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Physiological Effects of General HeatIncreasedDecreased Cardiac OutputBPMetabolic RateMuscle activity (2*)Pulse Rate Blood to internal organsRespiratory RateBlood flow to resting muscles VasodilationStroke Volume Thermo Therapy Indications:Only use passive heat when necessary to facilitate participation in active treatment Joint stiffnessMusculoskeletal pain Muscle spasmPrep for e-stim, passive and active exerciseIncreased Physiological Response of Body Systems/Structures to HeatSystemMechanism Blood flowDilation of arteries and arteriolesCapillary permeability Increased capillary pressureElasticity of nonelastic tissuesIncreased extensibility of collagen tissueMetabolismFor every 10* C increase in tissue temp, rate of cellular oxidation increases by 2-3 x (van’t Hoff’s Law) Vasodilation Activation of axon reflex and spinal cord reflex, release of vasocactive agents (bradykinin, histamine, prostaglandin) EdemaIncreased capillary permeability Subacute/chronic traumatic and inflammatory conditions Contra-IndicationsAcute/subacute traumatic and inflammatory conditions Decreased circulation/sensation DVTImpaired cognitive function Malignant tumorsTendency toward hemorrhage or edemaVery young and very old patients Pre-Cautions Cardiac insufficiencyEdemaDecreased Physiological Responses of Body Systems and Structures to Local Heat ApplicationSystemMechanism Joint StiffnessIncreased extensibility of collagen tissue and decreased viscosity Muscle StrengthDecreased function of glycolytic processMuscle SpasmDecreased firing of II afferents of muscle spindle and increased firing of Ib GTO fibers reduces alpha motor neuron activity and decreases tonic extrafusal activity PainPresynaptic inhibition of A delta and C fibers via activation of A beta fibers (gate theory), disruption of pain-spasm cycleImpaired circulation Impaired thermal regulationMetal in treatment site PregnancyAreas where topical counterirritants have recently been appliedDemyelinated nervesOpened wounds Hot PacksCanvas pack filled with silica gen, heating by immersing in water between 165-170* FPacks between towels/covers to protect skin Treat time = 20-30 minutes, heat hits peak at 5 minutes If heat transfers too quickly, mottling (red/white areas) occurs and permanent burn damage may occurParaffin BathLiquid paraffin to body for production of heat Contains paraffin wax and mineral oil mixture in a 6:1 or 7:1 ratioMelts between 118-130* F, self-sterilizingTreatment temp: 125-127* FTreatment time: 15-20 minutesIndicationsPainful joints with arthritis/other inflammatory conditions in subacute or chronic phaseJoint stiffness of hands/wristsContraindicationsAllergic rashOpen wounds Recent scars/suturesSkin infection Contrast bathsAlternating hot/cold immersion to help decrease pain and swelling and increase circulation Water temps: Hot 104* F Cold 59*FIn subacute, hot: 3-4 minutes, cold: 1 minutesAlternate for 20-30 minutes, end in hot typically. End in cold if edema reduction is the goal Indications – any condition requiring stimulation of peripheral circulation in limbs, peripheral vascular disease, sprains, strains and traumas Contraindications – advanced arteriosclerosis, arterial insufficiency, loss of sensation to heat and cold Hydrotherapy (Whirlpool) Partial/total immersion baths with agitated water and mixed with air to be directed against or around affected part Can move extremities easily d/t buoyancy/therapeutic effects of water Chronic conditions: 99-104*FPeripheral vascular disease, cardiac problems, open wounds: at body temp or below (NOT exceeding 100*F)IndicationsSubacute/chronic musculoskeletal conditions (neck, back, shoulder) Contraindications Wound managementPre-Cautions Local immersion: decreased temp sensationImpaired cognitionRecent skin graftConfusion/disorientation Deconditioned state No Longer on NPTE: Fluidotherapy and Infrared Lamp Physiological Effects of General ColdIncreasedDecreased Blood flow to internal organsMetabolic RateCardiac outputPulse Rate Stroke volumeRespiratory rate Arterial BP, Shivering (when cold temp drops) Venous BP Cryotherapy Indications Acute/chronic traumatic and inflammatory condition sEdemaMuscle spasmMusculoskeletal pain Thermal burnsDECREASED Physiological Response of Body Systems/Structures to ColdSystemMechanism Blood flowSympathetic adrenergic activity VASOCONSTRICTION of arteries, arterioles and venules Capillary permeability Decreased fluids into interstitial fluid Elasticity of nonelastic tissuesDecreased extensibility of collagen tissue MetabolismDecreased rate of cellular oxidation Muscle strength Decreased blood flow, increased viscous properties of muscle (long duration >5-10 minutes) Muscle spasm Decreased firing of II afferents of muscle spindle, increased firing of Ib GTO fibers decreased alpha motor neuron activity and thus decreases tonic extrafusal activity Vasoactive agentsDecreased blood flowContraindicationsImpaired circulation Impaired sensation Peripheral vascular diseaseProlonged application over superficial nerves could neuropraxia, Raynaud’s, sensitivity or allergic reaction to cold Pre-Cautions Hypertension Impaired temperature sensationOpen woundOver superficial nerveVery old, very young Cognitive changes Cold PacksINCREASED Physiological Responses of Body Systems and Structures to Local Cold ApplicationSystemMechanism Joint StiffnessDecreased extensibility of collagen tissue and increased tissue viscosity Pain thresholdInhibition of A delta and C fibers via activation of A beta fibers, interruption of pain-spasm cycle, decreased sensory and motor conduction, synaptic transmission slowed or blocked Increased blood viscosityDecreased blood flow in small vessels facilitates RBC adhering to one another and vessel wall, impeding blood flowMuscle strengthFacilitation of alpha motor neuron (short duration 1-5 min)Vinyl casing filled with silica gel/sand-slurry mixTreatment temp: 0-10*FTreatment time: 10-20 minIce PacksCrushed ice folded in moist towel/placed in plastic bag, covered by moist towel applied to body partTreatment time: 10-20 minutes Ice MassageFormed by freezing water in paper cup Adding salt makes ice colder Patient experience: cold, burning, aching, numbnessTreatment time: 5-10 minutesMove in small area in slow (2 in/sec) overlapping circles, with each circle covering ? of previous stroke Vapocoolant Spray Liquid that produces rapid cooling when applied to skin Used to reduce spasms by desensitizing trigger points Spray 18-24 inches from area at 30* angle Passively stretch before and during application Treatment time: 10-15 minutesIndicationsMyofascial referred pain, trigger points Deep Thermo Therapy Indications Joint contracturesMusculoskeletal painMuscle spasmSubacute and chronic traumatic and inflammatory conditions ContraindicationsAcute infectionsImpaired circulation, cognitive function or sensation Malignancy Pacemaker Very young, very old UltrasoundIndicationsOpen woundsNeuromasPeriarticular conditionsContraindicationsDo not use to reduce swelling, promote joint healing or for long term pain relief for musculoskeletal conditions Acute inflammatory joint pathologiesHealing fx Thrombophlebitis Use of radium/radioactive isotopesTx over brain, ear, eye, heart, cervical ganglia, carotid sinuses, reproductive organs, spinal cord, directly over pacemakers/pregnant uterusPre-Cautions Metal implantsOsteoporosisPlastic implantsPrimary repair of tendons/ligaments or scar tissuesEpiphysis of growing bone US ParametersFrequency:3 MHz – superficial 1 MHz – deepIntensity 0.3-1.5 w/cm2 depending on treatment goals Lower intensities/pulsed US – acute conditions or thin tissuesHigher intensities/continuous US – chronic conditions or thick tissues Tissues fat/high in water content – US penetrates more deeply with less attenuation More protein (muscle/connective tissues) – US is absorbed more but penetrates lessDuty CycleFration of time US energy is on over one pulse period (20% duty cycle could be on 2 msec and off 8 msec)Thermal Effects (continuous US, duty cycle is 100% - no on/off time)Increased tissue temperatureIncreased pain thresholdIncreased collagen tissue extensibility Alteration of nerve conduction velocity Increased enzymatic activity Increased tissue perfusion**Excessively high temps may produce sudden, strong ache caused by overheating – REDUCE INTENSITY IMMEDIATELY Non-Thermal (pulsed US, has a duty cycle) Cavitation – alternating compression and expansion of small gas bubbles in tissue fluids caused by mechanical pressure waves Indirect contact (water immersion) – for irregular body parts Keep sound head in water 1 cm from skin surface at right angle to body part PhonophoresisUse of US to drive medications through skin into deeper tissues, substances absorbed more readily because membranes may be more permeable (local analgesics – lidocaine, anti-inflammatory drugs – dexamethacain, salicylates, hydrocortisone cream)Indications Subacute/chronic musculoskeletal conditions GoalsPain modulation, decrease inflammation ParametersDuty cycle: Pulsed 20%Time: 5-10 minutesIntensity: 0.5-0.75 w/cm2 Mechanical Spinal Traction Distraction applied to separate vertebral bodies/elongate spinal structuresCan be sustained, intermittent, positional, gravity assisted, inversion, continuous or staticCervical Traction: 20-30 POUNDS to cause distraction Neck position: 0-5* Flexion for C1-C420-30* Flexion for C5-C70* for disc dysfunction Lumbar Traction: 25-65 POUNDSLumbar position:90* hip/knee flexion (90/90 position) for spinal stenosis Prone with no pillow – posterior herniated disc IndicationsDegenerative discDiscogenic painHerniated nucleus pulposus (disc protrusion) Joint disease or stiffnessMeniscoid blocking muscle spasmNerve root impingementSubacute/chronic joint pain ContraindicationsImpaired cognitive function Spinal tumors/infectionsSpondylolisthesisRheumatoid arthritisOsteoporosis Very young and very old patients Vascular compromise (vertebral artery syndrome) Pre-CautionsAcute inflammation aggravated by traction Acute strains and sprainsClaustrophobia Hiatus herniaJoint stability Pregnancy TMJ problems with use of halter. Remove dentures. Consider using mouth pieceIntermittent Compression Used to decrease/prevent formation of edemaSerially compresses a sleeve placed over part to be treatedPart is elevated and patients BP determines setting of the deviceSetting should not exceed the patients DIASTOLIC BPUse 2/24 hours a day IndicationsChronic edemaLymphedema (post-mastectomy) Stasis ulcerTraumatic edemaVenous insufficiencyAmputation ContraindicationsAcute inflammation or infection in treatment areaAcute DVT or pulmonary edemaArterial insufficiencyCancerDiminished skin sensation HTN Kidney or cardiac insufficiencyCognitive dysfunction Very young and frail elderly Continuous Passive Motion (CPM) Provides mechanical PROM to jointSize of motion arc, position of arc, rate of motion can be controlledCPM inhibits adhesion formation, improves cartilage nutrition via better fluid mechanics and may stimulate the production of chondrocytes. Can minimize contractures, decrease post-op pain, improve circulation IndicationsPost-immobilization fractureTendon/ligament repairTKR – Should NOT be used following uncomplicated TKR THR ContraindicationsThrombophlebitis or DVT, Discontinue if increases pain, edema, inflammation Tilt Table Used to elevate patient from horizontal to vertical position in controlled and incremental mannerCan be used to deal with orthostatic hypotension and as a preventive measure for osteoporosis development by providing WB for bedridden patients Provides positioning for stretch of hip flexors, knee flexors, ankle PFA drop in BP, diaphoresis (excessive sweating) agitation are indications to return patient to more horizontal position Elastic wrap/abdominal binder may be applied to prevent venous pooling Lip/nail bed color are good qualitative signs to indicate the status of peripheral oxygenation Time should not exceed 45 minutes 1 – 2 x / day IndicationsProlonged bed restImmobilization Spinal cord injury Head injury ContraindicationsUnstable fracturesConfused or anxious patient Massage Used to increased BP, stretch/loosen scar tissue, reduce edema and pain, relax muscles Indications Subacute/chronic musculoskeletal condition Muscle spasm Superficial scar formation EdemaPostural drainageContraindicationsAcute inflammation/febrile condition Severe atherosclerosis or varicose veins Phlebitis and thrombophlebitisAreas of recent surgery Cardiac arrhythmia or heart failure Malignancy Hypersensitivity Severe rheumatoid arthritisHemorrhage in areaEdema secondary to kidney dysfunction Venous insufficiency Stroking (effleurage) – gliding of hands over surface of skin. Superficial stroking – light contact. Deep stroking – heavy pressureKneading (petrissage) – grasping and lifting tissuesLoosening adhesions and increasing venous return Friction – compression of tissue using small circular or long stroking movements, usually with the palmar surface of hand/fingers Stretch scars and loosen adhesionsTapping (tapotement) – rapid striking with palmar surface of hand and/or fingers, cupped hand (clapping/percussion) or ulnar edge of hand and fingers (hacking) Cupping – applied to chest to mobilize bronchial secretions Vibration – shaking of tissue using short, rapid quivering motion with hands in contact with body part With cupping for postural drainage to loosen adherent secretions Electrotherapy IndicationsPain modulation Muscle spasmImpaired ROM Muscle re-education Disuse atrophy (weakness) Soft tissue repair (wound healing) Edema reduction Spasticity (reduce hypertonicity) Denervated muscle ContraindicationsHealing fracturesAreas of active bleedingMalignancies or phlebitis in treatment area Superficial metal implantsPharyngeal or laryngeal musclesDemand-type pacemakerMyocardial diseasePre-Cautions Areas of impaired sensation and severe edema Parameters Based on GoalMuscle strengthening, edema (muscle pump), ROM Slowly increase intensity until muscular response is observed10-25 muscle contractions sufficient to obtain tx goal Interrupted/ramped modulation of current allows muscle to recover between stimulation periodsStimulation on/off of > 1:3 minimizes fatigue effects Muscle spasm (fatigue) Continuous 1:1 on/off Muscle Re-Education Stimulation for multiple sets of singular or multiple muscle repititionsSessions: 10-30 minutes Iontophoresis Chemical ions driven through skin by continuous direct current for therapeutic resultTherapeutic ion must be placed under an electrode of similar charge to “push” chemical past skin (transdermal) into deeper soft tissue Cathode (NEGATIVE) used for:Salicylate (pain relief) Acetate (calcium deposits)Dexamethasone (anti-inflammation) Iodine (soften scars) Anode (POSITIVE) used for: Hydrocortisone (anti-inflammation) Lidocaine (pain relief) Magnesium or calcium (muscle spasm) Lithium (gout) Zinc (dermal ulcers) Copper (fungal infections) Contraindications Impaired skin sensation Allergy/sensitivity to therapeutic agent/direct currentRecent scars, cuts, bruises or broken skin Metal in/near treatment area TENS Provides AFFERENT stimulation for pain management by affecting peripheral and central nervous system Impulses stimulating Large A fiber afferents, can act to block the pain impulses (Gate Control Theory) Stimulation can cause release of body’s own endorphins/enkephalins which inhibit pain/pain transmission Current may be symmetrical or asymmetrical biphasic (AC) or monophasic (DC) Electrodes may be at point of pain, at dermatomes of nerve roots, over trigger/acupuncture points, proximal/distal to pain site, segmental related myotomesContrainications Demand-type pacemakers (anywhere on body) Over chest area of patients with cardiac dysfunction Over eyes, laryngeal or pharyngeal muscles, head and neck of patient after CVA/epilepsyApplication to mucosal membranes Conventional High Rate TENSUses HIGH frequency (75-120 pps) SHORT pulse width (50-100 microseconds) and LOW intensity Temporary relief of acute/chronic pain Onset of pain relief is relatively fast Treatment Duration: 20-60 minutes Acupuncture-Like (Strong, Low Rate) TENSUses LOW frequency (1-4 pps) WIDE pulse width (150-300 microseconds) and HIGHER intensity than conventional TENS Used more with chronic conditions with longer last pain relief Treatment Duration: 30-40 minutesBrief Intense TENSHIGH pulse rate (150 pps) LONG pulse width (300 microseconds) for rapid-onset, short term pain reliefPain relief for painful procedures (wound debridement, deep friction massage, passive stretching) Treatment Duration: 15 minutes Burst Mode TENSCombines characteristics of both high and low rate TENSStimulation of endogenous opiates but current is more tolerable to patient than low rate TENS Onset of analgesia similar to low rate TENS Treatment Duration: 20-30 minutesModulation Mode TENS Method of modulating parameters of TENS for purpose of preventing neural/perceptual adaptation due to constant E-StimFrequencies, intensities, pulse widths can be alerted by >10%, 1 – 2 x / second High Volt Pulsed Monophasic Stimulation Form of pulsed direct current (DC) stimulation using high-volt twin spikes with pulse widths in microsecondsChemical, polar and thermal effects of DC are minimized because of SHORT DURATION (pulse width) of stimulus Useful with denervated musclesNot tolerated well by patients IndicationsMuscle stimulation/reeducation Reduction of pain from TENS like propertiesReduction of edema (increased turgot) Facilitation of wound healing RussianUses HIGH frequency (2500 Hz), modulated to 70 pps for comfortIndicationsUsed for strengthening of normal muscle by assisting with muscle contraction during volitional activities such as isometric exercises and short arc joint movements Interferential Current (IFC) Crossing of 2 sinusoidal waves having similar amplitudes, but different carrier frequencies. Waves interfere with one another to generate amplitude modulated beat frequency IndicationsPain reliefMuscle strengtheningFunctional Electrical Stimulation (FES) AKA NMES Can use alternating current (Ac at 80-100 Hz) to stimulate an innervated muscle for general stimulation or direct current (DC) interrupted with long pulse width for denervated muscleEncompasses wide range of stimulator units and techniques Indications Disuse atrophyImpaired ROM Muscle spasm Muscle reeducation Spasticity management Useful as alternative or supplement to use of orthotic deviceIf skin is sensitive or patient senses burning, larger electrodes, reduced intensity or increased pulse width may be indicatedAC better tolerated than DC DC is preferred in research over AC Duty Cycle: should increase as muscle atrophy or weakness increases to prevent over fatigue during treatmentMinimal/no atrophy/weakness – 1:1 or 1:2 ratioModerate atrophy – 1:3 or 1:4 ratioSevere atrophy – 1:5 to 1:10 ratio Biofeedback (EMG) Electronic instrument that monitors muscle activity of selected muscles/provides physiological information (feedback) to the patient Patient tries to manipulate/change the feedback, to voluntarily controls muscle activity Goals are either enhancement (quad iso contraction) or reduction (upper trap muscle spasm) of the EMG activity Relaxation training is combined with EMG biofeedback when trying to achieve progressive muscle relaxation NOT a form of E-Stim Chronaximetry – test of electrical excitability of peripheral nerves, RARELY PERFORMED Electromyography (EMG) – clinical EMG consists of recording of electrical potentials of muscles Nerve Conduction Velocity – test that determines time it takes for a muscle to respond after peripheral nerve has been stimulated UE avg conduction – 45-70 m/secLE avg conduction 50 m/sec Strength Duration Curve – test of excitability in which the intensity of current required to produce a minimal muscle contraction is plotted against a set of measured durations. RARELY performed ................
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