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Physical agents

Energy and materials applied to patients

Types of physical agents

Thermal
Diathermy
Ultrasound
cryotherapy
Mechanical
Water
Traction
massage
Electromagnetic
UV
Laser
TENS
Pulsed shortwave diathermy
Electrical Stimulation

General contraindications

Pregnancy
Malignancy
Pacemaker or implanted device
Impaired sensation
Impaired mentation

Effects of physical agents

Inflammation and healing
Pain reduction
Collagen extensibility
Muscle tone

Modalities as adjunct to therapy

Based on the physiological response of tissues
Understand the responses to injury
Understand how tissues heal

Rehabilitative process

Decisions

Available options
Which modality will be most effective

The healing process

Inflammatory response phase
Proliferation(Fibroblastic) repair phase
Maturation remodeling phase

Inflammatory stage

1-6 days
Immediate vasoconstriction
Vasodilation
Clot formation
Phagocytes

Vasoconstriction

rapid constriction of the blood vessels to decrease blood flow to the area

Inflammation

redness Rubor
swelling Tubor
tenderness Dolor
increased temperature Calor

Angiogenesis

Neovascularization
Development of new blood vessels
Healing cannot occur without angiogenesis

Factors that impede healing

Local factors:
Type, size and location of injury
Circulation
Degree of injury
Tissue integrity
Age
Nutrition
Disease/co-morbidity
Infection
Vascular supply
External forces*** physical agents

Healing of musculoskeletal tissue

Type and extent of the injury
Regenerative capacity of the tissue
Vascular supply of the injured site
Extent of damage to the extracellular framework

Cartilage

Limited ability to heal
Lacks lymphatics, blood vessels and nerves

Injuries combined with injury to subchondral bone
Stem cells used

Tendons and ligaments

Repair potential for tendon is controversial
Differences
Stress is needed to increase the strength

Skeletal muscle

Skeletal muscle cells cannot proliferate
Stem (reserve or satellite cells) can proliferate and differentiate to form new skeletal muscle ???

Bone

Able to heal itself with like tissue
Bone can heal by two means: primary or secondary healing

Pain

Unpleasant sensory and emotional experience associated with actual or potential tissue damage.

Nociceptor

A receptor neuron that is preferentially sensitive to a noxious stimulus (causing damage to normal tissues) or a stimulus that would become noxious if prolonged. (Book 2, Chapter 1)

Acute pain

This type of pain has a sudden onset, relatively short duration, mild to severe intensity, with a steady decrease in intensity over several days or weeks. Usually associated with a specific condition, injury or tissue damage caused by disease. (e.g. toothache, needle sticks, burns, childbirth, sprained ankle)

Referred pain

pain that is felt at a place in the body different from the injured or diseased part where the pain would be expected

Trigger points

Small, tense, hypersensitive areas of tenderness that RADIATE pain to specific area when compressed

Afferent fiber

a neuron that carries sensory information to the central nervous system

Mechanisms of pain receptions and transmission

-Specificity and pattern theories
-Pain receptors
-Perioheral nerve pathways
-Central nerve pathways
-Sympathetic nervous system influences

Thermoreceptor

a sensory receptor that responds to heat and cold

A-delta fibers

fast
myelinated peripheral nerve fibers
send sharp
localized
distinct sensations

C fibers

Nerves that transmit
-dull
-poorly localized pain
-nerve fibers that carry messages for dull
-aching
-slow
-Burning

Proliferation

3-20 days
Angiogenesis
Fibrosis
Period of scar formation
*Wound is covered and begins to regain some of initial strength
*During the proliferation phase, an injured area has the greatest amount of collagen, yet tensile strength is low.

Maturation

9+ days
Damaged tissue returning to original cell type
Remodeling replaces temporary cells
Collagen realigns
Cells return to normal function

What tissues are affected by infared modalities?

Superficial
ex. epithelial

Acoustic spectrum

Ultrasound

Wavelength

the distance (measured in the direction of propagation) between two points in the same phase in consecutive cycles of a wave

Frequency

the number of complete wavelengths that pass a point in a given time

Fibrosis

Proliferation of fibrous connective tissue; scar formation

Injury management using modalities

Inflammation stage:
RICE
Second 2 stages:
Various modalities

Chronic injury

Persists
Can have acute symptoms on top of chronic symptoms

Modalities for inflammatory stage

...

Modalities for proliferation

...

Modalities for Maturation

...

Gate control theory

-Nociceptors send afferent signals to spinal cord at C6
-Signal passes through spinal cord to thalamus and to cerebral cortex
-Cerebral cortex sends efferent signals back to the spinal cord
-Meanwhile, beta fibers are stimulated by touch, ice, etc.
-Beta fibers move up afferent pathway to spinal cord where they interfere with efferent signals from the cerebral cortex.

Endorphins and enkephalins theory

Endorphin and enkephalin are the body's natural painkillers.
When a person is injured, pain impulses travel up the spinal cord to the brain.
The brain then releases endorphins and enkephalins along descending nerve fiber from the brain.
Enkephalins block pain signals in the spinal cord (bind to receptor of nociceptor and change signal).

Thermal physical agent

Transfer energy to a patient to produce an increase/decrease in tissue temperature
Types:
Deep heating agents- Ultrasound and diathermy
Superficial heating agents- Hot pack
Cooling agents- Cold pack

Mechanical Physical agents

Agents that apply force to increase or decrease pressure on the body.
Types:
Traction- Mechanical traction
Compression- elastic bandage/stockings
Water- Whirlpool
Sound- Ultrasound

Electromagnetic Physical agents

Apply energy in the form of electromagnetic radiation or an electrical current.
Types:
Electromagnetic fields- Ultraviolet and laser
Electric currents- TENS

ICF model

International classification of functioning and disability.
Considers the body, the whole person, and the person in society.

Physical Agents

Energy and materials applied to patients to assist in rehabilitation.
Usually used with other interventions and not as the sole intervention.

Effects of physical agents

The application of physical agents primarily results in modification of tissue inflammation and healing, relief of pain, alteration of collagen extensibility, or modification of muscle tone.

Physical Agents for promoting tissue healing:
Initial injury

Prevent further injury/bleeding- Static compression, cryotherapy
Clean open wound- hydrotherapy

Contraindications:
Exercise
Motor-level ES
Thermotherapy

PA for Prevent/decrease joint stiffness

Thermotherapy
Motor ES
Whirlpool
Fluidotherapy

PA for chronic pain

Thermotherapy
ES
Laser

PA for increased circulation

Thermotherapy
ES
compression
Hyprotherapy

PA for progression to proliferation stage

Pulsed ultrasound
ES
PSWD

PA for regaining/maintaining strength

Motor ES
Water exercise

PA for regaining/maintaining flexibility

Thermotherapy

PA to control scar tissue formation

Brief ice massage
Compression

Pathological or physical result of an injury

INFLAMMATION PHASE
Vasoconstriction
Vasodilation
Clot formation
Phagocytosis
PROLIFERATION PHASE
Epithelialization
Fibroplasia/collagen production
Wound contracture
Neovascularization
MATURATION PHASE
Collagen synthesis
Collagen realigns
Healed injury

Edema

Swelling caused by fluid accumulation outside the vessels.

Muscle hematomas

Can cause pain, limit motion, and increase scar tissue formation.

During the proliferation phase of healing

...

Informed consent

Intro- Name, qualifications
Inform patient of the activities of the day

Precaution

Think through every part of modality to ensure safety.

Effects of physical agents

Inflammation
Pain reduction
Collagen extensibility
Muscle tone

Angiogenesis

Development of new blood vessels
Veovascularization
Healing cannot occur without angiogenesis

Local factors that effect healing

Type, size, and location of injury
Infection
Vascular supply
External forces

Systemic factors that effect healing

Age
Nutritional status
Concurrent disease
Anemia
Hypovolemia
Drugs and other Tx

Pain

Unpleasant sensory or emotional experience associated with actual or potential tissue damage.

Nociceptors

Respond to noxious stimuli

Chronic pain

Continues beyond the normal time of tissue healing
Persistent

Acute pain

Biologically meaningful
Pathologically

Levels of experiencing pain

Tissue damage
Pain sensation
Thoughts
Emotions
Suffering
Pain behaviors

Thermoreceptors

Sensory receptors which respond to heat or cold.

Pain in cutaneous

Well localized
Sharp, pricking, tingling
A delta fibers

Musculoskeletal pain

Dull, heavy, aching, and harder to localized

Transmission of pain

Nociceptor
Peripheral nerve
Spinal cord
Thamalus
Cerebral cortex

Pain assessment tools

Visual analog
Pain chart/picture
McGill pain questionnaire
Activity profile
Numeric pain scale

McGill pain drawing

...

Ransford pain assessment

...

Numeric pain scale

Most common acute pain profile used in sports medicine clinics.
Patient is asked to rate pain on a scale from 1 to 10 with 10 representing the worst pain they have experienced or could imagine.
Question asked before and after treatment.

Visual analog

10cm line drawn
No pain on left and worst pain on right
Patient asked to mark where their pain is on the line
PT measures where the mark is
# of cm is pain level

Pain management

Pharmacology
Analgesics
NSAIDS: aspirin, ibuprofen, naproxen sodium
-Non-steroidal antiinflammatory drugs
Acetaminophen
Opiods
Antidepressants
Local injection

Borg numeric pain scale

Provides instructions
Provides a list of numbers and associated levels of pain
Asks patients to rate pain now, best day in 30 days, and worst day in 30 days.

Radiation

energy that is radiated or transmitted in the form of rays or waves or particles

radiant energy

energy that is transmitted in the form of (electromagnetic) radiation
-Travels through space in a straight line
-Several modalities fall under radiant
-Depth of effectiveness based on wavelength

Infared

invisible short frequencies of light before red in the visible spectrum

Acoustic spectrum

Ultrasound

Radiation by be:

Reflected
Refracted
absorbed
Transmitted

Infared modalities

Grouped together by wavelength
Penetrating heat that falls within the specific wavelength

What tissues are effected by infared modalities

Superficial
ex. epithelial

Fibroplasia

Period of scar formation
Fibroblasts
Growth

RICE

rest, ice, compression, and elevation

Acute injury

sudden onset due to a specific trauma, such as twisting the ankle

Physical agents used to modify healing process:

Cryotherapy
Thermotherapy
Ultrasound
Electromagnetic radiation
Light
Electric currents
Compression

T Cells

T cells in spinal cord receive excitatory input from nociceptors and inhibitory input from sensory nerves and descending fibers from the brain, determining whether or not a person will feel pain.

Evaluating a patient's pain

Consider:
Patient's source
Intensity
Duration
How it affects a person's function, activity, and participation.

Pain scale uses

Visual analog and numeric best for a quick estimate
Semantic differential for more detailed description

NSAIDS

nonsteroidal anti-inflammatory drugs
Lower doses necessary to reduce pain than to reduce inflammation
Gastrointestinal irritation and bleeding are main long term complications

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