Hand Therapy Review CourseUC Irvine Medical Center

Orange, CAFebruary 24-26, 2017

Physical Agent Modalities for the Hand TherapistAlessia DiGennaro Kerner, OTR/L, CHT

Hand Therapy Review CourseUC Irvine Medical Center

Orange, CAFebruary 24‐26, 2017

Physical Agent Modalities for the Hand Therapist

Alessia DiGennaro Kerner, OTR/L, CHT

Objectives

1. Understand physiologic changes with modalities.

2. Review procedures, contraindications and precautions of each modality.

3. Objectively assess the efficacy of PAMs.

What is a Physical Agent Modality?

Procedures and interventions that are systematically applied

to modify specific client factors when neurological, musculoskeletal,

or skin conditions are present that may be limiting

occupational performance. (Bracciano, 2008)

What Can Modalities Affect?Pain

Blood & Lymphatic Flow

Tissue Healing

Nerve Function

Tissue Extensibility

Edema & Inflammation

Muscle Excitability

Metabolic Changes

Modality TypesThermotherapy &

Application of electrical current

Methods of Energy Transfer

Conduction Thermal transfer between two surfaces by direct contact

Hot/Cold PacksParaffin

Convection Transfer of heat by movement of a medium

FludiotherapyWhirlpool

Conversion Energy converted to heat in the tissues by friction

UltrasoundDiathermy

Radiation Direct transfer of energy without a medium

LaserUV

Evaporation Absorption of energy by conversion from liquid to vapor

Spray & StretchSweating

Superficial Thermal Modalities

Hot packs

Paraffin

Fluidotherapy

Hydrotherapy

Cryotherapy

Physiological Effects of Heat

Reduces pain

Decreases muscle guarding, spasms and protective posturing

Improves connective tissue extensibility

Improves tissue healing

Ranges of Superficial Heat

• 98.6F (37.5C)Normal temperature of tissue

• 98–101F (37 – 38.5 C)

Mild heat

• 101–103F (38.5 – 40 C)

Moderate

• 104-113F (40 – 45C) (Feels very hot)

Vigorous: Therapeutic range

• +113°

Potential Tissue Damage

Effectiveness of Heat

Benefits of heat depend upon

Type

Duration

Depth

Temperature

Stretch

Contraindications for Heat

Impaired sensation

Vascular compromise or disease

Diabetes with impaired circulation

Acute injury or inflammation

Vascular instability

Skin graft, Replant

Malignancy/Cancer

Recent or potential hemorrhage

Precautions for Heat

Poor thermoregulation

Poor sensation

Edema

Impaired cognition

Impaired speech/language

Cardiac conditions

Rheumatoid Arthritis

Hot Packs

Conduction

H2O in tank: 165°- 170°F

Penetrates 1-2 cm.

6-8 towel layers

Commercial terry cloth equals 4 layers

Temperature remains elevated 45-60 min.

Treatment time 10-20 min.

Hot PacksAdvantages

InexpensiveEasy set upPassive stretchLarge tx areaHome program

DisadvantagesStatic positionObserve skinBurnsHeavyPoorly conform

Electric heating pads

ThermaCare heat wraps

Rice or flax packs

Portable Heating Options

Paraffin

Conduction

Low specific heat

Circumferential heating

113º-129º F

Treatment 10-20 min

Dip or immersion

ParaffinAdvantages

Soothing/lubricatingHighly conformingElevateCost effectiveHome program

DisadvantagesMessyCross contaminationRestock materialsOpen wound

Precautions with Paraffin

Do not apply to: Open wounds

Burned tissue

Insensate areas

Otherwise same as with other heat

modalities

Fluidotherapy

Convection

Warm-up prior to use

112-118 F

Corn cob particles

Treatment 10-20 min

Fluidotherapy

Advantages

AROM or PROM

Adjustable temperature

Adjustable agitation

Desensitization

Disadvantages

Semi-dependent position

Expensive

One patient treated/time

Respiratory irritation

HydrotherapyConvection

Temp 91 degrees

Treatment 10-20 min

AdvantagesLubricates dry skinCleansing effectDressing removalAROM

DisadvantagesDependent positionTank sterilizationAdditives cytotoxic

Due to disadvantages of whirlpool, pulsed lavage with suction is often preferred for wound care

Cryotherapy Physiological Effects of Cryotherapy

Decrease inflammation &/or edema

Pain modulation

Decrease guarding &muscle spasms

Cameron 2009

Cryotherapy

Ice packs

Cold packs

Vapocoolant sprays

Ice probes

Cold compression units

Contraindications for Cold

Diminished sensation

Compromised vascular system Replants

New graft/flap

Diabetics with compromised sensation

Peripheral Vascular Disease

Very young/elderly

Open wounds

Cold UrticariaA histamine response that causes

raised red areas (hives) as a localized response

Systemic Urticaria: facial flushing, ↑ blood pressure, ↑ heart rate, light headed

Contraindications for Cold

Raynaud’s PhenomenonCyanosis, pallor, redness following exposure to cold

Associated with autoimmune conditions such as RA and Lupus.

Contraindications for Cold

CryoglobulinemiaTissue ischemia occurs with Application of cold secondary to an abnormal blood protein turning into a gel.

Associated with:Autoimmune conditions Chronic liver disease Multiple melanomaInfection

Paroxysmal Cold Hemoglobinuria(PCH)

Hemoglobin released from damaged RBC and lysed RBC can be seen in urine, leading

to subsequent anemia.

Therapeutic Application of Cryotherapy

Most Treatments range: 23°– 32 F

Responses to coldStage I Cold 1 - 3 minutesStage II Burning 3 - 5 minutesStage III Aching 5 - 7 minutesStage IV Numbness 7+ minutes

**General timeline, varies with tissue/patient

Cold Packs Conduction

Silica gel stored at 23 F

Moist towel enhances effectiveness

Penetrates 1-2 cm

AdvantagesEasy to useLarge tx areaHome program

DisadvantagesConform poorlyObserve skin changes

Ice Massage

Vigorous cooling

Effective for small areas

Small paper cup or popsicle stick

Cryocup

Treatment 3-5 min

Burning aching numbness

Ice Massage

AdvantagesCools quicklyEasy to applyMonitor skin changesHome ProgramInexpensive

DisadvantagesPatient toleranceMessyCovers small area

Cold Compression Units

Circulated cold water

Pneumatic pressure

Acute injuries

Conformity issues

Temperature adjustable

Cold Vapocoolant Spray “Spray and stretch”

Evaporation

Trigger point, referred pain & acupressure

Method:Place muscle on stretchSpray at 30°angle2 feet from skin6 sweeps parallel to mm. fiber10 cm. per second

Ultrasound

Ultrasound

Sound wave that produces changes in tissues

Electrical energy converts to mechanical (sound) energy

Mechanical pressure waves cause vibrating molecules to bump into adjacent molecules, transferring energy from one to another

A chain reaction continues though a material until the energy is dissipated

Ultrasound TransducerTransducer = “Sound head”

Contains a crystal that converts electrical energy into high frequency sound waves by expanding and contracting, called Piezoelectric effect

The machine often has interchangeable sound headsDifferent sizes

Different frequencies1 MHz or 3 MHz

Google, 4/1/13

Relates to:Area of the transducer from which the US energy radiates

Vibration is not uniform so the ERA is typically smaller than the total area of the sound head

Treatment area should not exceed 2x the ERA

ERA can be found on stickeron ultrasound cord

Effective Radiating Area Beam Non-uniformity Ratio

Relates to:Ratio of peak power and average power output

Lower BNR = More comfortable

Regulations 6:1 or less

Hot spots

Ultrasound Parameters

Frequency

Spatial Average Intensity

Duty Cycle

Duration ofTreatment

Relates to: Depth of penetration

Expressed in MHz

1 MHz heats 2-5 cm.“Deep, slower to get warm”

3 MHz heats 1-2 cm.“Hot, fast and shallow”

Frequency

Spatial Average IntensityRelates to:Magnitude of the force in a sound wave

Expressed as W/cm²

Greater intensity = greater temperature increase with continuous ultrasound setting

No specific guidelines on selecting intensity

Devices allow for up to 3.0 W/cm2, usually .25-2.0 W/cm2

Turning up the power (intensity) simply sends more energy to the same depth.” (Knight, 2007)

Duty CycleRelates to: Proportion of total treatment time US is on

Expressed as a percentage or ratio

Continuous100% Thermal Modality

Pulsed10%, 20% or 50%Non-thermal Modality

Application of UltrasoundFull contact with skin

Sound head parallel with skin

Constant movement of sound head(2-5 cm/sec)

Overlap strokes (1/2 of ERA)

Absorption of UltrasoundEnergy penetrates tissue that is high in water content.

US passes through to deeper tissues

Fat, blood

Energy is absorbed well, into dense tissue that are high in protein.

Tissues heat up

Ligament, Tendon, Fascia, Joint capsule, scar tissue

Absorption dependent on coupling medium. Ultrasound gel: 96%Ultrasound lotion: 90%Betamethasone (.05%) in ultrasound gel: 88%

Physiological Effects of Thermal Ultrasound

Increase extensibility in collagen-rich tissues

Decrease joint stiffness

Decrease spasm

Decrease pain

Promote tissue healing

Temperature Increases with Thermal Ultrasound

Continuous treatment at1W/cm² & 1MHz = ↑ by 0.36°F (0.2°C) per minute1W/cm² & 3MHz = ↑ 1.6°F (0.9°C) per minute

So… to get a tissue temp increase of 5°F (3°C) it would take

5 minutes at 3MHz10-15 minutes at 1MHz

Knight, 2007

Tissue temperature changes and benefits last for approximately 4 minutes after treatment ends.

Stretch during or immediately afterward for best benefits.

Physiological Effects of Non-thermal Ultrasound

Decrease inflammation

Increase cell membrane permeability

Stimulate tissue regeneration (soft tissue & bone)

Increase fibroblastic activity

Synthesize collagen– increases tensile strength

Generally associated with pulsed US

20% for most research

Contraindications for Ultrasound

Insufficient circulation, thrombophlebitis or DVT

Malignant tumors & cancer

Pregnancy

Acute infection May use 24 hours after antibiotics are started

Joint cement or plastic components

Psoriasis

Children (over growth plates)

Over CNS tissue, eyes, reproductive organs, electronic implants

Precautions for UltrasoundAcute inflammation

Impaired cognition

Decreased/lack of sensation

Fractures Specific devices deliver very low dose US: 0.15 W/cm2; at 20%, 15-20 minutes

PVD: Be careful with thermal US

Can go over metal implants if sound head is kept moving and patient has normal sensation

Phonophoresis

Related to:The application of therapeutic US toassist in the diffusion of medication throughthe skin

Increase permeability of stratum corneum.

Ultrasound absorption lessened with medication in coupling medium. May decrease benefits of ultrasound.

Drug is more concentrated in treatment area but does become systemic.

Medications Used in Phonophoresis

Local Analgesics: Lidocaine, Lidex, Theragesic cream

Local Anti-inflammatory medications: Hydrocortisone or Dexamethasone

Non-steroidal medications: Salicylates

1.Need prescription for medication used with phono2.Need to use a coupling medium with phono3.Pre-heating area with a hot-pack or thermal ultrasound beforemay enhance penetration 4.Suggested treatment parameters:

3 MHz frequency, continuous, 0.5-.75 W/cm²for 5-10 minutes

Contraindications for Phonophoresis

Check for allergy to medication being used

Same as contraindications to ultrasound

Electrotherapy

Electrotherapy BasicsRelates to:Flow or movement of ions or electrons via electrical current

Produces chemical, mechanical,thermal and magnetic changes in stimulated tissues

Electrical current flow takes pathof least resistance. Moves from high (cathode) to low (anode) electron concentration

Electrotherapy uses direct current, alternating current and pulsed current to delivery therapeutic benefit

Direct CurrentUnidirectional - continuous flow of particles in one direction

Used for iontophoresis, wound healing, stimulation for denervated muscles

Alternating Current

Bi-directional – continuous flow of charged particles

Symmetrical or asymmetrical

Used for IFC & Russian stimulation

Pulsed CurrentNon-continuous flow of AC delivered in a series of pulses which last < 1 sec. before next series of pulses.

Unidirectional or bi-directional

Physiological Effects of Electrotherapy

Pain reduction

Stimulate tissue healing

Reduce edema

Facilitates muscle contraction

Strengthen motor patterns

Electrotherapy Terms

Charge

Resistance/Impedance

Amplitude

Duration

Frequency

Ramp

D Lingle 2013

Charge

Cathode: negative pole; attracts (+)

Anode: positive pole; attracts (-)

Cations: positive ions

Anions: negative ions

D. Lingle 2013

Resistance/Impedance

Relates to:Opposition to the flow of charged particles

Skin impedance offers resistance to current flow

Resistance varies throughout the body depending upon:

Water content, blood flow, patient activity or position, conducting medium

Decrease resistance by keeping patient & electrodes hydrated, and clean

D. Lingle 2013

Pulse Amplitude“Intensity”

Relates to:Maximal current (voltage) achieved in a monophasic pulse or in each phase of a biphasic pulse

Measured in milliamps (mA)

Needs to be strong enough fortherapeutic benefit

Peak Amplitude = Highest point of pulse

Devices have full adjustability of these settings

Pulse Duration“Pulse width”

Relates to:Time period that current is “on”

Interval between beginning and end of all phases of pulse

Expressed in milliseconds

Generally set between 200 & 400 milliseconds

Devices have full adjustability of these settings

Pulse Frequency“Pulse Rate”

Relates to:Pulses per second

Expressed as pps Pulses per second (pulsed current) Beats per second (interferential current) Cycles per second (alternating current)

Typical NMES setting is between 35-50 pps

Ramp

Relates to:Gradual increase in theintensity of a musclecontraction

On/Off CycleRelates to:

Periods of electrical stim versus periods of no stim

Expressed as a ratioOn Time

Typically 8-12 secondsOff time

Typically 10 – 50 seconds

On/Off Ratio

1:1, 1:2, 1:3, …

Example

1:5 = 8 seconds on, 40 sec off

Or 10 seconds on, 50 sec. off D Lingle 2013

ElectrodesSkin & hair

Coupling agent

1/2 diameter of electrode spacing

Electrode size

Muscle sizeSmall muscle: Monopolar placement Small electrode over motor point, slightly large

electrode elsewhereLarge muscle: Bipolar placement 2 electrodes of same size over proximal & distal

muscle

Electrode Placement

Superficial musculature = close together

Deeper musculature = farther apart

Areas of decreased skin resistance

Trigger points, motor points & acupuncture points are frequently close together.

Direct: electrodes are placed directly on the painful site.

Contiguous (bracketed): electrodes are placed around the painful tissues.

Proximal to painful areas

Parallel to pain, linear or crossed

Over path of peripheral nerve

Dermatome: At SC nerve root and distal end of dermatome

Electrode Placement Neuromuscular Electrical Stimulation

NMESStimulation of innervated muscle to restore muscle function:

Muscle strengthening

Spasm & spasticity reduction

Prevent disuse atrophy

Enhancement of ROM

Muscle reeducation

Neuromuscular Electrical Stimulation

Fast-twitch fibers

Immobilization atrophy = large, fast twitch fibers

Normal AROM = small, slow twitch fibers

Combine with functional task or active motion

Treatment TimeFrequency and duration of treatment depend on goals

StrengtheningNeed 10 – 15 strong contractions per treatmentDuty cycle 1:5 →1:3 delivered 1-3 times per day

Ramp up 2 sec., 6 sec. on, ramp down 2 sec. = 10 sec.

50 seconds off

Total treatment time = 10-15 minutes

EnduranceDuty cycle 1:3, Ramp up/down 1-2 sec., Time 30+ min., 1x/day

Interferential CurrentIFC

Pain & edema control

Quadripolar

Electrode placement so currents intersect

“Beat” creates therapeuticeffect

Interferential Current

Example:

Channel 1 = 4000Hz Channel 2 = 4100Hz

“Beat” = 100Hz

Interferential Current

Quadripolar (“True- Interferential)

Pre-modulated IFC

Interferential CurrentPain control

Low beat frequency (1-10 Hz)

Intensity: moderate sensory to motor level

Theory: Release of opiates

Higher burst frequency (80-150 Hz) affects widest range of receptors but duration of pain reduction is thought to be less

Intensity: Strong sensory level

Edema Reduction

Medium beat frequencies (15 Hz) may reduce edema by activating musculoskeletal pumping action.

It may inhibit sympathetic activity assisting with fluid drainage.(Goats, GC, 2009)

High Volt Pulsed CurrentHVPC

Prevention of edema in acute inflammatory stage Use cathode as the active electrode, and anode as

dispersive

Intensity below motor threshold

Tissue healing Cathode or anode is the active electrode placed at

the wound

Intensity comfortable sensory stimulation

High Volt Pulsed CurrentWaveform: twin peaked monophasic pulsed current

Pulse duration: fixed within unit

Frequency: 1 – 120 Hz

Amplitude: to patient tolerance

Active electrode is usually smaller than the dispersive

Polarity: positive or negative

Russian Stimulation

Used for muscle strengthening

Medium frequency, AC, bursts to elicit tetanic contraction

10 sec. on, 50 sec. off for 10 min.

Variable evidence of it’s effectiveness

Transcutaneous Electrical Stimulation

TENSUsed to modulate pain perception

Pulsed current

Modulation TENS units have modulations built in to decrease

accommodation Waveform parameters such as frequency, duration and

intensity, are periodically changed to decrease the chances of accommodating to the stimulation, which make it less effective.

Michlovitz 2012

Pain Control Theories Related to TENS

Gate Control Theory (Melzak and Wall 1965)

When an electrical current is applied to a painful area, transmission of the perception of pain via small diameter, slow, “C” fibers to the brain is inhibited by the activity of the large diameter, fast conducting, “A” proprioceptive sensory nerve fibers

This closes the gate to the pain perception to the brain

Application: Conventional (High Frequency) TENS

Pain Control Theories Related to TENS

Endorphin Release Theory or Opiate-Mediated Control Theory

The brain can secrete analgesic substances such as endorphins (endogenous opiates) that act on the CNS & PNS to modulate pain and provide a sense of well-being

Application: Low Frequency TENS & Brief Noxious level TENS

Conventional vs. High Rate TENS

High pulse frequency (90-150 pps)

Short (low) pulse duration (50-100 msec)

Intensity: comfortable, Sensory level (tingling)

Length of treatment: 20-60 min

(+) Fast pain relief (-) short carryover

Gate theory

“Accupuncture-like” TENS

Low pulse frequency (2-10 pps)

Long pulse duration 160 - 400 msec.

Intensity: Motor level (visible muscle twitches)

Length of treatment: 20-45+ minutes

Longer relief of pain (possibly 2 – 6 hrs)

Often used for non-acute pain

Possible method of action:

release of endorphins

ElectroacupunctureNoxious, Brief & Intense TENS

High pulse frequency: > 100 pps

Long pulse duration: (300-1000 msec)

Intensity: strong motor level to uncomfortable

Length of Treatment : brief, just a few min.

Possible method of action:

through the release of endorphins (& possibly blocking pain perception)

Used prior to painful activity

High level of analgesia is achieved for a short period of time

Contraindications to Electrical Stimulation

Demand cardiac pacemakers

Indwelling stimulators

Trunk of pregnant patient

Carotid sinus/artery

Eyes

Unstable fractures

Active TB

Cancer

Peripheral Vascular disease

Hx seizures

Peripheral nerve disease

Infections

Rapid fatigue syndromes

Precautions for Electrical Stimulation

Areas of decreased sensation

Excessive Adipose tissue

Unhealed incisions

Cardiac conditions

Bony prominence

Impaired cognition

Pt. unable to provide feedback

Over growth plates

Skin irritations to electricity or gels

When driving or operating machinery

Iontophoresis

The delivery of ions into the body for therapeutic purposes using an electrical current; transcutaneously via passive absorption over time

IontophoresisDirect current

Electrically charged electrode will repel a similarly charged ion

(+) ions placed under (+) electrode

(-) ions under (-) electrode

Delivery electrode contains medication

Non-delivery or return electrode opposite polarity

D. Lingle 2013

Coulomb’s law in electrophysics states that:

Like charges repel and opposite charges attract

Positively charged ions (cations) will be repelled from the positive pole

Negatively charged ions (anions) will be repelled from the negative pole

Before Using Iontophoresis!

Need to obtain a prescription from the treating physician for medication used with iontophoresis

Therapeutic Effects of Iontophoresis

Dependent upon medication selected, but include:

Decrease Inflammation (acute and chronic)

Decrease Pain

Soft tissue de-mineralization (calcium deposits)

Promote Wound healing

Decrease Scar tissue/adhesions

Decrease Hyperhidrosis

Medications Used with Iontophoresis

ION POLARITY PURPOSE

Dexamethasone (-) Decrease inflammation

(tendonitis, tendonosis)

Acetic Acid (-) Helps dissolve Calcium deposits

Iodine (-) Decrease scar tissue

Lidocaine (+) Decrease local pain

Tap Water (+) (-)Switch halfway

thru tx.

Decrease hyperhidrosis

(sweaty palms/soles of feet)

Dosage with Iontophoresis

Inflammatory conditions: 4.0 mA/10 minutes

Treatment time may vary depending on patient tolerance (common 2.0 mA/20min.)

Scar formation: intensity 4.0 mA/20 min.

Number of treatment sessions: generally 6 treatments, no more frequent than every 2 days

Some skin reaction is common due to DC current

Manipulating Dosage with Iontophoresis

40 mA minutes = 4.0 mA X 10 minutes

40 mA minutes = 3.0 mA X 13.3 minutes

40 mA minutes = 2.0 mA X 20 minutes

40 mA minutes = 1.0 mA X 40 minutes

40 milliamp minute treatment can be broken down into any of the following:

Contraindications with Iontophoresis

Damaged skin/open skin lesions

Known sensitivity or allergy to therapeutic ions

Moderate to severe sensory impairment

Acute injury if bleeding still occurring

Fresh scars

Over electronic implants

Over area of exposed metal

Cardiac Pacemakers: demand type

Pregnancy: first trimester

Cancer or history of cancer

Precautions with Iontophoresis

Poor contact between electrode and skin

Patient tolerance to treatment

Matching polarity of ion with correct electrode

Inspect skin for reaction from previous iontophoresis treatment

Intermittent Pneumatic Compression Pump

Edema reduction for subacute and chronic edema (not acute edema)

Applies pressure to assist with venous and lymphatic drainage

Never set pressure greater than 10mmHg below diastolic blood pressure Generally 30-50 mmHg in UE

On/off generally 3:1

Treatment time 45-60 min

Intermittent Pneumatic Compression Pump

Precautions

Impaired sensation

Impaired communication or cognition

Controlled HTN

Cancer in the area

Stroke or TIA

Areas of superficial nerves

Contraindications

Pulmonary edema

CHF

DVT

Uncontrolled HTN

Obstructed venous or lymphatic return

Post arterial re-vascularization or repair

Skin infection

Unhealed fx

Things to Remember…

Inspect skin: Prior to, during & after treatment

Determine cognitive status

Check sensory status in treatment area

Combine heat and stretch when indicated

Objective measurements…

Assessing Effectiveness of Modalities

PainNumeric Pain Rating Scale (NPRS)Visual Analog Scale (VAS)

EdemaMeasure circumference or volume

ROMMeasure with goniometer

Muscle GuardingObserve

Strength/Motor FunctionGrip, pinch, MMT

FunctionObserve ADL/IADL, Patient rated evalsJebsen hand, etc.

Scar/Tissue HealingMeasure pliability, Wound assessments

Documenting Modalities& Setting Treatment Plans

Documentation of modalities should allow any therapist to step in and complete a treatment without difficulty.

Parameters: Location, duration, equipment used, & treatment response (objective improvements)

Be a researcher… write objective treatment goals for the use of PAMs and reassess patient status frequently to evaluate the benefits of PAMs.

Continue using PAMs only when you notice a therapeutic benefit!!!

ReferencesBracciano A,(2008), Physical Agent Modalities: Theory and Application for the Occupational Therapist, Slack Inc.

Cameron, M, (2009), Physical Agents in Rehabilitation: From Research to Practice, Saunders Elsevier.

Fedorczyck , J, (2012) The Use of Physical Agents in Hand Therapy, ASHT Hand Therapy Review Course.

Knight, KL, Draper, DO, (2007), Therapeutic Modalities: The Art and Science With Clinical Activities Manual, Lippincott Williams & Wilkins.

Bellew, JW, Michlovitz, S, Nolan, TP, (2016) Modalities for Therapeutic Intervention, F A Davis.

ASHT Test Prep book 3rd edition

Contact Information

alessia.otrcht@yahoo.com