| Physical Therapy Modalities Helpful for the Family Clinician to Know |
Physical Therapy Modalities Helpful for the Family Clinician to KnowNews Author: Laurie Barclay, MD Release Date: December 12, 2007; Valid for credit through December 12, 2008
December 12, 2007 — Various treatments and modalities that a family clinician should know and include in physical therapy orders are reviewed in an article published in the December 1 issue of the American Family Physician.
"Physical therapists are an integral part of inpatient and outpatient treatment of neurologic and musculoskeletal injuries and disabilities," write Scott E. Rand, MD, from the Conroe Medical Education Foundation in Conroe, Texas, and colleagues. "They also can assist with and augment the care of patients with cardiac, pulmonary, and developmental disorders. Family physicians should have some understanding of the various treatments and modalities used by physical therapists."
Although existing guidelines recommend physical therapy as part of the treatment regimen for musculoskeletal conditions, these lack specific recommendations regarding which exercises and adjunct modalities should be used.
To decrease pain and increase mobility and flexibility, physical therapists use specific techniques and modalities. In patients with low back pain, some studies suggest that having physical therapists instruct patients on how to perform specific exercises may improve outcomes. Evidence of efficacy is variable for most modalities, and there is a dearth of randomized controlled trials to support their use.
Because any given clinical condition may benefit from use of several different modalities, treatment decisions for an individual patient should be based on the expertise of the therapist, availability of the equipment, and goals set by the attending clinician.
When prescribing physical therapy, the clinician should specify the diagnosis (using proper coding to allow for accurate insurance billing and reimbursement); type, frequency, and duration of the prescribed therapy; specific protocols or treatments that the clinician wants the therapist to use; therapeutic goals; and safety precautions, such as joint range-of-motion limitations, weight-bearing limitations, and illnesses that affect participation in therapy). For a therapist to perform the requested services, clinician signature and date are required.
Frequently used modalities of physical therapy include ultrasound, phonophoresis, iontophoresis, electrical stimulation, and low-level laser therapy.
In ultrasound therapy, high-frequency sound waves are used to warm superficial soft tissues or with the intention of facilitating tissue healing at the cellular level. Ultrasound may be useful for tendon injuries or for short-term pain relief of muscle strain or spasm, but it should not be used near malignant tumors, nerve tissue in a patient who has recently had a laminectomy, joint replacements, permanent pacemakers, thrombophlebitis, eyes, reproductive organs, areas of acute inflammation, epiphyseal plates, or over breast implants. For Olympic athletes, exemption is needed for use of ultrasound.
Phonophoresis refers to use of ultrasound to deliver therapeutic medications to subcutaneous tissues. This modality may be useful for inflammatory conditions including tendonitis, arthritis, and bursitis, and contraindications are the same as for ultrasound.
During iontophoresis, an electric current helps deliver ionically charged substances through the skin to reach deeper tissues. Therefore, it may be indicated for calcific tendinopathy, inflammatory conditions, or hyperhidrosis. Contraindications to use of iontophoresis include allergy or sensitivity to the substance being applied, open wounds, or impaired sensation. Iontophoresis also should not be used in the immediate vicinity of metallic implants, wires, or staples.
Electrical stimulation causes a therapeutic effect by generating an action potential in nerve tissue, thereby causing a muscle contraction or change in sensory input. Electronic muscle stimulation may be useful for muscle spasm or contusion, whereas transcutaneous electrical nerve stimulation may help relieve neuropathic pain. Electrical stimulation is contraindicated in patients with cardiac pacemakers, known cardiac arrhythmias, or thrombophlebitis or thrombosis. It should not be used at all on the abdomen or pelvis of pregnant patients, and it should be used only with caution in patients with cardiac disease, malignant tumors, open wounds, or in those with impaired sensation, cognitive function, or communication ability.
Low-level laser therapy acts via absorption of photon radiation, thereby affecting cellular oxidative metabolism and reducing concentrations of prostaglandin E2. This modality may be effective for minor musculoskeletal pain, carpal tunnel syndrome, osteoarthritis, or rheumatoid arthritis. However, it should be used with caution in patients with malignant tumors or in those being treated with anticoagulants, corticosteroids, or immunosuppressants, and it should not be used on the uterus of pregnant patients. Patients and therapists should use safety goggles to limit eye exposure to therapeutic wavelengths.
Specific clinical recommendations are as follows:
"The frequency and duration of physical therapy treatments will vary based on the patient's condition," the study authors conclude. "Acute muscle strains often benefit from daily treatment over a short period, whereas chronic injuries are usually addressed less frequently over an extended period. . . . It is important for the physical therapist to document the patient's progress so that the physician can modify the care plan, if needed."
The study authors have disclosed no relevant financial relationships.
Am Fam Physician. 2007;76:1661-1666.
Clinical ContextFor patients with neurologic and musculoskeletal injuries and disabilities, physical therapy is a cornerstone of management. In addition, physical therapy can be useful in the treatment of patients with cardiac, pulmonary, and developmental conditions. Therefore, it is useful for family practitioners and primary care providers to be familiar with available modalities of physical therapy and treatment regimens, and indications and contraindications for their use.
Treatment decisions for an individual patient should be based on the expertise of the therapist, availability of needed equipment, and goals set by the attending clinician. The present review describes recommended use of various modalities of physical therapy and necessary components of a physical therapy prescription.
Study Highlights
Pearls for Practice
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