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

2. 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

3. Physical Agents Heat Heat Cold Cold Water Water Pressure Pressure Sound Sound Electrical Current Electrical Current

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

5. 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 -Hot packs -Paraffin bath Superficial heat -Paraffin bath Superficial heat  Hydrotherapy -Whirlpool -Whirlpool -Hubbard tank -Hubbard tank  Shortwave diathermy Deep heat  Ultrasound -

6. 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

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

8. 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

9. 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

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

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

12. Superficial Heat  Infrared  Hot packs  Paraffin wax  Hydrotherapy

13. Red/Infra-Red Phototherapy

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

15. Paraffin Bath  Tank containing a mixture of paraffin and mineral oil  52-53 C  Areas that are diffucult to heat  Helps to soften the skin

16. Effects 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.

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

18. 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

19. Precautions  Already existing edeme  Patients with sensory loss  Patients who are confused

20. 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

21. 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.

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

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

24. Paraffin Bath Advantages Advantages  Useful for the distal extremities  Softens the skin Disadvantages 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

25. Hydrotherapy

26. 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

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

28. 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

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

30. 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

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

32. Hubbard Tank (Butterfly -shaped)

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

34. Low Level Laser Therapy Cold Laser Therapy 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

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

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

37. 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 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)

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

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

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

41. PAIN CONTROL AND SELECTIVE STIMULATION PAIN CONTROL AND SELECTIVE STIMULATION  Pain theories Gate control theory Gate control theory Endorphin release theory Endorphin release theory Postexcitation depression of the sympathetic nervous system Postexcitation depression of the sympathetic nervous system

42. Low-frequency currents Diadynamic current types Low-frequency currents Diadynamic current types  Diadynamic current is particularly suitable for treating pain in small joints (e.g. finger joints and wrist joint).  Segmental application of diadynamic current gives outstanding results in reflex dystrophy (Südeck’s disease) and in superficial hyperalgesia.  A familiar example of the latter is the effect of diadynamic current in the treatment of herpes zoster.  Although there is still little known about the underlying mechanism, the results are astonishing.

43. Medium-frequency currents  Although many different types of medium- frequency current may be used, the best known application is interferential therapy   The specific application form known as ‘Russian Stimulation  medium-frequency alternating current is suitable for treatment of deeper-lying tissues (muscles, tendons, b urs or periosteum

44. TENS (Transcutaneous Electrical Nerve Stimulation) 1-Conventional TENS: -high-frequency, low-intensity TENS -the most generally used of the TENS current types 2-Acupuncture-like TENS: -low-frequency, high-intensity TENS 3-Burst TENS: -modification of ‘acupuncture-like’ TENS -applied if Conventional TENS proves ineffective, and is particularly suitable for the treatment of deeper lying painful regions (myofascial pain) and cases of chronic pain.

45. 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

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

47. 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

48.  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.

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

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

51. Soft Cervical Collar

52. Three Points of Pressure

53. Three Point Pressure  Providence Nocturnal Scoliosis Orthosis  Coronal Control Transverse Transverse Sagittal Sagittal

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

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

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

57. Halo

58. 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

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

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

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

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

63. Simple becomes difficult

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

65. 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.

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