Techniques of Application: Cryotherapeutic Agents

Cryotherapeutic Agents

General Technique of Application

1. Check Vital Signs

2. Inspect the patient’s skin before applying the cold to determine if any rashes or discolorations are present

3. Test for patient’s sensation

4. Verify the circulatory status of the area to be treated

5. Make sure that patient has not had frostbite in the area and never experience exacerbation of spasticity

6. Give rationale of the treatment

7. Position the patient relaxed and comfortable

8. Draped the patient properly and don’t exposed unnecessary parts

9. Apply the cold modality

10. Provide the proper treatment procedures of application

Post Treatment Procedure

1. Check patient’s skin for signs of adverse effects and frostbite

2. Check patients Vital Sign or prepare patient for the next treatment

Cold Packs

- Usually made of silica gel just like HMP and endothermic chemical gels

- Treatment temperature of -5 deg C for at least 2 hours before use

- Remains at low temperature for 15-20 mins

Ice massage

- an ice cylinder formed by freezing water in a styrofoam cup or juice

- a lollipop stick or wooden tongue depressor which may or may not be placed in water during freezing process

- Treatment duration – 5 -10 mins

- Technique of Application

1. Surface area of 10 cm by 15 cm

2. Overlapping longitudinal strokes or circular strokes covering one half of the previous stroke

- Advantage

1. The risk of damaging tissue is minimal because temperature will not drop below 15 deg C

- Disadvantage

1. Do not apply over bony areas and superficial nerve

- Four Distinct Sensation

C-old

B-Burning

A-ching

N-umbness

Ice Towels

- Terry cloth soaked in a bucket of crushed ice

- Treatment temp of 10-14 deg C for 10-15 mins duration

- Treatment Procedure: towel wrapped around the joint or muscle which changed every 4-5 mins(45-60 secs, other book)

- the most impractical method to use

Cold Baths

- a basin with water and crushed ice

- treatment temperature of 13-18 deg C (Braddom 4-10 deg C)

- best for treating distal extremities

- most practical method to use in treating distal extremities

Vapocoolant Sprays

-made of flourimethane and ethyl chloride

- non toxic, non inflammable volatile liquid which spray to the area being treated that produce rapid cooling

-today, most sprays are made up of organic materials due to hazardous effect

- used in treating trigger points in Myofascial Pain Syndrome and mucle spasm

-Technique of Application

1. Invert container, nozzle down and hold about 18-24 inches from the skin with 30 deg angle and spray 4 inches /sec

2. Repeat the first procedure for 2-3 times

3. Allow liquid to completely evaporate before applying the next sweep

4. The muscle should be passively stretched before and during the application

5. Cover the entire area from the origin of the pain to the referred pain

6. Then have patient exercise after the procedure

Controlled Cold Compression Units

- cooled water is circulated through a sleeve which applied to extremity which is then inflated intermittently

- treatment temp of 10-25 deg C or 7.5 deg C with pressure of 60 mm Hg

- acute musculoskeletal injury with soft tissue swelling after surgical procedure

Sample Outline: Cryotherapy

Cryotherapy- therapeutic application of cold

Cryokinetics- used of cold in therapeutic exercise

Modes of Transmission of Cold Therapy

1.Conduction – commonly used

Factors affecting magnitude change:

*temperature gradient differences between the cold and the tissue

*time and pressure

*thermal conductivity of the area being cooled

*type of cooling agent

2. Convection – least common, not practical to use

3. Evaporation – consist of highly volatile liquids that evaporate rapidly in contact with warm objects

Physiologic Effects of Cold

1. Increase blood viscosity

2. Vasoconstriction

3. Decrease metabolism thus decrease metabolic by products and decrease leukocytic phagocytic action which lead to retardation of healing

4. Decrease blood flow thus decrease bleeding and decrease removal of metabolites

Biophysical Effects

1. Hemodynamic Effects

-Quick icing can lead to cutaneous vasoconstriction

-Prolonged icing can lead to shivering and the Hunting Response of Lewis (5-10 deg C)

Causes:

a. Direct action of cold on smooth muscle of blood vessels

b. Reflex cutaneous of anterior hypothalamus as cooled blood returns, more vasoconstriction; in general, shivering and increased metabolic occurs

2. Decreased in Blood Flow

Causes:

a. Vasoconstriction

b. Increase in blood viscosity

c. Decrease production of metabolites

d. Effects of on post traumatic edema and inflammation

*less fluid filtration into the interstitium

*less inflammation and less pain

*decrease in metabolic rate

e. effects on peripheral nerve- decrease in motor and sensory nerve conduction velocity

* sensory- type A> type C

* motor- A gamma blocked before A alpha

f. effects on muscle strength

* increase in mm strength in quick icing

*decrease in mm strength in prolonged icing

g. neuromuscular effects

*transient reduction in spasticity

(note: some books say it can decrease but some researches imply that it can also increase)

General Indications of Cryotherapy

1. Musculoskeletal conditions (sprain, strain, bursitis, tendinitis)

2. Acute conditions

3. Chronic Inflammation

4. Myofascial Pain Syndrome

5. After orthoperic procedures

6. Pain and muscle spasm

7. Emergency treatment for minor burns

8. Edema

9. Spasticity

General Contraindications of Cryotherapy

1. Cold Conditions

· Raynaud’s Phenomenon

· Cryoglobilinemia

· Paroxysmal Cold Hemoglobulinuria

· Cold Urticaria or Cold Hypersensitivity

2. Cold Intolerance

3. Impaired Sensation

4. PVD

5. Impaired Circulation

6. Prolonged application over superficial nerve

7. Cardiac Disease or Cerebrovascular Insufficiency

8. Over the posterior rami of trunk

9. Throat ear and side of neck

10. Cancer and sickle cell anemia

11. Unrealiable patients

12. Severe abnormal BP

Sample Case: Superficial Heating Modalities

Hot Moist Pack

A 5 yr old boy comes to your clinic with a fracture of (L) wrist 2months ago. Your initial treatment is to use heating modality prior stretching the wrist, what heating modality are you going to use to address your goal?

A 64 yr old woman was diagnosed to have (B) rheumatoid arthritis of the hand. She complains of pain on (B) hands and you plan to use heating modality. What heating modality are you going to use to alleviate patient’s condition?

Paraffin Wax Bath

A 35 yr old construction worker complains of low back pain two days ago. The physiatrist diagnosed patient’s condition as muscle spasm of the back. What heating modality are you going to use to decrease patient’s symptoms?

Patient comes to you with complain of aching pain on the upper cervical area. You opt to use heating modality to decrease patient’s symptoms, what heating modality to use to best address patient’s complain?

Sample Rubrix Grading in Electrotherapy

Name: 1. Introduction 2. Vital Signs 3. Rationale	Case number: (5 points) Comments:
1. Patient Position 2. PT’s stance 3. Draping 4. Proper Body Mechanics	(5 points) Comments:
1. Proper Procedures 2. Initiation of Treatment 3. Reminders (if apply)	(5 points) Comments:
1. Post Treatment Procedure 2. After Care 3. Reminders (if apply)	(5 points) Comments:
1. Vital Signs 2. Home Instructions 3. Side Questions (if apply)	(5 points) Comments:

Sample Outline: Electromyography Biofeedback (EMG)

Biofeedback- nearly instantaneous return of information to a person about physiologic functions of which he or she might otherwise be unaware of

- Technique using equipment to reveal to some human beings some of their internal physiologic events in the form of visual and auditory signals to teach them to manipulate these involuntary or unfelt events by manipulating the displayed signals

Types of Biofeedback:

1. Thermobiofeedback

2. Galvanic Skin Response Biofeedback

3. HR/ Blood Volume

4. Pressure Feedback

5. EMG Feedback

6. Position Biofeedback

7. Sphincter Control Training

8. Respiratory Biofeedback

9. Feedback Goniometer

Biofeedback can assist the rehabilitation process in the following ways:

1. Enable the patient to identify the faults in the body mechanics by themselves

2. Enable the patient to try gradual correction of abnormalities based on received information

3. Provide a clear treatment goal to be accomplished by the patient

4. Allows the PT and pt to experiment the possible movement strategies

5. Helps reinforcing the appropriate motor behavior

Electromyography (EMG)

-Recording of the electrical activity generated in a muscle for diagnostic purposes

-Recording and study the electrical activity of the muscle

Types of EMG

*Clinical EMG- diagnosis

*Kinesiologic – for research and rehab

Concept Use: Motor Unit Action Potential

Uses of EMG as biofeedback:

1. Help the patient to regain the function of muscle that may have been lost or forgotten following an injury

2. Measures electrical activity of muscle not muscle contraction

3. Do not directly measure the muscle contraction, measure only the electrical activity associated with a muscle

4. Patient should understand that the electrical activity implies information about the quality of the muscle contraction but does not measure the strength of that muscle contraction specifically

Principles of Biofeedback

1. Middaugh’s Conceptual Framework

· PT evaluates the patient, sets parameters in the instrument, plans the strategies and provides the px instructions about the strategies to be followed

· Patient follows the strategies, the biofeedback system records the parameter, display the information before the patient

· Patient in turn tries to perform movement strategies alter the biofeedback signal, altering the physiological changes, producing therapeutic benefits

2. It obeys the theories of motor learning and motor control

3. It makes use of two types of feedbacks:

· Intrinsic – body’s internal feedback mechanism (visual, auditory vestibular proprioceptive)

· Extrinsic- derived from external sources (PT comments, biofeedback devices)

General Uses of Biofeedback in Physical Therapy:

1. To correct disorder

· In px with hemiplegia and CP, use to control spasticity and muscle re-education

· Use to dystonic px to reduce uncontrolled movement and posture

· In postural disorder to correct abnormal posture

· In functional breathing disorder such as hyperventilation and shallow breathing

2. To improve balance control

· Standing/balance training with force plate connected to a visual display in patient with hemiplegia and paraplegia

3. To control incontinence

· Use a balloon like device in the rectum

4. To control stress in stress induced disorders

· Beneficial in inducing relaxation in tx of stress disorders

5. Training walking pattern (gait)

· Use in monitoring weight bearing through the use of pressure sensitive pad in the shoe

· Re educate muscle groups in different phases of gait

6. Conditions in which control over some defective muscle movement is attempted

EMG Biofeedback in PT:

1. Motor retraining

2. Spasticity reduction

3. General relaxation training

Components of EMG Biofeedback

1. EMG Signal – gives measure of motor unit action potential of a muscle because it is hard to quantify, it is altered to be more meaningful to px and PT

2. Equipment- basic units have one channel, 2 channels used to monitor muscle simultaneously

3. Electrodes- General Rule : 2 active or recording electrodes/ one reference electrode

Presentation of EMG Signals

1. Visual Display

- Fluctuating needle meter read

- Flashing numbers

- A series of progressively lit lights

- Oscilloscope or computer screen

2. Auditory Feedback

- either threshold or proportional type

Threshold mode- turning a tone on or off when EMG amplitude reaches a level predertermined by PT

Proportional mode- produces a sound that modulated proportionally to EMG amplitude

Techniques of Application

1. Before using EMG biofeedback, PT should be familiar with motor unit activation and device used

2. Test Machine

3. Before attaching, clean electrodes and skill with alcohol to remove dirts and oils

4. Skin hair may have to be shaved to reduce electrical impedance

5. Give rationale

6. Patient should understand that the machine will not help to cause the mm contraction but simply monitor the mm activity

Clinical Application

1. Mm relexation vs Mm recruitment

2. Criteria for best candidates for EMG-BF training:

- Potential voluntary control must exist

- Motivation and cooperation are essential

- Inability to follow commands

Specific Considerations

· Progression of training

· Types o mm contraction

· Joint segment training

Contraindications:

· Neglect

· Severe Aphasia

· Visual or Hearing problems

· Complete paralysis

· Severe sensory deficits

· Proprioception loss

Sample Outline: Electrodiagnosis

Electrodiagnosis

The detection of electrical reaction of muscles and nerves for diagnosis, prognosis and therapy by the use of electrotherapeutic current and electromyography. It is the study of electrical activity in motor units when stimulated by electrical pulses.

Uses:

1. Presence of normal and abnormal electrical excitability

2. Limits of pathology

3. Involvement of motor and sensory components

4. Presence of demyelination and axonopathy

5. Know the extent of pathological changes

Physiological Basis of Electrodiagnosis

1. Stimulation of Nerve Fibers

-Electrical potential of nerve is 90 mv

-demonstrates accommodation

2. Stimulation of Muscle fibers

- potential difference of 70 mv

3. Refractory Period- amount of time takes for an excitable membrane to be ready for a second stimulus once it returns to its resting state following an excitation

- absolute

-relative

4. Accomodation – the ability of the tissue to adapt itself to slowly increasing intensity

- Law of Dubois of Reymond

- in denervated muscle , it has lost power of accommodation except for long duration and slow rise peak intensities will be able to produce a brisk contraction

5. Action Potential

-impulse

-ability of a nerve and muscle membrane to develop transient changes in potential which is transmitted from one point to another

6. Reaction of Degeneration – the failure of the muscle to contract when stimulate by a tetanizing current

-Partial Reactioon of Degeneration

-Full/Complete Reaction of Degeneration

-Absolute Reaction of Degeneration

7. Polarity Reversal

Cathode is more effective in normal nerve, partial and complete denervation

Anode is effective in degeneration with atrophy

**sometimes in complete or partial denervation, the reverse may occur. Try both

Contraindications

1. Pacemakers/ patient depending on cardiac device

2. Over the carotid sinus

3. Abdominal area during pregnancy

Sites of Involvement

1. UMNL

2. LMNL

3. Neuromuscular Transmission Disorder

4. Myopathies

5. Functional Disorders

Clinical Applications

*Anterior Horn Cells

Poliomyelitis

Progressive Muscular Atrophy

ALS

Syringomyelia

*Nerve Root

Prolapsed

IV disc traction injuyry

Trauma

*Nerve Axon

Neuritis

GBS

*Myoneural Junction

MG

*Muscle Fibers

Myopathy

Dystrophy

*Plexus

Traction Injury

Wounds

Waveforms used in Electrodiagnosis

1. Rectangular

-Rheobase

-Chronaxie

-Nerve Excitability Test

-SDC

2. Rectangular and Triangular

- Galvanic/Faradic

Methods of Electrodiagnosis

1. Rheobase and Chronaxie Test

*Rheobase- measured using the cathode on the motor point of the nerve or bipolar technique

- it is the intensity of current needed to produce a minimal perceptible and palpable contraction

N ormal Value = 2-18 mA or 5-35 V

*Chronaxie- time necessary to induce minimal visible contractions with the stimulus twice the rheobase

Normal Values = < 1 ms

2. Pulse Ratio

- Ratio of the intensity of the current needed to produce a muscle contraction with 1 ms duration to that required if the duration of the pulse is 100 ms.

- A crude test:

Innervated- little or no difference but always lesser than 2.2:1

Denervated- > 2.5:1

Complete Degeneration- no response to 1

3. Nerve Excitability Test

- An electrical test which uses a short duration pulsed low frequency current to determine the state of excitability and conduction of a nerve trunk

- Performed 1 -2 days after onset of paralysis and repeated periodically

- Stimulating Points of Nerve Trunk

a. Facial Nerve- 3 branches are anterior to the mastoid

b. Erb’s points- lower inner angle of supraclavicular fossa

c. Ulnar nerve- upper point- above the medial epi of the elbow

Lower point- just above the wrist near the ulnar border

d. Radial Nerve- halfway down the arm posteriorly

e. Tibial Nerve- slightly above the center of the popliteal crease

f. Common peroneal nerve- medial to biceps tendon at the poplietal crease

g. Deep peroneal nerve- just behind of fibula

h. Superficial peroneal nerve- one cm below the deep peroneal nerve

4. Strength Duration Curve

- Intensity/time curve, intensity/duration curve

- A curve obtained by joining points that graphically represent the threshold values along the ordinate for various durations of stimulus displayed along abscissa

5. Reaction of Degeneration Test

-a gross screening test to differentiate a muscle with (N) peripheral innervations from a muscle with peripheral denervation

- done 10 days after the onset of the problem

-aka Galvanic Faradic Test

6. Nerve Conduction Test

-asses the time and quality of the conduction of neural impulses In peripheral motor and sensory nerves

Reference: Electrophysical Agent by Wadsworth