Physiotherapy techniques are frequently used preparatory to the chiropractic adjustment to improve function, relieve spasm, minimize pain, and enhance circulation and drainage. They are often used before primary care to relax the patient and condition tissues, and posttherapy to relive pain and prevent deformities resulting from trauma or disease and to maintain what has been gained in treatment. There are also times when it may be considered primary therapy. Rehabilitation objectives are shown in Table 10.1.

While this chapter has not made an attempt to describe the physics involved for each modality, both practitioner and therapist should be well acquainted with underlying fundamentals to prescribe appropriate procedure, intensity, duration, and technique, as well as effectively analyze methodology and evaluate treatment.

The roles several procedures play in chiropractic physiologic therapeutics are described such as for massage, traction, mechanical supports, colonic irrigation, dietetics, cryotherapy, heat, infrared radiation, shortwave diathermy, microwave diathermy, ultrasonic diathermy, sinusoidal currents, galvanic current, iontophoresis, ultraviolet therapy, therapeutic exercises, and acupuncture.

As techniques in application vary extensively with the equipment used, it is important that both practitioner and therapist be fully acquainted with the equipment manual furnished by the manufacturer. In purchasing equipment, the physician must assure that the equipment meets all government and professional standards.

Function        Dysfunction       Primary Therapy                         
Strength        Weakness          Exercises against resistance

Physiologic     Spasticity        Thermotherapy, ultrasound, autosugges-
elasticity                        tion, biofeedback therapy, postural
                                  correction, relaxing exercises

                Spasm             Pain relief, "gate" blockage tech-
                                  niques, relaxing exercises, heat

                Tension           Relaxing exercises, hydrotherapy, bio-
                                  feedback, hypnotherapy, psycho-
                                  therapy

Physical        Contracture       Stretching exercises, joint mobiliza-
elasticity                        tion, ultrasound, thermotherapy

Coordination    Incoordination    Strengthening and relaxation exer-
                                  cises, coordination training and
                                  practice.

Chiropractic physiotherapy is the therapeutic application of forces and substances that induce a physiologic response and that uses and/or allows the body's natural processes to return to a more normal state of health. It makes use of the therapeutic effects of:

• Soft tissue manipulation and massage. The latter may include stroking, compression, percussion, vibration, mild passive joint motion, nerve stimulation, and several forms of reflex and trigger-point therapy.

• Mechanotherapy, including active and passive exercise; traction, either intermittent or sustained; and structural braces, shoe lifts, casts, or other supports.

• Light, heat, cold, air, and water are natural forces that are the prerogatives of all people to be free to apply.

• Hydrotherapy, in its traditional forms.

• Electrotherapy, when therapeutic procedures are in keeping with a justified physiologic intent and reaction.

• Nutritional planning, dietetics, and special food or nutritional supplementation. These have been described in Chapter 9.

The rational use of the forces and substances shown in Table 10.2 first requires an understanding of their mechanism of action and their predictable effects on pathophysiologic processes and on tissues with impaired function and tolerance. Second, an understanding of the abnormal or diseased state must be determined; ie, the quantity and quality of the abnormal processes involved at the time of therapy are the primary criteria for proper application.

In contrast, a diagnostic entity may at various times in its course entail several of abnormal physiologic reactions and processes; therefore, treatment must vary with the abnormal process and be adapted to it rather than statically limited by a specific unalterabIe concept of a disease entity. Disease is not a thing, but a process --a normal process out of time or phase, and the primary intent of chiropractic physiotherapeutics is to help the body adapt to and/or normalize the detrimental processes of a diseased state.

Physical Agent                 Primary Effect      Secondary Effects             
Hot water, hot air, radiant    Thermal             Hyperemia, sedation of sensory
heaters, incandescent lamps,                       or motor irritation, attenua-
diathermy, microwaves                              tion of microorganisms

Cryotherapy (vapocoolants,     Hypothermal         Sedation, decongestion, ischemia
ice)

Ultraviolet (sun, heated       Photochemical       Erythemia, pigmentation, acti-
metals, carbon arc, mercury                        vation of ergosterol
vapor arc)

Ultrasound                     Mechanical, ther-   Cellular massage, heat, sedation
                               mal, chemical

Low voltage galvanic           Electrochemical     Polar, vasomotor
currents

Low-frequency interrupted      Electrokinetic      Muscle stimulation, increase
current, sinusoidal current,                       of venous and lymph flow, re-
other alternating currents                         flex stimulation

Vibration, massage, traction   Kinetic             Muscle stimulation, increase
(intermittent), therapeutic                        of venous and lymph flow,
exercise                                           tissue stretch, reflex stimu-
                                                   lation

Any physiotherapeutic process must parallel the concomitant pathogenesis and be directed at stopping and/or reversing the process as it currently exists. For these reasons, it is advantageous to review briefly the pathophysiologic processes from the initial trauma to the extreme of fibrosis.

Whether a tissue becomes primarily injured through direct overt trauma or microtrauma, or is undergoing a change as a secondary reaction to a pathologic process initiated elsewhere, the following stages usually occur: hyperemia, passive congestion, consolidation of the protein exudate, formation of a fibrinous coagulate, organization through fibroblastic activity, fibrosis, ischemia, and, therefore, possibly more fibrosis and/or atrophy. See Table 10.3.

These processes often exist in different ratios within the same tissue at the same time. However, one usually dominates; and treatment should be directed primarily for it. Changes or modifications in therapy are often necessary as the dominant feature alters.

The presence of a coexisting neuropathy must also be realized. The area of therapy should be considered as not only the local tissue but also the neuromere or spinal segment directly involved. If one relates this process to the physiotherapeutic measures and their effects, it is understandable how appropriate these procedures may be.

1. Ice packs:   vasoconstrictive effects.

2. Galvanism:   vasoconstrictive, hardening of tissues effects.

3. Pulsed ultrasound:   dispersing effects; increased membrane permeability effects.

4. Rest, with possible support:   prevents irritation and further injury.

1. Alternating hot and cold applications, preferably in a 3:1 ratio every few hours:   revulsive effects.

2. Light massage, particularly effleurage:   revulsive effects.

3. Passive manipulation:   effects of revulsion, maintenance of muscle tone, freeing of coagulate and possibly early adhesions.

4. Mild range of motion exercise:   effects same as 3.

5. Alternating current stimulation, of a surging nature:   effects same as 3.

6. Ultrasound:   increase in gaseous exchange, dispersion of fluids, liquefaction of gels, and increased membrane permeability effects.

1. Local moderate heat, preferably of a moist nature:   mild vasodilation, increased membrane permeability effect.

2. Moderate active exercise:   revulsive effects, freeing of coagulant and early adhesions, maintenance of tone, and ligamentous and muscular integrity effects.

3. Motorized alternating traction:   effects same as 2.

4. Moderate range of motion manipulation:   effects same as 2.

5. Ultrasound:   hyperemia, liquefaction of gels, dispersion of gases and fluids, increased membrane permeability, and tissue-softening effects.

6. Sinusoidal current, surging or pulsating:   effects same as 2.

1. Deep heat, prolonged (eg, diathermy):   prolonged vasodilation, increased membrane permeability, increased chemical activity effects.

2. Deep massage (eg, petrissage or other soft-tissue manipulation:   tends to break down fibrotic tissue and create more elasticity.

3. Vigorous active exercise, preferably with slight traction or at least without weight bearing:   maintains muscle and ligamentous integrity, stretches fibrotic tissues, breaks adhesions, and creates greater elasticity.

4. Motorized alternating traction:   effects same as 3.

5. Negative galvanism, particularly with an antisclerotic (eg, potassium iodine):   vasodilation, softening, liquefaction, and antisclerotic activity effects.

6. Ultrasound:   effects causing softening of tissues as previously described.

7. Active joint manipulation:   reduction of muscular spasm, breaking of adhesions and fibrotic tissue, and restoration of physiologic motion effects.

MASSAGE

Therapeutic massage provided by a professional should not be confused with that given by an unlicensed practitioner. Scientifically applied massage acts mechanically on the tissues that are directly and reflexly contacted on deeper or possibly remote visceral structures. When applied to stretch adhesions and contractures or to relocate prolapsed organs, the term "bloodless surgery" is sometimes used.

      Physiologic Effects

Massage increases the flow of blood and lymph; increases pulse beat; raises blood pressure when moderately forceful; reduces edema, congestion, and exudates; reduces joint effusions and coagulates; stretches and/or breaks tissue and interseptal adhesions; increases urinary production; increases respiration when moderately forceful; sedates motor and sensory nerve activity; and removes lactic acid from musculature and relieves fatigue. When applied to the abdomen, it increases peristalsis and the elimination of intestinal residues and debris.

      Indications

Massage is especially useful in conditions in which relief of pain, reduction of swelling, or mobilization of contracted tissues is desired. It is almost always indicated in posttraumatic swelling and induration such as seen in strains, sprains, subluxations, bruises, and tendon and nerve injuries. It is often used in such disorders as arthritis, periarthritis, bursitis, neuralgia, fibrositis, spastic low-back pain, paralytic conditions, and psychoneurosis.

Massage does not increase muscle strength and is not a substitute for exercise. Strength develops in muscles contracting actively, preferably against resistance.

      Contraindications

Typical contraindications include skin infections and ulceration, local acute inflammatory processes, adiposis dolorosa and other lipodystrophies, abrasions, cuts, acute deep or visceral inflammations, phlebitis, thrombosis, and other vascular diseases where there is a tendency to hemorrhage such as with varicosities, peptic ulcers, a menstruating uterus, acute osteomyelitis, tubercular joints, any infectious bone or joint disease, or malignant neoplasias.

      General Rules of Application

Adequate lubricant should be used to avoid irritating the skin. Too vigorous or traumatic forces, or too lengthy a treatment time must be avoided. Blood vessels, inflamed nerves, or other sensitive structures or areas should be avoided during deep stroking or effleurage. Regional massage should be applied centripetally toward the heart.

Prior to treatment, inform the patient what you are going to do, how you are going to do it, and why it is necessary. This avoids patient anxiety and enhances cooperation.

      Massage Media

Lotions, creams, oils, and other lubricants are primarily used to reduce friction and soften skin or scar tissue. Powders such as talcum make kneading strokes easier, but avoid powders on the faces of patients with respiratory problems.

Before applying the medium, clean the patient's skin at the application site, inform the patient about the medium, and assure the patient is not sensitive to the medium. Following therapy, remove the medium with alcohol if indicated but never pour alcohol directly on the skin. Inspect the area after cleaning and record findings.


Common Massage Techniques

      General Effleurage

Essentially, effleurage means stroking the skin with light or heavy pressure. On large areas, the hands are relaxed, the fingers are together, and the palms serve as the primary contact point. On small areas, the thumbpads and/or fingerpads are used. Movements are long centripetal strokes where skin contact is maintained at the end of each stroke when returning to the starting position. Mild effleurage is often used as a preliminary to, between, or to conclude other massage techniques.

      Fulling Effleurage

Using the palms and fingers, one hand pushes with this technique while the other hand pulls. This procedure is frequently useful in the lower back and on large muscle areas.

In low-back musculoskeletal conditions, place one hand on the far side from the spine, pointing fingers laterally. Place the other hand with fingers pointing medially on the near side of the spine. The far hand is pulled toward you as the near hand is pushed away from you while avoiding pressure on the spinous processes as the hands meet and cross to the opposite side.

      Knuckling Effleurage

Very deep effleurage is accomplished by making a fist and placing the dorsal surface of the first phalanges on the part to be massaged and then forcefully extending the wrist in a flicking motion. Movements proceed in a centripetal direction.

      Shingling Effleurage

This type of effleurage is when one stroke is made on top of the previous stroke, like over-lapping shingles on a roof. One hand is placed on the part and moved toward you. At the completion of this movement, the other hand is placed where the first hand started and moved toward you. As one hand completes the stroke, the other hand begins a stroke. Direction is up the part (cephalad) such as on a limb or the spine.

      Bilateral Tree Effleurage

This is a common spinal technique where the hands are placed on the lower back; the fingers are together and point medially with the palms next to but not on the spinous processes. The hands are removed after each lateral stroke, and the direction of the effleurage progresses up the spine.

      Petrissage (Compression)

This is a muscle kneading technique where little or no lubricant is used. The hand(s), rather than sliding over the skin, contacts the muscle and rolls and compresses it against bone or another structure. Tissues are sometimes alternately kneaded between the fingers of one hand and the thumb of the other hand.

      Tapotement (Percussion)

This is a series of rapid percussion strokes by:

• Tapping with the volar surface of the fingers extended, alternating hands in rapid succession.

• Slapping with palm and fingers, alternating hands in rapid succession.

• Hacking in rapid succession with palms facing each other, fingers relaxed, and using the ulnar borders of the hands during contact.

• Thumping, similar to hacking but with hand made into a fist.

• Cupping, slapping with the palms in a cupped position, fingers semiflexed.

• Pincemont, a gentle pinching of tissues between the thumb and index finger in rapid succession.

Traction tables can be designed to apply continuous traction and/or intermittent traction combined with heat, vibration, and/or massage. See Figure 10.1.

Physiologic Effects of Continuous Moderate Traction:

1. Immobilizes and "splints" injured or overstressed musculoskeletal tissues.

2. Relieves spastic muscles by placing them in "physiologic rest."

3. Relieves compression effects on articular tissues due to spasm or other pressure-inducing factors.

4. Reduces circumference of intervertebral disc. Therapy helps to restore normal positioning.

5. Relieves compression effects of foramenn distortion and/or narrowing.

6. As a by-product of the previous features, it helps to dissipate congestion, stasis, and edema of associated tissues.

7. Stimulates proprioceptive reflexes.

8. Stretches fibrotic tissues and adhesions.

Physiologic Effects of Intermittent or Alternating Traction:

1. Increases vascular and lymphatic flow; thus reducing stasis, edema, and coagulates in chronic congestion.

2. Helps "tone" muscles, thereby reducing fatigue and restoring tissue elasticity and resiliency.

3. Stretches and helps free periarticular and articular adhesions and fibrotic infiltrations.

4. Encourages expansion and contraction of disc tissues; thereby improving the nutritional media.

5. Stimulates proprioceptive reflexes.

Contraindications of Continuous and Intermittent Traction:

1. Local osseous infections such as osteomyelitis, tuberculosis, etc.

2. Osteoporosis and/or osteomalacia.

3. Osseous neoplasias.

4. Severe cardiovascular and/or hypertensive disease.

5. Localized vascular disease and/or with a tendency for hemorrhage in the area.

6. Advanced cachexia.

7. Pregnancy (in areas that might adversely affect the gravid uterus).

8. Diseases of the spinal cord.

Further Contraindications to Intermittent Traction:

1. Inflammatory and/or rheumatoid arthritis.

2. Severe spasms.

3. Acute inflammations of musculoskeletal tissues such as myofascitis, bursitis, tendinitis, etc.

4. Acute intervertebral disc syndrome.

General Rules of Application

Physiologic Effects

Mechanical supports hold structures in a sustained position and thus promote healing. See Figure 10.4. They relieve weight-bearing or motion stress on joints and osseous structures. They relieve muscle, tendon, and ligament stress from postural and/or motion efforts.

Some supports such as shoelifts allow stretching and/or contracting of musculoskeletal tissues and thus encourage structural alterations. In anomalous and/or acquired malformations, shoelifts and other supports may provide for a structural deficiency of formation.

Contraindications

Contradictions arise where immobilization may promote the organization of inflammatory coagulates and consequent adhesions and/or fibrotic infiltration --depending on time and nature of the condition. Immobilization can also encourage muscular atonicity weakness and/or atrophy --depending on time and nature of the condition.

Immobilization or a sustained position may promote unsatisfactory stretching and/or contractual changes --depending on time and nature of the condition. Immobilization can also cause vascular stasis, congestion, or ischemia --depending on time and nature of the condition.

Basic Rules of Application

Be certain of patient comfort yet firm fitting of the device. See Figure 10.5. Hold the part in proper position, usually that of "physiologic rest." Avoid friction or other irritation of the skin; avoid pressure on blood vessels, nerves, or other vital structures; avoid pressure that may cause impairment to venous or lymphatic drainage; initially allow for swelling; and avoid stress on ligaments, muscles, tendons, or other tissues.

Watch for adverse symptoms such as pain, pallor, pulselessness, paresthesia, or swelling. Periodically check and re-evaluate support and its function. When possible, use periodic mobility, passive or active exercises, or any other proper therapy to counteract the deleterious side effects of immobilization. Much of this can be minimized by passive exercise (manual, mechanical, electrical) of adjacent joints.

General Considerations in the Use of Braces or Jackets

Braces or jackets are applied to the body for support or immobilization of a specific part or region to correct or prevent deformity and to assist or restore function. Common indications for braces are local pain, weakness, degeneration, or paralysis.

In prescription, it should be kept in mind that one of the basic principles of design is to provide adequate surface area for the distribution of forces involved. Accurate contouring helps.

If immobilization of a joint is desired, the brace will require long lever arms with maximum pressure distribution to give comfort and be effective. Proper design should consider simplicity, durability, minimal weight, necessary strength, and be as inconspicuous as possible for cosmetic reasons.

Prescription for a support or device should be specific, recorded in the patient's record, and should include the part(s) to be braced, type of brace, material, type of joints, and special considerations, After delivery, the brace should be checked to assure that the prescription has been filled properly and that it fits the patient adequately.

Progressive therapeutic exercises, both passive and then active, should be used during and following the use of braces.

Spinal Braces

Spinal braces have been used widely for hundreds of years for both corrective and supportive goals such as relief of pain, prevention and correction of deformity, protection against further injury, and as an aid in supporting weakened muscles and ligaments.

Any involved spinal biomechanics should be understood before spinal braces are considered. Remember that the spinal column acts as a flexible elastic rod for maintaining the upright position where intrinsic stability is provided by:
(1) the discs,
(2) muscular support, and
(3) ligament straps. The compression, shearing, twisting, and bending forces withstood in daily living are the result of these combined intrinsic factors and extrinsic loading.

Because of the intervertebral discs, the spine as a whole is quite flexible, elastic, and plastic. When the anulus fibrosis is intact and the nucleus has not been displaced, the elastic limits by compressive forces cannot be exceeded without vertebral fracture. The end-plate will usually fracture before the vertebral body unless advanced bone disease exists that predisposes bone failure (eg, osteoporosis, cystic cavitations, etc).

The spine can be considered a segmental elastic column supported by the paraspinal muscles attached to the sides and located within the abdominal and thoracic cavities. Trunk muscles convert these cavities into rigid-walled cylinders capable of transmitting forces developed in loading the spine and thus relieve some pressure on the spine itself. For instance, the greater the weight lifted, the greater the activity of the trunk, chest, and abdominal muscles.

Without trunk support and cavity pressures, forces on the lumbosacral disc would be 30% greater and those on the lower thoracic spine would be about 50% greater. A tight corset about the abdomen leads to less abdominal and thoracic muscular activity when lifting, indicating that the effect of these muscles can be at least partially replaced by external support.

Both gait and energy expenditure are influenced by spinal appliances. A patient with an appliance restricting axial spinal rotation walks slower with shorter steps in order to maintain a comfortable pace, maintain balance, and conserve energy.

In the use of any spinal appliance, spinal motion is increased in the segments adjacent to the end of the appliance. This may be purposeful in design; if not, resulting discomfort may require extension of the brace well above and below the involved area to relieve discomfort.

Except for a hyperextension brace, almost all spinal appliances depend partially on compression to achieve their goal. In spinal support, it is generally assumed that relief from back pain is the result primarily of abdominal compression and secondarily from the decrease in lumbar lordosis.

Molded Jackets

Jackets made of plaster of paris, leather, or plastic are molded to fit the contour of the body and assist in distributing even pressure. They are often useful in providing spinal support for debilitated patients in degenerative disorders such as osteoporosis, chronic poliomyelitis, and severe spinal deformities and congenital anomalies, and to restrict movement after acute strain or sprain. See Figure 10.6.

Applications of Rigid Supports for the Back

Commonly used in cases of back pain, a rigid spinal brace often provides an efficient method of obtaining abdominal compression with an anterior force and distributing the counterforce over a wide area when properly fitted with the rigid uprights contoured to follow the lumbar curve.

Manufactured in several styles, the rigid back support essentially consists of a pelvic band at a level between the greater trochanter and the iliac crest and a thoracic band at the level of T8. These bands connect by two lateral and posterior uprights and usually with a corset front.

The typical dorsolumbar brace is a long brace consisting of a wide-fitted pelvic band and two long posterior paraspinal uprights extending to the shoulders. The uprights are connected in the midthoracic area by a short transverse bar, with straps from the uprights passing over the shoulders and under the axillae to the transverse bar. A full-length abdominal apron is often attached.

If the goal is to immobilize, a rigid support should be used that is designed and fit to accomplish this purpose (eg, supports using plastics, metal, and/or leather). If the goal is to allow slight mobility after inflammation has subsided, then a support allowing some motion can be used (eg, fabrics or materials offering some elasticity, flexibility, and/or plasticity such as foam collars or elastic bandages).

Belts

While corsets are commonly prescribed for women, belts are more common for men. The substitution of the common elastic belt is strictly to satisfy the male ego for the corset is by far a more efficient support.

In sacroiliac inflammatory or hypermobile disorders, a trochanteric belt, usually from 2 to 3 inches wide, is worn around the pelvis between the trochanters and iliac crests. However, this type of appliance may offer less than ideal support because of a too narrow width.

Sacroiliac and lumbosacral belts are similar in design and function, differing essentially only in width. The sacroiliac belt is usually from 4 to 6 inches wide, while the lumbosacral belt is usually from 8 to 16 inches wide. Both sacroiliac and lumbosacral belts are often useful in back pain resulting from disc disorders; however, they fail to provide sufficient immobilization in extremely severe conditions unless they are made of inflexible and inelastic material and incorporate metal stays.

Aspirated Air Belts

A relatively new product to protect and support the lower back, especially as an aid during rehabilitation following low-back trauma (sprain and/or strain) is the inflatable "air belt." An air belt is a uniquely designed light-weight yet strong lumbar support that can be worn either inside or outside of clothing. It incorporates many advantages of a heavy inflexible corset yet is lightweight and "is automatically custom-fit" to conform to the patient's unique body shape. Unlike rigid corsets, motions of normal daily living are not restricted when it is worn and the patient has immediately control of the pressure.

The examples shown in Figures 10.7 and 10.8 are designed so interconnected chambers in the belt allow conformity to the patient's spine. These supports have a Camrelle inner liner for moisture absorption and a durable outer shell to provide rigidity. As the chambers are aspirated with air by a "tuck away" palm grip bulb, the chambers expand and apply forward pressure over the muscles of the lower back. This relaxes stressed spinal muscles and ligaments and encourages proper biomechanical balance and segmental alignment.

Corsets

Corsets are encircling garments having vertical and/or horizontal metal stays. They generally encase the region between the pubis and lower ribs. The higher the back of the corset, the greater spinal support.

Corsets are often prescribed to assist weakened muscles or to limit spinal motion. In general, a corset is worn only during active hours, but in cases of severe low back pain, it may give relief if worn both day and night. As always, prolonged constant support produces weakened muscles and ligaments and encourages fibrosis.

Extremity Supports

A large variety of elastic and hinged appliances are available to support and/or immobilize an injured shoulder, elbow, wrist, knee, or ankle. Taping is another common technique used to achieve the same objectives. Examples are shown in Figure 10.9 and Figure 10.10.


Considerations in Chronic Disorders

In addition to chiropractic articular adjustments, procedures involving regional mobilization, articular support, and muscle re-education are often highly beneficial. Nevertheless, the use of supportive appliances is always a matter of weighed clinical judgment. When used wisely with a thorough knowledge of biomechanics, application may be highly beneficial as an adjunct to corrective adjustments in many acute and chronic disorders.

Note: Immobile support without the advantage of prior mobilizing adjustments and not used in conjunction with neuromuscular re-education rarely achieves optimal goals.

      Regional Mobilization

The goal of regional mobilization by external appliances is to regain or maintain mobility of the affected region by enhancing the correction of pertinent articular fixations and obtaining symmetric mobility for successful muscle reeducation and support by bracing.

Muscle stretching is often helpful, but it is essentially useless and possibly contraindicated in tightening tissues on the convexity of a scoliosis. Manual or mechanical muscle stretching is effective and should be specific for the concavity of the low thoracic, thoracolumbar, and upper lumbar regions. Unfortunately, it is rarely beneficial in stubborn fixations in the upper thoracic region or at lumbosacral angle. It is most effective in all regions during the formative stages but rarely helpful after bony changes have occurred. Nevertheless, any degree of restricted articular mobility that can be restored will be of benefit to the patient.

Recommended isotonic or isometric exercises should be done gently (to tolerance) and repeated several times a day. Stretching by a properly designed back brace or corset has limited value in correcting lumbosacral and high thoracic curves, but intermittent spinal traction may be helpful.

      General Objectives in Joint Support

The aims of corsets, braces, adjustable frames, and casts are fourfold:

(1) to support weak underlying musculature;
(2) to correct alignment by direct pressure over regions of convexity;
(3) to correct alignment by distraction forces; and
(4) to promote active correction by shifting intrinsic load and inducing the patient to maintain the correction in the sitting and upright positions.

      Muscle Re-education

Muscle re-education is often essential in the care of chronic spinal and extraspinal disorders, but it must be prescribed only after very accurate analysis and should be carried out under supervision or counsel of a practitioner skilled in clinical biomechanics.

Rightly so, colonic irrigation (intestinal lavage, colon bath) has received severe criticism in the past decade. However, the objections have not been directed against its clinical indications. The fault has not been with its rationale but toward licensed and unlicensed practitioners guilty of unjustified use or claims, overuse, disregard for its contraindications, or unskilled application.

Severe disease with intestinal paralysis will usually be indicated by a lack of gastrointestinal sounds. An enema should never be administered or prescribed until after a complete neurologic workup and physical examination has been made that includes extremely thorough abdominal palpation, percussion, and auscultation. Fluoroscopy or contrast-media roentgenography may or may not be indicated.

Note: The term physician does not refer to one who administers physics (cathartics); rather, it is derived from the Greek word physikos, meaning natural; originally, one who treats with natural methods.

Indications

An enema cleanses the colon of debris causing putrefaction, fermentation, or possibly impaction. It can foster peristalsis; stimulate intestinal secretions; diminish absorption of toxins; relax intestinal spasms; relieve excessive flatus; tone intestinal musculature, cleanse acquired or developmental irregularities and/or diverticuli; and stretch and help free strictures, adhesions, and fibrotic invasions. As a by-product of many of these features, it can relieve abdominal pain and enhance an inhibited postdigestion elimination process in many cases.

A literature search reveals that saline enemas are used for such diverse disorders as laryngitis, jaundice, acne, and peptic ulcers. Very warm (not hot) enemas are used to relieve asthma attacks, functional anuria, and nocturnal enuresis. Saline enemas with water at 75°--80°F are often suggested during fasts and for gallbladder disorders. Cool enemas have been used for centuries to reduce fever. Garlic water enemas (a few crushed buds steeped in a quart of water) are reportedly helpful in amoebic dysentery and mononucleosis. The October 3, 1980, edition of the JAMA reported that coffee enemas, in particular, have become very popular throughout the nation in the treatment of chronic degenerative diseases.

Nutrient enemas may be of value when ingestion is halted short-term for the ambulatory patient, but they are a poor substitute for intravenous feeding for the incapacitated.


Contraindications

Frequent use of enemas is not without a certain degree of danger. Prolonged use may result in such bowel disturbances as inflammatory changes, hemorrhage, and ulcerations. Pressure ruptures have been reported. Caution is always advised.

Contraindications include severe cardiovascular or other debilitating disease; abdominal arteriosclerosis, aneurysm, phlebitis, thrombosis, or whenever there is a tendency or predisposition to hemorrhage; overt intestinal, peritoneal, colonic, rectal, or anal inflammations; and degenerations characterized by loss of normal mucosal strength with a tendency to perforation. Other common contraindications are severe anemia; exophthalmic goiter; anal disease where the insertion of any apparatus or the application of any intracolon pressure may be harmful such as with severe hemorrhoids or strictures; and malignant gastric, intestinal, colonic, or rectal neoplasias.


General Rules of Application

While methods vary with the type of equipment used and the condition being treated, a few generalizations can be made.

• Insert the lubricated rectal tube gently, increase and decrease pressure and flow slowly, and immediately stop and investigate whenever there is a complaint of discomfort or pain.

• Do not fatigue or traumatize the patient by excessive time or frequency, and do not exhaust gut muscle tonicity, secretions, or bacterial flora by excessive length and/or frequency of treatments.

• Avoid excessive pressure rate of flow and/or volume, and remove the rectal tube gently and carefully.

Enemas, used since the earliest times, are of special value in obtaining relief in acute constipation, as well as in chronic spastic or atonic constipation and various forms of colitis and kindred conditions. Almost any therapeutic procedure may be preceded by a cleansing enema if justified.

Patient Position. The patient should assume the knee-chest position or lay semi-laterally recumbent (Sims' position) on the right side with the head supported by a pillow.

Technique. The method of administration is either through a soft rubber rectal tube or an anal syringe. Allow some fluid to drain into a basin or toilet to remove any air in the tube before it is inserted. The lubricated nozzle should not be inserted more than 5 or 6 inches, and the fluid should be allowed to flow slowly in gentle spurts. The container should not be held more than 12--18 inches above the anal orifice, and not more than 3 pints of fluid should be used with adults even if more can be tolerated.

If cramping occurs, stop the flow and resume slowly after the discomfort ceases. Discontinue when patient tolerance is reached. Cramps are usually the result of too rapid flow or a solution that is too cool.


Common Formulas

The types of solutions most frequently used consist of ordinary tap water, (warm or cool), a normal saline solution, or water containing a small amount of glycerin, turpentine, magnesium sulphate (Epsom salts), peroxide of hydrogen, mineral or vegetable oil, milk and molasses, bicarbonate of soda, bismuth subcarbonate, and many other combinations, depending on the disorder involved and the goal to be achieved. Soap suds enemas should be avoided because they tend to be harmful to the delicate membrane lining of the colon and rectum (Postgraduate Medicine, Vol 83).

      Cleansing Enemas

• Glycerine - 15 cc Tepid water - 1--3 pints, to tolerance

• Salt - 1 tablespoon Water - 1--3 pints, to tolerance

      Fecal Impaction

An intestinal lavage is highly valuable in cases of uncomplicated impaction. When any accumulation occurs in the rectum, enemas should be given in smaller quantities, 1--6 ounces. This may be administered through a fountain syringe or, if oil is used, through a piston syringe. In the type of constipation in which hardened fecal masses collect and stick to the inner surface of the colon and manifest by dyschezia, lavage encourages the large intestine to resume its normal tone.

The following formulas are used to advantage (2 or 3 times in an 8-day period if necessary) in cases of uncomplicated adult fecal impaction:

• Epsom salts - 30 gm
  Glycerin - 30 cc
  Turpentine - 15 cc
  Tepid water - 1--3 pints, to tolerance

• Turpentine - 60 cc
  Castor oil - 60 cc
  Starch - 50 gm
  Tepid water - 1--3 pints, to tolerance

      Detoxification

Strongly brewed tepid coffee has been found useful in detoxifying the colon. Use twice the first week and then once a week for 3--5 weeks, thereafter once a month for 5 months. A quantity is used to patient tolerance. The formula for adult application is as follows:

• Olive or peanut oil - 20 cc

• Strongly brewed tepid coffee - 1--3 pints, to tolerance

If only one therapy were allowed in the treatment of athletic and recreational injuries, most clinicians would choose cryotherapy --the therapeutic application of cold. This does not imply that cold is only beneficial for these injuries.

Physiologic Effects of Cold

      Local Consequences

• Vasoconstriction, thus causing a decrease in secretions and/or exudation; edema reduction.

• Decreased capillary blood pressure followed in 5--8 minutes by increased pressure and slowed pulse.

• Decreased nerve metabolism.

• Reflex vasoconstriction of internal organs.

• Decreased perspiration, glandular activity, and muscle metabolism.

• Increased muscular tone.

• Anesthetic to nervous system. Lessening of pain and associated muscle spasm by counterirritation.

      General Consequences

• Decreased muscle fatigue.

• Increased respiration.

• Increased heart rate.

• Increased leucocytosis.

Note: The above effects are primarily the result of short periods of local cold. After 3--5 minutes, the vasoconstrictive effects are fatigued, and the opposite effects on the cardiovascular system thereby develop. For example, local vasodilation, reflex internal vasodilation, deceased heart rate and respiration, and increased blood pressure. However, after this phase, vasoconstriction returns.

      Indications for Local Cooling

The primary use is in such acute trauma as burns, strains, and sprains. After injury, cold helps to limit the extravasation of blood into tissue spaces and thereby helps to prevent edema. Cooling may be used in acute bursitis, arthritis, chondromalacia, tendinitis, myositis, splinting, etc.

      Contraindications to Local Cooling

Whether local or general, cold should not be applied to weakened individuals such as in old age, infancy, cachexia, advanced cardiovascular disease, high blood pressure, circulation problems such as Raynaud's phenomenon, etc. Avoid use if the patient has had frostbite of the involved area, and do not apply when the patient is cold or shivering.

      General Rules for Applying Cold

Avoid prolonged application and, therefore, possible frost bite. Place a warm moist cloth between the cold pack and the skin -- never use direct contact. See Figure 10.11.

Apply heat to other parts of the body simultaneously to prevent generalized chilling, particularly over the heart and head where excess vasoconstriction may be contraindicated. Warm the patient after treatment if chilling occurs.

      Plastic Bag Pack

The local application of a bag of ice chips wrapped in a towel and placed on the patient from 5 to 20 minutes may be helpful. The plastic should be strong enough to prevent easy tearing; assure that there are no holes that would result in leakage.

Before application, explain to the patient what is to be done and why. Check perception of skin sensation and for hypersensitivity to cold. Rather than wrapping the bag in a towel, many practitioners recommend that a lukewarm towel be placed on the part to be treated, the plastic bag ice pack applied, then a dry towel covering the bag to reduce warming.

      Vapor Coolant Sprays

When using either a fluori-methane or ethyl chloride spray, be sure to use a pressurized container fitted with a fine-spray nozzle. Explain the procedure to the patient, check skin sensations, and use extreme caution in cases of diminished sensation. Take precautions to protect both patient's eyes and your eyes from vapors, and to minimize inhalation of vapors.

Expose only the area to be treated; protect surrounding areas. Invert the container and hold it about 2--2-1/2 feet from the area to be treated so the stream strikes the skin at the site of pain. In terminating the treatment, wipe the skin with a towel and check the patient's skin.

In applying the spray, depress the outlet release and sweep outward from the painful area. Do not sweep back and forth. Continue the outward sweeping until the area has been covered with spray, no more than twice. However, in applying ethyl chloride spray, depress the outlet release and sweep back and forth over the area to be treated. The speed should be about 4 inches per second. Two or three sweeps should result in a white frosting effect appearing on the skin. Stop spraying, remove the frost gently with a towel, and continue to spray for another two to three series or until symptoms are relieved.

Note that ethyl chloride is very flammable. Never use near heat or allow smoking in the same room.


Ice Massage

This technique is often helpful in acute strains. It is done by simply rubbing an ice cube or ice frozen in a plastic cup over the acute area. The ice is moved about 5 inches per second. The doctor may wrap an ice cube in a towel as an alternative to protect his or her hand, leaving an exposed part of the cube to contact the patient's skin.

Editor's Note:   My personal favorite low tech tool is the humble Dixie Cup.   Fill it half way with water and freeze.   Tear off the bottom, and peel away the the bottom half-inch, twist the top into a convenient handle, and away you go!   Like ultrasound, the best technique is to draw small circles, with the next circle overlapping one-half of the previous circle, and moving forwards about 1 inch per second.   This constant, forward motion helps prevent frostbite damage.

Before application, explain the procedure to the patient and what sensations will be felt. Check skin sensation; use caution if diminished. Check for hypersensitivity to cold, and avoid use if the part has a history of frostbite. Use either a circular or back-and-forth movement. Do not massage for more than 5 minutes.

If treating a large area, divide it into areas no more than 6 inches in diameter. Ice massage each area separately until skin anesthesia is noted, but no longer than 5 minutes. Pressure should be firm, but not heavy. Avoid massaging over bony prominences, especially the elbow. Check patient's skin after treatment.

The stages of sensation experienced by the patient should be noted as the treatment progresses. The first response is that of cold, then a burning, next an aching pain after about 3 minutes, then follows a numbness or anesthesia with a relief of pain. The area may remain crimson for 10 minutes following massage. The patient usually notes less pain and can move the affected area more easily.


Extremity Immersion Cold Bath

Immersion of an extremity in water at a temperature between 55° and 65°F from a few seconds to 15 minutes may be used to reduce local swelling and muscle spasms. Some patients cannot tolerate such immersion, and the duration of treatment must be limited to patient tolerance.

Before application, explain the procedure to the patient. Maintain correct water temperature by adding additional cold water or ice. Stop treatment immediately if spasticity increases.

      Cryokinetics

The word cryokinetics is a coined term for a treatment concept in which cooling of the part is followed by active exercise. Cooling, accomplished by either immersion or ice massage, to a state of mild analgesia is followed by muscle activity. This method is effective in acute extremity strains.

      Combined Local Cooling and Remote Heating

This is a method to reduce muscle spasm or spasticity. Remote heating maintains the core temperature and thus inhibits shivering and the central augmentation of muscles spindle activity. Some degree of CNS sedation occurs.

      Cold Wet Packs

Cold wet packs can be made from cloth, gauze, towels, or woolen blankets wrung out in cold water. Small packs are applied as would be a compress. They are used locally to reduce swelling after sprains or contusions by producing local vasoconstriction and reducing bleeding into injured tissues and to decrease swelling and pain in acute bursitis and fibrositis.


Contrast Baths

Sudden alternate immersions of the extremities in first hot and then cold water greatly stimulates peripheral circulation in the limbs. Two water containers are used, each large enough to accommodate the part of the body affected. One is filled with hot water from 95° to 105°F, and the other is filled with cold water from 55° to 65°F. The first and final immersions are always in the hot water.

Timing routines may vary, but they should be exact. For example:

• 3 minutes in hot, 1 minute in cold; alternate for 31 minutes.

• 4 minutes in hot, 1 minute in cold; alternate for 28 minutes.

• 5 minutes in hot, 2 minutes in cold; alternate for 33 minutes.

Thermotherapy is another common form of physiotherapeutic application. See Table 10.4. Heat may be used effectively in subacute and chronic traumatic conditions but not during the acute stage. It is frequently used in strains, sprains, stiff joints, muscle spasms, rheumatoid and other arthritic conditions, bursitis, and chronic backache, and before massage, exercise, and chiropractic adjustments.

Local heating, for example, will increase the temperature, metabolic activity, and circulation through the area. The increased blood flow delivers nutrition to the tissues and removes the waste products of tissue metabolism at a more rapid rate. This is important for efficient tissue healing. Heat, when indicated, will relax muscle spasm and reduce associated pain.

Caution must be used with patients that have impaired circulation, impaired sensation for temperature or pain, or a poor tolerance to heat. Heat should not be used in acute traumatic injury because swelling will increase. Heat should not be used in the early stages of infection because the process will be encouraged to spread.

     1. Thermotherapy                     5. Low frequency currents
        a. Hot moist packs                   a. Direct current, eg
        b. Infrared                              low voltage galvanism
        c. Heating pads                      b. High voltage current
        d. Ultraviolet                       c. Alternating current
        e. Paraffin                             (1) Sine wave
        f. Fluidotherapy                        (2) Faradic current
                                                    (a) TENS
     2. Cryotherapy                                 (b) Muscle stimulators
        a. Ice
        b. Cold packs                     6. Hydrotherapy
        c. Vapocoolant sprays
        d. Clay compresses                7. Exercise therapy
        e. Cold therapy
        f. Cold immersions                8. Rehabilitative therapy
        g. Cryokinetics
        h. Alternating heat and cold      9. Meridian therapy
                                             a. Pressure techniques
     3. Diathermy (high frequency)           b. Acupuncture
        a. Short wave                        c. Auriculotherapy
           (1) Induction or coil field       d. Ryodoraku
           (2) Condenser field
        b. Microwave                     10. Vibratory therapy
        c. Ultrasound
                                         11. Traction and Stretching
     4. Interferential current 
        (medium frequency)               12. Bracing and Supports

Physiologic Effects of Local Heat

      Local Consequences

• Dilation of blood and lymphatic vessels.

• Increases phagocytosis and cutaneous blood flow.

• Increases perspiration and suppurative process.

• Relieves spasm and associated pain.

• Sedates nervous system; analgesic.

• RefIexly dilates blood and lymphatic vessels in deep and remote tissues, depending on site.

      General Consequences

• Increases perspiration.

• Increases circulation and heart rate.

• Lowers blood pressure.

• Increases respiration.

• Slight rise in alkalinity.

• Increases urine formation with loss of water, salts, urea, and nitrogenous substances.

Contraindications to Local Heat

Adverse signals include acute inflammatory processes, particularly when accompanied by fever, suppuration, and/or edema; conditions in which there is a tendency to hemorrhage; malignant tumors; over a gravid uterus or encapsulated swellings where vasodilation may cause dispersion and/or rupture; where there is a deficiency of thermal nerve reaction; acute tuberculosis; diabetic gangrene; and the very young or elderly.

      General Rules of Application for Local Heat

Any therapy is governed by basic criteria if it is to be used effectively with wisdom. Physical therapy is no exception. The basic rules regarding the use of physical therapy in general are shown in Table 10.5.

In using heat, test any heated object before application to judge temperature. When heat is increased such as with an infrared lamp, discontinue if the patient complains of immoderate warmth. In fomentations or other direct contact heat, make certain the skin is dry; enclosed moisture may become steam and cause burning. With direct contact heat, pad bony prominences and/or other sensitive areas. In patients liable to cerebral congestion and in cases of fever, apply cold compress to the head. Never apply heat for a length of time that prolonged tissue congestion is created.

1. Be sure you know what you are confronted with (ie, symptoms, patient status and environment, pathophysiology involved).

2. Choose the modality or regimen best suited for the presenting complaint.

3. Guard against insufficient treatment. Intervals of long duration between treatment will result in failure. Generally speaking, treatments scheduled once a week are of little value.

4. Guard against excessive treatment. Do not "overtreat."

5. Explain to the patient what to expect; eg, long-term results, temporary results, the anticipated number of treatments necessary, etc).

      Infrared or Radiant Heat Radiation

A 250-watt heat lamp may be used at a distance of from 15 to 24 inches, depending on the tolerance of the patient. See Figure 10.12. The duration of treatment may range from 15 to 45 minutes, but just 5 minutes of infrared may be adequate to relax taut perispinal muscles before a chiropractic adjustment.

Before application, explain the procedure to the patient, give safety instructions, and define what sensations the patient may experience. As with any modality, select patient position pursuant to patient comfort and relaxation, body mechanics, condition requirements, and equipment placement. Clean the skin, and check skin sensation. Cover all recent scar tissue, abrasions, or new skin with thick wet pads of gauze or cotton held in place with tape. Remove all metal and jewelry from the patient that might be subject to radiation. The lamp reflector should be positioned at a right angle to the part treated. If treating the face, cover the eyes with damp cotton or gauze pads. Contact lenses should be removed. Following treatment, check the skin of the area heated.


Hydrocollator Packs

Ultrasound is a vibration at a frequency above that which can be heard by the human ear. The frequencies used for therapy are about one million cycles per second. This high-frequency alternating current produces mechanical vibration of a crystal in the transducer or treatment head that can be directed into tissues to penetrate to a depth of 4 cm or more. The ultrasonic vibration passing into tissue causes internal friction resulting in the production of deep heat. See Figure 10.18.

Physiologic Effects

In general, ultrasound produces a deep heating of the tissue, increases blood flow, removes exudates, relaxes muscle spasm, and produces analgesia for the relief of pain.

Mechanical Effects.   Increases molecular movement or the so-called "micromassage" effect, disperses fluids, and increases membrane permeability.

Thermal Effects.   Hyperemia, thus increases alkalosis and leucocytosis, and increases glandular activity.

Chemical Effects.   Increases gaseous exchange. Thixotropic gels may be liquified. It also increases ionization through membranes and enhances chemical oxidation.

Neural Effects.   These may occur because of the preceding effects on the nervous system or specific neurons and are best understood with a review of the pathogenesis of the specific disease.

Mechanical, chemical, thermal, pathogenic, and psychic irritations cause the nervous system to respond through an alteration in its normal physiologic homeostasis. These responses result in the signs, symptoms, and morphologic characteristics of a given disease. These neurotrophic responses may also be sensitized and result in an aberration of normal neuron sensitivity with the subsequent maintenance, facilitation, and/or production of disease processes occurring as the nervous system responds to the average extrinsic and intrinsic stresses of normal life processes.

Ultrasound affects the nervous system in such a way to reduce its conductivity and, therefore, tends to abort the maintenance of a neural pattern of disease. It is because of this latter effect that any application of ultrasound should be applied to several areas because they parallel the pathogenic process and may include:

• The local area of disease phenomenon, to provide symptomatic relief, and to dissipate the pathologic processes before an intrinsic source of neuropathy can be created.

• Known areas of referred or reflex neurologic phenomenon and to abort the presence or formations on intrinsic areas of neuropathy.

• Over the synaptic areas of the specific neuromere where "sensitization" of the neurotrophic process may have or has occurred. Treatment of a nerve root or other neurologic area should be done at low intensity for approximately one-half the duration of that for the primary site.

Contraindications

Contraindications include advanced heart disease, application over the stellate ganglion, vascular affections (eg, thrombosis, hemorrhage, etc), malignancies and/or precancerous lesions, tumors, gonads, the pregnant uterus, pulmonary tuberculosis, the eye, areas of sensory paralysis or impairment, over epiphyses, over spinous process or directly over any bony prominence, and with infections where dispersing and/or expansion is undesirable. Overuse of ultrasound can decalcify bone.

      Intensity

The intensity of dosages from 0.5 to 2.5 watts per square centimeter is considered safe, depending on the area being treated and the patient's reaction. The patient should feel no pain or significant discomfort, A sense of burning, tingling, or pain indicates that the treatment dosage is too intense. Ultrasound over the spinal nerve roots should always be at low intensity (0.5 watts per square centimeter).

      Time

Time usually varies from 4 to 5 minutes in acute conditions and from 8 to 10 minutes in treating chronic conditions. Whenever the patient complains of pain, it indicates that the sound head is not moved fast enough or that the intensity is set too high. If ultrasound is preceded by deep heat such as with diathermy, from one-half to two-thirds of the usual dosage is recommended.

      Application Considerations

Before therapy, explain procedure to the patient, explain sensations to be experienced, and check the area to be treated and skin sensitivity. Never treat any part of any patient who has an external or implanted pacemaker.

The technique of application with the common movable sound head consists of:

• Application of a coupling medium:
  (1) mineral or a similar oil is best for even surfaces;
  (2) a water bath or condom filled with water (free of air bubbles) is best for irregular surfaces.

• Setting of machine for proper intensity and time.

• Slow circular movement over a prescribed area. The usual recommendation is an area of approximately 10 square inches, which should be covered in about 30 seconds (slightly faster if higher wattage is used). With a water bath, a distance of from 1/2 to 1 inch is advised. Intensity and time should vary with the condition.

      The Coupling Medium

A coupling medium must be used between the applicator (sound head) and the skin surface. Mineral oil, Aquasonic 100, or an ultrasound gel should be used.

Maintain movement of the sound head at all times to prevent overheating. Hold the sound head perpendicular to the surface being treated, and do not have the sound head tilted because this would cause a loss of sonic therapy to the part.

      Oil Coupling Agent

Acute conditions:   0.5 to 1.0 for thin tissues; 1.0 to 1.5 for thick tissues.

Chronic conditions:   1.0 to 1.5 for thin tissues and 1.5 to 2.0 for thick tissues.

Sinusoidal current is an alternating current of low voltage and milliamperage. Its low frequency ranges from 50 to 1,000 oscillations per second. The current increases gradually through the zero point until it reaches a negative level equal to the positive rise. From this negative point, it returns to zero again to complete one cycle. Thus, each cycle contains an equal amount of positive and negative electricity and is therefore neutral --having no polarity or chemical effect on tissue as galvanic current would.

Sinusoidal current produces muscle contraction, thus it can be used in the stimulation of weak and paralyzed muscles. To avoid injury, never stimulate a muscle beyond its limit of fatigue as a fatiguing muscle will show a slowing response. Atrophied and degenerated muscles may fatigue in two contractions.

The main action of sinusoidal current is muscle contraction, thus making it useful in the mechanical exercise of weakened muscles. It also can increase circulation, strength, nutrition, and metabolism of muscle. The muscle contraction produced has a mechanical massage effect and helps in the movement of venous blood, lymph, and exudates from tissue --all which are important in restoring a healthy state of the tissues involved.

Many aspects of physiotherapy can be helpful in the treatment of the senior citizen. Such therapy may help in improving circulation and drainage of the tissue, which is so important in the delivery of nutrition to tissues and in carrying away the waste products of cell metabolism. These attributes help tissue healing, relieve pain and muscle spasm, and relax the patient --thereby enhancing chiropractic care of the patient.

Physiologic Effects

All contractile currents have as their primary effect the exercising, toning, and massaging of muscle tissue. The following physiologic responses are noted from muscle stimulation:

• Decongestion and detoxification, hyperemia and hyperlymphemia, and stretching of fibrotic tissues and/or adhesions.

• Sinusoidal current stimulates all tissue cells within the bipolar path. Recurrent hydrogen and hydroxyl concentration takes place at every interruption that is simultaneous with the neuromuscular response. In this context, it has some nutritional effects.

Individual current selections have the following pertinent characteristics:

• Slow sinusoidal may be too slow to cause significant skeletal muscle contractions. It is more stimulating to smooth muscle.

• Moderate surging sinusoidal causes gradual contraction and relaxation of skeletal muscle.

• Rapid or pulsating sinusoidal is particularly advantageous where there is a partial reaction of degeneration. This is especially applicable for treating lower motor neuron lesions.

• Sustained or constant sinusoidal maintains muscle contraction and if continued may fatigue the reflex and induce muscle relaxation. Thus, it is of primary benefit in reducing spasm and associated pain so often seen with low-back syndromes.

Contraindications

Never apply an electric current through the heart or with any technique that brings a considerable amount of current through the chest. Do not stimulate any part of any patient who has a pacemaker. Do not stimulate near a recent or nonunion fracture site, over recent scar tissue or new skin, or over abrasions. Other contraindications include:

• Conditions where hemorrhaging might occur.

• Any disease state where muscle contractions may secondarily (and disadvantageously) disperse or release a localized pathologic process (eg, near an abscess).

• A condition where muscle contractions may disrupt a healing process (eg, the consolidation of a hematoma).

Galvanic current is a direct current of low voltage, usually not exceeding 100 volts and of low amperage usually not greater than 50 milliamperes. Constant galvanic does not cause muscle contraction; its action is based on the polarity of the current. This unidirectional current consists of a stream of ions that flow at low tension in one direction, giving this current distinct polarity.

Galvanic current has a chemical action because negative ions travel toward the positive pole and positive ions travel to the negative pole. The carrying of these ions or chemicals into or through the tissues is called iontophoresis or ion transfer. It is this process that produces the galvanic action of the current in the body tissues.

It's important that the correct electrode is applied on the involved area to receive the desired effect. The plate must be properly covered and well moistened for proper contact.

• The anode (positive pole) relieves pain and swelling and is more sedative. It attracts acids and repels bases. It is a vasoconstrictor and relieves pain in acute conditions because it reduces congestion.

• The cathode (negative pole) is more stimulating and irritating. It is used more for chronic conditions. It attracts bases, repeIs acids, dilates blood vesseIs, relaxes tissues, and softens tissues. It relieves pain in chronic conditions because it tends to soften tissue and increases circulation.

Dosage

When properly applied, galvanic current can bring about a rearrangement of ions in the tissues and help remove waste products, which often produce a sedative effect that relieves associated pain. The dosage of the current should never be set beyond the patient's comfortable tolerance. Normal tolerance is about 1/2 to 1 milliampere per square inch of the smallest electrode surface used. A duration from 15 to 30 minutes may be used depending on the condition of the patient.

      Physiologic Effects

The clinical application of direct and low-frequency currents depends entirely on an understanding of the simple physioIogic facts on which this application is based. This is the only current that is applied according to polarity. To avoid the excessive stimulating effects, the current is started and brought to its maximum slowly.

      Polar Effects

Galvanic current produces both the effects of heat and of specific chemical effects of polarity. Following is a list of actions at each pole:

      Positive Pole

• Attracts acids and repels bases.

• Contracts and hardens tissues.

• Diminishes congestion by vasoconstriction.

• Relieves pain in acute conditions by reducing congestion.

• Decreases nerve sensitivity.

      Negative Pole

• Attracts bases and repels acids.

• Dilates and softens tissues.

• Increases congestion by vasodilation.

• Relieves pain in chronic conditions by softening tissues and increasing circulatory flow.

• Increases nerve sensitivity at low intensity and decreases sensitivity at high intensities.

Through galvanism, ions are moved into the body because of their electric charge. Each ion carries into the body a certain amount of charge. Keep the following points in mind:

• The amount of electricity applied determines the number of ions that move into the body. Thus, the number of ions transferred into the body depends mainly on the amount of current used and not on the concentration of the solution. A solution of 2% is generally used, but there is no advantage in using a solution greater than 1%.

• The chemicals are pIaced on the pole that repels them. They are driven into the tissue toward the pole that attracts the chemical. Solutions used for such ion transfer should not contain impurities.

If a chemical is to be ionized, an absorbent material saturated with the solution to be ionized is placed on the area to be treated. A thin sheet or strip of metal or a pad is used to make electrical contact between the patient and the absorbent material acting as the electrode. In certain cases, the part to be treated is immersed in a solution of the material to be ionized.

Cotton and cellu-cotton are preferred for covering the electrodes. Asbestos paper, cellu-cotton, felt, or gauze are used when the absorbent material is the active electrode. Electrode contact must be even because unequal pressure will produce a concentration of current at pressure points.


Substances Commonly Used

      Positive Pole

• 2% Magnesium sulphate

• 2% Copper sulphate

• 2 Zinc sulphate

• 2% Calcium chloride

      Negative Pole

• 2% Sodium chloride

• 2% Potassium iodine

The major effects of ultraviolet radiation are to produce local erythema, pigmentation, counterirritation, and metabolic and bactericidal effects.

Minimal Erythema Dose

Human skin sensitivity varies considerably because of individual variation in the thickness of the stratum corneum and the amount of superficial pigmentation. The minimal erythema dose (MED) is that measure of uItraviolet radiation that will produce minimal erythema in the average Caucasian skin within a few hours after exposure.

The MED for the high-pressure mercury arc in a quartz burner is about 15 seconds at a distance of 30 inches. See Figure 10.20. It is usually determined by observation on exposure to the volar aspect of the forearm. It's necessary to determine the MED two or three times a year as both patient sensitivity and equipment output may change with age.

The MED is an average quantity, and the dosage for an individual patient in fractions or multiples of the MED should be prescribed with respect to probable sensitivity in relationship to average sensitivity. It is usually possible to increase progressively the number of MED's used in each treatment of a patient as the stratum corneum thickens and sensitivity to the radiation decreases. Pigmentation decreases sensitivity; thus, brunettes are less sensitive and reddish-blondes are more sensitive than blondes.


Physiologic Effects

      Local Erythema Dose

First degree:   slight reddening that usually appears in a few hours and disappears in 1 or 2 days.

Second degree:   plainly visible reddening, "mild sunburn," with slight desquamation and pigmentation.

Third degree:   intense reddening, slight edema, marked desquamation and pigmentation. This is the usual counterirritant dose.

Fourth degree:   intense reddening, edema, exudation, painful blistering, and pigmentation. This is the usual destructive and/or bactericidal dose.

      Pigmentation and Metabolic Effects

• Activates skin sterols to vitamin D, thus aids in calcium absorption and calcium-phosphorus metabolism (antirachitic effect).

• Increases red blood cells and reticulocytes.

• Improves tone, elasticity, and secretory functions of the skin.

• Accelerates general physiologic activity and raises basal metabolism rate.

      Bactericidal Effects

Ultraviolet rays have a lethal effect on some bacteria, viruses, fungi, and other microorganisms when exposed to the proper spectral band.

      Counterirritation Effects

There are two major counterirritation effects:

(1) by absorption of destroyed albumin in the irradiated "area";
(2) by reflex neurologic stimulation of the irradiated "zone."

It was just a few years ago that the use of electromyography was restricted to within research and the larger institutions. Today, however, such electrodiagnosis is increasing in popularity within private chiropractic practice, especially within those offices using recent kinesiologic findings and techniques.

The Neurophysiology Involved

The activation and display of eIectric activity in the motor unit constitute the basis for electrodiagnostic techniques. The motor unit (anterior horn cell, its axon and terminal branchings, and innervated muscle fibers) is the physiologic unit of the nervous system. This unit is governed by the all-or-none principle.

Activation is comprised of an impulse passing from the anterior-horn cell through the axon and its twigs to the myoneural junctions. At the junctions, a chemical mediator is liberated that initiates an excitation wave along each muscle fiber, with contraction occurring about 1 millisecond after the action potential. The electrical activity displayed by an electromyograph represents the summated muscle-fiber action resulting from the motor-unit action potential.

Each motor neuron has a threshold of stimulation, and impulse velocity varies according to the axon's diameter and presence of a myelin sheath. The number of muscle fibers per unit varies from several hundred in a large limb muscle to only a few in an extrinsic eye muscle.

A muscle fiber's action potential changes from 100 millivolts positive to 15 millivolts negative outside the cell membrane, with recovery to the resting state immediately following the excitation wave. Despite intensity, a stimulus will not excite the cell during the absolute refractory period, which is the first 0.2 millisecond of the total delay period prior to recovery.

Electric disturbances can be recorded, amplified, and displayed by an electromyograph if an exploring electrode is placed in the vicinity of a cell membrane undergoing a poIarity change. It is the electric characteristics of both the tissues and the equipment that influence the amplitude, duration, and shape of the activity dispIayed.

      Instrumentation

Regardless of manufacturer, most nerve stimulation and electromyography equipment include electrodes, preamplifier and loudspeaker, an oscilloscope, a physiologic stimulator, and a magnetic tape recorder and camera for data storage.

Electrodes vary from surface type to monopolar, coaxial, and bipolar electrodes. Selection depends on technique and area of interest.

      Areas of Application

Diagnostic proficiency in EMG analysis is the result of study and experience based on a thorough knowledge of the physiology and pathology involved. There are several excellent texts on electrodiagnosis that may be used for reference.

Before application, a thorough knowledge of a normal electromyogram must be at hand. For example:

• The muscle at rest

• Insertional activity

• Characteristics of maximal and minimal muscle contraction

• Characteristics of normal nerve stimulation and reflexes

• Velocity changes effected by age and changes in temperature.

An adequate knowledge of the pathophysiology involved must also be available. Basically, the three ways a lower motor neuron responds to an insult are:

(1) by wallerian degeneration,
(2) neurapraxia, and
(3) axonstenosis or axonocachexia.

Physiologic Effects of Acupuncture

The Far Eastern philosophy and basic principle of the art and science of healing is the art of prevention. The essential art is therefore that of foreseeing and preventing rather than treating sickness after it manifests in painful or distressing body and mental symptoms.

In the West, the average practitioner's first contact with the patient does not generally occur until after symptoms have made their appearance. Thus, the Western healer's first task will, of necessity, be that of restoring a sick person to a state of health, rather than maintaining the good health of a healthy person.

Meridian Therapy (eg, acupuncture, moxibustion) is based on the ancient Chinese philosophical concept that man is a small universe and a replica of the larger one; that every function of body and mind is governed by the same natural laws of positive and negative magnetic attraction and controlled by the same vital forces of energy that keep the universe functioning.

The Chinese of ancient times were remarkably advanced in their thinking. Centuries before the West had words to name them, atoms, neutrons, protons, electrons, and their actions were a part of the Chinese concept of the universe. The Chinese somehow conceived, with no means of proof of the orbital arrangement of atoms within matter, matter within earth, planets within the solar system, galaxies within the universe, and all as one vast indivisible entity. They believe that all things are linked together in a harmoniously balanced chain. Catastrophe, war, chaos, illness, etc, are said to result from a violation of this harmony. Acupuncture is looked to as the restoration of physiologic harmony (viz, systemic functional balance, homeostasis).

Complications of and Contraindications to Acupuncture

Complications of acupuncture arise mainly from the negligent use of the needle. Therefore, acupuncture without the needle such as electroacutherapy or other nonneedling techniques may eliminate virtually all common complications of acupuncture. The more serious forms of complication associated with the use of the needle are damage to organs such as pneumothorax (puncture of the lung), paralysis (damage to nerves), hematoma (injury to an artery), and peritonitis. Such complications, however, are rare. Less severe forms of complication include ecchymoses, microhemorrhages, physical discomfort, and areas of analgesia. First- or second-degree burns to the skin are the most common complication if one uses moxibustion. Some other thoughts to keep in mind are:

• Precautions should be taken for patients with blood clotting disorders.

• The bladder should be emptied before treatment on the lower abdomen.

• Nonaseptic handling of the needles may lead to infections such as hepatitis.

• Infrequently, fear of the needles or hypersensitivity may lead to a type of fainting called "needIeshock" or "needle reaction." This usually happens during the first treatment if it does occur. Hypotension frequently accompanies the reaction. In this event, remove the needles and place the patient flat with legs raised for 5--10 minutes. After a short rest, treatment may be resumed so that the patient does not acquire a fear of acupuncture.

• Occasionally a point will bleed after removal of the needle. Sterile gauze should be applied with pressure for a few minutes,

• Do not use any point on the abdomen of a pregnant woman. Several acupuncture points, including those on the abdomen, can induce labor or initiate abortion.

• One also should beware the masking of symptoms because acupuncture can effectively suppress pain. Accurate diagnosis of the patient's condition is essential.

• Contraindications include attempting to balance body energy too quickly in the aged or feeble.

• Electrical stimulation may affect the operation of a cardiac pacemaker. Therefore, the use of an electric acupuncture stimulator is contraindicated in patients with pacemakers. Adequate precautionary measures must also be taken before using electric stimulation on patients with cardiac arrythmia or other known significant cardiac conditions.

      The Rationale

As with chiropractic, acupuncture can be described as external treatment of internal disorders. The Chinese developed the theory and located the junction points on meridians of energy transmission to and from vital organs of the body thousands of years ago.

Acupuncture theory is clouded in mysticism. According to Chinese philosophy, for example, it is not suitable to perform a treatment of acupuncture during a stormy day (especially in thunderstorms), due to an alteration of "Chi" (life energy). It is classically not used on cranial points of infants; over tumors; in proximity to radio installations or power-generating stations; immediately following a meal; or during high winds (because vital energy is of an electrical nature). Patients under the influence of alcohol should not be treated.

It is also taught that a practitioner not in good health should not treat a patient: the practitioner's heartbeat, pulse rate, and respiration rate should represent the norm. According to the historic teaching, the disturbed vital energy in the practitioner could react unpredictably on the patient and either make the treatment ineffective or detrimentally aggravate the patient's disturbances.

These comments regarding acupuncture represent but a brief overview on the subject as based on Eastern belief. In the Western World, research to support the physiologic effects of acupuncture has increased rapidly since 1965. Although these concepts appear strange to the Western mind, there is no doubt that Chinese theory and empiricism applied successfully for thousands of years has formed a foundation for scientific inquiry.

      The Energy System

Acupuncture is a system of healing based on the ability of the body to heal when its cyclic energy system is intact and balanced. As described above, the practice of acupuncture is based on theories of energy flow in the body. This energy, Chi, runs in a continuous line, traversing the body on the upper and lower extremities as well as the front and back and sides of the torso.

According to the Chinese, there is within the human body a force called "Chi" that, when present, imparts life to the body and directs its function. Its definition closely resembles the "innate intelligence" described by Dr. D. D. Palmer. When it is withdrawn, death results. Chi is thought of as life force or life energy that moves and functions through channels or meridians connecting to vital organs and to each other. The anatomical areas on which the energy flows are called meridians. In the classic teaching, interference to this energy resuIts from such external forces as wind, cold, heat, germs, poisons, trauma; or from such internal forces as emotional upset, stress, or organic malfunction.

This meridian network is best understood by the Western mind to be physiologic rather than anatomical. Yet, this is not unique: the referred pain traced from a trigger point focus usually follows a course that does not follow anatomical routes. To the Oriental however, the Chi pathways constitute a definite anatomical system in the body, just as are the nervous, circulatory, lymphatic, and other systems of the body.

One "plasmic" effect of the cyclic "energy system" referred to in acupuncture is visible with Kirlian photography and detectible with various instruments that measure electrical resistance on the skin. It is not visible or measurable on autopsy at present, either because we do not have the instruments to detect its anatomical containers or this energy has a unique method of having its trajectory guided.

      Basic Concepts of Application

A meridian may be treated with needles, electric stimulus, herbs, chemicals, heat, cold, spinaI manipulation, color, sound, ultrasound, hypnosis, medication, exercise, breathing regimens, massage, bleeding, and other means. Meridians are described as narrow paths located variably about a half inch beneath the skin. They project twig-like shoots to the skin level along its course. These shoots, or vertical extensions of the meridians, are numbered and used as the focal point for inserting needles, applying moxa, stimulating with electricity or massaging, depending on the effect desired.

      Terminology

All meridians are connected and continuous but are named and numbered differently when the meridian changes its course. This occurs, with a few exceptions, at the distal phalange of specific digits of the upper and lower extremities.

If the meridian ends at a particular digit, its highest number will be at the root of the nail of that digit. Another meridian then starts close to the one just ended and has #1 as its designation and appears on the same extremity. The name of the meridian also changes. This changing of the name and number is for nomenclature purposes only, since the meridians are continuous and connected.

      Obstacles and Stimulants to Energy Flow

The energy flow of Chi can be disengaged by a wound, which, if located in a position that crosses the course of the meridian and separates the skin, can alter its course. This can be permanent if scar tissue remains after healing and cuts across the course of the meridian. This difficulty can be normalized by an acupuncturist.

The flow of Chi can also be obstructed by loss of a part of the body. Imbalance of the energy system, either through blockage, too much energy, too little energy, or the energy flowing too fast or too slow or in an irregular fashion, produces clinical symptoms. These symptoms are said to reflect the organism reacting to the imbalance: It is having difficuIty adapting to the environment as well as showing symptoms of not having the proper amount of energy necessary for health.

The energy system can become imbalanced by any force that is stronger than the resistant or adaptive forces of the body. Common examples include overeating or starvation, too much or too little exercise, too many wrong habits; eg, not enough sleep, poor nutrition, not enough self expression, etc.

      Analysis and Redirection of Energy

The physiologic effects of acupuncture are linked to the recuperative powers resident in a particular person. For example, if an individual has a blood dyscrasia, the doctor using acupuncture would examine the patient using both modern methods (if known) and traditional methods. This would include general observation, pulse diagnosis, and tongue, eye, and skin analysis. In the process of determining where the imbalance exists, he would find out when the patient first contacted the disorder and at what time of day and year its manifestations were most severe and when it was less clinically evident.

If the examination indicates a liver that is deficient in energy, the acupuncturist might deduce that the liver is involved with the blood dyscrasia. If the liver is found deficient, he would seek where the additional energy is, realizing that the organism has 100% energy supply. If there is a deficiency in one area, there will be an excess of energy in another. This excess is not necessarily in another meridian. There can be two or more organs sharing it. Once located, the energy can then be directed from the organ (system) that has an overabundance either because it is blocked or a stimulus is being directed to it. The objective is to bring the energy from the excessively energized organ to the energy-deficient organ.

There is 100% energy, and each area is to have its necessary share. According to the philosophy, the needs of each area vary with time of day and season. During each season (spring, summer, late summer, fall, and winter), specific organs receive an additional amount of energy for just the length of that season each year. Taking this into account allows the practitioner to derive maximum benefits for the patient by scheduling the major treatments accordingly and guiding the living habits of the individual so they coincide with the body's condition.

The time of day for treatment is also taken into account, based on the same principle except there is a change every two hours when one organ is receiving an additional amount of energy and another organ is operating at a physiologic deficiency. Thus, all organs have a specific time in each 24-hour period in which they will have additional energy and specific times during the same 24 hours when they will be deficient in energy. These rules are considered when attempting to balance the organs. The practitioner must also find the initiating cause of the organic involvement; eg, the drinking of milk causing liver crisis; the eating of pepper causing gastritis.

Physiology normalizes in proportion to the degree of amendable pathology and the degree of recuperation possible. The effect of the acupuncturist's intervention can be monitored by electrical instruments that give a readout on the amount of current flowing along circuit shoots to the skin.

There are many types of such instruments on the market, yet all are essentially the same. They can give an audio signal and/or visual measure (readout) and, usually with the same probe, deliver a measured amount of electricity to the acupoint. This can have the effect of stimulating, retarding, sedating, adding to, or taking away energy contained at the site of a particular meridian. This local focus will have an effect on the entire meridian system because one cannot affect one meridian and not influence them all.

      Major vs Minor Roles in Therapy

Acupuncture has been found an indicated therapy in most conditions of pain and abnormal physiology, though it may not always be the therapy of choice for it may have a relatively minor role in establishing the norm in some cases. For example, if subluxation is interfering with the flow of Chi, a chiropractic adjustment should be administered. Another example of acupuncture having a minor role is with postpoliomyelitis, in which case rehabilitation of a physical and nutritional nature would be the main constituents of the therapeutic plan.

Meridian therapy is also an aid to monitoring normal physiology by recognizing slight deviations before they become rooted. At the first sign of an imbalance in any of the systems of the body, the doctor can give preventive guidance to the patient so he will not have to provide therapy later.

Therapeutic benefits can be derived from the use of finger pressure, a needIe, electrical devices, moxa, a spring-loaded probe, or a nonconductive material used with friction on the acupuncture point. There is a time and place for each technique, and all are effective when applied with judgment and special care. Use of a needle, pressure, and electrical devices are the easiest procedures to apply, and there are established guidelines for their application. The use of moxa, bleeding, or a friction device is also regulated by experience and clinical judgment.


Concluding Remarks

The Executive Board of Governors of the American Chiropractic Association encourages the judicious development of curriculae, research, and clinical procedures of this ancient healing method, and that it be integrated, when appropriate, as an adjunctive and supportive procedure that may complement the chiropractic adjustment. This modality should be used only by the doctor of chiropractic who is qualified by education and clinical experience, and who has been examined and certified by an appropriate accreditation body.

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