Physical Agents, Orthotic and Prosthetic Use in Rehabilitation Prof. Dr. Ece Aydoğ PMR

Learning objectives: 1. be able to enumerate physical therapy agents 2. be able to describe action mechanisms of hot and cold treatments 3. be able to enumerate indications and contraindications of hot and cold treatments 4. be able to enumerate electrotheraphy agents and describe the general use policies of electrotheraphy. 5. be able to describe orthoses and prostheses and count the types and overall usage policies

Physical Agents Heat Cold Water Pressure Sound Electrical Current

General Indications Purported Uses Modulate pain Reduce or eliminate inflammation Increase rate of healing Modify muscle tone Increase connective tissue extensibility

Physical Modalities Cryotherapy: Ice packs, commercial cold packs, iced towels, ice massage, cold baths (immersion), vapocoalant spray, contrast baths. Radiant heat: Infrared Conductive heat -Hot packs -Paraffin bath Superficial heat Hydrotherapy -Whirlpool -Hubbard tank Shortwave diathermy Deep heat Ultrasound -

Physical Modalities Ultraviolet radiation İntermittent compression pump Mechanical spinal traction Electrical stimulation Transcutaneous electrical nerve stimulation (TENS) Interferential stimulation Direct current High voltage pulsed galvanic stimulation Electromyographic biofeedbak

Cryotherapy Historical perspective Ancient Greeks and Romans Late 1880’s, cold compresses after surgery Early 1960’s, cold therapy widely recognized by healthcare as a result of studies by Grant (1964) and Hayden (1964). Military studies.

Effects of cold therapy Pain relief A decreased nerve transmission in pain fibres Cold reduces the activity of free nerve endings Cold raises the pain threshold Cold causes a release of endorphins Cold sensations over-ride the pain sensation - known as the pain gate theory

Effects of cold therapy Reduces Bleeding and Swelling Vasoconstriction followed by dilation is known as the Hunting Response. Reduces Muscle Spasm This is not fully understood but is thought to be due to ice slowing the conduction velocity of sensory and motor nerves, as well as the activity of muscle spindle cells (responsible for muscle tone), resulting in a decrease in motor activity. Decreases Metabolic Rate

Ice Contraindications Precautions Cold hypersensitivity Raynaud’s disease Regenerating peripheral nerves Precautions Over superficial main branches of nerve Peroneal nerve Open wounds Poor sensation

Application 10 minutes is sufficient. Re-applied regularly, every 2-3 hours. Following approximately the first 3-5 days of an acute injury

Superficial Heat Infrared Hot packs Paraffin wax Hydrotherapy

Red/Infra-Red Phototherapy

Conductive Heat Hot Packs Moist heat Canvas filled wityh silica gel Immersed in water of about 77 C

Paraffin Bath Tank containing a mixture of paraffin and mineral oil Areas that are diffucult to heat Helps to soften the skin

Effects Local metabolism is increased. Local persipiration is increased. Local vasodilation with hyperemia occurs. Muscle relaxation is promoted. Sensory nerve endings are sedated. Capillary pressure and cell permiablity are increased and can promote edema.

Indications Subacute and chronic traumatic and inflammotory conditions Infrared Subacute and chronic traumatic and inflammotory conditions Seeping wounds that should be dried Preheating prior to electrical stimulation Hotpack Paraffin baths

Contraindications Pregnancy Acute inflammotory conditions Active Cancer Active bleeding Patients with cardiac insufficiency Extremly old adults and children less than 4 years old Patients with peripheral vascular disease Tissues that are devitalized by x-ray theraphy Already existing fever

Precautions Already existing edeme Patients with sensory loss Patients who are confused

Advantages İnfrared The practioner may visually monitor the part being treated with infrared radiation The infrared lamp does not contact the patient, so tenderness is not aggravatedd. Clean wounds are safer from the risk of infection

Disadvantages İnfrared Small, local area with an infrared lamp is diffucult Positioning diffuculties Glare from a luminous lamp can be irritating to the patient’s eyes.

Advantages HP Risk of burning is minimized Local areas can be treated effectively

Disadvantages HP The larger packs can be heavy Potential enfection if an open wound is present Skin response diffucult to monitor

Paraffin Bath Advantages Useful for the distal extremities Softens the skin Disadvantages Liquid paraffin can be messy Heat level of paraffin bath to be excessive Movement must be minimized in a paraffin bath The tank and paraffin are cumbersome to clean

Hydrotherapy

Hydrotherapy Water can be advatageously as a medium for exercise (gravity eliminated environment) Upward movement is assisted, and downward movement is resisted. Water will affect movement through it is viscosity. Viscosity serves to resist movement through the water in all directions The buoyancy supports the weight of the part, while the viscosity resist the movement

Hydrotherapy Whirlpool Water is agitated by an electric turbine Used for both heating and cooling

Whirlpool Purpose and Effects The agitation in a whirlpool can serve several purposes: Phasic stimuli to the skin afferents The warm water continues to feel warm through-out the treatment

Whirlpool Purpose and Effects Increase hydrostatic pressure Increase lymphatic circulation Provides a means of grading exercise Decreases the thermal gradients within the water

Whirlpool Indications Open wounds and burns Subacute and chronic traumatic and inflammotory conditions Peripheral vascular disease Peripheral nerve injures and other conditions that produce muscle weakness

Fluidotherapy Dry whirlpool containing crushed corn husks. İncreases the circulation by increasing heat in the tissues. It also increases range of motion.

Hubbard Tank (Butterfly -shaped)

Hubbard Tank Indications; Generalized wounds, such as burns Generalized painful conditions General sedation or relaxation

Low Level Laser Therapy Cold Laser Therapy Primary Effects – Similar to effects of Infrared therapy Secondary Effects – Cell proliferation, protein synthesis, growth factor secretion, neurotransmitter modification Tertiary Effects – System effects; Increase immune response, stimulate bone healing

Conditions Commonly Treated with Low Level Laser Carpal Tunnel Syndrome Soft Tissue Injuries Arthritis Tendonitis Edema Nerve Injury Sprains/Strains Wounds Burns

Low Level Laser Therapy Contraindications Absolute Pregnancy Malignancy Avoid the Thyroid Gland Avoid the Epiphysis Photosensitive patients Immune-suppressed patients Relative Botox Injections Anti-Inflammatory meds Steroid Injection Some machines use magnetic energy as well no pacemakers

Ultrasound Therapeutic Ultrasound sends high frequency sound waves through tissue and has a thermal effect. Therapeutic ultrasound frequency used is 0.7 to 3.3.MHz Maximum energy absorption in soft tissue is 2 to 5 cm. Intensity decreases as the waves penetrate deeper. They are absorbed primarily by connective tissue: ligaments, tendons, and fascia (and also by scar tissue)

Ultrasound Typical applications of Ultrasound Pain control (Munting 1978) Increase tissue extensibility (Knight 2001) Accelerate healing wounds (Dyson 1978), bone fractures (Duarte 1983) Phonophoresis Application of ultrasound in conjunction with a topical drug preparation for enhanced delivery (ex. hydrocortisone). Enhanced delivery (McNeill et al Pharm Res 1992)

Ultrasound Two types of benefit: Thermal effects Non thermal effects Indications: Soft tissue shortening (Joint contractures, scarring) Subacute and chronic inflammation

Electrical Stimulation Common uses: Pain control (TENS, interferential) Iontophoresis (Direct Current) Muscle stimulation (NMES) Tissue healing (wound care)

TENS (Transcutaneous Electrical Nerve Stimulation) Pain control 2 theories of how TENS may control pain Gate control theory – high frequency TENS Opiate-mediated control – low frequency TENS (Acupuncture- like TENS)

TENS Gate-control theory of pain modulation Ex. Bump your head, you rub it. From Kandel, Schwartz, and Jessell Principles of Neural Science

TENS Opiate-mediated control E-stim may promote endorphin release Endorphins E-stim may promote endorphin release Cats Non-human primates

TENS Contraindications Patients with cardiac pacemakers Pregnancy Sites over the carotid sinus, laryngeal or pharyngeal muscles, sensitive eye areas, or mucosal membranes Do not use while operating hazardous machinery

Iontophoresis Iontophoresis – use of direct current to enhance transcutaneous administration of ionizable substances. Most commonly used: Dexamethasone – anti-inflammatory agent Conditions: Epicondylitis, tendonitis, etc…

Iontophoresis Iontophoresis may use tap water or anticholinergic drugs to control hyperhidrosis of hands or feet. Direct current is used, initially 3 times per week, but reducing in frequency until maintenance treatment may only be required every 6 weeks or longer

The rehabilitation of those individuals with neurological impairments will require the use of therapeutic procedures and activities to regain their previous level of functional ability.

Spinal Orthosis An external device applied on the body to: Limit motion Correct a deformity Reduce axial loading Improve function of a particular segment

Orthotic Goals Pain relief Mechanical unloading Scoliosis correction Intra-cavity pressure Three point pressure system Scoliosis correction Immobilization Post surgical Post traumatic Kinesthetic reminder (soft collar)

Soft Cervical Collar

Three Points of Pressure

Three Point Pressure Providence Nocturnal Scoliosis Orthosis Coronal Control Transverse Sagittal

Jewett Anterior compression fractures (T6-L2) Three point pressure system - Sagittal Encourages Hyperextension Discourages Flexion Three point Hyperextension Orthosis

Rigid Cervical Collar Tri-planar cervical immobilization Common names Aspen Miami J Philadelphia Queen Anne Thomas Collar Malibu Many, many more Don’t memorize --- A. Einstein

Cervical Thoracic Orthosis Lower Cervical Upper Thoracic Post surgical Post trauma Easy to don/doff Discourages motion in three planes CTO

Halo

TLSO Thoracic and Lumbar spine insults and injuries Intra-cavity pressure Multiple 3 pt. pressure systems Difficult to don Various materials Discourages motion in all 3 planes

Lumbosacral Orthosis Fractures LBP / Soft tissue Spondylosis Spondylolisthesis Spondylolysis Stenosis Discourages motion in 3 planes Multiple 3 pt. Pressure systems Intra-cavity pressure

Chairback Post surgical immobilization Low Thoracic and Lumbar issues Encourages posture Discourages Hyperextension Discourages Flexion

Hybrid TLSO Compression Fracture LSO bi-valved w/Thoracic extension Discourages motion in 3 planes in Lumbar Encourages Extension in Thoracic

Orthotic Challenges Skin breakdown Unsightly appearance Compliance Kinship strain Sedentary lifestyle Two handed and four handed donning Osteopenia / Osteoporosis Warmth Environment Anatomy Restrictive

Simple becomes difficult

When to Consider P&O Services Simple Immobilization Pre- and Post-surgical Immobilization Simple tissue injuries and Non-operative Arthritis Inflammation Kinesthetic / Postural reminders Chronic pain management Consultations are FREE

Orthotic Management and Prosthetic Management While assessment and management of the patient were always inherent in orthotic services, code 97760 now specifically includes the words assessment and management. For example, this code includes the provider's time associated with determining the proper orthotic design in relation to the patient's skin integrity, sensibility and healing of tissues with or without surgical repair (eg, static vs dynamic, prefabricated vs custom designed, choice of materials such as thermoplastic, pulleys, and elastic tension). The code also includes the fitting of the orthotic, training in use, care and wearing time of the orthotic, and brief instructions in exercises that are to be performed while the orthotic is in place.

An amputee, learns to walk down stairs with a microprocessor controlled Ossur POWER KNEE, while Undergoing prosthetic training.