9/11/2018. Property of Aegis Therapies. Do not duplicate without written permission 1

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1 EFFECTIVENESS OF BIO PHYSICAL AGENTS ON OUTCOMES FOR THE OLDER ADULT WITH CHRONIC CONDITIONS Presented by Shonda McCauley, OTR/L And Mason Smith, COTA 2 TRAINING AGENDA Electrotherapy Overview Quality Indicators & Clinical Indications Ultrasound Electrical Stimulation Diathermy Evidenced Based Research Project duplicate without written permission 1

2 ELECTROTHERAPY AN OVERVIEW Generally, physiology is the same for people of all ages. If Physical Agent Modalities work for athletes and young people, why not use them with seniors when health problems severely impact quality of life? 4 ELECTROTHERAPY AN OVERVIEW Modality Issues Certification Competency Comfort Modalities not traditional in SNF setting Modalities are tools Complexity of machine variables Diathermy uncommon in U.S. Different manufacturers, same end product F.D.A regulated! 5 GUIDELINES Always check state practice acts Oklahoma does NOT have any guidelines requiring certain hours of CEUs or certifications in use of EPAs. AOTA position paper (2012) Check off procedures 6 duplicate without written permission 2

3 QUALITY INDICATORS & CLINICAL INDICATIONS Targeting Customer and Therapy Common Issues 1. Quality Indicators and Quality Measures SNF resident problems, categorized and measured a. internally, for facility use b. in the industry and marketplace c. (go to compare nursing homes ) 2. Clinical Indications common, universal patient problems assessed and treated by therapists 7 QUALITY INDICATORS AND QUALITY MEASURES Treated by therapy (directly or indirectly) 1. Falls 2. Behavior Problems 3. Depression Meds 5. Cognitive Impairment 6. Incontinence 7. Fecal Impaction 8. Pressure Ulcers 9. Weight Loss 10.Bedfast State 11.Decline In ADLs 12.Decline in ROM 13.Activity Level 14.Restraints 15.Pressure Ulcers 8 CLINICAL INDICATIONS Treated with modalities, influencing QIs and QMs 1. Edema 2. Pain 3. Decreased ROM 4. Increased Tone / Spasm 5. Weakness 6. Wounds 7. Neuropathy 8. Decreased Neuromuscular Performance 9. Incontinence duplicate without written permission 3

4 ELECTROTHERAPY AN OVERVIEW 10 ELECTROTHERAPY AN OVERVIEW Electrotherapeutic Agents 1. Electromagnetic (diathermy) 2. Sound Waves (ultrasound) 3. Muscle Electrical Currents 4. Nerve Electrical Currents 11 HEAT AND TEMPERATURE Pertinent physical effects of heat Rise in temperature ( molecular acvity) Expansion of the material (molecules move farther apart) Acceleration of chemical reactions Reduction in the viscosity of fluids Influence of electric/magnetic properties 12 duplicate without written permission 4

5 EQUIPMENT Regulated by the FDA each manufacturer Calibration annually by electrotherapy tech Respect universal precautions Shower caps over diathermy drum Cover machines, as needed Cover lead wires, as needed 13 ULTRASOUND 14 THE PHYSICS OF ULTRASOUND Humans 16 to 20,000 Hz; US > 20,000 Hz Mechanical energy passes through a medium, not a vacuum Piezoelectric effect voltage applied across a crystal creates longitudinal waves Continuous or bursts of voltage continuous or pulsed modes Intensity is in watts/cm 2 15 duplicate without written permission 5

6 THE PHYSICS OF ULTRASOUND Piezoelectric effect Synthetic crystals in 2 to 3mm thick slices Most plumbium zirconium titanate (PZT) Sandwiched between two electrodes and cemented to the transducer treatment surface Current flows from electrode to electrode causing the crystal to vibrate and emit waves Avoid heavy impact with the sound head 16 THE PHYSICS OF ULTRASOUND Frequency Parameter Frequencies of 1 MHz and 3 MHz 1 MHz depth of penetration to 2.5 inches 3 MHz depth of penetration to 1 inch Frequency, not intensity determines depth of penetration Benefit of ultrasound therapist controls the depth that heating occurs! Higher the frequency, the faster the heating 17 THE PHYSICS OF ULTRASOUND Energy from sound head is in the shape of a cone Interactions with tissue: 1. Cavitation creates micro meter sized bubbles 2. Acoustic Streaming energy causes the bubbles in the tissue to stream 3. Heat from the friction of oscillating molecules rubbing against each other 18 duplicate without written permission 6

7 PHYSIOLOGICAL EFFECTS OF ULTRASOUND Pulsed Ultrasound Non thermal mechanical effects Streaming influences cell membrane Cellular diffusion rates Membrane permeability Nerve conduction Accelerates synthesis of collagen Indications Tissue repair Reduction of edema Pain management 19 PHYSIOLOGICAL EFFECTS OF ULTRASOUND Continuous Ultrasound Thermal when ssue temperature is increased to between 40 and 45o C. Effects metabolic rate enzyme activity accelerate tissue healing collagen extensibility increase ROM neural sensitivity decrease pain Vasodilatation increases blood flow to the area, improves the delivery of nutrients and cells, and accelerates the removal of waste products. Must use proper technique! 20 FACTORS GOVERNING OPTIMAL APPLICATION OF US Coupling Mediums Ultrasound cannot travel through air it needs direct patient contact with transducer Ultrasound gel is most commonly used and high viscosities make it user friendly. Keep the sound head in full contact and parallel to the treated area. Make sure there is adequate gel. Water bath good for uneven and small anatomical structures and/or very painful injury sites. 21 duplicate without written permission 7

8 FACTORS GOVERNING OPTIMAL APPLICATION OF US 1. E.R.A.: effective radiating area Treat ONLY 2x the ERA ERA is always smaller than the transducer surface 2. Move sound head at the proper speed Never use a stationary technique Fast movements translate to treatment areas that are too large uneven tissue exposure and treatment effects A good rate is about an inch and a half per second (toasting a marshmallow) If patient complains of pain, decrease the intensity 22 ULTRASOUND INDICATIONS FOR USE US does two main things Thermal: Heats tissue to increase extensibility and reduces pain OR Non Thermal: Alters cell membrane permeability to accelerate tissue healing 23 ULTRASOUND INDICATIONS FOR USE Thermal Need to increase blood flow Subacute and chronic inflammation Muscle spasm Subacute and chronic pain Joint stiffness and contractures Stretching Non Thermal Acute pain and injury Tissue healing Neurological factors (trigger points, s/p stretching) 24 duplicate without written permission 8

9 ULTRASOUND INDICATIONS FOR USE Strong evidence that the effectiveness of ultrasound depends upon when in the tissue healing process it is used! Ultrasound is good for heating tendons, ligaments, joint capsules, and fascia smaller, site specific. Ultrasound is not so good for heating muscle due to its lower absorption and typically large surface areas. 25 ELECTRICAL STIMULATION 26 ELECTRICAL STIMULATION AN OVERVIEW Safe Well regulated Calibration and safety checks Considerable variables Many indications for use 27 duplicate without written permission 9

10 ELECTRICAL STIMULATION AN OVERVIEW Electrical Stimulation One lead wire carries the current from the stimulator through the electrodes to the patient Electrical current flows through the patient Other lead wire carries the current back to the stimulator, completing the circuit Stimulator + - Patient Cathode negative pole 28 APPROVED FORMS OF E STIM NMES (Neuromuscular Electrical Stimulation) Use of electrical stimulation for activation of muscles through stimulation of the intact peripheral motor nerves. Main treatment goals are to strengthen weak muscles and to help in the recovery of motor control EMS (Electrical Muscle Stimulation) The use of electrical stimulation for direct muscle activation of denervated muscle fibers in the absence of peripheral innervation. Main treatment goals are to retard muscle atrophy, and to local blood flow FES (Functional Electrical Stimulation) Use of NMES to promote functional activities, e.g., stimulating ankle dorsiflexors during gait TENS (Transcutaneous Electrical Nerve Stimulation) Use of externally applied electrical stimulation for pain management 29 FDA APPROVED FORMS OF E STIM Pain Interferential Premodulated TENS / NMES symmetric TENS / NMES asymmetric biphasic [ACP PENS] Microcurrent Muscle Stim High Volt Galvanic Pulsed (HVPC) Direct Current Russian Stim Medium Frequency Medium Frequency burst 30 duplicate without written permission 10

11 INDICATIONS FOR USE, BY E STIM TYPE Pain management Muscle weakness Reduction of edema Increase local circulation Tissue/wound healing Decrease spasticity Contracture management 31 INDICATIONS FOR ELECTRICAL STIMULATION: REVIEW OF LITERATURE Application IFC Premod MF HVP Micro- Russian Current Pain Management Acute Chronic Spasms Post-Operative Muscle Weakness Min to moderate Moderate to Severe Disuse Atrophy Re-education Increase ROM Inflammation / Edema Increase local circulation Tissue healing Spasticity management Contracture management TENS 32 DIATHERMY AN OVERVIEW 33 duplicate without written permission 11

12 DIATHERMY AN OVERVIEW Electromagnetic radiation SWD is nonionizing 1. Pulsed non thermal: sufficient off time to dissipate heat thermal: high intensity and/or rate, can generate heat dependent on machine/settings/manufacturer 2. Continuous thermal response, no off time degree of heating based on intensity 34 DIATHERMY AN OVERVIEW Advantages Can heat deeper tissues Treat areas larger than ultrasound Does not reflect off bone (periosteal pain) Longer stretch window (10 15 minutes after completion of SWD treatment) Easy set up Supervised generally, constant attendance not needed 35 PHYSIOLOGICAL EFFECTS OF DIATHERMY Usage Most popular modality in Europe Historically used to treat infections still effective (decreased with use of antibiotics) New units shielded, easy to use Only one unit manufactured in U.S. Magnatherm Most units imported from Europe (Mettler and ACP) 36 duplicate without written permission 12

13 PHYSIOLOGICAL EFFECTS OF DIATHERMY Non thermal Alter cell membrane permeability Influence cellular chemistry by increasing cellular activity Stimulate mitochondral activity Increased microvascular perfusion (healthy subjects and diabetic ulcers) Just as with ultrasound, lower energy levels can generate significant, positive effects 37 PHYSIOLOGICAL EFFECTS OF DIATHERMY Non thermal tissue healing specifics Attracts macrophages and neutrophils to the damaged tissue Increases T cell lymphocyte activity Increases cellular PO2 thus improving macrophage and osteoclast activity Reverses damaged cell polarity from + to (related to osmotic gradients) Increases number of fibroblasts 38 PHYSIOLOGICAL EFFECTS OF DIATHERMY Thermal When tissue temperature is increased to between 40 and 45o C Effects metabolic rate enzyme activity accelerate tissue healing collagen extensibility increase ROM neural sensitivity decrease pain Vasodilatation increases blood flow to the area, improves the delivery of nutrients and cells and accelerates the removal of waste products Must use proper technique! 39 duplicate without written permission 13

14 DIATHERMY INDICATIONS FOR USE Non Thermal Acute injury with edema Rheumatoid Arthritis exacerbations Arterial insufficient wounds (direct and indirect) Tissue healing in presence of poor circulation Thermal Need to Increase blood flow Subacute and chronic inflammation Muscle spasm Pain Joint stiffness and contractures Stretching 40 DIATHERMY INDICATIONS FOR USE Edema non thermal to mild heating Pain moderate to vigorous heating Peripheral neuropathy mild to moderate heating Venous insufficiency wound non thermal to mild heating Arterial insufficiency wound non thermal to mild heating Diabetic ulcer moderate to vigorous heating 41 RESEARCH 42 duplicate without written permission 14

15 RESEARCH: PURPOSE Explores three drivers combined with conventional OT practice: Evidence based use of BPAs Evidence based economics Quality improvement 43 RESEARCH: DESIGN Retrospective study Using EMR of patients with multiple chronic conditions treated with BPAs All within Post Acute Care settings between 2010 and 2015 Includes data from initial POC prior to initiation of BPAs with index date being first date of treatment with BPAs Control group did not received BPAs 44 DEMOGRAPHICS AND OUTCOMES BPA Non BPA n=8393 n= (16 84); 73 (11 84); Age SD 9 SD 9 15 (0 30); 13 (0 13); LOS SD 9 SD (0 3); 0.79 (0 3); Functional Admit SD 0.58 SD (0 3); 1.74 (0 3); Functional Discharge SD 0.87 SD ( 2 3); 0.96 ( 3 3); Functional Gain SD 0.78 SD 0.80 HMO/MCO Payor Medicare Part A No Rehospitalization 76.30% 73.00% Yes 23.70% 27.00% No 51.20% 50.40% D/C Community Yes 48.80% 49.60% 45 duplicate without written permission 15

16 VALUE EQUATION 46 VALUE EQUATION 47 VALUE EQUATION 48 duplicate without written permission 16

17 RESEARCH: RESULTS/CONCLUSION Significant difference noted as compared to control Improved functional performance The project was able to demonstrate how the use of BPAs can improve performance in occupations Occupation based interventions plus BPAs can enhance functional outcomes while containing costs 49 THANK YOU! Aegis Therapies welcomes all persons in need of its services and does not discriminate on the basis of age, disability, race, color, national origin, ancestry, religion, gender identity, sexual orientation or source of payment. Interpreter Services are available at no cost. Please visit your local Aegis Therapies location for assistance. Servicios de interpretación están disponibles sin costo. Visite su sucursal local de Aegis Therapies para recibir asistencia. 我们提供免费传译服务 请探访您的本地 Aegis Therapies 地点以获得协助 ATS A duplicate without written permission 17