Categories of Physical Agents
Thermal
Mechanical
Electromagnetic
Thermal Physical Agents
Transfer energy to a patient to produce an increase/decrease in tissue temperature
Increasing Tissue Temp
Increases circulation, metabolic rate, and soft tissue extensibility
or to decrease pain
Decreasing Tissue Temp
Decreases circulation, metabolic rate, or pain
Types of Thermal Physical Agents
Deep heating agents
Superficial heating agents
Cooling agents
Deep Heating Agents
Ultrasound
Diathermy
Superficial Heating Agents
Hot pack
Paraffin
Cooling Agents
Ice pack
Mechanical Physical Agents
Apply mechanical force to increase/decrease pressure on the body
Types of Mechanical Agents
Traction
Compression
Water
Sound
Traction
Mechanical Traction
Compression
Elastic bandages, stockings
Water
Whirlpool
Sound
Ultrasound
Electromagnetic Physical Agents
Utilize application of electromagnetic energy in the form of electromagnetic radiation or electrical current
Variation in what changes the effects and depths of electromagnetic PA's?
Frequency and intensity of electromagnetic radiation
Electromagnetic PA's can
Depolarize nerves
Cause sensory and motor responses to control pain or increase muscle strength and control
Types of Electromagnetic PA's
Electromagnetic Field
Electrical Current
Electromagnetic Field
Ultraviolet, laser
Electrical Current
TENS
General Contraindications to PA's
Pregnancy
Malignancy
Pacemaker/Implanted Devices
Impaired Sensation
Impaired Mental Status
Reasons why physical agents fall out of favor
Lack of evidence to support effectiveness
Greater effectiveness with other treatment options
Laziness on the part of the community using the physical agents
Things that pull physical agents back into favor
Improvements in the physical agents and research backing the use
Ease of using the physical agent
Choosing a PA: consider...
Primary underlying problem
Problem most likely to respond to treatment
Goals of effects of treatment
Contraindications and precautions
Evidence for physical use
Cost, convenience, availability
PA's have what effect on the level of impairment?
THEY HAVE A DIRECT EFFECT on the level of impairment that can prompt improvements over the level of functional limitation and disability
PA's are used in conjunction with or in preparation for
Therapeutic exercise
Functional training
PA's can
Reduce/eliminate soft tissue inflammation or circulatory dysfunction
Increase the healing rate of soft tissue injury
Remodel scar tissue
Modulate pain
Modify tone
Increase connective tissue extensibility and length
Treat skin conditions
Primary determinants to the outcome of any injury
Type and extent of injury
Regenerative capacity of tissues involved
Vascular supply to injured site
Extent of damage to the extracellular framework
When selected and applied appropriately, PA's can
Accelerate the completion and resolution of the phase of tissue healing
Stimulate necessary processes to resume if they are stopped
Accelerate overall recovery
Improve final patient outcome
Minimize risk of adverse effects from delayed or incomplete heali
When selected and applied inappropriately, PA's can
Prolong inflammation
Increase severity of associated symptoms
Prevent or delay healing
Increase probability of adverse consequences and therefore, a poor overall patient outcome
In terms of inflammation and healing, Thermal PA's can
change the rate of circulation and rate of chemical reactions
In terms of inflammation and healing, Mechanical PA's can
control motion and alter fluid flow
In terms of inflammation and healing, Electromagnetic can
alter cell function particularly membrane permeability and transport
Inflammation Phase
Vascular response
Immune response
Hemostatic response
Proliferation Phase
Covers wound and injury site
Epithelialization
Collagen Production (fibroplasia)
Wound Contracture
Formation of new blood vessels
Maturation Phase
Modifies the scar tissue into its mature form
Collagen Synthesis/Lysis Balance
Collagen Fiber Orientation
Healed Injury
Local Factors
Type, size, and location of injury
Infection
Vascular supply
External Factors
PA's
Systemic Factors in Healing
Age
Disease
Medications with systemic effects
Nutrition
Nutrients that are important to inflammation and healing
Vitamins C, D, E, zinc
Modification of inflammation and tissue healing
Can result in accelerated patient progress toward active participation and goal achievement
Four Cardinal Signs of Inflammation
Heat
Redness
Swelling
Pain
Stage of tissue healing determines what?
Treatment goals
Choice of physical agent
First Stage: Initial Injury- Control Bleeding and Inflammation
Minimize wound bleeding
Minimize secondary tissue damage
Minimize edema
Minimize pain and muscle spasm
PRICE
First Stage: Initial Injury- Tx Goals
Prevent further injury or bleeding
Clean open wound
First Stage: Initial Injury- Effective Agents
Static compression
Cryotherapy
Hydrotherapy (immersion or non-immersion)
Acute Inflammation- Treatment Goals
Control pain, edema, bleeding, release and activity of inflammatory mediators, facilitate progression to proliferation phase
Acute Stage of Inflammation/Healing- Physical Agents to help with pain
Cryotherapy
Hydrotherapy
ES
PSWD
Acute Stage of Inflammation/Healing- Edema
Cryotherapy
Compression
Sensory level ES
PSWD Contrast bath
Acute Stage of Inflammation/Healing - Bleeding
Cryotherapy
Compression
Acute Stage of Inflammation/Healing - Release of Inflammatory Mediators
Cryotherarpy
Chronic Inflammation Tx Goals
Prevent or decrease joint stiffness
Control pain
Increase circulation
Progress to proliferation phase
Chronic Inflammation- Prevent/DC Joint Stiffness
Thermotherapy
Motor ES
Whirlpool
Fluidotherapy
Chronic Inflammation- Control Pain
Thermotherapy
ES
Laser
Chronic Inflammation- Increase Circulation
Thermotherapy
ES
Compression
Hydrotherapy (immersion or exercise)
Chronic Inflammation- Progress to proliferation phase
Pulsed ultrasound
ES
PSWD
Remodeling/Maturation Stage Tx Goals
Regain or maintain strength
Regain or maintain flexibility
Control scar tissue formation
Remodeling/Maturation Stage- Regain/Maintain strength
Motor ES
Water exercise
Remodeling/Maturation Stage- Regain/maintain flexibility
Thermotherapy
Remodeling/Maturation Stage- Control Scar Tissue Formation
Brief ice massage
Compression
What type of pain is well localized, sharp/prickling/tingling?
Cutaneous Noxious stimulation pain
What type of pain is poorly localized, dull/heavy/aching?
Musculoskeletal Structure pain
What type of pain refers superficially, and has an aching quality?
Visceral pain
Pain Management- Goals of Care
Resolving underlying pathology when possible
Modifying discomfort and suffering
Maximizing function within the limitations imposed by patient's condition
Pain Management- Goals of Persistent Pain
May need integrated multidisciplinary treatment
Psychological and physiological therapies, physical agents, and exercise
Benefits of Using PA's for Pain
Directly moderates inflammation, modulates pain at the spinal cord, alters nerve conduction, or increases endorphins
May also help resolve underlying cause
Allows patient to interact with their injured body-parts and practice independent pain management s
Commonly used PA's for pain reduction
Cryotherapy
Thermotherapy
ES
Traction
Measuring pain for documentation?
VAS
Numberic SCales
Comparison with Predefined Stimulus
Face Scale
Muscle Tone- Definition
Muscle tone is underlying tension in the muscle that serves as a background for contraction
Muscle Tone- Hypotonicity
Abnormally low tone
Flaccidity
Flaccidity is total absence of tone
Examples are Down syndrome, poliomyelitis
Muscle Tone- Hypertonicity
Abnormally high tone
Rigidity
Velocity independent resistance to stretch
Spasiticy
Velocity dependent resistance to stretch
Clonus
Rhythmic oscillations or beats of involuntary contraction in response to quick stretch
How are PA's used to alter muscle tone?
Directly- by altering nerve conduction or sensitivity
Indirectly- by reducing pain or the underlying cause of pain
Tx Goals for hypertonicity
decrease tone
PA's for hypertonicity
neutral warmth or prolonged cryotherapy to hypertrophic muscles
Contraindicated for hypertonicity
quick ice of agonist
Hypotonicty Tx
Increase tone
Hypotonicity PA's
Quice Ice
Motor ES of agonists
Hypotonicity Contraindicated
Thermoptherapy
Fluctuating tone Tx Goals
Normalize tone
PA's for Fluctuating tone
Functional ES
Measuring Muscle Tone- Quantitative Measures
Dynamometer or myometer
Isokinetic testing systems
EMG
EMG
Electromyography
A record of electrical activity sampled from muscles at rest and during contraction, using surface, fine wire or needle electrodes
Pathologies that can cause motion restriction
Contracture
Edema
Adhesion
Mechanical Block
Spinal Disc Herniation
Adverse Neural Tension
Weakness
The role of PA's in motion restriction
Increase soft tissue extensibility
Control inflammation and adhesion formation
Control pain during stretching
Facilitate motion
T/F: Physical agents are generally sufficient to reverse or prevent motion restrictions.
FALSE
They are NOT sufficient to reverse or prevent motion restrictions. They are used as adjuncts to treatment
Using PA's to increase soft tissue extensibility
Increase temperaturecan alter viscoelasticity of soft tissue fibers, allowing plastic deformation to occur
Using PA's to control inflammation and adhesion formation
Limit edema during acutre inflammatory stage... limits degree of immobilization
Using PA's to control pain during stretching/PROM
To allow for increased stretching and sooner initiation of motion
Using PA's to facilitate motion
Principles of buoyancy (water), muscle contraction (Russian electrical current) to initiate motion
General Contraindications
Pregnancy
Malignancy
Pacemaker or other implanted electronic device
Impaired sensation
Impaired mental status
Days 1 to 6 after injury
Inflammation phase
Days 3 to 20 after injury
Proliferation phase
Day 9 onward
Maturation phase
When does the inflammation phase begin?
When the normal physiology of tissue is altered by disease or trauma
What does the inflammation phase do?
Attempts to distroy, dilute, or isolate the cells/agents that may be at fault
It is necessary for healing
What happens when the inflammation phase becomes inappropriate?
results in autoimmune diseases, and can cause damage and excessive scarring
Components of the Inflammation Phase
Vascular Response
Immune Response
Hemostatic Response
Inflammation Phase: Vascular Response
Swelling and Redness
Mediated by histamines, kinins, and prostaglandins
Inflammation Phase: Immune Response
Activates neutrophils and other infection fighting cells
Complement System
Inflammation Phase: Hemostatic Response
Stops bleeding
Proliferation Phase involves four simulations processes, which are:
Epithelialization
Collagen production
Wound contraction
Formation of new blood vessels
Which is the longest phase of healing?
Maturation
Can persist more than a year after injury
Maturation Phase: Scar realignment
Balanced synthesis and lysis of collagen are required for normal remodeling of scar
If production of collagen is greater than lysis, what happens?
A keloid or a hypertrophic scar results
What collagen is replaced in the maturation phase?
Type 3 is replaced by type 1
Acute, Subacute, and Chronic Inflammation
Acute- no more than 2 weeks
Subacute- no more than 4 weeks (usually 2-4)
Chronic- lasts for months or years
Chronic Inflammation
Simultaneous progression of active inflammation, tissue destruction and healing
What causes chronic inflammation?
Persistence of injuries (cumulative trauma( or other interference with normal tissue healing
Immune response to either an altered host tissue or a foreign material (ex: implant/suture) or autoimmune disease (ex: RA)
Factors Affecting the Healing Process
Local factors
External force
Systemic factors
What accounts for 50% of the complications of wound healing?
Infection