week 1 Flashcards
Pathology
study of structural changes in body fluids, cells, tissues and organs
Physiology
study of mechanical, physical and biochemical functions of living organisms
Pathophysiology
study of abnormalities in physiologic functioning of living beings. To examine disturbances of normal mechanical, physical and biochemical functions either caused by a disease or resulting from a disease or abnormal syndrome or condition
Aetiology
causes of disease
Pathogenesis
development of disease
Clinical manifestations
signs and symptoms
Epidemiology
study of disease occurrence, patterns and distribution in human populations
What is Heat Therapy?
Heat therapy, or thermotherapy, has been used for centuries to manage pain and aid recovery.
Contact Heating Methods:
Hot packs and pads used for localised heating to relieve pain
Paraffin Wax Baths
Effective for arthritis and joint stiffness
Hydrotherapy
Warm water immersion for muscle relaxation
how does Heat Therapy work
- vasodilation to supply the site with O2 and nutrients
- rate of local tissue metabolism- increased by which warming promotes healing
- Pain Modulation: Heat activates Transient Receptor Potential (TRP) channels, which block pain signals.
- Connective Tissue Effects: Enhances collagen extensibility, making tissues more flexible
- Muscle Relaxation: Heat lowers nerve sensitivity, reducing spasms & stiffness
Heat Therapy in sports PRIOR to game/ training
Prepares muscles for movement by increasing tissue elasticity & blood flow.
Heat Therapy in sports AFTER to game/ training
Promotes faster recovery by removing waste products and enhancing glycogen resynthesis.
Heat Therapy in sports in recovery/ injury prevention
Regular heat therapy can reduce muscle damage & stiffness.
Heat Therapy in clinical practice/ recommended for conditions including
Knee osteoarthritis
Low back pain
Delayed Onset Muscle Soreness
methods of heat transfer
convection, conduction, radiation
Possible Physiological Effects of Heat
a) Local heating of tissues
b) Vascular effects
c) Metabolic reactions
d) Neuromuscular effects
e) Connective tissue effects
f ) Effects on viscosity
Metabolic Effects of heat
rate of chemical reactions increase w temp. this causes an O2 uptake increase and metabolic waste products increase
Neuromuscular Effects of heat therapy
Increased nerve conduction velocity with increase tissue temperature
Afferent nerves stimulated by heat may have an analgesic effect by acting on the “pain gate” mechanism
* Reduction of Pain
* Relaxation of muscle spasm
Connective Tissue
Effects from heat therapy
Extensibility of collagen tissue has been shown to increase with heat application if simultaneously stretched
Effects on Viscosity from heat therapy
- Raising the temperature of
liquids lowers their viscosity - Influences lymph, blood and joint fluid
Therapeutic Uses of Heat
- Relief of pain
- Relief of muscle spasm
- Increase in joint range of
movement - Lengthening of scar tissue
- Sedation/relaxation
- Resolution of chronic
inflammation
Superficial Heating examples
- hot packs
- wax baths
- infrared lamps
- most forms of superficial
heat application are
conductive - heat is transferred from
warmer to cooler by
conduction
Deep Heating examples
- ultrasound
- shortwave diathermy (SWD)
- microwave diathermy
- occurs by conversion of another form of energy to heat
- e.g.: energy in ultrasound waves produce heat in deeper tissues
what are Hot Packs
- Provide a superficial moist heat
- Stored in a thermostatically controlled hydrocollator
- Wrap in 2-4 layers of towel for insulation before applying to the patient
what are hot packs advantages
- Ease of preparation and application
- Variety of shapes and sizes
- Moist, comfortable heat
- Relatively inexpensive
what are hot packs disadvantages
- No method of temperature control once applied to patient
- Do not conform to all body parts
- Can be awkward to secure
- Only retain heat for approx.20 minutes
- Passive treatment
- May be too heavy
- Hot water hazard and spillages
what are Paraffin Wax
- Efficient source of superficial heat due to its low melting point
- Liquid state allows even
distribution of wax - Often used in treatment of
rheumatoid arthritis (RA)
what are the paraffin wax advantages
- Even distribution
- Adds moisture to skin
- Can be used as exercise tool after treatment
- Comfortable moist heat
- Relatively inexpensive
what are the paraffin wax disadvantages
- Can only be used for
distal extremities (hands
and feet) - No method of
temperature control once
applied to the patient - Only retains heat for
approx. 20 minutes
Guidelines for safe application
a) Contraindications and Precautions
b) Skin Tests
c) Warnings given
d) Monitoring during and after
contraindications to heat therapy
- Circulatory insufficiency
- Risk of dissemination
- Exacerbation of existing conditions
- To eyes or testes
- Broken skin
- DO NOT apply over transdermal drug patches or implants as may increase
absorption of the drug which can be fatal
(Fentanyl)
Deep Vein Thrombosis (DVT): Heat application over an area with DVT could dislodge a thrombus, leading to a life-threatening embolism.
Local Infection: Heat can exacerbate infection and promote bacterial growth in cases such as abscesses, osteomyelitis and septic arthritis
Malignancy: Heat therapy can increase circulation, potentially accelerating cancer growth if applied near a tumour
Severely Impaired Circulation: Heating ischaemic tissue could exacerbate tissue breakdown or cause burns due to impaired heat dissipation.
Pregnancy: Whole-body heating is dangerous during pregnancy, and local heat (trunk, abdomen, pelvis) should be avoided over the foetal area
Recently Radiated Tissue: Heat is contraindicated to an area if it has received radiation. Tissues may respond inadequately due to ‘tissue devitalisation’ for 3–6 months post radiotherapy
Acute inflammatory skin disorders such as eczema and dermatitis as heat can exacerbate these conditions
Inbuilt stimulators or metal implants: e.g., pacemakers is a CI in first 4 weeks of insertion
precautions to heat therapy
- Care using in conjunction with other modalities
- Care if lying a patient on heat pack
- May need more towels in
application
Metal Implants: Metal can concentrate heat, raising the risk of burns if heated
Epilepsy: Though not directly contraindicated, practitioners should be cautious as thermal interventions may have unknown effects
Photosensitivity: Some skin conditions and medications cause increased sensitivity to heat and UV exposure
Over Open Wounds: Heat can delay wound healing and cause discomfort
Skin Tests: Thermal Sensitivity Test
- Tests the patient’s ability to discriminate hot from cold at the area to be treated
- Done for ALL heat applications
- Demonstrate on a non-affected area first
- Typical items used are test tubes filled with warm and cool water
- Care for spillages and dry or change linen immediately
- Record the outcome
verbal Warning for a Heat Treatment
When having a heat treatment all you should feel is a mild, even, comfortable warmth.
If you feel any more than this, or if heat concentrates in any particular spot or it starts to feel uncomfortable,
please call me immediately otherwise you may be in danger of being burned. Please do not move or touch
any of the equipment during the treatment.
Do you understand this warning?
Do you have any questions?
Are you happy to proceed?
Monitoring heat application during
For hot packs, check skin
immediately after application and
again after 8 minutes and
regularly thereafter
* Observe skin and ask patient
regarding the temperature of the
pack
* Look for even erythema,
* Should be NO concentration of
the sensation of heat
* Bell/buzzer with patient
Monitoring heat application after
- Skin should be a nice
even erythema after
the application - Clean up immediately
What is Cryotherapy?
Cryotherapy is the use of cold to treat injuries,
Types of Cryotherapy
Ice packs, gel packs
Cold Water Immersion
cryotherapy in relation to Pain Relief (Hypoalgesia):
Reduces nerve conduction velocity, lowering pain perception.
Blocks pain signals via mechanisms like the pain gate theory
cryotherapy in relation to :Blood Flow Changes (Haemodynamics):
Constricts blood vessels, reducing blood flow and inflammation
Effects are greater in superficial tissues than deep muscles
cryotherapy in relation to : Inflammation Reduction
Lowers white blood cell activity, reducing inflammation and tissue damage
Minimises oxidative stress, preventing unnecessary tissue damage
cryotherapy in relation to Prevention of Secondary Injury:
Slows metabolism around the injury, limiting cell death and promoting healing
Physiological Changes Due to Cooling
- Decreased skin temperature
- Decreased muscle temperature
- Decreased intra-articular temperature
- Changes in blood flow
- Decreased tissue metabolic rate
- Decrease in nerve conduction velocity
rapid locally and gradual deeper
Changes in Blood Flow (Skin) bc of cryotherapy
- Blood flow decreases immediately during the first minutes of cold application
due to vasoconstriction - Autonomic nervous system response triggered by stimulation of thermal
receptors in skin - Increased blood viscosity and reduced blood flow
- Reduced heat conduction to skin
- After 5-10 minutes vasoconstriction gives way to vasodilation
- This may last 15 minutes before being replaced by another episode of
vasoconstriction
Changes to Blood Flow (Muscle) bc of cryotherapy
- Response in muscle to cooling is less dramatic
- Decreased blood flow
- Vasoconstriction
- Increased viscosity of blood
Reduced Metabolic Reactions bc of cryotherapy
- Metabolism is a series of chemical reactions
- Cooling tissue will reduce the rate of these chemical reactions (Van’t Hoff’s Law)
- Opposite to heating tissue
- Limits likelihood of ischemia (secondary cell hypoxic damage)
Decrease in nerve conduction velocity bc of cryotherapy
- All nerve fibres are not equally affected by cooling
- Myelinated nerves and smaller diameter fibres most affected
- Smaller type A fibres are most affected
- Fast pain, mechanoreceptors, cold receptors
- C fibres (unmyelinated) are least affected
- Chronic pain
- Reduced motor skill
- Reduced motor nerve conduction of afferent feedback
Proposed Therapeutic Uses of Cold
- Relief of pain
- Treatment of acute injury
- Secondary cell hypoxia
- Effects on motor system
- Relief of muscle spasm
- Treatment of oedema
- Treatment of chronic inflammatory conditions
Relief of Pain from cryotherapy
- Decreased conduction
velocity of pain receptors and neurons - Decreased release of pain-
inducing irritants - Release of endorphins and
encephalins - Also reduction of muscle
spasm
Treatment of Acute
Injury cryotherapy
- Immediate application of cold minimizes the extent of soft tissue damage (secondary cell hypoxia) and bleeding
- Decreased metabolism
- Decreasing the inflammatory response may limit oedema formation
cryotherapy Effects on Motor system
- Long applications of ice reduces muscle strength
- Short applications increase
isometric muscle strength - Reduced motor skills &
coordination - Due to slowed nerve
conduction
Reducing muscle
spasm cryotherapy
- Reducing pain helps to
reduce muscle spasm - Reducing muscle spasm
allows increased range of
movement
cryotherapy Treatment of Oedema
No indication that isolated use of ice alone increases function, reduces swelling and pain in acute LAS
* Cryotherapy and exercise,
greater effect on reducing
swelling compared to heat
cryotherapy Treatment of Chronic Inflammatory
Conditions
Cryotherapy may be
beneficial in these
conditions by relieving
pain
May also have a role in
the management of acute
inflammatory flare ups
Local Immersion
- Involves placing part in mixture of cold water and flaked ice
- Temperature can be controlled by varying the amount of ice that is added
Cold Packs
- Self made using towel and ice flakes
- Commercial cold packs
- Commercial cold packs may be colder than ordinary ice packs
- Potential to cause ice burns
- Need to wrap in towel before application
- Cold packs are applied for approximately 10-15 minutes (depth of target tissue)
Ice Towels
- Towel placed in a mix of water and flaked ice and wrung out
- Ice flakes will adhere to the cloth of the towel.
Ice Massage
*Uses blocks of ice for direct massage
*Ice is kept moving over the body part
Cold Compression Units (e.g. Cryocuff)
- Cold water is applied to body parts via a sleeve which introduces compression at the same time as cooling.
- Often used after orthopaedic surgery
Excessive Local Cold on Normal Tissue consequences
- Can result in an ice burn
- This is characterised by erythema and skin
tenderness a few hours after treatment. - Cryotherapy can also cause injury to superficial
peripheral nerves
Contraindications to cryotherapy
- Circulatory insufficiency
- Exacerbation of pre-existing
conditions - Cold sensitivity ( e.g.
Raynaud’s) - Cold urticaria
- Cryoglobulinemia
- Regions treated within 3-6
months by radiotherapy - Severe organ states
Cold Hypersensitivity (Cold Urticaria): Can cause severe allergic reactions, including anaphylaxis
Cryoglobulinemia: Cold exposure can lead to increased blood viscosity, causing blockages in small blood vessels
Raynaud’s Disease/Phenomenon
pregnancy
Precautions to cryotherapy
- Unable to communicate
- Sensory loss
- Note:
- Extreme care required
when icing near superficial
nerve, neuropraxia can be
a consequence
Local Infection: While cryotherapy is generally safe, care should be taken when applied near infected tissue
Recently Radiated Tissue: Radiated tissue may have altered circulation and sensation, increasing the risk of adverse reactions
Monitoring During and After cryotherapy
- Cold feeling is noted very quickly
- This is followed by burning/aching pain at around 2-7 minutes
- Local anaesthesia/analgesia occurs at 5-12 minutes
- Check after 5 minutes of application
- Even redness during and after application
- Shouldn’t be uneven/mottling of skin
- Leave bell/buzzer with client
cryotherapy Warning and Informed Consent
- This is an ice treatment. You will feel gradually increasing cold, which
may be followed by a period of discomfort. The area should then go
numb. If you feel any extreme discomfort or pain you must call me
immediately as there is a danger of an ice burn. Please do not
move or touch any of the equipment during treatment. - Do you understand?
- Do you have any questions?
- Are you happy for me to proceed with treatment?
Muscle Injuries
One of the most common injuries in sport
10% - 55% incidence
Types of acute injuries
Contusion
Strain/tear
Chronic/Overuse injuries
Focal thickening/fibrosis
Compartment syndrome
DOMS
Cramps?
Muscle contusion
A muscle contusion usually occurs when a muscle is
subject to a sudden, heavy compressive force, e.g.
direct blow to the muscle Overlying skin remains intact
Muscle contusion - haemotoma
Muscle compression causes muscle fibre damage and rupture of microvessels
A large area of local hemorrhage (bleeding) is called a haematoma
Triggers an acute inflammatory
response to remove the damaged
tissue and initiating repair
Pain results from accumulating
blood exerting pressure on nerve
endings
Pain increases with movement or with pressure to area
IntrAmuscular hematoma
extravasation of blood
within intact muscle fascia results in increased intramuscular pressure, subsequently compresses & limits size of hematoma but can cause acute compartment syndrome.
IntERmuscular hematoma
develops if fascia
surrounding muscle is torn & extravasated blood has
access to spread into interstitial & interfascial spaces
Hematoma Complication: myositis ossificans, what is it
Occurs when hematoma calcifies within the muscle approx 3 wks post injury
Osteoblasts replace some of the fibroblasts in healing process
Hematoma Complication: myositis ossificans, what can cause it
rebleed,
inappropriate treatment eg heat or massage
In case of thigh: knee effusion present, prone knee flexion < 45°
Hematoma Complication: myositis ossificans, what are the signs
Don’t improve in expected time frame
Improvements cease with subsequent deterioration
Ongoing signs of inflammation
Increase in morning pain & pain with activity
Night pain
Palpable lump
what is a Muscle strain / tear
A muscle is strained or torn when some or all of
the fibres fail to cope with the demands placed
upon them e.g. excessive tensile force. it can be common in 2 jt muscles and during deceleration.
mild muscle strain 1st degree
Minor swelling
Minor discomfort
No or minimal loss of
strength
No or minimal
restriction of movement
Represents tear of few
fibres
moderate muscle strain 2nd degree
Significant swelling
Significant discomfort,
Pain on contraction
Loss of strength
Restriction to
movement
Represents tear of
significant number of
muscle fibres
severe muscle strain 3rd degree
Complete tear of muscle,
Virtually complete loss of muscle function
Pathobiology of muscle injury
Skeletal muscle healing is a repair process (in contrast to bone which regenerates)
Heals with a scar which replaces the original tissue
3 phases of repair
- Inflammation (Destruction phase)
- Proliferation (Repair phase)
- Maturational (Remodelling phase)
Healing of skeletal muscle from initial trauma
Initial trauma
Ruptured myofibres contract
Hematoma fills gap between myofibre stumps
Chronic/Overuse Muscle Injury examples
Focal tissue thickening/fibrosis
Compartment syndrome
Delayed onset muscle soreness (DOMS)
Focal thickening/fibrosis
Repetitive microtrauma caused
by overuse damages muscle
fibres
Leads to adhesions between
muscle fibres & formation of
cross-linkages in fascia
Palpated as firm, taut,
thickened bands arranged in
the direction of stress
May present as large areas of
increased muscle tone &
thickening
Compartment Syndrome
Exercise raises
intracompartmental pressure & vicious cycle occurs
Muscle hypertrophy may be precipitation factor
Signs
- Pain commences during
activity, ceases with rest
(does not ‘warm up’)
Diagnosis may involve compartment pressure testing
Muscle soreness (DOMS)
Develops 24-48 hours after unaccustomed physical activity
Often more severe after eccentric exercise e.g. downhill running
Etiology unclear, theories proposed include:
Lactic acid
Muscle spasm
Torn tissue
Connective tissue
Enzyme efflux
Tissue fluid
Muscle cramps
A muscle cramp is a painful, involuntary muscle contraction that occurs suddenly & can be temporarily debilitating.
Current theory: related to abnormal neuromuscular
control at a spinal level in response to fatigue during or imediately after exercise
what is Tendinopathy 3 stages
3 stages of tendinopathy
Reactive, disrepair, degenerative
Degenerative = Collagen
degeneration (disarray &
separation)
Increased mucoid ground
substance
Increased cells and vascular
spaces +/-neovascularization
Absent inflammatory cells
tendinopathy signs
Pain sometime after exercise
(next day)
Painful at rest, ‘warms up’ with
use, then worsens in cool down
Local tenderness & thickening
Swelling or crepitus may be
present
Tendinitis
inflammation of the tendon
paratenonitis is
inflammation of outer layer of tendon, occurs when tendon rubs of bony prmoinces
signs and symptoms of paratenonitis
Acute oedema & hyperaemia
Infiltration of inflammatory cells
Rare occurrence
Signs
- Crepitus (due to fibrinous
exudate filling tendon
sheath)
Difficult to differentiate
from tendinosis
Tendon tear signs
Sudden onset of pain
Localised tenderness
generally occurs at a site of least blood supply
Tendon Healing- 3 phases of repair
Inflammation (Destruction phase)
- Necrosis predominates
- Tenocytes migrate to area
Proliferation (Repair phase)
- Synthesis of collagen
Maturational (Remodelling phase)
- Repair tissue changes from
cellular to fibrous
- Alignment of collagen fibres in direction of stress
Ligament injuries occurs when
abnormal or excessive movement
of the joint.
grade 1 of ligament sprain
stretched fibres but normal ROM on stressing ligament
grade 2 of a ligament sprain
considerable proportion
of fibres torn, stressing of
ligament reveals increased
laxity, but definite end point
grade 3 of a ligament sprain
complete tear of ligament with excessive joint laxity and no end
point (be wary using pain as guide)
Ligament healing
Initially hemostasis activated & fibrin clot formed
then inflam response
Formation of new tissue
Remodelling
properties of scar
Collagen disorganised
Smaller collagen fibres
Immature cross-links
Closed (simple) fractures
The skin remains intact over the fracture site
Open (compound) fractures
The fractured bone disrupts skin integrity, creating a potential pathway for infection
manifestation of fractures
pain, tenderness, swelling loss of function, nerve function loss, deformity of long bones, blood loss
fracture objectives for treatment
reduction- restoration of a fractured bone to its normal postion
immobilisation- prevents movement
preservation- rehab exercises to restore function
fibrocartligous callus formation in bone healing
capillaries continue to develop, tissue develops into granulation tissue, fibroblast produce a fibrocartilgous soft callus bridge (not strong enough to WB)
Greenstick fractures
Occur when one side of the bone buckles while the opposite side fractures under tensile stress
Torus (buckle) fractures
Result from axial compressive loading, causing circumferential cortical bulging
Growth plate (physeal) fractures
Vulnerable sites in children and adolescents, commonly presenting as avulsion fractures when excessive tensile forces detach a portion of bone at the tendon or ligament insertion
imparied healing bc of bone
malunion (inadequate alignment), delayed union (not in normal time frame), nonunion (failure for bone repair)
Bone Healing Process
Haematoma Formation: Blood collects at the fracture site
Fibrocartilaginous Callus Formation: Soft callus develops within a week
Ossification: The soft callus is replaced by hard bone over several months
Remodelling: The bone is reshaped to its original form, which may take years
later complications of fractures
Avascular Necrosis: Loss of blood supply leading to bone death
Chronic Pain: Persistent discomfort post-healing
Malunion: Abnormal healing alignment leading to secondary complications (e.g., osteoarthritis)
Soft tissue injuries – Ligament, muscle, or tendon damage may result in long-term functional impairment.
Early Complications of fractures
Compartment Syndrome: Increased pressure within muscle compartments
Infection: Especially in open fractures
Acute compartment syndrome
Neurovascular injury
Deep vein thrombosis (DVT) / pulmonary embolism (PE)
