CONTRAINDICATIONS AND INDICATIONS FOR PHYSICAL THERAPY MANAGEMENT

Florida is a “direct access with provisions” state, which means an individual may go directly to a physical therapist for evaluation without a physician’s referral first and may receive treatment for 30 days. After 30 days, the therapist must obtain a treatment plan signed by an approved healthcare provider (FPTA, 2021).

Florida Statute 486.021 and Florida Senate Bill CS/HB467 outline modalities used by physical therapists, which include:

  • Assessments to include the endocrine, nervous, cardiovascular, pulmonary, integumentary, and musculoskeletal systems
  • Treatment for or prevention of any disability, injury, disease, or other health condition
  • Rehabilitation by the use of:
    • Exercise and physical modalities
    • Chemical modalities
    • Properties of air (air-fluidized therapy)
    • Electricity
    • Massage
    • Radiant energy, including ultraviolet, visible, and infrared rays
    • Ultrasound
    • Water
    • Acupuncture, including dry needling
  • Performance of tests of neuromuscular functions or electromyography as an aid to diagnosis
  • Referral or consultation with a practitioner of record if the patient’s condition is found to be outside the physical therapist’s scope of practice
    (FBPTA, 2021; Florida Legislature, 2020)

Therapists must be aware of both the indications and contraindications for each modality in order to prevent the occurrence of adverse events.

Heat

A thermogenic agent induces an increase in temperature and subsequent physiological changes to the superficial layer(s) of skin, fat, tissues, blood vessels, muscles, nerves, tendons, ligaments, and joints. These include hot packs, heating pads, paraffin bath, infrared, ultrasound, and fluidotherapy.

SUPERFICIAL HEAT

Indications for use of superficial heat in subacute to chronic conditions include reducing pain and muscle spasms, relaxing skeletal muscles, and decreasing 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

DEEP HEAT

Deep heat modalities include ultrasound, shortwave diathermy (SWD), and microwave diathermy (MWD), the latter two which convert electromagnetic energy to thermal energy. Indications for use of deep heat include treatment of various soft tissue disorders, including bursitis, tendonitis, degenerative arthritis, musculoskeletal pain, and contractures, and promotion of wound healing.

Contraindications for deep heat include those for superficial heat above and:

  • Over the eyes
  • Over a pregnant uterus
  • Over a malignant area
  • Near the heart, brain, spine, laminectomy sites, or epiphyseal plates of children
  • In patients with:
    • Pacemakers
    • Metal plates
    • Screws, pins, and external fixators
    • Joint replacement components
  • (Seidel et al., 2021)

Ultrasound

Ultrasound uses high-frequency sound waves to provide deep heating to muscles, tendons, joints, and ligaments. The waves produce transfer energy to the surface of the body and can target deeper soft tissues. It is indicated for use in the treatment of a variety of musculoskeletal pathologies such as osteoarthritis, tendon injuries, and or any other soft tissue injury.

Ultrasound is contraindicated for use:

  • Over open wound, acute inflammation, or acute infection
  • Over malignancies or metastatic lesions
  • Over areas with decreased sensation
  • Over active epiphyses in children
  • On parts of the body with metal implants, e.g., joint replacement
  • Near or over a pacemaker
  • In pregnant patients
  • Around eyes, breasts, or gonads
  • Over fractures
  • Near or over any implanted electrical stimulation device
  • In patients with thrombophlebitis
    (Matthews & Stretanski, 2020)

Phonophoresis

Phonophoresis refers to use of ultrasound for delivering therapeutic medications to subcutaneous tissues. It is used in physical therapy to enhance the absorption of topically applied analgesics and anti-inflammatory agents. Phonophoresis is indicated for and may be useful in the treatment of inflammatory conditions including tendonitis, arthritis, and bursitis. Contraindications are identical with those for use of ultrasound (see above).

Electrotherapy

Electrotherapy uses electromagnetic radiation to stimulate nerve or muscle. Common types include:

  • Transcutaneous nerve stimulation (TENS)
  • Interferential therapy (IFT)
  • Neuromuscular electrical stimulation (NMES)
  • Iontophoresis for delivery of medications to deep tissues

Indications for use include:

  • Acute and chronic pain
  • Neuromuscular disease
  • Joint effusion and edema
  • Disuse muscle atrophy
  • Wound and bone healing

Electrotherapy treatment is contraindicated:

  • Over carotid sinus, heart, or pregnant uterus
  • Over pacemakers and automatic implantable cardioverter defibrillators
  • Over battery-operated implant devices such as drug delivery pumps, neurostimulators, and cochlear implants
  • Over major skin defects/wounds that cannot be covered with Vaseline
  • In patients with an IUD containing metal
  • In patients with seizure disorder, active hemorrhage, malignancy, circulatory impairments, and arterial or venous thrombosis
    (Seidel et al., 2021)

Iontophoresis

Iontophoresis is the process of using an electric current to deliver a therapeutic agent transdermally to reach deeper tissues. Indications for use may involve local, regional, or systemic delivery. Localized agents include anesthetics for pain management, corticosteroids, and antiperspirants. Regional delivery includes anti-inflammatory agents. Systemic delivery includes fentanyl for analgesia (Seidel et al., 2021).

Contraindications for iontophoresis include those noted above and hypersensitivity or adverse reactions associated with the drug to be administered. Patients with prior medical histories of cardiac arrythmias or hypercoagulability should not receive the procedure near a cardiac pacemaker or superficial blood vessels (Sheikh & Anterpreet, 2020).

Light Therapy (Phototherapy)

Light therapies include ultraviolet light and low-level laser therapy and are indicated for acute and chronic pain and inflammation, stimulation of collagen metabolism, and promotion of wound healing.

Light therapies are contraindicated for treatment:

  • Over eyes
  • Over skin cancers
  • In patients with organ disease, systemic lupus erythematosus, fevers, or acute inflammation
  • In patients with irradiation of the neck region, seizures, epilepsy, and hyperhidrosis
    (Seidel et al., 2021)

Dry Needling

Dry needling is an invasive intervention that uses a thin, solid filiform needle to penetrate the skin and stimulate underlying myofascial trigger points and muscular and connective tissue for the management of neuro-musculoskeletal pain and movement impairment. Dry needling can be carried out at a superficial or deep tissue level.

Indications for use of dry needling include:

  • Minimum criteria is met for diagnosis of myofascial trigger points, including:
    • Spot tenderness in a palpable band of skeletal muscle
    • Subject recognition of pain with palpation
  • A “jump and shout” sign on palpation

There are both absolute and relative contraindications for the use of dry needling. Absolute contraindications include:

  • In a patient with needle phobia
  • In a patient who is unwilling (e.g., fear, patient beliefs)
  • In a patient unable to give consent due to age-related, communication, or cognitive issues
  • In a medical emergency or in acute medical conditions
  • Over an area or limb with lymphedema
  • Into a muscle or area in patients on anticoagulant therapy or with thrombocytopenia

Relative contraindications are those that should be used with caution, including patients with or who are:

  • Abnormal bleeding tendency
  • Compromised immune system
  • Vascular disease
  • Diabetes
  • Epilepsy
  • Pregnant
  • Children
  • Frail
    (Physiopedia, 2021)