TI Week 4 Summary PDF

biophysical modalities: definition 4.1 intro to biophysical modalities “therapeautic modalities represent the administration of thermal, mechanical, electromagnetic and light energies for a specific therapeutic effect” therapeautic interventions therapeautic excercise manual therapy pt education **p...

biophysical modalities: definition 4.1 intro to biophysical modalities “therapeautic modalities represent the administration of thermal, mechanical, electromagnetic and light energies for a specific therapeutic effect” therapeautic interventions therapeautic excercise manual therapy pt education **physical agents or therapeautic modality physical modalities: clinical decision making “clinical decision-making can be thought of as the process of using information, experience, and judgments to decide which clinical interventions will most likely improve the problems identified in the examination” hope to answer what do we want to achieve and what interventions and parameters of those interventions will most likely help us achieve a positive result or outcome? * selection of appropriate modality will impact the success of an outcome comprehensive management * treats whole person interventions work together to promote: - positive outcomes - meet fxnal and pt goals >> common interventions (pic) - * therapeutic modalities: no well established literature 2014 APTA “choose wisely” campaign stated therapeutic modalities are considered adjuvant interventions -meaning these types of interventions should only be used in conjunction w other more well-supported forms of management: therapeutic exercise, manual therapy & pt education * therapeutic mods still heavily used 2014 centers of medicaid and medicare services state ultrasound and e-stem are still used heavily * use literature to predicate when we use ther mobs biophysical modalities: types cryotherapy: use cold to induce a therapeutic/ physiological response in tissue result- decrease in temp thermal modalities: results in an increase in tissue temp (can be hot or cold) -in lecture he’s talking about heat for this one electrotherapy: results in depolarization or activation of peripheral n’s or creation of electrical gradients in tissue mechanical therapy: use mechanotransduction ultrasound: uses sound waves to promote physiological responses in tissue- result in thermal and non-thermal effects electromagnetic therapies: use radio waves to promote physiological responses and tissueresult either thermal or non-thermal effects biophysical modalities clinical application * varied clinical application what they have found: 1. pain modulation 2. skeletal muscle performance 3. inflammatory management and tissue 4. flexibility and range of motion healing keep in mind * when do we use modalities? * what parameters do we use when we utilize mods? considerations : stages of healing adherence of POC disease states fear avoidance behavior pts thoughts/beliefs (of modalities) biophysical modalities: assessment and outcomes adjuvant vs prim management (ex: therapeutic exercise) quantitative vs qualitative benefit (ex: changes in ROM or perceived pain) quality research physiological outcomes and pts condition biophysical modalities: precautions and contraindications precautions “reflect situations in which a pt is at some risk of experiencing an adverse event” contraindications “situation in which a drug, procedure or surgery should not be used bc it may be harmful to the pt” ex: DVT- cant use mechanical mod bc clots hemorrhagic conditions electronic implants bc of electrical currents pregnancy (they dont know why so its best not to use)- doesnt effect baby or mom malignancies bc we dont want to promote growth * we rely on pt to tell us if they’re having discomfort can be dangerous of they cant vocalize it take-aways 1. therapeutic modalities represent the administration of thermal, mechanical, electromagnetic and light energies for a specific therapeutic effect. 2. biophysical modalities are adjuvant treatments to a comprehensive plan of care 3. care should be taken in selecting a biophysical modality with special attention to its physiological effects on and potential harm to a patient 4.2 intro to thermal modalities thermal modality definitions cryotherapy: form of therapy uses cold to promote therapeutic and physiologic responses by decreasing tissue temperature, its a form of thermal ablation thermotherapy: uses heat to promote a therapeautic or physiological response by increase tissue temp * use of either cold or heat modalities will allow clinician to cause desired physiological change in tissue by altering tissues temp types of thermal modalities modes of cryo and thermal therapies therapeautic cold ice cold water cold gel-filled packs vapocoolant sprays therapeautic heat warm water heat packs light waves sound waves affected tissues direct heat from thermal modalities will not penetrate deeper than 1cm into soft tissue cold therapies may have potential to affect tissue deeper than heat temp changes primarly affect superficial tissue and blood vessels factors of direct temperature change 1.temperature differential 2.surface area ex: the larger the area, the more energy that dissipates and a slower change we're going to see in temperature 3.time: more time exposure, the more communal energy transmission 4.conductivity: tissues w increased water content: more conductive more adipose tissue: less conductive deeper structure>harder to change tissue temp -tissue takes longer to cool and rewarm 5. activity level: predicate speed w which energy’s transport in body can resolve in increased cooling or heating 6.agent type: type of cooling or heating agents as the ability to maintain its temp and determine how quickly tissue temp will change. primary modes of energy transfer conduction: most common form of energy transfer -transfer heat bw 2 interacted molecules -energy will travel downstream -heat will travel to places that are cooler convection evaporation indirect temperature change heat in circulated blood disperses quickly loss of heat in circulated blood is harder to recover from * deeper tissues can be affected by temp n changes thru circulation of warmed or cold blood * prim reason for difference in energy dissipation and gain is due to physiological changes and tissue following a temp change (blood vessels) consequence of temp in vascular system is vasodilation and vasoconstriction vasodilation: physiological effect of heat -greater volume of blood dispersing so heat is lost quickly (in image A) vasoconstriction: physiological effect of cooling -smaller volume of blood * recover from heat loss takes longer (image B) -greater potential for indirect temp change via cryotherapy and deeper tissue * indirect response and tissue of cold therapies thought to be reason modality can effect deeper tissue take-aways 1. cryotherapy cools tissue to promote therapeutic and physiologic responses. 2. thermotherapy heats tissue to promote a therapeutic or physiological response. 3. the depth of temperature change in tissue is thought to involve the rate of energy dissipation in the blood stream. 4. cold therapies are thought to be able to change the temperature in deeper tissues than heat therapies. 4.3 Cryotherapy Indications and Effects Cryotherapy form of therapy that uses cold to promote therapeutic & physiological responses by decreasing tissue temp Physiological changes of cryotherapy blood flow = vasoconstriction inflammation = decreased metabolism & vasoactive agents (decreases bases that cause inflammation) muscle performance = decreased nerve conduction peripheral nerve = decreased nerve conduction Prime reason for cryotherapy management of acute trauma management of secondary clinical presentations of acute trauma management of spasticity in pt muscles - PD, MS, CP, CNS dysfxn - decreases muscle, spindle discharge (1:50 review) hubbard hayden & grant cryotherapy w. acute msk injuries active military return faster from ankle sprain positive effect on return to fxn hawk et al early therapy = returned to activity sooner Cryotherapy decreasing BF. (15 min or less) Vasoconstriction in cutaneous tissue via smooth muscle contraction reduction in vasodilating transmitters increased blood viscosity DRG stimulation Decrease in BF & combo of vasoconstriction less opportunity for local blood to pull energy from external heat source Inflammation & Cryotherapy (debated) physiologically - decrease capillary permeability - decrease leukocyte counts - decrease cellular metabolism fxnally - decrease intramuscular pressure - possible protection against compartment syndrome formation - decreased cellular demands & associated secondary tissue - decrease secondary tissue injuries/tissue death - application can affect inflammatory processes under certain circumstances - acute intense = increase inflammation - long term intense or mild cold = minimize inflammation Peripheral N. Performance S & M Physiologically increase nerve threshold for depolarization decrease nerve conduction block nerve conduction Fxnally increased pain tolerance careful applying to superficial Longer application = greater conductivity loss neural tissue affects performance negatively Muscle performance decreased BF decreased motor n conduction decreased sensory n conduction MAYBE jt awareness reduction ulnar/radial n posterior tibial n always adjust interventions if using cryotherapy for 10 min or more to account for performance Summary cools tissue for therapeutic & physiologic response - change in treated tissues - change in blood - change in sensory & motor n fxn - change in inflammatory processes cryotherapy found to be indicated for use in pt w/ acute musculoskeletal injuries 4.4 Modes and Assessment of Cryotherapy Modes ice & gel packs massage vapocoolant contrast baths compression units Cold packs crushed ice w/ water or wet towel barrier b/w pack & skin properly position for underlying condition RICE - penetrates deeper than gel packs - just make sure part is exposed - rest, ice, compression, elevation - acute msk injury ice massage smaller areas of skin HEP/self management trigger points 5-10 min vapocoolant combined w/ stretching for myofascial tension/ trigger points repeated several times in one tx no deep penetration contrast baths - common for energy transference cryotherapy convection w/ water turbulence jets/pumps ensures circumferential contact w/ cooling agent (submerged) difficult to clean contraindication circulatory insufficiency compression units manual circulation of cold water for constant cold dif shapes/configurations for body parts filled cuff for compression every 1-2 hours EDUCATE PT ON USE AT HOME Outcomes after specific agent edema pain ROM (pre and post) fxnal mvm muscle guarding /I know these - summary dif modes, unique applications/benefits/risks acute msk injuries affects assessed in obj testing , 4.5 Cryotherapy Application Indication, Acute MSK trauma considerations muscle spasms myofascial pain syndromes delayed onset muscle soreness all based on goals Modes ice & gel packs massage vapocoolant contrast baths compression units *4/5 use conduction for energy transference* PRICE know this! Preparation & Expectations Patient Education Assessment asses pt medical status acuity of injury experience intense cold, burning, aching, then analgesia examine for hypersensitivity rvw precautions list (hyper/hyposensitivity) align w/ goals skin becomes red after use avoid significant stress at injured tissue for 1-2 hours after ice application Parameters tx time (10 min intervals 2-3x per tx & stop as soon as analgesic) cryokinetics (normally precede tx unless trying to reach deep) session itinerary (how organize session for goals of cryotherapy effects) barriers pt position/tolerance (skin exposed and protected) cooling agent (cost, fxn, time, effect, pt pref, evidence) know these know these too! Summary cryotherapy for acute msk, manage pain, prevent effusion & secondary tissue death most common form of energy transfer used conduction proper assessment & setting appropriate expectations for pt prior to cryotherapy best practice several parameters for safety precautions/contraindication (know them!!) 4.6 Thermotherapy Indications & Effects Definition - The use of heat, from any source, to promote therapeutic or physiological response by increase tissue temperature - Can include ultrasound, superficial heat, electromagnetic therapies Physiological Changes in Thermotherapy - Physiological Changes - Metabolic Reactions - Vascular Effects - Neuromuscular Effects - Connective Tissue Effects - ALL dependent on - Extent of temperature increase in tissue - Rate of energy added - Volume of tissue exposed - Composition absorbing tissue - Capacity of tissue to dissipate heat - Thermal therapy best indicated for pain management & anti spasmodic Metabolic Reactions - Heat will increase cell activity & metabolic rate - Increase oxygen uptake by tissues - Increase circulation Vascular Effetcs - Vasodilation - Starts in cutaneous receptors, sends afferent information to SC - Then mediates release of chemicals, causing vasodilation in vasculature - Causes mild Inflammation local to tissues exposed to - Increased Vascular Permeability - Increased Blood Flow - Primarily effecting cutaneous tissue - Minimal change found in muscle tissue Neuromuscular Effects - Elevated Pain Threshold (Increased pain tolerance) - Mediated by Thermal Gate Control - Increased Nerve Conduction Velocity - Decreased Alpha Motor Neuron Activity - Anti-Spasmodic - Heat thought to decrease gamma efferent nerve activity, resets muscle spindles - Allows max sensitivity to stretch - Decreases sensitivity in muscle spindle, relaxes muscle Connective Tissue - Physiological Change - Increased Elasticity - Decreased Blood Viscosity - Blood is a form of connective tissue - Functional Change - Decreased Joint Stiffness - Increased Muscle Flexibility Important Consideration - Degree of penetration modality has - Direct energy will effect superficial cutaneous tissues most Take Aways - Thermotherapy heats tissue to promote therapeutic & physiologic response - Thermotherapy may lead to physiological changes in treated tissue - Thermotherapy has been found to be most indicated for use in patients w/ pain & impaired range associated w/ stiffness & muscle spasms 4.7 Modes & Assessment of Thermotherapy Modes - Moist Heat Packs - Offers moderate results w/ - Reducing Pain - Reducing Muscle Spasms - Increasing Tissue Extensibility KNOW THIS KNOW THIS - Paraffin Wax - Conducts heat slowly, decreases risk of burn - Provides moist heat for sensitive skin & Scar Tissue - Combined w/ exercise, can improve stiffness, ROM, & grip function - Electric Heating Pad - Used primarily as part of home exercise program to manage pain - Risk for wearing while falling asleep - Increased risk for burns KNOW THIS KNOW THIS - Fluidotherapy - Convection Modality - Has all advantages of normal heat as well - Additional Advantages - Will not increase inflammation in patients w/ edema - Can be used w/ open wound, dressed for protection - Additional Disadvantages - Limited body parts can be treated Outcomes - Pain - ROM - Muscle Guarding - Documentation - Thermal Modality Used - Method of Application, including duration - Body Area Treated - Patient Position for Intervention - Special Precautions or Application Concerns Contraindications Take Aways - Different modes of thermotherapy have unique application, benefits, & risks to them - Each mode aims to treat pain, ROM, or muscle spasms - Affects are assessed as part of objective testing in form of degrees of ROM, pain, quality of guarding/funcitonal movement 4.8 Thermotherapy Application Indication - Thermotherapy usually used during remodeling phases of tissue healing - Best indicated to - Manage Pain - Reduce Muscle-Guarding Spasms - Increase ROM Modes - Many modes of thermal modality (Previous lecture) - To provide any therapeutic effect, tissue temps should be 104-113 - Exposure to tissue could be as long as 30 minutes before degree of temp change has occurred - To increase deep tissue, continuous ultrasound or shortwave diathermy should be used - Important Consideration - What the makeup of the soft tissue being treated - Presence of fat in tissue will decrease conductivity of energy transfer - Heat transfer most commonly completed via conduction/convection - Radiation also a method to transfer energy (Infrared Lamps) Pre-Exercise - Select populations may benefit from combo of heat exercise more than others - What’s been found in Thermotherapy - Increased blood flow & vasodilation - Increased functional outcomes & pain relief in lower back pain - Decreased pain & disability & increased walking speed in patients w/ knee osteoarthritis - Decreased strength & endurance initially after use Combined w/ Stretching - Consistent thermotherapy application w/ low loads of stretching over prolonged periods of time, results in greater tissue extensibility w/o tissue damage - Outcome - Plastic Deformation - Increased ROM - Muscle Relaxation - Decreased Joint Stiffness - Considerations - Degree of Temperature Elevation - Parameters of Stretch - Magnitude - Duration - Speed - Patient Tolerance Preparation & Expectations - Assessment - Assess patient’s medical status - Acuity of injury - Assess precautions/contraindications - Examine for hypersensitivity/hyposensitivity - Review precautions list - Align w/ goals - Patient Education - Mild to moderate heat sensation - Change is skin coloration - Frequency of skin checks - If part of home exercise program, they have to do it regularly Parameters - Treatment Time - Typically b/w 15-30 minutes - Session IItinerary - Heat prior to stretching or pain management at beginning or end of treatment is best supported - Application of heat prior to movement might cause increased therapeutic benefits - Low Back pain, Knee osteoarthritis - Patient Position/Tolerance - Position exposes treatment area & comfortable for patient - Muscle Spasms - Be careful w/ degree of stretch - Low level stretching w/ heat may elongate tissues - Avoid positions where patients lie on top of heat - Barriers - Need barriers b/w heat & patient to avoid burns - Says 6-8 layers - Heating Agent - Depends on the involved structure, pathophysiology, tissue being treated, degree of temperature elevation - Heat usually chosen during remodeling phase of tissue - Or when contractions persist Contraindications KNOW THESE Thermotherapy Application (Hot vs. Cold) Cold Therapy - Best indicated for acute presentation - Musculoskeletal Injuries Heat Therapy - Best indicated for subacute/chronic stages - Soft tissue healing Take Aways - Thermotherapy primarily indicated for pain management, decrease muscle spasms, improve ROM - Many modes, most common form of energy transfer is conduction - Complete proper assessment/set expectations for patient prior to use - Several parameters to promote safety/insure therapeutic outcomes - Numerous contraindications, know them 4.9 Therapeutic Ultrasound Define Explain- frequency intensity, duration, duty cycle Generating US waves Transmissivity and Attenuation for US waves Ultrasound waves are sound waves that are high frequency acoustic vibrations. Can be thermal and nonThermal A medium is needed to conduct for ultrasound to better penetrate the skin Frequency- cycles per second. Common ones- 1-3megaHZ Intensity- amount of energy delivered per unit of area Mode and Duty cycle- the total amount of energy emitted during treatment Beam Uniformity- Intensity of the ultrasound across a treatment area. Treatment area- area exposed to the ultrasound waves Generation of Waves Piezoelectric effect ability of an object to generate an electrical field from an applied mechanical stress Reverse Piezoelectric effect Using ultrasound. The creation of sound waves from the electrical currents shrinking and expanding the crystals in the ultrasound head. Attenuation The reduction of energy as it passes through tissue. Absorption and Dispersion and Reflection US head must be on the skin, because air will attenuate 100% Transmissivity-how much a coupling medium allows USwaves to pass through. The greater the transmissivity, the more waves pass through. Bad mediums will reflect or refract waves. 9.10 Indications for Therapeutic Ultrasound Obj: summarize the use precautions contraindication Indications for Ultrasound Very little evidence for consistent therapist benefit, parameters are poorly described Inflammation and pain were the main determining factors to indicate ultrasound treatment should be used however, most studies today have conflicting evidence disproving the positive benefits of US. Pain and Inflammation graph was based off of poor quality studies, and researcher bias. Conflicting findings and low physiological findings. Note: there are better treatment routes for pain and inflammation than ultrasound treatments Also no compelling evidence for use of pulse ultrasound Precaution and Contraindications 9.11 Ultrasound Parameters for Treatment Obj: how freq, intensity, mode, and duration affect thermal and non-thermal effects Relationship between mode and intensity with treatment dosage summarize basic techniques for US transducers, and retionale for size of treatment area Review Parameters- Freq, 1-3 mega hertz 3= superficial penetrations 1= deeper penetration Mode. Energy emitted during treatment pulsed- periodic interruptions in production continuous- no interruptions Normally in percentages. 20-50% ? Pulsed 100% continuous Intensity and Dosage Energy delivered per unit of area. watts/cm3 Duration- determined by freq, intensity, size of treatment area, and therapeutic goals Thermal outcomes- high intensity, short duration. OR low intensity , longer duration Treatment area should never be bigger than 3-4 times the size of the ultrasound head (ERA) Application Technique- maintain cotact Speed- 2-4cm/sec Record treatment description Record Patient position Activity: Thermal Therapy Thermal therapy’s primary role is as an anti-spasmodic. / pain management TRUE/FALSE How does heat affect tissue physiology to promote a therapeutic response? (Waterfall) 1. vasodilation 2. increases metabolic rate 3. 4. increase n. conduction - decrease alpha motor n. for tonicity increased elasticity Based on these physiological responses, what other therapeutic responses might heat mediate? psychosocial aspects, increased ROM, increase healing Activity: Cryotherapy Cryotherapy should be used in chronic stages of soft tissue healing. TRUE/FALSE used in acute trauma/post op acute inflammation/pain How does cryotherapy affect tissue physiology to promote a therapeutic response? (Waterfall) 1. decrease n conduction 2. vasoconstriction 3. 4. motor & sensory decreased metabolism Based on these physiological responses, what other therapeutic responses might cold mediate? autonomic depression, preventative care from further injury Activity: Ultrasound Ultrasound has relatively poor evidence supporting its use as a therapeutic physical modality. TRUE/FALSE How does ultrasound (non-thermal) affect tissue physiology to promote a therapeutic response? (Waterfall) 1. 2. 3. 4. cell permeability increase mast cell degranulation free radical formation mechanical US = mechanotransduction * to influence change at cellular level through cavitations and acoustic streaming (waves) Based on these physiological responses, what other therapeutic responses might non-thermal US mediate? pain/inflammtion control (healing), psychosocial ROM Pain tolerance VAS guarding inflammation/edema measurement (palpate too) gait analysis, posture analysis ROM Palpation Subjective Report VAS JT mob Increased Flex anything is really tiny difference, hard to tell Activity: Matching – US Characteristics higher = less penetrate, lower = deeper energy delivered in a certain time frame (1 sec) 1. Frequency 2. Intensity 1. 2. 3. Related to treatment goals and energy being emitted. Smaller will result in a greater change of thermal effects. Mode/Duty Cycle on/off times 4. 3. Energy that is emitted in any given time. 4. Energy delivered to a unit area. 5. Depth of wave penetration. Duration confused 5. Treatment Area MORE ATTENUATION MORE ENERGY BEING BLOCKED SO LESS ABSORPTION? DOES REFLECTING MORE MEAN GOOD OR BAD IM SO CONFUSED Activity: Discussion - Attenuation higher frequency - more attenuation where it’s opposite for estim good better absorption PROTEIN muscle better bc more refracts so use water bad blocks energy from traveling protein than fat!!!!! not penetrating thru tissue poor absorption oooooooo How do ultrasound waves differ from electromagnetic waves with regards to tissue attenuation? i think this is in regard to US and the other is in regards to estem/electrical current ok ok i get thank u Activity: Roleplay – Heat vs Cold Dr. Stern has a question about how each type of modality will impact other therapeutic interventions. Activity: Clinical Interpretation You are using an ice cup to lower your patient’s tissue temperature and your patient has noted an ongoing sensation of burning for 4 minutes. What might this be indicative of? chemical changes, a delta fibers triggered then c fibers triggered, then change of connectivity feeling burning which is chemical response leading to numbness from the connectivity change Which type of feedback would you give this patient? normal, educate prior and tell them its part of the process but if need change they can do ice w/ barrier Activity: Clinical Interpretation You are attempting to cool a patient’s skin and intramuscular temperature as much as possible using ice in a plastic bag or frozen vegetables. Which physical agent and mode would be MOST effect to decrease tissue temperature? ice chunks/water in towel pressure and ice - for loss of heat faster Activity: Clinical Interpretation A patient with a history of an acute deep vein thrombosis requests that you use ultrasound as part of their treatment today to increase tissue extensibility. NO What would you do? Educate only numbers summation in relation to thermal and US know chart about TES EXAM 50 Q ICF model - relationship b/w anatomical and physiological system - what part - management principles model: what is that (prognosis) motor learning principles: differences in stages different tasks taxonomy of motor learning (classifying a task) what motor learning activity most complex when in motor learning would you use specific practice types and types of feedback grading of tissue know b/w healing stages, when anticipate to use PROM or what stage would expect scar tissue remodeling to occur during subacute what types of interventions when use ESTIM over shockwave when not use schockwave what settings for TES for pain management (chart) 50 q’s 10-12 q’s per week i feel like we know this stuff omg we do hehe we’re going to be okay! perioddd