PHOTOTHERAPY AND LASER TREATMENT

PHOTOTHERAPY AND LASER TREATMENT.ULTRASONIC-, VIBRATING- AND BAROMETRIC THERAPY. CLIMATE-, BALNEO-, PELOIDO-AND HYDROTHERMAL THERAPY. SPA-TREATMENT. RESORTS OF UKRAINE. SANATORIUM SELECTION

 

Phototherapy. The mechanism of action. Features of application in clinical practice

I. Features of light Rays

Light – electromagnetic fluctuations of environment in a range from 1000 micrones-1 mm (mc) up to 2 nanometers (nM) they have properties of particles (quantums, photons) and waves. Quantum – the portion of radiant energy back proportional to length of a wave. In a spectrum of light in the greatest size of quantums short ultra-violet beams have. The spectrum of light beams consists of three basic parts:

– Infra-red (IR) rays occupy its site in lengths from 780 nM up to 1000 mc;

– Seen Rays – from 400 nM up to 780 nM;

– Ultra-violet (UV) rays – from 2 nM up to 400 nM. In all three optical ranges sources of laser rays are created. Laser radiation is monochromatic (rigidly fixed length of a wave), coherently (an identical phase of radiation for all fluctuations), is polarized (has the fixed orientation of vectors of an electromagnetic field in space). All this provides small divergence and a high orientation of laser rays (LR).

In physiotherapy are applied mainly low intensive lasers in infra-red and red ranges, in continuous and pulse modes. It is used the LR for an intravenous irradiation of blood, and the  unfocused rays – for influence on sites of a skin and mucous membranes in diameter up to 30 sm. The density of a stream of energy makes 5-10 mWt/sm².

Each part of a light spectrum shares also on three sites: long-wave (A), midle wave (B) and short-wave (C), this division has essential value for UV-therapy as clinical application of long ultra-violet rays (LUV) essentially differs from application short (SUV). Lengths of a wave in the apparates (devices): LUV-320-400 nM, MUV-280-320 nM, SUV- 180-280 nM (nM-one milliard part of meter).

Distinguish cold and hot luminescence. In a cold luminescence distinguish cold allocate for its basic kinds:

– chemical – a luminescence arising because of chemical (biochemical) reaction;

– tribo – a luminescence developing under influence mechanical influence (friction),

–  photo – a luminescence shown at or after light influence,

– electro – a luminescence of bodies (gases) at passage through them of an electric current

At interaction of light with a skin of the person the part of optical radiation is reflected, other part is absorbed. The factor of reflection of the weak -pigmented skin reaches 50-55 % (for perpendicular rays). At increase of an ungle of rays’ falling it may grow up to 90 %. The pigmented dark skin absorbs rays in the greater degree than light.

At absorption by tissues of an organism of laser  radiation its coherence and polarization disappear on depths 0,2-0,3 mm though the rays reaches depth in 6-7 cm.

 

II. The mechanism of action of light beams on biological objects

At absorption of light by living organisms in them the following basic reactions may develop:

– Photosynthesis – formation of complex organic molecules (an example – synthesis of vitamin”D” in the skin);

-Photolysis – destruction organic connection and living cells (an example – processes in a skin at erythermal influence of UVR) with formation of biologically active substances;

– Photoreception – development of neuroreflex reactions in various receptor systems in a skin, mucous membranes and in a retina of an eyes. An individual kind of photoreception is the photoinformation acting almost exclusively through organ of sight;

– Photoheating – rise in temperature of tissues under influence of light rays;

– Photoelectrisation – occurrence in tissues of weak electric currents.

IR=rays , penetrating  through a skin and mucous membranes on depth up to 4-5 cm, render mainly thermal influence(thermal rays ).

Seen rays render weak thermal and information influence.

– The expressed thermal effects from electrolight medical lamps are connected to presence in a spectrum of their radiation up to 90 % of infra-red beams

Photochemical influence and weak photo-electric (depth of penetration of 1,5-3 cm). UV-rays render weak thermal, expressed photochemical (photosynthesis and photolysis) and photo-electric influence. UV –rays, especialy in a short range, may damage (injure) nuclear substance of cellsand their genetic formmatios (depth of penetration into tissues – up to 0,1-0,6 mm).

 

Briefly about a history of phototherapy

Using with the medical purpose solar rays (Heliotherapy) is applied from immemorial times. Application of artificial light for treatment of patients has the little more than a centenary history. In middle of 80-th years of XIX century medical application of UV-rays and before all in therapy of a skin tuberculosis (N.R.Finzen) and electrolight baths for thermotherapy began. Widely are known the “Sollux’s and Minin’s lamps; a little bit later have appeared a lamp “Infraruzh” and etc.

 

A lamp “Infraruzh”

 The engineering of the lamps with UV-radiations developed also. At the end of 60th years of our century began to apply the Laser therapy (in physiotherapy – low intensive laser radiation).

 

The mechanism of medical action of light rays (at assignment of therapeutic dozes)

Infrared Lamps

Infrared lamps are a form of conversion heat. Radiant energy, in the form of photons, is emitted from all substances and is converted into heat. Infrared rays are located in the electromagnetic spectrum that is beyond the red portion of visible light. Infrared radiation is divided into two spectrums. Near-infrared, or luminous, includes some visible light and has a wavelength of 770-1500 nm; and far-infrared or nonluminous, has a wavelength of 1500-12,500 nm.The depth of penetration as well as the thermal energy produced in the body sur­face is dependent on the wavelength. As the wavelength increases, the depth of the penetration decreases. Near-infrared electromagnetic energy has a depth of penetration of 5-10 mm. Far infrared has a depth of penetration of approximately 2 mm.

The amount of energy that is absorbed and converted to heat depends on other factors as well. The angles at which the rays strike the surface influence the intensity of the thermal reaction. The amount of radiation absorbed is greatest when the rays are perpendicular to the surface. As the rays angle away from the perpendicular, the rays are refracted away from the surface and the intensity decreases in proportion to the cosine of the angle. Another factor that influences the intensity of the radiant heating is the distance of the source from the surface being treated. This is determined by the inverse square law, which states that the intensity of irradiation varies inversely with the square of the distance from the source. Therefore, as the distance is halved, the intensity increases fourfold.

 

The infrared generators are divided into two categories: luminous and nonluminous. Luminous rays are produced by tungsten carbon filament lamps and include portions of the visual spectrum from which visible light is located. Spiral coils of metal wire wrapped around nonconductive material produce the nonlu-minous rays, although some visible light is produced as indicated by the low-intensity glow. Electricity flowing over the wire meets resistance, producing rays. The luminous lamps have a deeper penetration into the subcutaneous tissue because of its smaller wavelengths.

When using infrared lamps, the patient is cleaned of all ointments, and jewelry is removed from the treating area  Areas that are not treated should be covered with protective towels, especially the eyes and hair. The lamp is positioned approximately 20-45 cm from the surface to be treated. The distance is determined in part by the patient’s tolerance to heat, as well as specifications of the particular piece of equipment, which is dependent on the lamp’s wattage. Also, the lamp should not be adjusted while it is over the patient because of the risk of the lamp falling on the patient. The skin should be checked frequently to assess for mottling and burns. (Burns are more likely to occur over bony prominences or areas where the lamps are placed too close to the body. With repetitive intense treatments, skin pigmentation changes may occur. The main advantage of infrared treatment is that it does not involve weight on the body and, therefore, is tolerated by patients who cannot tolerate direct contact or weight such as hot packs. Also, larger surfaces can be treated, particularly the thoracolumbar region. The main disadvantage of infrared treatment is the risk of burns, particularly over the bony prominences, as well as the drying effect, which may be intolerable to some patients.

 

Massage with infrared treatment

 

IR=rays render mainly thermal influence on a tissue that causes:

– Amplification of blood circulation in a skin and in internal organs (it is especial in appropriate splanchnotome) as a result of carry of heat by blood and reflex reactions; a hyperemia;

– Increase of permeability of tissues;

– Activation of a metabolism;

– resorption of the infiltrates, fresh cicatrixes and solderings;

– Stimulation of regeneration;

– Antispastic effect;

– Anesthetic and sedative action (at weak-thermal and thermal dozes);

– Decrease of the raised arterial pressure;

– Drying of a skin (becoming wet ulcers, eczema);

– Sudorific effect with detoxication of an organism;

– Decreasing of of thermolabile microorganisms’ activity.

 

Seen rays have the following sides of the action:

– Stimulation of the nervous system- at bright illumination or red (orange) light;

– Calming, sedative effect – green, blue beams,

– Depression – black color;

– Dark blue and blue rays destroy the bilirubin of blood (are applied at newborn’s hyperbilirubinemia);

– Rhythmic weak light flashes on frequencies 5-12 Hz  render sedative influence, and on frequencies 20-40 Hz – stimulating action;

– Thermal effects.

UV-rays in therapeutic dosages influence biochemical and physiological processes in tissues:

– Photolysis and formation of biologically active substances;

– Photosynthesis (vitamin “D” and melanin);

– Phagocytosis’ activation, producing of interferon and immunoglobulins;

– Stimulation of ACTG;

– Stimulation of blood circulation;

– Anesthetic action;

– Increase of permeability of tissues;

– Stimulation of a metabolism and processes of regeneration of tissues;

– Bactericidal effect;

– Normalization of coagulability of blood;

– Antitoxic action;

– Stimulation of connective tissue formation;

-Desensitizing effect (in course application of UV-rays).

Medical action: anti-inflammatory, desensitizing, trophic, vitaminformating, bactericidal, immunostimulating.

The mechanism of action of low-intensive laser irradiation

The laser beam penetrating deep into tissues influences atoms, selectively on molecules, nervous receptors and cellular structures (effect of biological activation).

 

Laserotherapy

There is an improvement of microcirculation, permeability of tissues raises, exchange processes are activated, is braked per oxidative oxidation of lipids, that all together may promote easing of aseptic inflammatory process and infiltrates resorption. The laser irradiation in this or that degree reduces tactile and painful sensitivity a zone of influence. It stimulates mechanisms of local and general immune protection of an organism. Laser rays suppress ability to live of microorganisms. At influence on superficial tissues segmental reflex and general reactions develop, that, in particular, is used in laser-reflex puncture.

At an irradiation the laser of blood occurs activation of erythrocytes ferment systems, that results in increase of oxygen capacity of blood. Incontinuous procedures of an irradiation of blood result in decrease of speed of thrombocytes aggregation and contents of fibrinogen increase of a free heparin level and fibrinolytic activity of a blood serum:

Medical effects: metabolic, improving microcirculation, analgetic, immunomodulating, anticogulating, desensitizing.

 

III. Indications and contra-indications to phototherapy

Indications to application of IR and seen rays:

– acute, subacute and chronic painful syndromes and inflammatory processes: a neuralgia, neuropathy, radiculopathy, myalgia, myositis , a rhinitis etc.

– a trauma of tissues (with 2-of 3-d day);

– arthrosises and arthritises, a polyarthritis;

– badly healing wounds and ulcers;

– fresh cicatrixes and solderings;

– peripheral ischemic syndromes, including the obliterating diseases;

– newborns” hyperbilirubinemia;

– neurosises and neurosolike conditions.

 

Indications to application of UV-rays :

– Preventive, general health-improving action at adults and children (antirachitis action);

– Preoperative preparation of patients (suberythemal and weak-erythemal dozes);

– Diseases of peripheral nervous system;

– Initial displays of a cerebral atherosclerosis;

– Neurosises and neurosolike conditions;

– Diseases of the locomotorium: an osteochondrosis of a backbone, osteoarthrosis,artrosises, arthritises, a polyarthritis, myositis etc;

– Diseases of  the Respiratory System: a bronchitis, a bronchopneumonia, a bronchial asthma, a tracheitis;

– Skin illnesses: pyodermia, psoriasis, neurodermitis scleroderma, vitiligo, seborrhea, fungous dermatomycosises, alopecia;

– diseases of ear, nose and throat: a rhinitis, tonsillitis, angina;

– surgical illnesses: an erypsipelas, badly healing wounds and ulcers, furunculosis, combustions and frostbites;

– a tuberculosis(various forms, especially a tuberculosis of a skin);

– a sepsis (the UV-irradiation of blood).

Indications to the laser-therapy:

– Diseases and damages of the locomotorium;

– Diseases and damages of peripheral nervous system;

– Diseases of the cardiovascular system (IHD, hypertonic disease, vascular diseases of extremities);

– Diseases of the digestion system (ulcers of a stomach and a duodenum);

– Diseases of urinogenital system: adnexitis, uterus’ cervix anabrosis , an endometritis, a prostatitis;

– Diseases and damages of a skin: wounds, ulcers, combustions, decubituses, frostbites, herpes, itching dermatosis, lichen planus;

– Diseases of the ear, throat and nose: tonsillitis, a pharyngitis, a laryngitis, an otitis;

-Thymus-dependent immunodeficit conditions.

 Contra-indications to phototherapy:

– Malignant neoplasms;

– System illnesses of blood (especially white),

– Feverish conditions;

-Local purulent processes,

– Acute infectious diseases (excepting the Acute Respiratory Deseases);

– Pemphigus;

– Expressed bleeding;

– Cardiovascular insufficiency of III stage;

– Hypertonic disease of III stage;

– photodermatitises;

– A cirrhosis of a liver and expressed nephrosclerosis (for UV-rays) (realization of light –thermal procedures in zones of an arrangement of the banal tumours is undesirable)

VI. Methodical features of phototherapy

The basic kinds of phototherapy may be carried out as local, segmental-reflex and general procedures.

The light-thermal procedures usually carry out in oligothermal and thermal regimens, sometimes in hyperthermal (light baths). Their average duration – 10-20 of minutes. They can be released daiy (at acute pathology- 3 times per day), o course of treatment – 5-15 procedures

The UV-therapy is dosed out with the help of biodoses. One biodoze – the least erythermal time of an irradiation of the patient’s skin (it is usual in the bottom of a stomach) on a distance of 50 cm. It is determined individually, but depends, in particular, on capacity of the UV-lamp. The definition of a biodoze on dermal integuments is carried out by biodosimeter “BD-2”. It is a metal plate with 6 rectangular apertures opening during an irradiation with an interval in 10 seconds. In result a skin in the first aperture is irradiated 60 s. and in the last 10. In 24 hours on threshold erythema establish a biodoze equal to time of an irradiation of a skin in seconds above that aperture in which the skin for the first time clearly turns pink (for shortest time of an irradiation).

Distinguish small erythermal dozes (1-2 biodozes), average (3-4), big (5-8) and hypererythermal (over 8 biodozes). Large hypererythermal biodozes nominate basically at some local irradiations of a skin.

To UV-therapy apply sources of long-wave radiation (320-400 nM), integrated (280-380 nM) and short-wave radiation (180-280 nM) For the general influence apply sources of LUV-and IUV-rays. For local – mainly all three kinds of rays. Besides, IUV-rays are used for treatment of diseases of mucous membranes and for disinfecting air in the closed premises (rooms) and water. SUV-rays are applied also to a ultra-violet irradiation of blood in special devices. At the general influence irradiate serially forward and back surfaces of a body of the patient. Three circuits of the general UV-irradiation are accepted:

 

                 

 

The basic, accelerated and slowed down. Thus daily irradiations begin according to 1/4,1/2 go 1/8 biodozes and gradually lead up to 3-4 biodozes. Course of treatment – 15-25 days.

Within the frame of preoperative preparation of patients the courses of general, suberythermal and weak erythermal an irradiation are carred out during 6-8 days.

Local procedures of the UV-irradiation carry out on a skin and mucous membranes. Sensitivity of mucous membranes to UV-radiation is determined on a method of N.Tkachenko by means of biodosimeter “BUV-1”. It represents a plate with 4 apertures which put on on radiographic cone of ultrasonic head posed compactly above a papilla, where sensitivity of a skin comes nearer to sensitivity of mucous membranes. Apertures of a plate open on one with an interval in 30 seconds, and a biodoze determine in 12-24 hours.

The irradiation of mucous membranes begins with 1-1,5 biodozes and gradual increasing by 0,5-1 biodozes lead up to 3 biodozes. On a course – 5-6 procedures.

Local irradiation of a skin by UV-rays begin with 1,5-2 biodozes. The same site 3-6 times with an interval in 1-3 days, raising a dosage on each subsequent procedure on 0,25-1 biodoze Probably irradiate allocation of several fields of an irradiation and then procedures will carry out daily, but on different fields.

 

 

Ulcer treatment by lamp of UV – rays

The method of photochemotherapy (PCT –“Puva-therapy”) – is carried out with a preliminary sensitization of a skin to LUV-rays with the help of connections of furocumarin’s line (Puvalenum, Psoralenum, Beroxanum, Psoberanum and etc.) Photosensibilizators are entered in an organism orally and paranterally after some hours or one day prior to an irradiation Then the irradiation will be carried out, begin  about 1/8 biodozes which through everyone 1/8 procedures raise on 1/2-1 biodozes, reaching  up to 3-4 biodozes at the general irradiation and 5-6 biodozes at local.

On a course – 10-12 procedures. It is applied almost exclusively at skin diseases:psoriasis,vitiligo,fungous mycosises and etc.

For Laser therapy  use optical radiation red (632 nM) and infra-red (800-1200 nM) ranges.Irradiation by unfocsed ray carry out on distance to a technique, the backlash  from a ultrasonic head  up to a skin makes 20-30 mm During one procedure irradiate 1-5 fields, which the general area up to 400 cm².

Dosing of laser influences is carried out on density of a current of energy of radiation with the help of measuring instruments of capacity by them -1 and them –2.

Duration of procedures from 20 seconds about 5 minutes on one field. At influences on some fields – totally about 20 minutes.

Influences by the laser on one point are carried out contactly within 20-30 seconds, total duration of procedures – up to 2-3 minutes more often. Procedures are carried out daily or in day, on a rate of 10-20 procedures. The repeated course of Laser therapy may be carried out in 2-3 months

V. The equipment for light-thermal , ultra-violet and laser influences

Light-thermal devices:

– Lamps of infra-red radiation – “LIR-5M”;

– Lamps of seen (infra-red) radiation “Sollux”(stationary and desktop);

– A lamp of dark blue light (Minin’s lamp);

– Electrolight baths for a trunk and extremities;

– Baths (trays with blue beams):”BRL-11”,”SLA-21”(for not thermal light influence);

UV-rays devices

– Selective sources :”LUV-13”,”UUV-1”,”UUL-1-A”,”RUB-1”,”RUS-1” ,”ERL-10”,”EBL-5”.

Integrated sources :”AMQ-250-1,375,1000 and their modifications(in devices “RQT-11-M-desktop,”RMQ-21-M on a support).For an irritation of nasopharinx –“UVB NP-1”.Cold light(luminescent) lamps “LE-153 “ in radiatores”RUVS-1” (on a support),”RUVT-2” (desktop).

Low-intensive lasers

On rays of red color:

-“UVL-01” “Btrry”,”FALM-1,”ALIB-1”-1 (for intravenous irradiations of blood).

 

Infra-red lasers:

“Pattern” and “Pattern – 2K”,”MILTA” ,”ALT-05”,” “Photothrone” For Laser-puncture: ”Bluebell”,”Vita-01”,”Leve-Laser”.

Apparatus Btl-102sondy

 

ULTRAVIOLET LIGHT THERAPY

 Throughout history, the beneficial effects of sunlight have been recognized and appreciated by many. Some cultures, such as the ancient Egyptians, Chinese, East Indians, Romans, and Aztecs, actually worshipped the sun itself as a god. Many in these cultures believed the sunlight to have healthful effects, and the practice of sun bathing was common.

The advent of Christianity resulted in suppression of pagan practices such as sun worship and sun bathing. However, a renewed interest in the sun and its powers resurfaced in the 18th and 19th centuries. As science and medicine continued to evolve, many physicians began to advocate the therapeutic use of sunlight for specific medical conditions. Unfortunately, the sun as a therapeutic agent was often unreli­able (on cloudy days), inconvenient to use indoors, and difficult to regulate because of positional changes and seasonal variations in intensity. This fueled efforts to pro­duce artificial illumination that could duplicate the therapeutic effects of sunlight.

By the late 1800s, scientific investigation into the physical properties of sunlight and other forms of energy had advanced significantly. In 1868, Angstrom mapped out the invisible light spectrum, and ultraviolet light was a distinguishable entity. The medical use of ultraviolet light gained popularity. In 1877, Downes and Blunt proved that light could kill bacteria. Niels Finsen first used sunlight concentrated with lenses and later began using a carbon arc ultraviolet lamp to treat lupus vulgaris. Finsen’s treatment of cutaneous tuberculosis with ultraviolet light won him the Nobel Prize in 1903.^: By 1933, Frank Krusen published Light Therapy which included a complete list of over 150 conditions for which benefit was claimed for using ultraviolet light therapy . Although this list included diseases for which the benefit of ultraviolet light therapy was wellestablished, it also included diseases such as hypertension, the common cold, and hyperacidity of the stomach. Ironically, although ultraviolet light therapy was once popular in the early days of physical medicine and rehabilitation (PM&R), today relatively few physiatrists and decreasing numbers of other rehabilitation professionals actually use ultraviolet therapy. Its inclusion in this text and in standard PM&R textbooks is primarily for historical purposes. A more detailed account of the history of ultraviolet radiation use may be found elsewhere.

Physics of Ultraviolet Light

Ultraviolet light is a form of radiant electromagnetic energy produced when the electrons in stable atoms are activated to move to higher, unstable orbits. As these electrons move back to their original orbit, they release energy in the form of elec tromagnetic radiation. Ultraviolet radiation is transmitted by oscillatory motion in the form of electromagnetic sine waves that travel in a straight line . Wavelength is measured ianometers (nm) .

Ultraviolet light also may be identified by its frequency, defined as the number of oscillations or cycles that occur within a given unit of time. Frequency is meas­ured in cycles per second or Hertz (Hz). Wavelength and frequency have an inverse relationship. The longer a wavelength is, the fewer the number of cycles that may occur within a second. Conversely, the shorter the length of a wave, the higher the wave frequency and the higher its energy content. Like other forms of radiation, ultraviolet waves can be reflected, refracted (scattered), and absorbed.

Ultraviolet light was named for the position of its wavelength in the electro­magnetic spectrum relative to the wavelength of violet light, which is on one extreme end of the visible light spectrum . Visible light is actually composed of a broad spectrum of colors. Each color is defined by a different wavelength. The wavelengths of the visible light spectrum range from 400 nm to 800 nm, whereas the frequencies range from 7.5 X 10 to 3.75 X 10.

The word ultraviolet meaning “beyond violet,” is actually a misnomer because the name implies that its wavelength, which ranges from 180 nm to 400 nm, is greater than the wavelength of violet light (400nm). Some researchers have further classi­fied ultraviolet light into three subdivisions, based on wavelength and other prop­erties. Ultraviolet-A (UV-A) has relatively long wavelengths, in the 320-nm to 400-nm range, closest to the visible light spectrum. UV-A also has relatively shorter frequencies. Ultraviolet-B (UV-B) has shorter wavelengths in the 290-nm to 320-nm range, and ultraviolet-C (UV-C), with the shortest range of wavelengths, at 180 nm to 290 nm, has relatively higher frequencies. UV-A and UV-B are also known as near ultraviolet because of their proximity to the visible light spectrum, and UV-C is known as far ultraviolet because of its greater distance from visible light.

Photobiologic Effects

The ability of ultraviolet light to produce biologic changes in human tissue depends on several factors: (1) the wavelength of the UV radiation; (2) the amount of energy absorbed or reflected by the tissue; (3) the distance from the radiation source; (4) the angle of delivery of the radiation; and (5) the time of exposure to the radiation. Natural ultraviolet light comes from the sun’s radiation, although most of the ultraviolet rays in sunlight are absorbed by the earth’s atmosphere. Only 5-10% of solar energy that penetrates the atmosphere is in the ultraviolet wavelength range.

Though some near ultraviolet (UV-A and UV-B) rays in sunlight penetrate the earth’s atmosphere to produce biologic effects, most UV-C rays are absorbed by the upper atmosphere and never reach the earth’s surface. The known biologic effects of UV-C rays are produced from exposure to artificial lamps. Ultraviolet-A radiation causes increased pigmentation or tanning of the skin and a weak erythema (sun­burn) reaction. Ultraviolet-B also increases skin tanning and causes a more intense (100-1000 times) erythema reaction with the possibility of blister formation. Whereas the effects of UV-A and UV-B radiation are primarily in the dermal layer of skin, the main effect of UV-C occurs in the epidermal layer. Erythema effects from a UV-C lamp peak at a wavelength of 250 nm but rarely cause an intense erythema or blistering. This is because skin reflects radiation with shorter wavelength (UV-C) much more easily than radiation with longer wavelength (UV-A and UV-B).

 

Beneficial Effects of Ultraviolet Light

The main beneficial effects of ultraviolet light include:

Erythema. Erythema, or redness of the skin, is produced by congestion of cuta­neous capillaries. If the ultraviolet dosage is sufficiently high, an inflammatory response is produced with an associated vasodilatation mediated by histamine. Ultraviolet radiation wavelengths of 254 nm and 299 nm are most effective at pro­ducing erythema.

Bactericide. The bactericidal effect of ultraviolet light has been known since 1877. Ultraviolet radiation interrupts the synthesis of DNA and RNA in bacteria, and it is used to sterilize air and water. Bactericidal effects are best achieved with ultraviolet wavelengths in the 250-nm to 270-nm range.

Wound Healing. The erythema and increased blood flow improves oxygenation to the skin and promotes wound healing by stimulation and proliferation of endothelial cells and granulation tissue. Bactericidal and virucidal effects on wound pathogenic organisms also may aid wound healing.

Pigmentation. An increase in pigmentation (tanning) follows vascular and inflammatory changes of the erythema reaction. Previously synthesized melanin in deeper epidermal skin layers is spread by capillaries to a more superficial position within the epidermis. This produces an immediate tanning effect (within min­utes) . Activation of new melanin production by epidermal melanocytes and trans­fer of this pigment to epidermal keratinocytes results in additional delayed tanning (within days, lasts for months). Ultraviolet wavelengths of 254 nm and 297 nm are the most effective for tanning.

Superficial Exfoliation. Ultraviolet light causes dead epithelial cells, eschar, and necrotic tissue to slough off. This enhances wound debridement and aids in the treatment of some cutaneous diseases.

Application Techniques in Ultraviolet Therapy

Techniques used in the therapeutic application of ultraviolet light depend on the type and wavelength of ultraviolet radiation to be used, associated physiologic effects, and the goals of treatment (e.g., tanning, wound debridement). Protocols have been used to determine the therapeutic dosage of ultraviolet light by determining the dose (exposure time) of ultraviolet radiation required to produce desired effects. This minimum exposure time may be different for individual patients and should be individually determined.

Normally, after skin exposure to ultraviolet light, there is a latent period of 2-6 hours. The skin then becomes red and warm from vasodilatation. This reaction peaks in intensity about 8-10 hours after exposure. Holtz reported that this reaction includes intercellular edema in the prickle cell layer of skin and a concentration of leukocytes in local blood vessels. Erythema developing after ultraviolet light exposure is divided into four levels: first, second, third, and fourth-degree erythema.

First-degree erythema is a painless reddening of the skin within 4-6 hours and lasting for 24 hours. A second-degree erythema reaction also develops after 4-6 hours and involves reddening and soreness of the exposed skin area. This reaction resembles mild sunburn, lasts for 3-4 days, and is accompanied by increased pigmentation and mild superficial exfoliation. A third-degree erythema reaction starts earlier (within 2 hours) and includes more severe sunburn signs and symptoms with redness, tenderness, and edema, which may last several days. Pigmentation is more pronounced as is the exfoliation, which is typically a peeling off of superficial skin layers. Fourthdegree erythema is initially similar to third-degree erythema changes, but as severe skin edema and exudation separate the superficial skin layer from deeper layers, blister formation occurs.

A device for use in determining ultraviolet radiation dosage, called an erythrometer, can be made from material that is opaque to ultraviolet such as cardboard, metal, or black paper. Some descriptions of the erythrometer and the procedure for biologic ultraviolet dosage testing differ slightly but utilize the same basic principles. Four to six small (approximately 0.75 cm X 0.75 cm) openings spaced 0.75 cm apart are cut out of the opaque material and the erythmome-ter is then taped on the patient’s volar forearm or lower abdomen. A sliding cover for the erythmometer is made from the opaque material so that one opening or all openings can be progressively covered. The patient’s and the therapist’s eyes should be protected, and all of the patient’s skin that is in the field of the UV lamp should be draped except for the forearm.

The ultraviolet lamp is positioned 60-90 cm (2-3 feet) away from and perpendi­cular to the treating surface and is turned on. Initially, only the first opening is exposed. After 15 seconds of exposure, the second opening is uncovered, and the first opening remains exposed. Each of the next two to four openings is progressively uncovered at 15-second intervals, until the lamp is turned off at a total of 90 seconds of exposure. With this protocol and using an erydirometer with six openings, the first opening uncovered would have had an exposure time of 90 seconds, and the last opening uncovered would have been exposed for 15 seconds. The erythrometer is removed, but the position of each opening is marked for later reference. The patient is asked to monitor the forearm every 2 hours (while awake) for the next 48 hours and record which site becomes erythematous and when, and how long the erythema lasts. The minimal erythema dose (MED), or the minimum ultraviolet exposure time required to produce a mild (first degree), latent erythema lasting 24 hours (determined erythema reaction), can be calculated using this information.

Ultraviolet radiation dosages are in multiples of the MED exposure time for each individual patient . For most UV lamps, 1 MED is achieved with an exposure between 5 and 15 seconds in Caucasians. Exposure at 2.5 times the MED causes painful (second-degree) erythema within 6 hours, lasting 4 days. At 5-10 times the MED, painful (third-degree) erythema and blistering develops. Ultravio­let dosages in this range should be limited to small areas of exposure.

The UV-therapy  is dosed out with the help of biodoses. One biodoze – the least erythermal time of an irradiation  of the patient”s skin(it is usual in the bottom of a stomach) on a distance of 50 sm. It is determined individually, but depends, in particular, on capacity of the UV-lamp.The definition of a biodoze on a dermal integuments is carried out by biodosimeter “BD-2”.  It Is a metal plate with 6 rectangular apertures opening during an irradiation with an interval in 10 seconds. In result a skin in the first aperture is irradiated 60 s. and in the last 10. In 24 hours on threshold erythema е establish a biodoze equal to time of an irradiation of a skin in seconds above that aperture in which the skin for the first time clearly turns pink (for shortest time of an irradiation)

Distinguish small erythermal dozes (1-2 biodozes), average (3-4), big (5-8) and hypererythermal е (over 8 biodozes). Large hypererythermal  biodozes nominate basically  at some local irradiations of a skin.

To UV-therapy  apply sources of long-wave radiation (320-400 nM), integrated (280-380 nM ) and short-wave radiation(180-280 nM ) For the general influence apply sources of  LUV-and IUV-rays. For local – mainly all three kinds of rays . Besides,IUV-rays are  used for treatment of diseases of mucous membranes and for disinfecting air in the closed premises(rooms) and water. SUV-rays are  applied also to a ultra-violet irradiation of blood in special devices. At the general influence irradiate serially forward and back surfaces of a body of the patient. Three circuits of the general UV-irradiation  are accepted:

The basic, accelerated and slowed down. Thus daily irradiations begin according to 1/4,1/2 go 1/8 biodozes and gradually lead up to 3-4 biodozes. Course of treatment – 15-25 days.

Within the frame of preoperative preparation of patients the courses of  general suberythermal and weak erythermal an irradiation are carred out  during 6-8 days

Local procedures of the UV-irradiation carry out on a skin and mucous membranes. Sensitivity of mucous membranes to UV-radiation is determined on a method of In.N.Tcachenko  by means of biodosimeter “BUV-1”. It represents a plate with 4 apertures which put on on radiographic cone of ultrasonic head posed compactly above a  papilla , where sensitivity of a skin comes nearer to sensitivity of mucous membranes. Apertures of a plate open on one with an interval in 30 seconds, and a biodoze determine in 12-24 hours.

The irradiation of mucous membranes begins with 1-1,5 biodozes and gradual increasing by 0,5-1 biodozes lead up to 3 biodozes. On a course  – 5-6 procedures.

Local irradiation of a skin by UV-rays begin  with 1,5-2 biodozes. The same site 3-6 times with an interval in 1-3 days, raising a dosage on each subsequent procedure on 0,25-1 biodoze Probably irradiate allocation of several fields of an irradiation and then procedures will carry out daily, but on different fields.

 

Ultraviolet Light Administration

Procedures

Ultraviolet radiation treatment space should be private and temperature-con­trolled, because bare skin exposure is necessary. Absorption of ultraviolet radiation by oxygen in the air may result in ozone gas accumulation. Therefore, adequate ventilation in the treatment area is necessary. Depending on the desired effect, the physician may prescribe generalized exposure (mild intensity radiation for a wide spread or generalized condition); a regional exposure (one or more body parts are targeted at one time while the nontreated parts are covered with a towel or drape); or a contact exposure (directed to a focal area, such as a wound).

Careful documentation of details of the ultraviolet treatment is required. His­tory of past exposure to ultraviolet radiation and the erythema response is impor­tant. History of recent use or exposure to photosensitizing substances should be obtained. If more than one lamp exists in the department, the specific lamp used for the treatment should be documented as should the specific distance between the lamp and the patient. The type (generalized, regional, direct), time, and angle of exposure; response of the skin and the patient, and use of medications and top­ical substances after exposure should be noted.

Equipment

Early electric ultraviolet lamps were made of carbon arc electrodes. These were followed by mercury vapor lamps, and by the early twentieth century, by quartz lamps which are quartz tubes filled with argon gas and liquid mercury. Some quartz lamps, known as “hot quartz lamps,” are now rarely used in PM&R settings. These lamps are high pressure, high temperature, mercury-filled and air cooled. Hot quartz lamps produce ultraviolet radiation in both the near and far bands. Hot quartz lamps can be used when generalized exposure is needed or for more focused regional exposure of a body part.

Other so-called cold quartz lamps are low-temperature, low-pressure, mercury-filled lamps. Cold quartz lamps are much more common and have the advantages of being smaller, more portable, usually hand-held devices. Cold quartz lamps emit 90% of their ultraviolet rays in the 253.7-nm (bactericidal) band, and they are typ­ically used to treat skin ulcers and other focal cutaneous conditions.

Only qualified professionals should operate ultraviolet therapy equipment. All equipment should be accurately calibrated on a regular basis and visually inspected daily. Regular servicing by qualified technicians should be performed at least every 6 months.

Precautions

Because the cornea and retina are very sensitive to ultraviolet light, the eyes of the patient and the therapist or UV lamp operator should always be shielded with ultraviolet-opaque goggles. Exposed areas of skin, particularly prominent body parts that are not intended for treatment, should be covered during ultraviolet therapy sessions. Several substances are known to have photosensitizing proper­ties, and patient consumption of these substances should be avoided prior to ultraviolet light exposure. This includes foods such as strawberries and shellfish and medicines such as insulin, quinine, sulfonamides, certain diuretics, hormones, and oral contraceptives. Exposure following intake of these substances may result in potentiation of the effects or side effects of the ultraviolet light exposure, alter­ation of the effect of the medication, or both. Patients should be questioned about contact with or use of these substances before ultraviolet light therapy.

Extra caution should be used in persons with very fair or atrophic skin because the relative absence of pigment or the relatively reduced skin thickness will result in decreased reflection, increased absorption, and relatively increased intensity. This effectively increases the risk of adverse effects. Because the risk of energy absorption and tissue injury could be additive, ultraviolet light therapy should be avoided immediately after application of superficial heating modalities. In general, elderly patients, infants, and chemotherapy patients have low tolerance for ultraviolet light therapy. This physical agent should be used sparingly with these special patient populations.

Clinical Applications for Ultraviolet Light

Currently, the main clinical application in the rehabilitation setting for ultraviolet light therapy is in the treatment of pressure ulcers of the skin and other wounds. The desirable effects of ultraviolet light that aid wound healing have been studied using UV-A, UV-B, and UV-C. These effects include increasing epithelial turnover, epidermal hyperplasia, and fibroblast activity, which accelerate wound closure. The release of prostaglandin precursors, which may mediate cell proliferation, and histamine, which increases cutaneous blood flow and accelerated DNA synthesis, further assists the wound healing process. The shorter wavelength (180-250 nm) UV-C directly applied using a hand-held cold quartz lamp is the most common method used for treatment of wounds. The bactericidal effect of UV-C inactivates bacteria to further promote healing. This property of ultraviolet light is particularly useful when treating chronically colonized or infected wounds. In a recent in-vitro study, UV-C has been shown to inhibit growth of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Entero-coccus faecalis (VRE). Despite emerging evidence supporting its effectiveness, the use of ultraviolet light for wound healing in the rehabilitation setting appears to be decreasing. This may be due to the availability of other alternative treatments, such as topical antibiotics and dressings, and the actual or perceived expense of equipment or time associated with ultraviolet therapy.

Several other conditions have been treated with ultraviolet light, though uncommonly by the physiatrist or in the rehabilitation setting.

Psoriasis. This is perhaps the skin condition most commonly treated with ultraviolet radiation. Literature support for the treatment of psoriasis is well established. Treatment is accomplished with ultraviolet radiation either alone or in combination with additive photosensitizing substances, such as tar-based topical ointments or ingested psoralen drugs. Two established anti-psoriatic treatment techniques are known by the acronyms TUVAB (Tar and UV-A and UV-B) and PUVA (Pso-ralen + UV-A). In the TUVAB protocol, a coal tar ointment is applied to the affected area, then removed, followed by UV-A and UV-B exposure at 4 MED, increasing daily by 2 MEDs. In the PUVA protocol, the patient ingests psoralen prior to UV-A exposure. Because of some safety and side effects concerns, the PUVA protocol is indicated in only select cases.

Acne Vulgaris. Ultraviolet radiation has been used to promote superficial desquamation in patients with acne vulgaris.

Neonatal Jaundice. Exposure to ultraviolet radiation has been used to prevent the development of jaundice in term and premature neonates.

LASER THERAPY

Laser therapy is another example of a therapeutic technology that currently is not widely used by physiatrists or in the rehabilitation setting. However, unlike ultraviolet therapy, which has been used clinically for over 100 years, laser tech­nology is still relatively new (40 years old) and actively expanding, and the clinical use of lasers is growing. An extensive review of laser technology is beyond the scope of this chapter, but the reader is referred to a fairly recent review of this topic for further reading.

The word laser is an acronym for light amplification by stimulated emission radi­ation. The use of lasers for surgical cutting and cauterization is very familiar to most clinicians. Another type of laser with more potential applications in the PM&R setting is the low-intensity laser. This type of laser is also referred to as the “cold,” “low power,” or “low level” laser. Laser is a form of light or radiation from another part of the same electromagnetic spectrum as ultraviolet light. Lasers characteristically produce light that is monochromatic (each laser device emits a beam of only one wavelength), coherent (waves travel in highly-ordered, parallel waves), and polarized. Like other forms of radiation, laser energy can be transmitted, reflected, or absorbed by tissue. High-intensity laser radiation has output power in excess of 60-75 milliwatts (mW) which is accompanied by tissue damage and thermal effects. In contrast, low intensity laser has output power that typically is <0.5-l .0 mW. At such a low power, low-intensity laser beams are undetectable and not associated with any significant tissue temperature changes. Accordingly, low-intensity laser radiation works by initiating athermic photochemical reactions within cells. These reactions occur with extremely small power intensities.

The most commonly used low-intensity lasers are produced by helium-neon (HeNe), gallium arsenide (GaAs), and gallium aluminum arsenide (GaAlAs) devices. Typical wavelengths of low-intensity laser therapy using HeNe, GaAs, and GaAlAs are 632.8 nm, 904 nm, and 820 or 830 nm, respectively. A variety of delivery systems, treatment approaches, application techniques, and waveform options exist, and all of these variables may affect treatment results.

 

                                           

 

 

 

 

The reported clinical effects of low-intensity laser radiation include marked improvements in wound healing, nerve repair, musculoskeletal pain, and various inflammatory processes. Although several related studies have been conducted and literature support for low-intensity laser therapy is growing,

 

THERAPEUTIC ULTRASOUND

Physical Properties of Ultrasound

Ultrasound is mechanical radiant energy derived from the application of an electric current on a crystal, which results in a vibratory motion. This motion is then applied to particles of the medium, through which it travels in the frequency range beyond the upper limits of sound perception. See Table 1 for the various applications of ultrasound energy. The human ear is capable of perceiving sound frequencies between 16 Hz and 20,000 Hz. Sound with a frequency greater than 20,000 Hz is called ultrasound. As the frequency increases from a given sound source, the sound beam diverges less. Audible sounds tend to spread in all directions, whereas ultrasound beams with their higher frequency are well collimated, similar to the light beam emerging from a flashlight. As a result, ultrasound beams at typical treatment frequencies are sufficiently collimated to selectively sonicate a limited target area for a physical therapy treatment.

As the ultrasound beam travels through the treated tissue, its energy decreases secondary to absorption and scattering, which is collectively referred to as attenuation. Scattering refers to the deflection of sound out of the beam that occurs when the sound contacts a reflecting medium, whereas absorption refers to the conversion of the mechanical energy of an ultrasonic wave into heat. Tissues with high collagen and protein content will absorb large amounts of the ultrasound energy and thus are more reactive to ultrasound energy. For instance, bone and cartilage, which have a high collagen content, absorb most of the ultrasound energy, whereas skin and fat will absorb minimal ultrasound energy owing to their low collagen content.

Absorption occurs partly because of the internal friction in tissue that needs to be overcome in the passage of sound. The higher the frequency, the more rapidly the molecules are forced to move against this friction. Attenuation, or weakening, of the sound beam occurs as the energy is absorbed, resulting in less available energy to propagate further to the deeper tissue. At frequencies greater than 20 MHz, superficial absorption predominates because less than 1% of the energy passes through the first centimeter. A frequency of 1.0 MHz is commonly used for physical therapy treatments because it offers an adequate compromise between depth of penetration of the ultrasound energy and heating of tissue. Many ultrasound units are also equipped to provide sonication at frequencies of 3 MHz for treatment of superficial tissues.

Sound waves that are produced by ultrasound units are either continuous or pulsed. A continuous wave is one in which the sound wave intensity remains the unchanged, whereas a pulsed wave is intermittently interrupted. Pulsed waves are further classified by specifying the fraction of time the sound is present over one pulse period. This fraction is called the duty cycle and is calculated by using the following equation:

Duty cycle = duration of pulse (on time)/pulse period (total cycle time) Most ultrasound units have the capability to adjust their duty cycle, ranging from 0.05 (5%) to 0.5 (50%), with the most common duty cycle being 20%.

 

Intensity and Effective Radiating Area

Another factor that effects ultrasound conduction is intensity. Intensity refers to the strength of the ultrasound beam or, in other terms, the rate at which the ultrasound energy is delivered per unit area. Intensity is typically expressed in terms of watts per centimeter squared (W/cm²). If all other variables are left constant, increases in intensity will result in increases in tissue temperature. The measurement of intensity is made by dividing the total power output (in watts) of the ultrasound applicator by the area (in square centimeters) of the ultrasound head or applicator, also known as the effective radiating area (ERA). The ERA is determined by using an underwater microphone (acoustic hydrophone) that scans the transducer at a distance of 5 mm from the radiating surface and records all the areas in excess of 5% of the maximum power output found at any location on the surface of the transducer. The ERA is always smaller than the transducer surface. Common ERA measurements found on ultrasound heads are 0.5 and 5 cm² . However, it should be noted that the ultrasound beam is not truly homogeneous under the ERA, which creates relative hot spots. Therefore, the intensity measurement is typically an average intensity and is also referred to as the spatial average intensity. The relative hot spots where the greatest intensity can be found are referred to as the spatial peak intensity and should be known by the therapist.

Apparatus Sonopuls 434

 

Ultrasound head

 

To ensure that these relative hot spots do not cause tissue damage to the sonicated area by exposing any one area to high intensity ultrasound energy, the therapist must use a moving applicator technique.

The term beam nonuniformity ratio (BNR) is used to describe the homogeneity of the ultrasound beam and is measured as the ratio of peak intensity to average intensity. The greater the ratio difference of the BNR, the less homogeneous the ultrasound beam, resulting in the above-mentioned hot spots. For example, if an ultrasound beam has a 7:1 BNR with a desired intensity of 1.0 W/cm², the true intensity could be as high as 7 W/cm². A desirable BNR should be as low as possible, between 2 and 6 W/cm². In the United States, ultrasound units made after 1979 are required by the Food and Drug Administration to have labels indicating the BNR.

One must consider other variables of intensity when using pulsed or interrupted ultrasound. When the pulse is off, the intensity will be zero, and when it is on, the intensity will be at its peak. This maximum intensity is referred to as the temporal peak intensity, or the pulse average intensity. The temporal average intensity measures the average intensity over the entire pulse period, including both the on and off times. For example, a pulsed beam of 1.5 W/cm² with a duty cycle of 50% would have a temporal average intensity of 0.75 W/cm² (1.5W/cm² X 0.5 = 0.75 W/cm²). By manipulating the duty cycle, the amount of energy delivered to the treatment area can be controlled, even though the temporal peak intensity is held constant. This method can be used to ensure less heating of the tissues when a nonthermal effect of ultrasound is desired.

When documenting an ultrasound treatment, the therapist must clearly specify the ultrasound variables used, including frequency, intensity, duty cycle, total duration of treatment, and location of treatment with anatomic landmarks. For example, 1 MHz / 1.0 W/cm² / pulsed 20% / 7 minutes / to the R subacromial space. When using continuous ultrasound, one must include the frequency, the spatial average intensity, the continuous wave, the duration, and treatment area, for example, 1 MHz / 2.0 W/cm² / cont / 5 min to the lumbar spine, left of L5.

Spatial average intensities used for therapeutic purposes range from 0.25 to 2.0 W/cm². The World Health Organization limits the spatial average intensity to 3.0 W/cm².

Generation of Ultrasound through the Piezoelectric Effect

As mentioned, ultrasound is derived from an oscillating electrical current applied to a crystal, typically synthetic crystals such as barium titanate or lead zirconate titanate (PZT), causing the crystal to expand or contract. These crystals are said to possess the property of piezoelectricity. There are two types of the piezoelectric effect: direct and reverse (indirect). The direct piezoelectric effect is the generation of an electric voltage across a crystal when the crystal is compressed. If the crystal is expanded, a voltage of opposite polarity is induced. A sound wave that contacts the crystal will cause the crystal to expand and contract at the same frequency of the sound wave and, in turn, will induce an oscillating voltage across the crystal surface. This direct piezoelectric effect is used for converting ultrasound into an electric signal that replicates the sound pattern, which can then be processed and analyzed.

The reverse piezoelectric effect is die contraction and expansion of the crystal in response to an electrical current applied to the crystal surface. An alternating current causes the crystal to vibrate at die frequency of the electrical oscillation. In this manner, ultrasound can be generated at any desired frequency. The ultrasound crystal is consequendy referred to as a transducer, because it converts electrical energy into sound energy. The crystals are sliced into thin, fragile wafers, approximately 2-3 mm thick, and then placed in an applicator to protect them. The entire applicator is commonly referred to as the transducer or the ultrasound head. A coaxial cable connects the ultrasound head to the console, where the various ultrasound parameters can be adjusted to die desired settings.

Biophysical Effects

The biophysical effects produced by ultrasound can be grouped into two categories:

1.    Thermal—effects produced by ultrasound elevadng tissue temperature

2. Nonthermal—effects believed to be caused by mechanisms other than tissue temperature elevation

The mechanism of some of the biophysical changes that are produced by ultra­sound may be thermal, nonthermal, or a combination of both. Many responses to ultrasound, such as pain reduction, are poorly understood and their mechanisms are purely speculative.

Thermal Effects

Therapeutic ultrasound has been used extensively for its thermal effects to elevate tissue temperatures approximately 5 cm or more. Typically, the thermal effects are used for the treatment of subacute or chronic inflammation, muscle spasm, pain, and stretching of collagenous tissue contracture. The physiologic responses attributed to a thermal mechanism include increase in collagen tissue extensibility, alterations in blood flow, changes ierve conduction velocity producing a decreased sensitivity of the neural elements, increase in pain threshold, increased enzymatic activity, and changes in the contractile activity of skeletal muscle.

In order to achieve ultrasound’s thermal benefits, specific tissue temperatures must be reached. Based on studies by Lehman and Lehman et al. an increase of 1°C (mild heating) accelerated metabolic rate in healing tissue. An increase of 2-3°C (moderate heating) reduces muscle spasm, pain, and chronic inflammation, and increases blood flow. More vigorous heating (> 4°C) decreases viscoelastic properties and inhibits sympathetic activity.

As discussed, ultrasound attenuation or absorption and the consequent tissue temperature elevation are frequency dependent. At 3.0 MHz, the majority of the ultrasound energy is absorbed at depths less than 2.5 cm, whereas at 1.0 MHz, tissue temperature elevation can be measured up to 5 cm. Therefore, when treat­ing relatively superficial injuries such as tennis elbow or ankle sprains, a 3-MHz set­ting is preferred. Another consideration when using different frequencies is the rate at which the tissue temperature is elevated. Draper and colleagues found that, at 3 MHz, the heating rate is three times faster than at 1 MHz, which may support the use of shorter duration of treatment times when using 3 MHz.

Ultrasound can be used to selectively heat periarticular structures and the muscle at the muscle bone interface. Intensities of 1.0-2.0 W/cm³ with treatment times of 5-10 minutes were required to elevate the tissue temperature higher than 4°C to allow significant stretching of tendons when a stretch was applied while the tendon was at an elevated temperature.

When attempting to increase the tissue temperature, one must also consider the possibility of blood flow-induced cooling and tissue thermal conduction that may reduce thermal efficiency. A baseline threshold ultrasound intensity and duration is required to overcome this cool down, which may be significantly different than the standard treatment time of 5 minutes at 1.5 W/cm².

When the primary goal of a treatment is to increase the blood flow, ultrasound is thought to create a mild inflammatory response. However, the research is mixed. It does appear that treatment times and intensities that produce the desired result of increased blood flow are far larger than what is clinically performed. Treatment times of 10-20 minutes at intensities greater than 2 W/cm², continuous wave, 1 MHz showed increases in blood flow and skeletal muscle temperature. Without these duration and intensity levels, the blood flow increases were inconsistent or nonexistent.The pain threshold has also been shown to be increased by elevating tissue tem­perature from ultrasound at 0.8 MHz, continuous wave, at 1.5 W/cm². This is what is commonly expected when using thermal agents for tissue temperature elevation and may also help reduce muscle spasm.

 

  

 

Nonthermal Effects

When ultrasound is used with a pulsed duty cycle, the thermal effects are minimized. Pulsed ultrasound at 20% is commonly used to achieve nonthermal effects or “healing” effects, effects that cannot be explained by a thermal mechanism. Note that if one were to use 20% pulsed ultrasound and increase the duration five fold, one may achieve thermal heating, as if continuous ultrasound were used. These nonthermal effects include cavitation, acoustic streaming, microstreaming, and chemical reactions. The effects of nonthermal ultrasound are numerous, including increases in cell membrane permeability and diffusion; increases in intracellular Ca²⁺; mast cell degranulation; histamine and chemotactic factor release; increases in rate of protein synthesis and fibroblast stimulation leading to increased collagen synthesis and strength; changes electrical activity iervous tissue; increases in enzymatic activity; and increases in angiogenesis.

Cavitation refers to various kinds of sonically generated activity of gas or vapor-filled bubbles. The vibrational effect of ultrasound can cause expansion or con­traction of gas bubbles that may be found in tissue fluid or blood. This cavitation may be stable or transient, having the potential to cause tissue damage. If the bubbles are in the field pulse, with a limited change in overall amplitude, stable cavitation is thought to occur, which is thought to result in diffusional changes along the cell membrane, consequently altering cell function. Transient or unstable cavitation refers to the violent collapse of bubbles within the tissue fluid or blood, resulting in tissue destruction and possibly blood vessel damage, with the safe range for peak intensity to prevent unstable cavitation being < 8 W/cm².

Acoustic streaming is thought to be another mechanism that causes nonthermal effects of ultrasound. Acoustic streaming refers to the steady flow of cellular fluids along the cell membrane induced by ultrasonic pulses or waves. Consequent changes in ion fluxes across the cell membrane and resultant changes in cellular activity are thought to occur. Noted increases in cell membrane and vascular permeability have been found withiormal treatment intensities with ultrasound.

Similar to acoustic steaming, microstreaming refers to microscale eddying that takes place near any small vibrating objects, such as gas bubbles, that have been set into oscillation by a sound field, but appear to have a more adverse effect. This process affects cells more directly, causing cell lysis, alteration of cellular function, degradation of DNA, and inactivation of certain enzymes.

Indications and Contraindications

Ultrasound is commonly used in rehabilitation for a variety of musculoskeletal dysfunctions including muscle spasms and pain, joint contractures, bursitis and tendinitis, neurofibromas, and pain following sprains and strains . There has been increased popularity of the use of ultrasound for wounds, both open and closed, and bone healing. Other uses of ultrasound include treatment of plantar

Indications of Ultrasound

Muscle spasm

Pain from immobilization, rheumatic processes, degenerative joint disease, trauma

Joint contracture

Bursitis

Tendinitis

Neurofibromas

Plantar warts

Scar tissue remodeling

Wound healing

Tendon healing

Bone healing

Transdermal drug delivery

 

Contraindications of Ultrasound

Over the eye

Over open spinal cord (e.g., s/p laminectomy)

Over the heart, over pacemakers

Areas of malignancies or suspected malignancies

Thrombophlebitis

Over pregnant uterus

 

Ultrasound Applications Warranting Special Caution

Over areas of epiphysis of growing bone in children Areas of vascular insufficiency Areas of dysthesia, hypothesia Areas with pins (surgically implanted) Areas with glue and artificial joints warts, remodeling of scar tissue, and noninvasive techniques to allow transdermal drug delivery Copious amounts of research are reported on the clinical applications for ultrasound; however, much of the results present contradictory conclusions.

Although there is contradictory information regarding the efficacy of ultrasound, the contraindications of ultrasound are less ambiguous. Ultrasound should not be used over the eye because temperature elevations at the poorly vascularized lens can lead to cataract production. Sonication over the spinal column was once contraindicated, but researchers now know that the bones surrounding the spinal cord prevent the ultrasound beam from reaching the neural tissue. However, irradiation over an open spinal cord (e.g., pt. s/p laminectomy) is contraindicated because the spinal cord is not protected.

Ultrasound performed over the heart should also be avoided, because there is evidence of electrocardiographic (ECG) changes, namely ST-segment elevation, following application of ultrasound. Furthermore, as with electrical modalities, care must be taken to avoid ultrasound exposure to the heart of persons with car­diac pacemakers because the ultrasound beam may interfere with the electrical cir­cuitry of the pacemaker.

It is commonly known that ultrasound should not be used on malignant tissue or in areas where malignancies may be located. It has been suggested that ultra­sound has the potential of increasing cellular detachment, resulting in the possi­bility of metastasis. If there is any uncertainty about whether an area has some malignant tissue based on the patient’s past medical history and clinical signs, it is best to avoid ultrasound. This same principle applies to areas of thrombophlebitis, in which a thrombus could be released.

Under no circumstances should ultrasound be used over the pregnant uterus. Temperature elevation in fetuses has been shown to result in low birth weight, brain size reduction, and orthopedic deformities in guinea pigs. It is probably best to avoid ultrasound over the low back and abdominal region of women during their reproductive years, unless reassured by the patient that there is no chance of her being pregnant. In men, ultrasound should be avoided over the testes because it may produce temporary sterility.

Ultrasound over areas of epiphysis of growing bone in children should be used with caution, although it is believed that therapeutic levels of ultrasound are safe. However, there is evidence of retardation of bone growth at intensities greater than 3.0 W/cm² and using a stationary transducer.

Similar to heating pads and cold packs, caution must be taken when using ultrasound on poorly vascularized areas or areas of impaired temperature or pain sen­sation. Poor vascularization, as in patients Reynard’s syndrome, may result in overheating of the tissue because of inadequate heat dissipation. Patients with reduced sensation may be unable to detect pain or changes in temperature, increasing their risk of injury from ultrasound.

When treating patients with metal implants or pins, ultrasound can be safely incorporated into the treatment if the moving transducer technique is used. However, most of the materials used for joint replacements have high-density polyethylene components and use methyl methacrylate cement, which have not been thoroughly tested for safety or integrity in response to ultrasound sonication.

Tissue Healing

Ultrasound has been proposed as a treatment to facilitate the healing of tissues. It is used in the treatment of many types of tissue injuries ranging from tendon injuries to open wounds. Numerous articles have been written on ultrasound’s effect on tissue healing; however, the ultrasound parameters vary considerably among the studies. Furthermore, it is difficult to study tissue healing because of the complexity of the healing process and because there are many steps in the healing process for which the regulatory mechanisms are still undefined.

Since the late 1960s, Dyson and associates at Guy’s Hospital in London have con­ducted numerous studies on pulsed, low-intensity ultrasound at 3 MHz on the heal­ing of skin lesions. In 1968, Dysooted accelerated healing of lesions in the ears of rabbits with TIW treatments. In 1978, chronic varicose ulcers were treated with TIW ultrasound for a month. Those treated with ultrasound had a significant reduction in ulcer size (66% of the original size) compared with the control group that received mock ultrasound (92% of original size) . A later study demonstrated increased protein synthesis of fibroblasts in vitro and in vivo.

Fyfe et al. studied the vascular permeability and release of histamine in rats fol­lowing one treatment of ultrasound at the ankle. Histologic sections showed increased degranulation of mast cells. Also, evaluation of the leakage of a dye from the blood indicated that ultrasound induced an increase in vascular permeability.In 1988, Dyson continued her work with another study using low-intensity, pulsed ultrasound showing increased calcium transport in fibroblast cell membranes in culture. Later in 1990, ultrasound was used to treat skin lesions in rats, with daily ultrasound treatments for 5 days. Results showed increased blood vessels per area of granulation tissue, increased granulation tissue, fewer polymorphonuclear (PMN) leukocytes and macrophages, and more fibroblasts.

The study of ultrasound’s effect on tendon and ligament has evolved from the work of Dyson et al. In most of these studies, ultrasound intensities are higher (1.5 W/cm²), frequencies are 1.0 MHz, and duty cycle is either pulsed or continuous. Roberts et al. showed potential harmful effects of ultrasound after treating induced lesions of forepaw flexor profundus tendons in rabbits. Ultrasound was used 5 days/week through a window in the splint that was used to protect the lesion. Treatment interfered with healing, demonstrated by the fact that the breaking strength of all ultrasound treated tendons was 0 newtons (N), whereas the nontreated tendon strength was 1 N. Later, Stevenson and colleagues studied the effect of ultrasound (3 MHz, 0.75 W/cm² X 20 days starting 4 weeks after surgery) on surgically repaired profundus tendons in chickens. After 6 weeks of treatment, there was no difference in the tensile strength of the tendons between the treated and control groups; however, it was reported that the treated chickens were able to flex their toes better than the control group. Enwemeka treated surgical repairs of rabbit Achilles tendons with daily ultrasound for 9 days beginning the day after surgery. Exposure to ultrasound induced significant increases in the tensile strength and energy absorption capacity of the tendons. Furthermore, Jackson et al. admin­istered ultrasound to the Achilles tendon lesions in rats daily for 8 days, then four times a day until sacrifice at 15 or 21 days. Collagen synthesis and tendon breaking strength were both increased in the sonicated group.

The healing of muscle and nerve injury has also been studied. In 1989, Gillett et al reported that continuous ultrasound at 1.5 W/cm² every 12 hours following injection of lidocaine into the anterior tibialis resulted in an accelerated rise in the activity of the muscle enzyme ornithine decarboxylase (ODC) and a subsequent decrease in the activity by 48 hours after injury (ODC activity is an index of cell proliferation and differentiation). This study supports the theory that ultrasound accelerates early inflammation and repair. Hong et al. studied the effects of ultrasound on crushed tibial nerves in rats. They used continuous ultrasound at 0.5 or 1.0 W/cm² TIW for 35 days beginning 5 days after injury. The recovery rates of motor nerve con­duction velocities and the amplitude of the evoked compound muscle action potentials (measured by electromyography [EMG]) were faster when ultrasound was used at 0.5 W/cm², but the recovery rate was slower with the group treated at 1.5 W/cm².

Recent interest has developed in the potential role of ultrasound to facilitate heal­ing in fractures. However, in the past, ultrasound was thought to interfere with the healing process of fractures or the break up of calcified tissue. Early studies by Dyson indicated that pulsed ultrasound at 0.5 W/cm² performed four times per week would accelerate the repair process during the inflammatory and early proliferative phases of repair. More recent studies by Heckman and Kristiansen reported acceleration of tibial and Colles’ fractures in humans. Treatments were begun within 7 days of fracture and given through windows in the cast. Frequencies around 1.5 W/cm², intensities of 30 mW/cm², and durations of 20 minutes were used.

In summary, ultrasound can facilitate healing in several ways. Probably the most important effect of ultrasound is its ability to increase oxygen delivery to the wound. In addition, it is thought that ultrasound can increase collagen deposition and protein synthesis, which is enabled by the piezoelectric effect. Other factors include increased mast cell degranulation (initiating vasodilation), increased blood flow to the wound, and the possibility of decreased infection, which may be related to increasing oxygen.

Other Commonly Treated Conditions

Joint contractures due to trauma, immobilization, surgery, or even insidious onset, as is frequently found in cases of adhesive capsulitis of the shoulder (frozen shoulder), are commonly treated in physical therapy. The restricted joint motion can be the result of degenerative arthritis, muscle tone, or cartilage dysfunction. If motion is restricted by periarticular connective tissue changes, ultrasound may be of benefit. As described in the section on thermal effects of ultrasound, ultrasound can be used to heat these collagen tissues to allow increased extensibility of tissues. It is important to note that ultrasound alone will not cause increased range of motion (ROM); stretching during or after the application of ultrasound is required. One component of joint contractures may be scar tissue, which can also be heated and stretched because of the high collagen content of scars. To achieve the necessary temperature increases in the selected tissue, the intensities must be of sufficient energy (> 1.0 W/cm²), the time of treatment sufficient (typically > 7 minutes), and the treatment area small enough to allow selective sonication.

Research on the effect of ultrasound on bursitis and tendinitis is mixed, with some studies showing enhanced recovery with ultrasound. However, most studies tend to show litde statistically significant benefit of ultrasound, although ultrasound is commonly used to treat these conditions.

Treatment Considerations

Although some conditions (e.g., plantar warts) were treated in the past with a stationary ultrasound applicator, the consensus today calls for the moving applicator technique. The stationary technique has beeoted to cause hot spots that can be responsible for stasis of blood flow, venular endothelial damage, and platelet aggregation, in addition potential tissue damage. By moving the applicator at the recommended speed of approximately 4 cm/second, the ultrasound energy is distributed evenly throughout the sonicated tissue.

To ensure tiiat die ultrasound energy is transmitted from the applicator to the treated tissue, a coupling agent must be used. This approach ensures that the ultrasound energy is not totally reflected at die air-tissue interface before it even reaches die dssue and will eliminate “overheating” of die ultrasound crystal owing to die fact that ultrasound waves are unable to travel dirough air. The objecdve of the coupling agent is to eliminate as much air as possible between the applicator and tissue to ensure maximal energy entering the selected tissue. Most commercially available ultrasound gels are adequate. For patient comfort, it is best to preheat die gel slighdy.

 

When sonicating irregular, bony surfaces, several options exist to ensure proper coupling. Some ultrasound units have the capability to switch sound heads, which allows the therapist to use a smaller sound head . This method can ensure more direct contact with the tissue being treated. Another option, which can work well with open wounds to minimize trauma from contact with the applicator, is the use of a closed rubber balloon filled with water The balloon is placed between the applicator and the tissue being treated with ultrasound gel at the skin-balloon and balloon-applicator interfaces. Another option when treating a distal extremity is to immerse the extremity to be treated in a basin filled with water

 

Treatment by ultrasound with

 the help of water

 

The ultrasound head should be held 0.5-3.0 cm from the skin, using the moving ultrasound technique. To ensure proper coupling, accumulated air bubbles on the patient’s skin and applicator head should be wiped off. If it is available, a plastic or rubber basin should be used instead of a metal basin because some of the ultrasound energy will be reflected off the metal, potentially increasing the intensity in treated areas near the metal.

When determining the intensity for an ultrasound treatment, consideration must be made to the desired effect of ultrasound and the tissue or condition being treated  For treatment of chronic disorders, vigorous heating may be desired. To ensure maximal heating, Lehman recommended turning the intensity up until the patient senses a dull ache, and then decreasing the intensity slightly below pain threshold. In areas of deep soft tissue, such as in the hip and back, intensities greater than 1.5 W/cm² may be required. In areas of thin, soft tissue with bony prominences, it may be prudent to reduce the intensity to 0.5-1.0 W/cm² and use a 3-MHz frequency.

As noted, a smaller sized applicator may be desired; however, special considerations need to be made. Because of the size of the sound head (ERA), there is a reduced amount of ultrasonic energy emitted from the applicator head. For instance, if the size of the applicator head is 5 cm², it will emit half the amount of energy as a 10 cm² head at the same intensity. Therefore, to ensure an adequate dose with the smaller sound head, the therapist may be required to double the treatment time.

Another consideration when using ultrasound is to ensure proper maintenance of the ultrasound unit. Units should be checked annually for homogeneity of the beam shape (measured by the BNR) to reduce the risk of hot spots, intensity, and power. The transducer assembly should also be checked periodically for water tightness because this part is prone to deterioration. All electrical components should also be checked periodically, including the cable assembly. These tests are typically performed in a biomedical instrumentation department.

Controversies Concerning Ultrasound

Although the effects and mechanisms of ultrasound are not clearly understood, ultrasound is a widely used modality in rehabilitation. The use of ultrasound tends to be based on empirical experience, although the research on ultrasound provides contradictory information. Recent work by Gam and van der Windt involved extensive reviews of the research on ultrasound in the treatment of musculoskele-tal disorders. Much of the research was found to be lacking information regarding the description of drop-outs, randomization methods, ultrasound apparatus, sham-ultrasound apparatus, control of apparatus, mode of delivery, size of sound head, treated area, and treatment time. In research studies that could be statistically analyzed, there was little evidence to support the use of ultrasound in the treatment of musculoskeletal disorders. It is clear that further well-designed research studies need to be conducted to clearly justify the use of ultrasound and to determine the appropriate parameters that should be used for common dysfunctions.

Summary

Therapeutic ultrasound is one of the most common modalities used in rehabil­itation today. Ultrasound can generate acoustic energy capable of affecting tissues to depths of 5 cm, either through its thermal or nonthermal effects. Ultrasound can be used to treat a variety of musculoskeletal disorders by elevating the pain threshold, increasing collagen extensibility, increasing oxygenation and blood flow to tissues, increasing cell membrane permeability, enhancing transdermal drug delivery, and facilitating tissue healing.

Although numerous studies have been performed on ultrasound, the benefits of ultrasound are not clearly justified secondary to contradictory research. Aggressive research with properly designed studies needs to be performed to improve our ability to offer effective treatment. Ultimately, these research studies not only will empower therapists to more carefully match treatment variables with specific musculoskeletal disorders but also should encourage therapists to stop using treatment procedures that are not effective.

PHONOPHORESIS

Phonophoresis may be defined as ultrasonic energy used to enhance skin permeability, allowing uncharged or charged molecules of drugs into dermal tissues. Ultrasound refers to sound waves with frequencies beyond the human audible range of 20 kHz. High-frequency waves in the 800-1000-kHz range are generated by applying alternating current to a crystal, usually quartz or silicone dioxide. Through a phenomenon known as the piezoelectric effect, the electric current causes the crystal to undergo rhythmic deformation producing ultrasonic vibrations. The vibrations are hen transferred through a coupling medium to tissue surface. In phonophoresis, the coupling agent (water or gel) is replaced with the drug to be delivered. Phonophoresis can thus be used as a transdermal drug delivery system.

Historical Background

In 1954, Fellinger and Schmid first reported use of phonophoresis to enhance drug delivery in treatment of arthritis using hydrocortisone ointment. In 1963, Griffin and Touchstone used cortisol to demonstrate percutaneous penetration into paravertebral nerve and skeletal muscle. Hydrocortisone has been used successfully for treatment of sprains, strains, tendinitis, bursitis, and epicondylitis.

Mechanism of Action

Phonophoresis is different from simple ultrasound therapy in that the drug is delivered to deep tissue by ultrasound energy and the clinical effect is associated with the pharmacologic effect of the drug. The exact mechanism of action of phonophoresis is still unknown, but several theories hold that ultrasound may cause intracellular diffusion from high-speed vibration of drug molecules along with vibration of the cell membrane and its components. Other theories involve the cavitation effect of ultrasound. Cavitation may cause mechanical stress. Tem­perature elevation or enhanced chemical reactivity causes drug transport. Brown suggested that ultrasound increased cell permeability and drug absorption by raising skin temperature. Increased tissue permeability has been attributed to mechanical “stirring” and increased pore size. Other studies suggest that changes in stratum corneum lipid structure enhance percutaneous absorption.

Applications of Phonophoresis

Transcutaneous drug delivery through use of topically applied agents is a well-known treatment for conditions such as angina, hypertension, motion sickness, and local musculoskeletal injuries. Anti-inflammatory agents and local anesthetics have been used to treat pain and inflammation. Steroid phonophoresis generally has been used in conditions for which steroid injection is considered. Advantages of using phonophoresis over injections include:

1. The method of delivery is noninvasive.

2. There is little or no systemic absorption, minimizing the risk of hepatic and
renal injury from drug elimination. Studies that substantiate this finding doc­
ument absence  of dexamethasone,  hydrocortisone,  and  salicylates  after
phonophoresis in humans.

3. Patient comfort is increased.

4. Drug delivery can be terminated rapidly through termination of ultrasound.

5. There is a low risk of infection when used on intact skin.

6. Delivery of selected drugs is enhanced.

Phonophoresis should be limited or is contraindicated in the following conditions:

1. Broken skin surface and skin infections

2. Allergy to the drug used for phonophoresis

3. Conditions with reduced temperature and light touch sensation

4. Peripheral vascular diseases

5. Malignancies

6. Pregnancy

7. Presence of cemented prosthesis

8. Weak and unstable joints

9. Presence of keloid or exuberant scar formation

Equipment

Performance of phonophoresis requires an ultrasound machine that is AC pow­ered, has two or more frequencies of operation, and has outputs that are easily adjusted. The treatment head is sized to treat irregular body surfaces and has a transducer that senses poor coupling. There is total contact between the gel and transducer that is constantly moved at a rate of 1 inch per second. The pulsed mode of ultrasound is preferred to minimize thermal injury. The usual treatment dose is 1.0-1.5 watts/cm² for 5 minutes.

 

            

 

Review of Drugs Used for Treatment of Musculoskeletal Conditions

The most frequendy used and most studied drug for phonophoresis in musculoskeletal conditions is hydrocortisone. Ten percent hydrocortisone has been shown to be more effective than 1 % hydrocortisone in the treatment of humeral epicondylitis, subdeltoid bursitis, and bicipital tendinitis. Byl and associates studied the effects of phonophoresis with corticosteroids on collagen deposition in pigs under controlled conditions. Collagen activity, as measured by level of hydrox-yproline, showed decreased levels in the subcutaneous tissues but not in the sub-muscular or tendinous tissue. This highlights the limitations of phonophoresis for conditions deeper than subcutaneous tissue. This observation was substantiated by Muir and colleagues, who studied phonophoresis of hydrocortisone in canine knees. Compared with intra-articular steroid injection, phonophoresis was shown to be ineffective in delivering the hydrocortisone into the knees. However, phonophoresis has been shown to be superior to ultrasound alone using 10 % cor-tisol solution in the hind leg joints of dogs. Because of the potential for adverse effects, systemic effects of hydrocortisone phonophoresis have been studied. Ten percent hydrocortisone did not appear to suppress adrenal function in patients who received phonophoresis with dexamethasone every other day for 2 weeks over the shoulder area. Similarly, no increase in blood levels of cortisol was found in a blinded study of healthy human volunteers who received 1.0 watts/cm² ultrasound treatment using either 10 % hydrocortisone gel or Aquasonic gel for a total of two treatments, 1 week apart. Many PT clinics use dexamethasone in Aquasonic V₃% gel. There are many anecdotal reports of benefits in using this for treating lateral epicondylitis. To date, there is no clear scientific data available to verify which medication or dose of medication works best and how much of the active ingredient is actually absorbed. Oziomek and associates, who studied effects of phonophoresis on serum salicylate level, suggest that phonophoresis is substrate specific. Topical application of salicylates with and without use of ultrasound resulted io increase in serum salicylate level. Thus, they concluded that perhaps no appreciable absorption of salicylates occurred in subdermal tissues. A double-blind study by Benson et al. using benzydamine, a nonsteroidal anti-inflammatory drug for phonophoresis, also found no percutaneous absorption.

Summary

 Phonophoresis as a modality for transdermal drug delivery in the treatment of selected musculoskeletal disorders appears to be useful. Inflammatory conditions such as tendinitis bursitis and epicondylitis are some of the conditions that have been successfully treated, and phonophoresis could be considered a viable modality before the use of invasive procedures such as surgery or injections.

 

Superficial Heating Modalities

The use of superficial heat for therapeutic effects has a long history. It has been used in the form of dry heat such as the sun, heating pads, or water bottles, and wet heat, such as hot baths and saunas. Conditions for which heat has been used include pain relief, general relaxation, decreasing spasms, and improving range of motion (ROM). Superficial heat modalities, which are a form of thermotherapy, include hot packs, heating pads, paraffin baths, fluidotherapy, hydrotherapy, and infrared lamps.

Regardless of the type of superficial heat modality, certain characteristics are common to all forms. Superficial heat modalities have maximum temperature elevations at depths of approximately 1 cm. This is a result of the limitation of penetration only to the skin and subcutaneous tissue. If deeper heat penetration is desired, for example, into muscles or deep joint capsules, then an alternative modality must be considered such as ultrasound.

Superficial heat modalities are considered to be an adjunctive treatment to be used in conjunction with other treatments including ROM, stretching, and exercise in order to achieve an appropriate beneficial response. For example, if the treating physician provides only analgesics and therapeutic modalities to treat an athlete’s symptoms (e.g., pain, swelling, or stiffness), the athlete will not be able to return to activity safely or effectively.

The determination in selecting and administering superficial heat modalities is multifactorial and requires an understanding of the patient, the condition being treated, and the characteristics and limitations of the modality. For example, the effect of superficial heating is a result of a direct influence on local tissues as well as an indirect effect on deeper and distal tissues. An understanding of direct and indirect effects of heat is necessary to choose the appropriate modality for treatment. Another factor to consider is that body habitus influences the modality selected in that subcutaneous adipose tissue affects the depth of penetration of many modalities. Adipose tissue has a lower conductivity, which limits the ability of heat to penetrate through the subcutaneous layer. Also, in selecting a modality, one must realize that there are a few well-designed clinical trials demonstrating the efficacy of specific modalities to specific conditions.

METHODS OF HEAT TRANSFER

Heat is transferred from one source to another source from one of three methods: conduction, convection, or conversion.

Conduction is the transfer of thermal energy between two bodies in direct con­tact. The transfer of heat occurs when there is a difference in temperature between the two objects. As the temperature increases in the colder object, the energy and, subsequently, the heat decreases in the warmer object unless there is a constant input of energy into the warmer object such as an electrical heating pad. Examples of conduction include heating pads, hot packs, and paraffin baths.

Convection is the transfer of heat between two objects of different temperature that are in direct contact with one another but one of the objects is flowing relative to the other object. The temperature gradient is maximized in this condition, which produces a higher intensity of heating. Examples of convection include whirlpools and fluidotherapy.

Conversion is the transfer of heat by the conversion of energy such as sound waves and infrared rays to heat and is dependent on the resistive properties of the material. An example of conversion is infrared lamps.

INDICATIONS

Analgesia

Analgesia is a frequent indication for the use of superficial heat modalities (Table 1). Although the direct effect of heat from a superficial modality is limited to the skin and subcutaneous tissue, the indirect effect of heat on pain modulation may relate to more complex mechanisms of impairment to nerve impulses from reaching the higher central pain centers. Inhibition of the pain impulses as described by the gate theory is one possible mechanism. Large alpha-beta fibers, carrying afferent impulses to the substantia gelatinosa in the dorsal horn of the spinal cord, inhibit the ability of A-delta and C fibers from fully conducting to synapses. The pain-generated impulses are blocked from reaching higher level sen­sory pain centers, thereby providing an analgesic effect.

On et al. investigated the analgesic effect of local superficial heating following a painful electrical stimulus. Sympathetic skin response amplitudes decreased significantly following local heating and did not return to their initial levels within 15 minutes after the heat application was stopped. The analgesic effect may have been due to suppression of cortical pain sensation from increased levels of endorphins, as well as local inhibition of afferent C fibers.

Additional studies have postulated a more direct effect of superficial heat on pain modulation. The application of infrared radiation over the ulnar nerve at the elbow in human subjects demonstrated an analgesic effect of the distal arm in the area supplied by the nerve. Also, when the modality was applied to the skin, demonstrated an increase in pain threshold was demonstrated. These effects were thought to be due to temporary conduction block.

Spasticity

Spasticity can occur from various causes. Spasticity as a result of direct injury to muscles or tendons can occur from overuse injuries or direct trauma. Muscle spasms may also occur as a result of a guarding mechanism to protect associated structures. For example, a lumbar disk herniation may produce spasms in the lumbar paravertebral musculature to restrict back motion and prevent further injury. The sustained contractions of the muscles produce pain, inducing further muscle spasms. This results in a spasm-pain-spasm cycle. Superficial modalities are used as an adjunct treatment to disrupt the cycle, allow resolution of the muscle spasm, and improve pain control. The mechanisms by which this may occur are not clearly understood. However, many patients find that heat has an overall relaxing quality that contributes to the decrease in spasticity.

One study showed that the application of heat decreased frequency of impulses along the gamma motor neurons. The efferent gamma motor neurons innervate the muscle spindles, which are involved with the stretch reflex arc. Decreasing gamma efferent impulses diminishes the stretch reflex and subsequently decreases alpha motor activity. The result is muscle relaxation.

Fountain and associates evaluated the effect of ultrasound, hot packs, and infrared radiation on static forces of the neck in patients with poliomyelitis. They found that a decrease of resistance in passive lateral flexion of the neck musculature and, therefore, a decrease in spasticity, with each of the three modalities. The effect of the modalities remained 15 minutes after the application of the modalities had ceased.

Hyperemia

Superficial heating has been demonstrated to produce hemodynamic changes. Heat produces a local vasodilator response in the superficial blood vessels that dissipates the heat away from the area. It has been demonstrated that forearm blood flow may increase threefold following treatment with hydrotherapy at a temperature of 45°C. Correlating with the increased blood flow is an increase in metabolism. In the acute inflammatory stage, this may have deleterious effects because it can lead to increased edema and hemorrhage. However, in the chronic inflammatory stage, heat can assist with the resolution of inflammation from the vasodilatation effects by increasing nutrients, antibodies, and leukocytes and clearing metabolic elements.

Range of Motion and Stretching

Although superficial heat modalities have a limited depth of penetration into tissue, in areas where there is little adipose tissue or soft tissue covering, such as the hands and feet, application of heat is beneficial for ROM and stretching exercises owing to the effect on soft tissue. Several studies have evaluated the effect of heat on soft tissues.

An evaluation of the extensibility of a rat tail tendon under conditions of stretching, heat, and combination of heat and stretching simultaneously showed that extensibility was maximized with heat and stretching combination. Additional studies have demonstrated that the extensibility of tendons can be maintained after elongation with the combination of heat and stretching simultaneously when the stretching is continued during the cool-down period. The experimental find­ings suggest that the use of heating modalities in conjunction with physical therapy increases extensibility of collagen tissues including tendons and joint capsules and reinforces the notion that superficial heating modalities should be used in conjunction with other therapies to improve therapeutic response. Wright and colleagues demonstrated the effect of superficial heat applied to the metacarpophalangeal joint. They showed that heating the surface temperature to 45°C by an infrared lamp produced a 20 percent decrease in stiffness in the joint compared with the stiffness at 33°C.

CONTRAINDICATIONS

There are several conditions in which the treating provider must not use heat thermotherapy as a form of treatment . Acute injuries, hemorrhage, and acute inflammation are contraindicated due to the vasodynamic effects of heat. In the initial stages of an acute injury, heat will exacerbate the condition by increasing edema and hematoma formation from the increase in blood flow and increased endothelial lining permeability. This ultimately will impair the healing process.

Processes in which hemorrhage is of concern should not be treated with heat due to the increase in blood flow with heat therapy. This includes persons who have bleeding disorders, such as hemophilia, or whom have chronic atrophic skin changes associated with prolonged steroid use that may result in increased friability of the capillary system.

The application of heat in an area of ischemia is contraindicated because metabolic demands are increased as a result of the application of heat and may exceed the supply that can be provided through the impaired vasculature system. This can lead to infarction of tissue. Also, burning of tissue can occur more readily in ischemic areas as the rate of destruction exceeds the ability of the body to supply the necessary elements to repair the tissue. The risk of burn formation also increases, because heat will accumulate when the arterial inefficiency prevents ade­quate shunting of heat away from the heated area.

Areas that are insensate should not be treated with the application of heat, because the ability to receive pain feedback is impaired. The patient’s ability to report excessive heat depends on intact receptors and pain pathways. Heat and pain fibers begin firing at approximately 43-45°C, and tissue damage can begin at 45°C. The inability to sense heat and pain prevents the treating provider and the patient from knowing when the safe levels of pain threshold have been exceeded. This factor increases the risk of burns. Patients with spinal cord injuries may receive heat application above the level of injury provided the sensation is normal. When there is uncertainty about the intactness of the sensation in the area to be treated with the application of heat, formal temperature testing using warm and cold objects as well as pinprick sensation should be assessed before the application of any heat process.

Localized areas of malignancy including metastasis are contraindicated because the heat and subsequent increase in metabolic activity may increase the growth of the tumor. Also, theoretically the increase in blood flow may increase the likelihood of metastasis.

Heat therapy is contraindicated in conditions that impair a patient’s ability to communicate or respond to pain, such as dementia, delirium, or other forms of cognition impairments. Again, the inability to identify correctly when the pain threshold has been exceeded and adequately convey this information to the treating provider increases the risk of burns to tissue.

THERAPEUTIC AGENTS

The response of tissue to heat is dependent on several factors: the intensity of the heat, the duration of the heat, and the area treated. The therapeutic range of temperature is typically between 40°C and 45°C. Between 45°C and 50°C, the rate at which burns occur doubles for every 1° increase. The duration for superficial modalities is typically limited to 20-30 minutes. Temperatures reach a maximum after 3-5 minutes, and beyond 30 minutes, there is no significant increase in blood flow. Frequency is dependent on the condition treated and the patient response to therapy. If the patient has not had relief with a trial of 10 treatments or approximately 2-3 weeks, then a different therapeutic approach should be considered. As a general precaution, repeated and prolong skin exposure to heat has been shown to result in erythema ab igne, a skin condition of brown mottled pigmentation and telangiectasia.

 

FANGOTHERAPY (Pelotherapy)

Silt sulphidic and peat muds are widely used in resort and others medical establishments of Ukraine. The mechanism of their action is connected to thermal and physical and chemical effects.

 

 

Mud preparation  (“Mud Kitchen”)

 

The hydrogen sulfide, trace substances and organic substances of muds during procedures will penetrate through a skin and mucosas into an organism, having medical an effect. Under influence of warm and hot mud procedures the permeability of tissues raises, amplify blood circulation and a metabolism, processes of an angenesis are activated. Antibiotic substances of muds have antiseptic an effect. Adequate on temperature and durations mud procedures normalize activity of various organs: joints, a liver, a stomach, an intestine, kidneys, female and man’s sexual sphere, nervous system.

 

Medical effects: improvement of central bood circulation and microcirculation, anti-inflammatory, resorptional, desensitizing, stimulating an angenesis, аnalgetic, normalizing function.

Medical muds are applied mainly at stages of regenerative treatment, and also at chronic diseases.

 

The basic indications

1. Illnesses of a locomotorium: an arthritis, an arthrosis, a polyarthritis, a polyarthrosis, myalgia,  myositis,  an osteomyelitis,  tuberculosis  of bones and joints, consequences of traumas of a backbone, joints, bones, muscles, tendons, an osteochondrosis of a backbone.

2. Illnesses of nervous system: a neuralgia, a neuropathy, a radicular set of symptoms, a polyneuropathy, consequences of an encephalitis, a myelitis, a poliomyelitis, traumas head and a spinal cord, peripheric nervous system.

3. Gynecologic illnesses: a vulvovaginitis, peri-and parametritis, salpingo-oophoritis, a hypoactivity of sexual glands, initial and secondary barreness, consequences of operation on female sexual 0rgans concerning inflammatory processes.

4. Diseases of Ear, Throat and Nose: a chronic frontal sinusitis, maxillary sinusitis, ethmoiditis, rhinitis, tonsillitis, laryngitis, pharyngitis, mastoiditis, neuritis of acoustical nerves.

5. Internal diseases:  chronic bronchitis, gastritis, hepatitis, ulcer of vetricule and duodenum, gastroenteritis, pyelonephritis.

6. Fresh scar-adhesive and sclerosing processes.

 

The basic contraindications to a fangotherapy

1. Septic and feverish conditions.

2. All kinds of tumours and illnesses of a white blood, a polycythemia.

3. Local purulent processes.

4. Various diseases in a phase of an exacerbation.

5. Ischemic Heart Disease with often attacks of a stenocardia or with a stenocardia of a strain.

6. An idiopathic hypertensia of II and III stages.

7. A cirrhosis of a liver, a nephrosclerosis.

8. Cardiovascular failure.

 

The basic methods of a fangotherapy:

mud baths, applications, compresses, tampons (vaginal, rectal), a fangotherapy a method of solar heating, electromud procedures, ultraphonoforesis with  a medical mud.

In drugstores there are mud medicinal preparations (extracts): Peloidinum, pelodistillate, FIBS (Filatov’s Biological Stimulator), Gumisolum etc. they, however, in the greater measure concern to therapy by biostimulators than to a fangotherapy.

 

The basic mud health resorts of Ukraine:

Berdyansk, Evpatoria, Saky, Кujalnik, Slavyansk. On them are used silt sulphidic muds. On large balneal health resorts: Мyrgorod, Моrshyn, Truskavets, Chmelnik – is applied, mainly, peat muds.

Hot Packs

Hot packs consist of silica beads or gel encased in a canvas pack The silica can absorb several times its volume in water. Hot packs come in a variety of shapes and sizes, allowing them to be customized to fit the area to be treated, including the low back and cervical regions . Because the heat source is not  constantly applied to the hot packs, the heat dissipates quickly as it transfers from the hot packs to the body part.

 

The packs are immersed in hot water tanks overnight to allow them to absorb moisture and heat. The packs are heated to a temperature of 70-80°C. The hot packs are removed from the water tanks and wrapped in six to twelve layers of towels. Some hot pack manufacturers supply terry cloth cases, providing the equivalent of three to six layers of toweling. Because of the high heat of the packs when they are removed from the water, they must be wrapped to prevent burns of the skin. The more towels applied, the greater the decrease in conduction between the hot pack and the skin and, therefore, less elevation in skin temperature. Typically, the elevation in skin temperature ranges from 37.8°C to 46.1°C.

 

Hot packs should not be placed under the patient. This can increase the risk of burns by the increased extraction of water from the packs. Patients who cannot tolerate the weight of the hot packs can be placed on their side with the pack draped over the treatment area so the amount of direct weight on patients is minimized. Otherwise alternative heating applications should be considered.

The patient’s skin should be checked at 5-minute intervals to assess for signs of excessive heat exposure such as mottling of the skin. The duration of treatment is 20-30 minutes. After treatment, the packs should be return to the tank for 30 minutes before initiating the next treatment.

An advantage of the hot pack is that it is usable where other modalities such as water immersion cannot reach, for example, the neck region. A disadvantage of the hot pack is that some people cannot tolerate the weight of the pack.

 

Paraffin Baths

Paraffin baths are another form of conductive heat transfer. Paraffin, which typically melts at 54.5°C, stays liquid with a melting point of 47.8°C when mixed with mineral oil.

 

Preparing process of paraffin and ozocerite are providing in a special room.

 

 Mixing the wax with the mineral oil results in a substance with a lower specific heat, which allows patients to tolerate a much higher temperature than water therapy. The therapeutic temperatures of paraffin baths are typically 48-54°C.

 

The melt paraffin сould be save in a special container.

 

 

Therapeutic effects are typically for decreasing pain or to increase soft tissue extensibility. It is used primarily for the distal extremities including the hands and feet. Although temperature penetration is limited to approximately 1 cm, in the distal extremities, this typically is sufficient.

Paraffin mixture is commercially available and is mixed in a ratio of 6:1 or 7:1 of wax to mineral oil. The mixture is heated in plastic or stainless steel tanks . The units have built-in heating thermometers, which are set to a temperature of 45-57°C. Before treatment the extremity must be cleaned to prevent bacterial build-up at the bottom of the paraffin bath, which may occur over time with repetitive use.

 

There are three principal methods of applying liquid paraffin. In the dipping technique, the body part is repetitively dipped in the paraffin bath so that layers of paraffin are applied.

The first layer must completely cover the body part treated so that subsequent layers cannot get between the first layer and the skin. If this occurs, the heat will be prevented from dissipating, and a burn may occur. It is also important to instruct the patient not to move the fingers or foot because the paraffin may crack and compromise the protective barrier of the first layer. The body part is then removed from the paraffin and wrapped in plastic followed by a towel. This insulates the paraffin and produces a mild to moderate amount of heat.

The second technique involves submersion of a body part, particularly the hands and feet. With this technique, the body part is initially dipped and then removed. The initial layer solidifies against the cooler skin, forming a protective barrier from higher temperatures. The body part is then reimmersed and maintained submerged in the bath for 15 minutes. This method produces a higher temperature in the skin compared with the dipping technique.

 

The third technique involves brushing the paraffin on the desired body part with up to 10 coats. This is often done on areas of the body that are not conducive to dipping in the paraffin. This technique typically produces only slight increases in temperature. After completion of the treatment, the paraffin is then peeled off the skin.

An advantage of the paraffin bath is that it provides an even heat over irregularly shaped body areas, especially the hand, foot, and ankle region, reducing the risk of burns over the bony prominences. The disadvantage is that it is messy. Also, open wounds and infected wounds should not be immersed in a paraffin bath because heat can exacerbate the condition, and there is the risk of contamination to the tank and the wound.

Fluidotherapy

Fluidotherapy is a relatively new form of superficial heat therapy. The device has been in existence since the 1970s. Fluidotherapy is a form of dry heat, and the transfer of energy is by convection. Fine solid particles in the form of silica or cel­lulose such as corncob particles are heated and suspended in warm air that is forced through the particles. The properties of fluidotherapy are similar to liquid.

An evaluation of fluidotherapy compared with whirlpool and paraffin baths showed that heat absorption was greatest with fluidotherapy during a 15-minute treatment of the hand. The three methods were also compared using in vivo temperature measurements of the joint capsule in the hands and feet. The temperature rises were noted to be greatest with fluidotherapy.

The typical temperature range for the fluidotherapy can be varied depending on the setting of the air. Temperatures are usually between 38°C and 50.6°C, depending on the patient’s tolerance.

There are variations among the fluidotherapy units, with the smaller units able to accommodate distal extremities such as the hand and foot. Larger units can accom­modate proximal portions of the extremities including the thigh. The application of fluidotherapy initially involves removing all jewelry on the involved extremity. Open wounds should be protected with plastic covering to prevent particles from becom­ing embedded in die wound. The patient inserts the body part to be treated through a sleeve and into the unit. While the hand or foot is in the unit, exercises including stretching and ROM can be performed. The duration of the treatment is typically 15-20 minutes. On completion of the therapy, the unit is turned off and the patient removes as many particles are possible before removing the body part from the unit.

The advantage of fluidotherapy is that it is a dry heat with a lower specific heat, which allows higher temperatures to be used compared with hydrotherapy. In addi­tion, owing to the fluid nature, irregular body surfaces such as the hands and feet can achieve uniform temperature without increased risk of burns over bony promi­nences. Also, the patient is able to move the limb so that exercise can be per­formed simultaneously, which can produce an improved stretch compared to using heat alone or stretching alone.

Heating Pads

Heating pads typically come in two forms: electric and water filled. The electric heating pad generates heat from the flow of electrical current through wires in the pad, and the temperature is regulated by the control of the current flow. The water-filled pads generate heat by circulating water through tubing in the unit. Water-filled heating pads control temperature thermostatically, allowing for safer control compared to electric heating pads.

Heating pads are pliable, which allows them to be applied or wrapped around body surfaces that are curved, such as the leg and lumbar region. Unlike the hot pack, heating pads provide a continuous supply of heat. Heating pads are used frequently in the home setting and in institutions, particularly for pain relief and muscle spasms in the back and neck region. They are readily available from a variety of manufacturers and are used in an unsupervised setting. Therefore, in addition to the general precautions and contraindications for the use of heat modalities, the patient should be instructed on the proper use of a heating pad.

Injuries do occur with improper use of electric heating pads. Annually, the Consumer Product Safety Commission receives reports of an average of eight deaths from heating pads, mostly due to fires. Fires occur when the insulation breaks or becomes worn, allowing the electrical wires in the pad to ignite the material, or when the electric cords become cracked. Burns are another concern with electric heating pads. At the low setting of an electric heating pad, the temperature can reach 51°C. Also, at the lowest setting with a temperature of 42°C, second-degree burns can be produced in 12-20 hours. Patients should be instructed not to use heating pads for longer than 30 minutes. The heating pad should be placed over the body part, not underneath, because this will produce increased focal heating and trapping of heat, increasing the risk of developing a burn.

Gel Packs

Gel packs are another form of superficial heat modality that is available for home use. Gel packs are filled with a gelatinous material that can be frozen or heated. They are available from a variety of manufacturers and come in various shapes and sizes. The packs are heated by placing them in water that was previously boiled for 5-10 minutes or by placing them in the microwave for 30-60 seconds. The pack is then wrapped in a towel or insulated sleeve and applied to the body part for 20-30 minutes. The gel packs are convenient and simple to use, but the heat dissipates quickly from the pack.

CONCLUSION

Superficial heating modalities, when selected appropriately and used in conjunction with other treatment options including ROM, stretching, and exercise, can be an effect treatment option for various conditions. The treating provider’s understanding of the physiologic response to heat, pathophysiology of the condition to be treated, and response of the patient to the treatment are paramount to developing an appropriate treatment plan.

 

Cryotherapy

Cryotherapy, or cold therapy, has been used for centuries to treat many ail­ments. Superficial cooling is a basic tool for all rehabilitation practitioners owing to its simplicity, low cost, safety, and effectiveness. Most forms of cryotherapy are based on superficial cooling agents, with energy transfer occurring through conduction. Conduction involves the transfer of energy through direct contact. The cold surface (usually ice or other cold modality) extracts energy or heat from the warmer surface (usually skin). The larger the temperature difference between the two surfaces, the larger the drop in tissue temperature.

Although conduction is the primary mechanism of energy transfer in most cryotherapy techniques, exceptions to this rule exist. Vapocoolant spray extracts energy or heat through evaporation. As the liquid spray is emitted and comes in contact with the skin, it vaporizes, which requires heat or energy. The skin temperature drops as the spray is applied due to energy loss in the evaporative process.

Hydrotherapy is another exception to the conduction rule. The transfer of energy or heat through convection occurs during hydrotherapy. The temperature of the skin and underlying tissue drops as the cool water current passes by the warm skin extracting heat in an attempt to equalize the two temperatures.

MECHANISMS OF ACTION

Cold acts through several mechanisms to produce the desired therapeutic effects. First, cold results in immediate arteriole vasoconstriction, which decreases the delivery of blood to the cooled area. This occurs through sympathetic fibers and by a direct effect on the blood vessels. In addition, the use of cold can decrease the delivery of substances carried in the blood. Some of these agents may be undesirable vasoactive agents such as histamine. Without the delivery of large amounts of histamine, inflammation and fluid filtration are kept to a minimum.

Another substance that is retarded by cooling is cytochrome oxidase. This can cause mitochondrial damage; therefore, its decrease as a result of cooling can be beneficial in retarding secondary injury. The hunting response has been described as a delayed vasodilation of arterioles after cooling. This protects the peripheral tissues from cold induced damage.

Neuromuscular effects of cooling are well documented. The cooler the muscle, the slower the rate of firing. The site of the thermal effect is the sensory terminal itself. With cooling, the tendon jerk is diminished. This is due to the decreased tone of the muscle at the spindle level. The motor nerve fibers display prolonged twitch in both contraction and relaxation. The nerves demonstrate conduction slowing with cooling and effectively become blocked at the neuromuscular junction. As temperature decreases, the amplitude and duration of the motor unit end plate potentials increase, and the frequency of their firing decreases.

The peripheral nerves are affected by cryotherapy as well. The duration of action potential recovery is increased after cooling, and the action potential duration itself increases inversely as the temperature decreases. The rate of stimulation required to obtain fusion of the twitches to complete tetanus drops as the temperature decreases. The cooling effect on spasticity lasts long after application of ice (up to at least 30 minutes) .

The threshold at which patients experience pain has been found to be decreased with the use of cryotherapy. This is thought to be due to a direct effect of temperature reduction oerve fibers and receptors. The diminished sensitivity of the muscle-spindle afferent fibers to discharge may contribute to this decrease in pain and also to muscle spasms.

However, cryotherapy also causes some effects that may be less desirable, such as increased tissue and blood viscosity, which can result in decreased elasticity of the tissue and increased resistance to motion. This could hamper therapeutic efforts, because it becomes progressively more difficult to perform skilled motor tasks as cooling takes effect.

As cold compresses are applied, skin temperature drops first, then the subcutaneous adipose tissue temperature slowly decreases, the intra-articular region (syn-ovium) is cooled, and finally the rectal (core) temperature drops. As little as 5 minutes of cooling can produce a decrease in intra-articular temperature, and the decrease is linear until 30 minutes. Rewarming takes longer than 1 hour, perhaps because of vasoconstriction. Compared with compresses, ice baths cool superficial tissues faster and have a more dramatic cooling effect, but they exert a lesser effect in the deep tissues.

INDICATIONS

The most common indications for cryotherapy are:

•   To decrease muscle tone

•   To decrease spasticity in upper motor neuron lesions

•   To facilitate muscle contraction and muscle reeducation

•   To decrease bleeding

•   To decrease edema

•   To alleviate thermal burns

•   To increase pain threshold

•   To decrease inflammation

•   To decrease joint pain and edema

•   To decrease collagenolysis

•   To decrease synovial inflammation

In patients with increased muscle tone, application of cryotherapeutic agents have been shown to decrease tone and spasticity through reflex decreases in motor neuron activity and muscle spindle discharge. Not only does abnormal muscle tone diminish through the application of cryotherapy, but muscle strength and endurance increase, facilitating muscle re-education and contraction.

In an acute musculoskeletal injury, cold has been found to decrease bleeding, edema, and delivery of inflammatory cells. In addition, cryotherapy is believed to increase the pain threshold in both chronic and acute conditions through direct and indirect mechanisms. The pain receptors are impaired by old directly, and the reduction of spasticity, edema, and inflammation contribute to the relief of pain.

The use of cold has been shown to inhibit the development of burns, shorten healing time, and decrease severity of the burn. The more quickly the cold is applied after the initial burn, the better the therapeutic effects.

Cryotherapy may also decrease collagenolysis and synovial inflammation and, therefore, slow joint destruction in patients with rheumatoid arthritis.

PRECAUTIONS

Cryotherapy is contraindicated:

•   In areas with absence of sensation

•   In patients with cold hypersensitivity

•   In patients with arterial insufficiency

•   In patients with cryopathies, such cryoglobulinemia, paroxysmal cold hemo-
globinuria, and Raynaud’s phenomenon

Prolonged joint cooling with topical ice can lead to nerve palsy and extensive axonotmesis. Ulnar and peroneal nerve damage have been reported in the literature. To prevent these complications, avoid compression of nerves that lie relatively superficially, avoid the use of gel packs, which produce temperatures below freezing, and do not ice areas where patients may be insensate and unable to feel a cold “burn.”

The nerve injury thought to be caused by cold is likely a result of direct injury to the nerve membrane as well as secondary injury due to neural ischemia, edema, and suspension of axoplasmic transport. Some patients have been reported to have “hypersensitivity” to cold. The release of histamine or histamine-like substances causes cold urticaria. Symptoms include erythema, itching, and sweating. These cases are rare but do constitute a contraindication to cold therapy.

Additionally, patients with arterial insufficiency should not receive prolonged cold therapy because of the already compromised delivery of blood.

Additional precautions for the use of cold include cryopathies such as cryoglobulinemia, paroxysmal cold hemoglobinuria, and Raynaud’s phenomenon.

SPECIAL CONSIDERATIONS

The major component of vapocoolant spray, fluoromethane, is made of dichlorodifluoromethane and trichlorofluoromethane, both of which harm the environment by destroying ozone in the upper atmosphere. This product is still used in some locations and is still sold in the United States. However, it does require a medical prescription by a physician for use.

The amount of subcutaneous adipose tissue directly relates to the rate of temperature decrease when ice is applied and rewarming when ice is removed due to the depth of the tissue, poor conductivity, and insulatory characteristic. In practice, a client who has little adipose tissue will benefit from a 10-minute ice pack application, whereas a client with a greater adipose layer may require as much as a 30-minute cold pack application to receive benefit.

Cryotherapy can alter a client’s true range of motion (ROM) and strength. This can result in a skewed evaluation or re-evaluation. Ice increases the viscosity and decreases the elasticity of muscle and, therefore, can decrease the potential ROM for a given muscle. Clinically, measurements taken after cryotherapy is applied can appear more restricted than their actual values. Therefore, measurements should always be made before the application of cryotherapy. Performance can be diminished as well, and fine motor skills or activity involving full ROM may be impaired by the application of cryotherapy techniques.

Additional confounding occurs with strength measurements. Strength of a given muscle group appears to increase temporarily after cryotherapy. Thus, true strength measurements should be taken before cryotherapy. In addition, greater work can be accomplished after cryotherapy because the client may be able to per­form therapeutic exercise with greater weight than without cryotherapy. This factor needs to be taken into consideration when prescribing or directing thera­peutic exercises.

Ice is used to prevent inflammation in the first 24-48 hours after an acute injury. After that time, if swelling has been prevented, ice is to be discontinued because it can delay the healing process.

Ice immersion, chipped ice in a bag, ice massage, and applying frozen vegetables to the involved site are inexpensive and easy for the client to perform as part of his or her home exercise program.

CHOOSING A TYPE OF CRYOTHERAPY

The size and type of the area to be treated and time constraints are factors to consider when selecting a cryotherapeutic agent. A large treatment site requires a larger agent; therefore, a large commercial ice pack, chipped ice, or iced towel would be appropriate. Ice massage is used if a small region, such as a small muscle, tendon, or joint, is involved. If a distal extremity is involved, ice immersion is the treatment of choice. If time is limited and a muscle region is small, ice massage provides quicker results for cooling than an ice bag

METHOD OF ADMINISTRATION

Commercial Gel Ice Packs. Commercial gel ice packs are applied to the entire region with a layer of towels placed between the client’s skin and the pack  ryo For increased cooling effect, the towel is moistened with water and then placed on the treatment area and secured with a strap. The treatment time is 10-15 minutes, depending on the amount of adipose tissue.

Chipped Ice Bag. Scoop chipped ice into a plastic bag. To decrease the temper­ature more significantly, add one part water to three parts ice. Secure opening, and place on treatment site for 10-15 minutes.

Ice Massage. Water is frozen in paper cups, and the paper is partially peeled back to expose the ice. The therapist grasps the cup and rubs the ice in quick sweeping circular movements over the target area for 5-10 minutes . The patient should report analgesia of the region after the session.

Iced Towels. A towel that has been submerged in ice water or chipped ice is placed over the joint or muscle and secured with a strap . This is beneficial when performing the contract/relax method during therapeutic exercise. The towels will need to be reapplied throughout the session because the iced towels warm quickly. The duration of application is the duration of the exercise session.

Iced Bath Immersion. The muscle or joint to be treated is placed in a basin or a whirlpool filled with crushed ice and water at a temperature around 13(C-27°C for 10-20 minutes . The duration is dependent on the temperature: the lower the temperature, the shorter the duration of treatment. Immersion is beneficial when treating an extremity and circumferential cooling is needed.

Vapocoolant Spray (Fluoromethane). The glass bottle of vapocoolant spray is held with the nozzle down approximately 12-18 inches above the treatment site, so that the stream will directly contact the skin . Spray the site at a rate of 4 inches/second in one direction. Perform PROM while spraying and have the client perform active ROM immediately afterwards. The entire process can be repeated three to four times. Rewarm the skin manually or with a hot pack, if necessary.

Apparatus treatment  Uses a different apparatus, which provide a cryo effect.

 

Kryotur Beh IV

 

Cryoflow

 

Kryopalliknie

REIMBURSEMENT

At the time of this writing, Medicare, Medicaid, and most large insurance com­panies are not reimbursing providers for cryotherapy treatment. Many hospitals and clinics continue to provide this service to the client pro bono. Some clinicians may instruct clients to perform the ice treatment at home after their session is complete, because many types of cryotherapy are easy to perform independently and are inexpensive.

 

AQUATIC AND HYDROTHERAPY

History

Humans have used water for healing and spiritual rituals since ancient times. One of the earliest known instances were the hygeinic installations found in proto-Indian culture around 2400 B.C. There has also been mention of the use of the therapeutic properties of water in ancient Mesopotamia, Egypt, India, China, Rome, and Greece. Many religions including Judaism, Christianity, Hinduism, and Islam hold ceremonies involving water.

Medieval Europeans built religious structures around thermal springs such as the Benedictine Abbey at Pfaefers, Switzerland, erected around a.d. 740. Using thermal springs as their source, healing pools were built in Aachen and Baden-Baden, Germany; Bath, England; and Spa, Belgium. Some of these baths have evolved into the well-known European health resort spas of today.

Native Americans have long used hot air sweat lodges, followed by a cold plunge, for medical and spiritual purposes. English, Dutch, and French settlers built their settlements near some of these springs in the 1600s placing wooden tubs next to their stone huts for bathing. In the 1700s, John de Normandie and Benjamin Rush sought out colonial mineral springs to analyze their chemical and medicinal value. Thomas Jefferson built the Sweet Springs spa in West Virginia based on diagrams of ancient Roman baths.

The use of water’s therapeutic and healing properties gained popularity among the Western medical community in the 1800s. The American Medical Association (AMA) Committee on Sanitaria and Springs published their first report in 1880, classifying the nation’s 646 known springs and mineral water pools. Not long after this, Albert Charles Peale classified 2822 active therapeutic springs. One of the better-known larger thermal pools was constructed in Hot Springs, Arkansas, and at its peak in 1896, 19 spa doctors were working there. Together they collaborated to publish medical theories and cases in the Hot Springs Medical Journal

Until the beginning of the 20th century, spas and their pools had not often been used for therapeutic exercise. Charles LeRoy Lowman, who founded the Orthopedic Hospital for Children (now Rancho Los Amigos) in 1913, observed paralyzed patients exercising in a wooden tank at the Spaulding Hospital for Crippled Children in Chicago. Afterward, he returned to California and converted the hospital’s lily pond into two therapeutic pools. One was a fresh water pool used for therapy with patients who had been paralyzed or had poliomyelitis; the other pool contained saline water and was used to treat patients with infectious diseases.

PHYSICAL PROPERTIES OF WATER

Aquatic and hydrotherapy have evolved considerably in this century, taking advantage of increased knowledge of the physical properties of water and the phys-iologic responses of the human body to immersion. Much of this research came from the push to send man into space because water’s buoyancy made it the most convenient environment on earth in which to mimic the weightlessness found outside our atmosphere. Knowledge of the physical properties of water and the physiologic responses of patients when submerged is vital to the proper and safe treatment of patients in aquatic therapy.

Density, Specific Gravity, and Buoyancy

Density (represented by the Greek letter p is the ratio of a substance’s mass (m) to its volume (v) as stated in the formula: Density (p) = m/v.

As substances can exist in a solid, gaseous, or liquid state, density is temperature dependent.

 

Вtl 3000-ALL

 

The specific gravity of a substance is the ratio of the density of a substance to the density of water. Water’s specific gravity is defined as 1.00 at 4°C. The average human has a specific gravity of 0.974. Bone, muscles, connective tissue, and organs, which are considered lean body mass, have a specific gravity close to 1.10. Fat mass, which is essential body fat combined with fat in excess of essential needs, has a density of approximately 0.90.

Any object with a specific gravity less than 1.00 floats in water. This is explained by Archimedes’ Principle, which states that there is an upward force on any body, that is submersed that is equal to the volume of water it has displaced. Thus, the average human will be at floating equilibrium when 97.4% of his or her body’s volume has been submerged.

Buoyancy is the upward force generated by a liquid that enables submerged objects to have decreased apparent weight compared with their weight on land. Buoyancy acts opposite the force of gravity resulting in the off-loading benefit that the aquatic therapeutic environment offers. This decreased weight bearing can be measured in humans in relation to the level their body has been submersed

 

 

It is important to consider the center of gravity (COG) in relation to the center of buoyancy (COB) when working with patients in the water. The point where all force moments are in equilibrium is the COG. Similarly, the COB is defined as the center of all buoyancy force moments summating each body segment. Because the lower limbs of humans are denser than the chest, which contains the air-filled lungs, the COG and the COB are at different locations in the body. The COG is found slightly posterior to the midsagittal plane of the second sacral vertebra, and the COB is located in the midchest. Because the force of buoyancy opposes the force of gravity if these two centers are not maintained in alignment, a torque or rotational force can result, causing instability and the possibility of a weak dependent patient or a patient with paralysis being forced into a face down-position

Hydrostatic Pressure

Measured at a specific point, fluids exert an equal pressure in all directions. Water pressure or hydrostatic pressure (P) is measured in force (F) per unit area (A): P = F/A.

The pressure exerted by a fluid is proportional to the density of the fluid and its depth. The earth’s atmosphere also exerts pressure on water’s surface, adding to the force of hydrostatic pressure. Every foot depth of water exerts a pressure of 22.4 mmHg, so that at a depth of 4 feet, a pressure of 89.6 mmHg is experienced. This is much greater than the average venous or lymphatic pressure, and is slightly greater than the average diastolic pressure on land, allowing hydrostatic pressure to promote edema resolution.

 

 

Feet bath

 

 

Radon bath

 

 

Water Flow

The flow of water can be either laminar or streamline, resulting in a smooth flow with all layers at equal speed. As the speed of water flow increases, minor oscillations develop, creating uneven flow that disturbs the parallel alignment of the path of water and results in turbulence.

The molecular attraction of a fluid also contributes to resistance to movement through viscosity. This occurs through the internal friction of the fluid, resulting in a disruption or decrease in flow. Thus, the major factors in water motion are viscosity, turbulence, speed, fluid density, and if enclosed, the radius of the enclosure.

Drag

Objects moving in a fluid or water environment are subject to the force created by the turbulence that develops behind the moving object and is known as drag. Drag develops in two ways:

1.   Form drag, which provides an additional resistance to movement through
the water or fluid’s direction opposite that of the moving object

2.   Surface drag, which develops through friction between the boundary layer of
water or fluid and the moving object

The force of drag is dependent on the frontal area of the submersed object, its size, shape, velocity, and the coefficient of drag. Water is used as a therapeutic modality in all its forms: water, ice, and steam. The specific heat capacity of a substance is a measure of the energy that it has stored as heat. Water has a specific heat capacity of 1.00, which is much greater compared with that of air, which is 0.001. This allows water to store heat 1000 times more easily than an equal volume of air.

Water also is a superior conveyor of heat compared with air. Thermal energy transfer from heat occurs in three ways:

1.   Through conduction, which is a result of molecular collisions over a small distance

2.   Through convection, which is the result of the mass movement of large numbers of molecules over great distance

3.   Through radiation, which is the heat transfer resulting from electromagnetic wave transfer

Water conducts heat well, transferring heat 25 times faster than air. Water’s thermal conductivity and high specific heat allow it to retain and transfer heat to an immersed body part for therapeutic treatment.

THE PHYSIOLOGY OF IMMERSION

Circulatory System Effects

Venous and lymphatic pressure develop as a result of a vertical system of columns with valves to prevent backflow. Pressure within these systems varies depending on location, with the greatest pressures being found peripherally (~ 30 mm Hg) and the lowest at the right atrium (2 to -4 mmHg). These one way valves divide the columns into many shorter ones of decreased height in order to convey blood or lymph using lower pressure gradients.

When a human subject is immersed to the neck, the surrounding pressure of water causes an increase in venous pressure of- 14-18 mmHg, resulting in a pressure of ~ 14-17 mmHg at the right atrium. This increased venous pressure results in displacement of a large quantity of blood upward through the thighs, abdominal cavity vessels, great vessels of the chest, and finally into the heart. Overall, a 60% increase in

 

 

 

central blood volume is appreciated. Cardiac volume increases by ~ 30%, producing greater stretch of the myocardium. Increased stretch is a healthy response to increased blood filling and results in a greater force of contraction owing to the improved actin myosin filament relationship in the myocardium. This improved myocardial efficiency from greater cardiac filling consequently increases stroke volume and is known as Starling’s law. The average increase in stroke volume is ~ 35%, which is close to the exercise maximum for sedentary, decon-ditioned individuals on land and equivalent to ~ 71-100 ml/beat. Increased stroke volume (SV)  is a factor in increased cardiac output (CO), as seen in their relationship represented by the equation: CO = SV X HR (heart rate).

3. Schematic of cardiovascular changes following immersion. Changes in CO and heart rate are temperature dependent, with a 30% increase in CO seen at 30°C and 121% at 39°C. HR decreases 12-15 bpm at 25°C, and a 15% decrease is seen at thermoneutral temperatures. HR increases are experienced in warmer water, possibly due to decreased peripheral resistance at increased temperatures and increased vagal effects.

Pulmonary System Effects

Compression of the chest wall by water pressure results in altered respiratory function and an increase in the work of breathing after immersion. The rib cage shrinks approximately 10% when submersed, resulting in decreased lung volumes and expiratory flow rates and an increase in the time it takes to move air. Chest wall compliance is also reduced by water pressure resulting in an increase in pleural pressure from -1 to +1 mmHg. Overall, the water pressure on the chest is responsible for 25% of the greater work of breathing required after submersion to the neck.

The larger factor that accounts for the remaining 75% of the increased work of respiration after immersion results from the shift of blood to the thorax, which allows for less lung volume to be filled by air. Diffusion capacity, or the ability of the alveolar membrane to exchange gases, is also decreased slighdy after to-the-neck immersion reducing blood oxygen concentration. This occurs because the lung beds are overly distended with blood displaced from the abdomen and extremities. The overall result is a 60% increase in the work of breathing when immersed to the neck . The result is that water presents an outstanding workload challenge to the respiratory system beyond that found on land and is an excellent medium in which to train and increase the efficiency of breathing. However, consequendy, caution must be used with respiratory compromised patients and it is not recommended to allow a patient with a vital capacity of less than 1.0—1.5 L to participate in aquatic therapy.

Musculoskeletal System Effects

The compressive effects of water pressure and reflex regulation of blood vessel tone combine to increase blood flow after immersion. Research shows that most of the increased cardiac output is directed to skin and muscle. Resting baseline muscle blood flow on land has been measured at 1.8 ml/min/100 gm tissue compared with 4.1 ml/min/100 gm tissue after submersion up to the neck. The same research found tissue perfusion to increase 30% with submersion to heart level, an equivalent amount as cardiac output increase during immersion. In summary, increases in blood flow seen with immersion translate into increased metabolic waste removal, edema reduction, and increased oxygen delivery to muscle tissue.

 

 

Conditioning Effects

Cardiorespiratory conditioning can be accomplished in water with highly fit athletes and deconditioned patients. Deep water running with a buoyant vest and no ground contact has been found to be equal to running on land in highly fit subjects when training intensity and frequency are equal, allowing athletes to maintain their VO₂max in an unweighted environment after injury. This is also found with deconditioned subjects and can be accompanied by a decreased heart rate when the exer­cise is performed at lower temperatures. For deconditioned or geriatric patients, water’s supportive quality can also help to improve postural capabilities and bal ance, decreasing the risk of falls. Other studies also confirm the benefits of water exercise training in maintaining and improving cardiorespiratory performance in comparison to land. Thus, water provides an excellent and often superior alternative to training on land when decreased weight bearing on injured limbs or the ability to produce movement errors without suffering a fall are desired.

AQUATIC THERAPEUTIC EXERCISE

Indications

Throughout the history of hydrotherapy, forms of treatment consisted of more passive techniques, such as soaking in mineral springs. More recently, research has proven exercise to be an important component of a healthy lifestyle, and as a result, more active forms of aquatic therapy have developed.

Aquatic therapeutic exercise can prove beneficial in improving flexibility, range of motion (ROM), strength, balance, coordination and proprioception for patients with a variety of diagnoses. These diagnoses include, but are not limited to, rheumatic diseases, chronic pain, neurologic conditions, stable cardiorespiratory pathology, and injuries that necessitate decreased weight bearing such as sprains and fractures or after orthopedic surgeries

As with conventional land-based physical therapy, the ultimate goal is to discharge the patient with an independently performed exercise program in order to maintain strength, conditioning, and functional gains. In the case of aquatic exercise, the patient typically must locate a community swimming pool where he or she may continue the exercise program independently or join one of the many aquatic exercise classes sponsored by local gyms, YMCAs, and community pools. For many geriatric patients and patients suffering from rheumatic diseases, the Arthritis Foundation offers an excellent standardized aquatic exercise program with instructors who must be certified by the Arthritis Foundation and follow their protocol. It may be helpful for health-care practitioners to compile a list of community pools or programs in the patient’s area to provide him or her with a smoother transition to a pool in the community after discharge.

All aquatic therapy exercise programs must be initiated only after a complete evaluation of the patient by a licensed therapist. The patient’s program should include an on-land component, except in some cases in which reports of pain have made it impossible for the patient to perform any exercise outside of the pool. In those cases, the goal will still be to progress exercise eventually to land-based forms.

Aquatic Therapeutic Exercise Progression Cole et al. identified three scenarios for aquatic therapeutic exercise progression:

1.   Wet to dry transition. This begins with aquatic therapy and then transitions to a land-based exercise program. It is recommended when musculature chosen for strengthening and the associated joint(s) are affected by axial and compression
forces. An example would be after orthopedic surgeries, when weight bearing is decreased. Water-based exercise allows a more gradual return to full weight bear ing with progression to land-based activities as permitted by the referring physician’s protocol and as tolerated by the patient.

2.   Dry to wet transition. Therapy begins with a land-based program but resultsin aggravation of the patient’s condition. After the exacerbation has resolved andthe patient demonstrates sufficient strength and functional gains, the patient mayreturn to performance of a land-based exercise program.

3.   Wet only. Exclusive performance of aquatic therapeutic exercise is recommended only for those patients who cannot tolerate any form of land-based exercise or prefer to perform aquatic exercise only. These patients still should bereassessed periodically in the physical therapy clinic for functional gains resultingfrom their aquatic exercise program and the possibility of eventually toleratingsome form of out-of-pool exercise.

It is extremely important to consider that, because most patients will tolerate a greater amount of exercise earlier in water than on land, the patient risks overex-ertion and irritation of the injured body part during their first few sessions. Therefore, the therapist must monitor the new aquatic therapy patient closely, encouraging him or her to begin slowly and allow a comfortable level of exercise to develop initially. This is best accomplished through emphasizing gait and gentle ROM during the first few sessions, with a gradual progression to more strenuous aquatic exercise. The therapist must diligently record the types of exercise, duration or quantity of repetitions, and the intensity level (if equipment is used to increase resistance). This will assist the therapist and the patient through a smoother increase in intensity of the aquatic exercise program.

 

Aquatic Therapeutic Exercises

Six types of therapeutic aquatic exercise were identified by Genuario et al to create a well rounded program with the possibility for progression in difficulty.

1.    Water walking or slow jogging at varying depths, emphasizing normal gait

2.    Slow, gentle, rhythmic ROM and stretching to emphasize flexibility

3.    Vigorous movement with increased speed to increase strength and endurance

4.    Dynamic rhythmic movement or altering gait patterns to increase proprioception and improve balance and neuromuscular coordination

5.    Walking or running at increased speed at various depths to improve cardiorespiratory fitness and conditioning

6.    Swimming

The major determinants of resistance when exercising in the water are buoyancy, speed of movement, the resistance afforded by the water’s viscosity, and the surface area of the body parts, moving through the water. During aquatic exercise, buoyancy can assist, support, or resist movement, depending on the positioning of the patient and the limb(s) he or she is/are moving. If the extremity is moving toward the surface, as with shoulder abduction, the movement will be buoyancy assisted. When an extremity moves across the surface, as during horizontal shoulder abduction or adduction, the movement will be buoyancy supported. Resistance afforded by buoyancy can be encountered with movement away from the water’s surface as with shoulder extension, which begins with the arm resting on the surface of the water.

Because buoyancy acts in the direction opposite gravity, movement in buoyancy-resisted planes offers an interesting advantage over exercise performed outside the water. Conventional land-based strengthening ROM exercises are normally in planes against gravity, thus strengthening the antigravity musculature. However, water-based exercise can be used to strengthen gravity-assisted musculature while standing upright and without the use of pulleys or other exercise equipment. Through the use of buoyant equipment, such as foam hand buoys the force of buoyancy and the work of the musculature that is normally assisted by gravity is increased.

Stretching can be aided by buoyancy. Many patients find it more comfortable and effective to stretch soft tissue in a gravity free environment, allowing them to improve their kinesthetic sense and awareness of an injured body part. Stretch­ing should be performed after an initial warm-up session of walking for the safest, most comfortable, and effective results.

Aquatic Exercise Equipment

Exercise equipment may be used in the water to increase the resistance against movement by using objects that enlarge the surface area of the limb being moved or by using buoyant objects to work in buoyancy-assisted, supported, or resisted planes. There are many types of aquatic exercise equipment available. Examples include webbed gloves with or without weights, hand paddles with blades that may be adjusted in graded amounts to increase surface area. Foam dumbbells (hand buoys) or foot cuffs of varying sizes may be used to alter buoyancy .

Equipment can also be used to increase the buoyancy of the patient, such as flotation vest, long foam tubes (“noodles”) or belts similar to those worn on boats or for waterskiing. One device that may be used to assist with deep water exercise is the Aquajogger™. Buoyant equipment can prove helpful for patients who cannot tolerate full weight bearing. In addition to buoyant waist belts during deep water exercise the patient may also use buoyant hand buoys or foot cuffs until he or she can progress to a level at which less assistance is required to keep the head above water.

Masks and snorkels may be beneficial for performing a variety of swimming and exercise techniques in the prone position. Patients requiring cervical spine stabilization exercises may perform them using a mask and snorkel together with the assistance afforded by the buoyancy of the water.

Aquatic Therapy Contraindications and Precautions

Each facility needs to establish procedures regarding contraindications and precautions to ensure the safety of patients and staff. The aquatic environment is unique and requires specific procedures to be implemented. These procedures vary depending on the comfort and skill level of the health-care professional. Edu­cation of referring practitioners is extremely important to ensure that appropriate patients are referred who can safely participate in aquatic therapy.

Precautions

The aquatic environment is one with its own specific set of precautions and considerations. Following are areas to exercise caution and special handling at times. Patients with the following medical conditions or related care need not be excluded from aquatic therapy.

Urinary. Treatment of urinary problems includes the use of indwelling, exter­nal, or suprapubic catheters. Leg bags, sport bags, or bed bags may be worn in the water. Empty the collection bag before participation to avoid spills. Sports bags are smaller and more discreet, and can increase a patient’s comfort level but need to be emptied more frequendy.

 

Contraindications to Aquatic Therapy

1. Bowel or bladder incontinence

2.Open wounds, including IV sites

3.Uncontrolled seizures

4.Uncontrolled autonomic dysreflexia or blood pressure

5.Fever > 100°F within 24 hours

6.Tracheostomy

7.Infectious diseases. (HIV and hepatitis are not contraindicated. Observe universal precautions during aquatic activity)

8.Vital capacity of less than 1-1.5 L

9.Unstable angina or atrial fibrillationm

Bowel. Continence is important for sanitation and patient comfort. Colostomies may be worn in the water if they are secured properly and emptied before participation. A shirt or one-piece bathing suit may be worn to increase patient comfort. Consistent bowel programs for patients with spinal cord injuries is a necessity. There can be no episodes of incontinence between each scheduled program. Once a program results in incontinence, it may require a week to be re-established, during which time a patient will not be allowed to use the pool.

Menstruation. An internal collection device is required.

Open wounds. Superficial wounds must be covered with a waterproof dressing. Patients with open areas created by intravenous (IVs) or subclavian lines may participate as long as these are located on areas of the body that can be easily kept out of the water, such as the upper arm or neck. Some facilities permit patients with halo cervical stabilization devices to participate in aquatic therapy if the pin sites remain dry. Sheepskin liners on some vests can be changed after the session.

Orthotic Stabilization Devices. It is important to allow patients the freedom to participate in aquatic therapy without splints or braces. This may be the only environment where they can move freely without these devices. Orthotic stabilization devices that must be worn by patients and are permitted in the pool include soft collars, Philadelphia collars, Somi braces, Minerva braces, Aspen collars and thoracic lumbar sacral orthoses (TLSOs). After the aquatic session, these orthotics can be dried or patients can have an extra set of pads to replace wet ones after the session.

Autonomic Dysreflexia. Autonomic dysreflexia is a specific life-threatening medical condition that affects spinal cord-injured patients with lesions at T6 or above. Symptoms may include severe pounding headache, sweating, nausea, and blurred or spotted vision. Immediately loosen any restrictive clothing, check catheter tubing for obstruction, empty urine bags, and elevate the patient’s head. If symptoms persist, remove the patient from the pool and keep the head elevated. Seek medical assistance immediately if a cause is not identified. Facility policies must be established for treatment should this occur during an aquatic therapy session.

Respiratory Problems. Patients with respiratory compromise must have a mini­mum vital capacity of 1.0-1.5 L. These patients may experience shortness of breath in chest-deep water secondary to the effects of hydrostatic pressure. Patients requiring oxygen may participate in aquatic therapy using extension tubing with an oxygen cannister on deck. Patients with asthma who experience sudden changes in temperature in the aquatic environment may experience an asthma attack. Gradually introduce these patients into the water and be careful when exiting the pool that they do not become overly chilled. Refer to the previous section on hydrostatic pressure and pulmonary system effects for more information.

Thermoregulation. Many patients’ thermoregulatory systems are affected after injury or illness. Water and air temperatures need to be considered depending on the condition being treated. In therapeutic pools, with water temperature at 88°F or above, patients need to be monitored for overheating and dehydration. Drinking water must be available. Other patients may be susceptible to excessive chilling and need to be monitored for hypothermia during and after the aquatic session.

Circulatory. Immersion of patients in water above thermoneutral temperatures (98°F [36.5°C]) has been shown to accelerate heart rate and increase blood pressure. Patients with cardiac conditions must be approved by their physician before treatment.

Medical Conditions Exacerbated by Fatigue/Heat. Therapeutic water temperatures can cause fatigue in patients who are deconditioned or have a medical condition such as multiple sclerosis or Guillain-Barre syndrome. It is imperative that individuals with multiple sclerosis and Guillain-Barre syndrome be monitored closely during aquatic therapy. The patient’s energy level should be monitored before, during and after sessions. Begin therapeutic pool treatments with lower intensity workouts of shorter duration (~ 15 minutes initially). Increase the level of intensity and treatment length gradually. Many individuals with multiple sclerosis and Guillain-Barre syndrome can successfully participate and maximize the benefits of therapeutic aquatics if temperatures are monitored closely. If significant fatigue lasting more than 2 hours after the session is experienced, then aquatic therapy is not an appropriate modality for these individuals and should be discontinued.

Therapeutic Pool Selection and Maintenance

Ideally the therapeutic pool should allow a variety of depths so that buoyancy maybe varied depending on the patients’ needs. Water temperatures vary from 82-98°F, depending on the patient population served. Athletes and fit individuals who tolerate a higher intensity workout will require a lower water temperature because heart rate is directly influenced by water temperature.

Patients who are deconditioned, are neurologically impaired, have spinal cord injuries above the sixth thoracic vertebrae level, or are diagnosed with rheumatic disease require warmer temperatures. This may be due to thermoregulatory system impairment or their tendency to have a lower exercise output. Thus, they will not usually increase their heart rates through exercise at the same rate as the more fit or athletic patients.

The environment surrounding the therapeutic pool requires consideration as well. Air temperatures should not be more than 10°F below water temperature. Pool decks, entries and exits, and bathroom facilities are mandated by the Americans with Disabilities Act to provide the public with accessible accommodations for all individuals.

 

                     

 

Pool sanitation is extremely important because infection or skin irritation can occur depending on the type and quantity of chemicals used. Respiratory, gastrointestinal, urinary tract, and, rarely, central nervous system infections have been associated with pools. However, in almost all cases, the pool used was found to be contaminated as a result of poor or no disinfection. To ensure that a safe and sanitary environment exists for aquatic therapy, chemical levels must be monitored daily. A staff member must be knowledgeable in the appropriate and safe chemical levels for sanitation. Certification of an employee as a pool operator (CPO) or a contract with a pool maintenance company to assist with monitoring the pool sanitation is recommended. Policies must be established for incidents involving pool contamination, such as blood, feces, and vomitus. It is advisable for the pool facility manager to be in contact with the state’s agency of public recreation or health department to determine requirements that exist in his or her jurisdiction.

 

AQUATIC THERAPY TREATMENT TECHNIQUES

Water Shiatsu (Watsu)

Watsu was developed by Harold Dull in 1980 at Harbin Hot Springs, California, and is based on his studies in Japan of zen shiatsu which is practiced on land. Watsu is a combination of shiatsu and warm water therapy originally created to attain well-ness in all individuals. Eastern philosophy embraces a mind-body relationship that is not always accepted in traditional aquatic rehabilitation. Zen shiatsu and Watsu incorporate passive stretches, joint mobilization, and acupoints to balance the flow of energy through the meridians (pathways of energy) as the therapist cradles the patient. Centering and connecting with the breath are essential components of Watsu. Therapists learn to adapt Watsu movements to physical restrictions or limitations and outline a program designed on individual goals. Patients are passive participants as the therapist gently floats, rocks, and swirls them through warm water. Patients experience a profound relaxation from the water’s support and the continual rhythmic movement, working through a specifically designed transition and sequence of movements that are learned and applied in treatments. Therapists stabilize or move individual body segments through the water, resulting in a passive stretch to another segment as a result of the drag forces encountered by the water. The treatment usually lasts for 1 hour, but can be adjusted depending on individual tolerance. Warm water is essential for the patient to achieve a state of relaxation. Water temperatures should never exceed 98°F (37°C).

Watsu precautions include all aquatic therapy precautions that were previously stated in this chapter. There are some specific precautions related to Watsu treatments: Watsu is a physically close, intimate, non-sexual technique, and it is important to know your comfort level in performing these techniques and to be aware and respect your patient’s feelings. The close physical contact necessary to perform Watsu can release deep emotions in patients. Hypersensitivity to vestibular stimulation may cause symptoms of motion sickness. Use movements that are slow and smooth, and that involve less turning and rotation of the head.

Initial sessions can begin at 5 minutes and gradually increase to 60 minutes in length.

Limiting factors of Watsu are that it is a close patient-to-therapist technique and a warm water environment is essential. Watsu is practiced worldwide. Harold Dull has established the not-for-profit Worldwide Aquatic Bodywork Association to explore the benefits of giving and receiving aquatic bodywork, and to make it available to everyone.

Bad Ragaz Ring Method

The Bad Ragaz ring method was developed in Bad Ragaz, Switzerland, in the 1960s. Current techniques have been significandy influenced by proprioceptive neu-romuscular facilitation (PNF). These diagonal ROM exercises have been used to simulate normal functional movement patterns. The patterns used have been adapted to be performed in a horizontal position in the water. The method is used for muscle re-education, strengthening, spinal rotation and elongation, relaxation, and tone inhibition in the water. The patient is floated at the surface of the water using flotation devices to support the neck, trunk, and extremities. Resistance is provided by negative pressure produced behind the patient as he or she is dragged through the water. There are three ways in which the therapist acts in relation to the patient:

1.    Isokinetically.  The   therapist provides  fixation  while  the  patient movesthrough the water either toward, away from or around the therapist. There sistance is determined by the speed of movement by the patient.

2.    Isotonically. The therapist acts as a movable fixed point. Patients can bepushed or swung in the opposite direction of their movement, increasing theresistance encountered. Conversely, a therapist moving the patient in theopposite direction of the intended movement can assist movements.

3.    Isometrically. The patient holds a fixed position while being pushed throughthe water by the therapist, promoting muscle stabilization.

Patients can also be moved passively through the water to promote relaxation and tone inhibition through trunk rotation and elongation techniques.

Sessions can begin at 5 minutes, increasing to 45 minutes with breaks incorporated. Passive relaxation techniques may be used to increase relaxation and decrease hypertonicity in the neurologically involved patient at the beginning or end of a session. Techniques that increase spasticity should be avoided. Resistance can be increased as the patient becomes stronger by:

•  Adding flotation devices to the trunk or extremities

•  Changing the direction of movement

•  Incorporating quick reversals

•  Providing more distal than proximal handholds causing the patient to controlmore body segments

• Increasing the level of difficulty or speed at which movements are performedSome specific precautions related to the Bad Ragaz ring method include all aquatic therapy precautions mentioned previously and hypersensitivity to vestibular stimula­tion, and care must be takeot to overstretch weak joints, causing further damage. A limiting factor of the Bad Ragaz method is that it requires 1:1 therapist-to-patient interaction to be performed

Halliwick Method

The Halliwick method was developed by James McMillan in the 1950s at the Halliwick School for Crippled Girls in England. Although McMillan had no medical training, his background was in engineering, including the field of fluid mechanics, and his method is based on the principles of hydromechanics and human development that are used in swimming and therapy. Four principles of instruction were established:

1.    Mental adaptation is the recognition of two forces acting on the body in water: gravity and up-thrust. In combination, these result in rotational movement.

2.    Balance restoration emphasizes the use of large patterns of movement, particularly with the arms, to restore or maintain balance. Instruction involves the use of wide-ranging body movements to move the body into different postures while maintaining balance control. The most important of these postures is the immediate response around midline.

3.    Inhibition is the ability to create and hold a desired position or posture and the ability to contain all unwanted movement.

4.    Facilitation is the ability to create a mentally desired and physically controlled movement (e.g., swimming) by any means without flotation aids. These phases of learning are in an order by which the cerebral cortex learns all physical movement. Known as the developmental sequence, these phases are set out in a structure know as the Ten Point Program:

1.    Mental adjustment and disengagement

2.    Sagittal rotation (control)

3.    Simple progression

4.    Basic swimming movement

5.    Vertical rotation (control)

6.    Lateral rotation (control)

7.    Combined rotation

8.    Mental inversion/up-thrust

9.    Turbulent  gliding

10. Balance in stillness

Instruction takes place in groups of no more than seven swimmers, each with his or her own assistant who guides them through series of games and water activities that are lead by an experienced Halliwick instructor. The Halliwick method is learned in an atmosphere where fun and games are encouraged. There are two main purposes to this method: (1) to teach swimmers about themselves and their balance control in water and (2) to teach swimming. A limitation to the Halliwick approach is that it requires close therapist-to-patient interaction to be performed.

Ai Chi (Aquatic Tai Chi)

Developed byjun Konno from Tokyo, Japan, ai chi, or aquatic tai chi, uses tai chi techniques. The benefits include increased flexibility and ROM, improved circulation of energy along important acupoint meridians, decreased stress, increased mental alertness, improved kinesthetic awareness, and enhanced breathing through learned yogic breathing techniques. Diagnoses treated with ai chi include orthopaedic injuries, neurologic diseases, anxiety or depressive disorders, rheumatic diseases, fibromyalgia, cardiac conditions, respiratory diseases, and prenatal and chronic pain.

A benefit to ai chi is that it can be performed independently once the patient has learned a safe program that is appropriate for his or her needs.

Burdenko Method

The Burdenko method, developed by Igor Burdenko, is a combination of water and sports therapy. The methods are an application of water and land based exercises to maintain health and quality of life and to enhance physical performance. His method combines the advantages of both water and land, using both shallow and deep-water activities. The Burdenko method is based on six qualities: balance, coordination, flexibility, endurance, strength, and speed.

This method challenges the COG on land and COB in water. Water characteristics include working in a vertical position in deep water, exercising in multiple directions, exercising at different speeds, and beginning in deep water and progressing to shallow water. This interaction between the two environments is believed to be the key to faster, safer, and more efficient body function. The Burdenko method works on the body as a whole, not just the injured part. The goal is to establish harmony of function in the body using a holistic approach. The water and land programs each consist of three stages: (1) warmup (walking, stretching, running), (2) working out sports qualities (coordination, balance, flexibility, endurance, strength, and speed), and (3) cool-down (e.g., stretching, breathing and shaking).

HYDROTHERAPY: METHODS OF APPLICATION

Wound Healing and Hydrotherapy

There continues to be much controversy and research regarding the effectiveness of whirlpool and Hubbard tank therapy in the management of wound healing. The Agency for Health Care Policy and Research (AHCPR) Clinical Practice Guidelines for the Treatment of Pressure Ulcers consider the use of whirlpool and Hubbard tank treatments for the cleansing of pressure ulcers that contain thick exudate, slough, or necrotic tissue. Whirlpool or Hubbard tank treatment should be discontinued when the ulcer is determined to be clean. Caution must be taken so that wound trauma does not occur from the high pressure water jets in the whirlpool. The water turbulence can damage granulation tissue and migrating epidermal cells. As a result, the water jets should not be positioned close to the wound. Treatment assessment is essential, and whirlpool use should be discontinued once exudate, slough, and necrotic tissue are cleared to prevent further damage.

Whirlpool Baths

There are basically two types of whirlpool tanks: fixed and portable tanks. “Lowboy” and “highboy” tanks are for extremity or trunk immersion. This treatment provides heat, gentle massage, debridement, and relief of joint pain and stiffness and promotes relaxation of muscles. The immersed body parts can perform active, active-assistive, or passive ROM exercises while the body parts are submerged.

Hubbard Tanks

Full-body immersion whirlpools are known as Hubbard tanks. An overhead lift with a stretcher is usually used to get the patient into the water. Water temperature should not exceed 1° above normal body temperature. Patients with burns requiring debridement of necrotic tissue, slough, or thick exudate may benefit from full-body immersion treatments. Burn patients may also benefit from dressing removal in water and from active exercise assisted by the water.

Certain patients with open wounds may also be suitable candidates for Hubbard tank therapy. A study of postabdominal surgical patients found a decreased gas build-up after surgery in the intestines, facilitated wound healing, and decreased anxiety with tank therapy.

The advantages of the Hubbard tank are its ability to obtain full-body immersion, achieve wound debridement, facilitate active exercise, and decrease pain and anxiety in patients who have contraindications to participating in the therapeutic pool

Duration

Physiologic effects are generally achieved in 20 minutes when used as a heating modality. Borrell and colleagues demonstrated that 20 minutes was long enough to increase skin, muscle, and joint capsule temperature in the hand and foot.

For whirlpools, a standard whirlpool chair that sits outside of the tub to allow lower extremities to be immersed or a whirlpool bench that sits inside a tank to fully immerse the lower half of the body is available.

For Hubbard tanks, stretchers with mechanical lifts are available.

 

Disinfection of Hydrotherapy Tanks

Currently, there are no universal standards for cleaning and disinfecting hydrotherapy tanks. The Centers for Disease Control and Prevention recommend that sodium hypochlorite 70% per 100 gallons of water be added to the tank before the patient enters to produce free chlorine residual of about 15 mg/L. These concentrations have been found to reduce the microbial contamination in water from 104 to less than 10 colony-forming units per milliliter in a controlled study with patients with burns.

Pulsed Lavage

Pulsed lavage offers an alternative or adjunct to hydrotherapy for wound healing. Pulsed lavage is described as a system delivering an irrigation solution under pressure by an electrically powered device. This pressure cleanses the wound of debris, increases tissue perfusion, and enhances a clean wound bed for granulation to occur. Pulsed lavage delivers a pulsating stream of fluid that loosens necrotic tissue from the wound and may concurrendy be used with suction to remove debris and irrigating solutions. The AHCPR guideline suggest that irrigation pressures less than 4 psi may be inefficient to remove surface pathogens and debris, and that irrigation pressures greater than 15 psi may cause wound trauma and drive bacteria into wounds. These pressure range recommendations were derived from studies conducted by Brown et al., Rodeheaver et al., Wheeler et al., and Stewart et al. and a series of studies performed at Walter Reed Army Hospital. Normal saline is the preferred cleansing agent because it is physiologic, will not harm tissue, and adequately cleanses most wounds.

Advantages

Pulsed lavage can be used for treatment of patients who need to remain in their room secondary to isolation or medical compromise. Patients with tracheostomies or ventilators may receive pulsed lavage treatments for wound care with significantly decreased risk of water aspiration and increased safety regarding electrical equipment during treatment with water. Pulsed lavage treatments can continue after discharge in the home and may promote shorter hospital stays.

Contraindications and Precautions

Pulsed lavage is contraindicated near exposed blood vessels, eyes, or dura. The skill of the professional or caregiver performing the treatment is important to prevent spray from contaminating the surrounding treatment area, the patient, or the person administering the treatment. The irrigation fluid should be suctioned as fast as it is sprayed to decrease the risk of contamination. Two people may perform the technique, with one administering the fluid stream and the other suctioning the debris and remaining fluid. Caution must be taken when using pulsed lavage near exposed muscle.

Research comparing the effectiveness of pulsed lavage and whirlpool on wound cleansing is scant. Additional clinical studies comparing die effects of the two on wound cleansing and healing are needed. Recognizing the progressive financial restrictions facing the clinician, future comparisons should also include cost analyses of the two methods. Total cost per incident, number of treatments required to achieve wound closure, and per-treatment costs should be included in future research.

Contrast Baths

Contrast baths are an alternating application of hot and cold generally applied to distal extremities, using a 3:1 ratio of hot to cold, applied with compresses or immersion. Contrast baths are used primarily for increasing blood flow through an area. Contrast baths promote a type of vascular exercise causing alternate constriction and dilation of the local blood vessels, which stimulates increased peripheral circulation. This process aids in removing wastes that accumulate in areas of inflammation and assists in bringing nutrients and oxygen to the area.

Indications

Contrast hydrotherapy is an effective treatment for subacute, postacute, and chronic cases of tendinitis, bursitis, and arthritis. It is also effective for desensitiza-tion of neuropathic or sympathetic pain syndromes, such as reflex sympathetic dystrophy (RSD). Contrast baths can assist in the treatment of RSD by reducing edema and normalizing sympathetic neuroregulation of blood vessels.

Contraindications and Precautions for Contrast Baths

Advanced atherosclerosis and advanced peripheral vascular disease should be treated with extreme caution to avoid the exacerbation of ischemia. In the presence of open wounds, the containers should be sterilized before and after use. Pad the edges of containers to avoid constriction of the circulatory or lymphatic system. Watch skin coloration and monitor patient’s pulse. Adhere to those precautions and contraindications relating to other applications of heat and cold.

Contrast Bath Procedures

Begin with hot water immersion for 10 minutes.

Repeat the procedure for 3-5 repetitions per treatment session.

For edema reduction, begin with cold water immersion for 1 minute, followed by hot water immersion for 4 minutes, continuing for 3-5 repetitions, ending with cold water immersion.

 

Sitz Baths

A sitz bath is a bath in which the pelvis is immersed in hot aor cold water. Traditionally, hot sitz baths have been used for relief of postpartum perineal pain, and one of the most routine orders for postpartum patients is the warm sitz bath. Studies have investigated the effectiveness of hot versus cold sitz baths, intermittently, to relieve postpartum perineal pain. Scientific observation would suggest a change to ice therapy to decrease edema and hemorrhage, thus decreasing the length and severity of postpartum pain. Alternative medicine treatments include hot, cold, and contrasting (hot/cold) sitz baths to decrease pelvic discomfort. Further research appears warranted in this area. Warm sitz baths are effective in treating hemorrhoids and anorectal pain. Naturopathic hydrotherapy uses sitz baths for pelvic disorders, as well as indications for treating sciatica, insomnia, headache, congestion, constipation, and incontinence.

SUMMARY

Humans have used hydrotherapy for healing and spiritual rituals for centuries. The use of water’s therapeutic properties gained popularity in the medical community in the 1800s, but its frequency of use by the medical establishment has varied since then. The field of aquatic therapy has grown tremendously in the late 20th century, serving as an adjunct to land-based therapies. Water’s physical properties, including buoyancy and increased resistance to movement compared to air, provide advantages that cannot be found in land-based programs.

Aquatic therapy techniques need continued development as health-care professionals acquire skill and comfort in performing them and continue to note the important role the therapeutic use of water can have in a patient’s rehabilitation. Research on pulsed lavage techniques and hydrotherapy immersion in the treatment of wound care remains scant. Further research is needed to support the effectiveness of aquatic and hydrotherapy procedures and to promote evidence-based health-care practice within the financial constraints now faced in the 21st century.

 

CLIMATOTHERAPY

Climate – the long-term regimen of weather developing on the big site of the Earth.

 

Weather – a physical condition of sublayers of an atmosphere in concrete geographical district at present time (during definition of the basic meteorological elements).

Microclimate – a complex of meteorological conditions in a small geographical site or in the closed premises. Exist multivariants of artificial medical devices with an artificial microclimate, so-called climattrones. . To their number, for example, it is possible to relate: sauna or the steam bath, having indications to medical application. The climate is shaped by three basic groups of factors: atmospheric, earth and space.

 

The basic meteorological elements(ME) , describing climate and weather: temperature, humidity of air, atmospheric pressure, a saturation of air Oxygenium and ozone, movement of air (rate of a wind), deposits, a condition of an atmospheric electricity (including the contents of airions  in 1 sm3 of air). Allocate climates of plains, mountains, the seas, seaside coast. Allocate also climatic girdles: cold, moderate and hot. The following medical types of weathers are known:

 

Type I. Rather favorable weathers (with a steady course of the basic ME in regimens favorable for the person).

Type II. Favorable weathers (ME are mobile in moderate limits).

Type III. Adverse weathers (with an unstable course of the basic ME or with their extreme deviations).

Sometimes allocate type IV. Especially adverse weathers: thunder-storms, hurricanes, strong blizzards, squalls.

At III and IV types of weathers ill people should limit the labour loads and undertake preventive actions in order to prevent development of crisises and aggravations of symptoms of health. Меteorological Reactions:

I degrees – at change of weather – subjective deterioration of state of health,

П degrees – adverse sensations prove to be true change of a pulse rate, arterial pressure, RVG, REG, ECG and other objective parameters.

Ш degrees – occur attributes of development of crisis  or progress of pathological process: hemoptisis , attacks of a bronchial asthma, high arterial pressure , attacks of a stenocardia etc.

In a climatotherapy it is possible to allocate its following forms:

– Actually a climatotherapy (treatment of disease mild a mountain climate, kidneys – a climate of desert etc.);

– An air-cure – treatment by fresh air in dosed and not dosed forms;

– A heliation – treatment by solar rays in dosed and weak dosed forms;

– A thalassotherapy – treatment by factors of the sea (mainly sea bathings).

Microclimatotherapy – treatment by a microclimate natural (caves, grottoes) or artificial (the hydrochloric and uranium mines, artificial climatotrones of the the closed premises).

 

The air-cure is shown at many diseases, but is especial the patient with diseases of cardiovascular system, bodies of respiration and nervous system.

The heliation is most expedient at diseases of a skin (psoriasis, a pyoderma, wounds, ulcers etc.), a rachitis, chronic diseases of bodies of respiration (bronchitis, pneumonia), neurosises, a neurangiosis in mild forms.

 

 

Thalassotherapy: a myocardial dystrophy, ischemic heart disease  without often attacks of a stenocardia and the expressed arrhythmia, idiopathic hypertensia I-II of a stage, neurosises, vegetativ vascular disfunction  on the mixed type, an atherosclerosis of various bodies and systems, chronic diseases of a locomotorium, a consequence of operations on a nem and traumas, illness of  respirattory system  etc.

 

 

Contraindications

The air-cure in a broad sense practically has no contraindications. Air baths may be counterindicative at acute infectious diseases, acute diseases of bodies of respiration, exacerbations of rheumatic disease and others.

The heliation counterindicatives at feverish conditions, malignant neoplasms, illnesses of a blood, at acute infectious diseases, at ischemic heart disease with often attacks of a stenocardia, at photodermatites, a thyrotoxicosis etc.).

The thalassotherapy has basically the same contraindications, as a heliation.

Climatic health resorts of Ukraine: the Southern coast of Crimea (Аlushta, Feodosya), the Zakarpattye resort district, Slavjanogorsk.

Sanatorium treatment (ST) – a stage in system of the restore treatment (RT).

Ukraine has unique resort resources with various climatic, balneo- and mud factors. The most typical and functional – high-grade medical institution of resort zones is the sanatorium – the independent stationary establishment which is carrying out realization of the phases health-improving measures , the broken functions of an organism directed on restoration, fastening before the achieved results of treatment, application of new effective methods of treatment and organizational forms of work.

 

The purposes of resort treatment:

Preventive:

1.   Influence on risk- factors (hypodynamia, adiposity, hypercholesterinaemia).

2.   Improvement of physical work capacity.

3.   Improvement of a mental condition.

4.   Hardening of an organism.

Medical:

1.   Influence on pathogenetic links of the diseases” development.

2.   Improvement of a functional condition of the organs and systems at patients.

3.   Improvement of a clinical condition of patients.

4.   Minimization of medicamentous therapy.

 

Rahabilitation:

1.   Restoration of the broken functions of an organism.

2.   Liquidation of the consequences of traumas, operations.

3.   Full (partial) restoration of work capacity.

4.   Physical and psychological rehabilitation.

5.   Improvement of of the life quality.

 

Classification of the resorts .

Distinguish resorts climatic, balneological and mixed.

 

Climatic resorts. On climatic conditions resorts may be seaside, mountain and plain (located in woods, forest-steppe and steppe district).

The basic improving – medical factors of climatic resorts are aerotherapy, heliotherapy, sea bathings (thalassotherapy), bathings in lakes and the rivers, koumiss therapy , treatment by a grapes.

The major climatic resorts of Ukraine are in Crimea. For seaside zones dry, hot solar summer, a warm and long autumn, early spring and short soft winter are characteristic. Practically all year here are possible airheliotherapy; sea bathings – since May till October.

Group of the Odessa resorts represent “Lermontovskiy” a resort, “Arcady”. There are a combination of a steppe and soft sea climate and a plenty of sunny days there. Widely are used the muds of the Odessa estuaries. In this group it is a lot of sanatoria of a cardiological structure.

Rather cool and damp climate of plains has a sedative action on the nervous system. These resorts are shown for the recovering and weakened patients.

In forest-steppe and steppe zones it is a lot of the climatic and koumiss-treatment resorts, with warm and dry air in summer time.

 

 

 

Balneological resorts

The basic medical factor of this group of the resorts is mineral waters (МW). Conditionally them divide on only balneological (where МW are applied to baths and other water procedures) and balneological drinking. MW divide into 7 basic groups: waters without specific components and properties; carbonic; sulphidic; ferruterous; with the contents of arsenic; bromic; iodine and with the high contents of organic substances; radonic; silicon.

Among balneological resorts the important place belongs to the Prykarpattyan resorts (Truskavets, Morshyn), the resorts of Zakarpattya (Svaljava, Pol’ana Kwasovaja, Synjak), Podolia (resorts of the Chmel’nik, Sataniv, Gusjatin), of the Ukraine East (Myrgorod, Berjozovskye mineral waters).

 

 

Mud resorts:

Slavyansk, Kujal’nik, Evpatoria, Saky, Azov-sea resorts (Berdjansk).

Depending on the location sanatoria may be local and located in resort zones. In most cases it is necessary to prefer improvement of patients in local sanatoria, staying in which patients do not feel sharp changes in a climate

 

On structures of treatment distinguish sanatoria:

·        For patients with a rheumatism (Alushta , Odessa, Chmel’nic, resorts near Azov sea);

·        For patients with disorders of functions of the locomotorium (mud resorts of the Morshyn, Evpatoria, Saky , Kherson, Azov sea coast , Zakarpattya, Chmel’nik);

·        For patients with the  diseases of  the respiratory system (not tuberculosis ethyology)- Alushta , Truskavets, Evpatoria, Saky , Yalta, Ochakov, Azov sea coast , Zakarpattya );

·        For patients with the psychoneurological  diseases (Evpatoria, Saky , Odessa, Azov sea coast , Zakarpattya );

·        For patients with diseases of the digestion organs (Truskavets, Morshyn, Evpatoria, Saky, Odessa, resorts near Azov sea, Myrgorod , Zakarpattya, Chmel”nik );

·        For patients with diseases of kidneys and urine ways (Truskavets, Morshyn,Yalta, Zakarpattya , Gusjatin,Sataniv);

·        For patients with diseases of a skin (Morshyn, Evpatoria, Saky, Zakarpattya);

·        For patients with diseases of the endocrine system and disordes of a metabolism (Truskavets, Evpatoria, Myrgorod, Zakarpattya);

·        resorts for patients with tuberculosis  (function in each area of Ukraine);

 

 

Selection of patients for ST is made in treatment-and-prophylactic establishments (TPE). Distribution and distribution of permits are carried out by trade unions by social insurance.

The expediency of a direction of the patient on ST is determined by the attending physician who makes out the necessary documentation: an extract from the case record (a card of the outpatient), a sanatorium card (F. 076/R). TPE gives out the sanatorium card with the conclusion of medical social commission of experts (МSСE) about necessity of the ST on the hands the patient.

Before a direction of the patient on ST the attending physician should organize the physical instrumental and laboratory inspection of the patient, according to a character of disease, sanitation of chronic seats of an infection, antirecidive (relaps) treatment.

After ST ending by the patient it is given the tear-off coupon of a sanatorium card (an extract from the case record), with the data on the treatment carried out in sanatorium, its efficiency, recommendations for the further improvement, for transfer to a polyclinic on a residence.

Contra-indications for stay of patients on a resort are established by sanatorium advisory advice led by the head physician. Advice determines presence of contra-indications for the ST, necessity of the transvering of the patient in another TPE or his evacuations in a place of a permanent adress, need for support of the patient (term of revealing of contra-indications should not exceed 5 days from the moment of entering the patient in sanatorium). In case of an establishment at the patient of contra-indications for the ST the certificate (act) in triplicate is made: One goes to controls of health protection on a residence, another – in TPE (the trade-union organization), directed the patient on the ST, the third copy remains in sanatorium after investigation of the reasons of a wrong direction of the patient on the ST, the expenses connected to evacuation and support of patients to a residence, are carried out due to medical institution, is groundless giving out a sanatorium card which, in turn, has the right to collect the spent means with the concrete persons.

 

The general contra-indications for ST are:

·        All diseases in the acute  period; the somatic diseases with indications  to hospitalization;

·        The chronic diseases witch are needed in special treatment;

·        Infectious diseases; bacillus-carring;

·        Malignant neoplasms;

·        System diseases of blood;

·        Active tuberculosis;

·        Emaciation, amyloidosis of the  internal organs;

·        Epilepsy,psychopathy,intellectual backwardness, demanding of the individual conditions for a care and treatment;

·        Cardiac insufficiency of the II-III degrees;

·        The general epidemiological contra-indications.

Course of the sanatorium treatment – 18-24 days.

 

The basic health-improving aspects  of the ST : sanitary-hygienic and differential  modes according to character and severity  of disease: rational and dietetic therapy; maximal use of natural medical means (climatic -, helio -, talass -, balneological -, phyto -, speleo -, peloid therapy), in a combination from procedures of the hardening , physiotherapeutic exercises, massage, medicamental  treatment and psychotherapy.