CHAPTER 1: THE RATIONALE OF PHYSIOTHERAPY IN CHIROPRACTIC
Chapter 1
The Rationale of Physiotherapy in Chiropractic


From R. C. Schafer, DC, PhD, FICC's best-selling book:

“Applied Physiotherapy in Chiropractic”

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Introduction 
   Premise 
   Historical Background  
   Conceptual Role
Scope of Application 
   Physiotherapy Utilization 
   Common Physical Agents and Their Effects 
   General Considerations for All Treatments
Assisting Natural Healing Processes 
   The Stages of Healing  
   Procedural Applications Relative to Pathogenesis  
   Basic Rehabilitation Concerns  
Closing Remarks
References

Chapter 1: The Rationale of Physiotherapy in Chiropractic

The effects of electric current on the body have stimulated profound excitement in the field of physiologic therapeutics. Becker’s text, Body Electric, [1] clearly elucidates the effects that electric stimulation can have on the body. His work and that of others have flamed interest in types of modalities that might even duplicate the body’s intrinsic electric currents. Picker demonstrated that microcurrent stimuli could increase ATP production, increase protein syntheses, and impact positively on membrane transport. [2] Along with this new emphasis on duplicating the body’s energies, the chiropractic profession holds a great interest in rehabilitating the injured patient. Recent advances in electrotherapeutics such as the arrival of Russian stimulation and advanced technology in rehabilitation equipment have further nurtured this concern.

It is hoped that practitioners will use adjunctive procedures as a part of a holistic approach to total case management. Emphasis should be on those therapies duplicating the body’s natural responses, those that alleviate symptoms, and those that aid in restoring normal functions of the body.


     INTRODUCTION

Chiropractic physiologic therapeutics encompasses the diagnosis and treatment of disorders of the body, using the natural forces of healing such as air, cold, electricity, rest, exercise, traction, heat, light, massage, water, and other forces of nature. To use these forces on a rational basis, the practitioner must have knowledge of their actions and an understanding of their predictable effects on the tissues and pathophysiologic processes involved.

The word physiotherapy is generally considered to be a shortened form for physiologic therapeutics: treatment by physical or mechanical means.

The term physical therapy is used in reference to the application of specific modalities, including rehabilitative procedures, concerning the restoration of function and prevention of disability following disease, injury, or loss of a body part. [3] The phrase may also be considered synonymous with the term adjunctive therapy. To improve circulation, strengthen muscles, improve or normalize joint motion, and normalize other functional imbalances, for example, the therapeutic properties of the natural forces of healing described above are applied.

The Council on Physiological Therapeutics of the American Chiropractic Association defines chiropractic physiotherapy as the therapeutic application of forces and substances inducing a physiologic response and use and/or allow the body’s natural processes to return to a more normal state of health. [4]

A variety of therapies has proved to be effective. The most common clinical applications include the therapeutic use of cold, electricity, exercise, rest, heat, light, massage, nutrition, oriental therapies, rehabilitative procedures, supports, braces, traction, trigger-point therapy, vibration, and water. See Table 1.1.


     Table 1.1. Common Types of Physiologic Therapeutics

ApplicationDefinition
ActinotherapyTreatment of disease by rays of light, especially actinic (rays of short wavelength occurring in the violet and ultraviolet parts of the electromagnetic spectrum) or chemical light.
CryotherapyTreatment by means of cold; eg, the application of ice packs to a body part to relieve swelling.
ElectrotherapyThe treatment of disease by means of electricity.
HydrotherapyThe treatment of disease by using water; eg, Hubbard tank, sitz bath.
MechanotherapyThe treatment of disorders using active and passive exercises; eg, traction (intermittent, sustained, or intersegmental), braces, shoe lifts, and casts or other supports.
Meridian therapyThe evaluation and treatment of disorders using the Oriental systems.
Nutritional therapyThe use of nutritional planning, dietetics, and special food or nutritional supplementation.
Rehabilitative therapyThe treatment and training of the patient that is geared toward attaining maximum potential for normal living physically, psychologically, socially, and vocationally.
Trigger point therapyThe stimulation of trigger points on the body surface by manual or other means.
Vibration therapyThe therapeutic use of soft-tissue manipulation, mechanical vibration, and massage.



     PREMISE

As long as people have been thinking, feeling, creating, and deciding, they have sought relief for their discomforts. Their first source and recourse were to those natural agents and forces in their surrounding environment; viz:

  1. Heat such as derived from the sun, hot mineral springs, baths, and warm mud or clay packs.

  2. Actinic rays such as the ultraviolet effects of sunlight.

  3. The cleansing effects of water proper (internally and externally) and the varieties of mineral water.

  4. The force of moving or running water.

  5. The benefits of massage, rubs, and stroking.

  6. The reduction of dislocations.

  7. The extension effect of traction.

  8. The energy and nutrition of certain foods, including herbs, spices, and supplements.

  9. The encouragement and counsel of an understanding attitude and a positive mental outlook.

  10. The privileges of rest, relaxation, and support.

The application of physiologic therapeutics thus predates all schools of healing. Its use is generic in the healing arts; thus, such natural methods and forces are the common property of all practitioners who are duly recognized by society and its laws to treat human ailments.


     HISTORICAL BACKGROUND

The application of physiologic therapeutics in chiropractic was firmly established at the National College of Chiropractic in 1914 approximately. However, the forces of nature have been used throughout history as a means of facilitating the body’s healing processes.

During early recorded civilization, both Eastern and Western cultures had much to do with building the foundation of the healing arts. The Babylonians gave the first key to the nature and prevention of communicable diseases. The early Hebrews originated public hygiene and developed a weekly day of rest for recuperation.

In the Chinese Kong-Fou, written almost 4700 years ago, the popularity of massage is well documented. The Chinese, as far back as 2838 B.C., offered advances with their development of manipulation, massage, anthropometry, acupuncture, moxa, pulse diagnosis, and herbs. Records are also clear that manipulation, massage, and acupuncture were practiced by the Japanese at least as early as 600 B.C. Early Chinese and Hindu writings also included exercise therapies.

The Egyptians developed skill in manipulation and the use of natural forces as far back as 2500 B.C. There is evidence that heliotherapy in the form of light and water sunbathes in the temple of Aesculapus (the sun god) were used to treat rheumatism and muscle wasting in 1400 B.C. By 770 B.C., treatment in Aesculapion sanctuaries was essentially based on bathing, fasting, drugs, and suggestion. The temple priests also stressed the importance of massage (amid an atmosphere of hypnotic-like suggestion and incantations) in the treatment of epilepsy, dizziness, and headaches.

The early Greeks used a multitude of mechanical devices for stretching the spine and setting dislocations. A wide variety of crude traction devices were invented. Hippocrates, in 450 B.C., contributed to physiologic therapeutics by recording his observations of the effect of heat and cooling on the body. Among his many recordings, he also wrote Manipulation and Importance to Good Health and On Setting Joints by Leverage.

Herodicus, a contemporary of Hippocrates, is often called the first great drugless healer: “The one who laughed at the use of tonics.” He was a great athlete who achieved wide fame by curing diseases by correcting abnormalities in the spine, which he did in the relatively healthy through therapeutic exercise and in the weak by manipulation with his hands. [5] He was criticized by Aristotle because “He made old men young and thus prolonged their lives too greatly.”

In later Greece, Claudium Galen (130—200 A.D.) became the most distinguished practitioner of his time. He was the first to teach the proper positions and relationships of the vertebrae and the spinal column, the examination of urine in certain diseases, the value of specific foods during illness, the critical days of fever, the significance of the pulse and arteries, and many other features of health and disease. Among his many recordings, Galen is attributed with 16 books on exercise and massage, and his many findings influenced physicians for centuries.

Documents disclose that heat and hydrotherapy (eg, hot springs) were used in America as a general body heating technique in 1706. It was not until 1745, however, that the first book on electrotherapy was published —wherein it suggested the use of torpedo fish to treat gout. By 1870, the practice of electrotherapy had greatly advanced. Galvanism and ultraviolet light were commonly used as therapeutic measures before 1900.

For centuries, the use of sun rays, mineral spas, therapeutic exercise, and massage have been popular in both Eastern and Western Europe. The use of physiologic therapeutic devices was initiated and developed in America by the nonallopathic professions, with pioneer chiropractors offering some leadership in both application and development. [6] The various applications were originally described as actino-therapy, electro-therapy, hydro-therapy, mechano-therapy, etc.

Spinal analysis and adjustment have always been emphasized in the practice of chiropractic, but they have never constituted the sole scope of therapy used by the majority of practitioners. A chiropractor patented an automated “traction couch” in 1914, and Drs. A. L. Foster and W. C. Schultz of the National College wrote extensively on the physiology of the nervous system and reflex therapies during the early part of this century. In the 1920s, Dr. J. S. Riley made frequent mention of various peripheral reflex techniques in vogue in chiropractic at that time.

Physical therapy and the many modalities we know today did not become generally accepted by the allopathic medical community at large until 1914—1918, when their use was demanded by the Armed Services during World War I.


     CONCEPTUAL ROLE

The role of physiologic therapeutics in the practice of chiropractic can best be appreciated by the answers to four basic questions:

  1. What role and place does physiologic therapeutics play in the practice of chiropractic? The agents and forces of nature in their basic state, but controlled, represent therapeutic aids and privileges that belong to all the healing arts. When adjunctive procedures are used, it should be in such a way that the body’s innate natural responses are duplicated; eg, the use of microcurrent stimuli to promote healing. Therapies might also be used preparatory to a chiropractic adjustment such as relieving muscle spasm, dispersing edema, or alleviating pain. It also seems reasonable that rehabilitative procedures should be used in the restorative phase of soft-tissue injury.

  2. What is the relationship between physiologic therapeutics and the chiropractic adjustment? The answer to this question is fourfold:

    • First, solely the structural adjustment of a patient cannot always be considered to effect adequate case management by itself. Rest, exercise, diet, temperature control, sensory stimulation, circulation enhancement, and proper elimination are a few of the other important factors of health that must be addressed.

    • Second, physiotherapeutic procedures often enhance and augment the structural adjustment by means of physical agents and forces. Heat tends to relax tense muscles, thus making them more receptive to adjustment. Certain forms of diathermy and galvanism often soften indurated tissue, allowing a corrective adjustment to hold a more favorable position for a longer period. When applicable, joint traction applied before and an orthopedic support applied after structural manipulation takes advantage of the biomechanical forces of intrinsic stress relaxation and creep. Both of these properties are a function of time that is difficult to achieve manually. [7]

    • Third, when physiologic therapeutics are properly applied, the humeral, chemical, and cellular elements of the body are more competently readied and conditioned to allow for a more effective response to the structural adjustment.

    • Fourth, total body function is enhanced. Physiotherapy aids proper elimination, promotes proper nutrition, and affects the mental and emotional status of the patient in a constructive manner.

  3. What is the major objective in the use of physiologic therapeutics? At all times, the primary purpose is to bring the body to homeostasis, to health, as effectively as possible. A secondary objective is to help the body normalize or adapt to the abnormal processes of a diseased state. An incorrectly applied physiotherapeutic measure, however, may worsen the condition. Another significant factor is strengthening a weakened area following injury.

  4. What are the general actions of physiotherapy and, basically, how do they work? Any form of energy applied to human tissue exerts a primary physical (physiochemical) action. This action, in turn, initiates secondary physiologic or cellular alterations, either locally or systematically, that lead to therapeutic changes.


The efficiency of physical therapy in the treatment of injury and disease depends largely to:

(1) the direct reflex effects of the stimulating agent employed and
(2) the influence of these agents exerted through the autonomic centers.

The typical procedure and the force of a physical modality are applied through the skin. Besides protection, the skin is the greatest neural sensorium of the body —being responsible for perception, absorption, excretion, and temperature regulation functions. Stimulation of cutaneous receptors brings about numerous vascular changes; eg, dilation, increased permeability of vascular walls, and increased circulation. Sundry reflexes are also initiated that have numerous nociceptive and autonomic implications.



     SCOPE OF APPLICATION

The scope of clinical application of physiologic therapeutics in chiropractic is directed by customary use based on scientific and empiric evidence, the physiologic effects of the agent or modality applied, and the individual patient and pathophysiologic needs at hand.


      Physiotherapy Utilization

Most basically, the common procedures of physical therapy on a clinical level may be classified into several categories. Typical considerations include cryotherapy, diathermy, exercise, hydrotherapy, interferential current, low-frequency current, microcurrents, meridian therapy, thermotherapy, and rehabilitative therapies. See Table 1.2.


     Table 1.2. Basic Forms of Physiotherapeutic Applications

1.   Thermotherapy
     a.   Hot moist packs
     b.   Infrared
     c.   Heating pads
     d.   Ultraviolet
     e.   Paraffin
     f.   Fluidotherapy

2.   Cryotherapy
     a.   Ice
     b.   Cold packs
     c.   Vapocoolant sprays
     d.   Clay compresses
     e.   Cold therapy
     f.   Cold immersions
     g.   Cryokinetics
     h.   Alternating heat and cold

3.   Diathermy (high-frequency)
     a.   Short wave
          (1)   Induction or coil field
          (2)   Condenser field
     b.   Microwave
     c.   Ultrasound

4.   Interferential current (medium frequency)
5.   Low-frequency currents
     a.   Direct current, eg, low-volt galvanism
     b.   High voltage current
     c.   Alternating current
          (1)   Sine wave and other
                 muscle stimulating currents
          (2)   Faradic current
     d.   TENS
     e.   Microcurrent
     f.   H-wave

6.   Hydrotherapy

7.   Exercise therapy

8.   Rehabilitative therapy

9.   Meridian therapy
     a.   Pressure techniques
     b.   Acupuncture
     c.   Auriculotherapy
     d.   Ryodoraku

10.   Vibratory therapy

11.   Traction and Stretching

12.   Bracing and Supports

      Common Physical Agents and Their Effects

Each of the common physical agents has reasonably specific primary and secondary effects. Heat from any source, for example, has a primary thermal effect with secondary effects in hyperemia, sedation, and attenuation of microorganisms. Cold from any source offers a hypothermal primary effect with secondary effects of decongestion, ischemia, and sedation.

Photochemical and electrochemical effects are seen with some physical agents. For example, sunlight, heated metals, and carbon or mercury-vapor arcs present primary photochemical effects and secondary effects of erythema, pigmentation, and activation of ergosterol. Galvanic current offers a primary electrochemical effect and secondary polarization and vasomotor effects.

Kinetic and electrokinetic effects are seen with other physical agents. For instance, vibration, massage, traction, and therapeutic exercise offer primary kinetic effects with secondary actions of muscle stimulation, increased venous and lymph flow, stretching of tissue, and reflex stimulation. Electric currents (eg, low-frequency, alternating, interrupted, sinusoidal) give primary electrokinetic effects with secondary effects of muscle stimulation, increased venous and lymph flow, tissue stretching, and reflex stimulation. Ultrasound therapy is unique in that it offers primary mechanothermochemical effects with secondary effects of intracellular massage and thermal sedation.

A brief summary of common physical agents and their effects are shown in Table 1.3.


     Table 1.3. Brief Resume of Common Physical Agents and Their Effects

Physical AgentPrimary EffectSecondary Effects
Hot water, hot air, radiant heaters, incandescent lamps, diathermy, microwave [4]Thermal (superficial and deep)Hyperemia, sedation of sensory or motor irritation, attenuation of microorganisms
Cryotherapy (vapocoolant, ice)HypothermalSedation, decongestion, ischemia
Ultraviolet (sun, heated metals, carbon arc, mercury vapor arc)PhotochemicalErythemia, pigmentation, activation of ergosterol
UltrasoundMechanical, thermal, chemicalCellular massage, heat, sedation
Low-volt galvanic currentsElectrochemicalPolar, vasomotor
Low-frequency, interrupted current, sinusoidal current, other alternating currentsElectrokineticMuscle stimulation, increase of venous and lymph flow. Reflex stimulation, pain control
Vibration, massage, traction, intermittent, therapeutic exerciseKineticMuscle stimulation, therapeutic tissue stretch, reflex stimulation

Note: Occasionally, a claim to a third party (eg, insurance company) is rejected on the basis of duplicated therapies billed on a unit basis for a disorder treated during a particular visit. For example, hot water, hot air, radiant heat, heat lamps, diathermy, and microwaves all have a primary thermal effect and all have secondary effects of hyperemia, sedation, and the tendency to weaken microorganisms. Note that several of these procedures deliver warmth to superficial areas and others to deep tissues. A determination of the appropriateness of application on a patient during a visit can only be made after careful evaluation of the patient, with a full understanding of the pathophysiology involved, and with thorough knowledge of the physiologic effects of each modality. If duplication is necessary (eg, application of preadjustment superficial moist heat and postadjustment diathermy for deep heating), clinical justification should be explained in any submitted report and noted in the patient’s records.


      General Considerations for All Treatments

The rational application of modalities requires a basic knowledge of the actions and effects on pathophysiologic processes. Any therapeutic agent possesses a potential for effectiveness and a potential for danger. Each modality has its indications and contraindications, and certain precautions must be observed if the modality is to be applied safely and effectively in line with the biophysics and physiologic responses involved.

When properly applied, benefits are gained in normalizing function, preventing and minimizing pain and deformities, and maintaining what has been gained in treatment. The physician-operator must be well acquainted with the physics involved and the underlying application fundamentals to properly prescribe or use an appropriate modality, as well as be skilled with the technique of application, its intensity and duration, and to effectively analyze the anticipated effects.

The widespread considerations for treatments are described in Table 1.4.


     Table 1.4. General Considerations for All Treatments

I.   Preparing the patient
      A.   Check the following data:
1.   Diagnosis
2.   Correct area
3.   Correct modality and usage
4.   Contraindications
5.   Special instructions
6.   Vital signs
      B.   Determine the procedure to be used:
1.   Type of modality
2.   Method of application
3.   Patient position
4.   Timing
      C.   Check the unit’s use and operation:
1.   How it works
2.   How to explain how it works
3.   Know how to use it
4.   Be sure it is working correctly
5.   Check the connections
6.   Properly ground the unit
II.   Starting the treatment
A.   Tell the patient your name — be sure he or she knows it.
B.   Know exactly what you are doing and how to do it.
C.   Be calm and reassuring — act with confidence.
D.   Explain the procedure to the patient by discussing:
       1.   What you are going to do.
       2.   The sensation the patient should fee (test it on yourself).
       3.   How long the treatment will be.
       4.   How the patient can signal for aid if there is a problem (have a bell handy).
E.   Instruct the patient to remove necessary clothing. Offer assistance if necessary. Give clear directions.
F.   Position the patient carefully.
G.   Inspect the patient. Check skin and skin sensitivity to the modality.
H.   Start the treatment and set the timer. Make note of starting time.
I   Monitor the patient frequently.
III.   Terminating the treatment
A.   Turn off the unit.
B.   Dry and check the patient’s skin.
C.   Check the patient for dizziness, nausea, and faintness.
D.   Ready the patient for the adjustment, make him or her comfortable before applying another procedure, or instruct the patient to dress.
IV.   Precautions and complications
 Immediately note any signs of burns or other problems and take appropriate action.
V.   Schedule the patient’s next appointment


      MULTIPLE THERAPIES

The issue of using more than one therapy with similar effects during a patient visit has been extensively explored as the profession strives to establish reasonable standards of care. Unfortunately, this issue may ultimately be decided by the insurance industry rather than by consideration of what is best for the patient.

Limiting the application of modalities was refuted by Ronald Melzack in 1989. [8] He reported that there is no longer any doubt that it is possible for one to reduce many types of pain by means of sensory modulation. Further, he stated, “The effects of two or more therapies given in combination are cumulative. Two therapies, each with slight effects that may not reach statistical significance compared to a placebo, may produce significant reductions in pain when given together. For this reason, multiple convergent therapy is increasingly becoming the standard approach to pain problems.”

Two or more therapies should not be used if they duplicate effects (eg, two therapies producing superficial heat, two muscle-stimulating currents), but a clinician could build a case for using two, three, or possibly four modalities on a specific area based on appropriate clinical findings. It is the responsibility of the practitioner to justify the use of even one modality by proper records, thorough documentation, and a comprehensive rational approach to patient care.



     ASSISTING NATURAL HEALING PROCESSES

The primary intent of chiropractic physiologic therapeutics is to assist the body in adapting to and/or normalizing the aberrant processes in an abnormal state and in alleviating pain. The abnormal process existing at the time of therapy determines the particular type of therapy applicable. Any injury or disease state comprises a number of abnormal physiologic reactions depending on its state of healing or adaptation. Thus, therapy must be varied according to the process at hand to assist the body in normalizing or adapting to the condition. The therapeutic goal is usually to stop or reverse a noxious reaction that is preventing or delaying normal healing processes.

Table 1.5 lists the major criteria and rules regarding physical therapy


     Table 1.5. General Criteria and Rules Regarding Physical Therapy

  1. Be sure you know what you are confronted with (ie, symptoms, conditions, pathophysiology involved).

  2. Choose a modality that is best suited for the presenting complaint.

  3. Guard against insufficient or excessive treatment.

  4. Intervals of long duration between treatment resuls in failure.
    Generally, treatments scheduled once per week are of little or no value.

  5. Don’t “overtreat” with certain modalities.

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


No inflammatory process (traumatic or nontraumatic) is static. It continues to produce harmful effects on the patient until either the inflammatory process or the individual’s defensive powers are defeated. As these effects may be systemic as well as local, the response to injury is also both systemic and local. For this reason, functional and pathologic disorders and their effects must be evaluated from the standpoint that the physiology of the whole person is disturbed and not from the view that an otherwise well-off person is afflicted with a local defect or that only a part of the total system is affected.


Table 1.6 lists those items that should be notated in patient records as they pertain specifically to therapy.


     Table 1.6. General Criteria and Rules Regarding Patient Records

  1. List the specific area of the body where the therapy is applied.

  2. Indicate the type of therapy used (eg, high-volt, interferential, ultrasound).

  3. In cases of low or medium frequency, record whether sensory or motor stimulation was used.

  4. For high frequency modalities, note whether continuous or pulsed.

  5. In cases of low-volt galvanic, record the polarity.

  6. In TENS treatment (including high-volt or interferential therapy), record the frequency used.

  7. Record treatment time.

  8. Note any adverse patient reaction or comments.



      Soft-Tissue Injury

It has been only in recent years that the actual pathology involved in most tissue trauma has been investigated or understood. [12] Whereas in years past it was felt that injuries healed by the regeneration of damaged tissue, we now understand that soft-tissue injuries heal, in general, by the formation of scar tissue.

Further, Oakes identified three distinct phases involved in the management of the injured patient. [13]

The first phase is called the acute inflammatory stage and generally lasts 0—72 hours. This stage is characterized primarily by inflammation, pain, and edema following either extrinsic or intrinsic trauma. More than half of tissue damage occurs by the effects of bleeding and not by the tear itself. Table 1.7 identifies the pathology involved in soft-tissue trauma. Tearing is generally obvious, but in some cases it may be hidden or be at the microscopic level (eg, deep spinal or hip strain or sprain). The practitioner must make every effort to direct attention to calming the injured area. Thrusts to the site of injury are not recommended during the first 72 hours following trauma. The adverse effects of this initial phase can be minimized by cold, pressure, elevation (when logical), and rest. Whenever possible, the injured area(s) should be immobilized to provide rest. Sensory stimulation with high-volt or interferential modalities is of paramount importance in alleviating pain.


     Table 1.7. Initial Effects of Soft-Tissue Trauma

First-, second-, or third-degree tear
Damage to phospholipid plasma membrane
Free arachidonic acid
Prostaglandin synthesis
Cascade of reactions, including triggering histamine and bradykinin reactions,*
which cause instant inflammation and double the wbc count.
Nociceptor endings stimulated
Pain, inflammation, and edema

Note: Histamine is a depressor amine normally found in the body that exerts a pharmacologic action when released from injured cells, producing an initial red flush that is followed by localized edema and heat because histamine is a vasodilator of capillaries and arterioles. Histamine is a product of histidine, a basic amino acid in protein. Bradykinin, a plasma kinin, is a chain of amino acids liberated by the enzyme kallikrein. Kallikrein is normally in an inactive state in the blood. When activated in tissues via bleeding, it acts on *2-globulin of blood plasma to produce further vasodilation. Released trypsin and plasmin can also produce the conversion.


Resolution begins after bleeding stops to organize minute thrombi to form the richly vasculated granulation tissue that allows:

1.   The inflammatory stage where white blood cells dissolve extravasated blood elements and tissue debris, characterized by swelling and local tenderness.

2.   The reparative stage, where the network of fibrin and the fibroblasts begin the reparative process, characterized by local heat, redness, and diffuse tenderness.

3.   The toughening stage of fibrous deposition and constant inflammatory reaction, often characterized by palpable thickening and induration in the area of reaction, with tenderness progressively diminishing. Invariably, the greater the bleeding, the more acute and diffuse the inflammatory stage, and greater induration and fibrous thickening can be anticipated.

The healing phase generally lasts from 48 hours to 6 weeks or more. This is the period of collagen synthesis and deposition. Treatment plays a key role in helping the patient’s body develop the type of scar tissue that has both strength and flexibility. Recent studies indicate that microcurrent stimulation profoundly effects ATP production, protein synthesis, and membrane transport. It is also known that modalities producing deep heat can have an impact on protein synthesis. Intersegmental modalities may assist in providing mobility as injured tissues begin to heal.

Since the effects of injury and the body’s efforts to defeat them are constantly changing, the doctor cannot rely on one observation or one major symptom in evaluating the condition of the patient, especially one seriously injured or ill. Repeated observations must be made and indications of the patient’s circulatory status, temperature, blood pressure, pulse, respiration, color, and vitality must all be considered to obtain as clear a picture as possible of the patient’s condition and the treatment required at the moment the particular observation is made. Pain, tenderness, local swelling, spasm, ranges of joint motion, neurologic findings, weakness, vital signs, and the psyche are the doctor’s primary indices for evaluating the progress of recovery.


      Procedural Applications Relative to Pathogenesis

Whether a tissue becomes primarily injured through frank trauma or microtrauma, or is undergoing a change such as a secondary reaction to a pathologic process initiated elsewhere, several stages usually occur. [11] The best approach is to anticipate each step in the healing process and provide the opportunity for natural processes to express themselves. This is not to say that if a variation is seen at one of the normal stages of healing that treatment should not be varied accordingly. Increased local swelling and tenderness during a later stage typically indicate an infectious process. See Table 1.7.

While these stages and their processes usually exist in varying degrees in tissues simultaneously, one process usually dominates. Treatment should be directed primarily at the dominant process and altered as the dominant feature changes. In this context, the presence of a coexisting neuropathy must be realized and the area of therapy should be considered as not only at the site of local symptoms, but also at the neuromere(s) or spinal segment(s) directly or indirectly involved.

Nothing should be done during the complicated healing stages that might disrupt the natural process or restimulate bleeding or swelling. The injury itself is usually all the local stimulation necessary for maximum response. The uses of direct massage, heat, hydrocollators, whirlpool baths, ultrasonics, and other extrinsic stimulants in this initial stage are usually contraindicated as they only add additional irritation to an already maximally stimulated part.


      Basic Rehabilitation Concerns

Once the stage of likely recurrent bleeding and swelling has passed, a gradual rehabilitation program can be initiated that encourages the inflammatory reaction of resolution to pass quickly and reduce fibrous thickening of tissues. [12] Killett believes that the remodeling phase may last from 3 weeks to 12 months or more.9 Here, collagen is remodelled to increase the physiologic capabilities of the injured structures to withstand the stress imposed on it. Whereas the healing phase emphasizes increasing the quantity of collagen, this phase involves attempts to improve the quality of the collagen.

This program may be accelerated once the stage of fibrous thickening occurs and is noted through inspection and palpation. Much atrophy, muscle weakness, and fibrous induration can be eliminated by applying progressive rehabilitative procedures as soon as possible. Naturally, timing must be coordinated with the type of injury; eg, bone injuries require longer support and rehabilitation than do soft-tissue injuries.

When necessary, continuous support during the resolution stage must be provided by external measures without impairing natural healing process. The common means are through tapes, bandages, splints, and foam-type braces. However, while extensive and prolonged immobilization assures a painless recovery in most instances, it always carries with it a degree of related fibrosis and atrophy. On the other hand, quickly initiated and gradual rehabilitation speeds the reduction of swelling and tenderness, and minimizes fibrosis and atrophy. Thus, a compromise must often be made.


     CLOSING REMARKS

Physiotherapeutic procedures can often enhance and augment specific structural adjustments by means of physical agents and forces. The goal is to assist the body in adapting to and/or normalizing the aberrant processes of a patient in an abnormal state. In each application, the primary purpose is to bring the body to homeostasis as effectively as possible.

While the stages of healing and their processes usually exist in varying degrees in tissues simultaneously, one process usually dominates. Treatment should be directed primarily at the dominant process and altered as the dominant feature changes, keeping in mind that each of the common physical agents has reasonably specific primary effects and secondary effects. Nothing should be done during the complex stages of healing that might disrupt natural processes.

Undertreatment or infrequently administered therapy will undoubtedly fail to produce the results desired. On the other hand, overtreatment, whether it be of time or intensity, may counteract the beneficial effects desired. In any particular stage of physiologic activity, a misapplied or too vigorous application may be an insult to the lesion as well as to adjacent healthy tissues, causing a return to active inflammation.



     REFERENCES:
  1. Becker RO, Selden G:
    The Body Electric: Electromagnetism and the Foundation of Life.
    New York, William Morrow, 1985.

  2. Picker RL:
    Low-volt pulsed microamp stimulation, Parts 1 and 2.
    Clinical Management, 9(2—3).

  3. Thomas CL (ed):
    Taber’s Cyclopedic Medical Dictionary, ed 14.
    Philadelphia, F.A. Davis, 1981, p 1098.

  4. ACA Council on Physiological Therapeutics:
    Physiotherapy guidelines for the chiropractic profession.
    ACA Journal of Chiropractic, June 1975, p IX, S—66.

  5. Schafer RC:
    Chiropractic Health Care, ed 3.
    Des Moines, IA, The Foundation for Chiropractic Education and Research, 1978, p 14.

  6. Ibid: pp 31—32.

  7. Schafer RC:
    Clinical Biomechanics. Baltimore,
    Williams & Wilkins, 1983, pp 356—357.

  8. Melzack R:
    Pain modulation: Gate control theory.
    Paper presented at Challenge of the Lumbar Spine Conference,
    McGill University, November 2—5, 1989.

  9. Kellett J:
    Acute soft-tissue injuries —a review of the literature.
    Medicine and Science in Sports and Exercise, 18:5, October 1986, pp 489—500.

  10. Oakes SW:
    Acute soft-tissue injuries: Nature and management.
    Australian Family Physician (Supplement), 10:3—16, 1982.

  11. Schafer RC:
    Chiropractic Management of Sports and Recreational Injuries.
    Baltimore, Williams & Wilkins, 1982, pp 168—169.

  12. Ibid: p 197.

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