March, 1962 P H Y S I O T H E R A P Y Page 3 C o n t e n t s Page D eep Pool Im m ersion T herapy 3 N a tio n a l C ouncil for the C a re o f C ripples in South Africa 6 Som e Im pressions o f R e h ab ilitation in U .S .A . and C a n ad a 7 G roup D em onstration in Cape Town Post G ra d u atio n C ourse 9 G eneral 10 B ranch News 11 S tu d e n ts’ Colum n 12 N a tional Fitness Congress 14 V acancies 16 DEEP POOL IMMERSION THERAPY M r . K. 1. S. N IC O L , M .S .A .S .P ., M .C .S .P ., H .T ., D .P .E . Paper delivered to the P ost-G raduate Course in Cape Town, 1961 H y d ro th e ra p y has developed as a b ra n c h o f physical m edicine, from th e use o f n a tu ra l w a ters as a m ean s o f in te rn al a n d e x te rn al tre a tm e n t. H y d ro th e ra p y being a section o f spa th e ra p y , m ay be su b -d iv id ed in to m any p a rts o f wet th era p y . T h e w hole o f this e m b ra ce s a field o f suffi­ cient im p o rta n c e to ju stify a p o st-re g is tra tio n q u a lifica tio n for C h a rte re d P h y s io th e ra p ists in G r e a t B rita in , w h o direct it to th eir p a tie n ts. Deep Pool T herapy D e ep-pool im m e rsio n th e ra p y being a p a rt o f h y d ro - th era p eu tic m ea su re s now availab le, is no d o u b t, w o rth y o f critical e v alu a tio n . A lth o u g h deep po o ls a re o ften expensive to instal, a nd to m a in ta in , m o re a re at p re sen t being p lanned o r built. T h e re is n o th in g new o r m y sterio u s a b o u t the beneficial effects o f p o o l-th e ra p y , the R o m a n s used it extensively. H ow ever, th e tec h n iq u es have been b ro u g h t up to d a te so th at it is specialised. T h e g row ing interest o f th e m edical p ro fessio n , especially th at o f the O rth o p a e d ic S u rg e o n s, have been q u ick to tak e a d v a n ta g e o f p ro p e rly ap p lie d pool th e ra p y , p a rtic u la rly in respect to m uscle a n d jo in t re -e d u c atio n , as a m eans o f speeding up co nvalescence. T h e ideal m edium befo re p e r­ m itting weight b e arin g , is to a d m in iste r c o n tro lle d activity an d specific m a n ip u la tio n s in w a ter, in o rd e r to p ro m o te m uscle d e v elopm ent w ith an efficient c irc u la to ry fu n c tio n . It can be envisaged th a t th e in creasin g d e m a n d will c o n tin u e to grow fo r such tre a tm e n t, e m b ra c in g a g re at v ariety o f c o nditions. E quipm ent Water T he w a ter m ay be m ineralized o r plain. N a tu ra l w aters from springs do n ot need c h lo rin a tin g , if k e p t c o n sta n tly flowing. So long as it is devoid o f taste , sm ell and d oes not stain, it is econ o m ica l. Temperature T h e te m p e ra tu re ranges from 90°F. to 1 0 2 'F . av era g in g 96°F. A n u n d e r w a te r d o u c h e if used fo r m assage being 5°— 10°F. a b o v e th e te m p e ra tu re o f th e pool, a n d is c o n ­ nected to a h ot a n d cold m ixing c h a m b e r. Size T h e size a n d sh a p e o f po o ls vary, w ith the d e p th from 2 ' 6" to 5 ' 6" av era g in g 4 ' 6" fo r a d u lts. It sh o u ld be surfaced w ith non-slip tiles a n d u n d e r these a special lining o f lead or a sp h a lt to prevent leakage. T h e c ap a city is from 600 gallons to 10,000 g a llo n , 6,000 g a llo n s being a goo d average. C o lo u r d e c o ra tio n , lig hting a n d v en tilatio n sh o u ld receive co n sid era tio n fo r co n g en ial su rro u n d in g s a n d to prevent co n d en satio n . P hysiotherapists attending a tw o-dav refresher course at the U niversity o f Cape Town were given a dem onstration o f the technique o f suspension at the P rincess A lice H o m e , R etreat, recently. Instructing is M r. K. N icol (in white c oat), and looking on is M rs. C. S te y n (le ft) the h o m e 's head p h y sio ­ therapist. (A ck n o w led g em en t to A rgus.) Pool A pparatus W here p a tie n ts a re severely h a n d ic a p p e d , they a re low ered into th e p ool on a “ g a n try ” , a series of slings o r a stre tc h er, secu rin g th e p a tie n t by stra p s. T h e g a n try is run o u t o ver th e p ool a n d let d ow n by som e h y d ra u lic m echanism . T h e p a tie n t m ay be tre a te d in th e s tre tc h e r o r can v a s slings so long as this d oes n ot im p e d e th e exercise o f th e p art u n d e r tre a tm e n t. An a d ju s ta b le inclined p lin th , a tta c h e d to o n e side o f the po o l is a lso useful in th e early stages fo r specific p u rp o se s, e.g. to localise m o v em e n ts a n d m a n ip u la tio n s. M ost o f th e a p p a r a tu s sh o u ld be ta k e n o ut to d ra in o v e r­ n ight, to offset d e te rio ra tio n . As th e force o f g ravity is reduced in w a ter, th e p a tient m ay be s u p p o rte d in th e u p rig h t p o sitio n , by parallel bars ru n n in g a cro ss th e p ool. W eighted a n d m oveable sto o ls o r benches a re useful to exercise in sittin g , also in s ta n d in g fo r c h ild ren . R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page 4 P H Y S I O T H E R A P Y March, 1962 T h e re is a h a n d ra il all ro u n d at w a te r level to p ro v id e h a n d a n d fo o t fixation a n d to serve as a h e a d re st in th e c o rn e rs a lo n g w ith th e use o f a sling in su spension. T o assist b o d y bu o y a n cy , a ir rings a n d c o rk floats a re used. F o r re -e d u c a tio n o f w alking, sp lin ts o f perspex o r fibre glass etc. help to sta b ilise th e legs. It is de sirab le to use th e m inim um o f a p p a ra tu s , by m aking full use o f th e su p p o rtin g w a ter only. Advantages o f Pool Therapy A lth o u g h som e h y d ro th e ra p e u tic principles can n o t be a p p lie d so well, if a t all, by a ny o th e r m eth o d , it c a n not p ro d u c e a m axim um effect in m any cases, w ith o u t the sim u lta n e o u s use o f v a rio u s d ry tre a tm e n ts o n a lte rn a te days. D a ily u se o f p o o l tre a tm e n ts c a n b ecom e e x h au stin g fo r c e rta in pa tie n ts. (a) Because o f th e large lim b a n d bod y m ovem ents p e r­ m issible w ith b u o y a n c y assisting in a p o o l, the p a tie n t experiences a feeling o f well being, a n d o f en jo y a b le a chieve­ m en t in even th e sim plest o f m anoeuvres. (b) It is in this w a te r m edium th a t all p aresed m uscles m ay acc o m p lish th e ir in itial jo in t m ovem ents, especially to m aste r w e ight-bearing, sta tic sittin g a n d w alking, lo n g befo re th is is p e rfo rm e d on land. (c) Even resistance exercises in m any cases can o n ly be p e rfo rm e d in w a te r w hen c o n sid erin g p ro g ressio n to the p ro -p rio ce p tiv e n e u ro -m u s c u la r fa cilitatio n te c h n iq u e o u t o f w ater. T h is is a d ire c t a d v a n ta g e o v e r its siste r su sp en sio n m eth o d o f sling th e ra p y , in th e d e p a rtm e n t, a lso in respect o f im p ro v in g b o d y b a la n ce in all po sitio n s, a lo n g w ith the a d d itio n o f its c o m p le te th erm al a c c o m p a n im e n t. H e re is a g reat o p p o rtu n ity to develop m uscles, b o th in­ trin sic a lly a n d extrinsically, im p ro v in g n e u ro -m u scu lar c o -o rd in a tio n a n d sta b lisa tio n fo r fu n c tio n al activity. Therapeutic Effects T h e m ain effect is th e force o f b u o y a n cy w hich is o f g re a te r use in respect o f g ra d u a te d th e ra p y , as c o m p a re d w ith th e effect o f g ravity being e lim inated. F ric tio n is to all in te n ts a n d p u rp o se s, elim in a ted in the w a te r d ue to a bsence o f w eight o n th e lim b, a llow ing passive a n d active m ovem ent th ro u g h a n increased range, a lo n g w ith reduced pain. T h e th e rm a l effect o f th e s u rro u n d in g w a te r w arm s the to ta l surface a re a o f th e b ody (excluding th e head), in d u cin g re la x a tio n o f m uscle tissue giving a sedative effect o n nerve endings, w ith im p ro v e d c irc u la tio n , th u s e n h a n c in g a m o re efficient m uscle fu n c tio n . T h e physiological fu n c tio n is assisted by im proved m eta b o lism , skin activ ity a n d o f th e h e at reg u la tin g m ech­ anism . T h e benefit to be gained is m ost m ark e d in all cases o f m uscle re -e d u c a tio n w hich is o f p rim a ry im p o rta n c e , im ­ p ro v in g p ow er a n d c o n tro l. T h e u n d e r-w a te r d o uche, p ro d u c es a hy p e rae m ia a ro u n d th e jo in ts, a n d assists in th e a d so rp tio n o f in fla m m a to ry a n d fibrous th ic k e n in g s, dispersing them in m uscles, a ro u n d te n d o n s a n d jo in ts . T h u s it offsets th e de v elo p m en t o f tra u m a tic a rth ritis in som e fra c tu re a n d p o st-o p e ra tiv e o rth o p a e d ic cases. I t a lso h as a slight analgesic effect a n d helps in ove rco m in g the d isc o m fo rts c aused by stre tc h in g th e tissues. T h e th e rm a l effect assists in th e rem oval o f w aste p ro d u c ts d ue to fa u lty m eta b o lism , a cc ele ratin g th e in te r­ change, betw een b lo o d a n d tissue fluids by a c tiv a tin g the c irc u la tio n o f b lo o d a n d lym ph. T h e psychological benefit is o b v io u s w hile h a n d lin g a p a tie n t in w ater, gain in g confidence in his tre a tm e n t, g ener­ ally, leading to increased p erseverance to pro g ress and achieve fu rth e r goals. Considerations M any p a tie n ts h a v e su p e rim p o sed psychological c a u s a ­ tions. H e re 1 v e n tu re to suggest th a t o v e r 7 0 % o f c o n d itio n s we tre a t a re p sy c h o so m a tic in o rigin, so it is de sirab le to rem ove th e p a tie n ts from th e influences w hich m ay prevail in th e ir w o rk in g a n d d om estic life, w herever possible, hence th e p la n n in g o f larg e h o spitalised h y d ro th e ra p y centres, especially fo r rh e u m a tic cases. T h e p a tie n t is m o re easily ab le to p ro v e his cap a b ilitie s assisted by th e skilled h y d ro ­ th era p ist. H y d ro sta tic Pressure H y d ro s ta tic pressure— is ex erted e q u ally in all directions a n d increases ro u g h ly by 1 lb. p e r sq u a re in ch fo r every tw o feet vertically below th e surface. T h is p re ssu re has a m ark e d effect on re sp ira tio n a n d c irc u la tio n , so th a t tim e m ust be allo w ed fo r a d ju s tm e n t a n d th e a m o u n t o f im m er­ sion o f th e th o ra x will v ary w ith different types o f cases. It is th is h y d ro sta tic p re ssu re th a t e n ab les a p a tie n t to stand a n d w alk in w ater, long b efore he c a n do it o n la n d .lt acts as a c o rset a ro u n d th e b ody, giving th e a b d o m in a l m uscles su p p o rt. T h is e n ab les th e d ia p h ra g m to w o rk easily, aiding th e v e nous re tu rn as th e b re a th in g is deeper a n d vital c a p a ­ city increased. D ynam ic Pressure D y n a m ic p re ssu re — is utilised to v ary the resistance o f m ovem ents. T h is is increased if th e speed o f th e m ovem ent is a cc ele rated . By re la tio n s h ip o f th e b o d y to th e w ater, the g re a te r th e su rfa ce a re a o f th e b o d y th e g re a te r the resistance a n d difficulty fo r th e w a te r to flow p a st it. T h e re fo re m ove­ m en ts a n d p o sitio n s a re varied acc o rd in g ly . T h is calls on th e th e ra p is ts ingenuity. W ave resistance— is co n sid ere d w ith w eak p a tie n ts as an in itial pro g ressio n . Buoyancy B u o y a n cy — th e u p th ru s t o f th e w a te r is utilised to first o f a ll s u p p o rt th e p a tie n t, as in a c o n tin u o u s sling, to assist a n d to re sist b o d y m ovem ents a c c o rd in g to th e muscle stre n g th . A tm o sp h e ric tem perature a nd hum idity— th is h o t and h u m id e n v iro n m e n t will re ta rd h e a t loss fro m th e body. I t is very necessary to give a tte n tio n to signs o f fatigue as h e at is ge n era te d from m u sc u la r a ctivity. T h e re fo re the b o d y sh o u ld n o t b e c o n tin u a lly im m ersed u p to th e neck, a n d th e d u ra tio n o f tre a tm e n t m u st be re g u la te d accordingly a n d c o n sid e ra tio n sh o u ld be given to d aily p o o l th era p y in th is re sp ec t. In view o f the fa ct th a t it is physically a rd u o u s to w ork im m ersed in w arm w a ter, th e re sh o u ld b e a m p le p h ysio­ th e ra p is ts to a ssu re a ro ta tio n o f th o se w o rk in g in a busy deep p o o l cen tre. Differences C o m p a re d w ith o th e r fo rm s o f physical tre a tm e n t in the p h y sio th e ra p y d e p a rtm e n t, th e difference is o b v io u s; a w et tre a tm e n t being a d m in istere d w ith to ta l th e rm a l a p p lic a ­ tio n in su sp en sio n , utilising b u o y a n cy as a reverse to the effect o f gravity. A lo n g w ith this, h u m id ity , h y d ro sta tic a n d dy n a m ic pressures a re given c o n sid e ra tio n w hen perfecting th e te c h n iq u e o f p o o l th era p y . In th e p o o l, p a tte rn s a n d specific m o v em en ts a re initiate d w ith g re a te r active w o rk . I t is instin c tiv e to p e rfo rm som e m ov em e n t w ith e n jo y m e n t in w a te r a n d so develop an a b ility c o n sciousness w hich is n o t alw ays c o n sid ere d by the p a tie n t o n d ry la n d , w hile lying in a p a th y o n a bed. T h e d ry fo rm o f th e ra p y m ost sim ila r to th a t in th e pool is k in es io th e ra p y in sling su sp en sio n . A lth o u g h slings are less expensive to in stall it does n ot suffice o r is it so ex ac tin g fo r th e p h y sio th e ra p ist, especially in th e e arly stag es o f a tre a tm e n t p ro g ra m m e . H ow ever, p o o l th e ra p y sh o u ld be c o rre la te d w ith a p p ro p ria te tre a tm e n t in th e d e p a rtm e n t, a n d need n o t be used if th e la tte r is a ll th a t is necessary. I n w a te r a g re a te r n u m b e r o f synergist a c tin g m uscles a re b ro u g h t in to play because o f th e in sta b ility o f a w a ter m edium . T h is in tu r n facilitate s in v o lu n ta ry activ ity o f in trin sic m uscle g ro u p s w hen they a re in ca p ab le o f p e rfo rm ­ ing as p rim e m overs. H e n ce b a la n c e a n d sw im m ing e x e r­ cises in v a rio u s p o sitio n s will stre n g th e n these a n d the im p o rta n t larg e g ro u p tru n k stabilisers. Types o f Conditions Treated T h e aim o f th e tw o m ain g ro u p s o f c o n d itio n s tre a te d in th e d eep im m e rsio n p ool a re : (a) R e s to ra tio n o f sk eletal m uscle stre n g th . (b) Im p ro v e d ra n g e o f jo in t fu n c tio n . R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) In the form er, th e fo llow ing types o f c o n d itio n s a re c on- 'd e red : a cute a n te rio r p o liom yelitis, flaccid paralyses, S' me spastic p araly ses asso c iated w ith u p p e r-m o to r n e u ro n fesions, hem iplegia, m u sc u la r d y stro p h ies, d e b ility a n d where in te r-th o ra c ic v ital c a p a c ity needs to be im proved in respiratory involvem ent. Secondly, fo r in creasing jo in t m obility, po o l th e ra p y is ised to trea t the effects o f tra u m a tic jo in t injuries, sp ra in s in d fractures, expecially th o se fo llow ing in d u stria l injuries and stiffness fo llow ing im m o b iliz atio n o f jo in ts . P e ri­ arthritis, fibrositis, c h ro n ic o ste o a n d rh e u m a to id a rth ritis , spondylitis, th e fo llo w u p a fte r c e rta in p o st-o p e ra tiv e c o n ­ ditions and o rth o p a e d ic p ro c e d u re s o f large jo in ts , also to offset the de v elo p m en t o f o ste o p o ro sis. C ontra-indications J. R e sp irato ry d iso rd e rs th a t a re sufficiently severe to be a d anger to th e p a tie n t’s recovery, especially if th e a b ­ dom inals a re also b a d ly affected c au sin g difficulty to expel w ater from the th ro a t. 2. In flam m ato ry c o n d itio n s in a c u te a n d su b -a c u te sy n o ­ vitis, tuberculosis, a rth ritis , febrile cases, a n d infective skin co n d itio n s. 3. In m u sc u la r d y stro p h y , if th ere is difficulty w ith sw al­ lowing a n d som e in ab ility to h old the h e ad u p rig h t, is an ad d itional c o n tra -in d ic a tio n . 4. C a rd ia c involvem ents, high b lo o d p re ssu re a n d a rte rio - clerosis; renal diseases, if cystitis, n e p h ritis o r inco n tin en c e are present, po o l tre a tm e n t s h o u ld be p o stp o n e d . T echnique o f T rea tm e n ts Floating— it is a d v a n ta g e o u s fo r th e p a tie n t to be ta u g h t floating p o sitio n s first, fo r its psychological im p o rta n c e and to o b ta in m uscle re la x a tio n . W h en ap p reh e n siv e, the body assum es th e a ttitu d e o f flexion b u t flo atin g su pine cou n te rac ts this ten d e n cy , especially if th e p a tie n t a b d u c ts the arm s a n d legs, re tra c tin g th e sh o u ld e r b lad e s to g eth e r. T o prevent th e legs fro m sin k in g , th e a b d o m in a ls a re c o ntracted slightly. P ro g re ss to flo atin g in th e p ro n e p o sitio n , giving less m an u a l s u p p o rt so th a t th e p a tie n t p e rfo rm s the necessary m o v em en ts h im s e lf to im prove b a la n c e c o n tro by g ro u p m uscle a ctio n . A lthough it is m o re in k e eping to p e rfo rm all m ovem ents, with th e lim bs im m ersed, 1 pe rso n ally w o uld ag ree to a patient sw inging a n a rm o r leg o u t o f th e w a ter, because it de m o n stra tes th e p a tie n t’s c a p a b ility o f th a t p a rtic u la r m ovem ent, a n d it is o ften psychologically beneficial, th e re ­ fore, n o t to be re stra in e d u nduly. T his leads me to th e p ro p rio c e p tiv e n e u ro m u s c u la r facili­ tatio n technique, b e ing in itiate d in w a ter to facilitate p ro ­ gression, la te r exercising th is m eth o d in th e p h y sio th e ra p y de p artm e n t, th is being a d irect u p -g ra d in g o f th e p a tie n t’s th era p eu tic achievem ents. Group P ool Therapy— In d iv id u a l p o o l w o rk is progressed to G ro u p w o rk to stim u la te th e co m p etitiv e elem ent a n d to a p p rec ia te th e effect o f space, fo r freedom o f m ovem ent. In this instance specific a n d general active rem edial exercises are c arried o u t to in clude w alking, sw im m ing a n d playing games. U n d e r w a ter exercises a re n o t m erely d o in g th e sam e dry land exercises, o nly in w ater. T he a p p lic a tio n is a special te c h n iq u e a n d m u st be studied and directed to o b ta in th e p ro p e r p ro g ressio n s a n d use the w ater m edium to th e full a d v a n ta g e , so o b ta in in g the expected results. Progression— I t is well w o rth w hile th a t th e th era p ist should try all m o v em en ts in w a te r a n d in different p o sitio n s to o b ta in a c o m p re h en siv e u n d e rsta n d in g o f th e effect o f exercises. F o r in stan c e th e m uscle w o rk o f w a lk in g is in reverse o f th a t o n la n d . B uoyancy assists th e legs to c om e up a nd resisting b u o y a n c y w hen p lacing th e leg d ow n, instead o f it being assisted by gravity. M o vem ents in w a te r a re e ith e r Passive, A ssisted, A ctive o r R esisted. March, 1962 Ten-point P rogression o f H y d ro th e ra p e u tic M uscle R e-education P u rp o sefu l passive m ovem ents. (T o re -establish a p a tte rn o f m ovem ent). S ta tic h o ld in g c o n tra c tio n s, w ith the lim b a t b u o y a n t level. A c tive b u o y a n t— a ssisted m ovem ents a re perfo rm e d . L a te ra l u n assisted m ovem ents a g ain st th e viscosity o f th e w ater, w ith th e lim b at b u o y a n t level. A t th is stage, it c a n be observ ed th a t th e b u o y a n t level will be raised as th e m uscle p o w e r im proves, befo re it is p ossible to d etect such im p ro v e m en t w ith m an u a l m uscle testing. 5. A t surface level a p p ly wave resistance. 6. M o v e m en t w ith b u o y a n cy resisting. 7. R e d u ce d m an u a l a n d artificial s u p p o rt. 8. S im u lta n e o u s c o n tra c tio n w ith b o th o rig in a n d in ­ se rtio n o f a muscle. 9. In c re a se d speed o f lim b m ovem ent. 10. U n d e r w a ter m an u a l resistance utilising th e p ro p rio ­ ceptive n e u ro m u s c u la r fa cilitatio n te c h n iq u e. T h is includes sta b iliz a tio n a n d b a la n c e tra in in g in the flo atin g a n d kneeling p o sitio n s a s d o n e o n a m at, a lso in sittin g a n d sta n d in g . Conclusion W hile c o n sid erin g pool th e ra p y it is stressed th at h y d ro ­ th e ra p y is o nly a p a rt o f th e physical m edicine a rm a m e n t­ a riu m w hich is used c o n jo in tly w ith o th e r m easures in the p h y sio th e ra p y d e p a rtm e n t. It is a m eth o d o f im p ro v in g c o n ­ d itio n s w ith re m a rk a b le ra p id ity , tre a tin g the p a tie n t as a w hole w hile c o n c e n tra tin g on specific im provem ents. I t is ideal fo r a p h y sio th era p ist tra in e d in h y d ro th e ra p y to fo llo w a p a tie n t’s tre a tm e n t regim e th ro u g h from the p ool to th e d e p a rtm e n t, being th e th e ra p is t m o st fa m ilia r w ith th e p a tie n t’s c apabilities. T h e beneficial results o b ta in e d in su itab le cases leads one to su p p o se th a t a w ide use o f this fo rm o f re h a b ilita tio n is long o v e rd u e, th ro u g h o u t p h y sio th e ra p e u tic cen tres, w hich will b ecom e m o re im p o rta n t in th e fu tu re. In S o u th A frica we have a few h o sp itals w ith deep po o l in stallatio n s, b u t th ere a re also n u m e ro u s u n d e rd ev e lo p e d places fro m w hich n a tu ra l m ineralized springs flow. T hese m ay well be d e v elo p sd in to spas a n d th e S o u th A frica n Society o f P h y s io th e ra p y m ay well c o n te m p la te m ak in g th e necessary a p p ro a c h to d e velop these in to useful re h a b ilita ­ tio n c en tres o n a N a tio n a l scale. T h e re a p p e a rs to be a scarcity o f p h y sio th e ra p ists tra in e d in H y d ro th e ra p y , so it is h e a rte n in g to see th a t efforts a re being m ad e to in tro d u c e stu d e n ts o f p h y sio th e ra p y in deep pool im m e rsio n techniques. R e f e r e n c e s T. G . R e a h , 1957, The British Journal o f P hysical M edicine, 20, I. W . M enzies, 1950, P hysiotherapy Journal, 36, 9. Page 5 S O M E E X A M IN A T IO N H O W L E R S Term inology P h y sio th e rap y : p ro v id es su p p o rt fo r stre tc h ed ligam ents. F ric tio n s: a re given fo r h yperaem ia. W h en h y p e rae m ia is sufficient th e p a tie n t m oves to a chair. T he H e a d : is extrem ely vital. M a ss a g e : th e tissues a re picked off the bone. M u scle : E x te n so r d ig ito ru m c o m m u n ist. Frozen Shoulder: T h e a rm w as ta k e n u p by th e ele v ato r. 1. 2 . 3. 4. P H Y S I O T H E R A P Y R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )