3.

Physical Medicine

Loretta Logan, DPM, MPH Carl Harris, DPM

Introduction
Physical Medicine is a very important area in the realms of podiatric medicine. This chapter presents an overview of physical medicine with a review of the physical therapy modalities that are common to podiatric practice. It also provides a brief list of reference sources that can assist you in your study of the subject. The authors would like to acknowledge Elliott Rosensweet, D.P.M (former Director of the Department of Physical Medicine at the New York College of Podiatric Medicine) for his dedication to the practice of podiatric medicine and for imparting knowledge that was valuable in putting this chapter together.

Physical Therapy
Physical therapy is the treatment of pain, disease, or injury by physical means. It is the health profession concerned with promotion of health, with prevention of physical disabilities, and with restoration of function to patients disabled by disease, injury, or pain. Physicians use the therapeutic properties of heat, cold, electricity, ultraviolet radiation, exercise and massage as opposed to medical or surgical procedures to treat and rehabilitate patients.

Advantages of Physical Therapy

The advantages of physical therapy are: Modalities can be applied directly to affected body parts You can get immediate results in acute conditions It is non-habit forming when needed to treat chronic conditions

Disadvantages of Physical Therapy

The disadvantages of physical therapy are: It is time consuming. Patients generally have to be treated several times per week for several weeks and treatments generally last over 15 minutes each visit. Modalities that are prescribed for home use may have to be used several hours per day It can be costly to both the doctor and the patient. Setting up your office with physical therapy equipment may take upwards of five to ten thousand dollars. Several visits to the physicians office can be costly to the patient Chronicity is a factor. One or two treatments usually do not cure the patient. Several weeks or more of therapy is generally required Patient compliance is also an issue. Being consistent with a prescribed physical therapy regimen is a large part of its success. Several factors can lead to reduced patient compliance

Orthopedics | Physical Medicine

205

Physical Therapy Use in Podiatry

Physical therapy aids in the treatment of trauma (acute or chronic), arthritis, muscular paralysis, skin lesions and postoperative conditions.

Beginning Treatment with Physical Medicine

Physical medicine must begin with a complete history and physical examination. The physician must then render a diagnosis or a working differential diagnosis and decide what he or she wants to accomplish with physical therapy. Next, a treatment plan should be put in place that includes the modalities to be used, the method in which the treatment is to be applied, the duration of treatment, and the frequency of visits.

Objective of Physical Therapy

The objective of physical therapy is to begin with a physical action that will lead to a physiologic reaction. The physiologic reaction will be guided by the various characteristics of the modality being rendered. Examples: Icing an area will lead to vasoconstriction Applying a warm pad will lead to vasodilatation Electrical stimulation of a muscle will lead to muscle contraction Massaging a muscle will lead to muscle relaxation Physical Medicine Modalities Therapeutic Cold (Cryotherapy) Cryotherapy is the use of local cold applications for therapeutic reasons Physiologically local cold therapy causes an initial vasoconstriction that subsequently causes a decrease in local blood flow leading to a decrease in local swelling and hemorrhaging. The initial period of vasoconstriction may be followed by a reactive vasodilation with prolonged cold application. It occurs as cold paralyzed vascular smooth muscle relaxes. This secondary vasodilation is said to act as a protective mechanism to maintain temperatures at a level adequate to avoid tissue damage. Local cold application also decreases metabolic activity, slows nerve conduction, lessens muscle tone, reduces muscle spasm and spasticity, and produces superficial anesthesia.

Indications for Cold Therapy

Local cold application for therapeutic purposes is indicated in the treatment of: Mechanical trauma Muscles spasm and spasticity Pain Acute inflammation Adjunct in muscle re-education Ischemic limbs to retard the development of gangrene Preserve tissue viability with temporary compromise in vascularity

206 The 2005 Podiatry Study Guide

Contraindications for Cold Therapy

Cold therapy is contraindicated with the following conditions: Vasospastic disorders ( Raynauds) Fibrocystic stiffness Arthritis (cold will increase stiffness) Cold intolerance High blood pressure (cold will increase blood pressure when applied to large parts of the body) Pregnancy (contraindicated in all PT modalities) Cold should be used cautiously with the very young, the elderly, and with people who have peripheral vascular disease or other circulatory problems. In addition, you should also be aware of the possibility of frostbite with cold therapy.

Application of Cold Therapy

The three methods for applying cold therapy are: Conductive Evaporate Convective Conductive cooling occurs when there is direct contact with the cold object and the body part to be cooled. Heat is transferred from the body part to the cold object. This method of cooling is used most commonly. It is effective in the treatment of acute traumatic conditions such as ankle sprains, strains, postoperative foot and ankle procedures, tendonitis, bursitis, fractures, contusions, and muscle spasms. It has also been beneficial in the treatment of heel pain secondary to plantar fasciitis and cramps secondary to mechanical causes of trigger points. Conductive cooling includes the following: Ice massage (moving a block of ice over the surface to be cooled) Ice and water (immersion into ice water or cold applicators) Cold packs (3 types) Plastic bags or wet towels filled with cubed or shaved ice (frequently used and inexpensive) Chemical cold packs (expensive, can not be reused, chemical burns can occur if the pack ruptures, temperatures produced by mixing chemical contents are not consistent) Flexible gel cold packs (convenient and reusable) Evaporative cooling occurs when a cold substance applied to the skin uses thermal energy to evaporate. The temperature on the surface of the skin is lowered. Though not as common as conductive cooling, evaporative cooling has also been applied in the treatment of foot pain secondary to acute trauma, trigger points causing foot pain, cramps secondary to mechanical causes, and neuritic pain in scar tissue. The use of vapor-coolant sprays such as ethyl chloride or fluoromethane are examples of evaporate cooling.

Orthopedics | Physical Medicine

207

Convective cooling occurs when there is air movement over the skin. It is not a cooling method that is common to foot and ankle pain. Cold therapy is usually performed as part of RICE therapy and, at times, along with intermittent compression devices. RICE therapy consists of: Rest Ice Compression Elevation

Therapeutic Heat
The physiologic effects of heat application depends on several factors. They include the modality being used, the mode of application, the size of the area being treated, the depth of penetration, the temperature changes in the tissues, and the strength, duration, and extent of the physical agent being applied. Regardless of these parameters the general therapeutic effects of local heat application include the following: Vasodilation, which leads to increase blood flow Increase in the rate of tissue metabolism (with prolonged, extensively elevated temperatures tissue metabolism is decreased leading to denaturation of protein and eventually cell death) Increase in the extensibility of collagen tissue Assistance in the resolution of inflammatory infiltrates, exudates, and edema Decrease in joint stiffness Reduction in muscle spasm Pain relief Indications for Heat Therapy Local heat therapy is often used to alleviate foot and ankle pain. Heating may be used when treating subacute or chronic stages of arthritis, tendonitis, myositis, bursitis, tendonitis, tenosynovitis, sprains, strains, factures, dislocations, contractures, inflammation and pain. It is important to remember that heat is used for subacute and chronic conditions and is not indicated for the treatment of acute inflammatory processes. You cannot use time as the sole element to determine whether a condition is acute, subacute or chronic. The presenting signs and symptoms should be the leading factor in your decision and subsequent treatment plan. Consider the following when making your decision: Acute condition pain on mobilization and immobilization, edema and erythema that are still increasing Subacute condition pain initiated with mobilization, edema and erythema has leveled off Chronic condition pain in a part when that part is put through its greatest range of motion, edema and erythema are diminishing Contraindications for Heat Therapy Heat therapy is contraindicated with the following conditions: Acute conditions Loss of sensation (diabetes, alcohol abuse, medications, etc.) With hyposensitivity you cannot tell if some devices are getting hot or not. Infections Open skin wound/ulceration Malignancy (can make it grow faster) Hemorrhagic diastheses (with bleeding you want vasoconstriction, not vasodilation) Metal implants (screws, pins, bullets, scrap metal) contraindicated with deep heating modalities Fracture (contra-indicated with deep heating modalities) Open apophyseal sites (contra-indicated with deep heating modalities, interferes with the normal growth pattern of bone)

208 The 2005 Podiatry Study Guide

 Pregnancy (contra-indicated with all PT modalities) Poor circulation (cant redistribute heat adequately and will burn the area; with increased metabolism the demand for oxygen and nutrients will increase, but the system is not getting it. Also, the blood system is used as a cooling agent in this case. It has to take away the heat. If this heat cannot be disbursed the tissue will burn. Applications of Local Heat Therapy There are two methods of categorizing therapeutic heating modalities. The first is based on the modalities ability to heat superficial tissue versus deep tissue. The second method subdivides the modalities according to the primary mode of heat transfer into the tissues conduction, convection or conversion. Conduction is the transfer of heat from one point to another (modality to the body part) without movement in the modality producing the heat. There is direct contact between the modality and the body part to be heated. Convection is the transfer of heat by movement of heated particles in liquids or gases. Conversion is the transfer of other forms of energy into heat by absorption. Nonthermal energy is transformed into thermal energy. Superficial Heating Modalities The superficial heating modalities include modalities from all three primary modes of heat transfer. The superficial modalities that heat by conduction are hot packs and paraffin baths. Those that heat by convection are hydrotherapy, fluidotherapy, contrast baths and hot air. The superficial modalities that heat by conduction and convection have a depth of penetration of 1-2 mm. The superficial heating modality that heats by conversion is radiant heat with a depth of penetration of 5 mm. The following section will provide a review of the superficial heating agents most commonly used in podiatry. Hot Packs (Hydrocollator Packs) Hydrocollator packs are canvas sacs filled with a silicone gel. They are heated in a thermostatically controlled container filled with water heated at 160-170F (71-80C). The gel absorbs and holds the heated water. Because the pack is too hot for direct contact on the skin, it is insulated with towels before applying it to the body part to be treated. As the pack cools, the towel is removed. The hydrocollator pack has a depth of penetration of up to 1-2 mm and is therapeutically effective for 20-30 minutes. Hydrocollator packs have several advantages. They conform directly to the body part you wish to treat, are convenient and easy to use, and can be used by the patient at home. In addition the packs are inexpensive, reusable, and last a long time (i.e., as long as five years with consistent use). Any condition requiring superficial heating can be treated with a hydrocollator pack. They have been especially beneficial in the treatment of arthritis, muscle spasm, and pain. The packs should not be used with the conditions earlier mentioned as being contra-indicated with heat. Paraffin Bath Paraffin baths are reservoirs filled with a 1:7 mixture of mineral oil and paraffin. The temperature of the bath is thermostatically controlled at a temperature of 125-130F (51.7 to 54.5C). There are three methods of paraffin application. Dipping is the approach most commonly used. The body part being treated is submerged into the heated paraffin 10 times, pausing between each dip to allow the layer of paraffin to solidify. The area is then covered with plastic and an insulating cover for 10-20 minutes. Afterwards the paraffin is stripped off and returned to the bath. Some physicians choose to discard the paraffin instead. A slight alteration to this method would be to paint on the first layer of paraffin, then dip the treated area nine more times for a total of 10 layers of paraffin. To prevent contamination of the paraffin the foot can be placed in a plastic bag before applying the first layer of paraffin. You must be sure to let the first layer cool off before applying additional layers or it can become too hot.

Orthopedics | Physical Medicine

209

Another approach to treatment with paraffin baths is continuous immersion. The extremity is first dipped once or twice to allow for a layer of insulated solidified paraffin to form on the skin. The extremity is placed and kept in the paraffin for 20-30 minutes. Heating, though more intense with this method, is still well-tolerated. With this method, skin temperatures decrease less rapidly. A less common method for applying paraffin is to brush the paraffin onto the skin. This is a good approach for areas that are sensitive or difficult to treat. The advantages of paraffin baths are that you can treat small areas, something you are unable to do with whirlpool or contrast baths. You can also regulate the temperature more easily. Paraffin baths can be used in the home setting. Indications for paraffin bath treatment include contractures associated with rheumatoid arthritis, scleroderma, burns, and injuries; subacute or chronic aspects of trauma, arthritis, or tendonitis; and joint stiffness. Paraffin baths should be avoided in patients who have an allergy or hypersensitivity to paraffin, acute conditions, PVD, ulcerations and dermatitis, and any conditions having a contra-indication to heat in general. Contrast Baths Contrast baths consist of two tubs filled with water. One is filled with hot water at about 100-110F (40.643.3C) and the other with cold water at about 59-70F (15-20C). There is alternating exposure to heat and cold. The foot is initially soaked in hot water for 10 minutes and switched to cold water for one minute. This is followed by alternating hot soaks of four to five minutes and cold soaks of one minute for a total of 30 minutes. You should end with hot water. The result is alternating periods of vasodilation and vasoconstriction stimulating a pumping action. A reflex hyperemia is produced with neurologic desensitization. The advantages of contrast baths are that they can be used in the patients home. They should be used as many times a day as possible. Care must be taken to control the temperature of the water. Contrast baths are used to treat patients with sympathetically mediated pain (RSD) though patients may prefer to begin bath temperatures that are a little less hot or cold. They are also used to treat mild arteriosclerosis, and are beneficial in the treatment of joint stiffness and pain associated with rheumatoid arthritis. Contrast baths can also be used with acute conditions. In this case you begin and end with cold. Hydrotherapy (Whirlpool) Whirlpools are the primary form of hydrotherapy used in podiatry. They use a fluid medium (water) to transfer superficial thermal and mechanical forces to tissue. The agitated water in whirlpool baths is used to produce heating, cooling, massage, and debridement. The warm water causes an initial stimulation, but as the body gets use to the temperature, the muscles relax. Whirlpools can also be used with cold water. With cold water the reaction is entirely stimulatory. The patients foot is placed in the whirlpool and treated for 15 minutes with the temperature of the water set at 100-104 F for therapeutic heat. The level of agitation can be adjusted to that which is desired by the physician and comfortable for the patient. If the condition requires cold rather than heat, the water temperature should be about 70F. Heating with hydrotherapy is used in the treatment of pain and joint stiffness associated with chronic and subacute stages of the following conditions: contractures, arthritis, tendonitis, tenosynovitis, neuritis, strains, sprains, connective tissue disease, varicose veins, and early stages of peripheral vascular disease. Hydrotherapy has also been used in the treatment of suppurating wounds and decubitis ulcerations. Applying heat through hydrotherapy should be avoided in those conditions in which heat is contraindicated. Hydrotherapy can be used for acute conditions only when the temperature is adjusted to make the water cold. A patient being treated with hydrotherapy should never be left alone.

210 The 2005 Podiatry Study Guide

Infrared Infrared falls under the category of radiant heating. Radiation, which is in the electromagnetic spectrum and absorbed by the body as heat, is termed radiant heating. Infrared radiation is emitted from glowing substances such as those found in toasters and ordinary light bulbs. When using modalities emitting infrared radiation, the physician must pay careful attention to the distance and the angulation of the projected radiation. Increasing both these parameters could control the intensity of heat produced. When used properly, infrared provides comfortable therapeutic warmth with a depth of penetration of up to 5 cm. Its physiologic properties include increased circulation, lowering of blood pressure, increased respiration and increased perspiration. It also has a sedative effect on nerve endings. There are two types of infrared commonly used by physicians and therapist to administer superficial heat: v luminous and Non-luminous. Luminous infrared is referred to as near infrared (wavelength of 10,000). It includes those units that deliver infrared radiation derived from incandescent or glowing sources, such as hot wires or bulbs Non-luminous infrared is referred to as far infrared (wavelength of 20,000-40,000). Units of this type are derived from a nonglowing source. They include household radiators, moist heat, chemical heat packs and bimetallic burners The advantages of infra-red are that there is no direct contact with the patient, the region being treated is constantly visible, and the intensity of heat is easily changed by moving the unit closer to or further from the patient. The disadvantages are that dry heat may cause drying of the skin and you cant use it on patients with neuropathy because you cannot monitor the exact temperature. Application of Infrared Luminous lamps are applied directly over the area to be treated at a distance of 24-36 inches. Treatment time ranges from 1030 minutes depending on the area you are treating. Non-luminous lamps often feel hotter than the luminous lamps, thus they are placed at distances a little further away from the source being treated, i.e. 30-40 inches. They are also angled at about 45. Treatment time is basically the same as luminous lamps. Treatment with infrared is indicated in the treatment of mild to chronic pain, muscle spasms, rheumatic joints in which direct temperature elevation of the joint is contra-indicated but relief of secondary spasm is needed, various manifestations of inflammation, lesions resistant to healing, injuries that cant tolerate the weight of a moist heat pack, and as an adjunct therapy with other physical therapy modalities. Ultraviolet Ultraviolet is another physical therapy device that falls under radiation, but unlike other electromagnetic agents used in physical therapy, which have a thermal effect on tissues, ultraviolet therapy produces a direct photochemical reaction in the skin resulting in erythema (UV-A) and pigmentation (UV-B). It also has a bactericidal and sungicidal effect (UV-C). Ultraviolet is now rare as a physical therapy modality but still has applications in dermatology and neonatology. The dose of ultraviolet (UV) light that will produce, within a few hours, a minimal erythema of the skin is termed the minimal erythema dose (MED). Treatment with ultraviolet light is often prescribed in terms of a multiple of MEDs. In general, ultraviolet treatments begin with one or two MEDs and do not exceed five MEDs, thereby avoiding tissue progression or damag Ultraviolet A (UV-A) occupies the lowest energy portion of the UV spectrum and is important because of its ability to produce tanning with a minimum of skin erythema. UV-A is used commercially for tanning and medically for psoriasis (i.e. PUVA) Ultraviolet B (UV-B) is more likely to cause skin erythema and burning in comparison to UV-A on an equal dose basis. Ultraviolet B is adjunctive when combined with the Goeckerman treatment for psoriasis Ultraviolet C (UV-C) occupies the most energetic part of the therapeutic UV spectrum. It is important because it is bactericidal and sungicidal

Orthopedics | Physical Medicine

211

Sources of Ultraviolet Hot Quartz lamps These lamps were once very common. They operate with high pressures of mercury. The MED of these lamps may be about 15 sec at a distance of 75 cm. Cold Quartz lamps These lamps are germicidal and have a relatively low mercury pressure. Sun lamps They contain a tungsten filament to vaporize mercury thereby establishing an arc. Ultraviolet seems to have its greatest application in skin disorders that include, but are not limited to the following: Decubitis ulcers Granulating tissue Diabetic ulcers Burns Venous ulcers Psoriasis Infectious dermatitis Local radiation (bactericidal & fungicidal) Individuals who have fair complexion, skin atrophy, or are photosensitive (medications, cosmetics) should avoid UV therapy. Important considerations include protection of the eyes, which might result in injury, and avoidance of excessive exposure, which could result in sunburn. Deep Heating Modalities Conversion is the method of heating employed by the deep heating modalities. In addition to the superficial heating of radiant heat, conversion includes all forms of diathermy. Diathermy is the application of therapeutic heat to body tissues through the use of a machine that generates a high-frequency electromagnetic current. The therapeutic effects of diathermy depends on the temperature, which should be at least 103-104F; the application time, which should be at least four minutes; the rate of temperature rise (the faster the rise the more intense the therapeutic effect); and the size of the area being treated (the larger the area treated, the greater the overall response). The three diathermy agents are ultrasound (US), short wave diathermy (SWD), and microwave diathermy (MWD). These modalities are capable of deep penetration with a depth of penetration of up to 5 cm. Ultrasound (US) Ultrasound is the use of ultrasonic waves to generate deep heat in the tissues for therapeutic purposes. A highfrequency electrical current (0.8 to 1 MHz) causes vibration of crystals in the ultrasound head at 17,000 cycles per second producing a sound wave. The sound is transmitted into the tissue, gradually absorbed, and converted to heat. The greatest build up of heat is at the interface of two separate tissues with the greatest difference in density between those two tissues. Thus, the greatest build up is at the point of bone and the periosteal layer above the bone. The physiologic effects of US are heat (causes vasodilation and increased blood flow), mechanical (causes increase in tissue elasticity), and chemical (causes increase in the permeability of cell membranes and increase in the rate and volume of diffusion across cell membranes). The application of US should begin with the use of a coupling medium between the US head and skin surface to be treated. Coupling mediums that have been found to produce adequate transmission include Soni-Gel, AquaSonic, Ultra-Sonic, and Medco. Other commercial water miscible preparations may also be used. Mineral oil has been applied as a coupling medium, however the oil absorbs some of the sound waves, which reduces the total intensity of the treatment. Degassed water is also a good coupling medium for the use of US under water. There are two methods of applying US, direct and indirect. With direct application the US is placed, with the use of a coupling medium, directly on the part to be treated. This method is best used when you are treating smooth surfaces where some pressure does not cause pain. The US head is then moved in a slow (1 to 2 cm/sec), overlapping, circular or linear (longitudinal) motion in an area that is twice the size of the US head being used. Care must be taken when treating over bony prominences because you can get a concentration of energy and heat build up if the area is exposed to continuous US for too long. This could cause a burn.

212 The 2005 Podiatry Study Guide

Figure 1. Ultrasound

The direct method of US can be altered to emphasize its nonthermal properties. In this case, the US is set to deliver brief pulses of high-intensity US separated by longer pauses of no US. There is no need to move the US head because there is no build up of heat due to the cooling of tissues in the off cycle. The strength or intensity of the US and the time of treatment can remain the same. This allows the use of US in conditions where you dont want heat build up, but can benefit from the other properties of US (chemical and mechanical). A therapeutically beneficial treatment time for US is eight minutes (range is 5-10 min) per surface area (a surface area is equal to twice the circumference of the US head). Ultrasound does not penetrate through the bone. It is absorbed by and reflected off the bone. Thus, when treating a joint or the soft tissue around a joint ultrasound must be applied to both the plantar and dorsal services of the joint for eight minutes each. The intensity for US is expressed in watts/cm2, which represents the field of energy under the transducer (US head). The average intensity used in podiatry is 0.5 to 1.5 watts/cm2. Assuming no neurological deficit and the comfort of the patient, the therapeutic use of US should not cause pain. With the dosage set at maximum tolerable levels, the patient should feel no more than mild warmth in the area being treated. Discomfort can be avoided by adjusting the wattage as needed. The following intensity guidelines are suggested for ultrasound in the foot: 0.5 watts/cm2 for superficial tissue penetration (tendonitis, bursitis) 1.0 watts/cm2 for moderate tissue penetration (plantar met heads) 1.5 watts/cm2 for deeper tissue penetration (heel spur syndrome) The indirect method of US is employed when you want to avoid direct contact between the US head and the part being treated. It can be applied in the following cases: 1) over bony prominences to avoid heat build up, 2) when the patients condition is hypersensitive to touch; and 3) over denuded areas such as ulcerations to aid in debridement. Therapy is rendered under water. The water acts as a conducting medium and dissipates the ultrasound so that it is not hitting one prominent point. Before beginning this process, the following must be done: The water must be degassed This can be done by boiling the water or letting it sit for several hours Dissolved gases in water causes bubbles to collect on the US head or skin, thus interfering with wave transmission Make sure the ultrasound head is water tight and that the unit is working properly Placing a few drops of water on the US head and turning the intensity to maximum can test if the unit is functioning properly. If the unit is properly tuned and working you will see the water vibrate, boil, and evaporate The modality should be properly grounded Use a plastic container Metal picks up heat from the US

Orthopedics | Physical Medicine

213

 Dont use a whirlpool The foot should be clean Once ready to perform indirect US, the patients foot and the US head are placed under water. One of two procedures can be followed. With the first procedure you place the US head 1/2" from and facing the area to be treated. The US head is kept moving, and the time and intensity remains the same as in the direct method. The second procedure alters this method by facing the US head away from the foot and keeping it steady. In this case, the US is going all over the water treating a larger surface area. Because of the larger surface area being treated the time should be doubled, but the intensity remains the same. Phonophoresis Phonophoresis is the use of US to drive molecules into the skin usually for their anti-inflammatory and anesthetic properties. The indications and contra-indications for this procedure takes into account both the use of deep heat and the medication being used. The medication itself, when containing the ingredients needed in coupling gels, can act as the transmission medium. Medications commonly used for phonophoresis include the following: 1-10% Hydrocortisone ointment (anti-inflammatory) 1-4% Iodex (Iodine with salicylate (anti-inflammatory, sclerolytic, analgesic) Myoflex (10% salicylate) ointment (anti-inflammatory, analgesic) 2-5% Lidocaine ointment (analgesic) Dexamethasone and 2% Lidocaine gel (anti-inflammatory and analgesic) The indications for US include subacute and chronic stages of joint pathology, bursitis, tendonitis, tenosynovitis, myositis, fasciitis, sprains, strains, dislocations and neuritic pain in scar tissue. Ultrasound under water has been used to assist in the debridement of ulcers. Ultrasound, though questionable, has also been reported to have some benefit in the treatment of verucca plantaris. It is suggested that the direct method is more effective than the indirect method for this purpose. Ultrasound is contra-indicated with acute inflammation, infections, PASO (peripheral arterial sclerosis obliterans), malignancies, bleeding tendencies, fractures, open apophyseal plates, metal implants near the skin (continuous heat), any other contra-indications mentioned earlier as contra-indicated with heat. It should be noted that the literature states that US is the only type of diathermy that may be used safely with metal implants. It should be used with caution. Metal implants near the skins surface can cause a burn. In order to avoid a build up of heat, pulsed US should be employed. Short Wave Diathermy Short wave diathermy is the application of high-frequency currents (radiowaves) for therapeutic use. It heats tissue with a combination of induced electrical currents and the vibration it imposes on the molecules of a tissue. As the radiowaves pass through tissues their actual penetration depends on properties of the tissue and the characteristics of the applicator. Capacitive applicators emphasize electric field heating. They produce energy absorption and the highest temperatures tend to occur in water-poor substances such as subcutaneous fat. In areas such as the feet and ankles where fat is negligible, uniform heating occurs Inductive applicators generate magnetically induced eddy currents. They have demonstrated higher energy absorption and the greatest temperatures in water-rich, highly conductive tissue such as muscle. The energy is not being absorbed by fat and thus penetrates deeper There are a variety of applicators that exist for SWD. When considering inductive electrode heating, three applicators exist: 1) Drum applicators consist of coils encased in a rigid container; 2) Pad applicators are semi-flexible mats with a coil connected to a SWD machine. 3) Cable applicators are rubber-coated cables that were wrapped around an extremity or laid over the body; Cable applicators are no longer in use because of safety concerns. When

214 The 2005 Podiatry Study Guide

using capacitive electrode heating, the applicator consists of two plate-like electrodes that the patient is placed in between. During treatment with SWD the patient should only feel mild warmth. Caution must be taken because you cannot preset the temperature. The heat will build up slowly and the intensity will need to be adjusted if it becomes to warm. Care must also be taken to avoid build up of heat and hot spots in areas of bony prominences, for example. The patient must be constantly monitored when SWD is in use. Short wave diathermy is indicated for treatment of pain secondary to muscle spasm, stiffness, contractures, and subacute and chronic joint disease. It can also be applied for vasodilatation, and has been recommended in the treatment of vascular occlusion to provide heating proximal to the occlusion and reflex vasodilatation distal to it. Short wave diathermy to the lumbar area can lead to reflex heating and vasodilation to the extremities. Short wave diathermy has the same contraindications as ultrasound and heating modalities in general. Patients with metal implants should not be treated with SWD because heat will be concentrated and burn the surrounding tissues. In addition, when using SWD all metal objects should be removed because selective heating of metal parts occurs with SWD. Individuals with pacemakers, arrhythmia problems, and women who are pregnant should avoid exposure to SWD. Short wave diathermy should not be used in neuropathic patients because it is hard to control the temperature. Microwave Diathermy (MWD) Microwaves are a form of electromagnetic radiation used to selectively treat muscle. It has been used in the past to heat superficial muscles and joints and to speed hematoma resolution. Microwave diathermy has generally been replaced by SWD and US and is not used for its therapeutic benefits in the United States. Its basic use today is to potentiate the effects of chemotherapy and radiation.

Electrical Stimulation
Electrical stimulation modalities are very effective and have a long history of use in physical therapy. These modalities have a common goal, stimulation of tissue for therapeutic purposes. There are two classifications of therapy through electrical simulation: 1) muscle stimulation, and 2) physiologic reaction within the tissues. Muscle stimulation of innervated muscle will occur with just about any current used. Stimulation of denervated muscle will only occur with DC currents. Physiologic affects will only occur with DC currents. With electrical stimulation, there are various pulse types that relate to the different currents. Monophasic All or most of the current is on one side of the neutral line. This means that there are unequal charges either mostly positive or mostly negative. There is polarity. This is called a direct (DC) current. It is also referred to as a galvanic current Biphasic There is equal amounts of current on either side of the neutral line. The positive charges equal the negative charges. There is no polarity. This is an alternating (AC) current Polyphasic This is a series of biphasic currents. Again, the positive charges equal the negative charges and there is no polarity. Thus, it is also an AC current Direct (DC) currents are monophasic currents that provide a constant electron flow from the negative electrode to the positive electrode with no oscillitations or alterations. The polarity stays constant. This type of current will produce major chemical and thermal reactions that will produce physiologic reactions in the tissues leading to stimulation of muscle. Alternating (AC) currents are biphasic or polyphasic currents that provide alternating electron flow from the positive to the negative electrode and vice versa. There is no polarity. Since there is no polarity with AC currents there are no physiologic changes in the tissue (thermal or chemical). Only muscle stimulation will occur. When applying electrical stimulation you may set your modality to deliver either continuous or interrupted pulses. Continuous pulses are present at an even, uninterrupted rate. Interrupted pulses vary in the number of pulses

Orthopedics | Physical Medicine

215

and the time intervals inbetween the pulses. There are also three variables of the pulse that can be controlled leading to different therapeutic effects. Width (pulse duration) length of each pulse, time each pulse will last A short stimulus excites sensory A moderate stimulus excites sensory & motor A long stimulus excites sensory, motor, and pain A long stimulus is needed for chemical changes Peak (pulse strength) height measured in volts, intensity of pulse The higher the peak the greater the depth of tissue penetration and stimulation For a short pulse duration, you need a high-pulse strength or intensity to generate a response Rate (number of pulses per second - pps) # of peaks per period of time The greater the number of pulses, the greater the amount of current, therefore, the greater the strength. With short pulse duration you need a high-pulse rate to create a response Low # of pps (1-15) muscle will twitch Moderate # of pps (20-40) tetany with no fatigue High # of pps (40-100) tetany with fatigue (Fatigue can be eliminated by interrupting the current for about three to four seconds to allow the muscle to restimulate) When altering the pulse variables for a desired response you should take into account the following characteristics: Increasing only the duration (width) of the pulse will result in a stronger contraction, leading to a decrease in pain Increasing only the intensity (peak) of the pulse will result in a deeper penetration and a stronger contraction, leading to a decrease in pain Increasing only the rate of the pulse will result in a stronger contraction, but not enough to reduce pain

Application of Electrotherapy
Low Voltage Low voltage electrostimulation can be accomplished with an AC current or a DC current. Low Voltage AC current Low Voltage AC current is a biphasic (low frequency) current. There is no polarity because the positive currents equal the negative currents. Because there is no polarity, there is little to no physiologic effects. It is primarily used for muscle stimulation. It stimulates innervated muscles only. Its also used to prevent phlebitis, break adhesions, and create joint motion. Two equal size electrodes are used. Treatment must be done daily. Low Voltage DC current Low voltage DC current is a monophasic, galvanic current. The positive currents do not equal the negative currents, thus, there is polarity. There is chemical accumulation of ions in the skin leading to a physiologic stimulation. The indications are similar to low voltage AC. Unlike low voltage AC currents, it will stimulate innervated as well as denervated muscles. Low voltage DC current is the only current that will stimulate denervated muscle. This is strong current that may be uncomfortable. It can hurt or burn the patient. This is the current that is used for iontophoresis. Two electrodes are used for treatment: one large (negative) electrode and one small (positive electrode). The treatment time is daily for innervated muscle and two times per day for denervated muscle. The positive currents cause vasoconstriction to decrease bleeding, congestion and edema in the tissue. It dehydrates and hardens the tissue. It decreases nerve irritability and is used in acute conditions to relieve pain. In addition, a positive current is more germicidal than a negative current

216 The 2005 Podiatry Study Guide

 The negative currents cause vasodilation and increases hyperemia, bleeding, and congestion. It softens tissues and is used in chronic conditions to increase blood flow into the tissues and relieve pain. It will increase nerve irritability at low intensities; therefore you must increase the intensity when using negative currents. It is less germicidal than positive currents. It will stimulate innervated and denervated muscle High Voltage DC current High Voltage DC - Direct (DC) current is the only current with high voltage. It is a monophasic current with either positive or negative polarity. It has all the same positive and negative current characteristics of low voltage DC current, except it does not stimulate denervated muscle. The positive current is for acute conditions and negative current is for chronic conditions. High voltage DC current is the current most commonly used in podiatry. We want a current with a short pulse duration and a high pulse rate when using high voltage DC current in order to get the greatest patient comfort when stimulating the muscle (innervated). This current uses a large (negative) electrode and a small (positive electrode) and should be administered once a day for therapeutic benefits. When using high voltage electrical stimulation, care must be taken to use the appropriate pulse rate (pps). A guide is listed. Edema reduction 8-32 pps Muscle strengthening 30-50 pps Pain reduction 60 pps Reduce muscle spasm 50-1000pps Chronic conditions use negative current with a low pulse rate (1-20) Acute conditions use positive current with a high pulse rate The indications for electrical stimulation are pain, restriction of joint mobility, muscle spasm, disuse atrophy, tissue damage, edema absorption, and minor PVD. Electrical stimulation is contra-indicated with pacemakers and large amounts of bleeding in the tissues. The disadvantages of low voltage are that it is painful and may cause burns. The disadvantages of high voltage are that it does not stimulate denervated muscle and cannot be used for iontophoresis. Iontophoresis needs a low voltage. Also, it is difficult to stimulate large masses of muscle with high voltage. Iontophoresis Iontophoresis is the use of a low voltage DC current to move ions through the tissues and into the parts you are treating. Positive ions are forced in with positive currents and negative ions are forced in with negative currents. There are two electrodes. The negative electrode should always be larger than the positive. You want to dissipate the negative current over a larger area so you dont create a burn. Therapy should be rendered three times per week. The advantage of iontophoresis is that whatever ions do get in they are contained to a limited area. The disadvantage is that it is hard to control the dosage of the medication that actually gets into the body.

Figure 2. Iontophoresis

Interferential Interferential uses two opposite currents that interfere with each other leaving a more advantageous lower frequency current. Unlike other currents where most of the stimulation takes place directly underneath the electrode, with interferential it occurs between the electrodes where the two currents meet.

Orthopedics | Physical Medicine

217

Russian Currents Russian current is a surging current similar to surging currents found with regular AC or DC devices. This means that it is not a continuous level of stimulation, but instead starts low and increases to a maximum level. It surges from low to high. It is used primarily for muscle stimulation. When using Russian or surging currents there must be a resting time between each session of stimuli. The machine should be set so that there is a 3:1 interval of rest time to stimulus time. Combined HV and US Combined HV and US is often used for the positive dual effects on the tissues. Transcutaneous Electrical Nerve Stimulation (TENS) Transcutaneous electrical nerve stimulation (TENS) is the use of a low voltage, low amperage electrical current to create analgesia via differential nerve excitation. Though we dont really know how TENS works there are two theories: 1) Tens stimulates A-fibers (non-pain carrying fibers), which inhibits the passage of C-impulses (fibers that transmit pain) to the brain The Gate Theory; 2) When you use an electrical current on the body such as TENS, it increases the secretion of endorphins, which will decrease the amount of pain. The major indication for TENS is chronic intractable pain from varies conditions. It is used in athletes to decrease pain and break spasms. It is therapeutically beneficial in ulcer treatment (increase circulation and ACTH release). Acute pain is now also being treated with TENS. This modality is contraindicated with pregnancy, cardiac pacemakers and sensory impairment (the patient needs to be able to feel the stimulus). Application of TENS TENS is a two channel device with two electrodes per channel. For chronic intractable pain, place one electrode on the area of pain and the other electrodes around the area of pain forming a barrier cutting off the impulse to the brain. One electrode should be placed along the nerve root that runs to the area of pain, proximal to the area of pain. For neuroma treatment (or other entrapments) place one electrode on the dorsum of the foot and one on the plantar aspect. For post-op pain, place one electrode on either side of the incision site immediately following the procedure.

Figure 3. Tens - Focus

The variables that must be adjusted on the TENS device are the amplitude (intensity or strength of the current), width (length of the pulse), and rate (# of pulses per minute). There are several different modes of TENS therapy. Conventional TENS (original TENS when it was first developed) High rate, low width, amplitude to tolerance Short duration and slow onset of analgesia 5-60 min before analgesia develops Brief Intense TENS (good on the athletic field)

218 The 2005 Podiatry Study Guide

 High rate, long width, amplitude to tolerance Short duration and fast onset of analgesia Treatment time is 10-20 minutes
Low-rate TENS (LEMPE) Low rate, long width, amplitude to tolerance Long duration, and slow onset of analgesia Treatment time is 30 minutes Burst TENS (not available in all units) On/off: two to three bursts per second of seven pulses per burst, then pause, then repeat (done to decrease discomfort) Long width, amplitude to tolerance Long duration, slow onset analgesia Modulation TENS (for chronic intractable pain) The unit itself changes the rate and the width while the amplitude is held constantly high Long duration and fast onset of analgesia There is no overload like that which occurs with continuous high amplitude Modulation eliminates accommodation: the body will adjust to the electrical current so that the patient feels the current continuously

Other Types of Physical Therapy Modalities

Continuous Passive Motion (CPM)
Continuous passive motion is device that passively moves a patients joint or extremities through a predetermined range of motion. Modalities are available that move the MPJs, knees, toes, ankle writs, and jaws. When used early enough after surgery it can reduce pain edema and hospital stay. The physiologic effects of CPM are that it maintains ROM, which allows blood to flow in to the area. Motion provides joint nutrition and relieves the build up of waste products. CPM is a passive ROM device that is part of active rehabilitation. It should not be used as the sole means of therapy, but combined with other modalities such as US or whirlpool. Early use of CPM provides the best result. It is generally prescribed for home use and used several times per day. The patient comes back to the physician every couple of weeks for follow-up and re-evaluation of their condition. Continuous passive motion will reduce edema, which leads to pain reduction, which in turn leads to increased active ROM. Its indicated in the rehabilitation of trauma of all types (fractures, tendon surgery, surgical implants, etc). It should not be used with active infection or unstable fractures.

Figure 4. CPM Machine

Intermittent Compression
Intermittent compression is a boot or stocking that is applied to the leg that is attached to a device that provides alternating periods of compression and relaxation when applied to the extremity. It does this by inflating and deflating with air at set time intervals. The amount of compression is also pre-set.

Orthopedics | Physical Medicine

219

Intermittent compression is indicated in the following conditions: Post-op to prevent phlebitis and prevent chronic ulcerations associated with venous stasis edema Trauma surgery (to prevent phlebitis), accidents (to reduce edema) Edema venous and lymphatic (Venous edema leads to pressure on capillaries, then to impaired arterial circulation, then eczema, then atrophy, then ulcers.) Compression on the lower extremity leads to further compromise in your heart and lungs. You also put compression on the arterial system when you put pressure on the venous system. Thus intermittent compression is contra-indicated with CHF, Acute pulmonary edema, recent deep vein thrombosis, and severe PASO (arterial sclerosis). Complications with Intermittent Compression are rare, but may include heat build up from pressure and bulla formation secondary to friction from the boots. This can be avoided by using a stokinette under the boot. Before and after the use of Intermittent Compression you should take circumferential measurements of the foot and leg. The points of measurement should be: Knee 6" below the knee 3' above the ankle Ankle Midtarsal region This modality is generally for home or institutional use where it can be used on a daily basis, several times per day.

Massage, Manipulation, and Traction

Massage is defined as therapeutic manipulations of the soft tissues of the body with the ultimate goal of normalizing those tissues. Massage is a term also used to signify the use of hand motion on the surface of the living body whose effect is to achieve a therapeutic response. The physiologic effects of massage may be classified as reflex and mechanical. Reflex effect effects produced in the skin by the stimulation of the peripheral receptors, which transmit impulses through the spinal cord to the brain and back again. Various sensations of pleasure, relaxation, and sedation may be achieved as the reflex impulses cause relaxation of muscles and dilatation or constriction of arterioles Mechanical effect effects that assist the return flow circulation of blood and lymph as massage is given with the greatest force in the centripetal direction. These effects stretch adhesions between muscles allowing for enhanced muscular effort Massage is an art rather than a science. Natural ability is an important factor. Skill is required rather than strength. The types of massage utilized in western medicine are derived from the Swedish system. These primary techniques of massage include the following stroking (effleurage), Compression (petrissage), and percussion (tapotement). Stroking (effleurage) is movement of the heads in a distal to proximal manner (superficial or deep) over the surface of the skin which promotes the return flow of circulation and aids in lymph drainage. The force of the stroke should be centripetal Compression (petrissage) consists of kneading, squeezing, and applying friction to the tissues. Kneading may be described as a motion of manipulating soft tissue, i.e. picking it up between the fingers. Squeezing is performed with larger portions of the muscle by using two hands or by compressing the muscle with one hand and object. Friction is a motion performed rapidly in a circular motion, usually with the thumb or heel of the hand Percussion (tapotement) consists of alternating percussive movements that stimulate the tissues. It includes hacking, slapping, beating, and cupping. Hacking involves the outer border of the hands, while clapping is performed using the palms of the hand in a similar manner. Cupped hands usually produce a deeper sound. Beating is a similar technique, which involves using a clenched fist

220 The 2005 Podiatry Study Guide

The various massage techniques are not done in sequence but are intermingled with various techniques used for different purposes. Various conditions are applicable to massage wherein the reduction of swelling, relief of pain, or mobilization of contracted tissues is desired. Such conditions include but are not limited to the following: Arthritis Mobilization of contracted tissue Bursitis Joint stiffness/contracture Muscle spasm Sprains/strains Neuritis Relief of pain Fibrositis Ttendonitis Edema It is important to have a proper diagnosis since certain circumstances will preclude the application of therapeutic massage. Such a list includes, but is not limited to the following: Malignancies Infection Tumors Neuropathies Fractures Clotting disorders Thrombophlebitis Dislocations Ulcerations Burns Tissue atrophy Skin diseases Aneurysms Systemic disease (acute)

Manipulation and Traction

Since there is some overlap involving massage, it should be mentioned that manipulation and massage both involve similar hand positions and movements. Manipulation also involves the passive movement of a joint for therapeutic purposes. The difference between traction and massage, is that the former usually involves machinery alone and the latter consist mostly of hand movements. Listed are other systems involving massage which are beyond the scope of this chapter. Eastern massage Reflexology Acupunucture

Assistive Ambulatory Devices

Assistive devices that aid in ambulation are promoted as adjunctive physical therapy aids, which complement the effect of actual physical therapy. Thoughtful planning is essential so as not to waste money, impair function, delay healing, and destroy a patients confidence. Benefits directly related to assistive devices include relief of pain, stability, renewed confidence in ability to function, and prolonged ambulation. Other advantages related to using assistive devices to aid in ambulation are increased circulation, decrease in mineral loss from the bones (calcium), and enhanced pulmonary and renal function performance. It is important to convey to the patient that motivation and will power are essential in the ability to master the art of assistive ambulatory aids. There are a number of ambulatory devices available but the more popular ones are: axillary crutches, walkers, forearm crutches, and canes. Incidentally, walking sticks, which are popular in European countries, have not been widely promoted in the continental Unites States. Thus, this device will not be discussed. The most stable devices to the least stable are: Walker Axillary crutches Forearm crutches Cane

Orthopedics | Physical Medicine

221

Walker Walkers, because of their construction of four legs, provide a more stable and wider base of support as opposed to either canes or crutches. Patients who are elderly, uncoordinated, or who require maximum assistance are the prime candidates for this device. The patient should have good arm strength and the ability to grasp firmly with both hands. Elderly patients who are undergoing rehabilitation find walkers very useful and beneficial. Crutches (Axillary) Axillary crutches are the most commonly prescribed crutches in the United States. Adequate wrist and upper arm strength are needed because this type of ambulatory aid is used primarily for weight bearing and propulsion as opposed to as a balance and sensory aide. Measurements for axillary crutches starts with the total length of the crutches and the height of the handle. Crutch fitting can be done based on the overall crutch length of the hand grip length. Overall Crutch Length; Method I: Measure from the axillary area to the bottom of the heel and add one or two inches. Method II: Measure from the anterior fold of the axilla (approximately two finger widths) to a point six inches anterolaterally from the foot. Hand Grip Length (Length from Top of Crutch to Hand Grip): The wrist should be extended and the elbow flexed at 200 to 300. The shoulders should be level. Instructions for Crutch Walking The crutches should be placed 6 to 12 inches in front of and outside of both feet. The patient leans slightly forward grasping the handles firmly so that the weight is concentrated there and not in the axillary region. There are various types of gait in utilization of crutches, but the majority of the time a three point crutch gait is used. Hence both crutches and the weaker extremity work together. Move both crutches forward simultaneously Then advance the weak extremity Next advance the strong (normal) limb Ascending the stairs: . Set both crutches close to the first step while facing the stairs Push firmly on the grips of the crutches, straighten the elbows, and place the unaffected extremity on the first step. Continue to climb in this manner Descending the stairs: Lower both crutches and the affected extremity from the landing to the next step below while bending the knee of the unaffected extremity as much as possible to assist in balancing Now, lower the body while leaning on the crutches, at the same time lower the unaffected extremity by placing it on the same step

222 The 2005 Podiatry Study Guide

Forearm Crutch
These types of crutches require adequate grip strength of the forearm used for weight bearing. It should support no more than 50% of the total body weight. This ambulatory device consists of a tubular aluminum shaft, adjustable for patient comfort and ease of use, with a bent forearm piece angulated in a perpendicular manner just above the hand piece. It should extend approximately two inches below the elbow. This device is lightweight, but requires greater skills than the axillary crutch. Upper limb strength is essential in order to equalize the balance of the person and allow for safe ambulation.

Figure 5. Quad Cane

Figure 6. Canadian Crutches

Canes
The purpose of a cane is to increase the base of support while decreasing the load and demand on the lower limb. These ambulatory devices assist with acceleration and deceleration during locomotion. Canes are prescribed for various disabilities to improve balance, decrease pain, aid in postoperative healing, and to compensate for weak muscles. Types of Canes J Canes They are shaped like a J. They are the least stable type of cane Bent cane These are more stable because the weight runs parallel in line with the cane Quad cane These are even more stable than both the Bent and J canes. It has four legs on the bottom for added stability Walker cane This is the most stable of all canes because of its broad secure base of support with four legs Cane Length The total length of the cane should equal the distance from the upper borders of the greater trochanter to the bottom of the heel of the shoe. The patient should be able to stand with the elbow flexed at approximately 300 with both shoulders level. Cane Walking The cane must be used on the opposite side of the affected extremity. The cane and the affected limb move at the same time.

Orthopedics | Physical Medicine

223

References
Bruno, J and Helfand, AE: Ultrasound and Some Podiatric Considerations. Journal of the American Podiatric Association 66:9, 1976. 2. Delisa, JA and Gans BM: Rehabilitation Medicine: Principles and Practice, 3rd Ed., Philadelphia, Lippincott Raven, 1998 3. Hunt GC. ed.: Physical Modalities for Foot Pain. 231-255. In Schroeder, MA: Physical Therapy of the Foot and Ankle. New York: Churchill Livingstone, 231-255, 1988. 4. Kahn, J: Principles and Practice of Electrotherapy, 2nd Ed. New York: Churchhill Livingston, 19915. 5. Kottke FJ and Lehmann JF: Krusens Handbook of Physical Medicine and Rehabilitation. 4th Ed. Philadelphia: W.B. Saunders Company, 1990. 6. Rusk HA and Taylor EJ (ed): Rehabilitation Medicine. 4th Ed. Saint Louis: The C.V. Mosby Company, 1977.

224 The 2005 Podiatry Study Guide