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
Cold
Water
Pressure
Sound
Electrical Current

4. General Indications Purported Uses Modulate pain
Reduce or eliminate inflammation
Increase rate of healing
Modify muscle tone
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
-Paraffin bath Superficial heat
Hydrotherapy
-Whirlpool
-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
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.

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 Precautions Cold hypersensitivity
Raynaud’s disease
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
Areas that are diffucult to heat
Helps to soften the skin

16. 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 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

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 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

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

34. 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
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

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
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)
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)

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)
Iontophoresis (Direct Current)
Muscle stimulation (NMES)
Tissue healing (wound care)

41. 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)

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

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

44. 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

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

46. 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

47. 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.

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

49. 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)

50. Soft Cervical Collar

51. Three Points of Pressure

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

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

54. 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

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

56. Halo

57. 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

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

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

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

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

62. Simple becomes difficult

63. 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

64. Orthotic Management and Prosthetic Management
While assessment and management of the patient were always inherent in orthotic services, code 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.

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