Physical agent modalities such as heat, cold, ultrasound and shortwave diathermy are commonly used in physical therapy to provide pain relief and improve tissue healing. Cryotherapy uses cold therapy to reduce pain and inflammation by constricting blood vessels and decreasing nerve conduction velocity. Superficial heat modalities like hot packs and paraffin baths are used to relax muscles and increase blood flow in subacute and chronic conditions. Deep heat modalities like ultrasound and shortwave diathermy penetrate deeper tissues to promote tissue repair through increased circulation and collagen synthesis. Proper application and duration of these modalities is important for achieving therapeutic effects while avoiding harm.

1. PHYSICAL AGENT MODALITIES
Dr Sarankumar G Moderator
Junior resident Dr Ravi Gaur
1

2. Physical agent modalities
 Modalities like cold, heat , sound , electromagnetic waves electricity and
mechanical forces are used to produce desirable therapeutic effect
 Commonly used in pain relief or modulation / reduce inflammation / improve
circulation/ tissue remodelling/ reduction or elimination of edema
2

3. CRYOTHERAPY
3

4. Cryotherapy
 Treatment by lowering tissue temperature
 Major physiological effects
 Changing local sensation
 Muscle relaxation
 Vasoconstriction followed by vasodilation
4

5. MECHANISM
 Decreases the excitability of free nerve endings
 Thus decreases the nerve conduction velocity of pain fibres
 Decreases local neuronal activity ( including small fibre in muscle spindle and golgi
tendon organ)
 Thus decrease the rate of afferent muscle fibre activity further reduces the muscle
spasm
5

6. Vasodilation
 Spinal cord reflex to preserve local temperature
 Partially from changing sensitivity of vessel to local nerve stimulation
 Paralyse the vessel wall muscle through blockage of nerve impulse to vessels
6

7.  Local temperature decreased uncomfortable sensation of cold
aching sensation stinging and burning sensation
complete numbness around 15 minutes after cold application
 Skin vessel progressively constrict to temperature of approximately 50*F at which
point it reaches maximum constriction
 50*F for 15 mins vessel begin to dilate
 Maximum vasodilation at 32*F (0*C)
7

8. Indication
 Acute injury , swelling ( controlling haemorrhage and edema)
 Acute contusion
 Acute muscle strain / ligament sprain
 Bursitis
 Tenosynovitis , tendinits
 Muscle spasm / guarding
 Chronic pain
 Myofascial trigger point
8

9. Contraindication
 Impaired circulation
 Peripheral vascular disease
 Hypersensitivity to cold
 Skin anesthesia
 Open wounds or skin conditions
 Local infection
9

10. Types and techniques
 Icepack
 Cold whirlpool
 Chemical cold spray
 Contrast bath
10

11. General consideration
 Therapeutic effect decreases with increasing tissue depth
 15 minutes is necessary to achieve analgesia effect 20 minutes is usually
recommended treatment duration
11
Limited local tissue 32* - 50* F
Larger area ( whirlpool) 50 – 60* F
Whole body cryotherapy 65 – 80* F

12. Ice massage
 Cool soft tissue more rapidly than ice pack
 Apply in a circular or longitudinal fashion
 Each succeeding stroke stroke covering half the previous stroke
 15 to 20 minutes
 Once skin become numb terminate the procedure
 Monitor local tissue for all time i/v/o frost bite
12

13. Ice massage
13

14. Ice packs
 Filled with petroleum distillate gel or simple way is to put crushed ice in plastic
 Cooled to 60*F ( 15*c) in refrigerator before use
 Commonly used in acute and subacute injury
 Should not lie on top of cold pack
 Treatment duration 20 mints
 Elastic bandage is applied to hold pack in place and to provide compression
14

15. ICE PACKS
15

16. Cold spray
 Fluori-methane used less commonly
 Does not provide adequate deep penetration of cold
 Primary action of cold spray is to stimulate Aβ fibre to reduce painful arc as well as
muscle spasm
 Spray and stretch technique to relieve muscle spasm
16

17. Cold spray
 Hold spray bottle 30 to 45 cm away from skin surface so that jet stream of coolant
to meet the skin at acute angle at rate of 10cm/sec in single direction
 3 to 4 sweep at a direction is sufficient
 Eyes nose mouth should be covered if applied near face
 Too many sweeps can freeze the skin and cause frost bite
17

18. Cold spray
18

19. Contrast bath
 Alternatively applied hot and cold packs
 Treat subacute swelling through vasodilation – vasoconstriction response
 Cold container 50 – 60* F ( 10 -15*C)
 Hot container 104 – 108*F (40*-42*C)
 Total duration – 20 mins
 1 min in cold and 3 min in warm immersion
19

20. THERMOTHERAPY
20

21. Thermotherapy
 Used to increase tissue temperature
 Two types
 Superficial ( <1cm deep)
 Deep ( aka diathermy 3-5cm deep)
21

22. SUPERFICIAL HEAT
22

23. Mechanism
 Both pain and temperature are carried to brain by lateral spinothalamic tract
 Gate control theory suggest more temperature signals will reduce pain signals
 Both cold and warm receptors discharge minimally at 91*F maximally between 99 –
104* F
 Pain receptors stimulated again at temperature > 113*F
23

24. Action over blood flow
 Only affects cutaneous blood flow to increase
 Subcutaneous blood flow to muscle and fat layer decreases initially
 Energy absorbed long enough period to increase cutaneous blood flow
hypothalamus will reflexively increase blood flow to underlying tissues such as
subcutaneous muscle and fat as well
24

25. Over skeletal muscle
 Relax skeletal muscle
 MOA : decreases the stimulus threshold of muscle spindle and decreases the
gamma afferent firing rate
25

26. Indications
 Subacute and chronic inflammatory conditions
 Subacute or chronic pain
 Subacute muscle strain /ligament sprain
 Subacute contusion
 Muscle guarding / spasm
 Decreased rom of joints
 Myofascial trigger points
26

27. Contraindications
 Acute musculoskeletal conditions
 Impaired circulation
 Peripheral vascular disease
 Skin anesthesia
 Open wound
 Infection
27

28. Types and devices
 Heating pad
 Hydrocollator packs
 Paraffin bath
 Hot whirlpool
 Infrared
28

29. Hydrocollator pack
 Pack comprises canvas pouches of petroleum distillate
 Thermostat maintain temperature of 170* F , removed by tongs or scissors before
use
 Size
 Lower or middle back – 24 × 24 inch
 Cervical – 6 × 18 inches
 Duration 15 to 20 mins
 Not to lie on packs – (1) risk of burn (2) force silicate gel out
 Check for burns
29

30. Hydrocollator pack
30

31. Paraffin bath
 Efficient method to apply superficial heat especially to small joints such as IP joints
 m/c used in Rheumatoid arthritis and osteoarthritis
 Provide 6 times amount of heat available in water because mineral oil in paraffin
lowers the melting point of paraffin
 Both paraffin and mineral oil has low specific heat which enhances patient ability
to tolerate heat from paraffin better than water
31

32. Paraffin bath
32

33. Content and storage
 1 gal of mineral oil to 2 ib of paraffin
 Paraffin is stored in thermostat
 Can increase thermostat upto 212*F thus killing any bacteria that grows in paraffin
 The mineral oil reduces the ambient temperature of paraffin which is set at 126*F
 IF Paraffin become soiled it should be replaced at no longer than 6 month interval
33

34. Method
 Treated extremity should be dipped in paraffin for couple of seconds and removed to
allow paraffin to harden slightly
 Repeat until 6 layers is formed – first layer is highest on body segment and each
successive layer lower than previous one
 If not done so heat will not dissipate and patient could be burned
 For 20 to 30 minutes
 Care for contamination while removing
34

35. Infrared
 Electromagnetic modality rather than conduction modality
 Penetration no greater than 1cm
 Dry heat modality compared with other forms
 Increases the local temperature without unit touching the patient hence can be
used in patient with skin defect
 Commonly used to elevate temperature during and after surgical procedure
35

36. Infrared
 Superficial skin burns sometime occur because of intense IR radiation and reflector
become extremely hot( 4000*F)
 Warm moist towel over body segment may enhance heating effect
 Areas not being treated must be protected by clothes or dry towels
 Check every few minutes for mottling
 Distance from area to be treated to the lamp should be adjusted according to the
treatment time
 Standard formula is 20 inches equals 20 minute of treatment time
36

37. IR heating lamp
37

38. Hydrotherapy
 Treat the patient through the medium of water
 Can be performed in swimming pool, hubbard tank or whirlpool
 Of this whirlpool is m/c used
 Patient can move treated part in whirlpool easily to get added benefit of exercise
 Two types
 Cold – acute and subacute conditions
 Warm whirlpool
38

39. method
 Temperature 98 -110* F ( 37-45*C)
 Time 15 -20 minutes
 Jet flow 6 -9 inches from body segment
 Benefits – increase circulation , relieve spasm, massaging, vibrating effect of
whirlpool
 Excellent for RA and OA to increase systemic blood flow and mobilisation without
too much pressure on joint
 Aerobic exercise in water to increase ROM, flexibility and muscle power .
39

40. DEEP HEAT MODALITIES
40

41. Ultrasound
 Oscillating sound pressure wave with frequency greater than upper limit of human
hearing range
 Medical uses
 Diagnostic
 Therapeutic
 Therapeutic ultrasound produce high frequency acoustic energy to produce
thermal and mechanical effects in tissue
 Hence used in soft tissue disorders
41

42. Parts
 Applicator
 Matching electrical circuit
 High frequency electrical generator
 Power amplifier
 Transformer convert 110 – 220 volt AC to high frequency one
 Matching circuit quarantine effective oscillation of piezoelectric crystal inside
applicator in resonant frequency
42

43. UST
43

44. Schematic components of USD
POWER SUPPLY
AC
HIGH FREQUENCY
GENERATOR
POWER
AMPLIFIER
MATCHING CIRCUIT
PEIZOELECTRIC
CRYSTAL
ULTRASONIC
OUTPUT ENERGY
44

45. Physiology and mechanism
 Thermal effects
 Heat produced when acoustic energy is absorbed especially at or near the surface
of structure with high attenuation coefficient
 Bony structure and lungs which contains air have more attenuation coefficient
 Attenuation – loss of ultrasound energy when propagating into tissue ( scattering
or absorption)
45

46.  Non thermal effects
 Cavitation – oscillation of bubbles in sound field
 Media motion( acoustic streaming and microstreaming-interstitial fluid moves in
direction of bubble or obstacle)
 Standing waves- produced by superimposition of incident and reflected waves –
result in local heating of tissues
 Clinical significance of non thermal effects are still unclear
46

47. Techniques
 Applied with stroking technique allows more even energy distribution
 Ultrasound probe is moved over approximately 25cm2 in circular or longitudinal
fashion for 5 to 10 mins
 Keeping probe stationary should be avoided- potential creation of standing waves
and local hot spots
 Output or intensity adjusted to below pain threshold
 Coupling agent between probe and skin is essential as ultrasound is not able to
penetrate thin layer of air
 It should not be salt based may damage ultrasound probe
47

48. Techniques
 Applied indirect or immersing method when treating irregular surfaces such as foot or
ankle
 Target body part is placed in container filled with degassed water
 Delivery can be pulsed or continuous depend on thermal or nonthermal effect preferred
 Piezoelectric crystals has vibration frequency ranging from 0.8 to 3 Mhz
 1Mhz output frequency – affect upto 5 cm deep
 3MHz upto 2 to 3 cm deep
48

49. INDICATION
 Enhance proliferation, collagen production and non collagen protein synthesis –
muscle and tendon healing
 Promote fibroblast production
 Increases calcium uptake
 OA KNEE
 Lateral epicondylitis
 Muscle spasm
 Low intensity pulsed UST ( for non union fracture)
49

50. Fibroblast
PROTIEN EXPRESSION OF
ALPHA SM ACTIN -MIGRATION
GENE AND PROTIEN
EXPRESSION OF PCNA -
PROLIFERATION
GENE AND PROTIEN
EXPRESSION OF TYPE 1 AND 3
COLLAGEN – COLLAGEN
SYNTHESIS
Expression and secretion of
TGF β
50

51. Contraindications and precautions
 Acute injury/ inflammation
 On pregnant uterus
 Impaired sensation and person with cognitive impairment
 Near nerve brain eye and reproductive organs
 Malignancy ( increases growth / spread)
 Pacemaker
 Implants containing plastic material
 On epiphysis
 Near spine or laminectomy sites
51

52. Sonophoresis
 Application of ultrasound to skin increases permeability and enable delivery of
various substance into and through skin
 Ultrasound of low to medium frequencies ( 20 to 200kHz and 0. 2 to 1 MHz) is used
resulting from stronger cavitation effect
 In musculoskeletal disorder phonophoresis with topical steroid or NSAID has been
effective in pain reduction in MPS, OA Knee , CTS and epicondylitis
52

53. Shortwave
 Produces heat by converting electromagnetic energy into thermal energy
 Generate heat by oscillating high frequency electrical and magnetic field to move
ions, rotate polar molecules and distort non polar molecules
 Bandwidth 13.56, 27.12 and 40.68 MHz used m/c is 27.12 ( wavelength of 11m)
 Therapeutic effect happens at 40*c to 45*c
 Higher temperature cause protein denaturation result in irreplaceable call damage
and acute pain
53

54. shortwave
 Temperature increase is measured by specific absorption rate which represent rate
of energy absorbed per unit area of tissue mass
 SAR directly proportional to square of induced electrical current
 Inversely proportional to electrical conductivity of tissue
54

55. Techniques
 Short wave energy delivered via
 Capacitor electrodes
 Inductor electrodes
55

56. Capacitor electrodes
 Consist of 2 condenser plates in between strong electric field is created
 Produce more power absorption and heat generation in areas with high resistance
to passage of electric field such as subcutaneous fat
 Plate and patient treated area act like capacitor
 Highest temperature occur in areas with highest electric current density usually
those near plate surface
 Heat produced by friction of molecules occurring due to attraction and repelling of
positive and negative ions and alternating electric field periodically and rapidly
56

57. 57

58. Inductive electrode
 Induction coils that produce stronger magnetic field
 Alternating magnetic field also moves ions and charged molecules result in heat generation
 More heat generation in deeper high water content tissue such as muscle
 Different shapes of electrode available
 Pad electrodes ( placed on two sides of back)
 Cable electrode (rubber coated cable wrapped around extremity
such as knee)
 20 to 30 minute of treatment is necessary to achieve enough heating and maximum therapeutic
effect
58

59. 59

60. Pulsed SWD
 Produced by interrupting the output of conventional continuous SWD at consistent
interval
 Hence heat dissipation occur during off time
 Induce dose dependent increase rate of fibroblast and chondrocyte proliferation
 Induce membrane proliferation of damaged cell ( theorised)
 Recent metaanalysis – small significant effect of pulsed SWD on pain and muscle
performance only when power levels were high enough to induce local thermal
sensation
60

61. Indications
 Preferred if target area is interior of large joint such as hip knee or ankle
 Pulsed SWD – acute condition
 Continuous SWD – subacute and chronic conditions
 Treatment of choice when uniform elevation of temperature required
 Muscle spasm
 Chronic pain ( inc pain threshold dec nerve transmission )
 Increase elasticity of connective tissue
Hence can be used in contractures of joint
61

62. Contraindications
 Impaired sensation
 Cognitive disability
 Epiphyseal plates
 Metal implants
 Cardiac pacemakers ( cessation of impulse, VF, loss of pacing)
 Implanted deep brain stimulators (death reported)
 Implanted electrical leads
 Edematous tissue, moist skin, eyes, fluid filled cavity, pregnant uterus ,menstruating
uterus
62

63. Microwave
 MWD produce heat by converting electromagnetic energy into thermal energy
 Generate heat by oscillating high frequency electrical field to lesser extent
magnetic field – induce vibration of molecules high in polarity
 Shorter frequency than SWD
 Does not penetrate tissue as deeply as shortwave or ultrasound
 Penetration decrease with increase of microwave frequency
 915 MHz ( wavelength 33cm) and 2456 MHz ( 12cm , m/c used)
63

64. Technique
 One or two electrode or applicator operating in continuous or pulse mode
 Applicator can be rectangular or round
 Applied perpendicular to skin of target site
 Penetrating depth 3-5cm
 Best for area with low s.c fat content so tendons muscles and joints can be covered
effectively
64

65. Indications
 Absorbed significantly by water – hence used in muscular pain
 Due to limited penetration used in superficial muscles and shallow joints
 Chronic neck and back pain ( recent studies- failed to show additional benefits)
 Joint arthritis
 RCT on MWD shows MWD of 3 times a week for 4 weeks significantly improve pain
and function in moderate OA knee with benefits retained for atleast 1 year
65

66. Contraindication
 Impaired sensation
 Cognitive disability
 Epiphyseal plates
 Metal implants
 Cardiac pacemakers ( cessation of impulse, VF, loss of pacing)
 Implanted deep brain stimulators (death reported)
 Implanted electrical leads
 Edematous tissue, moist skin, eyes, fluid filled cavity, pregnant uterus ,menstruating
uterus
66

67. Extracorporeal shock wave therapy
 Shock wave used are high intensity pulsed mechanical waves with relatively low
repetition frequency
 Temperature increase in focal area is negligible for therapeutic frequency
 Pressure amplitude currently used range from few bars to more than 100
megapascals (1Mpa = 10bar)
 Shock wave travel faster than sound. At wavefront positive pressure raises followed
by longer phase of negative pressure
67

68. How waves are generated?
 Focussed shock waves are generated by 3 ways
 Electrohydraulic
 Electromagnetic
 Piezoelectric generators
68

69. Electrohydraulic generators
 Electrode placed in first focal point of semiellipsoid reflector and high voltage is
switched to tips of electrode to generate electrical spark
 Shock wave is released by vapourisation of water between electrode tip
 Shock waves are then reflected to second focal point (therapy adjusted to target
site of body) by metal ellipsoid reflector
69

70. Electromagnetic generators
 Features flat coil and isolated conductive membrane
 High current pulse through coil generate and induce 2* magnetic field with
opposite polarisation in opposite membrane
 These forces repulse and accelerate metallic membrane away from coil to create
acoustic pulse focussed on acoustic lens
 Treatment target is placed on focal point of lens
70

71. Piezoelectric shock wave generator
 Contains few hundred to few thousand piezoelectric crystals mounted on inner side
of spherical surface.
 High voltage pulse to crystals – contract and expand to generate pressure pulse in
surrounding medium
 Focussed by geometric shape of sphere and increase in amplitude during
propagation of wave to focal point where target is positioned
71

72. ESWT
 Generated pressure pulse are concentrated into small focal area of 2-8mm in
diameter
 Energy flux density is term used to describe dose of shock wave energy in
perpendicular direction to direction of propagation
72
ESWT ESD
Low energy 0.08-0.28 mJ / mm2
Medium energy 0.28- 0.60
High energy > 0.60

73. Radial shock wave
 Emerged for treatment of tendinopathy – effective
 Compared with conventional does not have focussed side effect
 Wave disperse eccentrically from applicator tip
 Advantage : wider effective regions without precisely locating painful joints
73

74. Physics
 Pressure waves are generated by accelerating a projectile with compressed air
through a tube at the end of which an applicator is placed
 Projectile hits the applicator and applicator transmit generated pulse wave into
body
 Pressure amplitude is only a few bars
74

75. Technique
 2000 to 3000 shock wave for 3 consecutive sessions applied at weekly interval
 USG is used to determine the location and depth of target site
 Highest and most tolerable energy output within medium intensity range is ideal
option when applying focussed shock wave on soft tissue disorder
 High intensity treatment for bony non-union – may induce swelling local analgesia
required
75

76. Technique
 High energy ESWT performed in hospital or ambulatory surgery centre
 Medium to low energy ESWT or RSWT in office without anesthesia
76

77. 77

78. Indications
 Plantar fasciitis ( destroy sensory unmyelinated fibres and elicit neovascularisation)
 Success rate is 60 – 70% for chronic plantar fasciitis
 Rotator cuff calcified tendinopathy
 Level 1 evidence – atleast 6 month effectiveness of focused shock wave of medium
intensity regime in reducing shoulder pain dissolve calcification and improve
shoulder function
 No evidence for noncalcfied shoulder tendinopathy
78

79. Indications
 Able to stimulate bone remodelling
 Nonunion ( hypertrophic > atrophic)
 Delayed unions
 Fractures
 Controversy still exist
 Lateral epicondylitis ( conflict exist)
79

80. Contraindications
 Bleeding disorder
 Pregnency
80

81. COMPLICATIONS
 Soft tissue swelling
 Ecchymosis or hematoma
 Redness of skin
 Increased pain
 Skin erosions
 Nerve lesions
 Transient bone edema
 Humoral head osteonecrosis
81

82. Electrotherapy
82

83. Physiology and mechanism
 Segmental inhibition of pain signals to brain and dorsal horn of spinal cord ( gate
control theory)
 Activation of descending inhibitory pathway and stimulation of release of
endogenous opioid and other NT like serotonin GABA noradrenaline and
acetylcholine
83

84. Physiology and mechanism
84

85. MODALITIES and INDICATIONS
MODALITY INDICATION
TENS Nociceptive pain ( acute , subacute , chronic)
/ neuropathic
Percutaneous electrical nerve stimulation Mild to moderate pain
Electrical twitch obtaining intramuscular
stimulation
Myofascial pain syndrome
Interferential current Musculoskeletal conditions/ neurologic
conditions/ incontinence
Electrical myostimulation Sarcopenia MPS
High voltage galvanic stimulation Wounds weakness fatigue
microcurrent Depression ptsd anxeity, neuropathic pain,
fibromyalgia
Iontophoresis Acute/ subacute / chronic pain soft tissue
inflammation , pain prophylaxis, swelling
85

86. Transcutaneous electrical nerve stimulation
 Small widely used portable units that deliver electric current to skin through
surface electrode
 Commonly used TENS units
 Conventional or traditional ( frequency greater than 50 HZ)
 Acupuncture like TENS( frequency of 1 to 10 HZ)
 Within each type patient can adjust intensity ( amplitude) width ( duration) rate (
frequency) and mode ( pattern) of electric current based on desired effect
86

87. TENS
 Conventional TENS provide tingling sensation to patient
 Acupuncture like TENS provide burning needle sensation
 Normally 30 minutes per session
87

88. 88

89. INDICATIONS
 Chronic pain
 Low back pain ( not reasonable and necessary)
 Painful diabetic polyneuropathy
 Myofascial pain syndrome
 Spasticity reduction
89

90. Precautions and adverse effects
 Contact dermatitis
 Damage to skin ( partial or full thickness burn)
 Contraindications
 Electrode ( pacemaker, intrathecal pumps and spinal cord stimulator)
 Near gravid uterus
 Insensate skin or cognitive impairment
 DVT
90

91. Interferential current
 Type of electrotherapy uses
alternating medium frequency
electric current ( 4000HZ) signals of
different frequencies
 2 waves in phase – constructive
interface
 Out of phase – destructive interface
 Based on synchronisation resultant
wave ranges from double the
amplitude to zero
 The frequency of resultant wave
equals difference in frequency
between 2 signals
91

92. IFC
 In the practical application signal frequency beat frequency amplitude and cycle
time can be adjusted as needed
 Advantages over low frequency TENS
 Penetrate skin more easily by decreasing skin impedance
 Amplitude can be fixed or modulated so that point of maximum amplitude
interference changes
 This helps in creating low frequency current deep within treatment area
92

93. USES
 Used in variety of musculoskeletal and neurological condition and in urinary
incontinence
 Recent studies shows
IFC does not show any unique attribution over placebo if given alone
as combination therapy can show some benefits over placebo
in chronic low back pain IFC combination therapy show benefit even at 3rd month
CONTRAINDICATION
Near open incision or abrasion
93

94. Iontophoresis
 Technique of using charges of ions and particle to drive them across tissues under
influence of imposed electric field
 Also referred as injection without needle
 To produce this effect a positive and negative charge is applied to skin to
administer a drug transdermally
94

95. Technique
 Solution to be phoresed is placed in electrode of same polarity
 Then positive, negative and ground electrodes are applied to skin
 DC of typically 10 to 30 mA is applied to drive into tissues
drugs commonly delivered
lignocaine , dexamethasone
95

96. Uses
 Lateral epicondylilts
 Shoulder tendonitis
 Lidocaine iontophoresis (1 % to 4% lidocaine with or without epinephrine at 20mA
/ min to 80 mA/ min dose applied for 5 to 10 mins
 Used during arterial or venous canulation
96

97. Microcurrent
 Electric current of extremely low amplitude
 Deliver stimulation directly to brain by means of earclip electrode or directly to
body
 Earclip electrode delivered with protocol called cranial electrotherapy stimulation
 Body stimulator with regular electrode referred as microcurrent electrical therapy
97

98. Uses
 CES used in anxiety depression and insomnia fibromyalgia and neuropathic pain (
in spinal cord injury patient too)
 Some benefit in pain sleep fatigue
98

99. Cervical and lumbar traction
99

100. Cervical traction
 Distract cervical vertebrae and can be applied continuously or intermittently
 Effect :
 Elongation of cervical vertebrae relieve pressure on intervertebral disc
 Relieves pressure on spinal nerve root
 Reduce pressure on facet joint
 Elongate cervical musculature
100

101. Treatment duration
 Facet joint pathology – 25min
 Degenerative disc disease 10 min
 Disc protrusion – 8-10 min
 Muscle spasm 20 min
101

102. Indications
 Degenerative disc disease
 Herniated or protruded intervertebral disc
 Nerve root compression or radicular pain and associated muscle spasm
 OA/ facet joint inflammation
 Capsulitis of vertebral joints
 Muscle spasm
102

103. Contraindication
 Acute injury
 Unstable spine
 Tumour / meningitis
 Fracture
 Spinal cord compression
 Positive vertebral artery test
 Osteoporosis
 Rheumatoid arthritis
103

104. Precaution
 In trauma – never attempt
 Monitor closely for pain
 Improper traction result in rupture of cervical esophagus
 Excessive duration / traction weight – internal jugular vein thrombosis
 Low tension should be used in hypermobility
 Mandibular occipital harnesses should not be used if patient suffering from TMJ
pathology
104

105. Lumbar traction
 Lumbar traction distract lumbar and possibly the lower thoracic vertebrae and can
be continuous or intermittent
 Effect :
 Elongation of lumbar vertebrae relieve pressure on intervertebral disc
 Aids reabsorption of nucleus pulposus
 Relieves pressure on spinal nerve root
 Reduce pressure on facet joint
105

106. Treatment duration
 Facet joint pathology – 25min
 Degenerative disc disease 10 min
 Disc protrusion – 8-10 min
 Muscle spasm 20 min
106

107. Indication
 Degenerative disc disease
 Herniated or protruded intervertebral disc
 Nerve root compression or radicular pain and associated muscle spasm
 OA/ facet joint inflammation
 Facet joint pathology including hypomobile facet joint
 Muscle spasm
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108. Contraindication
 Acute injury
 Unstable spinal segment
 Cancer meningitis
 Extruded disc fragment
 Advanced disc degeneration
 Spinal cord compression
 RA , Osteoporosis
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109. Precautions
 Monitor closely – discontinue if symptom increase
 Low tension traction used if ligamentous injury suspected
 Only sustained or continuous traction if lumbar motion contraindicated
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110. THANK YOU
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