Modalitas Rehabilitasi Medik

Roni Linson Girsamg G1A217075

Pembimbing : dr. Patrick William Gading, Sp.KFR

KEPANITERAAN KLINIK SENIOR

BAGIAN REHABILITASI MEDIK RUMAH SAKIT RADEN MATTAHER
PROVINSI JAMBI
2019
KEDOKTERAN FISIK (dr. Frank H. Krusan)
Penggunaan modalitas fisik seperti cahaya, panas, dingin, air, listrik, pijat,
manipulasi, latihan, dan alat-alat mekanik untuk diagnostik dan terapetik
seperti terapi fisik, terapi okupasi dan rehabilitas fisik
Infrared Radiations
 Infrared radiations (IRR) are electromagnetic
radiation that lies within that part of
electromagnetic spectrum between visible light
and microwave radiation.
 The radiation is characterized by wavelength
extended from 760 nm to 1 mm.
 IRR can be subdivided into 3 regions (A,B &C)
according to their absorption and their effect
upon the tissue.
760nm to 1 mm
 Classification of infrared radiation
Penetration Wavelength Type
5 mm reach 760 - 1400 IRA(short
to dermis nm or near IR)

Up to 1 mm to 1400 – IRB(long
epidermis 3000 nm or far IR)
Not used 3000nm – IRC
therapeutically 1 mm
 Production of Infrared
 Infrared is produced as a result of molecular motion within
heated materials. All hot bodies emit IR, as increase the
temperature of any material above absolute zero result in
vibration and rotation of molecule within the material .
 The wavelength of the emitted IR are determined by the
temperature of the material. The higher the temperature
of the body, the higher the frequency, and the shorter the
wavelength.
 Absorption and penetration of IRR
 IRR is strongly absorbed near the skin
surface and the heat is carried to deeper
tissues by conduction and by the circulating
fluids.
 The absorption and penetration of IRR rays
depend on:
1- Wavelength of the rays
2- Angle of incidence of the rays.
3- The intensity of the emitting source.
4-The distance of the radiating source from the
tissue.
Physiological Effects of Infrared
IRR is considered as superficial
heating modality
 Cutaneous vasodilatation
 Increase metabolism
 Neurological effect (Pain control)
 Effect on connective tissue
1- Cutaneous vasodilatation

Heating with IRR leads to vasodilatation of the blood

vessels as a result of:
 release of chemical mediator histamine like
substance
 axon reflex mechanism.

Vasodilatation causes increase blood flow in the

cutaneous circulation
Vasodilatation starts after short period of
exposure to IRR and leads to redness of
the skin that appears as irregular patchy
erythema and its intensity depends on the
degree of heating.

 This local erythema appears immediately

after exposure to IRR and lasts 30 minutes
after treatment has stopped.
2-Increase metabolism

Increase temperature by IRR leads to increase

metabolic activities within the superficial tissue due to
direct effect of heat on chemical process in the cell

Increase metabolic activities lead to improve cell

function and improve tissue healing.
3- Neurological effect

The heat production by IRR leads to relief

pain by:
 Stimulation of sensory nerves (A-Beta nerve
fibers) lead to inhibition of pain at the level
of the spinal cord.
 Decrease activity of muscle spindle leading
to relaxation of muscle
 Removal of waste products as the result of
improving circulation and increase venous
return thus removing the source of pain
stimulation.
Effect on connective tissue
 The heat effect of IR leads to increase the
extensibility of connective tissue and
therefore is used prior to exercise to
increase range of motion (stretching and
mobilization exercises).
N.B.
Increasing tissue extensibility by heating
through IRR will not decrease soft tissue
shortening. So infrared must be used in
conjunction with stretching and ROM
exercises.
 Therapeutic Uses of Infrared
Pain
Muscle spasm
Incisional wound (Acceleration of
healing)
Subacute and chronic inflammation of
musculoskeletal system
Chronic mild to moderate edema
Prior to stretching &mobilizing
exercises
Some skin conditions (fungal infection)
 Contraindications
1.Acute inflammation
2.Acute infection
3.Open wounds
4.Impaired sensation
5.Impaired circulation
6.Over pregnant uterus
7.Eyes
8.Metal
 Hazards and Dangers
Burns: The main danger of IR treatment is
the burn. It occurs if
1- heat is too intense.
2- the patient is not fully aware of the level of
heating.
3-the patient is unable to communicate with
physiotherapist.
Eye damage : The eye should be covered
with a light towel or head turned away during
the application of IRR to avoid eye surface
dryness or possible irritation.
Therapeutic Ultrasound
Description

Acoustical energy (sound waves) above the range of human hearing

– Therapeutic range: 0.75 to 3.3 MHz
Effects:
– Thermal
– Nonthermal (mechanical)
Uses

• Calcific bursitis
• Inflammatory conditions
• Joint contractures
• Pain
• Muscle spasm
• Acute orthopedic injuries (low pulses, low intensity)
Production of Ultrasound

An alternating current is passed through a

crystal
The current causes the crystal to vibrate
– Electropiezo effect
Vibrating crystal produce high-frequency
sound waves
Effective Radiating Area (ERA)

Area of the crystal that actually

produces sound waves
– Produces more than 5% of the
energy at 5 mm from the
transducer face
ERA
ERA is always smaller than the
transducer face
Energy is concentrated near the
center
Beam Profile

Multiple waves emerge from the

head
Energy diverges as it moves
away from the source
Energy is uniform close to the
head
– Near zone (Fresnel zone)
Becomes less consistent farther
away from the head
– Spatial peak intensity
Spatial Peak Intensity
Modes of Application

Continuous
Ultrasonic energy is constantly produced
Can produce thermal effects based on:
– Output intensity
– Treatment duration
Pulsed
Ultrasonic output is regularly interrupted
Produces nonthermal effects
Pulsed Output

Ultrasonic output is cycled

“On” and “Off”
– On = Pulse length
– Off = Pulse interval
Expressed as a Duty Cycle
Continuous Output (100% Duty Cycle)
– ON/(ON+OFF) * 100
– 20mSec/(20mSec+10mSec)
* 100
– 20/30 * 100
– 67%
Pulsed Output (67% Duty Cycle)
Output Frequency

Measured in megahertz (MHz)

– 1 MHz = 1,000,000 waves per
second
Determines the depth of effects
1 MHz Output
– Penetrates 5 to 7 cm
– Thermal effects last longer
– More divergent beam
3 MHz Output
– Penetrates 2 to 3 cm
– Heats 3 times faster than 1 MHz
output
– More collimated beam
Thermal Effects

Increased sensory nerve conduction velocity

Increased motor nerve conduction velocity
Increased extensibility of collagen-rich
Increased vascular permeability structures
Increased collagen deposition
Increased blood flow
Reduction of muscle spasm
Increased macrophage activity
Enhanced adhesion of leukocytes to damaged endothelial cells
 Heating Classifications

IncreaseUsed For
Mild 1°C Mild inflammation
Accelerate metabolism
Moderate 2° – 3°CDecreasing muscle spasm
Decreasing pain
Increasing blood flow
Chronic inflammation
Vigorous 3° – 4°CTissue elongation
Scar tissue reduction
Thermal Effects

• Same as other heat modalities

– Smaller volume of tissue
– Shorter duration of effects
• Preheat the skin with a moist heat pack
– Decreases the time to reach vigorous heating
• Poorly vascularized, collagen-rich tissues are preferentially
heated
– Fascia, tendon, scar tissue
• Tissues containing an increased proportion of fluid do not heat as
well
– Adipose tissue, articular fluid
Nonthermal Effects
• Increased cell membrane
permeability
• Altered rates of diffusion
across the cell membrane
• Increased vascular
permeability
• Secretion of cytokines
• Increased blood flow
• Increased fibroblastic activity
• Stimulation of phagocytosis
• Granulation tissue
production
• Synthesis of protein
• Synthesis of collagen
• Reduction of edema
• Diffusion of ions
• Tissue regeneration
• Formation of stronger
deformable
connective tissue
Nonthermal Application

Pulsed output

– 20 to 25% duty cycle

– Nonthermal output intensity
Continuous output

– 100% duty cycle

– Output intensity of less than 0.3 W/cm 2
Wound Healing

Tendon Healing
Continuous US application may:
– Increase tensile strength
– Increase collagen deposition
Skin Ulcers
3 MHz, low-intensity pulsed
output may assist the healing
process
Cover the wound with an
occlusive dressing
Fracture Healing

Low-intensity pulsed output

Accelerates rate of fracture
healing for:
– Acute fractures
– Nonunion fractures
– Stress fractures
Requires specialized unit
Biophysical Effects:
– Mechanical (sound) energy PARAMETERS
strikes bone Frequency 1.5 MHz
– Microvibration of bone ERA 3.88 cm2
triggers growth
(osteogenesis) Intensity 30 mW/cm2
Treatment Duration20 minutes
Daily
Contraindications
• Acute conditions (thermal
mode)
• Ischemic areas
• Areas of impaired circulation
• Over areas of deep vein
thrombosis
• Anesthetic areas
• Over cancerous tumors
• Sites of active infection or
sepsis
• Over the spinal cord or large
nerve plexus in high doses
• Exposed penetrating metal
(eg, external fixation devices)
• Around the eyes, heart, skull,
or genitals
• Over the thorax in the
presence of an implanted
pacemaker
• Pregnancy when used over the
pelvic or lumbar areas
• Over a fracture site before
healing is complete
• Stress fracture sites or sites of
osteoporosis
• Over the pelvic or lumbar area
in menstruating female
patients
Shortwave therapy
Description

• High-frequency electrical currents

– Radio waves

• Pass through the tissues

• Cause molecular vibration
• Results in deep heating
• Capable of heating large volumes of tissues
• Causes both thermal and nonthermal effects
Uses

Thermal Effects Nonthermal Effects

• Deep heat
• Edema reduction
• Increased blood flow
• Lymphedema reduction
• Increased cell metabolism
• Superficial wound
• Increased tissue
extensibility healing
• Muscular relaxation • Treatment of venous
• Possible changes in stasis ulcers
enzyme reactions
Types of Shortwave Diathermy

Induction Field
Capacitive Field
• Induction Field Diathermy

• Places the patient in the electromagnetic field

• Selectively heats muscle
• Also referred to as:
– Condenser field diathermy
– Magnetic field diathermy
Induction Field
Diathermy (Cont.)

• A coil is housed within a drum

• Current flowing within the coil produces a rotating
magnetic field
• Magnetic field produces eddy currents in the
tissues
• Eddy currents cause friction that produce heat
• Although rare, cables are sometimes used in
place of drums
Capacitive Field Diathermy

• Uses the patient’s tissues as a part of the circuit

• The tissues’ electrical resistance produces heat
• Selectively heats skin
– Muscle is heated via conduction from the adipose
• Also referred to as “condenser field diathermy”
Capacitive Field Diathermy (Cont.)

• Heat is produced by
the dipole effect +
-
+
-
• Charge particles +
- +
+
-
within membrane +
-

align with the field

• The movement
produces heat
Biophysical Effects

Inflammation

• Assists in removal of cellular debris and toxins

• Nonthermal:
– Alters diffusion rate across the cell membrane
• Thermal
– Increases intramuscular metabolism
Biophysical Effects

Blood and Fluid Dynamics

• Vasodilation increases:
– Blood flow
– Capillary filtration
– Capillary pressure
– Oxygen perfusion
• Increased fibroblastic activity and capillary growth
• Effects occur deeper than other forms of heat
Biophysical Effects

Tissue Elasticity
• SWD can vigorously heat deep tissues
• Alters collagen properties, allowing it to elongate
• Requires stretching during and/or immediately following the treatment
• Multiple treatments are required
Biophysical Effects

Wound Healing

• Nonthermal SWD increases rate of phagocytosis

• Number of mature collage bundles increase
• ATP activity increases (assisting wound regeneration)
• Necrosed muscle fibers decrease
Contraindications

• Metal implants or metal • Sensory loss

jewelry
• Cardiac pacemakers
• Ischemic areas
• Peripheral vascular disease
• Perspiration and moist
dressings: The water collects
and concentrates the heat.
• Tendency to hemorrhage,
including menstruation.
• Pregnancy
• Fever
• Cancer
• Areas of particular
sensitivity:
– Epiphyseal plates in
children
– The genitals
– Sites of infection
– The abdomen with an
implanted intrauterine
device (IUD)
– The eyes and face
– Application through the
skull
Laser & Light Therapy
What is Laser Therapy?

Light Amplification by the Stimulated Emission of Radiation

Compressed light of a wavelength from the cold, red part of the spectrum of
electromagnetic radiation

• Monochromatic - single wavelength,

single color
• Coherent - travels in straight line
• Polarized - concentrates its beam in a
defined location/spot
 What Does It Do?

Laser light waves penetrate the skin with no heating

effect, no damage to skin & no side effects.

**Laser light directs biostimulative light energy to the

body’s cells which convert into chemical energy to
promote natural healing & pain relief.

Optimizes the immune responses of blood & has anti-

inflammatory & immunosuppressive effects.
Physiological Effects
• Biostimulation – improved metabolism,
increase of cell metabolism
– Increases speed, quality & tensile strength of
tissue repair
• Improved blood circulation & vasodilation
– Increases blood supply
• Increases ATP production
• Analgesic effect
– Relieves acute/chronic pain
• Anti-inflammatory & anti-edematous effects
– Reduces inflammation
Physiological Effects
Stimulation of wound healing

– Promotes faster wound healing/clot

formation
– Helps generate new & healthy cells
& tissue
Increase collagen production

– Develops collagen & muscle tissue

Increase macrophage activity

– Stimulates immune system

Alter nerve conduction velocity

– Stimulates nerve function

 LASER Regulation
LASERs - classified by the FDA’s Center for Devices
& Radiological Health based on the Accessible
Emission Limit (AEL).

Class Levels 1-4

• 1 = incapable of producing damaging radiation levels (laser
printers & CD players)
• 2 = low-power visible lasers (400-700 nm wavelength, 1 mW)
• 3 = medium-power lasers - needs eye protection
» 3a – up to 5 mW
» 3b** – 5 mw-500 mW
• 4 = high-power lasers– presents fire hazard (exceeds 500 mW)
 High vs. Low Level Lasers
Low
High

– Surgical Lasers – Medical Lasers

– Hard Lasers – Soft Lasers
– Thermal – Subthermal
– Energy – 3000-10000 – Energy – 1-500 mW
mW – Therapeutic (Cold)
lasers produce
maximum output of
90 mW or less
– 600-1000 nm light
Parameters

Laser
Patient
– Wavelength
– Need medical history &
proper diagnosis – Output power
• Diabetes – may alter – Average power
clinical efficacy – Intensity
– Medications – Dosage
• Photosensitivity
(antibiotics)
– Pigmentation
• Dark skin absorbs
light energy better
Parameters – Energy Density

Dosage (D) Dosage is dependent on:

Amount of energy applied per unit area
Measured in Joules/square cm (J/cm2)
– Output of laser in mW
– Joule – unit of energy – Time of exposure in
seconds
– 1 Joule = 1 W/sec
– Beam surface area of
laser in cm 2
Various dosage ranges per site (1-9 J/cm2)
Parameters – Energy Density

Recommended Dosage Range

– Therapeutic response = 0.001-10 J/cm2

– Minimal window threshold to elicit response
– Too much – suppressive effect
– Open wounds – 0.5-1.0 J/cm2
– Intact skin – 2.0-4.0 J/cm2
– Average treatment – 6 /cm2
 Indications
Indications

– Soft tissue injuries

– Fractures
– Osteoarthritis, Rheumatoid Arthritis
– Pain
– Wounds & Ulcers
– Acupuncture
Contraindications
Contraindications
– Application over eyes
– Possibly can damage cellular structure or DNA
– Cancerous growths
– Pregnancy – over & around uterus
– Over cardiac region & Vagus nerve
– Growth plates in children
– Over & around thyroid gland & endocrine glands
– Patients who have been pre-treated with one or
more photosensitizers
Treatment Precautions
Better to underexpose than to overexpose
Avoid direct exposure into eyes (If lasing for extended periods
of time, safety glasses are recommended)

May experience a syncope (loss of consciousness)

episode during treatment during chronic pain, but very
rare
If icing – use BEFORE phototherapy
– Enhances light penetration
If using heat therapy – use AFTER phototherapy
– Decreases light penetration
MedX Laser & Light Therapy

Laser probe
SLD (2)
Electrical Stimulation
What is Electrical Stimulation (ES)?

Electrical Stimulation cause muscle contraction

High Volt Pulsed Stimulation
Parameters

Current: Monophasic

Amplitude: Adjustable Parameters

0 to 500 mA • Duty cycle
Voltage: • Electrode alternating rate
0 to 500V
• Electrode balance
Pulse Frequency:
1 to 120 pps • Intensity
Pulse Duration: • Polarity
13 to 100 µsec • Probe electrode
Phase Duration: • Surge/Ramp
20 to 45 µsec
Theory

Short-duration, high amplitude (voltage) pulses can produce

comfortable, moderate contractions.
– Short phase duration targets sensory nerves and motor nerves
– Wave form is modified to decrease total current to improve comfort
Each electrode has a known polarity
– May cause galvanic (ion) changes
– Short phase duration and long interpulse interval probably negates any
effect
Uses
• Reeducation of peripheral
nerves
• Delay denervation and
disuse atrophy by
stimulating muscle
contractions
• Reduction of post-traumatic
edema
• Increase in local blood
circulation (unsubstantiated)
• Restoring range of
motion:
• Reduction of muscle
spasm
• Inhibition of spasticity
• Reeducation of partially
denervated muscle
• Facilitation of voluntary
motor function
Effects

Neuromuscular Stimulation
– Moderate to strong muscle contractions
– Less torque production than NMES
Pain Control
– Sensory-level (short-term)
– Motor-level
– Acute pain: Positive electrode over painful site
– Chronic pain: Negative electrode over site
Effects

Edema Control

– Negative electrode may prevent the formation of

edema
– Causes the gaps between endothelial cells to close,
preventing leakage
Edema Reduction

– Motor-level stimulation “milks” the venous and

lymphatic vessels.
Effects

Blood Flow

– Associated with frequency and intensity of muscle

contraction
Wound Healing

– Electrode polarity kills or repels different microbes

– Assists healing and inhibits bacteria growth
– Direct current techniques are more effective than
HVPS
Transcutaneous Electrical
Nerve Stimulation
Parameters

Current: Biphasic

Total current flow Adjustable Parameters

0 to 100 mA Intensity
Pulse frequency Mode (output modulation)
1 to 150 pps
Pulse duration
Pulse duration
Pulse frequency
10 to 500 µsec
Phase duration
5 to 250 µsec
Uses

• Control of acute or chronic pain

• Management of postsurgical pain
• Reduction of post-traumatic acute pain
Effects

High – Frequency TENS (Sensory Level)

– Short phase duration (< 100 µsec)

– High pulse frequency (60 to 100+ pps)
– Sensory-level output
– Activates spinal gate
– Long-term treatment
• Output must be modulated to reduce accommodation
Effects

Low – Frequency TENS (Motor level)

– Long phase duration (150 to 250 µsec)
– Low pulse frequency (2 to 4 pps)
– Motor-level output
– Pituitary gland releases:
• ACTH
• β-lipotropin
– Causes the release of β-endorphin
• Binds to the A-beta and C fiber receptor sites
• Blocks the transmission of pain
Effects

Brief – Intense TENS (Noxious level)

– Long phase duration (300 to 1,000 µsec)
– High pulse frequency (> 100 pps)
– Noxious-level output
• Very short treatment duration
– Creates a negative feedback loop in the CNS
• Theoretically “short circuits” the pain carrying loop
• Opiates inhibit the release of Substance P
– Blocks or reduces pain transmission
Interferrential Stimulation
Parameters

Current: Alternating
Two alternating currents form a single
interference current. Premodulated output is
based on a single alternating current.
Current: 1 to 100 mA
Current flow (RMS) 0 to 50 mA
Voltage: 0 to 200 V
Carrier Frequency:
Fixed at 2500 to 5000 Hz
Beat Frequency: 0 to 299 Hz
Sweep Frequency: 10 to 500 µsec
Adjustable Parameters
• Intensity
• Beat frequency – Analogous to the
number of cycles or pulses per second
• Burst duty cycle – Bursts separated by
periods of no stimulation (interburst
interval)
• Interburst interval – Duration of time
between bursts
• Premodulation (e.g., Russian
Stimulation)
• Ramp
• Sweep – Variation in the beat
frequency; Set with a low value and a
high value
• Vector/Scan – Variation in current
intensity
Theory
Interference Wave
Carrier Wave

• High-frequency waves easily overcome

skin resistance
• The two waves are slightly out of
frequency
• They cancel each other out and produce
a frequency of 1 to 299 Hz in the tissues
Variable Wave • Results in a comfortable stimulation
capable of depolarizing sensory and
motor nerves
Uses

• Acute pain
• Chronic pain
• Muscle spasm
Effects

Pain Control

– Similar to TENS
– Most frequently used for motor-level pain control
Muscle Contractions

– Neuromuscular re-education
– Edema reduction
Notes and Precautions

Do not use in the presence of unknown pain or pain of central origin

Can cause electrode burns, skin irritation
Motor-level use can cause muscle spasm or muscle soreness
Neuromuscular Electrical
Stimulation
 Parameters

Current: Biphasic, Premodulated

Total current: Adjustable Parameters

0 to 200 mA
Intensity
Pulse frequency:
1 to 200 pps Pulses per second
Phase duration: Duty cycle
20 to 300 µsec
Reciprocal rate
Intrapulse interval:
Appx. 100 µsec Ramp
Theory

• Current type varies by manufacturer

• Tends to have long phase duration
• Biphasic and alternating current decreases possibility of electrode irritation
Uses

• Maintaining range of motion

• Muscle reeducation
• Prevention of joint contractures
• Prevention of disuse atrophy
• Increasing local blood flow
• Decreasing muscle spasm
Effects

Can produce substantial muscular tension

Capable of increasing strength

– Used when limb is immobilized

– Also slows the onset of atrophy
Duty cycle is required to prevent fatigue
Iontophoresis
Parameters

Current: Direct

Total current: Adjustable Parameters:

Up to 5 mA Dosage:
Voltage: – Amperage
80 V – Duration
Dosage: Polarity
0 to 80 mA/min
Theory

• The charges associated with a DC can “drive” medications into

the tissue
• Medication must have an electrical charge
• Negative charges driven from the cathode
Attracted towards the anode
– And vice-versa
• Requires specialized electrodes to hold the medication
Dose-Oriented Treatments

• Medications are
delivered in mA/Min
– Milliamp Minutes
• Function of the amount
of current times the
duration of the
treatment:
– 5 mA applied for 20
minutes
• 5mA * 20 min = 100 Dose-oriented treatments provide
mA/Min the basis for the Ionotopatch™
– 4 mA applied for 25 which delivers the medication
minutes using a low current applied for an
• 4mA * 25 minutes = extended time.
100 mA/Min
Uses

Delivers medication to the tissues to

treat:
– Acute inflammation
– Chronic inflammation
– Arthritis
– Myositis ossificans
– Myofascial pain syndromes
– Delivering local anesthetics before
injection or other minor invasive
procedures
– Hyperhidrosis
Notes and Precautions

Controlled medications require a physician’s prescription:

– Each patient requires his/her own prescription
– Follow any notes or instructions provided by the pharmacist.
– State practice acts may further regulate the delivery of iontophoresis.
The exact medication dosage delivered is unknown.
Erythema under the electrodes is common
Too intense of a treatment dose can result in electrode burns
Do not reuse electrodes
– Medications remain, contaminating the electrode
Microcurrent
Parameters

Current:Monophasic.
(Polarity reverses)

Total current flow: Adjustable Parameters:

1 to 999 µA (Peak current) Intensity
25 to 600 µA (RMS)
Polarity/alternating polarity
Pulse frequency:
0.1 to 1000 Hz Ramp
Pulse duration: Threshold – Ohm Meter
0.5 to 5000 µsec
Phase duration:
0.5 to 5000 µsec
Theory

• Small, subsensory pulses can affect the function of healing

tissues
• Injured tissues have a reversal of their normal electrical charges
(“injury potential”)
• MET attempts to normalize the electrical potential
• Activation of ATP and increased ATP levels
• The efficacy of MET has not been substantiated.
Uses*
• Acute and chronic pain • Temporomandibular
joint dysfunction
• Acute and chronic
inflammation • Carpal tunnel
syndrome
• Reduction of edema
• Superficial wound
• Sprains healing
• Strains • Scar tissue
• Contusions • Neuropathies

* Efficacy has not been established

Notes and Precautions

If the patient is dehydrated, nausea, dizziness, and/or headaches may result.

Electrical “shocks” may be reported by the patient when MET is applied to scar tissue.

– Caused by decreased electrical resistance.

Thankyou