Physical therapy

# Overview
Physical therapy (or physiotherapy as it is known outside the U.S.) is a healthcare profession concerned with prevention, treatment and management of movement disorders arising from conditions and diseases occurring throughout the lifespan. Physical therapy is performed by either a physical therapist (PT) or a physical therapist assistant (PTA) acting under the direction of a PT.  However, various non-PT health professionals (e.g., chiropractors, Doctors of Osteopathy) employ the use of some physical therapeutic modalities in practice. A program of physical therapy will typically also involve a patient's caregivers.
Physiotherapy or Physical Therapist or PT is a health care professional who examines, treat, advice & instruct person with movement dysfunction, bodily malfunction, physical disorder, healing and pain from trauma and disease, disability, physical and mental conditions, by using physical agents like exercise, mobilization, manipulation, hydrotherapy, mechanical, and electrotherapy.
PTs utilize a patient's history and physical examination in diagnosis and treatment, and if necessary, PTs will also incorporate the results of laboratory and imaging studies. Electrodiagnostic testing (e.g., electromyograms, nerve conduction velocity testing) may also be of assistance. PTs practice in many settings, such as outpatient clinics or offices, inpatient rehabilitation facilities, extended care facilities, patient homes, education or research centers, schools, hospices, industrial workplaces or other occupational environments, fitness centers and sports training facilities.
For decades, physical therapy practice has been the subject of criticism for its lack of a research base, and "most physical therapists continued to base practice decisions largely on anecdotal evidence." The World Confederation for Physical Therapy, has called on the profession to adopt and adhere to evidence-based practices formally based on the best available scientific sources.
A systematic review comparing the value of physiotherapists versus orthopedic physicians to triage referrals from primary care physicians found benefit of physiotherapists when summarizing two randomized controlled trials and 11 cohort studies published through April 2020.

# History
Physicians like Hippocrates and Hector are believed to have been the first practitioners of a primitive physical therapy, advocating massage and hydrotherapy to treat patients in 460 B.C. The earliest documented origins of actual physical therapy as a professional group, however, date back to 1894 when four nurses in England formed the Chartered Society of Physiotherapy.  Other countries soon followed and started formal training programs, such as the School of Physiotherapy at the University of Otago in New Zealand in 1913,  and the United States' 1914 Reed College in Portland, Oregon, which graduated "reconstruction aides."
Research catalyzed the physical therapy movement. The first physical therapy research was published in the United States in March 1921 in The PT Review. In the same year, Mary McMillan organized the Physical Therapy Association (now called the American Physical Therapy Association (APTA)). In 1924, the Georgia Warm Springs Foundation promoted the field by touting physical therapy as a treatment for Polio.
Treatment through the 1940s primarily consisted of exercise, massage, and traction.  Manipulative procedures to the spine and extremity joints began to be practiced, especially in the British Commonwealth countries, in the early 1950s. Later that decade, physical therapists started to move beyond hospital based practice, to outpatient orthopedic clinics, public schools, college/universities, geriatric settings (skilled nursing facilities), rehabilitation centers, hospitals, and medical centers.
Specialization for physical therapy in the U.S. occurred in 1974, with the Orthopaedic Section of the APTA being formed for those physical therapists specializing in Orthopedics. In the same year, the International Federation of Orthopaedic Manipulative Therapy was formed, which has played an important role in advancing manual therapy worldwide ever since. In the 1980s, the explosion of technology and computers led to more technical advances in rehabilitation. Some of these advances have continued to grow, with computerized modalities such as ultrasound, electric stimulators, and iontophoresis with the latest advances in therapeutic cold laser, which finally gained FDA approval in the U.S. in 2002.

# Physiotherapy modalities
PTs uses individuals history and do physical examinations in their diagnosis & setting a treatment protocol, and if necessary, will include the results of laboratory and imaging studies.
Physiotherapist uses various modalities like-
- Exercises like active, passive,aerobic,cardio,strengthening,stretching etc.
- Hydrotherapy
- Mobilization
- Manipulation
- Electrical Modalities like Ultrasonic Therapy, Laser, Microwave Diathermy, Interferential therapy, TENS (Transcutaneous Nerve Stimulator),Shock Wave Therapy and many more.
Active Exercise Motion derived from a part by doing voluntary contraction and relaxation of its controlling muscles.
Active Assistive exercise voluntary contraction of muscles controlling a part, assisted by a therapist or by some other means.
Aerobic Exercise a type of physical activity,which increases the heart rate and as a result use of oxygen is increased in order to improve the overall body condition.
Ballistic stretching's rapid, jerky movements employed in exercises,for stretching of muscles and connective tissue.
Buerger-Allen exercises- Perform to enhance blood circulation of the legs and feet. In this exercise the lower limb s are raised to 45-90 degree angle with some support for 2 to 3 minutes until skin blanches. After that the feet and legs are lowered or the patients adopt a high sitting posture for 5 to 10 minutes until redness appears, Followed by flat lying on bed for 10 minutes.
Cardiovascular Exercise are exercises to enhance cardiovascular system capacity. Done at least twice per week, with most programs conducted three to five or more times weekly. The contraction of major muscle groups must be repeated often enough to elevate the heart rate to a target level determined during testing. Used in cardiac rehabilitation, or as a preventive measure.
Corrective Exercise are exercises planned and performed to attain a specific physical benefit, such as maintenance of the range of motion, strengthening of weakened muscles, increased joint flexibility, or improved cardiovascular and respiratory function.
Endurance Exercise Involvement of several large groups of muscles and is dependent on the delivery of oxygen to the muscles by the cardiovascular system; used in physical fitness programs as well as cardiovascular and pulmonary function testing.
Isokinetic exercise are dynamic muscle activity performed at a constant angular velocity.
Isometric Exercise (Iso= Same, Metric-Length) Active exercise performed against constant resistance, without change in the length of the muscle.
Isotonic Exercise(Iso= Same, Tonic= Tone) are active exercise with negligible change in the force of muscular contraction, with shortening of the muscle.
Kegel Exercises- Exercise for strengthening of pelvic floor and prevention urinary incontinence. Performed by a series of contractions and relaxations of perineal muscles. Done with the help of Kegels Exerciser.
McKenzie Exercise are exercise regimen used in the treatment of low back pain and sciatica, prescribed according to findings during mechanical examination of the lumbar spine and using a combination of lumbar motions, including flexion, rotation, side gliding, and extension. It is sometimes referred to as McKenzie extension exercises, but this is a misnomer because the regimen involves movements other than extension.
Muscle-Setting Exercise (Static Exercise) are voluntary contraction and relaxation of skeletal muscles static/constant muscle length or moving the associated part of the body.
Passive Exercise Movement or motion done to a body part or segment by another individual, machine or outside force or by voluntary effort of another segment of patient's own body.
Pelvic Floor Exercise-Combination of strength and endurance exercises of pelvic floor muscles (circumvaginal or perianal). These are used in  stress urinary incontinence; the patient is taught to isolate and contract muscles 103 times daily.
Quadriceps Setting Exercise - Isometric exercise to strengthen (Quadriceps) muscles needed for ambulation. The patient is instructed to contract the quadriceps muscle while at the same time elevating and dorsiflexing the heel and pushing the knee toward the mat.
Range Of Motion (ROM) Exercises are exercises that move joint through its full range of motion, that is, to the highest degree of motion of which joint normally is capable; they may be either active or passive.
Examples of range of motion exercises:
- Flexion: The bending of a joint in the body.(angle between the joint decreases)
- Extension: A movement opposite to that of flexion in which a joint is in a straight position.
- Rotation: Pivoting a body part around its axis, as in shaking the head.
- Adduction: Moving toward the midline of the body or to the central axis of a limb.
- Abduction: A movement of a limb away from the median plane of the body; the fingers are abducted by spreading them apart.
- Circumduction: A combination of movements that cause a body part to move in a circular fashion.(combination of all movements like flexion,extension,abduction and adduction).
- Supination: Extension of the forearm to bring the palm of the hand upward.
- Pronation: Movement of the forearm in the extended position that brings the palm of the hand to a downward position.
- Inversion: Movement of the ankle to turn the sole of the foot medially.
- Eversion: Movement of the sole of the foot laterally.
Resistive Exercises-performed against an opposing force(as tolerated by a person) to increase muscle strength.Resistance applied may be either isometric,isotonic or isokinetic.
Static Stretching Exercise-placement of muscles and connective tissues at their maximum length by a constant force in the direction of lengthening.
Strengthening Exercises- also known as force increasing exercises, prescribed to a person who shows weakness in individual muscles or muscle groups. Performed with relatively high resistance, but with few repetitions(3 to 10) followed by 1-2 minutes of rest.It is performed daily in early stages of rehabilitation.

## Electro Therapy
The therapeutic use of electricity to the human body as in the treatment of pain,paralysis or muscles weakness.
Numerous modalities are in use like Ultrasonic therapy(UST),Transcutaneous Electrical Nerve Stimulation(TENS),Interferential Therapy(IFT),Laser,Shock wave Therapy,Diathermy,Traction(Cervical or Lumbar) and many more.

## Ultrasonic Therapy (UST)
Defined as a high frequency acoustic energy,available in longitudinal waveforms in frequency range of .5 to 3.5 MHz. Most commonly used frequencies for treatment purpose in UST are .75 to 3.0 MHz(1 MHz = 1,000,000 cycles/second).
'Indications For UST'
i-Acute soft tissue injuries.
ii-Inflammation of joint capsules,tendons,bursa & ligaments associated with degenerative & inflammatory disorders like osteoarthritis,rheumatoid arthritis,repetitive stress injuries,gout.
iii-Wound Healing.
iv-Chronic Indurate Oedema.
v-Scar Tissue.
'Contraindications For UST'
i-Vascular Conditions like Thrombophlebitis or Phlebothrombosis.
ii-In Burger's disease,atherosclerosis,varicose veins or any other conditions where blood supply is poor or insufficient.
iii-Infected Lesion like Cellulites,Abscess or Carbuncles.
iv-Areas near Malignant Tumor.
v-Areas around Pregnant women uterus.
vi-Person with Metal or plastic Implants.

## TENS
TENS or "Trans-cutaneous Electrical Nerve Stimulation" is a modern non invasive, drug free pain management electro therapeutic modality(electroanalgesia).
Frequently used for acute or chronic pain in neck,back,joint pain of shoulder or knee etc, work or sports related injuries e.g. carpal tunnel syndrome,postural musculo-skeletal pain due to faulty work culture.
Types Of TENS
- High Rate TENS-
Pulse Rate- 50-100 Hertz
Pulse Width- 50-100 s(micro second)
Treatment Time-30-60 minutes/session or 7-9 hours(if required)
Uses- Acute & post operative pain, increased Muscle tone.
- Pulse Rate- 50-100 Hertz
- Pulse Width- 50-100 s(micro second)
- Treatment Time-30-60 minutes/session or 7-9 hours(if required)
- Uses- Acute & post operative pain, increased Muscle tone.
- Low Rate TENS-
Pulse rate- 1-5 Hertz
Pulse Width- 150-300 s
Treatment Time- 15-30 minutes/session
Uses- Chronic pain,Shows good results on tissues/skin of diabetic neuropathy,neuralgia where long pulse width is needed
- Pulse rate- 1-5 Hertz
- Pulse Width- 150-300 s
- Treatment Time- 15-30 minutes/session
- Uses- Chronic pain,Shows good results on tissues/skin of diabetic neuropathy,neuralgia where long pulse width is needed
- Brief Intense TENS-
Pulse Rate- 80-150 Hertz
Pulse Width- 40-250 s
Treatment Time- 10-20 minutes
Uses- Acute or chronic pain.
- Pulse Rate- 80-150 Hertz
- Pulse Width- 40-250 s
- Treatment Time- 10-20 minutes
- Uses- Acute or chronic pain.
- Burst Mode TENS-
Pulse Rate-50-100 hertz(delivered in bursts mode with 1-4 pulses/second)
Pulse Width-50-200 s
Treatment Time- 25 minutes
Uses- Chronic muscle spasm, Neuro-musculo-skeletal pain like sciatica syndrome.
- Pulse Rate-50-100 hertz(delivered in bursts mode with 1-4 pulses/second)
- Pulse Width-50-200 s
- Treatment Time- 25 minutes
- Uses- Chronic muscle spasm, Neuro-musculo-skeletal pain like sciatica syndrome.
Indications For The Use Of TENS
i-Musculoskeletal Pain like joint pain from osteoarthritis or rheumatoid arthritis,post operative pain,posttraumatic pain.
ii- Neurogenic Pain like pain after spinal cord injury,trigeminal neuralgia,brachial plexus avulsion etc.
iii- Visceral Pain & dysmenorrhea.
iv- Headache,Migraine, Toothache.
Contraindications For The Use Of TENS
i-Person with metal or Plastic Implant.
ii-Over chest wall of cardiac patients.
iii-Over Larynx,eyes,pharynx or mucosal membrane.
iv-Head or neck region of patient with recent history of epilepsy or stroke.

## Interferential Therapy (IFT)
It is a form of electrical treatment in which two medium frequency sinusoidal currents(4000 to 5000 Hz) are used to produce a low frequency current effect.
Principle
The IFT works on interference effect where 2 medium frequency currents cross in the patient's tissues.One current is kept constant at 4000 Hz, while frequency of another keep varying between 3900-4000 Hz. An interference effect at a "beat frequency"(difference between two medium frequency currents) is produced where the current cross(low frequency current effect produced at the desired point by changing the point of electrodes).
Indications For The Use Of IFT
i- Pain Relief.
ii- Muscle Stimulation.
iii- Increased Blood Flow.
iv- Wound healing & tissue repair.
v- Reduction of oedema.
Contraindications For The Use Of IFT
i-Person with metal or Plastic Implant.
ii-Over chest wall of cardiac patients.
iii-Patients with skin problem eg skin cut,dermatitis.
iv-Pregnant women's uterus.
v- Malignant Tumor.

## LASER
LASER stands for Light Amplification by the Stimulated Emission Of Radiation.
Compressed light of a wavelength from cold red part of the spectrum of electromagnetic radiation,it is monochromatic(single wavelength & color),Coherent(travel in a straight line) & polarized(concentrates its beam in defined location or spot).
LASER Regulation
Classified by the FDA's center for Devices and Radiological Health based on the Accessible Emission Limit.
Class Level Of LASER:-
I -laser radiation are not considered to be hazardous.
2 IIa levels of laser radiation are not considered to be hazardous if viewed for any period of time   1*1000seconds.
3-II levels of laser radiation are considered to be a chronic viewing hazard.
4- IIIa levels of laser radiation are considered to be, depending upon the irradiance, either an acute intrabeam viewing hazard or chronic viewing hazard, and an acute viewing hazard if viewed directly with optical instruments.
5- IIIb levels of laser radiation are considered to be an acute hazard to the skin and eyes from direct radiation.
6- IV levels of laser radiation are considered to be an acute hazard to the skin and eyes from direct and scattered radiation.
Types Of LASER
4 types of LASER-
1-Crystal & glass (solid -rod) - Synthetic Ruby.
2-Gas (Chamber) - HeNe, Argon, CO2.
3-Semi conductor(Diode channel) -Gallium Arsenide.
4-Liquid (Dye)- Organic dye as Lasing medium

### Indications For the Use Of LASER
i-Soft Tissue Injuries.
ii-Pain.
iii-Osteoarthritis & rheumatoid arthritis.
iv-Fracture.
v-Open Wound.
vi-Diabetic & Pressure ulcer.
Contra Indications For the Use Of LASER
i-Application over or around eyes.
ii-Malignant or cancerous cells.
iii-Pregnant women uterus.
iv-Over and around Thyroid or endocrine glands.
v- Epiphyseal Plates in children.
vi-Over vagus nerve.
vii- Over cardiac region.
viii- Patients who have been previously treated with photo sensitizers.

## Shock Wave Therapy
Shock Wave Therapy or Extracorporeal Shock Wave Therapy- involves direct bursts of high pressure sound waves at the affected area.Useful in the treatment of Tennis Elbow,Plantar Fascitis,Calcaneal Spur etc.
Characteristics Of Shock Wave Therapy
-Peak Pressure - typically 50-8- MPa(MegaPascals){according to ogden et al 2001} and 35-120 MPa {according to speed,2004}.
-Fast Pressure Rise- usually less than 10 ns(nanoseconds).
-Short duration -Usually about 10 s(microseconds).
-Narrow effective beam- 2-8 mm(millimeter) diameter.
Indications For Shock Wave Therapy
i-Tennis & golfer elbow.
ii-Plantar Fascitis.
iii- Calcaneal Spur.
iv-Jumper's Knee.
v- Achilles Tendon.
vi-Calcifying Tendinitis of Shoulder.
Contraindications For Shock Wave Therapy
i- Epiphyseal Region should be avoided.
ii-Malignant or cancerous cells.

# Specialty areas
Because the body of knowledge of physical therapy is quite large, some PTs specialize in a specific practice. While there are many specialty areas in physical therapy, the following are the five most common specialty areas in physical therapy:

## Cardiopulmonary
Cardiovascular and pulmonary rehabilitation physical therapists treat a wide variety of patients with cardiopulmonary disorders or those who have had cardiac or pulmonary surgery. Primary goals of this specialty include increasing patient endurance and functional independence. Manual therapy is utilized in this field to assist in clearing lung secretions experienced in patients with cystic fibrosis. Patients with disorders including heart attacks, post coronary bypass surgery, chronic obstructive pulmonary disease, and pulmonary fibrosis are only a few examples of those who would benefit from cardiovascular and pulmonary specialized physical therapists.

## Geriatric
Geriatric physical therapy covers a wide area of issues concerning people as they go through normal adult aging, but is usually focused on the older adult. There are many conditions that affect many people as they grow older and include but are not limited to the following: arthritis, osteoporosis, cancer, Alzheimer's disease, hip and joint replacement, balance disorders, incontinence, etc. 
Geriatric physical therapy helps those affected by such problems in developing a specialized program to help restore mobility, reduce pain, and increase fitness levels.

## Neurological
Neurological physical therapy is a discipline focused on working with individuals who have a neurological disorder or disease. These include Alzheimer's disease, ALS, brain injury, cerebral palsy, multiple sclerosis, Parkinson's disease, spinal cord injury, and stroke. Common problems of patients with neurological disorders include paralysis, vision impairment, poor balance, inability to ambulate, and loss of functional independence. Therapists work with patients to improve these areas of dysfunction.

### Guillain-Barre syndrome physical therapy

### Paraplegia physical therapy

## Orthopedic
Orthopedic physical therapists diagnose, manage, and treat disorders and injuries of the musculoskeletal system as well as rehabilitate patients post orthopedic surgery. This specialty of physical therapy is most often found in the out-patient clinical setting. Orthopedic therapists are trained in the treatment of post operative joints, acute sports injuries, arthritis, and amputations.
Joint mobilizations, strength training, hot/cold packs, and electrical stimulation (e.g., cryotherapy, iontophoresis, electrotherapy) are modalities often used to expedite recovery in the orthopedic setting. Additionally, an emerging treatment in this field is the use of sonography to guide treatments like muscle retraining. Those who have suffered injury or disease affecting the muscles, bones, ligaments, or tendons of the body will benefit from assessment by a physical therapist specialized in orthopedics.

### Ankylosing spondylitis physical therapy

## Pediatric
Pediatric physical therapy assists in early detection of health problems and uses a wide variety of modalities to treat disorders in the pediatric population. These therapists are specialized in the diagnosis, treatment, and management of infants, children, and adolescents with a variety of congenital, developmental, neuromuscular, skeletal, or acquired disorders/diseases. Treatments focus on improving gross and fine motor skills, balance and coordination, strength and endurance as well as cognitive and sensory processing/integration. Children with developmental delays, cerebral palsy, spina bifida, and torticollis are a few of the patients treated by pediatric physical therapists.
- Another PT specialty area is Integumentary (treatment of conditions involving the skin and related organs).

# Education

## United States
In the U.S., physical therapists must have a graduate degree from an accredited physical therapy program before taking the national licensing examination. Federal law also requires physical therapists to pass the National Physical Therapy Examination after graduating from an accredited physical therapist educational program before they can practice. Also physical therapists must apply for a state license to practice. Each state regulates licenses for physical therapists independently.
According to the American Physical Therapy Association, there were 210 accredited physical therapist programs in 2008of those 23 offered the Master of Physical Therapy, and 187 offered the Doctor of Physical Therapy (DPT) degree. Most programs are in transition to a DPT program.

# Evidence-based practice
For decades, physical therapy practice has been the subject of criticism for its lack of a research base. In a late 1990s survey of English and Australian physical therapists, fewer than five percent (5%) of survey respondents indicated that they regularly reviewed scientific literature to guide practice decisions. Despite an overall positive attitude towards evidence-based practice, most physical therapists utilized treatment techniques with little scientific support. Although numerous calls have been made for a shift toward the use of research and scientific evidence to guide practice decisions, at least throughout the 1990s, "most physical therapists continued to base practice decisions largely on anecdotal evidence."
To overcome these limitations, the World Confederation for Physical Therapy, the American Physical Therapy Association (APTA), and a number of authors have called on the profession to adopt and adhere to evidence-based practices formally based on the best available scientific sources.

# Practice variation
Variation in abilities has been studied.

# Satisfaction with care
Patients are satisfied with care by physiotherapists. Satisfaction may relate more to interpersonal attributes of therapists and processes of care rather than outcomes of care.

# Comparison to physicians
A systematic review comparing the value of physiotherapists versus orthopedic physicians to triage referrals from primary care physicians found advantages of physiotherapists when summarizing two randomized controlled trials and 11 cohort studies published through April 2020.
A separate trial found similar health outcomes but possibly lower costs comparing physiotherapist with primary care physicians.

# Journals and publications
Physical therapists have access to a wide range of publications and journals. Some are dedicated solely to physical therapy topics, while others (e.g., various orthopedic and surgical journals) cover a broader range of health-improvement topics, including physical therapy.