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PST 324: MANUAL
THERAPY
COURSE OBJECTIVES:
The objectives of the course are to
• acquit the students with the background of manual
therapy and its development
• define manual therapy and enumerate its various
classifications including massage
• inform students about various forms of massage,
preparation of patient and massage application
• unravel the various techniques involved for
different body regions including specific cases like
scars, ulcers etc
• expose students to the use of bandaging and the
various techniques of bandaging in physiotherapy
practice.
• At the end of the course, each student should be
able to
• understand the history of manual therapy and its
development
• Know the classification of MT and different
applications
• Understand massage, usage and be able to apply it
for therapeutic purposes
• Apply bandage appropriately for patients
Definition of Manual Therapy
• Definition:
• Manual Therapy is a skilled hand movements intended
to produce any or all of the following effects:
• improve tissue extensibility; increase range of motion
of the joint complex;
• mobilize or manipulate soft tissues and joints;
• induce relaxation; change muscle function;
• modulate pain; and
• reduce soft tissue swelling, inflammation or movement
restriction.
• by The International Federation of Orthopaedic
Manipulative Physical Therapists (IFOMPT)
Definition
• Korr (1978) described manual therapy as the
"Application of an accurately determined and
specifically directed manual force to the body, in
order to improve mobility in areas that are
restricted; in joints, in connective tissues or in
skeletal muscles
• Manual therapy can be utilized to assess
dysfunction, increase joint range of motion,
decrease pain, and improve healing
FORMS OF MANIPULATION
• Three notable forms of manual therapy are
manipulation,
• mobilization and
• massage.
Manipulation and Mobilization
• Manipulation: A passive, high velocity, low
amplitude movement applied to a joint complex
within its anatomical limit.
• It is a sudden low amplitude thrust applied to a
joint which goes beyond the anatomical ROM
• It takes the joint beyond the voluntary and usual
normal range of motion but within its anatomical
limits
• The intention is to restore optimal motion, function,
and/ or to reduce pain
MANIPULATION
• Manipulation is always used to adjust the spine in
addition with therapeutic exercise
• Manipulation is the artful introduction of a rapid
rotational, shear or distraction force into an
articulation.
• Manipulation is often associated with an audible
popping sound caused by the instantaneous
breakdown of gas bubbles that form during joint
cavitation
MOBILIZATION
• Is a series of passive movement which does not go
beyond the normal range of motion.
• It is a manual therapy technique comprising a
continuum of skilled passive movements to the
joint complex that are applied at varying speeds
and amplitudes,
Definition
• Mobilization is a slower, more controlled process of
articular and soft-tissue (myofascial) stretching
intended to improve bio-mechanical elasticity
MASSAGE
• Massage is typically the repetitive rubbing,
stripping or kneading of myofascial tissues to
principally improve interstitial fluid dynamics.
• A massage is the use of rhythmically applied
pressure to the skin and soft tissues of the body.
• Massage is used to reduce tension,
• anxiety, stress, and
• promote overall circulation, relaxation, and
flexibility.
HISTORY OF MANIPULATION
• Hippocrates (460–385 BCE), the father of medicine,
was the first physician to describe spinal
manipulative techniques
• He used gravity, for the treatment of scoliosis.
• In this case, the patient was tied to a ladder and
inverted (Withington 1928).
•
• The second technique he described involved the
use of a table with various straps, wheels, and
axles enabling traction to be applied. The hand,
foot, seated body weight, or a wooden lever could
then be used to impart spinal pressure or thrust to
treat a “gibbus” or prominent vertebra.
• Hippocrates noted that this treatment should be
followed by exercises
MANIPULATIONS IN THE TIME OF HIPPOCRATES
Patient with spinal dysfunction hung on a ladder
Sitting and Walking on the spine of patient
• Claudius Galen (131–202 CE), a noted Roman
surgeon, provided evidence of manipulation
including the acts of standing or walking on the
dysfunctional spinal region
ADVANCES IN 19 CENTURY
• Nobody questions these early origins of
manipulative therapy and its effectiveness.
• It would appear that physicians and surgeons
tended to abandon the general acceptance of
spinal manipulation by the 18th century.
•
• The reason for this is not completely clear but may
have been the ineffectiveness of indiscriminate use
• The danger involved in manipulating a spine
weakened through tuberculosis, a disease of
epidemic proportions in certain locations at this
time.
• It is from the 19th century onwards that
manipulative therapy became an area of contention
between the various professions involved in its
practice.
• Manipulation can trace its origins from parallel
developments in many parts of the world where it
was used to treat a variety of musculoskeletal
conditions, including, spinal
disorders (Schiotz 1974)
• It is acknowledged that spinal manipulation is and
was widely practised in many cultures and often in
remote world communities such the Balinese
(Connor 1986) of Indonesia, the Lomi-Lomi of
Hawaii, in areas of Japan, China and India
((Handy 1934),
• by the Shamans of Central Asia, by Sabodors in
Mexico by bone setters of Nepalas, Russia and
Norway (Anderson 1992)
• What of Africa and Nigeria?
• There is no direct evidence of such practice in any
documents of communities such as Babylon,
Mesopotamia, Assyria, and even Egypt (Sigerist
1951)
• Historical reference to Greece provides the first
direct evidence of the practice of spinal
manipulation.
• The detail in which this was described suggests
that the practice of manipulation was well
established and predated to 400 BCE (Sigerist,
1951)
ADVANCES IN MANIPULATION
• Manipulation again tended to become the domain
of the village healers in various areas of Europe
and Asia. These were called bone setters
• These bonesetters had passed on the traditional
healing arts on to their children since time
immemorial, even before formal recognition of the
medical profession, but then they were far more
visible within society.
• In 19 century, a significant portion of the established
medical profession expressed disdain for the
bonesetters and their practices and did their best to
run them out of business.
• At the same time, however, they had to recognize just
how popular these bonesetters had become to the
general populace.
• It was suggested by James Paget, one of the most
famous surgeons of the time, that doctors would do
well to observe bonesetters and learn from them what
is good but, at the same time, avoid what is bad.
• However, it appears that the medical community
still did not appreciate the benefits of joint
manipulation. Even Paget himself often attributed
the bonesetters' successes more to luck than skill
and frequently referred to them as “enemies”
• 1882, manipulation was again evident in medicine.
It was the topic of meetings and papers, and the
first book had been written on the subject and
Bone setting was the main topic at the annual
meeting of the British Medical Association's
section on surgery.
• the greatest change in views by the medical
establishment at that time was that manipulation
could actually be consistently effective.
• Robert Jones, the founder of British Orthopaedics,
wrote, “We should mend our ways rather than
abuse the unqualified.
• Dramatic success in their hands should cause us to
enquire as to the reason. It is not wise or dignified
to waste time denouncing their mistakes, for we
cannot hide the fact that their successes are our
failures”
• in 1910 came the following observation: “It is very
remarkable that the medical profession for so long
has neglected a wide field of therapeutics”.
• And so it seemed that without a suitable champion
within the medical profession, spinal and peripheral
joint manipulation would forever remain the domain
of the bonesetters.
• However, by the end of the 19th century, certain
events unfolded that irrevocably changed the way
manipulation was viewed and practised around the
world.
SOME AUTHORS IN
MANIPULATION
• Andrew Taylor Still was born in 1828, was the son
of a physician who was also a Methodist minister.
He was influenced by his father to go into
medicine. In the mid-1800s, a physician could be
“apprenticed,” and Still probably only attended one
seminar of formal medical education.
• As a child, Still had suffered from chronic
headaches. He had noted one day, while falling
asleep with his neck wedged between the roots of
an oak tree, that his headaches were completely
relieved.
• Using this and other experiences, he began to
slowly conceive of a theory whereby health could
only be maintained and, therefore, disease
defeated, by maintaining normal function of the
musculoskeletal system.
• Apart from manipulative techniques, he also
incorporated the idea of magnetism.
• From 1874, while working on his new anatomically
and biomechanically based theories, Still referred
to himself, in what was a very successful clinical
practice, as “the Lightening Bone Setter.” Still was
openly critical of the medical profession and its
methods
• With this he was denied access to the medical
school, but he later discovered that he can not
solve all the problems, he then established
American Osteopathic College in Kirksville,
Missouri in 1892 and this is the beginning of
Osteopathic Medicine.
DANIEL DAVID PALMER
• DDP was born in Canada in 1845, his parents
migrated to the United States in search of work but
Palmer and his younger brother remained in Canada
as factory workers until 1865 when they rejoined
their family.
• Palmer was well educated and an avid reader of all
things scientific. After working for 20 years as a
horticulturist, schoolteacher, and farmer, he
turned his energies to becoming a “natural healer.
• Palmer stated in his book, Chiropractic Adjustor,
that he learned about manipulation from the work
of a medical practitioner named Jim Atkinson,
whose work 50 years earlier propounded similar, if
not the same, principles as the new healing art of
chiropractic
James Mennell and Edgar Cyriax
• Mennell in 1912-1935 served as the medical officer
lecturing on massage therapy at the Training School of
St Thomas's Hospital.
• Mennell was engrossed in the use of physical means,
including manual therapy, in the treatment of
musculoskeletal dysfunctions.
• In 1917, Mennell published his text Physical Treatment
by Movement, Manipulation and Massage.
• In his book, he clearly detailed how symptoms of
thoracic spinal origin can closely mimic true visceral
symptoms
• He thus cautioned against accepting the relief of
pain through spinal manipulation as being equated
with a cure of organic disease.
• He clearly advocated the use of spinal
manipulation only following a thorough examination
(including medical diagnostic and laboratory tests
if necessary) that differentiated visceral from
spinal symptoms.
• This emphasis on differential diagnosis was to
significantly influence his own son (John McMillan
Mennell) and James Cyriax.
John McMillan Mennell
• Like his father before him, John Mennell set about
trying to educate as many physicians as possible in
the art and science of orthopaedic-based spinal
manipulative therapy
• his professional altruism is that his teaching was
never confined to any one profession but to all who
had the education and training to learn effective
and safe manipulative technique
James Henry Cyriax
• James Cyriax qualified in medicine at St Thomas's
in 1929, becoming a specialist (member of the
Royal College of Physicians, MRCP) in 1954. His
greatest gift to both professions is found in his
classic Textbook of Orthopaedic Medicine, Volume
I, originally published in 1954
• he laid out the foundation of a method of logical,
clinically reasoned, differential diagnosis, which he
called “selective tissue tension testing.” This
clinical philosophy was to irrevocably change the
way orthopaedic manual physical therapists
thought, taught, and practised.
• Died in 1985, he said If I am remembered for
anything, I hope that it will be my contribution in
orthopaedic differential diagnosis through selective
tissue tension testing
MANUAL THERAPY IN RECENT
TIME
• In the 1950s, physical therapists from around the
world were beginning to research, develop, and
organize.
• Freddy Kaltenborn from Norway and Stanley Paris
from New Zealand were already lecturing on
manual therapy.
•
• In 1954, a young physiotherapist named Robin
McKenzie was to “accidentally” cure one of his
chronic patients, the famous Mr. Smith.
• Within a few years, McKenzie was teaching his
methods and philosophy worldwide.
• McKenzie has shown that manual techniques are
often not the only, or even the most appropriate,
approaches to correct a lumbar dysfunction.
• Second, he defined one of the major contra-
indications to manipulation of the lumbar spine,
i.e., deviation with neurological sign
• Geoff Maitland from Australia been influenced by
Mennell, Cyriax, and Stoddard, In 1965, he was
invited to Britain to teach his manipulative
techniques.
• He took the opportunity to introduce his ideas on
how gentle oscillatory movements could be used
prior to manipulation to accurately attain the
motion barrier.
• He also indicated that these techniques were, in
many cases, superior to thrust techniques.
• The use of these gentle, safe mobilizations became
an integral part of training in orthopaedic manual
therapy
• Based on the emergent biomechanics of
MacConaill, Kaltenborn envisaged regaining motion
through focusing on motion at the joint surfaces,
i.e., with distraction, compression, glides, and
conjunct rotation. With his close friend and
colleague they promoted the use of
arthrokinematics and osteokinematics in both
assessment and treatment of articular motion
dysfunctions.
• This starkly mechanical approach has been
competing for many years with Maitland's use of
tissue tension and reaction.
• The committee and consultants included
• McKenzie,
• Paris,
• Kaltenborn,
• Maitland, and
• Grieve, together with a Danish therapist named
Hanne Thorsen.
MANIPULATIVE THERAPY IN
NIGERIA
Professor Vincent C.B. Nwuga
Prof V.C B Nwuga
• He is a Nigerian Physical therapist who specialized in
manual therapy.
• He is the progenitor of Nwugarian techniques.
• He had his Physiotherapy education in Nigeria, in the
US and Canada.
• He evaluated the various schools of thought, blended
the theories and came up with his own techniques
called Nwugarian technique
• He was influenced with the work of Cyriax, Mennell,
Maigne, Maitland and osteopathic thinking
• He attempted to integrate the thought of these
authors with some innovation of his own.
• In 1976, he published a book Manipulation of the
Spine.
• He was the first professor of Physiotherapy in
Africa and in Nigeria and the founding father of
Department of Medical Rehabilitation, Obafemi
Awolowo University, Ile Ife
• His school of thought was integrated in 1996
called Nwugarian Institutes of back pain
• His techniques revolved round about Vertical
Oscillatory pressure, Transverse Oscillatory
Pressure, Vertical thrust, etc
INDICATION FOR MANUAL
THERAPY
• Tissues adhesions
• Joint reduced range of motion
• Contracture of ligaments, muscles and tendons
• Lost of function
• Any part of the body with
• tissue contracture or restriction;
• reduced range of motion of the joint complex; or stiff
joints
• soft tissues spasm or tenderness
• Joints dysfunction
• Muscle dysfunction or malfunction,
• Acute or chronic pain in musculoskeletal area ; and
• soft tissue swelling, inflammation or movement
restriction.
CONTRAINDICATION
• Manipulations should not be done in the following
circumstances
• to the spine if there is severe osteoporosis
• if there is any tumor or malignancy in the area
• to the cervical region if there is dysfunction with
the flow of blood within the vertebral artery
• if there is bleeding in a joint
• if there is a loose body in the joint
• total joint replacements
• joints near a growth plate
• until a full diagnosis is reached
• A part of the body with metallic implant
• Acute inflammation
Classification of Manual Therapy
• MANUAL THERAPY can be classified into 2 main
groups:
• Active techniques.
• This involve movement by the patient
• Passive techniques:
• Patient is inactive during the process
• These are divided again into Dynamic and Static
techniques
• Dynamics are techniques in which joints are mobile
• Statics techniques are method in which joints are not
mobile
CLASSIFICATIONS
• All techniques
Active Passive
Dynamics StaticsStatics
MOBILIZATION
• MOBILIZATION: Mobilisations primarily consist of
passive movements which can be classified as
physiological or accessory.
• The purpose is to provide short term pain relief and
to restore functional movements by achieving full
range at the joint
• Joint mobilisation is a treatment technique which
can be used to manage musculoskeletal
dysfunction, by restoring the motion in the
respective joint.
• Such restriction may be found in joints, connective
tissues or muscles.
• By removing the restriction the source of pain is
reduced and the patient experiences symptomatic
relief.
INDICATION FOR MOBILIZATION
• Manual therapy and mobilisations are indicated for
5 symptom groups
• Break down or reduce adhesions
• Improve range of motion
• Lengthen muscles and tendons
• Reduce swelling and oedema
• Decrease pain
• Restore functionality
INDICATION FOR MOBILIZATION
• Painful Joints: This may be caused by arthritis
Capsular adhesions
• Joint Hypomobility: Resulting from adhesions,
muscle and ligamentous contractures
• Subluxation: as a result of trauma, weak ligament
and surrounding muscles
• Progressive limitation: Capsular adhesion,
ligamentous contracture
• Functional Immobility: prolong immobilization
CONTRAINDICATION
• Absolute contraindication: This is a no go area for
mobilization techniques.
• Acute inflammation: infection joint effusion etc
• Malignancy: osteosarcoma, etc
• Bone disease: osteoporosis
• Excessive pain
• Total Joint Replacement, metallic implant
• Newly formed or weakened connective tissues
PHYSIOLOGICAL AND
ACCESSORY MOVEMENT
• Physiological movement are rotational movement
that can be performed by patients
• Accessory Movement: They are movement in the
joint and surrounding tissues necessary for normal
ROM but can not be carried out by the patient.
Accessory motion can be component or joint play
• Component motion are those motion that
accompany active motion but are not under
voluntary control.
• Example: motion such as upward rotation of
scapular and rotation of clavicle which occur in
shoulder flexion; rotation of fibular which occur in
ankle motion
• Joint Play: It is a motion that occur between the
joint surfaces and also the dispensability or give in
the joint capsule which allows the bone to move
• The movement are necessary for normal joint ROM,
though cannot be done actively but can be done
passively. It includes distraction, compression,
rolling, sliding and spinning of joint surfaces. The
word arthrokinematics is used to describe these
SOME DEFINITIONs
• Self Mobilization: (Auto Mobilization). This is self
stretching techniques that specifically use joint
traction or glides that direct the stretch force to
the joint capsule
• Mobilization with movement: MWM is the
concurrent application of sustained accessory
mobilization applied by a therapist and active
physiological movement to end range applied by
the patient.
• Thrust: It is a high velocity, short amplitudes
motion which patient cannot prevent. It is
performed at the end of pathological limit.
• It is aimed to alter positional relationship, snap and
adhesion and to stimulate joint receptors
• Glide: Gliding is a mobilization techniques that with
the aim of increasing ROM in a specific direction.
• Distraction: Distraction is like a traction
techniques with the aim of separating the articular
surfaces of the joint, restore ROM and moderate
pain intensity
JOINT SURFACES
• The types of motion occurring between bony
partners in a joint is influenced by the shape of the
joint surfaces. The shape may be described as
ovoid or sellar
• In ovoid joints, one surface is convex, the other is
concave.
• In sellar joint, one surface is concave in one
direction and convex in the other with the opposing
surface convex and concave.
JOINT SURFACES
• Joint surfaces are usually irregular, but in every
joint, there normally concave and convex joint
surfaces.
• In every peripheral joint, one should know which
one is convex and which one is concave so as to
know the direction of gliding
• A concave surface is similar to a concave lens and
a convex surface t a convex lens
CONDITIONS FOR JOINT
MOBILIZATION
• Painful Joints: Painful joints, reflex guarding and muscle
spasm can be treated with gentle joint-play techniques to
stimulate neurophysiological and mechanical effects
• Small amplitude oscillatory and distraction movement are
used to stimulate the mechanoreceptors that inhibit the
transmission of nociceptive stimuli at the spinal cord.
• Joint Hypomobiliy: Reversible joint hypomobililty can be
treated with progressively vigorous joint-play stretching
techniques to elongate hypomobile capsular and
ligamentous connective tissue.
• Sustained and oscillatory stretch forces are used to distend
the shortened tissues mechanically
Subluxation
• Malposition of one bony partner with resect to its
opposing surface may result in limited motion and pain.
This can occur in traumatic injury, after periods of
immobility or with muscle imbalance
• Manipulation is used to reposition an obvious
subluxation such as elbow or capitate-lunate
subluxation
• Progressive limitation:
• Diseases that progressively limit movement can be
treated with joint play techniques to maintain available
motion or retard progressive mechanical restriction.
• The dosage distraction or glide is indicated by the
patient response to treatment and the state of disease.
Functional Immobility
• When a patient cannot functionally move a joint for
a period of time, the joint can be treated with
gliding or distraction techniques to maintain
available joint play and preventing restricting effect
of immobility.
CONCEPT OF JOINT MOBILIZATION
AND MANIPULATION
• SOAP format, Subjective, objective reach a
physical diagnosis and plan of treatment
• History, Observation, Examination and Evaluation,
reaching a physical diagnosis and plan your
treatment.
• SCREENING TEST. This is a designed as short
course procedure in patient evaluation to allow the
therapist to regionalized the area of pathology. PT
is not confirming the problem but it localized the
region of the problem
SCREENING TEST
• UPPER QUARTER, This includes cervical, thoracic,
T1-T5, shoulder, elbow, forearm, wrist and hands
• LOWER QUARTER: This includes thoracic spine of
T6-T12, Lumbar spine, SIJ, hip, Knee ankle and
foot.
• Screening test is important because majority of
patient have problems in contractile and non
contractile tissues
• Contractile = muscle, tendon, non contractile are
ligament capsule and nail
HOW DO YOU KNOW THE AFFECTED
PART
• This is by selective tension test (SIT)
• It consist of Active ROM, Passive ROM and
resisted Test
• AROM provides information as to quality of rom in
that joint. i.e capsular pattern limitation, painful
arch syndrome, limitation in ROM, muscle tear or
stress,
• PROM: Provides an information on non-contractile
inert tissues .e.g ligament.
• An end feel is observed.
• It also involved several provocative tests which will
provoke a pathology
KALTEBORN SCALE ON
ACCESORY MOVEMENT
• Kalteborn designed a scale to measure degree of
stiffness which could be called accessory movement at
a specific joint of the body
• 0=No movement (joint ankylosis)
• 1=Considerable decrease in movement
• 2= Slight decrease in movement
• 3=Normal movement
• 4= Slight increase in movement
• 5= Considerable increase in movement
• 6= Unstable Joint or instability
Hypomobility
Hypermobility
• Resisted test: Place the joint in a mid ROM and ask
the patient to contract isometrically against the
physiotherapist hand in a way that there is no
movement of the joint.
• The external force must be greater than the
contraction force.
• In RT the pain and strength of the contraction
indicate the degree of lesion of tissues. A painful
and weak contraction means a major lesion
probably grade II, but if it is a strong contraction
with pain it may be grade 1 strain
• Painless and strong contraction is normal
• Painless but weak contraction is neurological
• Provocative Tests: For upper limb, lower limb, and
the spine
• X ray, MRI and other labouratory tests
RESISTED TEST
• Resist each of the functional movement earlier
mention for each joint.
• PROM: The segment of the body esp. peripheral
joints to be tested is moved by Physiotherapist.
Pain in the joint during movement indicate a
pathology especially of ligament or joint surfaces
END FEELS
• End feel is the resistance obtained during passive
movement of any joint at the first time
• The end feel is the quality of movement perceived
by the practitioner at the very end of the available
range of motion. The end feel can reveal a great
deal about the nature of various pathologies
• It is the sensation imparted to the examiner's
hands at the end point of the available range of
motion.
• The texture of resistance felt when a joint reaches
the end of its range of motion.
NORMAL AND PATHOLOGICAL
END FEEL
• Normal end feel are restriction to ROM which was not
caused with any disease or pathology
• Pathological end feels are restriction caused by a
disease
Types
• Hard (Bony): motion is stopped when bone contacts
bone. Normal end for some joints. Abnormal if there are
loose fragments in joint that stop the motion
• Soft: motion is stopped by soft tissues being
compressed. Normal for some joints. Abnormal if there
is a boggy feel to motion, indication of oedema
Firm or springy
• Firm or springy: motion is stopped by soft tissue
that have reached there limit of stretch. If motion
is limited this is a sign of tissue shortening. It may
be as a result of foreign body in a joint.
• Empty: motion is stopped in response to the
patients request (experiencing considerable pain)
always abnormal. It is characterised with acute
lesion. There is marked pain on slight touch
• Spasm: muscle contraction and pain are expected
at the end of the ROM always abnormal feel
• Capsular pattern limitation: It is a limitation in all
ROM a pathological end feel resulting from
tightening of capsule and ligamentous in
extensibility
LOOSE/Open AND CLOSE PACKED
POSITION
• Loose pack position is a position of joint in
which the joint capsule is most relaxed.
• It is the position in which the joint has
greatest amount of joint play movement.
• a point in the range of motion of a joint at
which articulating surfaces are the least
congruent and the supporting structures are
the most lax.
•
•
• During mobilization, the joint is placed in loose
pack position
• Loose pack position for knee joint is 250
Flex,
• Hip Joint 30 flex; 30 abd; slight ER,
• Elbow, 70 flex; 10 sup,
• gleno-humeral joint 55-70 abd; 30 horiz add,
neutral
• Close pack position:
• Position with the most amount of joint congruency
•Capsule and supporting ligaments maximally tight
•Accessory motion is minimized
• Gleno-humeral joint: Maximal abd & er, elbow,
Full ext & sup
• Hip: Ligamentous: full ext, abd, IR, Bony: 90 flex;
slight abd; slight ER knee joint, Full ext & ER
•
•
IMPORTANCE
• it is important to start joint assessment and
treatment in the open-packed position. Since the
joint has the most available room for movement,
mobilizations are best tolerated in this position.
• For example, the open-packed position of the knee
is 25 degrees of flexion. The close-packed position
is full extension. At 25 degrees of flexion the knee
is loose- one can assess varus and valgus ligament
stress testing
• Biomechanically, the knee is 'unlocked.' Following
an injury, the body favors this position because
there is space for swelling and other fluid to
accumulate within the joint.
• Manipulation of a joint should be in the open-packed
position, but often times we cannot target a specific
joint unless we lock out or close-pack the surrounding
joints.
• For example, when performing a prone SIJ distraction
manipulation, the hip needs to be placed in extension,
abduction, and internal rotation.
• These three movements are the close-packed position
of the hip joint. You must lock out the hip so you do not
manipulate it when you are targeting the SIJ
TREATMENT PRINCIPLE
• Patient Positioning: Patient should be in the most
comfortable position to aids relaxation. And to
decrease muscle tension. If patient is not relaxed,
PT will be working against tension or tissues
resistance hence, maximum comfortability is
essential.
• PT positioning: PT should observed correct
biomechanics. i.e correct posture. This will prevent
excessive load on the back by making use of knee
and lower back.
• Fixation: Fixation and mobilization. Hand of the
therapist must be closed to the joint space
especially during gliding.
TREATMENT DIRECTION
• In distraction, movement should be done at right
angle to the treatment plane
• Distract from 5-8 seconds and rest four minutes
• Treatment Progression.
• Start with distraction, b/c distraction increases
Rom in all direction
• Then proceed to gliding
• You can distract for 10 times, re evaluates and
another 10 trial
• If there is no increase in ROM, re evaluate.
Muscle Energy Technique MET
• describes a broad class of manual therapy
techniques directed at improving musculoskeletal
function or joint function, and improving pain
• Muscle energy is a direct and active technique;
meaning it engages a restrictive barrier and
requires the patient's participation for maximal
effect. As the patient performs an isometric
contraction there is
• inhibition of agonist muscles by Golgi tendon organ
activation results in direct inhibition of agonist
muscles
• A reflexive reciprocal inhibition occurs at the
antagonistic muscles
• As the patient relaxes, agonist and antagonist
muscles remain inhibited allowing the joint to be
moved further into the restricted range of motion.
FORMS OF MET
• In the course of knee flexion (or any other joint), a
muscle or group of muscles contracts in order to
produce the desired movement.
• The active muscle(s) in flexing the knee are the
hamstring group on the back of the thigh. The
active muscles in any action are known as the
agonists
• At exactly the same time another set of muscles
relaxes, so that the movement will be produced in a
smooth coordinated manner.
•
• When the knee bends it is the muscles on the front
of the thigh that relax in this way, the quadriceps.
• These muscles, which are capable of performing
precisely the opposite movement if they contract
(i.e. straightening the knee), are known as the
antagonists
• The coordination between the opposing muscles of
any area is automatic and it happens without
conscious effort.
• It depends upon a physiological law which declares
that contraction of any muscle will produce, under
normal conditions, relaxation of its antagonist
• When we speak of muscles being antagonistic, we
of course do not mean that they have a grudge
against each other.
• Rather, it indicates that one muscle’s action will be
directly opposed by another’s.
• They balance each other and thus work together
cooperatively by virtue of the one releasing its
contraction, and relaxing, as the other contracts,
to produce coordinated movement.
As the muscles on the front of your arm
(the flexors) contract, in order to allow you
to lift a glass to your lips, so the muscles
on the back of your arm, the extensors,
relax, in order to allow this to happen
smoothly without jerking or hesitation. The
flexors in this example are contracting and
as they do so they are getting shorter. This
is called a concentric contraction. While
this is happening it is important for the
antagonists to continue to exert some
effort, in order to maintain stability. If they
were completely relaxed (e.g. paralysed)
then the movement would be uncontrolled,
uncoordinated, spastic and jerky (as
occurs in people with nerve damage such
as in cerebral palsy).
When it is time to put the glass down again,
the opposite happens. As the extensors
straighten out the elbow, the flexors, in a
controlled manner, release their hold on the
bent elbow joint
• In this particular example, the flexors of the arm
(which bent it in the first place) do not just release
all effort or there would be a sudden straightening
of the arm and the glass would smash onto the
table.
• Rather, they continue to contract but while they
are doing so, they get longer and release the pull
on the elbow.
• Being able to contract and at the same time stretch
is a most important muscular facility. This is called
an eccentric contraction
RECIPROCAL INHIBITION
• To use MET efficiently we need to be aware of the
fact that muscles are mutually antagonistic to their
opposite numbers and that this offers us a
wonderful way of making tight muscles relax.
• The automatic quality of an antagonist relaxing
when its opposite number is tightening
(contracting) is known as reciprocal inhibition.
APPLICATION
• If the muscles of the front of the arm, to stay with that
example, are tense, possibly after gardening, tennis or
an injury, one can use the muscles on the back of the
arm to relax these tight muscles.
• Take the arm to its maximum comfortable degree of
straightness, ensuring that in doing so it does not
produce pain (which it would if it went beyond its
present restriction barrier),
• and at that point, whilst restraining your lower arm
with your other hand (i.e. preventing it from moving),
tried to gently take your arm towards a greater degree
of straightness, by contracting the muscles of the back
of your arm, what would happen?
• As one tries to make the arm straight (i.e. pushing
gently towards the
restrictive barrier) one would be contracting the
muscles of the back of the
arm.
These are the antagonists of the tight muscles which
are in trouble and by preventing any movement from
taking place (by using your other hand), it is
possible to ensure that no strain occurs at the painful
joint or in the tight muscle(s).
One would in effect have a matching of forces. The
extensor muscles would be trying to pull the arm
straight, while your free arm resists this, completely
and exactly.
This is called an isometric contraction. The forces
match each other and no movement occurs
• As this isometric contraction of the extensor
muscles is taking place to try to straighten your
arm, their antagonists (the shortened flexors)
would be obliged to relax, according to
physiological law. Therefore, after this MET
isometric effort, which could last for 5–10 seconds,
you would find that the arm which was previously
limited in its ability to straighten would be capable
of an increased degree of normality.
• The barrier, or point of bind, would have been
pushed back a little as the flexor muscles relax.
• By repeating this whole procedure several times,
until no further gain in the range of movement is
noted, it might be possible to completely normalize
the shortened muscles.
Post-isometric relaxation
• This time, the very muscles which had shortened
(the agonists) would be contracting against
resistance and, after an appropriate period, say 5–
10 seconds, of this isometric contraction (no
movement allowed to occur, only effort) a new
phenomenon would become apparent.
• This is called post-isometric relaxation (PIR).
• This means that any muscle, or group of muscles,
which is isometrically contracted is obliged to
relax afterwards.
• So if a muscle is tense or tight and it is then
isometrically contracted, it will, to some extent,
release and relax afterwards, allowing it to be more
easily stretched afterward
WHICH METHOD TO BE USED
• The presence of pain is frequently the deciding factor
in choosing one or other of the methods described (PIR
or RI).
• It is clear that when using PIR, the very muscles which
have shortened are being contracted.
• If the area is already painful and any contraction could
well trigger more pain, it might be best to avoid using
these muscles and choose instead the antagonists.
• The antagonists, which are usually pain free, might
well be the first choice for MET use, when the
shortened muscles are very sensitive.
Later, when pain has been reduced by means of
muscle energy (or other) methods, PIR techniques
(which use isometric contraction of the already
shortened muscles rather than the antagonists used
in RI methods) could be used.
To a large extent, deciding whether a condition is
acute or chronic can determine the method best
suited to treating it
ISOTONIC MET METHOD
• When the muscles of your arm contract as you
bring a glass to your lips, they are both contracting
and shortening. Technically this is called a
concentric isotonic contraction. This means that
the two ends of the muscle(s), the origins and
insertions, that are contracting are getting closer
together.
• This is what people do when they lift weights and,
as is obvious from that activity, this helps to tone,
strengthen and ‘build’ muscles.
• So we can usefully introduce concentric isometric
activities when we want to achieve increased
strength and tone.
• In isotonic concentric contractions the effort of the
contracting muscle is resisted but not quite
overcome.
• Should a group of muscles be weak, after disuse for
example, and should you wish to tone these up, you
have a perfect tool in concentric isotonic methods
of muscle energy.
ECCENTRIC ISOTONIC
CONTRACTION
• contrast to this last example, when your arm is
putting a glass down, the muscles will be
contracting but despite this they are also
lengthening.
• Technically this is known as an eccentric isotonic
contraction.
• Here the muscle’s origin and insertion (where the
muscle attaches into bone as an anchor point) get
further apart, despite the contraction of the
muscle.
• This can be used to dual effect in particular
exercises, especially if performed very slowly
(note: a slow eccentric isotonic stretch is
abbreviated as a SEIS).
• The two effects of a SEIS are to tone the muscle
that is slowly eccentrically stretching, while at the
same time this activity is creating a reciprocal
inhibition of its antagonist, so allowing the
antagonist to be more easily stretched afterwards.
Myofascial Release
• Myofascial Release is a safe and very effective
hands-on technique that involves applying gentle
sustained pressure into the Myofascial connective
tissue restrictions to eliminate pain and restore
motion.
• This essential “time element” has to do with the
viscous flow and the piezoelectric phenomenon: a
low load (gentle pressure) applied slowly will allow
a viscoelastic medium (fascia) to elongate.
• It is a therapy that treat skeletal muscle
immobility and pain by relaxing contracted
muscles, improving blood and lymphatic
circulation, and stimulating the stretched reflex in
muscles
• What is fascial:
• Fascial is a thin, tough, elastic type of connective
tissue that wraps most structures within the
human body, including muscle. Fascia supports and
protects these structures
• soft tissue can become restricted due to
psychogenic disease, overuse, trauma, infectious
agents, or inactivity, often resulting in pain, muscle
tension, and corresponding diminished blood flow.
Techniques For planta fascilitis
Techniques for soleus or calf muscle
MFR does not use oils or lotions, it is
performed dry so that the practitioner
avoids glide over the skin but can feel
deeper into the tissue.
MFR cultivates a sense of touch so that
each and every treatment is uniquely
delivered with skilled ‘listening’ hands
Techniques using fingers for Hamstring muscle
Using a molding-
conforming non-
fist stroke from
the
tarsals up over the
retinaculum.
Using knuckles
engage and stroke
the area just lateral
to the tibialis and
medial to the
anterior tibialis from
the ankle to the
tibia condyle
Place knuckles
together forming a
“roof”. Place this roof
over the tibia with the
lateral edge of the
tibia riding in the peak
of the roof. Engage and
stroke from the ankle
to the tibial condyles
then separate hands as
you spread laterally
and medially.
Using the flat of the forearm
near the elbow stroke from
the upper trapezius to the
iliac crest and over the sacral
fascia
At level of scapular inferior
angle
“turn the corner” and stroke
with
position shown
• Trauma, inflammatory responses, and/or surgical
procedures create Myofascial restrictions that can
produce tensile pressures of approximately 2,000
pounds per square inch on pain sensitive structures
that do not show up in many of the standard tests
(x-rays, myelograms, CAT scans, electromyography,
etc.)
• Myofascial Release Treatment session is performed
directly on skin without oils, creams or machinery.
• This enables the therapist to accurately detect fascial
restrictions and apply the appropriate amount of
sustained pressure to facilitate release of the fascia.
• Myofascial release (MFR) therapy focuses on releasing
muscular shortness and tightness
• Indication for MFR.
• back, shoulder, hip, pain in any area containing soft
tissue
• Temporo-Mandibular Joint (TMJ) disorder, carpal tunnel
syndrome, or possibly fibromyalgia or migraine
headache
Causes of Myofascial Pain
• Pain can be generated from the skeletal muscle or
connective tissues that are 'bound down' by tight
fascia.
• Pain can also be generated from damaged
myofascial tissue itself, sometimes at a 'trigger
point' where a contraction of muscle fibers has
occurred
• The restriction or contraction inhibits blood flow to
the affected structures, thus accentuating the
contraction process further unless the area is
treated.
• The goal of myofascial therapy is to stretch and
loosen the fascia so that it and other contiguous
structures can move more freely, and the patient's
motion is restored
• The specific releases to different parts of the body
vary, but generally include gentle application of
pressure or sustained low load stretch to the
affected area.
• Progress is gauged by the level of increased motion
or function experienced, and/or decrease in pain
felt by the patient.
Examples of Joint Mobilisation Techniques
• Muscle Energy Techniques
• Myofascial Release
• Mobility Exercises
• Traction
Traction
• traction is an process which pulls 2 segment of the body away from one another to create expansion and eliminate compression
• The word traction is a derivative of the Latin word "tractico“
• which means "a process of drawing or pulling
• It can be used for the spine (Cervical and Lumbar) and peripheral joints (Upper and Lower Limbs).
• For the Peripheral Joints, the types includes Skin traction and Skeletal Traction
Skin Traction
• skin traction is widely used in the lower limb for femoral fractures, lower backache, acetabular and hip fractures.
• Skin traction rarely reduces a fracture, but reduces pain and maintains length in fractures
• Method
• The skin is prepared and shaved -it must be dry. Friar's balsam may be used to improve adhesion.
• The commercially available strapping is applied to the skin and wound on with an overlapping layer of bandage. The bandage should not extend above the level of the fracture.
Complication of Skin Traction
• Distal Oedema
• Vascular obstruction
• Peroneal nerve palsy
• Skin Necrosis over bony prominence's
• If the tapes slip rather use skeletal traction if possible
Skeletal Traction
• Skeletal traction involves using screws, wires, or pins to keep bones in place
• skeletal traction is often only a temporary measure until definitive treatment can be applied.
• The specific technique of skeletal traction varies.
• Distal femoral or proximal tibia sites are most frequently used for pin placement
TRACTION FOR PHYSIOTHERAPY
• CERVICAL
• Cervical traction devices treat different types and causes of neck pain, tension, and tightness.
• It can be intermittent or continuous. It is applied for about 15 minutes per session
• Cervical traction helps to relax the muscles, which can significantly relieve pain and stiffness while increasing flexibility.
• It’s also used to treat and flatten bulging or herniated disks.
• It can alleviate pain from joints, sprains, and spasms. It’s also used to treat neck injuries, pinched nerves, and cervical spondylosis.
• These improvements may lead to improved mobility, range of motion, and alignment.
• This will allow you to go about your daily activities with greater ease
METHOD OF CT
• Manual cervical traction
• Manual cervical traction is done by a physical therapist. While you’re lying down, they’ll gently pull your head away from your neck. They’ll hold this position for a period of time before releasing and repeating. Your physical therapist will make adjustments to your exact positioning in order to get the best results.
MECHANICAL
• Mechanical cervical traction is done by a physical therapist.
• A harness is attached to the head and neck as patient is lying flat supine.
• The harness hooks up to a machine or system of weights that apply traction force to pull the head away from the neck and spine
Over-the-door cervical traction
• An over-the-door traction device is for home use.
• Attach the head and neck to a harness.
• This is connected to a rope that’s part of a weighted pulley system that goes over a door.
• This can be done while sitting, leaning back, or lying down.
• 10% TBW CT as the ideal weight with minimal side effects and with highest therapeutic efficacy.
NECK STRETCHER
SIDE EFFECT
• Generally, it’s safe to perform cervical traction, but remember that results are different for everyone.
• The treatment should be totally pain-free.
• It’s possible that you can experience side effects such as headache, dizziness, and nausea upon adjusting your body in this manner.
• This may even lead to fainting.
• Stop if you experience any of these side effects, and discuss them with your doctor or physical therapist
CONTRAINDICATION
• It’s possible to injure the tissue, neck, or spine.
• cervical traction should be avoided if in patient with:
• rheumatoid arthritis
• Post-surgery hardware such as screws in your neck
• a recent fracture or injury in the neck area
• a known tumor in the neck area
• a bone infection
• issues or blockages with vertebral or carotid arteries
• osteoporosis
• cervical instability
• spinal hypermobility
• Cervical traction devices work by stretching the spinal vertebrae and muscles to relieve pressure and pain.
• Force or tension is used to stretch or pull the head away from the neck. Creating space between the vertebrae relieves compression and allows the muscles to relax.
• This lengthens or stretches the muscles and joints around the neck.
LUMBAR TRACTION
• Lumbar traction is the process of applying a stretching force to the lumbar vertebrae through body weight, weights, and/or pulleys to distract individual joints of the lumbar spine
• Lumbar traction is a therapeutic modality used by some physical therapists to treat back pain or sciatica.
• Lumbar, or low back, traction helps to separate the spaces between vertebrae
Types of Lumbar Traction
• Continuous Traction
• Continuous or bed traction uses low weights for extended periods of time (up to several hours at a time). This long duration requires that only small amounts of weight be used.
• It is generally believed that this type of traction is ineffective in actually separating the spinal structures.
• In other words, the patient cannot tolerate weights great enough to cause separation of the vertebrae for that length of time
Sustained Traction
• This type of traction involves heavier weights applied steadily for short periods of time (for periods from a few minutes up to 1 hr). Sustained traction is sometimes referred to as static traction
• Intermittent Mechanical Traction
• Intermittent traction is similar to sustained traction in intensity and duration but utilizes a mechanical unit to alternately apply and release the traction force at preset intervals
Manual Traction
• Manual traction is applied as the clinician's hands and/or a belt are used to pull on the patient's legs.
• It is usually applied for a few seconds duration or can be applied as a sudden, quick thrust
Auto-traction
• Auto-traction utilizes a specially designed table that is divided into two sections that can be individually tilted and rotated. The patient provides the traction force by pulling with the arms and/or pushing with the feet. Investigations of auto-traction have reported favorableclinical results but no change in size or location of lumbar disc herniation
Positional Traction
• This form of traction is applied by placing the patient in various positions using pillows, blocks, or sandbags to effect a longitudinal pull on the spinal structures.
• It usually incorporates lateral bending and is only affected to one side of the spinal segment
Gravity lumbar traction
• This involves using a chest harness to secure the patient as the treatment table is tilted to a vertical position, thereby using the weight of the lower half of the body to provide a traction force
HOW DOES IT WORK ?
• Several theories have been proposed to explain the possible clinical benefit of traction therapy.
• Distracting the motion segment is thought to change the position of the nucleus pulposus relative to the posterior annulus fibrosus or change the disc-nerve interface
• In addition to separating the vertebrae, traction has been shown to reduce nucleus pulposus pressure and increase foraminal area
• However, it is unlikely that mechanical changes observed in a prone position will be sustained after a patient resumes an upright, weight bearing posture
• It is possible that some forms of traction stimulate disc or joint repair whereas others promote tissue degradation
EVIDENCE
• Summary evidence in recent systematic reviews and clinical practice guidelines concludes that mechanical lumbar traction is not effective for treating acute or chronic nonspecific low back pain (LBP); however, many physical therapists continue to use it, primarily as an additional modality.
Exercises to Improve Hip Mobility & Loosen Tight Hips• Lying Hip Rotations
• Piriformis Stretch
• Butterfly Stretch
• Frog Stretch
• Kneeling Lunge
• Traveling Butterfly
• Squatting Internal Rotations
• Pigeon Stretch
Cross one
ankle across
the opposite
knee and
rotate the hip
in and out.
Lying Hip Rotations
Piriformis Stretch• Cross one knee over the opposite thigh and pull the
knee toward the opposite shoulder.
Butterfly Stretch
• it with two feet together and move the knees
toward the floor.
Frog Stretch
• On all fours, separate the knees as wide as one can and rock back and forth.
Kneeling Lunge
• Get into a lunge position and keep the chest tall as you move the hips back and forth.
Traveling Butterfly
• Move from the long sitting position to the butterfly
position.
Squatting Internal Rotations
• Move from the long sitting position to the butterfly
position.
Pigeon Stretch
• Sit with one knee bent to 90-degrees in front, and
one knee behind, rotating the back hip forward and
backward.
BANDAGING
• Bandage: a strip or roll of gauze or other material
for wrapping or binding any part of the body.
• a long strip of thin or elasticized fabric that is
wrapped around a wound or injured part of the
body to protect or support it
• Bandaging is a process of applying a bandage.
USES
Bandages may be used to
• stop the flow of blood,
• absorb drainage,
• cushion the injured area,
• provide a safeguard against contamination,
• hold a medicated dressing in place,
• hold a splint in position, or
• otherwise immobilize an injured part of the
body to prevent further injury and to
facilitate healing
CAUTION IN BANDAGING
• If the skin is broken a sterile pad or several
thicknesses of sterile gauze should be placed over the
wound before tape or bandaging material is applied
over the pad to hold it in place.
• Adhesive tape is never applied directly on a wound
• The bandage should not be made so tight that it
interferes with circulation.
• A pressure bandage should be applied only for the
purpose of arresting haemorrhage
• A bandage does not have to look good to be effective;
in an emergency, that the bandage serves its purpose
is more important than its appearance.
RULES OF BANDAGING
• Apply the outer side of the tail of the bandage to the injured
part.
• Bandage limbs from below upwards and from within
outwards.
• Apply a bandage so that each layer covers two-thirds of the
previous one. Keep the edges parallel.
• Never bandage without having previously applied a pad of
cotton wool. Such a pad should around a limb or a finger.
The cotton wool prevents compression of the veins and still
allows the bandaging to be firm. If there is a wound, gauze
should be placed over it before the cotton wool is applied.
• Stand in front of the hand or foot when bandaging a limb.
• In dressing a limb or fixing a splint do not cover the
tips of the fingers or toes; they are a useful guide
to whether the bandage is too tight. Blueness of
the nails and swelling or numbness of the fingers
indicate the need to loosen the bandage.
• Make all reverses or crossings in a line on the outer
side of the limb.
•
• When bandaging the elbow, keep it at right angles
and make sure that a large pad of cotton wool is
placed round the joint to avoid constricting the
blood vessels.
• When bandaging the knee keep it slightly bent.
• Complete the bandage with a safety-pin or a narrow
strip of adhesive plaster.
TYPES OF BANDAGE
There are four main types of bandage
• gauze,
• compression,
• triangular and
• tube
• Gauze bandage (common gauze roller bandage
• The most common type of bandage is the gauze
bandage, a simple woven strip of material, or a
woven strip of material with a Telfa absorbent
barrier to prevent adhering to wounds.
• A gauze bandage can come in any number of
widths and lengths, and can be used for almost any
bandage application, including holding a dressing
in place.
Compression bandage
• The term 'compression bandage' describes
a wide variety of bandages with many different
applications
• 1 Short stretch compression bandages are applied
to a limb (usually for treatment of lymphedema or
venous ulcers. This type of bandage is capable of
shortening around the limb after application and is
therefore not exerting ever-increasing pressure
during inactivity.
• This dynamic is called resting pressure and is
considered safe and comfortable for long-term
treatment.
• Conversely, the stability of the bandage creates a
very high resistance to stretch when pressure is
applied through internal muscle contraction and
joint movement.
• This force is called working pressure.
• Long stretch compression bandages have long
stretch properties, meaning their high compressive
power can be easily adjusted. However, they also
have a very high resting pressure and must be
removed at night or if the patient is in a resting
position
Esmarch Bandage is a narrow
natural rubber (latex) or
synthetic rubber (latex-free)
strip that is used to control
bleeding by applying it around a
limb in such a way that blood is
expelled from it.
Esmarch Bandage is ideal for
orthopedic blood-less surgery.
Triangular bandage
• Also known as a cravat bandage, a triangular bandage
is a piece of cloth put into a right-angled triangle, and
often provided with safety pins to secure it in place.
• It can be used fully unrolled as a sling, folded as a
normal bandage, or for specialized applications, as on
the head.
• One advantage of this type of bandage is that it can be
makeshift and made from a fabric scrap or a piece of
clothing.
• The Boy Scouts popularized use of this bandage in
many of their first aid lessons, as a part of the uniform
is a "neckerchief" that can easily be folded to form a
cravat.
Tube bandage
• A tube bandage is applied using an applicator, and
is woven in a continuous circle.
• It is used to hold dressings or splints on to limbs, or
to provide support to sprains and strains, and it
stops bleeding
Techniques of bandage
• When an individual is injured and required
bandaging, being familiar with the various ways on
applying a bandage can greatly help.
• proper bandaging can help protect the injury as
well as stabilize the affected body part
• The type of bandaging to perform usually depends
on the body part where the injury was sustained.
Circular turn
It is the simplest of the roller bandaging techniques
wherein the bandage is rolled over the affected area in a
circular motion, such that each layer is overlapping the
previous layer completely.
As we move on to other techniques, you will notice that
most of these start and end with circular turns, as it helps
in anchoring the bandage.
This technique is mostly used on parts of the body with
uniform circumference, such as the leg, forearm, or finger.
Spiral turn
Like the circular technique, even the
spiral bandaging technique is used on
body parts with uniform circumference.
However, the two differ with respect to
the way the bandage is wrapped and the
area covered. As opposed to the circular
technique, wherein each layer is
completely overlapped by the
subsequent layer, in this technique, each
layer only overlaps ⅔ of the preceding
layer. Unlike in the case of circular
bandaging, wherein the width of the
bandage is same as that of the roll of
bandage, in the spiral technique, the
bandage can be used to cover the entire
limb
Spiral reverse turn
• This is considered as a complex method that is utilized
in bandaging the calves and lower forearms. You can
start by wrapping the bandage around the affected
area two times.
• Move the bandage up at a 30-degree angle and place
the thumb of your free hand on the upper edge.
• The next step is to turn the bandage over so the side
on top is now the bottom. Continue to wrap around the
affected limb so the folds in the turns are aligned.
Connect the end of the bandage using safety pins,
fastenings or tape.
Diverging Spica Technique
Also referred to as reverse spiral
bandaging, this technique is most often
used on body parts with varying
circumference.
Although the turns are spiral, the
bandage is reversed on itself, such that
it stays firm on body parts with varying
circumference.
In this case, you are supposed to secure
the bandage after the first turn, hold it
by your thumb, and reverse it downward.
The same step has to be repeated with
each turn.
Ascending Spica Technique
Also known as figure-of-eight bandaging, the
ascending spica technique is considered the
most useful technique of roller bandaging. Start
by creating two cyclical turns.
The next step is to wrap the bandage around the
back of the joint and around so that it forms the
figure eight around the joint. One have to
continue to wrap the bandage over itself,
covering two-thirds of the previous layer. You
have to encircle the end around the top of the
joint.
Lastly, secure the end of the bandage using
safety pins, tape or fastening
This technique is most often used on joints, like
the wrist, elbow, or ankle.
Recurrent TechniqueIn this case, the bandage is wrapped several times around
itself; hence the name. Starting from the forehead, it begins
with two circular turns.
When it reaches back to the forehead, it is secured and
taken over the head to the back of the head. Subsequently,
it is folded and brought the forehead, and once again taken
all the way behind.
Every turn goes left and right of the first turn, until the
entire head is covered, and then it is secured after rolling it
around the head a couple of times.
Other than the head, recurrent bandaging is also used on
the finger or amputated limb.
Basic knowledge about bandage wrapping techniques can
prove handy in times of emergency. We usually tie the
bandage in a circular method, wherein each turn covers the
preceding turn until the bandage is firmly secured.
While it is not incorrect, it is not as effective as other
techniques.
demigauntlet bandageone that covers
the hand but
leaves the
fingers exposed.
gauntlet bandage
a glovelike bandage
covering the hand and
the fingers. A figure-
of-8 bandage covering
the hand and fingers.
Baton Bandage : a figure-of-8 bandage
supporting the mandible inferiorly and
anteriorly; used in mandibular fracture.
one binding the
elbow to the side,
with a pad in the
axilla, for fractured
clavicle.
Velpeau's bandage