PAMS (Physical Agent Modalities) I - Exam 4

Question 1

PAMS (preparatory)

Answer 1

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

Question 2

PAMS Categories

Answer 2

Superficial theramal agents
Deep thermal agents
Electro therapeutic thermal agents
Mechanical devices

Question 3

Superficial Theramal Agents

Answer 3

Fluidotherapy
Hyrotherapy/whirlpool
Cryotherapy (cold packs, ice)
Hot packs
Water (contrast baths)
Paraffin
Infrared
Other commercially available heating or cooling technologies

Question 4

Deep Thermal Agents

Answer 4

• Ultrasound
• Phonophoresis - use of ultrasound to administer medication through the skin
• Short-wave diathermy - sit under and heat directed to a part

Question 5

Electrotherapeutic Agents

Answer 5

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)

Question 6

Mechanical Devices

Answer 6

• Vasopneumatic devices (Edema)
  used on lymphedema, fills up with air and creates a
  pumping action
• Continuous passive motion machines (CPM)

Question 7

OT must demonstrate verifiable competence and knowledge

Answer 7

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.”

Question 8

Superficial Thermal Agents: Heat

Answer 8

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)

Question 9

Physiological Effects of Heat: Mild Physiological Response

Answer 9

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

Question 10

Physiological Effects of Heat for increasing Tissue Elasticity: Vigorous Heat

Answer 10

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

Question 11

Physiological Effects of Heat

Answer 11

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

Question 12

Indications for the use of Heat

Answer 12

• 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

Question 13

Contraindications for the use of Heat

Answer 13

• 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

Question 14

Precautionary Use with Heat

Answer 14

• Deep vein thrombosis (only under physicians order)

* Infection (under physician order)

Question 15

Hot Packs

Answer 15

• 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

Question 16

Hot pack core

Answer 16

• Canvas covering filled with bentonite clay or silica gel

* Retains heat well and uses slow conduction heat transfer

Question 17

Heat pack covers

Answer 17

(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

Question 18

Microwavable Over the Counter Packs (CAUTION)

Answer 18

• They do not heat evenly and tend to have hot spots

* Make sure pt understands precautions

Question 19

Disadvantages of Hot Packs

Answer 19

• 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

Question 20

Ex of uses of Hot Packs

Answer 20

• 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

Question 21

Billing - HCPC 97010 (service based code - untimed)

for hot packs

Answer 21

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

Question 22

Paraffin Wax Bath (PWB) - HCPC code 97018

Service based code

Answer 22

• 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

Question 23

Fluidotherapy: HCPC 97022

Answer 23

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

Question 24

Fluidotherapy Precautions

Answer 24

• Diminished sensibility
• Can cause edema secondary to the arm being in a
  dependent position (b/c arm is down)

Question 25

Fluidotherapy Advantages

Answer 25

• Deep tissue temp rise
• Exercise while heating
• Self sterilizing
• Pleasant stimulation without pressure
• Great for desensitization
• Easy to administer

Question 26

Fluidotherapy Disadvantages

Answer 26

• Expensive ($5000 - $6000)
• Bulky and Noisy
• Messy (need a small broom and vacuum)
• Must coach pt on getting in and out of unit
• Long warm up time
• Potential overheating and blow fuses
• Dependent position

Question 27

Fluidotherapy Indications

Answer 27

• Hypersensitivity
• Exercise with heat
• Exercise with resistance
• ROM in a painful extremity
• Heat with open wounds (use plastic bag)

Question 28

Billing for Fluidotherapy

Answer 28

Depends on the goal of the modality

• If the pt is just sitting and not moving and you are using
  it for thermal purposes then 97022 (service based and
  similar to hot packs so charge 1)
• If using it for desensitization then you could bill
  neuromuscular re-education or sensory re-education
  (how much time did you spend follows the 8 min rule)

* If performing therapeutic exercises then could bill
  therapeutic procedures (9710)

Question 29

Whirlpool - HCPC 97022

Answer 29

Heating Method - convection

• Not used much anymore
• Heat source hot water
• Temp - 90-120 degrees

Potential dangers - cross contamination of open wounds

Advantages:

• Deep tissue healing
• Can exercise in water
• Facilitates debridement
• Can adjust temp

Disadvantages:

• Time consuming set up and clean up
• Space requirements
• Must be cultured quarterly

Indications:

• Open wounds
• Exercise
• Desensitization
• Chronic Pain
• Relaxation
• Pain relief for burns (cool water)

Question 30

Contrast Bath (HCPC 97034)

Answer 30

Heat Method - conduction
Source:
  * Hot and cold basins
Indication:
  * Pain and Edema

2 Basins, one with cold water (13-18 C) and one hot
(35-45 C) No more than 110 degrees

Immerse injured part into warm water 10 mins initially
Cool water 1 min, then hot water 4 mins
Perform 15-20 mins all together

Vasodilation followed by vasoconstriction to improve
circulation, gets rid of swelling)

Benefit:
* Control over temps, easy home program for edema

Disadvantage:
* Must sterilize containers with open wounds
* Would not recommend for home program in pt
with open wounds

Question 31

Documenting Heat Modality

Answer 31

• Type of modality
• Position of body part
• Time of Tx
• Reasons for choosing the modality
• Relate to functional goal
• Include modality specific parameters when possible

Question 32

Cold Therapy

Answer 32

• Decrease inflammation-edema control
• Pain control/analgesic affect
• Decrease spasticity (time dependent)
• Decrease histamine through vasoconstriction
• Decrease nerve conduction
• Decrease muscle spasms
• Cooling tissues after stretch helps maintain elongation
  of tissue
  ** Great for shoulders - penetrates 10cm beneath skin
  can reach the cuff

Question 33

Cold Therapy Contraindications

Answer 33

• Individuals that are cold intolerant, cold can cause a
  systemic response and vascular compromise
• Vascular insufficiency increases risk of frost bite
• Blood clotting disorders - cold makes it thicker
• Over an area with peripheral vascular disease

Question 34

Cold Therapy Precautions

Answer 34

• Cognitively impaired
• Over an open wound unless using a whirlpool or water
  flushing modality
• Hypertension
• Poor sensation
• The very young or very old

Question 35

Cold Therapy Adverse Effects

Answer 35

• Tissue damage <54 degrees F
• Frostbite: 14 - 24 degrees F
• Nerve damage - excessive exposure
• Huntington’s reaction - unwanted vasodilation with over
  20 mins exposure at consistent cold temp (<59 F)
• Ice burns occur frequently secondary to people at home
  putting a cold pack either directly on skin or applying a
  pack and forgetting about it

Question 36

Cold Therapy Treatment

Answer 36

• Assess pt and set goals
• Determine if cryotherapy is the most appropriate
  modality for the desired tx effect
• Determine what are the precautions and if cryotherapy
  is contraindicated
• Which is the best cooling agent

Question 37

Cold Therapy: Ice or Cold Pack

Answer 37

Cooling Method: Conduction
Ice Pack: Crushed ice, wrapped in a moist towel or bag
Cold Pack: water retained in a colloidal silica gel
pack kept in cooling units at 5 degrees C
cooling for at least 30 mins btwn applications

Question 38

Ice Packs

Answer 38

• A tea towel, pillow case or thin covering should always
  be placed btwn the ice pack and skin to avoid frost bite
• If applying to the hand, leave the finger tips open
• Tx time: 15-20 mins (at home can perform once every hr)
• Temp of tissue continues to decline even after cold pack
  removed for up to 1 hr and 20 mins if the pt is not
  moving around

Question 39

Homemade Ice Packs

Answer 39

• Ice slushy: 1:2 or 1:4 mix of alcohol and water placed in a
  zip lock freezer bag (double bag), the alcohol lowers the
  melting point of ice thus it remains in slushy form
• Palmolive dish soap may also be used to make a
  homemade gel ice pack (double bag)
• A bag of frozen peas or corn

Question 40

Ice Massage

Answer 40

Cooling Method: conduction, release of latent heat
causing ice to melt
Cold Source: ice

Rapid Cooling

Very focal - good for tennis elbow or medial epicondylitis

Question 41

Ice Massage Indications

Answer 41

• Pain
• muscle cooling
• localized inflammation
• trigger points
• frozen shoulder - better than heat b/c it is not stiffness as
  much as it is inflammation that is the problem

Treatment time varies based on location
5-10 mins
careful around boney prominences
less time required to cool tissue

Question 42

Ice Massage Precautions

Answer 42

• Pt will feel cold, burning, aching then numbness
• Intense erythmia usually results
• Keep ice moving or freeze injury could occur
• Messy so keep towel under pt
• Good for trigger points - b/c ice quiets down the nerve
  and the trigger point is a nodule that the muscle forms
  as a response to the nerve pain

Question 43

Infrared and Light Therapies

Answer 43

(IR) - is invisible radiant energy, electromagnetic radiation
w/ longer wavelengths than those of visible light,
extending from the nominal red edge of the visible
spectrum at 700 nanometers

    most of the thermal radiation emitted by objects near
    room temp is infrared

• Aids in circulation
• Used for diabetic neuropathy and pain
• Various therapeutic delivery methods
• Hand held units
• Machines
• Anodyne

Question 44

Other Light Therapy

Answer 44

• Green light to enhance Circadian Rhythm, help with
  sleep disorders
• Blue light for skin cancer lesions
• Both Green and Blue have been used for cancer tx and
  acne

Question 45

Laser Therapy

Low Level Laser Therapy or Cold Laser LLLT

Answer 45

• Low-level laser therapy (LLLT) refers to the use of a
  red-beam or near-infrared laser with a wave-length
  btwn 600 and 1000 nanometers and power of 5-500
  milliwatts
• Low-level laser do not produce heat
• Pain reduction
• Adhesion reduction
• Improve scar mobility
• Axillary webbing - lasers work well on

Question 46

Continuous Passive Motion Machines (CPM)

Answer 46

Strange but lumped under superficial modality

• This is for pt that you don’t want to get stiff or develop
  adhesions
• Machines move the extremities for them and the amount
  of degree is determined by pt
• With hand CPM the vendor will set pt up but we have to
  interviene to help modify padding or where the velcro is
  attached.
• These are not always contraindicated with CRPS pt, if
  they are just stiff and don’t have all the autonomic signs