Individual physiotherapy
Complied by Dr. Rafiqul Islam
Massage
Massage, or the manipulation of the soft tissues of the body by the therapists hands, although a limited part of physiotherapy and not used as widely as formerly, is still of great value if used with discretion. It consists of sustained pressure and relaxation of the tissues; it may be brisk and stimulating if required to produce expectoration; or gentle and soothing when used to induce relaxation of tense muscles. It improves circulation and so helps to disperse swelling, to loosen adhesions, and to check the accumulation of chronic inflammatory products.
The manipulation may be by stroking or kneading, by friction or percussion according to the condition being treated and the result required. Special techniques have also been evolved, e.g., connective tissue massage which utilises a reflex effect to stimulate wasted tissues. Other special methods can produce active hyperwmia (increased flow of blood) by frictions for injuries to ligaments, tendons and muscles; or they can be used to improve local circulation in treatment of ulcers, or to assist plastic repair.
Heat and Electrotherapy
Heat is utilised in two ways :
1. As a sedative to obtain relaxation and relief of muscle spasm and pain, e.g. in acute arthritis.
2. As an accelerator of the circulation. It thereby improves the blood supply to an area and so reduces congestion, e.g. in weak or paralysed muscles. This increased blood flow will also carry away the unwanted products of inflammation as in carbuncles or a septic finger, and will help to prevent adhesions in ruptured muscles such as those connected with the movement of arthritic joints.
Radiant Heat and Infra-red Rays are given by focusing the rays from a lamp on to the incapacitated part of the body. The rays penetrate below the skin layer and the heat causes a more vigorous blood flow in the area.
Moist Heat. In some cases, forms of moist heat are preferred including hot packs, medicated mud packs, and hot saline baths. The heat improves the circulation in the skin and subcutaneous tissues.
Paraffin Wax Baths. Wax baths for the alleviation of rheumatic stiffness in the hands and feet, and occasionally in other joints, is given for patients both in hospital and in out-patient physiotherapy departments or clinics. The skin must be clean and dry and free from any grease. The patient sits in a comfortable chair near a small table on which stands a small bath of melted wax at 48-9 C (120 F). For protecting the clothing against drips of wax the patients lap is covered with a piece of plastic or rubber sheeting.
The hands (or limbs) are fully immersed in the softened wax several times until it forms a glove. They are then lifted out gently and the excess wax allowed to drip from the finger tips back into the bath.
In some oases the physiotherapist applies the wax with a brush (like a pastry brush) while the patient spreads his hands on grease-proof paper. The physiotherapist then wraps grease-proof paper or some other protective material around the hands which are then wrapped round with a blanket and rested upon the patients lap.
After about twenty minutes (first applications will be for shorter periods) the wrappings are removed and the wax is peeled off like a pair of gloves, when the skin will be found to be covered with beads of sweat. The natural heat engendered by the close-fitting wax covering is very soothing to the inner tissues and enables the patient to move the stiffened joints more freely. Other physical treatment is then proceeded with on the warmed limb.
The wax method of giving heat is particularly useful for stiff and scarred hands and feet.
If the doctor has ordered the wax to be applied frequently (sometimes it is used daily), the patient may be given a supply to use at home.
For feet and ankles, warm mud is sometimes applied as an alternative to wax. But if the patient has any varicose veins the treatment is dangerous because the heat will induce inflammation.
Short Wave Diathermy. When heating of deeper structures is required short wave diathermy may be given. A special machine is used and a comfortable heat induced in the part of the body by using carefully selected electrodes in the form of rubber-covered pads or special discs which are connected to the machine. If they are correctly placed, the short wave electric current, in passing from one to the other will pass through the part to be treated, causing heat to be generated in the tissues. Short wave diathermy is frequently prescribed for neck and shoulders, as well as for knees and ankles.
The skin must be clean and dry. The therapist fixes the electrode plates (suitably sized according to the part being treated) and after about four minutes a very gentle warmth should be felt.
The therapist will ask the patient if it feels hot. On no account must it feel uncomfortably hot, or the skin will be burned. Sufferers sometimes believe, quite wrongly, that hot treatment will bring speedier relief and so they do not tell the therapist that it feels really hot. Patients should remember that people vary and the therapist can only tell from the patients description whether or not too much current is being applied.
Short wave diathermy is usually applied for about five to ten minutes the first time, the period being gradually increased until fifteen or twenty minutes is reached. Headaches sometimes indicate that the patient needs shorter treatments or that he has had sufficient treatments, and that is for the doctor to judge, but he can only do so if the patient tells him of any discomforts or disabilities connected with the treatment.
Faradisin induces correct function of muscle groups when their action has been temporarily interfered with by injury, disease, or disuse, e.g., in the quadriceps muscle after operation on the knee, or in the small muscles of the feet in cases of flat foot.
The patient puts his foot in a small bath of tepid water. The therapist has two electrodes (small pieces of metal connected to the electrical apparatus) wrapped in wet cloths, one being placed in the water and the other applied to the muscle or joint.
Usually the electrode is pressed gently against the flesh, then raised, the operation being repeated a little higher, or more to one side, as the toning is required. As the electrode is applied and the current switched on by the therapist, the patient feels a slight prickling sensation which gradually spreads through the limb and muscular contraction is felt.
It helps the therapist to adjust the strength of the current and the position of the electrode if the patient describes just how strong these contractions feel or in which direction they seem to have the strongest effect.
In foot treatment the patient is occasionally allowed to sit for a short time with feet in the water, but should inform the therapist when the current feels stronger or weaker.
When muscles are very weak, the movements can be assisted either by the physiotherapist or by the use of special apparatus with slings on ropes which
support the part being treated.
A frame known as the Guthrie-Smith Frame has been designed for the purpose of
supporting the ropes in any
position.
The physiotherapist will then be able to judge whether she needs to increase or reduce the current for the patient.
In other cases where the extremities are not the focal point, electrodes wrapped in wet cloths are applied simultaneously, again giving a sense of contraction.
At least twenty minutes rest after each treatment is advisable, since patients attending a clinic, who are well enough to travel home without hospital transport, should not attempt the return journey immediately.
This method is used to teach muscle sense and to restore rhythm, and once the pattern of movement has been re-established the treatment is discontinued.
Other electrical machines provide types of current with different properties. Interrupted galvanism is used to stimulate contraction of paralysed muscles until recovery begins. Yet other types can assist cases of circulatory disturbances or swelling.
Artificial Sunlight has stimulating and healing properties and is produced by powerfully bactericidal Ultraviolet Rays. The effects are due to chemical changes in the skin and an increase of activity in the tissues, and it is used for cleansing and stimulating the healing of ulcers, slow healing wounds, pressure sores, some skin lesions, and certain types of baldness. Dosages may be given to produce a mild or a strong reaction. General doses of ultraviolet light may also be used for their tonic effect on the whole body in cases of debility, or to prevent recurrent colds. The patient feels no particular sensation during treatment, but it is necessary to have the eyes protected by goggles from the fierceness of these light rays.
Ultrasonic Therapy
Ultrasonics or treatment by ultra-sound therapy is a branch of physical therapy using different principles. By means of a High Frequency generator, a treatment head (or applicator) and a medium such as oil or water for conduction, it makes use of vibrations which are too rapid to be heard. It is a valuable complement to other physical methods and is superior to them in the treatment of selected patients with fibrositic and certain arthritic conditions, or patients with scar tissue and soft tissue injuries, effusion, sprains, and ligament and tendon injuries.
Passive and Active Movements
Joint movements of all kinds may be performed either by use of passive movements using an external agent such as a piece of apparatus or the hands of the physiotherapist, or by the contraction by the patient of his own muscles, which is called active movement.
Passive Movements have a limited sphere of usefulness but used with discrimination can make a valuable contribution towards recovery, e.g. traction (a form of pulling) to the spine, either manually or with specially designed apparatus, can reduce pain and muscle spasm. They may also be used to maintain a small range of movement in muscles and joints where active movements are impossible and to preserve the patterns of movement while muscles are paralysed, as in poliomyelitis, or they may be given to correct deformities from birth, such as wry neck and club feet.
Manipulations are a special technique of passive movement particularly designed for alleviating conditions of the spine, including some types of disc lesions.
Active Movements are by far the most important of physical measures used, but they are not always the most enjoyable or the most appreciated! By the active use of the muscles, power, strength and endurance are restored to weak muscles, faulty posture can be corrected, joint range improved, and co-ordination retrained.
When muscles are very weak, the movements can be assisted either by the physiotherapist or by the use of special apparatus with slings on ropes which support the part being treated. A frame known as the Guthrie-Smith Frame has been designed for the purpose of supporting the ropes in any position; this improved form of suspension therapy enables the physiotherapist to give the patient a progressive series of exercises. Assistance is decreased stage by stage and the patient gradually progresses to free unassisted movements.
Later, as recovery takes place, the physiotherapists hand, or springs or weights, are offered as objects of resistance against which the working muscles must make some effort. Later still, practice sessions on various types of equipment may be added, but mechanotherapy as a separate form of treatment is not used a great deal in Bangladesh.
Proprioception is the power to appreciate ones muscles and joints and this power can easily be lost as a result of pain and stiffness, but function can be re-educated by accurate and careful muscle training. If a wrong movement pattern is built up, e.g., a limp, then great patience is necessary by both patient and therapist to regain the feel of the correct movement and to practise it until it becomes automatic. Muscle can also be re-educated when there is little or no pattern there, as in poor posture or a long-standing stiff joint which has been made movable again by surgery.
Daily activity is made up of habit movements such as walking and touching things. These movements need practically no, thought, although they may
be very complex, because there is a pattern in the brain for each activity.
If even a small part of a movement is lost, the whole unconscious mechanism is put out of action and it is often surprising how great a disability results.
In order to restore function, the steps and stages of any activity must be analysed, and separate exercises need to be worked out for each. When the individual movements are restored then the automatic pattern in the brain can be regained.
Modern methods of exercise use natural and functional patterns of body movements, although special techniques are still used for retraining the co-ordination of a set of movements, for muscle action, good posture, and relaxation.
Pool Therapy
In a number of establishments such as CRP there are special hydrotherapy pools to which the ordinary public has no access. The pools are somewhat smaller than the usual public baths and the room is kept much warmer. They are for the use of disabled children and adults who come during various hours of the day for selected sessions.
The physiotherapist goes into the pool with the patients when the treatment necessitates her presence. Special swimming instructors are present with other groups, teaching them how to keep buoyant, to balance, and to propel themselves in the water.
Pool therapy consists of special exercises with and without the assistance of specially designed equipment and using the buoyancy of water. It is usually given in conjunction with other forms of physical treatment, although it should not be used for patients with certain diseases of the heart, chest and kidneys, or in those with skin disorders, open wounds, or incontinence.
In this form of treatment (which may last from five to thirty minutes each session) the water is not medicated.
Its special advantages are the warmth of the water (about blood heat) which relieves pain and aids relaxation, the elimination of
gravity so that body
weight is relieved, and the lessening of friction which makes the patient comfortable and movement easier.
Weight-relieving positions and a fine gradation of exercises can be obtained, and the patient finds that changing position is less difficult. The physiotherapist can watch the movements and muscle action more easily too.
Pool therapy has a recreational value and the patient enjoys it, which gives an increased impetus to recovery. For the severely handicapped the ability to swim may also provide a means of general exercise, recreation and social contacts at a later stage of rehabilitation.
The patient is brought into a new environment where all the movements which he has found difficult are made easier, where the temperature and buoyancy of the water ease his pain and give him a feeling of wellbeing. He senses that he is making progress, his efforts are rewarded, he feels more cheerful and he is stimulated to greater effort.
Spas. Many forms of water treatment are available abroad, where all treatments are ordered and given under medical supervision. Since spa waters vary in their temperature and their curative qualities, certain spas have come to be recognised as being especially suitable for certain complaints, although the ideal conditions of rest, relaxation, and freedom from worry, which residence at the spa provides, play a big part in the treatment.
The waters may be drunk, or used externally in the form of douches, immersion baths at various temperatures, aeration or whirlpool baths, brine, mud or peat baths, contrast baths, wet packs, and Turkish, steam or hot air baths, according to the condition being treated and the effect desired.
