Occupational therapy programs tables of content

PROGRAM: ULTRASOUND

MODALITY: THERMAL ULTRASOUND
I.X. PROCEDURE FOR THERMAL ULTRASOUND
DESCRIPTION/PURPOSE:
Ultrasound is defined as inaudible, acoustic, mechanical vibrations of high frequency that produce thermal and non-thermal physiological effects. Thermal effects are achieved by using continuous mode.
OBJECTIVES/GOALS:

Increases collagen extensibility of tendons, joint capsules and scar tissue in preparation for activities.

Increases motor and sensory nerve conduction velocities which assist in reducing pain.

Alters the contractile activity of skeletal muscle, thereby reducing muscle spasm.

Reduces muscle spindle activity.

Increases blood flow by producing reflex vasodilation.
INDICATIONS:

Decreased soft tissue extensibility.

Scar tissue.

Pain.

Muscle spasm.

Acute and chronic soft tissue inflammatory processes such as bursitis, tendinitis.
CONTRAINDICATIONS:

Over the eyes.

Over the heart, or on patients with advanced heart disease.

Demand pacemaker.

Over or near pregnant uterus.

Over the testes.

Malignancy.

Over epiphysial plates.

Over cervical stellate ganglion or vagus nerve.

Over carotid sinuses.

Circulatory insufficiency; i.e., deep vein thrombosis or occlusive vascular disease.

Acute or severe sepsis or infection.

Myositis ossificans.

Thermal Ultrasound (cont.)
PRECAUTIONS:

Absent of diminished sensation to pain and temperature.

Residents with psychological or physical hypersensitivity to ultrasound.

In an area of cemented prostheses.

In an area of tendon repair.

Areas of reduced circulation, e.g., recent scar.
INSTRUCTIONS/PROCEDURES:

Prior to beginning treatment, review the medical record and obtain adequate knowledge of patient’s condition, disability, and referral for treatment.

Instruct the patient in procedure, length of treatment, goals and symptoms to notify therapist of, if they should occur.

Position patient comfortably with area to be treated fully exposed.

Check sensation of area to be treated and apply coupling agent. (If area to be treated has an irregular surface topography or is sensitive to pressure, ultrasound may be applied under water in a plastic tank).

Turn intensity to “0" and turn on unit. Set the timer for duration of treatment.

Apply sound from head firmly to area to be treated making solid contact. Move the applicator in longitudinal or circular overlapping strokes at a rate of 4 cm/second.

Motion should be slow enough to insure proper absorption but fast enough not to produce an excessive amount of absorption or a feeling of pain. (Strokes should overlap 50% of previous stroke).

The total area covered is usually 2 to 3 times the size of the irradiating crystal for every 5 minutes of exposure.

Adjust the intensity (generally 0.5-2.0 w/cm) to a sensation of mild warmth.

The duration of treatment will be determined by the diagnosis, area to be treated, and method of application (generally 5 min. per 6-8 square inch area).

See attached handout for suggestions for determining ultrasound dosage.

At termination of treatment:

Turn intensity to “0" and turn off unit.

Remove coupling agent from area treated with wascloth.

Dry off with bath towel.

Discard wet linen.

Clean sound head with isopropyl alcohol.

Return equipment to designated area.

Chart significant differences in patient’s condition, response treatment, etc.

Thermal Ultrasound (cont.)

Special considerations:

Caution is suggested when using ultrasound immediately after the application of heat and cold modalities as this may alter the patient’s perception of warmth and pain.

Avoid immersing an part of the operator’s body into the water bath as much as possible during underwater techniques since long term effects of ultrasound energy exposure have not been evaluated.

If periosteal pain occurs, check position of sound head, intensity, and amount of coupling agent.

Ultrasound may also be utilized for phonophoresis with 5% or 10% hydrocortisone cream, myoflex, etc.

Frequency:

Based on therapist’s clinical judgment and physician referral, frequency may

range from 1x/day to 3 or 4x/week. If there is no positive benefit after 4

applications, ultrasound should probably be discontinued. Reassess patient’s

response to treatment on a weekly basis.

DOCUMENTATION:
(Same as Electrotherapy)
RESOURCES:
American Occupational Therapy Assoc. (1992). Position paper: Physical Agent Modalities. American Journal of Occupational Therapy, 46-1090-1091.
Gann, N. (1991). Ultrasound: Current Concepts. Clinical Management, 64-69.
Hecox, B., Mehreteat, T.A., and Weisberg, J. (Eds.) 1994. Physical Agents Norwalk, CT; Appleton and Lange.
Trombly, C. (1995). Occupational Therapy for Physical Dysfunction.


PROGRAM: ULTRASOUND

HANDOUT
ULTRASOUND TERMINOLOGY
Frequency - The number of oscillations per unit of time, usually expressed in cycles per second (Hz). Most therapeutic ultrasound units operate at 1.0 MHz (one million cycles per second). Some units also operate at 3.0 MHz.
Attenuation - The reduction of energy of the sound beam due to scattering and absorption. Attenuation and tissue absorption increase as the frequency increases.
Intensity - The energy of the sound beam, which can be expressed in the number of watts per square centimeter (M/cm). Therapeutic intensities may range from 0.1 to 3.0 W/cm.
Absorption - The amount of the energy absorbed by the tissues. This increases as the frequency increases, and also is increased by the presence of protein.
Continuous Mode - The ultrasound beam is emitted without interruption, thereby elevating tissue temperature.
Pulsed Mode - The ultrasound beam has short interruptions, thereby preventing thermal build-up, but maintaining the ultrasound’s mechanical effects.
Cavitation - The production through ultrasound of gas or vapor-filled bubbles in tissue fluids. Cavitation can be stable or transient. Transient cavitation may cause severe damage because of the collapse of these bubbles. Transient cavitation can be avoided by using the lowest intensity necessary to produce the desired effects, by using higher frequencies, and by moving the applicator throughout the treatment.
Standing Wave - The incident wave at the tissue interface may interfere with reflected waves, creating a standing wave with points of very high intensity. This also must be avoided by continually moving the applicator.
Acoustic Streaming - The steady circular flow of cellular fluids induced by ultrasound. This is thought to cause changes in cellular activity to stimulate tissue repair.
Dusty Cycle - The fraction of time when the ultrasound is present during one pulsed period, e.g., 2 ms/4ms=0.5=50% when using pulsed-mode ultrasound.
PROGRAM: ULTRASOUND

HANDOUT
GUIDELINES FOR DETERMINING DOSAGE

Continuous mode ultrasound more effectively elevates tissue temperature, used for its thermal effects.

Pulsed ultrasound which has a less than 50% duty cycle minimizes thermal effects, used for its non-thermal effects.

The higher the frequency, the greater the absorption in superficial structures.

3 MHz - used when target tissues are superficial or 1-2 cm below the skin

surface.

1 MHz - used when target tissues are located in depths of 3-5 cm.

Muscle absorbs 2x as much ultrasound as fat, bone absorbs 10x more ultrasound than does soft tissue.

The target tissue must be treated for at least five minutes to achieve adequate tissue heating.

When using ultrasound for wound healing, ideally utilize frequency of 3 MHz with pulsed wave and 20% duty cycle.

Treatment intensities generally range from 0.5 W/cm to 2.5 W/cm with the higher intensities being utilized when the target tissue is very fleshy or deeply located. Areas with less soft tissue coverage such as elbows or ankles are usually treated at 1.0 Wcm or less with a higher frequency.

A mild sensation of warmth should be felt by the patient when using thermal ultrasound.

Higher intensities may be chosen when the purpose of treatment is to elevate tissue temperature of periarticular structures during or preceding a slow sustained stretch.

Lower intensities may be utilized for pain reduction and relief of muscle spasm.

Size of transducer must be considered when calculating total ultrasound exposure.

Some literature suggests that the number of ultrasound treatments should not exceed 14. If ultrasound were to be continued, the course of 14 treatments should be followed by several weeks rest before resuming.

PROGRAM: ELECTROTHERAPY
MODALITY: HIGH VOLTAGE PULSED CURRENT
DESCRIPTION/PURPOSE:
High voltage stimulators have an output between 300-500 volts. Common to high voltage stimulators is a monophasic pulse type with a double peak shape. These monophasic pulses are very short. The duration of each pulse has been measured to range between 5 and 75 microseconds and a high peak current. The high peak current does not mean high average current, which in most high voltage stimulators cannot exceed 1.5 to 2.0 milliamperes. The very low average current output of the high voltage stimulators makes them very safe.
The pulse parameters are the factors that allow a greater variety of physiological responses. The key benefit of the high voltage stimulator is its versatility in clinical application. The very short pulse duration of the high voltage group creates a stimulation which is quite comfortable and one which most patients can tolerate. This very short pulse duration followed by a very long interpulse interval eliminates the formation of any appreciable chemical or thermal effects in the tissue.
The combination of the short pulse duration and high peak current of the high voltage stimulator is a major reason that it is capable of evoking three main excitatory responses: 1) sensory stimulation, 2) muscle contraction and 3) temporary accumulation of positive or negative charges in the stimulated tissue.
High voltage stimulators, at present, cannot stimulate denervated muscles, nor can they perform effective iontophoresis due to the very short pulse duration. A very strong contraction of a large muscle mass may also be difficult to achieve.
OBJECTIVES/GOALS:

Edema reduction.

Decreased muscle spasm.

Increased circulation - vasodilation.

Decreased pain.

Prevention of muscle atrophy.

Wound healing by providing a positive or negative polarity.

Inhibition of spasticity.

Muscle re-education.

Muscle strengthening.

Electrotherapy (cont.)

INDICATIONS:

Pain acute or chronic.

Impaired joint mobility (Joint range of motion).

Protective muscle spasm.

Muscle disuse atrophy in post injury conditions.

Dermal and subdermal tissue damage e.g., pressure ulcers, post-surgical wounds, burns, etc.

Edema.

Peripheral circulatory disorders.

Intra-articular effusion.

Muscle re-education.
CONTRAINDICATIONS:

Over the carotid sinus area.

Patients with cardiac pacemakers.

Not used transcerebrally.

Not used over pregnant uterus.

Not used over or near cancerous malignancy.

Not used to relieve pain syndromes until etiology has been established.

Hemorrhagic conditions.

Peripheral vascular problems involving clots.

PRECAUTIONS:
Very obese residents.
PROCEDURE:

Intelect model 700-C

Dial the function selector switch in the center of the panel to desired setting: either Prob, Continuous, Surge, Reciprocate 2.5 secs., Reciprocate 5 secs., or Reciprocate 10 secs.

Set the polarity switch to Positive (+) or Negative (-).

Dial the Pulses/Sec to the determined rate.

Attach the dispersive pad to the patient.

Attach the active pad or pads to the patient unless you are going to use the probe with the roller electrodes. If you are using the roller electrodes, use a conductive gel on the area of the patient where high voltage is going to be used.

Turn Treatment Time Knob to the determined total time of the treatment.

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Electrotherapy (cont.)

Turn the Timer clockwise past 5 and then set treatment time.

Set the On/Off Switch to On. The Amber and Green Lights will both come on.

If the Red Reset Light comes on, then On/Off Switch must be set of Off. The operator should then count to three and rotate and On/Off Switch to the On position and the Green and Amber lights will come on to signal that the unit is operable.

Rotate the vernier potentiometer clockwise until patient’s tolerance is reached.

Adjust the pulse interval control to the desired setting for the patient: 5 for the strongest sensation and 255 for the smoothest sensation.

Frequency/Duration
Treatment time varies from 30 minutes to 60 minutes and may be performed TID to BIW depending on the clinical problem, the treatment goals and the tolerance of the patient. Please refer to the “Clinical Applications Guidelines for High Voltage Stimulation by Gad Alon, Ph.D., P.T.” page 10-11 of Operator’s Manual for Intellect Model 700C. Effectiveness of the modality should be re-evaluated after 6 treatments.
DOCUMENTATION:

The documentation must relate why this modality required the service of a skilled therapist to administer.

The documentation must relate the relationship of the modality to a functional activity.

RESOURCES:
Cummings, J (1991). Iontophoresis In R.M. Nelson and D.P. Currier (eds.), Clinical Electrotherapy (pp. 317-329). Norwalk, OT: Appleton and Lange.
Snyder-Mackler and Robinson, A, J (Eds.) 1989 Clinical Electrophysiology. Baltimore: Williams and Wilkins.
Trombly, Catherine A. (1995). Occupational Therapy for Physical Dysfunction. Baltimore: Williams and Wilkins.

OCCUPATIONAL THERAPY

PROGRAMS

Section 16

PROGRAM: SEATING AND POSITIONING
DESCRIPTION/PURPOSE:
Appropriate seating and positioning creating normal alignment between the head, neck, trunk, and pelvis lays the foundation for quality motor control.
OBJECTIVES/GOALS:
Upright posture facilitates alertness, decreases tone and aids in maintaining vital functions such as respiration, cardiac output, etc. It also assists in maintaining skin integrity, muscle tone, self-care skills and social interaction. Refer to the handout to outline specific benefits and goals.
INDICATIONS:

Poor postural alignment due to orthopedic deficits.

Increased/decreased tone causing poor anatomical alignment.

Compromised skin integrity.

Poor postural alignment due to dementia.

Poor postural alignment due to neurological deficits.
CONTRAINDICATIONS:

Medically unstable.
PRECAUTIONS:

Specialized seating needed to manage decubiti.

Postural spasms that may cause tightening of positioning devices thereby decreasing blood flow, motor control, etc.

Need for graded endurance programming with new seating devices.

Specific precautions for each powered device as outlined by the manufacturer.

Cognitive impairments that may limit judgment when using high tech seating devices.

Sensory loss and edema.

EQUIPMENT:

Tape measure.

Special seating forms.

Various cushions, lateral supports, etc. to try for evaluation.

Standard wheelchairs that can be adapted for specialized seating.

Seating and Positioning (cont.)

ASSESSMENTS:

Wheelchair evaluations - refer to wheelchair prescription program.

Specialty seating systems available from various manufacturer.

Note resource page for further information.
PROCEDURES:

All seating and positioning evaluations are under a physician’s prescription.

Complete a total OT and/or PT evaluation to note all limitations and areas that positioning would be important to increase or maintain function.

Develop a treatment plan that would encompass the obtaining of appropriate seating devices, analysis of funding for these, and programs of endurance for tolerating the devices.

Once seating/positioning device has been completed further analysis from the optimum postural position needs to take place relating to functional tasks.

The total seating/positioning device must be outlined for the staff/family with reasons for and explanations of how to achieve and maintain alignment.
DOCUMENTATION:
Refer to handout on how to document for positioning/seating interventions.
RESOURCES:
Refer to resource outline and tot he Assistive technology program.

PROGRAM: SEATING AND POSITIONING

OPTIMAL WHEELCHAIR SITTING POSITION

Symmetry

9 Body is aligned and balanced right and left of midline. 9 Trunk is aligned according to normal cervical, thoracic and lumbar curves.

Pelvis/Hips

9 Equal weight bearing on bilateral ischial tuberosities. 9 Hips in neutral rotation and level to the horizontal plane. 9 Buttocks centered on the seat. 9 Pelvis/hips placed as far back as possible on the seat. 9 Pelvis/hips positioned in a 90" angle. 9 Pelvis maintains slight anterior tilt to promote normal lumbar lordosis. 9 Seatbelt fastened across the hips at 45" - 90" angle.

Knees and Ankles

9 Knees at 90" angles. 9 Knees pointed straight ahead. 9 Knees level with the hips or slightly higher. 9 Ankles at 90" angles. Q Feet supported on firm surface (footrest or floor if resident is not being moved). Q Toes pointed straight ahead. Q Approximately 25% of body weight transmitted to the floor (or footrest).

Trunk/Body

Q Body is aligned vertically. Q Trunk does not demonstrate lateral curvature. Q Body does not lean too far forward or back. Q Slight lumbar lordosis.

Arm and Shoulder Position

Q Elbows rest comfortably on the armrests or lap tray. Q Shoulders relaxed and level.

Head Position

Q Head in midline between shoulders, slightly forward. Q Neck slightly extended to allow full visualization of the immediate environment. Q Chin tucked (neutral).

WHAT ARE THE BENEFITS OF MAINTAINING AN OPTIMAL

SITTING POSITION?

LEVEL OF AROUSAL. Upright posture facilitates alertness through visual-vestibular and proprioceptive sensory feedback mechanisms.
VITAL FUNCTIONS: RESPIRATION AND CARDIAC OUTPUT.

Mechanism of Respiration:
1. Enlargement of chest cavity causes negative pressure resulting in inspiration.

Ribs expand upward and outward, enlarging chest capacity.

Diaphragm descends, enlarging chest capacity, abdomen moves outward as a result.

Neck accessory muscles may be used to supplement elevation of rib cage.

Relatively negative pressure causes air to move into check, expanding lungs.

Passive recoil of chest and diaphragm result in passive expiration.

Negative pressure generated from efficient respiration assists in drawing blood back toward the chest as pressure becomes negative during inspiration.

Cardiac Output:
Cardiac Output equals Stroke Volume X Heart Rate (CO=SVxHR)

Stroke volume may be directly influenced by the sitting posture of the patient as it impacts upon respiration and pressure forces on the heart.

Cardiopulmonary benefits of an upright posture.
Allows accessory muscles and rib cage to assist with respiration more efficiently.

Decreases effects of gravity on chest expansion.

Mobilizes pulmonary secretions.

Facilitates circulation of blood back from the extremities, promoting blood flow into the heart which improves stroke volume.

Discourages pooling of blood volume in the abdomen.

Decreases compression of chest and thus facilitates refilling of the heart chambers for increased stroke volume.

III SKIN INTEGRITY. Proper positioning allows for distribution of weight bearing

over larger surface areas and away from bony prominences. When sitting

properly, weight is distributed primarily along the buttocks, thighs, and plantar

surfaces of the feet.

IV VISION. Visual regard of the environment is facilitated through upright

posture.

V PERCEPTION is enhanced through reception of normal proprioceptive input

through the feet, back, legs, and buttocks. Midline orientation is enhanced,

as well as upright posture of the head and neck which enhances visual and

auditory perception.

VI MUSCLE TONE is normalized through the appropriate weight-bearing that is

realized through good sitting position. For example, extensor muscle tone of

the back is enhanced through upright posture.
VII MUSCULOSKELETAL INTEGRITY is maintained through appropriate align-

ment of joints and muscles. Joints that are more functional in lengthened,

shortened, or mid-range positions are maintained.
VIII SELF CARE, WORK AND LEISURE activities are enhanced through abilities

to assume and maintain proper sitting position. Proper sitting posture allows

for movement of the extremities and interaction with the environment that may

not be possible in abnormal sitting postures.

IX SOCIAL INTERACTION AND COMMUNICATION are all greatly influenced

by sitting posture. Upright trunk and head posture facilitates interaction with

others and lessens the negative aesthetic and psychological effects of using

a wheelchair. Respiratory support to speaking functions and positioning the

extremities to use alternative communication devices are other areas of

function that can be positively impacted.

X ROLE PERFORMANCE. Proper positioning can maximize independent

functioning in certain skills and decrease the need for assistance. Quality of

life, then, can be greatly enhanced through the ability to maintain a proper

sitting position.

WHAT ARE SOME OF THE COMMON POSITIONING ALTERNATIVES FOR

THE WHEELCHAIR OR CHAIR?

NOTE: Refer to catalogs of seating equipment for illustrations and more detailed descriptions of products: Alimed, Jay Medical, OTTO-Bock, Pin-Dot and ROHO are some of the more frequently used commercial vendors. Addresses are in the section on “Additional Resources”.

1. SEAT BOTTOMS/BACKS

Sling Upholstery - Standard wheelchairs are usually supplies with “sling” naugahyde upholstery. These will usually stretch out, some sooner or later depending upon the quality. They can be reinforced early on (i.e., doubling the upholstery) to prolong stretch from occurring. Once stretched out the only solution is to replace.

Solid Seat/Back

Wood is used often to reinforce seats. It can be placed on the metal uprights over the top of the existing sling seat, or can be mounted to the wheelchair frame (the seat height can be lowered to accommodate). The metal hooks used to attach the wood to wheelchair frame are the most expensive in adding this option to seats. Several options exist for solid inserts, including some that are made of high density plastic which offer better protection against mold/mildew and spread of infection. Note that compliance may be difficult to get for placing a cushion over the solid insert and this may preclude using this option. A permanent installation of a combination solid seat and cushion is the best option in this instance.

Seats can be altered to accommodate or correct postural problems by changing the shape of the foam or angle of the metal hooks used to attach the solid seat.

Wedging or inclining the seat is a common correction used to prevent some patients from sliding forward out of the chair. Patients who have increased extensor tone may benefit from this adaptation. Caution: Patients who have wedged seats require ability to tolerate more than 90 degree hip flexion. Wedge seats can also increase posterior pelvic tilt, and probably should NOT be used as a first alternative for patients who slide forward in the chair.

Drop seats can be used to lower the seat height to enable shorter residents to reach the floor.

Seat Backs may also need to be altered for some patients who have increased extensor muscle tone through the trunk. Wedging the trunk with the thickest part of wedge at shoulder level assists in bringing the shoulders forward over the hips to decrease upper body extensor muscle tone. High trunk extensor muscle tone usually requires use of seat belt to keep pelvis positioned. Seat backs may also provide lumbo-sacral and/or lateral support.