W4 PPT- Modalities- Compression, CPM & Diathermy PDF

Modalities (PTA 1009) Power Point #4 Compression, CPM and Diathermy  2 ©Stanbridge University 2023 Compression Source: www.pinterest.com Source: www.eplasty.com ...

Modalities (PTA 1009) Power Point #4 Compression, CPM and Diathermy  2 ©Stanbridge University 2023 Compression Source: www.pinterest.com Source: www.eplasty.com  3 ©Stanbridge University 2023 Objectives By the end of this section the student should be able to describe: Anatomy of fluid movement Types of compression Signs of inflammation Types of edema Indications, contraindications and precautions Dosage and frequency  4 ©Stanbridge University 2023 Anatomy- Fluid Movement Fluid travels in the body in 3 major pathways: ▫ Circulatory system ▫ Lymphatic system ▫ Interstitial space 90% of fluid on arterial side of capillary bed is absorbed on the venous side Where does the other 10% go?  5 ©Stanbridge University 2023 Anatomy- Fluid Movement 10% of the fluid, protein and debris are removed by the lymphatic system Fluids in interstitial space are held by a gel matrix Gel Matrix Functions: ▫ Spacer between the cells ▫ Prevents excessive movement of the fluid into lower body ▫ Prevents the rapid spread of bacteria through tissues  6 ©Stanbridge University 2023 Anatomy- Fluid Movement Lymphatic system- 3 Functions 1) Regulation of fluid balance through transport of fluid and proteins (only mechanism for protein removal) 2) Along with the immune system provides defense against cancer/infection 3) Transport of digested fat from the gut Can carry up to 10x the normal volume but not for a long time  7 ©Stanbridge University 2023 Anatomy Review: 3 Systems CARDIAC & PULMONARY SYSTEMS LYMPHATIC SYSTEM Source: Marieb and Hoehn, 2019 Source: Behrens, 2014  8 Anatomy Review ©Stanbridge University 2023 Blood flow in veins * Venous return is dependent upon: 1. Skeletal muscle contraction 2. One-way valves 3. Respiratory movements Source: Marieb and Hoehn, 2019  9 ©Stanbridge University 2023 Anatomy Review EDEMA occurs if things are not working properly at the CAPILLARY LEVEL 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 Source: Marieb and Hoehn, 2019  10 ©Stanbridge University 2023 Increased Hydrostatic Pressure Gradient caused by: Hypertension Decreased cardiac output Vasodilation Venous congestion Decreased lymph transport Decreased Osmotic Pressure Gradient caused by: Poor nutrition- protein deficiency Decreased capillary protein concentration Vasodilation Tissue injury Increased tissue protein concentration  11 ©Stanbridge University 2023 Review: Inflammatory Process Inflammation ▫ Body’s initial response to harmful stimuli or injury ▫ Mediated by histamines ▫ Chemical mediators increase:  Venous permeability  Movement of plasma and WBC’s from the blood to interstitial space  Platelet mobilization for clotting ▫ Increased fluid in interstitial space is termed EDEMA  12 ©Stanbridge University 2023 Inflammatory Process https://ib.bioninja.com.au/standard- level/topic-6-human-physiology/63- defence-against- infectio/inflammation.html  13 ©Stanbridge University 2023 5 Cardinal Signs of Inflammation An acute inflammatory process is present when you observe: ▫ Redness (Rubor)- dilation of small blood vessels ▫ Heat (Calor)- increased blood flow locally/systemically (fever) ▫ Pain (Dolor)- afferent pain fibers from injured tissue ▫ Edema (Tumor)- Release of chemical mediators, WBC’s and platelets causing increased capillary permeability ▫ Loss of Function  14 ©Stanbridge University 2023 Edema Edema is clinically present when there is approximately 30% increase above the normal fluid volume in the interstitial space It represents the body’s failure to compensate for increased fluid in a region Edema occurs due to increases in infiltration/decrease in absorption Source: www.flickr.com  15 ©Stanbridge University 2023 Edema Acute Edema 1) Local- due to tissue injury in response to: ▫ Mechanical ▫ Infectious ▫ Toxic nature 2) Widespread- ▫ Metabolic disease  Examples: congestive heart failure, malnutrition, liver disease, etc Source: www.wikipedia.com  16 ©Stanbridge University 2023 Edema Chronic or Progressive Edema= Lymphedema Result of venous and/or lymphatic obstruction Lymphatic return is limited because the obstruction cause an overload by compensating for lack of adequate venous return. Often painless and mildly warming Common symptoms (sxs): ▫ Heaviness ▫ Warmth ▫ Aching ▫ Stiffness ▫ Shiny/tight skin ▫ Loss of skin folds  17 ©Stanbridge University 2023 Edema Lymphedemas Primary: Congenital lack of adequate lymphatic drainage Secondary: Result of an acquired injury to venous or lymphatic system Source: Behrens, 2014  18 ©Stanbridge University 2023 Edema Early edema: characterized by pitting (high protein) Source: www.shutterstock.com Chronic edema: characterized non pitting trophic skin changes (rough, leathery) Excessive deposits of protein & fibrinogen (fibrosis) Source: www.meded.ucsd.edu  19 ©Stanbridge University 2023 Edema Edema is classified as follows: ▫ 1-14 days = ACUTE ▫ 14 days – 3 months = SUBACUTE or POST ACUTE ▫ 3+ months = CHRONIC Source: Behrens, 2014  20 ©Stanbridge University 2023 Edema Examination of edema should include: Timing of symptoms of edema Medical/surgical History Pain Self- treatment Medications Functional limitations  21 ©Stanbridge University 2023 Edema can cause: Increased risk of infection Decreased blood flow and nutrient to tissues Decreased mobility, strength and function Increased pain due to mechanical pressure on free nerve endings  22 ©Stanbridge University 2023 Edema Treatment How do we treat Edema? R= Rest I = Ice C= Compression E= Elevation  23 ©Stanbridge University 2023 Compression Definition of Compression: Application of external mechanical pressure to the body for therapeutic purposes Source: Bellew 2016 Notice the size of the figures indicate higher pressure distally and lower pressure proximally Source: www.alibaba.com  24 ©Stanbridge University 2023 Compression Physiologic effects: ▫ Supports the skin thus allowing muscles to have counter pressure which makes “fluid pumping” more effective ▫ Stimulates capillaries (lymphatic and circulatory) to absorb interstitial fluid ▫ Altered pressure around the capillaries decreases edema formation  25 ©Stanbridge University 2023 Compression Physiologic effects (continued): ▫ Narrows the cross-sectional area of the vein which increases the speed of the blood flow (less time for fluid to leak out) ▫ Makes the valves more competent by increasing the muscle pump activity ▫ Pressure changes improve oxygen delivery and CO2 uptake  26 ©Stanbridge University 2023 Compression Take girth measurement Take patient’s ABI prior to wrapping (learn in PTA Practice II) ▫ Ankle-Brachial Index (ABI) is the ratio of the systolic pressure in the ankle relative to the systolic pressure in the brachial artery in the arm; most common measurement of LE perfusion ABI > 1.30 Non compressible; rigid arteries 1.00 to 1.29 Normal; no blockage 0.80 to 0.99 Mild blockage 0.41 to 0.79 Moderate PAD (peripheral artery disease) 0.00 to 0.40 Severe PAD  27 ©Stanbridge University 2023 Types of Compression Types of Compression Bandages: 1. Long stretch (ACE wraps - elastic)  Produces high pressure at rest, and low pressure for working muscles  Applied with 50% stretch and a 50% overlap  Extends up to 200% of original length 2. Short stretch- (inelastic)  Produces high pressure for working limbs, and low pressure at rest  Applied with 50% stretch and 50% overlap  28 ©Stanbridge University 2023 Types of Compression 3. Multi-layered bandages Source: Behrens 2014 ▫ Apply moderate to high resting pressure through use of several bandages containing elastic and inelastic layers ▫ Used to treat venous stasis ulcers ▫ Provides protection, absorption and compression  29 ©Stanbridge University 2023 Types of Compression 4. Semi rigid bandages Treated (wet) gauze to an area that hardens when it dries. Used for venous stasis ulcers Example: Unna boot- 35-40 mmHg Source: www.healthproductsforyou.com  30 ©Stanbridge University 2023 Types of Compression Intermittent Compression Pumps  UE and LE pneumatic pumps  Sequential  30-80mmHg  UE 30- 60mmHg  LE 40-80 mmHg ▫ Tx time 30 min→4 hours ▫ Freq 3x/wk→ 4x/day Source: Pierson and Fairchild 2018  31 ©Stanbridge University 2023 Types of Compression Intermittent compression Pumps ▫ Compression at intermittent cycles used to control edema ▫ Used to decrease chronic and post-traumatic edema ▫ Can be coupled with cold (Gameready) or electrical stimulation  Electrical Stimulation Current is not increased until after desired inflation is achieved Source: Bellew 2016  32 ©Stanbridge University 2023 Types of Compression Source: www.medimotion.ca Compression Garments  UE/LE/Trunk ▫ 16-18 mmHg- Off the shelf garments and antiembolism stockings ▫ 20-30 mmHg for scar tissue control ▫ 30-40 mmHg for edema control ▫ Improve venous circulation in active patients ▫ Garments should be fit when level of edema is minimal ▫ Ave lifespan of garment is 6 months  33 ©Stanbridge University 2023 Types of Compression Source: www.juzousa.com  34 ©Stanbridge University 2023 Compression Taught in the program In Modalities lab we will begin practicing how to use ace wraps to support joints Goal is: ✓Begin learning the figure 8 or herringbone pattern ✓Learn how to perform the 50% stretch and 50% overlap method ✓Begin practicing how to cover different body shapes In PTA Practice II you will learn the system for venous wrapping  35 ©Stanbridge University 2023 Compression- Evidence I Hansrani et al, The role of compression in the management of soft tissue ankle injuries: a systematic review; European Journal of Orthopedic Surgery and Traumatology, 2015; 25(6): 987-995 - Compression may reduce swelling and improve the quality of life in individuals who have suffered an ankle sprain Lasinski et al, A Systematic Review of the Evidence I for Complete Decongestive Therapy in the Treatment of Lymphedema From 2004 to 2011, 2012; 4(8):580- 601 -Compression used with manual lymphatic drainage is effective in reducing lymphedema  36 ©Stanbridge University 2023 Indications for Compression Venous Insufficiency Venous Ulcers Traumatic edema from localized inflammatory response (sprains, strains, hand/foot trauma) Post-surgical edema Amputations (stump wrapping/stump socks) Prevention of thrombophlebitis/DVT Lymphedema  37 ©Stanbridge University 2023 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 Cellulitis post antibiotic tx and after cardinal signs of infection have diminished  38 ©Stanbridge University 2023 Contraindications for Compression Arterial insufficiency (ABI < or = 0.5) Arterial wounds Untreated cardiac or pulmonary edema Source: Pierson and Fairchild 2018 Renal edema Acute infections (like cellulitis) Acute DVT Edema without diagnosis Diabetic with Cellulitis  39 ©Stanbridge University 2023 Red Flags for Systemic (Organ) Edema Total body edema or total Bilateral edema of extremities quadrant edema Sudden onset without traumatic event Edema that occurs Progressive edema simultaneously with fever, Distal edema with complaints of sweats and chills shortness of breath at rest or with Edematous body part with red exertion streaks Edema involving the face or arm that is Calf pain and edema after present with discoloration of the chest, trauma arm or face, loss of carotid pulses, Edema that is warm or hot and dysphagia, wheezing, chest pain, painful to palpation headaches, dizziness orthopnea Arterial vascular changes present such as paleness, cool skin temperature, skin is tight and shiny  40 ©Stanbridge University 2023 Methodology for Compression Compression garments  Classes of compression (Preventative, I-IV)  Custom vs. OTC  Replace q 6 months  Dosages: Hayes, P. 108 Pneumatic Compression Pumps  Diastolic pressure is maximum mmHG for venous ulcers  Dosages: Hayes, P. 108 Lymphedema bandaging: ▫ Short stretch requires special training  Pressure gradient: Distal greater than proximal  CDT includes massage and exercise protocols  Replace q 6 months  41 ©Stanbridge University 2023 Documentation Type of compression used Vital signs (if necessary) Volumetric or circumferential measurements (before and after tx) Region of body treated Dosage: time, max mmHg (position, extremity) # and size of bandages used Patients' response to treatment Patient education Document compression, capillary refill, sensory check and mobility of extremity  42 ©Stanbridge University 2023 Continuous Passive Motion Source: www.medcomgroup.com Source: www.freepik.com  43 ©Stanbridge University 2023 Objectives By the end of this section the student should be able to describe: Physical principles and benefits of CPM Physiological responses Indications, contraindications and precautions Dosage and frequency  44 ©Stanbridge University 2023 Continuous Passive Motion Passive motion that is performed by a mechanical device that moves a joint slowly and continuously through a pre- set, controlled range of motion Benefits: -Decreased adhesions, contracture development -Improved early ROM gains -Improved synovial fluid lubrication -Decreased post operative pain -Reduces edema -Stimulates tissue healing  45 ©Stanbridge University 2023 Continuous Passive Motion CPM benefits continued: -Prevents the degrading effects of immobilization -Enhances healing of the incision over the moving joint -Provides stimulating effect on healing of tendons and ligaments  46 ©Stanbridge University 2023 Continuous Passive Motion Indications: Pain Limited ROM Edema Susceptibility to contractures or adhesions Muscle or joint stiffness  47 ©Stanbridge University 2023 Continuous Passive Motion 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, etc.)  48 ©Stanbridge University 2023 Continuous Passive Motion Prescription: Initial arc: 200-300 Progress: 100-150 / day as tolerated Rate of motion: 1 cycle/45 sec - 2 min Frequency: 4-8 hrs/ day for best compliance Duration: < 1 week  49 ©Stanbridge University 2023 Continuous Passive Motion Knee CPM Shoulder CPM  50 ©Stanbridge University 2023 Continuous Passive Motion Clinical evidence (only 4 studies) to support the use of continuous passive motion is lacking Basic science supports the common clinical practice of continuous passive motion implementation postoperatively in knee cartilage restoration procedures There is a need for high-level evidence studies to address this void in our literature Joseph A. Fazalare, MD; Michael J. Griesser, MD; Robert A. Siston, PhD; David C. Flanigan, MD, The Use of Continuous Passive Motion Following Knee Cartilage Defect Surgery: A Systematic Review, Orthopedics, 2010 ; 33 (12), DOI: 10.3928/01477447-20101021-16  51 ©Stanbridge University 2023 Continuous Passive Motion- Evidence Logerstedt C et al,. JOSPT, 2010- Knee meniscal and articular cartilage lesions Logerstedt C et al., JOSPT, 2010- Knee ligament sprain  52 ©Stanbridge University 2023 Diathermy (SWD and PSWD)  53 ©Stanbridge University 2023 Objectives By the end of this section the student should be able to describe: Types of Diathermy Physical principles of Diathermy Physiological responses Indications, contraindications and precautions Advantages and Disadvantages Dosage and frequency  54 ©Stanbridge University 2023 Diathermy 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  55 ©Stanbridge University 2023 Diathermy (SWD and PSWT) Physical principles of diathermy (SWD and PSWD) Purpose and physiological effects of PSWD ▫ For thermal and non thermal affects Utilizes an electromagnetic field where heat is generated as eddy currents pass into the tissue  56 ©Stanbridge University 2023 Diathermy (SWD and PSWT) Produces heat via CONVERSION of high-frequency electromagnetic energy to heat energy ▫ Ave Frequency: 27.12 MHz ▫ Ave Wavelength: 11m Approved by the FCC (Federal Communications Commission) Continuous (CSWT) or Pulsed (PSWT) Continuous is expensive and has a high potential for burns (rarely used)  57 ©Stanbridge University 2023 Physiological Effects of Diathermy Human body= significant water H20 is positive on one end and negative on the other end (dipole) Once exposed to CSWD these molecules are ionically pushed around Causes internal friction as they try to rotate back to natural state Oscillations cause currents in the tissue Causes heat that comes from within the tissue No sensation of heat noted on superficial tissue  58 ©Stanbridge University 2023 Diathermy (SWD and PSWT) Eddy currents Source: Bellew, 2016 Source: Behrens, 3rd ed 2014 Oscillation and friction of the water molecules may cause what are referred to as eddy currents within the underlying tissues. The friction creates heat within the tissues (Red circles in the picture on the right)  59 ©Stanbridge University 2023 Diathermy (SWT and PSWT) Tissues with high conductivity heat up the most ▫ Muscle ▫ Blood ▫ Sweat Most effective in increasing tissue extensibility (i.e. capsular tightness) Always consider adipose tissue- it is slower to heat up, but retains heat therefore, once hot, very slow to cool down  60 ©Stanbridge University 2023 Diathermy Adipose and Diathermy Adipose tissue doesn’t have as much water content as blood or muscle (less of a conductor) It does have strong insulation properties and if it is in the concentration of the electromagnetic field, the retained heat in the tissue will exponentiate (see capacitive method)  61 ©Stanbridge University 2023 Diathermy (SWD and PSWT) Diathermy can utilize two different types of fields to heat tissue. 1. Condenser/Capacitive (electric field biased) Method- not as common a. Plates on either side; Patient completes the circuit 2. Induction (magnetic field biased) Method a. Coils are wrapped around the extremity b. Drum  62 ©Stanbridge University 2023 Diathermy (SWT and PSWT) Condenser/Capacitive method ▫ The patient completes the circuit ▫ Strong electrical and weak magnetic field ▫ The patient completes the circuit ▫ The oscillation of ions in the tissue creates heat ▫ Heat is the strongest where the density of the field is greatest (most Source: www.btlnet.com oscillation of ions)  63 ©Stanbridge University 2023 Diathermy (SWT and PSWT) Condenser/ Capacitive method of diathermy Source: Bellew, 2016  64 ©Stanbridge University 2023 Diathermy (SWT and PSWT) Condenser/Capacitive method (cont) Produces more superficial heating- i.e. adipose tissue and shallow muscle, some bone Used over shallow places with little adipose tissue Source: www.slideplayer.com  65 ©Stanbridge University 2023 Diathermy (SWT and PSWT) Induction Method- (top pictures) Places the patient in the electromagnetic field of the electrodes Uses a strong magnetic field and weak electric field that create eddy currents The eddy currents oscillate the ions which create heat Creates a greater depth of penetration Used over areas of high-water content ▫ Muscle and synovial fluid Source: www.expertsindia.com  66 ©Stanbridge University 2023 Diathermy (SWT and PSWT) Induction method (cont.) Heats more vascular tissues such as muscle and nerve and other low impedance areas that have edema, effusion or a recent hematoma Most effective in increasing blood flow to aid in healing (i.e. muscle strain)  67 ©Stanbridge University 2023 Diathermy (SWT and PSWT) PWST (Pulsed) There is an interruption in the flow of high frequency current, so it is on for a brief period and off for an equal or longer period The off period allows the heat from the on period to dissipate Pulse Frequency 26-800 pps Pulse duration 20-400μs  68 ©Stanbridge University 2023 Diathermy (SWT & PSWT) SWT and PSWT Increases tissue temperature >3cm (up to 5 cm deep) which allows for heating of the muscle Increased temp in the tissue up to 40C  69 ©Stanbridge University 2023 Diathermy (SWT & PSWT) Source: www.generalmedtech.com  70 ©Stanbridge University 2023 Diathermy (SWT and PSWT) Thermal effects: 20 min Thermal effects: 20 min Increased metabolism Reduced edema Increased perspiration Increased extensibility of Increased oxygen tension with connective tissue (with increased tissue temperature stretching) Local vasodilation with Decreased muscle spindles hyperemia Increased body temperature, Muscle relaxation via effects on respiratory and pulsed rates. the muscle spindles and GTOs Decreased blood pressure (when applied for 1-2 hours or centrally)  71 ©Stanbridge University 2023 Diathermy (SWT and PSWT) Non-Thermal effects: treatment up to 30-60 min ▫ Increased number of fibroblasts and chondrocytes ▫ Increased number of white blood cells and histocytes ▫ Absorption of hematoma ▫ Reduction of inflammation ▫ Improved edema absorption ▫ More rapid collagen deposition and orientation (rats) ▫ Accelerated regeneration in the PNS (rats) ▫ Stimulation of osteogenesis (dogs)  72 ©Stanbridge University 2023 Diathermy (SWT and PSWT) Indications Pain- i.e. 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  73 ©Stanbridge University 2023 Diathermy (SWT and PSWT) Contraindications –(SWT and PSWT) Infections Patients, staff or visitors wearing Recent x ray therapy pacemakers Existing fever Implanted systems or leads Cardiac Insufficiency (neurostimulators) Older adults and children under 4 Pregnancy (Therapist or patient) Patients who are generally Internal and external metal debilitated objects that cannot be removed Over epiphysis of growing bones Active bleeding (including Ischemic tissue menses or acute trauma) Hemophilia Malignancies Pain and sensory deficits  74 ©Stanbridge University 2023 Diathermy (SWT and PSWT) Diathermy additional treatment set up 1 towel placed flat over treatment area or monode drum covered for open wounds Diathermy caution sign placed up on door The monode drum is positioned over the treatment area 1-3 inches away, drum facing parallel to treatment area Non-magnetic call light/bell for patient in case of emergency or to alert PTA  75 ©Stanbridge University 2023 Diathermy (SWT and PSWT) 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)  76 ©Stanbridge University 2023 Diathermy (SWT and PSWT) Dose is based on: 1. Patient response during treatment (heat, no heat felt) 2. Intended goal (thermal/non thermal affects) 3. Phase of healing (acute, subacute vs chronic)  77 ©Stanbridge University 2023 Diathermy Dosage- PSWT Non-Thermal effects: 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  78 ©Stanbridge University 2023 Diathermy Dosage- SWT and PSWT Thermal effects: Intensity >5 W is considered thermal and is reserved for Sub-acute/chronic conditions 21 W is the average dose thermal effects Longer pulse durations (300-400 μs) Higher frequencies introduce (>300 pps) Duration- 20 minutes Heating of tissues lasts longer than that with ultrasound giving the therapist additional time to perform therapeutic interventions  79 ©Stanbridge University 2023 Diathermy unit example- manufacturer overview video  80 ©Stanbridge University 2023 Diathermy- Evidence C Martin et al.; Ankle Ligament Sprain: Clinical Practice Guidelines; JOSPT, 2013; 43(9): a1-a40 ▫ Clinicians can use PSWT to reduce edema and gait deviations associated with ankle sprains C Kelley et al.; Adhesive Capsulitis: Clinical Practice Guidelines; JOSPT, 2013; 43(5): a1-a31 ▫ SWT can be useful when combined with mobility and stretching exercises to reduce pain and increase ROM in patients with shoulder adhesive capsulitis  81 ©Stanbridge University 2023 Diathermy- Evidence Y. Laufery, I G Daryz; Effectiveness of thermal and athermal short-wave diathermy for the management of knee osteoarthritis: a systematic review and meta-analysis; Osteoarthritis and Cartilage; 2012; 20: 957-966 ▫ There is evidence to support the use of thermal SWT to reduce pain and improve muscle performance on patients with osteoarthritis