affecting the directions, strength andelasticity of fibres.

ULTRASOUND EFFECTS Tissue temperature rise Decreased nerve conduction velocity Increased circulation Increased tendon extensibility Reduced adhesion formation Decreased pain Muscle relaxationULTRASOUND INDICATIONS Neuromuscular, musculoskeletal disorders Sprains and strains; adhesive capsulitis Arthritic conditions - acute and chronic Bursitis, tendinitis, including calcific tendinitis Neuromas, scars, dupuytrens contracture

Plantar warts Hematomas

AdhesionsPRECAUTIONS Over heating of the cutaneous tissues may occur if the intensity is set too high Transducer is moved too slowly Transducer surface is not kept parallel to the skin surfacePRECAUTIONS Over heating of the periosteum may occur if:

~ The transducer is held too close to the bone~ The intensity is set too high~ The transducer is moved too slowly

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CONTRAINDICATIONS Epiphysis of growing bones Over reproductive organs Over a gravid uterus Over the heart Over the eye; over anesthetic areas Over ischemic areas; directly over the spinal column or brain Over a fracture (until well healed) Deep vein thrombosis Arterial disease, hemophilia, malignancy TB of the lungs or bone Over the thoracic region of a patient with a pace makerAPPLICATION OF ULTRASOUND Apply coupling medium to the part being treated and place the transducer against the

coupling medium. The unit should never be turned on without coupling medium because thecrystal may over heat.

Keep the transducer moving slowly Turn the intensity up to the desired level Avoid bony prominences and keep the transducer parallel to the skin as possible The patient may get a mild sense of warmth. If the patient gets too hot, or uncomfortable, the

wattage should be reduced to a tolerable level Treat for the desired time

US IMMERSION METHOD Good for treating hands, wrists, feet and elbows Place the transducer and the treating part in a container of water Keep the transducer moving slowly and within 1cm of the part being treated. Duration: acute 3-4 minutes; chronic 5-10 minutes

SHORT-WAVE DIATHERMY Uses high frequency currents to heat the body tissues The heat results from the resistance offered by the tissue to passage of the electric current. The patient's sensation is an important guide as the regulation of dosage, as it should produce

only a mild comfortable sensation of warmth and not a sensation of heat It is imperative that the sensory perception of the patient be normal in the use of diathermy.PRECAUTIONS Remove metallic pins, buttons, and hair Metallic objects must not contact the patient, as they will concentrate the heat and could

cause burns. Pins, keys, jewelry, watches and buckles.TEN MAJOR EFFECTS Thermal Stimulation Increased Blood flow Hypotonicity

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Increase in visceral circulation Endocrine changes Oxidation Phagocytosis Detoxification Increase in capillary pressure

DOSAGE LEVEL I For patients who have no appreciable specific pain or in the treatment of visceral conditions,

gradually increase temperature to where the patient just perceives a comfortable yet distinctsensation of “velvety" warmth.

Dosage Level II For patients who have pain, the temperature is increased to a point just below the level of

Dosage I. The patient should perceive no detectable sensation of warmthGENERAL RULE The more acute the condition to be treated, the less temperature elevation and the shorter the

treatment duration.ELECTRODE POSITIONS The three common electrode positions are:

Transverse Longitudinal CO-planar

GENERAL RULEThe thicker the body part to be treated, the greater should be the electrode -skin distance,which is provided by air spacing or towels

INDICATIONS URI Chronic osteoarthritis ProstatitisCONTRAINDICATIONS Over pregnant uterus Over wet skin Patients with pacemaker Peptic ulcers Rheumatoid Malignancy

MICROWAVE DIATHERMY The configuration of a pattern is determined and controlled by the distance that it is placed

from the patient and the shape of the reflector. The power output of the microwave unit is adjusted in accordance with the size and shape of

the body part treated. The smaller heat output of a microwave unit warms tissues in a much more local area.

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There is little penetration into deeper organs. Most of the effects of microwave radiation are due to heating of tissues by conversion. The heat build up occurs mainly because of the resistance offered by tissue constituents to

high frequency current, and a specific temperature distribution results within body tissues. Contact is not necessary, and smaller confined areas can often be treated more effectively. The field that can be heated at any one time is relatively small. Microwave has little, if any effect on deep joints or viscera

MICROWAVE DIATHERMY PRECAUTIONS If vigorous heating effects are desired, the applicator must be brought close to the surface of

the skin. The applicator should not be brought into contact with the skin. Avoid sweat droplets forming on the skin that can be selectively heated. During treatment near the head, the eyes should be shielded with special goggles. Watches must be kept away from the high frequency field, Hearing aids must be placed at least 4 feet from the treatment field. The director should be placed from 1-7 inches from the patient depending on the type that is

used.

TREATMENT DURATION Treatment duration exceeding 2O minutes is inadvisable

INTERFERENTIAL THERAPYThe name interferential therapy stems from the concept of two currents interfering with

each other The major problems with the standard low frequency currents lie with the resistanceoffered by the skin and the relatively long pulse duration. Normal human skin has a veryhigh resistance to the passage of a low frequency current.When the skin resistance is high, a larger potential difference (voltage) has to be applied to

the skin in order to achieve an adequate current flow in the tissues. The larger the applied voltage, the more likely it is that the stimulus will become

uncomfortable for the patient. If the skin resistance is lowered, then a smaller applied voltage will be required to produce a

given current flow in the tissues. Little resistance is offered to a higher frequency alternating current The net result is that if the applied current has a higher frequency, the skin resistance will be

low, with all the advantages of a more comfortable and efficient stimulation. In addition, thehigher frequencies will mean shorter pulse durations and this will lead to a morecomfortable stimulus

Problems arise, however, that in order to gain the advantages of lowered skin resistance, thefrequency of the current used needs to be approximately 4,000 Hz,

At this medium frequency the current is well outside the usual biological range of between0.1 and 200 Hz.

If however, two medium frequency sine waves are applied to the skin and tissues in such away that there is a difference in frequency between the two currents, then a rather interesting

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effect occurs, I.F. currents are produced by the interfering of the two medium frequency, alternating

currents. Two such medium frequency currents, one at 4,000Hz and the other at 4, 100 Hz When these two currents are superimposed on one another, it can be seen that the effect of

the blending of these two medium frequency sine waves is a variable increase in amplitude(intensity) of the resultant current.

The intensity of the current rises and falls, this is described as a "beating "of the twofrequencies. The "beat" frequency is the number of times in each second that the current rises and in

intensity to the maximum and falls away to its minimum value The beat frequency in Hz is simply the difference in frequency between the two medium

frequency currents. This "beating" is the actual "interferential effect" The beat frequency relates solely to the number of times per second the intensity increases

and decreases. The medium frequency (4,000 Hz) is called the carrier frequency The current flowing in the tissues is approximately 4,000 Hz but its intensity is increasing

and decreasing (beating) within the range of about 0.1 to 200 times per second.

INTERFERENTIAL THERAPY PRE-MODULATED It is possible to deliver I.F. currents to a patient using two, instead of the conventional four

electrodes. In this system, the two currents are “'mixed" in the machine and delivered to the patient via

two electrodes. There is a significant difference between this technique and the standard method using four

electrodes. In the conventional method, the I.F. current is produced endogenously. In the pre-modulated mode however, the actual I.F. currents are applied via electrodes to the

patient's skin It is most unlikely that there is any significant clinical difference between the two methods,

other than the obvious ease of application of the premodulated method. For many situations, the premodulated mode is probably the method of choice, for

example, in muscle stimulation.INTERFERENTIAL THERAPY TREATMENT DURATION The average treatment time for most applications being 20 to 30 minutes. On the first treatment session, it is wiser to halve this, in order to ensure that there is no

abnormal response from the patient. There have never been a set number of treatment sessions for any particular clinical

problem since all patients and problems are different However, if the overall treatment program has been carefully designed and delivered then

good results should be expected fairly quickly. I.F. like other forms of electrotherapy is meant to be used as an adjunct to other forms of

treatment. In most cases, six to ten sessions of I F together with other measures should produce

considerable improvement in the patient. There is no point in continuing with a technique which appears to be having no effect

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If the patient's condition is unchanged after one or two treatments, then the situation needsre-assessing.

Assuming that the machine is working correctly and is applied properly, then poor resultsshould indicate possible change in electrode position and/or a change in frequency/intensity.

INDICATIONS Pain relief both acute and chronic

Reduction of edema

Re-education and strengthening of muscle.

Stimulation and improvement of circulation

General facilitation of healing

INTERFERENTIAL THERAPY I.F. can and should be combined with other modalities. Combining treatments implies giving two different but complimentary treatments at different

times or in some instances at the same time (ice, moist heat)

Spinal Traction Definition The application of a drawing or pulling force along the long axis of the spine in order to:

Stretch soft tissuesSeparate joint surfacesSeparate bony fragments

DISTRACTION A form of dislocation in which joint surfaces have been separated without rupture of the

binding ligaments and without displacementINVERSION Turning upside-down or other reversal of the normal relation of a partTYPES OF TRACTIONCONTINUOUS TRACTION This particular form involves lightweight applied for prolonged periods of time. It is generally accepted that this form is ineffective at producing separation because of the

slight force used. This type of traction is generally used to align and stabilize adjacent body parts when there

are fractures and/or dislocations.CONTINUOUS TRACTION An example of continuous spinal traction is the halo type device used following a fracture of

the cervical spine. It may also be used after certain surgical procedures such as spinal fusions.SUSTAINED (STATIC) TRACTION Sustained traction applies a constant amount of force. Sustained traction is used from only a few minutes to as long as 30 minutes The shorter duration seen with static traction is coupled with a greater traction force than that

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seen with continuous traction. Static traction is used mostly for WD herniations and may be effectively applied in both the

cervical and lumbar spine Sustained traction is probably most helpful in the early phases of treatment when there is

significant guarding and muscle spasm present. As the patient's condition improves, intermittent traction may prove to be more helpful.

Home cervical traction units (over-the-door) devices are examples of sustained traction. These devices use a traction force that ranges from 5 to 15 pounds Although the forces probably are not great enough to create any significant separation, many

patients find these devices helpful

INTERMITTENT TRACTION Utilizes a mechanical traction device that alternately applies traction and allows relaxation

for a time period of several minutes to one-half hour. This allows intermittent stretch of soft tissues, joint separation and inhibition of the disc,

which can be beneficial for the treatment of soft tissue injuries, joint fixation, nerve rootcompression, degenerative disc disease, or an acute or chronic herniated disc.

The application of different traction forces that are alternately applied and released(hold/rest).

In this form of traction a moderate force is applied for a period of time usually from 30 to 60seconds.

This is referred to as the “hold time" The moderate force is then reduced to a lesser traction force that is applied for a shorter

period from 10 to 20 seconds - the “rest period" The traction device alternates between the two different forces for the treatment duration,

thereby producing not only traction and separation, but also some degree of movement. It is most often used for joint dysfunction and degenerative disc disease. It can be used for disc protrusions with longer hold/'rest periods (60 seconds hold 20 seconds

rest).

MANUAL TRACTION Traction applied manually by the doctor. The traction forces usually are applied for a few seconds at a time and, typically, in a

rhythmic nature. Although manual traction may often be beneficial by itself, it is often employed prior to other

mechanical forms of traction in order to assess the patient's tolerance. Patients who may be intolerant of manual traction probably will not respond well to more

aggressive forms of traction Manual traction may often provide relief for patients with cervical stiffness, disc problems,

headaches, and other conditions. The amount of traction applied may vary, depending upon the patient’s condition, the part of

the spine being tractioned, and the strength of the doctor.

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POSITIONAL TRACTION Involves placing the patient in a particular position to increase motion in a specific direction

at a specific segment of the spine. Pillows, blocks, and sandbags may be used to accentuate the position and increase traction. These techniques are incorporated into many of the procedures used by McKenzie in his

extension protocols for LBP patients.

GRAVITY LUMBAR TRACTION This may be achieved by a variety of inversion apparatuses.

The patient is secured by the ankles or thighs and allowed to invert in some degree up to 90degrees.

The weight of the upper body is affected by gravity and allows traction of the spine,especially of the lumbar segments.

Flexion-Distraction This is achieved with a specialized table on which the patient is placed in a prone position

with the ankles strapped to the caudal end of the table. The table is then unlocked, so that the lower half of the table is allowed to flex. By placing cephalad and anterior pressure on the vertebra above the motion segment being

treated, very specific distraction is applied to the motion segment involved Many tables can also rotate and/or sidebend they’re lower half, allowing even more

specifically therapeutic distraction to the segment. Traction is applied in an intermittent fashion, creating a pumping effect. Flexion Distraction can be a very effective method for the treatment of acute and chronic

intervertebral disc protrusion (medial and lateral), facet syndrome, Spondylolisthesis,retrolisthesis, discogenic spondyloarthrosis, anterior or posterior innominate, and sacruminferiority.

Cox, using the flexion-distraction technique, found in 43 cases of medial disc protrusion that3 responded to this treatment:

In 57 cases of lateral disc protrusion, 55 responded to this treatment, alleviating the need forsurgery.

INTERSEGMENTALTRACTION Involves the application of mechanical rollers that move up and down vertically as they track

longitudinally along the paraspinal structures. The tension, speed, and amount of travel of the rollers are modified to patient comfort.As they move, the rollers lift and separate the vertebral units and exert a mild tractioning effect. This type of "traction" is more appropriately termed a form of Passive mobility rather thantraction. In addition to the application of the mechanical forces, many of the intersegmental traction

tables simultaneously incorporate the use of vibration and heat with the mobilization. The primary benefit of intersegmental traction is seen in patients who are stiff, tight, and

generally tense.

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This is a very gentle form of therapy that affects whole segments of the spine. In addition to any mild effect that this procedure may have on the movement of the spine, it is

very comfortable and relaxing.INTERSEGMENTAL TRACTION Intersegmental traction meets with high patient acceptance; consequently, it is overused in

many practice situations As with all other forms of therapy, Intersegmental traction should be provided to those

patients who will benefit from the procedure.

It should not be a routine part of the treatment of every patient.EFFECTS Suction: A subatmospheric pressure is created when two vertebrae are pulled apart, causing a

centripetal force on the disc. Distraction: The distance between the articular surfaces increases with sufficient traction. Ligamentous tautening: The anterior and posterior longitudinal ligaments are stretched,

causing further centripetal force on the disc. Relaxation of the musculature: Cyriax reported EMG silence 3 minutes after continuous

traction. Widening of the IVF Straightening of the spinal curves.

INDICATIONS IVD protrusions Facet syndrome Nerve root compression Spondylolisthesis Retrolisthesis Discogenic spondyloarthrosis Muscular spasm Anterior or posterior innominate Sacral inferiority Early scoliosis It should be borne in mind, that traction is usually not the only therapy used. As with other

forms of therapy, when it is used the doctor should be alert to changes in the patient'scondition that warrant modification in treatment methods.

It is particularly important to keep in mind the following rule.- If treatment increases peripheral pain and/or symptoms, it should be discontinued untilboth the condition and the therapy have been re-evaluated

PRECAUTIONS To minimize any potential injury resulting from inappropriate use of traction (e.g.. too much

weight or improper patient position), traction should be initiated gently, with progressivelyincreasing force and time as the patient condition warrants.

Following the application of traction, a patient should be allowed a short rest period beforeresuming activities.

It is not uncommon for patients to feel some pain relief during the application of traction, only

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to have the relief disappear at tile end of tile treatment session. It is suggested that the patient should be gradually returned to the upright position to maintain

relief.CONTRAINDICATIONS Structural disease secondary to tumor or infection Vascular compromise, hypertension, atherosclerosis, phlebitis, angina, and a history of stroke

or transient ischemic attack. Acute sprains, strains, and other musculoskeletal inflammatory processes. Pregnancy Instability Osteoporosis and other bone-weakening conditions Hiatal hernia Ankle, knee or hip joint dysfunction Patients with aortic aneurysms Patients with active peptic ulcers Patients who are claustrophobic

CERVICAL TRACTION Maximum separation of the cervical vertebrae occurs when the cervical spine is flexed to 25 to30 degrees except for the atlantoocccipital and atlantoaxial joints, which should be tractionedwith a 0 degrees angle of pull. Research has shown that supine traction is superior to sitting traction. It is particularly important that patients are able to relax Consideration must be given to the effect of the traction device on the TMJ In order to produce a desired effect the traction force must be great enough to effect astructural change at the spinal segment Much less force is required for the cervical region

CERVICAL TRACTION PROPER POUNDAGE Forces of 25 to 45 pounds are necessary to produce measurable changes in the posteriorstructures. The maximal force should not exceed 45 pounds Forces of 120 pounds have been shown to be necessary to cause a disc rupture at the C5-C6level

CERVICAL TRACTION PROPER POUNDAGE It has been shown that a traction force of only 10 pounds will produce a separation of theatlantoaxial joints; consequently less force is necessary when the upper cervical spine is thetarget area. For the safe and effective application of traction to the cervical spine: It is suggested that the doctor begin with a traction force of between 10 and 15 pounds If the patient improves, continue at the same poundage or increase poundage by 5-pound

increments to a maximum of 45 pounds.

CERVICAL TRACTION

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PATIENT POSITION Positioning of the patient has a direct effect on the location of the traction effect: If the head is allowed to lay on the table with the cervical spine in a neutral or extended

position, the traction will exert its maximal effect on the anterior intervertebral structures suchas the IVD.

When the objective is separation of the interbody joints, the patient should be positioned insuch a neutral or extended position.

If the head is maintained in a flexed, forward- bent position, the traction will exert its maximaleffect on the posterior structures, such as the facet articulations and the WF.

When the objective is separation of the posterior articulations, the patient should be positionedwith the neck in a flexed position.

The greater angle of flexion, the lower in the cervical spine is the area affected by the tractionforce.

The position of the head and neck can be adjusted to ensure that separation occurs at thedesired location.

This is most easily accomplished by communicating with the patient during the initialapplication.

The best position is the one that localizes the traction force in the area of pain.CERVICAL TRACTION ANGLE OF PULL It is suggested that an angle of 0 to 15 degrees be used for the upper cervical spine. The angle should be increased by 5-degree increments for each progressively lower cervical

segment Both the angle of pull and the position of the head have a similar effect in changing the

location of the traction forces.CERVICAL TRACTION DURATION Traditionally, spinal traction is applied in 20-minute increments Treatment times may vary depending on the nature of the condition, the type of equipment

used, and the response of the patient.CERVICAL TRACTIONTREATMENT FREQUENCY As with other forms of therapy, spinal traction has a specific physiologic effect and should be

used when that effect is desired. The application of sustained and intermittent traction is usually only warranted for relatively

short periods of time. Daily treatment is suggested for the first 3 days, followed by three times weekly for 2 to 3

weeks If traction is to be helpful, some relief should be seen within the first three to five treatments. Unlike other forms of traction, intersegmental traction may be warranted on a continuing basis

in some patients. It should not, however, serve as a substitute for stretching and flexibility exercises, nor shouldit be used as a standard procedure for all patients seen.

LUMBAR TRACTION There is a great variation in the methods used to apply traction to the lumbar spine.

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Traction node (sustained or intermittent) depends on both the disorder being treated and on thecomfort of the patient.

Disc protrusions usually are treated more effectively with sustained traction or with longerhold-rest periods of intermittent traction (60 seconds hold, 20 seconds rest).

Joint dysfunction and degenerative disc disease usually respond to shorter hold-rest periods ofintermittent traction (30 seconds hold, 10 seconds rest)

LUMBAR TRACTIONPROPER POUNDAGE Begin with approximately 50 pounds If the patient improves, continue at the same poundage or increase poundage by 10-pound

increments to a maximum of 125 pounds. The patient position, whether prone or supine, and the amount of flexion or extension used

depend on the disorder being treated, on the experience of the doctor, on the comfort of thepatient, and on the type of equipment being used.

LUMBAR TRACTION ANGLE OF PULL To treat lumbar conditions the proper angle of pull is between 15 and 50 degrees To affect the lower thoracic and upper lumbar segments (L1 -L3); the angle of pull must be

15 to 30 degrees To affect the lower lumbar segments (L3 -L5); the angle of pull must be 30-50 degrees. Hypolordosis of the lumbar spine should be treated with an angle of pull from 15 - 30degrees. Hyperlordosis should be treated with an angle of pull from 30 to 50 degrees. The lower in the lumbar spine the traction is intended, the greater the angle of pull.

LOW VOLTAGE GALVANIC Galvanic current allows stimulation of deinervated muscle as well as the possibility ofdriving ions into the tissues called iontophoresis. A galvanic current is a unidirectional (monophasic) current flowing for an indefiniteduration. Low frequency alternating currents are utilized because of the continued need forelectrical stimulation of atrophied muscle, especially for patients with CNS lesions. Low frequency alternating current: a current in which the direction of electron flowchanges at a rate between l and 2000 Hz. Sine wave: a low frequency alternating current that takes the shape of a sine curve Faradic current: a low frequency alternating current with 2 unequal phases The iontophoresis effect is not frequently used.

LOW VOLTAGE THERAPY IONTOPHORESIS On the principle that like charges repel and opposites attract, ions of various substancesare placed under their similar polarity electrode and driven through tissues by currentsusually less than 5 mA. Copper sulphate, sodium chloride, lidocaine and a corticosteroid

LOW VOLTAGE THERAPY

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EFFECTS Contraction of innervated muscle Pain relief Edema reduction

LOW VOLTAGE THERAPYINDICATIONS

Stimulation of weak and/or atrophied muscles Nonsystemic edema

LOW VOLTAGE THERAPYCONTRAINDICATIONS

Through the brain, heart or eyes Over bony prominences Fractures Skin lesions Malignancy Anesthetic areas Over a gravid uterus

LOW VOLTAGE THERAPY APPLICATION Place pads firmly on treating parts; can use hot packs, cold packs, for combinationtherapy. Quadrapolar or bipolar technique may be used. If unequal sized pads are used, the smaller pad will produce a greater effect. A probe may be used for specific stimulation of motor points. Set mode to: Pulse, if a gentle treatment is desired, to avoid further trauma or to dispersefluid. Set mode to: Surge, if a series of muscle contractions is desired (e.g. for muscle re-education) Set mode to: Tetanize, if a tetanic contraction is desired to fatigue the muscle (e.g.. formuscle spasm or muscle tension) Choose the pulse width, "on ramp" time, and/or "off ramp time. Set the timer to desired time Increase the intensity slowly to patient tolerance or until the desired muscle contraction isachieved. Treatment duration depends on the effect desired and the integrity of the muscle beingstimulated

LOW VOLTAGE THERAPY Dr. Kots of the Soviet Union has suggested the following times: To increase circulation: 2 sec on, 2 sec off To reduce spasm and pain: 12 sec on, S sec off For strength, endurance, and velocity: 10 sec. on, 50 sec. off

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TENS TENS should apply to any form of electrical stimulation that is applied via surfaceelectrodes. The term has been used for small portable stimulators that can be attached to the belt orclothing and used for various time periods for the relief of pain. In general the primary effect of TENS is the relief of pain. Many health practitioners are finding TENS to be an effective, safe, noninvasive, andcost effective method of treating acute, chronic and psychogenic pain of innumerableorigins.

TENS INDICATIONS Chronic pain Acute pain Intractable pain (TENS can provide adequate relief of pain secondary to malignancy.Results are best with trunk and extremity pain and worst with pelvic and perineal pain. Rehabilitation: The use of TENS for the reduction of pain during rehabilitation canincrease performance and shorten disability. Care must be taken to not allow the TENS to obliterate pain to the extent that the patientloses protective cues and overstresses the part being rehabilitated.

TENS CONTRAINDICATIONS Pacemakers Carotid nerve stimulation Laryngeal stimulation During pregnancy

TENS ELECTRODE PLACEMENT Electrode placement is one of the most critical factors for the success of TENS Directly over or around the painful site Over trigger points Over acupuncture points Within a specific dermatome At the site of the corresponding nerve root

TENS The most significant complication of TENS is local skin rashes produced by theconduction gel or tape. There are no contraindications to 24-hour use of "high TENS". "Low" TENS, however,should be used only 30-40 minutes at a time, as "Low TENS" causes muscle contraction andmay cause soreness if used for longer periods. Electrodes should be removed every day or two to clean the skin and inspect the area.

SOFT TISSUE MANIPULATIONCertain manipulations of the soft tissues of the body; these manipulations are most effectivelyperformed with the hands, and are administered for the purpose of producing effects on thenervous and muscular systems and the local and general circulation of the blood and lymph.

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EFFECTS Mechanically assisting the flow of blood and lymph to increase circulation and reduce edema Maintenance of muscle flexibility and viability Breaking up scar tissue, adhesions, and fibrosis Sedation Stimulation

CONTRAINDICATIONS Acute circulatory disturbances Acute inflammation Malignancy Edema secondary to heart decompensation, kidney disease, embolus, obstruction of lymph

channels, thrombus Hyperesthesia of the skin Communicable disease

SPECIFIC METHODSEffleurage - stroking motion and begin with light pressure and progress to heavier pressure astolerated and terminate with light pressure.Petrissage - Kneading or rolling motion, strokes are either in a centripetal direction ortransverse to the muscle fibersRolfing - is a deep massage that strives to separate the fascia between muscles Friction - is usedto break up superficial and/or deep adhesions of muscle or other soft tissues. No lotion is usedand small circular or linear strokes are used to loosen the tissue beneath the skin.Transverse friction - is a specific type of friction massage that is used to treat tendinitis ortenosynovitis. It is performed perpendicular to the tendon sheath, causing the tendon to separatefrom the sheath and slide through it more easily.Tapotement - includes tapping, slapping, cupping motions. It is useful for increasing circulationto an area and for postural drainage to increase the release of abnormal secretions from the lungs.

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Frequency (50 to 100 hz ) and duration (0.1 -1 ms)

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