What is a Modality?
a Treatment intervention designed to have a therapeutic effect.
How to use modalities
use as an adjunct to treatment use to enhance primary treatment spend about 15 minutes on modalities.
Thermal Energies
Hot and Cold are relative terms Hot - more thermal energy Cold - less thermal energy Heat transfers from areas of high energy (Hot) to areas of low energy (cold) Heat goes from areas of high concentration to areas of low concentration
Converting Celcius to Farenheight
(C x 9/5) + 32 = F
Converting Farenheight to Celcius
(F-32) 5/9 = C
Specific Heat
water = 1 calorie/gram amount of heat per unit mass (energy) needed to raise the temperature of a substance one degree Celcius
Max Temp for a Whirlpool
110 degrees
Max temp for paraphin wax
125 degrees (higher than water because less energy goes into raising the temperature of the wax each degree)
Fluidotherapy
ground corn cob can treat at higher temp than water because less energy goes into raising the temp –> gives off less energy
Thermal Conductivity
Metal Spoon in Pot Sand has a higher conductivity than wood
Magnitude of Application
Cold pack on ankle vs. full cold bath immersion use the more localized application if the patient is medically unstable.
Physiological affects of heat application
BP - decreases HR - increases
Physiological effects of cold application
BP - increases HR - decreases
Duration of Hot pack application
6-8 minutes - penetrates to a depth of 1/2 cm 15-20 minutes - penetrates to a depth of 1-2 cm depth of penetration increases as the length of application increases
How application of cold affects the blood vessels
1st constricts the blood vessels eventually, dilates the blood vessels (this is why your skin gets red when an ice pack has been on for a while. Make sure when you press down on the skin that the skin blanches and refills) (Hunting Response)
cyclical pattern to keep the temp from dropping below 50 degrees Farenheight
Different ways to transfer thermal energy
Conduction Radiation Convection Evaporation
Conduction
physical contact that results in a transfer of heat
Radiation
Heat propagated through air NOT through direct contact
Convection
Thermal energy is set in motion often combined with conduction and radiation i.e. hot whirlpool or a fan
Evaporation
extracts energy when converting from liquid to gas transfer of heat from sweat fluid –> vapor resulting in a cooling effect
Why are hot days so dangerous?
energy transfers from how to cold, so on a hot day when the temp outside is higher than body temp, the environment is actually transferring heat to the body rather than the body loosing heat to the environment. This could be especially problematic for a person who is exercising.
effect of heat on metabolic rate
heat increases metabolism (o2 uptake)
NOT good for traumatic injury
effect of cold on metabolic rate
cold decreases metabolic rate (o2 uptake)
e.g. packing a detached limb in ice decreases its need for O2
what to do right after trauma (1st 48-72 hours)
R - Rest / I - Ice / C - mild compression / E - elevation
Causes of Trauma
not just from accidents (one bad event etc.) can also be from overuse, overstretching
1st inflammation process
body responds with vasoconstriction in the area
2nd inflammation process
vasodilation increases blood flow and an increase release of inflammatory chemicals (histamin, brady plinen prostaglandins) the inflammatory chemicals increase capillary pressure and permeability (due to increased blood flow) fluid leaves the capillaries –> interstitial tissue –> edema/swelling (best sign that inflammation is occuring) edema compresses microcirculation causing secondary hypoxia (inflammation is required for healing to occur)
Secondary Hypoxia (treatment)
Caused by swelling/edema apply cold (this slows metabolism)
Other effects of ice
minimizes release of inflammatory chemicals such as prostaglandins
vasoconstriction + an increase in blood viscosity
Durration of Cold Pack Application
10 - 15 minutes of using ice or a cold pack
A Cryocuff can stay on for up to 2 hours
How application of heat affects the blood vessels and other bodily systems
Application of heat causes the blood vessels to dilate.
Heat decreases Sympathetic nervous system activity
Effects of Heat on joint viscosity and soft tissue extensibility
Heat decreases joint viscosity
Heat increases soft tissue extensibility
Effects of Cold on Joint viscosity and soft tissue extensibility
Cold increases joint viscosity
Cold decreases soft tissue extensibility
What intervention should you use for pain or muscle spasm
heat or cold
Effects of Cold on Pain and Muscle Spasm
cold decreases pain and muscle spasm because it decreases nerve conduction velocity which slows the transmission of pain back to the Central Nervous System
when muscle spindles are hyperactive, they increase infp to dorsal horn
cold, decreases activity in muscle spindles
Some uses for Cold application
treating people with spacticity (a neurological condition)
Clonus - rhythmic shaking, hyperactive muscle spindles
cod used to decrease tone and spasticity
cold results in a temporary decrease in nerve conduction velocity
Cold should be used if there is inflammation in the region
Heat - effect on pain and muscle spasm
heat doesnot have a consistant effect on nerve conduction velocity
it does increase blood flow and vasodilation, washing out inflammatory byproducts
promotes relaxation and provides a competitive sensory input
Heat results in gamma output to efferent system which decreases activity in muscle spindles
4 signs of acute inflammation
Swelling (tumor), Heat (calor), Redness (rubor), Pain (dolor)
What is the approximation skin temp?
92 degrees
Temperature of Cold pack at time of application + depth of penetration
50 degrees
penetration is up to 4 cm, but is most dramatic at 1 cm
effects of cold application last longer than effects of cold application
Temperature of hot packs at time of application + penetration depth
110 degrees
only penetrates 1-2 cm, and the effects do not last as long as the effects of ice
gradients are higher with cold than hot when compared to normal skin temp.
Contraindications/Precaustions for heat
- accute inflammation
- fever
- thrombus formation (i.e. after surgery, heat could dilate the blood vessels and release the clot into the heart/lungs)
- skin and lymphatic cancers (we don’t want to increase the metabolic rate in the area
- Peripheral vascular disease (peripheral arterial occlusive disease) (i.e. diabetics with poor circulation, sometimes a lack of hair growth in the area can be observed; the body can’t shunt blood there to cool the ares–> so don’t heat it)
- Radiated Tissue - radiation results in a compromided ability for the patient to handle heat (even x-rays)
- patients with impaired sensation (mentation), or cognitive issues (monitor closely so they don’t get burned)
- medically unstable patients (i.e. low bp (heat lowers b.p. even more))
- Actively infected tissue
Contraindication/Precautions for cold
- severe hypertension (HTN)
- Cardiac respiratory conditions
- hyperactive sympathetic nervous system
- people with allergic reactions to cold (uticaria)
- peripheral vascular disease
- open wounds
- regenerating peripheral nerve (nerve more brittel with cold application)
- impaired sensation/mentation (because it is hard to get accurate feed back from the patient)
How to instruct a patient when ice or heat is being applied
1 liability is burns from hotpacks
instruct patiens to give feedback about the application. Instruct that the treatment should be at a comfortable level (watchout for people with egos)
General Use of Heat
- Before stretching, exercise, joint mobility
- before mobilization, traction, massage
- reduce pain and muscle spasm
- after the acute inflammatory response (to promote healing)
- prior to electrical stim to decrease skin resistance
- promotes relaxation
General Use of Cold
- After exercising, stretching or joint mobilization
- help to reduce bleeding or edema
- following trauma as a part of rice
- reduce pain and muscle spasm
- reduce spasticity
- cryokinetics
Cryotherapy Modalities
- ice masssage
- ice packs
- cryocuff
- clod bath immersion
- vapocoolant spray
How to treat using ice massage
Start with a large area and then start to target a smaller area constantly moving the ice
treat for 5-10 minutes
4 stages of sensation when using ice
- cold
- lowgrade burning (warmth)
- dull ache
- numbness
How to wrap the ice
Bags of Actual Ice - place in a pillow case or a wet towel (a wet towel will improve the conductivity)
How to make cold packs
water + alcohol in a ziploc, often with a sponge in there
(the blue gell packs also use alcohol to decrease the freezing point allowing the gel to kepp from becomin frozen solid)
cool bath immersion
67-80 degrees
Cold bath immersion
55-66 degrees
Very Cold Bath Immersion
32-54 degrees
Vapo coolant spray
does not increase joint viscosity and joint stiffness the way that ice does
Superficial Heating Modalities
- hydrocollator packs (hot packs)
- paraffin wax
- fluido therapy (whirlpool with corn saw dust)
- infrared
- hot bath immersions
- contrast baths (alt hot and cold4 min hot 1-2 min cold (only use cold after severe trauma) these are good for sinus headaches b/c it sesensitises hyper sensitive areas)
Treatment with hydrocollator hot packs
- 15-20 minute treatment time
- unit should be kept at 160-170 degrees
- packs take 20 minutes to reheat after being out for a while
- *** wrap the hot pack in 6-12 towel layers (each turkish towel side is 3 layers
- use a regular towel as the final towel layer so that it can be washed/changed easily between patients
- use more towels if there is going to be pressure from the person’s body weight
- INSPECT the skin before placing the hotpack, for piercings, open wounds, blood folw etc.
- place a sheet over pack and body if pt is lying prone (helps with conduction)
Capillary refill test
skin should not stay red when pressed in, should blanch
there is a risk of pressure ulcers with superficial heating modalities
Paraffin
- 125-127 degrees
- often used to decrease stiffness in the hand or wrist
- have patient wash his or her hands before putting them into the wax
- take off any jewelery
- openwound lesion is a contraindication
- good for wrist extension and thumb opposition
- 5 layers / 5 dips (glove technique)
- can’t exercise during this type of treatment
- treatment time should be 15-20 minutes
- sometimes therapists will put a heat pack over the paraphin
- there is also a paint brush technique where the wax is painted on
Fluido Therapy
- 115 degrees
- takes 15 minutes to heat up
- inspect skin before treatment
- no open wounds
- exercises can be performed while in the machine
- treatments shouls last 15-20 minutes or less
infrared
- heat lamp should have no direct contact with body
- luminous (aka near luminous) (8,000 - 15,000 angstroms)
- nonluminous (aka far luminous) 15,000 - 150,000 angstroms)
- the infrared spectrum is 8,000 - 150,000 angstroms
Deistance for Luminous infrared
24-30 inches usually, but this varies from lamp to lamp so read the instructions for the particular lamp you are working with
Distance for nonluminous infrared lamps
30-36 inches usually, but read the directions that come with the specific lamp
Reasons to use infrared
- pt with hypersensitivity to pressure
- large treatment area
- face (wouldn’t put a hot pack on the face) (have the person close their eyes
- constant source of heat where as heat packs loose their heat over time
becareful not to dry out wounds
wounds don’t heal as well when dried out
Law of inverse squares
intensity of the infrared waves varies inversely with the square of the distance between the source radiating intensity and the absorbant area
So, as you move the lamp farther away, the intensity decreases a lot more than the distance moved
at half the distance, the light will be 4x more intense.
I = 1/d^2
Cosign Law
infrared light will propagate best when applied at a right angle to target tissue
if you tilt the light to a 30 degree angle, you will loose 30 percent of its intensity
Depth of penetration with infrared
The depth of penetrationis greater with hotpacks than it is with infrared
nonluminous infrared lamps penetrate even less
infrared treatments stay concentrated superficually and provide a more intense heating sensation, but do not penetrate as deeply
VERY Hot Bath Immersions
105-110
usually for localized applications
only use with patients that have good thermal regulation capabilitiess
HOT bath immersion
100 - 104 degrees
WARM hot bath immersion
97-99 degrees
warm pool applications
keep the temp lower (92-95) if the pt has poor circulation and or an open wound
Big tanks usually have a temp of 95 degrees
.Contrast baths
alternate hot and cold baths
hot (3-4 min)
cold (30-60 seconds)
total treatment time should be about 15 minutes
when used on the hands, it is good for sinus infections because it shunts blood away from the face
start with hot and end with cold
good for vasodilation and constriction desensitization
Ultrasound
- deep thermal effect, up to 5 cm deep
- also has non-thermal effects
Sound Waves
subsonic - 20 Hz or less
sonic - 20 - 20,000 Hz
Ultrasonic - greatere than 20,000 Hz
Frequencies for Therepeutic ultrasound
1 MHz or 3 MHz
Depth of penetration is greater at 1 Mhz (5cm)
3MHz only has a depth of 2 cm (more effective than a hot pack since a hot pack penetrates 1-2 cm deep, but looses heat over time of treatment and looses intensity the deeper it goes.)
The Ultrasound Machine
a step up transformer increases the voltage and an oscillating circuit to increase the frequency pass out into the cable that leads to the ultrasound head (transducer) converts electrical energy into another kind of energy
reverse Piezo Electric effect
Therapeutic Ultrasound
- intensity should be at 0.1 - 2.0 watts/cm2
- the higher end gives a heating effect
Measurement for Frequency
Hz
Measure for intensity
W/cm2
Ultrasound vs. Heat Packs
Depth of penetration is greater with ultrasound
- ultrasound doesn’t stimulate heat receptors on the skin the same way a hot pack does
Ultrasound modes
- continuous mode
- pulsed mode
Duty Cycle %
ontime / (ontime + off time)
What duty cycle to use for a thermal effect?
100%
What duty cycle should be used for a non-thermal effect?
50%-20%
Spatial Average Intensity (continuous)
meaning, what you would typically set your machine at for a continuous application
1.5 Watts
Temporal Average Intensity
spatial avg. intensity x duty cycle
1.5 watts/cm2 x 50% DC = .75 watts/cm2
Ultrasound gel
Aquasonic gel or mineral oil
enhances movement of sound waves
aka conductive gel
there are some gel disks that have ultrasonic gel also
Under water Ultrasound
only put the machine in up to the coaxial cable
often used for carpal tunnel or other hand issues
Use slightly higher intensity because some energy is lost in the water when compared to the gel transmission
no direct contact with the body part
General considerations when performing ultrasound
make firm contact to avoid any airbubbles
use overlapping circles moving in and out of the area
Ultrasound Absorption
Absorption varies depending on what area you sonate
absorbed well in tissue with lots of collagen and where tissue consistency changes (muscle –> tendon etc.)
works great on frozen shoulders
can use while stretching
purpose of non-thermal ultrasound
nonthermal facilitates stimulation of cell activity for healing without heating
Contraindications for Ultrasound
Over organs (stomach, liver, lungs, spleen, bowels, heart, kidneys)
Over the pelvis, abdomen and lumbar (lower back) region in pregnant or potentially pregnant females.
Over highly ultrasound-sensitive organs (eyes, ears, ovaries, testicles, brain, spinal cord)
Over mucous membranes (mouth, nose, rectum/anus, vagina)
On patients with pace-makers on patients with phlebitis, deep venous thromboses
On patients with hemophilia
On patients with spina bifida or surgical laminectomies of the spine
On tissue and/or bone with active infection
Over areas suspected to be cancerous or pre-cancerous
Over de-sensitized (numb, hypoaesthesia) areas of the skin (eg. diabetic neuropathy)
Over open sores or lesions
In the front of the upper neck (thyroid region)
Over areas that have had cortisone injections in the last 30 days
move quickly over spine
Thermal Ultrasound effects
- increases metabolism
- increases blood flow
- increases soft tissue extensibility
- decreases joint viscosity
Physiological Effects of Ultrasound
- Mechanical
- Acoustic Streaming and cavitation
- movement of intra and extra-vascular fluids
- increase in cell membrane permeability
- increase in macrophage and mast cell activity
- increase in chemotactic factor activity
- increase in fobroblast activity
Cavitation
increases the pressure of the tissue because of the increase in sound waves
Stable Cavitation
Pressure comes in and goes away
this is what we want
like partially blowing a bubble, but not enough for it to take off, just for it to return to its original shape
Unstable Cavitation
destroys tissue
this result can not be acheived with our ultrasound machines
indications for ultrasound use
- soft tissue restrictions
- sub-acute and chronic inflammation
- musculoskeletal pain and muscle spasm
- wound healing
- phonophoresis
- treatment time considerations
(ultrasound is not the best choice when the only complaint is pain.)
ultrasound in wound care
used with hydragel at a very low frequency
also used for debreidment
Phonophoresis
ultrasound used over topical medication to enhance absorption
may not actually work
attempted frequently with dexamethasone and salicylates
get the rx from the dr. for a bunch and just get approval when you want to use it
size of treatment area with ultrasound
only good for areas less than 3x the surface area of the head
if the area in need of treatment is larger, not enough of the effect will be concentrated enough to have an effect over such a large area
treatment times for ultrasound
time based on the size of the area
treatment time is also longer if trying to warm tissue for stretching
treatment time is shorter when the non thermal treatment effects are desired
Chart for ultrasound intensities
Intensity of 0.5 (1MHz .04) (3MHz .3)
Intensity of 1.0 (1Mhz .2) (3MHz .6)
Intensity of 1.5 (1 Mhz .3) (3Mhz .9)
Intensity of 2.0 (1 Mhz .4) (3 Mhz 1.4)
Contracture
High intensity and vigerous stretching
used as a way of trying to avoid the need for surgery
otherwise start at a lower intensity
Ultrasound Contraindications
- pacemaker/implanted device
- metal implants if superficial
- not directly over a joint replacement
- not over the eyes, ears or genetalia
- not over or around a suspected blood clot
- not over a pregnant woman’s uterus
- cancerous tissue/infection
- active bleeding /hemorrhage
- not over the heart
- not over growing epiphyseal plates
- not directly over the spine
- not over the carotid sinus
Mechanical Modalities
Traction
Traction
use of external forces to create distraction on soft tissue and joint surfaces
Sustained Traction
constant pull on the area
intermittent traction
ie on for 10 second, off for 10 seconds
Continuous traction
We dont usually do this. This is usually something a person gets in a hospital after a traumatic accident. Usually macheines are set up at the bed
Effects of traction
- decreases intervertebral pressure
- stretches and elongates the soft tissues
- stimulates the mechanoreceptors
Traction sources
- manual
- positional
- gravity
- mechanical (hanging weights, pneumatics, motorized)
Cervical Manual Traction
- Sub occipital with fingertips
- sub occipital with webspace
- Temporal - Parietal with Palms
Cervical Mechanical Traction (try manual 1st)
- position
- Harness/saunders device
- poundage15-45 lbs (avg. 25 lbs) 10-15% of body weight
Vertebral Artery test
pre-screen test for cervical traction
supine patient with head tilted back but supported
turns head to each side for 30 second holds on each side
extreme dizeyness, ringing in the ears (tinitus), nausea, pupils dilate, or if person feels like they are going to pass out, then do not do cervical traction
Head harness
straps come off occiput part
too much compression on tmj
Saunder’s device is more common now
Best position for cervical traction
Supine
Mechanical Lumbar Traction
- Position supine with hips and knees at 90/90 deg.
- lumbar corsetsits with top at umbilicus
- thoracic corset should have the upper edge sitting at the zyphoid process
- the 2 corsets should overlap, there should not be a gap
- poundage 25-50% of body weight
Positional Lumbar Traction
- people with issues on one side
- lay on side opposite from injury with a wedge or a roll + pillow under waist
- turn toward affected side
- hold for 3-5 minutes
- have someone push down on illiac crest or down on illiac crest + up on shoulder
General Traction Considerations
- relaxation helps
- pain peripheralization is generally not good, if peripheralized pain becomes more centralized, that is a good result
- bilateral radiation is bad - there could be spinal cord involvement
- other treatments to use as alternatives: patient education, flexibility, strength, posture, body mechanics
Indications
- nerve root impingement
- disc herniations
- degenerative joint disease
- degenerative disc disease
- spinal hypomobility (limited ROM)
- Paravertebral muscle spasm
- paravertebral pain
Evaluate the patient’s pain level at rest
if pt has sharp shooting pains at rest, the pain cold be reffered to the back from the visceral organs, esp. the kidneys
Traction Contraindications and Precautions
- Spinal CA
- Spinal Infections
- Severe RA
- Severe Osteoperosis
- Acute injuries (not immediately after whiplash for instance)
- spinal instability / hyper mobility
- Pregnancy (lumbar)
- Hiatal Hernia (lumbar)
- COPD Patients (lumbar)
- TMJ (Cervical)
- Patient anxiety
- fragile skin
- check for earings, hair and jewelry that could be in the way
When to use more flexion durring cervical traction
if the lower cervical spine is affected, use more flexion
if the upper cervical spine is affected, use less flexion
other things to consider for cervical traction
place a lumbar roll under the patient’s knees
keep the pads under the ears when using the traction table.
turn toward the negative setting to pull slower, turn toward the positive setting to pull faster
usually set the machine to do 10 seconds on and 10 seconds off with the “on” poundage set at 20 lbs., and the “off” poundage set at 0-5 lbs
change the height of the table to change the amount of flexion
Yoga poses that can create spinal distraction
Child’s pose
Cobra pose (for distraction on the anterior side of the spine)
External Compression
- use of external forces and pressure over extremities to mobilizeextravascular and intervascular fluids
- intermittent pneumatic compression pumps, ace wraps, custom or stock compression garments
-
Use of compression relating to edema
- (may get swelling in the lower leg when the hip is replaced due to damage of the lymphatic vessels up by the replacement site)
- compression socks can be helpful post op to prevent edema and dvt
- TEDS or anti-emboli socks are often used which provide a very low pressure
- Johhny Copper Compression socks
Use of Massage relating to edema
- effleurage (work your way from the bottom of the leg to the top while wrapping hand around the circumferance of the leg)
Other ways to treat edema
- exercise, do heel pumps
- Quad Steps exercise
- external Water pressure
- contractions created by electrical stimulation
Contraindications for the use of compression with edema
dont use compression for edema when the edema is caused by esrd end stage renal disease or CHF. The edema in these cases should be managed medically because the organs that are not working properly can’t handle extra fluid
Other causes of edema
sometimes patients will develop edema when they have low muscle tone (these patients may benefit from compression socks)
Hydrostatic pressure
if there is high hydrostatic pressure in a capillary, then tissue will flow out of the capillary
Osmotic Pressure
has to do with chemicals concentrations
proteins in the surrounding tissue will attract fluid to that tissue
Edema in malnourished people
malnourished people develop swelling because there is not enough osmolarity in the capillaries to hold the fluid in
this should be treated with diet not with compression
External compression for use in patients with venous stasis
- venous stasis means that there is poor venous return
- this can occur when valves become incompetant over time due to trauma, radiation, obesity, lack of a good muscle calf pump (often when a person has a shuffling gait rather than a heel to toe walk), pregnancy can create extra pressure on the venous system (shld wear compression socks durring the last few months of pregnancy), history of blood clots that have widened the veins and resulted in a residual loss of elasticity
(Plebitis often accompanies venous stasis - inflammation of the vein)
Hemosiderian Deposits
brown staining because there is such high pressure in the capillaries that they leak dead RBCs
Venous stasis wounds and other things associated with venous stasis
these wounds heal well, they are the only wound that uses compression to assist healing
- superficial vericosities
hard consistancy of tissues because fibrin and fibrogen form stiffness in interstitial tissue, tissue fibrosis
- dependency pain (pain when the leg is hanging down
- limited ROM
- may want to put the foot of the bed higher than the rest of the body slightly
Intermittent Pneumatic Compression Pump
- preset to push air into the bladder surrounding the affected area
- measured in mmHGs
- skin inspection
- take the person’s BP, you should NEVER exceed the person’s diastolic pressure becuase that would block arterial blood flow
- girth measurements are recorded in cm
- does the pt have good sensation? can he tell you if there is too much pressure?
- pt should NOT feel his own bounding pulse or tingling/numbness
- put a cotton stocking on 1st and then the nylon sleve to keep the nylon sleve clean
mmHg to use for intermittent Pneumatic compression pump for lower extremity
30-60 mmHg
mmHg to use for intermittent Pneumatic compression pump for upper extremity
20-50 mmHg
compression to rest ratio to use for intermittent Pneumatic compression pump
3 to 1
pt should do active contractions during the rest period
ending treatment with Pneumatic compression pump
put on an ace wrap or compression sock to maximize the benefit to the patient after the treatment has ended
Lymphedema
often there is a complete blockage of the lymphatic system
Petrosage - massage to try to open the lymph system
Although this cannot be cured, areas of chronic edema are prone to infection, so the therapy keeps it moving
Indications for IPC and other forms of compression
- post traumatic edema
- edema due to lymphatic dysfunction
- residual limb shrinkage (amputee, shape stump for prosthesis)
- prevention of thrombus (if already present, then stay away)
- tissue remodelling after burns/trauma (prevents hypertrophi8c scarring)
- orthostatic hypertension
Contraindications for compression
- arterial insufficiency
- infections/active cancerous tissue
- thrombus present
- completely obstructed lymphatics
- systemic edema due to CHF or ESRD
Treatment time for compression
1-2 hours ideally, if only 20 min at facility, use ace wraps and compression socks to maintain any therapeutic effect
