Therapeutic Modalities Midterm Exam

Therapeutic Modalities

• Purposes of modality use:
  • Promote and improve wound healing, pain relief, flexibility, muscular strength, speed, coordination, power, agility, and cardiorespiratory endurance
• The art and science of modality use involves considering:
  • Tradition, experience, science, and theory
• Modality selection criteria:
  • Thorough evaluation resulting in a correct diagnosis
  • Understanding of pathologic and physiologic changes associated with injury
  • Treatment plan outlining therapeutic goals
  • Understanding of modalities' effects, indications, and contraindications

Evidence-Based Practice

• Definition of Evidence-Based Medicine (EBM):
  • Medicine based on the latest and most rigorous scientific evidence, integrating with clinical experience and patient preferences
• Definition of Evidence-Based Practice (EBP):
  • Application of EBM principles to professional practice
• Types of outcome measures:
  • Clinician- or disease-oriented outcomes (e.g., physiological data, X-ray results, ROM measurements)
  • Patient-oriented outcomes (e.g., patient's assessment of current health status, quality of life, symptoms)
• Levels of evidence:
  • Not specified in the provided text, but generally ranges from high-level evidence (e.g., systematic reviews, randomized controlled trials) to low-level evidence (e.g., expert opinions, case studies)
• Best practices:
  • Specific treatment plans to resolve a patient's condition in the most complete way
• Standard of Care:
  • Another term for best practices
• Clinical Practice Guidelines:
  • Systemically developed statements that describe the best and achievable practice for a specific area of care

General Application Procedures

• Approaches to modality application:
  • Cookbook approach: following a protocol for each injury without considering individual patient factors
  • Critical thinking approach: organized procedural outline with broad guidelines that empowers the clinician
• Standard operating procedures:
  • Specific guidelines and protocols for performing a specific task
  • Form of quality control
  • Promotes consistency, but may have potential disadvantages (e.g., promoting a cookbook approach, being daunting to learn)
• 5-step application framework:
  • Foundation: description, effects, advantages, disadvantages, indications, contraindications, and precautions
  • Pre-application: selecting the proper modality, preparing the patient psychologically and physically, and equipment preparation
  • Application: following procedures, adjusting parameters, and ensuring safety
  • Post-application: equipment removal, patient cleanup, recording treatments, and providing instructions
  • Maintenance: routine maintenance and repairs

Injury Record Keeping

• Purpose of record keeping:
  • Communication and quality control
  • Legal protection
  • Research
  • History
  • Traffic patterns
• Types of SOAP notes:
  • Initial note: written after the initial assessment
  • Progress note: periodic documentation of treatment results
  • Discharge note: written when treatment is discontinued
• Initialing and dating notes:
  • Always date and initial notes to establish when the entry was created and to identify the clinician responsible for the entry

Tissue Response to Injury

• Cardinal signs of inflammation:
  • Rubor (redness)
  • Calor (heat)
  • Edema (swelling)
  • Dolor (pain)
  • Funca laesa (functional loss)
• Sequential events of the inflammatory process:
  • Injury
  • Ultrastructural changes
  • Chemical changes
  • Hemodynamic changes
  • Metabolic changes
  • Permeability changes
  • Leukocyte migration
  • Phagocytosis
• Macro- vs microtrauma:
  • Macrotrauma: caused by a large insult, resulting in immediate tissue disruption (acute injuries)
  • Microtrauma: caused by small or low-grade stress, wearing away tissue over time (chronic injuries or overuse)
• Neutrophils vs macrophages:
  • Neutrophils: smaller, faster, and more numerous, arriving at the injury site first and providing a temporary first line of defense against bacterial infections
  • Macrophages: larger, living for months, and reproducing, providing a long-lasting second line of defense and cleaning up cellular debris to prepare for repair
• Recurring vs chronic inflammation:
  • Recurring inflammation: reinitiated acute inflammation before the previous episode of acute inflammation has finished
  • Chronic inflammation: begins in a slow, unnoticed manner, occurring when the inflammatory response cannot eliminate the cause of injury
• Primary vs secondary injury:
  • Primary injury: direct result of the initial physical forces
  • Secondary injury: the body's response to the traumatized tissue
• Secondary enzymatic and metabolic responses:
  • Secondary enzymatic: release of enzymes from lysosomes to digest cellular debris
  • Secondary metabolic: caused by prolonged local ischemia, resulting in a deficit of blood to the area
• Edema vs swelling vs inflammation:
  • Inflammation: local response to injury
  • Edema: accumulation of fluid portion of blood in the tissues
  • Swelling: increase in tissue volume due to extra fluid and cellular material

Immediate Care of Orthopedic Injury

• RICES:
  • Rest
  • Ice
  • Compression
  • Elevation
  • Stabilization
• Immediate care vs acute care:
  • Immediate care: 7-12 hours
  • Acute care: 0-4 days
• Cryotherapy in immediate care:
  • Decreased blood flow theory
  • Decreased secondary injury theory

The Healing Process

• Phases of repair:
  • Hemostasis and inflammation: lymphatic drainage
  • Epithelialization: developing a membranous tissue covering exposed tissue
  • Proliferation: angiogenesis, collagen synthesis, and wound contraction
  • Remodeling: contraction, restructuring, and collagen reconstruction
• Healing modifiers:
  • Immediate care procedures
  • Pain
  • Wound closure
  • Exercise
  • Modalities
• Therapeutic goals and corresponding modalities:
  • Stimulate healing process: ultrasound, E-stim, hot packs
  • Promote lymphatic drainage: massage, cryokinetics, edema pressure devices
  • Moderate pain: cryokinetics, cryostretch, TENS

Understanding and Relieving Pain

• Anatomy review:
  • Hypothalamus: control station for the body's activities
  • Thalamus: sensations such as heat, cold, pain, and touch
  • Cerebral cortex: intensity and location of pain
  • White and grey matter: afferent and efferent nerves
• Pain perception modifiers:
  • Heredity
  • Psychosocial experience
  • Prior pain experience
  • General life stress
• Pain pathway:
  • Noxious stimuli travel to the spinal cord, entering through the dorsal horn, and exiting at the ventral horn into the thalamus, then to the cerebral cortex
• Pain theories:
  • Specificity: specific nociceptive receptors in the periphery, sending impulses on specific neural pathways
  • Pattern: denies the existence of specific pain receptors, proposing that pain occurs when it reaches a certain threshold
  • Gate control: operates at the spinal level, proposing a gate mechanism that allows only one sensation at a time
  • Neuromatrix: pain is a multidimensional experience, unique to each person
  • Fear Avoidance: proposes that acute back pain turns into chronic pain due to fear and avoidance behaviors
• Origins of orthopedic pain:
  • Nociceptive: response to injury to the body
  • Neuropathic: complex, chronic pain, usually due to tissue damage
  • Idiopathic: unknown origin
  • Learned: developed from a patient's pain memories
• Placebo and placebo effect:
  • Placebo: a medically inactive substance that appears as the real thing
  • Placebo effect: measurable, observable, or felt improvement in health not attributable to treatment