Physical agents unit 1

• Protection phase
• 2-4 days post injury
• Acute/inflammatory phase
• Physiological effects
• -Vasoconstriction or vasodilation
• -hemostasis/clot formation
• -Cell mediated phagocytosis

• Repair phase
• 6 weeks or greater
• Sub-acute/proliferation phase
• Physiological effect
• -Epithelialization
• -Collagen production
• -Closure/contraction
• -Revascularization

• Late phase
• Between 6 weeks and 3 months
• Chronic/maturation phase
• Physiological effects
• -Collagen balance -- synthesis/lysis
• -Collagen remodeling

• Decrease blood flow/tissue metabolism
• Increase threshold for pain perception
• Decreased blood flow/increased viscosity
• Decreased inflammation, pain, local metabolism
• Decreased intramuscular pressure

• 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)

• Strengthening/relaxing mu
• Decrease pain/edema
• Neuromuscular reeducation
• Increase tissue and wound healing

• Decrease edema
• Modeling scar tissue

Decrease compression on structures

• Modulate pain
• Edema reduction
• Stretching and loosening of adhesions
• Muscle relaxation
• Sedation
• Increased venous and lymphatic flow

• 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

• Firm pressure that mobilizes
• Kneading, picking up, wringing, skin rolling
• Mobilizes skin, subcutaneous, and deep muscle tissue

• Striking to stimulate
• Stimulates tissue mechanically or by reflex action
• Cupping, beating, hacking, pounding

• Deep compression of tissue
• Small, localized, penetrating; performed in a circular or transverse direction
• Mobilize adhesions or treat chronic inflammation

Shake, tremor

• 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

• Endangerment sites
• Abnormal sensation; increased or decreased
• Diminished skin, joint integrity
• Debilitated patient
• Areas with excessive body hair

• 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

• Stoking and stretching of tissues
• -Relax tense tissues
• -Release adhered tissues
• -Restore tissue mobility

• 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

• 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

• 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

• atoms/molecules passed from one object to another
• Heat transfer from a warmer to a cooler object

• 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

Heat from a warmer to a cooler object by transmission of electromagnetic energy without heating of an intervening medium

• 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)

• 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

• 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

• 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

• 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

• acute inflammation
• active bleeding
• malignancy
• Peripheral vascular disease
• Sensory loss
• Decreased mentation
• Thrombophlebitis
• Pregnancy
• Multiple sclerosis

• Open wounds
• Cold urticaria
• Cardiac dysfunction
• Regenerating peripheral nerves

• Bowel incontinence
• Bleeding wounds
• Seizure disorders
• Fear of water
• Very young and very old

• 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

• 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

• Hypertension
• Cold hypersensitivity
• Impaired circulation
• Thermoregulatory disorders
• Over superficial nerves
• Open wounds
• Impaired sensation
• Poor cognition
• In the very young or very old

• 4 steps
• Cold
• Burning
• Aching
• Numb

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

• Pressure (movement in hair follicles, light, deep, or touch)
• Base of hair follicles or skin

• Pain (distension)
• Wall of gastrointestinal tract, pharynx, skin

• Tension (distension, length changes, tension changes)
• Skeletal muscles, between muscles and tendons

• Temp change (cold, heat)
• Skin, skin and capsules in joints and ligaments

• 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

• 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

• Heavily myelinated
• Proprioception, touch, pressure
• Prolonged pain or abnormal pain transmission

• 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

• 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

• 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

• protection
• PRICE
• submaximal isometrics
• Gentle PROM and AAROM with grade I/II mobilizations

• Begin to move out of acute phase modalities
• Heating agents may be of benefit
• Move from sub maximal isometrics to AAROM, AROM as tolerated

• Usage of heating modalities
• AROM with progressive isotonic strengthening, moving towards functional rehabilitation
• Goal specific training
• Pain control is important as stages progress

• 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

• 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

• 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

• Intense burning
• Out of proportion to expectations following injury
• Vasomotor instability

• Related to neurons or pathways concerned with affect or emotion
• Limbic system most likely to be involved 
• Pain behaviors displayed are related to tolerance 
• -Tolerance is related to fatigue, lack of control, stress and anxiety
• Modalities unlikely to help

• 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

• 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

• 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)

• Possibly increased peripheral nerve healing
• Increased tendon/ligament healing
• Increased bone healing after fracture or fusion

• 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

• As a deep-heating modality
• -Joint contracture and scar tissue
• -Pain and muscle spasm
• -Subacute or chronic soft tissue inflammation
• To facilitate healing

• 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

• Increase temperature
• Dehydration of tissue
• Coagulation of protein
• Thermolysis
• Evaporation

• Photobiostimulation
• Anti-inflammatory applications
• Wound healing - combine with debridement

• wound healing
• bone regeneration and fracture healing
• herpes simplex wounds
• epicondylitis
• tendinopathies
• carpal tunnel syndrome
• arthritis

• 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

Uses an applicator system that requires making the patients tissues part of the dielectric capacitor

• Uses an inductive applicator to produce oscillating magnetic fields inducing "eddy" or currents in tissues
• Tow types of coil applicators - Drums or sleeves

• increased metabolism
• increased perspiration
• vasodilation
• increased oxygen uptake and accelerated healing
• increased extensibility of connective tissue
• muscle relaxation
• decreased muscle stiffness

• 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

• Type of diathermy
• Deliver very low intensity electromagnetic waves that do not heat tissues

• 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

• 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