Use of Microwave Diathermy in Physiotherapy

*Introduction:-

*Microwave Therapy:-

~Microwave Diathermy is a form of electromegnetic radiations lying between the  short waves and infrared waves.

~Microwave Diathermy is does not penetrate as deep as short wave diathermy.

~It genewrates strong electrical field and relatively little megnetic field.

~Microwave diathermy uses electromagnetic radio waves with frequencies of 915 and 2456 MHz.14 Based on the physical properties of these waves and the corresponding dimensions of the microwave antennae, microwave diathermy has two unique properties that can be used to clinical advantage.

~The first is that microwaves are selectively absorbed in tissues with high water content, such as muscle. This makes microwave diathermy ideally suited to treat pathologic processes that occur in the muscles and adjacent fat.

~The second is that microwaves are more easily focused than the short waves used in short-wave diathermy, thereby decreasing energy leakage and making heating more efficient.

~Microwave diathermy has a high frequency and shorter wavelength  than a  short wave diathermy.

~Microwave diathermy also has several unique side effects of which the clinician must be aware. First, microwaves can cause cataract formation, so protective eyewear must be worn whenever microwave diathermy is used. Second, in addition to the precautions and contraindications to the use of short wave diathermy listed earlier, microwave diathermy has a selective affinity to heat water, so this technique should not be used in patients with edema, blisters, or hyperhidrosis because the sweat beads may become heated and cause burns to the skin.

*The mechanisms by which heat exerts its analgesic effect extend beyond the simple effects of heat locally on the target tissue. Locally, heat elicits the following physiologic responses:

(1) increased blood flow

(2) decreased muscle spasm

(3) increased extensibility of connective tissue

(4) decreased joint stiffness

(5) reduction of edema

(6) analgesia

Physiological Effect:-

~ Heat Produce

-> Increases Diameter of blood vessels

-> Increase Blood circulation

-> Remove Waste Products

->Increases Nutrients Supply in the affected area

-> Relief Pain/Reduce Muscle Spasm

*Therapeutic Effect:-

~Pain – Traumatic and Rheumatic condition
~Muscle spasm
~Inflammation
~Infection
~Fibrosis
~Delayed healing.

*Indication of MWD:-

~Disorder Of Musculoskeletal System
~Sprain
~Strain
~Capsular lesion
~Degenerative joint disease
~Joint stiffness
~Torticollis
~Chronic Inflammatory Condition
~Tendinitis
~Bursitis

*Contraindication of MWD:-

~Anesthetic area
~Malignant tissue
~Severe/excessive edema
~Metallic implant
~Cardiac pacemaker
~Over wet dressing
~Acute inflammation
~Infected open wound
~Impaired thermal sensation
~Unreliable patient
~Recent radiotherapy
~Pregnancy
~Severe cardiac abnormality
~Blood pressure abnormality
~Reproductive organ (near testes)
~Brain Tuberculosis
~Bleeding tendency.

~Because the sensation of temperature and pain are both carried to the higher centers via the same neural pathways, it is not unreasonable to imagine that heat exerts a modulating effect at the spinal and supraspinal levels.

~In addition, the feeling of well-being associated with therapeutic heat most likely causes the release of endorphins and other neurotransmitters, further modifying the pain response.

~It should be noted that although the beneficial nature of therapeutic heat cannot be denied, this treatment modality is not without side effects. The relative contraindications
Although these precautions are not absolute,
special care should be taken should a decision be made to
use therapeutic heat in these clinical settings.
Choosing a Therapeutic Heat Modality
The clinician who is considering the use of therapeutic
heat as an adjunct in the treatment of his or her patient’s
pain has a variety of heating modalities from which to
choose (Table 336-3). Although the indications for the
use of therapeutic heat apply to all therapeutic heating
modalities discussed in this chapter, each modality has
its own distinct advantages and disadvantages, which
not only can influence the success or failure of this therapeutic
intervention but also can determine the incidence
of side effects and complications if the wrong modality is
cIncreased blood flow
Decreased muscle spasm
Increased extensibility of connective tissue
Decreased joint stiffness
Reduction of edema
Analgesia
Relative Contraindications to Therapeutic Heat
Lack of or reduced sensation
Demyelinating diseases
Acute inflammation
Bleeding disorders
Hemorrhage
Malignancy
Inability to communicate or respond to pain
Atrophic skin
Ischemia
Scar tissue
chosen or is used in the incorrect clinical situation (Table
336-4). As a practical consideration, the failure to match
the modality to the patient will usually result in a lessthan-optimal
outcome.
When matching the modality to the patient, it is essential
to understand the underlying physics of each therapeutic
heat modality. Each heat modality accomplishes the delivery
of heat to the target tissue by a specific physical mechanism
of heat transfer. For sake of organization, these mechanisms
can be divided into the categories of conduction, convection,
and conversion. Whereas conduction and convection
provide primarily superficial heating, conversion has the
Microwave diathermy uses electromagnetic radio waves with frequencies of 915 and 2456 MHz.14 Based on the physical properties of these waves and the corresponding dimensions of the microwave antennae, microwave diathermy has two unique properties that can be used to clinical advantage. The first is that microwaves are selectively absorbed in tissues with high water content, such as muscle.15 This makes microwave diathermy ideally suited to treat pathologic processes that occur in the muscles and adjacent fat.16 The second is that microwaves are more easily focused than the short waves used in short-wave diathermy, thereby decreasing energy leakage and making heating more efficient.

Microwave diathermy also has several unique side effects that the clinician must be aware of. First, microwaves can cause cataract formation, so protective eyewear must be worn whenever microwave diathermy is used.17 Second, in addition to the precautions and contraindications to the use of short-wave diathermy listed earlier, because microwave diathermy has a selective affinity to heat water, this technique should not be used in patients with edema, blisters, or in patients with hyperhidrosis because the sweat beads may become heated and cause burns to the skin.

Microwave Diathermy
Microwave diathermy (Figure 5.16) overheats tissues by means of the microwave-frequency electromagnetic field. Microwaves are electromagnetic waves of a wavelength from 0.1 to 100 cm. They can be generated by a special generating lamp called a magnetron. Microwaves’ characteristics are different from those of radiowaves and similar to infrared and visible radiation. Therefore, they undergo reflection, dispersion, refraction, and diffraction on various complicated tissue structures. About 50% of the microwave beam applied to the skin is reflected; the rest is absorbed by tissues at depths of only 6–8 cm. Microwaves cause an oscillation of ions in electrolytes and molecules in polarized dielectrics and in this way create heat. The most overheated are tissues containing a lot of water, such as blood and muscles; fat tissue containing little water is only slightly affected.

Microwaves are applied to the body by means of radiators that are connected to the magnetron. Radiators can be of different sizes depending on the kind and location of pathology. They are usually placed 5–10 cm from the skin surface. The microwave dosages are estimated in a similar way to shortwave diathermy (I, II, III, and IV). Another classification, based on watts, includes mild dosages (up to 20 W) and strong dosages (up to 150 W): the most often-used dosages are those between 20 and 100 W. Treatment duration, depending on indications, is 5–15 minutes. The usual course of treatments includes 10–15 sessions.

Indications for microwave diathermy are generally similar to those for shortwave diathermy. A superficial penetration of microwaves should not constitute any limitation, because a reflexive mechanism seems to be a leading mode of action for both methods. Therefore this kind of therapy can still be widely used for, among other conditions, arthritis, back pains, neuralgias, and (using a special radiator) chronic adnexitis.

Contraindications are the same as in the case of shortwave diathermy. It is also important to remember that microwaves can be harmful; eye lenses and the reproductive tissues of testicles and ovaries are especially at risk. Partial protection can be provided by screening the room in which the microwave diathermy is performed.

Standard Microwave Diathermy Applicators
When microwave diathermy was first introduced in 1946, there was great hope that it would provide significant improvements in heating patterns over those of shortwave diathermy. The short wavelength provided the capability to direct and focus the power and couple it to the patient by direct radiation from a compact, small-size applicator. This was originally believed to be a distinct improvement over quasi-static and induction field coupling provided by the cumbersome capacitor and coil-type applicators.

Microwave diathermy had been used for a considerable number of years before any quantitative evaluation was made of the modality. The biophysical aspects were described by Schwan and Piersol (1954, 1955) and Schwan et al. (1965) who measured the dielectric properties of human tissues over a wide range of frequencies (from audio through microwave frequencies). Using these results, Schwan described the dependence of relative heating in the tissue on the thickness of the skin, and subcutaneous fat, and the frequency of a plane wave normally incident on the surface of the skin.

It can be shown both theoretically and experimentally that microwave applicators operating at a frequency of 918 MHz are superior to those operating at a frequency of 2450 MHz in terms of heating deep tissue. When compared with shortwave applicators, the 918-MHz applicator will heat more uniformly in the musculature with smaller surface and subcutaneous fat heating. The more uniform power distribution of the 918-MHz microwave applicator seems to be clinically more desirable than the toroidal pattern of the shortwave applicator. Experimental studies show that an absorbed EM power density of 50–180 W/kg is required to produce the necessary temperature increases for diathermy applications (Guy, 1975b).

Contraindications

Patients for whom test stimulation is unsuccessful.


Patients who are unable to properly operate the system.


Patients with demand-type cardiac pacemakers.


Patients exposed to diathermy. Do not use short-wave diathermy, microwave diathermy, or therapeutic ultrasound diathermy (all now referred to as diathermy) on patients implanted with a deep brain stimulation system. Energy from diathermy can be transferred through the implanted system and can cause tissue damage at the location of the implanted electrodes, resulting in severe injury or death. Diathermy is further prohibited because it may also damage the deep brain stimulation system components. This damage could result in loss of therapy, requiring additional surgery for system replacement. Injury or damage can occur during diathermy treatment whether the deep brain stimulation system is turned on or off. All patients are advised to inform their healthcare professional that they should not be exposed to diathermy treatment.


Patients exposed to magnetic resonance imaging (MRI). Do not use a full body radio-frequency (RF) coil or other extremity coils on patients implanted with a deep brain stimulation system. Because energy from MRI can be transferred through the implanted system, the potential for heat generation at the location of the electrodes exists. This isolated temperature rise may cause tissue damage at the location of the implanted electrodes, possibly resulting in severe injury or death. Injury can occur during MRI treatment whether the deep brain stimulation system is turned on or off. All patients are advised to inform their health care professional that they should not be exposed to MRI. In the instance that MRI must be performed, follow the guidelines provided in Appendix E precisely.
Contraindications

Patients for whom test stimulation is unsuccessful.


Patients who are unable to properly operate the system.


Patients with demand-type cardiac pacemakers.


Patients exposed to diathermy. Do not use short-wave diathermy, microwave diathermy, or therapeutic ultrasound diathermy (all now referred to as diathermy) on patients implanted with a deep brain stimulation system. Energy from diathermy can be transferred through the implanted system and can cause tissue damage at the location of the implanted electrodes, resulting in severe injury or death. Diathermy is further prohibited because it may also damage the deep brain stimulation system components. This damage could result in loss of therapy, requiring additional surgery for system replacement. Injury or damage can occur during diathermy treatment whether the deep brain stimulation system is turned on or off. All patients are advised to inform their healthcare professional that they should not be exposed to diathermy treatment.


Patients exposed to magnetic resonance imaging (MRI). Do not use a full body radio-frequency (RF) coil or other extremity coils on patients implanted with a deep brain stimulation system. Because energy from MRI can be transferred through the implanted system, the potential for heat generation at the location of the electrodes exists. This isolated temperature rise may cause tissue damage at the location of the implanted electrodes, possibly resulting in severe injury or death. Injury can occur during MRI treatment whether the deep brain stimulation system is turned on or off. All patients are advised to inform their health care professional that they should not be exposed to MRI. In the instance that MRI must be performed, follow the guidelines provided in Appendix E precisely.
Short-wave diathermy. Short-wave diathermy uses an oscillating electromagnetic field of high frequency to heat body surface areas. It heats to a tissue depth of 2 to 3 cm. Despite gradual decline in its use, short-wave diathermy still finds its place in treatment of large-surface body areas, such as lower extremities, upper extremities, and back. A study by Garrett and colleagues43 concluded that pulsed short-wave diathermy was more effective than 1-MHz ultrasound in heating a large muscle mass and resulted in the muscles’ retaining heat longer.

?
Microwave diathermy. Microwave diathermy uses electromagnetic radiation by microwaves and heats to a lesser tissue depth than short-wave diathermy. It is primarily used to heat superficial muscles and joints such as the shoulder. Besides its use in musculoskeletal conditions, this modality has been employed to reduce the potential effects of cancer chemotherapy and radiation treatment.44
Clinical Use
The lack of convincing experiments with larger animals using microwave heating and the absence of a reliable method for continuous and nondestructive measurements of intratumor temperature have delayed fundamental clinical trials.

Crile (1962) reported the treatment of four children with osteogenic sarcoma by surgical exposure and microwave diathermy heating of the tumor and surrounding tissues to temperatures of 50°-60°C for 15 to 25 min. Shortly afterward, x-ray therapy was applied. The aim was to destroy the tumor, by heat, while leaving the dead bone as an autograft. Such a drastic approach falls far outside the range of the normally accepted limits of hyperthermia. In a later review of these patients, Hartman and Crile (1968), although impressed by the survival for more than 5 years of one of the children, recognized that other forms of treatment (e.g., massive irradiation of the bone) could be a better answer for their purposes.

Brenner (1975) treated 15 patients with superficial metastases by combined microwave heating and x-irradiation. Regression of some metastases was reported as being achieved with lower doses of radiation than commonly seen. Sarcomas were thought to be more sensitive than carcinoma.
Heat Therapy
Application of heat can raise the pain threshold and produce muscle relaxation. Moist heat produces greater elevation of the subcutaneous temperature than dry heat and is often preferable for relief of pain. A randomized, placebo-controlled, double-blind clinical trial examining the effects of local hyperthermia induced by 433.92-MHz microwave diathermy in OA of the knee found that three 30-minutes sessions per week for 4 weeks produced significant improvements in pain reduction and physical function.71

Superficial heat penetrates the skin only a few millimeters and does not reach deeper joints such as the hip and knee. In contrast, a heat mitten may raise the temperature of the small joints of the hand.72

Dosage
For commercial hot packs (temperature, 165–170°F), treatment time is 15–30 minutes, and the temperature is adjusted to the patient’s tolerance by using commercial covers or increasing towel thickness between the patient and the hot pack. For diathermy, patients undergo 30-minute sessions three times weekly for 4 weeks.

Precautions
The risk of thermal injury is higher in patients with poor circulation or impaired sensation.68 Use heat therapy with caution in patients who have reduced peripheral circulation or severe cardiac insufficiency. Be aware of superficial metal implants and open or closed wounds in the skin.

Physiological Effect
Heat Produce -> Increases Diameter of blood vessels -> Increase Blood circulation -> Remove Waste Products ->Increases Nutrients Supply in the affected area -> Relief Pain/Reduce Muscle Spasm

Therapeutic Effect
Pain – Traumatic and Rheumatic condition
Muscle spasm
Inflammation
Infection
Fibrosis
Delayed healing.
Tenosynovitis

Indication of MWD
Disorder Of Musculoskeletal System
Sprain
Strain
Capsular lesion
Degenerative joint disease
Joint stiffness
Torticollis
Chronic Inflammatory Condition
Tendinitis
Bursitis
Contraindication of MWD
Anesthetic area
Malignant tissue
Severe/excessive edema
Metallic implant
Cardiac pacemaker
Over wet dressing
Acute inflammation
Infected open wound
Impaired thermal sensation
Unreliable patient
Recent radiotherapy
Pregnancy
Severe cardiac abnormality
Blood pressure abnormality
Reproductive organ (near testes)
Brain
Tuberculosis
Bleeding tendency.

Properties of Microwaves
 Microwave diathermy (MWD), is a form of
electromagnetic radiations lying between shortwave and

Use of LASER in Physiotherapy

*Introduction:-

*What is laser therapy?

~Laser therapies are medical treatments that use focused light. Unlike most light sources, light from a laser (which stands for light amplification by stimulated emission of radiation) is tuned to specific wavelengths. This allows it to be focused into powerful beams. Laser light is so intense that it can be used to shape diamonds or cut steel.

~Laser Therapy treatment is a non-invasive therapy that makes use of intense beams of light of specific
wavelengths to help reduce pain related to your injury. LASER stands for ‘Light Amplification by Stimulated Emission of Radiation.’

~When it comes to therapeutic use, lasers are often referred to as Cold Lasers, Low-Level Laser Therapy (LLLT) or High Power Laser Therapy (HPLT).The Low-Level Laser Therapy utilizes red (and close to red) infrared light on areas of injury or wounds in order to mend the soft tissue and also to give relief from acute and chronic pain.

~When the lights of specific wavelengths are targeted to a particular area of body, physiological changes take place in the cells. This process is known as photobiomodulation.
~In simple yet realistic terms, the laser can be considered to be a form of light amplifier – it provides enhancement of particular properties of light energy.

~Laser light will behave according to the basic laws of light, in that it travels in straight lines at a constant velocity in space. It can be transmitted, reflected, refracted and absorbed. It can be placed within the electromagnetic spectrum according to its wavelength/frequency which will vary according to the particular generator under consideration.

~There are several aspects of laser light which are deemed to be special and are often referred to in the literature. These include monochromacity, coherence and polarisation. There remains some doubt as to exactly how essential these particular aspects of laser light are in relation to the therapeutic application of this energy form.

~Monochromacity is probably the most important factor, as many of the therapeutic effects have been noted in various trials with light which is non-coherent. Additionally, it is thought that the polarisation is soon lost within the tissues & may therefore be less important than was thought at first.

*Types of Laser:-

(1) Power Laser – It is used for the destructive or surgical purpose.
(2) Soft Laser     – It has a very superficial effect and is used principally for treating the skin.
(3) Mid Laser     – Its depth of penetration is sufficient to produce the biological effect on deeper tissue without damaging.

*Physiological effect of Laser:-

~Wound healing
~Analgesic effect
~Anti-inflammatory
~Counterirritant
~Normalization of tissue
~Endorphin release
~Re-absorption of edema fluid.
~Penetration
~Absorption
~Dehydration
~Coagulation of proteins.

*Indication of Laser:-

~Laser therapy indication Open lesions
~Incisions
~Decubitus ulcers
~Lacerations
~Diabetic ulcers
~Burns
~Chronic and acute pain especially those of musculoskeletal origin. e.g- arthritis, sprains, tendinitis, ~contusions, lumbago, neuralgia, neuritis.
~Restricted joint ranges of motion.

*Contraindication of Laser:-

~Epileptic patient
~Cardiac patient
~Patient with a pacemaker
~Skin disease
~Pregnant women
~Growing cartilage in children.
~Directly eyes.

*Parameters:-

~Most LLLT apparatus generates light in the Red Visible & Near Infra-red bands of the EM spectrum, with typical wavelengths of 600 -1000nm. The mean power of such devices is generally low (1-100mW), though the peak power may be much higher than this.

~The treatment device may be a single emitter or a cluster of several emitters, though it is common for most emitters in a cluster to be non laser type devices. The beam from single probes is usually narrow (Æ1mm-6 or 7mm) at the source. A cluster probe will usually incorporate both higher and lower power emitters of different wavelengths.
~The output may be continuous or pulsed, with narrow pulse widths (in the nano or micro second ranges) and a wide variety of pulse repetition rates from 2Hz up to several thousand Hz. It is difficult to identify the evidence for the use of pulsing from the research literature, though it would appear to be a general trend that the lower puling rates are more effective in the acute conditions whilst higher pulse rates work better in more chronic conditions.

~There is a growing body of support that suggests that the pulsing settings are of secondary importance in terms of clinical doses.

*Dose Calculations:-

~Most research groups and many manufacturers, recommend that the dose delivered to a patient during a treatment session should be based on the ENERGY DENSITY rather than the power or other measure of dose. Energy Density is measured in units of Joules per square centimetre (J/cm2).

~One of the most significant inhibitors to the more widespread adoption of laser therapy in the clinical environment relates to the difficulty in getting these ‘effective’ laser doses to work on a particular machine. Few devices enable the practitioner to set the dose in J/cm2. Some will provide Joules, some Watts, some watts/cm-2 etc etc.

~It is currently argued that Joules  (i.e. Energy) may in fact be the most critical parameter rather than Energy Density. The debate is not yet resolved, and the energy density will be used here, mainly because the published research almost exclusively cites it, and therefore, it may be of more use when it comes to trying to replicate an evidence based treatment dose.

~Some machines offer ‘on board’ calculations of this dose, whilst other machines require the operator to make some simple calculations based on several considerations:

~output power (Watts)
~irradiation area (cm2)
~time (seconds)
~If PULSED – pulse width, frequency and power settings
~ENERGY DENSITY (J/cm2) = Total amount of energy (J) / Irradiation area (cm2)

~TOTAL ENERGY (J) = Average Power (Watts) x Time (sec)

~AVERAGE POWER (Watts) = Peak power (W) x Frequency (Hz) x Pulse Duration (sec) (PULSED OUTPUT ONLY)

~There are various alternative methods for calculating these doses, but those cited above offer a reasonably simple
method should one be needed.

~Most authorities suggest that the ENERGY DENSITY per TREATMENT SESSION should generally fall in the range of 0.1 – 12.0 J/cm2 though there are some recommendations which go up to 30 J/cm2. It has been previously suggested that a maximal (single treatment) dose of 4 J/cm2 should not be exceeded. The evidence would not support that contention. Again as a generality, lower doses should be applied to the more acute lesions which would appear to be more energy sensitive.

*Use:-

~Laser therapy may be used to:

~shrink or destroy tumors, polyps, or precancerous growths
~treat pain, including back nerve pain
Lasers can have a cauterizing, or sealing, effect and may be used to seal:

~nerve endings to reduce pain after surgery
~blood vessels to help prevent blood loss
~lymph vessels to reduce swelling and limit the spread of tumor cells
~Lasers may be useful in treating the very early stages of some cancers, including:

cervical cancer
penile cancer
vaginal cancer
vulvar cancer
non-small cell lung cancer
basal cell skin cancer
For cancer, laser therapy is usually used alongside other treatments, such as surgery, chemotherapy, or radiation.

Laser therapy is also used cosmetically to:

remove warts, moles, birthmarks, and sun spots
remove hair
lessen the appearance of wrinkles, blemishes, or scars
remove tattoos

*PHYSICAL MECHANISMS:-

~According to quantum mechanical theory, light energy is composed of photons or discrete packets of
electromagnetic energy. The energy of an individual photon depends only on the wavelength. Therefore, the energy of a “dose” of light depends only on the number of photons and on their wavelength or color (blue photons have more energy than green photons, that have more energy than red, that have more energy than NIR, etc).

~Photons that are delivered into living tissue can either be absorbed or scattered. Scattered photons will eventually be absorbed or will escape from the tissue in the form of diffuse reflection. The photons that are absorbed interact with an organic molecule or chromophore located within the tissue.

~Because these photons have wavelengths in the red or NIR regions of the spectrum, the chromophores that absorb these photons tend to have delocalized electrons in molecular orbitals that can be excited from the ground state to the first excited state by the quantum of energy delivered by the photon. ~

According to the first law of thermodynamics, the energy delivered to the tissue must be conserved, and three possible pathways exist to account for what happens to the delivered light energy when low level laser therapy is delivered into tissue.

~The commonest pathway that occurs when light is absorbed by living tissue is called internal conversion. This happens when the first excited singlet state of the chromophore undergoes a transition from a higher to a lower electronic state. It is sometimes called “radiationless de-excitation”, because no photons are emitted.

~It differs from intersystem crossing in that, while both are radiationless methods of de-excitation,
the molecular spin state for internal conversion remains the same, whereas it changes for intersystem crossing. The energy of the electronically excited state is given off to vibrational modes of the molecule, in other words, the excitation energy is transformed into heat.

~The second pathway that can occur is fluorescence. Fluorescence is a luminescence or re-emission of light, in which the molecular absorption of a photon triggers the emission of another photon with a longer wavelength.

~The energy difference between the absorbed and emitted photons ends up as molecular vibrations or heat. The wavelengths involved depend on the absorbance curve and Stokes shift of the particular fluorophore.

~The third pathway that can occur after the absorption of light by a tissue chromophore, represents a number of processes broadly grouped under an umbrella category of photochemistry. Because of the energy of the photons involved, covalent bonds cannot be broken. However, the energy is sufficient for the first excited singlet state to be formed, and this can undergo intersystem crossing to the long-lived triplet state of the chromophore.

~The long life of this species allows reactions to occur, such as energy transfer to ground state molecular
oxygen (a triplet) to form the reactive species, singlet oxygen. Alternatively the chromophore triplet state
may undergo electron transfer (probably reduction) to form the radical anion that can then transfer an electron to oxygen to form superoxide.

~Electron transfer reactions are highly important in the mitochondrial respiratory chain, where the principal chromophores involved in laser therapy are thought to be situated. A third photochemistry pathway that can occur after the absorption of a red or NIR photon is the dissociation of a non-covalently bound ligand from a binding site on a metal containing cofactor in an enzyme.

~The most likely candidate for this pathway is the binding of nitric oxide to the iron-containing and copper-containing redox centers in unit IV of the mitochondrial respiratory chain, known as cytochrome c oxidase (see below).

~It should be mentioned that there is another mechanism that has been proposed to account for low level laser effects on tissue. This explanation relies on the phenomenon of laser speckle, which is peculiar to laser light. The speckle effect is a result of the interference of many waves, having different phases, which add together to give a resultant wave whose amplitude, and therefore intensity, varies randomly. Each point on illuminated tissue acts as a source of secondary spherical waves.

~The light at any point in the scattered light field is made up of waves that have been scattered from each point on the illuminated surface.If the surface is rough enough to creat e path-length differences exceeding one wavelength, giving rise to phase changes greater than 2Pi.jpg, the amplitude (and hence the intensity) of the resultant light varies randomly.

~It is proposed that the variation in intensity between speckle spots that are about 1 micron apart can give rise to small but steep temperature gradie nts within subcellular organelles such as mitochondria without causing photochemistry. These temperature gradients re proposed to cause some unspecified changes in mitochondrial metabolism

* BIOCHEMICAL MECHANISMS:-

~There are perhaps three main areas of medicine and veterinary practice where LLT has a major role to play These are

(i) wound healing, tissue repair and prevention of tissue death;

(ii) relief of inflammation in chronic diseases and injuries with its associated pain and edema;

(iii) relief of neurogenic pain and some neurological problems. The proposed pathways to explain the mechanisms of LLLT should ideally be applicable to all these conditions.

*What is LLLT?

~Low Level Laser Therapy (LLLT) sometimes known as Low Level Light Therapy or Photobiomodulation (PBM) is a low intensity light therapy. The effect is photochemical not thermal. The light triggers biochemical changes within cells and can be compared to the process of photosynthesis in plants, where the photons are absorbed by cellular photoreceptors and triggers chemical changes.

~Low Level Laser therapy (LLLT) is the application of light to a biologic system to promote tissue regeneration, reduce inflammation and relieve pain. Unlike other medical laser procedures, LLLT does not have an ablative or thermal mechanism, but rather a photochemical effect which means the light is absorbed and cause a chemical change 6. The reason why the technique is termed low level is that the optimum levels of energy density delivered are low and it is not comparable to other forms of laser therapy as practiced for ablation, cutting, and thermal tissue coagulation 7.

~The first law of photobiology explains that for a low power visible light to have any effect on a living biological system, the photons must be absorbed by electronic absorption bands belonging to some molecular photo-acceptors, which are called chromophores 8. The effective tissue penetration of light at 650 nm to 1200 nm is maximized.

~The absorption and scattering of light in tissue are both much higher in the blue region of the spectrum than the red, because the main tissue chromophores (hemoglobin and melanin) have high absorption bands at shorter wavelengths and tissue scattering of light is higher at shorter wavelengths. Water strongly absorbs infrared light at wavelengths greater than 1100 nm. Therefore, the use of LLLT in animals and patients almost exclusively utilizes red and near-infrared light (600-1100 nm) 9.
~According to Posten et al, properties of low level lasers are:

a) Power output of lasers being 0.001- 0.1 Watts.
b) Wave length in the range of 300-10,600 nm.
c) Pulse rate from 0, meaning continuous to 5000 Hertz (cycles per second).
d) Intensity of 0.01-10 W/cm2 and dose of 0.01 to 100 J/ cm2 5.

*The Usage of LLLT:-

~The temporomandibular disorders (TMDs) have been identified as the most important cause of pain in the facial region. Low Level laser therapy (LLLT) has demonstrated to have analgesic, anti-inflammatory and biostimulating effects. The LLLT is a noninvasive, quick and safe, non-pharmaceutical intervention that may be beneficial for patients with TMDs 37.

~Another study proposed a novel combination of neural regeneration techniques for the repair of damaged peripheral nerves. A biodegradable nerve conduit containing genipin-cross-linked gelatin was annexed using beta-tricalcium phosphate (TCP) ceramic particles (genipin-gelatin-TCP, GGT) to bridge the transection of a 15mm sciatic nerve in rats. Electrophysiological measurements (peak amplitude and area) illustrated by compound muscle action potential (CMAP) curves demonstrated that laser stimulation significantly improved nerve function and reduced muscular atrophy.

~Histomorphometric assessments revealed that laser stimulation accelerated nerve regeneration over a larger area of neural tissue, resulting in axons of greater diameter and myelin sheaths of greater thickness than that observed in rats treated with nerve conduits alone 38.

*The use of low level laser:-

~to reduce pain, inflammation and edema, to promote wound, deeper tissues and nerves healing, and to prevent tissue damage has been known for almost forty years since the invention of lasers.

~This review will cover some of the proposed cellular mechanisms responsible for the effect of visible light on mammalian cells, including cytochrome c oxidase (with absorption peaks in the Near Infrared (NIR)). Mitochondria are thought to be a likely site for the initial effects of light, leading to increased ATP production, modulation of reactive oxygen species, and induction of transcription factors. These effects in turn lead to increased cell proliferation and migration (particularly by fibroblasts).

*Dangers of Laser:-

Eye damage if the beam is applied directly to the eye.
There is no thermal effect in the skin.
Pregnant uterus- avoid.

 

 

Pectoralis major muscle :-

Pectoralis major :-

Pectoralis major muscle :-

Muscle details :-

pectoralis major muscle

  • Clavicular head: anterior surface of the medial half of the clavicle. As a whole, adducts and medially rotates the humerus. It also draws the scapula anteriorly and inferiorly. The pectoralis major (from Latin pectus, meaning ‘breast’) is a thick, fan-shaped muscle, situated at the chest (anterior) of the human body.

Origin :-

  • anterior surface of medial half of clavical .
    half the breadth of anterior surface of manubrium and sternm up to 6th costal cartilages .
    second to sixth costal cartilarges .
    aponeurosis of the external oblique muscle of abdomen .

Insertion :-

  • it is inserted by a bilaminar tendon on the lateral lip of the bicipital groove .
    the two laminae are continuous with each other inferiorly .

Nerve supply :-

  • medial and lateral pectoral nerves .

Action :-

  • acting as a whole the muscle causes ; abdution and medial rotation of the shoulder .
    clavicular part produces :- flexion of the arm .
    sternocostal part is used in :-
    – extension of flexed arm against resistance .
    – climbing .

Platysma muscle :-

Platysma :-

Muscle details :-

platysma muscle

This muscle covers a portion of a neck muscle known as the sternocleidomastoid. The platysma muscle is expansive in size, with a broad width that spans the collarbone, or clavicle, and the side of the neck. Its point of origination is the upper portions of the pectoral, or chest, and the deltoid, or shoulder.

Origin :-

upper parts of pectoralis and deltoid fasciae . fiber run upwards and medially .

Insertion :-

anterior fibers to the base of mandible , posterior fibers to the skin of the lower face and lip and may be continuous with the risorius . nerve supply :-

Nerve supply :-

The platysma is supplied by cervical branch of the facial nerve.

Action :-

platysma muscle action

releases pressure of skin on the subjacent veins depresses mandible , pulls the angle of the mouth downword as in horror or surprise .

Related pathology :-

In Bell’s palsy platysma muscle commonly paralysis .

Buccinator muscle :-

Buccinator :-

Muscle details :-

buccinator muscle

The buccinator muscle is a thin, four-sided facial muscle that is located in each of the cheeks. The buccinator muscle is a facial muscle located in the cheeks. The main action of this muscle is to compress the cheek against the teeth.

Origin :-

upper fiber , from maxilla, opposite molar teeth .
lower fiber , from mandible, opposite molar teeth .
middle fiber, from pterygomendibular raphe .

Insertion :-

upper fiber , straight to the upperlip .
lower fiber , straight to the lowerlip .
middle fiber decussate before passing to the lips .

Nerve supply :-

he buccal branch of the facial nerve (cranial nerve VII). Sensory innervation is supplied by the buccal branch (one of the muscular branches) of the mandibular part of the trigeminal (cranial nerve V).

Action :-

buccinator muscle action

flattens cheek against gums and teeth ; prevents accumulation of food in the vestibule .

Related pathology : –

In Bell’s palsy baccinator muscle commonly paralysis .

Use of Traction in Physiotherapy

*TRACTION
*Introduction:-

~Traction is the act of drawing or pulling and relates to forces applied to the body to stretch a given part or to separate 2 or more parts.Currently, traction is used effectively in treatment of fractures.

~In physiatric practice, use of traction often is limited to the cervical or lumbar spine with the goal of
relieving pain in, or originating from, those areas.

~Since the days of Hippocrates, correction of scoliosis also has involved traction. There are various types of  traction currently in clinical use.

~The most common are mechanical, hydraulic or motorized, manual, and autotraction.

~Mechanical forms of traction use a hydraulic or motorized pulley system with weights, along with a harness or sling device to attach to the patient’s body.

~Manual traction involves the therapist using his or her hands on the patient’s body, with the body weight of the therapist providing the tractive force.

~Autotraction is controlled by the patient pulling on bars or handles at the head of the table, without direct involvement of a therapist.

~Gravitational traction with a tilt table and underwater variations of traction are also in clinical and home use but are less frequently employed than the other forms described.

*PHYSIOLOGIC EFFECTS OF TRACTION:-

~In the cervical spine, the most reproducible result of traction is elongation. In a classic study, Cyriax
reported applying force of 300 pounds manually, with a resultant 1 cm increase in cumulative lumbar spine interspace distance.

~Studies have shown that optimum weight for cervical traction to accomplish vertebral separation is 25 pounds. Additionally, 2-20 mm elongation of the cervical spine has been shown to be achievable with 25 or more pounds of tractive force.

~Studies have demonstrated that anterior intervertebral space shows the most increase in cervical flexion of 30°.

~Traction in the extended position generally is not recommended, because it is often painful and may increaserisk of complications from vertebral basilar insufficiency or spinal instability.

~Once friction is overcome in the lumbar spine, the major physiologic effect of traction is elongation.
Investigators have reported widening of lumbar interspaces requiring between 70-300 pounds of pull.

~This widening averaged up to slightly more than 3 mm at one intervertebral level. The length of time that the  separation persists remains indeterminate, with studies documenting distraction durations of 10-30 minutes after
treatment.

~Data on dimensional and pressure changes of lumbar disks caused by traction are not conclusive. Decreases in interdiskal pressure with 50-100 pounds of traction have been documented, but evidence exists that some  applications actually cause an increase in interdiskal pressure.

~Therefore, evidence is inconclusive, with much information favoring at least temporary reduction of the herniated component of an abnormal lumbar disk with concomitant traction.

~Some theories on the physiologic effects of traction suggest that stimulation of proprioceptive receptors in the  vertebral ligaments and monosegmental muscles may alter or inhibit abnormal neural input from those structures. As with other theories to explain the physiology of traction, there is little to no empirical evidence to fully
support it
.
*OUTCOME STUDIES RELATED TO TRACTION:-

~Criteria have been suggested that would allow the true effects of traction to be delineated. These criteria include (1) randomized controlled trials, (2) blind outcome assessments, (3) equivalent co-interventions, (4)monitored compliance, (5) minimal contamination and attrition, (6) adequate statistical power and description of study design and interventions, and (7) relevant, functionally oriented outcomes.

~No traction outcome study to date has incorporated these criteria. Despite inadequacies in the literature,randomized, controlled trials that meet some of these criteria do provide some insight into the efficacy of traction as a treatment modality. A review of randomized, controlled trials of traction analyzed English languagestudies done between 1966 and 2001. The only conclusion that could be drawn, based on this review, was that there exists poor evidence to support the effectiveness of traction for back pain relief. A subsequent review, by Graham and colleagues, arrived at 2 clinical conclusions; one conclusion favors the use of intermittent traction over a continuous protocol, and the other does not support the use of continuous traction. The reviewers felt there was inconclusive evidence overall for either form of traction, based upon the methodologic quality of the  numerous studies reviewed.

~A systematic literature review by Clarke and colleagues further supported the aforementioned conclusions regarding traction for low back pain. Through an examination of randomized clinical trials, the authors determined that the evidence did not support the intermittent or continuous use of traction alone to treat low back pain in mixed groups of patients suffering from this condition, whether or not sciatica was present.

~Owing to inconsistent results and methodologic problems in most of the studies involved, the authors also did not recommend traction for patients with sciatica. Clarke and his coauthors also said that because the available  research was insufficient, they could not comment on the use of traction in combination with other therapies.

~What can be reasonably derived from these studies is that more work needs to be done to be able to make evidence-based recommendations on the application of traction for back pain. Additional evidence is also needed to evaluate the optimal type and position of the tractive forces for various clinical conditions, as well as to assess the use of traction as a component of a patient’s treatment, rather than as an isolated modality.
~The Agency for Health Care Policy and Research (AHCPR) review of the literature on traction resulted in a conclusion that “spinal traction is not recommended in the treatment of acute low back problems.”

~”there is little evidence to support the continued use of traction in the management of acute low back pain (LBP).” Despite these recommendations, the widespread use of lumbar traction remains relatively high, with up to 20% of patients in the United States and 30% of those with low back pain and sciatica receiving traction as a treatment.

~Studies that claim improvement after traction report modest and very short-term improvements, with limited or no improvement in overall function. Additionally, these studies have significant design flaws. While a particular group of patients may benefit from a particular type of traction for either short-term or long-term improvement in functional outcome, the literature currently does not identify this patient population.

~In addition, it is important to note that although high quality evidence supporting the use of traction for the treatment of low back pain is currently scarce, there is likewise insufficient data in the literature to show that traction is not effective for this problem.

*CERVICAL TRACTION:-

Cervical Traction

*TECHNIQUES FOR APPLYING TRACTION:-

~Cervical traction generally is accomplished with a free-weight–and–pulley system or an electrical, motorized device. Adequate pull is achieved by using a head or chin sling attached to a system that can provide pull in a cephalic direction.

~Motorized devices are applied easily but require the patient to be attended. Free-weight–and–pulley systems often are used in the home with 20 or more pounds of water or sand and a pulley system attached to a door. If a tractive force of only 20 pounds is possible, the system is likely to fail to achieve therapeutic results.

Cervical Band

 

~Advise patients not to attempt cervical traction at home alone, because they may find themselves in uncomfortable positions and may need assistance doffing the traction devices.

~Most home traction systems are difficult for patients to set up without assistance. Home cervical traction may cause increase in pain or may fail to produce significant pain relief unless professionally monitored on a periodic basis. At the initiation of home traction, the patient should be required to demonstrate proper use of equipment to the  satisfaction of the prescribing physician or therapist.

~In the lumbar spine, adequate pull with weights and pulleys or motorized devices to achieve vertebral distraction  usually can be obtained with the proper apparatus. Generally, a harness is attached around the pelvis (to deliver a caudal pull), and the upper body is stabilized by a chest harness or voluntary arm force (for the cephalic pull).

~Motorized units have the advantage of allowing intermittent traction with less practitioner intervention. If the goal of tractive force is to distract lumbar vertebrae, 70-150 pounds of pull usually are needed. Friction between  the treatment table and patient’s body usually requires tractive force of 26% of the total body weight before  effective traction to the lumbar spine is possible.
~Many traction devices use a split table that eliminates the lower body segment friction.

~Body weight theoretically should provide enough pull to distract lumbar vertebrae and eliminate mechanical devices.

~Gravity traction is applied almost exclusively in the lumbar region. After 10 minutes of inversion traction, documented increases in intervertebral separation are noted; however, side effects also are frequently reported,  including increased blood pressure, periorbital petechiae, headaches, blurred vision, and contact lens discomfort.

~A study from Hungary re-analyzed an old method of applying traction in the treatment of patients with lumbar or  cervical diskopathy.

~Patients were vertically suspended by a special harness in a warm-water bath, with a specified amount of weight applied to the lower limbs. One harness allowed for traction on the lumbar spine, while the other focused on the cervical region. The study participants had land-based physical therapy exercises and the weight bath therapy, while a control group only had the exercises.

~Therapeutic benefit was perceived to be greater by patients treated with a combination of the weight bath and exercise than it was by patients in the control group, according to result following treatment and at 3-month follow-up.

~The treatments were well tolerated, and no adverse effects were reported. Although the study concluded that this form of traction treatment “is a relatively straightforward, non-invasive, and low-cost intervention that can be implemented anywhere,” further research may be needed to corroborate the findings of this pilot study. Such  investigation may need to be supplemented with cost and feasibility data before widespread implementation is initiated.

*INDICATIONS FOR TRACTION::-

~The literature does not give clear indications what types of neck or low back pain may improve from traction. Studies strongly suggest that traction does not produce significant influence on long-term outcome of neck pain or low back pain.

~Practitioners who rely on sound scientific advice may use traction rarely. Practitioners who are receptive to empirical treatments may be amenable to the concept that traction may separate vertebrae and decrease the size of herniated disks, thereby benefiting radiculopathy; however, no consensus has been reached among clinicians or researchers in this area.

~In a 2008 review investigating the use of lumbar traction for patients with chronic low back pain, Gay and Brault found only 10 randomized, controlled trials addressing this treatment. As a group, the studies contained  more evidence against the use of traction than they did for it. The authors broke the information into  subcategories based on whether the data covered patients with back and lower limb pain or with low back pain alone. They also looked at sustained and intermittent traction in these patient groups.

~The results indicated a lack of benefit in the use of sustained traction for chronic low back pain, with or
without lower limb symptoms. Motorized, intermittent traction, which has been aggressively marketed
(eg, VAX-D, DRX9000), likewise did not seem to differ in efficacy from simple intermittent axial traction.

 

*CONTRAINDICATIONS TO TRACTION:-

~No scientific reports clearly delineate contraindications for traction. The practitioner must rely on empirical information and opinion.

~Old age has been cited as a relative contraindication.

~Most practitioners agree that contraindications to cervical or lumbar traction include, but may not be limited to, the following:

1. Ligamentous instability,

2. Osteomyelitis,

3. Diskitis,

4. Primary or metastatic tumor,

5. Spinal cord tumor,

6. Severe osteoporosis,

7. Clinical signs of myelopathy,

8. Severe anxiety, and

9. Untreated hypertension.

~In the cervical spine, the practitioner also must take into account the fact that patients with vertebral basilar artery insufficiency may be more susceptible to cerebrovascular complications. Furthermore, patients with advanced rheumatoid arthritis or connective tissue disorders may be at risk for atlantoaxial instability.

Relative Contraindications:

1. Midline herniated nucleus pulposus,

2. Acute torticollis,

3. Restrictive lung disease,

4. Active peptic ulcer,

5. Hernia,

6. Aortic aneurysm, and

7. Pregnancy.

*REFERRAL CONSIDERATIONS

~The Physiatrist who refers patients for traction must write a detailed and specific prescription that includes at least the following patient information:

~ Age,

~Sex,

~Diagnosis,

~Underlying medical conditions,

~Precautions needed, and

~Recommended follow-up.

~Traction should not be a single treatment approach but rather should be 1 part of a comprehensive rehabilitation treatment program. The most effective use of traction is likely to improve the patient’s activity level, mobility, and overall function.

Specific items to outline in traction referrals also should include the following information:

~Position (of the body, neck, or hip and knee),
~Mode of application (continuous or intermittent),

~Weight to be applied,

~Concurrent modalities (eg, heat),

~Frequency and duration of treatment,

~Reevaluation guidelines and time frames,

*SPINAL TRACTION:-

~Spinal traction is a form of decompression therapy that relieves pressure on the spine. It can be performed manuaually or mechanically. Spinal traction is used to treat herniated discs, sciatica, degenerative disc disease pinched nerves, and many other back conditions.

Lumbar Traction

* What does spinal traction do?

~Spinal traction stretches the spine to take pressure off compressed discs. This straightens the spine and improves the body’s ability to heal itself.

*Different types of lumbar traction have been described:-

Effect of Spinal Traction

~First of all there is mechanical traction, using a mechanical device and a specially designed table that is
divided into two sections.

[1] The device delivers a certain tension to perform the traction. The patient wears
a harness, which consists of two rings, to support the patient.

[2] Autotraction also utilized a table divided into two sections, the patient provides the traction force by pulling with the arms and/or pushing with the feet.

[3] Finally there is manual traction performed by the therapist, pulling at the patient his ankles. Another way of manual traction is with the patient his legs over the therapist his shoulders, the therapist will place his arms on the patient’s thighs and pull.

[4] Continuous traction is applied for several hours with the use of a small amount of weight. Sustained traction has a shorter duration but a larger tension force.

[5] Intermittent traction is similar sustained traction but alternately applies and releases the traction force  at certain intervals.

* Clinically Relevant Anatomy:-

~The lumbar spine amount to 5 moveable vertebrae numbered L1-L5. This complex anatomy is a considerable  combination of these strong vertebrae, multiple bony component linked by joint capsules, ligaments/tendons,  muscles and highly sensitive nerves. The upper body weight is distributed to the lower extremities by way of the sacrum and pelvis. This reduces the amount of work required by spinal muscles.

~To achieve these functions:, the lumbar spine must consist of:

Relevant Anatomy

Resistance:

~Kyphotic and lordotic sagittal plane curves
~Increased mass of each vertebra from C1 to the sacrum

And Elasticity:

~Lordotic and kypohoic curves
~Motion segments (or functional unit): composed of two adjoining vertebrae, intervertebral disc, ligaments, two
facet joints and capsules
~Structure of the lumbar vertebrae:

Ligaments:

Effect on back

~Anterior longitudinal ligament (ALL): from C2 to the sacrum
~Costal ligaments: connect the heads of the ribs to the vertebrae
~Intertransverse ligaments: inferior surface to the superior surface
~Posterior longitudinal ligament (PLL): from C2 caudally to the sacrum
~Interspinous
~Ligamentum flavum
~Intervertebral disks
~Facet joints
~Spinal cord/nerve roots
~Vertebral arch
~Cauda equina

*Epidemiology /Etiology:-

(1)Low Back Pain:-

~ Low back pain (LBP) poses a significant problem to society.
~ Low back pain is the world’s number one cause of disability and one of the most prevalent health conditions.
~ Most patients also report radicular syndromes. Specific low back pain represents only 15% of all back-pain problems, and 50% of specific back pain is due to a prolapsed intervertebral disc (PID), in which the nucleus pulposus herniates through a tear in the annulus fibrosus, resulting in irritation of the adjacent nerve root  and causing a typical radiculopathic pain. Generally, pain that lasts less than 4 weeks is classified as acute pain.
~ The main clinical phenomena in acute LBP are pain and neurological disorders that affect daily activities.
~ Lumbar disc herniation: Disc degeneration might be caused by several conditions.Considerable proportion of patients with lumbar disc herniation remains symptomatic even after undergoing conservative treatments.
~ Lumbago – Sciatica: Epidemiological studies have shown that the rate of persistent sciatica is 1.6% in a given population while this rate increases to 25% with aging up to 64 years.

*Mechanism of Action:-

~Several theories have been proposed to explain the possible clinical benefit of traction therapy. Distracting  the motion segment is thought to change the position of the nucleus pulposus relative to the posterior annulusfibrosus or change the disc-nerve interface . These effects are plausible based on studies examining the kinematics of the lumbar spine during traction therapies. In addition to separating the vertebrae, traction has been shown to reduce nucleus pulposus pressure and increase foraminal area . However,it is unlikely that mechanical changes observed in a prone position will be sustained after a patient resumes an upright, weight bearing posture. Any lasting clinical response to traction therapy would more likely be because of the  effect of traction on the mechanobiology of the motion segment or neural tissues.

~Complicating the issue further is that not all traction therapies exert the same force on the spine and animal  studies have found the mechanobiology of the disc to be sensitive to the amount, frequency, and duration of  loading. It is possible that some forms of traction stimulate disc or joint repair whereas others promote tissue degradation.

~Although these variables have not been systematically examined, even in animal models, what is known regarding  disc mechanobiology should alert us to the possibility that not all traction therapies are equal. If distracting the spine can influence disc and joint mechanobiology, different modes of traction may result in different clinical results. Systematic reviews of lumbar traction therapy have typically not considered that different effects may exist based on force and time parameters[17]

~Traction trials have most often included patients with a mix of clinical presentations including back-dominant low back pain (LBP), leg-dominant LBP, or both. However, a patient with only dominant LBP and no radiculopathy is likely experiencing pain from a sclerotomal source, such as facet joints or disc, whereas sciatic pain, even if caused by disc herniation, may be predominately of neural origin. Although it is reasonable to suspect that traction therapies may affect these conditions differently, there is insufficient evidence to support this hypothesis. Distraction-manipulation and positional distraction are mechanically different than traditional traction (intermittent or sustained). Rather than allowing forces to be dispersed throug hout the lumbar tissues, these treatments attempt to concentrate them in a smaller area.

~AT, for example, allow the patient to concentrate the force by finding the position that most relieves their pain and applying  distraction in that position. Distraction-manipulation, most often used by chiropractors and physical therapists, is performed on treatment tables that allow the operator to determine the moment-to-moment vector and timing of the distractive force. These techniques include FD (Cox technique), Leander technique, and Saunders Active Trac  method, among others.

*Differential Diagnosis:-

~In an effort to maximize conservative treatment in a population with higher rates of progression to costly  interventions, such as surgery and injections, a trial of traction could be considered for patients who have a  preference for this treatment or who are unresponsive to other physical therapy interventions. Summary evidence in recent systematic reviews and clinical practice guidelines concludes that mechanical lumbar traction is not effective for treating acute or chronic nonspecific low back pain (LBP).
~However, many physical therapists continue to use it, primarily as an additional modality. Indeed, expert  clinical opinion, theoretical models,and some research evidence suggest that certain patients with LBP respond positively to traction. A study published in the March 2016 issue of JOSPT investigates the effectiveness of traction in prone as an adjunct to an extension-oriented exercise program in patients with LBP and leg pain and explores whether a previously identified set of patient characteristics is associated with better outcomes from traction.

~Low back pain – Either alone or in combination with other treatments, traction has little or no impact on pain  intensity, functional status, global improvement and return to work among people with low back pain.

~Lumbar disc herniation – Herniated lumbar disks are the central cause of sciatica. Cohort studies suggest that  the condition of many patients with a herniated lumbar disk improves in 6 weeks. In other words a conservative therapy is generally recommended for 6 weeks in the absence of a major neurologic deficit. There is no proof that conservative treatments change the natural history but some offer slight relief of symptoms. A few examples are NSAIDs (= reduce back pain, but they have a less clear benefit in patients with sciatica). A meta-analysis of 32 randomized trials showed no significant benefit of lumbar traction.

~Sciatica – Traction and exercise therapy were significantly inferior to surgery.

*How much % of body weight must be used?

~In deciding what traction weight to apply, one must consider 2 aspects:

~what weight will overcome friction between the body and the bed; and
~what amount of force is required to exert an effect on the lumbar spine. Judovich showed that a traction force of 26% of the patient’s body weight was required to overcome friction. The use of a split tabletop with friction
-free rollers reduces this to a negligible amount. In its absence, a force in excess of 26% of the body weight  must be used before any effect can be produced at the lumbar spine.
~Optimal weights for traction have been investigated by assuming that intervertebral widening or reduction of  disk protrusion achieves the effect of traction; however, only the former has been demonstrated experimentally.
~Despite the studies, it remains unclear what magnitude of force is required to cause the desired effect in the  intact human spine. The mechanism by which traction may have its effects is not fully understood, and the neuromodulation of pain, which may require very low weight, must also be considered as a possible effect.
~This notwithstanding, clinical experts recommend using motorized traction on a friction-free surface and advocate a  wide range of traction weights within their treatment regimes. Maitland suggests 10 to 65kg, with an average of  30 to 45kg; Cyriax suggests 40 to 85kg; Grieve suggests 13 to 34kg; and Hicklings suggests 32 to 68kg.

 

*Placebo comparison:-

~From a systematic review[36] six studies compared traction with sham traction .Sham traction is a low
-weight or placebo traction that the given researcher considers to be ineffective. Three studies used motorized  traction (2 on a split tabletop, 1 on a plain tabletop)), 1 used autotraction, 1 used gravitational traction,  and 1 used traction as part of bedrest. Only the study by Beurskens et al was of a high quality, and all gave  negative results except for the inconclusive result of Moret et al.

*Clinical Bottom Line:-

~Lumbar traction is used by physiotherapist for threatening patients with low back pain and leg pain. There are  different types of lumbar traction: mechanical traction, autotraction and manual traction. There had been shown  that lumbar traction reduce nucleus pulposus pressure. Lumbar traction can be used in many disorders of the low back: lumbar disc herniation, low back pain and lumbago-sciatica. A few clinical trials still questioned the effectiveness of lumbar traction.

* risks of spinal traction:-

~There are no long-term risks of spinal traction. Some side effects may occur during or after treatment. Many people experience muscle spasms after traction. Some have pain in the treated areas.

~Spinal traction is not for everyone. A physician can determine if the risks are worth the potential rewards based on your medical history.

*Spinal traction can have several effects. For instance, traction can help:

~Decrease compression forces and help distract vertebral bodies. It can help mobilize the facet joints in the  spine. This can also increase the (intervertebral) space where the spinal nerves exit out of the spine and help
~decrease irritation of these nerves.
~Enhance nourishment of the disc and nerve
~Decrease muscle spasm
~Stretch the muscles and connective tissues along the spine
~Increase circulation
~Decrease the sensitivity and pain in the joints of the spine
~Spinal elongation and the flattening of curvature in the spin
~Some conditions in the spine that it may help with include:

~Nerve pain and weakness down the arm and legs from disc and nerve injuries; radiculopathies
~Advanced degenerative changes in the spine, stenosis
~Biomechanical joint stiffness in the spine
~It is important to be carefully assessed by your physiotherapist to determine how appropriate spinal traction is  in your case. This is dependent on your signs and symptoms, the acuity of your injury and stage of healing, your past and current medical history, and your response to previous treatment. When carefully and appropriately  selected for by you and your physiotherapist, spinal traction is an effective treatment choice.

*Indication:-

1. Spinal nerve root impingement:

? Herniated disc

? Ligament encroachment

? Narrowing of the inter vertebral foramen

? Osteophyte encroachment

? Spinal nerve root swelling

2. Joint hypo mobility

3. Spondylolisthesis

4. Degenerative joint disease

5. Extrinsic muscle spasm and muscle guarding

6. Discogenic pain

7. Joint pain

8. Compression fracture

9. Lumbar disc disorders of primary origin

*Contraindication:-

? Acute strains

? Sprains

? Inflammation

? Respiratory problem

? Claustrophobia

? Osteoporosis

? Infection

? Tumor

? Rheumatoid arthritis

? Pregnancy

? Cardiovascular disease

? Hernia

? Cauda Equina Syndrome

? Neoplasms

? Pott’s Disease and all inflammatory diseases of the vertebrae

? Cardiac or circulatory disease and severe respiratory problems

? Post-operative patients within 3 months of back surgery

 

*How is spinal traction administered?

Spinal traction therapy can be administered manually or mechanically, depending on your needs.

(1)Manual spinal traction:-
In manual spinal traction, a physical therapist uses their hands to put people in a state of traction.
Then they use manual force on the joints and muscles to widen the spaces between vertebrae.

(2)Mechanical spinal traction:-
In mechanical spinal traction, you will lie on a table that has special tools to stretch the spine.
A physical therapist will attach a series of ropes, slings, and pulleys to your body to mechanically relieve pressure.

*Precautions

~Joint hypermobility
~Acute inflammation
~Claustrophobia or anxiety associated with traction
~Cardiac or respiratory insufficiency (lumbar and inversion traction); cervical traction risk for internal jugular
thrombosis; BP fluctuations
~Pregnancy (increased ligamentous laxity and risk for abdominal compression)
~Symptoms increase with traction; hx of aggravation with traction
~TMJ dysfunction (cervical) if using chin strap

 

 

 

 

Risorius muscle :-

Risorius :-

Muscle details :-

risorius muscle

The risorius begins around the parotid gland, a salivary gland in the back of the jaw, and wraps around the platysma muscle, a muscle located in the chest and neck. … Smiling and frowning are two of the facial expressions that are created by all of the facial muscles working together.

Origin :-

The risorius originates from the masseteric fascia.

Insertion:-

The risorius inserts into the skin of the angle of the mouth.

Nerve supply :-

Buccal branch of the facial nerve.

Action :-

risorius muscle action

Upon activation the risorius pulls the angle of the mouth laterally.The risorius retracts the angle of the mouth to produce a smile, albeit an insincere-looking one that does not involve the skin around the eyes. Compare with a real smile, which raises the lips with the action of zygomaticus major and zygomaticus minor muscles and causes “crow’s feet” around the eyes using the orbicularis oculi muscles.

Related pathology :-

In Bell’s palsy risorius muscle commonly paralysis .

Mentalis muscle :-

Mentalis :-

Muscle details :-

mentalis muscle

The mentalis is a paired central muscle of the lower lip, situated at the tip of the chin. It originates from the mentum and inserts into the chin soft tissue.

Origin :-

The origin of a muscle refers to the location in the body in which the muscle begins. The origin of the mentalis muscle is the incisive fossa of the mandible.

Insertion :-

The insertion point of the mentalis muscle is skin of the lower lip. Since it attaches to the skin of the lower lip, when this muscle contracts.

Nerve supply :-

Mandibular branch of facial nerve (VII).

Action :-

mentalis muscle action

Mentalis has two actions:

– protrusion of the lower lip
– elevation and wrinkling of the skin of the chin

Ralated pathology :-

In Bell’s palsy mentalis muscle commonly paralysis .

Depressor labii inferioris muscle :-

Depressor labii inferioris :-

Muscle details :- 

depressor labii inferioris muscle

This muscle arises from the oblique line of the mandible, and inserts on the skin of the lower lip, blending in with the orbicularis oris muscle. At its origin, depressor labii is continuous with the fibers of the platysma muscle. Much yellow fat is intermingled with the fibers of this muscle.

Origin :-

depressor labii is continuous with the fibers of the platysma muscle. Much yellow fat is intermingled with the fibers of this muscle.

Insertion :-

the skin of the lower lip, blending in with the orbicularis oris muscle.

Nerve supply :-

the mandibular division of the facial nerve. This muscle helps to depress the lower lip.

Action :-

depressor labii inferioris muscle action

This muscle helps to depress the lower lip.

Related pathology :-

In Bell’s palsy depressor labii inferioris muscle commonly paralysis .

Depressor anguli oris muscle :-

Depressor anguli oris :-

Muscle details :-

depressor anugi oris muscle

The depressor anguli oris (triangularis) is a facial muscle associated with frowning.The depressor anguli oris arises from the oblique line of the mandible, whence its fibres converge, to be inserted, by a narrow fasciculus, into the angle of the mouth.

Origin :-

it is continuous with the platysma . tubercal of the mandible .

Insertion :-

the orbicularis oris and risorius; some of its fibers are directly continuous with those of the caninus, and others are occasionally found crossing from the muscle of one side to that of the other; these latter fibers constitute the

Nerve supply :-

Mandibular branch of facial nerve (VII) .

Action :-

depressor anguli oris muscle action

The depressor anguli oris is a muscle of facial expression. The muscle depresses the corner of the mouth which is associated with frowning.

Related pathology :-

In Bell’s palsy depressor anguli oris muscle commonly paralysis .