Therapeutic Modalities

part 1

Chairul Huda Al Husna, S.Kep., Ns

Introduction
Modality the application of a form of energy to the body that elicits an involuntary response Therapeutic having healing properties

Chapter 1 : The Injury Response Process

Reaction to stress and injury Stress mechanical, chemical, or emotional force on the body and its cell maybe regarded as stress Reaction of cell :
It adapts to the stress It is altered but recover It dies

Chapter 1 : The Injury Response Process

Stage of stress response :
Alarm stage Resistance stage Exhaustion stage

Chapter 1 : The Injury Response Process

Injury process 2 stages
Primer response to injury Secondary blockage oxygen cell damage

Result inflammatory mediator, hemorraghe, and edema Wound healing phases inflamatory phase, proliferation phase, and maturation phase

Chapter 1 : The Injury Response Process

Cardinal signs of inflamation
Heat blood flow , metabolic rate Redness idem + histamine release Swelling leakage of inflammatory mediator into the surrounding tissues block venous return Pain mechanical pressure on or chemical irritation of nerves triggered by release inflammatory mediator Loss of function

Chapter 1 : The Injury Response Process

Mediators of inflamation
Heparin inhibits coagulation Histamine vasodilation of arterioles & increased vascular permeability Kinins produce pain Neutrophils first line cellular defense phagocytes Prostaglandins produce pain too + same effect with histamin Serotonin local vasoconstriction Leukotrienes cause smooth muscle contraction + increase vascular permeability

Chapter 1 : The Injury Response Process

Edema reduction
Key : prevent from occurring Strategies to reduce edema :
Voluntary muscle contraction Compression devices Elevation Electrically-induced muscle contraction (muscle milking) Pasive Range of Motion Massage Passive Motion Compression Wraps

Too much is not good, calm down

Chapter 2 : The Physiology and Psychology of Pain

Chapter 2 : The Physiology and Psychology of Pain

The withdrawal reflex :
stimulation to superficial pain travel along the afferent nerve fiber (nociceptors) spinal cord brain WARNING in other side motor neuron travel along efferent nerve fiber generate protective movements contraction to withdraw from the damage

Chapter 2 : The Physiology and Psychology of Pain

Assesment of Pain
Where is your pain? When did your pain begin? What is duration of your pain? Have you ever experienced this pain before? Can you describe how the pain feels? Is the pain getting better or worse? Does your pain increase with activity? Do you have more pain after activity? Do you have pain at night?

Chapter 2 : The Physiology and Psychology of Pain

Acute Pain
< 6 months Cause by the activation nociceptors When the tissue has healed acute pain ends

Chronic Pain
Nociceptive chronic pain continual activates nociceptors ex: arthritis Neuropathic chronic pain abnormality neuron of the pain system Characteristics : last longer than 6 months, difficulty in sleeping, depression, etc.

Thermal Modalities
Skin thermoreceptors high responsive to heat and cold Mechanisme :
Conduction : e.g ice pack, moist heat pack Convection : e.g warm or cold whirlpol Radiation : e.g infrared lamp Evaporation : e.g vapocoolant spray Conversion : e.g short wave diathermy, ultrasound

Thermal Modalities

The Effects Cold Modalities

Local effect Systemic Effect
Vasocontriction General vasocontraction in response to Decreased rate of cell metabolism cooling of the posterior hypothalamus resulting in a decreased need of oxygen Decreased respiratory and heart rates Decreased production of cellular wastes Shivering and increased muscle tone Reduction in inflammation Decreased nerve conduction velocity Decreased pain Decreased muscle spasm Decreased muscular force production

General Indication & Contraindication for Cold Treatments

Indications Acute injury or inflammation Acute or chronic pain Small, superficial, first-degree burns Postsurgical pain and edema Use in conjunction with rehabilitation exercises Spasticity accompanying central nervous system disorders Acute or chronic muscle spasm Neuralgia Contraindications Cardiac or respiratory involvement Uncovered open wounds Circulatory insufficiency Cold allergy/cold induced urticaria Anesthetic skin Advanced diabetes Peripheral vascular disease Raynauds phenomenon Lupus

Effect (cold application) on inflammation

Reducing the release of inflammatory mediators Decreasing prostaglandin synthesis Decreasing capillary permeability Decreasing leukocyte/endothelial interaction Decreasing creatine kinase activity

The other effects...

Cellular response : decrease cell metabolism reduce damaging cellular reaction Blood and fluid dynamics : local arteriole vasoconstriction increase blood viscosity reduce blood flow Edema formation : vasoconstriction decrease permeabilty reduces edema Nerve conduction : decrease transmit impulse increase depolarization threshold impuls affects pain perception interrupting nerve transmission Muscle spasm : reduces muscle spasm Muscle function : reduces nerve conduction decreases sensitivity of muscle spindles decreases ability rapid muscle movement

The Effects Heat Modalities

Local effect
Vasodilation Increased rate of cell metabolism Increased delivery of leukocytes Increased capillary permeability Increased venous and lymphatic drainage Edema formation Removal metabolic wastes Increased elasticity of collagen-rich tissues (ligament, joint capsule, tendon, skin) Analgesia and sedation of nerves Decreased muscle tone Decreased muscle spasm Decreased pain Increased nerve conduction velocity

Systemic Effect
Increased body temperature Increased pulse rate Increased respiratory rate Decreased blood pressure

General Indication & Contraindication for Heat Treatments

Indications Subacute or chronic inflammatory conditions Reduction of subacute or chronic pain Subacute or chronic muscle spasm Decreased range of motion Hematoma resolution Reduction of joint contractures Contraindications Acute injuries Impaired circulation Advanced arthritis (vigorous heating) Poor thermal regulation Anesthetic areas Neoplasm Thrombophlebitis

Classification of Heating Agents

Superficial heat Deep Heat

Infrared lamps Moist heat pack Paraffin baths Warm whirlpool

Microwave diathermy Shortwave diathermy Ultrasound

Effect heat application

Cellular reponse : increase cell metabolic rate demand oxygen and nutrient metab Blood and fluid dynamics : vasodilation vessels decreased viscosity of blood increase blood flow Edema formation : vasodilation increased edema but easier to remove reabsorbtion lymphatic (increased) and venous too Nerve conduction : increase nerve conduction reduce pressure nerve sedation Muscle spasm and function : increase muscle spasm reduced ischemic and pain

Effect (heat application) on inflammation

Heat metabolic rate blood supply delivery nutrients to healing process & removal debris & inflammatory metabolites Increase deliveri leukocytes phagocytosis

Comparison Hot Vs Cold

Effect Effective dept Duration of effect Blood flow Rate of cell metabolism 5 cm Hours (vasoconstriction) Cold Heat 1-2 cm (superficial) 2-5 cm (deep) Begin to dissipate after removal modalities (vasodilation)

Oxygen consumptiom
Cell wastes Fluid viscosity Capillary permeability Inflammation Pain Muscle spasm Muscle contraction

(reduced sensitivity of muscle spindles and decrease pain) (reduced nerve conduction and increased viscosity)

(reduced ischemia and pain) (increased nerve conduction and decreased viscosity)

Deciding whether to use cold or heat

Questions : 1. Does the body area feel warm to the touch? 2. Is the injured area still sensitive to light to moderate touch? 3. Does the amount of swelling continue to increase over time? 4. Does swelling increase during activity? 5. Does pain limit the joints range of motion? 6. Would you consider the acute inflammation process to still be active? 7. Does the patient continue to display improvement with the use of cold modalities?
If all the answer are no use heat modalities If the number of yes answers increases indication to use cold

Highlights
Heat exchange is based on a temperature gradient, with energy always moving from high concentration to low concentration (from hot to cold) Heat exchange by conduction, convection, radiation, and evaporation. Therapeutic cold decreases cell metabolism; therapeutic heat increases cell metabolism Cold modalities can be safely used for acute, subacute, and chronic condition. Heat should not be used while acute stage Cold vasoconstriction, heat vasodilation

Therapeutic Modalities
part 2 The Applications

Chairul Huda Al Husna, S.Kep., Ns

COLD PACKS
Used for :
Acute trauma Pain Muscle spasm Postsurgical care

Primary effects :
Reducing secondary trauma Limits formation of edema with compression & elevation

Indications
Acute injury or inflammation Acute or chronic pain Postsurgical pain & edema

Contraindications
Cardiac or respiratory involvement Uncovered open wounds Circulatory insufficiency Cold allergy and/or hypersensitivity Anesthetized pain

Duration : 20-30 minutes per session

Ice massage
Used for :
Muscle spasm Trigger points Prior to ROM exercise Rapid cooling of the skin

Primary effects :
Decrease sensitivity of cutaneous nerve receptors Decreases pain

Indications
Subacute injury or inflammation Acute or chronic pain Muscle strains and contusion

Contraindications
Cases in wich pressure on the injury Suspected fractures Uncovered open wounds Circulatory insufficiency Cold allergy and/or hypersensitivity Anesthetized pain

Duration : 5-15 minutes (or until the ice runs out)

Ice Immersion
Used for :
The body part, usually the foot and ankle or elbow, wrist, and hand

Primary effects :
Decrease cell metabolism prevent secondary hipoxic injury reduces release inflammatory mediators Decrease pain

Indications
Acute injury or inflammation Acute, chronic, or postsurgical pain Prior to ROM exercise

Contraindications
Cardiac or respiratory involvement Uncovered open wounds Circulatory insufficiency Cold allergy and/or hypersensitivity/ intolerate cold temperature Anesthetized pain

Duration : 10-15 minutes Temperature range : 10 12,6 C

CRYOSTRETCH
Used for :
Vapocoolant spray skin quickly evaporates and cools the skin

Primary effects :
Cools the skin and desensitizes nerve endings Elongates muscle fibers and other soft tissue, breaking muscle spasm

Indications
Trigger points Muscle spasm Decreased ROM

Contraindications
Allergy to the spray Acute and/or postsurgical injury Open wounds Contraindications relating to cold applications Contraindications relating to passive stretching Use around the eyes

Duration : 3-4 sweeps, if treat deep area increased duration spray

Hot And Cold Whirlpools

Used for :
Delivering heat or cold treatment ROM exercise Promoting muscular relaxation Decreasing pain and muscle spasm Provides supportive medium for ROM exercise Water provide resistance to rapid motions Cause sedation, analgesia, and increased blood flow Longer lasting of intramuscular tissues Decreased ROM Subacute or chronic inflammatory condition Peripheral vascular disease Peripheral nerve injuries

Primary effects :

Indications

Contraindications
Fever (in hot whirlpools) Patients requiring postural support during treatment Skin conition

Duration : 5- 10 minutes (initial phase), 20-30 minutes (treatment phase) Temperature : cold (10-15 C), hot (32-49 C)

Moist Heat Pack

Used for :
Localized superficial heating Pain Muscle spasm Chronic inflammatory conditions Increasing muscle, tendon, and fascia elasticity

Primary effects :
Increasing bloood flow (vasodilatioan) Increased cell metabolism Muscular relaxation to reduce muscle spindle sensitivity

Indications
Reduction of subacute or chronic pain Subacute or chronic inflammatory condition Hematoma resolution Decreased ROM Reduction of joint contractures Infection Acute condition Peripheral vascular disease Impaired circulation Poor thermal regulation

Contraindications

Duration : 20 30 minutes

Paraffin Bath
Used for :
Delivered heat to small Warm temperatures

Primary effects :
Increasing bloood flow (vasodilatioan) Increased prespiration Increased cell metabolism

Indications
Subacute or chronic inflammatory condition(e.g arthritis of the fingers) Limitation of motion after immobilization

Contraindications
Open wounds : wax and oils would irritate the tissues Skin infection : the warm excellent for breeding bacteria Sensory loss Peripheral vascular disease

Duration : 15 20 minutes Temperature range : 47,8 52,2 C

Appendiks
Fluidotherapy Contrast therapy
Heat modalities

Deep-Heating Agents : Therapeutic ultrasound Shortwave diathermy Electrical stimulation Transcutaneus Electrical Nerve Stimulation (TENS) Neuromuscular Electrical Stimulation Iontophoresis Microcurrental Electrical Stimulation

Thank You