Week 1 Flashcards
What are physical agents?
Energy and materials applied to the body to help patients heal
Physical agents are generally described in ___ and ___
Categories of energy and types of physical agents
What are the categories of energy?
Thermal, mechanical, and electromagnetic
What are the types of physical agents?
- Deep heating
- Superficial heating
- Cooling
- Traction
- Compression
- Water
- Ultrasound
- Electromagnetic fields
- Electrical currents
What do physical agents do/goals?
- Modify tissue inflammation and healing
- Relieve pain
- Alter collagen extensibility
- Modify muscle tone/contracting ability
What are the phases of healing?
- Inflammatory phase (acute vs. chronic)
- Proliferative phase
- Maturation phase
Factors that can move modalities away or from usage?
• Pregnancy – Does modality (or energy from modality) reach
fetus?
• Malignancy – Can modality (or energy from modality)
accelerate growth/metastasis?
• Pacemaker or other implanted electronic device – Does
energy reach device?
• Impaired sensation/mentation – End point often report of
feeling and therefore an issue if patient has decreased
sensation.
Rank of priorities when choosing a physical agent for a patient
- Highest/first: Primary underlying problem/problem most likely to respond to treatment
- 2nd: treatments that address more than one problem simultaneously
- Lowest/last: symptomatic treatment only
Thought process when choosing a physical agent
- Goal and effects of treatment
- Contradictions and precautions
- Evidence for physical agent use
- Cost, convenience, and availability of the physical agent
With physical agents, it is often ____ to find studies of the highest quallity
difficult
Combining complimentary physical agent types
- RICE: Rest, Ice, Compressions, & Elevation
- Heat & TENs (same time or one after the other)
- TENs and Ice (same time or one after the other)
- E-Stim (NMES) & heat
What happens in the inflammation phase of healing?
Prepares wound for healing.
- Days 1-6
What happens in the proliferation phase of healing?
Rebuilds damaged structures and strengthens the wound
- Days 3-20
What happens in the maturation phase of healing?
Modifies the scar tissue into its mature form
- Day 9 onward
What are the factors affecting the healing process?
- Local factors
- External factors
- Systemic factors
What are the local factors affecting the healing process?
type, size, and location of injury. Whether or not there is an infection.
The vascular supply to the part of the body
What are the external factors affecting the healing process?
The use of physical agent come in to play to help complement the healing process
What are the systemic factors affecting the healing process?
The patient’s age (slower when older), disease factors that can impair healing, medication, nutrition
Important determinants of healing of specific tissues
- Regenerative capacity of the tissue, vascular supply, or extent of damage.
Healing of cartilage
- Limited ability to heal
- Lacks lymphatics, blood vessels, and nerves
- Cartilagenous injuries that also involve subchondral bone allow inflammatory cells from bone to gain access to repair the injured cartilage.
Healing of tendons and ligaments
• The potential for repair of these tissues depends on
the type of tendon or ligament, extent of damage,
vascular supply, and control of movement
• If healing occurs, tendons possess a unique scar
maturation phase that can achieve an advanced
state of repair
• Ligaments heal better with controlled passive
mobilization
(can still be 30-50% weaker after healing is done)
Healing of skeletal muscle
• Can be injured by trauma, strain, or muscle
diseases
• Healing can occur in some cases through stem cells
that can proliferate and differentiate
• After severe contusion, a calcified hematoma may
develop – myositis ossificans is rare complication
Healing process of bone
At least four stages of healing:
•Inflammation (begins shortly after impact)
- Creates hematoma, disrupts blood supply, lowers pH
• Soft callus (begins after swelling subsides)
- Stabilizes fracture, decreases pain, and reduces chance of fat embolism
• Hard callus (3 weeks to 4 months)
-Corresponds to clinical healing period
• Bone remodeling (takes months to years)
-Healed fibrous bone is converted to lamellar bone, and
medullary canal becomes patent again
The most common symptom prompting patients to seek medical attention and
rehabilitation is ____
Pain
Definition of pain
Pain is an unpleasant sensory and emotional experience
associated with actual or potential tissue damage, or described in terms of such damage.
A warning of actual or potential tissue damage is ___
Pain
Pain is a combination of what factors?
mechanical, neurological, psychological and
sociological factors
____ is often, but not always, a reliable indicator of location and severity of tissue damage
Pain
Pain is 100% from the ____
brain
Pain is a multiple system output, activated by an ____ which is activated whenever the brain ___
dividual’s specific pain
neural signature.
Perceives a threat
Assessing pain in patients
- Visual analog and numeric scales
- Comparison with a predefined stimulus
- Be aware of cognitive issues
- Semantic differential scales
- Word lists and categories to describe pain
- Daily activity/pain logs
- Body diagrams
- Open-ended, structured interviews
- Physical examination and testing
- Take cultural difference into consideration
Characteristics of the A-delta primary afferent neurons
- respond to intense mechanical stimulation and heat or cold
- short duration, sharp, stabbing, or pricking sensation
- small and myelinated
- 4-30 m/s
- 20% of pain afferents
- not blocked by opioids
Characteristics of the C-afferent primary afferent neurons
• longer duration, dull, throbbing, aching, burning, tingling, diffusely localized,
accompanied by sweating, increased heart rate and blood pressure, and nausea
• small and unmyelinated
• 0.5-2 m/s
• 80% of pain afferents
• can be blocked by opioid medication
Characteristics of the A-beta primary afferent neurons
• non-painful sensation related to vibration, stretching, and mechanical pressure
Types of pain found in the superficial/skin
Sharp/pricking/vibrating and easily located
Types of pain found in the musculoskeletal tissue
Dull/Achy/Heavy and more difficult to localize
Types of pain found in visceral tissue
Aching quality, frequently referred superficially
Two main things to think about in physical agents regarding pain control
- Endogenous Opioid System
* Gate Control
Endogenous opioid system for pain control
- Opiopeptins (a.k.a. Endorphins, Enkephalins, and
Dynorphins) control pain by binding to specific opioid receptors
–Released in times of emotional stress and
result in raised pain threshold
–Possible explanation for noxious stimuli (i.e.
acupuncture) causing pain relief of preexisting pain
Gate control for pain control
A-delta & C-fibers open the gate that results in pain within the nervous system.
A-beta fibers closes the gate to decrease sensation of pain. (this is how TENs unit at a low level works)
Types of pain
- Transient Pain
- Acute pain
- Chronic/persistent pain
- Nociceptive
- Neurpathic
What is transient pain?
- Elicited by activation of nociceptive tissues in the body in the absence of tissue damage
- Goes away without treatment
What is acute pain?
- usually relatively short duration
- defined etiology
- may be localized
- Reflex mechanism for protection from damage
What is chronic/persistent pain?
- longer duration, often persisting longer than typical for a condition
- often inadequate response to appropriate care
- associated with more emotional reactions
What is nociceptive pain?
Has a clear stimulus-response relationship with the initial injury.
Can be acute and lead to chronic
What is neuropathic pain?
- Burning or lancinating quality
- Usually accompanied by signs or symptoms of neurological dysfunction, such as paresthesias, itching, anesthesia, weakness
- Radicular vs. Referred pain
Can be acute and lead to chronic
What are the characteristics of pain?
Referred or Radicular
What is referred pain?
- May be acute or chronic
* In many cases pain is away from origin/source of pain.
What is radicular pain?
Pain that travels along a nerve
What are the types of sensitization?
Peripheral and Central
_____ sensitization is due to the release of local chemical and sometimes no stimulus
Peripheral
Central sensitization occurs in the ___
CNS
Individuals with central sensitization have primary hyperalgesia which means ___
Increased duration and magnitude of CNS response for pain
Individuals with central sensitization have secondary hyperalgesia which means ___
They have an enlarged receptor field, that might been previously localized but later spreads
Individuals with central sensitization have allodynia which means ___
non-noxious stimuli becoming painful
What are the goals of care for pain management?
• Resolving underlying pathology when possible
• Modifying discomfort and suffering
• Maximizing function within the limitations imposed by
patient’s condition
For patients with persistent pain we may need ___, which include ____
integrated multidisciplinary treatment
Psychological and physiological therapies, physical agents, and
exercise
What are the benefits of physical agents with helping pain?
• Directly moderates inflammation, modulates pain at the spinal cord, alters nerve conduction, or increases endorphins
• May also help resolve the underlying cause
• Allows patient to interact with their injured body-parts and
practice independent pain management skills
• Allow a movement/therapeutic window
• Avoids medication-related side-effects Avoids medication-related side-effects
Most commonly used types of physical agents in PT
- Cryotherapy (Ice, cold packs)
- Thermotherapy (hot packs)
- Ultrasound (used for mechanical and thermal effects)
- Electrical stimulation (in the form of pain control with TENs)
- Traction
____ is an important component of pain management
Exercise
Selecting appropriate exercises for patients with chronic pain
can be
Challenging
What is the normal core temperature of the human body?
37 degrees C +/- 1
Human tissues function best between ___ - ___ deg c
35-38
Hypothermia is anything below ____
35 deg C
Hyperthermia is anything above ___
35 deg C
Skin and other peripheral tissues are slightly __ than the core temp
Less. (32-34deg)
Ways that heat exchange occur between the skin and air
Evaporation and non-evaporation
Via evaporation by the means of ___
Skin and respiratory passages
Heat exchange between the skin and air via non-evaporation includes ____
Radiation, conduction, and convection
What is radiation?
Energy being transferred from one surface to another in order to hit the surface. (sunlight)
What is conduction?
Laying two surfaces together that have diff. temps on each other to change the body temp
What is convection?
Rubbing two surfaces together that have diff. temps on each other to change the body temp
How does heat exchange happen in the body?
Countercurrent exchange
What is countercurrent exchange?
Cool venous blood from extremities being warmed by the arterial blood flow from the core
What does the physiological effect of local heating depend on?
Depends on the degree of tissue temperature rise (TTR)
Factors that determine how much there will be a TTR
- Gradient
- Specific heat
- Volume
- Rate
A greater temp gradient will give a _____ TTR
Greater
The higher specific heat = ____
More energy to heat, slower loss. Lowe degree of TTR
The larger the volume of tissue is exposed the ____ TTR is
Higher
In rate of heat applied, when a slow transfer of heat is applied, TTR_____ by blood carrying heat away
is balanced
In rate of heat applied, when a fast transfer of heat transferred is faster than what the blood can carry, TTR is too ___, which results in pain and burn results
Great
Physiological effects of using heat on tissues are
- Vasodilation
- Brings in more nutrients
- Picks up more waste
- Increase in metabolism
- • For every 10 deg C rise in
temp., there is a
2-3 fold increase in the
rate of metabolism
- • For every 10 deg C rise in
- Pain relief
- Decrease stiffness
Additional physiological effects of using heat on tissues are
• Enhance extensibility of tissue
• Requires elevation of
tissue temp to 40-45 deg C
• Stretch should be applied
after a tissue reaches
peak and then tissue
maintained in stretch
position until it cools back
down
• Reduce muscle spasms/decreased strength
• Due to decreased firing
rates of type II ms spindle
afferents and gamma
efferents, while increasing
firing rate of type Ib fibers
from Golgi tendon organs
• All of this leads to
reduction of firing rate of
alpha motor neurons
• This is same principle that
can help to break pain-
spasm cycle
• Occurs for 1st 30 minutes
after application of heat,
and then increases again to
pre-treatment levels after
2hrsGeneral precautions for heat
• Areas of decreased sensation and innervation
• Areas of decreased circulation
• Treating large volumes of tissue
• Poor thermal regulation – children and elderly
• During pregnancy
• Cardiac insufficiency
• Metal in the area
• Areas of watery edema – increased risk of burn
• Scars and new skin
• Over areas where topical counterirritants have
been recently applied
• Lying directly on the heat pack
• Heating bony prominences
What are the contradictions for heat
• Areas of arterial insufficiency or arterial disease
• Areas prone to hemorrhage
(hemophilia, acute trauma, long-term steroid use)
• Acute inflammatory site
• Elevating tissue temperature in area of malignancy
• Impaired cognitive function
Therapeutic effect of superficial heat
• Affect skin temp. w/o heating deeper tissues
• Penetrates about .5 cm w/peak temp. at 6-8
min
• Depth of penetration dependent on amount of
subcutaneous fat
• Possible to heat small joints of hand/foot
where little subcutaneous tissue is present
• Tissues at 1-2 cm require longer durations
(15-30 min)
• At 3 cm, only get about 1 deg C rise in temp.
• May affect deeper tissues through reflex mechanisms
Physical agent: Hot pack
• Heat transfer by conduction (superficial)
• These are considered moist heat
• Use 6-10 layers of towels (hot pack covers equal 2-3
layers of towels)
• Heat typically for about 20 minutes for maximal results
• Always check patient after 5-6 minutes as the heat is
reaching max temp around that time.
• Prevents inadvertent burns
• Patient should feel warmth similar to towels fresh out
of the dryer
Precautions and contradictions of a hot pack
- Precautions
- Any precautions for use of heat
- Lying on the packs, especially when treating trunk
- Heating bony prominences
• Contraindications
- Any condition where heat is contraindicated
Advantages of a hot pack
• Easy to use.
• Inexpensive materials (packs and towels).
• Short use of clinician’s time.
• Low level of skill needed for application.
• Can be used to cover moderate to large areas.
• Safe because packs start cooling on removal from the
hydrocullator.
• Readily available for patient purchase and home use.
Disadvantages of a hot pack
• Hot pack must be moved to observe the treatment
area during treatment.
• Patient may not tolerate the weight of the hot
pack.
• Pack may not be able to maintain good contact
with small or contoured areas.
• Active motion not practical during treatment.
• Moderately expensive equipment (heated water
cabinet)
Physical agent: Paraffin treatment
• Heat transfer by conduction • Mineral oil added to paraffin alters melting point and lowers specific heat making higher temperatures tolerable • Specific heat (approx .65 Btu/lb.oF) • Water specific heat = .938 Btu/lb.oF) • Temp ranges from 126 -130 deg F • Effects are those of superficial heating
Indications of a paraffin treatment
- Arthritis
- Chronic orthopedic conditions
- Joint stiffness, contractures
- Scleroderma
Precautions of a paraffin treatment
- Any condition for which heat is to be used with caution
- Small scratches – should be covered with gauze
- Scar tissue
Contraindications of a paraffin treatment
- Any condition in which heat is contraindicated
- Open wounds
- Draining lesions
- Rashes, infections which might be contagious
- New skin or recent scar tissue
- Water on skin – can cause a burn
- Jewelry – can cause a burn
Application of the paraffin treatment
• Before treatment
- Area to be treated must be clean and dry
- Metal must be removed from area to be treated (if it can’t be removed, cover with
several layers of gauze)
- ALWAYS check the temperature of paraffin
before applying treatment
- It is normal for paraffin to feel hottest around nail beds
- Warn patient not to touch areas of tank near
heating element
Methods of applying a paraffin treatment
• Dip - Milder heating
• Body part relaxed and still, if moved after a layer is applied, it will crack and create hot spot
• Dip into tank, remove and repeat once dripping stops
• A thick “glove” should be applied (about 6-10 layers)
• Plastic bag is placed over glove followed by towel to reduce heat loss
• 10-15 minute treatment or until paraffin
cools
Other method of applying paraffin treatment
• Immersion – more vigorous (may have easier time reaching 40-45 deg C)
• Involves placing body part back into tank once 1-layer “glove” has been formed
(allow 5-15 seconds to harden before placing back into tank) and glove may (or may not) melt during treatment
Advantages of paraffin
- Covers irregular surface
- Gives good hyperemia
- Easy to use
- Inexpensive
- Body part can be elevated if using the dip-wrap method
- Oil lubricates and conditions the skin
- Can be used by patient at home
Disadvantages of paraffin
- Can be messy, especially if spilled
- Not good for large areas
- Cannot use with open lesion
- Cannot exercise during treatment
- Cannot see the part during treatment
- Flammable
- Risk of cross-contamination if the paraffin is reused
- Part in dependent position for dip-immersion method
Physical agents: cold treatment
• Ideal Tissue Temperature for Treatment
• 15-25 deg C (59-77 deg F)
• Magnitude of temperature change depends on
• Temperature difference between tissue and cold source
• NOTE: temp of freezer or cold pack unit may be
difference between safe treatment and damage
• Crushed ice machine is not as cold as home freezer • Exposure time
• Conductivity of area being treated (eg. Fat is an insulator
and will hinder cooling of deeper muscle tissue)
• Type of cooling agent (ice vs water) • Effect of blood flow in the area
Methods of cooling or removal of heat from an object
• Conduction
- Cold packs, ice massage, cold towels
• Convection
- Fan
• Evaporation
- Vapocoolant sprayPhysiological effects of cooling treatments
• Vasoconstriction
• Decrease metabolism
• Pain relief
- Decrease in nerve conduction velocity
• Augment muscle contraction
- <5 min ice massage has been shown to increase isometric strength
- Due to facilitated motor nerve excitability and psychological motivation
• However, can decrease muscle strength if > 30 min
- Due to decreased blood flow and nerve conduction, and
increase ms viscosity and soft tissue stiffness.
Cold treatment on an acute injury is thought to be most effective _____
5-10 min after injury, but can still be helpful for up to 72 hours after injury
What is the goal of a cold treatment on an acute injury
– Controls inflammation through vasoconstriction and
decreased permeability of vessels
– Decreases pain, numbs the injured area
– Prevents secondary hypoxic ischemia, which is a result of
increased distance for oxygen to diffuse from blood vessel
to tissues.
Why prevent inflammation?
• Leukocytes and macrophages “clean up” the site
• Swelling increases sensitivity to pain and restricts movement
to prevent further injury
• Allows inflammation phase to progress and repair
Precautions for cold treatments
• Skin sensation which is not normal
• Previous frostbite to area
• Anesthesia from ice could mask exercise induced pain
• Prolonged applications
• Hypertensive patient
- Blood pressure should be monitored because it goes up with cold immersion
• Packs or ice stored at 0 deg F or -17 deg C should not be applied directly to the skin
• Decreased cognitive level
• Very old/very young individuals
• Over the superficial main branch of a nerve
• Directly over an open wound( can be around it)
Contraindications of cold treatments
Cold hypersensitivity
• Compromised local circulation
- Particularly arterial PVD
- If tissue is ischemic and you further reduce blood flow, tissue damage may result
• Cold intolerance
• Cryoglobulinemia
•Raynouds disease
• Paroxysmal cold hemoglobinuria
• On regenerating superficial nervesSensations during cold treatments
- Cold
- Warm, burning
- Aching, tingling
- Numbness
Types of cold treatment: Cold packs
• Gel
- Temperature usually 23 deg F (-5 deg C)
- Must be chilled 2 hours to acquire proper temp (4-5 hours for new pack)
• Chemical
- One use
- Chemicals can cause skin burn if pack leaks
- Generally, not as good as other options as it does not maintain its coldness long
enough
Types of cold packs continued
• Water:Alcohol homemade pack
- Use 2:1 ratio of water to alcohol and freeze in plastic bag
• Crushed Ice
- If using in combination with
compression, evacuate as much air as possible
Application of cold packs
• Time
- 15-30 minutes (colder the source, the shorter the time)
- Longer time for patients with more subcutaneous fat
- Not necessarily removed once numbness is reached
as that is only skin that has reached optimal temp., but must be removed before frostbite (occurs at 3-10 deg C/ 39-50 deg F)
- For first 24 hours of musculoskeletal injuries, Knight
recommends applying for 30 minutes of every 2 hours
• Use wet towel, paper towel, or “handiwipe” to preserve sanitation of pack, and to enhance transfer of cold
Ice massage
• Before the first treatment, check sensitivity to cold by using ice massage in an area about 1½ inches squared for just a couple minutes
• If hypersensitive, the skin blanches, has a leather texture, and an elevated surface
• Cover an area about 3-6 inches in diameter
• Time – 5-15 minutes or until beyond numbness (again, numbness only means skin temperature is ideal, not necessarily the tissues we are treating)
• Using overlapping circles, cover area in a systematic
way
• Do not let drips run down patient’s skin (wipe after
every 5-10 strokes – do so carefully as to not irritate
skin)
Cold bath or whirlpool
• Immerse part in 13-18 deg C (55-65 deg F) water
• Can use water and crushed ice
• Time – colder water, less time (few seconds to 10 minutes – leave until a little after numbness is achieved)
• Toe cap may make foot more
comfortable
Cold-compression units
• Cryocuff – “thermos” type
container full of water and
attached to cuff. Applies compression also
Documentation for physical agents should include ____
- Heating/Cooling agent used (type and size)
- Patient positioning
- Area treated (location and size)
- Number/Type of layers between agent and skin
- Treatment duration
- Response to intervention (pre-test/post-test)
- Should be reproducible for future visits
Chronic inflammation occurs in which phase of healing?
Maturation
Chronic inflammation occurs due to ____
- persistent force producing re-injury
2. immune response from infection or reaction to implant
____ results in an increase collagen production which forms thicker tissues and adhesion
Chronic inflammation
What are the effects of cyrotherapy?
- Hemodynamic effects
- Vasconstriction
- Hunting response
- Cold induced vasodilation
What is hunting response?
A cycling of temp(heating and cooling) in the human body directly underneath the area where a cold agent is applied.
How long does it take for the hunting response to happen?
15 mins
What is cold- induced vasodilation?
Apply cryotherapy to the region, if it cools to more than 1 deg C and it is maintained for more than 15mins. This can result in edema
What is the depth of penetration for cooling agents?
1-3cm
How long should you apply a cold treatment to facilitate a muscle contraction?
5 mins
Clinical indications for cryotherapy: Cryokinetics and cryostretch
- Early intervention following injury
- Initiating new therpeutic exercise program for patient in chronic pain
- Increase muscle performance for athletes in training
Application of a vapocoolant spray used for cryostretch
- Management of trigger points
- Spray along the muscle fibers
- Apply a progressive stretch
Cryokinetics ice bath protocol:
- Apply cold agent x 20 mins or until region is numb
- Stretching/strengthening x 3-5 mins until sensation returns
- Reapply cooling agent until numbness returns
- Repeat stretching/stregthening
- Sequence repeated approximately 5x
Unintended effects of cryotherapy
- Reduced ROM
- Reduced strength
- Psychological effects
Capillary refilling should start within ____, so we know there is no frostbite
2 secs
Indications for use of thermotherapy
- Pain control
- Increase tissue extensibility to increase ROM and flexibility
- Accelerate healing of injured tissues
- Reduce muscle guarding or spasms
Contraindications of thermotherapy
- Recent or potential hemorrhage
- Thrombophlebitis
- Impaired sensation
- Impaired mentation
- Malignant tumor
Adverse effects of heat
- Burns:
Erythema ab igne: staining of the skin/ irritation
Blisters
- Fainting
- Bleeding
- Increased edema
