Electrophysical Agents

Case Study

Question

• A patient presents with a chronic injury to the tendon of supraspinatus following a fall onto the point of shoulder several months earlier.

Supraspinatus• A muscle that connects the scapula to the

humerus• Origin: Supraspinous fossa of the scapula• Insertion: Greater tuberosity of humerus• Action:

– Abduction of the arm (early range & following that is done by anterior fibers of deltoid)

– Also stabilizes shoulder joint as it is part of the rotator cuff muscles

Supraspinatus as aRotator cuff Muscle

• Tendon fuse into the underlying capsule of the shoulder joint

• Plays an important role in stabilizing the shoulder joint

• Tone of muscle assists in holding the head of humerus in the glenoid cavity of scapula during shoulder joint movements

Subjective Assessment

How long has the pain been Onset- Months

What movements trigger pain To confirm that the movement is abduction of

arm as it is the specific movement carried out What daily activities trigger pain

To find out what ADL(s) it affects Find out if patient plays sports and if it is

swimming or throwing sports Pain Intensity

To plan out type of exercise and treatment

Questions to ask the patient/

Complaints

Objective Assessment

1. Look out for Swelling or Oedema2. AROM/PROM- AROM first, then

PROM. Assess if movement inhibited by pain, impingement, tightness etc

3. Pain Rating4. Muscle Strength5. Palpation- Check for painful spots,

muscle tightness, muscle wasting

Goals

• Short-term goal– Increase range of motion (abduction);

active range– Pain relief

• Long-term goal– Restore to full range of motion

(abduction)– Permanent pain relief

Treatment

Possible Modalities

•Ultrasound•Shortwave Diathermy•Heat Pack•Paraffin Wax•Microwave Diathermy•Infra-red radiation

Selection of Modalities

Cryotherapy VS Heat Therapy• Injury is chronic• Cryotherapy is more suited for acute and sub-

acute stage• Heat therapy is more suited for chronic stage

as…Useful for pain relief, swelling and

inflammation in the chronic stageTherefore, heat modalities are recommended

Advantages of thermal effects

– Promotes relaxation– Relief pain– Increase blood flow– Facilitate healing– Prepare stiff joints and tight muscles

for exercise

Modalities Temperature Change

Penetration Depth

Heat pack 2-5 Degrees 1-2 cm (Max)

Paraffin Wax 2-5 Degrees 1-2cm (Max)

Infra-red 5-6 Degree 1-2mm3mm on sole and palm

SWD Condensor- 5 DegreesInductor- 7-8 Degrees

Depend onarrangement

MWD 5-7 Degrees 3 cm

Ultrasound 8 Degrees 3MHZ- 16mm1MHZ- 50mm

Possible modalitiesUltrasound Short wave

DiathermyMicrowave

Nature of modality

Conversive heat modalities

Penetration Depth

Depth of 5cm or more

4cm is the greatest absolute heating of deep tissues

More superficial than SW; 3-4cm

Temperature change

Up to 8 deg 5 (condensor)7-8 (inductor)

5-7 deg

Duration of Temperature Change

about 30-45 minutes for alll

Physiological effects

Reduce pain & muscle spasm

Reduce pain, muscle spasm, stiffness, oedema

Reduce pain, muscle spasm, soften tissues, accelerate healing

Best Modality of Choice

• Ultrasound– Thermal effect as patient presents

chronic injury– Has deep penetration depth – Long Duration of temp change– High absorption by tendons– Easy to be match contours of shoulder– Provides sufficient coverage for a small

tissue like a tendon

List of Contraindications

• Cardiac pacemakers• Patient is expecting• Area is ischemic• Thrombosis• Phlebitis• Metallic implants in treatment area• Metallic effects on or near treatment

area

Before treatment• Hot/Cold Test and sharp/blunt test• Give patient standard warning

– During treatment, all you should feel is a mild comfortable warmth. If you feel, any thing hotter, if you feel the heat concentrating in one area, or a sharp pain, you are in danger of being burnt. Alert me when this occurs and during treatment, don’t move, don’t fall asleep and don’t touch anything. Got it?

Method of Application

• Direct Contact using ultrasound gel as a coupling medium– Soundhead is in contact with skin– Suitable for treating area where surface

being treated is larger than soundhead– Not using immersion technique as it is not

convenient to be used on the shoulders– Not using gel pads (as another medium)

as effects are superficial.

Area applied

• As tendon of supraspinatus is at the greater tuberosity of humerus, the area of modality applied will be at that area.

Duration & Dosage

• As it is a chronic condition,

– 0.8-3.0 W/cm2– 1mHz (for deep penetration)– Continuous– for 7 minutes– mild to comfortable warmth.

Desired Physiological effects

• Increase vasodilatation; promotes blood flow and facilitate healing

• Decrease pain; by decreasing nerve conduction velocity

Progression of Treatment

• Recommend patient to come on a weekly basis

• Each visit, we’ll take note of patient’s ROM and pain rating

• If shows improvement, we’ll continue with treatment.

Progression of Treatment

• Encourage mobility exercises (targeting the shoulder abduction) to the limit of motion before onset of pain

– Prevent further decrease in active range of motion.

Progression of Treatment

• Once pain subsides, we will recommend stretching and strengthening exercises

– to increase ROM as much as possible and restore functional strength

• Ie. Using therapy bands and light weights for shoulder abduction

Bibliography

• http://emedicine.medscape.com/article/93095-overview

• http://www.ehow.com/about_5531020_supraspinatus-tendinosis-treatment.html