Modalities A review of commonly used modalities
Modalities A review of commonly used modalities
Determine patient response
Always monitor the patient’s response to modalities
Interview the patient and obtain verbal and non-verbal responses
Identify complications or secondary effects caused by the modality
Determine both positive and negative outcomes from the modality
Modalities Included
Superficial Thermotherapy
Hot packs
Paraffin bath
LASER
Deep Thermotherapy
Ultrasound (US)
Phonophoresis
Cryotherapy
Cold packs
Ice massage
Electrotherapy
Interferential Current (IFC)
Functional Electrical Stimulation (FES)
TENS
Conventional
Acupuncture-like
Brief intense
Burst mode
Modulation mode
Iontophoresis
Intermittent Mechanical Compression
Mechanical Spinal Traction
Superficial Thermotherapy
Indications
Joint hypomobility, musculoskeletal pain/spasm, preparation for exercise or electrical stimulation, subacute or chronic traumatic and inflammatory conditions
Precautions
Cardiac insufficiency, edema, impaired circulation, impaired thermal regulation, metal implants at treatment site, open wounds
Contraindications
DVT, impaired cognitive function, decreased circulation or sensation, malignant tumors, acute and early subacute traumatic and inflammatory conditions, tendency toward hemorrhage or edema, very young or very old patients
Superficial Thermotherapy: Hot Packs
Hot packs
Packs are placed between towels or covers to protect skin
8 layers of toweling should be used
If heat is transferred too quickly, skin mottling or permanent burn damage may occur
Patient’s skin should be checked periodically during treatment
Treatment time: 20-30 minutes
Superficial Thermotherapy: Paraffin
Paraffin
Therapeutic application of liquid paraffin to a body part for the purpose of heat transmission
Often used for small or irregularly shaped body parts such as the hand or foot
Contraindications: open wounds, recent scars or sutures, skin infections, allergic rash
Treatment time: 15-20 minutes
Superficial Thermotherapy: LASER
Light Amplification by Stimulated Emission of Radiation (LASER)
The frequency of the laser light and the type of tissue determines the depth of light penetration
Low intensity “cold” lasers are utilized in rehabilitation settings and may be biostimulative and facilitate healing
Acute conditions: lower energy density ranges of 0.05 and 1 J/cm2 are recommended
Chronic conditions: higher dosages of up to 40 J/cm2 are recommended
Deep Thermotherapy
Indications
Pain modulation, increase soft tissue extensibility, reduce or eliminate soft tissue inflammation or restriction, accelerate tissue healing
Precautions
Metal implants, osteoporosis, primary repair of tendons or ligaments or scar tissue, open epiphyses and healing fractures, acute inflammation
Contraindications
Impaired circulation or sensation, impaired cognitive function, thrombophlebitis, joint cement, plastic components, vital areas (brain, ear, eye, heart, cervical ganglia, carotid sinuses, reproductive organs, spinal cord, cardiac pacemaker, pregnant uterus), use of radium or radioactive isotopes
Deep Thermotherapy: US
Ultrasound (US)
Select appropriate sound head size with an effective radiating area (ERA) of approximately half the size of the treatment area
Example: 1cm2 = wrist; 5cm2 = shoulder or leg
Select the optimal parameters for either a thermal effect of non-thermal effect
Must use a medium (such as US gel) to treatment area and move the sound head at approximately 4 cm/second
Deep Thermotherapy: US
Thermal effect
Intensity: 0.3-1.5 W/cm2
Frequency:
1 MHz for tissue up to 5 cm deep
3 MHz for tissue 1 to 2 cm deep
Duty cycle: continuous, 100%
Non-thermal effect
Intensity: 0.5-1.0 W/cm2
Frequency:
1 MHz for tissue up to 5 cm deep
3 MHz for tissue 1 to 2 cm deep
Duty cycle: pulsed, 20-50%
Treatment time: 5 to 10 minutes for each treatment area that is twice the ERA of the transducer
Example: an area of 20 cm2 treated with a sound head with an ERA of 10 cm2 should take 5-10 minutes
Phonophoresis
Indications
Pain modulation, decrease inflammation in subacute and chronic musculoskeletal conditions
Precautions and contraindications
See US section
Phonophoresis
Used to drive medication through the skin into the treatment area
Common medications include Hydrocortisone, Dexamethasone, salicylates, Lidocaine, or other ointments
Intensity: 1-3 W/cm2
Treatment time: 5-10 minutes
Cryotherapy
Indications
Pain modulation, reduce or eliminate soft tissue inflammation or edema, reduce muscle spasm or spasticity, acute and chronic traumatic and inflammatory conditions, thermal burns
Precautions
Hypertension, impaired temperature sensation, open wounds, application over a superficial nerve, very old or very young patients
Contraindications
Cold hypersensitivity or intolerance, impaired temperature sensation, cryoglobulinemia, peripheral vascular disease, Raynoud’s disease
Cryotherapy: Cold Packs
Cold packs
Keep the patient warm throughout treatment
Dampen a towel with warm water and place cold pack on towel
Place pack on patient and cover with dry towel to reduce warming
Treatment time: 10-20 minutes
Cryotherapy: Ice Massage
Ice massage
Use an ice cylinder formed by freezing water in a paper cup
Patient will experience cold, burning, aching, and then numbness during treatment
Avoid bony areas and superficial nerves
Treatment time: 5-10 minutes or until analgesia occurs
Electrotherapy
Indications
Pain modulation, muscle spasm or re-education or weakness, impaired range of motion, soft tissue repair or wound healing, edema, spasticity, denervated muscle
Precautions
Areas of impaired sensation, severe edema
Contraindications
Healing fractures, areas of active bleeding, malignancies or phlebitis in the treatment area, superficial metal implants, pharyngeal or laryngeal muscles, demand-type pacemaker, myocardial disease
Electrotherapy: Interferential Current (IFC)
Two sinusoidal waves are crossed to generate an amplitude modulated beat frequency
Used for pain modulation or muscle strengthening
Bipolar (premodulated IFC)
Active and dispersive electrodes used over a small area
Quadripolar (IFC)
Two sets of electrodes placed diagonally to one another over a large area
Electrotherapy: Functional Electrical Stimulation (FES)
Also known as neuromuscular electrical stimulation (NMES)
Used for disuse atrophy, limited ROM, muscle re-education or spasm or spasticity
Also used in combination with or instead of an orthotic device
Alternating current is used to stimulate innervated muscle for general stimulation
Direct current is used for denervated muscle
Electrotherapy: Functional Electrical Stimulation (FES)
Duty cycle
Current on:off time in seconds
Ratio should increased as weakness or atrophy increases
1:1 to 1:2 ratio for minimal or no atrophy
1:3 to 1:4 ratio for moderate atrophy
1:5 to 1:10 ratio for severe atrophy
Electrotherapy: Transcutaneous Electrical Stimulation (TENS)
Provides afferent stimulation for pain modulation
Current
Symmetrical or asymmetrical biphasic (AC)
Monophasic (DC)
Electrode placement
Site of pain, dermatome, trigger point, proximal or distal to the pain site, segmental related myotome
Electrotherapy: Transcutaneous Electrical Stimulation (TENS)
Conventional (high rate) TENS
Indicated for temporary relief of acute or chronic pain
Amplitude: comfortable tingling sensation, paresthesia without muscle activation
Pulse rate: 50-80 pps
Pulse duration: 50-100 µsec
Treatment duration: 20-60 minutes
Pain relief duration: temporary
Acupuncture-like (strong, low-rate) TENS
Indicated for chronic pain
Amplitude: strong, comfortable, rhythmic muscle twitches
Pulse rate: 1-5 pps
Pulse duration: 150-300 µsec
Treatment duration: 30-40 minutes
Pain relief duration: long lasting, possibly >1 hour
Electrotherapy: Transcutaneous Electrical Stimulation (TENS)
Brief intense TENS
Indicated to provide rapid onset, short-term pain relief during painful procedures
Amplitude: patient tolerance
Pulse rate: 80-150 pps
Pulse duration: 50-250 µsec
Treatment duration: 15 minutes
Pain relief duration: temporary (30-60 minutes)
Electrotherapy: Transcutaneous Electrical Stimulation (TENS)
Burst mode TENS
Indicated for stimulation of endogenous opiates, analgesia
Amplitude: comfortable, intermittent paresthesia
Pulse rate: 50-100 pps delivered in bursts of 1-4 pps
Pulse duration: 50-200 µsec
Treatment duration: 20-30 minutes
Pain relief duration: long lasting (hours)
Electrotherapy: Transcutaneous Electrical Stimulation (TENS)
Electrotherapy: Transcutaneous Electrical Stimulation (TENS)
Modulation mode TENS
Used to prevent neural or perceptual adaptation
Frequencies, pulse widths, intensities can be altered by ten or more percent, one or two times per second
Electrotherapy: Iontophoresis
Continuous direct current is used to drive chemical ions through the skin
Therapeutic ion must be placed under an electrode of similar charge
Cathode (negative pole) used for salicylate, acetate, dexamethasone, iodine
Anode (positive pole) used for hydrocortisone, Lidocaine, magnesium, calcium, lithium, zinc, copper
Contraindications
Impaired skin sensation, allergy or sensitivity to therapeutic agent or direct current, metal in or near treatment site, recent scars, cuts, bruises or broken skin
Electrotherapy: Iontophoresis
Clean and inspect the skin before treatment
Dose: product of time and current intensity
Anode: 1.0 mA/cm2
Cathode: 0.5 mA/cm2
Duration: 10-40 minutes
Intensity: turn up slowly to selected level
Observe treatment area every 3-5 minutes and after treatment
Intermittent Mechanical Compression
Indications
Chronic edema, postmastectomy lymphedema, stasis ulcer, traumatic edema, venous insufficiency, amputation
Precautions
Uncontrolled hypertension, impaired sensation, malignancy, obstructed lymph or venous return
Contraindications
Acute infection, acute inflammation in treatment area, acute DVT, acute pulmonary edema, arterial insufficiency, cancer, diminished sensation, edema with cardiac or renal impairment, cardiac or renal insufficiency, impaired cognition, infection in treatment area, obstructed lymph channels, very young and frail elderly patients
Intermittent Mechanical Compression
Assess patient’s blood pressure in order to determine device settings
Elevate the limb
Inflation:deflation ratio is approximately 3:1
Edema reduction at 45-90 seconds:15-30 seconds
4:1 is often used to shape a residual limb
Treatment duration: varies depending on patient tolerance
Lymphedema: 2 hours to two 3 hour sessions
Traumatic edema: 2 hours
Venous ulcers: 2.5 hours 3x/week to 2 hour periods
Residual limb reduction: 1 hour to 3 hour sessions, totaling 4 hours
Mechanical Spinal Traction
Indications
Joint disease or hypomobility, meniscoid blocking muscle spasm, degenerative disc, discogenic pain, herniated nucleus pulposis, nerve root impingement, subacute or chronic joint pain
Precautions
Acute inflammation aggravated by traction, claustrophobia, acute strains or sprains, hiatus hernia, joint instability, osteoporosis, pregnancy, TMD with halter use
Contraindications
Rheumatoid arthritis, impaired cognitive function, spinal tumors, spinal infections, spondylolisthesis, vascular compromise, vertebral artery syndrome, very young or very old patients
References
Cameron MH, Physical Agents in Rehabilitation: From Research to Practice. St. Louis, MO; Elsevier; 2003.
O’Sullivan SB, Siegelman RP, IER’s National Physical Therapy Examination Review & Study Guide. Evanston, IL; International Educational Resources, Ltd.; 2008.
Siegelman R, Bianco T, Dirkes A, Chavez E, IER/TherapyEd Exam Preparation: Physical Therapy Course Manual version 4.0. Evanston, IL; International Educational Reources, Ltd.; 2008.
American Physical Therapy Association. Minimum required skills of physical therapist assistant graduates at entry-level BOD G11-08-09-18. Available at: http://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/BOD/Education/MinReqSkillsPTAGrad.pdf#search=%22pta%20minimum%20skills%22. Accessed December 20, 2012.