Focus On…Mobility/Rehabilitation

‘Current’ trends in rehab therapy

Once considered as part of a sports medicine program, electrotherapy modalities are getting long-term care residents back in the game. Mark Richards explains how

Electrotherapy is effective for people of all ages. Generally speaking, seniors tend to respond to three types of electrotherapy used in long-term care: electrical stimulation, ultrasound, and diathermy (which involves generating localized heat in body tissues). It is one thing to get a football player back in the game, but it’s an entirely different achievement for a senior to regain the ability to walk or to feed, dress, and groom herself.

Electrotherapy in Long-Term Care Rehab
Rarely is electrotherapy used as stand-alone therapy. It is another option in the therapy toolbox that the clinician can incorporate into the patient’s treatment plan to achieve optimum results. For instance, if a patient has had a total knee replacement, pain may limit how far the knee can be stretched or how much exercise the therapist can administer to improve range of motion (ROM). When, in conjunction with the therapeutic exercise program, the patient is treated with one of the electrotherapy modalities, he or she can better tolerate the ROM and strengthening exercises because swelling and pain have been reduced. In essence, electrotherapy does not replace therapy, but facilitates it.

The FDA has approved 11 different electrical stimulation waveforms, which gives the clinician flexibility in treatment options. With this range of acceptable waveforms, the therapist can select the one best suited for the individual and the condition. The energy provided by electrical stimulation, ultrasound, and short-wave diathermy machines helps to reduce swelling and pain, and increases circulation, which stimulates the cells to heal damaged tissue.

Ultrasound and diathermy machines also have variables that allow the clinician to individualize treatment. For instance, the machines can be adjusted to provide the exact depth of energy penetration and thermal response required, depending on whether the tissue requires heating or not. But as flexible and effective as these machines are, clinicians must receive good training and ongoing support for modality use to reach their full potential.

Contraindications and Risks
As beneficial as electrotherapy interventions might be, each modality has its own unique set of limitations, which depends on each patient’s condition. There are some contraindications. For example, if someone has a pacemaker, the FDA states that diathermy or electrical stimulation cannot be used on that patient, but ultrasound is permissible (except in the area immediately around the pacemaker). If a patient has a metal implant, diathermy cannot be used directly over the implant, but the other two modalities are allowable.

One of the FDA’s broadest contraindications is when a patient has an active cancer. In other words, if there are metastatic lesions or an active tumor in the treatment area, a different care plan must be created because most of the modalities increase circulation and the therapist wants to avoid feeding an active cancer.

Although cognitive impairment or dementia might be a consideration, they do not exclude a patient from electrotherapy treatments. In fact, the treatments are soothing and well tolerated.

The Goals and Benefits of Electrotherapy
Consider someone recovering from a stroke. Perhaps the patient has lost the ability to feed herself because arm function was compromised. Electrostimulation can reeducate weakened or deconditioned muscle in a part of the body that is neurologically impaired. The functional goal is to improve mobility and function in the arm.

Electrical stimulation, ultrasound, and diathermy are also effective in facilitating wound healing and treating contractures, both common and significant problems for nursing home residents. Electrical stimulation can also be used to help treat urinary incontinence.

For most conditions, positive changes are usually noticed within the first two or three treatments. However, for some more challenging problems, it may be a couple weeks before noticeable improvement is observed. A good clinician closely monitors the patient’s response, and if the desired change is not forthcoming, adjusts the plan of care accordingly.

Conclusion
Whether it is provided in-house or by a contracted provider, CMS reimburses for the use of modalities under certain conditions. The ultimate value of electrotherapy lies in the life-altering changes for the patient. To see the light shine in the eyes of someone who relied on a mechanical lift now transfer without it, to watch a person who couldn’t hold a spoon begin to feed himself, and to enjoy the smile of someone who is not in pain are just some of the triumphs of electrotherapeutic rehabilitation. “Sports medicine for seniors” can help your residents get back in the game.

Wound Healing
A 50-year-old woman developed colorectal cancer when she was in her 30s. At that time she received the treatment of the day: cobalt therapy. This intensive treatment was very damaging to the tissues and she developed a large sacral ulcer. Now, 20 years later, the wound had grown so large her family could no longer care for her and she was admitted to a skilled nursing facility, where many different wound care approaches were tried. Medicare indicates that if after 30 days of conservative treatment (wound care dressings, nutritional interventions, pressure relief, etc.) the wound does not show significant improvement, the therapist may begin to treat the wound with electrical stimulation or diathermy. Consequently, after 20 years, electrical stimulation was initiated and in a very short time the size of the wound was reduced by one-half. The wound continued to respond to the point where it was manageable by the family and the patient returned home.

Contracture
Contracture management is a significant issue in long-term care. A contracture may be the consequence of a neuromuscular disorder or stroke. One woman had a contracture so severe that she could not propel her wheelchair. Hoping to restore her mobility, her therapist began a series of electrical stimulation treatments. Eventually she gained enough range of motion and strength in her upper extremities to operate a powered wheelchair. This woman began to feed herself again and was now being cautioned by staff to slow down!

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