# data[].attributes.body
• Acute pain
• Chronic pain
• Acute swelling
• Myofascial trigger points
• Muscle guarding
• Muscle spasm
• Acute muscle strain
• Acute ligament sprain
• Acute contusion
• Bursitis
• Tenosynovitis
• Tendinitis
• Delayed onset muscle soreness
• Reducing temperature

# data[].attributes.body
• Raynaud’s disease or phenomenon
• Over an area with circulatory compromise
• Peripheral vascular disease
• Hypersensitivity to cold
• Cold intolerance
• Cryoglobulinemia
• Paroxysmal cold hemoglobinuria
• Over a regenerating peripheral nerve

# data[].attributes.body
• Over a superficial nerve
• Hypertension
• Impaired sensation or mentation
• Patients who are very young or very old
• Over an open wound

# data[].attributes.body
• Subacute and chronic inflammatory conditions
• Subacute or chronic pain
• Decreased ROM
• Facilitate healing
• Muscle guarding
• Muscle spasm
• Myofascial trigger points
• Subacute muscle strain
• Subacute ligament sprain

# data[].attributes.body
• Acute musculoskeletal conditions
• Recent or potential hemorrhage
• Thrombosis
• Impaired sensation
• Impaired mentation
• Malignant tumor
• Infrared irradiation of the eyes
• Over an open wound

# data[].attributes.body
• Pregnancy
• Cardiac insufficiency
• Impaired circulation
• Poor thermal regulation
• Edema
• Metal in the area
• Demyelinated nerves
• Over areas where topical counterirritants have been applied

# data[].attributes.body
Acute and post-acute conditions (nonthermal US)

Soft tissue healing and repair

Scar tissue

Joint contracture

Chronic inflammation

Increase extensibility of collagen

Reduction of muscle spasm

Pain modulation

Increase blood flow

Soft tissue repair

Increase in protein synthesis

Tissue regeneration

Bone healing

Inflammation associated with Myositis Ossificans

Plantar warts

Myofascial trigger points

# data[].attributes.body
Thermal US for acute and post-acute conditions

Thrombophlebitis

Eyes

Reproductive Organs

Pregnancy

Pacemaker or implanted cardiac rhythm device

Malignancy

Epiphyseal areas in young children

Total Joint Replacements

Central Nervous System tissue

# data[].attributes.body
Fracture
high-intensity ultrasound may cause pain and impair
healing

# data[].attributes.body
Post acute musculoskeletal injuries
• Muscle guarding
• Joint contractures
• Myofascial trigger points
• Pain management
• Soft tissue healing
• Nerve healing
• Bone healing

# data[].attributes.body
• Acute injury or inflammation
• Areas with ischemia
• Impaired sensation
• Impaired mentation
• thrombosis
• Fluid-filled areas or organs
• Joint effusion
• Eyes
• Contact lenses if treating near head
• Over moist clothing and moist wound dressings
• Malignancies
• Testes
• Pregnancy
• Epiphyseal plates in children
• Cardiac pacemakers & other implanted electronic medical devices
• Intrauterine devices
• Watches or jewelry on the patient
• Metal implants
• Infection

# data[].attributes.body
• Impaired circulation
• Poor thermal regulation
• Pelvic area during menstruation
• Obesity

# data[].attributes.body
Facilitation of wound healing
• Pain reduction
• Increasing the tensile strength of a scar
• Decreasing scar tissue
• Decreasing inflammation
• Bone healing and fracture consolidation

# data[].attributes.body
Directly over the eyes
• Malignancy
• Low back or abdomen during pregnancy
• Within 4-6 months of radiation therapy
• Over hemorrhaging areas
• Over the thyroid glands
• Epiphyseal plates in children

# data[].attributes.body
• Impaired sensation or mentation - patient may not be
able to report any discomfort during treatment
• Light sensitivity - includes those with abnormally high
sensitivity to light and individuals who are taking
medication that may make them sensitive to light
(photosensitizing medication); usually applies more to
the use of UV light; stop use of light if adverse effects
occur
• Tattoos - the ink used for the tattoo could potentially
overheat; need to avoid treating over areas with tattoos

# data[].attributes.body
• Acute, post-acute, chronic pain
• Stimulation of denervated muscle
• Retarding muscle atrophy
• Muscle strengthening
• Muscle reeducation
• Stimulation of venous and lymphatic circulation
• Management of edema
• Muscle spasms
• Muscle guarding
• Wound, fracture, tendon, ligament healing

# data[].attributes.body
• Pacemaker, implanted cardiac defibrillator
• Malignancy
• Pregnancy
• Placement of electrodes over the carotid sinus
• Areas where venous or arterial thrombosis or
thrombophlebitis is present

# data[].attributes.body
• Impaired sensation
• Impaired mentation
• Cardiac disease
• Areas of skin irritation or open wounds

# data[].attributes.body
• Muscle reeducation
• Regaining neuromuscular control
• Increasing isometric and isotonic strength of
a muscle
• Relaxation of muscle spasm
• Decreasing muscle guarding
• Pain reduction
• Psychological relaxation

# data[].attributes.body
• Any musculoskeletal condition that a muscular
contraction might exacerbate

# data[].attributes.body
• Spinal disc bulge or herniation
• Spinal nerve root impingement
• Joint hypomobility
• Subacute joint inflammation
• Muscle spasm

# data[].attributes.body
Osteoporosis

Fractures

Where motion is contraindicated

Acute injury or inflammation

Joint hypermobility or instability

Peripheralization of symptoms with traction

Uncontrolled hypertension

Pregnancy

Positive vertebral artery test (for cervical traction)

# data[].attributes.body
• Structural diseases or conditions affecting spine
• Tumor
• Infection
• Rheumatoid Arthritis
• Prolonged systemic steroid use
• Pressure of traction harness may be hazardous
• Hiatal hernia
• Vascular compromise
• Displaced annular fragment
• Traction no longer appropriate when annular fragment loses connection with body of the disc

• Medial disc protrusion
• If disc protrusion is medial to nerve root, then traction force may increase impingement of disc on the nerve

• When severe pain resolves fully with traction
• Could mean that traction has increased compression on nerve root leading to complete nerve block
• Claustrophobia or other psychological aversion to traction
• Manual or positional traction may be better
• Inability to tolerate prone or supine position
• Cervical traction may be applied in sitting
• Disorientation
• May become entangled in belts/harness
• Recommended that only manual traction techniques be used if the patient is disoriented

• Temporomandibular joint problems
• Precaution when performing cervical traction; recommend
halter which applies force at occiput and avoids pressure
on mandible
• Dentures
• Keep dentures in place during cervical traction to maintain alignment of TMJ

# data[].attributes.body
• Lymphedema
• Traumatic edema
• Chronic edema
• Venous stasis ulcers
• Wound healing following surgery
• Prevention of Deep Vein Thrombosis (DVT)

# data[].attributes.body
• Compartment syndromes
• Peripheral vascular disease
• Presence of (DVT) or thrombophlebitis
• Local superficial infection
• Congestive heart failure (CHF)
• Acute pulmonary edema
• Displaced fractures

# data[].attributes.body
• Impaired sensation or mentation
• Uncontrolled hypertension
• Cancer
• Superficial peripheral nerves

# data[].attributes.body
• Increase coordination
• Decrease pain
• Decrease neuromuscular excitability
• Stimulation circulation
• Facilitate healing
• Restore joint mobility
• Remove lactic acid
• Alleviate muscle cramps
• Increase blood flow
• Increase venous return
• Retard muscle atrophy
• Increase ROM
• Edema
• Stretching scar tissue
• Adhesions
• Muscle spasm
• Myositis
• Bursitis
• Fibrositis
• Tendinitis
• Revascularization
• Raynaud’s disease
• Intermittent claudication
• Dysmenorrhea
• Headaches
• Migraines

# data[].attributes.body
Arteriosclerosis

Thrombosis

Embolism

Severe varicose veins

Acute phlebitis

Cellulitis

Synovitis

Abcesses

Skin infections

Cancers

Acute inflammatory conditions

# data[].attributes.body
Muscle Strengthening

Muscle Re-education following surgery or injury

Reduction of Muscle Spasms

Edema Management

# data[].attributes.body
• Pacemaker, implanted cardiac defibrillator
• Malignancy
• Pregnancy
• Placement of electrodes over the carotid sinus
• Areas where venous or arterial thrombosis or
thrombophlebitis is present
Additional contraindication for use of electrical stimulation for
muscle contraction:
• Musculoskeletal problems where muscle contraction would
exacerbate the condition

# data[].attributes.body
• Impaired sensation
• Impaired mentation
• Cardiac disease
• Areas of skin irritation or open wounds
Additional precaution for use of electrical stimulation for
muscle contraction:
• May cause delayed-onset muscle soreness

# data[].attributes.body
Acute pain

Chronic Pain

# data[].attributes.body
• Pacemaker, implanted cardiac defibrillator
• Malignancy
• Pregnancy
• Placement of electrodes over the carotid sinus
• Areas where venous or arterial thrombosis or
thrombophlebitis is present
• Musculoskeletal problems where a muscle contraction
would exacerbate the condition

# data[].attributes.body
• Impaired sensation
• Impaired mentation
• Cardiac disease
• Areas of skin irritation or open wounds
• Low-Frequency or Burst Mode may cause delayed-onset
muscle soreness if used for more than 30 minutes

# data[].attributes.body
• Depends upon medication being used:
• Calcium deposits - acetic acid
• Fungal infection - copper
• Inflammation - dexamethasone phosphate
• Scar tissue - potassium iodide
• Delivery of local anesthetic - lidocaine
• Plantar warts - salicylate
• Muscle relaxer - magnesium
• Hyperhidrosis - tap water
• Wounds - zinc

# data[].attributes.body
• Pacemaker, implanted cardiac defibrillator
• Malignancy
• Pregnancy
• Over areas of known thrombosis or thrombophlebitis
• Allergy to ions being administered

# data[].attributes.body
• Impaired sensation
• Impaired mentation
• Cardiac disease
• Areas of skin irritation or open wounds

# data[].attributes.body
Critically Appraised Topic (CAT)

Question

Does circulating cold water cryotherapy with or without intermittent pneumatic compression (IPC) influence shoulder joint position sense (JPS) compared to no intervention in recreationally active adults?

Population/Patient

Recreationally active adults

Intervention/Indicator

Circulation cold water cryotherapy with IPC

Control/Compare

Circulating cold water cryotherapy without IPC and no intervention

Outcome

Shoulder joint position sense (JPS)

Clinical Bottom Line

This study found that neither circulating cold water cryotherapy without IPC, nor circulating colder water cryotherapy with IPC had any significant affect on shoulder joint position sense in recreationally active adults. As such, these modalities may not be suitable for enhancing proprioceptive acuity in this population.

Summary of Key Evidence

1.      Study Design

Randomized crossover trial

2.      Sample

20 recreationally active adults (mean age: 24.3 +/- 3.2 years)

3.      Procedure

Participants underwent three conditions in a randomized order:

·         Circulating cold water cryotherapy with IPC

·         Circulating cold water cryotherapy without IPC

·         Control (no intervention)

Each intervention lasted 15 minutes, with a 48hr washout period between sessions. Shoulder JPS was assessed before and after each intervention using a laser pointer repositioning task.

4.      Outcome Measures

Shoulder joint position sense measured by absolute error in degrees during a repositioning task.

5.      Results

No significant differences were observed in shoulder JPS across the three conditions. Both cryotherapy interventions (with and without IPC) did not significantly alter JPS compared to the control.

Appraisal

Strengths of the study

Randomized Crossover Design: each participant served as their own control, reducing inter-subject variability and enhancing the study’s internal validity.

Practical Relevance: The interventions studied are commonly used in sports and rehab settings, making the findings directly applicable to clinical practice.

Weaknesses of the study

Limited Participant Information: No details on the demographics of the participants such as age, gender, or specific activity levels are disclosed which leads to generalization. Results may vary amongst other groups.

Lack of Detailed Methodology: Lacked specifics regarding duration and intensity of the interventions. No exact methods we given to assess JPS, diminishing the study’s rigor.

Short-Term Assessment: The study appears to assess immediate or short-term effects. Long term effects of these interventions on proprioception remains unknown.

Citation

Stanhope, E.N., Warnett, R.L., Burt, D.G., Cutler, S.W., Kell, J.W.G., & Naemi, R. (2024). The influence of circulating cold water cryotherapy with or without intermittent pneumatic compression on shoulder joint position sense (JPS) in recreationally active adults: A randomized crossover trial. Journal of Bodywork and Movement Therapies, 40, 1008-1013. https://doi.org/10.1016/j.jbmt.2024.07.022

Appraised by:    Brett Bucey_____         Appraisal Date:  04/25/2025___

# data[].attributes.body
Critically Appraised Topic (CAT)

Question

Does the use of NMES improve muscle strength in adults diagnosed with acute or late septic shock in the ICU compared to no intervention?

Population/Patient

Adults diagnosed with acute or late septic shock in ICU settings

Intervention/Indicator

Physical therapy with neuromuscular electrical stimulation (NMES)

Control/Compare

Physical therapy without NMES

Outcome

Muscle strength, functional capacity, ICU length of stay, mortality

Clinical Bottom Line

Physical therapy combined with NMES does not significantly improve muscle strength, functional capacity, or clinical outcomes compared to physical therapy alone in patients with septic shock. Current evidence does not support routine use of NMES in this setting.

Summary of Key Evidence

1.      Study Design

Randomized crossover clinical trial

2.      Sample

ICU patients with acute and late septic shock

33 patients

3.      Procedure

Participants received two interventions (physical therapy with and without NMES) in a random order with a 48hr washout period

Interventions applied within 72hrs of ICU admission

4.      Outcome Measures

Muscle strength (Medical Research Council scale)

Functional capacity

ICU length of stay and mortality rates

5.      Results

No significant differences in strength, functional performance, or clinical outcomes between groups

Time in ICU and mortality were not influenced by NMES

Appraisal

Strengths of the study

Crossover design enhances internal control and reduces variability

Early intervention aligns with clinical interest in early mobilization

Outcome measures are clinically relevant

Weaknesses of the study

Small sample size may limit statistical power

Short intervention and follow-up period

Only single sessions assessed – no long-term NMES exposure

Generalizability limited to similar ICU settings

Citation

Lago, A. F., Basile-Filho, A., de Oliveira, A. S., de Souza, H. C. D., dos Santos, D. O., & Gastaldi, A. C. (2022). Effects of physical therapy with neuromuscular electrical stimulation in acute and late septic shock patients: A randomised crossover clinical trial. PLOS ONE, 17(2), e0264068. https://doi.org/10.1371/journal.pone.0264068

Appraised by:    ____Brett Bucey_______     Appraisal Date:  04/25/2025____