PM&R physical and occupational therapists have had formal education in and regularly utilize the following therapeutic modalities, manual techniques, and therapeutic approaches.

Ice/cryotherapy ö Ice and cryotherapy reduce tissue temperature, thereby reducing inflammation. This temporarily allows increased muscular stretch and reduces spasticity.

Heat ö Heat (hot pack) is used for local relaxation of the treated area as well as for generalized relaxation. This allows for more effective stretching and mobilization.

Paraffin ö Paraffin is a hot wax, used primarily in hand therapy, and gives the same local benefit as hot packs.

Ultrasound ö Ultrasound uses sound waves which convert to heat in the deep tissues, making scar tissue more responsive to stretching. "Pulsed" ultrasound also has an anti-inflammatory effect.

Electrical Stimulation ö Electrical current can be delivered at various frequencies and intensities to relax or strengthen muscles and reduce pain.

TENS (Transcutaneous Electrical Stimulation) ö The patient is educated in the use of this small, portable electrical device that is used to control pain.

Biofeedback ö Biofeedback is a system that trains the patient to gain control of his or her own musculature. This technique is usually used to improve muscular relaxation but may also be used to increase muscular contraction.

Therapeutic exercise ö Therapeutic exercise is the use of exercise for stretching muscles and joints, or strengthening muscles to gain increased power, endurance and stabilization.

Manual techniques ö Techniques for treating pain originating from the soft tissues (muscle and connective tissue) or caused by joint restrictions and nerve adhesions. Manual therapy combines soft tissue and joint mobilization techniques with neuromuscular reeducation, utilizing Proprioceptive Neuromuscular Facilitation (PNF) principles and patterns. Techniques are often instrumental in bringing about immediate functional gains.

Manual Techniques:

1. Massage

• Swedish - A system of long strokes, kneading and friction techniques on the more superficial layers of the muscles, combined with active and passive movements of the joints.

• Deep Tissue - A system which release the chronic patterns of tension in the body through slow strokes and deep finger pressure on the contracted areas, either following or going across the grain of the muscles, tendons and fascia.Ê It is called deep tissue because it also focuses on the deeper layers of muscle tissue.

• Trigger point Therapy - Applies concentrated fingertip pressure to "trigger points" (areas of hyper-irritability in a taut muscle band) to break the cycles of spasm and pain.

• Reflexology - Massage based around a system of points in the hands and feet thought to correspond, or "reflex" to all areas of the body.

• Shiatsu and Acupressure - Oriental-based systems of finger-pressure which treat special points along acupuncture "meridians" (the invisible channels of energy flow in the body).

• Anma - - Japanese massage technique used to treat chronic pain.Ê Area of concern is first warmed through a series of strokes using the hands, heels of hands, elbows and thumbs.Ê Light pressure is applied first graduating to a deeper, vibrating pressure.

• Pregnancy Massage - Applied like any regular Swedish or Deep Tissue massage with special attention paid to the positioning of the client and body areas most subject to discomfort (such as the low back, lateral and abdominal muscles and upper traps).

2. Joint mobilization techniques -Ê Release joint restrictions that limit joint range of motion

3. Cyriax ÷ James Cyriax was an English physiotherapist who developed the "scanning examination," designed to accurately diagnose physical disorders. The physical examination and the subjective history must be done in such a manner as to clearly understand the patient's problems and the physical basis of their symptoms. The principle used is that a damaged structure causes pain when tension is placed upon its fibers. Differential diagnosis is made based upon reproduction of the patient's complaint.

4. Maitland ÷ Based on the work of G.D. Maitland, an approach to the use of manual techniques which emphasizes evaluation of the patient's clinical signs and symptoms and directing treatment to these signs and symptoms rather than focusing on a diagnosis.

5. Mulligan ÷ A treatment approach based on gentle mobilization of the spine and extremities. The goal of these painless mobilizations is immediate improvement in the patient's condition.

Nerve mobilization techniques:

1. Butler ÷ A treatment approach based on the concept of "tension" throughout the nervous system, and that with injury there may be areas of hypersensitivity. The technique utilizes "tension testing" to identify affected structures and involves movements of the trunk and extremities which help patients to decrease inflammation and irritation andÊreturn the nervous system to its normal resting tension.

Other schools and approaches:

Bobath ö A treatment approach based on the concept that the central nervous system reacts to internal and external stimuli. The body may over-react to a stimulus and leave the patient with abnormal tone, or spasticity. Bobath techniques are quite useful for pediatric and hemiplegic patients because they are based upon the inhibition of spasticity and facilitation of normal movement.

McKenzie - This is a systematic approach to evaluation and treatment of spinal mechanical pain. This approach is based upon effects of repeated movements and /or static positioning. Treatment is focused on centralization of the nucleus pulposis (the jelly inside the disc between the vertebrae), and involves a series of individualized exercises with the goal of abolition of symptoms, maximization of function and prevention of recurrence.

Proprioceptive Neuromuscular Facilitation ö A set of techniques which use the body's proprioceptive sense (sense of the location and orientation of a limb or joint) to hasten the response of the nerves and muscles to treatment. These techniques are highly effective in strengthening patients and in improving their ability to control muscle contractions across 1 or more joints.

Muscle Energy Techniques ÷ A system of treatment based upon the utilizationÊof the patient's own musculoskeletal forces to realign positional imbalances within the body. Effective in the management of disorders of the neck, thoracic spine and rib cage as well as the lumbar and sacral spines.

Ergonomics training ö The use of equipment, positioning, and body mechanics to minimize injury at work and at home.

Orthotics - Fabrication of custom molded shoe and upper extremity orthotics (braces/splints) or evaluation of patient's orthotics.