Srimathi’s Electrotherapeutic Agents Manual N Srinivasan
INDEX
A
Active therapy 2
Acute
inflammatory conditions 46
local inflammation 44
pain 28, 46
traumatic pain 45
Additional tests 10
Advanced electrotherapeutics 192
Already existing fever 46
Alternating
circuit 55
currents 61
AME compression cycling bag 177
Amount of weight 186, 188
Amplification 130
Amplitude modulated frequency 68
Ancillary instrument contents 224
Angina pectoris 47
Application of harnesses 188
Application
safety 177
strategy 99
techniques 160
time 144
Applicator mode 123
Approximate weight of pack 98
Arthritic joints 45
Arthrosis deformities 44
Auscultation 9
Available pulse type 175
Average intensity 154
B
Basic
concepts 1
knowledge 5
Beam nonuniformity in ratio form 153
Beat frequency 66
B-endorphin and dynorphin 195
Bipolar application 70
Breathing pattern 9
Burns 145
C
Calculation of
altered dose 122
dosage 122
Cancerous tissues 47
Carbon-filled silicone rubberized electrodes 73
Cardiac
insufficiency 47
pacemakers 47
Cardinal signs 18
Cardiovascular status 9
Carrier frequencies 72
Cavitation 161
Cervical region 188
Chest mobility 9
Chronic
pain 28
recurring pain 24
Circulation disorders 44
Classification of physical agents 38
Closing pain gate 33
Coherence 132
Cold
baths 43
laser 42
muscles 54
quartz 119
therapy 86
whirlpools 93
Color code 72
Combination therapy 164
Combined wave currents 62
Commercial Kennys’ packs 106
Common notes to faradic and galvanic currents 54
Compensated waveform 63
Compression 8
Conducting leads 58
Conductive
heat modalities 104
heating 38, 41
Connecting jacks 59
Constant direct current 52
Contact directors 143
Contrast baths 42, 43, 109
Convective
heating 38, 41
modalities 42
Conventional physical modalities 176
Conversive
heating 38, 41
modalities 42
Cooling agents 42, 43, 46
Corelation of pain with clinical findings 29
Coupling medium 158
Cranial nerve integrity 9
Crooks’ lense 118, 129
Current
carrier 72, 82
conduction 82
delivery 72, 82
frequency 50, 52, 179
leakage 237
transmission 73, 82
Cycle of application 185
D
Deblocking muscle spasm 75
Deep
heat producing modalities 86
pain 29
venous thrombosis 47
Defective circuit 237
Deformities 8
Depth of
penetration 208
transmission 153
Diadynamic currents 63
Diode laser 135
Dosage calculation 175
Dry scaly skin 54
Duration of
application 114, 127, 137
treatment 148
Dynamic interference field 67
E
Edema 46
Effectiveness threshold 194
Electrical
heating pads 42, 108
stimulation 2
Electrode placement 59, 81, 172, 194
Electrodes 57
Electrokinesis 75
Electromagnetic
induction therapy 141, 165
radiations 42
Electromyograph 219
Electrophysical therapeutic agents 1
Emotional and physical mental pain 29
Energy
density/radiation exposure 136
production/power output 135
Equipment 234
Erythema 122
ESWT generators 201
Extracorporeal shock wave therapy 192, 199
F
Factors affecting
cold treatments 90
transmission 155
Faradic
currents 43
galvanic conduction test 51
type current 49, 50
Fatigue test 44, 51, 54
Fluidotherapy 42
Focusers 143
Frequency of treatment 208
Functional limitations or restrictions 9
G
Galvanic type currents 52
Gate control theory 33
Generated heat 114, 127, 137, 144, 160, 175
Gliding 8
Gross edema 54
H
Half value distance 157
Hard/power laser 131
Hazards of electrophysical equipments 236
Heat 2
storage dissipation 99
Heating agents 45
Hematoma 45, 76
Hemorrhagic condition 46
High
frequency currents 45, 85
intensity pain 54
voltage
pulsed galvanic stimulation 178
twin spiked direct current 63
Hold time 186
Hospital model
fluidotherapy tanks 110
nonluminous IRR lamps 113
steam bath tubs 108
table top luminous IRR lamp 114
Hot
air
baths 106
cabinets 42
compresses 106
packs 42
quartz 119
Hunting-reaction 87
Hydrocollator packs 42, 97
Hyperstimulation 193
I
Ice
immersions 43
massage 43
packs 43
towels 43
Idiopathic joint pains 45
Impaired skin sensation 54
Improvement of
circulation 2
range of motion 3
Increased bleeding time 44
Increases activities of neural receptors 46
Inflammation 18, 51
Infrared radiations 42, 111
Initial evaluation 5
Insonation therapy 148
Intensity 72
Interferential currents 41, 43, 65
Intermittent
compression pump 176
traction 183
Interrupted
depolarized direct current 52
galvanic current 52
modulated currents 62
surged faradic current 50
Introducer circuit 55
Investigation of possible source of referred pain 10
Iontophoresis 42, 44
Irradiants 42
Irradiation
proportion 125
therapy 111, 118, 130
J
Jobst pneumatic pump 177
Joint effusion 20
K
Key muscle 9
Kilohertz electromagnetic device 167
Kromayer's lamp 123
L
Large diameter field director 143
Laser 42, 130
energy 136
measurements 135
power 136
Light 130
Lint cloth 59
Location of pain 29
Longitudinal director 143
Low
frequency currents 38, 41, 43, 49
power pulsed short wave 167
Lumbar
region 189
traction harnesses 187
Luminous generators 113
M
Macroshock 236
Mains cord 59
Malignancies may metastasize 46
Massage 2
McGill pain questionnaire 29, 32
Measurement of UVR energy 125
Medium frequency currents 38, 41, 44, 65
Metal implants 44
Microcurrent stimulation 196
Microshock 236
Microwave diathermy 42, 141
Mid laser 131
Migraine 76
Milliamperes indicated by meter 148
Mode of transmission 153
Modernization 177
Modes of applications 183
Modified galvanic currents 43
Modulating
agents 42, 43
currents 41
parameters 81
Modulation depth 68
Monochromaticity 132
Motor
ability 9
unit action potential 219
Mucosal membranes 44
Muscle
spasm 46
weakness 44
Muscular weakness 45
Myalgia 43
N
Near and far field 153
Nerve
conduction test 44
trunk 9
Neuralgia 43
Neuroids 44
Neurological tests 9
Neuromodulation of pain syndromes 78
New equipment 235
Nonthermal agents 42
Nonthermal effect 161
O
Objective data 7
Open wounds 47
Outcome of groups of words 32
Output range 144, 160, 175
P
Pain 18, 25
drawing 29, 31
gate theory 78
modulation 33
perception 26
postulates 26
Paraffin wax
bath 42
therapy 101
Paresthesia 75
Partial incontact 137
Passive therapy 2
Patient circuit 57
Peak intensity 153
Peloid packs 105
Pen electrodes 57
Penetration
angle 114, 127
depth 99, 103, 114, 136, 144, 160, 175
Peripheral nerve injuries 44
Phantom
limb sensation 83
pain 29, 76
Phonophorosis 42
Physical
agents 35
modalities 48
Physiologic gate 33
Physiological effects of shock 237
Placement
angle 137, 144
distance 114, 126, 137, 144
Positive sharp wave 230
Postirradiation care 207
Postoperative pain 43, 45, 51, 83
Power 8
density 136
pins 237
Pregnant uterus 44, 47
Pres plex plastic 171
Prevents fluid stasis 46
Primary circuit 55
Principal goal in
acute phase 2
chronic phase 3
Principles of treatment 205
Prolonged traction 182
Promotion of tissue healing 2
PSU Decks’ muscular atrophy 75
Pulse
lengths 50, 52, 179
shape 50, 52, 179
types 50, 52
Pulsed
electromagnetic energy 166
laser measure 136
ultrasound 159
PUVA apparatus 120, 124
Q
Quadripolar application 71
Quality of pain 29
Quantity of pain 29
Quartz and barium titanate 158
R
Radiating pain area 174
Recent injuries 76
Rectified current resisters 55
Reduced skin sensation 47
Reduces
inflammatory response 46
local metabolism 46
swelling 46
Reduction of
fibrous tissue and adhesions 3
muscle tension 2, 3
swelling and edema 3
Referred pain 29
Regular mode 123
Relaxes muscles 45
Relief of pain 2, 3, 53
Relieves
muscle spasm 45, 46
pain 45, 46
Respiratory capacity and functions 9
Reverse piezoelectric effect 149
Reynauds’
disease 83
phenomenon 47
Rheumatic and arthritic conditions 76
Rubberized carbon filled silicon carbon electrodes 82
Ruby laser 134
Russian currents 64
S
Safety 234, 228
measures 160
Saturated pain area 174
Saw toothed 50
Scar tissues and contractures 54
Sensation 9
Sensory disorders 44
Shock 147
wave parameters 205
Short wave diathermy 42, 165
Sister Kennys’ packs 106
Skin
disorders 44
infections 46
lessions and infections 54
Small circular field director 143
Smoothing circuit 57
Snow blindness 128
Solar elastosis 128
Space peak average/space average intensity 154
Spatial coherence 132
Special
agents 42, 43
currents of LFC 60
Spectrum 69
Spike wave currents 62
Spinal traction 181
Stability 8
Stages of inflammation 19
Standing waves 162
Steam baths 106
Stellate ganglion blocks 76
Stereodynamic interference 67
Stimulated emission of radiation 130
Stimulating agents 42, 43
Strength duration mode teans 197
Stress incontinence 45
Subjective information 5
Suggestive treatment parameters 196
Superficial
heat producing modalities 86
metal implants 54
pain 29
Supportive care 2
Surged
alternating currents 61
faradic current 50
Surging circuit 57
Sweep 69
types 69
T
Technical notes 49
Techniques of application 184
Temperature
gradiant 103
raise 99, 103
Temporal coherence 132
Theraktin tunnel 120
Thermal agents 42
Thrombophlebitis 44, 47
Tourmaline and Seignettes’ salt 158
Traction 8
Transcutaneous
electrical nerve stimulation 42
electroanalgesic nerve stimulating 42, 43, 78
Treatment
duration 178
frequency 99, 125, 175, 178, 189
methodology 3
process 3
Tridymite formation 121
Tripolar application 71
Types of
electrode spacing 171
spinal fraction 182
U
Ultrasound 148
Ultraviolet
generators 121
radiations 42, 118
V
Vapocoolant sprays 43
Vas grades 31
Vector scan 67
Visceral pain 29
Visual analog scale 29
Vital capacity and flow rates 9
W
Wand type 140
Warm whirlpools 93
Warts 46
Weakens the connective tissues 20
Whirlpool baths 42, 43
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Chapter Notes

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Basic Concepts1

 
INTRODUCTION
A variety of musculoskeletal problems can be helped by Physiotherapy, which is normally the only manual—Hands on therapy offered by conventional medicine. This type of a medicine deals with a variety of joint articulation and manual manipulations of the peripheral joints and spine along with a variety of other modalities, the physical agents, to support or enhance the effects of these manipulations. This pocket book includes some of those additional forms of supportive care, and the instructions about applications and required amounts of correct therapeutic ranges to be selected, which most textbooks have not given. With this in view, the following contents will give all those required information at a glance including the general description of the used modalities/supportive care, so that the upcoming student physiotherapists can have instructions complete enough to perform the techniques effectively. This book also serves as an effective guide for practicing physiotherapists, and in particular the practicing orthopedicians for a basic and quick knowledge about the Electrophysical Therapeutic Agents.2
 
Supportive Care
This supportive/ancillary care falls into two primary categories— Passive Therapy and Active Therapy.
 
Passive therapy
Includes those treatment modalities that do not require any energy expenditure of the patient. Rather, the modalities are applied to the patient while he or she lies quietly on a therapy table and the modalities include manual massage, thermal electricity, cold applications, stimulating currents, manual and mechanical tractions, and hence forth.
 
Active therapy
Unlike passive therapy, this demands some active involvement of the patient. Rather than being the passive recipient of therapeutic procedures, the patient must be an active participant in the therapy. Among the active therapeutic modalities are exercise, education, retraining, and work hardening. Current evidence and treatment trends are focusing more attention on active forms of therapy.
As this book concentrates only on physical modalities we shall further discuss in depth about the passive therapy.
 
Goals
The use of various physical modalities, such as heat, cold, electrical stimulation, manual massage, etc. is common in the treatment of pain and many other musculoskeletal conditions. These modalities are principally effective during the early phases of treatment and are often directed at controlling symptoms such as pain and swelling. Patient participation in the application of these therapeutic procedures is limited primarily to a passive role. In addition to their value during the early/ acute phases of care, many of these modalities may prove useful during the more chronic phases of treatment also.
The principal goals in acute phase includes:
  • Relief of pain (e.g. TENS, Ultrasound, Heat, Ice).
  • Reduction of muscle tension (e.g. Electrical stimulation, Heat, Massage).
  • Improvement of circulation (e.g. Electrical stimulation, Heat, Ultrasound).
  • Promotion of tissue healing (e.g. Electrical stimulation, LASER, UVR, Ultrasound).
    3
The principal goal in chronic phase includes:
  • Relief of pain (e.g. TEANSC, Ultrasound, Heat, Ice).
  • Reduction of swelling and edema (e.g. Electrical stimulation, Ultrasound, Heat, Cold, Massage).
  • Reduction of muscle tension (e.g. Electrical stimulation, Heat, Massage).
  • Reduction of fibrous tissue and adhesions (e.g. Electrical stimulation, Ultrasound, Massage).
  • Improvement of range of motion (e.g. Electrical stimulation, Heat, Microcurrent, TEANSC, Massage).
Recent evidences indicate that the use of many of these treatment tools may positively affect the healing process and reduce healing time and stimulate the body to perform a specific function.
Keeping these goals in mind and to select the most appropriate form of therapy, it is imperative that the clinician recognizes the particular physiological, psychological and emotional needs of the patients' condition, and understand the principles of treatment as they apply to such a condition. In addition consideration must also be given to the contraindications for treatment and to patient safety.
 
TREATMENT METHODOLOGY
 
Treatment Process
The problems arising from loss of function, pain and various other reasons, are different for individual patient, therefore treatment must be planned to meet his individual needs. In this way, the patients' and the physiotherapists' time are used to the best advantage and some result should be expected from every treatment session, if there is none the treatment is ineffective and should be altered or discontinued. This may seem to be a council of perfection which should always be kept in mind.
Most physiotherapy practitioners will give You a lot more time than you may usually be used to get from your family doctor. A first visit can last from half an hour to two hours, enabling the therapist to learn as much about patient and his personal life, as the therapist needs to suggest the best possible treatment.
 
Taking a case history
Before starting the treatment, the first concern of any good therapist is to find out what is wrong with the patient and more importantly why the patient is physically unable or simply ill. To do this, a therapist 4will go through a process known as History taking (see subjective information also). This will include a clear picture, personality, temperament, and the physical state of the patient. The process goes on in the following way:
  • The full history taking will occur on the first visit to a therapist, requiring approximately half an hour to two hour.
  • During this time the patient should be prepared for questions and investigation methods that go far beyond what a conventional medical practitioner requires.
  • The therapist attempts to gather the clear clinical picture, obvious signs and symptoms, lifestyle, diet habits, social circumstances, relationships, bowel habits, sleep patterns, mental and emotional status and so on.
  • A skilled therapists will also note the body language as how the patient sit, what is he doing with his hands, where is he looking, etc.
As the above information, may, to a maximum extent reveal more about the patient than what they do or do not say. These informations will enable the therapist to get a clear idea of what type of modality to be selected, position to be adopted during the treatment, what dosage to be given, the number of treatment sittings required, what home program is to be advised and avoid an inappropriate selection of treatment modalities, to a lack of compliance on patients' part, or perhaps to a combination of these factors, which will end up in limitation in success and treatment may need to be modified several times to determine the best method in managing the patients' condition.
The management of each patient should follow a logical and proven sequence that incorporates both passive and active modalities. Selection of treatment methods and procedures should be based on a variety of factors including:
  • The condition at hand
  • The individual patient
  • The experience of clinician.
Goals should be identified for both the therapist and the patient. As one goal is attained, new goal should be identified as needed. If goals are not reached within a reasonable time period, the entire patient interaction should be revalued.
 
Evaluation
Patient care is a problem-solving process. Simply depicted, it is a feedback loop and is compatible with the problem-oriented medical 5record approach. So, a thorough clinical evaluation through physical examination is of primary importance. Keeping the above process in mind and to execute a good and correct pattern of treatment, the following evaluation pattern is to be strictly followed. The reader is also requested to refer to several other sources for in-depth study of evaluation procedures.
  • Basic knowledge
  • Initial evaluation
  • Subjective information
  • Objective data
  • Interpretation
  • Assessment
Basic knowledge: All therapists must be well-equipped with the basic knowledge, not only in the physiotherapy methodologies but also in the other branches of medical sciences and an in-depth knowledge of medical conditions related to physiotherapy. It is essential to understand the underlying pathology, since a disease implies an abnormal state of the body and concern the structure and/of function of a part or the whole. A thorough knowledge of the disease, pathology, differential diagnosis, clinical manifestations and prognosis, becomes a must for the therapist to plan a correct pattern of treatment, to select a modality, and finally to plan the rehabilitation process as some diseases leaves a permanent influences on the body systems. The influences are:
Impairment
: A defect in structure and/or function, or a loss of a part of the body.
Disability
: Loss/reduction of the functional ability.
Handicap
: The patient is disadvantaged by his disability.
Initial evaluation: This process enables the therapist to understand the patient and approach him more skillfully. It should start while the patient is entering the room, keen observation should be made on.
  • How the patient walks and/or enters the department?
  • How the patient attempts to approach you?
  • The postural abnormalities in his standing pattern.
  • How the patient sits along with his postural abnormalities in sitting pattern?
  • How the patient answers and responds to the basic questions?
  • Whether patient uses any type of body language?
  • What the patient do with his extremities on and off?
  • Orientation, facial expressions, etc.
Subjective information: In the evaluation process the subjective information, which is nothing but the case history, is often of first 6importance. Though the patient comes with a case report, it becomes a must to come to a conclusion whether the patient can be managed fully with physiotherapy procedures or should be referred to other specialties by gathering the history from the patient directly in through his attendant with a clear and neat Face-to-face conversation and entering it in the report forum.
After gathering the informations like, name, age, sex, occupation, natural habits, referred specialist, provisional diagnosis, both from the report and from the patient, ask for the following questions:
  1. After determining the exact nature of the patients' complaint, trace the development of symptoms step-by-step from their earliest beginning up to the time of conclusion.
  2. Ask the patient to describe how he perceives his symptoms:
    • Establishing the location, type and nature of the pain or symptoms.
    • Determining whether the pain and symptoms fit into a pattern related to:
      • Segmental reference zones
      • Nerve root patterns
      • Extra segmental reference patterns such as dual reference
      • Myofacial pain patterns
      • Peripheral nerve patterns
      • Circulatory pain.
  3. Describe the behavior of the symptoms through a 24 hour period like:
    • Identify which motions or positions cause and influence the symptoms.
    • Determine how severe or how limiting the problems' are.
    • Determine how irritable the problem is by how easily the symptoms are evoked and how long they last.
    • Briefly describe his general health, medications being taken, any diagnostic investigations and X-ray studies have been done.
  4. Describe any previous history of the condition. If so, the previous treatments and the results of that.
  5. Describe the related history, such as any medical or surgical interventions.
  6. Finally, in cases that seen trivial, a tactful enquiry as to why the patient decided to seek the advice or treatment, and to what extent he is worried by his problem or disabilities, will often give a valuable clue to the underlying problems.
  7. Describe whether the problem affects the patients' occupation, family, social life, or other environmental situations.
    7
Objective data: This data includes the thorough clinical evaluation of the patient. The part complained of is examined according to a rigid routine which should become habitual. If this is done, familiarity with the routine will ensure that no step in the examination is forgotten. Accuracy of observation is essential it can be acquired only by much practice and by diligent attention to detail.
The examination of the part complained of, does not complete the clinical examination. It sometimes happens that symptoms felt in one part have their origin in another. The possibility of a distant lesion must therefore be considered and an examination is made of any region under suspicion.
Thus, the clinical examination is correlated with each other and concluded with a brief examination of the rest of the body. So systematically administer tests that will define the anatomic structures involved and the functional limitations of the patient, which falls under the following headings:
  • Examination of the part complained of,
  • Investigation of possible source of referred symptoms,
  • General examination of the body as a whole.
  1. Examination of the part complained of: The following steps are only a guide. The technique will naturally be varied according to the individual preference. Nevertheless, it is useful to stick to a particular routine, for a familiarity, which it will ensure that no step in the examination is forgotten.
    1. Exposure for examination
      • Exposure of the examination part adequately in a good light.
      • This will avoid any mistakes that are made during the examination.
      • Always remember to expose the sound side also for comparison.
    2. Inspection: This should be carried out systematically. Make observations of activities and appearance of body parts. Evaluate:
      • The bones—observe the general alignment and position of the parts to detect any deformity, shortening or unusual posture.
      • Observe by comparing both the sides and note any visible evidence of contour changes, status of inflammation (cardinal signs—swelling, heat, altered function, redness, pain (SHARP)) atrophy, hypertrophy or asymmetry.
      • The color and texture of skin—look for general appearance of the skin, redness, cyanosis, pigmentation, texture, area of lost hair, scars and/or keloids.
        8
      • ADL—Such as gait, ability to sit, stand, dress himself, general independence, and general ease of movement.
      • AIDS—Look for any use of adaptive aids for support and ambulation.
    3. Palpation: There are four points to consider:
      • Temperature: By careful comparison of both sides judge whether there is an area of increased warmth or of unusual coldness. Both denotes an increase or decrease of vascularity.
      • Bones: Investigate the general shape and outline of the bone and feel for thickening, abnormal prominance, disturbed relationship of normal landmarks.
      • Soft tissues: Check the muscle for spasm or wasting, joint tissues for synovial thickening or fluid distension in the membrane, local swelling and contractures.
      • Tenderness: The exact site of local tenderness should be traced and make an attempt to relate it to a particular anatomical structure.
    4. Measurements
      • It is often necessary to measure the limb length, particularly in lower limb, where discrepancies between both sides are important.
      • Measure the girth of the muscle and compare with the sound side muscle if any asymmetry is suspected.
      • Measure for all the active and passive rang of motion.
    5. Deformities: A deformity exists when a joint cannot be placed in the neutral position. A few examples are cubitus valgus, genu valgum, fixed flexion deformity, etc. The degree of deformity at a joint is determined by bringing the joint as near as it will come to the neutral position and measuring the angle by which it falls short.
    6. Stability: This depends upon the integrity of the articulating joints, intact ligaments and healthy muscles. When the joint is unstable there is abnormal mobility. The test include:
      • Traction: Separate the joint surfaces and note if the pain is increasing or decreasing and how easily they are moving apart.
      • Compression: Approximate the joint surfaces and note if the pain increases or decreases.
      • Gliding: Glide the bones on one another and note how easily the bones move and cause pain.
    7. Power: The power is determined by instructing the patient to move the joint against the resistance of the examiner, by 9carefully comparing it with the sound side. A standard grading chart is:
      • 0—no contraction.
      • 1—a flicker of contraction.
      • 2—a slight contraction in gravity elimination.
      • 3—a good contraction against the gravity.
      • 4—a good contraction against the gravity with an added resistance, (the maximum as what the patient can take).
      • 5—a normal contraction.
    8. Sensation: A careful observation of the cortical integration and control is made by the following methods of checklists:
      • Two-point discrimination
      • Stereognosis
      • Body awareness of limbs and trunks
      • Spatial awareness
      • Perception of vertical alignment
      • Associated reactions, synergies, synkinesis
      • Postural, righting, protective and balance reflexes.
    9. Neurological tests: Any indication of motor weakness or change in sensation directs the evaluator to specific tests to determine nerve, nerve root or CNS involvement. Evaluate:
      • Key muscle—strength and reflexes of muscle.
      • Motor ability—central versus peripheral muscle control.
      • Sensory—temperature, perception, superficial and deep pressure, pain and proprioception.
      • Nerve trunk—pain or pressure or stretching of trunks.
      • Cranial nerve integrity
    10. Cardiovascular status
      • Endurance testing such as determining a target heart rate and pulse rate before, during and after exercises.
      • Circulation integrity such as, extremity pulse, color, edema, temperature, skin texture and color of nails particularly in lower limbs.
      • Monitor symptoms such as syncope, venous stasis and embolism.
    11. Respiratory capacity and functions
      • Auscultation.
      • Breathing pattern, including rate and rhythm.
      • Ability to cough effectively.
      • Functional limitations or restrictions.
      • Vital capacity and flow rates.
      • Chest mobility.
        10
    12. Function: It is necessary to test the function of the part to know how much does the disorder affect the part in its fulfillment of the everyday activity. This test includes:
      • Active range of motion.
      • Passive range of motion.
      • Is passive range greater than active range?
      • Is movement painful?
      • Determination of crepitus along with the movement.
      • Determination of stage of injury—acute, subacute, chronic.
      • Determination of stability and mobility of the joint. A general grading scale is:
        0—Ankylosed
        1—Considerable limitation
        Hypomobile
        2—Slight limitation
        3—Normal
        4—Slight increase
        Hypermobile
        5—Considerable increase
        6—Unstable
        7—Regular ADL activities.
    13. Additional tests: Many patients require other specific testing procedures, depending on their disability. So a series of special tests, unique to the specific tissue in each region, are carried out if necessary in order to confirm or rule out the structures in questions.
  2. Investigation of possible source of referred pain: When the source of the symptoms is still in doubt after careful examination of the part complained of, attention must be directed to possible extrinsic disorders with referred symptoms. This will entail examination of such other regions of the body as might be responsible.
    For example, in a case of pain in the shoulder it might be necessary to examine the neck for evidence of a lesion interfering with the brachial plexus, and the thorax and abdomen for evidence of diaphragmatic limitation, because either of these cases may be a cause of shoulder pain.
    Again, in a case of pain in the thigh the examination will often have to include a study of the spine, abdomen, pelvis and genitourinary system as well as a local examination of the hip and thigh.
    11
  3. General examination of the body as a whole: The mistake is sometimes made of confining the attention of the patients' immediate symptoms and failing to assess the patient as a whole. It should be made a rule in every case, however trivial it may be, to form an opinion not only of the patients' general physical condition but also of his psychological outlook like his personality, the social context, culture, general interactions, the mind state, avoidance behavior, his total experience during the course of pathology. In simple and straight forward cases this general survey may legitimately be brief and rapid, but it should be never omitted.
Interpretations: The correct interpretation of the data from the subjective and objective data should be skillfully correlated to the other clinical investigations. As such, adequate to know-how to interpret various diagnostic tests like laboratory investigations, other tests and radiological findings is a must. This helps in diagnosis and should be interpreted with the extent of dysfunction and the overall influence of the ailment.
Assessment: Once the patients' subjective information, objective data and their interpretations are gathered, the information are clearly registered in a report form and integrated to determine an overall assessment of the patient and the presenting problems.
  • List the problem areas—when appropriate, state the problems as they relate to the involved anatomic structures.
  • Determine clearly the major versus minor problems—identify problems that can be dealt with directly by using physiotherapy procedures versus those that should be referred to other specialties.
  • Finally, with the assessment statistics received plan the treatment.
 
Treatment Plan
The choice of most appropriate treatment for any given conditions varies from patient to patient. Therapy that is effective for one patient may not necessarily be helpful for another who is suffering from a similar disorder. Likewise, the choice of which treatment to use for a given patient varies from therapist to therapist. So when developing a therapeutic plan of action, thought must be given to the nature of the treatment itself. Treatment that is physically demanding or that places excessive financial demands on patients may not be in their best interest. It is important to consider what is planned from the prospective of all concerned.
Whenever a clinician attempts to establish a treatment plan, attempts must be made to set reasonable and attainable therapeutic goals for 12the patient. If treatment is to be effective, the patient and the clinician/ therapist must agree on the goals and the process involved in achieving them. A wide knowledge of the techniques available and the ability to apply them with skill and in genuine are needed. The suitability of any technique used is judged by the patients' response and the extent to which it is effective for achieving or accelerating his recovery. As treatment ensues, the plan should be evaluated and modified accordingly.
After assessing the patients' needs, the next step is to plan the treatment, which involves:
  • Treatment goals
  • Indications and contraindications
  • Implement plan
  • Evaluate plan
  • Home program
 
Treatment goals
  1. Goals and objectives of treatment
    • These are based on:
      • The problems identified during evaluation and assessment.
      • The psychologic status, such as the patients' adjustment to the problem, motivation and personality.
      • Socioeconomic and cultural reactions and expectations.
      • Home or alternative care—the physical and emotional environment, family reaction, cooperation and responsibilities.
      • The patients' vocational plans and goals.
    • Each goal should be operationalized to include:
      • A measurable outcome.
      • Specific conditions or tests used.
      • The time expected to accomplish the goal.
    • Short-term goals:
      • Reflect the component skills needed to attain the long-term goals.
      • Are they helpful in directing the decision making process.
    • Long-term goals:
      • Are a final measurable outcome expected at the conclusion of a therapeutic or rehabilitation program or at the conclusion of one phase of a program.
      • Are often described in functional terms.
  2. Plan of care
    • Determine what therapeutic approaches will most appropriately meet the goals consider resources available to the patient situations.
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    • Select techniques or therapeutic modalities that will fulfill the plan and meet the goals.
    • Determine what modes of evaluation will be used to document the change reflected in the goals.
    • Anticipate the length of treatment and plan for discharge consider any alternate services for treatment.
 
Indications and contraindications
Each treatment procedure may be used more effectively and safely in some patients that—in others—in such cases, any factors that either contraindicate a specific treatment or call for precautions when applying treatment must be recognized.
  • Indications: Those factors that specifically indicate the applications of a particular modality, for example, acute swelling is an indication for ice.
  • Contraindications: These are grouped under two categories.
    • General contraindications: Include a variety of relatively common conditions in which the use of certain modalities may be unwise, e.g. diabetes, pregnancy, thrombophlebitis, etc. which complicate the treatment process and call for additional precautions when treatment is applied.
    • Absolute contraindications: Some treatments should absolutely not be attempted in the presence of these factors, for example, while using stimulating currents over the areas of acre and open wounds may aggravate the condition or give adverse chemical reactions.
 
Implement plan
Once the plan of care, indications and contraindications are established use procedures and techniques that will fulfill the plan and meet the goals.
 
Evaluation plan
Frequently evaluate and reassess the effectiveness of the procedures and techniques and modify them or the treatment plan whenever indicated.
  • Compare original data with current data at frequent intervals.
  • Identify goals that have been met, those that need modification, or new goals according to changes in the patient or his lifestyle.
 
Home program
A home program should be viewed as an extension of the treatment plan of care.14
  • Early identification of the patients' home or alternative care setting, family reactions, social and economic capabilities equipment needed, and vocational plans provide a foundation for anticipating adjustment to and compliance with a home exercise program.
  • Identify who could and would work with patient at home:
    • Involve that person early in the program in order to make the transition easier.
    • Teach the person what to do observe his/her techniques and schedule a follow-up visit to review techniques and answer questions.
  • A home, school or job visit prior to discharge is advisable in any situation in which there are questions of adaptation or compliance. An in-home physiotherapy service can assist greatly in the transition from hospital to home and can provide follow-up care if necessary.
  • Motivation and compliance are two situations difficult to control. The following are some suggestions that may influence the patient.
    • Have early involvement of the family and patient when establishing goals and assisting with the treatment plan. Teaching a home program on the day of discharge and expecting understanding and follow through is unrealistic. The home program should consist of previously learned activities.
    • Convey the importance of the program with enthusiasm.
    • Provide the patient with simple drawings and clearly written instructions of exercises, indicating; frequency, duration, and number of repetitions, alternative home remedies for heat or cold treatments.
    • Be realistic, provide the least amount of exercises and home remedies to accomplish the goals. Avoid long, tedious routines.
    • Work with the patient and family to fit the program into their anticipated daily schedule.
    • Provide check points for the patient so that he can see his progress or note the results of maintenance.
    • Schedule the patient for re-evaluation at appropriate intervals and revise the program according to the new level of performance. Project a termination date.
  • Maintain a copy of the home program in the patients' records.
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Treatment Implementation
Prior to the initiation of any treatment procedure, the following are to be strictly followed and then implement the treatment:
  • Inform the patient about his diagnosed condition.
  • Reassure the patient.
  • Since all the patients who are posted for therapeutic modalities show the main indication Pain, communicate the patient that our total attention will be directed at their pain primarily.
  • On showing some improvement the patient should be reminded of the three major goals and the importance of following through until recovery is complete.
    • We want to get you out of pain as quickly as possible
    • It is important that we address the underlying problems that lead to the pain.
    • We want to teach you how to take care of yourself so that problems do not return.
  • Nature and purpose of the proposed treatment
  • Known risks and consequences of the proposed treatment excluding those eventualities that are too remote and improbable to bear significantly on the decision process of a reasonable person or are too well known to require statement.
  • Benefits to be expected from the proposed treatment, with an assessment of the likelihood that the benefits can be realized.
  • All alternative treatments that might reasonably be used, including all the information provided above which must be given for the alternatives as well.
  • Prognosis if no treatment is given
  • All costs, including the amount and duration of pain generally involved, the potential impact on lifestyle and ability to resume work and the economic cost of both the treatment and aftercare.
At the time of initiation instruct the following:
  1. Show a simple demonstration by yourself, which will also get to know the functioning of using the modality, so that the patient is fully confident and cooperate to his fullest possible extent and do not get exited by seeing the electrical equipment.
  2. Instruct the patient as what is the experience he is going to appreciate during the treatment, e.g. a sharp pricking pain sensation during the start of an electrical stimulation or the warmth feeling with thermal agents.
  3. Strictly warn the patient not to move from the positioned mode, if so, it may alter the therapeutic outputs from the instrument.
  4. Also warn the patient not to touch any of the leads, electrodes, etc. or the electrotherapeutic instrument as a whole during the 16course of the treatment, which may give a shock, or at times severe burns, or overdose.
  5. Tell the patient to inform you if the sensation felt by him during the course of the treatment is uneasy or uncomfortable by simply raising his thumb or index finger, if very painful by raising the total hand and finally if unbearable by raising the total limb as a whole and not to shout or get exited.
  6. Tell the patient to inform you immediately if he feels too much sweating or feeling thirsty or needs a break during the course of treatment.
  7. Simultaneously check the sensations for every 2 to 3 minutes and adjust the intensity to prevent any possible dangers.
 
THE ATTENDANT
The use of an attendant is to be considered as another adjunct of treatment available to the patient who needs rehabilitation. The attendant is not only helpful as a more dynamic rehabilitation tool to the implemented present treatment and resultant recovery, but also considered as a necessity in promoting self-sufficiency for the patient with residual permanent disability, whenever the patient is away from the therapists' help.
Generally speaking, the attendant as a whole can be considered as self-help device, who plays an active and important role in the rehabilitation of a patient. The major goals in use of such a self-help device can be summarized as:
  1. To re-assure, educate, regularly train the patient and encourage patient to actively participate in the treatment program.
  2. To encourage independence in daily activities despite partial or total loss of function.
  3. To regularly monitor the patient activities and improvement, and help to build his self-esteem.
  4. To provide more dynamic treatment devices.
  5. To train and plan for adjustment of the home, to function at home as well as at the physiotherapy center.
  6. To mould the patient to achieve either partial or complete economic independence.
With the above priorities in view, it is necessary to train the attendant in a proper form and progress with the rehabilitation of the patient. The following points serve well:
  1. Inform the attendant about the patients' diagnosed condition.
  2. Reassure the attendant.
  3. Inform about all the necessity and importance of the attendant, what works to be performed, noted and reported by him to the therapist.
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  4. Inform the attendant to involve in the program more actively and at the earliest in order to make the transition easier.
  5. Teach the attendant what to do—observe his or her techniques and schedule a follow-up visit to review techniques and answer questions.
  6. Be realistic, provide the least amount of exercise and home remedies to accomplish the goals. Avoid long tedious routines.
  7. Instruct to work with the patient to fit the program as a daily schedule.
  8. Also teach him all the positioning and supporting techniques to help to maintain body alignment against weakened segments thus preventing either permanent loss of power in overstretched and over fatigued muscles and to prevent possible permanent deformity.
  9. Explain the benefits to be expected from the proposed home side treatments.
  10. Provide him with simple drawings and clearly written instructions of exercise, indicating frequency, duration and number of repetitions and alternative home remedies for heat and cold treatments.
  11. Provide check points to him, for the patients' active participation in the program, so that he can see the progress and inform the therapist whenever asked for.
  12. Schedule the attendant for re-evaluation at appropriate intervals and revise the program according to the new level of improvement and performance.
  13. Instruct the attendant to take care to see that the problem do not return and complicate the condition.
  14. Explain the importance of independence and instruct to slowly reduce the assistance as the patient improves.
  15. Inform the attendant to maintain a copy of all the home remedies implemented by him in the patients' records along with the termination date of assistance.
Even if future plans indicate any change in vacation, either outside or inside the home, consideration should be given to the amount and the kind of home side assistance, he will still be engaged in. The kinds of responsibilities will depend on the attendants' role at any given period of the patients' life, but also a quick guide for the household duties, and as a manager. The involvement and role of attendant may change according to the extent of handicap, age, family status, economic and social status of the patient. As the patient is the control key factor, the attendant should be skilled enough to identify the changing physical and mental stature of the patient. Accordingly, the nature of assistance should be modified on scientific basis to help or to improve the level of independence of the patient.