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PHYSICAL MODALITIES. Be familiar with the characteristics of physical modalities that are applied for therapeutic purposes Identify physiological and therapeutic effects of physical modalities Be familiar with contraindications and precautions in using physical modalities

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Presentation Transcript
learning objectivies

Be familiar with the characteristics of physical modalities that are applied for therapeutic purposes

Identify physiological and therapeutic effects of physical modalities

Be familiar with contraindications and precautions in using physical modalities

Identify adverse effects for each modality

Learning objectivies
learning objectives cont d
Learning Objectives Cont’d . . .
  • When given a clinical scenario, be able to:
    • Define goals of treatment with a specific physical modality
    • Choose the appropriate device
    • Select the appropriate parameters
    • Apply the treatment safely and competently
    • Modify treatment if needed
indications for traction

To treat a variety of cervical and lumbar spine problems

    • Creates separation of vertebrae
    • Alters proprioceptive discharge of spine
    • Stretches connective tissue
    • Stretches muscle
    • Improves blood and lymphatic flow
    • Decreases pressure on disk
Indications for Traction
physiological effects

Vertebral joint distraction

    • Elongation of the cervical spine of 2–20 mm, can be achieved with 25 pounds or more of tractive force
  • Reduction of compression and nerve root and disc irritation
  • Reduction of pain, muscle spasm, and inflammation
  • Loosening of adhesions in the dural sleeves
Physiological Effects
friction

Friction is the counterforce that opposes motion or attempted motion

Friction is always parallel to the surface in contact and opposite in direction.

friction
friction1

Friction must be considered when applying traction. You must overcome friction in order to achieve separation of joints.

When using a split table for lumbar traction friction is eliminated.

Friction
traction techniques
Traction Techniques
  • Manual Traction
traction techniques1
Traction Techniques
  • Manual Traction
  • Traction Machines
traction techniques2
Traction Techniques
  • Manual Traction
  • Traction Machines
  • Wall-Mounted Traction
traction techniques3
Traction Techniques
  • Manual Traction
  • Traction Machines
  • Wall-Mounted Traction
  • Inversion Traction
contraindications

General:

    • Malignancy in the region of the spine
    • Osteopenia
    • Infectious process
    • Congenital spinal deformity
contraindications
cervical contraindications

Cervical ligamentous instability

    • RA, Down's Syndrome, Marfan Syndrome, Achon-droplastic dwarfism
  • Infectious process of the spine
  • Atlantoaxialsubluxation with spinal cord compromise
  • Vertebrobasilar insufficiency
Cervical Contraindications
lumbar contraindications

Pregnancy

Caudaequina compression

Aortic aneurysms

Restrictive lung disease

Active peptic ulcer disease

Hiatal hernia

Lumbar contraindications
positioning

Cervical:

    • sitting or supine position is ordered. Depends on patient's comfort in different positions. To relieve symptoms of nerve root compression, 20°–30° of flexion optimally opens the intervertebral foramina.
  • Lumbar:
    • Supine with 90° of hip and knee flexion is the most common position used. Reduces lumbar lordosis and the spine is relatively flexed, opening the intervertebral foramina.
Positioning
positioning continued

Intermittent vs. continuous:

    • Intermittent forces provide a greater pull. These are used for distraction, when neural foramina opening or retraction of herniated disc material is desired
    • Continuous traction is used for prolonged muscle stretch, such as in muscle relaxation
Positioning continued
amount of pull

Cervical spine:

    • Distraction requires >25 pounds; amounts greater than 50 pounds do not provide additional advantage. For cervical radiculopathy may use 25 pounds with neck flexion described earlier
  • Lumbar spine:
    • For posterior vertebral separation requires forces> 50 pounds; for anterior separation forces > 100 pounds are needed
Amount of pull
adverse effects

Increased pain due to “rebound effect”:

    • Patient will initially feel relief after the treatment but start to experience increased pain thereafter potential worse than initially
    • Science behind it not well understood
    • Likely due to large forces on the spine
    • Avoid by gradually progressing forces and constant re-evaluation of patient response
Adverse Effects
continuous passive motion cpm

A technique in which a joint is moved constantly in a mechanical splint to prevent stiffness and to increase the range of motion

Usually used post-operatively

Thought to prevent scar tissue from developing and decrease the problem of stiffness

Continuous passive motion (CPM)
physiological effects1

Stiffness following surgery or injury to a joint develops as a progression of four stages : bleeding, edema, granulation tissue, and fibrosis

CPM properly applied during the first two stages of stiffness acts to pump blood and edema fluid away from the joint and periarticular tissues

This allows maintenance of normal periarticular soft tissue compliance

Physiological effects
indications

Joint replacement

Synovectomy

Contracture release

Excision of heterotopic ossification

Fixation of intra-articular fractures

Indications
precautions

The use of CPM in conjunction with anticoagulation therapy may produce an intra-compartmental haematoma

  • Skin irritation from the straps or carriage cover may develop
precautions
contraindications1

Soft tissue constraints (ligaments) are insufficient:

    • If the joint is unstable
    • If rigid fixation of fractures have not been attained
contraindications
application

General principles:

Often applied in the recovery room immediately after surgery even when the patient is wearing brace or surgical bandages

The arc of motion is often a low arc of 20 to 30 degrees is used initially and progressed to 10 to 15 degrees per day

application
application continued

The rate of motion is usually 1 cycle per 45 seconds or per 2 minutes

The amount of time on the CPM machine ranges from 1 hour, three time a day to continuous for 24 hours. After surgery use is for 6 to 8 hours a day

Duration minimum for CPM is usually less than one week when a satisfactory range of motion is reached

Application continued
adverse effects1

Increased bleeding

  • Return to the operating room for evacuation of hematoma
  • Nerve compression palsies
  • DVT
  • Wound complications:
    • CPM must not be used through the full range of motion until the swelling has been reduced. This is accomplished by "working" the end-ranges of motion
Adverse effects
mobilization therapy

A manual therapy technique comprising a continuum of skilled passive movements to the joint complex that are applied at varying speeds and amplitudes, with the intent to restore optimal motion, function, and/or to reduce pain

Uses a grading system for progression of force

Mobilization therapy
grading system

Grade 1:

    • Passive movement in a small range, approximately 15-25% of the available joint play range
  • Grade 2:
    • Bone is passively moved in a moderate range to 50% or half of the available joint play range
  • Grade 3:
    • Passive force causes one bone to move to the end of the available joint play range
  • Grade 4:
    • Bone is passively moved to the end-range, and a fast thrust is performed. This is manipulation
Grading system
manipulation

A passive, high velocity, low amplitude thrust applied to a joint complex within its anatomical limit

      • Active and passive motion occurs within the range of motion of the joint complex and not beyond the joint’s anatomic limit)
  • Requires extensive training and supervision
  • NOT performed at the PT tech level
Manipulation
physiological effects2

Improve tissue extensibility

Restore range of motion of a joint complex

Optimize muscle function

Reduce soft tissue swelling, inflammation or movement restriction

Physiological effects
therapeutic effects1

Modulate pain

Induce relaxation

Increased mobility

Improved function

Therapeutic effects
precautions and contraindications

Severe osteoarthritis or osteoporosis

Tumor or malignancy in the area

The cervical region if there is dysfunction with the flow of blood within the vertebral artery

Joint bleeding

Loose body in a joint

Joints near a growth plate

Precautions and contraindications
application1

Detailed knowledge of anatomy and biomechanics is required to perform this skill

Clinical practice and experience is essential in understanding joint play and the desired motion of each joint

Mobilization is not a skill to be preformed at the PT tech level unless advanced training has be taken

application
adverse effects2

Fracture

Dislocation

Joint capsule tearing

Ligamentous tearing

Muscle or tendon injury

Nerve damage

Adverse effects
comprehension check

How much distraction of the cervical spine is achieved with 25 pounds of traction?

What position causes the most intradiscal pressure? Which causes the least?

What are the general contraindications of traction?

When should intermittent vs. continuous traction be applied?

What amount of pull in needed in the lumbar spine?

Comprehension Check
comprehension check1

What is the goal of the CPM?

What are the contraindications of CPM?

Describe the grading system of mobilization

What is manipulation? Are PTTs allowed to manipulate?

What are the adverse effects of mobilization and manipulation?

Comprehension check
comprehension check2

2-20mm of distraction of the cervical spine is achieved with 25 pounds of traction

Seated, bent forward with weights in the hands causes the most intradiscal pressure. Lying supine causes the least

Comprehension Check
answers

The general contraindications of traction are:

    • Malignancy in the region of the spine
    • Osteopenia
    • Infectious process
    • Congenital spinal deformity
Answers
answers1

Intermittent traction is for a greater pull. It is used for distraction when neural foramina opening or retraction of herniated disc material is desired. Continuous traction is used for prolonged muscle stretch, such as in muscle relaxation

For posterior distraction, forces> 50 pounds are needed. For anterior separation, forces > 100 pounds are needed

Answers
answers2

The goal of the CPM is to prevent scar tissue from developing and decrease the problem of stiffness

  • The contraindications of CPM are:
    • Soft tissue constraints (ligaments) are insufficient:
      • If the joint is unstable
      • If rigid fixation of fractures have not been attained
answers
answers3

The grading system of mobilization:

  • Grade 1:
    • Passive movement in a small range, approximately 15-25% of the available joint play range
  • Grade 2:
    • Bone is passively moved in a moderate range to 50% or half of the available joint play range
  • Grade 3:
    • Passive force causes one bone to move to the end of the available joint play range
  • Grade 4:
    • Bone is passively moved to the end-range, and a fast thrust is performed. This is manipulation
answers
answers4

Manipulation is a passive, high velocity, low amplitude thrust applied to a joint complex within its anatomical limit. PTTs are NOT allowed to perform manipulation

  • The adverse effects of mobilization and manipulation are:
  • Fracture
  • Dislocation
  • Joint capsule tearing
  • Ligamentous tearing
  • Muscle or tendon injury
  • Nerve damage
answers