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Pain signals arrive from the pain fibers (A-delta and C) at the spinal cord, along with signals from other peripheral fibers (A-beta) and the brain. The solid arrows depict stimulation conditions that tend to open the gate and send pain signals through. The dotted arrows indicate inhibition conditions. Pain signals enter the spinal cord and pass through a gating mechanism before activating transmission cells, which send impulses to the brain (from text by Sarafino EP. Health Psychology, Biopsychosocical Interactions, Third Edition. John Wiley & Sons, Inc. New York: 1998.)
THE WHOLE PROCESS OFTHE WHOLE PROCESS OF
RESTORING A DISABLED PERSON TORESTORING A DISABLED PERSON TO
A CONDITION IN WHICH HE OR SHEA CONDITION IN WHICH HE OR SHE
IS ABLE TO RESUME NORMAL LIFE.IS ABLE TO RESUME NORMAL LIFE.
Rehab is usually divided intoRehab is usually divided into
Several PhasesSeveral Phases
•Phase one—ImmobilizationPhase one—Immobilization
•Phase two-Early motionPhase two-Early motion
•Phase three-StrengtheningPhase three-Strengthening
•Phase four-Functional activityPhase four-Functional activity
•Phase five-Return to full activityPhase five-Return to full activity
The Phases of RehabilitationThe Phases of Rehabilitation
THE BRANCH WHICH DEALS WITHTHE BRANCH WHICH DEALS WITH
PHYSICAL METHODS OF TREATMENTPHYSICAL METHODS OF TREATMENT
EMPLOYED AS A MEANS FOREMPLOYED AS A MEANS FOR
ENCOURAGING RECOVERY OF JOINTENCOURAGING RECOVERY OF JOINT
MOVEMENTS AND MUSCLE POWERMOVEMENTS AND MUSCLE POWER..
promote activitypromote activity
correct insufficiencycorrect insufficiency
encourage the patient to use hisencourage the patient to use his
TYPES OFTYPES OF
PASSIVEPASSIVE- DIRECTED TOWARDS- DIRECTED TOWARDS
ALLEVIATION OF SYMPTOMS BYALLEVIATION OF SYMPTOMS BY
USING HEAT, COLD, COUNTERUSING HEAT, COLD, COUNTER
IRRITATION, MASSAGE,ANDIRRITATION, MASSAGE,AND
ACTIVEACTIVE--RESTORATION OFRESTORATION OF
FUNCTION BY EXERCISES.FUNCTION BY EXERCISES.
PASSIVE MOVEMENTSPASSIVE MOVEMENTS
These movements are produced by anThese movements are produced by an
external force during muscular inactivity.external force during muscular inactivity.
Manual Mobilization TechniquesManual Mobilization Techniques
-Passive stretches to
-Lengthen muscles due
to inhibition of tendon
Controlled stretching is
-overcome resistance of
Manipulation of joints
the range &
PASSIVE MOVEMENTSPASSIVE MOVEMENTS
A lengthening reaction of a tight orA lengthening reaction of a tight or
shortened muscle is obtained byshortened muscle is obtained by
strong contraction of antagonist.strong contraction of antagonist.
To restore Range of movement in stiffTo restore Range of movement in stiff
Used to maintain extensibility.Used to maintain extensibility.
Results from application of externalResults from application of external
force, when the muscle is not able toforce, when the muscle is not able to
Active MovementsActive Movements
Achieved by muscular contraction inAchieved by muscular contraction in
response to a demand, presented in aresponse to a demand, presented in a
manner suitable to the patient’s abilitymanner suitable to the patient’s ability
to respond.to respond.
ACTIVE MOVEMENTSACTIVE MOVEMENTS
to only the
forces of gravity.
Performed by patient’sPerformed by patient’s
own muscular effortown muscular effort
When the muscle
is applied to
for the deficiency.
be strong to
are adapted in
every part of
range of muscles.
The forces of
the action of
This type of exercise is used inThis type of exercise is used in
conjunction with other methods whichconjunction with other methods which
induce relaxation to reduce a state ofinduce relaxation to reduce a state of
wasteful tension in muscles, whichwasteful tension in muscles, which
limits the range of joint movement.limits the range of joint movement.
Orthopaedic AppliancesOrthopaedic Appliances
Quadriceps board Hip circumductor Heel exerciser
Parallel walking bar
Isotonic ExerciseIsotonic Exercise
In isotonic exercise, a body part is moved andIn isotonic exercise, a body part is moved and
the muscle shortens or lengthens.the muscle shortens or lengthens.
Although sit-ups, push-ups and pull-ups areAlthough sit-ups, push-ups and pull-ups are
isotonic, lifting free weights, like dumbbells andisotonic, lifting free weights, like dumbbells and
barbells, is considered the classic form ofbarbells, is considered the classic form of
isotonic exercise.isotonic exercise.
Lifting an object off a desk is an
example of isotonic
contractions. A near isotonic
contraction is known as
• ConcentricConcentric—the “up”—the “up”
contraction when acontraction when a
muscle shortens.muscle shortens.
• EccentricEccentric-the “down”-the “down”
contraction when acontraction when a
muscle lengthens.muscle lengthens.
Forms of Resistance Exercise-Forms of Resistance Exercise-
There are two main features to note regarding
As the load on the muscle increases, it finally reaches a point
where the external force on the muscle is greater than the force
that the muscle can generate.
Thus even though the muscle may be fully activated, it is forced
to lengthen due to the high external load.
This suggests that skeletal muscles are very resistant to
lengthening, thereby allowing very high levels of tension to
develop as can occur in isometric exercise
OPEN CHAIN ANDOPEN CHAIN AND
CLOSE CHAINCLOSE CHAIN
OPEN–OPEN– WHEN LIMB IS NOT FIXED,WHEN LIMB IS NOT FIXED,
ALLOWED TO MOVE FREEALLOWED TO MOVE FREE
CLOSEDCLOSED– WHEN THE LIMB IS– WHEN THE LIMB IS
FIXED TO MAINTAIN CONTACTFIXED TO MAINTAIN CONTACT
WITH GROUND REACTIVEWITH GROUND REACTIVE
Means whether the hand or foot stays in contactMeans whether the hand or foot stays in contact
with either a stable surface or a piece of equipmentwith either a stable surface or a piece of equipment
that moves in a predetermined way.that moves in a predetermined way.
transmit less force to the joint (although they tootransmit less force to the joint (although they too
can be stressful) and often are more functionalcan be stressful) and often are more functional
when you perform closed chain exercises, youwhen you perform closed chain exercises, you
often strengthen several muscle groups.often strengthen several muscle groups.
AnAn Open chain activity is one in which theactivity is one in which the
extremity can move in any direction.extremity can move in any direction.
Because it is not attached at the end.Because it is not attached at the end.
For example, if you raise one of your feet offFor example, if you raise one of your feet off
the ground, you can move that leg in anythe ground, you can move that leg in any
direction or sequence of movements.direction or sequence of movements.
Because of the increased stress on joints, keep
open chain activities to a minimum.
Open chain exercises do a good job of
targeting one set of muscles for strengthening,
but they increase the forces transmitted to the
If you opt for an open chain activity, keep the
Contractions developed while the joints remainContractions developed while the joints remain
•““The irresistible force meets the immoveableThe irresistible force meets the immoveable
•Generally considered the most intense type ofGenerally considered the most intense type of
muscle contraction.muscle contraction.
Forms of Resistance
MUSCLE CONTRACTS INDIVIDUAL OF JOINTMUSCLE CONTRACTS INDIVIDUAL OF JOINT
ON WHICH MUSCLE ACTS.ON WHICH MUSCLE ACTS.
FIRST FORM OF STRENGTHENING EXERCISEFIRST FORM OF STRENGTHENING EXERCISE
USED DURING PAINUSED DURING PAIN
PREVENT ATROPHYPREVENT ATROPHY
LESSEN SWELLINGLESSEN SWELLING
HELD FOR 5 SECS WITH REST OF 10 SECS.*HELD FOR 5 SECS WITH REST OF 10 SECS.*
10 REPETITIONS.10 REPETITIONS.
DONE AT DIFFERENT ANGLESDONE AT DIFFERENT ANGLES
Isometric ExerciseIsometric Exercise
In this type of strength-training exercise, your
muscles contract but your joints don't move and
muscle fibers maintain a constant length.
The exercises are typically performed against
an immovable surface for example, pressing your
palm against a wall.
Isometric training is effective for developing total strength of a
particular muscle or group of muscles.
It's often used for rehabilitation because the exact area of muscle
weakness can be isolated and strengthening exercises can be
administered at the proper joint angle.
This kind of training can provide a relatively quick and convenient
method for overloading and strengthening muscles without any
special equipment and with less chance of injury.
• Generated by the hydraulic style of weightGenerated by the hydraulic style of weight
machines, or by Isokinetic dynamometers.machines, or by Isokinetic dynamometers.
• Resistance is created by restricting the velocity atResistance is created by restricting the velocity at
which a joint can rotate through a Range ofwhich a joint can rotate through a Range of
• The subject pushes as hard as s/he can, but theThe subject pushes as hard as s/he can, but the
machine only allows the exercising body part tomachine only allows the exercising body part to
move as fast as the machine is set to go.move as fast as the machine is set to go.
Forms of Resistance Exercise-Forms of Resistance Exercise-
Manual MedicineManual Medicine
Manual therapy refers to specific skillsManual therapy refers to specific skills
by the therapist in muscle, joint andby the therapist in muscle, joint and
somatic dysfunctionsomatic dysfunction
As with any discipline, some therapistsAs with any discipline, some therapists
have exceptional skills in this areahave exceptional skills in this area
Manual therapy is best utilized as anManual therapy is best utilized as an
integrated part of a comprehensiveintegrated part of a comprehensive
treatment programmestreatment programmes
Manipulation AndManipulation And
MOBILISATIONMOBILISATION Low amplitude andLow amplitude and
pressure movement.pressure movement.
MANIPULATIONMANIPULATION Larger amplitude andLarger amplitude and
more forceful movement.more forceful movement.
Thrusting techniquesThrusting techniques: Application of a: Application of a
high-velocity, low-amplitude thrust to ahigh-velocity, low-amplitude thrust to a
Forces the joint beyond the physiologicForces the joint beyond the physiologic
range of movement to the anatomicalrange of movement to the anatomical
limits of motionlimits of motion
Contraindications:Contraindications: Osteoporosis, AcuteOsteoporosis, Acute
inflammation, Infection, Tumor,inflammation, Infection, Tumor,
Structural instability, VertebrobasilarStructural instability, Vertebrobasilar
It is defined as the scientific manipulation of the soft tissueIt is defined as the scientific manipulation of the soft tissue
which is performed by using the palmar aspect of the hand.which is performed by using the palmar aspect of the hand.
It aims to increase the blood circulation and relief from pain.It aims to increase the blood circulation and relief from pain.
Therapeutic effectsTherapeutic effects
Increase fluid exchange in tissue without changing volumeIncrease fluid exchange in tissue without changing volume
of fluid pressureof fluid pressure
Reduced swellingReduced swelling
Decreases toxinsDecreases toxins
Increased flexibilityIncreased flexibility
Remodeling of connective tissueRemodeling of connective tissue
Decrease spasm in musclesDecrease spasm in muscles
Reflex EffectsReflex Effects
– Stimulation of peripheral receptors in theStimulation of peripheral receptors in the
skin produce centrally mediatedskin produce centrally mediated
sensations of pleasure and peripherallysensations of pleasure and peripherally
cause muscle relaxationcause muscle relaxation
Mechanical EffectsMechanical Effects
– Consists of measures to assist return flowConsists of measures to assist return flow
circulation of blood and lymph andcirculation of blood and lymph and
measures that produce intramuscularmeasures that produce intramuscular
motion to stretch adhesions and mobilizemotion to stretch adhesions and mobilize
fluid accumulationfluid accumulation
Other StretchingOther Stretching
Progressive stretch mobilizationProgressive stretch mobilization
Sustained progressive stretchSustained progressive stretch
Spray and stretchSpray and stretch
Muscle energyMuscle energy
Myofascial Release &Myofascial Release &
Myofascial releaseMyofascial release involves activeinvolves active
or voluntary muscle contractionor voluntary muscle contraction
along with passive massagealong with passive massage
requires feedback from therequires feedback from the
patient's body to determine thepatient's body to determine the
direction, force and duration of thedirection, force and duration of the
to facilitate maximum relaxation ofto facilitate maximum relaxation of
the tight or restricted tissuesthe tight or restricted tissues
Mobilization iMobilization includes those manualncludes those manual
procedures which attempt to increaseprocedures which attempt to increase
Joint range of motionJoint range of motion beyond thebeyond the
resistance barrier which limits passiveresistance barrier which limits passive
range of motion or exerciserange of motion or exercise
May involve either an accessory glideMay involve either an accessory glide
of the joint or a physiologic movementof the joint or a physiologic movement
of the jointof the joint
Rhythmic repetitionsRhythmic repetitions with minimalwith minimal
force may provide pain reliefforce may provide pain relief
Differs from manipulation orDiffers from manipulation or
adjustment by the absence of aadjustment by the absence of a
forceful thrust or jerking movementforceful thrust or jerking movement
Maitland's grades of mobilizationMaitland's grades of mobilization::
Grade I - Grade IVGrade I - Grade IV
Gate-Control Theory –Gate-Control Theory –
Ronald Melzack (1960s)Ronald Melzack (1960s)
Described physiological mechanismDescribed physiological mechanism
by which psychological factors canby which psychological factors can
affect the experience of pain.affect the experience of pain.
Neural gate can open and closeNeural gate can open and close
thereby modulating pain.thereby modulating pain.
Gate is located in the spinal cord.Gate is located in the spinal cord.
Gate Control Hypothesis:
Wall & Melzack 1965
Hypothesized interneurons activated by A-beta fibers
act as a gate, controlling primarily the transmission of
pain stimuli conveyed by C fibers to higher centers.
i.e. rubbing the skin near the site of injury to feel
i.e. Transcutaneous electrical nerve stimulation
i.e. dorsal column stim.
Three Factors InvolvedThree Factors Involved
in Opening and Closingin Opening and Closing
the Gatethe Gate
The amount of activity in the painThe amount of activity in the pain
The amount of activity in otherThe amount of activity in other
peripheral fibersperipheral fibers
Messages that descend from theMessages that descend from the
Gate-Control TheoryGate-Control Theory
Gate is open Gate is
Conditions that Open theConditions that Open the
Physical conditionsPhysical conditions
– Extent of injuryExtent of injury
– Inappropriate activity levelInappropriate activity level
Emotional conditionsEmotional conditions
– Anxiety or worryAnxiety or worry
Mental ConditionsMental Conditions
– Focusing on painFocusing on pain
Conditions That CloseConditions That Close
the Gatethe Gate
Physical conditionsPhysical conditions
– Counter stimulation (e.g., heat, message)Counter stimulation (e.g., heat, message)
Emotional conditionsEmotional conditions
– Positive emotionsPositive emotions
– Relaxation, RestRelaxation, Rest
Mental conditionsMental conditions
– Intense concentration or distractionIntense concentration or distraction
– Involvement and interest in life activitiesInvolvement and interest in life activities
Thermal TherapiesThermal Therapies
A number of thermal modalities thatA number of thermal modalities that
produce pain relief directly and indirectlyproduce pain relief directly and indirectly
These include:These include:
– VariousVarious Cold applicationsCold applications
– HeatHeat in the forms ofin the forms of
– Radiant heat,Radiant heat,
– Shortwave diathermy,Shortwave diathermy,
– Microwave and LaserMicrowave and Laser
Heat is transferred either byHeat is transferred either by
conduction,convection & Radiation.conduction,convection & Radiation.
Heating leads toHeating leads to --
– -- Increase in metabolic activityIncrease in metabolic activity
– -- Decrease in viscosityDecrease in viscosity
– -- Collagen tissue extensibility is increasedCollagen tissue extensibility is increased
– -- Nerve StimulationsNerve Stimulations
– -- Blood vessels - ErythemaBlood vessels - Erythema
((vasodilatation - due to release of substancevasodilatation - due to release of substance
'H' Bradykinin)'H' Bradykinin)
Therapuetic Effest ofTherapuetic Effest of
Encourage HealingEncourage Healing --
– by increasing metabolic rate cell activity.by increasing metabolic rate cell activity.
– decreased viscosity.decreased viscosity.
Control of InfectionControl of Infection --
– dry heat like I.R. is used in skin & surfacedry heat like I.R. is used in skin & surface
Relief of PainRelief of Pain --
– Heating is most effective non analgesic method.Heating is most effective non analgesic method.
-It relieves pain by opening the "pain gait-It relieves pain by opening the "pain gait
Increase in level of Endorphins.Increase in level of Endorphins.
Reduction of Muscle spasmReduction of Muscle spasm ––
– by inhibiting the lower motor Neuron pool, thusby inhibiting the lower motor Neuron pool, thus
there is no excitation & relief from musclethere is no excitation & relief from muscle
Sedative EffectSedative Effect --
– Psychosomatic role of EndorphinsPsychosomatic role of Endorphins
Increase in joint ROMIncrease in joint ROM ––
– Collagen extensibility analgesic effect increaseCollagen extensibility analgesic effect increase
Prophylaxis of Pressure soreProphylaxis of Pressure sore --
– Decrease blood flow reduce risk of skinDecrease blood flow reduce risk of skin
Oedema reductionOedema reduction --
– In Reflex sympathetic osteodystrophy,In Reflex sympathetic osteodystrophy,
post traumatic oedema, as heat causespost traumatic oedema, as heat causes
vasodilatation and increase rate of fluidvasodilatation and increase rate of fluid
Excess of HeatExcess of Heat ––
– -increases pain-increases pain
Physiological ReactionsPhysiological Reactions
to Heatto Heat
The major factors determining theThe major factors determining the
number and intensity of thenumber and intensity of the
physiological reactions to heat are:physiological reactions to heat are:
– Level of tissue temperature: therapeuticLevel of tissue temperature: therapeutic
range is narrow: 43range is narrow: 43oo
C [109.4C [109.4oo
F] to 45F] to 45oo
– Duration of tissue temperature elevationDuration of tissue temperature elevation
[5 to 30 minutes][5 to 30 minutes]
– Rate of temperature rise in tissuesRate of temperature rise in tissues
– Size of the area treatedSize of the area treated
Heat IndicationsHeat Indications
Muscle spasmMuscle spasm
Decreases joint stiffness andDecreases joint stiffness and
Myofascial pain and FibromyalgiaMyofascial pain and Fibromyalgia
Hematoma resolutionHematoma resolution
Bursitis and tenosynovitisBursitis and tenosynovitis
Superficial thrombophlebitisSuperficial thrombophlebitis
Acute inflammation, abscess, trauma,Acute inflammation, abscess, trauma,
edema or hemorrhageedema or hemorrhage
Bleeding disordersBleeding disorders
Inability to communicate or respondInability to communicate or respond
Poor thermal regulationPoor thermal regulation
Areas of malignancyAreas of malignancy
Ischemia (Inadequate blood supply)Ischemia (Inadequate blood supply)
Atrophic skin & Scar tissueAtrophic skin & Scar tissue
Conduction – Hot PacksConduction – Hot Packs
Hot (hydrocollator) packsHot (hydrocollator) packs
– Clinically useful temperature for 30Clinically useful temperature for 30
– AdvantagesAdvantages include low cost,include low cost,
minimal maintenance, long life,minimal maintenance, long life,
patient acceptance, and ease ofpatient acceptance, and ease of
– Alternatives include electric heatingAlternatives include electric heating
pads, gel pads, hot water bottles,pads, gel pads, hot water bottles,
and circulating water heating padsand circulating water heating pads
– Exposure time: 20 minutesExposure time: 20 minutes
CONDUCTION HEATINGCONDUCTION HEATING
(A)Wax Bath(A)Wax Bath
-- Paraffin wax melts at 54 deg.C. pointParaffin wax melts at 54 deg.C. point
can be lowered by adding liquid paraffin,can be lowered by adding liquid paraffin,
mineral oils in a ratio of 1:7.mineral oils in a ratio of 1:7.
-- Wax-baths have temp. betweenWax-baths have temp. between
42 - 52 deg.C.42 - 52 deg.C.
-- Wax is in molten state in boxes.Wax is in molten state in boxes.
-- Temperature maintained by thermostat.Temperature maintained by thermostat.
Method of applicationMethod of application
(a)(a) DIP & WrapDIP & Wrap..
– Part is immersed for a second in wax, withPart is immersed for a second in wax, with
drawn & allowed to cool, then reinserted 2-3 sec.drawn & allowed to cool, then reinserted 2-3 sec.
– Repeat 6-12 times.Repeat 6-12 times.
– produce a coating of wax.produce a coating of wax.
– Limit the rate of heat loss by wrapping in towel.Limit the rate of heat loss by wrapping in towel.
– Terminate after 15 mins. by which time the waxTerminate after 15 mins. by which time the wax
is solid.is solid.
(b)Dip & Leave in(b)Dip & Leave in
– for achieving higherfor achieving higher
temp. for 15-20 mins,temp. for 15-20 mins,
– use paint brush anduse paint brush and
apply wax.apply wax.
– 1st layer acts as1st layer acts as
– in between 2nd layer &in between 2nd layer &
1st there is air trapped,1st there is air trapped,
adding to insulatingadding to insulating
AnalgesicAnalgesic Open woundsOpen wounds
Decrease muscle spasmDecrease muscle spasm Defective ThermalDefective Thermal
Soft and pliable-skin /Soft and pliable-skin /
Convection – HeatConvection – Heat
Heat LampsHeat Lamps
– An easy way to warmAn easy way to warm
superficial tissuessuperficial tissues
– 250-watt bulb, 40 to 50250-watt bulb, 40 to 50
cm from the patientcm from the patient
– Whirlpool baths & Hubbard tanksWhirlpool baths & Hubbard tanks
– Pumps agitate water and provide convectivePumps agitate water and provide convective
heating, massage, and gentle debridementheating, massage, and gentle debridement
– Temps: 33Temps: 33oo
C to 36C to 36oo
C are considered neutralC are considered neutral
– Hubbard tank temps limited to 39Hubbard tank temps limited to 39oo
– Single extremity treatments can be moreSingle extremity treatments can be more
rigorous and in a healthy individualrigorous and in a healthy individual
temperatures from 43temperatures from 43oo
C to 46C to 46oo
C are possibleC are possible
Buoyancy allows aerobic exercise, rangeBuoyancy allows aerobic exercise, range
of motion and weight bearing that wouldof motion and weight bearing that would
not be possible out of waternot be possible out of water
Water can be soothing and relaxing andWater can be soothing and relaxing and
particularly helpful to an anxious andparticularly helpful to an anxious and
fearful patientfearful patient
Short-term individual treatment shouldShort-term individual treatment should
be followed by group classes andbe followed by group classes and
thereafter should be carried outthereafter should be carried out
Therapy in warm water isTherapy in warm water is
beneficial for diagnoses suchbeneficial for diagnoses such
– Myofascial Pain SyndromeMyofascial Pain Syndrome
– Rheumatoid ArthritisRheumatoid Arthritis
Therapy in cool water isTherapy in cool water is
recommended for heatrecommended for heat
sensitive disorders such assensitive disorders such as
multiple sclerosismultiple sclerosis
Convection – ContrastConvection – Contrast
Alternating immersion in hot and coldAlternating immersion in hot and cold
water to produce a vascular exercisewater to produce a vascular exercise
through active vasodilatation andthrough active vasodilatation and
vasoconstriction of the blood vesselsvasoconstriction of the blood vessels
Hot/cold ratios are used depending onHot/cold ratios are used depending on
patient tolerance; typically ratio is 4:1patient tolerance; typically ratio is 4:1
Thought to be effective due to reflexThought to be effective due to reflex
hyperemia produced by the alternatinghyperemia produced by the alternating
exposure to heat (43exposure to heat (43oo
C) and cold (16C) and cold (16oo
CONTRAST BATHCONTRAST BATH
-- Both heat & cold appear useful inBoth heat & cold appear useful in
relieving pain & spasm.relieving pain & spasm.
-- Spasticity reduced by cooling.Spasticity reduced by cooling.
-- Recent trauma benefits of coolingRecent trauma benefits of cooling
later same injury benefits by heat.later same injury benefits by heat.
-- Joint stiffness is reduced by heat.Joint stiffness is reduced by heat.
-- Oedema is reduced by ice.Oedema is reduced by ice.
Deep Heat ModalitiesDeep Heat Modalities
Short wave DiathermyShort wave Diathermy
Laser (non-surgical)Laser (non-surgical)
Arbitrarily defined as sound at frequencies aboveArbitrarily defined as sound at frequencies above
the limits of human hearing (i.e., more thanthe limits of human hearing (i.e., more than
20,000 Hz)20,000 Hz)
Ultrasound machines use ceramic and quartzUltrasound machines use ceramic and quartz
piezoelectric crystals to produce ultrasonicpiezoelectric crystals to produce ultrasonic
Intensities of 0.5-2.0 Watts/cmIntensities of 0.5-2.0 Watts/cm22
are usedare used
Frequencies of 1 MHz (deep) or 3 MHzFrequencies of 1 MHz (deep) or 3 MHz
TheThe Pizoelectric crystalsPizoelectric crystals change the shape &change the shape &
frequency & so drive metal plate to & fro atfrequency & so drive metal plate to & fro at
same high frequency, producing a train ofsame high frequency, producing a train of
compression waves in the medium of contact.compression waves in the medium of contact.
-- 60-80% Ultrasound energy is lost60-80% Ultrasound energy is lost
from beam.from beam.
-- Less the protein content of tissue,Less the protein content of tissue,
less is the absorption of UltraSound.less is the absorption of UltraSound.
USED FOR MUSCULOSKELETALUSED FOR MUSCULOSKELETAL
MUSCLE SPASM, JOINT STIFNESS,MUSCLE SPASM, JOINT STIFNESS,
FOR SOFT TISSUE INJURIES.FOR SOFT TISSUE INJURIES.
It uses a generator to turn UltrasoundIt uses a generator to turn Ultrasound
in short burstsin short bursts
this reduces the time,& intensitythis reduces the time,& intensity
hence the amount of energy availablehence the amount of energy available
in each pulse is high for mechanicalin each pulse is high for mechanical
than thermal effect.than thermal effect.
PRINCIPLES OFPRINCIPLES OF
WATER BATH APPLICATIONWATER BATH APPLICATION
----WHEN PARTS ARE IRREGULAR,WHEN PARTS ARE IRREGULAR,
IMMERSIBLE IN BATHIMMERSIBLE IN BATH..
PRINCIPLES OFPRINCIPLES OF
DIRECT CONTACTDIRECT CONTACT
USING K-Y JELLY, CREAMSUSING K-Y JELLY, CREAMS
HELPS IN HIGH TRANSMISSIVITY OFHELPS IN HIGH TRANSMISSIVITY OF
THIXOTROPIC SUBSTANCES- WHICHTHIXOTROPIC SUBSTANCES- WHICH
BECOME FLUID ON VIBRATIONBECOME FLUID ON VIBRATION
((B) Non ThermalB) Non Thermal --
a)a) CavitationCavitation :-:- formation of tiny gasformation of tiny gas
bubbles in tissuebubbles in tissue
Stable Transient or CollapseStable Transient or Collapse
for streamingfor streaming damaging.damaging.
Use pulse to reduce cavitationsUse pulse to reduce cavitations
– b)b) Acoustic StreamingAcoustic Streaming :-:-
Steady circulatory flow due to radiationSteady circulatory flow due to radiation
Effects on RepairEffects on Repair
(A)(A)AcuteAcute - Decrease Ca++ diffusion- Decrease Ca++ diffusion
increasing production & release ofincreasing production & release of
wound healing factor.wound healing factor.
(B)(B)ProliferativeProliferative - Promote Collagen- Promote Collagen
Synthesis of greater Tensile strength.Synthesis of greater Tensile strength.
(C)(C)RemodellingRemodelling - Improves- Improves
extensibility of mature collagen.extensibility of mature collagen.
THERAPUETIC EFFECTS OFTHERAPUETIC EFFECTS OF
ACUTE AND SUBACUTE
SCAR- EXTENSIBLITY INCREASED
PAIN RELIEF- IN HERPES ZOSTER
HEALING OF VARICOSE ULCERS
IDENTIFY STRESS FRACTURE – BY
PAIN INCREASE ON APPLICATION .
Precautions and contraindicationsPrecautions and contraindications
– fluid-filled cavitiesfluid-filled cavities
– joint replacements containingjoint replacements containing
– open epiphyseal platesopen epiphyseal plates
– the eyes, brain & testicles should be avoidedthe eyes, brain & testicles should be avoided
– should not be used over a pregnant uterusshould not be used over a pregnant uterus
Pain is used as an endpoint to avoidPain is used as an endpoint to avoid
tissue destructiontissue destruction
A process in which a continuous directA process in which a continuous direct
current is used to drive electricallycurrent is used to drive electrically
charged molecules or atoms (ions) intocharged molecules or atoms (ions) into
the tissuesthe tissues
Iontophoresis delivers high concentratesIontophoresis delivers high concentrates
of polar substances, or medicinalof polar substances, or medicinal
agents, into the skin, but to questionableagents, into the skin, but to questionable
The amount of medicine transferredThe amount of medicine transferred
through the skin is directly related to thethrough the skin is directly related to the
duration of treatment, current density,duration of treatment, current density,
and concentration of the ions in theand concentration of the ions in the
musculoskeletal inflammatorymusculoskeletal inflammatory
conditions, such as bursitis, andconditions, such as bursitis, and
pain reliefpain relief
Common medicationsCommon medications includeinclude
dexamethasone, lidocaine anddexamethasone, lidocaine and
impaired skin sensation,impaired skin sensation,
broken skin or bruises, and metalbroken skin or bruises, and metal
in or near the treatment areain or near the treatment area
Short Wave DiathermyShort Wave Diathermy
Radio waves are used toRadio waves are used to
heat superficial tissue byheat superficial tissue by
conversion with inductionconversion with induction
coil applicators orcoil applicators or
condenser padscondenser pads
Most commonly usedMost commonly used
frequency: 27.12 MHzfrequency: 27.12 MHz
Treatment time: 20-30Treatment time: 20-30
Electromagnetic Fields -Electromagnetic Fields -
The most efficient conversionThe most efficient conversion
of electric energy to heat due toof electric energy to heat due to
to & fro motions of ion, thusto & fro motions of ion, thus
producing high frequencyproducing high frequency
-Heat is produced by dipole-Heat is produced by dipole
rotation of polar moleculesrotation of polar molecules
back & forth.back & forth.
-There is conversion by-There is conversion by
molecular distortion due tomolecular distortion due to
electron clouding.electron clouding.
Physiological EffectPhysiological Effect
– The therapeutic effects of continuousThe therapeutic effects of continuous
SWD given at an intensity that causeSWD given at an intensity that cause
– -- Increase temp. of both skin & muscles &Increase temp. of both skin & muscles &
intra-articular by (3-6.6 deg.C)intra-articular by (3-6.6 deg.C)
– (1 deg. Less for Intra articular)(1 deg. Less for Intra articular)
– Cable or coil, wrapped round the partCable or coil, wrapped round the part
into flat spiral.into flat spiral.
– Metal plates positioned byMetal plates positioned by
supporting arms.supporting arms.
– (A) Electrodes placed 2-4 cms skin -(A) Electrodes placed 2-4 cms skin -
Electrode distance.Electrode distance.
– (B) Electrodes placed parallel to the(B) Electrodes placed parallel to the
skin surface.skin surface.
– (C) Electrodes placed size should be(C) Electrodes placed size should be
enough the achieve uniform electroenough the achieve uniform electro
Pulsed ShortwavePulsed Shortwave
-27-12 MHz frequency use for-27-12 MHz frequency use for
– -tissue Trauma.-tissue Trauma.
– -Post op periods-Post op periods
– -Traumatic Synovitis-Traumatic Synovitis
– -Accelerates tissue healing.-Accelerates tissue healing.
– -Accelerates nerve regeneration.-Accelerates nerve regeneration.
– -Drum type electrodes - Place closed to skin or as-Drum type electrodes - Place closed to skin or as
– -Conventional S.W.-Conventional S.W.
– Different pulse width, & repetitions are prescribed.Different pulse width, & repetitions are prescribed.
– Wilson -Wilson - 1hr/day-- 600 pulse/s. --38 w.1hr/day-- 600 pulse/s. --38 w.
– Pasila -Pasila - 20 mins.—600 pul/s --3820 mins.—600 pul/s --38
ContraindicationsContraindications ----Rarely anyRarely any
complication so safe except in -complication so safe except in -
Pacemakers / TBPacemakers / TB
Frequency -2450 MHzFrequency -2450 MHz 915915
Wavelength -12.245 cms.Wavelength -12.245 cms. 32.7932.79
High frequency oscillating currentsHigh frequency oscillating currents
produced by Magnetronsproduced by Magnetrons
which produce radio frequencies, which arewhich produce radio frequencies, which are
radiated via antennae or a transistor.radiated via antennae or a transistor.
this is fed through a emitter thus a microwave isthis is fed through a emitter thus a microwave is
These waves are absorbed in tissues toThese waves are absorbed in tissues to
provoke ionic movements leading toprovoke ionic movements leading to
The heating is proportional to absorbedThe heating is proportional to absorbed
Heating greater at surface than in withinHeating greater at surface than in within
– so use contact emittersso use contact emitters
1/2 value depth of penetration - 3 cms.1/2 value depth of penetration - 3 cms.
Most radiation lost through the skin.Most radiation lost through the skin.
Precaution over bonyPrecaution over bony
prominences due toprominences due to
reflection of the wave at thereflection of the wave at the
bone interface maybone interface may
produce increased heatproduce increased heat
absorption in the tissuesabsorption in the tissues
superficial to the bone.superficial to the bone.
Laser TherapyLaser Therapy
Light amplificationLight amplification
by the stimulatedby the stimulated
emission ofemission of
Ruby 694 Red light
Helium 632 Red light
A -A - Immediate perception of cold & painImmediate perception of cold & pain ..
– Levis's Hunting LawLevis's Hunting Law - There is initial- There is initial
vasoconstrictionvasoconstriction lasting forlasting for 15 mins15 mins followedfollowed
byby vasodilatationvasodilatation ofof 15 mins15 mins again to beagain to be
followed by vasoconstriction. This is calledfollowed by vasoconstriction. This is called
Hunting ReactionHunting Reaction ..
– This is to prevent ischemic effect ofThis is to prevent ischemic effect of
prolonged cold.prolonged cold.
Constriction recurs due to washingConstriction recurs due to washing
away of the metabolitesaway of the metabolites
The cause ofThe cause of vasodilatationvasodilatation is stillis still
not elucidated,not elucidated,
–(a) May be due to substance 'H'(a) May be due to substance 'H'
(Levers 1936).(Levers 1936).
–(b) Muscle activity reduces due to(b) Muscle activity reduces due to
fall of temperature & smoothfall of temperature & smooth
muscles flattenmuscles flatten..
Lowering matabolic rateLowering matabolic rate ––
–Vant 'Hoff’s LawVant 'Hoff’s Law ..
-- reduced O2 uptake.reduced O2 uptake.
-- reduced production ofreduced production of
-- Slowing healing.Slowing healing.
Subsequent reduced flow in musclesSubsequent reduced flow in muscles
Decreased nerve conduction &Decreased nerve conduction &
decrease in paindecrease in pain..
EFFECTSEFFECTS (A)(A) Recent injuriesRecent injuries - PRICE- PRICE
Initially for 2 hrs, as this reduces Metabolic rate &Initially for 2 hrs, as this reduces Metabolic rate &
secondary cell necrosis & release of lysins. Thussecondary cell necrosis & release of lysins. Thus
decreasesdecreases local oedema. (Mclean 1989).local oedema. (Mclean 1989).
– -This should not be given beyond 25 mins. to 30-This should not be given beyond 25 mins. to 30
mins. or else leads to nerve damage.mins. or else leads to nerve damage.
– -Should not be given beyond 48 hrs as the healing-Should not be given beyond 48 hrs as the healing
response is delayed as neo-epithehalization isresponse is delayed as neo-epithehalization is
Methods of Applying IceMethods of Applying Ice
((A)A) Local immersionLocal immersion
– Temperature around 16-18 deg.C. for 15-20Temperature around 16-18 deg.C. for 15-20
– Water from Tap + Flaked Ice.Water from Tap + Flaked Ice.
(B)(B) Evaporating SpraysEvaporating Sprays --
– -- Fluroisomethane -Fluroisomethane -
– Nozzle 45 cm from skinNozzle 45 cm from skin
– 5 sec application.5 sec application.
Cold PacksCold Packs
– IceIce -- Terry Towels held inTerry Towels held in
plastic sheet.plastic sheet.
apply some oil onapply some oil on
skin to reduce run off of waterskin to reduce run off of water
from skin (Icefrom skin (Ice
– Ice TowelsIce Towels - Replaced every- Replaced every
2-3 mins for total 20 mins.2-3 mins for total 20 mins.
For muscle & allowsFor muscle & allows
movement & exercises to bemovement & exercises to be
performed with cold.performed with cold.
– Ice massageIce massage
– Ice cubesIce cubes in paper or clothin paper or cloth forfor
Pain reliefPain relief
Neuro facilitation.Neuro facilitation.
Contraindications of IceContraindications of Ice
Cold SensitivityCold Sensitivity
Cold urticariaCold urticaria
Cardiac diseaseCardiac disease
Arterial B.P. if High -Arterial B.P. if High -
Emotion & Psychology.Emotion & Psychology.
Cold IndicationsCold Indications
Musculoskeletal traumaMusculoskeletal trauma
Edema/hemorrhage control &Edema/hemorrhage control &
Muscle spasmMuscle spasm
Adjunct in muscle re-educationAdjunct in muscle re-education
Reduction in metabolic activityReduction in metabolic activity
Transcutaneous electrical stimulation andTranscutaneous electrical stimulation and
Interferential therapyInterferential therapy
are the two most common forms used forare the two most common forms used for
pain modulationpain modulation
By varying parameters such as frequency,By varying parameters such as frequency,
waveform, pulse duration, electrodewaveform, pulse duration, electrode
configuration, and duration of stimulus, aconfiguration, and duration of stimulus, a
range of therapeutic effects is possiblerange of therapeutic effects is possible
Both types of electrotherapy are thought toBoth types of electrotherapy are thought to
have similar actions through segmentalhave similar actions through segmental
inhibition or activation of descending pain-inhibition or activation of descending pain-
inhibitory systemsinhibitory systems
myocardial disease,myocardial disease,
superficial metal implants andsuperficial metal implants and
over pharyngeal or laryngeal musclesover pharyngeal or laryngeal muscles
Electrical StimulationElectrical Stimulation
– Pain ModulationPain Modulation: TENS, Interferential, H-: TENS, Interferential, H-
– Muscle SpasmMuscle Spasm: Produces muscle fatigue: Produces muscle fatigue
& relaxation& relaxation
– SpasticitySpasticity: Fatigue of the agonist,: Fatigue of the agonist,
reciprocal inhibitionreciprocal inhibition
– Impaired Range of MotionImpaired Range of Motion: Used for: Used for
mechanical stretchingmechanical stretching
– Disuse Atrophy & StrengtheningDisuse Atrophy & Strengthening: Does: Does
not strengthen normal muscles morenot strengthen normal muscles more
rapidly than traditional approachesrapidly than traditional approaches
Electrical StimulationElectrical Stimulation
Indications (contd:)Indications (contd:)
– Wound healing & Edema ReductionWound healing & Edema Reduction
For immobilized and injured muscles,For immobilized and injured muscles,
electrical stimulation maintains isometricelectrical stimulation maintains isometric
and when there is splinting and pain, itand when there is splinting and pain, it
may supplement volitional movementsmay supplement volitional movements
and speed of recoveryand speed of recovery
Transcutaneous ElectricalTranscutaneous Electrical
Nerve Stimulation (TENS)Nerve Stimulation (TENS)
produces analgesia in a wide range ofproduces analgesia in a wide range of
medical conditionsmedical conditions
TENS units are non-invasive, easy toTENS units are non-invasive, easy to
use, safe and inexpensiveuse, safe and inexpensive
TENS units are small simple devicesTENS units are small simple devices
consisting of a power sourceconsisting of a power source
(rechargeable battery), one or more(rechargeable battery), one or more
signal generators and a set ofsignal generators and a set of
Transcutaneous ElectricalTranscutaneous Electrical
Nerve Stimulation (TENS)Nerve Stimulation (TENS)
High frequency (or conventional)High frequency (or conventional)
TENSTENS typically results in immediatetypically results in immediate
pain relief that lasts while the stimuluspain relief that lasts while the stimulus
is on, but usually abates when theis on, but usually abates when the
stimulation stopsstimulation stops
In acupuncture-like (or low frequency)In acupuncture-like (or low frequency)
the high stimulus intensity is painfulthe high stimulus intensity is painful
and many patients cannot tolerate itand many patients cannot tolerate it
but the benefit is longer lasting painbut the benefit is longer lasting pain
Interferential TherapyInterferential Therapy
It is based on theIt is based on the
principle that theprinciple that the
interference betweeninterference between
two medium frequencytwo medium frequency
currents produces a lowcurrents produces a low
frequency current thatfrequency current that
will be induced in thewill be induced in the
deep tissuesdeep tissues
Allows effective stimulation of
is predominantly a cutaneous
or superficial stimulus
Interferential treatments are
usually provided directly by a
Treatment involve the use of
two pairs of electrodes and
most units allow variation in
waveform, frequency and
amplitude or intensity
Used in a self-administered
Electrode placement and
remain more art than
H-Wave TherapyH-Wave Therapy
A powered muscle stimulator that atA powered muscle stimulator that at
low frequency produces comfortable,low frequency produces comfortable,
rhythmic, non-fatiguing musclerhythmic, non-fatiguing muscle
contractions that increase local bloodcontractions that increase local blood
flow and lymphatic drainageflow and lymphatic drainage
At high frequency, H-Wave therapy isAt high frequency, H-Wave therapy is
purported to break the pain cyclepurported to break the pain cycle
similar to conventional TENSsimilar to conventional TENS
SCENAR THERAPYSCENAR THERAPY
This treatment method uses the SCENAR (Self Controlled Energo-NeuroThis treatment method uses the SCENAR (Self Controlled Energo-Neuro
Adaptive Regulator) deviceAdaptive Regulator) device
SCENAR helps the body heal itself through locating problem areas andSCENAR helps the body heal itself through locating problem areas and
subsequently re-activating the body’s self-regulatory mechanism whichsubsequently re-activating the body’s self-regulatory mechanism which
was destroyed by an accident or diseasewas destroyed by an accident or disease
Advantages of SCENAR therapy:Advantages of SCENAR therapy:
One of the best electrotherapy tools availableOne of the best electrotherapy tools available
No negative side effectsNo negative side effects
Very few contraindicationsVery few contraindications
Totally safeTotally safe
No medications requiredNo medications required
Re-actives the body’s self-regulatory mechanismRe-actives the body’s self-regulatory mechanism
Effects felt after just a few sessionsEffects felt after just a few sessions
Functional ElectricalFunctional Electrical
electrical stimulation (NMESelectrical stimulation (NMES
– The first commercially available FESThe first commercially available FES
device treated foot drop bydevice treated foot drop by
stimulating the peroneal nervestimulating the peroneal nerve
during gaitduring gait
– Involve the use of NeuroprosthesesInvolve the use of Neuroprostheses
– In the upper motor neuron spinalIn the upper motor neuron spinal
cord injured patient,cord injured patient,
– May increase strength,May increase strength,
– Normalize blood pressure,Normalize blood pressure,
– Allow for limited ambulation andAllow for limited ambulation and
lead to a sense of well-beinglead to a sense of well-being
– Also used for shoulder subluxationAlso used for shoulder subluxation
and dorsiflexionand dorsiflexion
– Assist in gait training.Assist in gait training.