Stanbridge - T4 - Modalities - W4 - Compression, CPM, & Diathermy

Modalities (PTA 1009)

• Compression, CPM, and Diathermy are discussed in this presentation.

• Compression is the application of external mechanical pressure to the body for therapeutic purposes.

Objectives

• The student should be able to describe the following:
  • Anatomy of fluid movement
  • Types of compression
  • Signs of inflammation
  • Types of edema
  • Indications, contraindications, and precautions for compression
  • Dosage and frequency of compression

Anatomy- Fluid Movement

• Fluid travels through three main pathways in the body:

  • Circulatory system
  • Lymphatic system
  • Interstitial space

• 90% of fluid absorbed on the arterial side of capillary bed is absorbed from the venous side.

• 10% of fluid, protein and debris are removed by the lymphatic system.

• Fluids are held within interstitial space by a gel matrix.

• Gel matrix functions as:

  • Spacer between cells
  • Prevents excessive fluid movement into the lower body
  • Prevents rapid spread of bacteria throughout tissues

• Lymphatic system Functions as:

  • Regulates fluid balance (only mechanism for protein removal)
  • Works with the immune system to defend against cancer/infection
  • Transports digested fat from the gut
  • Can transport up to 10 times the normal volume but not for long time

• A review of the Cardiac and Pulmonary Systems and the Lymphatic System is also included. Demonstrates the relationship between circulatory and lymphatic systems in fluid movement.

Anatomy Review: 3 Systems

• Blood flow in veins is dependent on:
  • Skeletal muscle contraction
  • One-way valves
  • Respiratory movements

Edema

• Edema occurs if things at the capillary level aren't working properly.
• Arteriole end-exit of O2, water, and nutrients
• Venous end-entrance of CO2, water, and wastes
• Filtration and Absorption influenced by pressure gradients and concentrations. (Capillary level)
• Types of Edema:
  • Acute
    • Local: due to tissue injury (mechanical, infectious, toxic)
    • Widespread: metabolic disease (i.e., congestive heart failure, malnutrition)
  • Chronic or Progressive= Lymphedema
    • Result of venous and/or lymphatic obstruction
    • Often painless and mildly warming, General Symptoms - Heaviness - Warmth - Aching - Stiffness - Shiny/tight skin - Loss of skin folds
• Stages of Lymphedema

Early vs. Chronic Edema

• Early edema is characterized by pitting.
• Chronic edema is characterized by non-pitting, trophic skin changes (rough, leathery), and excessive protein deposits (fibrosis).

Edema Classification

• Edema is classified as follows:
  • Acute (1-14 days)
  • Subacute/Post-acute (14 days - 3 months)
  • Chronic (3+ months)

Examination of Edema

• Examination should include:
  • Timing of edema symptoms
  • Medical/surgical history
  • Pain assessment
  • Self-treatment
  • Medications
  • Functional limitations

Edema Causes and Treatment

• Edema can cause:
  • Increased risk of infection
  • Decreased blood flow and nutrient supply to tissues
  • Decreased mobility, strength, and function
  • Increased pain from mechanical pressure on nerve endings.
• Treatment: RICE (Rest, Ice, Compression, Elevation)

Compression

• Definition: Application of external mechanical pressure to the body for therapeutic purposes.
• Physiological effects:
  • Supports skin, allowing for more effective fluid pumping by muscles
  • Stimulates capillaries (lymphatic and circulatory) to absorb interstitial fluid
  • Altered pressure around capillaries decreases edema formation
  • Narrows cross-sectional area of vein, increasing blood flow, and decreasing fluid leakage
  • Makes valves more competent, increasing muscle pump activity
  • Improves oxygen delivery and CO2 uptake
• Take girth measurement and patient's ABI prior to wrapping
• Types of Compression Bandages:
  • Long stretch (ACE wraps - elastic)
  • Short stretch (inelastic)
  • Multi-layered bandages
  • Semi-rigid bandages (e.g., Unna Boot)
• Intermittent Compression Pumps
• Compression Garments
  • UE/LE/Trunk garments

Contraindications for Compression

• Arterial insufficiency (ABI ≤ 0.5)
• Arterial wounds
• Untreated cardiac or pulmonary edema
• Renal edema
• Acute infections (e.g., cellulitis)
• Acute DVT
• Edema without diagnosis

Precautions for Compression

• Mixed venous and arterial ulcers (ABI = 0.5–0.8)
• Diabetes
• Paralysis
• Malignancy
• Sensory deficits
• Altered mental state
• Sensitivity to compression
• Inability to comply with home instruction
• Genital lymphedema with compression for LE's

Red Flags for Systemic Edema (Organ)

• Bilateral edema of extremities
• Sudden onset without traumatic event
• Progressive edema
• Edema involving the face/arm with discoloration of the chest/arm/face loss of carotid pulses, dysphagia, etc.
• Total body, total quadrant edema
• Edema that occurs simultaneously with fever, sweats, and chills
• Inflammatory changes (e.g., red streaks)
• Calf pain and edema after trauma
• Edema warm/hot to palpation
• Arterial vascular changes (paleness, cool skin temperature, tight/shiny skin)

Methodology for Compression

• Compression garments
• Classes of compression (Preventative, I-IV)
• Custom vs. OTC compression
• Replacements every 6 months
• Dosages
• Pneumatic Compression Pumps
• Diastolic pressure maximum mmHg for venous ulcers
• Dosages
• Lymphedema bandaging:
• Short stretch requires special training
• Gradient: distal > proximal
• Includes
  • Massage
  • exercise
• Replace every 6 months

Documentation for Compression

• Type of compression used
• Vital signs (if necessary)
• Volumetric/circumferential measurements (before and after tx)
• Region of body treated
• Dosage (time, max mm Hg, position, extremity)
• Number and size of bandages used
• Patient response to treatment
• Patient education
• Document compression, capillary refill, sensory check, and extremity mobility

Continuous Passive Motion (CPM)

• Passive motion by a mechanical device

• Benefits: Decreased adhesions, improved ROM gains, improved synovial fluid, decreasing post-operative pain, reducing edema, and stimulating tissue healing.

• Indications: Pain, limited ROM, edema, susceptibility to contractures/adhesions, muscle/joint stiffness.

• Contraindications: Increased pain after use, use with anticoagulants that put the patient at risk for intra-compartment hematoma, unwanted translation of opposing bones (fracture, arthrodesis).

• Prescription:

  • Initial arc: 20°-30°
  • Progress: 10°-15° / day as tolerated
  • Rate of motion: 1 cycle/45 sec - 2 min
  • Frequency: 4-8 hrs/ day for best compliance
  • Duration: < 1 week

Diathermy (SWD and PSWT)

• Types of Diathermy
• Physical principles of Diathermy
• Physiological Responses
• Indications, contraindications, and precautions
• Advantages/Disadvantages of Diathermy
• Dosage and frequency
• Deep Heat (Tissue penetration 3-5 cm)
• Can treat up to 25x the size of an US transducer head (large area)
• Heat transfer via: Conversion
• Continuous or Pulsed Mode
• Non-Thermal effects
• Thermal effects

Indications for Diathermy

• Pain (e.g., sub-acute and chronic low back pain, trigger point pain, osteoarthritis, muscle strain, bursitis)
• Limited ROM (soft tissue tightness, DJD, joint stiffness)
• Inflammation (including chronic inflammation)
• Reflex heating
• Pelvic Inflammatory Disease
• Herpes Zoster
• Peripheral nerve regeneration
• Increased metabolism of cells

Contraindications for Diathermy

• Infections
  • Recent x-ray therapy
• Existing fever
• Cardiac insufficiency
• Older adults/children under 4
• Patients who are generally debilitated
• Over epiphysis of growing bones
• Ischemic tissue
• Hemophilia
• Patients, staff, or visitors wearing pacemakers
• Implanted systems or leads (neurostimulators)
• Pregnancy (therapist or patient)
• Internal/external metal objects that cannot be removed
• Active bleeding (including menses or acute trauma)
• Malignancies
• Pain and sensory deficits

Diathermy Dosage

• Common Doses (Low to High):
  • Dose I – No sensation of heat (Acute)
  • Dose II – Mild heating sensation (Subacute)
  • Dose III – Moderate heating sensation (Resolving inflammatory process)
  • Dose IV – Vigorous heating that is tolerable below threshold (Chronic).
• Dose is based on:
  • Patient response during treatment (heat, no heat felt)
  • Intended goal (thermal/non-thermal affects)
  • Phase of healing (acute, subacute, vs. chronic)

Diathermy (SWT and PSWT): Non-Thermal Dosage

• Intensity ≤ 5 W – used for acute conditions
• Narrow pulse durations (65-80 µs)
• Medium pulse rates (100–200 pps)
• Duration up to 30-60 minutes
• Treatment frequency
  • Acute: 2-3x daily
  • Sub-Acute: 2-3x/wk
  • Chronic: 1x/wk

Diathermy (SWT and PSWT): Thermal Dosage

• Intensity > 5 W – considered thermal and is reserved for sub-acute/chronic conditions
• 21 W is the average dose for thermal effects
• Longer pulse durations (300-400 μs)
  • Higher frequencies introduce (>300 pps)
• Duration – 20 minutes
• Heating of tissues lasts longer than with ultrasound, giving the therapist additional time for therapeutic interventions.

Explore the principles and applications of diathermy in therapeutic settings. This quiz covers the mechanisms of heat generation, targeted tissues, effective conditions for use, and the role of electromagnetic fields in diathermy's induction method. Test your understanding of diathermy in treating soft tissue injuries and hematomas.