What is a

Physical Agent?

* Application of a force or substance/device that causes change.

*The change we would like to produce is progression thru the rehab process (processing you to a more healthy state).

PA that we provide

in physical therapy setting?

The should __________.

"bells and whistles"

*Help the PT Rx

*Facilitate progression thru the rehab process.

*Should always have specific purpose and goal.

Responsibilites for

use of PA.

*APTA and MO practice act. Guidelines for specific use of PA.

*General knowledge necessary for application of PA. (potential for harmful side effects.

A  modality is

administered along with

_______________.

other important PT interventions in order

to make them successful.

Along with a PA

Also Provide__________.

*pt edu

*Adjunctive therapies

- Flexibility

-Strengthening

-Balance

- Supportive therapies (taping or assist devices)

* Data Collection to determine effectiveness

*Documentation of agent parameters and outcomes

Considerations when using a

PA?

*Indications, Contraindications, Precautions

*Always relative to the situation

* Effects (normal, abdnormal, adverse)

*Impaired sensation (goal of Rx?)

*Impaired mentation (pt expectations?)

*Comm barrier (pt expectations?)

Types of

PA?

*Thermal - Heat/Cold (Superficial/Deep)

*Mechanical (Traction/Compression)

*Electromagnetic

*Electrical

General Effects of

PA

*Modify inflammation and healing

*Relieve Pain

*Alter collagen extensibility

*Modify muscle tone

Signs of

Inflammation

*Heat - increased bld flow and local metab

*Redness - increased bld flow

*Swelling - blocked lymphatics

*Pain - chemical irritation and pressure (jt splinting and muscle inhibition)

*Loss of fxn - from pain and swelling

The right modalities at the right time can help

________.

accelerate and facilitate progress into and through

the rehabilitation process.

Phases: Inflammation

and Repair

Inflammation:  1-6 days

diathermy

the application of shortwave or microwave electromagnetic energy

to produce heat w/in tissues, particularly deep tissues

cryotherapy

therapeutic application of cold

*used to decrease circulation, metabolic rate, or pain.

thermotherapy

therapeutic application of heat

*used to increase circulation, metabolic rate, and soft tissue extensibility or to decrease pain.

Ultrasound

(has both thermal and nonthermal effects)

sound w/in a frequency of greater than 20,000 cycles/seconds.

*Continuous ultrasound _________.

*Pulsed ultrasound ___________.

*used to heat deep tissues to increase circulation, metabolic rate, and soft tissue extensibility, and decrease pain.

*used to facilitate tissue healing or promote transdermal drug penetration by nonthermal mechanisms.

Thermal agents

*transfer energy to a pt to produce an increase or decrease in tissue temp.

(Ex: hot packs, ice packs, ultrasound, whirlpool, diathermy)

Mechanical Agents

* apply force to increase or decrease pressure on the body.

(Ex:  water, traction, compression, and sound)

Progression of inflammation and

Repair

*Pathological or Physical insult

- Inflammation phase

- Vasoconstriction

- Vasodilation

- Clot Formation

- Phagocytosis

- Proliferation Phase

- Epithelialization

- Fibroplasia/Collagen Production

- Wound Contracture

- Neovascularization - new vessels form where the old ones broke.

- Maturation Phase

- Collagen Synthesis/Lysis Balance

- Collagen Fiber Orientation

- Healed injury

Consider a sprained ankle.

Inflammation is normal in this situation.

Do we wants to interfere?

Not always good for tissues, but this can make patient more comfortable.

Need to decide why to interfere, how much, how long, and in what ways?

During the Inflammation phase

there are symptoms?

(1-6 days)

*Increase bld flow, Increase temp, redness, pain, limping, swelling

(over stretch muscle, ligament, disrupted blood vessels and neurologic structures, parts of the injured site have been impinged.)

During the inflammation phase...

(2-5)

2. ↑blood vessel permeability

3. vasodialation of non-injured vessels

4. Fluid into interstitial space

5.  Disrupted vessels bleed and transiently constrict to control bleeding (mediated by norepi for about 5-10 min)

During the inflammation phase ?

*Prostoglandins _________.

*Intracellular chemicals ___________

*Histamine __________.

*Leukocytes __________.

*produced by mast cells 2ndary to cell membrane rupture.

*from disrupted cells released into surrounding tissues.

*released by  mast cells, platelets, and basophils for about another hour causing continued swelling.

*line vessel walls to get ready to exit to the interstitial space for clean up.

Types of Inflammation

*also be aware of reduced or impaired inflammation - a inflammation that is slow to response, (could be older, malnutritous, chronic injury)

nAcute = 2 wks (

Interference with normal healing (cumulative trauma)

Chronic

Imflammation

*Problematic

*Progression of inflammation, tissue destruction, and impaired tissue healing

*Inadequate progression into the healing phase

Pain

*Very Individual

*Clinicians must be sensitive to the pain of their pts

*A subjective situation that we attempt to objectify.

Need the right amount of inflammation to start the healing process.

May use ice for ________.

*for pain, but don't want to lose right amt

 of inflammation. Let it get inflammed and allow pt to

 rest.

(sometimes PT will want to reduced inflammation, and sometimes they may want to produce it)

Acute Pain

Chronic Pain

 nStarts as acute

*change in the SNS and adrenal activity. (chronic pain may have more than one cause)

-results in decreased enkephalins and increased sensitivity or nociceptors.

-vital signs important!!!!

*Clinician may not be able to eliminate chronic pain.

-Esp if sympathetic changes have occurred

-Measure pain control in terms of fxn. (if pt tells you, I am 25, you say, pt reports pain level 25 out of scale of 0 to 10.

 Referred Pain

 nPain experienced distant to site of insult

 nFrom one nerve area to point of innervation

Responses

to Pain

*increase RR

*increased HR

*increased BP

*or maybe vaso-vagal response (BP and HR Drops, pt may pass out)

Needed for a good clinican dx of referred

pain...................

 nRx for cause of pain will get you better results in most cases than treating resultant pain.

Phantom Pain

 nThe painful part is non existent.

Symptom

Magnification

 *Everybody is capable of using psychology.

Knowing whether a pt's pain is acute,

chronic, or referred will _________.

peripheral or CNS dysfunction w/o ongoing tissue damage.

seen in diabetic  neuropathy, postherapetic neuralgia, and phantom pain limbs.

the pathways that transmit pain continue to discharge after the discontinuation of intense or repeated stimulation.

Then, even a small additional stimulus exceeds the threshold that is percieved as painful.

Specificity

Theory

 There are specific nerve endings for each sensation.

  heat

  cold

  pressure

  pain

Free nerve endings in the skin sense pain.

Common Referred pain can be pain originating from the central portion of the diaphragm that is freq felt ________.

The gallbladder also freq refers pain to __________.

Spleen refers pain to the __________.

lat tip of each shoulder.

the right shoulder or inf angle of right scapula

left shoulder

What can we use

to  decrease or eliminate phantom pain?

Physical Agents: Heat, Cold, Touch,

Compression. To change their sensory map.

Pattern

Theory

 *Increased intensity or frequency of stimulation of a receptor to sense any sensation can result in pain.

Gate Control

Theory of Pain

 nSecond order neurons in the dorsal horn of the SC (T cells , interneurons)

Pain Gating

A- beta nerves are inhibitory and respond to non

painful stimuli to influence ___________.

 * the interneuron in the substantia gelatinosa

  large diam

  meylinated

  low threshold (of pain with something like cold)

C fibers _________

(pain transmitted by these fibers have slow onset after the initial painful stimulus, are long-lasting, emotionally difficult to tolerate, and tend to be diffusely localized.)

small unmyelinated nerve fibers that transmit action potentials quite slowly. They respond to noxious levels of mechanical, thermal, and chemical stimulation, causing pain that is generally decribed as dull, throbbing, aching, burning. May also be reported as tingling or tapping.

C fibers can be accompanied by autonomic

responses such as ______________.

sweating, increased HR, increased BP, or

nausea. The pain asso w/ C-fiber activation

can be reduced by opiates.

A-delta fibers _________.

(sensation asso with this fiber activity are sharp, stabbing, or prickling)

transmit more rapidly that C fibers b/c they are  myelinated.

The are most sensitive to high intensity mechanical stimulation, however they can also respond to stimulation by heat or cold and are capable or transmitting innocuous info.

Pain sensations transmitted by A-delta

fibers have a ______________.

*quick onset after the painful stimulus,

*last only for a short time,

*are generally localized to the area from which the stimulus arose

* are not generally associated w/ emotional involvment.

*Generally not blocked by opiates.

Central Pathway Input

1. Peripheral first order C fibers and A-delta fibers from peripheral to grey matter.

2. C and A-delta fibers synapse, either directly or via interneurons, w/ second-order neurons in the superficial dorsal horn or the grey matter (the substantia gelatinosa)

3.The interneurons in the dorsal horn are known as transmission cells(T cells)

4. T cells make locate connections w/in the spinal cord.

5. Inhibitory interneurons in the substantia gelatinosa are activated by input from large-diameter, myelinated, low - thershold sensory neurons (primarily A-beta nerves) that respond to  non painful stimuli.

6. These inhibitory interneurons release various neurotransmitters, including norepinephrine, serotinin, and enkephalins to modulate the flow of the afferent pathways.

7. Thus the T cells recieve excitatory input from the C fibers and A-delta nocieptor afferents and inhibitory input from large diameter, nonnociceptor sensory afferents and from descending fibers from higher brain centers.

The balance of these excitatory and

inhibitory inputs influences whether _______________.

the individual feels pain and how severe the pain sensation is.

An example of

specificity theory

nerve fibers that response to heat will always transmit the sensation of heat and not pain, no matter how intensely or frequently it is stimulated

similarly, pain fibers will only transmit a sensation of pain and never a sensation of heat

An example of

Pattern Theory

nerve transmit the sensation of heat when stimulated lightly, but the same nerve may transmit pain when stimulated intensely.

Interneuron lives ___________

Dorsal Horn in SC

Current Ideas

of Pain

nCombination of specificity/pattern/gate control.

nSpecific pain fibers – nociceptors

n50% of sensory fibers have pain function

nQuality of pain depends on the tissue stimulated.

We are inhibiting excition of pain by _____________.

We are going to inhibit some pain b/c _____________.

exciting excition of cold.

we are going to provide a different sensation for the brain. (we are slowing the ability of the brain to process pain.

Pain is Created by:

 nMechanical Stimulation

Pain-Spasm-Pain-Cycle

** nociceptor activation communicates w/ T-cells which communicate with anterior horn cells to cause muscle contraction.

SNS contribution

Autonomic response to pain __________

Startle or emotion _____________.

Reflex Sympathetic Dystrophy/Complex Regional Pain Syndrome (RSD/CRPS)

 nAutonomic response to pain – BP, HR, sweating, cutaneous blood vessel constriction (might be pale)

Endogenous

Opioids

(Pain Killers produced w/in our bodies)

(Endorphin)

 nCNS has specific opiate binding sites and production centers for opiopeptins (endorphins). These peptides bind with specific receptors sites to control pain.

Muscle Spindle

Golgi tendon organ

(GTO)

-we could stimulate  mechanical with stretch and cold at same time.

Reason for

RSD/CRPS?

patient who have an injury, they have change is SNS, it doesn't work normally anymore in the extremitiy in which the injury occurs (usually doesn't happen right away)

Physical Agent

Will ___________.

 nIntervene with pain

if so, document what pt tells you and state that pts family sitution could be contributing to the current processing of pain. (may have to referr this pt to the kind of support they need)