Lecture 1 Exam | PTAP-130: Therapeutic Modalities

based off lecture 1 exam study guide!

What is the clinical definition of pain (as defined by the IASP)?

“An unpleasant sensory & emotional experience which follows actual or potential tissue damage or is described in terms of such”

What is nociception?

The neural process of encoding a noxious stimulus (mechanical, chemical, or thermal) that is intense enough to potentially damage a body tissue

• It’s the process of our body figuring out what is painful/harmful

  • Think of your reaction to casually bumping into a table vs. touching a hot stove

• Most never results in consciously perceived pain

What are the 3 stages in the Vicious Pain Cycle?

Pain → spasm → ischemia

What are the stages in the Persistent (Chronic) Pain Cycle?

This is just a more detailed Vicious Pain Cycle

Pain → muscle guarding → restricted ROM → muscle weakness & atrophy → decreased function → psychological stress

What’s the difference between acute vs. chronic pain? (These are not the same as acute/chronic tissue healing!)

What is the cause? Timeframe?

Acute:

• short-term

• caused by trauma/infection/post-surgical

• first 6 weeks

Chronic:

• long-term

• cause uncertain or not correctable; medical treatments have been ineffective

• longer than 3-6 months

What is hyperalgesia?

Cause?

Excessive sensitivity to pain, which may be caused by nerve damage

What is allodynia?

Provide an example

Pain due to stimulus that does not normally provoke pain

(ex. light touch hurts)

What is analgesia?

Provide an example

Absence of pain/sensation in response to a stimulus that would normally be painful, usually due to an interruption in the nervous system pathway between the painful area & the brain

(ex. after surgery, around the scar, some people don’t feel pain due to nerve ending damage)

What is referred pain?

Pain you feel in one part of your body while the actual source of the problem/injury is elsewhere in the body

What is visceral referred pain?

Pain arising from deep body structures (organs) that can be difficult to locate, & at times, can be felt at another distant site

(ex. shoulder pain caused by a heart issue)

What is a trigger point?

What are 4 characteristics of a trigger point?

A focus of hyper irritability in a tissue that’s usually palpable

• when compressed, it’s locally tender

• prevents full lengthening of muscle

• weakens the muscle

• gives rise to referred pain

What is the Gate Control Theory?

Where in the body does this theory occur? What is used to “close the gate”?

Non-painful sensory input can inhibit (“close the gate”) the transmission of pain signals at the spinal cord level

• The dorsal horn is where nociceptive input gets regulated by non-nociceptive input (touch, cold, heat) — physical agents use this to help “close the gate”

Pharmacological pain management:

This is the first line of treatment for moderate-severe acute pain!

1. What are the 3 goals of it?

2. What are the 6 different types?

3. Provide common examples of the different types of medications

1. Control pain by modifying inflammatory mediators at the periphery; Alter pain transmission from the periphery to the cortex (brain); Alter the central perception of pain

2. NSAIDS, Analgesics w/o anti-inflammatory, Opioids, sometimes antidepressants & anticonvulsants, sometimes local injections of corticosteroids or anesthetic for local inflammation

3. NSAIDS = ibuprofen, aspirin, naproxen sodium; Analgesics w/o anti-inflammatory = acetaminophen (Tylenol); Opioids = morphine, fentanyl, oxycodone

Non-pharmacological pain management:

1. What are the 5 goals of it?

2. What does the acronym RICE stand for?

3. What does each component of RICE do for pain management?

1. Control inflammation; Inhibit nociception; Provide clear guidelines for activities that encourage appropriate stress on the tissues; Teach rest & relaxation; Repeatedly reassure the patient

2. Rest, ice, compression, elevation

3. Rest = allows damaged tissues to heal; Ice = reduces inflammation → reduces peripheral sensitization in the tissues; Compression & elevation = reduce edema

What are dermatomes?

A skin area supplied by one dorsal (sensory) nerve root

What area of skin is dermatome C2?

Posterior head

What area of skin is dermatome C3?

Posterolateral neck

What area of skin is dermatome C4?

AC joint

What area of skin is dermatome C5?

Lateral arm

What area of skin is dermatome C6?

Lateral forearm & thumb

What area of skin is dermatome C7?

Distal phalanx of the middle finger

What area of skin is dermatome C8?

Little finger & ulnar border of hand

What area of skin is dermatome T1?

Medial forearm

What area of skin is dermatome L2?

Anterior proximal thigh

What area of skin is dermatome L3?

Middle third of anterior thigh

What area of skin is dermatome L4?

Patella & medial malleolus

What area of skin is dermatome L5?

Fibular head & dorsum of foot

What area of skin is dermatome S1?

Lateral & plantar aspect of foot

What area of skin is dermatome S2?

Medial aspect of posterior thigh

What are myotomes?

The group of muscles primarily innervated/controlled by a single motor nerve group

What are the 5 cardinal signs of inflammation?

Include the Latin terminology!

1. Heat (calor)

2. Redness (rubor)

3. Swelling (tumor)

4. Pain (dolor)

5. Loss of function (functio laesa)

What are the 3 stages of tissue healing & their rough timelines?

1. Inflammation (days 1-6)

2. Proliferation (days 3-20)

3. Remodeling/Maturation (days 9-onwards; could be 1-2 years)

Inflammation Phase:

1. What starts the inflammation phase?

2. What are the 2 goals of acute inflammation?

3. What cells are involved & what do they do to prepare the tissue for healing?

4. What happens if no inflammation occurs?

1. When the normal physiology of a tissue is altered by disease or trauma

2. Restore function by eliminating the pathological or physical insult; Replace the damaged or destroyed tissue & promoting regeneration of normal tissue structure

3. Platelets = coagulate to block off the injured area; Neutrophils = fight infection; Macrophages = remove any dead cells

4. Healing can’t take place

Proliferation Phase:

1. What are the 2 goals?

2. What’s happening during this phase and how does it happen?

3. What is the relationship between collagen & strength during proliferation?

1. Cover the wound; Provide strength to the injury site

2. Injured tissue gets replaced by newly formed tissue; Fibroblasts = make collagen, which makes new connective tissue; Neovascularization = new capillaries form through angiogenesis (new vessels come from pre-existing ones)

3. During this phase, the injured area has the greatest amount of collagen, yet its tensile strength can be as low as 15% of that of normal tissue

Remodeling/Maturation Phase:

1. What is the goal of this phase?

2. What 2 things are happening to the newly-formed scar tissue?

3. What physical signs show that remodeling is still occurring?

1. To restore prior function to the injured site

2. Fiber orientation begins to mimic that of pre-injured tissue; Improves balance of collagen synthesis & lysis

3. The scar will appear redder/darker than the surrounding tissue

How do you position a pt for short-term supine?

1. Pillow under head

2. Pillows or bolster under the knees

This minimizes excessive lumbar lordosis!

How do you position a pt for short-term prone?

1. Pillowcase inside cutout of table

2. Pillow or bolster under the shins

3. Pillow under stomach/hips

How do you position a pt for short-term side-lying?

1. Pillow under head

2. Small towel roll under the waist (not-typical)

3. Pillow between the knees w/ pt hugging another pillow

How do you position a pt for short-term sitting?

1. Small bolster or towel roll behind small of back; Can also place a pillow

2. Hips flexed to 90° by elevating feet w/ a stool or lowering the table to the ground

What are the 5 types of energy transfer?

Describe them & provide an example

1. Convection — direct contact (ex. moist heat pack)

2. Conduction — movement of air, matter, or liquid (ex. fluidotherapy)

3. Conversion — energy transforms from one form into another (ex. ultrasound)

4. Radiation — transfers heat through air (ex. infrared lamp)

5. Evaporation — transformation of liquid to gas (ex. vapocoolant sprays)

Physiological Effects of Thermotherapy:

What are the 3 different levels (temperatures) of heat?

1. Mild = 104°F

2. Vigorous = 104-111.2°F

3. Damage = greater than 111.2°F

What are the 6 indications of thermotherapy?

1. Pain reduction & management

2. Reduce muscle guarding

3. Increase soft tissue extensibility

4. Increase ROM

5. Osteoarthritis

6. Rheumatoid arthritis

What are the 7 contraindications to thermotherapy (heat)?

1. Impaired sensation

2. Impaired mentation

3. Malignant tumor (cancer)

4. Recent or potential hemorrhage (bleeding)

5. Peripheral vascular disease (PVD; narrowing, blockage, or spasms in a blood vessel → blood can’t get to peripheral areas of the body)

6. Thrombosis (formation of a blood clot inside a blood vessel → blood flow is obstructed)

7. Infrared radiation of the eyes

What are the 10 precautions to thermotherapy (heat)?

1. Acute injury/inflammation

2. Pregnancy

3. Impaired circulation

4. Poor thermal regulation (body can’t maintain normal internal temperature)

5. Edema

6. Cardiac insufficiency

7. Metal/jewlery in the area

8. Open wounds

9. Over areas where topical counterirritants have recently been applied

10. Demyelinated nerves (damage to myelin sheath → slows or stops electrical impulses)

What are 5 superficial heating agents (methods/types)? What are 2 deep heating agents (methods/types)?

Superficial:

1. Moist heat packs

2. Air-activated heat wraps

3. Warm whirlpool

4. Fluidotherapy

5. Paraffin wax

Deep:

1. Continuous, uninterrupted ultrasound

2. Continuous, shortwave diathermy

What are the treatment times for thermotherapy (moist heat, fluidotherapy. & paraffin)?

1. Moist heat packs = 10-20 minutes (10 minutes for achieve maximum skin temperature change)

2. Fluidotherapy = 10-15 minutes

3. Paraffin wax = 15-20 minutes

What are the 5 physiological effects of cryotherapy (cold)?

1. Vasoconstriction of superficial blood vessels

2. Reflex vasconstriction (when blood vessels involuntarily vasoconstriction is response to smooth muscle contraction)

3. Reduce blood flow

4. Reduce metabolic rate

5. Decrease elasticity

What are the 5 indications for cryotherapy (cold)?

1. Pain reduction

2. Reducing muscle guarding

3. Reducing muscle spasticity

4. Reduce inflammation

5. Reduce edema

What are the 6 contraindications for cryotherapy (cold)?

1. Hypersensitivity to cold

2. Raynaud’s disease (temporary narrowing of small blood vessels in fingers & toes → hands & feet become cold)

3. Cryoglobulinemia (blood proteins clump together in cold temperatures → blood vessels get blocked → inflammation)

4. Paroxysmal cold hemoglobinuria (exposure to cold temperatures triggers immune system to destroy its RBCs)

5. Peripheral vascular disease (PVD; narrowing, blockage, or spasms in a blood vessel → blood can’t get to peripheral areas of the body)

6. Over an area of circulatory compromise

What are the 5 precautions for cryotherapy (cold)?

1. Over the superficial main branch of a nerve

2. Over an open wound

3. Hypertension (vasoconstriction makes the heart work harder than it already has to)

4. Poor sensation or mentation

5. Very young & very old pts

With cryotherapy, what tissue temperature may result in thermal damage to tissue?

50°F or below

What are the 5 different methods/types of cryotherapy (cold)?

1. Ice massage

2. Game Ready (cold w/ compression)

3. Gel ice packs

4. Cold baths

5. Vapocoolant sprays

What are the treatment times for cryotherapy (ice massage, Game Ready, gel ice packs)?

1. Ice massage = 5-10 minutes for 10×15 cm area (can go up to 20 minutes)

2. Game Ready = 10-30 minutes (depends on temperature)

3. Gel ice packs = 10-15 minutes

Patient response to treatment:

1. When performing a skin assessment prior to applying heat/ice, what 3 characteristics are you looking for?

2. What are the 2 types of pigmentation you can observe? What are they indications of?

1. Color (pigmentation), continuity (presence of wounds, blisters, or rashes), temperature

2. Pale or bluish = decrease in blood flow (frostbite); Pink or red = increase in blood flow (burn or inflammation)

Patient response to treatment:

1. What is blanching?

2. How do you perform a Capillary Refill Test? What do the results tell you?

1. When a reddish/colored area of skin temporarily turns white/pale when you press on it

2. Apply pressure to the skin → area of skin turns white/pale → pigmentation should reappear within 3 seconds; Longer response time may indicate impaired circulatory function or possible increased sensitive to heat/cold if scar tissue is present

Patient response to treatment:

1. What is erythema?

2. What is pallor?

3. What is mottling of the skin? What can this be an indicator of?

1. Redness of the skin caused by hyperemia (increased blood flow)

2. Paleness, ashen/gray, yellowish skin

3. Spotty patches of erythema that occur after application of thermal agents; Can be a warning sign of potential inability of the tissue to respond appropriately/adequately to the thermal agent

Patient response to treatment:

1. What 3 changes occur after heat application?

2. What 2 changes occur after cold application?

1. Local vasodilation, erythema, & possible perspiration

2. Vasoconstriction, then reflex vasodilation after 8 minutes of application

Patient response to treatment:

What are contraindications for heat/cold related to temperature of the area to be treated?

1. Red & warm = pt may have infection or inflammation

2. Cooler & pale = pt may have impaired circulation (vascular insufficiency)

What are 3 thermal & 4 non-thermal purposes for using ultrasound?

Thermal Purposes:

1. Heats deep tissue

2. Increase tissue extensibility

3. Heating tendons, ligaments, joint capsules, & fascia

Non-thermal Purposes:

1. Accelerate body’s natural healing process

2. Increase cell membrane permeability

3. Promotes function of various types of cell

4. Particularly effective during inflammatory phase of tissue repair

What are the 8 indications for using ultrasound?

1. Soft tissue shortening

2. Pain control

3. Tendon & ligament injuries

4. Introduction of medication through phonophoresis (topical agent application using US)

5. Dermal ulcers

6. Surgical skin incisions

7. Carpal tunnel syndrome

8. Tissue with high collagen content & tissue boundaries

What are the 9 contraindications for ultrasound?

1. Malignant tumor (cancer)

2. Pregnancy

3. Central nervous system tissue

4. Joint cement

5. Plastic components

6. Pacemaker/implantable cardiac rhythm device

7. Thrombophlebitis (blood clot blocks 1 or more veins)

8. Eyes

9. Reproductive organs

What are the 4 precautions for ultrasound?

1. Acute inflammation = heat can exacerbate this

2. Epiphyseal plates = high-dose US w/ intensities greater than 0.5 W/cm² shouldn’t be applied over growing epiphyseal plates

3. Fractures = low-dose US can accelerate Fx healing, but high-intensity can cause pain & may impair Fx healing

4. Breast implants = heat may increase pressure inside, causing it to rupture

What is indirect ultrasound?

What makes it different from direct ultrasound? How is the sound head oriented in relation to the involved body part? Generally, what intensity should be used?

When water is used as a coupling agent instead of gel typically for uneven surfaces (ex. hands/fingers or feet)

• The involved body part & sound head of the US device are submerged in a plastic container of water

• The sound head is held 1-2 cm away from the body part

• Intensity must be increased by 50% (0.5) compared to direct

What is the difference between pulsed and continuous ultrasound?

How are they written on the ultrasound machine? What general patient conditions are they used for? What intensities are used for each?

Duty factor parameters (aka the percentage of on time/(on + off time))

Pulsed:

• 20% (most common) or 50% duty cycle

• used for acute pain & non-thermal effects

• 0.3 - 1.0 W/cm² intensity

Continuous:

• 100% duty cycle

• used for chronic pain & thermal effects

• 0.5 - 2.0 W/cm² intensity

What are the 5 parameters for ultrasound?

1. Frequency (MHz)

2. Intensity (W/cm²)

3. Duty Cycle (continuous or pulsed)

4. Size of Treatment Area

5. Duration

What are the 2 different frequencies used for ultrasound? When would you use them?

1. 1 MHz = DEEP tissues (2.5 - 5 cm)

2. 3 MHz = SUPERFICIAL tissues (1 - 2 cm)

Patient response to treatment:

What can the pt expect to feel with ultrasound?

• Normally, the pt should not feel anything aside from the ultrasound gel & the sound head on their skin

• Depending on the treatment, the sound head may get warm

• Pt should inform if it gets too hot or yields a stinging sensation

What are the 4 indications for cervical traction?

1. Osteoarthritis

2. Radiculopathy (radiating nerve pain that “shoots down” their body)

3. Disc herniation (when the soft center of a spinal cushion pushes through & presses on nearby nerves)

4. Tension headaches

What are the 3 indications for lumbar traction?

1. Low back pain

2. Radiculopathy (radiating nerve pain that “shoots down” their body)

3. Disc herniation (when the soft center of a spinal cushion pushes through & presses on nearby nerves)

What are the 11 contraindications for traction?

1. Any motion that is contraindicated (pts are prescribed to not move in certain directions)

2. Acute injury or inflammation

3. Joint hyper mobility or irritability

4. Peripheralization of symptoms with traction

5. Uncontrolled hypertension

6. Spinal infections

7. Rheumatoid arthritis

8. Osteoporosis

9. Cancer of the spine

10. Fractures

11. Hernias, hemorrhoids, aneurysms

What are the 8 precautions for traction?

1. Disc protrusions

2. If pain resolves immediately after traction

3. Displaced annular fragment

4. Pregnancy

5. Claustrophobia

6. Inability to tolerate prone/supine position

7. Disorientation

8. Acute injury or ligament strains

What is the friction coefficient? What is the standard?

Why is this used? When is it used?

1. An amount that tells you how much of your traction pulling force gets “eaten up” by friction between the table and the pt’s body during lumbar traction; Standard is 0.5 (50%)

2. Used to account for the friction between the pt & the table when pulling on a pt for lumbar traction; Also takes into account whether the pt has a thoracic harness or not & if there is a split table

3. Only used in the absence of a split table; Considers the pt being pulled w/o the thoracic harness & w/ the thoracic harness

What is the difference between static & intermittent traction?

Static:

• low force & shorter treatment duration usually used for initial/acute phase

• force is consistently held throughout the total treatment time

Intermittent:

• greater force & longer treatment duration

• force is held at max for a hold time, then released to the min force for a relax time

What are the parameters for cervical traction?

Include goal of treatment, total force, hold/relax time, & total treatment time

Initial/Acute Phase:

• 7-9 lbs

• static

• 5-10 min

Joint Distraction:

• 20-29 lbs; 7% of body weight

• 15/15 sec

• 20-30 min

Decreased Muscle Spasm:

• 11-15 lbs

• 5/5 sec

• 20-30 min

Disc Problems or Stretch of Soft Tissue:

• 11-15 lbs

• 60/20 sec

• 20-30 min

What are the parameters for lumbar traction?

Include goal of treatment, total force, hold/relax time, & total treatment time

Initial/Acute Phase:

• 29-44 lbs; 25% of body weight

• static

• 5-10 min

Joint Distraction:

• 50 lbs; 25-50% of body weight

• 15/15 sec

• 20-30 min

Decreased Muscle Spasm:

• 25% of body weight

• 5/5 sec

• 20-30 min

Disc Problems or Stretch of Soft Tissue:

• 25% of bodyweight

• 60/20 sec

• 20-30 min

Patient response to treatment:

What is radicular pain? What is centralization? What is peripheralization?

1. Radiating nerve pain

2. Symptoms move back towards the spine (good sign)

3. Symptoms spread further away from the spine (bad sign)

What is manual traction?

When is it used?

Traction before by the clinician using their hands or extensions (belts/harnesses)

• used before attempting mechanical traction to determine whether symptoms centralize or peripheralize

What are the indications (mechanical, 4, & physiological, 5, effects) for myofascial release & STM?

Mechanical Effects:

1. Stretch intramuscular CT

2. Enhance tissue repair & scar formation

3. Break up adhesions

4. Increases ROM

Physiological Effects:

1. Reflexive = Sedation (reduces BP & HR, reduces anxiety & stress)

2. Relieves tension

3. Increases blood flow

4. Reduces pain

5. Increases lymphatic & blood flow

What are the 6 contraindications for myofascial release and STM?

1. Fever = may be a sign of acute inflammation or systemic distress

2. Acute inflammation = massage may spread inflammation

3. Skin conditions = anything contagious or that could be worsened by applying pressure

4. Blood poisoning & infections = massage increases circulation in both the lymphatic & circulatory systems

5. Malignancy (cancer) = massage increases circulation in both lymphatic & circulatory systems

6. Bleeding & bruising = possible disruption of tissues already damaged

What are the 8 precautions for myofascial release & STM?

1. Recent surgery = contact physician + be careful where & how much pressure you apply

2. Burns = skin is extremely fragile

3. Recent fractures = stability of the fracture site will need to be discussed with the physician

4. Decreased sensation = pt may not be able to provide accurate feedback

5. Increased sensitivity to touch = be aware of pt’s reaction to massage & adjust accordingly

6. Cardiovascular disorders = pts may be on medications & increased circulation may/may not be desired

7. Edema = some may be indication, while others may be contraindications/precautions

8. Osteoporosis = bones are brittle & fracture more easily

What are the 8 techniques used for myofascial release & STM?

1. Effleurage

2. Petrissage

3. Tapotement

4. Myofascial skin rolling

5. Myofascial spreading technique

6. Scar mobilization

7. Trigger point release

8. Transverse Friction (Cross-Friction)

What is effleurage?

Include technique, why it’s used, & what it’s effects are

Slow, repetitive strokes applied by sliding & gliding hands over body commonly used to being/end or to transition

• Has the mechanical effect of stretching muscle & fascia; increases venous & lymphatic circulation

What is petrissage?

Include techniques & effects

After effleurage; includes kneading to break adhesions

• Pressing, rolling, squeezing to improve mobility in superficial & deep muscle fascia

• Improves circulation & cellular nutrition

What is tapotement?

What are the 3 techniques?

Percussion movements performed in a rapid, alternating matter w/ minimal force

• Hacking = hands neutral & facing each other, striking w/ ulnar side of wrist/hand (don’t hack over the kidneys!)

• Rapping = uses a lightly closed & loosely held fist

• Cupping = hands cupped & thumb held against 1st metacarpal; light force creates a hollow sound

What is myofascial release?

What are the 2 types?

A set of soft tissue techniques aimed at relieving soft tissue from the abnormal grip of tight fascia; Relieves mobility restrictions & pain

1. Myofascial skin rolling technique

2. Myofascial spreading technique

What is scar mobilization?

What are the different techniques? What are the effects?

Various massages techniques to separate tissues & break up adhesions created by skin scarring

• lifting, broadening, & applying shear forces

• may lead to increased skin, muscle, & joint flexibility

How do you perform Trigger Point Release?

What does trigger point release do?

Pressing firmly on a trigger point for 20-60 seconds, gradually increasing pressure to the point that the pt reports discomfort

• causes the sarcomeres to lengthen

What is Transverse Friction (cross-friction) technique?

How long should this be performed?

What conditions is this technique indicated for?

Repetitive, specific, non-gliding technique that produces movement between the fibers of the CT (2-3 cycles per second for 5-20 minutes)

• Used for any condition where mobility has been compromised by irregular tissue remodeling (ex. sprains, strains, tendinitis, tensynovitis, plantar fasciitis)