Mechanical Agents

Mechanical Agent Modalities

theraputic mech devices to apply froces such as compression, distraction, vibration, or controlled mobilization

Instrument assisted modalities

refers to the therapeutic use of an instrument or tool that is manually applied to target specific tissues such as Skin, Fascia, and other connective tissues, or muscle

Mechanical agent physiological

Mechanical deformation (stretch movement of collagen fibers), localized inflammatory response (increased blood flow) and activation of the immune system

Examples of Mechanical Agents

• Compression (Wraps, compression garments, short or long stretch)

• Superficial effleurage or manual lymphatic drainage (MLD)

• Taping (elastic, athletic, Leaukotape with Hypafix)

• Cupping

• steel Blading

• Massages devices

Changes with fascia and superficial vessels/nerves

• increase stiffening of the carotid and other vessels with pregnancy and post menopausal women

• arterial stiffening with age, especially carotid and femoral

• Hypertension affects the extensibility of arteries

• Post radiation arterial changes, stenosis, weakening of the wall

Desired Depth

.1mm skin

.6mm epidermis

1.5mm Nerves and lymphatics

2.5 mm Fascia

3.5mm muscle start

4 components involved with Edema

1. capillaries

2. tissue channels

3. macrophages

4. initial lymphatics

Circulatory system

• Arterial functions: nutrients/immune

• Venous functions: carry de oxygenated blood, a reservoir

• Capillary functions: fluid and nutrient exchanges

• Lymphatic Functions: Remove excessive fluid and waste product. return fluid and plasma proteins to the blood, alert the immune system

Types of lymphatic system failures

• dynamic insufficiency: increase lymphatic load- healthy lymphatic system

• Mechanical insufficiency: Normal lymphatic load- on a damaged lymphatic system

• Combined insufficiency: Increased lymphatic load - on a damaged lymphatic system

Causes of Edema

• imbalance between hydrostatic and osmotic pressure

• venous or lymphatic obstruction or insufficiency

• increase capillary permeability

• immobility

• pregnancy

• neurological injury

• surgery/ trauma

Volume Measurements

Used to quantify the edema in a patient and compare the affected limb to the non affected.

What is the gold standard for Volume Measurements

Perometer: volume is determined from the 3D silhouette cast of the limb. Only con is that it doesn’t provide a composition breakdown

Water displacement

Clinic would use a volumetric edema gauge system, however this is not realistic in a clinic due to

• money for equipment

• time to perform

• water source

• patient may not be able to submerge limb due to wounds or limb being to large

bioimpedance

Electrical current through the body via 2 points of contact

measures the body’s resistance in response to this electrical current to provide an assessment of extracellular fluid, intercellular fluid, and total body water

• tissues with high levels of fluid and electrolytes have high conductivity while fat and bone slow the single down

Bioimpedance Cons

Most rely on population-specific data to create an estimate, which does not consider that body geometry

impedance is greater with extremes in levels of fat. hydration is higher in significant obesity, so it underestimates body fat

Measuring progress with treatment with edema

1. initial measurements

2. during treatment to judge progress

3. before and after treatment

4. progress notes for MDs, patients and/or insurance

5. at discharge

Contraindications to compression in general

• arterial insufficiency

• neuropathy

• inability to communicate pain and discomfort

• Ankle Brachial Index: <0.8-40 mmHg at most, >0.5 to <0.8:23-30 mmHg at most, <0.5: compression should be avoided

Compression: principles

Compression: Forces exerted to an area on the body surface

Pascal’s Law: when pressure is applied (functional activities) on a fluid (a muscle or muscle group) in a closed container (fascia and compression bandage) there is an equal increase at every other point in the container

Sub-Bandage or Interface Pressure

Pressure exerted by compression on the skin expressed in mmHg

Resting Pressure (RP)

pressure exerted by the compression on the bandaged segment at rest

Working Pressure (WP)

pressure exerted by the compression on the bandaged segment during muscle contraction

Categories of compression

No stretch: 0% (cast)

Low Low stretch: 1-50% (Durelast, Una Boot)

Low stretch: 51-90% (lymphedema brown bandages)

Medium Stretch: 91-140% (lekelast)

High stretch >140% (ace, tubigrip)

Benefits of gradient compression

• Increase:

venous and lymphatic circulation/transport

muscle pump temperature

tissue temperature

• Decrease:

Risk of DVTs and severity of post-thrombotic syndromes

fibrosclerotic tissue

pain reduced via reduced stress on nerves, joints, ligaments, and fascia

Hypertrophic scarring from burns and trauma act as a mold for the growth of new tissue

• Helps with shaping a residual limb and fluid reduction

General rules with Gradient Compression

Needs to be gradient: more pressure distal

Worn while exercising

Types of compression must meet the needs of the person

Compression MUST go at least 2 inches above where the edema stops

cannot prevent a person from performing ADL

Garments: help maintain the reduction a person has received with bandageing or preventatively post op to limit the amount of edema

compression pumps

Uses:

post-op edema or inactivity to prevent DVTs, and dependent edema. post-traumatic edema, chronic venous insufficiency

Only use in low-pressure settings: 40 mmHg on LE and 25 mmHg on UE

Precautions for compression pumps

• Arterial insufficiency

• open wounds

• fragile skin

• easy bruising / clotting issues

• reduced sensations

• inability to communicate pain, pain with the pump

• genital involvement

• active cancer

• edema in the adjacent trunk

Taping (theories with pain reduction)

• removes pressure on free nerve ending

• allow more fluid movement to reduce pressure on painful tissue

• increase sensory receptor reactions (decrease pain or abnormal sensations)

• blocks stimulation to the brain like TENS

Adverse outcomes with taping

Too much stretch on tape: Reaction will not be uniform on skin, often seeing blisters, scabs, or skin irritations/burns in select areas

Allergic reaction to tape: Will usually be uniform, can be bumps, discolorations, itching or any skin irritation

Athletic Tape Roles

• restricted motion of an injured joint

• compress soft tissue to reduce swelling

• support anatomical structures involved with the injury

• serve as a splint

• secure dressing

• protect the site from being reinjured

Athletic Tape Mechanism

• enhances proprioceptive feedback from a limb or joint

• provide support

• limiting motion will prevent injury and allow the injured tissue to heal

• gate theory

• limits edema by increasing the tissue pressure to limit ultrafiltration from arterial capillaries

• feedback for postural or mechanical control

Athletic Tape Disadvantages

• skin damage

• damage to other joints/tissues from limiting area under application

• tape can lose stiffness over time

• can develop dependency

• costly with prolonged use

Leukotape and hypafix

-reduce pain

-provides support and stability to joints

assist in realigning structures or joints alignment

sensory feedback via cutaneous mechanoreceptors

help protect the area

restores functional movement

postural tape

does not affect circulation or ROM

Leukotape and hypafix Disadvantages

risk of skin breakdown or allergy

expensive

can restrict blood flow if to tight

damage to other joints/tissues from limiting area under application

can develop dependency

Elastic Tape theories in increasing ROM

to find the direction for tape, gently pull skin around joint in different directions to see which reduces pain

then apply the stabilization strip in the SAME direction

the decompression strips would be PERPENDICULAR

Elastic Tape theories for scar reduction

passive prolongs static stretch can improve

• lengthening of the tissues

• encourages proper laydown of tissue

don’t apply the tape over incision is 6 weeks out

usually applied alternating medial and lateral in incision/cut with pressure towards midline

Elastic Tape disadvantages

• does not stick as well as normal tape

• may be to elastic to provide support

• risk of skin break down

• expensive with prolong use

Precautions with Elastic Taping

• there should be 15-20% stretch inherent in the tape, up to 40% with pull

• When possible stretch the skin (flex/bend) instead of the actual tape

• if pt has never been taped before use a test patch

• remove if itching

Precautions or contraindications with cupping

• areas of current or previous DVTs

• Directly over superficial veins/arteries

• over an infection

• over an open wound

• avoid boney area

Precaution:

• pediatrics

• fragile skin

• geriatrics

• pregnancy

• mensurating women

Theories: impact of skin and tissue

Compressive stress to skin at the rim

tensile stress to skin/tissue under the cup (distraction forces)

Cupping uses a (-) low pressure, like a vacuum, to move fluid and displace the the layers in cutaneous tissues

Cupping Outcomes/Results

Increases:

• temperature

• circulation

• healing

Decrease:

• Blood pressure

• muscle tension

• scars from trauma or burns

• cellulite appearance

ABSOLUTE contraindications of IASTM (steel Blades)

Relative Contraindications/ precautions of IASTM

• Cancer

• Mature Scars

• Kidney dysfunction

• Pregnancy

• RA

• Varicose Veins

• Lymphedema

• Polyneuropathy

• Tattoos

• Osteoporosis

• Diabetes

• CHF

Benefits for IASTM

• increase precision with regards to location and shape

• can feel the tissue through the tool

• increased tactile feedback

• decreased stress/ fatigue on clinician

• noninvasive

• easy to clean up

IASTM Mechanical

Pressure and shear on collagen fibers initiated inflammatory cascade

• increase blood flow

• stimulates release of cellular mediators and growth factors to draw fibroblasts to the area

• fibroblast proliferation - collagen production - connective tissue healing

Traumatic Hyperemia: which leads to pain relief and decreased scar tissue

Pain Relief from IASTM

stimulates type 1 and type 2 mechanoreceptors

• types I: superficial capsule, limbs and vertebrae

Type II: deep capsule

Pain relief via gate control control theory

decreased central sensitization/ altered neural input

Indications for IASTM

• Cumulative trauma

• tendinopathies

• trigger points

• fascial restrictions

• ligament sprains

• edema

• soft tissue entrapment

• post operative

Clinical Use of IASTM

Goals are to increase rom, decrease pain, improved connective tissue mobility/texture

warm up/recover from performance, reduce edema

However no evidence for optimal parameters

Instrument Selection

• Size

• conforms to different body surfaces

• single bevel: penetrates deeper that double bevel edges

• double bevel edges can be applied in both directions

• Concave instrument on convex body part: disperses forces over a large area and improved patients tolerance

• convex instrument on convex body part: focuses force at a small surface area, more specific treatment

Method Strokes

Brush

Sweep

Fan
Strum
J stroke

Negative outcome

-soreness

-bruising

-petechiae

-should be mild and of a short duration

-manage with use of ice

Foam rolling Application

Located the Tender spot in the muscle

Place the ball/cane on the tender area

apply pressure with: hands, body weight

hold and roll for at least 30 sec

Release pressure for 10 secs and then repeat 4-5 times

BE CAREFUL OF PRESSURE ON NERVES

Theragun Percussive Therapy

Uses rapid, repetitive strokes to stimulate blood flow and heat

only use for 30 seconds of each area

deliver 16 mm of amplitude at a speed of 40/29 percussions per second on the body

different attachments and an adjustable arm

no complling reasearch

Mechanical Agents Documentation

• history Of condition and/or subjective comments

• current conditions/objective measures

  • skin

  • edema/girth

  • pain scale

  • adl ability

• treatment parameters

• outcomes or response to treatment