Modalities How to use a modality during treatment: Introduce yourself Overview of modality What are the effects of the modality? Goal What should the patient feel? What should the patient do if they do not have the expected feelings Contraindications Subjective and objective measurements Proper positioning and draping Bell/timer Initial and final inspection of the treatment area Conversions Celsius to Fahrenheit conversion 9/5 C + 32 = degrees in F Fahrenheit to Celsius conversion 5/9 (F-32) =C 1 lb= 45 kg 1 in = 2.5 cm 1 kg = 2.2 lbs 1 cm = .4 in Cryotherapy Types/Treatment temperatures Cold/ice packs Ice massage Ice soaked towels Vapocoolant Cold baths Cryocuff Controlled compression unit Indications Reduce acute inflammation Reduce/control pain Reduce spasticity Reduce muscle spasm Contraindications Cold hypersensitivity Cold intolerance Over a regenerating nerve Cryoglobulinemia Raynaud’s syndrome Impaired circulation/ peripheral arterial disease Proxysmal cold hemoglobinuria Physiological effects Vasoconstriction Decrease nerve conduction Increase pain threshold Alter muscle strength Reduce spasticity Decrease metabolic reactions Therapeutic Heat Types/Treatment temperatures Superficial: hot pack Paraffin Fluidotherapy Infrared lamp Warm whirlpool Deep: Ultrasound Diatheramy Indications Pain control Reduce muscle spasm/ guarding Increase soft tissue extensibility Facilitate healing Subacute and chronic inflammation Contraindications Acute inflammation Acute hemorrhage Impaired sensation Impaired mentation DVT/thrombophlebitis Severe peripherial vascular disease Existing fever Malignancy/ cancer Radiation therapy Infrared lamp over eyes Physiological Effects Increase collagen extensibility Vasodilatation Increase rate of local metabolism Reduce muscle spasm Temporarily reduce strength Reduce pain Intermittent Compression Pump (ICP) Indications Edema Venous insufficiency Lymphodemia Contraindications Heart failure or pulmonary edema DVT/ thrombophelbitis Obstructed lymphatic or venous return Severe PAD Acute infection Acute fracture or trauma Pain during compression Cellulitis Malignancy Physiological Effects Improve venous and lymphatic circulation Limits shape and size of tissue Increase tissue temperature Massage Indications Chronic edema Muscle soreness, aching, tension Tension headaches Amputees residual limb desensitization and shaping Scar tissue Chronic muscle strains Acute muscle spasm Tendonitis Contraindications Acute inflammationFever Acute bleeding/ bruising Hemophilia Skin disease or condition Cancer or TB Severe sensitivity to touch or pain Presence of foreign bodies DVT/thrombophelbitis/ blood clot Edema with unknown cause Types of Strokes Effleurage-use to start and finish Petrissage- kneading, picking up, wringing, and skin rolling Deep friction- targets tendons, ligaments, and muscles Physiological Effects Increase blood flow and lymph flow Increase flow of nutrients Removal of waste products and metabolites Stimulation of the healing process Resolution of chronic edema and hematoma Increase extensibility of connective tissue Pain relief Increase joint movement Facilitation of muscle activity Stimulation of autonomic functions Stimulation of visceral functions Removal of lung secretions Sexual arousal Promotional of local and generalized relaxation Ultrasound Types Pulsed (non thermal) 5-10 min Continuous (thermal) 8-10 min Immersion Characteristics Frequency 1 MHz = 2-5 cm deep 3 MHz = 1-2 cm deep Effective radiating area (ERA) is slightly smaller than the sound head. Treatment area should be two times the ERA. Absorption of ultrasound energy- Poor=blood, fat, and water Better= muscle, collagen Best= bone (10x more than soft tissue) Reflection- 99% of waves are reflected back into the sound head Refraction- happens when the sound head is not parallel to the tissue Attenuation- as ultrasound waves pass through media and tissue layers, there is a definite reduction in amplitude and power outlet Parameters: Superficial & chronic continuous 3 MHz, .5-1.0 w/cm squared Superficial & acute pulsed 3 MHz, .5-1.0 w/cm squared Deep & chronic continuous 1 MHz, 1.5-2.0 w/cm squared Deep & acute pulsed 1 MHz .5-1.0 w/cm squared Effects Pulsed: promotes healing (collagen formation and protein synthesis) Increase membrane permeability Promotes tissue regeneration Can reduce pain in an acute lesion Decrease inflammation Continuous: aids in the resorption of exudate Decrease pain by increasing pain threshold Increase extensibility of connective tissue and contractile tissue by altering the visco- elasticity of connective tissue Increased blood flow Indications Soft tissue shortening Pain control Dermal ulcers Surgical skin incisions Tendon injury Bone fractures Carpal tunnel syndrome Plantar warts & herpes zoster Contraindications Malignant tumor Pregnancy CNS tissue Methylmethacrylate (cement used for some joint replacements) Pacemaker Thrombophlebitis Eyes Reproduction organs Aseptic Technique Procedures or methods used to create or maintain a sterile field Guidelines All items within the boundary of a sterile field must be sterile Once the sterile package is opened the edges are not considered sterile Once donned properly, sterile gowns are considered to be sterile in the front from should level to tabletop level, including the sleeves. You must keep hands and arms above table level. Tables are only considered to be sterile ate the table top level Only sterile items and personnel in sterile attire may enter a sterile area or touch sterile items without causing contamination. Unsterile personnel may not reach across into a sterile area. Everyone is responsible to maintain the sterile field. Penetration of a sterile covering or barrier is considered to be contamination of a sterile field. When there is doubt about the sterile quality of an area, fields, or an item, consider it unsterile. Cleanliness Cleaning- the physical removal of organic material or soil from objects Disinfecting- performed by using pasteurization or chemical germicides Sterilizing- destruction of all forms of microbial life by steam under pressure, liquid, or gaseous chemicals, or dry heat. Universal Precautions Hand washing- number one way to prevent the transmission of diseases Protective equipment- gloves, gowns, masks, protective goggles, scrub suits, accessories Disposal- any waste that is saturated with any body substances will be considered infectious waste and disposed of properly. Wound Care A wound is an injury in which the skin is torn, pierced, cut, or otherwise broken. Wound Types Pressure ulcer- caused by external forces Arterial insufficiency- results from arteriosclerosis Venous insufficiency- caused by obstruction or decreased competence of venous valves Neurotrophic ulcer-occurs in many patients with Diabetes or Leprossy with a peripheral neuropathy Post-surgical wounds Trauma wounds Skin disorders due to allergic reactions Conditions/ Diseases associated with chronic wounds Poor sensation Poor circulation Contamination/ infection Malnutrition Trauma Diabetes/ PVD Wound Terms Necrotic- dead tissue, progresses from white/gray to tan/yellow to brown/black Eschar- black/gray/brown dead tissue adhered to wound tissues Slough- yellow/tan dead tissue, stringy or non loosely adherent to healthy tissue Granulation- laying down of collagen matrix, pink buds to bright red tissue Scab- collection of dried blood cells and serum on top of the skin surface Full thickness- through the skin; may include muscle, nerve, or bone Partial thickness- includes the epidermis; may include part of the dermis but does not extend through the dermis Physical Therapy Intervention Hydrotherapy Electrical stimulation Ultrasound CPM machine Early controlled ROM Positioning to protect healthy tissue Debridement Dressings Gauze- absorbs exudates while allowing topical agent to be in close contact with wound. Impregnated dressings- prevents tissue adherence while absorbing exudates. Films- helps to keep wound bed moist in non-infected shallow wounds with minimal exudates. Maintains moist wound environment to facilitate debridement by autolysis and encourage epitheal migration. Foams- combines benefits of moist wound environment for non-infected wounds with absorbency for moderate to high amounts of exudates. Hydrogel- keeps tissues moist as this dressing absorbs exudates. Used with shallow or deep wounds with minimal to moderate exudates. Hydrocolloid- protective covering that combines with wound exudates to form a gel protection of the wound. Calcium alignates- for wound with moderate to heavey exudates and uneven (tunneling) ulcers, as they can absorb up to 100 times their weight in wound fluid. Methods of application Dry to dry Wet to wet Wet to dry Occlusive Rigid Continuous Passive Motion Benefits Can maintain or gain ROM Keeps soft tissue elongated Increased nutrition to joint Promotes healing Decreases edema Decreases possibility of scar tissue adhesions Decreases pain Decreases sense of stiffness Cost- effective Indications Post fracture Post joint injury Post joint surgery After immobilization of any type Soft tissue contractures Contraindications Unstable fractures If ROM is contraindicated Taping Uses Provides stability Reduce pain Re-align structures more optimally Provide feedback Types Athletic tape Micropore/ transpore McConnell Common areas taped Ankle Knee Scapula Back Wrist Fingers Hydrotherapy Types Whirlpool (102 degrees F) Extremity whirlpool High boy Low boy Hubbard tank (97- 100 degrees F) Contrast bath warm-(80-104 degrees F/ cold 55-67 degrees F) Irrigation devices Exercises pool (79- 97 degrees F) Benefits High specific heat- retains heat well Ability to provide buoyancy (upward thrust on the body in the opposite direction to the force of gravity) Ability to provide resistance Hydrostatic pressure to the body Indications Water exercise Orthopedic problems Cardiac fitness Exercise during pregnancy Exercise- induced asthma Conditions benefiting from superficial heat Conditions benefiting from superficial cold Wounds Pain Edema Contraindications Local- maceration around the wound Bleeding Full body immersion- cardiac instability Infectious conditions that may be spread by water Bowel incontinence Severe epilepsy Suicidal patients Temperatures Cold- 32-79 degrees F acute inflammation Tepid- 79-92 degrees F exercise/ subacute inflammation Neutral warmth- 92-96 degrees F open wounds Mild warmth- 96-98 degrees F increase mobility in burn pts Hot- 99-104 degrees F decrease chronic pain, increase relaxation Very hot- 104-110 degrees F increase soft tissue extensibility (limited body area only) NEVER GO ABOVE 110 DEGREES F Traction Types Intermittent Static Manual Mechanical Over the door cervical traction 90/90 lumbar traction Self- traction Positional traction-lumbar spine Effects Joint distraction Reduction of disc protrusion Soft tissue stretching Muscle relaxation Joint mobilization Immobilization Indications Disc bulge or herniation Nerve root compression Nerve root impingement Joint hypomobility Subacute joint inflammation Paraspinal muscle spasm Contraindications When motion is contraindications Acute injury or inflammation Joint hypermobility or instability Traction peripheralizes symptoms Uncontrolled hypertension Patient positions Supine- cervical or lumbar Prone- lumbar (posterior disc herniation) Sitting- cervical or self- lumbar Sidelying- lumbar (positional) Equipment Needed Head halter or Saunders belt Harness or belts Placed directly on skin Top of thoracic belt at xiphoid belt Top of lumbar belt superior to iliac crests Spreader bar Split traction table Area treated should be over split of table Parameters Static for inflammation, when symptoms are aggravated by motion, and muscle stretch Intermittent for DJD or facet joint problems Static or intermittent for long hold time for disc protrusions For static the first treatment should be 25-50 pounds for lumbar and 8-10 pounds for cervical To decrease symptoms related to compression problems use up to 50% of body weight for lumbar and 7% for cervical To decrease muscle spasms, stretch soft tissue, or promote reduction of disc herniation use 25% of body weight for lumbar and 12-15 pounds for cervical For intermittent traction the off cycle force should be about half the amount of force of the on cycle The first treatment should last 5-10 min. Treatments should not last more than 40 min. Biofeedback Uses of electronic instruments to accurately measure, process, and feed back reinforcing information about muscle contraction via auditory or visual signals. Indirect way of measuring muscle activity Measured in microvolts Uses The goal is to help patients develop more voluntary control of muscle function Neuromuscular relaxation (inhibition) Muscle re-education (recruitment) Equipment Biofeedback machine Electrodes sized depends on muscle Conduction medium (usually built into electrode) Clean the skin with alcohol Place the electrode over muscle, and parallel to the directions of the fibers Will have visual or auditory feedback Sensitivity Threshold goal for the patient Gain/sensitivity High gain= more sensitive for muscle re-education Low gain= less sensitivity to promote relaxation.