Foundations- Intro to Physical Agents – Flashcards
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Examples of Thermotherapy
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Hydrocollator packs Fluidotherapy Paraffin
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Examples of Deep Heating Modalities
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Diathermy (not use much anymore) Ultrasound Diathermy and US also have non-thermal, mechanical properties
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Examples of Cryotherapy
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Cold packs Ice massage Vapocoolant spray (own class, do not have same properties as ice packs)
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Examples of Phototherapy
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Cold laser, SLD (superluminous diode), Low intensity light therapy (LILT)
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Examples of Mechanical Agents
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Traction Intermittent compression
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Examples of Hydrotherapy
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Whirlpool Pulsed lavage (wound care) Aquatic exercise
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Describe important elements of patient education when using physical agents.
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1. Goals of treatment- why you are choosing this approach, expected outcome (informed consent) 2. What pt should expect to feel during Rx 3. Encourage ongoing communication- If they have any discomfort they should let you know 4. Collaboration- Pt is an active participant/partner in care
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Describe the 5 cardinal signs of acute inflammation.
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Calor- heat Rubor- redness Tumor- swelling Dolor- pain Functio laesa- loss of function
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Time frames for the 3 phases of tissue repair
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Inflammatory Phase: 1-6 days Proliferative phase: 3-20 days Maturation Phase: 9 days and on Time frames are approximate, depends on individual pt as well as extent of injury, intrinsic, and extrinsic factors
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Describe the physiologic effects of thermal modalities as they relate to pain modulation.
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1. Moist heat causes local vasodilation - reduces ischemia. If there is decreased ischemia, there should be a decrease in pain. Moist heat can also have a sedative effect on the nerve endings (reduces transmission of pain). Break in pain can lead to a decrease in muscle tension. Increase in local circulation can improve blood supply and enhance healing. 2. For ice - cold decreases nerve conduction velocity in pain fibers - numbness helps break pain cycle. In acute injuries, ice decreases local metabolic demands - allows tissues to maintain viability during periods of limited circulatory supply. 3. Superficial Vasodilation - Hyperemia - Reflex activation of sympathetic cholinergic nerve fibers - Release of AcCh - Triggers relaxation of smooth muscle surrounding the blood vessels
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Arndt-Shultz Principle
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40-45 degrees C, 104-113 degrees F 1. Temps below this level do not have therapeutic value as heating modalities 2. Temps above this level can cause tissue damage 3. Must also consider rate of temp change and time of exposure
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List the 5 methods of heat transfer - for each category, give an example of a physical agent that acts through this method.
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1. Conduction: direct contact, molecular collision. (Hot packs, cold packs) 2. Convection: mov't of air or water, passes over skin surface leading to heat exchange (Whirlpool, fluidotherapy) 3. Evaporation: heat abstraction, skin cools as fluid evaporates (Vapocoolant spray- spray and stretch) 4. Conversion: one form of energy converted into heat (US- sound waves generate heat in tissue due to increased molecular motion) 5. Radiation: transmission by electromagnetic rays (thru air) (Heat lamp)
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How would you distinguish between superficial and deep thermal modalities? Give examples of each.
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Superficial: Penetrate 0.5 - 1.0 cm; Ex: Hot packs, paraffin, infrared lamps, fluidotherapy Deep: Short wave diathermy, US, Microwave diathermy
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What factors should be considered when selecting an appropriate physical agent/ modality?
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1. Goals of Rx 2. Stage of healing process/clinical presentation- Acute inflammation- heat would not be appropriate 3. Availability of modalities: cost, efficiency 4. Time management 5. Clinician/pt preference 6. Sequencing of Rx- Exercise first then cold pack vs. cold pack first then exercise (Using ice first takes away some pain but then if you have pt do balance exercises you have also taken away some proprioception, pt may also not be able to tell if exercise is too intense.) 7. Complicating factors/comorbidities 8. Contraindications/precautions 9. Evidence-based information/strength and availability of supportive research 10. APTA Guide to PT Practice 11. Presence and degree of pain`
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What is the appropriate temperature range for the hydrocollator tank?
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160-170 degrees F
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Indications for application of hot pack
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1. Pain relief 2. Reduce muscle spasm 3. Increase soft tissue extensibility prior to stretching 4. Promote soft tissue healing 5. Decrease joint stiffness 6. Encourage general relaxation 7. Prior to application of electrical stimulation 8. Consensual heating
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Contraindications for application of hot pack
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1. Acute inflammation 2. Fever 3. Cardiac insufficiency 4. Hemorrhage or acute risk of bleeding 5. Very young, very old pts 6. PVD/decreased peripheral circulation 7. Infection 8. Over areas of known malignancy 9. Thrombophlebitis 10. Where liniment has been applied (find out about ointments pt may typically use, could cause rash) 11. Over Rx site for radiation therapy
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Precautions for application of hot pack
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1. Edema 2. Poor sensation 3. Barriers to communication 4. Metal implants (depth?- can heat get deep enough to reach it. Location?)
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Outline the proper procedure for application of a hot pack. (Be sure to specify the correct number of towel layers that should be placed between the patient and the modality, as well as between the modality and the environment.)
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1. Pt education: Tell pt what you are going to do, explain why you are going to do it, describe what pt should feel, encourage pt feedback throughout Rx 2. Pre-Rx Assessment 3. Preparation of target area: Should be free of clothing- pack is moist will make clothing damp during Rx- pt should be draped or wear gown. Remove jewelry due to possibility of skin irritation 4. Preparing the hot pack: **6 to 8 LAYERS** of toweling b/w pack and pt. Commercial terry cloth cover counts as 4 layers. Tuck in tabs. **Cover w/ 1-2 LAYERS** of towels to insulate heat. Avoid having pt lie directly on hot pack v. Rx duration 15-30 minutes (20 minutes is usual max)
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Aspects of pt education
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1. Tell pt what you are going to do 2. Explain why you are going to do it 3. Describe what pt should feel 4. Encourage pt feedback throughout Rx
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Aspects of Pre-Rx Assessment
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1. Review hx and clinical presentation for contraindications/precaautions 2. Assess skin integrity and sensation (check sharp/dull) 3. Determine outcome measures- will be repeated at end of Rx to measure pt response (ROM, pain scale, presence of muscle spasm/trigger point)
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Aspects of Preparation of target area
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1. Should be free of clothing- pack is moist will make clothing damp during Rx- pt should be draped or wear gown 2. Remove jewelry due to possibility of skin irritation
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Aspects of Preparing the hot pack
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1. ***6 to 8 layers*** of toweling b/w pack and pt- Commercial terry cloth cover counts as 4 layers 2. Tuck in tabs 3. ***Cover w/ 1-2 layers*** of towels to insulate heat 4. Avoid having pt lie directly on hot pack 5. Rx duration 15-30 minutes (20 minutes is usual max)
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Aspects of Positioning and Draping
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1. Position for pt comfort and to allow application of hot pack to target area 2. Body part should be well supported to promote pt relaxation 3. Drape for comfort and modesty
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What to do during treatment
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1. Perform interim checks- skin color, temp, pt subjective response 2. Pt should have call bell or means of contacting therapist during course of Rx
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Aspects of Post-Rx Assessment
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1. Check skin for appropriate response 2. Check pt's subjective response: "how are you feeling?" 3. Repeat outcome measures (pain scale, ROM, tenderness on palpation, etc.)
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Normal Rx response (hot packs)
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Pink skin Moist, presence of perspiration Mildly warm to touch
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Adverse Rx response (hot packs)
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Excessive redness, burns, or blisters Pt discomfort **Fainting- usually due to orthostatic hypotension, monitor vitals, raise legs, lower head
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Why would paraffin be used as a component of a physical therapy plan of care
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Form of conductive heat, contours well to body
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Indications for use of Paraffin
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1. Rx of distal extremities: hands, feet, ankles 2. To alleviate jt pain and stiffness 3. To improve tissue extensibility, soften adhesions- Rx of healed scars and burns
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Contraindications of use of Paraffin
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1. Open wounds 2. Acute jt inflammation 3. Decreased sensation (need to be able to tell if they hit the bottom or sides of the tank)
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Precautions for use of Paraffin
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1. Barriers to communication 2. Impaired ability to follow directions 3. Must instruct pt not to touch bottom or sides of tank**
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What is the correct temperature range for paraffin?
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113-122 Degrees F
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What is the most common method of paraffin application?
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Glove method: 6-12 dips, then remove Wrap hand or body part in wax paper, then towels to insulate heat Wax remain on approx. 15 minutes (while warm)
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How would you educate a patient who will be receiving paraffin?
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1. Informed consent: tell pt what you are going to do, explain why you are going to do it 2. Describe what pt should feel 3. Encourage pt feedback throughout Rx 4. Caution pt not to touch bottom or sides of tank 5. Pt must be instructed to limit mov't of body part during application
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What would be considered a normal versus adverse response to Rx with paraffin?
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Normal- Pink skin, Oily skin, Perspiration Adverse- Presence of burns or blisters, Excessive redness, Patient discomfort
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What is fluidotherapy and when would it be used?
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Superficial heating modality. Heats by convection and conduction- dry heat Self-contained tank of small particles circulated by warm air current. Air speed and level of agitation can be adjusted. Tactile input from small particles can act to desensitize Rx area.
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Advantages vs. disadvantages of fluidotherapy
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Advantages 1. Avg heat absorption from fluidotherapy Rx 3X greater than paraffin (1977 study) 2. Pts may tolerate dry heat better than moist heat at same temps 3. Pt may move body part, exercise during Rx 4. Therapist may perform hands-on technique during Rx 5. Unit easy to maintain 6. Particles are bacteriostatic- self-cleaning 7. Temp of unit can be kept constant throughout course of Rx Disadvantages 1. Can take 30 minutes to heat up prior to treatment
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Factors to consdier when applying cold
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1. Temp gradient (diff in temp b/w skin and modality) 2. Duration of exposure 3. Surface area/location and degree of exposure
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Systemic effects of cold
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Vasoconstriction Increased BP Decreased HR Increased stroke volume Increased CO Decreased RR Increased Tidal volume Decreased skin temp Decreased sweating Shivering Increased ms tone- may inc spasticity Decreased metabolic rate
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Local effects of cold
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Local vasoconstriction Decreased local metabolism Blocks histamine reaction (limits inflammation) Decreased edema Decreased bleeding Decreased NCV (analgesia) Decreased pain Decreased muscle guarding Can interrupt pain cycle Decreased muscle spindle activity Increased muscle viscosity Decreased extensibility
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Explain how ice limits secondary tissue damage following an acute injury.
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1. Trauma damages vascular system @ site of injury 2. Lack of blood supply means less O2 surrounding tissue- may result in secondary ischemic damage 3. Ice reduces demand for O2 by slowing local metabolic rate in surrounding tissues- Decreases energy demand in those tissues 4. Ice limits extent of secondary injury- Decreased O2 demand gives time for swelling to decrease and blood supply to return
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What is the Hunting response? How does it affect the treatment duration for application of cold modalities?
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1. Reflex vasodilation in response to prolonged cold 2. Body's attempt to maintain homeostasis, preventing tissue injury due to cold exposure 3. Vasodilation occurs after approximately 20 mins and helps re-warm tissues 4. Body does not like to stay in vasodilation so it goes into Hunting response in order to maintain homeostasis. Body goes through reflexive vasodil response in attempt to re-warm tissues. This is why you do not want to have ice on for too long in an acute injury where you are trying to reduce swelling.
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When would a physical therapist choose a cold modality versus a thermal modality? Explain your rationale.
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1. Acute injury 2. Acute inflammation 3. Acute or chronic pain due to muscle spasm 4. To reduce fever 5. To decrease edema 6. In UMN lesions- "quick" ice to facilitate tone, prolonged application to decrease spasticity 7. Rx of trigger points
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Outline contraindications and precautions for the therapeutic application of cold.
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1. Heart disease/angina 2. Open wounds older than 48-72 hours (do not want vasoconstriction, want to promote granulation tissue to grow 3. Hypersensitivity to cold; cold uticaria, Raynaud's disease (Like an allergic rxn to cold)- Raynaud's: circulation issue, distal circ is more sensitive to cold than normal, fingertips and toes will blanch, turn white. Normal in a normal temo, just reacts when exposed to cold. 4. Decreased sensation (means of feedback for the Rx)
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Explain how and why a physical therapist might make modifications to the application of cold based on the age of the patient.
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Needs to be carefully evaluated and monitored bc geriatric pts may experience: 1. Less efficient vasoconstriction 2. Less shivering or no shivering (decreased metabolic rates w/ age) 3. Decreased ability to produce and retain heat 4. Overall decreased tolerance to cold
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What is the method of transfer for therapeutic application of cold?
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Heat abstraction (from body to cold pack) Conduction
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Provide some examples of cryotherapy techniques.
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1. Commercial cold packs 2. Ice packs 3. Whirlpool (cold = 50 to 60 degrees F, 15 to 20 mins) 4. Ice massage 5. Contrast baths (alternating heat/cold) 6. Vapocoolant spray **** 7. Should be considered a separate category
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Is vapocoolant spray a cryotherapy modality? Why or why not?
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Considered a separate category- only has sensory effects, physically feels cold but does not have all the physiological responses
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Describe the treatment procedure for application of a cold pack, including essential elements of patient education.
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Pt education: 1. Confirm hx and screen for contraindications/precautions, informed consent (Rx procedure, rationale/goals of Rx, what pt may expect to feel), encourage pt feedback at start of Rx and throughout session (call bell) Pre-Rx Assessment Application of Pack: 1. Temp of commercial refrigeration unit for cold packs should be 0 to 10 degrees F 2. Position and drape- for comfort, modesty and may also drape to keep pt warm 3. May position pt w/ affected body part elevated if treating for edema 4. Cover Rx area w/ single layer of moist toweling, apply pack and insulate with 1-2 layers of dry toweling 5. Duration of Rx 10 to 15 minutes, 20 minutes max 6. Pt should be monitored frequently for subjective and physiological response Post-Rx Procedure
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What aspects should the physical therapist consider during pre- and post-treatment assessment for application of cold packs?
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Pre-Rx Assessment: 1. Assess skin integrity, sensation 2. Select outcome measurements and perform baseline measurement (ROM, palpation, pain scale, etc) Post-Rx Procedure: 1. Remove pack and perform post-Rx skin assessment 2. Obtain pt's subjective response to Rx 3. Repeat outcome measurements
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Which factors might affect clinical decision making when choosing between cryotherapy and thermotherapy?
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Similar effects: 1. Decrease pain 2. Decrease edema- Subacute or chronic responds better to heat, acute responds better to cold 3. Decrease muscle spasm Clinical decision making: 1. Stage of injury 2. Goals of Rx 3. Area to be treated 4. Pt preference 5. Indications/contraindications
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What is a "trigger point"? How would you identify presence of a trigger point during patient assessment?
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1. Small area of localized muscle spasm 2. Palpable- feels like a small "knot" 3. "jump sign"- brief localized twitch on palpation 4. May have area of associated pain- referral patterns 5. May be caused by trauma/injury or abnormal stresses to muscle tissue 6. "Active" trigger point- pain at rest or with mov't 7. "Latent" trigger point- causes pain only when palpated 8. Common areas: Upper trapezius, Piriformis, Glut medius, Biceps femoris (hamstrings), Gastroc, Iliopsoas, Pectoralis
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Describe how cold modalities could be used to address the presence of a trigger point.
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1. Rx of small areas of painful muscle guarding 2. Rx of acute pain- to decrease pain, decrease edema, reduce bleeding (bleeding that will cause bruising)
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How does patient education prior to ice massage differ from patient education prior to application of a cold pack?
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1. Explanation of Rx rationale 2. **Description of what pt should feel- 4 stages: cold, burning, aching, numbness (CBAN)** 3. Encourage to provide beedback
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Describe the proper Rx procedure for application of ice massage, including duration of Rx and elements of pre- and post-Rx assessment.
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Pt education Rx Preparation: 1. Review contraindications/precautions 2. Check skin integrity and sensation 3. Perform outcome measurements 4. Position and drape 5. Drape to keep pt warm- want local effects of ice massage only Technique 1. Rub ice at moderate speed 2. Use rhythmic motion 3. Blot area as ice drips 4. Usual duration of Rx: 5 to 10 minutes- Depends on desired effects (anesthesia) Post-Rx Assessment 1. Check skin- color, temp 2. Pt feedback- subjective response 3. Assess effects of Rx- did you meet intended goals
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What are some of the contraindications and precautions for use of vapocoolant sprays?
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Contraindications 1. Open skin 2. Respiratory disease 3. Raynaud's disease 4. Cold uticaria 5. Decreased circulation (PVD, arterial insufficiency) 6. Decreased sensation (if it only has sensory effects and you have decreased sensation it is pretty useless) Precautions 1. Must perform VAT before stretching neck** 2. Barriers to communication 3. Need well-ventilated area 4. Avoid contact with eye/nose/mouth/mucous membranes 5. Pt apprehension and/or objection to use of aerosol spray
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When and how should the vertebral aa test be performed?
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1. Always peform before stretching the neck 2. Patient is supine with PT sitting or standing at the head. PT cradles head on both side. Bring head slowly into extension and side bending to end range, rotate head in same direction as side bending. Engage pt in conversation, instruct pt to keep eyes open and observe for nystagmus, pupillary changes, or visual distrubances. Ask pt about vertigo/dizziness. STOP test of pt demonstrates any s/s
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Outline the proper Rx procedure for application of vapocoolant spray, including patient education, as well as pre and post-Rx assessment.
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Rx Procedure 1. Screen pt for respiratory problems 2. Pt education 3. Pre-Rx assessment- skin, sensation, AROM/PROM, pain scale, palpation 4. VAT must be performed prior to stretching Cx spine 5. Position and draping- shield pts eyes, nose, and mouth if working near pt's face "Spray and Stretch" 1. Hold bottle nozzle down, about 2 feet away 2. Strike at an acute angle 3. Spray in one direction only- follow path of ms fibers if possible 4. Spray at rate of approx. 4 in/sec 5. One sweep of spray at a time 6. Too much spray, too quickly can frost skin 7. Cover Rx area 1-2 times 8. Take pt through available ROM while applying spray 9. Apply gentle end range stretch 10. If desired, hold new range and repeat cycle 11. Can complete cycle 2 to 3 times 12. Have pt perform AROM 13. Teach pt to perform active stretching (HEP) Post-Rx Assessment 1. Skin, subjective response (pain scale), AROM/PROM, palpation (presence of pain and/or ms tension
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What would be considered a normal vs adverse response to Rx with vapocoolant (spray and stretch)?
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Normal 1. Mild redness 2. Transient decrease in skin temp Adverse 1. Excessive redness 2. Itching 3. Wheal formation
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Provide an alternative to use of vapocoolant spray for Rx of trigger points and limited ROM.
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1. Use ice- quick strokes prior to stretching 2. Apply ice in same direction, roughly same speed as you would apply spray 3. May use alternative due to environmental concerns, if pt or PT has resp. problems
