Modalities Flashcards
What is a modality?
Often think of PAMS, but a modality is any applied therapeutic agent or regimen.
The evolution of modalities
The traditional modality of OT was crafts
The term modality, has a broader definition
The modality or occupation are variable and based on level of expertise
But no matter what they have a therapeutic effect that impacts occupation and function
Other modalities (NOT PAMs)
Purposeful activity-crafts, ADL
Therapeutic exercise
Talk therapy
Biofeedback
Facilitation and inhibition techniques
AROM, AAROM, PROM
How are PAMs used?
In OT, we use these as adjunct or preparatory modalities
What qualifies as adjunct or preparatory?
Medium
The means (the thing) by which the therapeutic effect is transmitted
- theraball
- exercise class
- ADL class
- ultrasound
For Example, if you are trying to increase AROM, the medium could be: exercise bike, theraball, ultrasound
Method
Steps and sequence or approach used to activate the medium
- 10 min on the exercise bike
- 3 sets of 10 ball lifts
- 3 mhz, .8 intensity for 6 min
What mediums might you use to increase independence with dressing?
Hot pack - to decrease viscosity and pain and increase ROM
Theraputty - provide resistance to increase grip strength for dressing
Ultrasound - decrease inflammation
Massage - decrease edema, increase aROM to make dressing easier
ADL group - facilitate motor learning
Functional activity - promote strength and endurance
What methods might you use with heat increase independence with dressing?
Hot pack:
- 15 minutes
- apply towel
- check skin
- remove heat
AOTAs stance on PAMs
- PAMs must enhance the patients ability to perform purposeful activity or increase the ability to participate in daily occupations
- The therapist must have documented proof they have been trained in the appropriate use of the PAM
You must meet both of these requirements!
You must meet AOTA’s Guidelines no matter what
- this includes the Code of Ethics (competency)
Than you have State Licensure Requirements
- get a state and report back
Documenting PAMs
What was applied and the parameters
- dosage: the temperature or hz
- duration: the time
- even if you don’t charge for it
Site of application
Treatment duration
Physiological response from treatment
- skin was unremarkable and pt reports pain has decreased
- tissue was pliable
Responses from patient
What is a PAM?
Interventions or technologies that produce a response in soft tissue through the use of light, water, temperature, sound , electricity, or mechanical devices.
Can hurt people
PAMs don’t cure anyone.
- they enhance intervention
4 primary classifications of PAMs:
- Superficial thermal
- Deep thermal
- Electrotherapeutic
- Mechanical
Primary mechanisms of heat transfer to the body
Conduction
Convection
Radiation or conversion
Conduction
Superficial
1-3 cm
There is direct contact between the body and the heat or cold source. The temperature conducts between one to the other.
- Paraffin: 125-130º
* Immersion, dip, brushing
- Hot packs 160-175º for container, pack 104-113º
- Ice pack
Convection
Superficial
1-3cm
Particles or molecules such as air or water move across the body
Heat tissue by fluid motion around tissue
- fluidotherapy: 115º
- whirlpool (hydrotherapy): 100-104º for heat, 90-100º for wound
* if you exceed 100º on a wound, you will create wound death
Indications for superficial thermal agents
Subacute and chronic inflammation
Subacute and chronic pain
Subacute edema removal
Decrease ROM
Trigger points
Muscle guarding or spasm
Subacute muscle strain
Subacute ligament sprain
Subacute contusion
Precautions for superficial thermal
Monitor blood pressure, respiration, skin color
Client comfort
Discontinue if:
- redness
- blisters
- petechiae: red vessels, rash-like
Contraindications for superficial heat
Very old or very young
Tissue compromise (wound)
- creates cell death
Impaired sensation
Impaired or surgical vascular structure
- heat causes dilation of blood vessels, may rip through stitches
Malignancies: cancer
- may increase distribution of cancer cells
Acute inflammation (edema)
DVT
- can cause it to bust
Pregnancy
- not over belly
Bleeding tendency (Coumadin)
Primary tendon or ligament repair
Advanced cardiac disease
Impaired mental ability
Semi-comatose
Compromised circulation
PVD
Open wounds or skin conditions
Superficial thermal examples
Impacts skin and subcutaneous tissue to 1-3cm
Hydrotherapy or whirlpool - convection
Cryotherapy, icepacks, ice bath (limb) - conduction
Ice massage - convection
Hot pack (thermotherapy) - conduction
Warm soak, contrast bath - conduction
Paraffin - conduction
Water - conduction
Infrared heating - conduction
Dosage for superficial heat
Goal is to get tissue 102-113º
Hotter is not better, above 113º (tissue temp)
- Results in catabolism and cell death
Mild dose: changes temp less than 6º
- effect is somatosensory (feels good, that is it)
- elevates tissue temp to <104º
- slow rate and low increase in temperature
- short duration
Moderate dose: changes temp by about 6º
- effect is moderate increase in blood flow
- elevates tissue temperature to 102 - 106º
- effective when heat is indicated, but edema may occur
Vigorous Dose: increases temp by 14º
- effect is marked increase in temp and blood flow
- elevates tissue to 107-113º
- rapid rate and high increase in temp
- long duration
- may be beneficial for ischemic conditions when heat is indicated and edema is not a concern
* Decreases viscosity of tissue and interstitial fluids
Analgesic effect of superficial heat
pain releif
Vascular effects of superficial heat
Decreases muscle spasms
Histamines are released
Vasodilatation
- reduces ischemia and muscle spindle activity
Metabolic effects of superficial heat
Increased blood flow brings more O2, nutrients, and enzymes
Connective tissue responses to superficial heat
Extensibility of collagen and tissue (8-10 minutes after application)
- increases ROM
- decrease stiffness
Cryotherapy indications and what it does
Analgesia: through decreased nerve conduction
Slows the metabolic effect by decreasing edema and inflammation
- Short term: increase tone
- Long term: decrease tone
Vasoconstrictor (15 min or less), decreases motor unit firing
- decrease spasm
Vasodilation (15 min or more)
Precautions and contraindications of cryotherapy
Precautions:
- effects can last several hours
- rewarming takes at least 20 min
- monitor closely
- never longer than 20 min
- side effects: itching, hives, whelps
- can cause a temporary increase in BP
Contraindications:
- cold intolerant
- open wounds
- vascular repairs
- raynaud’s
- PVD
- avoid superficial nerves
How temperature change occurs in cryotherapy
Conduction
- Icepacks
Convection
- Whirlpool
- Ice massage
Evaporation
- Sweat
- Fluori Methane spray
Benefits and utilization of cryotherapy
Cold-stinging/burning-aching-numb
Cheap, easy to use at home
Ice pack: 30-45º for15-20 min
Ice massage: 5-10 min
Cold immersion/whirlpool-35-75º for 15 min
Ice towel: change out every 5-6 min
Cold compression units: 50-70º for 15-20 min
Fluori-menthane
Contrast bath
Combination of warm (vasodilatation) and cold (vasoconstriction)
Pain-Edema-Circulation (healing)
Hot-100-110 degrees
Cold 60-70 degrees
Contrast bath indications
Edema removal
Pain reduction
Subacute or chromic inflammation
Impaired circulation
Contrast bath contraindications
Acute injuries
Hypersensitivity to cold
Open or infected wounds
Contraindications related to heat and cold
Ice bath
0-27º C (30-60ºF) (not very uniform!)
Water and ice
10-20 minutes (the colder, the shorter)
Warm soak
Upper extremity: 100-105º
Lower extremity: 100-102º
Total body: 95-98º
Deep modalities
Those modalities that produce heat/effect greater than 3cm
Electric modalities
Radiation modalities
Laser
Therapeutic ultrasound
Different from diagnostic or surgical
Up to 5cm
Works by converting electrical energy to ultrasonic energy
- A crystal in the head vibrates to create the sound waves which in turn cause the muscle tissue to “vibrate”
- Sound waves enter the body. The molecules in the way are pushed aside (back and forth by the alternating phases of the waves)-this is a one way, longitudinal wave.
- The sound waves travel best through solids (bone and dense tissue), less through liquid (blood)
- Impacts tissue by cavitation and acoustic streaming
Ultrasound equipment
A standard ultrasound unit:
- A generator (the box): the power supply, an oscillator circuit transformer
- Coaxial cables
- Transducer: contains the crystal
* New ones don’t break
* Also called the head
* Various sizes
* The head should be approximately ½ the size of the treatment area
Ultrasound ERA
Effective Radiating Area
Usually found on the tag
How much of the head is actually producing waves
The higher the better
Ultrasound BNR
Beam non-uniforming ration
- The smaller the better(6:1 or less)
- The waves are non uniform by nature, this is an indication of just how non uniform they are 1-6 W/cm2
- The peaks are what cause discomfort or hot spots
- Anything above 8W/CM2 is dangerous
Continuous ultrasound physiological effects
Increase tissue extensibility
Increase blood flow
Decrease pain (by way of increasing pain threshold)
Increase enzymatic activity
Increase metabolic rate
Reduce spasms
Stable cavitation (good)
Cellular perm-fluid movement
Unstable Cavitation-occurs when the gas bubble expand and collapse in the blood stream-causes pain and discomfort; occurs when intensity is too high
Pulsed ultrasound physiological effects
Increase cell permeability and diffusion
Increase histamine, protein/collagen synthesis
Decrease pain
Increased cell permeability-due to cavitation
Increased cell diffusion-acoustic streaming
Increased tissue repair
Micromassage, to decrease pain
Increases phagocytic activity and the mobility of fibroblasts
Vasoconstriction and dilation: edema
Increase tissue repair by increasing histamines, granular activity and increasing phagocyte cells: due to acoustic streaming
Phonophoresis
Ultrasound (thermal or non thermal) is often said to “drive” meds, usually, anti-inflammatory, lidocaine or corticosteroids.
It softens the stratum corneum and allows for enhanced absorption of a topical medication
1. Must be TOPICAL and intended to be used with US
2. Must be tested and approved with ultrasound
Contraindications of ultrasound
Acute injury if 100%
Breast implants
Blood clots
Joint cement or prosthesis
Pace makers
Growth plate of children
Unprotected nerve or spinal cord
Eye
Heart
Pregnant uterus
Testes
Thrombosis
Freshly repaired tendon or bone
Infection or malignancy
Organs
Clinical dosing model for therapeutic ultrasound
Non-thermal: acute injury/tissue healing
Mild thermal (1ºC): sub-acute injury/tissue healing
Moderate thermal (2-3ºC): chronic inflammation, pain, trigger points
Vigorous heating (4ºC+): stretch collagen
Performing an ultrasound
- Duty cycle
- Frequency
- Intensity
- Time: 5-8 minutes
- Apply medium: US gel (96%) or lotion (90%)
- Treat
- Document
Duty cycle of ultrasound
Amount of time the unit is heating
Continuous: 100%
- deep heat
Pulsed: 10%, 20%, or 50%
Frequency of ultrasound
1MHz: 3-5cm
3MHz: 1-2cm
Intensity of ultrasound
0.1-0.5: acute
0.5-1.0: subacute
0.5: wound healing
1.0-2.0: chronic; increase blood/O2 flow; scar tissue remodeling
What to use stationary technique for ultrasound
Trigger points and scar tissue
50% pulsed or less
Mediums used for phonophoresis
Theragesic cream = 97%
Lidex gel = 97%
Biofreeze = 80%
Eucerin Cream = 0%
Hydrocortisone powder in US gel = 29%
Immersion techniques for ultrasound
Produces less heat than direct contact
Place limb in water with the head
Increase the intensity one level
Increase the time by 2 minutes
Serran wrap/water balloon technique for ultrasound
For wounds
Place wrap and then gel
Use wound parameters
Two basic effects of electrotherapeutic agents
muscle contraction and pain releif
Physiological effect of electric current in electrotherapeutic agents
1MA (milli amp) = tingling sensation
Most units we use are in this area (4MA-ionto is the highest)
16 MA = cannot release grasp - muscle contraction
50 MA = pain may pass out
100 MA (3 amps)= ventricular fibrillation – heart issues
6 A = myocardial contraction and infarction, burns, death
Order of recruitment using electrotherapeutic agents
Sensation-sensory level response (TENS, Interferential)
Skeletal-muscle contraction-motor level (NMES)
Pain-noxious level response (endorphin theory)
2-3 hours of pain relief after, lots of pain during
Direct current
Galvanic current came about – continuous flow of electricity.
Noxious, can damage tissue and nerves
Will contract a muscle with or without an intact nerve innervations, so we don’t use it
Indirect current
The current is not continuous
More comfortable, doesn’t burn or damage tissue
Will cause a contraction if the nerve innervation is intact
Types of E-stim
All therapeutic electric stimulators are TES
Transcutaneous electrical stimulators
They are indirect current (except iontophoresis)
They go through the skin
They must have an intact nerve innervation
The majority are TENS (transcutaneous nerve stimulators) - but we associate TENS with pain relief
Examples of E-stim
Electrotherapeutic
- Electric biofeedback – myoelectric training
- Neuromuscular electrical stim
- Functional electric stim
- Transcutaneous electrical stim
- Electric stim for tissue repair
- High volt, galvanic stim
- Iontophoresis
Mechanical
- Vasopneumatic devices
- Continuous passive motion (CPM)
Therapeutic goal of NMES
Stimulation of innervated muscle to increase strength, ROM, decrease spasticity, disuse atrophy, and muscle reeducation
Therapeutic goals of TENS
Use of transdermal e-stim for pain modulation
Therapeutic goals of FES
Use of e-stim as an orthotic substitute to perform functional movements or activities
Therapeutic goals for IFC
Stimulation of nerves for pain modulation and to facilitate deeper physiological response
E-stim currents
Direct current
- continuous flow of particles in one direction
- you set is at positive or negative (iontophoresis)
Alternating
- continuous bidirectional flow of particles
* symmetrical or asymmetrical
* balanced or unbalanced
> the more balance, the more comfort
E-stim waveforms
The “shape” pf the current
- pulsed or alternating
Different shapes feel different
- Sine
- Triangular
- Rectangular
E-stim pulse width or phase duration
The length of time between the beginning and end of all phases in a single pulse
Usually expressed in microseconds
The longer the width/duration, the more time something can happen
- Recruitment, pain
- As pulse width increases the depth of the current increases
Set it based on what you are doing
- Sensory stimulation: 20-150 (gate control) 50 most common
* Tens
- Muscle stim: 200-300 microseconds (use 300)(endorphin)
* NMES, some tens
- Noxious: 600+
E-stim pulse rate or frequency
The number pulses per second (pps) or cycles per second (Hz)
This determines the type of muscle contraction
- Machines are usually preset at 35, 50 or 80
- The higher the more comfortable, but may fatigue quicker
1 - 20pps: twitch
25 - 50pps: muscle contraction
50 - 80pps: tetanic
What is the difference between TENS and NMES?
NMES is just TENS turned all the way up
Really isn’t it’s all about width and rate
The lower the width, the higher the intensity will need to be
Acute injury - low width, high frequency
Chronic - high width, low frequency
E-stim intensity or amplitude
What you adjust to the patient’s comfort level
Expressed in milliamps
Typically, 35-80 but varies based on machines
E-stim RAMP (rise and fall)
Gradual increase of intensity to desired level
About comfort and recruitment
Usually, 2-5 seconds
E-stim duty cycle
Ratio of on and off
1:1 = rapid fatigue
1:4 = reduced fatigue time
Electrodes
Self sticking, reusable
The smaller the electrode, the higher the current density
Smaller electrodes can create the perception of increased intensity
If they are wearing out, they can cause surface burns and tissue damage
Not sticking
- Sweat, dirt, hair, lotion
- Dry skin
Position of electrodes
Monopolar - one active electrode (iontophoresis)
- Treatment at site
- Dispersive at a distance (6-12 inches)
Bipolar or quadrupolar
- Along belly or treatment site
- Closer = superficial
- Farther = deeper
Synchronous vs. reciprocal e-stim
If you are using more than one set of electrodes
Synchronous - all at the same time
Reciprocal - alternate one and off
Neuromuscular stimulation
Used to create a muscle contraction
Frequently used with:
- CVA to overcome reflexes and establish appropriate motor engrams
- Spinal Cords: area of innervation
- Musculoskeletal: Increase ROM, assist with atrophy or disuse, break through adhesions, and relieve pain or spasms
Parameters for NMES
Symmetric, biphasic square waveforms are best tolerated
- Asymmetric work well with smaller muscles, but there is a higher risk of burns and irritation
Amplitude Intensity-set to pt tolerance up to 100mA.
- The greater the intensity, the greater the muscle contraction
Pulse duration: varies from .2-.4 based on pt comfort.
Duty Cycle: varies, usually 25% or 1:4
Ramp: the time it takes to reach peak, 2-3
Clinical use of NMES
Treatment of disuse and atrophy
Increasing or maintaining ROM
Muscle re-education
Orthotic substitution
Other benefits
- Pain relief
- Edema reduction
Contraindications and precautions of NMES
Contraindications
- Demand pacemakers
- Pregnancy
* On a foot or hand ok
- Placement along anterior neck
* Some are doing this with feeding
Precautions
- Know arrhythmia
- Fresh incisions or tendon repairs
- Insensate skin
- T6 or above spinal cords
Low frequency TENS
10Hz or less (usually 2-4 Hz)
Also called acupuncture (means low pulse frequency that is constant) or burst (low pulse frequency that occurs in bursts of pulses instead of continuous individual pulses)
Intensity (amplitude) is usually 1.5 to 5 x the perception threshold (the first sensation of paresthesia)
Endorphin release theory
More effective on thermal pain
can take several hours to achieve analgesia
Some studies show an effect for up to 12 hours
Pulse duration: 150 or more
High frequency TENS
10Hz or greater (usually 80 Hz or more)
Also called Conventional TENS
- Often perceived a the most comfortable
- Place to start
Gate control theory-stimulation of large diameter afferents should inhibit the second order neurons from carrying pain impulses from the small diameter afferents
Pulse duration (width) is short - less than 150
Amplitude (intensity) is comfortable
Uses for TENS
Chronic Pain
PostOp Pain: decreased use of drugs
Obstetrics
Neuropathic pain
Cardiac: reducing angina
Pediatric Use
Musculoskeletal Pain
Esophageal distension and pain
TENS electrode placement
No strong research
Over or around painful area
Over the dermatome
Over acupuncture points
Over trigger point
Treatment duration for TENS
15 minutes to 4 hours, 1-6x a day “as needed”
IFC
One of the most common types of E-Stim
Considered medium frequency-4000Hz modulated by a low frequency of 1-250 Hz
Commonly used for:
- Urinary incontinence
- Osteoarthritis pin
- Low back pain
- TMJ Pain
- Enhance bone healing
- Decrease soft tissue pain
- Decrease proliferation with palmer psoriasis
- Improve vascular status in PVD-Increase blood flow
- Migraines
- Decrease hyperreflexia in MS
Contraindications of IFC
Lower abdomen of pelvis during pregnancy
Over cervical region
Over hemorrhagic area
With an electric implant
Over embolus or thrombosis
Over malignancy
With cardiopathies
Excessive hair
Why is IFC preferred over TENS?
The effects are quicker (15 minutes or less) for anagesic
How is IFC delivered?
Bipolar-two electrode
Quadripolar
Quadripolar with scan
Stereodynamic
Parameters of IFC
Mode: constant (80bps) or sweep (80-150bps)
Time: typically, 20 minutes, can be more or less
Typically, the machines are preset
4000 Hz-frequency
Pulse duration-250
Think about moving while in it
Mesh glove: CRPS
Iontophoresis
A method of transferring the ions of a specific medication into soft or hard tissue
An electrically charged electrode will repel a similarly charged ion
Uses for iontophoresis
Used because it is:
- Non-invasive
- Site specific
- Low risk of infection
- Enhanced drug penetration to directed site
Common uses
- Pain relief-site specific, not general
- Decrease inflammation
- Treat calcifying tendonitis with frozen joints
- Treat hyperhidrosis
- Anesthetic for dental
- Edema reduction
- Scar tissue
Iontophoresis treatment
Parameters will depend on the medication used, the drug must be approved for iontophoresis, and you MUST know the polarity. Remember, “electrically charged electrodes will repel similarly charged ions”
If the medication is + you will use a + charge
What if you use 2=lidocaine and dexamethasone???
Two treatments
Black – negative
Red or white - positive
Medications and their charges for iontophoresis
Acetate (-)=dissolves calcium deposits
Chlorine (-)=softening of tissue (scars)
Dexamethasone (-)=reduces inflammation
Glucocorticoid (-)=reduces inflammation
Iodine (-)=softening of connective tissue (scars)
Penicillin (-) kills bacteria
Copper (+)=antiseptic and antifungal
Glycoperronium bromide (+)=stops palmer sweating
Hyaluronidase (+)=decreases edema
Hydrocortisone (+)= reduces inflammation
Lidocaine (+)= pain release
Tap water (+ and-)=decreases sweating
Iontophoresis dosage
The dosage is proportional to the current magnitude (A) used and the duration of the application (T)
To calculate: A x T=Dosage
For example:
30mA min of Dexamethasone can be delivered:
- At 3 mA for 10 minutes or
- At 1mA for 30 minutes or
- At 2 mA for 15 minutes
The magnitude is based on patient comfort
Shortwave diathermy
Produces electromagnetic energy at 27.12 million cycles per second.
This is applied as a pulsed electromagnetic field to the tissue treated
Can have thermal or non thermal effects
The Drum produces a pulsed magnetic field into the tissue, causing sub thermal and thermal effects in high water content tissue (blood, muscle and joint synovium)
5cm
Uses of shortwave diathermy
Increases blood flow and thereby healing
Reduces pain
Increases cell membrane permeability - decreasing edema
Increases collagen production and encourages growth
Increases tissue elasticity
Sub theramal - minimal heat shortwave diathermy
Post trauma or surgery
- Reduce pain
- Reduce edema
Pain associated with osteoarthritis
- Reduces pain
Improve tissue healing
- Ligaments, cartilage, wounds, tendons and muscle
- Absorption of hematomas
- Diabetic sores
Set up for diathermy
Position the client so they are comfortable, they need to be as still as possible during treatment
Place shower cap over the drum
Drape towel over exposed skin
- To absorb sweat with thermal
- Privacy and warmth
Position drum over treatment area, but do not touch the towel or skin
Set parameters - treat for 30 min
Dosage for sub thermal diathermy
- 4% duty cycle
- Pulse rate of 400 PPS
- Pulse duration of 65 uSecs
- 150 watts output power
- Average power is 3.9 watts
Dosage for thermal diathermy
10-33% duty cycle
- Rate of 800 pps
- Pulse duration 100-400 usec
Average power is 10-48 watts, peak 150 watts
Treatment duration 20 minutes
- Use 1˚ to produce mild heat
* For elderly or over boney area
- Use 2˚ to produce moderate heat
- Use 3˚ to produce vigorous heat
Check frequently, should be warm, not hot
Uses for thermal diathermy
Mild
- Elderly, arthritis
- Boney area, distal radius
Moderate to vigorous
- Chronic low back pain
- Increase blood flow
- Increase extensibility of tendons, joint capsule
* Increase AROM
Precautions for diathermy
Do not perform over carotid sinus, vagus nerve, or pharyngeal muscles
Do not use over organs, heart, eyes, or testes
Do not use overactive cancer
- Exception for terminal patients for pain relief
Do not use with fever, inflammation, or infection
Do not use over pregnant abdomen
Do not use over exposed spinal cord (laminectomy)
Do not use overgrowth plates of children
Do not use over metal (in clothing or internal)
Do not use over or close to a DVT
Documenting PAMs
The agent applied and the treatment parameters
- Ultrasound
* Frequency
* Intensity
* Duty cycle
Site of application
- Left epicondyle
Treatment duration
- 8 minutes
Physiological response to the treatment
- Unremarkable
Subjective response to treatment- “feels better”
Conversion
Taking ultrasound and converting it to heat
EMS (electrical muscle stimulation)
Stimulation of denervated muscle/nerve to facilitate healing and maintain viability
ESTR (e-stim for tissue repair)
Use of E-stim for facilitating wound healing, decrease edema, and improve circulation
HVGS (High-voltage pulsed current)
Stimulation of denervated muscle, facilitation of wound healing, edema reduction, and pain modulation
