Physical Modalities: Biofeedback, Compression, and Traction Study Guide

Course Overview and Physical Modalities

• Course Code & Title: PTAC 112R - PT Procedures 1

• Core Topics: Biofeedback, External Compression, and Traction

Biofeedback

• Definition and Mechanics:

  • Biofeedback is a clinical method used to convert energy from physical actions into visual or auditory feedback that a patient can see and hear.

  • In physical therapy, the most common form utilized is Electromyography (EMG) biofeedback.

  • EMG biofeedback quantifies muscle tone, helping identify for the patient how active or relaxed a target muscle is at any given time.

  • Sensor and Electrode Types:

  • Surface electrodes (sensors) are placed over the skin of the target muscle and connected to the biofeedback machine.

  • Internal sensors can be used for pelvic floor rehabilitation.

  • Needle EMG is utilized specifically in neurological diagnostic testing and research settings.

• Clinical Indications:

  • Muscle Weakness: Assists the patient in learning how to activate an isometric or isotonic contraction and hold it effectively.

    • Isometric contraction - A muscle contraction where the length of the muscle does not change while tension increases, often used in rehabilitation to enhance muscle strength without joint movement.

    • Isotonic contraction - A muscle contraction where the muscle length changes while tension remains constant throughout the movement, commonly utilized in physical therapy to improve muscle endurance and strength through active movement.

  • Weakness caused by muscle inhibition due to pain or swelling.

  • Hemiplegia - A condition characterized by paralysis on one side of the body, often resulting from brain injury or stroke, affecting motor function and requiring specific rehabilitation strategies to improve mobility and strength.

  • Pelvic floor dysfunction (e.g., urinary or fecal incontinence).

  • Chronic pain conditions.

  • Muscle Tension and Spasm: Assists the patient in learning how to voluntarily relax overactive muscles.

  • Tension headaches (HA).

  • Pelvic floor pain disorders.

  • Chronic pain conditions.

  • Neuromuscular Coordination: Assists the patient in learning how to activate the correct muscle at the correct time with the appropriate amount of force.

• Contraindications:

  • Acute inflammatory conditions (ex: arthritis flare-ups), recent fractures, or any condition where enhanced blood flow may exacerbate the problem)

  • Pregnancy when combined with the use of an internal sensor.

  • Bladder, vaginal, or rectal infection when combined with the use of an internal sensor.

• Application Procedures:

  • To Increase Muscle Activation:

  1. Explain the application and function of the sensors to the patient.

  2. Establish a baseline with the patient's target muscles completely relaxed; adjust the biofeedback threshold so that no signal is produced at rest, but visual or auditory feedback is triggered when the required muscle actively contracts.

  3. Have the patient practice voluntarily contracting the muscle to trigger the signal.

  4. As the patient's performance improves, increase the threshold level so biofeedback is not triggered until a stronger motor unit contraction is achieved.

  • To Decrease Muscle Activation (Relaxation Training):

  1. Explain the application and function of the sensors to the patient.

  2. Establish a baseline with the target muscles relaxed; adjust the biofeedback threshold so that no signal is produced when the muscle is resting, but feedback triggers when excess or unwanted muscle activity occurs.

  3. Have the patient practice keeping the muscle relaxed to avoid triggering the biofeedback signal.

  4. As the patient improves, refine the threshold so that biofeedback is triggered by increasingly smaller amounts of involuntary tone or muscle tension.

External Compression

• Definition and Mechanisms:

  • External compression refers to a constant or intermittent mechanical force that increases external fluid and tissue pressure on a body part.

  • Therapeutic goals:

  • Increase fluid balance and overall circulation.

  • Prevent venous blood pooling in the extremities.

  • Prevent edema formation following acute tissue injury.

  • Modify scar tissue and contracture formation.

• Clinical Indications:

  • Altered Venous and Lymphatic Circulation:

  • Normal physiological balance: Hydrostatic pressure is normally higher inside veins than in extracellular spaces, causing fluid to leak out into the interstitial space. This interstitial fluid is normally picked up by the lymphatic system and returned to the venous circulation.

  • Pathologic Edema: Occurs when excess fluid leaves the venous system or when an inadequate amount of fluid is picked up by the lymphatic vessels.

  • Common causes: Venous dysfunction, prolonged standing, physical inactivity, pregnancy, acute trauma/injury, tumor growth, radiation therapy, or surgical removal of lymphatic structures.

  • Prevention of Deep Vein Thrombosis (DVT): Prevents venous stasis and blood clot formation resulting from post-operative immobility.

  • Venous Stasis Ulcers: Impaired venous circulation leads to severe tissue breakdown, ulceration, and necrosis. Compression bandaging and graduated compression stockings are primary treatment modalities.

  • Post-Amputation Rehabilitation: Applied to shape the residual limb and control post-surgical edema prior to prosthetic fitting.

  • Post-Burn Rehabilitation: Application of specialized compression garments to minimize hypertrophic scar formation.

• Application Methods and Types:

  • Compression Bandaging (Long Stretch):

  • A form of static compression.

  • Distal pressure must always be greater than proximal pressure.

  • Long stretch bandages (e.g., Ace Wraps) can provide $60 - 70\,\text{mmHg}$ of pressure.

  • Best suited for immobile patients or limbs.

  • Applied with moderate tension stretch.

  • Must be applied using a Figure-8 wrapping pattern rather than simple horizontal turns.

  • Clinical example: Acute post-injury swelling management.

• Compression Bandaging (Short Stretch):

  • A form of static compression.

  • Distal pressure must strictly exceed proximal pressure.

  • Short stretch bandages extend far less than long stretch wraps.

  • Best suited for mobile, active patients.

  • Applied using a Figure-8 wrapping pattern rather than horizontal wrapping.

  • Clinical example: Lymphedema bandaging management.

• Combination Bandaging:

  • Utilizes multiple layers combining elastic and non-elastic materials.

  • Provides higher pressure distally than proximally.

  • Cumulative high pressure is generated via multi-layer material stacking.

  • Clinical examples: Lymphedema care and venous leg ulcer management (e.g., Unna boot).

• Compression Garments:

  • Static compression modality.

  • Antiembolic stockings (TED hose): Provide $30 - 40\,\text{mmHg}$ of pressure.

  • Scar tissue control garments: Provide $20 - 30\,\text{mmHg}$ of pressure.

  • Adjustable velcro-closure long limb wraps.

• Intermittent Compression Pump: can last an hour or pt. can rent and take home

  • Intermittent pneumatic compression modality.

  • Step-by-step application protocol:

    1. Measure and record baseline circumferential measurements of the limb.

    2. Place the inflatable sleeve over the limb and attach the pneumatic hose to the compression pump unit.

    3. Position and maintain the limb in an elevated position.

    4. Obtain the patient's resting blood pressure prior to starting treatment.

    5. Set inflation pressure to a level just below the patient's resting diastolic blood pressure.

  • Pressure ranges:

    • Upper Extremity (UE): $30 - 60\,\text{mmHg}$

    • Lower Extremity (LE): $40 - 80\,\text{mmHg}$

  • Timing ratio: Intermittent compression requires a $3:1$ ratio of on-time to off-time (inflation:deflation).

• Ankle-Brachial Index (ABI) Assessment: do not do intermittent compressions before you calculate the ABI to ensure accurate readings, as these compressions may artificially inflate the measurements.

  • Definition: The ratio of lower extremity systolic blood pressure to upper extremity systolic blood pressure:     $\text{ABI} = \frac{\text{Systolic BP}_{\text{LE}}}{\text{Systolic BP}_{\text{UE}}}$

  • Measurement Protocol: Take blood pressure at the upper arm (brachium), take blood pressure at the lower leg/ankle (calf), and divide lower extremity systolic pressure by upper extremity systolic pressure.

  • Static Compression Guidelines Based on ABI:

  • $\text{ABI} > 0.8$: Static compression is safe at full standard range ($30 - 40\,\text{mmHg}$).

  • $\text{ABI} = 0.6 - 0.8$: Static compression is safe at a reduced range ($23 - 27\,\text{mmHg}$ ).

  • $\text{ABI} < 0.6$: Compression is strictly contraindicated. (DO NOT DO TREATMENT)

  • Diagnostic Classification Table:

  • Normal: Range $1 - 1.4$ | Concern: None | Clinical Comments: No PAD present.

  • Abnormal (Blockage): Range $< 0.9$ | Concern: Blockage | Clinical Comments: Narrowing of arteries in the legs.

  • Abnormal (Rigid Arteries): Range $> 1.4$ | Concern: Rigid arteries | Clinical Comments: Arteries fail to compress with cuff; evaluate for underlying PAD.

Steps on calculating and taking the ABI:

1. Measure the systolic blood pressure in both the arm and the ankle

2. For the ankle, use the highest pressure from either the tibial artery or dorsal pedal artery.

3. Calculate the Ankle-Brachial Index (ABI) using the formula:
   $ABI=\frac{Highest\text{ systolic ankle pressure}}{Highest\text{ systolic arm pressure}}$

4. Compare the ABI result against normal ranges to identify abnormalities such as blockage or rigid arteries.

• Contraindications for Intermittent Compression Pump:

  • Heart failure or pulmonary edema (review chart; inquire about heart disease, dyspnea, cardiac medications, BP, and bilateral leg swelling).

  • Recent or acute DVT, thrombophlebitis, or pulmonary embolism (assess limb for pain, swelling, and localized erythema).

  • Obstructed lymphatic or venous return (assess swelling and investigate underlying cause).

  • Severe Peripheral Artery Disease (PAD) or arterial insufficiency ulcers:

  • Manifests as calf pain during ambulation (intermittent claudication); evaluate arterial sufficiency.

  • Acute local skin infections.

  • Low serum protein levels ($< 2\,\text{g/dL}$): Forcing extracellular fluid into blood vessels further dilutes serum protein concentration.

  • Acute trauma or unhealed fracture: Intermittent motion may cause excessive displacement at the injury site (Note: Static compression remains acceptable).

  • Recent arterial revascularization surgery: External pressure may occlude newly grafted blood vessels.

• Precautions for Compression Pump:

  • Impaired sensation or mentation.

  • Uncontrolled high blood pressure (hypertension).

  • Active cancer/malignancy.

  • History of stroke or cerebrovascular insufficiency.

  • Care when applying pressure directly over superficial peripheral nerves.

• Adverse Effects of Compression:

  • Exacerbation or aggravation of underlying organ failure.

  • Tourniquet effect leading to peripheral tissue ischemia.

  • Paradoxical worsening of swelling or edema.

• Documentation Requirements:

  • Specific type of compression device used.

  • Exact anatomical area treated.

  • Inflation and deflation cycle durations.

  • Compression and inflation pressure parameters ($\text{mmHg}$).

  • Total treatment duration.

  • Objective and subjective patient response to treatment.

Traction

• Definition and Mechanics:

  • Traction is defined as a mechanical or manual force applied to separate joint surfaces and stretch surrounding soft tissues (muscles, tendons, ligaments).

  • Applications focus predominantly on the axial spine, but traction is also beneficial for arthritic proximal appendicular joints (hips and shoulders).

  • Evidence-Based Research Findings:

  • Traction as a standalone intervention performs no better than sham treatment.

  • Traction does not demonstrate superior outcomes over other physical therapy interventions.

  • Cervical traction demonstrates positive therapeutic efficacy.

  • Lumbar traction demonstrates less favorable overall outcomes due to the significant magnitude of force required to distract lumbar vertebrae.

• Physiological Effects of Spinal Traction:

  • Distracts intervertebral joint surfaces:

  • Requires approximately $60\,\text{lbs}$ ($60\#$) of tensile pull in the lumbar spine to generate articular gapping.

  • Requires $15 - 30\,\text{lbs}$ ($15 - 30\#$) of pull in the cervical spine to achieve joint distraction.

  • Widens the intervertebral foraminal spaces.

  • Decreases mechanical pressure on spinal nerve roots.

  • Reduces herniated disc material protruding onto spinal nerve roots.

  • Stretches soft tissues.

  • Relaxes paraspinal musculature.

  • Mobilizes spinal facet joints.

  • Intermittent traction provides Grade I or Grade II joint mobilizations, which modulate pain.

• Clinical Indications:

  • Back and neck pain with or without radiating radicular symptoms.

  • Intervertebral disc herniation or disc bulge.

  • Spinal nerve root impingement.

  • Joint hypomobility (Note: Target spinal segments cannot be isolated completely; hypermobility may inadvertently be introduced at adjacent segments).

  • Subacute joint pain.

  • Paraspinal muscle spasm.

  • Plan of Care (POC) Integration: Traction must never be used in isolation; the comprehensive POC should incorporate patient education, body mechanics training, postural re-education, stretching and strengthening exercises, activity modification, and complementary physical agents.

• Contraindications:

  • Conditions where increased spinal joint motion is prohibited (e.g., acute fracture).

  • Acute spinal injury or acute local inflammation.

  • Joint hypermobility or structural joint instability.

    • Prior history of dislocated joints.

    • Down Syndrome (due to upper cervical ligamentous laxity).

    • Rheumatoid Arthritis (RA).

    • Marfan syndrome.

    • Pregnancy (due to systemic ligamentous laxity).

  • Peripheralization of symptoms during traction application.

  • Uncontrolled hypertension:

    • Stop treatment if resting blood pressure is $\ge 140/90\,\text{mmHg}$.

    • Stop treatment if traction increases either systolic or diastolic BP by $> 10\,\text{mmHg}$.

    • Stop treatment if pulse rate increases by $> 10\,\text{bpm}$.

• Precautions:

  • Structural diseases or conditions of the spine (requires reduced force application).

  • Pressure from stabilization belts around the abdomen or thorax.

  • Displaced annular disc fragment (traction will be ineffective).

  • Medial disc protrusion (protruding towards the spinal cord; traction may exacerbate cord compression).

  • Complete resolution of severe pain during traction:

    • May indicate complete nerve conduction block; perform neurological testing (sensation, motor strength, deep tendon reflexes) before and after treatment; stop immediately if neuro testing shows new or worsening deficits ($+$).

  • Claustrophobia

  • Inability to tolerate required prone or supine positioning.

  • Disorientation or cognitive impairment.

  • Temporomandibular Joint (TMJ) dysfunction.

  • Use of full or partial dentures.

• Adverse Effects:

  • Exacerbation or increase of spinal pain.

• Application Techniques: very dependent upon system being used

  • Manual Traction: The physical therapist applies distraction forces directly using their hands or specialized mobilization belts.

  • Mechanical Traction: Utilizes motorized traction equipment to deliver pull forces. A split table (traction table) is used to eliminate friction forces between the patient's body and the table; equipment availability varies by clinic.

  • Static Traction: Applies a steady, unchanging force magnitude throughout the duration of treatment.

    • Indicated for acute inflammation, symptoms aggravated by movement, or acute disc protrusions.

  • Intermittent Traction: Force fluctuates between a high hold force and low relax force every few seconds throughout treatment.

    • Long hold times are used for disc protrusion; short hold times are used for joint dysfunction.

  • Self-Traction: The patient utilizes their own body weight and positioning to apply traction forces.

  • Positional Traction: The patient assumes specific positions over supportive bolsters or rolled towels to open target spinal segments.

• Positional Traction Setup Protocol:

  • Towel roll size can be adjusted to optimize patient comfort.

  • Flex the hip until flexion movement is palpated at the targeted spinal segment.

  • Rotate the thoracic spine until motion is palpated at the targeted segment.

  • Lumbar Traction Parameters:

• Initial Injury / Acute Phase:

  • Force (start low): $29 - 44\#$ ($29 - 44\,\text{lbs}$)

  • Hold / Relax Time: Static hold

  • Total Duration: $5 - 10\,\text{min}$

• Joint Distraction:

  • Force: $50\%$ of total body weight

  • Hold / Relax Time: $15\,\text{sec} / 15\,\text{sec}$ ($15/15$)

  • Total Duration: $20 - 30\,\text{min}$

• Decrease Muscle Spasm:

  • Force: $25\%$ of total body weight

  • Hold / Relax Time: $5\,\text{sec} / 5\,\text{sec}$ ($5/5$)

  • Total Duration: $20 - 30\,\text{min}$

• Disc Issues or Stretch Soft Tissue:

  • Force: $25\%$ of total body weight

  • Hold / Relax Time: $60\,\text{sec} / 20\,\text{sec}$ ($60/20$)

  • Total Duration: $20 - 30\,\text{min}$

  • Cervical Traction Parameters:

• Initial Injury / Acute Phase:

  • Force (start low): $7 - 9\#$ ($7 - 9\,\text{lbs}$)

  • Hold / Relax Time: Static hold

  • Total Duration: $5 - 10\,\text{min}$

• Joint Distraction:

  • Force: $20 - 29\#$ ($20 - 29\,\text{lbs}$)

  • Hold / Relax Time: $15\,\text{sec} / 15\,\text{sec}$ ($15/15$)

  • Total Duration: $20 - 30\,\text{min}$

• Decrease Muscle Spasm:

  • Force: $11 - 15\#$ ($11 - 15\,\text{lbs}$)

  • Hold / Relax Time: $5\,\text{sec} / 5\,\text{sec}$ ($5/5$)

  • Total Duration: $20 - 30\,\text{min}$

• Disc Issues or Stretch Soft Tissue:

  • Force: $11 - 15\#$ ($11 - 15\,\text{lbs}$)

  • Hold / Relax Time: $60\,\text{sec} / 20\,\text{sec}$ ($60/20$)

  • Total Duration: $20 - 30\,\text{min}$

Personal notes