Physical Agents
Physical Agents
What do they consist of and who are they applied to?
Examples?
Frequently referred to as modalities
Physical Agents
• Consists of energy and materials applied to patients to assist in their rehabilitation.
• Includes heat, cold, water, pressure, sound, electromagnetic radiation, and electrical
currents
• Frequently referred to as modalities
What are the 3 stages of tissue healing?
Inflammation Should last how long?
Characterized by what?
Modalities assist with reducing what in the inflammation phase?
Proliferation Phase lasts how long typically?
What is deposited in the damaged area to replace damaged tissue?
What should modalities assist with in this phase?
Maturation phase should last how long?
What happens in this phase?
What kind of modalities?
Inflammation -> Proliferation -> Maturation
• Inflammation (day 1-6)= First phase of recovery
• Characterized by what?
• Modalities: assist with reducing circulation, reducing pain, reducing enzyme activity rate, controlling motion,
promoting progression to proliferation phase.
• Proliferation (day 3-20) = collagen is deposited in damaged area to replace damaged tissue
• Modalities: assist with increasing circulation, increasing enzyme activity rate, promoting collagen deposition,
progression to remodeling phase
• Maturation (day 9- up to 2 years) = deposition and resorption of collagen. Remodels to resemble original tissue
• Modalities: assist with altering collagen deposition and resorption, improving alignment of new collagen fibers
Modalities for Motion Restriction
How do we know which Modality will allow you to reach that goal?
How does the depth of the structure determine the type of heating we use?
Modalities for Motion Restriction
• Source of motion restriction
• Goals of treatment
• Collagen extensibility increased as temperature increases (what does that
mean?)
• Depth of structure determines type of heating (superficial vs deep)
Looking at the reason for motion restriction will determine what we do.
In general, goals of treatment are to do what?
Modalities are used to reduce what?
What is the pain triangle?
How does this cycle continue to exacerbate?
Treatment goals:
• Reduction of a symptoms
• Promotion of a response
• Goals can be interdependent
• Modality to reduce pain may reduce level of discomfort enough to decrease
protective muscle guarding in the area
• Modality may reduce swelling, which reduces pain and stiffness
• Pain triangle
• Pain causes muscle guarding, contributes to decreased mobility, which causes more
pain. Cycle continues to exacerbate.
Cryotherapy
Why do we use it?
Cryotherapy
• Therapeutic use of cold
• In rehabilitation setting, it can:
• Control inflammation, pain, and edema
• Reduce spasticity
• Control symptoms of multiple sclerosis
• Facilitate movement
Categories
What are the 3 categories?
What would be considered a cooling agent?
What category would ultrasound fall under?
Which category revolves around incr. or decr. pressure on the body?
Which category uses electrical current and can you give some examples?
Thermal
• Heating (thermotherapy) and cooling agents (cryotherapy)
• Ultrasound, diathermy, hot packs, ice packs
Mechanical
• To increase or decrease pressure on the body
• Traction, compression, water (hydrotherapy), ultrasound
Electromagnetic
• Apply energy in the form of electromagnetic radiation or electrical current
• Electromagnetic fields: ultraviolet (UV) radiation, infrared (IR) radiation, laser, daithermy
• Electrical currents: TENS (transcutaneous electrical nerve stimulation), NMES (neuromuscular
electrical stimulation)
Modalities for Tissue Healing
Acute inflammation
• Goals: control pain, edema, bleeding, and the release and activity of inflammatory
mediators, and progression to proliferation phase.
1. Which modalities would be indicated at this stage?
2. Which modalities would be contraindicated at this stage?
1. RICE (cryotherapy)
2. Heat therapy
General
Contraindications
& Precautions for
Modality Use
Contraindications for application of physical agent (modalities) examples?
• Contraindication (absolute contraindication)
• Precaution (relative contraindication)
• Contraindications for application of physical agent (modalities)
• Pregnancy- we dont know if its safe
• Malignancy- could make the cancer grow
• Pacemaker or other implanted electronic device (deep
brain stimulator, spinal cord stimulator, implanted
cardioverter defibrillator)
• Impaired sensation- cant feel if its too much
• Impaired mentation
Clinical
Considerations
What must you consider when deciding on which modality to use?
• Treatment time available
• Inpatient vs. outpatient
• Actual time to deliver modality
• Frequency of PT visits
• Length of time since injury
• Acute vs. chronic
• Short vs. long recovery expected
• Medical stability of patient
• Indications, precautions, and contraindications
• Cognitive status of the patient
• Ability to learn new information
• Ability to consent, provide feedback on sensation
• Assistance at home
• Patient expectations
• Prior experience
• Knowledge from outside sources (TV, MD, friends, family, etc.)
• Your patient education re: sensations associated w/modality
What are the effects of cold?
What is blood viscosity?
It is recommended cold not be applied for >__ minutes, particularly in distal extremities
If someone has a PAD or PVD should we use cold?
• Vasoconstriction
• Constriction of the cutaneous vessels and reduced blood flow
• In the application area, and to a lesser extent, areas distant to the site.
• Also thought to increase blood viscosity, increasing resistance to flow
• It is recommended cold not be applied for >15 minutes, particularly in distal extremities
What are some effects of modalities?
• Reduce tissue inflammation
• Accelerate tissue healing
• Relieve pain
• Alter collagen extensibility
• Modify muscle tone
Modalities for
Tissue Healing
Why is muscle contraction not appropriate in the inflammation phase?
What modalities are appropriate?
What are we trying to inhibit?
Acute inflammation
• Indicated modalities for pain, edema, inhibition of inflammatory mediators
• Cryotherapy (or contrast baths)
• Hydrotherapy
• Sensory level E-stim
• SWT (non-thermal short-wave therapy)
• Pulsed ultrasound
• Laser light
• Compression
• Contraindicated modalities
• Thermotherapy (why?)
ICF MODEL
ICF Model views functioning and disability as a complex dynamic interaction between what 2 things?
Takes what into consideration?
Emphasis on what rather than on condition or disease?
• International Classification of Functioning
• ICF Model views functioning and disability as a complex dynamic interaction between the health condition of the individual and contextual factors of the environment, as well as personal factors.
• The language of the ICF model
• Considers the body, the whole person, and the person in society
• Neutral to cause
• Emphasis is on function rather than on condition or disease
• Designed to be relevant across cultures, age groups, and genders
• Focuses on abilities and what is right, versus disability and what is wrong
COLD and EDEMA
What will cold do to edema?
Reduces the intravascular fluid pressure how?
Controls increases in capillary permeability by decreasing what?
Does using cryotherapy help with edema associated with immobility and poor circulation?
Edema associated with immobility and poor circulation is best managed with what?
• Used to reduce edema, especially acute inflammation
• Reduces the intravascular fluid pressure by reducing the blood flow into the area through vasoconstriction and increased blood viscosity
• Controls increases in capillary permeability by decreasing vasoactive substances such as histamine
• Should be applied as soon as possible after acute trauma with compression, and elevation
• Helps to move fluid in the venous and lymphatic drainage systems
• RICE ( PRICE, POLICE, PEACE & LOVE)
Not effective in decreasing edema associated with immobility and poor circulation
• This is best managed with
• Compression
• Elevation
• Heat
• Exercise
• Massage
Modalities for
Tissue Healing
Chronic inflammation
What the goal?
1.Which modalities would be indicated?
2.Which modalities would be contraindicated?
• Goals: Decrease joint stiffness, control pain, increase circulation, promote progression to proliferation phase
1.Heat, compression, exercise, electro stim, warm water, contrast baths
2. Cryotherapy (not recommended but not a contraindication)
Documentation should be able to reproduce what?
You should be able to reproduce the exact same treatment based on the documentation alone!
• Modality type
• Location
• Parameters
• Response to modality
• Subjective and objective response
• Problems?
Contraindications
for Cryotherapy ?
Angina or cardiac dysfunction, unless localized away from thorax
Arterial insufficiency/PVD
Cold hypersensitivity (cold induced urticaria)
Raynaud disease or phenomenon
Decreased sensation
Peripheral nerve injury
Cold intolerance
Cryoglobulinemia
Paroxysmal cold hemoglobinuria
Modalities for Tissue Healing
Proliferation goals?
Maturation goals?
• Strengthening modalities?
• Stretching modalities?
Modalities for Tissue Healing
• Proliferation
• Goals: controlling scar tissue formation, ensuring adequate circulation, maintaining
strength and flexibility, promoting progression to remodeling phase.
• Maturation
• Goals: regain or maintain strength and flexibility, control formation of scar tissue,
reversing adverse effects of earlier healing stages.
1.NMES, isometrics, MM contraction, strengthen, water
2. Traction, heat
APTA
2015 Choosing Wisely Initiative
Documentation must justify what about modalities?
Are modalities alone considered physical therapy?
Can you just do modalities in a Rx?
• Documentation must justify the necessity of the exclusive use of modalities, the use of modalities, in the absence of other skilled therapeutic or educational interventions. Modalities alone are not physical therapy.
• The use of heat should be supported by evidence and used to facilitate an active treatment program
• “don’t use whirlpools for wound management”
You cant just do modalities in a treatment.
Precautions for
Cryotherapy
Why is hypertension a precaution?
Over the superficial main branch of a nerve
Opens wounds
Hypertension-because cold will incr. BP even more
Decreased sensation
Decreased mentation
Very young/old patients
Modalities for Pain
RESPECT THEIR PAIN BUT DONT LET IT DERAIL RX!
What can pain interfere with?
What does pain do to the muscles in the body?
• Pain
• Essential to prevent individuals from causing tissue damage, but it can interfere with
normal activities and cause functional limitation and disability
• Can interfere with sleep, work, exercise, and rehabilitation
• Relieving pain can allow patients to participate in ADLs and their active rehabilitation
program
• Goals:
• Limit adverse consequences of disuse
• Improve patient’s activity and level of participation
• Progression toward patient’s functional goals
Pain can inhibit muscles in the body to cause atrophy and more pain
Evidence Based Practice
What is high level, mid level, low level evidence?What are the clinical practice guidelines for?
What does it give recommendations for?
• EBP “requires that clinical practice decisions be guided by the best available relevant
clinical research data in conjunction with the clinician’s experience and individual
patient’s pathology and preferences”
• Use of current best evidence in making decisions about the care of individual patients
• Application of scientific method
• Goal is to provide the best patient care by assessing available research and applying it to
each individual patient
• Levels of evidence
• High level: meta-analysis of Randomized controlled Trials (RCT-gold standard)
• Midlevel: Systematic reviews, individual RCT
• Low level: Case report
Clinical Practice Guidelines
• Systematically developed statements that attempt to interpret current research
• Give recommendations for diagnostic and prognostic measures and for preventive or therapeutic interventions
Effects of Heat
What does it do to blood flow?
Where does vasodilation occur?
To heat deep muscles use what?
• Vasodilation
• Increases the rate of blood flow
• Vasodilation occurs where the heat is applied, and to a lesser degree, it can occur in more distal and deeper vessels
• Superficial heating does not heat to the depth of most muscles.
• To heat deep muscles, use
• Exercise
• Ultrasound
• Diathermy
Modalities for Pain
Acute
Acute pain goals? Indicates what kind of modalities?• Acute pain goals: Control pain and associated inflammation, avoid aggravating the pain
• Indicated modalities
• Sensory-level ES
• Cryotherapy
• Laser light
• Compression
• Contraindicated modalities
• Thermotherapy (if edema present)
• Motor-level ES
Purpose of Superficial Heating
What does it do to our metabolism?
What happens to our tissue extensibility?
Does it promote swelling?
How does it change our nerve conduction?
Increased metabolism in tissues being heated
Pain reduction
Reduction of muscle guarding or spasm
Vasodilation
Increased tissue extensibility
Increased perspiration
Increased oxygen tension w/ increased temperature
Promotion of local swelling
Increased body temp., RR, HR w/ decreased BP
Changes in nerve conduction velocity/firing rate
Modalities for Pain
Chronic Pain
Chronic pain goals?
How is it different from acute pain?
What kind of modalities?
Is the pain only physical?
Contraindicated modalities?
• Chronic pain goals: Shift from resolving the underlying pathology and controlling symptoms TO promoting function, enhancing strength, and improving coping skills
Pain can be both physical and psychological
• Indicated modalities
• Exercise
• Water therapy
• Motor-level ES
• EMG biofeedback
• TENS (to promote function, not interfere with function)- for pain relief
• Contraindicated modalities
• Bed rest (relative contraindication)
• Passive modalities-
Contraindications for Thermotherapy
Name some...
Contraindications for Thermotherapy
Acute inflammation
Existing Fever
Malignant tumor
Acute hemorrhage (recent or potential)
Radiation therapy
Thrombophlebitis
Impaired sensation/mentation
Caution with patients having diabetes due to common sensation impairments in distal extremities
Infrared irradiation of the eyes
What is the most common modality injury?
How does it occur?
Burns
• Most common modality injury
• Excessive heating can cause protein denaturation and cell death
• Can occur if heat is applied
• Too long
• Too hot
• When the patient does not have protective vasodilation response to increased tissue
temperature