Physical Agents: Exam I

Question 0

Transfers

• • Definition
• • Subtype
• • Purposes

Answer 0

= Safe movement of person from one place to another
– Bed mobility = Changing a patient’s position in bed

Purposes:

(1) Safely person from one place to another
(2) Rehabilitation or training
- - Develop functional strategies, motor patterns, and strength
- - Increase independence with movement

NOTE: Whereas we perform these movements automatically, person with disabilities will need assistance or training to learn to do on their own

Question 1

Levels of assistance

Answer 1

• • Dependent (D) = <25% by patient
• • Max assist (Max A) = 25-50% by patient
• • Mod assist (Mod A) = 50-75% by patient
• • Min assist (Min A) = >75% by patient
• • Independent (I) = 100 % by patient
  • • No physical assistance or supervision required
  • • May be independent with device (qualify in documentation)

Contact guard assist (CGA)
= Hands in contact with patient for safety
– On gait belt, belt loop, shoulder, pelvis
– Cases of balance deficit and fall risk

Stand-by assist (SBA)
= Stand close to patient to provide verbal or tactile cues, directions, or instructions
– No physical assistance (may provide protection if safety is compromised)

Question 2

Transfer equipment

Answer 2

= Used only when needed to perform transfer safely, gradually removed from use to promote patient independence

(1) Gait belt = used to help maintain balance or during lift
(2) Sliding board = smooth, WB platform bridges gap btw surfaces
(3) Hydraulic, pneumatic, or electrical lifts = used for obese, NWB, paraplegics, amputees, recent skin grafts
(4) Bed accessories (e.g., bed frame/rail, transfer board, draw sheet, trapeze bar) = assist bed mobility
(5) Assistive ambulation devices (e.g., crutches, canes, walkers)
(6) Wheelchair accessories (e.g., IV, O2) = may impede transfer
(7) Tub/shower chairs = facilitate movement on slippery surface

Question 3

Transfer documentation components

Answer 3

(1) Type of transfer
(2) Surfaces moved to and from (may use uni- or bidirectional arrow)
(3) Assistive devices or equipment if used
(4) Assistance level required (e.g,, Mod A, SBA)
- - Qualify which part of transfer if it differed throughout
- - Qualify nature of assistance (e.g., verbal cues)
(5) Number of assistants (e.g., 2 = x2 or +1)
(6) Special circumstances or considerations (e.g., knee immobilized)

NOTE: Must provide enough detail that transfer could be repeated exactly

Question 4

Guidelines for transfers

Answer 4

(1) Safety is #1 priority (for patient and self)
(2) ID special considerations
- - Comorbidities and morbidity (e.g., disease, limitations, special conditions)
(3) Plan ahead
- - Know start and end
- - Gather equipment/supplies
- - Corral and prepare assistants (if needed)
- - Clear area of potential hazards (e.g., catheters, IV lines, furniture, rugs)
(4) Explain transfer plan to patient (clear, concise, action-oriented ~ cognitive ability)
(5) Allow patient to help as much as possible SAFELY
(6) Adjust transfer height to shortest person assisting
(7) ID person in charge (usually at patient’s head)

Question 5

Protect self from injury

Answer 5

(1) NEVER have patient hold neck
(2) Slow and controlled movement
- - Use BW, not muscles or momentum
(3) Get HELP if in doubt
(4) Beware fatigue
- - Build endurance
- - Caution at end of day
(5) Good body mechanics
- - Wide BOS
- - Close to patient (their COG in your BOS)
- - Neutral spine (normal lordosis)
- - Hip and knee flexion < 60 degrees
- - NOT deep squat (hard to stand)
- - Pivot turn (move feet, don’t twist)

Question 6

Protect patient from injury

Answer 6

(1) Keep hands on patient
- - Near edge of surface
- - After transfer complete
- - DO NOT LEAVE ALONE until certain they are stable
(2) Put self in position to prevent patient fall
- - Sitting: At side and slightly front
- - Standing: At back or weak side
- - Stairs: Behind on way up, in front on way down
(3) Help lower falling patient to floor
- - Do not try to stop fall
- - File incident report
(4) Control patient movement
- - Hands on key points of control
- - Heavier areas of body = shoulders, trunk, hips, gait belt
- - Other parts of body guide, guard, or block
- - Use knees to block knee buckling
- - Use feet to assist progression
- - Let patient see where they are going
- - Improves confidence, body mechanics, reaction time, ability to assist
(5) Patient footwear with traction
(6) Patient assist as much as possible

Question 7

One person transfers (B LE WB)

Answer 7

(1) Stand pivot:
- - Stand, pivot, sit
- - Less commonly used (more energy required than squat pivot)
- - Benefits
- - Transfer to higher surface or to get over arm rest
- - Used for strength training
- - May be safer for PT
- - Easier if transfer requires feet shuffling
(2) Squat pivot:
- - Stand halfway (clear surface), pivot, sit
- - More commonly used (less energy required than stand pivot)
(3) Seated transfer
- - Stay seated, slide/move over (may require sliding board to bridge gap)

General considerations:

• • Minimize distance between chair bed seat (at angle or 90 degrees)
• • PT position
  • • Wide BOS
  • • Knees and hips bent (can also use rolling stool)
  • • Block knees (prevent buckling) during stand
  • • Flat back
  • • Lean back as patient stands (move COM into BOS)
  • • Use gait belt for control
  • • Slight momentum to initiate movement
• • Patient position
  • • Scoot hips forward before transfer
  • • Lean forward (“nose over toes”) before stand and push through feet
  • • One foot forward before lift to make pivot easier
  • • Push on chair arm rests, chair seat; pull on rail or overhead bar

Question 8

Sliding patient forward in chair

Answer 8

Patient:

(1) Lean back and slides down chair
- - May need to block knees so they don’t too far
(2) Grab handles or bars to pull forward

PT assist:

• • Stand in front
    (1) Grasp gait belt and rock patient back and forth
  • • Patient leans side to side as you pull each hip forward
      (2) Grasp hips or gait belt and pull forward
      (3) Put hand under thigh and ischial tuberosity and pull forward
      (4) Use gait belt as sling around hips to pull hips forward
      (5) Put draw sheet on wheel chair and pull out
      (6) Grasp under knees, lift up and pull forward ***

Question 9

Lifting patient from chair

Answer 9

• • Patient scoots and flexes forward
• • Grasp belt
• • Wide BOS
• • Bend knees
• • Patient clasps shoulders/waist OR pushes on hand rails
• • Rock patient back and forth before lift (momentum)
• • Give verbal cues
    
    • • Ask patient to help

Question 10

Feet positions for pivot

Answer 10

Patient:

• • Back foot bears most of weight
• • NWB or PWB should be forward

PT:
With lift --
-- Pinch one or both patient knees with own knees 
  -- Prevent buckling
With pivot --
-- Front foot in direction of pivot
-- Uncross feet with pivot

Question 11

One person dependent lift

Answer 11

= Transferring from one chair to another with patients feet off floor (B LE NWB)

• • Sit on stool (w/ wheels) in front of patient
• • Grab behind knees
• • Lift feet off floor
• • Hold legs between thighs or knees
  • • Can cross ankles to relieve pressure on knees
• • Patient arms on lap
• • Flex patient trunk
• • Patient head on shoulder opposite direction of movement
• • Head lock between arm and trunk
• • Grab gait belt
• • Shift weight backward
• • Lift patients butt off surface
• • Pivot and lower

NOTE: Head lock may not be possible if patient is large relative to PT

Question 12

Two person swing

Answer 12

= Two person transfer for B LE NWB patient
– Usually from wheelchair to bed

• • Shorter PT in front
• • Taller PT behind

Behind:
– Reach underneath arms and grab patients arms (crossed over belly)
– Patient may grasp wrists and squeeze elbows into side of body
– Tuck arms into chest and straighten legs to lift
Front:
– Grasp under knees (bent or straight) and lift
– Direct bum onto table
– Person behind readjusts to move upper body onto table

NOTE: “Fireman’s carry” alternative lift less used because of poorer PT body mechanics (excess flexion at trunk)

• • One person on each side of patient
• • One arm underneath both legs
• • Other arm behind back
• • Patient puts arm over shoulder

Question 13

Three person lift

Answer 13

= Transfer for B LE NWB patient who cannot flex at middle (e.g., SCI)

• • Order PTs shortest to tallest from legs to head (legs, hips, shoulders, head)
  • • May need fourth so that “captain” can control head
      
      • • Must support head if patient cannot
• • Get patient as close to body possible = shorter lever arm = less energy
  • • Move patient to edge (e.g., bed sheet slide)
  • • Patient arms crossed or by side
  • • Log roll away to get arms underneath
  • • Roll patient into chest
• • Shuffle in sync sideways to new location
  • • Coordinate with verbal instructions

CAUTIONs:

• • May require more people depending on size of patient and ability to control head
• • Coordinate all movements so that spine remains straight
• • Do not impede each other
• • Lack of coordination may cause patient to twist
• • Shorter arms may not be able to get arms around patient
• • Consider instead using board or mechanical lift

Question 14

Wheelchair transfer types

Answer 14

– Stand pivot
– W/C to/from bed or mat (higher surface)
– W/C to/from toilet
– W/C to/from car
– Watch patient’s head
– Put patient’s hand on stable surface inside car
– Sit on seat
– Move legs into car
NOTE: If too high (e.g., truck):
– Sit on floor and scoot onto seat
– Start with feet on stool

• • Squat pivot
  • • W/C to/from toilet
• • Seated scooting
  • • Could use sliding board

– Two person swing

Question 15

Wheelchair transfer guidelines

• • Prep W/C
• • Prep patient
• • Guard knees

Answer 15

(1) Prep W/C
- - Lock brakes
- - Remove arm and leg rests
- - Remove seatbelt
- - Make sure all necessary attached equipment comes with (e.g., IV, catheter)

(2) Prep patient
- - Feet flat on floor
- - Scoot butt cheeks forward one at a time (shift weight opposite)
- - Reposition feet (FWB limb behind, PWB in front)
- - Anterior pelvic tilt
- - Lean forward
- - Push off surface
- - May reach one hand to put on second surface

(3) Guard patient knees with PT knees
- - Knees outside
- - Feet inside or outside

Question 16

Bed mobility guidelines

• • Goals
• • Preparation
• • Body mechanics

Answer 16

Goals:

• • Safety for PT and patient
• • Minimize energy required by PT
• • Progress toward independence

Prepare bed:

• • Make flat
• • Adjust height to shortest assistant
  • • Level of hips when knees and hips slightly flexed
  • • Level of mid-thigh if standing upright

Body mechanics:
– PT
– Wide BOS
– Flexed knees
– One foot forward in direction of movement and one foot facing sideways
– Lunge into direction of movement
– Draw sheet or arms under key points of control
= Heaviest parts of body (upper trunk/shoulders and lower trunk/hips)
– May need to support under head or neck if patient can’t lift head
– Best is to use draw sheet
– Have patient assist as much as is safe (decrease drag)
– Lift head
– Bend knees
– Bridge hips
– Push down on elbows or feet
– Pull on bar
– Coordinate movements among assistants and patient
– Count and move
– Slide (do not lift)
– Reduce energy required
– BUT be aware of skin conditions

Question 17

Bed mobility: One person assist

• • Move up
• • Move down
• • Move to side

Answer 17

General:

• • Hold draw sheet at opposite corners OR put arms under key points of control
• • Perform several small steps
  • • Have patient lift hips and scoot
  • • Have patient lift shoulders and scoot
  • • Reach under shoulders or hips to help scoot

Moving up in bed:
– Draw sheet
– Gather on one side at upper body and one side at lower body
– Lunge onto side facing foot and slide up
Alternative: Grab sheet at head of table and pull up
– Without draw sheet
– Bend knees, lift and scoot hips up

Moving down in bed:

• • Draw sheet
  • • Same as moving in opposite direction
• • Without draw sheet
  • • Stand at end of table
    • • Grab at calves to pull down
  • • Bend knees, lift and scoot hips down

Moving to side:

• • Move one part at a time
  • • First shoulders/upper trunk
  • • Second hips
  • • Third legs

NOTE: Do not move segmentally if person has spine problem

Question 18

Bed mobility: Two person assist

– Three methods

Answer 18

(1) One on each side holding draw sheet at key points
(2) One on each side with arms staggered under hips and shoulders

(3) Both on same side
- - One with arms under shoulders
- - One with forearms under hips

Question 19

Bed mobility: Rolling

• • Supine to sidelying
• • Sidelying to prone

Answer 19

General:

• • ALWAYS roll towards PT (otherwise dangerous)
• • Bottom arm in 90 ABD (out of way)
  • • Upper arm across body
• • PT hands on key points of control (hips, shoulders)
• • Patient lifts head and looks toward roll
• • Bend patient knees EXCEPT if spine problem
  • • Pull on bent knees
• • Sit back like into chair
• • Adjust position once roll complete

Supine to sidelying: 
-- Segmental rolling (typical)
  -- Hooklying
  -- Roll upper trunk/shoulders first
  -- Roll lower trunk/hips/knees second
NOTE: Sidelying more stable if knees and hips bent
-- Logrolling (spine problem)
  -- Roll whole body as unit

Sidelying to prone:

• • Ensure table is wide enough for supine - sidelying - prone
• • Move bottom arm out of way (e.g., above head or by side)
• • Extend hips and knees
• • Roll TOWARDS

Question 20

Bed mobility: Supine to sit

Answer 20

• • First roll supine to sidelying
• • PT position:
  • • Stand in front
  • • One arm under shoulders
  • • One arm at legs (grab behind knees)
• • Lower legs off table while lifting shoulders
  • • Downward torque of legs helps lift
  • • Can do legs first if safe (i.e., trunk bending OK)
• • Patient pushes off bed with both arms
• • Plant feet on floor (may use stool)
• • KEEP HANDS ON PATIENT until stable/safe upright

Question 21

Special transfer considerations:

• • First time up
• • Hemiplegia
• • Post THA
• • Painful limbs

Answer 21

First time up

• • More prone to orthostatic hypotension
• • May feel nauseous, be prepared for vomiting
• • May be scared and fearful

Hemiplegia

• • Easier to transfer to unaffected side
  • • BUT to increase independence practice to sides
• • Shoulders at risk for subluxation (due to loss of muscle tone) (especially inferior)
  • • Avoid stress at shoulder
  • • Don’t pull under arm (e.g., use belt not arms with 2 person lift)

Post THA

• • Post-op ROM precautions will differ depending on approach
• • Posterior approach
  • • Minimize FLEX, ADD or IR
  • • Use ABD pillow during transfers
  • • Do not flex hips/trunk > 90
  • • Do not turn trunk to surgical side while seated or standing (causes IR of hip)

Painful limbs

• • Be careful
• • Provide extra support to limb during transfer so that painful joints don’t move
• • Wrap pillow around painful limb
  • • Prevent bumping
  • • Keep immobilized (e.g., post-surgical limb)

Question 22

Special transfers considerations

• • Lumbar trauma
• • Fragile skin/burns
• • Obesity
• • Gurney transfers

Answer 22

Lumbar trauma or surgery:

• • Minimize lumbar motion
• • Log roll
• • Avoid side bending when going from sidelying to sit
• • Avoid trunk motion during transfer
• • If wearing brace to help minimize motion can use as key point of control (but do not tug)
• • Still use gait belt

Fragile skin

• • Long term steroid use or elderly
• • Tears easily
• • Avoid sliding/dragging or excess skin contact (shear forces)
  • • Lift instead

Obesity

• • Get help if too big to move alone
• • Use mechanical lift

Gurneys
– Lock wheels

Question 23

Special transfers considerations

• • Spinal cord injury (acute and chronic)
• • Medications
• • Brain injury (cognitive defects)

Answer 23

Spinal cord injury

• • Acute
  • • Likely have internal or external fixation devices
  • • Avoid further damage to injury site
  • • Logroll
  • • Do not PULL legs or arms (will distract vertebrae)
• • Chronic
  • • May have developed osteoporosis (lost density due to lack of WB)
    • • Long bones of LEs and vertebrae particularly at risk even with mild stress
    • • Avoid bending forces through long bone
  • • Not concerned with original SCI

Medications

• • May alter patients perception, balance, and cognition
• • May be prone to dizziness, vomiting

Brain injury

• • May show poor judgment
  • • Often unsafe even if physically able
  • • Often require more supervision and cueing vs. less physical assistance
    • • Cues must be short, clear, action-oriented
    • • Usually one step at a time
    • • Lots of repetition
• • HAVE PATIENCE

Question 24

Ambulation aids

• • Definition
• • Purpose
• • Indications

Answer 24

= Device used during ambulation

Purpose:

• • Make ambulation safe
  • • Decrease WB on limb
  • • Increase BOS
  • • Improves ability to balance
  • • Larger area within which COG can move w/o losing balance

Indications:

• • Compensation for impairments:
  • • Decreased strength in LE or trunk
  • • Decreased balance
  • • Pain with WB
  • • Decreased WB because potential for damage (e.g., operation, injury)
  • • LE amputation (with or without prosthetic)

Question 25

Limitations to using ambulation aids

Answer 25

• • Requires more energy
    
    • • Fatigue faster
• • Limited speed and mobility
• • Promotes (unnecessary) dependence on device
    
    • • Loses confidence in walking ability
    • • Becomes fearful of walking without device
• • Predisposes UE to injury
  • • Unused to WB

Question 26

Types of devices

– Most to least stable

Answer 26

– Parallel bars

• • Walkers
  • • Standard (no wheels)
  • • Front wheeled walker (FWW)
  • • All wheeled walker (WW)
  • • Hemiwalker (used on one side)
• • Crutches (bilateral) (cxs)
  • • Axillary
  • • Forearm (Lofstrand)
• • Canes (bilateral)
  • • Four point (i.e., “quad”)
  • • Wider BOS (more stable) but less natural gait
  • • Offset shaft
    • • Puts weight bearing down through BOS
  • • J-cane
• • Crutch (unilateral)
    
    • • Use opposite affected limb
• • Cane (unilateral)
    
    • • Least stable

Question 27

Ambulation aids accessories

Answer 27

• • Platform (i.e., trough or shelf)
  • • Releases WB on wrist/hand
  • • Used on axillary crutches, walkers, less often cane
• • Rails
• • Baskets
• • Seats
• • Brakes
• • Gloves
  • • Help prevent nerve compression injury in hand

Question 28

Fitting ambulation device

• • Handgrip height
• • Crutch length
• • Forearm crutch
• • Platform attachment
• • Width of walker/parallel bars

Answer 28

Handgrip height
– Put device in position for use
– Allow ~20 degrees elbow FLEX
– LE can spear ground when elbow EXT and shoulder depressed
= Wrist crease (styloid process) at level of handgrip when arm by side

Crutch length

• • Put base of crutch slightly in front of body (at angle) and top under armpit
• • 2-3 finger width between axillary and top of crutch
  • • Prevents compression of axillary nerve
• • Alternative estimates for patient in bed:
  • • Height x 0.77
  • • Axillary fold to heel
  • • Arms 90 degrees ABD olecranon process to fingertips of other arm

Forearm crutch

• • Top of cuff as high as possible w/o impeding elbow FLEX
  • • 2-3 cm distal to olecranon

Platform
– High enough to allow functional shoulder depression (clear LE during swing)

Walker/bar width
– As narrow as comfortable (~2” on either side of hips)

Question 29

Ambulation preparation

• • Device
• • Accessories
• • Weight bearing status
• • Safety

Answer 29

Device
– Minimum required support
– Greatest mobility (least stability) that is safe
– Check for fit and safety (e.g., rubber tips, bolts)
Accessories
– Plan to protect necessary ones during ambulation (e.g., IVs, catheters, braces)
Weight bearing status:
– Full weight bearing (FWB)
– Partial weight bearing (PWB) = pounds or %BW
– Touch down weight bearing (TDWB) = Only weight of leg
– Formerly toe touch weight bearing (TTWB)
– Encourage normal heel-toe pattern vs. forefoot contact
– Cue to use very little weight (e.g., “walk on eggshells”)
– Weight bringing as tolerated (WBAT) = Limited by pain, confidence
– Use scale to give patient sense of appropriate weight
– Non weight bearing = Foot off ground
Safety
– Gait belt (around waist, hold with palm up)
– Footwear with traction (e.g., NOT regular socks)

Question 30

Guarding techniques

Answer 30

• • Good body mechanics
  • • Knees slightly flexed
  • • Wide BOS
  • • Staggered stance
  • • Close to patient (COM within our BOS)
• • ALWAYS one hand on gait belt
  • • Other hand used as needed (e.g., stability at hips/shoulders, holding accessories)
• • On flat surface
  • • Stand behind and slightly to side (patient’s weaker side)
  • • Stand behind if tendency to fall backward, in front if tendency to fall forward
• • On stairs, ramps or curb, ALWAYS on downhill side
  • • One hand on gait belt, one hand on railing or shoulder
• • Coordinate timing of foot advance (avoid trip)
• • Anticipate and prepare for problems (e.g., loss of balance)
• • Slowly lower to ground if fall occurs
  • • Slow their momentum
  • • Hook under arms
  • • Protect head
  • • Go down onto your knees
  • • Slide down leg
• • NEVER leave patient unattended

Question 31

Crutch gait patterns

• • Four point
• • Modified four point
• • Two point
• • Modified two point
• • Three point
• • Three-one point
• • Bilateral swing-to or swing-through

Answer 31

• • Four point (slowest)
  • • PWB LE, 2 crutches
  • • R cx – L LE – L cx – R LE
  • • Slow but very stable
    • • Good for weak, unstable, or novice patient (e.g., bilateral weakness, balance deficits)
• • Modified four point
  • • PWB LE, 1 crutch OPPOSITE to impaired leg
  • • Crutch – Impaired leg – Good leg
• • Two point (faster)
  • • PWB, 2 crutch
  • • R crutch with L leg – L cx with R leg
• • Modified two point
  • • PWB, 1 crutch OPPOSITE to impaired leg
  • • R cx with L leg – L cx
• • Three point (fastest)
  • • NWB LE, 2 crutches
  • • 2 cx w/ NWB leg – WB leg
  • • Step-to: WB leg steps up to level of crutches
  • • Step-through: WB leg steps beyond crutches
    • • Wider BOS actually more stable if person has strength, confidence, and ROM
• • Three-one point
  • • PWB LE, 2 crutches
  • • 2 cx w/ PWB leg – WB leg
• • Bilateral
  • • B PWB LE (e.g., B trauma, paraplegia, CP)
  • • Swing-to or swing-through

NOTE: “Modified” AKA “One point” (e.g., two-one or four-one point gait)

Question 32

Walker gait patterns

• • Three point
• • Three-one point
• • Swing-to

Cane gait patterns

Answer 32

Walker:

• • Three point (‘step-to)
  • • NWB LE
  • • Advance walker – Step WB leg into walker center
• • Three-one point
  • • PWB LE
  • • Advance walker w/ WB LE – Step WB leg into walker center
• • Step-through
  • • B PWB
  • • Advance walker – Swing both legs to middle

Cane:

• • Same as crutches except no three-point or three-one point
• • Hold cane opposite to impaired side
• • Try to advance cane with normal UE swing

Question 33

Sit-to-stand

• • Crutches
• • Walker
• • Immobilizer

Answer 33

Crutches:

• • Two crutches in one hand (same side or opposite affected)
• • Move body forward
• • Good leg behind (greater WB)
• • Other hand push off chair
• • Lean forward
• • Stand
• • Rearrange crutches one in each hand

Walker:

• • Walker in front of body
  • • Sitting on higher surface
  • • One hand on walker and one push off chair
      
      • • Do not put both hands on walker (unstable)
  • • Both hands push off chair
    • • Move one hand to walker when partially standing
• • Walker to side of body
  • • One hand on walker and one push off chair

Immobilizer:
– Leg unable to fox slides forward along floor as patient stands

NOTE: Teach patient to stand from other surfaces (e.g., toilet, chair w/o armrests, low couches, cars)

Question 34

Stand-to-sit

• • Crutches
• • Walker
• • Cane

Answer 34

Crutches:

• • Turn around so back is facing surface
• • Scoot back until backs of legs touch chair
    
    • • Put strong leg behind affected leg
• • Put both crutches on one side (one hand hold)
• • Reach back with one or both hands
  • • Put hand(s) on chair
• • Lean forward, butt back, sit down
• • Put crutches on floor

Walker/Cane:
– Same as crutches, but walker remains in front and cane propped on chair

Question 35

Doors w/ ambulation aid

Answer 35

• • Approach at angle
• • Use aid as doorstop
• • Squeeze through smallest available space

Automatic closing or heavy door:

• • Open partway
• • Stop door with tip of ambulation device
• • Step through

NOTE: May require several small steps

Question 36

Stairs, curbs, and ramps with ambulation aid

Answer 36

Upstairs:

• • Good leg goes up first
  • • Must be able to advance BW onto good leg (weight shift forward)
• • Follow with aid and affected leg

Downstairs:

• • Bad leg goes down first w/ aid
  • • Can also lead with aid
• • Weight bear through aid
• • Bend hip and knee of unaffected leg
• • Follow with unaffected leg

– Always use handrail with one hand (more stable)
– Ideally on impaired side (if available)
Crutches:
– Hold both in one hand (by handgrips or one vertical/one horizontal)
Walkers:
– Fold or turn sideways and use opposite to rail
– Put front legs on forward step
Immobilizer:
– Extend hip so leg drags behind when ascending
– Flex hip so leg stays in front when descending

NOTE: Do not impede or trip patient; cue which leg to lead and to use rail

Question 37

Stand-to-floor transfer

• • Crutches
• • Chair
• • Wall

Answer 37

Crutches
– Both on one side of body (same as affected LE)
– Hold handgrips together
– Lower body until kneeling or seated (forward or back)
– Leaning forward
– Bring bad leg behind (if knee EXT)
– Fall forward onto hand
–Rotate onto good side
NOTE: Can use table or chair to help get lower to ground
– Bend knees and lean back to sit

Chair:
-- Lower body off chair with chair behind 
-- Lower body using chair to side
Wall:
-- Slide down wall

Reverse:
-- Face floor
-- Use arm on unaffected side
-- Use crutches on affected side
-- Shift weight forward
-- Push up using UE and good LE
NOTE: Can scoot closer to table or chair to push on
Can use device to assist getting up

Question 38

Falling with ambulation device

• • Occurrence
• • Techniques

Answer 38

Occurrence:

• • Patients with impaired balance (e.g., CVA patient w/ hemiparesis)
• • Patients using assistive devices long term

Techniques:
– General rules
– GET AID OUT OF THE WAY
– Teach slowly and incrementally onto cushy surface
– Forward:
– Let go of device
– Fall on hands with arms forward (protect head)
NOTE: Can practice first falling against wall
– Backward:
– Flex trunk and head while reaching forward slightly (protect head)
– Need to teach forward flex in reaction to falling back
– Fall on bum

Question 39

Ambulation documentation

Answer 39

• • Activity (e.g., amb, sit-to-stand, gait pattern, speed)
  • • Note if speed is other than self-selected pace
• • Distances
    
    • • Be objective (e.g., feet or meters)
    • • Can indicate rest in middle by “x 2” (e.g., 30 m x 2)
      • • Indicates tolerance to activity
      • • Note time of rest (e.g., 2 min)
• • Device used
• • Precautions (e.g., WB status, platform, immobilizer)
• • Assistance level required for each part of activity (e.g., CGA, Mod A)
    
    • • Assistance left blank indicates none needed
• • Terrain/surfaces
    
    • • Level vs. uneven (e.g., lawn, sidewalks, parking lot, doorways)
    • • Friction level (e.g., tile, low pile carpet, high pile carpet)
    • • Up or down (e.g., curbs, ramps, stairs)
• • Use abbreviations (e.g., amb, FWW, cxs)

Question 40

Modalities

• • Definitions
• • Purposes

Answer 40

= Application of a form of energy to the body to elicit an involuntary response

Purpose:

• • Provide best possible environment for healing process to occur
• • Reduce symptoms
• • Improve comfort level
• • Increase ability of patient to do activities that will facilitate healing:
  • • Strengthening
  • • Stretching
  • • Exercise

Question 41

Goldilocks Principle

Answer 41

= Stress on a system has a window of positive effect
– Between too little and too much
= Window of therapeutic stress

Too little stress = body stays as it was, system unchanged
Too much stress = cause damage to system
– Harming patient is worst outcome
Just right = positive outcome
– Causes changes that make system better

NOTE: Goal for all interventions (e.g., exercise, modalities, manual therapy)

Question 42

Wolff’s Law

Answer 42

= Stresses placed on bones cause changes in internal structure of bone

• • New bone forms along lines of stress
• • Goldilocks Principle applied to bones

Too much = osteophytes and excess bony growth
Too little = no new bone forms (bone weakens)
Just right = bone remodels and retains strength

Question 43

Arndt-Schultz Principle

Answer 43

• • Modalities are stresses applied to the body
• • Intensity of modality (stress) must be in therapeutic range to:

(1) Be of value
(2) Not damage body

Question 44

General Adaptation Syndrome (GAS)

Three stages:

(1) Alarm stage
(2) Resistance stage
(3) Exhaustion stage

Answer 44

= Body’s mechanism for coping with stress

Alarm stage:
= Initial reaction to change in body’s environment (i.e., “fight or flight”)
– Dramatic physiological reaction
– Small change in stress results in large change in physiological activity
– Body gathers resources needed to restore body to homeostasis

Resistance stage:
= As stress continues, smaller change in response despite large increase in stress
– Response begins to plateau
– Includes either physical of psychological resistance
– Stress in this stage causes positive or adaptive responses
= Positive stress (“eustress”)

Exhaustion stage:
= Stress becomes so high that body can no longer tolerate additional stress
– Body systems start to fail
– Leads to injury or illness
– Stress causes negative or maladaptive changes
= Negative stress (“distress”)

Question 45

Injury (primary vs. secondary)

Answer 45

= Excess stress causes cell damage/death

Primary = tissue damage directly related to trauma
– Irreversible, but body can make repairs (e.g., ankle sprain)
Secondary = tissue damage caused by body’s response to primary injury
– Treatable/preventable (e.g., swelling)

Two types of secondary injury:

(1) Enzymatic = dead cells release enzymes, break down membranes of live cells
(2) Metabolic = ischemia (swelling) impedes circulation, causing:
- - Decreased ATP production
- - Cells switch to anaerobic metabolism due to lack of oxygen and glucose
- - Collection of metabolic wastes
- - Cell damage and death due to hypoxia

Question 46

Homeostasis

• • Injury
• • Modalities

Answer 46

Homeostasis:

• • Energy supply (available) = demand (need)
• • Internal environment maintained in equilibrium

Injury: Energy demand (need) > energy supply (available)
Modalities: Affect demand (need) or supply (available)

Ice: Decreases need (slows metabolism)
– BUT also decreases available (decreases circulation)
Heat: Increases available
– BUT also increases need (metabolism increases)

NOTE: Need to balance effect of modality on energy available and energy need

Question 47

Scope of practice

Answer 47

= Legal boundaries describing what a professional can and cannot do

• • Defined for each state by state practice act
• • Applies to all forms of interventions

Question 48

Informed consent

Answer 48

= Patients educated about diagnosis, treatment options, and potential risks and benefits of proposed treatments before treatment begins

Explain:

(1) What you want to do
(2) Potential benefits and risks
(3) Patient’s role (i.e., what they must do to make treatment effective)
(4) What they should and should not expect to experience (e.g., hot pack should not burns their skin, but should provide comfort and may increase skin redness)

Question 49

Negligence vs. Incompetence

Answer 49

Negligence:
= Clinician provides care outside standard (accepted manner) or scope of practice

Can be attributed to:

• • Bad behavior (e.g., bad choices despite knowing better)
• • Faulty equipment (e.g., unsafe)

NOTE: Equipment must be inspected and calibrated regularly by qualified service person

• • Documentation of equipment checks required by regulating agencies
  • • Hospitals or large organizations
• • May not be regulated in private practice (potential legal problem)

Incompetence:
= Clinician lacks ability to perform professional duties adequately
– Makes bad decisions because of not knowing enough

NOTE: May be due to inadequate training of new equipment or techniques, or insufficient continuing education

Question 50

Indications

Contraindications

Precautions

Answer 50

Indications
= Problem (e.g., symptoms) for which a given treatment is appropriate
– Example: Symptoms of a cold are indications for taking a decongestant
NOTE: “Indicated” refers to the treatment (e.g., decongestant is indicated for signs and symptoms of a cold)

Contraindications:
= Problems for which a treatment is not advisable
NOTE: “Contraindicated” refers to treatment that is likely to cause more harm than good
– Examples:
– Ultrasound contraindicated for fracture
– E-stimulation contraindicated for person with pacemaker
– Pregnancy is contraindication for most medicines

Precautions:
= Reasons to use caution when giving a treatment (AKA “relative contraindications”)
– In more severe case, may become contraindication
NOTE: Systemic problems are often precautions for applying local modalities

Question 51

Guides for treatment

Answer 51

• • Knowledge of cause (etiology)
• • Natural history of disease (pathology)
• • Presence and nature of symptoms (palliative or curative)
  • • Palliative = treat symptoms (e.g., pain medication for cancer patient)
  • • Curative = treat underlying cause (e.g., chemotherapy for cancer)

Question 52

Patient positioning guidelines

Answer 52

(1) Comfort:
- - Enhances the treatment (especially if goal is pain reduction)
- - Patients often don’t know what positions are more comfortable
- - Patient is able to relax (less guarding)

(2) Expose treatment area:
- - Use sheets or towels to drape and maintain patient modesty
- - Have patient wear appropriate clothing

(3) Treatment area accessible:
- - Clinician must be able to comfortably, safely, and easily reach treatment area

Question 53

Patient positions

Answer 53

• • Supine = face up (lying flat or semi-reclined)
• • Prone = face down (fully flat)
  • • Quarter prone (halfway between sidelying and prone)
• • Sidelying
• • Sitting
  • • Long = knees EXT
  • • Short = knees FLEX over edge of table
• • Elevated = extremity above level of heart
• • Dependent = extremity below level of heart

Question 54

Reasons for documentation

Answer 54

(1) Required by LAW
(2) Know what you did
(3) Know whether treatment worked
(4) Decide how to change treatment based on response to previous treatment
(5) Communication with other health care providers and payers
(6) Adherence to clinic guidelines
(7) Research

NOTE: Documentation must be consistent with other providers so that all whose it can understand (only use accepted medical terminology and abbreviations)

Question 55

Process for evaluating if treatment was harmful

Answer 55

(1) Was harm caused? – YES –
(2) Was treatment applied correctly? – YES –
(3) Were parameters appropriate (e.g., settings)? – YES –
(4) Were patient instructions given and followed? – YES –
(5) Was it the right treatment? – NO –
NOTE: Go through these steps before eliminating treatment
– If answer YES to #1-4, then #5 is NO = toss treatment

Question 56

Process for evaluating if treatment was appropriate

Answer 56

(1) Were results good?
(2) Were results expected?
(3) Could results be better?
(4) How to enhance results?

NOTE: Even if results are positive, go through process to determine if treatment could do better (i.e., improve conditions and/or target impairment better)

Example: Patient with headaches may feel looser and more relaxed after massage (positive outcome), but treatment is not as good as it can be if headaches not relieved

Question 57

Process for treatment

• • Choice
• • Application
• • Evaluation

Answer 57

(1) Choice:
- - Choose appropriate treatment based on history and physical exam
- - Indicated
- - NOT contraindicated
(2) Application
- - Put patient in appropriate position
- - Patient comfortable
- - PT comfortable
- - Treatment area exposed and accessible
- - Equipment inspected and deemed safe before use
- - Educate patient (= informed consent)
(3) Evaluation
- - Document details so that it is repeatable
- - Procedure
- - Outcomes
- - Evaluate outcomes and reevaluate treatment

Question 58

Injury response stages

Answer 58

Inflammation (1-10 days) = materials delivered to site

• • Purposes:
  • • Gather materials for repair
  • • Defend body agains foreign substances (walls of edema)
  • • Decontaminate injured area
    • • Phagocytosis of bacteria and debris to prepare for repair
  • • Contain the effects of injury
• • Substages:
• • Vascular response
• • Hemostatic response
• • Cellular response
• • Immune response

Tissue repair:
– Proliferation (3-20 days) = build structure with cells

• • Remodeling (>9 days) = perfect structure
  • • Requires repeated breaking down and rebuilding process
  • • Length depends on extent of injury

NOTE: Overlap among stages (occur concurrently)

Question 59

Inflammation:

• • Vascular response
  • • Starling forces

Answer 59

– Arterioles vasoconstrict
– Short term response to prevent blood loss
– Margination
– WBCs line walls of capillaries (prepared for release)
– Arterioles vasodilate
– Increases blood flow to area
– Increases supply of WBCs, nutrients, and O2
– Increases capillary permeability
– Fluids and proteins leak into injured area
= EDEMA

Starling forces:

• • Pre-injury:
  • • Capillary hydrostatic pressure = Tissue oncotic pressure
  • • Flow out = Flow in
• • Post-injury:
  • • Tissue oncotic pressure&raquo_space; Capillary hydrostatic pressure
  • • Flow out&raquo_space; Flow in
    • • Due to excess proteins in interstitial tissue (draws fluid out of capillaries)
    • • Returned to circulation via lymphatic system

Question 60

Edema fluid types

Answer 60

Transudate
= First fluid to escape wound
– Primarily water
– Clear and low viscosity

Exudate
= Follows transudate
– Contains WBCs and proteins
– Thicker and cloudy

Pus
= Exudate with high WBC concentration
– Yellow indicates breakdown of bacteria

Question 61

Problems with edema

Answer 61

= May cause secondary injuries due to:

• • Ischemia = blocked blood flow
  • • Causes metabolic injury
    • • Decreased energy production
    • • Cell death due to hypoxia
• • Functional limitations
  • • Limited movement (e.g., reduced ROM of joints)
  • • Hygiene
• • Pain
  • • Chemical and mechanical stimulation of nocioceptors
• • Stimulates GTOs
  • • Inhibits muscle contraction
  • • Overtime causes muscle atrophy and loss of function

Question 62

Inflammation

• • Hemostatic response
  • • Purpose
  • • Process
  • • Problems

Answer 62

Purpose:
– Control blood loss from injured vessel

Process:

• • Small vessels retract and seal (ends come together)
• • Platelets create fibrin net in vessels
• • Fibrin net captures RBCs and other proteins to form clot

Problem:

• • Clot may form in damaged lymph vessels
  • • Blocks escape of proteins from interstitial area
  • • Creates HEMATOMA = collection of blood outside vessels inside tissue
  • • Same problems as edema (e.g., pain, metabolic injury, limited ROM)

Question 63

Inflammation

• • Cellular response
• • Immune response

Answer 63

Cellular response:
-- WBCs migrate to area
  -- Digest bacteria and debris
  -- Disintegrate
-- Disintegrated WBCs releases digestive enzymes 
  -- Act as chemotactic agents 
  -- Attract more WBCs and enzymes to site
= Pro-inflammatory 
  -- Perpetuates inflammatory cycle

Immune response:
– Enzymes attracted to area by bacterial toxins or immune complexes
– Body puts more WBCs into circulation
= Pro-inflammatory

Question 64

Cardinal signs of inflammation

Answer 64

• • Heat
  • • Increased blood flow
  • • Increased metabolism
• • Redness
  • • Increased blood flow
  • • Increased metabolism
  • • Histamine response
    • • Scratch test to localize primary site of inflammation (bright red spot)
• • Swelling
  • • Increased blood flow
  • • Capillary permeability
  • • Hemorrhage
  • • Blocked venous return
• • Pain
  • • Chemical and mechanical stimulation of nocioceptors
• • Loss of function
  • • Primary and secondary tissue damage
  • • Decreased ROM

Question 65

Chemical mediators of inflammation

• • Common agents
• • Purposes

Answer 65

Common agents:

• • Bradykinin
• • Histamine
• • Prostaglandin
• • Cytokines

Purposes:

• • Regulate response (turn on/off parts of process)
• • Signal body about cell damage
• • Facilitate removal of cell debris

Question 66

Normal resolution to inflammation

Answer 66

• • Chemical mediators dissolve clots
  • • Opens up blood and lymph vessels
    • • Fluid removed from tissues
      • • Edema resolved
• • No infection or cellular debris remains
• • Site is ready for repair
  • • Repair begins before inflammation phase finishes

Question 67

Tissue repair: Proliferation

• • Fibroplasia
• • Angiogenesis
• • Epithelialization
• • Granulation tissue
• • Wound contraction

Answer 67

1) Fibroplasia
– Fibroblasts produce collagen
– Fibers arranged in random orientation
2) Angiogenesis
= Revascularization
– Intact capillaries produce endothelial buds
– Buds form arch over site of damage on vessel
3) Epithelialization
– Epithelial cells at edges of wound proliferate
– Migrate across wound
– Migrate into wound
NOTE: Can be problematic for very deep wounds
4) Granulation tissue
– Collagen fibers laid down haphazardly
– Rapid response
– Disorganized
– Fills in from bottom of wound
5) Wound contraction
– Edges of wound at surface symmetrically contract over time
– Decreases size of wound
NOTE: Functional deficits occur due to wound contraction of large wounds and burn
– Reduces motion (expansion) available in skin
– Causes contractures
– Rigid scars over ribs may prevent breathing

Question 68

Tissue repair: Remodeling

• • Purpose
• • Process
• • Factors

Answer 68

Purpose:

• • Perfect rebuilt structure so that is functions properly
  • • AKA “maturation phase”

Process:

• • Formation of final scar tissue via collagen turnover:
  • • Collagen conversion = Type III to Type I
    • • Type III collagen
      • • Initially laid down (temporary filler)
      • • Weak, gelatinous, and disorganized web
    • • Type I collagen
      • • Stronger, fiber-like and linearly organized
      • • Greater tensile properties
  • • Four stages of scar formation: Collagen changes quality
      
      • • Deposition – Conversion/Wound contraction –
      • • Decreased remodeling – Mature scar
    • • Intervention most effective early on (i.e., stage 2), ineffective once scar matures

Factors:

• • Stimulus for conversion = STRESS (physical or tensile)
  • • Breakdown of old collagen ~ formation of new, well-organized collagen
  • • Lots of oxygen required for collagen cross linking
  • • Except for bone, scar tissue <70% as strong as original tissue
    • • If insufficient for function, otherwise compensation (other structures, altered function)
• • Local and systemic factors influence tissue repair
• • Nutrition
• • Age
• • Presence of other disease
• • Medications
• • Periods of immobilization (e.g., forced or voluntary; due to casting or pain)

Question 69

Excessive scar formation

• • Hypertrophic scar
• • Keloid

Answer 69

• • Hypertrophic scar
  • • Overproduction of TGF-B = accelerates collagen production
  • • Thick scar but doesn’t extend beyond borders
  • • Aesthetically unpleasant but functional
• • Keloid
  • • Overproduction of hyaluronic acid = stimulates fibroplasia
  • • Abnormal metabolism of melanocytes stimulating hormone
  • • Scar extends beyond border of wound
  • • Functionally limiting (limits ROM)

NOTE: Nature of scarring depends on variety of factors that differ among individuals

Question 70

Chronic inflammation

• • Definition
• • Characteristics

Answer 70

= Inflammation stage lasts too long after initial injury, interfering with tissue repair
– Distinct from recurrent inflammation secondary to repeated injury

Characteristics:

• • Lymphocytes and monocytes predominate
  • • Neutrophils predominate in acute inflammation
• • Lack some cardinal signs of inflammation (e.g., redness, heat)
  • • Often exhibits lack of function and pain
• • Excessive scar formation
• • Tissue degeneration

Question 71

Potential problems with inflammation

Answer 71

• • Inflammation stage lasts too long
  • • Continued breakdown interferes with rebuilding phases
  • • Hypoxia leads to secondary enzymatic metabolic injury
• • Hypoxia or other factors (local or systemic)
  • • Result in poor collagen quality (requires high amount of oxygen)

– Unprotected wound when fragile leads to re-injury

• • Inadequate stress during repair and remodeling
  • • Excess wound contraction (e.g., contractures, impaired ROM)
  • • Weak scar formed
• • Excess collagen formation due to continued stimulation of repair
  • • Abnormal scar

NOTE: Understanding each stage of repair is critical to timing intervention appropriately

• • Too soon: re-injure, impede repair and result in weak, abnormal scars
• • Too late: secondary injuries, excess wound contraction due to inadequate stress

Question 72

Pain pathways

• • Ascending
• • Descending

Answer 72

• • Ascending = Sensory afferent
    
    • • Anterolateral system
    • • Multiple parallel tracts carry pain signals
      • • Redundant (ipsilateral, contralateral, bilateral)
      • • Pain signal may be hard to get rid of
    • • Multiple synapses (spinal cord, brainstem, cerebellum)
    • • Opportunity to convert pain signal to other sensations
• • Descending = Motor efferent
  • • Run adjacent to ascending pain pathways
  • • Certain chemicals can inhibit synapses in pain pathway
    • • Endogenous opiates (endorphins)
    • • Neurotransmitters
  • • May block transmission of pain

Question 73

Peripheral sensory receptors

• • Nocioceptors
• • Non-nocioceptive

Answer 73

Nocioceptors = Pain receptors

• • C fibers = Small, unmyelinated, slow transmission
  • • Triggered by thermal, mechanical or chemical stress (polymodal)
  • • Diffuse, achy, nagging, burning, and hard to localize pain
• • A-Delta fibers = Larger, thinly myelinated, faster transmission
  • • Triggered by strong mechanical pressure or intense heat only
  • • Fast, bright, sharp, stabbing and localized pai
• • Both found in varying concentrations in different tissues, but present in most
• • Sensitive to repeated or prolonged stimulation
  • • Pain sensation may be disproportionate to extent of tissue damage
• • Stimulated by:
  • • Mechanical stress
  • • Chemical irritation
  • • Intense heat or cold

Non-nocioceptive receptors:

• • A-Beta fibers = low-intensity mechanical receptors (not pain)
  • • Large, myelinated, very fast transmission
  • • Sense light touch

Question 74

Gate control theory

• • Definition
• • Mechanism

Answer 74

Definition:

• • A non-painful stimulus can inhibit the transmission of a painful stimulus
• • At the spinal cord level

Mechanism:

• • Non-nocioceptive receptors stimulated concurrently with nocioceptors
• • Large diameter A-Beta receptors transmit signal faster to brain
• • Competes with pain perception coming from nocioceptors
  • • Non-nocioceptive signal “shuts gate” for pain signals
  • • Pain perception temporarily reduced
• • Gating occurs at T-cell and substantia gelatinosa (dorsal horn)
  • • Small and large fibers converge
  • • Large fibers inhibit T-cell (by facilitating SG)
  • • Small fibers decrease inhibition of T-cell (inhibit SG)
  • • T-cell gate determines which signal continues into spinal cord

Example: Rubbing sore spot temporarily reduces pain (perceive pressure instead)

Question 75

Chemical mediators of pain

• • Bradykinins
• • Prostaglandins
• • Substance P

Answer 75

Bradykinins:

• • Released by injured cells
• • Directly stimulates nocioceptors

Prostaglandins:

• • Synthesized after cell injury
• • Directly sensitize nocioceptors (lower threshold for stimulation)

Substance P:

• • Triggers vasodilation (influence release of other chemicals that cause pain)
• • Indirectly stimulates nocioceptors

Question 76

Types of pain:

• • Nociceptive
• • Non-nocioceptive

Answer 76

Nociceptive pain:
= Pain resulting from mechanical trauma, chemical irritation, or ischemia
– Local pain = due to local tissue damage
– Referred pain = perceived in location other than site of injury
– Trigger points
= points of localized muscle spasm that refer pain to distant sites

Non-nocioceptive pain:
– Peripheral neurogenic pain = Radicular pain (subset of referred pain)
– Central pain
= Perception of pain due to changes in CNS persisting after tissue has healed
– Affective pain
= Pain related to emotional or psychological stress
– May overlie or stem from other sources of pain (e.g., physical pain from injury)

Question 77

Pain-spasm cycle

• • Cause
• • Treatment

Answer 77

Cause:

• • Pain causes muscles to tighten and guard
  • • Spasm = low level increase in muscle tone overtime
• • Spasm prevens adequate oxygen delivery to muscle
• • Ischemia causes cell damage and death
• • Metabolites accumulate
• • Pain increases
• • Muscles spasm more

Treatment:

• • For some, cycle will resolve
• • For others, may need to break cycle:
  • • Reduce pain or reduce spasm
    • • Massage (mechanically break up spasm, increase blood flow)
    • • Pain medications or muscle relaxants
    • • Modalities to increase blood supply or relax muscle (heat, US)

Question 78

Pain perception

• • Pain threshold
• • Pain tolerance
• • Factors
  • • Gender
  • • Anxiety
  • • Peers
  • • Competition
  • • Placebo

Answer 78

Pain threshold = Stimulus (e.g., pressure) required for person to feel pain

Pain tolerance = Duration of pain person can endure

Factors:

• • Gender:
  • • Men have higher pain threshold and tolerance than women
  • • Women more likely to fear pain
  • • Unknown relative effects of social, psychological, cultural or physiological factors
• • Anxiety
  • • Anxious/fearful people have lower pain tolerance (not threshold)
  • • Past pain experiences may increase anxiety about experiencing pain
• • Peer pressure
• • Training and competition
• • Contact sports
• • Placebo effect
  • • NEVER UNDERESTIMATE power of placebo

Question 79

Pain assessment tools

Answer 79

• • 10 cm visual analog scale (VAS)
• • 10 point verbal rating scale (VRS)
• • Descriptors of pain quality
• • Observation of non-verbal cues
  • • Neonatal observation scales
• • Pediatric pain scales
  • • Pictures (e.g., Wong-Baker Faces Scale, Oucher scale)
• • McGill Pain Questionnaire
  • • Where (images of body)
  • • How much (VRS)
  • • Nature (descriptive words)

Question 80

Heat transfer mechanisms

• • Conduction
• • Convection
• • Evaporation
• • Radiation
• • Conversion

Answer 80

Conduction
= Direct contact between two objects with thermal gradient

Convection
= Movement of molecules (usually liquid or gas)

Evaporation
= Transfer of heat away from body due to conversion of liquid to gas
– Energy used in conversion of liquid to gas state

Radiation
= Transfer of electromagnetic energy without a medium

Conversion
= Conversion of one form of energy to another (can generate heat)

NOTE:

• • Cryotherapy involves removing heat via conduction, convection, or evaporation
• • Thermal modalities use conduction, convection, radiation, or conversion

Question 81

Rate of heat transfer by conduction

• • Thermal gradient
• • Thickness
• • Tissue type
• • Area

Answer 81

D = Rate of heat loss (degrees/min or cal/s)

D = (Area x k x (T1-T2))/Thickness

Area = Area of body surface cooled or heated
K = Coefficient related to tissue conductivity
– Adipose tissue is poor conductor
– Bone is poor conductor
– Fluid-rich tissues are good conductors (e.g., muscle, blood vessels)
T1-T2 = Thermal gradient between tissue and modality
– Certain modalities maintain gradient longer than others
Thickness = Thickness of tissue ~ Depth of target tissue

Question 82

Factors affecting degree and depth of cooling

Answer 82

– Rate of heat transfer
– Duration
– Longer duration causes deeper cooling
– Properties of cold source
– Latent heat of fusion = Energy required to change state
~ How long cold retained
– Higher latent heat = Remains cold for longer
– Specific heat = Energy required to increase temperature
~ How much heat absorbed
– Higher specific heat = Stays colder for longer

NOTE: Max depth of cooling = 4-5 cm (most tissues in body can be accessed)

Question 83

Rates of tissue cooling

• • Skin
• • Subcutaneous
• • Muscle

Answer 83

Skin:

• • Pre-cooling temperature ~ 85-86 degrees F
• • Drops drastically rapidly via conduction (to 80 degrees F)
• • Remains cold throughout treatment (plateaus < 30 min)

Subcutaneous:

• • Drops rapidly but less drastically than skin
• • Remains cold during treatment
• • Begins warming immediately after cold removed

Muscle:

• • Cools less rapidly (deeper) and less overall decline
• • Gradual decline during treatment
• • Continues to cool after cold removed
  • • Skin and subcutaneous remove heat from muscle to warm back up
  • • Vasoconstriction temporarily reduces amount of warm blood returned to muscles

Question 84

Intra-articular cooling

• • Duration of cold effects ~
  • • Degree of cooling
  • • Rate of rewarming
    • • Factors

Answer 84

• • Intra-articular temperatures decrease in predictable ratio to skin decrease
  • • Knee decreases by 6.5 degrees for every 10 degrees skin decreases
• • Duration ~ Degree of cooling and rate of rewarming
• • Rate of rewarming
  • • Depth of tissue
      
      • • Superficial tissues rewarm faster than deep structures
  • • Area cooled
      
      • • Smaller joints rewarm faster than large
  • • Distance from heart
  • • Type of tissue and activity
      
      • • Vascular tissue (e.g., muscle) rewarms faster with activity/exercise
          
          • • Before OR after cold application
          • • Increases blood flow to area
      • • Joints and ligaments do not rewarm with activity (avascular)
  • • Duration of treatment
    • • Predictable relation between duration of treatment and rewarming
      • • Longer duration, slower rewarming
      • • Deeper tissue cooling with longer application
      • • 30+ minutes may be better for acute care (rapid rewarming w/ 10-20 min)

Question 85

Tissue effects of temperature drop

Answer 85

General progression:
Relative reductions (2-13 degree decrease in skin temp)
– Decreased metabolism
– Decreased muscle spindle activity
– Decreased nerve conduction velocity (motor and sensory)

Absolute temperatures (68-32 degrees skin temp)
– Decreased acetylcholine (motor neurotransmitter)
– Lymph vessel constriction (~ 60 deg F skin)
– Still larger than constricted arterioles
– Helps reduce swelling
– Analgesia (~56-58 deg F skin)
– Maximum decrease in local blood flow (~57 deg F skin)
– Flow decreases immediately
– Levels off after ~13 min
NOTE: If person is numb, the have max decrease in blood flow

• • Increased risk of tissue damage (~55 deg F)
• • Decreased nerve conduction velocity by 10% (<55 deg F)
• • Decreased metabolism by 50% (<50 deg F)
• • Tissue death (32 degrees F)

Question 86

Cold effects:

• • Decreased cell metabolism
• • Vasoconstriction

Answer 86

Decreased metabolism:

• • Decreased oxygen and energy demand
  • • Reduces secondary metabolic injury and cell death
• • Decreased production of cell waste
  • • Reduces pain

= Decreases positive feedback loop of inflammation

Vasoconstriction (smooth muscle contraction)
– Decreased blood flow
– Decreased inflammation (decreased fever and WBCs)
– Decreased edema
– Decreased hemorrhage (maybe)
– Decreased pain
– Decreased mechanical stimulation of nocioceptors
– Decreased wound healing
– Increased peristalsis, gastric acids, and gastric blood flow
= Increased digestion
– Due to local placement of ice on abdomen

NOTE: Vasoconstriction can occur in contralateral limb due to systemic/neurovascular response

Question 87

Cold effects

• • Decreased nerve conduction velocity
• • Decreased muscle spindle activity
• • Decreased excitability of free nerve endings

Answer 87

Decreased nerve conduction velocity:
-- Decreased pain (analgesia)
-- Decreased muscle spasm
-- Decreased muscle strength
   -- Only while muscle is cooled
-- Slows reaction time
-- Slows movement velocity
NOTE: Proprioception intact just slower response 

Decreased muscle spindle activity:
– Decreased muscle spasm
– Decreased spasticity (excess tone)
– Decreased force production
– Decreased MVC during cold application
– Muscle performance impaired at 64 deg F (critical temp)
NOTE: Muscle strength increases after removal of cold

Decreased excitability of free nerve endings:

• • Decreased pain
  • • Increased threshold for stimulating nocioceptors

Question 88

Cold effects

• • Facilitation of motor unit
• • Redness
• • Joint and soft tissue stiffness

Answer 88

Facilitation of motor unit:
– Increase motor neuron excitability
– Decreased arthrogenic muscle inhibition (joint inhibits muscle)
NOTE: Opposite to effects of decreased muscle spindle activity
– Increased muscle strength
– After cold removed and temperatures return to baseline
– Higher strength than at baseline ~3 hr post-icing
NOTE: Clinically relevant to testing and risk of injury

Redness:

• • Hemoglobin carries more oxygen when cold
• • Reactive hyperemia (increased blood flow) when cold removed

Joint and soft tissue stiffness:
-- Decreased collagen elasticity
-- Decreased muscle power
-- Increased viscosity 
NOTE: May increase risk of stretch injury

Question 89

Systemic effects of cold

– Precautions

Answer 89

• • Drop in core temperature (0.2 deg F):
  • • Hypothalamus triggers responses that:
      (1) Minimizes heat loss in periphery
      - - Vasoconstriction –> Increase BP
      - - Decreased HR
      - - Decreased RR
      (2) Generate heat
      - - Increase muscle tone –> Increase metabolism
      - - Shivering –> Metabolic effect (reflex response)

Precautions:

• • Problematic for individuals with hypertension or circulatory diseases
• • Balance volume of tissue exposed with temperature and duration

Question 90

Cryotherapy

• • Indications
• • Contraindications

Answer 90

Indications

• • Pain
• • Muscle spasm
• • Spasticity
• • Acute inflammation
    
    • • Edema
    • • Metabolite accumulation
• • Hemorrhage

Contraindications

• • Arterial insufficiency = inadequate blood flow to periphery
  • • PVD, advanced diabetes
• • Hypersenstivity to cold = allergic reaction
  • • Flu-like symptoms (e.g., fever, chills)
  • • Wheals, hives, itching
  • • Anaphalaxis, irritated eyes and throat
• • Raynaud’s syndrome
  • • Vasospasm response to cold and stress
  • • Insufficient blood flow to distal extremities (pain and discoloration)
• • Open, uncovered wound (first 2-3 weeks)
  • • Decreases blood flow needed for healing
• • Cryoglobulinemia = serum proteins form gel in vessels
  • • Results in ischemia
• • Paroxysmal cold hemoglobinuria
  • • Lysed RBCs release hemoglobin

Question 91

Cryotherapy

• • Precautions
• • Special considerations

Answer 91

Precautions

• • Respiratory problems
• • Hypertension
• • Poor sensation
• • Superficial peripheral nerve damage (e.g., ulnar, peroneal)
  • • Neuropraxia = demyelination causes temporary loss of nerve function
  • • Axonotmesis = degeneration of axon due to prolonged pressure

Special considerations
– Frostbite
– Tissue death (32 deg F)
– Increased risk <55 deg F (long duration)
– Highest risk with gel packs and vapocoolant spray
– NO risk with crushed ice packs <60 min
– Analgesia
– Injury risk if active while numb
– Hunting response
– Cold-induced vasodilation
– Early theory that cold increased blood flow (restore homeostasis)
– Later determined blood flow changes not physiologically significant
– Small changes in flow do not negate cooling effect
= Applying cold does not cause warming

Question 92

Conductive cooling agents: Pros and cons

• • Ice bag
• • Ice towel
• • Gel pack
• • Ice cup

Answer 92

Ice towel:

• • Pros
  • • Cools tissue faster (wet surface)
  • • More comfortable initial contact
  • • Longer duration cooling than gel pack
  • • No risk of frostbite
• • Cons
  • • Wet bad for open wound
  • • Cannot reuse
  • • Messy

Ice bag

• • Pros
  • • Longer duration cooling than gel
  • • No risk of frostbite
  • • Dry is good for open wounds
• • Cons
  • • Cannot reuse

Gel pack:
– Pros
– Conformable
– Reusable
– Easy to set up
– Cons
– Shorter duration cooling effect (rewarms quickly)
– Superficial cooling only
NOTE: Ice cools more because it stays at freezing until it melts (phase change)
– Gel gradually and linearly warms
– Higher risk of frostbite (lower freezing temperature than ice)
– Place barrier between gel and skin
– Unable to cool to temps for decreased NCV, decreased metabolism or analgesia

Ice cup:

• • Pros
  • • Can combine with massage
  • • Good for small, irregular surfaces
  • • Interact with patient throughout treatment
  • • Longer duration (phase change) and faster cooling (pressure/contact)
• • Cons
  • • Not good for large area
  • • Time intensive

Question 93

Controlled cold units

• • Pros
• • Cons

Answer 93

Pros:

• • Easy application
• • Compression as well as cold
• • Long duration continuous cooling
• • Conforms well to body part
• • Can elevate limb while coolin
• • May be able to get intermittent compression
• • Some can maintain set temperature

Cons:

• • Expensive
• • May cause peripheral nerve damage (pressure plus cold)
• • Plastic barrier of sleeve limits cooling (50-77 deg F)
• • Only apply to extremities

Question 94

Ice plus compression

• • Benefits
• • Methods
  • • Most effective

Answer 94

Benefits:

• • Faster cooling
  • • Limits rewarming blood flow
  • • Increases conductivity (eliminates air)

Methods:

• • Commercial cuffs
  • • CryoCuff
  • • DuraKold
• • Plastic wrap w/ ice pack
• • Elastic wrap w/ ice pack

Most effective cooling:

• • Elastic wrap and ice (greater compression)
• • Compression over (rather than under) ice
• • Elastic wrap greater than plastic for intramuscular cooling
  • • No difference between plastic and elastic for skin cooling

NOTE: Differences in cooling may not have significant clinical effects

Question 95

Convective cooling agents

• • Ice bath
• • Cold whirlpool (CWP)

Answer 95

Pros:

• • Can perform ROM exercises while cooling
• • Great conformity/contact with tissues
• • Large volume, whole extremities or body

Cons:

• • Cannot elevate
• • Very uncomfortable (painful)

Ice bath:

• • Much colder (32-34 deg F)
  • • Shorter duration
  • • Smaller volume should be exposed
  • • Rapid cooling

Cold whirlpool

• • Less cold (50-65 deg F)
  • • Larger volume
  • • Longer duration

NOTE: Use neoprene toe and finger caps to make more tolerable

Question 96

Topical cooling agents

• • Vaspocoolant spray
• • Topical gel

Cooling garments

Answer 96

Vapocoolant spray:

• • Two types:
  • • Ethyl chloride
    • • Flammable, toxic, risk of frostbite
  • • Flourimethane
    • • Non-flammable, non-explosive, low risk of frostbite
    • • BUT has CFCs (not available)
• • Application:
  • • Apply slowly in parallel stripes over muscle
  • • Often used prior to or during passive stretch
• • Cooling effects:
  • • ~15 deg F decrease in SKIN temp (NOT subcutaneous)
  • • Temporary superficial temperature change (superficial sensory receptors)
• • Pain relief:
  • • Gating of sensory nocioceptors (thermal stimulus)
  • • Analgesia

Topical cold gel:

• • Creates perception of cold
  • • Neurovascular response by body
• • No or little change in tissue temperature
  • • Some skin receptors do respond to menthol
• • Reduced pain

Cooling garments:
– Manage heat-related disability (long duration in hot environments)
– Military
– MS patients
– Elite athletes
– Variety of shapes and sizes (e.g., vest)
– Effectively help maintain higher intensity exercise for longer
NOTE: Precooling can also be done just drinking cold water

Question 97

Thermotherapy indications

• • Superficial heat
• • Ultrasound
• • Diathermy

Answer 97

General thermal agents:

• • Pain
• • Muscle spasm or stiffness
• • Chronic inflammation
• • Chronic edema or hematoma
• • Joint stiffness or contracture

Ultrasound

• • Same as thermal but deeper (high intensity)
• • Bone healing (low intensity)
• • Soft tissue healing (low intensity) (?)
  • • Pro-inflammatory

Diathermy
– OA or synovitis (?)

Question 98

Thermotherapy contraindications

• • Superficial heat
• • Ultrasound
• • Diathermy

Answer 98

General thermal agents:

• • Vascular insufficiency (especially venous)
• • Acute inflammation or injury
• • Over infection
• • Over malignancy or tumor
• • Where topical heat agents recently applied

Ultrasound: Same as thermal plus --
Directly over --
-- Electrical implants (e.g., pacemaker)
-- Unprotected spinal cord
-- Anterolateral neck (cervical ganglia, carotid sinus, vagus nerve)
-- Plastic implants
-- Blood clot
-- Pregnant uterus
-- Testes, eyes, heart
-- Unfused epiphysis (adolescents - teens)

Diathermy: Same as US plus -- 
Directly over -- 
-- Moist wound dressings
-- Metal implants
NOT
-- Electrical implants (e.g., pacemaker)
-- Unprotected spinal cord
-- Anterolateral neck (cervical ganglia, carotid sinus, vagus nerve)
-- Plastic implants