PAM Flashcards
Nerve Fiber types
C fibers (nociceptive)
-Small, unmyelinated (transmit slowly)
-Dull, achy, throbbing, burning
-Can be blocked by opiods
A-delta fibers (nociceptive)
-Small, myelinated (faster than C fibers)
-Sharp, localized, stabbing, or pricking
A-beta fibers (non-nociceptive)
-Large, myelinated (faster than A-delta or C fibers)
-Vibration, stretching of skin, mechanoreception
Pathway of the pain transmission
Dorsal horn of SC – up to thalmus via spinothalamic tracts – to sensory cortex to be processed as a conscious pain sensation
Gate Control Theory
A-alpha and A-beta provide input to these inhibitory interneurons. This can inhibit pain signals to the brain.
A-alpha and A-beta can be stimulated by electrical stimulation or massage.
Endogenous Opioid System
- opiopeptins (endorphins) bind to opioid receptors that inhibit pain signals
- inhibits by controlling amount of calcium and potassium that move into and out of cell during depolarization.
- also has an indirect effect on blocking GABA (GABA - inhibits A-beta)
Tolerable levels of topical preparations or TENS to create burning or prickling sensations stimulate the EOS for pain modulation
What is central sensitization
Facilitation of nociceptive impulses in CNS
Pain is real but no longer accurate to state of tissue
3 aspects
-Facilitation of synaptic transmission in spinal cord
-Inhibition of endogenous opioid system
-Altered processing of nociception in the brain
DTRs scale
O - absent
1+ - diminished
2+ - NORMAL
3+ - brisker than average
4+ - hyperactive
Modified Ashworth scale
0 - no increase in tone
1 - slight increase in muscle tone manifested by a catch and release at end of ROM
1+ - slight increase in muscle tone manifested by a catch and release less than halfway through the ROM
2 - more marked increase in muscle tone through most of ROM
3 - considerable increase in muscle tone, passive movement difficult
4 - affected part rigid
Types of heat transfer methods
- Conduction - direct contact (MHP, CP, paraffin)
- Convection - circulating medium; air or water moving in constant motion across body. (whirlpool, fluidotherapy)
- Conversion - non-thermal form of energy converted to heat (US and diathermy)
- Radiation - transfer of heat from energy source of higher temp to one of a lower temp (radiation lamp, laser, UV light)
- Evaporation - absorption of energy (vapocoolant spray)
Hunting response to cold
cycling between vasoconstriction and vasodilation occurs when exposure to cold for greater than 15 min (<35 deg F). Mostly occurs in distal appendages
Increased physiological responses to cryotherapy
Joint stiffness
Pain threshold (gate theory)
Increased blood viscosity
Muscle strength (for short duration 1-5 min) - facilitates alpha motor neuron
Decreased physiological responses to cryotherapy
Blood flow (vasoconstriction)
Capillary permeability
Decreased extensibility/elasticity of collagen
Decreased metabolism
Decreased in muscle spasm
Decrease in muscle strength
Decrease spasticity
Cryothearpy contraindication
Hypersensitivity - urticaria, hives, welts
Intolerance - severe pain, numbness, color changes
Cryoglobulinemia - aggregation of serum proteins distally
Paroxysmal cold hemoglobinuria - hemoglobin released into urine
Raynaud’s - digital cyanosis
Over regenerating peripheral nerves
Over area with circulatory compromise or PVD
Sequence of sensation with application of crytothearpy
Intense cold – burning – aching – analgesia – numbness
Cold Pack application
- shoulder be applied for ~20 min
- Remove jewelry.
- technically says used a moist towel
- Reaches 2cm deep
- Cold pack s can be applied every 1-2 hours for pain reduction and inflammation control.
- For spasticity – 30 min with inspection every 10 mins
Vapocoolant spray
- rapid cooling through evaporation
- most commonly used with trigger points (deep and hypersensitive localized spots in a m that cause referred pain pattern)
- Provides a counter-irritant stimulus to the cutaneous thermal afferent nerves that overlay the muscles…..causes reduction in motor neuron activity = decrease in resistance to stretch.
- Can help break cycle and allow the m to be stretched
- Process:
- 3-4 sweeps (proximal to distal…and only 1 direction) in the direction of the m fibers.
- 30 deg angle from skin
- 12-18 inches from skin
- Helpful with torticollis, neck or LBP caused by m spasms, acute bursitis, and hamstrings tightness.
Increased physiological responses to thermothearpy (heat)
Cardiac output (Increased blood flow)
Metabolic rate
pulse and respiratory rate
vasodialation
Edema
increased capillary pressure
Increase elasticity of tissue
Decreased physiological responses to thermotherapy (heat)
Decreased blood pressure
Decreased muscle activity (m spasm)
Decreased blood to internal organs
Blood flow to resting muscle
Decreased stroke volume
Decreased tone
Contraindications to thermotherapy (heat)
- Acute MSK trauma
- Arterial disease
- Bleeding or hemorrhage
- Over area of compromised circulation
- Over area of malignancy
- Peripheral vascular disease
- Thrombophlebitis
Hot pack time, temp, layers
Transmission: conduction
6-8 layers (hot pack covers are 2-3 layers)
Check within 5 mins
Total time: 15-20 mins
Temp: 158-167 deg in hydrocollator
- should not lay on it.
- Maximum surface temp is reached in 6-8 min….so must check during first 10 mins.
- don’t remove towel layers during the treatment session
- Must reheat 30 min in hydrocollator between uses (takes 2 hrs initially to heat in hydrocollator)
Paraffin bath
Transmission: conduction
* 6:1 to 7:1 ratio of paraffin wax to mineral oil ratio
* Glove method, immersion method, or pain method
* Time: 15-20 mins
* Temp: 113-122
* Best for small, irregularly shaped areas such as wrist, hand, foot for more even distribution of heat.
* Has a lower specific heat that allows the pts to tolerate better than water at the same temp
* Can’t be applied to area with open wound or infected skin lesions.
Dip-wrap (Glove method)
- place into bath and remove an let it harden
- re-dip 6-10 time
- the wrap with plastic bag and then towel wrapped around it
- 10-15 min
There is a paint application that is just pretty much like the above but the paraffin is painted on the extremity due to unable to place in paraffin for some reason. (Left on for ~20 mins)
Dip-Reimmersion (Immersion)
- Dip 6-10 times initially.
- Then put back in paraffin and keep in for the remainder (up to 20 mins)
- use lower head 113* and keep it off when hand is immersed.
Ice Massage
Transmission: conduction
treatment time 5-10 min or until analgesia.
Don’t go over bony areas or superficial nerves
Selecting sound head size for US? How fast should it move?
Select a sound head that has an ERA (effective radiating area) of 1/2 the size of the treatment area.
Don’t cover an area 2-3x the size of the ERA.
Move sound head ~1.5 inches/sec (slowly)
(according to PTFE exam 4cm/sec)
Acoustic streaming
Occurs with US. Movement of fluids along the boundaries of cell membranes.
May produce alteration in cell membrane activity
Increase cell wall permeability
Increase intracellular calcium
Increase macrophage response
Increase protein synthesis
Accelerate tissue healing
Attenuation
intensity decreases as it travels through material (in regards to ultrasound)
Reflection
Redirection of the beam occurring at tissue interfaces
Refraction
beam enters the tissue at one angle and continues at a different angle
Cavitation
- gas-filled bubbles and expand and compress secondary to pressure changes caused by the US
- Stable: oscillate in the size in response to pressure changes…but don’t burst
- Unstable: bubbles change in size over several cycles and then burst.
Coupling agent for US
- to decrease acoustical impedance
- Gels, gel pads, mineral oil, water, or lotions
Effective Radiating Area (ERA)
- area of the transducer that transmits US energy.
- it is always smaller than the total size of the transducer head.
Amount of treatments for US
- primarily dependent on the objectives
- Thermal effects: usually applied later in the healing process. It is most commonly administered 2-3x/week.
- Nonthermal effects: usually applied earlier in the healing process. As frequently as 1x/day.
- A positive response should be evident within 3 sessions
- Failure to see a positive response justifies a change of the US parameters or alternative interventions.
Indirect method of US. How it is performed, why it is performed…
Used for US irregular body parts
Plastic container due to less reflection of the sound waves
Keep the sound head in water and 1 cm from the skin surface.
Otherwise utilize the same as with direct contact.
Depth of penetration of US and which MHz does it pair with?
- This is considered the frequency
- higher frequency is absorbed more rapidly tan US through lower frequency.
3Mhz: Superficial 1-2.5cm deep (our book says 1-2)
1Mhz: Deep. up to 6cm deep (our book says 5)
Continuous US vs Pulsed US
Continuous US = thermal effects
Pulsed US = non thermal effects (<50% duty cycle; typically between 20-50%)
This is considered the duty cycle
Pizoelectrical effect
causes crystal to expand and contract
Thermal effects of US
Acceleration of metabolic rate
Alteration of NCV
Reduction of pain and spasm
Increased soft tissue extensibility
Increased circulation
Nonthermal effects of US
- Acoustic streaming - steady, circular flow of cellular fluids for transport
- Microstreaming - smaller scale of acoustic streaming
- Cavitation - formation, growth, and pulsation of gas filled bubbles
- Can promote tissue healing!
Absorption coefficient (which has highest and lowest)
Bone has highest, followed by tendon and cartilage
Blood and fat have the lowest
Intensity of US based on Frequency
1 MHz penetrates 5 cm, 1.5-2.5 W/cm^2
3 MHz penetrates 1-2 cm, 0.5-1.0 W/cm^2
Settings for US to increase extensibility of soft tissue shortening or pain control
Continuous
1 MHz, 1.5-2.5 W/cm^2
3 MHz, 0.5-1.0 W/cm^2
5-10 minutes
Settings for US for wound healing, tendon/ligament injuries, phonophoresis
20% duty cycle
3 MHz, 0.5-1.0 W/cm^2
3-10 minutes
Settings for US for bone fracture healing
20% duty cycle
1.5 MHz, 0.15 W/cm^2
20 minutes
Settings for US for carpal tunnel
Pulsed
1 MHz, 1.0 W/cm^2
5-15 minutes
Contraindications for US
Malignant tumor
Pregnancy (over abdomen, low back, pelvis)
Joint cement
Plastic components
Pacemaker
Carotid sinus
Thrombophlebitis
Eyes
Reproductive organs
Over CNS tissue
Infection
Precautions for US
Acute inflammation
Epiphyseal plates
Fractures
Breast implants
Potential adverse effect of US
Burns
Standing waves - blood cell stasis (effect of holding sound head stationary)
Cross contamination
Hydrostatic pressure
Pressure exerted by a fluid on a body immersed in a fluid
Pascal’s Law: Fluid exerts equal pressure on all surfaces of a body at rest at a given depth.
Pressure increased in proportion to the depth of the fluid
Buoyancy
- Upward force in opposite direction of gravity (when immersed in water)
WB % in water due to the buoyancy
Submerged to knees = 75% WB
Submerged to ASIS = 50% WB
Submerged to xiphoid process = 33% WB
Submerged to C7 vertebrae = ~10% WB
Viscosity
Magnitude of cohesive forces between molecules specific to liquid
Trigger point (2 types)
hyper-irritable spot in skeletal muscle that is associated with a hyper-sensative palpable noudle in a taunt band.
- Active TP: Active trigger point - produces local tenderness and pain, referral of pain or paresthesia to a distant site, and peripheral or central sensitization
- Latent TP: sensitive spot from which pain or discomfort is elicited by compression only
Effects of Dry needling
Normalizes excessive chemicals and pH
Restores local circulation
Reduces local and referred pain
Improves ROM
Decreased trigger point sensitivity
Mobilization Grades
Australian Techniques
Grade 1: 0-25% of range; decreases pain
Grade 2: 25-75% of range; decreases pain
Grade 3: 50-100% of range; increases mobility
Grade 4: 75-100% of range; increases mobility
Purpose/Effects of Mechanical/Manual Traction
Joint distraction
Reduction of disc protrusion
Soft tissue stretch
Muscle relaxation
Joint mobilizations
To achieve joint distraction with mechanical traction what are the parameters and what is the purpose?
Lumbar – 50% of Body weight – 25% for soft tissue stretch
Cervical – 7% of Body Weight (scorebuilders says 13-20%) – 7-10% for soft tissue
Won’t start at this weight but will have to gradually get to here for the effects.
Will cause a separation of the facet joint and open the intervertebral foramen which will relieve pressure on the nerve root, and decrease compressive forces on the facet
How to reduce of a disc protrusion with lumbar traction
Lumbar 60-120 lbs or ~50% body weight
Cervical 12-15 lbs.
separation of vertebral bodies occurs a higher forces causing a decrease in intradiscal pressure that causes a suction-like effect on the nucleus, drawing it back centrally.
To achieve soft tissue stretching with mechanical traction
Lumbar - 25% of body weight
Cervical - 12-15 lbs (7-10%)
stretching the surrounding spinal muscles, ligaments, tendons, and discs can decrease the pressure on the facet joints, nerve roots, and vertebral bodies without joint separation.
How to achieve muscle relaxation with mechanical traction
Lumbar - 25% of body weight
Cervical - 12-15 lbs
Intermittent - stimulates the mechanoreceptors through the active movement/motion
Static - inhibits the motor neurons from firing.
Maintaining 0-5 deg of cervical flexion during cervical traction is good for?
C1-C5 – increasing intervertebral space and joint separation
Maintaining 25-30 deg of cervical flexion during cervical traction is good for?
C5-C7 – increasing the intervertebral space and joint separation
Maintaining neutral spine of c spine for cervical traction is good for?
disc dysfunction…by neutral spine it means ~20 deg of cervical flexion
What is the difference in flexion versus more neutral with cervical traction?
Flexion = greater separation of the posterior structures (facets and intervertebral foramen)
Neutral = greater separation of anterior structures including the disk space.
How to determine the angle for the cervical traction?
C1-C5 = 0-5 deg of flexion
C5-7 = 10-20-35 deg of flexion (scorebuilders said up to 35*)
Determining treatment time for mechanical traction
5-10 min for acute conditions or disc protrusions or herniated discs
10-30 mins for all other conditions.
Determining Static vs intermittent traction
Static: for disc protrusions or when symptoms are aggravated by motion
Intermittent: disc protrusion and joint distractions. (or don’t tolerate static)
3:1 hold/rest ratio is recommended.
1:1 hold/rest ratio is recommended for mobility.
Supine vs Prone position for lumbar traction
Supine: goal to open up intervertebral foramen, separate the facet joints, or elongate the muscles
Prone: posterior herniated lumbar disc.
Angle of pull/ amount of hip flexion for lumbar traction
L5-S1: 45-60 deg hip flexion
L3-L4: 75-90 deg of hip flexion
Purpose of a tilt table
Stimulate postural reflexes to cutneract orthostatic hypotension
Facilitate postural drainage
Gradual loading of one or both LE
Begin active head or trunk control
Stretching for hip flexors, knee flexors, and PF.
Myofascial release
To release restrictions in myofascial tissues
Myofascial restrictions can produce tensile pressures of ~2,000 lbs per square inch
Relies on feedback from tissues
What is direct biofeedback and an example of?
provides accurate external information reflective of the internal biological process being monitored (HR monitor)
What is transformed biofeedback
provides external processed information representative of the internal biological process being monitored (EMG biofeedback)
What type of modality is infrared laser?
Elecromagnetic
Which phase of healing is characterized by lymphocytes supplying antibodies for an immune response?
Inflammation
What describes a tremor?
Low amplitude oscillations
Which are the interpretations consistent with Cyriax regarding mm testing that reveals a minor lesion of the MSK unit?
Strong and painful
Sharp and intermediate pain is what nerve fiber?
A delta
Large and myelinated describes which nerve fiber?
A beta
Small and unmyelinated describes which nerve fiber?
C fibers
Small and myelinated describes which nerve fibers?
A delta
Which nerve fiber has the slowest action potential
C fibers
Which wound shapes MOST likely close the quickest during the proliferation phase of healing?
Linear
What are the 5 signs of inflammation
Calor (heat)
Rubor (red)
Tumor (swelling)
Dolor (pain)
Functio laesa (loss of function)
Definition of Creep
transient lengthening or deformation with application of fixed load
(effect of stretching on tissue)
Definition of stress relaxation
decrease in the amount of force required over time to hold a given length
(effect of stretching on tissue)
Definition of plastic deformation
elongation, produced under loading, that remains when the load is removed
(effect of stretching on a tissue)
Which DTR corresponds with diminished after performing a muscle stretch reflex test?
1+
What is the definition of specific gravity?
- Ratio of the density of a substance to the density of a standard
What is the definition of specific heat?
Measure of the ability of a fluid to store heat.
What is the definition of total drag force?
Force exerted on a person opposing the direction of body motion
What has the lowest specific heat
Air
What has the highest thermal conductivity
Water
Pt in hospital for pneumonia. Complains a recent onset of pain in her R calf. It is warm to the touch, swollen, and painful with compression. Which of the following contraindicaitons for superficial heat is MOST likely the case
Thrombophlebitis
A condition in which a blood clot in a vein causes inflammation and pain (from google)
What is the process of remodeling ligament and disc tissue via intermittent traction?
Hysteresis
What is the cetripetal force?
a force that effectively reduced a disc protrusion
Benefits of self traction?
Can readily change position, low force, and cheap
What force should cervical traction never exceed?
30 lbs
What position for lumbar traction is best for degenerative disc or joint
Supine position with hips at 90/90
What cervical position for traction is most effective for C6-7 and C8-T1
Cervical flexion of 30-35 deg
What position for traction is best for disc protrusion
Prone
Above what frequency will provide a tetanic contraction?
greater than 35pps
What pulse width (duration) is used to depolarize a motor nerve and induce a muscle contraction?
150-350 usec
Comparing sensory stimulation to motor stimulation. Sensory stimulation requires modifications to which parameters
SENSORY
* short phase duration and high frequency with low current amplitude.
Low current amplitude enough generate sensory but below the motor.
MOTOR
* sufficient phase charge to elicit m contraction. Low frequency and long phase duration.
What happens physiologically and electrically with stimulated muscle contractions?
Type II (fast-twitch) fibers recruited first with e-stim, Type I (slow-twitch) recruited first with physiological contractions.
Which sensory fiber propagates an action potential the fastest?
A beta
if not specific with sensory in general motor fibers are the fastest
Which waveform does not leave a net charge in the tissue?
Symmetrical balance biphasic current
Beat frequency is defined as
difference b/n the carrier frequency and the intersecting frequency
Which wave form is utilized for direct m depoliarization of denervated m?
Direct current
You have been treating a patient with a 4cm stage 3 decubitus over the right heel. You note green/yellow, pungent exudate at the wound site and opt to use electrical stimulation. Your choice of electrode placement and polarity would be which of the following?
Negative electrode is placed in the wound
What is direct biofeedback and an example of?
provides accurate external information reflective of the internal biological process being monitored (HR monitor)
Current (electrotherapy)
- directed flow of charge from one place to another.
- Measured in amperes
Voltage
- measure of electromotive force or the elctrical potential difference
- Electrons will only flow b/n 2 points when there is a diff in the quantity of electrons b/n the 2 points.
- Magnitude of the diff b/n the (+) and (-) is teh voltage.
- Measured in volts
Resistance (electrotherapy)
- ability of a material to oppose the flow of teh ions through it.
- Measured in ohms
- Ohms law: current in a conductor varies in proportion to the voltage and inversely with the resistance.
Direct Current
- constant flow of electrons (+) to (-).
- Polarity remains constant and can be modulated for therapeutic use.
- direct m depolarization of denervated m OR iontophoresis
Alternating current
- polarity that continuously changes from (+) to (-) that changes with direction of current flow.
- Biphasic, symmetrical or asymmetrical
- measured in cycles per second or hertz
Pulsed Current (Pulsatile)
- non-continous flow of direct or alternating current.
- Either monophasic or biphasic
Frequency (electrotherapy)
- number of pulses delivered through each channel per seond.
- AKA rate. Labeled as pulses per second (pps)
What is uptraining with regards to biofeedback and what can it help with?
Facilitating a muscle contraction
What can it help with:
Force production during MVC
Decreased latency of motor unit recruitment
Increase neural excitability
Increase voluntary activation
The signal threshold is set at or just above level of predetermined maximum volitional EMG amplitude
What are the general parameters to elicit muscle contraction with electrical stimulation
Pulse Frequency: 35-50Hz
Pulse Duration: 150-350us
Amplitude: differs based on desired result
On/off: 1:5
Ramp: 2 sec
Time: will vary
What type of electrical stimulation waveform will you do if you desire muscle contraction?
Russian or Pulsed Biphasic
- Requires an intact peripheral nervous system
What type of electrical stimulation will you use for muscle contraction without an intact motor unit?
EMS
Frequency of treatment of innervated muscles (Russian or Pulsed Biphasic)
< 30 pps = separate contractions
35-50 pps = tetanic contraction
50-80 pps = stronger contraction
On:off ratio in the treatment of innervated muscles (Russian or Pulsed Biphasic)
Strengthening - 1:5 - beginning
Muscle spasm - 1:1 → muscle fatigue
Edema control - 1:1 → pumps edema
Amplitude in the treatment of innervated muscles (Russian or Pulsed Biphasic)
- Strengthening
Healthy - at least 50% MVIC
Injured - at least 10% MVIC - Motor re-education: Lowest amplitude to produce result
Treatment time in the treatment of innervated muscles (Russian or Pulsed Biphasic)
Strengthening: 10-20 minutes (10-20 contractions)
Re-education: No longer than 20 minutes
When would you use High Rate TENS and what are the parameters?
“conventional TENS”
For acute pain control
Pulse Frequency: 100-150 pps
Pulse Duration: 50-80us
Amplitude: comfortable sensory
Time: PRN
When would you use Low Rate TENS and what are the parameters?
“acupuncture like TENS”
For chronic pain control for the endogenous opioid affect.
Pulse Frequency: 2-10 pps
Pulse Duration: 150-300 us
Amplitude: visible contraction
Time: 20-30 min (45 mins max)
The benefits should last around 4-5 hours.
Parameters for Tissue Healing when utilizing electrical stimulation?
Waveform: HVPC
Pulse Frequency: 100-105pps
Pulse Duration: 100 us
Amplitude: comfortable tingling
Time: 45-60 mins
Wound Type - Polarity
- Acute (or infection) utilize (-) polarity
- Chronic (or inflammation) utilize (+) polarity
How to treat current edema with electrical stimulation
Pulsed Biphasic or Russian
Pulse Frequency: 35-50 pps
Pulse Duration: 150-350us
Amplitude: visible contraction
Time: 20-30 mins
How to utilize electrical stimulation to prevent edema?
Waveform: HVPC
Pulse Frequency: 100-120pps
Pulse Duration: 40-100us
Amplitude: 90% of visual motor threshold (comfortable tingling)
Time: 30 mins
(-) pad is Active pad on area of potential edema (-)
(+) pad is dispersal pad placed way proximal
Viscogenic pain
- pain from pathology of internal organ that refers to site distant from organ….this can mimic msk pain
- Does not change based on position, diffuse and poorly localized
- Often have systemic symptoms: N/V/F, weight loss, pallor, profuse sweating, and abnormal vital signs
Pain characteristics based on the body structure
Bone - Deep and dull
Vasculature - Throbbing
Nerve - Sharp
Muscle - Aching
Which of the following is not a characteristic of chronic pain?
- long duration
- diffuse
- sharp
- aching
sharp
Chronic pain occurs over a six-month period or longer. It is often described as diffuse, dull, and aching. Chronic pain is associated with autonomic responses, musculoskeletal tension, and nausea.
Which of the following is not a characteristic of chronic pain?
- long duration
- diffuse
- sharp
- aching
sharp
Chronic pain occurs over a six-month period or longer. It is often described as diffuse, dull, and aching. Chronic pain is associated with autonomic responses, musculoskeletal tension, and nausea.
Why would someone have periosteal pain with US?
- An ultrasound unit with a high beam nonuniformity ratio
- A high beam nonuniformity ratio produces a less uniform beam and therefore places the patient at greater risk for undesirable side effects such as periosteal pain or hot spots.
What is BNR (beam nonuniformity ratio)?
- Ratio between the spatial peak intensity and spatial average intensity.
- Intrinsic factor of the quality of the piezoelectric crystal.
Higher the quality of the crystal = the lower the BNR.
Lower BNR = less likely to experience hot spots and discomfort during treatment.
- The higher the BNR the more critical to move th transducer more rapidly to avoid undesirable effects, such as pain from periosteal inflammation.
When selecting the effective radiating area of the soundhead, what is the MOST important factor for the therapist to consider?
1.The beam nonuniformity ratio
2.The size of the area to be treated
3.The desired depth of penetration
4.The condition of the patient’s skin
- The size of the area to be treated is the most important factor to consider when selecting an appropriate soundhead size.
- Effective radiating area (ERA) refers to the area of the soundhead that transmits ultrasound energy. The ERA is always slightly smaller than the total size of the transducer’s soundhead.
- Larger areas require the therapist to use larger soundheads.
- Soundheads vary in size, but most often range from 5-10 cm2.
- A soundhead should not be used to treat an area larger than four times the ERA of the soundhead.
Cold packs are typically stored in cooling unit that should be approximately how many deg F?
25 deg F
What is the most appropriate duration for the application of a cold pack?
20 minutes
A cold pack contains silica gel and is available in a variety of shapes and sizes. The most common application time is 20 minutes.
When treating a patient with ice cup massage, the treatment should continue until the patient reports analgesia which typically takes how long to occur?
5-10 minutes
Ice massage typically cools tissues more rapidly than other types of cryotherapy, including an ice pack or ice bag and analgesia is typically achieved within 5-10 minutes. The therapist should inspect the skin during treatment and after the completion of treatment. Normally, the skin should appear to be red or dark pink. An abnormal response is most often noted by the presence of wheals or a rash.
When treating a patient with cold bath immersion, what water temperature would be most appropriate?
55-64 degrees Fahrenheit
The water temperature for cold bath immersion should be between 55-64 degrees Fahrenheit. The body part should be immersed for 15-20 minutes to attain the desired therapeutic effects. The lower the temperature selected, the shorter the duration of treatment.
When treating a patient with vapocoolant spray, at what dista
12-18 inches
The spray should be applied at 12-18 inches and at a 30 degree angle to the skin. It must be applied in one direction only and not in a back and forth motion. Special care must be taken to cover the patient’s eyes, nose, and mouth if spraying near the face.
Which transcutaneous electrical nerve stimulation (TENS) technique would utilize the shortest pulse duration?
acupuncture-like
brief intense
conventional
noxious
conventional
Conventional TENS is characterized by the delivery of electrical pulses having short duration and high frequency with low current amplitude.
Which electrical stimulation term is most associated with the “rate” of stimulation?
frequency
Frequency controls are often labeled as rate and are expressed in pulses per second or Hertz.
Which electrical stimulation term is used to describe the intensity of the electrical current?
amplitude
Amplitude refers to the magnitude of current. Amplitude controls are often labeled intensity or voltage and can be expressed in volts, microvolts or millivolts.
When first utilizing electrical stimulation for muscle strengthening, what is the most appropriate on:off ratio?
1:5
The long off time is required to minimize muscle fatigue. As the patient gradually gets stronger, the ratio may be decreased to 1:4 or 1:3.
What type of current is most effective in stimulating a denervated muscle?
direct current
Direct current is characterized by a constant flow of electrons from the anode (i.e., positive electrode) to the cathode (i.e., negative electrode) for a period of greater than one second without interruption. Electrical stimulation of a denervated muscle using direct current has been used in an attempt to maintain the muscle, although the benefit is debatable
Which theory would best describe the rationale for using the depicted electrical stimulation set-up if the goal was to decrease wrist flexor tone?
successive induction
concentric strengthening for wrist flexors
eccentric strengthening for wrist extensors
reciprocal inhibition
reciprocal inhibition
Reciprocal inhibition describes the process of muscles on one side of a joint relaxing to accommodate contraction of the opposing muscle group. Therefore, contraction of the wrist extensors may cause the spastic wrist flexors to relax.
The minimum electrical stimulation current amplitude required to produce an action potential is known as:
propagation
chronaxie
rheobase
accommodation
rheobase
Rheobase refers to the minimum current amplitude of indefinite duration required to produce an action potential for any type of tissue. The relative ease by which a tissue can be stimulated is primarily determined by the strength of the stimulus and the duration the stimulus is applied.
Which of the following properties is characteristic of large electrodes when compared to smaller electrodes?
decreased impedance
increased impedance
increased current density
decreased current flow
decreased impedance
Decreased impedance is associated with large electrodes when compared to smaller electrodes. The remaining options are all associated with a smaller electrode size.
Which measurement is used to denote the frequency of electrical stimulation?
pulses per second
Frequency determines the number of pulses delivered through each channel per second. Frequency controls are often labeled as rate and are expressed in pulses per second or Hertz. The frequency affects the number of action potentials elicited during the stimulation.
Contrast Bath
104-106 deg – Warm/Hot
50-60 deg –Cool/Cold
3-4 mins of hot and 1 min of cold
25-30 mins total
Which therapeutic modality should be avoided when treating a patient currently taking an antihypertensive medication?
fluidotherapy to the forearm and hand
ultrasound to the anterior thigh
whirlpool using a Hubbard tank
mechanical traction of the lumbar spine
Whirlpool using a Hubbard tank
Placing a patient in a large tank of warm/hot water (i.e., Hubbard tank) will cause systemic vasodilation, essentially enhancing the effect of the antihypertensive medication the patient is already taking. This could result in a dangerously low blood pressure response.
Which variables are most relevant when administering hydrotherapy?
elevation and time
temperature and pressure
temperature and elevation
pressure and time
Temperature and pressure
Hydrotherapy is the medicinal use of water for positive health benefits. These health benefits come from the mechanical and thermal effects of water interacting with the body. It includes the use of physical water properties, specifically temperature and pressure, to manipulate the body’s flow of blood, the endocrine system, and associated neural systems in order to treat the symptoms of certain diseases.
Which medical condition would be most susceptible to adverse effects caused by exercising in an aquatic environment with a high ambient temperature?
osteoarthritis
multiple sclerosis
osteoporosis
Guillain-Barre syndrome
multiple sclerosis
Multiple sclerosis is a chronic autoimmune inflammatory disease of the central nervous system characterized by demyelination of the myelin sheaths that surround nerves within the brain and spinal cord.
Patients with multiple sclerosis often have extreme sensitivity to heat, potentially resulting in significant worsening of their current status.
Which type of tank would require a patient sitting in water up to their mid-chest level to have their hips and knees fixed in flexion?
High boy tank
Highboy tanks have dimensions that allow for sitting with the hips and knees flexed. Lowboy tanks allow for long sitting, and a Hubbard tank has the dimensions to support full body immersion. An extremity tank would not have adequate space to permit sitting within the tank, regardless of lower extremity position.
Which of the following factors is least likely to contribute to the risk of syncope due to hypotension during a hydrotherapy treatment?
use of beta blockers
water temperature of 60 degrees Fahrenheit
body immersion in a Hubbard tank
immersion in a sitting position
water temperature of 60 degrees Fahrenheit
Colder temperatures will cause vasoconstriction and temporarily increase blood pressure. Factors that increase the risk of hypotension and syncope include larger exposed body surface, higher water temperatures, and the use of antihypertensive medications.
Which of the following is not a contraindication for hydrotherapy?
diminished sensation
compromised circulation
incontinence
hypersensitive residual limb
hypersensitive residual limb
Hydrotherapy can be an effective treatment intervention following amputation to desensitize a residual limb. The remaining options are contraindications to hydrotherapy.
Which of the following is an indication for hydrotherapy?
macerated wound
bleeding wound
eschar in wound bed
diabetic ulcer
eschar in wound bed
Hydrotherapy is often utilized as an intervention to remove slough and eschar from the wound bed. Wound specific contraindications include maceration and bleeding. Caution should be used when treating a diabetic ulcer with hydrotherapy since sensation and circulation are often diminished.
For intermittent compression the pressure should not exceed the pts______?
Diastolic pressure
Intermittent compression for the upper extremities require how much compression?
30-60 mmHg
Intermittent compression for the lower extremities require how much compression?
40-80 mmHg
What is a condition that would be a contraindication to the use of an intermittent vasopneumatic compression device?
arterial insufficiency
Intermittent vasopneumatic compression devices can be used in the treatment of lower extremity edema to help move fluid out of the periphery. However, before compression can be used, it must be ensured that the patient does not have impaired arterial circulation as the use of compression will worsen the already impaired circulation.
When setting the amount of pressure for an intermittent vasopneumatic compression device, which value (based on the pt) would most likely restrict arterial blood flow and create a potential medical emergency?
pressure greater than the recorded systolic blood pressure
When using an intermittent vasopneumatic compression device, pressure greater than the recorded systolic blood pressure would restrict arterial blood flow and result in serious cardiovascular complications.
Compression garments are available over the counter if they have a compression class (CC) of less than:
20 mm Hg
Compression garments are ordered by compression class (CC). Garments with a CC of less than 20 mm Hg are available over the counter while garments with a higher resting pressure require a prescription.
When applying a compression bandage, which scenario would result in the greatest amount of applied pressure?
Increased applied bandage tension to a limb with a small radius
Compression bandages follow the Law of Laplace, which states that the pressure of a bandage system is directly related to the tension applied to the bandage and inversely related to the radius of the limb. Therefore, the larger the surface area that a bandage covers, the more spread out the constant force of a bandage is.
The maximum compression pressure for treatment of venous edema most closely approximates the:
diastolic blood pressure
The diastolic blood pressure value most closely approximates the maximum compression pressure for treatment of venous edema. This maximum value is necessary in order to prevent occlusion of the blood vessels.
Iontophoresis
- ions introduced through direct current to the body
- based on like charges repel and as a result ions in a solution in similar charges will move away from the electrical source and into the body
- (+) – carried into the body’s tissue from the (+) pole (anode)
- (-) – carried into the body from negative pole (cathode)
- Electrode containing the solution = active electrode
- Second electrode = dispersive electrode
2-3 main things used for iontophoresis (that I want to know). The ions used
- Dexamethasone (-) – Inflammation – Negative (-)
- Acetate (+) - break up calcific deposits
- Lidocaine – Analgesia, inflammation – Positive (+)
- Zinc oxide – Healing, dermal ulcers, wounds – Positive (+)
- Magnesium (+) – for m relaxant and vasodialator
Which two actions would decrease the likelihood of a burn when using iontophoresis?
- increasing the size of the anode relative to the cathode
- decreasing the current density
- increasing the space between electrodes
- decreasing the current density
- increasing the space between electrodes
What form of current is used to drive medicine through the skin during iontophoresis?
direct current
Iontophoresis is a modality which uses continuous, direct electrical current to deliver therapeutically charged ions through the skin and into the systemic circulation.
Which of the following is most likely to decrease the likelihood of a burn during iontophoresis?
increasing the current density
decreasing the current density
decreasing the treatment time
decreasing space between electrodes
decreasing the current density
The likelihood of a burn can be decreased by increasing the size of the cathode relative to the anode, decreasing the current density, and increasing the space between the electrodes
Which type of ion does the cathode repel?
positive
negative
neutral
alternating positive and negative
Negative
The cathode is negatively charged (repelling negative ions) and the anode is positively charged (repelling positive ions).
Which physiologic principle accounts for significantly reduced joint compression when walking in waist high water?
inertia
viscosity
buoyancy
hydrostatic pressure
Buoyancy
Archimedes’ principle of buoyancy states that there is an upward force on the body when immersed in water equal to the amount of water that has been displaced by the body. This force significantly reduces joint compression when submerged in water.
What percentage of body weight would be borne through the lower extremities when walking in water immersed up to the neck?
10%
The deeper the body is immersed in water the greater the buoyant force exerted on the body. As a result, with near full body immersion the actual weight bearing forces are extremely minimal.
Effleurage
- massage technique that is characterized by a light stroke that produces a reflexive response.
- The technique is performed at the beginning and end of a massage to allow the patient to relax.
- Strokes should be directed towards the heart.
- Effleurage can also be applied as a deep stroke to produce both a mechanical and a reflexive response.
Friction
- Incorporates small circular motions over a trigger point or muscle spasm.
- Deep massage technique
- Penetrates into the depth of a muscle and attempts to reduce edema, loosen adhesions, and relieve muscle spasm.
- Friction massage is used frequently with chronic inflammation or with overuse injuries (Fig. 8-81).
Petrissage
- Kneading, where the muscle is squeezed and rolled under the therapist’s hands.
- Goal = loosen adhesions, improve lymphatic return, and facilitate removal of metabolic waste from the treatment area.
- Petrissage should be performed in a distal to proximal sequence.
- Two hands over larger muscle groups or with as few as two fingers over smaller muscles.
Tapotement
- Massage technique that provides stimulation through rapid alternating movements such as tapping, hacking, cupping, and slapping.
- Primary purpose of tapotement is to enhance circulation and stimulate peripheral nerve endings.
Vibration
- Places the therapist’s hands or fingers firmly over an area and utilizes a rapid, shaking motion that causes vibration to the treatment area.
- Initiates this motion from the forearm while maintaining firm contact on the treatment area.
- Used primarily for relaxation.
Length of time for massage
15 mins for the back
8-10 mins for smaller area or a joint
Which of the following temperatures represents an appropriate temperature setting for fluidotherapy?
105 degrees Fahrenheit
120 degrees Fahrenheit
135 degrees Fahrenheit
150 degrees Fahrenheit
105 degrees Fahrenheit
Appropriate temperature for fluidotherapy should be between 100-118 degrees Fahrenheit. Fluidotherapy consists of a container that circulates warm air and small cellulose particles. The superficial heating modality generates dry heat through forced convection.
Which of the following are benefits of superficial heating agents?
- decreased nerve conduction velocity, increased pain threshold
- increased nerve conduction velocity, decreased pain threshold
- increased nerve conduction velocity, increased pain threshold
- decreased nerve conduction velocity, decreased pain threshold
Increased nerve conduction velocity, increased pain threshold
Heat will increase nerve conduction velocity and increase pain threshold. Cryotherapy has many benefits including decreased nerve conduction velocity and increased pain threshold.
Which physiologic effect occurs with the application of superficial thermotherapy?
decreased tissue extensibility
decreased muscle spasm
decreased metabolic rate
decreased nerve conduction velocity
decreased muscle spasm
Superficial thermotherapy refers to the local or general use of high temperatures in rehabilitation, with the goal of increasing skin temperature and superficial subcutaneous tissue up to depths of two centimeters. Superficial thermotherapy results in decreased muscle spasm, increased tissue extensibility, increased metabolic rate, and increased nerve conduction velocity.
Which of the following is not a physical effect of spinal traction?
stretch soft tissue
relax muscles
reduce disk protrusion
reduce sequestration
reduce sequestration
Sequestration is a stage of herniation in which the nucleus pulposus breaks through the annulus fibrosis and lies outside the disk in the spinal canal. Mechanical traction would be ineffective in reducing this type of herniated disc.
Which of the following would pose a red flag to gravity-assisted traction?
disk herniation
hypertension
muscle guarding
joint pain
hypertension
Gravity-assisted traction is the use of body weight as a distractive force. The patient is harnessed and hangs in an inverted position, allowing gravity to create distractive forces. This method of traction is acceptable only in patients without hypertension, as it has been shown to raise both systolic and diastolic blood pressure significantly.
When performing intermittent traction on a split traction table, the table should be split:
at the start of the session
when the session is over
when the traction force is at its lowest level
when the traction force approaches its maximum force
when the traction force approaches its maximum force
The use of a split traction table can eliminate the majority of friction between the patient’s body and the treatment table. If intermittent traction is used, the table should be split when traction approaches its maximum force.
How many degrees of cervical flexion are most appropriate to target the upper cervical spine during traction?
5 degrees
15 degrees
30 degrees
40 degrees
5 degrees
The amount of flexion in the cervical spine allows clinicians to target specific spinal levels: upper cervical spine (C1-C2) = 0-5 degrees of flexion, midcervical spine (C3-C4) =10-20 degrees of flexion, lower cervical spine (C5-C7) = 25-35 degrees of flexion
A physical therapist decides to use mechanical lumbar traction to treat a patient with an L4 disk herniation. Which of the following patient positions and treatment parameters would be the most appropriate?
- patient in prone with a force of 25% of total body weight
- patient in prone with a force of 50% of total body weight
- patient in supine with a force of 25% of total body weight
- patient in supine with a force of 50% of total body weight
patient in prone with a force of 25% of total body weight
The patient in a prone position results in greater separation of the anterior structures such as the disk spaces. A force of 25% of the total body weight is strong enough to stretch soft tissue and treat a disk protrusion; a force of 50% of the total body weight is strong enough to cause actual separation of the vertebrae.
Pt being treated with ionto for LE ulceration with goal of promoting tissue healing. Which ion?
- Zinc: (+) charged and used for promoting healing and with open lesions and ulcerations.
