PAMS (Physical Agent Modalities) I - Exam 4 Flashcards
PAMS (preparatory)
Used in preparation for concurrent and purposeful occupation-based activities or interventions that ultimately enhance engagement in occupation
Only administered by therapists with theoretical background and technical skills
PAMS Categories
Superficial theramal agents
Deep thermal agents
Electro therapeutic thermal agents
Mechanical devices
Superficial Theramal Agents
Fluidotherapy Hyrotherapy/whirlpool Cryotherapy (cold packs, ice) Hot packs Water (contrast baths) Paraffin Infrared Other commercially available heating or cooling technologies
Deep Thermal Agents
- Ultrasound
- Phonophoresis - use of ultrasound to administer medication through the skin
- Short-wave diathermy - sit under and heat directed to a part
Electrotherapeutic Agents
Use of electricity and electromagnetic spectrum to facilitate tissue healing, improving muscle strength and endurance, decreased edema, modulate pain, decrease the inflammatory process and modify the healing process
- Neuro-muscular electrical stimulation (NMES)
just movement - Functional stimulation (FES)
doing some kind of activity - High volt pulsed current (HVPC)
decrease swelling - Transcutaneous electrical stimulation (TENS)
pain modulation - Interferential Current (IFC)
deep, great for shoulder pt, helps with endorphins
and opioid release, creates a pain modulation effect
that lasts after electrodes are off - Direct Current (DC)
most dangerous type of current, can cause burns, used
in iontophoresis, only current that can fire a denervated
muscle - Iontophoresis (electrodes to admin meds)
Mechanical Devices
- Vasopneumatic devices (Edema)
used on lymphedema, fills up with air and creates a
pumping action - Continuous passive motion machines (CPM)
OT must demonstrate verifiable competence and knowledge
Effects of the Modality:
- Biophysiological
- Neurophysiological
- Electrophysiological
Safety in choosing to use a modality and in application:
- Knowledge of precautions
- Proper procedure and performance
Practice acts very from state to state
Kansas and MO do not require certification
Minnesota, Florida and Nebraska do
Liability is the main issue - Hippocratic oath: “First do no harm.”
Superficial Thermal Agents: Heat
Principles of Thermotherapy
CONDUCTION: An exchange of heat when 2 surfaces come into contact. Heat is transferred from the warm object to the cooler one (i.e. hot/cold packs, paraffin)
moves from high heat entity to low heat entity
same with cold
CONVECTION: An exchange of thermal energy between an object and the fluid or substance moving past it
(fluidotherapy, whirlpool) can be warm or cold
CONVERSION: Energy converted to heat. This form of heat is able to penetrate deeper into tissue. Converts vibration waves into heat
(continuous ultrasound - sound waves)
RADIATION: Devices heat is getting to you by radiating through the air (infrared heat)
Physiological Effects of Heat: Mild Physiological Response
Analgesic/Pain Reduction - heat less than 100-104 degree
Higher than body heat but not much higher, good for pain reduction
- Alters nerve conduction
- Decreases protective posturing, muscle guarding
- Gate control theory/ opiate mediated pain
- TENS Effect
- Good for sub-acute injuries
Physiological Effects of Heat for increasing Tissue Elasticity: Vigorous Heat
Connective Tissue Effects:
* Increased tissue extensibility
* Decreased joint stiffness
* Temperature for therapeutic effectiveness for tissue
extensibility must be at least 104 - 113 degrees to
increase tissue pliability
Effectiveness Depends on: * Duration of heat * Depth of penetration * Degree of heating achieved * Degree of stretch applied post heat * The amount of tissue exposed * The type of tissue between the applicator and the target tissue
Physiological Effects of Heat
Metabolic and Vascular Effects
* Vasodilation occurs with superficial heating
* Indirectly effects sympathetic nervous system via
spinal cord reflex (helps with muscle guarding)
* Cutaneous thermoreceptors carry afferent impulses to
the spinal cord (feel the heat)
* Heat stimulates the release of histamine which produces
vasodilation
* Heat with elevation aids venous return
Lots of fat causing impedance effects delivery of the heat
Indications for the use of Heat
- Decrease pain and muscle spasms (mild)
- Relax the pt (mild)
- To precondition tissue, increase softness and flexibility
(vigorous) - Increase blood flow and metabolism (ideally more mild
but both can do ) - Stiff joints (vigorous)
- Adhesions and scar tissue (vigorous)
- Contractures (vigorous)
- Chronic arthritis (paraffin)
- Chronic and sub-acute inflammation: heat decreases
viscosity of the fluid, making it easier to massage the
swelling out following application. So it can respond
better to massages - Neuromas
- Muscle spasms
Contraindications for the use of Heat
- Diminished sensation (use caution)
- Absent sensation (never use)
- Very young or very old (cognition)
- Nerve laceration with an insensate hand
- Impaired circulation (use caution with diabetics)
- Vascular instability (skin graft, replant) don’t want to
overtax system with hot or cold - Raynaud’s disease - vascular disease. Heat hardens
arteries and causes damage (vigorous heat) - Acute inflammation
- Impaired cognition/mentation
- Open wounds
- Over a malignant site (don’t want it to spread)
- Over rashes and skin conditions (not to area)
- Bleeding tendencies/hemophelia (heat makes it worse)
- RA
Precautionary Use with Heat
- Deep vein thrombosis (only under physicians order)
* Infection (under physician order)
Hot Packs
- Uses conduction through layers of towels as a method of
heat delivery - Temp of water in the hydroculator ranges from 160-180
degrees Fahrenheit - Never apply hot pack directly to skin
- If tissue is being stretched with heat you must exercise
more CAUTION b/c blood flow is impaired
(could have an increased risk of burn if not watched b/c
Nn are not sensitive as normal and may not be able to
feel heat as normal
TIPS:
* Temp of the hot pack reaches a depth of 1cm
(except in hand and foot where it goes much deeper)
The temp in the treated area will remain elevated
compared to normal 45-60 mins
* Therapeutic temp for tissue extensibility last fro approx
10 mins following removal
* Heat penetrates much deeper in the hand and foot b/v
of countercurrent blood flow, thus you can reach deeper
structures such as ligaments
* Always check pt skin at 3-4 mins and again at 7-8 min
until they have had a few tx
* Fair complexions might require more layering of towels
* At 15 mins the temp of the hot pack starts to decrease
to the point that it is not therapeutic (10-15 mins)
* Tissue destruction occurs at 122 degrees in a normal
individual and can occur at a lesser term in India with
nerve or circulation injuries
* Do not lay on top of hot packs b/c the pressure combined
with heat increases chances of burns
Hot pack core
- Canvas covering filled with bentonite clay or silica gel
* Retains heat well and uses slow conduction heat transfer
Heat pack covers
(Turkish Towels)
* Cover counts as 2 layers
* Must have 6-8 layers with a small or cervical pack
(one cover and 2 towels folded in half = 6 layers)
* Recommend 8-10 layers with a larger pack
* You can use 2-3 of the larger Turkish towels to make
4-6 layers
Microwavable Over the Counter Packs (CAUTION)
- They do not heat evenly and tend to have hot spots
* Make sure pt understands precautions
Disadvantages of Hot Packs
- Therapist can not observe body part
- Hand or body part is static during application
- Cost and time of washing linen
- Weight of the pack might not be tolerated
Ex of uses of Hot Packs
- To relax the upper trapezius in a client with a shoulder
injury so they don’t hike their shoulder during AROM,
PROM, exercise or functional activity - To precondition a stiff wrist after a cast removed to allow
the joints to move more freely - In a osteo - arthritic hand with joint stiffness and tight adductor pollicis to improve skin elasticity
- To soften scar tissue prior to scar massage and
interventions to work on decreasing adhesions - To relax the pectorals major and minor while lying supine
with a towel or foam roll btwn their shoulder blades
Billing - HCPC 97010 (service based code - untimed)
for hot packs
Service based code thus untimed = 1 no matter how long
Reimburses at $0
Medicare bundled the service with other HCPC codes
Document bilateral but Medicare does not care
Must document it was performed and charge for service
Paraffin Wax Bath (PWB) - HCPC code 97018
Service based code
- Heat Method: Conduction
- Liquid mix of paraffin wax and mineral oil
- Premixed in beads or blocks of paraffin
- Operating temp = 125-130 degrees F
- Paraffin has a low specific heat, therefore the hotter temp
of 127-130 does not cause the tissue damage that a hot
pack would at the same temp - Specific heat is a measure of the heat required to raise
the temp of a given amount of substance/tissue,
1 degree - Great for osteo and degenerative arthritis (NOT RA)
- Great for working on composite flexion of digits
can have pt either actively flex to their max range or
tape them in flexion (can also be done w/ hot packs)
– Use caution when doing this, blood flow might be
affected with stretch which will reduce tissue
tolerance to heat creating more risk of injury
Wrap/Gloving Technique:
* Have client remove any jewelry
* Have client wash hands
* Check temp of therabath, add paraffin if too hot
* Have pt immerse extremity into the bath while avoiding
contact w/ sides or bottom
* Fingers relaxed and slightly abducted
* After 1st dip, allow paraffin to cool a few seconds then
dip again
* Repeat dipping 7-10 times
* Place hand in plastic bag, Saran Wrap or paper towels
then covered with mitt or towel wrap
* Pt in a comfortable position with hand in elevation
while it cools (15-20 mins)
Other Less Common Techniques:
* Immersion - dip once then immerse 10-20 mins
hot and uncomfortable for pt
* Dip Immersion - dip 10 x then immerse 10-20min * Brush Technique - use a paint brush to apply 10 coats * Pouring technique - pour paraffin over a target area that can not be reached
Fluidotherapy: HCPC 97022
Heating Method: convection
Rapid rate of heat transfer - can get hot quick
Operating Temp: 115-116 degrees
Can use lower temp for conditions such as CRPS or
when you are focusing on desensitization
* Uses dry heat and synthetic medium
* Dry whirlpool
* More sanitary than water
* Temp easily adjusted
* Agitation can be adjusted
* Pt can move and perform exercises
* Organic cellulose medium originally made of corn
husks
Fluidotherapy Precautions
- Diminished sensibility
- Can cause edema secondary to the arm being in a
dependent position (b/c arm is down)
