PROTOCOL

PHYSIOTHERAPY

DEFINITIONS

PHYSICAL MEDIA: Covers:

THERMOTHERAPY: It is the use of heat for therapeutic purposes, which is divided into: Superficial
thermotherapy: Heating by applying compresses, infrared.

RIOTERAPY: Corresponds to the application of cold to achieve physiological therapeutic effects,

through ice packs or bags, cold wraps, ice massage, immersion in ice water.

ELECTROTHERAPY: It is the application of energy to the human body, to generate desired and
therapeutic biological responses on the tissues, which is divided according to its frequency: low
frequency (TENS and EMS), medium frequency (interferential current, ultrasound)

MASSOTHERAPY: Use of the hands and body to treat musculoskeletal or other conditions

Risk Factors or Consequences of Pathology/Pathophysiology (Disease, Disorder or Condition)

 Low back pain
 Cervicalgia
 Back pain
 Muscle tear

Injuries, Functional Limitation or Disability

 Alteration of occupational functional capacity.
 Inability to climb stairs.
 Inability to perform repetitive work.
 Loss of muscle elasticity, strength and resistance.
 Inability to tolerate prolonged sitting posture.

EXAM
Clinic history
- Sociodemographic variables (age, gender, race, education).
- Occupation.
- Growth and development (dominant hand).
- Environment (Attachments, characteristics. Living place).
- General health status (health perception, physical, psychological, functional and social function).
- Health habits (risk behaviors, level of physical activity).
- Family history, medical history.
- Reason for consultation (patient needs, recent physiotherapy intervention, mechanism of injury.
- Functionality.
- Medicines.
- Other clinical tests (laboratory tests, medical history review, others).
Review by systems

Anatomical and Physiological State.

- Cardiopulmonary: Blood pressure, heart and respiratory rate, edema.
- Integumentary: Color and integrity of the skin.
- Skeletal muscle: Range of motion, strength, symmetry, weight, height.
- Neuromuscular: Coordination, balance, gait.

TESTS AND MEASUREMENTS

- Anthropometric Characteristics: Body dimensions and body composition.
- Body Mechanics: During activities of daily living, tasks or activities.
- Gait and Balance: Analysis of gait, dynamic and static balance.
- Integumentary integrity (skin).
- Joint mobility and integrity: Goniometry, muscle length, soft tissue extensibility, flexibility.
- Motor function: Dexterity, coordination, functionality and agility.
- Muscle performance: Manual muscle examination, movement patterns, muscle tension.
- Pain: Analog scale (FAD).
- Posture: Analysis of dynamic and static postural alignment.
- Flexibility: Flexibility tests.
- Home management, self-care.
- Sensory integrity: Sensitivity Test.
- Work, academic, recreational activities: integration or reintegration.

PHYSIOTHERAPEUTIC DIAGNOSIS
It is the process and the final result of the evaluation and examination data, which the Physiotherapist
organized into signs and symptoms, syndromes, or categories to determine prognosis and
relevant intervention strategies.

FORECAST
 2 – 6 months: Demonstrate optimal muscular performance and the highest level of functioning in
the
activities of daily living, work and leisure.
 Sessions: 6 to 30 in 80% of cases.
 Factors that require more sessions: Age, accessibility and availability of resources, adherence,
chronicity, anatomical and physiological changes associated with growth and development,
complications.

LUMBALGIA
DEFINITION
Low back pain refers to pain located in the lumbar region that extends from the lower edge of the
rib cage to the sacrum and is a musculoskeletal condition with considerable disability
associated. It has been estimated that 85% of adults suffer from low back pain at some point in their
lives.
their lives.

Classification
There are different established classifications, according to the time of evolution, origin and
accompanying signs and symptoms. According to the time of evolution, it is classified into acute low
back pain and chronic, recurrent, non-specific and persistent low back pain.

Acute low back pain is defined as an episode of pain lasting less than six weeks and subacute low back
pain is one that persists between six and twelve weeks. Chronic low back pain has a persistence of
more than twelve weeks. Recurrent low back pain is defined as a new episode after a period of six
months free of symptoms, but not an exacerbation of chronic low back pain. Non-specific low back
pain is defined as low back pain not attributable to a known specific pathology (example: tumor,
infection, osteoporosis, radicular syndrome, ankylosing spondylitis, fractures, inflammatory processes
or cauda equina syndrome).

EPIDEMIOLOGY
Low back pain is the main cause of activity limitation and absence from work in much of the world,
causing an enormous economic burden for individuals, families, communities, society.
industry and governments.

The prevalence of low back pain is greater than 84%, with an annual prevalence between 15 and 45%
and an incidence in adults of 5% per year, with the peak prevalence between the ages of 35 and 55
years. After the initial episode, 44 to 78 percent of people experience pain recurrence and 26 to 37
percent are absent from work.

RISK FACTOR'S
According to the origin, the most common cause (70%) is non-specific low back pain, a diagnosis that
is established by exclusion. There is low back pain of mechanical origin that occurs in 27%, this
includes degenerative disc or facet disease and herniated disc. Among the less prevalent causes are
those of visceral or referred origin (non-malignant), which represent 2% of cases (for example, aortic
aneurysm, pelvic or gastrointestinal diseases). And finally, non-mechanical or miscellaneous pain (1%)
where neoplastic, inflammatory, infectious and metabolic causes are included.

The most frequently reported risk factors are heavy physical work, frequent bending, rotations, lifting,
repetitive work, static postures and vibrations. Psychosocial risk factors include stress, anxiety,
depression, distress, and job dissatisfaction. 8

Physical activity is related to the appearance of low back pain, unlike sedentary lifestyle (39% vs.
18.3%, respectively). Other factors that have been associated with the presence of low back pain
include smoking and scoliosis.

ALARM SIGNS
The initial clinical history allows us to identify the warning signs that are risk factors detected in
patients with low back pain, which could be related to the development of a serious disease compared
to other patients who do not present this factor.10,8
 Age less than 20 years and over 55
 Recent history of violent trauma
 Non-mechanical pain, constant, progressive (not relieved with rest)
 Chest pain
 Previous medical history of malignant tumor
 Prolonged use of corticosteroids
 Drug abuse and immunosuppression, HIV
 Systemic commitments
 Unexplained weight loss
 Expanded neurological symptoms
 Structural deformity
 Fever

CLINICAL AND RADIOLOGICAL DIAGNOSIS

The evaluation must begin by determining the time of evolution of the symptoms to be able to classify
them as mentioned above. A good history and physical examination are important, although in most
cases it will be non-specific low back pain, probably mechanical. It is also important to determine the
origin of the pain through review of the medical history, physical examination of the lumbar spine,
palpation, assessment of posture and gait, specific tests and neurovascular evaluation.

Generally, performing radiographs in anteroposterior and lateral projection is not useful in the acute
process. The request for x-rays should be limited to the presence of warning signs. In this type of
mechanical pain, it is not advisable to do complementary radiological studies, unless treatment with
spinal manipulations is planned or if the very unfavorable evolution makes it advisable.

PHYSIOTHERAPEUTIC TREATMENT FOR LUMBALGIA

Physical Modalities
 Electrotherapeutics:
- TENS
 Physical Agents:
- Sonic Agents
- Thermotherapy: Hot Pack.
 Non-Thermal Physical Agents:
- Agent: Laser.
 Manual Therapy Techniques:
- Massage: It is not recommended as a sole treatment but can be used to relieve pain
- Passive mobilizations

The literature in general does not recommend the physical modalities mentioned as sole treatment.
for the management of low back pain, but as adjuvants.

Exercise Modalities
 Flexibility exercises: Range of motion and stretching of trunk and MMII muscles.
 Body Mechanics: Training in postural control and hygiene.
 Relaxation: Breathing exercises and relaxation techniques.
 In recurrent acute low back pain there is moderate evidence that the incorporation of exercise, both
in its aerobic modality and in that of flexibility and strengthening of the trunk muscles, can reduce the
frequency and intensity of recurrences in recurrent acute low back pain.
 Strengthening: It should be aimed primarily at the most deficient muscles.
 Back school: Group education is recommended once the intense pain has passed as a method of
prevention and management of pain in future episodes. The goal is to prevent recurrences. Postural
information, biomechanics, risk factors, information on cognitive aspects of pain, harmful habits, etc.
are given.

CERVICALGIA
DEFINITION
The presence of pain in the cervical region encompasses a wide range of alterations that, as a cause
or effect, are located in the posterior and posterolateral region of the neck, with or without irradiation
to adjacent areas and segments. Essentially, they are ailments of bone, joint or muscle origin that
affect the perispinal region, with the most common etiology being degenerative processes.

The physiotherapy treatment modalities most used to address mechanical neck pain are the following:
manual therapy, exercise, heat, cold, cervical traction, ultrasound, transcutaneous electrical nerve
stimulation (TENS), other forms of electrotherapy and phototherapy. Its effectiveness has generally
been studied in the short term with inconclusive results.
CAUSES
The poverty or richness of objective signs distinguishes the type of neck pain, and it may even be of
psychosomatic anxiogenic origin. The most frequent etiology corresponds to degenerative processes.
On the other hand, neck pain can also be a direct cause of brachialgia or trigger neuralgia that extends
to neighboring areas, receiving names such as cervicobrachialgia, Barré-Liéou syndrome.

Main causes
 Rectification of cervical lordosis
 Trigger points
 Misalignment of the cervical spine
 Muscle contracture (mainly upper trapezius fibers)
 Degenerative processes

EPIDEMIOLOGY
Current clinical evidence shows that more and more patients are coming to the various healthcare
services suffering from pain in the spine and, especially, in the cervical spine. Nearly 50% of
individuals complain of neck pain at some point in their lives.

Chronic persistent neck pain, with or without upper extremity pain, is common in the general adult
population with a prevalence of 48% for women and 38% for men, persistent complaints in 22% of
women and 16%. % Men's.

The annual incidence of episodes of mechanical neck pain treated by primary care physicians is
estimated at 12 per 1,000 subjects who come to the clinic2, it constitutes one of the main health
problems treated in primary care physiotherapy units.13

CLINICAL DIAGNOSIS
The first thing to do is an interview aimed at the patient's ailments and dysfunctions (pain
assessment), secondly, carry out a detailed examination taking into account the following aspects.
- Static posture inspection.
- Dynamic inspection of movements.
- Palpatory examination.
- Joint path tests.
- Joint stability tests.
- Muscle contraction tests against resistance
- Tests of meningeal-spinal involvement (Valsalva, cough and expectoration).
- Tests for detecting sensory alteration according to dermatomes.
- Checking the deep tendon reflexes.
- Balance tests.

Finally, assessment by imaging tests (x-rays, MRI and CT) of the segments supposedly affected by the
alteration, mainly in the case of alterations of the cervical spine and degenerative processes.

PHYSIOTHERAPEUTIC TREATMENT FOR CERVICALGIA

There are many treatments available for patients with neck pain, conservative strategies such as
medication, manual treatments, and patient education.

Physical Modalities
 Electrotherapeutic Modalities:
- TENS: to reduce pain. Muscle spasms and trigger points
 Physical Agents
- Sonic Agents: ultrasound (taking advantage of its thermal and mechanical effects on the different
tissues involved).
- Thermotherapy: Hot Pack.
 Manual Therapy Techniques:
- Massage: to reduce muscle contractures
- Passive mobilizations and traction: to reduce joint stiffness and help decompress the intervertebral
discs and nerve roots.

Manual therapy has not been shown to be effective when used exclusively to reduce the intensity of
pain. However, combined with pharmacological treatment, exercise and health advice, it has proven to
be effective in the short term.

Exercise Modalities
 Flexibility exercises: Range of motion and stretching: mainly cervical paravertebrals, dorsal,
trapezius, scalenes and sternocleidomastoid.
 Body Mechanics: Training in postural control and hygiene.
 Relaxation: Breathing exercises and relaxation techniques.
 Strengthening: It should be aimed primarily at the most deficient muscles.
 Back school: Group education is recommended as a method of prevention and management of pain
in future episodes. The goal is to prevent recurrences. Postural information, biomechanics, risk factors,
information on cognitive aspects of pain, harmful habits, etc. are given.

MUSCLE STRAIN
DEFINITION
Muscle strain is a breakage of fibers due to sudden and violent stretching of the muscle. The clinical
picture depends on the extent and nature of muscle destruction and hematoma that develops at the
injury site.

A muscle tear is a serious strain that usually affects a bundle of fibers. Many times it has to be
resolved with surgery.

MECHANISM OF INJURY
Muscle injuries are one of the most common traumas during sports practice. Its frequency varies from
10 to 55% of all injuries suffered. Almost all of them involve four muscle groups: hamstrings,
adductors. Quadriceps and calf muscles. Muscle injuries can be shear type (caused by contusion, strain
or laceration), in which the muscle fibers and their basal lamina and mysial sheaths, as well as nearby
capillaries, are all ruptured.

EPIDEMIOLOGY
About 90% of all sports-related injuries are bruises or strains. Muscle lacerations occur infrequently.

Muscle tears make up 31% of all elite soccer injuries. Its high prevalence is well documented in
international literature, both in football and other sports.

Muscle injuries at the thigh level are the most common in track and field athletes (16%), but have also
been documented in sports such as rugby (10.4%), basketball (17.7%) and American football
(46%/22% practice/game).
Hamstring strain or tear injuries represent a significant percentage of
acute neuromuscular injuries.
CLASSIFICATION
Based on clinical evidence, muscle injuries have traditionally been classified as mild, moderate or
severe.
 Mild (grade I): Tear of just a few muscle fibers, with mild inflammation and accompanied by
discomfort, with no or minimal loss of strength and restriction of movement.
 Moderate (grade II): Greater muscle damage with a clear loss of function (ability to contract).
 Severe (grade III): Occurs when the tear extends through the entire cross section of the muscle
and results in an almost complete loss of muscle function.
The traditional classification system described above does not take into account the exact location of
the injury. With current capabilities and the availability of modern imaging techniques such as
magnetic resonance imaging (MRI) and ultrasound imaging (US), it can now be accurately identified.

DIAGNOSIS
Physical exploration
- Integumentary integrity (skin)
- Pain
- Edema
- Perimetry
- Joint mobility
- Contractile state of the injured muscle

Image
Unless an avulsion fracture is suspected, x-rays are of little use. In these
cases ultrasonography (US) and magnetic resonance imaging (MRI) are recommended.

PHYSIOTHERAPY TREATMENT
Physical Modalities
Muscle tears are generally treated conservatively with rest, ice, compression, and elevation; followed
by rehabilitation. Large intramuscular hematomas can be aspirated, this reduces pain symptoms and
may decrease recovery time. 21
Early mobilization as well as the management described above is recommended in the initial stage.
 Physical Agents:
- Cryotherapy: Cold pack, cryomassage to reduce inflammation
- Sonic Agents: Ultrasound to contribute to tissue repair
 Manual Therapy Techniques:
- Soft tissue mobilization (gradual): Used to reduce pain and fibrotic limitations.

Exercise Modalities
After the acute phase:
Immobilization should be limited to a duration of less than one week, to avoid the adverse effects of
immobility and after that begin active rehabilitation. Exercise is crucial for the regeneration and correct
orientation of myofibrils.
 Strength and resistance training (concentric, eccentric, isometric) affected muscles.
 Balance and coordination: Training or retraining of motor function, neuromuscular education or
reeducation.
 Flexibility exercises: Range of motion and stretching (gradual).
EQUIPMENT AND ELEMENTS THAT THE PHYSIOTHERAPY SERVICE HAS
FOR PATIENT MANAGEMENT
- Hydrocollater with Hot Packs
- Fridge with cold packs
- TENS
- Ultrasound
- Laser
- Electrostimulator
- Neurodine
- Endless band
-Step
- Set of weights for lower limb
- Dumbbell set
- Therbands game
- Bobath Balls
- Mats
- Rockers
- Posturometer
- Hand kit
- Hand table
- Dynamometer