Effect of Fluori-Methane® Spray on Passive Hip Flexion

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Effect of Fluori-Methane Spray on Passive Hip FlexionL. ROBERT HALKOVICH, MS,WALTER J. PERSONIUS, MA,H. PETER CLAMANN, PhD,and ROBERTA A. NEWTON, PhD

The purpose of the study was to evaluate the influence of Fluori-Methane sprayas a method of affecting passive range of motion measured at the right h ip joint.Subjects were 30 normal volunteers randomly divided into an experimentalgroup and a control group. A special table was constructed to position andstabilize each subject for monitoring the right lower extremity's resistance toside-lying straight leg raising. Specific right hip flexion goniometric measurements were compared and analyzed before and after application of Fluori-Methane spray to the soft tissues overlying the posterior part of the right thigh.The results of the study showed that the experimental group, which receivedapplication of Fluori-Methane spray and static passive stretch, did significantly(p < .02) increase the range of passive hip flexion over that of the control group,which received only static passive stretch.Key Words: Cold, Contracture, Physical therapy, H ip joint.

Vapocoolant application can be defined as intensespot cooling produced by rapid evaporation of abottled hydrocarbon compound on selected areas ofthe skin. Although vapocoolants such asEthyl Chloride* spray and Fluori-Methane spray have beenused clinically with reported success, their effectshave been described qualitatively and not quantitatively. Historically, vapocoolant application has beenreported to increase active joint range of motion1;assist in the reduction of muscle spasm2; diminishlocal, referred, and chronic pain perceived by thepatient3; act as a counterirritant4; and serve as aneffective local anesthetic.5

The purpose of this study was to evaluate Fluori-Methane spray as a method of increasing passiverange of motion measured at the right hip joint.Fluori-Methane spray is a vapocoolant used in themanagement of restricted joint range of motion dueto a shortening of the soft tissues surrounding thatjoint structure. The spray has been thought to alterpassive range of motion by way of neuromusculo-skeletal pathways and has been used in the clinic fora number of years. However, no objective evidencehas been documented concerning the spray's effectiveness. Using experimental design and a quantitative joint measurement technique, a controlled trialwas designed to test the validity of clinical observations associated with vapocoolant application.METHOD

Subjects were 30 normal volunteers, 13 men and17 women, randomly divided into an experimentaland a control group. They ranged in age from 19 to39 years, with a mean of 24.5 years.A specially designed table was constructed to po-sition and stabilize each subject for monitoring theforce of the right lower extremity's resistance to side-lying straight leg raising (Fig. 1). Each subject as-sumed left side lying on the force table with the rightlower extremity resting on the secondary level of theforce table.

* Gebauer Chemical Co, 9410 St. Catherine Ave, Cleveland, OH44104.Mr. Halkovich is Assistant Professor, School of Related HealthSciences, Department of Physical Therapy, University of HealthSciences/The Chicago Medical School, North Chicago, IL 60064(USA).Mr. Personius is Assistant Professor, School of Allied HealthProfessions, Department of Physical Therapy, Medical College ofVirginia-Virginia Commonwealth University, Richmond, VA 23298.Dr. Clamann is Associate Professor, School of Graduate Studies,Department of Physiology, Medical College of Virginia-VirginiaCommonwealth University, Richmond, VA 23298.Dr. New ton is Assistant Professor, School of Allied H ealth Professions, Department of Physical Therapy, Medical College o f Virginia-Virginia Commonwealth University, Richmond, VA 23298.Adapted from a paper presented at the Fifty-sixth Annual Conference of the American Physical Therapy Association, Phoenix, AZ ,

June 1980.This article was submitted November 16, 1979, and accepted April29, 1980.

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Fig. 1. Force table. A. Radial arm. B. Skateboard app aratus.

The right lower extremity was positioned and secured on a skateboard apparatus. Ball bearings wereattached to the skateboard undersurface to minimizefriction between the subject's lower extremity and thesecondary level of the force table. A radial arm,composed of galvanized pipe, was attached to theundersurface o f the primary level of the force table atits center. This center point corresponded to the cen terof rotation of the hip joint of ea ch subject. The radialarm extended from the center of the primary level ofthe force table out to the periphery and was able torotate in an arc of 180 degrees around the circumference of the primary level of the force table. The topsurface of the secondary level of the force table wasmarked in one-degree increments from 50 degrees to155 degrees to produce a surface goniometer. Thisdevice was used to measure the pelvifemoral angle indegrees of motion as the skateboard apparatus passed

Fig. 2. C. Transducing cell and 200-lb load cell accessory. D. Bridge amplifier. E. Digital voltmeter. F. Surfacegoniometer.

over these goniometric markings on the secondarylevel of the force table.6

The tip of the right greater trochanter was identified and marked on each subject. This point waspositioned directly beneath a suspended plumb bob,thereby aligning the centers of rotation for both theright hip joint and the radial arm.7

The right lower extremity was positioned and secured to the skateboard apparatus and positioned atthe neutral angle as measured by the surface goniometer. Stabilization was applied to the anterior superior iliac spines bilaterally, to the sacrum, and tothe left thigh by means of fitted pads and belts. Anankle cuff was applied just superior to the tip of theright lateral malleolus. A cable from the ankle cuffwas aligned at a 90-degree angle to the long axis ofthe right lower extremity and affixed to a Gould-Statham model UC3 universal transducing and 200-lb load cell accessory incorporated within the radialarm (Fig. 2). Force data from the load cell wereamplified through a Gould-Statham model SC1105bridge amplifier and displayed on a Data Precisionmodel 248 digital voltmeter.:):

After the subject had been p ositioned and stabilizedas described, a threshold force was ascertained forpassive hip flexion. The threshold force was definedas that force needed to evoke a "pulling" sensation inthe right popliteal fossa with the knee in 180 degreesof extension, when the radial arm was m oved aroundthe circumference o f the force table at about 5 degreesa second.8 At the point the subject acknowledged a"pulling" in the popliteal fossa, the radial arm wasstopped, the prepelvifemoral angle was measured,and the voltmeter reading was recorded. Measurement of the pretest pelvifemoral angle was obtainedby the surface goniometer, which was drawn on thesecondary level of the force table (Fig. 2). Pelvifemoral angle was defined a s the angle opening postero -inferior to the hip joint constructed by two lines, onebetween the tip of the anterior superior iliac spineand the tip of the ischial tuberosity, and a secon d linedepicting the long axis of the lower extremity andused to ascertain the degree of hip flexion in relationto the stabilized pelvis.9 The identification o f a threshold force ensured that the hip would be passivelyflexed with the same amount of force following treatment procedures. The mean threshold force for theexperimental an d control groups was 3.08 kg and 3.17kg , respectively.

Experimental-group subjects were given application of Fluori-Methane for over approximately a45-second period. Six applications, each lasting about

Gould-S tatham Products, 2230 Statham B lvd, Oxnard, CA93030. Data Precision Corp, Audubon Rd, Wakefield, M A 02115.

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TABLEComparison of Pelvifemoral Angle Measurements Before an d After Fluori-Methane Treatment

Source

ExperimentalGroup (n = 15)ControlGroup (n = 15)

s

1.70 0.57

Pelvifemoral Angle(mean degree s)

119.60 (Pretest)122.50 (Posttest)118.30 (Pretest)118.60 (Posttest)

MaximumRange ofPelvifemoralMeasurements(degrees)5.502.00

MeanDifference

1.21a0.21

five seconds on and three seconds off, were appliedto the skin overlying the entire length of the semimembranosus, semitendinosus, and biceps femorismuscles from origin to insertion. Application of thespray was administered with the knee maintained in180 degrees of extension. Rate of sweep w as about 12cm a second. Each sweep took five seconds to complete. Control-group subjects received no applicationof Fluori-Methane spray but were maintained inthe threshold-force position for a similar 45-secondperiod. Following this period, the voltmeter readingwas rechecked. If this second force reading variedfrom the threshold force reading, the right lowerextremity was repositioned until the threshold forcereading was reestablished. The posttest pelvifemoralangle was then measured and recorded.RESULTS

The difference in prepelvifemoral and postpelvife-moral angle measurements among the 30 experimental and control group subjects was calculated. Themean difference in pelvifemoral angle measurementfor the experimental and control groups was 1.21degrees and 0.21 degrees, respectively, as seen in theTable.Among the experimental-group subjects, 10 sub

jects displayed an increase in passive hip flexion, 3subjects showed a decrease in passive hip flexion, and2 snowed no change. The total increase of all experimental-group subjects combined w as 23 degrees.Among the control-group subjects, five subjectsdisplayed an increase in passive hip flexion, twosubjects showed a decrease in passive hip flexion, andeight subjects showed no change. The total increaseof all control-group subjects combined was 3.25 de

grees.The mean differences and maximal range of pelvifemoral angle measurements between the pretestand posttest experimental and control groups werestatistically significant (p < .02) as determined by an

unpaired t test and summ arized in the T able.10 Interpretation of this data analysis indicated that the experimental group, which received application ofFluori-Methane spray, significantly increased therange of passive hip flexion over that of the controlgroup.DISCUSSION

Factors that caused an increase in passive hipflexion of experimental-group subjects may have b eenneurophysiological or mechanical, or a combinationof both. Neurophysiological effects may have beencaused by cold, tactile, and static-stretch stimuli; mechanical effects would have been caused by staticpassive stretch.Application of Fluori-Methane spray does notappear to affect muscle sp indle afferent firing directly.Lippold and associates reported a decrease in afferentdischarges from muscle spindles after cooling 5Cbelow body temperature.11 However, Travell has reported that the application of Fluori-M ethane sprayto the skin of one subject did not decrease intramuscular temperature but did cause substantial cutaneouscooling.12 Therefore, inasmuch as temperature effectscaused by Fluori-Methane spray may be limited tothe skin, application of the spray would not directlyalter the afferent discharges from muscle. An indirecteffect on muscle afferents may p ossibly be caused bystimulation of cutaneous afferents that could influence gamma motoneurons and subsequently the muscle afferents. I believe this study was not affected bycutaneous input that was facilitatory to the motorsystem because the dependent variable was passiverange of motion. Only the hip joint was free to movethrough its range of motion. No active hip range ofmotion w as noted in the subjects by the experimenterduring test procedures.

Because the F luori-Methane spray is pressurizedand emitted from a fine nozzle, the vapocoolantstrikes the skin as a jet stream, which may act as a

a Statistically significant (p < .02).

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tactile stimulant ana logous to light tou ch or brushing.Cutaneo us receptors that have bee n show n to respondto tactile stimuli are free nerve endings, touch receptors, and endings surrounding hair follicles.13 Theseskin receptors may have been influenced by the innocuous stimulation of the skin, thereby causing aflexor-reflex response with contraction of the hipflexors and relaxation of the hip extensors.14 A trueflexion response would facilitate the knee flexors aswell, but because the knee joint was maintained in180 degrees of extension by means of the skateboardapparatus, only the h ip joint w as free to mo ve throughits range of motion. The relaxation of the hip extensors may have been responsible for the decrease intension noted with 55 percent of the experimental-group subjects.

Hunt has shown that gamma motoneurons respondmore readily to touch of the skin than do alphamotoneurons.15 He showed that with initial lighttouching of the skin, the gamma activity increases,but after about two seconds of continu ous light touching of the skin, the gamma activity decreases to alevel below that of its initial resting rate. This occurred without muscle contraction that would unloadthe muscle spindle. The decrease in gamma activityappears to be a form of adaptation. This may havehappened in my study because the Fluori-Methanespray was applied continuou sly for about five se condseach sweep. The sequence of events may be that thevapocoolant stimulates cutaneous afferents that decrease gamma motoneuron discharge, which in turnbias the intrafusal muscle fibers. This spindle biaswould then decrease spindle afferent activity andultimately decrease the activity of the alpha mo toneu rons and extrafusal muscle fibers of the hamstringmuscles. This would allow more passive stretch to beapplied to the soft tissues of the posterior thigh, thusincreasing passive range of motion measured at thehip joint.

Mechanical adaptation of muscle and connectivetissues to passive static stretch may have b een respo nsible for the decreased tension as monitored by thestrain gauge. Static stretch was applied to the softtissues of the posterior part of the thigh in the experimental and control groups. When these soft tissueswere stretched, tensile stress may have been sharedbetween the muscles' parallel and series elastic components.16 Threshold force in this study was as highas 6.9 kg for the control group and 5.7 kg for theexperimental group, and therefore may have resultedin a plastic elongation of the muscles' parallel andseries elastic components. The static stretch and resulting plastic elongation may have been responsible

for the decrease in tension monitored by the straingauge. The control group, which received only staticstretch, demonstrated a slight decrease in tension in14 percent of the subjects. Therefore, the static stretchalone may have been a factor in decreasing tensionof the soft tissues of the posterior part of the th igh. Inthe experimental group, static stretch and Fluori-Methane spray may have interacted to produce softtissue elongation.

The results of this study provide information thatcan be u sed by p hysical therapists in treating patientswith joint mobility deficits in an effort to preventdeformities or to restore function. The fact thatFluori-Methane spray had a significant effect onincreasing the range of passive hip flexion lends someobjective support to the selection of this method oftreating patients with joint mob ility deficits caused byneuromuscular dysfunction.Further research on Fluori-Methane spray needsto be carried out to determine its mechanism ofaction. Using neurophysiological techniques in animal experiments, the neural pathways and mechanisms that may be activated by Fluori-Methanespray could be investigated by monitoring alpha andgamma m otoneurons, Golgi tendon organs, and spindle and cutaneous afferent nerves. In addition, reflexversus supraspinal influences need to be differentiated.

SUMMARY

Thirty subjects were studied to assess the effects o fa vapocoolant spray, Fluori-Methane, as a methodof affecting passive hip flexion. Each subject in thecontrol group and experimental group was positionedand stabilized on the force table. A strain gauge,mounted on the force table, monitored tensile forceof the soft tissues of the right posterior part of thethigh during test procedures. Statistical analysis ofthe differences between pretreatment and posttreat-ment pelvifemoral angle measurements was carriedout by means of an unpaired t test. Results of thestatistical analysis indicated that application ofFluori-Methane spray increased passive hip flexionin the experimental-group subjects over that of thecontrol-group subjects (p < .02).

Acknowledgments. Many thanks to Otto D. Payton,PhD, John McM Mennell, MD, Janet G. Travell,MD, and David G. Simons, MD, for their valuableadvice and gu idance during preparation o f this paper.

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P h y s Th e r 5 8 : 5 6 7 - 5 7 9 , 1 9 7 84 . Gammon GD, S ta rr I: S tu d ie s on re l ie f o f pa in by coun t er -irr i ta t ion. Journal of Clinica l Invest igat ion 20:13-20, 19415. We eks VD, Travel l J: How to Give Pa in les s Inject ions . NewYork, NY, Grune & S t r a t t on , In c . 1 957 , pp 31 8 - 3226. Jen se n RH, Smid t GL, Johns ton RC: A t ech n ique for ob ta ini ng m e a su r e m e n t s o f f or c e g e n e r a t e d b y h ip m us c l e s . A rc hP h y s M e d 5 2 : 2 0 7 - 2 1 5 , 1 9 7 17. John s ton RC, Smid t GL: M easu remen t of h ip motion dur ingwa lk ing. J Bone Join t Surg [Am] 51 :10 83 -1 09 4, 196 98. M edeir os J, Smidt GL, Burmeiste r LF, et a l: The inf lu en ce ofi som e t r ic e x e r c i s e a nd p a s s i v e s t r e t c h on h i p joi n t m oti on .P h y s Th e r 5 7 : 5 1 8 - 5 2 3 , 1 9 7 79. M i lch H: The p e lv i femora l an gle . J Bone Join t Surg [Am] 24:1 4 8 - 1 5 3 , 1 9 4 2

1 0 . Kilpatr ick SJ: Stat ist ica l Principles in Health Care Informat ion, ed 2 . Ba l t imore , MD, Univ er s i t y Park Pre ss , 1975, pp1 3 1 - 1 7 01 1 . Lippold O, Nichol le J, Redfearn J: A stu dy of a f feren t d is charge produced by cool ing a mammal ian musc l e sp ind le . JP h y s i ol 1 5 3 : 2 1 8 - 2 3 4 , 1 9 6 01 2 . Travel l J: M yofasc ia l tr igger poin ts: Clinica l v iew. In Bonic aJJ , A i b e -F e s s a r d D ( e d s ) : A d v a nc e s i n P a i n R e s e a r c h a ndTherapy . New York , NY, Raven Pre ss , 1976, vo l 1 , pp 919-9 2 61 3 . Catt e ll McK, Hoagland H: Res po n se of t a c t i l e r ec ep tors toin t ermi t t en t s t imula t ion . J Phy s io l 72:392-404, 193114 . H enn eman E , Houk J: Fe edback con t rol of musc l e : In t roductory con ce p t s . In Mou nt ca s t l e VB (ed): M ed ica l Ph y s io logy ,ed 13. S t . Loui s , MO, C. V . M osby Co, 1974, vo l 1 , pp 6 3 3 -6 3 415 . H un t CC: The re f l ex a c t i v i t y of mammal ian sma l l nerv e f iber s .J P hy s i o l 1 1 5 :456 - 46 9 , 1 95116 . Close R l : Dynamic prop er t i e s of mammalian ske l e t a l mu sc l e .P h y s i ol Re v 5 2 : 1 2 9 - 1 9 7 , 1 9 7 2

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Effect of Fluori-Methane® Spray on Passive Hip Flexion