6.2. SPECIFIC OPERATING PROCEDURES * 6.2.1. ULTRASOUND THERAPY A. Procedure: Ultrasound is high frequency sound waves that produce temperature elevation to the deeper structures without causing excessive heating of the superficial layers through the use of coupling agents B. Preparation of the Patient; i, Position the patient comfortably with the area to be treated adequately Supported, exposed and relaxed, ii. Inspect the part for any cuts, abrasions, excessive swelling, warmth or any skin condition iii, Inform the patient about the treatment and sensation to be experienced — a mild heat C. Treatment: iis Explain the procedure ii, Apply generous amount of coupling agent, Spread the gel evenly over the transducer iii, Slowly increase the intensity, apply the transducer to the skin and move continuously in small circular motions iv. Duration of the treatment is between 05.25 minutes, based on levels e Acute © Sub-acute ° Chronic D. Indications I. Acute injuries fl. Acute inflammation ae aE OE an —Vi. Vil. VII. Xi. XIl. XI. XIV. XV. Chronic indurated edema Scar tissue Soft tissue shortening (1 or 3 MHz frequency depending on the tissue depth at 1-2.5 W/em2 intensity) Pair control (Continuous ultrasound, | or 3 MHz frequency, 0.5 to 3.0 W/em2 intensity) Dermal ulcers (0.8 to 1 W/cm2 intensity, 3 MHz frequency) Surgical skin incisions (0.5 to 0.8 W/cm2 intensity, pulsed) Tendon injuries (0.5 to 1.5 W/cm2 intensity, Continuous, | or 3 MHz frequency) Resorption of calcium deposits Bone fractures (pulsed, 0.1 W/cm? intensity, 1.5MHz frequency) Carpal tunnel syndrome (1 MHz frequency, |W /cm2 intensity. pulsed) Phonophoresis (3 MHz frequency, Pulsed, 0.5 to 0.75 W/cm2 intensity) Plantar warts (0.6 to 0.8W/cm2 intensity, Continuous) Herpes zoster infection(7) E. Contraindications IL. . Ml. Iv. Vv. Vi. VIL. VIL. IX x. XL. Xi. Avoid exposure to the developing fetus Malignancy Vascular abnormalities including DVT and severe atherosclerosis Acute infections Joint Replacement Hemophiliacs Specialized tissue e.g. eye and testes The stellate ganglion The cardiac area in advanced heart disease The spinal cord following laminectomy The cranium Active epiphyseal regions in children(7) F. Precautions1. Anesthetic areas should be treated with caution if a thermal dose is being applied II. Subcutaneous major nerves and bony prominences Ill. Always use the lowest intensity which produces a therapeutic response IV. _ Ensure that the applicator is moved throughout the treatment V. Ensure that the patient is aware of the nature of the treatment and the expected effects VI. If pain, discomfort or unexpected sensations are experienced by the patient, the treatment intensity should be reduced. If the symptoms persist, the treatment should be terminated. VI. Methyl methacrylate cement and plastic are materials used for fixation or as . components of prosthetic joints. Because these materials are rapidly heated by ultrasound, it is generally recommended that ultra-sound not be applied over @ cemented prosthesis not increase where plastic components are used.(7) G. Infection control: i. Clean the transducer head with tissue paper after every use ii. Transducer head must be cleaned with the alcohol swabs in infectious patients(8) 6.2.2. INFRARED RADIATION a. Procedure: Infrared radiation is a convenient system to heat parts of our body. It has the advantage over direct contact in that radiation can capillaries and neuron terminals are. When heat comes from a direct contact source it heat directly the area where the blood has to heat the external layer of the skin and heat is transferred to the deeper layer by conduction. b. Preparation of the Patient: i. Position of patient should be comfortable and adequate ii. Avoid undue movement of the patient iii, Test the skin sensation of the patient iv. _ Expose the area which is going to be treated.iii. iv. vi vii. viii. iv. vi. Areas with Remove all “ the metal objects like rings safety pins etc. © Treatment: Explain the procedure Avoid very short distance between the patient and the infra-red radiation (IRR) lamp as it can result in burns and scalds. In case of modalities like IRR lamps where intensity regulation may not be available, the amount of heat received by @ patient will be determined by the distance of the lamp from the part being treated respectively. The distance should be such that erythema does not occur until ten minutes after the treatment has started, while the application time should be short and under no circumstance must it exceed 30 minutes. d. Indications Acute pain Muscle spasm Prior to stretching Superficial wounds and infections Arthritic joints Antidote of excessive UV radiations(7) e. Contraindications poor or deficient skin sensation Generalized advanced cardiovascular disease Local areas of impaired peripheral circulation Extensive scar tissue Deep X Ray treatment or other ionizing radiation (in the last 6 months) in the region being treated Malignant tissue (except in terminal / palliative / hospice care) Subjects with reduced levels of consciousness or impaired understanding Acute febrile illness ajx. Some acute skin iti ix. conditions e.g. eczema, dermatitis Sensitive structu eyes and testes)(7) nae f. Precautions The patient should be instructed not to touch the glass bulb inside the lamp while in use to avoid burns. ii, The patient's skin must be clean and free of grease or liniment The eyes must be protected with goggles or cotton wool soaked in water, especially if any part of the face is to be irradiated. iv. Never position the lamp such that it could drop onto the patient.(7) 6.2.3, PARAFFIN WAX BATH b. Procedure: Paraffin wax bath is the utilization of paraffin wax at a temperature 40- 44 degree Celsius. The application of hot wax through dipping with the lint cloth and apply to patient’s extremities .This wax has low thermal conductivity, so that the heat will stay in the tissues for a longer period. c. Preparation of the patient: i. Position the patient comfortably with the area to be treated adequately supported, exposed and relaxed. ii. The part to be treated must be cleaned and free form cuts, rashes or infections iii, Inform the patient about the treatment and sensation to be experienced — a moderate heat d. Treatment: i, Explain the procedure ii, Therapist should wear gloves iii, Dip the lint clothe in the wax bath, clear the excess wax on the cloth and wrap it around the area to be treated iv. Duration of the treatment 20 — 30minutes e. Precautions:Pati ‘lent should be cautioned not to change position during treatment ii. Paraffin can easily fall to the floor during treatment making the floor slippery iti, Paraffin wax is flammable. iv. Don't use wax over the area with circulatory insufficiency. Contraindicated if skin is broken f. Infection control: v. i. Change the lint cloth once a week ii. Wax bath to be cleaned with the spirit when the wax is replaced with new (once in four months) iii. Lint cloth has to be discarded if used in infectious patient (9) 6.2.4. MOIST HEAT THERAPY a. Procedure: Silicon hot packs are conductive type of superficial moist heat. The temperature has to be maintained between 70 — 100 degrees Celsius b. Preparation of the patient: i. Drape the patient, expose the area to be treated, place the patient in comfortable position The part to be treated must be cleaned and free form cuts, rashes or infections Inform the patient about the treatment and sensation to be experienced — a mild heat which will be increased gradually. c. Treatment: i. Explain the procedure to the patient ii. Place the towel between the patient's skin or treatment area and the hot packs iii, Wrap additional towels depending on patient’s tolerance to heat iv. Duration of the treatment is 10 — 30 minutes b. Precautions: ai. Extra tows ili: el must be utilized, so heat is oie taeeal Not transferred too quickly and ii. It sh i i should not be used in acute inflammation or injuri iii, It should not be used in malignancy( 10) - 6.2.5. SHORT WAVE DIATHERMY a. Procedure: High frequer gl quency current produced deep heat with in body tissues for therapeutic purposes. It produce: ; es. It produces heat below the skin surfaces through conversion heat transmission. b. Preparation of the patient: i. Drape the pati pe the patient, expose the area to be treated, place the patient in comfortable position. ii, The part to be treated must be cleaned and free form cuts, rashes or infections iii. Inform the patient about the treatment and sensation to be experienced — a Deep heat ec. Treatment: Explain the procedure to the patient ii. Place one layer of the towel over the treatment area. iii. Position the treatment area midway between two electrodes iv. Allow the machine to warm up first two minutes Increase the intensity until the patient feels a soothing sensation Give the patient the call bell in case the heat is more. vii, Duration of the treatment 15-30 minutes d. Indications i. Subacute or chronic pain ii. Muscle spasm iii, Sprains & Strains iv. Wound healing y. Subacute Inflammation vi. Chronic Inflammation vii, Rheumatoid Arthritisviii. Tendonitis Osteoarthritis(7) Contraindications Areas of poor or deficient thermal skin sensation Metal in the tissues : Circulatory compromise or deficit including ischemic tissue, thrombosis and associated conditions Advanced cardiovascular conditions Pacemakers Pregnancy Recent or current hemorrhage Avoid irradiation of the lower trunk, abdomen or pelvis during menstruation Malignancy Active tuberculosis Deep X Ray therapy or other ionizing radiations (in the last 6 months) in the region to be treated Patients who are unable to cooperate(7) Precautions Avoid active epiphyseal regions in children Avoid specialized tissues (e.g. eye and testes)(7) 6.2.6. ELECTRIC STIMULATION a. Procedure: Electrical stimulation is the use of electricity to stimulate nerves and muscles. It is used to accomplish a variety of therapeutic purposes, such as effect on de innervated muscles, innervated muscle and decreased spasm b. Preparation of the patient: The part to be treated must be cleaned and free form cuts, rashes or infections Inform the patient about the treatment and sensation to be experienced — mild pricking sensation c. Treatment: a; a the procedure to the Patient i. Place the dispersi palin siete n an antagonistic muscle surface and active af eing treated sf Set the intensity based on the muscle contraction iv. Duration of the treatment 10 — 30 minutes d. Precautions; i. ; Use correct type of current for de innervated and innervated muscles Equipment should be over mackintosh sheet o turning Make sure the intensity knob to be tuned to zero prior on the machine iv. Stimulations should not be used in Patients with pac Pain of unknown origin emakers, Pregnancy (abdominal and/or pelvic area), e. Infection control: i. Use new cotton padding for every treatment.(11) 6.2.7. CRYOTHERAPY a, Procedure Cryotherapy describes multiple types of cold application that use the type of electromagnetic energy classified as infrared radiation. When cold is applied to skin (warmer object), heat is removed or lost. This is referred to as heat abstraction. The most common modes of heat transfer with cold application are conduction and evaporation.(12) b. Treatment i. Cryotherapy is usually applied for 20 to 30 minutes for maximum cooling of both superficial and deep tissues. Barriers used between the ice application and skin can affect heat abstraction. Research has shown that a dry towel or dry elastic wrap should not be used in treatment times of 30 minutes or less. Rather, the cold agent should be applied directly to the skin for optimal therapeutic effectsc i. ii. iii. iv. v. vi. Furthermo: a es Ie packs can be molded to the body's contours, held in place by @ om, i. Pression Wrap, and elevated above the heart to minimize swelling and Pooling of fluids in the interstitial tissue spaces eee tte turing the initial treatments, the skin should be checked frequently for wheal or blister formation Precaution Decreased cold sensitivity and/or hypersensitivity Cold allergy Raynaud's disease or cold Urticarial Hypertension Uncovered open wounds(13) 6.2.8. Vapo Coolant Sprays Procedure Fluoromethane is a nonflammable, nontoxic spray that uses rapid evaporation of chemicals on the skin area to cool the skin prior to stretching a muscle, The effects are temporary and superficial. b. Treatment i. When using a Vapo-coolant spray to increase ROM in an area where no trigger point is present, the patient is comfortably positioned with the muscle passively stretched, The bottle of Vapo-coolant spray is then inverted and held at a 30° to 45° angle and sprayed approximately 12 to 18 inches away from the skin. The entire length of the muscle is sprayed two to three times in a unidirectional, parallel sweeping pattern as a gradual stretch is applied by the clinician, When using this spray to treat trigger points and myofascial pain, the clinician must first determine the presence of an active trigger point.This is accomplished by pu followed by application of firm seconds, ig the muscle under moderate tension, Pressure over the painful site for 5 to 10 © Precautions Do not spray in the eyes, Do i a ; not use this product on diabetics or persons with poor circulation or insensitive skin. Over application of the product might alter skin pigmentation.(9) 6.2.9. EXERCISE THERAPY a. Procedure: Exercise is a physical activity which improves one's health, Physicians, and physical therapist, have found that exercise plays an important role in the maintenance of brain, nerve and muscle function in the human body. Therapeutic exercises have been designed to enhance a variety of aspects of physical fitness in patients suffering from diseases and dysfunctions. New research suggests that exercise may delay mental deterioration with age and disease. b. Goals of Exercise therapy c i, To improve blood circulation ii, To improve co-ordination Maintain balance iv. To increase muscle power v. Joint mobility vi. To improve flexibility vii. To strengthen the muscles viii. To increase respiratory capacity Preparation of the patient: i, Positioning the patient ii. Explanation and demonstration of the exercise Various types of exercise are Active exercise ii, Active Assistive exerciseResistive exercise iv. Passive exercise v. Mobilization vi. Independence in mobility vii. Spinal exercise viii. Respiratory exercise ix. Strengthening exercise x. Co-ordination exercise xi. Vertigo exercise xii. Mat exercise xiii. Postural drainage xiv. Therapeutic Massage xv. Chest manipulation xvi. Diabetic exercise xvii, Antenatal exercise Post natal exercise xix. Pre-operative exercise XX. Post-operative exercise xxi. Pelvic floor exercise xxii. Ambulation exercise 6.2.10. PULMONARY FUNCTION TEST Pulmonary function test is performed to assess the functional states of the lungs. It measures how well the lungs take in and exhale air and how efficiently they transfer oxygen into the blood. H a. Procedure: In a pulmonary function test or spirometer test, a person breathes into mouthpiece that is connected to an instrument called a Spiro meter. The spiro meter records the amount and the rate of air that is breathed in and out over a specified time. Some of the test tained by normal, quiet breathing and other tests require forced measurements are ob! inhalation or exhalation after a deep breath. It is designed to measure changes in volumeand can only measure lung volume compartments that exchange gas with the atmosphere. Spiro meters with electronic signal Outputs also measure flow (volume per unit of time). A device is usually attached to the Spiro-meter which measures the movement of gas in and out of the chest and is referred to as a Spiro-graph. Precautions: i. Donoteata heavy meal before the test ii. Do not smoke for 46 hours prior to the test Do not exercise strenuously prior to the test iv. If you have dentures, wear them during the test to help you to form a tight seal around a mouth piece of the Spiro \- meter, b. Infection control: i, Turbine pneumotach has to be cleaned once a week with cidex solution ii, Mouth piece has to be discarded after each use.(8) 6.3, POLICIES OF PHYSIOTHERAPY DEPARTMENT 6.3.1. Policy for Physical Therapy Consult Information Referrals to the physiotherapist for evaluation/treatment shall be submitted or send to physiotherapy department. The request will contain the following information: i. Patient's name (last, first, middle initial). ii. Patient's date of birth. iii. Duty station and phone number, if active duty; home phone number if non-active duty. iv. Complaints, medical findings, and reason for referral v. Pertinent medical history vi. Date of referral vii. Referring Provider's legible signature along with typed, stamped or printed name,