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Physical Agents in Rehabilitation From Researchto Practice
Physlcal Agents ln Rehabllltatlon From Research to Practice Second Edition
Stichelle H. Cameron, PT, OCS l:est Lecturer l:aCuate Program of PhysicalTherapy j,.:ruel Merritt College I i
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SAUNDERS An Imynntof Elsevrcr 11830WesthneIndustrralDnve St Lours,Mrssoun63146 JnnO
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PHYSICAT ACENTS IN REHABILITAIION FROM RESEARCH TO PRACTICE Copyright @ 2003, Elsevier. AII rights resenzed.
0.7216-9378-4
No part of thrs pubhcatron may be reproduced or transmrtted rn any form or by any means, electroruc or mecharucal, mcludng photocopyrng, recordmg, or any nformailon storage and retneval system, wrthout permrsslon m wntmg from the pubhsher Permrssronsmay be sought drrectly from Elsevrer's Health ScrencesRrghts Department rn Phrladelphra, You may USA phone. (+ l)215-238-7869, fax. 1+ l)215-238-2239, emul:
[email protected]. also complete your request on-lme vta the Elsevrer Screncehomepage (http:/iwww.elsevrer com), by selectrng 'Customer Support' and then'Obtarmng Permrssrons'.
NOTICE Rehabrhtatron ls an ever-changrng field Standard safety precautlons must be followed, but as new research and clrrucal expenence broaden our knowledge, changes m treatment and drug therapy may become necessary or appropnate. Readersare advrsed to check the most current product mformahon provrded by the manufacturer of each drug to be admrmstered to verfiy the recommended dose, the method and durauon of admmrstratlon, and contrarndrcauons It rs the responsrbrlrty of the hcensed prescnber, relyrng on expenence and knowledge of the patlent, to determrne dosagesand the best treatment for each rndrvrdual patlent. Nerther the Pubhsher nor the author assumes any habrlrty for any mlury and/or damage to persons or properq/ ansrng from thrs pubhcatron.
Prevrous edrtron copyrtghted 1,999 Acqus fironsEdrtor'Manon Waldman DevelopmentalEdttors Sue Bredenstemer,Maqory Fraser PublrchmgSerwcesManage r' John Rogers ProlectManagar- Kathleen L Teal Deugner"Kathr Gosche CoverArt Kathr Gosche Pnnted m the Umted States of Amenca Lastdrgrtrstheprmtnumber'9
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tothememoryof Thisboobis dedicated myhusbandanddearest friend Cameron John rnetoaim high encouraging for I Vutmymindto. methatI coulddo whatever andteaching
Michelle H. Cameron, PT, OCS, is the owner of Health Potentials, a health education and consulting company. Sheis a physical therapist clinician, a teacher, researcher, and author, and now also a full-time medical student at the Universiry of California, San Francisco. She wrote the first edition and the currenr edition of this book, PhysicalAgents in Rehabilrtatrcn: FromResearch toPractice,published by Saunders.In addrtion, her research on phonophoresis is published in PhysicalTheraVy,the Journal of the Amerrcan Physical Therapy Association, and in ClinicalManagementmag-
vl11
azine, and earned her the California APTA Clinician ResearchAward. Michelle has also written and edited numerous articles on electrical strmulation, ultrasound and phonophoresis, and wound management, and wrote the section on ultrasound in Saunders'Manual for Physical TheraVy Practice.Michelle's discussions of ultrasound, electrical sumulation, thermal agents, biofeedback, and wound management bring together current researchand practice to provide the decisionmaking and hands-on tools that support optimal care within today's health care envirorunenr.
Acknowledg*ents First and foremost, I want to thank the readers and purchasersof the first edition of thrs book. Wrthout l"ou, there wouldn't be a second editron. In particular, I would like to thank those readerswho took the time to contact me with their comments, thoughts, and suggestionsabout what worked for them and what didn't. And, special thanks are due Dr. Marjorie -ltoore for her review and input on Frgures 3-4 duough 3-7 inthe chapter on pain. Thank you also to my friends, famtly, and col,eagues.Your ongoing support, encouragement, and patience has kept me h.ppy and relatrvely sane :,hroughthis endeavor and the rest of my hfe. I would also like to give specialthanks to: Andrew Allen, publishing director at Elsevier Science,for his consistent support throughout this nroject; As well as Marion Waldman, executive editor; Sue 3redensteiner, developmental editor; and Marjory
Fraser,ancillary and website developer and editor, for therr ongomg support. The contrrbuting authors to the first edition, including David Selkowitz, as well as those who have been part of both editions, and Sara Shapiro who is new to the team; Sara,for her persistenceand dedication with a job that turned out to be much more than she bargained for; Juhe Pryde, Diane Allen, and Gail Widener, who updated their respective chapters thoroughly and promptly; and Linda Monroe for keeping this text in line with the APTA Cuide to PhysrcalTheraprstPractice,second edition, and keeping my neck healthy through my hours at the computer. MichelleH. Cameron
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Lontrtbutors Diane D. Allen, MS, PT Adj unct Assistant Professor SamuelMerritt College FhysicalTherapist T:nterimHealth Care SanJose,California ChaVter(: ToneAbnormalrties
Linda G. Monroe, MPT, OCS PhysicalTherapist PnvatePractice and Guide to Physical ChaVter5: MotionRestictions TherapistPractice(secondeditioncontent) Suzana Otafro-Lata, MS SiomedicalEngineer 3ostonScientificCorp/Symbiosis 1"[iami,Florida Radiation(firstedrtion) Chayter'12:Electrornagnetic
Diana Perez,BSc,P! MSc lart-time Faculry& CourseCoordinator Faculryof Medicine Schoolof Physicaland OccupationalTherapy l-l.cGillUniversity l"tontreal,Quebec
julie A. Pryde, MS, PA-C, PT, OCS, SCS, ATC, CSCS AdjunctAssistantProfessor SamuelMerritt College Oakland,California PhysicianAssistant Muir OrthopaedicSpecialists Walnut Creek,California and Tissue ReVair Chayter2: Inflammation
Sara Shapiro, MPH, PT AssistantClinicalProfessor Universiryof CaliforniaSanFrancisco GraduateProgramin PhysicalTherapy SanFrancisco,California Owner Apex Wellness& PhysicalTherapy Chayter8: ElectricalCurrents
Gail L. Widerter, PhD, PT AssociateProfessor SamuelMerritt College Oakland, California Chayter4: ToneAbnormaliues
ihysical Therapist l"Ledi -Club Physiother apyand Me dicalWellness Center Radiation(firstedition) Chayter'12:Electromagnetic
xl
Pref^ceto theSecond Edition -:: rvriting the first editron of this book I tned to meet = need that I beheved exrsted-the need for a book -r the use of physical agents in rehabilitatron that -:...ered the breadth and depth of this material in a ::adly accessible and easy to understand manner. - rut together a text that leads the reader from the iasic scientificand physiological prrnciplesunderlying :::e applicatlon of physical agents,to the researcheval:.rng their clinical use, and thence, to the practrcal :.--arlsof selectrngand applyrng each specrficphysrcal :.-nt to optrmize patlent outcome. The enthusrasm ",,,:iewhich the first edition of this book was received, -:-:^udrng complimentary comments, adoption by :-;rly educational programs, and purchase by many :5cians, shows that the need was there and I met it. Given how well the first edition of this book was :r:eived, I was Ieery to make too many changes for --:-:ssecond edition. I have done my best to keep all :::. positive aspectsof the first editron whrle updatrng ::-. in-formatronin all chapters. In addition, the con-.:rs and language of the second editron of the -1-:erican Physical Therapy Associailon's Curde to :;:."sical Therapst Pracficeand the principles of evr:=::ce-basedmedicme have been incorporated rnto *-:s new edition, and a few areashave been clarified ::::nproved in other ways. Updates include consideri: rr1of the most recent researchin all areas,with par:::,ar attention to meta-analyses and systematlc ::l-iews of the literature. Over 50 new illustrauons :,:'"-e been added to clarrfy and update content. In : iirion, all aspects of the text, includrng the case ::;dies, have been modified to be conslstentwrth the -:":'-{eto Phyncal TherapistPractrce,second edrtion.* 1:-e order of the chapters has been changed and, the -1= Preferred Physrcal Theraprst Pracfice PatternsSM are copy:;:-:2002 Amencan PhysrcalTherapy Assocratronand are taken :-i:- rrhe Gwde to Physrcal TheraprstPractue (Gurde to Physrcal T:-::aprst Practrce,2"d Ed. Pht,s Ther 200I,81,9-744) All rrghts :r:,=:-.'ed. Preferred Physrcal Theraprst Practrce PatternsSM rs a :l j.:nark of the Amencan Physrcal Therapy Assocratron
origrnal chapter on traction and compressionhas been drvrded mto two separatechapters,in order to reflect patterns of clmrcal practice rather than the physical propertres of drfferent physical agents.The electrical currents chapter has also been rewritten to make its sfyle, content and level of detail more similar to that of the other chaptersin section rwo of the book. This chapter has been shghtly simplified and shortened while strll thoroughly covering all aspectsof the applicatron of electncal currents rn rehabilitation. In additron to updating this book, there is now comparuon Evolve Online Learning Resources,which is available onlne at hW :/ / evolve.elsevier.com/Cameron The Student ResourceCenter provides a Study Guide with many boards-type multiple-choice questions to help students learn and assess their knowledge. Instructors' resourcesare available to instructors who adopt thrs book. The Instructors' Resource Center rncludes suggestlonsfor laboratory activities, means to assessand document student competence in the selection and application of physical agents, and an electronic image collection of most of the figures in the text. Images in the collection can be copied into PowerPoint presentatlons. The Preface to the First Edition states that this book was intended primarily for physical therapy students and physical therapists although I believed that rt would also meet the needs of physical therapist asslstants,occupauonal therapists, chiropractors and physrcrans,and students m these fields learning about the use of physrcal agents. Since the first edition was releasedrt has come to my attention that many others, including athletic trainers, occupationai therapy assistants,osteopaths,veterinariansand animal trainers also find this book to be a useful tool in their practice. I hope that this new edition continues to meet a wide range of professionals'needs for a readily accessrble, ciear, and thorough text on the appiication of physrcal agentsin rehabilitauon. Michelle H. Cameron xl11
Pref^ceto theFirstEdition Teachingclassesand courseson physical agents,I was =equently asked by ^y students,"ls there a book you '.".'ouldrecommend that covers all this information?" ,rd I would respond, "One of these days I'll write :re.' So, when the phone rang and the person on the :--her end of the line said, "l'm calling from the pub''sher W.B. Saunders.Will you write a new textbook :n physical agents for us?" I immediately said "Yes, ;ue.'Then came the shock, the work, the excite::rent, and now, here, a few years and a few life events "-z.er, that book. is dthough there are other texts on physical agents,I ielieve none cover the information with the same breadth and depth as this one. After reading this book -:-e readerwill be familiar with all the physical agents ':sed by rehabilitation clinicians, including thermal =:ients, water, mechanical agents, and electrical ;gents. The reader will also understand the rypes of :aient problems that can be treated effectively with and the physical properties and phys::-,rz5l.u1agents ::iogical effects of physical agents. Additionally, the :eader will be able to apply this knowledge to select physical agents and treatment parame":propriate ::rs and to use safe and effective application tech::ques in order to optimize patient outcome. The :zader will also have a thorough understanding of -"4-:]yusing physical agents benefits patients, the rypes :: benefits that can be achieved by such interven:ons, and the mechanisms by which such interven:ons produce their effects. This book provides rehabilitation students and ::acticing clinicians with a thorough understanding =:d firm basis for applying physical agents in rehabili-jon. Aithough intended primarily for physical therand physical therapists,this publication ":y'srudents : so meets the needs of physical therapist assistants, : ;c,upationaltherapists,chiropractorsand physicians, =d students in these fields learning about the use of ::lvsical agents.The book is structured to be used by
students as a course text with outlines and objectives at the beginning of each chapter, lists that summarize content throughout the text, and chapter reviews; however, it can certainly be used by practicing clinicians as a reference. There is an accompanying instructor's manual and a study guide available to further facilitate the teaching and learning of the presented information. This book is divided into three sections.The first includes chapters about the physiological processes most commonly affected by the application of physical agents, the second includes chapters about the specific different rypes of physical agents and their application, and the third includes chapters about integrating the application of physical agents with other treatment proceduresand provides suggestions for future research on the application of physical agents in rehabilitation. In Section'l , the reader learns about tissue inflammation and healing, pain, tone abnormalities, and motlon restrictions. This information is presented first so that the information gained from assessment of a patient's presentingproblems can be used in making decisions regarding the selection and application of physical agents. In Section2, rhe readerleams about the specificphysical agentsand their recolrunended clinical uses.Details of contraindicationsand precautionsand specific guidelines for clinical application are presented in consistendy formatted passages that are immediately recognizable and make the material easy to understand and review. The physical and physiological bases for the application of physical agentsare describedfirst, followed by an examination of the researchon the effects of physicai agents,in order to provide a basisfor the recommended clinical application guidelines. This section includes chapters on thermal agents, hydrotherapy, traction and compression, ultrasound, electromagnetic fields and electrial currents.
xvr
Preface to the First Edition
Chapter 6, onthermal agents,describesthe mechanisms and effects of decreasing or increasing tissue temperature and the clinical application of both cooling and heating agents. Chapter 7, onhydrotherapy, describesthe basisfor the therapeutic application of water and provides guidelines for using water to cleanseopen wounds or as an environment for exercise.Chapter B covers the application of mechanical force in the forms of traction and compression;the section on traction focuses on the application of mechanical traction to the spine, while the section focuses on the use of compression for controlling edema. Chapter 10, on electromagnetic agents, describesthe electromagnetic spectrum and the physical agents, including ultraviolet, lasers, and diatherml, that apply electromagnetic radiation to achieve therapeutic effects. Chapter 1.t, on electrical currents, describesthe rypes of electrical currents used in rehabilitation and their application to produce muscle contractions, modulate pain, promote tissue healing, and facilitate transdermal drug penetration. All chapters in Sectionsl and 2 include clmical case studies that illustrate the presented material within the context of patient care and demonstrate the clini-
cal decision-making processesused in selectionof the optimal physrcal agentsand treatment parameters. Section3 integrates the information from the prior rwo sections. Chapter t2 discusses how physical agents may be used in conjunction with each other and with other rypes of interventions. A discussion of how physical agents may be used within the context of different health care delivery systems is also provided in this chapter. The final chapter explains why further research on the use of physical agents in rehabilitation is needed to validate and enable the progress of clinical practice and includes suggestions to direct such research. This is the book on physical agents that I and my students have been looking for. The logical and consistent format of each chapter makes the presented information readily accessible,and the depth of information, complete referencing, and illustratrve case studies facilitate the reader's understanding of how physical agents may be applied safely and effectively to enhance patient rehabilitation. Michelle H. Cameron
Contents z T0 PHYSICAL AGENTS, 1 INTR0DUCTION Definitronsand Examplesof PhysicalAgents,z of PhysicalAgents,z Categories History of the Useof PhysicalAgentsin Medicineand Rehabilitation,+ The Roleof Rehabilitationin PatientCare.s The Roleof PhysicalAgentsin Rehabilitation.o Effectsof PhysicalAgents,z GeneralContraindrcations andPrecautrons for the useof PhysicalAgents,ro ChapterReview,ro
Z: 4 TONE ABNORMALITIES, Dtane D. Allen and (]ail L. Widener Muscle Tone Deftned, za Terminology for Tone Abnormalities, zo Measuring Muscle Tone, 77 The Anatomical Basesof Muscle Tone and Muscle Activation, So Abnormal Muscle Tone and It's Consequences,qj Clinical Case Studies, to+ Chapter Review, ro7
lor RESTRICTI0NS, 5 MOT|ON hnda C. tUlonroe
ONE PATHOLOGY ANDPATIENT SECTION PROBLEMS ,s ANDTISSUE REPAIR, 2 INFLAMMATI0N JuheA. Pryde InflamationPhase(Days1-Q, rs ProliferationPhase(Days3-20),z+ Maturation Phase(Duy 9 On),zo ChronicInflammation,30 FactorsAffectingthe HealingProcess,sz Healingof SpecificMusculoskeletal Tissues,s+ ClinicalCaseStudy,sz ChapterReview,.tZ
+r 3 PAIN, Types of Patn,+z Mechanisms of Pain Reception and Transmission, +5 Pain Modulation and Control, sz Measuring Pain,5zt Pain Management Approaches, 57 Clinical Case Studies,rs Chapter Review, 6;
Introduction. t t z Types of Motion, rrz Patternsof Motion Restriction, 445 TissuesThat Can Restrict Motion, 4'tj PathologiesThat Can CauseMotion Restrictions,,t,tb Assessmentof Motion Restrictions,I tq Treatment Approaches for Motion Restrictions, 't23 The Role of Physical Agents in the Treatment of Motion Restrictions. I 26 Clinical Case Studies, rz7 Chapter Review, rz8
AGENTS TWO THEPHYSICAL SEGTION ISS ANDHEAT, AGENTS: GOLD 6 THERMAL Physical Principles of Thermal Energy, ts+ SpecificHeat, t s4 Modesof HeatTransfer,t s+ erapy, 437 Cold-Cryoth Effectsof Cold.rsa xvrl
Contents
xvlll
z,a CURRENTS, ELECTRICAL
Uses of Cryotherapy, 441 Contraindications and Precautionsfor Cryotherapy, 144 Contraindications for the Application of Cryotherapy, t44 Precautionsfor the Application of Cryotherapy,'t4b Adverse Effectsof Cryothercpy, 44b Application Techniques, r47 Documentation, t55 Clinical CaseStudies,rlt
Heat-Thermother rsa Effectsof.Heat,
SaraShadro
Introduction and History, zzo Terminol ogy for Electrical Currents, 220 Effectsof ElectrrcalCurrents, 227 Clinical Applications of Eiectrrcal Currents, zso ElectricalCurrent in ClinicalPracttce,zsz C ontraindications fo r Electri cal Stimulation, zs7 Precautionsfor ElectricalStimulati on, 238 Documentation, 250 ClrnrcalCase Studies,zsr Chapter keview, zs+
apy,', sa
Uses of SuperfictalHeat, rbz Contraindications and Precautionsfor Thermotherapy, rbz Contraindications for the Use of Thermotherapy, rbs Precautionsfor the Use of Thermothercpy, rb+ Adverse Effectsof Thermotherapy, r66 Application Techniques, t 68 Other Means of Applying Therm otherupy, 't77 DocumentatLon, 't77 Clinical Case Studies,rzz
zar HYDROTHERAPY, PhysicalPropertresof Water,262 PhysiologicalEffectsof Hydrotherapy, zos Uses of Hydrptherapy, zzo Contraindications and Precautionsfor Hydrothe rapy, 278 Contraindications for Local Immersion Forms of Hydrotherapy, zza Precautionsfor Local lmmersion Forms of Hydrotherapy, 27q Contramdrcauons for Full Body Immersion Hydrothe rapy, 280 Precautionsfor Full Body Immerston Hydrotherapy, 284 Precautionsfor Full Body Immersion in Hot or V"ry Warm Water, zrz Precautionsfor Nonimmersion Hydrotherapy, 283 Adverse Effectsof Hydrotherapy, zrs Application Techn iques, z8+ Documentation, 2q5 Safery IssuesRegardingHydrothe rapy, Including Infection Control and Pool Safery,zot Clinical Case Studies,zqs Chapter Review, "toz
Choosing Between Cryotherapy and Thermotherapy, r8o ChapterReview,rBc
rar ULTRASOUNDn History,rso Terminology, t87 Generation of Ultrasound, rg3 Effectsof Ultrasound, rg3 Thermal Effects, rqs Nontherm al Effects, r qs Clinical Applications of Ultrasound, tsb Contramdications and Precautionsfor Ultrasound,zo+ Contraindications for the Use of Ultrasound, zoq Precautionsfor the Application of Ultrasound,zob Adverse Effectsof Ultrasound. zoz Applrcatron Technrque,207 Documentation, 2to Clinical Case Studtes,zr r Chapter Review, zr4
:O; 1 0 TRACTION, Effectsof SprnalTraction, .lo8 Clinical Indications for the Use of Spinal Traction, s to Contraindications and Precautionsfor Spina1 Traction, srz Contraindlcatlons for the Use of Traction, ;2.;
,l::ll:' :lll:i:t: illill
xix
CONTENTS
for the Useof Traction,s,t4 Precautions AdverseEffectsof SpinalTraction,sr7 srs ApplicationTechniques, Documentation.ss+ ClinicalCaseStudies,-tst ChapterReview,ssl
s+o 1 1 COMPRESSION, Effectsof ExtemalCompression,s42 Clinicallndicationsfor the Useof External Compression,3+3 for External Contraindicationsand Precautrons s+9 Compression, Contraindicationsfor the Useof Intermittent or CompressionPumps,s+o Sequential Precautionsfor the Useof Intermittent or CompressionPumps,.t5r Sequential 35.r AdverseEffetsof ExternalCompression, ApplicationTechniques,3t 3 Documentation,3b2 ClinicalCaseStudies,soz ChapterReview,s66
',2 ELECTROMAGNETIC soo RADIAT\0N, -llrchelleIL Cameron.Dtana Perez.and Suzana Otafio-Lata
Physical Properties of Electromagnetic Radia tiorr, szt Physiological Effects of Electromagnetic Radi atiorr, szs PhysicalProperties of Ultraviolet Radiation,sz.r Effectsof UltravioletRadiatron,374 ClinicalIndicationsfor the Useof Ultraviolet Radiation,szt Contraindicationsfor the Useof Ultraviolet Radiation,szz Precautions for the Useof Ultraviolet Radiation,szz AdverseEffectsof UltravioletRadiation.sza ApplicationTechniqves,s7q Documentation,382 SelectingaWLamp,ssz ClinicalCaseStudy,saz PhysicalProperties of Lasers,38.3 Effectsof Cold Lasers,s8t ClinicalIndicationsforthe Useof Cold Lasers.s8b
Contraindlcatronsand Precautionsfor Lasers,:8z Contramdrcationsfor the Use of Lasers,.188 Precauuonsfor the Use of Lasers,.taz PhysicaiPropertiesof Diathermy-Thermal and Nonthermal, .lB8 Typ.r of Diathermy ApplLcators,38q Effectsof Diathermy, 3q2 Clinical Indrcations for the Use of Diathermy,3q3 Contraindications and Precautionsfor Diathermy,395 Contramdrcauons for All Forms of Diathermy,3go Contrandications for Thermal-Level Diathermy, iqb Contraindications for Nonthermal Pulsed ShorwvaveDiathermy, 3q7 Precautionsfor A11Forms of Diathermy, 3q8 Precauilonsfor Nonthermal PulsedShorwvave Diathermy, jgg Adverse Effectsof Diathermy, 3qq Applicatron Techn Lques,i qq Documentatton, 402 Selectrnga Diathermy Devic e, 403 Clinical Case Studtes,/to+ Chapter kevtew, +ob
THREEINTEGRATING SECTION AND AGENTS INTOPRESENT PHYSIGAL PRACTICE FUTURE AGENTS INTO PHYSICAL 13 INTEGRATING PATIENT CARE,+,s Attributes to be Consrderedin the Selectionof Physical Agents,+rb Usrng Physical Agents in Combinatron with Each Other or with Other Interventions, +zo Using Physical Agents within Different Health Care Delivery Systems,+27 Chmcal CaseStudres,+za Chapter Revtew,+.17
RESEARCH AND FORFUTURE 14 DIREGTIONS APPLICATI0N, ++, Why Further Researchon the Physical Agents in Rehabilitation Is Needed, ++z
Contents
Areasfor FutureResearchon Physical Agents,++z of Future MethodologicalCharacteristics Researchon PhysicalAgents,++6 Conclusion,4i3 ChapterReview,+5s
APPENDICES Terms, Used A Glossary of Commonly +ss Abbreviations and B Commonly Used Acronyms, +oo C Unils,+ot
Introductionto Ph icalA7ents :,'i l
SUMMARY
OF
IIVFO RMATlOA/
Definitions and Examplesof PhysicalAgents Categoriesof PhysicalAgents History of the Use of PhysicalAgentsin Medicine and Rehabilitation The Role of Rehabilitationin Patient Care
COVERED
The Role of PhysicalAgents in Rehabilitation Effectsof PhysicalAgents GeneralContraindicationsand Precautionsfor the Use of PhysicalAgents Chapter Review t, ,
,.,.,
OB]ECTIVES UVoncomVletion of this chayter,thereaderwill beable to:
t . Describe, categorize, and compare the types of
5 . Identify the physiologic effects of physical
physical agents used in rehabilitation. 2 . Summarize the history of the clinical application of physical agents. 3 . Explain the role of rehabilitation in patient care. 4 . Explain the role of physical agents in rehabilitation.
agents. 6 . Outline the general contraindications and precautions for the use of physical agents.
'l o Introduction
This book is intended primarily as a course text for those learning to use physical agentsin rehabilitation. It was written both to meet the needs of studenrs learning about the theory and practice of applying physical agents and to assistpracricing rehabilitation professionalsin reviewing and updating their knowledge about the use of physical agents. This book describes the effects of physrcal agents, gives guidelines on when and how physical agents can be most effectively and safely appiied, and describes the outcomes that can be expected from integrating physical agents wrthm a program of rehabilitation. The theory underlying the application of each agent and the researchconcerning its effects are covered to provide a rationale for the treatment recommendations. Information is also provided on the physiologlc processesnfluenced by physical agents in general,and regardingthe specific effects produced by specific agents.After reading this book, rhe reader will be able to integrate the ideal physical agenr(s)and treatment parameters within a complete program of rehabilitation care to promore optimal patient outc om e. This book uses a framework for describing the clinical use of physical agenrs based on rhe Gwde to PhysrcalTherapstPracilce,2ndedttion (herein nored as the Guide).1However, this book presentsmore specific, research-basedinformation regarding the theaU, rationale, assessment process, and treatment parametersfor the applicarion of physical agentsthan provided by the Guide. It is important ro note that the Guide is based on descriptions of preferred practice patterns for selected patient diagnostic groups. These practice patterns are not prescriptive, nor are they based on a review of available research evidence. Following this introductory chapter, the book rs divided into three secrions.The first section covers the different rypes of musculoskeletaland neuromuscuiar problems that may be addressed by the use of physical agents. The second section describes the physical properties, physiologic effecrs, and application techniques for the different rypes of physical agents available.The third secrion integrates information from the first wvo and summarizes how different rypes of problems may be influenced by different physical agenrs, how rreatments with physical agents may be integrated into a patienr's compiete plan of care, and how physical agenrsmay be applied under different health care delivery
to Physical Agents
systems.The final chapter discussesdirectionsfor future researchon the useof physrcalagentsin rehabilitation.A glossaryof termsand abbreviations used in describingand documentingthe apphcationof physicalagentsrs provrdedin Appendx A on pages 456-459.
DEFINITIONS ANDEXAMPLES OFPHYSICAL AGENTS Physicalagentsare various forms and means of applying of energy and materials to parienrs. Physical agents include heat, cold, water, pressure, sound, electromagnetrcradratron,and electncalcurrents.The term Vhysicalagentcan be used to describethe general rype of energy,such as electromagnetic radiation or sound; a specific range within the generaltype, such as ultraviolet radiation or ultrasound and the actual means of applying the energy, such as an ultravioiet lamp or an ultrasound transducer.The rerms Vhysical modality and modality are also frequently used in place of the term yhysical agent and are used interchangeably in this book, with variation for ease of reading.
CATEGORIES OFPHYSICAL AGENTS Physical agents are most readlly categorized as thermal, mechanical,or electromagnenc (Table 1-1). Thermal agents include deep-heatingagents,superficial heating agents, and superficial cooling agents. Mechanical agents include traction, compresston, water, and sound. Electromagnetic agents include electromagneticfields and electricalcurrents.
Thermal Agents Thermal agents transfer energy to a patient to produce an increase or decreasein tissue temperature. Different thermal agents produce the greatestchange in temperature in different rypes and areas of tissue. For example, a hot pack producesthe greatesttemperature increasein superficial tissueswith hrgh thermal conductiviry in the area directly below rt. In contrast, an ultrasound produces the most heat in tissues with high ultrasound absorption coefficlents, such as tendon and bone. It produces this effect up to a depth of 5 cm but only in a small area, approximately twice that of the effective radiating area of the transducer.
4 o INTRODUCTION TO PHYSICAL ACENTS
Thermal
Deep-heatmg agents Superficral heatrng agents Cooling agents
Drathermy Hot pack Ice pack
Mechanical
Tracuon Compressron Water Sound
Mechamcal tracuon Elastrcbandage Whrrlpool Ultrasound
Electromagnertc
Electromagnetlc fields Electrrc currents
TENS
Thermal agents that increase tissue temperature are most commonly appliedwhen increasing of circulation, metabolic rate, and soft tissue extensibiliry or the decrease of pain ire expected to promote the goals of treatment. Thermal agents that decreasetissue temperature are most commonly applied when decreasing circulation, metabolic rate, or pain is expected to promote the treatment goals. A full discussion of the principles underlying the processesof heat transfer, the methods of heat transfer used in rehabilitation, and the effects, indications, and contraindications for applying superficial heating and cooling agents is provided in Chapter 6. The principles and practice of applying deep heating agents are discussedin ChapterT inthe section on thermal applicarions of ultrasound and in Chapter 1,2inthe section on diathermy. Ultrasound is a form of sound that cannot be heard by humans becauseof its high frequency. It is defined as sound with a frequency of greater than 20,000 qgcles/second. Ultrasound a mechanical form of enerry composed of alternatingwaves of compression a.rrdrarefaction. Ultrasound is used as a physical agent :n rehabilitation to produce both thermal and nonthernal effects. Thermal effects, including increased deep and superficial tissue temperature, are produced by :ontinuous ultrasound waves of a sufficient intensiry while nonthermal mechanical effects, including caviadon, microstreaming, and acoustic streaming, are ?roduced by both continuous and pulsed ultrasound. l-hermal-level ultrasound is used for the same pur:oses as other thermal agents when deep tissue is rvolved. These purposes include increasing circula-
Ultravrolet
tion, metabohc rate, and soft tissue extensibiliry and decreasing pain. Ultrasound is applied in a pulsed manner to optlmlze the nonthermal effects and facilitate tissue healing or promote transdermal drug penetration. Further information on the theory and practice of applying ultrasound can be found in Chapter 7.
Agents Mechanical Mechamcal agents apply mechanical force to increaseor decreasepressurein or on the body. Water provides resistanceto increaselocal pressure,hydrostatic pressure to increase circumferential pressure, and buoyancy to decreasepressureon weight-bearing structures. Traction decreasesthe pressure berween structures, and compression increases the Pressure between structures. Water can be applied by immersion or nonimmersion techmques.The therapeutic application of water is known as hydrotherafy. Immersion in water produces pressure around the immersed area, provides buoyancy, and, if there rs a difference in temperature between the area and the water, transfers heat to or from the area.Movement of the water produces local pressure,which can be used as resistancefor exercise when an areais immersed and for cieansingor debriding openwounds with orwithout immersion. Further information on the theory and practice of hydrotherapy is provided in Chapter 9. Tracilon is most commonly used to alleviate pressure on structures, such as nerves or joints that produce pain or other sensory changes or that become inflamed when compressed.Tractron application can
4 c Introduction
normalize sensationand prevent or reduce damage or inflammation of compressed structures. The pressure-relievingeffects of traction may be temporcry or permanent, depending on the nature of the underlying pathology and the force, duration, and means of traction application used. Further information on the theory and practice of applying traction is provided in Chapter 10. Compression is used to counteract tluid pressure and control or reverse edema. The force, duration, and means of application of compression can be varied to control the magnitude of the effect and to accommodate different patient needs. Further information on the theory and practice of applying compressionis provided in Chapter 1,1,.
neticAgents Electromag Electromagneti c agents apply electro magnetrc energy in the form of electromagneticradiation or an electrical current. Variation of the frequency and intensity of electromagnetic radiation changes its effects and depth of penetration. For example, ultraviolet radiation, which has a frequency of 7.5 x 1914so 1915 cycles/second,produces erythema and tanning of the skin but does not produce heat, whereas infrared radiation, which has a frequency of 1011 to L014 cycles/second,produces heat only in superficial tissues. Continuous shorrwave diathertrtl, which has a frequency of 10 million to 100 million cycles/second, produces heat in both superficial and deep tissues. When shortwave diathermy is pulsed to provide a low average intensity of energy,it does not produce heat; however, the electromagneticenergy is thought to modify cell membrane permeabiliry and cell function by nonthermal mechanisms and thus acts to control pain and edema. Further information on the theory and practice of applying electromagnetic radiation is provided in Chapter 12. The effects and clinical applications of electrical currents vary according to the waveform, intensiry duration, and direction of the current flow and according to the rype of tissue to which the current is applied. Electrical currents of sufficient intensiry and duration can depolarize nerves, causing sensory or motor responsesthat may be used to control pain or increase muscle strength and control. Electrical currents with an appropriate direction of flow can attract or repel chargedparticlesand alter cell membrane permeabiliry to control the formation of edema, promote
to Physical Agents
tissue healing, and facilitate transdermal drug penetration. Further information on the theory and practice of electrical current application is provided in Chapter B.
AGENTS HISTORY OFTHEUSEOFPHYSICAL ANDREHABILITATION INMEDICINE Physical agents have been a component of medical and rehabilitation treatment for many centuries and are used acrossa wide variery of cultures. For example, the remains of origrnal bath houses with steam rooms and pools of hot and cold water that can still be seen in many major cities of the ancient Romans and Greeks provide evidencethat these cultures used heat and water to maintain health and treat various musculoskeletal and respiratory problems.2 The health benefits of soaking and exercising in hot water regained populariry many centuries later with the advent of health spas in Europe in the late 19th century in areas of natural hot springs. Today, the pracr tices of soaking and exercising in water continue to be popular throughout the world becausethey provide resistance, thereby allowing the development of strength, endurance, and buoyancy, and reducing weight bearing on compression-sensitivej oints. Other examples of the historic use of physical agents include the use of torpedo fish, in approxrmately 400 n.c., to apply electric shocks to the head and feet to treat headachesand arthritis, and the use of amber in the 17th century to generate static electriciry for the treatment of skin diseases,inflammation, and hemorrhage.3 There are also reports from rhe LTth century of charged gold leaf being used to prevent scarringfrom smallpox lesions.a Before the widespread availabiliry of antibiotics and effective analgesic and antiinflammatory drugs, physical agents were commonly used to treat infection, pain, and inflammation. Examples of such applications include the use of sunlight for the treatment of tuberculosis, bone and joint diseases,and dermatologic disorders and infections, and the use of warm Epsom salt baths for the treatment of sore or swollen limbs. Although physical agentshave been used for their therapeutic benefits throughout history over time, new uses, applications, and agents have been developed, and certain other agents and applications have fallen out of favor. New uses of physical agents have developed as a result of increased understanding of
I o INTRODUCTION TO PHYSICAL AGENTS
the biologic processesunderlying disease, dysfunction, and recovery, and in response to the availability of advancedtechnology. For example, the use of transcutaneous electrical nerve stimulation (TENS) for the treatment of pain was developed based on the gate control theory of pain modulation, as proposed by Melzack and Wall. In contrast, the various modes of TENS application now available are primarily the result of the recent development of electrical current generators that allow fine control of the frequency, intensiry, and pulse duration of the applied electrical current. The use or specific application of a physical agent falling out of favor, usually occurs because the treatment is ineffective or because other, more effective ffeatments are developed. For example, infrared lamps were commonly used to treat open wounds because the superficialheat they provide can dry out the wound bed; however, these lamps are no longer used for this appiication because of the knowledge that wounds heal more rapidly when kept moist.5,6 During the early years of the 20th century sunlight was used to treat tuberculosis; however, since the advent of antibiotics, which are generally effective in eliminatnng bacterial infections, physical agents are now rarely used to treat tuberculosis or other infectious diseases.A number of physical agentshave waned in populariry becausethey are cumbersome,have excessive associatedrisks, or interfere with other aspectsof ffeatment. For example, the use of diathermy as a Ceep-heatingagent was very popular 20 to 30 years ago, but becausethe machines are large and awkward :o move around, can easily burn patients if not used appropriately, and the electromagnetic fields can nterfere with the functioning of computer-controlled equipmentnearby, diathermy is rarely currently used -l the United States. This book focuses on the physical agents most :ommonly used in the United States today. Physical sgents that are not commonly of current use in the ',-nited Statesbut were popular in the recent past, and iose that are popular abroad or are expectedto come back into favor as new delivery systems and applica:ons are developed, are covered more briefly. Also -:rcludedin this book is some discussionof modalities being used abroad that are awaiting :urently :nproval by the Food and Drug Administration (FDA) :er clinical use in the United States.The populariry of :arricular physical agentsand applications is basedon :eir history of clinical use and, in most cases,
research data supporting their efftcacy; however, in some cases,their clinical application has continued despite the lack or limitations of supporting evidence. In most cases,more researchis necessaryto elucidate the ideal treatment and patient characteristics for optimal resultsand the precisenature of the outcomes to be expectedfrom the application of physical agents in rehabilitation.
THEROLE OFREHABILITATION PATIENT IN CARE Rehabilitation is a goal-oriented treatment process designed to maximize independence in individuals who have compromised function as a result of underlying pathologic processes and secondary impairments. Rehabilitation generally addressesthe sequelae of pathology rather than the pathology itself. A number of classification schemes exist to categorrze the sequelae of pathology. In 1980 the Wodd Health Orgaruzation (\MHO) published the first classification scheme known as the International Classification of Impairments, Disabilities and Handicaps (ICIDH).7-eThir scheme, based primarily on the work of Wood, classifies the sequelae of pathology as impairments, disabilities, and handicaps.10,11 Shordy thereafter, Nagi developed a model that classified the sequelae of pathology as impairments, functional limitations, and disabilities.12In L993, the National Center for Medical Rehabilitation Research(NCMRR) published a classificationscheme der:ed from a combination of the Nagi model and the original ICIDH mode1.13Most recently, in2001, WHO further revised their classification scheme in their International Classification of Functioning, Disabiliry and Health (ICIDH-2) scheme.la The models of disability and the language used have been revised over time to reflect and creare changesin perceptions of people with disabilities and to meet the needs of different groups of individuals. The original models were intended to differentiate disease and pathology from the limitations they produced. These models were developed primarily for use by rehabilitation professionals. The new expandedmodels have a more positive perspectiveon the changes resulting from pathology and diseaseand are intended for use by a wide range of people, including communiry, national, and global institutions that create policy and allocate resourcesfor persons with
5
4 o Introduction
disabilities. Specifically,the NCMRR model added a category of societallimitations to the functional problems associatedwith disabiliry and it abandoned the previous linear modeling approach to reflect the frequently nonsequential nature of the relationships bewveen categories.The ICIDH-2 has tried to change the perspective of disabiliry from the negative focus of "consequencesof disease"used in the 1980 model to a more positive focus on "components of health." Thus, while the first ICIDH used categoriesof impairments, disabilities, and handicaps to describe sequelae of pathology, ICIDH-2 uses categories of health conditions, body functions, activities, and participation to focus on abilities rather than on restrictions and limitations. This book usesa scheme consistentwith the terminology and framework of the Cuide to Physical TherapistPractice,2nd edition, which is based on the work of Nagi (Fig. 1-1), to evaluate clinical findings and determine a plan of care for the casestudies presented.l
Pathology Diseaseor injury
Functional limitation Restrictionsin the ability to performcomponents of daily life
Disability Inabilityto performtypical activitiesof daily living
Figure1-1, Ciassificationof the sequelaeof pathology. (Data from American Physicai Therapy Association: Cuide to PhysicalTheraqstPractice,ed 2, Alexandria,VA, 200I, The Associatron.)
to Physical Agents
According to the Nagi scheme, the sequelae of pathology are classified as impairments, functional limitations, or disabilities.T,r2Pathologyrefers to the alteration of anatomy or physiology due to diseaseor injury. Lumbar disc herniation and joint inflammation are examples of pathology. are defined as alterations in Impairments anatomic, physiologic, or psychologic structures or functions as the result of some underlying patholagy.7'rzAn impairment is a measure at the organ or organ system level and is equivalent to a sign or an objective measure. For exampie, decreased cervic mobiliry diminished deep tendon reflexes, and absent sensation are all impairments. Impairments may lead to functional limitations or disabilities. A functional limitation, as defined by the Nagi model, is a restriction in the abiliry to perform an acdviry in an efficient, typically expected, or competent manner. Examples of this classification include an inabiliry to lift more than 20lbs or a limitation in sitting tolerance. The Nagi model, then, defines a disabiliry as the inabiliry to perform activities requiredfor self-care,home, work, or community roles. Examples of disabiliry according to the Nagi model are the inabiliry to lift one's child or to walk to the bathroom at home. While medical treatment is genenlly'directed at the underlying pathology or disease, rehabilitation focuses primarily on reversing or minimizing the associated impairments, functional limitations, and disabilities. Essentially, rehabilitation professionals must assessand set goals not only at the level of impairment, such as pain, decreasedrange of motion, or hypertonicity, but also at the level of functional limitation. These goals should include the patient's goals, such as being abie to get out of bed, ride a bicycle, work, or compete in a marathon.
AGENTS THEROLE OFPHYSICAL INREHABILITATION Physical agents are tools to be used, when appropriate, as components of rehabiiitation. The American Physical Therapy Association's (APTA) position statement concerning the exclusive use of physical agents, published in 1995, states that "Without documentation which justifies the necessiryof the exclusive use of physical agents/modalities, the use of physical agents/modalities, in the absenceof other skilled therapeutic or educational intervention, should not be
,I o INTRODUCTION TO PHYSICAL AGENTS
considered physical therapy.'1s This is a clear statement that the APTA believes that the use of physical agents alone does not generally constitute physical therapy, and that, in most cases, physical agents should be applied in conjuncrion with orher inrerventions. The skilled application of physical agents that constitutes a component of physic altherapy involves the integration of the appropriate intervention(s), which may include the application of a physical agent or agentsor the education of the patienr in such application, into the complete program of a patient,s care to facilitate progress toward the functional goals of ffeatment. The aim of this text is to give clinicians a berter understanding of the theory and appropriate applica:ion of physical agents.Therefore the examples, documentation, and clinical casestudies described focus rn the physrcal agent being discussed.Inclusion of all eossible goals and interventions for a given impair:rrent or iimitation is beyond the scope of this book. Physical agents have direct effects primarily at the -evel of impairment. These effects can then promote -:nprovements at the levels of functional limitation disability. Physical agents are used primarily to "nd :educe or eliminate soft tissue inflammation or circu-atory dysfunction, increase the healing rate for soft ::ssue in1ury, modulate pain, modify tone, increase :onnective tissue extensibiliry and length, remodel --:artissue,or treat skin conditions. For example, ther=al agents can be used to increase circulation and ,:celerate the metabolic rate to acceieratehealing, :::d electrical currents can be used to stimulate sen:1ry nerves to control pain or to stimulate motor :-irves to produce muscle contractions. Physical agents are frequently used in conjunction ',-:fi, or in preparation for, other interventions such as --:-erapeuticexercise, functional training, or manual :-cbrhzation to increase the efficacy of these inter=rtions. For example, a hot pack may be applied :=:ore stretching to increase the extensibiliry of the :::erficial soft tissuesand thus promote a more effec:'.'e and safe increase in soft tissue length when the ,:etching force is applied. r,Vhen considering rhe application of a physical .:ent, one should begin the examination by checking : -r physician's referral, if one is required, for a diag--:;is of the patient's condition and any precautionsto :. observed.The examination should include but nor := jmited to the patient's medical history; subjective : : rplaints; review of systems, tests and meisures;
functional status; and disabilities. The examination findings are then evaluated and, when possible, quantified. Following this analysis, a plan of care is established including anticipated goals. Given an understanding of the effects of different physical agents, the clinician can assesswhether treatment using a physical agent may help the patient progress toward the anticipated goals. The clinician can then determine the treatment plan, including the ideal physical agent(s) and treatment parameters if indicated. The treatment plan is modified, as appropriate, when the patient's outcome is assessed.The sequence of examination, evaluation, and intervention is followed in the casesrudiesin Section 2 of this book. Goals and interventions in this text prim afiIy refer to treatment of impairment with the physical agent(s)being discussed.
EFFECTS OFPHYSICAL AGENTS Modiff inflammation and healing Relieve pain Alter collagen extensibility Modiff muscle tone The application of physical agents primarily resulrs in modification of tissue inflammation and healing, relief of pain, alteration of collagen extensibiliry or modification of muscle tone. A brief review of these processesfollows; more complete discussions of these processes are provided in Chapters 2 through 5.
Inflammation andHealing When tissue is damagedby trauma or disease,it usually responds in a similar and predictable way. The first phase of recovery after damage has occurred is inflammation. This is followed by the proliferative phase of healing, which is completed during rhe maturation phase. Modification of inflammation and tissue healing can result in acceleratedpatient progress toward more active participation in rehabilitation and can expedite achievement of the therapy goals. Faster tissue repair can also reduce the risk and severiry of the adverse effects of prolonged inflammation, pain, and disuse. Thermal agents generally modify inflammation and healing by changing the rate of circulation and the
4 o Introduction
rate of chemical reactions. Mechanical agents control motion and alter fluid flo*, and electromagnetic agents alter cell function, particularly membrane permeability and transport. When selected and applied appropriately, physical agents can acceleratethe completion and resolution of the phasesof tissue healing, stimulate necessaryprocessesto resume if they have stopped, accelerate recoveryj and improve the final patient outcome. Physical agents can also minimize the risk of adverse effects from delayed or incomplete healing. However, if selected or applied inappropriately, physical agents may prolong inflammarion, increasethe severity ofassociatedsymptoms, prevent or delay healing, and increase the probabiliry of adverse consequencesand a poor outcome. A brief review of the processesof inflammation and healing and the factors that influence rheir progression follows; a more complete discussion of these processes is provided in Chapter2. During the inflammatory phase of healing, which generally lasts for I to 6 days, the ceils necessary for removing debris and limiting bleeding enrer the rraumatized area. This phase is characterized by heat, swelling, pain, redness, and loss of function. The more quickly this phase is completed and resolved, the more quickly healing can proceed and the lower the probabiliry of joint destruction, excessive pain, swelling, weakness, immobilization, and loss of function. Physical agents generally assist during the inflammatory phase by reducing circulation, reducing pain, reducing enzyme activiry rate, controlling motion, and promoting progression to the proliferative phase of healing. During the proliferative phase, which generally starts within the first 3 days after injury and lasts for approximately 20 days, collagen is deposited in the dama ged areato replace tissue that was destroyed by the trauma; in addition, if necessary myofibroblasts contract to accelerate closure, and epithelial cells migrate to resurface the wound. Physical agents generally assist during the proliferative phase of healing by increasing circulation, increasing errzyme acdviry rate, promoting coliagen deposition, and promoting progression to the remodeling phase of healing. During the maturation phase, which usually srarrs approximately 9 days after the initial injury and can last for up to 2 years, both deposition and resorption of collagen occur. The new tissue remodels itself to resemble the original tissue as closely as possible to
to Physical Agents
best serve its original function. During this phase, the healing tissue changes both in shape and structure to allow for optimal functional recovery.The shape conforms more closely to the original tissue, often decreasingin size from the proliferative phase, and the structure becomes more organized; thus, greater strength is achieved with no change in tissue mass. Physical agents generally assist during the remodeling phase of healing by altering the balance of collagen deposition and resorption and improving the alignment of the new collagen fibers.
PainControl Pain is an unpleasant sensory and emotionai experience associatedwith or describedin terms of actual or potential tissue damage.16-18puitr usually protects individuals by preventing them from performing activities that would cause tissue damage; however, it may also interfere with normal activities and thus result in functional limitation and disability. For example, pain frequently interferes with an individual's ability to sleep,work, or exercise.Relieving pain can allow patients to participate more fuliy in normal activities of daily living and may acceleratethe initiation of an active rehabilitation program, thereby limiting the adverseconsequencesof disuseand ailowing more rapid progress toward the patient's functional goals. Pain may be due to an underlying pathology, such as joint inflammation or pressure on a nerve that is in the processof resolution, or by a pathology, such as a malignancy, that is not expected to fully resolve. In either circumstance,relieving pain may facilitate resolution of the functional limitations and disabiliry that result from the underlying pathology and can therefore assist the patient. The use of pain-relieving interventions, including physical agents, may be continued as long as pain persists and should be discontinued when the pain resolves. Physical agents can control pain by modi Aing pain transmission or perception or by changing the underlying process causing the sensation. Physical agents may act by modulating transmission at the spinal cord level, changing the rate of nerve conduction, or altering the central or peripheral release of neurotransmitters. Physical agents can change the processesthat causepain by modifying tissue inflammation and healing, altering coliagen extensibility, or modifying muscle tone. The processesof pain per-
4 o INTRODUCTION TO PHYSICAL AGENTS
;eption and pain control are explained in greater Cetailin Chapter 3.
Extensibility Collagen Collagen is the main supportive protein of skin, tenCon, bone cartlTage,and connective tissue.19Tissues -hat contain collagen can become shortened as a :esult of being immobilized in a shortened position or -ceing moved only through a limited range of motion. :-mmobilization may be the result of disuse as a result rf debilitation or peripheral or central neural injury, or :nay be due to the application of an external device such as a cast, brace, or external fixator. Movement nay be limited by internai derangement, pain, weak:tess,or poor posture or may be due to the application rf an external device. Soft tissue shortening may ;ause impairment of restricted joint range of motion, shortened muscles,tendons, or joint capsules. To return soft tissue to its normal functional -ength, thereby allowing fuli rnotion without damagng other structures, the collagen must be stretched. Coliagen can be stretched most effectively and safely 'vhen it is most extensible. Since the extensibiliw oF ;ollagen is temperature dependent, increasing in :esponse to increased temperature, thermal agents are frequently applied before soft tissue stretching to cptimize the stretching process20-24(Frg. I-2). The processesunderlying the development and treatment cf motion restrictions are discussed in detail in Chapter 5.
f o ?h z UJ F
x
UJ
z
ul (5 J J
o () TEMPERATURE Figure1-2. Changesin collagenextensibiliqyin response ro changesin temperature.
9
Muscle Tone Muscle tone is the underlying tension that servesas a background for contraction in a muscle.2s Muscle tone is affected by both neural and biomechanical [actors and can vary in responseto a pathology, expected demand, pain, and position.26Abnormal muscle tone is usually the direct result of nerve pathology or is a secondary sequela of pain due to injury of other tissues."' Central neryous system injury, as may occur with head trauma or a stroke, can result in increased or decreased skeletal muscle tone in the affected area, whereas peripheral motor nerve injury as may occur with nerve compression,traction, or sectioning, can decrease skeletal muscle tone in the aFFected area. For example, a patient who has had a stroke may have increased tone in the flexor muscles of the upper extremiry and the extensor muscies of the lower extremity on the same side, whereas a patient who has had a compression injury to the radial nerve as it passesthrough the radial groove in the arm may have decreased tone in the wrist and finger extensors. Pain may cause an increase or decreasein muscle tone. Muscle tone may be increased in the muscles surrounding a painful injured area in order to splint the area and limit motion, or tone in a painFul area may be decreasedas a result of inhibition. Although protective splinting may prevent further injury as a result of excessive activiry, if prolonged it can also impair circulation, retarding or preventing healing. Decreasedmuscle tone as a result of pain-as occursr for example, with the reflexive hypotonicity of the knee extensors-that causes buckling of the knee, when knee extension is painful, can limit activity and thus result in functional iimitation. Physical agents can alter muscle tone either directly, by altering nerve conduction or sensitivity or by altering the biomechanical properties of muscle, or indirecdy, by reducing pain or the underlying problem causing pain. Normalizing muscle tone will generally reduce Functionallimitations and disabiliry allowing the individuai to improve the performance of functional and therapeutic activities. Attempting to normalize muscle tone may also promote better outcomes from passive treatment techniques such as passive mobilization or positioning. The processes underlying changesin muscle tone are discussedfully in Chapter 4.
10
4 e Introduction to Physical Agents
tion to such tissue.Somephysicalagentsaccelerate the growth or metastasisoFmalignanttissue.These effectsarethoughtto resultfrom increasedcirculation or alteredcellularfunction. Care must also be taken when consideringtreatingany areaof the body that Pregnanry currendy has or previously had cancercelis, since Malignanry malignanttissuecan metastasizeand may therefore Pacemaker be oresentin areaswhere it hasnot yet beendetected. Impaired sensation ih" ,rr" of physicalagentsis generallycontraindiImpaired mentation catedwhen rfreenergyof the agentcanreacha pacemakerbecausethe energyproducedby someof these agentsmay alter the functioning of the pacemaker and thus dangerousiychangethe patient'sheartrate. Restrictionson the use of particulartreatmentinterImpairedsensationand mentationare contraindior freventions are categorizedas contraindications Contraindicationsare conditionsthat render cationsor precautionsfor the use of many physical cautions. a particularform of treatmentimproper or undesir- agentsbecausethe end limit for the applicationof theseagentsis the patienl'sreport of how the treatable,while precautionsare conditionsunder which ment feels. For example,for most thermal agents, be applied should of treatment form a particular the patient'sreport of the sensationof heat being absolute The terms limitations.6 special care or with comfortableor painful is used as a guide to limit be can relative contraindications and contraindications the intensity oFthe treatment.If the patient cannot and precautions, place of contraindications used in feelheat or pain due to impairedsensation,or cannot respectively. report this sensationaccurateiyand consistentlydue and preAlthough the specificcontraindications cautions for the application of particular physical to impaired mentation or other factors affecting agentsvary,a numberof conditionsare contraindica- the ability to communicate,the applicationof the tions or precautionsfor the use of most physical treatmentwould not be safe and is thereforecontraindicated. agents.Thereforecautionshouldbe usedwhen conand precautions,includSpecificcontraindications sideringapplicationof a physicalagentto a patient and featuresto assess patient ask the to ing questions with any of theseconditions.In patientswith such of eachphysicalagent, the application before before conditions,the nature of the reslriction,the nalure this book in eachoFthe 2 of in Section are provided and distribution of the physiologic eFfectsof the types of physical different the chaptersconcerning physicalagent,and the distributionof the energyproagents. The ducedby the physicalagentmust be considered. conditionsfor which treatmentwith most physical or requirecautionarc prcg agentsarecontraindicated REVIEW CHAPTER nancy, malignancy,the presenceof a pacemaker, Physicalagentsarevariousforms of energyandmateimpairedsensation,and impairedmentation. rials and their means of applicationas applied to Pregnancyis generallya contraindicationor prepatients.Physicalagentsinclude heat, cold, water, caution for the application of a physical agent if radiation,and elecpressure,sound,electromagnetic the energy produced by the agent or the physiologic effectsof the agentmay reachthe fetus.These trical currents.These agentscan be categorizedas restrictionsapply becausethe influencesof these thermal, mechanical,or electromagnetic'Physical types of energyon fetal developmentare usually agentshave been used for many centuriesand by many culturesand continue to be used today as a not known and because Fetai development is adversely affected by many influences,some oF comoonentof rehabilitation. Rehabilitationfocuseson the treatment oF the which aresubtle. sequelaeof pathology,includingimpairments,funcor precautionfor Malignancyis a contraj.ndication tional limitations,and disabilities.Physicalagentsare the applicationof physicalagentsif the energyproincludedin rehabilitationcareprimarily to afFectthe ducedby the agentor the physiologiceffectsoFthe agentmay reachmalignanttissueor alterthe circuia- impairments dftecrly, thereby reducing functional
CONTRAINDICATIONS GENERAL FORTHEUSE ANDPRECAUTIONS AGENTS OFPHYSICAL
4 I INTRODUCTION TO PHYSICAL AGENTS
limitation and disability. The use oFphysical agents is generally integrated into a program of patient treatment that includes other interventions to optimize the benefit and outcome. When appropriately selectedand applied, physical agents can promote the resolution of inflammation, acceleratetissue healing, relievepain, increasesoft tissue extensi.bllity, and/or modify muscle tone. Most physical agents should not be applied when the energy provided by the agent or the physiologic effects produced can reach a fetus, malignant tissue, or a pacemaker. In addition, physical agents that use the patient's report as a guide for dosage or intensity should not be applied to patients with impaired sensation or mentation.
l1
11. WagstaffS: The use of the InternationalClassification of Impairments,Disabilitiesand Handicapsin rehabilitation, Physiotherayy 68:548-553,1.982. 12. Nagi S: Disability conceptsrevisited.In Pope AM, Tarlov AR, eds:Disabilityin America:Towarda National Agendafor Prevention, Washington,DC, 1,991,, National AcademyPress, 13. National Institutes of Health: ResearchPlan for the Irlailonal Center for Medical RehabilitarionResearch, Bethesda, I\AD,1993,The Institutes. 14. World Health Organization International Classification of FunctioningDkability and Heahh (ICIDH-2), Geneva, 200l, The Organization. 15. American Physical Therapy Association: Positionon exclusiue useof Vhysicalagentsmodalities, Alexandria,VA 1995,Houseof Delegates ReferenceCommrttee,25-95. 16. Sweet WH: Pain: In lield J, Magoun HW, and Hall WE: Handbook of Physiology, Section I, References Neurophysiology, vol. 1, WashingtonDC,1959,Amer 1. American Physical Therapy Association: Guide to PhysiolSoc,pp. 459-506. PhysicalTheraVistPractice,ed 2, .Alexandria,YA, 2001,, 17. BonicaJJ:Pain:What is sciencedoing about rt?Pain The Association. 2:12-15,1975. 2. JohnsonEW: Back to water (or hydrotherapy),J Bacb 18. Merskey H, ed: Classification of chronic pain: Musculosbel Med 4(4):ix,1.994. Descriptionof chronicpain syndromesand definition 3. BakerLL, McNeal DR, BentonLA, et al: Neuromuscular of pain terms,Pain 13(SupplS):s1,, L986. ElectricalStimulation:A PracticalCuide, ed 3, Downey, 1,9. Dorland'slllustrared MedicalDictionaryed2g,PhiadeIphia, CA, 1,993, LosAmigosResearch & EducationInsrirute. 2000,WB Saunders. -1.RobersonWS: Digby'sreceipts,Ann Med HistT(3):216, 20. Lentell,G, Hetherington Eagan et al: The useof ther! J 1925. mal agentsto influencethe effectiveness of low load proJ. Hyland DB, Kirkland VJ: Infrared therapy for skin longed stretch,J Orthoy SVortPhys Ther 16(5):200-207, ulcers,AmJ Nurs80(10): 1800-1801,1980. 1.992. 5. CummingsJ:Role of light in wound healing.In Kloth L, 21,.WarrenC, LehmannJ,Koblanskii: Elongationof rat tail McCullochJM,IeedarJA,eds: rWo und H ealing:Alternativ es tendon:Effectof load and temperature, ArchPhysMed -474, 484,1.97 inManagement, Philadelphia,1990,FADavis. Rehabil 52:465 1.. -. Melvin JL, Nagi SZ: Factorsin behavioralresponse 23. Warren C, LehmannJ, KoblanskiJ: Heat and stretch to impairments, Arch Phys Metl Rehabil 51.:532-537, procedures:An evaluation using rat tarl tendon, Arch 1,970. PhysMed Rehabil 57:122-126,1976. :. SchenkmanM, Buder RB: A model for muitisystem 24. CerstenJW: Effect of ultrasoundon tendon extensibilevaluation,interpretatioq and treatment of individuals rty,AmJPhysMed34:362-369,1955. with neurologic dysfunction,Phys Ther 69(7):538-547, 25. LehmannJ, MasockA, WarrenC et al: Effectof thera1989. peutictemperatureson tendon extensibility,ArchPhys ;. World Health Organization International Classification of M ed Rehab il 5 I :481-487,I970. Imyairments, DisabilitiesandHandicaVs (ICIDH), Geneva, 26. KeshnerEA: Reevaluatingthe theoreticalmodel under1980,The Organization. iying the neurodevelopmental theory: A literature - -,. Wood PHN: The languageof disablement:A glossary review,PhysTher6I:L035-I040,1981. relatingto diseaseand its consequences, Int RehabMed 27. Brooks VB: Motor control: How postureand move2:86-92,1.980. mentsaregoverned,PhysTher63:664-673,1983.
:€-*'
Pathologyand Patient Problems
Inflammation and ssueReVair JulieA. Pryde,MS, PA-C,PT,OCS,SCS,ATC,CSCS SUM,T,IARY O1 lNFOR -nflammation Phase(Days 1-Q lroliferation Phase(Days 3-20) -\laturation Phase(Day 9 on) lhronic Inflammation
WATlOIV
COVERED
Iactors Affecting the Healing Process Healing of SpecificMusculoskeletalTissues Clinical CaseStudy Chapter Review
OBJECTIVES Uponcomyletionof this chaVtet,the readerwill beable to: Define inflammation and identify its possible causes. Identify the five cardinalsignsof inflammation and tfeir causes. List the phasesof tissueinflammation and repair and their relative time ftames. Describethe four responsesof the inflammatory phase. Discussedemaand its qualitative variability. Describethe four processesthat occur in the oroliferation phaseof healing.
7 . Differentiate between the different types of collagenand their rolesin tissuerepair. 8. Describethe differencesbetween the cellular fesponsesin acute and chronic inflammation. 9. Identify local and systemicfactorsthat can affect tissuehealing. 10. Discusshow different types of musculoskeletal tissueheal. 11. List the physical agentsthat can affect or modify tissuehealing.
13
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Trauma or injury to vascularizedtissueresultsin a coordinated,complexJand dynarnic seriesof events collectively refered to as inflammatiotland re7air. Although there are variationsbenveenthe responses of different tissue t)?es, overall the processesare remarkably similar The sequelaedepend on the sourceand site of injury, the stateof local homeostasis, and whether the injury is acute or chronic.The ultimate goal of inflammation and repair is to restore function by eliminating the pathologicalor physical insult,replacingthe damagedor destroyedtissue,and promoting regenerationof noImal tissuestructure. Rehabilitation professionalstreat a variety of inflammatory conditionsresultingftom trauma, surgical procedures,or problematic healing.The clinicianwho is calledupon to managesuchinjuriesneeds to understandthe physiology of inflammation and healingand how it canbe modified. The cliniciancan enhancehealing by the appropriate application of various physical agentsJtherapeutic exercises,or manual techniques.The foundation for a successful rehabilitation program requiresan understandingof biomechanics,the phasesof tissuehealing,and the effects of immobilization and therapeuticinterventions on the healingprocess. Common Causesof Inflammation Soft tissue trasma (spfains, stfains, and contusions) Fractures Foreign bodies (sutures) Autoirnmune diseases (rheurnatoid arthritis) Microbial agents (bacteria) Chemical agents (acid, alkafi) Thermal agents fturns or frostbite) Irradiation (fV or radiation)
This chapterwill provide readerswith information about the processes involvedin inflammationand tissue repair so they can understand how physical agentsmay be used to modify these processesand rmprovepatrentoutcome. The processof inflammationand repairconsistsof three phases:inflammation,proliferation,and maturation. The inflammation phasepreparesthe wound for heaiing;the proliferationphaserebuildsthe damaged structuresand strengthensthe wound; and the marurationphasemodifiesthe scar ussueinto it' matureform (Fig.2-1).The durationof eachphase variesto some degree,and the phasesgenerallyover-
Figure2-1. Flow diagram of the normal phasesof inflam-^-r^-
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-^-^:-
One o PATHOLOGY AND PATIENTPROBLE\4S
Iap. Thus the timetables for the various phasesof healing provided in this chapter are only general guidelines,not precisedefinitions(Fig.2-2).
(DAYS 1-6) PHASE INFLAMMATION Inflammation, from *re Latrn inllamel meaning "to seton fire," beginswhen the normal physiologyof tissue is alteredby diseaseot trauma.l This immediate protectiveresponseattemptsto destroy,dilute, or isolate the cellsor agentsthat may be at fault. It is a norprerequisiteto healing.Ifthere is no nal andnecessary inflammation,healingcannotoccur.Inflammationcan aisobe harmful, particularlywhen it is directedat the '.vrong tissue or is overly exuberant.Ior example, :nappropriatelydirectedinflammatory reactionsthat '-rnderlieautoimmune diseasessuch as rheumatoid :nhritis can causeexcessivescarrinq,which can be
ul
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10 15 20 25 30 35 40 45 s0DAYSFROM TIMEOFINJURY
s
: gure2-2. Time line of the phasesof inflammation and .,1air.
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15
disfiguring and limit joint mobility. Although the inflammatory process follows the same sequence regardlessof the causeof injury somecausestesultin or prolongationof certalnevents. exaggeration CorneliusCelsusfirst describedthe inflammatory phasenearly2000yearsagoasbeingcharacterizedby the four cardinal signsof calor,rubor,tumor,anddolor (Latin terms for heat, redness,swelling, and pain). Functiolaesa(lossof function) was later addedto this list by Virchow, bringingthe numberof cardinalsigns of inflammationto five (Table2-1). An increasein blood in a given area, known as hyyeremia, accountsprimarily for the increasedtemand rednessin the area of acute inflammaperature tion. The onset of hyperemiaat the beginningof the inflammatory responseis conffolled by neurogenic and chemicalmediators.2Localswelling resultsfrom increasedpermeabiliryand vasodilatationof the local blood vesselsand infiltration of fluid into the interstitial spacesof the injured area.Pain resultsftom the pressureof the swelling and from irritation of painsensitivestructuresby chemicalsreleasedfrom damagedcells.2Both pain and swellingmay result in loss of function. There is somedisagreementin the literatureabout the duration of the inflammationphase.Someinvestigatorsstatethat it is relativelyshort,lastingfor less than 4 days,3'aand othersbelieveit may last for up to This discrepancymay be the resultof indi6 days.5,6 vidual and injury-specificvariationor the overlapping natureof phasesof inflammationand tissuehealing. The inflammatory phase involves a complex sequence of interactive and overlapping events includingvascular,cellular,hemostatic,and immune processes. Humoral and neuralmediatorsact to control the inflammatorv phase.
Z-t Cu.airralSignsof Inflammation Sign (Bnglish)
Sign (Latin)
Heat
Calar
Increasedvascularity
Redness
Rubar
lncreasedvasculariry
Swelling
Tumor
Blockageof lymphatic drainage
Pain
Dolor
Physrcalpressureand/or chemical iIIitation of pain-sensitivestructures
Lossof function
Functiolaesa
Painand swelling
l6
2 . Inllamnratiou nnd fi,,ue kfnir
Vascular Response Alterations in the anatomy and function of the microvasculature, inciuding the capillaries, post-
capiliary venules and lymphatic vessels,are among the earliest responsesin the inflammatory phase.T Trauma.such as a lacerarion.sprain.or contusion physicallydisruptsthesestructuresand may produce bleeding,fluid loss,cell injury and exposureof tissues to foreign matedal,including bacteria.The damaged vesselsrespondrapidiy with transientconstdctionin an attempt to minimize blood loss. This response, which is mediatedby norepinephrine,generailylasts for 5 to 10 minutesbut can be prolongedin the small vesselsby serotonin releasedfrom mast cells and platelets. Followingthe transientvasoconstrictionof iniured vessels,the noninjured vesselsnear the injured areadilate.Capillarypermeabilityis also increased by injury of the capillary walls and in responseto chemicalsreleasedfrom injured tissues(Fig.2,3). The vasodilation and increase in capillary permeability are initiated by histamine, Hageman f a c t o r . b r a d y k i n i n .p r o s r a g l a n d i n a s .n d c o m p l e ment fractions.Vasodilationand increasedcapil lary permeabilitylast for up to t hour after tissue damage.
Histamine is released by mast cells, platelets, and basophils at the injury site.dHistamine causesvasodilation and increased vascular permeability in venules, which contributes to local edema (swelling) formation. Histamine also attracts leukocytes to the damagedtissuearea.9Histamine is activefor approximately t hour after tissue injury10 (Iig. 2-4). Separation of endothelialcell junctionscreates gapsallowing leukocyte to escape
Erythrocytes
lvlarginationof leukocytes on endothelialsudace Figure2-3. Vascular responseto wound healing.
I VasoactiveMediators . Histamine . Serotonin . Bradykinin . Anaphylatoxins . Leukotrienes/ Prostaglandins . PlateletActivating Faclors{PAF)
Chemolactic Factors . FormylatedPeptides . LymPhokines . Monoklnes
Activation ol Plateletsand CoagulationSystem
tt Thfombus Formatron
FlecruitrnenV of Stimulation Inflammatory Cells
vasoaclrve Mediators tl
v
Pe-rea5rlity
IncreasedVascular Pemeability Acute lnflammation . PMNS . Platelets
Chfonic lnflammalion . Macrophages . Lymphocytes . PlasmaCells
Fiqure 2-4. Mediatorsofthe inflammatoryresponse.
One . PATHOLOCY AND PATIENT PROBLEMS
Hagemanfactor (also known as dotring faaor Xll), an enzyme found in the blood, is activated by contact with the negatively charged surfaces of the endothelial lining of vesselsthat are exposed when vesselsare damaged.The role of Hagemanfactor is wvofold. First,it activatesthe coagulationsystem to stop local bleeding. Second, it causes vasoconstrictionand increasedvascularoermeabiliw by actlvatingother plasmaproreins.lt conuert"plasminogen to plasmin and prekallikrein to kallikrein, and it activates the altemative complement Dathw a y r l ( F i 82. - 5 ) . Plasmin augmentsvascularpermeability in botlL the skin and lungs by inducing breakdown of fibrin and by cleavingcomponentsof the complementsystem. Plasminalso activatesHageman factor, which initiatesthe cascadethat generatesbradykinin. Plasmakallikrein attractsneutrophils and cleaves kininogen to generateseveralkinins suchasbradykinin. The ability of a chemical to attuactcells is known as cheffiotaxis. Kinins, suchas bradykinin,are biolog! cally active peptides that are potent inflammatory substancesderived lrom plasma. Kinins function similarly to histamine,causinga marked increasein permeability of the microcirculation.They are most prevalentin the early phasesof inflammation, after
Figure2-5. Hageman factor activation and inflammatory tr p.li, f^r
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they ge rapidly destroyedby tissueproteases
oI Ktnlnases.'"
Prostaglandins(PCEs)are producedby nearly all cellsin the body and are releasedin responseto any damageto the cell membrane.Two prostaglandins affectthe inflammatory phase:PGEl and PGEr.PGE, increases vascuJar permeabilityby anragonizing vasoconstdction,and PCE2atffactsleukocytesand synergizes the effects of other inflammatory mediators such as bradykinin. Proinflammatoryprostaglandins are alsothought to be responsiblefor sensitizingpain receptors.In the early stagesof the healingresponse, prostaglandinsmay regulatethe repair process;they are also responsiblefor the later stagesof inflammation.13 Steroids and nonsteroidalantiinflammatory drugs inhibit prostaglandinsynthesis.Ior example, acetyisalicylic acid (aspirin) and acetaminophen (Tylenol@)disrupt the production of prostaglandins but act at different points in their synthesis.Since prostaglandinsare responsiblefor febrilestates,these medicationsareeffectivein reducinsfever. The anaphylatoxins C3a.C4a.andC5aareimportant products of the complement system. These complement fractions causeincreasedvascularpermeabilify andinducemastce11 and basophildegranultaion, causinga further releaseof histamineand thus potentiatinga further increasein vascularpermeabiliqt QabIe2-2). Aside from the chemically mediated vascular changes, changes in physical attraction betlveen blood vesselwalls also alter blood flow. Durins the initial vasoconstriction. rhe opposingwalls oF the small vesselsbecomeapproximated,causingthe lining of the blood vesselsto stick together Under normal physiologicconditions,the cellmembranesof the inflammatory cells and the basement membranes have mutually repulsivenegative chargesjhowever, after injury this repulsiondecreases and the polarity may actuallybe reversed.This resultsin a decreasein the repulsionberween the circulatinginflammatory cellsandthe vesselwalls andcontributesto the adherenceof inflammatory cellsto the blood vessellinings. As blood flow slows resultins from vasoconstriction of the postcapillaryvenulesandincreasedpermeabiliry of the microvasculature,an increasein the cellularconcentrationoccursin the vessels,resulting in increasedviscosiry In the normal physiological state, the cellular componentsof blood within the microvasculatureare confined to a central axial column,and the blood in conractwith the vesselwall
18
2 . Inflauuntion
2-2 Mediators of the Inflammatorv Response Response
Mediators
Vasodilation
Histamine Prostaglandins Serotonin
Increasedvascular permeabihty
Bradykinin C3a,C5a PAF Histamine Serotonin Prostaglandins
Chemotaxrs
Histamrne Monokines Kallikrein Lymphokines
Fever
Prostaglandins
Pain
Prostaglandins Hagemanfactor Bradykinin
is relativelycelf free plasma.Very early in the inflammatory response,neutrophilsin the circulatingblood begin migrating to the injured area.The sequenceof eventsin the journey of these cells from inside the blood vesselto the tissueoutsidethe blood vesselis known as extavasation. The neutrophils,which are a type of leukocyte(white blood cell),breakaway from t}te centralcellularcolumn of blood and start to ro11 along the blood vessellining (the endothelium)and adhere.They line the walls of the vesselsin a process known as margination. Within t hour, the endothelial lining of the vesselscan be completelycoveredwith leukocytes.As thesecellsaccumulate,they lay down in Iayersin a processknown as yavemetting,Certain mediatorscontrol the adherenceof leukocytesto the endothelium, either enhancing or inhibiting this process. for example, fibronectin, a glycoprotein presentin plasmaand basementmembranes,has an important role in the modulation of cellular adherence to vessel walls. After injury to the vessels, increasedamountsof fibronectinare depositedat the injury site. The adherenceof the leukocytesto the endotheliumor vascularbasementmembraneis critical for the recruitmentof leukocytesto the site of the injury.
nnd Ti<
After margination occurs, leukocytes begin to squeezethrough the vesselwalls in a processknown The leukocytesinsert their pseudopods asdiayedesis. junctions into the betweenthe endothelialcells,crawl *rrough the widened junctions, and assumea position betlveen the endothelium and the basement membrane.Then, attracted by chemotacticagents, *rey escapeto reachthe interstitium.This processof leukocytemigration from the blood vesselsinto the perivasculartissuesis known asezgrationFlg.2-C1. Edema is an accumulation of fluid within the extravascularspaceand interstitial tissues.Edemais the result of increasedcapillaryhydrostaticpressure, increasedinterstitial osmotic pressure,and an overwhelmed lymphatic systemthat is unableto accommodate this substantialincreasein fluid and plasma proteins.Edemaformation and control are discussed in detail in Chapter 11.The clinicalmanifestationof edemais swelling. The fluid that first forms edemadurins inflammation has very few cells and very litcle piotein. This fluid is known astransudate. Transudateis madeup of predominandydissolvedelectrolytesand water and has a specificgravity of lessthan 1.0.As the permeability of the vesselsincreases,more cellsand lower molecular weight plasma proteins cross the vessel wall, making the extravascular fluid more viscousand cloudy. This cloudy fluid, known as exudate,has a specificgravity of greaterthan 1.0.lt is alsocharactertzed 6y a high content of lipids and cellular debris. Exudateis often observedearly in the acute inflammatory processand forms in responseto suchminor injuriesasblistersand sunburns. The loss of protein-rich fluid from the plasma reducesthe osmotic pressurewithin the vesselsand increasesthe osmotic pressureof the interstitial fluids.which. in turn. increasesthe outflow of fluid from the vessels,resultingin an accumulationof more fluid in the interstitial tissue.When the exudate'sconcentration of leukocytesincreases,it is known as prs or supFurative exudate.Pus consistsof polymorphonuclear neutrophils, liquefied digestion products of underlyingtissue,fluid exudate,and very often bacteria if an infection is present.When localizedsuppurative exudateoccurswithin a solid tissue,it resultsin an abscess, a localizedcollectionof pusburiedin a tissue,organ,or confined space.Pyogenicbacteriaproduceabscesses. Fourmechanismsare responsiblefor the increased vascularpermeabilityseenin inflammation.The first
One . PATHOLOCY AND PATIENT PROBLEX'IS
19
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Chemoanractant
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:erris. nor ma tnd fluom .uid to!
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Sour"" o, ,nru,, Figure2-6. Illustration of leukocytic events in inflammation: margination, adhesion, diapedesis,and emigration in responseto a chemoattractantemanatingfrom the sourceof the iniury
and predominantmechanismis endothelialcell conraction, which leadsto a widening ofthe intercellular iunctions or gaps. This mechanism affects venules ',vhilesparingcapillariesand arterioles.It is controlled by chemicalmediators and is relatively shortJived, lastingfor only 15to 30 minutes.laThe secondmech anismis a resultof direct endothelialinjury and is an immediate, sustainedresponsepotentially affecting all levelsof the microcirculation.This effect is often seenin severeburnsor lytic bacterialinfections,andis often associatedwith plateletadhesionand thromboendothesis or clot formation. Leukocyte-dependent iralinjury is the third mechanism.Leukocytesbind to lhe area of injury and releasevarious chemicalsand enzvmes that damase the endothelium and thus
increasepermeability.The final mechanismis leakage by regeneratingcapillariesthat lack a differentiated endothelium and therefore do not have tight gaps. This may accountfor the edemacharacteristicof later healinginflammatror.(Frg.2-7).
Response Hemostatic The hemostaticresponseto injury controlsthe blood losswhen vesselsare damagedor ruptured.Platelets, the first cellsat the siteofthe injury enterthe areaand bind to the exposedcollagen,releasingfibrin to stimulate clotting. Plateletsalso releasea regulatoryprotein known as Vlareletderivedgrowthfaaor (PDCF), which is chemotacticand mitogenic to fibroblasts
20
2 . Inflammation and TissueRepair
MECHANISM OF LEAKAGE ANDDISTRIBUTION
Endothelial contraction . venules
Directinjury . all microvessels
Leukocyte-dependant . mostlyvenules .lungcapillaries
Regeneraling endothelium . capillaries . olhervessels
Arteriolar dilatation
Openingof capillary beds
Venular dilatation I
Increased bloodtlow B Figure2-7. A, Illustration of four mechanismsof increasedvascularpermeability in inflammation. B, Vascularchanges associatedwith acute inflammation
and may alsobe chemotacticto macrophages, monocytes,andneutrophils.lsThus plateletsplay a role not only in hemostasisbut also contdbute to the control of fibrin deposition, fibroblast proliferation, and angiogenesis.
When fibrir and fibronectin enter the injured area they form cross-linkswith the collagento createa fibrin lattice.This tenuousstructur€providesa temoorary plug in the blood and lymph vessels,limiting local bleedingand fluid drainage.The lattice sealsoff
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Ore . PATHOLOCY AND PATIENTPROBLEMS
damagedvesselsand confinesthe inflammatory reaction to the areaimmediately surroundingthe injury The damaged,pluggedvesselsdo not reopenuntil later in the heaiingprocess.The fibrin latticeservesas the wound's only sourceof tensilestrengthduringthe inflammatoryphaseof healing.l6
Response Cellular Circulatingblood is composedof specializedcells suspendedin a fluid known as ylasma.These cells include erythrocytes (red blood cells), leukocytes (white blood cells),and piatelets.Redblood cellsplay a minor role in the inflammatory process,although they may migrateinto the tissuespacesif the inflammatory reactionis intense.The primary role of the red blood cells,oxygentransport,is carriedout within the confinesof the vessels.Art inflammatory exudatethat containsblood usually indicatessevereinjury to the microvasculature. The accumulationof blood in a tis sueor organis refeffed to asa hematama; bloody fluid that is present in a joint is called a hemarthrosis. Hematomas in muscle can cause pain and limit m o r i o no r f u n c t i o nr:h e yc a na l s oi n c r e a ssec a r i s s u e formation. A critical function of inflammation is to deliver leukocytesto the area of iniury via *re circulatory system.Leukocytesare classifiedaccordingto their structure into polymorphonucleocytes(PMNs) and mononuclearcells. PMNs have nuciei with several lobes and contain cytoplasmic granules.They are Furthercategorized,by their preferencefor specific histological stains, as neutrophils, basophils, and eosinophiis.Monocytes are larger than PMNs and have a singlenucleus.ln the inflammatory process, leukocytes play the important role of clearing the injured site of debris and microorganismsto set the stagefor tissuerepair(Fig.2-8). Migration of leukocytes into the area of injury occurswithin hours of the in1ury.Eachleukocyte is specialized and has a specificpurpose.Someleukocytes aIe more prominent in early inflammation, whereas others become more impoftant during the later stages.Initially the number of leukocytes at rhe injurysiteis proporrional to theirconcenrration in the circulatingblood (Table2-3). Sinceneutrophils have the highest concentration in the blood, they predominatein the early phasesof inflammation. Chemotacticagentsreleasedby other cells,suchas mast cellsand platelets,attractleuko-
CONNECTIVE TISSUE I\,IATRIX
27
VESSELS
CONNECTIVE TISSUE CELLS
A
Basement
@
membranel Collagentype lV Laminin Fibronectin Proteoglycans Entaclin
Mastcell
n
rioroorast Itl
Elasticfibers
V
td'.\
rg
Collagen fibers
l\,4acrophage
d\+d Proteoglycans
-----,--J
Basophil Figure2-8. Intravascular cells, colnective tissue matdx, and cellsinvolved in the inflammatory response.
$ g
2-3 Cot ."ntration of Leukocytes in Adult Human Blood Typ"
Concentration
Poly morphonuclear Cells Neutrophils Eosinophils Basophils
62.0./. 23% 0.4./.
Mononucleat Cells Monocytes Lymphocytes
5.3./. 30.0%
cytes at the time of injury. Neutrophils rid the injury site of bacteria and debris by phagocytosis. When lysed, the lysosomes of the neutrophils release proteolytic enzymes (proteases)and colwhich begin the lagenolyticenzymes(collagenases),
22
2 c lttllatttttntion
debridementprocess.Neutrophils remain at the site of the injury for only 24 houri, after which time they disintegrate.However, they help to perpetuatethe inflammatory response by releasing chemotactic agentsto attractother leukocytesinto the area. Basophils release histamine after injury and contribute to early increasedvascularpermeability. Eosinophilsmay be involvedin phagocytosisto some degree. Ior 24 to 48 hoursafteran acurernjury.monocytes predominate. Monocytes make up bewveen 4o/o and 8% of the total white blood cell count. The predominanceof thesecellsat this staseof inflammation is thoughr to resuk in parr from rheir longer lite span.Ly'rnphocytessupply antibodiesto mediatethe body's immune response.They are prevalent in chronicinflammatory conditions. Macrophage Products Proteases Elastase Collagenase Plasminogen activator Chemotactic factors fot other leukogztes Complement components of the alternative and classical pathways Coagulation factors Growth-promoting factors for fibroblasts and blood vessels Cl'"tokines Arachidonic acid metabolites Monocytes are converted into macrophages when they migrate from the capillaries into the tissue spaces. The macrophage is considered the most important celi in the inflarnmatory phase and is essen-
nnd Tisstc Reyair
tial for wound healing.Macrophagesare important becausethey produce a wide range of chemicals. They play a major role in phagocytosisby producing enzymes such as collagenase(Fig. 2-9). These enzymesfacilitatethe removal of necrotictissueand bacteria.Macrophagesalso produce factors that are chemotacticfor other leukocytes. Macrophagesalsoprobablyplay a role in localizing the inflammatory processand attractingfibroblaststo the injuredareaby releasingchemotacticfactorssuch as fibronectin. Macrophages chemically influence the number of fibroblastic repak cells activated; therefore,in the absenceof macrophages,fewer, less mature fibroblastsmigrateto the injuredsite. Platelet derived growth factor (PDGI) releasedby platelets during clotting is also releasedby macrophagesand canactivatefibroblasts.In the later stagesof fibroplasia,macrophagesmay also enhancecollagendeposition by causingfibroblaststo adhereto fibrin. As macrophages ingest microorganisms, they excreteproductsof digestionsuchashydrogenperoxide, ascorbic acid, and lactic acid.17Hydrogen peroxideassistsin the control of anaerobicmicrobial growth. The other two products signal the extent of the damagein the area, and their concentration is interyreted by the body as a need for more macrophagesin the area.l8This, in turn, causes increasedproduction of by-products, which then resuitsin an increasedmacrophagepopulation and a more intenseand prolongedinflammatoryresponse. Macrophagesare most effectivewhen oxygen is presentin the injured tissues.However,they can toleratelow oxygen conditions,as is apparentby their presencein chronic inflammatory states.Adequate oxygentensionin the injuredareais alsonecessaryto minimizethe riskof infecrion.I issueoxygentension
Macrophage
Figure2-9. Diagrammatic repres€ntationof the processof phagocl,tosis.
Oqe . PATHOLOCY AND PATIENT PROBLEMS
nt t-
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dependson the concentrationof atmosphericoxygen available for breathing, the amount of oxygen absorbedby the respiratoryand circulatorysystems, and the volume of blood availablefor tlansDortation. as well as rhe stare of the tissues.Local topical application of oxygen to an injured area does not influencetissueoxygen tension as much as the level of oxygenbrought to the injured areaby the circuiating blo6d.le-2t
lmmune Response The immune responseis mediated by cellular and humoral factors. The roles of lyrnphocytes and phagocyticleukocytesin the immune responsewere discussedpreviously.The other mechanisminvolved in the immune responseis the complementsystem which is an important sourceof vasoactivemediators. The complementsystemis one of the most important plasmaprotein systemsof inflammation as its components participate in virtually every inflammatory
ClassicalPathway Activated by immune complexes of antibodies withantigens
23
response.The complementsystem can be activated by antigen-antibodycomplexesand by bacteria,foreignmaterial,and other cellularproducts. The complementsystem is a seriesof enzymatic plasma proteins that is activated by two different pathways, the classical and the alternative.22 Activation of the first componentof either pathway of the cascaderesults in the sequentialenzymatic activationof the downstreamcomponentsof the cascade(Fig.2-10).The end product of the cascade,by either pathway, is a complex of C6, C7, C8, and C9, which form the membraneattack complex (MAC). The MAC creates pores in plasma membranes, *rereby allowing water and ions into the cell. This causesloss of membraneintegrity and cell lysis. The subcomponents generated earlier in the cascade also have important functions. Activation of components C1-C5 produces subunits that enhance inflammationby making bacteriamore susceptibleto phagocytosis(known asopsonization), attractingleukocytes by chemotaxisand acting as anaphylatoxins.
AlternativePathway Activated by cell surfaces
ActivatesClr+C1s
Ite
to on
ActivatesC6, C7, C8, C9 to form membraneattack complex (MAC)
Figure2-10. Overview of the complement system- classicaland alternativeactivation pathways.
24
2 . ltrflarnrnatiortntt/1 li.,ttc Rcfatr
Anaphylatoxinsinducemastcellandbasophildegranu- the classical pathway, C1, C2, and C4 are not lation, causing the release of histamine, platelet involved in the alternativepathway. activatingfactot and leukotrienes.Thesefurther proln summary therearethreemajor consequences of mote increasedvascuiarpermeability. the inflammatory phase.Iirst, fibrin, fibronectin,and The classicalpathway of the complement cas- collagencross-linkto form a fibdn lattice that limits cade is activated by an antigen antibody complex blood loss and providesthe wound widr some initial interactingwith *re first componentof the complestrengdr.Then macrophagesbegin to remove damment cascade, C1.C1 consistsof threeproteins:C1q, aged tissue.finally, endothelialcells and fibroblasts C l r . a n d C l s . C i q b i n d s t o t h e a n t i g e n - a n t i b o d y are recruitedand stimulatedto divide. This sets the complex, resultingin a conformationalchange.Clr stagefor the proliferationphaseof healing(Table2-4). enzymaticallyactivatesC1s so that it can act on C4 and C2. C4 and C2 are cieavedro form C4bC2a,a (DAYS PR0LtFERATt0N PHASE 3-20) complex that acts as a C3 convertase.C3 is cleaved into C3b and C3a by the C3 convertase.C3b then The secondphaseof tissuehealingis known as the cleavesC5, producingC5aand C5b. C5b activatesthe yhase.Thisphasegenerallylastsfor up to Vroliferation production of the terminal products of the cascade, 20 daysand involvesboth epithelialcellsand connecc6-c9. tive tissues.lo Its purposeis to coverthe wound and The alternativepathway of the complementcas- impart strengthto the injury site. cadeis activatedby a variety of cellularand microbial Epithelial ceils form the covedng of mucous and productsand by foreign material.The binding of C3 serousmembranes,and the epidermis of the skin. with tlvo plasmaproteins,factorsB and D, catalyzes Comective tissueconsistsof fibroblasts,ground subthe conversionof C3 to C3bBbwhich functionsas a stance,and fibrous strandsand providesthe structure C3 convertasegeneratingadditional C3a and C3b in for other tissues.The structure,strength,and elastican amplificationstep.C3b then cleavesC5, resulting ity of conn€ctivetissuevariesdependingon the type in the formation of the MAC, C6-C9. In contrastto of tissueit comorises. Fourorocesses occursimultane-
p
,-O ,"--ary
of Eventsof the InflammatoryPhase
Response
Changes in the injured area
Vascular
Vasodilationfollowed by vasoconstnctionat the capillaries,postcaprllaryvenules,and lymphatics Vasodilationmediatedby chemicalmediators histamine,Hagemanfactor,bradykimn, prostaglandins, complementf ractions Slowingofblood flow Margination,pavementing,and ultimatelyemigrationof leukocytes Accumulationof fluid in the interstitialtissuesresultingin edema
Hemostatic
Retractronand sealingoff of blood vessels Plateletsform clotsandassistin burldingoffibrin lattice,which servesasthe wound's sourceoftensile strengthin the inflammatoryphase
Cellular
Delivery ofleukocytesto the areaof injury to rid the areaof bacteriaand debrisby phagocl,tosrs Monocytes,the precursorsof macrophages, areconsideredthe most important cellin the inflammatoryphase Macrophagesproducea numberofproducts essentralto the healingprocess
lmmune
Mediatedby both cellularand humoralfactors Activationof the complementsystemvia the alternativeand classicalpathwaysresultingin componentsthat increasevascuiarpermeability,stimulatephagocytosrs, and act aschemotactic stimuli for leukocytes
One . PATHOLOCY AND PATIENT PROBLEMS
they begin to align themselvesperpendicuincreases, lar to the capillaries. The fibroblastssynthesizeprocollagen,composed of three polypeptide chainscoiled and held together by weak electrostaticbondsinto a triple helix. These chains undergo cleavageby coilagenaseto form Epithelialization tropocollagen.Multiple tropocollagen chains then :oithelialization, *re reestablishmentof the epider- coil together to form collagen fibrils, which then make up collagenfilaments and ultimately combine ::ris,is initiated earlyin prolilerationwhen a wound is ..rperficial.often within a few hours of injury73 to form collagen fibers (Fig. 2-13). CrossJinking .\tLena wound is deep,epithelializationoccurslater, between collagenmoleculesprovides further tensile =:ter collagen production and neovascularization. strengthto the injuredarea. Tissue containing the newly formed capillaries, :oithelialization providesa protectivebarrierto pre-.ent fluid and electroly'telossand to decreasethe risk fibroblasts,andmyofibroblastsis refercedto asgranulation tissue.As the amount of granulation tissue :i infection.Healingof the wound surfaceby epithethereis a concurrentreductionin the sizeof -:alizationalone doesnot provide adequatestrength increases, the fibrin clot, allowing for the formation of a more 3 meet the mechanicaldemandsplacedon most tispennanentsupportstructure.Theseeventsare medi:ues. Suchstrengthis provided by the collagenproated by chemotacticfactorsthat stimulate increased :uced duringfibroplasia. During epithelialization,uninjured epithelial cells fibroblasticactivity and by fibronectinthat enhances misration and adhesionof the fibroblasts.The fibrob:om the margins of the injured area reproduceand tasasinitially produce a thin, weak-structuredcolla:rigrate over the injured area,coveringthe surfaceof --rewound and closingthe defect.It is hypothesized genwith no consistentorganizationknown asty7eIII Thrs period is the most tenuoustime during rat the stimulusfor this activity is the lossof contact collagen. the healingprocessdue to the limited tensilestrength :rhibition that occurswhen epithelial cells are norof the tissue. During the proliferation phase an =ally in contact with one another. The migrating :rithelial cells stay connectedto their parent cells, injured areahas the greatestamount of collagen,yet -:rerebypulling the intact epidermisover the wound its tensile strensth can be as low as 15% of that of normaltissue.2i :Cge. When epithelial cells from one edge meet Iibroblasts also produce hyaluronic acid, a glyrigrating cellsfrom the other edge,they stop moving :ue to contactinhibition (Iig. 2-11).Aithough clean, cosaminoglycan(CAC), which draws water into *re :.oproximatedwounds can be clinically resurfaced area,increasesthe amount of intracellularmatrix, and '.,.'ithin48 hours, larger open wounds take longer to facilitatescellularmigration. It is postulatedthat the compositionof this substanceis relatedto the num]t *ren takes severalweeks for this thin :esurface,24 thereby implyber and location of the cross-bridges, ,ayerto becomemultilayeredand to differentiateinto ing rhat the relationship benveenCAC and collagen =e variousstrataof normalepidermis(Frg.2-12). 17'28 dictatesthe scararchitecture. The formation of cross-1inksallows the newly Production Collagen formed tissueto tolerateearly,controlledmovement without disruption. However, infection, edema, or ibroblasts make collagen. Fibroblast growth, excessive stressonthe healingareamay resultin further takes place in connective tissue. :nown asfibroplasra. and additional depositionof collagen. hflammation :ibroblastsdevelopfrom undifferentiatedmesenchycollagen depositionwill result in excessive Excessive ral cells located around blood vesselsand in fat. that may lirnit the functional outcome. 1ey migrate to the injured areaalongfibrin strands, scarring By the seventhday afterinjury thereis a significant :r responseto chemotacticinfluences,and arepresent increasein the amount of collagen,causingthe tensile i.rroughoutthe injured area.25Adequatesuppliesof strength of the injured area to increasesteadily.By :>,ygen,ascorbicacid, and other cofactorssuch as day 12, the initial immature ty?e IIl collagenstartsto inc, iron, manganese,and copper are necessaryfor :broplasia to occur.26As the number of fibroblasts be replacedby type I collagen,a more mature and :us1y in the proliferation phase to achieve coales:ence and closureof the injured area:epithelializa:on, collagenproduction, wound contraction, and ::eovascularization.
e o t-
d rd o. )le c)e e-
25
26
2 o Itflannation
anl7'issra
Refair
With Injurybasal cells detach irom the basementmembrane.
ce s
The cells migratewhile holdingon to their 'parent'cellsand pulllhem into the center to close the wound. Contact Inhibition
when thetwosrdesmeet,movement ceases,
Basalcells differenliateand proliferate...
...1obecomemultilayered and restorethe epidermis.
Figure 2-11. Schematicdiagramof epithelialization.
strongerform.16,29,30 The ratio of type I to type III collagenincreases sreadilyfrom chispojnron.
Wound Contraction Wound contractionis the finai mechanismfor repairing an injured area.In contrast to epithelialization, which coversthe wound surface,contractionpullsthe edgesof the injured site toged-rer, in effect shrinking the defect.Successfulcontractionresultsin a smaller areato be repairedby scarformation. Contractionof the wound beghs approximately5 days after injury
and peaksafter about 2 weeks.31Myofibroblastsare the primary cel1sresponsiblefor wound contraction. Myofibroblasts,identified by Gabbianiet aI rn 1971, are derived from the same mesenchymaicells as fibroblasts.32 Myofibroblastsare similarto fibroblasts exceptthat they alsopossess the contractileproperties of smooth muscle.Myofibroblastsattachto the margins of the intact skin and pull the entire epithelial layerinward.The rateof contractionis proportionalto the number of myofibroblastsat and under the cell marginsandis inverselyproportionalto the latticecol lagenstructure.
Otc . PATHOLOCY AND PATIENTPROBLEMS
HEALINGBY PRIIVARYINTENTION
27
HEALINGBY SECONDARYINTENTION
24 hours
3 to 7 days
lvlitosis Granulationtissue lvlacrophage Fibroblast New capillary
Fibrous union Wound contraction
; ale rion.
)7r, iasts rties :rar_ :e1ial ral to :cell : col-
Figure2-l2 Diagrammatic comparison of healing by primary intention (left) and secondaryintention (right).
Accordins
rn
rhc
.'.t,''o
tr:mc
th"^^,
.h"
'.vound margin beneath the epidermis is the location :f myofibroblast action.33 A ring of myofibroblasts noves inward from the wound margin. Although :ontractile forces are initially equal, the shape of the
picture frame predictsdre resultantspeedof closure (Frg.2-14).Linear wounds with one narrow dimension contractrapidly;squareor rectangular wounds, wi*r no closeedges,progress at a moderatepace;and circularwounds contractmost slowly.34
28
2 . lrrflotnrnationnnd li..tc Rcynir
Collagen filament Collagen fibril
Primitive coUagen fiber Collagen fibers
Figure 2-13.Dragran-matic representalion of one uopocollagenunit joinirg wirh orhersro lorm collagentilamenrs and, ultimately, collagenfibers.
Figure2-14. Illustration of the picture frame theory of wouno contlactron.
If wound contraction is uncontrolled it can result in the formation of contractures. Contracrures are con ditions of fixed high resistance to passive stretch that may ^result from fibrosis of tissues surrounding a joint.35 Contractures may also result from adhesio'ns, muscle shortening, or tissue damage. Contractures are discussedin greaterdepth in Chapter 5.
Wounds that are rapidly closedwith sutureswith minimallossoltissueandminimalbacterialcontamination can heal without wound contraction.This is known a, healingbv yrimaryunionytimaryinrenrionor When thereis significantlossof tissueor frst ixtention. bacterialcontamhation,wound contractionis necessaryto closethe wound. Wound contractionis the feature that most clearly differentiatesprimary ftom secondaryhealing,alsoknown as healingby secondary intentioxor iadirectuniou.36 Later approximationof a wound's edgeswith suturesor the applicationof skin graftscan reducewound contractionand is krrown as healiugbydelayedyrimatyintention .37'38fo minimize contraction,graftsmust be appliedearlyil the inflammatory phase,beforethe processofcontractionbegins.39 As scartissuematures,it developspressureand tension-sensitivenerveendingsto protect the immature vascularsystem,which is weak and can bleed easilywith any insult. During the proliferationphase, the scaris red and swollen due to the increasein vascularity and fluid, the innervationof the healingsite, and the relativeimmatudty of the tissue.The tissue can easily be damagedand is tender to tension or pressure.
Neovascularization Neovascularization,the developmentof a new blood supply to the injured area, occurs as a result of angiogenesis, the growth of new blood vessels. Healing cannot occur without angiogenesis. These new vessels are needed to suppiy oxygen and nutrients to the injured and healing tissue. It is thought that macrophages signal the initiation of neovascularizatron. Angiogenesis can occur by three different mechanisms: generation of a new vascular network, anastomosts to preexisting vessels,or coupling of the vesselsin the injured area.4o Vesselsin the wound periphery develop small buds that grow into the wound area. These outgrowths eventually come in contact with and join other arterial or venular buds to form a capillary loop. These vesselsfill the injured area,giving it a pinkish to bright red hue. As the wound heals, many of these capillary loops ceaseto function and retract, giving the mature scar a more whitish appearance than the adjacent tissues. Initially the walls of these capillaries are thin, making them prone to injury Therefore immobilization at this stage may help to protect these vesseis and permit further regrowth, whereas excessiveearly
One . PATHOLOGY AND PATIENT PROBLEITIS
/ith
motion can causemicrohemorrhagingand increase 'he likelihood of infection.
29
p ,-s aou"*enTypes
JLS
,or 30r
:om :lary rfa skin nas ma39 and leed
SItC,
ssue nor
looo rgionew ts to that ^-L
f the buds wths artehese rioht
illary ature rt trstnm, tltza^ :ssels early
(DAY PHASE MATURATToN I0N) -\s dre transitionfrom the proliferationto the maturaion stageof healingis made,changesoccurinthe size, :orm, and strengthof the scartissue.The maturation rhaseis the longestphasein the healingprocess.It can rersist for over a year alter *re initial insult. During -Jristime the number of fibroblasts,macrophages, nyofibroblasts,and capillariesdecrease and the water :ontent of the tissue deciines.The scar becomes '.vhiterin appearanceas the collagenmaturesand the '.'ascularitydecreases. The ultimate goal of this phase :srestorationofthe prior functionof the injuredtissue. Severalfactors determine tl-terate of maturation :rrd the final physicalcharacteristics ofthe scar.These :rclude fiber odentation and the balanceof collasen .vnrhesis andlysis. Throughout the maturation phase, synthesis and lysrs of collagen occur in a balancedfashion. llormonal stimulation secondary to inflammation :ausesincreasedcollagendestructionby the enzyme ;ollagenase.Collagenaseis derived from polymor:nogranular leukocytes, the migrating epithelium, ai-rdthe granuiationbed. Collagenaseis ableto break -re strong crossJinkingbonds of the tropocollagen =olecule,causingit to becomesoluble.It is then .xcretedasa wasteby-product.Although collagenase :smost activein the actualareaofthe injury its effects :an alsobe noticed,to a lesserextent,in areasadja-enr to the injury site. Thus remodelrngoccurs --:rrough a processof collagenturnover. Collagen,a glycoprotein,providesthe extracellular :amework for all multicellularorganisms.Although :ore than 27 types of collagenhave been identified, re following discussionis limited to types I, Il, and -llr' f|able 2-5).AII collagenmoleculesaremadeup of -rree separatepolypeptide chains wrapped tighdy :ogetherin a triple left-handedhelix.Type I collagenis re primary collagenfound in bone,skin, and tendon, andis the predominantcollagenin maturescars.Type -l collagenis the major coliagenin cartilage.Type III :ollagenis found in the gastrointestinaltract, uterus, and blood vesselsin adults.It is also the first woe of :olJagen ro be deposited duringrhehealingproceis. During the maturationphase,the collagensynthe;ized and depositedis predominantlyrype I. The bal:nce between synthesisand lysis generallyslightly
Tw"
Distribution
Most abundantform ofcollagen:skn, bone,tendons,and most organs
II
Major cartilagecollagen,vitreoushumor
III
Abundantin blood vessels,rrterus,skin
IV
Ali basementmembranes Mrnor componentof most interstitial ussues
VI
Abundantin most interstitialtissues
VII
Dermal-epidermaljunctron
UII
Endothelium
x
Cartilage
X
Cartilage
favors synthesis.As type I collagenis strongerthan the rype III collagendepositedin the proliferation phase,tensile strengthincreasesfaster than mass.If the rate of collagenproduction is much greaterthan the rate of lysis, a keloid or hypeftrophic scar can result. Both keloids and hypertrophic scarsare the result of excessivecollagendepositiondue to inhibition of lysis. lt is believedthat this inhibition of lysis is due to a genetic defect. Keloids extend beyond the original boundaries of an injury and invade the suffounding tissue,whereas hypertrophic scars, although raised, remain within the margins of the original wound. The treatment of keloid scars through surgery medications,pressure,and iradia44 tion hasonly limited success.42 Collagen synthesis is oxygen dependent,while collagenlysis is not.asThus, when oxygenlevelsare low, the processof maturation is weighted toward lysis,resultingin a softer,lessbulky scar.Hypertrophic scarscan be managedclinicallywith prolongedpressure,which causesa decreasein oxygen,resultingin decreasedoverall collagensynthesiswhile maintaining the level of collagenlysis.37This is one of the basesfor the use of pressuregarmentsin the treatment of patientssufferingftom bums, and for the use of elastomerin the managementof scarsin hand therapy. Eventually,balanceis achievedwhen the scar bulk is flattenedto approximatenormal tissue.
30
2 . Inflannatiou
Collagensynthesisand lysis may last for up to 12 to 24 monthsafreran injury.The high rateof collagen turnover during this period can be viewed as both detrimentaland beneficial.As lonq as the scartissue appearsredderrhanthe surroundingtissue,rernodeling is sLilloccurring.AJthougha joint or rissuesrructure canIosemobiliry quickly duringthis stage,sucha Ioss can still be reversedthrough appropriateinterventron. The physical structure of the collagen fibers is largelyresponsible tor the finalfunctionof rheinlured area.Collagenin scartissueis always lessorganized than collagen in the surrounding tissue. SCarsare inelastic,so redundantfolds are necessaryto Demit mobiliryof the srruturesto which they areattached. To understandthis conceptbetter,onemay considera spring,which, aithoughmadeof an inelasticmaterial, has a spiraledform that, like the redundantfolds of a scar,allows it to expandand contract.If short, dense adhesions are formed, these will restrict motion becausethey cannotelongate. Two theorieshave been proposedto explain the orientation of the collagenfibers in scar tissue:tlre inductiontheory and the tensiontheory.Accordingto the induction theory the scarattemptsto mimic the charactedsticsof the tissue it is healins.46Thus a densetissueinducesa dense.highlycro"s-linledscar, whereasa more pliable tissueresultsin a loose,less cross-linkedscar.Densetissuetypes havea preferential status when multiple tissue types are in close proximity. Basedon this theory, surgeonsattempt to designrepair fields that separatedenseand soft tissues.If this is not possible,as in the caseof repaired tendonleft immobileover bone Fracrures, adhlsions and poorly gliding tendonscan result.In such cases, earlyconrrolledmovementmay be beneficial. According to the tension theory, the intemal and extemalstresses placedon the injuredareaduring the maturationphasedeterminethe final tissuestructure.aoMuscle tension, joint movementJsoft tissue loadingand unJoading. fascialgliding. temperarure changes,and mobilizatjon are alJ forces that are thought to affect collagensfiucture.Thus the length and mobility of cheinjuredareamay be modified-by the applicationof stressduringthe appropriatephases of healing.This theory has been supported by the work of Arem and Madden, which has shown *rat the two most important variablesresponsiblefor successful remodeirngare the phasei of the repair processin which mechanjcal forceswere introduced
and fi>:uc Rerair
and the natureof the appliedforces.aT Scarsneedlowload, long-duration stretch during the appropriate phasefor permanentchangesto occur Studieshaveshown *rat the applicationof tension duringhealingcausesan increasein censilestrength. and immobilization and stress deprivation reduce tensilestrengthand collagenstructure.The recovery curves for tissue experimentallyimmobilized For bet:ween2 and 4 weeks reveal that these processes cantakemonths to reverse,andreversalis oftennever complete. Eachphaseof the healingresponseis necessary and essentialto the subsequentphase.In the optimal scenario,inflammation is a necessarvaspectof the healingresponse and the [irst srept;ward recovery, seting rhe stagefor the ocherphasesof healing.It repeatedinsults or injury occur,however, a chronic inflammatory response may develop that can adverselyafFectthe outcomeof the healingprocess. Acute inflammatory processescan have one of four outcomes.Iirst, and most beneficial,is the complete resolutionand replacementof the injured tissue with like tissue.Second,and most common,is healing by scarformation.The third is the formation of an abscess.Fourth is the possibility of progressionto chronicinflammation.1o
CHRONIC INFLAMMATION Chronic inflammation is the simultaneousproqression of activeinflammation.tissuedestruccion,-and healing.Chronicinflammationcanarisein oneof two ways. The first follows acute inflammation and can be due to the persistenceof the injurious agent(such asa cumulativetrauma)or to someother interference with the normal healing process.The second is a resultof an immune responseto eitheran alteredhost tissueor a foreign material,such as an implant or a suture,or is t}le resultof an autoimmunediseasesuch asrheumatoidarthritis. The normal acute inflammatory processlasts for no morethan2 weeks.II ir continuesfor morechan4 weeks,it is known as subacute inflammation.3 Chronrc inflammationis inflammationthat lastsformonths or years. The primary cells presentduring chronic inflammation aremononuclearcellsincludinglymphocytes, macrophages, andmonocytes(Iig. 2-15).Occasionally eosinophilsare alsopresent.aB The progressionof the inflammatory responseto a chronicstateis a resultof
O e . PATHOLOGY AND PATIENT PROBLEMS
31
Characteristics / Functions
Leukocyte e
Associatedwith . chronic inflammation . phagocytosts
Lysosome
n IJ
e
ibrolyticpathways Regulatescoagulation/f
v
Regulateslymphocyteresponse
)t :S
Ivlonocytesare convertedto macrophageswhen they emigrate from capillanesinto the tissue spaces
:r
v ^l
a
IC
v' If ic
Associatedwith . chronicintlammation
=
immuneresponse Key cell in humoraland cell-mediated
tn
rf :l-
te
Lymphocyte
Ll'
Sparse endoplasmic reticulum
tn
ro
Associatedwilh . allergicreactions . parasiticinfectionsand associatedinflammatoryreactrcns
Granules
Modulatesmasi cell-mediatedreactions rS-
rd 1Q
Eosinophil
ch ce
Assocrated with . acuteinflammation . baclerialandforeignbodyphagocytosis
a )st :a
ch :OI
r4 ric OI
m1ly he oI
@
. Not phagocytic . Contarnshistamine,which causes increasedvascular permeabilfy
Basophil
Figute2-15, Cellular components of acute and chronic inflammation.
32
2 . Itflafltfiatiot
both immunologicand nonimmunologicfactors.The macrophageis an important sourceof inflammatory a n di m m u n o l o g im c e d i a c oa r sn di s a n i m p o r t a ncro m ponent in the regulationof their actions.The role of eosinophilsis much lessclear,althoughthey are often presentin chronic inflammatory conditions that are causedby allergicreactionsor parasiticinfection.4s Chronic inflammation also results in increased fibroblastproliferation,which in turn increasescollagen production and ultimately increasesscar tissue and adhesionformation. This may lead to a loss of function asthe delicatebalancebetweenootimal tensile strengthand mobility of tbe involvei tissuesis lost.
FACTORS AFFECTING THEHEALING PROCESS A number of factors, either local or systemic, can impact or modify the processesof inflammation and repav (Table 2-A1.Localfactors that can affect wound healing include the type, size, and location of the injury infection, blood supply, and external physical forces.
LocalFactors
awl Tissre Repair
Smallerwounds heal faster than larger wounds, and sursicalincisionsheal faster*ran wounds caused by blunl trauma.l6Softtissueinjuriesover bonestend to adhereto the bony surfaces,preventingcontraction and adequateoppositionof the edgesand delaying healing.l6 lnfection Infection in an injured area is the most problematic local factor that can affect healing.Among the complications of wound healing, S0'/" are due to local infection.ll Infections affect collagen metabolism, reducingcollagenproduction and increasinglysis.49 lnfectionoften preventsor delayshealingand encourgranulauon agesexcessive tissueformation.l6 Vascularsupply The healing of injuries largely dependson the availability of a sufficient vascular supply. Nutrition, oxygen tension, and the inflammatory responseall depend on the microcirculatory system to deliver rheir components.50Decreasedoxygen tension resultingfrom a compromisedblood supplycanresult in the inhibition of fibroblastmigration and collagen slmthesis,leadingto decreasedtensilestrengthof the injured area and increasedsusceptibility to infection.2o
Type, size,andlocation oftheiniury Injurieslocatedin well-vascularized tissue,suchas the scalp,heal fasterthan thosein poorlyvascular- Extefnalforces ized areas.16Injuries in areas of ischemia, such as those that may be caused by arterial obstruction or excessivepressure,heal more slowly.16
h p
2-6 FactorsInfluencing Healing Local
Systemic
Type, size,andlocationofinjury Ag" Infection
Infectionor disease
Vascularsupply
Metabolicstatus
Movement/excessive pressure
Nutrition
Temperaturedeviation
Hormones
Topicalmedications
Medication
Electromagnetic energy
Fever
Retainedforeignbody
Oxygen
The application of physical agents including thermal agents,electromagneticenergy,and mechanical forcesmay also influenceinflammation and healing. Cryotherapy (cold therapy), thermotherapy (heat), therapeutic ultrasound electromagnetic radiation, electricalcurrents,and mechanicaipressurehave all been used by rehabilitation professionalsin an attempt to modify the healingprocess.The impact of thesephysicalagentson tissuehealingis discussedin Section2 of this text, which describeseach type of physicalagent,its effects,and its clinicalapplications. Movement Early movement of a newly injured area may delay healing.Thereforeimmobilization may be usedto aid early healing and repair.However, sinceimmobiliry can result in adhesions and stiffness by altering collagencrossJinkingand elasticiry continuouspassive motion (CPM) with stricdy controlled parameters is often usedto remobilize and restorefunction safelv.)rThe use of CPM in coniunctionwi*r short-
One o PATHOLOGY AND PATIENT PROBLEMS
ied nd ac-
rtrc mcal i0, -19
ur-
-:] ofl,
all ver ion' iult 9€n Lhe
:erm immobilization, compared to immobilization alone, has been shown to achieve a better func:onal outcome in some studies; however, odrer srudieshave found differencesonly in early rangeof Ir has also been reponedrhar padents =ocion.5753 :iilizing CPM during the inflammatory phaseof soft :ssue healingafter anterior cruciateligament reconjrruction usesignificandylesspain-relievingnarcotics -,:ranpatientsnot usingcPMs4(Fig.2-10.
Factors Systemic Age -\ge is a factor to be consideredbecauseof variations :r healingbetween the pediatric,adult, and geriatric :opulations.In childhood,wound closure occurs :rore rapidly than in adulthood becausethe physio-rgical changesand cumulative sun exposure that -;cur wtth aging can reducethe healingrace.ss A :ecreasein the density and cross-linkingof collagen, '...'hichresultsin reducedtensile strength,decreased :-umbersof mast cells and fibroblasts,and a lower s- 1n" : rre oI epiLne]ializaLion. occursin the elderly.56 :oor organizationof cutaneous vesselsin olderpeo:le alsoadverselyaffectswound healing.
33
leading to a decrease in local blood flow. Neuropathies, which are alsocommon,canincrease the potential for trauma and decreasethe ability of softtissuelesionsto heal. Patientswho are immunocompromised,such as those with acquired immune deficiency syndrome (AIDS) or those taking immunosuppressivedrugs after organtransplantation,are more prone to wound infections becausethey have an inadequateinflammatory response.AIDS alsoaffectsmany other facets of the healing processthrough its impairment of phagocytosis,fibroblast function, and collagensynthesis.59 Problemsinvolving the circulatorysystem,including atherosclerosis, sicklecell disease,and hypertension, can also have an adverse effect on wound healing since inflammation and healing depend on the cardiovascularsystemfor the delivery of components to the local area of injury Decreasedoxygen tension resulting from a reducedblood supply can result in an inhibition of fibroblast migration and a decreasedcollagensynthesis,resulting in decreased tensilestrengthandmakingthe injuredareamore susceptibleto reinjury Wounds with a decreasedblood supplyarealsomore susceptibleto infection.20'60
tc-
IEI-
ical
LOn,
Disease --.' number of diseasescan affect wound healing ::ther direcdy or indirectly.Ior example,poorly con:ol1eddiabetesmellitus impairs collagensynthesis, r:r.creases the risk of infection due to a dampened and decreases -:rununeresponseJ phagocytosisdue to 58Peripheralvasirerations in leukocytetunction.S0 :.rlar compromiseis alsoprevalentin this population,
I AII an tof dLn rof )ns.
Figure2-16.CIM machine. (Courtesy Thera-l(netics Jompany, Cherry Hill, New Jersey.)
Medications Patientswith injuries or wounds often take medications with systemiceffectsthat alter tissuehealing. Forexample,antibioticscanpreventor fight off infection, which can help to speedhealing but may also havetoxic effectsthat inhibit healing. Corticosteroids,such as prednisoneand dexamethasone,block the inflammatory cascadeearly on by blocking the release of arachidonic acid.61 Corticosteroidshavebeenshown to impair all phases of healingby stabilizingcell membranesand inhibiting the production of prostaglandins.They also decreasethe margination,migration, and accumulation of monocytesat the siteof inflammation.62 They severelyinhibit wound contracture,decreasethe rate of epithelialization,and decreaseahetensilestrength of closed, healed wounds.6366 Corticosteroids that are administeredat the time of injury have a greaterimpact becausedecreasingthe inflammatory responseat this early stagedelayssubsequentphases of healingand increasesthe incidenceof infection. In comparisonwith corticosteroids,nonsteroidal antiinflammatory drugs (NSAIDs)such as ibuprofen are lesslikely to impair healing.They act later in the
34
2 . l la
tnaliol, oud Tis
inflammatory cascade,interruptingthe production of prostaqlandinsfrom arachidonic actd6r Fil 2-77). ih"y Jr. ttot thorrghtto adverselyaffectthe function NSAIDs can of fibroblastsor tissue macrophages.6T causevasoconstrictionand suppressthe intlammatory response,l2however, and some NSAIDs have been found to inhibit celi proliferationduring tendon healing.6B
Studieshave shown that a deficiency of specific nutrients may also affect healing. Vitamin A deficiencvcanretardepithelialization,the rateof collagen synthesis,and croisJinking.TlThiamine (vitamin B) collagenformation, and vitamin ieficiency decreases the tensilestrengthof healed B. deficiencydecreases Vitamin ti"ssue andreducesthe fibroblastnumber.72'73 C deficiency impairs collagensynthesisby fibroblasts, increasesthe capillary rupture potential, arld /a increasesthe susceptibilityof wounds to infection Many mineralsalsoplay an important role in healins. Insufficientzinc can decreasethe rate of epithelialization, reduce-ocollagensynthesis,and decrease tensilesuength.-5 Magnesiumdeficjencymay also causedecreasedcollagensynthesis,and copperinsutto a reduction ficiencymay altercrossJinking,leading in tensilestrength./a
Nutrition Nutrition can have a profound effect on healing tissues.Deficiencyof any o[ a number of important amino acids,vitamins, minerals,or water, as well as insufficient caloric intake, can result in delayed or impairedhealing.This is becausephysiologicalstress from the injury inducesa hypermetabolicstate.Thus if insufficient "fuel" is availablefor the processof inflammationand repair,healingis slowed. ln most cases,healing abnormalities are asso- HEALING OFSPECIFIC ciated with general protein-calorie malnutrition TISSUES MUSCULOSKELETAL rather than depletion of a single nutrient.69Such is The primary determinantsof the outcomeo[ any the casewith patientswith extensivebums who are injury are the type and extent of the injury the rege-nin a prolongedhypermetabolicstate A protein de[ieritive caoaciw of the tissuesinvolved, the vascular ciency can result in decreasedfibroblasticproliferaof damagelo tion, reduced proteoglycanand collagensynthesis, supplvof the iniuredsrte,andthe extent of princrples basic framework.lhe decreasedangiogenesis,and disrupted collagen the extracellulai howall tissues; remodeling./0Protein deficiency can also adversely inflammation and healing apply to which may lead to an increased ever, there is some tissue specificity to the healing affect phagocyto_sis, response.For example,the liver can regenerateeven riskoI infection.ou
Figure2-17, Comparison of the site in the inflammatory cascadeacted on by NSAIDs and steroids
Ore . PATHOLOCY AND PATIENT PROBLEMS
when over half of it is removed, while even a thin hactureline in cartilageis unlikely to heal.
Cartilage
r ) f
:I
Cartilagehas a limited ability to heal becauseit lacks lymphatics, blood vessels,and nerves.77However, ;artilage reactsdifferently when injured alone than -.vheninjured in conjunction with dre subchondral 'cone to which it is attached.Injuriesconfinedto the ;artilage do not form a clot or recruit neutrophilsor nacrophages,and the cells adjacent to the injury ,how a limited capacityto induce healing.This lim:red responsegenerallyfails to heal the defect, and -Jrese lesionsseldomresolve.Ts In injuries that involve both articular cartilage and subchondralbone, the vascularizationof the :ubchondralbone allows for the formation of fibrinibronectin gel, giving accessto the inflammatory -ells and permitting the formation of granulation :ssue. Differentiationofgranulationtissueinto chonCrocytescan begin within 2 weeks. Normafappearng cartilagecan be seenwithin 2 months after the njury However,this cartilagehasa low proteoglycan :ontent and is thereforepredisposedto degeneration :nd erosivechanges./Y
Tendons andLigaments Iendons and ligamentspassthrough similar stagesof realing.Inflammationoccursin the first 72 hours,and :o1lagensynthesis occurs within the first week. - ibroplasiaoccursfrom intrinsic sourcessuchasadja:ent cells,and from extrinsic sourcessuch as those :rought in via the circulatorysystem. The repair potential of tendon is somewhat con=oversial.Both intrinsic cells such as epitendonous :nd endotendonouscellsand extrinsicperitendonous rells pafticipate in tendon repair.The exact role of -Jresecellsand the final outcome dependon several :actors,including the type of tendon, the extent of iamage to the tendonsheath,the vascularsupply,and -he duration of immobilization. The first two stages rftendon healing,inflammationandproliferation,are similar to the healing phasesof other tissues.The -hird phase,scarmaturation,is unique to tendonsin -iat this tissuecan achievea state of repair closeto :egeneration. During the first 4 days following an injury, the with an infiltration of nllammatory phaseprogresses
35
both extrinsicand intrinsic cells.Many of thesecells developphagocyticcapabilities,while othersbecome fibroblastic.Collagensynthesisbecomesevident by days7 to 8, with fibroblastspredominatingat around day 14.Earlyin this stage,both cellsand collagenare oriented perpendicularto the tendon's long axis.80 This orientation changesat day 10, when new collagen fibersbeginto alignthemselvesparallelto the old longitudinalaxis of the tendon stumps.BlFor the following 2 months,thereis a gradualtransitionofalignment, through remodelingand reorientation,parallel to the lone axis. Ultimate maturation of the tissue dependson sufficientphysiologicalloading. If the synovial sheathis absentor uninjured, the relative contributions of the intrinsic and extrinsic cellsare balancedand adhesionsare minimal. If the synovial sheath is injured, the contributions of the extrirsic cellsoverwhelm the capacitiesof the intrinsic cellsand adhesionsarecommon. Factorsaffectingthe repairof tendonsare different from those associatedwith the repair of ligaments.s2 Studieshave shown that mobilization of tendonsby controlled forcesacceleratesand enhancesstrengthening of tendon repair, but mobilization by active contractionof the attachedmusclelessthan 3 weeks after repair generallyresultsin a poor outcome.]he poor resultsmay be a result of the fact that high tension can leadto ischemiaand tendon rupture.Recent studieshavefound no significantdifferencein tendon strengthwhen tendonsare exposedto controlledlow lt or high levelsof passiveforce after repair.8384 appearsthat mechanicalstressis neededto promote appropriate oientation of the collagen fibrils and remodelingof collageninto its mature form and to optimize strength,but the amount of tensionnecessary to promote the optimal clinical responseis not certaln."",""
Many variablesinfluencethe healing of ligamentous tissue,the most important of which are the rype of ligament,the sizeof the defect,and the amount of loadingappiied.For example,injudesto capsularand extracapsularligaments generallystimulate an adequate repair response,while injuries to intracapsular ligamentsoften do not. In the knee,the medial collateral ligament often heals without surgicalintervention, whereasthe anteriorcruciateligamentdoesnot. These differencesin healing may be due to the s)movial environment, the limited neovascularization, or the fibroblastmigrationfrom surroundingtissues.Treatments that stabilize the iniurv site and
36
2 c Inflannatiot
maintainthe appositionof the torn ligamentcanhelp *re ligamentheal in its optimal length and minimize scarring.However, mature ligamentousrepair tissue is still30% to 50oloweakerthan uninjuredligament.sT This does not usually clinically significantly impair joint function becausethe repairedtissue is usually larger than the uninjured ligament. Early, controlled loading of healingligamentscan also promote healing, althoughexcessiveloading may delay or disrupt the healingprocess.88,89
atdTissue Repait
Stages of Fractsre Healing 1. Impaction 2. Induction 3. Inflammation 4. Soft callus 5. Hard callgs 6. Remodeling
Young children have a more elastic bone structure that allows their bones to bend, accountingfor the greenstick-typefracturesseenin this population. Muscle Skeletal Induction is the stage when cells that possess Musclesmaybe injuredby blunttraumacausing a conosteogeniccapabilitiesare activated.lnduction is the tusion,byviolent contractionor excessive stretchcaus- least well-understood stage of bone healing. lt is ing a strain,or by muscle-wastingdiseases. Although thought that the cells may be activatedby oxygen skeletalmusclecellscannotproliferate,stemor reserve gradients,forces,bonemorphogenicproteins,or noncells,known as satellite rclls,can,under some circumcollagenousproteins. Although the timing of this stances, proliferateanddifferentiateto form new skele- processis not known exactly,it is thought to be initital musclecellsafterthe deathof adultmusclefibers.79 ated after the moment of impact.The durationof this Skeletalmuscleresenerationhas beendocumentedin stageis alsonot known, althoughthe influenceof the musclebiopsy tp.ii-".rr kom patientswith diseases induction forcesseemsto lessenwith time. Therefore such as musculardystrophy and poll'rnyositis;howoptimizing the early conditions for healing to miniever, skeletal muscle regenerationin humans after mize the potentialfor delayedunion or nonunionis traumahas not beendocumented.Followins a severe imperative. contusion.a calciFied hematoma.known is nyasiis Inflammationbeginsshordy after impact and lasts ossifcans, may develop.Myositis ossificansis rarefof until somefibrousunion at the fracturesiteoccurs.At lowing surgeryif hemostasisis controlled. the time ofthe fracture,thereis disruptionofthe blood supplyand formationof a fracturehematoma,aswell asa decrease in oxygentensionand pH. This environBone ment favors the growth of the early fibrous or cartilagiBone is a specializedtissuethat is able to heal itself nous callus.This callusforms more easilythan bone with like tissue.Bone can heal by two mechanisms: and helpsto stabilizethe fracturesite, decreasepain, primary or secondaryhealing.Primaryhealingoccurs andlessenthe likelihoodof a fat embolism.lt alsorapwith rigid internalfixation of the bone,while second- idly andefficiendyprovidesa scaffoldfor furthercircuary healingoccursin the absenceof suchfixation. latiorqandfor canilageandendostealboneproduction. Bone goes through a seriesof four histologically The amount of movement at the fracturesite infludistinct stagesin the healing process:inflammation, encesthe amount and quality of the callus. Small soft callus,hard callus,and bone remodeling.Some amounts of movement stimulate callus formation, investigatorsalsoincludethe stagesof impactionand while excessivemovement can disrupt callusformainductionbeforeinflammationin tltis scheme. tion andinhibit bony union. Impactionis the dissipationof the energytrom an The soft callus stage begins when the pain and insult. The impact of an insult is proportionalto the swelling subsideand lasts until the bony fragments energy applied to the bone and is inverselyproporare united by fibrous or cartilaginoustissue. This tional to the voiume of the bone. Thus a fracture is period is marked by a greatincreasein vasculariry more likely to occurif the forceis greatot the bone is ingrowth of capillariesinto the fractufe callus, and small. Energydissipatedby a bone is inverselyproincreasedcellproliferation.The tissueoxygentension portional to its modulus of elasticity.Therefore the remains low. but the oH returns to normal. The bone of a personsufferingfrom osteoporosis,which hematoma becomes organized with fibrous tissue has low elasticiry will sustaina fracturemore easily. cartilageand bone formation; however, no callus is
Orc t PATHOLOGY AND PATIENT PROBLEMS
37
) Clinical CaseStude a The following casestudy summarizesthe conceptsof inflammationand repairdiscussedin this chapter.Based on the scenariopresented,an evaluationof the clinical findingsand goalsoftreatment areproposed.
Case 4
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JPis a 16-year-oldhigh schoolstudent.Sheinjured her right anlle 1 week ago playing soccerand was treated conservativelywith crurches;rest, ice. compression. and elevation (NCE); and NSAIDs. She rcports some improvement,althoughsheis unableto play soccerdue to continued complaints of right lateral ankle pain. Her x-rayfilms showedno kacture,andherfamily physician diagnosed the injury as a grade II lateral ankle sprain. Shecomesto your clinic with an order to (evaluateand treat.' JPsustainedthis injury during a cutting motion while dribblinga soccerball. Shenoted an audiblepop, immediate pain and swelling,and an inabiliry to bearweight. Shereportsttrat herpainhas decreased in intensityftom 8/10 to 6/10 but that it incleaseswith weight bearing and with certain demonstrated movements. The objectiveexam revealsmoderatewarmth of dre skin of the anterolateralaspect of the right ankle. Moderateecchymosisand swellingare alsonoted,with a girth measurement of 34 cm on the right ankle compared with 30 cm on the left. Her range of motion is restrictedto 0 degreesdorsiflexion,30 degreesplantarflexion,10 degreesinversio4 and5 degreeseversion,
with pain noted especiallywi*r plantarflexion and inversion. She exhibits a decreasedstance phase on the right lower extremity. Pain and weakrressoccur on strengti tests of the peroneals,gastrocnemius,and soleusmuscles.JP also exhibits a marked decreasein proprioception,as evidencedby the single-legbalance test.Her anteriordrawertestis positive,and hertalar tilt rsne8at1ve. EVALUATION OF CLINICALFINDINGS The patient presentswith impairmentsof pairl loss of subtalarand talocmalmotioq decreased strengthof the evertomand plantarflexors,increasedgirth of the right ankle, and decreasedproprioceptionresultingin functional iimitation of ambulationand sportsactivitv. She performs home activities independently,without che useof adaptiveequipment. PREFERREDPRACTICEPATTERN Impaired joint Mobiliry, Motor Function, Muscle Performance,and Range of Motion AssociatedWith CoonectiveTissueDysfunction,(4D). PLAN OF CARE The goals of treatment at this time are to control the pain and edema,acceleratethe resolutionof the acute inflammatory phaseof h€aling,and speedthe recovery olJP'snormalrangeof motion, strength,proprioception, and function.
PhysicalTheraPistPracticePattemssMl4DjisCopyright2002AmericanPhysicalTherapy Associatron.All rights reserved. :'reFerred le n.
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visible radiographically.The callusis electronegative :elative to the rest of the bone during *ris period. Osteoclasts remove*re deadbonefrasments. The hard callusstagebeginswhei a sticky.hard ;allus coversthe endsof the fracture,and endswhen 1ew bone uniteswith the fragments.This period cor:espondsto d:)eperiodofclinical and radiologicalfracrure healing.The duration of this period dependson ;he fracture location and the patient's age, and can rangeftom 3 weeksto 4 mon*ts. The remodelingstagebeginswhen the fractureis 'coth clinicallyand radiologicallyhealed.It endswhen -,hebone has returned to its normal state and the catency of the medullary canal is restored. The ibrous bone is convened to lamellar bone, and the nedullary canalis revised.This processcan take severalmonths to severalyearsto complete.90
CHAPTER REVIEW The processesof inflammation and tissue repair involve a complex and dynamic seriesof events,the ultimate goal of which is the restorationof normal function. In these events the involved tissue progressesthrough three stages:inflammation,proliferation, and maturation. The inflammation phase involves interaction of hemostatic.vascular cellular. andimmuneresponses mediatedby a numberof neural and chemical factors.The proliferation phaseis characterizedby epithelialization,fibroplasia,wound contractior\ and neovascularization. The maturation phaseinvolvesbalancedcollagensynthesisand lysis to ultimately remodelthe injuredarea. This seriesof eventsfollows a similar timely and predictablecourse.If the normal healing processis interferedwith however, healingmay be delayedor
38
2 e ln[Iammaion
and Ti>sue Reyair
15. PierceCF,MustoeTA, SeniaRM et al: In vivo incisional wound healingaugmentedby PDCF and recombinant c-sis gene homodimeric proteins, / E^xyMed 167: 975,987,1988. 16. Maninez-HemandezA, Amenta PS:Basicconceptsin wound healing. In Leadbener \48, Buckwalter JA, lxflammatlo4ParkRidge, GordonSL,eds:Spons-lxduced IL, 1990,AmericanAcademyof OnhopaedicSurgeons. 17. Hardy M: The biology of scar formation, Phys Ther 69:1074-1024,1989. 18. RutherfordR" RossR: Plateletfactorsstimulatefibroblasts and smooth muscle celis quiescent in plasma serumto proliferate,J CellBlol69:196-203,1976. 19. Mathes S: Roundtablediscussion:probiem wounds, References PersyectPIasrrc Surg 2 :89-120, 1988 L. Stedmar'sMedrcalDrcnoxaryed 25, Baltimore, 1990, 20. Whimey JD, Heiner S, Mygrant BI et al: Tissue and Williams & Wilkins. wound healingeffectsof sholt duration postoperative 2. Price SA, Wilson LM: Pathophysiology: Cliwcal o*lgen therapy,Biol ResNursJan;2(3):206-215 ed 2, New York, 1982, Coxceptsol DiseaseProtesses, ,2001. 21. Davidson JD, Mustoe TA: Oxygen in wound healing: McCraw Hili. more than a nutrient, \1(/oundReValr Regen May3. KellettJ: Acute soft trssuenjunes a review of the hterature,Med St SVorts Ererc18:489-504,1986. Jun;9 Q):175- 177,2001,. 4. Galrett WE Jr,LohnesJ: Cellularand matrix responses 22. Bell.anttJA,ed: ImnunologyIII, ed 3, Piitadelphia,1985, WB Saunders. to mechanicalinjury at the myotendmousjunction. In 23. Werb A, Cordon S: Elastasesecretionby stimulated Ieadbetter\48, BuckwalterJA, Cordon SL,eds:Spons' macrophages, ItducedInflammauot,Park fudge, IL, 1990,American J ExyMed 142:361-377 , 1975 . 24. Madden JW: Wound healingrbiologic and clinical feaAcademyof OrthopaedicSurgeons. of tures.ln SabistonDC, ed: Davk-ChrktoyherTextbook 5. AndriacchiI SabrstonP, DeHavenK et a1:Ligament: Swgety,ed 1L, Philadelphia,1997,WB Saunders. Injury andrepair InWoo SL-l BuckwalterJA,eds:It4ury 25. Clark RA-F:Overview and general considerationsof and ReVaitof theMusculosleeletal Saftllsaes, Parkfudge, wound repair. In Clark MF, Henson PM, eds: Tle IL, 1988,AmericanAcademyof OrthopaedicSurgeons. Molecular atd Cellular Biology of \Y/oundRepak, New 6. CarrettWE Jr:Musclestraininjuries:Clinicaland basic York, 1988,PlenumPress. aspects, Med Se SponsExerc22:436443,1990. 26. Stotts NA, Wipke-Tevis D: Co"factors in impaired 7. FantoneJC,Ward PA:Inflammation.ln RubrnE, Farber 1996. wound healing,Ostony42(2):44-56, Pl'riladelphra, 1988,JBLippincott. lL, eds:Pathology, L Wrlkerson CB: lnflammauon ln corurectlvelisoue: 27. LevensonS:Practicalapplicationsof experimentalstudies rn the care of primary closedwounds, An J Surg andmanage ment.Athl Ttututkg20:298-301 etrolog'y , 1985. 104:273-282 9. ChristieAI: The tissueinjury cycleand new advances , 1962. toward its managementin openwounds, Athl Trafuing 28. Nemeth-CsokaM. KovacsayA: The effect o[ glycosaminoglycans(CAC) on the intramolecularbind26:274-277 , 1,991. ngs of collagen,ActaBiol30(4):303-308, 1,979. Pathologic 10. RobbrnsSL,KumarV CotranRSet al: Robbins 29. Lachman SM Soft TissueInjuries ut Spotts, St. Louis, BasisofDisease, ed5, Philadelphia,1994,WB Saunders. 1988,Mosby. 11. Fantone JC: Basic concepts in inflammation. In LeadbetterWB, BuckwalterJA, Gordon SL, eds:S7otls- 30. Hunt TK, Van Winkle W Jr: Wound healing. In HeppenstallR3, ed: FractureTreatment and Healing, lwlucedhflamnalox, Park tudge, IL, 1990, American Philadeiphia,1980,WB Saunders. Academyof OrthopaedicSurgeons. 31. Daly T: The repair phase of wound healing: 1.2.PeacockEE\!/oundRepaLr, ed3,Phlladelphia,1984,WB re-eprthehalization and contraction. In Kloth L, Saunders. in McCullochJ,Feederl, eds \X/ound Healing:Abernatives 13. SalterRB,SimmonsDF,Malcom BW et al: The biologiManagement, Phl.adelphia,1990,FA Davis. cal effectsof continuouspassivemotion on the healing oI modified of fu1lthrcknessdefectsin arhcularcartilage,J BaneJoint 32. Cabbiani C, Ryan G, Majeno Gr Presence fibroblastsin granulationtissueand their possiblerole Swg 62-A:1,2321251, 1980. in wound contractioo,Experiertia27:549-550,1971. 14. Majno G, PaladeCE: Studieson inflammauon.L The 33. Watts CT, Grillo HC, GrossJ: Studiesin wound heal effect of histamine and serotoninon vascularpermeing: II. fhe role ofgranulationtissuein contraction,Ar?l ability: an electronmrcroscoprcstudy,/ BnphysBiochem Surg l4B1,53- 1,60, 1,958. Cytolll57l,1961,.
chronic inflammation may result. Various local and systemic factors can influence the progression of inflammation and tissue repair, including physical agents utilized by clinicians to facilitate the healing process. The rehabilitation specialist must assessthe state of inflammation and repair to determine the appropriate agent to incorporate into the treatment plan for an optimal outcome. The reader is referred to the Evolve Website at http://evolve.elsevier.com/ Cameron for study questions pertinent to *Lis chapter.
One . PAIHOLOGY AND PATIENT PROBLEMS
-VcGrath MH, Simon RHr Wound geometry and the kinetics of *re wound contraction,PlastReconstr Surg 72:66-73,1983. Taber's Cyclopedic MedicalDicuonary, ed 75,Philadelphia, 1985,FADavis. Billngham RE, RussellPS:Studieson wound healing, with specialreferenceto the phenomenaofconftacture rn expe mental wounds in rabbit skin, Am Surg 144:961, . , 1,956 SawhneyCP,Monga HL: Wound contracturein rabbits and the effectiveness of skin graftsin preventingitJBlr PlastSurg23:318-321,1970. Stone PA, Madden JW: Biological factors affecting wound contraction,SurgFotuu 26:547-548,1975. RudolphR: Contractionand the control of contraction, VorldI Surg4:279-287,1980. Alvarez OM: Wound healing. In Fitzpatrick T, ed: in CeneralMedicite,ed 3, New York, 1986, Dermatology McCraw-Hill. EyreDR: The collagensof musculoskeletal 5oft tissues. In LeadbetterWB, Buckwalter JA, Cordon SL, eds: SVonsInduced lxflammatiott,Park Ridge, IL, 1990, AmericanAssociarion of Orthopaedic Surgeons. McPhersonJM, Piez KA: Collagenin dermal wound repair.In Clark RAI, HensonPM, eds:Ile Molecularaftd Cellular Biologyof \Yound Repai, New York, 1988, PlenumPress. Kosaka M, Kamrishi H: New concept of ballooncompression wear for the treaffnent of keloids and hypertrophic scars,PlastRecottstr SargOct;108(5): 1454-1,455 , 2001. Uppal RS,Khan U, KakarS et al: The effectsof a single doseof 5-fluorouracilon keloid scars:a clinicaltrial of timed wound irrigation after extralesionalexcision, PlastRecottstt Sutg Oct;108(5):12f8-1224, 2001.. Hunt TK, Van WinlleW: WoundHealing:NormalRepair - Fundamentals of \Yourd Managemettin Swgery,South Plaintield. NJ,1976,Chirurgecom, Inc. MaddenJ:Wound healing:the biologicalbasisof hand surgery,Clh PlastSutg3:3-11,1976. Arem AJ, Madden IW: Iffects of stress on healing wounds: I. Intermittent nonryclica\ tensi.on,J SurgRes 2 0 : 9 31 0 2 , 1 9 7 6 . Fantone JC: Basic concepts of inflammation. In LeadbetterWB, BuckwalterJA,Cordon SL,eds:SponslnducedInflammauon, Park fudge, IL, 1990, American Academyof OrthopaedicSurgeons. Irvin T: Collagenmetabolismin rnfectedcolonicanastomoses,SurgCyxecolObstet143:220-224, 1976. CanicoT, Mehrhof A, CohenI: Biologyofwound healng, SurgClinNonhAn 64:721-733,l9B4. Woo SL, GelbermanRM, Cobb NC et a1:The importanceof controlledpassivemobilization on flexor tendon healing: a biochemical study,Acta OnhoVScatd 52:61,5-622,1,981.
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52. CelbermanRH, Woo SL,LothringerK et al: lffects of early intemittent passiveimmobilization on healing canineflexor tendons,l HandSurgT:170-175, 1982. 53. Lau SK, Chiu KY Use of continuouspassivemohon after total knee arthroplasty,/ AnhtoylastyApr;16(3): 336-339, 2001. 54. McCar*ry M\ Yates CK, Anderson MA et al: The eff€cts of immediate continuous passivemotion on pain duringthe inflammatoryphaseof soft tissuehealcruciare IigamentreconsuucEion, ing followingancerior 1993. IOSPT 17(2\:96-101, 55. Thomas DR: Age-relatedchangesin wound healing, -620,2001. DrugsAging18(8):607 56. Holm-PetersonP,Viidik A: Tensilepropertlesand morphologyof healingwounds in young and old rats,Scand Surg6:24-35,!972. I PlastReconstr 57. van de Kerkhoff PCM, van BergenB, Spruijt K et al: Age-related changes in wound healing, Cln Lrerc 4, 1994. Dernatol1,9:369-37 58. Goodson W, Hunt T: Studies of wound healing in experimentaldiabetesmellitus,/ SurgRes22:22L227, 1997. 59. PetersonM, Barbul A, BreslinR et al: Significanceof T-lymphocytesin wound healing, Surgery2:300-305, 1987. 60. Cogia PP: The biology of wound healtLng,Ostomy 38(9):12-22, 1992. 61. LeadbetterWB: Corticosteroid injection therapy n sports injuries. ln Leadbetter SE, Buckwalter JA, GordonSL,eds:Spo*-lxducedl(lannation, Parkfudge, IL, 1990,AmericanAcademyof OrthopaedicSurgeons. 62. Behrens TW, Coodwin JS: Oral corticosteroids.ln Leadbetter\48, BuckwalterJA,Gordon SL,eds:SportsIxducedlaflannation, Park fudge, IL, 1990, American Academyof OrthopaedicSurgeons. 63. EhlrichH, Hunt T: The effectof cortisoneand anabolic steroidson the tensilestrengthof healingwounds,A tl Sutg 170:203-206 , 1969. 64. BakerB, Whitaker W: Interfercncewith wound healing by the local ac on of adrenocorticalsterolds. 46.544-551, Eudoctixology 1950. 65. Howes E, Plotz C, Blunt J et al: Retardationof wound healingby cortisone, Surgery 28:177-1,81,,1,950. 66. StephensF, Dunphy J, Hunt T; The effect of delayed administration of corticosteroidson wound contracture,Ann Surg173:214-218 , 1971. 67. Abramson SB:Nonsteroidalanti-inflammatorydrugs: mechanismsof action and therapeuticconsiderations. In LeadbetterWB, Buckwalter JA, Cordon SL, eds: SVons-lxduced lnflammatlox,Park fudge, IL, 1990, AmericanAcademyof OrthopaedicSurgeons. 68. fuley CP,Cox M, HarrallRL et al: Inhibition of tendon cell proliferatronand matrix glycosaminoglycansynthesis by non-steroidal anti-inflammatory drugs in vitro,J HandSurg[Brl]rn;26(3):224-228, 2001.
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2 . Iaflamnation and TissueRepair
69. Albina JENutrition in wound heaLng,/Parnter E4teul
-376, 1,994. Nutr18(4):367 70. PollackS:Wound healing:a revtew.III. Nutritional factors affectrngwound healing,J Dernatol Sutg Onco! 1,979. 5:615-619, 7 1 . FreimanM, SerfterE, Connerton C: Vttamin A defiSutg,Forutt21t81-82,1'970. cienry andsurgicals:rress, 72. AlverezOM, GrlbreathRL:Thramrneinfluenceon collagen during granulation of skin wounds, J Surg Res 32:24-31, 1982. 73. GrenierJF,AprahamianM, Cenot C et al: Pantothenic acid (vitamin Br) effioency on wound healing, Acta . VtaminolEnzymol4:81-85, 1'982 74. Pollack S: Systemicdrugs and nutritional aspectsof wound healing,C/laDernatol2:68-80,7984. 75. Sandstead HH, HenriksenLK, GreferJLet al:Zinc nutri' ture in the elderly rn relauonto taste acuiry immune response,and wound healng, An J Cln Natr 36(Suppl 1982. 5):1046-1059, 76. Maitra AK, Dorani B: Roleof zinc m post-injurywound 1992. heahtg,Arch EmergMed Jut;9(2):122-124, 77. AthanasrouKA, ShahAR, HernandezRJet al; Basicsci' ence of arttcular cartilage repatr, Clin Spons Med Ap420(2):223-247,2001. 7 8 . GelbermanR, GoldbergY An K-N et al: Tendon ln Woo SL-l Buckwalter JA, eds: It4ury and Repar of Soft Tssues, Park fudge, IL, 1988, Musculosheletal AmericanAcademyof OrthopaedicSurgeons. 79. CaplanA, CarlsonB, FaulknerJet al: Skeletalmuscle.In Woo SL-Y Buckwalter JA, eds ltlury and Repai of Soft Tissues,Park fudge, IL, 1988, Musculosheletal AmericanAcademyof OrthopaedicSurgeons.
80. Strickland JW: Flexor tendon injuries, Otthoy Ret 15(10):21, 1986.
8 1 .LmdsayWK: Cellularbrologyof flexor tendonhealing ln Hunter JM, SchnerderLH, Mackin EJ, eds Tendon Sutgeryof theHand,St Louis, 1987,Mosby. AkesonWH, FrankCB,Amiel D et a1:Lrgamentbrology and biomechanics. In Frnnerman G, ed: Ameticax Symyostuwor Syons Surgeon's Acadenyof Onhoyaedrc M eddne, SrLours,1985,Mo sby. 83. KetchumLD: Primarytendonhealing:a revie:w, J Haxd 1977. Surg,2:428'435, 84. Goldfarb CA, Harwood F,Silva MJ et al: The effect of vanatlons rn applied rehab rtation force on collagen concentration and maturation at t}le intrasynovial flexor tendon repair slte, J Hatd Sutg lA,:tt] Sep;26(5):B4 I -846, 2001. 85. PeacockEE Jr: Brologicalprinciples in the healing of long tendons,Srrg Cln NonhAn 45:46L-476,1965 86. Potenza AD: Tendon healng wthin the flexor digital sheathin the dog,J Boxelont Sutg44A:49-64, 1,962. 87. FrankC, Woo SL-l Amiel D et al:Medial collateralligarn rabbits, ment healing:a multrdrscrplnaryassessment Med 1L.379'389,1983 AnJ Spons BB. FronekJ,FrankC, Amiel D et aLThe effectsof intermittent passlvemotron (lPM) in the healingof medial collateralligaments,Ir4 nsOrthoVResSocS:31,1983. 89. Long M, Frank C, SchacharN et al: The effects of motion on normal and healingirgaments , TMnsOfthol ResSocT:43,1982. 90. McKibben B: The brology of fracturehealing in long bones,J BoneI ont Surg(Bk) 60:150'162, 1978.
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S U A4A/A I R Y O F 1 , ^ / FO R M A T I O N C O V E R E D Typesof Pain -Mechanismsof PainReceptionand Transmission PainModulation and Control -\4easuringPain
PainManagementApproaches Clinical CaseStudies Chapter Review
rof
ong
OB]ECTIVES ofthis chayter,thereaderwill beableto: Uponcompletion L Differentiate acute,chronic, and referredpain.
2 . Discussthe peripheraland central mechanisms of nociception and pain transmission. Appraisecurrent theories ofpain control. 1 . Selectand apply appropriatemethods and tools to quantify and quali$r pain.
5. Compareand contrastvarious medical and usedto concrolpain. physicaltherapies 6. Evaluatethe use of physicalagentsfor ^^-+-^lt:-^
-^t-
4l
42
3 . Paitr
Painis an experiencebasedon a complex interaction of physical and psychologicalprocesses.it has beendefinedasan unpleasantsensoryand emotional experienceassociatedwith actual or potential tissue damageor describedin terms of suchdamage.l-3Pain usuallyservesas a warning to protect the body from damage and thus, although unpleasant,serves an essentialfunction in survival.aIt is important to realize that pain is not just the activationof receptorsof but also d:re noxious stimuli, known as nociceytion, sensoryexperiencesassociatedwith such activation, as well as the suffering and alterationsin behavior with suchactivation. associated Pain is the most common symPtom prompting patientsto seekmedical attention and is also a predominant D,mptom leadingpatientsto receiverehabilitation.s Many patients with musculoskeletalor neurologicalimpairmentspresentwith compiaintsof pain,andmostof theseindividualsconsiderpaincontroi or relieFto be the primary goalof treatment.oPain may also contribute to physicalimpaiment and disability, limiting participation in home, work, and recreationalactivities./The pain complaintsencountered 6y rehabilitation professionalsare generally relatedto inflammation of musculoskeletalor neurologicalstructurescausedby injury trauma,or degenerativedisease.Thesestructurescan be sourcesof of peripheral the responsiveness painandcanincrease pain recepto$to other painful stimuli.B-10 The goalsof pain treatmentinclude resolvingthe underlying pathology causingthe pain, when possible; modifying *re patient'sperceptionof the discomfort; and maximizing function within the limitations imposed by the source of pain, whether or not the sourceof pain can be modified. The final goal of treatment is resolution of the underlying condition. However,evenwhen the sourceof paincanbe modified by treatment,for example,in the caseof strucrural malalignmentbecauseof poor posrure or imbalancedmusclelength,or when the pain is caused by a self-limiting condition such as inflammation after an acutesoft tissueiniury it is beneficialto control pain during recovery so that the patient can participatemore fully in a rehabilitationprogram to correct the underlying deficit. When the pain is causedby a conditionthat cannotbe direcdymodified, suchasphantomlimb painor rheumatoidar*rritis,pain controlmay facilitateincreasedparticipationin a rehabilitation program, increasedpatient function, and decreased disabiliry
TYPES OFPAIN Pain can be categorizedaccordingto its duration or Acutepain is generor referred. sor:rceasacute,chronic, allv definedaspain oflessthan 6 mon*rs'duration for which an underlying pathology can be identified.ll Acute pain is felt in responseto actualor Potentialtissue damagethat resolveswhen tissuedamageor the threat of damagepasses.Chronic pain,alsoknown as persistentpain, persistsbeyond the normal time for tissue healing.l0Chronic pain conditions are generally the result of activation of dysfunctionalneurological or psychological responsesthat cause the individual to continueto experiencethe sensationof pain evenwhen no damagingor threateningstimulus is present.Referredpain is the experienceof pain in oneareawhen the actualor potentialtissuedamageis in anotherarea.Krowing whether a patient'spain is acute,chronic,or referredwill help the cliniciandeterthat may be conmine the mechanismsandprocesses tributing to the sensationand facilitate selectionof the most appropriateinterventionto controlor relieve this sFnptom.
AcutePain Acute pain consistsof a complex combination of unpleasantsensoryperceptual,and emotionalexpedences with associated autonomic, psychological, emotional, and behavioral reactions that occur in responseto a noxious stimulus provoked by acute Acute pain is generallyviewed injury or disease.l2'13 as biologically meaningful,useful, and timelimited. Acute pain is mediated through rapidly conducting pathways and is associatedwith increasesin muscle rone,heart rate. blood pressure.skin conductance, and other manifestationsof increasedsympathetic nervoussystemactivity.l4The intensity and location of the pain are usually relatedto the degreeof tissue inflarnmation.damage.or destructionin the areain which the pain is felt. Acute pain is generallywelllocalizedand defined,althoughits degreeof localization vades to some extent with the type of tissue involved. Pain sensationsfrom the skin are localized wirh grear accuracy.whereasmuscle pain is [requentlymorediffuse.l5l6 Acutepain lastsas longas the noxious stimulation persists.Acute pain servesa protective function foilowing an injury by Limiting activity to preventfunher damageandpromotetissue healingand recovery;however,it may alsoadversely
Ore . PATHOLOGY AND PATIENTPROBLEMS
,iect an individual's quality of life and impair the ,:,iry to function. Treatment of acute pain resulting from muscu:,.<eletalinjury generallyattemptsto facilitatereso,:on ofthe underlyingdisorder,reduceinflammation, .:-: modify the transmissionof pain from the periph::. ro the centralnervoussystem.
Pain - hronic
e ,f 5
n t5
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rf te
of rial. in Ite 'ed ed. cie rce. ?ttc 10n sue iin 'eLlisue zed iegas .ring SSUC
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-,:onic pain starts as acute pain. Most authors and ::anizations define chronic pain as pain that does -:: :esolvein the usualtime it takesfor the disorder :: :eal or that continuesbeyond the durationof nox: -s stimulation.lT However, some authors and :::anizations use time-based definitions, defining : :rnic pain asany pain lastinglongerthan 3 months The useof time-based definitionsis : i months.18'19 - : recommendedbecausethey do not take into .:-:trunt the variablecourseand duration of different :.=ologies and thereforedo not differentiatelong:.::: pain causedby chronic or progressivediseases : :athological states,such as rheumatoid arthritis, ftom painthat persists -:':er, or neuralentrapments, Chronic pain generpathology has resolved. the :'-:: stimuliareno longer ,-. :ontinuesevenatternoxious : :--'.'eandwhen thereis no longerany tissuedamage : -rreatof tissuedamage,whereaspain from a long::= disorderis generallyassociatedwith a long-term - rous stimulus.It has beenestimatedthat approxi-::ely one third of the American population has . -.::nic pain and 1,47ool the U.S. population suffers := chronicpain relatedto the joints andthe muscu: :ieletalsystem.20'21 with Jhronic persistentpain is generallyassociated -...;ical, psychological,and social dysfunction (see : - :.: . Patientswith chronicpain generallyhave been : - . :ically inactivefor a prolongedperiod,resultingin ;. of strength,skiil, and enduranceand thus progres: disability.They often dramatizetheir complaints, -,::ting that their pain is unbearableor incapacitattreatment,which - = andftequentlyreceiveexcessive , :-effective but can result in drug misuseor abuse -: progressivedependenceon others, including ':. -,i carepractitionersand family members.These including :::ents alsooften show signsof depression, : =,:r'edsleeponset and frequentawakening,altered The painbehavior , :--;rghabits,andsocialisolation.22 : -::epatientwith chronicpersistentpainmay be per-- ,tp..l hw Fin:nri:l o,in 23,24
43
Common Features of Patients with Ghronic Pain Have pain of several months' or years' duration. Have pair similar to the initial pain that is associatedwith a medical problem or injury. History of many treatment failures provided in great detail. Many medications tried, with a minimal to poor response. Continuous use of analgesics and tranquiJizets, despite patients' testimony that the medications offer no notable or long-lasting relief. Pain described as being unbearable and incapacitating. Strong belief that pain has an unidentified organic cause. Desire and willingness expressed to undergo "any treatrnent" for pain relief, Claim that everything will be fine if only the "doctor would treat my pain." Pain not relieved by any medical or surgical treaknent. Sqbstantial psychosocial changes present, especially depression, although patients vehemendy deny the label; they hequendy do admit to feeling frustated, angry, and iffitable, with disturbed sleep, altered moods, weight changes, decreased energy, decreased physical, social, recreational, and sexual activities, and increased family stresses and economic difEculties. From Cildenberg PL, DeVaul M: The ChrcnicPain Patient: andManagemeat, New York, 1985,Karger. Evaluatiotl
Chronic persistent pain may be the result of changesin sympatheticnervoussystem and adrenal activity, reducedproduction of endogenousopioids, or sensitizationof primary afferent and spinal cord neurons. Decreasedlevels of enkephalinsand increasednumbers and sensitivity of nociceptors have been observed in individuals with chronic pain.25These individuals frequendy have increased sensitivity to both noxious (hyperalgesia)and nonnoxious (allodynia)stimuli.26These changesin pain perceptionmay be the result of a processknown as wherebythe pathwind-uyor centralhyyersensitizatiaq ways that transmit pain continue to dischargeafter the discontinuationof intense or repeatedstimulation. Then, evena small additional stimulus exceeds Thus the threshold that is perceivedas painful.2T-3o for an individual with a painful condition that is severeor long-lasting,the noxious stimulation may
44
3 . Pait
resultin increasedpain receptoractivity and a consequentreducedtolerdnce for othernoxiousor nonloxious stimuli. Understanding of this sensitization mechanismhasled to increasedstudy and use of preemptive analgesiabeforeproceduresthat are known to be painful in an attempt to reducepostprocedural painandreducerecoverytime.31-33 Psychologicaland social factors have also been implicated in the etiology and maintenance of chronic pain.3aThe disturbedsleepassociatedwith depression may causemusculoskeletal pain,and the decreased activirymdy perpetuatepain by causing '2 weakness i".on'diiiorring. lndiuidualswiti "nd chronicpain alsofrequentlyadopt the dependentsick patient role and behaviors of the chronic invalid, which result in progressively reduced functional activiryto These behaviors may be unintentionally encouragedby the individual'sfamily members,who, i n a n . a t r e m p rh t oe l p a . c c u a l lpyr o m o t e* r e d e p e n d e n t
tissue include the pain associatedwith myocardial infarctionor anginacausedby cardiacischemiathat is felt in the upperchest,left shoulder,iaw and arm, and pain originating from the central portion of the diaphragmthat is frequently felt in the lateraltip of either shoulder.The gallbladderalsofrequendyrefers pain to the dght shoulderor the inferior angleof the right scapula,and the spleenrefers pain to the left shoulder It is proposedthat pain is refered in one of three ways: from a nerye to its area of innervation,from one area to another derived from the same dermatome, or from one area to another derived from the sameembryonicsegment,becausethe peripheral neuralpathways from thesedifferent areasconverge on the same or similar areasof the spinal cord and synapse with the same second-orderneurons to ascendthe spinalcord and reachthe centralcortex.39 For example,pain is referredfrom the diaphragmto role za the tip of the shoulder becauseboth of these areas Ideally,the developmentof chronicpain shouldbe initially developin the neck regionduring embryonic prevented by early identification of individuals at development, causing drem both to have efferent risk. Patientswith prolonged, severe,or very disinnervationfrom the phrenicnerveand afferentinnerabling acute pain are at increasedrisk of developing vation to the secondthroughfourth levelsof the cervichronic pain. Therefore, to reduce this risk, paincal spine.When pain that may be of eithervisceralor controlling interventions,such as physical agentsor musculoskeletalorigin convergeson the sameneuron medications,shouldbe appliedduring the acutestage in the spinal cord, it is usually interpreted to be of of an iniury and during the later recovery phases, musculoskeletalorigin. This may be becausemuscuw h e n .p a i ni ' s r i l lr h e r e s u l ro f p a i n r e c e p t oar c c i v a - loskeletal injuryandpainareso much morecommon tion.Jo S h o u l dc h r o n i cp a i nd e v e l o ps. u c c e s s ftur e l a t - that the brain "learns"that activity arrivingalongthat ment usually requires that all components of the pathway is associatedwith pain stimulusin a particudysfunction be addressed.Multidisciplinary treatIarmusculoskeletal area. ment programsbasedon a biopsychosocialmodel of Clinicians who treat neuromusculoskeletaldyspain have been specificallydevelopedto address functionmust be awareof the potentialfor pain referthese problems.a These treatment programs are ral and be familiar with common pain referral described beiowin the sectionon painmanagement. patternsto determinethe sourceof a patient'scomplaints and select appropriate treatment methods. Thereforewhen a patienrwith pain in a muscuReferred Pain loskeletalarea seekstreatment, the clinician should Referred pain is felt at a location distant from its first determineif the sourceof the pain is locatedin source. Pain may be referred ftom one joint to the areaof this sensation.Painof musculoskeletal orianother,from a peripheralnerve to a distal area of gin generallyvarieswith position or movementof the innervation.or from an internal organ to an area painful area,whereaspain causedby dysfunction in of musculoskeietal tissue.For example,hip joint other systemsgenerallyvaries with stresson those pathologyoccasionallyreferspain to the knee,particsystems.For example, shoulder pain that is aggraularly in children,and compressionofthe spinalnerue vated by raising the arm is likely to originatein the rootsat the L5 S1 level asthey exit throughthe spinal shoulder,whereas left shoulder pain that is aggraforamenmay causepain in the lateralleg becausethis vated by all forms of strenuousexercisemay be is the areaof sensoryinnervation.37.38 Common refercausedby a cardiaccondition.When assessing pain ral patternsfrom internal organsto musculoskeletal that is determinedto be of musculoskeletal origin, it is
Oqe . PATHOLOCY AND PATIENT qROBLEMS
:iso important to accurately determine the struc:.rre(s)at fauit to provide the most effective treat:rent. This can.be done by performing provocative :ests to reproduce the patient,s chief complaint. ?hysicalagentsmay effectivelyrelievereferrej pain; :.oweverthey shouldnot be usedas a ,ubstituti for :etermining the true sourceof the pain or for treatins := underlyingcause.They may be usedfor pain reliei '.';hilethe sourceofthe pain is beinginvestigated,dur_ :rg the recoveryprocess,and for conuollinq referred :arn where rhe underlyingcausecannorbe direcrly :eated.
MECHANISMS OFPAIN RECEPTION AND IRANSMISSION Specificity and pattern theories Pain receptors Peripheral nerve pathways Central pathways Sympathetically mediated pain The role ofsubstance P iain is generally felt in response to stimulation of :eripheral nociceptive structures. The stimulus is :ansmitted along peripheral nerves to the central ---ervoussystemJ from where it can reach the cortex .rd consciousness. The sensation of pain and the tdividual's response to the sensation are influenced .....a variety of factors, including the physiological ::echanisms of the pain receptoff, the anatomy of :ain transmitting structures, neurotransmitter levels, ::rd the motivation, behavior, and physiological -rd emotional state of the individual. Variations in ::ry of these factors can alter the individual,s :3rception of pain severity, type, location, and :lIatlon.
Specificity andPattern Theories Jver the years,varioustheoriesregardingthe nature :: peripheralpain receptionand transmissionhave ::en proposed.The primary early theorieswere the .:ecificity theory and the patterntheory Currentthe_ ::1es ntegrate componentsof both of these with :::orerecentfindings and obsewations.Accordingto -:respecificirytheory, as describedby Von lrey ind :-hers,the sensation of pain dependson the stimula_ - rn of specificnerveend,ings thar arespecialized for 42Thus a specrficrype :ch rype of sensarion.40 of
45
nerve fiber will always transmit the samesensation. no matrerhow intenselyor trequentlyir rssrimulared. According to *ris theory specific pain fibers are responsiblefor the transmissionof the sensationof pain (Iig. 3-1,.,1). Von lrey supportedthis theory with his identificationof freenerveendingswidely distributed in the skin that causeda sensationof pain when stimulated.He proposedthat thesefreenewe endinss were specificpain receptors.l2 Although rhe ,peJi_ ficity theory is consistentwith Von lrey,s findings,it has sincebeen found that the sensationof pain ioes not havethe preciseone-to-onerelationshipwith the type of receptorstimulatedthat would be predicted by-the specificitytheory The specificitytheory also failsto accountfor the fact that many qypesof siimuli are perceivedas painful and that pain can be modu_ Latedby input from the spinal cord or brarn.The limitations of the specificitytheory led to the devel_ opment of an alternativeexplanationof pain percep_ tion, the patterntheory According to the pattern theory the sensation . or pam re-sultsftom an appropriateintensity or fre_ quency of stimulation of receptorsthat also respond to other stimuli such as touch, pressure,or tem_ perature.'3Neural impulsesFromcheperipheryare combined and modified to summate in central nervous system structures,where the pain is then iocalizedand inrerprered. Accordingto rhe patrern theory and spatial summation of impulses _temporal along the pathways from the skin to the cerebral levels determinesthe individual,ssensationof pain (Iig. 3-1, B). This theory accountsfor the fact that a wide variety of stimuli cause the sensation of pain and also suggestsa role for centralinfluencebv pain summacion:however,ic [ar]sto considerthe roleo[ the idenLified specialized pain receprorsrruc_ tures and to account for affective or central pain modulation. theodesintegratecomponentsof the speci_ .. .Cuffent ficity theory and the pattem theory with other,more recent findings neuralanaLomyand Lhe ,regarding runcflonsot endogenous neurotransmiEters. currenf findings indicate that specific nerve endings called uociceprors respondro all painfulstimuli.anj specific nerve ryoes. small myelinatedA-delta tibers and unmyelinatedC fibers,transmitthe sensationof oain from these nerve endings to the spinal cord and thence,within specifictracts,to the brain.The quali$ of the pai,ndependson the type of tlssuefrom whicL the stimulusoriginatesand on which ofthe tvvonerve
46
3 . Ptritt
SPECIFICITY THEORY
Specialized heat receptor
PATTERNTHEORY
,il'il*l1ll-l l'il-11il*l{ll-l lil*l{1 |, Action potentials
-1,,,*1,*1,*1.*"1*l* Actionpotentjals
Figu]e3-1. Specificigz versuspattem theory of pain.A, Specificreceptorsfor eachrype of sensation.B, Patternof actionpotentialsresultingin sensation of pain. rypes transmitsthe pain; the intensiry of the pain is cles,and bareareasof axolemmathat are not covered relatedto the fidng rate of *re nerves.Painfrom cutaby Schwanncellprocesses.46 Nociceptors arepresent neous noxious stimulation is usuallv oerceived as in almostall typesof tissue.However,no nociceptors sharp.pricking.or tingling and is eisy to localize. are presentin the nucleuspulposusand the inner part 50 whereaspain from musculoskeletalstructuresis usuof the annulusfibrosusof the spinaldiscs.aT ally dull, hear,y,or achingand is harderto localize.aa Nociceptorscan be activatedby intense*rermal, Visceralpain has an aching quality similar to that of mechanical,or chemicalstimuli from exogenousor musculoskeletalpain but tends to refer superficially endogenoussources.Ior example,intensemechanirather than deeply.15Pain transmittedby C fibers is cal stimulation,suchas that causedby a brick falling usually dull, long-lasting,and aching,whereas pain on someonersfoot or a piece of broken bone comtransmittedby A-delta fibers is generallysharp.The pressinga nociceptor,will resultin nociceptoractivaintensity of the pain and the responsesto it are tion. Chemicalstimulation by exogenoussubstances thought to be more severewhen the relativeintensity suchas acid or bleach,or by endogenouslyproduced of nociceptive receptor stimulation is greater than substances suchasbradykinin,histamine,and arachithat of nonnociceptivereceptor stimulation, when donic acid, which are releasedas part of the inflamlevels of endogenousopioids are low, and with matory Iesponseto tissuedamage,can also activate certain vadations in *re individual's psychological nocic€ptors.Because thesechemicalmediatorsremain state.45 after the initial physical stimulus has passed,they generallycausepain to persist beyond the duration of the initial noxious stimulation. It is important PainReceptors to note that chemical mediators of inflammation Nociteytors are free, noncorpuscularperipheralnerve also sensitizenociceptors,reducing their activation endingsconsistingof a seriesof spindle-shaped, *rick thresholdto other stimuli.51,s2 This is the reason*rat, segments linked by thin segments to produce a clinically, many activities and stimuli to recendy injured areasare perceivedaspainful evenwhen they "string-of-beads"appearance.The beads and end :re nnt d:ma oino bulbs contain mitochondria,glycogenparticles,vesi-
Ote . PATHOLOGY AND PATIENT PROBLEMS
When nociceptors are activated, they releasea variery of neuropeptides from their peripheral terminals, including substanceP and a number of breakdown products of arachidonic acid such as prostaglandinsand leukotrienes.25 Nociceptorsalso convert the initial stimulus into electricalactivitv. in the form oI actionpotenrials. by a processknown as (Fig.3-2).It is thoughtrhat the released t'an,ductionzr neuropeptidesmay initiate or participatein transduction becausethey sensitizenociceptors.53 The action potentialsresultingfrom the processof transduction propagatefrom the nociceptorsalong afferentnerve pathwaystoward the spinalcord.
Peripheral NervePathways
47
C fibers,alsoknown asgroupIV afferexts, aresmall, unmyelinatednervefibersthat transmitactionpotentials quite slowly, at the rate of 1.0 to 4.0 meters/second.58They respondto noxiouslevelsof mechanical, thermal, and chemicalstimulation,causingpain that is generallydescribedas dull, throbbing, aching, or b:rgg^":d be reportedas tingling or rapry{."l= pingr"0o(Fig.3-3).The pain sensadons ffansmifted by these fibers have a slow onset after the initial painful stimulus, are longJasting,emotionally difficult for the individual to tolerate,and tend to be diffusely localized, particularly when the stimulus is intense.6l'62 They canbe accompaniedby autonomic responsessuch as sweating,increasedheart rate and blood pressure,or nausea.63 The pain associatedwith C-fiber activationcan be reducedby opiates,and this pain_rcliefis blockedby the opiate antagonistnalox-
Nociceptorsgive rise to two typesof first-orderafferent nervefibers,C fibersandA-deltafibers.The activone.oa ity in both rypes of fibers increasesin responseto A-delta fibers, alsoknown asgrouVIII afferexts,are peripheralnoxious stimulation,includingthat associ- also small-diameterfibers; however, they transmit atedwith acuteinflafirmationor muscleischemia.54-56 more rapidly than C fibers, at a rate of about 30 Eightypercentof afferentpain-transmittingfibersare meters/second,because they are myelinated.5S'65 C fibers,and the r ematnrng20%oare A-delta fibers.57 They are most sensitiveto high-intensitymechanical Cenerally,about 50% of the sensoryfibers in a cutastimulation,althoughthey canalsorespondto stimuneousnervehavenociceptivefunctions.45 lation by heat or cold and are capableof transmitting
Tissue
Mastcell 6---<4!)
Btood vesset ffi
/-\ =-'tfz\ Histamine (o o)*r( \-./
/,+
Substance P ,/
Leukotrienes
Arachidonicacid
\
Prostaglandins
Figule3-2. Pain transduction. (Modified with permission from lields HL, Levine JD: Pain-mechanisms and management fmedical p rogressl,WestJ Med 1.4I:347-357, 1984.)
3 . Pail
48
Stimuli
w
lvlechanical
0
il
Thermal
,n''
C fiber
Qltl) Chemical Stimuli
-
&t!
Yrxii
High intensity mechanical
Figure 3-3.Peripheral painpathways. nonnoxiousinformation.ooThe sensationsassociated with A-delta fiber activity are generallydescribedas sharp, stabbing, or pricking.asThe pain sensations transmitted by these fibers have a quick onset after the painful stimulus, last only for a short time, are generallylocalizedto the areafrom which the stimulus arose,and are not generallyassociatedwith emotional involvement.The pain associatedwith A-delta fiberactivationis generallynot blockedby opiates.6T Mechanicaltrauma usually activatesboth C and A-deltafibers.Takethe exampleof a brick landingon someone'sfoot. Almost immediately the individual feelsa sharpsensationof pain. The initial pain is followed by a deepachethat may last for severalhours or days.The initial sharp pain is transmittedby the A-deltafibersand is producedin responseto the highintensitymechanicalstimulationof the nociceptorsas a resultof the impact of the brick.The later,deepache is transmitted by the C fibers and is produced in responseto stimulationby chemicalmediatorsof inflammation releasedby the tissue after the initiai injury
either spinalcord.The C andA-deltafiberssynapse, direcdy or via interneurons,with second-orderneurons in the superficialdorsalhorn of the gray matter 7t SomeA-deltafibers (the substantiagelatinosa).58,68 penetratemore deeplyinto the dorsalhorn to terminate at the normal termination sites of A-beta afferents.The second-orderneuronsin the dorsalhorn are or T cells(Frg.3-4). known astransmission T cells make local connectionswithin the spinal cord,eitherwith efferentneuronsaspaft of spinalcord reflexesor with afferentneuronsthat oroiecttoward . o n L i n u eodr r e p e L i L iC v e- i i b e ra c t i v a L i o n t h ec o r t e xC can sensitizethe T cells,causingthem to fire more rapidly and to increasedreir receptorfield size, and input from other interneuronsoriginatingin the substantiagelatinosaof the spinalcord or from descending fibers originating in higher brain centers can inhibit T-ce1lactiviry72Inhibitory interneuronsin the substantia gelatinosaare activated by input from large-diameter,myelinated, low-threshold sensory neurons (primarily A-beta nerves) that respond to nonpainfu1stimuli.73,7a Theseinhibitory interneurons releasevarious neurotransmitters,including norepinephrine, serotonin, and enkephalins,to modulate rhe flow of t-heafferenrpainpar-hways.-sI hus t-he transmissioncellsreceiveexcitatoryinput from the C fibersand A-deltanociceptorafferentsand inhibitory
Thalamus C fiber (unmyelinated, slow;chronic parn)
Dorsal horn
Brainstem Spinothalamic tracts
Soutce of pain
@
Pathways Central
A-deltaliber (myelinated,last; acute pain)
The peripheral first-order C and A-delta afferents project from the periphery to the gray matter of the
Figure3-4. Ascendingneural pathway of pain via A-delta and C fibers.
Substantia gelatinosa
Fl :::
ai :tc :::l
O e . PATHOLOCYA^D PATIENTPROBLL\/IS
:.:tuf from large-diameter.nonnocicepror sensory ::rerenrs and- From fibers f rom hrgher ^d_"rTldi.ng. : - : r n c e n r e r s ' J( l ' i g .3 5 ) . T h e b a l a n c eo f t h e s ee x c r t a :,-ry and inhibitory inputs influences whether or not ---e individual feels pain and how severe the pain sen;:.rion is .73The inhibition of pain by inputs from non: rciceptor afferents is known as yain gatixg and rs :-scussed in greater detail below in dte section on : , i n m o d u l a t i o na n d c o n r r o lr h e o r i e ' . Transmission cell activation can also increasemus:-e spasm via a spinal cord reflex in which the trans-'-:ssioncell synapseswith anterior horn cells to cause :uscle contractions. The ongoing muscle contrac-rtrns can then cause accumulation of fluid and tissue ::itants. The contracting muscles may also directly :3come initiatorc of further nociceptive impulses by :.echanically compressing the nociceptors. In this .'.ay the combination of ongoing chemical and :echanical stimuli can set up a self-sustaining cycle : - pain causing muscle spasm, which then causes :-ore pain. This is known as the pain-syasm-yaincycle .ig. 3-6). Many interventions indirectly reduce pain, ..en after their direct analgesiceffect has passed, :ecause they reduce muscle spasms and thereby ::rerfere with this self-perpetuating cycle. Ascending second-order nerues carry stimuli ...'ithinthe spinal cord toward the higher brain centers - ig. 3-7). The second-order pathways that carry pain ::imuli are located primarily in the anterolateral , , p e c Lo f l h e c o r d . - 8T h i s a r e ao I t h e s p i n a lc o r d a J s o
49
Figure3-6. Pain-spasm-paincycle: nociceptor activation resultingin T cell activation stimulating an anterior hom cell to causea muscle fiber to contract,resulting in accumulation of fluid and tissue irritants and mechanical c o m p r e s . i oor Fr h er o c i c e p t o r a n idn c r e a s i rrgo c r c e p t o r acuvauon.
transmits information about temperature and touch. Most axons in the anterolateral system cross midline in the spinal cord to ascend contralaterally. Substantia '.cclceptive Information regarding pain is transmitted within the Cerebral gelatinosa :'deltaand C fibers cortex anterolateral cord via both the lateral spinothalamic {inhibitory tnlerneuron) tract and the larger anterospinothalamic tract to projI ...,/....... I ect to the thalamus. The lateral spinothalamic tract Thalamus projects direcdy to the medial area of the thalamus, whereas the anterospinothalamic tract separatesfrom the lateral spinothalamic tract in the brain stem to synapse with neurons in the reticular formation and the hypothalamic and limbic systems to then project to lateral, ventral, and caudal areas of the thalamus. The anterospinothalamic tract also relays information 'lonnociceptive to the periaqueductal gray matter, where there is a l.'betaandA-gammafibers large concentration of opiate recepto$, and is thought, : gure 3-5. Simple diagram showing the gate control thereby, to be associated with pain modulation. Impulses relayed via the lateral spinothalamic tract ::rechanismof pain modulation through the activation are involved in transmission of sharp pain and in :i A-delta and C-fiber input and gating/iniibition by locaiization of the painful stimulus, whereas those : lnnociceptor A-beta sensoryneruesand higher center :rput. sent via the anterospinothalamic tract are involved in
+
3 . Pail
of smooth and cardiacmusclesand with glandular Primary somatosensory secretion.This contrastswith most of the nervoussysconex
Thalamus
lnsula cortex
Hypothalamus
Midbrain
Reticular formation
Periaqueductal grey mater Lateralspinothalamic lract Anlerospinothalamic lracl
Nociceptor Spinal cord
Figure 3-7. Centralpainpathwaysfrom thespinallevelto the higherbraincenters. transmissionof more prolonged,achingpain and are thought to have stronger associationwith the disturbing emotionsthat accompanythe pain sensation. The second-orderneurons synapsein the thalamus with third-orderneuronsto projectto the cortex,from where the sensationof pain canreachconsciousness.
Sympathetic Nervous System Influences The sympathetic nervous system is a component of the autonomic nervous syslem.The autonomic nervous system consists of the sympathetic and parasympathetic svstems and is concerned with the activities
tem, which is concernedwith voluntary activationof the skeletalmusclesor with transmissionof sensory impulsesfrom the periphey'e,sO(Fig.3-8).The sympa*retic newous systemis consideredto be primarily involved in producingeffectstlLat preparethe body for "fight or flight," such as increasingheart rate and blood pressure,constdctingcutaneousblood vessels, and increasingsweating in the palms of the hands. Althoughit is normalfor the sympatheticneffous system to be activatedby acutepain or injury stimulation of the sympatheticnervoussystemefferentsdoesnot usuallycausepain.81HoweveEabnormalsy,rnpathetic activationrcausedby a hyperactiveresponseof the sympatheticnervoussystemto an acuteinjury or by a failure of its responseto subside,can increasepain signsandsymptomsof severityandcauseexaggerated vasomotoror sympatheric acrivirysuchas excessive sweating reactions.In patients with such signs and symptoms,pain relief can often be achievedby interruptingsympatheticnervoussystemactiviqyby chemical or surgicalmeans.B2-84 h addition, stimuli that evoke sympathetic discharges,such as the starde pain. reflexor emotionalevents,frequendyexacerbate sympaIt hascherefore beenproposedthat excessive thetic nervous system activation may increaseor maintainpain.Bo,79 Painthat is believedto involvesympa*reticnervous systemoveractivationhas a variety of names,including causalgia,reflex sympatheticdystrophy (RSD), shoulder-handsyndrome, posttraumaticdystrophy, Sudeck'satrophy, and sympatheticallymaintained pain.BsCurrently,the InternationalAssociationfor the Study of Pain(IASP)recommendsthe use of the term (CRPS).86 comylexregionalyainsyndrome CRPSinvolving tissuedamagewithout nervedamageis categorizedas tvoe I. and CRPSassociated with nerveinvolvementis caiegorizedastype IL86 CRPSgenerallyincludes the following signs and symptoms: severe pain that is out of proportion to the inciting injury or disease,hyperesthesia(excessive reaction to painful stimuli), and allodynia (the sensationof pain in responseto stimuli that are not usuallypainful).CRPSfrequendyalsoincludestrophic changessuch as skin atrophy and hyperhidrosis, edema,stiffness,increasedsweating,and decreased hair growth.86These symptoms generally result in decreased function and,if the syndromeis prolonged, sporryosteoporosis in the affectedarea.8Othersen-
o e.
PATHOLOCY AND PATIENTqROBLEI'\S
51
Eye
Superiorcervical gangron
Salivary granos
ch"d";;;h""'-'eyes,nose,mouth
r
J..",",
Svmoathetic cnatn
Parasympathetic nervoussystem Figure3-8. The autonomic nervous system.
sory vasomotot and skeletal motor abnormalities have also been associatedwith this syndrome.e8 CR.PScan occur in any areaof the body but is most common in the hand and, in suchcases,is frequently associatedwith ipsilateral restriction of shoulder motion. CRPS may develop as a consequenceof major or minor trauma,after visceraldiseaseor cen_ tral nervoussystem lesions,or without any known antecedentevent. The mechanismby which the sympatheticnerv_ ous systemaffectspain is not well understood;how_ ever,it may be the result of direct excitation of the nociceplor> by the sympathecic efferenrfibersor by the neurorransmifters releasedby rhe sympa*teric nerves.The normal activationof sympatheticactivity causedby pain may in some casesactivatethe affei_ ent C fibers,turther increasingpain,which couldthen
increase sympathetic activatioq creating a self_ zustaining vicious cycle. This cycle could amplify the sensationof pain and the signs of sympathetic activity, causingthem to^persistlong after an injury or diseasehas resolved./3 It has aiso b""n propos"i that faulty sympathetic effector mechaniims that cause inappropriate vasoconstriction,vasodilation, increasedcapillary permeabiliqz,or smooth muscle tone may indirectlycauseor exacerbatepain.45
p TheRoleofSubstance SubstanceP is a chemicalmediator that is thought to be involved in the transmissionof neuropathii and inflammatory pain. It is abundantin the centralnervous sy^s^tem and is found in approximately20% of C fibers.89It is alsoreleasedfrom'peripherainociceptors
3 . Pain
52
and has been detectedin inflammatory exudate.90-92 P release Substance has beenshown to excirepaintransmittingneuronsin the dorsalhorn of the spinal cord, and to be involved in nociceptiveprocessingat the spinal cord level.e3'9s Although less than 57o of the neurons in the dorsal horn expresssubstanceP receptors. the maioriryof pairr-transmirting neurons expressthese receptors.SubstanceP levels in the spinal cord increasein responseto induction of joint inflammation and in response to movement of inflamedjoints. Highly elevatedlevelsof substanceP have also been found in the cerebrospinalfluid of patients with persistentpain. SubstanceP receptor activationappearsto be invoived in the sensitization of pain-transmittingneuronsand in the development of hyperalgesia.95-98 Substance P release andreceptor to cissueinjury acLivation is thoughtro be a response andstress. A number of mechanismshave beenorooosedfor the action of substonceP on pain tiansmission. SubstanceP may facilitateexcitationof afferentpain fibers by activatingthe neurokinin-1receptorsin the spinal cord.99'100 When releasedinto the periphery substanceP increasesthe productionofthe inflammatory mediator prostaglandinE2 and the releaseof cytokines from macrophagesand neutrophils.l0l Both prostaglandins and cytokrnessensrtrze primary "Ff"r"^t.^.i.".t^'.
to explain pain control and modulation. These prooosed mechanisms attemDt to correlate what is lnown regardingpeople'seiperienceof pain with the structuresand physiologicalprocessesthought to be involved in pain transmission.Accordingto the gate control theory pain is modulated at the spinal cord level by inhibitory effects of nonnoxious afferent input. Accordingto the theory of endogenousopiates, pain is moduiatedat the peripheral,spinal cord, and corticallevelsby endogenousneurotransmitteffthat havethe sameeffectsasopiates.Psychologicalcentral control mechanismsare also thought to affect pain perceptionand control. Various physical, chemical, and psychological interventionshave beendevelopedbasedon the current understandingof the mechanismsunderlying painmodulation.Forexample,transcutaneous electrical nervestimuiationffENS) deviceswere developed basedon the gate control theory of pain modulation. AIso, the efficacy of a number of establishedtreatment aooroaches is now betterunderstoodbecause the unierlying mechanisms of pain control have becomeclearer.For example,it is now thought that themal agents,which havebeenusedto controlpain for centuries, may be effective for this purpose becausethey gate pain transmissionat the spinal cord.
t
{ l
;
i02
Treatmentsio control pain basedon the inhibition of substance P releaseor on the use of specificsubstanceP antagonistsare currentlybeingresearched.92 Opiates may in part exert an analgesiceffect by inhibiting *re releaseof substanceP from peripheral nervesl however, studies indicate that substanceP receptor-expressing neuronsare not the major site of actionof opiates.96'103
PAIN MOOULATION ANDCONTROL Gate control theory The endogenous opioid s;rstem
A number of observations make it apparent that pain transmission and perception are subject to inhibition and modification. for example, rubbing or shaking an area that hurts can relieve pain in that area, and stress can cause pain not to be felt at the time an injury occurs.Anumber of mechanismshave beenorooosed
Gate Control Theory The gate control theory of pain modulation was first According proporedby Melz.ck andWall in 1965.-3 to *Lis theory severityof the pain sensahonrs determined by the balanceof excitatory and inhibitory inDuts to the T cells in the spinal cord. These ce1ls receiveexcitatoryinput from a and A-delta nociceptor afferentsand inhibitory input, via the substantia gelatinosa,from large-diameter A-betanonnociceptor sensoryafferents.Increasedactivity of the nonnociceptorsensoryafferentscausespresynapticinhibition of the T cells,and thus effectively closesthe spinal the sensation sateto the cerebralcortexanddecreases ot parn(seefrg. 5-Jl. Many physical agents and rnterventrons are thoughtto controlpainin pan by activatingnonnociceptivesensorynerves,thereby inhibiting activation of pain transmissioncellsand closingthe gate to the For example,electrical transmissionof pain.1O4'tos stimulation,traction, compression,and massagecan ali activate low-threshold, large-diameter,nonnoci-
t
T
E
: I
One . PA|HOLOCY
AND PATIENT PROBLEMS
J5
:3Jtivesensorynervesandthereforemay inhibit pain by naloxone,an opiate antagonist.l13 Thesefindings :;rsmission by closingthe gateto paintransmission demonstratedthat these endogenouspeptides are '-.h"
Figule3-9. Indirect inhibition of pain by application of opiatesto opiate receptom.
54
3 . P/ritl
Electricalstimulation of areaswith hish levels of suchasrhePAGMandr-heraphenucleus, opiopeprins. hasbeenfound to stronglyinhibit the transmissionof pain messagesby some spinal dorsal horn neurons, therebycausinganalgesia.118,119 Electricalstimulation of theseareasof the brain can also relieveintractable pain in humans and increasethe amount of betaendorphinin their cerebrospinalfluid (CSI).120 Since these effects are reversedby the administrationof naloxone,they have beenattributedto *re releaseof opiopeptins.l2lThe concentrationof opiatereceptors and opiopeptinsin the limbic system,an areaof the brain largely associatedwith emotionalphenomena, also provides an explanation for the emotional responsesto pain, and for the euphoriaand relief of emotional stressthat is associatedwith use of morphine andthe releaseof opiopeptins.l22 The releaseof opiopeptinsis thought to play an important role in the modulation and control of pain during times of emotional stress. Levels of opiopeptinsin the brain and CSFbecomeelevated,and pain thresholdsincreasein both animalsand humans when stressis inducedexperimentallyby the anticipation of pain.r23'124 Experimentally,animals have been shown to expedencea diffuse analgesiawhen placed under stress.Humans demonstratea naloxone-sensitiveincreasein pain thresholdand a parallel depressionof the nociceptive flexion reflex when su6jectedto emotional s;ess.124,125 These findings indicatethat pain suppressionby stressis most likely causedby increasedopiopeptin levels at the spinal cord and highercentralnervoussystemcenters. The endogenousopiate system also provides an explanationfor the paradoxicalpain-relievingeffects of painful stimulationand acuouncture.Bearableleve1sof painful stimulation,suchastopicalpreparations that causethe sensationof burning,or noxiousTENS that causesthe sensationof pricking or burning,have been shown to reducethe intensity of less bearable preexistingpain in *re areaofapplicationand in other areas.125 Painful stimuli have also been shown to reduce the nociceptive flexion reflex of the lower limb.126Becausethese effectsof painful stimulation areblockedby naloxone,they arethought to be medi1 2 -1 2 8 aL e db y o p r o p e p t i in) .11 2 5 P a i nm a yb e r e l i e v e d becausethe applied painful stimulus causesneurons in the PACM regionsof the midbrain and thalamusto produceandrelease opiopeptins.l2s Placeboanalgesiais alsothought to be mediatedin paft by opiopeptins.This claim is supportedby the
observation that the opiate antagonist naloxone can reverse placebo analgesia and that placebos can also produce respiratory depression, a typical side effect of oPioids.l29'130
MEASURING PAIN Visual analog and numeric scales Comparison with a predeffned stimulus Semantic differential scales
To determine the most appropriatetreatment for a patient'spain and to assessthe efficacyof suchtreatment, it is helpful to assessthe natureand severiryof d:repatient'sexperienceof pain. Suchan assessment should attempt to ascertainthe causesand sourcesof pain, the intensity and duration of pain, and the degreeto which the pain resultsin disabilityor handicap.Variousmethodsand assessment toolshavebeen developedto quantifi/ and qualify both experimentally induced and clinical pain. These methods are basedon patientsrating their pain on a visual analog or numeric scale,comparingtheir presentpain with that experiencedin responseto a predefined,quantifiable pain stimulus, or selectingwords from a list to describetheir present expedenceof pain. Different tools providedifferentamountsand typesof information and requirediffering amountsof time and cognitive ability to complete.
Visual Analog andNumeric Scales Vsual analogandnumericscalesassess pain severiry by askingthe patient to indicatethe presentlevel of pain on a drawn line or to ratethe pain numericallyon a scaleof 1 to 10 or 1 to 100.131 With a visualanaloe scale.the patientmarksa positionon a horizonraloi verticalline, where one end of the line representsno pain and the other end representsthe most severe pain possibleor the most severepain the patient can imagine (Fig.3-10).With a numeric rating scale,0 is no pain and 10 or 100,dependingon the scaleused,is the mostseverepainpo'sibleor the mort qeverepain the patientcanimagine. Scalessimilarto the visualanalosor numericscales h a v eb e e nd e v e l o p e ldo r u s ew i t h i n d i v r d u a lws h o have difficulty using numeric or standard visual analogscales.lor example,childrenwho understand
Oqe . PATHOLOGY AND PATIENT PROBLEMS
Worstpain possible Pleaseplacaan X on thislineto indicat€ howsevereyourpainis now. Worstpain possible
f L
F .
f
tf
cc
Thesetypes of scalesare frequendyusedto assess the severiry of a patient's clinical pain because they are quick and easy to administer, are easily understood,and provide readily quantifiabledata.131 However, visual analog and numeric scalesprovide only a singlemeasureof the patient'spain complaint and fail to provide information about the patient's affectiveresponseto pain or the effect of the pain on his or her functionalactivity level.Also the reliability of visual analogand numeric rating vades between individuals and with the patient group examined, although the tr,vo scales have a high degree of agreementberween them.132These types of measures are most useful in the clinical setting when a quick estimate of a patient's perceivedprogressor change in symptoms over time, or ir responseto different activities or treatment interventions, is desired.
No pain
Figure3-10.Visual analogscalesfor rating pain severity.
witha Predefined Stimulus Gomparison
words or pictures but are too young to understand numericreDresentations of Daincan use a scalewith faceswith differentexpressions to representdifferent experiencesof pain, as shown in lig. 3-11.This type o[ scalecan also be used to assessoain in patients with limited comprehensionbecauseof linguage barriers or cognitive deficits. Pain scalesare also availablefor rating pain in very young children and infants. These are based on describingthe child's expressionand behavior[able 3-1).
Painquantificationmethodsthat involve comparison with a predefinedpainful stimulus are intended to provide a greaterdegree of intersubject reliabilit'y than visualanalogandnumericscales.Ior this rype of assessment, the individual comparesthe severity of his or her symptomswith the samepredefinedstimulus, causingtheir rating scalesto be more similar. Stimuli used for comparisoninclude the application of a toumiquet to the upper extremity to produce ischemiaand the applicationof electrical,thermal,or fingertip pressurestimuli.133,13a The toumiquet pain test is reported to correlatewell with pain assessMatching the ments using a visual analog scale.135
Which face shows how much hurt you have now?
/a\ /G\ /a\ \c/ a-Ar,;\ aA\ \7 !, 0 No hurt
1 Hurts littlebit
\r/
2 Hurts littlemore
\r/ \tY
3 Hurts evenmore
4 tlurls wholelot
5 Hurts worst
Figure3-11. Facescalefor rating pain severity in children age 3 years and older and others with limited numeric communication ability. The patient usesthis tool by pointing to eachface and using the brief word instructions under it to describepain intensiry from Wong DL, Peny SE,Hockenberry M} Matemal Child NursingCare,ed 2, St. Louis,2002, Mosby.)
56
p
3 . P/ril
f-t
*"orr"tal Infant Pain Scale(NIPS)Operational Definitions
Behaviorand score
Description
Facial Exqession 0 Relaxedmuscles 1 Cnmace
. Restfulface,neutralexpression . Tight facialmuscles,furrowedbrow, chin,jaw (negativefacialexpression n^<"
cty 0-Nocry I - Whimper 2 -Mgorouscry
-^,
'fh
".,1
h'^,-\
o Quiet, not crying o
Mild mnrnino
infPrmrrfPnr
. Loud screams,nsing,shrill,continuous(Note:Silentcry may be scoredif baby s ntubaced, a" evrdenced by obvrousmourh.lacialmovemenr.t
Breathing Patterns 0 - Relaxed 1 Changein breathrng
o Usualpatternfor thrsbaby o Indrawng. 'regular.tasterrhanusu"l.gaggrng. breachholding
Arrrrs 0 Relaxed/restraned 1 Flexed/extended
. No muscularrigidiry occasionalrandommovementsof arms . Tense,straightarms,rrgidor rapid extension,flexion
Legs 0 Relaxed/restrained 1 - Flexed/extended
. No muscularngidiry occasionalrandom1e8movement . Tense,straiShtlegs,rigid or rapid extension,flexion
Stateof Atorsal 0 - Sleeping/awake I Fussy
o Quret,peaceful, sJeeping, or alertandsettled o A1ert,resdess,and thrashing
NeonataiInfantParnScaleO 1989,Ch dren'sHosprtalof EasternOnrano.Usedwrth permrssron. Score0 = no parnhkely,maxlmum score7 = severeparnhkely.
intensity of clinical pain with electrical, thermal, or fingertip pressure stimuli has also been reported to correlate well with other measures of pain and has been reported ':r' to have a high degree of intrasubject reliability. lJ- gowever. I hese:ypes o[ pajn arressment tools also have a number of limitations. They require that the patient expefience clinical pain at the time at which the comparison stimulus is applied to make an accurate compadson. Also if a patient has severe pain, it may be both impractical and ethically unacceptable to induce a sufficiendy intense pain to provide a comparison with the clinical pain. For patients with pain that is different in quality from the pain of the expeimental stimulus; for example, burning or tingling rather d-ranthe ache of ischemic pain, a quantitative comparison may not be possible or meaningful. This type of pain measure also fails to
take into account, or report on, the emotional, behavioral, or motivational components of a patient's clinical condition. Thus although comparison pain measures may allow for a reliable gauge of some types of pain, particularly experimentally induced pain or clinical acute pain that is moderate or less severe, they are not well-suited for measuring clinical pain that is severe or chronic, or that has a quality different from that of the comparison stimulus.
Differenlial Semantic Scales Semantic differential scales consist of word lists and categories that represent various aspects of the patient's pain experience.The patient is asked to select, from these lists, words that best describe his or her present experienceof pain. These types of scales
One . PATHOLOGY AND PATIENTPROBLEMS
rre designedto collecta broad rangeof information :bout the patient's pain experienceand to provide ;uantifiable data for intra- and intersubiectcompar,,ons.The semanticdifterentialscaleincludedin rhe ,McGillpain questionnaire,or variationsof this scale, painl38-140 :re commonlyusedto assess Gig. 3-12). This scaleincludesdescriptorsof sensory affective, :nd evaluative aspects of the patient's pain and =roupsthe words into vadouscategorieswithin each rf these aspects.The categodesinclude temporal, ,.patial,pressure,and thermal to describethe sensory :spects of the pain; fear, anxret'4,and tension to jescribethe affectiveaspectsof the pain;and the cogitive experience ofthe painbasedonpastexpedence :nd learned behaviors to describe the evaluative .spectsof the pain. The patient circlesthe one word r eachof the applicablecategoriesthat bestdescribes :hepresentpain.13e,140 Semantic differential scales have a number of comparedwith other :dvantagesand disadvantages of pain measures. They allow assessment and rypes quantificationof various aspectsof the pain's scope, quality,and intensiry Counting the total number of '.vords chosen provides a quick gauge of the pain of pain severity severiryA more sensitiveassessment :an be obtained by adding the rank sums of all the '.vordschosento producea pair ratingindex (PRI).For sreaterspecificitywith regardto the mostproblematic area,an index for the three malor categoriesof the questionnairecan also be calculated.laO The primary of this scalearethat it is time-consuming 3isadvantages :o administer,and it requiresthe patient to have an ntact cognitivestateanda high levelof literacy.Civen -iese advantagesand limitations,the most appropriateusefor this type of scaleis when detailedinformaion about a patient's pain is needed,such as in a :hronic pain treatmentprogramor in clinicalresearch.
0therMeasures Other measuresor indicators of pain that may provide additionaluseful information about the individual's pain complaint and clinical condition include daily activiq/pain logs indicating which activities easeor aggravatethe pain, body diagramson which *re patient canindicatethe locationand natureof the pain (Iig.3-13), and open-ended,structuredinteru1"-r.141'1426physical examination that includes observationof posture and assessmentol strength, mobiliry sensation,endurance,responseto func-
J/
tional activity testing,and soft tissuetone and qualiry canalsoaddvaluableinformationto the evaluationof the severityand cause(s) of a patient'spain complaint. In selectingthe measuresto be used to assess pain, one should considerthe duration of the symptoms, the cognitive abilities of the patient, and the amount of time appropdateto assessthis aspect of the patient's compiaint. In many situations, a simple visual analogscalemay be sufficient to provide information regardinga progressivedecreasein pain as che parient recoversfrom an acute injury. However,in more complexor prolongedcases,more detailed measures such as semantic differential scalesor a combinationof severalmeasuresare more appropriate.
APPROACHES PAIN MANAGEMENT Pharmacological approaches Systemic aoalgesics Spinal analgesia Local injections to painful structrres Physical agents Multidisciplinary pain treatnent programs
Once the severity and nature of an individual's pain hasbeenevaluatedand, ideally,its sourceand nature determined,the goaiso[ treatmentinclude eliminating the cause of pain, controlling the nociceptor input, and reducing the degree of patient impairment. A wide rangeof pain managementapproaches may be used to help achievethese goals.These approachesare basedon our cuffent understanding of pain transmissionand control mechanisms,They may act by controlling inflammation, altering nociceptorsensitiviry increasingbinding to opiate receptors, modifying nerve conduction, modulating pain transmission at the spinal cord level, or altering higher-levelaspectsof pain perception.ln addition, some treatmentapproachesalso addressthe psychological and social aspects of pain. Different approachesare appropriate for different situations and clinical presentationsand are frequently most effectivewhen usedtogether The primary intervention used to alleviate pain is the administration of pharmacologicalagents. Although pharmacologicalagentsare often effective for this purpose, they can also produce a variety
3 . Paiq
58
Whaidoesyourpainteellike? Someof the words belowdescribeyour presentpain. Indicatewhich wordsdescribeit best. Leaveout any word group group-the onethatappliesbest thatis notsuitable.Useonlya singlewordin eachappropriate 1
2
'1Flickering 2 Quivering 3 Pulsing 4 Throbbing 5 Beating .6 Pounding
l Jumping 2 Flashing 3 Shooting
3 l Pricking 2 Boring 3 Drilling 4 Stabbling 5 Lancinating
4 1 Sharp 2 Cutting 3 Lacerating
5
6
7
8
'1Pinching 2 Pr€ssing 3 Gnawing 4 Cramping 5 Crushing
'! Tugging 2 Pulling 3 Wrenching
1 Hot 2 Burning 3 Scalding 4 Searing
l Tingling 2 ltchy 3 Smarting 4 Stinging
I
'10
11 l Tiring 2 Exhausting
l Sickening 2 Suffocating
14
15
16
1 Fearful 2 Frightful 3 Terrifying
1 Punishjng 2 Gruelling 3 Cruel 4 Vicious 5 Killing
1 Wretched 2 Blinding
17
18
19
1 Spreading 2 Radiating 3 Penetrating 4 Piercing
'1Tight 2 Numb 3 Drawing 4 Squeezing 5 Tearing
l Dull 2 Sore 3 Hurting 4 Aching 5 Heavy
1 Tender 2 Taut 3 Rasping 4 Splitting
I Cool 2 Cold 3 Freezing
1 Annoying 2 Troublesome 3 Miserable 4lntense 5 Unbearable 20 l Nagging 2 Nauseating 3 Agonizing 4 Dr€adful 5 Torturlng
Figure 3-12. Semantic differential scale from the McGill Pain Questionnaire. (Reprinted from Melzack R: The McGill Pain Questionnaire: major properties and scoring methods. In Pain, Amsterdam, 7975, Elsevter Science.)
ofadverseeffects.Thereforethe useofphysicalagents, which alsoeffectivelycontrolpainin many caseswhile producingfewer adverseeffects,may be more appropriate.Somepatients,particularlythose with persist-
ent pain,may needintegratedmultidisciplinarytreatment, which includespsychologicalaswell asphysiologicaltherapies,to achievepain relief or a retum to a morenormalfunctionalactivitylevel.
Ohe . PATHOLOCY AND PATIENT PROBLEITIS
59
Nonsteroid aI anti i nf Iam m atory dru gs NSAIDs have both analgesicand antiinflammatory properties and can therefore relieve pain from both inflammatory and noninflammatory sources. 4/7> shooringpain They inhibit peripheral pain and inflammation by inhibiting the conversion of arachidonic acid to prostaglandinsby cyclooxygenase;howeveq much X Sharppain lower doses and blood levels are required to NSAIDs reducepain than to reduceinflammation.143 been shown to reduce both spontaneous have Pleasemarkthetype and mechanicallyevoked activity in C and A-delta andlocationof your painon thesepictures fibers in acute and chronic models of joint inflammation. Evidencealso existsthat NSAIDSexert central analgesiceffects at the spinal cord and at the dtalamus.144-148 Front Back A.lthoughNSAIDs have excellentshort- to mediumFigure3-13. Body diagramsfor marking the location and term applicationfor the control of moderatelysevere nature ofpain. pain causedby musculoskeletaldisorders,particularly when the pain is associatedwi*r inflammation, sideeffectscanlimit their long-termuse.The primary long-term complicationof most NSAIDs is gastroinPharmacological Approaches testinal iritation and b1eeding.149,1s0 NSAIDs also cause decreased platelet aggregation and thus Pharmacologicalanalgesicagents control pain by modifying inflammatory mediatorsat the penphery, prolonged bleeding time. They can cause kidney damage, bone maffow suppression, rashes and alteringpain transmissionfrom the periphery to the anorexia,and decreasedrenal blood flow in dehycortex,or alteringthe centralperceptionof pain. The selection of a particular pharmacologicalanalgesic drared natienrs.lsll52 tlsins different NSAIDs togetherincreasesthe risk of sideeffects. agentdependson the causeof the pain, the length of The first NSAID was aspirin.Many other NSAIDs, time the individual is expectedto needthe agent,and the side effectsof the agent.Pharmacological agents such as ibuprofen (Motrin), naproxen sodium (Naprosyn,AJeve),and piroxicam (Feldene),are now may be administeredsystemicallyby mouth or injection, or locally by injection into sffucturessurround- availablebo*r over *re counter (OTC) and by preing the spinal cord or into painful or inflamed areas. scription. The principal advantagesof these newer NSAIDs over aspirin are that some have a longer These different routes of administrationallow conduration of action, allowing lessftequent dosingand centrationof the drug at different sitesof pain transbetter compliance,and some causefewer gastroinmission to optimize the control of symptoms with testinal side effects. However, for most patients, varyingdistributions. aspirin effectively relievespain at considerablyless expense,although with a slighdy higher risk of Systemicanalgesics gastrointestinalbleeding, than the newer NSAIDs. Administration of a systemicanalgesicis usuallythe Recendy, specific cyclooxygenaseq,?e 2 (COX?) primary me*rod of pain management.This type of inhibitor NSAIDs, such as celecoxib (Celebrex) treatmentis easyto administerand inexpensive,and can be an effective and appropdate pain-relieving and rofecoxib (Vioxx), have been developed.Prior NSAIDs inhibited both cyclooxygenasetypes 1 and interventionfor many patients.A wide rangeof analgesic medicationscan be systemicallyadministered 2. CyclooxygenaseLype 1, catalyzesthe production of prostaglandins associated with joint inflamorally or by other routes.Thesemedicationsinclude mation while cyclooxygenaseUtpe 2 catalyzes (NSAIDs), nonsteroidalantiinflammatorydrugs acetproduction tlte of prostaglandinsthat protect the aminophen,opiatesand opioids,andantidepressants.
fuIil,lo.n
60
3 t Pain
effects. They control pain that cannot be relieved by nonnarcotic agents and are most effective when the pain is dull and poorly Tocalized. The side effects of opiates, including nausea, vomiting, sedation, suppiession of cough, gastrointestinal mobility, and respiration, as well as their propensity to causephysicai iependence and depressionwith long-term use, limit their application for the long-term management of drugs. -,s.,rfoik"1eta1 pain. Respiratory depression also limits the dose that can be used even For short-term Acetaminophen administration. Tolerance causesdrug doses to mainAcetaminophen (Tylenol@) is an effective analgesic tain pain conlrol and to experience withdrawal, and for mild to moderately severe pain; however, unlike causesa consequent rebound increase in pain when an NSAID, it has no clinically significant antiinflamuse of the drug is decreased or discontinued after matory activity.lsa Taken in the same dosage as long-term use. Opiates are generally used clinically to aspirin, it has analgesic and - .antipyretic effects reliene postoperative pain or pain due to malignancy' comparable to those of aspirin.l5aAcetaminophen ts Unfortunately, concerns about tolerance and side administered primarily by the oral route, although effects frequently result in the administration of administration by suppository is effective for patients insufficient doses of these medications to patients who are unable to take medications by mouth. with severe pain, resulting in unnecessarilyhigh levAcetaminophen is useful Forpatients who cannot toiThe risk of psychological addiction els of pain.157,IsB erate NSAIDs because of gastric irritation or when or habituation should not prevent the appropriate use prolonged bleeding time causedby NSAIDs would be of opiate medications, particularly in the managea disadvantage.Prolonged use or large doses of acetament of terminal illness. minophen can causeliver damage;this risk is elevated Opiates can be delivered by mouth, intravenously, an occaalso are rashes Skin alcoholic. in the chronic 6 popular or by direct intraarticular iniection.159'160 sional side effect of this medication. particuiarly and effective means of administration, for hospitalized patients, is patient-controlled anaiOpiates a pump to Opiatesarenarcoticdrugsthat containopium,deriva- gesia (PCA). With PCA, patients use ielf-administer smali, rcpeated intravenous doses' dvesof opium,or any of severalsemisyntheticor synThe amount of medication delivered is limited by thetic drugs with opium-like activiqy. Morphine, preestablished dosing intervals and maximum doses hydromorphone, fentanyl, and meperidineare exama defined period. Pain control is more effective within appiicaclinical for used pies of opiatescommoniy eFfects are less common with this adverse and slightly have drugs tions. Although these opiate than with more convenadministration oF means opito all bind they differentmechanismso[ action, opiate administration tional,physician-controlled of them of all receptors,and the-effects
qut mucosa. Thus COX2 inhibitors have more speiific antiinflammatory effects and a lower risk of gastrointestinal irritation and bleeding. NSAIDs are primarily administered orally, although one, ketorolac fforadol@), is available for administration bv iniection.15311t" mode of administration does not aiter the analgesic or adverse effects of these
ate-specific methods.'"','"" are reversed by naloxone'1ssThe opiates differ and primarily in their potency, duration of action, restrictionof useasa resultof variationsin pharmaco- Antidepressants particularlythe tricyclicssuch as Antidepressants, dynamicsandpharmacokinetics' (Elavil@), have been found to be an amitryptiline It hasbeenproposedthat opialesprovideanalgesia of chronic pain treatcomponent adjunctive effective by mimicking the effectsof endorphinsand binding effective for this being doses with smaller ment, receptorsitesin the centralnervous to opiate-specific for the treatused typically those than application systlm.ls6'1heymay also relievepain by inhibiting these drugs o[ The efficacy depression.l63'164 of ment tire release of presynaptic neurotransmittersand to be thought pain is of chronic treatment the for inhibiting the activity of interneurons early in the and function, nerve on sleep, effects their to nociceptive pathways to reduce or block C-Fiber related with chronic patients that shown have Studies mood. inputsinto the dorsalhorn.116 pain who are also depressedreport much-higher levWhen givenin sufficientdoses,opiateswill control Lls of pain and show more pain-related behaviors even the most severeacutepain with tolerableside
One o PATHOLOGY AND PATIENT PROBLEMS
-j:an those who are not depressed.1'6s'1'66 Although it -i not certain if the higher 1evel of pain in such :arients is the cause or the product oF their depres::cn, the use of antidepressants in either situation ::ray prove beneficial. Spinalanalgesia :-ain relieFmay be achieved by the administration of irugs such as opiates, local anesthelics,and corlicos:eroids into the epidural or subarachnoid spaceof the ,rinal cord.167This route of administration provides ,nalgesia to the areas innervated by the segments of ::e cord receiving the drug and is therefore most =Jective when the pain has a spinal distribution, such .s a dermatomai distribution in a single limb. The :im.ary advantages of this route oF administration =:e that the ' ^ ^ - " .drus * D " . / | bvoasses the blood-brain barrier .:rd that high concentrations reach the spinal cord at :riate receptors at sites of nociceptive transmission, --:rusincreasing the analgesic effects while reducing :dverseside effects. Opiates administered spinally exert their effects by 'rimulating opiate receptors in the dorsai horn of -:'respinal cord.168When administered spinally, fatsoluble opiates have a rapid onset and a short dura=on of action, whereas water-soluble opiates have a slow onset and a more prolonged duration of .ction.169 Local anesthetics delivered spinally have --ne unique abilir,y to completely block nociceptive =ansmissionl however, with increasing concentra:on, these drugs also block sensory and then motor =ansmission, causing numbness and weakness.17o {igh dosesof these drugs can also causehypotension. These side effects of local anestheticslimit their appli;ation to the short-term control of pain and diagnostic rurposes. Catabolic corticosteroids, such as cortisone and dexamethasone, can be administered to the epidural or subarachnoid spaceto relieve pain due to nfiammation of the spinal nerve roots or surrounding strLlctures. These drugs inhibit the inflammatory :esponse to tissue injury; however, because of the side effects of repeatedor prolonged use, including fat and muscle wasting, osteoporosis, and symptoms of Cushing's syndrome, these drugs are not suitable for iong-term application.
Localinjection Local injection of a corticosteroid,opiate,or a local anestheticcan be particularlyeffectivefor relieving pain associatedwith local inflammation.ls9Such
67
injections can be administered into joints, bursae, trigger points, or around tendons and can be used for therapeutic purposes, to relieve pain, or for diagnostic purposes in identification of the structure(s) atfauh.l7l Although this type o[ treatment can be very effective, repeated local injections of corticosteroids are not recommended because they can cause tissue breakdown and deterioration. Local injections of corticosteroids directly after acute trauma are also not recommended because these drugs reduce the inflammatory response and may thus impair healing. Local injections of aneslhetics generally provide only short-term pain relief and are therefore used primarily during painFulprocedures or J:^^-^^+:^^11,, u r d S r r u ) L r L4 r r y .
PhysicalAgents Many physical agents effectively control or relieve pain. They are thought to exert these effects by moderatingthe releaseof inflammatory mediators, modulating pain at the spinal cord level, altering nerve conduction, or increasingendorphin levels. They may also indirectly rcducepain by decreasing the sensitivityof the musclespindlesystem,thereby reducingmuscle spasms,or by modifying vascular tone and the rate of blood flow, thereby reducing 4 lnaddition, physicalagents edemaor ischemia.172-17 may reducepain by helpingto resolvethe underlying causeof the painfulsensation. Different physical agentscontrol pain in different ways. For example, cryotherapy,the applicationof cold,controlsacutepain in partby reducingthe metabolic rate and thus reducing the production and reieaseof inflammatorymediatorssuchasserotonin, histamine,bradykinin, substanceP, and prostaglanThesechemicalscausepain direcdyby stimudins.17s iating nociceptors and indirectiy by impairing the local microcirculationand, in so doing, can damage tissueandimpair tissuerepair.Reducingthe releaseoF inflammatory mediatorscanthus direcdy reiievepain causedby acute inflammation and may indirectly limit pain by controllingedemaand ischemia.These short-termbenefitscan also optimize the rate o[ tissuehealingand recovery. Cry otherapy, thermotherapy, electrical stimulation, and traction, which provide thermal, mechanical, or other nonnociceptivesensory stimuli, are thought to alleviate pain in part by inhibiting pain transmissionat the spinalcord. Physicalagentsthat
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act by this mechanismcan be usedfor the treatment 'needed,and so becomesmore independentof the of acuteand cfuonic pain becausethey do not gener- health care practitionerand pharmacologicalagents. ally produce significant adverse effects or adverse The application of such physical agents at home interactions with drugs, and they do not produce can be an effective component of the treatment physical dependencewith prolonged use. They are of both acute and chronic pain.177This type of selfalsoeffectiveand appropriatefor pain causedby contreatment can also assistin containins the costs of ditions that cannot be direcdy modified, such as medicalcare. pain causedby malignancyor a recentftacture,and Physical agents.usedeitheraloneor in conjunction for pain caused by peripheral nervous system with other interventions, such as pharmacological pathology, such as phantom limb pain and periphagents,manual therapy, or exercises,can also help eralneuropathy.lT6 remediatethe underlying causeof pain while conElectrical stimulation is also thought to control trolling *re pain itself. For example, cryotherapy pain in part by stimulatingthe releaseof opiopeptins applied to an acute iniury controls pain; however, at the spinalcord and at higherlevels.l2BStudieshave this treatment also controls inflammation, limiting shown that pain relief by certain types of electrical further tissue damage and pain. In this case, the stimulationis reversedby naloxone.128 use of NSAIDs, rest, elevation, and compression, Physicalagentshave many advantagesover other in conjunction with cryotherapy,could also prove pain-modifying interventions. They are associated beneficial, although it may make assessmentof with fewe5 andgenerallylesssevere,sideeffectsthan the benefits of any one of these rnterventlonsmore pharmacologicalagents. The adverse effects from difficult. The selectionof physical agentsand their using physical agentsto control pain are generally specificmechanismsof action and modesof applicalocalized to the area of application and are easily tion for controlling pain are discussedin detail in avoidedwith care in applying the treatrnent.When Section2 of this book regardingthe differenttypes of usedappropriately,attendingto all contraindications . h - . ; " , 1 " " " . r . and doserecommendations,the risk of further injury ftom the useof physicalagentsis minimal. For examMultidisciplinary PainTreatment Programs ple, an excessivelywarm hot pack may causea burn in the areaof application,but this risk can be miniOver the past 2 to 3 decades,multidisciplinary prorntzedby carefully monitoring the hot pack's tempergramshave beendevelopedspecificallyfor the treatature, using adequate insulation between the hot ment of chronic pain.a,178 Theseprogramsare based pack and the patient, not applyinghot packsto indion a biopsychosocialmodel of pain and attempt to vidualswith impaired sensationor an impaired abiladdressthe multiple facets of chronic pain with a ity to report pain, and by checkingwith the patient multidisciplinary coordinated program of care.4'179 for any sensationof excessiveheat. Patientsalso do These programs attempt to addressnot only the not developdependenceon physicalagents,although physical and physiological aspectsof the patients' they may wish to continue to use them even after pain but also the behavioral,cognitive-affective,and they are no longer effective because they enjoy environmental factors contributing to their sympthe sensation or attention associatedwith their toms by the useof medical,psychological,and physiapplication.Ior example,patientsmay wish to concal interventions.lBo,lBl tinue to be treatedwith ultrasoundeventhough they Psychologicalintervention is focusedon improvhave reacheda stageof recoverywhere they would ing the coping skills of patients and modi$ring benefit more from active exercise.Physicalagents their behavior,whereasphysicalactivitiesarefocused also do not generallycausea degreeof sedationthat on reversing the adverse effects of the sedentary would impair an individual'sabiliry to work or drive lifesryle adopted by most patients with chronic sarery. pain. Coping skills can be improved with relaxation Many physical agents have the additional training, activity pacing,distractiontechniques,cogadvantageof being readily used independendyby nitive restructuring, and problem solving.1B2,1B3 patientsto treat themselves.Ior example,a patient Behaviormodificationusingthe principlesof operant can be educatedto apply a pain-controllingagent, conditioning can also alter the patient's perception such as heat, cold, or electricalstimulation, when of and responseto pain.184Graded activation and
ex di
ac AI
le th m m be to
th m Ie n(
One . PATHOLOGY AND PATIENT PROBLEMS
::.:3rciseprograms,in which the patient iearns the ---:erenceberweenhurt and harm, can help patients .,.-:ih chronic pain retum to a more functional, ,:ive lifestyle.l8s The patients' family members ::: generally involved in these programs by -::rning appropriatecopingskillsfor *remselvesand -:e patient. Such involvement can assistthe family :embers to help individuals with chronic pain :-.cre effectively rather than reinforce pain-related ::haviors. In contrastwith traditional treatment approaches :--,acutepain,in which the goal of careis to eliminate =e sensation of pain, the goals of care in most =ultidisciplinarypain treaffnentprogramsalsoinclude ::rning to cope and function with pain that may r rt resolve,although frequently patientsalso report
63
a reduction in pain after completing these proGoals of treatment also generally grams.186'187 include decreasingdependenceon health care per sonnel and pain relieving medications,particularly h a b i t - f o r m r nogp i a r e so r o t h e rn a r c o L i cisn:c r e a s i n g physical activities; and retuming patients to their usual social roles. If necessarynarcoticmedications are replacedwith non-habit-forming drugs or with nonchemicalmodes of pain relief such as exercise or physical agents.aMany studies have shown that multidisciplinary pain treatment programs do result in increasedfunctional activity levels while reducing pain behaviors and the use of medical i n c e r v e n t i o ni ns p a r i e n t sw i t h c h r o n i cp a i n . 8 8l q l These programs have also been shown to be cost elfe ctrve.rBI,I 92194
) Clinical CaseStudies a The following casestudiessummadzethe conceptsof pain discussedin this chapterBasedon the scenariopresented,an evaluationofthe clinicalfindingsandgoalsof ft€atmentareproposed.This is followed by a discussion ofthe factorsto be consideredin treatmentselection.
Case'l M? is a 45-year-oldfemale who has been referredto physicaltherapywirh a diagnosisoflow backpain and a physician'sorderto evaluateand fteat.MP complainsof severecentral low back pain that is aggravatedby any movement, particularly forward bending. Shereports no radiation of pain or other symptoms into her extremities.Paindisturbsh€r sleep,and sheis unableto work at her usualsecretarialjob or perform her usualhousehold taskssuchasgroceryshoppingand cleaning.Shereports that the pain startedabout4 daysago,whenshe reached to pick up a suitcase,and hasgraduallydecreasedsince its initial onset ftom a severity of 8, on a scaleof 1 to 10,to a severity of 5 or 6. Her only curent treatment is 600 mg ibuprofe4 which she is taking 3 times a day. The obiective exam is significant for resuicted iumbar range of motion in all planes. Forward bending is restricted to approximately 207o of norma| backward bending is resfticted to approximately 50% of normal, and side bendingis resriccedro approximately30qoof nonnal in both directions. Palpablemuscleguardingand tendemess in the lower lumbar areaoccur when the patient is standing o! prone. All neurological testing, including straight
leg raise and lower exftemity sensation, strength, aad reflexesarewithin normalLirnics. OF CLINICALFINDINGS EVALUATION This patient seeksmedical treatment for the impainrlents o[ low back pain and restricted lurnbar range of motion. These impairments have resulted in difficulties with her nomal functionalactivitiesof sleeping,working, shopping, and cleaning. A.lthough further analysis may help identify the speciticsffucturescausingthis patient'spain, its rccentonsetrelatedto a specificevent usingthe painful areaand its gradualresoludonover tl.re last few days indicatethat her pain is acute and is the result of local musculoskeletalinjury and probable inFlammadon. PREFERREDPRACTICEPATTERN Impaired Joint Mobility, Motor lunction, Muscle ?erformance, Range of Motion, arrd Reflex Integrity AssociatedWith SpinalDisorders,(4I). PLANOF CARE The goalsof treatmentat this time includecontrolling pain to allow MP to sleep and return to other functional activities as soon as it is safe for her to do so. The anticipated goals of treatment would also include regaining normai lumbar rante of motion and, ideally, preventing a recurtence of the present svmDtoms, Continued
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3. Pniu
) Clinical Case Stttdies-cottt'd ASSESSMENTREGARDINGSELECTIONOF THE OPTIMAL TREATMENT The optimal intervention would ideally address the acute s1'rnptomof pain and the underlying inflammation and, if possible,would help to resolveany underlying structural tissue damage or changes.Although a single ffeatxoentmay not be abie to addressall of theseissues, treafinentsthat addressasmany of theseissuesaspossib1eand that do not adverselyaffectthe patient'sprogress arerecommended. As is explainedingreaterdetailin Part 2 of this book, a number of physical agents, induding cryotherapyand electricalstimulation,may be used to control this patient's pain and reducethe probable acute inflammationof the lumbar structures,and lumbar traction may also help to relieve her pain while modifying the underlying spinal dysfuncrion.
Case 2 tj is a 45-year-oldfemalewho hasbeen referredfor therapy with a diagnosisof low back pain and an order to evaluate and treat, with a focus on developing a home program. TJ complains of stiffaess and generalaching of her lower backthat is aggravated by sittingformore than 30 minutes.she reportsoccasiorulradiationof pain into her left lateral leg but no other s;.rnptoms in her extremities. She states*rat the pain occasionallydisturbsher sleep,and she is unableto work at her usualsecretarial job becauseof her limited sitting tolerance.Shecanperform most ofher usualhouseholdtasks,suchasgrocery shopping and cleaning, although she ftequently receives help from her family. She reports that the pain started about 4 years ago,when she reachedto pick up a suitcase,and althoughit was initially severe,at a levelof 10 on a scaleof 1 to 10, and subsidedto somedegreeovel the first few weeks, it hasnot changedsignificandy in the past 2 to 3 years and is now usually at a level of 9 or greater Shehashad multiple diagnosticteststhat have not revealedany significaotanatomicalpathology,and she has received multipie treatments, including narcotic analgesicsand physicaltherapy consistingprimarily of hot packs,ultrasonography, andmassage, without significant benefit. Her only current treaftnent is 600 mg of ibuprofeq which sheis taking 3 times a day.The objective exam is significant for restricted lumbar range of motion in all planes.Forward bending is restrictedto approximately40% of normal, backward bending is restrictedto approximately50% of normal, and side bendingis resffictedto approximately507oof normalin both directions.?alpationrevealsstiffnessof the lumbar facetjoints at L3 throughL5 and tendemessin the lower lumbar area. All neurologicaltesting, including lower extremity sensation, strength, and reflexes are within
a
normal limits, although srraightleg raisingis limited to 40 degreesbilaterally by hamstring tightness and prone knee bending is limited to 100 degreesbilaterally by quadricepstighmess.T| is 5 leet 3 inchestall and reports her weight to be 180 pounds.She reportsthat she has gained 50 pounds sinceher initial back injury 4 years ago. EVALUATIONOF CLINICAL FINDINGS This patient seeksmedical ueatrnent for the impairments of low back pain and restricted lumbar range of motion. These impairments have resulted in difficulties widr her normal functional activities of sleeping, working, shopping, and cleaning. Although funher analysis may help identify the specificstructurescausingtJrispatient's pain, the long duration of the pain is well beyond t}re normal time neededfor a minor backinjury to resolve.The lack of changein her pain over the previous years and its lack of responseto multiple treatmentsindicatethat her pain may have a variety of contributory factors beyond local tissue damage, including deconditioning, psychological dysfunction,or socialproblems. PREFERREDPRACTICEPATTEFN Tmn:irarl
Pn
f/R\
PLAN OF CARE The proposed goals of treatrnent at this time may include controlling pain and regaining normal lumbar range of motion. However, the primary goals of treatment would be to retum fl to her maximal functional level and minirnize her dependenceon medicalpersonnel and further medical treatment. ASSESSMENTREGARDINGSELECTIONOF THE OPTIMAL TREATMENT The optimal intervention would ideally addressthe functional limitations causedby this patient's chronic pain and provide her widr independent means to manageher symptomswithout adverseconsequences. Thus the probablefocusof carewould be on teachingTJ coping skills and improving her physical condition, including strength and flexibiJity. The useof physical agentswouid probably be restricted to independent use for pain managementor asan adjunctto promoteprogressiontoward more functional goals-As is explained in greater detail in Section2 of this book, a number of physical agents, including cryotherapy, thermotherapy, and electrical stimulation,may be used by patientsindependentlyto conuol pain, while thermotherapy may also be used to help increasethe extensibiliry of soft tissuesto allow for more effective and rapid recovery of flexibiliry.
PreferedPhysicalTherapistPracticePaternssMl4Iand4Bl arecopynght2002AmericanPhysicalTherapy AIl rightsreserved. Association.
One . PATHOLOGy AND PATIENT PROBLE|S
CHAPTER REVIEW
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3. Merskey H, ed: Classificationof chronicpain: description of chronic pain syndromesand definition of pain terms,Parn(Suppl3)3(Suppl):S1, 1986. 4. Vasudevan SV, Llnch NT: Pain centers: organization and outcome, \YestJl\en $4F}532-535, t99t. 5. Vasudevan SV Rehabilitation of dre patient with chronic pain: is it cost effective?PainDigest2:99-L0L, 1992. 6. KazisLE,MeenanRI, AndersonJ:Painin the rheumatic diseases: investigationsof a key healt! statuscompo^er,t',Afthhk Rheum4(Suppl2):10-13,1983. 7. StrangP: Emotionaland socialaspectsof cancerpain, ActaOncol31(3):323-326 , 1992. 8. Stubble HG, Crubb BD: Afferent and spinal mechanismsof joint paiq Pah 55:5-54,1.993. 9. SlukaKA: Painmechanismsinvolved in musculoskeletai disorden,/ Onhop SVonPhys Ther24(4):240-254, 1,996. 10. Crigg B StubbleHC, SchmidtRI: Mechanicalsensitivity of group III and IV afferents from posterior articular nerve in normal and inflamed cat knee,J Newolhysiol 55635-643,7986. 11. BonicalJ: TheMaxagementof Pain, ed 2, Philadelphia, 1990,Lea& Iebiger 12. BonicalJ: Importanceof the problem.In Aronoff GM, ed: Evaluationand Treatmettof ChroxicPain, Baftinore, 1985,Urban & Schwarzenberg. 13. VasudevanSV Management of chronic pain: what have we achievedin the last 25 years?In Ghia JN, ed: The Muhidisciylinary Pain Cexter: Otgaxization and Petsoaxel Functions for Pait MaxagemetyBostoq 1988, Kluwer. 14. Melzack B" Dennis SC: Neurophysiologicalfoundations of pain. In StembachM, ed: ThePsychology of Pain,NewYork,1978, RavenPress. 15. KellgrenJH: Observationson referredpain arisingfrom muscle. Clin Sci3:175-190. 1938. 16. StaffPH: Clinicalconsiderationh referredmusclepain and tendemess-connectivetissuereactions,EutJ Appl Phvsiol57:369-372. 1988. 17. Black RC: Evaluationof the pain patrent,J Disabil 1,: 85-97,1990. 18. InternationalAssociationfor the Studyof ChronicPain, Sr.rbcommittee on Taxonomy:Classificationof Chronic Pain.Paiz(Suppl);3:SL-5225. 1986. 19. Crue BL, ed: Paix: Research axd Trcatment,New York, 1974,AcademicPress. 20. Osterweis M, Kleinman A, Mechanic D, eds Paix and Dkability - Clixlcal Behavioral axd Public Polky PersVectite:Coumittee on Paix, Dkability and Chrcnk References Illness Behavior,Washingto4 DC, 1987, National 1. SweetWH: In FieldJ, MagounHW, Hall \4' eds: AcademyPress. Haxdbook ofPhysiology. Section 4:NeuroVhysiology, Volume 27. Magni C, Caldieron C, Luchini SR et al: Chronic I Washington,DC, 1959,AmedcanPhysiological musculoskeletalpain and depressivesymptoms in Society. the generalpopulation:an analysisof the 1st national 2. BonicaJJrPain:what is sciencedoing abott \t? Paix health and nutrition examination survev data.Paix 43: 2:12-15,1975. 299-307. 1,990 .
?ainis the result of a complexinteractionof physical :nd psychologicalprocesses that occurwhen tissueis damagedor at risk of being damaged.The sensation -nd experienceof pain varieswith the duration and -.ourceof the painful stimulus to produce acute, :hronic, or referredpain. Pain is generallyperceived 'vhen specializedpain receptors(nociceptors)at the f,eripheryare stimulatedby noxious thermal,chemi:al, or mechanicalstimuli. Nociceptorscausetrans:nissionof the sensationof pain along C fibers and A-deltafibersto the dorsalhom olthe spinalcord and -Jrence,via *re thalamus,to the cortex. Pain trans:rission may be inhibited at the spinal cord level by activity of A-beta fibers that transmit nonnoxious sensations,or at the pedphery,spinal cord, or higher levelsby endogenousopiates.Painmay alsobe modiied indirecdy by disruption of the pain-spasm-pain cycle.The severiqrand quality of an individual'spain canbe assessed usinga variery ofmeasures,including visualanalogand numeric scales,comparisonwith a predefinedstimulus, or selection of words from a givenlist. Thesemeasurescan help to direct careand indicate patient progress.A number of approaches can be usedto relieveor control pain. Theseinclude pharmacologicalagents,physical agents,and multidisciplinary treatment programs. Pharmacological agentsmay alter intlammation or peripheralnociceptor activation or may act centrally to alter pain transmission.Physicalagentscan also modiflz nociceptor activation and may alter endogenousopiate levels. Multidisciplinary treatment programs integrate pharmacological,physical, and other medical approacheswith psychologicaland social interventions to address the multifaceted dysfunction of chronic pain. A good understandingof the mechanisms underlying pain transmissionand control, the tools availablefor measuringpain, and the various approachesavailablefor ffeating pain is required to selectand direct the use of physicalagentsappropriately within a comprehensivetreatment program for the patientwith pain.The readeris referredto the Evolve website http://evolve.elsevier.com/Cameron for study questionspertinentto *ris chapter.
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3 . Ptlilr
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3041985. 791. Keele IJ, Caidwell DS, Queen KT et aL Pain coping strategies in osteoarthdtis patients, / Cotsuh Cllx Psvchol55208-212.1987. 792. Mayer TC, GatchelRJ,Mayer H et aL A prospective two-year study of functional restoration in industrial low back injury-an objectiveassessment procedure, JAL4A 258t1763-1767, 1987. 193. Stieg RL, Williams RC, Timmermans-Williams G et al: Cost benefits of interdisciplinarychlonic pain fteatmenq Cli J Paih1t189-193,L986. 194. Simmons JW, Avant WS jr, Demski J et al: Determining successfulpain clinic treatrnent tlrough validation of cost effectiveness.Sdxe 1.3:342-344. 1988.
ToneAbnor lities DianeD. Allen,MS, PT, and Cail L. Widener,PhD, PT
SUMA,IARY
OF INFORMATI
-\luscleTone Defined Terminology for Tone Abnormalities -\leasuringMuscle Tone The Anatomical Basesof Muscle Tone and Muscle Activation
OT/ COVERED
Abnormal Muscle Tone and lt's Consequences Clinical CaseStudies Chapter Review
OBJECTIVES Uponcomyletionofthis chayte4the readerwill beable to: 1 . Define muscle tone and identify tone changesin
the normal adult. 2 . Use appropriateterminology to describe abnormalmuscle tone. Describequantitative and qualitative metrhods usedto measuremuscletone,determining when eachis appropriate. J . Identify the activeand passiveelementsof muscletlat contribute to muscle tone. J . Describethe function of the alpha motor neuron and its conduction of electrochemical signals. 6 . Idenri$rperipheral,spinal,and supraspinal sourcesofinput to the alpha motor neuron.
7. Describemuscle tone differencesresulting from changesin excitatory and inhibitory input to alpha motor neurons. 8. Discussvarious patholoSiesthat might result in abnormal muscle tone, including the q/pe of tone abnormality that is likely to occur. 9. Identifr clinically relevant consequencesof increased,decreased,or fluctuating muscle tone. 10. Determine appropriatemanagementof patientswith abnormal muscle tone, stating the expectedeffect ofvarious treatments.
/5
74
4 . ToneAbtormalities
Significantproblemsin both muscletone andmuscle activation severely limited Mrs. H's function. While she sat in her wheelchair, her thorax was kyphotic, her head was exaggeratedlyextendedforward, her left arm writhed, her left leg danced,and her right arm huggedher right knee to her chest.Her mouth and tongue worked continuously.The constant involuntary motion, or dyskinesia,was probably a result of large doses of medication used to control the lack of motion, or akinesia,typical of her Parkinson'sdisease.Her dyskinesiaalternatedwith a "freeze state" in which her left arm and les would slow and then stop:shewould let go of heriighc leg and becomestill in her chair, sitting with a masked faceand both feet on the floor like a sedatestatue.In the akineticfreezestate,eventhe simplestfunctional movementsbecamenearlyimpossiblefor her Mrs. H's dyskinesiaand freezesrepresentfluctuations in the tone and activation of her muscies. Muscle activation, or contraction,is readily understandablebecauseit is usuailyvisible through movements and can be measuredby the force or torque generatedarounda joint. ]n contrast,muscletone is a quality that is difficult to define or quantify. It is observablein its extremestatesand evenin its normal fluctuations. The difficulty lies in the perpetually changingnature of muscletone and in the many factors that affectit. This chapterdescribesaccepteddefinitions of muscletone and its relatedconceptsJ ways of measuringmuscle tone, the anatomic basesfor muscletone, and some of the issuesthat arisewhen tone is abnormal.Examplesand problemsare drawn from both neurorehabilitationand orthopedic settings.The focus,asin the rest of this text, is on problemsthacmay be affecredby physicalagenrs.
MUSCLE TONE DEFINED Muscle tone is variously describedas muscletension at rest,readinessto move or hold a position,priming or tuning of the muscles,lor the degreeof activation beforemovement.Muscletone is the underlyingtension in the muscle that servesas a backsroundfor To defineit moreconcrerely, contraccjon. musclerone is the passiveresistanceto the stretch of a muscle. The subjectmustbeinstructednot to resistthe stretch aoolied so that whatever resistanceis noted can be aitiibnt"d to the vadous components of muscle tone rather than to voluntary muscle contraction. The componentsof muscle tone include the active
resistancegenerated by neurally activated muscle fibers and the oassive.biomechanicaltension inherent in the connectivetissueand muscleat the leneth agentsuseJin atwhich the mu'cleis tested.2 Physical physicaltherapymay affect the neuralor the biomechanicalcomponents oI muscletone,or both. The following example may help clarify some concepts.A runner'squadricepsmuscleshave lower tone when tlte runner is relaxed and sitting, with feet propped up, than when those samemusclesare lengthenedover a flexedkneeand preparingfor imminent contractionat *re starting block of a race (Iig. 4-1).The differencebetrveenthe lower tone and the highertone canbe palpatedasa qualitativedifference in the resistanceto finger pressureover the musclein eachinstance.In the relaxedcondition,a palpatingfinger will sink into the muscleslightly becausethe muscle provides so little resistanceto that deforming pressure,which is a type ofstretchon the surfacemuscle fibers. The finger will register relative sofmess comparedwith the hardnessor resistance to deformation that is felt in the "ready' condition.In the ready condition, both the biomechanicaland the neural componenrscontrjbuteto a greater resistanceto deformatiorqor increasedmuscletone.Irom a biomechanicalstandpoint,the muscleis stretchedover the flexedknee,so any slackin the soft tissueis takenup, and the contractileelementsare positionedfor most efficientmuscleshorteningwhen the newessignalthe muscleto contract.Irom a neural standpoint.when the runneris poisedat the startingbloci, the neural activity increasesin anticipationof the beginningof the race.This neural activation of the quadricepsis greaterthan when the runnerwas sitting and relaxed; it presetsthe musclefor imminent contractron. Note that *re samequalitativedifferencein resistanceto fingerpressurecouldbe palpatedif the runner relaxedand then contractedthe quadricepsvoluntarily. One of the difficultieswith tone identificationand descriptionisthe overlapbetweenhow a musclelooks beingpreparedto and feelswhen it is subconsciously move or hold, and how it looks and feelswhen it is consciouslyorderedto contract.A key to the assessment of muscletone is that no activeresistanceto t}le musclestretchoccurs.If a subjectis unableto avoid actively resisting, then the tonal qualiqy assessed when the muscleis stretchedwill be a combinationof tone and voluntary contraction.Even people who have normal control over their musclessometimes have difficulty relaxingat will; therefore,one can see
Olrc . PATHOLOGY AND PATIENTPROBLEMS
Hightonein quadriceps muscle
Lowtonein quadriceps muscle
Figure4-1. Normal variations in muscle tone.
',vhythe differentiationbetween muscletone andvoluntarymusclecontractionmight be difficult. The continually changingnature of muscie tone can also lead to problems with its identification. Despitethe differencesin tone between the relaxed andimminent-contraction,or readystates,the runner in the exampledescribedaboveis consideredto have normal muscletone in bot! instances.Normal. then. rs a spectrumratherthan a precisepoint on a scale. Abnormal muscle tone may overlap normal muscle tone at either end of the span(Iig. 4-2), but it has the following distinction:with abnormal tone, the individual has a restrictedability to changethat tone to prepareto move readilyor to hold a position.In other words, slow movement is not abnormal unless an
Normalmuscletone
t_
Nol
muscre
i"" -.I__-Abnormaliy low muscletone
I
l
Excesstve I muscre I ,on: | t---_T__l Abnormallyhigh muscletone
Figure4-2. Normal muscle tone is a spectrum.
4 o ToneAbrormalities
76
individual can oflly move slowly. Lower tone is not abnormalunlessan individual cannotincreaseit sufficiently to preparefor movement or holding. Higher tone is not abnormal unless the individual cannot alter it at will, or unlessit occursuncomfortably as muscle spasms,cramps,or inefficient use of energy. Normal muscletone, then, is not a particularamount of passiveresistanceto stretch,but ratheris a controltensionsto supportnormal lablerangeof appropriace movementand posture.
FORTONE ABNORMALITIES TERMINOLOGY Flaccidityls the term used to denote lack of tone or zero resistanceto passivemovementwithin the middle rangeof the muscle'slength,andis usuallyconcuris rent with total paralysisof the muscle.Hyyotoniciry to resistance decreased to describe term used the stretchcomparedwi*r normal muscles.Ilaccidity is an extremecaseofhypotonicitY. Hyyenonicity,the term for high tone, may be ei*rer resistance to spastic,detinedas velocity-dependent in muscles like the (quick or rigid, stretch).3 siretch that to stretch are resistant Mrs. H's freezestate,which is applied quickly or slowly. A hypertonic or h)?otonic musclemay ormay not havesomedegreeof voluntary conffactility.Mrs. H, for example,hasboth rigidity and akinesiaduringa fteeze,which meansthat shealsohas difficulty initiating voluntary movement. The term sgasticitrhas had wide clinical use but causesconfusionunlessit is narrowly defined ffable 4-1).The termhassometimesbeenpairedwlth yaralysrs,which is the lossof voluntary movement,and has shared the blame for the loss of function noted in
patient conditions labeled syasticparalysisor syastic Muscle tone and voluntary muscleconhemiplegia.a,s traction,however,are distinct from eachother,as are spasticityand loss of function. Muscle tone and posture arealsodifferententities.Ior example,an individual who presentswith an adducted and internally rotatedshoulder,a flexedelbow,and flexedwrist and fingers,holdingthe hand closeto the chest,canbesaid to havea flexedpostureof the arm. He or she cannot be saidto havespasticityuntil the passiveresistanceto at differentvelocitiesfor eachof the stretchis assessed involved muscle groups. Spasticirycoexistswith hyperactivestretchreflexesin its qypicalclinicalpreseniationa,6but becausepatientswi*l rigidiry canalso the rwo terms have hyperactivesrrecchreflexes,7 should not be equated.In addition, some confusion becauseit has has arisenregardingthe term spasticity beenappliedto abnomal muscletonehavingdifferent underlying neural pathologies,such as spinal cord injury versusstrokeor cerebralpalsy To clari$zusein will be applied only to a particular this text, sl2asticiry qype of abnormal muscle response,whatever the pathology,in which quickerpassivemusclestretches than slowerstretches.r elicit sreaterresistance Clonusis the term usedto describemultiple rhythmic oscillationsor beatsin the resistanceof a muscle responding to quick stretch, observed particularly with stretchto ankle plantar flexors or wrist flexon. The claso-knifephenomenonconsistsof initial resistance followed by a sudden releaseof resistance responseto a quick stretch of a hypertonic muscle, much like the resistancefelt when closing a pock etknife.A musclespasmis an involuntary strong tractionof a muscle,typically asthe resultof a
P*'
What SpasticityIs and Is Not ts:
A type ofabnormal muscletone
Paralysis
One type of hypertonicity
Abnormalposturing
resistanceto passivemusclestr€tch Velocity-dependent
A particuiardiagnosisor neuralpathology HyPeractivestretchreflex MusclesPasm Voluntarymovementrestrictedto movementin flexor or extensorsynelSy
Note: Spasticity,when present,is not alwaysthe causeofmotor dysfunction.
O,,e . PATHOLOGY AND PATIENT PROBLEMS
stimulus.A client who has pain in the low back may have muscle spasmsin the paraspinalmusculature that cannotbe relaxedvoluntarily. For those who, like Mrs. H in the example describedearlier, have fluctuating abnormal tone, qualitative descriptionsare appl.ied.Mrs. H's tone variesbetweenrigidiry of the muscleson both sidesof her joints during a fteeze,and altematinghigher and iower tone in agonistsandantagonistsaboutthe joints duringher dyskineticstates.Muscletone is especially difficult to assesswhen it is fluctuatingwildly, so it is commonto describevisiblemovementratherthan the tone itself. The common term used to describeany type of abnormal movement that is involuntary and hasno purposeis /ysbixesia.Sornespecifictermsused to describevarioustypes of dyskinesiaarechorelform moveftteflts or chorea(dance-Iike,sharp, jerky movements), ballismus (ballistic or large throwing-rype movements),tremorQow-amplitude,high-frequenry oscillatingmovements),athetoidmovements (w orm'llke writhing motions), anddystonia (involuntarysustained musclecontraction).One exampleof dystoniais seen in the condition called spasmodic tonicollis,or wry necb, in which the individual'sneckmusculatureis continuously contractedon one side and the individualholds the headasymmetrically.E
MEASURING MUSCLE TONE Severalquantitative and qualitative methods have been used to assessmuscletone. Its variabiliry with subtle intrasubjector environmentalchanges,however,Iimits the usefulnessof staticmeasuresof muscle tone. In addition, measuringtone at one point in time during one movement ot stateof the muscle(at rest or during contraction)provideslittle information about how the muscletone enhancesor limits a differentmovementor state.9Thereforeexaminersmust be carefulto record*re specificstateof conffactionor relaxationof the musclegroup in questionwhen they assessmuscle tone, and not interpret the results as true for all other statesof the musclegroup. In other words, ankle plantar flexor hypertonicity assessed at rest cannotbe said to limit ankle dorsiflexiondurins che swing phaseof gait unlesste'ting is completeJ while the client is upright and moving the leg forward. The methods described in this section for measuringmuscle tone, then, should be used with two caveatsin mind. Iirst, the examinershouldavoid generalizingthe resultsof a singletest, or evenmulti-
77
ple tests,to all conditionsof the muscle.Second,the examinershould include measuresof movement or functionto obtaina more completepictureof the subject'sability ro usemuscletone appropriately.
Measures Quantitative Passiveresistanceto stretchprovided by muscletone can be measuredby tools similar to those used to measurethe forcegeneratedby a voluntarily contracting muscle.When a voluntary contractionis measured, a subjectis askedto "push againstthe device with all your strength.' When muscle tone is measured, a subjectis asked to nrelax,ar'd 1etme move you." Suchmeasuresare restrictedto the assessment of musclesthat are both reasonablyaccessibleto the examinerandeasyto isolateby the subjectto contract or relax on command.Muscles at the knee. elbow. wrist, and ankle, for example,are easierto position and to isolatethan trunk muscles. One protocol for quantifying muscle tone in the ankle plantar flexors was describedby Boiteau et al and utilizes a hand-held dynamometer or myometer.10The subjectswere seatedand positionedso that their feet were unsupported. The head of the dynamometerwas placedat the metatarsalheadsof the foot. The examiner passively dorsiflexed the ankle to a neutral position with pressurethrough the dynamometet severaltimes at different velocities. The examiner controlled the velocitiesby counting seconds:completingthe movementin 3 secondsfor a slow velocity and in less than half a second for a fast velocity.The authorsreportedhigh reproducibility (intraclasscorelation coefficients= .79 and .90) for both the high- and low-velocity conditions.l0 Comparinghigh- andlow-velociryconditionsenables the examinerto distinguishbetweenneuraland biomechanicalcomponentsof spasticity. A diagnostictool frequendy used for quantifying muscletone in researchis eiectromyography(EMC) (Iig. a-3). EMC is a record of the electricalactivity sampledfrom musclesat restand duing contraction, usingsurface,fine wire, orneedleelectrodes(Fig.4-4). During voluntary musclecontraction,the recordwill show deviationsaway from a straightisoelectricline €ig. a-O. The number and size of the deviations (peaksand valleys) give a measureof tlte amount of muscle tissue that is electrically active during the contraction.When a supposedlyrelaxedmuscle demonstrateselectricalactivity when stretched,that
4 . Tore Abnorualities
78
activity is a measureof the neurally derived muscle tone at that moment. to usingEMC to evalThereareseveraladvantages uate muscletone. One advantageis its sensitivityto low levelsof muscleactiviqythat may not be readily palpableby an examiner.In addition, precisetiming of muscleactivationor relaxationcanbe pickedup by EMG andmatchedto a commandto contractor relax. of thesebenefits,EMC can be usedto proBecause vide biofeedbackto a subjectwho is trying to leam how to initiate contractionor relaxationin a particular musclegroup.tl Another advantageof EMC is that
Figure 4-3. Setupfor performingsurfaceEMC
Figure4-5. Example of an EMC tracing from the extensor poilicis longus (uyyer ttacing) and flexor pollicis muscles (lower ttacing) dudng an isometdc contraction ofthe flexor pollicis longu. muscle.The nidJle na.ing is the force output produced with a 60% maximum voluntary contraction (MVC). (Reprintedwith permission from Basmajian fV, De luca CJ:Mu',|e, Alive:I hei,Funrio'1' byElectromyograyhy Revealed , ed 5, BaltLrnore, 1985,Williams & Wilkins.)
I
z=
in some casesit can differentiatebetweenthe neural and biomechanical components of muscle tone, which oaloation alone is unable to do. If a relaxed muscle-showsno electricalactivity via EMG when stretched, but still provides tesistanceto passive stretch,then its tone can be attributed to the biomechanical properties rather than the neural componentsof the muscleinvolved. Disadvantasesof EMC include its restriction to monitoring oJy a local areaof muscletissuedirecdy adiacentto the electrode.It also requiresspecialized equipment,and sometimestraining, that is beyond the budget of many clinical facilities. In addition, muscletone and activemusclecontractioncannotbe distinguishedfrom eachother by looking at an EMC record. A label of some kind must state when the subject was told to contract and relax and when the musclewas stretched.Although EMC is capable ofrecordingthe amount of muscleactivation,it measures force only indirectly via a complex relationship betweenactivitv and forceouttrrut.12
Figure4-4. Disposable (sma11),surface, and fine wire EMC electrodes.
One . PATHOLOGY AND PATIENT PROBLEMS
Somemeasuresof muscle tone have been develf,pedto test particulartypes of abnormalities,not just :one in general.One of these is calied the yexdulum :Jit,which is intendedto test spasticity.The test con-.istsof holding an individual'slimb so that when it is :ropped, gravity providesa quick stretchto the spasic muscle.The resistanceto that quick stretchwill :rop the limb trom falling beforeit reachesthe end of :s range.The measurement of spasticity, via an elec=ogoniometerl3 or isokineticdynamometer,14 is rhe Cifferencebetv,'eenthe angle at which the spastic ruscle "catches"the movement and the angie *re rmb would reachat the end of its normal range. 3ohannonreporredthe resr-rerest reliabiliryas hi-gh ivhen the quadricepsmuscle was tested consecuiveLy in 30 patientswho had spasticityafter experiencinga stroke or head injury.la A limitation of the cendulumtest is that somemusclegroups cannotbe :ested by dropping a limb and watching it swing, specifically,the musclesof the trunl
Measures Qualilative -\4uscletone is more often assessed oualitativelvthan quanticatively. Oneclinicalmeasure in commonusei, a s-point ordinal scalethat placesnormal tone at 2+. No tone and hypotonia are given scoresof 0 and 1+, respectively,and moderateand severehypertoniaare givenscoresof 3+ and4+, respectively.ls The clinician obtainsan impressionof the muscletone relativeto normal by passivelymoving the patient at varying
79
speeds.When muscle tone is normal, movement is light and easy.When muscletone is decreased, movement is still easy or unrestuictedbut the limbs are hear,y, as if they are dead weight. When tone is increasedfor a particularmuscle,the movementthat mechanicallystretches*rat muscleis stiff or unyielding. Various movementsmust be made at multiple joints to distinguishbetweenthe differencesin muscle tone of the flexorsversusthe extensors,for instance. Another common qualitativeway to assess muscle tone is to observethe responseelicitedby tappingon its tendon,activatingthe musclesftetchreflex.As with the clinicaltone scale,in this5-pointscale,2+is considerednormal,0is absentreflexes, 1+ is diminished,3+is briskerthan average,and4+ is very brisk or hyperactive.16The nonnai responses for differenttendonsdiffer For example,a tap on the patellar tendon will normally resultin a slight swing of the free lower leg from *re koee.In contrasqa bicepsor tricepstendon tap is still considerednormal if a small twitch of the musclebelly is observedor palpated;actualmovement of the whole lower arm would generallybe considered hyperactive.Normal responsesare determined by what is typicalfor that tendonreflex.In addition,symmetry ofreflexes,assessed by comparingthe responses to stimulationof the left and right sidesof rhe body, determinesthe degreeof normalcyofthe response. The Ashworth ScalelTand the Modified Ashworth ScaielBwere developedto specificallymeasurespasticity. Iive ordinal grades are defined, from 0 (no increasein muscletone)to 4 (rigidly held in flexion or
F*,
Modified Ashworth Scalefor Grading
Grade
Description
0
No increaseinmuscletone
1
Slightincreaseinmuscle tone,manifestedby a catchand releaseorby minimal tesistanceat the end of the rangeof motionwhen the affectedpart(s)is moved in flexion o! extension
1+
Slightincreaseinmuscle tone,manifestedby a catch,followed by minimal resistancethroughoutthe remainder(1ess than ha10ofthe ROM
2
More markedincreaseinmuscle tone throughmost of the ROM, but affectedpart(s)easilymoved
3
Considerableincreasein muscletone,passivemovementdifficuit
4
Affecredpan(s)rigidin flexionor extension
ROM, mngeof notion. Reprintedwith permissionof the American PhysicalTherapy Associaiion.From BohannonRW, Smirh MB: Interraterreliabiliry of a Modified Ashworth Scaleof MuscleSpastrcity, PhysThet67:207,1987.
80
4 . Tore Abnornalities
extension).An intermediategradeof 1+ distinguishes the original Ashworth Scale and the Modified Ashworth Scale,and is defined by a slight catch and continued minimal resistance through the range [able 4-2). Bohannon and Smith reported,867 o/o interrater agreementwhen testing 30 patientswho had spasticityin the elbow flexor muscles.lB
and its surrounding connective tissue. The practitioner must have an understandinsof the anatomical basestor both tone and accivatlonro determine appropriatephysical agentsto apply when either is dysfunctional.The anatomicalcontributionsto muscle tone and activationarereviewedin this section.
Muscular Contributions to Muscle Tone and General Considerations When Measuring Muscle Activation Tone The relativepositionsofthe limb, body,neck,andhead with respectto one another and to gravity canall affect muscletone. For example,the asymmetricand symmetric tonic neck reflexes(AfNR and STNR,respectively) are known to influence the tone of the flexors and extensorsof the arms and legs,dependingon the positionof the head(Iig. 4-Q, both duringinfanry and in subjectswho haveneurologicaldeficits.leSubdedifferencesin muscletonedueto thesereflexescanbepalpatedwhen the headpositionchangesevenin subjects with matureandintactnervoussystems.Likewise,the pull of gravity on a limb to stretchmuscles,or on the vestibularsystemto ffiggerresponses to keepthe head upright, will changemuscle tone accordingto the position of the headand body.The testingposition,therefore, must be reportedfor accurateinterpretationand replicationof any measurementof tone. Additional generalrulesformeasuringmuscletone includestandardizationof touch and considerationof the musclelengthat which a group of musclesis to be tested.The examinermustbe awaretlat touchinsthe subiect'sskin, eitherwith a hand or wirh an initrument, can influencemuscletone. The handholdsand inshument placementmust therefore be consistent for accurateinterpretationand replication.The length at which a specificmuscle'stone is testedmust also be standardized.Becausemuscle tone differs with passivebiomechanicaldifferencesat the extremesof range,and rangeof motion (ROM) canbe alteredasa result of long-tem changesin tone, the most consistent length to measuremuscletone is at the midrange of theavailablelengrhoI the muscletested.
THEANATOMICAL BASES OFMUSCLE TONE ANDMUSCLE ACTIVATION Muscle tone and muscleactivation originate from interactions between nervous system input and the biomechanicaland biochemicalpropettiesof the muscle
Muscleis composedof (1) contractileelementsin the musclefibers,(2)cellularelementsprovidingstructure, (3) connectivetissue providing coveringsfor the fibers andthe entiremuscle,and(4)tendonsattachingmuscle to bone.When neuralinput signalsthe muscleto contractor relax,biochemicalactivityof the contractileelements shortens and lengthens muscle fibers. As the conffactileelementswork, they slideagainsteachother, facilitated by the cellularelementsto maintain structure and the connectivetissuecovedngsto providesupport andlubricationwhile the musclechanges length. The myofilaments, actin and myosiq are the contractile elementsof muscle.With neurai stimulation of the musclefiber,storagesitesin the musclereleasecalcium ions that allow the actin and myosin moleculesto bind together.The bindingoccursat particularsitesto form cross-bridges Qlg. a-4. Breakingof thesecrossbridges,so that new bondscan be formed at different sites,is mediatedby energyderived from adenosine ffiphosphate(AT?).As bondsare formed,broken,and reformed, the length of the contractile unit, or sarcomere,changes.The cycle of binding and releasingcontinues as long as calcium ions and AT? are presenl Calcium ions are taken back into storasewhen activation of muscleceases.SourceswirlLin the musclesupply an adequateamount of AT? for short-duration activities,but themusclemustdependonfuel delivered by the circulatorysystemfor longer-duration activities. Actin and myosin myofilaments must overlap for cross-bridgeformation to occur (Iig.4-B). When the muscle is sftetchedtoo far, cross-bridges cannot be formedbecause thereis no overlap.Whenthe muscleis in its most shortenedpositiory actin andmyosin run into the stuctural elementsof the musclefiber andno further cross-bridges can be formed. In the midrangeof muscle,actin and myosin canform the greatest of cross-bridges.The midrange, then, is the length which that musclecan generatethe greatestamount force, or tension.This length-tensionrelationshipis of the biomechanical propertiesof muscles.
Ofte . PATHOLOGY AND PATIENT AROBLETIS
SYMMETRICAL TONICNECKREFLEX(STNR) STIMULUS RESPONSE Necktlexed Tonechangesso armsflex,legse)dend
STIIVULUS Neckextended
RESPONSE Armsextend,legsflex
ASYMMETRICAL TONICNECKREFLEX(ATNR) STIMULUS FESPONSE Neckrotationto oneside Tonechangesso jaw limbsextend andskulllimbsflex
SYMMETRICAL TONICLABYRINTHINE REFLEX(TLROR STLB) STIMULUS RESPONSE Proneor supineposition Tonechangestowardtotalflexion notedby labyrinths in head or totalextension
Figure4-6. Reflex responsesto head or nec.l(posrtion.
81
a2
4 o Tore Abnonralities
Midrange
Lengthenedsarcomere
Shortenedsarcomere
Sarcomere Figure4-7.Cross-bridge formationwithin musclefibers. Other biomechanicalpropertiesof musclesinclude friction and elasticiry lriction between connective tissuecovedngsas*rey slidepastoneanothermay be affectedby pressureon the tissuesand by the viscosity of the tissuesand fluids in which they reside. Elasticity of connective tissue results in varying to stretchat differentmusclelengths.When responses tissue becomestaut, as it is when a muscle is fully lengthened,corurectivetissuecontributesmore to the overallresistanceof the muscleto stretch.When connective tissue is slack,it contributesvery little to a muscle'stension.ln fact, when muscleis stimulated to contract while it is shortened,there is a delay beforemovementcanoccuror forcecanbe generated while the slackin d-reconnectivetissueis taken up. The runner'scrouch in lig. 4-1 takesup some initial slackin the quadricepsbeforethe start of the raceto reduceany delayin activation. Bodr activecontractileelementsand passiveproperties of the tissuescontribute to muscle tone and activation. Howeveq muscle tone can be generated from the passiveelements alone, whereas muscle activationrequiresboth activeand passiveelements.
Figure4-8. Relationshipbetweenactin and myosin at lengths. threedifferentsarcomere Physicalagents,such asheat and cold, can change both muscletone and activationby alteringthe accessibility of AfP to the myofilamentsthroughimproved circulationandby changingthe elasticityor friction of the tissues. Physical agents can aiso change the amountof neuralstimulationof the musclefibers.
toMuscle Tone and Neural Contributions Activation NeuralsourcesoI input that contributeto muscletone and muscleactivation come ftom the periphery the s p i n a cL o r d . supraspinb a rl a i nc e n t e r {' F : g . 4 9 ) . "nd Even though multiple areasof the nervous system may participate, all of them must work through the final common pathway, the alpha motor aeuron,
Orc I PATHOLOGY AND PATIENT PROBLEMS
83
major neurophysiologicaltext for a more complete descriptionof known input to alphamotor neurons.
Spinalcord
PeriPheral nerves(conlainbothsensory andmotorfibers)
Figure4-9. Schematic drawing of the nervous system, front view
which ultimately stimulatesmusclefibers to contract (Iig. 4-10).The generation,summation,and conduction of an activatingsignalin alphamotor neuronsare criticalcomponentsof muscletone and activation.In this section,discussionof nerve structureand function will be followed by an accountof some significant influenceson the alpha motor neuron. See a
Structureandfunctionof nerves Nerve cells,or neurons,include most of the components of o*rer cells,including cell bodieswith a cell membrane,nucleus,and multiple intemal organelles that keepthe cell alive.The distinguishingfeaturesof a neuron include the multiple projections,cal)edden drites,that recele stimuli-usually ftom other nerve cells-and the singleaxonalprojectionthat conducts stimuli toward a destination.The axon endsin multiple synapticboutons(Iig. 4-11).Theseboutonstransmit stimuli across the naffow gap, or synapse, betweena bouton and its targetmusclefibers,bodily organs,glands,or other neurons.Although a few specialized neurons can receive electrical,mechanical, chemical,or thermal stimuli, most neuronsrespond to and transmit signalsvia chemicalsknown as neura, tra smitters, Neurotransmittermoleculesaremanufacturedand storedin *re synapticboutons (ltg. a-n). An electrical signalconducteddown an axon causesthe release of thesemoleculesinto the synapticcleft. The molecules crossthe cleft and, if the postsl'napticcell is anotherneuron,bind to one of the chemicallyspecific receptor sites covering the dendrites,cell body, or axon(Fig.4-13). The neurotransmitterdopamine exemplifies the specificity of neurotransmittersand is significantto the study of muscletone and activation.Dopamineis normally found in high quantitiesin the neuronsof the substantianigra,oneofthe basalganglia,which is discussedlater in this chapter.Deficits in the production or use of dopamine result in rigidity, resting tremors.anddiFticulry initiacingandexecuting movement,luall manifesrarions of Parkinson's disease.2l The binding of a specificneurotransmitterwith its receptorsite tendseither to exciteor inhibit *re postsynapticcell.Whether the posts)mapticcell responds, by transmittingthe signalfrom the receptorsiteto the rest of the ce1l,dependson summation, or adding together,of many excitatory and inhibitory signals. Summation may be spatial or temporal (llg. a-M). Input to receptorsitesfrom many different synaptic boutonsat onetime resultsin spatialsummation,and sequential stimulation through the same receptor sitesresultsin temporalsummation.Excitatoryinput must exceedinhibitory input if the sum is to cause signal conduction down an axon. A single neuron
a4
4 . Tofle Abttorlfltlities
Neuronsin descendingiracts
Cellbody in spinalcord Sensoryneurons
:--------+ Spinal tnterneurons fromopposite sideof body
Spinalinterneurons Figure4-10.Alpha motor neuron: the final common pathway ofneural siSnalsto muscles.
ty-picallyreceivesinput from hundredsor thousands ot other neurons. Once excitatory stimulation reachesa particular threshold level, the signal is conducted down the axon in an action potential (having the potential to causean action).The action potential rapidly transforms the membraneof the neuron from its electrochemical state at rest. Membrane transformation occursin a wave of electrochemicalcurrentthat progressesrapidly from the cell body down the axon to the svnapticboutons.
Figure4-11. A typical alpha motor neuron.
At rest, the neuronal membrane separatesthe concentrationo[ sodium (Na+), chloride (Cl-), and potassium(K+)ions on the inside of the cell from the concentrationon the outside. Na+ and Cl are in greaterconcentrationoutsidethe cell,andK+andnegatively chargedprotein moleculesare in greatetconcentrationinsidethe cell.In addition to the chemical differenceacrossthe membrane,an overall electrical differenceexists immediately adjacentto the membraneof approimately -20 mV, with the insideof the membranemore negativethan the outside.Biological systemswith a differencein chargeor concenkation betweentlvo areaswill come to equilibriumif possible. Becauseof the electrochemicalditference,the membraneis saidto havea restingpotential,which is the potential for movement of ions toward equilibrium if the membraneallowed it. Channelsor holes in the membrane allow selective movement of ions from one side of the membrane to the other Allowing movement of only some ions Potassiumions makesthe membranesemipermeable. move fteely acrossthe membranewhen the neuronis at rest. Somemembranechannelsopen and closeat specific times to allow certain other ions to move gradieats.Still other accordingto their electrochemical ions are actively moved through the membrane from one sideto the other in a biochemicalpumping processThis processrequiresenergybecausethese ions are
85
O e. PATHOLOGY AND PATIENTPROBLEMS
P41. lvlultipledischargesfrom neuronA will activateneuron B temoorallv.or in time
NeuronD
2. Discharges fromneuronsA, C, andD willactivateneuronB spatially, or frommultiplespaceson neuronB Fiqure4-14. Temporal and spatial summation of input to Figwe4-12, Synapsebetween pre- and postsynapticneurons at rest.
Figure4-13. Synapsebetween pre- and postsynapticneurons when activated.
gradienqthat is, moved againsttheir electrochemical they move farther away from equilibrium of chargeor concentrationon the tvvosidesof tne memorane. When an action potential sweepsdown an axon, channelsin the membraneopen,allowing Na+ions to rush into the cell,therebyalteringboth the concentration and the electricaldifferencesbetweenthe inside and outside of the membrane. Durins the action pocenrial, the polardifferencebewveenthe electrical chargeinside and outside the membranechangesin that location; that is, that sectionof membranehas depolarrzed,with an increasein positive chargeon the inside. A sodium-potassium pump quickly restoresthe electrochemicaldifferencebetween the insideand outsideby transportingNa* ions back outsidethe cell andK* ions backinside.The endresultof the sodium-potassiumpump is repolarizationof that sectionof the cellmembrane. The successive depolarizationand repolarizationof membrane sections continues dovrm the axon until thosechangesstimulatethe reieaseof neurotuansmitters from all of the axon'ssynapticboutons(seeFig.4-13). The speedof conductionof an actionpotentialdepends on the diameterof the neuronandthe insulationavailable alons the axon. Neurons with smaller diameters have
4 . Tone Abnonnalities
86
slower conduction velocities. Larger-diameterneuronshavefasterconductionvelocities. Insulationspeedsthe ffansmissionof a depolarizing wave by increasing the speed with which the ions move across the membrane. A fatty tissue called myelin, provtded by Schwann cells in the peripheral in the cennervoussystem(PNS)andoligodendrog,tes tral nervoussystem(CNS),is the sourceof insulation for neurons.Myelin wraps around the axonsof neurons,leavinggapsat regularintervals(Iig. 4-15).When a depolarizing wave travels down an axon, it moves quickly down sectionswith myelin on them and slows at gapswhere no myelin is present,at the nodes of the signalslowsatthe nodesandtravRanvierBecause els very quickly between nodes,it appearsto jump all the ftom one node to the next in rapid succession This lumpway to the endof all the axonalbranches.z2 conductlon ing is refenedto assabatory Qi.g.4-1Q. The fastest conduction velocities recorded in human nervesare up to 70-80m/sec.23Temperature chanqescan alter these velocities.When axons are
Figule4-15. Myelin formed by Schwanncellson a periphetal neuton. Myelin
Node of ranvier
Figure4-16.Saltatoryconductionalong a myelin-wrapped axon.
cooled, as with the application of ice packs,nerve conductionvelocity slows by approximately2 m/sec for every 1"Cdecreasein temperature.24 Once the signalreachesthe synapticboutons and neurotransmittersare released,there is a slight delay for the moleculesto move acrossthe svnaptic cleft. Evenat 200Angst om units (200x 10-Ibm), it takes time for diffusion and then reception by the next neuronor targettissue.In addition,the receivingneuron must sum all of its input, both excitatory and inhibitory, before an action potential can develop. Therefore, larger numbers of connectionsbetween neurons take longer to transmit a signal than do smallernumbers.The shortestconnectionknown is connection of the musclestretch the singlemoxosynaptic reflex, observablewhen certain tendons are tapped (Ilg. 4-17).It is so called becausethere is only one synapsebetween the sensoryneuron receiving the stretch stimulus and the motor neuron transmitting the signalto the musclefibersto contract. Monorymapticffansmissiorlasrecordedftom muscle stretch (tap) to initiation of muscle stretchreflex contraction,hasbeenrecordedinas little as25 millisecondsat the arm.25The length of time betweenstimuareinvolved lus andresponsewhen multiple s1'napses is longer For example,when the arm is working to move a loadandvisualinputindicatesa suddenchange in the load,it takesapproximately300millisecondsfor the arm musclesto respondto that input.25[f a person unexpectedlysaw a ball begin to drop off a shelf 1 meter aboveher, the ball would fall approximately44 centimetersbeforeshecouldstartto move to catchit.
Stimulation ofMuscle Sources ofNeural Thealphamotorneuron Muscle tone and activationdepend on alpha motor neuronsfor neural stimulation.An alpha motor neurorq which is sometimescalled an axteriorhorx cell, hansmits signalsfrom the CNS to muscles.With its cellbody in the ventralor antedorgray matter or horn of the spinalcord (Fig.4-18),its axon exits *re spinal cord,andthusthe CNS,throughthe ventralnerveroot. Each axon eventually reaches muscle, where it branchesand imeruates benveen6 (in the eye muscle$ and 2000 (in the gastrocnemiusmuscle)muscle The musclefibers innerfibersat motor endplates.26 vatedby a singleaxonwith its branches,which is one motor unit (Iig. 4-19),all conffactat oncewheneveran actionpotentialis transmitteddown that axon.A sin-
Otre t PATHOLOCY
AND PATIENT PROBLEA"IS
87
Spinalcord (lrans\,€rsecross section) Peripheral nerye
Musclespindle
la afferentnerve
alphamotorneuron
Figure4-17. Monosynaptic muscle stretch reflex.
Ventral(anterior) horn Figure4-18. Alpha motor neuron: cell body in anterior horn of spinal cord, axon exiting spinal cord. gle action potential generated by the alpha motor neuron cannot provide its motor unit with a graded signal; each action potential is "all or none." When sufficient motor units are recruited, the muscle contracts. More forceful contraction ofthe muscle requires an increasednumber or rate of action potentials down the same axons, or recruitment of additional motor units. Activation of a panicular motor unit depends on dte sum of excitatory or inhibitory input to *rat alpha motor neuron (Fig. 4-20). Excitation or inhibition, in tun, depends on the sourcesand amounts of input via the thousands of neurons tlnt synapse on that one particu-
Figure4-19. One motor unit: alpha motor neuron and muscle fibers irLnervatedby it. lar alpha motor neuron. An understandingof the sources of input to alpha motor neurons is essential when atl-emptingto conffol motor unit activation or altermuscle tone via physical agentsor othermeans Clable4-3).
Inputfromtheperiphery The PNS includes all of the neurons that project outside of the CNS even if the cell bodies are locatedwithin the CNS.The PNSis composedof the alpha motor neurons,gamma motor neurons,some
88
4 . Tore Abtonnalities
Actionpotenlialpastthis line
Actionpolenlialpastthisline
Alphamotorneuron
Alphamotorneuron
MOTORUNITAT REST
MOTORUNITACTIVATED
Action potenlialpast this line
Alphamotorneuron OR
IV]OTOR UNITACTIVATED
Figure4-20. Balanceof excitatory and inhibitory input to the alpha motor neuron at rest and when activated.
p
l-S Irrp,r. ,o Alpha Motor Neu(ons (Simplified) From peripheral receptors
From spinal sources
From supraspina[ sources
Musclespindlesvia Ia sensoryneurons
Propriospinalinterneurons
Cortex, basalgangJiavia corticospinaltract
GTOs via Ib sensoryneurons
Cerebellum,red nucleusvia rubrospinal
cutaneousrecePtorsvia other sensoryneurons
Vestibularsystem,cerebellumvia ue(rih',1^<-ih,l
r.,.r"
Limbic system,autonomicnervous systemvia reticulospinaltracts
autonomic nervous system effectorneurons,and all of the sensoryneuronsthat carry information from *re periphery to the CNS. In this section,discussion will focuson sensoryinput from muscles,joints, and skin to alphamotor neurons. Sensory neurons can stimulate neurons in the spinal cord directly (Fig. 4-21), so they can have a quickerandlessmodulatedeffecton alphamotorneurons than some otlter sourcesof input that must traversethe brain. Quick, relatively stereotypedmotor responses, cal7edreflexes,commonly result from unmodulatedperipheralinput. At its simplest,a reflex involvesonly one synapsebetlveena sensoryneuron and a motor neuron;that is, the monosynapticstretch reflex definedpreviously(seelig. 4-12).In the monosynapticcase,for everyactionpotentialin the sensory neuron,the motot neuronreceivesthe sameunmodu-
lated input. Most reflexes,however,involve multiple inteneurons in ahespinal cord between the sensory and motor neurons.Becauseof the volume of input from multiple neuronsand sources,the actualmotor responseto a specificsensoryinput canbe modulated accordingto the contextof the action.27 The presumed objective of many peripheral sourcesof inpucin chenormallyfunctioningnervous system is to protect the body, counter obstacles,or adaptto unexpectedoccuffencesin the environment duringvolitional movement.Becauseof its directconnectionsin *re spinalcord,peripheralinput canassist function even before the brain has received or processedinformation about the successor failure of the movement.Peripheralinput also influencesmuscletone and is ftequentlythe medium throughwhich physicalagentseffectchange.
Ore . PATHOLOGY AND PATIENT PROBLEMS
89
Peripheral cutaneous receptor Figure4-21, Sensoryinput into spinal cord to alpha motor neurons.
Muscle spindle Insidethe muscle,lying parallelto musclefibers,are (Frg.4-22).When sVixdles sensoryorganscalledmuscle a muscleis stretched,asit is when a tendon is tapped to stimulatea stretchreflex, the musclespindlesalso arestretched.Receptorswrapped aroundthe equatorial regionsof the spindlessensethe lengtheningand send an action potential through sensoryneurons, specifiedas tyye Ia, rnto the spinal cord. A primary destinationof this signalis the pool of alpha motor neuronsfor the musclethat was stretched(homonymousmuscle).If the excitatoryinput of the Ia sensory neurons is sufficiendy greater than any inhibitory input from elsewhere,the alpha motor neuronswill generatea signalto contracttheir associatedmuscle fibers. Severaltaditional facilitation techniquesfor increasingmuscle tone use the stretch reflex: quick stretch,tapping,resistance, high-frequencyvibration, and positioning a limb so that graviry can provide stretchot resistance. Another destination for signals transmitted by type Ia sensoryneuronsfrom the muscle spindle is the pool of alpha motor neuronsfor the antagonist muscle to inhibit activity on the opposite side of the joint. In other words, signalsfrom the muscle spindlesin the bicepstend to excitealphamotor neurons of the bicepsand to inhibit those of the triceps (Iig. 4-23).This is an exampleof reciprocalinhibition,
which helps ensure that a muscle is not working againstits antagonistwhenit is activated. Becausemuscles shorten as they contract, and musclespindlesregisterlengtheningof musclesonly if they are taut, spindlesmust be continuallyresetto eliminate saggingin the center portion of the spindles. Camma motor neuronsinnervatemusclesoindlesat the end regionsand.when stimulated,ciuse the equatorial region of the spindle to tighten (see Iig. 4-22). In other words, gamma motor neurons sensitizethe spindlesto changesin musclelength.28 Gamma motor neurons are typically activated at tlre sametime as alpha motor neuronsduring voluncoactitary movement, a processcalledalVha-gamma vation.zgIn addition, gamma motor neurons can be activated separatelyfrom alpha motor neurons to preparethe musclespindleto senseexpectedchanges in length that might occur during voluntary movement. A good exampleof this occurswhen someone walks acrossan icy sidewalk, knowing that a slip is probable. Gamma motor neurons are activated to increase spindle sensitivity so that muscles respondvery quickly if one foot startsto slip on "an ure lce. Golgi tendon organs Colgi tendon organs (GTOs) are sensory organs located in the connective tissue at the junction
90
4 . TotrcAbuol
nlities
juncBecause of their locationat the musculotendinous tion, CTOs have been shown to signal a maximal stretchof the muscleand are thus thought to protect agairstmuscledamage.JU CTOshavealsobeenshown to be extremeiysensitiveto activecontraction,particularly small amounts of muscle tension.3lHouk and Hememan estimatedthat dresesensoryreceptorscan respondto activationof oneortwo singlemusclefibers thatareLn5efles with thatL I U. ' CTOsarelimitedin their ability to sensesteadyor larger1eve1s of muscular tension, however, so *rey must be supplemented by Ia sensory many other types of peripheral input in signaling overafferent neuron Encapsulated all musclecontraction.32 muscle spindle CTOs rransmit signals via type lb sensory neuronsto the alphamotor neuronpools o[ both the homonymous and antagonist muscles. The input to homonymousmusclesis inhibitory to stop signaiing the muscle fibers to contract.This spinai reflex responseis called autogenicinhibitiou.The input to alpha motor neuronsof antagonistmusclesis excitatory to signalcontraction.The purposeof the CTOs is regulatoryduring activemusclecontraction,possibly ro helppur on rhe brakesduringacrivarion. Note that musclestretchcanprovide contradictory input to an alphamotor neuron.Quick stretchstimuIatesthe spindlesto registera changein length,facilitating muscle contraction. Prolonged stretch may initially facilitate contractionbut ultimately inhibits contractionas the GTOs registertension at the tenFigure 4-22.Musclespindlewi*Lin a muscle. don and signalinhibition to the homonymous alpha betweenmusclefibers and tendons(Iig. 4-24).They motor neurons.Prolongedstretchis thus traditionally function in serieswith musclefibers,which is in conused to inhibit abnormally high tone in agonists trast to muscle spindies,which function in para1lel. and facilitate antagonist muscle groups. Inhibitory Figure4-23" Reciprocal inhibition: muscle spindle input excites agonist muscles and inhibits antagonistmuscles.
Peripheral neryes
Biceps
Ia afferentnerve
Peripheral
One . PAIHOLOCY AND PATIENTPROBLEMS
GTOs
Figure 4-24.CTOswithin a muscle.
pressureon the tendon of a hypertonicmuscleis also drought to stimuiate the CTOs to inhibit abnormal muscletone in the agonistswhile facilitatingantagonists.33 Thesetechniquesshouldbe consideredwhen positioning a patient for application of physical agentsor other modalities.
9l
Cutaneous receptors Stimulation of cutaneoussensoryreceptorsoccurswith every interaction of a person's skin wirh the extemal world. Temperature,texture, pressure,pain, and touch are all transmitted through these receptoff. Cutaneous reflex responsestend to be more complex than muscle and tendon responses, involving multiple muscles. Painful stimuli at the skin, like stepping on a tack or touching a hot iron, will ultimately facfitate alphamotor neuronsof wi*rdrawal musdes.In a flexor withdrawal reflex, the hip and knee flexors or elbow Bexorsare signaled to pull the foot or hand away ftom the painful stimulus.If the body is upright when the painful stimulus occurs, a crossedextension reflex is likely. Alpha motor neuronsof the oppositeleg'ship andkneeextensor muscleswill be facilitated so that when the foot is withdrawn ftom the painful stimulus, the other leg can supportthe individual's weight (Fig.4-25). Becausemusclesare linked to eachother neurally via spinalinterneuronsfor more efficientfunctioning, traditional antagonistson oppositesidesof joints are frequendy inhibited when a particular agonist is facilitated. Ior example, when the biceps muscle is facilitated during a withdrawal reflex, the triceps Figure4-25. Ilexor withdrawal and crossedextensionreflexes.
92
4 . ToneAbnorualities
muscle of the same arm is inhibited. Likewise, if a muscleis contractingstrongly,many of its synergists wiil alsobe facilitatedto contractto help the function of the orisinalmuscle. Treatrnent techniquesthat use cuaneous receptors to increase muscle tone include quic( light touch; manual contacts;brushing; and quick icing. Techniquesthat use cutaneousreceptolsto decrease muscletone include slow stroking,maintainedholding, neutralwarmth, and prolongedicing.33The facilitative techniquesprobablydirect attentionto the part of the body that the patient is about to activate,and the cutaneousreceptorsregisterchangesin input. The brain seemsto alert itselfwhen changesare occurring, preparingitself to respondwith movement, which necessitates increasesin muscletone. The inhibitory techniquesbegin in a similar way to the facilitative techniquesby directingatt€ntionto the relevantpart oI the body.Because o[ the slow repetitive.or maintained nature of the stimuli, however,the cutaneous receptorsadaptto the input. The brainignoreswhat it alreadyknows is there,andgeneralrelaxationis possible,with a diminution of muscletone. Becausecutaneousreceptorscan alter muscletone, any physical agent that touches the skin can change tone, whether the touch is intentional or incidental. Thus it is necessary to considerthe locationandtype of cutaneous input provided whenever using physical agents,especiailybecausethe effect on musde tone may be counterto the effectdesiredfrom the asentitself. Inputfromspinalsources In addition to the sensoryinformation from the periphery that signaisalphamotor neurons,circuitsof neurons within the spinal cord also contribute to excitation and inhibition. Thesecircuitsarecomposedof intemeurons, neuronsthat con-necthffo other neurons.Propriosoinal pathwaysareone rype of neuralcircuitthat iommunicate intersegmentdly, between different levels within the spinal cord. They receive input kom peripheral afferents,aswell asfi'om many of the descendingpathways that arediscussed below,andhelpproducerynergiesor particularpattemsof movements.34 Ior example,when a client flexesthe elbow forcefully againstresistance, propriospinalpathwaysassist in the communicationbetvveenneuronsat multiple spinallevels.The resultis coordinatedrecruitmentof synergisticmusclesthat add force to the movement. That same resistedarm movement also facilitates flexor muscleactivity in the oppositearm via the pro-
priospinal pathways. Both of these principleshave beenusedin therapeuticexercisesto increasethe tone and forceoutput from musclesin oersonswith neuroIogicaldysfunction.ss'3Supraspinal sourcesof input Suyrasyinalrefersto CNS areasthat originate abovethe spinal cord in the upright human (see Frg. 4-9). Ultimately these brain areasinfluence alpha motor neurons by sending signals down axons in a variety pathways.Any voluntary subconscious, of descending or pathologicalchangein the amount of input trom descending pathways alters the excitatory and bhibitory input to alphamotorneurons.Suchchanges, in tufl\ alter muscletone and activatiorl dependingon the individual and the pathway or tract involved. Severalof the major descendingpathways and their in relationto influenceon motorneuronsarediscussed the brainareasto which they aremost closelyrelated. Sensorimotor cortical contributions Volitional movement originatesin responseto a sensation,an idea,a memory or an extemalstimulus to move,act.or respond.The decisionro move is initiatedin tlre cortex,with signalsmoving rapidly among neurons in various brain areasuntil they reach the motor cortex.Axons ftom many of the neuronsin the motor cortex form a corticospinaltract (from cortex to spinal cord) that runs through the brain, mosdy crossesat the pyramidsat the baseof the brain stem, and descendsto synapseon appropriatealphamotor neuronson the opposite side of the spinal cord (Iig. 4-26. When the alphamotor neuronshave sufficient excitatoryinput,a;tion potentialssignalall the associated musclefibers to contract.Corticospinalinput to alpha motor neuronsin the spinal cord is primarily responsiblefor voluntary contractionand contributes lessto muscletone. Cerebellum Ior everyset of instructionsthat descendthrough the conicospinaltract to signalposture or movement,a copy is routed to the cerebellum(seelig. 4-2Q. The neuronal activity of the cerebellum functions to comparethe intendedmovementwith the sensoryinput it receivesabout the actualmovement.The cerebellum registersany discrepanciesbewveenthe signal from the motor cortex and the accumulatedsensoryinput from musclespindles,tendons,joints, and skin of the body during the movement.Cerebellaroutput helps
One . PATHOLOGY AND PATIENT PROBLEMS
Midlineof brain, brain stem, and spinal cord
Ehainstem
C€rebellum
Conispinal tract Peripheral nervesto right side of body
tract schematic pathwayfrom 4-26.Corticospinal Figure andspinalcord. Jortexro cerebeLlum co(ect for movement errorsor unexpectedobstacles io movementvia the cortex and the red nuclei in the brain stem.The red nuclei,in tum, cansendsignalsto *re alpha motor neurons through the rubrospinal nacts (RuSTs).Ongoing correctionis successfulonly it a movemenris comduring slower movemencs: pletedtoo quickly to alte5information about the suc-
93
cessor failure of the movement can improve subsequenttrials.Both corticospinaland rubrospinalinputs to alphamotor neuronsfunction primadly to activate musculature.Direct influencesof the cerebellumon muscletone and posture are mediatedthrough connectionswith the vestibulospinaltracts0/STr. Basal ganglia The basalgangliafunction asa movement-and tonemodulating system.Any volitional movement involves processingthrough connectionsin these five nuclei, or groups of neurons:putamen,caudate,globus pallidus, subthalamicnucleus,and substantianigra (Iig. 4-22). Multiple chains of neurons looping through thesenucleiandbackto motor corticalareasinfluence the planningand posturaladaptationof motor behavior. Dysfunction of any of the nuclei of the basalganelia is associatedwith abnormaltone and disordered movement.In the exampleftom the beginningof the chapter,Mrs. H's tone and movementpattemsexemplify wvo of the extremeforms of abnormaliryseenin basalgangliadisorders:the rigidity and akinesiaof a freezestateand the wildly fluctuatingtone and dyskinesia associatedwith high levels of the medication usedto treat Parkinson'sdisease. Other descending input The VSTshelp to regulateposture by transmitting signals ftom the vestibularsystem to the alpha motor neuronpoolsin the spinalcord.The vestibularsystem receivesongoinginformationaboutthe positionofthe head and the way it moves in spacewith respectto graviqy.The vestibularnucleialsointegrateand transmit responsesto information received about the movementof the headvia the joing muscle,and skin of rheheadandneck.The VSTsand related receptors tracts generally facilitate the extensor (antigraviry) alpha motor neurons of the lower extremity and trunk The to keepthe body andheaduprightagainstgraviqF. muscles tends to be higher tone of antigravity musde than the tone of other musclegroupswhen a person hasa neurologicaldeficit,partly becauseof the stretch that gravity placeson them and partly becauseof the increasedeffort requiredto stay upright. The reticulospinal tracts S.STs) transmit signals from the reticularsystem,which is a group of neuron cell bodies located in the central region of the brain stem, to the spinal cord. The reticular system receivesa rich supply of input from multiple sensory systems, including vision, auditory, vestibulaE and
94
4 o Tote Abtornalities
Putamen Globus pallidus Subthalamic nucleus
ANTERIOR CROSSSECTION LATERALVIEW
TRANSVERSE CROSSSECTION FiguJe4-21, Basal ganglia widrin the brain: side and cross-sectional views.
somatosensoryand the motor cortex.In additior\ it receivesinput from the auronomicnervoussysrem (ANS) and hypothalamus, reflecting the individual's emotions,motivation,andalertness. Muscletonedifferencesbetweensomeonewho is slumpeddueto sadness or lethargyandsomeonewho is happyandenergeticis mediated dlrough thesetracts. The RSTscan also help regulateresponses to reflexesaccordingto the context of the current movement. Ior example,whiie walking, someonemay stepona sharpobjectwith the nght foog noticing it only as the left foot is leaving the ground. Instead of allowing dre expected flexor withdrawal reflex on the right (which would causethe personto fall), the RSTshelp increaseinput to the alpha motor neuronsof extensormuscleson the right,momentarily permitting weight bearhg on that sharpobject until the left foot canbe positionedto bearweight. Limbic system The limbic systeminfluencesmovement and muscle tone via the RSTsand throush connectionswith the
basalganglia.Circuits of neuronsin the limbic system provide *re ability to generatememones and attachmeaningto them. Changesin muscletone or activation can occur as a result of emotions recalled with particularmemoriesof reai or imaginedevents. For example, fear may heighten one's awareness when walking into a dark parking lot, activatingthe s;,rnpatheticnervous system (SNS)to start planling for fight or flight. The SNS activatesthe heart and lungsto work faster,dilatesthe pupils,and decreases the amount of blood pulsing through the internai organs, diverting that blood flow to the muscles. Muscle tone is increasedto get ready to fight or flee from any potential dangerin the parking lot. Muscle tone may fur*rer increasewith a suddenunexpected noise, but then decreaseagain to an almost limp state when the noise is quickly identified as fwo good friends approaching from behind. Patients may have similar changes in muscle tone wi*r emotionalresponsesto fearsof falling or of increased pain.
One . PATHOLOGY AND PATIENT PROBLEMS
)ummary -Muscletone and muscle activation depend on the normal compositionand functioning of the muscles, *re PNS,and the CNS.Although both biomechanical neuandneuralfactorsinfluencemuscularresponses, ral stimulation through the alphamotor neuronsis a powerful influenceon both muscletone and activarion, especiallywhen the muscleis in the midrangeof its length.Multiple sourcesofneural input, both excilatory and inhibitory are required for normal funcrioning of the alpha motor neurons (seeTable 4-3). Ultimately the sum of all the input determinesthe amount of neurally derived muscle tone and activamuscles. don seenin the associated The assumptionin this sectionhas been that the body is intact. The motor units, with both the alpha motor neuronsand the muscle fibers, have all been functioning normally and receiving normai input ftom all sources.When pathologyor injury affectsthe muscles,alpha motor neurons,or any of the sources of input to the alphamotor neurons,abnormalitiesin muscletone and activationmay result.
MUSCLE TONE ANDIT'S ABNORMAL CONSEOUENCES canresultin abnorManytypesof injuriesor pathologies mal muscletone, some of which are corsidered in this section.One exampleof sucha pathology is depictedin
il V PRll\ilARYlMPAlRl\,1ENT
to muscletone Iie.4-28, with possibleconsequences (see \ t'"n present. also Fig. 1-1).383e unld fulr.tjon an impairmentthat abnormalmuscletoneis considered may or may not lead to functional changes.Evaluation of muscletone before and after a fteahnent canindicate the effectivenessof the treatrnentin reducingmuscle tone or in changing its precipitating condition. Treatrnent decisionswill dependon the role abnormal muscletone playsin exacerbatingfunctional limitations or disabfity, or whether it is lilely to result in future problemssuchasadverseshorteningofsofttissue. of muscle In this section,some of the consequences tone abnormalities are listed and rehabfitative treatof abnormaltone mentsarediscussed, The consequences depend on circumstances,each of which must be assessedalons with the evaluation of muscle tone. Circumstancescouldindude any additionalimpairments the patient has,aswell asthe psychologicalphysiological and environmentalresourcesavailableto the patient. A young, active, optimistic patient tends to have less severefunctional limitations than an older, sedentary depressedpatientwith the samedegreeof impairment. Note that any observedchangesin muscle tone consequentto a pathologicalcondition dependon the remaining input available to that muscle's alpha motor neurons.The remaininginput may includepartial or aberrantinformation from sourcesdamagedby the pathology,normal information ftom undamaged sources,and alteredinput from undamagedsourcesin
at Soine NerveRootComoression
PATHOLOGY
95
Figure 4-28.Classification scheme for pathologies and ih.i
&I
Hypotonicity in SensorydeficitsParesisin Pain thatnerve specificmuscles samemuscles
' .^^""^".-.""
95
4 . Tore Abronnaliries
units. If all the motor units of a particular muscle are involved, the muscle tone is flaccid and muscle activation is not possible;the muscleis paralyzed.Sometimes the :rrm flaccid?aralysris is usedto describesucha muscle'stone andlossof activation.When diseaseor iqury of the alpha motor neurons removes neuronal input from the muscle,denervationresults.Denervation of a muscleor group of musclesmay be whole or partial. Tone LowMuscle Examplesof processesthat may result in symptoms of denervation include poliomyelitis, which affects the Abnormally low muscletone resultsftom loss of the cell bodies;Guillain-Barr6rymdrome,which attacksthe normal alpha motor neuron input to otherwise normal Schwanncellsso that the axora areessentiallydemyelimuscle fibers.Although some muscle or motor endnated; crush or cutting types of trauma to the nervesl may alsoresultin low muscletone,this platediseases discussionis limited to neuronalpathologies.Losses andnerve compression. When poliomyelitis eliminatesfunctioning alpha may result kom damageto the alpha motor neurons motor neurons, recovery is limited by the number themselves,so that the relatedmotor units cannotbe activated.Lossof neuronalstimulationof the muscles of intact motor units remaining.Each remaining may also result from conditionsthat either increase alphamotor neuronmay increasethe numberof muscle fibers it innervatesby increasingits number of inhibitory input or prevent adequate excitatory input axonal branches,This processis known as rearboizfrom reachingthe alphamotor neurors Qig.a-29). ing- lntact neurons may thereby reinnervate muscle Low muscie tone means there is insufficient fibers that lost their innervationwith the desuuction activationof the motor units to preparefor holding or of associatedalpha motor neurons (Iig. 4-30). Such movement. Consequencesinclude (1) difficulty muscleswould be expectedto have larger-than-nordeveloping adequate force output for posture or malmotor units,with more musclefibersbeingir:nermovemengwith secondaryproblemsresultingfrom vated by a singlealpha motor neuron.40Denervated lack of movement,and (2)poor posturecausedby fremuscle fibers that are not closeenough to an intact quentsupportingof weight throughtaut ligaments,as alpha motor neuron for reinnewation will die, and in a hyperextendedknee.Poor postureresultsin cosmetically undesirablechangesin appearance,espe- loss of muscle bulk (atrophy) will be evident. Maintaining the length and viability of the muscle cially with a slumped spine or drooping facial fiberswhile any possiblerearborizationtakesplaceis muscles. Stretchedligaments cancompromisejoint advocated.4o,41 integriry andleadto pain flable 4-4). Recoveryafter injury to the axonsof alphamotor neurons includes the possibility of regrowth of Alphamolorneurondamage If alpha motor neuronsare damaged,electrochemical the axons from an intact cell body, through any remainingmyelin sheathstoward the musclefibers.zu impulseswill not reachthe musclefibers of thosemotor responseto the pathology.When an individual has a movementproblem,he or shewill usewhateverneural resourcesare most availableto solveit. For example,high muscletone may be usefulfor somepatients ifincreasedquadricepstone allows weight bearingon an otherwiseweak leg.
Figure4-29.Inhibition of alpha motor neuron:inhibitory input exceeds excitatoryirput.
Alphamolorneuron
Alphamotorneuron
97
O'E . PATHOLOCY AND PATIENT PROBLEMS
p
4-4
Consequences
of Abnormally
Low Muscle Tone
1. Difficulty developingadequateforceoutput for normalpostureand movement a. Motor dysfunction endurance b. Secondaryproblemsresultingfrom lack of movement,e.g.,pressuresores,lossof cardiorespiratory 2. Poorposture a. Relianceonligamentsto substituteformuscleholding-eventual stretchingof ligaments,compromisedjoint integriqy,pain b. Cosmeticallyundesirabiechangesin appearance, e.g.,slumpingof spine,droopingof facialmuscles c. Pain
Figure4-30. Rearborization of remaining axons to innervate orphaned muscle fibers after polio eliminates some alpha motorneurons.
Regrowth is slow, however, proceeding at a rate of I-8 rr:m/day,al and may not be able to continue if the distance is too far. Again, maintaining the viability of muscle fibers while regrow*r takes place is advocated.40Recovery following Guillain-Barr6 syndrome depends both on remyelination of the axons, which can be fairly rapid, and on regrowth of any axons that were secondadly damaged during the demyelinated pei.od.42
Rehabilitation following alpha motor neuron damage Rehabilitation of patients who have denervation hcludes treatmen* that faciiitateactivationof alpha motor neurons.In the past, physicalagentsincluded electricalstimulation to facilitatemusclefiber viabil-
ity while axonsregrewor rearborized.Electricalstimulation for this purpose has become controversial, with evidencethat the quiescence ofdenervatedmuscle may actually trigger regrowth of neurons (see Chapter B).Additional physicalagentsdrat are used after alphamotor neuron damageincludehydrotherapy and quick ice.33,a3 Becauseof buoyanry, hydrotherapy may be used to support the body or limbs and resist movement with range-of-motionexercisesin the water43 The combination of buoyancy and resistancecan help strengthenremaining or retuming musculature(see Chapter9). Quick ice (seeChapterQ or light touch on the skin over a particularmusclegroup adds excitatory input to any intactalphamotorneuronsvia cutaneoussensoryneurons.oo
9A
4 . Toqe Abqotmalities
Other treatment options include range-of-motion exerciseand therapeuticexerciseto maintain muscle length and joint mobiliqy and to strengthen the remainingmusculature.Treatmentalsoincludesfunctional training d:at teachespatients to compensate for the movement losses they have experienced. Orthotic devicesmay be prescribedto supporta limb tor function while the muscleis flaccid or to protect the nerveftom beingoverstretched. Note that excitatoryinput to an alpha motor neuron that is not intact will be ineffective.The alpha motor neuronthat is not intact cannottransmit information to its relatedmuscle fibers, either to change tone or to contract voluntadly. Also, if alpha motor neuronsare damagedin a cut or crush in1uryor by compression,local sensoryneuronsbringinginformation in the same nerve would also be damasedand unableto provide sensoryinput. Insufficientexcitationof alphamotorneurons If a pathologyaffectsperipheral,spinal,or supraspinal sourcesof input to alphamotor neurons,but doesnot affectthe alphamotor neuronsor musclefibersthemselves,low muscletone may result.The alphamotor neuronsmay be stimulatedto transmitinformationto muscle fibers to contract if excitatory input can be raisedto a higherlevelthan inhibitory input. Any condition, however,that prohibits alpha motor neurons ftom receivingsufficient excitatory input to activate the musclefiberswill resultin decreased muscletone. lmmobilization One condition that altersperipheralsourcesof input to the alpha motor neuron is applicationof a cast to maintain a position during healingof a ftacture.The cast applies a fairly constant stimulus to cutaneous receptorsbut inhibits receptionof the vadety of cutaneous input ordinarily encountered.The cast also inhibits movement at one or more joints. restricting lengtheningor shorteningof the local muscles.Alpha motor neurons are thus deprived of normal alterationsinmusclespindle,GTO, orjoint receptorinput. When the cast is removed, the result is typically a measurablelossof strengthin the musclesand a loss of ROM in the joints. Muscle tone is also affected, witl-r decreasedactivation of *re motor units and increasedbiomechanicalstiffness.Becausethe neural and biomechanical components of muscle tone counter one another in this case,the actual change in resistanceto passive sffetch must be carefully
assessed.The known effects of immobilization in decreasingmuscie tone have been used deliberately to lower hypertonicityin severecases.aa Stroke or head injury Other ways to affect supraspinalinput to the alpha motor neurons are through loss of blood supply or direct injury to cortical or subcorticalneurons/ as occurs with strokes or head injuries. The resulting muscletone changesdependon the remainingproportion of excitatory and inhibitory input to the alpha motor neurons.For example,if the descendingtracts are destroyedon one side,volitional movement and muscle tone may be lost in the associatedmuscles. However,most of the alphamotor neurongroupsthat receiveinput from multiple descendingkacts will not loseall descendinginput. Thosealphamotor neurons must adapt to a new proportion of excitatory and inhibitory input when the input from the damaged tractsis lost. The usualprogressionfrom flaccidityto increasedtone aftera stroke36 may be a resultof adaptation to new levelsof inhibitory and excitatoryinput. The predictionof muscletone changesin a particular individual after a strokeis complicatedby the fact that lesions within the supraspinalareas do not always completely eliminate the corticospinaltract. The portion of the tract that remainscan still be used to signalvolitional movement.In addition, although most of the fibers of the corticospinaltract crossto slmapseon the oppositesideofthe body ftom *re origin of those axons,some of the fibers do not cross. Therefore even if all of one corticospinaltract is destroyed,some fibers of the opposite corticospinal tract may provide enoughinput to alpha motor neurons for the tone in someof the musclesto remainrelativelynormal. Rehabilitation to increase muscle tone Physical agen* are not often associatedwith the rehabilitationofpatientswho havehad a stroke,head injury or other supraspinallesions.However, they canbe a valuableadjunctto the therapeuticexercises, orthotics, and functional training o[ traditional neurorehabilitation.s,36 Electrical stimulation, biofeedback,hydrotherapy,and quick ice may all be used.33 The intent of any treatment choice is to affect the alphamotor neuronsvia the remainingintact pedpheral, spinal,and supraspinalsourcesof input. Quick icing and tapping, for example,are facilitative techniquesthat can increasetone via cutaneousand mus-
Oqe . PATHOLOGY AND PATIENT PROBLEMS
99
ce spindlereceptors,respectively,and, when paired However, EMC studiesof patientswith hypertonic"r:d-r voiuntary movement, can increasefunctional ity haveshown essentiallyabsentactivity in the planscror output. Electricalstimulation might be comtar flexors during swing, as in normal gait.7Another t=ed with resistanceof the musclebeine stimulated study of upper extremity function found deficitsdue - of synergistic musclesto increase tone-andactiva- to inadequaterecruitment of the agonists,not by =3n via intemeuronsof the spinalcord.Many authors increasedactivity in the spasticantagonistmuscles.4T :;ve describedin much more detail the treatrnent Instead,voluntary movement is hindered by slowed =oices availableto the rehabilitation specialistfor and inadequate recruitment of the agonist and =creasingmuscletone and motor output in patients delayedterminationof agonistcontraction.4 a'tro havehad a strokeor head injury.s'33'36'45'a616" On the other hand, someresearchers have shown i:x below summarizes treatment suggestionsto that coactivation of spastic antagonists increases =crease low muscle tone for improved functional with faster movements, substantiating the claim r--dvation, that abnormal activation inhibits voluntary motor control.'8 Additionally, a review of multiple drug studies has revealedimproved function irt 607. to TreatmentSuggestionsfor Low Muscle Tone 707oof paients receivingintrathecallyadministered Ilydrotherapy baclofen,a drug that reducesspasticity.The authors Quick ice statetllat r/spasticiB/ rcductsoncakbe associatedwith (when Eectrical stimulation muscle Ebers are improved voluntary movement,' although it is also innervated) possiblethat a decreasein tone will haveno measuraBiofeedback ble effector evena negativeeffecton function.49 Eght touch Tapping Secauseof the controversy,it cannot be stated Resistive exercises unequivocally that hypertonicity itselt inhibits Range-of-motion orercises voluntary movement. However, other effects of Therapeutic exercises hypertonicity must not be ignored. These include Funcional training (1) muscle spasms that contribute to discomforq Orthotics (2) hypertonicity in a musclegroup on one side of a joint that canresultin contractures(shortenedresting Iength) or other soft tissue changes;(3) abnormal HighMuscle Tone posturesresulting from hypertonicity that can iead -\lany pathologicalconditions result in abnormally to skin breakdown ot pressureulcers;(4) resistance :igh muscletone.Any ofthe supraspinallesionsmento passive movement of a nonfunctioning limb ioned in the previoussectioncould ultimately result that results in caregiverdifficulties during assisted ::r hypertoniciry,eventhough they begin with some dressing, transfers, hygiene, and other activities; :orn of low muscle tone. Only the loss of alpha and (5) possibly a stereotypedmovement pattem rlotor neurons themselveswill be restricted to a that could hhibit alternative movement solutions :rypotonicpresentation;hypertonicity doesnot occur flable 4-5). asa result of lesionslimited to the alpha motor neu:ons.Instead,hypertoniciry is a result of abnormally Pain,eold,andstress righ excitatory input compared to the inhibitory An exampleof a peripheralsourceof input that might rnput to an otherwise intact alpha motor neuron, lead to hypertonicity is input from sensoryreceptors rvhateverthe sourceof that input (seelig.4-20). registeringpain. Cutaneousreceptionof painful stimResearchershave argued about the effects of uli, and the consequentwithdrawal or crossedextenhypertonicity, particularly spasticiry on function. sion reflexes,have already been discussed.Painful Somehave pointed out that spasticityof tlre antago- stimuli to the musclesor joints commonly result in nist does not necessarilyinterfere with voluntary increasedmuscle tension. This muscle tension is a movement of the agonist.a During walking, for form of hypertonicity and may be seen as muscle example,it has been assumedthat spasticiqyin the spasmsin *re paraspinalmusculatureof a person ankle plantar flexors preventsadequatedorsiflexion with back pain, for example.Suchmusclespasmsare during *re swing phaseof gait, resultingin toe drag. known asguardingandarethoughtto be a mechanism
ron. Abtot'rdlities Abtotndlnies 1 . To4' 1'
rO0 100
A B
I
Tone MuscleTone HighMuscle High Abnormally of Abnormally l-S Cottr"q.,.n.es Cor,r"r.,.n.esof 4-5
Par i:*-*il"-m'd
I I
I I
1. Discomfoltorpain lrommusclespasms
3. Abnormalposlure
rranslers dressing,rranslers wi$ bathing, dressing, assistwi$bathing, caregiversro assist effort by caregivers effort Iocreased 5. Iocreased
I
tives aLtema may inhibit developmenrof movementaltematives 6. Developmentof stereot/pedmovementpattemsthat mav -. i n h r b tfunction tru - b o n M a y or o - may m a . onot r inhibir 7. May
I I
4. Skin breakdown
I
I
usedtoavordfurrnerpain'Luardinsprobably\asaAntaSofustscdnbesdmula|edwl!,Llreslscede\erc (seeLhapleru) slimulatron co-n- elecrrical .omponelras wel' as a peripheral supraspinal I the limbic and n\us pon".ri, bec"u"" dte emotions I Spinalcordinjury ;ystem aresoheavilyinvolvedint'\e inlerpretationof I
;ii"ii::::'r'.,:;'".respondsrocodviapedp' ::*#i:':'Ji"J1:#?(i"JLH",i.",TilI is inhibitory and excitatory input trom supcsprnal systems.when homeostasis
I eral and supraspinil t hel saJJreceiveinput.kom propnosptnal sources. ard lhe body mry rhre.r.ned,nuscleron" increases I or rlle lesron l beeLnto shre:. Mu"cle lone also tends to increase and other neurons below Lhe le\el Immedialelyfo[owin8 the iniuly' f.oYev:I' lh: n:ry' I w;h otherttueals,r€gisteredas stress.Hypertonicitv ou' cysremic rr?ically trl a sta|f,called,tlt at ',ao'b,n I nay be palpablern various mu"cle Crouos such as tro.ern'rneshouLdersandneck'whenanindividua|whi(hitshutsdo\aa|a|andbelow|helevel may lasrtor\oursot weeksandI rniury I}e condrrion reeisrersmorpqeneralpanolperceivesdsrtuarionas -tf" tlaccid to.le ot *le alteLtedmuscles by the is marked .ell-esreem The nus body or ro '-hi.a,"n ne ,o I level reflexaclivity]ike the mus of spinal the loss and for fighl or fli8ht, and Lhereslofrhe clesareprelparing l
bodyi'""g'"g"di"oth;.sNSresponses. :fffi;*H,yJ."*:1fr1j,H,,',:"::;:,Hi:
LheSCIalows;lpha motoinelrons beLowthelewl ofl f4;atment for reducing high tone splllPadentswith hy?erlonicitydueto pai4 cold,or stress the injury to respondespecialyeasiLyto musd€ thusI The hypeftorurty input cutaneous dle, GTO, or can be treated-in severalways. The first and most I apparentis known as spaslicitysince.quickstretchl effective measr.rreis to remove the source of the elicits Sreaterlesistancethan slow stretch hvpertonicity; fteat the biomechanical cause of a\e l Oui.k stretchmay occurnof onl/ when $e mus-I *r-. lb. o"uenr,or :lleviare ti" sness Wlren "!i". for rone b-urak? u h:r.everl tesLed clesarespeciticallv not poss'be not appricableor ih""" '""r.rr..;r. the weight ot a limb sudd€rlyl otherwiseineffecdve,treatmentto decreasemuscle lhe patienlmovesand -e pull on the musdes-for exampleal exedsa differe.lt axdrionrechnique' tone md) ndude edJ(auon ir mayl level EMGbi;fe.dback,Lhcu"eofneurralwannmorhear patlentwhohasa complere-thora'ic ,n-ury
-t'j,i'j::' l:f,ilrfi[::Tru"': ili.ff i;: H: H:i'j " ":,1::::,ix'jniJ:?;;*'
relaxation ol a panicular muscle group$ Muscles ro 'e'axor dire.rl**rth ue:balcue" canb. aooroacl'ed rruscle relaxauon. ro elcit towels uooltl:r,onetrold indirectly,bv Aliematively,musclescanbe approached in reciprocal wiich results stimulating tire antagonists,
andlowersasonistmuscletone. inhibirionof asonists
tifted, the foot hangs down with Lhe an*]e, pLantar-I flexed when chelegis placedthe weiShrrandsool 3n'qlemovespdssively intol rneballofthefoorandc,he relativedorsiflexion lf the foot Placemenris qujc&l the piantar flexors are quickly stretched and cLonusl
mavbeseen
l
the hl,petdni.ity k geak on oneside Frequendy, oI a joint 6,n on L\e otAerbe.ase L\. loc of gnviqr' F unidn{tio.t on tAe ms of a linb. Bdu* n\. parlmi wiL\ scl bs m acri'e novenmr dr:t Gn romcr the h'"etun.iq, nusle shofreninsends $ o(ur in L\e tus.l* L6:r n rcbtivet noft hyp.donic.The bionechani.:l stiltrs of the hrpd 6ni. n$cls $us imres6, :d .oMctofts cn d.vdop Su.h.otuactofts mi.nibitturctios suchs di.$n$, tsfeB, andpositionnrsforpa$ure reliet r@th g ttw. rton ldtt loll owlng SCI nb.tive Gnse-of.nohon qeEises,5051prclorsed ;fteb,33 posirionins!r othoiie to mainbin nhcdonal m$.1e len8rh,lo.a1dr sy*ehi. oediatio$, trnd sucettl have beenlsd b .onEr ?ither L\e hypa&niciry or rAe ..ndadurcs ink&d.8 virh nnction. Heat couldbe usedb.for beloresEetchi.€ dI shonenedmuscles(seeChapEr O, blt t nu* be .aEtully nonit ied be.auseol L6epatieosspo@tial in*ditivig/ b painor dedeasd *tration SelowL\e GveloI dr spinalcoid injrry. orhe locrt applied one iiliSiti.€ L\.iapies, such as pnlongcd i.iry, lould tleoreti€Iy alleviak h),Tdoniciry in pati.ns lvirh scl Howeve! researchn hcki.€ eith{ to cor. am or to rejed ihe ustulnes of n\e* a8enbin this popdation.F$ctiml electial stinulation gEs) has alsobecru*d to intreasen\eircrion oI p{etic nus d* in L\is population (seeChaper 3) bui !o! for
d\ar afiecr hlrnission of neucl impulrs in the CNS,like nulriple slerosn (ILS)qn resultin hypq. tori.irr Hypeionicity in patienb lo11owin8all oI thef patholosts h the Esult oI a .hangein inpur b :lph,ndtorn rbns(s..FU a 20)Theexftntorthe paiholo&/ ddtrnines {hdh{ many mu*ld ChrPs ae affeded or ody a Gq and whei!- alphanotol neuoN b a pani.ular m$cle 96|plo* a1lor only sone of a paticular sourceoI srpraspinalinplt. nypertmbhy: Nin.ry inpaiment ot adaprne
The reuiophysiologi.:lne.hanisnof b,petuni.iq k in sob. disprE. A varieryof deahent appnches addresb,peibnici4' bafd on asunptiDns aboutlhe way $e neNoussysen fun.tions Ll one apprca.h, developedby Bobath,sthe nenoussFEm n duned to tunction as a hEcrchy in *hnh Lhes|praspitrl cnec .ontdl L\e sFiml ftnks ol nov.nat, and sbnom:l iotus' iesLftsnon los of mnibibry .on. tul fron hjghtr cenEn The csulbnt n\dapelti. *que.rt is 6 nomalEe n\e hypetoni.iq belon before fa.ilhting nomal novem.dt In ,noL\ei appGch, the tur.onentd apF6icn, whnh k bas.d on a sysEm ndd€l oI L\e neno's sy*en, each hoe€nent h 3 Frcdld oI smorinotor noriv*ional, bionechmi.:1, and enwomenhl input.e'* Ttr€ pimry goal ol the neFous q,*en id pod!.ing noenent r to aconpltuh i!€ d4ned bs! AIt* a lesiondevelopr,the neio's sysEn !*s its rcraining larimb with SCI nay alsonaw nusde spasm, resourc* to penom novenent bsk. Ht?doni.ir, then,n,y be L\e he* adaptiveepose $e nerous ge.*aUy adibubble b p,inhil sdmuli, exapt i\ar sy*.n .a mke Siven i6 aeailableresourcesafter patidb nay be mwar oI tAepainbedu* sffo9 injury nth{ dxn a ptmary Bult of L\einjrr/ i6elr. s€mlsa*mg hon below[\e kvel of nhei.jur/ donot An enmple of tul o enkd ft*oning h as 6tr1 e.h dreeEbral cotu. Mwcle spasm may a&obe lo{s: p,ti.nh with parsis m sonetlms ablcto use atubuEd b vbeGl stimuli su.h .s i urjftry tad tunk :id lowei dtemi./ .xftNor ht"etonidry b i.Gdior dhtend.! bladde(oi3de ot1relinEtul iri lold m upitlr posture In L\is cs, hyperbniciq n ation5t ldentifi.ationandrnoval oI the p:i.ftlstin an adaDtivcresDonse b a.comrfishthe hsk of Frn' uli aie rhe lisr seps in aleviari.3 nusci. spastr. einnis anupn;ht pstuE lrt irimimtiis the hyptr wh.n musdespasmsde penhEnt, teq!€nt, or i.nibit iunctron,and aE withou! idmtinabk and rcmovable bni.ity in sd.h a .as would d.deas luciion udes concumr inftass in .ontoled voluntary mov+ aE .au*s, 3y*enic or lo.aly qe.ad n.diotim m.nt arecliciEd On nlleoth{hand, conkolledmov* soi.tin spcscdh€dtd :Ieviah L\e.5r Getul ev:l mentis alwaysprelenbleb hypetoni.iq, iI i! en be u,tim ot nhesoure oI a nuscle spasn nu* o(!r clicited Contol inplies n\eabiliq,b makechang* in belon anyphtri.:l agdt oi reahenr isapplied a ftspose asodns to envnomenhl dem:ndsl whecas ihe hlp.6ni. exknsorftspore ne.tioned abdveis rclarivet $rcoryped The us of a ${eoLsioN Edn .eiebDl @dLi dnodes or seke, rypedhyperctu.respoBe lof hrchon*em! b bld.k ftrbr:l palst tunos, CNSi.fecriorr or hcadinj!ry r eo n d . o i m l 5 5 6 6ay i.sul! in hypetunicit In additioq .onditions s p o n b n e o s deeo p m e d o t m o n
l02
4 . Toflc Abnothralities
Evidencethat hypertonicity may be an adaptive includesrhe factthat it is not an immediate resDonse ,"qu"la of injury but instead develops over time Iollowing a cortical stroke, recoveryof muscle tone and voluntary movement follows a fairly predictable At first, musclesareflaccidand paralyzed course.36,44 on the side of the body oppositethe lesion,without eiicitablestretchreflexes The next stageof recovery by increasingresponseo[ the musis characterized clesto quick stretch and the beginningof voluntary motor output that is limited to movement in flexor Becausemuscle or extensorpatterns,calledsynetgies. tone and synergy patterns ot movement appear ar approximatelythe same time. clinicianstend to eguate the two, but spasticity and synergy are distinct from each other (seeTable 4-1). Furtherrecovery stages include progression to full-blown spasticity and ultimately the gradual normalization of muscle tone. At the same time, voluntary movement shows full-blown synergy dependence,progressing to the mixing of synergles,.and finally iesolvins to controlledmovementof isolatedmusculature.3i A particuiar patient's course of recovery may stall, skip, or plateauanywhere along the way, but it doesnot regress
anxiety is a criticaiadjunctto any treatrnentintended to reducemuscletone. It a patient has severehypenoniciryor if many that influence areaffected.techniques musclegroups -decrease individual the or calm arousal to ANS the include techniques Such be used. mighr generally warmrh, neutral rocking. slow music, or ioft lietrtine slo* i,roklng. maintajnedtouch,33rotation of the trunk, or hydrotherapy (see Chapter 9), as long as the patient feels safely supported For example, hydrotherapy in a cool water pool is particularly advocatedfor patientswith MS to reducespasticity' Stretchingand cold packsare also of benefit in temof MS, but they lack porarilvr-educing t}e spasciciry of allowing gende b"nefi, ivdroth"rupy t add.d a diminishedpull of wjth ,".rn"-ot--otion exercises gtavrty.""
Rigidity: a consequence of CNS pathology Some cerebrallesions are associatedwith rigidity insteadof spasticity.Head injuries,for example,may result in one o[ two specificpattems of riSidity that mav be eicherconstantor intermittentBothpatterns inciudehypertonicity in the neck and back extensors, the hip extensors,adductors,and internal rotators, the knee extensors,and the ankle plantar flexorsand invertors.The elbows are held rigidly at the sides, Rehabilitation to decrease muscte tone with the wrists and fingersflexed in both pattems, Rehabilitationto address hyperronicity after a elbows are flexed,and stroke depends on whether the clinician believes but in decorticaterigidiry the in decerebraterigidity they are extended.The rwo that hypertonicity inhibits function or instead is a rypesof rigidiryare thoughrto indjcatethe levelo[ nroduct of adaptivemotor control.In either case,the t'h"lesion'ibot e or belowthe rednucleusin the brai'n emphasis is on return of independent function, stem,respectively.In most patientswith head iniury the whether that necessitatestone reduction or however,the lesionis diffuse,and this desiSnationis reeducation of controlled voluntary movement unhelpfui. Two positioning principles can diminish pafiems. be consideredalong Treatmentto reducehypertoniciqyin preparatron rigidity in either caseand should the patient (1) reposition therapies: any other with icing' couldincludeprolonged tor functionalmovement with emphasis listed, posrures to those opposite in inhibitory pressure,prolonged stretch,33inhibrtory flexion hip and flexion trunk and neili slisht casting,sTor positioning. Reeducationof controlled on positiorq supine the (2) avoid and degrees, past 9b voluntary movement pattems could include weight which promotes extensionin the trunk and limbs bearing to facilitate normal postural responsesor via the symmetricaltonic labyrinthine response(see training with directed practice of functional moveTtg.a-Q. ment patterns.4sReductionof hypeftonicity may, irl canresultin biomechanical fugidity, like spasticiqy, fact, be a product of improved motor control in the placement in the long-term after following example.If a patientfeelsinsecurestanding muscle stiffness period of time the longer The position. uprjght, muscle Lone will increasecommensurate shortened positioning to or exercises witli the anxietylevel.If balanceand motor control without range-of-motion the biomechanigreater the group, elongatea muscle are improved such that the patient feelsmore confithe best cure for is Prevention occur. cal clanses that dent in the upright position, hypertonicity will also but of hypertonicity, be reduced.4sPositioningfor comfon and to reduce biomeclianical comPonents
One . PATHOLOGy AND PATIENT PROBLEMS
::-ioticss8 or serialcastingsT have alsobeenusefulin ::Jucing the musclestiffnessrelatedto hypeftonicity. ---:at may be used to increaseROM temporarily ::Iore applyinga castor orthotic. Parkinson's disease usually includes rigidity, .',-richoccurs throughout the skeletal musculature :.-jrer than being limited to a particular extensor ::tern. In addition to pharmaceuticalreplacement :: dopamine,bvtreatment can include temporary ::Cuction of hypeftonicity through heat and other .:neral inhibiting techniques to allow patients to :-complish particular functions. The following box ;':mmarizes treatment suggestionsto decreasehigh =uscletone.
TreatmentSuggestionstor High Muscle ToneAssociated with Pain, Cold, or Stress ReEove source r Eliminate pairr . Warm patient . Alleviate stress Relaxation techniques EMG biofeedback Neutral warrnth Heat Hydrotherapy Cold towels Stimulation of antagonists . Resisted exercise o Electrical stimulation .\ssociated with Spinal Cord Injury Selective range-of-motion exercises Prolonged stretch Positioning Orthotics Medication Surgery Heat Prolonged ice Associated with Ceretrral Lesions Prolonged ice Inhibitory pressure Prolonged stretch Inhibitory casting Positioning Reeducation of voluntary movement patteflrs Genetal relaxation t€chrdques o Soft lighting or music
o . . . . .
103
Slow rocking Neutral wa!:Erth Slow stroking Maintained touch Rotation of the trunk Hydroth€rapy
Associated with Ngidity Positioning Range-of-motion exercises Orthotics Serial casting following head injury Heat Medication General relaxation techniques (as listed above)
Fluctuating Muscle Tone Commonly, pathology of the basalgangliaresultsin disordersof muscletone and activation.Not only is voluntarymotor output difficultro initiare,execute. and control, but the variationsin muscletone seenin this population can be so extreme as to be visible with movement. The resting tremors of a patient with Parkinson'sdiseaseand the dyskinesiasseen in the examplewith Mrs. H while she is medicated are examples of fluctuating tone that result in involuntary movement. A child with athetoid-type cerebralpalsy, for whom movement is a series of involuntary writhings, also demonstratesfluctuating tone. When an individual has fluctuating tone that movesthe limbs through largerangesof motion, contracturesare usually not a problem, but inadveftent self-inflictedinjuries sometimesoccut As a hand or foot flails around,it will sometimesrun into a hard, immovableobject.Patientsand caregiverscanbe educated to alter the environment, padding necessary objectsor removingunnecessaryonesto avoid harm. Ifthe fluctuatingtone doesnot resultin movementof large amplitude, then positioning and range-ofmotion treatments should be considered.Neutral warmth has been advocated to reduce excessive movementresultinsfrom muscletone fluctuationsin athetosis.6o
to4
4 . ToneAbtonralities
) Clinical CaseStuilies I The following casestudiessummarizethe conceptsof tone abnormalitiesdiscussedin this chapterand are not intendedto be exhaustive.Basedon the scenariospresented,an evaluationof the clinicalfindingsand goalsof treatmentareproposed.Theseare followed by a discussion of the factorsto be consideredin treatrnentselection. Note that any technique used to alter tone abnormalitiesmust be followed with functionaluse of the musculatureinvolvedifthe patientis to improve the ability to hold ormove.
Case I CM is a 37-year-oldbusinessman who saidthat the first signs of his Bell's paisy appearedafter a long airplane flight when he slept with his head againstthe window. He'd had a cold, but whedrer or not this factor and his nap on the planeprecipitatedhis unilateralfacialparalysis,he did not know. A noticeabledroop was visible on the left sideof his face,and he was havingtroublewith lip closureto control salivaand eatproperly. Wat is thenuscletoxeln theleftfaclalmuscles? Wat techxi4ues *,ould be appropiau for changiagthe toae fot this EVALUATION OF THE CLINICALFINOINGS Bell's palsy is any disorderof the facial newe, usually only on one side, with varied etiologies.The sudden onset of GM's symptomsmay indeed have been instigated by the chilling of the side of his face while on the airplaneor by his cold virus. If the entire facialnerveis affectedon the left, then none of the muscle fibers on the left side of the face will be able to receivesisnals ftom any alphamotor neurons.and the muscleswill be flaccid. If the facial nerve is only partially affected, then some mssclesmight be hy?otonic. GM noted that the entire left side of his face felt as though it was being pulleddownward. PREFERREDPRACTICEPATTERN ImpairedMotor Functionand SensoryIntegriqyAssociaed With NonprogressiveDisordersof the CentralNervous System*Acquired in Adolescence or Aduithood, (5D). PLAN OF CABE Iortunately, reinnervationof tie muscle fibers is common following a facial palsy, usually within 1 to 3 months. Muscle tone can be expectedto normalizeas reinnervationoccursif the muscle and connectivetissueshave been maintainedso that secondarybiomechanicalchangesdo not intedere.Thereforeanticipated
goals of treatment would include prevention of overeyeprotection(while *re blink stretchingof soft tissuesJ reflex is lost), and strengtheningof musclesonce reinneNalion occurs. PROPOSEDTREATMENTPLAN AND RATIONALE Cendepassivemovementof the facialmusculaturemay be indicatedto countersofttissuechangesresultingfrom lack of active movement.Otherwise, CM may be Ieft with a cosmeticallyunacceptable facialdroop when the musclesare reionervated.A patch or other form of protection over the left eyemay be requiredto preventeye injury while the motorcomponentof the comealreflexis paralyzed.As the muscle fibers are reinnervated,the emphasiswill be on exercises to elicitvoluntarycontraction rattrerthan on improvingmuscletone. Quick icing or light touch on the skin over a panicularmusclethat is beginningto be innervatedmay help CM to isolatea muscleto move it voluntarily.Practiceof facial move' mentswhile looking in a miror may provideextrafeedbackforCMwhile he is attemptingto reestablish oormal activation of the facial muscles.Electricalstimulation with biofeedbackmay be used to help the patient resumefunctiononcemusclesarereiru:ervated.
Case2 ELwas young,only in her 40s,for the severiryof arthritic damageto herrighthip. The damagewas most likely the resultofabnormaluseof the right legfollowing a caseof polio when shewas an infant. Severalsurgeriesin childhood to stabilizethe foot andto transfera hamstrinetendon anreriorly to linction for rhe quadricepshad ailowed her independentambularion,but her limp had worsenedover the last severalyears.The head of the femur had slippedout ofthe acetabulumand moved fartLer up toward her trunt EL had to walk on her right toes sincethe right leg was functionallyseveralinches shorterthan the left. After a successfirl total hip replacementchatevenedtheleglengt-hs. ELwaslearning ro walk again.Her gait trainingwas more complexthan is typical following total hip replacementsurgerybecauseof her complications.During supinepassiveROM of her right leg (within the limits allowed by her postoperativetotal hip precautions),the ankle plaatar flexors resisted stretch.Her hip and kneemoved very easilybut the leg feit heary, almost like deadweight. Basedon theinformationyresented,howshauldEIls muscle nxe bedescibedix thehfu flexors? Thebaeeextensots? The aable ylannr flexors?\Y/hattteatmenttechxi4ueswould be aypropriateto ahet the muscletonelabeledix the yreceding
-fl
O e. PATHOLOGY AND PATIENTPROBLEMS
EVALUATION OF CLINICALFINDINGS Both the hip flexorsand kneeextensomarehypotonic,a 1 on the clinical tone scale,witJr decreasedactivation of the alpha motor neurons.The ankle plantar flexor would be expectedto have biomechanicalshortening,causing stiffnessand resistanceto musclestretchat ttre end of a diminishedROM, a resultof habitualtoe walking.If passive movement resultedin resistancein the middle of the available range, then the anlle plantar flexor would be labeledhypenonic,a 3 on the clinical tone scale.Neumlly mediated hypertoniciry is unlikely with this diagnosis sinceno spinalor supraspinal neurallesionsareevident. The hip flexor alphamotorneuronsmay be temporarily inhibited becauseof pain in the incisionarealateralto the hip. If this hypothesisis correct,normalization of muscletone and voluntary contractionwill progressas paln resolves. The quadricepsmuscle was presumablyaffectedby the polio since the hamstring tendon was transferred many yearsago.The quadricepswould havebeenhypotonic following loss of the affected alpha motor neurons: no activationwould have been possiblevia those neurons,eitherfor passiveresistance to stretchor for voluntary contraction. Efs present knee extensor, the hamstring muscle,is probably normal in tone, which will be apparentoncethe hip healsfurtherandpain resolves. Having no information about EIls muscle tone or strengthbeforethe totalhip replacementsurgerythe c1inicianmust palpatefor activationof the musclesduring voluntary contraction.EMC testing of the quadriceps, hip flexors, ankle plantar flexors, and hamstrings may aisoprovide information about the number and size of activemotor units in eachmusclegroup. Suchinformation could differentiate between muscles tl-rat were more or less affected by poliomyelitis. Muscles that wele mole affecteddo not have the samecapacityfor motor unit recruiffnent during strength training as musclesthat were lessaffected.The goalsfor strengthening would be reducedinmusclesthat were more affected.
105
PROPOSEDTREATMENTPLAN AND RATIONALE Pain control could be accompLishedwith physical ag€nts,soft tissuemobilization, and positioning. (See Chapter6 for instructionson the useof heat or cold, or see Chapter 8 for instructionson t}re use of electrical stimulation.) Gait training and functional training with appropiate feedbackand practice will be necessary Cait trailing in a pool will take advantageof buoyancy andthe resistance the waterprovidesagainstmovement and could begin as soon as the surgicalincision is weli healed(seeChapter9). The hypotonicity is expectedto becomelessapparenta6 EIJspain decreases and she is betterableto contractat will. Treatment of the ankle plantar flexors must include prolongedstretch,preferablywith priorheat or thermallevel ultrasound(seeChapters6 and 7) tor soft tissue remodeling.Stretchcould be accomplishedwith exerciseor weight bearingon the whole foot. Somewould advocateserialcastingiffunctional dorsiflexionrangeof motion cannotbe obtailredin any other way.
Case3 S?,a 24-year-oldfemale,had noticed intermittent back pain over the last severalmonths. Her lifestyle had changed significandy from that of an a*rlete, training regularly,to that of a studengsitting for long periods. The pain increaseddramaticallyyesterday,however, while she was bowling for the first time in a couple of years.On€ of her problemsat this point is the palpable musclespasmin the paraspinalmusclesat the lumbar level. \Vhat is theundetlyingst nuluscaus;flgthe ftusclesVasmi' Whattteatmentis ayproliate to alle\)latethespasm?
PREFERREDPRACTICEPATTERI\ Impaired Joint Mobiliry, Motor Functioq Muscle Performanceand Range of Motion AssociatedWith Joint Arthroplasry, (4H), or Impaired Motor Function andSensoryIntegrityAssociatedWith Acute or Chronic Po\meuropathies,(5C).
EVALUATION OF CLINICALFINDINGS Muscle spasmsgpically originate hom painful stimuli, evenif the stimuli aresubde.Possiblestimuli in SP'scase include injury to muscle ftbers or other tissue while engagingin vigorous but unaccustomedactivity, pain signals from a facet joint, or nerve root irritation. The consequenttensionin the musclemay hold or splintthe injured area to avoid local movement that could iritate and exacerbate the pain.Ifpersistengthe musclespasmitself can contribute to the pain and discomfon by inhibiting local circulation and setting up its ou'n painful feedback loop.
PLAN OF CARE Anticipated goals include pain alleviation at the hip, incision healing, and improvement of hip muscle activation, recruitrnent, and timing to improve functions such as gait and transfen, Increasingthe ROM at the ankle will alsobe necessary
POSSIBLEPREFEBREDPRACTICEPATTERNS Impaired Joint Mobility, Motor Function, Muscle Performance,and Range of Motion Associatedwith Connective Tissue Dysfunction, (4D), or lmpaired Joint Mobility, Motor lunctio4 Muscle Performance, and Ranse of Motion Associated with Localized Contirued
t06
4 . Tonc Abtonnnlitics
) Clinical CaseStudies-cont'd a Inflammatior:,(4E),or Impaired Joint Mobiliry, Motor Iunction, Muscle Performance,Rangeof Motion, and ReflexIntegrity Associatedwith SpinalDisorders,(4F), or ImpairedPosture,(4B). PLAN OF CARE The anticipatedgoalsof treatmentwould includeidentifying and removing the causeof the painful stimulus. Frequendy,temporarily easingthe muscle spasmfirst allows more accurateidentification of the underlying pathology. PROPOSEDTREATMENTPLAN AND RATIONALE Diagnosingthe sourceof the painful stimulusis beyond the scopeof this chapter,but many texts are devotedto the subject.6l-63Once stimulus identification and removaloccurs,the musciespasmmaydiminishbyitself or or ir may requireseparale treatment. Heat.uluasound, massagecan increaselocal circulation(seeChapters6 and 7).Prolongedicing,neutralwarmth, or slow stroking couldbe usedto diminishthe hypertonicitydirecdyand thus allow restorationof more normal local circulation. Once the painful feedbackloop of the musclespasmis Educationshould broken,patienteducationis necessary. includeinstructionson preventivestrengtheningof local musculatureand avoidanceof posturesand movements that reaggravatethe initial injury Other sretching and s[€ngtheningexercises havebeenidentifiedbutwill not be discussed in this text on physicalagents.
Case4 RB had a lefthemiplegiafollowing a stroke.He had progressedfrom an initial flaccidparalysisto his curent status of hypertonicity in the biceps brachii and ankle plantar flexors.When askedto lift fus left arm, he was unable to do so without elevating and retracting his scapula,abductingand externallyrotating his shoulder, arld flexing and supinatingat the elbow, all consistent with a flexor synergy. When standing, he tended to rotateintemally and adducthis left hip, with a retracted pelvis and a hyperextendedknee, consistentwith the lower extremity extensor synergy pattern. He was dependentin bed mobility and transfersbecauseof lack of controlledmovementofthe left sideofhis body.The hypertonicity in the arm and leg increasedwhen he attemptedto keep his balancein a standingposition or takestepswith a quad-cane. of muscletaneareaVqoyriatelx euluatittg Wat measures Mr. B? \Yhat trcatlne t is aVyroVriateconsideitg Mr B's
OF CLINICALFINDINGS EVALUATION usingstretch Muscletone would most likely be assessed reflexes,the clinical tone scaleor the Modified Ashworth Scale,andctnical observation.Mr, B was found to havea hyperactive sEetch leflex in both the biceps and the triceps,but muscle tone in t}le triceps was h'?otonic, wi*r a 1 on the clinicaltone scale.The bicepsandplantarflexors were given a 1+ on the Modified Ashworth Scale which equaleda 3 on the clinical tone scale,During quick stretchof the plantarflexors,clonuswas apparent,lasting for three beats. During clinical observation, Mr. B rested his left forearm in his lap while sitting with his back supponed, but when he stood, gravity quickstretchedhis bicepsoncethe weight of his foream was unsupported,and the elbow flexedto approximately80 degrees.During bed mobility, transfers,or standing,fuli elbow extension was never observed.His left anl-le bouncedwith plantarfledon clonuswhen he first stood up, ending with weight mostly on the ball of his foot unlesscarewas taken to position the foot beforestanding to facilitate weight bearing through the heel. Other possibletestsforMr B'smuscletoneinclude*re pendulum test for *re biceps,a dynamometer ol myometer test for the plantar flexors, or EMG studiesto compare muscle activity on the tlvo sidesof Mr. B's body. These quantitativemeasureswould be especiallyuseful for researchthat rcquiresmore pr€cisemeasurementthan describedabove. the qualitativemeasures PREFERBEDPRACTICEPATTERN ImpairedMotor lunction and SensoryIntegrity Associated With NonprogressiveDisorders of the Central Nervous System-Acquired in Adolescenceor Adulthood, (5D). PLAN OF CARE Coais are focusedon improving Mr. B's function and preventingsecondaryproblems. PROPOSEDTREATMENTPLAN AND RATIONALE Appropriate treatment techniques for Mr. B may come Only from multiple sources andtheoreticalbackgrounds. a few techniquesthat influencemuscletone will be discussedhere.Prolongedstretchof the bicepsor the plantar flexors may be incorporated into functional activities like standing or weight bearing on the hand to normalize musde tone. Prolongedicing (seeChapter 6) may be added if soft tissue shortening is inhibiting full passive ROM. Exercisesto facilitate activity of the antaSoniststo inhibit the biceps or plantar flexors may be used. Electical stimulation of the triceps and dorsiflexors would have the dual benefit of inhibiting hypertonic
Orc . PATHOLOCY AND PATIENT PROBLEMS
musculature and strengthening muscles ttrat are currendyweak (seeChapter8). EMC biofeedbackmight be usedduring a specifictask to train Mr. B in more appropriate activation pattems for the bicepsor plantar flexors. The hypertonicity increase seen during standing could be alleviatedwith techniquesto increaseMl B's alignment, balance,and confidencewhile standing. If he is better able to relax in this posture, his muscle tone will decrease aswell. Discussionof specifictherapeuticexercisesto enhanceMr B's balanceis bevond the scopeof this chapter
Case 5 Mrs. H was eagerto tell her story. Her Parkinson's diseasehad progressed, with increasingftemor and harder and longer freezes of her limbs between dyskinetic statesthatl€d to the graduallossof handwriting,reading ability, and other functions. She had taken increasing dosesof a dopaminereplacementdrug with deceasing benefit.Becauseof her good health otherwise,shewas deemeda good candidatefor a surgicalprocedurecalled a vallidonmv andhada 3- to 4-inch recentincision visible in the left sideofher scalp.Now shecouldsignher name with her right hand and read print on an exercisesheet. But shestill froze a few times eachday,when shewould find any movement difficult, although not impossible with sufficient effort, until her muscle tone diminished afteran hour orso. EVALUATIONOF CLINICAL FINDINGS Mrs. H, describedat the beginningof this chapter,is an example of a patient with fluctuating muscle tone during her dyskinetic periods and rigid hypertonicity during her freezestates.Her limbs have suchlarsemovements
l07
during her dyskinetic periods that loss of motion will probablynot be a problem.Her trunk and neckmuscles, routinely positioned with a thoracic kyphosis and forward-extendedhead.however,could righten. PREFERREDPRACTICEPATTERN Impaired Motor Function and Sensory Integrity AssociatedWitJr ProgressiveDisorders of the Central NervousSystem,(5E). PLAN OF CARE Anticipated goals of treatrnent include avoiding injury preventingsecondaryproblemslike soft tissueshortening,and promoringindependentfuncrjon. PROPOSEDTREATMENTPLAN AND RATIONALE Mrs. H's environment should be assessedand her wheelchairfootplatespaddedto avoid injury when her flailing limbs koock against objects. Posture training, active and passive RON4, locally applied heat, and supine positioning can help maintain her trunl< and necktissueintegrity.In Mrs. H's case,sinceher dyskinesia is a result of massivedosesof a dopanrinereplacement drug, one might ask why she does not have the dose reducedor the drug eliminated to decreasethe fluctuationofher muscletone. Her responseis that she prefers dyskinesiato a treeze: it is easier to initiate movement and therefore function in the former condition. The pati€nt's preference takes precedence, althoughreportsof specific,effectivetherapyfor dyskinesiaale ra!e. Neutral warmth, as is used in attretosis, and hydrotherapy,for its resistanceto limb movement but require inall directions,havepotentialeffectiveness further study.
ireferred PhysicalTherapistPraclicePattemssN4I4R, 4D,4L, 4F, 4l{, 5D,5E, and 5Gl are copyright 2002 AmericanPhysicalTherapy All riehtsreserved. .\ssociation-
REVIEW CHAPTER Muscletone is definedasa muscle'spassiveresistance :o stretch.The resistancehas both a neural compo:rent, from the activation of motor units via alpha :notor neurons,and biomechanicaland biochemical :omponents,from the propertiesof the musclefibers and conrrectivetissue surrounding them. NeurallyCerived tone abnormalities resuit from abnormal ;hangesin the inhibitory and excitatoryinput to the alphamotor neuron.Abnormal changesmay occuras a result of peripheral,spinal,or supraspinalpatholo3iesthat affecteither the alphamotor neuronitself or any of the sourcesofinput to the alphamotor neuron.
If the resultis hypotonicity, the goal of rehabilitation is to increase the muscletone to promoteeasieractivation of motor output, improve posture,and restore an acceptablecosmeticappearance.If the result of abnormalinput to the alpha motor neuron is hypertoniciqy,the goal of rehabilitationis to decreasethe muscle tone to decreasediscomfort, easeROM and caregivingactivities, a1low normal positioning, and preventcontractures.If the resultof abnormaiinput is an uncontrollablefluctuationof muscletone, the goal of physicaltherapyis to increasefunction asmuch as possibleand prevent injuries. Some treatment ideas have been suggestedthat make use of the structures
108
4 . ToneAbnonxalities
and neurophysiological principles described here. Later chapters in this text explain more fully how physical agents may be used to manage some of the problems presented when muscle tone is abnormal. ih" reader is referred to the Evolve website at http://evolve.elsevier.com/Cameron for study questions pertinent to this chapter
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One . PATHOLOGYAND PATIENTPROBLEMS
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Motion Rest cfions Linda C. Monroe,MPT, OCS
SUMl\IARY
OF INFORMATION
lntroduction Typesof Motion Patternsof Motion Restriction TissuesThat Can RestrictMotiorr PathologiesThat Can CauseMotion Restrictions Assessmentof Motion Restrictions
COVERED
Treatment Approachesfor Motion Restrictions The Role ofPhysical Agents in the Treatment of Motion Restrictions Clinical CaseStudies Chapter Review
OBJECTIVES Uyon comyletionof this cha2zter, the readerwill beable to: 1 . Define different b?es of motion. 6. Selectand apply appropriatemethods to 2 . Describedifferent patternsof motion determinethe structuresand restrictions. pathologiescontributing to motion 3 . Identify tissuestl.ratcan restrict motion. restrictions. Discusspathologiesthat can contribute to 7. When presentedwith a clinical caseinvolving a motion restrictions. motion restriction, evaluatethe clinical findings, 5 . Selectand apply appropriatetools and methods proposetreatment goals,and identi$zpossible to quantify and qualify motion restrictions. interventions.
ltl
lt2
5 . .Ilotiot
Re strittions
INTRODUCTION This chapter discussesmotion between body segments and the factorsthat can restrict such motion. The amountof motionthat occurswhen onesegment oI the body moves in relationto an adjacentsegment is known as rangeof motiox(ROM).1When a segment of the body moves through its. available ROM, all tissuesin that region, including the bones, strucligaments,tendons.intraarticular ioint capsule, tur"r. mrr.les, nerves,fascia,and skin may be affected.When all of thesetissuesfunction normally, ful1, normal ROM can be achieved;however, dysfunction of any of these tissuesmay contribute to a restriction of the avai.lableROM. Many patients in rehabilitationseekmedicaltreatmentwith an impairment of restricted ROM. To restore motion most effectively,the therapist must understandboth the factorsthat influencenormal motion and the factors thatmay contrjbuteto motionrestrictions.' fhe impairment of restricted motioh may contribute directly or indirecdy to patient functional limitation and disability.3-6lor example, restricted shoulderROM may stop an individual from raising the arm aboveshoulderheightandmay preventhim or her from performing a job that involvesoverhead lifting, This impairment may also contribute indirecdy b further pathology by causingimpingement of the rotatorcuff tendons,resultingin pain.weakoflifting capaciry. ness,andadditionalLimitation ROM is generaliyiimpathology, absence of In the of anatomior approximation ited by the lengthening of the sott flexibility and The integrity cal structures.T joint, and relationshape and the a tissuessurrounding o[ amount the affect structures. ship of the articular it joint midrange, is at a When motion that can occur. a small o[ application with the cangenerallybe moved force.This is becausethe collagenfibersin the connective tissuesurounding the joint are in a relaxedstate, loosely oriented in vadous directions, and only sparselvcross-linkedwith other fibers,allowingthem t; dist;nd readily.As *re joint approachesterminal motion, the collagenfibersbegin to align in the direction of the stressandstartto straightenMotion ceases at the normal terminal range when the fibers have achievedtheir maximum alignmentor when soft or bony tissuesapproximate.Ior example,ankle dorsiflexion normally ceaseswhen *re fibers of the calf muscles have achieved maximum alignment and the musclesarefully extended,whereaselbow flexion normally ceaseswhen the soft tissuesof the anterior
arm aonroximate with the soft tissuesof the antedor foreanl, and elbow extensionceaseswhen the olecranon processof the ulna approximateswith the olecranonfossaofthe humerus(Fig.5-1) The normal ROM for all human joints has been measuredand documented;howeveqthesemeasures vary wirh the individual'sage,sex,and health stawith age Rang"of -otion generallydecreases tur.B-10 and is qreaterin women than in men, althoughthese differeicesvary with differentmotions andjoints and are not consistentfor all individuals.ll-l9Becauseof this variabiliry normal ROM is generallydetermined bv comparisonwith the motion of the contralateral limb, if'available, rather than by comparisonwith notmative data. A motion is considered to be restrictedwhen it is less than that availablefor the samesegmenton the contralateralside of the same individual. When a normal contralateralside is not available-as occurs,for example,with the spinemotion is consideredto be restrictedwhen it is less than normal for the individual'sageand sex.
OFMOTION TYPES Motion ActiveandPassive The motion of body segmentscan be classifiedas ei,theractiveor yassiveActive motion is the movement producedby contractionof the musclescrossing a joini. Assessmentof activeROM can provide information about an individual's functional abilities' Active motionmay be restrictedby muscleweakness, abnormal muscle tone, Pain originating trom the musculotendinousunit or other local structures,an inability or unwillingness of the subject to follow directions,or as the result of restrictionsin passive ROM.20 Passivemotion is movementproducedentirely by an externalforce without voluntary muscle contraction by *re subiect.The externalforce may be produced by gravity, a machine,another individual, or another'pirt of the subiect'sown bodyl Passive motion may be restdctedby shorteningof the soft tissues,edema,adhesion,mechanicalblock, spinal disc neuraltension. or adverse herniarion, ROM is greaterthannormalactive Normalpassive ROM when motion is limited by *re distention or aooroximation of soft tissue, but both types of -otio.r ut" equalwhen motion is limited by approxiof passive a fewdegrees mationofbone.Forexample,
One c PATHOLOGY AND PATIENTPROBLEMS
113
' gure5-1. A, Ankle dorsiflexion limited by solt tissuedistension.B, Elbow flexion limited by soft tissueapproxima'-:n. C, Elbow extensionlimited by bone approximation.
,::kle dorsiflexion motion are available beyond the .::rit of active motion because the limiting tissues are - astic and may be extended by an external force that i greater than that of the active muscles when at ter:::inal active ROM. A few degrees of additional pas,. .'e elbow flexion are availabie beyond the limit of .:,ive range because the limiting ris'ues are com::essible by an external force greater than that of the ::iive muscles in that position and because the ::proximating muscles may be less bulky when ,"laxed. This additional passive ROM may protect ,iint structures by absorbing external forces during ::rivities, particularly those performed at or close to -- .-A ^t ,.ri,'" ."^."
Physiological andAccessory Molion :rysiological motion is the motion of one segment of ::re body relative to another segment. For example, :nysiological knee extension is the straightening of -:reknee *rat occurs when the leg moves away from re thigh. Accessory motion is the motion that occurs : . ' w e e n t h e ' o i n r , u r f a c e sd u r i n g n o r m a lp h y s o l o g i r l m o t i o n . T14 24 3F o re x a m p J ea. n c e r i ogr l i oi n g o f t } e
tibia on the femur is the accessorymotron that occurs d u r i n g p h y s i o l o g i c akl n e e e x r e n s i o nr l i g . 5 - 2 ) . Accessorymotions may be intraarticular,as in the prior example of anterior tibial gliding during knee extension,or extraarticular,aswith the upward rotation of lhe scapula during physiological shoulder flexion (Iig. 5-3). Accessorymotions cannot be performed actively in isolation from their associated physiologicalmovement;howeveSthey may be performed passivelyin isolation from their associated physiologicaimovement. Normal accessorymotion is required Ior normal active and passivejoint motion to occur.The direction of normal accessorymotion depends on the shape of the articular surfacesand the direction of physiologicalmotion. Concavejoint surfacesrequire accessoryglidingto be availablein the directionof the associatedphysiological motion of the segment, whereasconvexjoint surfacesrequireaccessorygiiding to be availablein the opposite direction of the associatedphysiologicalmotion of the segment.2llor example, the tibial plateau, which has a concave surface at the knee, glides anteriorly during knee extensionwhenthe tibia is moving anteriorly,and the
ll4
Figure5-2. Accessoryanterior gliding of the tibia on the femur during physiological kneeextension.
Figure5-3. Extraarticular accessory motior\ which is the upward rotation of the scapula that accompaniesshoulder flexton.
5 . Motion Restictions
Femur
O$e . PATHOLOGY AND PATIENT PROBLMS
:emoralcondyles,which have convexsurfacesat the
PATTERNS OFMOTION RESTRICTION Capsular andNoncapsular Patterns ofMotion Restriction l1le restrictionof motion at a joint canbe classifiedas :aving either a caysularor a noncaVsular pattern. A :apsularpattem of restrictionis the specificcombina:on of motion lossthat is causedby shorteningof the 'oint capsulesurroundinga joint. Eachsynovialjoint ras a unique capsularpattern of restriction.Capsular rattems generally include restrictionsof motion in ::rultipledirections.Ior example,the capsularpattern :or the glenohumeral joint involves restriction of 3xternal rotation, abduction, internal rotation, and lexion to progressivelysmaller degrees.Capsular f,attemsof restrictionmay be causedby the effusion, ibrosis, or inflammation commonly associatedwith legenerativejoint disease,arthritis, immobilization, fnd acutetrauma. A noncapsularpattern of restdctionis a combina:on of motion loss that doesnot follow the capsular eattem.A noncapsularpattem of motion lossmay be :ausedby ligamentousadhesion,an internalderange:rrent,or an extraarticularlesion.ligamentous adhe,ionwill limitmotion in the directions*lat stretchthe adheredligament. For example,an adhesionof the :alofibularligament after an ankle sprainwill restrict :nkle inversion because this motion olaces the :dheredligamenton srretch;however,thjs adhesion '.vill not alter the motion of the ankle in other direc:ons. Internal derangement,the displacement of .oose fragmentswithin a joint, will generallylimit :rrotiononly in the directionthat compresses the frag:nent. Ior example,a cartilagefragmentin the knee -,villgenerallylimit knee extensionbut will not limit klee flexion. Extraarticularlesions,such as muscle adhesions,hematomas, cysts, or inflamed bursae, nay limit motion in the directionof either stretchor .ompression,dependingon the nature of the lesion. For example,adhesionof the quadricepsmuscle to -rheshaftof the femurwill limit stretchinsof the mus;le, while a poplicealcyst will limit compression of -J-re popliteal area.Both of these lesionswill restrict irotion in the noncapsularpattern of restrictedknee Jexion.with fulJ.painless kneeexrension.
115
TISSUES THAT CANRESTRICT MOTION Contractile andNoncontractile Tissues Any of the musculoskeietaltissuesin the area of a motion restrictionmay contributeto that restriction. Thesetissuesaremostreadilyclassifiedascontractile or notlcontractile flable 5-1). Contractile tissue is composedof the musculotendinousunit, which includes *re muscle,the muscuiotendinousjunction, the tendon, and the tendon's interfacewith bone. Skeletal muscleis consideredto be contractilebecauseit can contractby forming cross-bridges of the myosin proteins with the actin proteins within its fibers.24 Tendonsand their attachmentsto boneareconsidered contractilebecausecontractingmusclesapply tension direcdyto thesestructures.When a muscleconftacts, it appliestensionto its tendons,causingthe bonesto which it is attachedand the surroundins tissuesto movethroughtheavailable accjveROM. *hen all the componentsof the musculotendinousunit and the noncontractiletissuesare functioning normall, the availableactiveROM will be within normal limits for the ageand sexofthe subject.Injury or dysfunctionof contractiletissuegenerallyresultsin a restrictionof active ROM in *re direction of movement oroduced by contraction of the m usculotendinousunit. Dysfunction of contractiletissue may also result in pain or weaknesson resistedtestingof the musculotendinousunit. For example,a tear in the anteriortibialis muscleor tendon can restrictactivedorsiflexion at the ankleandreducethe forcegeneratedby resisted testing of ankle dorsiflexion,but this lesion is not
Contractile tfusue
Noncontraatile tissue
Muscle
Skin
Musculotendinousjunction Ligament Tendon
Bursa
Tendinousinterface with bone
Capsule Articular cartilage Intervertebraldisc Peripheralnerve Dura mater
5 . Moriofl Resttictiotts
ll6
likely to alter passiveplantar flexion, dorsiflexion, ROM, or activeplantarflexion strength. A11tissuesthat are not componentsof the musculotendinous unit are considered noncontractile. Noncontractiletissuesincludeskin, fascia,scartissue, ligamenqbursa,capsule,articularcanilage,bone,intervertebraldisc,newe, and dura mater When the noncontractiletissuesin an areaare functioningnormally, the passiveROM of the segmentsin that areawill be within normallimits. Injury or dysfunctionof noncontractile tissue can causea restrictionof the passive in question ROM o[ the johcs in rheareaof the cissue oI actjveROM.2s to restriction andmayalsocontribure The direction,degree,andnatureof the motion restriction dependson the type of noncontractiietissue involved,the type of tissuedysfunction,andthe severiqyof involvement.Forexample,adhesivecapsulitisof *re shoulder,which involvesshorteningof the glenohumeraljoint capsuleand elimination of the inferior axiliaryfold, will restrictbothpassiveandactiveshoul(Iig. 5-4). derROM in a capsularpattem26-31
THATGANCAUSE MOTION PATHOLOGIES RESTRICTIONS Contracture Motion may be restrictedif any of the soft tissue structuresin an area have become shortened.Such
may soft tissue shortening,known as a contracturet noncontractile tissues.32,33 A occur in contractileor resuitcontracturemay be causedby immobilization ing from external splinting provided by a cast or splint, for example.Contracturesare also causedby imbalanceof musclepower resultingfrom weakness, ascouldbe causedby poliomyelitisor from spasticity from central, nervous system (CNS) damage, for It has been proposedthat immobilizaexample.33,34 tion results in contracturebecauseit allows anomalouscross-linksto form betweencollagenfibers and it causesfluid to be lost from fibrous connectivetissue,includingtendon,capsule,ligament,and fascia.34 36 Anomalous crosslinks can developwhen tissues remain stationarybecause,in the absenceof normal stressand motion, fibersremainin contactwith each otherfor prolongedperiodsand startto adhereat their points of interception.Thesecross-linksmay prevent normalalignmentof the collagenfiberswhenmotion is attempted.They also increasethe stressrequiredto stretchthe tissue,limit tissueextension,and resultin contracture(Iig. 5-5).Iluid losscanalsoimpair norrnal fiber gliding,causingcollagenfibrilsto haveclosercontactandlimitins tissueextension.32 The risk of contractureformauon rn responsero immobilization is increasedwhen the tissuehas been injuredbecausescartissue,which is formedduringthe proliferationphaseofhealing,tendsto havepoor fiber alignmentand a high degreeof cross-linkingbenveen
,:'.:ii.:'.,.\\
', \ ,:.,. } . ' . . . ' . , ] 1.',:
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r 1 1:.:.,.,.; f.r-.:. .,_
,"/
l\.'::,r,ll '.':i L\
li
J,/ \'::,1.'tl\ Normal inferiorjoint capsule HUmerus
Figure5-4. Joint capsuleshorteningand adhesionrestricting shoulder rangeof motion.
One . PATHOLOGY AND PATIENTPROBLEMS
CollagenFibersat Resl withCrosslinks
NormalCollagen Fibersat Rest
I t I I
I + 5-5. Normal collagenfibersandcollagenflberswith Figure cross-links.(FromWoo SL,Matthews [{ AkesonWH et to immobility.Correlative aLConnective tissueresponse study of biomechanicalmeasurementsof normal and Mayimmobilized rabbrtktrces,Anhitls andRheumatism, permission of 197 5. This material is used by 78(3):262, June of JohnWiley & Sons,Inc.) Wiley-Liss, Inc.,a subsidiary its fibers.Restrictionof motion after an irlury may be further aggravatedif a concurrentproblem, such as sepsisor ongoing trauma, amplifies the inflammatory scarring.33 responseand causesexcessive A persistentshort€ningof a musclethat is resistant A muscle to stretchis known as a musclecofltracture. contracturecanbe causedby prolongedmusclespasm, guarding, muscle imbalance, muscle disease, or ischemicmusclenecrosis,and by immobilization.33A musclecontracturemay limit both activeand passive motion of the joint(s)that the musclecrossesand can also cause deformity of the joint(s) normally cont'^ll.J
hv thp mr,vle
Edema Normally,a joint capsulecontainsfluid but is not fully distended.This allows the capsuleto fold or distend
tt7
when the joint moves, altering its size and shape as required for movement through fuI1 ROM. If excessivefluid forms inside a joint capsule,a condition known as ixtraatticularedema,the joint capsule becomesmore distended,limiting i* folding and further distention and potentially restrictingbo*r passive and activejoint motion in a capsularpattem.For example,intraarticularedema in the knee will producethe capsularpattern of knee flexion being more limited than kneeextension. Accumulation of fluid outside of the ioint, a condition known as extraarticularedema,may also restdctactiveand passivemotion by causingsoft tissue approximation to occur earlier in the range. Extraarticularedema generallyrestrictsmotion in a noncapsularpattem. Ior example,edemain the calf musclemay resffict knee flexion ROM while having no effecton kneeextensionROM.
Adhesion Adhesion is the abnormal joining of parts to each Adhesionmay occurbetvveendifferenttypes other.37 of tissue for various reasonsand ftequendy causes restriction of motion. During ttre healing process, scartissuecan adhereto surroundingstructures,and fibrofatty tissue may proliferate inside joints and adherebetweeninftaarticularstructuresas it matures into scartissue.38 Prolongedjoint immobilizatioq even in the absenceof local injury can also causethe synovial membrane sunounding the joint to adhereto the cartilageinside the joint. Adhesionscan affect both the quality and the quantity of joint motion. For example, with adhesivecapsulitis,not only doesthe joint capsuleshorten,it alsoadheresto the slmovialmembrane. This lirrli* motion andreduces,or evenobliterates,the space between the cartilage and the sl,novial membrane, thus blocking normal synovial fluid nutrition that can and causingarticular cartilage^d-egeneration alterthe qualityof joint motion.rr
Mechanical Block Motion canbe mechanicallyblockedby bone or ftagments of articularcartilage,or by tearsin intraarticular discs or menisci. Degenerativejoint diseaseor malunion of bony segmentsfollowing fracturehealing frequendy resultsin a bony block that restricts joint motion in one or more directions (Fig 5-Q This is becausethese pathologies cause bone to
tta
5 . Motiofl Restictioqs
length of the spinal column without interuption of transmission.au Adverseneuraltensionis the presence of abnormal responsesproduced from peripheral nervous system structures when their ROM and stretch capabilitiesare tested.arAdverseneural tension may resulcfrom majoror minor nerveinjury or may be causedindirecdy by extraneuraladhesions that result in tethering of the nerve to surrounding structures.Nerve injury may be the result of trauma due to friction, compression,or stretch.It may alsobe causedby disease,ischemia,inflammation, or a disFigure5-6. Osteophytesblocking metatarsophalangeal ruption in the axonaltransportsystem.42 ]schemiacan extenston. pressure extravascular fluid, blood, be causedby ftom discmaterial,or soft tissueswith decreased mobiliqy. joints. hypertrophy in or around the Loosebodiesor Adverseneural tensionis most commonly due to fragmentsof articular cartilage,causedby avascular restriction of nerve motion. A number of structural necrosisor ffauma,canalsoalterthe mechanicsof the features predispose nerve motion to restriction. joint, causing"lockingoin variouspositions,pain,and Nerve motion is commonly restrictedwhere nerves pass through tunnels, as, for example, where *re other dysfunctions.33 Tearsin intraarticularfibrocarti laginous discs and menisci caused by high-force median nerve passesthrough the carpal tunnel or traumaticinjury or by repetitivelow-force straingenwhere the spinal nervespassthrough the interuerteerallyblock motion in one directiononly. bral foramina.Peripheralnewe motionis alsolikely to be restrictedat points where the nervesbranch;for example,where the ulnar nerve splits at the hook of DiscHerniation Spinal the hammateorwhere the sciaticnervesplitsinto the pironeal and tibial nervesin the fiigh. Placeswhere Spinaldischerniationmay resultin direct blockageof sninal motion if a portion of *re discal material the systemis relativelyfixed arealsopoints of vulnerbecomestrapped in i facet joint or if the disc comability; for example,at the duramater at L4 or where pressesa spinal nerve root where it passesthrough the common oeronealnerve oassesthe head of the the vertebralforamen. Other pathologiesassociated fibula. The system is also ielatively fixed where with spinal disc hemiation, including inflammation, nervesare closeto unyieldinginterfaces;for example, hyp€ftrophic changes,decreaseddisc height, and where the cordsof the brachialplexuspassover the pain, may further limit spinal motion. Inflammation first rib or the greateroccipitalnerve passesthrough *re fasciain the posteriorskull.al about the spinalfacetjoint or herniatedsegmentcan limit motion by narrowing the vertebralforamenand compressingthe nerveroot. Hypertrophicchangesat Weakness the vertebral margins and facet joints, as well as decreaseddischeight, alsonarow the vertebralforaWhen musclesare too weak to seneratethe force men, making the nerve root more vulnerable to requiredro move a segmenL of the body throughits compression.Painmay limitmotion by causinginvolnormal ROM. activeROM will be restricted. untary musclespasmsor by causing*re individual to weakness may be the result of contractile restrictmovementsvoluntarily. changessuch as atrophy or injury poor along the motor nerves,or poor synaptic sion at the neuromuscularjunction. Osleophytes
Adverse Neural Tension
Under normal circumstances,the nervous system, including *re spinal cord and the peripheralnerves, must adapt to both mechanicaland physiological stresses.39 lor example,during forward flexion of the trunk, the newoussystemmust adaptto the increased
0therFactors Motion restrictions may also be causedby other factors, including pain, psychological and tone.Painmay restrictactjveor passive
O,te . PATHOLOGYAND PATIENTPROBLEMS
dependingon whether contractileor noncontractile sffucturesare the sourceof the pain. Psychological factorssuchasfeat poormotivatior! or poor compr€hension are most likely to causerestriction of only active ROM. Tone abnormalities,particularlyhypotonia or flaccidity, may also impair the control of activemusclecontractionsand may thus limit active ROM.
ASSESSMENT OFMOTION RESTRICTIONS When a patient seeksmedical treatment for complaints of limited motion. an examination of the mobility of all the structuresin the areaof the restriction, including the joints, muscles,intra- and exffaarticular structures. and newes. should be made. Evaluationof all these findings is required to determine the pathophysiology underlying the motion restrictioq identify the tissues limiting motioq and assessthe severity and irritability of the dysfunction.€ This comolete examination and evaluation will direct treatment to the appropriatestructure(s) and will facilitate selectionof the optimal intervention to meet goals.Ongoing assessment of outcomes is required to modify treatment appropriately in responseto changesin the dysfunction. This will accelerateand optimize progresstoward the treatment goals.22,23'42 A variety of tools and methodsare availablefor quantitativeand qualitative assessment of motion andmotion restrictions.
Measures 0uantitative Goniometers,tape measures,and various types of inclinometersare commonly usedin the clinical setting for quantitativeassessment of ROM. Thesetools provide objective and moderately reliable measures of ROM. and are oracticaland convenientfor clinical use. Radiographs,photographs,electrogoniometers, flexometers,and plumb linesmay be usedto increase the accuracyand reliability of ROM measurement. Theseadditionaltools areoften usedfor researchpurposesbut are not availablein most clinical settings. The different tools provide different information about the available or demonstratedROM. Most tools,includinggoniometers,inclinometers,and electrogoniometers,provide measuresof the angle, or changein angle, between body segments,whereas other tools, such as the tape measure,provide measuresof the changein lengthof bodysegments.aa
l19
Measures 0ualitative techniquessuchassoft tissue Qualitativeassessment palpatiorSaccessorymotion testing,and end-feelprovide valuableinformation about motion restrictions that canhelp to guidetreaunent.Soft tissuepalpation may be usedto assessthe mobility of skin or scartissue,local tendemess,the presenceof musclespasm, skin temperature,and the quality of edema.It is also usedto identify bony landmarksbefore quantitative measurementof ROM.
TestMethods andRationale Active, resisted,passive,and accessorymotion, and neuraltensiontestingcanbe usedto determinewhich tissuesare restrictingmotion and the nature of ttre pathologiescontributingto a motion restriction. Activerangeof motion Active ROM is testedby askingthe subjectto move the desiredsegmentto its limit in a given direction.The subjectis askedto reportany s)'mptomsor sensations, such as pain or tingling, experiencedduring this activity. The maximum motion is measuted,and the quality or coordination of the motion and any associated symptoms are noted. Testing of active ROM yields ' information regardingthe subjecCsability and willingnessto move functionally and is generally most useful for assessingthe integrity of contractile structures. The following questionsshould be noted when testingactiveROM: 1. Is the ROM symmetrical, normal, restricted,or excessive? 2. Whatis *re quality of the availablemotion? 3. Are any signs or symptoms associatedwith the motion?
Resisted muscle testing Resistedmuscle testing is performed by having the subjectcontracthis or her muscleagainsta resistance strong enough to prevent movement.45,46 Resisted muscletestsprovide information about the ability of a muscleto produceforce.This information may help detemine whether contractileor noncontractiletissuesare the sourceof a motion resffictionsincemuscleweaknessis commonly the causeof a lossof active ROM.47 Cyriax25has identified four possibleresponsesto resisted muscle testing and has proposed interpretations for each of these responses(able 5-2).
5 . Motiot Restrictiotts
120
Interpretation
1. Strongand painless
No apparentpathologyof contractileor neryoustissue
2. Strongand painful
trAinorlesionof musculotendinousunit
3. Weak and painless
Completeruptureofthe musculotendinousunit Neurologicallesion
4. Weak and painful
Partialdisruptionof the musculotendinousunit Inhibitionby pain due to pathologysuchasinflammation, f',.r"'" ^' -.^-1,.Concurrentneurologicaldeficit
lromCynaxJ: Textboab of Orthoyedic Medicine,ed 6, Baltimore,1975,Williams & Wilkins.
When the force is strong and there is no pain with testing,this indicatesno pathology of contractileor nervoustissues.When the force is strongbut pain is producedwith testing,this usuallyindicatesa minor structurallesionof the musculotendinousunit. When the force is weak and there is no pain with testing, this indicates a complete rupture of the musculotendinous unit or a neurologicaldeficit. When the force is weak but pain is producedwith testing,this indicatesa minor structurallesion o[ the musculotendinousunit with a concurent neuroloeicaldeficit or inhibition of conffacdon resultinglrom pain causedby pathology such as inflammation, fracture, or neoplasm. Passive rangeof motion PassiveROM is assessedby the tester moving the segment to its limit in a given direction. During passive ROM testing, the quantity of available motion is measured,and the quality of motion and symptoms associatedwith motion and the end-feel are noted. End-feelis the quality of the resistanceat the limit of passivemotion felt by the clinician.An end-feelmay be normal (physiological)or abnormal (pathological).A normal end-feelexistswhen passive ROM is full and the normal anatomyof the joint stops movement. Certain end-feelsare notmal for some joints but may be pathological at other joints or at abnomal points in the range.Other end-feelsare abnormal if felt at any point in the motion of any joint. Normal and abnormalend-feelsfor most joints arelistedinTable 5-3.20,42'47 PassiveROM is normally
limited by stretchingof soft tissuesor by the opposition of soft tissuesor bone and may be restrictedasa result of soft tissue contracture,mechanicalblock, or edema.The amount of passivemotion available and *re quality of the end-feel can assist in the determination of tlre structures at fault and the nature of the pathologiescontributingto the motion resffiction.4/ Combining the findings of active range of motion assessment, resrsted muscle testing, and passive range of motion Combining the findings of active ROM, resisted muscle testing, and passive ROM can assist in differentiatingbewveenrestrictionsoI motion caused by contractile and nonconffactile structures. For example, if active elbow flexion is restricted, the elbow flexors are weak and passiveelbow flexion rangeis normal, then the structureslimiting motion are most likely to be contractile. In contrast, if both active and passive elbow flexion ROM are restrictedand the strengthofthe elbow flexorsis normal, then noncontractile tissues are proba involved. Other combinations of abnormality may indicate muscle substitution durine active ROM testing, psychologicalfactors limiting motion, use of poor testing technique, or pain inhibi musclecontraction(lable 5-4).To definitelyimpli a particular pathology or a particular stuucturq the findings of thesenoninvasivetests may need to be correlatedwith the findinss of other
pf 5-3 Descriptions and Examplesof Different Types of End-Feels Type
Description
Exarnples
Comments
Hard
Abrupt halt to movement when two hard surfaces meet
Normal: elbow extension Abnormal:resuitof malunion fractureorheterotoPic ossification
May be normal or abnormal
Firm
Leathery firm resistance when rangeis limited by joint capsule
Normal: shoulderrotation Abnormal:resultofadhesive capsulitis
May be nomal or abnormal
Soft
Gradualonsetofresistance when softtissue approximatesorwhen rangeis limited by length of muscle
Approximation:kneeflexion Musclelength:cervicalside bending
May be normal or abnormal, dependingon tissuebulk andmusclelength
Empry
Movement stoppedby subjectprior to tester's feelingresjstance
Passiveshoulderabduction stoppedby subjectdue to pain
Always abnormal
Spasm
Movementstoppedabrupdy by reflexmuscle contraction
?assiveankledorsiflexionin subiectwith spasticitydue to uppermotor neuronlesion Active trunk fl€xion in subiect with acutelow backinjLrry
Always abnormal
Springyblock
Reboundfelt and seenat end ofrange
Causedby loosebody or displacedmeniscus
Always abnormal
Boggy
Resistance by fluid
Kneejoint effusion
Always abnormal
Extended
No resistancefeltwithin the normal rangeexpected for t-hepanicularjornt
Jointinstabiliryorhypermobility
Always abnormal
ed 3, New York, 1991, lrom Cote L, CrutcherMD: The basalganglia.In KandelERuSchwartzJH,fessellTM, eds:P/wiVlesofNeuralSciexce, :Lsevier.
h g
5-4 Combining the Findings of Active Rangeof Motion, ResistedMuscle Testing, and PassiveRange of Motion Assessment Active range of motion
Resisted testing
Passive range ofmotion
Int€rpretation
Normal
Normal
Normal
No pathologyrestrictingmotion
Normal
Normal
Abnomal
Pathologybeyondterminalactiverangeof motion Poortestingtechniquefor passiverangeof motion
Normal
Abnormal
Abnormal
Poortestingtechniqueforpassiverangeofmotion Strengthat least3/5butless*ran 5/5
Normal
Abnormal
Normal
Strengthat least3/5 butless*Ian 5/5
Abnormal
Normal
Abnormal
Nonconffactiletissuerestrictingmotion
Abnormal
Abnormal
Normal
Contractiletissueiniury resuictingmotion
Abnormal
Normal
Normal
Poorrestingtechniquesforactive rangeof motion or psychologicalfactorslimiting activerangeof motion
Abnormal
Abnormal
Abnormal
Conuactileandnoncontractiletissuesrest ctinSmotion
122
5 . Motiofl Restrictiofts
proceduressuch as radiographicimaging, diagnostic injection, arthroscopic exploration, and blood tests. motion Passive accessory Passiveaccessorymotion is testedusing joint mobiThe clinician can lization treatrnent techniques.s,13 to assess the motion use thesetreatmenttechniques joint surfaces and the extensibility of maior of ligamentsand portions of the joint capsule.During accessorymotion testing the clinician notes qualitatively if the motion felt is greatertharl lessthar5 or similar to the normal accessorymotion expectedfor that joint in that planein the particularindividual and Ac."ttory if pain is produced with testing.22,4e-50 motion testing may provide information about joint mechanicsnot availablefrom other tests.Ior example, a reduction of accessorygliding of the glenohumeral joint when passive shoulder tlexion is normal may indicatethat glenohumeraljoint motion is resfticted,and the motion of the scapulothoracic joint is excessive. Musclelength Muscle length is tested by passively positioning muscle attachmentsas far apart as possibieto elongate the muscle in the direction opposite to its action.4sThe testing of muscle length by this technique will producevalid resultsonly if pathology of the noncontractilestructuresor muscletone doesnot limit jointmotion. When testingthe lengthof muscles that crossonly one joint, the passiveROM available at that joint will indicatethe length of the muscle.Ior example, the length of the soleus muscle can be assessedby measurement of passive dorsiflexion ROM at the ankle.To test the length of a musclethat crossestwo or more joints, the musclemust first be elongatedacrossone o[ the joints and then that joint must be held in that position while the muscle is elongatedas far as possible acrossthe other joint that it crosses.4s The oassiveROM availableat the joint wiil indicate the length of the muscle. second the length of the gasrocnemiusmuscle For example, can be tested by first elongatingit acrossthe knee, by placingthe knee in full extension,and then measuring the amount of passivedorsiflexionavailableat the ankle. It is essentialthat multijoint musclesbe fully extendedacrossone joint before measurement
at the other ioint to obtain a valid test of muscle length. Adverseneuraltension Adverseneuraltensionis usuallytestedby passively placing neural structuresin their position of maximum length.Evaluationis basedon comparisonwith the contralateralside, comparisonwith norms, and of the symptomsproducedin the position assessment maximum length. of Adverse neural tension tests include the passive straight leg raise (PSLR"Lasegue'ssign), prone knee bend, passiveneck flexion, and upper limb tension tests.The PSLRis the most commonly used neural tension test and is intended to test for adverseneural tensionin the sciaticnerve. Becauseadverseneuial tensiontestsmay alsoprovoke s;rmptoms in the presence of pathologies associatedwith the muscles or joints, it is recommended that maneuversthat apply tension to the nervoussystembutdo not additionallystressthe muscles or joints be used to differentiatethe sourceof symptoms with this ty?e of test. Ior example,the PSLRtest can provoke symptomsin the presenceof pathologiesassociated with the hamstringmusclesor the sacroiliac,iliofemoral,orlumbarspinalfacetjoints. Therefore at the onset of s)'rnptomswith this test, additionaltensioncan be appliedto the nervoussystem by passivelydorsiflexingthe ankleto increasethe tension on the sciaticnerve distally or by passively flexing the neck to tighten the dura proximally. If these maneuversincreasethe patient'ss;'rnptoms,adverse neuraltensionratherthan joint or musclepat'hologyis probablythe causeof symptoms.al
toRange of andPrecautions Contraindications Techniques Motion when Rangeof motion techniquesarecontraindicated motion of a part may disrupt *re healing process. However, some controlledmotion within the range, speed,and toleranceof the patientmay be beneficial during the acute recovery stageor immediately following acute tearc, ftactures,and surgery Limited, controlled motion is recommendedto reduce the severity of adhesion,contracture,decreasedcirculation, and loss of strength associatedwith complete immobilization.33,aT
123
O e. PATHOLOGY AND PATIENTPROBLEMS
Contraindications techniquesare con-Lctiveand passiveassessment =aindicated: 1 In the region of a dislocation or an unhealed fracture. ?. Immediatelyfollowing surgrcalproceduresto tendons,ligaments,muscle,joint capsule,or skin.
F
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Precautions Caution should be obsewed when performing active or passiveROM techniqueswhen motion to -Jrepart might aggravatethe condition. This may SCCUr:
1. When there is an infection or an inflammatory processin or aroundthe joint. 2. In patientstaking pain medicationwho may not be ableto respondappropriately. 3. In the presenceof osteoporosisor any condition that causesboneftagiliry. 4. With hypermobile joints or joints prone to subluxation. 5. In painful conditionswhere the techniquesmight reinforcethe severityof the symptoms. 6. In patientswith hemophilia. 7. In the regionof a hematoma. 8. lf bonyankylosisis suspected 9. Immediatelyafter an injury where therehasbeen a disruptionof soft tissue. 10. In the presenceof myositis ossificans. In additioq neural tension testing should be per[ormedwith cautionin the presenceof inflammatory conditions;spinal cord symptoms; tumors; signs of nerveroot compression;unrelentingnight pain; neurologicalsymptomssuchasweakness,reflexchanges, or lossof sensationlrecentparesthesiaor anestltesial al a2 Detailed and reflex sympathericdystrophy.3q contraindicationsand precautionsfor each specific neuraltensiontest areprovidedin other textsdevoted to the assessmentand treatrnent of adverseneural rension.4l
APPROACHES FOR MOTION TREATMENT RESTRICTIONS Stretching Currendy,most noninvasiveinteruentionsfor reestablishing soft tissue ROM involve sffetching.Clinical
TIME
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and experimentalevidencedemonstratesthat stretching can increasemotion; however, the results may not be consistentand the recommendedprotocols vary51 When a stretch is applied to connectivetissues,within the elastic limit, over time the tissues may demonstratecreep,stressrelaxation,and plastic deformation.S2Creep is transient lengthening or deformation with the application of a fixed load. is a decreasein the amount of force Stress-relaxation required over time to hold a given length (Fig.5-7). Creepand stressrelaxationcan occurin soft tissuein a short time and are thought to be dependenton Plastic the viscous components of the tissue.53'55
124
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appliedfor a proiongedtime to causeplasticdeforma_ tjon. The Jengthof-timenecessary ro determinerhac no furcherROM gainsarepossibleis nor known and ] is probablydepe"ndent on rhe specificpoLhologyor j p at h o l o g i ecsau s i n gr h er e srr i c t i o a n n di L s d u r a t i oLnr . j additionLotime.the forcedirectionandspeedof the I
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rissueor cau,inghypermobiliry. I Many srretchingLechniques ro increasesoft tis_ | sue lengrbhave beendescribed. The mosLcommon I of stretching are passive sLrerching.pro. I to"r prioceptive neuromuscular facilitation (PNI), and I ballistic stretching(Table5-5). To perform a passive I
Fisure 5-8.plastic deformation versus elastic deformation.*[:'f';:" deformation is the,elongationproducedunder loading drat remainsafter the load is removed (Iig. 5-8). After plastic deformation,tissuewill have a permanent increasein length. A controlledstretchmust be
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77:1090-1096,1997.
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One c PAIHOLOGY AND PATIENT PROBLEMS
lathological tissueshave not been established,it is generally recommended that low-load, prolonged iorces be applied to minimize the risk of adverse effects. Manipulation of a joint while the subjectis anes-Jretizedalso involves passivestretchingof the soft dssuesto increaseROM. Manipulation under anesihesiacan producea rapid increasein ROM because high forcesthat would otherwisebe painful or cause musclesto spasmmay be applied.Thesehigh forces may cause greater increasesin soft tissue length andmay tear adhesionsto increasemotion; however, -fie risk of damaging structures or exacerbating inflammation may be greaterwith such techniques -.han with stretching while the subject is fully conscious. Proprioceptive neuromuscular facilitation techniques for muscle stretching inhibit contraction of rhe musclebeins stretchedand facilitate contraction This is achievedby having the o[ its opponent.5o subject actively contract and then voluntarily relaxthe musclesto be stretchedbefore the applicacion of the stretching force. PNF techniqueshave the advantageover other stretching techniquesof rncluding a motor leaming component ftom the repeatedactive muscle contractionslhowever, their use is frequendy limited by the requirement that a skilled individual help the patient perform the techruque. Ballisticstretchingis a techniquein which the subiect performsshort, bouncingmovementsat the end of the availablerange.Although somepeopleattempt to sffetch in this manner, ballistic stretchingis not generally used or recommended,becauseit may increasetissue tightness by activating the sketch reflex.5/
Motion The formation of conffactures is a time-related processthat may be inhibiredby motion.3sMotjon can inhibit contractureformation by physically disrupting the adhesions between gross structures and/or by limiting intermolecular cross-linking. Active or passive motion also stretches tissues, promotes *reir lubrication, and may also alter their metabolic activiqy,s4Becauseactive ROM may be
125
contraindicatedduring early stagesof healing,particularly when contractile tissue is damaged,passive motion may be usedto limit conEactureformation at this stage.For example,continuouspassivemotion (CPM) can be used to prevent motion loss after joint trauma or surgery.In addition to inhibiting the formation of contractures and adhesions, CPM has been shown to acceleratehealing, improve the orientation of collagen fibers, and inhibit edema formation.5s-61
Surgery Although the noninvasiveapproachesof stretching and motion frequently resolve or prevent motion restrictions,in some casesthese approachesare not effective and surgery may be required to optimize motion. Surgery will be necessaryif motion is restrictedby a mechanicalblock, particularly if the mechanicalblock is bony. In such cases,the surgical procedureremovessome or all of the tissueblocking motion. Surgerymay also be required'if stretching techniquescannotlengthena contractuleadequately due or if the functionallengthofa tendonis decreased procedures to hypertoniciqy.For example,Z-plasry arefrequentlyperformedto lengthentheAchillestendon in children with limited dorsiflexioncausedby congenitalplantar flexion contracturesor by hypertonicity of the plantarflexor muscles.Z-plasty is generally preformedwhen it canbe expectedto permit a more functional sait than is achievedwith noninvasive techniques alone.9 Surgical procedures to increase ROM are also frequently performed in adults. For example, surgical releasemay be performed to restoremotion limited by a Dupuytren's contracture,and tenotomy may be performedwhen tendonlengthlimits motion. Surgerymayalsobe performed to releaseadhesionsand lengthenscarsthat have formed after prolonged immobilization. Ior example, patients with extensivebums who have received limited medical intewention frequently develop contractures that cannot be stretched sufficiendy to allow fuIl function and therefore require surgicalrelease.Surgeryis more commonly requiredto releaseadhesionsthat form after injury if by prolongedinflammationor scarringis exaggerated infection.
126
5 . Motiott Restrictiotts
OFPHYSICAL AGENTS INTHE THEROLE TREATMENT OFMOTION RESTBICTIONS Although physical agents alone are generally not sufficient to revelse or prevent motion restdctions, they may be used as adjuncts to the treatment of such impairments. Physical agents combined with other appropriate treatment can enhance the functional recovery associatedwith regaining normal motion. Physicalagents are generally used as componentsof the treatment of motion restrictions becausethey can increasesoft tissueextensibility, control inflammation, contuolpain, and facilitate moUon.
Extensibility Increase SoftTissue Physicalagentsthat increasetissuetemperaturemay be used as componentsof the treatment of motion resftictionbecausethey canincreasesofttissueextensibiliry thereby decreasingthe force required to increasetissuelengthand decreasingthe risk of injury during the stretching procedure.62'64 Applying physical agentsto soft tissuebefore prolongedstretching can alter the viscoelasticityof the fibers, allowing 66 To achievethe plastic deFormationto occur.65 maximum benefit from the use of physical agents that increase soft tissue extensibility, agents that increasesuperficialtissuetemperature,such as those describedin Chanter6. shouldbe usedbeforestretching superficialtiisues, whereas agentsthat increase deep tissue temperature, such as ultrasound and diathermy,shouldbe usedbeforestretchingdeepsoft tissues.
Control lnflammation andAdhesion Formation A numberof physicalagents,panicularlycryotherapy and certain types of electricalcurrents,are thought
to control inflammation and its associatedsigns Controlling and symptoms after tissue injury.6z,6e inflammation may help to prevent the development of motion restrictions by limiting the formation of edema during the acute inflammatory stage and thereby limiting the degreeof immobilization. Controlling the severity and duration of inflammation alsolimits the durationand extentof the proliferative responseand may thus limit the formation of adhesionsduring tissuehealing.
PainDuring Stretching Control Many physical agents, including thermotherapy, cryotherapy,and electricalcurrents,can help to control pain. This effect may assistin the treatment of motion restrictionsbecause,if pain is well controlled, tissuesmay be stretchedfor a longer period, which may increasetissuelength more effectively.If pain is controlled,motion may also be initiated soonerafter inlury limiting the lossof motion causedby immobi lization.
Motion Facilitate Somephysicalagentsfacilitatemotion and thus assist in tlle treatment of motion restrictions. Electrical stimulation of the motor nervesof imervated muscles or direct electrical stimulation of denervated muscle can make muscles contract, These muscle contractionsmay complementmotion producedby normal physiological contractionsor substitute for such conffactionsif the subject does not or cannot move independently. Water may also facilitate motion since it provides buoyancy to an immersed body to assistwith motion againstgravity.The buoyancy of water may prove particularly beneficialin assisting patients with active ROM restrictions causedby contractiletissueweakness.
127
Ote . PATHOLOGY AND PATIENT PROBLEMS
) Clinical Case Studies I The following casestudiessummadzethe concePtsot motion restrictionsdiscussedin this chapter.Basedon the scenariopresented,an evaluation of the clinical findingsand goalsof treatmentareproposed.Theseare followed by a discussionof the factorsto be considered in treatmentselection.
Case 4 TR is a 45-year-oldmale who has been referred to physicaltherapywith a diagnosisof a right L5, Sl iadiculopathy. He complains of constant mild to moderatelysevereright low back pain that radiatesto his right buttock and lateral thigh after sitting for more than 20 minutes and that is relievedto some degreeby walking or lying down. He rcPortsno numbness,tingling, or weaknessof the lower extremities.The pain staltedabout 6weeks ago,the moming afterTR spenta day stackingfirewood, at which time he woke up with severelow backand rightlower extremitypain down to his lateral calf. He also had difficulty standing up sffaight.He has had similar problemsin the past;however,they have always ful1yresolvedafter a couple of daysofbed restand a few aspirins.TRfirct saw his doctor regardinghis presentproblem 5 weeks ago, and at that time he was prescribeda nonsteroidalantiinflammatory drug and a muscle relaxant and was told to take it easy.His symptoms improved to their current level over t}le following 2 weeks but have not changedsince that time. He hasalsonot beenable to retum to his job as a telephoneinstallersincethe onset of symptoms 6 weeks ago. An MN scan last week showed a mild posterol;teral disc bulge at L5-S1 on the right. The patient has had no prior physical*rerapy for his back problem. The objectiveexam is siSoificanttor a 50o/. restrictionof lumbar active ROM in folward bending and right sidebending.both of which causeincreased right low back and lower extremity pain. Left side bendthe patient'spain.Passivestlaight leg raising decreases ing is 35% (on rhe right, limited by right lower extremity pain),and 60% (on the left, limited by hamstringtiShtness).Palpationrevealsstiffnessand tendemessto right unilateral posterior-anteriorPressureat L5-S1 and no notableareasof hypermobility.All other tests,including lower extremity sensatlon,strength,and reflexes,are witlin normal limits. OF THE CLINICALFINDINGS EVALUATION This patientpresentswith the impairmentsof restricted lumbarforward-bendingand right side-bendingmotion,
pain, restrictedlumbar nerveroot mobiliry on the right, is indicatedby the restrictedpassivestraightleg raising test, and bul8ing of the L5-S1disc,TheseimPairments have resultedin a iimitation of sitting toleranceand ao inability to retum to work. PREFERREDPRACTICEPAfiERN lmpaired Joint Mobility. Motor Function, Muscle Peiformance,Range of Motion, and Reflex Integrity AssociatedWith SpinalDisorders,(4F) PLAN OF CARE The anticipated goals of ueatment at this time are to reducepain and increasesitting tolennce sufhciendy for the patient to be able to retum to limited duty wo*. The long-term goals of treatment are to fully alleviate pain, recumlumbar rangeo[ morion to normal,increase passivestraight leg raising and sitting toleraoceto within normal limits, and have ttre patient retum to his full work dutles. ASSESSMENTREGAFDINGSELECTIONOF THE OPTIMAL TREATMENT The optimal treatment for this patient would separate the disc spacesand/or reduce disc protrusion, thus decreasingcompressionon the nerveroot and aliowing improved,pain free motion. Thereforethe interyention of ihoice at this time is Eaction.The approPdatetype of of treatmentare discussed tractionand the parameters in Chapter10.
Case2
MP is a 40-year-oldfemale diagnosedwith adhesive capsuLitisof the left shoulder Shereportsthat her shoulder first beganto hurt about 6 months a8owithout any apParent cause. Although *rc pain has almost comPletely resolvedsince that time, her shoulder has also gradually become more stiff, preventing her from reaching up to brush her hair and from reachingbehind herself to zip up her skirts. The obiective evaluation is significant for restrictedROM of the left shoulderasfollows:
Left
Active Range of Motion
Right
Flexion Abduction Hand behindback
100" 170' 80' 170' Leftsacroiliac Central thoracolumlolnt barjunction Continued
728
5 . Motiot
Restrictiotts
) Clinical Case Swdies-cont'd PassiveRange of Motion Intemal rotation Extemalrotation
Right 90' B0'
Left 50' 10'
Glenohumeralpassiveinferior and posterior glide are both restrictedon the left. MP has had no pdor trcatmPnr
F^r rhi< n'^hl.-
EVALUATION OF THE CLINICALFINDINGS This patient presentsimpairments of testrictedactive and passivemotion of her left shoulderin a capsular pattem, reducing her ability to perform activities of daily living, including grooming and dressing. This patient's signs and symptoms and their duration indicate that the problem has probably progressedto t}le remodelingstageof healing,with some possibility of chronicinflammation,MP doesnot report significant pain at this time. No tone abnormalitiesarenoted. This patient's signs and symptoms are consistent with the diagnosis of adhesive capsulitis, which occursmost often in the shoulder.30,69,70 The onset of this problem is frequendy reported to be insidious, although it may be associatedwith other pathology such as local trauma, tendiaitis,cerebrovascular accident,or swgery of tlre neck and tl\ohx.27,29'30'69 Predisposingfactors include female gender,history of diabetes,immobilizatioq and ageover40 yea$.29's0,71 PBEFERREDPRACTICEPATTERN Impaired Joint Mobility, Moror Functioq Muscle Performance,and Range of Motion AssociatedWith ConnectiveTissueDysfunction,(4D) PLAN OF CARE The anticipated goals of treatment at dris time are to restore normal active and passive motion of the
I
left shoulder and to give MP the abiliry to perform all activities of daily living in t}le manner she used previously, using both upper extremities. Since her shoulderROM is probably restrictedby soft tissue shortening, interyention should be dilected at increasing dre extensibility and length of the shortened tissues, particularly the anterior inferior capsule of the glenohumeral joint. Other appropriate goals for this late stage of healing are to control scar tissue formation and to ensure adequate circulation. Although no strength abnormalities were noted on this initial evaluation, the patient's strength should be reevaluatedas she regains ROM since she may have strengtJrdeficits at these end rangesdue to disuse. Should strength deficits become appareng an additional goal of treaftnent would be to restore normal streneth to the left shoulder muscles. ASSESSMENTREGARDINGSELECTIONOF THE OPTIMAL TREATMENT Although there is disagreement conceming the optimal intervention for adhesivecapsulitis,it has been suggestedthat treatments that increasethe extensibfity and length of the restricted soft tissues around the glenohum€ral ioint and decreaselocal inflammation facfitate the resolution of this problem.3072,73 As is explained in greater detail in Section 2 of this book, a number of physical agene that provide localized deep heating may increase the extensibfity of the tissues, whereas other physical agents, such as ice or low-dose ultrasound, may facilitate resolution of the inflammation. Thermottrerapy could be used in conjunction with stretching and raoge-of-motion activities to lengthen the shortenedtissues.Joint mobfization and later strengthenlng may also be necessaryto regain full function of the should€r.
PrefenedPhysicalTherapistPatlemssMl4D and 4F]arecopyright2002AmericanPhysicaltherapyAssociation.A.llrightsreserued.
CHAPTER REVIEW The musculoskeletaland neural structures of the body are normally abie to move. Active movement occurs when muscles contract, and passivemovement occurswhen the body is actedon by an outside force.Physiologicaljoint motion is the motion of one segmentof the body relativeto another,while accessory motion is the motion that occursbetween the joint surfacesduring normal physiologicalmotion.
The amountof motion normally availabledependson the joint being consideredand may also vary wi& the subject'sage, sex, and health status; howeveq motion may be restrictedby a variety of pathologies including contractures,edema,adhesions,mechanical blocks,spinaldisc herniation,adverseneural teosiorq and weakness.Motion will be restrictedin a capsularpattern if the capsulesuffoundinga joint is affectedand otherwisecan be restrictedin a noncap
Ow c PATHOLOGY AND PATIENTPROBLEMS
129
13. SullivanMS, Dickinsin CE,Troup JD: The influenceof ageand genderon lumbar spinesagittalplanerangeof motion, Spine19682-686, 1994. 14. HolmesA, Wang C, Han ZH et al:The rangeandnature of flexion-extension motion in the cervical spine, Spine t9:2505-2510 , 7994. 15. Kublman KA: Cervicalrangeof motion in the elderly, AtchPhysMed Rehabil74:107t-1079, 1993. 16. EinkaufDK, GohdesMl, JensenCM et al: Changesio spinal mobility with increasingage in women, Plys Ther67:370-375, 1987. 17. Lind B, SihlbomH, Nordwall A et aL Normal rangeof motion of the cervical spine,Arch PhysMed Rehabil 70:692-695 , 1989. 18. DesrosiersJ, Hebert R, Bravo, et al: Shoulderrangeof motion of healthy elderly people: a nomative study, t995. PhysOccuVThetCetiatr73:101-11,4, Brown IM, Downed PA, 19. Iiebert J: Active shoulder References range of motion in personsaged 60 years and older, Foundations and Exercise: L KisnerC, ColbyLA: Therapeutic PhysOc.cup TherCeriatrt3:L15-128,1995. ed3,Phrladelphia, 1996,IA Davis. Tethni4ues, 20. Kessler RM, Hertling D: Managemeutof Commoa of muscleto othersofttisGS:Comparison 2. Cummings Disorders,PhysicalTheraVyPrillci7lesand Musculoskeletal suein limiting elbowextension, J OnhoySponsPhys Philadelphia, 1983,Harper & Row. Methods, 4, 1984 . 5(4):170-1,7 Ther 21. Kaltenborn FM: Mobllizatiax of the Extrenity Joints: 3. SofbergJO: The stiff elbow,Acta OnhoVScand67: ed 3, Oslo, Techni4ues, and BasicTreatmext Examination 626-631 , 1996. .1.CooperJE, Norwat 1980,Olaf Norlis Bokhandel. ShwedykE,QuanburyAOetal:Elbowjoint restriction:Effecton upperlimb motion duringper- 22. Maidand GD VenebtalManipulation,ed 5, London, 1986,Butterworths. formanceof three feeding acivities, Arch PhysMed 23. SaundersHD, SaundersR: Evaluation,Treatmettaad Rehabil7 4:805-809 , 1993. Disoders: Spine, ed 3, Pteventionof Musculoskeletal J. BadteyEM, WagstaffS, Wood ?H: Measuresof Saunders Group. MN, 1995, (disability) Chaska, arthritis in relation to in functionalability Phlladelphia, Dis 43:563-569, 24. Cuyton AC: TextboobofMedicalPhysiology, of jointmotion,AnnRheum impairment 1981,WB Saunders. 1984. PG,Engelke KA:Effectsof exercise 25. Cyri,ax J: Textbook of OnhoVaedicMedictue, ed 6, 6. Godges JJ,MacRae Baltimore,1975,Williams & Wilkrns. and on hip rangeof motion,trunt muscleperformance NeviaserJf:The ftozenshoulder:Diagnosis 26. NeviaserRJ, . 7 3:468-477 1993 gaiteconomy, PhysThet , andmanagement,C/lnOnhoV223:59'64,1987. of the 7. Nordin M, Irankel YH Basic Blomechaxics System,ed 2, Philadelphia,1989, 27. Andrews AW, Bohannon RW: Decreasedshoulder Musculosbeletal rangeof motion on pareticside aker stroke,PhysThel Lea& Febiger. 66:768-772, 7989. 8. American Academy of OrthopaedicSurgeons:Joint Edinburgh, 28. fuzk TE, Pinals RS: Irozen shoulder, Senin Athtitis Motiox:Methodsof MeasurixgandRecordittg 1982. Rheun11:440-452, 1965,ChurchillLivingstone. Scodand, 29. Bunker TD, Anthony ?P: The pathology of frozen 9 . ShinaburgerNI: Limited ioint mobility in adults with shoulder:a Dupuytrenlike disease,/BoreJoitttSurgBr diabetesmellitus,P, ys Ther67:2L5-218,1987. 77:677-683, 1995. Dudgeon BJ: Shoulder limitation AK, Sheny DD, 1 0 .Libby in juvenilerheumatoidarthritis,Atch PhysMed Rehabil 30. ParkerRD, Iroimson AJ, Winsberg DD et al: Irozen clinicalpicshoulder Part 1: chronology,pathogenesis, 72:382-384,1991,. nhopedics 1.2:869-873 ture, andtreatment,O , 7989. 11. RoachKI, Miles TP: Normal hip and knee activerange a review oflitersyndrome: N: Frozen shoulder 31. Grubbs Thet 7\: o[ rnotion: ttre relationship to age, Phys ature,JOfthol SlrottsPhysThert8:479-487 ,1993. 656-665, 1,99t. 32. AlesonWH, Amiel D, Woo SL-YImmobiliry effectson 12. Iilbert I, Iuhri JR,New MD: Elbow, forearm,and wrist synovial joints, the pathomechanicsof joint conftacpassiverangeof motion in personsagedsixry and older, -32 1795-Irc,1980 ture,Biorheology PhysOuup ThetCetiatr10:17 , 1992.
:Jlar pattern.Vadoustestsandmeasuresmay be used = determine the degreeof motion restdctioq the =sue involved, and the nature of the pathology :cntributing to a motion restdction.Motion restric:ons may be treated conservativelyby stretching :-rd morion or, in somecases.may requireinvasive :urgery Physical agents may seffe as adjuncts to :rese interventionsby increasingsoft tissueextensiiility beforestretching,controllinginflammationand -dhesionformation during tissuehealing,controlling :ain during stretchingor motion, or causingor assistrg with motion. The readeris referredto the Evoive -.vebsiteat http://evolve.elsevier.com/Cameron for :rudy questionspertinentto this chapter.
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5 . Motioft Restictioas
33. Salter RB: Textbaoleof Disorders and lnjuies of the Musculoskeletal System,ed.2,BaIamore,1983,Williams &wilkins. 34. Iranl C, AkesonWH, Woo SL-t et al: Physiologyand therapeuticvalue of passivejoint motion, Clin OnhoV 185113-125,1984. 35. Woo SL,Matthews JV,Akeson WH et al: Connective tissueresponseto immobiliry. Correlativestudy ofbiomechanicaland biochemicalmeasurementsof normal and immobilized rabbit knees, Anhitis Rheum 18: 257-264,1975. 36. Akeson WH, Amiel D, Abel MF et al: Effects of immobilization on joints, Clin Onhap 219:28-37, 1987. 37. Dorlaxds lllustatedMedicalDictioxary,ed 29, Philadelphia, 2000,WB Saunders. 38. EnnekingWI: The intraarticulareffectsof immobilization on the human knee,/ Boneloint Surg 54A:973,
52. Taylor DC, Dalton JD, SeaberAV et al: Viscoelastic propertiesofmuscle-tendonunits:the biomechanicsof stretching,AmJ SponsMed 18:300, 1900. 53. Fung YC: Biomechanics:Mechanical Properties of Living Tissues, ed 2. New York: Springer-Verlag 7993. 54. McClure PW, Blackbum LG, Dusold C: The use spLintsin the treatmentof stiffness:biologic rationale and an algorithm for making clinical decisions, Plys Ther74:1101-1 107.1994. 55. Norkin CC, Levatgie PK:Joint Structurcand Fuftctiott: Comprehexsive Analysis, ed 2, Philadelptta, 1990, Davis. 56. Voss Dt, ionra MK. Myers Neuromuscular Faciliation,ed 3, Philadelphia, Harper& Row 57. LamontagneA, Maloun F, fuchards CL: behavior of piantar flexor musde-tendonunit at r972. J OtthopSportsPhysTher26:244-252 , 1997. 39. SlaterH, Buder DS: The dynamic centralnervoussysSalterRB, SimrnondsDF,Malcolm BW et al: The ter:e.ln Cieve'sModetnMaxual ed,2,New York, 1994, logicaleffectofcontinuouspassivemotion on the /-L..--L:lr I :..:----^^ !L'ur!r,,! !rvuB urrc. ing of fulI thicknessdefectsin anicular cartilage: 40. Oliver J, Middle drtchA: Functional Anatomyof theSyine, experimentalinvestigatton in dtenbbit,J BoneI oiat London,1991,Butterworth-Heinemann. 62A:1232-1251, 1980. 4L. ButIerDS: Mobilizatiottof theNenous Systen,Edirtbvgh, 59. SalterRB, Bell RS,KeeleyIW: The protecriveeffect 1991,ChurchillLivingstone. continuous passivemotion on living anicular cartilage -fomberlin 42. acute septicarthritis: an experimentalinvestigation JP,SaundersHD: Evaluatiox, Tteatuext and Preventioxof MusculosbeletalDisorders:Ettremities,ed 3, rhe abbit, Clix Onhoy 159:223-247,198\. Chaska,MN, 1994,SaundersGroup. 60. FrankC, AkesonW, Woo S et al: Physiologyand 43. Creenman PE: PrinciVtesof Manual Medicine, ed,2, peutic value of passive joint motion, C/,, BalcJmore, 1996,Williams& Wilkins. 185t113-125, 1984. 44. Norkin CC, White DJ: Measurement of Joint 61. Covey MH, DutcherK MaryinJA etal: Efficacyof Motiot: A Cuide to Coaiometry, Philadelphia,1985,FA tinuous passive motion (CPM) devices with Davis. -400,I9BB. bws, J Burx CareRehabil9:397 45. Kendali Fl McCreary EK: Muscles:Testingaxd Futction, 62. LentellC, HetheringtonT, EaganJet al: The useof ed 3, Baltimore,1983,Williams & Wilkins. mal agentsto influencethe effectivenessof low 46. Daniels L, Worthrngham C: Muscle TestingTechaiques prolonged stretch, J Onhop Spon Phys Ther 1 of Manual Examixation,ed 4, Philadelphia, 1980, WB 200-207 ,1992. Saunders. 63. WarrenC, LehmarrnJ,KoblanskiJ:Elongationofrat 47. ClarksonHM, Cllewich CB:Musculosbeletal Assessmeat: tendon: effect of load and temperawre, Arch Phys Joixt Range of Motion aud Manual Muscle Streagth, Rehabil52:465-474, 484, 1971. Baltimore,1989,Williams & Wilkns. 64. WarrenC. Lehmam J, KoblanskiJ: Heacand 48. fuddle DL: Measurement of accessory motion: procedures:an evaluationusing rat tail tendon, cdtical issues and related concepts, Phys Ther 72: PhysMed Rehabil57:122-126 , 1976. 865-874, 1992. 65. CerstenJW: Effectof ultrasoundon tendon 49. .N4intsN, Dvir Z: Wrist complex mobility: a study of 1tr7, AnJ PhysMetl 34:362-369 , 1955. passive flexion and extension and accessorymove66. LehmannJ, MasockA, Warren C et al: Effect of ments, PhysiotherCaxada 40:282-285, t9BB. peutic temperatureson tendon extensibiliryArcl 50. Binlley J, StratfordPW, Cill C: Interraterreliability o[ A4edRehabil51:481-487 , 1970. lumbar accessorymotion mobility testrrLg, Phys Thet 67. Hocutt JE,Jaffe\ Rlplander CR: Cryotherapyin 75:786-795,1995. spratns.An J Syon: Med l0:3 | 6-319, 1982. 51. Bonutti PM, Windau JE: Static progressivestretch ro 68. Cote DJ, ?renticeWI, Hooker DN et al: reestabLishelbow range of motioq Clh OnhoV of three treatment proceduresfor minimizing 303:128-134,1994. sprainswelling,PftysTher68(7):1072-107 6, 1988.
Ore o PATHOLOGY AND PATIENT PROBLEMS
69. Patten C, Hillel AD: The 11th newe syndrome, Arch Onlaryngol Head Nec* Sutg 1!9:215-220, f993. 70. Emig EW, Schweitzer M!, Karasic D et al: Adheiive capsulitis ofthe shoulder: MR diagnosis,AmJ Roextgenol 164(Q:1457-1459,f995. 71. Kozin I: Two uniqueshoulders:adhesivecapsulitisand sympathetic dystrophy syndrome of r'j:otion, Postgrad Med73:207-216,1983.
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72. Rizk TE, Morris L, Gavant MI: Treatment of adhesive capsulitis(frozenshoulder)witharthrographiccapsular distension and rupture, Arch Phys Med Rehabil75: 803-807,7994. 73. RizkTE, PinalsRS,TalaiverASrCorticosteroid injections in adhesive capsulitis: investigation of their value and 1991. site,ArchPhysMed RehabilT2:20-22'
ThePhysicalAgents
ThermalAgents: ld andHeat SUMMARY
OF INFORMATIOIl
Physical Principles of Thermal Energy SpecificHeat -Vodesof Heat Transfer Cold-Cryotherapy Effectsof Cold Usesof Cryotherapy Contraindicationsand Precautionsfor Cryotherapy AdverseEffectsof Cryotherapy Application Techniques Clinical CaseStudies Heat-Thermotherapy EffectsofHeat
COVERED
Usesof SuperficialHeat Contraindicationsand Precautionsfor Thermotherapy AdverseEffectsof Thermotherapy Application Techniques Other Means of Applying Thermotherapy Clinical CaseStudies Choosing Between Cryotherapy and Thermotherapy Chapter Review
OBJECTIVES IJVonampletion of this chaytet,the readerwill beabk to: 1 . Identi$r the physicalpropertiesof and the physiologicalresponsesto, thermal agents. 2 . Analyze the physiologicalresponsesto thermal agentsnecessaryto promote particular treatment goals. 3 . Assessthe indications, contraindications,and precautionsfor the use of thermal agentswith respectto different patient management situations. ,| Evaluatedifferent gzpesof thermal agents with respectto their potential to produce
desiredphysical and physiological effects. 5 . Chooseand use the most apPropriatethermal agent to obtain desiredtreatment goals. 6 . Presentedwith a clinical case,evaluatethe clinical findings, proposegoalsof treatment, assesswhether a superficialthermal agent would be the best treatment, and, if so, formulate an effectivetreatment plan, including the most appropriatethermal agent,for achievingthe goalsof treatment.
133
134
6 c Thermal Aeents: Cold atd Heat
This chapter discussesthe basic physical principles and physiologicaleffects of transfering heat to or ftom patients by using thermal agents.The clinical applicationsof cold and superficialheatingagentsare also addressed.Superficialheating agentsare those that primarily increasethe temperatureof the skin andsuperficialsubcutaneous tissues.In contrast,deep heating agents also increase the temperature of deepertissues,includinglargemusclesand periarticular structures,and generallyreachto a depth of about 5 cm. The clinicalapplicationsof deep-heatingagents are not coveredin this chapter but are discussedin Chapters7 ard 1.2. The therapeutic application of themal agents resultsin the transferof heat to or ftom a patient's
body and bewveenthe variouscomponenttissuesand fluids ofthe body.Heattransfermay occurby conduction. convection,conversion,radiation, or evaporation. Heatingagentstransferheatto the body,whereas cooling agents transfer heat away ftom the body. Thermoregulationby the body also uses the above processesto maintain core body temperatureand to maintainequilibriumbetvyeenintemalmetabolicheat production and heat loss or gain at the skin surface. The following section of this chapter discussesthe physicalprinciplesofheat transferto or ftom the body and wittrin *re body. This sectionis followed by discussionsof the physiologicaleffects of cooling and heating and directionsfor the clinical applicationof superficialcoolingandheatingmodalities.
PHYSICAL PRINCIPLES OFTHERMAL ENERGY HEAT SPECIFIC Specificheat is the amount of energyrequiredto raise the temperatureof a given weight of a material by a given number of degrees.Different materialsusedas thermalagentsand differentbody tissueshave different specificheats (lable 6-1). For example,skin has higher specificheat than fat or bone,and water has a higher specificheat than air. Materials with a high specificheat requiremore energyto achievethe same temperatureincreasethan materialswith a low specilic heat.Materialswith a high specificheat alsohold more energythan materialswith a low specificheat when both are at the same temperature.Thermal agentswith a high specificheat, such as watet are therefore applied at lower temperaturesthan airbasedthermalagents,suchaslluidotherapy,to transfer the sameamount ofheat to a patient.The specific
p
e-t Sp."nc Heat of Various Materials Material
Water Averagefor human body Skin Muscle Iat Bone
Specificheat in /g/'C
4.19 1.01 3.56 3.77 3.75 2.30 1,.59
heat of a materialis generallyexpressedin joulesper gramper degreesCelsius.
MODES TRANSFEF OFHEAT Different physical agentstransfer heat by different modes.Theseincludeconducrion.convection.conversion, radiation, and evaporation,as discussedin detailin the following sections.
Conduction: HeatTransfer byDirect Contact SuchasHotPacks andColdPacks Heating by conduction is the result of energy exchangeby directcollisionbetweenthemoleculesof tlvo materialsat different temperatures.Heat is conductedfrom the materialat the highertemperatureto the material at the lower temperatureas the faster moving molecules in the warmer material collide with the moleculesin the cooler material and cause them to accelerate.Heat transfercontinuesuntil the temperatureand the speedof molecularmovementof both materials become equal. Heat may be transfered to or from a patientby conduction.If the physical agent used has a higher temperaturethan the patient'sskin, for example,a hot pack or warm paraffin, heat will be transferred ftom the agent to the patient,and the temperatureof the superficialtissues in contactwith the heatingagentwill rise.If the physical agent used is colder than the patient's skir5 for
Tgo . THE PITYSICAL ACENTS
:xample,anice pack,heatwill be transferredftom the :atient to the agent,andthe temperatureofthe super-cial tissuesin contactwith the coolingagentwill fall. Heat can also be transferredfrom one areaof the :ody to another by conduction.Ior example,when :ne areaof the body is heatedby an extemalthermal :gent,the tissuesadjacentto and in contactwith that :rea_will increasein temperaturedue to heating by :cnoucuon. Heat transferby conductionoccursonly between raterials of different temperaturesthat are in direct :cntact with eachother.lf there is any air berweena :cnductivethermal agentand the patient, the heat is :rst conductedfrom the thermal asent to the air and =en ftom the air to the patient. Rateot heattransferbyconduction -he rate at which heat is transferredby conduction :erween tvvo matedalsdependson the temperature :ifferencebetween the materials,their thermal con' iuctivity, and *reir areaof contact,and is expressed :y *re following formula. areaofcontactx thermalconductivityx remn."t"'"
iate of a-ea! :ansfer
li Ff"'"-."
tissuethickness
The thermal conductivity of a material describes -,\erateatwhich it transfersheat by conductionandis expressed x'C/cm) ffable in (callsec)/(cm2 .eneralJy 5-2).Note that this is not the sameasa material'sspe:ific heat. A number of guidelinescan be derived from the precedineformula.
p"
Thermal Conductivity of Various Materials
Material
Silver A.lumrnum Ice Waterat 20 "C Bone Muscle Fat Airat0'C
Thermal conductiviw (caVsec),1(cm2 x 'Clcrir)
1.01 0.50 0.005 0.0014 0.0011 0.0011 0.000s 0.000057
135
for heatlransferbyconduclion Guidelines 1. The greaterthe temperaturedifferencebetweena heating or cooling agent and the body part it is applied to, the faster the rate of heat transfer.For example,the higher the temperatureof a hot pack, the more rapidly the temperatureof the area of the patient's skin in contact with the hot pack will increase.Generally,the temperaturesof conductive physicalagentsare selectedto achievea fast but safe rateoftemperaturechange.Ifa heatingagentisonly a few degreeswarmer than the patient, heating will take too long; by contrast,if the temperaturedifference is large, heat transfer could be so rapid as to quickly burn the patient. 2. Materialswith high thermal conductivitytransfer heat more rapidly than those with low thermal conductivity.Metals have high thermal conductivity, whereas water has moderate thermal conductivity and air haslow thermalconductivity. Heating and cooling agents are generally composedof materialswith moderatethermal conductivitv to orovide a safeand effectiverate of heat transfer Materialswith low thermal conductivity canbe used as insulators to limit the rate of heat transfer For example,some types of hot packs are kept hot by soakingin and absorbingwater that is kept at approx'C 'F). (125 imately 70 The high temperature,high specificheat, and moderatethermal conductivity of the water allow efficientheattransfer:however.ifthe pack is applieddirecdy to a patient'sskin, the patient will probably soon feel uncomfortablyhot and could easilybe burned.Thereforetowels or terrycloth hot pack coversthat trap ai5 which has low thermal conductivity, areplacedbetweenthe packand the patient to limit the rate ofheat transfer.In general,six to eight layersof toweling are placedbetr,veena hot pack and a patienq however, if the patient gets too hot, additional layersof toweling can be addedto further limit the rate of heat conduction. Note that newer towels and coversare generally thicker and thereforeact asmore effectiveinsulators than older ones.Sincesubcutaneous fat haslow thermal conductivity,it also actsas an insulator,limiting the conductionofheat to or ftom the de€pertissues. Because metal has high thermal conductivity, metal jewelry should be removedfrom any areathat will be in contactwith a conductivethermal agent.If metal jewelry is not removed,heat will rapidly transfer to the metal, with the potential to burn the skin that is in contac!with it.
135 136
ThermalAgeflts:CoMandHeat 6. ThetmalAgerrts:ColdandHeat
Becauseice has higher thermal conductivity than water evenat thanwater it causesmore iapid coolingthan water, ,^/ater, th"ttti"l conductivitiesof Th" thermal the he sametemperature.ihe jifferent commercially available cold packs vary, different some somebeinghigher than water or ice and othersbeing the brand or type of Theiefo"re,when changing lower. tower.Theiefore, -assume not issume that th; new cold :old pack used,one should n"ot tor the same manner.for rhesamemanner, packcanbe packcanbe appliedin the layersof samenumber numberof layers orr with with the same of rime. time, o a-ount amountof insulatingmaterialasthe old pack. 3. Thi larger the areaof iontact between a thermal agent and the patient, the greaterthe total heat transfer.Ior example,when a hot pack is appliedto up to patient is immersed immersedup when a patient entire back, back,or when the entire the the neck in a whirlpool or a Hubbard tank, the total amount ofheat transferredwill be greaterthan ifa hot the calf. pack is appliedonly to a smailarea-overlying ' 4. The'rcte o[ iemperaturerise decreaslsin propottionto tissuetiickness.When a thermalagentisin contact with a patient's skin, the skin temperature increasesthe most and deeper tissuesale proglessively lessaffected.The deeperthe tissue,the lessits t"-p"rutur" wili change.Thereforeconductivethermal agentsarewell-suiledto heatingor coolingsuperficial tissuesbut should not be usedwhen the goal is to changethe temperatureof deepertissues.
I an areaof the body and producesa local changein tis- | temperature,the circulationconstandymovesthe I suetemperatufe, Sue heatedblood out of the areaand moves coolerblood I into t[]e areato returnthe localtissuetemperatureto a I convectionreduces normal level.This local coolingby convectionreduces I local rhe localth€ impact of superficialheating agentson the the | the rate of increasesq" tissuetemperature.Vasodilationincr..u::t I rare,at,whichthe tissue circulation,increasingthe rare,at.which circulation. I vasodilaIhus. the vasodllanormal.r Thus, Ieturns returnsto normal. temperatule cemPerature I plotects the tistion that occursin responseto heat protects I burning' risk of burning the suesby reducing l
Energy I Type of rype oreners from One One Conversion from Conversioni conversion trii::5;**r'':5?:fifi:1T:ff ".;f,1"}"tr conversioni and and Diathefmy, Diathefmy, Ultfa'Ound Ultfa'Ound SUChaS aS tOAn.thef An.thef SUCh I Metabolism Metabo'ism *.r*lrul;":ili"T;ft:?il*1t;f;ji:: I Heattransfer Heat transferby conversioninvolvesthe conversionof I a nonthermalform of energy,suchasmechanical,elec- | trical, or chemical energy, into heat. Ior example, I ultrasound,which is a mechanicalform of energy,is I converted into heat when applied at a sutlicient I intensity to a tissue that absorbsultrasoundwaves. I Ultrasoundcausesvibration of moleculesin the tiszue, I which generatesfriction between the molecules,I resultingin an increasein tissuetemperature.When I diathermy, an elecffomagneticform of energy,,is I applied to the body, it causes rotation of polar I
ofa bycirculation HeatTransfer convection: such as Temperature Different of a Medium
the between in friction whichalsoresults molecules, I teto*"T: intissue tncrease ::1"::1"-:""d "" "t-:T: I
Heattransferby convectionoccurs contact betwe;n a circulatingmedium and another This is in contrastto materialofa differenttemperature. is constantconthele heatingby conduction,i[which tactbJwveena stationarythermalagentandthe patient. During heatingor .ooltg by coniection the thermal agentis in moiion, so new pirts of the agentat the initi"altreatmenttempetature'keep coming into contact with the patient'sbodypart.As i resulqhiat transferby convectiontransfersmore heat in the sameperiod of time than heat transferby conductionwhen the same matedal at the same initial temperatureis used.For example,immersionin a whirlpool will heata patient's skinmorerapidlvthanimmersionina bowl o[water of the sametempeiature,and the fasterthe water moves, the morerapii the rateofheat transferwill be. Blood ciiculatingin the body alsotransfersheat by local changesin tissuetemperaconvectionto redu-ce ture. For example,when a therial agentis appf;d to
I causingit to become cold. Thermal energy is con- | vertedinto chemicalenergyto drivethis reaction. I Unlike heatingby conduction_orconvection,heat- | ing by conversionis not affectedby the temperature I of the thermal agent.When transferringheat by con- | rate of heat transfer depends on the version, I _the power of the energysource.The power of ultrasound I and diathermy is usuallymeasuredin watts, which is I the amount of energyin joulesoutput per secondThe I amount of enelgy output .by a chemical reaction I depends on the reacting chemicalsand is usually I measuredin joules.Jhe rate of tissue temperature I increasealso dependson the size of the area being treated,the size of the applicator,efficiencyof transmission ftom.the apPlicatorto-the Patient,and the type of tissuebeingtreated.Different t'?es of tissues absorbdifferent forms of energyto different extents and thereforeheat differently'2
Fruidotherapy,wtrirtpoot,etooiiii.uiu-tl* fi""'"".H]tltrn',"'"::5:ll:ftrtfi," I a chemicalreactionthat extractsheat from the pack, asthe resultofdirect
TTT'oC THE PHYSICAL AGENTS
Heattransferby conversiondoesnot requiredirect -':rtact betvveenthe thermal agent and the body; - ,.wever,it doesrequire any interveningmaterial to :. a good transmitter of that type of energy.For ,:':ample,a transmissiongel, lotion, or water must be ,-.ed between an ultrasound transducer and the ::rient to transmit the ultrasoundbecauseai1 which :-:ght otherwise come between the transducerand -- e patient,transmitsultrasoundpoorly. Physicalagentsthat heat by conversionmay also -:ve other nonthermal physiological effects. Ior .:.:ample,although the mechanicalenergy of ultra.:und and the electricalenergyof diathermy canpro:'ice heat by conversior5they are also thought to :ve direct mechanicalor electricaleffectson tissue. .- ful1discussionof absorptionand the thermal and :nthermal effectsof ultrasoundand diathermy can : e foundin Chapters7 and,12, respect:ely.
ladiation: Exchange ofEnergy Directly without :n Intervening Medium SuchasInfrared Lamp -:--eating by radiation involves the direct transfer of :rergy from a materialwith a higher temperatureto ne with a lower temperaturewithout the needfor an rtervening medium or contact.This is in contrastto -eat transfer by conversion,in which the medium :rd the patientmay be at the sametemperature.It is .-so different from heat transfer by conduction or :cnvection,which both requirethe thermal agentto :e in contactwith the tissuebeingheated.The rate of :emperatureincreasecausedby radiationdependson
the intensity of the radiation, the relative sizes of the radiation source and the area being treated, the distance of the source from the treatment area, and the angleof rhe radiarionro the ti"sue.
Evaporation: Absorption ofEnergy astheResult ofConversion ofa Material froma Liquid toa Vapor StateSuchasVapocoolant Sprays Sweating A materialmust absorbenergyto evaporateand thus change form from a liquid to a gas or vapor. This energy is absorbedin the form of heat, either from the matedai itself or from an adjoining material, resultingin a decreasein temperature.For example, when a vapocoolantsprayis heatedby the warm skin of the body, it changesfrom its liquid form to a vapor at its specific evaporationtemperature.During this process,the spray absorbsheat and thus cools the skin. Another exampleis the evaporationof sweat, which alsoactsto cool the body. The temperatureof evaporationfor sweatis a few degreeshigherthan the normal skin temperature;therefore,if the skin temperatureincreasesfrom exerciseor an extemalsource and the humidity of the environmentis low enough, the sweatproducedin responseto the increasedtemperature will evaporate,reducing the local body temperature.If the ambient humidiry is high, evaporation will be impaired. Sweating is a homeostatic mechanismthat servesto cool the body when it is overheatedto help return body temperaturetoward ule nolmal lange.
COLD-CRYOTHERAPY Jryotherapy,the therapeuticuse of cold, has clinical ipplicationsboth in rehabilitationand other areasof nedicine. The primary useof cryotherapyoutsideof :ehabilitationis for the destructionof malisnant and ronmal'gnanttissuegrowths, for which very lo:emperaturesare used and the cooling is generally :pplied directly to the tissuebeingtreated.In rehabil:tation,miid cooling is usedto control inflammatior! cain, and edema; to reduce spasticity; to control :ymptoms of multiple sclerosis;and to facilitate movement (Iig. 6-1). This type of cryotherapy is a p p l i e dr o r h e s k i nb u t c a nd e c r e a st ei s s u et e m p e r a ture deepto the areaof application,includingintraariicular areas.r Cryotherapy exerts its therapeutic
737
Figure 6-1. Cryotherapyagents.
138
6 . Tlrcrnal Ageflts: Cold awl Heat
effectsby influencinghemodynamic,neuromuscular, and metabolic processes,the mechanismsof which areexplainedin derailin the Following secrions.
EFFECTS OFCOLD Hemodynamic effects Initial decrease in blood flow Later increase in blood flow Neuromuscular effects Decreased nerve conduction velocitv Increased pain threshold Altered msscle strength Decreased spasticity Facilitation of muscle contraction Metabolic effects Decreased metabolic rate
Figure 6-2. How cryotherapydecreases bloodflow
Hemodynamic Eflects
the circulatory rate by increasing blood viscosirytherebyincreasing the resistance to flow. It is thought that the body reducesblood flow in immediate constriction of the cutaneous vessels responseto a decreasein tissuetemperatureto proand a reductionin blood flow. This vasoconstric- tecrotherareasfrom excessive decreases in temperation persists as long as the duration of the cold ture and stabilize core body temperature.The less applicationis limited to lessthan 15 to 20 minutes.a blood that flows through an area being cooled,the Studiesshow that repeatingice application after an smaller*re amount of blood that is cooledand thus initial 20-minute application for 2 repetitions of *re less other areas in the circulatory system are 10 minutes off and 10 minutes on lowers blood affected. Reducing circulation results in a greater flow significantly more than a single 20-minute ice decreasein the temperatureof the area to which a application.'The vasoconstrictionand reduction coolingagentis appliedbecausewarmer blood is not in blood flow producedby cryotherapyis most beingbroughtinto the areato raiseits temperatureby pronouncedin the areawhere the cold is applied convection,and lessof a decreasein temperaturein because this is where the rissue temperature otherareasof the body becauselittle of the cold blood decrease 1sgreatest. is circulatedto theseareas. Cold causescutaneousvasocorstrictionby both directand indirectmechanisms(Fig.6-2).Activationof Laterincreasein bloodtlow the cutaneouscold receptorsby colddirecdystimulates The immediatevasoconstrictionresponseto cold is a the smoodrmusclesof the blood vesselwalls to conconsistentand well-documentedphenomenonlhowtract.Coolingof the tissuealsodecreases the production ever,when cold is appliedfor longer periodsof time andreleaseof vasodilatormediators,suchashistamine or when the tissue temperature reachesless than and prostaglandins, resultingin reducedvasodilation. 10 'C (50 'F),vasodilationmay occur.This phenomeDecreasingthe tissuetemperaturealso causesa reflex non is known as cold-inducedyasodilation(CIVD) and activationof sympatheticadrenergrc neurons,resulting was first reported by Lewis in 1930.7His findings in cutaneousvasoconsftictionbo*r in the areathat is were replicatedin a number of later studies;810howcooledand,to a lesserextent,in areasdistantfrom the ever,vasodilationhas not beenfound to be a consissiteof coid application.6 Cold is alsothought to reduce tent responseto prolongedcold application.4,11
Initialdecrease inbloodflow Generally, if coldis appliedto the skin,it causes an
Two c THE PIIYSICAL ACEATS
Lewis reported that when an individual's fingers z-ereimmersedin an ice bath, their temperatureinihowever,after 15minutes,theirtem=lly decreased; -rature cyclicallyincreasedand decreased(Iig. 6-3). :avis cofielatedthis temperaturecycling with alter-dng vasoconstrictionand vasodilation and called It is proposedthat the huntis rhe huntingrespozse. rg responseis mediatedby an axonreflexin response = the pain of prolongedcold or very low tempera::res, or that it is causedby inhibition of contraction :i the smooth musclesof the blood vesselwalls by .{reme cold.12Maintained vasodilation, without --.'cling,has also been observedwith cooling human :orearmsat 1 "C (35"D for 15minutes.u Cold-inducedvasodilationis most likely to occur = the distal extremities,such as the fingers or toes, -arthaoolicationsof cold for more than 15 minutesat 'C. Although the amount of =-p"iutur"r below 1 rasodilation is usually small, in clinical situations :,,-here vasodilationshould be avoided,it is generally =commended that cold applicationbe limited to 15 srnutes or less,particularlywhen treating the distal r*remities. When vasodilationis the intendedgoalof :eatment, cryotherapy is also not recommended ':ecause it doesnot consistendyhavethis effect. Although the increasein skin rednessseenwith the :cplicationof coldmay appeartobea signof CIVD, it is :.-tually thought to be primarily the result of an increase = the oxyhemoglobin concentrationof the blood due
139
to the decreasein oxygen-hemoglobindissociation that occursat lower temperaturesl31Fig.6-4). Since cooling decreasesoxygen-hemoglobindissocialion, making less oxygen available to the tissues, coldto bean effective inducedvasodilationis not considered oxygendeliveryto an area. meansof increasing
Effects Neuromuscular Cold has a variety of effectson neuromuscularfunction, including decreasingnerve conduction velocity, elevating the pain threshold, altering muscle force generatior5decreasingspasticity,and facilitating muscle contraction. velocity oecreased neruec0nduction nerveconducWhen nervetemperatureis decreased, tion velociry decreasesin proportion to the degree and duration of the temperaturechange.laDecreased newe conduction velocity has been documentedin responseto the application of a superficialcooling agent to the skin for 5 minutes or longer.lc The decreasein nerve conduction velocity that occurs with 5 minutes of cooling fully reverseswithin 15 minutes in individuals with normal circulation. However,after 20 minutes of cooling,nerve conductionvelocitymay take30 minutesorlonger to recover dueto the greaterreductionin temperaturecausedby the longerdurationof cooling.l6
o
z
100
Lll
f
o
IE t!
56 zF
= H10 z
x<
Y o
E !,1
z ii0
Figure6-3. Hunting response,cold-induced vasodilation cf finger imrnersed in ice water, measuredby skin temoeraturechange.(Irom Lewis T: Observationsupon *re ieactionsof the vesselsof the human skjn to co\d,Hean 15177-208, I93Q.\
E{* 7Al =.t !J
f 0
Figure6-4. Effect of temperature on oxygen-hemoglobin dissociation curve- (Irom Barcrott J, King W: The effect of temperature on the dissociation curve of blood, J Physiol39.374-384, 1909.)
t40
6 o Thetmal Asents: Cold ard Heat
Cold can decreasethe conduction velocity of tion, thus conffolling post-injury edemaformation.19 both sensoryand motor nerves.It has the greatest Reducingedemacan aileviatepain that resultsfrom effect on conduction by myelinated and small compressionof nerves or other pressure-sensitive fibers and the leasteffect on conductionbv unmvelistructules. nated and large fibers.l6A-delta fibers,whicfr are small-diameter,myelinated,pain-transmittingfibers, Alteredmusclestrength demonstrate the greatest decreasein conduction Dependingon the durationof treatmentand the timvelociqyin responseto cooling.Reversibletotal nerue ing of measurement,cryotherapyhasbeenassociated conductionblock can also occurwith the aoplication with both increasesand decreases inmuscle strensdl of iceoversuperficially locaredma;ornervebranches ]sometricmusclestrensthhas beenfound to suchas *re peronealnerve at the lateralaspectof the direcdyafter the applicationof ice massagefor 5 mi Knee." utes or less;however the duration of this effect nor beendocumented.To The proposed painthreshold Increased for this response to brief coolinginclude The application of cryotherapy can increase the of motor nerve excitability and an increased pain thresholdand decrease the sensationof pain.The logicalmotivationto perform.In conrast,after proposed mechanisms for these effects include ing for 30 minutes or longer, isometric counter-iritation via the gate controlmechanismand strengthhas beenfound to decreaseinitially and the reductionof musclespasm,sensorynewe conduc- to increasean hour later, to reach greaterthan tionvelocity, or postinjuryedema.18 cooling strengthfor the following 3 hours or Stimulation of the cutaneouscold receptorsbv (Iig. 6-5).The proposedmechanismsfor the cold may providesufficienrsensoryinput io block strength after prolonged cooling include red the transmissionol painful stimuli fully or partially of blood fiow to the muscles,slowed motor alongthe spinalcord to the cerebralcortex,increasing conduction,increasedmuscleviscosity,and pain threshold or decreasingpain sensation.Such joint or soft tissuestiffness. gatingof the sensationof pain canalsoreducemuscle It is important to be aware of these changes spasmsby interrupting *re pain-spasm-paincycle, muscle strength in responseto *re application as describedin Chapter 3. Cryotherapy may also cryotherapysincethey canobscureaccurate, reduce the pain associatedwith an acute rnjury by assessmento! muscle strengthand patient reducingthe rate ofblood flow in an areaand decreas- It is therefore recommendedthat muscle ing the rate of reactionsrelated to acute inflammabe consistendymeasuredbefore the application Figure 6-5. Effectsof cold on stength of musclecontraction. @ata ftom Oliver RA, Jobnson DJ, Wheelhouse WW et al: Isometricmuscle contractionresponseduring recovery from reduced rntramuscular temp€rature, ArchPhysMedRehabil60:L261,29,1,979;JohnsonJ, Leider IE: Influenceof cold bath on maximum handgripstrength, PerceVt Mot Skills44:323-325, 1977;DaviesCTM, YoungK: Effectof temperatureon the contractile properties and musclepowerof tricepssurae in humans, J Aypl Physiol 55191-195 , 1983.)
Tgo . THE PIIYSICAL AGENTS
--:)'otherapyand that pre-cooling strength not be :rmpared with postcoolingstrengthwhen trying to paI.renrprogress. 5SeSS spasticity Decreased r,hen applied appropriately,cryotherapy can tem-,,crarilydecreasespasticity. Two mechanismsare ::oposed to act sequentiallyto produce this effect: ::st, a decreasein gammamotor neuronactivity and? ;ier, a decreasein afferentspindleand Colgi tendon ::gan activity. A decreasein the amplitude of the -r.chillestendon reflex and integratedelectromyogra--1y (EMC) activity have beenobservedwithin a few rconds of the application of cold to the skin.2a,25 -hesechangesarethought to be relatedto a decrease = the activity of the gammamotorneuronsasa reflex =action to stimulation of the cutaneouscold recep=rs. This fast responsemust be relatedto stimulation :j cutaneousstructuressincethetemperatureof the ruscles cannot decreaseafter such a brief period of :coling. After more prolongedcooling,lastingfor 10 to 30 ainutes, a temporarydecreaseor eliminationof spas:city and clonus, depressionof the Achilles tendon :eflex,and a reductionin resistanceto passivemotion :ave aisobeen observedin some oatientswith soasThesechangesare thou;ht to be causei by :city.25-2e in the dischargefrom the afferentspindles : decrease -rd Colgi tendon organs as a result of decreased :)uscle temperature.30 These later effects generally 1 to :ersist for 1.5 hours and can thereforebe taken :dvantageof in treatmentby applyingcryotherapyto lypertonic areasfor up to 30 minutes before other rterventions, to reducespasticityduring functional
741
MetabolicEffects Decreased metabolic rate Cold decreases the rate of all metabolicreactions, including those involved in inflammation and healing.Thus cryorherapycan be usedto control acute inflammation, because it is not recommended when healing is delayed becauseit may further impair recovery The activiry of cartilagedegradingenzymeq including coliagenase,elastase, hyaluronidase,and protease,is inhibited by decreases in joint temperature,almostceasingat joint temperatures of 30 "C (86 "I) or lower.3l Thus cryotherapyis recommendedas a ffeatment for the prevention or reduction of collagen destruction in inflammatory joint diseasessuch as osteoarthritisand rheumatoid arthritis.
USES OFCRYOTHERAPY Inflammation control Edema control Pain control Modifi cation of spasticity Sjmptom management in multiple sclerosis Facilitation Cryokinetics and cryostretch
lnflammation Control
Cryotherapycan be usedto control acuteinflammation and thereby acceleraterecovery ftom injury or trauma.32Decreasingtissue temperatureslows the rate of the chemical reactions that occur during -r rhprrncr rri. ,.ri0itiF< the acuteinflammatory responseand alsoreducesthe heat, redness,edema,pain, and lossof function assoFacilitation otmuscle contraction ciatedwith this phaseof tissuehealing.Cryotherapy -he stimulusof a brief applicationof cryotherapy directly reducesthe heat associatedwith inflamma:s thoughtto facilitatealphamotor neuronactivity tion by decreasingthe temperatureof the area to :o producea contractionin a muscle that is flaccid which it is applied.The decrease in blood flow caused jue to upper motor neuron dysfunction.25 by vasoconstrictionand increasedblood viscosiqy, This and the decreasein capillarypermeabilityassociated :ffect is observedin responseto a few secondsof with cryotherapy, impede the movement of fluid :ooling andalsolastsfor only a short time. With more :rolonged cooling of evena tew minutes, a decrease from the capillariesto the interstitial tissue,thereby controllingbleedingand fluid lossafter acutetrauma. .:r garnmamotor neuron activiq/ reducesthe force These effectsreducethe rednessand edemaassoci:f muscle contraction.This brief facilitation effect ated with inflammation. As describedin more detail :f cryotherapy is occasionallyused clinically when to stimulate production below, cryotherapy is thought to control pain by the of appropriate rying decreasingthe activity of the A-delta pain fibers and :notor pattems in patientswith upper motor neuron by gating at the spinal cord level. Controlling *re -esions.
142
6.
Thentt,rl Ageats: CoA 4t d Heat
edemaand pain associatedwith inflammation limits the loss of function associatedwith this phaseof tissuehealing. It is recommendedthat cryotherapy be applied immediately following an injury and throughout the acute inflammatory phase. Immediate application helpsto controlbleedingand edema;thereFore, the soonerthe treatmentis applied,the greaterand more irnmediate the potential benefit.33Clinically, local skintemperature canbe usedto estjmatethe itaeeof healingand tlus to determineiI cryorherapyis indicated.If the temperatureof an areais elevated,the area is probably still inflamed and cryotherapy is likely to be beneficial.Once the local temperature returnsto normal,tie acuteinflammaLion hasprobably resolvedand thereforecryotherapyshouldbe discontinued. Acute inflammation usually resolves within 48 to 72 hours of acute trauma but may be prolongedwith severetrauma. inflammatorydiseasessuch as rheumatoid arthritis, or with chronic recuffent injuries. If the temperature of an area remains elevated for longer than appropriate for the patient's condition, the possibility of an infection should be consideredand the patient should be referred to a physician for further evaluation. Cryo*rerapy should be discontinued when acute inflammationhas resolvedto avoid slowins chemical reactionsor impairing circuiationduring"the larer stagesof healing when these effectsof cryotherapy canimpederecovery The prophylacticuse of cryotherapyafter exercise has also been shown to reduce the severitv of delayed-onset muscle soreness(DOMS).34DOMS is thought to be the result of inflammation from muscleand connectivetissuedamagecausedby exercise.35'36 Clinically,the prophylactii use of cryotherapy after aggressivejoint or soft tissuemobilization, or,after lighr activiryin an areawith a preexisting inflammatiorS can effectively decreasepostactivity soreness. Although cryotherapycan help to control itflammation and its associatedsigns and symptoms, the causeof the inflammation must also be addressed direcdy to preventrecurence.Ior example,if inflammationjs causedby overuseof a tendon,*Lepadent's useof thar tendonmusrbe modifiedif recuirence of symptomsis to be avoided. When cryotherapy is applied with the goal of controlling inflammation, the treatment time is generally limited to 15 minutes or less because
longerapplicationhas beenassociatedwith vasodilation and increasedcirculation.T-1o However, since reflex vasodilationin responseto cold has not been shown to occur outside of the distal exffemitieslonger treatmentdurationsmay be used for areas other than the distal extremities.4,llTo limit the probability of excessivedecreasesin tissue temperatureand cold-inducedinjury cryotherapyapplications should be at least t hour apart so that the tissue temperature can retum to normal between tleatments.
Edema Gontrol
Cryotherapycan be usedto control the formation of edema, particularly when the edema is associated with acute inflammation.3TDuring acute inflammation, edemais causedby extrava;don of fluid into the interstitium caused by increasedintravascular fluid pressureand increasedvascularpermeabiliw. Cryotherapy reducesthe intravascularfluid pressuie by reducingblood flow inro the areavia vasoconstriction and increasedblood viscosity.Cryotherapy also controls increasesin capillary permeability by reducingthe releaseof vasoactivesubstances, suchas histamine. To minimize edema formation, cryotherapy should be applied as soon as possibleafter an acute trauma. The formation of edema associatedwith inflammation will be most effectively controlled if the cryotherapyis appliedin conjunctionwith compression and elevation of the affected area.38,39 Compressioncan easily be applied with an elastic wrap (Fig. 6-Q, and elevation should be above the level of the heart. Cornpressionand elevationreduce edema by driving extravascularfluid out of the swollen areainto the venousand lymphatic drainage systems.The combined treatment of rest, ice, compression,and elevationis frequendyreferredto bythe acronym RICE. Cryotherapy is not effective in controlling the formation of edema caused by immobiliw and poor circuladon.Itr such cases,increasedrather than decreasedvenous or lymphatic circulation is required to move fluid out of the affected area. This is best accomplishedwith compression,elevation, heat, exercise,and massage.40 The mechanisms of action of this combination of treatrnents are discussedin detail in Chapter 11 in the section on compression.
Tvo . THE PIIYSICAL AGENTS
743
Modification ofSpasticity
:gure6-6,Cryotherapy with compressionand elevation.
Cryotherapycan be usedto temporarilyreducespasticity in patients with upper motor neuron dysfunctions.As explainedabove, brief applicationsof cold, lasting for about 5 minutes, causean almost immediate decreasein deep tendon reflexes.Longer applications,for 10 to 30 minutes, also decreaseor eliminateclonusand decreasethe resistanceof musclesto passivestretch.24Becauselonger applications oI cryotherapycontrolmore of the signsof spasticiry cryotherapyshould be applied for up to 30 minutes when this is the treatmentgoal.The decrease in spasticity producedby prolongedcooling generallylasts for t hour orlonger afterthe treatment,which is sufficient to allow for a varietyof therapeuticinterventions, inciudingactiveexercise,sffetching,functional :ctiwitipc nr hwoienc
rainGontrol
Symptom Management inMuliiple Sclerosis
-1e decreasein tissue temperature produced by :notherapy may direcdyor indirectlyreducethe sen.:rion of pain.Cryotherapydirecdyand rapidly mod:es the sensationof pain by gatingpain transmission .'.-id:r activiqyof the cutaneousthermalreceptors.This rmediate analgesiceffect of cold is exploitedwhen .apocoolantspraysor ice massageare used to cool -':e skin before stretching the musclesbelow. The ::duced sensationol pain allows the stretch to be :ore forcefuland thus potentiallymore effective. Applyt.tg cryotherapy for 10 to 15 minutes or :nger cancontrol pain tor 1 or more hours.This pro.:nged effect is thought to be the result of blocking ::nduction by deep pain-transmittingA-delta fibers, :rd by gating of pain transmissionby the cutaneous -'ermal receptors.l6 fhe effectis rhoughrro be pro:nged becausethe temperatureof the arearemains wer than normal tor 7 or 2 hours after removal of =e coolingmodality. Rewarmingof the areais slow :ecausecold-inducedvasoconstrictionlimits the flow :i warm blood into the area,and subcutaneousfat :sulatesthe deepertissuesfrom rewarming by con:uction from the ambientair. The reduction of pain by cryotherapy can also -rterrupt the pain-spasm-paincycle, resulting in :educedmuscle spasmand prolongedalleviation of :ain evenafterthe temperatureof the treatedareahas :eturnedto nomal. Cryotherapycanalsoreducepain rdirectly by alleviatingthe underlying causeof this ,vmptomj suchasinflammationor edema.
The symptomsof somepatientswith multiple sclerosis are aggravatedby generalizedheating, such as occursin warm environmentsor with activity. This groupofpatientscanrespondwell to generalizedcooling, with improvementsin electrophysiological measuresand in clinicalsymptomsand function.alCooling with a vest has been shown to improve fatigue, muscle strength,and posturalstability in a group of patientswith heat-sensitivemultiple sclerosiswhen comparedwith a shamnoncoolingvest.42
Facilitation The rapid application of ice as a stimulus to elicit desiredmotor patterns,known as4lrrb icing rs a technique developedby Rood. Although this technique may be used effectively in the rehabilitation of patientswith flaccidity resulting from upper motor neurondysfunction,it tendsto haveunreliableresults and is thereforenot commonly used.43 The resultsof quick icing are unreliablebecausethe initial phasic withdrawal patternstimulatedin the agonistmuscles may lower the restingpotentialof the antagonists,so that a secondstimuluselicitsactiviqyin the antagonist musclesratherrhanin the agonists.r4 This produces motion first in the desireddirection. followed bv a reboundmovementin the oppo,itedirectjon.lc i.ras also been proposed*rat icing may adverselyimpact motor control causedby dysynchronizationof the cortexasa rerultof increased symparhetic tone.45
144
6 o Thennal Asents: Cold and Heat
andCryostretch Cryokinetics Cryokinetics is a technique that combinesthe use of cold and exercisein the treatment of pathology or disease.46This technique involves applying a cooling agentto the point of numbnessshordy after any injury to reducethe sensationof pain and thus allow *re patient to exercise and work toward regainingrangeof motion (ROM) as early as possible in the recovery process.4/This approach is most commonly used in the rehabilitation of athletes. Cold is applied first for up to 20 minutes, or until dre patient reports numbing of the area; then the patient performs strengthening and stretching exercisesfor 3 to 5 minutesuntil sensationretums.48 The coolirg agent is then reapplieduntil analgesia is regained.This sequenceof cooling, exercise,and recooling is repeated approximately five times. Because*re numbnessproducedby the cryotherapy masksthe pain relatedto the injury to avoid further trauma and tissuedamageit is essential*rat, before applyingthis technique,the exactnatureof the inlury is known and the therapistis certainthat it is safeto exercisethe areainvolved.
CONTRAINDICATIONS
fortheApplication of Cryotherapy o Coldhypersensitivity o Cold intolerance ' Cryoglobulinemia
The useof cryotherapyis contraindicated. . . . . . in patients with cold hypersensitivity, cold intolerance, cryoglobulinemia, paroxysmal cold hemoglobinuria, Ra1'naud's disease, or Ra1'naud's phenomenonso Cold Hypersensitivity (Cold-indtceil Urticaria). Someindividualshave a familial or acquiredhypersensitivityto cold that causesthem to developa vascular skin reacrionin responseto cold exposure.sl This reactionis marked by *re transientappearance of smooth, slightly elevatedpatches,which are redder or more pale than the surroundingskin and are often attended by severeitching. This responseis
Cryosftetchis dre applicationof a cooling agent beforestretching.The purposeofthis sequence oftreatmentsis to reducemusclespasmandthusallow greater !o range-of-motion increases with stretching.
CONTRAINDICATIONS ANDPRECAUTIONS FOR CRYOTHERAPY Although cryotherapyis a relatively safe treatment modality, its use is contraindicatedin some circumstancesand it should be applied with cautioo in others.Cryotherapymay be appliedby a qualified clinicianor by a properlyinstructedpatient.Rehabilitation cliniciansmay useall forms of cryotherapy are noninvasiveand do not desftoy tissue.Patients may use cold packsor ice packs,ice massage,or contrastbathsto treatthemselves. If *re patient's condition is worsening or is
improving within the period of two or three ments, the treatment approach should be
and chansedor the patient should be referredto physicianfor further evaluationevenwhen apy is not contraindicated.
o . o .
Paroxysmalcold cryoglobinuria Raynaud'sdiseaseor phenomenon Overa regeneratingperipheralnerve Overan areawi*r circulatorycompromise or peripheralvasculardisease
or cold-induced known as coldhyyersexsitivity These symptoms can occur only in the area of applicationor all over the body. Cold lrtolerance. Cold intolerance. in the form severe pain, numbness, and color changesin
to cold,canoccurin patientswith sometypesof matic diseasesor following severeaccidentalor -^l
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LU urc
l:-:--
ur6rLb.
CryogJobulinemia. Cryoglobulinemia is an mon disorder characterizedby the aggregation serumproteinsin the distalcirculationwhen the di extremities are cooled. These aggregatedproteins a precipitate or ge1that can impair circulatioq
Two o THE PHYSICAL A GENTS
r:':al ischemiaand then gangrene.This disordermay - idiopathic or may be associatedwith multiple :','eloma, systemiclupus erythematosus, rheumatoid ;:-:rritis,or other hyperglobulinemicstates.Therefore =e therapistshouldcheckwi*r the referringphysician :e;oreapplyingcryotherapytothe distalextremitiesof =,,' patientwith thesepredisposingdisorders. - troxysnal Cold Hemoglobituria. Paroxysmalcold ::inoglobinuria is the releaseof hemoglobininto the :::ae from lysedred blood cellsin responseto local or .-nerrlcvno
t^
"^
. . . over regenerating peripheral nerves Cryotherapy should not be applied directly over a regeneratingperipheralnervebecauselocal vasoconstriction or alterednerveconductionmay delaynewe regenelatron. ASK THE PATIENT: o Do you haveany nervedamagein this area? o Do you haveany numbnessor tingling in this limb? If so,where?
l,-l
:;vraud's Disease afld Phenomenon.Raynaud,s :iease is the primary or idiopathic form of paroxys=-aldigital cyanosis.Raynaud'sphenomenon,which -. more cofi)rnor\ is paroxysmaldigital cyanosisdue :: some other regional or systemic disorder.Both ::nditions are characterizedby sudden pallor and -.-anosislollowed by rednessof the skin of the digits ::ecipitated by cold or emotional upset and relieved :',-warm*r. Thesedisordersoccurprimarily in young .','omen. InRaynaud'sdiseasethe symptomsarebilat::ai and symmetricevenwhen cold is appliedto only :re area, whereas in Raynaud'sphenomenon,the :.rnptoms generallyoccuronly in the cooledextrem-'. Raynaud'sphenomenonmay be associatedwith =oracic outlet syndrome,carpaltunnel slmdrome,or
ASKTHE PATIENT o Do you have any unusual responsesto cold? If the patient answers"yes" to this question,ask for further details.Includethe following questions: . Do you developa rash when coldi (A sign of cold hyp ersensitivity) . Do you have severe pain, numhne<<
changes in your fingers*h"^';;;;i;;
ASSESS: . Testsensation In the presenceof sensory impairment or other signsof newe dysfunction,cryotherapyshouldnot be applieddirecdyover the affectednerve. . . . over an area with circulatory compromise or peripheral vascular disease Cryotherapy should not be applied over an area with impairedcircularionbecauseir may aggravate the condition by causing vasoconstriction and increasingblood viscosity. Circulatory impaiment may be the result of peripheralvasculardisease, trauma to the vessels,or early healing, and is often associatedwith edema.When edemais present,it is important that its causebe determined,sinceedema due to inflammation can benefit from cryotherapy, while edema due to impaired circulation may be increased.These causesof edema can be distinguishedby observationof local skin coloration and temperature.Edemadue to inflammation is characterized by warmth and redness,whereasedemadue to poor circulation is characterizedby coolnessand pallor.
en,l rnl^'
;;i;;
(Signiof Raynaudt dl"ur"zpheno-".ron1 . Do you geLblood in your urjn. .^tA) "+.. t -i-^ '"'"
rAsisnoiparoxysmut -ld h"-;;;,;;;;"
if the"responses'indicate that the"patient mayhave :oldhypersensitivity, coldintolerani",.t;gl;;ili"":nia,paioxysmal coij i,"-og1out.,uri;;ild;;ffi :ase,-or Raynaud's phenomlnon,;;;;i;;;;fu ' ' ror be applied.
145
lsl(rHEPArlENt ' lJo you havepoor circulationin this limb? fsj:ss: ' sf
146
6.
Thermal Aseflts: Cold qnd Heat
PRECAUTIONS
ol Cryotherapy fortheApplicati0n . Over the superficialmain branchof a nerve o Over an openwound
Applycryotherapywith caution, , . . . . over a superficial main branch ofa nerve Applying cold direcdy over the superficial main branch of a nerve, such as the peroneainewe at the lateral knee or the radial nerve at the posterolateral '52,53 elbow, may causea nerveconduction61ock.14,17 Therefore when applying cryotherapy to such an area,one shouldmonitor for signsof changesin nerve conduction,such as distal numbnessor tingling, and discontinuecryotherapyif theseoccur. . . . over an open wound Cryotherapyshould not be applieddirecdy over any deep open wound becauseit can delay wound healing by reducing circulation and metabolic rate.sa Cryotherapymay be appliedin areasof superlicialskin damagelhowever,it is important to realizethat *ris can reducethe efficary and safety of *re treatment becausewhen there is superficialskin damage,the cutaneousthermalreceptorsmay alsobe damagedor absent.These receptorsplay a part in activatingthe vasoconstrictio4pain control,andspasticityreduction producedby cryotherapy;therefore,theseresponses are likely to be lesspronouncedwhen cryotherapyis appliedto areaswith superficialskin damage,Caution should also be usedif cryotherapyis appliedto such areasbecausethe absenceof skin reducesthe insulatlayersandincreases ing protectionofthe subcutaneous coolinsto thesetissues. Llee riskof excessive
t Hypertension . In patientswith poor sensationor poor mentation . Very young andvery old patients ASSESS: . Inspectthe skin closelyfor deep wounds, cuts, or abrasions.Do not apply cryotherapyin the areaofa deepwound, and uselessintensecoolingif cuts or aoraslonsarepresen[. . . . when treating patients with hypertension Sincecold can causetransientincreasesin systolic diastolicblood pressure,patientswith should be carefullymonitored during the app of cryotherapy.55Treatmentshould be if blood pressureincreasesbeyond safelevels treatment. Guidelines for safe blood pressures individual patients should be obtained from physician. . . . when treating patients with poor or mentation Although adverseeffectswith cryothe:oPyarewe, the patient cannot sense or report discomfort the clinicianshould other abnormalresponses, tor the patient'sresponsedirectly.Check for responses to cold suchaswhealsor abnormal in color or strength,both in the areaof cold app tion and generally. . . . when treating very young and very old Caution should be usedwhen applying cryoth to the very young or the very old becausethese viduals frequendyhave impaired thermal and a limited ability to communicate.
ADVERSE EFFECTS OFCRYOTHERAPY Tissse death Frostbite Newe damage Unwanted vasodilation
A variety of adverseeffectshavebeenreported cold is applied incorrecdy or when The most severeadverseeffect ftom *re applicationof cryotherapyis tissuedeath caused prolonged vasoconstriction, ischemia, and
bosesin the smallervessels.Tissue death may result ftom freezingof the tissue.Tissuedamage
Two . THE PIIYSICAL ACENTS
:ccur when the tissue temperature reaches 15'C i9'I); however, freezing (frostbite)does not occur ':ntil the skin temperaturedropsto bewveen- 4" and -10 "C (39"to 14'F)orlower Excessive exposureto cold ray alsocausetemporaryor permanentnerve damage, :esultingin pairl numbness,tingling,hyperhidrosis,or ::erveconductionabnormalities.56 To avoid soft tissue :r nerve damage,the duration of cold application :tould be limited to under 45 minutes,and the tissue :emperature shouldbe maintainedabove15'C (59'F). Becausethe prolongedapplicationof cryo*rerapy :c the distalextremitiesmay causereFlexvasodilation :nd increasedblood flow, cryotherapy should be
Evaluatethe patientand set the goalsof treatment. Determineif cryotherapyis *re most appropdate treatment. Determinethat cryotherapyis not contraindicated for this patientor condition. Inspectthe areato betreatedfor openwoundsand rashesand assesssensation.Check the patient's chartfor any recordofpreviousadverseresponses to coldand for any diseases that would predisposethe patientto an adveneresponse. Ask the appropriate questionsof the patientasdescribed in the preceding sectionson contraindications andprecautrons. Selectthe appropriatecoolingagentaccordingto the bodypartto be treatedandthe desiredresponse. Selectan agentthat providesthe desiredintensity of cold treatment,best fits the locationand size of the area to be treated, is easily applied for the desired duration and in the desired nosition. is readily available.and is reasonablypriced. Ar agent that conforms to the contours of the area beingtreatedshouidbe usedto maintaingood contact with the patient'sskin. With agentsthat cool by conductionor convection,suchas cold packsor a cold whiripool, good contactmust be maintained bewveenthe agent and the patient's body at all times to maximize the rate of coolins. For brief coolingthe besrchoiceis an agentthaiis quickto apply and remove. Any of the cooling agents describedas follows may be availablefor use in a clinicalsetting,and the patient can readily use ice packs,ice cups,and cold packsat home. Ice packs and ice massageare the least expensivemeansof
147
applied for only 10 to 15 minutes when the goal of treatmentis vasoconstriction.
TECHNIQUES APPLICATION Cryotherapymay be appliedusinga vadety of materials,including cold or ice packs,ice cups,controlled cold compressionunits, vapocoolant sprays,f:,ozen towels,ice water,cold whirlpools,and contrastbaths. The following section gives details on application techniquesfor thesedifferent cooling agentsand the decisionsto be made when selectinga specificagent and an applicationtechnique.
providing cryotherapy,whereas controlled cold compression unitsarethemostexpensive. 5. Explainto the patientthe procedureand reasonfor applying cryotherapy and the sensations tlre patientcanexpectto feel. During *re application of cryotherapy by any means the patient will usually experiencethe tollowing sequenceof sensations:intensecold followed by burning,then aching,and finally analgesiaandnumbness.Thesesensationsarethought to correspondto increasingstimulation of the thermal receptors and pain receptors followed by blockingof sensorynerveconductionasthe tissue tpn^er^t-"ra
Ap.ra
)
SEOUENCEOF SENSATIONSIN BESPONSETO CRYOTHERAPY . Intensecold . Burning o Aching o Analgesiaandnumbness 6. Apply the appropriatecoolingagent. Seleafron thefollowinglist: Cold packsor ice packs Ice cupsfor ice massage Seeapplication Controlledcold compression methodsfor units Vapocoolant spraysor brieficing eachcooling agenton the Irozen towels following pages. Icewater immersion Cold whirlpool Contrastbath Continued
748
6.
Thennal Ase ts: Cold atd Heat
/. Assessthe outcomeof ffeatment. After completing cryotherapywith any of the precedingagents, reassessthe patient, checking particularly for progresstoward the set goals of treatmentand for any adverseeffectsof the treat-
ment. Remeasure quantifiable subjective conditions and objective limitations, and reassessthe impairments and disabilities. 8. Document the treatment.
Figure6-7. Cold packs. (Courtesy Chattanooga Croup, Inc., Hixson, TN.)
Figure6-8. Cooling units for cold packs. (Courtesy Chattanooga Group,Inc.,Hixson,TN.)
orlcePacks ColdPacks Cold packsare usually filled with a gel composedof silicaor a mixture of salineandgelatinandare usually coveredwith vinyl (Iig. 6-Z).The gel is formulatedto 'C (32'to 41 "I) for be semisoiidat between0' and5 the pack to conform to the body contourswhen it is within this temperaturerange.The temperatureof a cold pack is maintainedby stodng it in a specialized coolingunit (Fig.6-8)or in a freezerar 5 "C (23'I). Cold packsshouldbe cooledfor at least30 minutes betweenusesand for 2 hours or longer beforeinitial use.Patientscan useplasticbagsof frozenvegetables at home as a substitutefor cold packs,or they can make their own cold packs from plastic bags filled with a 4:1 ratio mixture of water and rubbing alcohol
cooledin a home freezer.The addition of alcohol to the water decreasesthe freezing temperature of the mixture so that it is semisolidand flexibleat -5 "C
(23'r).
Ice packsare made of crushedice placedin a plastic bag. Ice packs provide more aggressivecooling than cold packs at t'he same temperaturebecause ice has a higher specific heat than most gels and because ice absorbs a large amount of energy when it melts and changesfrom a solid to a liquid. 57 Both cold packs and ice packs are applied in a similar manrrer, as described below; however, more insulation should be used when applying a n i c e p a c k b e c a u s ei t p r o v i d e ' m o r e a g g r e s s i v coorng.
Tvo . THE PHYSICAL AGENTS
: quipment Required :ld Packs Cold packsin a variety of sizesand shapes appropriatefor differentareasof the body coolingunit Ereezeror spectalized Towelsor pillow casesfor hygieneand/or :nsula on
'ROCEDURE - Removeall jewelryandclothingfrom the areato be treated and inspect the area. ,. Wrap the cold pack or ice pack in a towel. Use a damp towel if a maximal rate of tissue cooling is desired. It is recommended that warm water be used to dampen the towel to allow the patient to gradualiy become accustomed to the cold sensation. A thin, dry towel can be used if slower, less intense cooling is desired. A damp towel is generally appropriate for a cold pack, whereas a dry towel should be used for an ice pack since ice provides more intense cooling. r. Position the patient comfortably, elevating the area to be treated if edema is present. :. Place the wrapped pack on the area to be treated and secure it well. Packs can be secured with eiastic bandagesor towels to ensure good contact with the patient's skin (Iig. 6-9).
t49
Ice Packs o Plasticbags o lce chips o Icechipmachineor keezer o Towels or pillow casesfor hygieneand/or insulatlon 5. Leavethe packin placefor 10 to 15minutesto conA recentsystrol pain, inflammation, or edema.58 cryotherapy on the research of review tematic is most time application a 1O-minute found that associswelling pain and the reducing effectivefor risk *re minimizing and injury atedwith softtissue 5e iniury further possible of sideeffectsand When cold is appliedover bandagesor a cast,the applicationtime should be increasedto allow the cold to penetratethroughtheseinsuiatinglayersto the skin.60In this circumstance,the cold pack shouldbe replacedwith a newly frozenpackif the originalpackmeltsduring the courseof treatment. If cryotherapyis beingusedto control spasticiry the pack should be left in placefor up to 30 minutes.With theselonger applications,check every 10 to 15 minutesfor any signsof adverseeffects. 6. Providethe patient with a bell or other meansto callfor assistance. Z. When the treatment is completed, remove the pack and inspectthe treatmentareafor any signs of adverseeffectssuchaswhealsor a rash lt is normal for the skin to be red or dark pink after icing. 8. Cold or icepackapplicationcanbe repeatedevery or 1 to 2 houm to controlpain and inflammation ADVANTAGES . EasYto use . lnexpensivematerialsand equipment . Shortuseof clinician'stime o L o w i e v eol f s k i Ur e q u i r e fdo r a p p l i c a t i o n . Coversmoderateto largeareas . Can be appliedto an elevatedlimb
6-9. A pplicationof a cold pack Figure
DISADVANTAGES o Packmust be removed to visualize the treatment areaduringtreatment . Patientmay not tolerateweight of the pack Continued
6 t Thernal Agents: Cold axd Heat
150
. Packmay not be able to maintain good contacton smallor contouredareas o Long duration of treatment comparedto massage with an ice cup
Figure 6-10.Icecup.
ICE PACKVEBSUSCOLD PACK o Ice packprovidesmore intensecooling o lcepackis lessexpensive o Cold packis quickerto apply
Figure 6-11.Wate(popsicle.
lceMassage
direct contact with the patient's skin. Water Ice cups (Fig. 6-L0) or frozen water popsicles62 clesaremadeby placinga stickor tonguedepre inro the water cup before freezing.When fro Irozenice (Fig.6-11)canbeusedto applyicemassage. cups are made by treezingsmall paper or Styrofoam the ice canbe completelyremovedfrom the cup the stick used as a handie for applying che icecupsof water.To use*rese,the therapistholds on to Patientscan easilymake ice cups or popsicles the bottom o[ *re cup and graduallypeelsback the home use. edge to exposethe surfaceof the ice and puts it in
Equipment Required o Smallpaperor Styrofoamcups . lteezel
or popsiclesticks(optional) Tonguedepressors water Towelsto absorb
Two . THE PIIYSICAL ACENTS
t5l
]ROCEDURE I Removeall jewelryand clothingfrom the areato be treated and inspect the area. - Place towels around the tueatment area to absorb any dripping water and to wipe awaywater on the r(!r
qurrrS
rrcdurrcrr(.
:. Rub the ice over the treatment area using small, overlapping circles (Fig. 6-12). Wipe away any water asit melts on the skin. r. Continueice massageapplicationfor 5 to 10 minutes or until the patient experiencesanalgesiaat thp
:. When the treatment is completed, inspect the treatmentareafor any signsof adverseeffectssuch as wheals or a rash. It is normal for the skin to be red or dark pink after the application of ice massage.Ice massagemay be appliedin the above mannerfor the local control of pain,inflammation, or edema.Ice massagecanalsobe usedasa stimulus for facilitatingthe productionof desiredmotor pattemsin patientswith impaired motor control. When appiiedfor rhjs purpose.t-heice is eicher rubbedwith pressurefor 3 to 5 secondsor quickly stroked over the muscle bellies to be facilitated. This techniqueis known asqukbicing. ADVANTAGES . Treatmentareacanbe observedduringapplication
ColdCompression Unit Controlled lontrolled cold compressionunits altematelypump :old water andairinto a sleeve*rat is wrapoedaround of che r par.ient s limb lErg.6-13 A.81.fhe temperature 'C 'I) .vatercanbe setat between10' and25 (50'to ZZ :o provide cooling.Compressionis appliedby internittent intlation ofthe sleevewith air.Controlledcold .ompressionunits are most commonly useddirectly after surgeryfor the control of postoperativeinflamnation and edema;however,they may alsobe usedto
Figuie6-12. Applicationof icemassage. o . o o
Can be usedfor smalland irregularareas Shortdurationof treatment Inexpensive Can be appliedto an elevatedlimb
DISADVANTAGES . Too time-consumingfor largeareas . Requires active participation by t'he clinician or patientthroughoutapplication
control inflammation and relatededemain other cirthe sleeve When appliedpostoperatively, cumstances. is put on the patient'saffectedlimb immediatelyafter completionof the surgerywhile the patient is in t'he recoveryroomJ and the unit is sent home with the patientso that it canbe usedfor a few daysor weeks after surgery The applicationof cold with compression in this mannerhas beenshown to be more effective dran ice or compressionalone in controlling swelling, pain, and blood loss after surgery and in assistingthe patientin regainingROM.63'64
152
6 o Tlrctnnl Agens: Cold awl Heat
A
Libertywille, IL).B, AutoChill@ Figure 6-13.A, Controlledcoldcompression unit. (CourtesyInCareMedicalProducts, System20B.(CourtesyAIRCAST@Inc,,Summit,NJ.)
Equipment Required o Controlledcold compressionunit . Sleevesappropriatefor area(s)to be treated . Stockinettefor hygiene PROCEDUBE 1, Removeall jewelry and clothing from the areato be treatedandinspectthe area. 2. Cover the limb with a stockinettebeforeapplying the sleeve. 3. Wrap the sleevearoundthe areato be treated(Fig. 6-14). 4. Elevatethe areato be treated. 'C 'I). 5. Setthe temperatureat 10' to 15 (50' to 59 6. Cooling can be applied continuouslyor intermittendy. For intermittent treatmentTapply cooling for 15minutesevery2 hours. Z. Cycling intermittent compressionmay be applied at all timeswhen the areais elevated. 8. When the treatment is completed, remove the sleeveandinspectthe treatmentarea.
ADVANTAGES o Allows simuitaneousapplicationof cold and compression . Temperatureand compressionforce are easilyand e m r rr e t ' c L r e n n t r n l l e r l
o Can be appliedto largejoints DISADVANTAGES . Treatment site cannot be visualized during treatment . Expensive o Usableonly for extremities o Cannotbe usedfor trunk or digits
Tg'o . THE PHYSICAL AGENTS
153
:!ure6-14. A, Application of controlled cold compressionunit. (Courtesy InCare Medical Products,Libertyville, IL.); .: C,B, I(nee CryolCuff@. (CourtesyAIRCAST@ Inc., Summit, NJ.)
Sprays andBrieflcing ,'apocoolant -e vapocoolant sprays ethyl chloride and lluori..'-ethanehave been used for many years to achieve :ief and rapid cutaneouscooling(Fig.6-15).These ::oducts cool by evaporation.Ethyl chloridewas first ;;ed for this purpose;however,sinceit is volatile, : . , mm a b J ea.n dc ap a b l eo f c a u s i negx c e s s i vt e m p e r a lluori-Methane, which also effec.rre decreases,65 -..'elycoolsthe skin but is nonflammableand causes -c redrrcrion rn lemDerature. was
incroduced.66
.--owever, FluoriMethane is a volatile chlorofluoro--arbon that can damage the ozone layer; therefore, .s use is not pemitted by a number of facilities, :-though it has been granted a nonessential class I ::oduct exemption from the Environmental Protection .-gency (EPA) to permit its use in a clinical setting.6T lue to these limitations of vapocoolant spray prod- . r r . m a n y c ' i n i c r a n sa p p l y b r i e f i c e m a s s a g eu. s i n g
ice cupsor popsicles,when rapid cutaneouscoolingis desired. Rapid cutaneouscooling is generally used as a componentof the treatmentof triggerpoints.Ior this application,the vapocoolantspray or brief icing is applied in parallel strokes along the skin overlying the muscleswith trigger points immediately before (Figs.6-16 and 6-1l). This stretchingthesemuscles6s type of treatmentis frequently applied directly after trigger point injection. The purpose of the rapid coolingis to provide a countedffitant stimulusto the cutaneousthermal afferents overlying the muscles to causea reflex reductionin motor neuron activity and thus a reduction in the resistanceto stretch69 This techrriquewas developedby JanetTravell,who describesthis combinationwith the phrase"Stretchis The "disffaction" the action;sprayisthe distraction."T0 of rapid cutaneouscooling is intended to promote
154
6 . Thennal Agents: Cold and Heat
greaterelongationof the musclewith passivestretching. The combination of sprayingwith vapocoolant spray followed by stretchingis known as "sprayand stetch."
or a contrastbath. Irozen wet towels are rarelyused becausethey are inconvenientand messy.The useof cold water, cold whiripools, and contrastbathsis discussedin detailin Chapter9 of thisbook.
Cryotherapy ofApplying 0therMeans Cryotherapymay also be applied using frozen wet towels,a bucketof ice or coldwater,a cold whirlpool,
Figure6-15,Vapocoolantsprays:ethyl chloride and lluori-Medune. (Courtesy GebauerCompany,Cleveland,OH.)
Figure6-16.Application of vapoc Figure6-17. Quick stroking with ice oolanr spray. r,Courtesy Gebauer cup Company, Cleveland,OH.)
PROCEDURE 1. Identifytriggerpointsanddreirrelatedtight muscles. 2. Position the patient comfortably, with all limbs and the back well supportedand the area to be Inspectthe areato treatedexposedand accessible. be treated.lf usingethyl chloridespray,protectthe surroundingareasof skin with petrolatumto avoid excessivecooling. Becauselluori-Methane produceslessintensecoolingthan ethyl chloride,the surroundingareasof skin do not need protection when Fluori-Methaneis beingused. 3. Apply tlvo to five parallelsweepsof the spray or 10cm ata speedof approximately brieficemassage muscle fibers. the direction of the per secondalong When using a spray,hold the bottle about 45 cm from the skin and angledso that the sprayhits the
skin at an angleof about30 degrees.If applying spraynearor aroundthe patient'shead,try to mj mize the patient's inhalation of the spray,
1arlywith ethyl chloride,sincethis substance producegeneralanestheticeffects. 4 . During the cooling, maintaingentle, smooth, tension on the muscle to take up any slack that develop.
5 . Immediately after the cooiing, have the take a deep brearh and then perform a gentJe sive stretch while exhaling. Contraction-/relaxa
techniquesmay alsobe usedto enhancethe RO increasesobtainedwith this procedure. 6 . Iollowing this procedure, the skin should rewarmed with moist heat, and then the m
shouldbe moved through their full activeROM
T$o . THE PITYSICAL AGENTS
155
. Limited to usefor brief, localized,superficialapplicationof cold beforestretching o Possiblenarcoticor generalanestheticeffectif ethyl chlorideis hhaled
ADVANTAGES ' Brief durationof cooling o Very localizedareaof application DISADVANTAGES r Fluori-Methanespraydamagesthe ozonelayer
Documentation locument the area of the body treated, dre type :f cooling agent used, the treatment duration, :atient positioning, and *le responseto treatment. locumentation is typically written in the SOAPnote Plan)fomat. The Subjective,Objective,Assessment, the modaliry sumrnarize only examples :cllowing to repintended are not and of treatment :omponent pian oI care. comprehensive :esenta
etaqhl' 0: 99 2 ante.trL*,,knzox | 5', M 4.: lttid.pafzuat Sjrlh dr4rraard pv*n | 6 lt t& | 5' Wil " tlr4t tA^444h" w,^Akq inlr^&4rd (^NL alahL, P: 9n '\l&L N, irL klm4 puatara aN 9? fu"I arltdtioa kluz, | 5', u A, 9 fE elztolzd', 3 X eath dat2 until nz'xl t'tzattnz* auaiolL
When applyingicemassage(lM) to the areaof dreright (R)lateralepicondyleto treatepicondylitis,document:
9: PLolapain in R talz.talell
!:
?t ela ! lqze fojn w4l*hq.
and' tuzUitrq
tAat ittt'tuen*-a' uilA'
) Clinical Case Stildies a The following casestudiessummarizethe conceptsof cryotherapy discussedin this chapter-Based on the scenariopresented,an evaluation of the clinical findings andgoalsof treatmentarepfoposed.Thesearefollowed by a discussionof the factors to be consideredin the selection of cryotherapy as tlr€ indicated ffeatment modality and in the selectionof the ideal cryotherapy agentto promoteprogresstoward the setgoals.
Case'l TF is a 20-year-o1dmale accountant.He injured his ght knee 4 months ago while playing footbail and was treated conservatively with nonsteroidal antiinflammatory drugs (NSAlDs) and physical therapy for I weeks, with moderate improvement in symptoms; however, he was not able to retum to sPots due to continuedcomplaintsof medial knee pain. A magneiic resonanceimaging (MRI) scan 3 weeks ago revealed a tear of the medialmeniscus,and the patient undelwent adhroscopic partial medial meniscectomy of his right knee 4 daysago.He has beenreferledto physical
therapv with an order to evaluate and ffeat TI in intencomplainsof paininhis kneerhat hasdecreased sit:y'komg /10 b7 /1'0sincethe surgerybut that increases with weight bearing on the right lower extremity. He also complainsof knee stiffness The objective exam revealsmoderate wannth of the skin of the right knee, panicularly at the anteromedial aspect, and RO{ restrictedto -10 degreesof extensionand 85 degreesof fiexion. The patient is ambulating without any assistive devicebut witb a decreasedstancephaseon the right lower extremity and with his right knee held stiffly in approximately 30 degreesof flexion tJrroughout the gait on rycle. Kneegirtb at the midPatellarlevelis l7 inches li2 left on the the righr and 15 inches EVALUATIONOF THE CLINICAL FINDINGS This patient presentswith the impainnentsof pain,loss of motion, and increasedgirth of the right k.nee,resultine in the disabilitiesof limited ambulationand sports activity. He is independent in his home environment witlout the useof adaptiveequipment Continued
756
6 . Tlrcrnal
Agcuts: Cold aul llcat
) Clinical Case Stttdies-cont'd PREFERREDPRACTICEPATTERI. impaired Joint Mobiliq/, Motor lunction, Muscle Performance,and Range of Motion AssociatedWith Bony or SoftTissueSurgery,(41) PLAN OF CARE The goalsof treatmentat this time are to control pain and edema,accelerateresolutionof the acuteinflammation phase of healing, and acceleratethe recovery of ROM and function. ASSESSMENTREGARDINGTHE APPROPRIATENESS OF CRYOTHERAPY AS THE OPTIMALTREATMENT Cryotherapyis an indicatedtreatmentfor the control of pain, edema,andinflarrmation.It cancontol the formation of edema,and compressionand elevationcanreduce edemaalreadypresentin the patienr'sknee.The application of cryotherapy early during the recovery from articular surgeryhasalsobeenassociated with an acceleration of functional tecovery.72Since the peronealnerve is superficialat the lateral knee, the patient should be monitored for signsof nerve conductionblock, such as tingling or numbnessin his lateralleg,during treab.nent. The presenceof any contraindications to the application of cryotherapy,suchasRaynaud'ssyndrome,shouldalso be ruled out before ttre application of cryotherapy. Cryotherapyalsoshouldnot be appliedifinfection is suspected.Although this patientdoeshave signsof inflammatiorl includingheat, rednessrpain, swelling,and loss of function, *re fact that his signs and symptoms have decreased sincesurgeryindicates anappropriatecourseof recoveryand *re probableabsenceof infection.A progressiveincreaseinthe signsandsymptomsof inflammation or complairts of fever and generalmalaisewould suggestthe presenceof infectioq requiring physician evaluationbeforethe initiationof rehabilitation. PROPOSEDTREATMENTPLANAND RATIONALE To obtain maximum cooling of the knee, cryotherapy shouldbe appliedto all the skinsurfacessurroundingthe kr.reejoint. A cold pack, ice pack, or controlled cold compressionunit could adequatelycover this area.In choosingamong theseagents,one should considerthe convenienceand easeof applicationof a cold pack, the low expenseand ready availabilityof an ice pack, and the additional benefits(althoughgreatercosr)of intermittent compressionprovidedby a controlledcold compressionunit. Ice massagewould not be an appropdate featment becauseit would take too long to apply to
a
sucha largearea.Immersionin iceor coldwaterwould also not be appropriate since this would require the swollen knee to be in a dependentposition, potentially aggravating the edema,and would required.readditional discomfortof imrne$ing *re entke distallower extremibTin coldwater Whetherusinga cold pack,ice pack,orcontrolledcold compression unit, cryotherapy should generally be applied for approximately 15 minutes to ensureadequate cooling of the tissuesand minimizing the probability ofexcessivecoolingor reactivevasodiiation.This treatment should be reappliedby the patient at home every 2 to 3 hours while signsof inflammationare still present(Fig.6-18).
Figure6-18. Application ofice pack to nght knee.
Case2 SC is a 4O-year-oldfemaleoffice worker Shehas been referredto therapywith a diagnosisoflateralepicondylitis and an order to evaluateand treat. SG complainsof constant moderate to severepain at her right lateral elbow that preventsher from playing tennis.The pain startedabout 1 month ago,the morningaftershespenta whole day pulling weeds, and remainedunchangedin severityor frequencyuntil3daysago.Shereportsa slight decrease in pain severiqyover the last 3 days,which she associates with startingto takean NSAID prescribedby her physician.Shehashad similarsymptomspreviously, aftergardeningor playingtennis,but thesehave always resolvedwithin a couple of days without any medical intervention.Objectiveexaminationrevealstenderness andmild swellingat the right lateraiepicondyleand pain witlout weaknesswith resistedwrist extension.All other tests,includingupper extremiry sensation,ROM, andstrength,arewithin normallimits.
TIyo C THE PHYSICAL
EVALUATION OF THE CLINICALFINDINGS This patientpresentswith the impairmentsof Paiq tenderness,and swelling of the right elbow resultingin an inabiliq' to participatein her normal sports activity of teffus.
PRACTICEPATTERN PREFERRED lmpaired Joint Mobility, Motor Function, Muscle Performance,and Range of Motion AssociatedWith I ^"'li'",1 T.Flrmm:rinn f4F\
PLANOF CARE The goals of ffeatment at this time are to resolvethe inflammation and control pain. The anticipatedlongterm goals of treatmentinclude the patient'sretum to playing tennis and prevention of recurrencesof this problem. REGARDINGTHE ASSESSMENT AS THE OF CRYOTHERAPY APPROPRIATENESS OPTIMALTREATMENT Cryotherapyis an indicatedtreatmentfor inflammation andpain,and canalsobe usedprophylacticailyafier exerciseto preventtie onset of inflammationand soreness. The advantagesof cryotherapyover other fteatments indicatedfor these applications,such as ultrasoundor electricalstimulation,are that it is quick, easy,and inexpensiveto apply,and the patient can apply it at home. Cryotherapyalone may not resolvethe Presentsymptomsandmay thereforeneedto beappliedin conjunction with otherphysicalagentsjactivitymodification,manual to achievethe protherapytechniques,and/or exercises posedgoalsoftreatment.Sincethe radialneweis superficialat the lateralelbow,the patientshouldbe monitored for signsofnerve conductionblockageduringtreamlent, suchastinglingor numbnessin her dorsalarm.The presence of any contraindicationsto the application of cryotherapy,such as Raynaud'ssyndrome, should be ruledoutbeforethe applicationof cryotherapy. PROPOSEDTREATMENTPLANAND RATIONALE Ice massage,an ice pack, or a cold pack can be usedto providecryotherapyto the areaoI the lateralepicondyle (Fig.6-19).Sinceice massagehasthe advantagesof taking little time to apply to tl|is smallareawhile allowing visualizationof the treatment area and assessmentof signs and symptoms throughout the treatment, this would be the most appropriateagent to use for this patient,althoughan ice pack or cold pack could aisobe used.An ice packor cold pack would be more appropriate if the symptomaticareawas larger;for example,if the areaextendedinto the dorsalforearm.Cryotherapy should be applied until the treatment area is numb,
tJ/
ACENTS
which usuallytakes5 to 10minuteswhen usingice massageorabout 15minuteswhen usinganicepackora coid pack.Tream-rent shouldbe discontinuedsoonerif numbness extendsinto the hand in the distribution of the radialnerve.Cryotherapytrealmentsshouldcontinueto be applieduntil the signsandsymptomsof inflammation haveresolved.Treatmentsshouldbe disconthuedthereproducedby cryotherapy aftersincethe vasoconstriction may retardthe later stagesof tissuehealing The patient shouldalso be instructedto apply cryotherapyprophylacticallyafter activitiesthat have previouslyresultedin elbow pain, such as terxis or gardening,to reducethe risk ofa recurrenceof her presentsymptoms.
Figure6-19. Application ofice massageto elbow.
Case 3 FBis a 60 year-oldmaletruck driver He hasbeenreferred to physicaltherapywith a diagnosisof osteoarthritisof the leftkneeandanorderto evaluateandtreat.He reports thathe hashadarthritisin thiskneefor the last5yearsand that he recendy started performing exelcisesthat have increasedthe strength,stability,andenduranceofhis Iegs but causeknee pain and thigh musciesorenessthe next day.His goalsin therapyare to controlthis postexercise program. of hisPxercise oiscomfonro allowcondnualion He performed his exercisesyesterday,and today the objectiveevaluationreveaisa mild increasein the temperofthe antedorthigh. atureof the leftkneeand tendemess Kneeginh andROM areequalbilaterally. OF THE CLINICALFINDINGS EVALUATION This patient presentswith the impairmentsof intelmittent left kneeand thigh pain resultingin the disabilityof '".f',.r".1
"'e'.i(c,.rivit'1/
PREFERREDPRACTICEPATTERN impaired Joint Mobility, Motor }unction, Muscle Perforrnance,and Range of Motion AssociatedWith LocalizedInflammation,(4E) Contmued
158
I |
I I I |
6 t Thennal Agefis: Cold antl Heat
I) Chnical Clinical v4rc Case Studies-contd Case Studies-eont'd t'"tttltEr-curtt t't I ||
PLANOF CARE PLANOFCARE goalsof treatmenr The goai" treatmentat this this time time areto eliminate eliminateposposrexercise rexercise thighmuscle joincsoreness. thigh muscleand knee kneejoinc soreness. -^^_^^ _ __ ASSESSMENTREGARDINGTHE llE OF CRYOTHERAPY AS THE OPTIMALTREATMENT TBEATMENT Cryotherapy Cryotherapyis an indicated indicatedtreatrnent treatrnentfor for delayed-onset delayed-onset muscle muscle.soreness sorenessand and joint in-0ammation:however, however,the t}le ioint inlammation; patient s exerciseprogram programshould shouldalso alsobe evaluated evaluated and Pacie.ntt,exercise modified as appropdate approPrjateto ro reducehis discomfort discomfon after ex€rcising. The exercrsmg. the presence presence of any contraindications otany contraindications ro the to the application of cryotherapy,such as Raynaud,sslmdrome, shouldbe ruledout beforetlle the application applicarionof cryotherapy.
I APPROPRIATENESS f:E_1Yf-tT_l!911?l!9
I I I I I I I I I
,
||
-
PROPOSEDTREATMENT PR6PoSED TREATMENTPLAN PLAN AND RATI9NALE RATIONALE II As in Cas€1. in Case 1, the *re application applicationof cryotherapy cryotherapyfor for 15 minmin- | | r-rres ut€s with an ice paci< packor cold packwould be b" appropriate upprop.iat" | | for treatment rreatmento[ of tlis this patient's pacJent,s knee. knee. The additional additional ll expense expense of a controlled of a controlled cold cotdcompression compression unit unitis isnotjusnotjus_ | | js no edema tified ciftedin this this case casesince sincethere thereis edemaand andtherefore th"reiore | | compr€s compression sionis not not n€eded. needed. patientshould The The patient shouldapply applythe rhe | | pack immediately after alrer completing his hi. exercisepro- | | "*",.i""'program.Sincethe peronealnerve nerveis is superficialat sup"erficial ar the lateral laieral | | knee, knee.the the patient patienishould shouldbe monitored monito;edfor for signs signsofnerve of nerve ll conduction conductionblockage. blockage.such suchastrnglhg trnglhg ornumbness ornum"bnes"inhis inhis | | lateral lateralleg. leg, during durjngtreatment. treatment. ll || ||
ll
PreferredPhysicalTherapistPraclicePatternssM[4] and4E]areCopyright2002AmericanPhysicalTherapisrAssociation. All rightsreserued. I
I
HEAT_THERMOTHERAPY
I Hemodynamic Effects
The therapeuticapplicationof heat is knownas thermothera7y. Thermotherapyis used clinically outside of rehabilitationprimarily to destroymalignanttissue growth or to treat cold-relatedinjuries.Wi*rin rehabilitation, thermotherapyis usedprimarily to control pain, increasesoft tissueextensibiliry_, increasecirculation, and acceleratehealing.Heat has these therapeutic effectsdue to its influenceon hemodynamic, neuromuscllar,and metabolicprocesses, the mechanismsof which areexplainedin detailfollowing.
I Vasodilation I Heat causesvasodilationand thus an increasein theI rate of blood flow.73When heat is appliedto one areaI of the body, there is vasodilation#h"r. the heat is I applied,and to a lesserdegree,systemically,in areasI disiant from the site of hJat application.SuperficialI heating agentsproduce mor. pionounc"d vasod a-l tion in thJ local'cutaneousblood vessels,where theyI causethe greatestchangein temperature,,nd l.ss I
EFFE'T' 0FHEAT
liffT'*,11:i:';iH'""fT"::'nt."i
Hemodynamiceffects Vasodilation
Neuromuscurar effects Changesin nerveconductionvelocityand Ering rate
3f::fi"*r"*:":l:$, Metaboliceffects Increasedmetabolicrate Altered tissueextensibility Increasedcollagenextensibility
changein temperature.Thermotherapyappliedto rheI whole body can also causegenenlized vasodilationI and may improve vascularendothelialfunction in theI
'"Til:,*:il:fi;'5jTi?l';l'"",.o,r"tion by u,,i_ | " ety of mechanisms,including direct reflex actlvation I of the smooth musclesof the blood vesselsbv rheI
;"i:ff.,::,*T:i*U'a:_,lm:
ceptors,or by increasingthe_!o_c-al releaseof chemicalI mediatorsof inflammation.7s,76 eig. 6_20).A recentI study demonstratedthat at least two independent! mechanismscontributeto the rise in skin blood flow I during local heating: a fast-respondingvasodilator systemmediated by the axonreflexes and -*. I
"
Two . THE PIIYSICAL AGENTS
Figure6-20. How heat causesvasodilation.
:lowly respondingvasodilatorsystem that relies on -ocalproductionof nitrous oxide.77 Superficial heating agents stimulate increased activity of the cutaneous *rermoreceptors. It is rroposedthat transmissionftom the cutaneoustherroreceptors via their axons direcdy to nearby cutareous blood vesselscausesthe releaseof bradykinin andnitrousoxide.Bradykininandnitrous oxide act as ','asoactivemediators stimulating relaxation of the ;mooth musclesof the vesselwalls to causevasodilaion.76-78This vasodilationoccurslocally,in the area -,vherethe heat is applied. Cutaneousthermoreceptorsalso project via the Corsalroot ganglionto synapsewith intemeuronsin *re dorsalhorn of the gray matter of the spinalcord. Theseinterneuronssynapsewith sympatheticneuronsin the lateralgrayhorn of the thoracolumbarsegmentsof the spinalcord to inhibit their firing andthus in symdecrease sympatheticoutput.79This decrease patheticactivity causesa reductionin smooth muscle contraction,resultingin vasodilationboth at the site ofheat aoplicationandin the cutaneousvesselsof the distalexirlmities.B0This distantvasodilativeeffectof thermotherapymay be used to increasecutaneous blood flow to an areawhere it is difficult or unsafeto apply a heating agent directly.BlFor example, if a patienthas an ulcer on his leg as the result of arterial insufficiencyin the extremity,thermotherapymay be aonliedto his lower backto increasethe circuiationto his lowet extremity and thereby facilitate wound
159
healing.This would be most appropriateif the ulcer was bandagedor did not toleratepressure,or if the arealackedsufficientcirculationor sensationto tolerate the direct applicationofheat. Becauseblood flow in the skeletalmusclesis primarily influencedby metabolicfactorsratherthan by changesin sympatheticactiviry,and superficialheating agents do not increasethe temperatureto the depth of most muscles,skeletalmuscle blood flow is much less affectedby superficialheating modaliThe use of exercise ties than is skin blood flow.82,8s or deep heating modalities, such as ultrasound or diathermy,or a combinationof theseinterventions,is thereforerecommendedwhen the goal of treatment is to increaseskeletalmuscleblood flow. Cutaneousvasodilation,and the resultingincrease in blood flow that occursin responseto increasedtissuetemperature,actsto protectthe body from excessiveheatingand tissuedamage.The increasedrate of blood flow increasestlte rate at which an area is cooled by convection.Thus when an areais heated with a thermal agent,it is simultaneouslycooled by circulatingblood, and as the temperatureof the area increases,the rates of circulation and cooling both increaseto reduce the impact of the thermal agent on tissue temperaturethereby reducing the risk of buming.
Effects Neuromuscular velocity andtiringrate in nerveconduction Changes ]ncreasedtemperaturehas long been known to increase nerve conduction velocity and decrease the conduction latency of both sensoryand motor nerves.84,85 Nerve conduction velocity has been to increase by approximately2 meters/secreported 'C (1.8'F) increasein temperature. for every I ond implications of theseeffectsare Although the clinical not well understood, they may contribute to the reducedpain perceptionor improved circulationthat occursin responseto increasingtissuetemperature. Newe firing rate (frequency)has also been found to change in responseto changesin temperature. 'I) 'C Elevationof muscletemperatureto 42 (108 has beenshown to resultin a decreasedfiring rate of gzpe II musclespindle efferentsand gamma efferentsand an increasedfiring rate of type Ib fibers from Golgi These changesin nerve firing tendon organs.86,87 rates are thought to contribute to a reduction in the firing rate of alpha motor neuronsand thus to a
160
6 . Thermal Aeents: Cold and Hcat
reductionin musclespasm.BB The decreasein gamma neuron activity causesthe stretch on the muscle spindlesto d-ecrease. reducingatferentfiring trom the spindles.ue The decreased spindleafferentacciviry resultsin decreasedalpha motor neuron activiqzand thus in relaxationof musclecontraction.
information, it is recommendedthat musclestrength and endurancealwaysbe measuredbeforeapplyinga hp.rtino mnri:linr
Metabolic Effects Increased metabolic rate
Increased oainthreshold Severalstudies demonstratethat the apolication of 9I The proiocal heat can increasepain threshold.eO posed mechanisms of this effect include a direct and immediatereductionof pain by activationof the spinal gating mechanismand an indirect, lateq and more prolonged reduction of pain by reduction of ischemiaand muscle spasm or facilitation of tissue healing. Heat increasesthe activity of the cutaneous thermoreceptors,which can have an immediate bhibitory gatingeffect on the transmissionof the sensationof pain at the spinalcord level.Stimulation of the thermoreceptorscanalsoresultin vasodilation, as describedabove, causing an increasein blood flow and thus potentially reducing pain causedby ischemia.Ischemiamay also be decreasedas a result of reductionof spasmin musclesthat compressblood vessels.The vasodilationproducedby thermotherapy may also acceleratethe recovery of the local pain thresholdto a normal levelby speedingtissuehealing. Changes in musclestrength Muscle strengthand endurancehave been found to decreaseduring the initial 30 minutesafter the application of deep or superficialheating agents.92-94 It is proposedthat this initial decreasein musclestrength is the result of changesin the firing rates of qfpe II musclespindleefferent,gammaefferent,and type Ib fibersfrom Golgi tendon organscausedby heatingof the motornerves.In tum, this decreases the firing rate of alphamotor neurons.Beyond30 minuresaftJrthe applicationof heat, and for the next 2 hours,muscle strength gradually recovers and then increasesto above pretreatmentlevels.This delayedincreasein strengthis thought to result in augmentationof the individual'spain threshold. Although changesin muscle strength produced by heating are not generallyused to modify a rehabilitation program, it is important to be aware of them when assessingmuscle strength as a measure of patient progress. Since comparing preheating strength with postheatingstrength from the same sessionor another sessioncan provide misleading
Heat increasesthe rate of endothermicchemicalreactions, includingthe rate of enzymaticbiologicalreactions.Increasedenzynnaticactiviqyhasbeenobserved 'C in tissuesat 39"to 43 (102"to 109'F),with the reaction rate increasingby approximately13% for 10'C (18'F) increasein temperatureand doubling for every 10'C (18 "F) increasein temperature.32 Enzymatic and metabolic activity rates continue 'C 'I). increaseup to a temperatureof 45 (113 this temperature,the protein constituentsof beginto denatureand enzymeactivity rates ceasing completelyat about50 "C (122'F).es Any increasein en4,'rnatic activity will result in increasein the rate of cellularbiochemical This can increaseoxygenuptakeand accelerate ing but may also increasethe rate of processes. Ior example,heat may acceleratethe ing of a chronic wound; however, it has also shown to increase*re activity of collagenase and thus acceleratethe destructionof articularcartilasei patientswith rheumatoid arthritis.3lTherefore motherapy should be used with caution in with acuteinflammacory disorders. Increasingtissuetemperatutealso shifts the gen-hemoglobindissociationcurveto the right, ing more oxygen availablefor tissuerepair (see 6-4). It has been shown that hemogiobin twice as much oxygen at 41 "C (106'F) as it does - 'rirh rhe rate of blood flow stimulatedby increased ture and the increasedenzymatic reaction rate, increasedoxygenavailabilirymay contributeto erationof tissuehealingby thermotherapy.
Altered Tissue Extensibility Increased collagen extensibility Increasing the temperature of softtissueincreases extensibility.9TWhen soft tissue is heated stretching, it maintains a gteater increase in
after the sketching force is applied, less force requiredto achievethe increasein length,andthe of tissueteadng is reduced.98,99 If heat is applied
T*o . THE PHYSICAI ACENTS
761
The indirect effects of thermo::llagenoussoft tissuesuchas tendor\ Iigament,scar nerve conduction.go and ischemiaare primarily tissue healing therapy on joint prolonged stretchinS, capsule before or :;sue, vasodilation and increasedblood flow. to attributable increases in whereby the tissue . -ascicde[ormation, proposed that the psychologicalexpebeen It has aiso coolincrease after most of the ."rsth and maintains and relaxingmay influas comfortable of heat dence if coilagenous In contrast, b" achieved.100,101 .-g]can pain. perception of patient s ence the prior elastic heating, without ,ssue is stretched Although thermotherapy may reduce pain of ::formation, whereby the tissueincreasesin iength etiology,it is not recommendedas a treatment any most o[ the applied but loses .'.'hilethe force is pain causedby acute inflammation becausean for generally occurs. ::creasewhen the forceis removed, in tissue temperaturemay aggravateother increase tissue 1e maintained elongation of collagenous -::at occursafter heating and stretchingis causedby signsand symptoms_ ^ofinflammationincludingheat, redness. and edema.LUa fibers and :rangesin the organizationof the collagen :: changesof the viscoelasticiqyof the fibers them:elvesratherthan to increasesin the number of fibers. Joint Range ofMotion andDecrease lncreased Forheat to increasethe extensibilityof soft tissue, --:e appropdate temperature range and sffuclures Stiffness ::ust be reached.A maximum increasein residual Thermotherapycanbe usedclinicallyto increasejoint :rgth is achieved when the tissue temperature ROM and decreasejoint stiffness. Both of these effectsare thought to be the result of the increasein : maintainedat 40"to 45'C (104'to 113"I) tor 5 to 101 -l minutes.B6 The superficialhearing agents soft tissue extensibility that occurswith increasing soft tissuetemperature.Increasingsoft tissueextensi:escribed in the following sectionscan cause this .:vel of temperatureincreasein superficialstruclures, bility contributesto increasingjoint ROM because :;ch as cutaneousscartissueor superficialtendons. it results in greater increasesin soft tissue length and less injury when a passivestretch is aPplied.A iiowever, to adequatelyheat deeperstructures,such :. the joint capsulesof large joints or deep tendons, maximum increasein length,with the lowest risk of injury is obtainedif the tissuetemperatureis main::ep-heatingagentssuchas ultrasoundor diathermy 'F) for 5 to 10 mintainedat 40"to 45 "C (104"to 1l3 ::ust oeuseo. utes and if a lowJoad, prolongedstretch i5 aPplied duringthe heatingperiodand while the tissueis coolHEAT OFSUPERFICIAL JSES that ing86l0l 1fig.6-21;.Thereforeit is recommended sffetchingbe performed during and/or immediately Pain control afterthe applicationof thermotherapy,sinceif the tisIncreased ROM and decreasedioint stifftress suesare allowed to cool before being stretched,the Accelerated healing effectsof the prior heatingon tissueextensibilitywill Infrared radiation for psoriasis and dermal ulcers be lost.
rainControl lermotherapy can be used clinically to control :ain. This therapeuticeffectmay be causedby gating :: pain transmission by activation of cutaneous --:rermoreceptors or may indirectly be the result of decreased muscle spasm, or healing, :::rproved ischemia.102 lncreasing skin temperature ::duced sensation of pain by altering ray also reduce the For examand/or transmission.l03 erve conduction produced in the senthe analgesia :le, it is likely that (the volar and nerue .cry distribution of the ulnar is applied when infrared radiation redial forearm), 'ver the ulnat nerveat the elbow,is causedby altered
Figure6-21. LowJoad prolonged stretchwith heat
162
6 o Theftnal Aeents: Cold atd Heat
joint stiffness,a qualThermotherapycandecrease iuy related to the amount of force and the time requiredto move a joint; as joint stiffnessdecreases, less force and time are required to produce joint For example,increasingtissuetempermotion.105-107 ature by placing the hands in a warm water bath or warm paraffin,orheatingthe surfacewith an infrared lamp, have all been shown to decreasefinger joint The proposedmechanismsof this effect stiffness.l0B are increasedextensibiliryand viscoelasticityof the periarticular stuuctures,including the joint capsule and surroundingligaments. When using a heatingagentto increasesoft tissue extensibilitybeforestretching,an agentthat canreach the shortenedtissuemust be used.Thus superficial agentssuch as hot packs,paraffin, or inftared lamps areappropriatefor usebeforestretchingskin, superficial muscle,joints, or fascia,whereas deep heating agents such as ultrasound or diathermy should be usedbeforestretchingdeeperjoint capsules,muscles, or tendons.
Healing Accelerated Thermotherapycanacceleratetissuehealingby increasing circulation and enzymatic activity rate and by increasingthe availability of oxygen to the tissues. Increasingthe rate of circulation acceleratesthe del.ivery of blood to the tissues,bringing in oxygen and other nutrients and removing waste products. The application of any physical agentthat increasescirculation can be beneficial during the proliferative or remodeling stagesof healingor when chronic inflammation is present.However,sinceincreasingcirculationcanincrease edema, the application of thermotherapy during the acuteinflammationphasecan prolongthis phaseand delayhealingandis thereforenot recommended. By increasingthe enzymatic activity rate, thermotherapy also increases*re rate of metabolicreactions, thus allowing the processesof inflammation and healing to proceedmore rapidly. Increasingthe temperatureof the blood also increasesthe dissociation of oxygen from hemoglobin,making more oxygenavailablefor the processes oI tissuerepair. Becausesuperficial heating agents increase the temperatureof only the superficialfew millimetersof the healingof tissue,they aremostlikely to accelerate only superficialstructures,suchasthe skin, or deeper tissuelayers exposeddue to skin ulceration.Deeper effects may also occur as the result of consensual
vasodilationin areasdistant ftom or deepto the of increasedtemperature.
lnfraredRadiation forPsoriasis Although the ultraviolet(U! frequencyrangeof tromagneticradiationis usedmost commonly in treatment of psoriasis,the infrared (IR) rangeis used occasionally for this application.109,110 increasedtemperatureof the upper epidermis dermisin the regionof psoriaticplaquesproduced IR radiationhas beenoroposedasthe mechanism the reductionin psoriaticplaquesthat occursin individualsexposedto IR radiation.110
for DermalUlcers lnfraredRadiation Infraredradiationhas beenusedfor the treatment dermal ulcers.The pumoseof such treatmentwas improve healing by increasingcirculation, bacterialgrowth, and dehydratingthe wound site. However, becausecurrent researchindicates wound healingis optimized with a moist ratler a dry environment,the applicationof IR radiation openwounds is no longerrecommended.l12
ANDPRECAUTIONS FOB CONTRAINDICATIONS THERMOTHERAPY Although thermotherapyis a relativelysate modaliw. its use is contraindicatedin some stances,and it should be appliedwith cautionin ers. Thermotherapyrnay be applied by a clinicianor by a properlyinstructedpatient. may useall forms of thermotherapy,andpatients be instructedto usehot packs,paraffin,or IR lamps home to treat themselves.When patientsare to use these modalities at home, thev should insftucted how to usethe modal.ity,including the tion it should be applied to, the temperatureto used, safety precautions,and the duration and quencyof treatment.Patientsmust alsobe taught to identify possibleadverseeffectsandmust be told discontinuetreatrnentshouldany ofthese occur. Evenwhen thermotherapyis not as with all treatments. if the patient's condition
worseningor not improving after tlvo to three ments, the treatrnent approach should be
or the patient should be refered to a physician reevaluation.
T\ro . THE PIIYSICAI
ACENTS
753
CONTRAINDICATIONS
fortheUseofThermotherapy o Acute injury or inflammation . Recentor potentialhemorrhage o Th'nmhnnhlphiti<
The use of thermotherapy is contraindicated. . . . . in the area of an acute iniury or acute inflamrration )o notapply heatto the areaofan acuteinjury or acute :Jlammation becauseincreasingtissue temperature :anincreaseedemaandbleedingasa resultofvasodila:on and increasedblood flow.11aThis may aggravate :re injury increasepain,andlordelayrecovery ASKTHE PATIENT: . When did this injury occur? Do not apply heat within the first 48 to 72 hours :lter an injury ASSESS: o Skintemperatureand colorand local edema Elevation of skin temperature, rubor, and local :dema demonstratethe presenceof acuteinflamma:on and indicate that heat should not be applied to -j]earea, . . over an area of recent or potential hemor:hage :leat causesvasodilation and an increasedrate of vasodilation maycausereopening :loodflow.Because increasingthe rateofblood flow in :ia vascularlesior5 ra areaof recenthemorrhagecanrestartor worsenthe :leeding.In addition,increasingblood flow in an area rf potential hemorrhagecan causehemorrhageto ::art. Thereforeit is recommendedthat heat not be :pplied to areasof recentor potentialhemorhage. ASKTHE PATIENT: . When did this inj!ry occtn? . Did you haveany bruisingor bleeding? ASSESS: r Visuallyinspectfor ecchymosis
o Imne itpd
. Malignancy o Infraredirradiationof the eyesllr Do not apply thermotherapyif the patient reports bruisingor bleedingin the previous48 to Z2 hours or if recentlyformed red, purple, or blue ecchymosisis presen[. . . . in areas with thrombophlebitis The vasodilation and increasedrate of circuiation causedby increasedtissuetemperaturemay causea thrombus or a blood clot to become dislodged ftom the areabeing treatedand to be moved to the vesselsof vital organs,resultingin morbidity or even death. ASK THE PATIENT o Do you havea blood clot in this area? ASSESS: o Check for calf swelling and tendemess(Homan's sign)before applyingheat to the leg. Do not apply thermotherapy if the patient says that there is a blood clot in the area.Do not apply thermotherapy to the leg if there is tendernessand swelling of the calf until the presenceof a thrombus in the lower extremityhasbeenruled out. . .. over areas with impaired sensation or to patients with impaired mentation A patient'ssensationand a report of heat or pain are used as the primary indicators of the maximum safe temperature for thermotherapy; therefore, a patientwho cannotfeeior reportthe sensationof heat can easilybe burnedbeforethe clinicianrealizesthat there is a probiem. Therefore heat should not be applied to areaswhere sensationis impaired or to patientswho may haveany other difficulty letting the therapistknow when they aretoo hot. ASK THE PATIENT o Do you havenormal feelingin this area? Colrhued
6 o Ther Ml Asents: Cold dttd Heat
164
DICATI0NS-cont'd C0NTRAIN ASSESS: o Sensationin the area Test tubes containing hot and cold water can be usedto teqgthermalsensation.Ifsensationis impaired only in the treatment area, heat may be applied proximally to increaseperipheralcirculationvia the soinalcord reflex,as describedabove.Note that sensation in the distal extremitiesis frequentlyimpaired in patientswith neuropathydue to diabetesmellitus. o Alertnessand orientation Do not applythermotherapyif the patient is unresponslveor conruseo. . . , over or near malignant tissue Thermotherapymay increasethe Srowth rate or rate of metastasisof malignanttissue,eitherby increasing circulationto the areaand/or by increasingmetabolic rate. ASK THE PATIENT Becausea patient may not know that he or she has cancer,or may be uncomfortablediscussingthis diagnosis direcdy, the therapist should first check the chart Fora diagnosisof cancer.Then askthe patient:
. Are you under the care of a physician for any major medicalproblem?lf so,what is the problem? . Have you experiencedany recent unexplained weight lossor gain? o Do you haveconstantpain that doesnot change? If the patient has experiencedrecent unexplained changesin body weight or hasconstantpain that does not change,deferthermotherapyuntil a physicianhas performed a follow-up evaluation to rule out malignancy.If the patient is known to havecancer,askr o Do you know ifyou havea tumor in *ris area? Thermotherapyshould generallynot be appliedin the areaof a known or possiblemalignanry;however,such treatmentmay be given,with informed consent,to provide relief of pain for the terminaLly ill patient.
Infraredirradiationof the eyes IR irradiation of the eyesshould be avoidedbecause such treatmentmay causeoptical damage.To avoid irradiation of the eyes,IR opaquegogglesshould be wom by the patientthroughouttreatmentusingan IR lamp, and by the therapist when near the lamp, as occurswhen settingup t]1etreatment
PRECAUTIONS
fortheUseofThemotheraPy o o o o
Pregnancy Impairedcirculation Poorthermalregulation Edema
Useheatwith caution. . ' ... during pregnanry A fetus may be damagedby maternalhyperthermia; however, since this is unlikely to occur with superticial heatingo[ the limbs. drermotherapymay be applied to such areas, but full body heating, as ociurs with immersion of most of the body in a whirlpool, should be avoided during pregnancy.
o o o o
Cardiacinsufficiency Metal in dre area Overan openwound Over areaswhere topical countedrritantshave recentlybeenapplied
Although matemal hyperthermia has not been demonsffatedwith application of hot packs to the low back or abdomen,suchapplicationis alsogenerally not recommended. ASK THE PATIENT . Are you pregnant? o Do you think you may be pregnant? . Are you trying to get pregnant?
r65
Tpo . THE PIIYSICAL AGENIS
-i -.hepatientis ormay be pregnant,do not aPplyheat l the abdomenor low back and do not immersethe :arient in a warm or hotwhirlpool . , over areas with poor circulation or in ratients with poor thermal regulation -.-:easwith poor circulation and patients wi*r poor :ermal regulation may not vasodilateto a nomal igree in responseto an increasein tissuetempera=re and thereforemay not have a sufficientincrease : blood flow when tissuetemperatureincr€asesto :--otect the tissues ftom buming. In general,poor =ermgl regulationis encounteredin the elderly and ';.ry yourlg. ASSESS: r Check skin temperatureand quality and nail qualiry, and look for tissue swelling or ulceration. Decreasedskin temperature,thin skin, poor nails, dssue swelling, and ulceration are all signs of rmpairedcirculation. Usemilder superficialheat in areaswith poor circu;:on or in elderlyor very young patients.Apply heat a: a lower temperatureor with more insulatiorSand c.eck thesepatientsftequently for any discomfortor ;3ns of burning. . . . in areaswith edema --ee application of thermotherapy to a dependent rruemiry has beenshown to increaseedema.loaThis ei:ct is thought to be the result of the vasodilation ;:d enhancedcirculationthat occurwith raisedtissue :errperatureand the increasein inflammationcaused F; increasedmetabolicrate. ASSESS: . -\4easurelimb girth in the area to be treated and comparethis with the contralateralside. Palpatefor pitting or brawny edema. Check for other signs of inflammation, including heat, redness,and pain. Do not apply heat with the area in a dependent srsition if edema is present.Heat may be applied -^rth cautionwith the areaelevatedif edemais presct and is thought to be a result of impaired venous ;:culation. . , . with patients with cardiac insufEcienry lleat can cause both local and generalizedvasodi;ion, which can contribute to increasedcardiac
demand.Because*ris may not be well toleratedby patients with cardiac insufficiency, such patients shouldbe monitored closelyif heat is applied,particularly if the heat is appliedto a Iargearea. ASK THE PATIENT o Do you haveany problemswith your heart? ASSESS: . In patientswith heart problems,check heart rate and blood pressurebefore,during, and after treatment. A slight decreasein blood pressureand an increase in heart rate are notmal consensual responsesto the application of heat. Discontinue heat treatment in a patient with cardiacinsufficiencyif the patient'sheart rate falls or the patient complains of feeling faint. . . . in areas with metal Metal has a higher thermal conductivity and higher specific heat than body tissue and therefore may becomevery hot with the applicationof conductive heatingmodalities.Ior this reason,jewelry shouldbe removedbeforethe applicationof superficialheating modalities,and cautionshouldbe appliedwhen there is metal, such as staplesor bullet fragments,in the superficialtissuesof the areabeingtreated. ASK THE PATIENT: o Do you have any metal in you in this area,suchas staplesor bullet fragments? . Pleaseremoveyour jewelryin the areato be heated. If there is metal present that cannot easily be removed,applyheatwith caution.Usemilder heat,at or intensiryor with moreinsulaa lower temperature tion, and checkthe areafrequently during treatment for any signs of buming. ASSESS: . Inspectskin for scarsthat may covermetal. . . . over any open wound Do not use paraffin over an open wound becauseit may contaminate the wound and is difficult to remove.All other forms of thermotherapyshouldbe appliedover open wounds with caution becausethe lossof epidermisreducesthe insulationof the subcutaneoustissues.If forms of thermotherapyo*rer than paraffin are usedin the areaof an open wound, they shouldbe appliedat a lower temperatureor intensity, Continued
r56
6.
Thetmal Aeents: Cold and Heat
PRECAUTI0NS-cont'd or with more insulation than would be used when treatins areaswith intact skin. One shouldalsocheck frequentlyduring treatmentfor any signsof burning. When applying a heating agent with the goal of increasingcirculationand acceleratingthe healingof an open wound, hydrotherapy with clean, warm water may be applieddirectly to the wound, or other superficialheatingagentsmay be appliedcloseto, but not diretdy over,dre wound to provide a therapeutic effectrihile reducingthe riskof cros'-conraminarion and burns. . . . over areas where topical counteriffitants have recently been applied Topical counterirritantsare ointmentsor creamsthat causea sensationof heat when applied to the skin. Suchpreparationsgenerallycontain substancessuch as men*rol that stimulate the sensationof heat by
EFFECTS OFTHERMOTHERAPY ADVERSE Bums Fainting Bleeding Skin and eye damage ftom IR irradiation
Burns Excessiveheating can cause protein denaturation and cell death.These effectsmay occur when heat is applied for too long, when the heating agent is too hot, or if heat is applied to a patient who does not have the appropriate protective vasodilation responseto increasedtissuetemperature.The effects viability are exploitedin the medical of heat on ce11 treatment of malignancies,where heat is applied with the goal of killing the malignantcells;however, in applicationof heat in rehabilitation,cell deadr is proteinbeginsto denatureat 45 to be avoided.Because 'C (113"F),andcelldeathhasbeenobservedwhen cells 'C were mahtained at 43 (109'F) for 60 minutesor at 46 "C (115"F)for only ZV2minutes,when applyingheat in rehabilitatioq the durationand tissuetemperature 116 shouldbe keptbelowtheselevels.l15
causing a miid inflammatory reaction in *re Thesepreparationsalsocauselocal superficial lation. If a thermal agentis appliedto an area*rat i already vasodilatedas the result of application of topical countedrritant, the vesselsin the area may be able to vasodilate furdrer to dissipate *Ie heat the thermal agent, and a burn may result.
ASK THE PATIENT . Have you applied any cream or ointment to areatoday? o If so,what type? If the patient has recently applied a topical terirritant to an area,do not apply a superficial ing agent. Tell the patient not to use this type oreparationbetorefuture treatmentsessionsand to apply a superficialheating agent at home usingthis type of preparation.
Overheating and tissue damage can be avoided
usingsuperficialheatingagentsthat get cooler their application,bylimiting the initial temperature the agent, and/or by using insulation between
agentand the patient'sskin. Ior example,hot that arewarmed in hot water beforebeine placed the patient start to cool as soon as they are from the hot water and applied, and are
unlikely to causeburns.In contrast,superficial ing agentssuch as plug-in electric hot packs or lamps that do not cool with use are more likely causeburns.The higher*re temperatureof a tive superficiaiheating agent,the greaterthe rate heat transfer to the patiencand thus the greater
risk of burns:thereforeit is important not to a conductive superficial heating agent and to use adequateinsulation.
To avoid bums,heatingagentsshouldbe applied the mannerrecommendedbelow.They shouldnot appliedfor longerperiods or at higher and the treatment time and temperature of the
agent should be reducedif the patient has circulation. Heating agents should not be where contraindicated, and all patients should be vided with a means of calling for assistance,such
bell. if the clinicianor anotherstaff memberis not
Two . THE PIIYSICAL A GENTS
167
rtheimmediatefteatmentarea.During the treabTrent, the brain to help the patient recover.Heating as small *eck to be surethat the patienthasnot fallenasleep, an areaasclinicallybeneficial,andremovingexcessive heavy clothing that insulates the whole body, may I]; instructthe patientto usea timer that ringsloudly jre also help to limit this consensualdecreasein blood a patient uses time if the *re treatment end of m and thusreducethe probabilityof fainting. pressure agent athome. heating srerficial may also feel faint when getting up after Patients be at home should agent used heating -\ superficial This is due to the additive hypotenthermotherapy. as a microwavable over time, such fe wpe that cools (orthostatic) hypotensionand postural effects of sive heating If an electric pick water botde. or a hot l,:i as describedabove. of the heat, effect hypotensive the type be the it should rad is usedby a patientathome, with a pillow durelevated patient's head the Keeping at all down a switch tar requiresthe patient to hold postdecrease help to can application the heat ing that ensures safety feature -es for it to stay on, This the by reducing postural hypotension ffeatment patient falls asleep if the ::e heatingpad will turn off of the completion at the change of positional extent cd stopsholding down the switch. patient the that is also recommended It treabarent. patient's skin be the It is recommended that remainin the positionusedduringt}le ffeatmentfor a s-.pecredfor bums beforeinitiating treatmentsincea minutes after the thermal agent is removed to few skin :;f,ent may have been burned previously.The allow blood pressureto normalizebeforerising. iculd alsobe inspectedduringand after thermother:cv. A recentsuperficialburn will appearred andmay -ve blistering.As the bumheals,the skinwill appear Bleeding :ale andscarred. The vasodilationand increasedblood flow causedby increasingtissuetemperaturemay causeor aggravate Fainting bleedingin areasof acutetraumaor in patientswith hemophilia.The vasodilationmay alsocausereopen3;casionally,a patient may feel faint when heat is ing of any recentvascularlesion. ::pLied. Iainting, a sudden, transient loss of con;-iousness,is generally due to inadequatecerebral :,ood flow and is most commonly caused by ltradiation lromInfrared SkinandEyeDamage :eripheral vasodilation and decreased blood with a decreased Inftaredradiationcanproduceadverseeffectsthat are ::essure,generallyin association ^-cartrate.llTHeatingan areaof rhe body generally not produced by other superficial thermal agents. These include permanent damageto the eyes and -uses vasodilationlocally and, to a lesserextent,in -eas distantfrom the siteof application.This distant, pemanent changesin skin pigmentation.Iniury to :r consensual,responsecan result in a sufficient *re eyes,including corneal burning and retinal and jecreasein cerebralblood flow to causea patient to lenticulardamage,is consideredto be the most likely ofIR radiationapplicationll3 andmost severe-hazard :aint during the application of thermotherapy.If a :atient feelsfaint while heatis beingapplied,lowering Prolongedexposureto lR radiationmay also cause epideriral hyperplasia.llB :\e headand raisingthe feet will bring more blood to
Evaluatethe patient problem and set the goalsof tleanneru. Determine if thermotherapy is the most appropriate treatrnent. Detemine that themotierapy is not contraindicatedfor this patient or Ihis condirion. Inspect the fteatment area for open wounds and rashes and assess sensation. Check the patient's
chart for any recordof previousadverseresponses to heat or for any diseasethat may predisposethe Ask the appropriate patientto an adverseresponse. questionsof the patient,asdescribedin the preceding sectionson contraindicationsand precautions. 4. Select the appropdate superficial heating agent accordingto the body Part to be treatedand the desiredresponse. Coainued
MA
b . Thenftal Agerts: Cold and Heat
When applying superficialheat, selectan agent that bestfits the iocationand sizeof the areato be treated,is easily applied in the desiredposition, allows the desired amount of motion during application,is available,and is reasonablypriced. Choose an agent that will conform to the area beingtreatedsothat itmaintainsgoodcontactwith *re body. If edemais present,an agentthat canbe appiied with *re area elevatedshould be used. When applying d-rermotherapywith the goal of increasingROM, it canbe beneficialto allow active or passivemotion while the treatment is being applied.Any of the heatingagentsdescribedbelow can be applied in the clinic; only hot packs and paraffinmay be appiiedby patientsat home. 5. Explainto the patientthe procedureandthe reason for applyingthermotherapy,and describethe sensationsthe patient canexpectto [eel. During the application of thermotherapy the patient shouid feel a sensationof mild warmth Dependingon the agentand the amount of insulation, the warmth may not be felt for the first few minutes of treatment.The patient should not feel
TECHNIQUES APPLICATION HotPacks Commerciallyavailablehot packsare usuallymadeo[ bentonite,a hydrophilicsilicategel, coveredwith canvas.Bentoniteis usedfor this applicationbecauseit can hold a largequantity of water for the efficientdelivery ofheat. Hotpacksaremadeinvarioussizesandshapes designedto fit differentareasof the body (Iig. 6-22) They arestoredin hot water kept at about70' to Z5"C thermostati(158'to 167'I) insidea purpose-designed, (Iig. stayson 6-23) *rat water cabinet cally controlled takes 2 hours q?e pack initially of hot at all times.This each use. betv/een to heatand30 minutesto reheat
excessivelyhot or feel any sensationof increased pain or burning.If the patient reportsany of these sensations,discontinuethe treatment or reduce the intensity of the heat. 6. AppIy the appropriate superficial agent. Selectfrom tltefollowinglist:
h
Hotpacks l Paraifin I Seeapplicationsfor Fluidotherapy I eachsuperficialheating on the following IR lamp I agent pug"t. Whirlpoolor I contrastbath ,l Z. Inspectthe treatedareaand assessthe outcome
pdrricularlyfor progressroward the ser g of treatment and for any adverse effects the treatment.Remeasurequantifiablesubj complaints and objective impairments and abilities. 8. Documentthe treatment.
Electric, plug-in heating pads are not mendedfor ciinicalusebecausethey do not cool ing applicationand thereforemay more easilybu patient.If patientsare usinga plug-in electrichea pad at home, advise them to use a pad that re( the "on" switch to be held down for the pad to
to use only the medium or low settings, to application at the medium setting to 20 minutes,
to discontinueuseif any sensationof pain, ov ing, or burning occurs. Patients should also advisedto inspect their skin for any signs of br direcdyafter the useof a hot pack and for the [o ing 24 hours.
Two C THE PHYSICAL AGENTS
-Jre 6-22.Hot packs of vadous shapes and sizes. ,uftesy ChattanoogaCroup, Inc., Hixson, TN.)
:::LripmentRequired . l-lot packsin a variety of sizesand shapes ,rpropriate for differentareasof the body . ,ipecializedheatingunit
169
Figure6-23.Thermostaticallycontrolled hot pack containers. (CourtesyWhitehali Manufacturing, City of Industry CA.)
. . . .
Towels Hot packcovers(optional) Timer Bell
: ?OCEDURE Removeclothing and jewelry from the areato be createdand inspectthe area. Wrap the hot packin six to eightlayersof dry towr l s .H o r p a c kc o v e r sw. h i c hc o m ei n v a r i o u s i z e s :o match the hot packs,can substitutefor two to rhree layers of towels Ffg. 6-2a). More layers shouldbe usedif the towelsor hot packcoversare o l d a n d h a v e b e c o m e- h i n o r i f t h e n a r i e n r :omplainsof feeling,oo*" rr" auring';;"Jrie;;. The towels can be preheatedto achievemore uniform heating throughout the treatment period. More layers of towels should be usedif ahebody part is on top of the hot pack than if the hot pack is piacedover the body part becausewhen the F i g u r6e- 2 4 H . o r p a c k c o v e r so f v d r i o u ss h a p e sa n d body part is on top of the packthe towels are comsizes.(CourtesyChattanooga Group,Inc.,Hixson,TN.) pressed,reducinginsulation of the body, and the underlying table providesmore insulation to the the increasedskin temperaturemay decreasethe pack, causing it to cool more slowly.llg If the patient's thermal sensitivity and the ability to patient complains of not feeling enough heat, judge the tissue'sheat toleranceaccuratelyand fewer layers of towels may be used for the next safely. treatmentsesslonjhowever,towels should not be 3. Apply the wrappedhot pack to the treatmentarea removed during heating with hot packs because and secureit weil (Frg.6-25).
6 c Tlrcrnol Agerts: Cold and Heat
170
4. Provide the patient with a bell or other means to cail for assistancewhiie the hot pack is on and j n s r r u c rt h e p a r i e n t r o c a l l i m m e d i a - e l yi f h e o r she experiences any increase in discomfort. If the patient feels too hot, extra towels should be placed berweer t-he hot pack and the patenr. I[ t]e p a L i e n rd o e s n o t F e e lh o L e n o u g h . f e w e r I a y e r s of towels should be used at the next treatment session. 5 . A f r e r 5 m i n u r e s .c h e c l
;1,r,nd
rrp:fmcnr
Paraffin Warm, melted paraffin can be used for thermother apy. For this application,the paraffin is mixed with mineraloil in a 6:1 or 7:1 ratio of paraffinto oil to reducethe melting temperatureof the paraffin from 'I) 'C 54 (129 to between45' and50 "C (113'to 122"I). Paraffincan safely be applied directly to dre skin at because of its low specificheat and this temperature 'h".-,T
.^^.1',.r,\/in/
F^r
th,<
ennl e:r,on
rhe
paraffin is heated and stored in a themostatically
F i g u r e6 - 2 5 .A p p l i c a . i o no f a h o t p a c k . ( C o u n e s ; Whitehall Manufacturing, City of Industry CA.) . Patient may not tolerate the weight of the hot pack o Pack may not be able to maintain good contac: with small or contoured areas . Acrive -notion noLpracricalduringtreaLmenL o Moderately expensive equipment (heated wate: cabinet)
controlled container Such containers are available in small portable sizes for home or clinic use ani in l.rger sizes oe.igned primari'y [or clinic use (lig. 6-26 4B). Paraffin is usually used for heatir: r h e d i s r a le x r r e m i r i e sb e c a u s er t c a n m a i n t a i ng o o C contact with these irregularly contoured areasPdr"[['n may also be applied to more proxima areai such a, r\e elbows and knee,, or even th. low back, by using the paint method describei following.
Ttro . THE PHYSICAL ACENTS
17l
: gure6-26. Thermostatically controlled paraffin baths. A, Small size for home or clinic use. (Counesy Chattanooga .roup, Inc., Hixson, TN). B, Largesize for clinic use.(CourtesyThermo-Electric,Imperial, PA.)
:quipment Required I Paraffin r Mineral oil (or commerciallyavailablepremixed paraffinintendedfor this application) PROCEDURE -here are three differentmethods by which paraffin ; commonly applied:dip-wrap, dip-immersion,and :aint. The dip-wrap and dip-immersionmethodscan rnly be used for treating the distal extremities.The :aintmethod canbe usedfor any areaof the body.For allthreemethods,do the following: i. Removeall jewelry from the areato be treatedand rnspectthe area. J. Thoroughly wash and dry the areato be treatedto minimize contaminationof the paraffin.
o Thermostaticallycontrolledcontainer o Ple
hro<
nr nrner
o Towels FortheDip-wrapMethad(forthewristaxd hand):
3. With fingersapart,dip the hand into the paraffinas far aspossibleand remove(Frg.6-27). Advise the patient to avoid moving the fingers during the treatment because this will crack the paraffin coating. Also, advise the patient to avoid touching the sides or bottom of the tank because these may be hotter than the paraffin. 4 . Wait briefly for the layer of paraffinto hardenand becomeopaque. Contiweti
172
6 . Thernnl Agehts: CoLl and Heat
Figure6-27. Application of paraffin by Figure6-28. Removing paraffin from a the dip-wrap method. (Courtesy The patient's hand. Hygenic Corporation,Akron, OH.)
5. Redip the hand, keepingthe fingersapart. Repeat steps3 through5 six to ten times. 6. Wrap *re patient'shand in a plasticbag,wax paperr or ueatment table paperand then in a towel. The plasticbag or paperpreventsthe towel from sticking to the paraffin,and the towel actsasinsulation to slow the cooling of the paraflin. Caution the patientnot to move the hand duringdippingor during the restperiodbecausethis may crackthe coating of paraffin, allowing air to penetrateand the paraffinto cool more raoidlv
7. E 1 . . , " i . + k . - - + " - - i k , L Leavethe paraffin in placefor 10 to 15 minutes or until it cools. 9. When the treatmentis completed,peelthe paraffin off the hand and either replacethe paraffin in the containerto melt or discardit (Iig. 6-28). FortheDip-immersion Method: 3. With fingersapart, dip the hand into the paraffin and remove. 4. Wait 5 to 15 secondsfor the layer of paraffin to hardenandbecomeopaque. 5 . Redipthe hand,keepingthe fingersapart. 6. Allow the hand to remain in the paraffin for up to 20 minutesand then removeit (Iig. 6-29). The temperatureof the paraffin should be at the lower end o[ the rangefor this method of application becausethe hand cools less during treat-
Figure6-29. Application of paraffin the dip-immersion method.
ment than with the dip-wrap method. The should be turned off durine the treatmentso the sidesand bottom of *re tan! do not too hot. ForthePaintMethad: 3 . Paint a Iayer of paraffin onto the treatment with a brush. 4. Wait for the layer of paraffinto becomeopaque. 5 . Painton anotherlayer of paraffinno largerthan first layer.RepeaLsteps3 through 5 six to ten times
6. Cover the area with plastic or paper and then wi toweling. As with the dip-immersionmethod, plasticor paperis usedto preventthe towel stickins to the paraffin and the towel acts as
fion to slow down the coolingof the parafft Caution the patient not to move the area duri treatment as this may crack the coating of paraffi allowing air to penetrate and the treatment area cool more rapidly.
7. Leavethe paraffinin placefor 20 minutesor until cools. 8 . When the treatment is completed, peel off paraffin and either replace it in the contalner melt or discard it. ForAll Methads: When the rreaunenris complere.inspeccthe ment area for any signs of adverse effects and ument the treatment.
Two . THE PHYSICAL AGENTS
'C Paraffinmay be sterilizedby heatingit to 80 ',176'F) andthen allowing it to cool overnight.Its temperature should be allowed to retum to 'C between45' and50 (773'to 122'I) beforeit is usedagainfor treatment. IDVANTAGES . -\4aintains goodcontactwith highly contouredareas . Easyto use .llexpensive . Bodypart canbe elevatedif usingthe dip-wrapmethod
:luidotherapy :-uidotherapy is a dry heating agent that transfers It consistsof a cabinetcontain::at by convection.l20 :g finely ground celluloseparticlesmade from corn ::bs (fig. 6-30).Heated air is circulatedthrough the ::rticles, suspendingand moving them so that they ::i like a liquid. The patient extendsa body part into
173
o Oil lubricatesand conditionsthe skin . Can be usedby patientat home DISADVANTAGES o Messyand time-consumingto apply . Cannot be usedover an open skin lesion as it may contaminatethe lesion o fusk of cross-contaminationif the paraffin is reused . Part in dependent position for dip-immersion method
the cabinet,where it floats, as if in water. There are also portalsin the cabinetthat allow the therapistto accessthe patient'sbody part while it is beingheated. Iiuidotherapy units comein a variety of sizessuitable for treating different body parts. Both the lemperature and the amount of particleagitationcan be controlled by the clinician.
:quipment Required . Iluidotherapy unit of appropriatesizeand shape for areasto be treated ) ROCEDURE l. Removeall jewelry and clothing from the areato be treatedand inspectthe area. i. Cover any open wounds with a plastic barrier to prevent the cellulose particles from becoming l^l--l
i - + 1 " .' " ' ^ , ' - J
:. Extend the body part to be treated through the portalof the unit (Fig.6-31). -. Securethe sleeveto prevent particlesfrom escapi^^ f,^*
rL.
""hi--r
: . S e t t h et e m p e r a t u raet 3 8 ' t o4 8 " C( 1 0 0 ' t o1 1 8 ' I ) . 5. Adjust the degreeof agitation to achievepatient comfort. -. The patientmay moveor exerciseduringthe treatrnent. :. Treatfor 20 minutes.
ADVANTAGES . Patientcan move during the treatmentto work on gainingactiveROM e Minimal pressureappliedto the areabeingtreated o Temperaturewell-controlledand constantthroughout treatment o
F,..'r^
"J-inictpt
DISADVANTAGES o Expensiveequipment o limb must be in dependentposition in someunits, increasingthe risk of edemaformation o The constantheat sourcemay resultin overheating o If the corn cob particlesspill onto a smooth floor, they will make the floor slippery Cafitfuued
174
6 . Tlrcrmal Aseflts: Cold atd Heat
Fluidotherapycontrols.(CourtesyChattanooga Figure6-30. Group, Inc., Hixson, TN.)
Figure 6-31. Application oF Fluidotherapy. ChattanoogaGroup, Inc., Hixson, TN.)
Lamps Infrared Infrared lamps emit elechomagneticradiation within the frequency range that gives rise to heat when absorbedby matter (Flg.6-32).lnfraredradiationhas a wavelengthof 770nm to I mm (106nm1.Iying bewveen visible light and microwaveson the electromagnetic spectrum(seelig. 12-1)andis emittedby many sources that emit visible light or W radiation, such as the sun. Infiared radiationis divided into threebandswith different wavelength ranges:IR-A" with wavelengthsof 770 to 1400nm; IR-B,with wavelengthsof 1400to 3000nm; and IR-C.with wavelengthsof 3000to 106nm. The IR sourcesusedin rehabilitationincludesunlighgIRlamps, andlow intensity lasers.Infraredlampsthat emit IR radiation in both the luminous (visible) and nonluminous (invisible) rangeswere availablefor clinical use in the pasq however, only those emitting luminous IR-A Figure6-32. Infrared lamp. (Courtesy Brandt radiation are currendy being manufactured.The lamps Inc., Brorx, NY.)
Two . THE PHYSICAL AGENTS
;'. ailable at this time generally emit IR radiation with '.'.avelengths of between780and 1500nm with a peak ::iensityat 1000nm. producedby IRradiThe tissuetemperatureincrease :ion is direcdyproportionaito the amountofradiation :-at penetratesthe tissue.This is relatedto the power --rd wavelengthof the radiatiorl the distanceo[ the :.diation sourcefrom the tissue,the angleof incidence ,: the radiationto the tissue,andthe absorptioncoeffi::nt of the tissue,Higher power IR will delivermore r=diationto the skin. Most lamps deliverIR radiation .'.ithpower inthe rangeof 50 to 1500watts.The wave.::rethof IR radiationusedclinically,which is beween -30 and1500nm, is absorbedwithin the first 1 to 3 mm :: humandssue.It hasbeenshownthat at least50% of beyond L radiationof 1200nm wavelengthpenetrates -.3mm andis thereforeableto passthroughthe skinto capillariesand cutaneous :,teract with subcutaneous Humanskinailowsmaxlmumpene::rve endings,l2l :ation of radiation with a wavelengthof 1200 nm radiation with a i'hile being virtually opaqueto "lR .r'aveiength of 2000.rmor gteater.113 The amount of energyreachingthe patientfrom an 3 radiation source is also related to the distance ::tween the sourceand the tissue As the distanceof ie sourceftom the target increases,the intensity of =diation reachingthe targetchangesin proportionto ie inversesquareof the distance.Ior example,if the :curceis movedfrom a posidon5 cm from the targetto : Dosition10 cm from the target,increasingby a factor :i 2, the intensity of radiationreachingthe targetwill 111to one-fourth of its prior level The amount of :rergy reachingthe targetis alsorelatedto the angle :i incidenceof the radiation.As the angleof incidence ::- the radiation changes,the intensiry o[ the energy ::achingrhe rargetchangesin proportionto the cosine -i the angleof incidenceof the radiation.For examPle, -'the angleo[ incidencechangesfrom 0 degrees(i.e.,
:quipment Required . IRIamp . IR opaquegoggles
175
perpendicularto the surfaceof the skin),wiLh a cosine with a cosineof f2rz, the intensity of i, to +Sdegrees, a factorofx/2r2.Thus,the intenwill fallby of radiation is greatestwhen the radiation the skin sity reaching sourceis closeco the parient'sskin and the radiadon beam is perpendicularto the skin surface,and, as the the intendistanceor *re angieof incidenceincreases, will diminish. the skin reaching the radiation sity of Infraredradiationis absorbedmost by tissueswith IR absorption Because coe[Ficients highIR absorption color.with primarily by skin affected aie .o-.[fi.i"n,t lighter than radiation more abiorbing darker skins positioning, and lamp radiation skins,with the same dark skin will absorbmore IR radiationand therefore increasemore in temperaturethan liSht skin A number of authorshave provided formulae for calculatingthe exactamount of heat being delivered or methodologies to a patiJnt by IR radiation,109'122 for measuringthe exacttissuetemperatureincrease;110 however,in clinicalpractice,the sensoryreport of the patient is usuallyusedto gaugethe skin temperature. The amount of heat transferis adjustedby changing the power output of the lamp and/or the distanceof the iamp from the patient so that the patient feelsa comfoftablelevel of warmth. Although the clinical use of IR lamps for heating superficialtissueswas popular during the 1940sand 19'50s,this practicehaswaned in recentyears.Its fall in populariry appearsto be the result of changesin practicestyle preferencesandlimitations in the quaniw of prblith.d tesearchdata ratherthan becauseof of excessiveadverseeffectsor lack of u.ry "uid"tl."efficacv. Most of the current use and theraoeutic recentliterature regardingclinical applicationsof IR radiationrelateto high-intensiryIR lasersintendedto rather producelocal burning and photocoagulation than to the lower-intensirylamps intendedfor gentle heatingduringrehabilitation
. Tapemeasureto measuredistanceof treatment areafrom IR source . lowe.Ls Continued
176
6 . Thermal Agants: Cold ard Hcar
PROCEDURE 1. Removeclothing and jewelry from the areato be treatedand inspectthe area.Drape the patient for modesty,leavingthe areato be treateduncovered. 2. PutIR opaquegoggleson the patientandthe therapist if there is a possibility of IR irradiation of the eyes. 3. Allow the IR lamp to warm up for 5 to 10 minutes soit will reacha stablelevel of output.109 4. Position*re patientwith the surfaceof the areato be treatedperpendicularto the IR beamand about 45 to 60 cm away from the source.Rememberthat the intensity of tJle IR radiation reaching the skin decreases, with an inversesquarerelationship,as *re distanceftom the sourceincreases, and in oroporcJon to thecosineof theangleof incidence oi the beam. Adjust the distancefrom the source and wattageof the lamp output so that the patientfeels a comfortablelevelof warmth. Measureandrecord the distanceof the lamp from the targettissue. 5. Providethe patient with a meansto call for assistance,and instruct the patient to call if discomfort occurs. 6. Instruct the patient to avoid moving closer to or farther from the lamp and to avoid touching the lamp since movement toward or away from the lamp will alter the amount of energyreachingthe patrent. 7. Setthelamp to treatfor 15to 30 minutes.Generally, treatment times of about 15 minutes are used for subacuteconditionsand up to 30 minutes for chronic conditions.Most lamps have a timer that
automaticallyshuts off the lamp when the rnpnt
timc
hrc
pLn
B. Monitor the patient'sresponsedudng treatment. maybe necessaryto move the lamp fardrer the patient becomestoo warm. Be cautious moving the lamp closerif the patient reports feeling warm enough as the patient may accommodatedto the sensationandmaynot the heatlevelaccuratelyoncewarm. 9. When the treatment is completed, tum off lamp and dry any perspirationfrom the area. ADVANTAGES . Does not require contact of the medium with patient. This reducesthe risk of infection and possiblediscomfort of the weight of a hor pack. alsoavoidsthe problemofpoor contactwhen ing highly contouredareas. o The areabeing treatedcan be observed the treatment. DISADVANTAGES o Lefraredradiationis not easilylocahzedto a treatmentarea. o It is difficult to ensureconsistentheatinsin all ment areasbecausethe amount of heat transfer affected by the distance of the skin from radiation source and the angle of the beam
the skin, both of which vary with tissue and may be inconsistent between sessions.
MEANS OTHER OFAPPLYING the distanceof THERMOTHERAPY Superficialheat may alsobe appliedby immersionin a walm whirlpool or a contrastbath, as describedin detailin Chapter9.
the agent from the patient, and patient's position or activity if these can be with the agentused.Documentationis typicaily ten in the SOAPnote format.The followins only summarize the modality component of
Documentation
ment and are noi intended to represent a sive plan of care.
Document the area o f tthe body treated,*re type of heating agent used, the treatment duration, and the
When applying a hot pack to the low back,
response to treatment. Also document treatment parameterssuch as the temperatureor power of the agent,the number and type of insulationlayersused,
Examples
9 : 9t,ela tu* Aa& pain al k4z4 7| | 0 0: NP tou* Ao&,,2A , N,t1^t'!14 LL,ebUuA <,4U'rrr!l
177
-1:9ain dsnza.azd, P,"!tu 7ll0 b.4ll0. 9i&lna U,lu,aruz ino*nzd. (,wn 30' to 60' . ?: 9ottlltuz uazol N? aL dlure W.\z 'tfulchihq anl, tla e'x lt^.qrL4lrr
,i,'l-renapplying paraffin to the right hand, document: !:?LcIatlhand, illnz,a.t ea.p*:al&pwitlL Pnar^ e lz.tatolr 1: 9aral$nllhand,, 50'e, l0', dipw^a'lt, Lzltendi'tta' ,+ 0enzalzn iolAf ili44n ,tL. 9+anlnal inlzt'pAalnnAzal e,^latian in 2aA2t |0 20 dzatu't, altzt atiw atn, pa,ttito tltlelchhq. AWekt tiz aAte ea"tt u A.blndaablan e. ?: &nlirulz u.tz o4 fa^a44in o,t al'arrz to" n hahd A4)42 ahekAinA dnd naliliynh& .r.hen applying lluidotherapy to the left leg, anlle, :rd foot, document:
9: ?tola 2 ot&teal|lfu,al I U, 42 "e, 2f . An*le .4n0m dt^irq 0 : ?A.addAz^a'pq hultnq
.,4: 1n*b.99 utavaun kwntuulAaXtlt 5 &yee.' P: oi'tanlbua (luifatAaaPa. P^aq&M' U, dAita dnd' P . dtte tl0IL anl. gait aajtuilia, in urddV Aqrn4' llotilt*a
When applyingIR radiationto the right forearm,document: 9: PLcla k fu'vatm pain wi& utitirry 0: 9k ll fu'rzatm,9R--41000nn', 10011)ol 50 cn fun 20ninulza., :1: tllili, uttali<'n o( untmth ol futza'vn; d*tendzd,50% 9: &alluz 9ll a't,ol'aw 2x Pztt
*^,itirrg
) Clinkal CaseStudies 1 The following casestudiessummarizethe conceptsof supedicialheat discussedin dris chapter.Basedon the scenariospresented,an evaluationof the clinical findingsand goalsof treatmentare proposed.Theseare followed by a discussionof the factorsto be consideredin the selectionof superficialthermotherapyas the indicatedtreatmentmodality and in the selectionof theideal thermotherapyagentto promote progresstoward the setgoals.
Case 4 MP is a 75-year-old female who has been referred for *rerapy with a diagnosis of osteoarthritis of the hands and an order to evaluateand treat with a focus on developing a home program. MP complains of stifftress and aching in all her finger joints, causingdifficulties in gripping cooking utensils and performing other household tasksand pain with w ting- Shereports that these s),rnptoms have gradually worsened over the last 10 years and have become much more severein the last month since she stopped taking ibuprofen due to gastric side effects. The objective exam revealsstiffrressand restrictedflexion ROM of the proximal interphalangealsto approximately 90 degrees,and mild ulnar drift at the carpometacarpal joints bilaterally. The joints are not warm or edematous, and sersation is intact in both hands. EVALUATIONOF THE CLINICAL FINDINGS This patient presentswiti the impairments of restricted finger RON! stifftiess and swelling of the finger joints, joints of andabnormalulnardrift of the carpometacarpal
the hands. These impairments have resulted in difficulties with the functional activities of cookine, household tasks,andwriting. PREFERREDPRACTICEPATTERN Impaired Joint Mobiiity, Motor Function, Muscle Performance,and Range of Motion AssociatedWith ConnectiveTissueDysfunction,(4D) PLAN OF CARE The goals of ueatment at this time are to increaseioint RON,I,leducejoint stiffrress,control pairl and increasethe patient's ability to grip cooking utensils, p€rform household usks, and write. Civen the chronic, progressive ruture of osteoartlritis, the treatment should focus on maintaining the patienCsstatus,optimizing her function, and slowing progressionof her disabfities if possible. ASSESSMENTREGARDINGTHE APPROPRIATENESSOF THERMOTHEBAPYAS THE OPTIMAL TREATMENT Superficialheating agentscanincreaset}re extensibfity of superficial soft tissue and are therefore indicated for the treatmentof ioint stif:frEssand restrictedROM. Superficial heating agentscanalsoreducejoint-r€lat€dpain. Reducing these impairments may also help decreasethis patienCs disabiliry. Thermotherapy is not conffaindicated for this patient at this time because,altlough shehas a diagnosis of osteoarthritis, which is an inflammatory disease,her hands do not show signs of acute in-flammationsuch as increasedtemperatureor edemaof the finger joints, Her Cantinued
17a
6 . Thernal Agents: Cold atd Heat
) Clinical Case Studies-cont'd Cautionshouldbe used, handsaisohaveintactsensation. however, since at the age oE 75 yeats she may have impaired circulation or impaired thermal regulation. Therefore the iatensity of the thermal agentshould be at the lower end of the rangegpically used PROPOSEDTREATMENTPLAN AND RATIONALE It is proposed that superficialheat be applied to the wrists, hands, and fingers of both hands. Paraffin, for or warerare approprjaleLreatments th-ridotherapy. these areas;however, a hot pack is not appropriate becauseit would not provide good contactwith these highly contoured areas. ?araffin has the additional advantageof allowing elevation while heat is being applied,thus reducingthe risk of edemaformation.It is aiso inexpensiveand safeenough to be used at home; ofnotallowing motion however,ithas the disadvantage during application. Therefore for optimal benefit, if paraffinis usedto treat this patient,sheshouldperform ictive ROM exercisesdirectly after removing the paraffin from her hands. Fluidotherapy and water Lave the advantageof aliowing motion during their application; however, Iluidotherapy is generally too expensiveand cumbersomefor useat home or in many clinics,and water immersion may result in edemaformationbecauset}Ie patient'shandsmustbe in a dependentpositionwhile beingheated.Civen *reseadvantages and disadvantages,walm water soaks together with if rhe parienrdoes would be most appropriare exercise and paraffinfof treatment, with this not developedema iowed by exercisewould be most appropriateif the patient developsedemawith soakingin warm water If paraffinis used,it shouldbe appliedusingthe dip-wraP methodratherthan the dip-immersionmethod sincethe former allows elevationof the hand and resultsin less intenseand prolongedheating.Thereforeit is lessiikely to result in edemaformation and is saferfor the older patientwho may have impairedcirculationand/or thermal regulation.
I
not letuned to his job as a carPenterbecauseof low by forward bending and back pain that is aSSravated Iow back stiffnesst}tat is most intenseduring $e first few hoursol the day.I(B reportsthar his pain is also by lyingsupinefor motethan5 minutesand aggravated to somedegreeby taking a hot shower'He alleviated is had beenmakinggood progress,with increasingIumbar ROM, strength,and endurance,until the last 2 weeks, when his progressreacheda Plateau The objective exam revealsspasmsof the lumbar Paraverteblalmuscles,a 507orestrictionof activeforward-bendingROM, and a 30% restrictionof sidebendingbilatelally,with a complaint of pulling of the 1ow back at the end of the range. Other objective measures,including activebackwardbendinS,passiveioint mobiliry, sensation, and lower extremity strengttr,are within oormal limits. OF THE CLINICALFINDINGS EVALUATION This patient presentswith impairments of resfficted trunk forward- and side-bendingROM, paravertebral musclespasms,and low back pain. He also has nor retumedto work sincehis injury' PREFERREDPRACTICEPATTERN lmpaired Joint Mobiliry, Moror Function, Muscle Performance, Range of Motion, and Refiex Integdty AssociatedWithSpinalDisorders,(4F) PLAN OF CARE The eoalsof ffeatment at this time are to decreaselow back pain and stifktess,to increaselumbar folwardbendingand side-bendingROM, and to havethe Patient tetumto worK.
ASSESSMENTREGARDINGTHE APPROPRIATENESSOF THERMOTHERAPYAS THE OPTIMALTREATMENT It is important to re alizethat 2 months after a soft dssue injury a patient's rehabilitation program should generallyfocus on activepartjciparionin a proSram Case 2 however the app{ipain. of srrerchingand strengtbening: back KB is a 45-year-oldmalepatientwi*r mild low activeexercisemay before physical agent a of suscation ladder and fiom a he fell 10 feet Two months ago, be indicated to improve performanceand accelerate tainedseveresoft tissuebruising;however,therewas no progress.Thermotheapy may be indicated for this evidence of a fracture or disc damagewith this tmuma. patient sinceit canreducepain, stiffness,and soft tissue KB was refered for physical therapy 1 month ago with optishorteningand becausethis patient has rePoftedthat a anorder to the diagnosisofa lumbarstrainandwith shower,which providessuperficialheating, helps hot to patient retuming goal of the with the function mize in dn dcriveexercise to alleviate his symptoms. There are also no conwork. KB i" currendypanicipating programto work on spinalflexibiligzand stabilization, traindications to the use of thermotherapy for this patient. but he often feelsstiff when surting to exerciseand has
TTyo . THE PHYSICAL ACENTS
PROPOSEDTREATMENTPLAN AND RATIONALE A deep or superficialheatingagentwould be appropriate for providingthermotherapyto this patient.A deep heating agent would be ideal since it could direcdy increasethe temperatureof both the superficialtissues and the musclesof the low back;however,a superficial heating agent would generally be used because diathermy, which can provide deep heating to large areas,is not available in most clinical setiings (see Chapter12)and ulhasoundcanonly provide deepheating to small areas(seeChapter 7). Superficialheating couldbe providedto the low backusingan lR lamp or a hot pack.A hot pack is most likely to be usedsinceIR lamps are aiso not availablein most clinical settings. to the useof thermotherThereareno contraindications apy for this patient. A hot pack could be applied with the patieot in a prone, side-lyingror sitting Positioq however, suplne positioningshouldbe avoidedsincehe reportsthat this agg(avateshis pain. More insulating towels may be n€ededin *re sitting position than in the prone or sidelying position due to compressionof tl.retowels and the insulatingeffectofthe backofthe chair.Treatmentwith any superficialheatiogagentwould generallybe applied for 20 to 30 minutes.Also, to optimize the ben€fit of increasedsoft tissue extensibilily, active or Passive stretchingshould b€ performedimmediately following the applicationofthe thermalagent.
Case3 BD is a 72-year-oldfemale with a 10-yearhistory of non-i.nsulin-dependent diabetes mellitus and a fullthickness ulcer on her lateral right ankle causedby aterial insufficiency.The ulcer has been presentfor 6 months and has been treated only with dressing changes.BD has poor arterial circulationin her distal lower extremities,but her physician has determined that she is not a candidatefor lower extremity bypass surgery Sensationis impaired distal to the patient's kneesand is intact proximal to the knees.The patientis alert and oriented.Shelives aloneat home and is independent in all activities of daily living; however, her walking is limited to approximately500 feet becauseof calf pain. BD has been referredto physicaltherapy for evaluationand treatmentof her ulcer.
179
EVALUATIONOF CLINICAL FINDINGS This patient presentswith the imPairmentsof loss of skin and underlying soft tissue on her right lateral ankle and reducedsensationin both lower extremities.Her ambulationtoleranceis limited, and she is requiredto change the dressing on her wound two or three times perweek. PREFEBREDPRACTICEPATTERN ImpairedIntegumentaryIntegdty AssociatedWith FullThicknessSkinInvolvementand Scarlormation,(7D) PLAN OF CARE The eoalsof treatmentat this time are to decreasethe achieve wound closure, and eliminate *o.rrrd "t"u, with openwoundsand risk associated high infection the the needfor dressingchanges. ASSESSMENTREGARDINGTHE APPROPRIATENESSOF THERMOTHERAPYAS THE OPTIMAL TREATMENT Thermotherapymay be indicated to achievethe proposed goals of treatment because it can improve circulationand thus facilitatetissuehealing Superficial heating agents can lncreasecirculation both in the areato which the heat is appliedand distally lncreasing tissuetemperatulecan also increaseoxygen-hemoglobin dissociation,increasingthe availability of oxygen for tissue healing. Becausethe application of thermotherapydirecdyto the distallowel exuemitiesof this patientis contraindicateddue to her impairedsensation in theseareas,proximalapplicationof thermotherapyto the patient'slow backor thighsmay be usedto increase the cilculation to her distal lower extremitieswithout excessive risk. PROPOSEDTREATMENTPLAN AND RATIONALE Thermotherapyusinga deeporsuperficialheatingagent would be appropriatefor this patient As with Case2, deepheatingwould be idealsincethis would affectboth deep and superficialtissue temperatuleslhowevet, a superficial heating agent is more likely to be used becauseofgreater availability.A hot pack or an IR lamp could be usedto heat this patient'slow back or thighs and shouldbe appliedfor about20 minutes.
All dghts ?referredPhysicalThempistPraclicePattemssM[4D, 4F and 7D] arc copyr\Eht2002AmericanPhysicalTherapy Association
6 t Thermal Aeerts: Cold and Heat
180
p
6-3 Effectsof Effect
and Thermotherapy Cryotherapy
Thermotherapy
Pain
Musclespasm Bloodflow Edemaformation Nerveconduction velocity Metabolicrate Collagenextensibiliry Jointstiffness
0 = decreases;+ = increases;0 = no effect.
CHOOSING BETWEEN CRYOTHERAPY ANDTHERMOTHERAPY Becausesome of the effectsand clinical indications for the useof cryotherapyand thermotherapyare the sameand othersare djfferent,thereare somesituations in which eithermay be usedand othersinwhich only one or the otherwould be appropriate.Table6-3 provides a summary of the effects of cryotherapy and thermotherapyto assistthe clinicianin choosing betweenthesetreatmentoptions.
blood flow,
increase nerve conduction
increasepain threshold, alter muscle strength, increase enzvmatic activitv rate. These effects thermotherapy are used clinically to control
increasesoft tissue extensibiliry.and healing. Thermal agents should not be applied situations in which drey may aggravate an
pathology,suchas a malignancy,or may cause age,suchas frostbite or burns.The readeris
Chapter Review
to the Evolve website at http://evolve.elsevier.
Thermal agentstransferheat to or from patientsby conduction, convection, conversiory or radiation. Cryotherapyis the transferof heat from a patient by use of a cooling agent, and thermotherapy is the transferof heat to a patientby useof a heatingagent. Cryotherapy has been shown to decreaseblood flow, decreasenerve conduction velociry increase pain threshold,alter musclestrength,decreaseenzymatic activity rate, temporarily decreasespasticiqy, and facilitate muscle contraction. These effects of cryotherapyare used clinically to control inflammation, pain, edema, and muscle spasml to reduce spasticirytemporarily; and to facilitate muscle conftaction.Thermotheraovhas beenshown to increase
Cameron for study questions pertinent to chapter
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Two . THE PITYSICAL ACENTS
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22. loLnson J, Leider FE:Influenceof cold bath on maximum handgrip strength, PerceVtMot Skills 44:323-325, 1977. 23. Davies CTM, Young K: Effect of temperature on the contractile properties and muscle power of triceps surae in humans,J Appl Physiol55:191-195, 1983. 24. Knuttsson E, Mattsson E: Effectsof loca1cooling oo monosynaptic reflexesin man, ScandJ RehabilMed 52:166-168,1969. 25. KnuttssonE: Topical cryotherapyin spaslciry,ScatldJ Rehabil Med2:159-L62 , 1970. 26. Hartvikksen K: Ice therapy in spasticity,Acta Neurol Scatrd38:79-83, 1962. 27. Mrghena O: Electromyographic characteristicsof donus and influence of cold, Arch Phys Med Rehabll 45:502-503 , 1964. 28. Miglietta O: Action of cold on spasticrty, AnJ PhysMed 52:198-205 , 1973. 29. PriceR, LehmannJl Boswell-Bassette S et al: Influence of cryotherapyon spasticityat the human ankle,Arr& PhysMed Rehabil7 4:300-304,1993. 30. Wolf SL,LetbetterWD: Effectof skin coolingon spontaneousEMG activity in fticeps suraeof the decerebrate cat,Braix Res91:151-155,1975. 31. Harris ED, McCroskery?A: The influenceof temperature and fibril stability on degradation of cartilagecollagen by rheumatoidsynovialcollagenase, N Eryl J Med 290:1,-6, 1,97 4. 32. Hocutt JE,JaffeR, RyplanderCR et al: Cryotherapyin arkle sprairs,AmJ SyonsMed 10(5):316-319, 1982. 33. Ohkoshi Y, Ohkoshi M, Nagasaki S: The effect of cryotherapyon intraarticulartemperatureand postoperativecareafter ante or cruciat€ligamentreconstntctton,An J SVotrs Med May-1v427(3):357-362,1999. 34. Meeusen\ Lievens?: The useof cryotherapyin sport injuries,SVotts Med 3:398-414 , 1,986. 35. Friden J, Sjostrom M, Ekblom B: A morphological study of delayed onset muscle sorctess,Erperiefitia 37:506-507 , 1981. 36. Jones D, Newhan D, Round J et al: Experimental human muscledamage:morphologicalchangesin relation to other indicesof damage,IPhysiolSTS:435-448, 1986. 37. Cote DJ,PrenticeWL, Hooker DN et al: Comparisonof threekeatment proceduresfor minimizing anklesprain swelltng,PhysTher68(71:1072-107 6, 1988. 38. Wilkerson GB: Treatment of inversion ankle sprain through synchronousapplicationof focai compression andcold,Athl Truia26220-225, 199L. 39. Quillen WS, Roullier LH: Initial management of acuteankle sprainswith rapid pulsedpneumaticcompressionand cold,J Onhop SponsPhys Ther4:39-43, 1982.
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Boris 44, Wiedorf S, Lasinski B et al: Lymphedema 60. MetzmanL, GambleJG,RinskyLA: Effectiveness of ice reductionby noninvasivecomplex lymphedematherpacksin reducing skin temperatureunder casts,Clir apy,Oncology -221, 1.996. 8(9):95-106, 1.994. OnhopSep;(330):217 4 T , BeenakkerEA, OparinaTI, HartgringA et al: Cooling 6r. Iarryr PJ,PrenticeNG: Ice treatment of injured ligaments:an expedmentalnod,el,NZ MedJ 9:12-14,1980. SarmentUeatment in MS: clinical improvement and decreasein leukocyte NO productioq NeutologySep 62. KrumhanslBR: Ice lollies for ice massage,Plys 11;57(5):892-894,2001. 49(10):1098 , 1969. 4 2 . CapelloE, GardellaM, LeandriM et al: Lowering body 63. SchroderD,PasslerHH:Combinationofcold and comtemperaturewitl a cooling suit as symptomaticfteatpressionafter knee sutgery:aprospectiv€ ment for thermosensitivemultiple sclerosispatients, study,KxeeSurgSyonsTtaumarol Anhrosc2B\:758-1 halJ NeurolSciNov;16(8):533-539, 1995. 1994. Umphred DA: NeurohgicalRehabllintiou,St. Louis, 64. Webb JM, Williams D, Ivory JP et al: The use of 1985,Mosby, compressiondressingsafter total knee replacement: 44. SelbachH: The principiesof relaxationoscillationas randomized coqtrolled tial, OnhoVedicsJat;21 a special instance of the law of initial value in 59-61,, 1998. cybemetic functions, Axn NY Acad Sci 98:1227-!228, 65. Travel J: Temporomandibularjoint pain referred 1962. musclesof the head and neck,J Ptosthetic Dent I0( 45. Celhom E: PirciVles of Autoaomic-Somatic htegration: 745,763,1960. Physialogical BasisandPsychololal and Clixiul Inpliutiotts, 66. Rubin D: Myofascial t gger point syndromes: Minneapolis, 1967,Universiry of MinnesotaPress. approach co marragement.A,ch Phys Med 46. Krright W: Cryothetapy:Theory Techxi4ue,Physiotogy, -I70, 1981. 62:107 Chattanooga,Tenn, 1985,ChattanoogaCorp. 67. Fluorimethaxe rcchxicalspeclfcatioxs, Cleveland, 47. Hayden CA: Cryokinetics in an early treatrnentpro1996,Cebauer Co. gram,JAn PhysTherAssoc44:990,1964. 68. TravellJC,SimonsDG:MyofascialPaiaand 48. BugajR The cooling analgesigand rewarming effectsof The Tigger PoinrManual, Baltrmore, 1983, ice massageon iocalizedskjn,PhysTher55(l):11-19,1975. Wilkins. 49. PrenticeWEr An electromyographicanalysis of the 69. Travell jC: Myofascialtrigger points: cljnical vjew. effectiveness ofheat or cold and stretchingfor inducing BonicaJJ,Albe-IessardD,ed.s: AAtaaces ln Pain relaxation in injured muscle,J Onhop SponsPhys Ther and Therapy, NewYork, 1976,RavenPress, 3tt33-137, 1982. 70. SimonsDC, TravellJC: Myofascialoriginsof low 50, Tiemey IM, McPheeSJ,lapadakis NM er al: Curett pain. 1: Priaciplesof diagnosisand treatment,P Medical Diagnosisand Treatwext.Norwalk, Cl 1998, Med73Q):70-77,1983. Appleton & Lange. 71. SimonsDC: Myofascialpain syndromedue to 51. Day MJ:Hypersensitiveresponseto ice massage: repolt points, Int RehabilMetl AssocMonogr 1, 7987. of a case,PhvsTher54t592-593 . 1974. ScarcellaJB, Cohr BT: The effect of cold therapv 52. PatkerJ! Smail NC, Davis DG: Cold-inducednerve the postoperativecourse of total hip and total palsy,Athl Traint876-77, 1.983. -852, arthroplastypatients, AnJ Onhop24(11):847 53. Creen GA, ZachazewskiJE,JordanSl: Peronealnerve 73. Bickford RH, Duff RS: Influenceof ultrasonic palsy induced by cryotherapy, Physician Sport Med tion on temperatureand blood flow in human 17(9)t63-70 , 1989. muscle,CrnRzs1:534-538,1953. 54. Lundgren C, Muren A, Zed.erfeldtB: Effect of cold Imamura M, Biro S, I(hara T et al: Repeated vasoconstrictionon wound healingin t}Ie rabbit,Acta therapy improves impaired vascularendothelial Chi Scand1,1,8:1, 1959. tion ir patientswith coronary rlsk factors,J Am 55. Boyer J! Iraser JRE,Doyle AE: The hemodlmamic CatdiolOcr;38(4):1083-1088, 2001. effects of cold imme rsiory Clix Sci 19:539-543,7980. 75. Crockford GW, Hellon M, ParkhouseJ:Thermal 56. CovingtonDB, BassettIH: When cryotherapyinjures, motorresponsein humanskin mediatedby local Physician SyonMed 2I(3)i 8-93, 1993. allusraes, 1.962. J Physiol161:1.0-L5, 57. Knight W: Cryotherayy in SFofi lniury Management, 76. Kellogg DL Jr, Liu I Kosiba II et al; Role of Champaign,IL, 1995,Human Kinetics, oxide in the vasculareffects of local warming of 58. BensonTB, Copp EP:The effectsof therapeuticforms skin in humans,J Ayyl PhysiolApr;86(4):1185-11 of heat and ice on the pain threshold of the normal 1,999. should.er, Rheumatol Rehabll13:101-104, 1974 . 77. Minson CT, Berry LI, Joyner MJ: Nirric oxide and 59. MacAuley DC: Ice therapy:how good is the evidence? rally mediated regulation of skin blood flow -384,2001. IxtJ SponsMerl.Jul;22(5)1379 -1626,2001. localheating,J AyyI PhysiolOc991(4):1619
Tso . THE PIIYSICAL AGENTS
-3.
Fox HH, Hilton SM: Bradykinin formation in human skin as a factor in heat vasodilation,/ Pltysbl142:219, 1958. -9. Guyton AC Textbaok of Medical Physiology,ed 8, Philadelphia,1991,WB Saunders. :4. AbramsonDl Indirect vasodilationin thermotherapy, ArchPhysMed Rehabil46:412-415 , 1965. !1. WessmanMS, Kottke FJ:The effect of indirectheating on peripheralblood flow, pulse rate, blood pressure and temperature,Atch PhysMed Rehabil48:567-576, 1967. .2. WWer DJ, McNiven DR: Effects of some physiotherapeutic agentson skeletaimuscleblood f1ow,Physiothetayy 6283-85, 1976. :3. Crockford GW, Hellon RF: Vascular responsesin human skin to infta-red radiation, / Physiol 149: 424-426,19s9. :-1. CurrierDP,IGamerJF:Sensorynerveconduction:heating effecs of ultrasound and infrared radiation, Caxada34:24I-246,1982. Physiothet :5. Halle JS, Scoville C\ GreathouseDGr Ultrasound effecton the conductionlatencyof t}Ie superficialradial rewe ln mar, PhysTher61:345-350,1981. :6. LehmannJF,Delateur BJ:Therapeutic heat. In Lehmann JF,ed TherayeuttHeat and CoA, ed 4, Baltimore, 1990, Williams & Wilkios. :7. Rennie GA, Michlovitz SL: Biophysicalprinciples of heating and superficialheating agents.In Michlovitz SL, ed: Thetnal Agents ix Rehabilitatior, Philadelphia, 1996,FADavis. 38. FountainIP, GerstenJW,SengerO: Decreasein muscle spasmproducedby ultrasound,hot packsand I\ Arcl PhysMed Rehabil41:293-299, 1960. !9. FischerM, SchaferSS:Temperatureeffectson the dischargefrequencyof primary and secondaryendingsof isolated cat muscle spindlestecorded under a rampand-holdstretch,Braix Res840(I-2):!'15, 1999. 10. Lehmann JF,Brunner GD, Stow RW: Pain threshold measurementsafter therapeuticapplication of ultrasound, mictowaves and nfrared, Arch PhysMed Rehabil 39:560-565,1'958. il. BensonTB, Copp EP:The effectsof therapeuticforms of heat and ice on the pain threshold of the normal 1974 Rehabil13:101-104, shoride4Rheumatol 92. Chastain PB: The effect of deep heat on isometric strengtt, PhysTher58:543-546,1978 93. Wickstrom R, Polk C: Effect of whirlpool on the strength and enduranceof the quadricepsmuscle in trained male adolescents,An J PhysMed 4091-95, 1961. 94. Edwards\ Harris \ Hultman E et al: Energymetabolism duringisometricexerciseat differenttemperatures of m. quadricepsfemoris in man, Acta PhysiolSand 80:I7-18,1970.
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95. tvtiller MW, Ziskin MC: Biological consequencesof -722, 1989. hyperrhermia, lJhtasoundMed Biol 1'5(8):707 96. BarcroftJ, King W: The effect of temPeratureon the dissociationcuwe of blood,I PhysiolS9:374-384,1909. 97. Lentell G, Hetherington T, EaganJ et al: The use of thermal agentsto iofluencethe effectivenessof lowload prolongedstretch,J OnhopSponPhysTher16(5): 200-207, 1992. 98. Waren C, LehmannJ, KoblanskiJ: Elongationof rat tail tendon:effect of load and temPeratwe,ArchPhys 4, 484' I971'. Med Rehabil52:465-47 99. Warren C, LehmannJ, KobianskiJ; Heat and stretch procedures:an evaluationusing rat tail tendon,Arch PhysMed Rehabil57:122-126 , 1976. 100. GerstenlW: Effectof ultrasoundon tendonextensibil1q',Afl l Phys'Med34:362-369,1'95s. 101. Lehmannl, MasockA, Waren C et al: Effectof therakch Phys peutictemperatureson tendonextensibilLty, Med Rehabil51:48I-487, 1970. 102. Kramer JI: Uitrasound:evaluationof its mechanical and thermaleffects,A rchPhysMed Rehabil6S:223-227, 1984. 103, SteilarJ,Habot B: Improvementof pain and disabiliry in elderlypatientswith degenerativeosteoarthritisof the knee treated with narrow band light th erapy,J An GeriatrSoc40(l):23-26,1992. j, Garett I Erickson D: Swelling of the Magness 104. upper extremity during whirlpool baths, Arch Phys Med Rehabil51:297-299, I970. 105. Wright V, JohnsR: ?hysicalfactorsconcernedwith the stiffnessof normai and diseasedjoints,/ohxsHoltblns HosyBull 706.215-229 , 1960. 106. Kik JA, Kersley GD: Heat and cold in the physical treaffnent of rheumatoid arthritis of the ktee, Axx PhysMed 9:270-274, 1968 107. BlacklungL, Tiselius P: Objective measurementof joint stiffness in rheumatoid arrhtitis, Acta Rheum . Scaad13:275, 1.967 108. Johns R, Wight V Relative impodance of various tissuesin joint stiffness,/ AVpl Physiol17:824-828, 1962. 109, Orenberg EK, Noodleman I\ Koperski JA et al: Comparisonof heat delivery systemsfor hyperthermia treatment of psoriasis,Int J Hypenhetn 2(3): 231-241 , 1986. 110. WesterhofW, SiddiquiAH, CormaneRH et al: Infrared hyperthermia and psoriasis,Arch Detmanl Res 279:209-210,1987. 111. Hyland DB, Kirkland VJ: Infra red therapy for skin 1801,1980. tlcers,AmJ Nuts80(10):1800112. Cummings J: Role of light in wound healing. In Kloth L, McCulloch JM, Ieedar JA, eds lYoundHeallxg Aheruativesifl Maftagenettt,Philadelphia, 1990, IA Davis.
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Thental Aeenrc:Cold aad Heat
113. Moss C, Ellis & Munay W et aI: hftated Radiatioq Nouioftkixg RadiationPlotectioft,ed 2, WHO Regional Publications,European Series, 25, Ceneva, 1989, World Health Organization. 114. Schmidt KL: Heag cold and inflammation, Rheunatology 38:391'404,1979. 115. SaparetoSA, Dewey WC: Thermal dose determinatron in cancer therapy, Iat I Radiol Oncol Biol Phys 1984. tQ787 -1QQ, 116. Homback NB: Hyyenherniaand Carcet Boca Raton, FL. 1984.CRC Press. II7. Canong Wl Revieu, of Mediul Physiology,ed 13, Norwalk, Cl 1987,Appleton & Lange. 118. KligmanLH: Intensificationof ultraviolet-induced dermal damageby infra-redradiation,ArchDermatolRes 272:229-238,1982.
119.Enwemeka CS,BoothCK,IisherSLet al:Decaytime of temperature of hot packsin two application positions,PhysThet76(5):596, 1996. 120.BorrellRM, HenleyES,PurvisH et al:lluidotherapy evaluationof a new heat modalty, Arch PhysMet Rehabil 58:69-71 , 1977. 121.HardyJD: Spectral transmittance and reflectance of excisedhuman skin, J AVyl Physiol9:257-264 1956. for physical 122.SelkinsKM, EmeryAF:Thermalscience medicine.In LehmannJF,ed:Therapeutic HeataudCokl" ed3, Baltimore, 1982,Williams& Wilkins.
SUMMARY
OF lNFORMATION
Jistory nrminology leneration of Ultrasound -ffects of Ultrasound Ilinical Applications of Ultrasound lontraindications and Precautionsfor Ultrasound
COVERED
AdverseEffectsof Ultrasound Application Technique Documentation Clinical CaseStudies Chapter Review
OBJECTIVES UVoncomyletionof this chayter,thereaderwill beable to: 6 . Chooseand use the most approPriate Recognizeand distinguishthe terminology used theraoeuticultrasound deviceand treatment ultrasound. therapeutic to describe parametersto obtain the desiredtreatment responses to physiological the Analyze goals. particular to promote necessary ultrasound 7. Evaluatedifferent therapeutic goals. treatment ultrasound deviceswith respectto their properties of, and the physical ) . Identify the for treating different patient potential to, therapeutic physiologicalresponses problems. ultrasound, Presentedwith a clinical case,evaluatethe J , Evaluatethe indications, contraindications,and clinical findings, proposegoalsof treatment' orecautionsfor the use of therapeutic assesswhether therapeuticultrasoundwould be patient ultrasoundwith respectto different the best treatment, and, if so, formulate an managementsituations. treatment plan, including the effective 5. Design appropriatemethods for selecting appropriatetreatment parameters,for achieving therapeuticultrasound treatment Parametersto the soalsof treatment. producedesiredphysical and physiological effects.
185
t86
7 o Ultrasound
HISTORY Methods to generate and detect ultrasound first becameavailablein the United Statesin the 19th century; however, the first large-scaleapplication of ultrasoundwas for SONAR (SoundNavigation and Ranging)during World War II. For this application,a short pulse of ultrasoundis sent from a submarine through the wate! and a detectoris usedto pick up the echo of the signal. Becausethe time required for the echo to reachthe detectoris nrooortional to the disrance o[ the detectortrom a refleciingsurface, the durationof this periodcanbe usedto calculatethe distanceto objectsunderthe wateg suchasother submarines or rocks. This pulse-echotechnology has sincebeen adaptedfor medicalimagingapplications, for "viewing" a fetus or other intemal masses,Early SONAR devicesused high-intensity ultrasound for easeof detection;however, it was found that these devicescan heat and thus damageunderwater life. Although this fact limited the intensity of ultrasound appropdatefor SONA\ it led to the developmentof clinical ultrasound devicesspecificallyintended for heating of biologicaltissue.Ultrasoundwas found to heat tissuewith a high collagencontent,suchas tendons, ligaments,or fasciaand, for the past 50 years or more, has beenwidely usedin the clinical setting for this purpose. More recendy, ultrasound has also been found to have nonthermal effects and, over the past 20 years, therapeuticapplicationsof these effects have been developed.Low-intensity pulsedultrasound,which producesonly nonthermal effects,has been shown to facilitate tissue healing, modify inflammation,and enhancetransdermaldrug delivery
WhatlsUltrasound? Ultrasoundis a type of sound,and all forms of sound consistof waves that transmit energy6y altemately compressing and rarefying material (Fig. Z-1). Ultrasoundis defined as sound with a frequencvof greaterthan 20,000cyclesper secondftlertz. Hz). ihls definition is based on the limits of normal human hearing.Humanscan hearsoundwith a frequencyof 16 to 20,000Hz; soundwith a ftequencygreaterthan this is known as uhrasound.Cenerally,therapeutic uitrasoundhas a ftequency of between 0.2 and 3.3 megahenz (MHz) in order ro maximize enery absorptionat a depth of2 to 5 cm ofsoft tissue.
Transducer
?
Compression
-----T----Rarefaction
Figure 7-1. Uitrasoundcompression-rarelaccionwave.
Audible sound and ultrasoundhave many properties.Ior example,asultrasoundtravels material, it gradually decreasesin intensity due attenuationin the sameway that the soundwe becomesquieter as we move farther from its (Frg 7-2). Ultrasound waves causea slight motion of material as they are transmitted, but
do not carry the material along with the Similarly,when someonespeaks,the audible waves of the voice reachacrossthe room. but the in front of the speaker'smouth is agitated slightly,not moved acrossthe room. Ultrasoundhasa variety ofphysicaleffectsthat be classiliedas thermalor flonthermaL Its ability increasetissuetemperatureis its thermaleffecqand ability to causeacousticstreaming, and cavitation.which mav alter cell membrane meability, are its nonthermal effects.This describesthe physicalpropertiesof ultrasoundand effectson the bodyin orderto deriveguidelinesfor optimal clinicalapplicationof therapeuticultrasoundThe followine sectionlists and definesthe used specificallyto describetherapeutic and its effects.Termsusedto describeuitrasound other physicalagentsaredefinedin the glossaryat end of this book.
Figure7-2. Decreasingultrasound intensity as tJ.re travelsthroueh tissue.
Two . THE PIIYSICAL AGEN'IS
TERMINOLOGY Transducer (sound head): A crystal that converts electricalenergyinto sound (Iig. Z-3).This term is alsousedto describethe part of an ultrasoundunit that containsthe crystal.
747
Power: The amount of acousticenergyper unit time. This is usuallyexpressedinWatts [V). Intensi$r: The power per unit area of the sound head. This is usuallv exoressedin Watts/centimeter squared 6vi.-2j. lh" World Health
FigureT-3.Ultrasound units:,A, transducer;B, frequency indicator; C, pulse duty cycle indicator; and D, power/intensiqy indicator. (Part one courtesy Rjch-Mar, Inola, Ok, Part Two courtesy Mettler Electronics, Anaheim, CA; Pan Three courtesy ChattanoogaGroup, Hixsoq TN.)
188
7.
Ultrasornd
Organizationiimits the averageintensity output by therapeuticultrasoundunits to 3 Wcm2.1 Spatial Average Intensiqz: The averageintensity of the ultrasoundoutput over the area of the transducer. Spatial Peak Intensity: The peak intensiry of the ultrasoundoutput over the areaof the transducer. The intensityis usuallygreatestin the centerof the beamandlowest at the edsesof the beam. Beam Nonunifoffiity Ratio (BNR): The ratio of the spatial peak intensity to the spatial average intensity(Fig.7-4).For mosr urirs rhis is usually berween5:1 and 6:1, althoughit can be as low as2:7,
= !1,
Time(ms)
EXAMPLEs Using a transducerwith a maximum BNR of 5:1,when the spatialaverageintensiryis set at 1 Wcm2, the spatialpeak intensiqrwithin the field couldbe ashigh as5 Wcm2. Using a transducerwith a maximum BNR of 6:1, when the spatialaverageintensiqyis set at 1.5Wcm2, the spatial peakintensitywithin the field couldbe ashigh as9 Wcm2. The IDA requires that the maximum BNR for an ultrasoundtransducerbe specifiedon the device. Continuous Ultrasound: Continuous delivery of ultrasound throughout the treatment period
(Iig.7-5). Pulsed LTltrasound: Delivery of ultrasoundduring only a portion of the treatmentpedod.Delivery of ultrasound is pulsed on and off throughout the
Figure 7-5.Continuous ultrasound.
= !D
Time(ms)
Figure 7-6.Pulsedultrasound. treatment period. Pulsing the ultrasound minimizesits thermaleffects(Iig.7-Q. Duty Cycle: The proportion of the total treatmeni time that the ultrasound is on. This can be expressedeitherasa percentageor a ratio.
'6
EXAMPLES
20okor 1.:5duty cycle,is on 20% of the time and off 80% o: rhe rjme. This is generallydelivered2 ms on.8 ms ol (Frg.7-7). 100% dury cycleis on 100% of the time and is tle same ascontinuousultrasound.
Figure7-4. Beamnonuniformify.
Spatial Average Temporal Peak (SAIP) Intensity The spatial averageintensity ofthe ultrasound during *re on time of the pulse (Iig. Z-8). Therapeutic
r89
Tgo . THE PHYSICAL ACENTS
=-
B
- SATP
!,
c
_ SATA Time(ms)
Time(ms)
Figure 7-8. SATPandSAIA intensiry Note that SAIA is equalto SAT?for continuous ultrasound. EXAMPLE
1wcm2 'ATP at 100%dutycycle= B
Tlme(ms)
7-7. Duty cycles:20okand5Ao/". Figure
ultrasoundunits displaythe SAIP intensityand the duty cycle. ln this chapter, all intensities are expressedas SAT| followed by the duty cycle, unlessstatedotherwise. Spatial Average Temporal Average (SAIA) Intensity: The spatial averageintensity of the ultrasoundaveragedover both the on time and the off time of the pulse. SAT?x duty cycle = SAIA ExAMPLE : w/cmz SAfP at 20% duty cycle =
i x 0.2= 0.2wcm2 SAIA
This is a measureof the amount of energydelivered to the tissue.SAIA units are frequentlyusedin the nonclinicalliteratureonultrasound.
1x 1 = 1wcmz 'ATA
Frequenry: The number of compression-rarefaction cyclesper unit of time, usually expressedin ryrles (Hertz, Hz) (Itg.7 -9).lncreasingthe freyer second in its depth quencyof ultrasoundcausesa decrease of penetrationand concentrationoI the ultrasound energyin the superficialtissues(Iig Z-10). Effective Radiating Area (ERA)r The area of the transducerfrom which the ultrasoundenergyradithe crystaldoesnot vibrate ates(Fig.7-11).Because uniformly, the ERAis always smallerthan the area of the treatmenthead.
trrftJttlfi
ifu'L,ru 1 and3 MHz. 7-9.Ultrasoundfrequencies: Figure
790
7 t Ulttasound
1 l\,4H2 3.3lvlHz
Transducer
Figure7-10. Frequencycontrols the depth of penetration of ultrasound; 1 MHz ultrasound penetrates approximately 3 times as far as 3.3 MHz ultrasound. (Courtesy Metder Electronics,Anaheim, CA.)
L______r________
L_____T_-___l
Nearlield
Far field
Figurc7-'12.Longitudinal cross-sectionof an ultrasouni oeam.
Transducer face Lengthof nearfield =
Wavelengthof ultrasound
In most human tissuethe majority of the ultrasound intensity is attenuatedwithin the first 2 to 5 cm oftissuedepth,which, fortransducersof mosr frequenciesand sizes,lieswithin the nearfield. Absorption: Conversionofthe mechanicalenergyor ultrasound into heat. The amount of absorptior that occursin a tissuetype at a specificfrequenc,is expressedby its absorption coefficient. The absorptioncoefficientis determinedby measririn3 the rate of temperaturerise in a homogeneous tissue model exposed to an ultrasound field oi known intensiry Absorption coefficientsare tissue and frequencyspecific.They are highest for r i s s u e sw i t h r h e h i g h e s rc o l l a g e nc o n t e n ta n d increasein proportion to the ultrasoundfrequencrSable 7-2). Reflection: The redirection of an incident bearn away from a reflecting surfaceat an angle equa. and oppositeto the angleof incidence(Frg.7-1?;.. Ultrasound is reflected at tissue interfaces,witl most reflectionoccurringwhere thereis the greaEest differencebetween the acousticimpedanceo:
Figure 7-11. Effectiveradiatingarea.
Near Field/Far Field: The ultrasoundbeam deliveredfrom a transducerinitially convergesand then diverges(Iig. 7'12). The near field, also klown as che Fresnelzone. js rhe convergentregion.and the far field, alsoknown asthe lraunhoter zone,is the divergentregion.In the nearfield thereis interferenceof the ultrasoundbeam.causingvariations in ultrasoundintensity.In the far field thereis little interlerence,resultingin a more uniform distribution of ultrasoundintensity.The length of the near field is dependenton the ultrasoundfrequencyand the EM of the transducerand can be calculated from the foilowing formula (Table7-1):
$ g
Radius oftransduce12
7-1 fength of the Near Field for Different Frequenciesof Ultrasound and Different Areas (ERA)ofultrasound Transducers Uttrasound frequency (MHz)
ERA (cm2)
Length ofnear field (cm)
3
5
33
I
1,
2.1,
3
1
6.3
1511
19l
Two . THE PHYSICAL AGENTS
g'-'
A bsorption Coefficients in Decibels/cm at 1 and 3 MHz lMHz
3MHz
llood
0.028
0.084
:at
0.14
0.42
\erve
0.2
0.6
tluscle (parallel)
0.28
0.84
(perpendicular) lr,!uscle
0.76
2.28
31oodvessels
0.4
I.2
ikin
0.62
1.86
Tendon
1.1,2
3.36
Cartilage
1.t6
3.48
throush tissue. Attenuation is the result of absorption, ieflection, and refraction, with absorption accountinq for about one-half of attenuation' Arrenuation coefficientsare Lissueand Frequency specific. They are higher for tissues with a higher collagen content and increase 1n proporlon to tne frequencv of the ultrasound flable Z-3) Half bepth' Ihe depth o[ tissue at which rhe ulrra7-4) sound inrensiryjs half irs initial intensity(lable at minima Standing Wave: Intensity maxima and apart fixed positions one-half waveleng*r -Standing ,r"ua, o..u, when tl-re uitrasound transducer and a reflecting surface are an exact multiple of wavelengths apart, allowing the reflected wave to
p
Z-t Oar"orrationof 1 MHz Ultrasound
Bone
Attenuation (dB/cm)
4.12
3
Iat
0.61
13
Nerve
0.88
Muscle
L2
24
Bloodvessels
\.7
32
Skin
2.7
39
Tendon
4.9
59
Cartilage
5.0
68
13.9
96
Bone
7-13.Ultrasoundreflectionandrefraction. Figure adjacent tissues. In the body, most reflection, about35T", occursat soft tissue-boneinterfaces There is 100% reflectiono[ ultrasoundat the airskin interface and only 0.1% reflection at the transmissionmedium-skin interface.There is no reflecdonat the transmissionmedium-soundhead interface,A transmissionmedium that eliminates the air bewveenthe sound head and the body is used in order to avoid an air-skin interfacewith hish reflection. Refriction: The redirectionof a wave at an interface occurs,rhe ultra(seeFig.Z-13).When refraccion angleand conat one tissue soundwave entersthe angle. a different rinuesdrroughthe tissueat in ultradecrease of the Attenuation: A measure wave travels 5ound intensityas che ulrrasound
BIood
p
z-o
oepthsin mmat 1 and3 MHz ""ff
Water
tt*lllz
3 MHz
11,500
3833
Iat
50
Muscle(parallel)
24.6
Muscle(perpendicular)
9
16.5 I 3
11.1
4
Tendon
6.2
2
Cartilage
6
2
Bone
2.1
Skin
7 . Ulttasouad
burst. With unstablecavitation,the bubbles over a number of cycles and then implode(Iig. Z-15).This implosionproduces brief, local pressureand temperaturerncreases causesfree radicalformation.Stablecavitation beenproposedasa mechanismfor the *rerapeutic effects of ultrasound,while cavitation is dlought not to occur at the i
of ultrasoundusedtherapeutically.2 Microstreaming: \4icroscaleeddying that takes near any small, vibrating object.
ilf:::' Figure 7-14.Formation of sranding waves. superimposeon *re incidentwave entedngthe dssue (Fig.7-14).Standingwaves can be avoidedby moving the soundheadthroughoutthe treatment. Cavitation: The formation,growth, and pulsationof gas-or vapor-filledbubblescausedby ultrasound. During the compressionphase of an ultrasound wave, bubbles present in the tissue are made smaller, and during the rarefaction phase they expand. Cavitation may be stable or unstable (transient).With stable cavitation, the bubbles oscillatein sizethroughoutmany cyclesbut do not
occursaround the gas bubblesset into oscilla by cavitation.3 Acoustic Streaming: The steady,circular flow of iularfluidsinducedby ultrasound. Thisflow is in scalethan with microstreamingand is thought alter cellularactiviry by transporringmatedal onepart ofthe ultrasoundfield to another3 Phonophoresis: The applicationof ultrasound a topical drug in order to facilitate
drugdehery$ig.7-1Q. In summary ultrasoundis a high-frequency wave that can be described by its intensity,
duqt cyd.e,EM, and BNR. It enters*re body and attenuatedin the tissueby absorption,reflection,a: refraction. Attenuation is ereatest in tissues with
high collagencontent and with the use of high
IVICFOCURRENIS '.:
;.'ful"':
| | ----) | \-./ \J
l----' t \_/
l
.V
STABLE cAVtrAloN( tv /-{ -----| | \_,/
)
|
\
^__ i^\
UNSTABLE ( ) CAVjTATION \__-,// \..
rveLostoru ! ; .,, i
:o, ",,,
I ,' Free
r!,, Badicals oH-.H*
'ii"#i:iiH'"
Figure7-15. Cavitation and mi.r^
Figure 7-16.Phonophoresis.
193
Ttvo . THE PIIYSICAL AGENTS
srnd frequencies.Ultrasoundcan generateheat, its ::rmal effect,and hasthe mechanicaleffectsof cavi =:on, microstreaming,and acousticstreaming.Both :e thermal and mechanicaleffects can be used to r:elerate the achievementof ffeatment goalswhen :-=asoundis appliedto the approprialepatholoSyat -e:nnr^hrrrfP
frrnP
OFULTRASOUND iENERATION ---=asoundis generatedby applying a high-ftequenry uemating electricalcurent to the crystal in the ffansr:er of an ultrasound unit. The crystal is made of a :;rerial with piezoelectricpropertiescausingit to =:-pond to the alternating current by expanding and =rtracting at the samefrequencyat which the current :-anges polarity. when the crystal expands it com=?ssest}Iematerialin front of it, andwhen it contractsit =efies the material in front of it. This altemating com:-ssion-rarefaction is the ultrasoundwav e Qtg.7-17). The property of piezoelectriciry,the abiliry to gensare electricityin responseto a mechanicalforce or = changeshapein responseto an electricalcurrent, 'r-asfirst discoveredby Paul-Jacques andPierreCurrie : :he 1880s.A varieryof marerialsarepiezoelectric, :;luding bone,natural quartz and synthetic plumbium =conium titanate(PZT),and barium titanate At this -jre, ultrasoundtransducersare usuallymade of PZT :ecausethis is the least costly and most efficient :::zoelectricmaterialreadilyavailable In order to obtain a pure singleftequencyof ultra-und from a piezoelectriccrystal,a singlefrequency :: alternatingcuffent must be applied to it and the -r'stal must be of the appropriatethicknessto res::rate with this frequency.Resonanceoccurswhen oi
cx
x
ooSoo 5o8o oH
the ultrasound frequency and the crystal thickness conformto the following formula: t-c '2t
where fis frequency,c is the speedof sound in the matedal, and t is the thicknessof the crystal.Thus thinner, more fragile crystals are generally used to generate higher frequenciesof ultrasound. These crystalsshouldbe handledwith care. Multiftequencytransducersusea singlecrystalof a thicknessoptimized for only one of the frequencies. The crystal is made to vibrate at other frequencies by application of those frequenciesof alternating electricalcurrents;however, this is associatedwith decreasedefficiency, variability in the output frequency,reduction of the EM, and increasedBNRa Recently,compositematerialshave been developed to deliver multiple frequenciesof ultrasound more accuratelyand eificiently.5 Pulsedultrasoundis producedwhen the high"frequencyalternatingelectricalcurrentis deliveredto the transducerfor only a limited proportion of the treatment time, asdeterminedby the selectedduty cycle.
OFULTRASOUND EFFECTS Ultrasoundhas a variery of biophysicaleffects lt can increasethe temperatureof deepandsuperficialtissues and has a range of nonthermal effects. Traditionally, although separately, theseeffectshavebeenconsidered both to some degree tha! should be aware the reader Continuous ultrasound. of with all applications occur uitrasoundhas the most effecton tissuetemperature; however, nonthermal effects can also occur with the use of continuousultrasound.Additionally, although pulsedultrasoundproducesminimal sustainedchanges in tissuetemperature,it probably doeshave a small brief heating effect during the on time of a pulse Althoush a number of studieshave demonsffatedthe biophyiical effectsof ultrasound,the degreeto which the findings canbe extrapolatedftom the exPedmental conditionsto specificclinicalapplicationsis still uncertain andrequiresfurtherstudy.o
^Xooo oo-o
I
\--//-
ll
Compression
ll:1 Rarefaction
igure 7-17, Ultrasound production by piezoelectric
EFFECTS THERMAL Affected Tissues The earliest studies demonstratingthat ultrasound can increasetissue temperaturewere published by
194
7 c Ufutasoutd
Hawey in 1930.7The thermal effectsof ultrasound, including accelerationof metabolic rate, reduction or confiol of pain and muscle spasm,alteration of nerve conductionvelocity, increasedcirculation,and increasedsoft tissue extensibility,are the same as those obtained with o*rer heating modalities, as describedin Chapter 6, except that the structures heated are different.s-10Ultrasound reaches more deeply and heats smallerareasthan most superficial heating agents.Ultrasound also heats tissueswith high ultrasound absorption coefficientsmore than those with low absorptioncoefficients.Tissueswith high absorptioncoefficientsaregenerallythosewith a high collagencontent,while tissueswith low absorp,tion coefficientsgenerallyhave a high water content. Thus, ultrasoundis pafticularlywell-suitedto heating tendons,ligaments,joint capsules,and fasciawhile not overheatingthe overlyingfat. Ultrasoundis generally not the idealphysicalagentfor heatingmuscletissue becausemuscle has a relativelv low absomtion coefficient;also.most musclesare much larger'than the availableultrasoundtransducers.
Factors Affecting theAmount ol Temperature lncrease The increasein tissuetemperatureproducedby the absorptionof ultrasoundvaries accordingto the tissueto which the ultrasoundis applied,aswell aswith the frequency,intensity, and duration of the ultrasound.The heatingrate is proportionalto the tissue's absorptioncoefficientat the applied ultrasoundfrequency.li Tissue absorption coefficients increase with increasedcollagencontent and in proportion to the ultrasoundfrequency.Thus, higher temperatures are achievedin tissueswith a high collagencontent and with the application of higher-frequencyultrasound.When the absorptioncoefficientis high, the temperatureincreaseis distributed in a smallervolume of more superficialtissuethan when the absorytion coefficientis low, sincechangingthe absorption coefficient alters the heat distribution but does not change the total amount of heat being delivered (Iig. Z-18).To increase*re total amount of heat being delivered to the tissue, the duration of ultrasound applicationor the averageultrasoundintensity must be increased.One MHz frequenry ultrasoundcan be usedto heat tissuesup to 5 cm deep,whereas3 MHz ftequenry shouldbe usedwhen the goalis to heat tissuesonlv 1 to 2 cm deep.Note that with 3 MHz ultra-
E
Depthot tlssue
Figure7-18.Temperaturedistributionfor 1 and 3 ultrasoundat the sameintensily. sound,althoughthe maximum temperature is higher,the depth of penetrationis lower theoreticalmodelspredictthat3 MHz ultrasound increasetissuetemperature3 timesmore than 1 ultrasound.an in vivo studv in which ultrasound applied to human calf muscle found an almost fold greatertemperatureincreasewith 3 MHz soundthan with 1 MHz ultrasoundannliedat 0.5 2.0 W/cm); therefore,clinically,an iniensity3 to times lower should be used when applying 3 ultrasoundthan when applying1 MHz ultrasound. During ultrasoundapplication,tissuetemp€ changeis also affected by factors other than sound absorption.Blood circulatingthrough the sue will cool the tissueswhile conductionfrom warmed area of rissueto another and reflection ultrasoundwavesin resionsof soft tissue-bonei faceswill heat the tissues.l3 On average, soft tissue temperature has shown to increasebv 0.2' C oer mrnutein vivo ultrasound delivered at 7 W/cm2 at 1 MHz. Nonuniformiw of the intensitv of ultrasound the variety of tissuetypes with different a coefficientsin a clinicaltreatmentarea,and at tissueboundaries,causethe temperature within the ultrasoundfield not to be uniform. The highesttemperatureis generallyproducedat soft sue-bone interfaces where reflection is sreat Moving the sound head throughout the appli helos to eoualizethe heat distribution and the incidenceof excessivelyhot or cold areas. The number of unknown variables, i the thickness of each tissue layer, the amount
Tvo . THE PHYSICAL AGENTS
-:ulation, and the distanceto reflectingsoft tissuer:re interfaces,makes it difficult to predict accu:e-:ly the temperatureincreaset}ratwill be produced ::::ically when ultrasound is applied to a patient. l:'-rs, initial treatmentparametersaresetaccordingto :ioretical and researchpredictions; however, the l.:ent's repoft of warmth is used to determinethe =-:l ultrasoundintensity.If the ultrasoundintensity -: :oo high, the patient will complain of a deepache =:n overheatingof the periosteum lf this occurs,the :r:asound intensity must be reduced in order to rcid burningthe tissue.If the ultrasoundintensity is =,: low, the patientwill not feel any increasein tem-:ature. More specificguidelinesfor selectionof the rjmal ultrasound ffeatment parametersfor tissue r:dng are given below in the sectionon application =:rrrique. Becausethe patientjs report is used to -:ermine the maximum safeultrasoundintensity,it s :ecommended*rat thermal-levelultrasoundnot be =:lied to patientswho are unable to feel or report =comfort causedby overheating
195
pendentlywhen consideringapplying a combination of agentseitherconcuffentlyor in sequence.
EFFECTS NONTHERMAL
Ultrasound has a variery of effects on biological processesthat are thought to be unrelated to any increasein tissuetemperature.These effectsare the result of the mechanicalevents Producedby ultrasound, including cavitation, microstreaming, and acousticstreaming.When ultrasoundis deliveredin a pulsed mode, with a 20y" or lower duty cycle, the heat generatedduring the on time of the cycleis dispersedduring the off time, resultingin no measurable net increasein temperatureThus, pulsedultrasound with a 20% ducy cycle has generallybeen used to apply and study the nonthermaieffectsof ultrasound. Somerecentstudieshavealsousedlow intensitiesof continuousultrasoundto study theseeffects'17 Ultrasoundwith a low averageintensity has been shown to increaseintracellular calcium,l8 increase increas.mast skinandcellmembranepermeabiliry,lo cell degranulation,increasechemotacticfactor and inConiunction PhysicalAgents Other lpplying increasemacrophageresponsivehistaminerelease,20 rith Ultrasound the rate of protein synthesisby increase and ness,21 -.'-ious have been demonstrated effects These fibroblasts.22 physicalagentscanbe appliedtogetherwith, and duty cyclesthat at intensities :.or to, or after the application of ultrasound. using ultrasound increasein temperaany measurable produce did not ,':plying a hot packprior to ultrasoundtreatmenthas to be nonthermal considered ture and are therefore :een shown to increasethe temperatureof only the to cavitation, been attributed tissue effects. They have ,;cerficial 1 to 2 mm of skin and subcutaneous 3".urt" -r;rile not affectingthe temPelatureof deepertissue acousticstreaming,and microstreaming.2l'23 compoessential processes are these cellularlevel Similarly,usinga warm conductionmedium ;-,'ers.15 processes in these '.:.i.1not affect the heating of deep tissues.Applyt"g changes nentsof tissuehealing,the producedby uitrasoundare thought to underlie the ,=asound in cold water coolsthe superficialskin by enhancedhealingobservedto occurin responseto the ::nduction and convection, thereby reducing the applicationof ultrasoundto a variety of pathologies. r;rease in superficialtissuetemperatureproducedby '-:asound. Applying ice prior to the application Ior example,increasingintracellularcalciumcanalter the enzymatic activity of cells and stimuiate their :i ultrasoundhasalsobeenshown to reduced:retemsynthesisand secretionof proteins becausecalcium :erature increase produced by ultrasound in the to :eeper gissues.l6Ice, or any other thermal ageng ions act as chemicalsignals(secondmessengers) calcium raouldbe appliedwith cautionpriorto the application cells. The greatestchangesin intracellular leveis have been reported to occur in response :: ultrasoundsincethe loss of sensationthat may be to 20o/opulsed ultrasound at intensities of 0.5 to of the accuracy reduce the agents can by these =used :atient's feedbackregardingdeeptissuetemperature. 0.75 W/cm2.18The fact that ultrasound can affect explains in part. why macrophageresponsiveness ,.lthough many cliniciansapply ultrasoundin con-:nction with electricalstimulation,with the goal oI ultrasoundis particularlyeffectiveduring the inflamwhen the macrophageis matory phase of repair, :cmbiningthe benefitsof both modalities,*rere is no 'It cell the dominant the efficacy time evaluating at this rype. is inrerestingro note that :'.rblishedresearch been shown to have a signifihas pulsed ultrasound general, one In of interventions. :i this combination on membranepermeabilitythan greater effect candy physical agent indeeach the effects of :rouid analyze
t96
7 . Uhrasotrd
continuousultrasound delivered at the same SAIA intensity.l9
OFULTRASOUND APPLICATIONS CLINICAL Soft tissue shortening Pair control Dermal rdcers Surgical skin incisions Tendon iniuries Resorption of calcium deposits Borle ftactures Carpal tunnel s'1'ndrome Phonophoresis Plantar avads Herpes zoster infection
Many studieswere limited by poor designand by fact that the ultrasound doses varied without any rationale.Iurther well-controlled using appropriate ultrasound doses are needed determine with greater certainty the clinical effi o[ therapeutic ultrasound and the optimal trea parameters to use.
Shortening SoftTissue Softtissueshofteninscanbe the resultof tion, inactiviry or scarring,and can causejoint of-motion (ROM) restrictions,pain, and functi limitations.Shorteningof the ioint capsule, ing tendons,or ligamentsis frequentlyresponsible and stretchingof th ruih ad.r"tre consequences, normal length their tissuescan help them regain of soft consequences thereby reversethe adverse sue shortening.Increasingthe temperature of tissuetemporarily increasesits extensibiliry ing the length gained for the same force of str 27 the risk of rissued amage.26 wlile alsoreduc-ing increasein soft tissuelength is alsomaintained effectivelyif the stretchingforce is appliedwhile tissuetemperatureis elevated.This increasedease stretchingis thought to be the result of altered coelasticiryof collagenand alterationof the matnx. Becauseultrasoundcan penetrateto the depth most joint capsules,tendons, and ligaments, since these tissueshave high ultrasound
Ultrasoundis commonly usedas a componentof the treatment of a wide variety of pathologies.These applicationstake advantageof both the thermal and nonthermaleffectsof ultrasound.The thermal effects are used primarily pdor to stretchingshortenedsoft tissueand for the reductionof pain. The nonthermal effectsare usedprimarily for alteringmembranepermeability in order to accelerate tissue healing. Althoueh much of the researchon the nonthermal effectstf ultrasound has been done using in vitro models, ultrasound at nonthermal levels has been shown to facilitatethe healingof dermalulcers,surgical skin incisions,tendon iniuries,and bone ftactures coefficients, ultrasound can be an effective p in both humans and animals. Ultrasound has also agent for heating these tissues pdor to penetradrug enhance transdermal been shown to The deep heating produced by 1 MHz continur and nonthermal thermal via both tion, probably ultrasound at 1.0to 2.5Wcmz hasbeenshownto delivery drug of transdermal mechanisms.This mode at increasinghip joint ROM effective more has also been Ultrasound is known as yltonoyhoresls. producedby infraredradj heating superficial the deposits, of calcium found to assistin the resorption 28 with exercis^e in conjunction when applied in the recovery i:r the removal of plantarwarts, and MHz continuous ultrasound at 1 5 Wcm2 from herpeszostervirus infection.The mechanismof to the triceps surae combined with static theseeffectsis uncertain. flexion stretching has also been shown to be use of ultraA summary of the researchon the effective than static stretching alone at soundfor theseapplicationsfollows. Gapsin curent dorsiflexion ROM.29The increasedROM o researchdo not allow one to concludewith certainty in both of these studieswas attributed to in that ultrasoundcan consistentlyproducethe clinical extensibility o[ the soft tissues due to heating effectsdescribed.Although there is evidenceto support theserecommendedclinicalapplications,recent ultrasound. The studies cited above indicate that systematic reviews of the randomized controlled ultrasound of sufficient intensity and duration studiesof the clinicaleffectsof ultrasoundfound that studiesro clearlydemonstrate increase tissue temperature may lncrease sott therewereinsuF[icient thar ultrasoundis more eftectivethan placebo.2425 extensibility, thereby combatting soft tissue
TgJo . THE PIIYSICAL AGENTS
:ning and increasingjoint ROM when appliedin con:rnction with stretching.The treatment parameters :ound to be effectivefor this applicationare 1 or 3 -r1Hzfrequency,dependingon the tissuedepth,at 1 0 -o 2.5 Wlcm2 intensity, applied for 5 to 10 minutes. :or optimal effect,it is recommendedthat stretching re applied during heating by ultrasoundand main:ainedfor5 to 10minutesafterultrasoundapplication .,vhilethe tissueis cooling(Iig.7-19).
PainControl Jltrasoundmay control pain by aiteringits transmis:ion or perception or by modifying the underlying :ondition causingthe pain. Theseeffectsmay be the :esultof stimulation oI the cutaneousthermal recep:ors or increasedsoft tissue extensibility due to rcreased tissuetemperature,the resultof changesin rerve conductiondue to increasedtissuetemperature rr the nonthermaleffectsof ultrasound,or the result ,.fmodulationoIinflammation dueto the nonthermal 3ffectsof ultrasound. Studieshave shown that ultrasoundcan be more :ifective in controllingpain than placeboultrasound :r treatmentwith other thermal agents,and that the :ddition of uluasoundto an exerciseprogramcanfurContinuousultrasound rer improve pain re1ief.30'32 :r 0.5 to 2.0 Wcm2 intensiquand 1.5MHz frequency :,as also been reported to be more effective than ,uperficialheating with paraffin or infrared or deep ::eatingwith shortr,vavediathermy for relieving the :ain from soft tissueiniurieswhen appliedwithin 48
t97
hours of injury.30Personstreatedwith ultrasoundhad lesspain,tendernessonpressure,erythema,restricted ROM, and swellingthan thosetreatedwith the other thermalagents.Also, more subjectsin the ultrasoundtreatedgroupwere symptom free2 weeksafterinjury than subjectswho received the other treatments. Given tl-rewide rangeo[ possiblediagnosestreatedin this study and the wide range of ultrasound doses used,the mechanismof the observedeffectsis uncertain. Ultrasound may have improved circulation or acceleratedthe processesof inflammation and healing of the involved tissues. Continuous ultrasound applied 3 times a week for 4 weeks at :1.0t o 2.0W /cm2 for 1.0minutesto the low backsof patientswith recentonsetof pain due to prolapseddiscsand nerveroot compressionbetrveen L4 and S2 has also beenshown ro resuitin significantly faster relief of pain and retum of ROM than placebo ultrasound or no treatment.2zThe authors discussthe concem that ultrasound at the intensity used may aggravatean acute disc rupture and statethat this did not occurbecauseso little ultrasoundwas able to reachthe disc through the overlying bone. "Continuous ultrasoundappliedat 1.5Wcm2 for 3 to 5 minutes for 10 treatmentsover a 3-week period followed by exercisehasbeenfound to be more effective than exercisealonein relievingpain and increasing ROM in patientswith shoulderpain.22Also, at the 3-month foliow-up, significandymore patientswho receivedultrasoundtreatmentreportedno pain than those who receivedexercisealone.The short duration of ultrasoundused in this study may have produced a slight increasein tissuetemperature,which may have resulted in increasedpatient comfort or increasedsott tissue extensibility, allowing greater gainsin ROM with exerciseand better resolutionof the underlyingpathology. The studiescited above indicate that continuous ultrasoundmay be effective for reducing pain. The tueatmentparametersfound to be effective for this on applicationare 1 or 3 MHz frequency,-depending *re tissuedepth, and 0.5 to 3.0 Wcm2 intensiqy,for 3 to 10 minutes.
Ulcers Dermal Figure7-19, Ultrasound being applied to the Posterior
Some studies have shown that ultrasound accelerates the healing of vascular and pressure ulcersl however, others have failed to demonstrate any beneficial
798
7 . Ultraso*td
effects with this application,and recent systematic reviews of the randomized controlled trials on the treatment of venous ulcersand pressureulcerswith therapeutic ultrasound concluded that there is no good evidenceof a benefit of ultrasoundtherapy in thesetypesof dermalulcers.33,34 Dyson and Suckling found that the addition of ultrasound treatment to conventional wound care proceduresresultedin significantlygreaterreduction in the area of lower extremity varicose ulcers.35 Ultrasoundwas applied pulsed at 20o/oduty cycle, at 1.0 Wcm2 intensity, 3 MHz frequency,for 5 to ll0 minutes to the intact skin around the border of 13 lower extremity varicoseulcers 3 times a week for 4 weeks. Sham ultrasound was applied, in a double-blindmanner,to 12 other ulcers to setve as a control.At 28 daysthe treatedulcerswere approximately 30% reducedin size, whereasthe shamtreated ulcers were not significantly smaller than their iniLial size. Using a "imilar procedure. McDiarmid and colleaguesfound that infectedpressureulcershealedsignificandymore quicldywifi the applicationof ultrasoundthan with sham treatment, whereas clean soresdid not.36The ultrasoundwas appliedpulsedat a 20o/odurl cycle,0.8W,/cm2intensity, 3 MHz fuequency,for 5 to 10 minutes 3 times a week. ln contrastrthreemore recentstudieshavefailedto demonstrateimproved healingof venousulcerswith ultrasound.3T-39 bne MHz ultr"asound was usedin the first two of these studies,and it is possiblethat this lower frequencymay have alteredthe efficacyof the treatment. In the third study, 3 MHz pulsed ultrasound was usedl however, 0.1% chlorhexidine,a cytotoxic agent, was used to cleansesome o[ the wounds. The addition of this cleanserto the treatment may have obscuredthe benefits of the ultrasound. The studiescited aboveindicatethat pulsedultrasoundmay be effectivein facilitatingwound healing. The treatment parametersfound to be effectivefor this application are 20o/oduty cycle, 0.8 to 1.0 Wcm2 intensity,3 MHz frequencyfor 5 to 10 minutes. Ultrasoundcan be appliedto a dermalulcer eitherby applying transmissiongel to the intact skin around the wound perimeterand treatingonly over this area (lig. 7-20), or the wound can be treated directly by coveringit with an ultrasoundcouplingsheet(Iig. 7 -27)orby placingit and the ultrasoundtransducerin warer (Iig.7 -22).
Figve 7-20, Ultrasound treatment of a wound: penwound application technique.
tigwe 7-21, Ultrasound being used to treat a venous stasis ulcer (Courtesy Jim Staicer, Beverly Manor ConvalescentHospital, Fresno,CA.)
FiguIeT-22,Ultrasound treatment of a wound: underwafPnnhli.,fi^h
fe.hnid,'e
T$,o . THE PIIYSICAL ACENTS
Skinlncisions I:e effect of ultrasound on the healing of surgical L'r incisions has been studied in both animal human sublects. Ultrasound applied at 0.5 cmz, pulsed 20Yo, for 5 minutes daily to fullskin lesionsin adult rats has been shown acceleratethe evolution of angiogenesis,a vital nponentof early wound healing.'O Argiogenesis *re developmentof new blood vesselsat an injury that serves to reestablish circulation and thus
ischemicnecrosisand facilitaterepair.It is prothat ultrasound may accelerate the developof angiogenesis by altering cell membrane
bility, particularly to calcium ions, and by ulatingangiogenicfactors1'nthesis and releaseby Byl and associates reported that low-dose high-doseultrasoundcan increasethe breakstrength of incisional wounds in pigs when ied for 1 week and that low-dose ultraincreaseswound breaking strength only in second week.atar The low dose was 0.5 W , pulsed 20"/", 1 MHz and the high dose was
Li W/cm'z,continuous,1 MHz. Both were applied 5 minutes daily, starting l day after the Ultrasoundhas alsobeenreportedto be beneficial the treatment of gymecologicalsurgical wounds I episiotomiesin humans.43,44 Ultrasoundapplied : the first and second postoperative days at -. W/cmz, 207" dut1 cycle, 7 MHz for 3 minutes been reported to reduce oain and accelerate toma resolution after these procedures.
::eatment with ultrasound has also been found relieve the pain from episiotomy scars when lied months or years after the procedure. Eeldhousereported successfultreatment of painful, irickened scarswith ultrasoundat 0.5 to 0.8 Wcm2, !:r 5 minutes, 3 times a week for 6 to 16 weeks, at tJ mon*rs to 4 years after episiotomy.aaEarlier Eiervention was tecommendedfor earlier relief of ',mptoms. The precedingstudiesindicatethat ultrasoundcan the healingof surgicalincisions,relievethe accelerate pain associatedwith theseprocedures,and facilitate ccvelopmentof strongerrepair tissue.The treatment :arametersfound to be most effectivewere 0.5 to 0.8 ; /cmr intensiry,pulsed20"/ofor 3 ro 5 minutes,3 to 5 -_mesa weeK.
799
Tendon Injuries Ultrasoundhas beenreportedto assistin the healing oftendons after surgicalincisionand repair Although some studieswith both animal and human subiects havereoortedtreatmentsuccess. othershavefailedto suppori thesefindings. Binderand colleaguesreportedsignificandyenhanced recoveryin patientswith lateralepicondylitistreated with ultrasound comparedwith those treated with sham ultrasound.4SThe ultrasound was aoolied pulsedwith a 20ol.duty cycle.1.0ro 2.0Wcm2lntensity? 1 MHz frequency,for 5 to 10 minutes for 12 treatmentsover a 4- to 6-week oeriod. In addition. Ebenbichler and co-workersreportedgreaterresolution of calcium deposits,greater decreasesin pain, and greater improvements in the quality of life in patientswith calcifictendinitisof the shouldertreated wi*r ultrasound comparedwith those treated with sham ultrasound.a6lor this study, ultrasound was applied for 24 l1-rr'irrute sessionswith a frequency of 0.89 MHz and an intensiry.2.5 Wcm2 pulsed mode 1:4 (sic.).In contrast to the positive findings of these studies,Lundebergand colleaguesreported no significant difference in the healing of lateral epicondylitis between ultrasound-treatedgroups and sham ultrasound-treatedgroups using either continuous or pulsed ultrasound.47,48 Downing and Weinstein also failed to demonstrateany benefit of continuousultrasoundat 107" lower intensity *ran patient discomfort in the treatment of subacromial symptoms.49 The differencesin outcome berween the above studiesmay be due to the use of ditferent ueatment parametersand the applicationof treatrnentat different stagesof healing. Becauseapplying ultrasound with parameters that would increase tissueremperature may aggravateacuteinflammatioq and because, conversely,pulsed ultrasoundmay be ineffective in the chronic,latestageof recoveryif the tissuerequires heating to promote more effective stretching or increasedcirculation, applying ultrasound with the same parametersto all patients may obscure any treatmenteffect. It is recommendedthat ultrasoundbe aonliedin a pulsedmodear a Iow intensiryduringtheacutephase of tendon inflammationin order to minimize the risk of aggravatingthe condition and to acceleraterecovery and that continuousultrasoundat a high enough intensity to increasetissuetemperaturebe appliedin
200
7 . Uhratotqd
combinationwith stretchingto assistin the resolution of chronictendinitisif the problemis accompaniedby soft tissueshorteningdueto scaring. Studieson the effect of ultrasoundon the healing of tendons after surgical incision and repair have yielded more consistentlypositive results,although one study has reported tendon weakening after 6 weeks of ultrasoundtreatment.Ultrasoundat 0.5 or 1.0Wcm2, continuous,1 MHz applied daily for tlle first 9 postoperativedayshasbeenshown to enhance the breakingstrengthof cut and suturedAchillestenThe strength of the ultrasounddons in rabbits.50,51 greater than that of sham-treated was teated tendons strength of those treated with 0.5 and the controls, was greaterthan that of ultrasound W,/cm2intensity Similar benefits have those treated at 1.0 Wcm2. of been reportedfrom the application 1.5 W/cm2. continuous, ll MHz ultrasound for 3 to 4 minutes ro repairedAchilles starting I day postoperatively 5l was applieddaily for tendonsin rats.52 I reatmenr the first I days and every other day thereafterfor up to 3 weeks. In contrastto the abovefindings,Robertsand colleaguesreponed reducedstrengthand healingin surgically repairedflexor profundustendonsin Z rabbits after treatmentwith pulsedultrasoundat 0.8 Wcmr, 1 MHz, for 5 minutesdaily for 6 weeks.54The results of this study have been calledinto questionbecause the strengthof the tendonsin both the treated and untreatedgroupswas more than 10 timeslower than has been reportedin other studiesfor normal flexor tendonhealingin rabbits.ssAlthough immobilization was attempted throughout the post-injury period, technicaldifficultiesin maintainingcastfixation, and thus apposition of the tendon ends, may have resultedin gapformation and thus poor strengthin all subjec*. The small samplesize and poor reportingof the data also call into question the validity of this study.Adverseeffectsof ultrasoundon tendon healing havenot beenreportedin other research. Overall, researchsupportsthe early use of ultrasound for facilitation of tendon healingafter rupture and repair.The ultrasounddosesfound to be effective for this applicarionare 0.5 to 1.5 W/cm2 intensity. continuous,1 or 3 MHz frequencyfor 3 to 5 minutes. Although high-intensiqyultrasoundhas been found to promotetendonhealing,the lower end of the range is recommendedin order to minimize *re risk of any potentially adverseeffect from heating acutely inflamedtissuepostoperatively.
Deposits ofCalcium Resorption Ultrasoundmay facilitate the resorption of deoosits. Two published case studies and a domized control trial havereportedfunctional ery pain resolution, and elimination of a depositin the shoulderfollowing applicationof sound; however, the mechanismsof this effect Althoueh the mechanismundt un1oown.46,56,57 ing calcific deposits resorption is not known, decreasein pain and improvementsin function be due to the reductionin inflammationproduced ultrasound.
BoneFractures Although pdor reports have recommended ultrasound not be applied over unhealed because thev have failed to provide data to this recommendation and becauserecent studies
demonstratedthat low-dose ultrasound can the fracturehealingtime in animalsand humans, fracture useof low-doseultrasoundto accelerate ins is now recommended.58,59The stimulation
bonegrowth by physicalmeanshasbeen for many years.At the beginningof the 18th it was observed *rat small direct currents acting at
periosteum induced bone formation, and in Iukada andYasudaproposedthat the of bone was the mechanismbehind this In 1983Duarte proposedthat phenomenon.60 sound may be a safe, noninvasive, and means to sdmulate bone growth. also
linked to rhe piezoelectricproperryof bone.61 applied very low-intensity ultrasound, deliv pulsedwith a 0.05?"dury cycleat approximately Wrcm2SAfPintensiw.at either4.93or 1.65MHz I ouencvto 23 rabbit fibulaethatwere osteomized 22 femursw\th drilled holes.Treatmentwas for 15minutesper day,starting1 day for 4 to 18 days. AII animals received osteotomies and were treated with uiuasound
erally so that the contralateralextremity could asa control.The treatedboneswere found to callusand trabeculaemore rapidlv than the bones(Fig.7-23). A similar study with a largersamplesize (139) alsoreportedaccelerationof bone healingwith sound.62 The ultrasoundwas deliveredpulsed
1.5 Wcm2 SATPintensiqy, 20T"durycycIe,0.15 frequency.Treatment was applied for 20
201
Two . THE PIIYSICAL AGENTS
- .'.'.starting1 day postoperatively,for 1.4to28 days. : :::echanicalhealingwas acceleratedby a factor of .virh rrearedfracturesbeingas strongas intact -'. .: in 17 days comparedwith 28 days for the con:: Jactures. studieshave :.vo double'blind,placebo-controlled ,.- demonstratedaccelerationof fracturehealingin AB
human subjectswith the application of ultrasound. Both usedthe ultrasoundsignaland treatrnentdurations describeddirectly above. One study reported acceleratedhealing of Colles' and tibial diaphyseal ftacturesby a factor of 1.5 (asdemonstratedby radiography),63 and the other reportedaccelerationof tibial fracture healing by a factor of 1.3 for clinical healingand a factorof 1.6for overallclinicaland radiographichealing.oa A devicespecificallydesignedfor the application of ultrasoundfor fracture healing was approved by the IDA in 1994 for home use. It has unadjustable, preset treatment parameters of 20To durl cycle pulsed,0.15Wcm2 SAfP intensity,1.5 MHz frequency and a treatmentduration of 20 minutes (Iig. 7-24).Tl'usdevrcers availableby prescriptionon1y. Currentresearchsupportsthe useof verylow-dose ultrasound for facilitation of fracture healing. The parametersfound to be effective are 0.15 Wcm2 intensity,207" duty cycle, 1.5MHz frequencyfor 15 to 20 minutesdaily.
Tunnel Syndrome Carpal =E[e7-23, lracture healing 17 days postoperatively,A, :r and, B, without ultrasound application. (Used i permission. from Duane LR: The stimulation of -:re growth by ultrasound. Arch Orthoy Trauma Surg . -:L53-159, 1983.)
Continuousultrasoundhasgenerallynotbeenrecommendedfor the treatmentof carpaltunnel syndrome becauseof rhe risk of adverselyimpactingnerve However, a conductionvelocity by overheating.65,66 recentstudy found that pulsedultrasoundproduced
Figu.eT-24.Ultrasounddevicefor home use for ftacture healing. (Courtesy Exogen, Piscataway,
NJ.)
202
7.
Ultrasoutrd
significantly greater improvement in subjective complaints (t <0.001,,paired t test), hand grip and finger pinch'trength. and electroneurographic variables(motor distallatencyp <0.001,pairedt test; p <0.001;, sensoryantidromicnerveconductionvelocru1 paired t test) than sham ultrasound treatment.o/ Thesebenefitswere sustainedat 6 months' [ollow up. The ultrasoundwas appliedfor 20 sessionsat 1 MHz mode 1:4,for 15 minfrequency,1.0W /cm2,'pulsed for these The proposedmechanisms utesper session. benefitsare the anti-inflammatoryand tissuestimulating effectsof ultrasound.
Phonophoresis is the applicationof ultrasoundin conPhonophoresis junction with a topical drug preparationas the ultrasound conduction medium. The ultrasound is intendedto enhancedeiivery of the drug through the skin, therebydeliveringthe drug for local or systemic drug deliveryhasa number of effects.Transcutaneous advantagesover oral drug administration.It provides a higher initial drug concentrationat the delivery site,68avoids gastric iffitation, and avoids first-pass deliveryalso metabolismby the liver Transcutaneous avoidsthe pain, trauma,and infectionrisk associated with injection and allows delivery to a larger area than is readilyachievedby injection. The first report of the useof ultrasoundto enhance drugdeliveryacrossthe skinwaspublishedin 1954.6e This was followed by a seriesof studiesby Griffin and colleaguesevaluating the location and depth of hydrocortisone delivery and the effects of varying ultrasound parameters on hydrocortisone The authorsof theseinitial studohonoohoresis.T0'73 ultrasound enhanceddrug delivery ies proposedthat by exefting pressureon the drug to drive it through the skin, However, becauseultrasoundexertsonly a few gramsof force,it is now thought that ultrasound increasestransdermaldrug penetrationby increasing the permeabilityof t}restratumcorneumthroughcavitation.TaThis theory is supportedby the observation can enhancedrug penetrarioneven that ulLrasound when the ultrasoundis appliedbeforethe drug is put on the skin.75 The stratum corneum is the superficialcornified layer of the skin that actsas a protectivebarrier,preventing foreign materials from entering the body through the skin (Iig. 7-25).Ultrasoundmay change stratum corneum permeabiligzby both thermal and
Hypodermis
Figule 7-25.Layersofthe skin. nonthermal mechanisms.It has been proposedtha: ultrasoundaltersthe skin porouspathwaysby enlarging the skin effectivepore radii and by crcatingmore poresor making the poreslesstoftuous.76Drug diffusion acrossthe stratumcorneumdependson both diifusion and partition coefficients. A recent studt demonstratedultrasound enhancementof diffusior coefficientsof a variety of solutesby up to 15-folciUltrasound,however, did not significandy enhance partition coeff icients.TT When the permeabiiityof the stratum corneumE increased,a drug will diffuse acrossit due to the differencein concentrationon either side of the skir:Oncea drug diffusesacrossthe stratumcomeum,it is initially more concentratedat the delivery site and is then distributedthroughoutthe body by the vasculr circulation;therefore,therapistsshouldbe awaretha: do becomesysdrugsdeliveredby phonophoresis delivenfor systemic the contraindications temic and of delivery to this mode of these drugs also apply Becausesix phonophoresistreatmentswith the cor€costeroid dexamethasonehave been shown not tc causean increasein urinary free cortisol,which is a measureof adrenalsuppression,a courseof six treaimentsis consideredsafefor patientswho do not have
Ttro . THE PIIYSICAL AGENTS
:r:ter contraindications for corticosteroid treat::nt.78 It is recommendedthat a drug not be deliv::=d by phonophoresis if the patient is already :=:eivinga drug of the sametype by anotherroute of l::ninistration sincethis increasesthe risk of adverse :-ects. Ior example, if a patient with rheumatoid :---eritisor asthmais taking corticosteroidsby mouth, :,'drocortisone or dexamethasoneshould not be ::-;enby phonophoresis. has been studiedfor its efficacyin Phonophoresis :cal and systemic drug delivery. In rehabilitation, :ronophoresisis studiedand usedprimarily for local -'jvery of corticosteroid and nonsteroidal anti:-Jammatorydrugsfor treatmentof tissueinflamma::n, such as tendinitis or bursitis;however, there is systemic -o a medicalinterestin transcutaneous as insulin that cannot be substances such of -iivery by mouth. effectively ::livered A brief review of the researchon phonophoresis ::-lows. Ior a more completereview of the principles =-d researchof phonophoresis,please consult the :::ently publishedliteraturereview by Byl.7eGriffin :::d colleaguesfound that, with the application of :-.'drocortisonephonophoresisto pigs, more hydro::rtisone was depositedin nerve than in muscle./u 1ey also reported that the highest ultrasoundfre::ency they used,3.6 MHz, was most effectiveand :,at a low intensity (0.1Wcm2) for a long d-uration 11 minutes) or a high intensity (3.0 W/cmz) for a :::ort duration(5 minutes)resultedin the most hydro::rtisone delivery.7l-73 In comparing the efficacy of different drug concenKleinkort and Wood -tions usedfor phonophoresis, :und that 10% hydrocortisonewas more effective ::an 1% hydrocortisonein relievingpain associated ;r*r tendinitisor bursitis.Bo However,a comparisonof :e ability of different media customarilyused for :lonophoresis to ftansmit ultrasound found that the :vdrocortisone preparationsmost commonly used for ris applicationdonot tansmit ulftasoundeffectively.Bl -lris calls into question the mechanismof hydrocortisince,when a poorly transmitting :.rnephonophoresis redium is used,very litde ultrasoundis able to reach re tissue.The energyis absorbedby the medium or causingheatingof the =flectedbackto the transducer, :arsducer. It has been proposedthat the enhanced :,ydrocortisonepenetrationreportedby Griffin and col€aguesmay havebeencausedby heatingof the skinby :onduction ftom the warm sound head rather than reinsa directeffectof the ultrasound.Bl
203
More recent studies, using media that transmit ultrasoundeffectively,have demonstratedenhanced transdermalpenetrationof drugs other than hydrocortisone using phonophoresis.For example,ultrasound has been shown to increase transdermal penetrationof mannitol and irrulin in rats and guinea pigs, increasingthe output of radiolabeledmannitol and inulin in the urine of the ultrasound-treatedanimals by 5- to 20-fold for 1 to 2 hours after treatment comparedwith controls.s2Urinary output was used asa measureof the systemicuptakeof *resedrugs. An in vitro comparison of the penetration of ibuprofen through human skin with ultrasound or with equal heating using a conductive heater has demonstratedthat the enhancementof transdermal drug penetration by ultrasound was not ody the Drug result oF the thermal effecrsof ultrasound.s3 of the application penetration was increasedwith however, both conductive heating and ultrasound; the increaseproducedby ultrasoundwas significandy greater than that produced by conductive heating alone. The researchat this time supports the use of ultrasoundfor facilitation of transdermaldrug penetration. The treatment parametersmost likely to be effective are 3 MHz frequency,to optimize ultrasoundabsorptionby the skin; pulsed207" duty cycle, to avoid heating of any inflammatory condition; at 0.5 to 0.75W/cm2 intensity,for 5 to 10 minutes.The drug preparation used should also transmit ultrasoundeffectively.
Zoster Warts andHerpes Plantar Plantarwarts and herpeszoster are both viral cutaneous lesions. Studieshave shown that ultrasound may facilitatehealingof theselesions;however, *ris applicationof ultrasoundis not widely usedby rehabilitation professionalsin the United Statesat this time. Plantarwarts are skin lesions containing thrombosed capillariesin a soft, whitish core coveredby hyperkeratoticepithelial tissue.They usually occur on the plantarsurfaceof the feet of childrenor young adults. They resembleplantar coms or callusesand are tender on pressure,Like other warts, they are probably viral in origin. Plantarwarts are prone to spreadingand tecurence but also ftequently resolve spontaneously without treatment. A wide range of treatments,including surgicalexcisionand cryosurgery
7 o Ultrasotnd
204
can effectively eradicate plantar warts; however, most treatmentsare painful and result in scarformation. Ultrasoundhasbeenproposedasa painless,relatively safemethod of treatmentof theseiesionsand has been used for this application for the past 30 years; however, studies regardingthis use of ultrasound have had varying results.Although all studies report successrates exceeding50%, the only publiied double-blind, controlled study showed litde clinically significant difference in the healing time bewu""n uliraso,rnd and sham-treatedgroups.84'85 The studies reporting ffeatment successwith ultrasound used the treatment parametercof 0.6 to 0.8 Wcm2 intensity,continuousapplication,for 7 to 75 minuteswith 2 to 15treatments. Ultrasound has been reported to be effective in the treatment of pain resulting from acute herpes The treatment parameters used were zoslex.B6,87 1 MHz ftequency,25"2.pulsedduty rycle, appliedfor I minute per EM of the transducerat 0.8 Wcm' intensitv adiacent to the vertebral column and at
CONTRAINDICATIONS ofUltrasound fortheUse . . . .
Malignanttumor Pregnancy Centralnervoussysremtissue Jointcement
0.5Wcm2 intensiqyaroundthe pedpheryof the cles.More than 80% of the pacientstreated ultrasoundin this mannerwere pain free at the clusion of treatment and on long-term compared with 46% o[ the placebo-treated Patient The authors propose that ultrasound may have had
viricidal effectin thesepatients.
FOR ANDPRECAUTIONS CONTRAINDICATIONS ULTRASOUND Although ultrasound is a relatively safe trei modalfr, it must be appliedwith careto avoid ing the patient. Ultrasound may not be used p"ti".ttt to treat themselves.It must be used by, under the supervisionof, a licensedpractitioner. Evenwhen ultrasoundis not contraindicated,if patient s condition is worsening or not within 2 to 3 treatments,reevaluarethe approach and consider changing the ffeatment referring the patient to a physician for reevaluation.
. Plasticcomponents e Pacemaker r Thrombophlebitis 'Eyes . Reproductiveorgans
metastasis,it is recommendedthat therapeutic soundnot be appliedto malignanttumors ln Caution should also be usedwhen treatinga . . . over a limb or body part with a malignant who has a history of a maiignant lumor or tumof sinceit canbe difficult to ascertainwhether any tumors remain.It is thereforerecommendedthat Although there are no researchdata concerningthe physicianbef effectsof applying therapeuticultrasoundto maliS- therapistconsultwith the refeffing a history with patient to a nant tumors in humans,the applicationof continuous applying ultrasound last 5 malignancywithin the Years ultrasoundat 1.0W /cm2,7 [AIfz, for 5 minutesfor 10 One should note that ultrasoundis usedas a treatmentsover a period of 2 weeks to mice with ponent o[ the treatmentof certainrypeso[ malignant subcutaneoustumors has been shown to iumors, ho*ever, the devicesusedfor this e orod-ucesignificantlylargerand heavjertumors comBB pured to tiore of untre-atedconuols The treared allow a number of ultrasoundbeamsto be directed mice also developedmore lymph node metastases' the tumor in order to achievea temperature Somemalignant the raneeof 42" to 43'C.89'91 Becausethis study indicatesthac therapeuticultrade.r"as" itt size or are eradicatedwhen heated sound may increasethe rate of tumor growth or
The use of ultrasoundis contraindicated. . ,
T$,o . THE PIIYSICAL ACENTS
r:thin this naffow range,while healthy tissueis left the therapeuticultrasounddevices :damaged.Because physicaltherapistsdo not allow to available :eneralt l:ch precisedeterminationand control of tissuetem:erat;re, and becauseprimary treatment of maliS-ncy is outsidethe scopeof practiceof rehabilitarion ::ofissionals, therapeutic ultrasound devices -:ended for rehabilitationapplicationsshouldnot be :;ed for treatrnentof malignancY. ISK THE PATIENT I Have you ever had cancer?Do you have cancer now? o Do you havefevers,chills,sweats,or night pain? . Do vou havePainat rest? . Haveyou had recentunexplainedweight loss? I the patienr has cancer at this time, ultrasound rould not be used.If the patienthasa history of can::r or signs of cancersuch as fevers,chills, sweats, ::ght pain, pain at rest,or fecentunexplainedweight -:is. the thlrapist shouid consult with the referring ::rysician in oider to rule out the presenceof malig:ancy beforeapplyingultrasound.
205
The patientmay not know if sheis pregnant,pardcu' larly in the first few days or weeks after conception; however,sincedamagemay occurduring earlydevelopment,ultrasoundshouldnot be appliedin any area where the beammay reachthe fetusof a patientwho is or might be pregnant. . . . over central nervous system tissue There is concernthat uitrasoundmay damageCNS tissue.Howeve! becauseCNStissueis usuallycovered bv bone,both in the spinalcord and in the brain, this is rarelya problem.The spinalcordmay be exposedif the oaiieni hashad a laminectomyabovethe L2 level. In such cases,ultrasoundshould not be appliedover or nearthe areaof the Iaminectomy. . . . over methylmethacrylate cement or Plastic
Methylmethacrylatecementand plasticare materials used'for fixation or as componentsof prosthetic ioints. Becausethesematerialsare rapidly heatedby it is generallyrecommendedthat ultraultrasound,9T soundnot be appliedover a cementedprosthesisot in areaswhere piistic componentsare used.Although verv little ultiasoundis able to reachto the depth of . . over the abdornen, low back, or pelvis of a most prostheticjoints,it is still recommendedthat the :atient who is, or maY be, Pregnant clinician err on the side of caution and not use this in areaswhere plastic or cement may be modaliqy with fetal -\tatemalhyperthermiahasbeenassociated present. may be used over areaswith Ultrasound micro:'cnormalities,including growth retardation, as screws, plates, or all-metal such implants metal tube microencephaly.neural :hthalmia, exencephaly, 92'93 metal is not rapidly heated since replacements pubioint There is alsoa :efects,and myelodysplasia hasbeenshown not to and ultrasound ultrasound, tv -:shedreport documentinga caseof sacralagenesis, plates.98 or screws loosen :ricrocephaly,and developmentaldelay in a child '.".,hosemother was treated 18 times with lowASK THE PATIENT: :rtensity Pulsedultrasound for a left psoasbursitis ea joint replacementin this area? :eween days 6 and29 of gestation It is therefore e Do you havea . to hold it in place? used cement Was :ecommendedthat therapeutic ultrasound not be . plastic components? ithave Does :pplied at any level in areaswhere it may reach a joint replacement,ultrasound a patient has If the :evelopingfetus. in the area of the prosthesis applied should not be The diagnosticultrasoundftequently used during dratneithercement has determined unrilthetherapist rregnancyto assessthe position and developmentof used. nor plasticwas re fetusand placentahas beenshown to be safeand -.vithoutadverseconsequences for the fetus or the ... over a pacemaker lnotnel-"'' -
ASKTHEPATIENT: . Are you pregnant,might you be pregnant,or are youtryingto becomepregnant?
Becauseultrasoundmay heat a pacemakeror interfere with its electricalcircuitry ultrasoundshould not be applied in the areaof a pacemakerUltrasoundmay be appliedto other areasin patrentswlth pacemaKers' Cant;nued
206
7 . Ulttasound
DICATI0NS-cont'd C0NTRAIN ASK THE PATIENT o Do you havea pacemaker?
. . . over the eyes
. . . over an area of thrombophlebitis
It is recommendedthat ultrasound not be over the eyes becausecavitation in the ocular
Becauseultrasoundmay dislodgeor causepartial disintegrationof a thrombus,which could then resultin obstruction of the circulation to vital organs,ulffasound should not be applied over or near an area where a thrombusis ormay be present. ASK THE PATIENT: o Do you havea blood clot in *ris area?
mrrr
demeoe
the pwcc
. , . over the male or female reproductive
organs
Becauseultrasoundat the levels used for rehabili tion may affect gamete development, it is
mendedthat it not be appliedin the areasof tlre or femalereproductiveorgans.
PRECAUTIONS
of Ultrasound fortheApplication . Acute inflammation ' Epiphyseal Plates
Ultrasoundat sufficientintensityto produceheatshouldbe usedwith caution. , , . . . in areas of acute inflammation Becauseheat can exacerbateacute inflammation, causing increased bleeding, pain, and swelling, impairing healing and delaying functional recovery, ultrasound at sufficient intensity to produce heat should be applied with caution in areas of acute inflammation. . . . over growing epiphyseal plates
. Fractures . Breast implants
the low levels used for fracture healine.l00At time, it is recommendedthat high-dose not be appliedovergrowing epiphysealplates. Becausethe age of epiphysealclosurevaries,ra, ographicevaluationratherdran ageshouldbe used determineif epiphysealclosureis complete. ... over a tracture
Althoush low-dose ultrasound has been shown fracrurehealing,the applicationof accelerate intensity ultrasoundover a fracturegenerally pain.There is alsoconcernthat highJevel may impair fracturehealing.Thereforeonly low ultrasound,as describedin the sectionaboveon ture healing,shouldbe appliedover the areao[ a ture.
The literatureregardingthe applicationof ultrasound over epiphysealplatesis controversial.Although one study reported that ultrasound applied at greater than 3.0 Wcm2 may damage epiphysealplates,ee . . . over breast implants Lehmannstatesthat it is safeto apply ultrasoundover Becauseheatmay increasethe pressureinsidea epiphysealplatesas long as there is no pain.uAlso, a implant and causeit to rupture,high-dose recent study reported no changein bone growth in shouldnot be appliedover breastimplants. skeletallyimmature rats with ultrasoundapplied at
Two . THE PIIYSICAL AGENIS
207
ADVERSE EFFECTS OFUTTRASOUND In general,ultrasound.has rarelybeenteportedto produceadverseeffects.101 However,a variety of advirse effectscanoccurif ultrasoundis appliedincorrecdyor when contraindicated.The most common adverse effectis a burn,which may occurwhen high-intensity, continuousultrasoundis applied,particularlyif a stationary application technique is used. The risk of burnsis furtherincreasedin areaswith impairedcircuIationor sensationandwith superficialbone.To minimize the risk of buming a patient, always move the ultrasoundheadand do not apply thermal-leveiultrasoundto areaswith impairedcirculationor sensation. Reducetfie ultrasoundintensity in areaswith superficialbone or if the patientcomplainsof any increasein discomfortwith the applicationof ultrasound. Ultrasound standing waves can causeblood cell stasisdue to collectionsof gas bubbles and plasma at antinodesand collectionof cellsat nodes102,103 (Fig. 7-2Q.This is accompaniedby damageto the endotheJiallining of the blood vessels.These effects have been demonstratedwith ultrasoundof 1 to 5 MHz frequencywith intensity as low as 0.5 Wcm2 and with asshort an exposureas0.1 second.Although the stasisis reversedwhen ultrasoundapplicationstops,
1. Evaluatethe patient'sclinical findings and set the goalsof treatment. 2. Determine if ultrasound is the most appropdate ffeatment. 3. Determine that ultrasoundis not contraindicated for the patient or the condition. Check with the patientandcheckthe patient'schartfor contraindicationsorprecautionsregardingthe applicationof ultrasound. 4, Apply an ultrasoundtransmissionmedium to the areato be treated. Apply enough medium to eliminate any air between the sound head and the treatmentarea. Selecta medium that transmits ultrasoundwell, does not stairy is not allergenic,is not rapidly absorbedby the skin, and is inexpensive.Gels or lotions meeting these criteria have been specificallyformulatedfor usewith ultrasound. OR
Figure. T-26.Bandingof blood cellsand plasmadue to sranolnS waves.
the endothelialdamageremains.Thereforein order to preventthe adverseeffectsof standingwaves,it is recommended that the ultrasound transducer be moved throughoutffeatmentapplication.
APPTICATION TECHNIQUE This sectionprovidesguidelinesfor the sequenceof proceduresrequiredfor the safeand effectiveapplication of therapeuticultrasound.
Ior the application of ultrasound under water, placethe areato be treatedin a containerof water (seeFig.7-22). 5. Selecta sound head with an EM approximately half the sizeof the treaffnentarea. 6. Selectthe optimal treatmentparametersincluding trltrasound ftequency,intensity, duty cycle, and duration; the appropriate size of the treatment areal and the appropdatenumber and frequency of treatments.Specificrecommendationsfor different clinical applications are given above in the sectionsconcerningthe specificclinicalconditions. Generalguidelinesfor ffeatmentparameters follow. FREQUENCY Selectthe ftequencyaccordingto the depth of tissue to be treated.Use 1 MHz for tissueup to 5 cm deeo and 3 MHz for tissue 1 to 2 cm deeo.The deoth of
208
7 . Ulttasound
penetrationis lower in tissueswith a high collagen contentand in areasof increasedreflection.
DURATION
DUTY CYCLE Selectthe duty rycle accordingto the treatment8oal. When the goal is to increasetissue temperature,a 100% (continuous) duty cycle should be used.r When applying ultrasound where only the nonthermal effects without tissue heating are desired, pulsed ultrasound wirh a 20'/' or lower duty cycle should be used.Although the nonthermal effectsof ultrasound41eprodugedby continuousultrasound,it is thought'that they are not optimized with application at this level.raAlmost all publishedstudieson the effectsof pulsedultrasoundhaveuseda duty cycleof 20%.
sound head. Ior most thermal or nonthermaL tions, ultrasoundshould be applied for 5 to 10 for eachffeatrnentareathat is twice the ERAof the ducer For example,when treatingan area2j cmz soundhead that has an ERA of 10 cm2,the tre duration should be 5 to 10 minutes. When treating areao[40 cm2with thesame10cm2,theueament tion shouldbe extendedto between10and20 When the eoalof treatmentis to increasetissue oerature. the fieatment duration should also idjusted accordingto the frequenry and intensity the ultrasound.Ior example,if the goal is to tissuetemperatureby 3'C, andthus reachthe therapeuticlevel of 40'C. if 1 MHz ultrasoundat intensityof 1.5Wcm2 is appliedto an areanvice ERAof the transduce!the treatmentdurationmust atleast9 minutes,whereasif the intensiryis to 2 W/cm2, the treatment duration need be only minutes.sIf 3 MHz ultrasoundis usedat an of 0.5Wcm2, the treatmentdurationmust be at 10minutesto achievetJresametemperaturelevel. In general,treabnentduration should be when lower intensitiesor lower frequenciesof soundare used,when ffeatingareaslargerthan the ERA of the transducer,orwhenhigher tissue peraturesare desired.Treatment duration should decreasedwhen higher intensitiesor ftequencies ultrasoundareused,when treatingareassmaller twice the ERAof the transducetorwhenlower temperaturesare desired. When ultrasoundis usedto facilitatebone longertreatmenttimes of 15 to 20 minutesare mended.
INTENSITY Select intensity according to the treatment goal. When the goal is to increasetissuetemperature,the patient should feel somewarmth within 2 to 3 minutes of initiating ultrasoundapplicationand should not feel increaseddiscomfort at any time during *re treatment.When using 1 MHz ftequencyultrasound, an intensity of 1.5 to 2.0 Wcmz will generallyproduce this effect. When using 3 MHz frequency,an intensity of about 0.5 Wcm2 is generallysufficient. A lower intensity is effectiveat the higher frequency becausethe energy is absorbedin a smaller,more superficialvolume oftissue,resultingin a greatertemperatureincreasewith the sameultrasoundintensity. Adjust the intensity up or down ftom these levels accordingto the patient'sreport. Increasethe intensiry if there is no sensationof warmth within 2 to 3 minutes and decreasethe intensiry immediately if thereis any complaintof discomfort.If thereis superficial bone in the treatment area, a slightly lower intensiry will be sufficient to produce comfortable heatingbecausethe ultrasoundreflectedby the bone in temperature. will causea greaterincrease When applying ultrasoundfor nonthermal effects, successfultreaffnent outcomes have been documentedformost applicationsusingan intensity of 0.5 to 1.0wcm2 SAIP (0.1to 0.2Wicm2 sATA),with as low as 0.15 Wcm2 SAT? (0.03Wcm2 s-.{TA)being sufficientfor facilitationof bonehealing.
Select the ffeahrrent duration according to the goal, the size of the area to be fteated?and the EM
AREATO BETREATED The sizeof areathat canbe treatedwith ul dependson the EM of the transducerand the tion of treatment.As explainedin the previous sion of duration of treatment, a treatment area
to twice the ERA of the sound head can be in 5 to 10 minutes. Smallerareascan be treated proportionatelyshortertimeslhoweve! it is imPr. cal to treat areasless than L1/ztimes the ERA of
Tgo . THE PIIYSICAL ACENTS
sound head and still keep the sound head moving within the area.Largerareascanbe treatedin proportionately longer times; however, ultrasoundshould not be usedto treat areaslarger than four times the EM of the transducer,such as the whole low back, long treatmentdurabecausethis requiresexcessively dons and, when heating is desired,resultsin some areasbeing heated while other previously heated areasarealreadyc ooling(Figs.7-27 and7-28). NUMBERAND FREQUENCYOF TREATMENTS The recommendednumberof treatmentsdependson rhe goals of treatment and the patient'sresponse.If -,.he patient is making progressat an appropdaterate toward the establishedgoals for this treatment, the ireatment should be continued.If the patient is not progressingappropriately,the treatment should be modified,either by changingthe ultrasoundparamerers or by selectinga different intervention.In most cases,an effect should be detectablewithin 1 to 3 eatments.Ior problemsin which progressis commonly slow, such as chronic wounds, or in which progressis hard to detect, such as with fractures, rreatment may need to be continued for a longer period.The frequencyof treatmentsdependson the level of ultrasoundbeing usedand the stageof healing. Thermal-levelultrasoundis usuallyappliedonly during the subacute or chronic phase of healing, when treatment 3 times a week is recommended; ultrasoundat nonthermai levels may be applied at earlierstages,when treatmentmay be as frequentas daily. These frequenciesof treatment are basedon currentclinicalstandardsofpracticesincethereareno publishedstudiesat this time comparingthe efficacy of differenttreatmentfuequencies. SEQUENCEOF TREATMENT ln most cases,uirasound may be applied before or atter other treatment interventions;however, when using ultrasound to heat tissue, it should not be appliedafrerany interventionthatmay impairsensation, suchasice.Also, when thermal-levelultrasound is used to increasecollagenextensibilityin order to maximize tlre increase in length produced with stretching,the ultrasoundmust be applied directly before,and if possibleduring, the applicationof the stretchingforce.Do not wait or apply anothertreatment betlveenapplyingthe ultrasoundand stretching sincet}Ietissuestartsto cool assoonasthe uluasound applicationends.
209
7. Priorto treatmentof any areawith a risk of crossinfection, swab the sound head with 0.5%oalcoholic chlorhexidine, or use the antimicrobial approvedfor this usein the faciliqy.as 8. Placethe soundheadon the treatmenrarea. 9. Tum on the ultrasoundmachine. 10. Move the soundheadwithin the treatmentarea. The soundheadis movedin orderto optimize the
Figwe7-27.Ultrasound applicationto the foot. (Courtesy Mettler Electronics,Anaheim, CA.)
Figure 7-28. Ultrasound application to the temporomandibularjoint flM) area.(CourtesyMettler Electronics, Aaaheim. CA.) Continued
2lo
7 . Uhrasouwl
Move the soundheadat approximately4 cm,/second, quickly enough to maintain motion and slowly enoughto maintain contactwith the skin. If the soundheadis kept stationaryor moved too slowly, the areaof tissueunder the centerof the transducer,where the intensity is greatest,will receive much more ultrasound than the areas under the edgesof the transducer.With continuous ultrasoundthis can result in overheatinsand buming of the cissues ac the centerof rhelield, and with pulsed ultrasoundthis can reducethe efficacy of the treatment. A stationary sound head should not be used when applying either continuous or pulsed ultrasound. If the sound headis movedcooquickly,the therapistmay nor be able to maintain good contact of the sound head with the ski4 and thus the ultrasoundwill not be ableto enterthe tissue. Move the soundhead in a mannerthat causes the centerof the head to changeposition so that all parts of the treatment area receive similar exposure.Strokesoverlappingby half the EM of the sound head are recommended(Fig.7-29). Keepwithin the predeterminedtreatmentareaof one and a half to four times the EM only. Keepthe surfaceof the soundheadin constant parallelcontactwith the skin in order to ensure
Documentation Document the area of the body treated, the ultrasound frequency,intensiry,and duty cycle,the treatment duration, if the treatmentwas deliveredunder water, and the patient's responseto t}Ie treatment. Documentationis typically written in the SOAPnote format. The following examples only summarize the modality component of treatment and are not intendedto representa comprehensive plan of care. Examples 1. When applying ultrasound(US)to the left lateral knee (L lat knee) over the lateral collateralligament (lCL), to facilitatetissuehealing,document: 9: 9t aepaahhiz ola f, hbaX h2z lx4intuilh twLinq A4L fui*and' (t*m (rtauzaf b oaa'tinnal aircz taat wz& Warhq1hr^aruUeolrlr f
Figure7-29.Strokingtechniquefor ultrasoundapplicauon.
that the ultrasoundis transmittedto the tissues. Poor contact will impede the transmission ultrasoundbecausemuch of it will be absorbed by intervening air or reflected at the air-tissue interface. In order to promote more ffeatment, some clinical ultrasound units
equippedwith a transmissionsensorthat gives signalwhen contactis poor. 11. When the treatment is completed,remove tJn conductionmedium ftom the soundheadandthe patientand reassess for any changesin status. iL2.Documentthe treatment. 0: 1192 tal..kn2z,9L9,0.5 11) lun2, prh"d 20%,3 milb 5 tuih.
.fu 9ailL dl 9 talu.al &.nzeunfh hhninq t4 I dzozaain+ (^qtt"r1r+ pan btd h2/xfa2aUzaf, i.(,,painuto&nd, 9: Rza,uz,az ditutttituzW
2. When applying ultrasound to the right anteriorshouldercapsule,document: 9: ?t o,ttb,a. alaul4 inpwin4 ll thnuld* |TOWand.it. aMeta Mz nlE urhzrLlm&ing hrrbhaih 0 : 119h inNanf afuuldzz. 2 .0 ) lan2,
5 nAr.,pf.eouzd,fu /t ftit" in4gLdzg'1ado 9U 4 9fuuldzaalduztionintza,tzdP"am| 20"ta | 30" 9: Aaaliruzll9 ut n&Nlda.
a's.aloue, (4UMrf
eV moliligalhn
and
Tgo . THE PHYSICAL ACENTS
2ll
) Clinical CaseSwdies I The following casestudiessummarizethe conceptsof applying therapeutic ultrasound as discussedin this chapterBasedon the scenariospresented,an evaluation of the clinical findings and goals of treatmentare prooosed.Theseare followed bv a discussionof factorsto be consideredin the selectionof ultrasoundas the indicated fteatment modality and in selectionof the ideal to promoteprogre"stoward the rreatmentparamerers goals(Fig.7-30).
Case 4 TR is a 60-year-oldmale,3 mon*rs post-openreduction and intemal fixation of a right hip fracture, with placementofa plateandscrews.He hasbeenrefenedtophysicai therapy for gait training with the restriction of limiting TR complainsof intemitweight bearingto his tolerance. tent dull pain in the right antedor groin that is aggravated by standingor walkingwithout an assistivedeviceandby lying prone.His pain is easedwhen he sitsor lies on his side. Sincethe hip fracturehe has walked only up to. approximately 50 [eet,maintaining partial weight bearing on his right lower extremity by using bilateral crutches and by flexing his right hip and knee throughout the gait cyde. He hasnot beenable to retum to work due to his resfiicted ambulation. Prior to the hip fracture,TR walked
2 miles a day at his iob without an assistivedevice and without pain.The objectiveexamrevealsdecreased hip passive ROM into extension and abduction, with tightness of the anteromedial hip capsule and guarding and spasmsof the hip adductor and flexor muscles.All other objectivemeasuresarewithin normal limits. EVALUATION OF THE CLINICALFINDINGS This patient presenswith the impairmentsof interm.ittent dull pain in the right anteromedialhip and shorteningof dre right anteromedialhip capsule,resultingin the disabilities of limited ambulationand inabiliq/ to work. PREFERBEDPRACTICEPATTERN Irnpaired Joint Mobility, Muscle Performance,and Rangeof Motion AssociatedWith Bony or Soft Tissue Surgery,(4I) PLAN OF CARE Goals of treatrnent include resolution of pain in the right anteromedialhip, normalization of the length of the anteromedialhip capsule,a letuln to 2 miles of ambulationper daywithout an assistivedevice,and full retum to work.
lmpairments
Eltectsof ultrasound
Dutycycle
Depthof problem
frequency Ullrasound
inlensity Ultrasound
Duration oitreatment
5 - 10min/2x EFA
Figure7-30. Decision-making concemingultrasound treaffnent parameters. Continued
7.
Ultrasourtl
) Clinical Case Studies-cont'd ASSESSMENTFEGARDINGTHE APPROPRIATENESSOF THERAPEUTIC ULTRASOUNDAS THE OPTIMAL TREATMENT Therapeuticulfiasoundisan indicatedtreatmentfor pain and for shortened deep soft tissue with a high collagen content. A superficial heating agentwould not be appropriate sirrcethe heat will not penetrateto the hip capsule, and diathermywould not be appropriatesincethe presence of metal contraindicates diathermy application, Therapeuticultrasoundcanreachdeeptissuesand is not contraindicated in the presence of metal plates and screws.The presenceof malignancy should be ruled oug and the patient's sensationin the anterior hip should be assessedprior to initiating treatnent. Ulftasound should not be lsed if the hip fracturewas associatedwith a malignancy. Thermal-level ultrasound should not be usedif sensationin t}le fteatmentareais not intact. PROPOSEDTREATMENTPLAN AND RATIONALE Itis proposedthat ultrasoundbe appliedoverthe areaof gr€atestsoft tissueshonening,the right anteriorgroin. A ftequenry of 1 MHz in orderto reachthe depth ofthe hip joint capsule,a continuousduty cycle ir order to increasetissuetemperatureandtherebyincreasesoft tisand an intensityof 1.5to 2.0 Wcm2, sueextensibility, adjustingas necessaryso that the patient feelsa sensation of mild warmth after 2 to 3 minutes of ultrasound applicationin order to producean adequateincreasein the temperatureof the hip capsuleare recommended. Sincethe treatmentareawill probablybe in the rangeof 20 cm2, a large sound head with an ERA of 10 cmz should be used.Given this relationshipof sound head ERAto fieatmentarea,ultrasoundshouldbe appliedfor approximately10 minutesin orderto raisethe temperature of the hip capsuleto within the therapeutic rangeof 40' to 45'C. It is essentialthat t]]e shortenedsoft tissues be stretched immediately following the ultrasound applicationand ideally during the ultrasoundapplication aswell. Treatmentwould generallybe applied2 or 3 times per week, consistentwith presentpracticepattems, and should be continued as long as progressis beingmadetoward dre treatmentgoals.
Case2 BJ is an l8-year-old female college student. She sustained a completerupture of her left Achilles tendon 6 weeks ago while playing basketball,and the tendon was surgicallyrepaired2 weeks later.Shehas been referred for physicaltherapyin order to attain a pain-freeretum to spofts as rapidly as possible.She complainsof mild discomfort at the surgicalincision site that increases
1
with walking. Her leg was in a cast,and BJ ambulated without weight bearing on the left, using bilateral axilThe castwas lary crutches,for 4 weekspostoperatively. removedyesterdayand shehasbeenhstructed to walk, bearingweight as tolerated,wearing a heeled "boot.' Shehas been instructed to avoid running or jumping for 6 more weeks. The objective exam revealsrestricted dorsiflexionROM of -15', mild swelling, tendemess, and rednessin the areaof the surgicalrepai! and atrophy of the calf muscleson the left. All other objective measuresarewithin normallimits. EVALUATION OF THE CLINICALFINDINGS This patient presentswith the impairments of restricted dorsifleion ROM, mild swelling, tendemessand rednessin the areaof the surgicalfepat indicatingcontinued inflammation, artd atrophy of the calf muscles.She also has the disabilities of limited ambulation and of being unable to paticipate in spofting activities at this time. PREFEFREDPRACTICEPATTERN lmpaired Joint Mobility, Motor lunction, Muscle Performance,and Range of Motion AssociatedWith Bony or SoftTissueSurgery,Pl\ PLAN OF CARE The goalsof treatmentare to resolvethe inflammatioq thereby limiting excessivescar formation, and to promote maximal strengtheningof the repairedtendon in the shortestperiod of time. At this initial stageof treatm€nt, the problems oI restrictedankle ROM and calf atrophy would generallynot be addresseddirecdy due to the fragile statusof the repair.As the inflammation problemswould be addressed, with proresolves,t.l.rese posed goals of achievingnormal ROM, strength,and musclemass. ASSESSMENTREGARDINGTHE APPROPRIATENESSOF THERAPEUTIC ULTRASOUNDAS THE OPTIMAL TREATMENT Therapeuticultrasoundmay be used at this time for facilitation of tendon repair in order to prcmote the developmentofgreater strengthin the repairedtendonTherapeuticultrasoundmay also promote completion of the inflammationstageof tissuehealingand progression to the proliferationand remodelingstages.As the signsof inflammation resolve,ultrasoundmay be used to increasethe temperatureof t}Ie tendon in order to facilitate stretching and recovery of normal ankle ROlr4; however,ultrasoundwill not promote the recoveryof musclemassor strensth.
T$o . THE PI{YSICAL ACENTS
Sinceultrasoundshould be used with caution over unclosedepiphysealplates,andsincettrispatientis ofan agewhere epiphysealclosuremay or may not be complete, radiographicstudiesof skeletalmaturity should be performedprior to applyingultrasound.If the studies indicatethat the epiphysealplatesareclosed,ultrasound maybe appliedin the usualmanner-If th€y indicatethat the epiphysealplatesare not closed,thermal-leve1 ultrasoundshouldnot be used;however,most authorcagree that low-level,pulsedultrasoundmay be used. PROPOSEDTBEATMENTPLAN AND RATIONALE Itis proposedthat ultrasoundbe appliedoverthe areaof the tendonrepair Selecta ftequencyof 3 MHz in order to maximize absorption in the Achilles tendon, which is a superficialstructure.For the initial treaffnent,selecta 20"/' pulsed duty cycle in order to avoid increasing the tissuetempemture,thereby potentially aggravatingthe inflammatory reaction, and select an intensity of 0.5 W/cmt, consistentwith the studies demonstratins improved tendon repair wrth ulcrasound.When thi signs of inflammation have resolvedand the goal of treaunent with ultrasound is to increasedorsiflexion ROM, the duty rycle shouldbe increasedto 100%,and the intensity may be increasedto between0.5 and 0.75 Wcmz in order to heat tie tendon prior to stretching. Since-thetreatment areawill probably be in the range of 5 cmz,a small sound head with an ERA of 2 to 3 cm2 should be used. Civen this relationshipof sound head ERAto treatmentarea,ulnasoundshouldbe appliedfor 5 to 10minutes.Treatmentwould generallybeapplied3 to 5 times per week, depending on the availability of resourcesand t}re importance of a rapid functional recovery In studies demonstrating enlunced tendon healingwith the applicationof therapeuticulkasound, the ultrasoundwas applieddaily; however,treatment3 timesper week is more consistentwith pres€ntpractice pattems.Due to tlle contouringof this areaandits accessibility,treatmentmay be appliedunderwater.
Case 3 JG is an 80-year-oldfemale with a 10 cm2 stage IV infectedpressureulcer over her left greatertroch;nrer. Sheis bedridderl minimally responsive,and completely dependenton othersfor feedingand bed mobility asthe resultof three strokesover the past5 years.Shedeveloped*re presentulcer6 months agoaftersufferinga loss of appelite due to an upper respiratoryinfection.JG is turned every 2 hours,avoidingleft side lying, has been placedon systemicantibiotics,and is receivingconventional wound care; however, her wound has not improvedin the lastmonth. Shehasbeenrefered to
213
physical therapy with the hope that the addition of other interventions may promote tissuehealing. EVALUATIONOF THE CLINICAL FINDINGS This patientpresentswith the impairmentsofsofttissue ulcerationand delayedtissuehealing.Her impairment of reducedstrengthand her disability of limited mobiliqy have contributed to the development of the pressure ulcer,placingher atrisk forsystemicinfection. PREFERREDPRACTICEPATTERN ImpairedIntegumentaryIntegriqyAssociatedWith Skin InvolvementExtendinglnto Fascia,Muscle,orBone and ScarFormation,(7E) PLAN OF CABE The goalsof treatmentat this time includeresolutionof wound infection, decreasein wound size, wound closure,and preventionof reulceration. ASSESSMENTREGARDINGTHE APPROPRIATENESSOF THERAPEUTIC ULTRASOUNDAS THE OPTIMAL TREATMENT Therapeulicultrasoundhasbeenshown in somestudies to facilitate the healing of chronic wounds, including thosewith infection.Sinceconventionalmodesoftreatment have failed to promote any improvement irl wound statusover tl-relast month, it is appropriateto considerthe addirion of adjunctivetreatmentssuch as ultrasoundto the treatment reeimenat this time. The use of ultrasoundis not contraindicatedin this oatient. although thermalJevelultrasoundshould not 6e used since t}re patient is minimally responsiveand would therefore not be able to report excessiveheating by the ultrasound. PROPOSEDTBEATMENTPLAN AND RATIONALE In most studiesdemonsftatingimproved healingwith the applicationof ultrasoundto chronicwounds, ultrasoundwas appliedto the periwound areaaloneltJ-rerefore, it is recommendedthat treatment of this patient shouldfocuson the areaof intact pedwound skin using a gel conductionmedium. Selecta frequencyof 3 MHz in accordancewith researchfindings regarding the use of ultrasound for wound healing and in order to maximize absorptionin t}le superficialtissuessurrounding the wound. Selecta 20Yopulseddury rycle in order to produce tlre nonthermal effects of ultrasound while avoidinS increasing tissue temperature. Select an intensity of 0.5 to 1.0 Wcm2, consistentwith the studies demonstratingimproved wound healing with ultrasound.Becausethe treatment areais in the ranee
Contmued
214
7.
Uhrasound
) Clinical CaseStudies-cattt'd a of 10 cm2,a medium-sizedsoundheadwith an EM of approximately5 cm2 should be used. Given this relationship of sound head ERA to treatment area, ultrasound should be applied for 5 to 10 minutes, and the treatment should be provided 3 to 5 times per week, dependingon the availability of resources.Treatment
with ultrasound should be continued until the wound closesor progressplateaus.One can exPectapploximately a 30% reductionin wound size per month. It is important to note that standardwound careprocedures shouid be continuedwhen ultrasoundis addedto the ffeatm€ntregimenfor a chronicwound.
All rightsreserved. PhysicalTherapistPraclicePattenssM l4l and7!] arecopyright2002AmericanPhysicalTherapistAssociation. Preferred
Chapter Review Ultrasound is sound with a frequencygreater than that audibleby the human ear.lt is a mechanicalcompression-rarefaction wave that travelsthrough tissue, producingboth thermal and nonthermaleffects.The thermal effects of ultrasoundincreasethe temperature of deeptissuewith a high collagencontent,and thus increasethe tissue'sextensibilityor controlpain. The nonthermal effects of ultrasound can alter cell membrane permeability and thus facilitate tissue healing and transdermal dlug Penetration. Therapeutic ultrasound may also facilitate calcium reso!ption,plantarwart resolution,and herpeszoster recovery In order to achieve these treatment outcomes, the appropriate frequency, intensity, duty cycle, and duration of ultrasoundmust be selected and applied.Ultrasoundshouldnot be appliedin situationswhere it may aggravatean existingpathology, such as a malignancy,or when it may causetissue damage,such as a burn. When evaluatingan ultrasounddevicefor clinicalapplication,one shouldconof the availablefrequencies, siderthe appropriateness pulseddury cycles,sizesof soundheads,andBNRsto the typesof problemsexpectedto be treatedwith the device.The readeris referredto the Evolvewebsiteat for study queshttp://evolve.elsevier.com/Cameron tions pertinentto this chapter. References radiaandnon-ionizing 1. Hill C\ TerHaarGrUltrasound tion protection,In SuessMJ, ed: WHO Regional 1981, No. 10,Copenhagen, European Series Publication, WorldHeal*rOrganization. CE,Al-KarmiAM, JoyceJMeta1:Thebiologi2. Goodman dependultrasoundr frequency caleffectsof therapeutic of the 14th annualmeetingof the ence.Proceedings inBiologyandMedicine, Regulation Societyfor Physical DC.1994. Washineton
3, IkamerJF:UltrasoundrEvaluationofits mechanical
rhetmaleff.ects, ArchPhvsMedRehabil65t223-227 ,198+ of 4. Pye SD, Milford Cr The performance physiotherapymachinesin Lothian Region, -359, 1994 1992,UhrasoudMed Biol20(4):347 5 . ChapelonJY,CathignolD, Cain C et aL New tric transducersfor thelapeuticultrasound, Med Biollan;26(1)t153-159 ,2A00.
6. BakerI(G,Robertson V, DuckfA: A reviewof Physical etfects, biophysical peuticultrasoundr 8 1 ( 7 ) r 1 3 5 1 - 12305081,, 7 . HarveyEN: Biologicalaspectsof ultrasonicwaves: 1930 general survey. BrblBull59:306'325, Heata in Therapeutic Therayy L LehmannJF:Uhrasound 1990,Williams& Wilkins,1990. Cold,ed4,Bakimore, 9 . Iehmann JF, Delateur BJ, StonebridgeJB et Therapeutictemperaturedistributionproduced ultrasoundasmodified by dosageand volume of
1967 48:662-666, ArchPhysMedRehabil exposed, DelateurBJ,WarrenG et al:Boneand 1 0 ,lehmannJF, ArchPhys tissueheatingproducedby uftrasound, -401, L967. 48:397 Rehabil 11. NyborgWN, Ziskin MCr Biologicaleffectsof 1.624,1985. sound,CliuDiagnUhtasound 12.DraperDO, Castel JC,CastelDr Rateof increasein human muscle during 1 MHz and 3 continuous ultrasound, J Onhoy Spon Phys
22(4):142-150 , I99s. ClouardRetal: 13.Darlas I SolassonA"
Calcul de la thermogenese,AnnalsReadaptation
Phys32:181-192 , 1989. 1,4.TerHaarG: Basicphysicsof therapeutic 64(4):tAA-L03 Physiothetapy , I978. 15. Lehmann Jf. SronebridgeJB. Delateur BJ. et inhumanthighs afterhotpack Temperatures followed by ultrasound,ArchPhysMed Rehabil 475,1,978. S, SorvistoP et a1:T 16. DraperDO, Schulties changesin deepmuscleofhumans duringice and sound therapies:an in vivo sttLdy, J Onhoy Syon Ther21(3): 153-157,I995.
Treo . THE PIIYSICAL AGENTS
2t5
l-, Harle J, Salih V, Mayia F et al: Effectsof ultrasound ts4.Ilemming K, Cullum H: Therapeutic ultrasound for on the growth and function of bone and periodontal plessur€ sores, Cochuxe Daabase Syst Rev (4): ligament cells in vitro, Uhrasoundix Medicineaxd Biology cD001275 , 2000. 27(4\:579-586 . 35. Dyson M, Suckling J: Stimulation of tissue repair , 2001, -:. MoftimerAJ, DysonM: The effectof therapeuticultraby ultrasound: survey of the mechanisms involved, soundon calciumuptakein fibroblasts,Ufuasound Med Physiotherapy 63:105-108,1978. BioI 14(Q:499-506, 1988. McDiarmid ! Burns?N, lewith GT et al: Ultrasound :i. Dimo MA, Crum LA, Wu J: The effect of tlerapeutic and the fieatment of pressure sores, Physbthetapy ulffasoundon electrophysiological parametersof frog 77Q):66-7O,1985. skin, UhtasoundMed Biol 15(5)t461-470, 1989. 37. LundebergT, Nordstrom f; Brodda-JansenG et al: -rl. FyfeMC, ChahlLA: Mast celldegranulation:a possible Pulsedultrasounddoesnot improve healingof venous mechanism of action of therapeutic ultrasound. dcers, Scad J RehabilMed 22:195-197, 1990. L)ltrasornd MedBiol 8(Srppl | ):62,1i82. 38. Eriksson SV, Lundeberg I Mdm M: A placeboil. Young S\ Dyson M: Macrophageresponsiveness to controlled trial of ultrasound therapy in chronic leg therapeutic ultrasound, Ubrasouwl Med Biol 16(8): ulceration, ScandJ RehabilMed 23:211-213,L991. 809-816,1990. 39. Terfuet C, KesselsACH, (nipschild P: A randomized il. HarveyW, Dyson M, PondJBet al: The stimulationof clinicaltrial of ultrasoundin the treatmentof pressure protein synthesisin human fibroblastsby therapeutic dcers, PhysTher76(12)11301-131,2 , 1996. ultasound,RheumanlRehabil14:237,1975. 40. Young S\ Dyson M: The effect of tierapeutic ultra-.3. Dinno MA, AI-Karmi AM, Stoltz DA et al: Effect of free sound on angiogenesis,Uhrasoundlv4edBiol L6(3): radicalscavengers on changesin ion conductancedur261-269, 1990. ing exposureto *rerapeuticultrasound,l,4emfu Biochem 41. Byl NN, McKenzieAI, WestJM et al: Low doseultra-247, 1993. 10(4):237 sound effectson wound healing:a controlled study with li. Robertson VJ, Baker KG: A review of therapeutic Yucaranpigs,ArchPhysMed Rehabll TS:65G664,1992. Itrasound: effectivenessstudies, Phys Ther JuI;81(7): 42. Byl NN, McKenzie Al, Wong T et al: lncisional wound 1339-1350,2001. healing:a controlledstudy of low doseand high dose -5. van der Windt DAWM, van derHeijdenCJMC,van der ultrasound,J Onhop SVon Phys Ther 18(5):6L9-628, Berg SC et al: Ultrasoundtherapy for musculoskeletal 1993. disorders:a systematjcreview,Paift81.257-271, 1999. 43. FergusonHN: Ultrasoundin the treatmentof surgical 16. Warren CG, LehmannJf; KoblanskiJN: Elongationof wounds, Physiothera?y 67(2):43,19BI. rat tail tendon:effectof loadand temperatore, ArchPhys 44. FieldhouseC: Ultrasound for relief of painful €piMed 52:465, 1971. siotomy scars,Prlsrbtherapy 65(7):217,1979. i7. LehmannJI, Masock AJ, Wanen CG et al: Effectsof 45. BinderA, Hodge G, CreenwoodAM et al: Is tierapeutherapeutictemperatureson tendon extenslblity,Arch tic ultrasoundeffectivein treatins soft tissuelesions? PhvsMed 51:487. 1970. tu Medl 290:512-514,1985. lE. LehmarrrJI: Clinical evaluationof a new approachin 46. Ebenbichler C\ Erdogmus CB, Resch KL et al: the treabnent of contractureassociatedwith hip fracUltrasound therapy for calcific tendinitis of the shoulture after intemal fixation,AtchPhysMed Rehabil42:95, der,N EnglJ Med 340:1533-1538,1999. \961. 47. LwdebergT, AbrahamssonI Haker E: A comparative i9. WesslingKC, DeVaneDA, Hylton CR: Effectsof static study of continuous ultrasound,placebo ultrasound stretchversusstatic sftetch and ultrasoundcombined and rest in epicondylalgia,ScandJ RehabMed 20:99on t cepssuraemuscleextensibilityin healthywomen, 1 0 11 , 988. PhysThet67(5):674-679, 1987. 48. Haker E, LundebergT: Pulsedultrasoundtreatmentin i0. lr{iddlemast S, ChatterjeeDS: Comparison of ultralateral epicondylitis, ScandI RehabMed 23:115-118, souod and thermotherapy for soft tissue injuries, 1991. Physiotherapy 64(L1):33L-332,1978. 49. Downing DS, WeinsteinAr Uhasound therapyof sub31. Nwuge VCB: Ultrasound in ffeatnent of back pain acromialbursitis:a double blind ft:Lal,PhysTher66(2). resulting ftom prolapsed disc, Arch Phys Med Rehabil 194-199, 1986. 64:88-89 50. EnwemekaCSr The effectso[ tlerapeutic ultnsound , t9B3. 32. Munting E: Ultrasonic therapy for painful shoulders, on tendon heaLrrg,An J PhysMed Rehabil6:283-287, Physiothetapy 64(Q:1,80-181,, 1978. 7989. 33. Flemming K, Cullum N: Therapeutic ulhasound for 51. EnwemekaCS, RodriguezO, MendosaS:The biomevenous leg ulcerc, Cochrane Danbase Syst Rev chanical effects of low intensity ultrasound on healing (4):CD001180, 2000. tendons, UbrasoundMed Biol t6(8):801-807, 1990.
216
7 . Ultrasottd
IriederSJ,WeisbergB,FlemingB etal: A pilot study:the therapeuticeffect of ultrasoundfollowing partial rupture ofAchilles tendonsinmale rats,L OnhopSyortPhys Ther1,0:39-46 , 1988. 53. JacksonBA, SchwaneJA, StarcherBC: Effect of ultrasoundtherapyon ttre repairof Achillestendoninjuries in rats,Med SciSponExerc23(2):171-t76, 1991. RobertsM, RutherfordJH,HarrisD: The effectof ultrasound on flexor tendon repairs in nbbits, Hand -20, 1982. 14(1):17 55. Turner SM, PowellES,Ng CS:The effectof ultrasound on healing of repaired cockerel tendon: is collagen crosslinkagea factor?J Haud Surg[BR] 14(a):a28-433, 1989. 56. Cline PD: Radiographicfollow-up of ultrasoundtherapyin calcificbursitis,PhysTher43:16,L963. 57. Corkiewicz R: Ultrasound for subacromialbursitis: a casereport,PhysTher64(1):46-47 , L984. 58. Griffin J, Karselis T: Physical Agents for Physlcal Therapists, Spring eld,IL, 1982,CharlesCThomas. 59. Hecox B, MehreteabTA, WeisbergJ:Physical Agexts:A ConVrehensive Tett fotPhysicalTherapkts,East Norwalk, CT, 1994,Appleton & lange. 60. FukadaE,YasudaI: On the piezoelectriceffectof bone, I2:!0,1957. J PhysSocJap 61. Duarte LR: The stimulation of bone growth by ultrasol:nd,Archiv Olthop Trauna Sury 101:153-159, 1983. 62. PillaAA, Mont MA. NasserPRet al: Non-invasivelowintensityuluasoundaccelerates bonehealingin the rabbit,J OnhoVTtauna4(3)246-253,199A. 63. KristiansenT, Pilla AA, Siffert RS et al: A multicenter study of Colles' fracture healing by noninvasivelow intensity ultrasound.Presentedat the 57th meeting of the American Association oI Orthopedic Surgeons, New O eans,February1990. 64. HeckmanJD, RyabyJP,McCabeJ et al: Accelerationof tibial fracture healing by non-iqvasive,low-intensity pulsedultrasound,rlBoneJtSurgT6A(I):26-34,1994. 65. Herrick Jl: Temperaturesproducedin tissuesby ultrasound: experimentalstudy using various technics,J Acoust SocAn 25:72-16 , 1953. 66. Oztas O, Turan B, Bora I et al: Ultrasound therapy effect in caryal tunnel syndrome,ArchPhysMed Rehabil D ec;79(12):I5 40-1544, 1988. 67. Ebenbichler CR, ReschKl. NicolakisP er al. Ulnasound fteatrnent for treating the carpal tunnel syndrome: randomised " sham" controlled txial,BMI 316:731-735, 7988. 68. McNeill SC, Potts RO. FrancoerMl: Local enhanced topical drug delivery (LETD) of drugs: does it truly exist?PharmRes9:t 422-1427, 1992. 69. Iellinger K, SchmidJ:K.linikund TherapiedesCfuonischen Celenlheumatismus.Vienna,1954,Maudrich, 70. G ffinJE,TouchstoneJC:Ultrasonicmovementofcortisol into pig tissues,I: Movement into skeletalmuscle, AnJ PhysMed 42:77-85, 1963.
71,.Griffin JE,TouchstoneJC, Liu ACY Ultrasonic
ment ofcortisol into pig tissues,II: Movementinto avefiebral new e,AmJ PhysMed 44:20-25, 1965. 72. Griffin JE,TouchstoneJC: Low intensity sisofcortisolin swine,Phy: Ther48:1.336-1344,1968. 73. Griffin JE, TouchstoneJC: Effects of ultrasonic quency on phonophoresisof cortisol into swine sues,ArlJ PhysMed, 51:62-78,1972. Mitragotri S, FarrellJ, Tang H et al: Determination tlreshold energ"ydosefor ultrasound-induced mal drug transport,.l'ControlRelease Jan3;6ts(7-2)t4t 75. Bommaman D, Okuyama Hj Stauffer P et Sonophoresis, I: The use of high fiequency to enhancetransdemal drug dehvery,Pharn 559-564,1992. 76. TangH, Mitragotri S,BlankschteinD et all descriptionoI transdermaltransponof hydrophilic meantsr application to low-frequency . J PharnSciMay;90(5):545-68,2001 77. Mitragotri S: Effect of therapeuticulffasoundon tion and diffusion coefficients in human
comeum, Release Mart2;7I(1):23-29 J Cofltrol , 2001. 7 8 . lranJdh Mt, Smith 51. ChenierTC e! ali Effect phonophoresiswith dexamethasoneon adlenal tion,J OrthopSVonPhysTher22(3):103-107 , 1995. 79. ByI NN: The useof ultrasoundasan enhancerfor scutaneousdrug delivery: phonophoresis,Pr,.,s -553,1995. 75(6)1539 80. Kleinkot JA, Wood AI: Phonophoresiswith 1 versus 10% hydroconisone,Phys Ther 55:13201975. 81. Cameron MH, Monroe LG: Relativetransmission ultrasoundby mediacustoma ly usedfo! sis,PhysTher72:142-1,48, 1992. 82. Ler.yD, Kost J, MeshulamY et al: Effect of on transdermaldrug delivery to rats and tuinea J Clin Invest83:2074-2078,1989. Brucks\ NanavatyM, JungD et al: The effectof soundon the in vitro penetrationof ibuprofen -70I, 1989. human epidermis,Pharn Res6(8):697 84. DelacerdaIG: Ultrasonictechniquesfor treatment plantar warts in athletes,/ Onhop SVonPhys Ther 100-103,1979. 85. BraatzJH,McAlistarBI, BroaddusMD: Ultrasound plantar warts: a double blind sttdy, Mili Med 199-201,1974. 86. JonesRJ:Treatmentof acuteherpeszosterusing soructherapy,PhysiotheraVy 70:94-95,1984. 87.JonesRJ, Silman GM: Trial of ultrasonict}lerapy acuteherpeszoster,Ptuctitionet 23L:1336-1,340 , 1987. 8 8 .Sicard-Rosenbaum L, Lord D, Danoff fV et al: Effects continuous therapeutic ultrasound on growth metastasisof subcutaneousmurine tumors, Plrys 75(1)t3-1,1, 1995.
Two O THE PHYSICAL AGENTS
Marmor JB, Pounds D, Hahn CM: Treating spontaneoustumo$ in dogs and cats by ultrasound-induced hyperthermia,lxt J Radlat Oxal Biol Phys4:967-973, 1978. {r, Marmor JB, Hilerio IB, Hahn CM: Tumor eradication and cell survivalafter localizedhyperthermiainduced by dtrasound,CatcerRes392166-217L,1979. ; 1 . SmachloK, Fridd CW, Child SZ et al: Ultrasonictreatment of tumors, 1: Absenceof metastasesfollowing treatrnentof a hamsterfibrosarcoma,Uhrasound Med Biol5:45-49, 1979ShistaK: Neural tube defectsand maternalhypenhermia in early prcgnancy: epidemiology in a human embryopopulatioq A n J Med Cenet12:28I-288,1982. Kalter H, Warkany J: Congenital malformations: etiological factors and their role in prevention, N EnglJ Med 308:424-431,1983. rS. Mdeod D\ Fowlow SB: Multiple malformations and exposureto therapeuricultrasoundduringorganogene1989. sis,AnJ Med CenetS4:317-319, CarstensenEL, GatesAH: The effectsof pulsedultrasoundon the fetus,/ Uhrasouad Med 3:145-147 , 1,984. )6. National Council of Radiation Protection and Measurements: Biological effects of ultrasound: Mechanisms and clinical implications. NCRP Report No. 74.Bedesda.MD. 1983.NCRP. 9
217
97. Normand H, DarlasI SolassolA et al: Etudeexperimentale de l'effet thermique des ultrasons sur Ie Med Phys materiel prothetique, Afla Reada?tation 32:793-201,7989. E, SommerJ:Ultrasoundinfluence 98. Skoubo-Kristensen on internal fixation with gid plate in dogs, Arch Phys Med Rehabil6S:37I-373,1982. 99. DeforestRE,Herick Jl JanesJM: Effectsof ultrasosnd on growing bone: an experimental swdy, Arch Phys Med Rehab34:21, !953. 100. SpadaroJA, SkarulisI AlbaneseSA: Effect of pulsed ultrasoundon bonegrowth in rats.?roceedingsof the 14th Annual Meeting of the Society for ?hysical Regulation in Biology and Medicine, Washington DC, 7994. 101. Nyborg \44: Biological effects of ultrasound: development of safety guidelines.?an II: Ceneral review, UhrcsoundMed Biol Mar;27(3):301-333,2001. 102. Dyson M, PondJB,Woodward B et al:The production of blood cell stasisand endothelialdamagein blood vessels of chick embryostreatedwilh ulffasoundin a stationary 1\4edBiol63:133-138,1974. wave held, Ultrasouxd 103. TerHaar G\ Dyson lvl, Smith SPr Ultrastructural changes in the mouse uterus brought about by ultrasonic inadiation at tlerapeutic intensities in standingwave heIds,UfuasouxdMed Biol5:167-179, 1979.
ElectricalC rents Sara ShaViro,MPH, PT 'a:ali.:.
SUMMARY
OF ]NFORMATION
Introduction and History Terminologyfor ElectricalCurrents !ffects of ElectricalCurrents ClinicalApplicationsof ElectricalCurrents
COVERED
ElectricalCurent in ClinicalPractice Documentation ClinicalCaseStudies ChapterReview ,:.::i.
oBIECTTVES Uyor comVletionof this chaptet,the readerwill beable to 1. Define the basicsettingsfor the use of electrical stimulation as they are appliedin the managementof neuromuscularand musculoskeletaldysfunctionsand wound care. 2. Identi$zthe physiologicaleffectsof electrical stimulation. 3. Be familiar with the multiple usesof electrical stimulation including musclere-educationand strengthening,gait training, spasticity reduction, wound care,and pain modulation. 4. Discussthe basicprinciplesof electrode size and materials,and demonstrate appropriateplacementtechniquesfor each aoolication.
5. Comparethe basicsimilarities,differences,and functional applicationsof high volt, mediurn frequenry and interferential,and DC for iontophoresisand then choosethe appropriate deviceto obtain the desiredtreatment goals. 6. Be familiar with the guidelines,precautions,and contraindications in working wit-l-relectrical stimulation devices. 7. When presentedwith a clinical case,analyze the clinical findings, proposegoalsof treatment, assesswhether electrotherapywould be an appropriatetreatment, and if so, formulate an effectivetreatment plan including the appropriatedeviceand treaunent parameters for achievingthe goalsof treatment.
219
220
8 c Elect
cal Ctrrexts
AND HISTORY INTRODUCTION An electricalcurrent is a flow of chargedparticles. The chargedparticlesmay be either electronsor ions. Electricalcurrentshavebeenappliedto biologicalsystemsto changephysiologicalprocesses datingbackas far as 46 AD, when it was recordedthat the electric dischargefrom torpedo fish was used to alleviate pam.''' In the late 18th and early19th centuriestherewas a revival of interestin medicalapplicationsof electrical currents.In 1791, Galvani first recordedproducing musclecontractionsby touchingmetal to a frog'smuscle.He caliedthis effectanimalelectriciw.A fewvears later,whenVolra construcredthe precursorro thi battery Calvaniusedthe currentput outby this deviceto producemusclecontractions.He named the current "Galvanic current.' In an atlempt to understandthe mechanismsby which electricalcurrentscausemuscle contractions,Duchennemappedout the locations on the skin where electricalstimulation most effectivelv causedspecificmusclesto contract.He called these locations "motor points."3 During the 1830s Faradaydiscovered*rat bidirectional electricalcurrentscouldbe inducedby a moving magnet.He called this cuffent "Iaradic curent." Iaradic current can be used to produce muscle contractions. In 1905, Lapicquedevelopedthe "law of excitation" relating the intensity and duration of a stimulusto whether it would producea musclecontraction.Lapicqueintro' ducedthe conceptof the strength-durationcurve,as descdbediater in this chapter The useof electricalcurrentsfor controllingpain is derived from the gate control theory of pain perception developedby Melzack andWall in the 1960s.For a more completedescriptionofthe historicaldevelopment of electricalstimulationthe readeris referredto SidneyLicht'sE/ertrod.iagnosis andElectomyography.4 Today, electricalstimuiation has a wide range of clinical applicationsin rehabilitation.These include pain control,T,Bfacilitating muscle siiengthening,5,6 the healingof recalcirrant wounds.eand rhe resolution of edemaand inflammatory reactionsfoilowing mlury or surgery'" Many professionals,including physicaltherapists, occupational therapists, physicians, chiropractors, and others, have found electricalstimulation to be a valuableand effectivecomponentof their therapeutic armamentarium.In an ongoing effort to provide
evidence-basedtreatment, researchershave ated the efficacy of electricstimulation for its
mon clinicalapplications. The proliferationof sophisticated machines hasalsoincreased interest the useof electricstimulationasan adjunctto itation treatment. These machines have m waveforms,allow a wide variety of parameter tion, and may include computer-generated images body partsand electrodeplacementfor specificdii
noses.The availabilityof small,patient-friendly that canbe usedat home hasalsoenhancedthe tivenessol electricalstimulationbv allowine ffeatmentbetweenclinic visits. Electricalstimulationcanbe aboliedto the a variety ofways. The electricitymay be delivered a stimulator implantedin the body, as occurswit cardiacpacemaker,or an externalstimulator can used to deliver cuffent to implanted or extemal face transcutaneouselecuodes.This chapter describesthe aoplicationof electricalstimulation external sdmulators that deliver current neouslyvia surfaceelectrodesappliedto the skin.
TERMINOLOGY FORELECTRICAL CURBENTS An issue that continues to complicate the use electricstimulationis the varieduseandmisuse minology describingtherapeuticelectrical 1986 the Clinical ElectrophysiologySection of American Physical Therapy Association publisheda terminologyguide in an attempt to dardizethe terminologyusedby clinicians, turers,researchers, educators, andengineers to therapeuticelectricalcurrents.A second edition this guide was published in 2000.11This guide helpedto promote the consistentuseof This chapter uses its terminology and Becausenot all manufacturersor cliniciansuse terminology, any alternativecommonly used arenoted in parentheses.
General Terms Electrical Current: The movement or flow chargedparticlesthrough a conductorin to an appliedelectricfield. Currentis noted asI is measuredin Amperes(A).
T*,o . THE PWSICAL
Charge:One of the basicproPeftiesof matter,which eitherhasno charge(is electricallyneutral),or may be negatively(-) or positively (+) charged Charge in Coulombs(C). is notid asQ andis measured Polarity: The property of having wo oppositely chargedconductors,with the positive called the ano[c, and the negative called the uthode' ln a conductor, free el;ctrons flow from an area of excesselectrons(negativepole)to an areadeficient in electrons(PositivePole). Voltage: The electrical force capable of moving chaieed particles through a conductor bewveen rwoiegions or points.VJltageis alsoknown asthe Voltage is noted as V and is Fotenti^ldifference. measuredin volts M. Resistance:The properryof a conductorthat resists or is in oppositionto the flow of chargedparticles. Resistanceis noted asR and is measuredin Ohms Ohm's Law: V = I x R is the mathematicalexpression of how voltage flf, current (l), and resistance(R), relate. opposilmpedance: The total frequency-dependent iion to currentflow. Impedanceis notedby Z and is measuredin Ohms (Cl).For biologicalsystems, impedancedescribesthe ratio of voltageto cuffent more accuratelythan resistancebecauseit is a frequency-dependentmeasure that inciudes the and resistance. effectsoI capacitance
ParametersTreatment Stimulation Electrical Waveforms Direct Current (DC); A continuousunidirectional flow of chargedparticlesis known as direttcutrcnt (DC). Dfuectcurrent is used to for iontophoresis and for stimuiatingcontractionof denervatedmuscle and also occasionallyto facilitatewound healing (Iig, 8-1). Alteinating Cutrent (AC); A continuous bidirectionalflow of chargedparticlesis known as current(AC)(Iig. 8-2).Altematingcurrent alternating hasequalion flow in eachdirection,andassuchno pulse charge remains in the tissues.Most commonlv. AC is deliveredas a sinewave The wavelengthis the durationo! 1 cycle.A cycleis from the time that the current departsfrom the isoelectric line (zero current amplitude)in one direction and then crossesthe isoelectricline in the opposite direction to when it returnsto the isoelectricline.
ACENTS
221
Figure 8-1. Directcurrent(DC).
Figure8-2. Altemating current (AC).
An inverse relationship between cycle duration and frequencyis inherent to the AC waveform: when the frequencyincreases,the cycle duration the and when the frequencydecreases, decreasesl (Fig. 8-3) cycledurationincreases Pulsed Curtent or Pulsatile Current: Electricalcurrent canbe delivereddiscontinuously,in a seriesof pulses separatedby periods when no current hows. This is known as Vulsedor yulsatilecutent' The current pulsesmay be either uni- or bidirecpulsesis known as tional.A seriesof unidirectional a monovhasic ?ulsedcurtent.In this case,charged move onlv in one direction.A seriesof Darticles tidirectional pulsesis known as a biphasicpulsed cunent(Fig.8-4). With a biphasic pulsed current, chargedparticlesmove first in one direction and ther;in tle opposite direction.A biphasicpulsed current may be symmetric or asyfirmetrrc,and if asl,rnmeuic,it may be balancedor unbalanced (Iig.8-5). Wirh a balancedpulse the chargeof thJ phasesare equal in amount and opposite in
222
8 . Electrical Cuttetts
+ polarlty
- polarity
- poladty
+ polarity + polariiy
- polarity Figure8-3, Illustration of the inverserelationshipbetween frequenry and cycle duration for an altemating current (},=Wavelength)
+ polarity
+ polarity
A
Figure8-5.A, Symmetric,B, balancedasymmetricand C, unbalanced asymmetricbiphasicpulsedcurrents.
Figure8-4. A, Monophasicand B, biphasicpulsedcurrents.
polariqy,resultingin a net chargeof zero. With an unbalancedpulsethe chargeof the phasesare not equaland the net chargeis not zero. Interferential Current: Interferentialcuffent is the waveform produced by the interferenceof &vo medium frequency(1,000to 10,000Hz) sinusoidal ACs of slightly different frequencies.These two wavefotms are deliveredthrough two setsof electrodesthrough separatechaffielsin the samestimulator.The electrodesare configuredon the skin so *rat the two AC currentsintersect(Iig. 8-6).When the currentsintersecttiey interfere, producinga higher amplitude when both currentsare in the samephaseand a lower amplitudewhen the rwo cuffents are in opposite phases.This produces envelopesof pulsesknown as beats.The beat frequency is equal to the difference between the ftequenciesof the two originalACs.The frequency* of slower originalAC is calledthe caderfreque cr'. For example,when a carrierftequencyof 5000Hz
- polarliy + polarlty
- polarlty
223
Two . THE PHYSICAL ACENTS
Figure 8-6.Int€rsecting medium frequencyalternatingcurrents producing an interferentiai currentbetweentwo crossed pairs of electrodes,(Irom May H-U, HansjiirgensA: Nemectrodlm Model7 Manual ^F
NT.-".r'^-
.]-|TJ
Daimlerstr. 15, IQrlsruche/ Germany,1984. Used with permission,)
interfereswith a cufient with a frequencvof 5100 Hz a bearfrequencyof 100Hz wifl 6e producedin the tissue(Iig. 8-7).Typically,electricalstimulation un.itsthat produceinterferentialstimulationallow the clinician to set the beat lrequency and some also allow the clinician to selectthe carrier frequency. It is proposedthat interferentialcurrent is more comfortable than other waveforms because it allows a low amplitude curent to be delivered through the skin, where most discomfort is produced,while deliveringa much higher current amplitude to deepertissues.Lrterferentialcurrent may also stimulatea larger areathan other waveforms. Of note, there is no publishedresearchto verify theseclaims.Additionally,interferentialcurrent is a continuousAC and thereforehas a hisher average amplitudethanpulsedwaveforms.
Premodulated Current: Premodulatedcuffent is a waveform produced by one channel (nvo electrodes) that has the same fom as the current produced by the interferenceof two mediumfrequenrysinusoidalACs,Premodulated currenthas a continuoussinusoidalwaveform with a medium frequenryanda sequentiallyincreasinganddecreasing currentamplitude.The advantages of interferential currenq including a lower current amplitude beingdeliveredto the skinanda largerareaof stimulatior5arenot reproducedby premodulatedcurrent. Russian Protocol: The Russianprotocol is comprisedof 2500Hz carrierfrequencyAC sinusoidal wave modulated to produce 50 bursts per second (bps).Eachburst (or envelope)is a polyphasic waveform delivered for 10 milliseconds followed by an interburst interveral of 50 milliseconds(Iig. 8-8).
224
8 o Electrical Curretts
+ polarity
ckcuit 2 Ee
.)
g o
o
Circuit1 Time (1 second)+
-polarlty
C2
Figure8-9. Monophasic pulsed current with of3 pulsesper secondand 9 pulsesper second.
Cirquits 1&2
Figure8-7, An alternating cuffent with a frequency of 5000Hz interferingwith an altematirg curent with a kequency of 5100 Hz to produce an interferential current with a beat fiequency of 100 Hz. (Irom May H-U, Hansjiirgens A: Nemectrodl'n Model 7 Manual of Nemectron CmbH, Daimlerstr.15, Karlsruche/Germany, 1984.Usedwith permission.) + polarlty .,i.,i-l 10msecil0mseci10msec
-polarity
Figxre8-8. Russianprotocol.
pulseto the end of the last phaseof a pulse. dwatiox refersto the duration of one phaseof pulse. Pulse and phase duration are expressedin microseconds(ps) or (m$ (Iig. 8-10). Interpulse Interval: The interpulseinterval is time betweenpulses(seelig. 8-10). Interphase Interval: The interphaseinterval is time befweenphasesof a pulse.This is referredto asintrapulseinterval(Iig. 8-11). Rise Time/Decay Time: Rise time is the time i takes for the current to increasefrom zero to peakduringany one phase.Decaytime is the it takes for dre current to decreasefrom its level to zero duringany one phase(Iig. 8-12). that this is differentfrom ramp up and ramp asdescribedbelow. On/Off Time: On time is the time durins which train of pulsesoccurs.Off time is the time trains of pulseswhen no curent flows. On off times are usually only used when stimulation is used to produce muscle tions. During the on time the muscle conffacts, during *re off time it relaxes. The off times
TimeDependent Parameters
neededto reducemusclefatigueduring the lation session.The sequentialon and off times
Frequenoyt Frequerrydescribesthe number of cyclesor pulsesper secondand is expressed asH errz $12) for rydes or pulsesper second(pps)for pulses(Iig. B-9). Pulse Duration/Phase Duration: Pulseduration is the time from the beginring of the first phaseof a
attempt to mimic the voluntary contract and phases of normal physiological exercise. The
tionship ofthe on and off time is often expressed a ratio.For example,if a muscleis stimulatedfor 1 secondsand then allowed to relax for 50
T.luo . THE PHYSICAI , CENTS
+ polarily
+polarity
I Phase Inlerpulse I duration interval !)
o
I r;-t,1--#'-y
t--ti lui
'lH o
ll
f-
!
-polarity
| , . - -PUrSe I I
duration
Time
Figure 8-12,Riseanddecaytimes.
+ polarity = I Phase Pulseduralion
li'*ii
t-ll
6
0
o
225
| I I
II
| I"
|
|
' ;--7Interpulse I interval
r-1 /-t
Time
-polarlty :jgure 8-10. lulse duration, phase duration, and inter:ulse interval for biphasic and monophasic pulsed cur:ents.
+ polarlty
this may be written as a 10:50secondon:off lime or a 115on:off ratio.The onroff ratio is a ratio of the on time to the off time (Iig. 8-13). Duty Cycle: Duty cycleis the ratio of the on time to the total cycle time, where the total cycle time is the on time plus the off time. Becausethe tetm duty cycleis trequentlymisunderstoodto mean onroff rhatthe clearerterminolrado,it is recommended ogy of "on:offtime" or "on:offratio"be used. Ramp Up Time/Ramp Down Time: The ramp up time is the time it takesfor the currenrto increase from zero to its maximum amplitude for any one on time. This is in contrastto the rise time, which describesthe time for the cuffent amplitude to increaseduring one phaseonly. The ramp down time is the time it takesfor the currentto decrease from its maximum amplitude to zero during any one on time, This is in contrastto the decaytime, which describesthe time for the currentamplitude to fall duringone phaseonly (Fig.8-14). Rampingis usedto producea "soft start,"allowing patientsto becomeaccustomedto the stimula+ polatity
-polarity
Figule8-11. Interphase interval for a biphasic pulsed current.
Figure8-13. On and off times for a biphasiccurrent.
226
8.
FiguJe 8-14. Ramp up Emh
.i^\xrh
Electical C lreflts
and
frnp.
-polality
tion asit increasesfrom a subsensorylevelto a sensory level and Finally reachesmotor threshold. Ramp up is generallyincludedin the on time while the ramp down time is includedin the off time.
otherElectrical Current Parameters Amplitude: Amplitude is the magnitudeof currentor voltage.While the term intensityis ftequendyused interchangeablywith amplitude,it is not the correct term to usein *ris context(Iig. 8-15). Modulation: Modulation refers to any pattem of variationin one or more of the stimulationparameters.Modulation is usedto limit neuraladaptation to an electricalcuffent. Modulation may be cyclic or random(Iig. 8-10. Frequenry Modulation: Irequency modulation refersto vadation in the number of pulsesor cvcles ner
Acl;"","4
+ polarity
-polarity
Figure8-15. Cuffent amplitude.
Figure8-16. Current amplitude modulation.
Amplitude
Modulation:
Amplitude
refers to variation in peak current amplitude.
Phase Duration or Pulse Duration Phasedurationor pulsedurationmodulation to variationin *re ohaseor oulseduration. Note that modulation of interferential waveforms is similar to that of pulsed however,the terminologyusedby most turers is different. Sweeyts generallyusedto t frequencvmodulationand saa,is usedto current amplitudemodulation. Curent modulationmakesthe effectivefield of change,causingthe patient to feel the focus of stimulation movine. Manufacturersoften claim currentscan be crossedat a preciselocation, ing the clinician to target arry area. However, due
differencesin tissueconductiviry,curent will generallyflow through bone and thus cannotbe ciselycrossed at thecenteroI a joint.
Tvo . THE PITYSICAL AGENTS
227
+++++++++++ Figule8-17.Burstmode.
Burst Mode: Burstmoderefersto a seriesof pulses deliveredin a packageor "envelope"as a single pulse.Theburstis generallydelivered with a pres" is rhe ent frequencyand duration.Burstduration time from the beginningto the end of the burst. The time betweenburstsis calledthe interburst intenal(Tig.8-77).
CURRENTS EFFECTS OFELECTBICAL Depolarization Nerve ;or most applications,elecfficalcurrentsexert their :hysiological effects by depolarizing nerve mem':ranes and thereby producing action potentials,the :lessageunit of the nervous system. Electricalcur:entswith sufficient amplitude, that last for a suffi:ient length of time, will causeenoughof a changein :rerve membrane potential to generate an action rotential. Once that action potential is propagated Jong the axon, the human body respondsto it in the sameway asit doesto abtionpotentialsthat areiniti:ted by physiologicalstimuli. An actionyotentialis the basicunit of nervecommurication.When a nerveis at rest,without physiologi:al or electrical stimulation, the inside is more regativelychargedthan the outsideby-60 to -90 milyate tial lvolts. This is known as the restig metnbrafle Tig. 8-18).When a stimulus of sufficient amplitude strength) is applied over a sufficient length of ime, the membrane rapidly depolarizesand then :epolarizes. This rapid sequential depolarization and repolarizationis known as an action potential ,AP).
Figure 8-18.Resting potential, membrane The restingmembranepotential is maintainedby most of the sodium ions being outside the cell and most of the potassium ions being inside the cell, When a sufficient stimulus is applied,sodium channels in the cell membrane open rapidly, while the potassiumchannelsopen slowly. Becauseof the high extracellularconcentrationof sodium, sodium ions rush into the ceIl though the open channels.This makesthe inside of the cell becomemore positively charged,reversingthe membranepotential.When the membranepotential reaches+30 mV the permeabiland potassiumchannelsrapily to sodium decreases idly open, increasingthe permeabilityto potassium. Becausethere is a high intracellularconcenffationof potassiumions, potassiumions then flow out of the cell, returning the membranepolarizationto its resting stateof-60 to -90 mV This sequentialdepolatization and repolarizationof the cell membranecaused by the changingflow of ions acrossthe cell memWhile the nerve is depoiarized,no additionalAPs can be generated.During this time the nerqecannot be further excited, however strong a stimulus is refractory applied.This periodis known asthe absolute period.Llter depolarization,prior to retuming to the restingpotential,there is a brief period of membrane hyperpolarization.During this perioda greaterstimulus than usualis requiredto produceanotherAL This period of hyperpolarizationis known as the relative period. refractory curve Slrength-duration The amount of electricalcuffent requiredto produce an AP in a specifictype of nerve varies and can be
228 Figure8-19.An action potential is the basicunit of nerye communication and is achievedby rapid sequential depolarization and repolarization in tesponseto stimulation. Note that depolarization starts when the Na+ gate opens and Na+ flows into the cell causing a rapid change from the resting membrane nomal potential to a more positively charged state. Sequential repolarization occurs as permeabiliry to sodium decreases causing the K+ channels to open and K+ to flow out ofthe cell, returning the membrane polarization to its resting s[a!e.
8 t Electrical Currents
+++++
++++++++++++
+++++
++++++++++++
Absolute refractory period
Relative refractory perlod Time
representedby the newe's strength-durationcurve 200 (Fig.B-20).The strength-durationcuwe for a nerveis a .t80 graphicrepresentationof the minimum combination * 160 of cuffent strength (amplitude) and puise duration needed to depolarizethat nerve. This interplay of = amplitudeandpulsedurationis the basisfor the speci() ficity of the effect of electricalstimulation.In general, lower currentamplitudesand shorterpulsedurations o can depolarizesensoryneweswhile higheramplitude a or longer pulses are needed to depolarize motor 20 newes.Evenhigher amplitudesand longerpulsesare neededto depolarizepain-transmittingC fibers.Thus, short pulses,generallyof lessthan 80 pseconds(80 x areusedto producesensorystimulation 10 oseconds), on1y,while longerpulses,of 150to 350 pseconds,are usedto producemusclecontractions.By keepingpuise durationsbelow 1 ms (10-r seconds),pain is miniFigure8-20. Strength-duratroncurye. mized becauseC fibersare not depolarized.Pulsesof greaterthan 10 msec.are requiredto producemuscle in denervaced contraction muscle will occur. For any rype of tissue, the mrrumum When the current amp)itude andpulse duration fall amplitude, with a very long pulsedurati,on,required The mi below the curte for a particular newe type, the stirrruoroducean action p otential is calJedrheobase. lation is consideredto besubthreshoidandno response imum durationit takesto stimulatethat tissueat
229
T\vo . THE PIIYSICAL ACENTS
ireobaseintensityisknown asthro ^ve. Rheobaseis a neasure of current amplitude, while chronaxie is a neasureof time/duration(Iig. 8-2'-,, Increasingthe currentamplitudeor pulseduration 'ceyond that which is sufficient to stimulate an AP '.vill not change the AP in any way. Neither a larger ror a fasterAP occurs.A11nerve APs are the same. They occur in an all-or-nonefashion.The sameAP rccurswith any stimulusabovethreshold,and no AP '.villoccurwith any stimulusbelow thresholdlevel. In addition to sufficient curent amplitude and pulse Curation,the current amplitude must rise quickly :or an AP to be triggered.If the cuffent rises too slowly the nerve will accommodate to the stimulus. -\ccommodationis the processof a nerve gradually cecominglessresponsiveto stimulation;a stimulusof ,ufficient ampiitudeand durationwhich usuallyproCucesa responseno longerdoesso. Accommodation occurswith a slow rate of cufient rise becauseof t-he :rrolongedsubthresholdstimulation. Once an AP is generated,it triggersan AP in the adjacentareaof the nervemembrane.This processis :al.ed propagatioxor conduction of the AP along the reuron. With normal physiologicalstimulatioq Al :ropagation occursin only one direction.With elecrically stimulated APs, propagationoccurs in both Cirectionsfrom the siteof stimulation;howeve5only :hose APs transmitted in the usual physiological iirection havean effect.
; r00 Ee0 =80
F ro 660 Eso
The speedat which an AP travelsdependson the diameter of the nerve through which it travels,and whether or not the newe is myelinated. The larger the newe diameterthe faster the AP will travel. Ior example,large-diametermyelinated A-alpha motor nervesconductat between60 and 120meters/second, while smallerdiametermyelinatedA-gammaand Adeltanervesconductat only 12 to 30 meters/second. Action potentialstravel faster in myelinated nerves than in nonmyelinated nerves. Myelin is a fatty sheath that covers the length of certain axons. The sheathis not continuous,and the smallgapsin it are callednodesofRanvier.Acti.onpotenttalspropagate along myelinated nerve fibers by jumping from node to node-a processcalled saltatorycoxduction Srg. 8-22). This movement or jumping of the AP between nodes increasesthe speed of conduction. For example, unmyelinated C-fibers that transmit slow pain and temperatureconduct at only 0.5 to 2 meters/second, which is much slowerthan the 12to 30 meters/secondconductionspeedof similar diametermyelinatedA-gammaandA-deltanerves.12
Muscle Depolarization In the late 1800sit was found that denervatedmuscles do not contractin responseto the pulsesof electricity that produce contractions in innervated muscles. Innervatedmusclesconffactin resoonseto electriciw becarsethe currentcausesdepoiarizationof their motor nerves.Denervatedmuscleswill contract in responseto long pulsesof electricity,lastingfor 10ms or longer. These longer duration pulses depolarize the muscle cell membrane direcdy. Becausedenervated muscle membrane does not accommodate,a slow rising stimuluscan be usedto producea muscle contractionin it.1i Direction of conduction --------------) -\\\:\\\
7N
z'_'_'__'-'_'--_\\\\:\ -
\-n"opt""t
*30 -' 20 10
Figure8-21. Chronaxie and rheobase
Figure8-22.Saltatoryconductionalong a myelinated nerve. (From Burt AM: Textboobof Neuroaxatomy, Philadelphia, 1997,WB Saunders,)
8 . Electrical Cutre ts
230
ofElectrical Currents lonicEffects Most electricalcurrentsusedtherapeuticallyhavebalanced biphasicwaveforms. This qype of waveform leavesno chargein the tissueand thus has no ionic effects.In contrast,DC pulsedmonophasiccurrentsand unbalancedbiphasicwaveforms,which areusedoccasionallyfor electricalstimulation,do leavea net charge in the tissue.This chargecanproduceionic effects.The negativeelectrode(cathode)attractspositivelycharged ions and repelsnegativelychargedionswhile *re positive electrode(anode)attractsnegativelychargedions andrepelspositivelychargedions (Fig.8-23). These ionic effects can be exploited therapeutically.Ior example,a DC canbe usedto repelionized drug moiecules and may thus provide a force to increasetheir transdermalpenetration.This applicaIhe tion of electrotherapyis known as i7l1to?horcsis. ionic effects of electricity are also exploited for the treatmentof inflammatory statesand to facilitatetisin detailbelow suehealing,asdescribed
APPLICATIONS OFELECTRICAL CLINICAL CURRENTS Contraction Muscle muscle lnnervated When action potentialsare propagatedalong motor nerves,the musclefibers innervatedby those nerves becomedepolarized,and contract.The muscle contraction produced by electricallystimulated APs is similarto that producedby physioiogicgenerationof
APs; however, there are some important differences betweenthesemusclecontractions. The primary differencebetweenelectricallystimulatedmuscleconffactionsandphysiologicallyinitiated muscle contractionsis the order of recruitment oi motor units. With electricalstimuiation,nerve fiben with the largestaxonaldiameters,which innervatethe larger,fast-twitchmusclefibers,areactivatedfirst and those with a smaller axonal diameter are recruited iater.14In contrast,with physiologicalcontractions. siow-twitch muscle fibers are activated the sma11er, before larser fibers. The fast-twitch muscle fibers. which contractpreferentiallyin responseto electrical stimulation, fatigue rapidly while the slow-twitch musclefibers,preferentiallyrecruitedphysiological.ly. aremore fatigueresistant.A clinicalimplicationof this differenceis thaq since stimulated contractionsare more fatiguing,longerresttimes are neededbetween conftactions(Frg.8-2a).In addition, becauseelectrically stimulated contractions may affect different motor units than thoseaffectedby physiologicalcontraction,it is recommendedthat patientsperformboth electricallystimulatedand physiologicalcontractionsifpossible,to optimizetheir functionalrehabilitation Another diff erencebetweeneiectricallystirnulated contractions and physiologically initiated contractions is the smoothnessof the onset of the con-
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1234567 Total treatment time (minutes)
FigweB-24. The effect of changxry he on:off ratio on the force of contractionproduced.Note that suongercontractions are produced when longer off times are used. (Adapted with pernission from Benton LA" Baker LL, Bowmarr B\ et al: FanctioualElecticalStimulaion:A Pracical Clinical Cuide, Rancho Los Amigos, RehabiJitation Center. RanchoLosAmigosHospital,1981,Downey, CA.)
Two . THE PIIYSICAL AGENTS
;raction.Physiologicalcontractionsusuallygradually increasein force in a smootl y graded manner. The force is regulated by physiological control of which motor units arerecruitedand the rate at which eachmotor unit is activated.The contractionis kept srnoothby asynchronousrecruitmentof motor units. ln contrast,electricallystimulatedcontractionsgenerally have a rapid and often jerky onset becauseall motor units of a given size fire simultaneouslywhen -,}restimulusreachesthreshold. Electrical stimulation is thought to strengtlen musclesby two mechanisms:overload and speciticity.l5 According to the overload principle, the greaterthe load placedon a muscle,and the higher tbrcecontractionit produces,*re more strengththat musclewill gain. This principle appliesboth to coniractions produced by electricalstimulation and to -.hoseproducedby physiologicalexercise.l6lnnormal healthyhuman subjectsit has beenshown that combining electricalstimulationwith a voluntary exercise regime does not cause greater strengtheningthan eitherinterventionalone,if the sameforceof contracrion is produced.lTIn additiorl in healthy subjects, rhegainsin musclestrengtharesimilarfor electrically stimulatedcontractionsand exercisewhen the same amountof forceis produced.l8 Accordingto the specificitytheory, sinceelectrical :timulation causeslarger,fast-twitch (type II) muscle tibers,which producea greaterlevel of force,to contract before smaller slow-twitch (type I) muscle fibers,electricalstimulationshouldbe ableto produce greaterstrength gains than exercisealone with the sameforce contractions.This theory is supportedby the findingsthat, in weak patientswith reducedmuscie strength or after surgery early use of electrical stimulation can result in a more rapid recoveryand greaterstrength gains than exercisea1one.19,20,21 A recentstudy has also demonstratedthat 4 weeks of electricalstimulation alone or in combination with voluntary exercise,applied after anterior cruciate ligament reconstruction,produced greater strength gainsthan exercisealone.22 Although electricalstimulation appearsto accelerate postoperativerecoveryof strength,researchindicatesthat by 12 weeks after surgery strength is not significantly different for patientswho exerciseand those who receiveelectricalstimulation.23 Electricalstimulation can also assistin rehabilitation by recruiting a larger pool of motor units than physiologicalactivity does. For example, electrical
231
stimulation of the lower extremiw in oatientswith hemiplegia hasbeenshownto proiuce improvedvoluntary recruitmentof motor units and improvements in gait following treatment.24The increasedgeneral excitability of the motor neuron pool produced by electricalstimulation may enhancedescendingcontrol of muscle recruitment and augment sensory input. The sensoryinput may also provide a cue for the patient to initiate a movement or activatea muscregroup. Electrically stimulated muscle contractlon can accelerateand improve patient rehabilitation by increasingmuscle strength and endurance.25 These can enhancethe quality of motor recruitment and carry over to improved performanceof functional activities. In order to produce strength gains in healthy muscle,the force of the stimulatedcontraction needsto be at least.50o/o of the maximum voluntary isometric contraction (MVIC), although the greateststrengthgainswill be achievedwith the maximally tolerated force of contraction. To produce strengtl gainsin injured patients,the stimulatedcontractionsmay have a force of as litde as 10% of the MVIC, although strongerconffactionswill be more effectiveif they are tolerated.For the greatestgainsin endurance,more prolonged periods of stimulation with lower forcecontractionsaremore effective.r2'26 Electricallystimulatedmusclecontractionscanalso support or assistwith joint positioning,functioning like an orthotic. Ior example,Baker and colleagues reported that an aggressiveprogram of electrically stimulatedcontractionof the musclessurroundinsthe shoulderover a 6-week oeriodreducedshouldersubluxation in patients with hemiplegiadue to stroke more effectively than facilitation programs, slings, or sitring support.2TA more recent smaller study in patrentswith hemiplegiadue to strokedemonstrated that neuromuscularelectrical stimulation (NMES) reducedshouldersubluxationslighdywhile the glenohumeral separationincreasedin the control group even though the affectedarm was supportedat all times.28 Several studies have also reported an improvementin gait in children with cerebralpalsy when NMES of the lower extremities has been includedin their treatmentregimenand an improvement in upper extremity function when NMIS of the upperextremitieshasbeenincluded.29-32 Studiesconcerningthe use of NMIS in patients with spasticityhaveprimarily focusedon stimulating the antagonist muscles. Howeve5 stimulating the
232
8 . Electicql
agonist and the antagonistsequentially,with bdef rest periods after each conuaction, may be more effectivesincethis would more closelymimic normal motor activiqy.Individuals without central nervous system(CNS)dysfunctionflex and extendthe elbow by firing *re bicepsand triceps sequentially,with a bdef latency period between them. Individuaiswith CNS dysfunction maintain some ongoing motor activity of both agonist and antagonistthroughout the movement,andthe latencyperiodis absent. Additionally, studieshave shown that eiectrically stimulated muscle contraction can promote blood flow in healthy individualsand in patientswith poor circulation.33-36 This increasein circulationcan accelerate tissue healing and has been demonstratedto help reducethe risk of deepvenousthrombosisfor-u1ion.35,37-40 Some studies suggest that sensory level electricalstimulationmay alsoaugmentperipheral blood flow, but this effect has been found to occur only in patients and not in healthy individu^r- 33.34.4i43
Another more recentuse of electricallystimulated muscle contractionsis for the treatfirent of urinary incontinenceassociatedwith pelvic floor dysfunction.44,45Electric stimulation for this purpose has been applied transcutaneously,percutaneously,and via intravaginal probes.46,47 Most reports have focusedon urinary incontinencein women, some review protocols tor men. In 1996, rhe Agency for Health CarePolicyandResearch(AHCPR)Cuidelines on udnary incontinencestatedthat pelvic floor electrical stimulationhasbeenshown to decrease incontinencein women with sress urinary inconrinence. and may be usefulfor urgeand mixed incontinence.48 Denervaled muscle When a musclebecomesdenervatedby nerve injury or disease it no longer contracts physiologically, nor cana contractionbeproducedby the usualelectrical stimulususedfor NMES.However,if the electrical currenthas a longer pulse duration, of more than 10 ms, the denervatedmusclewill contract.UsuallycontinuousDC is appliedfor a numberof secondsto produceconuactionsin denervatedmuscle.The duration of stimulation is controlled directly by the clinician depressinga manually controlled switch on a DC stimulator In orderto producea gradedcontractionin a denervatedmuscle, the curent amplitude can be gradually ramped up to reach full amplitude over a numberof seconds.
Cuftettts
Denervation causesmuscle to atroohv and
The entire muscle and the individual muscle becomesmaller,and fibroustissueforms be&veen muscle fibers. It has been suggestedthat stimulation of denervatedmusclesmav retard atrophy and fibrosis; however, studieshave that the final outcome of muscle denervationis improved by this intervention.49,50 In addition, is evidence from studies in rats that electrically lated contractions of denervated muscles may motor nerve sprouting and muscle reinnervatio
Thereforewe do not recornmendstimulationof tractionsin denervatedmuscleswith DC. Direct rent electricalstimulationhas traditionallybeenur for treatment of Bell's palsy (facial paralysisdue damage to the seventh cranial nerve); however, dence indicates that this treatment is no more
tive than placebo.s2,s3 Some studies have improved clinical recovery in patients with facial palsy in responseto long term sensory electricalstimulation.54,55
PainModulation A substantial body of research demonstrates
electricalstimulationcanmodulatepain.56-59 and Wall first orooosed that electrical stim
may reduce the sensation of pain by with its transmissionat the spinal cord level.T approach to pain control is known as the gate
theoryof parn andrs describedin detailin Chapter this book. Noxious stimuli are transmitted ftom the
ery along small myelinatedA-delta nervesand unmyelinatedC nerve fibers. According to the control theory activation of nonnocioceptorA nervefiberscaninhibit transmissionof noxious uli ftom the spinalcord to the brain. Electrical lation, when applied with appropriate can selectivelyactivateA-beta nerves.Because perceptionis determiled by the relative activity A-delta and C fibers cornparedwith A-beta when greaterA-beta activity is producedby stimulation,pain perceptionis decreased.60 A-beta nervescan be activatedby both short long durarion electrjcal current pulses.6l H
short duration pulses,lasting for bewveen50 to useconds.andwith a curent amDlitudethat a comfortablelevel of sensation,selectivelya thesenerves.Pulseftequenciesof 100to 150 pps
T+vo . THE PHYSICAL AGENTS
3enerallyfound to be most comfortablefor this appli :ation. This application of electricalstimulation is <nown as coflventioflal or highrateTENS.Becausethe :rimary pain-modulating effects of conventional ranscutaneouselectrical nerve stimulation (TENS) astonly while the stimulationis beingapplied,this rypeof TLNS should be appliedat the time when the f,atienthas pain and may be used24 hours a day if recessaryConventionalTENS can also interrupt the rain-spasm-paincycle, thereby resulting in some :eductionof painafter the stimulationstops.The pain :s reduceddirecdy by the electricalstimulatioq and -Jlisindirectly reducesmusclespasms,further reduc:ngpain unlessthe musclespasmrecurs. The stimulususedfor conventionalTENSis sener;lJy modulatedto limit adaptation.AdaptatJoiis a .iecreasein the kequencyof action potentials,and a jecreasein the subjectivesensationof stimulation, -.vhileelectricalstimulation is appliedif there are no ;hanges in the applied stimulus. Adaptation is a ,<nown property of sensory receptors caused by iecreasedexcitabiliry of the nerve membranewith :epeatedstimulation.Modulation of any of the stimu-ation parameters,including ftequency,pulse duraion, or current amplitude, is likely to equally :ffectivelyhelp preventadaptationto the stimulus. It has also been proposedthat electricalstimulaion may control pain by stimulatingthe production :nd releaseof endorphins and enkephalins.These known asexdogenous ;ubstances, oyiatetact in a manrer similar to morphine and are known to modulate f,ain perception.They modulate pain by binding to :piate receptorsin the brain and other areasand act.1g as neurotransmitors and neuromodulators.62 l1-reyalso activate descendinginhibitory pathways :hat involve nonopioid (serotonin)systems.It has ':een shown that endorphinand enkephalinlevelsare ncreasedfollowing the applicationof electricalstim'.rlation.63 Stimulationwith pulsedcurrentswith frequenciesof lessthan 10 pps have beenfound to most :ffectively increaseendorphin and enkephalin lev:ls,oaand a recentstudy found that naloxone,a mu :pioid receptor blockeS blocks the analgesiaproJuced by low frequencyTENS (a pp$ but not that rroducedby high ftequencyTLNS(100pps),whereas raltrindole, a delta opioid receptor blocker, blocks cnly the analgesia produced by high frequency TENS.OC It is thought that electricalstimulation can cause endogenousopiate productionand release.This may
233
be causedby repetitivemusclecontractionor repetitive stimulationof nociceptiveA-deltanerves.Ior this applicationa longerpulsedurationand highercurrent amplitude than used for conventional TENS are requiredbecausemotor nerves,and possiblyA-delta nerves,must be depolarized.Lower frequenciesof 2 to 10 pps are usuallyusedfor this applicationin order to minimize *re risk of musclesoreness. This aoplication of electricalstimulation is known as low mte or acupuncture-libe TENS. Iow rate TENS will usually conuol pain for 4 to 5 hours after a 20- to 30-minute treatment. It is effective for this amount of time because the halflife of the endogenous opiates releasedis approximately4112hours.low rate TENS should not be applied for more than 30 minutes at a time becauseprolonging the repetitive muscle contraction produced by *re stimulus can result in delayedonsetmusclesoreness. Another form of transcutaneous electricalstimulation also usedfor pain modulation is known as !ars, nodeTENS.This mode of TENS is thought to work by the samemechanismsas low rate TENS but may be more effectiveor better tolerated.Ior burst mode TLNS, the stimulation is delivered in bursts, or packages,composedof a number of pulseseach(see rig.8-17). Electricalstimulation may also control pain when the electrodesare placedon acupuncturepoints.This method of applicationis thought to stimulateenergy flow along acupuncture meridians that connect acupuncturepoints in the body.6667
Tissue Healing Anumber of studieshaveshown that electricstimulation can promote tissueheal.ing.9,10 Gardner,Frantz, and Schmidt'srecent metaanalysisof the effects of electrical stimulation on chronic wound healins found that in the majoriry of clinicai trials, electrica'i stimulation was associatedwith faster healing.6s They evaluatedfour different types of electricalcurrents for this application:low intensiry direct cufent (LIDC),high voltagepulsedcurent (}I\TC), AC, and TENS (i.e.,sensorylevel pulsedbiphasiccurent). Ior all types of electricalcurrent, electricalstimulation was associatedwith fasterwound healing.Although the usualcontroltreatmentin the clinicaltrialsvaried, the treatment of the control samplesin at least 10 of the studiesappearedto be stindardized.Moist dressingswere usedon the majority of controls,and
234
8 o ElectricalCurrents
whirlpool was usedin a few cases.At leasta number of the control sampleswere treatedwith an electrical stimulationplacebo.Iifteen studieswere includedin the final metaanalysis.The most common measufe usedto report changewas percentageof healingper week, The net effect of electricalstimulation across all studiesevaluatedwas !3o/oincreasedhealingper week, which reptesentsa 144% increaseover the control rate of healing.When wounds were categoized by type it was found that electricaistimulation was most effective for acceleratingthe healing of pressureuicers.The proposedmechanismsby which electricalstimulationpromotestissuehealinginclude attractionof appropriatecell typesto the area,activation of thesecellsby alteringcellmembranefunction, modificationof endogenouselectricaipotentialof the tissuein concertwith healingpotentials,reductionof edema, enhancementof antimicrobial activity, and promotion of circulation. Specificcells,includingneutrophils,macrophages, lymphocytes and fibroblasts,can be attractedto an injured healing area by an electricalchargebecause the cellsthemseivescarry a charge.69,70 This process of attractionis known asgalvanoaxr's. Activatedneutrophils,which are presentwhen a wound is infected ' or inflamed,are attractedto the negativepole, while inactive neutrophilsmove toward the positive pole. Macrophagesand epidermalcellsarealsoattractedto the positive pole while lymphocytes,platelets,mast cel1s,keratinocytes,and fibroblastsare attracted to the negativepole. It is generallyrecommendedthat, in orderto attractthe most appropriatecell types,the negativeelectrodebe usedfor treatmentofinfected or inflamedwounds andthe positiveelectrodebe usedif thereis necrosiswithout inflammationand when the wound is in the proliferativestageof healing.Tl Not only can electricalstimulation attract cellsto an injury site, it has also been shown to enhance fibroblast replication and increasethe synthesisof DNA and collagenby fibroblasts.72,73 libroblasts and the collagenthey produceare essentialfor the proliferationphaseof tissuehealing.The proposedmechanism of enhancedceli function is the ffiggering of calcium charurelopeningin the fibroblast cell membraneby the electricalcurrentpulse.The open channels allow calcium to flow into the cells,increasing intracellular calcium levels to induce exposure of additionaiinsulin receptorson the cellsurface.Insulin can bind to the exposedreceptors,stimulating the fibroblaststo synthesizecoliagenand DNA.74This
sequence of eventsis voltagedependent, with a mum calciuminflux andproteinandDNA occuringwhena highvolt pulsedcurlentwitha voltagein the rangeof 60 to 90 V is applied. higher and lower voltageshave lesseffect,
sdmulationcanalsopromoteepidermal celland phocytemigratiorlproliferation, andfunction.75 When skin and cell membranes are intact havean electricalcharqeacrossthem dueto the
of the sodium/potassium pumps.When tissue injured,therebyrupturingceil membranes, ions leak out of the cell, causingthe wound and adjacentareato becomeposidvelycharqedrelative the surroundinquniniur;d it"u[.ze,zzihis has be demonstrated in children with accidental
amputations where the stumptips were chargedrelativeto the uninjuredforearm.TS Thil trical potential differencesteadilvdeclinesover returningto normal only afterthe wound closes. Electricalstimulation can also reducethe
of edemaformedwith acuteinjury and tion.79This applicationof electricalstimulation been studied extensivelyby lish, Mendel and workers.10,80'83 The applicationof electrical tion duringthe acutestageof tissuehealingcan edemaformation but hasnot beenshown to the amount of edemaalreadypresent.This effect been demonsffatedin animal studieswith neqa polarity high voltagepulsedcurrent(HVPC)at the thresholdfor motor contraction.s4 Positive ity stimulation has been found not to affect formation.S3 Anumber of theorieshavebeensuggestedfor HWC alters microvascularpermeability to proteinsand reducesedemaformation. One suggeststhat the negativechargeof cathodal tion repels the negatively chargedserum essentiallyblocking their movementout of bl vessels.Another theory is that the current blood flow by reducing microvessel diamet althoughcathodalstimulationhasnot beenshown have an effect on microvesseldiameter85StilL
suggestedmechanisminvolves a reduction in sizein the microvesselwalls,therebypleventing plasmaprotein leakagethrough pores.In the ; histamine responseto acute trauma, these would be enlarsed.Prior studies listed have *rat both negative polarity and positive po H\?C decrease microvessel permeabiJity. that some other mechanismis likely to underlie
Ts,o . THE PIIYSICAL AGENTS
:educed edema formation produced by negative :olarity stimulationonly. that electricalstimuAlthoughit hasbeensuggested -ationmay enhancetissuehealingby having antimicro'cial activity, studies suggest that this is unlikely. L:r crder to inhibit bacterial growth, electrical currents nust be appliedeither at much highervoltagesor for :nuch longer times than usedin the clinical setting.s6-90 It is also possiblethat electricalstimulation facil:tates tissue healing by increasing circulation. i-{owever,studieshave shown that a musclecontracion is generallyrequiredfor electricalstimulation to ,rcreasecirculation, while tissue healing has been ;hown to be enhancedby submotorlevelsof stimulaion.36,41,42,91 Most studies use similar electrical stimulation ,arameters to promote wound healing. Negative :olarity is generallyusedduring the early inflamma:ory stageof healing,while positivepolarity is generally used later to facilitate epithelial cell migration acrossthe wound bed.Kloth recommendsusingnegarivepolarity for the first 3 to 7 daysof treatmentand ;hanging to positive polarity thereafter; however, recommendusingnegativepolarity someresearchers | '42,92 Ntematively,it hasbeenrec:or all treatments.4 cmmendedthat polarity be switched when wound realing reachesa plateau.Another recommendation is to usenegative polarity initially and for 3 days after -ire wound bed becomesfree of necrotic tissueand -$.edrainagebecomesserosanguinous, and thereafter '94 ro usepositivepol aiBJ,.93 The pulse duration recommendedwhen using H\?C to promote wound healingis between 40 and 100pseconds.This parameteris generallypresetin the deviceby the manufacturerand cannotbe changedby ihe clinician.The current amplitude should be suffi;ient to produce a comfortablesensationwithout a motor response.The pulse frequency should be between100and 125pps.At this time, the majority of studiesrecommendtreating for at least 5 days each weekwith eachtreatmentlastingfor 45 to 60 minutes.
DrugDelively Transdermal Transdermaldrug delivery (ontophoresis)is the use of a low voltageDC for moving chargedions across the dermalbarrier The use of iontophoresiswas first ro The primaryrouteo[ reportedin the early1900s.rs ion ffansportacrossor tfuough the skin is thought to In the be tfuough the skin poresand hair follicles.eT'e8
235
as drivingthe past,iontophoresis hasbeendescribed ions through the skin."99However,more recentstudies suggesithationtophoresismay promote ffansdermal drug penetration primarily by increasingthe permeability of the stratum corneum,the main bar.i", to t u.rri"r-"l drug uptake.100-102 The depth of drug delivery with iontophoresisis uncertain.Most studieshave demonstratedpenetration to a depth of 3 mm to 20 mm.103For example,in compadngiontophoreticdeliverywith passivedelivery of salicylicacid and lidocaineto ratsit was found that both drugspenetrated3 to 4 mm below the skin when deliveredby iontophoresisif the epidermiswas intact or by passive delivery if the epidermis was removed.104 Penetrationwas negligiblewith passive delivery when the epidermis was not removed. Passivedeliverywasthe applicationof the drug to the The authorsof skin without additionalenhancement. this study concludedthat iontophoresisallows salicylic acid and lidocaineto penetratethrough the stratum comeum. Another study demonstrated that sodiumethanolamineandlidocainecouldbe detected up to 2 cm laterally away ftom the iontophoresis treatmentelectrodein the intact skin of'rats.l0s Declining drug concentration wi*r distance was thought to be due to clearancefrom the site of application by the skin'smicrocirculation,resultingin systemic uptakeof the drug. Ior an electricalcuffent to be effectiveto facilitate transdermaldrug penetrationthe currentmust be at leastsufficientto overcomethe combinedresistance of the skin and the electrodebeing used.106The amount of electricityusedfor performingiontophoresis is describedin milliamp minutes (mA.minutes). This is the productofthe currentamplitude,measured in millamps,and the time, measuredin minutes.The numberof mA.minutes to be useddependsonthe specific electrodebeing used and is determinedby the manufacturer of the elecuode. At this time most manufacturetstecommendtreatingfor 40 mA.minutesfor eachiontophoresistreatment.In the past the recommendeddosehasrangedfrom 28 to 80 milliamp minutes.Studieshaveshown effectivedrug deliverywith a rangeof 40 to 80mA. minute treatrnents.lOT One can use a number of combinationsto achieve thi currendy recommended40 mA.minute dosage level. For example,a 1 milliamp current for 40 minutes, a 2 milliamp current for 20 minutes, or a 4 milliamp cunent for 10 minutes, all give a 40 mA.minute treatrnent Gable 8-1). In practice, one
8 . Electrical Cttrents
236
shouldsetthe cunentampiitudeto patientcomfortand A 8.1 C,r.t"ot Amplitude and Treahnent then adjustthe time to produce-thedesiredproduct Duration for IontophoresisTreatrnent Tvoical treaffnent current ampiitudes reported are V Dosein Treatinent be*reen 1.0 mA.minutesand 5.0 mA minutes;howCurent mA'minutes (-A) time (mlnsles) ever,currently availableclinicaldevicesonly allow a "-ojit..d" rud 4A maximumcuffentamplitudeof 4 0 mA.minutes 40 ln orderto promotecontinuousdeiiveryofthe ion4A 20 2 lzed drug, a direct current must be used for ion40 to.o 3 tophoresis.Unfortunately, this type of current can the under alsoproduceundesirablechemicalchanges 40 10 4 Sodiumhydroxide,which is caustic,can electiodes. discomform under the negativeeLectrode,causin^g^ trodes tecommend using iontophoresis only fo: iort. skin irritatiori, or chemical burns.1oeThis is or Iidocaine deliveringdexamethasone known as the albalinereactionReducir'gthe cufient with antiinflarnis a corticosteroid Dexariethasone wiLl density by making the-negativeeiectrodeIarger for trearmentd is recommended that acdon matory the risk of adverseeffects Hydrochloric helo decrease or bursidr tendonitis as such conditions inflammarorv is acii can form under the positive electrode This usinga iontophoresis, by is delivered known as tlre acidic rcactianand is generally less Dexamethasone phosphata sodium of dexamethasone solution 0.4% uncomfortablethan the alkalinereaction The negarivepolariry electrodeis usedto promote*rc Many different drugs can be delivered by ionp"rr.,rition oi th. .tegativelychargeddexamethason tophoresisas long as they.can be ionized and are jon throughthe skin (Iig. 8-25)' ' sdble in solution, are not alteredby the appiication thosphate Liiocaine is an anesfreticdrug.In the pasr,dexarn of an electricalcurrent,and are small or moderatein ethasoneandlidocainewere deliveredtogetherby ionsize. Different drugs have been used for the treatwith a positivechargebeingusedinitiallytc tophoresis, ment of differentpathologies(Table8-2);however,at orbmotelidocainedeliveryand then a negativecharg this time the manufaclurersof iontophoresiselec-
Recommended Used Clinically for Iontophoresis, Including lon Source,Polarity' po, Ions Indications, and Concentration IndicatioIrs
Ion
Concentration (%)
Acetate
Acetic acid
Calciumdeposits
Chloride
NaCl
Sclerolytic
2
Copper
CuSOo
Fungalin[ection
2
Dexamethasone phosphate
DexNarPOt
Inflammation
0.4
Hyaluronidase
Wydase
+
Scar
Iodine Lidocaine
@ 1:50,000 Lidocaine with epinephrine
MaSneslum
MgSOo
Salicylate
NaSal
Localanesthetic +
Musclerelaxant,vasodilator lnflammation,plantarwarts Hyperhidrosis
Tap watet Zinc
Edemareduction
ZnO,
Dermalulcers,wounds
TIN, . THE PIIYSICAL AGENTS
o I CH,O_ P I
ONa oNa
237
tophoresisshould not be as pahful as an inlectioq the lidocaineis not needed.Also, newer electrodesare buffered,addingto the safetyof dre treaffnent.It is therefore recommended that dexamethasonebe delivered alonewith the negativeelectrodeonly. The manufacturersof iontophoresis electrodes haverecommended lidocaine iontophoresis for local anesthesiain children; howeve5this techniquehasnot gainedmuch popularity.
ELECTRICAL CURRENT INCLINICAL PRACTICE Figure8-25.The molecular structure of dexarnethasone Contraindications, Precautions, andApplication ;odium phosphate.Note that 6e negativelychargeddexTechniques amethasone phosphateion is movedacrossthe dermalbar;ierby iontophoresisusingthenegativelychargedelectrode. The useandapplicationof electricaistimulationisnot without risks.There are widely acceptedcontraindibeingusedto promotedexamethasone deJivery1l0 cationsand precautionsthat havebeenestablishedto This combined proceduremimicked the combined applicaensure the best clinical practice and application of rion of lidocaine and dexamethasonebv iniection and thesetools. Thesecontraindicationsand Drecautions etp ntecp.r".{ h"l^-. providedchemicalbuffering.However, becauseion-
CONTRAINDICATIONS
forElectrical Stimulation
r Demandcardiacpacemakeror arrhythmias o Placementof electrodesover carotidsinus
Theuse of electricstimulationis contraindicated.,, . . . in patients with a demand pacemaker or known arrhythmias Electricalstimulation devicesshould not be used on patientswith demandcardiacpacemakersas electrical stimulationmay interferewith the functioning of this type of pacemakerand could alter t}Ie heart rate. Elecrical stimulationmay also aggravatean unstable arrhythmiathat is not treatedwith a pacemaker ASK THE PATIENT: o Do you havea cardiacpacemaker? o Do you have a history of heart problems or have you bedntreatedfor heartproblems? o What type of heartproblems? r How recendyhasyour doctorcheckedyourheart? If the patienthas a pacemaker,do not apply electricalstimulation.
o Areasof venousor arterialthrombosisor th rnmhnnhlphiti<
. Pregnancy-over or aroundthe abdomenor low back If the patient is unsureof his/her cardiacstatus,or has recently had episodesof cardiacarrhythmias or pain, the therapistshould consult with the referring physicianto rule out the possibility of cardiaccompromise during the use of electricalstimulation as a treatmentmodality. . . . over the carotid sinus. Care should be taken to avoid placement of electrodeson the anterioror lateralneck in the areasover the carotid sinusesas stimulationto theseareasmay induce a rapid fall in blood pressurethat may cause the patientto faint. . , over areas of venous or arterial thrombosis or thrombophlebitis. Stimulationshouldnot be placedover areasofknown venous or arterial *rrombosis or thrombophlebitis becausestimulationmay increasecirculation,increasing the risk of releasingemboli. Coxtixued
238
8 . Electical Cutrerts
DICATI0NS-cont'd C0NTRAIN ASK THE PATIENT: o Do you havea blood clot in this area? ASSESS: o Checkthe areafor increasedswelling,redness,and increasedtenderness.If any of theseare present,do not apply electricalstimulationuntil the possibility of a thrombushasbeenruled out.
Occasionally,electric stimulation is used for pain control during labor and delivery as an altemativeto generalanesthesia or a spinalblock.111-113 Electrodes canbe placedon the low backor onthe anteriorlower abdominal regior5 dependingon where the pain is felt. The patient increasesthe cuffent amplitudeduring a contractionand turns the amplitudedown or off betweencontractions.
.. . over the pelvis, abdomen, trunk and low back area during pregnanry.
ASK THE PATIENT
The effectsof electricalstimulationon the developing fetusand on the pregnantuterushavenot beendetermined.Thereforeit is recommendedthat stimulation electrodesnot be placedin any way that the current may reachthe fetus.Electrodesshouldnot be applied to the low back, abdomen,or hips (asmight be the casefor bursitis),where the path of the curent might crossthe uterus.
. Might you be pregnant? . Are you trying to get pregnant? The patientmaynot know ifshe is pregnant,particularly in the first few daysor weeks after conceptioru Becausedamage may occur early during development, electricalstimuiation shouid not be appliedin any areawhere the currentmay reachthe fetus of a patientwho is or might be pregnant.
o Arp rrnrrnreonrnt2
PRECAUTIONS
ForElectrical Stimulation o Cardiac disease . In patients with impaired mentation or in areas with impaired sensation
Electrical stimulation shouldbe applied withcaution,,. . . . to patients with a known history of cardiac disease,previous myocardial infarction, or other specifically known congenital or acquired cardiac abnormalities ASK THE PATIENT: o Do you havea known history of cardiacdisease? o Haveyou had a previousmyocardialinfarction? o Have you everhad rheumaticfever as a child or an adult? . Are you aware of having any cardiacproblemsat this time ?
o Mrlion;nr trrrnnr o Areas of skin irritation or open wounds o Iontophoresis after other physicai agents
ASSESS: o Check for surgicalincisions in the thoracic area, both anteriorlyand posteriorly. o Check the patient's resting pulse and respiratory rate before initiating treatment and check for changesin *resevaluesduringand/orafterapplying electricalstimulation. . . . to patients with irnpaired mentation or in areas with impaired sensation The patient'ssensationand reportingof pain are usually used to lmit the intensiry of current applied to within safelimits. If the patient cannotreport or feel pain, electricalstimulationmust be appliedwith caution and closeattentionmust be paid to any possible
Two o THE PHYSICAL AGENTS
tverse effects.In addition, patientswith impaired :entation may also be agitatedand try to pull off =: stimulation electrodes. Electrical stimulation =:y be used to treat chronic open wounds in areas .:rh decreasedsensationby first determining the ::oropriate current amplitude in an areawith intact -:$ation. ASSESS: I Sensationin the area. . ?atientorientationand level of alermess. . Patientagitation. . . to patients with known malignant tumors :--,houghthere is no researchconcerningthe effects :: applying eiectrical stimulation to malignant :jmorsTsince electricalcuffents can enhancetissue :owth, in most casesit is recommendedthat electri J stimulationnot be appliedto patientswith known :: suspectedmalignanttumors.Electricalstimulation :::ould not be applied to any area of the body of a :atient with a malignancybecausemalignanttumors ::n metastasizeto areasbeyond where they are fi$t :und or known to be. Occasionally,electricalstimu:iion is usedto control pain in patientswith known :alignancy. This is done when the improvement in --'.ralityof life affordedby this interventionis consid::ed to be greaterthan the possiblerisks associated rith the treaftnent. ASKTHE PATIENT . Have you ever had cancer?Do you have cancer now? o Do you havefever,sweats,chills,or night pain? r Do you havepain at rest? , Haveyou had recentunexplainedweight loss? . . over skin irritations or open wounds. aiectrodesshouldnot be placedover abradedskin or ,crown openwounds unlessthe electricalstimulation :; being usedto treat the wound. Open or damaged ;kin shouldbe avoidedbecause it haslower imped:nce and lesssensationthan intact skin and this may :esultin too much currentbeingdeliveredto the area, ASSESS: . Inspectthe patient'sskin carefullyprior to placing electrodes. . Check for increasedredness,swelling, warmth, rashesor brokenand abradedareas.
239
. . . when iontophoresis is being considered after another physical agent. It is recommendedthat iontophoresisnot be applied after the applicationof any physical agent, such as heat, ice, or ultrasound,which may alter skin permeabiliry. In addition, heat will causevasodilationand increasedblood flow that canacceleratedispersionof the drug from the treatmentarea. ADVERSEEFFECTSOF ELECTRICAL STIMULATION: r Electricalburns . Skin reactionsto the electrodes . Pain There arevery few potentialadverseeffectsfrom the clinicaiapplicationof electricalcurents. Carefulevaluation of the patientand review of the patient'spertinent medicalhistory and currentmedical statuswill minimize the likelihood of any adverseeffects.In addition, patients should be monitored throughout the initial treatment with electricalstimulation for any adverseeffects of the stimulation. If a patient is provided with an electrical stimulation uni.t for home use,the patient should be clearlyinstructedin its useand in early identificationof potential adverse effects. Electricalcurents can causeburns. This effect is seenmost commonly when a direct current is being applied.This is becausedirect current is always on, unlike pulsed current, resulting in high total charge delivery and high skin impedance.In addition, the chemicaleffectsproducedunder direct current electrodescan be caustic.If there is not enoughconduction medium on an electrode, as can occur wlth repeateduse of self-adhesiveelectrodesor poorly appliednonadhesiveelectrodes,the risk of burnsalso increasesdue to the increasedcurrent density in the areaswhere thereis adequateconduction. Skin irritation or inflammation may occur in the area where electrical stimulation elecuodes are applied becausethe pati€nt is allergicto the contact surfaceof the electrode,suchasthe adhesiveor foam rubber. If this occurs,a different type of electrode shouldbe tried. Somepatientsfind electricaistimulation to be pain.6rl. In suchpatients,increasingthe curent amplitudeslowly over a longerperiodof time may be bettertolerated.In patients who find all fonns of electrical stimulation painful,othertreatmentapproaches shouldbe used.
240
8 . Electicdl
Additionally, the student and clinician should be aware of research-based applicationtechniquesthat may be used acrossthe spectrum of the modality.
l. Assess the patJenr andserreatmenrgoals. 2. Determine if electricalstimulation is the most appropriatetreatmentmodaliry 3. Determine Lhatelectricalstimulation is not contraindicated for this patient or for the specific diagnosis you are treating. Check with the patient and review the patient's chart for contraindicationsor precautionsregardingthe appli cationof elecrrical srimulation. 4. Selectan electricalstimuiationun.itwith the necessarywavelorm and adjustableparametersfor the treatment (pain modulation, musclecontraction, tissuehealing,etc.) 5. Explain treatment procedure to the patient, including an explanationof what helshe might expect to experience,and any instructions or directions regarding patient participation with the electricalstimulation. 6. Position the patient appropriatelyand comfort>hhr fnr rhe trp:rmpnt
Z. Inspect *re skin where the treatment is to be applied for any signs of abrasions or skin irritation. Cleanthe skin and clip hair ifnecessary for good adhesion of the electrode to the skin, and thus good currentflow. The hair should not be shavedas this can causeskin cuts or abrasions. 8. Checkelectrodesand leadwires for continuity or signsof excessivewear and replaceany of those found faulqyor of concern. 9. AppIy the electrodesto the area being treated. Use conductive gel iF electrodesare not pregelled. Use the appropriatesize and number of electrodesto addressthe problem. For specific information on electrode selection and placement, please see the sections below on these toplcs. 10. Attach the lead wires to electrodesand to the stimulationunit.
Cuftefis
This sectionprovidesguidelinesfor the sequence proceduresrequiredfor the safeand effectiveapplication of therapeuticelectricalstimulation.
11. Set ootimal parameters for treatment
ing pulse frequency,pulse (phase)durati applicableto specificunit-, on/off time, uplramp down, and length of treatlent time. soecific information on parameterselection differenttreatmenteffects.pleaseseeTables8-3 8-5 andthe sectionon parameterselectionbelow12. Slowly advancethe amplitudeuntil the patient just able to notice a sensation under the
trodes. If a muscle contraction is needed achieverhe rrealmentobjectives.continue increasethe amplitudecontrol until a visible tractionjs apparent.If the patientcompJains discomfort, decreasethe current amplitude to sensorylevel. It may take more than one ment to familiadze a patient with the and procedure and to make them
with the necessarylevelof stimulationto the desiredoutcome.When elecrrical stimulaci is applied to promote tissue healing, where patient may be insensate,it is necessaryto more cautious and use an altemate area to
lish sensorylevel prior to placingelectrodesin arounda wound. 13. Observe*re patient'sreactionto the stim over the first few minutesof the treatment.If treatmentincludesmusclestrengthening, the amplitude and quality of the Question the patient regarding the
outcome and adiust oarametersbased on patient's response.The parametersmayneed to adiusted or the electrodesmav need to be mor
slightlyif the expectedoutcomeis not achieved. 14. When the treatment is completed,remove electrodesand inspect the patient'sskin for sisnsof adversereactionto the treatment. 15. Document the treatment, including placement,the parameters,waveform, and patient'sresponseto the treatment.
Itvo . TIIE PIIYSICAI AGENTS
241
)ATIENTPOSTIONING . rrienr positioningis dicratedby the area to be -:eated,the goal(s)of the treatment,and the device
ELECTRODETYPES Many differenttypesof electrodes areavailablefor use with electrical stimulation devices.The electrodes .cn Primenr t a t L e c e r h r e e iLJrues c<" are pauenr comserveasthe interfaceberwednthe patientandthe stim:rft and modesty. Upper extremity set-ups require ulator.They are connectedfrom the macfuneto the , i o n s l e e v eosr a h a l ( e r o p f o r w o m e n ,w h i l e m e n electrodes by cablesor leadwires.Whiie thereareelec:ray or may not be comfortablewith their shirts off. trodesthat canbe implantedin the tissues,only surface ','ith neck, upper and lower back, and hip set-ups, electrodesare discussedhere.There are a number of -:im.rily usedin pain control.the art oI appropriare considerations when selectingelectrodesfor electrical r:aping is essential.The clinician should ask the stimulationincludingmaterial,conductivegelif needed, ' r L i e n r. f r h e y t e e lp r o L e c ' eodr c o v e r e de n o u g hb y size,shape,andthe tissuesto be treated. reir clothing or additionalsheetsor towels the cliniThe electrodesmost commonly usedtoday are dis::anhas in place.If in doubt,an additionalcovering posableand flexibleand havea self-adhesive gel coatray add to a patient'scomfort. lor lower extremity ing that servesas the conductionmedium (Iig. 8-26). :et-ups,shortsare generallyadequateand allow the The conductionmedium decreases resistance between ratient to perform voluntary exercisewith the stimuthe electrodeand the skin. These self-adhesiveelec:tronrn place. trodesmay be designedfor singleuse or for multiple When applying electrical stimulation for muscle usesover a period a month or more. Although many ::rengthening,the limb should be securedto prevent electrodeson the marketmay appearto be madewid-r o r o r t h r o u g ht h e r a n g € w . i r h L h el o i n t t n a ' r h e similarmaterialand conductivegel,their conductiviry r:imulated muscles cross in mid-range. This will impedance,and comfort may differ. How often an : . ] o w c h ep a L i e nrro o e n o r ma s t r o n gi s o m e t r jcco n - electrodecanbe useddependson the natureof the gel ::actionin mid-rangeratherthan moving through the c o a r i r gO . n c eL h i sc o a r r r gs t a r r rt o d r y o u t .r h e c u r :angeandthen applyingmaximum forceat the end of r e n rd e n sr y b e c o m e sl e s su n i f o r m .c a u . i n gu r e v e n ::reavailableROM. The limb may be securedby plac curent delivery In areaswhere the electrodeis still .rg a barrierto motion in eitherdirectionor by using able to conduct,the curent densitywill be high, and :uff weightsto overpowerthe strengthof the muscle. this can caused-reskin under the electrodeto burn. .:r addition,most treatmenttableshave positioning Thereforeeiectrodesmust be inspectedregularlyand :r:rapsthat can be usedto facilitateboth appropriate dry or discolored onesshouldbe discarded. :nd comfortable positioning for the patient, while More longJastingelectrodesare made of carbon:raintaining the joint in a singleposition to facilitate impregnatedsilicone rubber, stainlesssteel or alu:n isometriccontraction. minum (seeFig. 8-2Q. The carbonrubber electrodes
Carbon-rubber eieclrooes (mustadd conductive medium)
Self-adhesive, pre-gelled
Figure 8-26.Examplesof differenttvpesof electrodes. Cottinueti
242
8 . Electtical Cnlre
areusedwith a gel conductionmedium,and the metal electrodes areusedwith a spongesoakedin normaltap water to promote conduction.Becausethesetpes of electrodesare not self-adhesive, they must be secured to the patient with tape, elasticsftaps,or bandages. Carbonrubberand other similarelectrodesshouldbe cleanedwith warm, soapywaterandnot alcohol. Selectionof electrodesize,shape,andtype depends on the treatmentgoals,the areato be ffeated,and the amount of tissue or muscle bulk tarseted.Because currentdensiry.which is r-heamountof currentdeliveredper unit area,is inverselyproportionalto the size of the electrode,larger electrodesare more comfortable than smaller ones. However. larqe electrodes cannottargetsmallareas. ELECTRODEPLACEMENT Electrodeplacementis cdticalto the outcomeoftreatment with electricalstimulation.Havins determined the ideal electrodeplacementthis sho;ld be docu. mented, noting distanceor approximation to bony landmarksor anatomicalstructures.so that follow-up sessionscan replicatethe placement.Diagramsare often helpful for this. In order to ensureevendelivery of current, electrodesmust lie smoothly againstthe skin with no wrinkles or gaps. Self-adhesiveelectrodesusuallymaintain good contact;however,with other types of electrodes,fiexiblebandagingis generally neededto maintain good electrode-to-skincontact. Electrodesshould not be placed direcdy over bony prominencesbecausethe higher resistanceof bone and the poor adhesionof electrodesto highly contoured surfacesincreasesthe risk of discomfort and burns and is less likely to produce therapeutic benefits. Figure8-27. The effect of electrode spacing. When the electrodesare closer together the current travels more superficially. When the electrodes are further apart the cuffen! SoesoeePer.
ts
The distanceor spacingbetlveenelectrodesaffects the depth and course of the current. The closer togetherelectrodesare configured,the more superficially the curent travels,and conversely,the greater the distancebetween them, the deeperthe current travels (Fig. 8-27).When stimulating contractionof largermusclegroupssuchasthe quadriceps,it is more comfortableand effectiveto placethe electrodesover the proximal and distalendsof the muscle,so that the curent travelsparalielto the direction of the muscle tibers(Iig. 8-28).Electrodesshouldbe at leastfwo fingers'width, or one inch, apartwhen appliedfor pain control, and at least two inchesapart when applied for motor contraction.Electrodesare placedfurther apartwhen stimulatinga musclecontractionbecause the changein shapeof the muscle during a contraction may movethe elecrrodes closetogether. When electricalstimulationis appliedto producea muscle contraction,one electrodeshould be placed over the motor point for the muscle.The motor point is the placewhere an electricalstimuluswill produce the greatestcontraction with the ieast amount oI electricity and is the area of skin over the locatioo where the motor nerve enters *te muscle. Charts of motor points are available;however,becausemost motor points are over the middle of the musclebelly. it is generallyeasy and effectiveto place electrodes over the middle of the musclebelly.The secondelectrode shouidalsobe placedon the muscleto be stimulated, and, as noted above,with the two electrodes alignedparallelto the directionof the musclefibers. When electricalstimulationis usedto controlnain.a varieryof eleccrode placements can be effecdv;.116 tf ftvo channels,and thus four elecffodesare used,the elecffodescan be placedto suround the areaof pain Electrodesf arther apart
Current
Two . THE PHYSICAI ACENIS
243
Eleckode configuration approximately parallelto :iberdirection)
placedoverthe low backfor elecFigute 8-29,Electrodes trical stimuiationtreaftnentto control low back pain. (CourtesyMettlerElectronics, Anaheim,CA.)
Figule8-28. Electrodesplacedover the proimal and distal endsofthe quadricepsmusclesfor maximum efficacy.
The tr,vochannelscanbe placedso that t-l.tey intersecq allowing *re current to cross at the area of pain (Iig. E-29)ot they may be placedparallel,eitherhorizontally or vertically.The two channelsmust intersectif an interferentialcurrentis desired.To changethe flow of current, it is generaliy easier to switch the lead wires beween elecuodesratherthan moving dre electrodes rhemse]ves. Placemenc over triggerpoinrsor acupuncture points,which aregenerallyareasof decreased skin resistance, has also been repofted to be effective.117 When dre electrodes cannotbe placednearor overthe painfularea,for exampleif the areais in a castor Ioca1 applicationof the electrodesis not tolerated,the electrodescanbe placedproximalto the site of pain along thepathwayof the sensorynerues supplyingthearea.116 When electricalstimulationis usedfor edemacontrol, the therapistmust detemine whether the edema is due to acuteinflammationor to lack o[ motion. For retardingthe formation of edemadue to acuteinflammatiory the negativepolarity treat:oent electrode(s) shouldbe placeddirecdyover the areaof edema,with the dispersiveelectrodemore proximal if possible(Fig 8-30).To reduceedemacausedbylack of motior5elec-
trically stimulatedcontractionsof the musclesaround the deepveinssupplyingthe areacanpump away the excessf1uid.For *ris aoolicationthe electrodesshould be placedon the appropriatemusclein the sameway lFig.8-31). ar recommended formuscleconrractions For electricalstimulation to promote wound healing, the treatment electrodesmay be placed in or around the wound (Iig. 8-32). One treatment electrode is usedwhen stimulation is applieddirectly in the wound andwvo or more treatmentelectrodes may be used when the stimulation is aooliedto the area a r o u n dr h ew o u n d .l f s L i m u l a t i oi sna p p l i e d i r e c c Jt o y the wound, a singie-useelectrodeconstructedby the therapist should be used. This type of electrodeis made of saline-soakedgauze placed direcdy in the wound. Aluminum foil or a single-patient,reusable eiectrodemay be placedoverthe gauze.The electrode is attachedto the lead wire with an alligatorclip. If stimulation is appliedto the intact tissuearound the wound, *re usual commercidly availableelectrodes, asdescribedabovermay be used.One largedispersive electrode,of oppositepolarity to the treatmentelectrode. shouid be olaced close to the wound site to ensuredeliveryof currentto the wound. Ior iontophoresisthe drug delivery electrode is placedover the areaof pathology and the dispersive or return electrodeis placedat least6 inchesaway,at a site of convenienceover a large muscle belly (Iig. 8-33).The drug delivery electrodeshould have the samepolariry asthe activeion of the drug to be delivered.Careshouldbe takento inspectthe surounding Continued
244
E . Ele.tricdl Ctttettts
Figure B-30. Electrode PLacement to retard acute edema formation at the ankle. Positive polarity dispersive electrode
FigureB-31. Electrodeplacement to reduce edema in the wrist and hand caused by lack of motion. (Counesy Mettler Electronics,Anaheim, CA )
to promotetissuehealinSplacement 8-32.Electrode Figure
skin area for abrasions.Current density must also be consideredhere. It is suggestedin the literature that current density not exieed 0.5 mA-/cm2when usinq the cathode as the delivery electrode and 4l 1.0riA/cm2 if the anodeis used
Figure 8-33. Electrode placement for iontoPhoresis' (CourtesyIOMED, Salt Lake City, Utah.)
Ts'o . THE PHYSICAL ACENTS
Selection Parameter -{lthough no one combination of electricalstimulaion parameterswill always be effectivefor a specific problemand treatmentgoal,with a thorough clinical assessmentand an understandinsof the effects of ;pecificelectricalarrranL,puru-"t"rs. rhe clinician canselectparametersthat are most likely to be effecive (seeTables8-3 to 8-5 for a summary o[ recomrnended treatment parameters).These parameters ;an then be rationally modified if the desiredtreatment goal is not achieved.The understandingof the contdbution of each individual parameterand their rnteractionsis essentialfor choosingthe appropriate reatrnent regimen.A unit *rat allows manipulation of a variety ofparametersis alsonecessaryso that the cliniciancanselectthe most effectiveand comfortable stimulation parameters.Careful selection of treatment parameterswill minimize discomfort while optimizing functionaloutcomewith electricalstimu1aBOn.
Pulse duralion Whenusingelectricalstimulationto producea muscle contraction in an innervated muscle, the pulse duration should be bewveen150 and 350 ps. Most unitswith an adjustablepulseduration allow a maximum duration of 300 ps, and many units intendedto be used only for stimulation of muscle contractions have a fixed pulse duration of around 300 ps. If the pulse duration is adjustable, most patients find shorter pulse durations more comfortable when stimulating smallermusclesand longer pulsed durationsmore comfortablewhen stimulatingiargermuscles. In addition, for similar applications, smaller people and children also often find shorter pulse durationsto be more comfortableand as effectiveas longer pulse durations.It is important to remember that as the pulse duration is shortened,a greater amolitudeis reouiredto achievethe samecontraction as producedbya longer pulse duration. Selectionof the ideal combination of pulse duration and current amplitude should be based both on patient comfort and achievement of the desired outcome of treatment. Most clinical units with blphasic waveforms intended to be used for pain control, and most portable units intended for use for pain control (frequendy called TENS uxits) allow the clinician to adjustthe pulsedurationof the symmetricor asym-
245
metric biphasic waveform. When using a biphasic waveForm for conventional TENS, the pulse duration should be between 50 and 80 ps in order to depolarize only the A-beta sensory nerves. When applying low rate acupuncture-likeTENS, the pulse duration should be between 100and 200 ps in order to depolarizethe motor nervesand possibly the Adelta nerves.Interferentialcurrent is also lrequently usedfor pain control. With interferentialcurrent the pulseduration is inverselyproportionalto the carrier frequency.If the carrier frequency is increasedthe pulse(cycle)durationwill decrease,and if the carrier frequency is decreased the pulse duration will increase.Manufacturersmay put a control for the carrierfrequencybut do not direcdy allow control of duration on units that deliver interferential current. When tlre carrier frequency is 2,500 Hz the cycle duration is 400 ps, when the carrier frequency is 4,000Hz the cycle duration is 250 ps, and when the carrier frequency is 5,000 Hz the cycle duration is 200ps. When usingelectricalstimulation to promote tissuehealing or to inhibit the formation of edema during the acute inflammatory response,HVPC is the recommendedwaveform. Most units that can deliver HVPC do not allow the pulse duration to be altered.The pulseduration is fixed in the rangeof 40 to 100 ps and appearseffective for these applicatlons. Frequency Irequency determinesthe type of responseor muscle contractionthat electricalstimulation will produce. When a low frequency of less than approximately 30 pps is usedto stimulatea motor newe, eachpulse will producea separatemuscletwitch contraction.As the frequencyincreasesthe twitches will occurmore closelytogether,eventuallysummatingto producea smoo*r tetanic contraction.This requires approximately 35 to 50 pps.Lrcreasingthe frequencybeyond the 35 to 50 pps rangemay producegreatermuscle strengtheningbut will also result in more rapid ,118 fatigueduringstimllation.r2,117 Selectionof frequency for pain control depends both on the selectedmode (high rate or low rate as well as t}re waveform TENSlike characteristics). and parameter options availableon the unit being used. With high rate TENS, the pulse frequency is selectedin a rangebetvveen100to 150pps,while low raterequiresthe pulseftequencyto be no greaterthan ten pps. Burst mode TENS units are generallypreset
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:1.,the manufacturerto provide 10 or fewer bursts ,:achsecond,with the pulseswithin the burst beingat :00 to 150 pps, thereby attempting to combine the :ffectsofhigh rate andlow rateTENSPulse frequency for promoting tissue healing :rould be in a rangeof 60 to 125pps When electrical ;imulation is usedto control the formation of edema :ue to inflammation, the pulse frequency is set to 120pps.However,when electricaistimulationis used .o iotrttol more longstanding edema by muscle usedare the sameas rhose rumping,the parameters with a frequencyof 35 to ,.edfor-musclireeducation :0 pps. 0n:otftime ilectrical stimulation is delivered continuously, :hrouehoutthe treatmenttime/ when appliedfor pain :ontrJl, tissuehealing,acute edemacontrol and ion:ophoresis.When used to produce muscie contrac:ons, an on:off time must be setin order to allow the nuscles to both contract and relax during the treat:rrent.The relaxationtime is neededto limit fatigue' When electrical stimulation is used for muscle on time is in the the recommended strengthening, off ,".rsJo[ 6 tJ l0 secondsand the recommended rime is in the rangeof 50 to 120seconds,with an inicialon:off ratio of 1:5.The long off time is requiredto minimize muscle fatigue. With subsequenttreatments, as the patient gets stronger,the on:off ratio to 1:4or even1:3.Whenthe goalof maybe decreased is to relievea musclespasm/the stimulation electrical at 1:1, with both the on andoff times is set ratio on:off 5 seconds,in orderto produce 2 and beinebetween the spasm.When the treatrelax and futigu. *ur-l" pump out edema,the on:off ratio to ment is intended the on and off times being with both 1:1 is alsoset at bewveen2and5seconds. Ramptime A ramp time may be neededwhen a muscle contractionis stimulated.The ramptime allowsfor a gradof forceratherthan a sudden ual increaseand decrease switchingfrom off time to when increaseanddecrease and on time,Ior most exercises wi*r longeron times,a ramp up and down of 1 to 4 secondsis recommended' However,someactivitiesdo not benefitand are actually impairedby a ramptime.Forexample,gaitffaining or table activities, in which the musclesfunction for a very short time, may actuallybe completedbeforethe stimulationreachespeak amplitude.In conftast,in a
249
patientwith spasriciryit may be necessaryto have a in orderto avoid iong r"-p dme, of 4 to 8 seconds. intone. stimulatinga generalizedincrease Currentamplitude When using electrical stimulation for muscle strengtiening,the current amplitude is a critical to producea conDara;eter.An amplitudesufFicient iraction of at leas;50% of maximum voluntary isometric contraction (MMC) strength is needed to increasestrengthin uninjured individuals.However, Snyder-Mackler and colleagues found that for patents recoveringfrom anterior cruciateligament ;econstruction,those treated with a current amplitude that producedcontractionsof at least10% of the MMC of the uninjuredljmb had greaterstrength gains and taster functional recovery than^controls stimulation.rr" irho did not receiveelectrical When electrical stimulation is used for muscle reeducation,the goal of treatment is functional outcome ratherthan maximum strength Electricalstimulation can assist with functional rccovery by feedbackot providing sensoryand_proprioceptive muscle by enhancing well as as motjon normal wllh sensory start may one purpose this For strength. which is the most comfortable'to Ievel-stimulation, to thestimuto becomeaccuslomed patient the allow to proamplitude the curent increase then lation, and ' patient tolerance within level ducea contraction musto reduce used is stimulation When electrical be suffionly need amplitude cle spasms,the curent cientto producea visiblecontraction. In orier to controlpain with electricalstimulation, the ffeatment should be as comfortableas possible For high rate TENS it is generallyrecommendedthat the airplitude be set to produce a gende sensation on1y,likened to tingling or vibration. However,some a itrong or maximally tolerated uutir'or,,".o--".td level of sensorystimulation for this application lt is likely that differentindividualsrespondbestto different levelsof sensorystimulationand that the ideal for a partjcularindiviiual will needto be determinedby *Le pariencand the clinicianfor low rateand burst theamplitudemustbesufficient TEtriSto be effective, to producea visiblecontraction. When usinq electricalsrimularionto promote tissuehealingor to retardthe fomation of inflammatorv edema, the current amplitude should be set to a comfortable sensory level. If the patient has decreasedor alteredsensationin the treatmentarea'
250
8 o Electrical Cttrents
the appropriateamplitudecan be determinedby first applying the electrodeto anotler areawith normal intact sensatlon.
Documentation Documentthe areaof the body treatedwith electrical stimulation,the treatmentduration,patientpositioning, electrode placement.ffeatment parameters. *re response to treatment. Documentation ls
Treatment time callywritten in the SOA?note (Subjective,Objectivg The length of a particular treatrnent depends on Assessment,Plan) format. The following examples patient toleranceand the goals of treatment. When using electricalstimulationfor musclestrengthening, only summarize the modality component of ment and are not intendedto representa it is generallyrecommendedthat the treatment last siveplan of care. long enoughto allow for 10 to 20 contractions.This will usuallytake 10to 20 minutes.This ffeatmentsesEXAMPLES sion should be repeatedmultiple times throughout When applyingelectical stimulation(ES)to the the day if the patient has an electricalstimulation (R)kneefor quadricepsmusclereeducationafter deviceavailablefor home use.When treating in *re anterior cruciateligament (ACL) reconsftuction, clinic, electricalstimulationis generallyappliedonce ument: for 10 to 20 minutes. When electrical stimulation is used for muscle tle A un'lLe ta itNdra'a.ndenlhr,t1"'rb^ntAzryad 9 : 9t, 42411'4t/, reeducation,the treatmenttime will vary baseon the e,xz^rhzLAzura, ik I^MbA u' d<'h.af,9X tazalnznf. functional activity being addressed,but is generally O: 8,9 b n ryad^i.a'pL na.ulz,t x 20nin, eb4r^'drt 1 442n uaahu,ned.iolia olltatz wudz anA aw*imal btzaol no more than 20 minutesat a singlesessionor lessif a pldz dualion 300 mdzn, wa'r4.fu.^n',, tAi4h, BLpAnAiL patientsshows signsof inattentivenessor fatigue. aah'tt u1rlaanlr. p4,t, on:a(J time |0aze:S0tez, 50 When using electricalstimuiation for pain control paodae no*i'nurn tatzla*A an',Nilade ta 2azcl2dtt, usinghigh rateTENS,a patientmaywear a home unit tit"L.9t i utuxfed ta allzrn4tfbctntaxf Wadrilr'tta.manal?, at all times asneededto relievepain.The low rate or &2e9. burst mode TENS modes, if being used, should be 2 uiail,ILEndlnar'fa' eolt^axlit!1t' 4: Pt allz b lczaN
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) Clinical CaseSwilies 1 The following case studies demonstrate the concepts of the clinical application of elecffical stimulation discussedin *ris chapter.Basedon the scenariospresented, an evaluation of the clinical findings and goals of treatment are proposed. These are followed by a discussionof tie factorsto be consideredin the selection of electricalstimulation asdre indicated treatnent modality and in the selection of the ideal electrical sdmulation parameters to promoteprogresstoward the setgoals.
bordersof both scapulae.DS deniesnumbnessor tingling inher upperextrernities.
Case 4
PREFERBEDPRACTICEPATTERN ImpairedPosture,(48)
DS is a 28-year-o1dfemale who has been referredto physical therapy with a diagnosiso[ upper back and neck pain. DS complainsof graduallyincreasingneck and upper trapeziuspain over the past 6 weeks. She reportsher pain is worse at the end ofher work day asa supermarket checker. She notes that her pain has becomemote intenseand frequent in the past mont!. DS statesher pain increaseswith lifting, carrying,and any twisting motion of her neck.Shehasbeenevaluated by a physicia& and her cervicalspinex-rayswere negative. Shehasno history of cardiacarhythmias and does nothave a pacemaker. Significantobjectivefindingsincludeupper€xtr€miry active rangeof motion (ROM) within normal limits. Her upper extr€mity sbength is 4+/5 bilaterally and is limited by neck pain. Her rhomboid and lower trapezius strengti are 4-l5 bilaterally. Neck rotation and lateral flexionROM are75o,.of normal.with pain on overpressure bilaterally. Forward fledon is uncomfortable in the final 30% of the range.Extensionis within normal limits. On palpation,there are significantnoduiesin bilateral upper trapeziusand triggerpoints along the medial
EVALUATIONOF CLINICAL FINDINGS This patient presentswiti impairmentsof cervicaland upperbackpain,restrictedcervicalROM, and decreased upper body strength.Theseimpairmentshave resulted in difficulry with her normal functional activities, especially her work-related duties of lifting and carrying.
PLAN OF CAFE Goals of treatrnent indude controlling pain and regaining normal cervicalROM so the patient canperform her work dutiesandother functionalactivities.The goalsof treahnent would alsoincluderegainingnormal upperbody streogth. ASSESSMENTREGARDINGTHE APPROPRIATENESS OF ELECTRICSTIMULATION AS A COMPONENTOF THE OPTIMALTREATMENT TENS(transcutaneous electricnervestimulation)isan indlcated fieatnent for the reduction of pain. Other physical atents suchasultasound or ice and heat might be usedin conjunctionwith electricalstimulation.This patient hasno conbaindicationsto the useof electricalstimulation. PROPOSEDTREATMENTPLAN AND RATIONALE It is orooosedtlnt electricalstimulationbe usedfor the contiol of pain, with the patient being issued a unit to use at home following evaluation and instruction (lig. 8-34).The following parametersarc chosen: Cantikued
8 . ElectricalCurrerts
252
) Clinical Case Studies-contld
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If the patient is experiencing significant relief while wearingthe TENSunit, shemay useitatwork. The lead wires canbe placedunder clothing,and *re unit can be placedin a pocket or clipped onto a waistband.With presenttechroloSy,amplitude controls are coveredso that they cannot be accidentallymoved, increasingor the current. decreasing
Case 2
Figure8-34. Treatment of upper back and neck pain with electrical stimulation. (Courtesy Rehabilicare, loc., New Baighton, Minn.) Electrodeplacement:
Waveform: Pulserate: Pulseduration:
One pair of electrodesupper cenrical,onepair lower cervlcal. Pulsedbiphasic(or interferential) 100-150 pps(or 100bps-150 bpsfor interferentiai) 50-80pseconds{suggestspell ^"t,c
Modulation: Amplitude: Treatmentduration:
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Yes Sensoryordy - to patient comfort The patientmaywear the unit throughout the day for pain conffol.
The patient will initially feel a gentle humming or buzzingunderthe electrodes.Oncecomfortable,patient may switch the unit to modulationmodesothereis litde or no adaptationto the stimulus.Becausethe patient will have a home unit, shewill be able to receivekeatment t.hroughoutthe day to minimize her pain at all times.DS will be reevaluatedfor revisionof parameters as well as update of home exerciseprogram weekly, asherproblem is with the ftequencyofvisits decreasing resolved.Use of the electricalstimulation is generally discontinuedat the patient'srequestupon reachingtolerableresolutionof pain.
YP is a 47-year-oldmale carpetlayer who developed severeright medial knee pain 4 months ago Arthroscopic surgeryrevealeda flap tear abrasionof the trochlearsurfaceof the femur,which was then debrided.\4 had his surgery3 weeks ago and comesto your physical therapy clinic with an order from his surgeon to evaluate and treat. On palpatioq there is mild warmth and tenderness of the patient's right knee. The surgical sites are heaiing well. His right patellar girdl is 5 cm greater than his left The right knee active ROM is from 10 to 50 degreesof flexion. \4 is ambulating household distanceswithout any assistivedevicebut with his fight knee in about 15 to 20 degreesof flexionduringstance.He has4/5 quadriceps snength on the righg within *re availableROM EVALUATION OF CLINICALFINDINGS This patient presentswith the impairments of pain, losso[ motioq and increasedgirth of his right knee, resulting in the disabilitiesof limited ambulationand inabiliry to work. PREFERREDPRACTICEPATTERN Impaired Joint Mobiliry, Moror Function, Muscle Performance,and Range of Motion AssociatedWith Bony or SoftTissueSurgery,(41) PLAN OF CARE The goalsof treatrnentat this time are to conhol pain and edema,andimprove ROM, strengtl, and function. ASSESSMENTREGABDINGTHE APPROPRIATENESSOF ELECTRICAL STIMULAIIONAS A COMPONENTOF THE OPTIMAL TREATMENT Electricstimulationwould be an appropriatetreatfiIent for this patientbecauseitwould facilitatethe generation of a greaterlevelof forcethan the patientwould be able to generateof his own volition. This patient has no contraindicationsto the use of electricalstimuiation. Electricallystimulatedmusciecontractionswould help increasethe patient'slower extremitystrengtl and may assistin eliminatingfluid from atoundhis knee,both of which would contributeto functionalimprovements
253
Ttyo . THE PHYSICAL ACENTS
TREATMENT PLANANDHATIONALE PROPOSED It is proposedthat electrical stimulationwith eithera protocolbe used biphasicsquarewaveformor Russian
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down lor comfort. 10%-50%of MMC muscle conractioq astolerated. The patientshouldbe encouragedto actively contract with the stimulationifhe is able. Sufficientto produce10to If available, 20 contractions. the patient shouldusea portablestimulation device at home 3 to 4 times a day, in orderto acceleratehis rcaovery.
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strength. Figure 8-35.Electricalstimulationto increase hamstringA, andB, quadriceps Continued
254
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Electrical C rreflts
) Clinical CaseSudies-cont'd
I
Case 3 MC is a 23-year-oldstudent.He injuredhis left ankleduring a soccergameat school.He was seenby tlle attending physician on the fieid and diagnosedwith a Grade II lateral anlle sprain. MC's anlle was packedin ice and he was sent to the locker room for immediate physical therapy follow-up. Given the mechanism of injury, there is rnost likely an active inflammatory processoccurring. The physician instructed MC to be nonweight bearing on crutches to rest the injured ankle. Visual inspection shows patient holding anKe in a single position with extreme hesitanry in allowing the therapist to move fhe joint. GendepassiveROM revealsrestrictions in all directions.There is minimal acriveROM. The joint is tender to touch,witll discolorationindicativeof intemal bleeding along the lateral surfaceand the inability to view the lateralmalleolusdueto swelling.The areais warm to ttre touch and slighdy reddened. The student is otlerwise healthyand deniesa history of canceqdiabetes,or other significanthealthproblems. EVALUATION OF CLINICALFINDINGS The patient presentswith impairmentsof pain, edema, and decreased ROM, resultingin limited ambulation. PREFERREDPRACTICEPATTERN Impaired Joint Mobility, Motor Functioq Muscle Performance,and Range of Motion AssociatedWith ConnectiveTissueDysfunction,(4D) PLAN OF CARE The goals of heatment at this time are to control edemaand oain. acceleratethe resolutionof the acute inflammatory phaseof healing,and speedthe recovery ofROM and functioo. ASSESSMENTHEGARDINGTHE APPROPRIATENESSOF ELECTRICAL STIMULATIONAS THE OPTIMAL TREATMENT Electricalstimulation usinghigh voltagepulsedcu(ent would be an appropriatechoice of treatmentas it has beenshownto retardthe formationof edemadurinethe
irflammatory stage of injury It is also known to help control pain. There is nothing in the patienCs history to indicate a contraindication to using electrical stimulation. PROPOSEDTREATMENTPLAN AND RATIONALE Electricalstimulatio& using a high voltage pulsedcurrent (I{\ryC) waveform, is chosenbasedon the literature indicating that it is effective at decreasrngedemaformation after injury (seelig. B-30).The following paramet€rsarc chosen: One ortwo treating Electrodeplacement: electrodesmay be used over the swolleq discoloredarea.(?olariqy is negative for treating electrodes.) The larger dispersiveelectrodeis placedproximally over either the calf or the quadriceps.This may be basedon comfort or other suspectedareasof swelling.Icemay be addedover the electrodesto further inhibit the formation of edema. Generallyfixed at 40-100 Pulseduratior\: ps for H\?C. 120pps Pulsefrequenry: Mode: Continuous Amplitude: Sensoryolrv. Ask the patientto statewhen a tingling or vibratory sensationjust beginsto occur Contrnueto increasethe amplitude until it reachesthe maximum tolerable level.If a contraction the is seen,decrease amplitude. 30minutes Treatmenttim€i
PrefenedPhysicalTherapistPracticePattemsSMl4B, 4D,and 4Il are copyright 2002 AmericanPhysicalTherapyAssociation.All righ=
Chapter Review This chapterassiststhe clinicianin understandingthe basicprinciplesofhow electricstimulationworks and how it can best be appliedclinicallyfor patient reha-
bilitation. The basisfor most usesof electricalstimulation is its ability to excite nerves to produce al action potential (AP).Once an A? is generatedby an electricalcurrent.the bodv resoondsto it in the same
Tqo . THE PIIYSICAL ACENTS
255
10. Mendel FC, Wylegala JA, Fish DR: Influence of high voltage pulsed current on edema formation following impact injury in rats, Phys Thet 72:668-673' 1992. 11. American Physical Therapy Association: Clinical in Termixology Electrophysiology.In Electtuthera7eutic PhysicalTherayy,Nexandria,VA, 2000,APTA. 12. BakerLL,WederichCL, McNealDRetal. Neuromuscular ed 4, Downey, CA,2000,LAREI Stimulation, Electrical 13. PetrofskyIS,?etrofskyS:A wide-pulse-widthelectrical stimulator for use on denervated muscles,J Clin Eng 17.331-338,1992. 14. Gamett R, StephensiA: Changesin the recruitment threshold of motor units produced by cutaneous stimulation in man, J Physiol(London) 31L463-473, T9BT. 15. Delitto A, Snyder-Mackler:Two theories of muscle strength augmentationusing percutaneouselectrical PhysTherT0:158-164,1990. sti.reulation, 16. Deluca CJ,LeFeverRS,McCue MP et al: Behaviorof human motor units in differentmusclesduringlinearly varying contractions,J Physiol(Londor) 329:113-128' 1,982. 17. Alon G, McCombe SA, Koutsantonis S et al: Comparisonof the eflectsof electricalstimulationand exerciseon abdominalmusculature,/OrthoPSponsPhys References Thet8:567-573, 7987. 1. McNealDR: 2000yearsof electricalstimulation.In: Wolf SL,GideonBA, SaarD et al: The effectof muscle 18. Electrical eds: Functlonal HambrechtFl ReswickJB, stimuiation during resistivetraining on performance New York, in NeuralPrcstheszs, AVylications Stinulatioa: Med L4:18-23,1986. Aml SVons parameters, 1977,MarcelDekker. et al: llectric stimulaMcKowenJM SJ, A, Rose 19. Delitto 2. Cambridge NA: Electrical aPParatusused in thigh musstrengthening exercise in voluntary vs. tion Soc Med,70:635-641, medicinebefore1900,ProcRoy Phys sutgery, ligament cruciate antedor after culature 1,977. Ther68:660-663 axdlts Electtizatian , 1988. onLocalized G-B:Akeatise 3. Duchenne London,1871, 20. ErikssonE,HaggmarkT: Comparisonof isometricmusandTherapeutics, toPathology Applicatioxs cle training and electlical stimulation supPlementing Hardwicke. muscle trainint in the recoveryafter major isometric Licht S, ed: In of electrodiagnosis. S: History 4. Licht, kneeligamentsurgeryAnJ SyonsMedT:169-17I'1979. ed 3, New Haven, afidElectromyograVhy, Electradiagftosis 2L. Godfrey CM, JayawardenaH, Quance TA et aL: CT,1971,ElizabethLicht. Comparisonof electrostimulationand isometric exer5. CurrierDP,MannR: Muscularstrengthdevelopment cisein strengtheningthe quaddcepsmuscle,Physiothet P/zys individuals, by electricalstimulationin healthy Can31:265-267, 1979. . 63:915-92I 19BB Ther , 22. Snyder-MacklerL, Delitto A, BaileyS et al: Ouadriceps of hemi6. Kralj A, Acimovic\ StanicU: Enhancement femoris musclestrengthand functional recoveryafter by meansof frrnctionalelecplegicpatientrehabiJitation (2)tI07-114, anteriorcruciateliSamentreconstruction:a prospective Prosthet OnhotInt Aug;17 tricalstimulation, randomizedclinicaltrial of electricalstimtlation,J Bone 1993. a new theory JointSurg77(8):I 166'1173' 1995. 7. MelzackR, Wall PD:Painmechanisms: 23. Morrissey MC, Brewster CE, Shields CL et al: The 1.50 97 1-979, 1965. Science effectsof electricalstimulationon the quadricepsdurB. SchusterG, MarsdenB: Treatmentof pain by tranMed postoperativekneeimmobilization,AnJ SVotts ing pracin general stimulation electicnerve scutaneous '114I, 1980. 13:40-45, 1985. Swg1.:!37 tice,J N eurolOrthop of wound healing 24. Mahdad M, BakerL: Effectof electricalstimulationon 9. Kloth,LC, IeedarJA:Acceleration recruitmentof motor units in patientswith hemiparepulsedcurrent,Pftys with high voltage,monophasic, sis,PhysThet77:517-51'B ' t977 Ther68:503-508,1988.
;ay asit doesto an A? that is physiologicallygener::ed. An electrically stimulated AP can produce a ::uscle contraction or it can produce a pleasantor :f,xious sensation.ElectricallystimulatedAPs can be :sed for many purposes,including muscle strength:ring, functional activities,and the control of pain =d edema. Elecffical cuffents can also have ionic ::Iects.Thesemay be usedto facilitatetissuehealing, :cntrol the formation of inflammatory edema,and :romote transdemal drug penetration. By under:-anding the language and the effects of electric --rrrents,the clinician can selectthe ideal treatment larametersto achievethe desired results.It is also jnportant to have an understandingof the history rf electric stimulation as well as the groundwork :esearchthat has examinedits applications,benefits, :r.rd contraindications,and which support its con:nued inclusion in evidence-basedpatient care. lhe reader is referred to the Evoive website at for study ques::ttp://evolve.elsevier.com./Cameron rons pertinentto this chaPter.
256
8 o Electtical Cwretts
25. Trimble MH, Enoka Rlvl: Mechanisms underlying the haining effects associatedwitl-r neuromuscular electrical stimulation, Phys Ther 7I:273-282, 1991,. 26. Alon G, Dar A, Katz-BehiriD et al: Efficary of a hybrid upper limb neuromuscularelectricalstimulation system in lesseningselectedimpairments and dysfunctions consequentto cerebral damage,J NeuroRehab 72:73-80,1988. 27. BakerL, ParkerK: Neuromuscularelectricalstimulation of the muscles surrounding the shoulder,Phys Ther 66:1930-1937 , 1986. 28. FaghriPD, RodgersMM, GlaserRM et a1:The effectsof functional electricalstimulation on shouldersubluxation, arm functionrecovery,and shoulderpain in hemiplegicstroke patients,ArchPhysMetl RehabilTS:73-79, 1994. 29. Carmrck, J: Clinical use of neuromuscular electrical stimulation for children with cerebral palsy. Part I: Lower €xfiemity, Phys Ther 73:505-613, 1,993. 30. Comeaux P, PattersonN, Rubin M et al: Effect of neuromuscularelectricaistimulationduringgait in children with cerebralpalsy,PediattPhysTher9:1,03-709, 1997. 31. Carmic\ J:Clinicaluseof neuromuscularelectricstimulation for children with cerebralpalsy.Paft 2lJpper extremity,PhysTher73:514-527,1993. 32. Carmick,J: Cuidelinesfor applicationof neuromuscular electricstimulationfor childrenwith cerebralpalsy, PediattPhysTher9:128-136, 1997. 33. Walker DC, Currier Di Threlkeld AJ: Effectsof high voltage pulsed electricalstimulation on blood flow, PhysThet68:487-485 , 1988. 34. IndergandHJ, Morgan BJ: Effects of high frequency transcutaneouselectricalnerve stimulation on limb blood flow in healthy humans,PhysTher74:ts61,-367, 1994. 35. KleckerN, Theiss W: Transcutaneouselectricmuscle stimulation:a "new" possibiliry for the preventionof thr ombosis?Vasa 23(1)23 -29, 1994. 36. Mohr I Aken I WessmanHC: Effectof high voltage stimulation on blood flow in the rat hind bmb, Phys Ther67:526-533 , 1987. 37. KaadaB, Emru M: Promotedhealingof leprousulcers by hanscutaneousneme stil:r].LJ'Ia:don, AcuyutlctElectrother Res13:165-770,1988. 38. Iinsen V, PersenL, Lovlin M et a| Transcutaneous electrical nerye stimulation after ma jor amputatton,J Bone Joitt Surg @r)70-B:109-112, 1988. 39. Faghri PD, Van Meerdewort HI, Glaser RM et al: Electrical stimulation-inducedcontraction to reduce blood stasisduring arthroplast'y,IEEE TransRehabilExg 5(1).62-9, 1997.
40. Merli GJ, Herbison GJ, Ditunno F et al: Deep thrombosis: prophylaxis in acute spinal cord patients,ArchPhysMed Rehabil69(9):661-664, 1988.
41. Lundebery TC, ErikssonSV Malm M: Electrical stimuiation improves healing in diabetic ulcers, PlastSurg29:328-331 , L992. 42. Lwd,ebergT, KlartanssonJ, SamuelssonUE: Effect electricnerve stimulation on healing of ischemic Eaps,Laxcet24:7L2-714, 1988. 43. BergslienO, TheresonM, Odemark H: The effects thlee electrothenpeuticmetlods on blood velocities human peripheral arterles, ScaxdJ Rehabil Med 29-33,1988. 44. SiegelSW,RichardsonDA" Miller Kl et al: Pelvic electricalstimulation for the treatment of urge mixed urinary incontinence ln women, 50(Q:934-940,1977 . 45. SoomroNA, I(hadraMH, RobsonW et ai: A randomized trial of transcutaneouselectrical stimulation and oxybutynin in patients with nstabifid1,IUrol) 66(l):146-149,2001 . GovierFE,Litwiller S,Nitti V et al: Percutaneous modulation for the reftactory overactive rcsultsof a multicenterstudy,/ Urol 165(4):1193-1
2001,.
van Balken MR, Vandoninck V Gisolf KW et Postedortibial nerve stimulation as treatment of lower urinary tract dysfunction,/
166(3):91 4-918,2001,. Agency for Health Care Policy and Research CuideLineson Urinary Incontinence,US Public ServicePubNo, March 1992,USDepartmentof andHuman Services. 49. Cirlanda P. Dattola R. Vita C et al: Effect of therapy in denervatedmuscles in rabbits: an trophysiological and morphological study, Exp 77:483-491, 1982. 50. PachterB\ EbersteinA, GoodgoldJ:Electrical tion effect on denervatedskeletalmyoEbersin rats: light and electron microscopic study,Arch Phys Rehabil63:427-430,1982. 5 1, Schimrigk K" Mclaughjlin J,Cruninger W: The effect elechicalstimulationon the experimentally ratmuscle, ScatdJ RehabilMed 9$5 -60, 1977. 52. BisschopC, Aaron C, BenceG et al: Indications limits of electrotherapyin Bell'spalsy.In ?ortmann ed:FacialNene, New York, 1985.Masson. 53. Huizing EH, MechelseK, StaalA: Treatmentof Palsy. An analysis of the available studies, OtoIaryngoI JuI-Aug;92(1-2):115- 12 1, 19I 1. c 4 . FanagherD, Kidd G, TallisR: Eutrophicelectrical ulation for Bell'spalsy,Clix Rehab1:265-27 1, 1987. 55. Targan RS,AIon C, Kay SL: Iffect of long-term cal stimulationon motor recoveryand improvement
Two . THE PIIYSICAL ACENTS
clinical residualsin patients with unresoived facial nerve pals, Otolaryugol-Head Neck Surg 122:246-252, 2000. ChabalC, Iishbain A, WeaverM et al: Long term transcutaneouselectrical nerve stimuladon (TENS) use: impact on medicationutilization and physicaltherapy costs,ClinJPaint4(!)$6-73, t988. ForsterEL,IGamerJI, Lucy SD et al: Effectof TENSon pain, medications,and pulmonary function following coronary artery bypass graft surgery, Chest 106(5): 1343-1348,1994. Ali J,YaffeGS,SerretteCr The effectof transcutaneous electric nerve stimulation on postoperativepain and pulmonaryfunction, Sutgery89t507-512, 1981. 49.Dawood Ml RamosJ:Transcutaneous electricalnerve stimulation [ENS) for the ffeatment of p mary dysmenorrhea:a randornizedcrossovercomparisonwith placebo TENS and ibuprofen, Obstet Gynecnl75: 656-660,1990. :{r. Wall PD: The gatecontrol theory of pain mechanisms: a re-examinationand rcstatement, Brain701:1-18,1978. l l . LevinMI, Hui-ChanC: Conventionaland acupuncturelike transcutaneouselectricalnerve stimulation excite similar alferent ftbers,Arch PhysMed Rehabil74(1): 54-60,1993. 52. PertCB, SnyderSH,:Opiatereceptor demonstrationin nervoustissue.Screzce 179:t0tt-1014. 1973. 53. SiolundBH, TereniusL, Eriksson,M: Increasedcerebrospinal fluid levels of endorphins after elecftoacupuncture,ActaPhysiotScand100:382-384,1977. 54. MannheimerJS,lampe CN, eds:ClinicalTra scutaneous ElectricalNewe Stimulation,Phl.adelptra, t9 84, FA Davis. 5 5 .Kalra A" Urban MO, Sluka KA: Blockade of opioid receptorsin rostralventralmedullapreventsantihyperalgesia produced by ffanscutaneouselectrical nerve stimulation [ENS), -/ PharmacolExp Thet 298(7): 257-263,2001. Omura Y Basic electrical parametersfor safe and effective electro-therapeutics [electro-acupuncture, TES, TENMS (or TEMS), TENS and electlo-magnetic field stimulationwith or without drug fieldl for pain, neuromuscular skeletal problems, and circulatory disturbances,AcupurctElectrothet Res12(3-4):201-225, 1987. witl-racupunc67.DebreceniL: Chemicalreleases associated ture and electdc stimulation: criacal reviews, Phys & -275, 1993. RehabMed 5(3):247 CardnerS,FrantzR, Schmidtl: Effectof electricalstimulation on chronic wound healing: a meta-analysis: \YaundReyai A Reget11495-503,1999. 6 9 .Iukushima K, SendaN, Inui H et al: Studiesongalvanotais of leukocytes.I. Calvanotaxisof human neutrophrlicleukocyres and merhodsof icsmeasurement. Merl I OsabaUxiv4:795-208.1953.
257
70. EricksonCA, NuccitelliR: Embryonicfibroblastmotility and olientation can be influencedby physiological elecutc frclds,J CellBial 98:296-ts07 , 1984. 71. Kloth LC: Electric stimulation in tissue repair. In Kloth L, Feedar J, eds Wouxd Healing Ahernativesin ed 2, Philadelphia,1995,FADavis. Management, 72. ChengN, Van Hoof H, BockE et al: The effectsof electdc cufients on AT? generation,protein synthesis,and membrane ffansport in rat skin, C/rn Onhoy 777: 264-272,1982. 73. BourguignonGJ, BourguignonLYW: Electric stimulation of ploteio and DNA synthesisin human fibroblasts,E4SEBJ 1:398-402, 1987. 74, BourguignonCJ,WencheJY,BourguignonLYW:Electric stimulationof human fibroblastscausesan rncreasern Ca 2+ influx and the exposureof additional insulin receptors,J CellPhysiol140:379-385, 1989. 75. CooperMS, SchliwaM: Electricaland ionic controlsof tissueceil locomotion in DC electric helds,J Neutosci Res73:223-244, 7985. 76. JaffeLF,VanableJW Jr Electricfie1dsand wound healing,Clir Dernatol2:34-44,1984. 77. BorgensRB, Vanable JS, Jaffe LI: Bioelectriciryand regeneration:largecurrentsleavethe stumpsof regenerating newt limbs, Proc Natl Aud Sci USA 74: 4528-4532,1977. 78. lllingworth CM, Barker Af: Measurement of electrical of amputated currentsemergingduringthe regeneration Meas1:87,1980. fingertips in childreq ClixPhysPhysiol 79. ReedBV Effectof high voltagepulsedelectricalstimulation on microvascularpermeability to plasma proteins:a possiblemechanismin minimizing edema,Phys Ther68:491-495,1988. 80. Bettany IA, Fish DR, Mendel IC: The elfect of high voltagepulseddirect curent on edemaformation following impact injury,PhysTher70:219-224,1990. 81. Bettany JA, Fish D\ Mendel FC: The effect of high voltagepulseddirect current on edemaformation following hyperflexio n in1ury, Atch Phys Med Rehabil 7 I:677-681, 1990. 82. BettanyJA, Iish D\ Mendel IC: Influenceof cathodal high voltage pulsed current aD acute edema,J Clitl Electrophysiol 2:724-733, 1990. 83. FishDR, Mendel FC,SchultzAM et al: Effectof anodal high voltagepulsedcurent on edemaformation in frog hindlinbs , PhysTherT1(10)724-730, 1991. 84. Taylor K, Mendel IC, Iish DR et al: Effect of high voltage pulsed current and alternating curent on macromolecular leakage in hamster cheek pouch 40, 1997. microcirculation,Plys Ther77:1729-77 85. KamesjL, MendelFC,FishDR et aLHigh voltagepulsed curent: its tfluences on diametersof histamine-dilated arteriolesin hamster cheek poucheq Atch PhysMed Rehabil76:38I-386, 1995.
258
8 . Electlicdl
86. Kincaid C, Lavoie K: Inhibition of bacterialgrowth in vitro following stimulation with high voltage, monophasic, pulsed current, Phys Ther 69:29-33, 1989. 87. SzuminskyNJ,AlbersAC, UngerP et al: Effectof narrow, pulsed high voltages on bacterial viabilit'1, Phys TherT4:660-667,1994. 88. Baranco SD,SpadaroJA,BergerTJ et al: In vitro effect of weak direct cuffent on Stayhykoccusaureus,Clln Onhop100:250-255 , I974. 89. Rowley BA, McKennaJ, ChaseGR: The iofluenceof eleccricalcurrent on an infecting microorganismin wounds,Ant NY AcadSci238:543-557,1974. 90. Ong PC,LaatschLJ,Kloth LC: Antibacterialeffectsof a silver electrodecarryingmicroamperagedirect cur6:14-18, 1994. rent ln vitro, J Clin ElearoVhysiol 91. Sherry JE, Oehrlein KM, Hegge KS et al: Effect of burst-mode ffanscutaneouselectricalnerve stimulation on peripheral vascular resistance,Phys Ther B 1 ( Q r 1 1 8 3 - 1 129010,1 . 92. Griffin JW, Tooms RI, Mendius RE et al: Efficacy of high voltage pulsed current for healing of pressure ulcers in patients with spinal cord injury Phys Ther 71:433-444,1991. 93. Unger P, Eddy L RaimastryS: A controlledstudy of the effect of high voltage pulsed curent ft{VPC) on wound healir.g, Phys Thet 7 t(suppl):5119' 1991. 94. Unger PC:A randomizedclinicaltrial oI dre effect of F{\/PC on wound healing, Phys Ther7 l(stppI): SII8, 1991. into the 95. LeducS:Introductionof medicinalsubstances depths of tissuesby electricalcu,rrent,Atlfl Electrobiol 3:545,1900. 96. Leduc S: Electic ionsaxd their useiu medicixe,Londorl 1908,Rebman. 97. Li SK,ChanemAH, TengCL et al: Characterizationof the ffanspot patiways induceddudng low to moderat€ voltaSeiontophoresisin human epidermalmembrane,J Pharn SciBT(I):40-48,1998. 98. SinghJ,RobertsMS: Traasdemal deliveryof drugsby iontophoresis: a review, Drug Desigx Deliv 4:1, 1989. Modalities 99. Starkey C: Electrical Agents. 7n TheraVeutic ed 2, Philadelphia,1999,FA Davis. fotAthleticTraiaets, 100. Chen T, Langer \ Weaver JC: Skin electroporation causes molecular transport acloss the stratum corneumthroughlocalizedtransportregions,J Investig 1998. DermatolSympProcAug;3(2):1,59-165, 101. Nimmo WS: Novel deliverysystems:electrotransPorq J Paix Synyton Maxage 8:760, 7992. 102. CullanderC: What are the pathwaysof iontophoretic current flow through mammalian skin? AA, Dug Del Dev9:119 , 1992.
Currettts
103. GlassJM, StephenRI, JacobsenSC:The quantiry and delivered distribution of radiolabeleddexamedrasone to tissueby iontophotesis,Int J Dermatol79.519-525, 1980. 104. Singh J, Roberts MS: Iontophoretic transdermal delivery of salicfic acid and lidocaine to local subcutaneousstructures,rr Pharm Sci 82(2):127-131' 1993. 105. Lai PM, Anissimov YG, Roberts MS: Lateral ion tophoretic solute transport in skin, J Pharn 16(l):46-54,1999. 106. Bertolucci LE: Introduction of anti drugsby iontophoresis:a doubleblind study,/ SVonPhysTher4:703-108,1982. 107.D elacerda FC: A comparative study of melhods of treatirent for shouldergirdle sy'ndrome, J OnhoV Spott PhYs Ther 1982. 108.Harris PR:lontophoresis:Clinical researchin loskeletal inflammatory condiiors, J OnhoV PhysThet4:109-172,7982. drug delivery: 109. HenleyEJ:Transcutaneous sis and phonophoresis, Cit Rev Phys Rehabil 2:139-t5I, 7991. LP,MahanPE,CiarloneAI: 110. Gangarosa managementof temporo-mandibularioint disorde and cfuonic head and neck pain, Cranio2tI39-1'5
t99r. 1 1 1 .L abrecque M, Nouwen A, Bergeron M et al: randomized controlled uial of approachesfor relief of low back pain during -263,1999. J Fan PractApr;48(4):259 1,72.Hanison RF.Woods T, ShoreM et al: Pain relief electricalnerye labour usins transcutaneous tion C|ENS):A TENS/TENSplacebo-controlled in two parity groups, Br J Obstet Cyxaecol.
46,1986. 93(7):739-7 D, LurieSet al:T 113.KaplanB,Rabinerson electrical nerve stimulation ([ENS) for adjuvant relief during labor and delivery IntJ Cytaecol -255,7988. Mar;60(3):251 114. Mannheimer IS: Electrodeplacementsfor neous electrical neffe stimulation, Phys Ther 1455-1,462,1978. 115. Melzack \ Stillwell DM, Fox EJ:Trigger points acupuncturepoints for pain: correlationsand implica'
aons,Pain3:3-23,1977. 116.Long DM: Stimulationof the peripheral system for pain control, Clin Neurosurg31:323-34$
1984. B,EdwardsRH: 117.JonesDA, Bigland-Ritchie
frequencyand muscle fatiguermechanicalresponser during voluntary and stimulated contractions, Neurol.May;64(2):401-4I3 , 1979.
Ts'o o THE PHYSICAL AGENTS
! 1 8 .SelkowitzDM: krprovementin isometricshengthof thequadriceps femorismusdeaftertrainingwith electricalstimulation,Pl ysTher65:186-196, 1985. Snyder-Mackler ! DelittoA, SualkaSWet al:Useof electricalstimulationto enhancerecovervof ouadri-
cepsfemoris muscleforce productionin patientsfollowing anterior cruciate ligament reconsuuctton, Phys Ther74:901-907,1994.
L!BRARY
Hydrothe
ieysical Propertiesof Water ihysiological Effectsof Hydrotherapy - sesof Hydrotherapy lontraindications and Precautionsfor Hydrotherapy r.dverseEffectsof Hydrotherapy
Application Techniques Documentation SafegzIssuesRegardingHydrotherapy,Including lnfection Control and Pool Safety Clinical CaseStudies Chapter Review
OBJECTIVES Uyon completionof this chayter,the readzrwill beable to: Discussthe physical propertiesof water, including heat transfer,buoyanry, resistance, and hydrostatic pressure. Identi$zthe physiologicaleffectsof cleansingwith water and of water immersion. Examinehow the physicalpropertiesand physiologicaleffectsof hydrotherapy can be usedfor cleansing,musculoskeletal support and resistance,cardiovascularand respAatorytraining, and for psychological benefits.
4. Assessthe indications, contraindications,and precautionsfor tlle useof hydrotherapy. 5 . Chooseand use the most appropriate hydrotherapy treatrnent technique to promote progresstoward desiredueatrnent goals. 6 . Presentedwith a clinical case,evaluatethe clinical findings, proposegoalsof treaffnent, assesswhetl-rerhydrotlerapy would be the best keatmeng and, if so, formulate an effective treatment plan including the appropriate hydrotherapy treatment techniquefor achieving the goalsoftreatment.
26r
252
9 c Hydtothetary
Hydrotherapy,derived from the Creek words hydro meaning "water" and "healing,"is the and therayeia, applicationof water, eitherintemally or extemally,for the treatrnentof physical or psychologicaidysfunction. This chapterconcernsonly the externalapplication of water when usedas a componentof physical rehabilitation.Hydrotherapy can be applied externally, either by immersion of the whole body or of parts o[ the body in water, or without immersionby sprayingor pouringwater onto the body. The effects and applicationsof both immersion and nonimmersionhydrotherapy arediscussed in chischapter. Bathingin water has beenconsideredhealingsince the beginningof recordedtime and acrossmany cultures,from Hippocratesin the 4th and 5th centuries 4.c.,who usedhot and cold water to treat a variety of diseases, to the Romansat the beginningof the 1stcentury A.D./who constructedtherapeuticbaths across their empire, to the Japanese, who have used ritual bathsfrom ancienttimesto the modem day.1The therapeutic use of water gained particularpopularitrTin Europein the late 19th century with the development ofhealth spasin areasofnaturalspringssuchasBadenBadenand Bad Ragaz,and shortly thereafterin the United Statesin similarareasof naturalhot springs.At this time,hydrotherapywasusedfor its effectsonboth the mind and the body: "lt is readily shown that no remedyfor lunacyexistswhich is at all comparableto the bath, owing to its purifying actionon the blood."2 The transitionof hydrotherapyfrom a preventiveand recreationalrole to a curativeor rehabilitativerole for diseases andtheir sequelaetook placeduringthe polio epidemicof the 1940sand 1950s,when SisterKenny included activities in water as a component of her treatmentofpatientsrecoveringfrom polio. Shefound that the unique propertiesof the water environment, includingbuoyancy,resistance, and support,allowed theseweakenedpatientsto perform a wide rangeof therapeuticactivitieswith greatereaseandsafetythan was nossibleon drvland.3u
Although hydrotherapy has been shown to have wide-ranging therapeutic effects and benefits, its use today continues to be limited in most clinical settingq largely due to the expensesassociatedwith lishing and maintaining a safe hydrotherapy ronment. Hydrotherapyis usedtoday primarily as componentof the treatrnentof wounds or to provi an enhancedenvironrnentfor therapeuticexercise. Iti also used occasionallyto control pain and/or Rehabilitation professionals mav also be involved
designing and instructing water exercise intended forhealth maintenance and/or disease tion in the community rather than in the dinical
PHYSICAL PROPERTIES OFWATER Water has a number of unique physical that makeir well-suitedto a varieryof applications.These properties include a high specificheat and thermal conductiviry and ability to provide buoyancy,resistance,and staticpressureto the body.
SpecificHeatandThermalGonductivity Water can transferheat by conduction and
and can thereforebe used as a superficialheating coolingagent.It is particularlyeffectivefor this cation becauseit has a high specific heat and conductiviw. The soecific heat of water is
matelv 4 timesthat of air.andits thermal is approximately25 timesthat of air flable 9-1). water retainsfour timesasmuch thermalenergyas equivalent mass of air at the same temperature, and
transfersthis thermal energy 25 times more rapi than air at the sametemperature.More details ing the effectsof specificheat and thermal iry on heat transfer,and on the principles of transferby conductionand convection,are in Chapter6 in the sectionon modesof heat
9-1 Comparison of SpecificHeat and Thermal Conductivity of Water and Air Speci6c heat 0/9,/'C)
Water
Water:air ratio
Therrnal conductiviw (Cal /sec)/(cm2 x 'Clcin)
4.1,9
0.0014
1.01
0.000057
4.1,4
24.56
Tso . THE PIIYSICAL AGENTS
Clinically,during hydrotherapy,heat is generally ::irsferred from warm water to a patient by placing -. patient's Iimb in a whirlpool filled with warm :ier. Heat may also be transferredfrom the patient ', :ooler water by immersinga limb or part of a limb -: whirlpool filled with cold or ice water.The ability : ',vaterto transferheat rapidly and efficiendyis one o[ performingexercises in a swim::he advanrages :,ag pool that is colderthan the patient'sbody temimmersion :::ature because,in such circumstances, .- -;hewater helpsto dissipatethe heat generatedby -.-3patientthrough exertionand may alsocounteract -.3 heat of a hotter climate. Stationary water transfers heat by conduction; : rving water also transfersheat by convection.As ,.::lainedin detailin Chapter6, the rate ofheat ffans-.: by convectionincreasesas the rate of fluid flow .:,ative to the body increases.Thus heating of a ::iient's limb in a whirlpool is acceleratedwith :-:reasingagitation of the watet and cooling of a ;:iient in a cold swimming pool is acceleratedas the ::dent movesmore quickly through the water in the ::ol.
Suoyancy : royanry is a force experiencedasan upward thrust on :-e body in the oppositedirectionto the forceof grav:.. Accordingto Archimedes'principle,when a body is :::tirely or partially immersedin a fluid at rest,it experi,::cesan upward thrust equal to the weight of the fluid The amountof fluid itdisplacesdependson :Cisplaces. 1e density of *re immersedbody relativeto the density :: the fluid. If the densityof the immersedbody is less :an the density of the fluid then it will displace a ,:nallervolume of fluid and will float. Converselv.if the ::nsiry of the immersedbody is greaterrhanthe d.n;:ry of the fluid, it will displacea largervolumeof fluid ,:rd will sink. Becausethe dersiqyof the human body is .ssthanthat of water,havinga specificgraviryofabout 974 comparedwith that of water, it floats in water -able9-2). If the relativedensity of the body compared .,,'iththe water is furtherdecreased, eitherby the addi:on of saltto the water or by attachingair-filledobjects ::.rchas a belt, vesq or arm bands to the patient, the :ody will float evenhigherin the water (Iig. 9-1).This when a personswims -:fecris commonlyexperienced :r seawater or usesa life jacket. The buoyancy of the body in water is usedclinically stressand compressionon weight-bearing :: decrease :ints, muscles,and connectivetissue(Iig. 9-2).lt rr,ay
263
9-2 Specific Gravity of Different Substances Substance
Specific gravity
Pure water
1
Saltwater
1.024
Ice
0.9r7 1 , . 2x7L 03
Averagehumanbody
0.97 4
Subcutaneous fat
0.85
alsobe usedto help raiseweakenedbody pansagainst graviry or to assistthe therapistin supportingthe weight of the patienCs body duringtberapeuticactivities.
Resistance The viscosity of water provides resistanceto the motion of a body in water This resistanceoccurs againstthe direction of the motion of the body and increasesin proportion to the relative speedof the body'smotion and *re ftontal areaof the body part(s) in contactwith the watef 6ig. 9-3;.In the clinicalsetting, the relativespeedof motion of the body can be increased by having the patient move faster in the water or by increasingthe speedat which the water movestoward the patient.The frontalareaof the body part in contactwith the water canbe increasedby the useofpaddlesor fins and canbe decreased by keeping the limbs more parallel to *re direction of movement resistanceprovided Qig 9-q. The velocity-dependent by water makes it a safe and effective strengthening and conditioningmedium for many patients.The fact that the resistanceof the water falls to zero when motion stopsprovidessafeqy,while the fact that the resistancecan be readily increasedby increasingthe speedof motion or the ftontal areain contactwith the water provideseffectivetraining.The variableresistance,andthuspressure,providedby movingwater can alsobe beneficialfor debridingandcleansingwounds.
Hydrostatic Pressure Hydrostaticpressureis the pressureexertedby a fluid on a body immersedin the fluid. Accordingto Pascal's law, a fluid exerts equal pressureon all surfacesof
264
? t HydrothetaFy
Personin water, floatinghead above waler
Personwith air-filledvesl in water, floaling head and shoulders above water
Person in waler, with a high concenlralionol dissolvedsalt, floatingheadand shoulders above water
Figure9-1. Buoyancy.
Figu]e 9-2. Patient exercising in water while wearing a foam vest to increase buoyancy. (Courtesy AOUAJOCCER@,Eugene,OR.)
a body at rest at a given depth, and this pressure increasesin proportion to the depth of the fluid (Iig. 9-5).Water exerts0.23mm Hg pressureper centimeter of depth (22.4 mm Hg per foot).4 Because hydrostaticpressureincreasesasthe depth of immersion increases.the amount of oressureexeftedon the distal extremitiesof an upright immersedpatient is greaterthan that exeftedon the more proximal or cranial parts of the body. Thus for example,when a patient'sfeet are immersedunder 4 feet of wate! the pressureexertedby the water will be approximately 88.9 mm Hg, which is slightly greaterthan nomal diastolic blood pressure.This external pressurecal have the same effects as the pressureexerted by devicesintended to produce compression,such as elasticgarmentsor bandages,asdescribedin detailis Chapter 11.Thereforeimmersionin water can assist in promoting circulation or aiieviating peripheral edema due to venous or lymphatic insufficienryHowever, in contrastto most other devicesusedto provide external compression,since the limbs must be in a dependentposition to maximize the hydro. staticpressureexertedby the wate! someof the benefits of the compressionproducedby immersion are counteractedby the increasein circulatory hydro staticpressureproducedby placinga limb in this position. The increasein venousreturn that resultsfrom increasingexternalhydrostaticpressureon the limbr
265
T*o . THE PHYSICAL AGENTS
: -re9-3. ::::stance.
H Fast-movingbody resultsin high resistance
Paddlesand fins increasefrontal area and increaseresistance
:;!re 9-4. Patient exercising in water using hand-held :.. icesto increasethe frontal areaand thus increasethe .;istanceof the water.
while the :-:y also facilitatecardiovascular-function, may help pressure :pport provided by this extemal joints muscles' or weak , irace unstable It is important to note that sincehydrostaticpres, -re increaseswith depth of immersion,the physio: qicaiand clinicalbenefitsof the hydrostaticpressure : ivater willvary with patientpositioning The great,;i effects will occur with vertical positioning, in '.aich the feet are immerseddeep in the watel The .lects will be much lesspronouncedif *re patient is ,-.vimmingor performingother activitiesin more hor:ontal po-sitionscloseto the water surface,where the
Slow-movingbody resultsIn moderateresistance
frontal Limbsstraightin frontdecrease areaanddecreaseresisiance
Figure9-5. Hydrostatic Pressure
limbs are kept at lower depths of immersion There effectswhen nonimarealsono hydrostaticpressure areused' techniques mersionhydrotherapy
OFHYDROTHERAPY EFFECTS PHYSIOLOGICAL etfectso[water arethe resultof its The phvsjological above The physjophvsicalprop"erties, as described iogi.ut .it".it o[ superficlalheatingor.cooling.by warm or coldwarerarerhe ,ameasthe Physlologlcal effects of heating or cooling with other superficial heatingor coolingagentsand includehemodynamic,
266
9 . HydrotheruW
Cleansing effects Pressure Dissolved surfactants and antimicrobials Musculoskelelal elfects Decreased weight bearing Strengtlening Slowed bone density loss Less fat loss than with other forms of exercise Cardiovascular effects lncreased venous circulation Increased cardiac volume Increased cardiac outpst Decreased heart rate, systolic blood pressure, and VO, response to ex€rcise Respiratory effects Decreased vital capacity Increased work of breatfiing Decreased exercise-induced asthma Renal effects Diuresis Increased sodium and potassium excretion Psychological effects Relaxing or invigorating, depending on temperature
open wounds. Water is used clinically both as a debridingagent,to remove endogenousdebris aswound exudateornecrotic tissue.andasa cleanser to remove exogenous waste, such as gravel adhereddressingmaterials,and to reduce burden.The presenceof necrotictissueand nation by microorganismsdelaywound healing.5,6 Productscan be added to water to increase cleansingpower. Suchadditivesaregenerally crobials or surfactants.Antimicrobials reduce microbecount in the water and thus on the surface the wound, while surfactants,such as soapor gent products, reduce surface tension and reducethe adhesionof debristo the tissue.A of clinicalbenefitsand risks are associatedwith ting additives in the water used for treating wounds. These are discussedin detail later in chapterin the sectionon the clinicaluseof .n-
F^' -ra'
'nr{ arp
Musculoskeletal Effects
The buoyancy o[ water unloadsthe weight anatomicai structuresand can thus allow pa neuromuscular,and metabolicchangesandmodificawith load-sensitiveioints to oerform exercises tion of soft tissue extensibility,For detaileddescrip- less trauma and pain. This effect can help tions of these effects,the reader is refered to the with arthritis,Iigamentousinstability,carrilage sectionson the effectsof heat and cold orovided in down, or other degenerativeor traumatic effectsof witer that are Chapter6. The physiological of the articular or periarticular structures of distinct from those of superficial thermai agents weight-bearingjoints to progressmore rapidly are describeddirecdy below. These effects include rehabilitation activities.For examole.since at cleansing,as well as musculoskeletal, cardiovascular, immersionweight bearingon the lower extremities respiratoryrenal.andpsychological changes. reducedby 75o/o,pattentsmay be able to weight-bearingexercisesor walk unassistedwith normal gait pattem in a pool, althoughthey can Cleansing Etfects form suchactivitieson dry land only with the can be used as a cleanser because of crutches.T Water it can soften Buoyancy can also be particularly helpful materials and exert pressure.Water is most comobesepatientsfor whom land-basedexercise monly used for cleansingintact skin; however, in extremestresses on the weight-bearingjoints. rehabilitation,its cleansingpropertiesare most often component suchindividualsaremore buoyantinwater than used as a of the treatment of open wounds where thete are exposedareasof subcuta- age, having more subcutaneousfat (seeTable 9they have greatly reducedjoint loading with neous tissueand the skin is no longer intact. In this based activities. Therefore, water-based circumstance,the hydrating effects and friction of may be usedto restorefimessin obesepatients water are used to soften and remove debris that is havedifficulty with other forms of exercise,al lodgedin a wound or adheredto the tissue.Water is paradoxically,exercisein water has been well-suited to this application becausethe force it to produce less weight and fat loss than exertsis proportionalto its rate of flow, and canthus of similar intensity and duration on dry land. be readily controlled.In addition, water can quickly Therefore.water-basedexerciseis recommended and easilveet into and out of the contouredareasof
Lto o THE PIIYSICAa ACENIS
267
- -:cving the fitnessand function of obesepatients '-: s not generallyrecommended for weightloss.
blood proximally from the extremities and thus enhancesvenous retum by shifting blood from the lee velocity-dependentresistanceprovided by peripheryto the trunk vesselsand thenceto the tho:::r can also be used to provide a force against rax and the heart. It has been shown that central - : h n u s c l e sc a nw o r k i n o r d e rr o g a i no r m a i n r a r n venous pressurerises with immersion to the chest .::gth. For example, water-basedexerciseshave and continues to increaseuntil the bodv is fullv ,:: shown to resultin increasedupper and lower immersed.l4W l " i * r i m m e r s i o nr o t h e n e i k , c e n t r a l -.miry strength in patients with neuromuscular blood volume increasesby about 600/o,and cardiac - -:ses, such as multiple sclerosis,and to maintain volume increasesby nearly307".r5'16 This increasein - . : . g r hi n h e a h h yi n d i v i d u a ) s .l l2l l f d i e d i r e c t i o n of cardiacvolume results in an increasein risht atrial :::r flow is adjustedto be in the samedirection as pressureof 14 co 18 mm Hg. to which the heart .: ratient's motion, the resistanceof the water can responds,accordingto Starling'slaw, with an increase : beusedto aid the patient'smotion. in the force of cardiaccontractionand an increasein ,5e hydrostaticpressure exertedby waterhasalso stroke volume.la This resultsin approximately30% ..:: shown to increaserestingmuscleblood flow by increasedcardiacoutput over baselinein responseto ' . to 2257oduring immersion of the body up to upright immersionup to the neck14(Iig. 9-O. :, neck.lr This is proposedto be the result of The increasein cardiacwork associatedwith this .::ced peripheralvasoconstrictionor increased increasedcardiacoutput is in contast to the decrease , lus return producedby the extemalcompression in heart rate that occursin responseto immersion in -- . ided by the water This increasein muscular water, and counters the reduced heart rate and - :d flow may improve muscularperformanceby reducedsystolicblood pressurethat occurwhen exer::::asing oxygen availability and acceleratingthe ciseat the samemetabolic rate or perceivedlevel of ,:-oval of waste products and may thus promote exeftion is performed in water rather than on dry ::e effectivemusculartraining. Iand.15,r7'19 VO2 (rateof oxygenconsumption)is aIs'o lower when exerciseis performed in water than when exercise at the samelevelof perceived exertion Effecls ", rdiovascular is performed on dry land. and VO, rate tmaximum --.. -,, cardiovascularbenefitsof hydrotherapyare priof oxygenconsumption)hasbeenfound to be slightly -,ily due to the effectsof hydrostaticpressure.The lower with maximal runninq in water than with :rostaticpressureexertedon the distal extremities maximal running o\ dry IanJ.20'22 Becauseof these -r upright immersion in water displacesvenous reducedphysiologicalresponses, exercisein waLer
I Strokevolume and t Cardiacoutput Figure9-6. Cardiovasculareffectsof rmmersron.
268
9.
Hydrothetary
has often been consideredto be lesseffectivefor cardiac conditioning than similar exerciseon dry land. However,it is important to realizethat thesereduced physiological responses are accompanied by an increasein strokevolume and cardiacoutout. which may increasemyocardial efficiency.ThuJ there is a physiological basis for using exercisein water for cardiac conditioning and rehabilitation. Also, a number of studies have shown that cardiovascular training effects,includingan increasedVO, *"* and a decreasedresting heart rate, do occur in healthy individuals in response to water-based exercise programs.22'23 Becausethe heart rate responseto exerciseis blunted in water, clinically the target heart rate may not provide an appropriateguidelinefor water exerciseintensity prescription.Thereforewhen a patient exercisesin water, it is recommendedthat the level of perceived exertion, rather than the heart rate response,be used as a guide for exerciseintensiry. The readershouldalsonote that the bluntins of heart rate and systolic blood pressurein responseto exercises that occur with water immersion may be obscuredif warm water is used,becauseincreasing the body'stemperaturemay elevatethe heartrateand reducethe systolicblood pressure.15,24 The velocity-dependentresistanceto motion provided by water also increasestie metabolicrate and energyexpenditure,asmeasuredbyVO2,by approximately a factor of 3 when an activity is performedat the samespeedin water as on dry land.2sThus exerciseperformedin water at one-halfto one-thirdof the speedwith which similar exerciseis performed on dry land has the sameeffect on the metabolicrate.26 This alteredresponsecanallow individualswith musculoskeletalconditionsthatlimit their speedofmovement to perfom exercisein water to maintain or improve their cardiovascular fitness.
Respiratory Effects Immersionof t1lewhole body in water increasesthe work of breathingbecausethe shift of venousblood ftom the peripheralto the centralcirculationincreases the circulationin the chestcavity,and the hydrostatic pressureon the chestwall increasesthe resistanceto lung expansionla(Tig. 9-7). Immersion in water up to the neck has been shown to decreaseexoiratorv reservevolume by about 50% and to i".r"ur. vital capaciryby 6y" to 72y"; theseeffects,combined,
increase the totai work of breathing by a 60o/o.z/'tvThus the workload challengeto the piratory system that occurs when exercrsers formed in water canbe usedto improve the and strength of the respiratory system. since this additional respiratory challengemay detrimentalto patientswith respiratoryor cular impairments that prevent or limit ada to this additional workload, such patients always be carefully monitored during water exercise.26 Water-based exercise is also often
for patients with exercise-inducedasthma severalstudieshave shown that water-based is lesslikely to causeasthmain theseindividuals exerciseon dry land.30,31 Variouspropertiesof includingthe absenceof pollenover the water, static pressureon the chest?hypoventilation, capnia, peripheral vasoconstriction,and the humidity of the inspiredair in rhe pool have beenproposedas mechanismsfor this effecr Althoush most of thesefactorshavenot been experimentally,it appearsthat the high humidity the air inspiredduringwater exercise,which drying and/or cooling of the respiratorymucosa, the most important factor in reducing inducedasthma.
RenalEffects Immersion of an individual up to the neck in has been shown to increaseurine production urine, sodium, and potassium excretion18,33,34 9-8).It is proposedthat theseeffectsare the result increasedrenalblood flow and decreased hormone (ADH) and aldosterone production. Waterimmersionis thought to causethese and hormonal changesin responseto the tion of blood volume and the relativecenrral volemiathat resultfrom the hydrostaticpressure water exeftson the periphery Theserenaleffects be taken advantaseof in the treatment of with hypervolemia,hypertension,and/or edema.
Psychological Effects As is well known to those who bathe or exercise water, water immersion can be invigorating relaxing.The variationsin thesepsychological
Two C THE PHYSICAL AGENTS
269
Figure 9-7. Respiratory effectsof immersion.
:rpear to depend primarily on the temperatureof -jrewater. While soakingin warm water is generally ::laxing, cold water immersion is found by most :3rsonsto be invigoratingand energizing.Thus the -3utralstimulationand supportof warm water canbe jsed clinically to provide a comforting and calming :rvironment for overstimulatedor agitatedpatients, .,,'hilethe invigorating effects of cold water can be
usedto facilitatemore activeexerciseoarticioationbv thosewho are generallylessactjveor responsive.i6 Although tlere is no published researchtlat has directly evaluatedthe effectsof water-basedexercise on mood, it has been proposed that the clinically observedpsychologicaleffectsmentionedabovemay be mediatedbv a centralorocesswithin the reticular acuvatmgsystem.'
270
? . HydtotlrcraVy
Figure9-8. Renal effects of immersion.
USES OFHYDROTHEBAPY SuperEcial heating or cooling Wound care Water exercise Pain control Edema control
Heating Superficial orGooling Warm or cold water can be usedclinicallyto heat or cool superficialtissues.Warm water and cold water transfer heat primarily by conduction,while warm and cold whirlpools transferheat both by conduction and by convection.3T The effectsand clinicalapplicaor cooling tions of heating superficialtissueswith water are the same as those produced when other superficialheatingor coolingagentsare usedand are describedin detail in Chapter6. Water has a number of advantagesover most other superficial thermal agents.It providesperfectcontactwith the skin, even in v€ry contouredareas,doesnot needto be fastened to the body, and allows movement during heatingor cooling. Its primary disadvantageis that, when it is applied to the extremitiesonly, the distal extremity must be in a dependentpositior5 which may aggravate edema.However,the edema-producingeffectof the dependentposition is somewhat counteracted produringimmersionin water by dre compression vided by the hydrostaticpressureof the water.
WoundCare Hydrotherapyhasbeenshowntoaccelerate the of woundsofvariousetiologiesincludingdiabetes litus, pressure,vascularinsufficiency,or bums. Hydrotherapymay alsobe usedin the careof dehisced due to trauma, surgery abscesses, necrotizing fasciitis, or cellulitis. Hydrotherapy is for wound carebecauseits cleansingproperties tate the rehydratior5 softening, and debridement necrotic tissue and the removal of exosenous debris, while the hydrostatic pressureoi water sion and the heat of warm water improve
(Fig.9-9).The use of hydrotherapyis also with the current understanding that it is important maintain a moist rather than a dry wound environmt
in orderto optimizewound healing.aa The useofhydrotherapyfor wound careis not As early as 1734, a Cerman physician,Dr
whirlpool has been used for the application hydrotherapyfor woundsl howeve5 recendy mersion tecbniquesof hydrotherapy have morepopularfor applyingthis type of treatment. changein practiceis due in part to concern the potentially damagingeffectsof placing pressureson the regeneratingtissue in wounds water agitatedby a whirlpool turbine and is also in part, to concemregardingthe potentialfor
277
Tgo . THE PIIYSICAL AGENTS
Softensnecrotictissue Removes wounddebris
:-':ction if a wound is allowed to soak in contami:::ed tank water for a prolongedperiodof time. fluid pressurecan -: hasbeenshown that excessive ::se wound ftauma and drivebacteriainto a wound, :.i that therefore,becausethe pressureof the water -: :rg directedat a wound in a whirlpool cari-notbe .:::;'ately controlied, there is a risk of applying too -::h or too little pressurewith this type of device.a) --=ough the pressureof the water beingappliedto a -und in a whirlpool canbe modified to someextent :. moving the turbine output toward or away from :: wound or by changingthe degreeof aeration, :: absolute amount of pressurebeing exerted is : :: known and cannotbe controlled.Thereforeit is ..:erally recommendedthat whirlpool treatments -: used only for cleansingwounds that contain ..-ensive *rick exudate, slough or necrotic tissue, :rss purulence,or dry escharwhen other,nonimmer::n hydrotherapydevicesmay be ineffectiveor when --:rimmersionhydrotherapydevicesarenot available, .:-i it is recommendedthat all forms of hydrotherapy ::atment b€ discontinuedwhen a wound is clean.1B Concernsregardingthe potential for wound infec::n with immersion hydrotherapy are the result of -,trortsof outbreaksof wound infection,most com-,:nly due to Pseudomonas aeruginosa but also occaaurcus,Acinetobacter ,rnally due to Staphylacoccus . tmannii or Candidaalbicans,after whirlpool treat-,3nts.46'50 Reportsof contamination of hydrotherthesemicroorganismshavebeen equipmentwith .:y , :ause for concern;however, a recentreport found :et only about 10% of whirlpools testedwere con--1na1s[.47,49,51 Whirlpool tink water may become by microorganismsfrom the patient -:ntaminated at that time, or by microorganismsthat :.ing treated ::come lodgedin the crevicesof the tank from prior -satmentsor betweentreatments.In order to reduce --.e risk of wound infection with hydrotherapy, a rmber of authors recommend the addition of --rtimicrobialadditives to the water when treating
lBacterialload I Barrierto epitheljaljzation
Figure9-9. Effectsof hydrotherapyfor wound care.
woundsl however, this practice is controversialat This controversy is based on the this time.46,49'54 conflict bewveenthe potential benefitsof improved infection control when antimicrobialsare used and the potential for adverseeffects, since it has been found that many antimicrobialproductsarerytotoxic to nomal tissueunlessusedat very dilute concenuations55-61 [able 9-3). These conflicting findings on *re benefits of using antimicrobial additives in hydrotherapy water lend support to the practiceof either usins an antimicrobialat the lowest effective
p
9-3 Toxicity Index for Wound and Skin Cleansers
Testagent
Toxicity index*
Biolex
1:100
SafK.lenz
1:100
Ultra Klenz
1:100
ClinicalCare
1:1,000
Uniwash
1:1,000
Ivory Soap(0.5%)
1:1,000
ConstantClens
1:10,000
Dermalwound cleanser
1:10,000
Puri Clens
1:10,000
Hibiclens
1:10,000
Betadinesurgicalscrub
1:10,000
Tecbnicarescrub
1:100,000
BardSkin Cleanser
1:100,000
Hollister
1:100,000
lrom ForesmanPA, Palrle DS, BeckerD et al A relativetoxicity index for wound cleaners,Vounds5(5):226-231 , 1993. *The dilution required tomaintain whit€ blood cell viability and phagocyticefficiency.
272
I . Hydtothetafy
concentrationor usingonly cleanwaterwithout additives when using a whirlpool to ffeat open wounds. The policy for the useof antimicrobialsin whirlpools inmost facilitiesis set by the infectionconuol department of *re facility, in accordancewith regulatory guidelines,and should always be followed. Whether or not additivesare usedduring whirlpool treaftnent of open wounds, the tank and turbine shouldalways be thoroughly cleanedand disinfectedbetweenuses. Recommendationsfor whirlpool cleaningprocedures are provided in this chapterin the sectionon safety issuesregardinghydrotherapy.In order to avoid the infection risks associatedwith whirlpool use, many facilitiesusenonimmersionhydrotherapytechniques for wound care because,with these techniques,the wound does not soak in potentially contaminated water insidea Dotentiallvcontaminatedtank.
p
A variety of devices can be used to apply hydrotherapy without immersion to wounds. In order to be safeand effectivefor this application,suchdevicesmust deliver fluid at a pressureof between 4 and 15 pi (poundsper squareinch)because, below this level,bacteria and debris are not effectively removed, while d wound traumamay occuror bacteria higherpressures. miy bedrivenrntothe tissue.46263A numbero[ devices have been shown to deliver fluid within *ris pressure rangeflable 9-4).Theseinclude a saLinesqueezebode wi*r an inigation cap or a 35-ml synnge with a irrigationdevicescan gaugeneedle.tlectricpulsatiJe be setto deliverpressurewithin this range. Cenerally,nonimmersionhydrotherapy is mended for the treatment of wounds necrotic,nonviabletissueor debris.This type of ment has been shown to facilitate the removal
S-l 1..;S"t;on PressureDelivered by Various Devices Irrigation pressure Osi) (nr:'r
hnttTa-l
Ilrrr l(lenz'
1.2
(Carington LaboratoriesInc.,Dallas,TX) Bulb Syringe(DavolInc.,Cranstoq N)
2.0
ript PistonIrrigationSyringe.60ml. with catherer (PremiumPlasticsInc.,Chicago) SalineSqueezeBotde,250mL, with irigation capt (BaxterHealthcareCorp.,Deerfield,IL) water rlK at lowest settlng fieledyne WaterPik,Fort Collins,CO)
6.0
lfflel
7.6
U5 5ylnge
wlth llpl
(AckradLaboratories,Inc.,Cranford,Nl) 35-ml syringewith 19gaugeneedleor angiocatheterr WaterPik at middle setting+ ffeledyneWaterPik,Iort Collins,CO)
8.0 1a
WaterPik at highestsetting+ ffeledyneWaterPik,FortCollins,CO) Pressurized CanrristerDey Wash+ (Dey Laboratories,Inc.,Napa,CA)
50
Ulcers:Clinical From U.S.Departrnentof Health and Human Sewices Treatment af Ptessure Ptuctice MD, 1994,U.S.Departrnentof Healthand Human Services. Cutdel;nes.kockvile, *Toolitde pressureforeffectivewound cleansing<4 psi. tAppropriatepressurefor safeand effectivewound cleansingat4 to 15 psi. *Toomuchpressureforsafewound cleansing>15 psi.
Two . THE PHYSICAL ACENTS
273
patient - - :- rric tissue,promotehealinS,andincrease --:on in both hospitaland homeboundpatients.o" : .; :ecommendedthat nonimmersionhydrotherapy ., :rntinued until all necrotic,nonviablematerialhas -.:-. removedand a full granulationbed is present.6s " ::mbination of immersion hydrotherapy,using a ,:,;ipool to softendebrisfollowed by nonimmersion : ::otherapy with a spray to removethis debrisand -.=::eria,hasalsobeenshown to be particularlyeffec: : :or the removalof bacteriafrom wounds.oo ',r,hen applying hydrotherapy to wounds, whether .j---: immersion or nonimmersion techniques, it is =.ottu.tt to b"lu.t." the potential benefitsto *re wound ,' c'-the potential for darnagingregeneratingSranulation :,-:e in the wound bed by mechanicaldisruption,or for =-igng the intact skin sunounding the wound- by moisture.Therefore -t..*tiotr ut u t"t,rlt of excessive be :crms of hydrotherapy should discontinuedwhen :i .voundbaseis fully coveredwith granulationtissue, rc -,heintact skin surroundinga wotrnd should always re lroroughly, though gendy, dried immediately after ,:=pletion of any hydrotheraPytreatment.
face,such as a mesh net sfietcher or trauma table-,that allows the water to pour off into a suitabledrain.7oThis t ?e of treatmentsetuphasdre additional advantagesof being less painful for the patient and allowing morerapiJ ueatrnentand greacereasein patienthandling.lf immersiontechniquJsare used foi the hydrotherapy ffeaftnentof bums,it h"t beenrecom-endedthat salt be addedto the water in order to reducesodiumloss ftom the patient to the water and to reducethe risk of hwonatrimia associatedwith the soaking of some patiens with extensivebums in water.71'72 Hydrotherapy is usednot only in the early treatment of burn wounds, when necrotictissueis present, but also in the later stagesof recovery after reepithelializationhas occurred.In this circumstancer the risk of wound infection is eliminated and the water is usedto provide a comfortableenvironment for exerciseand for active and passiverange of motion (ROM), helping to prevent contracturesand to facilitateincreasedROM in scarredareas.
in the regardingtheuseof hydrotherapy SEcialconcerns rMtmentof bums -:.-irotherapy is consideredto be an important comPo:;::r of the treatrnentof acutebum injuriesin most bum 69 ::-iersin the United States.4't The purposesand -:* of hydrotherapy in bum carearegenerallythe same s -]rosefor other types of wounds, except for a few :;reworthy differences.As with other typesof wounds, I :rotherapy is usedasa componentof earlytreatment : crderto cleanse,softer5and loosennecrotlcttssue l:ore debridement,and to reducebacterialcoloniza::r However, in contrast to most other types o[ . :unds, where suchdebridementis relatively painless, :r debridement of bum wounds is frequendy :,=emely painful becausethe wounds arelessdeepand :,:ny of the sensorynerves are still intact. Therefore -r=hdoseanalgesicsare generallyused during this pro,:Jure, necessitatingdoser monitoring of the patient :-:ing the fteaffnent. AIso, becausebum wounds are :::en extensive,covering a large area of the body, dre ::ger Hubbard tank whirlpools have traditionally been .ed for this application,and, with the increasingcon::n for and awarenessof the risks of nosocomialinfec-- ns with the useo[ immersionhydrotherapy,special r:nimmersion techniques for the treatrnent of bums These generally involve ::ve been developed.48'68 patient is lying on a surwhile the patient :::oweringthe
Typesof water exercise Varioustypesof exerciseincludjngswimming'runnng with or without a vest or belt, walking , cycleergometry, and other forms of upright exercisecanbe performedin water (Fig.9-10).In general,patientsare free to move about the pool while exercising,although they may be tethered to the side, as for example during in-place water running. The tether may be used to facfitate monitoring of the exerciseby the therapistor to increase resistanceand allow a wider rangeof activities,particularly in a small pool. The principles, mechanismso[ action, and rationalesfor performing exercisein water are discussedbelow; however,specificwater exercise proqramsare not coveredsincethey are de'cribedin i",iil in oth"r t.*tt devotedto aquarictherapy.T2
WaterExercise
usesof waterexercises General circulation, Exercisein warercan be usedto increase and flexibility, muscle strength,ioint viscoelasticity, cardiocoordination, ROM; to improve ambulation, vascularandrespiratoryconditioningandpsychologipajn.musclespasm, cal well-being;and to decrease and stiffness.The specificcontributionsof the unique physical propertiesof water, including its ability to retainand conductheat,and its buoyanry,resistance, and hydrostatic pressurein producing these effects, arediscussedin detail directly following.
q.
274
Hylrothcrnl't,
Becausethe buoyancyof water decreases the gravitational forcesplacedon weight-bearingstructures. patientswith weakenedlimbs or load-sensitivejoints can often perform strengthening,conditioning, and coordinationexercisesin water that they would not be ableto perform on dry land.This cancontributeto improved functional mobiliqy and strength. The resistanceprovided by water during movement cal also sewe as a force againstwhich musclescan work in order to developstrengthor, when appliedin the direction of oatient movement.can be usedto assist weakenedmusclesin the productionof movement.T6 Because the hydrostatic pressure provided by immersionin water can facilitatevenousreturn from the extremities,circulationmay be enhancedduring exercisein water comparedto similar exerciseperformed on dry land.As describedpreviously,the circulatory changes produced by the hydrostatic pressureof water on the extremitiesduring waterbasedexercisecan also facilitate cardiovascularand respiratoryconditioning,andhelp to tevetseand control the formation of peripheraledema.
Specilic uses olwater exercise
B Figuregl0. Water exercisein a swimming pool. A, Swimming,andB, jogging. The ability of water to retain and conductheat is used clinicallywhen a patient, or a paft of a patient, exerciseswhile immersedin warm water. The combination of hear Lransferand exerciseis parricularly effectivein certaincasesbecauseincreasingthe temperatureof soft tissuecan augmentthe vasodilation, increasedcirculation,decreasedjoint stiffness, increasedjoint ROM, and enhancedfunctional abilities that resultfrom exercrse.T4'75 The relaxingeffects of immersion in warm water may also improve the psychologicalwell-being of the patient during and afterwater-basedexercise.
Orthopedic problems Decreasedweight bearing on joints Velocity-dependent resistance Closed or open chain exercises Slowed bone density loss Neurological problems Proprioceptive input Increased safety Improved balance Cardiac fitness Cardiac conditioning in patients wilfi poor tolerance for land-based exercise Exercise in water during pregnancy Decreased weight bearing Less elevation of heart rate with exercise Decreased risk of maternal hyperthermia Exercise-induced aslhma Less exercise-induced asthma than with other forms of exercise
problens otthopedic The water environment can be used to provide gradedweight bearingand patient-controlledresistanceto help individualswith spinaland/or peripheral musculoskeletaldysfunction perform exercisesthey would have difficulty performingon dry land.7''7E This can allow for eariier exerciseoarticioation fol-
Two C THE PITYSICAL AGENTS
:-ving injury, surgery or immobilization and greater participationby patientswith load-sensitive ::,:ercise ::irditions such as osteoarthritisor spinal disc dis:.:cement.'oSuch exerciseparticipationmay also -:'ult in earlier recovery of and greater final func:rnal mobiliry in theseindividuals. Weightbearingcan6e gradedbyvaryingthe depth :: water immersionor by the useof flotation devices, :':ch as belts, arm bands,or hand-held floats, with ::eper immersion or more flotation devicesprovid---3 more unioading. Flotation devices also allow .-:3atermuscularrelaxationin the water by eliminat:,9 or reducingthe amount of work required by the :.:rient to stay afloat. Therefore the use of such ::vices is particularlyappropriatefor the patientwho :.:.nbenefit from both decreasedjoint loading and :3creasedmuscuiar activity. Ior example, patients .,-rth load-sensitivespinal conditions such as disc :dges or herniationsor nerveroot compressionmay -enefit from relaxed vertical floating in wate! sup:rrted by a flotation belt, to allow unloading of =e spinal intraarticular structures and relaxation :: theparaspinal muscles(Fig.9-11). Varying the resistanceprovided by water during =:<ercise, by altering the speed or direction of the -otion of the water or the speedof movement of :re patient, can alter the clinical effectsof the exer.'se.The fasterthe water moves toward the oatient. :;ainst rhe patients directionof movemenr,or the =ster the patient moves in the water, the greaterthe :esistanceagainstthe patient's movement and thus :le greaterthe strengtheningor endurance-building
Figure9-11, Relaxinqin a water vest.
275
effect of the activity. Exerciseintensity can thus be gradedby modifying the speedof water motion in a pool that allows control of water motion or by altering the speedat which *re patient is moving while exercising.If the flow of the water can be directedto be in, ratherthan against,the directionof the patient's motion, tlle resistanceof t]1ewater canalsobe usedto assistwith motion when musclesareweak in orderto allow strengtheningthrough a greaterROM. The tlpes of exercises performedin water must be carefully designedand selectedto addressdifferent conditions and to avoid exacerbatingexistingproblems or causingnew ones.The patient can perform either closed-chain or open-chainexercises in water Closedchainexercisescan be performedusingthe bottom of the pool to fix the distal exEemity when the patient is in shallowwater (Fig.9-12)or usingthe sideof tlre pool to fix the distal extremity when the patient is in deeper water. Open-chainexercisescan also be performedin eitherdeepor shallowwater,dependingon the areaof the body involvedand the t'?e of exerciseto be performed(Fig.9-13).Itis importantto selectthe appropriate exercisefor a particular problem and to be aware of the changesin biomechanicsif an exerciseusually performed on dry land is transferredto a water environment. For example,running on dry land is primarily a closed-chainactiviry whereaswhen running is performed in deepwater usinga flotation vest,it is entirely an open-chain activity. This changemay reduce pain Irom tibiofemoraljoint compressionby decreasing the weight bearing on this joint, but it may increase patellofemoraljoint pain by producingincreasedcompressionat this joint during open-chainknee extension. When designing rehabilitation programs that involve swimming, it is particularly important to guardagainstadverseeffectsof compensatorymotions becausesuch motions can causeproblems in other areas.77 For example,if the patienthas limited shoulder ROM and increaseslumbar or cervicalmotion to bring the shoulderout of *re water during freestyle swimming, the resultmay be problemsin thesespinal areas.In a similarmannet a patientwith hypomobiliqy of the thoracic spine may overusethe shoulder during freestyle or breast stroke swimrdng and increasesubacromialcompressionof the rotator cuff, causingtendon breakdown. Becauseexerciseinwater resultsin reducedweisht bearingon chebones.it hasgenerallybeenassumed that exercisein this environment does not assist in maintaining bone density in postrnenopausalwomen.
276
2.
-.
Hydrothcr.llrt'
;t..: . ,{
..:i:,,:.1* :ii:'::a'.::
Figure 9-12, Closedchainexercisein water.
Figure 9-13.Open-chain exercrse ln water.
However,because a recentcross-sectional andlongitudinal study has shown that water in exercisecan slow bone mineral densitylossin the lumbar spinein this population, water-based exerctse ts recommendedfor slowingbonemineralden,iryloss.80 prcblems I'leurclogical Water-basedexercisehas been recommendedto addressthe impaiments, disabilities,and handicaps resulting from neurological dysfunction becauseit provides propdoceptiveinput, weight relief, and a safe environment for movement.SlThe proprioceptive input may be particularlybeneficialfor patients with centralsensorydeficits,such as those that can
occur after a stroke or traumatic brain injury while the weight relief can increase ease of movement ani reduce the rjsk of Falljngto faci'irategreater movemenr exploratJon. functjonal acciviry training. ani strengthening in patients with weakness or impairei motor control.82 It has been proposed that the greate: movement exploration and the increased productior of movement errors that occur in water-based exercise are responsible for the balance enhancement tha: has been shown to result from water-based exercise programs.s3 Reduced loading due to buoyancy, ani the increased abdominal support from the hydrostatic pressure of water, may also provide assistance fo: breathing in patients with a weak diaphragm, as car occur after a spinal cord injury or with amyotrophic lateral sclerosis (AlS), although this must be balanceri against the increased breathing workload produced by the shift of fluids to the central circulation. The decreasedpatient weight caused by the buoyancy c: *re patient's body in water, and the support providei by the buoyancy and hydrostatic pressure of wate: may also contribute to patient progress by allowir:.: for easier patient handling by the therapist. Exercise in water using a variety of speciE; approaches, such as neurodevelopmental trainic: (NDT) or the Bad Ragaz method, has been recorrmended for improving function in patients with neurological problems.84,85These methods use verb;.., instructions and tactile cues to guide the patient iB practice normal movement progression and sequencing. The challenge of the activities can then be modfied by varying the depth of the water or by using tl,t support ofone ormore flotation devices.Thesemed ods are particularly recommended for improving stability and motor control. Cadiac litness Becausewater-basedexerciseprogramshave beer shown to maintain and increaseaerobic conditionig exercise in water can be used to provide general co= ditioning for deconditioned patients or for those who wish to increase their cardiovascular fitness.22,86 Ths form of exercise can be particularly beneficial for ca-diac conditioning in patients with conditions such as osreoarrhritis,posroperadverecovery.or joinr inscability that are aggravated by joint loading and th':s limit land-basedexercise. The increased cardiac output resulting
the hydrostatic pressure of water immersion, describedpreviously,has led some to investigatet+
Two o THE PIIYSICAL AGENTS
r:3cts of exercisein water for cardiacrehabilitation. :-.',o recent studies of patients with a history of --'.ocardialinfarction or ischemicheart diseasehave :::nonstrated improvement in heart function of , - rut 30% in parientsperformingexercisein water -:: a month.87,88 Exercisein water has also been :rlwn to reduce*re restingheart rate and increase -)r,nr*, maximum heart rate, and work capacityin -::Jthy older adultsand to improve respiratoryfunc--:r in patientswith chronic obsffuctivepulmonary .--.ease.1o,16 A novel form of water exercise consistins of :nersion in water in combinadonwitJr expiring :-:o water hasbeenfound to increasecardiacejection :=ction and to decreaseleft ventricularend-diastolic ::-d systolic dimensions at rest in patients with r::physema.This exercisealsoresultedin an increase ,---'heratio of forcedexpiredvolume in one secondto -::ced vital capacity (FEV1:FVC)and a decreasein :.COr. Theseresultssuggest*rat this type of water ::tercisemay improve both the breathingand cardiac :-:rctionof patientswith emphysema.90 in wabrduingwgnancy Exercise A number of studieson the effectsof exercisein '.ater during pregnancyindicate that this form of may be particularlyappropriatefor pregnant ,:':ercise ,.3r1s1.17,18,89 lxglcise in water providesthe benefits :: unloading the weight-bearing joints, conffolling :tripheral edema,and causinglesselevationoI heart :,:e, blood pressure,and body temperaturethan simi:i exerciseperformed on dry land. The American ,:llege of Obstetriciansand Clmecologistsrecom,ends that women keep their heart rate below 140 :€atsper minute throughout pregnancy.Thus, given :.e lower heart rate responseto exercisein water, ,,-omen may be ableto perform exercrseln water at a :gher level of perceivedexertion, and at a higher -,etabolic rate, than fiey could on dry land while Exercisein ;--ayingwithin safe heart rate limits.17'91 ,.-ater is alsothought to poselessrisk to the fetusthan :rd-based exercisebecauseit has been shown that :-e incidence of postexercisefetal tachycardia is :wer with this tvr:e of exercisethan with land-based , rq ao :l{eIC1Se.'-'--
Immersionin water, and thus upright exercise,or :-.'en immersion in an upright position in water, :-aceshydrostatic pressureon the immersed areas r-rd can thereforebe used to help reduceperipheral :Cemain pregnantpatients.This effect is the result
277
of improved venous and lymphatic flow and renalinfluenceddiuresiscausedby the hydrostaticpressure of water on the lower extremities.Becausehydrostaticpressureincreasesat increasingdepthsof wate5 control of peripheraledemais mostmarked when the patient exercises in an upright positionto producethe greatestpressureon the distallower extremities. Exercise-induced asthma Water-basedexercise.includingswimming, is particularly suited to patients with exercise-induced asthma becausethe water environment has been found to reducethe incidenceof asthmain theseindividualscomparedwith land-basedexercise.30,31 Also, a number of studies have shown decreasedsvmotoms of asthma and increasedfitnessin individua.ls with asthma. particularly children. in responseto swimming exercise.92,93
PainControl Hydrotherapy is often recommendedas a fteatment for the control of pain. Although there is litde data regardingthis application of hydrotherapy, hydrotherapy is thought to control pain by providing a high level of sensory stimulation to the peripheral mechanoreceptorsto gate the transmissionof pain sensationsat the spinal cord. Such a mechanismis consistentwith the reports by many cliniciansthat forms of hydrotherapythat provide the greatestsensory stimulatior! suchascontrastbaths,or water at a high temperaturewith a high level of agitation,are particularly effective in reducing pain. Cold water may alsocontributeto the reductionofpain by reducing acuteinflammation. Pain control may also result from the decreased weight bearingandincreasedease of movementproducedby waterimmersion.
Edema Control Water immersion has been shown to reduceperipheraledema.Ir is proposedthat thiseffectis dueto the hydrostatic pressure of water and the resulting changesin circulationand renal function. Therefore water immersion has been recommendedfor the treatment of peripheraledemawith a variety of etiologiesincluding venous or lymphatic insufficienry, renal dysfunction, and postoperativeinflammation.4,94 In addition to the effects of hydrostatic pressure on postoperativeedema,the cooling effects of cold
278
g.
Hy.lrctheral'y
water may also contribute to edema reduction by causingvasoconstrictionand reducingvascularpermeability.Thereforecold water immersionof a limb, or pan of a limb, is frequently usedas a component of the treatment of edema due ro recenr uauma when other signsof acuteinflammation are present. Immersioninwarmorhotwaterisnotrecommended in such circumstancesbecauseheatine the areaand placingit in a dependentpositioncan increase tissue temperatureand intravascularpressure,resulting in increasedinflammation and peripheralartedal flow, and thus increasedrather than decreasededema.95 In such casesit has beenfound drat the hieher the temperature4 of the water. the greaterthe amount oF edema.'" Contrast baths are frequendv recommendedand clinically used to control edema,with the rationale that the alternatingvasodilationand vasoconsffiction produced by the alternatingimmersion in hot and cold water may help to train or condition the smooth musclesof the blood vessels.However,becausethere areno researchdataon the efficacvor mechanismsof
this effect,it is recommendedthat clinicianscarefully assessthe effect of such treatmenton the individual patient when consideringusing this form of hydrotherapytreabTrent.
CONTRAINDICATIONS ANDPRECAUTIONS FOR HYDROTHERAPY Although hydro*rerapy is a relatively safetreatment modalify, its use is contraindicatedin some circumstancesand it should be applied with caution in others.96When applying hoi or cold water to a patient,all the contraindicationsand precautionsthat apply to the useof other superficialheatingor cooliqg agents,describedin detail in Chapter6, apply to this mode of superficialheating or cooling.ln addition,a number of contraindicationsand precautionsapply specificallyto the applicationof hydrotherapy,either by local immersionin a whirlpool or contrastbath,tr by whole body immersionin a pool or Hubbardtank, or by nonimmersionmethods.Thesearelisted in boxesand discussedin detailin the text that follows-
GONTRAINDICATIONS
for Locallmmersion Formsol Hydrotherapy . Macerationarounda wound r Bleedins
The use of local forms of hydrotherapy iscontraindicated... . . . when there is maceration around a wound Immersion hydrotherapy is contraindicatedwhen there is macerationof intact skin around a wound becauseit is likely to increasethe macerationandthus increasethe sizeofthe wound. ASSESS: . Inspectthe skin aroundthe wound for signsofmaceration, including pallor or other early indications ofbreakdown. When thereis macerationarounda wound, andwhen the cleansingbenefitsof hydrotherapy aredesired,nonimmersiontechniquesshouldbe usedto avoid excessiveor prolongedsoakingof the maceratedtissues.
. . . when there is bleeding Immersion hydrotherapy should not be applied there is bleedingin or near an areabeing for treatmentbecauseimmersionhvdrotheranv increasebleedingby increasingvenouscirculation a result of the hydrostaticpressureand may arterial circulation as a result of vasodilation if or hot water is used.
ASSESS: o Checkfor bleedingin or nearthe areabeing eredfor treatment. If bleedineis mild and has beendeterminednot be dangerousto tlre patient, nonimmersion therapymay be used.
Two . THE PIIYSICAL AGENTS
279
PRECAUTIONS
Fomsof Hydtotherapy hr Locallmmersion o Impaired thermal sensation in the area to be immersed
Jse local immersionforms of 'rydrotherapy with caution. . . . when there is impaired thermal sensation in =e area to be immersed -':eas with impaired thermal sensation are at :creasedrisk for thermalburns.Thereforein order to inimize this risk, the temperatureof the water to be :sed for hydrotherapy should always be checked ;ith a thermometer before the patient enters the ? ater.It is alsorecommendedthat the cliniciancheck =e water temperaturedirectly by placing a hand, ,'.'earing a cleanrubberglove,in the water beforethe :adent enters. Thermostatically controlled mixing ',dvesshouldalsobe usedto control the temperature : : the incoming water. ASKTHE PATIENT: . Canyou feelheat and cold in this area? ASSESS: . Thermal sensationcan be tested by applying test tubesfilled with cold orwarmwater to the areaand asking the patient to report the sensationof the strmulus. If the patient has impaired thermal sensatioqonly -.-r'ater at a temperatureclose to body temperature rrould be usedfor applyinghydrotherapy. . . when there is infection in the area to be :grmersed lydrotherapy is frequendyappliedto wounds when -n infection is presentin the areato be immersed.In ;uch circumstances,use the additional infection :ontrol measuresdescribedin the sectionofthis chap:er concerningthe use of hydrotherapyfor the treat:rent of wounds and in the section of this chapter ;onceming safety issuesregardingthe applicationof rydrotherapy.
o Infectionin the areato be irnmersed o Confusionor impairedcognition r
Rccent cLin oraFrq
ASSESS: o Check the area to be ueated for sigrs of infection. Signsof infection include induration, feveSerythema, and edema.Sinceall openwounds are colonizedwith bacteria,when treatingopenwounds with immersion hydrotherapy, one should take the sameprecautions aswhen an infectionis known to bepresent." . . with patients experiencing confusion or impaired cognition Hydrotherapyis frequentlyappliedwhenpatientsare confusedor have impaired cognition. For example, many patientshave openwounds, to somedegreeas a result of their impaired mental status, and many to patientswith burns are given high-doseanalgesics performed durpain the debridement during control ing or direcdy after hydrotherapy,which also results in impairmentof mental status. ASSESS: o Assessthe patient'slevel of cognitionand alertness. Check if the patient can effectively communicate discomfort. When a patient is confusedor is unable to effectively report discomfort or other problems for any other reason,one should provide direct supervision throughout hydrotherapy treatment and only use water at a temperaturecloseto body temperature. . . . in areaswitle recent skin grafts Extra careshould be taken when treatingrecentskin graftswith hydrotherapybecausea graft may not tolerate the mechanical agitation of a whirlpool or may not havea sufficientvascularresponseto compensate for extremeheat or cold.Therefore,the whirlpool agitator shouldalwaysbe directedaway from the areaof a graft,andwater with neutralwarmth (33' to 35.5'C; 92' m96" I) or rr'tldwarmth (35.5'to37"Cj 96' tog9'F) shouldbe usedwhen treatingrecentskingrafts.
280
I . Hy.lrcthercpy
FullBodylmmersion Hydrotherapy AII the contraindications and precautions for parrialbody immersionhydrotherapyapply to full body immersion hydrotherapy.'8In addirion, a number of contraindicationsand precautions.due
to the risks associatedwith deep water and the fact that most fuIl body immersion occursin a pool where the water is not changed between uses, apply uniquely to full body immersion hydrotherapy.
CONTRAINDICATIONS
lor FullBodylmmersion Hydrotherapy .
a"rdir.
ihcr"hilih'
o Infectiousconditionsthat may be spreadby water
The use of full body immersion hydrotherapyis contraindicated. . , . . . for patients with cardiac instability Iull bodyimmersionis contraindicatedin casesof cardiac instability,suchas uncontrolledhypertensionor heart failure,becausein suchcircumstances the heart may not be able to adapt sufficiendy in responseto the changesin circulationproducedby the hydrotherapy to mainraincardiachomeosrasis. ASSESS: o Checkwith the patient'sphysicianand review the patient'schart to determineif any cardiacinstability is present.Heart rate and blood pressureshould alsobe monitored during and after immersionin all paciencs with a historyof cardiacproblems. . . . for patients with infectious conditions that may be spread by water Patients with infectious conditions that may be spread by water should not use any qFpe of hydrotherapy where the water is not changed betweenuses.Thus suchpatiencsshouldnot ur. u pool but may usea Hubbardtank, where the water is changedbetween fteatments,for fuI1 body immersion. Infectious conditions that mav be soread by water include urinary tracr infections,tinea pedis.piantarwarts,and infectionspresentin open wounds.
o Bowel incontinence .
qcvPrP
pnilenev
o Suicidalpatients ASK THE PATIENT o Do you havea urinary tract infection,athlete'sfoog plantarwarts, or any open wounds?This question may be asked most readily in a written checkoff sheetgivento all patientsbeforeany pool activities. . . for patients with bowel incontinence Patients with bowel incontinence may not be immersedin water that will be usedbv otherDatientsIn patients wich bowel incontinenceand open wounds, careshould also be taken to avoid contamjnating the water usedfor hydrotherapy,and thus the wound, with bacteriafrom the patient'sown feces. ASSESS: . Checkthe patient'schartfor any notation bowel incontinence. Nonimmersion forms of hydrotherapy are recorrF mendedfor the treatmentof openwounds in patients with bowel incontinence. . . . for patients with severe epilepsy
. . . for suicidalpatients Full body immersionhydrotherapyshouldalsonotbc applied to suicidal patients becausethey have increasedrisk of drowning.
Tso . THE PIIYSICAL ACENTS
ERECAUTIONS lmmersion Hydrotherapy forFullBody o Confusionor disorientation e A f t e ri n g e s r i oont a l c o h obl y t h e p a t i e n t . Limited strength,endurance,balance,or ROM
Jse full body immersion hydrotherapy ,,rithcaution... . with patients experiencing confusion or ::sorientation -':11body immersion is occasionallyused for *re ::atment of confusedor disoriented patients who -:ve multiple or large open wounds or wounds : at are difficult to accessby other means.In such :::es, extra care should be taken to monitor the .,ater temperatureand to be sure that the patient ; weli and safely secured,with the head above the ,.-ater. . after ingestion ofalcohol by the patient --:11body water immersion should be avoided ::er the ingestionof alcohol becausethe impair::'.ent of judgment and cognitive functions that ::curs with intoxication and the hypotensive ::fects of alcohol ingestion can increasethe risk of ::owntng.
o o o .
281
Medications Urinary incontinence lear ofwater Respiratoryproblems
above water. Direct, hands-on assistance,with the therapist in *re water, can also be provided for patients who have difficulty keeping their heads abovewater. ASSESS: . Check strength, balance, and ROM before the patient enters the water. If any of these are significandy limited, secure the patient so that the head camot enter the water or accompany the patient into the water, at least for the first ueatment, to assessthe patient's safeqyin the water. . . . with patients taking medications Some medications,particularly those used to treat cardiovascular disease, alter the cardiovascular responseto exercise.It is therefore recommended that a physicianbe consultedto establishsafelimits of cardiovascular responsefor eachpatientbeforeinitiating an aquaticexerciseprogramwith any patient Ldr\x.,ts urcurLdL,urrb.
\SK THE PATIENT . lf you suspectthat a patient has recendy been drinkingalcohol-for example,if you smellalcohol on the patient'sbreath,ask,"Have you drunk alcohol in the last few hours?" . . with patients with limited strength, endurance, ralance, or range of motion .Jthough hydrotherapy is frequently used for treat:g limitations of strength, endurance,balance,or iOM, extremelimitationsin any of theseareascanbe '. saiety hazard for fuil body immersion hydrother'.py. Thetefore, for full body immersion hydro-rerapy treatment,a patient must have the abiliry to raintain *re headabovewater or, if unableto do so, rust be well and safelysecuredsoasto keepthe head
. . . with patients who have urinary incontinence A patientwith urinary incontinencemay be catheterized to allow full body immersion hydrotherapy; however,this is generallynot recommendedbecause immersion may increase the risk of urinary tract infectionin a catheterizedpatient. . . . with patients who have a fear of water Patientswith a fear of water will generallyrefuseto participate in immersion hydrotherapy. Ior such patients, altemative treabarentssuch as immersing only the area requiring treatment,using nonimmersion hydrotherapy,or using an intervention,such as dry land exercise,which doesnot involve the use of u/ater,shouldbe considered.
282
? . Hylltotherqry
HYDROTHERAPY-cont'd F0RFULLB0DYIMMERSI0N PRECAUTI0NS . . . with patients who have respiratory problems Although water-basedexercisecan provide respiratory and generalconditioningfor patientswith exercise-inducedastlma or other breathing problems,
sincewater immetsion increasesthe work of breathing, one should carefullymonitor patientswith respiratory problems for signs of respiratory distress throuehoutthe water immeffion treatmen[.
CONTRAINDICATIONS
in HotorVeryWarm lmmersion for Fu[.Body WaterTl . Pregnancy
Fullbody immersionin hot or verywarm water is contraindicated. . . . . . with pregnant pati€nts
o Multiple sclerosis o Poorthermalregulation . . . with patients who have poor thermal regulation Thermal regulation in responseto body heating is generallyaccomplishedby a combinationof conduction, convection,radiation,and evaporation.If a smal areaof the body is immersedin hot water,the pati with impaired thermal regulationmay still be ableo
Becausematernalhyperthermiahas beenfound to be teratogenicand is associatedwith a vadety of central newous systemabnormalitiesin the child, in order to minimize the possibiliry of matemal hyperthermia, dissinate heat bv conduction to areasin direct fuIl body immersionin a hot pool should be avoided with the heated area and by direct radiation of from the skin; however, the dissipationof heat during pregnancy,particularly during the first trimester, to the convection by blood circulating through the area when the effectsof heat are most hazardous fetus.99}ull body immersion in normal-temperature from other areasthat have not been heated and the pool wateris recommendedduringpregnanrybecause, production of sweat may be impaired.Becauseall as explainedabove,this can be an ideal environment thesemechanismsare impaired when large areas the body are heated,as occurswith fu11body for exerciseby the pregnantwoman. sion in hot or warm water, a patient with poor
ASK THE PATIENT: . Are you pregnant? o Do you think you might be pregnant? . . . with patients who have multiple sclerosis Patientswith multiple sclerosisshould not be placed in a hot orwarm pool becausetemperaturesabove31' C (88'F)may causeincreasedfatigueandweaknessin thesepatients.
mal reguiation may be at risk for thermal shock largeareasof the body areimmersedin hot water ASSESS: o Checkfor any history of thermalshockor any signsof poor thermal regulation.Because reguiationis frequendyimpairedin the elderlyard in infants,warm or hot water hydrot"herapyshould be limited to smallareasin theseindividuals.
Two . THE PHYSICAL ACENTS
283
TRECAUTIONS Hydrotherapy frr Nonimmersion . Maceration o
h,4rrr he inefFertiwe
- se nonimmersionhydrotherapywith :aution... when there is maceration around a wound ,.:ution should be taken to minimize the wettins of -.-actskinsunoundingawoundduecotheriskof cauiing : aggravatingmaceration.The intact skin shouldalsobe .:rdy and thoroughly dried after any type of hydrother,:v in orderto minimize the risk of maceratingthis tissue. becauseit may be ineffective ::cause nonimmersionhydrotherapy does not pro--Cebuoyancy or hydrostaticpressure,it is effective
iDVERSE EFFECTS OFHYDROTHERAPY
for only a limited number of problems that can be addressedby immersionhydrotherapy.Thus it canbe usedfor cleansingbut should not be usedwhen the cardiovascular, respiratory musculoskeletal,or renal effects of immersion are desired. Nonimmersion hydrotherapy also produces litde heat transfer becausethe water is in contactwi*r the tissuefor too brief a period.Thereforewhen consideringthe useof nonimmersionhydrotherapy,one must weigh these disadvantagesagainst the advantagesof reduced infection risk, increased ease of application, and reducedtreatmenttimes.
Burns, Fainting, andBleeding
Treatmentby immersionin a warm or hot whirlpool has the risks associatedwith other forms of superficiai thermotherapy,including buming, fainting, and bleeding.To minimize the possibility of any of these adverseeffects,the temperatureof the water usedfor hydrotherapyshould be kept within the appropdate range and should always be checkedwith a thermometer before the water touches the patient. Additionally, the therapistmay checkthe water tem)rowning perature by placing a gloved hand into the water. -he most severepotential adverseeffect of hydroBecausecertainpopulations,includingthe elderly,the rerapy is death by drowning, and it is imperative very youngj and those with impaired sensationor --ratadequateprecautionsbe taken to minimize this other neurologicaldeficits,are at an increasedrisk of .sk.The AmericanRed Crosshasidentifiedthe three suffering bums, the use of hot water should be r:rostcommon causesof drowning to be failureto recavoidedwhen treatingthesepatients.101 :gnize hazardousconditions and practices,inability The risk of fainting due to hypotensionis greatest :c get out of dangeroussituations,and lack of knowlwhen large areasof the patient'sbody are immersed .dge of the safestways to aid a drowning person.10o in warm or hot water. This risk may be further -;pecificrecommendationsfor safety precautionsto increasedin patientstaking antihypertensivemedicare taken to minimize the risk of drowning are pro' tions. Thereforein order to minimize the oossibiliw .-idedbelow in the sectionon safetyissuesregarding of faindng.only the partsof the body requiringtreairydrotherapy. ment in warm water should be immersed, and all Drowning Burns Fainting Bleeding Hyponatremia lofection Aggravation ofedema
284
I . Hytbothetupy
patientstaking antihypertensivemedicationsshould be closely monitored. Also, all patients should be well-supported during warm water immersion in orderto prevenrfallingshouldthe patienrfainr.
Sucha riskcanbe minimizedby usingnonimmersion hydrotherapytechliguesor, when usingimmersion techniques,stricdy adhedng to appropriatecleaning protocolsand usingantimicrobialsin the water
Hyponakemia
Aggravation ofEdema
lmmersion hydrotherapy has been associatedwith hyponatremiain patientswith extensivebum wounds.71 Hyponatremiaoccursbecausethesepatientscanlosesalt ftom *re open wound areasinto dre whirlpool water when the saiinity of the water is lower than drat of the tissuefluids.Thereforeto minimize the possibiliqyof this adverseconsequence of hydrodrerapy,salt should be addedto the whirlpool water when beating patjenrs with extensivebums or otherextensivewounds.72
Immersion in hot or warm water has been shown to increaseedemal02in the hands of patientswith upper extremity disorders,and this effect becomes mote pronouncedas the temperatureof the water increaies.95 Thereforein orderio avoidaggravationof edema,only cool water should be usedand dependency of the extremity in the water should be minimizedwhen signsoI acuteinflammarion arepresent.
lnfection A number of reports have documentedthe associa48 tion of hydrotherapywith infectionsin patients.46
APPLICATION TECHNIOUES This sectionprovidesguidelinesfor the sequenceof proceduresrequiredfor the safeand effectiveapplication of hvdrotheraow
1. Evaluatethe patientandset the goalsof treatment. above,can promote progresstoward the goalso[ 2. DetermineiI hydrorherapy is themostappropriate treatment. trealment. 3. Determine *rat hydrotherapy is not contraindiHydrotherapymay be an appropdatetreatment catedfor this patientor this condition. when progress toward the goals of treatment The treatmentareashould be inspectedfor the can be achievedby the use of superficialheat or presenceof any open wounds, rash,or o*rer sigrs cold, wound cleansingand debddement,or exerof infection, and sensation in the area should cisein a water environment,or where the goaisof be assessed.The patient's chart should also be treatment include controlling pain or edema. checked for any record of previous adverse Hydrotherapyis a particularlyappropriatemeans responsesto hydrotherapy/and the patient should of applying superficialheat or cold when the area be askedthe appropdatequestionsregardingconto be treatedis a distal extremity with varied contraindications.It is also recommendedthat heart touring and when dependencyof the limb will not rate and blood pressurebe measuredand recorded aggravate the patient's slrnptoms. Hydrotherapy if a largeareaof the body is going to be immersed. is the ideai intervention for wound cleansingand 4. Select the appropriate form of hydrotherapy debridement when therei' a moderateamountof accordingto the condition to be treated and the debris or necrotic tissue in a wound. When a desiredtreatmenteftects. wound is clean, hydrotherapy is not indicated; Selectfrom the following list when there is a large amount of necrotic tissue, Whirlpool , I more aggressivetreatment,as can be provided by Hubbardtank loreach | (SeeappJications surgicaldebridement,may be required.Exercisein Contrastbath hydrotherapy agent on I water is indicatedfor patientswith load-sensitive Nonimmersion the following pages.) I irrio:rian dewire I conditions or where *re benefits of resistance I or hydrostatic pressure of water, as described Pool I
Tlr,o c THE PHYSICAL AGENTS
The form of hydrotherapy selectedshould be one that producesthe desiredtreatmenteffects,is appropriatefor the size of the areato be treated, allowsfor adequatesafetyand control of infection, andis costeffective.The advantages and disadvantagesofthe differentforms ofhydrotherapy,based on treatrnentgoals,are provided below, together with the directionsfor their application.Detailed information on safetyand infe;;ion control is provided in the section on safety issuestoward the end of this chapter. Becausemost clinical settingshave only a limited selectionof forms of hydrotherapy,it is recommendedthat the availableform be usedif it is effectiveand safe.Ior example,if no nonimmersion devicesare availablefor treatinga small open wound on a patient'sankle, a whirlpool may be usedaslong asappropriateinfectioncontrolmeasures are taken; however, treatrnentof this condi tion shouldnot be provided in an exercisepool or Jacuzzr,where the same water will be used by other patients.In contrast,if hydrotherapyis being considered for cardiovascularconditionins but onJy nonimmersionhydrotherapydevicei are available,hydrotherapy should not be performed
28s
becauseit will be ineffective.In this case,a landbasedexerciseprogramshouldbe considered. 5. Explaiato the patientthe procedure,the reasonfor applying hydrotherapy, and the sensationsthe patientcanexpectto feel. During the application of hydrotherapy the patient may feel a sensationof warmth or cold, dependingon the temperatureof the water used. The patient will also feel gentle pressureif the water is beingagitated.The patientshouldnot feel excessively hot or cold.or excessive pressure. nor should the patient feel faint during the application of hydrotherapy.In general,hydrotherapyis not a painful procedureunlessit is being used for the treatmentof burnsor othersensatewounds in conjunction with debridement.The pain associated with this procedurecan usually be controlled to some extent by the administration of high-dose analgesics beforethe hydrotherapytreatment. 6. Apply the appropriateform of hydrotherapy. 7. When hydrotherapy is completed,assessthe outcome(s)of the treatment. Remeasureand assess progressrelative to the initial patient evaluation and the goalsof treatment. 8. Documentthe treatment.
Whirlpool A whirlpool is composedof a tank that canhold water and a turbine that provides agitation and aeration ir order to producemovement of the water in the tank. The tank is usually made of stainlesssteel, aithoughfiberglassand plastictanksare alsoavailable. Whirlpoolsareavailabiein a numberof differentshapes and sizesin order Lo allow for tredrmentof different body parts Qrgs.9-14 and 9-15).Exftemity tanks are suitablefor immersionof a distalextremiw.suchas a handor a fooc.whereaslow-boyandhigh-bbyranksare intendedfor immersion of largerpartsof the extremities andmay be usedfot immersionup to tlte waist. A whirlpool turbine is composedof a motor bracketed secureiyto the side of the whirlpool and pipes for air and water circulationsuspendedin the water (Iig. 9-1Q.The height and directionofthe turbine can Figure9-14. Extremity whirlpool. (Courtesy lerno Il1e, be adjustedto project the water pressuretoward ot Wilrningtorl OH.)
286
/.
Hydrotherupy,
Figure9-15.Low-boy whirlpool. (CourtesyWhitehall Manufacturing, Cigzof Industry C,r.7 away from the involved area.The turbine may be directedtoward the involved areain order to achieve maximum stimulation,as may be desiredto control pain or to removetightly adheredwound debris.The turbine should be directed away from the involved areaif the areais hypersensitiveor if granulationtissue is presentbecausethe high direct pressureof water from the turbine can adverselyaffectsuchconditions.Most turbinesalsoallow the clinicianto open
g-16.Whirlpoolturbine. Figure or close*re aerationvalve in order to further modifo the pressureof the water flow Whirlpools are generallyusedfor the treatmentof open wounds, or for exerciseor pain control, in lirnited areasof the body, suchasthe leg and foot or and hand.
Equipment Required o Hot and cold water mixing valves o Thermometerfor checkingthe temperatureof the water in the tank . A turbine to agitateandaeratethe water . Seator stretcherfor the patientto sit either in or out of chewarer.dependingon thearea
beingtreatedand the configurationof the whirlpool Craviry drain Heated,well-ventilatedspace Towelsand blankets
PBOCEDURE 1. Iill the tank with water Selectthe appropriate temperaturerangeaccordingto the condition and treatmentobjectives(lable 9-5).
A cold whirlpool, at 0" to 26" C (32" to 79" F\ should be usedfor the treaffnentof acuteinflammatory conditions of the distal extremities.Low temperaturescan be achievedby addingice to the
287
Tqo . THE PHYSICAL ACENTS
shown to increasethe Fmperature of subcutaneous tissueto within the rangerequired to produce these effects.lO3The higher end of this temperaturerangeis recommendedfor the treatment of chronic conditions,such as osteoarthritis or rheumatoid arthritis in the nonacute phases, when small areas are being treated, while the lower end of this range is recommendedwhen largeareasof the body areto be immersed. The whirlpool temperatureshould not exceed 'C highertempera43 (110'I) at any time because
whirlpool water; however,very low temperatures should not be used on large areas due to the increasedrisk of tissuedamage. A tepid whirlpool, at 2e 6 B "C (79"to 92 "l), shouldbe usedif the water is beingusedsolelyasa becausewarmertemperatures mediumfor exercise, arelikely to producefatigueandcoldertemperatures can inhibit muscle contraction. A tepid whirlpool may a.lsobe usedwhen an inflammatory condition arenot tolerated. is oresentif lower temDeratures A neukal warmlh whrrlDool. at 33" to 35.5 "C (92"to 96'F), should be used for the treatmentof openwounds and in patientswith circulatory,sensory, or cardiac disorders.Neutrai warmth may
S V
n ''..
-"-.rrr
hr rmq
The tank should be filled with water immediatelv beforeit is usedin orderto preventthe water
9-S Ctinical Applications and Sensationsof Whirlpool Treatment at Different Temperature Ranges Temperatnre range CC/F)
Clinical applications
Sensation
0 to 26/32to 79
Cold
Acute inflammation
26to 33/79to 92
Tepid
Medium for exercise Acute inflammationif colder temperaturenot tolerated
33to 35.5/92 to 96
Neutral warmth
Openwounds Medically compromisedpatients with circulatory,sensoryor cardiacdisorders Decteasetone
35.5to 37/96n 98
Mild warmth
Increasemobiliqr in bum patients
37to 40/99to 104
Hot
Control pain
40to 43/104to II0
Veryhot
Increasesoft tissueextensibility Chronic conditions Limited body areaonly
>43/>110 alsobe usedto control tone in patientswith neurologicallybasedhypeftonicity. 'C Mild warmth, at 35.5'to 37 (96'to 98 "I), may be usedfor the treatmentof bums onceepithelialization has begun. Such treatment promotes mobility and relaxationand minimizes energyloss by coolingor shivering.T2 A hot whirlpool,at37' to 40'C (99'to 104'I), or 'C 'F), a very hot whirlpool, at 40'to 43 (104'to 110 is recommendedfor the control of pain and/or to increasesoft tissue extensibility becausethis temperaturerange of whirlpool water has been
Shouldnot be used
temperaturefrom changingexcessivelybet\,veen filling and patientimmersion.If an antimicrobialis being used,it should be addedto the water as the whirlpool is beingfilled. 2. Allow the patientto undressthe areato be treated, andprovidea gownorhalterand pantsasnecessary formodesty.Do not allow any clothingto enterthe water becauseit may be suckedinto the turbine. When treating an open wound, the clinician must wear gloves, a waterproof gown, goggles, and a mask asuniversalprecautionsto protect the patient and the clinician from cross-infectionby Cantinued
288
? . Hydrothetayy
microorganismsthat may be carriedin the water or in airbornewater droplets. 3. Remove wound dressingsif aty are present and if they areeasyto removewithout causingpain or damaging *re tissue.Becauseadhereddressingsmay be easierto removeafter brief soakingin the water, this may be done as long as the dresshgsare removed before*re agitatorturbine is tumed on to avoid doggingthe turbine.Inspectthe skin andtestit for thermal sensitivity.Vital slgnsshouldbe checkedandrecorded beforeimmersingany areaof a patientwith a current or recentcardiovascularabnormaliwin a whirlnool. 4. Posirionthe patientcomforubly,wirh rhe aifected areaimmersedin the water.Try to avoidpressureof the limb on the edge of the whirlpool in order to avoid impairing circulation or nerve function or causingdiscomfort.Dry padding,such as a folded towel, may be placed on the rim of the tank to distribute pressure(Iig. 9-17). Do not allow the patient'sfinge$ or toesto beneartheturbineejector 5. Adjust the direction and aeration of the turbine. The entireturbine can be moved from sideto side and up and down to adjust its direction.The butFigure 9-17.Patient'slower extremiqrin whirlpool.Note terfly valve at the top of the shaft of the turbine towel paddingon edgeof tanl to dispersepressure. adjuststhe aerationof the water (seelig. 9-1Q. The hole at the lower end of the pipe through which air is forcedshould always be immersedat 10. When the treatment is completed, remove the ieast 2 inches below the surfaceof the water in limb from the wate5 dry the intact skin thororderto avoid overheatingof the turbine. oughly, and inspect the treated area. I(eep the 6. Tum on the turbine. body covered or wrapped after treatment to 7. Staywith the patientthroughoutthe hydrotherapy avoid chilling the patient. treatment and monitor the patient's vital signs 11. If the whirlpool is beingusedfor the treatmentof before,during,andaftertreatmentasnecessaryIt is an open wound, a clean,pressurizedrinseis recgenerallyrecommendedthat patientsnot be left ommendedafterthe whirlpool in orderto remove t;', h a etc,; a ^ ^." alone during wann or hot hydrotherapy treatrnents "Ff " " "1,, due to the risk of faintingor other heat-relateddis12. Reapply wound dressingsif open wounds are tress.Treatmentshouldbe discontinuedif thereare present. any abnormal or unsafe changesin vital signs. 13. Drain, rinse,and cleanthe whiripool accordingto 8. The patientmay exercisethe affectedpart during the the directionsgivenin the sectionon safeqyissues treatrnent.Movement is recommendedwhen treatregardinghydrotherapy. ment is for joint stiffnessor impairedROM or when edema without acute in-fiammation is present' ADVANTAGES o Can be used for heat transfer, for cleansingand 9. Whirlpools are generallyappliedfor 10 to 30 minutes, although shorter periods may be sufficient debridingopenwound,.or for exercise. for softeningwound eschar,while longer periods . Patientcanbe positionedsecurelyand comfortablyo Weakermusclescan move more freely d-ranon dry will increasethe amount of heat transferredto the patrent. 1and.
TgO I THE PIIYSICAL ACENTS
. ,illows movementwhileheatis beingapplied,unlike :drer conductivethermalagentssuchashot Packs. : SADVANTAGES . iize of tank limits the amount of exerciseand the ;ize of the areathat canbe treated.
. o . . o
289
Large quantity of water used. fusk of infection. Costs associatedwith cleaning. Costs associatedwith heating water. Time expended assisting the patient to dress and undress.
-rbbard Tank - Hubbard tank, named after the engineer who :,'.'entedit, is a large whirlpool intended for full ::dy immersion. These tanks vary somewhat in : :e but aregenerallyabout 8 feet long by 6 feet wide =:.d 4 feet deep, and they hold approimately 425 : J o n s o f w a t e r ( F i g .9 - 1 8 ) .l h e t a n k i s e g u i p p e d .-rh turbines. a stretcher,and a hoist to raise and :.ver the stretcher This large tank is particularly ,-:itablefor debridementof burnscoveringlargeareas :: the body and for dre treatmentof o*rer painful con::ions that affect large areasof the body Hubbard :nks canalsobe usedfor ROM exercisesfor multiple :-easor for ambulationif a walking trough is added; --rwever,theseproceduresare more often performed --a pool, exceptin caseswhere pool useis specifically ::ntraindicateddueto the risk of infection The popularity of the Hubbard tank haswaned in :icent years becauseof the considerableexpense :;sociated with providing such a large volume of .,..armwater and becauseof the time involved in ,-eaning this large poo1. Hubbard tanks must be :-eanedbewveeneach use in the same maruler as ,'.'hirlpoolsof other sizes,as describedin the section :n safetyissuesregardinghydrotherapy.
iquipment Required . Hot and cold water mixing valves . Thermometer for checking the temperature of the water in the tank . A turbine to agitate and aerate the water . Seat or stretcher for the patient to sit either in or out of the water, depending on dle area
Figure9-18.Hubbardtank. (CourtesyWhitehallManufacturing,City of lndustry CA.)
beingtreatedand the configurationof the whirlpool o Graviqydrain o Heated,well-ventilatedspace o Towels and blankets Cantiltued
290
9.
Hydrotheraw
PROCEDURE Treatment in a Hubbard tanl is applied in a similar mannel to tleatment in a whirlpool of any other size, as descdbed above, except that t}re water temperatureis generally kept in the slighdy lower rangeof 36" to 39' C (97' to 100"Q becausepatients cannotdissipatethe increaoein tissuetemperaLure as effectively when heat is applied to such a large area.Specificinstructionsfor placingpatientsin a Hubbard tank and removing them from the tank are asfollows: I Placerhe narienror rhe stretchernext to the tank, with the patient's weight evenly distributed. 2. Attach the hoist to the ringson the four cornersof the stretcher. 3 . Removedressingsif presentand easyto remove without causingpain or damagingthe tissue.If the dressingsare adhered,they can be removed after brief soaking in the water before the turbinesaretumed on. 4 . Raisethe hoist to lift the patient. Gently swing the patient on t}Ie stretcherover the water and then slowly lower the patient to just above the water 1eve1. 5 . Attach the head end of the stretcherto the support bracket. 6. Slowly lower the hoist until the foot end of the stretchertouchesthe bottom of the tank. 7 . Removethe hoist. 8. Adjustrhe forceanddireccionof t]e agitators. 9. Stay with the patient throughout the treatment to monitor the physioiogical responsesto the treaftnent and to be sure that the patient does not slide down the stretcher into the water (Fig.9-19). L0.Patientsgenerally stay in a Hubbard tank for about 20 minutes or until the procedure,suchas debridement,is completed. 1 , 1 When . the treatment is completed,reattach the hoist to the stretcher and remove the patient from the water 12.Dry the patientquickly and thoroughly.
Figule9-19.PatientintheHubbardtank. (Courtesy Ille, Wilmington, OH.)
13. Wrap or cover the patient immediately to chilling, leaving exposed any open wound rcnririno
rirpcqino
ADVANTAGES Can treat large areas or multiple areas of body.
Can be used For heat transfer,for and debriding open wounds, or forwater exerciseDISADVANTAGES
Cosdy to provide treatment. Cosdy equipmentand spacerequirements. Useslargeamount of warm water Time-consumingto fill, empty, and cleantanl< to placepatientin the tank. Requiresextra cautionwith regardto possible temic effectsof overheatingwith a largebody exposed.
Two C THE PIIYSICAL AGENTS
:cnhastBath -cntrast baths are appliedby alternatelyimmersing = area,generally a distal extremity, first in warm :: hot water and then in cool or cold water --rhough there are no published researchdata on =e effects of contrast baths, since this form of --.drotherapy is thought to ffain the vasculat i.'stem by inducing alternating vasodilation and .:soconsffictionrit is frequendyusedclinicallywhen
291
a goal of treatmentis to decreaseedema.The varying sensory stimulus is also thought to promote pain relief and desensitization.Thus treatmentwith a contast ba*r may be consideredwhen patients present with chronic edema; subacute trauma; inflammatory conditions such as sprains, strains, or tendonitis; or hyperalgesiaor hypersensitiviry due to reflex sympathetic dystrophy or other conditions.
:quipment Required ' Two water containers . Thermometer . Towels :ROCEDUBE : Iill two adjacentcontainerswith water. The containeff may be whirlpools, buckets,or tubs. Ii11 one containerwi*t warm or hot watet at 38' to 44 "C (80" to 104 "I), and the other with cold or cnnl rrrerpr et 10" rn
lR
'C
/55" rn 67 "F\ \I/h.^
using contrast baths for the control of pain or edema,it is recommendedthat the temperature differencebetween the warm and cold water be large; when using contrast baths for desensitization, it is recommended that the temperature difference between the wvo baths initially be small and then graduallyincreasedfor later treatments as the patient's sensitivity decreases. i. First,immerse the areato be treatedin the warm water for 3 to 4 minutes;then immersethe areain the cold water for 1 minute (Fig.9-20). :. Repeat*ris sequencefive or six times to provide a total treatment time of 25 to 30 minutes and end with immersionin the warm water :. When the treatment is completed, dry the area quickly and thoroughly. ADVANTAGES . May promote a more vigorous circulatory effect than heat or cold alone.
Figureg-20. Contrast bath. o Provides good contact with contoured distal extremities compared with other thermal agents. o May help to provide pain control without aggravating edema. o Allows movement in water for increased circulatory etfects. DISADVANTAGES . Limb is in a dependent position, which may aggravate edema. o Some patients do not tolerate cold immersion. o Lack of research evidence to support the effect of contrast baths on circulation.
292
q . Hytbothenfy
Nonimmersion Inigation Devices A variety of devices,including hand-held showers, syringes, and purpose-designedpulsatile inigation units, can apply hydrotherapy without immersion of the area to l:e teated.49,70,104 These devices apply water by sprayng it on the treatment area. Nonimmersion inigation devicesare parricularly wellsuited for the applicationof hydrotherapy to open wounds becauset-heyinvolve lessrisk of infection than whirlpoolsandbecausesome,althoughnot all,ofthese devicescan spray fluid onto an openwound within the appropriate,safe,andeffectivepressure lirnis of4 to 15 psi (seeTable9-4).However,becausewithout immersion water doesnot producebuoyancyor hydrostatic pressure,andthereforedoesnot reduceweight bearing or edemaor increasecirculation,the useof nonimmersion hydrotherapyis limited to situationswhere these arenotrequiredto achievethe goalsof treatrnent.
Becauseelecffic pulsatile irrigation devices deliverfluid at a controlledpressureand provide tion to remove contaminatedfluid, they are i suited to the treatment of open wounds.104 devices pumn an intermittent sffeam of fluid from
irrigation bagor bottle. The fluid is deliveredvia ing to a handpiecethat directsthe flow of fluid the wound. The usedand contaminatedirrigation fluid is removed from the treatment area by suction. handpiecehasa triggerto controlthe flow offluid canbe fitted with a vadety oftips to vary the fluid persion.With most ofthese devices,the tubing, piece,and tips are all intended to be discarded eachffeatmentin orderto minimize the risk of infection.Electricpulsatileirrigationdevicesare ablein both portableand clinicalmodels.This type treatmentis known aspulsedlavage.
Equipment Required . Nonimmersionirigation device o Irrigation fluid-usually bagsof sterilesaline o Towels PROCEDURE When applying nonimmersion irrigation, the following guidelines should be used. The clinician should always wear gloves, a waterproof gowr5 and eye, nose, and mouth protection during treatment becausethis qypeof treatment can spray contaminated fluid toward the clinician. In order to maximize comfort and optimize healing,clean,warm fluid should always be used for irigation. Clear5 warm water can be used for shower treatments, while sterilenormal salineis recommendedwhen irrigation is provided with other devices.It is recommendedthat treatmentbe appliedoncea day for 5 to 15 minutes or long enoughto hydrate hard escharor loosen debris.The appropriatefrequencyand duration of featment will dependprimarily on the size of the wound and the amount of necrotic tissue, exudate,or other debris present.In addition, when
using an electric pulsatile irrigation device, the lowing
treatment guidelines should be foll
Iunher specific directions for the use of brandsand models of these devicesare provided the manufacturers. 1. Although patientsmay be treated at the with this q,pe of device, in order to the risk of transmitting hfection, all treaunentsshouldbe performedin an enclosed seoarated from other patients. Pulsatile
alsogenerallyperformedusingsteriletechnique.
2. Sterilenormal salinein 1000-mlbagsis genera used as the irrigation fluid; in casesof infection, antimicrobials may be added this fluid. lt is recommendedthat the saline warmed beforeit is usedby placingit in a basin hot tap water. Hang the bag(s)of fluid on device.
Two . THE PIIYSICAL ACENTS
293
Attach the tubing, suctioncanister,handpiece,and irrigationtip to the device. Tlrn
nn thp nrmn
Selectthe treatment pressure.Most devicescan spray fluid at pressuresof between 0 and 60 psi and have a half-switch to limit the maximum of 4 to 8 psi are genpressureto 30 psi. Pressures erally sufficient for cleansing or debdding most wounds; however, the pressure can be adjustedaccordingto the nature of *re wound, rhe tip used,and the sensitiviqyof the patient. It is recommendedthat the lowest pressure that effectively loosens and removes debris be used and that the pressurebe decreasedif the patient complainsof pain,if bleedingoccurs,or if the tip is neara major or exposedvessel.The pressuremay need to be increasedin the presenceof tough escharor when thereis a iargeamount of necrotic dssue. Apply the treatment until adequate hydration andlor debridementis achieved(Iig. 9-21). This form of treatmentniay be followed by sharp debridement if necessary.to remove adhered necrotlctrssue. wound dressing. Reapplythe appropriate Pulsatileirrigationtreatmentsaregenerallyapplied oncea day but may be appliedmore ftequently to wounds that havegreaterthan 507onecrotic,nonviabletissuewith purulent drainageor a foul odor and, less frequendy,if the wound does not have purulent drainage or odor Treatrnent wi*r this type of device should result in a decreasein necrotic tissue and/or an increasein granulation within 1 week of initiating treatment.If this does not occur, the treatment approach should be reevaluated.
: DVANTAGES . Conffol of fluid pressureto stay within a safe and effective range for application to open wounds. r Reducedinfectionrisk becausethe fluid andwound debrisare removedftom the wound by gravity and suction. . Jetof fluid canbe directedto staywithin the wound bed.
Figure9-21. Using a nonimmersion hydrotherapy device to cleanse and debride a wound. (Courtesy Zimmer, Warsaw, IN.)
. Lesstime-consumingto apply than a whirlpool. . Savesthe expenseof filling, draining,and cleaninga whirlpool. . Doesnot requirethe patientto be transferredto the whirlpool area. o Useslessfluid *ran a whirlpool. o Normal salineratherthanwater appliedto the open wound reducesthe risk of hyponatremia. o Can be usedwherewhirlpooltreatmentis not recommended,suchaswith an unresponsiveor incontinent patient. . Iaster granulation of the wound bed reported in one study comparing pulsatile irrigation with whirlpool treatmentof wounds.105 DISADVANTAGES o Treatment with pulsatile irrigation device incurs the additionalexpenseof using new tubing, handpiece,and tip for each application. These components cost about $50 per treatment. . Does not provide the therapeuticbenefitsassociatedwith the buoyancyandhydrostaticpressureof immersionhydro*rerapy.
294
9 . Hyrltotlrcta1ry
Figve 9-22. Purpose-designed exercisepool with treadmill. (Courtest Iemo Ille, Wilmingto4 OH.)
Exercise Pool
may be ableto usea public or privateswimming pooiEithertype ofpool may be usedforindividual or
To optimize the cardiovascular, respiratory renal,or psychologicalbenefitsof hydrotherapy,the use of an exercisepool, which allows full body immersion and exercise,is recommendedunlessimmersion in water that will be used by other individuals is contraindicated.An exercisepool is aiso generallythe optimal meansfor applyinghydrotherapyto achievethe musculoskeletalbenefits associatedwith water immersion, aithough a whirlpool may be used when only the extremitiesrequireimmersion Both swimming pools and purpose-designed hydrotherapypoolscanbe usedfor the applicationof hydrotherapy.Most swimming pools are at least 100 feetlong and25 feetwide andhavea maximum depth of 8 feet, with a slopingbottom to producea gradual descent.Most purpose-designed hydrotherapypools are smallerand position the patient in the middle or at the edgeof the pool to allow performanceof specific types of exercises.Some hydrotherapy pools are equipped with an underwater treadmill,l07an adjustable rate-of-water flow, and/or adjustable depthswith movablefloorsin orderto providegraded exerciseactivityl0T(Frg.9-22).ArI exercisepool may be availablefor usein the clinicalsettingor the patient
treaLment.dependingon iLssize.with a therapist
ent,and/orfor independenthomeexerciseprograms,
Pooltemperature The cemperarure of thewaterin anexercise pool be kept at 26' to 36 "C (79"to 97 "I). The amount movement expected to be performed by the
shouidbe usedto determinethe optimal within this range. The warmer end of the range, 34'
36"C (93"to 97 "F),shouldbe usedwhen iow activities,such as light exerciseby elderly tionedpatientsor by patientswith afthritis,will be formed. This is becausewarmer temperaturesare comfortable and helo oatients who move less to sewe body heat while in the water The cooler end the range,2e to 28' C (79' to 82'F), is recommended recreational pools or where more intense exercise
be performedbecause the coolertemperaturedissi heat producedby the patien* and therefore them to perforrn more exercise,ot more vigorous cise, with less fatigue. The water temperature
'H not be allowedto be below 18.5"C (65 because iow temperaturescan impair *re muscles'ability contract.
TTyo . THE PHYSICAL AGENTS
: .;uipment Required . -\ppropdate space for the pool adequate srze, support,ventilation,andheating . Space to store auxiliary equipment, including ;hemicalsand mechanicalsystems . Spacefor patientsto showerand changeclothes . Watersupply : ROCEDURE The patient and the therapist should wear a bathing suit for pool exercise.The therapistmay wear other light clothing over the bathing suit if not planningto entet the water exceptin the case ofan emergency. - The therapistshould assistthe patientto enterthe pool ifnecessaryProvideramps,stairs,a ladder,or a lift to help patientsget into and out of the pool. : The patient may perform activities to improve strength,cardiovascularfimess, endurance,orfunctional activities,as determinedby the evaluation and plan of care. Activities may include upright exercise,walking in *re pool, swimming, or other forms of exercise.The patient may use flotation devices,a tether.or other obiectsto alter the resistanceor buoyanry effectsof the water.Water-based exerciseprogramscan be progressedby increasing *re number of repetitionsof an activity,increasing the speedof the activity,changingthe length of the lever arm, decreasingthe degreeof stabilization provided.or usinglargerfloarsto ilcreaseresistance.More detaileddescriptionsof water exercise programsarebeyondthe scopeof this text and can be found in booksdevotedto aquatictherapy. -t. The therapists should stay with the patient throughout the treatmentand monitor vital signs duringexerciseif the patienthasrisk factorsor any
295
Nonslip areaaroundpool Safeqyequipment Infection control equipment,including pump and filter, chemicals,and testingkit Towels Thermometer history indicatingthat this may be necessarylor example,heart rate and blood pressureshould be monitored in patientsrecoveringfrom myocardial infarction, and heart rate should be monitored in nrPonsnf
hrrrenrq
5. After completionof the water activities,the therapist shouldhelp the patientto get out of the pool if necessaryThe patient should dry the body and wrap up immediatelyto avoid chilling. ADVANTAGES Patientcanmovefreely.wirh Iessriskof falling. Decreasesweight bearing on joints. With immersion in water 60 inchesdeep,weight bearingon the lower extremities is reducedby 88to95%. Buoyancy may assist weak muscles to a1low increased performance of activeexercise. DISADVANTAGES Risk of falling when the patient gets into and out of the water becausewater around *re pool can make rh" fl^^'.1i-^o^,
fusk of infection from other individualswho have beenin the water Difficulty stabilizingor isolatingbody partsduring exercise. Risk of drowning. Iear amongsomepatientsof water rmmerslon.
locumentation locumentation of hydrotherapy should include the ::pe of hydrotherapy used, the patient's position :ndlor activities,the water temperature,the duration rf the treatment,and the outcome of or responseto -:re treatment. The fluid pressure and any water
additivesused should also be noted if aoolicable. Documentarion is rypicallywrjttenin rhe SOAPnote format. The following examples only summarize the modality component of treatment and are not intendedto representa comprehensiveplan of care.
9 . Hydtotherapy
295 Examples
oublic heal*r deoarbrent. Infection control
When applying a warm whirlpool to the right ankle to promote increasedmotion, document:
should also be consultedif a problem with control, such as frequent patient infectionsafter useof hydrotherap, arises.
9: ?Lok' n dnld2,4li&brA.a. datld4$iulhr ufth wal*in+. 0: 11/an.1l)9,36 "4, n an&12,, | 5 min, ?t pzalomzt fln0n &tv in+ innz.rtlio!1. .4; ?6OIL 9e inotzated,(^r!tu 10" t/, 5", ,nuzat2n duLaUorao+ APeLat^.ikzdunh+ g4if, 9: euthuzUP at alow (4llrwA\gabt^ainin* ond.tlv.rve,x
When applyingpulsatileirrigation to a sacralpressure ulcer,document: 9 : 9Lo-'ritnlzl.tu nmtz Aufui d4tz 04 hl&p, O: ?uld.ati2e itttigatim, | 000 zc waun ulinz, paeut'tz 25% o{ nan b aataal .pteutaz ubztv. 9t tz$. attz futry
When using pool exerciseto increasethe fitnessof a patient with exercise-inducedasthma and obesity, document: 9: Pt
^op*
arnlul4li.on, eonlir1112a.ur
Az Unil2i
AV
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andInfection Control for SafetyPrecautions Whirlpools These recommendationsapply for whirlpools of sizesand shapes,includingHubbardtanks. Safety 1. The tank should be properly grounded, and turbine must have a hospital-gradeplug. motor must be securelyfastenedto the outside the tank. Whirlpools should also be regularly for any breaks in wiring or becauseof the hieh risk of severeelectricali should any breachof electricalsafety occur rhi. t.,." ^F
"^";.-.^r
109
2. Do not run the turbine without water whirlpool becausethis can damage the motor. 3. The fteatmentroom shouldbe comfortably and well-ventilated but not drafty. Ventilation required in order to control the humidity of room and to remove aerosolized additives or
tious agentsfrom the air. A room temperature 25" to 30' C (77' to 8e \ wrth a relatrve of 50% is recommended.llo lnfectioncontrol Hydrotherapy tanks, having numerous crevices
SAFETY ISSUES REGABDING HYDROTHERAPY,being in frequent contact with warm water under pressure, provide an ideal INCLUDING INFECTION CONTROL ANDPOOL ground forinfectious organisms and are therefore SAFETY In order to optimize safetyand infection control during hydrotherapy, it is recommendedthat the following generalguidelinesbe adheredto. A facility hydrotherapy safety and infection control program the specificneedsof the facility should that addresses be developedin conjunctionwith an infectioncontrol specialistor in conjunctionwith the facility infection control committee. This program should take into account the specific safetrThazardsassociatedwith this type of treatment and the types of microorganisms most commonly encounteredat that time and place. The program must also be in compliance with the guidelines,rules,and regulationsof the 1oca1
ticularly likely purveyon of infection. The pri goal of infection control is to reducethe number microorsanisms in the environment and thus reduce the potential for infection.ll0 For infection control there must be appropdate
protocols and culturing of all relevant and protective garments should be worn by individualsprovidinghydrotherapycare.Many ties also add antimicrobialsto the water beins for treatment in an att€mpt to reduce with microorganisms. AII of these precautions
intendedto reducethe risk of patientor clinician tamination from water-borne bacteria, mist, fomites,or blood-bornepathogens.
TlNo . THE PITYSICAL AGENTS
1 . Cenerally,it is recommendedthat oniy clean water, without any antimicrobial,be usedin a whjrlpool when treat.ingany rype of open wound. As discussedpreviously, the use of antimicrobialsin the water when treatingopen wounds is controversial because althoueh -of these chemicalsoffer improved control intectionand cross-conramination, most have been found to be cytotoxic to healing tissue cellsevenwhen appliedat low concentrations. When infection control is a priority, antimicrobials should be used only at the lowest concentration stated by the manufacturerto be effectivefor antimicrobialaction.Soaos.detergents.or povidone-iodine shouldnoi be used for this applicationbecausetheir efficacyis reduced in the presenceof blood or tissue debris.112 Sodiumhypochlorite,in the form of householdbleach,can provide some control of in[ecLionduring hydrotherapy;however.its applicationis limited becauseit corrodesstainlesssteel tanks and releases chlorinevapors, which are idtating to many individuals. The chloramine form of chlorine has been recommendedfor use as an antimicrobial in whirlpool water becauseit does not coffode stainlesssteelor releasenoxious vaporsand is not inactivatedin the presenceof blood or tissuedebris. 2 . The whirlpool tank and turbines should be properly drained and cleaned after each use.Although there are slighdy varying cleaning proceduresat different facilities, all protocols are designedto optimize patient and cliniciansafety and minimize the risk of infection. In general the cleaningprocedure is as follows: a. The personcleaningthe whirlpool should wear rubberglovesand gogglesthroughout the cleaningprocedure. b. Drain the tank.Variousdrainageconfigurations or sumpsare availableto minimize the amount of water left at the bottom of the tznk. c. zunsethe tank with clean water direcdy from a hose. d. Scrubthe insideof the tank with a brushand detergentand *ren dnsethe tank again. e. Disinfectthe tank.A detergentmust be used before the application of the disinfectant
297
becausemost disinfectantsareinactivatedin tte presenceof blood or tissuedebris.112 At present there is no conclusiveevidenceto suDDortthe recommendationof one disinfeitint orr"t anotherl however, one should note *rat certain disinfectants are more effectiveagainstparticularmicroorganisms and that some bromine-baseddisinfectants cancauseallergicdermatitis.l13It is alsogeneralJyrecommended thatdisin[ecting agents be changedoccasionallyto reduce*re dsk of promoting the development of resistant strains.If the whirlpool was used only to treat areaswith intact skin, then lowlevel disinfectionof the whirlpool, usrrg7}Y" to 90% ethyl or isopropyl alcohol, 100 parts per million (ppm) sodium hypochlorite (the active ingredient of household bleach), a phenolicgermicidaldetergentsolution, or a quatemaryammonium germicidalsolution, is sufficient. However, if areaswhere the skin was not intact have been treated, intermediate-leveldisinfection, using 70o/" to 907" ethyl or isopropyl alcohol,a phenolic germicidal detergent solution, or an iodophor germicidaldetergentsolutiorl has been recommended.lll Chlorine-based productsshould not be usedto cleanstainlesssteeltanks because,with repeateduse, theseproductscorrodethe tank surface.To apply the disinfectant, fill the tank with hot water, add the appropriateamount of disinfecting ageng and expose all the inside surfaces of *re tank to dre solution for 10minutes. f. Cleanand disinfectthe turbine by runningit for 5 rninutes in a bucket with a detersent andthenfor 10minutesin a bucketwich-disinfectantsolution. Drain the tank. h. Rinsethe tank with cleanwater. t . Dry the tank thoroughly with clean towels. l . Wipe all tank stretchers,hoist cables,and seatswith disinfectantafter eachuse. 3. Culture samples should be obtained periodically from t}te tank, the turbine, the tank drains, and the water supply in accordance with facility and governmentalguidelines.47
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9 . Hydrotherayy
SafetyPrecautions andInfection Control for Exercise Pools Safety
board. a blanket. and scissors.A first-aid kit should alsobe available. Keepall chemicalsfor usein the pool in their original containers,off the floor, and in a locked cabiner Material SafetyData Sheetsfor all chemicalsmust be maintained and filed to be in compliance with Occupational Safery and Health Administration (OSHA)and EnvironmentalProtectionAgency (EPA) regulations.Avoid electricalshocksby keepingelectrical equipment,such as hair dryers, electrotherapy devices,and heaters,out of the wet environmento[ the pool and poolside.
Personnel fiaining Individualswho areresponsible for maintainingand cleaningan exercisepoolmustbe trainedin the useand hazards of the disinfectingand pesticidechemicals used.They shouldalsobe providedwith the necessary protectiveclothingfor handlingthesesubstances. Staff working with individualsin the pool should havelifesavingand rescuetraining and knowledgeof personal water safety techliques. At a minimum they shouid be certifiedto perform cardiopulrnonary resuscitation(CPR)and to provide advancedfirst aid. Infectioncontrol Ideally,a certifiedlifeguardshould be presentwhenBecausewater is not drained from an exercisepool everanyoneis in the pool. Staffshouldalsobe trained between uses,the pool water must be filtered and in emergency evacuation procedures and should treatedwi*r chemicaladditivesat all timesin orderto know the emergencyactionplan. prevent infection transmission.Coliform bacteri4 Ciardia lamblia,Pseudomonas aeruginosa, and various Satetyin andaroundflrepool types of staphylococcalbacteria,which can cause In order for the areaaroundan exercisepool to be intestinal,skir4 or earinfectionsin exposedindividusafe,and to minimize the risk of a patientslippingand als, are commonly found in water, and the risk of falling, the area surrounding the pool should have excessivebacterialgrowth is elevatedif the water is nonslip surfaces.Pool regulations,the water depth, warm. Airborne endotoxinsaround a pool may also and emergency procedures and phone numbers causerespiratoryproblemsin susceptibleindividuals. shouldall be clearlypostedin the pool area.Meansof Adequate infection control of a pool can be enteringthe pool should be appropriatefor patients' achievedwith continuousfilterine and chemicaldisambulatoryability andmay includestairs,ramps,ladinlectionof the poolwarerwith ch.lorine or bromineders,or lifts for nonambulatoryor impaired patients. The pH and chlorine or bromine levels of the pool Ior safetyin the pool, the depth of the water should water should be testedat the beginningof eachday be clearlymarked at intervalsaround the pool edge, and at least at two additional times during the dayand thereshouldbe hand grip barsail the way around The total alkalinity and calciumhardnessof the water r1.. .A-. ^F rh. ^^^1 shouldalsobe checkedwvicea month. ChemicaltestThe pool should be evacuatedduring power outing kits designedfor this applicationindicatethe safe ages and floods, and outdoor pools should not be ievelsfor thesetests.In order to minimize the risk of used during electricalstorms.Emergencyequipment high bacteriallevelsin a pool, it is also essentialthag should be kept near the pool at all times, and all such as detailedin the sectionon contraindicationsaboveequipmentshouldbe inspectedregularly.Emergency patients widr conditions tJrat may be a source of equipment should include a shepherd'scrook, a life infection not be allowed to use an exercisepool that ring, a rescuetube, resuscitationequipment,a spine would be reusedby themselvesor by others.
T\t'o . THE PIIYSICAL AGENTS
Case 4 fRis a 45-year-oldfemalewho hasbeendiagnosedwith osteoarthritisof both knees.Shecomplainsof bilateral kneepain that is worse on the right than on the left, and that worsens with standing or walking for mote than 5 rninutes.Sheusesa canein her left hand to control her kneepain and to assistwith balanceduring community and most householdambulation. She is able to walk approximately one-half block on a flat, level surface with her cane.Shedoesnot tolerateanti-inflammatory medications due to gastric complaints. The pain in her right knee startedabout 5 years ago, without any known aggravatingactivity, and has gradually worsened since tlrat time. The pain in her left knee startedabout 2 years ago,alsowi*rout any known aggravatingactivity. Shehas had no prior treatrnent for her knee pain. The obiective examis significant for obesity,posturaland gait deviations of bilateral genu valgum, bilateral foot pronatioq and weaknessand shortnessof the quadricepsand hamstring muscles.KneepassiveROM is -5" extensionto 95"flexion on *re right and 0" extension to 120" flexion on the left. FRusesa stepto gait for ascendingand descendingstairs. EVALUATIONOF THE CLINICAL FINDINGS This pati€nt has impairments of knee paiq abnormal lower extremiqy alignment, reducedlower extremiqz strength, reduced knee ROM, and excessivebody weight resultingin the functionallimitations of reduced standingand decreased ambulationtolerance. PREFERRED PRACTICEPATTERN Impaired Joint Mobility, Motor lunction, Muscle Performance,and Range of Motion Associatedwith ConnectiveTissueDysfunction,(4D) PLANOF CARE The goals of treatrnent indude decreasingknee pain and increasinglower exftmity str€ngdr and knee ROM to increasetlds patiendsstatding toleranceto 20 minutes and inseaseher walking toleranceto two blocks.The anticipated goalsofneatrnenrmayalsoindudedisconcinuing *re uie ofa cane,increasingcardiovascular, fitness,andlosingweight. ASSESSMENT REGARDINGTHE APPROPRIATENESS OF HYDROTHERAPY AS THE OPTIMAL TFEATMENT Although many forms of exercise could be used to increasethis patient's lower extremity strength and knee ROM, given her body weight and the reponed degeneration of her kneejoints, in order to avoid aggravationof her q,,mptoms,treatrnent with exerciseswith limited weight bearingon her iower extremiriesis proposed.This could be achievedby the useof a water environmenq although
299
other non-weight-bearing exercises,such as straight leg raises,or reducedw€ight-bearingexercises, such as stationary cyding, couldbe used.Water-based exercises are recommendedbecausethey have a number of advan, tages over non-weight-bearing,land-basedexercises. Theseadvantagesinclude allowing the patient to perform normal functional activities, such as walking without an assistivedevice,in order to tlain the muscles and develop the balarce skills required for nomal function, providing some pain conuol during the exercise, allowing fine grading of joint loading by varying the dep*r of the water, and allowing fine gradingof resistance by varyirg dre speed of patient movement. Should the parienthave lower exuerrutyedema,as is common jn inactiveobeseindividuals. the hydrostatic pressure providedby immersionmay alsoprovidetie additionalbenefitofedemareduction.Fromthe subjectiveandobjective evaluation reported above, it does not appear that hydrotherapy would be contraindicatedfor this patienq however, before initiating hydrotherapy, one should ascedain that the patient is not afraid of being in water and that she does not have any infections that may be spreadby water or any other medical conditionsthat would contraindicatethe useof this form of treatment. PROPOSEDTHEATMENTPLAN AND RATIONALE Pool exerciseis the only form of hydrotherapy that would addressaLlof the proposedgoalsoftreatment for this patient.Aithough soakingina warmwhirlpool may be comfortable and may temporarily decreasethis patient'spaiq and althoughlower extremiryactiveexercise in an exfiemity whirlpool may promote ROM to some degree,neither of these forms of hydrotherapy treatment is likely to provide sufficient resistanceto motion to increase the patient's lower extremity strengthand thus her functional standingand ambulation tolerance.For this patient's treatment the pool water should be kept slighdy warmer than generally 'C usedfor recreation,at 34"to 36 (93"to 95' I), in order to allow her to exercisecomfortablyat the slow paceto which shewill probablybe limited. A pool exerciseprogram may include forward and backward walking, eitier holding or not holding on to the hand rail, as necessaryfor balance,partial squats,kicking,and a variety of other closed-and open-chainlower extremity activities. This water-basedexerciseprogram is likely to be most effective if provided in coniunction with landbased exercises,active and passive stretching, joint mobilizatioq and a home exerciseproglam.
Case 2 ST is an B5-year-old femalewith stageIVpressureulcers in t-]reareas of botl-r femoral ereater trochanters and a
300
9 . Hydrotlrcralry
) Clinical Case Studies-cont'd stagell pr€ssureulcer over her sacrum.The ulcerin the areaofher right greatertrochanteris approximatelyI cm long and I cm wide and hasno undermining. The ulcer in the areaofher Ieft greatertrochanteris approximately9 cm long and 10 cm wide and hasapproximately1 cm of underminingalong the proximal border.Both of these wounds have yellow necrotictissueand a healy, thick exudate;no granulationtissueis visible.The ulcer over the sacrumis approximately5 cm by 10 cm and hasno necrotictissue.No tumels or sinustEcts areapparentin any of thesewounds.The patientis bedriddeq oriented to nameand place,and noncombative.Shehasa history of &vo strokes,one 3 years ago and the other 8 years ago, resuiting first in right and then in left hemipiegia, with hypertonicirythat is moderatelysevereandhasnot changedsignificandyin the last 2 years. She also has hypertensionthat is controlledbymedicatiooand generally keepsher blood pressureat orbelow 145/100. EVALUATIONOF THE CLINICAL FINDINGS This patient presentswith impairments of soft tissue int€grity and abnormal muscle tone and has reduced functionalmobility. Sheis also at dsk for the development of further pressureulcersand infection. PREFERREDPRACTIGEPATTERN ImpairedIntegumentaryIntegrity AssociatedWith Skin InvolvementExtendingInto lascia,Muscle,or Boneand Scarlormation"(7E) PLAN OF CAFE The goalsoftreatmentat this time includesofteningand removingthe necrotictissuethat is presentin the two wounds in the trochantericareasand removing debris from thesewounds in orderto facilitatewound closure, and to reduce the risk of infection and further tissue breakdown. Improving circuiationin the areasof the wounds may alsofaciLitatewound closure. ASSESSMENTREGARDINGTHE APPROPRIATENESSOF HYDROTHERAPYAS THE OPTIMAL TBEATMENT Hydrotherapy is indicatedfor this patient becausethis treatmentcansoftenanddebridenecrotictissue,cleanse wound debris, and, if provided by immersioa with warm wate! facilitateimprovedcirculation.Removalof necrotic tissue ftom a wound bed aod improving the local circulationcan acceleratewound healingand ciosure.In orderto optimize the treatmentoutcome,other forms of treatment, such as pressurerelief, electrical and stimuladoq exercise,appropriatewound dressings,
I
possibly other forms of debridementshould also be applied in conjunction with the hydrorherapy. The evaiuation of this patient doesnot indicatethat hydrotherapy would be contraindicated;however, the infection risk and safetyconcemslimit the qypesof hydrotherapy that would be appropdate. Also, hydrotherapy is indicated only for the hochanteric wounds, where necrotic tissue is present,not for the sacralwound, where no necrotrctissueis apparent.Neither whirlpool immersionnor nonimmersionifiigation would be contraindicated,althoughcareshouldbe taken to ascertain that the pati€ntcanfeelandreportheatinthe areasto be treatedbeforewarm orhotwateris used.Sinceitis most likely that this patienthasimpairedsensationand circulation in the areasof the pressureulcers,the water temperatureshouldbe no higherthan35.5"C (9d F). PROPOSEDTREATMENTPLAN Eitherimmersionor nonimmersiontechniquescould be used to apply hydrotherapyto this patient. Immersion techniqueshave the advantagesof allowing all the wounds to receivehydrotherapyat the sametime and providing potential circulatory benefits due to heat transferif warm water is used and due to hydrostatic pressureif the extremitiesare sufficiently immersed; however, becauseimmersion techniquesincreasethe risk of maceration of the intact tissue around the wounds,have a high infectiondsk, do not aliow control of the water pressureat the wound bed, cannotrestdct the hydrotherapy treatment to the trochanteric wounds, and requiremonitoringofvital signsduringtreatment,a A nonimmersiontechniquewouid be more apProPdate. nonimmersionform of hydrotherapywould alsobe easier, quicker,and lesscosdy to apply,althoughit would wi*r immernothave the circulatorybenefitsassociated sion.A.lthoughnonimmersionhydrotherapycanbepro vided by the useof either a mechanicalor an electrical device,the useof an electricpulsatileirrigationdeviceis recommendedfor the ffeatmentof this patient because this will allow close control of fluid pressureand removal of contaminatedfluid ftom the wound bed during treatment. Antimicrobials may be added to the fluid for either form of hydrotherapy.It is recommendedthat treatmentwith pulsatileinigation be prcvided once each day until the wound bed is fully granulated.Hydrotherapy of these wounds should be discontinued if bleeding occurs, if the amount of neclotic tissue does not decrease,or if t}le amourt of granulationdoesnot increasewithio 1 week. Should sharp debridement of necrotic tissue be indicated it is recommendedthat this be performed after the
T\vo . THE PHYSICAL ACENTS
hydrotherapy,when the necrotic tissueis likely to be !ofterand easierto lemove.
Case 3 femalewho sustaineda closedColles' FSis a 65-year-o1d iractureof her right arm 6 weeks ago.The fracturewas initially treatedwith a closedreductionandcastfixation. This castwas removed3 days ago,when radiographic reportsindicatedcallusformationandgood alignmentof *re ftacturesite.IS hasbeenreferredto therapywith an order to evaluateand treat. She has not rec€ivedany prior rehabilitation fteatment for dr.is injury. IS complainsof severepain, stiffness,and sweliingof her right wrist and hand. Sheis wearing a wrist splint and is not Lrsingher right hand for any functional activities at this time becauseshe is afraid that any activiry may cause further damage.FS is retired and lives alone. She is unableto drive at this time becauseof the dysfunctions ofher right handandwrist. The objectiveexamis signifiactiveand passiveROM of the right cant for decreased wrist. Active wrist flexion is 30" on the right and B0' on the left. Wrist extension is 25' on the right and 70' on the ieft. Wrist ulnar deviationis 10' on the right and 30! on the left, and wrist radialdeviationis 25' on the right and 0"on the left.Thereis alsomoderatenonpittingedemao[ rhe right hand, and the skin of the right hand and w st appearsshiny. FS'sfunctional grip on the right is limited by both muscle weakness and rest cted joint ROM. The patient is wearing a splint and is holding her hand across her abdomen. She reports severepain when her hand is touched, even lightly. A1lother objectivemeasures,includingshoulder,elbow, and neck ROM, upper exff€mity sensation,and left spper extremity strength,are within normal limits for this patient'sageand gender EVALUATION OF THE CLINICALFINDINGS This patient presentswith impairments of pain, hypersensitivity,restrictedROM, abnormaiskin appearance, andincreasedvolume of her right hand andwrist. These impairments, in conjunclion with her fear, have resulted in total disuseof this distal extremity for all functional activities and an inability to drive. Although this patient'ssignsand symptomsare consistentwithdisuse after a fractureand immobilization, they also indicate thatshe hasstageI reflexsympatheticdystrophy. PREFERRED PRACTICEPATTERN Impaired Joint Mobility, Muscle Performance,and Rangeof Motion AssociatedWith Fracture,(4C) -
301
PLAN OF CARE The anticipated long-term goals of treatment are to achievenormal sensation,function,ROM, strength,and volume of the right hand and wrist. In order to achieve thesegoals,the proposedshort-termgoalsfor the first 2 weeks of treatrnentareto decreasethis patient'spai& hypersensitivity,and fearsufficientlyto aliow herto initiate useof her right handto assistwith functionalactivities and to increaseher right wrist ROM by 20% to 50% in all planes. ASSESSMENTREGARDINGTHE APPBOPRIATENESSOF HYDROTHERAPYAS THE OPTIMAL TREATMENT Immersion hydrotherapy,using either a low level of water agitation in a neutral warmth whirlpool or a contrastbath with warm and cool water of similartemperatures,may reducedre hypersensitivityand hypalgesiaof this patient's hand while providing a suitable environment for activeexelciseto increasethe ROM and functional useofher hand.The hydrostaticpressureprovided by water imm€rsion and the altemating vasoconstriction and vasodilationproducedby a contrastbatJ:may also contribute to reducing the edema in this exffemity. The useof a warm or hot water whirlpool would not be recommendedbecausethe resultingincreas€in tissuetemperature, in conjunction with the dependent position of the extremity, is likely to aggravatethe edema already presentin this patient's hand. Although the evaluation of this patient doesnot indicate any conffaindication for the useof hydrotherapy,sincehotwatermaybe usedfor the conuast baih during the later stageso[ desensitization, her ability to sensetemperatureshould be assessed befor€ initiating treatment with a contrast bath. PROPOSEDTREATMENTPLAN Sinceimmersioninwateris requiredto providethe heat transfer,resistance,and hydrostatic pressurethat wiil produce the therapeuticbenefits of hydro*rerapy for thi6 patient, only immersion hydrotherapytechniques would be appropriatefor her treatrnent.As notedabove, a contrastbath is likely to be most effectivebecauseit may assistwith desensitizationand edema reduction while providing a comforuble environment for active exercise.It is recommendedthat contrast bath neatments be provid€d both in the clinic and by the patient aspart ofherhome program.It is recommendedthat the water temperature of the two baths initially be similar that t}|e temperaturedifand, as the patient progresses, ferencegraduallybe increased.
::erred PhysicalTherapistPracticePattemssM[4D, 4C, and 7E] are copyiight 2002AmericanPhysicalTherapyAssociation.Al1 rights
302
g . HydtothercW
Chapter Review
6. WinterGD: Formationofscabandthe rateof
ization in superficial wounds of the domestic Hydrotherapy is the application of water for theraN ature 193:293-294, 1962. peutic purposes.The unique physical propertiesof 1997. WadeJ:Sportssplash,RehabMgwt L0(4):64-70, 7. water, including its high specific heat and thermal 8. Gwinup C: Weight loss without dietary conductiviqy,buoyancy, resistance,and hydrostatic efficacy of different forms of aerobic exerclse,Am pressure,all contribute to its therapeutic efficacy. SyortMed 15275-279, 1987. Water can be used as a cleanser,and immersion in 9. KieresJ,PlowmanS:Effectof swimming and land water also producesa wide range of cardiovascular, ciseson body compositionof collegestudents,/ renal,and psychological respiratorymusculoskeletal, 31:1.92-f93 Med PhysFitness , 1991. 10. Ruoti RG, Troup Jl BergerRA: The effects of benefits. These beneficial effects of hydrotherapy swimming water exelcises on older adults, / include reducingthe bacterialload and the presence Syorts Phys Ther 19(3):140'1'45' 1994. pain, of debris during wound care, and controlling GM, Grigsby S, Winant D: The effectsof 11. Gehlsen edema modifying muscular demands,and reducing program on the muscularstrength fitness aquatic can be dudng water-basedexercise.Hydrotherapy Phys with multiple sclerosts, of patients endurance applied by immersion in water in a whirlpool, 1984 . 64(5):653-6s7 , Hubbard tank, contrast bath, or exercisepool or 12. Henler L, Provast-CraigM, SestiliP et al: Water by nonimmersion methods using a shower or a ning and the maintenance of maximum oxygen speci.alizediffigation device. Immersion methods sumption and leg strength tt runners, Med Sci provide all *re above-mentionedbenefits of hydroExerc24:3-5, 7991,. therapy;however,becauseimmersion can be associ- 13. BalldinUI, LundgrenCEC,LundvallJ et al: Changes the elimination of 133 Xenon from the anterior atedwith increasedrisksofinfection or drowning and musclein man inducedby immersionin water and can be time-consuming to apply, nonimmersion shifts in body positlon,AercsllceMed 42(5): hydrotherapytechniquesthat provide only cleansing 1971. effectshavebeendevelopedfor the treatmentotopen M, BalldinUI, LiljaB et al: Arborelius 14. wounds when onlytheseeffectsarerequired.In order duringimmersionwith the head inman changes to optimize the outcomeof hydrotherapytreatments, 1972. Med 43(3):593-599, water,AerosVace the treatment plan and equipment selectionshould U et aI:The HJ, Beckmann \[D, fusch Koubenec 15. take into accountboth the risks and benefitsassociof gradedimmersionon hean volume, central ated with the various meansof applying hydrotherpressure,pulmonary blood distribution and heart apy, and all appropriateprecautionsshould be taken Arch374:115-118,1978. it man,Pfleugers to provide a safe environment for such treatment. 16. Haffor AA, MohierJG, Harison AAC: Effectsof immersionon cardiacoutput of lean and fat male The reader is referredto the Evolve website at jects at rest and during exercise,Aliation, SVace for study queshttp://evolve.elseviercom/Cameron Med 62:123-127 ,1991'. tions pertinentto this chapter
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Two C THE PIIYSICAL AGENTS
-- Michaud T, Brennan D, Wilder R et al: Aquarun training and changes in treadmill running maximal oxygen consumption, Med Sci SpottsExerc 24:5-7, 1991,. - : Hamer TW, Morton AR; Water-running: training effects and specificity of aerobic, anaerobic and muscuiar parametersfollowing an eight week interval training programme,AustJ SciMed Syon22(1):13-22,1990. - -. AbramsonD, Brumet C, Bell Y et aL Changesin blood flow, oxygenuptake,and tissuetemperaturesproduced by a topical appiication of wet heag Arch PhysMed Rehab il 42:305-318,1961. -:. Gleim CW, NicholasJA:Metaboliccostsand heart rate .esponsesto treadmill walking in water at different depths and tempemtures,An J SponsMed 17Q):248252,1989. -i. EvansBW, CuretonKJ,PurvisJW:Metabolicand circulatory responsesto walking andjogginginwate! ResQ 49(4):442-449 , 1978. --. Hong SK,CerretelliP,Cruz JCetal: Mechanicsofrespi ration during submersion in water, ,t Aypl Physiol 27(4):53s-s3q1969. -:. PerkJ, PerkL, BodenC: Adaptation of COPD patients to physical training on land and i,n wate4 Eut RespirJ 9(2):248-252, 1,996 . ,i. Agostoni E, Curtner C, Torri G et al: Respiratory mechanicsduring submersionand negative pressure brearhrng, 1966. J Appl Physiol21(1):251-258, : '. Bar-YishayE, Cur I, inbar O et al: Differencesbetween swimming and running as stimuli for exercise-induced asrhma,EurI Apyl Physiol48:387-397, 1982. ::. Iitch KD, Morton AR: Specificiryof exercisein exer-581,1971. cise-induced asthma, Br MedJ4:577 ,i. Bar-OrO, Inbar I: Swimming and astJrmabenefitsand deleteriouseffects,SponsMed t4:397-405, 1992. ::. EpsteinM: Cardiovascularand renal effects of head out water immersion tn mat, Circ Res39(5):620-628, 1,976. :-+.Katz VL, McMurray \ Berry MJ et a1:Renalresponses to immersionand exercisein pregnancy,AfiJ Peifiatol 7(2):II8-121, 1990. :r. EpsteinM, Pins DS, SilvercW et al: Failureof water immersionto influenceparathyroidhormone secretion and renal phosphate handling in normal m an,J Lab Clit Med 87(2):218-226,1976. :5. BraslowJT: Punishmentor therapy:patients,doctors, and somatic remediesin the early twentieth century: PsychClinNanhAn 17(3)1493-513 , 1994. :-. HolmesC: Hydrotherapyas a meansof rehabilitation, Btl PhysMed5:93-95,1942. :3. FeedarJA, Kloth LC: Conservativemanagementof chronic wounds. In Kloth LC, McCulloch JN! Feedar lA, eds: \X/oundHealing: Ahenatives lx Mauagemeftt, ?hiladelphia,1990,FADavis.
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39. NeiderhuberS,StribleyR, KoepkeG: Reductionin skin bacterialload with the use of therapeuticwhirlpool, PhysTher55(5):482-486, 1975. 40. Walter PH: Burn wound managemenqAACN Clin IssuesCri CateNuts4Q):378-gB7, L993. 41. Burke DT, Ho CH, Saucier MA et al: Effects of hydrotherapyon pressureulcerhealing,.4nJPhysMed Rehabil 77(5)t394-398, 1998. 42. McCullochJ:Physicaimodalitiesinwoundmanagement: ulEasound, vasopneumatic devices and hydrotherapy, '1995 Ostouy \Y/ound Mgmt 41(5)130-32, 35-37, . 43. Winter GD: Iormation of a scaband the rate of epittrelialization of superficialwounds in the skin of the young domesticpig,Naturc 193:293-294,1962. 44. HahnJS:Lectureon the power and effectof fteshwater on the human body. 1734,Cermany. 45. Wheeier CB, RodeheaverGT, Thacker JG et al: Side effectsof high-pressureinigation, SurgCytecolC)bstet 143(s)i75-778,1976. 46. McGuckin M, Thorpe B" Abrutyn E: Hydrotherapyran outbrcak of Pseudotkonas aeruglnosawound infections related to Hubbard tanl ffeatments.Arch PhvsMed Rehabil62:283-285,l98l . 47. Tred,get EI, Shankowsky HA, Joffe AAM et al: Epidemiology of infections with Pseudomonas aetugittosa ln blrn patients: the rcIe of hydrotherapy, Clit IxfeaDk 15(Q:64L-649 , 1992. 48. Shankowsky HA, Callioux LS, Tredget EE: North Americansurveyof hydrotherapyin modem bum care, 1994. J BurnCareRehabil15(2).143-146, 49. fuchard P, LeFoch\ Chamoux C, et al: Pseudomonas aerugixosaoutbreakin a burn unit role of antimicrobials in tlle emergenceof multiply resistant strais, I lxfect D k 170(2\:37 7-383,1,99 4. 50. Wisplinghoff H, Perbix W, SeifertH: Risk factors for nosocomialbloodstreaminfectionsdue to Acixetobacter baumaxnli:a case-conffolstudy of adult bum patients, -66, 1999. Clix IxfeaDk 28(1):59 51. StanwoodW, PinzurMS: fusk of contaminationof the wound in a hydrotherapeutic ta*, Foot Axkle Int 19(3):173-176,1998. 52. Myers RS: SauwlersManual of PhysicalTherapyPractice, Philadelphia,1995,WB Saunders. 53. Walsh MT: Hydrotherapy:the use of water as a therapeuticagent.In ldichlovitz SL, ed.:ThermalAgentsin Rehabiliation, ed 3, Philadelphia,1996,IA Davis. 54. SteveL, Coodhart P,AlexanderJ: Hydrotherapy burn treatrneng use of chloramine-T against resistant microorganisms,Atch Phy, Med Rehab;l60(7).301-303, 1979. 55. CusterJ, EdlichRI, PrusakM et al: Studiesin the managementof ttre contaminatedwound: V An assessment of tlre elfectivenessof pHisoHexand Betadinesurgical scrubsolutions,Azrl Sutg 127:572-57 5, 1.97 1.
304
g . HydrotheruW
56. johnson A& White AC, McAnalley B: Comparisonof commontopicalagentsforwound fteatment cytotoxicity for human fibroblasts in culrure, \Younds 1.(3): 186-192,1989. 57. RodeheaverGl Kurtz L, KircherBJet al: PluronicI-68: apromising new wound cleanser, Axn Emetg Med 9(It):572-576,1980. 58. RydbergB, ZederfeldtB: Influenceof cationic detergentson tensilestrengthof healingskin wounds in the -320,1968. rar,ActaCh Sctnd134(5):317 p, Branden RA: Differential Weinberg C, 59. Burkey methodologiesfor the evaluationof skin and wound cleansers,\Younds5(6):284-29I, 1993. 60. ForesmanPA,PayneDS,BeckerD et aLA relativetoxiciry index for wound cleansers,\Vounds5(5):226-231, 1993. 61. Henderson JD, Leming JT, Melon-Niksa DB: Chloramine-T solutions:effect on wound healing in 0(8):628-631 guineapigs,AtchPhysMed Rehabil7 ' 1989. of water Cross A: Effect Cutright DE, 62. Bhaskar SN, lavage on infected wounds in the rat, I Periodontol I-672, 1969. 40(11):67 63. BrownLL, SheltonHl BomsideGH et al: Evaluationof wound irrigation by pulsatile jet and conventional methods,Axn Surg 187(2).170-173,7978. comPulsedlavage: 64. MorganD. HoelscherJ: PromoLjng fort and healingin home care,Ostomy\X/owdManage 46(4):44-49 , 2000. 65. Unive6ity Medical Cent€r Physical Therapy Departmena \fuund Care PratocolUsirtg the Pu[strac Vlound Debidemext Systen, Ltbbock, TX, 1994, UniversityMedical Center. 66. Bohannon RW: Whirlpool versuswhirlpool rinse for removalof bacteriafrom a venousstasisulcel PhysTher 62(3):304-308,1982. 67. Bingham HG, Hudson D, Popp J: A retrospective review of the bum intensivecareunit admissionsfor a year,JBumCareRehabil16(1):56-58,1'995. 68. Thomson PD,BowdenML, McDonaldK etal: A survey of bum hydrotherapyin the United States,J Bura Care Rehabilt1(2):I5I-1.55, 1990. 69. StaIey f"4, Richard R: Management of the acute bum 1997. wound: an ovewiew,Adv WouudCarc10(2):39-44' 70. Neville C, Dimick AR: The trauma table as an altemative to the Hubbard tank in burn care,J Bunt Care 4-575, 1987. Rehabil8(61:57 71. Said RA, HusseinMM: Severehyponatremiain bum patientssecondaryto hydrotherapy,Buns Incl Thetnal -329, 1'987 . Inj 13(4):327 72. HeadleyBJ,RobsonMC, Krizek TJ: Methods of reducing environmentalstressfor the acute bum patient, -9, 1,975 . PhysTher55(1):5 73. Bates A, Har'sor' N: A1uatic Therayy:A Comyrchenslve Ayyroach to IJse of A4uatk Exerciseix Trcatmext of
Onholzaedic lxjuries, Westbank, British Columbi4 Canada,1992,Swystun& Swystun. 74. Hoyrup G, \orvel L: Comparison of whirlpool and wax treatments for hand therapy, PhysiothetCax 38: 79-82,1986. 75. Templeton MS, Boo*r DL, O'Kelly WD' Effects of aquatictherapy on joint fledbility and functionalabil" iry in subjectswith rheumatic dlsease, J Onhop 6-387,1996. PhysTher2ts(Q:37 76. GenuarioSE,VegsoJJ:The use of a swimming pool i rehabilitation and reconditioningof athletic ContempOnhoV4:381-387, 1990. 77. Cole AL EaglestonRE, Moschetti M et al: rehabilitation aquatic rehabilitation strategies,/ Rehabil4(4):273-286, 1994. Musculosbel 78. Triggs M: Orthopedic aq\ratic the:€Py, Clin 77:30-3I, 199I. 79. Konlian C: Aquatic therapy: making a wave in the ment of low backinjurles,OnhopN urst8(7):I1'-1'B, 80. TsukaharaN, Toda A, Goto J et al: Cross-sectional loneitudinal studieson the effect of water elercise controlling bone loss in JaPanese -47, 1994. women.J Nutr SciVianlnol Tobyo40(7):37 81. Hurley R, Turner C: Neurology and aquatic ClinM gnt 11:26-29,1997. 82. JohnsonCR: Aquatic thenpy for an AIS patient,An OccupTher42(2):115-120 , 7988. of water 83. SimmonsV, HansenPD:Effectiveness on posturalmobility in the well elderly:an tal study on balance enhancement,I CerontolA Biol Med Sci57(5):M233-[238,1.996. 84. Harris SR: Neurodevelopmentaltreatment for teaching swimming to cerebral palsied 1978. PhysTher58(8):979-983, 85. Boyle AM: The Bad Ragazring method, 67:265-268,1981. 86. EyestoneED, FellinghamC, GeorgeJ et al: Effect water running and cycling on the maximum consumptionand 2 mile run performance,,42 / Med21:4L-44,1993. 87. McMuuay RG, FieseimanCC, Avery KE et al: hemodynamicsin water and on land in Patients coronary artery dlsease, CardioVuln Rehabil 1986. 88. Tei C, TanakaN: Thermal vasodilationas a of congestiveheart failure:a novel approach,/ 21(1):29-30,1996. 89. WatsonWJ, Katz W, HackneyAC et al: Fetal to maximal swimming and rycling exercise p re gnancy,Obstet C ynea I 77(3):382-386,t9 9 I. 90. KurabayashiH, Machida i, Kubou K: Improvement ejection fraction by hydrotherapy as rehabilitation patients with chronic puLmonary 1998. PhysiotherResInt 3(4):284-291,
Tg'o C THE PHYSICAL AGENTS
:1. AmericanCollegeof Obstetriciansand Gynecologists: Exerckeduring Pregxancyaxd PostnatalPeiod ACOC Home ExerclsePrcgrams,Wastingtoq DC, 1985, ACOC. :J. Huang SW,Veiga\ SilaU et al: The effect of swimming in asthmatic children participants in a swimming programin the city ofBahirrore,J Asthna 26:117-121., 1,989. :3. SvenoniusE, Kautto R, ArboreliusM Jr:Improvement after training of children with exercise-induced as*trrra,Acu PaediatrScaxd72:23-30, 1983. :J. Tovin BJ,Wolf SL,GreenfieldBH et al: Comparisonof the effects of exercisein water and on land on the rehabilitationof patientswith inftaafticularanterior cruciate ligament reconstructions,Phys Thet 74(B):
7r0-719,1994.
:5. MagnesJ, CarretI EricksonD: Swellingof the upper extremity during whirlpool baths, Arch Phys Med Rehabil51:297-299, 1970. :5. CleckJ:Precautionsfor hydrotherapeuticdevices,C/la MgntS:44,1983. :7. U.S. Department of Health and Human Services: Tteatmextof PressureUlcers:Clinical PractlceCuidelixes, Rockville,MD, L994,U.5.Departmentof Health and Human Services. :3. MoschettiM: Aquaticsrisk managem€ntsbategiesfor *re therapy pool, J Bach MusculosbelRehabil4(4): 265-272,1994. :9. McMu[ay RC, Katz W: Thermoregulationin pregnanry: implications for exercise, Spons Med L0(3): 146-158,1990. 0. American National Red Cross:LlfesavingRescue axd \Y/aterSafety, Washington, DC, 1989, Water Safety Program. t Hwang lC! Himel HN, Edlich RI: Bilateralamputations following hydrotherapy tank bums in a paraplegrcpat\ent,Burus21(1):70-71, 1995. 2. Byl N, Cameron M, Kloth L et al: Treatment and prevention goals and objectives.In Myers RS, ed:
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Saundets Maxual of Physkal ThetaVy Pructice, Philadelphia,1995,WB Saunders. 103. BorellPM, Parker\ HenleyEJet al: Comparisonof in vivo temperaturesproducedby hydrotherapyparaffin wax treatment and Fluidotherapy,Phys Ther 60 1,273-1276,1980. 104. LoehneHB: Enhancedwound careusingthe pulsavac system:casestudies,Acute CarePerspea 3(2),1,995. 105. Luedtke-HoffmanKA, SchaferDS: Pulsedlavageia wound cleansing,P/rys Ther80Q):292-300,2000. 106. HaynesLJ,Brown MH, HandleyBC et al: Comparison of pulsavacand sterile whirlpoolregardingthe promotion of tissue granulation, Phys Thet 74(55):54 FO-012-M), 1994. 107. HdI J, MacDonald IA, Maddison PJ et al: Cardiorespiratoryr€sponsesto underwatertreadmill walking in healthy females, Eur J AqVly Physiol 77(3):278-284,1998. 108. Edlich RF,Abidin MR, Becker DG et al: Design of hydrotherapy exercise pools, J Bum Care Rehabll 9(s):505-509 , 1998. 109. Arledge Rl: Preventionof electricalshock hazards in physical therapy, Phys Ther 58(1,0):1215-1217, 1978. 110. Atkinson G, Harrison A: Implications of the Health and SafetryAt Work Act in telation to hydrotherapy depaftments,PhysiotheraVy 67:263-265, 1981. 111. Arnerican PhysicalTherapy Association: HydratheraVy/ TheuyeuticPoollxfectionCoxttolCuidelixes,Alexandria,
vA,1994, APrA.
112. Bloomfield SF,Miller EA: A comparisonof hypocblorite and phenolicdisinfectantsfor disinfectionof clean and soiled surfacesand blood. spillages,I Hosp Infect 13:231-239,1989. 113. Loughney E, Hanison Jr Iritant contact derrnatitis due to 1-bromo-3-chloro-5,5-dimethylhydantoin in a hydrotherapy pool. fusk assessments:the need for continuous evidence-based assessments, OccupMed (Lond)48(7):461- 463,199B.
SUMMAR\
OF INFORMATION
:tfects of SpinalTraction llinical lndications for the Use of SpinalTraction lontraindications and Precautionsfor SpinalTiaction ldverseEffectsof SpinalTraction
COVERED
Application Techniques Documentation Clinical CaseStudies Chapter Review
OBJECTIVES Uponcomyletionof this chapter,the readerwill beable to: Discussthe physicalpropertiesof traction. Identi$zthe physiologicaleffectsof traction. Examinehow the physicalpropertiesand physiologicaleffectsof traction can promote particular treatment goals. Assessthe indications, contraindications, and precautionsfor the use of traction with respectto different patient management situations. Design appropriatemethods for selecdng traction devicesand treatment parametersto producedesiredphysicaland physiological ettects.
6, Chooseand use the most appropriatetraction deviceand treatment parametersto obtain the desiredtreatment goals. 7 . Evaluatedifferent traction deviceswith respect to their potential application for treating different patient problems. 8. Presentedwith a clinical case,evaluatethe clinical findings, proposegoalsoftreatment, assesswhet-hertraction would be the best treatment, and, if so, formulate an effective treatment plan including the appropriatedevice and treatment parametersfor achievingthe soals of treatment.
307
308
40 . Tractiott
Tractionis the applicationofa mechanicalforceto the body in a way that separates, or attemptsto separate? the joint surfacesand elongatethe surroundingsoft tissues.Tractioncanbe appliedmanuallyby the clinician or mechanicallyby a machine.Traction can also be appliedby the patient using body weight and the force of graviry to exert a force. Traction can be appliedto the spinalor peripheraljoints.This chapter focuseson *re applicationof mechanicaltraction to the the cervicalandlumbar spineandbriefly discusses applicationof traction to the spine by other means. Information on the application of traction to the peripheraljoints is not provided in this book since such traction is generallyprovided manually by the therapist and is therefore consideredto be manual therapyratherthan a physicalagent.Ior fur*rer information on the applicationof tractionto the peripheral joints, the reader should consult a manual therapy rcxt. Spinaltraction gainedpopularity in the 1950sand 1960sin responseto JamesCyriax's recommendations regardingthe efficacy of this techniquetor the treatmentof back and leg pain causedby discprotrusions.l A rangeof studiessuggestthat spinaltraction is more effectivefor reducingbackpain and returning patientsto activity that infraredradiation,corsetand bed rest,hot packsand rest, hot packs,massageand mobilization, and bed rest.2-5A number o[ studies, however,have failed to demonstrate*rat traction is more effectivet}tan other treatmentssuchas isometric exercises or that high forcetractionir any more effectivecbanlow forcetraction.6-Althoughat this time controversyremainsregardingthe effectiveness oftraction, this chapterpresentswhatis knownabout the efficacyof traction and makesrecommendations for treatment approachesthat are most iikely to be effective. It has been statedthat spinal traction can distract joint surfaces,reduce protrusions of nuclear discal matedal, stretch soft tissue, relax muscles, and mobilizejoints.1,8 Low-forcetraction,of 10 to 20lb, applied for a long duration, rangingfrom hours to a few days, can also be used to temporarily immobilize a patient. All of these effects may reduce the pain associatedwith spinal dysfunction. The stimulation of sensory mechanoreceptors that occurswith the applicationof traction may alsogate the transmissionof pain along afferent neural pain Dathwavs,
TRACTION EFFECTS OFSPINAL Joht distraction Reduction of disc protrusion Soft tissue stretchirg Muscle relaxation Joint mobilizatioo Patient immobilization
JointDistraction Joint distractionis defined as "the separationof articular surfacesperpendicularto the plane of articulation."9Distraction of the spinal joints may prove beneficialfor the patient who signsand symptomsrelatedto loadingof thesej or comoressionof the spinal nerve roots as pass through the intervertebral foramina. distractionreducescompressionon the joint and widens the intervertebralforamina, reducingpressureon articularsurfaces,i structures,or the spinal newe roots.10Thus distraction may reduce pain originating joint injury or inflammation or from nerve compression. It has beenproposedthat the applicationof a tion force to the spine can cause distraction of spinal apophysealjoints.r For distractjonto occur,
forceappliedmust be greatenoughto cause elongationof the soft tissuessurroundingthe joint allow the ioint surfacesto separate.Smaller of force will increasethe tension on, or elongate soft tissuesof, the spinewithout separatingthe surfaces.For example. a force equal to 25oo of
patient'sbodyweighthas beenshown to be to increasethe length of the lumbar spine; force equal to 50% of the patient'sbody been found to be necessaryto distract the zygapophysealjoints.11,12The amount of requiredto distractthe spinaljoints also varies the location and health of the joints. In general, larger lumbar joints. which have more and
surrounding soft tissues, require more force achievejoint distractionthan do the smallercen ioints.As mentionedabove.distractionoI the apophysealjoints hasbeendemonstratedwith a equalto 50% of total body weight; in contrast,a egual co approximateiy 7o'oo[ total body weight
beenreportedto be sufficientto distractthe vertebrae.l3It has also been shown that the
Two . THE PHYSICAL AG€NTs
309
pressurewas not reduced when self-tractionwas applied by the patient pulling on an overheadbar while lying dorm, wearing a pelvic hamessattached to a spring force scale,or when manual traction was pelvis appliedby onetherapistpulling on the subjecCs of DiscProtrusion Reduction while another puiled under tlre arms.21 Also, Lundsrenand Eldevik found that auto-tracrion,in -{ccording to Cyriax, "traction is the heatment of whici the traction fotce is limited by the patient's proposed The protrusions.nl :hoice for small nuclear abiliqyto pull with the arms,causedno changein the back clicking nechanismsfor discrealignmentinclude of hemiatedlumbar discson CT scan." aooearance intradiscal to decreased :f a discfragment,suctiondue the evidencefor the effectsof traction on Although toward disc back :ressurepullingdisplacedpartsofthe -ttecentet or tensingof the postedorlongitudinalligadiscalprotrusionsis not entirelyconclusive,it appears that with sufficient traction force, of at least 27 kg :nentat the posterioraspectof the disc,therebypush(60 lb) to the lumbar spine, some disc protrusions anteriorly material displaced ng any posteriorly _discal '.owarditsorjginalpositionI rr (tig. l0-l). are reducedby splnal traction, and that traction can reducesymptomsin patientswith local back or neck A numberofstudieshaveshownthat spinaltraction pain, or radicularspinal symptoms causedby a disc -zn reducespinaldiscalprotrusions,and a number of protrusion,if the protrusionis reduced.Thesesympauthorshaveproposedthat the reliefof backpain and tomatic improvementsmay be the result of reducing :elatedsymptomsthat occurswi*r the applicationof discal protrusion or may be due to concurent the :action is rhe result of a reductionin protrusionsof chanees in other associated structures, such as Studiesusing a variery of rucleardiscalmaterial.16,17 size of the neuralforamina,changesin the increased imagingtechniques,includingdiscography, Ciagnostic on soft tissuesor nerves,or modification of tension :pidurography, and computed tomography (CT), have the tone of the low backmuscles. that lumbar traction,usinga lorceof27 Jemonstrated :o 55 kg (60to 1201b),canreducea discprolapse,cause :etractionof hemiated discal material, and result in Stretching SoftTissue :linical improvement in those patients in whom the jiscal defectsare reduced.15,1LiO lt has beenreported Tractionhas beenreportedto elongatethe spineand increasethe distancebetween the vertebral bodies :trat symptoms generallyfail to improve when traction It is proposedthat and the facet joint surfaces.23'2s :sappliedto patientswith largediscalherniationsthat of the soft tislength theseeffectsaredueto increased ill *re spinal can-alor to those with calcification of the suesin the area,includingthe muscles,tendons,ligaCiscprotrusion.rt Although studiessupportthe beliefthat high-force ments, and discs. Soft tissue stretching using a moderate-load,prolonged force, such as that pro:raction can reducenuclear discalprotrusions,some :eporcsindicarethat lower forcesmay not produce vided by spinal traction, has also been shown to --|r'is effect.17Anderssonet al repolted that intradiscal increasethe length of tendonsand to increaseioint Increasingthe length of the soft tissues mobility.26-28 of the spine may provide clinical benefits by contributing to spinaljoint distractionor reductionof disc prorusion, asdescribedabove,or by increasingspinal iange of motion (ROM) and decreasingthe pressure on the facet joint surfaces,discs,and intewertebral newe roots evenwhen completeioint surfaceseparation is not achieved.
of forceproducesgreatervertebralsepara:r.ragnitude healthy spinesthan in spineswith signsof disc ion in Jegeneration.l4
Relaxation Muscle Figure10-1. Suction due to traction causingrealignment of nucleardiscalmaterial.
Spinaltraction has been reported to facilitate relaxIt has been proaiion of the paraspinalmuscles.16'29
310
40 . Ttactiofl
posedthat this effectmay be the resultof pain reductjon due to reducedpressure on pain-sensitive structures or gatingof pain transmissionby stimulationof by the oscillatorymovementspromechanoreceptors duced by intemittent traction.30As explained in detail in Chapter 3, reductionof pain by any means can facilitate muscle relaxation and a reduction of musclespasmsby inrerruptingthe pain-spasm-pain cycle. It has also been proposedthat static traction may causemusclerelaxationasa resultof the depression in monosynapticresponsecausedby sketching the musclesfor severalseconds,and that intermittent tractionmay causesmallchangesin muscletensionto producemuscle relaxationby stimulating the Golgi tendon organs(GTOs)to inhibit alphamotor neuron firing.31
JointMobilization Tractionhasbeenrecommendedasa meansto mobilize joints in order to increase joint mobiliry or decreasejoint-related pain.32,33Joint mobility is thought to be increasedby high-forcetraction due to stretchingof the surroundingsoft tissue structures. When lower levelsof forceare applied,the repetitive osci atory motion of intermittent spinaitractionmay also move the joints sufficiendy to stimulate the mechanoreceptorsand thus decreasejoint-related pain by gatingthe afferenttransmissionof pain stimuli. In this mannet the effectsof spinaltraction may be similar to those producedby manual joint mobilization techniques,except that with most traction techniquesa number of joints are mobilized at one time, whereaswith manual techniquesthe mobilizing forcecanbe more localized.
lmmobilization Palient Very lowJoad, prolongedstatic traction,using 4.5 to 9 kg (10 to 20 lb) appliedfor long periodsof hours to days,can be usedto temporarilyimmobilize a symptomatic spinal area and thereby relieve symptoms that would be aggravatedby spinal motion.12The benefitsof suchtreatmentarethousht to be the result of che entorcedlimited mobility ind bed rest produced by the belts and harnessesused to apply the ffaction, rather than being a direct effect of the traction force.34Although the applicationof traction in the hospital for this purpose was popular only a decadeor two ago, it has fallen out of favor at this
time due to the growing awarenessthat most patients with backpain do not benefitfrom prolongedbedrest and inactiviryrc The significantcost of providingthis ffeatment has also limited its aoolication.When this form of tractionis usedtoday,itii generallyappliedat home and seldomunder the direction or supervision ^F r nh"
CLINICAL INDICATIONS FOR THEUSE OFSPINAL TRACTION Disc bulge or herniation Nefve root impingement |oint hypomobility Subacuteioint infl ammation Paraspinalmuscle spasm
The clinicalindicationsfor the use of spinal include back or neck pain. with or without ating symptomswhen due to a disc bulge or tion, nerve root impingement, joint hypomo subacutejoint inflammation, or paraspinal spasm.Although substantialevidence the mechanicaleffectsof spinal traction, limitati in the data from clinical studres concernns use for the treatment of back and neck pain causedits use for tlese problems to be controversial.36 Becauseffeatment with traction has with a reductionor elimination beenassociated spinal pain, with or without radiating symptoms, because spinal traction has been shown to rer
mechanicaldysfunctionsassociatedwith such toms. the use of soinal traction is recommended consideration as a treatment option for such lems. The indications and recommendations for selection oftractionas a treatment modality,
following, and the guidelinesfor selectionof ment parameters, are based on the available data an understanding of the spinal pathologies that cause signs and symptoms in patients. If a pati signs and symptoms are known to be due to a
bulge or herniation, nerve root impingement, cute joint inflammation, or paraspinalmuscle and if cheseare aggravatedby joinr loading and
by distractionor reductionof joint loading,then tion may be effective in reducing or controlling
symptoms.Tractionis lesslikely to be effective thereis a largedischerniationthat protrudesinto
T,s,o . THE PIIYSICAL AGENTS
,:inal canal or when heniated or protruding discal :aterial hasbecomecalcified.
0iscBulge orHerniation -r a number of clinical studies, spinal traction has :een shown to relieve symptoms associatedwith a 153716" :jsc bulgeor herniatednucleuspulposus.2 proposed mechanism of this beneficial effect :rimary of the protrusion = reduction disc bulge or and thus =duction of compressionon the spinal nerye roots. lraction is most likely to improve the patient'sout:cme if it is applied soon after a discalinjury when rere is protrusionof soft nucleardiscalmaterial.This j becausetraction canreducenot only the protrusion rat has occurredbut can also reducethe risk of fur:rer protrusion.lT In contrast, a number of studies have failed to :emonstratea significantclinicalbenefit in response :: the applicationof traction to patientswith discal :rjuries.4,6,38 This lack of positive effect may be :elatedto the severiqyof the disc protrusionsin the :ubjectsstudied,the useof insufficienttraction force, ,r the use of sample sizes that were too small to jetect a treatment effect. Despite these equivocal i-ndings,spinal traccionremainsa common inrerr-entionfor treating patientswith discal protrusions :ad back or neck pain with or without radicular :ymptoms. Becauseit is likely that any correctionof a discal rrotrusion produced by spinal traction may be ;uickly lost if the patient returns to his or her prior :ctivities, it is recommendedthat all patients be :nstructedin other techniquesfor reducingstresseson -he spine after treatment with traction in order to avoid a rapid recuffenceof symptoms. Such tech-
Discbulge
311
niques may include correctionof posture and body mechanics,lumbar stabilization by exercise or a corset,self-traction,and a cautious,gradualreturn to prior activities. Other exercisesand mobilization techniquesmay also assistin maintaining the s1'rnptom relief and correction of discal positioning achievedwith spinaltraction.
Nerve Rootlmpingement Tractionhas beenreportedto help alleviatesignsand sympromsassociated with spinalnerveroot impingeparticularly ment, if it is- applied shortly after the onset of such symptoms.zTraction is generallyrecommended as the treatment of choice for patients with neurological deficits from spinal nerve root impingement.rvSuchimpingementmay be causedby bulging or hemiation of discalmaterial,as described above, or by ligament encroachment,narrowing of the intervertebral foramen, osteophyte encroachment, spinalnerveroot swelling,or spondylolisthesis (F|g. 10-2). In the latter cases,if sufficient traction force is applied,the size of the neural foramen may temporarily be increased,reducing pressureon the spinal nerve root.!2'14'40 lor example,when cervical lateral flexion and rotation to the same side, which both narrow the intervertebralforamen,aremarkedly limited by arm pain on the same side, indicating impingementof cervicalnerve roots, the application of traction may effectively reduce the arm pain by increasingthe sizeof the neuralforamenand decreasing pressureon the involvednewe(s). Some studies have reported good results when using traction for the treatment of pain and other related neurological s;.,rnptoms associated wi*r nerve root impingement,while othershave failed to
Narrowing Narrowing of of intervertebralfforamen intervertebral oramen
encroachment Osteophyte andspinalnerverootswellinq
Figure10-2. Causesof spinalnerve root compression.
312
'10 . Trdctioi
demonstrategreaterbenefitswith traction than with sham tractio;38,41'a3 Although the availabledata do not readily indicatewhich patientswill benefit from spinal traction, clinically, in general,those patients who report aggravationof symptomswith increased spinalloadingand easingof s;rmptomswith decreased spinalioadingaremore likely to respondwell to treatment with traction. It has also been recommended that traction be consideredfor patientswith symptorns of radiating pain or paresthesiathat do not improve with trunk movements.44
usedto reducethe pressureon inflamedjoint while the small movementsof intermittent may control pain by gatingtransmissionat the cord level.Thesemovementsmay alsohelp to tain normal fluid exchangein the joints to edema in or around the joints causedby inflammation.46Spinaltraction can be usedsafely the subacuteor chronicstagesof joint however, intermittent traction should be immediately after an injury during the acute matory phase,when the repetitivemotion may further injury or amplify the inflammatorytesponsa
JointHypomobility Becauselongitudinalspinaltraction canglide and distract the spinalfacetjoints and stretchthe soft tissues surroundingthese joints. spinal tracdon may prove beneficialin the treatment of symptoms causedby joint hypomobiliry However, spinal traction is not generallythe optimal treatmentif only individual segmentsarehypomobile becauseit appliesa mobilizing force to multiple ratherthan singlespinallevels.Such nonspecific mobilization could prove deleterious to the patient with hypomobility of one segment and hypermobility of adjoining segments.In such patients, the mobilizing force applied by traction would most probably causethe greatestincreasein motion in the most extensibleareas,the hypermobile segments,resulting in joint laxiqy,whiie having no effect on the mobility of the less mobile segments causing*re patient'ssynnptoms.Adjustingthe degree of spinal flexion during the application of traction localizesthe mobilizing effect of *re force to some degreeand thus may help to alleviatethis problem.45 Ior example,positioning the lumbar spine in more flexion localizesthe force to the upper lumbar and Iower thoracicspine,while positioningit in neutralor extensionlocalizesthe forceto the lowerlumbar area. Similarly, for the cervicalspine, the flexed position focusesthe forceson the lower cervicalarea,while the neutral or slightly extendedposition focusesthe forceson the upper cewicalarea.45 More detailedrecommendationsfor patientpositioningareprovidedin the sectionbelow regardingapplicationtechniques.
Subacute JointInflammation Traction has been recommendedfor reducins the painandlimitationsof functionassociated with subacutejoint inflammation.33 The forceof tractioncanbe
Paraspinal Muscle Spasm The maintainedstretchof statictraction or the tive motion of low-load, intemittent traction help to reduceparaspinalmusclespasm.1429 As previously,this effect may be secondaryto a tion in pain and the consequentinterruption of pain-spasm-pain cycleormay be causedby of alpha motor neuron firing due to depression the monosyrnapticresponseor stimulation of CTOs.JU Higherloadspinaltractionmay also ate protectiveparaspinalmusclespasmsby the underlyingcauseofpain, suchasa disc or herniation, or a nerve root impingement, interruptingthe pain-spasm-pain cycle.
CONTRAINDICATIONS ANDPRECAUTIONS FOR SPINAL TRACTION The applicationof spinaltraccionis
some circumstances,and it shouid be applied extracautionin other circumstances;4/ however,in cases,in orderto minimize the probability of consequences, when tuactionis first applied,it be appliedin a lessaggressivemanne5using a amount of force,and the patient'sresponseto ment should be closely monitored. Also, if patient's condition worsens in response to
with symptomsbecomingmore severe, ing, increasingin distribution,or progressingto domains (e.g.,from pain to numbnessor weal, the treatment approach should be reevaluated changed.lf the patient's signs or symptoms do improve wi*rin two or three treatments, the ment approach should also be reevaluated
changedor the patient should be referredto a cianfor further evaluation.
nvo . THEPIIYSICALAGENTS
313
...
CONTRAINDICATIONS
fortheUseol Traction
o Where motion is contraindicated o Witl an acute iniurv or inflammation
Theuse of spinaltractionis . .. contraindicated . . where motion is contraindicated -:action should not be usedif motion is contraindi:.:tedin the areato be affected;for example,with an -rstable fracture, in casesof cord compression,or :rortly after spinalsurgery ASKTHE PATIENT: r Haveyou beeninstructednot to move your neck or h,.1"2 Tf <^ h,, ,^,h^- 2
. If wearing a brace or corset: Have you been instructed not to remove your brace at any dme? . How recentwasyour injury or surgery? Do not useany form of traction if motion in the area is contraindicated. Consider direct treatment with other physical agents,such as heat or cold, or treat other involved areaswhere motion is allowed. . . with an acute injury or inflammation .-:ute inflammation may occur immediately after :auma or surgery or asthe resultof an inflammatory ::seasesuchasrheumatoidarthritis or osteoarthritis. r -:rceintermittent or static traction may aggtavate ::ute inflammationor interferewith the healingof an ::ute injury, traction should not be applied under :ese conditions. ASKTHE PATIENT . When did your inlury occur? . When did your pain stad? If the injury or onset of pain was within the last 72 hours,the injury is likely to still be in the acute nflammatory phase, and traction should not be rsed. As inflammationresolves,statictraction may 'ce used initially, with progressionto intemittent -Jactionasthe areatoleratesmore motion.
o Jointhypermobility or instability o Peripheralizationof symptomswith kaction o Uncontrolled (forinversion hypertension traction) ASSESS: o Palpateand inspect the area to detect signs of inflammation,includingheat,redness,andswelling. . If signsof acuteinflammation are present,it is recommended that the application of traction be delayeduntil they resolve. . . . to a hypermobile or unstable joint High-force traction should not be used in areasof joint hypermobiliry or instability becauseit may further increase*re mobility of the area.Thereforethe mobiliqyof joints in the areato which oneis considering applying traction should be assessedbefore the ffaction is applied.Joint hypermobility may be the resultof a recentfracture,joint dislocatior5or surgery, or it can be due to an old injury high relaxin levels during pregnancy and lactation, poor posture, or congenitalligament laxiry Joint hypermobility and instability, particularlyof the C1-C2 articulations,is also common in patientswith rheumatoid arthritis, Down's syndrome, and Marfan's s1'ndromedue to degeneration of the transverseadantar ligament. Therefore cervicaltraction should not be applied to patientswith thesediagnosesuntil the integrity ofthe transvefie adantar ligament and the stability of the C1-C2articulationshavebeenascertained. ASK THE PATIENT o Haveyou dislocateda joint in this area? . Do you have rheumatoid arthritis or Marfan's syndrome ? o
Are rrnrr nreonrnt?
ASSESS: . Assess joint mobiliry in the area that will be rffcete.,l hrr thp ttrrtinn
A11levels oI the cervicalor lumbar spine,depending on which is being treated,should be assessed, not just the symptomatic ones, since traction can affectthe mobilitv of multiole levels.
314
40 . Tlactiotl
G0NTRAINDICATI0NS-cont'd o Check the patient's chart for any diagnosis of rheumatoidarthritis,Marfan'ssyndrome,or Down,s syndromeand requestradiographic ,tudies to rule out C1-C2instabiliqy beforeapp)yingtraction. o Do not apply tractionin areaswhere joint hypermobility is detectedon manualor radiographicexamination or to areasthat havebeenpreviouslydislocated. When some segmentsare hypomobile and adjacent segmentsarehypernobile, it is recommended that the hypomobile segmentsbe treated with manualtechniquesratherthan mechanicaltraction siace manual techniquescan mobilize individuai spinalsegmentsmore specifically.
The use of spinal traction is contraindicated . , . . . . with peripheralization of synptoms Tractionshouldbe discontinuedor modified immediately if it causes peripheralization of symptoms because,in general,progressionof spinal symptoms ftom a centralareato a more peripheralareais indicative of worseningnervefunciion and increasingcom-
PRECAUTIONS
tortheUseofTraction
In caseswhere tractionshouldbe appliedwith caution,checkwirh the referringphysicianbefore initiating traction,startwith a low level of force, progressslowly, andmonitor the patient,s responseto the treatmentcloselyat all hmes. Precautions include: o Structuraldiseases or conditionsaffectinethe spine(e.g..rumor,infectjon.rheumatoidinhritis, osteoporosis, or prolongedsystemicsteroiduse)
pression. Continuing treatment when symptom peripheralizationoccurscouldresultin aggravationo[ the initial injury and prolongedworsening of sigm and symptoms. TELL THE PATIENT: . Let me know immediately if you get more pain o. other symptoms further down your arms or legr Stopthe tractionif this occurs. ASSESS: Rechecksensation,motor function, and reflexes the appropriateextremiqy(ies)if the patient complainsof peripheralizationof symptoms. Discontinue or modify traction if signs or toms peripheralize. Traction may be modified by decreasing load or changingthe patient's position. traction may be continued if peripheralization
symptoms no longer occurs.Mild aggravation centralsymptomsalonein a patientwith prior tral andperipheralsymptomsshouldnot be a for discontinuationof treatment.
o When pressureof the beltsmay be hazardous (e.9.,with pregnancy. hiaralhernia,vascular compromise,osteoporosis) o Displacementof annularfragment o Medial discprotrusion . Severe painfulJyrelievedby tracrion o Claustrophobia o Parients who canrottolerace the proneor supine posluon . Disorientation o Temporomandibularjoint (TM) problems . Dentures
T,s,o . THE PIIYSICAL AGENTS
.Jsetractionwith cautionfor , . . . patients with a structural disease or condi: >n affecting the bones of the spine l::ction should be applied with caution when the :-Jctural integrity of the spinemay be compromised. i -:h structuralcompromisemost commonly occurs :i3 to a tumor, infection,rheumatoidarthritis,osteo:i--rosis,or prolongedsystemicsteroid use. In these :::umstances,the spinemay not be strongenoughto i-stain the forcesof the traction,and thereforeinjury :=y result from the application of strong traction .::ces. Radiographicreports and other studies that --:y indicatethe natureand severityof the structural ::npromise should be checkedbefore deciding to ::Jiy tractionto patientswith theseconditions. ISK THE PATIENT . lo you have any diseaseaffectingyour bones or 'ornts? . lo you have cancer,an infection in your bones, :heumatoidarthritis,or osteoporosis? . lo you take steroid medications?If so, how long i)\/e
\/^'r
ftLpn
fhcm
?
Low-iorce traction only should be applied to patients i:*r structuralcompromiseof the spine.Therefore, :- many cases,manual traction, which allows more ,::ect monitoring of patient response,may be more ::propriate in thesepatients. . . patients for whom the pressure of the belts ray be hazardous iee pelvicbeltsusedfor the applicationof mechanical j:nbar ffaction may apply excessiveabdominalpres,'jre to pregnantpatientsor to thosewith hiatalhemia =d may place excessivepressureon the inguinal ;.3ion on those with femoral artery compromise. -ompressionin the areaof the femoralarteriesin the --:guinalregion can be avoidedby ensuringthat the :elvic belt is positionedwith its lower edgesuperiorto ::e femoral triangle and by tighdy securingthe belt and r.:epingit in direct contactwith the skin to preventit :orn slipping down during treatment.There is also ::ncem that the pelvic or thoracic belts may apply pressureto the pelvisor ribs of patientswith .:
315
Cervicaltraction shouldbe appliedwi*r cautionto patients with cerebrovascularcompromise,as indicatedby a positivevertebralartery test,becausepoor placementof the halter may further compromisecirculation to the brain. The halter should also be positioned away ftom the carotidarteriesin patientswith compromise of these arteries.This is most easily achieved by using a halter that distracts via the occiput ratherthan one that appliesforce to both the occiputand the mandible. ASK THE PATIENN o
Arc
rrnr r 6rcon^nt?
o Do you havea hiatalhernia? o Haveyou had any troublewith blockedarteries? . Do you get pain in your calveswhen walking a short distance?This is a sign of intermittent claudication, indicating possiblearterial insufficiencyto the lower extremities. o Do you haveosteoporosis? . Do you haveproblemswith your breathing? . Haveyou had a stroke? . Doyou getdrzzy when you put your headback? If compressionby the belts used for mechanical traction is hazardousto the patient, one should consider using other forms of traction, such as self-traction or manualtraction,that do not requirethe useof thesebelts.Fasteningthe beltslesstightly is generally notrecommendedbecausethis will allow them to slip during treatment,renderingthe treatmentineffective or increasingpressurein the inguinal region. If the patient'sresponsesindicate possiblecompromiseof the cervicalor lower extremity vessels,it is essential that the halter or beltsusedfor traction be positioned in such a manner that they do not compressthese vessels. . . . patients with a displacement of a fragment of annulus Once a fragment of annulus has become displaced and is no longer connectedto the body of the disc, tractionis not likely to changethe position of the disc fragment, and therefore treatrnent with traction is alsonot likely to improve the patient'ssymptoms. ASK THE PATIENT . Has a magneticresonanceimaging (MRI) or computed tomography (CT) scan of your spine been performed?Pleasebring me the report(s)ftom that (those)test(s). Continued
40 . Tt,tction
316
PRECAUTI0NS-cont'd Traction should not be used to treat symptoms resulting from a displaceddisc fragment that is no longerattachedto the body of the disc. . . . patients with a medial disc protrusion It has been proposed that traction may aggravate symptoms caused by a medial disc protrusion because,in such circumstances,the medial movement of the nerveroot causedby a traction forcemay increasethe impingement of the disc on the nerve root4e(Iig. 10-3). ASK THE PATIENT . Has an MN or CT scan of your spine been performed? Pleasebring me the report(s) from that (those)test(s). . . . patients for whom severe pain resolves fully with traction If severepain resolvesfully with traction, this may indicate that the traction has increasedrather than compressionon a nerve root. causinga decreased "^*^1"r"."^,"
hl^.lz
ASK THE PATIENT: o After a few minutes of traction: Have your toms changed? o If *re patient had severepain and repofts *rat pain has decreased:Has the pain completely away or is itjust lesssevere? ASSESS: . Test sensation,reflexes,and strengthbefore ment. Also, if the patient reportscomplete tion of severepain during keatment, check againand assessfor any changes. Shouidseverepain be fully relievedby traction,i recommended that the clinician immediately other indicators of nerve conduction, including
tion, reflexes,and strength, to rule out i nervecompression.If theseareworse,traction be stoppedimmediately.If these are not worse, forceof tractionmaybereduced6y50%,or the tion of the traction force modified, and traction be continued.If traction is maintainedat a level causesa nerve block, the patient may sustain a nerve injury as the result of the treatment.
Traction
=ry-
Traction
y
Figule10-3. A, Lateral disc protrusion compressingthe L4 nerve root. B, L4 nerve root compressionby lateral disc ffusion relieved by traction due to elongation of the lumbar spine and a consequentmedial movement of the r root. C, L4 nerve root compressionby medial disc protrusion aggravatedby traction due to medial movement of nerye root.
317
Two . THE PIIYSICAL ACENTS
. . patients experiencing claustrophobia cther psychological aversion to traction
or
i. number of patients are psychologically averse o the use of traction becausethis proceduregener:lly involves considerablerestriction of movement :.nd loss of control. In particular, patients with :lausfophobia may not tolerate the restriction of ::rovementrequired for the application of mechan-;allumbartraction.In suchcases,other forms oftracron that do not require immobilization with belts, ,.uchas manual or positionaltraction,may be better :olerated. .. . patients who cannot tolerate the prone or ;upine position -\ number of patients cannot tolerate the prone or :upine position for the period of time necessaryfor -he applicationof traction. Suchlimitations may be -]re result of their spinal condition or other medical :roblems suchasreflux esophagitis.In suchcases,the -rseof supportssuch as a lumbar roll may allow the patientto toleratethe position; cervicaltraction may ce appliedin the sitting position; or, for lumbar tracion, some of the self-traction techniquesmay be :ffective. ASKTHE PATIENT o Does lying on your back with your kneesbent for 15to 20 minurescauseany problems[oryou? o Does lying on your stomachfor :[5 to 20 minutes causeany problemsfor you? . . . disorientedpatients
in the halter or belts,becomingentangledor altering the amount of force drey receive.It is recommended that only manualtraction techniquesbe usedto treat disorientedpatients.
Usecervicaltractionwith cautionfor . . . . . . patients with (TM) problems
temporomandibular
joint
In patientswith TMJ problems,or a history of such problems,it is recommendedthat a halter that only appliespressurethrough the occiput be used rather than one that applies pressurethrough both the mandible and the occiput, becausethe latter may placepressureon the TMJs and thus aggravatepreexistingjoint pathology.Many cliniciansusean occipital halter with al1patientsin order to avoid the possibility of causingTMJ problemsin patientswho did not havesuchproblemspreviously. ASK THE PATIENT: o Do you haveproblemswi*r your jaw? . . . patients who wear dentures The patientwho wears denturesshouldbe instructed to keep the denturesin placeduring treatmentwith cervicaltraction becausetheir removal can alter the alignment of the TMJs and may causeproblems if pressure is applied to these joints through the mandible.To protect denturesand the teeth, as well asthe TMJs,an occipitalhaltershouldbe used.
It is recommendedthat mechanicaltraction not be appliedto disorientedpatientssincethey may move
ASK THE PATIENT: . Do you wear dentures? . Do you havethem in now?
Patient Recommendations andInstructions
TRACTION ADVERSE EFFECTS OFSPINAL
Instructthe patientto try to avoid sneezingor coughins while on full traction becausethese activities inirease intraabdominal pressure and can thus ilcreaseintradiscalpressure.It is also recommended rhat the patient empty the bladder and not have a heavymealbeforelumbar traction sincethe constriction of the pelvic beltsmay causediscomforton a fuIl bladderor stomach.
Although no systematic research has been performed on the adverse effects of spinal tractior\ some casereportssuggestthat prior symptomsmay be increasedby the application of lumbar traction exceeding50% of the patient'stotal body weight or by the application of cervical traction exceeding These 5b% of th; weight of the patient'shead.33'50 reportsstandin contrastto the finding that the force
318
,lo . Tractioll
responseto the applicationofinversiontractionl of traction must be at least50% of the patient'sbody fore, it is thought that the application of this type in order to achieve separation of the lumbar weight traction could increasethe risk of a cardiovascular in pain after vertebrae,r2 Becausea reboundincrease the initial applicationof high-forcetraction canoccur, dent or myocardial infarction in the patient Becauseof these uncontrolled hvpertension.52-54 it is generally recommendedthat traction force be use of inversion ffaction is not ble risks, the then be gradukept low for the initial treatmentand for its applicati therefore instructions ally increaseduntil maximum benefit is obtained. mended,and not provided in this book. are Specificrecommendationsfor the amount of traction Auto-traction,a form of self-tractionthat force to be usedfor differentregionsof the spineand differentspinalconditionsaregiven below in the sec- the useof a purpose-builttablewith sectionsthat be moved apartby the patient during treatment, tion on appiicationtechniques. It has been reponedthar some patientsexperience alsopopularfor a numberofyears;however,this of table is no longer being manufactured,and lumbar radiculardiscomfortafter receivinstreabrent with intermittentcervicaltracrionfor cerviialradicular fore directionsfor its applicationarealsonot in this book. symptoms.5lThirty-threepercentof the patientswho When selecdngthe rype of spinalrraction.patj were reported to experiencethis adverseeffect had position,tractionforce,and durationand ftequency and transitionallumbar vertebraeon roentgenograms, treaffnent to be used, the effects of these 837ohad evidenceof spinalosteoarthritis.Their onset of lumbarradiculopathyaftercervicaltractionsuggests parameters of treatment, the nature of the pa problem,andthe patient'sresponseto prior thataxialtensioninducedin the spinalcord'sduralcovshould be considered.Guidelinesfor the ering was transmittedfrom the cervicalspine to the applicationtechniquefor eachof the abovetypes lumbar nerveroots,and that limitationsin neryeroot ffaction, and the advantagesand disadvantages excursion caused by structural abnormalities and each,areprovidedfollowing.However,if the degenerativechanges in these patients probably tensionbeingplacedon the nerve undentandsthe principlesunderlyingthe resultedin excessive of this type of treatmengmany of thesetechniques symptoms. roots,provokhglumbarradicular be modified or adaptedbv the clinicianto suit indi Other adverseeffectsof spinaltraction have been describedin detail above in the sectionsdescribing ual cllnicalsituations,suchaswhen a patientdoes toleratethe standardposition(s)usedfor treatment andprecautions. contraindications when preferredequipmentis not available. Ior all forms of traction, the clinician should TECHNIOUES APPLICATION determineif the presentingsymptoms and pro are likely to respond to treatment with t(action. Traction can be applied in a varieqy of ways. clinician should also determine that traction is Treatmentwith traction at this time includesthe use contraindicatedfor this patient or condition.Tra of electric and weighted mechanicaldevices,selfcan be appliedto the lumbar or cervicalspine;h traction. Dositionaltraction. and manual traction. ln ever,someformsof rractionareappropriatefor the past, traction was also applied using inversion one areaor the other,while otherscan be applied techniquesand purpose-builtauto-tractiontables. eitherwith appropdatemodilications. Inversion tractiory which is applied by placing the patientin a devicethat requiresa head-downposition, usesthe weight of the patient'supper body to apply Traction Mechanical tractionto the lumbar spine.This form of tractionwas Mechanicaltraction can be applied to the lumbar fairly popularin the past70to 20 years;however,most invenion tractiondeviceshaverecendybeenremoved cervicalspine. A variety of belts and halters,and number of different patient ffeatment positions, from the U.S. market by their manufacturersdue to concemsregardingpotentialadverseeffectsin patients be usedto applytractionto differentareasof the spinc and to focusthe effecton differentseqmentsor strucwith hypertension.Significantincreases in systolicand diastolicblood pressureand oph*ralmic artery pres- tures. Electric mechanicaltraction units can appl'y static or intemittent traction of varying torce.With sure have been documentedin subjectswithout carstatic traction, the same amount of force is applied diovasculardiseaseor a history of hypertensionin
Ttvo o THE PFIYSICAL ACENTS
319
-.:oughout the treatment session. With intemittent ..tionr the traction force alternates between two set nts every few seconds throughout the tteatment .;sion. The force is held at a maximum for a number : seconds,the hold period, and is then reduced, usu,,. by about50%, for the following relaxationperiod.
and effectively,the following procedureshould be followed.
: :uipment Required ' :' Elearical MechanicalTraction . - ractionunit . , horacicand pelvicbelts,cervicalhalters . jpreaderbar . -xtensionrope
. Split traction table (optional) For \Y/eigh ted M echau i caI Traction o Traction device (ropes, pulley, weights) . Thoracic and pelvic belts, cervical halters o Spreaderbar o Weight bag for water, weights, or sand
Weighcedmechanicalrraction unit' dpply 5ratic rraction only, with the amount of force being determined by the amount of weight used. ln
nrlcr
ro
u: n Hn t , lJ'
m , . ,c! r! ,h. :v n , 1i \r - d
L
'"--'i^-
'rdrLru'r
^-r.r"
rd'c'y
: lOCEDURE alectrical Mechanical Traction Units :st clinics have one ormore electric mechanical trac-:r units available. These units use a motor to apply ,:tion forces to the Iumbar or cervical spine, statically : :ntermittently, and can be used to apply forces of up -0 : kg (150 lb). These units have the advantage of - r-1g able to apply static or intermittent traction to the ,rbar or cervical spine, and they allow fine, accurate :rtrol of the forces being appiied. These units also rw considerable variation ir patient position. The . -st significant limitations of electric mechanical trac' :r devicesare their cost and size (Iig. 10-4).
)ver-the-Door Cervical Traction Devices cervicaltractionunitscanbe usedfor - .er-the-door
-: application of static cervical traction only. The ::-ited treatment flexibility of these devices makes -..m appropdate primarily for home use. ln this set- -=. they have the additional advantages of being -.:xpensive, easy to set up, and compact. The patient ruld be educated regarding their position, and the i-:-ount and duration of force to use pdor to usine -:h a deviceat home. )ther Home Traction Devices . :rumber of other spinal traction devices are also . , i l a b l ef o r h o m e a p p l i c a t i o no f s t a t i co r i n t e r m i t '.:,r Iumbar or cervical traction (Iig. 10-5, A and B). -::se devices offer more treatment oDtions but are
Figure 10-4. Mechanical traction unit. ChattanoogaCroup, Inc., Hixson, TN.)
(Courtesy
320
40 . Tr.tctiotl
generally considerably more expensive than over-thedoor devices, are more complex to use, and generally take up more spacein the home.
Mechanical Lumbar Traction Procedure
Determine optimai patient position. When positioning the patient, try to achieve a comfortable position that allows muscle relaxati while maximizing the separation between tbc
1. Selectthe appropdatemechanicaltractiondevice. Various devices are available for applying mechanicalkaction to the lumbar spine in the clinic or home setting.The choicedependson the amount of force to be applied,whether static or intemittent traction is desired,and the settins in which the ueatmenrwill be aoplied.
involvedstructures. The relativedesreeofflexion extensionof the spine during traction determirs which surfacesare most effectivelv separated5 The flexedposition resultsin greaterseparation the posteriorsffuctures,including the facet joim and intervertebralforamina,whereasthe neutral extendedposition resultsin greaterseparation
Figure10-5. Examples of home traction devices. (A, Courtesy Chattanooga Group, Inc., Hixson, TN; B, Courtesv Elastatrac,SanJose,CA.)
Two . THE PIIYSICAL ACENIS
Anteriorseparation (backward bending)
321
Posterior separation (forwardbending)
: lure 10-6. Effects of anterior and posterior separation :-- the spinaldisc.
rie antedor structures,including the disc spaces Gig. 10-0. In most cases,a symmetrical cenftal forceis used,in which the directionofforce is in line with the centralsagittalaxisofthe patient(Iig. 10-2, -,{);however,if the patientpresentswith unilateral symptoms,a unilateraltraction force that applies mote fotceto onesideof the spinethan to the other may proveto be more effective.55 A unilateralforce canbe appliedby offsettingthe axisof the traction il the direction that most reducesthe patient's symptoms.Forexample,if *re patientpresentswid-r right low back and lower extremity pain that is aggravated by right sidebendingand is relievedby left sidebending,the tractionshouldbe offsetso as to applya leFtsidebendingforce(Iig.10-Z,B). For the applicationof ffaction to the lumbar spine, d-repatientmay be positionedproneor supine(Iigs. l0-8 and l0-9). Supinepositionirrg is more commonly used; howeveq prone positioningmay be ifthe patientdoesnot tolerateflexion advantageous being supine, or if the symptomsare reducedby or extensionor by beingin the proneposition.Creater lumbar paraspinalmusclerelaxationand lessEMG actjvityhavealsobeenreportedduringrractionin the prone rather than the supine position.56 Clinically,symptomsof discaloriginarealsousually most reducedin the proneposition,when the lumbarspineis in neutralor extensionandthe discspace is most separated(seelig. 10-Q,while symptoms due to facet joint dysfunction are most reduced when the patientis positionedsupinewidr dre hips flexed.when d-relumbarsoineis flexedandthe facet joints are most separatedi3Proneneutralpositioning ofuhelumbarspinealsolocalizesthe forceofthe
Figure10-7,Lumbar traction. A, Central axis lumbar traction. B, Unilateral lumbar traction. (A, Courtesy ChattanoogaCroup, Inc., Hixson, TN.)
haction to the lower lumbar segments, whereas supine flexed positioning localizes the uaction force to the upper lumbarand lower rhoracicsegments. The patientshould lie ona split traction table,wi*r the area ofthe spine to be distractedpositioned over Continuerl
322
| 0 . Trcctiotl
the split, and, if supine, with d1e lower extremrtres supported on a suitable stool that does not interfere with the motion ofthe traction rope. A spiit traction table separatesinto two sections,with one section sliding away from *re other when the sections are unlocked and traction is applied (Fig. 10-10). This type of table reduces the amount of traction force lost to friction between the patient and the table becausethe lower half of the patient's body moves with the lower section of the table. Thus less trac-
Figure10-8. Prone lumbar traction with spine in neutral or slight extension.(Courtesy Elastatrac,SanJose,CA.)
Figure10-9.Supinelumbar traction with spine in flexion. (Couftesy ChattanoogaCroup, Inc.,Hixson, TN,)
tion forceis neededwhen a split tableis usedthan when a nonsplittableis usedin orderto providethe same amount of distractiveforce to the lumbar spine.57Initially the patient should be positioned with the sectionsofthe tablelockedtogethersothat the uble doesnof moveas the patienrmovesjnto the treatmentposition.The sectionsshouldthen be slowly unlocked,after the traction force has beer applied,in order to controlthe speedat which the initial tractionforceis applied. 3. Apply the appropriatebeltsorhalter. Hear,y-duty non-slip thoracic and pelvic belr should be used to securethe patient during the application of mechanicallumbar traction (Fi; | 0- | 1\ I heseheltsmrr"t he nlacedwidl dte nor slip surfacedirecdy in contact widr t\e patients skin,andnot over the clothing,and both beltsmus be securelytightenedin order to preventslippir:g when the uaction force is applied.The belts ca: either be placed on the table at the appropriae level,andthen adjustedwhen *re patientliesdow: on them, or they canbe securedaround*re patiem first and then securedto d-retable after the patiecr lies down. The thoracicbelt is usedto stabilizethe upperbody abovethe level at which tractionforce is desiredin orderto preventthe patientfrom beini
Two . THE PIIYSICAL ACINTS
Figurel0-10. Splittractiontable.
323
Figure 10-12.Positioningof beitsforlumbartraction.
desired,generallyjust supedorto the iliac crests(or superiorto the superioredgeof the sacrumif the patientis prone)(Iig.10-12). When the patientis supinewith the lumbarspine in slight flexion, as indicatedto maximize distraction of the posteriorspinalstructures,the pelvicbelt shouldbe placedwith the fasteninganteriorlyand the rope posteriorly so that the pull is primarily from the posterior aspectof the pelvis (seelig. 10-9).\\4ren the patientis prone,with the lumbar spinein neutralor slight extension,as indicatedto maximize distractionof tie anterior spinal structures,the pelvicbelt may be placedwith the fastening posteriorly and the rope anterioriy so *rat *re pull is primarilyfrom the antedoraspectof the pelvis.58 4. Connectthe beltsor halterto the rractiondevice. Iasten the thoracic belt to the table above the patient'shead and connectthe pelvic belt to *re tractionunicusinga ropeanda )preaderbdr. 5. Settheappropriatetractionparametersf|able 10-1). Selectstaticor intemittent tractionand then, for statictraction,set the maximum tractionforce and :gure 10-11. the totalrracriondurar.ion, or, tor intermirrenr trocTraction belts. (CourtesyChattanooga tion, set the maximum and minimum fiaction force, ,roup, Inc.,Hixson,TN.) hold andrelaxtimes,andthe total tractionduration. pulled down the table by the force on the pelvic belt and in order to isolatethe tractionforce to the appropriate spirral segments.The thoracic belt shouldbe placedso that its lower edgealignswith the superior limit at which the traction force is desired,and with its upper edgealignedapproximately with the xiphoid immediately below *re greatesrdiamerero[ rbe rhorax. lhe pelvic belc should be placed so that its supedor edge aligns with the inferior limit at which traction force is
Static or lntermittent Traction Mechanicaltraction may be administeredstatically, with the sameforcethroughoutthetreatment,orintermittently, with the force varying every few seconds throughoutthe treatment.Someauthorsrecommend that only statictractionbe appliedin order to avoid a stretchreflex of the muscles;10 however,othersreport that static and intermittent traction are equally effective but that higher forcescan be usedwith intermittent traction.59No differencesin lumbar sacrospinalis Colititued
324
p
10 . Tt action
f O-f RecommendedParametersfor the Application of Spinal Traction Area ofthe spine and goals of treatment
Force
Hold/relax times (seconds)
Total traction time (minates)
Lambar Initial/acutephase Jointdistraction Decreasemusclespasm Disc problemsor stretchsoft tissue
13-20kg 22.5kg;50?l ofbody weight 25% ofbody weight
Static 15/1,5 5/5 60/20
5 -1 0 20-30 20-30 20 30
Cen'ical Initial/acutephase Jointdistraction
J-4 Kg
Static 15/1,5 5/5 60/24
5,10 20-30 20-34 20-34
Dprrp:
m',
c-,.-
Disc problemsor stretchsoft tissue
9-13kg;7% of bodyweight 57kg 5-7 kg
EMC activity or vertebral separation have been found when static and intermittent traction of the same force have been compared.60,61 lt is generally recommended that static traction be used if the area being treated is inflamed, if the patient's slmptoms are easily aggravated by motion, or if the patient's symptoms are related to a disc protrusion.lo Intermittent traction with long hold times may also be effective for treatment of symptoms related to disc protrusion, while shorter hold and relax times are recommended for ,ympton, relaredto joint dysfuncrions. HoldlRelax Times If intermittent traction is selected, the maximum traction force is applied dudng the hold time and a lower traction force is applied during the relax time. The recommended ratio and duration of the hold and relax times depend on the patient's condition and tolerance. In general, if intermittent traction is used for treatment of a disc problem, longer hold times, of approximately 60 seconds, and shorter relax times, of approximately 20 seconds, are recommended, whereas if traction is being used to treat a spinal joint problem, shorter hold and relax times of approximately 15 secondseach are recommended.ll Symptom severity should also be used as a guide for determin ing hold and relax times. When the patient's symptoms are severe, both long hold and long relax times are recommended in order to limit the amount of
movement. As the symptoms become less severe,the relax time can gradually be decreased,and when the discomfort has decreasedto a loca1ache rather than a pain, the hold time can also be reduced so that wher the symptoms are mild, the traction produces ac oscillatory motion with very short hold and relax times of approximately 3 to 5 seconds each.
Force Differentauthorsvaryin theirrecommendations witl regardto the amount of forceto be usedfor traction: however,most agreethat the optimalamountof force dependson the patient'sclinicalpresentation, dre goaL of treabrent, and the patient'sposition dudng reatment.10,17,18 lor all applications,the force should be kept 1ow during the initial tractionsessionin ordertc reddcethe risk of reactivemuscleguardingand spasm: and to determineif tractionis likely to aggravatethe patient'sslrnptoms.The tractionforcecanbeincreasei graduallyin subsequent sessions asthe patientbecome= usedto the procedure.It is recommendedthat, for aapplications, the tractionforceto the lumbarspinestan at between13and20 kg (25to 50lb). Whenthegoalis to decrease compressior on a spina nelveroot or facetjoint,sufficientforceto separatethe facetjoints in the areabeing treatedmust be used.Ii the lumbarspine,ithas beenshownthat this requiresa force of between 22.5 kg (50 lb) and approximatelv 60% of the patient'sbody weight.11'60'62
Two . THE PHYSICAL AGENTS
-ilhen
the goal is to decreasemusclespasm,stretch tissue, or exert a centripetalforce on the disc by icr-lal elongation without joint surface separation, :':.'er forceso[25Y" of total bodyweight for the lum:€: spine are generally effective.When this is the r-al. the applicationof a hot packin conjunctionwi*r :3 traction may result in greater spinal elongation ::-J thusmore effectivereliefof symptoms. rJghertraction forces are needed when patient ::sitioning, or the hamessor table,requiresthe trac::r forceto overcomegravity or friction betweenthe :;ient and the table.For example.when lumbar trac::r is appliedwithout a split tableandthe tractionhas = overcomethe friction between the Datient'sbodv .- j rhesurfaceo[ the table,highertractionforcesmay :E necessarywhereaswhen gravity and ftiction are =iuced, as occurswith lumbar traction when a split --:le is used,lower tractionforcesmay be sufficient. -he force of traction can be adjusted during or :E:weentreaffnents.The force should be decreased :;:ing the treatment if there is any peripheralizationof i,:ns oI s),'mptomsor, asmentionedabovein the sec---r:n on precautions, if thereis completereliefof severe :,=r. If the patient's syrnptoms are moderately -:reased by tractiorythe forcecanbei ncreased,by 2 to i sg (5 to 15lb) for lumbartractio4 at eachsubsequent =atrnent sessionuntil maximal reliefof snrnptomsis ;::reved. Tracdon force to the Iumbar spine should .-=rerallynot exceed50% of the patient'sbody weight. 'Vhen intermittent traction is used, the relaxed -:ce shouldbe approximately50% of the maximum -:ce orlesslhowever,total releaseof the forceduring :-e relaxedphaseof intermittent tractlon 1snot rec:rmended sincethis canresultin a reboundaggrava:rn of the patient'ssymptoms. TotaI Treatm ent D uration liere are no publishedstudiescomparingthe effects -- different fieatment durations; however. most ::'lthorsrecommendthat *re duration of a patient's =st treatmentwith traction be brief; that is, about 5 jrutes if the initial symptomsaresevereand 10min'-:esif the initial symptomsare moderate,in order to :jsessthe patient'sresponse.11,63 If severesymptoms ::e significantlyrelievedby brief low-force traction, re durationof treatmentshouldbe kept shorq other.-u'ise, symptom exacerbationafter the treatment is :<ely.If the patient'ssymptomsare partially relieved :ter 10 minutes of traction, it is recommendedthat :.reduration of the initial treatrnentnot be extended:
325
however, if symptoms are unchangedafter 10 minutes,the hold force may be increasedslightly or the angle of pull modified, and treatment may be continued for a further 10 minutes. Recommendations for *re durationofsubsequenttreatmentsvary ftom as short as8 to 10 minutesfor treatmentof a discprotrusionll to aslong as20 to 40 minutesfor this and other indications.38 Treauaentfor longerthan 40 minutesis generallythoughtto provideno additionalbenefit.
TreatmentFrequency Some authors state that spinal traction must be administereddaily to be effective;however,thereare no published studiesevaluatingthe outcome of differenttreatmentfrequencies.ll,3B 6. Startthe traction. When applyingtractionto the lumbar spine,if a split table is being used,first allow the traction to pull for onehold cycleto takeup the slackin the belt and rope and theq duringthe following relaxation of lhe traction, releasethe sectionsof the table slowly.If statictractionis beingused,the sectionsof *re tablemay be releasedafter the tractionforceis applied.The therapistshouldmanuallycontrolthe rate of separationof the sectionsin orderto prevent suddenmotion of the patientand the lower section of the table.If a split tableis not available,the traction devicewill takeup the slackin the belt andrope duringthe first hold cycle.When usinga split table, oncethe sectionsare released,the forceof the traction pulls the patient and the lower sectionof the tablesimultaneously, and so doesnot haveto overcomeftiction betweenthe patientandthe surfaceof the tabie. Ior this to occur,it is essentialthat the lower sectionof the table actuallymove back and forth during the hold and relax rycles, rather than being stationaryat its position of maximal excursion,where it will act as a staticsurface.The clinician shouldobservethe tractionbeingapplied,and the movementof t}retablefora few cycles,andthen make any necessaryadjustlents to ensurethat the tractionis producingthe desiredeffect. Z. Assessthe patient'sresponse. It is recommendedthat the clinicianassessthe patient'sinitial responseto the applicationof traction within the first 5 minutes of treatment so that any adjustmentscanbe madeat that time if needed. 8. Cive the patienta meansto callyou and to stop the tractlon. Contirued
10 . Tf.rctiott
326
Most electric mechanical traction units are equippedwith a patient safety cutoff switch that turns off the unit and rings a bell when activated. Instruct the patient to use this switch i[ he or she experiencesany increasein, or peripheralization of, pain or other symptoms. 9. Releasetraction andassessthe patient'sresponse. When the traction time is completed,lock the split sectionsof the table,releasethe tensionon the traction ropes,and allow the patientto restbriefly before getting up and recompressingthe joints. Then reexaminethe patient'ssignsand symptoms. ADVANTAGES . Iorce and time well-controlled,readilygraded,and replicable. o Once applied,doesnot require the clinician to be with the patientthroughoutthe treatment. o Electricalmechanicaltraction units allow the applicationof staticor intermittent traction. . Staticweighted devicessuch as over-the-doorcervical traction are inexpensiveand convenientfor independentuseby the patientat home. DISADVANTAGES o Expensive electricmechanical devices. .
Timc-.^n
tn
o Lack of patientcontrol or participation. . Restrictionby belts or halter poorly tolerated by somepatients. o Mobilizes broad regions of the spine rather than individual spinal segments,potentially inducing hypermobility in normal or hypermobilejoints. MECHANICALCERVICALTRACTION PROCEDURE64 1. Selectthe appropriatemechanicaltractiondevice. Variousdevicesareavailablefor applyingmechanicaltractionto the cewicalspinein the clinicorhome setting.The choicedependson the region o[ the body to be treated,the amountoIforceto be applied, whetherstaticor intemittent ftactionis desired,and the settingin which the treatmentwi.ll be applied. 2. Determineoptimal patientposition. When positioning the patient, try to achievea comfortablepositionthat allows musclerelaxation
while maximizing
the separation bewveen Sc
The relativedeereeof flexion involvedstructures. extension of the spine dudng ftaction determi
aremost effectivelyseparated.dr which surfaces flexed position resultsin greaterseparationof postedor structures,including the facet joints intervertebralforamina, whereas dre neutral extendedpositionresultsin greaterseparationot anteriorstructures,includingthe discspaces(see 10-6. ]n most cases.a svmmetricalcentralforce used,in which the directionof forceis in line the centralsagittalaxisof the patienqhowever,if patientpresentswith unilateralsymptoms,a eral traction force that aoplies more force to one
of the spinethan to the othermay proveto be effective.Ss A unilateralforcecanbe appliedby settingthe axis of the tractionin the direction most reduces*re patient'ssymptoms.Ior if the patientpresentswith right neck or arm that is aggravatedby right side bending and relievedby left sidebending,the tractionshould offsecsoascoapplya ieftsidebendingforce. Ior the application of traction to the spine,the patientmay be in the supineor the position(Iigs. 10-13and 10-14).Certain traction devices can only be used in one of positions, while others can be used in either tion. Ior examole. over-the-door cervical tracti
units must be applied with the patient whereas the Saundersoccipital cervical tra halter can only be usedwith the patient supinethe supineposition,uhecervicalspineis and non-weight-bearing, resulting in patient comfort and musclerelaxationand separation between the ceruical segments
when the sameamount of traction forceis with the patient in the sitting position.l3 When
patientis supine,cervicalflexior5rotation,andsi bendingcanbe adjustedfor patientcomfort and focus the traction force on the involved area 10-15).When cervicaltraction is appliedin the ting position,cervicalflexion and extensioncan controlledto a iimited degreeby placingthe pati facingtoward (moreflexion)or away from or more extension) the traction force;
cervicalside bendins and rotation are difficult
Tlco o THE PIIYSICAL ACENTS
: --e10-13.Supineceryicaltractionwith soft mandibu. .-.alterwith approximately 20- to 30-degreeangle of :o maximize separationof the intervertebral foram: :ld discspaces. .Jjust in the sitting position. Placing the cervical : i n e i n a n e u t r a l o r s l i g h L l ye x t e n d e dp o s i t i o n rcuses dre ffaction forces on the upper cervical : r n e . w h i l e p l a c i n gt l e c e w i c a ls p i n e i n a f l e x e d :osition focuses the traction forces on *re Iower :ervical spine.45,65Maximum postedor elongation :f the cervical spine is achieved when the neck and .ngle of pull are at approximately 25 to 35 degrees ,f flexion, as shown in Figure 19-13.ts'66 \pply the appropriate belts or halter. A number of different cervical halters have been :eveloped to maximize patient comfort and avoid :xcessive pressure on the TMJS during the applica: o n o f c e r v i c a rl r a c r i o rt F r g .l 0 [ 6 ) . f h e r e a r e s o f t :abric halters that apply pressure through both the nandibles and the occiput and soft fabric halters :hat apply pressure only through the occiput. The jaunders frictionless traction halte! which is solid and padded, is also designed to apply pressureonly :hrough the occiput. The adjustability of the halter, :he patient position, and the status of the TMJs
327
-l Figure10-14, Sitting ceruicaltraction, set up with the cervical spine in neutral.
Fig re 10-15. Supine cervical traction with right sidehpnrlino enrl rnrrr'nn
should all be considered in selecting the most appropriate cervical halter for a particular patient. The halter should be adjustable to accommodate variations in the shape and size of patients' heads
10 . Tractiolr
5. Set the appropriate rraction parameters ( Table 10-1). Selectstatic or intemittent traction and then, static traction, set the maximum tuaction lorce the cocalrractionduration, or, tor irtermittenr hon, set the maxlmum and mlrumum ractlon hold and relax times, and the total traction
Static or lntermittent Traction AB Figure10-16.Cervicaltractionhalters.A, Saundershal ter B, Mandibularhalter. and necksand to allow for differentanglesof traction pu1[.A halter that applies force through the mandibles and the occiput should allow adjustment of the distance behreen the occiput and spreaderbar, the chin and spreaderbar, and the mandiblesand occiput.The tension on the straps should be adjustedso *rat the pull is comfortably and evenly applied to both the occiput and tb.e mandibles. A halter that only applies pressure through the occiput should allow size adjustment and shouldbe adjustedto fit snuglyenoughto stay on during the applicationof traction.The soft halters can be used in the sitting or supineposition, whereasthe Saundershalter can only be used in the supineposition;however,the soft haltersthat apply pressurethrough the occiput tend to slip off the patient'shead when traction is applied, even when appropriatelyadjustedfor size,whereasdre Saundershalter,which alsoavoidspressureon the TMJs, generallyremains securelyin place when traction is applied. The Saundershalter is also designedwith a low-friction slidingcomponentfor the patient'shead so that the traction force does not have to overcome friction between the patient's head and the table. Therefore, slightly lessforce should be appliedwhen using this type of halterthan when usinga soft fabrichalter. 4. Connectthe beltsor halterto the tractiondevice. Ior cervicaltraction, all types of soft fabric halters are connectedto the traction deviceby a rope and spreaderbar, and the Saundershalter is connecreddirecdyro rhe Lracliondeviceby a rope.
Mechanical traction may be administered with dre same force throughout the treatment, or
mittendy.with the forcevaryingevery few throughout the treatment. Some authors
that only statictractionbe appliedin order to avoid stretchreflex of the musclesllohowever,othersrepo that static and intermittent traction are eouallv
tive but that hisher forcescan be usedwith tent tractionls9and others have found ffaction to be most effective for reducinqpain increasingcervicai ROM.67 It is generally mendedthat static traction be usedif the area treatedis inflamed,if the patient'ssymptomsare aggravated aggravated bymotion, bymotion, or if the the patient's patient'ssymptoms sympto. related to a disc proffusion.l0 Intermittent tract with long hold times may also be effective for ment of symproms related co disc prouusion. shorter hold and relax times are recommended rymptoms related ro joint dysfunctions.
Hold/RelaxTimes If intermittent ftaction is selected,the maximum
tion forceis appliedduringthe hold time and a tractionforceis appliedduringthe relaxtime. The ommended ratio and duration of the hold and times depend on the patient's condition and In general,if intennittent traction is used for
of a discproblem.Iongerhold rimes.o[ approxi andshorterrelaxtimes,of approximately 60 seconds, seconds,are recommended, whereas if traction is used to treat a spinal joint problem, shorter hold relax times of approximately 15 seconds each are
ommended.llSymptomseverityshouldalsobe used a guide tor detennininghold and relaxtimes.\A4.ren
patient'ssymptomsaresevere,both longhold and relax times are recommendedin order to limit amount of movement.As the symptomsbecome
Two . THE PIIYSICAL AGENTS
ivere, the relax time can gradually be decreased,and -rhen the discomfort has decreasedto a local ache :atherthan a pain, the hold time can also be reducedso :rat when the symptoms are mild, the traction proirces an oscillatory motion with very short hold and ::lax times of approximately3 to 5 secondseach. Force lifferent authors vary in their recommendationswith ::gard to the amount of force to be usedfor traction; :owever,most agreethat the optimal amountof force :ependson the patient'sclinicalpresentatiorlthe goals :: treament, and the patienr'sposition during treatrent.t0 I'For aLlapplications. the torceshould6e kept ow duringthe initial tractionsessionin orderto reduce ie risk of reactivemuscleguardingand spasmsandto jetermine if traction is 1ike1yto aggravatethe patient's i"rnptoms. The traction force can be increasedgradu.Jy in subsequent sessions asthe patientbecomesused -c the procedure.It is recommendedthat, for all appliations, the tractionforceto the cervicalspinestart at :et\,veen3and4 kg (8 to 10lb). When the goal is to decreasecompressionon a :lirlal nerveroot or facetjoint, sufficientforceto sep:.iatethe facetjoints in the areabeingtreatedmust be =ed. In the cewicalspine,9 to 13 kg (20 to 30 1b),or :pproximately 77:ool the patient's body weight, is .enera1lysufficient.11,60,62 \44:renthe goal is to decreasemuscle spasm,stretch :oft tissue, or exert a centripetal force on the disc by pinal elongationwithout joint surfaceseparation,5 to 7
329
of signsor symptoms o! as mentioned abovein the section on precautions,if there is completerelief of severepain. If the patient'ssymptomsaremoderately decreasedby traction, the force can be increased,by 1.5to 2 kg (3 to 5 lb) for cervicaltraction,at eachsubsequent tleatment session until maximal relief of slrnptoms is achieved.Traction force to the cervical spineshouldgenerallynot exceed50% of the weight of the patient'sheador 13.5kg (30lb). When intermittent traction is used, the relaxed forceshould be approximately50% of the maximum forceor less;however,total releaseof the forceduring the relaxedphaseof intermittent traction is not recommendedsince*ris canresultin a reboundaggravation of the patient'ssymptoms. Total Treatment D uratio n There are no publishedstudiescomparingthe effects of different treatment durations: however most authors recommendthat the duration of a patient's first treatmentwith traction be brief, about 5 minutes if the initial s;nnptomsaresevereand 10 minutesif the initial symptomsare moderate,in order to assessthe patient'sresponse.11,63 If severesymptomsare significandy relievedby brief low-force tractioq the duration of treaffnent should be kept short; otherwise, symptom exacerbationafter the treatmentis likely. If the patient'ssymptomsare partially relievedafter 10 minutesof traction,it is recommendedthat the duration of the initial treabnentnot be extended:however. if syrnptomsareunchangedafter 10minutes,the hold force may be increasedslighdy or *re angle of pull modified, and treatmentmay be continuedfor a further 10minutes.Recommendations for the durationof subsequenttreatmentsvary from as short as 8 to 10 minutesfor treatmentof a discprotrusionll to aslong as 20 to 40 minutes for this and other indications.38 Treatment for longer than 40 minutes is generally thoughtto provideno additionalbenefit. Treatment Frequency Some authors state that spinal traction must be administereddaily to be effective;however,thereare no published studiesevaluatingthe outcome of dif11,36 ferenttreatmentfrequencies. 6. Startthe traction. The patient should be observedfor the first few cyclesof cervicaltraction to ensurethat the halter Continued
tO . Tractiotl
is staying in placeand exertingforce through the appropriateareasand to ensurethat the patient is comfortable and not experiencingany adverse effectsfrom the treatment. the patient'sresponse. 7. Assess It is recommendedthat the clinician assessthe patient'sinitial responseto the applicationof traction within the first 5 minutesof treatmentso that any adjustments can be made at that time if needed. 8. Give the patienta meansto callyou andto stop the tractlon. Most electric mechanical traction units are equippedwith a patient safety cutoff switch that turns off the unit and rings a bell when activated. Instructthe patientto uset'hisswitch if he or she experiencesany increasein, or peripheralization of, pain or other symptoms. 9. Releasetractionand assessdre patient'sresponse. When the traction time is completed,lock the split sectionsof the tabie, releasethe tension on the traction ropes, and a1low the patient to rest briefly before getting up and recompressingthe
Self-Traction Self-tractionis a form of tractionthat usesgraviryand the weight of the patient'sbody, or force exertedby the patient, to exert a distractiveforce on the spine. Self-tractioncanbeusedfor the lumbarbutnot the cervical spine.Self-tractionof the lumbar spineis appropriate for home use by the patientwhose symptoms arerelievedbylow loadsofmechanicaltractionor that are associatedwith mild to moderatecompressionof
SITTINGSELF.TBACTION The patientshould: 1. Sit in a sturdy chairwith arms. 2. Hold on to the arms of the chair and push down ,, irh thc ,rrc
lifrino .h" r.unk to reduce rhe
weight on the spine (Iig. 10-17).The patient may
joints. Then reexamine the patient's signs symptoms. ADVANTAGES Forceand time well controlled, readrlygraded, replicable. o Once applied, does not require the clinician to with the patient throughout the treatrnent. o Electrical mechanical traction units allow the cation of 'tatic or incermittent traction.
. Staticweighted devicessuch as over-the-door vical traction are inexpensiveand convenient independentuseby *re patientat home. DISADVANTAGES r Expensiveelectricmechanicaldevices. . Time-consumingto setup. o Lackof patientcontrol or participation. . Resffiction by belts or halter poorly tolerated somepatients. . Mobilizes broad regions of the spine rather individual spinal segments,potentially hypermobjliryin normalor hypermobilejoints.
spinalstructures.Becausethe amountand duration force that canbe appiiedby self-tractionis limited the upperbody strengthof the patientand the wei of the lower body, self-tractionis not generally tive when high forcesare required to relieve toms with mechanicaltraction or when distraction the soinal ioints is necessary.Self-tractioncan appliedin a numberof differentways, a few o[ whi are describedfollowing. All methodsof applying tuactionattemptto fix the patient'supperbody and
gradethe forceof the traction by varying the of the downward pressureon the armsof the and thus the degreeof unweighting of the however. the patient should keep the feet on
floor at all times in order to control position.
Two . THE PIIYSICAL AGENTS
331
Figure10-18. Self-tractionbetween corner counters.
Figure 10-17.Sittingself-traction for thelumbarspine. SELF-TRACTION BETWEENCORNER ]OUNTERS - he patientshould: ,. Stand in a corner with solid counter surfaces behindthe patient. -. Place*te forearmson the counterand push down with the arms in order to decreasethe weight on the spineby unweightingthe feet (Iig. 10-18).The patientshouldleavethe feeton the groundin order coconrrollumbopelvicposirion. SELF-TBACTION WITH OVERHEADBAR ,he patientshould: , Standin a partialsquatunder a horizontalbar - Hold on to the bar andpull to reducethe weight on the spine(fig. 10-19).The patient shouldleavethe feet on the groundin order to controllumbopelvic posluon. ADVANTAGES r Minimal or no equipmentneeded. . Easyfor patientto perform.
Figure10-'19.Self-tractionwith overheadbar Corrinued
332
10 . Tractiotl
. Easyfor patientto control. o Can be performedin many environmentsand thus many times duringthe day. DISADVANTAGES . Low maximum torce; therefore may not be effective.
. Requiresstrong,injury-freeupperextremities. o C a n n o br e u s e df o r c h ec e r v i c aslp i n e . o No researchdata to support the efficacy of form of traction. Patientmust haveadequateposturalawareness controlto position the body appropriatelyfor imum benefit.
eitherthe body weight or the forceof the armsto pull on the lumbar spine.Positionsandways to apply selftraction other than those describedbelow can be developedby the clinicianor the patientwho is familiar with the principlesof self-traction.
Positional Traction Positional traction involves prolonged placement of *re patient in a position that placestension on one side of the lumbar spine only (Fig. 10-20). This type of traction gently stretchesthe lumbar spineby applying a prolongedlowJoad longitudinal force to one side of the spine. Although the low force associatedwith this form of traction is unlikely to causejoint distraction,it may effectiveiydecrease
Figure10-20.Positional traction to stretch and the 1eftlumbar area. muscle spasm. stretch soft ris'ue, or exert a tripetal lorce on the disc by spinal elongation
joint surfaceseparation.Positionaltraction may
Equipment Required o Pillow(s)
PROCEDURE Thepatientshould: 1. Lie on the side, with the involved side up and a pillow underthe waist at approximatelythe levelof the dysfunction.The pillow acts to side-bendthe lumbar spineaway from the involvedside,opening the joints anddiscspaceson the involvedside. 2. Rotatetowardthe involvedsideby movingthelower shoulderforwardandtheuppershoulderback. 3. Rotate further toward the involved side by straighteningthe inferior iower extremity,bending rhe 'uperior lower excremiry.and hooking che superior foot behind the inferior leg. Rotation toward the involved side further stretchesand opensthe involvedarea.
4. Adjust flexion/extensionto the positionof comfort and s;.'mptomrelief. 5. Maintain the position for 10 to 20 minutes. ADVANTAGES . Requiresno equipmentor assistance. o Inexpensrve. o Can be appiiedby the patientat home. o Low forcel thus not likely to aggravatean condition. o Positionreadily adjustable. DISADVANTAGES . Low force; therefore not likely to be wherejoint distraction is required.
Tto o THEPIIYSICAL ACENTS
333
. ieguiresagilityand skill by rhe parienrro perform :orrectly. r \o researchdata ro supportthe efFicacyoF thrs :crm of traction. -,:d co treat unilateral symproms originating :,in d-relumbar spineand can be a valuablecompor::rt of a patient's home program during the early -ges of recovery when symptoms are severeand =-;ible.
uanualTraction .'-:nualtraction is the application offorce by the *rer:::st in the direction of distracting the joints. It can be
\IANUAL LUMBABTBACTION - Positionthe patient in the position of least pain. This is usually supine,with the hips and knees flexed. - Positionyourself.IGreelat the patient'sfeet, facing rhe patlent. : Placeyour hands in rbe appropriareposition. behindthe patient'sproximallegs,over the muscle belly of the tricepssurae(Fig.10-21). - Apply traction forceto the patient'sspineby leaning your body back and away from the patient, k e e p i nygo u rs p i n ei n a n e u c r aplo s i L i o n . Adjust the force of the traction accordingto the Cesiredoutcome and the patient'sreport. Manual
Figure10-21. Manual lumbar traction.
usedfor the cervicaland lumbar spine as well as for the peripheraljoints. There are many techniquesfor applying manual traction; however, since manual traction is generally classified as manual therapy ratherthan asa physicalagent,only a few basictechniques for applying manual traction to the spine are describedin this book. Ior more detaileddescriptions of these and other techrLiquesfor applying manual traction to the spineor to the peripheraljoints, please consulta manualtheraovtext.10,68
traction may be static, of constant fotce, or intermi*pni
^F u,n/;no
t^r.c
MANUALCERVICALTRACTION PATIENTSUPINE ll. Positionthe patientsupine. 2. Positionyourself.Standat the head of the patient, ferino
the nerient
3. Placeyour hands in the appropriareposirion. Supinateyour forearmsso your hands are faced up; placethe lateral border of your secondfinger in contact with the patient's occiput and your thumbs behind*re patient'sears. 4. Apply traction.Apply forcethroughthe occiputby leaningback,keepingyour spinein a neutralposit:on (11g.10-22). PATIENTSITTING 1. Positionthe patientin the sittingposition, 2. Standbehindthe patient. 3. Placeyour handsin the appropriateposition.With your armsin a neutralposition,placeyour thumbs under the patient's occiput and the rest of your handsalongthe sideof the patient'sface. 4. Apply traction.Apply tractionthroughthe patient's occiputby lifting up (Iig. 10-23). Adjust the force of the traction accordingto the desiredoutcomeand the patient'sreport. Manual traction to the cervicalspinemay be static,of conof varyingforce. sLantforce,or intermirtenc. Connnued
1O o Tractiott
334
Figwe10-22.Manuacervical tracrion supine. ADVANTAGES o No equipmentrequired. .
qh^ri
o Forcecanbe finely graded. o Clinician i s p r e s e ntth r o u g h o ut r e a t m e nrto m o n i tor andassess the patient'sresponse. o Can be appliedbriefly, prior to settingup mechanical traction, to help determineif longerappiication of tractionwill be beneficial. o Can be used with patients who do not tolerate beingplacedin haltersor belts. DISADVANTAGES . limited maximum traction force,probablynot sufficient to distractthe lumbar facetjoints.
Documentation When applying traction, document the type of traction, the areaof the body the tractionis appliedto, the patient'sposition,the rype of halterif oneis used,the maximum force and the total treatmenttime, and the responseto treatment.When using intermittent traction, the force during the relax time and the hold and relax times should also be recorded.Documentation is typically wdtten in the SOAPnote format. The following examplesonly summarizethe modality component of treatmentandarenot intendedto represent a comprehensiveplan of care. EXAMPLES
When applyingintermittent mechanicalcervicaltraction, document:
Figure10-23.Manual cervicaltraction-sitting.
. Amount of traction force cannot be easily recorded. catedor specifically . Cannot be applied for a prolonged period trme. . Requiresa skilledclinicianto apply. 9: ?Lcp nIE pin pwn LAtalde.t<, u'.,,iat 0 : 9nr nzrh ceu, kn, N 4114un4u#. oo.ipUat AaAz't | 0 tgls 60 dztl 20 tzc, | 5 min. /L: n Ue funtl kartu aAtuLlr, tt w^;al f^i'a t . tlzalhzttt atuu]'r'or tu ciLot* altpt i^za4n2tu. equiaal 4n0m
fuauw,l Acna$tna 40"/"&, 60%, n dz Aud fu)zL 2 50%. ?: 9w14.uz(4lzek I 2 kA.l7kAnz'xrhzabnznl When instructing a patient in the application of traction, document: ?t cl o {u' (n& a 1 9 9E patn tAat iru;*a'tzo wilh lIuA.
0:
?t idb'alzd,
ih, azt4l^adi4a
i'L &aLL uilh a'ima., 9t
aaf'aa 50% 4. A
Tlto . THE PHYSICAL ACENTS
1 ?t o.dli.4zn b fz1444n ulkt^aalian a., dla!'a q'*U 2 A Maf -
ren applying lumbar positional traction, document:
! 9tcluUuBa c pninttut tu&zd. ep,3"5xlrp',niqlx
335
o: Arnla^
h'.tilt'nAl haAian, n 4idz Wn+ uilh F;ttotu al waitl, n a.i.dzAerd.,2a't{20 nLuna, JL ?ain dza^zntzA, 30%ctit ^O'nrl 04pdittnat taati'on. ?: PLkL pz*t^rtu haAin a4.a.l'otz at A'mz 2 -3\. Foo aa+, i!tx|.udine 4i*x A?+r)'zLl,,,firq.
) Clinkal Case Stadies a The following casestudiessummarizethe conceptsof spinal traction discussedin *ris chapter Basedon the scenariopresented,an evaluationof the clinicalfindings andgoalsoftreatment areproposed.Thesearefollowed by a discussionof the factors to be consideredin the selectionof spinal traction as the indicated treatment modality and in selectionof the ideal patient position, traction technique,and traction parametersto promote progresstoward the goals.
Case 4 TR is a 4S-year-oldmalewho hasbeenrefeuedto physicaltherapywith a diagnosisofa right L5, S1radiculopathy. He complainsofconstantmild to moderatelysevere right low backpain that radiatesto his right buttock and lateralthigh after sitting for more than 20 minutesand that is relieved to some degreeby walking or lying down. He reportsno numbness,tingling,orweaknessof the lower extremities.The pain startedabout 6 weeks ago, the morning after TR spent a day stackingfirewood. at which time he woke up with severelow back pain and right lower extr€miqypain down to his lateral calf; he alsohad difficulqystandingup straight.He had similar problems in the pasq however, they always resolvedfully aftera coupleofdays ofbed restanda few aspirins.TR first saw his doctor regardinghis present problem5 weeks ago,and at that time was prescribeda nonsteroidaianti-inflammatorydrug and a musclerelaxant and was told to take it easy.His sy'mptomsimproved to their curent level over the followine 2 weeks but have not chaneedsincethat time. He has also been unableto retum to his job as a telephoneinstallersince the onset of symptoms 6 weeks ago.An MN scanlast week showed a mild posterolateraldisc bulge at L5-S1 on the right. The patienthashad no prior physicaltherapy for his back problem.The objectiveexam is significant for a 5070 restriction of lumbar AROM in forward bending and right side bending, both of which cause increasedright low back and lower extremirypain. Left side bending decreasesthe patient's pain. Passive straightleg raisingis 35" on the right, Iimited by ght lower extremity paiq and 60' on the left, limited by
hamstringtightness.Palpationrevealsstiffnessand tendemessto right unilateralposterior-anteriorpr€ssureat L5-S1and no notable areasof hypermobility.All other tests induding lower extremity sensation, strength, and reflexesarewithin normallimits. EVALUATIONOF THE CLINICAL FINDINGS This patient presentswith the impairmentsofrestricted lumbar forward-bendingandright side-bendingmotion, pain, restdctedlumbar nerveroot mobility on the right, asindicatedby the restdctedpassivesffaightleg raising test, and bulging of the L5-S1disc.Theseimpairments have resulted in a limitation in sitting tolerance and an inability to retum to work. PREFERREDPRACTICEPATTERN Impaired Joint Mobiliry Motor lunction, Muscle Performaoce, Range of Motion, and Reflex lntegrity AssociatedWith SpinalDisorders,(4I) PLAN OF CARE The goals of fteatment at this time are to reducepain and increase sitting tolerance sufficiendy for the patient to be able to retum to limited dury work. The anticipatedlong-termgoalsof treatmentare to alleviate pain fully; to retum lumbar ROM, passivestraight leg raising, and sitting tolerance to within normal limits; and to havethe patientretum to his full work duties. ASSESSMENTREGARDINGTHE APPROPRIATENESS OF SPINALTRACNON AS THE OPTIMAL TREATMENT The distributionof this patient'spain andits responseto changesin loadingindicatethat his symptomsare probably relatedto the mild posterolateraldiscbulgeatL5-S1 on the right noted on his MRI scan.Traction is an indiwith catedtreahnentfor reducingsymptomsassociated a disc bulge or lumbar nerve root compressionand thereforeshouldbe consideredasa treatmentoption for this patient. Studieshave shown that lumbar traction can reduce disc protrusions and effectively relieve related symptoms. Traction is most likely to be effective for this patient if it is appliedin conjunctionwit}l otier Conunued
336
40 . Tutctiotl
) Clinical Case Stadies-cont'd treatrnenttechniquesincludingstrengthening,stabilization and stretchingexercises,joint mobilization, and body mechanicstrairring.Treatmentin the clinic should alsobe integratedwith a completehome program.The use of spinal traction is not contraindicatedin this patient sincethere is no displacedFragmentof annulus or areasof hypermobiJity,andthereareno indicationsof a hiatal hemia or a cardiacor pulmonarycondition that may be aggravatedby use of the belts for mechanical uacuon. PROPOSEDTBEATMENTPLAN AND RATIONALE It is proposedthat electricmechanicaltraction be used to treat this patient since this rype of traction device allows the greatestconnol of lumbar traction forceand the applicationof sufficientforce to distractttre lumbar vertebrae.Pronepositioningis recommended,if tolerated,to placethe spinein a neutralor slighdy extended position, and thus to provide greaterseparationof the disc spacesanteriorly and to localize the force to the lower lumbar segments. A traction force of 25% of the patient'sbody weight may be sufficientto progressthis patienttoward the set goals of beatment, silce this amount of traction force can producea centdpetalforce on the lumbar disc and reducea disc displacement.However, traction force of as much as 50% of the patient'sbody weight may be neededif joint distractionis required to alleviatethis patient'ssymptoms.It is recommendedthat the initial treatment be with a low force, of approxim ately 257" of the patient'sbody weight, or 13 to 20 kg (25 to 50 lb), in order to allow assessmentof the patient'sresponseto the treatmentand minimize the risk of protectivemuscle spasms.The tractionforcemay then be increasedfor subsequenttleatm€nts, if necessary,until a level is reachedat which the pati€nt respondswith approximateiy a 50% reductionin symptom sevedtyaftertreatment. The applicationof a hot packin conjunctionwith the traction may funher improve the patient'sresponse to the treamrentby increasingsuperficialtissueextensipain.27,28 bility and decreasing Becauseintemittent tmctionwith a ionghold time, of approimately 60 seconds,and a short reiax time, of approimately 20 seconds,is likely to have most effecton the discs,thesetime6aretecommended.Static traction may also be effective. The initial fteatlnent should be lirIlited to 10 minutes if tl:e oatient reoorts somereductronof symptomsin this time. It rltis is ins.rfficient to reducethe patient'ssymptoms,the treatment time may be extendedto up to 20 to 40 minutesfor sub-
I
If the application of mechanicaltraction in the manner describedabove relievesthis patient'ssymptoms,and particularly if lower forces and lower durations of treatment are effective,the use of self-tractionor posilional traction at home, with the patient lying on the left side, with the left side bent and right rotation, may also help this patientprogresstoward the Soalsof treatment.
Case 2 AW is a 75-year-oldfemale who has been referredto physicaltherapywith a diagnosisof osteoanhritiswitl-r moderately severe facet joint degeneration at C4 through C6 observedon x-ray. Shecomplainsof bilateral neck pain that is worse on the right than on the left. She also reports that h€r neck is very stiff first thing in the morning, loosening up tbroughout the day but becomingstiff andvery sorelatein the afternoonandfor the rest of the evening.Shehas no complaintsof upper extremity pain or stifftress;however,the neck stif&ress makesher feel unsafewhile driving,and when the pain is severe,sheis unableto participatein her sewingclass at the localseniorc€nter.Shehashad similar but gradually worsening symptoms intermittendy for the past 20 years, and her symptoms ale always more severeduring the winter In the past, AW has been referred to physical therapyfor treatmentofthese sgnptoms, and her treatment has included traction, heat, massage,and a few exercises.Within four to six visits this combinationof interventions has helped relieve her s;.'rnptom6for about a year until the following winter. At this time, the objective exam reveals a kyphotic thoracicposturewith a forward headposition.Cervical AROM is restrictedby approximately50% in all planes, and there is moderate hypertonicity of the cervical paraspinalmusclesand stiffnessof all the cervicalfacet joints on passiveintewertebralmotion testing,with the lower cervicaljoints beingstiffer than the uppercewical joints. Shoulder flexion and abduction AROM are limited ro 140' bilaterally, and all other objective tests,includingupperextremirysensation,strength,and reflexes,arewithin normallimits for this patient'sage. EVALUATIONOF THE CLINICAL FINDINGS This patieotpresentswith the impairmentsof an abnormal k1'photicthoracicposture,loss of neck movement in all planes,and pain.Thesehave causedfunctionaldifficultieswith driving and reducedparticipationin social aclivities. PREFERREDPRACTICEPATTEFN ImpairedPosture,(4B)
Two . THE PHYSICAL ACENTS
PLAN OF CARE The goalsof treatmentat dlis time are to reduceAW's neck pain by at ieast50%, so that she canreturn to full participationin her sewing class,and to increaseher activeandpassivecervicalROM and softtissuemobility sufficiendyto allow he! to drive safely.Coais of treatment should also include improving AW's postureand educatingher in a home programto prevent,or at least limit, recurrences ofher preseotsymptoms. ASSESSMENTREGARDINGTHE APPROPRIATENESS OFSPINALTRACTIONAS THE OPTIMALTREATMENT The application of spinal ffaction to the cervical spine is indicatedfor the treatment of joint hypomobiLity,particulariy when multiple spinal segmentsare involved, and for the relief of symptoms causedby subacutejoint inflammation. Spinal traction may also help alleviate this patient's spinalpain by gating its fiansmissionat tlle spinal cord or by reducing joint compression and iniammation. The movement of intermittent traction may help to reduce s),rnptomsresultingftom in{ammation by facilitating normal fluid exchangein the joints to relieveedemacausedby chronic inflammation. This change, combined with stretching of the periarticular solt tissue sb:r.lctures, may increasespinal joint and soft tissuemobiliqy and ceNical activeROM. The application of a deepor supedicialheating agentto this patienCsneck,pdor to or during the appJication of traction, may optimize the benefits of the tleatrnentby increasingsoft tissueexteosibfiq.,to facilitate greaterincreases in softtissuelength.As inprioryears,the application of traction and other passivemodalities alone is likely to result in only temporary control of this patient's symptoms; howeve5 more long-lasting benefits may be achievedby additionally addressingher posture and t}roracicmobility and by modifying her home activities. At the age of 75, this patient should be clearedfor impaiment ofvertebral or carotidartery circulationand for osteoporosisprior to the applicationof cervicaltraction. One shouldalsoascertainif shewears dentures;if so, she should be instructedto wear them during the treatment. It is also important not to assume that becausethis patient has toleratedtraction well in the past, shewill necessarilytolerateit equallywell at this time, particularly if she has experiencedany medical ev€nts,suchasa cerebrovascular accident,sinceshewas lasttreatedwith traction. PROPOSEDTREATMENTPLAN AND BATIONALE Once this patient is clearedfor the applicationof traction, a trial of manualtractionis recommendedto allow assessment ofheiresponseto tractionand to help determine *re ideal position prior to consideringthe use of other forms of traction. If manual traction affords her
55/
somerelief of s;-'rnptoms, then electricmechanicaltraction would be recommendedfor fieatment in the clinic to provide optimal efficiency and consistency of treatment. An occipital halter should be used in order to avoid compressionon the temporomandibularjoints (IMJs), and the patient should be positioned supine, with herceffical spineinabout24" offlexioq in orderto achievemaximum separationof the lower cervicaljoints and elongationofthe postedorspinalsftuctures. As with all traction treatments,the force of traction shouldinitially be low, at approximately4 kg (101b),for the first session.The amount of force may then be increasedby 1.5 to 2 kg (3 to 5lb) at each subsequent sessionuntil optimal symptom control is achieved.A low amount of force, ofs to7 kg$2 to 151b),which can elongatethe cervicalspinewithout disftactingthe joints, will probably be sufficient to alleviate this patient's s1'n-rptoms, and the useof more forcewill probablynot provide greaterbenefit. The tractioo force should not exceed13 kg (30 lb) at any time. Intemittent traction, with shorthold and relaxtimesofapproximately15 secoodseach,arerecommendedsincethis ratio is generaliy effective at reducing symptoms associatedwith the joints. The total duration of the traction heatment shouldbe benveen10and40 minutes,dependingon the patient'sresPonse. Becausethis patient is pres€nting with recuffent symptoms that are probably due to progressiveand chronic osteoathrids, it is also recommendedthat she obtain and be iostructedin the useof a simplemechanical traction device, such as an over-th€-doorceryical traction unit, for use at home. She may then use this device to treat aggravationsof similar symptoms that shemay experiencein th€ future.
Case 3 MS is a 30-year-oldfemalehigh schoolteacher.Shewas diagnosedwith rheumatoidarthritisat the ageof22 and has been referredto physicaltherapy for treaturentof neck pain. Shecomplainsof constantand severepain in her neck that is aggravatedby all neck movement,and she reports intermittent dizziness that is brought on by moving fiom sitting to standing or by looking up. The neck pain startedabout 3 or 4 yearsago and has gradually become more severe,while the dizzinessstarted only a few weeks ago.MS reportstlat at this time the pain keepsher awake at night and the dizzinessinterfereswith her ability to write on the chalkboardwhen she is at work. MS has no numbnessor tingling of her exftemitiesand reports that no x-ray films have been taken ofher neckin the last 3 years.Her objectiveexam revealsposturalabnormalities,including standingwith approfmately 20' of hip and knee flexion bilaterally, Continued
) Clinical Case Studies-cont'd
other joints, includingher hips and knees,it would not be expectedthat completerelief of symptomsor retum of ROM would be achieved.
bilateralgenu valgum, a moderately increasedlumbar lordosis,a flat thoracicspine,and a forward head position. The flat thoracicspineand forward head position are maintained in sitting. Cervical ROM testing was defened at the initial evaluationdue to the severityof the patient's reports of pain with motion. Her upper €xtremity strength was 4+/5 throughout widrin the availableROM, and her upper extremity sensationand reflexeswere witiin normallimits. EVALUATIONOF CLINICAL FINDINGS This patient presentswith impairmentsof stiffnessand loss of motion of her neck, neck pain, dizziness,and abnormalposture.Thesehave resultedin an inability to sleepthroughoutthe night and have limited her abiliry to perform her normd job-relatedactivity of writing on the chalkboard. PREFERREDPRACTICEPATTERN Impaired Joint Mobiliry, Motor Functioq Muscle Performance,and Range of Motion AssociatedWith CorrnectiveTissueDysfunction,(4D) PLANOF CARE Although goals of treatrnent could include resolving any of tie above impairments or functional limitations, this patient'sreportsof dizzinessassociatedwith neck pain and the diagnosisof rheumatoidarthritisshouldalertthe dinician to the possibility that this patient may have an unstableC1-C2 articulationdue to lisamentousinstability or osteoporosisas a result of prolonged systemic steroiduse.Becauseinstabiliqyat C1-C2 posesa signiftof osteocantrisk to the patient,andbecausethe presence porosisrequiresspecialcautionwith rhe applicationof traction, the initial goal, prior to applying Eaction or any other treatmeng should be to ascertainthe ligamentous stability and bony irtegrity of her upper cervical spine. theseboth requireradiographicstudiesthat must Because generallybe orderedby a physician, the patient should be referredback to her physician for further evaluation. Shouldall radiographicreportsindicatettrat her upper cervicalspineis stableand that shedoesnot have osteoporosis,she may retum to physical therapy for treatment of her complaints. The proposed goals of treatment would tlren be to relieve her pain ar'd dizziness and to increaseher cervicalROM sufficiendy to allow fuIl participationin job-relatedactivities.Because this patienthasa systemicdiseasethat affectsthe joints and tiat appearsto have causedpermanentchangesin PreferredPhysicalTherapistPracticePatternsSM[48,4D, and
1
THEAPPROPRIATENESS ASSESSMENT REGARDING OF SPINALTRACTIONAS THE OPTIMALTREATMENT If all tests indicate that spinal traction is not contraindi cated, tlen such treatrnent may improve this patient's cervical mobility, increasing her cervical ROM, and decreaseher neck pain. Theseeffectsmay be achieved by distractionor mobilizationof the cervicaljoints or by relaxationof the cervicalparaspinalmuscles.lt is also possiblethat cervicaltraction may help alleviatethis patient's dizzinesssince she associatesthis symptom with neckmotion;however,herdizzinessmay be dueto an inner ear or vestibular dysfunctiorl which would also be affectedby head position,in which case*ris synptom would probablynot respondto treatmentwith traction. Although traction may reduce this patient's symptoms sufficiendy to allow her to write on a chalk board,it is recommendedthat job site adaptations,such as the useof an overheadprojector,alsobe institutedto reducethestresses on hercervical spine. PROPOSEDTREATMENTPLAN AND RATIONALE It is proposedthat in orderto provideconstartmonitoring of *ris patient's severesymptoms, and to allow adjustmentoI the tractionforceand directionduringthe treatmengmanual traction be usedinitially to treat this patient.Shouldthe patient reportmoderaterelief of her pain with the application of manual ffactiorl then once optimal celvicalpositioningfor traction hasbeendetermined, staticmechanicaltractionmay be substitutedifit is thought that a longerdulation of keatment would be more beneficial.Staticcervicaltractionmaybe provided by an electricalor weighteddevice,but in eithercaseit is recommendedthat the patient be treatedsupinerather than sitting, to achieve maximum muscle relaxation, and it is recommendedthat low forcesbe usedinitially due to the severityofthe patient'ssymptoms. the forceof traction may be As treatnent progresses, increasedup to a maximum of 13 kg (30 lb) to achieve joint distractionif necessary,and iotemittent traclion may be usedifdis provesto be mote comfortableasthe patient toieratesmore motion. Treatment with spinal tractionshouldbe providedin conjunctionwith postural educationand recommendationsfor home or work site modificationsin orderto minimize th€ risk of svmptom re-aggravation or progression.
are copyright 2002AmericanPhysicalTherapy Association.Al1
Ttyo . THE PIIYSICAL AGTNTS
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11. JudovichB, Nobel CR: Traction therapy: a study of resistanceforces,An J Surg91tI08-114,1957. 12. Judovich B: lumbar traction flterapy, JAMA 159:549, 1955. 13. DeetsD, HandsKL, Hopp SS:Cervicaltraction:a comparison of sitting and supine positions, Phys Ther 57:255-261,1977. 14. Twomey Lf: Sustainedlumbar traction:an experimental study of long spine segments,SFhE 10:146-149, 1985. 15. OnelD, TuzlaciM, SadH etal: Computedtomographic investigationof the effect of traction on lumbar disc hemiatLors, Syine14$2-90, 1989. 16. Crieve CP: Mobilizatiox of the Syiae, ed 4, New York, 1984, Churchill Livingstone. 17. CyiaxJ: Textboob of Onhopaedic Medicine,vol II, ed 11, Eastbourne,UK, 1984,BalliereTindall. 18. IGauseM, RefshaugeKM, DessenM et al: Lumbar spinetraction:evaluationof effectsand recommended applicationfor treatment,Man Ther5(2):72-81 , 2000. 19. Mathews J: Dynamic discography:a study of lumbar traction, At1flPhysMed 9:275-279, 1968. 20. Cupta \ RamaraoS: Epidurographyin reduction of i.eferences lumbar disc prolapse by traction, Arch PhysMed Rehabil i. Cyriax J: Tettboobof OnhopedicMedicine,Volumel: 59.322-327 , 1978. Diagxosis of SoftTisueLesions, Londoq 1982,Bailliere 2 1. Andenson GBJ,SchultzAB, NachemsonAl: Intervetebral Tindall. disc pressuresduring traction, ScaxdJ RehabilMed 9: - MathewsJA,Mills SB,Jenkins YM et al:Backpainand BB-97,1,983. sciatica: controlled trialsof manipulatioqtraction,scle- 22. LundgrenAE, EldevikOP:Auto-tractionin lumbar disc rosantand epiduralinjections,Br J Rheumanl26: herniationwith CT examinationbeforeand after treat416-423 . ment, showing no change in appearanceof the herni, 1,987 U, CholerU, LindstromA et al:Auto-traction :. Larsson ated tissue,J OsloCity HosV36:87-91, 1986. for treatmentof lumbago-sciat:Lca, ActaOrthoped Scaad 23. BasmajianfV Ma ipulatiofl, Tractiofland Massage,ed 3, 51;791-798,1980. Baltimore, 1985,Wllliams& Wilkirs. - LidstromA, Zachrisson M: Physicaltherapyon low 24. CoalchisSC, StrohmBR: Cervicaltraction relationship back pain and sciatica,ScaaJ RehabilMed 2:37-42, of time to varied tractive force with constant angle of 1970. poII,ArchPhysMed Rehabil46:815-819,1965. : MoretNC, vander StapM, Hagmeijer R et al: Design 25. Worden RE,Humphrey TLr Effectof spinaltraction on andfeasibilityof a randomized clinicaltrial of vertical the length of the body, Arch Phys Med Rehabil 45 tractionin patientswith a lumbarradicularsyndrome, 318-320,1964. r\4atualTheralzy 3:203-211 . 26. LaBan MM: Collagen tissue: lmplications of its , 1,998 :. WeberH, Ljunggren E, WalkerL: Tractiontherapyin rcsponse to sffess in vitro, Atch PhysMed Rehabil 43: patientswith hemiatediumbar ioteNertebraldiscs, 461-466,1962. OsloCityHosp34:61-7 0, 1984. 27. LehmarnJ, Masock A, Warren C et al: Effect of theraJ -. Beurskens AJ, de Vet HC, KokeAJ et al: Efficacyof peutic temperatureson tendon extensibilty,ArchPhys tractionfor nonspecific 1owbackpain: 12-weekand Med Rehabil5I:48L-487 , 1970. 60-monthresultsof a randomizedclir:cal tial, Spiue 28. LentallC, Hethe ngtonT, EaganJeta1:The useof ther22:2756-2762,1,977. mal agentsto influencethe effectiveness of a low-load : ColdishCD: Lumbartraction.ln ToljsonCD. Kriegel prolonged stretch, I OnhoV SVon Phys Ther 16(5): [.AL,eds:Ixterdisciplinary Rehabilitatiox of LowBaclePaln, 200-207 ,1992. Baltimore, 1989,WilJiams & Wilkins. 29. Mathews JA: The effectsof spinal tracnon, Physiotherapy :. ParisSV LoubertPY Fouularions of ClinicalOnhopedics, 58lf4-66,1972. StAugustine FL,1990,InstitutePress. 30. Wall PD: The mechanismsof pain associatedwith . Maitland CD: WnebtalManiVuhtion, ed 5, London, cervical vertebrai disease.In Hirsch C, Zollerman Y, 1986,Butterworth. eds: Cervical Pain: Proceedingsof the Intemational
Jhapter Review 1e applicationof a distractingmechanicalforce to =e body is known astraction.Tnctionappliestension : the tissues,and when applied to the spine it can ::sult in joint surfacedistractiorl soft tissuestretch:.-g,musclerelaxation,joint mobilization, or patient ::rnobilization. The effects and clinical benefits of ;:inal traction dependon the amount of force used, *-.edirectionof the force,and the statusof the areato ,.: ch the traction is applied.Spinaltraction can be -;ed for the treatment of a disc bulge or herniation, --..rveroot impingement, joint hypomobility, suba::ie joint inflammation, or paraspinalmusclespasm. :
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lO o Traction
S1'rnposiumin Wenner-Gren Cente4 Oxford, 1.972, Pergamon. 31. SeligerV, DolejsL, KarasV A dynamomet c comparison of maximum eccentric,concentricand isometric contractionsusingEMC and energyexpendituremeasl:reme ts,EurJU/y Physiol45:235-244,1980. 32. SwezeyRL:The modem thrust of manipulation and tracAnhritisRheun12:322-331,1983. tiondtenpy, Semtu 33. SaundersHD: Useof spinaltractionin the fteatmentof neck and backconditlors, Clix Onhop179:31-38,1983. 34. CheadeMD, EsterhaiJL:Pelvictractionastreatmentfor acuteback pai\ Slit1e16:1379-1381,,799I. 35. PalB, Mangion P,HossainMA et al:A controlledtrial of contrnuouslumbar traction in the treatment of back pain and sciatica,Brl Rheunanl25:181-183,1986. 36. Van der Heijden CJMC, BeurskensAJHM, Assendelft WJJ et al: The efficacy of traction for back and neck paini a systematic,blinded review of randomizedclini1.995 . caltrial methods,Pl ys TherT5(2):93-104, 37. Hood LB, Chrisman D: lntermittent pelvic traction in tlre fieahnent of the ruptured intervertebral disc, Phys Ther4B:2I-30 , 1968. 38. Weber H: Traction therapyin sciaticadue to disc proIapse,J OsloCiy HosV23:167-176, 1973. 39. Grieve C: CommonVertebralloiat Problens,Edinburgh, 1981,ChurchillLivingstone. 40. SaundersHD, SaundersR: Eraluation,Tteatmentatd Prcvention of MusculosbeletalDisorders, Bloolrrington, MN, 1993,EducationalOpportunities. 41. Mathews JA, Hickling J: Lumbar traction: a doubleblind controlled study of sciatica,RheumRehabil14 222-225, 1975. 42. BuerskensAJ,de Vet HC, Koke AJ et al: Efficacyof traction fornon-specificlow back pain: a randomizedclinical tial, Lancet346(8990):1596-1,600 , 1,995. 43. BuerskensAJ, van der Heilden CJ,de Vet HC et al: The efficary of traction for lumbar back pain: designof a randornized clinical trial, J Maniy Physiol Ther 18(3): 141-1,47 , 1995. 44. PellecchiaCL: Lumbar traction:A review of the literaPhysTher20(5):262-267, 1994. ture,JOnhopSVons 45. CoalchisSC,StrohmBR:A study of tractiveforcesand angle of pull on vertebral intercpacesin the cervical spine,ArchPhysMed Rehabil46:820-824,1965. 46. McDonough A: Effect of immobilization and exercise on articular cartilage: a review of the literature,l OnhoV SponPhysTher3:2-9, 1.987 . for spinal 42. YatesDAH: Indicationsand contraindications 54:55-57 1972. tracion, Physiotherapy , 48. Quain MB, TecklinJS:Lumbartaction: its effecton respiradon, PhysThet65:1343-1346,1985. 49. Frymoyer lW, Moskowitz RW: Spinal degeneration: pathogenesisand medical management.In Frymoyer ixe:PinciVlesandPractice,New York, fW , ed: TheAduh S1z 7991, RavenPress.
50. EieN. KristiansenK:Comolicationsandhazardsof tion in the fteatment of rupturedlumbar disk, J OsloCityHosp72:5-12,1962. 5 1. LaBanMM, Macy JA, MeerschaertJR:Intermittent vical traction: a progenitor of lumbar radicular ArchPhysMed RehabilT3:295-296 , 1992. 52. Haskvitz EM, Hanten ST: Blood pressureresponse inversion ffaction, PhysTher66:1361-1364,7986. 53. Giankopoulos G, Waylonis CW Crant PA et Inversion devices:*reir role in producing lumbar tlaction, ArchPhysMed Rehabil66(2):100-702,1985. 54. Zrto M: Effect of two gravity inversion metlods heart rate, systolic brachial pressure,and artery pressure,PhysTher68:20-25, 1988. 55. SaundersHD: Unilateral lumbar traction, Plys
67:221-225,1981. 56.WeatherellW: Comparisonof activitv in normal lumbar sacrospinalis during staticpelvictractionin two different OnhopSponPhysther 8:382-390.1987. 57. Goldish CD: A study of mechanicalefficienry of table fiaction, SpifteL5:218-219, 1989. 58. SaundersHD: Lumbar l;r:actjon,JOnhoVSVonPhys I:3647, 1979. 59. Rogoff JB: Motorized intermittent traction. BasmajianfV, ed: Matiyulation, Tractioqaxd Baltimore,1985,Williams 8l Wilkins. 60. CoalchisSC,StrohmBR:Effectsof intefinittent on separatton of lumbar vettebrae,Arch Phys Rehabil50:25I-253, 1969. 61. Hood CJ,Hart DL, Smith HC et al: Comparisonof tromyographic activity in normal lumbar musculature durins continuous and intemittent fiaction, J Oftho? S?onsPhysTher2:137-147, 198I. 62. MeszarosTF, Olson \ Kulig K et al: Effect of 30%, and 60% body weight traction on the straight raisetest of symptomaticpatientswith low back J OnhopSyortsPhysTherOct;30(10):595-601,2000. 63. Hickling J: Spinal traction tecbrique, 58:58-63,1972. 64. Harris ?R: Cervical traction:review of literature treatment guidelines, Phys Ther N4;57(B):91 7977. 65. DaughertyRJ,ErhardRE: Segmentalizedcervical of tion. In KentBE,ed:1ztenatiotalFedewtion Yat! CO ., 1977. Madpulatit e Thetaykx Proceedtugs, 66. HseuhTC, JuMS, Chou YL: Evaluationof the effects pulling angle and force on intermittent cewical with the Saunder's Halter, J Formos Med D ec;90(12) :1234-9,1991. 67. Zylbergold RS, Piper MC: Cervicalspine disorders: comparison of three rlpes of traction, Spite t0(10):867-71, 1985. 68. Maidand CD PeipheralMaxiVulatiox,ed 3, L991. , Butterwordt.
:.1
SUMMARY
O F IA/F ORMATION
COVERED
AdverseEffectsof Extemal Compression Application Techniques Documentation Clinical CaseStudies Chapter Review
lifects of Extemal Compression Clinicallndications for the Use ofExternal Compression lontraindications and Precautionsfor External Compression : ::
OB]ECTIVES UVoncompletiotof this chapter,the readerwill beable to:
L
Discussthe physicalpropertiesof compression. Identify the physiologicaleffectsof compression. Examinehow the physical propertiesand physi ologicaleffectsof compressioncan promote particulartreatment goals. Assessthe indications, contraindications,and precautionsfor the use of compressionwith respectto different patient managementsituations. Design appropriatemethods for selectingcompressiondevicesand treatment parametersto producedesiredphysicaland physiological effects.
6. Chooseand use the most appropriatecompression deviceand treatment parametersto obtain the desiredtreatment goals. 7 . Evaluatedifferent compressiondeviceswith respectto their potential application for treating different patient problems. 8. Presentedwith a clinical case,evaluatethe clinical findings, proposegoalsoftreatment, assess whether compressionwould be the best treatment, and, if so, formulate an effectivetreatment plan including the appropriatedeviceand treaftnent parametersfor achievingthe goalsof treatment,
341
342
,l 4 . Com?ression
Compressionis the applicationof a mechanicalforce that increasesexternalpressureon the body or a body part. Compressionis generallyusedto improve fluid balanceand circulation or to modify scar tissueformation. Compression improves fluid balance by increasingthe hydrostaticpressurein the interstitial spaceso that it becomesgreaterthan that in the vessels.This can limit or reverseoutflow of fluid from blood vesselsand lymphatics. Keeping fluid in the vessels,or retumingit to the vessels,allows itto circulate rather than to accumulate in the periphery Compressioncan be static,exertinga constantforce, or intermittent, with the force varying over time. With intermittent compressionthe pressuremay be applied to the entire limb all at one time, or it may be appliedsequentially,startingdistallyand progressing proximally. The primary clinicalapplicationof compressionis for the control of peripheraledemadue to vascularor lymphatic dysfunction;howeve5 this physicalagent can also be appliedto help prevent the formation of deep venous thromboses,for residuallimb shaping after amputation,or to facilitatethe healingofvenous ulcers.l-3
EFFECTS OFEXTERNAL COMPRESSION Irnproved venous and lymphatic circclation Limits the shape and size of tissue Incf, eased tissue temperatuf €
Venous lmproved andLymphatic Circulation The controlled application of extemal compression has a variery of effectson the body. The nature and extent of these effects vary with the pressure applied and with the nature of the device used.a Both static and intermittent compression devices can increasecirculation since both can increasethe hydrostatic pressurein the interstitial spaceoutside the blood and lymphatic vessels.An increase in extravascularpressure can limit the outflow of fluid from the vesselsinto the interstitial soace. where it tendsto pool. keepingit in the circulitory system, where it can circulate. Intemittent compression may improve circulation more effectively than static compressionbecausethe varyrngamount of pressureis thought to milk fluids from the distal
to the proximal vessels.5,6 Milking is thought be achieved because,when the venous and phatic vesselsare compressed,the fluid in them pushed proximally, and then, when is reduced. the vessels can ooen and refill new fluid from the interstitial space.readv to pushedproximally at the next compression Sequentialcompressionis thought to provide more effective milking than single-chamber, mittent comDressionbecauseit can cause a of vesselconstrictionmoving in a proximal to ensure that fluid is pushed along the toward the heart rather than in a distal direction.
Improving circulation can benefit patients edema, may help prevent the formation of venous thromboses in high-risk patients, may facilitatethe healingof ulcerscausedby stasis.
Limits theShape andSizeofTissue Static compressiongarmentsor bandagingcan vide a form to limit the shape and size of tissue formation. This type of compression acts as a second skin, which, having an elastic pression element or being less extensible than
limits the shapeand size of the tissue.This effect compressionis expioitedwhen compression ing or garments are used over residuallimbs amputation, when compression garments are a over bum-damaged skin, and when
bandaging or garments are applied to limbs.
Increased Tissue Temperature Most compression devices, except those with
cooling mechanisms,increasesuperficialtissue perature becausethe device insulates the area which it is applied. A heavy compressionstocki or an air-filledsleevewill act as an insuiator, ing loss of body heat, thereby increasinglocal ficial tissue temperature.Although the increase garments temperatureproducedby compression not a direct effect of the compressiveforces,it been proposed that the increased activity of
ature-sensitiveenzymes such as collagenase, breaksdown collagen,producedby these may be the mechanismby which they control formation.B
Two C THE PHYSICALAGENTS
INDICATIONS : -INICAL FORTHEUSEOF 1(TERNAL COMPRESSION Edema Edema due to venous iosufEciencv Llrmphedema Deep venous thrombosis \-enous stasis ulcers R.esiduallimb shaping after amputation Control of hypertrophic scarring
:lema l0ses ofedema :::ma is the presence of abnormalamountsof fluid : --lreextracellular tissuespaces of the body.Normal i-:d equilibriumin the tissuesis maintainedby the :rance between the hydrostatic and osmotic pres..-:einsideand outsidethe blood vessels.The hydro;-dc pressureis determinedby blood pressureand :-3 effectsof gravity, while the osmotic pressureis :::ermined by the concentrationof proteins inside =-Coutsidethe vessels.The higher hydrostaticpres:::e insidethe vesselsactsto pushfluid out ofthe ves.;-s, whereas the higher protein concentration,and -*irsosmoticpressure,insidethe vesseisacts to keep -:id inside the vessels(Iig. 11-1).Under normal cir:iinstances, the hydrostatic pressurepushing fluid : :t of t}re veins is slighdy higher than the osmotic :;essurekeepingfluid in, resultingin a slight loss of --tid into the interstitial space. The fluid that is :..:shedout of the veins into the interstitial spaceis =,en taken up by the lymphatic capillaries,to be .::urned to the venous circulation at the subclavian :ins. This fluid, known as lynyhatk fluid or lymph,rs :h in protein,water, andmacrophages.
:igure11-1. Effects of hydrostatic and osmotic pressure :n tissuefluid balance.
343
A healthy diet, vascularsystem,and level of muscular contraction act together to ensure that the appropriateamount of fluid exits the veinsand flows back toward the heart. Dysfunction in any of n\ese mechanismscan result in increasedextravasationof fluid from the vesselsinto *re interstitial exftavascuIar spaceor reducedflow of venousblood or lymph back toward the heart, and thus the formation of edema. The most commonreasonspatientsdevelopedema are venous insufficiency or dysfunction of the lymphatic system.Theseare discussed in detailin the folIowing sections.Edemamay alsooccurafter exercise, trauma,surgeryor bums,orin conjunctionwith infection due to the increasedvascularcapillarypermeabif ity that occurswith the acuteinflammationassociated with theseevents.Increasedvascularcapillarypermeability increasesthe fluid flow out of the capillaries, causingan accumulationof fluid at the site of trauma or infection. The formation of edema due to acute inflammation is describedin detail in Chapter 2. Congestiveheart failure,liver failure,acuterenal disease,diabetic glomerulonephritis,malnutritiory and radiation injury may also contribute to peripheral edemaformation becausetheseabnormalstatescan alter circulationor osmoticpressurebalance. Edemadueto venousinsufiiciency The peripheral veins' function is to carry whole deoxygenatedblood from the periphery back to the heart.In a healthy vascularsystemthe restinghydrostatic venous pressureat the entranceto the right atriumofthe heanaverages 4.6mm Hg,andthispressure increasesby 0.77 mm Hg for each centimeter below the right atrium to reachan averageof 90 mm Hg at the ankle.9When the calfmusclescontract,they exerta pressureofabout 200mm Hg on the outsideof the veins,which pushesthe blood through the veins. Then, following the contraction,the pressurefalls to about 10 mm Hg to 30 mm Hg, ailowing the veins to refill. A healthy amount of skeletalmuscle activity, suchasoccurswith walking or running,or evenwith just rhyfimic isometricmusclecontraction,provides a milking action to propelthe blood in the veinsfrom the peripherybacktoward the heart.Muscle contraction is the primary factor propeliingboth lymphatic and venous flow, and valveswithin the vesselsprevent backflow of the fluid, ensuringrhat it moves proximally toward the heartratherthan beingpushed distally toward the distalextremities(Fig.l1-2).
1 'l . Confressiox
344
worsen becauseof increasedhydrostaticpressuredue to gravity.
Musclesrelaxed Musclescontracting . Valvesclosed . Valvesopen . No backflow . Forwardflow Healthyvessels
Lymphedema As explained above, the hydrostatic pressurethat pushesfluid out of the veins normally exceedsthe osmotic pressure keeping fluid inside them. Thrs resultsin a net flow of fluids and proteins into the interstitial space,producing lymph. To prevent the lymph from accumulatingin the interstitial spacg the lymphatic system,actingasan accessorychannd returnsit to the blood circulation.The lvmphatic tem consistsof a largenetrvork of vesselsand through which the lyr:nphaticfluid flows. L vesselsare found in almosteveryareawhere there blood vessels,and lymph flows along these passingthrough numerous lymph nodes, to into tle subclavianveins(Iig. 11-3).The lymph
'W fim|J
are concenlrared in the axillary. throat. groin.
Musclescontracting . Valves open . Forwardflow
Musclesrelaxed . Valves unableto close . Backflow
Vesselswith damagedvalves
1t-2. Valvesin venousandlymphaticvesselspreFigure ventingbackflow.
paraaotic areasand act to filter the fluid, bacteda and other foreign particles.The lymp vesselsof the right arm teminate in the right phatic duct and empqyinto the dght subclavian whereas the lvmohatic vesselsfrom all other terminate in the thoracic duct and empty into the subclavianvein. Once the lymphatic fluid reenters
circulatory system it is processedthrough the neys,alongwith other fluids,wasteproduct,and trolytes,and is eliminated. Fluid flows into the lymphatic systembecause Lack of physical activiry dysfunction of the concenffation of proteins inside the lymphatics i venous valves due to degeneration,or mechanical generally higher than in the interstitialspace.As obstructionof the veins by a tumor or inflammation veins, flow along the lymphaticvesselsin a can result in venous insufficiencyand accumulation the on muscleactiviry.such mal direcrion depends of fluid in the periphery.The most common cause which compressesthe walking or running, of venous insufficiency is inflammation of the vessels and prevents and valveswithin the veins, known as yhlebitis,which causesthickening particularly plasma proteins, of the vessel walls and damage to the valves. Decreasedlevelsof min, mechanical obstruction of the Thickening and loss of elasticiryof the vesselwalls elevates the hydrostatic pressure in the venous abnormaldistribution of lvmphatic vesselsor nodes,or reducedactivity can result in reduced system, and damageto the valves allows blood to phatic flow and the formation of fiow in both proximal and distal directions,rather Decreasedlevels of plasma proteins causefluid than just proximally through the veins, when the accumulatein t-he extravascularspace because musclescontract(seelig. 11-2).The retrogradeflow osmoticpressurethatnormally keepsfluid in the reducescirculationo[ deoxygenatedblood out of the phatic vesselsand the veins is reduced.If the p veins and thus increasespressurein the venous sysprotein level dropsbeiow *re normal rangeof 6 tem if fluid inflow from the arterial system is The eleuaredvenouspressureincreases to 8 g/dl or the plasma albumin levels fall unchanged. the amount of fluid that ente6 the extravascular 3.3 g/dL to 5.7 g/dL, lymphedemais likely to resuh healthy diet and adequate protein absorption spaceand thus causesedema.If *re limbs are then required to keep plasma protein at an piaced in a dependent position, the edema will
Tleo . THE PIIYSICAL AGENTS
345
lymphatic vessels,whereas secondarylymphedema is causedby some other diseaseor dysfunction.An exampleof primary lymphedemais Milroy's disease, in which the individual has hypoplastic,aplastic,or varicoseand incompetentllmphatic vessels.Patients wit! primary lymphedema often have backflow in the lymphatic vessels,and the rate of protein reabsorptionacrossthe vesselwallsis alsousuallyslowed. In secondary l1'rnphedema, lymphatic flow is impairedby blockageor insufficiencyofthe lymphatics. Inflammation, pregnancy,neoplasm, radiation therapy, uauma, surgery,and filariasisare all common causesof secondarylymphatic obstruction.l0-13 The most common causeof secondarylymphedema in the world is filariasis,a diseasecharacterizedby infestationof the ly'rnphaticsand obsruction of the l1'rnph vessels and nodes by microscopic filarial worms. Although this diseaseis commoninAsia, it is rarely seenin America, Australia, or Europe.In the United States,secondarylymphedemais usuallythe result of mechanicalobstructionof the vesselsby a tumor or inflammation,dysfunctionof the valvesdue to degeneratioqor removal of the lymph nodesas a componentofthe treatmentof breastcancer.
Figu]e 11-3.Lymphaticcirculation.
-evel.When lymphedemais causedby hypoproteine:ria, this underlying problem should be addressed :lst to pr€v€nt further edema formation and other : dvP
r
.^n
rFh.ac
Ly,rnphedemacan be primary or secondary, Jthough most casesare secondary.Primary lym:hedema is causedby a congenitaldisorder of the
Advelseconsequences of edema Edemaof any origin canresultin a variety of adverse clinicalconsequences, suchasrestrictionsof rangeof motion (R.OM), limitations of function, or pain. Reducing edema has also been shown to increase joint ROM and to decreasepain and joint stiffness.14,15 Persistentchronic edema,particularlylymphedemathat has a high level of protein, can also causecollagento be laid down in the area,leadingto subcutaneoustissue fibrosis and hard induration of the skin. This may eventually causedisfiguring and disabling contracturesand deformities (Iig. 11-4). Chronic edema due to venous or lymphatic insufficiency also increasesthe risk of infection because tissueoxygenationis reduced;this risk is further elevatedwith lymphedemabecauseof the presenceof a protein-rich environment for bacterial growdr.13,16 Advanced chronic lymphatic or venous obstruction may resultin cellulitis,ulceration,and,if unmanaged, partiallimb amputation.16 Thesemore serioussequelae are most likely to occur if the pressureof the excessfluid accumulatedinthe interstitialextravascular spacescausesartedalobstruction.Chronic venous insufficiencyalso often causesitching, due to stasis dermatitis,and brown pigmentationof the skin due
346
4'l c Conlzressiotr
Figure 11-4.Lymphedema. (Irom Lbing with lynyhoedema,Courtesy Michael Mason, Director, Adelaide Lymphoedema Clinic.)
to hemosiderin deposition. Jhese sign, are commor y seen on the medial lower leg (see lig. 11-Q. Early control of edema can help to prevent the progression and development of the signs and slmptoms of chronic edema and its associatedcomplications.
Howcompression reducesedema Compressionis effectivein controllingedemadue to venous insufficiency,lymphatic dysfunction,or any of the other previouslymentioned causesbecauseit increasesextravascularhydrostatic pressureand circulation.Ir'r2'\721If the patient has other underlying causesof edema, such as infection, malnutritior\ inadequatephysicai activiry, or organ dysfunction, thesemust also be addressedto achievean optimal outcomeand to preventrecurenceof the edema. Compressionof a limb with a staticor intermittent deviceincreasesthe pressuresuffoundingthe extremity to counterbalance any increasedosmoticor hydrostaticpressurecausingfluid to flow out of the vessels into the extravascularspace.If sufficient pressureis applied, the hydrostatic pressurein the interstitial extravascularspacesbecomesgreaterthan that in the veins and lymphatic vessels,reducingoutflow from the vesselsand causingfluid in the intentitial spaces to return to the vessels.22 Oncefluid is in the vesselsit can be circulatedout of the periphery,preventingor reversingedema formation. In addition, if an inter-
Figure11-5,Venousstasisulcer.Note the areasof ened skin around the ulcer due to hemosiderin (Counesy Jim Staicer, Beverly Manor Conval Hospital, Fr€sno,CA.)
mittent compressiondeviceis used,it may also to move the fluid proximally throughthe vessels.
Prevention ofDeep Venous Thrombosis Deep venous thromboses(DVTs) are blood clots i the deep veins. They can occur when circulation i
poor orwhen thereis inflammationof the veins.If culationis poor, the blood may move slowly to allow coagulationand the formation of a bus; thus, an intervention that increasesdre tory rate can reducethe dsk of thrombus formationDVT formation is most common in immobilized patientr.pan icularlyaftersurgeryor when from cardiac failure or stroke. Althoush thrombi.e formarion in the peripheralvenoussysL; is not generally itself a medicalhazard, it can pose a
risk to a patientbecauseany thrombus in the peripts ery may become dislodgedand move to block thc blood supply to vital organsor the brain. Suchblockage may causeorgan failure, a myocardial infarct.a stroke, or even death.Therefore preventingthe formationof DVIs in at-ri'k paLients is imperative. The prophylacticapplicationof externalcompression devicesto the foot and calf has been shown to reduce the incidenceof DVT formation in patients hospitalized for a vanety of reasons rncludingposrop erativeand postacutestrokecareand after spinaicord
Ts'o . THE PIIYSICAL ACENTS
''turyn'24'26(Fig.11-5).Extemalcompressiondevices :ray also protect againstpulmonary embolism and :educemortality. A recentreview andmetaanalysisof =iudieson graded compressionstockings reported -hat,of 624 patientswho used graded compression ,.iockings,81 (13%) developedDVTs, whereasin the -_:Y"lf::".p of 581 parients,154(27"') developed -)VTs.'' This is aooroximatelva 60% reductionin rsk of DVT forrn"tio.r. This effect was even more :ronouncedwhen the stockingswere usedin combi:ration with other prophylactic methods such as reparin. Metaanalyseshave shown compressionto -ce similarly,or possiblymore, effectivethan heparin -n reducingthe risk of DVIs andpulmonary eml:o1i.28,2e Compression is thought primarily to reduce -jrrombusformation by improving venous flow and -hus reducingvenous stasisand the opportunity for -Irombus formation.30,31 However, *re intermittent :ompressionmay also inhibit tissuefactor pathways :hat initiate blood coagulationor degrade*rrombi by :nhancingfibrinolytic accivity.32'35
Venous Stasis Ulcers Tenousstasis ulcers are areasof tissue breakdown ald necrosis that occur as the result of impaired '.'enouscirculation (Iig. 11-Q. Impaired venous cir:ulation, which may be the result of lack of muscle :ontraction, venous insufficiency, or mechanical rbstruction,canresultin poor tissueoxygenationand :lutrition, reduced local immunological responses, andan accumulationof waste products,all of which :an contribute to cell death and tissuenecrosis.36-37 3ecause compression canimprovevenouscirculation. andbecauseimproving circulationmay reducethese adverseeffects,diminish the risk ofvascularulcerformation, and facilitate healing of previously formed ulcers,compressionis the treatment of choice for venousstasisulcers. Compressionhas been shown to increasethe rate of healinsand reducethe rate of recurrenceofvenous stasisulc"ers.9,38,39 The addition of 4 hours of sequenLialintemittent compressiondaily to other regular ulcercareprocedureshasbeendemonstratedto acceleratehealingby closeto a factorof 10.40Compression cherapy is consjdered ro be the mosrimportantaspect oI the treatmentofvenous stasisulcers.41 It is proposedthat compressionfacilitatesthe healing ofvenous stasisulcersby improvingvenouscirculation, increasingtissue oxygenation,altering white
347
Useof irtemittent pneumaticcompression Figure'11-6. to prevent DVT formation in a bedriddenpatient. (CourtesyHundeighHealthcare, Manalapan, NJ.) Although cell adhesion, and reducing edema.42'43 compressionmay facilitate the healing of arterial pressureon ulcerswhen rbey resulrfrom excessive the arterialvesselsdue to chronic edema,in general compressionis contraindicatedin the presenceof arterialinsufficienrybecausecompressionof the arterial vesselsmay fur*rer impair arterialflow, aggravating ratherthan improving the condition.
LimbShaping AfterAmputation Residual Compressioncan be usedfor residuallimb reduction and shapingafter amputationin order to help prepare the limb for prostheticfitting (Fig. 11-Z).Both static and intermittent compressionare usedfor this application, although intemittent compressionhas been shown to reducethe residuallimb in approximately For half of the time requiredby other techniques.44 this type of application,when intermittent compression is used,it is applied in conjunctionwith wrapping with an elasticbandage.Compressionreduces residual limb size becauseit controls postsurgical edemaand preventsstretchingof the soft tissuesby excessivefluid accumulation.Residuallimb reduction and shapingis requiredin order to createappropriate areasfor functional weight bearing on a prosthetic device. The residual limb must be shaped so that the prosthesismaintains its position and alignment and promotes weight bearing on the appropriate structures.Excessivepressureon unprotectedbony
348
11 c Cottrfressiox
Figure 11-8. Hypertrophicscarring.
report in the United Statesof this applicationof compressionin 1.971.They demonstratedthat compree sion gaments decreasedthe height and vascularityof scartissueand increasedits pliabiliqy.52 Figure11-7.Compressionfor residuallimb shaping. Many mechanismsfor the effect of compression (CourtesySilipos,New York,NY.) on controlling hypertrophic scarring have beea proposed,Compressionmay direcdy shapethe scar prominencesshould be avoidedto promote comfort tissueby actingasa moid for the new tissue,decreasand function and to limit the risk of tissue breaking local edemaformation, and facilitatingimproved down. coliagenorientation.It has also been proposedth.at compressionreduces scar formation by increasing collagenaseactivity, either due to the increasedskiq Conhol ofHypertrophic Scarring temperatureor due to the increasein prostaglandin Hypertrophic scarringis a common complicationof E2 release,both of which have been shown to be AlLernatively. comdeep burns and other extensiveskin and soft tissue induced by compression.S'e53 inluries.a5,a6 While normal skin is pliableand aestheti- pressionmay controlscarformation by inducinglocal cally pleasing, and has clearly identifiable layers, tissuehypoxia.su hypeftrophic scarsare not pliable,have a raisedand When applying compressionto control hyperIossot jdentity o[ rhe ridgedappe,arance; trophic scar formation, treatment is generallyiniti."i9 l:"" skin Jayers"fFig.I l-8). Hyperrrophicscarsresulrin ated once the new epithelium has formed, and is poor cosmesisand the developmentof contactures then continued tor I to 12 months or longer until that may restrict ROM and function. The risk of the scar is no longer growing and has reached hypertrophic scarring is increasedwhen there is maturity. Compressioncan be applied with elastic delayed healing, a deep wound, repeated trauma, bandages, self-adherent wraps, tubular elastic infection,or a foreignbody presentand in individuals cotton supports,or elasticcustom-fitgarments.Widx js pressure the compressjon with a geneticpredisposition.Hypertrophic scarring any oFrheseapproaches, maintained at approximately20 mm Hg to 30 mm is most common in the areaso[ the sternum,upper Hg. It is recommendedthat the compressiondevice back,andshoulders.4S l:e worn 24 hours a day, except when bathing, ia Although many approaches,including surgery pharmaceuticals,passive stretch with positioning, order to achievemaximum benefit. Common complications of this treatment include skin irritation massage,and siliconegel, are usedto control hypertrophic scarformation,compressionis the most comconstriction of circulation, and restriction of joint mon.48sl Larson and colleaguesfirst publisheda motion.l8
349
Two . THE PIIYSICAL AGENTS
ANDPBECAUTIONS ]i:\TRAINDICATIONS q COMPRESSION { EXTERNAL
heart failure or cardiomyopathy,one must alsoascertain that the increasedfluid load that could be placed --.::e on the heart by the shifting of fluid from the peripharefew contraindicationsthat apply to all types ery in responseto treatmentwith compressionwill devicesl however, when compression --:-mpression impaired circulation, not be detrimentalto the patient. In such cases,the I :
]ONTRAINDICATIONS
orSequential turtheUseoflntermittent Pumps Compression r Heart failureor pulmonaryedema . Recentor acuteDVT, thrombophlebitis,or pulmonaryembolism e Obstructedlvmphatic or venousreturrr
-he useof intermittentor sequential :ompressionpumpsis contraindicated. ., . . in patients with heart failure or pulmonary : Jema
--:hough edemaof the dependentparts of the body : a corrunon consequenceof congestiveheart fail,:e (CHI), compressionpumps should not be used :: feat edema of this etiology becausethe shift :- fluid from the peripheral to the central circularln may increasethe stress on the failing organ ,-.'steln.CHI is the result of a decreasein the ability -: efficiency of cardiac muscle contraction that :ads to decreasedcardiac output. This stimulates --r increase in venous pressure and increased ::dium and water retentionrwhich all act to cause :Cema.Treatment of CHI requires decreasingthe -rad on the heart, whereas compressionincreases re cardiacload by increasingthe fluid load of the . eins. Thus compression tends to aggravate the :nderlying condition, resulting in worsening edema :nd potentially other, more serious side effects, -.uch as pulmonary edema, as CHI progresses.
o Severeperipheralarterialdiseaseor ulcersdue to "'tptirl
in
o Acute local skin infection . Significanthypoproteinemia-protein levels lessthan 2 g/dl o Acute lractureor other trauma Peripheraiedemadue to CHI is usuallybilateraland symmetrical. Pulmonaryedemaoccurswid:r prolongedor severe CHF It is the resultof elevatedlung capillarypressure causingfluid to leavethe circulationand accumulate in the alveolarair spacesin the lungs.Compressionis contraindicatedwhen pulmonary edema is present becauseit increasesthe fluid load of the vascularsystem and the pressurein the lung capillaries,potentially aggravatingthis seriousmedicalcondition. ASK THE PATIENT o Do you haveany heartor lung problems? o Do you havedifficulty breathing? . Are you taking any medicationsfor your heart or bloodpressure? o Do you haveswellingin both legs? ASSESS: o Checkfor the presenceof bilateraledema. . Do not use compressionto treat edemauntil you have ascertainedthat the edemais not due to CHI ^,
h,,ln^h:n,
a?lpmq
Continued
350
4 4 c Comptessiotr
C0NTRAINDICATI0NS-cont'd . . . in patients with recent or acute DVT, tlerornbophlebitis, or pulmonary embolism Compression,particularlyintermittent compression, shouldnot be usedwhen the patientis known to have a DVI, thrombophlebitis,or a pulmonary embolus becausethe thrombus may becomedislodgedor the embolusmay travel.This can occur becauseof direct mechanicalagitation of the clot by the compression or becauseof increasedcirculationproducedbv compression.If a rhrombusor embolusbecomesdislodged,it may travel in the bloodstreamto a distant site and lodge in a location where it impairs blood flow to an organsufficiendyto causeorgandamage, severemorbidity, or even death. Ior example, an embolusin the pulmonary arteriesproducesabout a 30% mortality rate, while an embolusthat lodgesin rhearte-ries supplyingthe brainmaycausea strokeor death./uCompression canhelppreventthe tomation of DVIs, but it shouldnot be usedwhen it is thoueht that a rhrombusmay alreadybe present. ASK THE PATIENT o Do you havepain in your calves? o How long haveyou not beenwalking? ASSESS: o Check for Homan's sign (discomfortin the calf on forceddorsiflexionof the foot), a sign of thrombosisin the lee. Requestfur*rer evaluationby a physicianifyou suspectthat theremay be a thrombusin the deepveinsof the leg.Delay the useof compressionuntil the patient has been clearedfor the presenceof thrombosesor thrombophlebitisin the areato be treated. . . . when lynphatic obstructed
or
venous
return
is
. Compressionis contraindicatedwhen lymphatic or venousreturn is totally obstructedbecause,in such cases,increasingthe fluid load of the vesselscannot reduce the edema until the obstruction has been removed. Lymphatic or venous retum may be obstructedby a thrombus,radiationdamageto the lymph nodes,an inguinal or abdominal tumor, or other masses.With partial obskuction of the ves-
selsor completeocclusionof onlv a few of the sels,treatmentwith compressionmay enhance functionineof the intact collateralvessels ASK THE PATIENT: o Do you know why you have swelling in legs/arms? o Is somethingobstructingyour circulation? If there is completelymphatic or venous tion, compressionshould not be used.Such tion may need to be treated surgically.When therc i partial obstruction,compressionmay be usedin junction with careful monitoring of the responseto the treatmentto ensurethat the is helpingto resolvethe edemaratherthan just shifti the fluid to a more proximalareaof the affected . . in patients with severe peripheral disease or ulcers due to arterial insufEciency Compressionshould not be used in patients severeperipheralartedal diseaseor where there ulcers due to arterial insufficienry becauseit aggravatethese conditionsby closingdown the easedarteriesand further impairing circulation the area.
ASKTHEPATIENT: . Do you get pain in your calveswhen walking? can be due to intemittent claudication, a sign peripheral arterial disease.
If an ulcer is present:Have you had problems your atedes; for example,heart bypasssurgery
bypasssurgeryin your legs?A historyof bypass geries suggeststlre presenceof arterial disease other areas. ASSESS: e If an ulceris present,try to det€rmineif it is due arterialinsufficiency.Ulcersdue to arterial ciency are usually small and round, with borders,and painful.They occurmost often on interdigitalspacesbetweenthe toesor on the malleolus. Request that an ankle-brachial index (ABI) obtained. This is generally performed by
Tg,o . THE PIIYSICAL ACENTS
,;:vices and is a measureof the ratio of the systolic :-rod pressurein the lower extremity to the sys- -c blood pressure in the upper extremiry. -:mpression should not be applied if the ABI is less ::n 0.8, indicating that the blood pressureat the :-de is lessthan 80'loof that in the upper extremity. . in patients with acute local skin infection ---ocalskin infection is likely to be aggravatedby the :--::licationof compressionbecausethe sleevesand ,r':n coveringsused increasethe moisture and tem:e:ature of the area, encouraging*le growth of :-;roorganisms.If a chronicskin infectionis present, .:gle-use sleeves that avoid cross-contamination ::m one patient to another, or reinfection of the i5e patient,may be usedfor the applicationof inter:rrtent complession. }SK THE PATIENT ' Jo you have any skin infectionsin the areato be leated? :SSESS: . nspect the skin for rashes,redness,or skin breakCownindicatingthe possiblepresenceof infection. . in patients with significant hypoproteinemia r erum protein level less than 2 g/dl) --Jroughperipheraledemais a common symptom of ;<-.ere hypoproteinemia, when the serum protein :'.'el is less rhan 2 gldL, the resultingedemashould ---r be treated with compressionbecausereturning -::id to the vesselswill further lower the serum pro::rr concentration,potentially resulting in severe :iverse consequences, including cardiac and :rnunological dysfunction.Severehypoproteinemia ::rr occur due to inadequatefood intake, increased
nutrient losses,or increasednutrient requirements dueto an underlyingdisease. ASK THE PATIENT . Haveyou recentlylost weight? o Haveyou changedyourdiet? o Do you haveany other disease? ASSESS: o Check the lab valuessection of *re chart for the serumprotein level. Delay the use of compressionuntil the patient's serumproteinIeve)is a6ove2 g/dI . . , in patients with acute trasma or fracture Intermittent compressionis contraindicatedirnmediately after an acute trauma because the motion caused by this intervention may cause excessive motion at the site of trauma, increasingbleeding, aggravatingthe acute inflammation, or destabilizing an acute fracture.Such effectscan causefurther damage at the site of injury and impair healing. Intermittent compression should be used for treating postffaumatic edema only after the initial acute intlammatory phase has passed, bleeding has stopped, and the area is mechanically stable. Static compression,as provided by stockings or wraps, may be used immediately after an acute ffauma to prevent edema and reduce bleeding. Directly after an ir1ury static compressionis frequendy appliedin conjunctionwith rest,ice,and elevation in order to optimize the control of pair5 edema,and inflammation. ASK THE PATIENT: o When did your injury happen? . Do you know ifyou brokea bone?
PRECAUTIONS
orSequenlial br theUseof lntermittent Pumps Compression . lmpaired sensationor mentadon o Uncontrolledhypeftension
351
a
Cancer Strokeor significantvascularinsufficiency Superficialperipheralnerves
352
'l4 . Cotflptession
PRECAUTI0NS-cont'd Applycompressionwith cautionto . . . . . . patients with impaired sensation or mentation Compression should be applied with caution to patients with impaired sensation or mentation becausesuchpatientsmay be unableto recognizeor communicatewhen pressureis excessiveor painful. ASK THE PATIENT: . Do you havenormal feelingin this area? ASSESS: o Sensationin the area . Alertnessand orientation Compressiongarmentsor low levelsof intemittent compressionmay be usedif the patienthas impaired sensationor mentation;however,suchpatientsmust be carefullymonitoredfor adverseeffectssuchasskin iritation or any aggravationof edemadue to constriction of the garmentsin tight areas. . . . patients with uncontrolled hypertension Compression should be applied with caution to patients with uncontrolled hypertension because compressioncan further elevateblood pressureby increasingthe vascular fluid load, Blood pressure should be monitored frequendy during treatment of these patients, and treatment should be stopped if their blood pressureincreasesabove the safe level determinedby *reir physician. ASK THE PATIENT: o Do you havehigh blood pressure? If so,is it weil controlledwith medication? ASSESS: o R p
Check with the patient's physician for guidelines on blood pressurelimits. . . . patients with cancer Compressioncanincreasecirculation,which may disturb or dislodgemetastatictissue,promotingmetastasi5,or may improvetissuenutrition,promotjngtumor
growth.Thereforealthoughtherehavebeenno of metastasisor accelerated tumor growth due to it is generallyrecommended useof compression, compressionnot be appliedwhere a tumor is or when it is thoushr that an increasein may causea rumor ro move or grow more Compression is ftequendy used to control phedemathat resultsfrom the treatmentof breast cerwith mastectomyor radiation.Expertsin dris vary in their opinions regarding the safety of treatment and the precautionsto be applied. While somedo not considerthe presenceor history malignancyto be a contraindicationto the useof pression, others recommend avoiding the use compressionin areascloseto the malignancyand others recommendnot applying this type of until the patient has been cancer-freefor 5 years. general,most agreethat the useof compression not be restricted during the time that patients receivingchemotherapy.hormonetherapy,or bi calresponsemodifiersfor treatmentoftheir cancer. ASK THE PATIENT o If edema results from treatment of breast askchepatienrif he or sheis receiving hormonetherapy,or biologicalresponsemodifiers treatmentof the cancer. ASSESS: . Howrecentwas the diagnosis ofcancer? If the cause of edema is unknown and the
has signs of cancer, such as recent unexp changesin body weight or constantpain that not change,treatment with compressionshould defered until a follow-up evaluation to rule malignancyhasbeenperformedby a physician. . . , patients with stroke or significant brovascular insuffi ciency Compression should be applied with caution patients who have had a stroke or have signs insufficiency,suchasa significantcerebrovascular tory of transientischemicattacks.Cautionis because the hemodynamic changes caused by comnression mav alter circulation to the brain.
TIN, . THE PIIYSICAL AGENTS
THEPATIENT =1'e you had a stroke?
jo you havelapsesin consciousness? . , in the area ofa superficial peripheral nerve nervepalsyhas beendocumentedfollowing a_pplication of inrermittenrsequentialcompres-:oru Significantweight loss,resuldngin lossof
EFFECTS OFEXTERNAT TOMPRESSION ll:e potentially adverse effects of compression gr.erally relate to aggravatinga condition that is -=--singedema or impairing rather than improving ;=:ulation if excessivepressureis used.When edema s :re resultof heart,kidney or liver failure or circularn' obstruction,as explainedin detail above in the ns-ussions of contraindications and precautions. :::rpressionmay aggravace the underlyingcondi:,,:n.Also, if too much pressureis used,*re compres;,:n devicemay act asa touniquet, impairingarteriai -;ulation and causing ischemia and edema. lf ---remia is prolonged, impaired healing or tissue -ath can occur. When compressionis effective in =ducing edemain an extremiry it is recommended -"t if this fluid accumulatesat the proximal end of =e extremity or where the extremity attachesto the =-ink, it should be mobilized using massage.l6'59 :: order to minimize the probability of adverse =culatory effectsfrom treatmentwith compression, :: is also recommendedthat the patient alwavs be =onitored closely for undesiredchangesin 6lood ::essureor edema,particulariywith the first applica:on of the treatment or with chanqestn reatment
APPLICATION TECHNIOUES Jompressioncan be applied in a variery of ways, :epending on the patient's clinical presentationand --negoals of treatment. Static compression can be :pplied with bandagesor gaments, and intermittent :ompressioncan be appliedwith electricpneumatic :umps. Staticcompressioncan be used to help conroi edemadueto venousorlymphatic dysfunctionor
JJ5
fat andmusclemassaroundthe peronealnerves,may predisposethesenervesto injury ftom compression devices.When compressionis applied over an area where there is a superficialnerve, particularly in a patient with significant weight loss, the clinician should monitor closelyfor symptoms of nerve compression,including changesin or loss of sensationor strensth.
inflammatioq to form the shapeof amputatedresidual limbs in preparationfor the use of a prosthetic device,or to control scarformation after burn injury. Both staticand intemittent compression,usedeither alone or togethet can be applied to help prevent the developmentof DVT in bedriddenpatients(see Iig. 11-5).Intermittent compressionis usedprimarily to prevent or reduceedemaformation in limbs with poor venousor lymphatic drainage,wit! static compressionbeing applied after this treatment to maintain Lheedemacontrol.
Compression Bandaging Compression bandages are generaTlyapplied by wrapping them aroundth.elimb in a figure 8 manner, starting distally and progressingproximally (Iig. 119). Circular circumferentialor spiral wrapping are generally not recommendedbecausethese configurations can result in the uneven aDDlicationof pressureand thus the uneven conff;l o[ edema. The bandageshould be applied tighdy enough to apply moderate, comfortable compressionwithout impairing circulation.To avoid slipping of the compression bandage on the skin, cohesive gauze or foam bandagesare often appliedunder the compression bandagesdirecdy againstthe patient'sskin. Soft cotton may also be used as an underwrapping to absorb sweat and to help distribute ptessuremore evenly. Compression bandageswith different amounts of elasticity and extensibility are available.These bandagesprovide varying amounts of resting or working pressureand canbe appliedin layersor individually.Restingpressureis pressureexertedby elastic when put on shetch. Al elastic bandageexerts this pressurewhether or not the patient is moving.
354
'11 c Contptessiott
Figure 11-9. Elasticcompression wrap of the foot, ankle, andleg.Note the figure8 wrapat the ankle.
Highly extensiblebandages,which can be extended tty 100% to 200%, provide the greatest resting pressurebecausethey exert the greatestrestoring force.Working pressureis pressureproducedby th! muscleswhen they are active and push againstan Figure I l-10. Development of working prr i n e l a s t rbca n d a g(eF i g I. l - l 0 ) .H i g h l ye l a s r ibc a n d a g e s A, Muscle relaxed.B, Calf musciecontracrrngano do nor promorethedevelopmenr of workingpressure ing againstthe Unna's boot to compressthe veins. becausethey stretch rather than provide resistance when the muscles expand. Inelastic bandagesthat are noc excensibleproducea low resringpressure but provide adequate resistanceto allow for the developmentof high working pressureduringmuscle activiry In general,it is recommendedthat if high-stretch bandages, suchasa new Ace wrap, areusedto control edema,they should be applied with only moderate tensionto avoidexcessive restingpressure,since,without activity,the high restingpressureprovidedby this type of bandagemay impair circulation.Low-stretch bandages, with 30% to 90oloextension,provide some degreeof both restingand working pressureand can thereforebe somewhateffectivewhen the patient is eitheractiveor ar rest.Inelasticbandagesare optimal foruseduringexercisewhen the activity ofthe muscles Figure11-11.Ioam paddingaroundanatomical trons. resultsin high working pressure,but generallythey do not controledemaeffectivelyor improvecirculationin a flaccidor inactivelimb. A semirigidbandageformed of zinc oxide-impregit is known asan Ur xa'sboot.Thists Wpicallvused nated gauzecan also exert working pressure.\.Vhe-n the treatment of venous stasis ulcersi0 Zinc oxi this type of bandageis appliedto the lower extremity impregnatedgauzebandagesbecomesoft when
Tlvo . THE PHYSICAL ACENTS
r allow molding around the involved limb, and then -rden asthey dry to form a sernirigidboot. The boot -s-refton the patient for as long as 1 to 2 weeks, and s then removed and replaced.An Unna's boot is :r-aortedto provide a sustainedcompressionforce of i-'mm Hg to 40 mm Hg.5d Ior all types of bandages,it is recommended ::t tensior! and thus compression, be greatest
5JJ
distally, and gradually decreaseproximally in order to achieve an appropriate pressure gradient. In order to maintain consistencyof pressurearound anatomicalindentations,such as the ankles,pieces of foam or cotton cut to size should be placed in these indentations before the bandage is applied (Iig. 11-11).
iquipment Required . Cohesivegauze,foam,or cotton underbandage . Bandages of appropriateelasticity . Cotton or foam for padding
:ROCEDURE - Removeclothingandjewelryfrom the areato be treated. Inspectthe skin in the area. Apply foam or cotton paddingaroundanatomical indentations. r Dressand coverany wound accordingto the treatment regimenbeingusedfor thatwound. i Apply a cohesivegauze, foam, or cotton under bandageto protect the skin ftom the compression bandageandminimize slippingof the compression bandage.Startdistallyandprogressproximally. Apply the compressionbandage,starting distally : and progressing proximally. When applying a bandage to the lower extremity, first apply it aroundthe ankle to fix the bandagein place;then wrap the foot and then bandagethe leg and thigh. Wrappingaround the foot should be from medial to lateralwhen on the dorsum of the foot, in the directionofpronation.6lWhen applyinga bandage to *re upper extremity,first apply it to the wrist to fix it in place;then wrap the hand and bandagethe
forearm and arm. Ior all areas,slightly more tension should be applied distally than proximally, and the bandageshould be applied in a figure 8 manner. ADVANTAGES . Inexpensive. . Ouick to apply onceskill is mastered. o Readilyavailable. r Extremity canbe usedduringtreatment. o Safefor acuteconditions. DISADVANTAGES o When usedalone,doesnot reverseedema. o Effectiveonly for conuolling edemaformation. . Requiresmoderateskill, flexibiliqy,andlevel of cognition to apply. . Compressionnotreadilyquantifiableor repiicable. o Bulky and unattractive. o Inelastic bandagesare ineffective in controlling edemain a flaccidlimb,
356
4 4 t Comlz'ession
Figure11-13.Upper extremity compressiongarmen: (CourtesyBeiersdorf-Jobst, Charlotte,NC.)
Figule 11-12.Antiembolism stockings. Beiersdorf-Jobst,Charlotte, NC.)
(Courtesy
Compression Garments Compressiongarmentscan provide various degrees of compression,and are availablein custom-fit sizes for al1areasof the body and standardoff-the-shelf sizesfor the limbs. They aregenerallymade of washable Lycra spandexand nylon and have moderate elasticityto provide a combinationof moderateresting andworking pressure.Inelasticorlow-stretchgarments,which providemoreworkingpressure, arenor made becausethese are too difficult to put on and take off. Off-the-shelfstockingsproviding a low compression force of about 16 mm Hg to 18 mm Hg, known as atltiembolism stocbfugs,are used to prevent DVT in bedriddenpatients62(Iig. 11-1,2). These stockings are not intended to provide sufticient compression to prevent DVT formation or alter circulationwhen the lower extremities are in a dependentposition. These stockingsshould fit snugly but comfortably around the lower extremities, and they should be worn by the patient 24 hours a day, except when bathing.Kneehigh and thigh high stockingsare simi-
larly efficientat reducingvenousstasis,and kneeh.igh stockin3saremore comforfablero wear and wrink} tess."" Custom-fit and off-the-shelf compression ga:ments, providing sufficient compressionto contrd edema and counteractthe effects of gravity on circulationin activepatientsor to modi$zscarformation after buns, are also available(Iig. 11-13).Thesega:ments are available in different thicknessesand with different degreesof pretensioningto providc pressurerangingfrom 10 mm Hg to 50 mm Hg.62-t pressureof 20 mm Hg to 30 mm Hg is generalhappropriatefor the control of scar tissueformatior while 30 mm Hg to 40 mm Hg pressurewill control edemain most ambulatorypatients.Lower pressure may be sufficientin mild casesof edema,and higho pressuremay be necessaryin more severe casesSome garments provide a pressuregradient su& that the compressionis greatestdistallyand decreases proximally. Although off-the-shelf stockings can improve venous circulation and control edema most patients,custom-fitgarmentsmay be in severeconditions or when an individual's li contoursdo not match off-the-shelfsizins. CustorDfit garmenrsmay includeoptionssuchasiippersaod reinforced,paddedareasto improve easeof use fit, and are effective in normalizing venous flow
many,caseswhere off-the-shelfgarmentsare ine tive.oaIn order for sizing to be appropriate,both tom-fit and off-the-shelf compression should be fitted when edemais minimal. This is erally first thing in the morning or after with an intermittent compressionpump. are available for both the upper and lower
ties, aswell asfor the trunk and head (seeFig. 11-13; They are also availablein a number of colors imnrnwp..l
.^.-
".;.
Ts,o . THE PIIYSICAL ACENTS
Jompressiongarmentsshould be applied by gather::g them up, placingthem on the distal areafirst, and =en graduallyunfolding them profmally. Sincethe ::gher-compression garmentshave more pretension::9, somepatientshave difficulty putting them on. A ::rmber of deviceshavebeendevelopedto assistwith :cnning thesegarments,or the patienrmay wear rlvo =ts of lower-compression gaments to provide a total ::mpression equal to the sum of both of them. Ior :-rample,*re patient could wear wvo pairsof 20 mm i'lg compressionstockingsinsteadof one pair of 40 :lm Hg stockingsto achievethe sameeffect. Compressiongarmentsneed to be wom every day =roughout the day, except for bathing, to control ,:Cema, improve circulation,or controlscarformation ::ost effectively.In general,with proper care,these .armentslast about 6 months, after which time they -,tsetheir elasticityand no longer exert the appropri::e amount of pressure.Garmentsalso need to be =placedif thereis a significantchangein limb size,as :ay occurwi*r changesin edemaor in body weight. -r order for *re compressiondeviceto be effective, ::rd to avoid the expenseof purchasingmany setsof .arments,it is recommendedthat a patientuseband:ges to treat edema initially, while limb size is still :iminishing, and that compression garments be
Intermittent Pneumatic Compression Pump j:rtermittentpneumaticcompressionpumps are used :r provide the force for intermittent compression. 1e pump is attached,via a hose, to a chambered ,-eeveplacedaround the involved limb (Iig. 11-1a). 1e specific methods of application for different :umps differ slighdy,and specificinstructionsfor the =pplicationof intermittent compressionare provided -,zithall pumps.Ceneralinsffuctionsthat apply to the :,pplicationof most pumpsaregivenbelow.Although rtermittent compressionis suitableforhome use,the :atient should always begin the course of therapy ;ndermedical supewision. Once satisfactoryreduction of edema has been :chievedwith the pump, the clinician should deter:1lne if continued control will be maintained with
5J/
ordered when the limb size appearsto have stabiIized. ADVANTAGES r Compressionquantifiable(unlikebandaging). o Extremiry can be used during treatment (unlike a pump). . Less expensive than intemittent compression devicesfor short-termuse. . Thin and attractive,availablein variouscolors. o Safefor acutecondition. o Can be used24 hours/day,as for modification of scarformation. o Preferredby patientsto compressionbandages.43 DISADVANTAGES o When used alone, may not reverseedema that is alreadypresent. . More expensivethan most bandages. o Needto be fitted appropriately. . Requirestrength,flexibiliqy,and dextedtyto put on. o Hot, particularlyin warm weather . Expensivefor long-term use, as they need to be replacedat least every 6 mon*rs and the patient requiresat leasttwo identicalgarmentsso that one is availablewhen the other is beinglaundered.
continueduse of the pump or if better resultswould be obtainedwith a compressiongarmentor bandaging. In general,sincea compressionpump is usedfor only a number of hours eachday, the patient should use a static compressiondevicebetween treatments with the pump in order to maintain the reversalof edema prbduied by the pump.aaThe use of intermittent compression in conlunction with static compressionalso generallyimproves the outcomeif compressionis being usedto modify circulation.For example,intermittent compressionpumping twice a week in conjunctionwith staticcompressionwith an Unna'sboot was found to approximatelydouble the rate of venousulcerhealingcomparedwith the useof static compressionwith the Unna's boot alone.65 Intermittent compressionis not generailyusedfor the control of scartissueformation.
358
1,1 . Cotrpression
There is some controversyin the currentliterature with regardto the use of compressionpumps for the treatment of lymphedema.Some authors state thar compressionpumps should not be used for the treatmentof this t)?e of edemadue to the possibiliq' of increasing proximal swelling and nonpittingfibrotic edema.66,flThese authors recommendthai specificmassagetechniquesbe usedto reduceproxirnal and then distaledema,and that bandagesor corn-. pressiongarments be applied after the edema has been reduced by these techliques. Other authors continueto recommendthe use of intermittent coDpressionpumps for the treatment of lymphedem;stating that nonpitting, fibrotic edemais a commoq complication of chronic lymphedema and that its developmentis not relatedto the use of compression pumps.68At this time, the author of this book has been unable to find any publisheddata in the peerreviewedliteraturedocumentingcomplicationsfrom the use of compressionpumps for the treatmentof ly'rnphedema.
Figure11-14. Intermittent pneumatic compressionbeing applied for treatment of lymphedema. (Courtesy Huntleigh Healthcare,Manalapan,NJ.)
Equipment Required . Intermittent pneumaticcompressionunlt o Inflatablesleevesfor upperand lower extremities . Stockinette
PROCEDURE is not contraindi1. Determinethat compression cated for the patient or the condition. Be certain to check for signs of DVI, including calf pain or tenderness associated with swelling. Take the patient's history or check the chart for CHI pulmonary edema, or other contraindications that m a y b e t h e c au s eo f r h e e d e m a .
Bloodpressure cuff
Removejewelry and clothing from the trea area and inspect the skin. Cover any open dressing. with gauzeor an appropriare
3 . Placethe patient in a comfortable position, with affected limb elevated.Limb elevation reduces
dre pain and the edemacausedby venous cienry ifappliedsoonafterthe developmentof
Tgo C THE PIIYSICAL AGENTS
:'.nptoms, because elevationailowsgravityto accel.:ate the flow of bloodin the veinstoward the heart. ,',jth chronicvenousinsufficiencyor ly,rnphaticdys:--rnction, elevationofthe limbsis generallyless effec:,.'ein reducingedemabecausethe fluid is trapped ...'ithinfibrotic tissueand cannotretum as readily to -re venousor lymphatic capillaries,from where it ::n flow backto the cenkal circulation. l.leasure andrecordthe patient'sbloodpressure. '.leasureand record the limb circumferenceat a ---umberof placeswith referenceto bony landrarks69 or take volumetric measurementsby dis: l a c e m e not I w a r e rl r o ma g r a d u a t ecdy l i n d e r . ilace a stockingor stockinetteover the areato be ::eatedandsmoothout all the wrinkles(Fig.11-15). r p p l y t h e s l e e v eF r o m t h e u n i r f F i g . 1 i - 1 6 ) . ieusable sleevesmade of washableNeopreneand rylon aregenerallyused(Iig. 11-17),althoughvinyl .leevesintendedfor singleusearealsoavailablefor applicationwhen thereis concernabout cross-con-,amination.The Neopreneand nylon sleevescan
.;ure 11-15.Application of stockinettebefore applica--:n of compression sleeve.
Figure 11-,16. Applicationof compression sleeve.
359
Figure'11-17, (Courtesy Compression sleeves. Chattanooga Group,Inc.,Hixson,TN.) be machinewashedin warm water and air dried or dried at low heat in a drier. The sleevesprovide intemittent or sequentialcompression,depending on their design. Single-chambersleevesprovide intemittent compressiononly, while sleevescomp o s e do F a s e r i e 'o f o v e d a p p i n cg h a m b e r cs . n inflate sequentially,startingdistally and progressing proximally,to producea milking effect on the extremity.As noted above,sequentialcompression hasbeenshown to resultin more completeemptying of *re deepveinsand a greaterincreasein fibrinolytic activity than single-chamber, intermittent compressionand is therefore prefered for most applications,31,43 althoughit hasnot beenshown to resultin greateraccelerationof venousblood flow I than single-chamber compression.3 B o L h s i n g l e a n d m u ] r i - c h a m b esrl e e v e sa r e availablein a vadety of lengths and widths lor treatmentof upper or lower extremitiesof various sizes. When using a compressionpump for the l r e a l m p r rn f e d e m ; i r i q r e c o m m e n d er d h a tt h e sleevebe long enoughto coverthe entireinvolved limb so that fluid doesnot accumulatein areasof the limb proximal to the end of the sleeve.When using a compressionpump for the prevention of DVT formation, either caif-high or thigh-high sleevescan be usedsinceboth havebeenfound to be effectivefor this application.24,30 8. Attach the hose from the pneumaticcompression pump to the sleeve.The pumps vary in size and compiexity from small home units intended for the treatment of one extremity to larger clinical units that can be usedto treat four extremitiesat differentsettingsall at one time (Iig. 11-18). ContitLted
360
1 'l . Conryressiorr
Figure 11-18. Intermittent compression units. (Courtesy Chattanooga Croup, Inc., Hixson, TN.)
9. Set the appropdate compression parameters, including inflation and deflation times, inflation pressure,and total treatment time. At this time there are litde research data to guide precise selectiono[ any of theseparameters. Thus, che parametersused clinically are derived from an understanding of the pathology being treated, measuresof the patient'sblood pressure,comfort, and observedefficacy in the individual patient. Most protocols use an inflation pressureslighdy below the patient's diastolic blood pressure, although higher pressurescan be used, and all units come with guidelinesfor treatmentparameters basedon their designand manufacture.The parameterrangesprovided below, and Iisted in Table 11-1,covel the rangessuggested by most manufacturersfor most pumps. INFLATIONAND DEFLATIONTIMES The inflation time is the period during which the compressionsleeveis beinginflated or is at the maximai inflation pressure,and the deflation time is the pedod during which the compressionsleeveis being deflated or is fully deflated. Ior the treatment of edemaor venousstasisulcersor for DVT prevention, the inflation time is generallybetween 80 and 100 seconds,and the deflationtime is generallyberween 25 and50 secondsin order to allow for venousrefiiling after compression.Ior residual limb reduction, these periods are generally shorter, with inflation time being bewveen40 and 60 seconds,and deflation time being between 10 and 15 seconds.Usually,the
pressureis appliedin approximatelya 3:1 ratio i n f l a t i o nt o d e f l a r i o nt i m e a n d t h e n a d j u s c e d it
saryaccordingto the patient'stoleranceand INFLATIONPRESSURE Inflation pressureis the maximum pressure the inflation time and is measured in millimeters mercury (mm Hg). Most units can deliver between
mm Hg and 120mm Hg of inflation pressure. single-chamber sleeve is used to provide compression, the chamber inflates to the
pressureand then deflates.When a m sleeveis usedto provide sequentialcompressioq distal segmentinflatesfirst to the maximum pr and then, as it deflates, the more proximal
inflate sequentially,generallyto slighdy lower I of pressure.Somerecommendthat inflation not exceeddiastolicblood pressurein the belief higherpressures may impair arteriaicirculation; ever,sincethe tissuesof the body protect the vesselsfrom collapse,higherpressuresmay be used this is necessary to achieve the desired ciinical come and does not cause painJ although close supervision is recommended when higher p
are used.Ior all indications,inflation pressureis erally betlveen 30 mm Hg and 80 mm Hg and quendy just below the patient's diastolic pressure. Because venouspressure is usuallyloweri the upper extremitiesthan in the Iower extremi the lower end of the pressurerange,30 mm Hg to mm Hg, is generallyused for the upper extremi w h i l e r h e h i g h e re n d o f r h e r a n g e .4 0 m m H g t o
Two . THE PIIYSICAL AGENTS
A E| 11-1 RecommendedParametersfor the
of Intemittent Compression
v
Iaflation/deflation tirne (seconds) (ratio)
Inflation oressute (run HC)
EdemaDVf prevention,venous 5taslsulcel
(3:1) B0-100/25-35
30-60uE 40-80LE
Residuallimb reduction
40-60/10-15
30-60uE 40-80LE
Problem
:r Hg, is generallyused for the lower extremities. -:wer pressuresare generally recommended for :.siduallimb reductionand shapingand for the treat=ent of posttraumatic edema rather than for the :3atment of problems caused by venous insuffi::ncy. Although high pressureshave been recom=ended for the treatment of lymphedema, current ::idelines indicatethat lower Dressures are saferand lay still be effectivefor this condition.6sTreatment ; -th inflation pressuresbelow 30 rnm Hg is not likely = affectcirculationor tissueform and is thereforenot :::ommendedfor any condition. .OTAL
TREATMENTTIME Ital treatment time recommendationsvary from 1 -: 4 hours per treafinent,with treatment frequency .--rgingfrom 3 times per week to 4 times per day.Ior =cst applications,treatmentsof 2 to 3 hours onceor -i'ice a day are recommended.The frequency and :iration of treatmentshould be the mlrumum neces:;ry to maintain good edemacontrol or satisfactory ::ogresstoward the goalsof treatment. ' ,. Providethe patientwith a meansto call you during the treatment. Measure and record the patient's blood pressureduring the trearment, and discontinuetreatmentif eitherthe systolicor diastolic pressureexceedsthe limits set for the patientby the physician. : . When the treatmentiscomplete/tum off the uniq disconnectthe tubing,and removethe sleeveand *re stockinette. :1. Remeasureand record limb volume in the same menner
ec in
5
ll. Reinspectthe patient'sskin.
367
Treatment time (hours)
1.4.Remeasureand document the patient's blood pressure. 15. Apply a compression garmentor bandageto maintain the reductionin edemabetween treatments and after discontinuingthe use of a compression pump. Maximum reduction of edemais usually achievedwith useof the pump for3 to 4 weeks. ADVANTAGES o Actively moves fluids and thereforemay be more effectivethan static devices,particularlyfor a flaccid limb. o Compressionquantifiable. . Canprovidesequential compression. . Requiresless finger and hand dexteriqyto apply than compressionbandagesor garments. o Can be usedto reverseaswell ascontroledema. o Use can be supervisedin a patientwho is noncompliant with staticcompression. DISADVANTAGES o Used only for limited times during the day, and thereforenot appropdatefor modification of scar formation. o Cenerallyrequiresa staticcompressiondeviceto be usedbetlveentreatments. . Expensiveto purchaseunit or to pay for regular treatmentsin a clinic. o Requiresmoderatecomfort usingmachineryto apply. c
1 1o. n r i r e <
elee*ieir.t
. Extremity cannot be used during treatment. . Patienccannot move aboucdurilg treatment. . Pumping motion of device may aggravate an acute condition.
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,l.l . Conq:'tession
9 : 9ntlunL pr in w,a.p.pitr4anX4zaa alow, inlz4mdznA4',
DOCUMENTATION When applying extemal compression, document the type of compression device, the area of the body being treated, inflation and deflation times, compression or inflation pressure, the total treatment time as applicable to the treatment, and the patientrs response to the treatment. Documentation is typically written in the SOAP note format. The following examples only summarize the modality component of treatment and are not intended to represent a comprehensive plan of care. Examples When applying a compression bandage to the left ankle after an acute sprain, document: 9 : 9t elo 9 an*12u&i'nntAalinotztt*z inffizPlll 0: N.QhtLuhA e,tatlizAanlagzu' f a!&t2 & tr*, (i#^z 8. ?t 14 k z4tfE ?h'otud. an qi^lh n 9", I l 0 | 12". 3 d.ull ble^, I an :1,: ?azLtzalnznt gi^n 10".
When applyjngintermittentpneumaticcompression to the right arm to treatlymphedema,document: ?f M4/|^It dtz^2a.ti,nan W edauL in tAL ,pa'al2 wzzta anl u'ur a,AbU' u^a a k2* wilA.ApLn And. 0: g?enLE, 60 4zel30^aL,50 nnfla, 2 bAid'. ,{: ?azbvalnatt attt w&ntz b eltuu k 530 ca, 2 4l0eL . ktt Ltzalnznt ll500 cc a4tut 2 u*z*a'oltazalnznr 11450eo B? Lrrnhnznl 135180, da.hg ahn innrdlalrl+ a4lr^ | 40165.n4 o!r.'wL eA&n* in P^rh"alnznr A!'od Ttttz'taw hA 2alazk eM'\aa o+t^.alh2rrr. 9: euniruz dail* 9?A az al'ottz.
When applying compressionhose to prevent D\ F^*"ri^h
rlnrlmpnt.
I : 9t wt oaiznlzd.x 3. O: eon'ltt4r4.i/n k44z BilAr, f8ja1 d.f.ftua 20 mrtut!4 30 (Jeu<'\n 24 k^lda!, wttilz.N i'LA2d. 4: tu4oliw tbnan'a ai*. lU' otht Liignl o+9U3 Wnalixn. 9: gnantzt olfuit ca*gitreva'b,pl a axn p*a'alm Aoazpnqan-
) Clinical CaseStudies a The following case studies suslrnarize the concepts of compressiondiscussedin this chapter.Basedon the scean evaluationof the ciinicalfindingsand nariospresented, goalsof fteatmentareproposed.Thesearefollowed by a discussionof the facto$ to be consideredin selectionof compressionas the indicatedtreatmentmodality and in selectionof the ideal compressiondeviceand treatment parameters to promoteprogresstoward rhegoals.
Case 4 IR is a 40-year-oldcarpenter.She has chronic lymphedemaof her right upper extremity and complainsof pain and swelling in this extremity that wolsens with useand is mqderatelyalleviatedby elevationand avoiding useof tfie extremity.Shefirst noticed*re swelliog2 or 3 years ago, but at that time it occurredonly after extensive use of her upper extremib/ at work; the sweilingwas mild and resolvedwith a night'srest.Over the last year, the swelling has worsened.Now it never resolvesfuily and is easily aggravatedby even light activity atwork or by yard work. FRreportsthat Byears ago she had a right mastectomyand 16 lyrnph nodes removedas part of h€r treatmentfor breastcancer She was also treated with chemotherapy and radiation therapy at that time and has had no recurrenceof the
malignancy.FR has been advisedby her physician to reducethe useofher right arm and elevateit when possibleto controlthe swelling.Atherrequest,shehasbeen referred to therapy for further management of her lymphedema.The objectiveexam revealsmodeate pitting edemaof the right arm and forearm,wi*r circumferential measurementsof 7 inches at the dght wdst comparedwith 6 inchesat the left wrist, 9Vzinchesat the right elbow comparedwith 11 inchesat the left elbow, and 14inchesat the right mid-bicepscomparedwith 11 inches at tl-te same level on the left. The swelling also causesmoderaterestrictionof elbow, wrist, hand, and fingerROM, ?assiveelbow ROM was measuredas 130' flexion and -10' extensionon the right comparedwith 145" flexion and full extension on the left. The skin of the patient'sright upper extremity appearsthin, flaky, AII othertess, and red,and herblood pressureis 120180. includingshoulderROM and upperextremitysensatioD, are within normal limits. OF THE CLINICALFINDINGS EVALUATION This patient presentfwith increasedginh and loss of motion of the right upper extremity and a risk of skin breakdown of this extremity. These impairments limit herwork andhome activities.
Tgo C THE PIIYSICAL AGENTS
9CEFERREDPRACTICEPATTERN h;. aired Circulation and Anthropometric Dimeasions -!;-.ociated With L).'rnphaticSystemsDisorders, (6lI) trl-AN OF CARE -:e goals of treatment at this time are to control and :e-,ice edemaand restoreROM in order to allow this :a-ent to continueto work at her presentjob and to peri-i= her usualhome and recreationalactivities.Conhol :i ,;,mphedemais also indicated to minimize the risk :i .iin breakdown and infection associatedwith tlis =.,dition. J"SSESSMENTREGARDINGTHE IPPROPRIATENESSOF COMPRESSIONAS THE 9PTIMAL TREATMENT -'-iough expertsin the fie1dof ll.rnphedemavary in ier recommendationsfor treatmentof this condition, !::t agreethat someform of compressionis indicated. l:inpression canprovideworking orrestingpressuteto =::aol fluid flow out of the venouscirculationand into =e lymphatic circulatioq and can also promote the =ovement offluid through the lymphaticvessels.Some ={Dertsrecommendthe use of specialmassagetech=;ues in conlunctionwith compressionin orderto pro=cte lymphatic flow, particularly in proximal areassuch - -,jreaxilla and the trunk, to aid or divert flow in areas -.-'.rerelymphatic function is compromised and where :ost compressiondevicesare not effective.Without .-::h additional ueaEnent, compression alone may ::sult in the accumulationof fluid proximal to the com::essiondevice,particularlyif proximallymphaticfunc:rn is impaired. Although *re useof compressionis genemllynot r€c::nmended in the presenceof malignancy,since this :atient has had no recurtenceof her diseaseafter more =an 5 years,most expertsagreethat compression may :e used. Although the lymphatic circulation in this :atient is clearlyimpaired,the fact that the severity of - er edemavaries,resolving ro someextentwith resrand .levation, indicates rhat the lymphatic circulation in the -.ghtr.rpperexcremityis not completelyblocked,and ieretore compressionis not contraindicatedfor this :eason. PBOPOSEDTFEATMENT PLAN AND RATIONALE nitially, it is recommendedthat compressionbe pro.rded by using an infermittentsequenrialpneumatic :ump. This fomr ofcompressionislikely to producethe ?stest and most effectivereversalof edemabecauseit providesboth compressionand the milking action of iequentialdistal to proximal compression.In order to control the formation of edema berween ueatments
363
with the pneumaticdevice,.wrappingwith an inelastic bandageduring the day to provide a high working pressure is recommended.When the reduction of edema plateaus,which usuallytakes2 to 3 weeks,pumpingcan be graduallydiscontinued.The patient should continue to use the bandageswhen working or exercisingher upper €xtremity. If the patient is not complianr with long-termuseof bandages, a compressiongarmentmay be used.However,sincethis type of garmentis madeof a moderately elasticmaterial, which developslimited working pressure,it maynot be aseffectiveasan inelastic bandagein maintaining edema control during exetcise or other hear,y upper extremity activity. It is recommendedthat the patient not b€ measuredfor fitting of a compressiongament at the initiation of treatmeqt becausea garmentfitted at that time will soon be too big if any edemareversalis achievedwith pumping or bandaging. The recommendedtreaffn€ntparametersat the initiation of heabrent, when the sequentialintermittent pneumaticcompressionpump is being used,are 80 to 100 secondsof inflation and 25 to 35 secondsof deflation, with a maximuminflation pressureof 30mm Hg to 60 mm Hg. The lowest inflation pressurethat achieves reductionofedemashouldbe usedin otder to minimize ttre risk ofcollapsingthe superftciallymphaticorvenous vessels.For most patients, treaffnent with the pump tor 2 to 3 hours once or twice a day is sufficient.AII parameterswi*rin these rangesshould be adjustedto achieveoptimal edemacontrol without pain and with the least disruption of t}le patient's regular activities. Compressionbandagesor garrnentsshould be worn at all. times, for bathing, when the pump is not .except oelnguseo. The appropriateuseofmassage,exercise,and activity modification should also be considered,in addition to treatment with compressioq to achieve the optimal outcome for this patient. The patient'sblood pressure shouldbe monitored before,during,and after the useof the compressionpump. If it becomesexcessivelyelevated, tie pressure,and if necessarythe duration, of pumping should be reduced. During pumping, the patiendsupper exffemity shouldalsobe elevatedabove the levelofherheart. This is most readilyachievedifthe palientIiessupineandplacesherarm on a pilJow.
Case 2 JU is a 65-year-oldmale.He has a full-thicknessvenous stasisulcer on his distalmedial left les. He reDortsthat the ulcer is minimally painful but iequire" frequenr dressingchangesbecausea large amount of fluid leaks kom it. The ulcerhasbeenpresentfor4to 6 monthsand is gradually getting larger. The only treatment being
,l'l . Conyression
) Clinical Case Studies-cont'd providedfor the ulcef at this time is the applicarionof a gauzedressirg,which the patient changeswvo or three The objectiveexam timesa daywhenhe noticesseepage. basefully covered with a red ulcer revealsa shallow,flat wit! granulationtissue,approimately 5 cm by 10 cm in area,with darkening of the intact skin aroimd the ulcer. Edemais alsopresentintheleftfoot, ankle,andleg.Anlde girth measuredat dre medialmalleolusis 9 incheson the iieht and 10 % inches on the left There are no siSns oi edema in the right lower exffemiry The Patient's blood pressureis 140/100,aodhe is currendytakingmedications to conkol hypertension. He had coronary artery bypasssurgery2 yearsago,at which time the left saphenousveinwas removedto be usedfor the graft.
I
rather than aterial insufficiency. ln order to rule out arterial insufficiency, an ankle-brachialindex (ABD should be obtained and compression shouid be appliedonly if *ris is above0.8.The presenceof unilateral rather than bilateral edema indicates that this patient'sedemais probably not due to cardiacfailureAssessmentfor Homan's sign should be performedto rule out a DVT before treatmentwith comPressionis initiated.
PBOPOSEDTREATMENTPLAN AND RATIONALE Twice-a-week treatmentswith intermittent compression using an htemittent sequentialpneumatic Pump in colr. junction with static compression with an Unna's boot tet,veen pumping treatments is recommended for this has creaqnencs pacient. ofcompression Thiscombination FINDINGS OF THE CLINICAL EVALUATION venous stasis of healing the promote to t""r, sho-r, subcutaneous ofskinand This patientpresentswith loss time needed tissueintegrity requiringhim to apPlywound dressings ulcersand to result in healingin half the with the Unna's provided is compression when static frequentlyand placinghim at risk forlocal infectionand of types combination that this *rought It is alone.66 boot possiblesepsis.He alsohasincreasedgirth of the ieftdiswound complete such rapid, produces compression of tal lower extremiry healinsind resolurionofedemabecauseitreducesederna by thJmiking action associatedwith sequentialdistal to PLANOF CARE proximal intermittent compression and then maintains The eoalsof treatmentale to achievewound closurein edema control with the continuous compression of to changes and ordeito eliminarethe needfor dressing the rieid Unna's boot. The recommended tr€atmeDt lower extremiqy of Control reducethe risk of infection. puru*"t".t for the sequential intermittent pneumatic edemais alsodesirable. compres"ionpump to Promorecirculationand control edema are80 to 100secondsof inflationand 25 ro 35 secPREFERREDPRACTICEPATTERN deflatiorl with a maximum inflation pressureof of onds With FulllmpairedIntegumentaryIntegriqyAssociated to 60 mm Hg and a ffeatment duration of 2 to 3 mm Hg (7D) 30 and Scarlormation, Skinlnvolvement Thickness hours. Adiustments should be made within these ranges in order to achieveoPtimaledemacontrol without paia ASSESSMENTREGARDINGTHE and with the leastdisruption of the patient's regularactivAS THE APPROPRIATENESSOF COMPRESSION ities. The Unna's boot should be wom at all tim€s TREATMENT OPTIMAL between inrermitteni comPressiontrearnenrs. lf ao This patient's ulcer and edema of the distal Iower Unnarsboot is not available,then compressionstockin8! extremity are probably due to poor venouscirculation. providing 30 mm Hg to 40 mm Hg of pressuremay be can Compressionis an indicatedinterventionbecauseit wom betwe€n PumPing treatments Since these stockwound heaiing facilitate improve venouscirculationto are easier to remove and reapply than the-Unna's ings more that are dressings Specialized control. and edema to once boot, the ftequencyof pumpingmay be increased absorbentand lessadherentthan gauzeare alsorecomshould be pressure blood patient's The a day. or tlvice mended to reducethe required ftequency of dressing the compresuse of and after during, before, monitored trauma changesand thus reducethe potentialforwound sionpump. Ifit becomessigniEcandyelevated,the forcg and inconvenienceto the patient. Contraindicationsto should be the use o[ compression,includingarterialinsufficiency, and if necessarythe duration, of pumping placed on the be should dressing appropriate reduced.An heart failure, and DVT, should be ruled out before the compression of the the application site before ulcer initiation of fteatmentwiti compressionThe patient's sleeve,boot, or stocking.A single-usesleeveshouldbe the possibility history ofcardiacbyPasssurgerysuggests used for pumping, or an occlusivebanier should be exttemities, lower in the insufficiency of arterial placedover the ulcer during PumPingin order to avoid although the presenceof edemaand the conformation cross-contamnahon. ofthe leg ulcerindicatethatitis probablydue to venous
T*,o O THE PHYSICAL AGENTS
It is essentialthat the patient continue to wear a compressionstocking after the ulcer has healed since his circuiatory compromiseputs him at high risk for recurence of edema and tissue breakdown in this extremity.
Case 3 ND is a 20-year-oldmale who sustainedan invercion sprainof his right anklewithin the last hourwhile playjng footbaLi. He complainsoi anklepain.sriffness, and swelling. The pain is primarily at the lateral anlle and increaseswhen he bearsweight on his right lower extlemity when walking. He is unable to run because of the pain. The objective evaluation revealsmildly increasedtemperature,swelling, and r€strictedpassive ROM of the right ankle.Aakle girth at the level of the medial malleolusis 12 incheson the risht and 11 inches on the left.Passive ankleROM was measured as 30'of inversionon t}le right, limited by pain, comparedwith 50" on the left, 20' of eversionon the right compared with 25' on the left, 0' of dorsiflexionon the right comparedwi*r i5'on the Ieft,and 40' of plantarflexionon the right comparedwith 50' on the left. During ambula, tioq ND protected his right ankle by decreasingthe durationof stancephaseon the right, decreasingdorsiflexion ofthe right ankleduringmidstance,and decreasing plantar flexion of the right ankle during terminal stance. EVALUATION OF THE CLINICALFINDINGS This patient presentswith increasedgirthJtemperature, pain,and restrictedmotion ofhis right anlle resultingin gait deviations,reducedambulation tolerance,and an inability to run. PREFERREDPRACTICEPATTERN Impaired Joint Mobility, Motor Function, Muscle Performance,and Range of Motion AssociatedWi*r ConnectiveTissueDysfunctioq (4D) PLANOF CABE The goals of treatrnent at this time are to control inflammation and swelling and to prevent further injury or damageto the involvedankleor to otherareas.I he anricipated long-term goalsof treatment include regainingnormal girth and ROM of the right ankle so that tie parient can retum to his pnor functionalacrivitjes,includinga normalgajtfor ambuLation andrunning.
365
ASSESSMENTREGARDINGTHE APPFOPRIATENESS OF COMPRESSION AS THE OPTIMAL TREATMENT Compression is indicated as a component of this patient'sinterventionbecausethis treatmentcanhelpto control the formation of edema;however,it will not be optimally effective in promoting tle achievementof this or other goalsof treatrnentif usedalone.When edemais causedby acuteinflammation,compressionis likely to be most effective if it is applied in conjunction with rest, ice, and elevation.Localrestcanbeachievedby the appropriate use of crutches;ice may be appliedas describedin Chapter I and, for optimal benefit, the patient,s ankle shouldbe elevatedabovethe leveiofhis heart.The useof crutcheswill also reducethe risk of further iniurv to other areasdue to stressebof an abnormalgaii pattem. Although the useof compressionis nor contraindicatedin tJrispatient. cheuse of inlermi(ent compressionis nof recommendedbecause,with suchan acuteffauma,the motion produced by intermittent compressionmay aggravatebleedingor displacea ftacture if one is present. PFOPOSEDTFEATMENT PLAN AND RATIONALE Sincethe useof intermittent compressionis not recommended,staticcompressionshouldbe used.This canbe providedmost readily by the use of an elasticcompression bandage.This rype of bandageis recommended becauseit provideshigh restingpressureduring res! i6 readily available,can easily be used by the patient at home, and is inexpensive.The bandage should be wrapped in a figure B marurer to provide consistent and comfoftablecompressionin all areas.It should be snug bucnoLsotighcthaLit Iimitscircularion. Foroprimalconl trol of edema, slighdy more compressionshould be applied distally than proximally. To apply cryotherapy in conjunctionwith the compression,the bandagemay be applied over or under an ice pack or cold pack. Since compressionshouldbe maintainedat a1ltimes until tie edemaresolves,whereascryotherapyshould generally be appliedfor 15 minutesevery 1 to 2 hours,placingthe pack over the compressionbandagemay be more time efftcient. The patient should also e.levatehis lower extremi4/ abovet}te level of his heart when possibleto achieve the most rapid rcsolution of the edema. Compressionshould be applied at all times until the edemaresolves.As the patientrecoversand the edemais reduced,an elasticcompressionbracemay be used in placeof the compressionbandage.
?referredPhysicalTherapistPracticePattemsSM[4D, 6H, and ZD] are copyrighr2002AmericanPhysicalTherapyAssociailon.All rights :eserved.
366
44 . Corrrqressiofi
Chapter Review Compressionapplies an inwardly directed force to the tissues,thereby increasingextravascularpressure and venousand lymphatic circulation.Externalcompressioncan be used to control edema,prevent the formation of DVI, facilitate venous stasis ulcer healing, and shaperesiduallimbs after amputation. canbe providedby a pneumaticpump Compression or by specialbandagesor garments.Pneumadcpumps provide intermittent compressionfor limited periods of time, whereas bandagesand garments provide static compressionand can be worn throughout the day. The choice of compressiondevice dependson the natureof the problembeingtreatedandthe ability of the patient to comply with the treatment. The use of traction and compressionis contraindicated when they may aggravate any existing condition or when they may causedamageto other areas.The reader is refened to the Evolve website at http:// for studv questions evolve.elsevier.com/Cameron pertinent to this chapter.
Abstract Soc Phys Reg Biol Med 15th Ann Washington,DC. 9. Ganong WF: Reuewof Medial Physiology,Nomvall', 1987,Appleton & Lange. 10. Nelson PA: Recent advancesin ftealrnent of phedema of the extremities, Ceriatrics2l:1621966. 11. Jungi WI: The prevention and managementof phoedemaafter treatmentfor breastcanc€r,1rt Med3:129-134,7981,. 12. SwedboreI: Effectsof treatmentwith an elastic and intemittent pneumaticcompressionin post tectomy patientswith lymphoedemaof the arm, I Rehabil Med 26:35-4I.7984. 13. ZeisslerRH,RoseCB, NelsonPA:Postmastectomy phedema,late resultsof treatmentin 385 patients, PhvsMed Rehabil53:159'166,1972. 14. Airaksinen O: Changesin posttraumaticanlde mobiliry, pain, and edemafollowing intemittent matic compression dtenpy, Arch Phys Med 70(4):341-344,1989. 15. ChlebounGS, Howell JN, BakerHL et al: Dneumatic compression effect on eccencric
inducedswelling,stiffnessand strengthloss,,4/tt
6(8):7 44-749, 1995. MedRehabil7 16.BorisM, WeindorfS, LasinskiB et al:
References reductionby noninvasivecomplex lymphedema MP et al:The effi1. RamosR. SalemBI. DePawlikowski 8(9):95-1'06 apy,Oncology stockings in theprevencompression caryof pneumatic , 1994. Chest 17. Matsen IA, Krugmire RB: The effect of tion of pulmonaryembolismaftercardiacsurgery, applied pressureon postftactureswe1lk:ry,, J Boxe 109(1):82-85 , 1996. Sutg 56-A:1586-1591, 1974. andnon-conthuous RH:Compression stockings 2. Samson 18. Airaksinen O, Kolari PJ,Herve R et al: Treatment for thetreatmentof foamdressings useof polyurethane post-fiaumaticoedemain lower legsusing venousulceration:a pilot st:udy,J DernatolSurgOncol Med 20(1 pneumaticcompressiol.Scafld J Rehabil 19(1):68-72 , 1993. 1,998. S et al: Intemittent pneuAH, Frangos SG, Kilaru 3. Chen mechanisms 19. Ouillen WS, RoullierLH: Initial managemenroF devices-physiological maticcompression SuryMay;21(5):383-392, anklesprainswith rapidpulsedpneumaticcoml of action,EurJ VascEndorasc and cold,JOnhoySponsPhysThet4:39-43,1982. 200r. 20. P,DenegarC: Traumaticedemaand the oI Kolb OJ, Shah BP et a1: Evaluation 4. WhitelawGP,Oladipo system,AthletlcTraining17:339-341, 1983. devices,Onhoyedics intermittentpneumaticcompression -261,2001. 21. KraemerWJ, Bush JA, Wickham RB et al: Influence Mar;24(3):257 compressiontherapy on symptoms following soft studiesof periodicextemal 5. KammRD: Bioengineering sue injury from maximal eccentricexercise,,l asprophylaxis against deepvenousthromcompression -95, SVons PhysTher31:282-290,200I. Biomech Eng 704:87 bosis,partI: NumericaIstudies, J 22. Gilbaft MK, Ogilivie-HarrisDJ, BroadhurstC et 1982. Antedor tibial compartmentpressuresduring studAH:Bioengineering 6. OlsonDA,KammRD,Shapiro tent sequentialpneumaticcompressionthemPy, as prophylaxis ies of periodicextemalcompression 1995. Metl23(Q:7 69-772, Spons part II: Experimental deep venous thrombosis, against AN, Fernandes Erg t04:96-I04, 23. Nicolaides JBPollockAV studieson a simulatedleg,J Biowech sequentialpneumatic compressionof the legs in 1,982. preventionofvenousstasisandpostoperatived€ep 7. WakimKG. Martin GM. KrusenIH: Influenceof cenSurgery 87:69-76, 1980. rhrombosrs, on localizededemaof an tripetalrhythmiccompression HastyJH:Theroleof ScurJH, 24. Caprini 1955 . 36:98-103 extremiry,ArchPhysMedRehabil JA, , modalities in a prophylactic program for deep M, AsturLianD: A review B. LeeRC,Capelli-Schellpfeffer thrombosis, SeminThronbHenosm 74:77-87, 1988. rcpaiandrenodeling 1995, ofthermoregulation oftissue
Two . THE PIIYSICAL AGENTS
l: Handoll HH, Iarrar MJ, McBirnie J et al: Heparin,low molecular-weightheparin, and physical methods for preventing deep vein thrombosis and pulmonary embolismfollowing surgeryfor hip fiactures,Cochrane DatabaseSystRet,(2):CD000305, 2000. i: Muir KW, Watt A" BaxterG et al: Randomizedtrial of gradedcompressionstockingsfor preventionof deepvein thrombosis after acute stroke, QJM Jun;93(Q: 359-364,2000. - Amarigiri SV, LeesTA: Elasticcompressionstockings for prevention of deep vein thrornbosts, Cochrane DatabaseSystRev(3).CD001484 , 2000. -! lreedman KB, BrookenthalKR, FitzgeraldRH Jr et ai: A meta-analysisof thromboembolic prophylaxis following electivetotal hip arthroplasty,J BoxeJointSwg An lul;82-A(7):929-938,2000. i: WestrichCH, HaasSB,MoscaP et al: Meta-analysisof thromboembolic prophylaxis after total knee arthroplasrT,J BoxeJointSurgtu Atg;82(61:795 -800, 2000. i. PidalaMJ, DonovanDL, KepleyRI: A prospectivestudy on inteimittent pneumaticcompressionin the prevention ofdeepvein thrombosisin patientsundergoingtotal hip or total kneereplacement,Swgery175:47-51, 1992. i - Ilam E,BerryS,CoyleA et al:Blood-flow augmentation of intermittent pn€umatic compressionsystemsused for the preventionof deepvein *rombosis beforesurgery,An J Surg171312-315, 1996. :- TarnayTI, Rohr PR,DavidsonAC et al: Pneumaticcalf compressioqfibrinolysis,and the preventionof deep venoustirombosis, Surgery88:489-495,1980. .; KniSht MTN, Dawson R: Effect of intermittent compressionof the armson deepvenousthrombosisin the -1268,1976. legs,Latcet2(7998):1265 :r SalzmanlW McManama GP,ShapiroAH et al: Effect of optimization ofhemodynamicson fibrinolytic activity and antithrombotic efficacy of extemal calf compression,Ann Sury206:636-641, 1987. --=.ChouhanVD, ComerotaAJ, Sun L et al: Inhibition of tissue factor pathway dudng intermittent pneumatic compression:a possiblemechanismfor antithrombotic effect, Arteriosclet Thromb Vasc Brbl Nov;19(11): 2872-2817 , L999. lj Homans J: The aetiology and treatment of varicose ulcersof d.releg,SargCyxeal Obstet24:300-311., 1917. :- BrowseNL, Bumand KG: The causeof venousulceration, Laxcet2:243-245 , 1982. :3. McCullochJM: Intermiftent compressionfor the treatment of a chronic stasis ulceration, Phys Thet 61 1452-1,453 , 198r . :;. SamsonRH, ShowalterD?: Stockingsand *re prevention of recuffentvenousulcets,DetmatolSurgApr;22(4): 373-376, 1,996 . r,'. Smi*r PC, Sarin S, Hasty J et al: Sequentialgradient pneumaticcompressionenhancesvenousulcerhealing: a randomizedtrial, 5argeryt0B871.-875, 1990.
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41. Kunimoto B, Cooling M, GullinverW et al: Best practices for the prevention and treatment of venous 1eg tlcers, Osnmy Vound ManageIeb;47Q):34-46,48-50, 2001. 42. Pekanmaki K, Kolari fl, Kirstala U: Intermittent pneumatic compressiontreatment for post-thromboticleg slcers, Clin Exp Detftatol 1,2:350-353,1987. 43. ColeridgeSmith PD, Thomas PRS,ScurrJH et al: The aetiology of venous ulceGtion:anew hypothesis,Br MedJ 296:1726-1728, 1988. 44. The Jobst Extremity Pump: Clixica! A1zplicatlotrs with an Overvlewof thePathophysiology ofEdema.Charlotte,NC, 1996,Beiersdorf-Jobst. 45. Deitch EA. Wheelahan TM. Rose MP et al: Hypenrophic bum scars:analysisof variables, J Truuma 23:895-898 , 1983. 46. Hunt TK: Disorders of wound healing, Vo d J Sutg 4:271-277 ,1980. 47. SullivanT, SmithJ,KermodeJ et al:Ratingthe bum scar, 7990. J BurxCareRehabil11:256-260, 48. Ward RS: ?ressuretherapy for the control of hypertrophic scar formation after burn injury: a history and revtew,J Bun CareRehabil12:257-262,L991. 49. RenoF,CrazianettiP CannasM: Eflectsof mechanical compressionon hypertrophic scars:prostaglandinE2 re\ease, ButttsMay;27(3):215-218,2001. 50. BermanB, FloresI: The treatmentofhypertrophicscars andkeloids,EurJDernatolDec;B(8):59L-595 , 1998. 51. StaleyMJ, fuchard RL. Use of pressureto treat hypertrophic bum scars,Adv WoundCareMay-Jun;10(3):4446,1997. 52. LarsonDL, Abston S, EvansEB et al: Techniquesfor decreasingscar fomation and contracturesin the -823, 197L. burned padent,I Trauna L1.:807 53. Kircher CW. Shedar MR. Shedar CL: Alteration of hypenrophic scars induced by mechanicalpressure, ArchDernatol11160-64,1975. 54. Brennan MJ, DePompolo RW, Garden FH: Focused review: postmastectomylymphedema,ArchPhysMed Rehab il TT:574-580,1996. 55. ReynoldsJP: Lymphedema:an "orphan" disease,PT Magazinelune.54-63,1996. 56. McGroryBJ,BurkeDW: P€ronealnervepalsyfollowing intemittent sequential pneumatic compression, Onhopedics Oct;23(70):1 103-1105,2000. 57. Pittman CR: Peroneainervepalsy following sequential pneumaticcompress ion,JAMA 261,:2201-2202 , 1989. 58. LachmannEA, Rook JL,Tunkel R et al: Complications associatedwi*r intermittent pneumatic compression, ArchPhysMed Rehabil73(5)1,82-485 , 1992. 59. Harris R: An introduction to manuai lvmohatic drainage:The VodderMechod,Mas"ageTherj 5:b5-66. 1992. 60. Hiatt WR: Contemporarytreatment of venous lower linb olcers,Axgiology43(10).852-855 , 1992.
358
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61. Staudinger P: ComyressiotSteV by Stey, Nuremberg, 1991,BeiersdorfMedicalBibliothek. 62. TheAtA-Glance Cuide to VascularSnckitgs, Cha{otte, NC, 1991,Jobst. 63. Benko T, Cooke EA" McNally MA et al Graduated compression stockings: knee length or thigh length, C/rz Onhop Feb;(383):197-203,200t. 64. SamsonRH: Compression stocking therapy for patients with chronic venous insufficiency, J CardiovascSurg 26:10,1985. 65. McCulloch jM, Marler KC, Neal MB et aL Intermittent pneumatic compressionimproves venous ulcer healing, Adv \(ound Care7 (4):22-24,26, 7994.
66. Foldi M: Treaftnent of lymphedema, NIN 7(3):7,2, 6, 8, 1995. 6-l. Augustine E: Lymphedema:the debau coxtixues, Magazixe N ov ember:10-11, 7996. 68. Jacobs L: Lymphedema: the debate continues, Maeazi e November:l1,7996, 69. Swedbore L Volumhometric estimation of the of lymphedema and its therapy by pneumatic ston,Scand Med 9:I3I-I35, 1977. J Rehabil
T-t
Erecffomagnetrc MichelleH. Cameron,pT OCS, Diana perez, BSc,pT, MSc, and SuzanaOtano_Lata, MS SUMMARY
OF I
PhysicalProperties of Electromagnetic Radiation Physiological Effects of Electromagnetic Radiation ?hysicalPropertiesof Ultraviolet Radiation :tfects of Ultraviolet Radiation llinical Indications for the Use ofUltraviolet Radiation AdverseEffectsof Ultraviolet Radiation \pplication Techniques locumentation lelecting a W Lamp ,linical CaseStudy ?hysicalPropertiesof Lasers :ffects of Cold Lasers
Clinical Indications for tl-leUse of Cold lasers Contraindicationsand Precautionsfor Lasers PhysicalPropertiesof Diathermy-Thermal and Nonthermal Types of Diathermy Applicators Etfectsof Diathermy Clinical indications for the Use of Diathermy Contraindicationsand precautionsfor Diathermy AdverseEffectsof Diathermy Application Techniques Documentation Selectinga Diathermy Device Clinical CaseStudies Chapter Review
oBIECTTvES UponcomVletionofthis chalzter,the readerwill beable to: .. Discussthe physicalpropertiesof 4. Determine how the physicalpropertiesand electromagneticradiation. physiological effects of elecuomagnetic radiation i. Classifythe differenrrangesand can promote particular treatment qoals. D,pesof etectromagnetic radiationusedtherapeuticallv_ 5. Assessthe indications, contraindiations, and including infrared, ultraviolet, cold lasers, precautions for Lheapplication of shortwave, and microwave_ electromagnetic radiation of different ft equencv !. Identify the physiologicaleffectsof the different rangeswirh respect to different patient rangesot electromagneticradiation. management sltuations.
370
,12 . Electonasrretic Radiation
5. Design methods for selectingthe most appropriateelectromagneticradiation device and treatment parametersto produce desired physical and physiologicaleffects. 7. Evaluatedifferent electromagneticradiation deviceswith respectto their potential to produce desiredphysicaland physiological effects.
8. Presentedwith a clinical case,evaluatethe clinical findings, proposegoalsof treatment, assesswhether electromagneticradiation would be the besttreatment,and,if so, formulate an effectivetreatment plan including the appropriatedeviceand treatment parametersfor achievingthe goals of tfeatment.
This chaptersewesas an introductionto the appiication of electromagneticradiation in rehabilitation. Physicalagentsthat deliver energy in the form of electromasneticradiationincludevariousforms of visible and inirisible llght, and radiation in the shortwave and microwave ranges.There ate a number of clinical devicesthat deliver electromagneticenergy, and a applicationsfor numberof recommendedor suggested widely used are these devices eachlhowever,none of United States. in the by rehabilitationprofessionals of Some are effectivefor the treaftnent disorders not related to the musculoskeletalsystem and are therefore more commonly used by other health professionals.Ior example,ultraviolet radiation has provenbeneficialin the treatmentof many skin disordersand is thereforemost frequendyusedby dermatologists. Others, such as cold lasers,have not yet
receivedFDA approval for clinical application, still others, such as diathermy,are unpopulardue the risks associatedwith their misuseand the lack definitiveinformation on their mechanismsof agentsareusedin a Although electromagnetic ited manner at this time, since they all have shown in the literatureto have therapeutic they will be discussedin this chapter.It is valuable the *rerapist to have a good understandingof th agentsand their effectsbecausethey can be utili; to achieveimprovedclinicaloutcomesin approPri patients.This chapterdiscussesthe physical ties and physiologicaleffectso[ electromagnetic ation, and providesguidelinesfor clinicalapplic and casestudies describingthe application of tpe of electromagneticradiation that may be for rehabilitationin the United States.
Two C THE PHYSICAL AGEATS
371
?IIYSICAI PROPERTIES OFELECTROMAGNETIC RADIATION iectromagnetic radiation is composed of electric ;:rd magnetic fields that vary over time and are :nented perpendicular to each other (Iig. 12-1). :iectromagneticradiationcan propagatewithout the -ed of a medium. All living organiims are continu:usly exposedto electromagnetic radiationfrom both ::tural sources,suchasthe Earth'smaeneticfield and
the ultravioletradiationfrom the suq and from manufactured sourcessuch as domestic electricalaopliances,compurers, andpowerlines Electromagnetic radiationis categorizedaccording to its ftequency and wavelength, which are inversely proportionalto eachother(Iig. 72-2).Lower-frequency electromagneticradiation, including extremely low
H lvlagnetic field
-----------> Direction of propagation
Resultant elechomagnetic field Figure12'1. Perpendicularorientation ofthe electricand magnetic componentsofan electromagnetic field.
42 . Electomasnetic Radiation
372
Wavelenglh
FiWrc12-2.The frequencyand wavelength of an electromagnetic wave are inversely related. As the frequency increases, the wavelenqthdecreases.
frequency (ELF) waves, shortwaves, microwavei infrared (lR) radiation,visible light, and ultravioletA and B (WA and WB), is nonionizing and cannc break molecular bonds or produce ions, and therefore be used for therapeutic medical applications. Higher-frequencyelectromagneticradiatior, such as x-rays and gamma rays, is ionizing and breakmolecularbondsto form ions.1'2Ionizing tion can also inhibit cell division and is th either not used clinically or usedin very small for imaging or to destroy tissue.Approximate quencyrangesfor the different types of radiation shown in lie. 12-3and are statedin the sections cerning each type of radiation. Only approxi rangesare given becausethe reported values di slighdy among texts.3 This chapter describes basic physical properties,physiologicaleffects, clinical uses of ultraviolet radiation, Iasers, ous and pulsedshorwvavediathermy,andmi
ll
30 Hz
300 Hz
3 kHz
30 kHz
300 kHz
3 l'/Hz
300 3 30 lr,lHz l',4H2 GHz
30 GHz
300 GHz
3 x 1 0 1 43 x 1 0 1 s 3 x 1 0 1 63 x 1 0 1 73 x 1 0 1 8 Hz Hz Hz Hz Hz
lonizingradiation
radiation Nonionizing
10 1 10,000 1,000 1 0 0 kmkmkmmm km km
100
10
10 1100 mmmmmmm
1
1 frn
100 nm
10 nm
1 nm
Figure12-3. The electromagneticspectrumrangesfrom low frequenciesin the Hertz rangeto over 1023Hz, with lengthsvaryingfrom over 10,000km ro lessthan I picometer.
100 pm
T+po. THE PIIYSICAL ACENTS
::athermy.BecauseIR radiation producessuperficial ..:aring. the clinical applicationof IR lamps is -:scribed in Chapter 6, togetherwith other superfi -,1 hp:tino:oent<
The intensiryof any type of electromagnetic radia-cn that reachesthe patient from a radiationsource, :':ch asa W lamp or a diathermycoil, is proportional = the energy output from the source, the inverse
J/5
squareof the distanceof the sourcefrom the patient andto the cosineofthe angleofincidenceof the beam with the tissue.Thus the intensity reachingthe skin is greatestwhen *re radiation source is close to the patientandwhen the beamis perpendicular to the surfaceof the skin. As the distancefrom the skin or the angle with the surface increases,the intensity of the radiationreachine*re skin will fall.
PHYSIOLOGIGAT EFFEGTS OFEI-ECTROMAGNETIC RADIATION lectromagnetic radiation can affect biological sys=ms via thermal and/or nonthermal mechanisms. :ecauseIR radiationand both continuousshortwave rrd microwavediathermycan increaserissuetem:erature,they are thought to affect tissuesprimarily :-.'thermalmechanisms.IR radiationheatssuperficial =sues, whereasshortwaveand microwave continu-:-rsdiathermyheat both superficialand deeptissues. he physiologicaland clinicaleffectsof thesethermal .:.entsare generallythe sameas those of the superfi:al heatingagents,asdescribedin detailin Chapter6, :tcept that the tissuesaffectedaredifferent. W radiationand low levelsof pulseddiathermyor ;er light do not increasetissuetemperatureand are ::erefore thought to affect tissues by nonthermal =echanisms.It has beenproposedthat thesetypesof :ectromagnetic energy cause changesat the cellular e'rel by altering cellmembranefunction and permeabilr_.'.4Nonthermal elecftomagneticagentsmay promote ::lrding of chemicalsto the cell membrane to trigger ::mplex sequences of cellularreactions.Becausethese :lents could promote the initial stepsin cellular func::n, this mechanismof action could explain*re wide .:riety of stimulatory cellular effects that have been :"cserved in responseto the applicationof nonthermal t'rels of elecftomagneticenergy. Electromagnetic .:\ergy may also affect tissuesby causing proteins to -rdergo conformationalchangesto promote active =nsport across cell membranesand to accelerate :denosinetriphosphate(AT?)synthesisanduse.s Many have invoked the Amdt-Schulz law to ::
u.I tt,
z
o
UJ
a 9 C' o
0 o INTENSITY OF STIMULATION
Figure 12-4.The Amdt-Schulz1aw. inhibitory This is demonstrated in many instances.Ior example,a low levelof mechanicalstressduringchildhood promotesnormal bonegrowth; either too litde or too much sffesscanresultin abnormalgrowth or fractures.Similarly,with some forms of electromagnetic radiationsuchas diathermy,althoughtoo low a dose may not produce any effect, the optimal dose to achievea desiredphysiologicaleffect may be lower than that which producesheat.If excessivedosesare used,tissuedamagedueto bumingmay result.
PHYSICAL PROPERTIES OFULTRAVIOLET RADIATION W radiationis electromagneticradiationwith a frequencyrangeof 7.5 x 1014to over 1015Hz and wavelengthsfrom 400 nm to below 290 nm. IJV radiation lies bewveenx-ray and visiblelight (seeFig.12-3).W radiationis dividedinto threebands-UVA. UVB. and UVC-with wavelengthsof 320 to 400,290 to 320, and lessthan 290 nm, respectively.WA, alsoknown
374
42 o Electtomasnetic
as long-wave UV, is nonionizing and producesfluowhile UVB, or middlerescencein many substances, wave U! which is also nonionizing, producesthe most skin erythema.UVC, short-waveW, is ionizing and germicidal.BecauseW doesnot produceheat,it is thought to produce physiologicaleffectsby nonthermal mechanisms.The most significantsourceof W radiation is the suq which emits a broad spectrum of W including WA, U\8, and WC. Both WA and the WB reachthe earthftom the suryhowever,WC is filtered out by the ozonelayer. The physiologicaleffectsof W radiationare influencednot only by the wavelengthof the radiation,but also by the intensity reachingthe skin and the depth of penetration.The depth of penetrationis affectedby the intensity of radiation reachingthe skin, the wavelength and power of the radiationsource,the size of the areabeingtreated,the thicknessandpigmentation of the skin, and the durationof treatment.The intensity of W radiation reachingthe skin is proportional to the power of the output of the lamp,the inversesquare of the distance of the lamp ftom the patieng and the cosineof the angleof incidenceof the beamwith the tissue.Thus the intensity reachingthe skin is greatest when a high-power lamp is used, when the lamp is closeto the patient, and when the radiationbeam is oeroendicularto the surfaceof the skin. Penetration is deepestfor W radiationwith the highestintensity, longest wavelength, and lowest ftequency.Thus WA penetratesfarthestand reachesthrough severalmillimeters of skiq while LI\E and WC penetrate less deeplyand arealmostentirelyabsorbedin the superficiai epidermallayers.The penetrationof W radiation is alsolessdeepif the skin is thickeror darker.6,'
Radi.ttiort
Production Erythema Ervthema.or rednessof the skin dueto dilation of thc superficialblood vesseiscausedby the releaseof hi tamines,is one of the most common and most obvious effectsof exposureto W radiation.SErythema producedprimarily in responseto UVB exposureor responseto WA exposureafter drug Without drug sensitizadon,WA is 100to 1000 lesspotent in inducingerythemathan WB. With sitization,the erythemalefficary of WA is similar that of WB alone,with lessrisk ol overexposure burning.The precisemechanismof W-induced thema is unknownl however, it is known that effect is mediatedby prostaglandinreleaseftom epidermis,and it may also be telated to the damagingeffectsof UV radiation.The severityof thema, which can produceblistering,tissue and pairl and the risk of cell damageare the factors limiting the frequency and intensity of exposureusedclinically.
Tanning Tanning, a delayed pigmentation of the skiry occurs in responseto W radiation exposure, effectis the resultofincreasedproductionand migration of melanin granulesand oxidation of Becausethe darkeningof melaninin the skin.9,10 pigmentation that occurswi*r tanning reduces penetrationof UV to deepertissuelayers,it is that tanningis a protectiveresponseofthe body.
hyperplasia Epidermal a thickeningof the hyperplasia, Epidermal layer of the skin, occursapproximately72 hours
RADIATION EFFECTS OFULTRAVIOLET Erythema production Tanning Epidernal hyperplasia Virarnin D sFthesis Other effects of ultraviolet radiation
W radiationhasbeenshown to causeskin erythema, tanning, epidermalhyperplasia,and vitamin D synthesis.It is thought that theseeffectsare the result of absorptionof electromagneticenergyby the cellsof exposedtissue,causingchemicalexcitationand facili processes. tationoI photobiological
exposure to W
radiation and, with repeated
sure,eventuallyresultsin thickeningof both the dermis and the stratum corneum that persists severalweeks.This effect is thought to be caused the releaseof prostaglandinprecursorsIeading by epidermalcells, increasedDNA sy'nthesis in increasedepithelialcellturnoverandcellular plasia.ll Epidermalhyperplasiais most in responseto WB exposure.It is also thought occur in order to protect the skin from excessive exposure. Becausetanningand epidermalhyperplasia IJV penetration, progressivelyhigher doses of radiation are generally required during a course clinical treatment with ItV.
Tlt'o . THE PIIYSICAL AGENTS
YitaminDsynthesis -V irradiationof the skin is necessaryfor the conver::on of ingested provitamin D to vitamin D.12,13 a€causevitamin D actsto control calciumabsorption ::rd exchange,it is an essentialvitamin for bone for=ation; it alsoinfluencesbrain,kidney,intestine,and :rdocrine function.MtaminD deficiencycanresultin :oor intestinal absorptionof calcium and can cause ::;kets, a diseasecharacterizedby failure of bone :ineralization. R.icketscan be the result of inade--Jateexposureto W radiation,inadequateintake of ::ovitamins, or poor kidney function. Although for rost individuals the exposureto W in sunlight is ::.rfficientto maintain adequatelevels of vitamin D ::oduction, W exposure may be inadequate in :edridden patients or in those who work for long :ours in undergroundenvironments.
375
reportsof UV therapybeingusedfor the treatrnentof scleroderma,eczema, atopic dermatitis, mycosis fungoides and vru)igo.17'19 These treatments may be appliedin conjunction with the useof photosensitizing drugs.W is alsousedoccasionallyasa componentof tr1,hout1t the treatmentof chronicopenwoundr.19-zz the clinicalapplicationof W radiationfor the treatment of skin disordersis within the scopeof physical therapy,suchtreatmentsaregenerallyprovided by derTreatmentof chronic matologistsor their assistants. wounds with W radiation,however,generallyis performedby a physicaltherapist. t/VB alone,or WA in conjunctionwith psoralen sensitization,known as PUVA, may be used for the ffeatmentofpsoriasisand otherskin disorders,includpruritus,and ing eczema,acne.piryriasisIichenoides, polymorphic lighr eruption.rJ-r)PWA or WA radiation alone is also used for the heabrent of vitiligo, disllfier etfectsof ultravioletradiation eczema,urticaria,lichen planus,graft-versus-host ease,cutaneous T-celllymphoma.unicariapigmen-\E radiation has been shown to affect the immune =-,srem,causing depressionof contact sensitivity, tosa, and a variety of photosensitivedisorders.26'27 for the trealmentofpsoriaClinicalrecommendations ::rangesin the distribution of circulating lymphoq,tes, =d suppression of mastcell-mediated whealing.la-16It sis are given below, and recommendationsfor the : proposedthat theseeffectsaredosedependengsuch treaf,nent of other skin disorders are available in the is suppressed literawre.2g,29 Clinical protocolsfor the treatmentof =at with low dosesthe immuneresponse o*rer disordersshouldbe developedand agreedupon =d with higher doses the immune responseis acti.ated.RecentlyWA has also been shown to inhibit in conjunction with the referring physician. :;cloocygenase2 expressionand prostaglandinE2 proThis mechanism is thousht to underlie *re --..rction.17 Psoriasis :eneficialeffectsof psoralenwith ultravioletA (PWA) : the treatment of scleroderma.It has also been Psoriasisis a common benign, acute,or chronic inflam=ponedthat WC, in adequatedoses,is bactericidal.lB matory skin diseasethat appearsto be basedon genetic predisposition. by brightred plaques It is characterized usually on the knees,elbows, and with silvery scales, INDICATIONS FOR THEUSE CLINICAL associated with mild itching (Fig.12-5). scalp, and is (1F RADIATION ULTRAVIOLET These dermatological q.nnptoms may also be associatedwith arthritic synnptomsknown as ysoiatk anhitis. Psoriasis There are numerous reports of successfultreatWound heding wirh UV radiatjonaloneor in conmenrof psoriasis 30-34 junctionwith sensitizingdrugs.25 Phototherapy of psoriasiswith W has a history of more than 75 -he earliestmodem clinical use of W radiation,for ;'/hich Neils linsen was awardedthe Nobel Prize in years:in 7925,Goeckermanintroduced a combina1903,was for the treatmentof cutaneoustuberculosis. tion of topical crude coal tar and subsequentW -r the 1920sand 1930sthe useof W radiationfor the irradiation. This treatment becamea standardther:eatment of skin disorders,includingpsoriasis,acne, apy for psoriasisfor half a century The therapeutic efficacyof W radiationin the treatmentof this con.nd alopecia,was very popular; however, with the dition is thought to be due to its ability to inactivate :dventof antibioticsandothermedications,the role of cell division and inhibit the DNA synthesisand mito,V radiation in dermatologicalmedicine has been sis of hyperproliferatingepidermalcellsthat are char:educed.At this time, [fV radiation is usedprimarily in Other proposedmechanisms :1e heatment of osoriasis.and there are also recent acteristicof psoriasis.25
376
12 . Elech'ontdgltctlc Radiatiort
Figure12-5.Psoriaticplaques.(From Arndt KA et al: Cutaneous Mediciueand Surgery:An IntegratedProgtan in Dermatology,vol 1, Philadelphia, 1996, \hE Saunders. Usedwith permission.) include altered leukocyte behavior and immunological activity, altered prostaglandin and cytokine release, as well as effects on cell metabolic function. The precise cellular targets and effector mechanisms of phototherapy have not yet been determined. Psoriasis is most responsive to UVA administered in conjunction with oral or topical psoralen sensitization (PUVA) and is almost as responrive Lo narrow band U\{B alone, at a wavelength of 311 t 2 rxrr. \' u Jo Psoriasjsi, nor rerponsivero UVC radiation and is minimally responsive to UVA radiation without drug sensitization. Use of UVA alone is also not recommended becausethe dose that does effectively clear psoriatic plaques also causessevere erythema, pigmentation, and an increased risk of melanoma.3T The use of W sensitizers in conjunction with W radiation for treatment of psoriasis has been studied extensively.The most commonly used sensitizers were tar-based topicals and psoralen-derived drugs. However, since studies on the use of tar-basedderivatives in conjunction with W radiation in the management of psoriasishave yieided mixed resuls, with some repoting that lhese products are valuable adjuncts to treahnent and others reporting that tar-basedproducts are no more effective *ian simple oil-based ointments, dre use of tar-basedproducts has lapsed and psoralenderived drugs are now the product of choice for this 'o applicac.ion.3SThe Iact t\at rar-basedproducLsare me'"y.nd expensrvealsoLim.rstJlerrpopulariry. I n r e c e n ty e a r s .t h e u s e o f p s o r a l e n - b a s et o dpical and systemic drugs in conjunction with WA (PWA)
for the treatmentof psoriasishasgrown in popularin This treatment combination was first describedb'. Tronnierand Schulein 1972andhassincebeenshow: to be effectiveby a number of other researchers.40 It:: thought d-ratpsoralenreducesappearance of psoriar; plaquesbecause,when activatedby WA, it cause: crosslinl<sto form betweenadjacentstrandsof DN.r, thusinterferingwith cellreplicationandpreventingtl: excessive cellproliferationcharacteristic of psoriasis. PUVA treatment has a number of side effeci.. including epidermal pigmentation and hyperplasia immune suppression,and the reieaseof free rai'-cals. Iree radicalscan damagecell membranesara cytoplasmic structures. Psoralensaione have al-.: been found to be carcinogenic.Therefore,work is = progressto searchtor sateralternativesensirizeAlthoughacirretin.corricosreroids. and fish oil ha'.: b e e ne v a l u a r efdo r r h i s a p p l i c a t i o nt h. e r ei s i n s u [ - cient evidenceat this time to supportthe useof thes: UV sensitizersfor the treatmentof psoriasis.4l-43 Refer to specificinformation on contraindicatiotj. and precautionsin the boxesthat follow.
Wound Healing
UV is only occasionallyused as a componentof ti:: treatmentof chronicwounds. However,unlike ulfi-sound and electricalstimulation, most authors sta= that UV doesnot havesufficientevidenceat this tin--: to support its use for this application.44 When W ; used for wound trearment.UVC i' rhe frequen--_ b a n d m o s r c o r n no n y c l ^ o s e r ' 0 2 T 1 his frequen;. bandis selectedbecauseit enhancesepithelializatio:desrroys bacLeria. causesminimal erythemaor ca:-ning.has a low carcinogenic etfect.and is abrorbe: almost equally by all skin colors.4sLIV radiation = thought to facilitate wound healing by increasu-: epithelialcell tumover, causingepidermalcell hype:plasia,2oacceleratinggranulation tissue formatioincreasingblood flow,a6killing bacteria,lsincreasi:-: vitamin D production by the skin, and promoti:: sloughingof necrotictissue.47Although the data c: the efficacy of UVC for this applicationare mixe: with some studiesreportingfasteror more comple= healingwith the addition of UVC to their treatmeii protocol for wounds and othersreportingno sigru:cantbenefit,sincethis physicalagenthasprovento'aE beneficial in somecases. iLmay beappropriate ro co.-.sider adding WC to the treatment of wounds t]:a: havenot respondedto, or are inappropriatefor, othe: typesof treatment.4S
Two . THE PIIYSICAL ACENTS
5/
/
CONTRAINDICATIONS
Radiation t0rtheUseof Ultravi0let
r Cardiac,kidney,or liver disease . Systemiclupus erythematosus o Fever
o Irradiationof the eyes . Skin cancer o Pulmonarytuberculosis
The application of ultraviolet radiation is contraindicated. . . . , to the eyes -V irradiationof the eyesshouldbe avoidedbecauseit .a-'r damage the cornea, the eyelids, or the lens. -posure of the eyes can be avoidedby having the ratientwear [tV-opaquegogglesthroughouttreatment :nd by having the therapistwear W opaquegoggles .vhenat risk of irradiation,suchas when tuming *re -V iamp on or off. Patientstaking Lry sensitizingdrugs ;uch aspsoralensshouldcontinueto wear W opaque :ye protectionfor 12hoursaftertakingthesedrugs.
. . . with patients with skin cancerl pulmonary tuberculosis; cardiac, kidney, or liver diseasel systemic lupus erythematosusl or fever W radiation should not be applied to areaswhere skin cancer is present becauseit is known to be effectsof lor detailso[ the carcinogenic carcinogenic.4g W radiation,pleaseseethe sectionbelow on adverse effects.lt is generallyrecommendedthat W radiation not be usedin patientswith pulmonarytuberculosis; cardiac,kidney,orliver disease;systemiclupuserythematosus;or fever,becausethese conditionsmay be bv exposureto [fV radiation. exacerbated
PRECAUTIONS
Radiation f0rtheUseof Ultraviolet . Photosensitizing medicationuse . Photosensitivity
Useultravioletradiationwith caution, . . patients ...with medication
using
photosensitizing
lare should be taken when applying W radiation ,o patients who are taking photosensitizingmed:cations. These medications include sulfonamide, ,etracycline,and quinolone antibiotics; gold-based nedications used for the treatment of rheumatoid arthritis; amiodaronehydrochloride and quinidines '-ised for the treabarent of cardiac arrhythmias; phenothiazinesused for the treatment of anxie4r; and psoralensused for the treatment of psoriasis. While patients are taking these medications, -hey have increased sensitiviqy to [fV radiation,
. Recentx-raytherapy o No doseof W radiationshouldbe repeateduntil the effectsof the previousdosehavedisappeared resultingin a decreasein the minimai erythemaldose and an increasedrisk of burning if too high a dose is used. A patient's minimal erythemal dose must also be remeasuredif the patient starts to take a photosensitizingmedication during a courseof UV treatment. . . . with photosensitive patients Someindividuals,particularlythosewith fair skin and hair coloringand thosewith red hair, are particularly sensitiveto W exposure.Becausethese individuals skin responseto have an acceleratedand exaggerated should be radiation of W W radiation, low levels minimal erythemal the usedboth when determining doseand for treatment. Continued
374
'12 . Electroma&retic
Radiation
PRECAUTI0NS-cont'd . . . with patients who have had (ecent x-ray radiation treatment
. . . un';l the effects of the prior dose have Peareo
It is recommendedthat W radiationbe apoliedwith cautionto areasthat havehad recentx-ray radiation exposurebecausethe skin in theseareasmay be more susceptibleto the developmentof malignancies.
In order to minimize the risk of burnsor an erythemal response,W irradiation should not repeateduntil the erythemal effectsof the dosehavedisappeared.
ADVERSE EFFECTS OFUTTBAVIOLET RADlATl0N25,50
recent review of the literature on rne carcfros
Buming Premature aging of skin Carcinogenesis Eye damage Adverse effects ofPtIVA
Burning
mous cell carcinoma and malienant melanoma. of W phototherapy,with and without concludedthat the therapeuticuse of WB has a risk of producing curaneoubcancers.excepr
on the skin of the male genitals;however, thereis definitecutaneouscarcinogenicrisk from PUVAtrea ment when oral systemic psoralens medications used.s1,52The incieased cancer risk with PWA r
be due to the carcinogenicityof the psoralensor be a responsespecificto the wavelengthof W tion usedfor this treatmentapplication.PI-IVA
Bumingby W radiationwill occurif too high a doseis used.Bumingcanusuallybe avoidedby carefulassess- ments may also exacerbate the effects of ment of the minimal erythemaldoseprior to initiating exposure to carcinogens.49 trealment and by avoiding further exposurewhen Becauseofthe potentialcumulativeadverse signsof erythema ftom a prior doseare still present. of repeatedlow-level exposureto W radiation,it recommended *rat clinicians avoid freouent excessiveexposure during treatment. This can Premature AgingofSkin achieved by wearing UV-opaque gogglesand Chronicexposureto W radiation,includingsunlight, opaqueclothing. is associatedwith prematureaging of the skin. This effect, known as actinicdamage,causestlre skin to EyeDamage have a dry coarse,leathery appearancewith wrinkling and pigment abnormalities.It is thought that W irradiation of the eyescan causea number of thesechangesareprimarily dueto the collagendegen- problemsincludingphotokeratitis, conjunctivitis, eration that accompanieslong-term exposureto IIV possiblysomeforms of cataracts.53 Photokeratitis radiation. conjunctivitis can occur acutely aker exposure WB or UVC. The symptoms of photokeratitis, inflammation of the cornea that can be Carcinogenesis painful, generally appear6 to 12 hours after Most of the information regardingthe carcinogenic exposureand resolve fully within 2 days, effect of W radiation concernsthe effect of propermanentor long-term damage,Conjunctivitis, longed and/or intense sunlight exposure.Prolonged inflammation of a\e insides of the eyelids exposure to W radiation, as occurs with exces- the membranethat coversthe comea,resultsin a sive exposureto sunlight,is consideredto be a major sation of gritty eyes and varying degreesof risk factorfor the developmentof basalcell and squa- phobia, teadng, and blepharospasm.Chronic
TTvo C THE PITYSICAL AGENTS
and WB exposure have been associated with 'Jre development of cataracts,characterizedby a loss of transparencyof the lens or lens capsuleof rhe eye. This association is even stronger for PWA becausepsoralensare depositedin the lens of -LIleeye.
Becauseof the risksof eyeirritation or damage,W opaqueeye protectionshouldalways be worn by the patient and the clinician during W treaffnent. Patientsshould alsowear W-opaque eye protection ior 12 hours after psoralenadministrationin order to protecttheir €yesfrom sunlightexposure.
379
Once the individual's responsiveness to a particular W lamp has been determined,the treatment dose can be selectedto produce the desired erythemal response.
Dose-Response Assessment
The W doseis gradedaccordingto the individual's erythemal responseand is categorizedas suberythemal,minimalerythemal, or firct, second-, or thid-degree erythemal, as describedfollowing.56 o Suberythemal dose(SED):No changein skin redness occursin *re 24 hours following UV exposure. c Minimal erythemaldose (MED): The smallest Adverse Effects of PUVA dose producing erythema within I hours after PWA is associatedwith all the adverseeffectsof UV exposure that disappearswrthrn 24 hours after :adiation,asdescribedpreviously.It is alsoassociated exPosure. 'with short-termnauseaand vomiting, which lastsfor . First-degree erythema(E1):Definite rednesswith 1to 4 hours after ingestionof the psoralen.Prolonged some mild desquamationappearswithin 6 hours eigh-dosePWA therapy can alsoresult in skin damafterexposureandlastsfor 1 to 3 days.This doseis age,including small,hyperpigmented,nonmalignant generally about 21/2time s the MID. -esions,keratoticlesionsthat may have premalignant o Second-degree erythena(E2):Intenseerythemawith listological characteristics, and squamousce1lcarciedema,peeling,and pigmentationappearswithin romas.54 2 hours or lessafter treatmentand is like a severe sunburn.This doseis generallyabout 5 times the MTD. APPLICATION TECHNIQUES o Third-degree erythema(E.): Erythema with severe When applying W radiation for therapeutic purblistering,peeling,and exudation.This doseis gen:loses, one must first determine *re individual erallyaboutl0 timestheMtD. :atient's sensitivity to UV radiation.ssThis varies In general,treatrnenttime is selectedas a proporvidely amongindividualsand canbe affectedby skin tion of the MLD. The MED for an individual is deterrigmentation, age, prior exposureto W radiation, mined in the manner described below. Because anduseof sensitizingmedications.Ior example,even repeated exposure to UV radiation generally :br Caucasians,there can be a four- to sixfold variadecreasessensitivity to W, prior exposureshould ion in minimal erythemal dose.7Sensitivity to W also be taken into account when determinins Llv :adiation is assessedusing the dosimetry procedure treacment dosageparameters. iescribedbelow. Sincepeoplebuild up a toleranceto W radiation Becausethe responseto W radiationcanvary sigwith repeatedexposuredue to darkeningof the skin rificandy with even slighdy different frequenciesof with tanningand thickeningof the skin by epidermal :adiation,the samelamp must be used for assessing hyperplasia,their MED will also increase.Thus to an individual's sensitivity and for all subsequent maintaineffectivetreatmentwirh a consistent oroporreatments. Ior example,the skin is 100 times more tion of the MID. eitherthe exposuretime shouldbe sensitiveto UV with a wavelengthof 300 nm than to increasedor the distanceof the lamp ftom the skin UV with a wavelengthof 320nrn. If the lamp must be should be decreasedwith repeated treatments. :hanged,the individual's responseto the new lamp Etposuretime shouldbe increasedbetween35% and :nust be assessedbefore it is used for treatment. 50o%at eachtreatment,with a maximum of 5 minutes leassessmentis also necessaryif there is a long total exposureif possible.If exposurefor more than 5 minutesis neededto produceanMLD, sincethe inten3apbetween treatmentsbecauselamp output inten;iqz decreaseswith prolonged use and skin tanning sity of the radiationreachingthe patient increasesas and hyperplasia decreasesover proionged periods. the lamp gets closerto the patient, the effectivedose
380
12 . Electtofltag6etic Radiatiort
can be increased by moving the lamp rather than by increasing the treatment time. For example, the distance of the lamp from the patient can be halved to increasethe intensity of radiation reaching the patient by a factor of 4. If the patient is receiving whole body exposure in a cabineq where the distance between the lamps and the patient cannot be changed, *ren the fteatment time must be adjusted to produce the desired ervthemal resoonse.
1 . PlaceUV-opaquegoggleson the patient and the clinician. 2 . Removeall clothingand jewelry from, andwash, an areaof the body leastexposedto naturalsunlight. The areasusually used are the volar forearm, the abdomen,or the buttocks. 3 . Take a pieceof cardboardapproximately4 by 20 cm and cut four squareholes2 by 2 cm in it. 4. Placethe cardboardon the test areaand drapethe areaaround the cardboardso that the surounding skin will not be exposedto the radiation. 5 . Setup the lamp 60 to 80 cm away frorn, and perpendicularto, the area to be exposed.Measure and recordthe distanceof the lamp from the area to be exposed. 6. Cover a1lbut one of the holesin the cardboard. 7 . Turn on the lamp. If using an arc lamp, allow the lamp to warm up for 5 to 10 mnutes to reach full power beforeturning it toward the patient.A fluorescentlamp will reachfuI1power and canbe usedwithin 1 minute of beingtumed on. Once the lamp has reachedfull power, direct the beamdirectly toward the areato be exposedand startthe timer. 9 . After 120seconds,uncoverthe secondhole. 10.After another60 seconds,uncoverthe third hole. 11.After another 30 seconds,uncover the fourth hole. turn o[f the lamp. T2, AFteranother30 seconds. According to this protocol, the first window will have beenexposedtor 240 seconds,the sec-
Oncean individual'sMED for a particularlamp has beendetermined,the treatmentdoseis set according to the diseasebeing treated and the protocol being used.Guidelinesfor treatrnentof psoriasiswith UVB or with PWA are given in the following sectionGuidelinesfor the treatmentof other problemswith W can be obtainedfrom the lamp manufacturersc from sometexts focusingon the treatmentof the particular problemor disease.
60 240 seconds seconds
120 30 seconos seconos Figure12-6. Setupfor IJV sensitivity assessment.
ond for 120seconds,the third for 60 seconds, the fourth for 30 seconds(Fig.72-Q.This col can be adjusted according to the
self-reportedtanning and burning response sunlisht. For individuals who tan but never rarely burrS longer exposures can be whereasfor thosewho burn easilvbut do not or for those taking photosensitizing shorterexposuresare recommended.More with shortertime differencesbetrveen can also be used to increase the accuracy of
Ior example, dose sensitivity assessment. could be eight holes in the cardboard,and holecouldbe exposedevery10 seconds. patient should observethe area for the The 13. hours following exposure.The area that mild reddenins of the skin widrin 8 hours disappears within 24 hours was ffeated with
MED.
381
Two . THE PHYSICAL AGENTS
The treatment setupsfor Ll\E and PUVA treatment are the same, except that for PUVA treatment the radiationis appliedafter psoralensensitization. 1. PlaceUV opaquegoggleson the patientand the clinlclan.
J. Removeclothing and jewelry from the areato be treated. 3. Washand dry the areato be treated. -1.Cover all areasl,otneedingtreatment,which may otherwisebe exposedto the radiation,wi*r a Wopaquematerialsuchasa cloth or papertowel. 5. Position the area to be exposed comfortably. Adjust the position of the lamp and/or the patient so that the distancebewveend-relamp andthe area to be exposedis the sameasit was when *re MED was determined.A-lsoadjustthe lamp to have the UV beamasperpendicularto *le treatmentareaas possible.Measureand record the distanceof the
for theTreatment of Psoriasis withUV Dosimetry Radiation Using UvB Initial dose recommendationsfor the treatment of psoriasisvary from 50ok of the MED to an E, dose ,about2Vztimes the MED), with increasesof 107oto 10"/" at each treatment, depending on *re skin Treatmentis given onceor twice a day, response.25,57 oncethe erythemafrom the prior doseresolves,andis terminatedwhen the plaquesclear Plaqueclearance may take severalweeks.Treatmentmaybe continued for a few sessionsafter complete clearanceof the plaquesin order to increasethe period of remission, andsomeclinicianscontinuewith lessfrequentmaintenancetherapy with the goal of keepingthe patient If severe,painful erythemawith blissymptomfree.5B tering developsat any time, the treatmentshould be stoppeduntil thesesignsclearand a lower W dose shouldbe usedwhen treatmentis resumed.
PuvA Using When providing PIJVA tueatmentsusing oral psoralens,the IJV irradiation is usually applied2 hours
I'*-
f'^-
rhP n.riehf
If using an arc Warm up rhe lamp i[ necessary. lamp, allow the lamp to warm up for severalminutesso thatit reachesfull powerbeforebeingused. A fluorescentlamp will reach fuII power within 1 minute of being switched on. I[ there is a glass filter on the 1amp,the lamp should be run for about 20 minutes beforebeing usedfor treatment in order for the filter to reach thermal equilibrium. 7. Stay closeto the patient,or give the patient a bell to cali you and a meansto tum off the lamp. Also, providethe patientwith a meansto openthe cabinetif whole body treatmentis beinggiven. 8 . Setthe timer. 9 . When *re treatment is complete, observe the treated area, and document tlte treatment given and any observableresponseto the treatment.
afteringestionof the drug.When the psoralenis delivered topically,the W exposureis providedimmediately after dre patient has soakedin a bath of weak psoralensolution for 15 minutes.Topical delivery of psoralensis less common than oral administration, with althoughthis route of drug deliveryis associated fewer acute side effectsand may result in a longer period oF remissionaFtertherapy.soErythemain responseto PWA hasa delayedonsetcomparedwith tlVB-inducederydremaand at first usually appears24 to 48 hoursafterthe exposureandpeaks72 hoursafter the exposure.PWA-induced erythema also differs from erythemainducedby W alonein that even2 to 3 times the MLD causesonly a slighdy greatereffect. PLIVAtreatmentsareusualiygiven2 or 3 timesa week to allow time for the erythema of one treatment to resolvebeforethe next treatmentis applied.The treatthe MED after ment doseis determinedby assessing the patienthastakenthe psoralen.Treaftnentis generally appliedto the whole body, and is usuallystarted d by I07" to at 40o/oto 70o/"ol the M.EDand increase 40ok eachweek in order to maintain *re response. Complete clearanceusually takes about 6 weeks, althoughthereis much variationamongindividuals.
382
12 . Electro tag etic Radiaion
DOCUMENTATION Document the area of the body treated, the type of W radiation used, the serial number of the lamp, the distance of the lamp from the patient, the treatment duration, and the response to tteatment. Example UIJ-Bb n b^urtl4 tah4t #6555, 60un pwnl pt, 4 druIzz. Ouh.ame:Illild e'ult]aha 6 tururt d4k^ e'aoattaz tattzl fua 24lu'lhA. 9to4jrli. Ffary" 5a.; 'tz,tolwt.
SELECTING A UVLAMP A numberof differentlampsthat output UV radiation at different rangesin the W spectrumand use different technologyto produce the radiation are currently availablein the United States(Iig. 12-7).fhe output ranges include broad-spectrumWA with wavelengthsof 320 to 400 nm, wide band (250 to 320 nm) and narrow band (311to 312 nm) LI\B, and UVC with wavelengthsof 200 to 290nm with a peak at 250 nm. The lamps canbe of the arc or fluorescent type.Arc lampsaregenerallysmalland emit radiation of a consistentintensity, whereasfluorescentlamps are long and emit higher-intensityradiation in the middle than at the ends.60 Singlearclampsarerecommendedfor treatingsmallareassuchasthe hand,and units incorporatingan array of arc lamps are recommended for treatment of larger areas.Iluorescent tubesare generallynot recommendedbecauseof the variability of intensity along their length. Ideally, a Iamp that producesa narrow band of radiation and providesuniform treatmentof the areawithin a reasonableamount of time shouldbe selected.
UVLampMaintenance Lamp surfacesshould be cleanedregulariyto remove dust, which will attenuate the radiation. Lamps
Figve 12-7.A W lamp. (CourtesyBrandt Industria. Inc.,Brorx, NY.)
should be replacedwhen their intensity decreases to the point where ffeatmenttimesbecomeunacceprlably long. The useful lifetime of most UV lamp6 is berween 500 and 1000 hours; afterward,thc output falls by a6out20% comparedwith the inidd ourput.
) Clinical CaseStudy a The following casestudy summarizessome of the concepts of ultraviolet radiation discussedin this chapter Basedon the scenaliopresented,an evaluationof the clinical findings and goals of fteatment are proposed. Theseare followed by a discussionof the factorsto be consideredin keatmentselection.
IR is a 2S-year-oldfemale with psoriasis.She has had tlis diseasefor about 8 years and has been successfullytreatedwith PWA in tJrepast. Prior courses of treaftnent have generally taken about 6 weeks and have resultedin clearanceof plaquesfor 6 months, with a gradual recurrencethereafter.Her last course
T$'o . THE PIIYSICAL ACENTS
383
of PIJVA treahnentswas completed 1 year ago, and she now has plaquescoveringareasapproximately4 by 8 cm on the dorsalaspectsofboth elbowsand covering areas approximately 5 by 7 cm on the anterior aspectsof both knees.She complainsthat these areas itch and are unsighd, and that she therefore always wears clothing that covers her elbows and klees when inpublic.
PROPOSEDTREATMENTPLAN AND RATIONALE Although both U\E and PWA have been found to be effectivefor tl.retreatrnent of psoriasis.the useof PWA is recommendedfor this patient becausethis fteatment has producedgood resultsfor her in the past and becausethe risk of buming with ?LIVA teatment is lesstlun *rat wiah [AE. The use of l]VB may be consideredbecauseof the carcinogenicnatureof psoralensandtreamrentwith PLIVA. In order to provide treatment with PWA" IR's skin EVALUATIONOF THE CLINICAL FINDINGS sensitivity to W radiation should first be assessed. This patient presentswith impairments of skin integdty Sensitivirytestingshould be catied out approximately and cosmesisJ as well as tie abnormal,uncomfortable 2 hours after the patient has taken oral psoralenand sensationof itching. The poor cosmesishas resultedio should be conductedusing the samelamp that will be her always wearing clotling that coversher elbows and used for treatrnent.BecauseFR has a number of areas knees. with plaques,treatmentshouldbe providedina Wcabinet and the areaswithout plaquesshould be covered. PREFERREDPRACTICEPATTERN Alternatively,a singlelamp couldbe usedto treateachof Impaired Integumentary Integrity Associated With the four involvedareassequentially.OnceIRs sensitivSuperficialSkinInvolvement,(7B) ity to tIV radiation while taking psoralenhasbeen determined, beatment wrth 40% to 70y. of her MED, PLAN OF CARE increasing by 107" to 407" each week, applied 2 or 3 The goals of treatment at this time include complete times per week, is recommended.This treatmentregiclearingof the psoriaticplaquesand a retum to a feeiing men shouid be continueduntil completeclearancehas of comfort when wearing clothes that expose tJre beenachieved,and possiblyfor a few more sessionsin patient'selbowsand/orknees. order to increased-reperiod of remission.After treatment with PUVA has been completed, the patient ASSESSMENT REqARDINGTHEAPPROPRIATENESS should be encouragedto wear clothesthat exposeher elbows and kneesbecausethe W radiationin sunlisht OF tjv RADIATIONAS THE OPTIMALTREATMENT Ll\E and WA in conjunction with psoralen sensitimay help ro controlher psoriasis: however,sheshould zation are indicated treatmentsfor psoriasisand have try to avoid exposirrg her skin to sunlight dudng the period of ?UVA treatmentsincetlis would increaseher beenshownto resultin the temporaryclearanceof pso aarcolaoues. llV exposureand thus increaseher risk of buming.
PROPERTIES PHYSICAL OFLASERS fhe rcrm laserts anacron;umforlight amplificationby stimulatedemissionof radiation (LASER).Although Albert Einstein originally outlined the principles underlying*re production of laserlight at the beginning of this century the first laserwas producedby Theodore Maiman in 7960.Laserlight is produced when an electronof an active medium undersoesa stimularedquancumjump from a higherto a-lower energy state, causingthe emissionof photons. The emitted photons collidewith other excitedelectrons, causingmore photon emission.This chain reaction produceslaserlight with a frequencycharacteristicof the activemedium. Ior example,a helium-neon(HeNe) laseremits visiblered light with a wavelengthof 633 nm, whereas a gallium-arsenide(Ga-As) laser emicslR radiarionwith a waveleng*rof 830nm.
The differencebetweenlaserlight and ot"herlight is that laserlight is moxochromatic, coherent, anddirectional. Monochromaticlight is all of the sameftequency;thus, if it is within the visible range,it is all of one color Becauseit is coherent,al1thewavesare in phasewith eachother (Fig.12-8),and becauseit is directional,a laserbeamexhibitsminimal divergence(lig. 1.2-9). The frequencyof the laserlight, aswell asthe type of tissue being irradiated, determinesthe depth to which the light penetrates.Laser light with wavelengths of between 600 and 1300nm optimizes *re depth of penetrationin human tissue,at 1 to 4 mm, and is thereforemost commonly usedin the clinical setting.61,62 For example, almost 99"/" of laser light with wavelengths of 300 to 1000 nm is absorbed in *re superficial3.6 mm of tissue,which is usually composed of skin.63,64 Laser light with a longer
384
12 . Electomagietic
A,A/ rvlva
.v.v. Figure12-8. Coherent waves produced by a laser.
Radiation
skirl it generatesheat in and destroys only selectedtissue directly in the beam while damageto surroundingtissues.65 Hot lasersare clinically to make incisions and to cautenze surgical procedures. They have a number of
tagesover traditional surgicalimplements:the is sterile,allows fine control,cauterizesasit cuts, resultsin lessscarring.Becausehot lasersdestroy sue,rhevarenot usedfor rehabilitarion. Low-intensiry"cold lasers(Fig. 12-10). output laserlight with lessthan 500 mW power, erally at around 50 mWcm2 power density with an energy density of less chan35 J,/cm2, been studied and recommended for use rn
tion becausethereis evidencethat this form of magneticenergymay be biostimulativeand healing.66,fl In general,lower-energydensiry between 0.05 and ! Jlcm2have been for the treatment of acute conditions, whereas
dosages oI up to 40J,/cm2 havebeenrecommended the fieatment of chronic conditions.66 Some
Figure 12-9.Directionallight producedby a laser,in contrastto the divergentlightproducedby othersources. wavelengthand lower frequency,suchas the IR producedby the Ga-Aslaser,penetratesdeeper,whereas laser light with a shorter wavelength and higher ftequency,suchasthe redlight producedbythe HeNe Iaser,penetrateslessdeeply.Although all frequencies of laserlight penetrateonly a few millimeters,deeper physiologicaleffectsarethought to occurbecausethe energymay promote chemicalreactionsthat mediate processes distanrfrom the siteof appJlcation. Laserintensity canbe expressedin termsof power, measuredinWatts; power density,measuredin watts per centimetersquaredflV/cm2);or energy density, measuredin Joulesper centimetersquaredQ/cmz). Powerdensity(Wcm2) =
PowerflAf Area of irradiation(cm2)
Energydensig'(J/cmz)
Power[4f x Time (s) Area of iradiation (cm2)
The intensity of the laseraltersits clinical effects. High-intensity "hot" lasersheat and destroy tissue, and, since the laser light is absorbedselectivelyby chromophores(light-absorbingmaterials)wi*rin the
have also found that the effectsof the laserare pronouncedwith short-duration,high-power than with long-duration,low-power doses the sametotal amountof energy.68 The use of cold lasersas a componentof tation first becamepopular in EasternEurope69 Asia and has since also becomecommon in and Canada;however,the IDA hasnot yet the use of cold lasertherapybecauseof validation of its clinical efficacy.The IDA the anlmal and cell culture studiesto be and the controlled clinical studiesto be too few not adequatelyreplicated.The FDA, however, grantedan investigationaldeviceexemption for gallium-aluminum-arsenide (GaAlAs)lowJevel for treatingsoft tissueinjuriesand. should research supportthe efficacyof coldiasers,it is ble that the IDA will approve their clinical tion for rehabilitation.Civen *re restrictionson clinical application of cold lasersat this time, *reir physiologicaleffectsand clinicalindications contraindicationsare discussedin this book. more completediscussionon the clinical of cold lasers, including specific application niques, case studies, and directions for selecting device, the reader should consult a Canadian
Europeantext that covers this subject or read materials provided by the manufacturersof devices .70,7t
Ts,o . TIIE PHYSICAT ACENTS
385
Figure12-10.A lowlevel laser devicelimited by federallaw to investigational use. (Courtesy Lasermedics,Inc., Sugar Land,
-"
Cauron- nvsng4onat oMce. ]t€ Mlc.olight A3O is [mne.r by Federal iu.ited siarsj re ro lrye*igational ure
:FFECTS OFCOLD LASERS Cellular effects Increased AIP and nucleic acid production Stimulation of macrophages Stimslation of fibroblasts to increase collagen production Altered nerve conduction and regeneration Vasodilation No mechanism of action has yet been established for :he possible biostimulative effects of *re cold laser; rowever, given the limited dep*r of penetration and reating provided by this type of radiation, and the fact :hat eLeckomagneticradiation in the IR to lt\E range rfthe spectrum is nonionizing, itis most likely that any :hysiological effects of cold lasersoccur at the cellular -eveland are produced by photochemical means.72'73It eas been proposed that cold lasersstimulate or inhibit ':iochemical, physioiogical, and/or proliferative activi:ies by altedng intercellular communication.T0'74
Cellular Etfects In vitro cell studies have demonstrated short-term activation of the electron transport chain, increased A T I s y n L h e " i sa. n d a r e d u c t i o ni n c e l l u l a -p H w i L h - h e a n n l i , . r - i o no F c o r d > s e . < - ' - 6 l t h a " a l s o b e e n oroposed that low-level laser irradiation can initiate
reactions at the cell membrane level via photophysical effects on calcium channels.TTThese biochemical and cell membrane changes are believed to cause the increasesin macrophage, fibroblast, and lymphocyte activity observed with low-level laser irradiation.Ts-82 These cellular reactions are thought to form the basis f o r t h e c l i n i c abl e n e [ i t so f l o w l e v e l a s e rt h e r " p y . It has been suggestedthat laser light, which is of a single wavelength, may be more clinically effective d-ran odrer forms of light because specific cell types may respond optimally to specific wavelengths of Iight; however, this theory has been criticized because itis l<nown that laserlight losescoherencein the tissues due to diffraction and scattering.S3Thus some authors have proposed that both noncoherent iight sourcesand cold lasersmay have similar biostimulative effects.s4
NerveConducti0n andRegeneration A number of studies have attempted to determine the impact of low level laser irradiation on nerwe conduction and regeneration; however, these studies have yielded conflicting results. Some studies have shown increased rates of nerve conduction, increased fre quency of action potentials,decreaseddistal sensory latencies,and acceleratednewe regenerationin response to laser stimulation, all of which indicate increased activation of the nervous tissue.8588In contrast, other
346
42 . Electlofiasletic
Radidtiot
studieshave shown decreasedratesof nerve conduc- aoolicationof cold lasersfor the treatmentof tion and increaseddistalconductionlatencies,indicatin patients.A further limitation to the application ing decreasedactivation of the nervous tissue.B9,90 lasersfor tissuehealins is that a number of Still other studies,attemptingto replicateprior results, have failed to show improved wound healing 4 have failed to demonstrate any change in nerve the use o[ this physical agent.2lq6108-110 conductionin responseto cold laseriradiation.9l-94 metaanalysisof the studieson lowlevel laser Civen the conflictingnatureof thesefindings,further on venousleg ulcer healing reponed finding no researchis necessaryto clarify the effectsof laserson dence of any benefit associated with this nerveconductionandto determinethe soecificoaramapplication of laser therapy.111At this time, etersrequiredto achieverheseeflects. atic,well-documentedclinicaltrialsare still needed
Vasodilation Some authors claim that cold laser irradiation can induce vasodilatior5particularlyof the microcirculation.9s,flAlthough this effecthasnot beenthoroughly researched. 'hould vasodllation occurin response to the clinical application of laser therapy, this could acceleratetissuehealingby increasingthe availability of oxygen and other nutrients and by speedingthe removalof wasteproductsfrom the irradiatedarea.
INDICATIONS CLINICAL FORTHEUSEOFCOLD LASERS Wound and fracture healing Musculoskeletal disorders Pain management
Wound Healing andFracture A number of studieshavebeenpublishedconceming the use of cold lasers to promote the healing of chronic and acute sursical wounds in both humans -Some '96'106 ar\d animals.77 of these studies have reported accelerationof wound healing, increased tensilestrengthof the wound, and increasedcollagen content of the wound tissueafter the aoolicationof Iow-levellasers.ln addition,it has beenihown that laser therapy can be deliveredthrough a variety of wound dressings.107 It is proposedthat laser energy facilitateswound healing by stimulating leukocytic phagocytosis and fibroblast proliferation, increasing collagenslmthesisand procollagenRNA levels, improving circulation, and inhibiting bacterial growth. Although many of the studiesexaminingthe eflect of lasers on wound healing report positive results,the lackofadequatecontrolsand the variation in, or poor reporting of, ffeatment parameterslimit the ability to developclearguidelinesfor the clinical
ascertain if, when, and how the use of low lasersmay facilitate soft tissue healing.
Studieson the effect of laserson the healins bone have also yielded mixed results, with showing accelerationof fracturehealing,some ing no effect on bone healing,and others delaved nostfractureossificationafter laser It is *roueht that low-level laser 6on-.112-1i6 ates bone healing becausethis type of energy increase the rate of hematoma absorption. remodeling,blood vesselformation,and calcium ositiorl as well as macrophage,fibroblast,and drocyteactivity.108 In addition,low-level laser produces a heat shock response and increases
cellularcalcium in osteoblasticcells.117 As with tissuehealing,fur*rer systematicstudiesare to delineatethe criteriathat determinewhe*rer levellaserirradiationenhancesbonehealine.
Disotders Musculoskeletal A number of studieshave been published the applicationoflowlevel lasertherapyfor the agementof pain and dysfunction associated wide ranse of musculoskeletaldisorders. these studies have yielded mixed results, a analysis reported that, on average,lowlevel therapywas more effectivethan placebofor the ment of musculoskeletaldisorders.118 Studiesconcemingthe treatmentof disorders with
low-level lasers have focused
anhritic and soft tissueconditions.Somestudies reported that lowlevel laser therapy can patients wi*r arthritis, resulting in increasedhand strengthand flexibility and decreasedpain and in patientswith rheumatoidarthrids,decreased and increasedgrip strengthin patientswith tis affecting the hands, and decreased pain imoroved function in oatientswith cewical < 6r-119-123 In cihtrast,-anumber of blinded, studiesusinglow-intensityIasersfor the treatrnent
T,,po . THE PHYSICAL AGENTS
:!-aoarthritis rePorted that this intervention did not A recent =iieve pain in'the subjects snrdied.r24'125 =eaan;lysis and reviewi of the studiesconcemingthe :ltcts of low-levellasertherapyon rheumatoidarthri- (RA) and osteoanhritis (OA) concludedthat there is ;fficient evidence to lecommend consideration of cwlevel lasertherapyfor short-termreliefofpain and in M, but that for OA, the resultsare :oming sdf&ress Different out=n-flictins in different 5tud1s5.126-129 :cmes miy be due to different laserdosesand different =ethods of application.It is proposedthat imProve::ents in arthritic conditions are the result of reduced :-flammation due to changesin the activity of inflam::atory mediators or the result of reducedpain due to :hangesin nerve conduction or activation. More stud:esareneededin this area!o elucidateboth the nature :nd the mechanism for the effects of low-level aser therapyon arthritic conditions.Ior thesestudies of :o bemostusefulin directingcare,the characteristics ie laserdeviceand the applicationtechniquesused, :ncludingwavelength, treatrnent duratioq dosageand ;ite of applicationovernervesinsteadof joints,should be clearlyand consistendydocumented
s87
PainManagement A number of studieshave found that low-level laser therapy can reducethe pain and dysfunctionassociated with muscuioskeletalconditions other than arthritis,inciudinglateralepicondylitis,low back^and 130'13-5 neck pain, triggJr points, and ihronic pain However,other studieshavefound no significantdifferencein subiectiveor obiectivetreatmentoutcomes when comparing the treatment with the lowlevel laserwith aiternativeshamtreatments.136-138 Given the limitations of the publishedresearchon the efficacyof low-level lasertherapyand the iack of definitive information regardingthe mechanismsof radiationor the action of this type of electromagnetic to make it is difficult parameters, ideal treatment clinical applicafor the definitive recommendations tion of cold lasersin rehabilitatior..
ANDPRECAUTIONS CONTRAINDICATIONS FORLASERS
CONTRAINDICATIONS
lortheUseofLasers
o Direct irradiationof the eyes . Within 4 to 6 months afterradiotherapy
o Hemorrhagingregions . Locallyto the endocrineglands
Theapplicationof lasersis contraindicated. , .
be directed at the eyes,and one should never look directly alongthe axisof the laserlight beam.
. . . directly to the eyes
. . . within 4 to 6 months after radiotherapy
Becauselasers can damage the eyes, all patients treatedwith lasersshouldwear gogglesopaqueto the wavelengthof the light emitted from the laserbeing usedthroughout treatment.orThe clinician applying the laser sf,ould also wear gogglesthat reduce the wavelenethof *re deviceused to a nonlrazardous level.Gogglesshouldbe markedwith the wavelength rangethey attenuateand their optical density within that band.The greaterthe optical density,the greater the attenuationofthe light. Safetygogglessuitablefor one wavelengt-hshould not be assumedto be safeat any otherwave length.Particularcareshouldbe taken with IR laserssincetheir radiationis invisibiebut can easilydamagethe retina.The laserbearnshouldnever
It is recommendedthat lasersnot be usedafter recent radiotherapy,becauseradiotherapyincreasestissue susceptibilityto malignanryandburns. . . . over hemorrhaging regions Laser therapy is contraindicatedin hemorrhaging regionsbecausethe lasermay causevasodilationand thus increasebleeding. . . . locally to the endocrine glands Given the wide variety of reported cellularlevel effects of laser*rerapy,thereis concemthat suchtreahnentmay alter endocrineglandfirnction. Thereforethe appLication of cold lasersto the endocrineqiandsis conftaindicated.
388
42 t Electtomasfledc Radiatiott
PRECAUTIONS
fortheUseof Laserses'l42 . o o o
Epilepsy levet Malignancy To the low backor abdomenduringpregnancy or menstruauon
Although there are no publishedreports of adverse effects in treating patients with these conditions, it is recommendedthat laser *rerapy not be applied to patientswith epilepsy,fever,or malignancyfor fear of worsening these conditions.Becausethe effects of low-levellasertherapyon fetaldevelopmentandfertility are not knowry it is also recommendedthat this t;,?e of ffeatmentnot be applied to the abdomenor low backduringpregnancyor menstruationor overthe gonadsat any time. Application over the epiphyseal platesprior to their closureis alsonot recommended.
Adverse Eflects of Lasers Although most reports concerningthe use of cold lasersreport no adverseeffectsin tlle tteatment area from the applicationof this physicalagent,therehave been reports of transient tingling, mild erythema,a buming sensation,andincreasedpain,numbness,and skin rash in responseto the applicationof low-level -141 Iasers.13,122,139 The primary hazards of laser irradiation are the adverse effects that can occur with irradiation of the eyes.laser devicesare classifiedon a 1 to 4 scale according to *refu intensity and associatedrisk of adverseeffects to unprotected skin and eyes. The lowlevel lasers used\ clinical and experimental applicationsare generallyof class3b, which means that although *rey are harmlessto unprotectedskir\ they do posea potentialhazardto the eyesif viewed alongthe beam.Exposureofthe eyescancauseretinal damagedue to the limited attenuationof the beam intensity by the outer suucturesof the eye.
PHYSICAL PROPERTIES OFDIATHERMY_ THERMALANO NONTHEBMAT Diathermy, ftom the Greek meaning "through heating," is the applicationof shortwave(10 to 100MHz
o . . o o o o
Embryoor fetus Over the gonads Epiphyseallinesin children Confusedor disorientedpatient Areasof decreased sensation Infectedtissue Sympatheticganglia,vagusnerves,or cardiac regionin patientswith heartdisease
Caution is recommendedwhen treatins who are disoriented or confused and when ing areaswith impaired sensationsince *re may not be able ro report discomfortduring treatmenr.Caution also is recommendedin ing areas of infection due to the possible effects of increasing circulation in the area, in the areas of the sl,rnpathetic ganglia, nerves,and cardiacregionin patientswi*r heart ease, should nerve conduction be altered in smlctures.
frequencyand 3 to 30 m wavelength)or mi (300 MHz to 300 CHz frequencyand 1 mm to 1 wavelength)electromagneticenergyto produce within tissues(seelig. 12-3).Shortwaveradiation within the radiofrequency range(3 kHz to 300 andwavelengthsof 1 m to 100km), which is ELt and microwaveradiation.Microwave has a ftequencybetween that of radiofrequency IR radiation.Both shortwave and microwave tion arenonionizing. In order co avoid interferencewith other quenry signalsusedfor communications,the Communications Commission GCC) which frequenciesof shortwaveand microwave ation canbe usedfor medicalanolications. diathermy (SWD) deviceshave been allocated three frequencybandscenteredon 73.56,27.72, 40.68MHz, with rangesof +6.78, 160, and 20 respectivelv.2 The 27.12MHz bandis most usedfor SWD devicesbecauseit hasthe widest width and is thereforethe easiestand least to generate.Microwave diathermy (MWD) for medical apolication have been allocated the
quencyof 2450MHz. The differentfrequency are usedto achieveclinical effectsin different ti typesandat differentdepthsfiable 12-1).
Ttx'o . THE PIIYSICAL AGENTS
Bo*r SWD andMWD canbedeliveredin a continu: rs orpulsedmodeand,when deliveredat a sufficient r . erageintensiry cangenerateheatin the body.la3-1+s ,'.tren delivered in a pulsed mode at low average :-tensities,heat is dissipated before it can accu:-ulatel however, pulsed low-intensity electrolagnetic energy in the shortwave or microwave :equency rangeis alsothought to producea number :: physiologicaleffectsby nonthermalmechanisms. : -rlsedSWD, when applied at nonthermal levels,is .:nerally referred to as Vulsedshortwavediathermy ?S\YD); however, t}re terms pulsed electomagnetic :.ld (PEMF), pulsed radiofrequency(PRF), or pulsed energy(PEME)have also been used ,.:dromagnetic this type of radiation. The terrn PSWD :describe in this text. - used The key factor that determineswhether or not a is ::achermydevicewill increasetissuetemperature -:e amount of energyabsorbedby the tissue.This is ;3temined by the intensity of the electromagnetic :,eld producedby the deviceand the type of tissue :: which the field is applied. A pulsed signal can :-low heat to dissipateduring the off cycle of the :'.rlse.Previouslypublishedliteraturehas categorized ::vices with an averagepower driving the applicator however, this is - j lessthan 38 W as nonthermal;146 :lsleading becausethe strength of the output field ::[vered to *re tissueis only a ftaction of this average : rwer. The strength of the incident magnetic field ::livered to the tissueis the important factor to con.:der. In clinical practice, one must rely on the ratient's report and on the data provided by the ::vice's manufacturerto ascertainwhether or not --:edeviceincreasestissuetemperature. When appliedat sufficientpower to increasetissue :3mperature,diathermy has a number of advantages :'rer other *rermal agents.It can heat deepertissues -'ransuperficialthermalagentssuchashot packs,and : can heat larger areasthan ultrasound.SWD is not ::flectedby bonesand thereforedoesnot concenhate :: the periosteumor posea risk of periostealbuming, :; doesultrasound:however.MWD is reflectedat tis,:reinterfaces,including *rose between air and skin, fat, and betweensoft r3tweenskin and subcutaneous :ssueand superficialbones,and thereforedoesproiuce more heat in t}le areascloseto theseinterfaces. -he reflectionof microwavescanalsoleadto the forration of standingwaves, resulting in hot spots in :ther areas.Both SWD and MWD treatmentsgener:Iy needlittle time for applicationand do not require
389
the clinician to be in direct contactwith the patient throughoutthe treatmentperiod.
TYPES OFDIATHERMY APPLICATORS There arethree different types of diathermy applicators: inductive coils, capacitiveplates, and a magnetron.146Inductive coils or capacitiveplatescan be used to apply SWD, while a magnetuonis used to apply MWD. A11PSWDdevicesavailableat this time useinductive coil applicatorsin a drum form. PSWD devicesdeliver very short pulsesof energy to avoid any cumulative increasein temperaturewithin the tissues.
Inductive CoilApplicators An inductive applicatoris made up of a coil through which an alternatingelectriccurrentflow s (Fig.12-11). The altemating cunent in the coil producesa magnetic field perpendicular to *re coil, which, in tuln, induces electric eddy currents in the tissues (tr1. 1,2-12).These induced electric currents cause chargedparticlesin the tissueto oscillate.The friction producedby this oscillationcausesan elevationin tissuetemPelature.
Figure12-11,An inductive coil SWD applicator setup with cablesaround the patient'slimb. This type of applicator producesa uniform, incident electromagneticfield that induces an electric field and current within the tarset tissue.
390
42 . Electofttasfletic
Ratliation
----+ Magnetic field ()
of Muscle at
Electriceooycurrents Conductivity
Figure12-12.Cenerationof masneticfields and induc, tion ofelectricfieldsby aninductivecoil. Heatingwith an inductivecoil is known asheating by the magneticfield method becausethe electriccurrent that generatesthe heat is inducedin the tissues by a magneticfield. The amount of heat generatedin an area of tissue is affected by the strength of the magnetic field that reachesthe tissue and by the sirength and density of the induced eddy currents. The streng*r of the magneticfield is determinedby the distanceof dre tissue from the applicatot and decreases in propoftion to the squareof the distance of the tissue from the applicator,accordingto the inversesquarelaw, but doesnot vary with tissuetype (ltg. L2-1.3).The strength of the induced eddy currents is detemined by the strengthof the magnetic field in the areaand by the electricalconductiviqyof the tissue in the area. The electrical conductivity of tissuedependsprimarily on the tissuelype and the frequencyof the signalbeing applied.Metals and tissueswith a high water and electrolytecontent,such as muscleor synovial f1uid,have high electricalconductivity, whereastissueswith a low water content, such as fat, bone, and collagen,have low electrical conductiviqy(Tables12-1 ar\d 12-2).Thus, inductive coils can heat both deep and superficialtissues,but they producqthe most heat in tissuesclosestto the applicatorand in tissueswith the highest electrical conductivity. Inductivecoil applicatorsareavailablein two basic forms, cablesand drums. The cablesare bundlesof plastic-coatedwires that are applied by wrapping them aroundthe patient'slimb. When an alternating electriccurrentflows through thesewires, eddy currentsareinducedinsidethe limb. A drum aoolicatoris made of a flat spiral coil inside a plasrii housing (Tig.12-L4).The drum is placeddirectly over the area beingtreated,and the flow of altematingelectriccunent
13.56
0.62
2 7. 1 2
0.60
40.68
0.68
200
1.00
2450
2.1,7
Irom Dumey CH, Massoudi H, Iskander MI: RadiationDosimetry Handbook.US$SAM-TR-85-73. of Utah, 1985,ElectricalEngineeringDeparunent.
tZ-Z Conductivity of Different 25MHz
$ g
(siemens/meter)
Liver
0.48-0.54
I(dney
0.83
Brain
0.46
Muscle
0.74.9
Iat
0.04-0.06
Bone
0.01
Irom Durney CH, Massoudi H, Iskander MI: RadiationDosimetryHandbook.USAiSAM-TR-85-73. of Utah, 1985,LleciricalEngineeringDepartment.
o zUJ F ED
g lr
tr ut z
= DISTANCE Figure 12-13.The typical behavior of magnetic strength delivered by an SWD device as the dir from the applicatorincreases.Note that this is an squarerelationship.
TIvo C THE PIIYSICAL AGENTS
,--the coil producesa magneticfield, which in turn ;-duceseddy currentswithin the tissues(Fig.12-15). liathermy deviceswith drum applicatorsmay have :re or two drumsor a singledrum that canbe bent to -:nform to the areabeingtreated.
Plates lapacitive -apacitive plate applicators are made of metal ::rcasedin a plastichousing.A high-ftequencyalter:,?tingelectric current flows from one plate to the ,--her through the patient, producing an electric
:igure12-14.An inductive coil SWD applicator in drum :rrm. (Courtesy Mettler Electronics Corporation, .-naheim,CA.)
391
field and a flow of curent in the body tissue that is bewveenthe plates (ligs. 12-16 and 12-17). Thus the patient becomesa part of the electrical circuit connecting the two plates. As cuffent flows through the tissue, it causes oscillation of chargedparticlesand thus an increasein rissue temperature. Heating with capacitiveplate applicatorsis knowa asheatingby the electricfield methodbecause the elecffic cuffentthat generates the heatis produceddirecdy by an electric fieid. As with the inductive coils, the amount of heat generatedin an areaof tissuedepends
Figure12-16.Capacitive plate SWD applicators placed around the target to produce an electric field directly. (Counesy Metder Electronics Corporation, Anaheim, CA.)
-------+ lvlagnetic f ield -----------+ Electriciield
:igure12-15.Magnetic field generated by an inductive :rum S\[D applicator and the resultant induced electric :e1d.
Figure12-17.Electric field distribution between capacitive S\4D plates.
392
12 . Electrctfiagnetic Rarliatiotr
on the strength and density of *re cuffent, widr most heatingoccuring in tissueswith the highestconductiviry. Becausecurent will always take the path of least resistance, when a capacitiveplateg4reof applicatoris used, the current will generally concentrate in the superficialtissuesand will not penetrateas effectively to deepertissuesif dtereare poorly conductivetissues, suchas fat, that is superficialto d-rem.Thus capacitive platesgenerallyproducemostheatin skinandlessheat in deeperstructures, in contrastto inductiveapplicators, which hear the deeperstrucruresmore eflectiveJy becausethe incidentmagneticfield canachievegreater penetrationto induce the electric field and current within the targetedtissuelaT1506ig. 10-18).
ment of malignant tumors by hyperthermia. Thc magnetronsusedclinicallyare similarto thoseusedn microwaveovensintendedfor cookinsfood. The mrcrowaves produced by a magnetrc generatethe most heat in tissueswith high electricJ conductiviry; however, this high-frequency,shorwavelength radiation penetratesless deeply SWD. Microwavesusuallvgeneratethe most heat r h es u p e r l i c i a l . k i n a .l r h o u g sho m ea u r h o r h s ave reported significant temperature increases in m and joint cavities in response to microwave tion.14'1,151,1s2 These differencesin reported depth heating appear to be related to vadations in
microwave frequencvused.from 91,5to 2450 and to variability in tissue deposition among
Magnetron
areasof the body and amongdifferentspecies.153 shallow depth of microwave penetration,the
A magnetron,which producesa high-frequencyalternating cufient in an antenna,is usedto deliverMWD. The alternatingcu(ent in the antennaproducesan electromagneticfield that is directedtoward the tissue by a curved reflecting director surroundingthe antenna(Iig. 1.2-19).The presenceof a director and the short wavelength of microwave radiation allow this type of diathermy to be focusedand applied to small, defined areas.Thereforethese devicescan be useful during rehabilitationwhen only small areasof tissueareinvolved;they arealsopopularfor the treat-
tion at tissue interfaces, and the potential for waves all contribute to an increased risk of
Figure12-18.Comparison of heat distribution with induc-
;;;;'-;wD
;i'.;;
rnductjv:+O
capacitive plate shortwave diathermy applicator, micro wave diathermy, and ultrasound.
"*ff:l::d
Ultrasound
E
heatingand burningof the superficialskin or fat this type of diathermydevice.
EFFECTS OFDIATHERMY Thermal Effects It applied aL sufficient intensiry, both SWD
MWD increasetissuetemperature.The p
TTvo C THE PIIYSICAL AGENTS
393
have a variety of physiologicaleffects.161 Although the mechanisms by which PSWD achieves these effectsare unknown, it has been proposedthat they are due to modification of ion bindins and cellular funcdonby the incidenLelectromagnetic fieldsand the resultingelectriccurrents.162,163
;gure 12-19.Microwave diathermy applicator.(Irom r-:tchenS, Bazi.nS: Clayrox'sElectrotherapy, ed 10, -rndon, 1996,WB Saunders. Usedwith permission.) ::fects of increasingtissuetemperatureare described :: detail in Chapter 6 and include vasodilation, j:creasedrate of nerve conduction,elevationof the :ain threshold,alterationof musclesffength,acceler:ion of enzymaticactiviry and increasedsoft tissue ::
Nonthermal Effects '.Vhen appliedat a low averageintensiry,with a short :ulse duration and a low duty cycle,diathermy does rot produceany maintained increasein tissue temferature becauseany transientheatingof tissues*rat rlay occur is dissipatedby the blood perfusingthe areaduring the off time of *re pulse. SWD, when rppiied at such nonthermallevels,is also thought to
perfusion Increased microvascular The applicationof PSWDfor 40 to 45 minutesat the maximum settingsof 600 pulsesper second(pps)at a generator power setting of 6 has been shown to increase local microvascular perfusion in healthy subjectsand aroundthe ulcersitein patientswith diabetic ulcers.164'165 Increasing microvascularperfusion, and thus local circulation. can increaselocal tissue oxygenation,nutrient availabiliry and phagocytosis.It has beenproposedthat the clinicalbenefits of treatment with PSWD are in part the result of increasedmicrovascularperfusion. Alteredcellmembrane functionandcellularactivity It has been reported that electromagneticfields can affect ion binding to the cell membrane,which can trigger a cascadeof biological processesincluding growth factoractivationin fibroblastsandnervece1ls, macrophageactivation,and changesin myosin phos171PSWDis alsothought to affectthe phorylation.166 regulation of the cell cycle by altering calcium ion binding,and it has beenshown that exposureto elecffic fields can acceleratecell growth and division when it is too slow and inhibit it when it is too fast.172,173 It has beenproposedthat alterationof cef lular activity and stimulationofAT? and protein synthesismay underlie the observedclinical benefitsof PSWD.174
INDICATIONS CLINICAL FOR THEUSE OFDIATHERMY History The use of diathermy dates back to 1892, when d'Arsonval used electromasneticfields with 10 kHz ftequencyto producea seniationof warmth without the muscular contractionsthat occur at lower frequencies.SWD was introducedto the medicalfield in the early 20th century and it was frequendyusedin the United Statesin the 1930sfor the treatment of hfections. However, despite a number of reports indicatine *rat SWD can be an effective treatment
394
42.
Electtornast etic R.tdi4tiort
modaliry its use declined by the 1950s with the advent of antibiotics and with concems regarding potentialhazardsto the patientandthe operatorif the equipment was applied inappropriately.Diathermy alsolost popularitybecause,by its nature,the electromagneticfield carurotbe readily containedto eliminate interferencewith other electronic equipment and becausemost diathermy devicesarelarge,expensive, and cumbersometo use. In recentyears there has been some resurgenceof interestin this technology, particularlyin specializedwound carepractices, in responseto ttre publicationof a number of studies regarjing the nonthermaleffectsof pulseddiathermy and the production of some smaller treatment devices; however, the clinical application of diathermy,whether for thermalor nonthermaleffects,is still limited due to the paucity of well-substantiated treatment guidelinesand information regardingthe physiologicalmechanism of action of this type of intervention, the poor historical record of these devices,andthe high costof the devices.It is probable that, with further researchregarding dosage and mechanism of action, and with technological advancesto improve the shieldingof these devices, the use of diathermy may regain popularity in the UnitedStaresfor cenainclinicalapplications.
Diathermy Thermal-Level The clinical benefits of applying diathermy at a sufficient intensity to increase tissue temperature are the same as those of applying other *rermal agents,asdescribedin detailin Chapter6. Thesebenefits include pain control, accelerated healing, decreasedjoint stiffness,and, if applied in conjunction with stretching,increasedjoint rangeof motion Becausediathermy can increasethe ROM).175,176 temperatureof large areasof deep tissue,its use is healindicatedwhen trying to controlpain,accelerate joint stiffnessin large,deepstructures ing, or decrease s f t h es p j n e . s u c ha sr h eh i p j o i n to r d i t f u s ea r e a o
this type of electromagneticradiation and that this was the most effective treatment he ever used. However, at this time, antibiotics nor commonly availableor used. In 1965. Milinowski patented a device designed to electrotherapywithout heat generation.He that this deviceproducedgood clinical results eliminating the factors of patient heat tolerance contraindications when treating with heat.178 I
nonthermallevelsof PSWDhavebeenevaluated used clinically,primarily to control pain and and to promotewound, nerve,and fracturehealing-
PSWD indications fortheuseol nonthermal Clinical Control of pain aod edema Pain control Wound healing Nerve healing Bone healing
Contolol painandedena A number of studies conceming the effects PSWDon recoveryfrom soft tissueirquryhave imorovededemaresolutionand/orreductionof responseto the applicationof this type of electror Two double-blindstudieson netic energy179-182 effects of nonthermal PSS/D on acute ankle in edema,pairyand/or found a significantdecrease ability in the treatedgroup comparedwith a fteatedgroup, and a double-blindstudy assessing effects of PSWD treatment found that it pain, erythema,and edema after foot surgery Madmum power andpulseftequenrywereused of thesestudies.It shouidbe noted,however,that all studies on the use of PSWD have shown improvements.Both Barker et al. and McCill no significant differencesin pain, swelling, or between patients treated with PSWD and those with a placebo after acute ankle injuries.183,184 Painconttol
A number of studieshave evaluatedthe effect Diathermy Pulsed Shortwave Nonthermal PSSIDon pain.Double-blindstudieson the effecs usinga home PSWDdevicepJacedin a soft The first documentedclinicalapplicationof diathermy collar on patientswith persistentneck pain or at a nonthemal levei in the United Stateswas in the cewical injuries found significantlygreater 1930s,when Ginsberguseda pulsedform of SWD to in pain and increasesin ROM in patientsusing fighl infectionwithour producinga significanttemperaturerise in tissue.l-'He reportedsuccessfuLly device for 3 weeks than in patients treated wi6 The authorsof thesestudies sharndevice.18s,186 treatinga varieqyof acuteand chronicinfectionswith
TlNo . THE PIIYSICAL ACENTS
=estedthat theseeffectscould be due to modification :f cell membrane function by the electromagnetic :eld. Studieswithout double-blindcontrolshavealso :eportedthat PSWDcan decreaselow back and post: p e r a t i vpea i n . l BI'8 8 Wouml healing Nonthermal PSWDhas been shown to increasethe 3te of wound healing in both animal and human sub'ects.189 192This effeclhas beenfound with incisional .'lounds,189 pressure ulcers,190,192 and bum-related rjuries.l91 Surgicalwound sites in animals demon-.uatedincreasedcollagenformation, white blood cell :filtratioq and phagocytosis after treatment with :S\trID.It was proposedthat thesewere the result of rcreasedcirculationandimprovedtissueoxygenation. I'le ehealing Accelerationof peripheral nerve regenerationin 3ts and cats,and spinal cord regenerationin cats,in :esponseto the application of PSWD have been :eported;193-195 however,the authorsof this book are rot aware of any publishedclinicalstudiesregarding jre effectof PSWDon the recoveryor regenerationof ruman nervesat this time.
395
effects,it should not be usedwhen contraindicated, and appropdate precautions should be taken when necessary.199'200 When applying any form of diathermy at an intensity that may increasetissue temperature,all the contraindications and precautions that apply to the useof thermotherapy,asdescribedin detail in Chapter 6, apply. In addition, there are a number of other contraindicationsand precautionsthat applyuniquelyto this type ofphysicalagentandsome unique reasons for these restrictions. These are describedin detailin the relatedboxesthat follow.
Precautions fortheTherapist Applying Diathermy Thereis concernregardingpotentialhazardsto therapists applyingdiathermy due to the greaterexposure asa resultoftreating multiple patientsthroughoutthe day.Thesedevicesproducediffuse radiationand can thus irradiate the therapist if she or he is standing close to the machine.209'210 It is therefore recommended that therapistsstay at least 1 to 2 m away ftom all continuousdiathermy applicators,at least30 to 50 cm away from all PSWDapplicators,and out of the direct beam of any MWD device during patient
Bonehealing Animal studieshave shown accelerationof bone :ealing with the application of PSWD. A study in '-971 rcported.accelerationof osteogenesis by PSWD ifter tooth extractionwounds in dogs,196 and a recent ;cudyfound that PSWDaccelerated the healingof the zbbit fibula after osteotomy.lg7The authors of this 'rook are not aware of any publishedclinicalstudies :egardingthe effectof PSWDon human bonehealing :t this time.
Some reports have noted above-averagerates of spontaneousabortion and abnormalfetal development in therapists following the use of SWD equipmenq howeve5 other studies have failed to demonstrate a statistically significant coffelation betweenSWD exposureandeithercongenitalmalformation or spontaneousabortion,216,217 One comparison of SWD and M\[D exposureof therapistsfound that only MWD increasedthe risk of miscarriage.2l8 HoweveSa recentstudy found that shortwaveshave potentially harmful effects on pregnancyoutcome oflretapplications and are specificallyassociatedwith low birth weight. It has beensuggestedthat nonthermalPSWDmay This effectincreasedin a dose-relatedmanner219On :.lsohavetherapeuticbenefitswhen appliedin the treatbalance,given the currentresearchfindirrgs,it is rec:oent of vadous forms of neuropathy,ischemicskin ommended that therapistsavoid SWD and MWD 1aps,cerebraldiseases,and myocardial diseases.162 exposureduringp regnancy.22o Thereis also one report on the use of PSWD in the nanagementof headinjuries.198
Malignancy andElectromagnetic Fields
CONTRAINDICATIONS ANDPRECAUTIONS FOR DIATHERMY -\Jthough diathermy is a safe treatment modality 'vhen appliedappropdately,in orderto avoid adverse
Substantialcontroversyexistsregardingthe effectsof eleckomagneticfields on malignancy.The literature on this topic is primarily concemedwith the risks associatedwith living nearandworking with power lines. While some reports suggestthat the electromagnetic
396
| 2 . Electrotr.tgfletic
fields generatedfrom power lines may be linked to childhoodcancersand leukemia,othershavefailedto show suchan associat.on.221'222 In 1995,the Council of the American Physical Society determined *rat "The scientificliteratureand the reportsof reviewsby other panels show no consistent, significant link bet\,veencancerandpowerline fields.. . . No plausible biophysicalmechanisms for the sysrematic initiarion or promotion of cancerby these power line fields havebeenidentified."
Radiation
The electromasnetic fields associated with
lines are of much lower frequency(50 to 60 Hz) those used in pulsed or continuous SWD devi (27.12 |r'Glz); thus, the application of the from the studies on power lines to the effects SWD are limited. At this time there are no reco dations against using PSWD in the area of a nancy, and there are no indications that PSWD carcinogenic.
CONTRAINDICATIONS
lorAllForms ofDiathermy
. Implantedor transcutaneous neuralstimulators
All forms of diathermyare contraindicated. . .
becausethe electromagnetic energyof the diat may interfere with the functioning of the device.
. . . in patients with implanted or transcutaneous neural stimulators
of coma and death have been reported
Diathermy of any sort shouldnot be usedin patients with implanted or hanscutaneousneural stimulators
diathermyhasbeenappliedto patientswith deeo brain stimulators. AIso. burns can occur
diathermyis appliedto patientswith electrical tion wires ormetal containins electrodeson *reir
CONTRAINDICATIONS
Diathermy forThermal-Level o Metal imolants or oacemakers o Malignancy . Pregnancy
Thermal-leveldiathermy is contraindicated . . . . . . in patients with metal implants or pacemakers Metal is highly conductiveelectricallyand therefore can become very hot with the application of diathermy,leadingto potentiallyhazardoustemperature increases in adjacent tissues. The risk of extremetemperatureincreasesis greatestwhen there is metal in the superficialtissues,as can occur with piecesof shrapnellhowever,it is recommendedthat
. Eyes . Testes o Crowing epiphyses
diathermy not be used in any areas containing
closeto metal.This contraindicationaooliesto both insideand outsidethe patient.Thereforeall elry should be removedbefore diathermy is ap1 and careshouldbe taken that thereis no metal in furniture or other objectsclose to the patient treated. Diathermy should not be used on patients pacemakersbecausethese deviceshave metal ponents that can become overheated in response
Tgo . THE PIIYSICAL AGENTS
d-reapplicationof diathermy and becausethe electromagneticfields producedby diathermy devicesmay hterfere directly with the performanceof pacemakers,particulariythose of the demandtype. Although the risk of adverseeffectsis greatestif the thorax is being treated, it is generally recommended that diathermynot be usedto treat any areaof the body if a patient has a pacemaker,although some authors statethat the extremitiesmay be treatedin patients -,;th ^"""-,L.r.201
. . . in areas of malignancy The use of diathermy in an area of malignancy is contraindicatedunlessthe treatmentis for the tumor itself.Diathermy is occasionallyusedto treat tumors by hyperthermia;howeveq such treatmentsrequire fine control of tissuetemperatureand are outsidethe realm of the rehabilitation professional.Iine temperature control is required becausecertain cancer cellshave been shown to die at temperaturesof 42' io 43" C but to proliferate at temperaturesof 40' to At"a202
. . . in pregnant patients The applicationof dia*rermy during pregnancyi, contraindicateddue to concernsregardingboth the effectsof deepheat and the effectsof elecffomagnetic fields on fetal development.Maternal hyperthermia hasbeenshown to increasethe risk of abnormalfetal
397
development,and SWD has beenshown to be linked to increasedratesof spontaneousabortionand abnor, mal fetal developmentin anjmals.203-206 Diathermy exposure,particularly of the lower abdominal and pelvic regions,should be avoided dudng pregnanry, and sincethe disribution of an electromagneticfield is not predictablyconstrainedin the body, it is recommendedthat diathermy exposureof any other part of the body also be avoided.A discussionof the risks and precautions for pregnant therapists applying diathermy to patientsfollows the sectionon precautions for applyingdiathermyto pahents. , . . over the eyes The eyes should not be treated with diathermy becauseincreasingthe temperature of intraocular fluid may damage the intemal structures of *re eyes. . . . over the testes Itis recommendedthat diathermynot be appliedover the testesdue to the risk of adverselyaffectingfertiliqyby increasinglocal tissuetemperature. . . . over growing epiphyses The effects of diathermy on growing epiphysesis unknown; however, its use is not recommendedin these areasdue to the concem that diathermy may alrerthe rateof epiphyseal closure.
CONTRAINDICATIONS
forNonthermal Pulsed Shortwave Daathermy o Deeptissue o Substitutefor conventionaltherapvfor edema andpain
Nonthermalpulsedshortwave diathermyis contraindicated, . . . . . for the treatment of deep tissues such as internal organs Although contraindicatedfor the fteatment of internal organs,nonthermal PSWD can be used to treat .oft tissueoverlyingan organ.
o Pacemakers,electronic devices, ormetal i*-l--!-
^-,^--:-^\
ASSESS: o Check the patienCschart for any record of organ disease.Checkwith the patient'sphysicianbeforeapplying PSWDin anareawidr organdiseasepresent. . . . as a substitute for conventional therapy for edema and pain PSWDshouldnot be usedasa substitutefor conventional therapyfor edemaand pain.It is intendedto be
'l 2 . Electronr/rgfl etic Radiation
398
C0NTRAINDICATI0NS-cont'd an adjunctivemodality for applicationin conjunctron with conventionalmethods including compression, immobilization, and medications.
wire loops.Thereforeif a patienthasa metal implang the clinician should deteimine the rype of implant beforeapplyingPSWD.
. . . in the presence of pacemakers, electronic devices, or metal imPlants The electromagneticradiation of PSWD may interfere with the functioningof a cardiacpacemakerand thus may adverselyaffectpatientswith cardiacpacemakers. The EMI emitted by nonthermal PSWD devicescan also interfere with other electromedical and electronicdevices.ThereforePSWD should not be used over or near medical electronicdevices, including pacemakers,and should be usedwith caution witL ind aroundpatientswith other externalor implantedmedicaielectronicdevices i.lonthermalPSWDdevicescanbe usedto treat soft tissueadjacentto mostmetal implantswithout significantly heating the metal; however, when the metal forms closedloops, as occurswith the wires usedfor fixating rods and placesin surgicalFracturerepairs, heating may occur becausecurent can tlow n the
ASK THE PATIENT . Do you have a pacemakeror any other metal in your body? ASSESS: o Check the patient's chan for any information regar& ing a pacemakeror other metal implants-Ifthe patierr his apacemakeror is usingother medicalelectront devices,PSID shouldnot be usedexceptin extremc circumstances,such as when hying to save a
kom amputation. When considering the use PSWDin iuch circurnstances,the patient's physi' should be consulted,and the clinician should tly shield all medical electronicdevicesfrom ttre masnetic field. In the presenceof meral impla reqiest an x-ray and do not treat with PS\\D i[ -"t"i fo.rnt loops. If the patient has nonloopiq metal implants, PSWDmay be appliedwith caution
PRECAUTIONS
of DiathermY forAllForms o Electronicor magneticequipmentin the vicinity o ObesiV
Useall forms of diathermYwith caution. . . . . . in the presence of electronic or magnetic equipment
o Copper-bearing intrautedne conffaceptlve devices
equipment. Precise guidelines are not becauseinterferencedependson the exact ment and the shieldingof both the diathermy and the other equipment being used lf inter' occurs,then the two tyPes of equipment should usedat differenttimes.
A number of studiesand reportshave demonstrated the presenceof unwanted electricaland magnetic . . . with obese Patients radiarion around diathermy applicarors20--210 Diatl-rermyshouldbe usedwith cautionin obesep: Becausethe treatment field may interfere with any Capacitive equipmentsuchascomputers becauseit may heat fat excessively electronjcor magnecic increases greater in generally resulr aoolicators,which or computer-controlledmedical devices,it is recomother fat than oi t-hetemperature rypes,of ,appJicam mendedthat the leadsand applicatorsof dia*rermy obesepatients 16'211 with used be not should other m, from 5 preferably and devicesbe at least3 m,
Tto . THE PIIYSICAL AGEATS
. . . with patients using copper-bearing intrauterine contraceptive devices Although copper-bearingintrautedne contraceptive devicesdo contain a sma1lamount of metal, calculaions and in vivo measurementshave shown that
399
thesedevicesandthe surroundingtissueincreaseonly slightly in temperaturewhen exposedto therapeutic levels of dia*rermy.2l2,213 Therelore diathermy may be used by both therapistsand patients with such devices.
PRECAUTIONS
forNonthermal Pulsed Shortwave Diathermy o Pregnancy . Skeletal immatufiqy
UsenonthermalPSWDwith caution, . . . . . with patients
pregnant
or
skeletally
immature
electromagnetic energyon fetal or child development are not known, nonthermal PSWD should also be usedwith cautionduring pregnancyand in skeletally immrh
rrp hrtiPnfe
The useof thermal-leveldiathermyis contraindicated Curingpregnancy.In addition, since *re effects of
ADVERSE EFFECTS OFDIATHERMY Burns Diathermy can causesoft tissueburns when usedat rormal or excessivedoses,and becausethe distribuion of this type of energyvariessignificandywith the rypeof tissue,it canburn somelayersof tissuewhile 3paringothers.223 lat layersare at *re greatestdsk of 'curning, particularlywhen capacitiveplate applica:ors are used, becausethey are more effectively :']eatedby this tpe of deviceand becausefat is less -vell-vascularized than muscleor skin andthereforeis rot cooled as effectively by vasodilation.Because water is preferentially heated by all forms of diathermy,the patient's skin should be kept dry by wrappingwith towels to avoid scaldingfrom hot persDfatl0n.
APPLICATION TECHNIQUES Thermallevel diathermyis the most effectivemodal ity for increasingthe temperatureof large areasof deep tissue.Therefore treatment with this physical agent is most appropdatewhen the goal(s)of treatment can be achievedby increasingthe temperature oflarge areasof deeptissue. Nonthermal PSWD can reduce pain and edema and may acceleratetissuehealing.It can be used at the acute,subacute,and chronic stagesof an injury; however,the literatureand anecdotalreportssuggest that betterresultsareachievedwhen acuteconditions are treated.Although not documentedin the literature, favorable results have also been reported anecdotally for patients with lymphedema, cerebrovascularaccidents,and reflex sympatheticdystrophy (RSD).
42 . Electrorflaefletic
Evaluatethe patient'sproblem and determinethe goalsof treatment. Determinethat diathermy is *re most appropriate treaffnent. Becausediathermy inducesan electricalcurrent in the tissueswithout touching the patient's body, the use of this physical agent may be particularly appropriatein caseswhere direct contactwith the patientis not possibleor desirable for example,if infectioncontrolis an issue,if the patientcannottoleratedirect contactwith the skin, or if the areais in a cast.Because no heat accumulates with the aoolication of nonthermalPSWDandsincelirde or no senwith its use,nonthermalPSWD sationis associated canbe usedwhere heatis contraindicated or potentially hazardous,and it can be appJiedto insensate patientsor to thosewho cannottolerate*re sensations associated with otherphysicalagents,suchas cryotherapyor electricalstimulation. Determinethat diathermyis not contraindicated. Ask the appropriate questions and make the necessaryassessments, asdescribedin detailin the section on contraindicationsand precautions.to determineif treamrentwith diathermyis saFe. diathermydevice. 4. Selectthe mostappropriare Choose between a thermal and a nonthermal deviceaccordingto the desiredeffectsof the treatment, and between the different types of applicators (inductivecoil, capacitiveplate,or magnetron) accordingto the desireddepth of penetrationand the tissueto be treated. 5 . Explainthe procedureand the reasonfor applying diathermy to the patient and the sensationsthe patientcanexpectto feel. During the application of thermal-level diathermy,the patient should feel a comfortable sensationof mild warmth without any increasein - ^:- ^- ,l;^^^* c^*
The applicationof PSWDis not generallyassociated with any change in patienr sensation, although some patients report feeling slight tingling and/or mild wamth. This sensationmay be the resultof increasedlocal circulationin response to the treatment. 6. Remove all metal jewelry and clothing from the areato be treated.
Radiatiotr
All clothing with metal fasteningsor nents,suchas buttons, zippers,or clips,must removed from the treatment area. clothing, bandagesTor casts do not need to
removed prior to treatment with becausemagneticfieldspenetrarethese als unaltered; however, when thermal diathermv is used. it is recommended that ing be removed from the area so that towels
be appliedto absorblocal sweating.
7 . Cleanand dry the skin and inspectit if 8 . Position the oatient comfortablv on a chair plinth with no metal components.Position patient so that the area to be treated rs accessible.
9. If applying thermal-level diathermy, wrap areato be treatedwith towelins to absorb perspiration.If applying PS\[D, it is not sary to placetowels bewveenthe applicator the body, but a disposablecloth or plastic ing canbe usedover the applicatorwhen conditionsin which there is a risk of taminationor infection. 10. Positionthe deviceand the applicator(s)for tive and safetreatmentapplication. For an Inductive Applicator With cables. wraD th€ cable around the coveredlimb to be treated,spacingthe turns of cableat least3 cm apart.Userubberor wooden ers to ensurethat adjacentturns of the cabledo comeinto contactwith eachother. Altematively,coil the cableinto a flat spiral matelythe sizeof the areato be treated.Use separateadjacentpiecesof cableto ensure cent turns of the cable do not come into contact each other. Place the coil over the area to be
separatedby six to eightlayersof towels (Iig. 12With a drum applicato! place the drum dir over and close to the skin or tissuesto be keepinga slight air gap to allow for heat Contact should be avoidedwhen infection an issue. Position the center of the apolicator over
areato be treated.The treatmentsurfaceof the catorshouldbe placedfacingand asparallelto the suesbeingtreatedaspossible.
Tto o THE PIIYSICAL AGENTS
The patient should be advisedto move as litde as :ossibleduring the treatmentbecausethe strengthof =e field will changeif the distancebetweenthe appli=tor and the treatment area changes,decreasingin rioportion to the squareof the distancebetweenthe :eatment surfaceof the apPlicatorand the tissues :eing treated(seelrg. 72-73).For example,if the dis-;nce doubles,the sffengthof t}re magneticfield will jecreaseby a factorof4. Thus, maintainingthe appli :ator at a constantdistancefrom the patientis impor--antfor consistenttreatment. For a Capacitive Applicator :lacethe tlvo platesatan equaldistanceon eitherside :i the areato be ffeated, approximately2 to 10 cm 1 to 3 inches)from the skin surface(seeFig. 12-1Q. :qual placementat a slight distancefrom the body is :ecommendedfor evenfield distribution in the treat:nentareabecausethe field is most concentratednear -Jreplates.Unequal placementwill result in uneven :eating, with the areasclosestto the plate becoming rotter than thosefartherftom the plate(Tig.12-21). For a Magnetron Microwave Applicator ?lacethe applicatora few inchesfrom the areato be leated. Direct *re applicatortoward the area,with J-rebeamperpendicularto the patient'sskin. i1. Tune the device. SWD devicesallow tuning of the applicatorto each particularload. Tuning adjuststhe precise ftequenry of the device, within the accepted range,to optimize coupling bewveenthe device and *re load. Most modern diathermy devices
tigfie 12-20. Inductive coil applinpan;ator for SWD. Setup with patient's back. coil on the ;ake" Note the layer of towels.
401
tune automatically.To tune a devicethat requires manual tuning, first turn it on and allow it to warm up accordingto the manufacturer'sdirections;then turn up the intensityto a low level and adjustthe tuning dial until a maimal readingon the power/intensityindicatoris obtained. 12. Selectthe appropriatetreatmentparameters. When applying thermal-leveldiathermy, the intensity should be adjustedto producea sensation of mild warmth in the patient.The gaugeoF heating used in clinical practiceis the patient's reportedsensationbecausecalculationsof energy deliverv and temperatureincreasesare not reliThe pattem of energyand heat distribuable.224 tion by both SWD and MWD is difficult to predictbecauseit is influencedby the amount of reflection, the electrical properties of different g/pes of tissue in the field, the tissue size and compositior5 the frequency of the field, and the type, sizej georr,letry,and orientation of the applicator.This issue is further complicatedby evidence that the thermal sensationthreshold may be affected by the frequenry o[ radiation -fhermal-level diathermy is generally apphed.22a appliedfor about20 minutes. When applyingnonthermalPSWD,most clinicians select the intensity, pulse ftequency, and total treatrnenttime basedon the manufacturer's recommendationsand on their individual experience because the clinical research using these devices does not indicate clearly which parametersare most effective.Most manufacturers and studies recommend usinq the
All wood table with no metal components
Coxtirued
402
42 . Electtot raefletic Radilttiott
- - - - - - - - - . Electric lield
CaPacitiveprare
t|.Icd. .',I,I;,,'
-lr
ll
Capacitiveplate
B Figure12-21.Electricfield distributionin tissuewith (A) evenly and @) unevenly placed capacitiveSWD plates-
maximum strength and frequency availableon the device for all conditions and. if the patient repoftsany discomfort,reducingthe pulie rate until the discomfort resolves.Most PSWD treatmentsareadministeredfor 30 to 60 minutesonce or wvicea day,5 to 7 times a week. Both of the nonthermalPSWDdevicesmanufacturedin the United Stateshave six intensity settings,to provide various field strengths,and six pulsefrequencysettings,to provide between 80 and 600 pulses,of 65 microsecondduration, per second'22s,226 13. Providethe patient with a bell or other meansto call for assistanceduring treatmentand a means to tum off the diathermy device. Instruct the patientto turn off the deviceand callimmediately
DOCUMENTATION Documentthe areaof the body treated,the frequenry range,averagepower or power setting,pulserate,time of irradiation, type of applicator, fteatrnent duration, patient positioning, distance of the applicator ftom the patient, and the patient's responseto the ffeatment. Documentation is typically written in *re SOAP note format. The following examples summarize only the modality component of treatrnent and are not plan ofcare. intendedto representa comprehensive
if he or she experiencesexcessiveheating or increasein pain or discomfort. 14. Alter 5 minutes, check to be certain that parient is not too hot or is experiencing inrrerce
in crrmntnm<
When the treatrnentis complete.tum off the removerhe applicatorand towels.and inspect heaftnent area.It is normal for the area to slighdy red, andit may alsofeelwarm to the 16. Assessthe outcomeof treatment. Reassessthe patient, checking particularly any signsof burning and for progresstoward goalsof treatment.Remeasurequantifiable jectivecomplainrs andobjectiveimpairments disabilities. 12. Documentthe treatment. lD.
Examples When applying shortwave diathermy to low document: 9 : 9t ele tntu aa*, pdn ar hrd 7| | 0. 0: 27.12 lllfl'y cutiruou 9W9,.fatla btal 3, t<,h!',eaRl, Aalixolia 3" (ron patienl, patlz.at,Vaoaz,20 nA. .h nepoil a&hnUura^nh, paa daazaadto 4ll0, ?: A
When applying microwave diathermy to 1"rtlz^""
A^"'.^"^r.
T$,o . THE PIIYSICAL AGENTS
!: 9L4uil.L(luALandpAu h lb*p e,xlznai.u. :: 2450 nd+ ca iru
ihen applying pulsedshort\,vavedia*rermy to ulcer ::r the lateralaspectof the right distalleg,document: !: ?t 4e,l1r,*A.0.e A, a42.lul2.l to Aaw a paaiiaz in'qf.ub.d At 2 uxz*+. :: ?9Wg inle nf 6, Nhp^alz 600.p.Fr,u,ndialaltagitua,*ao4 vzttouz ina$lbizrutz ulz*, ap4lt'aattto l" &\an tare^nl h4., 45 minale,n. .r: Ilhzlt dimznttun* dpazatBT,(,tuh 9 x 5 atn tu 7 ><4 urLo!,a kat ut42*,.
i: Qlzliruz?9W9 a afuuz lx,tw, dey. 9inrA.rqp.99W9 cenpan nlo4oaa4l2^ patzna*et i/. im.pfankd,
A DIATHERMY SELECTING DEVICE ,;,henconsideringpurchasinga diathermydevice,the ::st considerationshould be whether it outputs a =ermal or nonthermal level of energy flable 12-3). his is particularlyimportant with devicesfor which :anufactureff make bo*r thermal and non*rermal :aims. There are diathermy devicesmanufacturedin :'-rrope,and availablein the United States,that canbe :Ciustedto be usedfor either thermal or nonthemal :tplication; by contrast,the diathermy devicescur:ndy manufacturedin the United Statescanbe used .:ther for thermal or for nonthermal applicationbut
403
not for both. The FDA differentiates between diathermy devicesaccordingto their thermal or nonthermal mechanismof action. Specifically,the IDA separatesdiathermy devicesinto "diathermy for use in applyingtherapeuticdeepheat for selectedmedical conditions" and "diathermy intended for the treatment of medicalconditionsby meansother than the generationof deepheat.' 226 \[4ren purchasinga device intended for *rermal treatments,oneshouldconsiderthe qypeofapplicator (plates,coils, or drum), the frequency band of the energy (shornvaveor microwave),and whether the deviceis self-tuning.In general,drums are the easiest to apply,althoughcoils may provide deeperpenetration when appliedto the limbs. SWD is generallypreferred over MWD since it has a more predictable distribution patten\ and self-tuningdevicesprovide greatereaseof use. The two nonthermal PSWDdevicescurrendy manufactured in the United Statesare very similar. They both havesix intensity settings,produce65-microsecond pulses,and allow adiustmentof the pulse frequencyto a maximum of 600 pps.At this maximum ftequency,thesedevicesdeliverenergyfor 3.9% ofthe total treatmenttime. For example,duringa 30-minute treatment at maximum ftequency,the electromagnetic field is on for 70.2secondsandis off for the remaining 28 minutesand49.8seconds.It is this high proportion of off time to on time, and the resulting low average powe! that allow any heating that may occur during the on time to be dissipatedby the circulatingblood duringtheoff timebetweenpulses.
p rz-o Tw.
Thermal
Shotnvnve Frequency
27.1.2MHz*
Applicator
Inductive coil
Incidentfield
Flcrrrnmeonetir
Tissuesmost affected
Deepand superficial
'SWD canalsohavea frequencyof
Nonthermal Mictowal'e 2450 Li.}].z
Pulsed Shor*'ave 27.1,2MHz
Capacitiveplate
Magneffon
inductivecoil drum
Electric
Electromagnetic
Electromagnetic
Superficial
Small areas
Deepand superficial
13.56or 40.68MHz; however,the most commonlyusedfrequencyis27.72 MHz.
12 . Electolttagfletic Radiatiorr
404
) Clinical Case Stildies a The following casestudiessumma ze the conceptsof diathermy discussedin this chapter.Basedon the scenario presented,an evaluationof the ciinical findings and goalsof treatmentareproposed.Thesearefollowed by a discussionof tJrefactors to be consideredin the selection of diathermy as the indicated treatment modality, and in the selectionof the ideal diathermy deviceand parametersto promot€ progresstoward the goals.
Case 4 SJis a 45-year-oldfemale physical therapist. She has been diagnosedwith adhesivecapsulitisof the right shoulderand hasbeenreferredto physicaltherapy.She complainsofshoulderstiffness,with a tight sensationat the end of range.Although sheis able to pedorm most of her work functions,shehas difficulty reachingoverhead, which interferes with placing objects on high shelvesand with serving when playing tennis, and she has difficulty reachingbehind her to fasten clothing. The objectiveexam revealsrestrictedright shoulderactive and passiverangeof motion (ROM) (seethe following information) and restrictedpassiveglenohumeraljoint inferior and posteriorgliding. All other tests,including cervicaland elbow ROM and upper extremity sffength and sensation,arewithin normallimits. Shoulder ROM AROM Flexion Abduction Hand behindback
RI 120' 170" 100" r70' R5"belowL
PROM !lexion Abduction Intemal rotation Externalrotation
130' 110' 50' 10'
175" 175" 80" 80"
EVALUATIONOF THE CLINICAL FINDINGS This patient presentswith the impairments of restricted right shoulderactiv€ and passiveROM and restricted glenohumeral joint passive mobility in a capsular pattern. These impairments have limited her ability to paticipate in sportsand to perform normal activities of daily living, including dressingand lifting over her head.
--/RppenRgopnAcrcE PATTEFN Impaired Joint Mobility, Motor Function, Muscle Performance,and Range of Motion AssociatedWith ConaectiveTissueDysfunction,(4D)
PLAN OF CARE The goals of treatment at *ris time are to regain fuIl active and passive ROM of the right shoulder and to retum to full sports paticipation and daily living activities. ASSESSMENTREGARDINGTHE APPROPRIATENESS OF DIATHERMYAS THEOPTIMALTREAIMENT The loss of active and passivejoint motion associated withadhesivecapsuiitisis thoughtto be dueto adhesion and loss of length of the anteriorinferior joint capsule. Thus effectivetreatmentshouldattempt to increasethe lengthofthe joint capsule.Increasingtissuetemperaturc prior to stretchingwill increasethe extensibilityof soft tissue,allowing the greatestincleaseinsofttissue length with the leastforcewhile minimizing the risk of tissue damage.Diathermy is the optimal modality for heating the shoulder capsulebecausethis thermal agent can reach large areasof deep tissue.A superficialheating agent such as a hot pack would not be as effective becauseit doesnot increasethe temperatureof tissueat the depthofthe joint capsule,and ultrasoundwould not generally be as effective becauseits heating is limited by the effectiveradiatingareaofthe soundhead. PROPOSEDTREATMENTPLAN AND RATIONALE A continuousdiathermy devicemust be used in order to increasetissue temperatur€.An SWD device with an inductive coil applicator in a drum form is recommended sincethis mode of applicationprovidesdeep, even heat distribution and is easy to apply. The device should be applied to the right shoulder, ideally with the shoulderpositionedat end of rangeflexion and abduction so asto apply a gentle stretch to the anterior inferior capsule.The diathermydeviceshouldbe setto produce a sensation of mild, comfortable warmth, and the treatment should be appliedfor approximately20 miautes" This diathermy treatment should be followed immediately by a low-ioad, prolongedstretchin orderto maximize ROMgains.
Case2 MB is a 24-year-oldfemale recreationalsoccerplayer who sustaineda grade II left ankle inversion sprain approximately48 hours ago.Shehas beenapplyingice and a compressionbandageto the ankle, resting and elevating the ankle asmuch aspossible,and using a caneto reduce weight bearing when walking. She has beer refered to physicaltherapyin orderto attaina pain-free retum to spoftsas rapidly aspossible.Shecomplainsof mod€nte pain at the lateral aokle that is aggravatedb1z
Two . THE PIIYSICAL ACENTS
weight bearingand of ankle swellingthat is aggravated when her ankle is in a dependentposition. The obiective examrevealsa mild increaseinsuperficialskin temperatureat *re left lateral ankle and edemaof the left ankle, with a girth.of 2514cm (10 inches)on the left compared with 211h cm (8% inches) on the right. Left anlle ROM is restrictedin allplanes,with 0' of dorsiflexionon tlre left and 10" on the right, 20' of piantar flexion on the left and 45' on the right, 10"of inversion on the left, with pain at the lateral ankle at the end of range,and 30' on the right, and 20' of eversionon the left and 30" on the right. Isometric testing of muscle strengtl againstmanualresistanceat midrangerevealed no abnormalities. EVALUATIONOF THE CLINICAL FINDINGS This patientp.esentswith ttre impairmentsof left ankle pain, increasedtemperature,swelling, and restricted ROM. These have resulted in the functional limitations of decreasedweight-bearing tolerance and limited ambulation. PREFEFREDPRACTICEPATTERN Impaired Joint Mobiliry, Motor Functior; Muscle Performance,and Range of Motion AssociatedWith Connective Tissue Dysfunction, (4D) PLAN OF CARE The goals of treatment at this time ale to conrol pain, resolveedema,and restoreoomal ROM in orderfor the patient to retum to fulI sports participation. The diagnosisofa gradeII anKe sprainindicatesthat tlere hasbeen some damage to the ankle ligaments;therefore, tlle goalsof treatmentshould also include healingof these soft tlssues. ASSESSMENTREGARDINGTHE APPROPRIATENESS OF DIATHERMYAS THE OPNMAL TREATMENT Nonthermal PSWD is an indicated adjunctive Eeament for pain and edemaand hasalsobeenshown to accelerate soft tissuehealing-Becausethis patient is already applying rest, ice, compressiorl and elevation to her ankle at home and desiresa rapid retum to full sports panicipatioo,*re addition of ?SWD treatrnentmay help maximize her rate of recovery Thermal-level diathermy shouldnot be appliedto dris patient sincethe useof all themal agents is contraindicatedin the presenceof acute injury or inflammation. PROPOSEDTREATMENTPLAN AND RATIONALE It is proposed that treatrnentwith nonthermal PSWD be started immediately following the evaluation in order to reduce pain and swelling. The patient's limb should be
405
placed in a comfortableelevatedposition in order to optimize ttre reductionof swelling.The PSWDapplicator should be positionedover the lateral aspectof the ankle,ascloseto the skin aspossible,with the centerof the applicatorover the areaof the anklepresentingwith the most markedswelling,and as parallelas possibleto the damaeedtissues. Daity application of PSWDfor 30 minutes, with power and pulserate settingsof 6, is generallyusedfor ffeatment of this t,?e of acuteinjury. If the patient complainsof any increasein discomfolt,the pulserateshouldbe decreased until the discomfort resolves.The PSWD treatment can be followed by the application of ice, after which the bandage.The ankleshouldbe wrappedin a compression patient should continuewith rest,ice, elevatiorl and compressionand should be instructed in appropriateambulaShemay also tion, weight bearing,and ROM exercises. needto wear a splint if the ankle is unstable.
Case 3 FG is an Bs-year-oldmale with a stage[V sacralpressure ulcer. He is bedridden. minimalJy responsive,and dependentfor all bed mobility and feeding activities. He is ableto swallow but eatspoorly.The ptessureulcer is 15 by 8 cm and 3 cm deepin the deepestarea.Thereis no tunneling or undermining. Approximately 70% of the wound bed is red and granulating,and 307ois covered with yellow slough. Treatrnent until this time has consistedo[ sharpdebridementand hydrocolloiddressings.Although this treatmenthasresultedina reduction of the yellow slough, there has been litde change in wound areaoverthe lastmonth. EVALUATIONOF THE CLINICAL FINDINGS Thi6 patient presentswith impaired soft tissue integrity and reduced strength. The impairment of tissue his integdty placeshimatrisk for infectionandincrease's need for medical care.His limited strengthhas made him dependentfor functionalmovement,includingbed mobility. PREFERREDPRACTICEPATTERN ImpairedIntegumentaryIntegrity AssociatedWith Skin InvolvementExtendingInto Fascia,Muscle,orBone and Scarlormation,(78) PLAN OF CARE The short-termgoals of treatrnentinclude achievinga completely red wound base and preventinginfection. Long-term goals may include reduction of wound size and, ideally, wound closure; however, given this patient's impaired nutritional and mobility status, wound closuremaynotbe achievable. Continued
'l2 . Electotqt gxetic R/r/liatiotl
405
)
Clinical Case Studies-coat'd
ASSESSMENTREGARDINGTHE APPBOPRIATENESS OF DIATHERMYAS THE OPTIMALTREATMENT Nonthermal PSWD has been shown to acceleratethe healing of chronic open wounds, including pressure ulcers. One advantage of this treatment modality over otier adjunctive ffeatments is tJrat it can be applied without removing the dressing, thus limiting the mechanical and temperature disturbance to tl-rewound and reducing the time required to set up the treatment. Also, since PSWD producesno 6ensatio4 it can be applied even if the patient is insensate or cognitively incapableof giving s€nsoryfeedbackabout the treatment. Limitiag the mechanical disruption of the wound is particularlyimportant in th.iscasesince70% ol the wound bed is coveredwith red granulationtissuethat is fragilebut doeshavethe potentialto heal. PROPOSEDTREATMENTPLAN AND BATIONALE A comprehensivewound care program that addresses pressurereliet dressings,the nutritional status of the patient, and debridement,when necessary,is required
tl
to optimize the healing of this patient's woundNon*rermal PSWDmay be usedas an adjunctto these interventionsto facilitate wouod healing and closureThe patient should be positioned with the wound exposedand with the treatmentsurfaceof the applicator as closeand as parallelto the tissuesto be treatedas possible,with the center of the applicator over the deepestpart of the wound, If tumeling were presenq the centerof the applicatorshould be positioned over the deepestportion of the tunnel in order to promote closureof the tunnel beforethe more superficialwound site closes.The treatmentsurfaceof tlle applicatorhead cartbe coveredwith a plasticbag or surgicalcoveringif infection control is anissue.Itis recommendedthat this wound be treatedeither ndce a day for 30 minutes or oncea day for 45 to 60 minutesat power and pulserate settingsof 6. If the patient appearsto have any discomfort, the pulse rate should be lowered to 5 or 4. The pulserate settingshould also be reducedif the surface of the wound appearsto be closingbeforethe depth of the wound hascompletelyfilled.
PreferredPhysicalTherapist PracticePatternsSMl4D and ZEI are copyright 2002 American PhysicalTherapy Association.All
Chapter Review Electromagnetic radiation can be appliedto a patient to achieve a wide variety of clinical effects. The natureof theseeffectsis determinedprimarily by the frequency and wavelength of the radiation and, to some degree,by the intensity of the radiation.The frequenciesof electromagneticradiation used clinically can be in the I\ visiblelight, W, shortwave,or microwave range. IR radiation producessuperficial heating and can be used for the same purposesas other superficialheatingagents.It has the advantage over other superficialheating agentsof not requiring direct contactwith the body. W radiation produces erythema and tanning of the skin and epidermal hyperplasiaand is essentialfor vitaminD sy'nthesis. It is usedprimarily for the treatmentof psoriasis.Lowintensity lasersin the visible, IR" and W frequency rangesareusedoutsideofthe United Statesfor a wide vaiieqFof clinicalapplications;howeveq they are not . - approved by the IDA for generalclinical application ar rhis time. Shortwaveand microwaveenergycan produceheat in deep tissuesand, when applied at a low averageintensiqy using a pulsed signal, may
decreasepain and edema and facilitate tissue
by nonthermalmechanisms.Although none of electromagneticagentsare now in widespreadusei the United States,most are commonly usedin countries.Additional supportiveliterature will likely increasetheir use in the United States. reader is referred to the Evolve website at htm: evolve.elsevier.com/Cameron for study hFrfinPnf
f^ rhia .hrnrer
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injuries;a double-blindrandomized sndy, PhysTher 81,(5):449 , 2001. : -11.BlidallH, HellesenC,Didevesen?et al:Softlasertherapy of rheumatoid arhrias, ScandJ Rheunatolt6: 225-228,1987 . ',-12. Waylonis CW, Wilke S, O'Toole DO et al: Chronic myofascialpain: managementby low output heliumneon laser therapy, Arch Phys Med Rehabil 69t -1020, 1988. 1,017 1J3. SilvermanDBn PendletonLA: A comparisonof the effectsofconLinuousandpulsedshortwavediathermy on pelipheral circulation, Arch Phys Med Rehabil 49:429-436,7968. lJ4. ConradiE, PagesIH: Effectsof continuousand pulsed microwave irradiation on distribution of heat in the gluteal region of minipigs, ScandJ RehabilMed 21: 59-62,1989. 115.Draper DO, Knight K, FujiwaraT et al: Temperature change in human muscle during and after pulsed short-wave diathermy, J OnhaV Spans Phys Ther discussion19-22, 1999. Jan;29(1):13-8; 116. Kloth LC, Zisken MC: Diathermy and pulsed radio frequenry radiation. In ldichlovitz SL, ed: Thetwal Agetttsin Rehabiliatior,Philadelphia,1996,IA Davis. 117.Verier 1,4,Ialconer K, Crawford SJ:A comparisonof tissue temperature following two shortwave diathermy techniques,Physiotherapy Canada 29(7): 2 7 - 2 5 , 7 9 7. 7 :18. Guy AW, Lehmann Jf; StonebridgeJB: Therapeutic applications of electromagneticpower, Proc IEEE 62:55-75,1974. :49. Van der Esch .1r4,Hoogland R: Pulsetl Shottwave Diathemy with theCuupuk 4.1I , Deltr, d1eNetherlands, 1990,Delft InstrumentsPhysicalMedicineBV 150. Hand JW: Biophysicsand technologyof electromagnetic h)?erthermia. In Guthrie M, ed: Methodsof Exterual HypetthennicHeatixg, Berlir,, 1990, SpringerVerlag. 151.McMeekenJA4 Bell C: Effectsof selectiveblood and tissueheatingon blood flow in the dog hindlimb, Exy PhyslolT5:359-366,7990. :52. Fadilah\ PinkasJ,WeinbergerA et al: Heatingrabbit joint by microwave appLcam1Arch PhysMed Rehabil 68(1,0):7 10-71,2,1987. 153. ScottRS,Chou CK, McCumberM et al: CompLications resultingfrom spuriousfields producedby a microwave applicator used for hyp etberrna, Int J RadiatOncolBiol Phys12(10):1883-1886, 7986. 154.McNven D\ Wyper DJ: |Aicrowave therapy and muscleblood flow in man,J MicrowavePower1,1,:168, 1976. 155.McMeekenJM, Bell C: N{icrowaveirradiation of the human forearm and hand, PhysiothetThearyPuctice 75:359-366,t990.
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156. Wyper DJ,McNven DR: Effectsof somephysiotherapeutic agents on skeletal muscle blood flow, -3I0, 1976. PhysiotheraVy 60(10):309 157. BensonTB, Copp EP:The effect of therapeuticforms of heat and ice on the pain thresholdof the normal shotlder,RheumanlRehabil13101-104,1974. 158. AbramsonDL. Chu LSW Tuck S et al: Effectof tissue tempenture and blood flow on motor nerve conducdlnvelociul, J An Med Soc798:1082-7088,1966. 159. Chastain PB: The effect of deep heat on isomet c strength,Phys Thet 58(5):543-546, 1978. 160. McMeeken JAA,Bell C: lffects of nicrowave irradiation on blood flow in tlle dog hind Iimb, Lxp Physiol 75:367-374, 1,990 . 161. Hayne CR: ?ulsedhigh frequencyenergy:itsplacein physrorhenpy, Physiotherapy70(12):459-466, 1984. 162. Markov MS: Electric current electromasneticfield effectson soft tissue:implicationsfor wound healing. \Vounds 7(3):94-770 , 1995. 163. Pilla AA, Markov MS: Bioeffects of weak electromagnetic fields, Rev EavircnHeahh 10(3-4):155-169, 7994. 764. Mayrovitz HN, Larsen PB: A preliminary study to evaluatetJIe effect of pulsed radio frequency field treatmenton lower extremityped-ulcerskinmicrocirculationof diabeticp atients,Woffids7(3)t90-93,1995. 165. Mayrovitz HN, LarsenPB: Effectsof pulsed electromagneticfieldson skin microvascularblood perfusion, -202,1992. Wounds 4(5):797 166. RozengurtE, Mendoza S: Monovalent ion fluxesand tl:e control of cell proliferationin culturedfibroblasts, Axx NY AcadSci339175-190,1980. 167. BoonsnaJ,SkperSD,VaronsSJ:Regulationof Na+,K+ pump activiry by nerve growth factor in chick embryo dorsal root ganglia cell6,/ Cell Physiol113:452-455, T982. 168. Cemsa D, Seitz M, Kramer W et aI: Ionophore A 23187rasiscyclicAMP levelsh macrophages by stimulation of prostaglandin E formation: Exy Cell Res tIB,55-62,1979. 169. Pilla A: Electrochemialhformatlot tald energytta sfer ifl tivo, Proc7rhlECLC, Washingtoq DC, 1972,A,rneican ChemicalSociety. 170. Markov MS, MuechsamDJ, Pilla AA: Modulation of cell-freemyosin phosphorylationwith pulsed radio frequencyelectromagneticfields.In Allen Mj, Cleary Si Sowers .lJ, eds: Charge and FieA Effects ifl Blosystems, ed 4, Singapore,1995, World Scientific. PublishingCo. 121. Markov MS, PillaAA: Modulation of cell-freemyosin light chain phosphorylation with weak low frequency and static magnetic fields, In Frey AH, ed: Ox the Nature of Electromagxetic Fieldltteructiots v,hhBioilogical Systezs,Austin-/NewYork, 1995,RC Landes/Springer
412
42 . Electlot
asnetic Radiatiott
172. Whitfield JBBoyntonAI, McManusJPet al: The roles of calciumandcyclicAMP in cellproliferation,Am NY AcadSci 339:216-240 , 1981. I73. CaradayDJ,LeeRC: Scientificbasisfor clinicalapplicationof electricfie1dsin soft tissuerepair In Brighton C! PollackS\ eds:Electromagxetics in Biology Medictue, SanFrancisco,1991,SanFranciscoPress. 174. Markov MS, Pilla AA: Electromagneticfield stimulation of soft tissues:pulsedradio frequencytreatment of post-operative pain and edema, \Youtrds7(4):
1,43-151, , r99s. I75. Yance AR, Hayes SH, Spielholz NI: Microwave diathermy treatment for primary dysmenorrhea,Phys Ther76(9):1003-1O08, 1996. 176. Coats CC: Continuousshort-wave(radio-frequencf diafitermy,BrJ SpottsMed23:123-127 ,1989. 177. Cnsbery Al: Ultrasoundradiowavesas a tltenpeutic agent,Med Rec19:I-8, 1934. 178. lvlilinowski ASl.Athetmapeuticdedce, U ted States Patent#3181535,1965. 779. PiIla AA, Martin DE, SchuettAM et al: Effect of PM therapyon edemafrom gradesI and II anlle sprains:a placebo controlled randomized, multisite, doubleblind clinicalstudy,/ AthletkTraifling31553, 1996. 180. Wilson DH: Treatmentof soft tissueinjuriesby pulsed electicalenergy,Br MedJ 2:269-270,1972. 181. PenningtonGM, DanleyDL, SumkoMH: Pulsed,nonthermal, high frequency electromagnetic field @iapulse)in the heatment of Crade I and Grade II a*Ie sprarns,Milit Med 153101-104, 1993. 182. Kaplan EC, Weinstock RE: Clinical evaluation of Diapulseasadjunctivetherapyfollowing foot surgery, 1968. J An PodiatrAssoc58(5):218-221, 183. BarkerAI, Barlow PS,Porter J et al: A double blind clinicalt al of low power pulsedshortwavetherapyin the treatment of soft tissue rn1ury, PhyslotheraVy 71(12):500,s04, 1,985. 184. McGill SN: The effectsof pulsedshornvavetherapy on lateral ankle sprains,N Z J Physiother5I.21-24, 1988. 185. Foley-NolanD, Barry C, CoughlanRJet al:Pulsedhigh ftequency (27 MHz) electromagnetic therapy for persistent neck pain: a double blind placebocontrolled study of 20 panents, Onhopedics 73: 44s-451,1990. 186. Foley-NolanD, Moore K, Codd M et a1:Low energy, high ftequenry pulsed electromagnetictherapy for acutewhiplash injuries,Scand J RehabilMed 24:57-59, 1992. 187. WagstaffP,WagstaffS, Downey M: A pilot study to compare the efficacy of continuous and pulsed magnetic €nergy (shortwave diathermy) on the relief of low back pain, Physiotherayy 72(1)t563-566, 1986.
188. SantiestebanAJ, GrantC: Post-surgical effectofpulsed shortwave therapy,J An PodiatrAssoc75(Q:306-309, 1985. 189. Cameron BM: lxperimental acc€lerationof wound heaIirry,An J OnhoV3(12):336-ts43 . , 1961. 190. Itoh M, Montemayor JS, Matsumoto E et a.l: Acceleratedwound healing of pressureulcers by pulsed high peak power electromagneticenergy prapulse), Decubitus 2:24-28, 1991. 191. IonescuA, IonescuD, Milinescu S et al Studyof effcieflcyof Dialuke theruyyox thedyxamicsof eazymes ir bumedvouxd. Proceedingsof the Sixth International Congresson Burns,6:25-26,7982. 192. SalzbergCA" Cooper-VastolaSA, PerezIJ et al The effect of non-thermalpulsed electromagneticenergr (Diapuise)on wound healing of pressureulcers in spinal cord injured patients:a randomized,doubleblnd sndy, \Y/ounds 7(1):11-16,1995. 193. Raji ARM, Bowden REM: Effectsof high peak pulsed electromagneticfields on the degenerationand regenerationof ttre common peronealnerve ln rats,J Boic JointSurg65:478-492,1983. 194. Wilson DH, Jagadeesh P,Newman PPet ai:The effecrr of pulsedelectromagneticenergyon peripheralnerrre rcgeneration,Awt NY Aud Sci238:575-580, L974. 195. Wilson DH, Jagadeesh P:Experimentalregenerationin peripheral nervesand the spinal cord in laboratory aqi mals exposed to a pulsed electromagneticfield, ParaVlegia 14:12-20,1976. 196. Cook HH, Narendan NS, Montogomery JC: effectsof pulsed,high-frequenrywaves on tl.rerate osteogenesis in the healing of extractionwounds
dogs,OralSurgts2(Q:1008-10L6, 1971. 197. Pilla AA: 2/.'12MHz pulsedradiofrequency eticfreHsacceletate bonercpait fu a rabbitfbula ttodel.Prcse\ted at the Bioelecuomagnetics meeting,Boston,1995. 198. SambasivanM: Pulsedelectromapneticfield in agementof head injuries, NeurolIndia 41 1993. 199.Hay"ward L, Statham A: Microwave, (SouthA.frica)37(1):7-9,1981. 200.Low J, Reed A: ElectrotheraVy Erylaixed: Prixciples Pra,ti e,London, I 990,Butterworch-Heinemanr. 201.Health Notice (Flazard) 80(10): Implaxtable Pacena kers-Ine4e,enceGenerated by Diathern y Washingtorl DC, 1980, Deparhnent of Human Services. Burr B: Heat as a therapeuticmodality agaixst Report 16.Bethesda,1W{, 1974,U.S.National lnstitute. Mcmurray RG. Katz VL: Thermoregulationin nancy: implications for exercise, Syons Med 1 1.46-1,58, 1990.
Tlt'o . THE PHYSICAL AGENTS
204. EdwardsMJ: Congenitaldefectsin guineapigsfollowing inducedhyperthermiaduringgestation,ArchPathol LabMed 84:42-48,1967. 205. EdwardsMJ: Congenitaldefectsdue to hyperthemia, Adt VetSciComyMed22:29-52,1978. 206. Brown-WoodmanPD, Hadley JA, WaterhouseJ et all Teratogeniceffects of exposure to radiofrequency radiatiot (27.12 MHz) from a short wave diathermy unrt,Ixd Heahh26(1\:1-10, 1988. 207. Totan S, Agnesod G: The assessmentof unwanted radiationarounddiathermyRI capacitiveapplicatom, H ealthPhys47(2):235-241,1984. 208. Lau RW, DunscombePB:Someobservationson stray magnetic fields and power outPuts from shortwav€ 1984. diathermyequipmenr,HeahhPhys46(4):939-943, 209. Lerman! CanerA, JacubovichR et al: Electromagnetic fields from shortwave dia*rermy equipment in physioraVy 82(B) :456' 458,1996. Physiothe therapydepartments, S et al: ElectroHM, Strelley 210. Martin JC, McCallum magnetic fields kom therapeuticdiadrermy equipmentr a review ofhazards and precaulions,PhysiotheraVy 77(I):3-7, 1991. 211. ChristensenDA" Dumey CH: Hyperthermiaproduction for cancertherapy:areview of fundamentalsand met\adq] Microt aee Power16:89-I05, 1987. 212. Nielson NC, HansenR, LarsenT: Heat induction in copper bearingIUDs during short wave diathermy, Scnd 58(5):495 ActaObstztCynecol , 1979. 213. Heick A, EspesenT, PedersenHL et al: ls diathermy IUD s?ActaObstet safein women with copper-bearing I99I. Cyneal Scand70(2):153-1,55, 21,4.DelpizzoY,JoytterKII: On the safeuseof microwave and shornazavediathermy unfts, Aust J Physiothet 33:152-767,1987. 215. CharteredSocietyof PhysiotherapyCuidelines forSafe Use of Microwave TherapyE4ulVment,Lor'don, 1994, CharteredSocietyof Physiotherapy.
413
216. KallenB, Malmquist G, Modtz U: Delivery outcome amoBg physiotherapistsin Sweden:is non-ionising radiation a fetal hazardi Arch Exviron Heahh 37: 78(1):15-18, 81-84, 1982.Repdnted in PhysiothetaVy 7992. 217. LarsenA, OlsenJ,SvaneO: Cenderspecificreproductive outcomeand exposureto high frequencyelectromagnetic radiation among physiotherapists,Scaxdl V otbEnvionHeahh17:318-323,1991. 218. Ouellet-HellsEom R, Stewart WF: Miscaniages among female physical therapistswho report using radio and microwavefrequencyelecromagneticradi atton,AmI EVideniol10:775-785' 1993 2\9. Lerman I Jacubovich\ Green MS: Pregnancyoutcome following exposure to shortlvaves amonS female physiotherapistsin Israel, An I Ind Med May;39(5):499'504,2001. 220. TakininenH, KyyroneneP,Hemminki K: The effects of ultrasound,shortwavesand physical exertion on pregnancy outcomes in physiotietapists, J Eyideniol Health44:196-201,1990. Commun 221..WerheimerN, LeeperI: Electricalwiring configurations and childhood cancer, An J Eyideniol 109 273-284,1979. 222. Milham S Jr: Mortality from leukemia in workers exposed to electrical and magnetic fields (letter), N EnglJMed 307:249,1982. 223. Su:rell JA, Alexander RC, Cohle SD: Effects of microwave radiation on living tissues,J kauma 27:935-939 , 7987. 224. JustesenD, Adair ER,StevensJ et aL Human sensory thresholds of microwave and infra-red radiation, 3:117,7982. magxetics Bioelectro FL:Electropharmacology, PompanoBeach, 225. sofPulserM: Inc. 226. Diapulse@:GreatNeck, NY: DiapulseCorporationof America.
Integrating Physical Agents into Presentand Future Practice
IntegratingPhysi Agentsinto rauent Lare tt
.
,.1
. ,;
SUMMARY
OF lNF ORMATION
COVERED
Using PhysicalAgents within Different Health CareDelivery Systems Clinical CaseStudies ChapterReview
Attributes to be Consideredin the Selectionof PhysicalAgents Using PhysicalAgents in Combination with each other or with other Interventions ,,'ll
OBJECTIVES Upon comVletionof this chayter,the readerwill beable to: 1. Summarizethe attributes to be consideredin the selectionof physicalagents. 2. Design treatment plans for a variety ofpatient problemsthat integrate the use of physical agentswithin a completerehabilitation program,
3. Evaluateclinical findings to determinewhen to use specificphysicalagentsand when to change agentsor treatment parameters. 4. Make decisionsregardingthe application of physical agentsunder different health care deliverv svstems.
415
416
| 3 . httegrtttiflg
Phvsical Age hts it to Pdtic at Care
During rehabilitation,patientsfrequentlyhave problems that may benefit from several interventions, including reatments using a number of physical agents.In suchcircumstances the clinicianmust select the optimal interventior\ or combinationof interuentions. Selectionis basedon an evaluationof the clinical findings from the initial patient examination,the goals of treatment, and the expectedeffects of the variousavailabletreatrnentoptions. Physical agents have direct effects primarily at the level of impairment and, when appropriately selected,can accelerateand enhanceresolution of functional limitations and disabilities. In order to selectand use physical agentsmost effectively,the therapist must understandthe physicaland physioIogical processesunderlying the patient's problems, the kinds of changesthat would promote resolution of these problems, and the nature of the effects of availablephysicalagents. The first section of this book discussed the types of problems most commonly treated with physical agents in rehabilitation, and the second section discussedthe nature of the effects of the availablephysical agents,particulariy as they relate to theseproblemsand their underlyingphysiological processes.This chapter integratesand summarizes the informationfrom dreseearliersections.Additional guidelines are provided to aide in the selection of treatmentoptionsin order to achieveoptimal patient outcome within the constraintsof the health care delivery system.Three clinical casestudies demonstrating the application of these guidelinesare provided at the end of the chapter.
ATTRIBUTES TOBECONSIDERED INTHESETECTION OFPHYSICAL AGENTS When selectinga physical agent for use in patient treatment,a number of attributesof the agentshould be considered,the first two being the goalsof treatment and the physiologicaleffectsrequiredto achieve these goals (Iig. 13-1). Having determined which physical agents can promote progress toward the goals of treatment, the clinician should then decide which of the potentially effective interventions would be most appropriatefor the particularpatient and the currentclinicalpresentation.Attending to the rule of "do no harm," all interventionsthat are contraindicatedshould be rejectedand all precautions
Goalsandeffectsof treatment
Figure13-1. Attributes to be consideredin the selection ^! -L..^:
-^ I --^---
should be adhered to. If a number of metho& would be effectiveand could be applied safely,the scientificmerit of the treatment approach,the ease and cost of application,and the availability of necessary resourcesshould also be considered.Having selectedthe idealphysicalagent(s),the clinicianmust then also selectthe ideal treatment parametersand meansof applicationand appropriatelyintegratethe use of the chosenphysical agent(s)into a complee frPrfmpnt
nr.ior2m
Goals andEffects ofTreatment Reducing impairments by affecting: Inflammation and tissue healing Pain Muscle tone Motion restdctioos
The immediatesoalsof treatmentthat can be with physical agents generally relate to red impairmentsby affecting inflammation and tissue ing, pairymuscletone,or motion restrictions. By ing mg impairments, lmpallmenrs, interventions lnrervennons wrm physical agen with pnyslcai contibute
to reducinq functional limitations and di
abiftties.Guidelinesfor heatment selectionbased the directeffectsofphysicalagentsarepresented in a narative form and aresummadzedin Tables13 to 13-4.Shouldthe DatientDresentwith more than problem.and thus havea numberof goalsfor ment, a limited numberof thesegoalsmay needto
Thtee O INTEGRATING PIIYSICAL AGENTS INTO PRESENT AND FUTURE PRACTICE
addressed at any onetime.ltis generallyrecommended that the primary problems, those underlying the other problems,andthosemostlikely to respondto the availableinterventionsbeaddressed first;however,the ideal intervention will facilitate progressin a number of areas fig. 13-2).Ior example,ifa patienthaskneepaindueto acute ioint inflammation. treatment should first be directedat resolvingthe inflammatioq however,the ideal intervention would also help to relieve oain. When the primary underlying problem. such as a malignanry, cannot benefit direcdy from an intervention with a physical agent,treatmentwith physical agentsmay still be usedto helpalleviatethe sequelae of theseproblems,suchaspainor swelling. Etfectsof difterentphysicalagents 0n intlammation andhealing Many physical agents affect inflammation and healingand, when appropriatelyapplied, can accelerate progress,limit adverse consequencesof the healingprocess, andoptimizethe final patientoutcome 13-1). However, when poorly selectedor mis' ilabie applied, physical agentsmay impair or potentially prevent completehealing.After any injury physioiogicaltissuesproceedthrough three stages-inflamrnation, proliferation, and maturation-in order to heal.At eachof thesestages,*re goalsof treatment, andthus the appropdateinterventions,will change.
2. Treatments that addressmorethanone problemsimultaneously
3. Symptomatic treatment only
Figure13-2.Prioririzinggoalsand elfectsof rreacmenr.
417
Initialinjury Immediatelyafter an injury or trauma,the goalsof treatment are to prevent further injury or bleeding and to clean away any wound contaminantsif the skin has been broken. Immobilization of the injured areawith the aid of a staticcompressiondevicesuch as an elasticwrap or with the useof assistivedevices such as crutches,a cast,or a brace,can limit further injury and bleeding. Motion of the injured area, whether active,electricallystimulated,or passive,is contraindicatedat this stagedue to the risk of causing further tissue damage and bleeding. Cryotherapy will also contribute to the control of bleeding by limiting blood flow to the injured areaas a result of vasoconstriction and increased blood viscosiry1,2 Thermotherapyis contraindicatedat this early stage becauseit canincreasebleedingatthe siteof injury by increasingblood fl-ow or reopeningvascularlesions dueto vasodilation.r-5 Hydrotherapy,involvingimmersion or nonimmersion techniques,can be used to cleansethe injured areaif the skin has been broken and the wound has becomecontaminated:however. sincethermotherapyis contraindicated,only neutral warmth or coolerwater shouldbe used.o Acuteinflammation During the acute inflammatory stage of healing, the goals of treatment are to control pain, edema, bleeding,and the releaseandactivity of inflammatory mediatorsand to facilitateprogressionto the proliferation stage.A number of physical agents,including cryotherapy, hydrotherapy, electrical stimulation, and pulsed shortwave diathermy (PSWD),can be usedto controlpain;however,the useof thermotherapy, intermittent uaction, and motor-level electrical stimulation is not appropriate.T'llThe use of thermotherapy is not recommendedbecauseit causes vasodilation,which may aggravateedema, and it increasesthe metabolic rate, which may aggravate the inflammatory response.Intermittent traction and motorlevel electricalstimulationshouldbe usedwith caution becausethe movement oroduced bv these physicalagentsmay cau5efurther rissueirritation and thereby aggravatethe inflammatory response. A number of physical agents, including cryotherapy, compression,sensoryJevelelectrical stimulation, PSWD, and contrast baths, may be used to control or reduceedema.l215Cryotherapyand compressioncan also help to control bleeding;fur*rermore, cryotherapywill bhibit the activity and release
418
p
43 t htegratitg
Physical Agents ittto Patiett
Care
13-l PhysicalAgents for of tissue
Initial injury
Goals of treatnent
Effective
Contraindicated
?reventfurtherinjury orbleeding
Staticcompression Cryotherapy
Localmodon dueto exercise,inteImittent tractionor motor-level eiectricalstimulation Thermotherapy
Cleanopenwound
Hydrotherapy (immersion ^r
Chronicinflammation
joint Prevent/decrease stiffness Control pain Increasecirculation
Progressto proliferation stage Remodeling
Regainor maintainstrength Regainormaintain flexibility Control sca!tissue formation
h^hihmerci^n\
Thermotherapy,motor e.s., whirlpool, Iluidotherapy Thcrm^rherahThPrm^rhF/,hv
" " F .
Cryotherapy
Cryotherapy
compression, hydrotherapy (immersionor exercise) Pulsedultrasound,e.s., PSWD Motor e.s.,watet exercise Thermotherapy,brief icemassage Compression
Immobilization Immobilization
e.s.= electrical stimulation.
of inflammatory mediators. Should healing be delayeddue to the inhibition of inflammatio-n, as may occur in the patient who is on high-dosecatabolic corticosteroids,cryotherapyshouldnot be used becauseit may fur*rer impair the processof inflammation and thus potentially delay tissue healing. There is also evidenceto indicate tlrat pulsed ultrasoundand PSWDmay promote progressionfrom the inflammatory stage of healing to the proliferative stage.
deeperstructuressuch as the shoulder or hip capsules,deep heating agentssuch as ultrasound diathermy must be used.l8-2o Motion may be ducedby activeexerciseor electricalstimulation, motion can be combined with heat by having patient exercisein warm water or Fl Thermotherapyand electricalstimulationcanbe to relievepain duringthe chronicinflammatory however,cryotherapyis generallynot duringthis stagebecauseit canincreasethe joint ness ftequendy associatedwith chronic inflar Ctuonicinllammation tion. Selectionbetweenthermotheraovand Should the inflammatory responsepersist and stimulationwill generallydependon the needfor becomechronic,the goals,and thus the selectionof additional benefits of each modality and the ot interventions,will change.During this stageof healselection factors discussedbelow. Circulation ing the goalsof treatmentare to preventor decrease be increasedby the use of thermotherapy, joint stiffness,control pain, increasecirculation,and stimulatior\ compression,water immersion,or promote progressionto the proliferation stage.The cise,and possiblyby the useof contrasrbadts.3,21'Lmost effective interventionsfor reducingjoint stifffinal goal of ueatment at the chronic inflammato ness are thermotherapyand motion.1417Superficial phaseof tissuehealingis to promote progression structuressuch as the skin and subcutaneousfascia the proliferative phase. Some studies indicate may be heated by superficialheating agentssuch as pulsed ultrasound, electrical currents, and hot packs or paraffin; however, in order to heat magneticfieldsmay promotethis transition.
ThTee C INTEGRATING PIIYSICAL AGENTS INTO PRESENT AND FWURE PRACTICE
Prulileration Once the injured tissuemovesbeyond the inflammatory stageto the proliferativestageof healing,the primary goals of treatment become controlling scar dssue formation, ensudng adequate circulation, maintaining strength and flexibiliry, and promoting progressionto the remodeling stage. Static compressiongaments can control superficialscartissue formatioq thereby promoting enhanced cosmesis and reducing the severity and incidence of contractures.26-28 Adequatecirculationis requiredto provide oxygen and nutdents to the newly forming dssue.Circulation may be enhancedby the use of thermotherapy,electrotherapy,compression,water immersion,or exerciseand possiblyby the useof connast baths.Although active exercrsecan lncreaseor maintain sffengthand flexibility during the proliferaelective stageof healing,the addition of motor-1eve1 trical stimulation or water exercisemay accelerate recoveryand provide additional benefits.The water environmentreducesloading,and thus the potential for uauma to weight-bearing structures,and may therebydecreasethe risk of regressionto the inflamThe support provided by the water matory stage.29 may also assistmotion should the musclesbe very weak, and water-basedexerciseand thermotherapy may promote circulation and help to maintain or increaseflexibility.3o,3l
Type ofpain
Goals of tieahent
Mattrntion During the final stageof tissuehealing,maturation, the goais of treatment are to regain or maintain strength and flexibility and to conffol scar tissue formation. At this point in the healing process,the injured tissues are approaching their final form. The focus of treabTrentshould therefore be on reversingany adverseeffectsof the earlier stagesof healing,suchasweakeningof musclesor lossof flexibility. Strengtheningand stretching exercisesmost effectively address these problems. Strengthening may be more effectivewith the addition of motorlevel electricalstimulation or water exercise,while srretchingmay be more effecrivewith the prior applior brief ice massage.l632 catjon of thermocherapy Shouldthe injury be of a qypethat is particularlyprone to excessivescarformatiorysuchas a burn, control of scarformation with compressiongarmentsshouldbe stage. conrinued throughouttheremodelinS Etlectsof differentphysicalagents on pain In addition to modifying the signs and symptoms associatedwith inflammation and tissue healing, and promoting the progressionof *rese processes, physical agents can be used to relieve pain (see Tat'Ie 13-2).Ditferent physicalagentsare indicatedor contraindicatedfor treating different types of pain aad for treatingpain of differing etiologies.
Effective agents
Contlaindicated
Sensorye.s.,cryotherapy Control inflammation
Cryotherapy
Therm^rhPDnw
Preventaggravation ofpain
lmmobilization Low-loadstatictraction
Localexercise,motor e.s.
e.s.,cryotherapy,
Re[erred
rh.'-^rhFr:h-
Spinalradicular
Decreasenerveloot inflammation
Traction
Decteasenerveroot compresslon Paindue to mallSnancy :-s.= electricalstirnulation.
Control pain
419
e.s.,cryotherapy,superficial tharmnrhar:nrr
420
43 . htteglatiftg
Physical Ageflts irrto Patiett
Acu'€pain When fteating acute pain, the goals of ffeatment are to control the pain and any associatedinflammation and to prevent aggravationof the pain or its cause.Many physicalagents,includingsensory-level electrical stimulation and cryotherapy, can relieve or at least reduce the severiry of acute pain.Z,8 Thermotherapy may reduce the severiqyof acute painl however, sinceacutepain is frequendyassociatedwith acuteinflammation,which is aggravatedby *rermotherapy,thermotherapyis generallynot recommended for the treatment of acute pain.33 CryorJrerapyis thought to controlacutepain by modulating ffansmissionat the spinalcord, by slowing or blockingnerveconduction,and by controllinginflammation and its associatedsigns and symptoms.T Sensory-level electricalstimulationalsorelievesacute pain by modulatingtransmissionat the spinalcord or by stimulatingthe releaseof endorphins.Briefly limiting motion of a painful areawith the aid of a static compressiondevice,an assistivedevice,or bed rest can plevent agglavationof the symptom or causeof acute pain. Very lowJoad, prolongedstatic kaction may be used for a number of hours or even a few days to immobilize a symptomatic spinal areatemporarily,therebyrelievingthe spinalpain and inflammation that would be aggravatedby lumbar spine motion.34,35 Becauseexcessivemovement or muscle contractionin the areaof acutepain is generallycontraindicated,exerciseor motor-levelelectricalstimulation of this areashouldbe avoidedor restrictedto a level that does not exacerbatepain. As acute pain startsto resolve,controlledreactivationof the patient may acceleratepain resolution.The water environment may be usedto facilitatesuchactivity.
Cate
tion andwater exercisemay be usedto increasemuscle strength in weak or deconditioned patients. Bed rest,which can resultin weaknessand further reduce functioryshouldbe discouraged in this patientpopulatior5 and since passive physical agent heatments provided by a clinician can encouragedependence on the clinician rather than improving the patienCs own coping skills, suchinterventions are generallynot recommended for the treatrnent of chronic pain. The judicious use of pain-controllingphysical agentsby patients themselvesmay be indicated when this helps to improve the patient's ability to copewith pain on a long-termbasis;however,itis importantthat such interventions do not excessivelydisrupt the patienCs functionalactivities.For example,TENS appliedby a patientto relieveor reducehis chronicbackpain may promote function by allowing him to participate in work-relatedactivitieslhowever,a hot packappliedby the patient for 20 minutes every lew hours would interfere with his abiliry to perform normal functional activitiesandwould thereforenot be recommended.
pain nebrred If the patient'spain is refenedto a area from an intemal organ or from anodrer loskeletal area, physical agents may be used to
however. the sourceof the nain should alsobe treated possible. Pain-relievingphysical agents such as motherapy, cryotherapy, or elecrical stimulation control referredpain and may be particularly benefici if complete resoludon of the problem is prolonged cannotbeachieved.Forexample,althoughsurgery be neededto fully relievepain causedby should the disease not place the patient at ris(
controlling interventionssuch as physicalor logicalagentsmay be used to control the associared
pain Chronic Pain that doesnot resolvein *re normal recovery time expectedfor an injury or diseaseis known as chronicpain.36The goalsof treatmentfor cfuonicpain shift ftom resolutionof the underlyingpathologyand control of symptoms to promotion o[ functiorl enhancementof strength,and improvementof coping skills. Although psychologicalinterventionsare the mainstay of improving coping skills in patients with chronic paiq exercise should be used to regain strengthandfunction.The water environmentmay be used to promote the developmentof the functional abilities and the capaciry of certain patients with chronicpaiq and both motor-levelelectricalstimula-
Radicularpain in *re extrernitiescausedby nerve root dysfunctionmay be effectivelytreated the application of spinal traction or by the use physical agents that cause sensory stimulation the involved dermatome, such as
cryotherapy,or electricalstimulation.3T,38 Spinal tion is effectivein such circumstancesbecauseit reducenewe root compression,addressingthe of the pain,while sensorystimulationmay the transmission ofpain at the spinal cord 1evel.39 Paindueb nalignancy
The treatmentof pain due to malignancymay fer from the treatment of pain of other
Thrce O INTEGRATING PHYSICAL AGTNTS /NTO PRESENT AND FUTURE PRACTICE
cecauseparticularcaremust be taken to avoid using lgenrs thar can promote the growth or metastasiso"[ nalignant tissue.Becausethe growth of somemaligeanciescan be accelerated by increasinglocal circulaion, agentssuchasuluasoundand diathermy,which are known to increased€ep tissue temperatureand :irculation,shouldgenerallynot be usedin an areaof :aalignancy.40,41 However,in patientswith end-stage :nalignancies,pain-relieving interventions that can :mprovethe patient'squality of life but may adversely :ffect diseaseprogressionmay be used wit! the patient'sinformed consent.
421
stimulated activity in tlese muscles causesreflex relaxationand tone reductionin opposingmuscles.42 Stimulation of hypertonic muscleswith motor-level electricalstimulationor quick icing has generallynot beenrecommendedbecausethis can increasemuscle tone; however, recentreportsindicate that electrical srimulationof hypertonicmusclesimprovespatient function by increasingthe strength and voluntary controlof thesemuscles.43,44 In patients wi*r muscle hypotonicity, where the goal of treatment is to increasetone, quick icing or motor-level electricalstimulation of the hvpotonic muscle(s) may be beneficial. In contrasr.the applicaConplexregionalpainsyndrone tion of heat to these muscles should generally be Physicalagentscan be usedto control the pain of avoidedsincethis may further reducemuscletone.In ,omplex regionalpain syndromeswith sy.rnpathetic patients with fluctuating tone, where the goal of :rervoussystem involvement. In general,lowlevel treatment is to normalize tone, functional electrical ;ensory stimulation of the involved area,as can be stimulationmaybe appliedto causea muscle,ormus:rovided by neutralwarmth, mild cold,water immercles,to contractat the appropriatetime during funcsion, or gende agitation of lluidotherapy, may be tional activities, Ior example, if a patient cannot :ffective, while more aggressivestimulation, as can maintain a functional grasp becausehe cannot con:e providedby veryhot water.ice,or aggressive agitract the wdst extensorswhile conkactingthe finger -rtion of water or lluidotherapy,will probably flexors, contractionof the wrist extensorscould be not be :oJerated andmay aggravate this ry?eof pain. producedby electricalstimulation at the appropriate time duringactivegrasping. Etfectsof differentphysicalagenb on musclelone ?hysical agents can temporarily modify muscle Etlects0f ditferentphysicalagenlson motionrestrictions :rypertonicity, hypotonicity, or fluctuating tone Physicalagentscan be effectiveadjunctsto the keatTable 13-3).Hypertonicity may be reduceddirectly ment of motion restrictionscausedby muscleweak:y the application of neutral warmth ot prolonged ness,pain, soft tissue shortening,or a bony block; :ryotherapy to the hypertonic muscles,or it may be however, the appropriate interventions for these :educedindirectly by the stimulation of antagonist different sourcesof motion restriction varv ffable :nusclecontractionwith motorlevel electricalstimul3-4). When active motion is restrictedby muscle ,ation or quick icing. Stimulationof antagonistmusweakness,the treatmentshould be aimed at increas:les indirectly reduces hypertoniciry because the ing musclestreng*r.This canbe achievedby repeated
p rs-sFhysical Agents for the Treatment of Tone Abnormalities Tone
Coals of tteahent
Effective
Contraindicated
Hypertonicity
Decteasetone
Neutralwarmttr or prolonged cryotherapyto hypertonic muscles Motor e.s.or quick ice of antagodsts
Quick ice ofagonist
Hypotoniciry
Increase tone
Quick ice ormotor e.s.ofagonists
Thermotherapy
Fluctuatingtone
Normalize tone
Functionale.s.
..5.= electricalstimulation.
422
l3 c Integtatirg Physical Agents into Patieflt Carc
overloadmuscle contractionthroush active exercise and may be further facilitaredby the use of water exerciseor motorlevel electricalstimulation. Water canprovidesupportto allow weakermusclesto move joints through greaterrange and can provide resistance for stronger musclesto work against.Motorlevel electricalstimulation can provide preferential training of larger muscle fibers, isolation of specific musclecontraction,and precisecontrol of the timing and number of muscle contractions.When range of motion (ROM)is Ijmitedby muscleweaknessaLne, rest and immobilization of the area are contraindicatedbecauserestrictinsthe active use of weakened muscleswill further reluce their strength and thus exacerbatethe existingmotion restriction. \A4renmotion is restrictedby pain,treatmentselection wiJl dependon whetherthe pain occursacresr andwith allmotionor if it occursin response ro actjve or passivemotion only. When motion is restrictedby pain *rat is presentat rest and with all motion, the first goal of treatmentis to reducethe severityof the pain. This can be achieved,as describedabove,with the use of electricalstimulation, cryotherapy,thermotherapy,or PSWD.If the pain and motion restriction are relatedto a compressivespinal dysfunction,
spinaltraction may also be usedto alleviatethe pain and promote increasedmotion. When activemotion is restrictedby painwith activemotion only, this indicatesan injury of contractiletissuesuchas muscleor When acrive tendon. witJrout completeruprure.4s and passivemotion ar€ both restrictedby pain, this indicatesthat noncontractiletissuesuch as lisament or meniscusis jnvolved.Physicalagentsrnuy h.lp restoremotion after an injury to contractileor noncontractiietissueby promoting tissuehealing or by controllingpain,asdescribedpreviously. When active and passivemotion are restrictedby soft tissueshorteningor a bony block, the restriction is generally not accompaniedby pain. Soft tissue shorteningmay be reversedby stretching,and thermal agentsmay be used pdor to, or in conjunction with, stretchingin order to increasesoft tissueextensibility and thus promote a safer, more effective stretch.30,31,46 The ideal thermal agentdependsupon the depth, size, and contoudng of the tissue to be treated.Deep heating agentssuch as ultrasoundor diathermy should be usedwhen motion is restricted by shorteningof deep tissuessuch as the shoulder joint capsule,while superficialheatingagents,suchas hot packs,paraffin,warm whirlpools, or infrared@)
Source of motion restriction
Goals of treatrnent
Effective agents
Muscleweakless
Increasemusclestrength
V/ater exercise,motor e.s.
Immobilization
?ain At restandwith motlon
Control pain
F.
Exercise
With motion only
Control pain Promotetissuehealing
Softtissueshortening
Bony block
e.s = electrical stimulation.
.^,^rhFrrnv
thermotherapy,PSWD, spinaltraction e.s.,cryotherapy, thermotherapy,PSWD Dependson stageofhealing (seeTable13-1)
Increasetissueextensibiliry Increasetissuelength
Th.'--fh"',--
Removeblock Compensate
None Exercise Thermotherapyor brief ice massageand stretch
Exerciseinto pain
Prolongedcryotherapy
Thermotherapyor brief ice massageand stretch Stretchingblockedjoint
Thrce . INTEGRAflNG PIIYSICAL AGENTS INTO PRESENT AND FUTURE PRACTICE
lamps,should be usedwhen motion is restrictedby shorteningof superficialtissuessuch as the skin or subcutaneousfascia.Ultrasoundshould be used for treatingsmallareasof deeptissue,while diathermyis more appropriatefor larger areas.Hot packs can be usedto treat large or small areasof superficialtissue with litde ormoderatecontouring,while paraffinor a whirlpool are more appropdate for treating small areaswithgreater contouring.IRlampscanbe usedto heat largeor small areas,but they provide consistent heating only to relatively flat surfaces. Because increasingtissueextensibilityalonewill not decrease soft tissueshortening,thermalagentsmust be usedin conjunctionwith stretching techniquesin order to increasesoft tissuelength and reversemotton restricdons causedby soft tissueshortening.Brief forms of cryotherapysuchasbrief ice massageor vapocoolant spraysmay also be usedprior to stretchingto facili tategreaterincreasesinmuscle lengthby reducingthe discomfort of stretching; however, prolonged cryotherapyshould not be used prior to stretching becausecoolins soft tissue decreasesits extensibiliry.47,48 When a bony block restrictsmotion, the goalsof ueatmentare to remove the block or to compensate ibr the loss of motion. While physicalagentscannot removea bony block,they may help with compensaiion for the loss of motion by facilitating increased rlotion at other joints. Motion may be increasedat otherjoints by the judicioususe of thermotherapyor brief cryotherapy with stretching, as described direcdy above. Such treatment should be applied with caution to avoid causinginlury hypermobility, or other dysfunctions in previously normal joints. -\pplying a stretchingforce to a joint that is blocked by a bony obstructionis not recommendedbecause :hisforcewill not increaseROM at that ioint and mav :auseinflammationby traumatizingthe intraarticula, stluctules. Addressing multipleproblemsandgoals iVhen patients presentwith multiple problemsand -]rushave multiple treatment goals,physical agents -jrat have multiple effects,or a variety of physical agentswith different effects,may be applied either :imultaneously or sequentially.For example, the :atient with chronic tendonitis and tendon shortenng may benefit from the application of a thermal agentbecause*ris type of physicalagentcanincrease ;oft tissue extensibility to promote more effective
423
stretching,and canalsoincreaseblood flow and circulation to facilitatehealine.Both of theseeffectswould facilitate progress towird the goals of treatment. Ideally,those physicalagentsthat producethe effect or effects that most closely match the processes needed for resolution of the patient's problem(s) should be selected.Iurther discussionof the sequential or simultaneousapplicationof different physical agentsis providedin the sectionon combiningtreat-
Contraindications andPrecautions Once the goalsof treatment,and the treaffnentinterventions that may promote progresstoward these goals, have been determined, treatment selection may be guided further by evaluation of the contraindicationsand precautionsfor the applicationof thesetreatmentoptions.In all cases,physicalagents that are contraindicatedfor the presentingcondition or for the specific patient should not be used, and appropriateprecautionsmust be taken when indicated.Sinceall physicalagentshave someconditions for which they are contraindicatedand since all should be applied with caution in certain circumstances,a considerationof contraindicationsand precautionsmay eliminatesometreatmentoptions. Although a number of conditions, including pregnancy, malignancy,the presenceof a pacemaker, impaired sensatioq and impaired mentation, indicate the need for caution with the use of most physical agents,the specificcontraindicationsand precautions for the specificagentbeingconsideredandthe specific patientsituationmust be evaluatedbeforea treatment may be used or should be rejected.For example, although the application of ultrasound to a pregnant patient is contraindicatedin any areawhere the ultrasound may reachthe fetus, this physical agentmay be appliedto the distal extremitiesof a pregnanrpatient becauseultrasoundpenetrationis limited to the area closeto the applicator.In contrast,it is recommended that diathermy not be applied to any areaof a pregnant patient becausethe electromagneticradiation prodrced by this type of agent reachesareas distant ftom the applicator.Contraindicationsand precautions for the application of specific physical agents are induded in sectiontwo of this book within the chapter concemingeachtype ofphysicalagent. Sincephysicalagentshave differing levelsof associated risk, when all other factors are equal, those
424
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Physical Agetts into Parieflt Care
with a lower level of risk shouldbe selected.Physical agentswith a low level of associatedrisk have a potentiallyharmful dosethat is difficult to achieveor is much greaterthan the effective therapeuticdose and have contraindicationsthat are easyto detect.In contrast,physicalagentswith a high level of associated risk have an effective therapeuticdose that is closeto the potentially harmful dose and have contraindicationsthat are difficult to detect.Ior examole. hot packs tlaat are heated in hot water haue a low associatedrisk becausealthoughthey canheat superficial tissuesto a therapeuticlevel in 15 to 20 minutes, they areunlikely to causea bum ifapplied for a longer period, provided that sufficient insulation is used becausethey startto cool assoonasthey areremoved from the hot water In contrast,ultraviolet(LlV)radiation has a high associatedrisk because a slight increasein the treatmentduration,for example,ftom 5 to 10 minutes,or usingthe sametreatmentduration for patients with different skin sensitivity may changethe effect of the treatmentftom a therapeutic level of erythema to a severeburn. Diathermy also has a high associatedrisk becauseit preferentially heatsmetal, which may have been previouslyundetected, and can burn tissue *rat is near any metal object(s)in the treatmentfield. It is generallyrecommended that agentswith higher associatedrisk be used only if those with lower risks would not be as effectiveand,when used,that specialcarebe takento minimize theserisks.
Merit Scientific If severalagentsmay promote progresstoward the goals of treatment,are not contraindicated,and can be appliedwith the appropdateprecautions,selection should be basedon the scientificmerit of tlte treatment approach.Six criteria of scientific merit have beenproposedfor guidancein treatmentselection.49 Treatment approachesthat meet these criteria are consideredto have a high degreeof scientificmerit. The proposedcriteria for determinationof scientific merit areasfollows: 1. The theories underlying the ffeatment approacharesupportedbyvalid anatomicaland physiologicalevidence. 2. The treatment approachis designedfor a specific patientpopulation. 3. Potentialside effectsof the treatment are presented.
4. Studies from peer-reviewedjournals support tha
rraetmenr'c
efFie:rrr
5 . Peer-reviewedstudies include well-designed, randomized, controlled clinical trials or wellexperimentalstudies. designedsingle-subject 6. The proponentsof the treatmentapproachare willins to discussits limitations. The more of thesecriteriathat are meq the better the quality of support for a treatmentand thereforc the more appropriate the treatment selection.For example,it is recommendedthat ultrasoundor SWD, at intensitiessufficientto raisethe temperatureof the shouldercapsuleby 3'to 5" C, followed by stretching be used to treat a restrictionin shoulderjoint ROM when the motion is restrictedby capsularshortening becausethis approachmeetsmost of the abovecriteria. There is valid evidencethat increasingtissuetemperatureincreasestissueextensibility,that increasing in soft rissueextensibilitypromotesgreaterincreases tissuelength in responseto stretching,and that both ultrasound and diathermy can increasedeep tissue 30314550-52 Thistreatmentapproach b temperature.16 designedfor patientswith specificproblemsrelated to loss of soft tissue length. Precautionsand contraindicationsfor the use of ultrasound,diathermy and stretchinghavebeenwell documented,and are studiesshowing that the applicationof deep ing agents prior to stretching can promote R gains.The authors of these studiesare also open discussing the limitations of their findingsAlthough this treatmentapproachdoesnot fully the fifth criterion for scientificmerit, because are no well-designed,randomized,controlled trials or well-designed single-subject studiesspecificallysupportingthe use of these heatingagentspdor to stretchingof the shoulder sule, selection of this treatment approach recommended, given no effective and safe
meets all of the other criteria for scientific Comrnoniy,eventhe besttreatmentscurrently ablemeet most but not all of the criteriafor meric. and given the absenceof befter
theseshouldbe used;however,tr€atment that meet few or none of the above criteria generallybe avoided. Treatment aooroaches that meet few or none
the criteriafor scientificmeritare alsooften ized by the following properties:53 1. Treatments are based on theodes that are
gruentwith anatomicalor physiological
Thrce . INTEGRATING PIIYSICAL AGENTS INTO PRESENT AND FUTURE PRACTICE
2. Treatment is said to be effective for a broad rangeof diagnoses. 3. Treatmentscan-notcauseharm. 4. There are no adequatelycontrolled studiesin peer-reviewedjournals. 5. The therapieshave an emotional appeal,and studiesthat fail to confirm their effectiveness areattacked. 6. Treatmentis advocatedby thosesellingor manufacturingthe necessaryequipmentwhenother treatmentsor equipmentaremore effective. Treatmentsthat fail to meet many of the criteria :cr high-quality support or that have many of the :haracteristicsof treabrents with poor support ideJly should not be used. For example, the use of :ragnetsto control pain and acceleratehealingis rec:mmendedby somepublicationsand practitioners;s4 :oweve5 the evidenceto suppoft their use doesnot :ave great scientific merit at this time. Treatment .-,.'ithmagnets has been recommendedfor a wide =nge of diagnoses,and it is claimed that magnets ::aveno adverseeffects.Although the poor quality of :--rpportfor this and other treatment approaches ::rouldguide cliniciansaway from their applicationat :ris time. clinicians should keep informed of new :rdings in order to integrate tlre use of innovative :eaffnent approachesinto clinical care should suffi :ent high-quality evidencebe presentedto suppot :telr use. Ingeneral,the treatmentswith physicalagentspre.entedin this book have sufficientscientificmerit to =ongly support their use; however, the scientific =erit of the supportfor differentapplicationsof each :eysical agentvaries.In addition, further researchis :equently needed to validate the efficacy of com=only used treahnentsand to determine the ideal :eatment parametersand patient characteristicsfor ,:rdmal efiect. During treatment selection,both the ::'erall scientificmerit of an approachand the scienic merit of the specificapplicationshouldbe consid::ed.
;ost,Convenience, andAvailability -equendy, cost, convenience,and availability influ=ce the selection of a physical agent treatment. .',rhoughideally theseshouldnot be the limiting fac=rs in treabTrentselectiorlwhen all other factorsare :-ual, cost efficiency should be consideredand, in i:ry situatior\ cost or lack of equipmentmay prevent
425
the application of certain treatments.When determining the cost of a ffeatment, the cost of the requiredmaterialsand equipment,aswell asthe associatedlabor and time costsrshould all be considered. Because,in general,the materialsused for applying physicalagentsare reusableor inexpensive,the cost of materials rarely limits treatment selection;however, since the cost of equipment or labor may be high, particularly if a high level of skill is required, thesemay limit or guide the selection.For example, when consideringapplyingultrasound,the costof the ultrasoundgel is notlikely to limit the selectionofthis treatment; however, the cost of an ultrasoundunit and the amount of skilled clinician time required to apply it may leadto the choiceof a differentcourseof treatment, Conveniencecan be ari important consideration when usinga physicalagentin the clinicalsettingand even more so when consideringrecommendinga physicalagentfor home use by a patient. In general, the easieran agentis to use,the more readilyits application can be delegatedto lesswell-trained and less cosdy personnel,or to the patient, and the lesslikely the agent will be used inappropriatelyor unsafely. However,it is important *rat physicalagentsthat are convenientto use not be substitutedfor those that would be more effective.For example,althoughhot packs,which heat superficialdssues.are easierto apply than ultrasound,which heats both deep and superficialtissues,hot packsshouldnotbe usedwhen the goalsof treatmentrequiredeepheating. The availabilityof a physicalagentmay alsoinfluencetreatrnentselection.Most rehabilitationfacilities in the United Stateshave hot packs, paraffin, cold packsor ice packs,ultrasound,electricalcurrentstimulation devices,and mechanicaltraction units available, and many facilities also have compression devicesand whirlpool(s);however, few have swimming pools,IRlamps,W lamps,or other electromagnetic field devices.Even when a specific physical agentis available,the devicemay not allow selection of the ideal treatmentparametersor setupand therefore should not be used. Ior example.the traction halterfor applydevicemay not havethe appropriate ing cervicaltractionwithout compressionof the temporomandibularjoints, or the ultrasound unit may not have pulsed duty cyclesto allow for ultrasound application without heating. Clinics outside the United Statesmay have and use different physical agents than those commonly used in the United
426
43 . Ifltegrqtittg
Physical Ageflts into Patieflt Care
When the goal of treatment is to conftol paiq a numberofphysical agentsmay be usedto impact different mechanisms of pain control. Ior example, cryotherapyor thermotherapymay be usedto modulate pain transmissionat the spinalcord,while motorlevel electricalstimulation may be usedto modulate pain through stimulationof endorphinrelease.These physical agentsmay be combined with other paincontrolling intewentions, such as medications,and may alsobe usedin conjunctionwith treatmentssuch as joint mobilization and dynamic stabilizationexercise, which are intended to addressthe underlying impairment causingthe pain. AGENTS INCOMBINATION PHYSICAL USING goal of treatmentis to altermuscletone, When the WITH EACH OTHER ORWITH OTHER a number of tone-modifyingphysicalagentsor other INTEBVENTIONS intewentionsmay be appliedduring or pdor to activity in order to promote more normal movement and In order to promote progresstoward the goals of to increasethe efficary of other aspectsof treatmenl treatment,a number of physicalagentsmay be used For example,ice may be appliedfor 30 to 40 minutes simultaneously,sequentially,or in conjunctionwith to the leg of a patientwith hypertonicity of the anlle other interventions.Treatmentsare generally complantar flexorsdue to a strokein order to control the bined when they have similar effectsor when they h)?ertoniciry of these muscles temporarily and addressdifferentaspectsof a common arrayof symptoms. Ior example,splinting,ice, pulsedultrasound, thereby promote a more normal gait pattem dudng gait training.Becausepracticingnormal movementis PSWD,and phonophoresisor iontophoresismay be acute phase usedduringthe inflammatory of healing. thought to facilitate the recovery of more normal movement pattems,such treatmentmay promote a can limit further injury; ice may control pain Splinting pulsed PSWD superiortreatmentoutcome. and limit circulation; ultrasound and progress proliferative When the soal of treatmentis to reversesoft tissue to the stage;and may promote shonening,the applicationof thermal agentsbefore phonophoresis and iontophoresis may limit dre inflammatory response. During the proliferative or dudng stretchingor mobilization is recommended in orderto promote relaxationandincreasesoft tissue stage, heat, motor-level electrical stimulation, and extensibility, thereby increasing the efficacy and exercisemay all be used,while ice or other inflammasafety of the treatment.Ior example,hot packsare tion-controlling interventions may continue to be often appliedin conjunctionwith mechanicaltraction applied after activity in order to reduce the risk of in order to promote relaxationof the paraspinalmusrecurringinflammation. cles and increasethe extensibility of the superficial andelevation(NCE) arefteRest,ice,compression, soft tissuesin the areato which the traction is being quendy combinedfor the treatmentof inflammation aonlied. and edemabecauseall of theseinterventionscan con' Physical agents are generally used more extentribute to inflammationand edemacontrol or reducsivelyduringthe initial treatmentsessionsin rehabilition. Rest limits and prevents further injury; ice reducescirculation and inflammation; compression tation when inflammation and pain control are a priority, with progressionover time to more active elevateshydrostatic pressureoutside the blood vesor aggressivetreatments,such as exerciseor passivE sels;andelevationreduceshydrostaticpressurewithin the blood vesselsofthe elevatedareato decrease capil- mobilization. Progressionfrom one physical lary filtration pressureat the arterialend and facilitate to another, or from the use of a physical agent venous and lymphatic outflow from dre limb. 55-58 another form of treatment, should be based the progressionof the patient'sproblem.Ior Electricalstimulationmay alsobe addedto this combihydrorherapy may be applied to cleanse nation to further control inflammation and the formadebride an open wound durine the initial tion of edemaby repellingnegativelychargedblood with inflammation. sessions;however, once the wound is clearS cellsand ions associared
States.Ior example, since the IDA approveslowintensity lasersonly as investigationaldevicesat this time, they are not commonly used in the United States.However,they are commonly usedin Canada andEurope.SWD is alsorarelyavailablein the United Statesat this time becauseof its associatedrisks and its interferencewith other electronicdevices;however,it is still commonly availableelsewhere.When treatingpatientsin their homes,the limited availability of physicalagentsgenerallyrestrictstreatmentto of hot packs.icepacks.or water. the application
Thrce I INTEGRAIING PITYSICAL AGENTS INTO PRESENT AND FUTURE PRACTICE
::atment shouldbe stopped,while the useof electri:l stimulationmay be initiated to promote collagen ::position.
427
however, since that time, reimbursementfor these serviceshas been reducedto reflect the lower perceivedlevel of skill requiredto apply theseagents.In January7997,Medicare changedits reimbursement PHYSICAL AGENTS WITHIN DIFFERENT schedule,bundlingthe paymentforhot packand cold JSING pack treatmentsinto tlre payment for all other sewDELIVEBY ]IEALTH CARE SYSTEMS icesrathrr than reimbursingseparatelyforthesetreat-Jniciansmay be calledupon to treat patientswithin ments.bvThe rationaleproposedfor this changewas ::iferent health care delivery systems both in the that (1) hot packs are easily self-administered;(2) - rited Statesand abroad.Thesesystemsmay vary in thesepacksare commonly usedin the home and thus rth the quantity and nature of available health require minimal professionalattentiory and (3) the ::r€ resources.Somesystemsprovide high levels of applicationofhot packsis usuallya precursorto other r.sources,in the forms of skilledcliniciansand costly interventions. :;uipmeng while othersdo not. At the presenttime, Although there is a growing emphasison the cost :e health caredeliverysystemin the United Statesis effectivenessof care,the goalsof treatmentcontinue ;:rdergoingchangedue to the needand desireto conto be, as they always have been,to obtain the best -in the growing costs of medical care. Utilizing outcomefor the patientwithin the constraintsof the : .-ailableresourcesof both personneland equipment health caredeliverysystem.Although it hasbeensug:- the most cost-effectivemanner is being empha- gestedthat the needfor costefficiencymay eliminate ::zed, resulting in new systems of reimbursement the use of physicalagents,this is not so. Rather,this ld increasedmonitoring of treatment outcomes. requirementpushesthe clinicianto find and use the --.simbursementhas moved from fee-for-service, most efficientways to provide those treatmentsthat ;-herethird-party insurancecompaniespay individcan be expectedto help the patient progresstoward :al service providers according to the nature and the goalsof treatment,whether this doesor doesnot -lantity of sewice provided, to capitatedpayment include the use of physical agents.In order to use physicalagentsin this manner,the clinicianmust be t. stems,where insurancecompaniespay a set rate :er treatment,or per case,independentof the type of ableto assess the presentingproblemandknow when :eatment provided.There has also beena growth of physical agents can be an effective component of :ealdr maintenanceorganizationsthat collectpremitreatment.The clinician must also know when and :ins from insuredindividualsand provide health care how to use physical agents most effectively and by employinghealthcareproviders. :=rvices know which ones can be used bv Datientsto treat In order to improve the efficiency and efficacy themselves flable l3-5). To achieverhe most cost:i health care as it relatesto patient functior5 both effectivetreatment,the clin.icianshouldalsooptimize --ealthcareprovidersand those paying for treatment the useof the variedskill levelsof differentpractition::e attempting to assessfunctional outcome in ersand the useof home programswhen appropriate. ::sponseto differenttreatmentoptions.Thesechanges In many cases,the licensedtherapistmay not needto are pres: reimbursementand outcomeassessment apply the physicalagentbut insteadmay assessand ':ring both serviceprovidersand third-party payers analyze the presentingclinical findings, determine :r find the most cost-efficientmeansto provide rehathe treatment plan, provide tlose aspectsof care services and to demonstrate itation the efficacy : of requiringthe skills of the licensedtherapist,and then -reir interuentions in improving patient function and train the patient or supervisedunlicensedpersonnel educingdisability. to apply those treatmentsrequiring a lower level of Some payersare attempting to improve the cost skill. The therapistcanthen reassess the patientregu:'{ectivenessof care by denying or reducing reimlarly to determinethe efficacyof the treatmentspro:ursementfor certainphysicalagenttreatmentsor by vided and the patient'sprogresstoward the goalsof :cluding *re cost of physicalagenttreatmentsin t}re treatment, and adjust *re plan of care accordingly. :eimbursementfor other services.Ior example,prior Aides may then provide many treatments with o January1995,many third-party payersprovided a physical agents,such as hot packs and cold packs, :isher level of reimbursementfor treatmentsinvolvto patients in the clinic and teach patients how, rg physical agents *ran for other intewentionsl when, and why to apply these agents safely and
43 . Ifltegatiflg
424
p o . o o o o o . .
Physical Ageflts into Patiettt Cate
13-5 Reguirementsfor Cost-EffectiveUse of Phy'sicalAgents Assessand analyzethe presentingproblem. Know when physicalagentscanbe an effectivecomponentof treatment. I(now when andhow cousephysicadgenrsmosteffecrively. Know the skill levelrequiredfor the applicationof differentphysicalagents. Optimizethe useofthe skilllevelsoi djfferentpractitioners. Usehome programswhen appropriate. Treatin groupswhen appropriate. patientsregula y to determinethe efficacyof the tteatmentsprovided. Reassess Adjustthe plan of careaccordingto the findingsof reassessments.
independentlyat home. In this situation, the time with the cliniciancouldthen be spentprovidingtreatment that the Datientcannotperform. Cost efficiencymay alsobL increasedby providing treatmentto groupsof patients,such asgroup water exerciseprogramsfor patientsrecoveringfrom total joint arthroplasty or for those with osteoarthritis.
Suchprogramsmay be designedto facilitatethe transition to a community-basedexerciseprogramwhen the patient reachesthe appropdatelevel of function and recovery Used in this manner, physical agents can provide cost-effective care and involve the patient in promoting recovery and achieving the on.rlc nf irp.?trnpnt
) Clinical Case Studies I The following six case studies demonstratethe processes involvedin the selectionofphysicalagentsfor the treabnent of patientswith a variety of problems that progress and change as their ffeatment progresses. These studies focus on the decision-makingprocess involved in the selectionof physicaiagents.Details of application techniques, including specific fteatment parametersand duratioo of treatment,are not included sincethese are provided in the chaptersregardingthe specihcphysicalagentsrecommended.
Case ,l TJ is a Z8-year-oldfemale who sustaineda sffoke 2 weeks ago.Upon evaluation,TJ hasa right hemiparesis wittr decreasedtone of her right upper and lower extr€mities.Her right humeral head is inferiorly subluxed from tJreglenoidfossa,and shehasminimaiactive movementof her right upper extremity.TJ'sright hand is also rnildly edematousand pale. During gait shehas a foot drop on the right and us€sa steppagegait with circumduction on the right to clear her toes during swing phase.She also hyperextendsher knee on the right duringstancephase.TJambulatesat a siow pacebut with good balanceonalevelsurfacewithout an assistive
device. She has poor balance when attempting to walk on an uneven surface.Passiverange of all major joints is within nomal limits. TJ does not complain of any pam. EVALUATION OF THE CLINICALFINDINGS This patient presentswith impairments of restricted active range of motion (LOM), decreasedstrength and hypotonicity of the right extremities, subluxation of the right glenohumeral joint, and edema of the right hand. These impairments have resulted in functional limitations in the use of her nght upper exuemity and have interferedwith her gait pattern and speed.Shealsohas poor balance,and thus impaired safety,when walking on uneven sutfaces.
PREFERREDPRACTICEPATTERN ImpairedMotor Functionand SensoryLrtegriryAssociated with NonprogressiveDisordersof the CentralNervous System-Acquiledin Adolescenceor Adulthood, (5D)
ntree . INTEGRATING PIIYSICAL AGENTS INTO PRBSENTAND FUTUM ?RACTICE
upper extremityj control the right hand edema,and optimize the pattern,speed,and saferyof TJ'sgait. ASSESSMENTREGARDINGTHE OPTIMAL PHYSICALAGENT INTERVENTION(S} Electricalstimulationmay be effectivefor reducingthe shoulderglenohumeralsubluxation,the edema of the right hand, and the foot drop and knee hyperextension on the right. An intermittent pneumatic compression pump could be usedin placeof electricalstimulationfor reducing ttre hand edema, and, once the edema is reduced,a compressionsleeve may be effective for maintainingnormal volume and fluid balance.Ordrotic bracingmaybe usedin placeof electricaistimuiationfor the shouldersubluxation,or for t}le foot drop and knee hyperextension.Selectionamongtheseoptionsdepends on th€ir effectivenessfor this particular patienE their availabiiity,patientand cliniciancomfortwith their use, and their cost.Water-orland-basedexerciseshouldalso be integrated into tJr€treatment in order to improve the patient'sbalanceand her other functionalactivitiesand to maintainactiveand passiveROM of the joints of the right upperand lower extremities. PROPOSEDTREATMENTPLAN AND RATIONALE The physical agents that could promote progression toward tIIe goals of treatment at this time, and tiat are not contraindicated,include electricalstimulatiorl compression,and water exercise.Becauseusingelectrical stimulation for multiple purposeson differentpans ofthe body is not generallypractical,itis recommended that electricalstimulation be reservedat this time for the applicationfor which it is most likely to be effective and for which other options are not as effective. Therefore it is recommendedthat electrical stimulation be used to rcduce the shoulder subluxation. Intermittent pneumaticcompressioncao then be used for limited pedods to reduce the upper exffemity edema,and a compressionglove or sleevecan be wom to maintaintlle edemacontrol.The right foot-drop and knee hyperextensioncan be controiled by use of an anklefoot orthosis(AlO). In addition to theseinterv€ntions, exerciseand functionalactivitiesshouldbe incorporated in the treatment plaa in order to oprimize functional recovery. FOLLOW-UP One month 1ater,after therapy sessionstwice a week, the tone in TJ's right upper and lower extremitieshas increased.Shenowhas mild spasticityofthe right upper extremity flexors, and the shoulder subluxation and right hand edemahave resolved.Her gait has improved suchthat shehasonly mild kneehyperextensionduring
429
stancephaseand a mild foot-drop during swing phase. The lower extremiry steppageand circumduction have lesolvedwith useofanankle footortlosis (AFO),andTJ is now able to walk up and down stairs safely holding on to onehand rail. EVALUATIONOF THE CLINICAL FINDINGS At this time, TJ continues to have impaiments of ton€ and ftmctionallimitations in her gait; howeve! he! tone has changedfrom h),?otonicto ht?€rtonic, t}re edema in her right hand has resolved,and her gait is much improved. PLAN OF CARE The goalsof treatmentat this time areto optirnizefunctional use of the right upper extremity by normalizing tone and motor control, and to optimize TJ's gait patte6
a
e.A
"-,J."F.h,
ASSESSMENTREGARDINGTHE OPTIMAL PHYSICALAGENT INTEBVENTION(S} The application of electricalstimulation to the right shoulderand the compressionto the right hand can be decreased and probably discontinued.The useof these interventionsshould be taperedwith closemonitoring for recurrenceof the problemsthey were intended to conuol. Shouid the impairments recur, treatrnent should be resumed,and a trial of discontinuatiol may be consideredagain at a later date. BecauseTJ continuesto havea foot drop and kneehyperextensionduringgait, it is recommendedthat use of the AFO be continued. Alternatively,this may be replacedwith motor- level elecfficalstimulationwith use of a foot switch to produce ankle dorsiflexionduring swing phaseby stimulating the tibialis ante or and to control knee hyperextensionduring stanc€phaseby stimulatingthe gastrocnemius-soleus muscles.At this time, thermal agents,includingproiongedicing or gentleheat,may be consideredfor reducing spasticity of the right upper extremity,particularlypdor to exerciseand functiooal activities. PROPOSEDTREATMENTPLANAND RATIONALE The physical agents that could promote progression toward the goals of ffeaffIlent at this time, and that are not contraindicated,include electricalstimulation, cryotherapy,and tltermotherapy.It is proposedthat at this time motor-level electricalstimulation be t ed to control the dght foot drop and knee hyperextension during gait. This is recommended in place of the AIO because the active contractions Droduced bv the elecrical stimuiaLionmore closely simulate the motor activity requiredfor normal gait.Thereforethis may Continuerl
430
'13 . Ilttegftttittg Physical Age,tts iltto Patieit Carc
) Clinical Case Studies-cont'd prcmote greater long-term recovery than tJre passive orthosis.It is also proposedthat gendeheat be used to reduce the hypertonicity of the right upper exu€miry prior to exerciseand functionalactivities,This is recommendedover prolongedicing as it is better toleratedby most patientsand is often as effective.Motor-levelelectrical stimulation to the antagonist extensorsof the right upper extremirymay alsobe consideredto leducetone in the agonistflexors.
Case 2 IS is a 23-year-oldmale who fell and tlvisted his right kneewhile playing footballand immediatelylimped off the field. Upon evaluationwithin a few minutes of his injury, IS complained of medial right knee pain that increasedwith weight bearing on his right Iower extremity. Objective testing of his right knee revealed tendemessover the medialjoint line, wi*r someredness and heat in the samearea.Someedemawas noted on palpation; however, knee girth was equal bilaterally. Passiveright knee flexion and extensionwere limited to 90" and 30', respectively,with complaints of medial knee pain and tightnessat the limit of both motions. Active motion and strengthtestingare defered due to the acute nature of the injury EVALUATION OF THE CLINICALFINDINGS This patient presentswith impaiments of restricted ROM, edema,and pain in his right knee.The injury is in the acuteinflammatory stageofhealing asindicatedby the presenceof the cardinalsignsof pain, heat,ledness, and edema; the pain is acute; and the rest ctio[ of motion is due to the pain and edema.The functional limitation of limping is likely to be due to the restriction of knee ROM and pain, and may also be influencedby reflex iohibition of contractionoI tle musclesconftolling kneeextension. PREFERREDPRACTICEPATTERN Impaired Joint Mobility, Motor lunction, Muscle Performance,and Range of Motion AssociatedWith CorrrectiveTissueDysfunction,(4D) PLAN OF CARE The goalsof fteatment at this time are to control pain and limit edemaformation, bleeding,and the releaseof inflammatory mediators associatedwith the acute inflammatory stage of healing.Treatment should also promote progression to the proiiferation stage of healing and prevent aggravationof the pain or injury Although regainingnormal ROM is a long-termgoalfor
I
this patient, it is recommended that the focus of treatmeot at this stagebe on controlling the pain and inflammation. ASSESSMENTREGARDINGTHE OPTIMAL PHYSICALAGENT INTERVENTION(S) Cryotherapy, compression,electrical stimulation, or PSWDcansafelybe usedto control edemaat this time, and all of these, except comptession,may also contribute to relieving pain. Although thermotherapy can alsobe usedto relievepaiq its useis not recomrnended for this patient at this time becauseit may aggravatethe edemaand bleedingand increasethe reieaseof inflammatory mediatorsassociatedwiti acuteinflammation. Cryotherapy should be included in the fteaftnent, becausedecreasingtissuetemperaturcwill also control the releaseof inflammatorymediators,and pulsedultrasound or PS\AD may be included to promote progression to the proliferationstag€of healing.Motion of the injured area should be r€strictedat this time to avoid aggravationof the pain orinjury. PROPOSEDTREATMENTPLAN AND RATIONALE The physical agents that could promote progression toward the goals of treatment at this time, and ttrat are compression, includecryotherapy, not contraindicared. electricalstimulation, pulsed ultrasound,and PSWD. Becauseit is not practicalto applyallofthese agents,th€ therapist should selectthose that can be expectedto have the greatestbeneficialeffect on the greatestnumber of the patient'sproblemsand that could be applied together Selectionshouldalsotakeinto accountthe scientificmerit ofthe proposedinteryention(s)and*re cost efficiencyand conv€nienceof providing the treahnent. Consideringall of the6ecriteria,it is proposedthat the patient be treatedwi*r the physicalagentsof ice and compression,with the possible addition of electricai stimulation.It is proposedthat PSWD and ultrasound not be used, although they may also be beneficial, becausethesephysicalagentscaffIot be appliedby the patient at home, are more cosdy to provide, and may not provide significantadditional benefit. It is recommendedthat the ice and compressionbe appliedin conjunctionwith rest and elevationto optimize the control of edema and inflammation, completing the classical combinationof NCE. This combination,with the addition of electricalstimulation, could be applied in the clinic and repeatedby tl.repatientat home.Cryo*rerapy and compressioncould be providedby a controlledcold compressionuniq however, sincethis device is costly and not availablein most settings,it is recommended
Three c INTEGRATING PIIYSICAL AGENTS INTO PRr SENT AND FUTUM
that cryotherapybe provided with an ice pack or cold pack and that compressionbe provided by an elastic compression bandage. The area should be rested between treatments,with the patient using crutches and limiting ambulation. Eiectricalstimulation could be provided by a portable stimulation device. It is proposed that this combination of interventions be appked by the patient at home until the warmth and redn€ssof his medial kaee resolve,indicatingprogression lrom the inflammatory to the proliferative stage ofhealing. FOLLOW-UP FS is evaluatedby a physician 3 days after his initial injuryand is diagnosedwith a sprainedmedial collateral iigament of the right knee. He retums tor therapy 2 weeks after the injury and reports that he applied ice, compression,and electricalstimulationto his right knee,with his right leg elevated,for 15 minutes every 2 hours for the first 2 days after the injury and then twice a day for another week. He also used crutches for ambuiation for the first week after his injury He discontinuedself-treatmentand the useofcrutchesafter 1 week becausethe heat arrd redness of his knee had fully resolved, and he is now taking an oral NSAID twice a day in compliancewith his physician'|s instructions. At this time, FS complainsof sorenessof the right medial knee that increaseswith turning to the left and worsensat the end of the day. He also reportsthat his kneeis stiff in the morning or after prolongedsitting.He is able to walk for about 20 to 30 minutes without an assistivedeviceand is thenlimited by pain and increased swellingof his knee.He hasbeenableto retum to work in a manufacturing planq on limited dury, restricted to sitting and no walking for ionger thart 5 minutes. lt is now 4 p.m., and IS was atwork for 7 hoursprior to this physicaltherapyappointment. The objective evaluation is significant for swelling and miid wannth of the right knee. Knee girth is 15 inches on the left and 161/2inches on the right. Knee ROM is asfollows: Left Active ROM PassiveROM
Fullextension, 130'flexion Fullextension, 140'flexion
Right - 15'extensiorl 90'flexion -10" extension, 100'flexion
Passivemotion of the right knee has a firm end feel,with pain in the medialkneeatthe end ofboth flexion and extensionrange.Medial knee pain is also producedwi& the applicationof a valgusstressto the right knee.
PL4CTICE
431
Although IS can ambulate without an assistive device, he has a shortenedstancephase on the right with reducedright kneeextensiondudngmidstance.He usesa stepto Saitfor ascendingand descendingstairs. EVALUATIONOF THE CLINICAL FINDINGS At this time, this patient continuesto have restricted ROM, edema,and pain in his right knee;however,the ROM has increasedsincethe initial injury, and the pain hasdecreased inboth severityandftequenry.The injury is progressing from t}le acute inflammatory stage of healing to *re proliferative stage, as indicated by the reducedpain, heat, and redness.The pain continuesto be acutesinc€it is associatedwith the normal duration of healing for th'is type of injury. The restdction of motion may be due to edema,shoneningof the knee capsule,oradhesionofthe medialcollatenl ligament.FS continuesto have an abnormalgaig which has resulted in an inability to performhis usualjob-relatedactivities. PLAN OF CARE The goals of treatrnent at this time continue to include controlling pain and edema and preventing aggravation of the pain or injury; however, since this injury is now progressingto the proliferation stageof heaiing, the current goals of treatrnent also include increasingROM by controllingscar tissueformatiorl incteasingsoft tissue extensibility,and decreasingedema.It is alsoimpoftant to maintain strengtl and flexibility and to ensure adequatecirculationin order to promote tissuehealingand progression to the remodelingstageofheaiing. ASSESSMENTREGARDINGTHE OPTIMAL PHYSICALAGENT INTERVENTION(S} Becausethis patient continsesto have pain and edema after 20 to 30 minutes of walking, it is recommended ttrat he continueto rest and apply ice and compressiorl with his knee elevated,when this occurs.Pulsedultrasoundor PSWDmay be usedto promoteprogressionto the remodelingphaseof healing.The physicalagentsof thermotherapyor hydrotherapy may be used to promote circulatiorl while motorlevel elecfticalstimulation and water exercise may be used to maintain stlength and flexibility. Thermotherapy to increasesoft tissueextensibility,or brief icing to distract ftom discomfort, may also be used p or to stretchiogto optimize increasesin soft tissuelengthand ROM. PROPOSEDTREATMENTPLAN AND RATIONALE The physical agentsthat could promote progresstoward tJ:e goals of treatment at this time, and that ale not contraindicated, include cryotherapy, s€nsory-levelaod motor-levelelectricalstimulation,compression,pulsed
43 . Integrati
432
g Pltysical Ageflts irto Patient Cale
) Clinical Case Studies-cont'd ultrasound, PSWD, thermotherapy, and hydrotherapy. The optimal ffeatment for this patient would be to use flexibiJity- and strength-promoting agents such as heat, hydrotherapy, and motor-level elecftical stimulation at the beginning of the treatrnent sessionsand to use painand inflammation-controlling agents such as cryotherap, compression,sensory-levelstimulation,and PSWD after activity. These physical agentsshould be integrated with other interv€ntions, including stretching or joint mobilization after *remotherapy, to increasesoft tissue length and tlus increaseROM and strengdrening exercises on dry land or in water or motor-level electrical stimulation to maintain or increasestrength. After drese inteNentions, rest and elevation may be combined wi*r ice, compression,and sensory-levelelectricalstimulation in order to contlol any pain or inflammation produced by the activity. These interventions may be performed by the patient at home aswell asin the clinic. This combination of interventions would be applopriate until ail signs of inflammation have fully resolved.When this has been achieved, the inflammation-controlling interventions should be discontinued and the other interventions continued until the patient's ROM and function have retumed to normal. Depending on the availability of resources, much of this patient'streatmentmay be performed independendy,although skilled intervention will be neededto guide the progressionof his treatmentas he:linc
nrnore<
Case 3 GH is a 45-year-oldmale diagnosedwith a low back strain.He reportsdlat his painstarted3 weeksagoaftei lifting a heary box from the floor at work. When lifting the box, he immediately felt a brief, sharp pain in his dght low back, followed by a dull ache in the samear€a thatincreasedin severityand spreadto his rightbuttock and poste or thigh over the following few hours. He stopped working immediately after the injury and was evaluatedand treatedby a physicianon the sameday. The physicianprescribedan NSAID and a musclerelaxant and instructedthe patient to use ice, to stay out of work for 1 week, to rest at home, and to avoid lifting. After 1 week the pain had subsidedslighdy but had not hrlly resolved.The physician recommendedthat GH stayout of work for another3 weeksand referredhim to physical therapy. CH reports having had a similar inci dent 5 years ago that kept him out of work for over a year, after which he retumed to a job with fewer lifting demands and continued to have intermittenq moderate low back pain. He is concemedthat he may not be able to retumto this job, which involvesoccasionallifting of
1
up to 70 lb. At this time GH complainsof constantlow back pain on the right side that is deep and aching, with occasionalsharptwinges.Although the painis constant, it variesin intensity from 6/10 to B/10on a visualanalog scale, worsening with forward bending and after prolonged sitting and occasionallydisturbingthe patient's sleep.CH denieshavingany lower extremitysymPtoms at this time. The objectiveevaluationis significantfor restrictedactivelumbarROM asfollows: o lorward bending: Fingertips to mid*righ, limited by right low backpain . Backward bending: 50% of normal, limited by stiffness o Sidebendingto the dghtr 30% of normal,limited by right low back pain o Side bending to the left: 50% of normal, limited by stiffness . Straightleg laise is 45 degreesbilaterallt iimited by hamstring tightness There is increasedtone of the lower lumbar paraspinal musclesand tendemessof the low back to palpationon the right, with decreasedpassiveintervertebralmotion of all lumbar spinallevels on centralposterior-anterior res!rn8. EVALUATIONOF THE CLINICAL FINDINGS This patient presents with impaiments of pair\ decreasedlumbar spine ROM, lumbar joint stiffhamstringlength,andlumbarparaspinal ness,decreased muscle hypertonicity. He has functional limitations of reduced sitting and lifting tolerance and disabilities of not working at this time. Theseproblemsare combined with preexisting low back pain, reduced lifting capaciry,and limited work performancedue to a pr€vious low back injury. The current imPaiments, the absence of heat and swelling, and the fact that dre initial injury occurred 3 weeks ago all indicate that this injury has progressedftom the acute inflammatory stage.There are now signsof both chronic inflammatioq including resLriction of motion by pain and joint stiffness, and proliferation, including restriction of motion by weaknessand loss of soft tissuelength and extensibiliry.Lumbar ROM may be restrictedby shortening of the paraspinalmusclesor by pain from the facet joints or posterior ligamentousstructures.There may alsobe spinaldiscinvolvement.Straight1e6raising is probably rest cted by shortness of the hamstring muscles-The presentcomplaintsof pain may still be classifiedas acute because3 weeks is within the usual time ftame for pain due to a low back strain to rcsolve; however,this patieot alsohaslong-termlow back pain
Tltree . INTEGL4TING PHYSICAL AGENTS /NTO PR-ESENTAND FUTUR-E PL4CTICE
ftom his prior injury. The hypertonicity of the left lower paraspinals is mostljkelya musclespasmin response to rocarPan. PREFERREDPRACTICEPATTERN Impaired Joint Mobility, Motor Function, Muscle Performance,Range of Motion, and Reflex Integriqy AssociatedWith SpinalDisorders,(4F) PLANOF CARE The goalsof treatrnentat this time include decreasingpain and lumbar joint stiffrress,increasinglumbar motion and strarghtleg raising,and increasingthe patient s sitting and lifting toleranceso that he canr€tum to work. Treafflents that increasecirculation are alsotecommendedsincethey may accelerate progression of healing at this time. Controlling scar tissue formatiorl normalizing musde tone, and maintaining strength and flexibfity should also be promoted since tiese will promote a more complete and rapid resolutionof disabfity. ASSESSMENTREGARDINGTHE OPTIMAL PHYSICALAGENT INTERVENTION(S) Thermotherapy canbe usedto relievepail decreasejoint stiftness, increase soft tissue extensibfiq,', and increase circulation. Neutral warmth may be used to decrease muscleh)?ertonicity, or more aggressiveheating may be usedto conrol painand therebyreducehypertonicityby inteuupting tlre pain-spasm-painrycle. Civen the probable deeplocation of the injury the use of deepheating agentssuch as ultrasoundor diatiermy would be more appropdatethan the useof superficialheating agentssuch as hot packs or paraffin. Although cryotherapy can also relieve pain, this form of treatrnent would not be indicatedbecauseit canincreasel'ointstiffness,decrease soft tissueextensibility, and reducecirculation. Spinaltraction may also be used to increase spinal joint mobiliry and decreases;'mptomsassociatedwith spinaldisc,muscle, or fac€t ioiot involvement, while water-based exercise and motor-level electrical stimulation may be used to enhancemuscle strength. PROPOSEDTREATMENTPLAN AND RATIONALE It is proposedthat a deep heating agent such as ultrasound or diathermy be used to decreasepain and stiffnessand enhancehealing and circulationin the deep tissuesof the lowback. This maybe followed bylumbar traction or manual joint mobilization. These passive interventionsshould be combinedwith an active exercise program involving stretching and strengtJrening exercises,either on land or in water, as well as posture and body mechanicstraining.CH's history of a lengthy and only partialrecoveryfroma prior work-relatedback
433
injury placeshim atincreasedrisk of developingchronic painl therefore, interventions t}lat focus on functional activities, reactivation, and enhancingt}Ie patient's abi.liry to help himself should be used. Becausettre deep heating agents,ultrasound and diathemt cannot be appliedby the patienthimselt the therapistwill haveto choosebetween using these agentsto optimize tissue healingand usingonly thos€ffeatmentsthat the patient canperfom himself, suchas exercise,self-traction,and hot packs,in order to reducethe risk of dependenceon passiveinteryentionby the therapist. FOLLOW-UP After 3 weeks of treatment with diathermy to the low back, mechanicallumbar traction, lumbar flexion and hamstring stretchingexercises,and posture and body mechanicstraining in the clinic, combined witJt insftuction in a home exerciseprogram, CH reports that his pain has decreasedslighdy, now varying in intensiry from 5/10 to 7/10. He reportsro improvement in his sleep, fus sitting tolerance, or his lifting abfity, and he has not retumed to work. Lumbar active ROM has increasedby apprcximately 10% in all planes, but straight leg raising has remained unchanged at 45 degreesbilaterally.Lumbar muscletone is now nonnal. CH's recallofhis home exercises is poor. EVALUATIONOF THE CLINICAL FINDINGS At this time, CH continuesto haveimpairmentsof pairl decreasedlumbar ROM, lumbar joint stiffness, and decreasedhamstringlength. He also continuesto have the functional limitations of reduced sitting and liking toleranceand the disabilityof beingunableto work. Six weeks after the initial injury healinghas probably progressedto ttre proliferationor possiblythe remodeling stage,and painhasbegunto progressto the chronictype rather than resolving.The ongoing pain, beyond tie usual duration for resoluiion of a low back shain, the minimal changein the severity of ttle pain, Iimitations in activities,and sleepdistlrbancesallindicatethat chronic pain is developing.Motion restrictionsareprobablydue pdmarily to soft tissueshorteningand may be resolving poorly due to poor patient compliancewi*r his home tfealmeol ProSram. PLANOF CARE The primary goalsof treatrnentat this time would be to addressthe impairmentsand disabil.iries relatedto the patient'schronic pain. These include promoting functioq including sleep and retum to work, increasing strength, and improviag coping skills. Treatment should also addressthe goalsof regainingsffength,flexibility, and soft tissuelenet!. Continued
434
'| 3 . Integtathg Physical Age, s ittto Patiettt Care
) Clinical CaseStudies-cont'd a ASSESSMENTREGARDINGTHE OPTIMAL PHYSICALAGENT INTERVENTION(S) Due to the importance of active patient involvemert with his treatmentat this time, it is recommendedthat the focusoftreatment be on activeexerciseand that t]re use of passivephysical agents,particularlythose that cannotbe appliedby the patienthimself,be minimized. Thereforethe useof diathermyshouldbe discontinued, and the useof hot packs,cold packs,home or self-traction, or electricalstimulationmay be considered.Waterbased exercise may be used to complement CH's land-basedexerciseprogram, and superficialheat or electricalstimulationmay be appliedby GH to control his pain, promoting increasedparticipationin exercise and functionalactivities.Superficialheatingagentsmay be appliedby the patient becausealthoughsuchagents do not affect deep tissuetemp€rature,they can cause someinoeaseindeep iissuecirculationandcanalleviate pain originatingh deepersbuctures. PROPOSEDTREATMENTPLAN AND RATIONALE It is proposedthat CH usesuperficialheat,cryotheraP, or electricalstimulationto control his pain and that he participatein a well-monitoredactiveexerciseprogram This that may includeland- and water-basedexercises. patient's history of prolonged low back pain and his presendyslow recoveryindicate that he is developing chronic pain. This, in conjunction witi the indications of poor compliancewith his home program,indicates a poor prognosisfor a rapid recovery with physical intervention alone. Psychological evaluation and treatment may be neededto addresspsychosocialissuesthat may be contributing to his symptoms and disabilities and to provide this patient with improved skills for coping with theseproblems.
Case4 CC is a 2r/z-year-oIdpreviouslyhealthy boy with second- and third-degre€burns to 30% of his total body surfacearea.He.sustainedthesebums 2 daysagowhen a pot was knockedoff ttre stove,pourirg hot oil onto his abdomenand legs.He was wearing only diapersat the time. Upon evaluationCC had skin lossover his lower abdomen and the anterior surfacesof both lower extremities.Most of the skin losswas panial thickness, witi some full thickness loss in patches in the central part of the bum. Most of the subcutaneoustissue is intact.Thereis necroticskin presentin the bumedareas. The perinealareawas spareddue to protectionby the diaper. CC complains of pain at rest that worsens with movement or with contactof the bumedareas.Active
ROM and testing of passiveROM and strengthof the lower extrem.itiesarelimited by pain. CC tries to avoid moving to mtimize his pairr and therefore spendsmost of his day lying io bed. EVALUATIONOF THE CLINICAL FINDINGS This patient presents with impairments of loss of inte8umentary integrity, pain, and restricted ROM. The injury is in the acuteinflammatory st€e of healing,the pain is acute, and the ROM restrictions are due to the pain. This patient'spain has also resultedin functional limitations in all activities. PREFERREDPRACTICEPATTERN Impaircd IntegumentaryIntegrity Associatedwith lullThicknessSkinlnvolvementand ScarFormation,(7D) PLAN OF CARE The proposed goals of treatment at t.his time are to remove necrotic tissue,optimize t}le environmentfor tissue healing and control pain. Hydrotherapy can be used to remove necrotic tissue, electricalstimulation and ultrasoundcan be used to eohancetissuehealing and cryotherapy, and thermotherapy and electrical stimulation canbe usedto controlpain. ASSESSMENTREGAFDINGTHE OPTIMAL PHYSICALAGENT INTERVENTION(S) In this patient,it is recommendedthat hydrotherapybe usedto assistwith the removalofnecrotic tissue.Water cansoftenthe necrotictissueand canalsoapply forceto help removeit. In addition,soakingin warm water at a temperaturecloseto body heat can help to conrrol the pain of debridement to some degree. Becausethis patient is young and does not have other health problems, it is not Jikelythat physicalagentswill be needed to enhancetle environmentfor tissuehealing.In addition, the areato be treatedis too largefor the application of electricalstimulation or ultrasound,and the use of therapeuticultrasoundis contraindicatedin this skeletally immature child. PROPOSEDTREATMENTPLAN AND RATIONALE The physical agent most likely to promote progression toward the goalsof treatment at tlis time, and *lat is not contraindicated, is hydrotherapy. Nonimmersion hydrotherapy with a shower,or immersion in a whirlpool followed by a shower, is recommended. Hydrotherapy softens and helps to remove neqouc tissue, although it is likely that tools will also need to be used to ensure that allnecrotictissueis removed.Endingthe treahTlent
Thrce c INTEGRATING PIIYSICAL AGENIS lNrO PRESENTAND FUTURT PRACTTCE
with nonimmersion hydrotherapy reduces the dsk of wound infecrion by washing off contaminated water Although a number of physical agents can effectively control paiq tley are generallyonly effective for moderate pain in a limited area.Becausethis patient'spain is coming from such a large area of tissue damage and is likely to be severemuch of the time, particularlydudng debridement,primarily pharmacologicapproachesto pain managementarerecommended. FOLLOW-UP Threemonths later,CC's bums have closed.The newly formed skin is thin, red, and smooth and his pain is much reduced.CC only complainsof pain from stretching whenmoving toward the end of his availableROM. EVALUATIONOF THE CLINICAL FINDINGS Although the burned areashave closed,healingis not yet complete.Ifproliferation continuesat this time, asit Irequentlydoesafter bums,hypertrophicscarsand contnctures may form. The risk for contractures is increasedby the fact that CC experiencespain with movementsat the end ofhis availableROM and thathe thereforeprobablyavoidsor limits thesemovements. PLAN OF CARE The goalsof treatmentat this time areto preventhypertrophic scarand contractureformation and to maximize functional recovery ASSESSMENTBEGARDINGTHE OPTIMAL PHYSICALAGENT INTERVENTION(S) Compressiongarmentshave beenshown to reducethe formation of hypertrophicscarsafter burns, and these garmentsare generallywell-tolerated.CC should also performROM exercisesto minimize the risk ofcontractufe formation.Theseexercises canbe performedon dry Iandor inwater. Exercisein water hast}Ie advantagesof warming the tissuesduring the exercise.if warm i,varer is used,and of being comfortable.However, with this young child, particular precautions for safety in the water should be obsewed,includingcontinualsupervision by a clinicianin tl.rewater and the use of flotation devices. PROPOSEDTREATMENTPLAN AND RATIONALE It is proposedthat CC be fitted for custom-madecompressiongaments for his iower extremitiesand trunk. Theseshouldbe wom at all times,exceptwhen bathing, for the following B to 12 months. CC will needat least two set6of gaments at any onetime so that he canwear one while the other is beingwashed.It is likely that he willneed to be fitted for atleastthreeorfour doublesets
435
of gaments ashe is at an agewhere he is growing rapidly, and compressiongannentsmust fit closely to be eff€ctive.Water-basedexercise,focusingon ROM, may be consideredif CC doesnot tolerateor cooperatewith land-basedexercises. Water-based exerciseis lik€lyto be more comfortable and fuq and therefore better tolerated,but is likely to be more difficult to provide due to the need for sp€cialfacilities,and specialattention to safety with this young child.
Case5 MP is a 40-year-oldfemale diagnosedwith adhesive capsulitisof the left shoulder.Shereportsthat hershoulder first beganto hurt about 6 months agowitlout any apparent cause.Although the pain has almost completely resolvedsincethat time, her shoulderhas also gradually becomemore stiff, preventing her from reaching up to brush her hair and from reaching behind to zip up her skirts. The objective evaluation is significant for restrictedROM ofthe leftshoulderasfollows: Right Active ROM Flexion Abduction Hand behindback PassiveROM Intenalrotation E>,temalrctation
Left
170' 100' 1,70' 100' Central Left sacroiliac thoracolumbarjoint 90" 80'
50" 10'
Glenohumeralpassiveinferior and posterior gLideare both restrictedon the left. MP has had no prior tr€atment for tlis prcblem. EVALUATION OF THE CLINICALFINDINGS This patient presentswith impairments of restrictedactive and passive motion of her left shoulder. These have resulted in a reduced abiliry to perform activities of daily Iiving, induding grooming and dressing. This patient's signs and syrnptoms, and the duration of her problem, indicate that the condition has probably proglessedto t}rercmodelingstageoI healing,with somepossibllity of chronic inflammation. She does not repoft significant pain at *ris time, and it appean that her left shouldermotion is restrictedby shorteningof the antedor inferior glenohumeraljoint capsule.No tone abnormaliuesarenoteo. PREFERREDPRACTICEPATTERN Impaired Joint Mobiliry, Motor lunctioq Muscle Performance, and Range of Motion Associated Witlr ConnectiveTissueDysfunctioq (4D)
436
13 . Ihtegdting
Physical Agents irtto Patiett Care
) Clinical Case Studies-cont'd PLAN OF CARE The goals of treatment at this time arc to restore normal active and passivemotion of the left shoulder and to allow MP to perform all activities of daily living in her prior mannerusingboth upper extremities.Becauseher shoulder ROM is probably restricted by soft tissue shonening,trhetreatmentshould be directedat increasing the extensibility and length of the shortened tissue, the anterior inferior capsuleof the glenohumeraljoint. Appropriate goals for this late stageof healing would alsobe to control scartissueformation and ensureadequate circulation. Although no strength abnormalities were noted on *ris initial evaluation, the patient's strength should be reevaluatedas she regains ROM since she may have strength deficits at tJ-teend ranges dueto disuse.Shouldstrengthdeficitsbecomeapparcnt, an additionalgoalof treatrnentwould be to restorenormal strengthto the left shouldermuscles. ASSESSMENTREGARDINGTHE OPTIMAL PHYSICALAGENT INTERVENTION(S) Thermotierapy wordd be the most appropriatephysical agent to use to increasesoft tissue extensibility and promote circulation.Becausettre tissuerestrictinethe ROM is which is deep,a deepheatingagentsucb the joint capsule, as ultrasoundor diathermy, rather than a superficialheating agentsuchasa hot pack, should be used.A deepheating agent applied to the anterior inferior aspect of the shoulder will increasecapsularextensibfity by elevating tie tissuetemperatureand,sincetissueextensibility will be increasedonly while the tissueis warm, the capsuleshould be stretchedduring or immediately after the applicationof this agent. Motorlevel electrical stimulation and wate!basedexercisemay also be used as componentsof an actives&etchingor stlengtheningprogram for this patient. PROPOSEDTREATMENTPLAN AND RATIONALE The most appropriatephysical agent for heating the anterior inferior capsule is thermal-level ultrasound. A.lthoughdiathermy could be usedfor this application, it would be less appropriatebecausemost lorms of diathermy carfrot be direct€dto such a small areaand becausediathermy devicesare not readily availablein most clinicsat this time. Ultrasoundshouldbe applied to the anteriorinferior aspectofthe glenohumeraljoint, with the shoulderina positionthat placestensionontie anterior inf€dor joint capsule,which would be at the limit of range for combined flexion, abductioq and extemalrotation.Manual joint mobilization and active and passivestretching should be applied during and immediatelyafter the applicationofultrasoundin order
I
to optimize gains in ROM, and the patient should be instructedin a home programof sffetching€xercisesin order to maintain and progressin gaining ROM. This programof deepheat and stretchingtechniquesshould be continued until the patient regains her full range of active, passive,and accessorymotions. Strengthening exercisesshould be addedif weaknessis noted at the end ofthe rangeasROM is regained.
Case 6 LM is an B4-year-oldmale with a stageIV ptessureulcer over his right greater trochanter LM has suffered 3 strokesover the last 10 years.At this time he is bedbound,hasflexionconuacturesof both upperandlower extremities,is cachecticand is beingfed via a nasogastric tube. The pressureulcer was first noticed 2 weeks ago, when itwas a stageII, and its areawas 4 cm by 3 cm. At this time LM's tuming schedulewas increasedfrom every4 hoursto every2 hours,and his bedwas changed from a regularmattressto an air mattress.however,in the last 2 weeks tl-rewound has worsened.It is now a stageIV, and its area has increasedto 6 cm by 5 cm. Approximately50% of the wound bedis blackand50% is yellow. Thereis no underminingpresent. EVALUATIONOF THE CLINICAL FINDINGS This patient presentswith impaiments of lossof tissue integrity,decreased activeand passiverangeof motion, and decreased strength.The tissueis not demonstrating healingat this time. Tissuehealingmust be initiated at the inflammatory stage. PREFEHREDPRACTICEPATTERN Impaired Integumentary Integrity Associatedwith Skin InvolvementExtendinginto lascia,Muscle,orBone and ScarFormation,(ZE) PLAN OF CARE The proposed goals of treatment at this time are to remove necrotic tissueand optimize the environment for tissuehealing.It is also hoped that wound closure canbe achieved;howeve! with *ris patient'spoor generalstateof healt!, wound closuremay not be possible. If it is not possible,the goalsof treatmentwould be to minimize wound progressionand reduce the risk of wound and systemicinfection. ASSESSMENTREGARDINGTHE OPTIMAL PHYSICALAGENT INTERVENTION(S} Hydrotherapy or sharp tools can be used to debride necrotictissueftom the wound. Debddementwill €nhance
ThTee . INTEGRATING PIIYSICAL AGENTS INTO PR-ESENT AND FUTURE PK4CTICE
wound healing and reducethe risk of infection. Dead tissuecannothealand canact asa mechanicalbarrierto tissue growth and as a nidus for infection. Electrical stimulationor ulftasoundmay also be usedto facilitate healing. PROPOSEDTREATMENTPLAN AND RATIONALE The physical agents that could promote progression toward the goalsof treaffnent at this dme, and tllat are not contraindicated,indude hydrotherapy, electricalstimulation, and ultrasound.Nonimmersion hydrotherapy, such as pulsed lavage, is safest and most effective to use for wound debridement becausethis allows control of the water pressureand avoidssoakingthe wound in contaminated water. Although both electrical stimulation arld ultrasound have both been shown to enhancepressure ulcer healing, since the evidencefor the effectivenessof electricalstimulation for tlis application is stronger,electrical stimulation is recommendedfor treatrnent of this patient. It is recommended that sensory-levelhigh-volt pulsed current electrical stimulation be used since most studies have shown t}lis to promote wound healing. In addition to interventions usingphysicalagents,a ftequent tuming schedule avoiding the right side, posirioning to minimize pressureon the dght lateral hip, and transfer tecfuriquesthat minimize shear and ftiction are recommended, A wound dressingthat keeps the wound bed moist, keeps the sunounding skin dry, and does not reguireft€quentchangesshouldbe used.A supportsurface that optirnizespressuredistribution and moisture controlshouldalsobe used. FOLLOW-UP Two months later the wound on LM's right lateral hip, in the areaof the greaterftochanter,is stil1open.However,
437
there is no longer any necrotic tissue present, and the wound base is now red. The area of the wound has also decreasedftom 7 cm by 5 cm to 3 cm by z cm. EVALUATION OF THE CLINICALFINDINGS The absenceof necrotic tissue and the red wound base,which is most likely granulationtissue,indicates that this wound has progressedfrom the inflammatory stage of healing to the proliferative stage of heaLing. PLAN OF CARE The primary goals of treatment at this time ale to continue to optimize the environment for wound healing and to protectthe wound. Removalof necrotictissueis notneededsincenon€is present. ASSESSMENTREGARDINGTHE OPTIMAL PHYSICALAGENT INTERVENTION(S} Debridement with hydrotherapy should be discontinued at this time as there is no longet necrotictissue in the wound and the granulation tissue tlat is present may easily be damaged by the hydrotherapy. Elecuical stimulation may be continued to enhance tissuehealing. PFOPOSEDTREATMENTPLAN AND RATIONALE It is proposed that hydrotlerapy be discontinued. Although electricalstimulation may be continued to promotetissuehealing,a trial without this intervention is recommendedso that disturbanceof the lragilegranulation tissue is minimized. Tissue healine should be carefullyrnonitoredand electricalstimulati,cnresumed ifhealing plateausor regresses.
PrefenedPhysicaiTherapistPracticePattemssMl4D,4l,5D,7Dand 7El are copyright 2002American PhysicalTherapy Associarion.All
Chapter Review It is recommended thatphysicalagentsbeselected for patienttreatmentwhen they canbe expectedto promote progressiontoward the goalsof treatment,can be appliedsafely,and when the support for their use hashigh scientificmedt. \ 41enappropriatelyselected andapplied,physicalagentscanaccelerate tissuehealing, control pain, reduce motion restrictions,and modify muscletone.However,for their applicationto be safe,physical agentsmust not be applied when contraindicated,and al1 recommendedprecautions must be adheredto. A.lthoughthere are specificcontraindicationsand precautionsto the applicationof
different physicalagents,pregnancy,malignancy,the presenceof a pacemaker,impaired sensation,and impaired mentation generallyindicate the need for caution when consideringthe use of any physical agent.A ffeatmentcanbe consideredto havehigh scientific merit if its useis supportedby valid theories,if it is designedfor specifictypesotpatients,if its potentially adverseeffectsarepresented,andifits efficacyis supportedbyweil-designedstudiespublishedin peerreviewed joumals. If the application of a physical agentis expectedto promoteachievementof the goals of treatment,to be safe,and to have high scientific merit, the cost, convenience,and availability of that
434
't 3 . I\tegrdting
Physicdl Agents into Patient Cfure
9. Wilson DH: Treatmentof soft tissueinluriesby pulsed electricalenergy,Br MedJ 2:269-270, 1972. 10. PenningtonGM, Danley DL, SumkoMH: Pulsed,nonthermal, high frequency elecromagnetic field (Diapulse) in the treatmentof GradeI and CradeII anlle sprains, Milit Med 153:10I-104,1993. 11. Kaplan EG, Weinstock RE: Clinical evaluation of Diapulseasadjunctivetherapyfollowing foot surgery/ An PodiattAssoc58(5):218-221 , 1968. 12. Cote DJ,PrenticeWE, Hooker DN et al: Comparisonof threetreatmentproceduresfor minimizing anklesprain 6' 1988. swelLng,PhysTher68(7)11072-107 13. Wilkerson GB: Treatment of inversion ankle sprain through synchronousapplicationof focal compression and cold,AthleticTraixing26:220-225 , 1991'. 14. Quillen WS, Roullier LH: Initial managementof acute compression anldesprainswith rapidpulsedpneumatic and cold,J OnhovSvortsPhysTher4:39-43, 1982. 15. Pilla AA, Martin DE, SchuettAM et al: Effect of PRI therapy on edemafrom gradesI and II ankle sprains:a placebo controlled randomized, multi-site, doubleblind clinicalstudy,/ AthleticTratuing3I:g'3,1996. 16. LehmannJ, MasockA, Warren C et al: Effect of therapeutic temperatureson t€ndon extensibilitT,ArchPhys Med Rehabil5I:481-487, l'970. 17. LehmannJF,Delateur BJrApplicationo[Heat and Cold in the Clinical Setting.In LehmannJl @d):Thetapeutic Heat aud Cold, ed 4, Baltimore, 1990, Williams & Wilkins. 18. Lehmann J! DeL atevr BJ Therlleutic Heat and Cold,ed 4, Baltimore,1990,Williams & Wilkins. 19. Lehmarur JF, Delateur BJ, Stonebridge JB et al: References in local L et al:Changes Therapeutic temperature distribution produced by 1. WestonM, TaberC, Casgranda to trauultrasoundasmodified by dosageand volume of tissue bloodvolumeduringcoldgel packapplication . 19(4):197'199, ArchPhysMed Rehabil48:662-666,1967 nhoV Phys Ther exposed, Spon matizedankles,/O 20. LehmannJF,Delateur BJ,Waren G et al: Boneand soft 1994. tissueheating producedby ultrasound,ArchPhysMed upperextremitycoolingfrom a 2. Wolf SL:Contralateral 1971. Rehabil48:397-401,1'967. PhysTher51:758'165, specificcoldstimulus, iradiation 21. Kamm RD: Bioengineeringstudiesof periodic external of ultrasonic 3. BickfordRlI, Duff RS:Influence compression as prophylaxis against deep venous andbloodflow in humanskeletalmuson temperature 1953. thrombosis: Part I: Numerical studres,J BionechEng cle,CircRes7:534-538, L04:87-95, 1982. 4. Iox HH, Hilton SM: Bradykininformationin human skinasa factorin heatvasodilation, J Physiol142:219' 22. Olson DA, I(amm RD, Shapiro AH: Bioengineering studiesofperiodic extemalcompressionasprophylaxis 1958. Rheumatology againstdeep venous thrombosis:PartII: Experimental 5. SchmidtKl: Heat,coldandinflammation, studies on a simulated\eg,J BionechEng 104:96-104, 38:39L-404,1979. 1,982. 6. McCullochJ: Physicalmodalitiesin wound managevasopneumatic devicesand hydro- 23. RischWD, KoubenecHJ,BeckmannU et a1:The effect ment: ultrasound, 35-37, 1995. of gradedimmersionon heartvolume,centralvenous therapy,Ostomy VoundMaxage41(5):30-32, pain?A reviewof dreclinical preisure,pulmonary blood distribution and heart rate 7. ErnstE.IialkaV lcefteezes Arch374:117,197B. ln man,Pfluegers of analgesiccoLdtherapy,J PainSynyton effectiveness 1994. 24. Haffor AA, Mohler JG,HarrisonAAC: Effectsof water 9(1):56-59, Manage formsof immersionon cardiacoutput of lean and fat male sub. TB,CoppEP:Theeffectsof therapeutic 8. Benson Ariat SyaceErviox Med heatandiceon the painthresholdof the normalshouliectsat restand du ng exercise, 7974. 62:125, 1991. Rehabil 13101-104, der.Rheuuanl
asentshouldalsobe consideredin treatmentselection. Although the applicationof a physicalagentmay be the only intervention used with a patient, generally physical agentsare used in conlunction with each other or in conjuncdonwith other intewentions,such as activeexercise,passivemobilization,or functional activities,in orderto optimize patientoutcome. The selectionand application of physical agents may vary under differenthealthcaredeliverysystems due to differencesin practical and financial constraints. Although under all systems the clinician should seek to provide the best possible care for patients, cuffent health care delivery systems frequendy requirethat suchcarealsobe providedin the most cost-effectivemarner. Costsmay be controlled by havingpatientsorpractitionerswith lowerskill levelsapply Eeatmentsunderthe directionof a therapist, when this can be done correcdyand safelyand when effectivenesscan be maximized by evaluating the effectsof specificinterventionson Patientfunctional outcome and selectingthose that are shown to produce the greatestbenefiq however, the potential for conflict beween minimizing cost and maximizing benefit can make ffeatment seiectiona complexand difficult process.The readeris referredto the Evolve for website at http://evolve.elsevier.com/Cameron study questiors pertinent to this chaptet
Three t INTEGRATING PIIYSICAL AGTATS I tfo pRE SENT AND FUTIIRE 9RAC.1ICE
25. Balldin UI, Lundgren CEG, Lundvali J et al: Chaneesin the elimination oF 133 Xenon from rhe anterior-ribial mu-sclein man induced by immersion in water and by shifts in body position, Aerospace Med 42(5):499 , 1971. 26. Ward RS: Pressuretherapy for tl:e control of hypertrophic scar formation after burn injury: a hisrory and review,J BurnCateRehabil12:257-262,j.991. 27. LarsonDL, Abston S, EvansEB et al: Techniquesfor decreasingscar formation and contracturesin the bumed parient,J Trauna 11:807-823, 1971. 28. Kircher CW, Shedar M\ Shetlar CL: Alteration of hypertophic scarsinduced by mechanicalpressure, Arrh DernatoI 1| | :60-64,1975. 29, WadeJ:Sportssplash,Rehabil Matage 10(4)164-70,1997 . 30. WarrenC, LehmannJ,KoblanskiJ:Elongationof rat tail cendon:effect of load and temperarure,Archphys Med Rehabll52:465,47 4. 484.I97 1. 31. Warren C, Lehmann j, KoblanskiJ: Heat and stretch procedures: an evaluationusingrat uil tendon,4r./r Phy:M edRehabil 57:122-| 26.1976. 32. GerstenIW: Effect of ulftasoundon tendon extensibiliry,An J PhysMed 34:362-369 , ISES. 33. Lehmann J! Brunner GD, Stow RW pain threshold measurementsafter therapeuticapplication of ultrasound, microwaves and,inftared, ArchphysMed Rehabil 39560-565,1958. 34. JudovichB:Lumbar tractionrherapy,JAA4A159:849,1955. 35. CheadeMD, EsterhaiJL:Pelvictractionastrearmentfor acutebackpaln, SVixe 16:1379 -1381,,1991,. 36. BonicaJJ:TheMaxagemettof Pain, ed 2, philadelphia, i990.Lea& Iebiger. 37. Hood LB, Chrisman D: Intemittent pelvic traction in the ueatment of the ruptured ilterverteb nl disc,phvs Thet48:21-30,1968. 38. Mathews JA, Mills SB,JenkinsVM et al: Backpain and sciatica:conftolledtrialsof manipulation,tractioq sclerosant, and epidural injections, Br J Rheunatol26: 416-423,1987 . 39. Lidstrom A, ZachrissonM: Physicaltherapy on low backpain and sciatica:an att€mptar evaluation,ScandJ RehabilMed 2 :37-42. 1970. 40. Sicard-Rosenbaum i, Lord D, Danoff JV et al: Effectsof continuous tlerapeutic ultrasound on growttr and metastasisof subcutaneousr,]r]uineturIlors,phvs Thet 75(l):3-ll, 1995. 41. Burr B: Heatasa theu?euticmodalityagaixstcancet\epott 16.Bethesda,MD, 1974,U.S.NationalCancerInstiiute. 42. BakerLL, McNeal D\ Benton LA et al: Neuromuscular Electical Stfutulation:A PracticalGuide, ed.B, Downey, CA. 1993.RanchoLosAmigosMedicalCenrer.
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43. Carmick Jr Clinical use of neuromuscularelectrical stimulation for children wirh cerebral palsy, phys Ther 73t505-513 , 1993. 44. CarmickJ: Use of neuromuscularelectricalstimulation and a dorsalwrist splint to improve hand function of a child with spastichemiparesrs, PhysThet77(e:66I-671, 1997. 45. Cyriax J: Textbooleof Orrhoyedk Medicfue, Volume I: Diagxoskof Sof TissueLesions, London, 1982,Bailliere Tindall. 46. LentellG, HetheringtonT, EaganJ etal: The useof thermal agentsto influence the effectivenessof low load prolonged stretch, J Ofthop Spon Phys Ther !6(3): 200-207,1992. 47. TravellJC, Simor,sDG:MyafascialPaix andDysfuxctioa: The Triger PointMaxual, Bahtrnore, 1983, Williams & Wilkins. 48. SimonsDG, TravellJG:Myofascialoriginsof low back pain. 1: Principles of diagnosis and treatment, postgtad Med 73(2):70-77 , 1983. 49. Harns SR:How should treatmentsbe critiquedfor scientlt\cmeit? PhysTher76(2):175-I8!, !996. 50. VerrierM, FalconerK,Crawford SJ:Acomparisonof tissue temperaturc following two shoftwave diatherrny tecb,tiques, Physiother Caxada29(7):21-28 , 1977. 51. Hand fW: Biophysicsand technology of electromagnetic hyperthemia. lq Guthrie M, ed: Method.sof ExterxalHyVethermicHeattu& Berlin, 1990, SpringerVerlag. 52. Comadi E, PagesIH: Effectsof continuousand pulsed microwave irradiation on distribution of heat in the glutealregionof minipigs,ScaxdJ RehabllMed2I:59-62, 1989. 53. Golden GS: Nonstandardtherapiesin developmental disabiliti.es,An J Dis Child 134:487-491, fgg} . 54. WeinbergerA, NyaskaA, Giler S:Treatmentof eryerimental inflammatory slmovitis with continuousmag-1201, 1996. netic fieId, IsrJ Med Sci32(1,2):7197 55. AbramsonDl: Physiologicalbasisfor the useofphysical agentsin p€dpheralvasculardisorders,ArchPhysMed Rehabil46:216-244 , 1965. 56. Stillwell GK: Physiatricmanagementof postmastectomy lymphedema, Med Clin Nonh An 46105I-1068, 1962. 57. Rucinski TJ, Hooker D, PrenticeW: The effects of intermittent compressionon edema in post acute ankle spralrc,JOSPTL4Q):65-69,\991. 58. SimsD: Effectsof posirioningon anlle edema,/OSpT 8:30-35, 1986. 59. PT Bdletin, 12/20/1997, p 11.
Directionsfor Futur esearch and AVVlication SUMMARY
OF 1I/F ORMATION
Why Further Research on the Use of Physical Agents in Rehabilitation Is Needed Areasfor FutureResearchon PhysicalAgents
COVERED
Methodological Characteristicsof FutureResearch on PhysicalAgents Chapter Review
oBlECrrvES Uponcomyletionofthis chaVter,thereaderwill beable to: l . Explain why there is a need for furtller research on the^useof physicalagentsin rehabilitation. Identi$r the areasin which further researchon the effectsof physicalagentsis needed.
3. Summarizethe methodolosical characteristics requaed for researchon phjzsicalagentsto guide progressin clinical practiie.
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442
44 . Dilectiofls for Future Researchatd Apylication
RESEARCH WHYFURIHER ONTHEUSEOFPHYSICALAGENTS INREHABILITATION ISNEEDED Although, as demonstratedthroughout this book, thereis research to supporttheuseofphysicalagentsin rehabilitatioryfurther researchis neededin most areas because,as with most medicaltreatments,the available scientific evidence is genenlly insufficient to proveconclusivelythat cunentclinicalpracticeis effective or thatitis deliveredin the optimalmanfier Due to theselimitations,the currentpracticeof appiyingphysicalagentsis basedon the availableresearchfindingsin conjunctionwith prior practicepatternsand the personalexperienceof the provider.This has resultedin variability in practice among practitioners with different trainingandpersonalexperienceandftom different locations,andhasprobablyalsoresultedinlack ofoptimalcareandsuboptimaloutcomesfor somepatients. For example, al*rough shortwave diathermy is commonly used in Europe, with reportedly good results,it is rarely usedin the United States.Because this physical agent is unlikely to produce different effectsin these different regions,it is probable that either some patientsin Europeare receivingtrearments that are not effectiveor that some patientsin the United Statesare not receivins treatrnentsthat could benefit chem.Iurther reseirch will help Lo ascertainwhich interventionsare effectiveandwhich are not, which methodsand treatmentparametersto use for optimal results, the benefits that can be expected from these interventions, and who will receive the greatest benefit from them. This will enhanceclinical practiceby improving patient outcomes,increasingthe consistencyand efficienry of care, and supporting reimbursementfor treatments usingphysicalagents. It is recommendedthat future researchon ohvsical agentsfocuson applications where empiricaiclinical evidence,pdor studies,andanecdotalreportssuggest, but do not definitively prove, that certain interventions are effective.Iuture researchshould attempt to determine if current practiceis effective,and if so, how it canbe optimized,and ifnot, which alternative interventionswould be effective.As further research is performed,it is expectedthat the findingswill support many cuffent applicationsof physical agents; however, it is also likely that future researchwill directmodificationsin the applicationof somephysicalagentsandfail to supportthe continueduseof oth-
ers.Studiesmay fail to support presentpracticeif an intervention is found to be ineffective or to be less effectivethan other availabletreatmentoptions.It is also expectedthat future researchwill promote the developmentof new applicationsof physicalagents. Onceappropriateareasfor researchare selected,it is alsoessentialthat future studiesbe designedto permit readyinterpretationand applicationof their findings.In many areas,moreresearch is neededbecause flaws in the availablestudies,such as inappropriate design,the use of inappropriatetypes or numbersof subjects,lack of or poor controls,the useof measures that havenot beenshown to be valid or reliable,limited assessment of outcome,or poor reportingof the preciseintervention used, restrict the applicationof their findings.Ior example,if the effectsof an intervention have been monitored without comparison with a control group who did not receivethat interventiory it cannot be determined whether the observedeffects were causedby the interventiontherebysupportingits use,or whetler they were due to chanceor normal progressionof the problembeing treated, thus not supporting its use. Appropdately designedstudieson the useof physicalagentsin rehabilitation will demonstratewhether or not specific interventionswith physicalagentscan promote progressiontoward the goals of treatment for specific problemsand how suchbenefitscanbe optimized. High-qualityresearchin the appropriateareaswill improvethe qualityofpatientcareandprovidesupport for reimbursement for treatments using physicai agentsbasedon provenpositivefunctionaloutcomesIn the absence ofsuch studiesitis possiblethat patiens will not receiveoptimal care,and it is likely that, over time, payeff will not continueto reimbursefor irrterventionsthat havenot beenprovento be effective.
AREAS FORFUTURE RESEARCH ONPHYSICAL AGENTS Physical properties and effects ofphysical agents Physiological effects of physical agents Clinical applications of physical agents Contraiodications, precautions, and adverse effects of physical agents
ThTee C INTEGRAIING PIIYSICAL AGENTS INTO PRESENT AND FUTURE PRACTICE
There are many areas where further researchon physical agents could promote improvements in patient care. These include the physical properties and effects of physical agents, *reir physiological effects,their clinical applications,the contraindications and precautionsto tleir use,and their potential adverseeffects. Although for most physical agents there is some researchin all of these ateas,more researchis neededin order to optimize clinicalapplicationsin rehabilitation. In general, the physical properties and effects of physical agents are well understood, but their interactionswith, and their effectson, physiological processesare less clear.In most areas,even less is known aboutthe specificeffectsof physicalagentson patient function. While further understandingof the physicalpropertiesand effectsofphysical agentsmay provevaluablein the developmentof treatmentapplications,studies regardingthe changesproduced in physiologicalprocessesand the resultantclinicaloutcomes are likely to provide the most guidancefor advancing andimprovingclinicalpractice.
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factors impacting the distribution of the heat producedby thesedifferentforms of diathermyand thus increasethe safety and effectivenessof their clinical application. Another areawhere researchon the physicalpropertiesand effectsof physicalagentshasbeenvaluable is in the developmentof new physicalagents.Most devicesdevelopedin recentyearsdeliverthe sameor similartypesof energyasthat deliveredbypreviously available physical agents. However, these newer devicestake advantageof technologicaland theoretical advancesto provide greaterrangesand control of the energyintensify or frequencyaswell asimproved safety and convenience.Researchusing thesenewer devicesis neededto gain a better understandingof their physical properties, potential applications in rehabilitation, and possible advantagesover older devices.In addition, further basic scienceand engineedng studiesmay yield other physicalagentsand further deviceimprovements. The low-energycold laseris an exampleof a physical agentthat was developedin recentyearsand that is now being applied clinically in rehabilitation in somesettings.Alaserproducesa beamof electromagPhysical Properties andEffects of Physical netic energythat has the unique physicalproperties Agents of being monochromatic,coherent,and directional. Although the physical properties of most physical At this time, low-energy laserdevicesproduceelecagentsare generallywell understoodand have been tromagnetic radiation with frequenciesand waveclearlydescribed,further researchis neededto clarify lengthsthat penetratethrough only a few millimeters the nature and magnitudeof their physicaleffectson of human tissue.4,5 Further researchon the ohvsical the body.Forexample,althoughit is known that therpropertieso[ low-energylasersmay promo; the mal energyis producedby friction betweenparticles, development of devices that can penetrate more qeepry. that *re amountof thermalenergyincreases in proportion to the relative rate of motion of these partiLongwave ultrasound is anotier physical agent cles,and that the amount of thermal energyrequired thatwas recentlydevelopedforapplicationin rehabilto producea given changein temperaturein a mateitation. This type of ultrasoundhasa much lower frerial varies with the specific heat of that material, quency and a longer wavelength than traditionally without further researchthe temperature increase usedultrasound,resultingin deeperpenetration.This and the distribution of heat in a patient'sbody when type of ultrasoundwas designedto be usedfor treatdifferenttherrnalagentsare appliedcannotbe readily ment of deep tissues;however, at this time, there is or accuratelypredicted.Takingthe specificexamples controversyin the literature concerningthe distribuof short wave diathermy and microwave diathermy, tion of the energywhen such low frequencies are both of which produce thermal energy and have used.o' AJchoughinitial repons indicatedthat the physicalpropertieswhich are well understood,curdeeperpenetrationof ultrasoundwith this frequency rent research has produced conflicting findings couldbe beneficialfor someclinicalapplications,later regardingthe distribution of the heat produced by reportsnote that.sincebeamdivergence increases at thesedifferentwavelengthsof electromagneticradiathis lower frequency,the intensity of the ultrasound tion in different rypes of tissueand by the different reachingdeepertissuesis very much reduced,possiappJicacors usedto delivertheserypesof electromag- bly to levelsthat are too low to producethe desired netic radiation.r-rFunherresearchcould clari,fiy d:re physiologicaleffects.Furtherresearchon the physical
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properties of this frequency range of ultrasound is neededto ascertainhow the energyis distdbutedand what clinicaleffectsit has.Iurther technicaldevelopments may also allow focusing of the beam while maintainingthe deeperpenetration. Another newer device.comoosedof a thermostatically controlledheating piate placedinside a wound dressing,has recentlybeendevelopedspecificallyfor the superficialdelivery of heat by conductionto the site of an open wound. This devicekeepsthe wound environmentwit-l-rina limited temperaturerangeat all times and is thus thought to promote wound healing. Iurther researchon the physical properties of this device,suchasits rangeof operatingtemperatureand its effecton local moisture,is neededto direct its clinical application. It is likely that in the future other physicalagents and devicesthat offer further control of energydelivery to patients will be developed. Ior example, devicesthat deliverheat for set amountsof time or at controlied but varying temperatures,devices that deliver electromagneticenergy with different pulse durationsand duty cyclesor with different ty?es of applicators,devicesthat apply stationary magnetic fields,or devicesthat apply compressionwith different pressuresor pressuregradientsor with alternative application devices, may be developed. As new devicesbecomeavailable,researchwill be neededto determinetheir physicalpropertiesand effectsand to ascertain whether they promote physiological changesthat produceclinicalbenefits.
Effects of Physical Agents Physiological
tions such as the use of ultrasoundor electricalcurrentsto facilitateftansdermaldrug deliveryand accelerate tissue healing or the use of thermotherapy, cryotherapy, or electrotherapy to control pain. Studiesconcemingthe effectsof physical agentson bacterialinfectionmay be particularlyvaluableat this time since many bacteriaare becoming resistantto availableantibiotics,necessitatingthe development of alternativetreatmentapproaches.Progressin these areaswill require examination of the physiological processesinvolved in both normal and abnormal function and the changesproducedin theseprocesses by the applicationof physicalagents. In orderto provide clinicianswith infomation that allows them to apply physicalagentswith more predictable results,future studiesshould seekto determine both the natureand the magnitudeof the effects of physical agents on physiological processesand attempt to determinehow theseeffectsvary with tissue t)?e and pathology.While prior researchgenerally evaluated the effects of physical agents at a macroscopiclevel, such as the effectsof heat on soft tissue extensibility or on arterial circulation, since current technologyalso permits examinationat the microscopiclevels of the cell, cellular components, and molecules,future researchshould also evaluate the physiologicaleffects of physical agentsat these levels.This will lead to an improved understanding of the mechanisms underlying the macroscopic effects of physical agents,thereby providing guidelinesforpredictingand controllingthe effectsofphysical agentson physiologicalprocesseswith greater precision.
Asenrs crinicar Apprication orphysicar {*-:gl T9:::1"1*:l.*: fT::1:: or physlcal agentsmay lacllltatery:l:il progress ln cltrucal practice,in order to optimize care, researchon tlre physiological effects and clinical uses of physical agents whose physical properties are already well understoodis also needed.Studiesshould examine the effectsof physicalagentson the physicaiproperties of tissue,such as muscleor tendon extensibility and cell membrane permeability, their effects on physiological processessuch as tissue healing and nerve conduction, and their effects on pathological statessuch as bacterialinfection. Iurther researchin these areas may delineate the magnitude of the effects produced by physical agents and the ideal treatmentparametento use to achievetheseeffects. Suchresearchwill also guide specificclinicalapplica-
Although researchon the physical properties and physiologicaleffectsof physicalagentswiil indicate which interventionsmay be effectiveand may clarily the mechanismsofinterventionsthatare known to be effective, clinical studies are needed to ascertainif interventionswith physicalagentsactually promote progress toward treatment goals. Clinical studies shouldalsoexaminethe effectsof differenttreatment parametersJsuch as method of application, treatment duration,intensity,and frequency.Ior example, when studyingthe effectsof electricalstimulationon musclestrengthening,a rangeof parametersmust be evaluated,including current waveform and parameters, electrodeplacement,and treatmentduration.In
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addition, the effects of applying physical agentsto patients of various ageswith different pathologies and with symptoms of varied acuiqyshould also be evaluated.Thesetypes of studiesare neededto optimize the applicationof physicalagentsandmaximize the accuracyof predictionsconcemingthe natureand extentof the benefitsof suchinterventions. It is recommendedthat clinical studies examine applicationsofphysical agentsthat arein frequentuse at this time but in which the dataregardingtreatment efficacyandoptimaltreatmentparameters areinconclusive.Novel applicationsof commonly usedphysi cal agents and possible applications of recently developedphysicalagentsshould also be evaluated. For example. clinical studies on the effects of phonophoiesis and traction should be performed because,althoughtheseinterventionsare commonly used to treat local inflammatory conditions and symptomsrelatedto spinaldisc buigesor hemiation, respectively,the benefitofthese interventionshasnot yet been conclusivelyproven, and the optimal treatment parametersand patient presentationsfor their applicationhavenotyet beendetemined. Takingthe example of phonophoresis, studies should first attempt to ascertainwhether, when using the common curent application techniques,phonophoresis reducesthe impairments and functional limitations associatedwith inflammation. If phonophoresisis found to be effective,one ,houid then evaluate whether changingany of the treatment parametersl such as the ultrasoundduty cycle,intensity and frequency,drug type and vehicle,or treatmentduration and frequency,altersthe effects.Studiesshould also evaluateif the treatmentis more effectivedurine cerrain stagesof inflammation or for cenain typei und depthsoftissue.In the caseof traction,studiesshould determinewhether the common currentaDDlications are etfective.and if so, whetherchangingir"ut-enr parameterssuchas the hold and relax times, traction force,or treafnent duration alter the effects,or if the treatment is more effectivewhen used for patients with sl,rnptoms of different etiology, duration, nature,or distribution. Studieson the effects of specificphysical agents wili provide information to guide cliniciansin selecting physical agent interventions and treatment parametersfor different patients and in predicting more accuratelyand reliably the outcome of such interventions.However, in order to direct the selection of the ideal treatlent, studies comparing the
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effectivenessof different tueatmentoptions are also needed.Ior example,although current studiesindicate that ultrasound and electricalstimulation may facilitatethe closureof openwounds,and that electrical stimulation,cryotherapy,and thermotherapycan reducepain,until studiescomparingthe effectiveness of these interyentionsare performed,it will not be clearwhich treatmentsare most effectiveand should thereforebe chosenfor clinicalapplicationin patient care.
Precautions, andAdverse Contraindications, Effects Agents of Physical Although more researchon the benefitsof applying physical agentsin rehabilitation will help to guide treatment selection, studies on the specific contraindications,precautions,and adverse effects of physicalagentsare alsoneededto determinewhether currentprecautionsareappropriateand to ensurethat teatments with physicalagentsare appliedsafely.At this time, restrictionson the useofphysicalagentsare frequendybasedon expectationsof possibleadverse effects and prior common practice rad:Ierthan on evidenceof the propertiesand effects research-based of physical agents.This may fail to prevent some restrictthe unsafeapplicationsandmay unnecessarily use of safeand effectiveinterventions.For example, in the absenceof researchto rule out detrimental effects,and due to concerntllat the integrity of bone may be disruptedin someway by ultrasound,some authorsrecommendthat ultrasoundbe appliedwith particuiar caution to patients with osteoporosis,d Although this may reducethe risk of harm to patients with osteoporosis,it may also prevent them from receivingtreatmentthatmay be beneficial. Although researchon the contraindicationsjprecautions,andadverseeffectsof physicalagentsis necessary,it is difficult to perform studiesin theseareas that provide definitivedataapplicableto clinicalpractice. This is becauseit is not ethical to placehuman subjects at avoidable risk by applying treatments thousht to be unsafein order to determineif treatmeniwarnings are justified.Therefore,in vitro studies,studiesusinganimal subjects,and casereportson adverseeffectsareneededto clarify the potentialrisks associatedwith the applicationof physicalagents. A number of conditions, including pregnancy and malignancy,have generallybeen consideredto be contraindicationsfor the application of physical
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agents.Although there is litde information on the effects of physical agents on these conditions, the ootential adverseeffects.such as fetal abnormalities or acceleratedgrowth or metastasisof malignanttissue,can be so detrimentalthat, without evidenceto demonstratethat suchapplicationsare safe,their risk is consideredto be excessivefor clinicalaoolicationor for researchusinghumansubjects.turther information regardingthe safety of applying physicalagents to patientswith *rese conditionsmay be particularly beneficialin clari$ing when physicalagentsmay be used,particularlyto control pain. However, in order to protect patients and clinicians, until research demonstrates definitively that applying physical agentsin the presenceof theseand other traditionally accepted contraindicationsis safe, clinicians must continue to practicewithin curent restrictionsand warnings. Studieson the dsksassociatedwith the aoolication of physicalagentsmay promote improviments in practiceby making applicationspreviously thought unsafeavailablefor ciinical use.Ior example,in the past,the presenceof metal in an areawas considered to be a contraindicationor a causefor cautionto the applicationof ultrasound.The reasonwas that, lacking specificresearch,it was thought that this agent may produce excesslvetemperature lncreasesin metal, as doesdiathermy,a previouslyavailabledeep heating agent.There were also concemsthat therapeutic ultrasound may loosen metal implants. Howeve! sincestudieshaveshown that ultrasoundis reflectedby, but doesnot heat,metal and that it does not loosen metal implants, ultrasoundmay now be appliedin areaswhere metal is present.Ior example, ultrasound may be applied to promote increased range of motion (ROM) in areaswhere drere is soft tissue shortening after the implantation of metal platesand screwsaftera fracture.v
METHODOLOGICAL CHARACTERISTICS RESEARCH OFFUTURE ONPHYSICAL AGENTS StudyDesign Case report Single-subject design Group design
The goal of most researchis to determinethe effect, or effects,of specificinterventionsasprecisely,definitively, and clearly as possible.Although this may appearto be a simpletask,it is fraughtwith both theoreticaland practicaldifficulties.Theoretically,it can be difficult to determinethe effectsof an intervention because,even if that interventionis consistentlyfollowed by a changein the subjects,one cannotbe certain that the interventionactuallycausedthat change. Ior example,if the applicationof traction is followed by a reductionin low backpain,one cannotbe certain tiat tlre tractionreducedthe pain since,in many indi viduals,iow back pain resolveswith or without the applicationof any treatment.Practically,it is particularly difficult to ascertaincauseand effect in clinical carebecausedifferentindividualsmay responddifferendy to the same inteffention, most interventions involve a number of components,and many patients progress,either toward or away ftom the goals of treatment, independentlyof the application of any intervention. Studies may be designed in various ways to attempt to overcome these problems and thus to detemine, correcdy and accurately, the effectsofinterventionswith physicalagentsto appropriatelyguidefutureclinicalpractice. Casereport The simplestform of researchis a casereport.A case report is a detailed description of an individual patient's cl.inicalpresentatioq the course of treatment, and the changesin clinical presentationthat occur during and generallyafter *rat courseof treatment. A casereport should include a thorough and complete descriptionof all aspectsof the patient's care and status, including which treatments were applied,when and how often they were applied,as well as the patient's age, gender,diagnosis,impairments, functional limitations and disabilitiesbefore, during,and after treatment. A casereport is generallythe first type of formal evaluation of a ffeatrnent approach that is performed. It is most valuablefor describingsuccessful methods for ueating various conditions when little other information is available.A casereportgenerally concernsthe applicationof a novel intervention for a common problem or the use of a common intervention for a novel application.The advantagesof casereports are that, when well written, they provide information about all aspectsof the patient's presentation and care in detail, and they require
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tics that can confound the interpretation of studies the investigator only to describe an individual's study, involving groupsof subjects.In a single-subiect presentation. Case reports do of treatment and course one are taken from measurements since all outcome any way. treatment to be changed in not requirethe between in status found any differences subject, they reports is that The primary disadvantageof case applyingand not appiyingthe intewention are likely only provide information about what was done to a to be due to the intewention.HoweveSalthoughsinpatient, patient what happened to that particular and gle-subject studieshavea number of advantagesover *re observed without clearlyindicatingwhat caused sincethey only evaluatethe responseof case repofts, certain which, if changes.Therefore one carrnotbe to an intervention,caution should a single individual any, of the intervention(s)in question causedthe generalizing the findingsof suchstudies in be applied observedchangesor if these changesoccurredindesubjects. to other oendendv of the interventions.Caution should also Studiesusing single subjectsare particularlysuitte observedwhen consideringapplying the findings of a casereport to other individualssincethe changes able for investigatingthe effectsof interventionson uncommon problemswhere largegroupsof subiects that occurredin the subjectof the report may have may not be availableand for analyzingthe effectsof beenuniqueto that individual. interventionson problemswhosenormal progression Singlecasereports can provide valuableinformation to guide clinical practice and further research. is so variableasto obscureany effectsof an intervention using a group design.However, in most situaWhen a number of casereportsdescribesimilar outcomesafter the applicationof a specificintervention, tions, comparing the effects of providing an interventionto onegroup of subjectsandwithholding this increasesthe likelihood that the intervention causedthe observedchangesand that it would cause it from anothergroupof subiectsmore clearlydemonsimilar changesin other individuals.This increases stratesthe effectsof that intervention and provides strongerevidenceto support its applicationto other the confidence with which the findings can be individualsin clinicalpractice. appliedto clinicalpractice.Singlecasestudieswhere treatmentis appliedand then withdrawn, and studies involving groups of subjects,some of whom receive Groupdesign When well-designed,studiesinvolving groupsof subthe intervention and some of whom do not, further jects usually provide the strongestevidencefor the strengthenthe proof of an associationbetween the effectivenessof an intervention.In general,the size treatmentand proposedeffect and improve *re qualand homogeneityof the groupswill havethe greatest ity of evidenceto justify applicationin clinical pracimpact on the qualiry of the findingsof a group study. tice. Large, homogeneousgroups of subjectsshould be usedwheneverpossiblein order to minimize the risk design Single-subiect A controlled study using one subject,whose status of failing to detect the effects of an intervention. When small, heterogeneousgroups are used, differwhen an interventionis appliedfor a period of time is encesbetween groups produced by an intervention comparedwith the status when the intervention is may be maskedby variabilitywithin the groups. not applied, provides more definitive information Ior example, if ultrasound is applied to a few aboutthe effectsof an inteNention than a casefeport. with tendonitisof varying degreesof acuity patients subjects, the intergeneral, for studies using single In and of varying tendonsand, after the treatment,no vention is appliedand withdrawn a number of times, differencesin pain or dysfunctionare found between andthe subject'sstatusduring orimmediately followthesepatientsand otherswho did not receiveultrawith the periods is compared ing the of application sound,the failureto detecta treatmenteffectcouldbe intervention was periods when the statusduring the due to the fact that (1) ultrasounddoesnot reducethe nor appleo. In contrast to casereports, single-subjectstudies pain or dysfunction associatedwith tendonitis, or that (2) the range of pain and dysfunction within can differentiatethe effects of time alone from the groups was greaterthan the range between the the effectsof the intervention under investigationwithgroups, or that (3) ultrasoundis effectivefor treating out the time and expenseof studiesinvolving groups only at certaindepthsor at certainstagesof tendonitis of subjects.Single-subjectstudiesalso eliminate the If this study was performedwith a largegroup differencesin initial status or individual characteris- acuity.
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of subjectswho all had tendonitis of the extensor carpiradialisbrevistendonin the acuteinflarnmatory stage,if *re heatment was effective,its effect will not be obscuredby variationswithin the groups of suolecls. Unfortunately,becauselargegroupsof individuals with similar characteristicsare difficult to recruit, many studies, particularly those involving human subjects,use small, heterogeneoussamplesand may thus erroneouslyconcludethat treatmentsare ineffective.Thereforewhen studieswith small,heterogeneousgroupsof subjectsfail to find treatmenteffects, while caserepods and single-subjectstudiesindicate that an intervention is effective,it is recommended that future researchreplicate these group studies usinglarger,more homogeneoussamples. Although studies using large, homogeneous groupsof subjectsoptimize the probability of detecting small, statisticallysign.ificanttreatment effects, the clinical significanceof theseeffectsmust also be taken into account when consideringapplying the findings to clinicalpractice.For example,although a study may find that applying heat before stretching the knees of patients who have had a total knee arthroplasty results in a statistically significandy greatergain in flexion ROM than stretchingwithout prior heating,if the differencein ROM gainsis only a few degrees,this may not be clinicallysignificantif it doesnot affectpatient function. A slight acceleration of recoverymay also be statisticallysignificantwhile not justifying the use of an intervention in general clinicalcare.Ior example,evenif applying traction is found to decreasethe recoverytime from a low back injury from 40 daysto 39 days,in most casesthe cost of applyingthis treatmentwill not be justifiedby this smalleffect.
Subjects In vitro (materials, tissue, cells) Animals (nomal, disease model, true disease) Humans (normal, patients)
Having selected the appropriate study design, basedon the nature of the effect being studied and the quality and availabilityof prior studies,an investigator must also select suitable research subjects. Subject selection will depend on the nature of the effect being studied, the qype of outcome data
desired, and the availability of different types of suDlec$. tissue,cells) In vitro(materials, The term in vitro, meaning "wi*rin glass," is used to describestudiesthat are carriedout in a containeror in a test tube ratherthan within a living organism.In vitro studiesuse various nonliving matedals or cell culturesassubjectsand canbe usedto evaluatemany of the physical properties and effects of physical agents,including the penetrationand absorption of different types of energyby different materialsand the effectsofthese typesofenergy on thesematerials. In vitro studies using biological materials can also yield information about the effectsof physicalagents on the physical or physiologicalpropertiesof these materials,suchasskin or cellmembranepermeability, tissueextensibiliry or cellviability. The advantagesof in vitro studiesarethat they can generally be replicatedaccuratelyand they permit close control of subjectand intervention variabiliry. However, although in vitro studies may provide information regardingthe effectsof physical agents on the physicalpropertiesof tissue,cautionshouldbe exercisedin applyingfindingsofthese studiesdirectly to the more complexsituationof a patient.Ior example, althougha cell grown in agarin a Petri dish may be killed ormaygrowmore rapidly when an electrical currentis applied,becauseof differencesin temperature, pH, tissueresistance,current density,chemical environment,or other factors,this samerype of cell may not respondin the samemanner if an electrical cuffent is applied to it when it exists in an open wound in a patient. Some of theselimitations of in vitro studiesmay be overcomeby using animalsas 'acerr.h
c,,h;e.r.
(normal, Animals disease model, truedisease) The term in vivors usedto describestudiesthat are cardedout within a livingbody.In vivo studiesusing animalsas subjectsallow examinationof the effects of physicalagentson the physicalpropertiesof tissue within a normal physiologicalenvironment.This is necessarybecausenormal physiological processes may alter the effectsof physicalagents.For example, a thermal agentappliedto live tissuewith an intact, responsivecirculationwill have lessimpact on tissue temperaturethan the samethermal agentappliedto the sametype of tissuein vitro, with no circulation. The circulatory system will bring blood from o*rer
Three o INTEGRATING PHYSICAL AGENTS /NTO PRESENT/ND FUTURE PRACTICE
areasto cool the heatedtissue.This responsewill be exaggerated as the tissuewams up and vasodilation occurs.The effectsof physicalagentson physiologicalprocesssuchascirculation,heartrate,or temperature, may also be evaluatedby in vivo studieswith
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circulation,andmay be usedto investigatethe effects of interventionson experimentallyinduceddysfunction such as pain; however, caution must be usedin applyingthe findingsof suchstudiesto patientswith pathologybecausethe effectsmay be differentin the rnimel cr,hiertc presenceof pathology. Normal,healthy animalsmay be usedto study the For example,although electricaistimulation may effects of physical agents on normal processesor not increasemuscle strength more effectively than characteristics suchastemperatureor circulatoryrate, exercisein normal subjects,it has beenfound to augwhile animalswith pathology can be used to study ment strengtheningwhen applied to patients after the ' effect(s) of physical agents on pathology or kneesurgery Studiesusingpatientscanprovideinforimpaiments such as muscle shortening,soft tissue mation concerningthe effectsof interventionswithin injury, circulatoryimpairment,or pain. In addition to the context of pathology,and can aiso provide inforallowing for evaluationwithin the context of a commation about changesin subjectivecomplaintsand plete physiological system, studies using animals objective impairments, functional limitations, and allow the investigatorsto perform proceduresand disabilities. take risks that may not be ethicai with human subStudiesusing human subjectshave a number of jects.Studiescanalsouserelativelylargesamplesizes limitations, includingthe difficulty of recruitingadeat lessexpensethan with human subjectsand control quate numbers of subjects;having limited control many potentially confoundingvariablessuchas subovervariabiliryin subjectcharacteristics suchasprobject activity level, age,gender,and diet. Nonetheiess, lem severity and duration, subject age, and subject the results of animal studies should be aonlied to gender; and having limited control over subject human patientswith caution becausedifierences behaviorssuchas activity level, diet, and other med'ical in human characteristic$such as body s\ze, body interventions.There are also ethical constraints composition,skin thickness,or normal temperature, limiting the natureof the proceduresthat can be permay alter the effects.Studiesusinganimalsalsogenformed on human subjects.In general,procedures provide erally cannot information concerning the that may causeharm or discomfort,such as a tissue effect of interuentions on the subiects' functional biopsy or the applicationof a physicalagentin a cirfimitationsor disabilities. cumstancepreviously contraindicated,may not be performedon human subjects,and informed consent (normal,patients) Humans mustbe obtainedftom all human subjectsbefotetheir may Studiesusing human subjectscan yieid information inclusionin a research study.Theserestrictions regardingthe physiological effects of interventions limit the ability to determinethe mechanismof an wi*rin the human body and their effects on the observedeffect and prevent appiication of an intersequelaeof pathology including impairments,funcvention in a blindedfashlon. tional limitations, and disabilities.The human subjects used in researchmay either be patients with Gontrols pathologyor subjectswithout pathology.Using indi vidualswith pathologyis generallypreferredbecause Becausechangesin subjectscan occurwhether or not this providesinformationthat is more readilyapplica- any interventionhas been applied,in order to deterble to other patients.However, since there may be mine whether observedchangesare causedby an limited accessto subjectswith problems of similar intervention, the outcome of subjects who have and severiqy, as well as financial and ethical conreceivedthat intervention should be comparedwith rypes straintsto applying or withholding potentially effec- the outcome of subjectswho have not receivedthat tive carefrom patients,many studieson humansare intervention. The subjectswho do not receive *re performedusingnormal subjects. intewention beingevaluatedareknown ascontr\ls. Studiesusing normal human subjectscan provide When appropriatelyselectedand treated,control information about the physical and physiological subjectscan control for the effectsof chance,normal effectsof interventions,suchastheir impact on tissue progressionof the outcomevariable,and nonspecific temperature,tissuelength,musclestrength,or blood effects of treatment. It is particularly important to
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control for tlese effectswhen evaluatingthe impact of physicalagentsin rehabilitationbecausemany of the problemstreatedin rehabilitationmay vary without any intervention and tend to resolveover time, andbecausemost of the treatmentsorovidedbv rehabilitation clinicians have a variew of nonsDecific effects.Forexample.low backpain canvary in location from one day to the next, with no clear cause, and canvary in severityamongindividuals;however, for most individuals, acute low back pain resolves within 6 weeks whether or not anv treatmentis Drovidpd. Nonspecificeffectsof tuearmenr includepaying attention to the patient, which may increasethe patient's motivation; monitoring progress, which may improve the patient'scompliance;and touching the patient, either directly or with a device,which may provide a sensorystimulus to block pain transmission,whether or not any type of energyis being delivered. Without the use of appropriatecontroisit is diffi cult, if not impossible,to determine if the changes observedin subjectswho received an intervention were causedby that intervention.Ior example,if it is found that, in a group, most subjects'low back pain resolveswithin 6 weeks when a heatment such as traction hasbeenapplied,it cannotbe concludedthat their progresswas due to *re applicationof the treatment rather than being the normal recoverypattem for this problem unlessa similar group of individuals with similarsymptomsandno treatrnenttook significandy longer to recover.A treatment can be considered effective only if subjects who received the treatment show greateror more rapid improvement than control subjectswho did not receivethe treatment. Therearemany differentways to treat controlsubjects who are not receiving the intewention being evaluated.Although itmay be simplestandmost convenient to provide thesesubjectswith no treaftnent, this is not recommended.If the control subiectsare not provided with the attention and sensations associatedwith *re active treatment. then onlv the effects of chance and normal progression.not the nonspecificeffectsof treatment,will be controlled for. Treatmentswith interventionsthat haveno direct physiologicaleffectscan yield as much as lorry percent improvement in outcome, panicularly when subjectiveoutcomemeasuressuch as pain are used. Thereforeif the effectsof the interventiongroup are comparedwith those of an untreatedcontrol group,
the intervention will probably appearto have been effective even when the effectsmay have not been specificto that intervention. In order to control for nonspecificeffects of an intervention,it is recommendedthat control subjects receive an alternative intervention that aDDearsas similaraspossibleto the inrerventionbeingissessed but that is known, or thought, not to affect the outcomebejngevaluated. Suchaltemariveinterventions are known as placebos. When researchingthe effects of physicalagents,it is recommendedthat placebos consistof applyingthe treatmentin the normal manner,but wi*rout del;ery of energy6y the device. Ior example,a placeboultrasoundtreatmentmay be given by applying a transmissionmedium to the treabnentareaand then placingthe ultrasoundtransducer on the areaand moving it within that areafor the same amount of time used for the active treatment group. The differencewould be that, for the activetreatment,ultrasoundwas deliveredto the subject, whereas for the placebo treatment, no ultrasound was applied. Similarly, a placebo hot pack treatment could be applied by using a pack at body temperatureinsteadof a heatedpack.In both of these examples,the activeand placebotreatmentsare similar with regardto the preparationfor applicationof the treatrnent,the amount of attention from the person applying the intervention, and the amount of time the subiect receivedcare.Thus if a difference in outcome is found between those receiving the placebo treatment and those receiving the active treatment,it is likely that this differenceis due to tl:.e intervention being studied rather than being a nonspecificeffectof providingtreatment. In orderto determinethe effectsof an intervention most accuratel, it is recommendedthat neither the subjectsof the study nor the individualsapplyingthe intervention know whether an active or a placebo treatment is being applied.This is known as doubleblindapVlication. Aphysicalagentmay be appliedwith a double-blindplacebocontrol if it doesnot produce any identifiable sensationin the subject and if the deviceproviding the ffeatment appearsto be delivering energy even when it is not. Ior example, low-intensity ultrasoundmay be appliedwith a double-blindplacebocontrolif a devicethat operatesnormally is used for the active ffeatment and another device modified to produce no output, although it appearsto operatenormally, is usedfor the placebo treatment.The two devicesshouldbe markedfor dif-
ThTee O INTEGRATING PITYSICAL AGENTS INTO PRESENT AND FUTURE PRACTICE
ferentiation;however,t}rekey to their identity should be concealedfrom the investigatorsuntil all intervention and data collection have been comDleted. Because thispreventsboth the subjects andthe investigators from knowing which device is active and which is inactive,it will eliminatebiasduringapplication of the interventionand datacollection. If the physical agent being evaluatedproducesa distinct sensationin the subjects,such as the sensation of heat from a hot pack or the sensationof a pull from traction, or if deactivateddevices to prevent knowledgeof the personapplyingthem arenot available,then the interventionmay be applied only in a single-blindmanner.Ior example,if only one device is available,low intensitiesof ultrasound or shortwave diathermy (SWD)that do not producea sensation of heat may be appliedin a single-blindfashion, with blinding of the subjectsonly, by setting the deviceto the desiredintensity for the activetreatment group and not tuming it on for the placebotreatment group. Hot packs,which producea sensationof heat in the subject,may be appliedin a single-blindfashion, with blinding of the investigators,ifhot packsare used for the active ffeatment group and unheated packssimilar in appeatanceare usedfor the placebo ffeatment group, and if the investigatorswear heatproof glovesso that they cannotfeel the temperature of the packs. Interventionsthat producedistinct sensationsand that require specific behaviors by the individuals applying them, such as compression,traction, most forms of electrical stimulation, or ultrasound or diathermy at intensitiesthat producea sensationof heat, cannotbe deliveredin a blindedmanner.When attempting to assessthe effects of these types of physicalagents,lower energylevelsofthe sameintervention or other interventionsrecommendedfor the sameproblemmay be appliedto the controlgroup for compadson.Ideally, in such circumstances, in order to control for confoundingeffectsof changingmultiple variables,the intervention applied to the control subjectsshouldfeelassimilaraspossibleto the active treatment,requirea similarftequencyand durationof application,and involve a similar degreeof personal attentionfrom the individuaJ applyingit. In order to avoid, or at leastminimize, confounding effectswhen usinghuman subjects,double-blind placebocontrolsshouldbe usedwhen possible;when dris is not possible, single-blind placebo controls should be used. Only if neither double- nor single-
451
blind applicationis possibleshould placeboor active alternativetreatmentsbe applied without blinding. When using animal subjectsor performing in vitro studies, blinding of the subjectsis not necessary; however, blinding of the investigatorsapplying the intervention and collectingthe outcome data is recolTunenoeo. Because,unlike most other rehabilitationinterventions suchas exercise.or ioint or soft tissuemobilization, many physical agents can be applied readily with double-biind placebocontrols, future research on the effectsof physicalagentsshould use doubleblind controiswhenever possible.This will support the conclusionthat differencesin outcome between subjectsreceivingan activetreatmentand controlsare due to the treatmentratherthan to someother aspect of careand will allow therapiststo apply the findings of suchstudieswith confidence.In contrast,if appropriate controls are not used, although much time, effort, and expensemay be expended, the study resuitswill not readily improve patient care.It will not be known whether the treatmentsbeine evaluatedareeffectiveandshouldbe usedwith oatilnts.or whetherany observedchanges in subjectitatuswere the result of chance,normal progression,or nonspecific effectsof the intervention.
0utcome Measures Reliability Once the investigatorhas selectedthe appropriate study designand controlsfor evaluatingthe effectsof an intervention using a physical agent, appropdate measuresof the outcome must also be chosen.The outcomemeasuresselectedshould be reliable,valid, and clinicallyrelevant.A measureis consideredto be reliable if the same or a similar result is produced when Lhemeasureis repeated.Ior example,goniometric measurementof activekneeflexionROM may be consideredreliableif the sameor a similaransleis reportedwhen activekneeflexionROM is meas-ured rcpeatedly. The reliability of a measuremay vary for different applicationsor populationsand with applicationby the same or another individual. Ior examole. a numericvisualanalogscalecompletedby the subject may be reliablefor the assessment of pain severiryin adultsbut unreliablewhen usedfor the assessment of pain in infants or young children or for the assessment of kneeROM in subjects. Sincemost measures
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44 . Directiors fot Futnte Researchand AVVlicatiofl
producemore similar resultswhen reappliedby the same individual (known as intrarater reliability) rhan when reappliedby different people (known as lzterraterreliabiii it is recommendedthat measurements be performedby only one individual,or by as few as possible,duringthe courseof a researchstudy.Iuture researchshould only use measureswhose reliability in the population being testedhas been proven, and the measures' reliability should be clearly documented"inall researchreports. Validity In contrastto reliability, which relatesto the reproducibility of a measure,validity relatesto its usefulness and the degree to which it representsthe property it claims to measute.Iot example, for a questionnaireto be a valid measureof disabiliry in a population, it must actually measurethe reduced ability of this population to perform normal activiin differties. Vadous forms of validiry are assessed ent ways, such as correlationwith other measures of the same characteristic,logical analysisof how the conterfif a measurerehtJs to the characteristic it claims to measure, or evaluation of how accurately the measurepredictswhat it claimsto predict. Measuresmay be valid by one standardbut not by another.For example,althoughmeasuresof abdominal strength and lumbar flexibiliry may have high content validity as measures of low back pain, becauseit appearslogical that they would be related to low back pain and may be predictorsof future low backpain,they arenot consideredto havegood criterion-relatedor predictivevalidity becauseit has been found that abdominal sftength and trunk flexibility do not correlatewith self-reportsof low back pain and do not predictwho will havelow backpain in the future.1o Clinicalrelevance As well asbeingreliableand valid, outcomemeasures usedin future researchconcerningthe effectsofphysical agentsshouldrelatedirectlyto the goal(s)oftreatment and should include measuresof the effectsof interventionson impaiment, functional limitations, and disability. In conkast to prior research,which focusedprimarily on the effectsof physicalagentson impairmeng examining, for example, the effect of thermotherapyon soft tissuelength and extensibility or the effectsof traction or electricalstimulation on
oain. future studiesshouldalsoevaluatethe effectsof these interventionson functional outcomessuch as walking speed,lifting capacity,or sitting tolerance. Futureresearchshouldalsoevaluatewhetherthese interventionsreducefunctionallimitations.Ior example, researchshould evaluatewhether spinaltraction facilitatesthe sublects'retumto work, promotestheir ability to shop independendy,or acceleratestheir retum to sportingactivity.Examplesof possiblestudies on the effectso[ physicalagentson functionallimitations and disability includeevaluatingthe effectof thermotherapy on ambulation distance,ambulation velocity,and the time requiredto retum to functional independenceafter total kneearthroplasryor evaluating the effectoftraction on the time requiredto retum to work and the level of work retumed to in patients with low back pain and radiculopathy.Data ftom such studieswill allow prediction of functional outcome in responseto treatment,and may be used to guide future practiceand to support reimbursement for treatment, In orderto provide further supportfor usingphysical agents in rehabilitatiorl future studies should demonstratenot only that physicalagentsoptimize the achievementofpatient goalsbut alsothat they do so in the shortest amount of time and for the lowest cost. In order to achievethis, researchevaluating the cost effectivenessof usingphysicalagents to achievespecific functional outcomesis required. In order to evaluatethe potential costs and benefits of an interventionrealistically,the costsof providing the intervention should be compared with the potential savingsassociatedwith reducingthe duration and severiqzof a patient'sdisabiliqyand handicap. Potential savingsmay include reducingloss of incometo the patient,reducingcoststo the employer with replacinga memberof the workforce, associated and avoiding costsassociatedwith providing further careto the patient.For example,providing tractionto patients with low back pain for 10 visits may cost $500; however, if it is shown that *ris accelerates their return to work by an averageof 1 week, this treatment can be consideredcost effective if the costs to those patients, their employers,and their insurancecarriersassociatedwith not working for 1 week are greater than $500. Studiesdemonstrating the cost effectivenessof interventions can provide strong support to justify reimbursementfor those interventions .
Thtee O INTEGRATING PHYSICAL AGENTS INTO PRE SENT AND FUTURE PRAjTICE
Reporting In recentyearstherehas beena growing interestand support for the practiceof evidence-based medicine. In this context,a number of systematicreviewsof the literatureandmetaanalyses havebeencarriedout and published.Thesetypes of reportsattempt to evaluate and synthesizethe findingsof prior direct studiesin a particulararea.A systematicreview ofthe literatureis comprisedof a systematicsearchfor publishedstudies concerninga specificquestion,evaluationof the quality of the studiesfound, and a summaryof their findings.A metaanalysisgenerallyalsocombinesdata from all randomizedcontrolledtrialsto determinethe efficary of an intervention. Ior example,there are recentmetaanalyses of the studiesconcerningthe use of spinaltraction for the treatmentof low back pain and of the studies concemingthe use of lowlevel laser *rerapy for the treatment of osteoarthritisand rheumatoid arthritis. Systematicreviews of the literature and metaanalysesconcerningthe efficacyofphysicalagentsfor various rehabilitation applicationsgenerally report that the evidence does support curent practice. However,in al3rst all areasthe researchis criticized for insufficientnumbersof subjectsstudiedand poor descriptionsof the interventionsused.This limits the conclusionsthat canbe drawn. Ideally, future studieswill include larger numbers of subjec*.AIso,itis essentialthat future studiesdescdbe fully all aspectsof the subjectsand of the intervention being evaluated.Subjectdescriptionsshould include dre number of subjects,their averageage and age range, their sex distributioq the types of problem being treated,severityand acuity or duration of the problem,and any other featuresthought to be pertinent to the specificquestionat hand. Descriptionsof the interventions should include the nature of the physicalagentusedand all treatrnentparameters.Ior example,in studies of the effect of ultrasound on wound healing,the subjects'averageageand agerange and sex distribution should be given. Information aboutwound etiology,size,and stageshould also be provided, and the ultrasoundfrequency,intensity, duty cycle, effective radiating area and treatrnent time, as well as the ffeatment area,should be clearlynoted. This type of reporting will allow one to draw clearer conclusionsregarding the efficacy of physical agents and the necessaryor optimal fteaftnentparametersto producethe bestclinicaleffect.
453
CONCLUSION Civen the advantagesand limitations of different study designs,subjects,controls,and outcomemeasures, various types of researchare neededto gain a full understandingof the effects of physical agents andto optimize their clinicalapplicationin rehabilitation. If future researchfollows the guidelinesprovided in this chapter,the effectsof physical agents, the mechanismsunderlyingtheseeffects,and the critical variablesfor producingthem will be more thoroughly understood,increasingthe effectivenessand predictabiliry of applying physical agents while potentially decreasingthe costs of patient care.It is alsoexpectedthat, althoughfurther researchwill provide many answers,it will also producemany more questions,particularlywith regardto optimizing the effectivenessof treatment.It is likely that, as particular interventions are found to be effective, further research will be needed to determine when, to whom, and how these interventions should be applied to obtain the best results;if these interventions are more effective than availablealternatives; and if they are more effectivewhen usedin conjunction with other interventions. Similarly,if studies show that an intervention is not effectivefor a particularapplication,further studies to investigateif it would be effectiveif appliedin a different manner, with different treatment parameters, or to subjectswith different charactedsticsor problems,may still be valuable.Thereforealthough the clinicalapplicationof physicalagentsin rehabilitation at any time should be guided by the available research,in order to continuallyimprove the quality of careprovidedto patients,it is essentialthat further research be performed and that clinicians stay informed of the findings of thesestudiesand modib/ their practiceaccordingly. Chapter Review Iurd:rerresearchconcerningthe useofphysical agents in rehabilitation is neededto increase*re development of evidence-basedclinical practice.This will improve the outcomesof treatmentand supportcontinued reimbursementfor such treabTrent.Research conceming the physical properties, physiological effects, clinical applications,and adverseeffects of physicalagentswill help to elucidatethe mechanisms by which physical agents exert tlretu effects, clarify
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'14 . Dbections for Fsture Researchand Application
the nature of theseeffects,and detemine the conditions under which these effects are optimized. Different study designswith varying degreesof complexity are neededto evaluatedifferent applications of physicalagents.Casereportsand single-subject, conrrolled studiesareneededro describe andevaluate treatments that appear to be clinically effective. Thesestudiesshouid be followed by conirolledstudIes wlrn groups or suolectsLn oroer to ascertatn whetner tnerr rrnorngscan Deapplredto otner rndlviduals, to clarify the nature and magnitude of,the specificeffectsof differentinterventions,and to identify idealtreatmentparameters. In order to provide information about the microscopic,macroscopic,and functionalimpactsof physical agents, future researchwill also need to use various qypesof subjects.Studiesusing patients as sublectswill provide information that iray be most reaiily applied 'and to other patients;however,2ue to the pract;al ethical limitations of performing researcn on people,parucutay wnen uslngpanents.
animal inuitrosrudies. reseaich. andsruire" using
normal human subjectswill be neededto evaluatethe effectsf physicalagentswhere theremay be risk to a patient from receivingthe intervention being evaluprocedures ated or ftom undergoingthe assessment being used. Future researchwill also need to use appropdate, and ideally double-blind, controls in oiaer to produce t".uit, fro- which conclusion, regarding ideal treatments can be drawn. This researchwill alsoneedto evaluatethe effectsof interventionswith reliable,valid,and functionallyrelevant
on patients' functional outcome will be. The reader is referred to the Evolve website at http://evolve. elseviercom/Cameronfor study questionspertinent to this chapter.
References andpulsed l. CoruadiE,?agesIH: Effectsof continuous mrcrowaveirradiationon distributionof heat in the qlucea. region of miniprys. S,and Med2):59-62 I Rehabil ioqo z. v"iri"rn, rut.orrerK,crawfordsJ:A comparison of tissueremperature followingnvo sho.nuu" diathermy physiother t977. techniques, CanidaZgltl,Zt-25, A et al:Heatingrabbit 3. Fadilah& PinkasJ,Weinberger joint by microwaveapplicator, ArchPhysMed Rehabil . 68(10):710-71,2,1987 of unfocused laserlight into the 4. KoLariPJrPenetration skin,AtchDetmatol Res 277:342'344, 1985. _ Med 5 Low levellasertherapy:a revr.w,Lasets Ilg ,?l' sL-i^4:141' r50' r9B9' . tsradnock 6. B,LawHT,Roscoe K:A guantltative compar-
iff:|.:'#"'ff'il""#ffi'1il:'fftr"fi#il:1";
tlerupy,,)i. the treatmentof acute ankle sfrains, physiiheraryBI(7):78-84, I9g5. VJ:Comparison 7. WardAR,Robenson ofheatingofnonlivingsoft tissueproducedby 45 kHz and 1 MHz !requencyultrasoundmactines, J OnhoySVonPhysTher 23(4):258-266' 1'996. B.S_weitzer In HecoxB, MehneabTA, RW:Ultrasound. Tettfot WeLsberg J,eds:Plysic^lAge\ts:A Col\Fteheasite Phvsical rheravkts' EastNorwalk'cl 1993'Appleton&
i|llj"^ r,r+-^-^..-., n "t outcomemeasures.ru,u,",","",J'J[Ii"i.; ;i ::Tt"",ffin::,Ai,1iTtrJi#',Truj will benefit from treatments with particular physical agents, how these treatments should be applied to optimize their eftectiveness,and what the nature and magnitude of the benefits of such interventions
Med Rehabit63:371-373.1982. 10. IacksonAW. Morrow IR. Brill pA et al: Relarionsof sitiesrsto low back pain in adults, up and sit-and-reach I OtthopSyonPhysTher27(I):22-26,7998.
Glossaryof Commonlv UsedTerms ., abscess:A localizedcollectionof pus absolute refiactory periodr Time after an action potential during which another action potential cannotoccul absorption: Conversionof energyincoheat accessory motion: The motion that occurs bewveenjoint surfacesduring normal physiologicatmouon action potential: Depolarizationof the nerve membrane;reversalof the transmembranepotential active motion: The movementproducedby contraction ofthe musclescrossinga joint acute pain: A combination of unpleasantsensory perceptual,and emotional experiencesthat occur in responseto a noxious stimulus provoked by acuteinjury and/or disease adhesion: Abnormal joining of partsto eachother adverse effect: Any result of a treatrnent that is undesirable adverse neural tension: The presenceof abnormal responsesproducedby peripheralnervoussystem structureswhen their rangeof motion and stretch capabilitiesaretested alternating current: A continuousflow of charged particlesin altematingdirections
amplitude: Electricalcurrentamplitude.This may be a measureof the currentor the voltase analgesia:Absenceof sensrbility to pain anode: Positivelychargedelectrode atrophyr Wastingor decreasein *re sizeof a muscle or an organ attenuation: Decreasein energyas radiation passes through a material buoyanry: A force experiencedas an upward thrust on the body in the oppositedirection to the force ofgravity capacitance:The ability to store charge; generally measuredin larads capsular pattern: The specific combination of motion loss that is causedby shortening of the joint capsulesurroundinga joint carotid sinus: The dilated ponion of the internal carotid artery *rat contains the pressoreceptors tlat are stimulated by and stimulate changesin blood pressure;locatedin the antedorneck cathode: Negativelychargedelectrode cavitation: The formation, growth, and pulsation of gasorvapor-filledbubblescausedby ultrasound chemotaxis: Movement in responseto a chemicai concentrationsradient
456
Clossary of Commody Used Tetms
chronaxie: The minimum pulse duration that will excitea nervefiber when a stimuluswith an ampli tude of twice rheobaseis applied chronic pain: Pain that does not resolve in the usual time it takes for a disorder to heal or that continues beyond the duration of noxious stimulation collagen: The main supportive protein of skin, tendon,bone.cartilage, andconnective tissue compression: The applicationof a mechanicalforce *rat increasesthe externalpressureon the body or a body part conductivity: A material'sability to propagatecunenq conductivity is inverselyproportional to resistivity connectivetissue: Tissuethat bindstogetherandsupportsthe variousstructuresof the body; madeup of fibroblasts,fibroglia,collagen,andelastin consensualresponse: A reflexoccurringon the oppositesideof the bodylrom the point of stimulation contractu(e: Shorteninsof soft tissue contraindication: Any condition that renders a particularform of treatmentundesirable or improper convection: Heat transferby circulationof a medium of a differenttemoerature .,D; cryother5-py: I he therapeuticuseof cold cuff€nti The rate of flow of chargedparticles;generally measuredin amperes debridementr The removal of foreisn matter and tissuefrom a lesion deviralized diathermy: (Creekfor "through heating")The application of shortwareor microwave frequencyelectromagneticenergyto heat tissues direct cuffent: An uninterrupted flow of charged particlesin one direction disability: inability to perform a task or the obligations of usual roles and typical daily activitiesas the resultof impairment disc herniationr Disruption of the annularfibers of the soinaldisc dwty cycler The proportion of the total treatment time tlat energy is being delivered; generally asa percentage or raLio expressed edema: The presenceof abnormalamounts of fluid rissuespaces of the body in the extracellular elasticdeformation: The elongationproducedunder loadingthat reversesafterthe load is removed electric field: The force field between elecfiic charges electrode: The medium or objectusedto conductan electricalcurrentto an objector a person
electromagneticradiation: Perpendiculadyoriented electricandmagnericfieldsthatvaryovertime embolus: A clot or other plug brought by the blood from one vesselto anothersmallerone to obstruct the circulation end-feel: The qualiry of the resistancefelt by the climotion nicianat thelimit of passive endogenous: Originatingfrom the body epiphysis: The end part ofa long bonethat is formed from a secondarycenterof ossificationand that is separatedfrom the main portion of *re bone by cartilageuntil skeletalmatudty is reached erythema: Rednessof the skin causedby capillary congestron exogenous: Originatingoutside*re body extravascular: Outsidethe vessels exudate: Iluid that has escapedfrom blood vessels and beendepositedin tissuesor on tissuesurfaces; has a high concentrationof protein, cells,or solid materialderivedfrom cells fibroblast: Cell that producesconnectivetissue flaccidity: An extremetype of musclehypotonicity in which no muscle tone is detectable;usually associatedwith paralysis ftequenry: The number of eventsper unit of time functional limitation: The inability to perform the tasksor behaviorsrecogrizedas essentialcomponentsof daiiy life galvanic current: Direct current galvanotaxis: Movement in responseto an electrical charge gate control theory of pain: The hypothesis that pain may be relieveddue to modulation of nociceptor transmissionat the spinal cord by largediametersensoryfiber activation handicap: The socialdisadvantage of a disability hematoma: A confinedeffusionof blood hernorrhage: Copious escape of blood from the vessels histamine: An vasodilation
endogenous amlne trrat causes
hydrostatic pressure: The pressure exerted by a fluid on an immersedbody hydrotherapy: The therapeuticapplicationof water hypertonicityr Abnormally increasedlevels of musby voluntary cletone that arenot readilydecreased relaXanon hypotonicilz: Abnormally decreasedlevels of muscletone that arenot readily increasedby voluntary tensins
Glossaty of Commody UsetlTerms
impairment: Any lossor abnormalityof anatomical, physiological, or psychological structure or tuncuon impedance: The sum of resistanceand capacitance inflammation: Initial tissue reaction to tissue injury infrared radiation: Electromasneticradiationwith a frequencyof l0Il to 10laryJes persecond intensiqz: Amount of power per unit area; usually expressed in Watts/cm2 intravascularr Within the blood vessels in vitro: "ln glass";study performedoutsideof a livmg orga sm in vivo: "In life"; study performed on a living orgarusm ionizing radiationr Electromagneticradiation that can break molecular bonds to form ions (e.g.,X
457
nonionizing radiation: Electromagnetic radiation that cannot break molecular bonds to form ions (e.g.,microwave,shorwave, infrared,visiblelight, ultravioletA andB) Ohm's law: voltage= currentx resistance oncotic pressure: The osmotic pressureof colloids : - ^ - ^ l l ^ r - ]^ l - . . - - ^ -
opiopeptins: Croup of endogenousneurotransmittersthat haveeffectssimilarto thoseof exosenous opiares osmotic pressure: The pressurethat brings about diffusion between fluids with different concentranons pain: An unpleasant sensory and emotional experience associatedwith actual or potential tissue damage or described in terms of such damage paralysis: A state in which no active muscle coniontophoresis: The transcutaneousdelivery of ions traction is possible; the loss of voluntary into the body for therapeuticpurpose using an movement electricalcurrent paresis: Lessseverereductionof activemuscleconischemia: Deficienry of blood in a part due to contraction than paralysis;only weak muscularconstrictionor obsffuctionof a blood vessel traction canbe elicited laser: Acronym for light Amplification by passivemotion: Movement producedentirely by an Stimulated Emission of Radiation; monochroextemal force without voluntary muscle contracmatic, coherent,directionallighr tion by the subject leukocyt?White blood cell; inilude a variety of cell periosteum: Connective tissue covering all types-neutrophils, basophils, eosinophils,ly,mbones phocytes,andmonocytes peripheral vascular disease: Ceneral term for dislymph: Transparentfluid found in lynnph vessels; easeofthe peripheralarteriesorveins;usuallyused consistsof liquid and a few cells that are mostly ro describe narrowingoI the arteries lymphocytes phonophoresis: The application of ultrasound lymphedema: Swellingof subcutaneoustissuesdue with a topical drug to facilitate transdermaldrug to the presenceof excessive lymph delivery magnetic field: The force field between magnetic physical agent: Various forms of energy and poles materialsapplied to patients and their means of margination; Adhesionofleukocytesto blood vessel application walls duringan earlyinflammation physiological motion: The motion of one segment modality: A physicalagent ofthe body relativeto another monocbromatic: Of one color piezoelectric: The property of producingelectricity muscle tone: The amount of resistanceto passive in response to the application of mechanical stretchof a muscle;underlyingtensionin a muscle pressure and of contracting and expanding that servesastlle backgroundfor contraction in responseto the application of an electrical myelin: A fatty insulating covering present at intercunent valsalongmost newe fibers plastic deformation: The elongation produced nerve conduction velocity: The speed at which under loading that remains after the load is actionpotentialstravelalonga nerve removed nociceptor: Specificnerve ending that respondsto power: The amount of energyper unit time; usually painful stimuli measuredin Watts
Glossaryof CommonlyUsedTetms
458
precautioni Any condition for which special care shouldbe takenpriorto renderinga particularform of treatment psoriasis: A common benign, acute, or chronic inflammatory skin diseasecharacterizedby bright red plaques with silvery scales,usually on the knees, elbows, and scalp, associatedwith mild itching pulsed shortwave diathermy: The therapeuticuse of pulsedshortwaveradiationin which heat is not the mechanismof action radiation: Exchangeof energy directly without an interveningmedium range of motion: The amount of motion that occurs when one segmentof the body moves in relation to an adjacentsegment referred pain: Pain that is felt at a location distant from its source relative refractory period: Time after an action potential during which another action potential can occur only in responseto a suprathreshold stimulus resistance: Iorce opposingmotion; may refer to the force of water againsta patient or the force oppos-ing the flow of electricalcurrent rheobase: The minimum currentamplituderequired to excite a particular type of nerue fiber when a pulse with an infinitely long duration is aoolied shortwave diathermy: Electromagnetic radiation .-;rh
,
F"n'rpnr-
^t
1O7 tn
108 nrlec
npr
second spasm:An involuntarymusclecontraction spasticity: A type of musclehypertonicity in which resistance to passive thereis a velociry-dependent stretch of a muscle; the muscle resists quicker stretchesmore than slowerstretches specificheat: The amountof energyrequiredto raise the temperatureof a givenweight of materialby a givennumber of degrees stratum comeum: The superficialcornified layer of the skin that actsasa protectivebarier strength-duration (S-D) curve: Illustration of the relationship between the current amplitude and pulse duration required to produce a threshold stimulus to createan action potential in different rypes of nerve fibers and directly in denervated skeletalmusclefibers
substance P: A peptide that is thought to be an important neurotransmitterfor the transmissionof painful stimuli substantia gelatinosa: Lamina II of the gray matter of the spinalcord where afferentpain-transmitting fiberssynapsewith interneurons tendinitis: Inflammationof tendc.rns tetany: Steady conffaction of a muscle without witching thermal agent: A physicalagent*rat canincreaseor decreasetissuetemperature thermal conductivity: Rate at which a material can conductthermalenergy thermotherapy: The therapeuticuseof heat thrombophlebitis: A condition in which inflammation of the vein wall precedesthe formation of a thrombus thrombosis: The formatiory development,or presenceof a thrombus thrombus: A clot in a vesselor in one of the cavities of the heart traction: The applicationof a mechanicalforceto the body in a way that separates,or attemptsto separate, the joint surfacesand elongatethe sutrounding soft tissues transducerr A devicethat convertsenergyfrom one form to another ultrasound: Soundwith a ftequencyof greater*ran 20,000cyclesper second ultraviolet radiationr Electromasneticradiation with a trequenryof 7.5x 10rato 10r)cyclespersecond urticaria: Vascular skin reaction marked by the transientappearanceof smooth, slighdy elevated patches that are redder or paler than the surrounding skin and are often attended by severe itching vasoconstriction: Diminution of the crosssectionof vessels,generallyof the arterioles vasodilation: Dilation of vessels,generally of the arterioles venous stasis ulcer: An area of tissue breakdown and necrosisthat occursas the result of impaired venouscirculation viscoelastic: Having both viscous and elastic propeftles viscosity: The physicalproperty of resistingthe force tendingto causea substanceto flow, causedby frictionbewveenthe moleculesofa substance
Glossaryof CommonlyUseilTenrs
wavef,ofln: The shapeor visual representationof the changein energy intensity oveitime
-
wavelength: The distance between two successlve points in a wave that are in the same phase of oscillation
and Commonly[JsedAbbreviations Acronvms /
AC: Alternatingcurrent AOTA: AmericanOccupationalTherapyAssociation APTA: AmericanPhysicalTherapyAssociation AIP: Adenosinetriphosphate BNR: Beamnonuniformity ratio CHF: Congestiveheartfailure CNS: Centralnervoussystem CSF: Cerebrospinalfluid CT: Computedtornography CVA: Cardiovascularaccident(stroke) DC: Direct cuffent DOMS: Delayedonsetmusclesoreness DVT: Deepvenousthrombosis EMG: Electromyography ERA: Effectiveradiatingarea ES: Electricalstimulation Commission FCC: Federal Communicacions FDA: Foodand DrugAdminisrration FES: Iunctional electricalstimulation HP: Hot pack HVPC: High-volt pulsedcurrent ICIDH: Intemational ClassificationoI Impairments, Disabilities,andHandicaps IP: Icepack IR: Infrared
460
L: Left MEDr Minimal erythemaldose(for W treatment) MRI: Magneticresonanceimaging MVIC: Maximum voluntary isometricconffaction MWD: Microwave diathermy NDT: Neurodevelopmentaitraining NMES: Neuromuscularelectricalstimulation PCr Pulsatilecuffent field PEMF: Pulsedelectromagnetic PNF: Proprioceptiveneuromuscularfacilitation PSWD: Pulsedshorwvavediathermy with ultravioletA PWA: Psoralens R: tught elevation RICE: Rest,ice.compression, ROM: Rangeof motion SNS: Sympatheticnervoussystem SWD: Shotwave diathermy TENS: Transcutaneous electricalnervestimulation US: Ultrasound UV: Ultraviolet WHo: World Health Organization ': Minutes ": Seconds #: pounds
Units Unit (abbreviation): Measureof
Pulses per second (pps): Irequency when the errpnt<
Ampere (A): Electricalcurrent. 1 Ampere = 1 Coulomb per second Calorie (C): Energy.l calorie - energy required to jncrease the temperature of I g of waterby 1"C Coulomb (C): Electricalcharge Farad (F); Electdcalcapacitance Gauss (G): Magneticfield strength gram (g): Weight lJ.ertz (Hz)t Frequency.7 Hertz - 1 cycleper second foule f): Energy.1J = 1 Wsecond meter (m): Length,distance Ohm (O): Electiicalresistance.t n = H Pounds per square inch (psi): Pressure
:ra
nnt
rurlp<
Siemen (o): Electricalconductance Volt (9: Electricalpotentialdifference Watt (W): Power 1W=1Jlsec Watt per centimeter squared @/cm2): Intensiqy
Prefixes for Units pico (p): 10-12 nano (n): 10-Y micro (p): 10-o milli (m): 10-3 KiIo (K): 103 Mega (M): 106 Giga (G): 10e
461
Index
A A-deltafibers,47 ABl. SeeAr:lle-brachial index (ABI). Abnormal fetaldevelopment,diathermy therapists,395 Abnormalmuscletone,95-L03 rl:
^f
qqF
rnnrrc 1o I
Absolutecontraindications, definition of 10 Absolute refractory p eriod, 227 Absorptiorl definition of, 190 Absorptioncoef{icientsin decibels/cm,191f AC. SeeAltemating current (AC). Accessorymotion, 113-115 Ace wrap, 354 Acetaminophen ffylenol) for pan,59,60 inhibiting prostaglandin synthesis, 17 Acetylsalicylicacid (aspirin),17 Achillestendon lcnothcnino nF 1?5
ruptureof casestudy of,212-213 ultrasotrnd for, 200 Acidic reaction,236 Aciaeto bactetbaumanni i, 271 Acoustic streaming, 195 definition of 192 Acquiredimmunodeficiencydisease(AIDS).33 Actin ". 'l *',."1" r^-. ao relationship to myosin, 82 Actionpotential, 85, 227, 228f Activemotio4 112-113 restiction of, 422 Active range-of-motion, 1I9, 121t Activiry pacing for pain, 62 Acupuncturelike transcutaneouselectricalnerve stimulatiory233
Acute inflammation, 417-418, 426 cellularcomponentsof, 31f thermotlerapy contraindicated for, 163 tractioncontraindicated,3 13 Acute inflammatoryphase,pulsedultrasound tor,426 Acute injury tJ-rermotherapycontraindicated for, 163 tractionconffaindicated,313 Acutelocalskin infection,externalcompression contraindicatedin, 351 Acute pain, 42-43 Acute renaldiseasecausingedema,343 Acute trauma, extemal compressioncontraindicated ir\ 351 ADH. SseAntidiuretic hormone (ADH). Adhesion control of, 126 restricthgmotioq 117 Adhesivecapsulitisof shoulder,casestudy of, 404-405 , 435-436 Adverse neural tension, 122 restricting motion, 118 Age affecting healing, 33 AIDS. SeeAcquiredimmunodeficiencydisease(AIDS). Air,262f Air-filled sleeve,342 A.lcohol use,hydrotherapy contraindicated for, 281 Aldosterone,268 Aleve. SeeNaproxen sodium (Naprosl'n, Aleve). Alkalinereactioq 236 Alpha-gamma coactivation, 89 Alpha motor neuron,84f,86-87,87f damageof,96-97 range-of-motion exercisefor, 98 rehabilitation following, 97-98 immnhiliz:rinn
9R
inhibition of, 96f input to, 88f insufficient excitation of 98 sensoryinput to, 89f
463
Index
464 AIS. SezAmyotrophic lateralsclerosis(AlS). Alternatingcurrent(AC),221f beat kequency, 224f defrttaor' ot, 221 frequenry and cycle dwation,222t intersecting medium ftequency, 223f Alternativeactivationpathways,of complementsystem, 23t,24 Amber to genentestaticelectricity,4 AmericanPhysicalTherapyAssociation(APTA),position statementon exclusiveuseof physicalagents,6-7 Amino acid deficienry, 34 Amitryptiline (Elavil), 60 Amplitude, 240 dehn:jon of, 226 Amplitude modulation,definition of, 226 Amputation,342 residual limb shaping ake+ 347-348 Amyotrophic lateral sclerosis(AIS), hydro dterapy tor,27 6 funphylatox\r\s, 17, 24 Aratomical indentations,foam paddingaround,355f Ancient Greekbath houses,4 AncientRomanbath houses,4 Anestheric,236 Angina refefiing pain, 44 28 Angiogenesis, Arfmal studies,448-449 Ankle dorsiflexionof 113f elasticcompressionw rap of, 354t fl"i,-l^rl-,.'"-.,
AITA. SzeAmerican PhysicalTherapy Association (APTA). Arachidonicacid,andhealing,34 Archirnedes'principle,263 Arm ftacture,casestudy of 300-301 Arndt-Schulz1aw,373,373f Arrhythmias, electrical currents contlamdi.catedwlth, 237 Arterial insufficiency,extemalcompression Arthritis ofhiP casestudy of, 104-105 .h^.L
t'artmcnt<
oF 4
Ascendingneuralpathway,4Bf Ashworth Scale,79-90 Asia,cold lasers,384 Aspirin,59. SeeAcetylsalicylicacid (aspirin). Asthma exercise-induced hydrotherapy to4 294 water exercisefor, 268, 277 As),nTmetric tonic neckreflexes(AfNR), 80, 81f 33 At.heroscierosis, Athetoid movements,TT Athetoid-rypecerebralpalsy,103 ATNR. SeeAsymmetric tonic neck reflexes (AINR). Attenuatiorl definition of, 191 Auto-traction,318 Autonomic nervoussystem,51f Axon, myelin-wrapped,saltatoryconductionalong,86f Axons,rearborizationof, 97f
F^'
B hydrotherapy for rianrrmpnt:tinn
nF 294
injuriesof caseswdy ot, 37, 254 inversionof casestudy of, 405 -l'^r"
Fl"v^'. ^F
treatment of, 105 sprainof casestudy of, 364-365 extemalcompressionfor, 358 Ank1e-brachialindex (ABI), 350 Annulusdisplacementtractioq 315 Anterospinothalamic tract, 49 Antibiotics,33,266 inwhirlpools, 277-272 59, 60-61 Antidepressants, Antidiuretichormone(ADH), 268 Antiembolismstockings,355,356f Antigen-antibodycomplex,24 Antirnicrobials, 33, 266 lnwbrlpools,27l-272
Backpain casestudy of, 105-106,25I-252 hotpack for low casestudy o1,178-779 electrodeplacementfo5 243f tractionfor,310 Backsuain,low, casestudy of,432-434 R:rrprie
nnlifnm
?9R
Bacterialinfectio4 future researchoq 444 BadRagazmerhod,276 Balance,limited, hydrotlerapy contraindrcatedfor, 287 Ballismus,definition of 77 Ballisticstretchingfor motion restriction,125 Bandage compression,353-354 for chroniclymphedema,363 elastic,347-348 inelastic for chroniciymphedema,363 semingid,354
Index
Basalganglia,93,94f Basophilsin inflammanor,22,3lt Bathhouses,ancient,4 Baths contrast,277 ,290-291,29It applicationtechniquefor,291 for acuteinflammation,417-478 Epsomsalt for sore or swollen limbs, 4 parafhn,171f applicationtechniquefor, 162 Beamnonuniformity,188f BeanNonuniformity Ratio @NR),188 Beats,222 Behaviormodification,62 Bel|'spalsy,232 casestudy of, 104 Be1ts,327 positioningfor lumbar traction,323f Bicepsbrachii,hypertonicityof, 106 Biofeedback -l--i-^-. ,^-.--L, , for high muscletone, 100 muscletone,98 Biphasicpulsedcurrert,221,222f Bleeding hydrotherapy contraindicated for, 278 resultingfrom hydrotherapy,2Sts-284 resulting ftom thermotherapy, T6T Blepharospasms,ultraviolet radiation, 378 Blood cells,bandingof, 207f Bloodclot electricalcurrentscontraindicated with, 238 tlrermotherapycontraindicatedfor, 163 Blood flow cryotherapydecreasing, 138f decrease in, 138-139 increasein, 15 Bloodvessels,growth otnew,28 BNR. SeeBeanNonuniformity Ratio (BNR). Body,buoyancyin water,263 Body diagramsfor markingpain,59f Bone coldlasersfor, 386 ftacture of ultrasoundfor, 200-201,201f healingof 36-37 pulsedshortrvavediathermyfor,395 Boneandjoint disease,4 BonybIock,422t,423 Bowelincontinence,hydrotJrerapycontraindicated for,280 Breastimplants,ultrasoundfor, 206 Breathing,268
465
Brieficing, t5!-152 applicationof, 154-155 Buoyatcy,263,264t Bum-damagedskin,342 Bums casestudy of,434-435 diathermy,398-399 hydrotherapytor,270-273,273 resulting hom hydrotherapy, 283 resultingftom lasers,387 resultingfrom thermotherapy,I66-167 ultravioletradiatioq 378 Bursitis,hydrocorrisonefor, 203 Burstmode,227,227f trarscutaneouselectricalnervestimulation,233 C Chberq47 transmittingpain,46 Cables,390 Calcifictendonitisofshoulder.ultrasoundfor. 199 calcium depositsof resorptionof, 200 osteoblasts lasers,386 ultrasound effect on, 195 Calor,15 Canada,cold lasersin, 384 Carcer. Seealso Maligr.ancies. extemalcomprcssioq352 Caxdidaalbicats,271. Capacitiveapplicator,401 CapaciavepIates,S9l-ts92 Capacitiveshortwavediathermyplates applicatorsof, 391f electricfield distributionbetween,391f Capillaryloop,2E Capi,tatedpayment,42T Capsularligaments, healingof 35-36 Capsularpattemsof motion restrictioq 115 Carcinogenesis, ultravioletradiation,378 Cardiacdisease,electricalstimulation,238 Cardiacfitness,water exercisefor,276-277 Cardiac insufficienry, drermotherapy effect on, 165 Cardiovascular accident,haction,318 Carotid sinus,electricalcurents conbaindicatedwirh,2ST Carpaltunnel syndrorne,ultrasoundfor,201-202 Cawierfrequency,222,245 Cartilage,healingof,35 Casereport,445-447 Casestudy of Achillestendonrupture,21.2-21.3 of adhesivecapsulitisof shoulder,404-405,435-436
466 Casestudy-cont'd of anKenjurles,2,37,254 of ankleinversion,4O5 of anlle sprain, 364-365 ofarm fracture,300-301 of backpain, 105-106,251-252 ofBell's palsy,104 ofbuns,434-435 of chroniclymphedema,S62-363 of epicondylitis,156-157 of hemiplegia,106-107 ofhip ardritis, 104-105 olhip fracture,2ll-2|2 of kneeinjury 155-156,430-432 of knee pah,252-253 otlowbackpain,ITl-l79 ofiow backstrain,432-434 otneckpan,2ll-212 of non-insulin-dependent diabetesmellitus, 779-180 of osteoarthritis,157-158,177-178,298-299, 336-ts37 ofParkinson'sdisease,107 of pressureulcer,213-214,299-300 ofpsoriasis,3S3 of radiculopathy,335-336 of rheumatoidarthritis,337-338 of sacralpressureulcer,406 of shoulderadhesivecapsulitis,404-405, 435-436 of stroke,428-430 hemiplegiafollowing, 106-107 of tissue healing, 436-437 ofvenous stasisulcer,363-364 Cast,alphamotorneuroq 98 Causalgia,S0 Cavitaaon,192t,1,95 definition of, 191-192 Celebrex.SeeCelecoxib(Celebrex). Celecoxib(Celebrex),59 Cellmembrane,ultrasoundeffecton, 195,393 Cellularresponseto iniury,2L-22 Celsus,Cornelius,15 Centralaxislumbartraction,321f Central hl.persensitization, 43 Cenhalnervoussystem injuriesof andmuscletone,9 tissueof ultrasoundcontraindicatedwith,205 Centralpainpathways,50f Centralpathways,48-49 Centralsensorydeficitslhydrotherapyfor,2T6 Cerebellum,muscles,92-93
Index
Cerebrallesions,hlrpertoniciryfollowing, 101 Cerebralpalsy athetoid-type,103 hypertoniciry following, 101 accidents.SeeStroke. Cerebtovascular Cerebrovascular comprornise,traction,315 insufficiency,externalcompressionfor, Cerebrovascular 352 Ceryicaltraction documentationo! 334 haltersfor,328f manual sining,333,334f suprne,333,334f mechantcal,S26-327 stpine,327f Charge,definition of,221 Chemotacticfactor,ultrasoundeffecton, 195 Chemotaxis,17 CHF.SzeCongestivehean failure(CHI). Children cryotherapy applicatiorr over,146 facescalesiq 55f healingin, 33 Chorea,definition of,77 Choreiformmovements,definition of,77 Chronaxie,229,229t Chronicinflammation,S0-32,418-479 cellularcomponentsof, 3l f tissuehealingpromotioq 418t Chroniclymphedema,casestudy of,362-363 Chronicpain,43-44,420 water exercisefor, 420 Chronicwounds, ultravioletradiationfor,375 Circulation poor contraindicatingcryotherapy,145 rhemotherapy e[fecton, 165 Circulatorycompromiseconbaindicating cryotherapy,l4s CIVD. SeeCold-inducedvasodilation(CIVD). Clasp-kdfephenomenoq76 Classicalactivationpathwaysof complement system,23f,24 Clinical relevance,452 ClinicsoutsideUnited States,425-426 Clonus,definition of 76 Closed-chainexercise,275,276f Cloning factor)OI, 17 Coaltar,375 Cognition,impaired,hydrotheraPycontraindicatedfor, 279 Cognitiverestructuring,62 Cohereotwaves,384f
457
Index
Cold effectsof 138-141 effectson musclecontractionstrength,140f hemodynamiceffectsof 138-139 high muscletone associated with, 99-100 treatrnent for, 103 hvnercFn.irnrirv
r^
contraindicating cryorherapy, L44 intolerance to contraindicating cryotheary, 144 -"r"h^li.
"Ff""f"
^F 111
neurcmusculareffectsot, 139-141 Cold cryotherapy,137-138 Cold hemoglobinuria,paroxysmal,contraindicating cryod\erapy,145 Cold-inducedunicaria,contraindicatingcryorherapy,I44 Cold-inducedvasodilation(CND), 138 Cold lasers effectsof, 384 FDA, 384 for procollagen RNA, 386 for surgical wounds, 386 for venouslegulcers,386 for wound healing,386 in.li.rii^n<
F^r ?R6
low-intensify,384 lower-energy,443 vasodilation,386 Cold pack,134-135,148,748f applicationtechnique,149-150,149f Cold therapy. SezCryotherapy (cold therapy). Cold whirlpool, 287 Coliform bacteria,29B Collagen andin|ury29 coldlasersfor, 386 extensibilityof and physicalagents,9 rcspondingto temperature,9f Iiben of normal, 117f ruifh.r^cc-lihL.
1 17f
increasedextensibilityof in lesponseto heat, 160-161 lysisof 29-30 --^,t,.^i:^-
^f
t<
t<
ryrnthesisof 29 and diabetesmellitus,33 dTpesof,29t Collagernse,29 Colles'fracturesultrasoundfor, 201 C^--1.-..
r .-.t.-
and immune response,23-24
Complement system-cont'd overviewof,23f Complexregionalpain syndrome(CR?S),50, 421 Compression,342-365 cryotherapy with, 143f external.SecExtemalcompression. for acuteinflammatioq 417 for kneeinjury,430 for residuallimb shaping,348f inrelmirrenr ennlirerinn
q4, nF ?6Ot
forvenousstasisulcer,364 intermiftent pneumatic for lymphedema,35Bf for suoke, 429 preventing DVI, 347f reducing€dema,346 sequential,359 slauc applicationtechniquefor, 353 for ank.lesprain, 365 garments,342 Compressionbandage,353-354 for chroniclymphedema,363 Compressiongarments,354-355 applicationtechniquefo5 357 Compressionhose for DVT, documentation of, 365 Compressionpumps,359 intermittent precautionswith, 351-352 intermittent pneumatic, 356 applicationtechniquefor, 358-359 sequential precautionswith, 351-352 Compression-rarefaction wave,ultrasound,1B6f Compressionsleeve,applicationof 359f Compressionstockings,342 graded,347 Compressionwrap elastic,354f Conduction, 734-136,229 by water,263 Conductivityof differenttissues,390 Confu sioq hydro*rerapy conhaindicated for, 279,281 Congestivehean failure (CHI) causingedema,343 extemalcompressioncontraindicated in, 349 Conjunctivitis, ultraviolet radiation, 378 Connectivetissue,elasticiqyof, 82 Contactsensitivity,ultravioletradiation,375 Continuouspassivemotion (C?M),32-33 machine Io! 33f Continuous shortwave diathermy, 4
hder
468
Continuous ultrasound, I9B| 197 definition of 188 Contractiletissues,restrictingmotion, 115-116,L15f resftictingmotion,116-117 ContracturesJ Conftaindications absolute definition of, 10 definition of 10 Contrastb adts,277,290-29I, 29It applicationtechniquefor, 291 Ior acuteinflammation,4l7 -418 Controlledcold compressionunit, 150,152f application tecbnique, 152-153, I53f Controls for researchstudies, 449-451 Convectioq 136 by water,263 electricalnervestimulation, Conventionaltranscutaneous 233 Coolingunits for cold packs,148f Coping skills for pain, 62 intrauterinecontracepdvedevices. Copper-bearing diathermy,399 Corticospinaltract,93f 236 Corticosteroids, and healing,33 localinjectionof 61 Cortisonefor pain, 61 Cost effectiveness,427, 42Bt Cotton supports,tubularelastic,348 COX2. SeeCyclooxygetase dlpe 2 (COX2) inhibitor CPM. SeeContinuouspassivemotion (CPM). Creep,I23,123t Cross-bridge,formatronof. 80-82,82f Cross-link,formation of, 25-26 CRPS.SeeComplexregionalpain syndrome(CRPS). Cryoglobulinemia contraindicating cryotherapy, 144-145 Cryokinetics,144 Cryostretch,144 Cryotherapy (cold dr erapy), 137-738 "A-".""
"tt".te
^F 1A6-117
aflecting healing, 32 agentsfor, 137f applicationtechniqueot, 1.47-148,1.53-154 to, 144-145 contraindications effectsof, 180f for acuteinfl ammatiorl 417 for bony block,423 f^, a ^ i.^n7{r 'li ii.
I 57
for extremiqt/ radicular pain referred ftom spinal nerue toot,420 for initial rnjuries,417 for kneeinjury, 156,430 for low back strair5 433 for motion restriction,422
Cryotherapy-cont'd for osteoarthritis,157-158 for pair, 420,426 lor relerred pain, 420 for soft tissueshortening,423 precautionsfor, 146 sequenceofsensationsin responseto, 147 lses of, L4L-144 vs.thermotherapy,180-181 with compressionand elevation,143f Cuffentamplitude electricalstimulation,249-250 modtiatron,226f. Curre^t density,244 Cushing'ssyndrome,corticosteroidsfor, 61 Custom-fit garments,elastic,348 CutaneousreceptorsJ 91-92 CutaneousT-celllymphoma,ultravioletradiation for,375 Cutaneousvasoconstriction,138 Cutaneousvasodilation,159 (-.,.1"< h.r <e.^n,i
1Rq
type 2 (COX2)inhibitor Cyclooxygenase pain,59 for Cy'riax,James,308 D DC. SeeDirect curent (DC). Debridementfor tissluehedrng,437 Decaytrme,225f deftniion of,224 Deepheating forlowback strair; 433 for shoulderadhesivecapsulitis,436 Deep tissue,nonlhermalpulsedshornvavediathermy f or, 398 contraindications Deepvenoustlrombosis pVT), 346-347 extemalcompressioncontraindicatediq 350 intermittentpneumaEc compression ptevent:.lj.l,347f 360-361 Deflationtimes for extemalcompression, Delayed-onsetmusclesoreness(DOMS), 142 D€layedprimary intentioo,28 Dendrites,83 Deneryatedmu6cle,232 Dependentsickpatient role,44 with, 44 Depression,disturbedsleepassociated Dermal ulcer infraredradiationfor, 162 ultrasoundfor, 197-198 Dermatologicdisorders,sunlightfor, 4 radicularpain referredfrom Dermatomefor extrem.iqy spinalnerveroot, 420
Itdex
Dexamethasone, 236 andhealing,33 for pain, 61 Diabetesmellitus and healing,S3 wound care hy drorherapy tor, 270-273 Diabeticglomemlonephdtiscausingedema,343 Diapedesis,18 Diaphragm refering pain, 44 Diathermy, 5 adverseeffectsof 398-399 applicationtechniquesfor. 400-401 associated risk of, 424 capacitiveapplicatorfor, 401 contraindications fo q 395-397, 396t definition of, 387 documentation for, 400 etfectsof,392-393 for adhesivecapsulitisofshoulder,404-405 for low backstraiq 433 for motion restdction,422 for pain from malign ancles,421 heat distributionfrom, 443 historicaldevelopment ot, 393-394 indicationsfor, 393-395 inductiveapplicatorfor, 401 magnetron microwav e applicator, 401-402 nonthermal effects of, 393 physicalpropertiesof 382-388 precautionsfor, 399 <.;Pnr;hc
meiir
rh'r'hi+
'hhk,i6-
^F
A)A
precautionsfor, 395 thermaleffectsof 392-393 typesof, 389-390 ultrasound convercioninto, 136 u,durcrury ucvrc(s - ^^^^ -i ^ ^^ ^c ii t-
selectionof 403-404 Direct curent (DC), 221f d,ehrutionof, 221 low intensity,233 Disability, definition of 6 Disc bulging of traction, 3 11 hemiation of restricting motion, 118 ffaction,311 protrusion of compressingL4nerverooq 316f reductionof, 309
469
Disc-cont'd nrntnrcinn
nf-rnnt'.{
tractior! 316 spinal sepa€tionon, 321f Diseaseaffectinghealing,33 Disorientation hydrotherapycontraindicatedfoq 281 traction,317 Distraction technigues for pain, 62 Disturbedsleepassociatedwith depression,44 DNA synthesis, electrical stimulatioq 234 Documentation of compressionhose,365 of electricalstimulation,250-251 ot externalcompression, 357-358 ot hy d.rorhenpy, 294-295 of spinaltraction,334-335 ^F rh.m^rh..:--
177
of ultrasound,210 of uluaviolet radiation,382 Dolor, 15 DOMS. SeeDelayed-onsetmusclesoreness(DOMS). Dopamine musde tone,83 replacementof for Parkinson'sdisease,107 Double-blind applicarion, 450 Drowning kom hydrotherapy, 283 Drum applicatorfor diathermy,401 Drums,390 Dupu)tren's contracture,125 Duty rycle, 189f definition of 1BB,225 DVL SeeDeepvenousthrombosis(DVf). Dynamic stabilizatio n exercise,426 Dynamometer,hand-held,77 Dyskinesia, definition of 77 Dystonia,TT E EastemEurope,cold lasers,384 Eczema,ultravioletradiationfor, 375 Edema adverseconsequences otJ345-346 causesof, 343-344 compressionreducing,346 eatarhp,aa,,
F^.
ta7
definition of 1B electricalstimulation,234 ortl otf tiIr'e, 249 rrF,rhehr
rima
?5O
electrode placemeat tor, 244t from hydrotherapy, 284
470 Edema-cont'd
l{r'PC,234
hydrctherapy for, 277-278 nonthermal pulsed shortwave diathermy for, 398 contraindications of limbs, 342 diathermyfor, 394 pulsedshort'arave restrictingmotion, 117 NCE for, 426 thermotherapy effect on, 165 Effective radiating area (EM), definition of, 189 Elasticbandage,347-348 Elasticcompressionwr aP,354t Elasticcustom-fitgarments,348 Elasticdeformationvs.plasticdeformation,124f Elavil, SeaAmitryptiline (Elavil). Etbow,113f Elderly cryotherapyapplicationover,146 healing iq 33 Elecuiceddy currents,389 Electric fields distributionof, 402f induction of,390f Electricshocksappliedvia torpedofish, 4 Electricalculrents,4, 219-255 affecting healing, 32 clinicalapplicationsof, 230-232,237 for, 237-238 conEaindications definirionof,220 eftects ot,227 -230 historicaldevelopmert of,220 ionic effectsof 230 termlr'ology for, 220-227 Electricalmechanicaluaction units,319 Electricalstimulation adverseeftectsof, 239-240 applicariontechnique of, 240-250 documentationof 250-251 for alpha motor neuron damage,97 for ankle injury 254 for cardiacdisease,238 for chronicinflammation,418 for edema,234 for extremiry radicular pain referred from spinal nerve rcot,420 for hemiplegia,107 for impairedmentation,238 for inl ammaaon, 249, 426 for kneeinjury 250,430 for motion restriction,422 for neck andbackpain' 251-252 for pain,62 f or proliferativephase,426
hulex
Electricalstimulation-cont'd tor reteredpai.n,420 for stroke,429 for tissuehealing,437 ftequenq,245-246 stimulation. SzeMotorJevelelectrical motor-level. muscletone,98 241 of lowerextremities, 239 of malignancies, 245-246 parameterselectton, for,241 patientpositioning for,238-239 precautions pulseduratio4 245 195 with ultrasound, of, 4 stalic,Seneration Electricity, Electrodes of, 240 application placemeftot,242-250 242 spacingbetneer., spacingof,242t typesof,247-242,241t 4 agents, Electromagnetic nonthermal,373 (ELF) 7-372 w aves,37 fieldfrequency Electromagnetic fields Electromagnetic 395-396 malignancies, ^;.-tetian
nt
71f
Electromagneticradiation, 37I -406 physical prope*ies of,37 t-372 physiologicaleffectsof, 373 ultrasound affecting healing, 32 Electromagneticspectrum, 372f wave, wavelengthof,372f Electromagnetic Electromyography (EMG), 77-7I biofeedback for high muscletone, 100 electrodes,78f surface,78f Electronic devices,nontJrermalpulsed shortrvave for, 398 diatlermy contraindications Electronic equipmeot, diathemy, 399 Elevation, cryotherapy with, 143f field frequency(ELF)waves. ELESeeElectromagnetic external compression pulmonary, EmboLism, contraindicatedir\ 350 (EMC). EMG. SeeElectromYograPhY Emigration,1I Emotionalstress,opiopeptins,54 End-feels,121t with, 388 Endocrineglands,laserscontraindicated Endogenousopioid system,53-54 Endorphins,426 Endurance,limited, hydrotherapyconuaindicatedfor, 281
471
Iader
Eosinophilsin inflammation,3lt 32 Epicondylitis, caseswdy of, 156-157 Epidermalhyperplasia,ultravioletradiatiorl 374 Epilepsy,hydrotherapycontraindicatedfor, 280 Epiphysealplates,ultrasound,206 Epiphyses,diathermycontraindicated,392 Episiotomies,ultrasoundfor, 199 Epithelialization,25 schematicdiagramof 26f Epsomsaltbathsfor soreor swolJenlimbs.4 ERA. SeeEffective radiating area (EM) . Eryrhema,379 ultravioletndiation, 374 Erythrorytes (red blood cells)and inflammatory response,2l Ethyl chloride,151,153f Evaporation,137 Exercise closed-chain,275, 276f dytramic stabilization, 426 for proliferativephase,426 heartrate responseto inwater,268 in hot water, 4 inwater, 265t open-chain,275, 276f pool t^' ^(ra^r*hrid.
?qq
r:noe-nf-mnrinn
for alphamotorneuron damage,98 F^' ^erF^rrth.iriq
^f ,q.4
watet exerdse for, 268, 277 Exercisepool, 293 infectionconuol for, 298 purpose-designed with treadmill,294f sateLyprccaurions to\ 297-298 Externalcompression conhaindicationsfo! 349-350 documentationf or, 357-358 elfects of,342-343 for ankle sprains,358 for cancer,352 insufficiency,352 f or cerebrovascular F^' h.martancinn
l'."l-"-r
?5?
for impaired mentation, 352 for impairedsensation,352
ri-
q61 "
motion, 114f Extraaticularaccessory Extraarticularedema,117 Exbacapsula!ligaments,healingof 35-36 Exffavasatioq1B Limbs. Extremities.Szea,lso edemaot,342 lower electricalstimulationof, 241 in whirlpool, 288f upper compressiongarment,355-356 electricalstimulationof, 241 whirlpool,285f Eyes damageto ultravioletradiatiorl 378-379 diathermy contraindic ated, 397 infrared irradiation to, 164 .A-",
17R
therapeutic for alphamotorneuron damage,98 usedwith physicalagents,7 water. SezWater exercise. asttrma Exercise-induced hydrotherapy for ,i^."-"-r"ri^-
Extemalcompression-cont'd for lymphatic circulation, 342 for lyrnphedema documentationof, 358 for stroke,352 for superficialperipheralnerve,353 for venouscirculation,342 indicationsfor, 343-344 inflation and deflationtimes,360 infl ation pressure,360-361
atqpe+< 167
lasers,387 contraindicatedin, 3BB ultravioletradiationcontraindicatedfor, 377 F Iace scalesratingpain in children,55f Facialparalysls,232 Iacilitation, 143 Iainting resulting ftom hydrotherapy, 283 resulting from therm otterupy, 167 Fast-twitch muscle fibers, 230f Fat layers, diathermy, 400 ICC. SeeFederalCommunicationsCommission
(rcc).
IDA. SzeFood and Drug Administration (FDA). Iear of water, hydrotherapycontraindicated for,28t Iederal CommunicationsCommission(FCC),medical applicationsfrequencies,387 Fee-tor-semice,427 Feldene.SeePiroxicam(Feldene). Fentanyl, 60 FES.Ssslunctional electricalstimulation(FES).
472
Index
Fetus abnomal d€v€lopmentof diathermytherapists,395 thermotherapyeffecton, 164 Iibrh 20 Iibroblasts cold lasersfor,386 electricalcharge,234 synthesizingprocollagen,25 Fibronectin,18,20 Fibroplasia,25 Fightor flight, 50, 94 Filariasiscausingsecondarylymphatic obstructioq 345 Finger,immersedin cold water,hunting responseof 139f Finsen,Neils,375 erythema,379 First-degree First intentioq 28 Flaccidparalysis,96 llaccidiqy, deftnition of, 76 Ilexor withdrawal, 91f Iluctuating muscletone, 103 Iluid balance,342 Iluidotherapy,171 applicationtechnique for,174-175,175f controIs,174t
Iree nerveendings,45 Irequency,definition of, 189,224 Irequencymodulation,definition of 226 Functiolaesa,15 Functionalelectricalstimulation(FES),101 Functional limitation, definition of, 6 Functiona.lftainint usedwith physical agents,7 G CABA. SeeGamma aminoburl'ric acid (CABA), pain. (CAC). GAG. SezGlycosaminoglycan Gait training,ramp time, 249 Callbladder referring pain, 44 (GaAlAs)low-level laser Gallium-aluminum-arsenide investigationaldeviceexemption FDA, 384 Callium-arsenide(Ga-As),382 Calvanotaxis,234 Cammaaminobutyricacid (CAIA), pain,53 Gamma rays, 372 Gatecontrolmechanism,49f Cate controltheory of painmodulation,5, 52-53, 232-233 Ciardia lanblia, 298 Glomerulonephritis,diabetic,causingedema,343 Clycosaminoglycan(GAC),25 C^ll
for complexregionalpain syndrome,421 for osteoarthritis,178 Fluorescent lamps,382 FluoriMethane, 151,153f loam paddingaroundanatomicalindentations,355f Iood and Drug Administration(FDA) cold lasers,384 diathermydevices,403 low-level laser gallium-aluminum-arsenide investigationaldeviceexemption,384 Ioot elasticcompressionwrapof, 354f fi',i/|^rhFanw
Iprf Fnr
Golgi tendonorgans(CTOr, 89-91,91f, 310 Gradedcompressionstockings,347 Graft-versas-host disease,ultravioletradiationfor, 375 Granulationtissue,25 Groupdesignstudies, 447-448 GroupIll afferents.SeeA-deltafibers. GroupfV afferents.SzeC fibers. GTO. 5zzGolgi tendonorgans(CTOs). Cua(ding,99-100 Guillain-Barre syndrome, 96 Gynecologicalsurgicalwounds,ultrasoundfor, 199
f^r
H ultrasound,209f Forcefor traction,324-325 Forearm,infraredirradiationfor documentalon of,177 FIacture alphamotorneuron,9S arln casestudy of,300-301 cold lasersfor, 386 Colles' ultrasoundfor,201 extemalcompressioncontraindicatedin, 351 healingstagesof 36 tibial diaphyseal ultrasound for, 201 ultrasoundfor, 201t 206
Hageman factor, 17 activationof, 17f HaLn,Joharn,270 Half depth,definition of 191 Halters,3l5 , 327 forTMJ,328 Saunders,328f Saundersfrictionless,329 Hamstring,253f Hand eclematn electtodeplacerr'er't tor, 244t paraffin for documentationof, 177
hdex Hand-helddlnamometer,ZZ Hard callusstage,37 Head injuries to alphamotorneuron, 98 hypertonicity following, 101 letlex responses to, B1f Headache,shocktreatmentsof. 4 Healing ageaffecting, 33 by epithelialization,25 by primary intentioq 2Zf by secondaryintention,2Zf tactors aftecting,32-84, 32t maturationphaseof, 29-30 olbone,36-37 shortwavediachermyfor, 395 .pulsed ot capsular ligamenr, 35_36 or carcftge,J5 phasesof, 8 physicalagentseffectsoq 417 primary 36 proliferationphaseo! 24-29 superficialheat for, 162 wound. SeeWound healing. Health caredelivery systen,s;427-42g Health spas,4 Hearrfailure,externalcompressionconrraindicared in, 349 FreaftraLeresponseto warer exercise,269 Hear.,l5..5ee akofhermotherapy (heat). ror hrghmusde tone, 100 for proliferative phase,426 low-load prolongedstretchwith, 161f specific,134, 134t, 262t of air,262t therapeutic application of, 4 transfer of by conduction,134-136 by convection,136 mod,esof, 734-137 watet harlsfet ot,263 Heat shockresponse,lasers, 386 Heating by magnericfield method,389 deep for low back strairl 433 of shoulderadhesivecapsulitis,436 superficial,270 Heavy-dutynon-slipthoracicbelts,822 Helium-neon(HeNe)laser,382 Hemarthrosis,2 1 Hernatoma and infl ammatoryresponse,21 inmuscles,2l Hemiplegia,casestudy of, 106-107
473
Herniplegia,spastic,definition of, 26 Hemorrhage laserscontraindicated[or, 388 thermotherapycontraindicatedfor, 163 treatment of, 4 Hemostaticresponse,19-20 Herpeszoster,ultrasound tor,203-204 High-intensityhot lasers,384 High muscletone,99-103 consequences of, 100t treatmentof, 100,103 High late transcutaneous electricainervestimulatioo,238 High voltagepulsedcurent (HWC), 233 i11p
arthritis of casestudyof, 104-105 rIACTUIEUF
casestudy of,27I-212 refering pain, 44 Hippocrates,262 Histamine aftertissueinjury, 16 ultrasound effect oq 195 Hold/relaxtimes for traction,324 noman's srgn,35U Home taction devices,320f Hose,compressionfor DW, 365 Hot packs,2, 134-135, 169t-17Of application ot, 167-169, 170t associated risk of, 424 beforestretching,7 documentationof, 177 for chronic paiq 420 for low backpairl 179 for motion restrictioq 422 for soft tissue shorterung, 428, 426 with ultrasound,195 Hot whirlpool, 287 Householdbleach,296 Hubbardtanl whidpools, 278, 286-287,286t,29Of applicationtechnique for, 289-290 Human studies,449 Hunting response,139,139f HM)C. SeeHigh voluge pulsedcurrent(HVpC). Hyaluronicacid,25 Hydrocortisone,203 Hydromorphone,60 Hydrostaticpressure. 263-264, 26Sf. 267,A4Z rnlluence on tissuefluidbalance,343f Hy drodterapy,3, 262-301 adverseeffectsof 283-284 applicationtecbrique ot,2B4-2BS bleedirg trom,283-284 bums from, 283 cardiovascular effects of,267-268
474
hrdex
Hydrotherapy-cont'd cleansingeffectsof 266 fo\ 278-279 corlfta]f\dications do cumentation of , 294-295 ,.1.^. ^,ni n d F,^'.
tae
edematrom, 284 faintingfrom,283 for alphamotor neurondanage,9T for ankleinjury documentationof 294 for arm fracture, 301 forburns,273,434 for central sensoryd eftcits,276 tor edema,277-278 for exercise-induced asthma documentationof, 294 forhigh muscletone, 100 for initial injuries,417 for obesity documentationof, 294 for osteoarthritis,299 torpan,277 for pressureulcer,300 forsuoke,276 for traumaticbrain injury,276 torwotnds,426-427 hyponatrernia,284 muscletone,98 musculoskeletal effects ot,266-267 patient educationfor, 285 physiological€ffectsof,265-269 ptecartjonstot,282-283 psychologicaleffectsof,268-269 renaleffectsof, 268 respiratoryeffectsof, 268 safeE of,295-298 selectionot,2S4-295 usesof,270-278 Hyperemia,15 Hypermobilejoint, tractioncontraindicated, 313 Hypersensitization,wind-up,43 H'?eftension andhealing,33 cryo*rerapyapplicationover,146 extemalcompression,352 Hyperthermia,matemal,164 Hypeftonicity, 101-102 definition of 76 following spinalcord injury treatrnentof, 101 following stroke, 102 Hypertrophicscars,29, 34Bf control of, 348 Hyponatremiaftom hydto$erapy,284
Hypoproteinemra causingl)'mphedema,345 exteff€l compressioncontraindicatedin, 351 I
Ibuprofen (Motrin) and healing,33 forpain,59 ultrasound,2OS Ice for acute inflammatory phase,426 for muscletone,426 for proliferative phase,426 thermalconductivityof, 136 with ultrasound,195 Icecup, 150f quick strokingwith, 154f lce massage,150 applicationtechniqr.re for, 151 for soft tissueshortening,423 lce packs,148 applicatjontechnique, 149-150 Icing briet,151-152 applicationof, 154-155 forhypertoncity,ll2 quick, 143 formusclehypotoniciry 421 Immersion cardiovascular effectsof,267f rcnaIeffectsof,270f respiratoryeffectsof,269f Immobilization,417 traction,310 Immune response,23-24 media{on of,23-24 Immunosuppressive drugs,33 Impactioq 36 Impairedcognitioq hydrotherapycontraindicated tor,279 Impairedmentation contraindicating physical agents,10 electricalstimulatioq 238 externalcompressioq352 thermotlerapy contraindicatedfor, 163 Impairedsensalion contraindicatingphysicalagents,10 electricalstimulatiorl 238 extemalcompressioq352 thermal hydrotherapy contraindicated for,279 thermotherapycontraindicatedfor, 163 Impairments,definition of, 6 Impedance,definition of, 221
475
hdex
Implanted nerye stimulators, diathermy contraindicated, 396 In vitro studies,448 In vivo studies,448-449 Incontinence bowel hydrodrerapycontraindicatedfor, 280
uinary,2ts2 hydrotherapycontraindicatedfor, 281 Indirectunioq 28 Induction,36 I-.1,,-ii^-
Fk.^-'
Qn
Inductiveapplicatorfor diathermy,401 Inductive coil applicator,389-390 shortwavediathermy,390t,391f, 392f, 402f magneticfields,390f Inductivedrum diathemy applicator,magneticfield,391f 363 Inelasticbandagefor chroniclynnphedema, lnfection d[<(ulB
rrcd!,r5,
rz
and diabetesmellitus,33 bacterial future res€archon, 444 from hydrotherapy, 284 hydrotherapy contratndrcatedfor, 279, 280 Infectioncontrol lo r whirlp o oIs,296-297 Inflammation acute.SeeAcute inflamnration. and fractures, 36 LdruurdL rrBur ur, rrr
causesof, 14 causingsecondaryly'rnphatic obstruction, 345 chroruc,30-32,478-419 cellularcomponentsof 31f tissuehealingpromotion,41Bt control of 126 .^,^tl.'atznw
Far
141 -1 A')
definition of 14 electrical stimulation .,,...^t
"^^lir"A.
).44
leukocyticeventsin, 19f phasesof, 14 E^--- ).^--^^ rruw uu6rd,,,
^t l tt ur, rir
time Lineof 15f physicalagentsfor,7-8, 417 RICEfor, 426 subacute,30 ffeatment of, 4 ultrasound,206 vascularpermeabiliryin, 1B-19 mechanismsof,20f
Inflammationphase, 8, 75-24,24t cardinalsignsof, 15 durationof 16 vascularresponse,16-17 NSAIDsvs.steroids,34f Inflammatorycascade, Inflammatoryresponse cellsinvolvedin, 21f mediatorsof, 16f, 1Bt Inflationpressurefor extemalcompression,360-361 360-361 Inflation times for extemalcompression, Infrared(IR)radiatiory 162,372 damagingeyes,167 damagingskin, 167 documentationof, 177 for dermalulcers,162 for motion restriction,422-423 for soft tissueshortening,423 to eyes,164 Tnkaredlamps,171-176, t7 5f applicationtechnique tor, 176-177 for openwounds,5 Inhibitory casting for hypertonicity, 102 Inhibitory pressurefor hypenonicity,102 Initial iqury, 417 tissuehealingpromotion,418t
Iniury acute thermotherapycontraindicatedfor, 163 313 haction contraindicated, d[cru,,B
rz "Edn,,5,
cellular responseto , 21-22 hemostaticresponseto, 19-20 immune responseto, 23-24 inlria|,417 tissuehealingpromotion,418t wound conuaction,26-28 Innervatedmuscle,230-231 Insulator,342 Insulin,ultrasound,203 lnrensit/, 226 definition of, 187-188 Letention, primary, 28 lnterbvrct i\teNal, 227 Iterlerential cuuent, 222 Intermittentcompression,342 applicationof ^"--"r"^
fnt R60t
for venousstasisulcer,364 lntermittent compressionpumps, precautionswidl 351-352 Intermittent compressionunits, 360f Intermittentpneumaticcompression for lymphedema,358f for saoke,429 preventing DVI, 347f
hdex
476
Intermittentpneumaticcompressionpumps,356 applicationtechniquefor, 358-359 InteImittent traction,323-324 durationof, 329 lorce for, 329 frequerr:y ot, 329 hold/relaxtimesfor, 328-329 Intemal organs,nonthermal pulsed shortwave diathermy contraindicationsf or, 398 Interphaseintewal, d ekrtrttor' of, 224 Interpulseinterval,225f defininon ot, 224 Intervertebralforamen,narrowing of 311 Inffaarticularedema,117 ligaments,healingof, 35-36 Intracapsular Inffauteine contraceptivedevices,copper-bearing, diathemy, 399 Investigational device exemptiorl gallium-aluminumarsenidelowlevel laser,FDA, 384 Ionic effects,230f Ions for iontophoresis,236t Iontophoresis,235-237 curent amplitude,236t drug deliveryelectrode for,243 electricalstimulation r'.'r-.-r
rinF
,50
electrodeplacementfor, 244f fo! acute inflammatory phase,426 ions usedfor, 236t tissuehealing settings,248t IR. SeeInfrared (IR) radiation. Irrigationpressure,272t Ischemicheartdisease,277
I(nee-cont'd injury of casestudy of 155-156,430-432 pain in casesndy of, 252-253 physiologicalextension,114f referedpainto,44 ultrasound appl.iedto documentationof, 210 with extension sfietchingforce, 797t :, Lasegues srgn,rzz LASER.SeeLight amplificationby stimulatedemissionof radiation(LASER). Lateraldiscprotrusioq compressingL4nerveroot,316f Lateral spinodulamic fi act,49 Leg elasticcompressionrvrapof, 354f fl"i,1^rh"'"..
:-:-o----!i^-
nn
nF ?31
stiffnessof increasedthroughsuperfictalheat,161-162 K Keloids,29 Ketorolacforadol), 60 Kinins,17 I(nee electricalstimulationof documentationof 250
arl
migration of, 2 1 Leukocyticphagocytosis,cold lasersfor, 386 Lichen planus, ultraviolet radiation for, 375 LIDC. SeeLow intensitydirect cuffent OIDC). Lidocaine,235,236 Ligaments,healingof 35-36 Light, monochromatic,382 Light amplificationby stimulatedemissionofradiation
(rAsER), 382-383 "^h"'"^r
Jewelry,metal,thermalconductivityoI, 135 Joints distractionof, 308-309 hypomobiliry of fiaction,312 mobilization of 426 uaction,310
aF 177
Leukocytes(white blood cells) arrdinflammatory response,21 concentrationin adult human blood,21f
'AiPr.F
J
f^'
Aaa,manranan
aFiefi< at *,r-ac
? R"97 lf
cold.SeeCold lasers. conuaindicationsfor, 387-388 385-386 effectonnerve conductionand regeneration, for osteoarthritis,386-387 for rheumatoid arthritis, 387 helium-neon,382 high-intensiryhot, 384 low-intensitycold,384 lower-energycold,443 Light touch for alphamotor neurondamage,97 Limbic system,94-95 Limbs edemaof,342 shapmg after amputatioq 347-348 .^--'.""inn
f^r
?/RF
Limited balance,hydrottrerapy contraindrcated tor, 281 Limited endurance,hydrotJrerapy contraindicated for, 281
Index
Limited range-of-motion, hydrotherapy contraindicated tor,28L Lirnitedstrength,hydrotherapyconuaindicatedfor, 281 Liver failurecausingedema,343 Localskininfection,acure,externalcompression . ^ h * r i n , , i' . . r . , J i ^
eC1
Longwaveultrasound,443 Lossof functioq 15 low backpain casesttdy of, 178-779 electrodeplacementfor, 243f Low backstrain,cases dy of,432-434 Low-boy whirlpool, 286f Low-intensirycold lasers,384 Low intensitydirect currenr(LIDC),233 LowJevel laserdevice,385f Low-loadprolongedsketchwith heaE161f Low muscletone,96-97 Low rateftanscutaneous electricalnerve stimulation,233 Lower-energycold lasers,443 Lower extremities electricalstimulationof, 241 in whirlpool, 2B8f Lumbarpositionalcracrion,docr.rmentation of, 335 Lumbarspine,sittingself-tractionfor, 331f L,-L^-
!-^-.:^-
Car!
belt positioning,323f manual,333,333f mechanical,320-321 positional application technique for, 332-333 prone,322f supirle,322f unilateral,32lf Lumbarzygapophysealjoints,distraction,308 Lymph, 343 Lymph nodes,344 Lymphatic circulation, 345f externalcompression,342 Lynphatic fluid, 343 Lymphaticreturq obstructed,externalcompression contraindicatediq 350 Lymphaticvessels,valvesin, 344f Lymphed,ema,344-345, 346 chroruc casestudy of 362-363 diathermy for, 400 extemalcompressionfor documentationof, 358 hypoproteinemiacausing,345 intermittentpneumaticcompressionfor, 358f
pnmary,345 secondary, 345
477
Lymphocytes electrcal charge,234 in inFlrhm:ri^n
?lf
ultravioletradiatioq 375 M MAC. SezMembraneattackcomplex(MAC). Macrophages electrical dtarge, 234 in inflamrnation,22,31t 32 oxyget effect on, 22 products ot,22 Magnesiumdeficienry,34 Magneticequipmengdiathermy,399 Magnetic fields generationof 390f heatingby, 389 strengthdeterminationof, 389 Magnehoq 392 microwave appLicator lor di.a$ermy,401-402 Magnets, scientific m eljt ot, 425 Malignancies causingsecondarylympharicobstruction,345 contraindicating physical agents,10 diathermy contraindi.cated,397 electricalstimulatioq 239 electromagnetic ftelds,395-396 extemalcompression,352 paintrom,420-421 thermotierapy contraindicatedfor, 164 ultrasoundcontraindicatedin, 204-205 Mahut tion causingedema,343 protein-calorieandhealing,34 Mandibularhalter,328f Mandibularjoint, ultrasound,209f Mannitol, ultrasound, 203 Manual cervical traction patientsitting,333,334f patientsupine,333,334f Manual lumbartraction,333,333f Manual mobilization used with physical agents,7 Margination, 18 Mast cells ultrasoundeffecton, 195 ultraviolet radiation, 375 Matemal hyperthermia,164 Maturation phase,419 ofhealing,8,29-30 Maximum voluntary isometric contlaction (M\1C), 231, 249 lvrcGrrpaln quesuoluErre,J,/,J6l Mechanicalagents,3-4, 8
478 Mechanicalblock restrictingmotion, 112-118 Mechanicalcervicaltr acion, 326-327 Mechanicallumbartractioq 320-321 Mechanical pressureaffecting healing, 32 Mechanicaltraction,318-319 appLication technique,319-320,330 Mechanicaltractionunit, 319f Mechanicaltraumaactivatingfibers,48 MED. SeeMinimal erythemaldose(MID). Medial discprotrusioq traction,316 Medicalapplicationsfrequencies,FCC,387 Medications affectinghealing,33-34 hydrotherapycontraindicatedfor, 281 in combinationwith physicalagents,426 photosensitizing ultravioletradiationcontraindicatedfor, 377 trarnsoermal delvery oI, 235:23/ Membrane restingpotential of, 85, 227f ultrasoundeffecton, 195,393 Membraneattackcomplex(MAC), 23 Mentation cryotherapyapplicationover,146 impaired.SeeImpairedmentation. Meperidine,60 Metabolicmte decreased,74l increased inresponseto heat, 160 Metal diadrermy contraind icated,397 thermotherapyeffecton, 165 Metal implants diathermy contraindrcated,396 nonthermal pulsed shomvave diatlermy contraindications for, 398 Metal jewelry,thermalconductiviryof 135 Metatarcophalangeal extensioq osteophytesblocking, 118f Methylrnethacrylatecement,ultrasoundcontraindicated with, 205 Microstreaming,192f,195 d,ehntronot,192 Microvascularperfusioq diadrermy,393 lvlicrowave applicator, magnetron, for di athermy, 401-402 Microwave diathermy(MWD), 382,404t applicator,393f knee documentationof 400 Microwaves,322 Mild warmth whirlpool, 287 Mnktng,342 Milroy's disease,345
Itder
Mineral deficienry, 34 Minimal erythemal dose (MED), 379 Mobilizatioq manual,usedwith physicalagents,7 Modality, definition of 2 Modifi ed Ashworth Scale,79-90,79t Modulation,definition ot, 226 Monochromatic light, 382 Monorytes definition of, 2 1 ;- :-a---^;^-
aa r rr
Mononuclear cells,2 1 Monophasicpulsedcvrent, 22!, 222f frequetcies,224f Monosynapticmusclestretchreflex,87f Morphine, 60 Motion facilitationof 126 for chronicinflammation,418 for motion restriction,125 restrictionot, 112-128,421-422 assessment of, 119-122 by tissues, 115-116, 115f pathologiescausing,116-119 pattemsof, 115 physicalagentsfor, 126 quantitativemeasures,119 testmethodsand rationale,I19-I22 ldeatrrlent tor, L23-125 water exerciseto4 422 qpes ot,172-11,5 Motor-level elecuical stimulation of motion reskiction,422 ofpain,426 of proliferativephase,426 of shoulderadhesivecapsulitis,436 Motorpoints, 242 Motrin. SeeIbuprofen(Motrin). Movement affecting healng, 32-33 Moving water, heat transfe4 263 MS. SezMultiple sclerosis(MS). Multiple problems, 423 Multiple sclerosis(MS),137 cryotherapy for, 143 hydrotherapy contrainfi.cated fo4 282 hypertoniciqy following, 101 Muscle compositionof, 80 conductiviryat differentfrequencies, 3B9t contractureof 117 depolarizadon ot, 229-230 extensibiliryof future researchoq 444 fibersof cross-bridge, 80-82,82f
Itd.ex
Muscle-cont'd fibers of-cont'd fast-twitch, 230f slow-fwitch, 230f hematomain, 21 lengdt of, 122 neural stimulation of, 86-87 reeducationof electricalstimulatioq 249,250 relaxationof traction,309-310 resisted testingof, 119-122,12It sensorimotor cortical input, 92 spasmof definitionot 76 electricalstimulatioq 249 traction,312 spinalinput, 92 spindleof 89, 90f strength of altered,140-141 changesin responseto heat, 160 electricalstimulatioq 249 supraspinalinput,92 Musclecontraction,230-232,242 ralrl
effprtc
nn
14OF
elecuical stimulation on/ off time, 249 settings,246t facilitatioq 141 Muscle stretch reflex, monosynaptic, 87f Muscle tone, 421,421t, 426 abnormalitiesof, 95-103 .l"""ifi.,ri^-
^f 05F
MyelirL 86, 86f Myelin-wrappedaxon,saltatoryconductionalong,B6f Myelv:uted newe,229t Myocardial infarction, 277 electdcalstimulatioq 238 refering pain, 44 traction, 3 1I Myohbroblasts,26-27 Myofilaments,80 Myometer,TT Myosin enl
mr'
tnnc
RO
relationship to actin, 82 N Nagi scheme,6 Naloxone,53 Naprosyn.SeeNaproxensodium(Naprosyn,Aleve). Naproxensodium(Naprosyn,Aleve),59 Naturalhot springs,4 NDT. SeeNeurodevelopmental training(NDT). Near field/far field, definition of 190 Neck Pamm casestudy of, 251-252 tractionfor, 310 '.fl.-
'.
tn
R1F
wry'77 Negative treatrnent elecaode,2 44f NeonatalInfant PainScale(NIPS),56t Neoplasms.SeeMalignancies. Neovascularizatioq2B-29 Nerve .^mnrec.i^n
^f
q6
conductionof anatomicalbasesof 80-95 and physical agents,9 biofeedback,98 definition of 74-75
hish,99-103 consequences of, 100t rr'lrmenr
^F
lnO
1O?
low,96-97 measuring,77-80 muscularcontributionsto, 80-82 neuralcontributionsto, 82-86 nomal variations in, 75f rehabilitationto decrease, 102 specrum of, 75f Musculoskeletal disorders,laser therapy ot, 386-387 Musculoskeletal pain, 44-45 MMC. SeeMaximum voluntary isometric contraction
(MVrc).
MWD. SeeMicrowave diathermy (MWD).
conductionvelocitiesof, 86, 159 decreased, 139-140 depolaization of, 227-229 endingsof ftee,45 firing rate of 159 healingof pulsedshortwavediathermyfor, 395 myelinated, 229f reopncation of 1"".'.tF."f -.
^i
i--i--.--^f
eA5-qRK ^F
traction,311-312 structureand function of, 83-84 superficial main branch of cryotherapyappJicationover,146 Nervoussystem,ftont view of, 83f Neuralpathway,ascending,48f
480
Itdex
ftaining (NDT), 276 Neurodevelopmental Neurologicalproblems,waterexercisefo\ 276 Neuromuscularelectricalstimulation(NMIS), 231 Neurons cormectionsbetween,86 inputto, B5f insulationfor, 86 slmapsebetweenpre- andpostsynaptic,B4f-85f traosmission,48 Neuropathy,33f
Ohm's law, definition of, 221 Oligodendrocytes, 86 On/off ttme,225f dehrrtion ot, 224-225 Open-chainexercise,275, 276t Openwound antimicrobials in whi rlpools, 271-272 cryotherapyapplicationover,146 electricalstimulationof, 239 tlrermotlrerapy effect on, 165- 166
NTa,,/^i-nchi*arc
n-i,i"
C?
Neutral warmth c^-1^.,, L^^1. ^,-^i^
iaa
whirlpooI,2BT Neutrophils electical charge,234 in inflammadon, 21.-22, 37t NIPS.SeeNeonatalInfant PainScale(NIPS). NMES.SeeNeuromuscularelectricalstimulation(NMES). Nociceptior\ 42 Nociceptors,45, 46 NodesofRanvier,229 Non-insulin-dependent diabetesmellitus,casestudy of, 179-180 Noncapsularpatternsof motion restriction,115 Noncontractiletissueslestrictiogmotion, 115-11.6, I15f Nonimmersion hydrothenpy, 272 Nonimmersion irrig ation d,evices,29I -292 applicationtechnique fo4 292-293 Nonsteroidalantiinflammatorydrugs(NSAIDs) and healing, 33 for paiq 59 in inflammatorycascade, 34f inhibiting prostaglandinsynthesis,17 Nontlermal electromagneticagents,373 Nonthermalpulsedshortwavediathermy,394 contraindications for, 397-398 indicationsfor, 395 precautionsfor, 399-400 NSAID. SeeNonsteroidal antiinflammatory drugs(NSAIDs). Numbness,lasers, 387 Nutritioq 34 0 Obesity btoyancy, 266 diathermy, 399 hydrotherapyfor d^.',mcnr,fi^n
'"."-r^..
5q
Opiates for pai4 53f,59, 60 lnrel iniertian nF 61 .iAF eFtc.r. ^F 6|,-61
spinaladministrationof, 61 substance152 Opioid system,endogenous, 53-54 Opioids,for paiq 59 Opiopeptins,53 emnrinn
crrecc
Sr'
Opsonization,23 Organtransplantatio4immunosuppressive drugs,and healing,33 Orthopedicproblems, water exercisefor, 274-275 Orthotic bracing for stroke, 429 Orthotic devicesfor alphamotor neuron damage , 98 Osmoticpressureinfluenceon tissuefluid balance, 343f Osteoarthritis casestudy of 157-158,177-178,298-299,336-337 lasertherapyof 386-387 nnnlevarni
Fnr ?Q9
range-of-motion exercisefo4 178 Osteoblasts,calcium,lasers,386 Osteophytes blockingmetatarsophalangeal extension,118f encroachmentof, 311 Outcomeassessmeng 427 Outcomemeasures,451-453 Over-tl-re-door cervicaltractiondevices,319 Overloadtheory,231 Oxygeq effect on m acrophages,22 Oxygen-hemoglobindissociationcurve,temperatureeffect on, 139f P
^F tqA
Obstructedllmphatic return,extemalcompression contraindicatedin, 350 Obstructedvenousretum, extemalcompression contraindicatedin, 350
Pacemakers contraindicating physical agents,10 diathermy contraindi.catedwidt, 396, 397 electricalcuffentscontraindicated with, 237 nontJrermalpulsed shortwave diathermy contraindicated wi*r, 398 ultrasoundcontraindicated with, 205-206
hrdex
Pain,15,41-65,426 achvity pacing fo! 62 acute,42-43 andmuscletone,9 body diagramsfor marking 59f chroruc, 43-44,420 controlof,52-53 duringstretching,126 coping skills for, 62 electrical stimulatioq 242 fuequency,245 settings,247t treatmenttime, 250 endogenousopioid system,58_54 etiologyof, I facescalesratingin children,55f gati\gj 49 highmuscletone associated with, 99_100 treatmentfo! 103 hydrotherapy for,277 lasertherapyof, BBZ management of, 57-64 McCill questionnaire,52, 5gf measurementof,54-52 modulation ot, 52-53, 282_283 gatecontrolmechanismof,49f multidisciplinaryueatrnentprogramsfor, 62_63 muscutosketetal, 44_45 nonrhermalpulsedshorrwavediathermv contraindications for, 399 opiates,53f pathwaysof central,50f peripheral,48f physicalagentscontroIIng, B-9.419,4I9r putsedshortwavediarherrnyfor, 394_395 laolculaa
referred from spinal n erve rcot, 420 reboundincreasein, 318 reception of, 45-47 retened, 44-45, 420 restricting motion, 118 specificiryvs.patternrheory of, 46|. substanceB 51-52 superficialheat for, 161 toumiquet test fo! 55-56 traction,316 ffansduction of, 47f transmission of, 45-46 rypesof, 42-43 ultrasoundfor, 197 viscerd,46 Painratingindex (PN),52 Pain-spasm-pain cycle,49f, 148
Painthreshold increased,140 in responseto heat,160 Pancakecoil, 402f Paraffin applicationof 168-169 dip-immersionapplicationo! 1Z3f dip-wrap applicationof 1Z2f documentationoi 1ZZ for motion restriction,422 for osteoarthritis, 1ZB removalof, lZBf Paraffinbaths,171f applicationtechniquefor, 162 Paralysis definition of 76 flaccid,96 spastic definition of 26 ?araspinalmusclespasm,traction,812 Parkinson'sdisease,83 casestudy of 107 resting tremors witl, 103 riSidity ir\ 102-108 Paroxysmalcold hemoglobinuria contraindicating cryotherapy,l4S Passiveaccessory motion, I22 Passivemotion, 112-113 continuous,32-33 machinefor, B3f restri,ctionof, 422 Passiverange-of-motion,121t Passivestretching,124 Patchfor Bell'spalsv 104 Pathologicalsequelae,classificationol, 6f Pathologlz,definition of, 6 Patient immobilization of traction, 3 10 posirioningof for electrical stimulation, 241 for :agidlry, 702 for whirlpools,288 Patientcare,rehabilitationrole in,5-6 Patrenr-controlled analgesia@CA),60-6.1 rauent education for hydrotherapy, 285 tortraction,3lT Pattem theory 45 r.,s.specificiqytheory, 46f _ favementitg, 18 PCA SeePatient-contlolled aaalgesia(pCA). PDCF..See Placelet-derived growi.r faccorpDCF). Pelvicbeks,315,322
4ar
Iwlev
442
Pelvicfloor dysfirnction,232 PEMI. SeePulsedelectromagnetic energy(PEME). PEM.F.SeePulsedelectromagneticfield (PEMI). ?endulumtest,79 Peripheralarterialdisease,extemalcompression contraindicated in, 350 Peripheralnerves pathw ays for, 47 -48 regenerating conftaindicating cryother apy, 145 superficial extemalcompression,353 Peripheralnervoussystem injury andmuscletone,9 Peripheralpain pathways,48f Peripheralvascularcompromise,33f Peripheralvasculardisease,145 Personneltrainingfor exetcisepools,297 Phagocytosis and diabetesmellitus,33f and healing,34 Phaseduration,225f defintton of,224,226 Phlebitis,344 192t 196,202-203 Phonophoresis, definition of, 192 drug concentrations for, 203 for acuteinflammatory phase,426 optimal ueatrnent parametersof, 445 Photokeratitis,ulhavioletradiation,378 Photophobia,ultravioletradiation,378 disorders,ultravioletradiationfor, 375 Photosensitive patients,ultravioletradiation Photosensitive contraindicatedfor, 377 medication'ultravioletradiation Photosensitizing contraindicatedfor, 377 Physicalagents adverseeffectsof future researchon, 445-446 altering muscle tone, 9 and collagenextensibiliry,9 av atlabtlilf of, 425-426 categoriesof, 2-4,3t (- llr:r-k: '- ^ I
^--l:-^r:^-dyy!!duulr
^l ur
future rcsearchon, 444-445 combnaaons of,426-427 contraindicationsfor, 10,423-424 future rcsearchon, 445-446 convenienceof, 425 cost ot, 425 definition of 2 eftects of, 7-9, 476 future researchor,, 443-444
Physicalagents-cont'd qcrLrurrrdB!qL,r,
r
examplesof, 2 exclusiveuseof 6-7 for pain control 8-9,61-62 future researchand applica .onof,442-454 of, 446-453 methodologicalcharacteristics goalsof 416 effects of, 417f ptroitJzir\g, 417f mechanical,3-4 novel applicationsof, 445 physiologicaleffectsof future researchon, 444 precautions for, 423-424 future researchon, 445-446 role in rehabilitation,6-7 af
".l".ti^.
L\6-l)6
L\6(
thermal,2-3 useof history oi 4-5 with other interventions, 7 waning popularity of, 5 Physicalmodality, definition of, 2 Physiological conuactions, 231 Physiologicalkneeextension,114f Physiologicalmotion, 113-115 Pi.r"'"
F
"^,
rh"^
, t7
illustrationof,28f Piezoelectc crystal,ultrasoundproductionby, 193f 59 Piroxicam(Feldene), 450 Placebos, Plantarwarts,ultrasoundtor,203-204 Plasmaandinflammatoryresponse,21 Plasmakallikeiq 17 Plasmin augmenting vascularpermeability, 17 Plasticdeformationvs.elasricdeformation,124f growth factor(?DCF) Platelet-derived ^-J:-O^--^!:^-
OO
role of, 19-20 Plateletsand inflammatory rcsponse,2I Plumbium zirconium titanate (PZI; 193 (PMNs). PMN. SeePolymorphonucleocytes Pneumatic device for chronic l1'rnphedema,363 PNL SeeProprioceptiveneuromuscularfacilitation (?NF). Polarity,definition of 221 Poli.omyeli:us,96,262 Polymorphonucleocytes @MNs),definition of 21 Pool tecbniquefor, 295 appLication satesl,295-298 Poolexercisefor osteoathrids, 299
Index
?oor circulation contraindicating cryodrerapy, 145 thermotherapyeffecton, 165 Poorsensalion,cryotherapyapplicationover,146 Poor thermal regulation, hydrotherapy contraindicated for, 282 Positional lumbar tractioq application technique for,
332-333
Positionaltraction,lumbararea,332f Positioning for electrical stimulatioq 241 fot ngidi.|1/,I02 for whirlpools,288 Positive treatment electrod,e,244f Posttraumatic dystrophy, 50 Potential difference, 221 Power, definition of 187 Precautions,definition of, 10 Prednisone,33 Pregnancy causingsecondarylymphaticobstruction,845 contraindicatingphysicalagents,10 diathermy contraindicated with, 392 electricalcurents contraindicated with, 238 hydrotherapy contraindicated.tor, 282 thermotherapy during, 164 ultrasound conkaind icated in,2QE,428 water exercisedwi.rrg,277 Prematureskin aging, uluaviolet radiatio& gZ8 Premodulatedcurrent,definition o! 228 Pressure ulcer casesudy ot,2L3-214,299-300 hydrorherapy to4 270-22A,A00 saclal casestudy of, 406 ultrasoundfor, 197-198 PRF.SeePulsedradiofrequency (PRF). ?N. SeePain rating index (PN). Prihen,
h'.li--
er
Primary intentior; 28 Primary l1'rnphedema,345 Primary union, 28 ?roblem solviag for pain, 62 Procollagen RNA, cold lasen for, 386 Proinflammatoryprosuglandins.sensicjzingpain rcceptors,17 Proliferationphase,419,426 othealirg, 8, 24-29 Prolongedstretch for hypenonicity, 102 Pronelumbar traction,322f Pronepositioq intolerancefor in traction,317 Propagafion,229 Proprioceptiveneuromuscularfacilitation(pNI), 124-725
483
Prostaglandins and healing, 34 and inflammatoryresponse,17 synthesisof inhibition of, 1Z Protein deficienryof and healing,S4 ultrasoundeffectoq 195 Protein-calorie malnutrition, 34 Pseud.omoxas aerugixosa, 271, 298 PSLR,t22 Psoralenultravioletradiation(tWA), B25 adverseeffectsof 379 for psoriasis,376,383 dosimetryfor, 381 keatment setupfor,381 Psoriasis casestudy of, 383 infraredradiationfor, 162 ultravioletradiationtor,375-376 dosimeay for, 381 ?soriaticanfiritis, ulhaviolet radiationfor, B7E-876 Psoriaticplaques,376f PSWD.SeePulsedshortrvavediathermy(PSWD). Psychological aversionto ftactio4 317 Psychological factorsaffectingpain,44 Pulmonaryedema,exremalcompressioncontraindicated ira 349 Pulmonaryembolism.externalcompression contraindicated in, 350 Pulsatilecurrent,defiruti,onof,221 Pulseduratioq 225f defirutton ot, 224, 226 Pulsedcurrent biphasic, 22! defirutton ot, 227 nrgnvorrage,155 monophasi,c,22L, 222f frequend,es,2241 Pulsedelectromagnetic energy(PEME),889 Pulsedelectromagnetic field (PEMI),389 Pulsedlavage,293 ?ulsedradiofrequency@RF),389 Pulsedshortwavediathermy(?SWD),389,404t for acuteinflammation, 417-418,426 for ankleinversion,405 ror oollenealrng,Jy) tor edema,394 for knee irrjury, 430 for motion restriclioq 422 rornerve neatmg,JyC for paln,394-395 for sacralpressureulcer,406
444
Pulsedshortwavediathermy(PSWD)-cont'd for wound healing, 395 nonthermal,394 f o! 397-398 contraindications indicationsfor, 395 precautionsfor, 399-400 olcer,403 Pulsedultrasound,lBBf definition of 188 for acuteinflammatory phase,426 Purpose-builttable,318 exercisepool with treadmill,294t Purpose-designed Pus,18 ?WA. SeePsoralenultravioletradiationGIIVA). PZL SeePlumbium irconium titanate (?ZT).
0 Quadricepsmuscles,electrodeplacementover,243f Quadricepsstrength,253f Quick ice, 143,151 for alpha motor neuron damage,97 for muscle hypotonicity, 421 muscletone,98 Quick stretch,100 Ouick strokingwith i.cec,rp, L54f R Radiation,137 Radiationinjury causingedema,343 Radiationrherapycausingsecondarylymphatic obstruction,345 Radicular pain in extremities referred ftom spinal nerve rcot,420 Radiculopathy,casestudy of 335-336 Radiotherapy,laserscontraindicatedwith, 388 Rampdown time, 226f dehntion of, 225 Ramptime, electricalstimulation,249 Rampup time, 226f deftnaon of, 225 Range-of-motion(ROM), 112 active,I1,9,121,t exerclse for alphamotorneuron damage,98 f or osteoarthritis,178 increasedthrough superhcialheat,I6t-162 limited hydrotherapy contrarr'drcatedfor, 2BI 121t passive, shoulder adhesionrestricting,116f techniques contraindicationsto, 122-123 Raynaud'sdiseasecontraindicatingcryothetapy,145
Inilex
Rearborizing, 96 Red blood cells and inflammatory response,2 1 Redness,15 Refened pan, 44-45, 420 Reflection, definition of , 190-191 Reflex s1'rnpatheticdystrophy (RSD),50 diathermy for, 400 Reflexes,88 Reftaction,definition of 191 Regeneratingperipheral nerves contraindicating cryodtenpy,l45 Rehabilitation,role in patientcare,5-6 Reimbursement,427 Relative contraindications, definition of, 10 Relative refractory period, 227 Relaxation training forhigh muscletone, 100 for pan,62 \eliability,451-452 Remodeling stage,37 tissuehealingpromotioq 418t acute,causingedema,343 Renaldisease, Repair,definition of 14 Reponing,453 Researchsubjects,448-449 Residuallimb shaping afteramputation,347-348 compressionfor, 348f Resist€dmusclet€stng, t19-722,t21t Respiratorydepression,60-61 Respiratorysystem,workload challengeto, 268 Resting membrane p otenaal, 85, 227f Pheobase,228, 229f Rheumatoid arthritis casestudy of, 337-338 lasertherapyof, 387 NCB (rest,ice,compressioqelevation),142 for inflammation, 426 Rigidiry,102-103 Risetime, 225f dekniaon of,224 Rofecoxibffior<),59 ROM. SzeRange-of-motion E OM). RSD. SeeReflex $,mpathedc dystrophy (RSD). Rubor,15 Rubrospinal tracts (RuSTs),93 Runner'scrouch, 82 Russianprotocol,definition of, 223
s ulcer,casestudy of, 406 Sacralpressure Safety of exerci.sepool, 297-298 of hy dr other apy,295-29I
hdex
Safety-cont'd of pool,295-298 ofwhirlpools, 296 Salirylicacid,235 Saltatoryconductioq 86 SAIA. SeeSpatialaveragetemporal average(SA.IA). Satellitecells,36 SAT?.SeeSpatialaveragetemporal peak (SAfP) intensity. Saundersfrictionlesshaher,329 Saundershalter,32Bf Scalp,healingof 32 Sca4226 Scar collateniq 30 gold leaffo! 4 m,r"',ri^^
', r" ^f ,A
Schwanncells,86, 86f SCI.SeeSpinalcordinjury (SCI). Scientific merit, 424 Second-degree erythema,379 Secondaryhealing,36 Secondaryintention, 28 SecondaryIymphaticobstrucrion,345 Secondarylymphedema,345 SED.SeeSuberythemaldose(SED). Self-adherent wraps,348 Self-adhesive gel,241 Self-traction,318,319 applicationtechnique,330-331 betweencomercounters,331,331f documentationof,334 sitting for lumbarspine,331f with overheadbar,331,331f Semanticdifferentialscales,56-57 Semirigidbandage,354 Sensation impaired.SeeImpairedsensation. Poor cryotherapyapplicationover,146 SensoryJevelelectricalstimulation for acuteinflammatioq 417 for pain, 420 Sequentialcompression,359 Sequentialcompressionpumps,precautionswith, 351-352 Shamultrasound,198 Shortwave dia*rermy (SWD), 404t capacitiveplates electricfield disuibution betweeq 391f continuous,4 for adhesivecapsulitisofshoulder,405 for low backpain documentarionof 400
Shortwave diathermy (SWD)-cont'd frequencies, 387 inductivecoil applicators,ts90f,39Lf,392f,402t magneticfield behavior,390f scientific merit of 424 EJdt\gof,401-402 Shornvaves,372 Shoulder adhesivecapsulitisof casesudy of, 404-405,435-436 water exercisefor, 436 calcifictendonitisof ultrasoundfor, 199 ultrasoundfor documentationof, 210 Shoulder-hands1'ndrome,50 Shoulderrange-of-motion,adhesionrestricting,116f Showerforbums, 434 Shrapnel,diathermycontraindicated, 397 Sicklecell disease,33 Singlearclamps,382 Singlemonosynaptic connection, 86 Single-subject designstudies,447 SisterKerny, 262 Sitting cervical traction, 327f Sittingself-traction,331f Skeletalmuscle,36 Skeletally tnmature patients, nontlermal pulsed shortwave diathermy, 399-400 Skin cleansers of bxiciqy index fo! 271t diseases of treatment of, 4 graftsof hydrotherapy contraindtcated for, 279 infection of extemalcompressioncontraindicatedin, 351 infrared irradiation adverse eftects,167 inspectionof 240 irritation of electricalstimulation,239 layersof, 202f premature aging of ultraviolet radiation, 377 lash of lasers,387 surgicalincisionsof ultrasoundfor, 199 Sleep,disturbed,associated with depression,44 Slow-twitch muscle fibers, 230f Smallpo4 scarring from, 4 SNS.SeeSympatheticnervoussystem(SNS). Soakingin hot water, 4
485
446
Index
SOAP(Subjecrive, Objective,Assessmeng ?lan)format, 250 Socialfactorsaffectingpain,44 q^.ipr'llim;r)fi^n<
6
Sodiumethanolamine,235 Sodiumhypochlorite,296 Sodiurr'rons,22T Softcallusstage,36 Softtissue increasedextensibilityof, 126 shonerungof , 422, 422t, 426 stretchingof tractiorl 309 ' 'lrre
SONAR(SoundNavigationand Ranging),186 Spasmodictorticollis,77 Spastichemiplegia,definition of 76 Spasticparalysis,defintion of, 76 Spasticity .^,-rh.'A-- F^' I /.q decreased,l4I defir-:tion of, 76,7 6t ramp time,249 Spatialaverageintensity,definition of 188 Spatialaveragetemporalaverag€(SATA)intensity, definition of 189,189f Spatialaveragetemporalpeak(SAT?)intensiry,189f definition of, 1BB-189 Spatialpeakintensity,definition of 188 Specihc graviry, 263t Specikcheat,L34, 134t,262t ot air,262t qha.ifi.ih,
rl''^n'
.< n:+tam
./5 ,q I
rhennr
15f
Spinalanalgesia, 61 JPrror
rvrw
rrtu!/
\r!v
hypertonicity f ollowing treatmentof, 101 muscletone, 100-101 Spinaldisc hemiationof rP
m^ri^n
I1R
s€paration on,321f Spinaldisease,tractioq 315 Spinal newe root swellingof 311 r
^f.^mhre..i^n
causes of, 311f Spinalshock,100 adverseeffectsof 317-318 applicationtechniques,3 18-319 conftaindicationsfor, 312-3L4
c^i--I
i--
^ii
^ -
-^-r,J
documentationof 334-335 durationof 325 effectsof, 308-309 for extremity radicular pain referred from spinal nerve rcot,420 for low backstrain,433 force for, 324-325 hold/relaxtimes for, 324 :-,]:^-!:^--
a^- a1n a11
precautionsfor, 314-315 recommendations for, 324t Spleenrefering pain,44 Splinting for acute inflamrnatory phase,426 Split tractiontable,323f Spondylolisthesis, 3 11 Spontaneous aboftion amongdiathermythempists,395 Sprayand stretch,153 Standingwave definition of 191 formation of 192f SaVhyloco ccusauteus,277 (tetir
nnmnra<
applicationtechniquefor, 353 for ankle sprairl 365 garments tissuesizeand shape,342 Static €lectricity, generation of, 4 Stationary water, heat transfer,263 Steroids in inflammatorycascade, 34f inhibiting prostaglandin synthesis, 17 STLR.SeeS)'rnmetrical tonic labyrinthine refl€x (STLR). STNR. SeeSymmetric tonic neck reflexes(STNR). Stockinette,applicationof 359f Stockings antiembolism,355,356f compression, 342 gradedcompressioq347 Sr'rr,,m.^h'i,h
?n?
Strength,Limited,hydrotherapy contraindrcatedfor, 281 Strength-durationcurve,227-229, 228t Stress high muscletone associated with, 99-100 r-'."h.^f
f^'
lne
opiopeptins,54 relaxaaorL,123, 723t Sftetching ballistic for motion restriction,125 for bony block,423 for motion restrictioq 123
487
btdex
qrrpr.hino-.^nr'd
for soft tissueshonening,422 hot packbefore,7 pain during controlo! 126 passle,124 quick, 100 sci.ennhcmeit of , 424 ,lpes ot, 124t Stroke alphamotor neuron,98 casestudy of, 428-430 diathermy for, 400 extemal compressior! 352 hemiplegia following casestudy of 106-107 hydrodterapyfor,276 hypertoniciryfollowng, f ,fi2 Strokingtechniquefor ultrasoundapplicatiorl210f Subacuteiofl ammation,30 Subacutejoint inflammation,tractioq 312 Suberythemaldose(SED),379 Substance P,51-52 c",-la.L'< ,r.
nhv 5n
Suicidalpatients,hydrotherapycontraindicated for, 280 Sunlighg therapeutic useof, 4, 5 Superficial cooling,270 Superficialheag270 applicationof,168 usesof, t6t-162 Superficialperipheralnerve,extemalcompression, 353 Supinecevical traction,327f Supinelumbar traction,322f Supineposition,intolerancefor, traction,317 Suppurative exudate, 18 Surfaceelectromyography, 78f Surfactants,266 Surgerycausingsecondarylymphatic obstruction,345 Surgicalskin incisions,ultrasoundfor, 199 Surgicalwounds cold lasersfor,386 gynecological,I99 SWD.SeeShorrwavediathermy(SWD). Sweating,137 Sweeps,226 Swelling,15 asdrma,277 SwimminS,exercise-induced Swimmingpool, 293 temnataaro
aF )a?-)aA
water exerciseir', 274f Symmeffictonic n€ckreflexes(STNR),80,81f Symmetrical tonic labyrinthine reflex (STLR),I 1f
Sympatheticnervoussystem(SNS) muscles,94-95 pain,50-51 Symptomperipheralization,ftaction contraindicated, 314 Syneryy,L02 T T cells,48 Table purpose-built,318 Tanning, ultraviolet radiation, 374 Tapping, muscle tone, 98 Taryet,226 Tearing,ultravioletradiation,378 Temperaturc collagenextensibilityrespondingto, 9f effecton oxygen-hemoglobindissociationcurve,139f increaseof, 194 tissue increased,342-343 Temporomandibulujoint [MJ) halters,328 tlactioq 317 Tendinitis, hydrocortisone for, 203 Tendon extensibilityof E,t-.o.e<pa,rh
an
AAt
healingof 35 injuriesof ultrasoundfor, 199-200 Tendonitis,calcificof shoulder,199 Tenotomy, 125 TENS. SeeTranscutaneouselectrical nerve stimulation GENS). Tensiontheory,30 Tepidwhirlpool,287 Testes,diathermycontraindicated, 397 Therapeuticexercise for alphamotor neurondamage,98 usedwith physicalagents,7 Therapist,applyingdiathermy,precautionsfor, 395 Thermal agents,2-3, 133-181 Thermal agents,utilization of,7 Thermal conductivity, 135t, 262t of air,262t of ice, 136 nFmareIipurplnr
IQ5
otwater,136,262f Thermal energy,physicalprinciplesof, 134-137 Thermal-leveldiathermy,394 contraindications for, 396-397 Thermal regulatioq poor, hydrodrerapy contraindicated for,282
488
Inder
Thermostatically conftolled heating plate, 444 Thermotherapy (heat), 158-t62 adverseeffects of, 166-167 affecting healing, 32 altered tissueextenslblhty, 1,60- 161 applicationtechniquesot, 1O -168 for, 162-164 contraindications effectsof 158-162,180f for bony block,423 for chronic inflamrnation, 418 for extremity radicular pain referred from spinal nerve root,420 for initial injuries,417 for low backstrain,433 for motion restriction,422 diabetesmellitus,180 for non-insulin-dependent lor pain,420,426 for refeued pain, 420 for soft tissue shortening, 422 hemodynamiceffectsof, 158-159 metaboliceffectsof 160 neuromusculareffectsof, I59 -1.60 of shoulderadhesivecapsulitis,436 precautiors for, 164-166 vs.cryo*rerapy,180-181 Thiamine deficienry, 34 Third-degree eryrhema,379 Third-parry payers,427 Thoracicbelts,heary-duty non-slip,322 with, 237 electricalcurrentscontraindicated extemalcompressioncontraindicatedin, 350 thermotherapy contraindicated for, 163 Thrombosis, electrical curents contraindicated with, 237 Tibial diaphyseal ftactures, ultrasound for, 201 Tissue altered extensibility of in responseto heat, 160-161 342 compression, fluid balance "
Ff"rt< nn
e4?f
heaLing casestudy of, 436-437 electricalstimulation,233-235 electrodeplacementfor, 244f h,h,re
a^- -^ J:^..t^-^!L,, rur r4uNu,vyaur/,
cr ucu<
for rheumatoidarthritis,338 h^-".1"-irac
far ??OF
intemittent. SzuIntemittent traction. lumbar,321.t belt positioning,323f lumbar positional documentationof, 335 manualcewical yducrI
rrLurrSr
uou,
vuar
patientsupine,333,334f
Th'amhnnhlehiti<
-'..""'"
Tone-modifying physical agents,426 Tonus,abnormal,101 Topicalcounterirritants,thermotherapyetfect on, 766 Toradol.SeeKetorolacfloradol) Torpedoftshto apply electricshocks,4 Torticollis,spasmodic,77 Toumiquetpain test,55-56 271t Toxicity index for wound and skin cleansers, Traction,3-4,308-339 annulusdisplacemeng315 cardiovascular accident,318 central axis lumba! 321f cerebrovascular compromise,315 cervical documentationof 334 haltersfoq 328f for backpain,310 for neckpain,3 10
reee^r.h
^n
A.4A
promotionof 418t physicalproperties of h,r,,to o<eareh
an
A44
temperatureof, 3 increased,342-343 joint [M). TMJ. SeeTemporomandibular Toneabnormalities,73-106
mechanical,3l8-319 applicationtechnique, 319-320,330 mechanical cewical, 326-327 mechanicallumbar,320-321 optimal treatmentparametersof, 445 -^-:,:^-^l
I.,-L^,
1ltF
application technique for, 332-333 pronelumbar,322f sittint cervical,327f spinal. SeeSpinal traction. staric,323-324,328 suctionfrom,309f unilaterallumbar,321f Tractionbelts,323f electricaln€rvestimulation[ENS), 5 Transcutaneous 233 acupuncture-like, burstmode,233 conventional,233 diathermy contraindicated, 396 gate control theory, 52 high rate,233 lowrate, 233
489
Index
Transcutaneouselectricalnerve stimulation [ENS)-cont'd urrts,245 rrrnenr
rmnlitrrrle
?4O
documentationof, 250-251 Fnrnhranir nein 49O r'"'r-"-r
ri-.
,5n
Transdermal drug delivery, 235-237 Transducer(soundhead),definition of 182 Transductioq47 Transmission cell activation, 49 Tlansmissionneulons,48 Transudate,18 Trauma acute extemalcompressioncontraindicatediq 351 causingsecondarylymphatic obstructioq 345 Traumaticbrain injury, hydrotherapytor,276 Tremor definition of 77 resting,103 Triryclic antidepressants,60 Tri.ggerpoints, 243 Tropocollagen unit, diagrammatic representation
Ultrasound,2-3, 185-214 applicationtechniqueof, 207-210 appliedto knee documentationof 210 with extensionstretchingforce,197t arcatrea:'€d,208-209 attenuationof, 191t clinicalapplicationsof 196-204 continuous,188f,197 definition of 188 contraindications for, 204-205 decision-making, 211f decreasing intensityof, 186f definition of, 186-187 documentationof, 210 durationof 208 duty cycleof 208 'ffa.r
^f hi"t.-i-.
105
aftD.r^n..1.i,,h
l05
effecton cellmembranepermeability,195 effecton chemotacticfactor,195 effecton histamine,195
ot,28t Tuberculosis, sunlightfor,4,5
.FfF.r ^-
-""r
aEt rr ^-
-.^+.i-
Tubularelasticcotton supports,348 Tumor, 15 Tylenol. SzzAcetaminophen [ylenol). Tlpe III collagen,25
effectsof 193 for Achillestendonrupble,2!3 for bone fracture, 200-201,, 201f for breastimplants,206 for calcifictendonitisof shoulder,199 for carpaltunnel syndrome,201-202
U Ulcer dermal infraredradiationfor, 162 ultrasoundfo5 197-198 pressure casestody ot, 213-214, 299-300 hy drotherapy for, 270-273, 300 sacral,406 rrlnecnr,nrl
$nr I a7-l ae
pulsed sholtwave diathermy, 403 cerr:l
nra<
varicose ultrasoundfor, 198 vascular ultrasoundfor, 197-198 venous electrical stimulation of, 251 venousleg cold lasersfor, 386 venousstasis,346f comPression fo! 347 intermittent compressionfor, 364
lOs ""11. I 05
f^' a^11..' F '"r"'..
?ol
for dermalulcers,197-198 for episiotomies, 199 for fuaca:res,20If,206 forgynecological surgical wounds,199 for herpeszoster,203-204 Fathin
irarnrc
)1')
for motion restriction,422 for pain, L97 for pain from malignancies,421. for plantarwarts, 203-204 $at *c<
t'leat
)l4
for pressureulcers,197-198 for soft tissueshortening,423 for surgicalskinincisions,199 for tendoninjuries,199-200 for tibial diaphysealfractures,201 for tissuehealing 437 f^,-,.i.^"",,1..," 10a for vascularulcers,197-198 for venousulcers,198,198f forwound, 19Bf
490
hrdex
Ultrasound-cont'd ftequercy,209 generationof, 193 halfdepthsin, 191t historicaldevelopmentof 186 rnpregnancy,42S intensity of 208 longitudinalcross-section of 190f Iongwave, 443 m,n'lih',l:r
i^inr,nOf
mannitol, 203 nonthermaleffectsot, 186,195-196 penetrationdepth of, 190f physicalagentswith, 195 precautions for, 206-207 productionby piezoelectriccrystal,193f productionof 193f crianrihc
mant
aF A)A
seqrence,209 sham,198 strokingtechnique[or, 210f temperaturedist bution for, 194f -192 termitology ot, 1.87 thermaleffectsof, 186,1.93-195 tissuesaffectedby, 193-195 Ultrasoundcompression-rarefaction wave, 1B6f Ultrasounddiathermy,conversioninto, 136 Ultrasoundelectromagnetic Gdiation, affecting healing,32 Ultrasoundtransducers, 190t Ultrasoundunits, 1B7f UltravioletA (WA), 372 associatedrisk of 424 UltravioletB (tAE), 372 for psoriasis,383 dosimeny for, 381 rrF"l_menf
(ah,h
f^r
qC I
Ultravioletlamp, 382f selectionof,382 Ultravioletradiarion,4, 375 adverseeffects of, 378-379 appLication techrfques tor,379-38A conuaindications for, 377-378 J^.'lmanrrii^n
^f
aqt
dose-rcsponse assessment of, 379-380 etfectsot,374-375 forpsoriasis dosimetryfor, 381 MED detemination for, 380-381 physicalpropertiesof, 373-374 physiologicaleffectsof, 373 sensitivityassessment of 380f Unilateral lumbar tra ctton, 321,t
Unna'sboot, 354 efhcacyof,357 for venousstasisulcer,364 Unstablejoint, ftactioncontraindicated,313 I l66er
evrrpmiriec
compressiongarment,355-356 electrical stimulation of, 241 Udnary incontinence, hydrotherapy contraindicated for, 287 Urtica a cold-induced contraindicating cry other apy,744 ultraviolet radiation for, 375 Urticadapigmentosa,uitravioletradiationfor, 375 LIVA. SceUltraviolet A (UVA). lJ\E. SeeUltraviolet B (LI\E). V Vdrdiry,452 Vapocoolantsprays,151-152, 153t applicationof 154-155,154f forsoft tissueshorteniag,423 Varicoseulcer,ultrasoundfor, 198 Vascularinsufficiency, wound care,hydr otherapy for,270273 Vascularpermeability in inflammation,18-19 plasmin augmenting, 17 Vascularsupply affecting healing, 32 Vascularulcer, ultras ound for, 197-I98 Vasoconstriction, cutaneous,138 Vasodilation,136 causedby heat,158-159,159f cold-induced,138 coldlasers,386 cutaneous,159 Velocity-dependent r eslstance,267 Venouscirculation,extemalcompression, 342 Venousinsufficienry causingedema,343-344 Venouslegulcer,cold lasersfor, 386 Venousreturn,obstructed,extemalcompression conhaindicat€diq 350 Venousstasisulcer,346f casestudy of 363-364 compressionfor,347 inte@ittent compressionfor, 364 Venousulcer electrical stimulation of documentationot 251 ultrasoundfor, 198,198f Venousvessels,valvesn,344f VestibulospinaltractsVSTs),93 Vioxx. SeeRofecoxib flfioxx). Visiblelight, 372
Index
Visualanalogscales,54-55,55t Vitamin A deficienct 34 Vitamin B1 deficiency,34 Vitamin 85 deficiency, 34 Vitamin C deficiency,34 Vitamia D, 375 Vitamin deficienry, 34 Vitiligo, ultraviolet radiation for, 325 Voltage,definition of, 221 VST. SezVestibulospinal tracts ffSTs). W Warm whirlpools for motion lestrictioq 422 Warmth for high muscle tone, 100 Water exercisein, 265f,266, 273-277 ounng Pregr\ancytl/ / for cardiachmess,276-277 for chronicpain,420 for exercise-induced asthma,269 for motion restdctioq 422 for neurologicalproblems,226 for orthopedicprobl ems,274-275 for shoulderadhesivecapsulitis,436 heartrate response inwater,268 qpes ot,273 usesof, 273-274 for osteoarthritis,178 heart rateresponseto exercise,268 movint heat transfer,263 physicalpropertiesof 263-265 specrficheat ot, 262t statronary heattransfer,263 therapeuticapplicationof, 3, 4 thermal conductivity of, f36 , 262f viscosityof 263 Waterpopsicle,150f Watetvest,275f Weakness, restrictingmotior\ 118 Weightbearingin wat€r immersion,275 wlidpool turbine,270-271,2g6t Whirlpools, 234, 285-286 a timicrobials in,271.-272 applicationtechnique tor,287-2BB cold,287 dtLsnfecttng,29T extremities,285f for arm fracture,301 for burns,434
Whirlpools-cont'd hot,287 H1$bad tank,273, 286-287,296t,29Ot application technique tor, 289-290 \ fectr.onconfiol for, 296-297 low-boy, 286f lower extremitiesiq 288f mild warmtlr, 287 neutral warmth, 287 patientposirioningfor, 288 satetytor,296 temperaturesfo! 287t tepid,,287 wafin
for motion restriction,422 White blood cells.SeeLeukocytes(white blood cells). Wind-up hlpersensitizatioq 43 Working pressure,developmento! 354f Wound chronic ultraviolet radiation for, 375 cleansenof toxicit'./ index fo\ 277t contractureof causeof,28 pictureftame theory of,28f healing of cold lasersfor, 386 electrical stimulailng of, 243 pulsed shorrr,,vavediathermy, 395 uluavioletradiation,376-377 vascularresponseto, 16f hydrotherapyfor,270-273,27lf macetationof hydrotherapy contraindicated for, 278, 282 open.SezOpen wound. surgical coldlasersfor, 386 gynecological,L99 ffeatment of, 5 ultrasoundfor, 198f Wrist, edemain, electrode placement for,244l Wry neck,77
x X-rays,372 ultravioletradiationcontraindicated for,378
z Z-plastyfor motion restriction,125 Zirc deftclency,34 Znc oxide impregna ted,gauze,354
lsBN0-7216-9378-4
il|ililrn
