A Handbook of Physiotherapy PDF

A Handbook of
PHYSIOTHERAPY
A Handbook of
PHYSIOTHERAPY
B.K. Choudhury
MBBS, DSM, MD (PMR)
Professor and Head
Department of Physical Medicine and Rehabilitation
Medical College, Kolkata
A.K. Bose
DPT, MIAP
Senior Physiotherapist
Medical College and Hospital
Kolkata
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A Handbook of Physiotherapy
© 2006, B.K. Choudhury, A.K. Bose
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system,
or transmitted in any form or by any means: electronic, mechanical, photocopying, recording,
or otherwise, without the prior written permission of the authors and the publisher.
This book has been published in good faith and belief that the material provided by authors
is original. Every effort is made to ensure accuracy of material, but the publisher, printer and
authors will not be held responsible for any inadvertent error(s). In case of any dispute, all
legal matters to be settled under Delhi jurisdiction only.
First Edition : 2006
ISBN 81-8061-683-5
Typeset at JPBMP typesetting unit

Printed at Gopsons Papers Ltd., A-14, Sector 60,Noida
to
My departed parents
and
in-laws
Who had shown the path to progress
Foreword
It is my proud privilege to foreword the book entitled A
Handbook of Physiotherapy written by Professor B.K.
Choudhury. I know Professor Choudhury since a long time and
have worked together in several institutions. I have seen him
taking keen interest in the discipline of Rehabilitation Medicine.
In fact, physiotherapy, a science, is an integral part of
Rehabilitation Medicine. Every medical graduate including the
postgraduate students of orthopedics, internal medicine and
neurology ought to know the fundamentals of physiotherapeutic
measures. In the outcoming modern and fast lifestyle most of
the health problems caused by excessive stress and strain can be
efficiently tackled by the physiotherapeutic measures rather only
by pharmacotherapy.
This book is aimed at those, who are not exposed to the light
of this subject and this would also benefit the students of
physiotherapy.
This book is a great boon for everyone concerned as it
is probably the first book to incorporate every aspect of
physiotherapy as well as physiotherapeutic measures.
I pray for his success in this endeavor.
Professor N.C. Ghosh

MS (Ortho)
Professor and Head
Department of Orthopedic Surgery
Medical College, Kolkata, WB
Preface
Physiotherapy is an excellent health care profession, which is
growing its importance and expending the scope of practice. Few
people appreciate the breadth of knowledge and skills required
to become a good physiotherapist. It is in fact a specialized job,
treating patients of all ages and both sexes with a wide range of
needs, helping and advising their careers, and educating the
public to help themselves. This course addresses all aspects of
working people with disabilities with special emphasis on the use
of information technology to assist empowerment.
Physiotherapists identify and maximize movement potential
through health promotion, preventive health care, treatment and
rehabilitation. The core skills used by physiotherapists include
manual therapy, therapeutic exercises and application of electro-
physical modalities. A physiotherapist uses physical means to
facilitate and return to functional independence and restoration
of normal lifestyle for individual patient.
Keeping in view of the above I was fascinated and thought
to circulate the essence of physiotherapeutic approaches to the
young students of physiotherapy and to the budding medical
graduates, even to the medical practitioners. Often I was asked
to name a comprehensive book so that an overall idea on
physiotherapeutic procedures can be obtained. It was really a
difficult task. Truly speaking physiotherapy is a science which can-
not be restricted in one single book. Still I tried to keep the
essential parts of this science in a comprehensive manner in a
single handbook. I realize by doing this I have done injustice to
this science. Many of the sections are either left or are given little
importance which should not have been. I may be excused for
the unintentional procedure. A constructive criticism is always
x A Handbook on Physiotherapy
welcome to build the health of this book. This is my humble way

of spreading the essence of physiotherapy.
I must show my gratitude to the person who had encouraged
me even on the first day of my thought, is Mr Sanat Kumar
Guha, my brother in-law. Though is engaged in a profession
completely different from medical science he encouraged me off
and on, and repeatedly pushed me to go ahead. I am very much
obliged to my wife and daughter because without their moral
support and active participation in various ways it would have
not been possible to bring out this book. They have sacrificed
many of their enjoyable times for this work. I am too thankful
to my co-author Mr A.K. Bose for his constant help and idea
in writing different sections of this book. I must offer my thanks
to those who have directly or indirectly associated to bring out
this book like M/s Jaypee Brothers Medical Publishers (P) Ltd,
New Delhi and Kolkata Branch.
In working on this book, I had come across a volume of
literatures and many books, out of which I could report only
some portions that I must acknowledge with no hesitancy. The
main aim of this book is to make this subject meaningful and
more realistic. However, this is only a handbook, so for detail
discussion a textbook is to be consulted.
B.K. Choudhury
Contents
1. Electrotherapy ...................................................... 1
2. Low Frequency Currents Used in Physiotherapy ..... 8
3. Transcutaneous Electrical Nerve Stimulation
(TENS) ............................................................... 15
4. Interferential Therapy (IFT) ................................ 21
5. Thermotherapy ................................................... 27
6. Ultrasound Therapy ............................................ 39
7. Electromagnetic Spectrums and EMG
Biofeedback ...................................................... 47
8. Cryotherapy and Hydrotherapy ........................... 58
9. Exercise Therapy ............................................... 63
10. Massage Therapy ............................................... 82
11. Manipulation, Suspension and Traction .............. 86
12. Orthosis and Braces .......................................... 95
13. Mobility Aids ................................................... 102
14. Physiotherapy in Some Common Conditions .... 105
Bibliography ............................................................... 115
Index .......................................................................... 117

CHAPTER
1
Electrotherapy
Electrotherapy is a section of physiotherapy, which is concerned with the

treatment of pathological conditions by the passage of electrical current or
radiation rays through the body. Electric currents passed through a biological
system can produce thermal, physiochemical and physiologic effect. To
understand the mechanism of action whereby electrical currents produce these
affects, some of the basic terminology and concepts of electricity are needed
to be clarified.
ELECTRIC CURRENT
Electric current is the flow of electrons through a conducting medium when
a potential is placed across the ends of the conducting pathway. The direction
of the current flow is exactly the reverse of the direction of the flow of electrons.
The essential factors for the production of an electric current are the
difference of potential (PD), a conducting pathway between the points of
potential difference. This potential difference is achieved by the use of a battery
or electromagnetic induction with a dynamo.
Current may be
• Alternating current (AC)
• Direct current (DC)
Electromotive Force (EMF) (E)

The force that causes the movement of electrons is called electromotive force
(EMF) and it is measured in volt.
Resistance (R)
It is the property inherent in any material, which opposes an electrical current
flow. The unit of electrical resistance is Ohm. One Ohm is equivalent to the
resistance offered by a column of Mercury of 106.3 cm long and 1sq mm
in cross-sectional area at a temperature of 0°C.
The material of the conductor, length, cross-sectional area and temperature,
2 A Handbook of Physiotherapy
all determine the resistance of a pathway.

For a given material the availability of free electrons to conduct a current
determines the resistance of the material. The grater the number of free
electrons the lower is the resistance.
For example, in rubber the electrons are bound closely to their nuclei
and have few free electrons and that is why it is a poor conductor of electricity.
So rubber acts as an insulator.
Magnitude of Current (I)

The intensity or magnitude of current (I) is the rate of flow of electrons through
the conductor per second. It is measured in Ampere. One Ampere is the rate
of flow of 1Coulomb of electrons per second (6.26 × 1018 electrons).
RELATIONSHIP AMONG MAGNITUDE OF CURRENT FLOW,

VOLTAGE AND RESISTANCE
The relationship of the above three factors is stated in Ohm’s law, which
states that the magnitude of an electric current varies directly with the EMF
and inversely with the resistance.
The formula expressing Ohm’s law –
I = E/R
That is, Amp = (Volt/ Ohm),
Where, I = current flow measured in Ampere.
E = emf measured in Volt.
R = resistance in Ohms.
RESISTANCE IN SERIES
Components parts of an electrical circuit can be connected either in series
or in parallel. Let us discuss the connection of three resistances in series:
Fig. 1.1: Resistance in series

Electrotherapy 3
a. As the current has to pass through each resistance in turn, then the total
resistance equals to the sum of the individual resistance (Fig. 1.1).
R (Total resistance) = r1 + r2 + r3
= 60 + 30 + 10
=100 Ohms.
b. The intensity of current flowing through each component equals to
I (Total amount of current) = (V/R)
= (200/100)
= 2 Amp.
c. The voltage drop across each resistance equals to
V = I × R
So V1 at r1 = I × r1
= 2 × 60
= 120 Volt.
Similarly V2 at r2 = 60 Volt.
and V3 at r3 =20 Volt.
RESISTANCE IN PARALLEL
In a parallel circuit the current has the liberty to flow in alternate pathway
not in a fixed path. Thus the current flow in each of the parallel pathways
is inversely proportional to the resistance of the pathway. The voltage drop
at across each of the pathways will be the same while the total resistance
will be less than any of the individual resistances (Fig. 1.2).
Fig. 1.2: Resistance in parallel

a. The total resistance equals to
b. The current flow equals to
c. The current flow across each path is
ELECTRICAL POWER
Power is the rate of doing work. To calculate this, time has to be considered.
It is measured in Watts.
Power (in Watts) = emf (Volt) × current (Coulomb)
FREQUENCY
It is the number of events occurring in unit time, i.e. number of complete
waves passing any fixed point in one second and is measured in Hertz.
By low frequency alternating current in electrotherapy we mean current
with frequencies between 50 to 100 cycles per second (50-100 Hz). High
frequency alternating current has a frequency of 1,000,000 c/sec (1 MHz).
Very high frequency alternating currents are in range of 1-50 MHz.
The characteristics of electrotherapeutic currents include their
direction, pulse, shape and amplitude. Indirect current (DC) there is
a constant flow of electron in one direction that is the polarity of the electrodes
are kept constant. A modification in the DC is, pulsed of interrupted DC.
In interrupted DC the direction of the current flow is not held constant.
Electrotherapy 5
In an alternating current (AC) the magnitude of flow of electrons constantly

change and the direction of flow reverses periodically. Since there is a constant
reversal of polarity of electrodes we never speak of positive or negative poles.
Figures 1.3a to c shows examples of alternating current.
Figs 1.3a to c: (a) Alternating current (sine wave), (b) Original faradic current
and (c) Square waves
The configuration that includes pulse and shape of both AC and DC can
take on many forms. In physiotherapy, we are more concerned about the
rate of rise of current. We can have immediate rise or can have slow rise.
The rate of rise of current directly affects the current’s ability to excite nervous
tissues (Figs 1.4a to c).
Figs 1.4(a to c): (a) Constant current, (b) Interrupted current, and
(c) Saw-tooth wave
The Duration of Current Flow

It is the period of time the current flows for each individual wave or pulse.
This period can vary from milliseconds for interrupted DC or AC to minutes
in uninterrupted DC.
The Amplitude of the Current Flow

It is the magnitude of current. The peak current is the maximum amplitude
of the current.
Surging of Current
In a surging current the intensity of each successive pulse gradually increases
in such a manner that each impulse reaches to higher intensity than that of
the preceding one and after the peak levels it either falls suddenly or gradually
(Fig. 1.5).
Fig. 1.5: Surging currents (Saw-tooth, triangular)
In physiotherapeutic practice most of the work is concerned with electrical

currents. So, it is important to know what type of current may be used or
desirable and their harmful effects.
TYPES OF CURRENTS
Following types of currents are used in practice:
a. Direct current
b. Low frequency, High frequency and Very High frequency Alternating
currents.
With DC the direction of flow of current is always the same. This type
of current may be allowed to flow continuously or it may be interrupted at
regular interval to short pulse of direct current. With alternating current the
direction of flow is regularly reversed. The most common type of alternating
current is sinusoidal or sine wave current.
Electrotherapy 7
CLASSIFICATION OF CURRENTS
Therapeutic current can be classified on the basis of direction, frequency,
voltage, amperage and biophysical effects.
a. On the basis of direction of flow of current:
• Alternating current—which flow in both direction
• Direct current—which flow in one direction.
b. On the basis of frequency:
• Low frequency currents—in the range of 50 to 100 Hz per second.
The primary use is stimulation of nerve and muscles. Various types of
currents are used in this category like direct current, interrupted direct,
high voltage pulse galvanic current, and TENS.
• Medium frequency currents—in the range of 100 to 4000 Hz per
second. These are basically used to stimulate deep-seated muscles and
nerves. Example, interferential currents.
• High frequency currents—here the frequency is more than 1MHz and
are used for deep voluminous heating of tissues. Example, Short Wave
Diathermy (SWD), Microwave Diathermy (MWD), and Ultrasound
Therapy (UST).
c. On the basis of voltage:
• Low voltage currents—where voltage is less than 100 Volt as in low
frequency currents.
• High voltage currents—where voltage is greater than 100 Volt as in
high frequency currents.
d. On the basis of amperage:
• Low amperage currents—where amperage is in the range of 1 to 30
mAmp. Example, high TENS.
• High amperage currents—where amperage remains from 500 to 2000
mAmp.
CHAPTER
2
Low Frequency Currents
Used in Physiotherapy
As stated earlier low frequency current is that whose frequency is in the range
of 50 to 100 Hz (cycles per second). The primary use of this type of current
is for the stimulation of nerves and muscles. Various currents in this category
are used for physiotherapeutic treatment. Among these, the commonly used
currents are direct current (DC) and Faradic current. Impulses with low
frequency and duration of less than 10msec (Short duration) are used for
stimulating normal or innervated muscles. Such current impulses are known
as Faradic current, whose repetition rate is more, usually 50 to 100 per second.
Low frequency impulses with a duration of more that 10msec (Long duration)
are termed as interrupted (modified) direct current and is used for stimulating
denervated muscles. The repetition rate is shorter, i.e. 30 per minute.
FARADIC TYPE CURRENT

A Faradic type current is a short duration interrupted DC with pulse duration
of 0.1-1 ms and a frequency of 50-100 Hz. This type of current is produced
by an induction coil known as Faradic coil. It consists of two unequal phases,
the first one is a low intensity but long duration and the second one is high
intensity but short duration. Now-a-days transistors and filters have eliminated
the first phase so that only high amplitude with short duration current persists.
It is a short duration interrupted DC with pulse duration of 0.1 to 1 ms.
Modern stimulators produce this type of current with varying duration of
impulses and the intervals between them.
Modification of Faradic Current for Interruption and Surging

Faradic current can be made interrupted at regular intervals to avoid fatigue
of muscles. Surged Faradic current is a modification characterized by gradual
increase in the intensity in such a manner that each impulse reaches to higher
Low Frequency Currents Used in Physiotherapy 9
intensity than that of the preceding one and after peak level it either falls
suddenly or gradually. It is otherwise known as Ramping (Fig. 2.1).
Fig. 2.1: Interruption and surging
PHYSIOLOGICAL EFFECTS OF FARADIC CURRENT

The physiological effects of Faradic current are:
• Stimulation of sensory nerves
• Stimulation of motor nerves
• Effects on muscle contraction.
Stimulation of Sensory Nerves

When Faradic type current is applied to the body there occurs a feeling of
mild pricking sensation as a result of stimulation of sensory nerve. This in
turn causes reflex vasodilatation of superficial blood vessels and thereby
induration or reddening. Faradic stimulation is applied by means of a Faradic
Stimulator (Fig. 2.2)
Stimulation of Motor Nerves

Faradic current stimulate motor nerves and if the intensity is sufficient there
occurs contraction of muscles supplied by it. As stimulation and thereby
contraction are repeated 50 times per second there occurs a tetanic type of
contraction. If it is continued for more than a short period of time the
concerned muscle get fatigued. That is why the current is surged or interrupted
give rest or relaxation to the muscle.
Effects on Muscle Contraction

When a muscle contacts as a result of electrical stimulation, the changes taking
place within muscle are similar to those associated with voluntary contraction.
There occurs increased metabolism with a consequent increase in the demand
for O2, and foodstuff associated with increased output of waste materials.
As the muscle contracts and relaxes it exerts a pumping action on veins and
lymphatic vessels lying within and around them.
Fig. 2.2: Faradic stimulator
Indications for the Use of Faradic Type of Current

Faradic current is primarily used to produce contraction of normally
innervated muscle and the current is usually surged to get nearly normal
contraction. Following are the use of Faradic type of current.
Facilitation of Muscle Contraction

When a patient is unable to produce a muscle contraction, Faradic current
is used to assist in voluntary contraction. It is seldom used to stimulate a
denervated muscle, as the amount of current required to produce contraction
is intolerable and unpleasant to the patient.
Muscle Re-education
Muscle action can be re-educated if voluntary muscle action is lost as a
result of prolonged disuse, as in intrinsic foot muscles in long standing
flat foot or muscle re-education of abductor hallucis in hallux-valgus. In these
cases Faradic current is used to produce contractions and as such help to
restore the sense of movement. Active contraction of muscle should be tried
at the same time.
Training of a New Muscle Action

After a tendon transplantation or other reconstructive operation Faradic
current is used for training a new muscle action. During stimulation patient
is asked to attempt voluntary contraction to get maximum benefit.
Neuropraxia is a type of peripheral nerve injury where transient physiological
conduction shuts down without any pathological change.
Neuropraxia of Motor Nerve

Here the impulses from the brain fail to reach the concerned muscle by the
nerve and so the voluntary power is lost. There is however no degeneration
of the nerve and hence it is stimulated below the site of lesion and the impulses
can pass to the muscle causing them to contract.
Severed Nerve
When a nerve has been severed, degeneration of the axon takes place. In
the early period of degeneration interrupted DC current may be used but
later on it should be replaced by Faradic type of current. It should be
mentioned here that nerve regeneration is purely a natural physiological
process. Electrical stimulation is used only to prevent disuse atrophy and
subsiquent fibrosis of muscle supplied by the nerve concerned.
Effect on Vascular Supply

Increased venous and lymphatic return is brought about by the pumping
action of alternate muscle contraction and relaxation by the use of Faradic
current.
Prevention of and Loosening of Adhesion

When there is effusion in to the tissues, adhesions are liable to form but
keeping the structures moving in relation to each other with the help of
electrical impulse can prevent all.
INTERRUPTED DIRECT CURRENT (GALVANIC CURRENT)

Interruption is the most useful modification of direct current (DC), where the
flow of current commence and cease at regular intervals. The rise and fall
of intensity may be sudden (rectangular) or gradual (trapezoidal, triangular,
saw-tooth) (Fig. 2.3).
Interrupted DC is commonly used for stimulation of denervated muscle
and for the electrodiagnosis purpose. The impulse duration and frequency
can be adjusted, a duration of 100msec being commonly used. Impulse
Fig. 2.3: Different forms of direct current
duration ranges between 0.01 to 300 msec. The frequencies of impulse vary
as per the pulse duration and the interval selected between them. For instance
duration of 100 msec requires frequency about 30 per minute.
Production of interrupted DC for the treatment can be availed from
modern stimulators using transistors and timing devices.
PHYSIOLOGICAL EFFECTS OF INTERRUPTED DC

If the intensity of the current and duration of impulses are adequate, a
contraction of denervated muscle can be initiated. The contractions are
sluggish (warm like movement) and contraction relaxations are slower. An
impulse with duration of 100 ms is the shortest, that is generally considered
satisfactory for the treatment of denervated muscle but it is often necessary
to lengthen this duration in order to eliminate contraction of innervated
muscle, which are unwanted.
Sensory Nerve Stimulation

When interrupted DC is applied to the body then there occurs a feeling of
stabbing or burning sensation as result of sensory nerves. This in turn causes
reflex vasodilatation of superficial blood vessels and consequent erythema
or redness of the skin.
Motor Nerve Stimulation

Interrupted DC stimulates motor nerve and as the stimuli are frequently
repeated each one produces a brisk muscle twitch followed by immediate
relaxation. So the beneficial effect is very low.
INDICATIONS OF INTERRUPTED DC
Interrupted DC has the ability of producing contractions in denervated muscle,
i.e. when a muscle is deprived of its nerve supply. A denervated muscle gets
wasted due to disuse and later on gets fibrosed. Ultimately it loses the usual
properties of a muscle like irritability, contractility, extensibility and elasticity.
Electrical stimulation in the form of interrupted DC may slow down these
processes. Though about 300 contractions of each muscle are desirable yet
it is not possible, as the muscle gets fatigued easily. So in general 90
contractions are considered as the minimum number to get the muscle
electrically contracted within physiological limit.
In the early stages of re-innervations a pulse of low duration may be
effective. Usually a slow rise pulse like triangular or saw-tooth is used as the
muscle contracts in a normal way (warm movement like contraction).
Duration of 100 ms is considered best to stimulate a denervated muscle but
higher duration like 300 msec or 1000 msec may be used to eliminate the
contractions of normal or innervated muscle lying near by.
Technique of Treatment of Interrupted DC

In order to stimulate a denervated muscle it should be noted that the current
must pass through all the muscle fibers. So one pad or electrode (Anode)
is fixed over the origin of muscle groups that serves as an active electrode
and another electrode (Cathode) is held over the lower end of the fleshy
belly of the muscle and pushed slowly down over it (Labile technique).
Alternate method is that 2 disc electrodes are placed firmly over each end
of the muscle to be stimulated. The most popular method is to place an
indifferent electrode over a distal part at the spinal cord and the active
electrode over the muscle belly near the motor point. It is the point or place
where the motor nerve enters the muscle.
Interrupted DC is applied with the help of a Galvanic Stimulatory (Fig. 2.4).
Prior to the application of the interrupted DC the equipment must be tested
for current leaking. The electrodes are to be covered with 8 layers of lint
jaconet to avoid chemical burn. For good conductivity the lint covering the
electrodes are to be dipped in 1 percent saline water. The patient’s skin is
to be prepared by washing with soap water and protecting any injury site
with Vaseline or Olive oil. The patient is to be kept in a resting or relaxing
state. Often patient should be asked to help in assisting voluntary contraction
of the muscle to be stimulated. It is not necessary that muscle will contract
best with anodal electrodes, so it is to be tested which pole is effective best.
It may vary from person to person.
Methods of Application
Faradic current can be applied by methods like motor point stimulation, nerve
conduction method or bath method.
Fig. 2.4: Galvanic stimulator
Motor point stimulation involves individual muscle. Here the in-different

electrode is placed at the origin of the muscle and the active electrode is
placed on the motor point. Usually a motor point is situated at the junction
of upper 1/3 and lower 2/3rd of a muscle belly. But exceptions and variations
are there. Slight adjustment of active electrode gives the required result. In
the nerve conduction method, the indifferent electrode is placed on convinient
area on the muscle to be stimulated and the active electrode at a point where
the nerve trunk is superficial.
In bath method, electrical current is passed in a tubor tray with water
onside. It this method is used where it is not possible to stimulate individual
muscle like small muscles of hand or foot. Bath method can be bipolar with
two electrodes inside the tray or unipolar with one electrode inside the tray
and the other one at a suitable place over the part to be treated.
IONTOPHORESIS
It is a technique in which medically useful ions are driven through the patients’
skin into the tissues by interrupted DC. It is otherwise known as ion transfer.
It is based on the principle that an electrically charged electrode will repel
a similarly charged ion viz a negative ion is applied under the cathode or
the reverse. If a medicine is in ionic form then it can be made to pass to
the body tissues through the skin under the influence of interrupted DC. Ions
may eventually become chemically active in the tissues which they pass. Thus
drugs are locally activated in the tissues for therapeutic purpose. The active
electrode is placed at the area to be treated. Iontophoresis is particularly
effective in the treatment of hyper-hydrosis using Glycopyronium Bromide.
It is also used in some other skin conditions.
CHAPTER
3
Transcutaneous Electrical
Nerve Stimulation (TENS)
It is one of the usages of interrupted DC and is a form of peripheral electrical
nerve stimulation through the skin that is primarily used for analgesia. So
in brief it is a form pain relieving modality (Electro-analgesia).
TENS is based on “Gate Control Theory” as described by Melzac and
Wall in 1965. The theory states that passage of pain sensation may be blocked
at various gates during its travel to the brain. The gates are located at neural
synapses in the spinal cord. Nociceptive (Pain impulse) information is
conveyed to the spinal cord along small diameter A-δ and C fibers. These
fibers have inhibitory influence on the interneurons as well as on transmission
cells (T-cell) located in lamina II, III of the spinal cord and dorsal horn
respectively. The interneurons within the substantia gelatinosa (SG) in the
spinal cord exert an inhibitory effect in the T-cell. Longer myelinated A- fibers
that carry proprioceptive impulse exert an excitatory influence on the T-cells
in the SG.
A noxious input along the small diameter afferents A-δ inhibits the SG
and the inhibitory interneurons, thereby opening the synaptic gate and
increasing excitatory input to the T-cell augmenting their discharge. Conversely
a preponderance of non-noxious input along the large diameter “A” fibers,
activates the inhibitory interneurons of the SG. These inter-neurons
subsequently close the spinal gate so that further T-cell activity is inhibited.
In this way ultimate perception of pain is thus diminished (Fig. 3.1).
TENS is the application of pulsed rectangular wave current via surface
electrodes on the patient’s skin. The current is often generated by small battery
operated machine that the output has a stimulating effect (Fig. 3.2).
Specification of TENS
Pulse shape—Usually rectangular
Pulse width—Varies from 50 to 300 ms but usually fixed at 100 ms.
Fig. 3.1: Diagrammatic representation of gate control theory of pain
Frequency—Can be between 2 to 600 Hz, commonly used is 150 Hz.

Intensity—Can be varied from 0 to 60 mA.
The wide range of variation in pulse width, frequency, intensity, etc. gives
great flexibility in treatment mode.
APPLICATION
Conductive round rubber electrodes covered with conductive gel in order
to get good skin contact are placed either at the site of maximal intensity
of pain or trigger points with elastic bands. Alternatively these can be placed
on appropriate dermatome of spinal segment. The patient’s skin should have
intact sensory mechanism.
TENS can be applied in two methods:
High TENS is used where the frequency is between 100-150 Hz.
Pulse width 100-500 ms
Intensity 12-30 mA
High TENS causes a tingling, pin and needle sensation. The stimulation
will cause impulses to be carried along large-diameter (A-fiber) afferent fibres
to produce pre-synaptic inhibition of transmission of nociceptive (pain path).
This method is the most popular one and is widely accepted. The other one
is Low TENS.
Here the parameters are frequency 1-5 Hz
Pulse width 100-150 ms.
Intensity > 30 mA.
Low TENS gives a sharp stimulus and causes muscle twitching. TENS
is given 20-30 minutes daily till the symptoms subside.
Transcutaneous Electrical Nerve Stimulation (TENS) 17
Fig. 3.2: Four channel TENS
ELECTRODIAGNOSIS AND STRENGTH DURATION CURVE

Due to disease or injury to the nerves or muscles, an alteration of response
to electrical stimulus does occur. This altered response is of considerable value
in diagnosing the type or extent of lesion. Reduction or loss of voluntary
power of a muscle may be due to:
a. A lesion of the upper motor neuron (UMN)
b. A lesion of the lower motor neuron (LMN)
c. A damage to the muscle itself
d. A fault at the neuromuscular junction.
Only the motor pathway of lower motor neuron, i.e. its exit from the
vertebral canal to the muscle can be normally accessible by electrical
stimulation.
Lesions at the nerve fiber are classified into three groups:
• Neuropraxia
• Axonotmesis
• Neurotmesis
Neuropraxia: Otherwise known as first-degree injury is a condition in which
bruising or pressure causes the nerve incapable of conducting impulses beyond
the site of lesion, but the damage is not so severe to cause degeneration
of nerve fiber. So, the electrical response to stimulation above the site of lesion
is hampered.
Axonotmesis: Here, the actual degeneration of nerve fiber takes place where
the sheath of the nerve remains intact. So, the electrical reaction to stimulus
to the nerve is lost. This is known as second-degree injury.
Neurotmesis: It is the third-degree injury where the nerve sheath and fiber
are severed, causing the same type of response as in the axonotmesis. Here,
regeneration of nerve cannot be possible if the nerves are not sutured end
to end. All these types of nerve lesion may be partial or complete or a
combination of the two.
Electrical stimulation is not only used for therapeutic purpose but it is
also used for detecting the electrical reaction of muscles and nerves lesion.
Thus electrodiagnostic tests such as Rheobase, Chronaxie, Strength Duration
Curves, Nerve Conduction Tests, etc. are carried out with the help of
interrupted direct current (DC). Of the above SD curve test is of immense
value.
RHEOBASE
It is the smallest amount of current (I) that will produce a muscle contraction
when the duration is very long (infinite duration). In practice an impulse of
100ms is used. Rheobase is reduced in denervated muscle as compared to
innervated muscle and often it rises when re-innervations occurs.
CHRONAXIE
It is the shortest duration of current that will produce a response with the
amount of current, which is, double that of Rheobase. Chronaxie of
denervated muscle is higher than innervated muscle. In denervated muscle
it is more than 1msec and in normal muscle it is less than that, if constant
voltage stimulator is used.
STRENGTH DURATION CURVE (SD CURVE)

It is an electrodiagnostic procedure where a graph is plotted with intensity
required against various durations of impulse to determine the status of
innervations of muscle. It is the most satisfactory method for testing the
electrical reactions of muscles in peripheral nerve lesion. It has got both
advantages as well as disadvantages.
The advantage is that it is a simple and reliable method indicating the
proportion of denervation. A series of tests show changes in the condition.
The disadvantage is that in case of large muscle only a proportion of the
fibers may respond, so that the full picture will not be possible. Also it does
not indicate the site of nerve lesion.
Procedure
A diagnostic muscle stimulator is used for plotting Strength Duration Curve.
Interrupted direct current of rectangular wave with different durations like
Transcutaneous Electrical Nerve Stimulation (TENS) 19
0.01, 0.03, 0.1, 0.3,1,3,10,30, and 100 msec are required. The stimulator
may be of constant voltage or constant current type.
Prior to application of electrodes, the patient’s skin resistance is reduced
by washing and soaking in warm water. The electrodes are secured at
convenient places like the indifferent electrode at the midline of the body
or at the origin of muscle group and the active electrode over the motor
point. Alternatively the two electrodes may be placed at each end of muscle
belly. To start with largest duration of impulse, i.e. 300 ms is applied and
the corresponding intensity of current required to get the minimum contraction
is recorded. Once again the duration is kept at just short of the previous one,
i.e. duration at 100 ms and the corresponding intensity is recorded to stimulate
the muscle. This procedure is repeated keeping the duration in descending
order and the corresponding intensities are recorded. Next the results of
intensities with corresponding durations are plotted in a graph in X-axis and
Y-axis and the points are joined in series to form a curve known as SD curve
(Fig. 3.3).
Observation
It is the shape of the curve that is an important feature in determining the
status of muscle innervations. When all the muscle fibers are intact the SD
curve is of a typical shape as shown below.
Fig. 3.3: Strength duration curve (normal)
When some of the muscle fibers of a muscle have degenerated

while others are intact then there appears a characteristic curve as shown
below (Fig. 3.4).
Fig. 3.4: Denervated SD curve
The curve rises steeply and moves to the right than the normally innervated
curve.
When some of the muscle fibers of a muscle have under gone
degeneration, while the others remain intact then there appears a different
type of curve having a kink. The impulses of lower duration stimulate both
innervated as well as denervated muscle fibers so a combination is obtained
with a stimulus of low intensity. As the durations are shortened the denervated
fibers show poor response and hence stronger stimuli are required to produce
a contraction. So the curve rises steeply like that of denervated muscle. The
typical curve shows a part of innervated curve and a part of denervated
curve which are joined at a point known as “Kink” as shown below. This
is known as “Exponential curve” (Fig. 3.5).
Fig. 3.5: Mixed type curve
As the regeneration of nerve fiber progresses the kink gradually disappears

and the curve shifts to the left side showing all features of a normal curve.
CHAPTER
4
Interferential Therapy (IFT)
An Australian scientist named H. Nemee developed interferential therapy in

1949. It is also known as “Russian current” as it was described by the Russian
scientist Dr. K.M. Kots.
Interferential therapy is a form of electrical treatment in which two
Medium Frequency Currents are used to produce a Low Frequency
Effect.
In other words: To obtain interferential effect two medium frequency
currents are used.
Significance of IFC Therapy

Low frequency current has a stimulating effect on excitable tissues. The
maximum stimulation is close to the surface in the vicinity of the electrodes,
and then diminishes considerably in depth due to the very high skin
impedance (resistance) encountered by the low frequency current.
In order to reach deep lying organs and tissues, a current of intolerable
intensity must be applied. If it is of intolerable intensity, it is ineffective.
Medium frequency currents of around 4000 Hz while able to stimulate
motor and sensory nerves experience a much lower skin impedance and do
not provoke skin irritation and its application is painless.
Because impedance is inversely proportional to frequency:
Z = α × 1/2 π (fc)1/2
Where Z = Impedance in Ohms
f = Frequency in Hertz
c = Capacitance of skin in microfarad.
The resistance of skin is 3200 Ohms at 50 Hz, while it is 40 Ohms at
4000 Hz.
The principle, upon which interferential therapy is based, is as follows.
Two alternating currents of medium frequency are induced into the tissues
separately, so that they cross in the treatment field perpendicular to each
other, to produce a low frequency effect in the treatment field.
Fig. 4.1: Beat frequency in IFT
The advantage is that it is not only painless but also it acts in depth without
damage to the underlying tissues.
Usually a medium frequency of around 4000 Hz is used.
One of the currents is always introduced at a constant frequency, i.e. 4000
Hz while the frequency of the 2nd one is variable, i.e. between 3900 to 4000
Hz or 4000 to 4100 Hz.
An interference effect at a “BEAT FREQUENCY” is equal to the difference
in frequency between the two medium frequency currents, which is produced
at the point where two currents cross (Fig. 4.1).
Example: Current A = 4000 Hz
Current B = 4100 Hz.
Beat Frequency = 100 Hz (Low frequency)

As said earlier one of the two currents is always used at a constant frequency
say 4000 Hz and the other frequency of the 2nd one is variable, i.e. between
two currents being formed, is 0-100 Hz:
4000 – 4000 = 0 Hz IC
4010 – 4000 = 10 Hz IC
4020 – 4000 = 20 Hz IC
4030 – 4000 = 30 Hz IC
……….. So on.
At the cross over point, these two completely distinct currents of medium
frequency will produce a new, biologically active low frequency current.
The concept is that the effective current is not introduced from outside
but is produced in depth or endogenously within the tissues or organs of
the human body.
Interferential Therapy (IFT) 23
Significance of Dynamic Interferential Field

With a square position of the electrode, the interferential field at the crossover
point is distributed according to exact physical laws. A static interferential
field is thus produced with a specific distribution of the interferential intensity.
The interference is zero within connecting lines of between electrodes of
the same circuit (Fig. 4.2).
Fig. 4.2: Line of interference
However, the interferential effect rises as one move away from these points
in either direction in angulations (i.e. in degrees) Maximum interference (i.e.
100%) being encountered at an angle of 45° (Fig. 4.3).
Fig. 4.3: Dynamic interferential field

In the modern machines a device is provided to move automatically and

rhythmically the static interference field; thus a dynamic IC is produced passing
through the whole area subjected to treatment.
Dynamic IC is reported to gain better and faster therapeutic result than
static IC field but in fact they have a similar heating effect. It is known as
SWING.
A Rhythmic Mode Indicates

That the frequency is swinging continuously from the lower to the higher
value and back.
Modern unit allow for the automatic applications of IC of selected
frequency, for example a constant frequency of 100 Hz of the whole range
from 0 to 100 Hz at a rhythmical rate or 0 to 10 Hz or 90 to 100 Hz. Each
of the biological active frequencies of the current has its own particularities.
Therefore the choice of frequency depends on the aim of treatment. If
a rhythmical range of 0-100 Hz is required, this is achieved by varying the
frequency in the second circuit between 4000 to 4100 Hz and 4000 to 3900
Hz (as the case may be).
A rhythmic mode indicates that the frequency is swinging continuously
from lower to the higher value and back.
In some units the beat frequency is 150 Hz, which is considered to be
effective in pain modulation. One of the major advantages of interferential
therapy is that the effects are produced in the tissues where they are required,
without unnecessary skin stimulation.
BIOLOGICAL ACTION OF IFT

1. Constant frequency of 100 Hz has a suppressing effect on the sympathetic
segment of the automatic nervous system and also has analgesic property.
So constant frequency is applied when there is severe pain accompanied
by vasospasm. It is also used as a preliminary treatment in nearly all
diseases treated by IFT.
2. Rhythmical frequency of 90-100 Hz is similar to that of constant frequency
of 100 Hz. But the rhythm in this case prevents tissue adaptation to the
same frequency, i.e. to the same stimulation.
3. A rhythmical frequency of 50-100 Hz has mainly a sedative and
spasmolytic effect.
4. Frequency below 50 Hz has a stimulating effect on the motor nerves, the
influence increases below 25 Hz.
A rhythmical frequency of 0-10 Hz or 0-15 Hz is therefore used to obtain
Interferential Therapy (IFT) 25
movements in the muscular contractures, example: for muscle exercise or

to strengthen vascular walls.
A rhythmical frequency of 0-10 Hz of suitable dose results in unsustained
muscular contraction, while a rhythmical frequency of 25-50 Hz has a tetanic
(Faradic) effect over muscles.
This rhythmical frequency often results in active hyperemia, acceleration
of the lymph flow and activation of cell functions, and it enables the restoration
of normal tissue reactions, including that of vascular walls. It prompts
elimination of toxic metabolic products, dispersion of edemas, removal of
tissue anoxaemia (often including pain) and activation of electrolyte
metabolism (Ca, K and Na for example).
The physiological effects are:
• Active hyperemia
• Acceleration of the lymph flow
• Activation of cell function
• Enables restoration of tissue reactions
• Prompts elimination of toxic metabolites
• Dispersion of edema
• Removal of tissue anoxaemia
• Activation of electrolytic metabolism (Ca, K, Na).
Some Authors Summarize:
a. Low frequency, i.e. 0-10 or 25 Hz as motor stimulation and muscle
contraction.
b. High frequency, i.e. over 50 Hz sympathetic effect.
The effect of a rhythmical frequency (i.e. 0-100 Hz) versus a constant
frequency of 100 Hz is not strictly differentiated and that of other frequencies
is always present. The following effects of interferential current stimulations
are accepted:
• Stimulation of blood circulation
• Analgesic effect
• Stimulating effect
• Selective response
INTERFERENTIAL THERAPY—Technique
The body part to be treated is encircled by four plate electrodes in such a
fashion that the two medium-frequency currents cross in it.
Before each application, the skin should be cleansed of contact medium,
if ultrasound was applied immediately before. The electrodes should be firmly
bound to the skin, but not too tightly. The intensity of the current selected
in IFT depends on the electrode area (objective criterion) and on the individual
sensitivity of the patient (subjective criterion). The average dose is within the
range of 4 to 50mA. The patient should experience a sensation of deep,
sufficiently strong, but pleasantly vibrating massage at rhythmical frequencies
and a pleasant tingling sensation at a constant frequency of 100 Hz. It should
be borne in mind that at ‘higher frequencies’ (constant frequency of 100
Hz and rhythmical frequency of 90 Hz) patients, as a rule, could tolerate
a higher intensity of current than that at lower frequencies, especially from
0-10 Hz.
Interferential therapy is given every day or every other day, the treatment
duration usually being of 10 to15 minutes, with a maximum of 30 minutes
(and in special cases up to 60 or 90 minutes). We recommend treatment
duration of 15 to 25 minutes. Depending on the disease 2, 10, 15 or 25
treatments will suffice.
CHAPTER
5
Thermotherapy
It is the process of heating tissues by various modalities in order to relief pain.

Heating tissues results in rise of temperature that causes
• Increased metabolic activity
• Increased blood flow
• Increased elimination of metabolic waste
• Stimulation of neural receptors in tissues.
Increased Metabolic Activity

Van’t Hoffs theory states that any chemical change is always associated with
rise in temperature. Consequently heating tissues will accelerate chemical
change, i.e. metabolism. As a result of increased metabolism there occurs
an increased demand for O2 and energy. Side by side there occurs increased
out put of metabolic waste.
Increased Blood Supply and Elimination of Metabolic Waste

Due to increased metabolism, biological waste products are formed which
act on the walls of the capillaries and arterioles causing dilatation of these
vessels. Heating of superficial nerve endings may cause reflex dilatation of
the arterioles thereby causing increase flow of blood. The superficial
vasodilatation causes erythema of the skin on which heat is applied.
Effects on Nerve Endings

Heat produces a sedative effect on the sensory nerve endings. It is also applied
as a counter irritant as the thermal stimulus affects passage of pain sensation.
Apart from these, heating of tissues may cause some indirect effect on muscles
and sweat glands.
Thermotherapy Constitutes
1. Short-wave diathermy
2. Hot packs, heat pads
3. Infrared therapy
4. Microwave diathermy.
SHORT WAVE DIATHERMY (S.W.D) (Fig. 5.5)

It is one of the most commonly used therapeutic modality for heating deeply
placed body structures thereby relieves pain. Diathermy means through and
through heating. Short wave diathermy (SWD) is a high frequency AC current
that sets up radio-waves with wavelength of 3 to 30 meters. The most
commonly used for medical practice has a frequency of 27.12 MHz and it
sets up radio waves of 11meter length. Since the impulses last for less than
0.001 ms which is quite far away from the range used for nerve stimulation,
it dose not stimulate motor or sensory nerves. When such a current passes
through the body no discomfort or muscle contraction occurs. So also the
evenly alternating current does not produce any chemical burn.
Thus, SWD provides a deep form of heat to the tissues of the body. A
Short wave diathermy has got two types of circuits. One is the machine circuit
known as the Oscillator Circuit, another one is the patient’s circuit or the
Resonator Circuit.
In the machine circuit high frequency current is made available by
discharging a condenser through inductance of low ohmic resistance. In order
to produce a high frequency current the condenser is made charged and
discharged repeatedly by incorporating a valve circuit. Nowadays solid-state
transistors or microchips are used instead of valves.
The patient circuit or resonator circuit is coupled with the machine circuit
by inductors. High frequency currents are transmitted from the oscillator circuit
to the resonator circuit with the help of a variable condenser. The oscillator
and the resonator circuits must be in resonance with each other. In other
wards the product of inductance and capacitance must be the same (Fig.
5.1).
Fig. 5.1: Circuit diagram of short-wave diathermy

Thermotherapy 29
An ammeter is placed in between which dose not reflect the amount of

current output but it shows that the oscillator and the resonator circuits are
in tune with each other which causes maximum power transfer to the patient.
Nowadays it is replaced by automatic tuners.
METHODS OF APPLICATION (Arrangement of Electrodes)

Electrodes are electrical conductors through which the high frequency current
is applied to the patient’s body tissues. Transfer of electrical energy to the
patient occurs via either in electrostatic or in an electromagnetic field.
Therefore two methods of applications are available.
• Condenser or capacitor field method.
• Inductothermy or cable method.
Fig. 5.2: Condenser/capacitor field method (Contraplane placement)
Condensor/Capacitor Field Method (Fig. 5.2)

Here electrical pads or disc electrodes are placed on each side of the part
to be treated separated from skin by insulators. The patient’s body tissue
act as dielectric while the pads act as electrodes. The high frequency current
enters in to the tissues to produce heat in accordance to Joules law. While
arranging the electrodes during treatment, consideration should be given to
the size of the electrodes, its spacing and position. It is a general rule that
the size of the electrodes should be larger than the part to be treated. Spacing
should be adequately wide apart otherwise superficial tissues will be heated
quickly. The electrodes are to be placed over towels or woolen separator
in coplanar position, i.e. the same surface or on contraplanar position, i.e.
on opposite surface or on cross-fire position, i.e. combination of the two.
Another way of placing electrodes is the monopolar technique where the

active electrode is placed over the site of lesion and the indifferent electrode
at some distance apart.
Cable Method
When sort wave diathermy is applied through a cable, the effect of a magnetic
field is experienced along with the effect of electric field. This magnetic field
may be utilized in patient treatment. The electrode is a thick insulated cable
which completes the patient circuit and is arranged in relationship to the
patient’s tissues but is separated by a layer of insulating material. As high
frequency current oscillates in the cable a varying electrostatic is set up
between its ends and a varying magnetic field around its central part. This
is shown in the following Figure 5.3.
Fig. 5.3: Electric and magnetic field around the cable electrode
Technique of SWD Application

Testing the Machine
Machine should be tested before use. When condenser electrode are used
these are placed opposite to each other with a gap where the therapist places
his or her hand. Then the machine is switched on and tuned. The intensity
is increased every time tuned until comfortable warmth is felt. Now the
machine is declared to be in usable condition.
Preparation of Patient
Patient is made to site or lie down on a non-metal, non-conducting chair
or couch. A deck chair (Aram-chair) is best suitable to place the electrodes
to heat back.
Clothing should be removed from the region of the part to be treated.
Patient’s skin is to be checked for intact sensation. Metal objects tied in the
region are to be removed so also any damped clothes. Wound or sinuses
should be cleaned and covered with dry dressing. Patient is to be placed
in a comfortable, relaxed position and the area must be dry. Hearing aids
must be removed and is kept well away from the machine otherwise serious
Thermotherapy 31
damage may occur. Patients having pace-makers or implants should not be

allowed to come near the machine and take this therapy. Female patients
in particular, should be asked for menstrual period and pregnancy. They
should not be allowed to undergo SWD. Female patients are too informed
to wear cotton dresses instead of synthetic ones.
Fig. 5.4: Coplanar arrangement of electrodes: (a) Correct spacing, and (b) Incorrect
spacing, resulting in the electric feld forming directly between the electrodes
Procedure
As indicated earlier the patient should be placed at a comfortable position
in an airy place. The pads or electrodes are placed on the part to be treated
and held in position by means of belts or Velcro straps. Woolen pads or cotton
pads are kept in between the electrodes and skin. The belts should not be
very tight lest it may hamper with the circulation. The leads or cables of the
electrodes should be of the same length specified for a particular machine
and should remain in parallel to each other. The pads are adequately spaced.
Too much close placing will result in passage of current directly to the
electrodes without passing through the body (Fig. 5.4b). When the patient
as well as the cables and electrodes are in position the machine is switched
on and the circuit is tuned by adjusting the tuner switch. Current intensity
is increased gradually and every time it is tuned till comfortable warmth is
experienced by the patient. The ammeter is no guide to the amount of heating
to the tissues; it is merely of value to tune the circuit. Consequently the dose
is estimated by the amount of heat experienced by the patient (subjective
sensation of heat). As the dose is patient-dependent, so the patient must be
taught to reveal the comfortness to the concerned physiotherapist. Any undue
heating is harmful as there may danger of burn. The average duration of
treatment is 5 to 15 minutes depending on the site of lesion and the type
of lesion.
Physiological Effects
The physiological effects of SWD are as follows:
Temperature
SWD produces heat in the body tissues. Increase in local temperature may
be due to production of heat. But if it is applied for sufficient time, then there
appears a rise in general body temperature due to circulation of blood through
the heated tissues.
Metabolism
Heat production as caused by SWD to the body tissues, increases the process
of metabolism in accordance with the Vent’s Hoff theory.
Circulation
SWD causes increase in circulation due to vasodilatation as direct effect.
Increased circulation drains the metabolic waste products.
On Nerves
Mild heating reduces excitability of the nerves and has got a soothing effect
on sensory nerve endings, thereby causing analgesia.
Muscle Tissue
Rise in temperature induces relaxation of muscles and increase in their
efficiency of action. The muscle fibers perform in a smooth way without
loosing the power of contractility.
Destruction of Tissues
Excessive heating by SWD may cause thermal burn and thereby tissue
damage occurs.
Increased Activity of Sweat Gland

Increase in local and general temperature causes sweating.
On Blood Pressure
Increased amount of heating by SWD causes fall in blood pressure due to
vasodilatation and drop in peripheral resistance.
Therapeutic Effects
Effects on Inflammatory Process
The vasodilatation so caused by SWD affects increased blood flow to the
area, making available an increased supply of O2, nutrition, antibodies and
Thermotherapy 33
Fig. 5.5: Short-wave diatheramy machine
white blood cells. Increase in all of the above may help in resolution of
inflammation. SWD is particularly beneficial in sub-acute or chronic
inflammation. But it is contraindicated in acute bacterial infection.
Effects on Bacterial Infection

Due to heating effect of SWD there occurs vasodilatation and exudation of
fluid in to the tissues. More RBCs along with antibodies pour to the site to
destroy the bacteria. This is of value in bacterial infection like boils carbuncles
and abscesses.
Effect on Traumatic Conditions

Exudation of fluid into the tissues and subsequently increased absorption,
removal of waste products causes relief of pain, swelling and assists in
repair of tissues.
Relief of Pain
It is obvious that mild form of heat is effective in relieving pain- due to a
sedative effect on sensory nerve endings. Pain as caused due to accumulation
of waste material may be reduced when such waste products of metabolism
are drained by increased circulation. Strong superficial heating relieves pain
probably by counter irritation. When pain is due to inflammatory process
resolution of inflammation is always accompanied with relief of pain.
Effect on Muscle Tissues

Heating of tissues induces muscle relaxation, relief of muscle spasm associated
with inflammation and trauma.
The uses of SWD may be summarized as follows:
a. Pain relief—in subacute and chronic condition like trauma, arthritis, soft
tissue pain, sciatica syndrome, etc.
b. Muscle spasm—due to trauma, inflammation, sprains, strains and
cramps, etc.
c. Joint stiffness—in trauma, arthritis like OA, RA, and AS.
d. Inflammation—in pelvic inflammatory diseases, irritable bowel
syndrome, mild infections and inflammations.
e. Musculoskeletal trauma—SWD heals the musculoskeletal trauma by
increasing the local circulation and removing the biological waste products.
Contraindications of SWD
Short wave diathermy is contraindicated in the following conditions:
1. Pregnancy
2. During menstrual period
3. Bleeding diathesis
4. Thrombosis
5. Peripheral vascular disease
6. Sensory loss or impairment
7. Malignancy
8. Fever
9. Metallic implants
10. Cardiac pace maker implant
11. Patients with hearing aids
12. Patients who are not in position to communicate.
Dangers of SWD
Burn— Heat burns can be caused by SWD. In severe cases there occurs
coagulation of the tissues followed by destruction. Burn may be due to
concentration of electric field or use of excess intensity of current or hyper-
sensitivity of skin or due to impaired circulation.
Scalds—Occurs due to moist heat. During treatment in hot humid condition
there occurs sweating which in turn, with heat, causes scald and blister
formation. Hence SWD should be given in an airy atmosphere.
Precipitatory gangrene—As heat accelerates metabolism, there occurs an
Thermotherapy 35
increase utilization of O2 which may hamper tissue healing.

Electric shock—An electric shock can occur if the machine circuit is
accidentally touched or leakage of current to the body of the machine. So
prior to use the machine must be checked or tested.
Faintness—Faintness can occur due to lowering of blood pressure as SWD
causes dilatation of blood vessels.
Giddiness—Any electrical current applied near to head region may cause
giddiness for the effects on the semicircular canal in the vestibulo-cochlear
part
MICROWAVE DIATHERMY
Microwave diathermy is the irradiation of the tissues with radiation of the
shorter wireless part of the electromagnetic spectrum (EMS) i.e. Hertzian rays
whose wavelength is in between infra red and short wave diathermy.
Microwaves are electromagnetic waves with wave length in between
1 to 12.25 cm and a frequency of 2450 MHz.
The principal function of microwave is the production of heat over a
particular area and thereby raises local temperature.
Production
Microwaves are usually produced by a special type of thermionic valve called
Magnetron. As with other thermionic valves magnetron requires time to warm
up, so the output is delayed. The apparatus consists of power supply,
magnetron oscillator, circuit intensity control, coaxial cable and emitter.
Magnetron as stated, is a special type of thermionic valve characterized by
centrally placed cathode, which is surrounded by a circular type of metal
anode. Coaxial cable carries the high frequency current from magnetron and
feeds to the aerial of the emitter. The aerial is fixed in front of a metal reflector
that directs the waves in one direction. The emitter is kept at a distance of
10 to 12 cm from the part to be treated.
PHYSIOLOGICAL AND THERAPEUTIC EFFECTS

The physiological effects of MWD are same as that of SWD. But there occurs
an increased amount of heat production as compared to SWD. Heat
production in MWD depends on the watery content of the tissues. The depth
of penetration is also less than that of SWD. The effective depth of penetration
is 3cm where as SWD penetrates up 6 cm. Microwaves are strongly absorbed
by water, so the tissues containing more watery material are readily get heated.
The uses of MWD are similar to SWD but it is used in superficial tissues with
increased water content as in traumatic soft tissue pain, arthritis, etc. The
treatment time is 10 to 20 minute. and the dose is about 200 Watts.
PARAFFIN WAX BATH THERAPY

It is one of the common and cheapest ways of heating tissues.
Treatment of various peripheral body parts with melted paraffin wax whose
temperature is maintained at 40°– 44°C is known as paraffin wax therapy.
Normal malting point of wax is about 51°– 55°C which may cause thermal
injury or burn to the tissues. In order to lower the temperature some impurities
like liquid paraffin, white petroleum jelly are incorporated in the proportion
of 3:1:1. This method of heating tissues is that it is the most convenient way
of applying conducted heat to the extremities. As the wax solidifies from its
molten state it releases latent heat and this energy is conducted into the tissues.
Wax gives off heat slowly due to its low thermal conductivity, but it cools
quickly when it is taken out of the bath. That is why in order to retain heat
it should be wrapped with a plastic sheet. The usual treatment time is 20
minutes.
Bath unit
It is a double-layered metal box, which is attached with a thermostat to keep
the temperature at 40°- 44°C. Inside the bath unit bee’s wax, liquid paraffin
(heavy type) and white petroleum jelly (Vaseline) are added in the ratio of
3:1:1 and the unit is connected to the power supply. The chamber is to be
kept covered (Fig. 5.6).
Treatment
The part to be treated must be clean and free from cuts, rashes or infection.
The patient is to be kept in a proper position so that he feels easy to take
wax therapy. The extremity or joint can be dipped inside the molten mixture
or alternatively molten mixture can be poured gently over the effected joint
with the help of a cup. Another way is to dip a 1inch or 2 inch paint brush
into the mixture and paint the part with molten wax. The first layer of wax
may be uncomfortable at the beginning, but after several layers of wax this
becomes much comfortable. Precaution should be taken not to move the
part after first layer of the wax, other wise cracks may develop and the
subsequent molten wax may penetrate the cracks and may cause burning
sensation. Usually ten layers of wax coating are done and the total part is
to be kept in plastic sheets for another ten minutes. Then finally, the wax
Thermotherapy 37
is discarded by breaking the waxed coat and it can be recycled on subsequent

treatments.
Effects
Following wax therapy, marked increase in the temperature of the skin and
other tissues occurs. Thermal effects stimulate superficial capillaries and
arterioles causing hyperemia and reflex vasodilatation. This causes relief of
pain. Heating has a sedative effect over the sensory nerve endings. Hence
it is very much useful in arthritic conditions like OA, RA and traumatic stiff
joints. Due to wax therapy, there occurs increase activity of sweat glands and
there by the tissues get moistened and pliable which indirectly helps in
increasing the range of movement of the body part. That is why in stiffness
of joints, wax therapy should be followed by mobilization exercises.
Contraindication
The contraindications are as follows:
1. Insensitive area
2. Peripheral vascular diseases
3. Open wounds
4. Skin infection
5. Allergic rashes
Fig. 5.6: Paraffin wax bath machine

ELECTRIC HEATING PAD

Electric heating pads are available in various sizes and shapes, which can
be applied to various parts of the body. The electric element inside the pad
is connected to a series of resistors to get the desired heat. Heating of body
parts is merely superficial which has a soothing effect upon sensory nerve
endings. Alternatively common hot water bag or bottle may be used. This
may be applied for 10-15 minutes twice daily for 7-10 days. A variable
resistance switch can be connected to control the amount of heat generated.
CHAPTER
6
Ultrasound Therapy
Sound is the periodic mechanical disturbance of an elastic medium such as

air. Sound requires a medium for its propagation. It cannot pass through
vacuum. The frequency of sound wave is the same as the rate of oscillation
of the source and is constant for a particular medium. It is caused by the
alternate compression and rarefaction of the particles of the medium.
Therefore, it is only the wave which moves forward but the particles vibrate
back and forth about a mean point.
The frequency of normal sound wave which the human ear can perceive
is between 20 Hz – 20 KHz (i.e. 20000 cycles per seconds). Sound waves,
as stated, with frequency higher than 20 KHz cannot be perceived by human
ear that is beyond the audible capacity. It is known as ultrasound. Ultrasound
with frequency of 1-3 MHz is used for medical therapeutic purpose.
Therapeutic ultrasound is commonly used as a physiotherapeutic modality
for its effective penetration through the body tissue. Sound and ultrasound
waves both are produced by vibration of matter. In case of US the frequency
as said is much higher than normal sound. Stream of pressure or vibration
waves produced from a transducer (treatment head) are transmitted to a fixed
area of body tissue, which in turn causes the molecules of the tissue to vibrate.
As high frequency sound waves are not obtainable by mechanical method
hence applying high frequency current to a quartz crystal, which in return
vibrates, cause production of US waves (Fig. 6.1). The quartz crystal made
up of barium titanate, deforms when subjected to a varying potential difference
(PD)—known as Piezo-Electric effect.
What is Piezo-Electric Effect?

The meaning of the word piezo is pressure. In 1888 Pierre and Currie
demonstrated that application of pressure, i.e. compression and
decompression to a quartz crystal produces electrical changes in the crystal.
Previously, this was known as Piezo-Electric effect. In 1910 Langevin described
the opposite theory that if a quartz crystal is subjected to a high frequency

alternating current then the crystal vibrates producing compression and
decompression in the matter. This is known as Reverse Piezo-Electric effect
and is being incorporated to produce ultrasound waves. So, in modern
ultrasound machines Reversed Piezo-Electric effect is utilized where a high
frequency potential difference causes high frequency oscillations in the crystal.
Fig. 6.1: Ultrasound machine
Production
The basic component of a US apparatus consists of a source of high frequency
current that is conveyed by a coaxial cable to a transducer circuit or treatment
head. High frequency current is applied to the crystal through a linking
electrode where the crystal is fixed to a metallic plate of the transducer. As
the potential difference is applied to the crystal it starts vibrating which in
turn vibrates the metallic head and thus ultrasound waves are produced (Fig.
6.2).
Fig. 6.2: Diagrammatic representation of ultrasound machine

Ultrasound Therapy 41
Strict frequency control of the high frequency current ensures a steady

and regular production of ultrasound waves. Various controlling switches are
incorporated to the ultrasound machine to get the desired effect. For example
a timer switch for the control of total treatment time, a switch for the
continuous or pulsed mode of production and a meter and a switch (intensity
knob) to note the amount of ultrasonic energy measured in Watts per Sq
cm of the treatment head. Apart from all these LED indicator lamp and mains
switch are also present on the machine. Space ratio, i.e. pulse ratio can be
adjusted as per the requirement, usually higher output and less interval in
chronic cases and the reverse in acute cases.
To summarize 1:1 is used for chronic cases and 1:4 in acute cases.
Ultrasound waves so produced cannot be propagated to the body tissues
as such, because in between the treatment head and the skin surface there
remains a thin layer of air, which is not a good conductor for propagation
of ultrasound waves. To overcome the situation some conducting material
are applied between the two such as Aquasonic gel, Liquid paraffin, Petroleum
jelly or Glycerol. These are otherwise known as coupling media.
PHYSICAL CHARACTER OF US THERAPY

Ultrasonic waves do have some physical characters, which are as follows:
Reflection of Ultrasound
Sound wave obeys the laws of reflection while passing from one medium
and encountering another medium which does not transmit it then the
reflection of sound waves takes place, i.e. it bounces back to the transducer.
As the reflected waves may damage the transducer head, so care should be
taken while applying sonic waves. Air is a bad conductor for propagation
of ultrasound waves. That is why a coupling medium is used in between
the part to be treated and the treatment head to minimize the reflection.
However, there occurs always some reflection of sound wave at the interface
which gives rise to the term aqua-sonic impedance. This is the ratio of reflected
and transmitted sound wave at an interface. When the impedance is low
the transmission is high.
Transmission of Ultrasound
Ultrasound waves obey the law of refraction as the light waves when it passes
from one medium to another, i.e. it deflects from its original path. It negligibly
deflects when the waves pass at right angle to the interface.
Attenuation of Ultrasound
Attenuation is the gradual reduction in intensity of Ultrasound beam after
emergence from the treatment head. The factors that contribute to attenuation
are:
• Absorption: Ultrasound is absorbed by the tissues of the body to which it
is applied and it results into heat. This constitutes the thermal effect of
ultrasound.
• Scatter: This normally occurs when the cylindrical ultrasound wave is
deflected from its path due to reflection occurring at various interfaces.
Due to these two facts US beam is reduced in intensity while passing inside
the tissue. This gives rise to a term “Half Value Distance” – which is the
depth of the soft tissue that gives rise to half of the intensity of US. For a
machine of 1MHz the HVD is 4cm and that for a 3MHz machine it is 2.5
cm. The ultimate fate of an US beam results in to a near field and a far
field. The extent of near field depends upon the radius (r) of the transducer
and the wave length (λ) of US. The depth of near field can be calculated
using the formula
NF = r2/λ.
Effects of Ultrasound on Tissues (Physiological)

Thermal Effect
When US waves are absorbed into the tissues they are converted into heat—
following the Newton’s law of conservation of energy. The amount of
production of heat depends upon the presence of protein-tissues, which absorb
US efficiently, therefore produce much heat. Heat production also depends
upon the type of insonation, i.e. continuous or pulsed. The amount of heat
increases with continuous type of insonation. Sometimes reflected waves like
reflection from a body part may increase the heat thereby may cause periosteal
pain. This can be avoided by the use of pulsed ultrasound with space ratio
of 1:1 to 1:4 or 1:7. Thermal effect increases vasodilatation, cell activity,
vascular supply and removal of waste products and thus causing resolution
of inflammation. Thermal effect also causes increase in extensibility of fibrous
tissues, scars, and adhesions.
Mechanical Effect (Non-Thermal Effect)

Non-thermal or mechanical effects of US are acoustic streaming, standing
waves, micro-massage and cavitations. US beam produces compressions and
rarefactions of cells and movement of tissue-flow in interstitial cells. Repeated
vibration of the tissues by US beam results in micro massage of the cells,

which helps to reduce edema. Unidirectional flow of tissue fluid as a result
of insonation is known as acoustic streaming which helps to increase the
permeability of tissue cells. Cavitations are the formation of tiny gas bubbles
in the tissues as a result of insonation. Cavitations may be stable or unstable.
In stable type the gas bubbles remains intact and it is helpful as it causes
micro-streaming. But unstable citations are potentially dangerous as collapsing
of this type of bubble cause considerable pressure and temperature changes.
Standing waves occur due to the reflected waves superimposed, on the
incident waves. The result is a set of stationary waves with peaks of high
pressure. This may hamper the flow of blood inside vessels and thereby results
in increased local temperature
Biological Effect
The biological effects of US are relief of pain, resolution of inflammation and
acceleration of healing of wound. These are utilized for therapeutic purpose.
Therapeutic Uses of Ultrasound

Ultrasonic waves are used for various therapeutic purposes. The most
common uses are:
1. Injuries and inflammation: US are often used after soft tissue injuries like
muscles, tendons, capsules and ligaments. It helps to remove traumatic
exudates and thereby reduces the danger of adhesion formation. Pain is
reduced due to its action upon the “C Fibers” of sensory pathway.
Accelerated protein synthesis stimulates the rate of repair of damaged
tissues. Hence it is useful in conditions like tendonitis, bursitis, chronic
sinovitis and muscular spasm. It is also effective in low back pain
spondylosis, etc.
2. Scar tissues: Scar tissue is made more pliable by application of US, which
causes effective stretching of scar tissue. If the scar is adhered to underlined
structure US may help in gaining its release. Hence it is used in contractures
after surgery, post burn contracture, keloids and Depuytrens contracture.
3. Chronic indurate edema: Chronis indurate edemas are best managed with
sonic beams, which break down the adhesion septures and forces the fluid
to resolute earlier.
4. Varicose ulcers: Ultrasound therapy is quite effective to promote the healing
of vericose ulcers.
Contraindications
i. Therapeutic US are contraindicated over metal or synthetic implants.
Because sonic beams reflect back without being absorbed.
ii. It is contraindicated in vascular conditions like thrombophlebitis because
insonation may dislodge a thrombotic embolus that may cause embolism.
iii. Insonation is contraindicated in cases of acute sepsis, rest the sepsis may
spread allover the body. Bacterial, fungal or viral infections are to be
avoided for US therapy.
iv. US are not applied over in radiated area (deep X-ray therapy) as
radiotherapy has a devitalizing effect on these tissues.
v. Tumors or malignant areas are not at all suitable for insonation as the
growth of cancer cells may aggravate and spread easily.
vi. US therapy is contraindicated in pregnancy as it may damage the fetus.
It should be mentioned here that diagnostic US scanning is different from
that used for therapeutic purpose.
vii. Patients having hearing aids or pacemaker are not allowed to take US
therapy. High frequency currents in the US machines may interfere with
these apparatus.
viii. Impaired such sensation areas are not suitable for US therapy as in
diabetic neuropathy cases, Hansens disease.
Technique of Application
US application to the body is done by following methods:
Direct Method
The treatment head or transducer is kept in direct contact with part to be
treated. Prior to it a suitable coupling medium like ultrasonic gel, liquid
paraffin, or glycerin is applied to the skin in order to eliminate air between
the skin and the treatment head. The machine is switched on, the treatment
time is adjusted and the intensity is increased. Prior to all these the machine
is tested for any live connection of the phase so that any danger of electric
shock can be avoided. Next the treatment head is placed over the coupling
medium and treatment the head is moved in concentric circles over the part
to be treated.
Water Bath Method

Here degassed water (previously boiled and cooled water) is used in a
container. The treatment head is held 1 cm from the skin and moved in small
concentric circles. In this method, treatment of joints of hand, forearm and
foot are insonated. Water serves the role of a coupling medium.
Bag Method
A rubber bag is filled with degassed water. A coupling medium is applied
between the rubber bag and the part to be treated and between the bag
and the treatment head. The rubber bag is placed on the irregular body surface
and insonation is given as in contact method.
In all cases the movement of transducer or treatment head over the body
part can be done either in overlapping circles, overlapping figure of eight
circles or transverse overlapping strokes (Fig. 6.3).
Fig. 6.3
Dosage: In acute condition the dosage should be 0.25 to 0.5 Watts/sq-cm

of the transducer for 5 to 6 minutes. In chronic condition it may be increased
to 0.8 to 1.5 Watts / sqcm for 10-15 minutes.
3 MHz machine is used for superficial conditions where as 1MHz machine
for deep lesions. Pulsed ultrasound is used to reduce the heating effect. Pulse
ratio of 1:1 is used in less acute cases; 1:7 is used in very acute cases. Numbers
of sitting are, daily for 10 to 12 consecutive days or till the symptoms subside,
or it depends upon the therapists’ experience.
PULSED ULTRASOUND
In continuous type of US therapy there occurs mechanical effect and side
by side thermal effects are also produced. But it is recognized that non-thermal
effect can have more mechanical and direct effects upon nerves. So, pulsed
ultrasound therapy began to be popular. In pulsed method, ultrasound
production and cessation occur at regular interval. Pulse ratio switches adjust
the duration of pulsed ultrasound and its interval time. Pulse ratio is the rate
of duration and pulse interval. The commonly used pulse ratios are 1:1, 1:4,
1:7 and 1:10.
Normally, the pulse duration is 2msec and the interval is 2msec or more.
When the ratio is 1:1 then the pulse duration is 2msec and the interval is
also 2msec. In a 1:4 ratio, the duration is 8 msec and the interval is 2msec.
Similarly different pulse ratio is obtained. Pulsed ultrasound produces minimal
thermal effect but maximal mechanical or non-thermal affects. It is used in
acute conditions, bony area, scar tissues or where movement of transducer
is low.
Ultrasound can be combined with other types of modalities like muscle
stimulator, TENS, iontophoresis, etc. This will helpful in special cases but
the cost of equipment restricts its use.
CHAPTER
7
Electromagnetic Spec-
trums and EMG Biofeed-
back
INTRODUCTION
Before going for infrared radiations we must know what “Electromagnetic
Spectrum” is.
The electromagnetic spectrum is the distribution of electromagnetic
radiation in which the parts or items are arranged according to the wavelength.
Infrared is one of the items of the electromagnetic radiations. The spectrum
is as follows (Fig. 7.1):
Radio-waves with wavelength 0.1mm to 100 km
Infrared waves with wavelength 750 nm to 0.4 mm
Visible light with wavelength 400 to 750 nm
Ultraviolet rays with wavelength 10 to 400 nm
X-ray and Gamma rays with wavelength 0.01 pm to 100 nm
This is represented in a diagrammatic way as follows:
Fig. 7.1: Electromagnetic spectrum
INFRARED RAYS
As indicated above visible light falls in between the infrared and ultra-violet
rays and so IR rays lie outside visible spectrum.
Hence infrared rays are electromagnetic waves with wavelengths of 750
to 400 nm. Any hot body can emit IR rays like fire, sunrays, electrical heating
coils, etc. IR rays are also known as thermeogenic rays, as it produces heat
when absorbed by the body tissue.
From their properties IR rays are divided into two types:

a. Long-rays with wavelength between 1500 nm and above
b. Short-rays with wavelength between 750 nm and 1500 nm.
For clinical purpose long IR rays are taken as those, which are emitted
from non-luminous generators, while short rays are emitted from luminous
source along with some visible rays and long rays. The difference between
the two types lies in their absorption and penetration. Long rays are absorbed
by water so they cannot penetrate deeply into the tissues to produce any
effect. On the other hand shorter rays are not so strongly absorbed by water
and they can penetrate to a varying degree into different tissues. The difference
is well understood in the household works. The maximum penetration power
of IRR is less than 2.5 cm. The effects of IRR are purely those of heat. Van’t
Hoff stated that any reaction capable of acceleration is accelerated by heat.
It is considered in conjunction with that of Grotthus that heat is produced
at the site of absorption of rays. Most of the rays are absorbed in the epidermis;
some of the shorter rays penetrate as far as superficial capillaries of the dermis.
Absorption at this level causes a mottled erythema, which appears during
irradiation and fades when the source of IRR is removed. Erythema is due
to the reflex dilatation of capillaries. The more deeply penetrating short rays
produce heat within muscle. This is useful in the treatment of deep-seated
lesions and chronic conditions, where an increase in circulation of the lesion
is imperative. The nerves supplying the sweat glands are also stimulated and
this together with the local vasodilatation produces increased sweating.
PRODUCTION
Non-luminous Generators
All heated materials produce IRR. Those that are non-luminous like the heated
coil of a heater, or any hot object produce long IR rays. Black fire clay
produces pure form of non-luminous IR. Non-luminous lamp for therapy have
heater wire embeded in insulating ceramic or porcelain cylender so that no
visible radiations are given out. All non-luminous elements require some time
to heat up before the emission of rays reaches maximum intensity (Thermal
inertia).
Luminous Generators
Short infrared rays are produced from incandescent lamps. Often the front
portion of the lamp is made red to filter out the short visible rays and ultra-
violet rays.
Electromagnetic Spectrums and EMG Biofeedback 49
Technique of IRR Application

As already mentioned before, IRR can be given by both luminous and non-
luminous generators. Both have their respective advantages. So the choice
lies upon the therapist who will judge which one will be more beneficial.
The thumb rule is that when there is acute inflammation or recent injuries,
the sedative effect of the rays obtained from the non-luminous generators
are usually applied. For lesions of a chronic type the counter irritant effect
of shorter rays of luminous generators prove to be of value.
The precautions those to be taken are against burn and scalding. Heat
burn may occur due to closeness of the generator (lamp) to the skin. Burners
are to be placed at least 18 inches from the part to be treated. Before applying
IRR the skin sensation should be checked. Patient should experience
comfortable warmth. Care should be taken to keep the face out of the source
of IR generator for the danger of developing premature cataract. The treatment
time is around 10 to 15 minutes.
Therapeutic Uses
Pain: IRR is an effective means of reliving pain. When heating is mild the
relief of pain is due to the soothing, sedative effect on the sensory nerve
endings. Heat causes vasodilatation, increases blood flow to the effected part,
which removes the waste products of metabolism and thereby relieves pain.
Muscle relaxation: Warmth causes relaxation of muscles and relief of pain,
which in turn also facilitate muscle relaxation. So, it is useful in muscular
spasm due to injury.
Contraindications
IRR should not be applied over the areas with defective arterial blood supply.
It is also contraindicated in cases of hemorrhagic diathesis.
It is not used over the parts with sensory impairment for the danger of
heat burn. It should not be applied over the face area directly as irradiation
cataract may develop.
ULTRAVIOLET RADIATION
UVR are those of the rays of electromagnetic spectrum that have wavelength
between 10 to 400 nm and that lie between the visible lights and the
X-rays.
UVR are of three types:

UVR-A
UVR-B
UVR-C
They are called active rays because they bring about chemical changes
in the tissues. The effect of rays varies according to the wavelengths and
their penetration power. Long ray are called “Biotic” and they are stimulating
to the living tissues promoting growth and healing. The short rays are “A
biotic” and are inimical to life and have destructive effect on the cells of the
body. The sunray emits UVR, which can often have an effect on skin, but
for therapeutic purpose UVR generators are used. Most of the generators
produce UVR from mercury vapor generators like high pressure or low
pressure mercury vapor lamp, fluorescent tubes, Kromayer lamp and Puva
box.
GENERATORS
Kromayer Lamp
Kromayer lamp is a water-cooled mercury vapor generator (Lamp) that
eliminates the danger of an infrared burn. It can be used in contact with
the tissues or with special applicator to irradiate inside a sinus.
It consists of a high pressure mercury vapor burner that is completely
enclosed in a jacket of circulating distilled water. The water here cools the
lamp at the same time it absorbs the unwanted IRR. A pump and a fan are
attached to it in order to cool the water. At the front of the lamp water
circulates between two quartz windows through which UVR emerges. The
water cools the burner (Fig. 7.2).
Fig. 7.2: Kromayer lamp

High Pressure Mercury Vapor Generator

This is a U shaped quartz tube, which allows passage of UVR and can
withstand very high temperature. The U tube contains Argon gas at low
pressure to lower the electrical resistance. A small quantity of mercury is kept
inside the tube. Two electrodes are placed at the ends of the U tube and
are sealed. The electrodes are connected to an AC source and a high potential
difference (400 volts) is applied in order to ionize the Argon gas. The ionized
Argon gas particles move inside the U tube and the electrons move towards
the positive terminal. Similarly the positive ions are attracted towards the
negative terminal. So, there occurs a movement of charged particles. The
collision of charged particles with neutral argon atoms cause further ionized
so that there is continues generation of ionized particles to sustain the current
flow across the tube. The flow of current can be seen as glow discharge.
Sufficient heat is produced to vaporize mercury inside the tube and the
mercury vapor becomes ionized.
Ultraviolet radiation is produced by the energy released from the
recombination of electrons and positive mercury ions. The whole process
of argon ionization, mercury vaporization and consequent ionization take
some time. The burner is placed on a parabolic reflector whose position can
be adjusted according to the need (Fig. 7.3).
Fig. 7.3: High pressure mercury vapour generator
Tridymite formation: The heat produced inside the burner of UVR causes
some of the quartz to charge to another form of silica called Tridymide. So,
total output of the lamp gradually falls and formation of tridymite increases.
This can be partly prevented by using a variable resistance in the burner
circuit. Along with UVR some IRR is also produced.
PUVA Apparatus: Irradiation with UVA can be made with the help of a special
fluoroscent tube, which may be mounted in a vertical battery on an wall
or on four sides of a box totally surrounding the patient. This form of ultraviolet
irradiation is usually performed two hours after the patient has taken a photo
active drug like psolaren. Hence the turn appears as PUVA (Psolaren
Ultraviolet A). It is used in Psoriaris.
Physiological Effect
The various physiological effects of UVR are carcinogenesis, erythema
reaction, thickening of epidermis, pigmentation, bactericidal effect, and
vitamin D formation etc.
• Carcinogenesis: It is a danger of longer use to UVB and UVC as these
rays have anti-DNA effect. So, prolonged exposure to shorter UVR should
be avoided.
• Erythema: Damage to the cell cause release of histamine like substances
from the epidermis and superficial dermis. Gradual diffusion of the
substances causes redness of skin due to dilatation of local blood vessels.
This erythematous reaction is used to classify the dosages of UVR given
to the patients. There are 4 degrees of erythema –E1, E2, E3, E4.
• E1: It is the first-degree erythema characterized by slight pink coloration
of skin with no irritation. Its latent period is up to 12 hours and lasts
for 24 hours.
• E2: The second-degree erythema is characterized by redness of skin
with slight irritation. Its latent period is 4 to 6 hours but subsides for 2
to 3 days.
• E3: This is the third-degree erythema, which causes painful reddening
of skin, and the skin becomes hot and irritated. The latent period is 1
to 4 hours but it lasts for a weak.
• E4: It has all characters of third-degree erythema. In addition blister
formation occurs.
• Thickness of epidermis: Over activity of the basal layers of the epidermis
causes marked thickening particularly the stratum cornium. This may
become 3 times thicker than their normal.
• Desquamation or peeling: The increased thickness of skin is eventually
lost as desquamation or peeling.
• Pigmentation: UVR stimulates melanocytes in the skin to produce melanin,
a pigment. Extent of pigmentation occurs according to the dose of UVR
and in individual cases.
• Production of vitamin D: UVR may cause conversion of 7 dehydro-

cholesterol to vitamin D. It is ideal for old patients who often face the
danger of osteoporosis.
• Bactericidal effect: Short UVR can destroy bacteria and other small
organism such as fungus on wounds.
Indication or Uses
UVR is used in various skin conditions for both infected and non-infected
lesions.
• Acne: UVR is used in acne where pustules, papules are present. An E2
dose of UVR gives beneficial result.
• Psoriasis: It is a skin condition which presents localized plaques in which
the rates of cell turn over from basal layer to the superficial layer are too
rapid. The aim is to decrease the rate of DNA synthesis of the cells and
thus, to slow down the proliferation rate. Treatment can be given using
PUVA, which is a resin when the patient takes a sensitizing drug psolaren
2 hours before exposure to UVR. In the nucleus of the cell psolaren binds
to DNA in presence UVR-A and this inhibits DNA synthesis and cell
division.
• Skin wounds: UVR is used in infected skin wounds such as ulcers, pressure
sores, and surgical incisions. UVR destroys bacteria and removes the
slough and promotes repair.
Contraindication
• Hypersensitivity: Skin becomes hypersensitive particularly to sunrays. Such
patients are not advocated to UVR.
• Deep X-ray therapy: UVR is not used in patients who are undergoing deep
X-ray therapy or chemotherapy, etc.
• Skin conditions: Some skin conditions like eczema, lupus erythematosus,
herpes simplex, etc. may become exacerbated with UVR treatment.
Dangers of UVR
Eyes: UVR may cause cataract. So, both the patient and therapist should
wear protective goggles.
LASER
One of the most useful treatment modality available for physiotherapy is that
of laser. Laser is an acronym for Light Amplification by Stimulated Emission
of Radiation. Laser beam is produced when the atoms of certain elements
are exited with electromagnetic radiation and as such they produce electro-
magnetic radiation of a particular wavelength. They have a unique feature
of a constant wavelength with very little divergence. They are also termed
as magic rays as they have diverse application in different fields.
In physiotherapy therapeutic lasers are used which are also known as soft
Lasers.
Usually Lasers are of three types:
i. Power Laser—which is used for destructive or surgical purpose.
ii. Soft Laser—has very superficial effect and is usually used fro treating
the skin.
iii. Mid Laser—it is type that is used in physiotherapeutic treatment. Their
depth of penetration is sufficient to produce biological effect.
Laser beam has a uniqueness of its own which differentiates its self from
other forms of light. The important features are:
a. Monochromacity: Which means laser beam has a particular color, which
is pure because of its single specific wavelength. Even if it passes through
a prism it produces the same color.
b. Coherence: Laser rays are synchronous to each other, even if they pass
into the space. They are coherent to each other in relation to time also.
c. Collimation: This means non-divergence. Laser rays travel parallel to each
other rather than diverging from each other.
Various forms of lasers are available like Helium-Neon laser, Ruby laser,
Carbon laser and Infrared laser. Of these Helium-Neon laser and Infrared
laser are used in physiotherapy.
Production of LASER
Laser is produced from the substances, which are capable of producing laser
rays on the basis of stimulated emission by radiation. A laser-producing
machine consists of components like casing medium, energy source and
mechanical structure. The medium may be gaseous, liquid, solid crystal or
semiconductor. AC current is used as energy source to excite the lasing
medium. The mechanical structure consists of a cylindrical chamber containing
the lasing medium and has got two mirrors at either end. One of them serves
as the reflector of photon of light across the cylinder; the other mirror is used
to reflect the photons as well as it allow the photons to exit through it. When
photon is applied to the atom of a lasing medium it may be absorbed or
reflected back. When an atom absorbs it then there occurs a change in the
electronic configuration. Thus an electron may jump from low energy level
to high energy level making the atom an excited one. As one excited atom
cannot stay for long time it always tries to regain its original configuration.
So the atom emits back the absorbed energy and this is spontaneous. But
form the spontaneous emission, laser ray will not be emitted. Hence when
an atom is in exited state it is made more exited by additional energy (released
by other atoms) so that stimulated emission is produced. Since this stimulated
emission is more than what is supplied it is known as amplification. Excess
energy is emitted in the form of photons of light. The reflecting mirror reflects
the photons through the lasing medium to agitate or to excite the atoms of
the medium. This increases the amplification process further. As a result more
and more photons are accumulated in the cylinder. When the accumulations
of photon are more than the capacity of the chamber they are emitted out
through the semi permeable hole present in one of the mirrors. The emitted
photons are the laser rays and are carried by fibro-optic cable to the probe
for treatment purpose (Fig. 7.4).
Fig. 7.4: Schematic diagram of laser
Method of Application
Some lasers are utilized for treatment, which comes in direct contact to
patients’ skin, where as others are placed at a certain distance, the outputs
can be controlled through switches. This can be continuous or pulsed. When
it is used in direct contact to patients’ skin it is applied at right angled to
the skin that is angle of incidence is ‘0°’. Patient and therapists must wear
protective devices like goggles. The treatment parameters as used being 550-
700 Hz and pulse width of infrared of 150n with peak power of 5 hours.
The lasers those are used from a distance from the patient’s body part are
usually mounted on a trolley or stand and the laser emitter is positioned at
a 30 cm from the patient. The He-Ne Laser is slightly defocused to cover
an area about 10 cm diameters.
Effects of LASER
The effects Laser therapy are
• Reduction of pain.
• Acceleration of repair process.
Laser has got pain in analgesic property. It can be used in the treatment
of acute and chronic conditions. The exact mechanism of pain relief has not
been known. Laser accelerates tissue repair and wound healing. This may
be due to phagocytes and facilitation of collagen synthesis.
Indications
• Wound healing
• Soft tissue injury
• Pain from trigger points.
Contraindications
• Patients having pacemakers.
• Epilepsy
• Cardiac patients
• Skin infections, etc.
EMG-BIOFEEDBACK
Biofeedback has been accepted as one of the modern tools in rehabilitation
medicine and physiotherapy. Biofeedback is a technique, using an equipment
to reveal to the human beings some of their physiological events electronic
in the form of signals and to modify the actions by manipulatory signals.
Biofeedback is process of furnishing the information on the body function
and the internal physiological events of an individual in the form of vocal
commands, visual or auditory signals. This technique incorporates a person’s
volition in to the gap of an open feedback loop. Biofeedback can well be
used with isokinetic dynamometer machine which is a device complex where
mechanical system is being used with computerized sensor and recording
mechanism to record the torque produced by the muscles.
Electromyography Biofeedback
This is otherwise known as EMG-biofeedback, which is commonly used in
physiotherapy. Muscles potentials are changed into auditory or visual cues
for increasing or decreasing voluntary activities. A set of surface electrodes
are placed on the selected muscle surfaces to detect electrical signals associated
with muscle contraction. These signals are amplified and translated to simple
auditory or visual signals. The state of muscle contraction or relaxation coming

via the electrodes are provided to the patients as visual or auditory display
that can be seen on a monitor kept in front or heard from a loudspeaker.
As the display bears an approximate relationship to the magnitude of muscle
contraction causing it, reeducation of muscle can be possible. It can be said
in other way that it will be possible to get the desired response from the
muscles. Patient’s volitional effort will certainly enhance the reeducation
process. Biofeedback is particularly helpful in the treatment of recovery of
peripheral nerve injury cases, writers’ cramp, tendon transplantation and to
reduce the spasticity in hemiplegia, CP, and muscle sclerosis.
The treatment duration of biofeedback is about 20 to 30 minutes per day.
Advantages
• EMG-biofeedback provides a correct information bout the condition of
the part to be treated.
• Patient gets involved with the procedures so the patient cooperates with
the physician.
Disadvantages
• No doubt it is a costly procedure. It treats the symptoms not the underneath
cause.
• It is unwanted to the patients who do not like wires to attached to their
body
• It needs trained personnel to operate the machine.
CHAPTER
8
Cryotherapy and
Hydrotherapy
COLD THERAPY
The application of cold or ice for the relief of pain, muscle spasm, swelling,
etc. is known as cryotherapy or coldtherapy Cryotherapy lowers the
temperature of the effected part quickly. Heat abstraction or cooling by
cryotherapeutic agents mostly occurs by conduction excepting the vaso-
coolant spray. The magnitude of cooling depends on the area affected and
duration. Cryotherapy is mostly used to:
a. Reduced pain
b. Reduce spasticity
c. Reduce muscle spasm
d. Reduced swelling
e. Promote repair
f. Provide excitatory stimulus when the muscles are inhibited
Physical Principle
When ice is applied to body heat is conducted from the skin to the ice to
melt it. To change the state, ice requires considerable energy (Latent heat
of fusion). To raise the temperature of one gram of ice at 0°C to one gram
of water at 37°C an amount of 491 Joules of energy is required. So when
cryotherapy is used it is better to use ice only but not cold water. Ice can
decrease the activity of fusimotor efferent system in muscles and this relieves
pain and muscle spasm. The effect of cold to relieve pain and muscle spasm
is more long lasting than that of heat. The effect of cold in therapeutic practice
depends upon various factors like:
a. Application of temperature of cold and the temperature of the part
receiving cold therapy.
b. Duration of application
Cryotherapy and Hydrotherapy 59
c. Density of skin, fat content, subcutaneous tissue, muscles, water content

and patency of circulation
d. Pathophysiology of the lesion.
Methods of Cooling
The usual methods of cooling are:
• Conductive cooling
• Convective cooling
• Evaporative cooling
Circulatory response: Cold application causes initial vaso-constriction as the
body tries to preserve the body heat. But after a short period there occurs
vasodilatation and again vasoconstriction. Later on alternate process of
vasodilatation and vasoconstriction occurs. This apparent “Hunting” for a
mean period of circulation is called “Lewis Hunting Reaction” which is
represented graphically as follows (Fig. 8.1):
Fig. 8.1: Lewis hunting
Body temperature: Cold application causes fall in body temperature. However,

severe local cooling may result in hypothermia, i.e. core temperature below
35°C. A 10°C drop in tissue temperature may again cause pain.
Neural effect: The skin contains a lot of thermal receptors (cold), which are
more than heat receptors. Cold receptors respond to cooling by a sustained
discharge of impulses. Cooling reduces the rate of conduction of an impulse
in a mixed peripheral nerve.
Reduction of spasticity: Spasticity is a pathological state of increased muscle
tone. It may be due to the damage occurring to the upper motor neuron,
also to the over activity of extra-pyramidal tract. Where as spasm is a normal
response to injury or pain and is manifested as an increase in the muscle
tone in a specific area with the apparent aim of limiting the movement and
further damage.
Excitatory cold: When cold is applied in an appropriate way it increases the
excitatory bias around the anterior horn cell combined with other forms of
excitatory impulse and with patients’ active participation, contraction is often
produced in an inhibitory muscle. This used in postoperative muscle inhibition.
TECHNIQUE OF APPLICATION
Application of ice therapy is done by various methods as follows:
a. Iced-towels: A mixture of ice flakes and cold water is kept in a bowl. Towels
dipped in this mixture are squeezed and applied over the affected part of
the body. The ratio of ice flex and cold water is 2:1. Usual treatment time
is 2 minutes and at best 10 towels can be used.
b. Ice pack: Canvas bags containing silicate gel or cashed ice are applied
over the body. The treatment time is about 10 minutes.
c. Emersion: Mixture of ice and water in 1:1 ratio is taken in a chamber
where the affected body part particularly the extremities can be dipped
for 10 minutes.
d. Ice-cube massage: Cubes of ice or ice-lollypops are generally massaged
with mild pressure over the body in a circular manner. It is applied over
the tendons, bursa, and muscle-belly or trigger point.
e. Vaso-coolant spray: Vaso-coolants like fluoro-methane, or ethyl chloride
kept under pressure in cylindrical containers are sprayed over the injured
body part. The flow of spray is kept at 30° angles to the body part keeping
the distance of 45 cm. Parallel sprays are made over the effected site to
get maximum result.
f. Cold chamber: Cases of rheumatoid arthritis are subjected to extreme
cold for a short period keeping in a cold chamber at a temperature of
–19°C.
Before application of cryotherapy a plastic sheet is placed beneath the
part to be treated. The area of treatment is to be adequately exposed.
Application of olive oil over the body part prior to ice therapy may protect
from ice burn.
Therapeutic Uses
• Initial vasoconstriction effect is used to restrict pouring of blood in to the
tissues thereby prevents edema formation or swelling as in sports injury.
• Alternate periods of vasoconstriction and vasodilatation (Lewis Hunting
Reaction) help in capillary blood flow. It reduces formed edema and
Cryotherapy and Hydrotherapy 61
removes waste material—thereby helps to reduce pain.

• Reduce metabolic rate (formation of energy from degraded food particles)
allows cooled muscle to contract many more times before fatigue sets in.
• Relief of pain occurs due to following mechanism:
• Inhibitory action of the sensory nerve and a soothing affect on it causes
relief of pain.
• Cold receptors (which are present many more times than the heat
receptors) inhibit the passage of pain sensation to the brain via posterior
root ganglion.
• Removal of metabolic wastes products reduce pain as these products
are the sources of pain.
• Diminution of spasm and spasticity occurs by reduced velocity of nerve
conduction (passage of nerve impulse in mm/m sec) and also by depressed
spasticity receptors like muscle spindle.
Application of cold breaks the vicious cycle of pain-spasm-more pain-
spasticity.
Contraindication
1. Psychological: Particularly elderly persons are very much apprehensive
about cold.
2. Cardiac causes: Cooling lowers blood pressure thereby increases the heart
rate. So, patients having weak heart cannot perform adequately.
Sometimes, cold precipitates cardiac arrest or infarction.
3. Application of ice to left shoulder is to be avoided as the sympathetic
nerve supply to left shoulder and to the heart are the same.
4. Peripheral nerve injury: Injured nerve show a poor response to cooling.
So prolonged cooling may damage the tissue.
5. Peripheral vascular disease: Due to improper blood flow the conduction
of cold cannot be done by the vessels so there may be ununiformity of
cooling of tissues. For example Raynauds, Burger’s disease.
6. Impaired skin sensation: Ice should not be applied to insensitive skin area
as in Hansen’s disease and Diabetes Neuropathy.
7. Cold sensitivity: Some persons are allergic to cold for which they develop
skin eruptions for which ice therapy may not be suitable to them.
HYDROTHERAPY
Hydro means water and therapy is a mode of treatment. So it refers to one
sort of exercise therapy using the property of water. Water possesses a unique
property of its own, i.e. the property of upward thrust otherwise known as
Buoyancy. This physical property is utilized in physiotherapy for treatment
of muscular weakness, stressed joint. Utilizing this property the gravitational
force is eliminated which, helps in physical exercise. The other property of
water, i.e. the turbulence, surface tension and viscosity offers varying degrees
of resistance.
Usually hydrotherapy is performed in a therapeutic pool with shallow water.
The depth of water varies at either ends to suit treatment for children and adults.
This pool is specially made with all safety measures. The water of the pool is
changed by means of electric pumps and the temperature is kept at a suitable
level. Technical trained persons take the patients to the pool and demonstrate
and at times perform the necessary exercises. Child patients use tubes or rings
to float. Flotation devices help either in assisting or resisting an action. PNF
techniques when done in water give satisfactory result. In absence of a pool,
whirlpool bath may be used to get some benefits of hydrotherapy.
Indications
Hydrotherapy is indicated in improving the power of muscle as in
poliomyelitis, arthritis, paralysis and cerebral palsy cases.
Benefits of pool therapy:
• Effects of buoyancy of water
• Effects of reduced gravity
• Musculotendinous relaxation
• Relief of pain.
Muscle re-education, strengthening of weak muscle, improvement of
circulation, increment in the range of joint motion improvement of balance,
co-ordination and posture and the functional activities are achieved by means
of hydrotherapy.
Contraindications
• Mentally disturbed person
• Seizures
• Vertigo
• Associated cardiac diseases
• Fear of water
• Skin diseases.
The frequency of hydrotherapy is twice or thrice a week, which gives
satisfactory result.
CHAPTER
9
Exercise Therapy
Therapeutic exercise is one of the key tools that a physiotherapist uses

to:
• Restore patient’s musculoskeletal status.
• Improve the cardiopulmonary well-being.
Every therapist needs to have a foundation of knowledge and skills that
can be used to manage the patients’ problems.
The ultimate goal of any therapeutic exercise program is the achievement
of symptom free movement and function. To effectively administer therapeutic
exercises to a patient, the physiotherapist must know the basic principles and
effects of therapeutic exercises on musculoskeletal, neuromuscular,
cardiovascular and pulmonary systems. Besides the therapists must be able
to perform a functional evaluation of the patient and must know the inter
relationship of the anatomy and kinesiology of the part. Also he should have
an understanding of the state of injury, disease or surgical procedures. He
must be aware of the potential complications, precautions and
contraindications.
AIMS OF THERAPEUTIC EXERCISE

The aims of therapeutic exercises include the prevention of dysfunction
of musculoskeletal structures and cardiopulmonary systems. It
also incorporates development, improvement, restoration and maintenance
of:
• Strength
• Endurance
• Mobility and flexibility
• Stability
• Relaxation
• Co-ordination, balance, functional skills
• Cardiovascular fitness
Human body and individual body system react, adapt and develop in
response to:
• Forces
• Stress placed upon them
Gravity is a constant force that effects the neuromusculoskeletal and
circulatory system.
What is Therapeutic Exercise?

Therapeutic exercise is defined as the systematic and planned performance
of bodily movements; posture or physical activity intended to provide a patient
with an aim to:
• Prevent impairment
• Improve, restore, or enhance physical function
• Prevent or reduce health risk factors
• Optimize overall health status, fitness and sense of well-being.
It is to be remembered that therapeutic exercises should not be made
generalized. It should be individualized in the light of the principle. It is to
be tailor-made to the individual deficit and demand. An individually designed
therapeutic exercise program is almost always a fundamental component of
physical therapy.
To develop and implement effective exercise one must understand the
effects of different types of exercise on body systems and its impact on key
aspects of physical function. So knowledge of anatomy, physiology,
kinesiology, pathology along with behavior science are also mandatory.
It is to be mentioned here that a physiotherapist must understand the
various aspects of the effects of therapeutic exercises program and should
explain to his/her clients (patients) about the procedures and outcome in
simple language, so that the patient bears a confidence upon him/her. To
have effective exercise program patients’ cooperation and active involvement
is absolutely needed. Whenever possible the therapist must demonstrate the
procedures of exercise on a non-effected part, which is least painful. Of long
run the therapists should withdraw himself/herself gradually from active
participation so that the patient may do every task for himself/herself.
SOME KEY TERMS USED IN EXERCISE THERAPY

• Force: It is the output of a muscle usually called its strength.
• Power: It refers to the rate of doing work. In muscle action it is the output
of muscle at specific speeds of contraction.
Exercise Therapy 65
• Endurance: It is the capacity to contract muscles at a specific rate for a

specific interval of time.
• Work: It is the action of a force over a specific distance in space. In body
it refers to the product of muscular force exerted through a specific range
of movement.
• Balance: It is the ability to align body segments against gravity to maintain
or move the body within available base of support without falling.
• Mobility: The ability of structures or segments of the body to move or to
be moved in order to allow the occurrence of range of motion for
functional activity.
• Stability: The ability of neuromuscular system through synergistic
muscle action to hold a proximal or distal body segment in a stationary
position.
TYPES OF THERAPEUTIC EXERCISE

Therapeutic exercises are broadly classified into following types:
a. Strengthening exercise or strength training exercise
b. Relaxation exercises
c. Coordination exercises
d. Mobilization exercises
e. Endurance exercises
f. Gait training exercises
g. Balancing exercises.
Apart from the above some special types of exercises are also practiced
in specific cases.
Strengthening Exercises
The key elements of muscle performances as already indicated are strength,
power and endurance. If any one or more of these areas of muscle
performance is impaired the functional limitation and subsequently disability
develops. Many factors like disease, injury, disuse or inactivity may lead to
muscle weakness and atrophy, which may ultimately impair muscle function.
Here only strengthening exercise is of immense value. As we know strength
is the performance characteristic of a muscle or muscle group, which produce
force in one maximal effort either dynamically or statically.
Strengthening exercises are a set of exercises those are used in increasing
the power of muscle or muscle group. It incorporates weight-training exercises,
resistance exercises, etc. the three elements of muscle performance, i.e.
strength, power and endurance can be improved by some form of resistant
exercise. Due to exercise therapy some form of physico-physiological changes

occur in muscles such as:
• Increase in size of the muscle fibers
• Increase in content of actin and myosin filament
• Increase in amount of metabolic enzymes
• Increase in stored nutrients
• Increased bone mineral density
• Decrease in bone demineralization
• Increased lean muscle mass and decrease in body fat
• Enhanced feeling of physical well-being
• Possible improvements in perception of disability and quality of life.
General Principle of Strengthening Exercises

While designing a strengthening program or resistance exercise the overall
levels of fitness must be considered. One should follow the SAID principle
(Specific Adaptation to Imposed Demand).
Specificity of training should be considered relative to the mode and the
velocity of exercises, movement pattern and position of limb during exercise,
e.g. training a person for climbing stairs should include training in ascending
as well as descending steps. Parameters for enhancement of endurance should
be geared.
Types of Contraction
Two types of muscle contraction occur when a body part is subjected to
exercise:
Static Contraction or Isometric Contraction

In this type of contraction the length of the muscle remains the same through
out the muscle wall and as such no movement at the corresponding joint
occurs. Hold period is very much important to recruit maximal motor units.
To achieve the static muscle performance an isometric contraction should
be held for 6 to 10 seconds. This allows time for peak tension to develop.
Usually 5 to 6 weeks time is needed to strengthen a weak muscle by isometric
training. Multiple angle isometers is a system of isometric exercise where
resistance is applied manually or mechanically at multiple joint positions within
the available range of movement (ROM).
Limitations: Strength improvement occurs only at or closely adjustment to
the training angle with little or no carry over to dynamic exercises. Resistive
isometric is not as effective as resistive dynamic exercise.
Exercise Therapy 67
Dynamic Exercises or Isotonic Contraction

A dynamic muscle contraction causes joint movement and excursion of a
body segment as muscle contractions and shortening. Here the muscle
contraction occurs in three forms:
Eccentric contraction: Muscle contracting eccentrically becomes longer and
thinner as they pay out and allow their attachment to be drawn apart by
force, producing movement. Eccentric exercise is a form of negative work.
For example: Lowering a dumb-bell from flexed position to extensor position
occurring in biceps muscle.
Concentric contraction: When a muscle contracts concentrically it becomes
shorter and thicker as their attachments are drawn close together and as such
joint movement occurs, e.g. lifting a weight in hand and flexing the elbow.
Here the concentric work is done by the biceps brachii muscles. Concentric
muscle work is used to build power. The physiological efficacy is high as
a considerable amount of energy is liberated during mechanical work.
Concentric muscle contraction accelerates body segment movement where
as eccentric contractions decelerated it. A combination of the both muscle
action is evident in countless tasks of daily life such as getting up from chair,
sitting back, getting up and climbing down stairs. Consequently, concentric
and eccentric muscle actions are the fundamental components of resistive
exercise program.
Isokinetic exercises: It is a form of dynamic exercise in which the velocity
of muscle shortening or lengthening and the angular limb velocity is
predetermined and is held constant by a rate timing device (Isokinetic
Dynamometer). Isokinetic means the movement that occurs at an equal speed.
This is otherwise known as Accommodating Resistive Exercise. So in isokinetic
speed of contraction the angular velocity of movement is kept constant but
the load may be varied. This strengthens the muscles more effectively than
training with constant load or even variable resistance machine.
RANGE OF MUSCLE CONTRACTION

There are usually three ranges of muscle contraction especially in dynamic
exercises. They are Outer Range, Middle Range and Inner Range. Muscles
with various powers are subjected to these ranges of contraction. An exercise
to Inner Range is used to gain or maintain movement of a joint in the direction
of muscle pull. Outer Range is used for muscle re-education where as the
Inner Range is used to maintain tone as well as power.
PROGRESSIVE RESISTED EXERCISE (PRE)

It is a general rule that effected or weakened muscle should be strengthened
progressively by resisted exercises, which are specific for the muscle or muscle
group. This is based on the 10 RM concept, i.e. the maximum loaded that
can be lifted 10 times. Progressive Resisted Exercise (PRE) is a system of
dynamic resistance training in which constant external role is applied to the
contracting muscle and incrementally progressed. Usually 6 to 12 repetitions
with 6 to 12 RM are used. Resistive exercises can be done manually by the
help of some type of instruments. But it is advisable to evaluate a person
before advising any exercises about the cardiorespiratory systems, age, and
inflammation of the part and also for cancer patients.
RELAXATION EXERCISE
Relaxation is the state in which the muscles of the body are relatively free
from tension. As a muscle is physiologically at a constant state of spasm,
which is known as ‘tone’, is never completely free from tension. But when
tone crosses the physiological limit due to various factors hypertonicity
develops, which causes hindrance to normal activity even therapeutic
exercises. To counteract this state of hypertonicity, relaxation exercise has
been utilized.
Relaxation exercises can be taught to the patients so that a regime can
be practiced alone or active resistive techniques may be used in the presence
of a physiotherapist. Relaxation exercises may be general or local, i.e. the
whole body may be taught to relax or only a part of the body as the case
may be. It can be done in lying, half-lying, side half-lying or right/left lateral
position or in prone position.
General Principle of Relaxation Exercise

• Patient should be placed in a quite area in a comfortable position – in
accordance with patient’s need.
• The clothing of the patient should be loose. Resistive clothing like belts,
corsets should be loosened.
• Bright light, strong colors should be avoided. The room should low lighted
with facility of soothing music.
• Soft tone of voice by the physiotherapist is an integral part of relaxation.
• Instruction by the therapist must be simple and easy to understand.
• Patients’ bladder to be evacuated prior to relaxation exercise.
Exercise Therapy 69
Relaxation exercises may be practiced by following methods:

• Contrast method.
• Reciprocal method.
• Suggestion method.
Contrast Method or Jacobson’s Relaxation

The idea is that a strong contraction of a muscle is always followed by an
equal relaxation of the same muscle, i.e. Excitation = Inhibition.
The technique consists of a sequence of contractions of muscles preferably
in distal to proximal sequence in each limb, alternately followed by letting
to go or relax for equal longer period of time. Deep breathing may be practiced
with relaxation of the part of the body. It is more practical to breath in while
tensing the muscle and breath out during relaxing.
Reciprocal Method or Mitchell’s Exercise

The basic principle of the method is that antagonistic groups of muscles always
relax reciprocally to the contraction of the agonist groups of muscles. So we
may expect that tension must be relieved by contraction of antagonistic
muscles. The technique is that those muscles, which create tension, i.e. the
antagonistic muscles are required to contract with diminution of tension
followed by active contraction of the antagonistics. So the patient is not
allowed to remain in comfortable position, rather is asked to stay in a tense
posture, then in a better position when relaxation proceeds.
Suggestion Method
This is an alternative method, which may be used for those who may not
perform much muscle action.
These patients are allowed comfortable, relaxing conditions:
• Warm well ventilated room
• Comfortable support
• Light covering.
By using quite, hypotonic, mellow tones, the patients’ thoughts are directed
to personally enjoyable state. The patient is taught to think each part of the
body in turn and then to think that to be very heavy, so that the part or
limb rolls out. The patient may be asked to raise the limb but at the same
time he is to be advised to think that it is not possible to do so. Deep sighing
type of breathing may be practiced. This is exactly what we practice in Yoga
therapy, i.e. Savasana.
Other Forms of Relaxation Exercises

Other forms of relaxation training are:
a. Transcendental meditation: It is very much useful for relief of pain and
tension in muscles and can be practiced by the patient himself in calm
and quite room.
b. Yoga training: Yoga means “unite”—that is uniting the body with the spirit
and unity of the various aspects of life to deliver a harmonious state.
Indication of relaxation exercises
The main indications of relaxation exercises are to learn or to relieve
• Pain
• Muscle tension
• Anxiety or stress
• Associated physical impairments like:
• Tension headach
• Blood pressure
• Respiratory distress.
COORDINATION EXERCISES
It refers to the use of right muscles at right time and maintaining appropriate
sequencing and intensity. It is the process of correct timing and sequencing
of muscles firing combined with appropriate intensity of muscular contraction
with an intension to the effective initiation and guiding of a particular
performance. It results in activation of motor units of multiple muscles with
simultaneous inhibition of all other muscles in order to get a desired effect.
It is the basis of smooth, accurate and efficient movement occurring at
conscious or at automatic level.
Components
The components of coordination activity are:
Volition: Ability to initiate, maintain or to terminate any activity.
Perception: Integration of proprioception and subcortical centers with motor
impulses and sensory feedback.
Engram formation: Neurological organization of muscular activity developed
in the extrapyramidal system for precise performance. It requirs almost 20,000
to 30,000 repitation in order to get engram in each activity.
Exercise Therapy 71
General Principles
Regular activities are selectively branched in to simpler components for the
trainees to follow correctly. The patient is taught to practice individual prime
movers. Patients’ concentration is focused on sensations produced by action,
in order to maintain precision. Patients should be allowed rest time otherwise
ensuing muscle fatigue might deviate concentration. Assistance is provided
whenever necessary. Patient may be advised to take short rest lest muscle
fatigue may decrease concentration. Prior to introduction of new movement
various inputs like auditory, sensory or visual inputs are to be given.
Progression techniques like increasing the range of movement and speed of
movement may be accounted for.
FRANKELS’ EXERCISE (Fig 9.1)

This type of exercise was originally developed by Dr HS Frankel in1889 to
treat patients with problems of in coordination and cerebellar ataxia due to
loss of proprioception. These exercises are designed to substitute the use of
vision and hearing having loss of proprioception and require a high degree
of mental concentration and visual controlled movement. These types of
exercises are effective in reducing ataxia and require some control of functional
movement.
Fig. 9.1: Frankels’ exercise

Principles
The techniques are available for both the upper extremity and for the lower
extremity although lower extremity exercises are commonly done. The exercise
progress from postures of greatest stability like lying and sitting to postures
of greatest challenge, i.e. standing, walking. As voluntary control improves,
the exercises progress to stooping and standing on command, increasing the
range and performing the same procedure with eyes closed. In training such
exercises each patient should have individual attention and should not be
left unattended. Each patient is trained gradually increasing to more difficult
task. Strong muscle contraction is to be avoided since progress is by complexity
not by strength. Exercises are to be performed by the patient with open eyes
first and then gradually with closed eyes.
Indication
Frankles’ exercise is usually performed in cases of cerebellar ataxia, primary
in coordination particularly in UMN lesion or peripheral nerve lesion.
MOBILIZATION EXERCISE
Mobility is the ability of structure or segments of the body to move or to
be moved in order to allow the occurrence ROM for functional activity where
ROM is the full range of possible motion. It is a passive movement performed
in such a manner that the effective range of movement is achieved.
Principle
Patient is to be kept in a comfortable preferably in relaxed position. Prior
worming of the tissues with hot packs worm water or even paraffin wax helps
in carrying out the process. The bone proximal to the effected joint is firmly
fixed with physiotherapists’ hand or strapped to a mechanical device and
the effective force is applied distally close to the joint. The ROM is to be
maintained beyond the pain-free the range and it is to be increased gradually
day by day till effective ROM is achieved. For example mobilizing a shoulder
in adhesive capsulitis or mobilizing a stiff knee joint.
Indications
a. Pain and associated muscles spasm: Small amplitude oscillatory and
destruction movement are done in the pain free range. It causes stimulation
of mechanoreceptors located in joint capsule, ligament, etc. which inhibit
pain at the spinal level through the pain gate mechanism. This also reduces
muscle spasm.
Exercise Therapy 73
b. Restriction of joint movement: Restriction of movement at the joint is

mainly due to adhesive capsulitis or mechanical obstruction due to
presence of torn-meniscus or capsular tightness. This can be over come if
stretching and mobilization exercises are performed.
c. Limitation of joint movement: Due to inflammatory diseases like
rheumatoid arthritis (RA) or ankylosing spondilitis (AS) the joint
movements will be gradually restricted which can be over come with
passive mobilization exercises.
Contraindication
• Hypermobility syndrome
• Joint effusion
• Infection of soft tissues and bones
• Fractures
• Malignancy
• Hemoarthrosis in Hemophilia
The techniques of mobilization exercises are passive stretching,
compression, and constant pull by traction.
ENDURANCE EXERCISE
Endurance is the capacity of a muscle to contract at a specific rate with a
specific load for a specific period of time. In other wards it is the ability of
a muscle or muscle group to sustain physical activity without undue fatigue.
Endurance is of three types such as Cardiovascular Endurance, Respiratory
Endurance and Musculoskeletal Endurance. But here we will discuss only
of muscular endurance.
Endurance is tested by subjecting the patients or persons to a full day’s
activity and observing their state at the end of the day. Infact endurance is
always a subjective assessment.
Endurance depends upon
• The strength of the muscle concerned
• Energy store
• Capacity of the circulatory system and respiratory system to supply O2 to
the concerned muscle or muscle group along with the capacity to drain
the metabolic waste.
Though strength and endurance are closely related to the performance
yet they do not always correlate well with each other. When a muscle or
muscle group is subjected to repetitive contraction many more times, then
the flow of blood is decreased causing a shift to an anaerobic metabolism.
This may lead to cramps, burning sensation due to accumulation of lactic

acid.
Endurance Training
It is the training or exercise program, which conditions the muscle and
augments its energy capacity for repetitive actions without being fatigued.
The key elements are low intensity muscle contraction, high repetitions
and a prolonged time period. Unlike strength training, muscle adaptation to
endurance training is achieved by increasing in their oxidative and metabolic
capacities, which allow better delivery and usage of oxygen.
Improvement of muscle performance is always based on overload
principle. That is if muscle performance is to be improved, then a load that
exceeds the metabolic capacity of the muscle must be applied, i.e. the muscle
must be challenged to perform at a level greater than that to which it is
accustomed.
In a strength-training program, the amount of resistance applied to the
muscle is always incremental and progressive. Where as in endurance training
more emphasis is placed on increased time, a sustained muscle contraction
or number of repetitions performed rather than increasing the resistance.
Endurance training program has three components:
• Warm-up period
• Aerobic exercise period
• Cool-down period.
Warm-up—Physiologically a time lag exists between the onset of activity
and the bodily adjustments needed to meet the physical requirement of the
body. The purpose of the warm-up period is to enhance the neural
adjustments in the body that must take place prior to physical activity. The
main changes are:
• Increase in muscle temperature— Higher the temperature higher is the
muscular efficiency due to reduction in muscle viscosity and increase in
rate of nerve conduction.
• Increase need for oxygen— To meet the energy demand of muscles.
• Dilatation of previously contracted capillaries—To increase the circulation
augmenting oxygen delivery and minimizing lactic acid formation.
• Adaptation in sensitivity of normal respiratory center to various exercises
stimulations.
• An increase in venous return.
Exercise Therapy 75
The warm-up should be gradual and sufficient to increase muscle as well

as core temperature without causing fatigue or reducing energy store. A 10
minutes period of total body movement exercise such as calisthenics, static
stretching and walking slowly is usually adapted. The attainment of an
increased heart rate within 20 beats per minute will be the target rate.
Aerobic exercise period—It is the conditioning part of the exercise program
where the intensity should be great enough to stimulate an increase in stroke
volume, cardiac output, enhance local circulation metabolism within an
appropriate muscle group. In aerobic exercises sub-maximal rhythmic,
repetitive, dynamic exercise of large muscle group is always emphasized. The
aerobic training can be done by any one of the four methods.
a. Continuous—A sub-maximal energy requirement sustained throughout
the training period, is imposed till a steady state is reached, when the
muscles obtain energy by means of aerobic metabolism. The activity can
be prolonged for 20 to 60 minutes without exhausting O2 transport system.
Work rate is increased progressively as training improvements occur. Then
the duration can be prolonged to get desired improvement.
b. Interval training—In this type, the exercises are followed by prescribed
rest interval. In fact the interval training tends to improve strength and
power more than endurance. This relief interval may be rest relief (Passive
recovery) or a work relief (Active recovery) and the duration may be from
a few seconds to several minutes. Work relief involves continuing the
exercise but at a reduced level. The longer the work interval, the more
the aerobic system is stressed. A significant amount of high intensity work
can be achieved with interval work if there is appropriate spacing of work
relief interval.
c. Circuit training—A series of exercises are incorporated in circuit training.
At the terminal part of the activity the patient starts from the beginning
and thus again moves through the series. This series activity is repeated
several times. Exercise modes involve large and small muscle groups and
also a mixture of static dynamic type activity. Circuit training can improve
strength and endurance by stressing aerobic and anaerobic systems.
d. Circuit interval training—It is a combination of interval training and circuit
training. It is very much effective as it interacts with the aerobic anaerobic
system in the production of ATP.
Cool-down period—A cool-down period is necessary following the exercise
period.
The aim of cool-down period is:

• To prevent pooling of blood in the extremities.
• To prevent fainting by increasing the return of blood to the heart and
brain.
• To enhance the recovery period with oxidation of metabolic waste and
replacement of energy store.
• To prevent myocardial ischemia and arrhythmia.
The characteristics of the cool-down period are similar to that of warm-
up period. Total body exercises such as calisthenics are appropriate. The
period should of 5 to 10 minutes.
BALANCING EXERCISE
Balance refers to ability to maintain the center of gravity over the base of
support usually in upright position. So balance is a dynamic phenomenon
that involves combination of stability and mobility. Balance allows a person
to stand or move in a controlled and coordinated manner. Balance and
posture are inter-related. Depending on the base and position of the CG and
line of gravity, a body is either balanced in equilibrium or not, where as posture
is any position of human body. Some positions or postures require more
muscle work to maintain posture. But whatever the position, balance must
be maintained otherwise the force of gravity will deviate the posture.
Maintenance of balance is dependent on the integration of sensory input
from exteroceptors, proprioceptors and the special senses like the eyes or
vestibular apparatus and also on the integration of motor systems and basic
postural reflexes. In a normal situation balance is maintained at subconscious
level. Usually patients are required to be trained to reach to stimuli rather
than to make a conscious voluntary effort to maintain equilibrium. Therefore
balance is the basis of all static and dynamic postures and must be considered
for balancing exercise program. Balance is to be maintained with two
approaches:
a. Static balance
b. Dynamic balance.
a. Static balance: It is based on proprioceptive neuromuscular facilitation
(PNF) principles and techniques. It is the rigid stability of one part of the
body on another. Balance is developed progressively from most stable
position to the least stable position. It is assumed that stability and head
control are to be established first as these are vital in all positions. Then
strong neck muscles can be used to augment the contraction of other
muscles.
Exercise Therapy 77
b. Dynamic balance: This approach is based on Bobath principles and

techniques. The body is usually in a constant state of adjustment to
maintain its posture and equilibrium, which may vary in strength
particularly when unsupported. The force always tends to upset the
balance so that the body falls on the ground. Consequently the body’s
reaction to maintain equilibrium will vary in degree. For example, when
a man walks on a slippery path the amount of body-adjustment will be
greater rather than when he raises his hand to his mouth. This is common
with normal individual. But for a paralysis patient the raising of hand will
definitely prove a test for balance.
Balance exercises training consists of:
• Maintenance of position
• Regaining balance.
Maintenance of position: Here the patient is instructed to maintain position
specially in prone kneeling, kneeling, sitting or standing against the therapists’
tapping techniques. It consists of strong taps on patients’ shoulder or thorax
at shoulder level in either direction alternately to train the patient to adjust
muscle tone. The force of tap should not be too strong to change the patient
position. For example, to tap at the patient’s back tending the body to move
slightly forward when the calf muscles start contracting.
Regaining balance: This is a day-to-day habit of man. Every time he is
constantly regaining balance. For example, in walking, the weight is just
transferred forward and legs are moved to regain balance. The therapist puts
the patient in a situation where the patient reacts to maintain or regain balance.
To regain the balance some movable supports are used like balance board,
roll and medicine balls.
GAIT TRAINING
Gait means human locomotion, which is, described as translatory progression
of human body as a whole produced by coordinate movements of body
segments. Normal gait is rhythmic and is characterized by alternating
propulsive and stabilizing motions of lower extremity. Walking is a complex
combination of balance and coordinated muscular contractions based on
normal tone, power and sensory input. So, walking is a relax activity which
takes place in a subconscious state. The center of gravity (CG) of human
body lies at a point 5 cm in front of the body of second sacral vertebra in
normal anatomical position. The line of gravity of human body in this position
(standing) runs from the vertex, through the hip, plane of external ear and
mid cervical vertebra, in front of the thoracic vertebra, through the mid lumbar
and in front of second sacral vertebra, through the plane of hip joints, in
front of the axes of the knee joint, in front of the ankle joint and through
the summit of the arches of foot (Fig. 9.2). The CG and the line of gravity
may change according to the position of the body.
Fig. 9.2: Line of gravity in standing position
Gait Cycle: It is a cyclic order of activities that occurs from the point of initial
heel contact of one lower extremity to the point at which the heel of the
same extremity contracts the ground. Gait cycle is considered as the functional
unit of gait. It is also referred to as stride. It consists of two phases’ stance
and swing (Fig. 9.3).
Exercise Therapy 79
Stance: It forms the 60% of the total duration of gait cycle when the foot
is in contact with the ground. Again this stand phase consists of heel strike,
foot flat, mid stance, heel off and toe off. There is also a period covering
11% of the stance phase when both feet are on the ground. This is called
double stance [(Fig. 9.3 (dotted lines)].
Swing: This phase occurs when the foot is off the ground and comprises
of 40% of the total time of the gait. It begins as soon as the foot leaves the
floor and ends when the heel of the same foot touches the floor.
Fig. 9.3: Normal gait cycle and double stance (in dotted lines)
Swing phase consists of phase of acceleration, mid swing and phase of

deceleration. The additional determinants of gait, which generally influence
the gait are:
• Pelvic rotation—The pelvis rotates by 4 degree on either side and elevates
the the C.G. by 6/16″.
• Pelvic tilt—The pelvis drips on the side of the swinging leg.
• Knee flexion—During mid-stance this decreases limb length.
• Knee and foot motion—Knee, foot movement smoothens out the vertical
excursion to 2″.
• Pelvic lateral displacement—This is the side ways sway of the pelvis.
The men duration of gait cycle is nearly 1 second.
Stride length—This is the distance between the heel strike of one leg and
the heel strike of the same leg. This is aproximately 156 cm on average.
Step length—This is the distance between the heel strike of one leg and the
heel strike of other leg. It is half of stride length.
Stride width—It is the distance from the midline of one foot to the midline
of other foot. It is about 8-10 cm.
Cadence—This is the number of steps per minute. It is about 80 to 120 steps
per minute depending on the speed of gait.
Gait Training
Walking should be trained as a reaction to sensory input based on normal
muscle tone. Standing balance is an essential prerequisite of walking.
Otherwise in gait training the patient will be in fear and will be in tense and
afraid to move. Walking aids feature in most gait training program as in:
a. Progression from parallel bars to the minimal enablement of patients to
walk.
b. For patients with non-weight bearing or partially weight bearing limbs.
c. Permanent aid like prosthesis for a lost limb.
It is necessary that when training for gait the patient should be subjected
to stand and walk within parallel bars. This gives confidence to the patient
towards his capabilities. For spastic patients especially in cerebral palsy it is
better to use long polls bilaterally rather than using conventional crutches.
Gait training is not complete until the patient can walk forwards, backwards,
sideways and also in a diagonal direction. To be fully independent the patient
needs to be able to climb stairs balance walking in slopes, uneven surfaces.
Patient is also asked to walk slowly on a marked line.
PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION (PNF)

This is a form of resistance exercise used to develop strength, muscular
endurance and dynamic stability. The strength of a muscle contraction is
directly proportional to the number of activated motor units, which obeys
the “all or non-law”. The functioning of these is dependent on the degree
of excitation of the motor neurons. Thus, the basic aim of these methods
of exercise is to stimulate maximum number of motor units into activity and
to hypertrophy all remaining muscle fibers.
This technique was developed by Kobat, Knott and Voss for the treatment
of paralytic patients and stressed on the importance of central excitation. It
uses mechanisms like maximum resistance, quick stretch and spiral diagonal
pattern to facilitate normal movement. In this multisensory approach
facilitation techniques are superimposed on movement pattern and postures
through the therapist’s manual contact, verbal command and visual cues.
The patterns of movement associated with PNF are composed of multijoint
multiplanner diagonal and rotational movement of the extremities trunk and
neck. Multiple muscle group contract simultaneously.
Technique: The basis of this technique lays on the importance of
proprioceptors in particular the muscle spindle. Stretch is one of the important
factors in the technique of PNF. The therapist’s hand should be positioned
over the agonists muscle group or their tendinous insertions which allow the
Exercise Therapy 81
Table 9.1: Pattern of movement of PNF
Flexion Extension
Shoulder Flexion, adduction and Extension, abduction and

external rotation internal rotation
Elbow Flexion or extension Extension or flexion
Forearm Supination Pronation
Wrist Flexion, redial deviation Extension, ulnar deviation
Finger and Thumb Flexion, adduction Extension, abduction
therapists to apply resistance to the appropriate muscle group. Rotation

elongates the muscle fiber and the spindle of the agonist muscle and increase
the excitability and responsiveness. The sequences of movement are distal
to proximal in coordinated form of muscle contraction. Slight manual traction
is indicated while doing exercises particularly in flexion pattern. Auditory cues,
i.e. verbal commands are given to enhance motor output. Tone and volume
of the verbal commands are varied to help to maintain patients’ attention.
Similarly, visual cues are also applied by asking the patient to follow the
movement of a limb to further enhance control of movement throughout
the range of motion (ROM). The usual patterns of movement in upper limb
are as follows in Table 9.1.
Exercises are usually performed according to the existing muscular power.
Muscle power are classified into 6 grades staring from grade 0 to grade 5
(oxford scale)
Grade 0 – No contraction of muscle
Grade 1 – Slight flicker with no appreciable movement
Grade 2 – Movement within available range eliminating gravity
Grade 3 – Movement within available range against gravity
Grade 4 – Full range of movement with resistance
Grade 5 – Normal muscle power
So in brief the necessary exercise therapy are indicated as follows:
In muscle groups having muscle power 0 to 1 usually passive exercises
are given, i.e. Full range of movement (FROM) of the joints of the effected
limb or body part. Here the physical therapist passively performs the exercise.
In muscle or muscle groups having muscle power 2 to 3, the patient himself
does the exercise actively up to his capability beyond which the therapist
assists the patient. (Assisted Exercise) Patients having muscle power of grade,
3 usually active exercise are indicated along with progressive resisted exercises
(PRE) i.e. resistance is given in a calculated way and gradually. Those patients
having muscle power of grade 4 need to have only resisted type of exercise
(RE) which can be done manually or with machines.
CHAPTER
10
Massage Therapy
Massage therapy is an ancient mode of treatment for painful muscles.

European cave painting depicting therapeutic touch dates back to nearly
15,000 BC. It is well documented that massage can be used to increase local
circulation and to decrease muscle spasm and stiffness. It is the mechanical
stimulation of the soft tissues of the body by rhythmically applied pressure
and stretching. Massage has been used not only for the sick but also for the
healthy people for therapeutic, restorative as well as for preventive purpose.
So massage is a healing art.
Definition
Massage can be defined as a group of procedures which are usually done
with hand on external tissues of the body in a variety of ways either with
a curative, palliative or hygienic point of view.
Massage incorporates certain manipulations on soft tissues which are
efficiently performed with palmer aspect of hand for producing effects on
nervous system and also on local and general circulatory system.
Features of Massage Technique

The essential features of massage technique are:
• Application of mechanical force to soft tissues of body
• Force applied must not produce any change in the joint position
• The technique must evoke some physiological or psychological effect to
achieve the goal.
Classification of Massage (Fig. 10.1)

Based on the magnitude of applied force, direction of force, duration and
means of application, massage can be classified into:
a. Stroking
b. Pressure manipulation
Massage Therapy 83
c. Tapotement percussion
d. Vibratory manipulation
Stroking
This technique consists of linear movements of relaxed hand along the whole
length of the segment. This is usually performed with fingers or fingertips.
The operators’ hands are relaxed and passed over the patient’s skin in a
rhythmic manner with pressure on fingertips producing a sedative effect.
Stroking may be superficial or deep (Effleurage). These two techniques can
be modified in a number of ways.
Pressure Manipulation
In this technique the hand of the therapist and the skin of the patient move
together as one unit and fairly deep localized pressure is applied to the body,
directed to the deeper tissues. The aim is to get maximal mechanical
movement of different fibers with application of pressure, which is tolerated
by the patient in a comfortable manner. Depending on the type and direction
of applied pressure, pressure massage may be of three types:
i. Kneading: Here the tissues are pressed down to the under lying farm
structures by alternate compression and release in a circular manner
parallel to the long axis of bone. Occasionally, kneading may be applied
over irregular area. It increases blood circulation to the tissues.
ii. Petrissage: Here the tissues are grasped and lifted away from the under
lying structures and intermittent pressure is applied to the tissues in a
direction that is perpendicular to the long axis of the bone. Different
techniques of the group are:
• Picking up: tissues are lifted away from the under lying structures,
squeezed and released using one or both hands.
• Wringing: Using both hands tissues are lifted from underlying
structures, squeezed, twisted and released.
• Skin rolling: The skin and the fascia are lifted up with both hands
and moved over the sub-cutaneous tissues by keeping a roll of
lifted tissue continuously ahead of the moving thumb.
iii. Friction: In this technique the tissues are subjected to small range of to
and fro movement performed with constant deep pressure by the finger
and the thumb.
Vibrating Manipulation
Here the mechanical energy is transmitted to the body by vibrations of the
distal part of the upper limb, which are in constant contact with the skin of
the patient. This method is towards the lungs and other hollow cavities. This
method consists of vibration and shaking.
Percussion and Tapotement Manipulation

In this technique a succession of soft, gentle blows are applied over the body,
which produces a characteristic sound. Here the striking hand or finger does
not come in constant contact with the skin of the patient and the body part
is stroked at regular interval. In this technique different body parts of the
practitioner are used and accordingly techniques are named as follows:
• Clapping – Palms are used
• Hacking – Ulnar border of hand is used
• Beating – Anterior aspect of clenched fist is used
• Tapping – Pulp of fingers are used
• Pounding – Medial aspect of clenched fist is used
Fig. 10.1: Classification of massage techniques
Physiological Effects and Benefits of Massage

The physiological effects of massage are as follows:
1. It increases venous and lymphatic flow from the extremities and also
decreases venous congestion.
2. It provokes and brings about the release of Histamine and other similar
substances by the stimulation of mast cells.
3. Massage activates axon reflex, which produces cutaneous vasodilatation.
4. It increases platelet count and neutrophil count.
5. It promotes rapid disposal of waste product.
6. It accelerates general status of well-being.
Massage Therapy 85
7. Soft tissue properties like elasticity, plasticity and mobility are improved
which are traumatized. It also reduces pain, stiffness, spasm and breaks
soft tissue adhesion.
8. it promotes lipolysis.
How often should Massage be used?

The frequency of treatment depends on the specific approach and scope of
treated area. Several approaches may require 10 minutes treatment or more
to release the full potential of massage. In out patient physical therapy
department massage is used for only as a part of rehabilitation process.
Contraindication
Massage is contraindicated when its application may worsen an existing
condition. Spread of infection, cases of bleeding or damaged tissues will be
detoriated by the application of further massage.
CHAPTER
11
Manipulation, Suspension
and Traction
MANIPULATION
The term manipulation is derived from the Latin word “manus” means hands
and its means to work or operate skillfully with hands. Manipulation is the
control or change especially by artful or unfair means to achieve a desired
purpose. More appropriately, spinal manipulation is an application of forces
to the muscles, tendons, ligaments, joints, capsules, bones and cartilages of
the vertebral column, which has a major goal of normal spinal motion and
the elimination of pain secondary to disturbed biomechanics. In other words
it is the skillful therapeutic use of a passive movement designed to maintain
or restore maximal pain free movements of the musculoskeletal system.
In medical usage for example, manipulation can be used to change
position of a fetus, to reduce broken dislocated bones into place or to move
a joint to its place under anesthesia.
Technique of Manipulation
The techniques applied for manipulation are:
a. Massage
b. Myo-fascial release
c. Rolfing
d. Stretch and release
e. Thrust
f. Joint mobilization
Medical techniques allow maximal restoration of movement but they may
be painful at times. Manipulations are always passive in nature, i.e. not under
patient’s voluntary control. Some manipulative therapies use the patient’s
muscle contraction or self-correction during treatment. In these cases patient’s
participation is an expected extra force that helps the techniques. Manipulation
Manipulation, Suspension and Traction 87
therapy occurs in response to existing extrinsic or intrinsic forces. Procedures

of manipulation are very skillful and one must be very cautious while
performing manipulation.
Indications
Implementation of manipulative therapy is usually indicated in:
• Biomechanical pain problems of the pelvis back and neck.
• Stiff joints due to trauma, inflammatory diseases or degenerative disorders.
• Soft tissue pain (Myofascial pain)
• Congenital laxity syndrome like Marfan’s syndrome, Ehlers-Danlos
syndrome, etc.
• Vertibro-basilar insufficiency
• Shoulder impingement syndrome.
Manipulative therapy is also quite effective in acute neck pain, cervical
radiculopathy, cervicogenic dizziness, carpal tunnel syndrome, migraine, and
thoracic outlet syndrome. Even some patients report improvements in
gastrointestinal discomfort, constipation after spinal manipulation.
Contraindications
The contraindications of manipulative procedures are:
• Fractures
• Infective arthritis
• Tumors
• Joint ankylosis
• Acute inflammatory disease
• Undiagnosed joint pain
• Emotional disorders
• Cauda equina syndrome
• Myelopathy
• Rheumatoid disease in cervical region
DANGERS
There are few risks with the application of spinal manipulation. Most
complications following manipulation were associated with cervical
rheumatoid disease. Techniques in which the neck is extended during the
procedure result in vascular compromise of the vertibro-basilar system or
spinal cord.
SUSPENSION THERAPY
Suspension is the process whereby the total body or parts of body are
suspended in slings and elevated by the use of variable length of ropes fixed
to one point or to several points above the body. Suspension frees the body
or the body parts from friction of the material, upon which the parts may
be resting. This process formats free movements without resistance.
Suspension is particularly suitable when there are:
a. No or less power of muscles
b. Mechanical resistance in movement
c. Skin sores or ulcers on dependent parts.
For suspension, usually a metallic frame with four legs covering the bed
or examination table is required. The top portion of the frame is fitted with
metallic mesh to which suspension ropes are attached with ‘s’ hooks. The
suspensory unit consists of rope and sling. Different body parts are suspended
by means of sling, ropes and hooks to the wire mesh. This was first designed
by Mrs. Gutherie Smith and the unit is popularly known as GSS Frame. There
are two types of suspension:
• Vertical fixation is used primarily to support a body part.
• Axial fixation: This occurs when all the ropes supporting apart are attached
to one ‘s’ hook.
TRACTION
It is one of the mechanical methods of treatment in physiotherapy. It is defined
as an act of drawing or exerting a pulling force to adjacent body parts usually
a joint away from each other. The resulting separation can decompress
irritated tissues, re-aligns body structures and relaxes tight structures. So
traction is the distraction or separation of the joint surfaces. For distraction
to occur within the joint, the surfaces must be pulled apart. The movement
is not always the same as pulling along the axis of one of the body partners.
For example if traction is applied to the shaft of the humerus, it will result
in a glide of the joint surface. Where as distraction of the glenohumeral joint
requires a pull at a right angle to the glenoid fossa. This is quite clear in Figures
11.1A and B.
Most studies have shown that elongation of spine by 2-20 mm can be
achieved with 25 lbs or more tractive forces. It is proposed that prolonged
pull on the spine with adequate tractive force leads to fatigue of corresponding
muscle and thereby it gives way. Traction by the way of pull stretches the
Figs 11.1A and B: (A) Traction applied to the shaft of humerus results in causal gliding
of the joint surface. (B) Distraction of glenohumeral joint requires separation at right
angles to the glenoid fossa
musculature of a strained muscle. The overall effects of traction are

summarized as follows:
• Distraction and separation of vertebral bodies
• A combination of distraction and gliding of facet joints
• Tensing of ligamentous structures of spinal segment
• Widening of inter vertebral foramen
• Straightening of spinal curves
• Stretching of spinal musculature
• Reduction of disc herneation
• Improved nutrition through interminant distraction of the disc.
Modes of Traction
The different modes of traction are continuous, sustained and interminant.
a. Continuous: This involves lightweight applied for prolonged period of time
for spinal stabilization. For example Cervical spine fracture, spinal fusion
procedures.
b. Sustained: This type of traction is applied with a constant amount of force,
which can be used for shorter period of time.
c. Interminant: It involves the application of different and increased traction
forces that are alternately applied and released (hold/rest). This is usually
done with an electric device.
Techniques for applying traction
There are four types of techniques for applying traction:
i. Manual: It is performed by a doctor or a physiotherapist without the
help of any mechanical motorized or electric device. The physiotherapist
uses his/her hand in pulling and mobilizing the part. Distraction is
obtained by the weight of the body.
ii. Mechanical: It is administered using a pulley or a rope and free weight

systems. Different mechanical weights are used according to the part to
be treated.
iii. Motorized: Mechanical traction is applied by using a motorized system
and administered in continuous or interminant period.
iv. Gravitational: Traction is applied taking help of gravity, i.e. suspending
a part of the body.
v. Auto traction: It is done by using a specially designed device that can be
self-administered. By and large mechanical tractions are used widely in
physiotherapy. This can be administered at home using pulley, rope and
free weight. Home traction units consist of traction belt (halters), nylon
ropes, pulleys and weight. Bags filled with sand or water according to
the required traction force, are used as free weight. Home traction facility
allows a patient to receive traction several times a day without going to
a clinic of and on (Fig. 11.2).
Parameters for Traction

The parameters of prescribed traction and to apply it consists of
a. Positioning: Body (sitting or supine)/spine (cervical spine at 20° to 30°
flexion).
b. Technique: Manual/mechanical/ automatic
c. Amount of pull
d. Duration
e. Form: Continuous, interminant.
f. Additional therapy: Like heat, SWD and exercises.
Fig. 11.2: Manual cervical traction (with devices)

Positioning is the key element in a traction procedure. Patient can be

positioned either in sitting or lying state. Interminant or continuous type of
traction can be applied according to the status of the patient. Similarly,
application of pull is also dependent according to the pain, muscular spasm
and part to be treated. The physician or physiotherapists are the best judges
to determine the duration of treatment. Additional application of heat, electric
devices or therapeutic exercise may have synergetic effect in reliving pain.
In physiotherapy tractions are commonly applied to cervical region, lumbo-
sacral region, knee joint and ankle joint (Figs 11.3A and B).
(A)
(B)
Figs 11.3A and B: Manual pelvic traction

Contraindications of Tractions
1. Ligamentous instability
2. Radiculopathy of unknown etiology
3. Acute injury
4. Rheumatoid arthritis
5. Metabolic bone disease
6. Tuberculosis of spine
7. Vestibular atherosclerosis diseases
8. Increase of pain through traction.
Fig. 11.4: Electric motorized traction unit
Cervical Traction
A disc lesion in the cervical spine though common yet occurs at times. Often
disc extrusions or nucleus-pulposus cause pressure either at the cord or at
the nerve root. Patients may present symptoms of peripheral neuropathy or
simple neuralgic pain appears over the upper limb radiating often to the back
of neck, scapular region or even to the chest wall. Symptoms increase with
activity and posture, especially at the position of flexion at the cervical and
upper thoracic spine and symptoms decrease with extension in that region
(axial extension or neck retraction). Hence cervical traction can be applied
in acute cases as well as in chronic painful condition of neck. A low intensity
external force like 5 to 15 lbs or 5 to 10% of total body weight is applied
with mechanical equipment. The stretch force is applied through positioning

of the patient, head halter and weighted traction force and pulley system.
Cervical traction can be given either in continuous, sustained or interminant
way according to the condition of the patient’s symptoms. The time period
can vary from 20 to 30 minutes or as long as several hours. But the recognized
time for stretch is about 20 minute. Sometimes low intensity (5 to 10 lbs)
prolonged stretch applied 1hour several times per day shows effective result.
Positioning is a key element in the cervical traction prescription.
Specification of sitting or lying supine should be best on the patient’s comfort.
If cervical traction is being administered to relief symptoms of nerve root
compression then 20° to 30° of flexion is optimal to open inter vertebral
foramen. Less flexion is effective in muscle spasm in absence of radicular
symptoms. Patients who present with features of vertigo may be put in supine
position for traction. For other particular patient in supine position and with
intermitting type traction (hold time/rest time) is quite effective. This is usually
done with an electric traction machine (Fig. 11.2).
Lumbar Traction
Lumbar traction is usually prescribed in cases of inter vertebral disc prolapses,
degenerative joint lesions, paravertebral muscle spasm and back pain with
root compression.
A minimum distraction force is equal to the one-forth of the patient’s body
weight. As in case of cervical traction, it is also given in acute as well as
subacute cases of back pain. It is given in the form of continuous, sustained
or intermittent variety. In the intermittent form, traction is applied with
increased distraction force with either hold or rest mode by electronic means.
Variation can be done in each item (Fig. 11.4).
Position: The usual body position for lumbar traction is patient in supine and
lumbar spine in a flattened position. Sometimes hip flexed at 90,° knee flexed
at 90,° using leg rest support in supine position is done to get better result
as the lumbar lordosis is maximally reduced with the low back well supported
on the traction table.
Traction force: As indicated the maximal traction force is nearly one-third
or one-forth of the body weight which is nearly equal to 30 to 35 lbs. This
is being done with electronic machine or by mechanical means using non-
slippery traction harness.
Duration: The duration of traction is about 30 minutes. But it can be prolonged
to several hours depending on the condition of the patient. Traction can cause
exacerbation of symptoms through high-poundage distraction force. It can
cause a negative pressure in the disc, sucking the nuclear material centrally.
Theoretically traction for too long period can cause an excess amount of
fluid accumulation in the disc causing an intradiscal pressure.
Both cervical and lumbar traction can be performed effectively at home.
Some home devices are also quite effective where as some cannot provide
adequate and reliable distraction forces. Apart from cervical and lumbar
traction other forms of traction like knee traction, ankle traction are also used
in physiotherapy (Figs 11.3A and B).
CHAPTER
12
Orthosis and Braces
The name orthosis derives from Greek word that means, “Making Straight”.
Their uses have been extensively documented in human history, predating
Christ until present day.
ORTHOSIS
An orthosis is an external mechanical device fitted to a body part to assist
or to restrict the function. An orthosis can be used to transfer load from one
area to another. The general reasons for which an orthosis is used are:
• Support
• Alignment
• Protection
In other words orthosis enhances the function of the body part.
Regional Orthosis
Orthoses are utilized in different sections of body parts like cervical regions,
thoracolumbar, lumbosacral, upper limb and lower limb, etc. Various types
of regional orthoses those are frequently incorporated in physiotherapeutic
management are discussed here. The basic principle of action of orthosis
is based on the “3 Point System of Jordan”. That is, to keep the orthosis
stable, the body applies one point pressure as opposed to 2 counter pressures
by the orthosis. The corrective force is directed towards the part to be
corrected (Fig. 12.1).
Body pressure
↓
↑ ↑
Pressure by orthosis Pressure by orthosis
Fig. 12.1: Three point system of Jorden

Potential complications of spinal orthosis:

• Loss of skin integrity
• Weakening of axial muscles
• Soft tissue contracture
• Osteoporosis
• Physical and psychological dependence
Cervical Orthosis (CO)

Cervical orthoses include the variety of cervical collars like:
• Soft cervical collar
• Firm cervical collar
• Hard or rigid cervical collar
These are made up from cotton or semisynthetic fibers, moulded plastic
material or from fiberglass according to their nature.
The soft cervical collar is probably the most commonly used orthosis.
It is prescribed for cervical muscle strain. It provides little restriction of cervical
movement, only reducing flexion and extension but does not restrict lateral
bending or rotation. It allows rest to soft tissue and works as a reminder to
the patient so that he/she can avoid extremes of neck movement.
Philadelphia collar is a type of hard collar, which provides more restriction
to movement. Simultaneously custom-made thermolabile plastic collars
provide stability to spine. It is used in conditions like cervical ligament rupture,
stable cervical spine fracture or after cervical surgery. SOMI (Sterno-Occipito-
Mandibular Immobilizer) brace is used for complete restriction of movement
of cervical spine.
Thoracolumbar Orthosis (TLO)

The thoracic spine is the most stable and least mobile portion of spine. It
owes to its stability to the thoracic cage with its connecting ribs and sternum.
But problems like compression fracture, fracture dislocation, scoliosis or
kyphotic deformity may occur.
The mode of action of TLO is same as described earlier, i.e. the three-
point action. Long Taylor’s brace, a variety of TLO is usually prescribed to
counteract in kyphosis, compression fracture of vertebral body, tuberculosis
of spine, etc. It has high thoracic uprights and shoulder straps. These straps
must be tightened to provide anti-deformity pressure. CASH (Cruciform
Anterior Spinal Hyperextension) brace is used to decrease kyphosis. It has
anterior cross-bar with pads at the four ends of the cross bar those are attached
with straps and Velcro. Milwaukee brace, the name derived from the name
Orthosis and Braces 97
Fig. 12.2 Milwaukee brace
of a town in USA is used to correct the reducible scoliosis in children. This

brace has a complex system of dynamic bracing mechanism. It not only
prevents forward bending but also derotates the effected vertebrae by its hump
pad (Fig. 12.2).
Lumbosacral Orthosis (LSO)

These are orthoses that are frequently prescribed for uncomplicated low back
pain and are primarily used to support and to immobilize the spine after
trauma or surgery. Applications of these orthoses are controversial but usually
they are prescribed to give comfort as well as support. Their application should
be for a temporary period during which the concerned muscles are to be
strengthened by therapeutic exercise program. The LSO are of several varieties
as available in the market. They should be considered, in the order from
least to most immobilization.
Corsets (Belts)
These are low spinal orthoses, which are made up of canvas or elasticized
material and are reinforced with metal or plastic stays or even with thermo-
mobile plastic pads. Corsets provide least restriction of spinal movement.

Corsets are more comfortable than conventional rigid metal orthoses. They
provide some warmth to extensor muscles of the spine and act as reminder
to the wearers to avoid spinal movement.
Braces
These are reinforced rigid metal frame padded with foam and canvas or
synthetic material with more immobilizing effect. They may be of different
length, shape, and configuration according to the needs of patients. It is usually
prescribed in cases of fracture vertebral body with displacement or
spondylolisthesis. Nowadays plastic moulded braces are widely used in place
of metallic framed brace. The anterior portion of the brace puts pressure over
abdomen and thereby increases intra-abdominal pressure. This also acts by
three-point pressure system.
Sometimes hybrid varieties of braces are used where the anterior portion
is made up of canvas only, without metallic frame. Where as the posterior
portion remains with metallic frame. This type of brace is more accepted
by the patient.
Upper Limb Orthosis

Upper limb orthosis (Splits) are normally used for following reasons:
1. It gives rest to the body part so that the patient does not hurt inflamed
joint, injured muscle or ligament or a fractured bone.
2. It prevents contracture as occurs in burn, injury or in spasticity.
3. It corrects the deformity in conjunction with surgery, occupational therapy
or physical therapy.
4. It promotes exercise for recovery of weak muscles or corrects muscle
imbalance.
5. It substitutes a lost function but not a lost part.
There are usually 2 types of splints:
a. Static splint
b. Dynamic splint
Static splint: Static Splint keep underlying segment from moving. They do
not posses any moving part and are simply used to give rest to the body
part and serve as rigid support. They prevent soft tissues to undergo
contracture. A static splint should not be used for prolonged period and during
the period of use physiotherapeutic measures should be undertaken.
Prolonged use of static splint may lead to atrophy of muscles and stiffness
of joints. Examples of static splint are cockup splint, frog splint, abduction
splint, etc.
Fig. 12.3: Dynamic cockup and an oppones hand splint
Dynamic splint: Dynamic splints have moving parts to permit, to control

or to restore joint movements. They have external or internal power source.
External power means providing motion primarily by elastics, springs, and
rarely pneumatic or electric systems. Internal power means primarily motion
through the action of another body part. For example, wrist extension or
shoulder motion by a harness and cable to operate finger grasp and release.
Dynamic splints provide prehension and static positioning of hand in a
functional position. For example, dynamic cockup splint, knockle blender splint
(Fig. 12.3).
These splints are worn till the functional recovery is achieved. In general,
about four to six weeks, is the time period for use. Some of the splints are
worn at night known as night splint. For example, molded AFO is used to
prevent foot drop.
Lower limb orthosis: Not infrequently ankle foot orthosis (AFO) are widely
used. The main factors are:
1. Mediolateral Instability at ankle.
2. Foot drop prevention
3. Stretching of Tendo-Achilles (TA)
4. Facilitates push off at late stance phase.
Again they are may be of static or dynamic variety. In dynamic type
anterior or posterior stops are used to get necessary function. Lower limb
orthosis or AFO are used in cases of foot drop occurring from Hemiplegia,
Hansen’s disease, any nerve injury or tendon injury. Examples of lower limb
orthoses are HKAFO, KAFO and AFO (Fig. 12.4).
Therapeutic Shoes
Some modifications are done in conventional shoes to make those effective
and functionally acceptable to the patient. Patients with calcaneal spur, planter
fasciitis, painful corn, post-fracture of calcanium or even flat foot deformity,
wear modified shoes.
Fig. 12.4: Below knee caliper (Lower limb orthosis) AFO
Fig. 12.5: Medical arch support (flat foot shoe)
Fig. 12.6: Excavated heel with sponge filling (for calcaneal spur)
Flat foot shoe: Here a medial arch support is provided to the insole, so
that it supports the arch of the foot effectively. The medial or lateral border
of the shoe may be raised by 4 to 6 mm in height according to the varus
of valgus deformity of foot (medial or lateral heel wedge). The heel sole is
elongated in an oblique way towards one-third of the sole, which is known
as Thomas Crooked Elongated Heel. Flat foot shoes should be worn for
prolonged period and side-by-side therapeutic exercises are to be continued
(Fig. 12.5).
Excavated heel shoe: The inside of the heel of a shoe is excavated and
filled with sponge so that any corn or spur may not come in contact with
the shoe-sole and so that the pressure trigger point may be avoided.
Sometimes heel may be raised in cases of Tendo-Achilles injury or calcanial
bursitis (Fig. 12.6). Some cushion lining of knee-ankle-foot orthosis (KAFO)
may be incorporated for insensitive foot, particularly for leprosy patients.
CHAPTER
13
Mobility Aids
Mobility Aids are appliances used to help disabled people to move at ease.
They enable the body weight supported by the upper limb and this build
up stability that helps in walking. The correct selection of a mobility aid
depends up on the following points:
• Degree of relief of weight bearing.
• Strength or power of patient’s upper limb as well as lower limb.
• Coordination of limbs.
• Other factors like motivation, age, mental status and acceptance.
Different types of walking aids are incorporated with the process of
improvement of condition.
The goals of use of walking aids are as follows:
• To improve balance.
• To decrease pain.
• To reduce weight bearing on injured or inflamed structure.
• To facilitate proprioceptive response.
• To compensate weak muscle function.
These mobility aids are of different shapes, sizes and material to suit the
condition of the patient, his age and economic capabilities. The aids include
parallel bars, walking frames, rollators, walking sticks, crutches and wheel
chairs.
INDEPENDENT MOBILITY AIDS

Parallel Bars
When a patient becomes unstable in walking, parallel bars are used. It helps
in satisfactory gait training. It consists of two horizontal rigid bars fixed with
two upright bars at the ends. Te horizontal bars give support to the patient
and the patient starts walking in the entire length, holding the bars. The patient
is taught the correct sequence of upper and lower limb movement. Two
mirrors are placed at the either ends of the bars, so that it gives a visual
Mobility Aids 103
feedback to the patient. In village areas two bamboos may be used to function
as conventional parallel bars.
Walking Frames
Walking frames are reasonably stable due to their wide bases and the center
of gravity (CG) fall on their bases. They are prescribed to the patients who
are unable to move independently due to weakness of muscles or even fear
of falling and old aged persons. With walker patients get confidence during
movement.
Rollators
A rollator is also a walking frame with two castors at the front legs and the
back legs are slightly shorter. These are particularly suitable for children who
may find difficulty in lifting walkers.
Walking Cane, Sticks, Tripads and Quadripads

Walking sticks are used by the patients with weakness of muscles on one
side of the body as in hemiparesis. The patient walks with support on the
stick. The height of the stick should be at the level of upper border of greater
trochanter. The patient should be instructed to hold the cane or the stick
on the opposite hand of affected side and advance it along with the affected
leg in a three-point gait pattern. When ascending stairs the sound limb is
moved first but while getting down the order is to be reversed. These aids
may be of wood, cane or aluminium with adjustable holes to suit different
patients. The sticks should have rubber ferrules, which prevents slipping on
polished floors. Sometimes walking aid may have three legs (tripods) or four
legs (quadripods) of its own. These give better stability, than walking sticks.
Tripads and Quadripads are usually reserved for patients suffering from
neurological conditions but may be used in rehabilitation of elderly patients
having joint problems.
Crutches
Crutches may be of three types:
• Axiliary crutch
• Elbow crutch
• Gutter crutch
These crutches help in mobility of the patient who has weak lower limb
or painful joint. In ambulation crutches particularly bear partial body weight.
Axiliary crutches should be of the length measured from anterior fold of axilla
to a point 6 inches forward and outside the lateral border of foot. Different
auxiliary crutches are used with four point, three point or two point gait pattern
according to the need of the individual patient. Weight is transmitted down
to arm to hand piece. Axillary crutches are made of wood or aluminium
with axillary pads, hand pieces and rubber ferrules. The length and position
of hand piece are usually adjustable. The axillary pad should rest against
chest wall usually 5 cm below the apex of axilla, weight is transmitted down
the arm to the headpiece when this elbow is extended. Patients should be
instructed not to take body weight through axillary pads as it may lead to
neuropraxia of brachial plexus. Elbow crutches are made up of metal or plastic
and a band is attached, which fastens on to the forearm to prevent the crutch
from slipping out of grip. The crutches are suitable for patients with good
balance and strong arm. Weight is transmitted in the same way as in the
axiliary crutch.
DEPENDENT MOBILITY AIDS

Dependent mobility aids include tricycles and wheel chairs. It is a second
home to the patient. Wheel chair should be designed for comfort and ease
of propagation. Wheel chairs are prescribed for the complete paraplegic
patients, bilateral amputees and spinal cord injury patients. Wheel chairs differ
in their size, design and construction, according to the need of individual
patient and their disabilities. Prescription of wheel chairs should be reserved
till no suitable mode of management is achieved.
Prior to the prescription of any kind of mobility aid to a patient,
improvement of power of shoulder flexors, depressors, elbow extensors, wrist
dorsiflexors and flexors of finger and thumb must be developed otherwise
satisfactory result may not be gained. Similarly transfer techniques from bed
to chair and vise versa, are to be trained to the wheel chair patients.
CHAPTER
14
Physiotherapy in Some
Common Conditions
Physiotherapy is usually indicated in the later part of any treatment but the
sooner it is started the better is the result. Recently physiotherapy is done
concomitantly with pharmacotherapy. In fact physiotherapy is an art and
science. This procedure is mainly indicated in neurological conditions and
in orthopedical conditions, though it is also done in some of the medical,
surgical and gynecological conditions. It can be safely said that there is hardly
any condition in medical science that dose not require physiotherapy. In the
present time this science is gaining its popularity day by day. We will discuss
the role of physiotherapy in some of the common neurological diseases and
orthopedic conditions.
Diseases of Nervous System

A neurological disease depends on the lesions of the nervous system, may
be the brain or of the spinal cord or of the peripheral nerves. Causes may
be due to injury (fractures, dislocations or callus) or due to diseases (infection,
tumor, poisoning or unknown cause). Symptoms occur according to the site
of lesion. Changes occur in the movements, in the sensations and in the
trophic conditions. Lesion may of upper motor type, lower motor type and
may be in sensory system.
Diseases of upper motor neuron includes mainly:
• Hemiplegia
• Cerebral palsy (CP)
• Primary spastic paraplegia
• Spinal cord injury, etc.
Diseases of lower motor neuron are:
• Poliomyelitis
• Paraplegia
• Progressive muscular atrophy

• Amyotrophic lateral sclerosis, etc.
Hemiplegia
It is a neurological condition where one-half of body gets paralyzed or
becomes inactive. It is due to the lesion (hemorrhage or infarction) in the
territory of middle cerebral artery in the brain.
The symptoms are paralysis or weakness of one side of body involving
the upper limb as well as lower limb. At first, i.e. in acute stage the patient
becomes unconscious and the limbs become flaccidly paralyzed, reflexes may
be inactive. But during the recovery stage flaccid muscles become spastic,
joint sensation regains causing feelings of pain. Skilled movements are lost
or depressed, abdominal and trunk muscles become weak and so the patient
does not bear weight to wards the effected site. Gradually recovery stage
sets in, where the muscles become spastic, reflexes may return but become
more exaggerated. The patient adapts a typical hemiplegic position, i.e. the
upper limb becomes abducted (comes close to the side), elbow semi flexed,
fore arm pronated and the wrist and fingers pronated. The lower limb is held
stiff, knee extended, externally rotated and the foot is strongly planter flexed.
Whatever degree of recovery takes place, the arm is the last to be restored.
Physiotherapeutic Management
The aims of treatment is:
• To lessen joint stiffness and deformity from muscle contracture
• To re-educate sensory perception
• To re-educate movement pattern
• To restore functional independence
By far the most important factor is the re-introduction of weight bearing
to the effected side. It is important to see that no fall or loss of balance occurs
during treatment, as this can adversely affect the patient’s confidence in
himself/herself and also towards his/her physiotherapist.
To reduce spasticity—following measures are usually under taken.
• Massage (effleurage, kneading and stroking)
• Passive movements (relaxed passive exercise)
• Suspension and pulley exercise
To re-educate movement Simple active movement of one single joint is to
be focused, so that the patient can give all his attention to the control of
that joint.
Physiotherapy in Some Common Conditions 107
To strengthen weakened muscle: Gentle progressive resistive exercise is to

be under taken.
To re-educate functional activity: Patient is taught to flex his knee, to dorsiflex
his foot (if possible) and to avoid abduction of hip and exaggerated tipping
of pelvis as the leg is carried forwards. He is to be trained to walk up and
down stairs and sit down and get up. Gait training program is an important
factor in exercises therapy. Patients are to be assessed every two weeks.
Functional electrical stimulation (FES) is of value in physiotherapy in stoke
patients. Activities of daily living (ADL) like dressing, feeding, toileting, etc.
are to be taught by occupational therapist.
Parkinson’s Disease
Parkinson’s disease is a progressive primary neuro degenerative disorder
described by James Parkinson in 1817.It is a motor system disorder. It is
one of the commonest diseases after the age of 50. The most common
symptom is tremor. The other symptoms are rigidity, bradykinesia, i.e.
slowness of movement and postural instability. It starts in upper extremity
from fingers to the arm and gradually to the lower limb. The tremor increases
with activity but disappears during sleep. During this problem the tone of
muscles increases to its maximum and so rigidity develops. The patient walks
with short shuffling gait (Festinating Gait).
Physiotherapy
Physiotherapeutic approaches in the management of Parkinson’s disease
are:
• Emphasis placed on prevention and education
• Massage in the form of gentle soothing type to improve circulation
• Passive movements—like gradual full range movement of all joints and
mobilization exercise
• Active exercises—like free assistive or resistive exercises and aerobic
exercises. GSS may be of value
• Dominant treatment concept termed as METERS (Movement Enablement
Through Exercise Regime and Strategies)
• Frankle’s exercise to improve balance in walking and Gait re-education.
Disseminated Sclerosis
It is otherwise known as multiple sclerosis. This condition occurs due to
scattered inflammation and demyelination of various parts of nervous system
whose etiology is unknown. The lower extremity is affected first; later on finer
movements of upper limb are effected. Control of bladder diminishes. The

gait is changed and the patient walks like cerebral diplegia. The clinical features
are varied, resulting in a complex combination of physical, psychological and
cognitive problems. The highly variable and unpredictable condition offers
a major challenge to physical therapists if they are to assists the individual
in managing this condition as effectively as possible.
Physiotherapy measures are as follows
Assessment of patients’ difficulties and needs are essential factors in
physiotherapy. It is started with passive exercises of both upper and lower
limbs and then gradually switched over to active movement of the limbs.
When ataxia is present Frankle’s exercise, proprioseptive neuromuscular
facilitations (PNF) exercises and balance exercises are administered. Re-
education in walking is to be practiced soon. Patient should wear night splint
to prevent deformity. Advice on postural management should be given.
Radial Nerve Palsy

This is a kind of peripheral nerve injury which leads to wrist drop. Here the
patient feels difficulty to lift the wrist and fingers i.e. paralysis occurs to the
wrist and finger extensors. It may be due to pressure (Saturday Night Palsy)
or injury. The patient keeps the limb semi flexed and pronated due to the
action of flexor muscles of hand. The wrists and fingers can be extended
passively indicating that there occurs no restriction at wrist joint or MCP joint
movement.
Physiotherapy
In every case of radial nerve palsy the limb should be splinted in almost full
extension of wrist by full cock-up splint in order to prevent contracture of
the long flexors. Dynamic cock-up splint is more useful in gaining muscle
power. Electrical stimulation in the form of Interrupted Galvanic current is
to be given to the extensors of wrist. The duration treatment may be of 3
weeks and can be repeated for another sitting of treatment. But active
movement of hand, fingers is mandatory.
Erb’s Palsy
It occurs as a result of birth injury due to traction between the baby’s head
and shoulder. The main strain falls on the upper roots (C5) of brachial plexus.
Often the force of traction may be excessive enough to involve the root below
(C6). The injury to 5th cervical root results in weakness of shoulder abduction
and external rotation due to involvement of Deltoids, Rhomboids,
Supraspinatus. Infraspinatus and Teres Minor muscles. At the elbow flexion
weakness occurs due to involvement of Biceps and Brachialis. At the fore

arm the Supinator gets weakened. Sensory involvement may occur at the
outer border of arm and forearm.
Physiotherapy
In early cases abduction splints are advised in order to keep the nerve roots
tension free and contracture free of soft tissues. Passive full range movements
should be done two or three times a day. Later electrical stimulations can
be advocated.
Facial Paralysis (Bell’s Palsy)

The seventh cranial nerve that is the facial nerve supplies all the face muscles
except the levator palpebrae and the muscles of mastication. The facial muscle
weakness may occur due to injury to the nerve itself or to some CNS
dysfunction. Very commonly compression to this nerve as occurs in exposure
to cold may lead to facial palsy. In this case Bell’s sign will be positive.
Weakness of muscles of one side of face develops and the muscles of face
on the contralateral (healthy side) side are being pulled to wards same side.
So patients often complain of deviation of face on the healthy side. The eye
on the effected side can be opened but cannot be closed fully. Due to paralysis
of buccinators muscle food particles often collect between teeth and cheek.
Often tears roll down from half closed eyes. Facial nerve may be involved
in cerebrovascular accidents (UMN) where both sides of forehead muscles
will be involved.
Physiotherapy
Avoidance of exposure to cold is the prime advice. Local warm fomentation
can be given. Facial muscle exercises like closing of the eyes, smiling, showing
teeth, raising upper lip, closing mouth, whistling, blowing, chewing, and
wrinkling forehead, dilating nostrils and pronunciation of wards are to be
carried out. Practicing these exercises is very very important. Next intermittent
galvanic stimulation to weak muscles can be given for a period of about three
weeks. Electrical stimulation is applied at specific motor points present over
the face. It is to be remembered that nerve regeneration is a physiologiclal
process. Electrical stimulation is applied only to keep the affected muscle
viable till regenerationof nerve is completed. Strength duration curve plotting
or Nerve Conduction Velocity tests indicate the prognostication of the
condition (Fig. 14.1).
Poliomyelitis
It is due to a viral infection mainly occurring in childhood. At present incidence
of this disease has gone down for adequate immunization program. The
Fig. 14.1: Motor points of the muscles supplied by facial nerve

anterior horn cell of spinal cord gets infected and so mainly motor function
is de-arranged. Muscle paralysis, wasting and deformity development are the
prime features of poliomyelitis.
Physiotherapy
During the acute phase nothing can be done except proper positioning of
limbs so far physiotherapy is concerned. Of course proper ventilation to lungs
is to be looked for. In the convalescent phase recovery of muscles power
begins. The degree of paralysis depends upon the extent of neuronal damage.
The treatment program is to be based upon the manual muscle chart (showing
the power). Planned exercises to specific individual muscle are to be done
to attain maximal physiological hypertrophy. Electrical muscle stimulation
in the form of galvanic current can be instituted in early period. Pool therapy
gives additive effect. Assistive exercises like tri-cycling provide high incentive
and maintain proper groove of movement. In the residual phase i.e. when
there is no further scope of improvement of muscle power or bulk, orthosis
of various form and design are used to get functional improvement. Some
patients may require reconstructive surgery, in the form of tendon lengthening,
transfer release of contracture, so other healthy muscles are to be strengthened
in order to get effective result.
Common Orthopedic Problems

We have gathered from our knowledge that most of the orthopedic problems
can be managed by three ways:
• Non-treatment
• Non-operative treatment (conservative)

• Operative treatment
In the first category simply reassurance or gentle advice will suffice. The
role a physiotherapist lies in the second group. Rest and support is the prime
importance. Rest and support is done with simple splints. Spinal orthoses
are required in case of neck pain, backache, etc. Therapeutic exercise of
different variety is prescribed here. Apart from exercises various types of
physiotherapeutic modalities like UST, SWD, MWD, IR, IFT, Wax Bath, and
Electrical Stimulations are incorporated to get the effective result. In the
operative group preoperative and postoperative physiotherapy are extremely
important as the success of operation lies with the pre- and postoperative
exercise therapy.
Post-fracture Stiffness
This is a very common problem encountered after fracture and subsequent
removal of POP cast. The range of movement (ROM) of the concerned joint
becomes diminished. Associated swelling and weakness of muscle may be
present.
Physiotherapy
The prime aim of physiotherapy lies on improving the movement range. So
mobilization of the joint is done after paraffin wax therapy. Here, paraffin
wax reduces pain and makes the soft tissues around the joint pliable. Some
times Continuous Passive Mobilizer (CPM) machine is used to do it. Weak
muscles are either strengthened manually by resistive exercises or by electrical
muscle stimulations.
Low Back Pain (LBP)

Normally low back points to lumbo-sacral spinal area. Causes of low back
ach are mainly due to trauma, chronic strain to back, slipped disc (PID) and
degenerative conditions of spinal segment. The conditions are Spondylosis,
Spondylolisthesis, Spina bifida, fracture of spinal body, prolapsed
intervertebral disk, etc. The main features are pain, limitation of spinal
movement and spasm of spinal muscles. Sometimes radiation of pain occurs
on lower limb.
Physiotherapy
Goals of management include relief of pain and muscle spasm, maintaining
the mobility of spine and strengthening the muscles of trunks. In acute cases
bed rest on firm flat mattress is advised. Both the hips and the knees may
be flexed to give relief to pain. In subacute conditions along with therapeutic
exercises pelvic traction is given to relief from spasm and nerve root
compression. Thermo therapy like SWD or UST even IR can be given. Spinal
corsets are advised and posture care is demonstrated. For accurate diagnosis
MRI of spinal region may be required. In some cases spinal braces are advised
for rigid support to the back.
Neck Pain
The guidelines of management are same as described above. Isometric neck
exercises are done and posture care of neck is to be explained clearly. Often
cervical collar of various forms is used by the patient. Ultrasound therapy
helps in reducing pain and stiffness of neck. Intermittent or sustained cervical
traction is used if radicular pain or vertigo persists. Local application of heat
gives additive result. Cervical collars are to be used for limited movement
of cervical spine. Often collars are used as reminder to the patients about
their problem, so that they can take appropriate care.
Osteoarthritis (OA) of Knee Joint (Knee Pain)

OA is a degenerative condition of synovial weight-bearing joints like the knee
joint, hip joint and ankle joint. Pain, restriction of movement and swelling
are the cardinal features of osteoarthritis. The concept of “wear and tear”
is generally attributed as a cause of osteoarthritis as this condition appears
with aging process. Some times deformities like Genu Varum or bow legs
do occur. The gait pattern is changed in chronic condition.
The physiotherapeutic management includes posture care like avoidance
of long time standing, long distance walking, getting up and down the stairs,
squatting and sitting cross-legged. Of course reduction of body weight is an
important factor. One thing is to be remembered here that climbing a few
steps up is 4 to 5 times harmful than walking a kilometer distance. Muscle
strengthening exercise of lower limbs is of immense value here particularly
the quadriceps and the hamstrings. Exercise with Continuous Passive Mobilizer
(CPM) machine is done to improve the range of movement. Modalities like
Ultrasonic therapy and Shortwave Diathermy relieve pain. Some times
Paraffin Wax bath therapy helps in the mobility of knee joint. Pain in knee
can be relieved by the use of TENS as well as IFT. Sometimes use of knee
brace, knee cap with patellar hole or even altering the sole of shoe gives
satisfactory result.
Frozen Shoulder (Stiff Shoulder)

It is a condition of shoulder joint where the movement of shoulder is restricted
and painful. The reason of this condition is diversified. Direct or indirect
trauma may initiate this but systemic diseases like diabetes, hypertension and
even stroke may cause frozen shoulder. The limitation of movements may
be due to adhesive capsulitis, tendonitis or bursitis.
Physiotherapeutic measures include mobilization exercises like pendular
swing, pulley exercises, manual stretching and mobility by the use of CPM
machine. Use of Ultrasound, Shortwave diathermy or IFT is very effective.
TENS may be applied in painful conditions. In refractive cases mobilization
under anesthesia (MUA) results satisfactorily but it should be followed by
aggressive physiotherapeutic measures.
Ankylosing Spondylitis (AS)

It is a chronic inflammatory disorder affecting the spinal vertebrae the hips,
shoulders, etc. It is common in male adolescents and adults where bony
ossification of ligaments, tendons occurs making the vertebral coloum
immobile. In neglected cases patients assume forward bending position
(Poker’s Back). Sternocostal joints and vertebro costal joint become fixed
so that chest expansion diminishes. Patient also complains of pain and stiffness
over back area and over hip joints.
Physical therapy in addition to pharmacological therapy plays an
important role in the management of this disease throughout its whole course,
more so in the initial stages. A general exercise program is formulated to
maintain the mobility of spine as well as other joints. Breathing exercises are
important to maintain chest expansion so that gaseous perfusion may be
effective. Patient is advised to swim if feasible. Prone lying posture is to be
maintained. It is always advisable to practice hip exercises regularly to keep
the hips mobile. Because if the hips get fixed then patient’s mobility will be
restricted which nobody likes to have. Ultrasound therapy is very effective
in relieving pain and stiffness. In completely ankylozed hip joint, joint
replacement surgery (partial or total) shows satisfactory result.
Rheumatoid Arthritis (RA)

Rheumatoid arthritis is an autoimmune systemic disease characterized as
polyarthritis, polyarthralgia, and other systemic manifestations. Smaller joints
of hands, shoulder, elbow, wrist, knee and ankle joints are involved. Even
temporomandibular joints are also affected. When this condition is allowed
to persist for long period deformities develop. Commonly effected joints are
the metacarpophalangeal joints and the proximal interphalangeal joints.
Physiotherapy
Physiotherapy is considered as additional mode of treatment. The aims of
physiotherapeutic measures are to relief pain, to improve the mobility of joints
involved and to prevent development of deformities thereby giving the patient
quality of life. Proper support to inflamed joint is very important. Paraffin
wax or simple warm saline bath to the part gives relief of pain and swelling.
Joints are to be passively moved to improve the ROM. Later active exercise
followed by PRE to be started to build up muscle power. Ultrasound therapy
may be advised to large joints and weak muscles are to be electrically
stimulated. Sometimes cryotherapy exhibits satisfactory result. Resting splints,
spinal orthosis, shoe modification and adaptive devices are often advised
to reach the goal.
Torticolis and Acute Wry Neck

Congenital torticolis is malposition of head due to developmental defect in
sternomastoid muscle, whereas wry neck is an acute condition occurring in
the adults due to trauma, inflammation or infection. The patient tilts his neck
to one side and can not move the head freely. Pain of course present along
with spasm of neck muscles. The basic objectives are to correct the deformity,
to hold the neck in correct position and to relieve pain. Passive exercises
and then stretching may be done. Ultrasound therapy is often advocated.
Specially designed molded cervical collars should be used during the rest
period and proper posture should be chequed and maintained during sleep.
Collar should be removed for exercises and discarded only after maximum
correction is achieved.
Bibliography
1. Forster A, Palastanga N. Clayton’s Electrotherapy: Theory and Practice, Bailliere
Tindall.
2. Hollis M , Cook PF. Practical Exercise Therapy, Blackwell Science.
3. Khatri S. Basics of Electrotherapy, Jaypee Brothers Medical Publishers. New Delhi.
4. Kisnar C, Colby LA. Therapeutic Exercise: Foundation and Technique, Jaypee
Brothers Medical Publishers, New Delhi.
5. Kendle and Kendle. Fundamental Principles in manual Muscle Testing.
6. Lippert LS. Clinical Kinetiology, Jaypee Brothers Medical Publishers, New Delhi.
7. Low J Reed. Electrotherapy Explained: Principle and Practice, Butterworth
Heinemann, London.
8. O’Young B. PMR Secrets, Jaypee Brothers Medical Publishers, New Delhi.
9. Sovage B. An Introduction to Electrotherapy, Faber and Faber Ltd, London.
10. Sinha AG. Principle and Practice of Therapeutic Message, Jaypee Brothers Medical
Publishers, New Delhi.
11. Sunder S. Textbook Rehabilitation, Jaypee Brothers Medical Publishers, New Delhi.
12. Wolf SL. Electrotherapy, Churchill Livingstone, London.
Index
A Disseminated sclerosis 107
Duration of current flow 6
Alternating current (sine wave) 5
Dynamic interferential field 23
Amplitude of the current flow 6
Dynamic splint 99
Ankylosing spondylitis 113
Arrangement of electrodes 29
E
B Effects of ultrasound on tissues 42
biological effect 43
Balancing exercise 76
mechanical effect 42
Beat frequency 22
thermal effect 42
Biological action of IFT 24
Electric current 1
Braces 98
alternating current 1
direct current (DC) 1
C Electric heating pad 38
Chronaxie 18 Electrical power 4
Classification of currents 7 Electrodiagnosis and strength duration curve 17
on the basis of amperage 7 Electromagnetic spectrum 47
on the basis of direction of flow of current 7 Electromotive force 1
on the basis of frequency 7 Electrotherapy 1
on the basis of voltage 7 EMG-biofeedback 56
Cold therapy 58 advantages 57
contraindication 61 disadvantages 57
methods of cooling 59 electromyography biofeedback 56
conductive cooling 59 Endurance exercise 73
convective cooling 59 endurance training 74
evaporative cooling 59 aerobic exercise period 75
physical principle 58 cool-down period 75
physiological effects 59 warm-up 74
body temperature 59 Erb’s palsy 108
circulatory response 59 Excavated heel shoe 101
excitatory cold 60
neural effect 59 F
reduction of spasticity 59 Facial paralysis (Bell’s palsy) 109
technique of application 60 Faradic type current 8
therapeutic uses 60 indications for the use of 10
Common orthopedic problems 110 effect on vascular supply 11
Constant current 5 facilitation of muscle contraction 10
Coordination exercises 70 muscle re-education 10
components 70 neuropraxia of motor nerve 11
general principles 71 prevention and loosening of adhesion 11
Corsets 97 severed nerve 11
Current flow 2 training of a new muscle action 11
modification of 8
D physiological effects of 9
effects on muscle contraction 9
Direct current 6
stimulation of motor nerves 9
Diseases of lower motor neuron 105
stimulation of sensory nerves 9
Diseases of nervous system 105
Flat foot shoe 101
Diseases of upper motor neuron 105
Frankel’s exercise 71
indication 72 mid laser 54
principles 72 power laser 54
Frequency 4 soft laser 54
Frozen shoulder 113 Laser beam 54
features 54
G coherence 54
collimation 54
Gait cycle 79 monochromacity 54
Gait training 80 Lesions 17
Galvanic current 11 axonotmesis 17
Galvanic stimulator 14 neuropraxia 17
Generators 50 neurotmesis 17
Lewis hunting 59
H Line of interference 23
Hemiplegia 106 Low back pain 111
Hydrotherapy 62 Low frequency effect 21
contraindications 62 Lower limb orthosis 99
indications 62
M
I Magnitude of current 2
Manipulation 86
Infrared rays 47 contraindications 87
contraindications 49 dangers 87
production 48 indications 87
luminous generators 48 technique of 86
non-luminous generators 48 Massage therapy 82
technique of IRR application 49 classification of massage 82
therapeutic uses 49 percussion and tapotement manipulation
Interferential therapy 21 84
Interrupted current 5 pressure manipulation 83
Interrupted direct current 11 stroking 83
different forms of 12 vibrating manipulation 84
indications of 12 features 82
methods of application 13 physiological effects and benefits of massage
physiological effects of 12 84
motor nerve stimulation 12 Medium frequency currents 21
sensory nerve stimulation 12 Mercury vapor generator 51
treatment of 13 Microwave diathermy 35
Iontophoresis 14 contraindication 37
Isokinetic exercises 67 paraffin wax bath therapy 36
physiological and therapeutic effects 35
J production 35
Jacobson’s relaxation 69 Mitchell’s exercise 69
Mixed type curve 20
Mobility aids 102
K dependent mobility AIDS 104
Kromayer lamp 50 independent mobility AIDS 102
crutches 103
L parallel bars 102
rolators 103
Laser 53 walking cane, sticks, tripads and
contraindications 56 quadripads 103
effects of 56 walking frames 103
indications 56 Mobilization exercise 72
method of application 55 contraindication 73
production of 54 indications 72
types 54 principle 72
Index 119
Motor points of the muscles 110 procedure 31
Muscle contraction 67 technique of SWD application 30
preparation of patient 30
N testing the machine 30
therapeutic effects 32
Neck pain 112 effect on muscle tissues 34
effect on traumatic conditions 33
O effects on bacterial infection 33
Ohm’s law 2 effects on inflammatory process 32
Original faradic current 5 relief of pain 33
Orthosis 95 Significance of dynamic interferential field 23
cervical 96 Significance of IFT therapy 21
lumbosacral 97 Square waves 5
regional 95 Static splint 98
thoracolumbar 96 Strength duration curve (SD curve) 18
Osteoarthritis (OA) of knee joint 112 denervated SD curve 20
interferential therapy 25
observation 19
P procedure 18
Parkinson’s disease 107 technique 25
Piezo-electric effect 39 Strengthening exercises 65
Poliomyelitis 109 general principle 66
Post-fracture stiffness 111 Surging of current 6
Proprioceptive neuromuscular facilitation 80 Suspension therapy 88
pattern of movement of 81
Pulsed ultrasound 45 T
PUVA apparatus 52 TENS 15
application 16
R four channel TENS 17
Radial nerve palsy 108 specification of 15
Relaxation exercise 68 Terms used in exercise therapy 64
general principle 68 Therapeutic exercise 63
Resistance 2 aims of 63
in parallel 3 types of 65
in series 2 Therapeutic shoes 99
Rheobase 18 Therapeutic uses of ultrasound 43
Rheumatoid arthritis 113 contraindications 44
Rhythmic mode 24 technique of application 44
bag method 45
direct method 44
S water bath method 45
Saw-tooth wave 5 Thermotherapy 27
Short wave diathermy (SWD) 28 causes 27
contraindications of 34 increased blood supply 27
dangers of 34 increased metabolic activity 27
methods of application 29 constitutes 27
cable method 30 effects on nerve endings 27
condensor/capacitor field method 29 Torticolis and acute wry neck 114
physiological effects 31 Traction 88
circulation 32 cervical traction 92
destruction of tissues 32 contraindications of tractions 92
increased activity of sweat gland 32 lumbar traction 93
metabolism 32 manual cervical traction 90
muscle tissue 32 manual pelvic traction 91
on blood pressure 32 modes of traction 89
on nerves 32 parameters for traction 90
temperature 32 physiological effects 88
techniques for applying traction 89 attenuation of ultrasound 42

Types of contraction 66 reflection of ultrasound 41
concentric contraction 67 transmission of ultrasound 41
dynamic exercises 67 Ultraviolet radiation 49
eccentric contraction 67 contraindication 53
progressive resisted exercise 68 dangers of UVR 53
static contraction 66 indication or uses 53
Types of currents 6 physiological effect 52
Upper limb orthosis 98
U V
Ultrasound machine 40 Voltage 2
Ultrasound therapy 39
physical character of 41

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A Handbook of

© 2006, B.K. Choudhury, A.K. Bose

First Edition : 2006

Typeset at JPBMP typesetting unit

Professor N.C. Ghosh

welcome to build the health of this book. This is my humble way

Bibliography ............................................................... 115

Index .......................................................................... 117

Electrotherapy is a section of physiotherapy, which is concerned with the

Electromotive Force (EMF) (E)

all determine the resistance of a pathway.

Magnitude of Current (I)

RELATIONSHIP AMONG MAGNITUDE OF CURRENT FLOW,

Fig. 1.1: Resistance in series

Fig. 1.2: Resistance in parallel

a. The total resistance equals to

b. The current flow equals to

c. The current flow across each path is

In an alternating current (AC) the magnitude of flow of electrons constantly

The Duration of Current Flow

The Amplitude of the Current Flow

Fig. 1.5: Surging currents (Saw-tooth, triangular)

In physiotherapeutic practice most of the work is concerned with electrical

FARADIC TYPE CURRENT

Modification of Faradic Current for Interruption and Surging

Fig. 2.1: Interruption and surging

PHYSIOLOGICAL EFFECTS OF FARADIC CURRENT

Stimulation of Sensory Nerves

Stimulation of Motor Nerves

Effects on Muscle Contraction

Fig. 2.2: Faradic stimulator

Indications for the Use of Faradic Type of Current

Facilitation of Muscle Contraction

Training of a New Muscle Action

Neuropraxia of Motor Nerve

Effect on Vascular Supply

Prevention of and Loosening of Adhesion

INTERRUPTED DIRECT CURRENT (GALVANIC CURRENT)

Fig. 2.3: Different forms of direct current

PHYSIOLOGICAL EFFECTS OF INTERRUPTED DC

Sensory Nerve Stimulation

Motor Nerve Stimulation

Technique of Treatment of Interrupted DC

Fig. 2.4: Galvanic stimulator

Motor point stimulation involves individual muscle. Here the in-different

Fig. 3.1: Diagrammatic representation of gate control theory of pain

Frequency—Can be between 2 to 600 Hz, commonly used is 150 Hz.

Fig. 3.2: Four channel TENS

ELECTRODIAGNOSIS AND STRENGTH DURATION CURVE

STRENGTH DURATION CURVE (SD CURVE)

Fig. 3.3: Strength duration curve (normal)

When some of the muscle fibers of a muscle have degenerated

Fig. 3.4: Denervated SD curve

Fig. 3.5: Mixed type curve

As the regeneration of nerve fiber progresses the kink gradually disappears

An Australian scientist named H. Nemee developed interferential therapy in

Significance of IFC Therapy

Fig. 4.1: Beat frequency in IFT

Beat Frequency = 100 Hz (Low frequency)

Significance of Dynamic Interferential Field

Fig. 4.2: Line of interference

Fig. 4.3: Dynamic interferential field

In the modern machines a device is provided to move automatically and