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EXAM ANSWER - Bharati Vidyapeeth (Deemed University)

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LONG CASE: Motor Point Stimulation for Muscles Supplied by Anterior Tibial Nerve (Deep Peroneal Nerve)

Definition

The Anterior Tibial Nerve = Deep Peroneal Nerve (DPN). It is a branch of the Common Peroneal Nerve.

Muscles Supplied by Deep Peroneal (Anterior Tibial) Nerve

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Equipment Required

• Faradic/Interrupted DC stimulator (IDC unit)
• Large dispersive/indifferent electrode (4x4 cm or larger)
• Small active/motor point electrode (1-2 cm pencil probe or small pad)
• Electrode gel / saline-soaked pad
• Couch / plinth
• Towels, straps

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Patient Preparation

1. Explain the procedure - what will be felt (tingling, muscle twitch), purpose, and duration.
2. Obtain informed consent.
3. Check for contraindications (see below).
4. Expose the anterior compartment of the lower leg fully.
5. Inspect skin - no cuts, wounds, rashes, or broken areas.
6. Clean skin with wet gauze.
7. Ask the patient to remove any metal jewelry near the area.

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Patient Position

• Hip in neutral or slight external rotation
• Knee slightly flexed (pillow under knee for comfort)
• Ankle in neutral/plantigrade position
• Foot hanging freely off the edge of plinth OR supported on a folded towel

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Electrode Placement

Indifferent (Dispersive) Electrode

• Large pad electrode
• Placed on the posterior calf / gastrocnemius area (or lumbar spine region)
• Secured with a strap or bandage
• Soaked in saline

Active (Motor Point) Electrode

• Apply gel to the motor point electrode tip
• Place it precisely on the motor point
• Move slightly to find the point of maximal contraction with minimal current

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Parameters / Dosage

• Long pulse duration (100-1000 ms)
• Slow interrupted DC (SIDC)
• Intensity: to produce a sluggish worm-like contraction

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Procedure - Step by Step

1. Position patient supine, expose lower leg.
2. Test sensation (light touch) to confirm patient can feel stimulation.
3. Place indifferent electrode on the posterior calf, secure it.
4. Apply gel to the active motor point probe.
5. Set frequency and pulse duration; intensity at zero.
6. Place active electrode over tibialis anterior motor point.
7. Slowly increase intensity until a clear dorsiflexion contraction is seen.
8. Ask patient to actively try to contract the muscle along with the stimulation (voluntary effort + electrical = best re-education).
9. Treat each muscle separately: Tibialis Anterior → EHL → EDL → EDB.
10. 10 contractions per muscle, 3 sets, rest between sets.
11. After treatment, remove electrodes, clean skin.
12. Record the intensity used and patient response.

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Indications for Motor Point Stimulation (DPN muscles)

1. Foot drop - Common Peroneal Nerve palsy (LMN lesion)
2. Disuse atrophy of anterior compartment muscles
3. Muscle re-education post-surgery (tendon repair, fracture)
4. Upper Motor Neuron lesions - spasticity management, reciprocal inhibition
5. Peroneal nerve injury (post-knee dislocation, fibular head fracture)
6. Post-immobilization weakness
7. L4-L5 radiculopathy with tibialis anterior weakness
8. Functional electrical stimulation (FES) for gait training in stroke, SCI

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Contraindications

1. Cardiac pacemaker / implanted defibrillator
2. Over carotid sinus area, heart, or transthoracically
3. Over eyes or anterior neck
4. Active malignancy / cancer in the area
5. Active thrombophlebitis / DVT in the limb
6. Skin infections, open wounds, burns at electrode site
7. Anesthetic / insensitive skin (risk of burns)
8. Epilepsy (over head/neck region)

1. Pregnancy (avoid over abdomen/pelvis)
2. Metal implants (screws, plates) in the stimulation field - use low intensity carefully
3. Circulatory disorders (peripheral arterial disease)
4. Bleeding disorders / anticoagulant therapy
5. Recent surgical wound
6. Skin hypersensitivity / allergy to electrode gel
7. Uncooperative / confused patient

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SHORT CASE I: Interferential Therapy (IFT) for Osteoarthritis Knee - Left

Definition of IFT

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Therapeutic Effects Relevant to OA Knee

1. Analgesia - Gate control mechanism (high frequency 80-150 Hz) and endorphin release (low frequency 2-4 Hz)
2. Reduced muscle spasm - Relaxation of periarticular muscles
3. Improved circulation - Vasodilation
4. Reduced edema / swelling
5. Facilitation of cartilage nutrition via pumping effect

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Patient Preparation

1. Explain procedure, obtain consent.
2. Check for contraindications.
3. Expose the left knee fully.
4. Inspect skin for cuts, infection, rash.
5. Clean skin.
6. Assess baseline pain level (VAS).

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Patient Position

• Left knee slightly flexed (rolled towel/pillow under the knee for comfort, or long sitting)
• Hip in neutral
• Foot supported

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Electrode Placement for IFT - OA Left Knee

4-Pole (Quadripolar) Technique - PREFERRED

Circuit 1 (Yellow): 
   - Electrode A: MEDIAL aspect of knee (above joint line)
   - Electrode B: LATERAL aspect of knee (below joint line)

Circuit 2 (Red):  
   - Electrode C: ANTERIOR aspect of knee (above patella)
   - Electrode D: POSTERIOR aspect of knee (behind knee, popliteal fossa)

• Electrode 1: Medial femoral condyle
• Electrode 2: Lateral femoral condyle
• Electrode 3: Anterior tibial plateau
• Electrode 4: Posterior popliteal area

2-Pole (Bipolar) Technique

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Parameters / Dosage

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Procedure - Step by Step

1. Position patient supine, knee slightly flexed.
2. Check the IFT machine - 4 leads, 4 electrodes (suction cups or pads).
3. Wet the electrodes or apply gel.
4. Place Electrode 1 (medial, above joint line) and Electrode 2 (lateral, below joint line) - Circuit 1.
5. Place Electrode 3 (anterior, above patella) and Electrode 4 (posterior/popliteal) - Circuit 2.
6. Ensure diagonal cross arrangement with knee at center.
7. Set parameters: beat frequency 80-100 Hz, sweep mode.
8. Turn intensity of both circuits simultaneously, slowly increasing.
9. Patient should feel a deep buzzing/tingling sensation in the knee joint.
10. Treat for 15-20 minutes.
11. After treatment, remove electrodes, clean skin, reassess pain (VAS).

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Indications for IFT

1. Osteoarthritis - knee, hip, shoulder (most common indication)
2. Rheumatoid arthritis (subacute/chronic phase)
3. Soft tissue injuries - sprains, strains
4. Muscle spasm and pain
5. Post-fracture pain and edema
6. Chronic back pain / neck pain
7. Bursitis, tendinopathy
8. Post-surgical pain (post-knee replacement)
9. Circulatory disorders / venous insufficiency
10. Stress incontinence (perineal electrode placement)
11. Delayed fracture healing

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Contraindications for IFT

1. Cardiac pacemaker / implanted stimulator
2. Active malignancy / cancer in the area
3. Active DVT / thrombophlebitis
4. Skin infections, wounds, burns at electrode sites
5. Anesthetic / insensitive skin
6. Over carotid sinus, heart, anterior neck, eyes
7. Epilepsy (near head/neck)

1. Pregnancy - avoid over abdomen/pelvis; knee treatment is generally safe
2. Metal implants at the site (knee replacement implants - use reduced intensity; many therapists treat over TKR with caution)
3. Active hemorrhage / bleeding disorders
4. Peripheral arterial disease (severe)
5. Skin hypersensitivity
6. Confused / uncooperative patient
7. Recent acute injury with marked swelling (wait 48-72 hrs)

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SHORT CASE II: Infrared Radiation (IRR) for Low Back Pain (Lumbosacral Region)

Definition of IRR

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Therapeutic Effects

1. Vasodilation and increased circulation - erythema (skin reddening)
2. Analgesia - reduced muscle spasm, counter-irritation
3. Muscle relaxation - reduced tone and spasm
4. Metabolite removal - improved local circulation flushes pain mediators
5. Increased tissue extensibility - better stretching of soft tissues post-heating

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Patient Preparation

1. Explain procedure, purpose, and what the patient will feel (warmth, not burning).
2. Obtain consent.
3. Expose the lower back fully (patient removes shirt/blouse).
4. Inspect skin - no broken skin, recent scars, sunburn.
5. Test sensation - thermal sensation test is MANDATORY: apply test tubes of hot and cold water to the area. Patient must be able to distinguish heat vs. cold before proceeding.
6. Position patient comfortably.
7. Remove any metal jewelry, dressings.

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Patient Position

• Pillow under the abdomen (reduces lumbar lordosis and patient comfort)
• Head in face hole or turned to one side
• Arms at sides or under head
• Feet over the end of the plinth or a pillow under ankles
• Full exposure of lumbosacral region

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IRR Lamp Setup and Placement

Lamp Type

• Non-luminous (infrared) lamp - standard for clinical use
• Wattage: 250W-1000W (most clinical lamps: 250-500W)
• Allow the lamp to warm up for 5-10 minutes before use (especially non-luminous)

Distance

Area Coverage

• Cover the lumbosacral region: L1-L2 to S1-S2 and bilateral paraspinal muscles
• Can cover the gluteal region if buttock pain is present

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Procedure - Step by Step

1. Position patient prone with abdomen pillow, expose lower back.
2. Perform thermal sensation test (mandatory).
3. Warm up the lamp for 5-10 minutes.
4. Place the lamp 45-60 cm away from the lumbosacral skin (perpendicular).
5. Tell the patient: "You should feel pleasant, comfortable warmth. Inform me immediately if it becomes too hot, burning, or uncomfortable."
6. Do NOT leave the patient unattended.
7. Check the skin every 5 minutes - look for:
   • Uniform erythema (expected and desired - mild reddening)
   • Blotchy/mottled redness = too intense - increase distance
   • No redness at all = too far - decrease distance slightly
8. Total treatment time: 15-20 minutes (maximum 20-30 min for large areas)
9. After treatment: remove lamp, inspect the skin, record response.
10. Advise patient not to expose the area to cold immediately after.

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Dosage Summary

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Precautions During Treatment

• Check skin every 5 minutes
• Do NOT allow patient to fall asleep
• Patient must NOT touch the lamp
• Do NOT direct lamp toward eyes (use goggles or cover eyes)
• Keep the lamp at the correct angle (perpendicular)
• Screen off nearby patients / maintain privacy

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Indications for IRR (Low Back Pain context)

1. Acute and chronic low back pain - muscle spasm, ligament sprains
2. Lumbosacral spondylosis / lumbar osteoarthritis
3. Muscle strains - paraspinal, gluteal
4. Sacroiliac joint pain
5. Fibromyalgia (local area treatment)
6. Sub-acute and chronic phases of disc prolapse (for muscle spasm)
7. Post-fracture pain (after healing)
8. Stiff joints - preparation for mobilization and exercise
9. Wound healing (chronic wounds, pressure ulcers)
10. Neuralgia - peripheral
11. Preparation before massage, stretching, or manual therapy

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Contraindications for IRR

1. Anesthetic / insensitive skin - cannot detect over-heating, burns will occur
2. Active bleeding or hemophilia (heat increases bleeding)
3. Deep X-ray therapy area (within 3 months)
4. Active malignancy / cancer in the treatment area
5. Over ischemic tissues (severely compromised blood supply - cannot dissipate heat)
6. Acute febrile conditions - increases temperature further
7. Open wounds / raw areas directly under lamp
8. Over the eyes (risk of cataract, retinal burns)

1. Impaired circulation (PAD, Buerger's disease)
2. Scar tissue (irregular vascularization)
3. Edematous tissues (fluid redistribution risk)
4. Skin conditions - eczema, psoriasis, dermatitis (may aggravate)
5. Pregnancy (avoid abdomen; lumbar region with caution)
6. Elderly patients with thin, fragile skin - reduce intensity/increase distance
7. Metallic implants near the surface
8. Over gonads (reproductive organs)
9. Vitiligo patches (uneven pigmentation)

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Quick Comparison Summary Table

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EXAM ANSWER - Bharati Vidyapeeth (Deemed University)

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LONG CASE: Motor Point Stimulation for Muscles Supplied by Anterior Tibial Nerve (Deep Peroneal Nerve)

Definition

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Muscles Supplied by Deep Peroneal (Anterior Tibial) Nerve

• Tibialis Anterior - Dorsiflexion and inversion of foot
• Extensor Hallucis Longus - Extension of big toe
• Extensor Digitorum Longus - Extension of toes 2-5
• Extensor Digitorum Brevis - Intrinsic extension of toes
• Peroneus Tertius - Dorsiflexion and eversion

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Equipment Required

• Faradic / Interrupted DC (IDC) stimulator
• Large dispersive (indifferent) electrode - 4x4 cm or larger
• Small active motor point electrode (pencil probe or small pad)
• Electrode gel / saline-soaked pad
• Plinth / couch, towels, straps

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Patient Preparation

1. Explain the procedure - what will be felt (tingling, muscle twitch), the purpose, and the duration.
2. Obtain informed consent.
3. Check for contraindications.
4. Expose the anterior compartment of the lower leg fully.
5. Inspect skin - no cuts, wounds, rashes, or broken areas.
6. Clean the skin with wet gauze.
7. Ask the patient to remove any metal jewelry near the area.
8. Test sensation (light touch and thermal) to confirm the patient can feel stimulation.

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Patient Position

• Hip in neutral or slight external rotation
• Knee slightly flexed (pillow under the knee for comfort)
• Ankle in neutral / plantigrade position
• Foot hanging freely off the edge of the plinth OR supported on a folded towel

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Electrode Placement

• Large pad electrode placed on the posterior calf / gastrocnemius area
• Secured with a strap
• Soaked in saline

• Tibialis Anterior - Upper 1/3 of the anterolateral leg, just lateral to the tibial crest, approximately 10 cm below the fibular head
• Extensor Hallucis Longus - Middle 1/3 of the leg, between tibia and fibula, lateral to tibialis anterior
• Extensor Digitorum Longus - Lateral to tibialis anterior in the upper-middle third of the anterior leg
• Extensor Digitorum Brevis - Dorsum of the foot, anterior to the lateral malleolus
• Peroneus Tertius - Lower 1/3 of the anterior leg, lateral aspect

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Parameters / Dosage

• Current type: Interrupted DC (IDC) / Faradic current
• Frequency: 50-100 Hz for innervated muscle; 1-20 Hz surged for re-education
• For denervated muscle (LMN lesion): Use Slow Interrupted DC (SIDC) with long pulse duration of 100-1000 ms to produce a sluggish worm-like contraction
• Intensity: Gradually increase to produce a visible strong muscle contraction at motor level - no pain
• Duration per session: 10-20 minutes
• Frequency of treatment: Once or twice daily

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Procedure - Step by Step

1. Position patient supine, expose lower leg.
2. Place the indifferent electrode on the posterior calf, secure it firmly.
3. Apply gel to the active motor point probe.
4. Set frequency and pulse duration; keep intensity at zero.
5. Place the active electrode over the tibialis anterior motor point.
6. Slowly increase intensity until a clear dorsiflexion contraction is visible.
7. Ask the patient to actively try to contract the muscle along with the stimulation - voluntary effort combined with electrical stimulation gives best re-education results.
8. Treat each muscle separately: Tibialis Anterior, then EHL, then EDL, then EDB.
9. Perform 10 contractions per muscle, 3 sets, with rest between sets.
10. After treatment, remove electrodes, clean the skin.
11. Record the intensity used and patient response in notes.

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Indications for Motor Point Stimulation

1. Foot drop due to Common Peroneal Nerve palsy (LMN lesion)
2. Disuse atrophy of anterior compartment muscles
3. Muscle re-education post-surgery (tendon repair, fracture fixation)
4. Upper Motor Neuron lesions for spasticity management and reciprocal inhibition
5. Peroneal nerve injury following knee dislocation or fibular head fracture
6. Post-immobilization weakness
7. L4-L5 radiculopathy with tibialis anterior weakness
8. Functional Electrical Stimulation (FES) for gait training in stroke or spinal cord injury

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Contraindications for Motor Point Stimulation

1. Cardiac pacemaker or implanted defibrillator
2. Over the carotid sinus, heart, or transthoracic application
3. Over the eyes or anterior neck
4. Active malignancy or cancer in the treatment area
5. Active thrombophlebitis or DVT in the limb
6. Skin infections, open wounds, or burns at the electrode site
7. Anesthetic or insensitive skin (risk of thermal and electrical burns)
8. Epilepsy (when electrodes are near head or neck)

1. Pregnancy - avoid over abdomen and pelvis
2. Metal implants (screws, plates) in the stimulation field - use low intensity carefully
3. Severe peripheral arterial disease
4. Bleeding disorders or anticoagulant therapy
5. Recent surgical wounds
6. Skin hypersensitivity or allergy to electrode gel
7. Uncooperative or confused patient

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SHORT CASE I: Interferential Therapy (IFT) for Osteoarthritis Knee - Left

Definition

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Therapeutic Effects Relevant to OA Knee

1. Analgesia through the gate control mechanism (high frequency 80-150 Hz) and endorphin release (low frequency 2-4 Hz)
2. Reduced periarticular muscle spasm and relaxation
3. Improved local circulation through vasodilation
4. Reduction of joint swelling and edema
5. Facilitation of cartilage nutrition via a pumping effect

---

Patient Preparation

1. Explain the procedure and what the patient will feel - a deep buzzing or tingling inside the joint.
2. Obtain informed consent.
3. Expose the left knee fully.
4. Inspect skin for cuts, infection, or rash.
5. Clean the skin.
6. Assess baseline pain level using VAS.
7. Check for contraindications.

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Patient Position

• Left knee slightly flexed (rolled towel or pillow under the knee for comfort)
• Hip in neutral
• Foot supported

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Electrode Placement for IFT - OA Left Knee

• Circuit 1 - Electrode A: Medial aspect of the knee, above the joint line
• Circuit 1 - Electrode B: Lateral aspect of the knee, below the joint line
• Circuit 2 - Electrode C: Anterior aspect of the knee, above the patella
• Circuit 2 - Electrode D: Posterior aspect of the knee, in the popliteal fossa

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Parameters / Dosage

• Machine frequencies: 4000 Hz for one circuit, 4000-4250 Hz for the second circuit
• Beat frequency for pain relief (gate control): 80-150 Hz
• Beat frequency for endorphin release (chronic pain): 2-5 Hz
• General sweep mode: 0-100 Hz sweep (recommended for OA knee)
• Intensity: Strong but comfortable tingling at sensory level - no pain, no motor contraction
• Duration: 15-20 minutes per session
• Sessions: Daily or 5 times per week, 10-15 sessions total
• Mode: Rhythmic sweep (6:6 seconds) is recommended for OA

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Procedure - Step by Step

1. Position patient supine with left knee slightly flexed.
2. Check the IFT machine - confirm 4 leads and 4 electrodes (suction cups or flat pads).
3. Wet the electrodes with water or apply conductive gel.
4. Place Electrode A (medial, above joint line) and Electrode B (lateral, below joint line) for Circuit 1.
5. Place Electrode C (anterior, above patella) and Electrode D (posterior/popliteal) for Circuit 2.
6. Confirm diagonal cross arrangement with the knee at the center.
7. Set parameters: beat frequency 80-100 Hz, sweep mode ON.
8. Increase intensity of both circuits simultaneously and slowly.
9. Patient should feel a deep buzzing or tingling sensation inside the knee joint.
10. Treat for 15-20 minutes.
11. After treatment, remove electrodes, inspect skin, and reassess pain using VAS.

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Indications for IFT

1. Osteoarthritis of the knee, hip, or shoulder
2. Rheumatoid arthritis in the subacute or chronic phase
3. Soft tissue injuries - ligament sprains, muscle strains
4. Muscle spasm and associated pain
5. Post-fracture pain and edema
6. Chronic low back pain and neck pain
7. Bursitis and tendinopathy
8. Post-surgical pain including after knee replacement
9. Circulatory disorders and venous insufficiency
10. Stress urinary incontinence (perineal electrode placement)
11. Delayed fracture healing

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Contraindications for IFT

1. Cardiac pacemaker or implanted electrical stimulator
2. Active malignancy or cancer in the treatment area
3. Active DVT or thrombophlebitis
4. Skin infections, open wounds, or burns at electrode sites
5. Anesthetic or insensitive skin
6. Over the carotid sinus, heart, anterior neck, or eyes
7. Epilepsy (near head or neck)

1. Pregnancy - avoid over abdomen and pelvis; knee treatment is generally cautiously accepted
2. Metal implants at the site such as total knee replacement - use reduced intensity with caution
3. Active hemorrhage or bleeding disorders
4. Severe peripheral arterial disease
5. Skin hypersensitivity
6. Confused or uncooperative patient
7. Acute injury with marked swelling - wait 48-72 hours before treating

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SHORT CASE II: Infrared Radiation (IRR) for Low Back Pain (Lumbosacral Region)

Definition

• Near / Short-wave IR (NIR): Wavelength 770-1500 nm, penetrates deeper (3-5 mm), produced by luminous lamps
• Far / Long-wave IR (FIR): Wavelength 1500 nm to 1 mm, penetrates superficially (1-2 mm), produced by non-luminous lamps

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Therapeutic Effects

1. Vasodilation and increased local circulation causing erythema (skin reddening)
2. Analgesia through reduced muscle spasm and counter-irritation
3. Muscle relaxation and reduced paraspinal tone
4. Removal of pain mediators and metabolites through improved circulation
5. Increased tissue extensibility - better soft tissue stretching after heating

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Patient Preparation

1. Explain the procedure and what the patient will feel (comfortable warmth, not burning).
2. Obtain informed consent.
3. Expose the lower back fully (patient removes shirt).
4. Inspect the skin - no broken skin, recent scars, sunburn, or rash.
5. Thermal sensation test is MANDATORY: Apply test tubes of hot and cold water alternately to the lumbosacral area. The patient must correctly distinguish hot from cold before proceeding. If thermal sensation is impaired, do NOT proceed.
6. Remove any metal jewelry, dressings, or creams from the area.
7. Position the patient comfortably.

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Patient Position

• Pillow under the abdomen to reduce lumbar lordosis and improve comfort
• Head in the face hole or turned to one side
• Arms at sides or under the head
• Feet over the end of the plinth or a pillow under the ankles
• Full exposure of the lumbosacral region from L1-L2 to the sacrum and bilateral paraspinal muscles

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IRR Lamp Setup and Placement

• 250W lamp: 45-60 cm from the skin
• 500W lamp: 60-75 cm from the skin
• 1000W lamp: 75-90 cm from the skin

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Procedure - Step by Step

1. Position patient prone with a pillow under the abdomen, lower back fully exposed.
2. Perform the thermal sensation test - both hot and cold must be correctly identified.
3. Warm up the lamp for 5-10 minutes.
4. Place the lamp at 45-60 cm distance from the lumbosacral skin, perpendicular to the surface.
5. Instruct the patient clearly: "You should feel pleasant, comfortable warmth only. Tell me immediately if it becomes too hot, burning, or uncomfortable."
6. Start timing - total treatment time is 15-20 minutes.
7. Check the skin every 5 minutes:
   • Uniform mild erythema (reddening) is expected and desired
   • Blotchy or mottled redness means too intense - increase the distance
   • No redness at all means too far - slightly decrease the distance
8. Do NOT leave the patient unattended at any time.
9. After treatment, remove the lamp, inspect the skin, and record the response.
10. Advise the patient not to expose the area to cold immediately after treatment.

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Dosage Summary

• Duration: 15-20 minutes (maximum 30 minutes for large areas)
• Distance: 45-75 cm depending on wattage
• Frequency: Once daily or alternate days
• Sessions: 5-10 sessions total
• Endpoint: Comfortable warmth with mild uniform erythema

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Precautions During Treatment

• Check skin every 5 minutes throughout
• Do NOT allow the patient to fall asleep
• Patient must NOT touch the lamp
• Direct the lamp away from the patient's eyes - cover eyes if the face is turned toward the lamp
• Keep the lamp at the correct angle (perpendicular)
• Screen off other patients to maintain privacy and prevent accidental burns

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Indications for IRR

1. Acute and chronic low back pain due to muscle spasm or ligament sprains
2. Lumbosacral spondylosis and lumbar osteoarthritis
3. Muscle strains of paraspinal and gluteal muscles
4. Sacroiliac joint pain
5. Fibromyalgia (local area treatment)
6. Subacute and chronic disc prolapse (for periarticular muscle spasm relief)
7. Post-fracture pain after bone healing is confirmed
8. Stiff joints - used as preparation before mobilization, stretching, or exercise
9. Chronic wounds and pressure ulcers (wound healing effect)
10. Peripheral neuralgia
11. Preparation before massage or manual therapy to improve tissue extensibility

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Contraindications for IRR

1. Anesthetic or insensitive skin - patient cannot detect overheating, severe burns will occur
2. Active bleeding or hemophilia - heat increases vasodilation and promotes hemorrhage
3. Area that has received deep X-ray therapy within the past 3 months
4. Active malignancy or cancer in the treatment area
5. Severely ischemic tissues - impaired blood supply cannot dissipate heat
6. Acute febrile conditions - raises body temperature further
7. Open wounds or raw areas directly under the lamp
8. Over the eyes - risk of cataract formation and retinal burns

1. Impaired circulation such as peripheral arterial disease or Buerger's disease
2. Scar tissue with irregular vascularization
3. Edematous tissues - fluid redistribution risk
4. Skin conditions such as eczema, psoriasis, or dermatitis that may be aggravated
5. Pregnancy - avoid over abdomen; lumbar region with caution
6. Elderly patients with thin, fragile skin - increase distance and reduce time
7. Metallic implants near the skin surface
8. Over the gonads or reproductive organs
9. Vitiligo patches due to uneven pigmentation and unpredictable heat absorption

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