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.

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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

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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.

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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