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Stage 1 of injury
- Protection phase
- 2-4 days post injury
- Acute/inflammatory phase
- Physiological effects
- -Vasoconstriction or vasodilation
- -hemostasis/clot formation
- -Cell mediated phagocytosis
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Stage ll of injury
- Repair phase
- 6 weeks or greater
- Sub-acute/proliferation phase
- Physiological effect
- -Epithelialization
- -Collagen production
- -Closure/contraction
- -Revascularization
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Stage ll of injury
- Late phase
- Between 6 weeks and 3 months
- Chronic/maturation phase
- Physiological effects
- -Collagen balance -- synthesis/lysis
- -Collagen remodeling
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Physiological responses to cryotherapy
- Decrease blood flow/tissue metabolism
- Increase threshold for pain perception
- Decreased blood flow/increased viscosity
- Decreased inflammation, pain, local metabolism
- Decreased intramuscular pressure
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Physiological responses to thermotherapy
- Facilitate tissue healing/relaxation
- Decrease spasms/pain
- Increase blood flow/tissue extensibility
- Increase metabolic rate
- Decreased viscosity and joint stiffness
- Decreased nerve conduction velocity
- Slight increase in muscle performance (short duration) or significant decrease (long duration)
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Physiological effects of electrotherapy
- Strengthening/relaxing mu
- Decrease pain/edema
- Neuromuscular reeducation
- Increase tissue and wound healing
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Physiological effects of compression
- Decrease edema
- Modeling scar tissue
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Physiological effects of traction
Decrease compression on structures
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Effects of massage
- Modulate pain
- Edema reduction
- Stretching and loosening of adhesions
- Muscle relaxation
- Sedation
- Increased venous and lymphatic flow
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Effleurage
- Strokes that glide
- Spreads lube and introduces touch
- Begins and ends; transitions
- For the frail, terminally ill, neonates, and infants
- Facilitates circulation
- Reduces lower motor neuron excitability and pain perception
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Petrissage
- Firm pressure that mobilizes
- Kneading, picking up, wringing, skin rolling
- Mobilizes skin, subcutaneous, and deep muscle tissue
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Tapotement
- Striking to stimulate
- Stimulates tissue mechanically or by reflex action
- Cupping, beating, hacking, pounding
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Friction
- Deep compression of tissue
- Small, localized, penetrating; performed in a circular or transverse direction
- Mobilize adhesions or treat chronic inflammation
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Contraindications to massage
- Acute inflammation
- Severe varicose veins
- Phlebitis
- Areas of recent surgery
- Thrombophlebitis
- Cardiac arrhythmia
- Malignancy
- Severe rheumatoid arthritis
- Hemorrhage in area
- Edema secondary to kidney disfunction
- Heart failure
- Venous insufficiency
- Hypersensitivity
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Massage precautions
- Endangerment sites
- Abnormal sensation; increased or decreased
- Diminished skin, joint integrity
- Debilitated patient
- Areas with excessive body hair
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Effects of myofascial release techniques
- Increase blood flow, histamine release and temp
- Decrease heart rate, RR and BP
- Increase flexibility, decrease NM excitability, edema reduction, and stretch of muscle and scar tissue
- Reduce anxiety, depression, and mental stress
- Activate spinal gait and release of endogenous opiates
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Myofasical release
- Stoking and stretching of tissues
- -Relax tense tissues
- -Release adhered tissues
- -Restore tissue mobility
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Stretch-cross hand release
- Myofascial release
- Heal of one hand in area of restriction; heal of other hand crossed in front
- Stretch using slow, deep pressure
- Reduces superficial and deep adhesions
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J-strokes
- Myofascial release
- One hand places the adhesions on stretch; other hands 2nd and 3rd fingers stroke in opposite direction forming a J
- Mobilize scar tissue
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Neuromuscular effects of heat therapy
- Increased nerve conduction velocity in normal nerves
- Decreased firing rate of alpha motor neurons
- -Relaxation of muscle spasm and contraction
- Increased pain threshold
- -via spinal gating mechanism
- -Sedation of sensory nerve endings with mild heat
- Decreased muscle strength in first 30 min post application
- -Increase in strength 2 hours post treatment
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Conduction
- atoms/molecules passed from one object to another
- Heat transfer from a warmer to a cooler object
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Convection
- Bulk movement of liquid/gas molecules that transfers heat
- Heat transfer by movement of air or fluid from a warmer area to a cooler area
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Radiation
Heat from a warmer to a cooler object by transmission of electromagnetic energy without heating of an intervening medium
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Thermotherapy contraindications and precautions
- Lack of thermal sensation
- Vascular insufficiency/disease
- Areas of recent/potential hemmorage
- Areas of malignancy
- Areas of acute inflammation or infection
- Recently applied liniments or heat rubs
- Unreliable situations (eg language barriers)
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Hydrotherapy effects
- Decreased weight-bearing
- Resistance for strengthening
- Increased venous circulation
- Increased cardiac volume
- Increased cardiac output
- Decreased heart rate and blood pressure response to exercise
- Decreased vital capacity
- Increased work of breathing
- Decreased likelihood of exercise-induced asthma
- Relaxing or invigorating depending on temp and activity
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Aquatic pool therapy precautions and contraindications
- Aspiration risk
- Tracheotomy/catheters
- Cardiovascular problems
- Uncontrolled seizures
- Tetraplegia or high paraplegia
- Respiratory compromise
- Fever
- Fear of water
- Fear of losing balance
- Neurological impairments
- Severe kidney disease during immersion
- Menstruation without internal protection
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Indications for whirlpool treatments
- Decubitus ulcers
- Open burns and wounds
- Post-hip fractures
- Post surgical conditions of hip
- Subacute and chronic musculoskeletal conditions of neck, shoulders, and back
- Rheumatoid arthritis
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Pulsed Lavage with Suction (PLWS)
- Non-immersion wound hydrotherapy or pulsed lavage with concurrent suction
- Wound irrigation
- Delivers low-pressure saline irrigation to a wound while concurrently suctioning wound debris and water
- Promotes epithelialization and promotes tissue profusion
- Decreases risk of cross contamination
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Contraindications to hydrotherapy used for heating
- acute inflammation
- active bleeding
- malignancy
- Peripheral vascular disease
- Sensory loss
- Decreased mentation
- Thrombophlebitis
- Pregnancy
- Multiple sclerosis
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Contraindications for cold hydrotherapy
- Open wounds
- Cold urticaria
- Cardiac dysfunction
- Regenerating peripheral nerves
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Contraindications to hydrotherapy administered via immersion
- Bowel incontinence
- Bleeding wounds
- Seizure disorders
- Fear of water
- Very young and very old
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Indications for cold therapy
- Acute muscle trauma
- -RICE
- -Over casts and bandages
- Pain and muscle spasm
- Myofascial pain syndrome
- Spasticity
- Special considerations
- -Multiple sclerosis
- -Facilitation of function in flaccid muscles
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Contraindications for cryotherapy
- Cold urticaria
- -develop wheels
- Cryoglobulinemia
- -abnormal blood proteins that form a gel at low temp
- Raynaud's phenomenon
- -blood vessels in fingers and toes go into spasm
- Paroxysmal cold hemoglobinuria
- -destruction of red blood cells by autoantibodies
- Compromised circulation
- Areas of nerve degeneration
- Areas of regenerating peripheral nerves
- Areas of peripheral vascular disease
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Precautions for cryotherapy
- Hypertension
- Cold hypersensitivity
- Impaired circulation
- Thermoregulatory disorders
- Over superficial nerves
- Open wounds
- Impaired sensation
- Poor cognition
- In the very young or very old
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Ice massage experience
- 4 steps
- Cold
- Burning
- Aching
- Numb
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Pain mechanisms
Pain receptors that are activated by intense thermal, mechanical or chemical stimuli called nociceptors
- Substance P
- -Chemical mediator released by nociceptors
- -May help w/ transmission of pain signals by sensitizing nociceptors
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Mechanoreceptors
- Pressure (movement in hair follicles, light, deep, or touch)
- Base of hair follicles or skin
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Nociceptors
- Pain (distension)
- Wall of gastrointestinal tract, pharynx, skin
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Proprioceptors
- Tension (distension, length changes, tension changes)
- Skeletal muscles, between muscles and tendons
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Thermoreception
- Temp change (cold, heat)
- Skin, skin and capsules in joints and ligaments
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C-fibers (group lV afferents)
- Unmyelinated
- Mechanical trauma, noxious heat, irritant chemical agents
- Dull, throbbing, aching, burning, tingling, or tapping
- Sensations have slow onset and can cover a diffuse area
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A-delta fibers (group lll afferents)
- Finely myelinated
- High intensity mechanical stimulation, also heat and cold
- Sharp, stabbing, pricking
- Sensation has a quick onset and usually localized to a specific area
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A-beta fibers
- Heavily myelinated
- Proprioception, touch, pressure
- Prolonged pain or abnormal pain transmission
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Interneurons
- Synapse with afferent nerve fibers in spinal cord and integrate the signals, determining how much pain is actually felt
- Nociceptive signals carried by C-fibers and A-delta fibers synapse with the spinothalamic tract that sends the signal to the brain
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Gate Control Theory
- Impulses ascending on A-Beta's stimulate the substantial gelationosa as they enter the dorsal horn
- Inhibits synaptic transmission in the A-delta and C fibers afferent pathways
- Pain message isn't transmitted
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Descending pain control mechanism
- Central control can affect dorsal horn gating process
- Impulses from the thalamus and brain stem are carried into dorsal horn
- These close the gait and block transmission of the pain message
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Stage l treatment
- protection
- PRICE
- submaximal isometrics
- Gentle PROM and AAROM with grade I/II mobilizations
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Stage ll treatment
- Begin to move out of acute phase modalities
- Heating agents may be of benefit
- Move from sub maximal isometrics to AAROM, AROM as tolerated
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Stage lll treatment
- Usage of heating modalities
- AROM with progressive isotonic strengthening, moving towards functional rehabilitation
- Goal specific training
- Pain control is important as stages progress
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Peripheral nociceptive
- Source of pain lies within injured musculoskeletal tissue
- Nociceptors in the tissue stimulated by noxious chemical, mechanical or thermal stimuli
- A delta and C fibers transmit stimulation
- Sharp and well localized
- Associated with acute inflammation and tissue damage; expected to subside as tissue heals
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Peripheral neurogenic
- Injury or dysfunction in peripheral nervous system
- Abnormal Impuse Generator Sites (AIGS)
- Injured neural tissue-radicular pain, associated with spinal dysfunction and peripheral nerve entrapment
- Localized to the nerve root or peripheral nerve sensory distribution
- Sharp and shooting pain
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Central pain
- Lesion or dysfunction within the CNS
- Abnormal sensitivity or discharge from the CNS
- Inconsistent symptoms; little or no correlation between stimulus and response
- Allodynia and hyperalgesia may occur
- -Pain provoked by a mechanical stimulus that does not typically cause pain
- -Heightened response to a painful stimulus
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Pain related to sympathetic nervous system
- Intense burning
- Out of proportion to expectations following injury
- Vasomotor instability
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Affective pain
- Related to neurons or pathways concerned with affect or emotion
- Limbic system most likely to be involvedĀ
- Pain behaviors displayed are related to toleranceĀ
- -Tolerance is related to fatigue, lack of control, stress and anxiety
- Modalities unlikely to help
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Cognitive Behavioral Therapy
- Psychological intervention focused on changing thought patterns and behaviors
- Can help change how the brain interprets pain, giving patients more control
- Three techniques
- -Pacing
- -Attention diversion - focusing on the positive
- -Goal setting
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Beam-non-uniformity ratio
- Ratio between the spatial peak intensity and its spatial average
- Smaller ratio's correspond to a more uniform beam
- Generally ratio's that are 6:1 or lower are acceptable
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Thermal effects of ultrasound
- Micro streaming, cavitation
- Increased extensibility of connective tissue
- Alter scar formation
- Decreased joint pain
- Increased blood flow
- Increase, decrease or don't change NCV (based on parameters)
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Post trauma effects of ultrasound
- Possibly increased peripheral nerve healing
- Increased tendon/ligament healing
- Increased bone healing after fracture or fusion
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Non-thermal effects of ultrasound
- Increase in intracellular calcium levels
- Increased cell membrane permeability
- Increased mast cell degranulation and release of histamine which is especially important in the acute phase
- Increase macrophage responsiveness
- Increased rate of protein synthesis by fibroblasts and tendon cells
- Increased nitric oxide synthesis in endothelial cells, resulting in increased blood flow
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Ultrasound indications
- As a deep-heating modality
- -Joint contracture and scar tissue
- -Pain and muscle spasm
- -Subacute or chronic soft tissue inflammation
- To facilitate healing
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Ultrasound contraindications
- In the region of a pacemaker
- During pregnancy; over pelvic, abdominal or lumbar regions
- Eyes and testes
- In a region of active bleeding or infection
- In a region of a tumor/malignancy
- In the region of a DVT or thrombophelitis
- Over the heart, stellate, or cervical ganglia
- Over the epiphyseal plates of growing bones
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Clinical applications of thermal or "hot" lasers
- Increase temperature
- Dehydration of tissue
- Coagulation of protein
- Thermolysis
- Evaporation
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Clinical application of low power or "cold" lasers
- Photobiostimulation
- Anti-inflammatory applications
- Wound healing - combine with debridement
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Indications for laser therapy
- wound healing
- bone regeneration and fracture healing
- herpes simplex wounds
- epicondylitis
- tendinopathies
- carpal tunnel syndrome
- arthritis
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Contraindications and precautions for laser therapy
- Class l, ll, llla pose no to minimal danger
- Class lllb can cause injury with direct viewing (LLLT)
- Class lV pose eye, skin, and fire hazards
- Epilepsy, fever, malignancy, decreased sensation, and infection not recommended
- Gonads
- Epiphyseal plates of children
- Sympathetic ganglia
- Vagus nerve
- Mediastinum
- Pregnancy
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Diathermy capacitive method
Uses an applicator system that requires making the patients tissues part of the dielectric capacitor
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Diathermy inductive method
- Uses an inductive applicator to produce oscillating magnetic fields inducing "eddy" or currents in tissues
- Tow types of coil applicators - Drums or sleeves
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Thermal effects of diathermy
- increased metabolism
- increased perspiration
- vasodilation
- increased oxygen uptake and accelerated healing
- increased extensibility of connective tissue
- muscle relaxation
- decreased muscle stiffness
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Non-thermal effects of diathermy
- restore cellular membrane potential and balance of ions
- increased fibroblasts and chondrocytes
- increased white blood cells and histiocytes in a wound
- absorption of hematoma
- reduction of inflammation
- reduction in edema in rats
- accelerated collagen proliferation and remodeling in rats
- accelerated regeneration of peripheral nerves in rats
- stimulation of osteogenesis in dogs
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Pulsed Electromagnetic Fields (PEMF)
- Type of diathermy
- Deliver very low intensity electromagnetic waves that do not heat tissues
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Microwave diathermy (MWD)
- Use magnetron device similar to those used in microwave ovens
- Applicator positioned perpendicular to skin's surface
- Less penetration depth than SWD
- Uncommon is USA
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Physiological effects of diathermy
- Combo of prolonged low load stretch + heat shown to effectively increase tissue flexibility
- Initial decrease in strength, followed by an increase
- Promotes soft tissue and bone healing
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