Physical Agents - Exam 1 Outline

What are therapeutic modalities?

Consist of energy and materials applies to patients to assist in their rehabilitation.

Examples: heat, cold, water, pressure, sound, light, electromagnetic radiation/currents.

What role do they play in the overall rehabilitation process and Plan of care?

•Act as a component of care, treat at impairment level (decreased shoulder ROM)

•Reduce inflammation, reduce pain, accelerate tissue healing, alter collagen extensibility, and modify muscle tone

What are some of the factors that determine the selection of a therapeutic modality?

•Subjective examination, injury site and type and severity, modality indication/ contraindication/ precaution, diagnosis and prescriptions, evidence, patient willingness

•Consider treatment effects, safety, evidence, and availability/cost

What are some of the synonyms for Therapeutic Modalities?

Modalities, biophysical/electrophysical/physical agent, therapeutic modality, physical modality

What are the 4 Primary effects (clinical indications) of therapeutic modalities?

Accelerate tissue healing/reduce inflammation, relieve pain, alter tissue extensibility, modify muscle tone

What are the different Categories of Therapeutic Modalities and what is the primary role (therapeutic effect) or use of each?

•Thermal agents: pain and healing, tissue extensibility, affect circulation

•Mechanical agents: compression to reduce edema, traction to alleviate pressure on joints or nerves

•Electrotherapy agents: induce muscle contraction

•Electromagnetic agents: alter cell permeability, healing

What should be included in documentation following application of a therapeutic modality?

Body area, duration, parameters, intention, patient position, outcome

What are the general contraindications and precautions for therapeutic modalities?

•Contraindications: pregnancy, malignancy, decreased sensation/mentation, pacemaker

•Precautions: conditions that require special consideration

What is the role of EBP in use of modalities? What are some sources for evidence?

•Apply best patient care in consideration of research and the individual, include patho

•Clinical practice guidelines, PubMed

What other practitioners use modalities?

OT, AT, chiropractor, massage, acupuncture, physiatrist, patients

What is the purpose of CPT codes?

Report medical procedures to charge for clinical services

What are the two categories of CPT codes? How do they differ? Which of these category do Evaluation codes fall into?

•Service or time-based

•Service is 1 unit regardless of time

•Evaluations are considered service based

•Service: evaluation, re-evaluation, hot/cold pack, mechanical traction, diathermy, whirlpool, paraffin, unattended ESTIM, biofeedback

•Time-based: ther ex, ther act, NMR, massage, manual therapy, gait training, attended ESTIM, dry needling, US, iontophoresis

Describe the 8 Minute Rule:

•Per Medicare rules: in order to bill 1 unit of a TIMED code you must perform direct treatment for at least 8 minutes

•Any billing questions will include the 8 minute rule chart and the CPT code.

8-22 minutes = 1 unit

23-37 minutes = 2 units

38-52 minutes = 3 units

53-67 minutes = 4 units (and so on)

What factors should be understood by the rehab professional for successful rehabilitation to enhance healing?

Biomechanics, phases of tissue healing, effects of immobilization, effects of therapeutic interventions, effects of nutritional status

What are the 3 phases of Inflammation and healing?

Inflammation:

Prepares the wound for healing

Days 1-2 (up to 6)

Proliferation:

Rebuilds damaged structures and strengthen the wound

Days 3-20 (up to 3 month)

Maturation phase

Modifies the scar tissue into its form

Day 7-9 and forward up to 1-2 years.

What is the function of the inflammatory reaction?

•Prepare the wound for healing

•Stop the bleed, remove debris, collect epithelial and fibrin cells

What are the 5 classic signs of inflammation?

Hot, red, swollen, painful, decreased function

What is the difference between edema and swelling? Hematoma and Hemarthrosis?

•Edema is fluid in extravascular and interstitial space, swelling is clinical manifestation

•Hematoma in tissue or organ vs in a joint

Be familiar with the order and basic purpose of the 4 responses in the inflammatory phase.

•Vasoconstriction: reduce blood loss

•Vasodilation: blood for nutrients and healing, histamine

•Hemostasis: control blood loss

•Phagocytosis: clear debris and prepare for tissue repair

What are clinical considerations/what potential modalities would be used during the inflammation phase?

•Consider: wound care, RICE, protect and rest, medications, pain inhibitory technique, pain-free exercise to reduce edema, nutrition, modalities

•Modalities: cryotherapy, high volt pulsed current, pulsed US, intermittent pneumatic compression

What is the goal of the proliferation phase?

Cover the wound and strengthen the injury site

How are collagen fibers laid down in the proliferation phase? (cross-linking pattern)

What is the tensile strength of Type III collagen fibers? What are the clinical implications? When do the wound fibers regain 80% of long-term strength?

Fibers are laid down in a cross-linking pattern to try and add strength to the injury repair.

Allows new tissue to tolerate same movements

•15% of normal

•Disruption to tissue can resurge inflammation and lay more collagen scarring

•6 weeks they regain 80% strength ;)

What phase of proliferation stage does the "picture Frame Theory" describe?

Picture frame theory is a part of the wound contracture phase. Day 5 and peaks 2 weeks

- Edges of the wound need to close

- Myofibroblasts are on the edges

- Shape of the wound predicts the speed of closure

- Circular takes longer

What is the difference between primary and secondary intention of healing?

•Primary: superficial, smaller, suture, or little infection no wound contracture

•Secondary: significant loss, bacterial contamination wound contracture

What is the basic purpose of neovascularization?

New blood supply to injured area (supply oxygen and nutrients)

What is the goal of the maturation phase?

Modify to mature form

What happens if collagen synthesis>lysis in the maturation phase?

keloid or hypertrophic scar forms

What are the main differences between hypertrophic and keloid scars? How is scarring managed?

•Keloid expands beyond borders and darker colored, very raised

•Manage by compression to decrease O2 needed for collagen synthesis

•Hypertrophic is more skin colored and within wound borders

What are some reasons for chronic inflammation?

•Persisting injuring agent, interference of normal healing process, immune response to implant or foreign object, autoimmune disorder

What are the basic differences in healing for cartilage, tendons/ligaments, skeletal muscle, bone?

•Cartilage: limited healing unless near subchondral bone or outer meniscus (decreased blood vessels, nerves)

•Tendons: repairs close to regeneration, do not move within 3 weeks of repair, align fibers with mechanical stress

•Ligaments: type and loading matter, usually 30-50% weaker

•Intracapsular heals worse than extracapsular

•Muscle: does not proliferate, uses satellite stem cells

•Bone: uses like tissue. Inflammation, soft callus, hard callus, bone remodeling

What other factors can affect the healing process?

•Local: injury size and type and location, circulation, infection

•Environmental: modalities, movement (CPM)

•Systemic: disease, medications, nutrition, age

What is the IASP definition of pain?

Unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage

What is the purpose of pain?

•A warning for actual or potential tissue damage

•Essential for survival

What is included in optimal pain management?

•Treating the source instead of the symptoms

•Mix of modalities and active therapy/ functional restoration

•Help patients understand pain and follow treatment plan

What is nociception?

•Neural process of encoding noxious stimulation

•Nociceptors, spinal cord, brain

Understand the basic pain pathway

Pathway of pain: *** pain is NOT the same as nociception

Ex) phantom limb, adrenaline helping someone not notice pain

- Pain receptors or nociceptors are activated by intense stimuli whether internal or external

- Types of painful stimuli: thermal, mechanical, chemical(polymodal)

- Nociceptive stimulus in converted into electrical activity to form and action potential (transduction)

- Signal travels along afferent nerves toward the spinal cord and the brain, connect to transmission interneurons brought to sp cord

Characteristics of A-beta fibers

- large and myelinated

Non Painful sensations related to vibration, stretching, mechanical pressure

Have own nerve endings

Conduct impulses quickly

DO NOT provoke a pain experience but can be involved in abnormal, prolonged pain and perception.

-depends on peripheral nerve, tissue, and behavioral context

Characteristics of A-delta fibers

- Small and myelinated

- Respond to intense mechanical stimulation and heat/cold

- Sharp pain, stabbing pain, pricking

- Quick onset, shorter lasting, and localized

- Not emotional

- Not blocked by opioids

Characteristics of C fibers

- Small and unmyelinated

- Respond to mechanical, thermal, and chemical stimulation

- Dull aching pain, throbbing, aching burning, tingling, tapping

- Slow onset long lasting

- Diffused locally

- Emotional

- Autonomic responses

- Can be blocked with opioids

Where does pain become "pain?"

•Pain is an output of the BRAIN

•Nociception is NOT the same as pain

What are the three dimensions of pain?

1. Sensory-discriminative: where and what

2. Motivational-affective: how person feels about it

3. Cognitive-evaluative: intellectual thoughts of pain and what it means

What are the three distinct outputs (from the brain) in response to pain?

1. conscious perception in cortex

2. physical actions both motor and social

3. activate homeostatic systems (ANS, immune, endocrine

Describe Gate control theory.

•Pain modulation/control mechanism.

•nociceptive signals inhibited by non-nociceptive input at spinal cord

•Modalities supply this input (pressure, temp, etc @ A-beta fibers)

Describe Endogenous opioid system.

•Pain modulation/control mechanism.

•endorphins bind to opioid receptors in areas that create analgesic effects to inhibit pain, why some painful stimuli like acupuncture relieve pain

Describe Pain-spasm-pain.

•Pain modulation/control mechanism.

•interneuron activation cause muscle contraction, muscle contraction accumulates fluid and irritants, further irritate nociceptors through compression, restart cycle and increase pain through T-cells

Describe SNS.

•Pain modulation/control mechanism.

•fight or flight response, chronic activation exacerbates pain

Describe Motor system.

•Pain modulation/control mechanism.

•stiff muscles to protect from more damage, impaired movement/balance

Describe the differences between acute and chronic pain.

•Acute: direct result of actual/potential damage from wound, disease, or procedure. Expected to resolve within 3 months. Treat with drugs, education, and modalities. Often self-limited.

•Chronic: endures longer than expected, inadequate responses to care, and significant impairment of function. Cause is generally unknown and treatment often to control pain, not cure.

Describe nociceptive pain.

Clear stimulus-response injury

Somatic or visceral, usually local

Expect impairments when chronic

i.e. post-op, injury

Describe neuropathic pain.

Lesion or disease to peripheral nerves

Paresthesia, anesthesia, itching, weakness

Unpredictable, tender, painful AROM/ PROM

i.e. CRPS

Describe central sensisitization.

Facilitated transmission, inhibited opioid system, altered brain processing

No anatomical correlate

i.e. WAD, fibromyalgia, RA, LBP

Describe Dysfunctional pain.

Is not protective

Persistent, spreading, worsening, without cause

Describe psychogenic pain

Psychological processes play large role

i.e. somatization and conversion disorder

Describe the basic types of tools for Pain assessment

•ROM/mobility, functional scales, edema and scar tissue

•Semantic differential scales (categories to describe pain)

•Quick: body diagram, VAS, faces scale

•Other: pain logs, structured interviews, patient centered goal worksheets

What are the pain management approaches?

Physical Agents:

-directly moderates inflammation, modulates pain at sp cord, alters nerve conduction or increases endorphins

Helps resolve the underlying cause

Allows interactions

Avoids medications

Cryotherapy: increases pain threshold and decreases inflammatory

Thermotherapy: vasodilation to improve healing

Electrical: EOS and gate control

Traction: decompress

Pharmacological:

Systemic analgesics: NSAIDS, acetaminophen, opiods, anticonvulsants, antidepressants, spinal injections, topical

Cognitive Behavioral:

- pacing: taking breaks

Cognitive restricting: teach pain related thoughts that are positive

Graded exposure: gradual self determination towards goal

Comprehensive program: based on biopsychosocial model: focus is not eliminating the pain but on independence and overall quality of life

Coordinated team: medication, exercise, OT, cognitive behavioral

What are the modes of heat transfer?

Conduction, Convection, Radiation, Conversion, Evaporation, Cryotherapy, Thermotherapy

What is conduction? What type of modality corresponds to it?

•Contact between two items of different temperatures, more superficial tissue

•Hot to cold until equalizing

•Ex: Cold pack/ice pack, Ice massage, Cold compression units, Moist heat packs, electric heating pad, air-activated chemical heating wrap, paraffin wax

What is convection? What type of modality corresponds to it?

•Circulating medium and another material of different temperature

•Faster heat abstraction

•i.e. blood circulation

•Ex: Fluidotherapy, whirlpool, Cold baths, Contrast bath

What is conversion? What type of modality corresponds to it?

•Non-thermal energy to heat

•Mechanical, electrical, or chemical E

•Does not need direct contact

•Ex: US, Diathermy, Activating a cold pack chemically

What is radiation? What type of modality corresponds to it?

•Energy transfer without a medium

•Temp change depends on: radiation intensity, size/distance of source

•Ex: Infrared lamps

What is evaporation? What type of modality corresponds to it?

•E absorbed to change liquid to gas

•Transfer E to liquid on skin, then it evaporates and takes heat with it

•Ex: Vapocoolant spray

What are the hemodynamic effects of cryotherapy and thermotherapy?

Cryotherapy:

•Initial decrease in blood flow

•Vasoconstriction: more SNS, less vasodilator stimulants, blood viscosity increase, smooth muscle contraction

•Vasodilation when 10oC or cooler for >15 mins (smooth muscle inhibit)

Thermotherapy:

•Vasodilation (smooth muscle relaxes, inflammation, less SNS)

What are the Neuromuscular effects of cryotherapy and thermotherapy?

Cryotherapy:

•Decreased NCV (mostly A-delta)

•Reduced pain/increased pain threshold (gate control, reduced spasm, slow NCV, reduce edema)

•Altered strength (may increase 5 mins or less, otherwise significant decrease)

•Reduced spasticity (decreased Golgi tendon input and muscle spindles)

•Facilitated muscle contraction (quick icing to elicit motor patterns in flaccidity)

Thermotherapy

•Changes in NCV and firing rate (decreased pain perception and spasm)

•Increased pain threshold through "pain gating" and reduced ischemia/spasm

•Decreased muscle strength for 30 minutes from firing rates

What are the metabolic effects of cryotherapy and thermotherapy?

Cryotherapy:

•Decreased metabolic rate

•Slows reactions of inflammatory products and cartilage degrading enzymes

Thermotherapy

•Rate increases 2-3x per 10oC

•Increased O2 uptake and availability for biochemical reactions and tissue repairT

What are the Tissue extensibility effects of cryotherapy and thermotherapy?

Cryotherapy

•Makes tissue more stiff

•Increases stretch when applied to spasm

Thermotherapy

•Increased and length maintained after cooling

5-10 mins of 40-45oC

What are the clinical indications for cryotherapy and thermotherapy?

•Cryotherapy: acute inflammation, OA/RA, edema, pain control, spasticity, MS symptom management, facilitation, reduced ROM, carpal tunnel syndrome

•Thermotherapy: pain control, increased ROM, decreased joint stiffness, decreased muscle spasm, accelerated healing, infrared for psoriasis

How do cryotherapy and thermotherapy impact pain? Edema?

•Cryotherapy: reduce edema by reducing vascular permeability and local metabolism. Decreases pain by decreasing NCV/pain sensation, pain gating, decreased pain-spasm-pain cycle, decreased effects of inflammation/edema

•Thermotherapy: pain decreased through "pain gating", decreased ischemia/spasm, and changes to NCV. Heat increases edema by increasing circulation.

What are the Contraindications and Precautions of Cryotherapy?

Contraindications:

•Cold hypersensitivity, cold intolerance, cryoglobulinemia, paroxysmal cold hemoglobinuria, Raynaud's, regenerating peripheral nerves, circulatory compromise

Precautions:

•Superficial main nerve branch, open wound, HTN, decreased sensation/mentation, young/old

What are the Contraindications and Precautions of Thermotherapy?

Contraindications:

•Hemorrhage, thrombophlebitis, impaired sensation/mentation, malignancy, IR radiation of eyes

Precautions:

•Acute injury/inflammation, pregnancy, impaired circulation, edema, cardiac insufficiency, metal, open wounds, topical counterirritant, demyelinated nerves

Know the depths of heating associated with superficial/deep and what modalities are used to achieve these.

•Superficial: scar tissue, skin, superficial tendons, use moist heat. Modalities: hot pack, hot pad, whirlpool, paraffin, fluidotherapy (about ½ inch depth)

•Deep: deep tendons, joint capsules, deep muscles. Modalities: US, diathermy (about 2 ½ inch depth)

What is Ultrasound? What are its possible effects on the body?

•What: sound wave with a frequency above 20,000 Hz

•Possible effects: increased tissue temp, reduced pain/spasm, accelerated metabolic rate and healing, increased circulation, increased soft tissue extensibility, increased cell membrane permeability

What are the different types of US?

•Diagnostic: internal structure imaging, echocardiography, echoencephalography, doppler blood, obstetrical doppler

•Surgical: tissue destruction, gallstone ablation

•Therapeutic: thermal and sub-thermal effects

Understand the pathway on how US waves are produced within an US machine.

Generator makes AC current, travels through cable transducer with piezoelectric crystal, converts electrical energy to acoustic energy, US waves produced

Understand the characteristics of US waves- Continuous vs Pulsed (duty cycle)

•Continuous: 100% duty cycle, no breaks

•Pulsed: 5-50% duty cycle, breaks in pulse production

Know the depth differences based on frequency of US.

3MHz: surface to 2cm

1MHz: about 2-5cm

Be familiar with the physical effects of US- thermal vs non thermal

•Thermal: increased tissue temperature (metabolic rate increase, reduce pain and muscle spasm, altered NCV), increased circulation, increased soft tissue extensibility. CONTINUOUS US

•Non-thermal: alters cell membrane (acoustic streaming cavitation microstreaming), increased cell permeability, enhanced inflammatory process

Why does the BNR of an US matter? EPA?

•BNR: when it is a greater ratio of peak BNR, more discomfort to patient (increased intensity variation)

•EPA: when small, less tissue area treated by US or less effective

What is the Law of Grotthus- Draper?

The more energy absorbed by superficial tissues, the less remains for underlying tissues. US penetrates high water content and is absorbed by tissue high in protein/collagen

What is attenuation? What factors influence energy absorption?

•Attenuation: decrease in US intensity as it passes through tissue (high in bone/ collagen)

•Factors: attenuation, absorption co-efficients, molecular friction, US frequency, contact with effective medium, treatment angle, blood flow

What are potential adverse effects of US?

Burns and blood cell stasis, damage to endothelial lining of vessels IF don't move transducer and ignore contraindications (impaired sensation/circulation), cross-contamination

What treatment parameter considerations need to be considered with US?

•Impairments, duty cycles, depth of tissue, frequency, intensity, treatment duration, area of treatment, application technique

•Image on Slide 21 is a good summary

What are the indications for Thermal US? For Non thermal US?

•Overall affects: increase blood flow, increase tissue extensibility, decrease pain and muscle guarding, decrease motor NCV, increase sensory NCV, tendon/ligament extensibility, reduce joint pain, accelerate wound healing for ulcers/surgical incisions/scars, bone fractures, carpal tunnel syndrome, phonophoresis

•Thermal: joint contracture or scar, pain or muscle spasm, subacute or chronic inflammation

•Non-thermal: acute injury or inflammation of soft tissue or peripheral nerve, open wounds, fracture

Why do tendons require a higher rate of heating for extensibility?

High levels of collagen and avascular

What are the therapeutic effects of US on muscle, bone, hemodynamics, Nerve conduction, tissue healing/inflammation?

•Muscle: heating (reduce guarding and pain, increase extensibility)

•Bone: reduce healing time or speed up delayed healing (piezoelectric bone property)

•Hemodynamics: thermal increase blood flow, non-thermal causes reflexive vasodilation that brings in nutrients and tissue repair/cleansing

•Nerve conduction: motor slowed, sensory sped up, elevated pain threshold

•Tissue: accelerate healing for vascular and pressure ulcers/surgical incisions/scars

Be familiar with the clinical indications/applications for US.

Soft tissue shortening, pain control, dermal ulcers, surgical skin incisions, tendon and ligament injuries, bone fractures, carpal tunnel syndrome, phonophoresis

What size should the treatment area be for US?

2x-3x size of soundhead ERA

Understand the application considerations related to US.

•Evaluate: patient appropriateness, transmission medium, sound head size, treatment parameters

•Thermal goals: subacute is 1oC, chronic inflammation and muscle spasm and pain modulation are 2oC, stretch collagen and increase blood flow is 4oC tissue temp increase

•Non-thermal: pulsed 20-50% with low intensity for inflammation/proliferation stages

•Apply: move sound head with slow strokes 4cm/sec keeping faceplate flat, then turn on machine, monitor patient throughout

What is phonophoresis? Is there strong or weak evidence related to phonophoresis?

Drug delivery through skin by use of US, generally supported by current research

What are the contraindications and precautions related to US?

Contraindications:

•Malignancy, pregnancy, CNS tissue, pacemaker, eyes or reproductive organs, DVT or thrombophlebitis, active bleed or infection, joint cement, plastic

Precautions:

•Acute inflammation, epiphyseal plates, fractures, breast implants

What are the Considerations for Diathermy

Types: Shortwave and microwave

Closer the applicator -> the greater the effect

Minimal reflection at tissue interface (vs US)

Deeper heating than superficial modalities

Larger area treated vs. US

Does not require constant attention

Inductive SWD

- Magnetic field produces eddy currents

- Deep tissues heated effectively

- ↓ impedance = ↑ conductivity = ↑ heating

Subcutaneous fatty tissue heated > muscle

What determines the temperature in the use of Diathermy?

Field intensity, tissue type, duty cycle, distance from patient

What are the thermal and nonthermal effects of diathermy? What are the indications/clinical applications for diathermy?

•Thermal: larger area than US, deep tissue healing, vasodilation, collagen extensibility, NCV, increased enzyme activity and metabolism

•Non-thermal: increased microvascular perfusion (oxygenation, nutrition, phagocytosis), altered cell membrane function and cellular activity (growth factor, macrophage activity, myosin/ATP/protein production)

•Thermal applications: pain control, accelerated tissue healing, decrease joint stiffness, increased joint ROM

•Non-thermal applications: control pain/edema, healing soft tissue/nerve/bone, improve OA symptoms

What are the two types of Shortwave diathermy applicators? With which applicator is the patient part of the electric circuit?

•Inductive coils: drum makes electrical eddies using magnetic field, deeper heating of muscles

•Capacitive plates: create an electric field, more superficial heating of fat and bone, **makes tissue a part of the electric field

What are the contraindications of diathermy?

Both:Neural stimulators like pacemakers, pregnancy

Thermal: Metal implants, Malignancy, Eyes, Testes, Growing epiphyses

Nonthermal: Internal organs, Substitute for conventional therapy for edema/pain, Metal implant

What are the precautions of Diathermy

Both: Near electric/magnetic equipment, Obesity, Copper-bearing IUD

Non-thermal: Skeletal immaturity

What are clinical decision making considerations in choosing US vs Diathermy?

•US: smaller areas of dense collagen (ligaments, tendons, joint capsules)

•Diathermy: tissues with high fluid content, large areas (muscles)

-Diathermy more common in Europe, most here are pulsed

What is traction?

Traction: tensional mechanical force applied to the body in a way that separates the joint surfaces and elongates surrounding soft tissues

Where and how can traction be applied?

Can be applied to spinal or peripheral joints

•Application of Traction to spine:

- Mechanical Traction devices

- Manual Traction by the clinician

- By the patient with body weight and gravity

•Application to Peripheral joints

- Traction applied manually by the clinician at the peripheral joints

- Considered manual therapy vs mechanical traction

Understand anatomy in reference to effects of traction.

•Total of 33 vertebral bodies

•Nutrients are received and removed by fluid compression

•Intervertebral foramen: Where the spinal nerve exits

•Facet joint (aka apophyseal or zygapophyseal joint): Synovial (posteriorly)

•Intervertebral discs: made up of the annulus fibrosis and nucleus pulposus

•If the annulus tears from the inside out, won't feel until something bulges (deforms soft tissue around annulus that is nerve innervated

Understand biomechanics in reference to effects of traction.

•Extension = compression of the disc posteriorly

- Narrow the foramen, compress the supraspinous and interspinous ligaments and facets

•Flexion = compression of the disc anteriorly

- Stretch the supra and interspinous ligaments and facets, widens the foramen