Contraindications
When is it contraindicated to use superficial heat?
1. Hemorrhage/Bruising/Burns- Heat will increase bleeding and injury
2. Thrombophlebitis-Vasodilation which may cause a blood clot to travel
3. Circulation Issues
4. Impaired Protective Sensation
5. Malignancy- May increase the movement of malignant cells
6. Infection-Vasodilation will increase the spread of infection
7. Over an Acute Injury/Inflammation
Describe each type of pain, and which modality to use for each.
1. Acute Pain: Generally less than 6 months duration, underlying pathology can be identified, sudden onset, lasts as long as the noxious stimuli persists ** Do not add heat for acute pain in the first 7-10 days, utilize cryotherapy or subthermal US **
2. Chronic Pain: Pain lasting longer than 3-6 months, result of activation of dysfunctional, neurological, or psychological responses, **utilize heat modalities**
3. Subacute Pain: a transitional, intermediate phase of pain that lasts between 1 and 3 months (or roughly 6–12 weeks)
What do attenuation and absorption mean in regard to ultrasound?
Attenuation: Loss of energy in the US beam due to scattering (reflection and refraction) and absorption
Absorption: Causes the thermal effects of US as the US is converted to heat in the tissues. High frequencies are absorbed more quickly.
Parameters for hot pack: temperature, time, and layers needed between hot pack and client
150-170 degrees F
15-20 mins
6-8 layers between pack and client (terry cloth + 3 layers of towels) or use a 10 towel layer minimum if lying directly on top of the moist hot pack
What should be documented in the "Objective" section of a modalities SOAP note?
• Pre-treatment: Relative assessments, contraindications, risks/benefits, pre-treatment pain rating
• Treatment: Patient positioning, skin preparation/washing, modality temperature, modality treatment procedure/parameters, monitoring patient, treatment time, patient instruction, etc.
• Post-treatment: Skin care, skin check, therapeutic activity/exercise, client-centered functional task, and education, post-modality treatment pain rating
When is it contraindicated to use cryotherapy?
1. Decreased Protective Sensation
2. Decreased Circulation
3. Cold Hypersensitivity (Urticaria)
4. Cold Intolerance
5. Cryoglobulinemia
6. Raynaud’s Phenomena
7. Over-Regenerating Peripheral Nerves
What is the gate control theory?
Nonpainful input closes the "gates" to painful input, which prevents pain sensation from traveling to the central nervous system.
Describe the Florida statues of using PAMs and modalities.
Required (1) Didactic training of at least 4 hours (2) 5 Supervised treatment sessions from an OT/PT or certified OTA/PTA > Supervisors must have a minimum of 24 months prior experience in the use of the device
** PAMS are not to be used in isolation & must be followed up with a functional task **
> Can ONLY be used alone when a client has bad wounds and wound healing or fully dependent clients, when no other OT goals can be addressed due to ADL and IADL dependence
Describe ultrasound BNR. What does it mean, and what is the ideal range? What can happen if the machine is outside of this range?
The smaller/lower the BNR, the more homogenous the beam produced by the transducer and the safer & more effective the treatment
We WANT a low BNR
A poor BNR > 6:1 → potential to create hot spots
8:1 max permitted BNR
Calculation: Do (Intensity x BNR) and this number must be less than 8 total, or else it’s not safe
BNR too high = hot spots, too low = ineffective
2:1-5:1 (move 1cm/second) – Move SLOWER
Which component of the ultrasound influences the rate of heating & strength?
INTENSITY
Define/describe Cryoglobulinemia. What is this a contraindication for?
Pt. has an abnormal blood protein that forms a gel when exposed to low temp.’s -gel formation can lead to ischemia or gangrene.
This is a contraindication for the use of cryotherapy.
How do PAMs affect pain? What are the advantages of using PAMs for pain management?
◦ Inhibiting inflammatory response
◦ Altering nerve conduction
◦ Increasing endorphin levels
◦ Inhibiting pain transmission at spinal cord
◦ Advantages: less side effects compared to medications, do not cause sedation or ADL disruption, maximize client's functioning within their limitations
Cryotherapy
CONDUCTION: Direct contact to tissue surface (ice cup/pack)
EVAPORATION: Liquid changed to gas (cold sprays)
CONVECTION: Movement of cold particles (cold whirlpool)
Heat
CONDUCTION: Exchange of thermal energy with contact – Hot packs, Paraffin
RADIATION: Transsfer of energy through electromagnetic waves – Laser therapy
CONVECTION: Conveyance of heat through moving particles – Fluidotherapy, whirlpool
Parameters for thermal ultrasound? Subthermal? When do you change frequency?
Frequency: 1MHz for deep & above elbow
3 MHz for superficial & below elbow
Thermal: Use for chronic injury: Continuous, 100% duty factor, delta T = 1o C, Intensity=1 W/m2, 7-10 minutes
Subthermal: Use for acute injury: Pulsed, 20% duty factor, 3-5 minutes
Describe ERA regarding ultrasound.
How does this relate to the size of treatment area?
Area of the ultrasound from which the energy radiates; The crystal does not vibrate uniformly which causes the ERA to be smaller than area of the ultrasound head
**Treatment area should be 2-3 times the size of the ERA**
Contraindications for Ultrasound?
1. Pacemaker/Implanted Defibrillator (over the thoracic area)
2. Implanted Medical Device
3. Active Cancer (directly over)
4. Pregnancy (over uterus)
5. Fever/Infection/Inflammation
6. Hemorrhage/Active Bleeding
7. Growing bones
8. DVT
9. Cardiac Disease
10. Methyl Methacrylate
11. Arthroplasties
12. Healing Bones/Tissue
13. Ischemic Tissue
14. Cranial Region
15. Spinal cord
16. Reproductive Organs
17. Vascular Compromise
Define & describe plastic vs elastic deformaiton
Plastic Deformation: when the tissue is taken to a length and most of the lengthening is retained after cooling. If heat is applied to collagenous tissue prior to or with stretching, the tissue can reach a state of Plastic Deformation
Elastic Deformation: the tissue is lengthened - however, the length does not remain after the force is removed. If not heated first, it will only reach Elastic Deformation
Describe the Piezoelectric Effect and Reverse Piezoelectric Effect
Piezoelectric effect: Ability of a material to generate electricity when mechanically deformed
Reverse Piezoelectric Effect: Electrical input causes a mechanical deformation (contraction and expansion of crystal – quartz or ceramic); Crystal in US head vibrates in response to electricity
Parameters for Cryotherapy modalities?
Cold Pack - in pillow case, should be in fridge for up to 1 hour before use, utilize for acute injuries and inflammation, 15-20 mins or CBAN. Utilize for larger treatment areas.
Ice Cup - round edges on towel, utilize for small areas of inflammation, good for if a client wants to do this at home, 5-10 mins or CBAN. Treatment area should be 6 inches in diameter.
During ultrasound, are high or low frequencies absorbed more quickly? Give one example of high frequency and low frequency US spots on body.
High frequencies are absorbed more quickly
Low absorption - fat, water, blood
High absorption - skin, tendon, bone
What is Urticaria? Describe the process of this in the body. What is this a contraindication for?
Cold hypersensitivity (contraindication for cryotherapy)
In response to cold, pt. develop bumps on the skin that are red and swollen -due to mast-cell degranulation ➨ release of histamine -in severe case, pt. has generalized swelling of mucous membranes and viscera -can even have systemic reactions: ⇓ blood pressure, ⇑ heart rate, and syncope
Describe each type of pain fiber: A-delta (type 1 and 2), A-beta, and C-fibers. Which type of fiber is affected by the use of PAMs?
A-BETA: Cutaneous receptors convey vibration, pressure, and light touch, large myelinated fibers. This type of fiber is affected by PAMs
A-DELTA TYPE 1: small, myelinated, and transmit fast, acute pain; gross touch, fast pain, capsaicin-insensitive, high heat
A-DELTA TYPE 2: small, myelinated, and transmit fast, acute pain; gross touch, capsaicin sensitive, low heat
C-FIBERS: respond to slow pain, low pH, heat; capsaicin insensitive, small unmyelinated fibers
What does "frequency" determine on an ultrasound? What happens when the frequency is higher or lower?
Frequency determines the depth of penetration.
Higher frequency = less depth penetration and vice versa
Name all of the parameters for (1) Fluidotherapy (2) Paraffin wax and (3) Contrast Bath. Include temperatures, preparatory steps, and timing.
• Fluidotherapy: Instructs client to perform exercise while in the unit. Temp = 105°-118° F. Time is 15-20 minutes. Beneficial for hypersensitivity. Instruct the client to perform exercise while in the unit.
• Paraffin: Dips the hand 7-10 times and ensures the client keeps the hand still to prevent cracks. Wraps the hand with plastic seal and dons mitten. Temp should be 126°-134° F. Time of rest in glove is 15-20 minutes.
• Contrast bath: Immerse the affected body part in hot water for 3-4 minutes. After the hot immersion, immediately immerse the affected body part in cold water for 1 minute. Hot should be 100° F-110° F; cold °50 F - 70°F. Alternate time in hot: 10’,4’,4’ 4’ x time in cold 1’,1’1,1,’, end with warm water x4
What category does the OTPF classify modalities?
Interventions to support occupations