CONTRAINDICATIONS AND INDICATIONS FOR OCCUPATIONAL THERAPY MANAGEMENT
Florida Statute 486.021 defines occupational therapy as “the use of purposeful activity or interventions to achieve functional outcomes.” Functional outcomes include maximizing independence and the maintenance of health for those limited by a physical injury or illness, cognitive impairment, psychosocial dysfunction, mental illness, developmental or learning disability, or adverse environmental conditions.
Occupational therapists use skilled observation or administration and interpretation of standardized or nonstandardized tests and measures to identify areas for occupational therapy services. Occupational services include, but are not limited to:
- Assessment, treatment, and education of or consultation with the individual, family, or other persons
- Interventions directed toward developing:
- Daily living skills
- Work readiness
- Work performance
- Play skills
- Leisure capacities
- Educational performance skills
- Interventions for development of:
- Sensory-motor functioning
- Perceptual or neuromuscular functioning
- Range of motion
- Emotional, motivational, cognitive, or psychosocial components of performance
- Use of assistive technology devices
- Orthotic devices
- Physical agent modalities as adjunct to or in preparation for purposeful activity
- Adaptation of environments and processes to enhance functional performance or promote health and wellness
(FSL, 2020)
A referral to occupational therapy should specify the diagnosis as well as any protocols or specific treatments the referring physician/provider requires to be followed (e.g., weight-bearing status, range of motion restrictions). Additional information provided may include any illness or medication that affects participation in therapy.
In many jurisdictions access to occupational therapy is contingent upon the prescription or referral of a physician. Florida occupational therapy practice laws and rules are silent on this issue. Regulations only state that a licensed Florida OT or OTA with an active, unencumbered license can provide occupational services. Other entities, however, may mandate a physician’s prescription for services (FL BOT, 2021).
When physical agent modalities are utilized in the practice of occupational therapy, they are always integrated into a broader occupational therapy regimen, such as preparation of an area for other treatment techniques used to improve functional ability. They may also be used along with therapeutic activity or exercise. Modalities may include heat, cold, sound, electricity, mechanical forces, and light in order to obtain a specific therapeutic response. Therapists must be aware of the indications for their use as well as contraindications in order to prevent the occurrence of adverse events.
Superficial Thermal Modalities
HEAT
Superficial heat is the use of a thermogenic agent such as a hot pack that induces a temperature increase and subsequent physiological changes to the superficial layers of the skin, fat, tissues, blood vessels, muscles, nerves, tendons, ligaments, and joints. Superficial heat provides pain relief, increases local blood flow and metabolism, and increases elasticity of connective tissues.
Indications for use of superficial thermal modalities include subacute to chronic conditions, pain and muscle spasms, and joint stiffness.
Superficial heat is contraindicated for patients with:
- Peripheral vascular disease
- Bleeding disorders
- Local malignancy
- Acute inflammation or trauma
- Edema
- Infection
- Open wounds
- Over large scars
- Impaired sensation
- Impaired communication or cognition
(Seidel et al., 2021)
COLD
Cryotherapy includes cold packs and ice and is indicated for relief of pain by causing local anesthesia and reduction of edema due to acute injuries or conditions. It also decreases nerve velocities, cellular metabolism, and local blood flow. Cryotherapy includes:
- Ice packs (most common method)
- Ice spray
- Immersion (simple or whirlpool)
- Ice massage
Cryotherapy is contraindicated in patients with:
- Complex regional pain syndrome
- Hemoglobinuria
- Cryoglobulinemia
- Impaired circulation (e.g., Reynaud’s disease)
- Urticaria (hives)
- Hypersensitivity to cold
- Skin anesthesia
(Physiopedia, 2021; Meydam, 2018)
HYDROTHERAPY
Hydrotherapy is the use of water indicated for the treatment of chronic diseases of the musculoskeletal system and connective tissues such as arthritis. Hydrotherapy includes:
- Contrast bath, in which the hand or arm is alternately immersed in warm water and cold water or ice; primarily used to reduce edema and increase blood flow
- Whirlpool bath hydrotherapy, used to reduce edema and increase blood flow to an affected area; water temperature can be adjusted based on the needs of the patient
Contraindications for the use of hydrotherapy include:
- Open wounds
- Active infection
- Altered sensation
- Heat or cold intolerance
(Meydam, 2018)
FLUIDOTHERAPY
Fluidotherapy uses a specially designed machine with a chamber containing small cellulose particles. The unit blows dry heat into the chamber, forcing the particles to move. When a limb is placed in the chamber, the unit provides dry heat and massage. Advantages for this therapy are that patients tolerate a much higher temperature than with other forms of superficial heat and that it permits exercise with relative ease to help increase range of motion.
This modality is often indicated for management of pain, edema, chronic inflammatory conditions, postfracture management, Reynaud’s syndrome, and desensitization.
Fluidotherapy is contraindicated for symptomatic pain relief, unless etiology is established, and in patients with:
- Malignant lesions
- Open wounds
- Serious infectious disease
- Circulatory disorder
- Hemorrhage
- Heat sensitivity
- Fever
(MacWan, 2018; Meydam, 2018)
HOT WAX
Paraffin, or hot wax, bath is used to heat a hand or foot prior to therapy to increase circulation and reduce pain or stiffness. Paraffin is melted, and the hand or foot is dipped several times to create a thick coating to retain heat. It is then wrapped in plastic wrap and towels to keep the heat in for a set period.
This form of therapy is indicated for treatment of rheumatoid and osteoarthritis of hands or feet, fibromyalgia, to soften skin caused by scleroderma, and management of trigger finger pain and muscle spasm.
Hot wax therapy is contraindicated in the presence of:
- Varicosities and other circulatory dysfunction
- Phlebitis
- Anesthetic areas
- Open wounds, rashes
- Unreliable patients
- Impaired thermal sensation
- Scar tissue
- Infectious area
(How to Relief, 2019; Seidel et al., 2021)
INFRARED LIGHT
Infrared light therapy provides electromagnetic radiation to heat an area in preparation for other treatment techniques. It is indicated for use in preparation for other forms of therapy for relief of pain and muscle spasm. Infrared light increases:
- Local temperature superficially
- Local metabolism
- Capillary permeability and blood flow
- Lymphatic and venous drainage
- Leukocyte and phagocyte activity
- Stimulation of sensory nerve
Infrared light therapy is contraindicated for use over:
- Pregnant uterus
- Malignant tissue
- Eyes
And in patients with:
- Peripheral vascular disease
- Acute inflammation
- Acute infection
- Open wounds
- Impaired sensation
- Acute febrile illness
- Deep X-ray therapy
(Omar, n.d.; Meydam, 2018)
Deep Thermal Modalities
Deep heat modalities include ultrasound and diathermy (SWD), both of which convert electromagnetic energy to thermal energy. Indications for use of deep heat are for treatment of various soft tissue disorders, including bursitis, tendonitis, degenerative arthritis, musculoskeletal pain, contractures, and for promotion of wound healing.
- Ultrasound uses sound waves to produce deep heating to increase blood flow to an infected area to promote healing. Ultrasound is used for phonophoresis, a method used to deliver medication under the skin to provide pain relief and control edema. Hydrocortisone is the most commonly used medication for this treatment.
- Diathermy uses a high frequency electric current to generate heat within body tissues, usually to large areas. It is indicated for use when it is not possible to use more concentrated forms of heat on an area due to positioning limitations or patient comfort.
(Seidel et al., 2021)
Contraindications for use of deep heat include those for superficial heat noted above and:
- In areas of malignancy
- In areas of sensory loss
- Over metallic implants or foreign bodies
- Over a pregnant uterus
- Over moist dressings
- In ischemic areas or arteriosclerosis
- In areas with phlebitis
- In areas near a cardiac pacemaker
- Over contact lenses
- Over metal-containing intrauterine contraceptive devices
- Over epiphyseal areas of developing bones
- In patients with active menses
Additional contraindications include conditions in which application of deep heat would require direct exposure of the eye, spine, laminectomy sites, brain, heart, or known ischemic area (Klein, 2019).
Electrotherapeutic Modalities
Electrotherapeutic agents use various forms of electric current to provide treatment to an area and, depending on the type of current used, these modalities can help relieve pain, reduce edema and inflammation, promote tissue healing, and facilitate muscle function and strength. Indications include:
- Transcutaneous electric nerve stimulation (TENS), for pain reduction by stimulating nerve endings
- Neuromuscular electrical stimulation (NMES), to help strengthen weak muscles and promote normal muscle movement patterns when used along with functional activities
- Functional electrical stimulation (FES), to help a patient initiate a muscle movement when more active movement is present in the muscle
(Meydam, 2018)
Contraindications for use of electrotherapeutic modalities include:
- Treatment of symptomatic local pain, unless the cause of the pain has been clearly established
- In areas where cancerous lesions are present
- Over skin areas that are swollen, infected, or inflamed
- In patients with serious infectious diseases or diseases that require heat or fevers to be suppressed
- To the anterior neck (carotid sinus) or the head
- In pregnant women
- For patients with cardiac demand pacemakers, battery-operated implant devices, or automatic implantable cardioverter-defibrillators (AICDS)
(Seidel et al., 2021)