guideline in physiotherapy mod ali ties

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3PARAFFIN THERAPYCONTRAINDICATIONS

Paraffin should not be used over open wounds, abrasions, acute skin disorders, or wherethere is diminished sensation.METHODS OF PARAFFIN THERAPY APPLICATIONS

When constant heat is required for a long period, two or three hours, the application of theparaffin boot, properly insulated, gives excellent results either by direct or reflexapplication.

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 the thickness 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 theimmersion method.

Dip the part in and out of the bath quickly so that a thin coating of paraffin congeals onthe

skin.

Repeat several times until the glove of paraffin is of sufficient thickness to allow the parttoremain 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 whichcannot beimmersed in the paraffin bath conveniently, paint the surface rapidly with a soft paintbrush.

When first applied, the paraffin will feel very warm, keep brushing until a thick coatingcovers 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 ULTRASOUND THERAPEUTIC ULTRASOUND

Therapeutic ultrasound is that which is used for therapeutic (rather than diagnostic)purposesand 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 timeconsumingand 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 the

patient’s tissues will produce heat. Because US is transmitted by skin and fat, the heat can be directed to the deepermuscle layers

where it is needed.4PULSED ULTRASOUND

The energy is on for a short period of time, then off; alternating so that the "on time" ordutycycle is approximately5-50% of the total time.

The "off time" allow the tissues to disperse the heat created, thereby minimizing oreliminating the thermal effect.PULSED ULTRASOUND

With the 5% duty cycle, there is virtually no heating

With the50% 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

contract

to 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

5CONTRAINDICATIONS

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

the

crystal 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, oruncomfortable, thewattage should be reduced to a tolerable level

Treat for the desired timeUS 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 shouldproduceonly 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 couldcause burns.

Pins, keys, jewelry, watches and buckles. TEN MAJOR EFFECTS

Thermal

Stimulation

Increased Blood flow

Hypotonicity6

Increase in visceral circulation

Endocrine changes

Oxidation

Phagocytosis

Detoxification

Increase in capillary pressureDOSAGE 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 distinct sensation of “velvety" warmth.

Dosage Level II

For patients who have pain, the temperature is increased to a point just below the levelof 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 theshorter thetreatment duration.ELECTRODE POSITIONS

The three common electrode positions are:

Transverse Longitudinal



CO-planar

GENERAL RULE

The 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 isplacedfrom the patient and the shape of the reflector.

The power output of the microwave unit is adjusted in accordance with the size andshape of

the body part treated.

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

7

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 constituentstohigh frequency current, and a specific temperature distribution results within bodytissues.

Contact is not necessary, and smaller confinedareas 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 visceraMICROWAVE DIATHERMY PRECAUTIONS

If vigorous heating effects are desired, the applicator must be brought close to thesurface 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 typethat isused. TREATMENT DURATION Treatment duration exceeding 2O minutes is inadvisable

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

each other The major problems with the standard low frequency currents lie with the resistance

offered by the skin and the relatively long pulse duration. 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 beapplied 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 toproduce agiven 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,

the

higher frequencies will mean shorter pulse durations and this will lead to a more

comfortable 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 suchaway that there is a difference in frequency between the two currents, then a rather

interesting

9

If the patient's condition is unchanged after one or two treatments, then the situationneedsre-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 infrequency/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 healingINTERFERENTIAL THERAPY

I.F. can and should be combined with other modalities.

Combining treatments implies giving two different but complimentary treatments atdifferenttimes 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 tissues

Separate joint surfaces

Separate bony fragments

DISTRACTION

A form of dislocation in which joint surfaces have been separated without rupture of thebinding ligaments and without displacementINVERSION

Turning upside-down or other reversal of the normal relation of a part

TYPES 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 theslight force used.

This type of traction is generally used to align and stabilize adjacent body parts whenthereare fractures and/or dislocations.CONTINUOUS TRACTION

An example of continuous spinal traction is the halo type device used following a fractureof 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 thanthat10

seen with continuous traction.



Static traction is used mostly for WD herniations and may be effectively applied in boththecervical and lumbar spine

Sustained traction is probably most helpful in the early phases of treatment when thereissignificant 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,manypatients find these devices helpfulINTERMITTENT TRACTION

Utilizes a mechanical traction device that alternately applies traction and allowsrelaxationfor 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 root

compression, 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 to60seconds.

This is referred to as the “hold time"

The moderate force is then reduced to a lesser traction force that is applied for a shorterperiod from 10 to 20 seconds - the “rest period"

The traction device alternates between the two different forces for the treatmentduration,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 20secondsrest).

MANUAL TRACTION

Traction applied manually by the doctor.

The traction forces usually are applied for a few seconds at a time and, typically, in arhythmic nature.

Although manual traction may often be beneficial by itself, it is often employed prior toothermechanical 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 moreaggressive forms of traction Manual traction may often provide relief for patients with cervical stiffness, discproblems,

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.

11POSITIONAL TRACTION

Involves placing the patient in a particular position to increase motion in a specificdirectionat a specific segment of the spine. Pillows, blocks, and sandbags may be used to accentuate the position and increasetraction.

These techniques are incorporated into many of the procedures used by McKenzie in hisextension 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 to90degrees.

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 proneposition

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 motionsegment 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 andchronic

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 discprotrusion that

3 responded to this treatment:

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

TRACTION Involves the application of mechanical rollers that move up and down vertically asthey track

longitudinally along the paraspinal structures. The tension, speed, and amount of travel of the rollers are modified to patientcomfort.

As they move, the rollers lift and separate the vertebral units and exert a mildtractioning effect.

This type of "traction" is more appropriately termed a form of Passive mobility ratherthan

traction. In addition to the application of the mechanical forces, many of the intersegmentaltraction

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.12 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 isoverused in

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

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 sufficienttraction.

Ligamentous tautening: The anterior and posterior longitudinal ligaments arestretched,

causing further centripetal force on the disc.

Relaxation of the musculature: Cyriax reported EMG silence 3 minutes after continuoustraction. 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's



condition 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-evaluatedPRECAUTIONS 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, withprogressivelyincreasing force and time as the patient condition warrants. Following the application of traction, a patient should be allowed a short rest periodbefore

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

13to have the relief disappear at tile end of tile treatment session. It is suggested that the patient should be gradually returned to the upright positionto maintain

relief.CONTRAINDICATIONS

Structural disease secondary to tumor or infection Vascular compromise, hypertension, atherosclerosis, phlebitis, angina, and a historyof 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 flexedto25 to

30 degrees except for the atlantoocccipital and atlantoaxial joints, which should betractionedwith 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

a

structural change at the spinal segment Much less force is required for the cervical region

CERVICAL TRACTION PROPER POUNDAGE Forces of25 to45 pounds are necessary to produce measurable changes in the

posterior

structures. The maximal force should not exceed 45 pounds

Forces of 120 pounds have been shown to be necessary to cause a disc rupture at theC5-C6

levelCERVICAL TRACTION PROPER POUNDAGE It has been shown that a traction force of only 10 pounds will produce a separation of the

atlantoaxial joints; consequently less force is necessary when the upper cervical spine isthetarget 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 TRACTION14PATIENT 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 orextended

position, the traction will exert its maximal effect on the anterior intervertebral structuressuchas the IVD. When the objective is separation of the interbody joints, the patient should bepositioned in



such a neutral or extended position. If the head is maintained in a flexed, forward- bent position, the traction will exert itsmaximal

effect on the posterior structures, such as the facet articulations and the WF. When the objective is separation of the posterior articulations, the patient should bepositioned

with the neck in a flexed position. The greater angle of flexion, the lower in the cervical spine is the area affected by thetraction

force. The position of the head and neck can be adjusted to ensure that separation occurs atthe

desired location. This is most easily accomplished by communicating with the patient during the initial

application. 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 changingthe

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 TRACTION

TREATMENT FREQUENCY

As with other forms of therapy, spinal traction has a specific physiologic effect andshould beused when that effect is desired.

The application of sustained and intermittent traction is usually only warranted forrelativelyshort periods of time. Daily treatment is suggested for the first 3 days, followed by three times weekly for 2to 3

weeks

If traction is to be helpful, some relief should be seen within the first three to fivetreatments. Unlike other forms of traction, intersegmental traction may be warranted on acontinuing basis

in some patients. It should not, however, serve as a substitute for stretching and flexibility exercises,nor should

it 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.

Traction node (sustained or intermittent) depends on both the disorder being treated and

on the

comfort of the patient.



Disc protrusions usually are treated more effectively with sustained traction or withlonger

hold-rest periods of intermittent traction (60 seconds hold, 20 seconds rest). Joint dysfunction and degenerative disc disease usually respond to shorter hold-restperiods of intermittent 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-poundincrements to a maximum of 125 pounds. The patient position, whether prone or supine, and the amount of flexion orextension 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 mustbe15 to 30 degrees To affect the lower lumbar segments (L3-

L

5);the angle of pull must be 30-50 degrees. Hypolordosis of the lumbar spine should be treated with an angle of pull from 15 -30

degrees. 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 possibilityof driving ions into the tissues called iontophoresis. A galvanic current is a unidirectional (monophasic) current flowing for an indefinite

duration. Low frequency alternating currents are utilized because of the continued need for

electrical stimulation of atrophied muscle, especially for patients with CNS lesions. Low frequency alternating current: a current in which the direction of electron flow

changes 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 varioussubstances

are 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



16EFFECTS

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 combination

therapy.

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

disperse



fluid. 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..for

muscle 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 is

achieved. Treatment duration depends on the effect desired and the integrity of the musclebeing

stimulatedLOW 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

17

TENS TENS should apply to any form of electrical stimulation that is applied via surface

electrodes. The term has been used for small portable stimulators that can be attached to thebelt or

clothing 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, and

cost 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 can

increase performance and shorten disability. Care must be taken to not allow the TENS to obliterate pain to the extent that thepatient

loses 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 the

conduction 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 contractionandmay cause soreness if used for longer periods. Electrodes should be removed every day or two to clean the skin and inspect thearea.

SOFT TISSUE MANIPULATIONCertain manipulations of the soft tissues of the body; these manipulations are mosteffectively

performed with the hands, and are administered for the purpose of producing effects onthenervous and muscular systems and the local and general circulation of the blood andlymph.18EFFECTS



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 heavierpressure as

tolerated and terminate with light pressure.Petrissage - Kneading or rolling motion, strokes are either in a centripetal direction or

transverse to the muscle fibers

Rolfing - is a deep massage that strives to separate the fascia between muscles Friction- is used

to break up superficial and/or deep adhesions of muscle or other soft tissues. No lotion isusedand 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 tendinitisor

tenosynovitis. It is performed perpendicular to the tendon sheath, causing the tendon toseparatefrom the sheath and slide through it more easily. Tapotement - includes tapping, slapping, cupping motions. It is useful for increasingcirculation

to an area and for postural drainage to increase the release of abnormal secretions from

the lungs.



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