1. Muscle spasms, relief of pain, decreased ROM.

2. Whirlpool. Open lesions.

b. Contraindications

1. Patients with decreased heat tolerance.

2. Therapeutic pool. Open lesions, urinary tract infection, diarrhea; extreme care should be taken in patients with cardiopulmonary involvement.

4. Fluidotherapy is a dry application of heat. A bed of finely ground solids (e.g., glass beads with an average diameter of 0.0165 in.) are blown with thermostatically controlled warm air. This creates a warm, semifluid mixture for treatment of the hand or foot. The temperatures are within the same ranges as the paraffin wax.

a. Indications. Relief of pain, muscle spasm, decreased ROM.

b. Contraindications. Sensory involvement, open lesions.

B. Deep heating: ultrasound. The application of high-frequency sound waves to the musculoskeletal system causes a deep heating response. This response is deeper than that induced by other physical agents, and it has been demonstrated that the intraarticular temperature of the hip joint rises by 1.43°C after a properly applied therapeutic dose. Typical patient exposure is 1 to 2 W/cm 2 for 5 to 10 minutes. Ultrasound can also be combined with electrical stimulation.

1. Indications. Pain relief, muscle spasm, and decreased ROM.

2. Contraindications. Local malignancy, unstable vertebrae (after laminectomy), pregnancy, spinal cord disease; ultrasound should not be applied directly over the eyes, brain, or spinal cord.

C. Cold. Cryotherapy is very effective in promoting vasoconstriction, thus decreasing restricted joint ROM resulting from an inflammatory process and aiding with pain relief. Cold modalities include ice packs, frozen gel packs (cold packs), and ice massage.

1. Indications. Swelling and inflammatory reactions, spasms, contusions, traumatic arthritis.

2. Contraindications. Decreased sensation, sensitivity to cold, Raynaud's phenomenon.

D. Mobilization generally means moving joints, including spinal joints, through an ROM designed to stretch the joint capsule and, in some instances, move the joint beyond the norm of its associated muscles. The technique is primarily used in patients with musculoskeletal pain.

1. Indications. Joint hypomobility, decreased proprioception, restriction of accessory joint motion, ligamentous tightness, adhesions, joint dysfunction.

2. Contraindications. Ligamentous laxity, unstable joints.

E. Massage is a widely practiced modality. It is intended to relieve pain, soft-tissue tightness, and muscle spasm. It is often used in conjunction with heat or cold applications. Other forms of massage include acupressure, connective tissue massage, postural integration (rolling), and deep friction massage.

1. Indications. Muscle spasm, decreased extensibility of soft tissues.

2. Contraindications. Cellulitis, malignancy, phlebitis.

F. Electrical stimulation is one of the oldest and most effective physical agents. Its purpose is to contract or reeducate muscle, relax muscle spasms, stimulate nerves to promote motion and pain relief, and generally improve circulation. A wide range of current types (AC and DC) and a wide variety of electrical generators [low-volt, high-volt, biofeedback, transcutaneous electrical nerve stimulation (TENS)] are available. No individual system or model is ideal for all clinical situations, and the therapist's choice depends on the desired therapeutic response.

1. Indications. Muscle reeducation, denervated muscles, pain relief, decreased general circulation, decreased muscle strength during immobilization, decreased ROM.

2. Contraindications. Phlebitis, demand pacemakers, hemorrhage, recent fractures.

G. Mechanical traction. Intermittent traction is utilized for spinal disorders, generally in conjunction with other modalities. The amount of traction prescribed depends on the area being treated and on the patient's tolerance. Its effectiveness in promoting relaxation through muscle stretching, relieving nerve compression, and relieving pain has been demonstrated. Patients receive intermittent traction two to three times per week on average for 20 minutes.

1. Indications. Muscle spasm, mild nerve compression, vertebral osteoarthritis.

2. Contraindications. Unstable vertebrae, local malignancy, spinal cord disease, osteoporosis, osteomyelitis, pregnancy.

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