Subjective Assessment

Present Complaint

• Specific areas

• Type, depth, quality and intensity

• Is it Intermittent or constant pain?

• Easing or aggravating factors?

• Abnormal sensations?

•  24-hour pattern of symptoms.

• Physical Limitations.

SIN Factor) Severity-Irritability-Nature

History of Present Complaint

• How Long?

• Initial cause (do they know)

• Have the symptoms changed since?

• Relationship of symptoms.

• Previous episodes .

Past medical history

• Tyroid, Heart, Rheumatoid arthritis, Epilepsy, Asthma, Diabetes, Steroids

• Recent X-rays or investigations

• Unexplained weight loss

• Fainting, dizziness, visual disturbances

• Cauda equina symptoms

• Other relevant previous/existing conditions?

• Potential treatment contraindications?

Drug History

• Dosage & frequency.

• Perceived effect.

  Any meds for a different condition?

• When was the prescription started?

• Dosage & frequency.

• Any Side effects?

Social History

• Age & gender.

• Home situation.

• Dependents.

• Occupation – Specific duties.

• Leisure activities.

•  Functional limitations/activities to return to.

• Goals- where do they want to get back to

SALTAPS

• See - See the mechanism of the injury

• Ask - Consent & find out what happened via the athlete. What they felt/feel, pain and symptoms.

• Look - Appearance of the injury. Bleeding, Swelling, Bruisin,g Discolouration, Bone/joint deformity

• Touch - Palpate the injury gently. Note the patient’s responses.

• Active ROM - Assess active movement ofthe injured

  site. Can they move the area through full ROM - Pain free?

• Passive ROM - If Active ROM is Ok, assess passively. Can the joint be moved (Via therapist

  input) full range?

• Strength - Can the patient apply force & move against resistance? Walk or stand unaided. Progress to functional tests - like running.

Cryotherapy

• Commonly used to manage acute soft tissue injuries

• Management of acute injuries / Recovery from exercise

• Cooling of tissues
  Reduce to 10 – 15 °C

Cryotherapy applications

Ice: Chips / Crushed / Wetted
Ice baths / immersion
Gel packs
Ice Massage
Cold sprays
Cryo cuffs
Contrast bathing
Phase Change Material
Cryotherapy Chambers

Cryotherapy Contradictions and cautions

Excessive local cooling (ice burn)
Conditions altering cold sensitivity
Raynauds phenomenon /cold urticaria / cryoglobinaemia
Sensory deficits
Cardiac disease
High (or low) blood pressure
Psychological associations with cold

NEVER APPLY ICE DIRECTLY
TO THE SKIN
CHECK PATIENT’S SKIN REGULARLY

Cryotherapy protocols

• Treatment explained and contraindications checked

• Patient is comfortable with the treatment area appropriately exposed & well supported

• Dry towel (& plastic sheet) under the treatment area

• Prepare ice pack: a bag of ice wrapped in a damp towel

• Apply ice pack to area & secure with a dry towel

• Check patient comfort & skin every 3 - 5 mins
  If there are any concerns, stop treatment immediately

Cryotherapy: Cryo cuffs

Ice application with compression
Specialised equipment
• Gravity device
• Electric pump
Different cuffs for different areas

Cryotherapy: Instructions

• Prepare cooler: Fill to line with water

• Add ice to the top

• Position EMPTY cuff with straps (not too tightly)

• Attach pipe and open valve using gravity to fill the cuff

• Close valve & detach pipe

Complete Treatment

Empty cuff before removing:

1. Connect tube and open valve to cooler

2. Position cooler below the cuff (i.e. use gravity)

3. Clean cuff between uses

Superficial Heat application

• Clay hot packs

• Wheat bags / Gel packs

• Paraffin wax

• Warm water immersion (whirlpool / hydrotherapy)

• Heat sprays / gels

Superficial Heat Therapeutic effects

Tissue Healing
Pain Relief
Sedative Effect
Increased Joint RoM

Superficial Heat Physiological effects

Metabolic activity increased
Increased blood flow & tissue fluid exchange
Stimulation of sensory nerves
Immediate skin arteriole vasodilation
Softening of collagen
Fluid viscosity reduced

Superficial Heat Contraindications & Precaution

Skin checks required (test tubes)
Patients with:
Cognitive impairment (e.g. dementia)
Circulatory insufficiencies (e.g. DVT, peripheral vascular disease)
Treatment should not be applied over:
Areas of malignancy
Active bleeding sites
Active epiphysis plates
Metal implants
Eyes

Superficial Heat Practical Applications

• 2 x towels

• 1 x appropriately sized hot pack

• Preparation table

• Towels folded in half lengthways

• Towels laid over each other at 90°

• Clay pack placed in centre of the ‘cross’

• Towels folded in (bottom towel first

• Hot pack wrapped in towels placed on pt

• 8 towel layers between pt andhot pack
  i.e. ‘folded in’ side against pt skin

Proposed Mechanisms for Effects of US

• Stable Cavitation: tiny gas bubbles formed by the dissolving of gas in the
  medium enabling acoustic streaming

• Acoustic Streaming: circulatory flow, eddying of fluids near vibrating
  structure i.e. cell membrane or gas bubbles – causes increase in cell
  membrane permeability potentially enhancing healing process

• Micromassage: Oscillatory movement of tissue (Compression and
  Rarefaction) is proposed to have an effect but there is less evidence

Ultrasound Contraindication

• Uterus during pregnancy

• Malignant tissue

• Open wounds / bleeding tissues

• Significant vascular abnormalities
  (e.g. DVT, emboli, arteriosclerosis / atherosclerosis)

• Haemophillia (not covered by factor replacement)

• Application over: active epiphyses in children / eyes / stellate ganglion/heart with

• pacemaker or heart in advanced heart disease/genitals / metal implants

CAUTIONS

Always use the lowest therapeutic intensity/dosage

Always keep the applicator moving throughout treatment

How does Ultrasound work?

The transducer probe generates and receives sound waves using a principle called the Piezoelectric Effect (ability of certain materials to generate an electric charge)

Ultrasound concepts and terma

• Attenuation: Reflection, Refraction and Absorption

• BNR: Variability of beam intensity (lower = better)

• Effective Radiating Area: Area of US head producing US

Frequency

This determines depth of penetration
Increased frequency = increased absorbency
1 MHz = Deep
2 to 5cm depth
3 MHz = Superficial
Up to 2cm depth

Intensity

This is the rate at which energy is being is being delivered to the tissue
Measured in Watts per cm2 (W/cm2)
Always use the lowest dose to achieve the desired therapeutic effect

Pulse ratio

Ratio of ultrasound machine producing US and rest periods in between
Expressed as a percentage or a ratio
time on : time off e.g. 1:4 or 20%

Treatment parameters

• Lesion depth:

  1Mhz = Deep (2 - 5cm)
  3Mhz = Superficial (< 2cm)

• Pulse Ratios:

  Acute 20 – 25%
  Sub-Acute 25 – 50%
  Chronic 50 – 100%

• Intensity:

  Acute 0.1 – 0.3 w/cm2
  Sub-Acute 0.2 – 0.5 w/cm2
  Chronic 0.3 – 0.8 w/cm2

Treatment time calculation

1. Select a treatment head applicator appropriate to size of area
   (e.g. 1cm, 2cm, 5cm)

2. How big is the treatment are compared to the size of the applicator (e.g. x1, x2, x3)

3. Calculate your pulse factor (add pulse ratio numbers together)
   (e.g. a 1:4 ratio would be 1 + 4 = 5)

4. Number of heads x pulse factor x 1 min = total minutes
   (e.g. 2 heads area at 1:4 ratio = 2 x 5 x 1 = 10 mins treatment)

Ultrasound protocol

Treatment explanation & contraindication check
Treatment consent gained from patient
Hot & cold sensory check (test tubes)
Applicator size selected
Treatment parameters selected (lowest therapeutic dose)
Time calculated (pulse factor x applicator heads on area)
Coupling gel applied to applicator
Applicator applied to skin and movement started
Remind Pt they must inform you if they feel abnormal
sensations during treatment (e.g. warming of tissues)
Treatment commences (applicator moved continuously)
Treatment completes applicator and skin wiped clean
Post treatment observations and patient subjective
Treatment parameters & details recorded in patients notes

Clinical Indications

Pain Relief (pain gate / opioid mechanism)
Muscle Stimulation (twitch to tetanic)
Increase Local Blood Flow
Reduce Oedema

IFT Principles

• Low frequency current offers potential
  therapeutic effects

• 2 x medium carrier frequencies

Carrier Frequency

This is the medium frequency current applied to the body

Amplitude Modulated / Beat

The frequency created via the out of sync carrier frequencies

IFT Electrodes & Area of Stimulation

Bipolar electrodes (2).
Quadripolar electrodes (4)
Co-planar
Contra-planar

Disposable / Single use
Suction / Vacuum
Reusable pads

IFT Treatment Parameters

• Bipolar / Quadripolar (2 or 4 electrodes)

• Electrode Type (pads, suction, disposable)

• Carrier Frequency (1kHz – 10kHz)

• Beat Frequency / AMF (sweep / constant, 0 – 150Hz)

• Sweep Mode (rise and fall of beat frequency)

• Surge Mode (rise and fall of intensity)

• Intensity (strong but comfortable)

• Treatment Time (acute / chronic)

• Treatment Time (acute / chronic)

Total treatment time usually 15-20 mins
(This may be constructed of different modes)
Acute = Shorter treatment times - 5-10 mins

IFT Beat Frequency

Muscle stimulation 10 - 20Hz (sweep)
Pain Gate 100 - 130Hz (constant)
Promote Healing 25 - 50Hz (sweep)
Reduce Swelling 10 - 100Hz (sweep)

IFT Constant and sweep cycles

Constant – frequency stays the same
Body may begin to accommodate
Sweep – Freq changes gradually
Attempt to reduce the accommodation
Wide sweeps seen to be ineffective & may be counterproductive

IFT Treatment Protocol

Contraindications & skin sensation check (sharp / blunt)
Treatment explanation and pt consent
Ensure patient comfort and appropriate positioning
Electrodes placed & secured around treatment area (sponges must be damp)
Input IFT treatment settings
Begin treatment and slowly turn up intensity to be ‘strong but comfortable’
After a few mins the intensity can be increased a little (only do this once)
Complete treatment time
Remove pads and check treatment area (observations)
Record pt subjective feedback & observations and full treatment settings

IFT Contraindications

Pacemaker
Advanced cardiovascular conditions
Epilepsy
Active / suspected malignancy
Patients who cannot comprehend Rx
Anticoagulation therapy / history of embolism

Do not place pads over:
Trunk / pelvis during pregnancy
Carotid sinus & Anterior neck region
Areas of reduced/altered sensation or circulation
Dermatological lesions e.g. dermatitis
Over metal implants
Bleeding tissues
Close to the eyes or in mouth
Varicose veins
Anterior chest wall
Over a joint replacement

Treatment Record

Treatment area and aim of treatment
Number of electrodes
Placement of electrodes
Frequency applied & sweep
Treatment Intensity (& / or pt subjective feedback)
Treatment duration

What is TENS

Electrical stimulation of nerves
Used for pain relief

TENS Theoretical Principles

Reduce pain through stimulation of sensory nerves
Proposed to relieve pain through:
Pain gate mechanism (A Beta fibres)
Opioid system stimulation (A Delta fibres)
Good evidence to suggest provides pain relief

What is TENS used for

• Regularly used in practice for chronic pain

• Research also supports use for acute p

• Patients are encouraged to explore the settings
  (within boundaries & guidance)

TENS Contraindications

Cancer
Pregnancy
Pacemaker
Metal implants
Epilepsy

Do not place the pads:
Over a pregnant uterus (womb)
Carotid sinus (Anterior neck) region
Areas of reduced or altered sensation
On dermatological lesions e.g. dermatitis

TENS Directins step by step

Test the machine by holding the pads between your fingers &
carefully increase the intensity to feel a tingling sensation
Check contraindications & complete skin sensation test completed before application
Area of skin where electrodes are to be placed must be clean. No cuts, grazes or skin irritation
Place the pads around the area of pain at least an inch apart (e.g. above and below)
Select treatment parameters (see other slides)
Switch the machine on slowly & turn up gradually until patient feels strong but comfortable
sensation
After a few mins the sensation will reduce slightly (accommodation) at this point turn the machine
up slightly
Do not turn the machine up too high as can cause over stimulation which may increase pain
There should be NO muscle contraction

Hi TENS Treatment Settings

High Frequency 80 – 130 hz (or pps)

Stimulates A-beta fibers, blocks pain signals through the Gate Control Theory.

Narrow pulse width ~ 100 micro seconds
30 minutes +

shorter pulse width for superficial pain relief).

Good acute pain relief

Lo TENS Treatment Settings

Lower frequency 2 – 5 hz

Targets A-delta fibers, stimulates endorphin release for long-lasting relief.
Longer pulses 200 – 250 micro seconds

Longer pulse width for deeper tissues

For chronic pain and deeper tissue relief.

Brief Intense TENS Settings

Aims to provide quicker pain relief

High pulse frequency (90 – 130 Hz)
High pulse width (200 micro sec +)

15 – 30 mins

Burst Mode TENS Settings

raditional / Hi TENS settings
…but with burst mode so current is interrupted
2 – 3 burst per second
Intensity can be slightly higher than Hi TENS (but lower than brief)

Please explain the therapeutic effects of ultrasound?
How do these relate to our patient and the stages
of healing?

• Non-Thermal Effects: (Pulsed Mode)

• Enhances cell membrane permeability

• Stimulates tissue repair and protein synthesis

• Reduces inflammation

• Promotes angiogenesis and wound healing

How would you explain the US treatment to a patient?

I’m going to use an ultrasound device to help reduce pain and improve healing in your [injured area]. This will send sound waves into the tissue, promoting blood flow and cellular repair. You might feel a gentle warmth or nothing at all, but it’s working to speed up your recovery. I’ll keep the device moving to make sure it’s comfortable and effective.

What should the patient feel during the US treatment?

• hermal Mode: Mild warmth, comfortable sensation.

• Non-Thermal Mode: Likely nothing noticeable; sometimes a slight tingling.

• Abnormal Sensation: Sharp pain, burning, or discomfort should be reported immediately.

How would you explain the TENS treatment to a patient?

I’m going to use a TENS device, which sends small electrical impulses to your skin. These impulses block pain signals from reaching your brain and help your body release natural painkillers. You might feel a gentle tingling or pulsing sensation, and I’ll adjust it to keep it comfortable. The goal is to reduce your pain so you can move more easil

What should the patient feel during the TENS treatment?

• Conventional TENS: A mild tingling or buzzing sensation—should not be uncomfortable.

• Low-Frequency TENS: A stronger pulse with muscle twitching, but still comfortable.

• Burst Mode: More intense, rhythmic pulses—strong but not painful.

Please explain the therapeutic effects of Cryotherapy?

• Vasoconstriction: Reduces blood flow, minimizing swelling and edema.

• Decreased Metabolic Rate: Slows cellular metabolism, reducing tissue damage and oxygen demand.

• Reduced Nerve Conduction Velocity: Slows down nerve signals, leading to pain relief.

• Muscle Spasm Reduction: Lowers muscle spindle activity, decreasing spasticity.

• Anti-Inflammatory Effects: Limits the release of inflammatory mediators.

What would you expect to see post cryo treatment?

• Decreased Swelling: Observable reduction in localized edema.

• Reduced Pain and Spasm: Patient reports less pain and muscle tension.

• Improved Range of Motion: Less stiffness, easier joint movement.

• Possible Temporary Numbness: Reduced sensation in the treated area for a short time.

How long would you apply the CRYO treatment for?

• Typical Application: 10–20 minutes, depending on the thickness of the tissue and depth of the injury.

• For superficial areas (like fingers or toes): 10–15 minutes.

• For deeper muscles or joints: 15–20 minutes.

• Should be applied every 2–3 hours during the acute phase of injury

How would you explain the CRYO treatment to the patient

I’m going to apply a cold pack to your [injured area] to help reduce swelling and numb the pain. You might feel it go through stages: cold, burning, aching, and then numbness. It’s important for the cold to reach the deeper tissues to be effective, but I’ll make sure it’s comfortable for you. Let me know if it gets too intense."

What Should the Patient Feel During CRYO Treatment?

• Cold Sensation: Immediate feeling of coolness.

• Burning or Aching: After 2–3 minutes, a deep ache or burning sensation.

• Numbness: After 5–7 minutes, the area should feel comfortably numb.

• If pain or discomfort increases instead of decreasing, the treatment should be stoppe

Expected outcome of post SH treatment

• creased Range of Motion: Muscles and connective tissues are more flexible.

• Reduced Pain and Stiffness: Patients report feeling looser and more comfortable.

• Improved Circulation: Area may look red and warm due to increased blood flow.

• Reduced Muscle Spasm: Less tightness in the affected area.

How long should SH be applied for

• 15–20 minutes is typical for moist heat packs, heating pads, or warm water immersion.

• This duration is sufficient to achieve therapeutic tissue temperatures (104°F–113°F or 40°C–45°C).

• Should be applied 2–3 times daily depending on patient tolerance and clinical goals.

How would you explain the SH treatment to the patient

I’m going to apply some gentle heat to your [affected area] to help relax the muscles, reduce stiffness, and improve blood flow. This will make it easier for you to move and reduce your discomfort. You should feel a warm, soothing sensation—not too hot. Let me know if it gets uncomfortable."

How should PT feel during SH treatment

• Comfortable Warmth: A gentle, soothing heat sensation.

• Mild Muscle Relaxation: A feeling of loosening in the targeted area.

• No Pain or Burning: If it becomes too hot or uncomfortable, the application should be stopped immediately.

Reccommended IFT settings

IFT Treatment Duration

Explaining the IFT Treatment to the Patient

I’m going to apply some small electrical currents to your [injured area] using four pads. These currents work together to block pain and promote healing. You might feel a gentle tingling or pulsing sensation—it should be comfortable, not painful. We’ll adjust it to your comfort level and let it work for about 15–20 minutes."

What should PT feel during IFT sensation

• Tingling or Pulsing Sensation: A comfortable, rhythmic feeling under the pads.

• Mild Muscle Twitching: Sometimes noticeable, especially at lower frequencies.

• No Pain or Burning: If it becomes sharp or painful, the intensity should be adjusted.

herapeutic Effects of Interferential Therapy: