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Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
Therapeutic exercises
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Therapeutic exercises

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Rehab Medicine …

Rehab Medicine
9/11/10

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  1. Physiatric Therapeutics
  2. Strength <ul><li>Strength: is the maximal force or torque that can be exerted by a muscle </li></ul>
  3. Factors that affect strength <ul><li>Determinants of strength </li></ul><ul><li>muscle’s ability to produce force is directly proportional to its x-sectional area </li></ul><ul><li>Parallel muscles: this corresponds to the x-section at the bulkiest part of the muscle </li></ul><ul><li>Pennate muscles: multiple x-sections are taken at R angles to each of the muscle fibers </li></ul>
  4. Factors that Affect Strength <ul><ul><li>> Pennate muscles are particularly adapted to force production, as many more muscle fibers are contained in pennate muscles & these fibers are shorter </li></ul></ul>
  5. Factors that Affect Strength <ul><li>Length-Tension relationship </li></ul><ul><li>> Maximum force of contraction occurs when a muscle is at its normal resting muscle length. </li></ul><ul><li>> If a muscle is stretched to much greater than resting length prior to contraction, resting tension develops, & active tension (the increase in tension during contraction) decreases </li></ul>
  6. Factors that Affect Strength <ul><li>Torque-Velocity relationship </li></ul><ul><li>Greatest amount of force is generated by a muscle during fast eccentric (lengthening) contractions </li></ul><ul><li>Least amount of force is produced during fast concentric (shortening) contractions </li></ul>
  7. <ul><li>Amount of force developed is summarized as: </li></ul><ul><li>Fast eccentric > slow eccentric > isometric > slow concentric > fast concentric </li></ul>
  8. Types of Muscle Contractions <ul><li>Static (Isometric) </li></ul><ul><ul><li>There is no movement of the load on which the muscle is acting </li></ul></ul><ul><ul><li>Internal reductions in muscle length with lengthening of elastic elements in series with the muscle </li></ul></ul><ul><li>Dynamic Contractions: </li></ul><ul><ul><li>Muscles may have lengthening or shortening fashions and the resistance may be applied in various manners </li></ul></ul>
  9. Types of Dynamic Muscle Contractions <ul><li>Concentric contractions: </li></ul><ul><ul><li>Muscle shortens as it contracts </li></ul></ul><ul><li>Eccentric contractions: </li></ul><ul><ul><li>Muscle lengthens as it contracts </li></ul></ul>
  10. Types of Dynamic Muscle Contractions <ul><li>Isotonic contractions: </li></ul><ul><ul><li>Tension of the muscle remains constant throughout the movement </li></ul></ul><ul><li>Isokinetic contractions: </li></ul><ul><ul><li>Movement is performed at a constant angular velocity but the load, resistive force or muscle tension vary </li></ul></ul>
  11. <ul><li>One-repetition maximum (RM) </li></ul><ul><li>The most weight that a person can lift one time </li></ul><ul><li>A commonly used term to express one’s current strength level </li></ul><ul><li>Current strength fitness level for a particular exercise can be expressed in terms of one’s multiple RM </li></ul>
  12. Programs to Increase Muscle Strength <ul><li>DeLorme technique </li></ul><ul><ul><li>Also known as progressive resistive exercise </li></ul></ul><ul><ul><li>Give maximum load of which the person can lift 10 times (10 RM) </li></ul></ul><ul><ul><li>The person then performs 3 sets of 10 repetitions for 5 days </li></ul></ul><ul><ul><li>First set, at 50% of given load, second set at 75% of given load, third set being the load itself 100% </li></ul></ul><ul><ul><li>5 th day, a new 10 rm is determined </li></ul></ul>
  13. Programs to Increase Muscle Strength <ul><li>Oxford Technique </li></ul><ul><ul><li>A reversal of the DeLorme’s technique </li></ul></ul><ul><ul><li>From 100% of 10 RM to 75% to 50% </li></ul></ul><ul><ul><li>Done because some persons cannot complete the 3 sets because of fatigue </li></ul></ul><ul><li>Regressive resistive exercise </li></ul>
  14. <ul><li>Critical to developing muscle strength is to exercise to the point of fatigue </li></ul><ul><li>Both high weight- low reps & low weight – high reps programs can be effective in achieving strength as long as exercise proceeds to muscle fatigue </li></ul><ul><li>Amount of mechanical work required by low weight – high reps exercise to reach muscle fatigue might be much greater than during higher weight exercise </li></ul>
  15. <ul><li>For better & faster results: increase the rate of contraction each session while lifting the same number of reps. </li></ul>
  16. Physical Agent Modalities
  17. Physiologic response to Heat Heat Decreased Blood viscosity Increased tissue temp Increased Local sweating Increased Phagocytosis Arteriolar Dilatation Increased Capillary Flow Increased Capillary Pressure Increased Capillary Permeability Increased Clearingof Metabolic waste Increased Supply of nutrients
  18. How Heat is being transferred <ul><li>Conduction-direct transfer between 2 bodies </li></ul><ul><li>Convection- uses movement of a medium to transport thermal energy </li></ul><ul><li>Radiation-refers to the thermal radiation emitted from any body whose surface temperature is above absolute zero </li></ul><ul><li>Evaporation-process of transforming a liquid into a gas </li></ul><ul><li>Conversion-transformation of energy into heat </li></ul>
  19. Types of Heating Modalities <ul><li>Superficial heat </li></ul><ul><ul><li>Achieve their maximum tissue temp. in skin and subcutaneous fat. </li></ul></ul>
  20. Superficial Heat <ul><li>Hot packs </li></ul><ul><ul><li>Contain silicone dioxide </li></ul></ul><ul><ul><li>Immersed in tanks with water heated to 74.5 deg. C </li></ul></ul><ul><ul><li>Treatment time is usually 20-30 mins </li></ul></ul><ul><ul><li>Transfer heat through conduction </li></ul></ul>
  21. Superficial Heat <ul><li>Hot pads </li></ul><ul><ul><li>2 types available </li></ul></ul><ul><ul><ul><li>Circulating fluid pads </li></ul></ul></ul><ul><ul><ul><li>Electric pads </li></ul></ul></ul><ul><ul><li>Have a potential to produce electrical shock if insulation is bad </li></ul></ul><ul><ul><li>Oscillating temp. of up to 5 deg. C. is noted </li></ul></ul>
  22. Superficial Heat <ul><li>Infrared Radiation </li></ul><ul><ul><li>Luminous IR emit near IR spectrum (770 to 1500 nm) </li></ul></ul><ul><ul><li>Non luminous IR emit far IR spectrum (1500 to 12,500 nm) </li></ul></ul><ul><ul><li>Heat is produced by inducing molecular vibration </li></ul></ul>
  23. Superficial Heat <ul><li>Precautions when giving IRR </li></ul><ul><ul><li>General heat precautions </li></ul></ul><ul><ul><li>Light sensitivity </li></ul></ul><ul><ul><li>Skin drying </li></ul></ul><ul><ul><li>Dermal photoaging </li></ul></ul>
  24. Superficial Heat <ul><li>Fluidotherapy </li></ul><ul><ul><li>Dry heating modality that uses heating w/ forced hot air & a bed of finely divided solid particles </li></ul></ul><ul><ul><li>Solid-gas mixture </li></ul></ul><ul><ul><li>May have a massaging action </li></ul></ul><ul><ul><li>Typical temp. range is 46.1 deg. C to 48.9 deg. C </li></ul></ul>
  25. Superficial heat <ul><li>Paraffin bath </li></ul><ul><ul><li>Paraffin wax and mineral oil is mixed in a ration of 6:1 to 7:1 </li></ul></ul><ul><ul><li>Applied in various ways </li></ul></ul><ul><ul><ul><li>Immersion </li></ul></ul></ul><ul><ul><ul><li>Dipping </li></ul></ul></ul><ul><ul><ul><li>brushing </li></ul></ul></ul>
  26. Deep Heating Modalities <ul><li>Ultrasound </li></ul><ul><ul><li>Acoustic vibration with frequencies above the audible range (> 20,000Hz) </li></ul></ul><ul><ul><li>- Therapeutic UTZ involves the use of high-frequency acoustic energy to produce thermal & non-thermal effects in tissues </li></ul></ul>
  27. Ultrasound <ul><li>Therapeutic range: </li></ul><ul><ul><li>0.75 Mhz to 3 Mhz </li></ul></ul><ul><li>Diagnostic Range: </li></ul><ul><ul><li>1 Mhz to 10 Mhz </li></ul></ul>
  28. Ultrasound <ul><li>Attenuation: US lose a portion of their energy while traveling through the tissue </li></ul><ul><li>Absorption is a major cause of attenuation and US is converted into heat </li></ul>
  29. Ultrasound <ul><li>2 types: </li></ul><ul><ul><li>Pulsed: emission of brief bursts or pulses of US interspersed with silence </li></ul></ul><ul><ul><ul><li>Less heat </li></ul></ul></ul><ul><ul><ul><li>Emphasize the non thermal effects </li></ul></ul></ul><ul><ul><li>Continuous: continuous emission of US </li></ul></ul>
  30. Ultrasound <ul><li>Thermal effects </li></ul><ul><ul><li>When the acoustic energy is absorbed, producing molecular vibration, thus heat is made. </li></ul></ul><ul><li>Mechanical effects </li></ul><ul><ul><li>Micromassage </li></ul></ul><ul><ul><li>Loosening of microscopic cell structure </li></ul></ul><ul><ul><li>Reversible decrease of viscosity of drugs </li></ul></ul><ul><ul><li>Depolymerization of proteins esp. in nerves, muscle and collagen cement </li></ul></ul>
  31. Ultrasound <ul><li>Non-thermal effects: </li></ul><ul><li>Cavitation: produced during the phase of relaxation and rarefaction. </li></ul><ul><ul><li>May cause platelet aggregation and even cell death </li></ul></ul><ul><li>Microstreaming: produced by stable cavitation with nearby particles being attracted to it. </li></ul><ul><ul><li>May cause cell membrane damage and death </li></ul></ul>
  32. Ultrasound <ul><li>Standing waves: produced by superimposition of incident and reflected sound waves. </li></ul><ul><ul><li>May cause stasis of red blood cells </li></ul></ul>
  33. Ultrasound <ul><li>Precautions/contraindications: </li></ul><ul><ul><li>Near brain eyes and reproductive organs </li></ul></ul><ul><ul><li>Gravid or menstruating uterus </li></ul></ul><ul><ul><li>Near pacemakers </li></ul></ul><ul><ul><li>Near spine/laminectomy sites </li></ul></ul><ul><ul><li>Malignancy </li></ul></ul><ul><ul><li>Skeletal immaturity </li></ul></ul><ul><ul><li>Arthroplasties (?) </li></ul></ul><ul><ul><li>Methyl methacrylate or high density polyethylene (?) </li></ul></ul>
  34. Shortwave Diathermy <ul><li>Heat is produced by conversion of electromagnetic energy to thermal energy </li></ul><ul><li>Heating pattern depends on the type of SWD unit and the water content of the tissue involved. </li></ul><ul><li>27.12 MHz (11 m wavelength) is most commonly used </li></ul>
  35. Short Wave Diathermy <ul><li>2 major types of Machines </li></ul><ul><ul><li>Inductive </li></ul></ul><ul><ul><ul><li>Achieve higher temperatures in water rich tissues (muscle, skin blood, etc.) </li></ul></ul></ul><ul><ul><li>Capacitative </li></ul></ul><ul><ul><ul><li>Achieve higher temperatures in water poor tissues (bone, fat, etc.) </li></ul></ul></ul>
  36. Short Wave Diathermy <ul><li>Precautions: </li></ul><ul><ul><li>Metal parts/jewelry, IUD, surgical implants </li></ul></ul><ul><ul><li>Contact lenses </li></ul></ul><ul><ul><li>Gravid or menstruating uterus </li></ul></ul><ul><ul><li>Skeletal immaturity </li></ul></ul>
  37. Microwave Diathermy <ul><li>Electromagnetic energy is also converted into heat </li></ul><ul><li>Heat is produced by the increased kinetic energy </li></ul><ul><li>Approved frequencies are 915 MHz (33 cm wavelength) and 2456 MHz (12 cm wavelength) </li></ul>
  38. Microwave Diathermy <ul><li>More water in the tissues, the faster they are heated! (like your microwave ovens) </li></ul><ul><li>915 MHz is preferred for muscle heating </li></ul><ul><li>Largely replaced by Ultrasound and Hot Packs </li></ul>
  39. Microwave Diathermy <ul><li>General Precautions: </li></ul><ul><ul><li>Metal </li></ul></ul><ul><ul><li>Pacemakers </li></ul></ul><ul><ul><li>Skeletal immaturity </li></ul></ul><ul><ul><li>Fluid filled cavities (e.g. eyes, effusions etc.) </li></ul></ul>
  40. CRYOTHERAPY Cold Decreased Tissue Temp. Increased Blood Viscosity And Vasoconstriction Decreased Metabolism Decreased Bleeding Decreased Removal of By Products Decreased Production of Metabolites Decreased Leucocyte Phagocyte Activity Retard Healing
  41. Physiologic Effects of Cold <ul><li>Hemodynamic </li></ul><ul><ul><li>Vasoconstriction </li></ul></ul><ul><ul><li>Decrease inflammation esp. during acute stages </li></ul></ul><ul><li>Neuromuscular </li></ul><ul><ul><li>Decreased conduction of nerves </li></ul></ul><ul><ul><li>Reduce spasticity </li></ul></ul>
  42. Physiologic Effects of Cold <ul><li>Joint and Connective Tissue </li></ul><ul><ul><li>May cause decreased synovial collagenase activity </li></ul></ul><ul><ul><li>Decreased joint extensibility </li></ul></ul><ul><ul><li>Increased joint stiffness </li></ul></ul><ul><li>Misc. effects: </li></ul><ul><ul><li>analgesia </li></ul></ul>
  43. Cryotherapy Agents <ul><li>Cold Packs </li></ul><ul><ul><li>Cooled at –12 deg. C. </li></ul></ul><ul><ul><li>Covered with moist towels </li></ul></ul><ul><ul><li>Duration of application is 20 to 30 mins </li></ul></ul>
  44. Cryotherapy Agents <ul><li>Ice Massage </li></ul><ul><ul><li>Direct application of ice </li></ul></ul><ul><ul><li>Used for localized symptoms and applied for 5 to 10 mins. </li></ul></ul><ul><ul><li>Studies show a decrease of temp by 4.1 deg. C at depths of 2 cm </li></ul></ul><ul><li>Cold Water Immersion </li></ul><ul><ul><li>Usually with water cooled to 5 deg. C. </li></ul></ul><ul><ul><li>Poorly tolerated </li></ul></ul>
  45. Cryotherapy Agents <ul><li>Cryotherapy Compression Units </li></ul><ul><ul><li>Used primarily for acute musculoskeletal injury </li></ul></ul><ul><ul><li>Cold water (7.2 deg. C) is pumped through a pneumatic sleeve at pressures of 60 mmHg are used </li></ul></ul><ul><li>Vapocoolant spray </li></ul><ul><ul><li>Fluori-Methane is used </li></ul></ul><ul><ul><li>Often used for patients with Myofascial Pain Syndrome </li></ul></ul><ul><ul><li>Spray and stretch routine is used </li></ul></ul>
  46. Hydrotherapy <ul><li>External application of hot or cold water </li></ul><ul><li>Uses a whirlpool bath or a hubbard tank </li></ul><ul><ul><li>Both uses agitation by aeration, dispersal of thermal energy through convection </li></ul></ul><ul><ul><li>Hubbard tank is used for whole body immersion </li></ul></ul><ul><ul><li>Used for adjunctive therapy for arthritis, infected wounds </li></ul></ul><ul><ul><li>Isotonic saline is used to prevent or minimize fluid shifts </li></ul></ul>
  47. Hydrotherapy <ul><li>Contrast baths </li></ul><ul><ul><li>Consist of alternating immersion of the distal limbs in hot (42 to 45 deg. C) then cold (8.5 to12.5 deg. C) </li></ul></ul><ul><ul><li>Effect is believed through cyclic vasoconstriction and vasodilatation </li></ul></ul><ul><ul><li>Beneficial for rheumatic diseases, neuropathic pain and Reflex sympathetic Dystrophy. </li></ul></ul>
  48. Other methods <ul><li>Phonophoresis </li></ul><ul><ul><li>Uses US to facilitate migration of topically administered medications </li></ul></ul><ul><ul><li>Corticosteroids are frequently used </li></ul></ul><ul><li>Iontophoresis </li></ul><ul><ul><li>Migration of charged particles across biological membranes under imposed electrical field </li></ul></ul><ul><ul><li>Used in delivery of medications </li></ul></ul><ul><ul><li>2 nd pass effect of drugs can be skipped because of topical application </li></ul></ul><ul><ul><li>Miliarisis are often reported in patients treated for hyperhydrosis </li></ul></ul>
  49. Manipulation
  50. Manipulation <ul><li>Use of the hands in the patient management process using instructions and maneuvers to maintain maximal, painless movement of the Musculoskeletal system in postural balance. </li></ul>
  51. Manipulation <ul><li>Thrusting </li></ul><ul><ul><li>Mobilization with impulse </li></ul></ul><ul><ul><ul><li>Relies on the reintroduction of movement in a restricted or dysfunctional area </li></ul></ul></ul><ul><ul><ul><li>High thrusting forces are to be avoided </li></ul></ul></ul><ul><ul><ul><li>Delivers the thrust at the deepest point of patient’s exhalation </li></ul></ul></ul><ul><ul><ul><li>Thrust lasts for about 0.5 sec. </li></ul></ul></ul><ul><ul><ul><li>Muscle guarding by the patient defeats the purpose </li></ul></ul></ul>
  52. Manipulation <ul><li>Mobilization with impulse, Contraindications: </li></ul><ul><ul><li>Unstable fractures </li></ul></ul><ul><ul><li>Severe osteoporosis </li></ul></ul><ul><ul><li>Multiple myeloma </li></ul></ul><ul><ul><li>Osteomyelitis </li></ul></ul><ul><ul><li>Tumors in bone/spine </li></ul></ul><ul><ul><li>Progressive neurological deficit </li></ul></ul><ul><ul><li>Congenital bleeding d/o </li></ul></ul><ul><ul><li>Poor manipulative skill </li></ul></ul><ul><ul><li>Cauda equina </li></ul></ul><ul><ul><li>Central cervical disc herniation </li></ul></ul><ul><ul><li>Hypermobile joints </li></ul></ul><ul><ul><li>Rheuma. Arthritis </li></ul></ul><ul><ul><li>Inflam. Phase of Ankylosing Spondylitis </li></ul></ul><ul><ul><li>Psoriatic arthritis </li></ul></ul><ul><ul><li>Reiter’s syndrome </li></ul></ul><ul><ul><li>Anticoagulant therapy </li></ul></ul>
  53. Manipulation <ul><li>Non Thrusting </li></ul><ul><ul><li>Articulatory Technique </li></ul></ul><ul><ul><ul><li>Combination of leverage, patient ventilatory movement and a fulcrum is used to achieve mobilization </li></ul></ul></ul><ul><ul><ul><li>Done by repeatedly applying a low velocity/high amplitude force to engage the barrier directly then move away from it. </li></ul></ul></ul>
  54. Manipulation <ul><ul><li>Muscle energy technique </li></ul></ul><ul><ul><ul><li>Involves the patient’s voluntary contraction of muscles against resistance supplied by the practicioner </li></ul></ul></ul><ul><ul><ul><li>Goal: to increase ROM and return symmetrical motion to the affected segments, strengthen weakened muscles </li></ul></ul></ul><ul><ul><ul><li>Dubbed as “contract-relax” </li></ul></ul></ul>
  55. Manipulation <ul><ul><li>Strain-Counterstrain </li></ul></ul><ul><ul><ul><li>Attempts to passively place a spinal segment or other joint into its position of greatest comfort or ease </li></ul></ul></ul><ul><ul><ul><li>Aimed at relieving painful dysfunction through a reduction in inappropriate afferent proprioceptor activity </li></ul></ul></ul><ul><ul><ul><li>Some patients tend to become “addicted” to this form of manipulation </li></ul></ul></ul>
  56. Manipulation <ul><li>Myofascial release </li></ul><ul><ul><li>Treats the neuromuscular-somatic unit as a whole </li></ul></ul><ul><ul><li>Uses a combination of manual traction and twisting movements </li></ul></ul><ul><ul><ul><li>Direct technique </li></ul></ul></ul><ul><ul><ul><ul><li>Engages the restrictive barrier and pushes it with constant force until released </li></ul></ul></ul></ul><ul><ul><ul><li>Indirect technique </li></ul></ul></ul><ul><ul><ul><ul><li>Uses the path of least resistance until free movement is achieved </li></ul></ul></ul></ul>
  57. Manipulation <ul><li>Craniosacral Therapy </li></ul><ul><ul><li>Technique for diagnosis and treatment by using the respiratory mechanism </li></ul></ul><ul><ul><li>Enjoys more of a hypothetical than hard scientific support </li></ul></ul><ul><li>Soft Tissue Techniques </li></ul><ul><ul><li>Uses lateral stretching, linear stretching, deep pressure or traction or a combination </li></ul></ul><ul><ul><li>Incorporates massage and acupressure </li></ul></ul>
  58. Manipulation <ul><li>Lymphatic pump </li></ul><ul><ul><li>Utilizes muscle forces and intrathoracic pressure changes to enhance lymph flow </li></ul></ul>
  59. Manipulation <ul><li>Potential side effects in Manipulation </li></ul><ul><ul><li>Autonomic effects </li></ul></ul><ul><ul><ul><li>Hypotension </li></ul></ul></ul><ul><ul><ul><li>Increased menses </li></ul></ul></ul><ul><ul><ul><li>Perspiration </li></ul></ul></ul><ul><ul><li>Transient increase in discomfort </li></ul></ul>
  60. Traction
  61. Traction <ul><li>Types of Traction </li></ul><ul><ul><li>Continuous </li></ul></ul><ul><ul><ul><li>Low force over a long period of time </li></ul></ul></ul><ul><ul><ul><li>Sometimes not well tolerated </li></ul></ul></ul><ul><ul><li>Sustained </li></ul></ul><ul><ul><ul><li>Uses greater pull, maintained for 20 to 60 mins. </li></ul></ul></ul><ul><ul><ul><li>Difficult to tolerate </li></ul></ul></ul><ul><ul><li>Intermittent </li></ul></ul><ul><ul><ul><li>Allow the use of greater forces for a shorter period of time </li></ul></ul></ul><ul><ul><ul><li>More tolerated </li></ul></ul></ul><ul><ul><ul><li>Uses a patient controlled protocol based on tolerance </li></ul></ul></ul>
  62. Traction <ul><li>Cervical Traction </li></ul><ul><ul><li>Maximum separation of occurs with the neck at 24 deg. Flexion </li></ul></ul><ul><ul><li>Best clinical relief noted when neck is flexed at 20 to 30 deg. Flexion </li></ul></ul><ul><ul><li>Prescribed often in sitting position but neck is most uncontrollable and patients have difficulty relaxing the neck muscles. </li></ul></ul>
  63. Traction <ul><li>Lumbar Traction </li></ul><ul><ul><li>Requires larger forces </li></ul></ul><ul><ul><li>Often done intermittently </li></ul></ul><ul><ul><li>Pain relief is often noted when the lumbar spine is in flexion </li></ul></ul>
  64. Traction <ul><li>Contraindications </li></ul><ul><ul><li>Osteomyelitis </li></ul></ul><ul><ul><li>Tumors </li></ul></ul><ul><ul><li>Unstable fractures </li></ul></ul><ul><ul><li>Severe osteoporosis </li></ul></ul><ul><ul><li>Hypertension </li></ul></ul><ul><ul><li>Cardiovascular dse. </li></ul></ul><ul><ul><li>Inadequate expertise </li></ul></ul><ul><li>Cervical c/I </li></ul><ul><ul><li>Central disc herniation </li></ul></ul><ul><ul><li>Hypermobile jts </li></ul></ul><ul><ul><li>Rheuma. Arth. </li></ul></ul><ul><ul><li>Carotid/vertebral artery disease </li></ul></ul><ul><li>Lumbar </li></ul><ul><ul><li>Cauda Equina </li></ul></ul>
  65. Massage
  66. Massage <ul><li>Defined as a group of procedures which are usually done with the hands such as friction, kneading, rolling and percussion of the external tissues of the body in a variety of ways, either with a curative, palliative or hygienic object in view. </li></ul>
  67. Massage <ul><li>Goals of treatment: </li></ul><ul><ul><li>Sedation </li></ul></ul><ul><ul><li>Adhesion reduction </li></ul></ul><ul><ul><li>Fluid mobilization </li></ul></ul><ul><ul><li>Muscular relaxation </li></ul></ul><ul><ul><li>Vascular changes </li></ul></ul>
  68. Massage <ul><li>Effects: </li></ul><ul><ul><li>Promote blood circulation </li></ul></ul><ul><ul><li>Reduce edema </li></ul></ul><ul><ul><li>Promote lymphatic flow </li></ul></ul><ul><ul><li>Reduction of adhesions </li></ul></ul>
  69. Massage <ul><ul><li>Reduce anxiety </li></ul></ul><ul><ul><li>Improve neural conduction </li></ul></ul><ul><ul><li>Improve immune system </li></ul></ul><ul><ul><li>Improve recovery of muscle ability to perform exercise </li></ul></ul><ul><ul><li>Myofascial flexibility </li></ul></ul>
  70. Types of Massage <ul><li>Effleurage: </li></ul><ul><ul><li>Stroking massage </li></ul></ul><ul><ul><li>Involves lightly running the hand over the skin </li></ul></ul><ul><ul><li>May be superficial or deep </li></ul></ul><ul><ul><li>Effective in returning venous/lymphatic flow </li></ul></ul>
  71. Types of Massage <ul><li>Petrissage: </li></ul><ul><ul><li>Compression massage </li></ul></ul><ul><ul><li>Includes kneading, picking up, wringing, rolling and shaking </li></ul></ul><ul><ul><li>Compression of muscle tissue </li></ul></ul><ul><ul><li>Mobilize fluid and tissue deposits </li></ul></ul><ul><ul><li>Break up tissue and muscle adhesion </li></ul></ul>
  72. Types of Massage <ul><li>Petrissage </li></ul><ul><ul><li>Kneading: </li></ul></ul><ul><ul><ul><li>Circular movements of one hand, superimposed on the other, a single hand, the knuckles, finger pads or the thumb compressing superficial soft tissues against the deeper ones. </li></ul></ul></ul><ul><ul><li>Picking Up: </li></ul></ul><ul><ul><ul><li>Compression of soft tissues to deeper ones </li></ul></ul></ul><ul><ul><ul><li>Grasping of the soft tissue </li></ul></ul></ul><ul><ul><ul><li>Release of soft tissue </li></ul></ul></ul><ul><ul><ul><li>Moving the hands to the new position </li></ul></ul></ul>
  73. Types of Massage <ul><li>Petrissage </li></ul><ul><ul><li>Wringing: </li></ul></ul><ul><ul><ul><li>Resembles picking up except once the tissue is grasped using two hands side by side, one hand pulls while the other pushes </li></ul></ul></ul><ul><ul><li>Rolling: </li></ul></ul><ul><ul><ul><li>Motion of gathering skin alone or muscle and skin between fingers and thumb and allowing the tissue to roll between the said digits before releasing and taking another nearby grasp </li></ul></ul></ul>
  74. Types of Massage <ul><li>Petrissage: </li></ul><ul><ul><li>Shaking: </li></ul></ul><ul><ul><ul><li>Soft tissue is grasped by the thumb and finger then is shaken vigorously side to side as they move down the length of the muscle </li></ul></ul></ul><ul><li>Friction Massage: </li></ul><ul><ul><li>Applying circular or transverse motions through the fingers, thumb or the heel of the palm of the hand to small area of tissue. </li></ul></ul><ul><ul><li>When applied correctly, no motion should occur between the skin and the finger </li></ul></ul>
  75. Types of Massage <ul><li>Tapotement: </li></ul><ul><ul><li>Percussion massage </li></ul></ul><ul><ul><li>Stimulation by rhythmic, alternating movements of the hands on the soft tissue of the patient </li></ul></ul><ul><ul><li>Clapping, hacking, vibrations, beating, pounding, tapping are its subtypes </li></ul></ul>
  76. Types of Massage <ul><li>Tapotement: </li></ul><ul><ul><li>Clapping: </li></ul></ul><ul><ul><ul><li>Uses cupping of hands while striking the body/muscle </li></ul></ul></ul><ul><ul><li>Hacking: </li></ul></ul><ul><ul><ul><li>Consist of repetitively striking the body with the medial border of the hands </li></ul></ul></ul><ul><ul><li>Vibration: </li></ul></ul><ul><ul><ul><li>Rapid up and down motion of pressure and release within the soft tissue without losing contact with the skin </li></ul></ul></ul>
  77. Types of Massage <ul><li>Tapotement: </li></ul><ul><ul><li>Beating: </li></ul></ul><ul><ul><ul><li>Strikes the body, palm down </li></ul></ul></ul><ul><ul><ul><li>Rarely used </li></ul></ul></ul><ul><ul><li>Pounding: </li></ul></ul><ul><ul><ul><li>Striking the body using the medial border of the fist </li></ul></ul></ul><ul><ul><ul><li>Rarely used </li></ul></ul></ul><ul><ul><li>Tapping: </li></ul></ul><ul><ul><ul><li>Uses the finger pads to percuss </li></ul></ul></ul>
  78. Types of Massage <ul><li>Acupressure: </li></ul><ul><ul><li>Technique of applying constant circular friction pressure to specific points for treatment purposes. </li></ul></ul><ul><ul><li>Used to control nausea, vomiting </li></ul></ul><ul><ul><li>Decrease post-operative pain </li></ul></ul><ul><ul><li>Treat headache and TMJ pain </li></ul></ul><ul><ul><li>Assist in pulmonary rehabilitation </li></ul></ul>
  79. Types of Massage <ul><li>Shiatsu: </li></ul><ul><ul><li>Based on the Japanese (日本) interpretation of the acupuncture theory and flow of chi. </li></ul></ul><ul><ul><li>Heavy pressure is applied perpendicular at certain points in the meridians in the body using the palm of the hand or heel of the foot. </li></ul></ul>
  80. Types of Massage <ul><li>Reflexology: </li></ul><ul><ul><li>Believes on homuncular representation of the entire human body in the hand or foot </li></ul></ul><ul><ul><li>Pressure is given on certain areas of the hand to heal or treat the organs represented </li></ul></ul><ul><ul><li>Often uncomfortable </li></ul></ul>
  81. Types of Massage <ul><li>Rolfing: </li></ul><ul><ul><li>Method of restructuring and realigning the deep fascial planes in the body through a variety of deep friction massage techniques. </li></ul></ul><ul><ul><li>Adheres to the concept of mind and body integration </li></ul></ul><ul><ul><li>May influence the psychological state to correct physical problems </li></ul></ul>
  82. Massage <ul><li>Contraindications and risks: </li></ul><ul><ul><li>Not performed in areas of malignancy, cellulitis, lymphangitis </li></ul></ul><ul><ul><li>Not applied to acute trauma or bleeding </li></ul></ul><ul><ul><li>Not applied to bloody areas where the practicioner is exposed to blood borne pathogens </li></ul></ul><ul><ul><li>DVT </li></ul></ul>
  83. Electrotherapy
  84. Normal Muscle <ul><li>The Motor Unit consist of: </li></ul><ul><ul><li>Alpha motor neuron </li></ul></ul><ul><ul><ul><li>Vary in size </li></ul></ul></ul><ul><ul><ul><li>Small neurons have low activation frequency </li></ul></ul></ul><ul><ul><ul><li>Large neurons innervate fast fibers </li></ul></ul></ul><ul><ul><li>Myoneural junction </li></ul></ul><ul><ul><li>Muscle fiber it innervates </li></ul></ul>
  85. Muscle Properties I IIa IIb Morphology Name Red Intermediate White Capillary density Intermediate Histochemical Myosin ATPase Mitochondria Glycogen Low Intermediate High Myosin HC HCs Hcfa HCfb Myosin LC LC 1a , 1b,2 Lcf 1,2,3 Lcf 1,2,3
  86. Muscle Properties I IIa IIb Metabolism Type Oxidative Oxidative/ glycolytic Glycolytic Aerobic Mixed Anaerobic Contractile properties Twitch Slow Fast Fast Fatigability Slow Intermediate rapid
  87. Muscle properties <ul><li>Orderly progression of stimulation </li></ul><ul><ul><li>Weak slowly conducting units with type I are are recruited first </li></ul></ul><ul><ul><li>Next recruited are the type II b fibers which have high conduction velocity. </li></ul></ul><ul><li>Artificial stimulation </li></ul><ul><ul><li>Reverse of the normal recruitment. </li></ul></ul>
  88. Muscle and response to electrical stimulation <ul><li>Studies have shown that continuous electrical stimulation of the normal, fast twitch fibers will result in transformation of the said fiber to a composition of type I characteristics </li></ul>
  89. Uses of Electrical stimulation <ul><li>NMES can be used as an orthotic assist </li></ul><ul><li>NMES, combined with voluntary contraction may improve the strength of selected muscles </li></ul><ul><li>NMES may help in preventing muscle atrophy in immobilized limbs </li></ul><ul><li>NMES may help in evaluating the etiology of the weakness </li></ul>
  90. ES and the myopathic muscle <ul><li>Studies have shown that Using Electrical stimulation in a myopathic muscle may delay the inevitable outcome, provided that 15% of the normal strength is present at the time of application </li></ul>
  91. ES and the denervated muscle <ul><li>Shown to preserve muscle bulk for only a short period </li></ul><ul><li>May induce a hybrid fiber type </li></ul><ul><li>May cause improvement in muscle tension </li></ul><ul><li>No data supports acceleration of reinnervation </li></ul>
  92. ES and Prevention of complications brought about by disuse <ul><li>Cardiovascular deconditioning </li></ul><ul><ul><li>Assist in reduction of venous pooling </li></ul></ul><ul><ul><li>Assist in improving cardiorespiratory fitness </li></ul></ul><ul><ul><li>Assist in improving stroke volume </li></ul></ul><ul><li>Osteoporosis </li></ul><ul><ul><li>ES may produce small increments in bone mass </li></ul></ul>
  93. ES and Prevention of complications brought about by disuse <ul><li>DVT </li></ul><ul><ul><li>NMES have been shown to decrease the plasma fibrinolytic activity. </li></ul></ul><ul><li>Psychological Effects </li></ul><ul><ul><li>Shown to help decrease chance of depression. </li></ul></ul><ul><ul><li>Showed to increase self esteem </li></ul></ul><ul><ul><li>May be due to increase in ß-endorphin levels. </li></ul></ul>
  94. Therapeutic Functional Electrical Stimulation <ul><li>Urinary Incontinence </li></ul><ul><ul><li>May help decrease stress induced urinary incontinence and motor induced urinary incontinence </li></ul></ul><ul><ul><li>ES and pelvic floor exercises shown a markedly decreased incidence of the above </li></ul></ul><ul><ul><li>May not improve bladder incontinence </li></ul></ul>
  95. Therapeutic Functional Electrical Stimulation <ul><li>Management of Spasticity: </li></ul><ul><ul><li>Studies showed a decrease in spasticity in familial spastic paraplegia </li></ul></ul><ul><ul><li>May not be effective for spasticity due to Spinal cord Injury </li></ul></ul><ul><ul><li>May decrease spasticity in stroke, esp. when used in conjunction with botulinum toxin injection </li></ul></ul>
  96. Therapeutic Functional Electrical Stimulation <ul><li>Upper limb hemiplegia </li></ul><ul><ul><li>May decrease the shoulder subluxation </li></ul></ul><ul><ul><li>May improve muscle tone and function </li></ul></ul><ul><ul><li>May improve function of a chronic hemiplegic arm </li></ul></ul><ul><li>Phrenic Nerve Stimulation </li></ul><ul><ul><li>May assist the tetraplegics in breathing continuously </li></ul></ul>
  97. Therapeutic Functional Electrical Stimulation <ul><li>As an orthotic device </li></ul><ul><ul><li>Often used only for patients who cannot tolerate appropriate bracing in scoliosis </li></ul></ul><ul><ul><li>Used as an adjunct to improve gait patterns in Hemiplegics </li></ul></ul>
  98. Other applications <ul><li>For Standing and gait </li></ul><ul><ul><li>Used for paraplegics, however, may be bulky and may add damage to joints </li></ul></ul><ul><ul><li>Newer equipment may require implantation </li></ul></ul><ul><ul><li>May exceed the oxygen utilization compared to those who use conventional orthosis </li></ul></ul>
  99. Other applications <ul><li>Restoration of Upper Limb function </li></ul><ul><ul><li>Implanted FES may be used to return hand use </li></ul></ul><ul><ul><li>Development of sensory feedback system for joint proprioception, contact, force, slippage, pressure and temperature are prerequisites </li></ul></ul>
  100. Other applications <ul><li>Wound healing: </li></ul><ul><ul><li>Increase the number of fibroblasts, collagen, protein and DNA synthesis </li></ul></ul><ul><ul><li>Increase neutrophilic granulocytes </li></ul></ul><ul><ul><li>Suppress mast cells which are responsible for scarring </li></ul></ul><ul><ul><li>Bacteriostatic and bactericidal properties </li></ul></ul><ul><ul><li>Improve blood flow </li></ul></ul>

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