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PHYSIATRIC THERAPEUTICS

Strength
• Is the maximal force or torque that can be exerted by a muscle

Factors that Affect Strength

• Size of the muscle
• Synchrony of the motor units
- using electromyography, there is an increased synchrony of motor units noted when
muscles are exercised and is increasing in strength
• Age factors
- Hypertrophy is thought to be age dependent
- Younger age groups tend to be outdone by older age groups by 2:1
- Hypertrophy is more noted in younger age groups while older age groups demonstrate
significant changes in IEMG
• Hormones
- Epinephrine may contribute to increasing strength
• Physiologic / Behavioral factors

Types of Muscle Contraction

• Static (Isometric)
- There is no movement of the load which the muscle is acting
- Internal reductions in muscle length with lengthening of elastic elements in series
with the muscle
• Dynamic Contractions
- Muscles may have lengthening or shortening fashions and the resistance may be
applied in various manners

Types of Dynamic Muscle Contractions

• Concentric contractions:
- Muscle shortens as it contracts
• Eccentric contractions:
- Muscle lengthens as it contracts
• Isotonic contractions:
- Tension of the muscle remains constant throughout the movement
• Isokinetic contractions:
- Movement is performed at a constant angular velocity but the load resistive force of
muscle tension vary

Programs to Increase Muscle Strength

• De Lorme technique
- Also known as progressive resistive exercise
- Give maximum load of which the person can lift 10 times (10 rep. maximum)
- The person then performs 3 sets of 10 repetitions for 5 days
- First set, at 50% of given load , second set at 75% of given load, third set being the
load itself
- 5th day, a new 10 rm is determined
• Oxford technique
- A reversal of De Lorme’s technique
- Done because some persons cannot complete the 3 sets because of fatigue
• The 1 RM or brief Maximal effort
- Maximum load of which the person can lift once and only once

Physical Agents Modalities

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Physiologic Response to Heat

heat

Decreased Increased Increased local

blood viscosity tissue temp sweating

increased Arteriolar
phagocytosis dilatation

Increased Increased capillary Increased capillary

capillary flow pressure permeability

Increased clearing Increased supply of

of metabolic waste nutrients

How Heat is being Transferred

• Conduction – direct transfer between two bodies
• Convection – uses movement of a medium to transport thermal energy
• Radiation – refers to the thermal radiation emitted from any body whose surface temperature
is above absolute zero
• Evaporation –process of transforming a liquid into a gas
• Conversion – transformation of energy into heat

Types of Heating Modalities

Superficial Heat
- Achieve their maximum tissue temperature in skin and subcutaneous fat

• Hot Packs
- Contain silicon dioxide
- Immersed in tanks with water heated to 74.5 ˚C
- Treatment time is usually 20-30 mins
- Transfer heat through conduction
• Hot Pads
- 2 types available
o Circulating fluid pads
o Electric pads
- Have a potential to produce electrical shock if insulation is bad
- Oscillating temperature of up to 5˚C is noted
• Infrared Radiation
A. Luminous IR emit near IR spectrum (1770-1500nm)
B. Non-luminous IR emit far spectrum (1500-12,500nm)
- Heat is produced by introducing molecular vibration

Precautions when giving IRR

- General heat precautions
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- Light sensitivity
- Skin drying
- Dermal photoaging
• Fluidotherapy
- Dry heating modality
- Solid-gas mixture
- May have a massaging action
- Typical temperature range is 46.1˚C to 48.9˚C
- Infected wound is a relative contraindication
• Paraffin Bath
- Paraffin wax and mineral oil is mixed in a ratio of 6:1 to 7:1
- Applied in various ways:
o Immersion
o Dipping
o Brushing

Deep Heating Modalities

Ultrasound
- Acoustic vibration with frequencies above the audible range
- Due to the piezoelectric characteristic of certain materials
Therapeutic Range: 0.75 Mhz to 3 Mhz
Diagnostic Range:1 Mhz to 10 Mhz

 Attenuation
- US lose a portion of their energy while traveling through the tissue
 Absorption
- Is a major cause of attenuation and US is converted into heat

2 Types:
Pulsed:
emission of brief bursts or pulses of US interspersed while silence
o Less heat
o Emphasize the non thermal effect
Continuous:
Continuous emission of US

Thermal Effects
- when the acoustic energy is absorbed, producing molecular vibration, thus heat is
made
Mechanical Effects
- micromassage
- loosening of microscopic cell structure
- reversible decrease of viscosity of drugs
- depolymerization of proteins specially in nerves, muscle and collagen cement
Non-Thermal Effects:
• Cavitation
- Produced during the phase of relaxation and rarefaction
- May cause platelet aggregation and even cell death
• Microstreaming
- Produced by stable cavitation with nearby particles being attracted to it
- May cause cell membrane damage and death
• Standing waves
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- produced by superimposition of incident and reflected sound waves
- may cause stasis of red blood cells

Precautions:
• near brain, eyes and reproductive organs
• gravid and menstruating uterus
• near pacemakers
• near spine/aminectomy sites
• malignancy
• skeletal immaturity
• arthroplasties
• methyl methacrylate or high density polyethylene

Short Wave Diathermy

• Heat is produced by conversion of electromagnetic energy to thermal energy
• Heating pattern depends on the type of SWD unit and the water content of the tissue involved
• 22.12MHz (11m wavelength) is most commonly used

2 Major Types of Machine

o Inductive
- Achieve higher temperature in water rich tissues
o Capacitative
- Achieve higher temperature in water poor tissues

Precautions:
- Metal parts/jewelry, IUD, surgical implants
- Contact lenses
- Gravid or menstruating uterus
- Skeletal maturity

Microwave Diathermy
• electromagnetic energy is also converted into heat
• heat is produced by the increased kinetic energy
• approved frequencies are 915MHz (33cm wavelength) and 2456 MHz (12 cm wavelength)
• more water in the tissues, the faster they are heated (ie. microwave oven)
• 915 MHz is preferred for muscle heating
• Largely replaced by ultrasound and hot packs

General Precautions:
- Metal
- Pacemakers
- Skeletal immaturity
- Fluid filled cavties (ie. eyes, effusions, etc)
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Cryotherapy

Cold

Decreased tissue Decreased

temperature metabolism

Decreased Decreased Decreased Decreased

bleeding removal of by production of leukocyte,
products metabolites phagocyte activity

Retard healing

Physiologic Effect of Cold

• Hemodynamic
- Vasoconstriction
- Decrease inflammation especially during acute stages
• Neuromuscular
- Decrease conduction of nerves
- Reduced spasticity
• Joint and Connective Tissue
- May cause decreased synovial collagenase activity
- Decrease joint extensibility
- Increased joint stiffness
• Miscellaneous Effect
- Analgesia

Cryotherapy Agents
• Cold Packs
- Cooled at -12˚C
- Covered with moist towels
- Duration of application is 20 to 30 mins
• Ice Massage
- Direct application of ice
- Used for localized symptoms and applied for 5 to 10 mins
- Studies show a decrease of temperature by 4.1˚C at depts of 2 cm
• Cold Water Immersion
- Usually with water cooled to 5˚C
- Poorly tolerated
• Cryotherapy Compression Units
- Used primarily for acute musculoskeletal injury
- Cold water (7.2˚C) is pumped through a pneumatic sleeve at pressures of 60mmHg are used
• Vapocoolant Spray
- Fluori-Methane is used
- Often used for patients with Myofascial pain syndrome
- Spray and stretch routine is used
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Hydrotherapy
- External application of hot or cold water
- Uses a whirlpool bath or a hubbard tank
o Both uses agitation by aeration, dispersal of thermal energy through convection
o Hubbard tank is used for whole body immersion
o Used for adjunctive therapy for arthritis, infected wounds
o Isotonic saline is used to prevent or minimize fluid shifts
- Contrast baths
o Consist of alternating immersion of the distal limbs in hot (42 to 45˚C) then cold (8.5
to 12.5˚C)
o Effect is believed through cyclic vasoconstriction and vasodilatation
o Beneficial for rheumatic diseases. Neuropathic pain and reflex sympathetic dystrophy
Other Methods
• Phonophoresis
- Uses US to facilitate migration of topically administered medications
- Corticosteroids are frequently used
• Iontophoresis
- Migration of charged particles across biological membranes under imposed electrical field
- Used in delivery of medications
- 2nd pass effect of drug can be skipped because of topical application
- Miliarisis are often reported in patients treated for hyperhydrosis

Manipulation
- Use of the hands in the patient management process using instructions and maneuvers to maintain
maximal, painless movement in postural balance

o Thrusting
 Mobilization with impulse
- Relies on the reintroduction of movement in a restricted or dysfunctional area
- High thrusting forces are to be avoided
- Delivers the thrust at the deepest point of patients exhalation
- Thrust last for about 0.5 sec
- Muscle guarding by the patient defeats the purpose

Contraindications:
- Unstable fractures - herniation
- Severe osteoporosis - hypermobile joints
- Multiple myeloma - rheumatoid arthritis
- Osteomyelitis - inflammatory phase or Ankylosing
- Tumors in bone/spine Spondylitis
- Progressive neurological deficit - psoriatic arthritis
- Congenital bleeding disorder - Reiters syndrome
- Poor manipulative skill - anticoagulant therapy
- Cauda equine
- central cervical disc
o Non Thrusting
 Articulatory Technique
- Combination of leverage, patient ventilatory movement and a fulcrum is used to achieve
mobilization
- Done by repeatedly applying a low velocity/high amplitude force to engage the barrier
directly then move away from it
 Muscle Energy Technique
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- Involves the patient’s voluntary contractions of muscles against resistance supplied by the
practitioner
- Goal: to increase ROM and return symmetrical motion to the affected segments ,
strengthen weakened muscles
- Dubbed as “ contract-relaxed”
 Strain Counterstain
- Attempt to passively place a spinal segment or other joint into its position of greatest
comfort or ease
- Aimed at relieving painful dysfunction through a reduction in inappropriate afferent
proprioceptor activity
- Some patients tend to become addicted to this form of manipulations
 Myofascial Release
- Treats the neuromuscular-somatic unit as a whole
- Uses a combination of manual traction and twisting movements
o Direct technique
•Engages the restrictive barrier and pushes it with constant force until released
o Indirect technique
• Uses the path of least resistance until free movement is achieved
 Craniosacral Therapy
- Technique for diagnosis and treatment by using the respiratory mechanism
- Enjoys more of a hypothetical than hard scientific support
 Soft Tissue Technique
- Uses lateral stretching, linear stretching, deep pressure or traction or a combination
- Incorporates massage and acupressure
 Lymphatic pump
- Utilizes muscle forces and intrathoracic pressure changes to enhance lymph flow

Potential Side Effects in Manipulation

• Autonomic effects
o Hypotension
o Increase menses
o Perspiration
• Transient increase in discomfort

Traction
Types of traction
• Continuous
- Low force over a long period of time
- Sometimes not well tolerated
• Sustained
- Uses greater pull, maintained for 20-60 mins
- Difficult to tolerate
• Intermittent
- Allow the use of greater forces for a shorter period of time
- More tolerated
- Uses a patient controlled protocol based on tolerance
• Cervical
- Maximum separation of cervical vertebrae occurs with the neck at 24˚ flexion
- Best clinical relief noted when neck is flexed at 20-30˚ flexion
- Prescribed often in sitting position but neck is most uncontrollable and patients have
difficulty relaxing the neck muscles
• Lumbar
- Requires larger forces
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- Often done intermittently
- Pain relief is often noted when the lumbar spine is in flexion
Contraindications
• Osteomyelitis
• Tumors
• Unstable fractures
• Severe osteoporosis
• Hypertension
• Cardiovascular disease
• Inadequate expertise
Cervical
• Central disc herniation
• Hypermobile joints
• Rheumatoid arthritis
• Carotid/vertebral artery disease
Lumbar
• Cauda equine

Massage
- 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

Goals of Treatment:
o Sedation
o Fluid mobilization
o Vascular changes
Effects:
o Promote blood circulation
o Promote lymphatic flow
o Reduced anxiety
o Improve immune system
o Improve recovery of muscle ability to perform exercise
o Adhesion reduction
o Muscular relaxation
o Reduced edema
o Reduction of adhesions
o Improve neural conduction
o Myofascial flexibility

Types of Massage
• Effleurage
- Stroking massage
- Involves lightly running the hand over the skin
- Maybe superficial or deep
- Effective in returning venous/lymphatic flow
• Petrissage
- Compression massage
- Includes kneading, picking up, wringing, rolling and shaking
- Compression of muscle tissue
- Mobilize fluid and tissue deposits
- Break up tissue and muscle adhesion
o Kneading
- 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
o Picking up
- Compression of soft tissues to deeper ones
- Grasping of the soft tissue
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- Release of soft tissue
- Moving the hands to the new position
o Wringing
- Resembles picking up except once the tissue is grasped using two hands side
by side, one hand pulls while the other pushes
o Rolling
- Motion of gathering skin alone or muscle and skin between fingers and thumb
and allowing the tissue to roll between the digits before releasing and taking
another nearby grasp
o Shaking
- 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
• Friction massage
- Applying circular or transverse motions through the fingers, thumb or the heel of the
palm of the hand to small area of tissue
- When applied correctly, no motion should occur between the skin and the finger
• Tapotement
- Percussion massage
- Stimulation by rhythmic, alternating movements of the hands on the soft tissue of the
patient
- Clapping, hacking, vibrations, beating , pounding, tapping are its subtypes
o Clapping
- Uses capping of hands while striking the body/muscle
o Hacking
- Consist of repetitively striking the body with the medial border of the hands
o Vibration
- Rapid up and down motion of pressure and release within the soft tissue
without losing contact with the skin
o Beating
- Strikes the body, palm down
- Rarely used
o Pounding
- Striking the body using the medial border of the fist
- Rarely used
o tapping
- uses the finger pads to percuss
• Acupressure
- Technique of applying constant circular friction pressure to specific points for treatment
purposes
- Used to control nausea, vomiting
- Decreased post-operative pain
- Treat headache and TMJ pain
- Assist in pulmonary rehabilitation
• Shiatsu
- Based on the Japanese interpretation of the acupuncture theory and flow of chi
- Heavy pressure is applied perpendicular at certain points in the meridians in the body
using the palm of the hand or the heel of the foot
• Reflexology
- Believes on homuncular representation of the entire human body in the hand or foot
- Pressure is given on certain areas of the hand to heal or treat the organs represented
- Often uncomfortable
• Rolfing
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- Method of restructuring and realigning the deep fascial planes in the body through a
variety of deep friction massage techniques
- Adheres to the concept of mind and body integration
- May influence the psychological state to correct physical problems
• Trager Psychological Integration
- Combination of gentle, hands on tissue work, movement reeducation and relaxation
exercises
- Movement work emphasizes ease and pleasure

Contraindications and Risks:

- Not performed in areas of malignancy, cellulites, lymphangitis
- Not applied to acute trauma or bleeding
- Not applied to bloody areas where the practitioner is exposed to blood borne
pathogens
- DVT (deep vein thrombus)

Electrography
The Normal Muscle
- The motor unit consist of;
 Alpha motor neuron
o Vary in size
o Small neurons have low activation frequency
o Large neurons innervate fast fibers
 Myoneural Junction
 Muscle fiber it innervates

Muscle Properties
I IIa IIb
Morphology
Name Red Intermediate White
Capillary Density  Intermediate 
Histochemical
Myosin ATPase   
Mitochondria   
Glycogen low intermediate high
Myosin HC HOs Hdfa HOfb
Myosin LC LC1a,1b,2 Lcf 1,2,3 Lcf 1,2,3
Metabolism
Type Oxidative Oxidative/glycolytic Glycolytic
Aerobic Mixed Anaerobic
Contractile
Properties Slow Fast Fast
Twitch slow intermediate rapid
Fatigueability

Muscle Properties
- Orderly progression of stimulation
o Weak slowly conducting units w/ Type 1 are recruited first
o Next recruited are the Type IIb fibers w/c have high conduction velocity
- Artificial stimulation
o Reverse of the normal recruitment

Muscle & Response to Electrical Stimulation

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- Studies have shown that continuous electrical stimulation of the normal, fast twitch fibers will result
in transformation of the said fibers to a composition of Type I characteristics

Uses of Electrical Stimulation

- NMES can be used as an orthotic assist
- NMES, combined w/ voluntary contraction may improve the strength of selected muscles
- NMES may help in preventing muscle atrophy in immobilized limbs
- NMES may help in evaluating the etiology of the weakness

ES & the Myopathic Muscle

- 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

ES & the Denervated Muscle

- Shown to preserve muscle bulk for only a short period
- May induce a hybrid fiber type
- May cause improvement in muscle tension
- No data supports acceleration of reinnervation

ES & Prevention of Complications brought by Disuse

- Cardiovascular deconditioning
o Assist in reduction of venous pooling
o Assist in improving cardiorespiratory fitness
o Assist in improving stroke volume
- Osteoporosis
o ES may produce small increments in bone mass
- DVT ( Deep Venous Thrombosis)
o NMES have been shown to decrease the plasma fibrinolytic activity
- Psychological Effects
o Shown to help decrease chance of depression
o Showed to increase self esteem
o May be due to increase in -endorphin levels

Therapeutic Functional Electrical Stimulation

- Ejaculatory failure
o Using a rectal probe, one can collect semen
o Semen quality and sperm motility were not affected
o Found to be safe w/ minimal autonomic dysreflexia & mild rectal mucosal changes
- Management of spasticity
o Studies showed a decrease in spasticity in familial spastic paraplegia
o May not be effective for spasticity due to spinal cord injury
o May decrease spasticity in stroke, esp. when used in conjunction w/ botulinum toxin
injection
- Upper limb hemiplegia
o May decrease the shoulder subluxation
o May improve muscle tone and function
o May improve function of a chronic hemiplegic arm
- Phrenic nerve stimulation
o May assist the tetraplegics in breathing continuously
- As an Orthotic Device
- Often used only for patients who cannot tolerate appropriate bracing in scoliosis
- Used as an adjunct to improve gait patterns in hemiplegics
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Other Applications
- For standing & Gait
o Used for paraplegics, however, may be bulky and may add damage to joints
o Newer equipment may require implantation
o May exceed the oxygen utilization compared to those who use conventional orthosis
- Restoration of Upper Limb Function
o Implanted FES may be used to return hand use
o Development of sensory feedback system for joint proprioception, contact, force, slippage,
pressure & temperature are prerequisites
- Wound healing
o Increase the number of fibroblasts, collagen, protein & DNA synthesis
o Increase neutrphilic granulocytes
o Suppress mast cells w/c are responsible for scarring
o Bacteriostatic & bactericidal properties
o Improve blood flow