Physical therapy and, specifically, physical therapist, health agent, working for the prevention, cure and palliation of musculoskeletal and postural problems.

The practitioner develops its work in four main areas:
* Assistance: work to promote, prevent, cure and alleviate the health of patients using the breadth of knowledge acquired in their training.
* Teacher: your job is to educate and promote knowledge of physiotherapy in the public and private colleges as well as training proposals called for continued training of the physiotherapist.
* Researchers: your job is to find scientific evidence of the modes of action of physiotherapy, offering the patient, therefore, those actions with greater guarantees of success, proven scientifically valid studies of the scientific community.
* Management and Administration : carry out his work in the direction of health care centers, educational or professional associations.

What is it and does a physical therapist?
Based on the current concept of health, physical therapists operate from three levels: primary (prevention, education and empowerment), secondary (healing process) and tertiary (treatment of diseases and functional recovery in chronic and processes already in place).

As will be live in:
* Schools of integration (enabling children with different disabilities to access education. Adaptation of the academic curriculum to the needs and actual capacities of the child).
* Special schools (children and youth with a skill level that require specific institutions).
* Fitness centers and sports clubs (enhances performance by correcting the sporting gesture and immediate recovery of the lesions).
* Health Centers (plowing Health education, promoting self-care, birth preparedness, treatment and monitoring of certain minor and chronic processes).
* General hospitals (Physiotherapy units within the department of Rehabilitation that includes Speech Therapy, Occupational Therapy, Orthopedics, Psychology ,…).
* Hospitals and specialized services (paraplegic, burns, major neurological syndromes, transplant, respiratory, cardiac ,.)
* Psychiatric Hospitals.
* Homes for the Elderly (preventive-therapeutic work that seek to improve quality of life in the elderly).
* Cabinets private (with the traditional and innovative aspects such as animal physiotherapy, rehabilitation Urogynaecological ,…).
* Mutual funds and private insurance business.
* Associations and SHGs.
* Day centers (facilities of residential social services were not improving the state looking for bio-psycho-physical being of the elderly without detracting from their usual environment ,…).
* Centers of education (health branch Vocational Schools, University of Physiotherapy ,…).
* Spas and Spa.
* Companies (operator ergonomics consultant to minimize occupational hazards).
* Animal Physiotherapy Centres (racetracks, zoos, veterinary centers ,…).
* Management and administrative posts.

And what is often forgotten: Physiotherapy is not just a means to restore or heal. It is also particularly true for once-recognized risk or vulnerability to be proactive. Extend back to disorder of body function that must be made irreversible, the physiotherapy management processes set in motion.

Consequently, the three areas of physical therapy are in the

• Prevention: (prevention) prevention of the emergence of diseases (so-called primary or Erstprävention) or the prevention of recurrence of a similar disease (so-called second or secondary prevention).
• Therapy (treatment) early and long-term treatment of acute and chronic illnesses, support to other treatment measures for acute illnesses. Improve the quality of life in older age.
• Rehabilitation: Measures to restore capabilities that enable it to participate in spite of physical impairments in daily life. Reduce or offset of loss of function, quality of life etc.

Consistent to the above here is how to implement this manipulation on muscle attachments points:

1. Palpate carefully for muscle mass of the lumbar spine or back or both as appropriate.

2. Identify the areas or hard spots (areas with increased muscle tone)

3. Start with the pressure with the thumbs from the area more caudal to the most cephalad muscle pressure points holding it for 10 seconds.

4.Después initial pressure with thumbs make circular paths for and against the hands of reloj.20 times in favor and 20 times anti-clockwise.

5. The next step is to lobby fast with a frequency of 1 per second to make forty.

As we can observe is an extremely simple technique in soft tissue treatment especially where there are trigger points, muscle spasms, increased tension in the tonic muscle and back pain syndromes.
Emphasize the simplicity of the technique, but I really hope that if anyone has applied this technique to be a physical therapist and not a professional masseur or false empirical or other professional.

Traumatic injuries of the flexor tendons of the hand are very common and can leave serious consequences ranging from a simple reduction of force, until a major limitation of flexion, limiting the overall role of the hand.

In this article we will focus on the case of a patient who attended the Emergency Unit of the European Hospital Georges Pompidou (Paris). In this hospital there is a service that specializes in hand surgery, the rehabilitation is conducted according to specific protocols.

The patient of 44 years goes by a domestic accident (breakage of a plate). Presents a deep cut on the palm side of the Zone II of the left index finger. In his case presents no complete vascular injury but a common functional impotence of the Deep Flexor (FCP) and Common Flexor Surface (FCS) and a radial edge of the anesthesia of the finger.
Realizándosele surgery is a suture in the tendon, an anastomosis of the radial collateral artery and a suture of the radial collateral nerve.

The post is smooth and the patient started physical therapy the day after your operation.

Basic Concepts

Then, for a proper understanding, we proceed to explain some basic concepts

2.1) topographical areas

In 1961, the Truth and Michot propose a classification that includes seven anatomical areas to divide the hand. The International Federation of Hand Surgery amends in 1980. Currently comprises 5 zones and 3 fingers for the thumb.

In this case only develop different parts of the fingers except the thumb, as the case of our patient.

Zone 1: Insertion of the distal flexor surface and covers the insertion of the deep flexor of the base of the third phalanx.

Zone 2: Called “No Man’s Land”: It goes from the distal palmar crease to the middle of the second phalanx.
This area is interesting from the anatomical point of view because at this level the deep flexor appears “punch” to the superficial flexor.

Zone 3: Occupies since leaving the carpal tunnel until the digital channel. This area is conducive to good recovery.

Zone 4: Carpal Canal Zone. Corresponds to the carpal tunnel area covered by the annular ligament anterior carpal pulley makes avoiding the phenomenon of string arc during flexion of the wrist. The median nerve is the most vulnerable surface of the channel.

Zone 5: Since the union of the musculo-tendinous flexor to enter the carpal tunnel. In this area, the tendons are surrounded by a paratendón which allows movement of large amplitude. It is a very favorable area for recovery if there is a nerve-associated vascular injury.

2.2) tendon healing

After a long evolution of ideas, all authors agree to define two types of tendon healing:
Extrinsic-healing: where there is a fibroblastic invasion of adjacent tissues, resulting adhesions.
Intrinsic healing-that is the ability of the tendon to regenerate itself through its own intra-tendon fibroblasts to migrate into the lesion.

During tendon repair, Shickland, discovers that the three phases will coexist two of wound healing mechanisms so indivisible.

* An inflammatory phase (3-5 days) characterized by a swelling and a hematoma.
* A fibroblastic phase (3-6 weeks) characterized by a high production of collagen.
* A phase remodelage (6-8 months) in which the maturation and organization of the fibers is a longitudinal mode under the effect of movements and the forces of traction.

Briefly explain the protocols of rehabilitation according to the stage of healing in the tendon that is:

From the day 1-21 after the intervention:
Analytical and global manipulation
Protection tendon (splint)
Tenodesis effect

From day 21 to 45:
Work of the scar (U.S., massage ..)
Passive movements
Active work and active-assisted soft -
Cryotherapy

Beginning 45 days:
Further work on the scar
Working towards an active extension / flexion
Extensor strengthening
Articulate and work towards easing the flexo-extension

3) Rehabilitation

The protocol type of rehabilitation will depend on the cooperation of the patient, the extent of the lesion, the surgical gesture and the use of rehabilitation equipment. Is essential and depends entirely on the patient
The goals of rehabilitation are:

-Promotes healing
-Reduce the incidence of adhesions
-Maintain joint mobility

All the techniques are accompanied by a protective splint in order not to risk the tendon regeneration. Turbiana sorts of techniques:

Technology-active: Active Flexion + Extension active
Semi-active techniques: Passive Flexion + Extension active (Kleinert)
Techniques-passive: Passive Flexion + Extension passive (Duran)

We shall develop the protocol for rehabilitation in post-operative acute phase (day 1-21 after intervention) according to the method Duran protocol used in HEGP

Method Duran (1975):

Passive rehabilitation protocols are based on the method Duran, in 1975, notes that a tendon travel of 3 to 5 mm is sufficient to prevent adhesion formation.

The advantages of passive mobilization are:
which is simple
-There is a low incidence of post-operative rupture
anti-IFP-flexo IFD

Development of the session:

Before starting the mobilization, submerge the hand of the patient in a container with saline solution which aims to soften the scars.

Duran describes 2 types of mobilization to optimize landslides:

One-manipulation (a) in flexo-extension of the IFD, which allows a sliding analytical with respect to FCP FCS.

One-manipulation (b) in flexo-extension of the IFP, which allows a sliding of the two tendons with respect to the structures surrounding the digital channel.

During the exercises, your elbow is in flexion and pronation for a relaxation of the flexors.

Other exercises in this acute phase are:

passive-movements of the metacarpophalangeal
passive-movements of the wrist to create the effect of tenodesis
passive-global movements of the fingers to flex.

The patient wears a splint Duran in thermoformed in the immediate postoperative period and as being very comfortable and very hygienic. This splint prevents stretching and allows the tendon healing. Is a
dorsal protective splint is worn for 4-5 weeks. The position of the hand is:
The wrist palmar flexion 40 °
MF-bent to 60-70 º
IFD-IFP-extension

During the period of immobilization the manipulation must be performed throughout the day by the patient (self-education). For proper self-education, he explained to the patient the need to make 10 moves in under the protection of passive flexion splint to be made at hourly intervals.

Conclusions:

The surgery of the flexor is a complex surgery, particularly injuries in zone 2. The cooperation of the patient (auto rehabilitation) and a correct approach in the acute phase postoperative physiotherapy is essential to obtain an optimal functional outcome.

Bibliography
- Magazine-Kine scientifique No. 458: Article “Lesions des tendons in zone II fléchisseurs: Évolution des idées et Rééducation” Jean-Marc Ovieve and Béatrice Bouscarat-Chapin.
- “Diplôme Inter-Universitaire of rééducation chirurgie et d’appareillage in the main 2001-2003″ François Delaquaize
- “Lesions des tendons des doigts longs flechisseurs: principes et appareillage of rééducation” Didier Galloy-Institut de la Main, Paris.
- “Comment improve chirurgie des tendons of the main” M. Merle, G. Dautel and C. Dumontel.

Material and Methods: A sample of 12 patients between men and women aged between 21 and 61 years subdivided into two groups according to sex to which they belong. Data were collected from each patient at the beginning and end of study time. Data processing was performed using the Statistical Program CaEst 1.2, and found the statistics: mean, standard deviation, variance, test of goodness of chi-square test signs of S and the linear regression.

Results: At the end of the study which lasted six weeks, the results were that 12 patients of the sample containing the twelve raised their health in some or all aspects, both physical and psychological. The improvement in the group of men is 100% as the 5 men included in the sample had improved. The improvement of women is also a 100% because the sample of 7 women returned improvement.

Conclusion: The use of physical therapy (thermotherapy, therapeutic exercise and manual-cinesiterapia) in patients with whiplash had a clear positive influence on this condition, improving the symptoms with which we are presented with the study patients.

Keywords: whiplash physiotherapy, thermotherapy, manual therapy. (No abstract in English)

INTRODUCTION
The whiplash injury is defined as a mechanism of acceleration and deceleration of the energy transfer to the neck. You can be the result of a car accident by rear or side collisions, but can also occur when diving or other types of accidents. Frontal impact induces excessive flexion of the neck and just after, the reaction force causing its total length and also when the reverse happens in a crash later. All this takes place very quickly, without giving time to exercise the muscles its protective function. Tension in the muscles causes, in turn, an increase of post-traumatic symptoms as the initial tension can cause strong contractions after choque.2

The transfer of energy can cause bone lesions or soft tissue injuries (Whiplash), which may involve a variety of demonstrations clínicas.2

In some cases the extension of the neck can be so excessive that it may even cause fractures of the cervical pathology or even beyond contractures, such as broken fibers músculo.2

EPIDEMIOLOGY
The accepted average incidence of this disorder as a result of road accidents in Western countries suggests values around 100 new cases of WAD per 100,000 inhabitants and year (but in different western countries have been different results).

In countries like New Zealand: annual incidence is 13 per 100,000 inhabitants. In Switzerland: annual incidence of 44 per 100,000 inhabitants.

By contrast, in countries like Norway, the incidence is 200 per 100,000 inhabitants and year.

A 2000 study reveals that in the U.S., the incidence is 200 per 100,000 inhabitants and year, a number much lower than the previous results of 1995, which revealed the alarming figure of 1107 cases per 100,000 inhabitants and year.

With respect to Spain, a study in clinical forensic medical Bilbao during the years 1995, 1997, 1999, 2001 and 2002 reveals that:
Mean age of subjects who suffered whiplash was 33.62 years, minimum 14 years and maximum of 72 years, there were 1.2 men for every woman.

97% were collisions with vehicles, this 97%, 96% were accidents by collision between vehicles in which the injured was a driver or occupant of a passenger car, most cases correspond with anteroposterior and subsequent collisions with a lower incidence of side or frontal mechanisms.

TYPES
Patients with whiplash injuries can be classified according to severity of signs and síntomas.2
-Grade 0: no discomfort in the neck, or physical signs
-Grade 1: neck pain, stiffness or discomfort vague. There are no physical signs.

-Grade 2: neck discomfort. Signs skeletal muscle: reduced mobility and painful signs.

-Grade 3: neck discomfort and neurological signs: hiporreflexia, paresis and sensory deficits.

-Grade 4: neck discomfort and presence of fractures and / or vertebral luxations.

Symptoms
The whiplash cause intense local pain in the neck area covering the area both before and after (with the corresponding muscles involved), with muscle contracture and painful limitation of mobility. Can be accompanied by dizziness or feeling of instability, referred pain to the neck or arm or even hand, vascular lesions, involvement of the temporomandibular joint and psychological symptoms.

TREATMENT
General treatment:
Pharmacological * (see annex table 2).
* Minimum immobilization
* Early Rehabilitation will pursue different objectives depending on periods of evolution of this disease (see Table1)

In our case, we applied a treatment that contains both patterns of acute (mostly) and patterns from chronic illness, as cases that present in the study are not acute or chronic, are at an intermediate step (process sub) 3 (see annex table 1).

Our goal is to see improvement in our patients following the implementation of physiotherapy treatment, whether treatment is effective with this pathology.

METHODOLOGY
The type of study we are conducting a prospective longitudinal observational study, we tried to verify how or how much we have improved the patients and the time it will take to do so, as the number of physiotherapy sessions that require physical therapy and received , after making a comparative study of the initial and final values to see which patients are best.

Study population. The study sample was 12 patients (5 men and 7 women) affected by a whiplash and who are receiving physical therapy sessions from a few weeks ago. Some of these patients, in addition to the physiotherapy sessions, are under drug treatment.

Selection criteria: Patients were chosen so that we had the same disease with different ages of the subjects. We also try to enter into the study both women and men, for a subsequent comparison between the sexes. They were also well chosen, given the scarcity of the pathology presented. The patients selected were all those in treatment.

Each patient had passed the questionnaire disability index neck, asking each one to read the questionnaire and fill it in terms of how it is at that time. This procedure is performed before starting the study with the patient, to obtain an initial assessment and end of the study, giving a final assessment for the subsequent comparison of results.

The reliability of this scale used as the test-retest test on an initial sample of 17 patients, concluded with a Pearson coefficient of 0.89, p = 0.5 or less. The alpha coefficients were calculated from a questionnaire carried out by 52 individuals, obtaining a total index alpha of 0.8, with all individual items over 0.75. The percent change in NDI scores were compared with the visual analogue pain scale, yielding a correlation of 0.6. Subsequently, related NDI scores again but this time with the McGill pain questionnaire, with a correlation of 0,69-0,70.1
Subsequently, and with all patient data, perform analysis of these data with the statistical program CaEst 1.2.

Equipment used: With the patients we used stretchers, chairs for treatment, infrared bulbs, tens, and autopasivos pulleys, wedges and a physiotherapist.

The patients performed the treatment in the physiotherapy room, applying a manual therapy combined with infrared heat for 10 minutes. Autopasivos continue the treatment and are supervised by the physiotherapist to perform correctly. The stretching is the next step and we are stretchers or chairs. The exercises and the application of analgesic currents are the last step being implemented separately, and the exercises were held in front of a mirror so that the patient might be and where the physical therapist was also present to discuss, monitor and correct these exercises if that were not properly made.

a) The exercises in the room:
-Cinesiterapia active mobilization of the neck to the extent possible and in all possible directions (flexoextensión, lateroflexión and rotations), stopping at the center every time you make a movement of the above and of course, accompanying the movement with their eyes.

-Autopasivos: supervised by the physiotherapist. Prevent failure in its performance as the patient is compensated with the position.

b) the exercises at home:
- Cinesiterapia active at home. The exercises also will be sent out to make the patient at home, except exercises autopasivos. Mobilization exercises of the neck in front of a mirror are recommended to maintain the gains in the living room supervised physiotherapy exercises.

RESULTS
In this study involving 12 patients, 7 men and 5 women, whose average age is 32.5 years and a standard deviation of 12.14. Concerning the analysis of the age of men and won half of 35.8 years and a standard deviation of 14.16. The analysis of age in the sample of women gives half with a value of 30.14 years and a standard deviation of 9.8.

After analyzing the questionnaires as a result gives us an average initial score of 32.08 points and a diversion of 7.05y a final score of 22.25 and a half standard deviation of 7.17

Next, we performed the chi-square. It is a test used to indicate the normality of the sample, obtaining the difference is not too large, we can not reject that hypothesis and say that our distribution is approximately normal. ”

The critical value that indicates the value below which makes it 95% of values in a Pearson’s chi2 distribution with 3 degrees of freedom, being 7815

The next test to which we have submitted to our sample S is the sign test to see if the improvement of the sample is due to chance or is the result of something other than this age, the number of sessions …

With 12 patients in the sample, that will improve and that 12 is due to chance, would have a probability of 0.00024, ie 0.024% of the same. Since this probability is less than 5% (0.05) conclude that the results are statistically significant, meaning that the improvement should not be random with a confidence level of 95%. The results were statistically significant.

A final test on the sample is linear regression. We conducted this test to see how values and factors influencing the initial score, age and number of sessions on the final assessment of each subject in the sample.

We want to predict the effect on the final score of our patients

(Y) of the variables “initial score” (X1), “Age” (X2) and “Number of sessions (X3). The coefficient of multiple determination gives us 0744, that is, we predict a 74.4% of the predicted variable (Y) variables from our postgraduate degree.

In our case, there is a strong correlation between the final and the initial assessment and age.

DISCUSSION
The treatment has been given to patients with the disease who is a combination of several types of techniques widely used in physiotherapy (such as thermotherapy, massage therapy and exercises cinesiterapia and mobility). In addition to this tax treatment to the patient, there are many techniques that could have been applied to this kind of pathology, and are aimed at completing the objectives apart from those we also imposed at the beginning of the study must achieve a total recovery patient, both of musculo-skeletal system and the bio-psycho-social surrounding that person back to the normal course of its life as best as possible, to perform their daily activities without any problems.

This treatment that we used can not be applied so broken down, with independent techniques, since the combination treatment is the recipe for success with our patient (get more effective treatment to provide the greatest benefit to our patient achieved through the combination of whole-technical).

The results that we leave the job after the application of appropriate physiotherapy treatment shows that the entire sample, 12 patients improved with respect to the initial situation in which they found not only improved physically, but also a psychological and social aspects, which are very important for a high quality of life.

We can say that the tax treatment of the sample survey has been effective, as all improved to a greater or lesser degree, having a range of improvement and slight improvement between the medical (which are the patients).

The results tell us that everyone is improving but there are subjects of the sample to improve more than others, hence the saying goes from slight improvement to the medical, as mentioned earlier.

We obtained the results that had a high correlation between the number of sessions and the patient’s age and the final state of health.

We found that those who received sessions, gained more improvement in a patient who received fewer treatment sessions. Therefore, we can easily deduce that more treatment sessions increases the improvement of the physical state of the patient with the consequences this has.

We must also talk about the relationship between the final score we obtained (the improvement of the patient) and the age of this because we can observe that patients with a lower age get more improvement than patients with a higher age. A young person experiencing an improvement physically higher than an older person.

Furthermore there is a curious fact, the presence of other diseases in these patients. Less in patients who have improved, we have found other associated diseases, such as a cervical osteoarthritis or cervical hyperlordosis, which are an obstacle to the time that the patient has more improvement.

One limitation found in this study is mainly the time, since most patients have not completed their full course of physiotherapy and as a result, we could not know the total number of sessions and the total extent of improvement achieved.

Another limitation found in this study is described above: the presence of associated diseases. These conditions do not permit the study to all patients alike, since it is the level of improvement condition. Another problem is that this disease is also associated with other types of treatment which is complemented by the study, so patients who have suffered the most treatment (added to try techniques that other pathology) than patients without such comorbidities, .

The correct would be that all patients had only the pathology of the study, so there is no additional treatment for some.

Comparing these results with earlier studies conducted on this disease 5,6,7 we can see that the specific exercises in the treatment of cervical disease are effective at improving the physical condition of the patient, in addition to the mobilization and implementation of and stretching exercises is also beneficial for the patient, while we agree with the above that the exercises by themselves do not improve the physical condition of the patient, but must be combined with other techniques.

A goal that we can make for the future is to continue to investigate the scientific evidence of the various techniques of physiotherapy in this condition for a better and proper application of treatments in patients suffering from this disease (either in its acute or chronic ).

CONCLUSIONS
The conclusion of this work, first, is that the entire sample of the study improved objectively.

Secondly, the improvement depends on factors such as number of sessions, age of the patient and a second instance, the presence of an associated disease.

Finally, with the support of the abovementioned documents, saying that the treatment that we have put the patient is effective because the entire sample has improved significantly and objectively for us besides a subjective improvement of the patient (each improvement in a different way according to the same). The improvement has been both physically and psychologically, and therefore, this translates into an increase in happiness and quality of life.

BIBLIOGRAPHY
1 – Vernon H, Mior S. The Neck Disability Index: a study of reliability and validity
2 – Verhagen AP, Scholten-Peeters GGGM, van Wijngaarden S, de Bie RA, Bierma-Zeinstra SMA. Conservative treatments for whiplash injury (Cochrane Review translated).
3 – Ana Fernández. Apuntes Physiotherapy in Rheumatology. Physiotherapy Special I.
4 – Cervical Overview Group Massage for mechanical neck disorders (Cochrane Review translated).
5 – Kay TM, Gross A, Santaguida PL, Hoving J, Goldsmith C, Bronfort G, Cervical Overview Group Exercises for mechanical neck disorders (Cochrane Review translated).
6 – Kay TM, Gross A, Goldsmith C, Santaguida PL, Hoving J, Bronfort G, Cervical Overview Group. Exercises for mechanical neck disorders.
7 – Conlin A, Bhogal S, Sequeira K, Teasell R. Treatment of whiplash-associated disorders – part I: Non-invasive interventions.
8 – Uhrenholt L, Gregersen M. Low-speed motor vehicle crashes – marginal values for whiplash-associated disorders.
9 – Childs SG. Cervical whiplash syndrome. Hyperextension-hyperflexion injury.