PHYSIOLOGICAL THERAPEUTICS

CRYOTHERAPY
 DEFINITION: The therapeutic use of cold
 Ice is inexpensive, readily available to both practitioner and patient and can be used in a
variety of forms.
 Has relatively few contraindications, and can be very effective in the treatment of pain,
edema, spasm and inflammation, especially in the first 24 to 48 hrs after an injury.
 In many instances in which heat is considered the modality of choice for its "soothing"
qualities, cooling would probably afford longer lasting and more complete results, and
therefore should be considered more often.
CRYOTHERAPY
EFFECTS
 Anesthesia
 Analgesia
 Reduction of edema
 Reduced Muscle spasm
 Reduced Spasticity
 Reduced manual Dexterity
CRYOTHERAPY
INDICATIONS
 Acute sprains and strains
 Acute inflammatory processes
 Acute trauma
 Acute and Chronic muscle spasm
 Spasticity associated with neurological disorders
CRYOTHERAPY CONTRAINDICATIONS
 Caution with geriatrics, infants, and cachexics
 Individuals with psychological aversion to cod
 Hypersensitive individuals
CRYOTHERAPY APPLICATIONS
 Ice packs
 Ice massage
 Cold compresses
 Extremity baths
HOT MOIST HEAT
 This is the most commonly used heat modality
 Transfers heat to the patient primarily by conduction
 Most common cause for malpractice in physiotherapy today is burns, and they are most
frequently caused by hot packs.
 The moist packs should be totally submerged in water to a minimum of 30 to 40 minutes
between use to regain their correct temperature (150 -180 degrees F)
 Hot moist heat can be used in conjunction with other therapies.
 Moist heat vs. dry heat: dry heat causes stiffness.

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EFFECTS
 Increased circulation to the area being treated.
 Relaxation
 Decreased pain
 Decreased muscle spasm
 Generalized effect (PR, BP)
INDICATIONS
 Non-acute sprains/strains
 Sinus conditions
 Menstrual cramps
 Arthritis, tendinitis, bursitis, capsulitis
 Decreasing pain before exercise
CONTRAINDICATIONS
 Acute conditions
 Patients on anti-coagulants
 Psychological hysteria or drug dependent
 Dermatological conditions
 Diabetic or alcoholic neuropathy
 Severe vascular occlusions
 Always have patient inform you if hot pack is too hot.
 Do not use steam packs over cuts or abrasions
 Do not use heat packs in conjunction with skin balm or liniments.
 Do not use toweling that is moist from use.

PARAFFIN THERAPY
 Paraffin is essentially hot wax that consists of seven parts paraffin and one part mineral oil
 Some authorities recommend a 4:1 ratio
 Purpose of the mineral oil is to lower the melting temperature of the wax.
 Without the mineral oil, the melted wax would be far too hot for therapeutic purposes.
 Because the paraffin-oil mixture has a low specific heat, it can be applied directly to the skin
if the circulation to the part is normal.
 Before the application, the part to be treated should be cleaned and dried, the thermesthetic
sense should be ascertained to be normal, and all jewelry on the part to be treated should be
removed.
 Temperature of the melted wax should be checked with a thermometer, but a finger pretest
by the doctor/therapist will even more assure the apprehensive patient that the mixture is not
too hot.
 Paraffin offers the same effects and advantages as any other form of superficial heat that is
transferred by conduction.

PARAFFIN THERAPY INDICATIONS

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

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PARAFFIN THERAPY
CONTRAINDICATIONS
 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 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 and
insulate 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 ULTRASOUND
THERAPEUTIC ULTRASOUND
 Therapeutic ultrasound is that which is used for therapeutic (rather than diagnostic) purposes
and is usually produced at 1 megacycle or 1 million cycles per second
 US has replaced diathermy for many types of conditions because it is less time consuming
and penetrates tissues well.
 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 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 contract
to pull the edges together.
 Remodeling--- increase tensile strength of scar by affecting the directions, strength and
elasticity of fibres.
ULTRASOUND EFFECTS
 Tissue temperature rise
 Decreased nerve conduction velocity
 Increased circulation
 Increased tendon extensibility
 Reduced adhesion formation
 Decreased pain
 Muscle relaxation
ULTRASOUND 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
 Adhesions
PRECAUTIONS
 Over heating of the cutaneous tissues may occur if
 the intensity is set too high
 Transducer is moved too slowly
 Transducer surface is not kept parallel to the skin surface
PRECAUTIONS
 Over heating of the periosteum may occur if:
~ The transducer is held too close to the bone
~ The intensity is set too high
~ The transducer is moved too slowly

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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 maker
APPLICATION 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, 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 distinct
sensation 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 warmth
GENERAL 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 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
 Prostatitis
CONTRAINDICATIONS
 Over pregnant uterus
 Over wet skin
 Patients with pacemaker
 Peptic ulcers
 Rheumatoid
 Malignancy

MICROWAVE DIATHERMY
 The configuration of a pattern is determined and controlled by the distance that it is placed
from the patient and the shape of the reflector.
 The power output of the microwave unit is adjusted in accordance with the size and shape of
the body part treated.
 The 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 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 very
high 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, 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, the
frequency 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 between
0.1 and 200 Hz.
 If however, two medium frequency sine waves are applied to the skin and tissues in such a
way that there is a difference in frequency between the two currents, 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 two
frequencies.
 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 needs
re-assessing.
 Assuming that the machine is working correctly and is applied properly, then poor results
should 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 tissues
 Separate joint surfaces
 Separate bony fragments
DISTRACTION
 A form of dislocation in which joint surfaces have been separated without rupture of the
binding ligaments and without displacement
INVERSION
 Turning upside-down or other reversal of the normal relation of a part
TYPES OF TRACTION
CONTINUOUS TRACTION
 This particular form involves lightweight applied for prolonged periods of time.
 It 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 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 to 60
seconds.
 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 90
degrees.
 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 sacrum
inferiority.
 Cox, using the flexion-distraction technique, found in 43 cases of medial disc protrusion that
3 responded to this treatment:
 In 57 cases of lateral disc protrusion, 55 responded to this treatment, alleviating the need for
surgery.

INTERSEGMENTAL
TRACTION
 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 than
traction.
 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'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 until
both 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 progressively
increasing force and time as the patient condition warrants.
 Following the application of traction, a patient should be allowed a short rest period before
resuming 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 to
30 degrees except for the atlantoocccipital and atlantoaxial joints, which should be tractioned
with 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 of 25 to 45 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 the C5-C6
level

CERVICAL TRACTION PROPER POUNDAGE

 It has been shown that a traction force of only 10 pounds will produce a separation of the
atlantoaxial joints; consequently less force is necessary when the upper cervical spine is the
target 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 such
as the IVD.
 When the objective is separation of the interbody joints, the patient should be positioned in
such a neutral or extended position.

 If the head is maintained in a flexed, forward- bent position, the traction will exert its maximal
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 be positioned
with the neck in a flexed position.
 The greater angle of flexion, the lower in the cervical spine is the area affected by the traction
force.
 The position of the head and neck can be adjusted to ensure that separation occurs at the
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 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 TRACTION
TREATMENT 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 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.

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 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 with longer
hold-rest periods of intermittent traction (60 seconds hold, 20 seconds rest).
 Joint dysfunction and degenerative disc disease usually respond to shorter hold-rest periods of
intermittent traction (30 seconds hold, 10 seconds rest)

LUMBAR TRACTION
PROPER 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 the
patient, 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 - 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 possibility of
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 various substances
are placed under their similar polarity electrode and driven through tissues by currents
usually 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 THERAPY

INDICATIONS
 Stimulation of weak and/or atrophied muscles
 Nonsystemic edema

LOW VOLTAGE THERAPY

CONTRAINDICATIONS
 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 muscle being
stimulated
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 surface
electrodes.
 The term has been used for small portable stimulators that can be attached to the belt or
clothing and used for various time periods for the relief of pain.
 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 innumerable
origins.
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 the patient
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 contraction and
may 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 MANIPULATION

Certain manipulations of the soft tissues of the body; these manipulations are most effectively
performed with the hands, and are administered for the purpose of producing effects on the
nervous and muscular systems and the local and general circulation of the blood and lymph.

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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 METHODS
Effleurage - stroking motion and begin with light pressure and progress to heavier pressure 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 is used
and 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 or
tenosynovitis. It is performed perpendicular to the tendon sheath, causing the tendon to separate
from the sheath and slide through it more easily.
Tapotement - includes tapping, slapping, cupping motions. It is useful for increasing circulation
to an area and for postural drainage to increase the release of abnormal secretions from the lungs.

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

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