PM& R Lecture Series
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Transcript of PM& R Lecture Series
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PM& R Lecture Series
Therapeutic Physical Agents
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Physical Medicine the application of physical agents
such as: heat cold sound water electricity and other mechanical
agents
in the treatment of disease.
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Therapeutic Heat Physiologic Effects:
Increase of 3oC increases collagenase activity
Heating hands to 450C reduces MCPJ stiffness by 20%
Changes of 5-7oC alter blood flow and collagen extensibility
Hot paraffin increases local skin temp by 7.5oC and intraarticular temp by 1.7oC
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Therapeutic Heat
A n a lg e s ia(h e a t s e rv e s a s c o u n te r-
ir r ita n t to p a in o n ne rv e s)
S e d a t io n
M u s c le R e la x a t io n(d e c f ir in g o f -s p in d le
f ib e r )
c le a r in g o fh e a t & m e ta b o lis m
s u p p ly o f O 2 ,n u t r ie n ts ,
le u k o c y te s
in c . in c a p illa ry f lo w
e d e m a(why heat not applied
im m e d ia te ly a f te rt ra u m a t ic in ju ry )
inc. in cap illary pressure
a r te r io la r d ila ta t io n
in c . in m e ta b o lis m(d u e to h e a t -p ro d u c e d
m etabo lite s like h is ta mine)
In c . in te m p e ra tu re
H E A T
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Therapeutic Heat Indications
relief of pain relief of spasm increased exetensibility of collagen tissue (e.g.
fractures/contractures) decreased joint stiffness (OA, RA) increased blood flow
* remember, the physiologic effects of heat manifest themselves only if the heat is applied for at least twenty minutes at a temperature of 40-45o C.
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General Indications Pain Muscle spasm Contracture Tension myalgia Production of
hyperemia Acceleration of
metabolic process Hematoma
resolution
Bursitis Tenosynovitis Fibrositis Fibromyalgia Superficial
thrombophlebitis Induction of reflex
vasodilatation Collagen vascular
disease
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General Contraindications Acute inflammation,
trauma or hemorrhage Bleeding disorders Cutaneous insensitivity Inability to
communicate or respond to pain
Poor thermal regulation
Malignancy
Edema Ischemia Atrophic skin Scar tissue Unstable angina or
blood pressure Decompensated
heart failure within 6 to 8 weeks of an MI
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mode of transfer heating modality depth of penetration
1. conduction (by direct contact)
hot packsparaffin
superficial
2. convection (via a medium in motion such as air, water)
hydrotherapyfluidotherapy
superficial (reaches skin and muscle)
3. conversion (actual conversion of a different form of energy to heat)
shortwave diathermymicrowaveultrasound
reaches area of ligaments, tendons, osseous structures
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Hot Moist Packs applied at a temperature
of 46oC stays warm for twenty
minutes or more inc blood flow by as
much as 68% sacks filled with silica
gel (expensive) blood flow doesn’t return
to resting level until 40 mins. after cessation
for analgesia and muscle relaxation
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Paraffin Wax Bath applied at a temperature of
45-54oC solution contains 1 part
mineral oil (useful for those whose skin had undergone trophic changes) to 7 parts paraffin (can be tolerated by px with sensory deficits)
higher temperature is tolerable without the risk of burns (due to high specific heat of paraffin)
commonly used on the hand and wrist and other uneven surfaces
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Paraffin Wax Bath Dipping technique
Immerse part 6-10 times to build up layers of paraffin
Followed by wrapping extremity with an insulating cover
Skin temp achieved: 47oC Subcutaneous temp change
of 3oC Intraarticular temp change of
around 1oC Continuous immersion
Dipped 6-10 times, then kept immersed for 20-30 mins
Subcutaneous temp change of 50C
Intraarticular temp change of 3oC
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Infrared Radiation Uses that portion of the EMS
from 7700-150000 A Maximum penetration of 3mm
(superficial) Dry heat (less comfortable) Commonly used to decrease
skin resistance by inc. blood flow (e.g. in Bell’s palsy)
Wound healing and other dermatological conditions (dries up wound but has no other effects unlike UV light)
Heat inversely proportional to distance and angle of delivery
Usual distance about 40-50 cm and perpendicular to surface treated
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Hydrotherapy
applied at a temperature of 33-43oC
full body immersion can increase core temp by 0.3oC
heat and exercise can be done at the same time
bouyancy effect permits easier movement of weak or painful extremities
agitation of medium permits gentle debridement (e.g. for burns)
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Fluidotherapy
Convection heating modality
Uses cellulose particles suspended in jets of warm air
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Contrast Bath One bath at 38 to 40oC The other bath at 13 to 16oC Produces reflex hyperemia and
neurologic desentisization Initial soaking in warm bath for
10 mins Followed by 4 cycles of alternate
1 to 4 minute cold soaks and 4-6 minute warm soak
Ends with cold soak to minimize edema
Used in treatment of CRPS type I (RSD)
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Ultrasound Diathermy
involves conversion of sound waves at a frequency faster than 17000-20000 cycles/sec
applied to tissues causing mechanical vibration which dissipates heat
deepest penetrating agent; only agent that can significantly heat the hip jt. (by 8-10oC)
both thermal and nonthermal effects
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Ultrasound Diathermy
Nonthermal effects Cavitation
US travelling through liquid produces bubbles which oscillate in size
Streaming Produces shear forces in
tissue that may accelerate metabolic processes
Standing waves Produces areas of
alternating high and low pressure
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Ultrasound Diathermy
Penetration dependent upon: Type of tissue Frequency (usually
1 or 3 MHz) Angle of orientation
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Ultrasound Half Value Depth in Millimeters
Medium 1MHz 3MHzAdipose tissue 50.0 16.5
Skeletal muscle (fibers parallel to sound beam)
24.6 8.0
Tendon 6.2 2.0
Skin 11.1 4.0
Skeletal muscle (fibers perpendicular to sound beam)
9.0 3.0
Cartilage 6.0 2.0
Compact bone 2.1 _
Kitchen and Bazin(1996) Clayton’s Electrotherapy 10th ed.
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Ultrasound Diathermy
Indications Musculoskeletal
conditions (tendinitis, arthritis, patellofemoral pain)
Contractures Wounds and
inflammation Trauma (subacute phase) Fractures
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Ultrasound Diathermy
Contraindications Fluid filled cavities (eyes,
gravid uterus) Spinal cord, esp laminectomy
sites Immature bone (e.g.
children) Heart, brain, cervical ganglia Metal implants Methylmethacrylate implants
(plastics, bone cement) Acute inflammation
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Injury
General Musculoskeletal Disorders:
Muscle spasmJoint stiffness
Pain
Tissue Repair:Soft tissue repair
Stimulation of blood flowBone fracture repair
Tendon repair
THERMAL EFFECT
CONTINUOUS WAVE
NON-THERMAL EFFECT
PULSED WAVE
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Shortwave diathermy involves conversion of
radiofrequency EM current into heat energy
commonly uses 27.12 Mhz uses condenser pads, plates
and internal metal electrodes for heat transfer (not very convenient)
penetration between skin and subcutaneous tissue
Can heat larger areas than ultrasound
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Shortwave diathermy Inductive applicators
Generate magnetic eddy currents in tissue
Highest temperature in water rich, highly conductive tissue (e.g. muscle)
Capacitively coupled applicators
Generate electrical fields Highest temperature in water
poor tissue like fat, ligament, tendon or joint capsules
May be pulsed or continuous
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Microwave diathermy
Uses 915 and 2456 MHz
Does not penetrate as deeply as SWD or US
Highest temperatures are achieved at the fat-muscle interface
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Therapeutic Cold
Decreases collagenase activity Cooling hands to 180C increases MCPJ
stiffness by 20% Icing an acutely inflamed knee
Decreases skin temp by 160 C Decreases intraarticular temp by 5-60
C
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Therapeutic Cold
a n a e s th e s ia
reflex v asodilatation(a f te r 3 0 m in s )
v a s o c o n s t r ic t io n( f irs t 5 -1 5 m in s )
d ecre ase in m eta bolism re la x a t io n(d e c f ir in g o f -s p in d le
f ib e rs )
C O L D
* cold can also stimulate a-motor neurons and cause muscles to contract rather than relax
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General Indications Acute musculoskeletal trauma
Edema Hemorrhage Analgesia
Pain Spasticity Adjunct in muscle reeducation Reduction of local and systemic
metabolic activity
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General Contraindications Ischemia Cold intolerance Raynaud’s phenomenon or disease Severe cold pressor responses Cold allergy Inability to communicate or respond to pain Poor thermal regulation Cutaneous insensitivity
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Therapeutic Cold
Modalities ice packs cryogel packs ice immersion ice cube ethyl chloride spray
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ElectrotherapyTranscutaneous Electrical Nerve
Stimulation (TENS) two theories:
gate control theory: electrical stimulus carried through large -
fibers which arrive at the substantia gelatinosa before the pain impulses traveling through the c-fibers.
treatment is effective only during application. endorphin stimulation:
TENS stimulates production of natural analgesics.
Treatment is effective even after cessation.
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Electrotherapy high frequency, low
intensity stimulates large diameter
afferent fibers Low frequency, high
intensity endorphin stimulation
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Other Modalities
Low power laser Not a heating modality Stimulates collagen
production, alters DNA synthesis, improves function of damaged nerves
FDA approved for CTS, neck, and shoulder pain
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Other Modalities
UV light no heating function uses part of EMS between 1800-
2900 angstroms dose is determined by testing
called Minimum Erythemal Dose (MED); erythema should appear w/in 30 mins- 1 hr and disappear after 24 hrs.
penetration does not exceed 0.1 mm
bactericidal (helps wound healing)
anti-rachitic (vit. D formation Anti-psoriatic
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Thank you!