187 terms

Physical Therapy

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PT defined
pathokinesiology of improper movement patterns
correcting improper movement though modalities, manual therapy, therapeutic exercise
modalities
heat, cryotherapy, ultrasound etc
manual therapy
hands on work
stretching, joint mobilization etc
therapeutic exercise
way to test the strength of muscles and flexibility
exercises to challenge those things and improve fcn
physical therapist roles
consultant advocate, guide, educator
PT areas of practice
skilled nursing
early intervention
school settings
acute care
outpt ortho
rehab
etc
who is appropriate to refer to PT
need some kind of impairment
nagi model is pathology→impairment→fcnl limitation→disability
WHO model is ICIDH disease→impairment→disability→handicap
also need to look at psychosocial /behavioral (ICF)
impairments
ROM
flexibility
pain
fcnl limitations
ambulation
stair negotiation
bed mobility
transfers
suatting/kneeling
balance, sitting, jumping
Functional Outcome Measures (foot and ankle A model, LEFS)
FAAM activities and daily living schedule
LEFS (lower extremity functional scale)
how to asses physical fcn
basic activities of daily living or activities of dl
tasks of self care ie feedin gdressing hygiene
instrumental activites of daily living - skills vital to independent living
disability
is individualized, depends on what you do
includes job duties and ADLs
impies impact on ability to complete requirements of normal daily life
LeBron is disabled if he sprains his ankle
ICF model of impairment/disability
not linear, one thing is not causation for another
initial PT eval
hx
ROS
tests/measures
dignosis/prognosis
create individualized POC
requirements in hx
pain presentation
if pperson is laughing and sayys 10/10 make note that pt is not presenting consistently with that
ROS
most PT spend more time on neuromuscular and musculoskeletal
Tests and measures
Active
Active Assisted
Passive ROM
postural asssesment
should be a plumb line through ear, shoulder, center of hips, greater trochanter, lateral malleoli
assesses standing posture
tug test
how fast person can stand up walk ten feet and turn around
ROM tests
inert tissues
ligaments and joint capsules
non contractile
normal end feels
hard is bony
soft is soft tissue aproximation ie knee flexion (two muscles squishing together)
firm is tissue stretch ie ankle df
hard end feels
hard occurs prior to completion of full rom from loose body or osteophyte
sspringy block end fee
lreboud is felt at end ROM means internal derangement like meniscal injury
empty end feel p
pain prior to reaching end ROM without any resistances
spasm end feel
probably due to inflammation if early in ROM
later in ROM means joint pooor kinematics/movement causing spasm
capsular end feel
prior to end range of motion
something involving inert tissues
commonly frozen shoulder
tibiotalar would have PF more limited than DF
STJ inversion>eversion
MTJ df then pf then addduction/medial rotation
MTPJ extension>flexion
non capsular pattern
ROM is not withing typical pattern for that joing
limitation primarily in one direction while other ROM WNL
goes against capsular pattern
usually accompanied by pain
inert tissues assesment
asses passively
1 pain and limitation inevery direction means joint problem
2 pain and limitation or excessive movements in some directions not others is more localized like ligament strain
3 limited movement that's pain free is usually hard endfield like asymptomatic OA
4 full ROM and no pain is WNL
if active and passive motions limited in same direction
joint or capsular involvement
then do joint integrity/mobility tests
active and passive motions limited in opposite directions
soft tissue or contractile structure porblem
focus on resistive movements to id exact structure oor muscle
manual muscle testing through range
through range (resist through full ROM)
neurological
manual muscle testing with isometric break test
isometric test to look at strength
0-5 scale
grading for contractile tissue
other assesments
DTR graded 0-4
dermatome sensation
myootomes
monofilament testing
joint play
special tests
joint play
accessory movmnts that are nonvoluntary
mobilization/manipulation
remember rolls/glides
DTR grading
absent
ddiminished
normal
brisk
clonus
lower quarter sccreen
direct access
pt can see PT without prescription
based on how long PT works and symptom pt has
special tests
anterior drawer
squeeze test - syndesmoses and high ankle sprains
thompson's test
navicular drop test - arch support
tinel's sign - carpal tunnel also peroneal
morton's test
homan's sign
dx
identifies impact of condition on fcn at level of symptom
fcnl level diagnosis
plan of care
objective, achievable goals
interventions
duration and frequency
anticipated discharge plans (where when)
how long should Rx for strength changes
minimum 6-8 weeks
educating pt
explain what needs to be addressed
explain they need to do exercises at home
allow for independence in mgmt of symptoms
pt goals
normal end feel for ankle df should feel
firm
other end feels
hard
soft
firm
empty
therapeutic exercise goals
sequence of exercises to improve fcn and mobility
goal is symptom free fcn
based off each individual's needs
forms of therapeutic exercise
aerobic condition
muscle performance
stretching techniques
minimally nm
breathing techniques
muscle fiber structure review
golgi tendon organ senses
changes in muscle tension not length
manual resistance training
strength based therex - resistance can change through ROM, good for early injuries
mechanical resistance training
strength based therex - can work larger muscle groups that are too large to do manual resistance, can get quantitative measure of progress
machinery is expensive, can't change based on ROM or pain in one spot in ROM
some machines can be tailored to pts ROM but expensive
overload principle
to see strength changes you need to exceed what muscle's used to doing and go past its metabolic capacity - results in hypertrophy, improved vascularization, increases strength and endurance
strength vs. power
force output is strength
power is force x velocity
if muscle contracts to maximize power it contracts with 1/3 of force it's capable of
stoplight for therex
if pain gets worse throughout exercise stop
if pain stays the same just monitor
if pain reduces/is tolerated well continue/all clear
efffective strengthening programs
delorme - 10RM then three sets of 10 at 50%, 75% and 100% of 10RM

oxforde - is same as DeLorme but percentages area in opposite order
neural adaptations
only want to use number of motor neurons needed for the activity, as they fatigue out others will be recruited to replace them
increases in first 4-8 weeks with limited muscle hypertrophy
from motor learning and improved coordination
duration of strength training
6 week minimum to 12
depends on cause of impairment
2-5 is from neuro reeducation
assumes people do things outside of PT
other comes from increased vascularization
muscle hypertrophy is where
muscle fibers themselves get thicker from myofibrillar volume from increase in protein sysnthesis
isometric exercise for
neurological recruitment
early in injury
people who can't do whole ROM
elders
exercise speed
torque and emg decreases with muscle speed
clearing pt foor therex
have they taken meds
if BP is over 180 systolic oor 10 diastolic
if diabetics over 250 FBS don't exercise
rhabdomyolysis
fairly rare
usually from traumatic skel m injury oor inherited myopathies
ex breaks down muscle and it doesn't repair and myoglobin gets released into blood and damages kidney
DOMS
12-24 hours to 24-48 hours after exercise
most likely culprit is lactic acid
prevented by gradual increase in intensity
STM
soft tissue mobilization = massage
type of manual therapy
STM types
effleurage
petrissage
cross friction
tappin
vibration
other manual therapies
stretching
joint mobilization
key schools of thought in manual therap
cyrix
greenman - muscle en
STM mechanism and indications
increases blood flow or moves fluid
for subacute pain
chronic pain
muscle spasm
edema
postrural drainage positions also
scar formation
STM contraindications
acute inflammation
severe athero
hemorrhage
chf
venous insuff
severe varicosities
efflurage
gentle massage with broad strokes
warm them up and end of soft tissue work
move towards heart
petrissage
kneading like motion
distal to proximal
loosens/breaks adhesions turns red
assists venous return
rhythmic lifting and compresseion
tapotement
tappping, includes cupping
enhance circulation and stim periph nerve endings
repetitive motions
lesser used
cross friction
chronic inflammation or overuse
adhesions to be minimized/broken up
postop scar tissue
go across fibers (think achilles)
can also be used over muscle spasm trigger points aka knots
use small circles or go across
cupping
make cup with your hand and rhythmically tap
use in cardiopulmonary therapy with postural drainage positions
can use over a muscle belly as well to improve muscle relaxation
asian cupping
supposed to bring blood to surface
other considerations in pt
superficial then deep
strokes go to heart
going to deep first leads to spasm
stretching types
self
manual
passive
active
static
PNF
manual stretching
pt isn't actively contributing therapist moves
don't stretch past joint ROM
hold for roughly 30s but to pt tolerance
don't stretch newly healed bones
PNF stretching and types
has an active component from pt
utilizes natural reflexes
contract to inhibit muscle then stretch again (autogenic) usually done submaximally
reciprocal inhibition is activating quads to inhibit hamstrings can do agonist contraction simultaneously or hold relax
joint mobilization
passive ROM assesment
is there any capsular pattern or abnormal end feel
at varying speeds and amplitudes based on grading
can be used to break up scar tissue under anesthesia
indications/contraindications for joint mobilization
joint mobility grading system
grade V goes almost to anatomical limit, usually aiming for cavitation/crack, usually done for cuboid
direction of mobilizations
know this chart
cryotherapy types
cold packs
ice massage
vapocoolant spray
RICE
modalities
cryotherapy
heat
infrared
etc
not meant to be a sole means of tx as they'll be back
cryotherapy works how
decreasing bloodflow
decreases edema
decreases met rate
decreases NCV
increased pain threshold
cryo indictiona
abnormal tone
acute or chronic pain
acute/subacute inflammtion
bursitis
musculoskeletal trauma
tendonitis
cryo contraindication
cold intolerance
reynauds
area of compromised circulation
PVD
skin anesthesia
infection
over regenerating nerves
cold pack
depth?
duration?
semisolid gel at roughtly 25 degrees F
used for roughly 20 min like others
2cm depth
use 1-2 hours with half to one hour in btw
why only cold fro 20 min
auto vasodilation after that
ice massage
for smaller areas
ice directly on skin
natural anesthetic
cold then burning then aching then analgesia
5-10 minutes
blood vessels overcompensate as sooon as you remove ice which helps with tissue healing
vapocoolant spray
breaks pain spasm pain cycle
over muscle trigger point/knot
3-4 passes 12" from skin then stretch
RICE
for acute trauma
decreases recovery time
usually 20 min on then repeat hourly to 4-5 times a day
hot packs/paraffin
decrease spasm
increased bloodflow
increased cap permeability
increase collagen extensibility
increase met rate
incr muscle elasticity
incr NCV and pain threshold
for muscle spasm and tone changes
heat indications
abnormal tone
decreaseed ROM
muscle guarding/spasm
subacute or chronic pain
heat contraindications
NOT FOR ACCUTE TRAUMA as it's already swollen and red
malignancies from increased circulation leading to mets
PVD
bleeding/hemorrhage
impaired sensation
area of compromised circulation
hot pack and layers
ideally there should be at least six layers so you don't burn pt
how long heat
20 min
heat penetration
about 1cm
moist/dry heat
dry is electric heating element
moist penetrates sooner and doesn't dry skin
paraffin
has low specific heat so it melts easily
more easily tolerated heat
good foor highly contoured areas like hand/fooot
113-122°F up to 135°for foot
remove jewelry so metal doesn't heat
don't use over wounds or infected sskin lesions
dip wrap method
don't let pt move in wax
dip then remove 6-10x
put plastic over wax and wrap in towel
lasts 10-15min
can stay in bath entire 20 minutes but don't let foot touch bottom so as not to touch heating element
can brush wax on if part can't be dipped
arthritis does well with it
deep heating agents
ultrasound - thermal or nonthermal settings
ultrasound
soudn waves to heat
wavelength/frequncy determines depth
piezoelectric crystals oscillate
need gel/lotion to transmit sound into skin as waves go through air poorly
beam non uniformity ratio
center gets deeper than periphery
sound head needs to be in constant motion to avoid burns - pt reports deep ache/burn from hot periosteum
use little overlapping circles
intensity of ultrasound
watts/cm^2
therapeutic range 0.5-2.5
ultrasound frequencies
higher frequency is absorbed superficially
1mHz is deeper 3mHz is superficial
area to tx in ultrassound
dont use in area more than 2-3x than sound head
takes too long
attenuation coefficient
some materials absorb heat more quickly
bone is quickest
thermal ultrasound
depth?
continuous head ultrasound
100% duty cycle
can go up to 5cm in depth
thermal ultraound indictiaons
good to use prior to streching and increaseing soft tisssue extensibility
chronic pain
decreaseing NCV
muscle stiffness/spasm
non thermal (pulsed) ultraound
low intensity
duty cycles 10-50%
most researhc at 20%
at the level of milliseconds so not detectable
nonthermal ultrasound MOA
not a lot of evidence behind it but supposedly from cavitation and microstreaming around cell membranes increasing cell permeability allowing PMNs and macrophages into area
proliferative and remodeling stages of healing
reabsorb ca deposits in soft tissue
how to ultrasound wounds
use in wound submerged in water
just use close proximity
pulsed ultrasound indications
Ca depositys
chronic inflammation
delayed soft tiss healing
dermal ulcers
joint contracture
scar tissue
pain
nonthermal us contraind
active bleeding
decreased circ
DVT
epiphyseal area
infection
malignancy
pelvic/lumber of preggers
pacemakers, cement, plastic
eyes heart genitalia
phonophoresis
continuous or pulsed us usuallly pulsed
transmit meds through skin
doesn't work that well or at all according to research
for GI issues when can't take oral meds
usually for inflammatory or analgesic issues
still need lotion or gel so make sure meds dont interact
iontophoresis
transcutatneous med through electrical stim through skin
less likely to irritate skin
infrared
very superficial just a couple mm
wavelength 780-1500nm
works like low level laser
newer pod use is anodyne
anodyne
increases blood flow to area
four flexible pads that can be used anywhere
fibromyalgia, tendonitis, DM neuropathy
a little deepr than infrared 3cm
incr circ decreases pain
can use over metal pacemekers
anodyne contraindications
malignancyy
womb
topical heating agents
low levellaser therapy
infrared frequ 820-840
non thermal photons
soft tissue
arthritis
wounds
nerve injury
sprain/strain
tendonitis
LLLT contraindicationa
IR vs LLLT
electrical stimulation
can use on wide variety of conditions
many settings
muscle strenghtnening, pain mgt, muscle reeeducation, stimulation of denervated muscle
electrical stim indications
decrease edemea or pain
disuse atrophy
ROM
incr local circ
reeducate muscle
relax spastic
electic stim contraind
never use with a pacemaker
can use if cancer free for years just let them know risk
electrical stim types
transccutaneous electrical nerve stim (tens)
interferential current
russian stim
iontophoresis
TENS
can use AC or DC (uses ions)
small portable unit can be used in house
utilizes gate control theory to communicate with inhibitory neurons in spinothalamic tract
interferential stim
combines two med frequency currents
two sets of electrodes set up at diagonals in a square
currents interact and get deeper
pain relief, incr circ, edema and inflammation
russsian stim
contraction to improve muscl estrength slow disuse atrophy
peripheral nerves must be intact
larger fast twitch fibers first which can be uncomfortable (physiologic is slow twitch more)
have pt contract muscle while stim is on to do both at the same time
fcnl electrical stim
relatively sim to russian stim
promotes muscle contraction
use stim while walking eg TA df in gait
premodulated electric stim
good for pain mgt
good foor smaller areas ie foot/ankle/elbow etc.
sometimes need higher current as theres no overlap like interferential
high volt galvanic stim
DC for deeper penetration
for edema and wound healing
iontophoresis
more evidance than phonophoresis
DC
like charges will repel
so use +charge to move +charged lidocaine
can get uncomfortable, get redness and irritation after 20 min treatment but tx can last longer
dont use with other tx as you want medication to stay local (dont heat etc)
indications contraindications for iontophoresis
hydrotherapy
typically warm unless you want antiinflmmatory
pool size varies
improves circulation
can use for wound debridement
can medicate whirlpool but won't be selective debridement
contrast bath
used a lot for edema
hot to cold to hot to cold
vasoconstrict dilate constrict... reduces edema
typically start in hot water 3-4min 104° then 50-60° for one minute
repeat for 25-30 minutes
contrast bath indications
arthritis
sprains/strains
desensitization
measaurements
to prove for insurance companies
ROM, circumferences for edema, duration of techniques
gait cycle percentages
ROM needed for gait
walking with flexed knees means
more fall risk
quad weaknesss can lead to buckling
quads peak activation
in early stance/heelstrike
just befoore toe off
when are hamstrings peak activated
late swing to decelerate
common gait deviations
hind foot pain
support reflex in nm pts, LE goes into extension on pressure on plantar
fall risk indicators in gait
flexed trunk posture
incr knee flexion
decr step length/cadence approaching obstacle
slower gait speeds
decreased slingle limb support and increased DLS
walking speed intervention
anything less than 1m/s needs intervention to reduce fall risk
falls epidemiology
1/4 over 65 per year 1/5 of those seriously injured
2.8 million injuries in ED/yr
average cost is 30,000 dollars for hospital visit
risk factors for falls
aging
occupational
poor mobility cognition or vision
prevention of fallls
screening living environment
clinical interventions (see if meds contribute, low BP, vit D, Ca, vision)
appropriate assistive devices
muscle strengthening, balance, retraining with PT
outcome measures in gait
timed up and go test
berg balance test
dynamic gait index
TUG
timed up and go
get up walk ten feet turn around and return to seat
<10s is low fall risk
10-20 is moderate fall risk so refer to PT
>24s predictive of fall within 6 months
berg balance test
14 items on a 5pt scale so 56pts total (0-4)
lower score is higher fall risk
Dynamic Gait Index
better than berg at assesssing fall risk
longer to administer
negotiate obstacles, stand on one leg and tap, stair negotiation
good for parkinsons, MS
8 tasks graded 0-3
higher score is better balance
<19 predicts fall risk in community
cane
straight
wide or narrow based quad canes
types of crutches
axillary
lofstrand
platform
walker types
standard
rolling
hemi
other assistive devices
wheelchairs
canes
not for non wb
asssist with balance
least supportive assistive device
cane and affected leg progress simultaneously
handle should allign with wrist crease or greater trochanter
axillary crutches
place crutches 6" lateral and 2" forward
lofstrand crutches
more for nm
more for fractures in europe
20-30° angle when holding hand grips
platform crutches
if pt can't wb through wrists
walker
most supportive assistive device
20-30 deg angle when holding hand grips
hemi walker
usually post stroke
for one upper extremity use
rollator
for easier continuous gait
if non wb they would need to hop so don't use
lesss stability than other walkers
two point gait
not for non wb pts, most normalized
progresss crutch and opposite LE simultaneously
requires two canes or crutches
three point gait
can be crutches, two canes or walker
walker then involved leg then uninvolved
four point gait
crutch then contralateral than other crutch then other contralateral
not for non WB
swing to
non WB pts
three point gait pattern
swing through
non WB pts
three point gait pattern
stairs with crutches
up with good down with bad
use handrail
up uninvolved then crutches and affected
down crutch and affected and then uninvolved
quadcane on stairs
just put flat part against step
walker on stairs
most are collapsible
so collapse and just use on side
don't use like picture unless nonfolding
guarding
assist person on stairs on weaker side
when pt uses current device properly/with stability
can use less stable
wheelchair considerations
physically capable
cognitive impair?
pressure relief
transfers determine type
wheelchair measurements
seat height
measure from heel to popliteal fold then subract 2" to clear foot rest
avg 16"
seat width
two inches past larger area of butt
reduce pressure on trochanters and allows for clothing
16-18"
back height of wheelchair
height of seat to axilla - 4"
back should be under inferior angle of scapula to use more UE, be cautious or go higher if poor core control
custom inserts exist for more core control
armrest height
seat to olecranon with elbow at 90°
some are removable for transfers
pressure relief
press up every 15-20 minutes to prevent ulcer formation
electronic chairs can have tilt in space
transfers in wheelchairs
make sure chair is locked
sit to stand (longer armest to support)
standing pivot
sliding board