Introduction to Physical Agents Review
Explain how and why a physical therapist might make modifications to the application of cold based on the age of the patient.
-Geriatric Patients -Less efficient vasoconstriction -Less shivering or no shivering -Decreased ability to produce and retain heat -Overall decreased tolerance to cold
What factors should be considered when selecting an appropriate physical agent/ modality?
-Goals of Rx -Stage of the healing process/ clinical presentation -Availability of modalities: cost, efficiency -Time management -Clinician/ pt preference -Sequencing of Rx [ex: ice can desensitize patients to exercises] -Complicating factors/ comorbities -Contraindications/ precautions -Evidence-based information/ strength and availability of supportive research -APTA Guide to Physical Therapist Practice -Presence and degree of pain
Describe systemic effects of heat exposure. What factors determine whether there will be a local versus systemic response?
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Relate the determinants of heat transfer to the 2nd law of thermodynamics.
2nd Law of Thermodynamics •Amt of heat transferred is directly proportional to temp gradient between agent & skin/ body surface •Amt of heat transferred is directly proportional to duration of application
Compare advantages and disadvantages to use of hot packs as a component of physical therapy treatment
Advantages: •Cost effective •Get progressively cooler during Rx •Easy prep/ clean up Disadvantages: •Weight of pack - can press on tender areas •Shape of pack - may not fit certain contours •Rx area not visible during application •Cannot monitor exact temperature of pack once it has been applied
Apply the Arndt-Shultz principle in defining the therapeutic temperature range for the application of thermal modalities.
Arndt-Shultz Principle (Therapeutic Window) - If its not intense enough - not effect, if its too intense then you get adverse effects Therapeutic Range: 40-45 degrees C, 104-113 degrees F
Describe the treatment procedure for application of a cold pack, including essential elements of patient education.
Confirm history and screen for contraindications/ precautions •Informed consent: •treatment procedure •rationale/ goals of treatment •What patient may expect to feel - normal vs. abnormal result •Encourage patient feedback at start of Rx and throughout session (call bell) •Assess skin integrity •Assess sensation •Select outcome measurements •Temperature of commercial refrigeration unit for cold packs should be 0 to 10 degrees F •Position & drape - for comfort, modesty and may also drape to keep pt warm during Rx •May position pt with affected body part elevated if treating for edema Cover Rx area with single layer of moist toweling, apply pack and insulate with 1-2 layers of dry toweling •Duration of Rx 10 to 15 minutes, 20 minutes max •Pt should be monitored frequently for subjective and physiological response
What are some of the contraindications and precautions for use of vapocoolant sprays?
Contraindications: •Open skin •Respiratory disease •Raynaud's disease •Cold uticaria •Decreased circulation - e.g. - PVD, arterial insufficiency •Decreased sensation Precautions: •Must perform VERTEBRAL ARTERY TEST before stretching the neck •Barriers to communication •Need well-ventilated area •Avoid contact with eyes/nose/mouth/ mucous membranes •Pt apprehension and/ or objection to use of aerosol spray
How does patient education prior to ice massage differ from patient education prior to application of a cold pack?
Description of what patient should feel - 4 stages (cold, burning, aching, numbness) Think "CBAN"
List the 5 methods of heat transfer - for each category, give an example of a physical agent that acts through this method
Direct Contact [Hot packs, Cold Packs] Convection -movement of air or water -[Whirlpool, fluidotherapy] Evaporation [Vapocoolant Spray] Conversion -One form of energy converted to heat -[Ultrasound] Radiation [Heat Lamp]
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.)
Explain Process to Patient Pretreatment assessment (history, skin, sensation, etc) •6 to 8 layers of toweling between pack and patient •Commercial terry cloth cover counts as 4 layers •Tuck in tabs •Cover with 1-2 layers of towels to insulate heat
Describe important elements of patient education when using physical agents.
Explain goals of Treatment What they should feel during Rx Encourage ongoing communication Collaboration
Why would paraffin be used as a component of a physical therapy plan of care? Describe indications, contraindications and precautions.
Form of conductive heat -Form Fitting Indications: •Rx of distal extremities: hands, feet, ankles •To alleviate joint pain and stiffness •To improve tissue extensibility, soften adhesions - Rx of healed scars and burns Contraindications: •Open wounds •Acute joint inflammation •Decreased sensation* -bottom and sides of tank are hot need to be able to withdraw hand or foot Precautions: •Barriers to communication •Impaired ability to follow directions •Must instruct patient not to touch bottom or sides of tank****
What is the method of transfer for therapeutic application of cold?
Heat abstraction Conduction
Describe how cold modalities could be used to address the presence of a trigger point.
Ice Massage and Vapocoolant in particular Promotes local relaxation
Compare methods of application of paraffin. What is the most common method? How would you perform these methods? (Describe each treatment procedure)
Immersion/Dip Immersion -2-3 Dips before immersion -then immersion for ~15mins -most intense and long lasting Glove Method -6-12 Dips then remove -Wrap hand or body part in wax paper then towels to insulate heat -wax stays for 15mins or until it cools Painting: -Up to 10 coats of wax -wrap in wax paper then towels -used on body parts that cant be dipped
Outline contraindications and precautions for the therapeutic application of cold.
Indications: •Acute injury •Acute inflammation •Acute or chronic pain due to muscle spasm •To reduce fever •To decrease edema •In UMN lesions - "quick" ice to facilitate tone, prolonged application to decrease spasticity •Rx of trigger points Contraindications: •Heart disease/ angina •Open wounds older than 48 to 72 hours •Hypersensitivity to cold: cold uticaria, Raynaud's disease •Decreased sensation
Provide a list of indications, contraindications and precautions for the application of a hot pack.
Indications: •Pain relief •Reduce muscle spasm •Increase soft tissue extensibility prior to stretching •Promote soft tissue healing •Decrease joint stiffness •Encourage general relaxation •Prior to application of electrical stimulation •Consensual heating -blood traveling through area gets heated as it goes to other areas Contraindications: •Acute inflammation •Fever •Cardiac insufficiency •Hemorrhage or acute risk of bleeding •Very young, very old patients •PVD/ decreased peripheral circulation •Infection •Over areas of known malignancy •Thrombophlebitis •Where liniment has been applied •Over Rx site for radiation therapy Precautions: •Edema •Poor sensation •Barriers to communication •Metal implants (Depth? Location?)
How would you educate a patient who will be receiving paraffin?
Informed Consent •Tell patient what you are going to do •Explain why you are going to do it (rationale) •Describe what patient should feel •Encourage patient feedback throughout Rx •Caution patient not to touch bottom or sides of tank •Patient must be instructed to limit movement of body part during application
Describe the physiologic effects of thermal modalities as they relate to pain modulation.
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. 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.
What would be considered a normal vs adverse response to Rx with vapocoolant (spray and stretch)?
NORMAL •Mild redness •Transient decrease in skin temperature ADVERSE RESPONSE •Excessive redness •Itching •Wheal formation
What would be considered a normal versus adverse response to Rx with paraffin?
Normal Response •Pink skin •Oily skin •Perspiration Adverse Response: •Presence of burns or blisters •Excessive redness •Patient discomfort
What aspects should the physical therapist consider during pre- and post-treatment assessment for application of cold packs?
Pre Treatment: -Patient Education -Skin Integrity -Sensation -Communication Post Treatment •Remove pack and perform post-Rx skin assessment •Obtain pt's subjective response to Rx •Repeat outcome measurements
Describe elements of pre- and post-treatment assessment accompanying application of a hot pack as a component of physical therapy treatment. What would be considered a normal Rx response? Abnormal or adverse response?
Pretreatment: -History -Skin Integrity -Sensation -Determine Outcome Measure (Pain scale, ROM, muscle spasm, trigger point, etc) Post-Treatment: -Check skin for appropriate response -Check patient's subjective response -Repeat Outcome Measures Normal Treatment Response: •Pink skin •Moist, presence of perspiration •Mildly warm to touch Adverse Responses: •Excessive redness, burns or blisters •Patient discomfort •**Fainting - usually due to orthostatic hypotension, monitor vitals, raise legs, lower head
How would you distinguish between superficial and deep thermal modalities? Give examples of each.
SUPERFICIAL •Penetrate .5 - 1 cm •EXAMPLES: hot packs, paraffin, infrared lamps, fluidotherapy DEEP Penetrates 3+cm •SWD •US •Microwave diathermy
What is the correct temperature range for paraffin? Explain why a patient can tolerate this temperature range when immersed in paraffin if water at the same temperature could potentially result in a burn.
Temperature range - 113 to 122 degrees Fahrenheit Low specific heat compared with water - releases heat at a slower rate (feels cooler than water would at the same temp)
When would a physical therapist choose a cold modality versus a thermal modality? Explain your rationale.
Thermal: Chronic Injury Muscle Spasm Cold: Acute injuries To Decrease Inflammation
When and how should the vertebral aa test be performed?
Vertebral a. test must be performed prior to stretching C/S Vertebral aa. test: supine head off table Extension side flexion and rotation to one side
What is the appropriate temperature range for the hydrocollator tank?
hydrocollator tank = tank for hot packs 160 to 170 degrees Fahrenheit
Is vapocoolant spray a cryotherapy modality? Why or why not?
should be considered a separate category has the sensory properties of cold - but does not evoke the physiological effects of cold
Describe the physiologic effects of thermal modalities as they relate to cardiovascular response.
vasodilation- hyperemia -Reflex activation of sympathetic cholanergic nerve fibers -Release of AcCh -Triggers relaxation of smooth mm surrounding the blood vessels •Increased heart rate •Decreased stroke volume •Increased cardiac output •Increased capillary permeability •Increased respiratory rate •Increased skin temp, increased sweating •Shunting of blood away from vital organs towards the skin •Decreased gastric motility •Decreased renal function •Increased basal metabolic rate •Decreased blood pressure •Increased core temp (excessive exposure)
How should you document treatment following application of a cold pack?
•Area treated •Duration of Rx •Position of patient •Response to Rx •Sequence - e.g. - therex, followed by cold pack
How should you document Rx following application of ice massage?
•Area treated •Position of patient •Response to Rx •Sequence - e.g - STM followed by ice massage
Describe the 5 cardinal signs of acute inflammation.
•Calor - heat •Rubor - redness •Tumor - swelling •Dolor - pain •Functio Laesa - loss of function
What are the body's main physiologic methods for thermoregulation?
•Changes in local circulation (skin) •Vasodilation •Vasoconstriction •Sweating (skin) •Shivering and piloerection
Provide some examples of cryotherapy techniques.
•Commercial cold packs •Ice packs •Whirlpool (cold = 50 to 60 degrees F, 15 to 20 min) • Ice massage •Contrast baths (alternating heat/ cold) •Vapocoolant spray***** (should be considered a separate category)
Explain how thermal modalities may be used to promote the healing process in soft tissue injuries.
•Facilitates healing in chronic conditions •In acute stage of injury, may delay healing •Avoid heat until 48 - 72 hours post-injury depending on clinical presentation - i.e. - signs and symptoms •Increases blood flow •Increases metabolic rate which can aid new cell growth •Flushes area of injury - helps get rid of waste products & metabolites
How does body tissue type affect depth of penetration for thermal modalities?
•Fat is an insulator: conducts heat 2X less than skin, 3X less than muscle. Amt of fat can determine depth of heating for certain modalities,
What is cryocompression and when would it be used?
•For Rx of edema/ inflammation •Simultaneous application of cold plus compression
Outline the proper Rx procedure for application of vapocoolant spray, including patient education, as well as pre and post-Rx assessment.
•Hold bottle nozzle down, about 2 feet away •Strike skin at an acute angle •Spray in one direction only - follow path of muscle fibers if possible •Spray at rate of approximately 4 in/ sec •One sweep of spray at a time •Too much spray, too quickly can frost the skin •Cover Rx area 1-2 times •Take pt through available ROM while applying spray •Apply gentle end range stretch •If desired, hold new range and repeat cycle •Can complete cycle 2 to 3 times •Have pt perform AROM •Teach patient to perform active stretching (HEP) •Pre-Rx assessment - skin, sensation, AROM/PROM, pain scale, palpation Post-Rx Assessment •Skin •Subjective response (pain scale) •AROM/PROM •Palpation - presence of pain and/or muscle tension
What are some of the indications, contraindications and precautions to use of contrast baths? Relate Rx indications to the physiologic effects of heat and cold.
•INDICATIONS: -Subacute swelling CONTRAINDICATIONS: -Must consider guidelines for both application of hot and cold •PRECAUTIONS: decreased sensation, age, barriers to communication
Explain what occurs during each of the 3 phases of tissue repair, and provide approximate time frames.
•Inflammatory Phase +/- Days 1-6 •Vasoconstriction •Vasodilation •Clot Formation •Phagocytosis •Proliferative Phase +/- Days 3-20 •Epithelialization •Fibroplasia/Collagen Production •Wound Contracture •Neovascularization •Maturation Phase +/- Day 9 onwards... •Collagen Synthesis/Lysis Balance •Collagen Fiber Orientation
Explain how ice limits secondary tissue damage following an acute injury.
•Lack of blood supply means less O2 surrounding tissue - may result in secondary ischemic damage •Ice reduces demand for oxygen by slowing local metabolic rate in surrounding tissues
In addition to general contraindications for application of cold, what factors should a PT consider prior to application of ice massage?
•No ice massage on open skin •Check skin turgor and consider pt age, overall condition prior to application
How would you write a note documenting Rx with vapocoolant spray (spray and stretch)?
•Patient position •Number of sweeps/ cycles •Pre and post-rx ROM •Response to Rx - skin, subjective response, pain, tenderness to palpation ... •Rx sequence
What is the purpose of positioning and draping prior to application of physical agents?
•Provides access to treatment target area •Encourages patient comfort •Assists goals of treatment - e.g. - elevation of edematous extremity •Maintains patient modesty •Protects clothing
What is the Hunting response? How does it affect the treatment duration for application of cold modalities?
•Reflex vasodilation in response to prolonged cold •Body's attempt at maintaining homeostasis, preventing tissue injury due to cold exposure •Vasodilation occurs after approximately 20 minutes & helps re-warm tissues Use this deliberately in patients with longstanding edema in which you are trying to work on vascular control of temperature - otherwise you want to avoid the hunting response
Describe the proper Rx procedure for application of ice massage, including duration of Rx and elements of pre- and post-Rx assessment.
•Review contraindications/ precautions •Check skin integrity & sensation •Perform outcome measurements •Position and drape •Drape to keep pt warm - want local effects of ice massage only •Rub ice at moderate speed •Use rhythmic motion •Blot area as ice drips •Usual duration of Rx: 5 to 10 minutes, depending on desired effects (e.g. - anesthesia) Post Rx: •Check skin - color, temperature •Patient feedback - subjective response •Assess effects of Rx - did you meet the intended goals?
Outline the proper Rx procedure for application of fluidotherapy, including elements of patient education
•Review history and clinical presentation for precautions/ contraindications •Perform skin & sensory assessment •Perform pre-Rx assessment - outcome measures •Position & drape - secure strap around portal •Monitor response to Rx - call bell •Perform post-Rx assessment
What is a "trigger point"? How would you identify presence of a trigger point during patient assessment?
•Small area of localized muscle spasm Palpable - feels like a small "knot" •"jump sign" - brief, localized twitch on palpation •May have area of associated pain - referral patterns
List important elements that should be taken into account when documenting a paraffin Rx.
•Specify chosen method of application •# of dips if applicable •Site of application •Patient position •Rx time •Response to Rx - outcomes
Which factors might affect clinical decision making when choosing between cryotherapy and thermotherapy?
•Stage of injury •Goals of Rx •Area to be treated •Patient preference •Indications/ contraindications
Give examples of each type of physical agent used in physical therapy practice: a. Superficial thermotherapy b. Deep heating modalities c. Cryotherapy d. Phototherapy e. Mechanical agents f. Hydrotherapy
•Superficial heat: •Hydrocollator packs •Fluidotherapy •Paraffin •Deep heat: •Diathermy •Ultrasound »Diathermy and US also have non-thermal, mechanical properties *** •Cryotherapy: •Cold packs •Ice massage •Vapocoolant spray •Phototherapy: •"Cold laser", SLD (superluminous diode), LILT •Ultraviolet •Mechanical: •Traction •Intermittent compression •Hydrotherapy: •Whirlpool •Pulsed lavage (wound care) •Aquatic exercise
What is fluidotherapy and when would it be used? Relate this to the relative advantages and disadvantages for use of this modality.
•Superficial heating modality •Heats by convection & conduction - dry heat •Self-contained tank of small particles circulated by warm air current Advantages: average heat absorption from fluidotherapy Rx 3X greater than paraffin (Belanger 1977) •Patients may tolerate dry heat better than moist heat at the same temperatures •Patient may move body part, exercise during Rx •Therapist may perform hands-on techniques during Rx •Unit easy to maintain •Particles are bacteriostatic - self-cleaning •Temperature of unit can be kept constant throughout course of Rx Disadvantages: -takes a while to warm up -no jewelry in the machine
List elements of clinical documentation following application of a hot pack.
•Treatment note should contain the following: -Site of Rx -Pt position -# of towel layers -Rx time -Response to Rx/ outcome -Rx sequence
Describe the Rx procedure for contrast baths, including appropriate patient education
•Two containers: •Cold: 50 to 60 degrees F •Warm: 104 to 106 degrees F •Total Rx time: 20 minutes •Ratio: 3 minutes warm to 1 minute cold, or 4 minutes warm to 3 minutes cold
What are some of the common locations for trigger points?
•Upper trapezius •Piriformis •Glut medius •Biceps femoris (hamstrings) •Gastrocnemius •Iliopsoas •Pectoralis
Provide an alternative to use of vapocoolant spray for Rx of trigger points and limited ROM.
•Use ice - quick strokes prior to stretching •Apply ice in same direction, roughly same speed as you would apply spray •May use this alternative due to environmental concerns, if pt or therapist has respiratory problems
What are the physiologic effects of cold? How would you determine whether application of cold will have local versus systemic effects?
•Vasoconstriction •Increased BP •Decreased HR •Increased stroke volume •Increased cardiac output •Decreased RR •Increased tidal volume •Decreased skin temp •Decreased sweating •Shivering •Increased muscle tone - may increase spasticity •Decreased basal metabolic rate •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 of connective tissue
When are vapocoolants used in physical therapist practice? Explain the Rx rationale using physiologic effects. What are some of the advantages and disadvantages for use of this modality?
•Works as counterirritant - can break pain cycle •Distracts patient during stretch and promotes relaxation •SENSORY EFFECTS ONLY*** •No significant physiological changes due to very brief exposure/ insufficient change in tissue temperature Indications: •Trigger points •Decreased range of motion •**** To numb area prior to injection (not a PT application, per se)