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Flashcards in Modalities Deck (55)
1

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

2

convection=

head transfer by movement of air or fluid from a warmer area to a cooler area

convection modalities: whirlpool, hubbard tank, fluidotherapy

3

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

4

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

5

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

6

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

7

list of superficial heating agents

hot pack
paraffin bath
contrast baths
hydrotherapy- whirlpool, hubbard tank
aquatic therapy

8

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

9

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

10

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

11

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

12

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

13

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

14

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

15

indications for cryotherapy

acute and chronic traumatic and inflammatory conditions

edema

muscle spasm/spasticity

MS pain

thermal burns

MS symptoms

16

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

17

cold packs

temp: 0-10 deg F
time: 10-20 minutes

18

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

19

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

20

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

21

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)

22

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

23

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

24

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

25

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

26

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

27

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

28

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

29

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

30

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

31

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

32

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)

33

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

34

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

35

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

36

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

37

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

38

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

39

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

40

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

41

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

42

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

43

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

44

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

45

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

46

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)

47

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

48

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

49

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

50

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

51

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

52

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

53

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

54

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)

55

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