Week 1 Flashcards
What are physical agents?
-Energy and material applied to patients to assist in rehabilitation Include: Heat Cold Water Pressure Sound Electromagnetic radiation Electrical currents
Thermal
- Transfer energy to a patient to increase or decrease tissue temp
- Can be superficial or deep
- Decrease inflammation, increase blood flow, effect pain in someway, increase elasticity of tissue, change nerve conduction velocity
- Ex:Hot packs, Cold packs, US, Whirlpool or Diathermy
Mechanical
- Applies force to either increase [break scar tissue, change blood flow or lymph flow] or decrease [compression forces, discs, spine, nerves] pressure on the body
- Ex: Water, Traction, Compression and Sound
Electromagnetic
- Applies energy via electromagnetic radiation or an electrical current
- Examples: UV radiation, infrared, laser, diathermy, and electrical stimulation
History
Long History of Use:
Ancient Romans & Greeks
Electrical torpedo fish, amber
Sunlight
Changes in use…
- Ineffective: IR lamps for wounds – dried out
- Inefficient: Sunlight for Tuberculosis
- Cumbersome: Diathermy
- Excessive risks: Diathermy
Can modalities be used alone?
NO
Eval/Planning for the Use of Physical Agents
- Dr referral as needed
- Medical diagnosis
- Precautions/Contraindications
Documentation
- Agents used
- Area of body treated
- Pt position during treatment
- Intervention duration
- Parameters
- Outcomes including progress towards goals
- Regressions or complications
- Want someone to repeat tx
Precautions
- Restrictions on the use of a particular treatment interventions
- Conditions under which a particular form of treatment should be applied with special care or limitations
Relative
Contraindications
-Restrictions on the use of a particular treatment interventions
Conditions under which a particular treatment should NOT be applied
Absolute
Pregnancy
Contraindications/Precautions
- If the energy produced by the agent may reach the fetus
- -Fetal development
- -Effects unknown
Malignancy Contraindications/Precautions
- If the energy produced may reach the malignancy or alter the circulation
- -Accelerate growth or metastasis of malignant tissue
- -Increase circulation & alter cellular function
Pacemaker or other implanted device Contraindications/Precautions
When energy produced can reach the device and alter the function of theses devices
Impaired Sensation or Mentation Contraindications/Precautions
- End limit is pt’s report of how it “feels”
- If pt can not feel or report sensation accurately application is not safe.
Selection of Physical Agents
- Goals/Effects of Tx
- Contraindications/Precautions
- Evidence for Phy. Agent use
- Cost, convenience, & availability
Quality Research
- Pt/Pop: Question should apply to a specific population
- Intervention: Specific
- Comparison: Control
- Outcome: Defined as precisely as possible
Effects of Physical Agents
- modification of tissue inflammation and helaing
- relief of pain
- modification of muscle tone
- alteration of collagen extensibility and motion restiction
Inflammation and Tissue Repair Goal
Restore function by eliminating the pathological or physical insult, replacing the damaged or destroyed tissue, and promote regeneration of normal tissue structure
Inflammation and Repair Phases
-The body’s first response to tissue damage, characterized by heat, redness, swelling, pain and often loss of function
- Inflammation (1-6 days) -can last up to 2 wks
- Proliferation (3-20 days)-can last 6-8 wks
- Maturation (day 9 and on) -can last up to 2 yrs depending on tissue
What happens in the inflammation phase?
- Vasoconstriction
- Vasodilation
- Clot formation
- Phagocytosis
What happens in the prolifteration phase?
- Epithelialization [epithelial cells start to reform]
- Collagen production
- Wound contracture
- Neovascularization
What happens in the maturation phase?
- collagen synthesis/lysis balance
- collagen fiber organization
5 Cardinal signs of inflammation
- Heat: increased vascularity
- Redness: increased vascularity
- Swelling: blockage of lymphatic drainage
- Pain: physical pressure or chemical irritation or pain-sensitive structures
- Loss of function: pain & swelling
Vascular Response
- Vasoconstriction followed by vasodilation at the capillaries, postcapillary venules & lymphatics
- -Vasodilation mediated by chemical mediators
- Leukocyte Extravasation
- -Movement out of the circulatory system and towards the site of tissue damage or infection
- Accumulation of fluid in the interstitial tissue (outside the vessels) -> edema
Hemostatic Response
- Controls blood loss when vessels are damaged or ruptured.
- Retracts & sealing off of blood vessels
- Platelets form clots and assist in building of fibrin lattice, which serves as wound’s source of tensile strength
Cellular Response
Phagocytosis
Monocytes
Macrophages
Resident Macrophages
Phagocytosis
Neutrophils rid the injury site of bacteria and debris
24 hrs then disintegrate
Monocytes
Predominate for 24-48 hrs
Convert to macrophages when they migrate from capillaries into the tissue spaces
Macrophages
- Most important cell in inflammation
- Produce while range of chemicals
- -Facilitate the removal of necrotic tissue and bacteria
- -Promote cell proliferation
- -Influence the number of fibroblastic repair cells
-Most effective when oxygen is present.
Proliferation (3-20 Days)
-Purpose is to cover the wound and regain some of it’s initial strength.
-Clinical signs:
Granulation tissue is generated which is characterized by red, beefy, shiny tissue with a granular appearance
Wound begins to fill
-At the Cellular level: Cell activity consists of macrophages-stimulated collagen synthesis, capillary formation, wound contraction & wound epithelialization
Epithelialization
The reestablishment of the epidermis
Early with superficial wound
Later with deeper injury
After collagen production and neovascularizatio
Components Involved in Tissue Healing
Fibronectin
Proteoglycans
Elastin
Collagen
Fibronectin
Tensile strength
“Glue” substances together
Proteoglycans
- Secreted by fibroblasts early in tissue repair
- Bind to fibronectin and collagen and help stabilize tissue
- Retain water to assist in hydration
Elastin
Protein that is cross-linked to provide elasticity
Collagen
- Most important protein, provides structural support and tensile strength
- 3 chains of amino acids coiled around each other in a triple helix
- 27 types identified
Collagen Production
-Fibroblasts make collagen
-Fibroblasts migrate to the injured area and fibroplasia (fibroblast growth) occurs
Fibroblast initially produce type III collagen
-Thin, weak, & no consistent organization.
By day 12, immature type III starts to be replaced by type I which is more mature & strong.
-During proliferation the injured area has the greatest amount of collagen, yet it can be as low as 15% normal tensile strength.
Wound Contraction
-Pulls the edges of the injured site together and in effect shrinks the defect
-Begins at day 5 & peaks at 2 weeks
-Myofibroblasts are primary cells responsible
-Speed of contraction:
Linear > Square/rectangular > circular
Neovascularization
- Development of new blood supply or the growth of new vessels = angiogenesis
- Healing cannot occur without it: Supplies oxygen and nutrients to injured/healing tissue
- Forms capillary loops: Gives scar it’s pinkish to bright red hue
- These loops cease as the wound heals leading to more mature scars [Whitish appearance]
Maturation
- Day 9 up to 2 years
- Clinical Signs: Shrinking and thinning of scar and loss of redness
- At the Cellular level: The collagen fibers remodel, mature, and gain tensile strength
Superficial heating agents
- Increase temperature of the skin
- Increase temperature if superficial subcutaneous tissues
Deep heating agents
- Increase temperature of deeper tissues
- Large muscles, periarticular structures
- Approx. 5 cm
Specific Heat
- Amount of energy required to raise the temp of a given weight of material by a given number of degrees
- The higher the specific heat the more energy required to heat
- Water: 4.19 (highest)
- Air: 1.01 (lowest)
Conduction
Materials of different temp that are in direct contact with each other
-Ex: Hot pack, paraffin, ice pack
Convection
Direct contact between a circulating medium and another material of a different temperature
-Ex: Whirlpool, fluidotherapy
Conversion
Conversion of nonthermal form of energy (such as mechanical, electrical or chemical) into heat
-Ex: Ultrasound, Disthermy
Radiation
Direct transfer of energy from a material with a higher temperature without the need for a intervening medium or contact
-Ex: infrared lamps, ultraviolet
Evaporation
Material must absorb energy evaporate and thus change form from a liquid to a gas or vapor
-Ex: Vapocoolant
Hemodynamic effects of cold
- Initial decrease in blood flow:
- -Vasoconstriction-protect the body, don’t want to spread the cold
- -Reduced release of vasodilator mediators: Histamine & prostaglandins
- -15-20 min
- -Increased viscosity/lower blood flow: 2 x 10 min application > 1 for 20 min
- Later increase in blood flow:
- -Tissue temp < 10 deg or > –15-20 min
- -“Hunting Response”: Greater in distal extremities
- -> 15 min not recommended where vasodilation needs to be avoided
Neuromuscular effects of cold
- Decrease nerve conduction velocity [A-delta fibers most effected]
- Increased pain threshold
- Altered muscle strength
- -Increased (5 min ice massage or less)
- -Decreased (30 min or longer)
- -Increases beyond precooling following 3 hrs
- Decreased spasticity
- -Decreased gamma motor neuron activity
- -Decrease afferent spindle and GTO activity
- -Can last 1-1.5 hours post application
- Facilitation of muscle contraction: Brief application facilitates alpha motor neuron activity in flaccid muscle due to UMN lesion
Metabolic Effects of cold
Decreased metabolic rate – good for acute inflammation but not so much for healing.
Uses of Cryotherapy
-Inflammation control [acute injury]
-Edema control [best with compression and elevation-RICE]
Reduce pain
-Modification of spasticity
-Symptom management in MS
-Facilitation: Quick Icing
-Cryokinetics: numb and strengthen in hot places
-Cyrostretch: reduce spasm to increase ROM
Contraindications of Cryotherapy
- Cold hypersensitivity
- Cold intolerance
- Cryoglubulinemia: Rare, gel impairs circulation leading to ischemeia and gangrene
- Paroxymal cold hemoglobinuria [pee blood after]
- Raynaud’s disease
- Over regenerating peripheral nerves
- Over an area with circulatory compromise or peripheral vascular disease [not the swelling we wanna get rid of]
Precautions with Cryotherapy
- Over superficial branch of nerve
- -Discontinue if distal numbness/tingling occur
- -Nerve conduction block
- Over an open wound: Delays wound healing by reducing circulation and metabolic rate
- Hypertension: Can increase systolic or diastolic BP
- Poor sensation or poor mentation
- Very old or very young patients: Impaired thermal regulation or communication
Adverse Effects of Cryotherapy
-Tissue death cause from prolonged vasoconstriction, ischemia, and thrombosis in the smaller vessels
-Tissue death from freezing
-Temporary or permanent nerve damage from excessive exposure to cold:
Pain
Numbness
Tingling
Hyperhidrosis
Nerve conduction abnormalities
Selection of Appropriate Cooling Agent
- Provides the desired intensity of cold
- Best fits the location
- Best fits the size of the area to be treated: Conforms to body and maintains contact
- Easily applied for the desired duration and desired position
- Readily available
- Reasonably priced
Sequence of Sensations in Response to Cryo
- Intense cold
- Burning
- Aching
- Analgesia [can’t feel pain]
- Numbness
Cold packs
Gel filled
Composed of silica, or saline and gelatin mixture
Stored in cooling units or freezer
-5° C or 23° F
Cooled for at least 30 minutes between uses and at least 2 hours before initial use
Ice Packs
Crushed ice placed in plastic bag
More aggressive cooling because ice has a higher specific heat
Needs more insulation for application
Home “Made” Cold Packs
Frozen vegetables
Plastic bags filled with 4:1 ratio mixture of water and rubbing alcohol cooled in home freezer
Application – Cold Packs or Ice Packs
- Remove jewelry and clothing from area to be treated and inspect the area
- Wrap cold pack or ice pack in towels
Damp vs. dry
Warm vs. cool - Position
- Place and secure
- Leave in place
10-20 – 15?
Up to 30 for spasticity
Check every 10-25
Provide a bell - When complete, remove and inspect area
Cold Pack Pros/Cons
Pros: Easy, low level of skill required for application Inexpensive Brief use of clinician's time Covers moderate to large areas Can be applied to an elevated limb
Cons: Pack must be removed to visual treatment area Weight of the pack Lack of contour on smaller areas Longer duration
Ice massage
- Good for trigger pts
- small areas
- ice cups or water popsicle
Application – Ice Massage
- Remove jewelry and clothing
- Place towels around area
- Rub ice over treatment area
4-6 inches in slow (2 inches/second) overlapping circles or longitudinal strokes - Continue for 5 to 10 minutes [Or until analgesia occurs]
- When complete inspect area
Ice Massage Pros/Cons
Pros:
Treatment area is observed during application
Can be used for small & irregular areas
Short duration of treatment
Inexpensive
Can be applied to an elevated limb
Cons:
Too time-consuming for larger areas
Requires active participation by the clinician or the patient throughout the application
Cold Compression Units
- Alternatively pump cold water and/or air into a sleeve that is wrapped around a patients limb [Or compresses an ice pack]
- Temp of the water is set between 10-25° C (50-77° F) to provide cooling
- Compression is provided by the air or gravity if no motor
Application Cold Compression Unit
- Remove jewelry and clothing
- Cover limb with stockinette [or pillowcase]
- Wrap the sleeve around the area to be treated
- Set temperature to 10° - 15° C
- Set continuously or intermittently (15 minutes every 2 hours)
- When complete, remove the sleeve and inspect area
Cold Compression Pros/Cons
Pros:
Allows simultaneous cold and compression
Temperature and compression fore are easily controlled and accurate [On some units]
Can be applied to large joints
Cons: Cannot visualize treatment area while on Expensive Usually limited to extremities Not really for trunk or digits
Vapocoolant Sprays and Brief Icing
- Originally Ethyl Chloride and Fluori-Methane
- -Flammable, anesthetic effects when inhaled, and depleted ozone
- -Now developed and branded
- Cools by evaporation
Recommended for treatment of:
- Myofascial pain syndromes
- After trigger points injections
- Restricted motion
- Minor sports injuries
Application – Vapocoolant Sprays and Brief Icing
- ID trigger points and their related tight muscles
- Position the patient comfortably and well supported
- Inspect the area to be treated
- Cover the patients eyes, nose and mouth if treating near the face
- Apply 2-6 parallel sweeps of the spray or strokes of the ice 1.5 to 2 cm apart at approx 10 cm per second along the direction of the muscle fibers
- During the cooling maintain gentle smooth steady tension on the muscle
- Immediately after the cooling provide a gentle passive stretch
- Following the procedure skin should be warmed and full ROM performed
Vapocoolant and Brief Icing Pros/Cons
Pros:
Brief duration of cooling
Very localized
Cons:
Limited to use for brief, localized, superficial application prior to stretching
Documentation
Area to be treated Type of cooling agent Treatment duration Patient positioning Treatment duration Response to intervention
Hemodynamic effects of heat
Vasodilation -> increased blood flow
Most in superficial local cutaneous blood vessels
Less in deeper vessels in muscles
Neuromuscular effects of heat
- Increase nerve conduction velocity and firing rate of sensory and motor nerves
- -2 m/second for every 1 deg C (1.8 F)
- -Reduce spasms by deceasing firing rate of alpha motor neurons
- Increased pain threshold
- -Cutaneous thermoreceptors heat and cause inhibitory gating effect [reduces pain caused by ischemia]
- Changes in muscle strength and endurance
- -Decreases during initial 30 min of deep or superficial
- -Gradual recovery & then increases above pretreatment levels – increased pain threshold
Metabolic effects of heat
-Increased metabolic rate
-Increased biochemical reactions:
Increased O2 uptake and availability for tissue repair.
Accelerate healing process
Altered Tissue Extensibility
- Increased collagen extensibility
- -Maintains greater increase in length after stretch
- -Less force needed
- -Plastic deformation can be achieved
- Deeper structures need deep-heating agents.
Uses of Superficial Heat
- Pain control [Not recommended for acute injuries due to aggravation other signs of acute inflammation]
- Increased ROM and decreased joint stiffness
- -104-113 deg F for 5-10 min = maximal increase in residual length with lowest risk of injury
- Accelerated healing
Contraindications to heat
- Recent or potential hemorrhage
- -Heat causes vasodilation which could reopen a vascular lesion
- -Can restart or worsen the bleeding
- -Should not be applied in the patient has bruising in previous 48-72 hours.
- Thrombophlebitis: Could cause clot to be dislodged and travel to a vital organ.
- Impaired sensation or mentation
- Malignant tumor: May increase the growth rate or rate of metastasis due to increased circulation
Precautions to heat
- Acute injury or inflammation
- Pregnancy
- Impaired circulation or poor thermal regulation
- -Not normal vasodilation leading to insufficient flow to protect tissues from burning
- Edema
- Cardiac insufficiency: Increased cardiac demand
- Metal in the area
- Over an open wound: Contamination and loss of insulation when loss of epidurmis
- Topical counterirritants
- Demyelinated nerves: Could cause conduction blocks
Adverse Effects of Thermotherapy
- Burns
Protein denaturation and cell death when applied to long, too hot or poor patient response to heat - Fainting
Sudden transient loss of consciousness due to decreased cerebral blood flow - Bleeding
In areas of acute trauma or patient with hemophilia
Re-opening of a vascular lesion
Hot packs
- Commercial
–Stored in hot water (158-167 deg F)
–Bentonite (hydrophilic silicate gel) covered in canvas
–Holds large amount of water
–Various sizes and shapes
–30 min to reheat after use (2 hrs for first use) - Chemical heating pads-
Activated by breaking an inner seal [1-8 hours] - Electric plug – in [Not recommended]
- Continuous low-level heat wrap
Application – Hot packs
- Remove jewelry and clothing from area to be treated and inspect the area
- Wrap hot pack in 6-8 layers of dry towels
A single “hot pack cover” substitutes for 2-3 layers - Position: More layers if patient is lying on the hot pack
- Place and secure
- Leave in place
15-20 minutes
Check every 10 minutes
Provide a bell - When complete, remove and inspect area
Hot Pack Pros/Cons
Pro: Easy to use and low skill level required to apply Inexpensive Brief use of clinician’s time Used for moderate to large areas Safe because they cool
Con:
Must be removed to observe treatment area
Weight of the pack may not be tolerated
Difficult contact with smaller / contoured area
AROM is not practical
Equipment to heat is moderately expensive & needed
4 likely outcomes of acute inflammation
- Complete resolution and replacement of injured tissue with like tissue [Most beneficial]
- Healing by scar formation [Most common]
- Formation of abscess-by pathogen during inflammation response not controlled by immune repsonse
- Progression to chronic inflammation
Chronic Inflammation
- The simultaneous progression of active inflammation, tissue destruction and healing
- Occurs in 1 of 2 ways
- -Cumulative trauma: Interference of healing process
- -Immune response to altered host tissue / foreign material or the result of an autoimmune disease (RA
Normal Acute Inflammatory Process
no more than 2 weeks
Sub acute Inflammation
if more than 4 weeks
Chronic Inflammation
months to years
Local Factors that affect healing
- Size, type, & location of injury
- Infection
- Vascular Supply
- External Forces
- Movement
Systemic Factor that Effect Healing
- Age
- Disease
- Meds
- Nutrition
Cartilage Healing
- Limited ability to heal because it lacks lymphatics, blood vessels and nerves
- Cartilage itself does not form clots –>healing fails
- Different if subchondral bone is involved
Tendon and Ligaments Helaing
- Inflammation occurs in the first 72 hours
- Collagen synthesis occurs in the 1st week
- Intrinsic and extrinsic cells participate in repair
- Orientation of cells/collagen are perpendicular to tendon early
- -Changes to parallel around day 10-2 months
- Ultimate maturation depends on sufficient physiological loading
Skeletal muscles Healing
- Skeletal muscle cells cannot proliferate once injured
- stem or reserve cells can form new skeletal muscle cells: Satellite cells
- After severe contusion, a calcified hematoma may develop: Myositis ossificans
Bone Healing
- Heals with “like-tissue”.
- Stages of fracture healing
- -Impaction, induction, inflammation, soft callus, hard callus, remodeling
Types of Pain
Acute
Chronic
Referred
Trigger Points
Acute Pain
- Is experienced when tissue damage is impending and after injury has occurred
- -Calor, rubor, tumor
-Underlying pathology can be identified
Chronic Pain
- Persists beyond normal time for tissue healing
- 3-6 months
- Result of activation of dysfunctional neurological or psychological responses
- Continue to experience pain even when no damaging or threatening stimulus is present
Nociceptors-Free peripheral nerve endings
- “String-of-beads” appearance
- Present in almost all types of tissues
- Activated by intense thermal, mechanical (brick / broken bone), or chemical (acid/bleach / histamine) stimuli-Internal & external
- Convert stimulus to electrical impulses (action potentials) through transduction along afferent nerves towards the spinal cord.
- Peripheral sensitization: release chemicals to increase the response to noxious stimuli
- ->Resulting in activities & stimuli are perceived as painful even though they are not damaging
Nociceptors are the terminals of two types of primary afferent neurons:
C-Fibers:
Small, Unmyelinated, Slow – 1.0 to 4.0 m/second
“Dull, throbbing, aching, or burning”
Slow onset
Long lasting, diffusely localized – emotionally difficult
A-delta Fibers:
Small-diameter but myelinated, Fast – 30 m/second
Sensitive to high-intensity mechanical stimulation but respond to heat/cold.
“Sharp, stabbing, prickling”.
Quick onset, last a short time, localized – not emotional
Mechanical trauma usually activates both
Spinal Cord Pathway
C and A-delta nerves -> interneurons (T-cells) -> neurons in the superficial dorsal horn of the grey matter of the spinal cord.
T-cells
- Transmission cells
- Integrate inform from nociceptive and non-nociceptive (A-beta) primary afferent fibers, other T-cells, & supraspinal sites (brain stem and cortex)
- This balance from excitatory (nociceptors) & inhibitory (sensory nerves) & descending fibers from the brain influence whether or not the person feels pain & how sever it is.
T-cells can….
- Cause muscles spasms through efferent anterior horn cells
- Result in pain-spasm-pain cycle
Pain-transmitting neurons
Cross midline & ascend to thalamus via lateral or anterospinalthalmic tracts
Referred Pain
- At a location distant from its source
- From one joint to another
- Peripheral nerve to a distal area of innervation
- Internal organ to an area of musculoskeletal tissue
Gate Control Theory
- Severity of pain sensation is determined by the balance of excitatory & inhibitory inputs (A-beta) to the T-cells in the spinal cord
- PA and interventions for pain relief
- -Inhibit activation of pain transmission cells: Pre-synaptic inhibition of T-cells
- -Closing the gate to the transmission of pain
The Endogenous Opioid System / Theory
- Control pain by binding specific opiate receptors in the nervous system
- Paradoxical pain-relieving effects of painful stimulation and acupuncture
- Noxious TENS (Acupuncture like)
Pain Management
- Pharmacological: systemic analgesics
- Physical Agents
Physical Agents for Pain Management
- Stimulate large diameter afferent fibers: TENS, Massage, & Analgesic balms
- Decrease pain fiber transmission velocity: Cold & Ultrasound
- Stimulate small diameter afferent fibers: Acupressure, Deep massage, & TENS
- Stimulate a release of endorphins : TENS
