Exam 1

What is a LASER?

Device that concentrates high energies into a narrow beam of coherent, monochromatic light

What are the properties of laser?

• monochromaticity

• directionality/collimation

• coherence

What is the mechanism of light therapy?

1. Uses an active medium

   1. Crystalline or solid state material

   2. Semi-conductor

   3. Gas

   4. Liquid 

2. Excitation mechanism

   1. Optical light

   2. Electricity

   3. Chemical Agent

3. Feedback mechanism

   1. Highly reflective mirror

4. Output coupler

   1. Partially transmissive mirror

What is the therapeutic window dosage of light?

• Visible/near IR (600-1300 nm)

• Solaris (660-880nm)

What are the measurement units of light?

• Power (Watts)

• Power density (W/cm2)

• Energy (Joules)

• Energy density (J/cm2)

What is power in regards to LASER?

rate of energy flow

• determines length of treatment

• 500-900mW

What is power density in regards to LASER?

amount of power per unit area

• high power = less application time

What is energy in regards to LASER?

effects of light on tissue

• Power x Time

What is energy density in regards to LASER?

amount of power per unit area = treatment dose measure

What are the parameters for LASER?

• energy density

• duty cycle

• duration of treatment (inverse between power & time)

• size of area being treated

• cold vs. hot/ low power vs. high power

• light cluster probe

What are the effects of LASER?

• promotes ATP

• promote collagen production

• modulate inflammation

• inhibit bacterial growth

• promote vasodilation (microcirculation)

• alter nerve conduction velocity & regeneration - over site of nerve compression

What are the indications for LASER?

• tissue healing: soft tissue & bone

• diabetic & venous ulcers/wound care

• pain

  • CTS, lat epicondylitis/tendinopathy, neck pain, chronic joint pain (OA), TMJ

• lymphedema

• dosage = 1-9 J/cm2 per point 

• every other day or less (not daily)

What are the contraindications for LASER?

• Malignancy

• Direct irradiation of eyes

• Within 4-6 months after radiotherapy

• Over hemorrhaging regions

• Over endocrine glands

What is the mechanism of heating with diathermy?

• Tissue temp rise

  • Absorption of high frequency electric and/or magnetic field energy

  • 27.12 MHz w/ 11m wavelength

  • convert into heat in tissues

• Beyond infrared portion

  • shorter wavelength & higher frequency

• Deeper penetration than infrared

• Longer wavelengths = thermal effect on musculature & connective tissue

• Unable to produce polarization & muscle contractions

What are the two types of diathermy?

• Short Wave Continuous

• Short Wave Pulsed

  • Electric (11m/27.12 MHz)

  • Magnetic (22m/13.56 MHz)

What are the effects of SWD - continuous?

• increase local metabolism

• increase perspiration

• local vasodilation w/ hyperemia

• muscle relaxation (muscle spindles, GTO)

• increase capillary pressure cell permeability

• linear increase in O2 tension

• increase extensibility of connective tissue

What are long term effects of SWD-Continuous?

• circulatory rebound phenomenon

• increase body temp

• increase respiratory & pulse rates

• decrease blood pressure

What are the indications for SWD-Continuous?

• increasing ROM of contracted joints using heat & stretching

• pain reduction

• reducing muscle spasm

• increasing blood flow to tissues in treatment area

• ex: knee OA, lateral epicondylitis, joint contracture

What are the effects of SWD-Pulsed?

• increased microvascular perfusion

  • increase local tissue oxygenation, nutrient availability, phagocytosis

• altered cell membrane function & cellular activity

  • trigger cascade of biological processes

  • stimulation of ATP & protein synthesis

What are the indications for SWD-Pulsed?

• Control of pain & edema

• Soft tissue healing

• Nerve healing

• Bone healing

• OA symptoms

• CTS

What are the contraindications for diathermy?

• Metal implants

• Pacemakers/TNS

• Very young/Very old (epiphyseal plates)

• Hemorrhage/Active bleeding

• Acute inflammation

• Eyes

• Cancer

• Ischemic tissue

• Cardiac insufficiency

• Fever/infection

• Pregnancy

• Reproductive organs

What is normal gait?

basic sequence of limb motions that serve to progress the body along a desired path while

• maintaining weight-bearing stability

• conserving energy

• absorbing shock of floor impact

What is the stance phase of the gait cycle?

when the foot is in contact w/ the ground

• comprises 60% of cycle

What is a gait cycle?

time from when one foot makes contact w/ ground to when that same foot makes contact w/ ground again

What is the swing phase of the gait cycle?

when the foot is suspended in/moving through air

• 40% of cycle

What components make up the stance phase?

• initial contact

• loading response

• mid-stance

• terminal stance

• pre-swing

What is the initial contact phase?

heel comes in contact w/ the ground (heel strike)

What is the loading response phase?

entire foot is in contact w/ the ground

• weight transferred onto outstretched limb

What is the mid-stance phase?

body progresses over limb

• fully bearing weight on limb

What is the terminal stance phase?

progression over limb continues

• body is ahead of LE

• weight moves to forefoot

• heel rises

What is the pre-swing phase?

rapid unloading of limb as weight shifts to other side

• end of stance phase

What are the components of the swing phase?

• initial swing

• mid-swing

• terminal swing

What is the initial swing phase?

starting to advance the limb forward just after the foot has come off the floor

What is the mid-swing phase?

limb continues to advance

• knee begins to extend

• foot clears the ground

What is the terminal swing phase?

knee extends

• process of slowing LE down

• preparing for initial contact

What is step length?

distance between initial contact of one limb to initial contact of the opposite LE

• ex: L step length = distance from heel of R to heel of L

What is stride length?

distance between initial contact of one limb to initial contact of same LE

• R stride length = distance from heel R to next heel strike of R

What is cadence?

number of steps per minute (steps/min)

What is speed?

distance per unit of time (m/sec or m/min)

When does max flexion occur during the stance phase for the hip?

• 20 degrees

• initial contact

• loading response

When does max flexion/dorsiflexion occur during the swing phase for the hip?

• 25 degrees

• mid swing

When does max extension/plantarflexion occur during the stance phase for the hip?

• 20 degrees

• terminal stance

When does max extension occur during the swing phase for the hip?

• 15 degrees

• initial swing

When does max flexion/dorsiflexion occur during the stance phase for the knee?

• 40 degrees

• pre-swing

When does max flexion/dorsiflexion occur during the swing phase for the knee?

• 60 degrees

• initial swing

When does max extension occur during the stance phase for the knee?

• -5 degrees (5 degrees flexion)

• many phases

When does max extension occur during the swing phase for the knee?

• -5 degrees (5 degrees flexion)

• terminal swing

When does max dorsiflexion occur during the stance phase for the ankle?

• 10 degrees

• terminal stance

When does max flexion/dorsiflexion occur during the swing phase for the ankle?

• 0 degrees

• mid-swing

• terminal swing

When does max extension/plantarflexion occur during the stance phase for the ankle?

• 15 degrees

• pre-swing

When does max plantarflexion occur during the swing phase for the ankle?

• 5 degrees 

• initial swing

What is the total ROM required for normal gait at the hip?

• 45 degrees

• 20 extension - 25 flexion

What is the total ROM required for normal gait at the knee?

• 55 degrees

• 5-60 flexion

What is the total ROM required for normal gait at the ankle?

• 25 degrees

• 15 plantarflexion - 10 dorsiflexion

What phases of gait may be impacted by LE ROM limitations?

What is a systems review?

brief exam of the anatomical & physiological status of the 4 systems

What are the components of a systems review?

• musculoskeletal

• neuromuscular

• integumentary

• cardiovascular

• communication, affect, cognition, learning

What does the musculoskeletal component of a systems review consist of?

• gross symmetry

• gross ROM

• gross strength

• height

• weight

What does the neuromuscular component of a systems review consist of?

• gross coordinated movement

• gross motor function

What does the integumentary component of a systems review consist of?

• pliability (texture)

• presence of scar formation

• skin color

• skin integrity

What does the cardiovascular component of a systems review consist of?

• HR

• Respiratory rate

• BP

• Edema

What does the communication, affect, cognition, and learning component of a systems review consist of?

• ability to make needs known

• consciousness

• orientation

• expected emotional/behavioral responses

• learning preferences

What type of decisions would a PT make based on the results of the systems review?

• What should I do next?

• What should I examine in more detail?

• What don’t I need to do?

• Document findings

• Identify need for further examination

• Identify need for referral

• Prepare to plan interventions

What are the levels of arousal?

• Alert/awake - appropriate interactions

• Lethargic/drowsy - difficulty focusing, drowsy

• Obtunded - need repeated stimuli, frequently confused

• Stuporous (semicoma) - vigorous/repeated stimuli to arouse, unproductive

• Comatose (deep coma) - unable to be aroused

What are the levels of orientation?

• Person - name, age

• Place - where they are

• Time - date

• Situation - what is going on? why are they here?

• Ex: AOx3, x4, etc.

What is the purpose of assistive devices?

• increase BOS

• support & redistribute LE weight during stance phase

What factors from chart review need to be considered when determining what type of AD to provide a patient?

• Current medical condition

  • Diagnosis, prognosis, precautions, WB restrictions

• PMH

  • anything that impacts mobility (wounds, respiratory compromise)

• Current health status

  • prolonged bed rest, deconditioned, orthostatic hypotension

• Prior level of function

  • prior use of AD, prior need for assistance, participation, activity level

• Home environment

  • stairs, railings, assistance available

What factors from the physical examination need to be considered when determining what type of AD to provide a patient?

• systems review

  • arousal, alterness, cognition

  • ROM & strength

  • balance

  • skin integrity

  • vitals

• transfer ability

• gait

• medical stability

What are the different types of weight-bearing restrictions?

• FWB - full weight bearing

• WBAT - weight bearing as tolerated

• PWB - partial weight bearing

• TTWB - toe touch weight bearing

• NWB - non-weight bearing

What are the types of assistive devices in order of descending stability & increasing mobility?

• parallel bars

• walkers

• axillary crutches

• forearm/loftstrand crutches

• canes

What are the types of gait patterns to use with ADs?

• Step-to

• Step-through

• Swing-to

• Swing-through

What is the step-to gait pattern?

LE in swing phase is advanced only to the level of the ADs

What is the step-through gait pattern?

LE in swing phase is advanced beyond level of ADs

What is the swing-to gait pattern?

Both crutches simultaneously followed by simultaneous advancement of LEs to level of ADs

What is the swing-through gait pattern?

Both crutches advance simultaneously followed by simultaneous advancement of LEs beyond the level of ADs

What is the 3-point gait pattern?

• patients w/ 1 involved LE

  • weak, painful, decreased weight bearing

• NWB

• TTWB

• PWB

• WBAT

• FWB

What is the 4-point gait pattern?

• patients w/ bilateral LE involvement

  • poor balance, incoordination, muscle weakness, fear of falling

• WBAT

• FWB

What is the 2-point gait pattern?

• same as 4 point but better balance, coordination, less fear of falling

  • AD & LE move at same time

• WBAT

• FWB

What are the borders of the femoral triangle?

• Superior = inguinal ligament

• Lateral = sartorius

• Medial = adductor longus

What structures are found within the femoral triangle?

• femoral nerve

• femoral artery

• femoral vein

• lymphatics of femoral canal

What is the function of a foley catheter?

provide continuous drainage of the bladder

What is the clinical implications of a foley catheter?

• attach bag securely, no pulling on the tube

• keep collection unit below level of the bladder

• drain urine from catheter prior to mobility activities

• risk of UTI

• advocate for removal if mobility allows

What is the function of the suprapubic catheter?

permits urinary drainage directly from the bladder through the lower abdominal wall

What are the clinical implications for a suprapubic catheter?

• don’t place gait belt over insertion site

• same collection bag precautions as foley catheter

What is the function of a peripheral IV?

catheter in the forearm or hand to provide fluid, blood products, medications, and/or nutrients into the circulatory system

What are the clinical implications for a peripheral IV?

• check IV site for swelling and redness

• if inserted near a joint, minimize doing ROM

• don’t take BP right over the line

• never change flow rate, notify nurse if IV stops

• avoid kinking tube

• can be disconnected to allow functional mobility

What is the function of a central IV?

catheter inserted into a central vein for multiple access points to allow IV meds/fluids, chemotherapy, TPN, blood sampling/transfusions, hemodialysis

What are the clinical implications of central IVs?

• huge infection risk

• implications for bathing, participation in sports etc.

• at risk behaviors need monitoring (line to the heart)

• rolling activities can advance catheter & cause irritability 

• no soft tissue mobilization near catheter sites

What is the function of gastric/feeding tubes?

remove gastric contents to prevent vomiting or distention & provide bowel rest

What are the clinical implications of gastric/feeding tubes?

• notify nurse if patient complains of nausea

• tube may be disconnected & clamped for ambulation (ask for assistance)

What is the function of nutrition devices?

tube leading directly into the stomach to deliver nutrition

What are the clinical implications of nutrition devices?

• can be disconnected for mobility

• alert RN on return to be reconnected

• indicated for those w/ swallowing problems

• don’t lay person flat without stopping feeding

What is the function of oxygen delivery devices?

externally applied devices to deliver oxygen

What are the clinical implications of oxygen delivery devices?

• keep O2 levels above 92% (can turn up O2 if titrate orders)

• don’t change levels on CO2 retainers

• monitor O2 sats at rest and during activity

• don’t leave patient w/ lowered O2 sats

• make sure patient returns to at least baseline levels after exercise

What is the function of wound drainage tubes?

drain fluid in surgical area (tubes sutured in place & covered w/ dressing)

What are the clinical implications of wound drainage tubes?

• anchor tubes before mobilization (pin to gown)

• notify nursing of changes in amount/consistency of drainage, increased pain, break in system

• ok to repressurize if comes undone (squeeze & close)

What is the function of abdominal drains?

collect material from surgically created stomas when bowel or ureters require rerouting

What are the clinical implications of abdominal drains?

• care must be used in placement of transfer belts

• if bag falls off or leaks, help patient back to bed & notify nursing

What are the clinical implications of an external dwelling catheter?

• must disconnect from wall suction

• often fall out/off during mobility or leak

• doesn’t have same rules of traditional catheters (no collection bag)

What is delirium?

• confused mental state in which you are confused, disorientated, and not able to think/remember clearly

• temporary & treatable

• post-general anesthesia remains in body 1-2 days