Occupational Therapy Association of Oregon By the end of the session you will all be Raving Fans of Physical Agent Modalities!

Transcription

1 Occupational Therapy Association of Oregon 2016 Ernie Escovedo OTD, OTR/L Lyn Cikara OTR/L Objectives By the end of the session you will all be Raving Fans of Physical Agent Modalities! Know what AOTA says Know more about how PAMs help us help our patients Know how to decide what to use for whom Know that you will do no harm 1

2 Pain Limitation ROM Review your present caseload with these impairments in mind Consider which PAMs may be useful towards impairment Adjunctive Therapies Something that is joined or added to another thing but is not an essential part of it Merriam Webster thermal ultrasound was used as an adjunct to stretching and orthotics which improve range of motion necessary for selffeeding light therapy was used to reduce pain in the shoulder to enable participation in meal preparation activity. Graded strengthening tasks were also used to minimize causal factors and insure long term outcome 2

3 Professional guidance from on high What AOTA Says Physical Agent Modalities: A Position Paper (1992; 1997; 2003; 2008; 2012) AOTA official document which defines PAMs, specifies use as preparatory to purposeful activity 3

4 AOTA Documents Scope of Practice: The practice of occupational therapy includes 1. B.5: Prevention of barriers to performance 1. C.2.e: Application of physical agent modalities and use of a range of specific therapeutic procedures to enhance performance skills (AOTA, 2014) AOTA Documents Standards of Continuing Competency Standard 3. Clinical Reasoning Skills 1. Application of evidence, research, findings, and outcome data in making decisions 2. The ability to assess previous assumptions against new evidence and revise decision-making process Standard 4. Performance Skills 1. Integrating current practice techniques and technologies 2. Updating performance based on current evidence-based literature in consideration of client desires and practitioner judgment (AOTA, 2010) 4

5 The best PAM approach is the one that meets the clients needs, not the clinicians favorite What do modalities really do? ) Provide energy to the tissue 1. Visible (light) 2. Audible (radio waves) 3. Touch (electricity, infrared) Conversion Conduction Convection Radiation (Knight & Draper,

6 Ultrasound What is it? Sound (mechanical pressure) wave Creates vibration of molecules in our tissues Friction and heat developed Ultrasound - How does it work? Electrical current converted to mechanical energy Crystals in transducer expand and contract Vibration emits mechanical pressure wave that transmits into tissue Clinician control parameters to elicit desired effect (thermal or sub-thermal effect) 6

7 Ultrasound: Effects in Tissue Increases blood flow necessary to flush chemical irritants (bradykinins, prostaglandins, lactic acid) (Koustopoulos& Rizopoulous, 2001) Results in altered viscoelasticity and matrix of collagen (Cameron, 2003) Mechanical effects increase histamine release (Knight & Draper, 2008) Nonthermal effects alters membrane permeability to accelerate tissue healing (Cameron, 2003) Diathermy What is it? From the latin To heat through High frequency electromagnetic energy (waves) into the tissue Pulsed energy Inductive drum technology (most common) 7

8 Diathermy How does it work? Same effects as ultrasound though the origin of energy is electromagnetic vs. mechanical pressure wave (Accelerated Care Plus 2015) Diathermy What Does it Do? Reduces Pain Increases circulation Edema reduction Tissue Healing (Bracciano, 2008; Knight & Draper, 2008; Cameron, 2003; & Draper & Prentice, 2002) 8

9 Pulsed Shortwave Diathermy - Evidence Synovial sac thickness and knee pain induced with high frequency SWD treatments (Jan, Chai, Wang, Lin, & Tsai, 2006) Short term effectiveness with reduction of pain and increased function and quality of life with low and high doses of pulsed shortwave diathermy (Fukuda et al, 2011) Electrotherapy How Does it Work? Primarily used to depolarize nerves, direct current used with denervated muscles or iontophoresis Introduction of electrical currents to tissue at varying frequencies (example: 4hz; 5 hz;, 35 hz; 75 hz; 100hz) Parameters, such as waveforms, pulse dimensions, and intensity influence effects in tissue 9

10 Electrotherapy What it Does (Accelerated Care Plus 2015) Electrotherapy - Forms (Accelerated Care Plus, 2015) 10

11 Electrotherapy - Evidence Frequency specific use conventional TENS is effective for pain control with patients taking opiods; Accupuncturelike TENS only effective with patients not using opiods (Leonard, Cloutier, & Marchand, 2011) Sensory stimulation via TENS may be beneficial to enhance aspects of motor recovery following a stroke, particularly when used in combination with active training (Neurorehabilitation and Neural Repair (2011) Pain Limited ROM What PAM approaches would be applicable to your client? What would you do following the application of the modality? 11

12 Occupational Therapy Association of Oregon 2016 Ernie Escovedo OTD, OTR/L Lyn Cikara OTR/L Client goalsand barriers drives the treatment not the modality 12

13 Occupational Performance Occupational performance is the active doing of the person in the context of the occupational form So what does this really mean? (Nelson & Jepson-Thomas, 2003) How well we do what we want to do and need to do, to live our lives the way we want to live them (Escovedo, :39pm) Occupation-Based Care.What does that mean? Occupational performance must first be analyzed prior to selecting of any intervention(s) Selected approach must directly affect or enable participation or performance task Establish an occupation-based goal Question to ask ourselves is the modality being used as a component based approach alone OR is it used and measured to enable a meaningful occupation 13

14 Occupation-Based Steps to Consider Client-centered approach Ask!!! -Tell me about your day to day life -What do you love to do? -What do you need to do? -What is important to you? Occupational performance based long term goals Driving Changing clothes/shoes for physical activity at school Caring for grandchildren Enjoying a meal family or friends Performing job duties Activity Analysis Occupational Therapy Practice Framework, 3 rd Edition (Framework III) Understand the demands a specific activity places on a client Understand the specific body structures, body functions, performance skills, and performance patterns that are required Determine the generic demands the activity or occupation makes on the client (Framework III) 14

15 Occupation Based Steps to Consider Occupational necessities to achieve performance Sit upright and rotate trunk Tolerate extended periods of physical or mental activity Adequate vision to drive Ability to lift body parts required with IADLs, ADLs Coordinated movement Occupation Based Steps to Consider Barriers/Needs Why can t the task be done? What is preventing or hindering participation? What is the effect on activity? What is the client s perception of their skills or limitations? pain, activity tolerance, weakness, coordination, edema, atrophy, cognition, visual-spatial 15

16 Occupation Based Steps to Consider Approaches What are the options: activity, manual techniques, postural adjustments, strengthening, physical agent modalities? Is there evidence to support the considered approach? What is the client preference or perceptions on considered approach? Time If we don t measure and document what we do, then we can t say it was us that made the difference 16

17 What are Outcomes? Outcomes are the end result of the occupational therapy process; they describe what clients can achieve through occupational therapy intervention (Framework III) Why Do We Need Outcome Measures? Provide credibility to our clinical observations and enable therapists to determine most effective programs and interventions (Law, Baum, & Dunn, 2005) Establishes whether change is attributable to the interventions we provided (Unsworth, 2000) Accountability to clients and payor sources (Baum, 1997) 17

18 Type of Outcome Measures 1. Generic (FIM; Medical Outcomes Study 36-SF 36)) 2. Disease or symptom-specific (Arthritis Impact Scale-AIMS) 3. Regional or body-part specific (Disability of Arm Shoulder Hand-Dash) 4. Patient Specific (Patient Specific Functional Scale) Outcome measurements also categorized as Performance oriented: measures change in occupational performance Component oriented: measures effectiveness of a specific intervention Documentation-Why? If we don t write it down, it didn t happen What did you do What area of the body did you treat What was skilled about it (why not an aide or family) What is the client at risk for without skilled observation What did it enable 18

19 Scenarios: CVA What!!! they want us to listen to them AND do something too! Assignment Determine a client goal Establish the goal requirements (what does the client need to do to achieve the goal) Choose a modality adjunct Choose an outcome measure Determine 3 key points to include in a progress note 19

20 Case Scenario: Treatment Options* Ultrasound Subthermal or Thermal application Electrotherapy Interferential Current Diathermy Subthermal or Thermal No worries What could possibly go wrong? 20

21 Contraindications Never, never, never Diathermy or electrotherapy with 1. Demand-type pacemaker 2. Defibrillators 3. Phrenic nerve or 4. Bladder stimulators 5. Over pregnant uterus 6. Over eyes 7. Epiphyseal plates (US, Diathermy) (Accelerated Care Plus, 2011; Bracciano, 2008; Draper, 2008; Cameron, 2003 Warnings/Precautions Active cancer: increasing blood flow to tumor; increases activity of tumor cells Severe infection: increasing metabolism, Acute or post-acute conditions: thermal modalities Over reproductive organs Areas of decreased sensation, circulation DVT Active bleeding Lumbar, abdominal region or uterus during pregnancy (Accelerated Care Plus, 2011; Bracciano, 2008; Draper, 2008; Cameron, 2003) 21

22 THANK YOU!!! 22