Modalities Flashcards
conduction=
heat transfer from a warmer object to a cooler object by means of direct molecular interaction of objects in physical conduct
conductive modalities: hot packs, paraffin
convection=
head transfer by movement of air or fluid from a warmer area to a cooler area
convection modalities: whirlpool, hubbard tank, fluidotherapy
raditation=
transfer of heat from a warmer object to a cooler object by means of transmission of electromagnetic energy without heating of an intervening medium
infrared waves absorbed by cooler body
radiation modality: infrared lamp
physiological effects of general heat application:
Increases:
- CO
- metabolic rate
- HR
- RR
- vasodilation
- elasticity
Decreases:
- BP
- muscle activity (sedentary effect)
- blood to internal organs
- BF to resting muscle
- SV
- joint stiffness
- muscle strength and spasm
- pain
Indications for superficial thermotherapy
- joint stiffness
- MS pain
- muscle spasm
- preparation for e-stim, passive and active exercises
- subacute and chronic traumatic and inflammatory conditions
- increase CT extensibility
- accelerate rate of tissue healing
Contraindications for superficial thermotherapy
- acute and early subacute traumatic and inflammatory conditions
- decreased circulation and/or sensation
- DVT
- impaired cognitive function
- malignant tumors
- tendency toward hemorrhage or edema
- very young and very old
Precautions:
- cardiac insufficiency
- edema
- impaired circulation
- impaired thermal regulation
- metal in tx site
- pregnancy
- areas where topical counterirritants have been recently applied
- demyelinated nerves
- open wounds
list of superficial heating agents
hot pack paraffin bath contrast baths hydrotherapy- whirlpool, hubbard tank aquatic therapy
hot pack
canvas pack filled with silica gel
heated by immersion in water 165-170 deg F
add 6-8 lays of toweling between
(terry cloth cover=4-6)
hot pack reaches peak heat w/in first 5 min- greatest risk for burn
if heat is transferred too quickly, mottling (red and white areas) occur and permanent burn damage may result
tx time: 20-30 min
Paraffin bath
contains a paraffin wax and mineral oil mixture in a 6:1 ratio
mixture melts between 118-130 deg F (self sterilizing)
treatment temp= 125-127 deg F
tx time: 15-20 minutes
indications:
- painful joints d/t arthritis or other inflammatory conditions in the subacute/chronic phase
- joint stiffness of the hands and wrists
contraindications:
- allergic rash
- open wounds
- recent scars/sutures
- skin infections
hydrotherapy
partial or total immersion baths in which the water is agitated and mixed with air to be directed against or around the affected part
-patients can move the extremities easily because of the buoyancy and therapeutic effect of water
convection heat
specific heat of water is about 4x that of air
types:
- whirlpool
- hubbard tank- full body immersion (don’t exceed 100 deg F)
- aquatic therapy (92-98 deg)
Indications:
- decubitus ulcers
- open burns/wounds
- postsurgical conditions or hip fractures
- subacute and chronic MS conditions of the neck, shoulders, back
- RA
- can be used for debridement and loosening of dressings.
- cleaning and disinfection are important!
Chronic conditions: do best b/w 99-104 deg F whirlpool: 103-110 deg F hubbard tank: 100 PVD: 95-100 deg open wounds: 92-96 deg F
Tx time: 20-30 minutes
abstraction =
the removal of head by means of conduction or evaporation
conduction= transfer of heat from a warm object to a cooler object by means of direct molecular interaction of objects in physical contact
-cold pack, ice pack, ice massage, cold bath
Evaporation= (heat of vaporization): highly volatile liquids that evaluate rapidly on contact with warm object.
-vapo-coolant sprays
contrast bath
use alternating hot and cold immersion to help decrease pain, increase circulation and decrease swelling
-produce vascular exercise through active vasodilation and vasoconstriction of the blood vessels
water temps:
- hot 104 degF
- cold 59 deg F
in the subacute stage, begin with hot immersion for 3-4 minutes and then cold for 1 min
alternate hot/cold for 20-30 minutes, ending in hot
indications:
- any condition requiring stimulation of peripheral circulation in limbs
- PVD
- sprains, strains
- acute trauma
Contraindications:
- advanced arteriosclerosis
- arterial insufficiency
- loss of sensation to heat and cold
physiological effects of general cold applications
Decreased:
- metabolic rate
- HR
- RR
- venous BP
- BF to periphery (vasoconstriction of arteries)
- capillary permeability (decreased fluids into interstitial tissue)
- elasticity/extensibility of collagen tissue
- NCV and synaptic transmission
Increased:
- BF to internal organs
- CO
- SV
- arterial BP, shivering (occurs when core temp drops)
- joint stiffness- decreased extensibility
- pain threshold
- vasoconstriction resulting in blanching
- if cold >20 min, reflex vasodilation will occur with reddening of the skin
adverse effects of cryotherapy d/t hypersensitivity
cold urticaria: erythema of the skin with wheal formation, associated with severe itching d/t histamine reaction
facial flush, puffy eyelids, respiratory problems
-severe cases: anaphylaxis (decreased BP, increased HR) with syncope are also related to histamine release
indications for cryotherapy
acute and chronic traumatic and inflammatory conditions
edema
muscle spasm/spasticity
MS pain
thermal burns
MS symptoms
general contraindications for cryotherapy
impaired circulation
impaired sensation
peripheral vascular disease
prolonged application over superficial nerves could result in neuropraxia, Raynaud’s phenomenon, sensitivity (urticaria) or allergic reaction to cold
Precautions:
- HTN
- impaired temp sensation
- open wound
- very old/ very young
- cognitive changes
cold packs
temp: 0-10 deg F
time: 10-20 minutes
ice massage
ice cylinder formed by freezing water in paper cup
physiological response stages: 1-cold 2-burning 3-aching 4-numbness
tx time: 5-10 min or until numbness
vapocoolant spray
liquid that produces rapid cooling when a fine spray is applied to the skin
used to reduce muscle spasm by desensitizing trigger points
tx tim: 10-15 min
spray and stretch
passively stretch before spray
Ultrasound
conversion=
mechanical energy produced by sound waves at frequencies between 0.8-3MHz and delivered at intensities between 1-3 w/cm2 is absorbed by body tissues and changed to thermal energy
3MHz used for superficial
1MHz used for deeper conditions
Intensity: 0.3-1.5 w/cm2
- lower intensities and pulsed are used for acute conditions or thin tissues
- higher intensities and continuous US may be used for chronic conditions or thick tissue
- if tissue is high in fat or water content, the US penetrates more deeply with less attenuation
- if there is more protein content (muscle or CT) the US penetrates more but penetrates less
US transducer
applicator contains a piezoelectric crystal (transducer)
transducer converts electrical energy into acoustical energy by means of reverse piezoelectric effect
- alternating voltage causes mechanical deformation of the crystal
- crystal resonates (vibration) at current frequency
- oscillating crystal produces sound waves with little dispersion of energy (collimated beam)
- oscillating sound wave produces mechanical pressure waves in the tissue fluid medium. The molecules within the tissue vibrate, and the resulting friction produces heat
Transducer size: 1-10 cm2
- should be relative to the size of the treatment area
- Effective radiating area (ERA)- area of the faceplate (crystal size) which is smaller than the sounded (chose ERA 1/2 of tx area)
characteristics of US
continuous:
- thermal effects (chronic conditions)
Pulsed:
-nonthermal effects (acute soft tissue injuries)
uneven intensity produces a high level of energy in the center of the US beam relative to the surrounding areas= “hot spot” (peak spatial intensity) in the be a
-moving the soundhead or switching to pulsed US tends to reduce it
spatial average intensity= total power (watts)/area (cm2)
duty cycle:
-fraction of time the US energy is on over 1 pulse period
attenuation
reduction of acoustical energy as it passes through soft tissue = absorption, reflexion and refraction
absorption is highest in tissues with high collagen and protein content (muscles, tendons, ligaments, capsules)
the scattering of sound waves that result from reflection and refraction produces molecular friction that the sound wave must overcome to penetrate tissues
depth of US penetration
3-5 cm
at 3 MHz
-greater heat production in superficial layers, caused by greater scatter (attenuation) of sound waves in superficial tissue
increased heat production in deep layers at 1MHz is caused by less scatter in superficial tissues
-thus more US energy is able to penetrate deeper
thermal US
produced by continuous sound energy of sufficient intensity
range: 0.5-3w/cm2 (intensity will vary depending upon tissue type and pathology)
increased tissue temp increased pain threshold increased collagen tissue extensibility alteration of NCV increased enzymatic activity increased tissue perfusion
excessive high temps may produce a sudden, strong ache caused by overheating of periosteal tissue (periosteal pain)- reduce intensity or increase SA of tx
non thermal US
generated by very low intensity or pulsed (intermittent) sound energy
related to duty cycle (20-50%)
cavitation: alternating compression (condensation phase) and expansion (rarefaction phase) of small gas bubbles in tissue fluids caused by mechanical pressure waves
indications for US
modulate pain
increase CT extensibility
reduce or eliminate soft tissue inflammation
accelerate rate of tissue/wound healing
reduce/eliminate soft tissue and joint restriction and muscle spasm
contraindications for US
- impaired circulation
- impaired cognition
- impaired sensation
- malignant tumors
- over an area with thrombophlebitis
- joint cement
- directly over plastic components
- over vital areas- brain, ear, eye, heart, cervical ganglia, carotid sinuses, reproductive organs, exposed or unprotected SC
- over pacemakers
- over abdomen, LB, uterus or pelvis during pregnancy
- healing fracture
Precautions:
- over metal,
- osteoporosis
- plastic implants
- primary repair of tendons, ligaments or scar tissue
phonophoresis
introduces therapeutic substances into the body aided by US
-substances seem to be absorbed more readily bc the membranes may be more permeable
Hydrocortisone, dexamethasone, salicylates, lidocaine, or other ointments are massaged into the part followed by US transmission gel
indications:
- subacute and chronic MS conditions’
local analgesic- lidocaine
anti-inflammatory- dexamethasone, salicylates
mechanical spinal traction
distraction force applied to the spine to separate articular surfaces between vertebral bodies and elongate spinal structures
may be sustained, intermittent, positional, gravity assisted, inversion, continuous or static
effects of mechanical spinal traction
Joint distraction:
- opening intervertebral foramen, relieves pressure on nerve root and decreases compressive forces on facets
- Lumbar region: 50% of BW (initial 30-40lbs)
- Cervical region: 7% of BW or ~20-30 lbs (initial 8-10lbs)
Reduction of disc protrusion:
- separation of vertebral bodies occurs at higher forces, causing a decrease in intradiscal pressure that creates a suction-like effect on the nucleus, drawing it back in centrally; the surrounding ligamentous structures are stretched taut, which also helps to push the disc centrally.
- lumbar: 60-120lbs or up to 50% BW
- cervical: 12-15lbs
Soft tissue stretching
- decreasing pressure on the fact joints, nerve roots, vertebral bodies and discs without achieving joint separation
- Lumbar: 25% BW
- Cervical: 12-15lbs
Muscle relaxation:
- both intermittent and static traction can decrease muscle tone
- traction can interrupt the pain-muscle spasm cycle by stimulating mechanoreceptors through the motion caused by interrupted tractions and by inhibiting motor neuron firing with static tractions
- same forces as stretching
Joint mobilization:
- at lower forces, intermittent traction stimulates mechanoreceptors to inhibit pain and decrease spasm
- high force traction causes decreased pressure on the joint and stretches surrounding soft tissue
- can’t be isolated to particular segment
contraindications for mechanical traction
- acute strings, sprains, inflammation
- spondylolisthesis
- fractures
- postop spinal surgery
- spinal joint instability/hypermobility
- SC compression
- HTN
- increased peripheralization of pain
- numbness/tingling
- decreased myotomal strength
- decreased reflex
Precautions:
- clastrophobia
- hiatal hernia
- vascular compromise
- pregnancy
- impaired cognition
- condition that compromises structure of the spine (osteoporosis, tumor, infection, RA)
cervical traction
0-5 deg flexion to increase intervertebral space at C1-4
maintained at 20-30 deg flexion for C5-7
maintained at 0 deg for disc dysfunction
acute phase:
- disc protrusion, soft tissue stretch, muscle spasm : 10-15 lbs or 7-10% BW
- joint distraction: 20-30 lbs
disc protrusions: static traction recommended - symptoms are aggravated by motion
lumbar traction
split table
supine 90/90 for spinal stenosis
prone for disc herniation
tx force:
- acute: 30-40lbs
- disc protrusion, spasm; elongation of soft tissues: 25% of BW
- joint distraction: 50 lbs or 50% of BW
intermittent mechanical compression
usd to decrease or prevent formation of edema
machine serially compresses a sleeve placed over the part to be treated
part is elevated and patient’s BP determines setting of device
-shouldn’t exceed DBP ?
at least 2 hours/day
Indications:
- chronic edema
- lymphedema
- stasis ulcer
- traumatic edema
- venous insufficiency
- amputation
Contraindications:
- acute inflammation or infection in area
- acute DVT or PE
- arterial insufficiency
- cancer
- diminished skin sensation
- kidney or cardiac insufficiency
- HTN
- cognitive dysfunction
- obstructed lymph channels
- very young and old frail patients
continous passive motion (CPM)
device that provides mechanical passive motion to a joint
size of the motion arc, position of the arc, and rate of motion is controlled
CPM inhibits adhesion formation, improves cartilage nutrition via better fluid mechanics and may stimulate the production of chondrocytes
Indications:
- post-immobilization fracture
- tendon or ligament repair
- TKR
- THR
Contraindications:
- thrombophlebitis or DVT
- CPM should be discontinued if increases pain, edema, or inflammation
tilt table
mechanical/electrical table designed to elevate patient from horizontal to vertical
Physiological effects:
- stimulate postural reflexes to counteract orthostatic hypotension
- facilitate postural drainage
- gradual loading of 1 or both LE
- begin active head/trunk control
- provide positioning for stretch of hip flexors, knee flexors and ankle PFs
Indications:
- prolonged bed rest
- immobilization
- SCI
- TBI
- orthostatic hypotension
- spasticity
Procedure:
- secure to table
- table raised gradually in 15 deg increments
- monitor VS: cyanotic lips or fingers may indicate compromised circulation
- time: based on pt. tolerance, shouldn’t exceed 45 min 1-2 x/day
return to supine with a drop in BP, diaphoresis, and agitation
contraindications:
- unstable fractures
- confused or anxious patient
massage
manipulation of soft tissues by hands
used to increase BF, stretch or loosen scar tissue, reduce edema and pain, relax muscles
indications:
- subacute and chronic MS conditions
- muscle spasm
- superficial scar formation
- edema
- postural drainage
Contraindications:
- acute inflammation or febrile condition
- severe atherosclerosis or varicose veins
- phlebitis and thrombophlebitis
- areas of recent surgery
- cardiac arrhythmia or heart failure
- malignancy
- hypersensitivity
- severe RA
- hemorrhage in area
- edema secondary to kidney dysfunction
- venous insufficiency
massage techniques
stroking
- beginning and end
- superficial strokes
kneading
-milking effect; aids in loosening adhesions and increasing venous return
friction:
- stretch scars and loosen adhesions
- small circular or stroking manner
tapotement:
- stimulation
cupping:
- chest to mobilize secretions
vibration:
- loosen secretions
general indications for electrotherapy
- pain modulation
- muscle spasm
- impaired ROM
- muscle re-ed
- disuse atrophy (muscle weakness)
- soft tissue repair (wound healing)
- edema reduction
- spasticity (reduce hypertonicity)
- denervated muscle
general contraindications for electrotherapy
- healing fractures
- areas of active bleeding
- malignancies or phlebitis in tx area
- superficial metal implants
- pharyngeal or laryngeal muscles
- demand type pacemaker
- myocardial disease
Precautions:
- areas of impaired sensation
- severe edema
iontophoresis
chemical ions are driven through the skin by continuous direct current for a therapeutic result
therapeutic ion must be placed under an electric of similar charge to “push” the chemical past the skin (transdermal) into the deeper soft tissue
-like charges repel
cathode (negative pole) is used for:
- salicylate -pain relief
- acetate - calcium deposits
- dexamethasone -anti inflammatory
- iodine - softens scars
anode (positive pole) is used for:
- hydrocortisone - antiinflammation
- lidocaine -pain relief
- magnesium or calcium - muscle spasm
- lithium - gout
- zinc - dermal ulcers
- copper- fungal infections
Contraindications:
- impaired skin sensation
- allergy or sensitivity to therapeutic agent or direct current
- recent scars, cuts, bruises or broken skin
- metal in or near area
transcutaneous electrical nerve stimulation (TENS)
provides afferent stimulation for pain management by affecting the peripheral and central NS
impulses stimulating the large A fiber afferents, can act to block the pain impulses (gate control theory)
stimulation may also cause release of the body’s own endorphins/enkephalins, which inhibit pain or pain transmission
current may be symmetrical or asymmetrical biphasic (AC) waveform or a monophonic (DC) waveform
electrodes may be placed at the point of the pain, at dermatomes of nerve roots, over trigger points, proximal or distal to pain site and at segmental related myotomes
contraindications:
- demand type pacemakers
- over chest area of patients with cardiac dysfunction
- over eyes, laryngeal or pharyngeal muscles, head and neck of patient with CVA or epilepsy
- application to mucosal membranes
types of TENS
Conventional (high rate) TENS:
- uses high frequency (75-120pps), very short pulse width (50-100 microseconds) , and low intensity
- provides temporary relief of acute or chronic pain
- onset of pain relief is relatively fast
- duration: 20-60 minutes
Acupuncture like (strong, low rate) TENS
- low frequency (1-4pps), wide pulse width (150-300 microseconds), higher intensities than conventional
- used more with chronic conditions with longer lasting pain relief
- duration: 30-40 min
Brief intense TENS
- high pulse rate (150pps), long pulse width (300 microseconds)
- rapid onset short term pain relief
- used to provide pain relief for painful procedures such as wound debridement, deep friction massage, passive stretching
- duration: 15 min
Burst mode TENS
- combines characteristics of both high and low rate TENS
- stimulation of endogenous opiates, but the current is more tolerable to patients than low rate TENS
- onset of analgesia is similar to low rate TENS
- duration: 20-30 min
modulation mode TENS
- a method of modulating the parameters of the the above TENS modes for the purpose of preventing neural or perceptual adaptation d/t constant e-stim
- frequencies, intensities or pulse widths can be altered by >10%, 1-2 times/second
high voltage pulsed monophonic stimulation
a form of pulsed direct current (DC) stimulation using high volt twin spikes with pulse widths in microseconds
the chemical, polar, and thermal effects of DC are minimized becomes of the extremely short duration (pulse width) of the stimulus
useful for denervated muscles
not tolerated well
indications:
- muscle stimulation/re-ed
- reduce pain from TENS like properties
- reduce edema (increased turgor)
- facilitate wound healing
russian current
uses high frequency (2500 Hz) current, which is modulated to 70 apps for comfort
indications:
-used for strengthening of normal muscle by assisting with the muscle contraction during volitional activities (isometrics and short arc joint movements)
Interferential current (IFC)
characterized by crossing of 2 sinusoidal waves having similar amplitudes, but different carrier frequencies
-the waves interfere with one another to generate an amplitude modulated beat frequency
indications:
- used for pain relief
- muscle strengthening
functional electrical stimulation (FES)
can use alternating current (AC 80-100Hz) to stimulate an innervated muscle for general stimulation or DC that is interrupted with a long pulse width for a denervated muscle
AKA neuromuscular estim (NMES)
encompasses a wide range of stimulator units and techniques
Indications:
- disuse atrophy
- impaired ROM
- muscle spasm
- muscle re-ed
- spasticity mgmt
useful as an alternative or supplement to the use of orthotics
if the skin is sensitive or the patient senses burning you should switch to:
larger electrodes, a reduced intensity or an increased pulse width may be indicated
AC is better tolerated than DC
although research indicates the estim of denervated muscles is not beneficial. use DC is preferred over AC
duty cycle:
on:off
min/no atrophy/weakness: 1:1 or 1:2 ratio
mod atrophy: 1:3 or 1:4 ratio
severe atrophy: 1:5 or 1:10 ratio
biofeedback
electronic instrument that monitors the muscle activity of selected muscles and provides physiological info (feedback) to the patient
patient tries to manipulate or change the feedback and thus voluntarily controls muscle activity
goals are either enhancement or reduction of the EMG activity
relax training is combined with EMG biofeedback when trying to achieve progressive muscle relaxation
not a form of e-stim
chronaximetry
a test of electrical excitability of peripheral nerves
rare
chronaxie value is the minimal amount of time that the current must be on in order to produce a min muscle contraction
-normal chronaxie value
electromyography
clinical EMG consists of the recording of electrical potentials of muscles
at rest, motor units should be electrically silent
with max contraction, the result should be an interference pattern
various abnormal patterns that indicate a specific problem
-fibrillation potentials seen in denervation
nerve conduction velocity
a test that determines the time it takes for a muscle to respond after the peripheral nerve has been stimulate
can be done over sensory nerves by determining the time it takes for a nerve to respond to a stimulus
UE conduction times can range from 45-70 meters/second
LE average is 50m/sec
UE average is 60 m/sec
NCV is slower in children 70
lower intramuscular temps slow NCV and higher temps increase NCV
test useful in assessing peripheral nerve lesions and neuropathies (CTS)
strength duration curve
a test of excitability in which the intensity required to produce a minimal muscle contraction is plotted against a set of measured durations.
-rare
graph results give an index of electrical excitability
steep, continuous curves displaced to the R indicate denervation
discontinuous curves indicate partial denervation
