Therapeutic Modalities: Difference between revisions
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== Introduction == | == Introduction == | ||
Physiotherapists use a variety of therapeutic modalities to help their patients/clients achieve therapy goals. | Physiotherapists use a variety of therapeutic modalities to help their patients/clients achieve therapy goals. The choice of which modality to use may depend on a specific condition, patient's needs and goals. This page will look at the rationale for use of a modality and its safety considerations. | ||
== Electrical | == Electrical stimulation == | ||
Electrical stimulating currents such as transcutaneous electrical nerve stimulation (TENS) and interferential current (IFC) utilize electrical energy, the flow of electrons or other charged particles from one area to another, causing depolarization of muscle or nervous tissue. Electrical stimulation has most commonly been used for the modulation of pain through stimulation of cutaneous sensory nerves and the following analgesic mechanisms | Electrical stimulating currents such as [[Transcutaneous Electrical Nerve Stimulation (TENS)|transcutaneous electrical nerve stimulation]] (TENS) and [[Interferential Therapy / Interferential Current (IFC)|interferential current]] (IFC) utilize electrical energy, the flow of electrons or other charged particles from one area to another, causing depolarization of muscle or nervous tissue. Electrical stimulation has most commonly been used for the modulation of pain through stimulation of cutaneous sensory nerves and the following analgesic mechanisms:<ref name="Prentice">Prentice WE, editor. Therapeutic Modalities in Rehabilitation. 4th ed. New York: McGraw-Hill Medical, 2011.</ref> | ||
# | #Activation of large diameter A-beta fibers inhibits the pain transmission, carried by A-delta and C afferent fibers, from the spinal cord to the brain - also known as the gate control theory of pain | ||
# | #Stimulation of A-delta and C fibers causes the release of endogenous opioids (endorphin and enkephalin) resulting in prolonged activation of descending analgesic pathways | ||
[[Image:399px-TENS.jpg|365x365px]]<br> | [[Image:399px-TENS.jpg|365x365px]]<br> | ||
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|- | |- | ||
| | | | ||
* | *[[Deep Vein Thrombosis|Deep venous thrombosis]] or [[thrombophlebitis]] | ||
*Hemorrhagic conditions | *Hemorrhagic conditions | ||
*Pregnancy | *Pregnancy | ||
| Line 45: | Line 43: | ||
*Cardiac failure (local) | *Cardiac failure (local) | ||
*Damaged or at-risk skin (local) | *Damaged or at-risk skin (local) | ||
*Infection or tuberculosis (local) | *Infection or [[tuberculosis]] (local) | ||
*Malignancy (local) | *Malignancy (local) | ||
*Recently radiated tissue (local) | *Recently radiated tissue (local) | ||
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< | <ref name="Prentice" /> | ||
'''Additional | '''Additional considerations''' | ||
*Test sensory integrity prior to application by asking patients to differentiate between light touch and painful stimuli | *Test sensory integrity prior to application by asking patients to differentiate between light touch and painful stimuli | ||
* | *Tissue with high resistance to electrical current include skin, bone, and necrotic tissue - electrodes should not be placed directly over bony prominences | ||
*Factors increasing skin impedance include the presence of hair and oil, and cooler skin temperatres | *Factors increasing skin impedance include the presence of hair and oil, and cooler skin temperatres | ||
*Applying IFC or TENS in combination with a thermal modality is not recommended as it increases the likelihood of an adverse effect | *Applying [[Interferential Therapy / Interferential Current (IFC)|IFC]] or [[Transcutaneous Electrical Nerve Stimulation (TENS)|TENS]] in combination with a thermal modality is not recommended as it increases the likelihood of an adverse effect | ||
*Large electrodes are more comfortable and allow current to travel deeper but the target is less specific - only large electordes should be used with medium frequencies (IFC) to disperse the current | *Large electrodes are more comfortable and allow current to travel deeper but the target is less specific - only large electordes should be used with medium frequencies (IFC) to disperse the current | ||
*Placing electrodes farther apart will allow the current to travel deeper - at lease 1 inch apart for pain control | *Placing electrodes farther apart will allow the current to travel deeper - at lease 1 inch apart for pain control | ||
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*Remember that the modulation of pain is not treating the cause of pain | *Remember that the modulation of pain is not treating the cause of pain | ||
<ref name="Prentice" /> | |||
== Thermal energy == | |||
[[Thermotherapy]] and [[cryotherapy]], the application of therapeutic heat and cold, are referred to as conductive modalities - they utilize the conduction of thermal energy to produce a local and occasionally a generalized heating or cooling of superficial tissues with a maximum depth of penetration of 1 cm or less.<ref name="Prentice" /> | |||
[[Image:Cold Hot Pack.jpg|384x384px]] | |||
=== [[Thermotherapy]] === | |||
Includes warm whirlpool, warm hydrocollator packs, paraffin baths, and fluidotherapy. Primary physiological effects of heat include:<ref name="Prentice" /> | |||
* Vasodilation and increased blood flow | |||
* Increased metabolic rate | |||
* Relaxation of muscle spasm | |||
* Pain relief via the gate-control mechanism and reduced ischemia | |||
* Increased elasticity of connective tissue | |||
It also works by stimulating fibroblast proliferation<ref name="Xia et al.">Xia Z, Sato A, Hughes MA, Cherry GW. [https://onlinelibrary.wiley.com/doi/abs/10.1046/j.1524-475x.2000.00138.x Stimulation of fibroblast growth in vitro by intermittent radiant warming.] Wound Repair Regen 2001; 8(2):138-144.</ref>, accelerating endothelial cell proliferation<ref name="Hughes et al.">Hughes MA, Tang C, Cherry GW. [https://www.magonlinelibrary.com/doi/abs/10.12968/jowc.2003.12.4.26487 Effect of intermittent radiant warming on proliferation of human dermal endothelial cells in vitro.] J Wound Care 2003;12(4):135-137.</ref>, and improved phagocytic activity of inflammatory cells<ref name="Price et al.">Price P, Bale S, Crook H, Harding KG. [https://www.magonlinelibrary.com/doi/abs/10.12968/jowc.2000.9.4.25972 The effect of radiant heat dressing on pressure ulcers.] J Wound Care 2000;9(4):201-205.</ref>. Heat is believed to have a relaxing effect on muscle tone by reducing muscle spindle and gamma efferent firing rates; there is also the theory that relaxation of muscle is assumed to occur with the disappearance of pain.<ref name="Prentice" /> | |||
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|- | |- | ||
| | | | ||
* | *[[Deep Vein Thrombosis|Deep venous thrombosis]] or [[thrombophlebitis]] | ||
*Hemorrhagic conditions | *Hemorrhagic conditions | ||
*Reproductive organs | *Reproductive organs | ||
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*Impaired circulation or sensation (local) | *Impaired circulation or sensation (local) | ||
*Damaged or at-risk skin (local) | *Damaged or at-risk skin (local) | ||
*Infection or tuberculosis (local) | *Infection or [[tuberculosis]] (local) | ||
*Malignancy (local) | *Malignancy (local) | ||
*Recently radiated tissue (local) | *Recently radiated tissue (local) | ||
| Line 152: | Line 143: | ||
*Risk of burn increases with the amount of subcutaneous fat because fat serves as an insulator | *Risk of burn increases with the amount of subcutaneous fat because fat serves as an insulator | ||
*Patients should not lie on top of hot packs or pads as pressure that compresses skin capillaries compromises the normal vasodilator response | *Patients should not lie on top of hot packs or pads as pressure that compresses skin capillaries compromises the normal vasodilator response | ||
=== [[Cryotherapy]] === | |||
Includes ice massage, cold hydrocollator packs, cold whirlpool, cold spray, contrast baths, ice immersion, cold compression, and cryokinetics, Primary physiological effects of cold include:<ref name="Prentice" /> | |||
* Vasoconstriction and decreased blood flow (within first 15 - 20 minutes) | |||
* Decreased metabolic rate | |||
* Pain relief with decreased muscle spasm via gate-control mechanism and decreased nerve conduction velocity | |||
Includes ice massage, cold hydrocollator packs, cold whirlpool, cold spray, contrast baths, ice immersion, cold compression, and cryokinetics, Primary physiological effects of cold include <ref name="Prentice" /> | Restriction of local blood flow reduces the potential for edema to develop. Slower metabolism releases fewer inflammatory mediators, reduces edema formation and decreases oxygen demand of tissues to minimize their chances of further injury from ischemia.<ref name="Weston et al.">Weston M, Taber C, Casagranda L, Cornwall M. [https://www.jospt.org/doi/pdfplus/10.2519/jospt.1994.19.4.197 Changes in local blood volume during cold gel pack application to traumatized ankles.] J Orthop Sports Phys Ther 1994;19(4):197-199.</ref><ref name="McMaster">McMaster WC. [https://journals.sagepub.com/doi/abs/10.1177/036354657700500305?journalCode=ajsb A literary review on ice therapy in injuries.] Am J Sports Med 1977;5(3):124-126.</ref> Cold decreases local neural activity, appears to raise the threshold stimulus of muscle spindles and depresses the excitability of free nerve endings, resulting in an increased pain threshold and reduced muscle spasm.<ref name="Ho et al.">Ho SS, Illgen RL, Meyer RW, Torok PJ, Cooper MD, Reider B. [http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.844.2013&rep=rep1&type=pdf Comparison of various icing times in decreasing bone metabolism and blood flow in the knee.] Am J Sports Med 1995;23(1):74-76.</ref><ref name="Merrick et al.">Merrick MA, Knight KL, Ingersoll CD, Potteiger JA. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1317720/pdf/jathtrain00031-0046.pdf The effects of ice and compression wraps on intramuscular temperatures at various depths.] J Athl Train 1993;28(3):236-245.</ref> | ||
Restriction of local blood flow reduces the potential for edema to develop. Slower metabolism releases fewer inflammatory mediators, reduces edema formation and decreases oxygen demand of tissues to minimize their chances of further injury from ischemia <ref name="Weston et al.">Weston M, Taber C, Casagranda L, Cornwall M. Changes in local blood volume during cold gel pack application to traumatized ankles. J Orthop Sports Phys Ther | |||
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|- | |- | ||
| | | | ||
* | *[[Deep Vein Thrombosis|Deep venous thrombosis]] or [[thrombophlebitis]] | ||
*Hemorrhagic conditions | *Hemorrhagic conditions | ||
*Chronic wound | *Chronic wound | ||
| Line 189: | Line 172: | ||
*Anterior neck, carotid sinus, regenerating nerves | *Anterior neck, carotid sinus, regenerating nerves | ||
*Impaired circulation (local) | *Impaired circulation (local) | ||
*Tuberculosis (local) | *[[Tuberculosis]] (local) | ||
| align="left" valign="top" | | | align="left" valign="top" | | ||
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*Test sensory integrity by asking patients to differentiate between hot and cold stimuli | *Test sensory integrity by asking patients to differentiate between hot and cold stimuli | ||
*Cold has the greatest benefit in acute injuries - avoid cold if healing is delayed because it could further impair recovery | *Cold has the greatest benefit in acute injuries - avoid cold if healing is delayed because it could further impair recovery | ||
*Rate of skin cooling is reduced with a towel between the agent and skin - 1 or 2 layers of protection is sufficient | *Rate of skin cooling is reduced with a towel between the agent and skin - 1 or 2 layers of protection is sufficient | ||
*Water has a higher conductivity than air – apply moisture to the towel | *Water has a higher conductivity than air – apply moisture to the towel | ||
| Line 221: | Line 204: | ||
*Local pain awareness, proprioception, muscle strength, and agility are reduced immediately post-cryotherapy – caution in prescribing activity | *Local pain awareness, proprioception, muscle strength, and agility are reduced immediately post-cryotherapy – caution in prescribing activity | ||
<br> | <br>Also see page for [[Cryotherapy Guidelines|cryotherapy guidelines]]. | ||
== Ultrasound == | == [[Ultrasound therapy|Ultrasound]] == | ||
Ultrasound utilizes sound energy, pressure waves created by the mechanical vibration of particles through a medium. The flow of ultrasound may be delivered as an uninterrupted stream (continuous mode) or delivered with periodic interruptions (pulsed mode). Ultrasound is classified as a deep heating modality capable of producing a temperature increase in tissues of considerable depth because it travels very well through homogenous tissue (e.g. fat tissue) <ref name="Draper et al. 1993">Draper D, Sunderland S. Examination of the law of grotthus-draper: Does ultrasound penetrate subcutaneous fat in humans? J Athletic Train | [[Ultrasound therapy|Ultrasound]] utilizes sound energy, pressure waves created by the mechanical vibration of particles through a medium. The flow of ultrasound may be delivered as an uninterrupted stream (continuous mode) or delivered with periodic interruptions (pulsed mode). Ultrasound is classified as a deep heating modality capable of producing a temperature increase in tissues of considerable depth because it travels very well through homogenous tissue (e.g. fat tissue).<ref name="Draper et al. 1993">Draper D, Sunderland S. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1317721/pdf/jathtrain00031-0056.pdf Examination of the law of grotthus-draper: Does ultrasound penetrate subcutaneous fat in humans?] J Athletic Train 1993;28(3):248-250.</ref><ref name="Draper et al. 1995">Draper DO, Castel JC, Castel D. [https://www.jospt.org/doi/pdfplus/10.2519/jospt.1995.22.4.142 Rate of temperature increase in human muscle during 1 MHz and 3 MHz continuous ultrasound.] J Orthop Sports Phys Ther 1995;22:142-50.</ref> Traditionally it has been used for its thermal effects but it is capable of enhancing healing at the cellular level. Continuous ultrasound is most commonly used when thermal effects are desired but non-thermal effects will also occur.<ref name="Partridge">Partridge CJ. Electrotherapy – foreword. Physiotherapy 1990;76(10):593-600.</ref> It has been shown to alter all phases of tissue repair: stimulates phagocytic activity of inflammatory cells such as macrophages,<ref name="Crowell et al.">Crowell JA, Kusserow BK, Nyborg WL. [https://www.sciencedirect.com/science/article/abs/pii/0301562977900709 Functional changes in white blood cells after microsonation.] Ultrasound Med Biol 1997;3(2):185-190.</ref> and promotes release of chemical mediators from inflammatory cells which attract and activate fibroblasts to the site of injury, stimulates and optimizes collagen production, organization and ultimately functional strength of scar tissue.<ref name="De Deyne et al.">De Deyne PG, Kirsch-Volders M. [https://academic.oup.com/ptj/article-abstract/75/7/629/2632916 In vitro effects of therapeutic ultrasound on the nucleus of human fibroblasts]. Phys Ther 1995;75(7):629-634.</ref> An examination of research studies to assess changes in blow flow with ultrasound produced inconclusive results; however, recent studies show that nitric oxide released by ultrasound therapy may be a potent stimulator of new blood vessel growth at the site of injury.<ref name="Rubin et al. 1990">Rubin MJ, Etchison MR, Condra KA, Franklin TD, Snoddy AM. [https://www.sciencedirect.com/science/article/abs/pii/030156299090006X Acute effects of ultrasound on skeletal muscle oxygen tension, blood flow and capillary density.] J Med Biol 1990;16:271-277.</ref> Ultrasound also aids in pain relief and the literature has proposed reduced conduction of pain transmission as a possible mechnism for the analgesic effects.<ref name="Srbely and Dickey">Srbely JZ, Dickey JP. [https://www.researchgate.net/profile/John_Srbely/publication/6223477_Randomized_controlled_study_of_the_antinociceptive_effect_of_ultrasound_on_trigger_point_sensitivity_Novel_applications_in_myofascial_therapy/links/5637ba3408ae7f7eb1852b1c.pdf Randomized controlled study of the antinociceptive effect of ultrasound on trigger point sensitivity: Novel applications in myofascial therapy?] Clin Rehabil 2007;21(5):411-417.</ref> More recently, low-intensity pulsed ultrasound has been shown to accelerate the rate of healing of fresh fractures due to the enhancement of angiogenic, chondrogenic, and osteogenic activity.<ref name="Rubin et al. 2001">Rubin C, Bolander M, Ryaby JP, Hadjiargyrou M. [http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.703.5528&rep=rep1&type=pdf The use of low-intensity ultrasound to accelerate the healing of fractures]. J Bone Joint Surg 2001;83(2):259-270.</ref> | ||
[[File:Ultrasound therapy.jpg|frameless|300x300px]]<br> | [[File:Ultrasound therapy.jpg|frameless|300x300px]]<br> | ||
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*Eyes, anterior neck, carotid sinus, reproductive organs | *Eyes, anterior neck, carotid sinus, reproductive organs | ||
*Electronic device | *Electronic device | ||
* | *[[Deep Vein Thrombosis|Deep venous thrombosis]] or [[thrombophlebitis]] (local) | ||
*Malignancy (local) | *Malignancy (local) | ||
*Pregnancy (local) | *Pregnancy (local) | ||
*Tuberculosis (local) | *[[Tuberculosis]] (local) | ||
*Recently radiated tissue (local) | *Recently radiated tissue (local) | ||
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|} | |} | ||
=== Continuous Ultrasound === | === Continuous Ultrasound === | ||
| Line 294: | Line 274: | ||
*Impaired cognition or communication | *Impaired cognition or communication | ||
*Eyes, anterior neck, carotid sinus, reproductive organs | *Eyes, anterior neck, carotid sinus, reproductive organs | ||
* | *[[Deep Vein Thrombosis|Deep venous thrombosis]] or [[thrombophlebitis]] (local) | ||
*Infection or tuberculosis (local) | *Infection or [[tuberculosis]] (local) | ||
*Malignancy (local) | *Malignancy (local) | ||
*Recently radiated tissue (local) | *Recently radiated tissue (local) | ||
| Line 320: | Line 300: | ||
<br> '''Additional Considerations''' | <br> '''Additional Considerations''' | ||
*Test sensory integrity by asking patients to differentiate between hot and cold stimuli or between light touch and painful stimuli | *Test sensory integrity by asking patients to differentiate between hot and cold stimuli or between light touch and painful stimuli | ||
*Avoid pre-treatment of the area with superficial heating or cooling agents - cumulative effect of a hot pack and ultrasound can lead to skin damage | *Avoid pre-treatment of the area with superficial heating or cooling agents - cumulative effect of a hot pack and ultrasound can lead to skin damage | ||
*Recommended treatment is 2 – 3x the effective radiating area (ERA) | *Recommended treatment is 2 – 3x the effective radiating area (ERA) | ||
*Circular head movement produces more even delivery of ultrasound energy since hot spots are dissipated better | *Circular head movement produces more even delivery of ultrasound energy since hot spots are dissipated better | ||
*To minimize the impedance difference at the steel/air interface, a suitable coupling medium must be utilized | *To minimize the impedance difference at the steel/air interface, a suitable coupling medium must be utilized | ||
*Best absorption of ultrasound energy in tendon, ligament, fascia, joint capsule and scar tissue <ref name="Watson">Watson T. Ultrasound in contemporary physiotherapy practice. Ultrasonics. 2008; 48(4): 321-329.</ref> | *Best absorption of ultrasound energy in tendon, ligament, fascia, joint capsule and scar tissue <ref name="Watson">Watson T. Ultrasound in contemporary physiotherapy practice. Ultrasonics. 2008; 48(4): 321-329.</ref> | ||
== LASER == | == LASER == | ||
Light Amplification for the Stimulated Emission of Radiation (LASER) utilizes electromagnetic radiant energy, the movement of photons through space. The low-power or cold laser produces little or no thermal effects but seems to have some significant effect on soft-tissue and fracture healing as well as on pain management. Light at the wavelength typically employed in laser therapy is readily absorbed by enzymes, hemoglobin, fibroblasts, and neurologic tissue. Laser has been shown to stimulate cell degranulation causing the release of potent inflammatory mediators such as growth factors <ref name="Young et al.">Young S, Bolton P, Dyson M, Harvey W, Diamantopoulos C. Macrophage responsiveness to light therapy. Lasers Surg Med | Light Amplification for the Stimulated Emission of Radiation (LASER) utilizes electromagnetic radiant energy, the movement of photons through space. The low-power or cold laser produces little or no thermal effects but seems to have some significant effect on soft-tissue and fracture healing as well as on pain management. Light at the wavelength typically employed in laser therapy is readily absorbed by enzymes, hemoglobin, fibroblasts, and neurologic tissue. Laser has been shown to stimulate cell degranulation causing the release of potent inflammatory mediators such as growth factors,<ref name="Young et al.">Young S, Bolton P, Dyson M, Harvey W, Diamantopoulos C. [http://lighttherapyuk.com/Bioptron%20References/Wound_healing/MF-03_S.Young_Macrophage-responsiveness-to-lighttherapy_1989_(1202).PDF Macrophage responsiveness to light therapy.] Lasers Surg Med 1989;9(5):497-505.</ref> activate phagocytic processes at the site of injury,<ref name="Karu et al.">Karu TI, Ryabykh TP, Fedoseyeva GE, Puchkova NI. [https://onlinelibrary.wiley.com/doi/abs/10.1002/lsm.1900090608 Helium-neon laser-induced respiratory burst of phagocytic cells.] Lasers Surg Med 1989;9(6):585-588.</ref> and activate fibroblast cell function to increase collagen deposition and improve tensile strength.<ref name="Kesava et al.">Kesava Reddy G, Stehno-Bittel L, Enwemeka CS. [https://onlinelibrary.wiley.com/doi/abs/10.1002/(SICI)1096-9101(1998)22:5%3C281::AID-LSM4%3E3.0.CO;2-L Laser photostimulation of collagen production in healing rabbit Achilles tendons.] Lasers Surg Med 1998;22(5):281-287.</ref>.Some reports also show a small decrease in edema produced by inflammation following laser therapy.<ref name="Honmura et al.">Honmura A, Yanase M, Obata J, Haruki E. [https://onlinelibrary.wiley.com/doi/abs/10.1002/lsm.1900120414 Therapeutic effect of Ga-Al-As diode laser irradiation on experimentally induced inflammation in rats.] Lasers Surg Med 1992;12(4):441-449.</ref>.Absorption by hemoglobin releases nitirc oxide resulting in endothelial cell proliferation and increased microcirculation.<ref name="Burke">Burke TJ. [https://journals.lww.com/aswcjournal/Citation/2003/12000/5_Questions_and_Answers_About_MIRE_Treatment.16.aspx 5 questions – and answers – about MIRE treatment.] Adv Skin Wound Care 2003;16(7):369-371.</ref>.Low dosages also result in significantly decreased sensory nerve conduction velocity effect in reducing pain.<ref name="Snyder-Mackler and Bork">Snyder-Mackler L, Bork CE. [https://pdfs.semanticscholar.org/848d/4daae49f70a4439071738b93c7615218a544.pdf Effect of helium-neon laser irradiation on peripheral sensory nerve latency.] Phys Ther 1988;68(2):223-225.</ref> | ||
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*Hemorrhagic conditions | *Hemorrhagic conditions | ||
*Eyes, reproductive organs | *Eyes, reproductive organs | ||
* | *[[Deep Vein Thrombosis|Deep venous thrombosis]] or [[thrombophlebitis]] (local) | ||
*Malignancy (local) | *Malignancy (local) | ||
*Pregnancy (local) | *Pregnancy (local) | ||
*Tuberculosis (local) | *[[Tuberculosis]] (local) | ||
| align="left" valign="top" | | | align="left" valign="top" | | ||
*Impaired cognition or communication | *Impaired cognition or communication | ||
*Infection | *Infection | ||
*Photosensitivity or systemic lupus | *Photosensitivity or [[Systemic Lupus Erythematosus|systemic lupus]] | ||
*Recently radiate tissue | *Recently radiate tissue | ||
*Anterior neck, carotid sinus | *Anterior neck, carotid sinus | ||
| Line 373: | Line 347: | ||
*Reduce the risk of adverse effect on the eyes by applying laser in a closed environment, providing protective goggles when necessary, and performing an 'in-contact' technique | *Reduce the risk of adverse effect on the eyes by applying laser in a closed environment, providing protective goggles when necessary, and performing an 'in-contact' technique | ||
== Resourses == | |||
The focus of this page is the rationale for use of a modality and its safety considerations. Contraindications, precautions, risks, and safety considerations are outlined in detail by Houghton et al. (2010).<ref name="Houghton et al.">Houghton PE, Nussbaum EL, Hoens AM. Electrophysical agents – contraindications and precautions: An evidence-based approach to clinical decision making in physical therapy. Physiother Can. 2012; 62(5): 1-80.</ref> | |||
== References == | == References == | ||
Revision as of 23:42, 7 July 2019
Original Editor - Melanie Vaillancourt
Lead Editors - Angeliki Chorti, Melanie Vaillancourt, Leana Louw, Oyemi Sillo, Kim Jackson, Candace Goh, Yvonne Yap, Manisha Shrestha, Sai Kripa, Admin, Evan Thomas, Scott Buxton and WikiSysop
This article is currently under review and may not be up to date. Please come back soon to see the finished work! (7/07/2019)
Introduction[edit | edit source]
Physiotherapists use a variety of therapeutic modalities to help their patients/clients achieve therapy goals. The choice of which modality to use may depend on a specific condition, patient's needs and goals. This page will look at the rationale for use of a modality and its safety considerations.
Electrical stimulation[edit | edit source]
Electrical stimulating currents such as transcutaneous electrical nerve stimulation (TENS) and interferential current (IFC) utilize electrical energy, the flow of electrons or other charged particles from one area to another, causing depolarization of muscle or nervous tissue. Electrical stimulation has most commonly been used for the modulation of pain through stimulation of cutaneous sensory nerves and the following analgesic mechanisms:[1]
- Activation of large diameter A-beta fibers inhibits the pain transmission, carried by A-delta and C afferent fibers, from the spinal cord to the brain - also known as the gate control theory of pain
- Stimulation of A-delta and C fibers causes the release of endogenous opioids (endorphin and enkephalin) resulting in prolonged activation of descending analgesic pathways
|
Contraindications |
Precautions |
Risks |
|
|
|
Additional considerations
- Test sensory integrity prior to application by asking patients to differentiate between light touch and painful stimuli
- Tissue with high resistance to electrical current include skin, bone, and necrotic tissue - electrodes should not be placed directly over bony prominences
- Factors increasing skin impedance include the presence of hair and oil, and cooler skin temperatres
- Applying IFC or TENS in combination with a thermal modality is not recommended as it increases the likelihood of an adverse effect
- Large electrodes are more comfortable and allow current to travel deeper but the target is less specific - only large electordes should be used with medium frequencies (IFC) to disperse the current
- Placing electrodes farther apart will allow the current to travel deeper - at lease 1 inch apart for pain control
- With any electrical device, increasing the intensity will first cause an electrical sensation followed by a motor repose and finally noxious stimuli
- Remember that the modulation of pain is not treating the cause of pain
Thermal energy [edit | edit source]
Thermotherapy and cryotherapy, the application of therapeutic heat and cold, are referred to as conductive modalities - they utilize the conduction of thermal energy to produce a local and occasionally a generalized heating or cooling of superficial tissues with a maximum depth of penetration of 1 cm or less.[1]
Thermotherapy[edit | edit source]
Includes warm whirlpool, warm hydrocollator packs, paraffin baths, and fluidotherapy. Primary physiological effects of heat include:[1]
- Vasodilation and increased blood flow
- Increased metabolic rate
- Relaxation of muscle spasm
- Pain relief via the gate-control mechanism and reduced ischemia
- Increased elasticity of connective tissue
It also works by stimulating fibroblast proliferation[2], accelerating endothelial cell proliferation[3], and improved phagocytic activity of inflammatory cells[4]. Heat is believed to have a relaxing effect on muscle tone by reducing muscle spindle and gamma efferent firing rates; there is also the theory that relaxation of muscle is assumed to occur with the disappearance of pain.[1]
|
Contraindications |
Precautions |
Risks |
|
|
|
Additional Considerations
- Test sensory integrity by asking patients to differentiate between hot and cold stimuli
- Wrap heating pads in 6 - 8 layers of toweling to protect the skin from burns
- Check patient after initial 5 minutes for excessive redness, blistering, signs of burning, generalized sweating (increased core temperature)
- Risk of burn increases with the amount of subcutaneous fat because fat serves as an insulator
- Patients should not lie on top of hot packs or pads as pressure that compresses skin capillaries compromises the normal vasodilator response
Cryotherapy[edit | edit source]
Includes ice massage, cold hydrocollator packs, cold whirlpool, cold spray, contrast baths, ice immersion, cold compression, and cryokinetics, Primary physiological effects of cold include:[1]
- Vasoconstriction and decreased blood flow (within first 15 - 20 minutes)
- Decreased metabolic rate
- Pain relief with decreased muscle spasm via gate-control mechanism and decreased nerve conduction velocity
Restriction of local blood flow reduces the potential for edema to develop. Slower metabolism releases fewer inflammatory mediators, reduces edema formation and decreases oxygen demand of tissues to minimize their chances of further injury from ischemia.[5][6] Cold decreases local neural activity, appears to raise the threshold stimulus of muscle spindles and depresses the excitability of free nerve endings, resulting in an increased pain threshold and reduced muscle spasm.[7][8]
|
Contraindications |
Precautions |
Risks |
|
|
|
Additional Considerations
- Test sensory integrity by asking patients to differentiate between hot and cold stimuli
- Cold has the greatest benefit in acute injuries - avoid cold if healing is delayed because it could further impair recovery
- Rate of skin cooling is reduced with a towel between the agent and skin - 1 or 2 layers of protection is sufficient
- Water has a higher conductivity than air – apply moisture to the towel
- Patient will report uncomfortable sensation of cold, stinging or burning, aching sensation, and complete numbness
- If core temperature is not maintained, reflex shivering results in increased tone
- Re-warming period should be at least twice as long as the treatment time (too frequent application increases likelihood of frostbite)
- Hierarchy of cooling, from most to least efficient, is as follows: ice immersion, crushed ice, frozen peas, gel pack – choose an agent with less cooling potential if the patient has risk factors for an adverse reaction
- Local pain awareness, proprioception, muscle strength, and agility are reduced immediately post-cryotherapy – caution in prescribing activity
Also see page for cryotherapy guidelines.
Ultrasound[edit | edit source]
Ultrasound utilizes sound energy, pressure waves created by the mechanical vibration of particles through a medium. The flow of ultrasound may be delivered as an uninterrupted stream (continuous mode) or delivered with periodic interruptions (pulsed mode). Ultrasound is classified as a deep heating modality capable of producing a temperature increase in tissues of considerable depth because it travels very well through homogenous tissue (e.g. fat tissue).[9][10] Traditionally it has been used for its thermal effects but it is capable of enhancing healing at the cellular level. Continuous ultrasound is most commonly used when thermal effects are desired but non-thermal effects will also occur.[11] It has been shown to alter all phases of tissue repair: stimulates phagocytic activity of inflammatory cells such as macrophages,[12] and promotes release of chemical mediators from inflammatory cells which attract and activate fibroblasts to the site of injury, stimulates and optimizes collagen production, organization and ultimately functional strength of scar tissue.[13] An examination of research studies to assess changes in blow flow with ultrasound produced inconclusive results; however, recent studies show that nitric oxide released by ultrasound therapy may be a potent stimulator of new blood vessel growth at the site of injury.[14] Ultrasound also aids in pain relief and the literature has proposed reduced conduction of pain transmission as a possible mechnism for the analgesic effects.[15] More recently, low-intensity pulsed ultrasound has been shown to accelerate the rate of healing of fresh fractures due to the enhancement of angiogenic, chondrogenic, and osteogenic activity.[16]
Pulsed Ultrasound[edit | edit source]
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Continuous Ultrasound[edit | edit source]
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Additional Considerations
- Test sensory integrity by asking patients to differentiate between hot and cold stimuli or between light touch and painful stimuli
- Avoid pre-treatment of the area with superficial heating or cooling agents - cumulative effect of a hot pack and ultrasound can lead to skin damage
- Recommended treatment is 2 – 3x the effective radiating area (ERA)
- Circular head movement produces more even delivery of ultrasound energy since hot spots are dissipated better
- To minimize the impedance difference at the steel/air interface, a suitable coupling medium must be utilized
- Best absorption of ultrasound energy in tendon, ligament, fascia, joint capsule and scar tissue [17]
LASER[edit | edit source]
Light Amplification for the Stimulated Emission of Radiation (LASER) utilizes electromagnetic radiant energy, the movement of photons through space. The low-power or cold laser produces little or no thermal effects but seems to have some significant effect on soft-tissue and fracture healing as well as on pain management. Light at the wavelength typically employed in laser therapy is readily absorbed by enzymes, hemoglobin, fibroblasts, and neurologic tissue. Laser has been shown to stimulate cell degranulation causing the release of potent inflammatory mediators such as growth factors,[18] activate phagocytic processes at the site of injury,[19] and activate fibroblast cell function to increase collagen deposition and improve tensile strength.[20].Some reports also show a small decrease in edema produced by inflammation following laser therapy.[21].Absorption by hemoglobin releases nitirc oxide resulting in endothelial cell proliferation and increased microcirculation.[22].Low dosages also result in significantly decreased sensory nerve conduction velocity effect in reducing pain.[23]
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Additional Considerations
- Reduce the risk of adverse effect on the eyes by applying laser in a closed environment, providing protective goggles when necessary, and performing an 'in-contact' technique
Resourses[edit | edit source]
The focus of this page is the rationale for use of a modality and its safety considerations. Contraindications, precautions, risks, and safety considerations are outlined in detail by Houghton et al. (2010).[24]
References[edit | edit source]
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Prentice WE, editor. Therapeutic Modalities in Rehabilitation. 4th ed. New York: McGraw-Hill Medical, 2011.
- ↑ Xia Z, Sato A, Hughes MA, Cherry GW. Stimulation of fibroblast growth in vitro by intermittent radiant warming. Wound Repair Regen 2001; 8(2):138-144.
- ↑ Hughes MA, Tang C, Cherry GW. Effect of intermittent radiant warming on proliferation of human dermal endothelial cells in vitro. J Wound Care 2003;12(4):135-137.
- ↑ Price P, Bale S, Crook H, Harding KG. The effect of radiant heat dressing on pressure ulcers. J Wound Care 2000;9(4):201-205.
- ↑ Weston M, Taber C, Casagranda L, Cornwall M. Changes in local blood volume during cold gel pack application to traumatized ankles. J Orthop Sports Phys Ther 1994;19(4):197-199.
- ↑ McMaster WC. A literary review on ice therapy in injuries. Am J Sports Med 1977;5(3):124-126.
- ↑ Ho SS, Illgen RL, Meyer RW, Torok PJ, Cooper MD, Reider B. Comparison of various icing times in decreasing bone metabolism and blood flow in the knee. Am J Sports Med 1995;23(1):74-76.
- ↑ Merrick MA, Knight KL, Ingersoll CD, Potteiger JA. The effects of ice and compression wraps on intramuscular temperatures at various depths. J Athl Train 1993;28(3):236-245.
- ↑ Draper D, Sunderland S. Examination of the law of grotthus-draper: Does ultrasound penetrate subcutaneous fat in humans? J Athletic Train 1993;28(3):248-250.
- ↑ Draper DO, Castel JC, Castel D. Rate of temperature increase in human muscle during 1 MHz and 3 MHz continuous ultrasound. J Orthop Sports Phys Ther 1995;22:142-50.
- ↑ Partridge CJ. Electrotherapy – foreword. Physiotherapy 1990;76(10):593-600.
- ↑ Crowell JA, Kusserow BK, Nyborg WL. Functional changes in white blood cells after microsonation. Ultrasound Med Biol 1997;3(2):185-190.
- ↑ De Deyne PG, Kirsch-Volders M. In vitro effects of therapeutic ultrasound on the nucleus of human fibroblasts. Phys Ther 1995;75(7):629-634.
- ↑ Rubin MJ, Etchison MR, Condra KA, Franklin TD, Snoddy AM. Acute effects of ultrasound on skeletal muscle oxygen tension, blood flow and capillary density. J Med Biol 1990;16:271-277.
- ↑ Srbely JZ, Dickey JP. Randomized controlled study of the antinociceptive effect of ultrasound on trigger point sensitivity: Novel applications in myofascial therapy? Clin Rehabil 2007;21(5):411-417.
- ↑ Rubin C, Bolander M, Ryaby JP, Hadjiargyrou M. The use of low-intensity ultrasound to accelerate the healing of fractures. J Bone Joint Surg 2001;83(2):259-270.
- ↑ Watson T. Ultrasound in contemporary physiotherapy practice. Ultrasonics. 2008; 48(4): 321-329.
- ↑ Young S, Bolton P, Dyson M, Harvey W, Diamantopoulos C. Macrophage responsiveness to light therapy. Lasers Surg Med 1989;9(5):497-505.
- ↑ Karu TI, Ryabykh TP, Fedoseyeva GE, Puchkova NI. Helium-neon laser-induced respiratory burst of phagocytic cells. Lasers Surg Med 1989;9(6):585-588.
- ↑ Kesava Reddy G, Stehno-Bittel L, Enwemeka CS. Laser photostimulation of collagen production in healing rabbit Achilles tendons. Lasers Surg Med 1998;22(5):281-287.
- ↑ Honmura A, Yanase M, Obata J, Haruki E. Therapeutic effect of Ga-Al-As diode laser irradiation on experimentally induced inflammation in rats. Lasers Surg Med 1992;12(4):441-449.
- ↑ Burke TJ. 5 questions – and answers – about MIRE treatment. Adv Skin Wound Care 2003;16(7):369-371.
- ↑ Snyder-Mackler L, Bork CE. Effect of helium-neon laser irradiation on peripheral sensory nerve latency. Phys Ther 1988;68(2):223-225.
- ↑ Houghton PE, Nussbaum EL, Hoens AM. Electrophysical agents – contraindications and precautions: An evidence-based approach to clinical decision making in physical therapy. Physiother Can. 2012; 62(5): 1-80.
