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What are physical agents
energy and materials applied to patients to assist in rehabilitation.
The are also called modalities.
Physical Agents are used to:
Modify tissue inflammation and healing
Relieve pain
Alter collagen extensibility
Modify muscle tone
Stages of Healing
A) Inflammation
B) Proliferation
C) Maturation
What is edema?
is the accumulation of fluid within the extracellular space and interstitial tissues
Transudate
Exudate
Pus
Pus
fluid containing neutrophils, liquefied digestion products of tissue and bacteria if an infection is present
Exudate fluid
cloudy, thicker fluid that occurs in response to minor injuries
transudate fluid
fluid that first forms during inflammation
What is Chronic Inflammation?
is simultaneous progression of active inflammation, tissue destruction and healing. Chronic inflammation may last for months or years due to persistent injury or interference with the normal healing process.
Chronic inflammation can result in the following complications:
Increased fibroblast proliferation —> increased collagen production —> increased scar tissue and adhesion formation —> possible loss of function
Factors affecting the healing process local
Type, size and location the injury
Infection
Vascular supply
Movement/ excessive pressure
Temperature deviation
Topical medications
Electromagnetic energy
Retained foreign body
Factors affecting the healing process system
Age
Infection or disease
Metabolic status
Nutrition
Hormones
Medication
Fever
Oxygen
healing of cartilage
limited ability to heal due to lack of lymphatics, blood and neural supply
healing of bone
Stages are impaction, induction, inflammation, soft callus, hard callus, remodeling
healing of skeletal muscles
severe injury can result in a calcified hematoma (myositis ossificans)
healing of ligaments
healing is dependent on the type of ligament, size of defect and load applied; mature ligamentous repair tissue is 30-50% weaker than an uninjured ligament
healing of tendons
adhesions are more likely to develop if the synovial sheath is injured; active contraction prior to 3 weeks post injury may lead to complications
What is the connection between healing and Physical agents?
Physical Agents can be used to promote tissue healing
The stage of healing determines the goals of intervention and physical agents to be used
Always be able to connect the physiology of the injury to the physical agent being used in the treatment/POC.
Pain defintion
Unpleasant sensory or emotional experience associated with actual or threatened tissue damage
Nocioceptors are activated by intense thermal, mechanical or chemical stimuli.
When nocioceptors are stimulated, the signal is converted to an electrical activity (action potential) that travels to the dorsal root ganglia of the spinal cord.
These signals are sent to the brain through 2 types of primary afferent fibers:
C fibers
A-delta fibers
Physical agents can decrease pain by:
Reducing the effect of the underlying problem (reducing edema —> signals to mechanoreceptors)
Modifying pain transmission or perception (more on this later)
C fibers
small, unmyelinated fibers that transmit signals relatively slowly
transmits signals that are described as dull, throbbing, aching, burning
slow onset of sensation, but long-lasting
can be difficult to tolerate emotionally
sensations are often accompanied by autonomic responses such as sweating, inc. BP, nausea
A-delta fibers
small, myelinated fibers that transmit faster
respond to high-intensity mechanical stimuli, heat or cold
Quick onset of sensation, but short in duration
transmit signals that are described as sharp, stabbing, pricking
non-painful stimuli
A-beta fibers are large myelinated fibers with receptors in the skin, bones and joints that transmit sensation related to vibration, stretching of the skin and mechanoreception
What can physical agents do to decrease pain?
Inhibit pain signal to the brain with the gate control theory of pain modulation. Gate control theory of pain modulation is the theory that pain is modulated at the spinal cord by inhibitory effects of innocuous afferent input. (Ex: vibration sensation is provided to inhibit reception of pain signal).
Endogenous opioid theory – The theory that pain is modulated at peripheral, spinal cord and cortical levels by endogenous neurotransmitters that bind to the same receptors of exogenous opioids.
Cutaneous pain
is typically well localized and sharp.
Musculoskeletal pain
is typically poorly localized and dull, heavy or aching
Visceral pain
refers superficially and has an aching quality.
The body’s response to pain
Pain-spasm-pain cycle is the cycle in which nocioceptor activation causes transmission cell activation that stimulates anterior horn cells to cause muscles to contract.
This produces compression of blood vessels, accumulation of chemical irritants, mechanical compression of the nocioceptor, and a resultant increase in nocioceptor activation.
Chronic pain
pain that does not resolve within the normal recovery time for an expected disease or injury; pain of varying levels that lasts for extended periods of time
Referred pain
pain that is referred to a musculoskeletal area from an internal organ or another musculoskeletal area
Radicular pain
pain that results from direct irritation of axons of a spinal nerve or neurons in the dorsal root ganglion an is experienced in the musculoskeletal system in a dermatome pattern.
Neuropathic pain
pain caused by a lesion or disease affecting the nerves; often described as burning; often accompanies by symptoms such as paresthesias, itching, numbness, weakness
Pain caused by malignancy
Be careful of contraindications unless being used to improve patient’s quality of life with end-stage malignancies.
Complex Regional Pain Syndrome
Believed to be the result of over activation of the sympathetic nervous system (previously RSD)
Acute pain
a type of pain that typically lasts less than 3 to 6 months, or pain that is directly related to soft tissue damage such as a sprained ankle or a paper cut.
Contraindications
Conditions under which a particular treatment should not be applied
precautions
Conditions under which a particular form of treatment may be permissible when applied with special care or limitations
contraindications/Precautions
Pregnancy
Malignancy
Pacemaker or other implanted electronic device
Impaired sensation
Impaired mentation
Selection of a physical Agent
Evidence-based practice should be utilized by the PT when including a physical agent in the POC.
Over utilization of physical agents is detrimental to the profession.
Use of physical agents that treat pain only are rarely reimbursed.
Informed Consent and Physical Agents
Explanation of findings, description of interventions - including risks, benefits and alternatives of interventions
Opportunity to ask questions about the examination/evaluation, diagnosis, prognosis or proposed interventions
A formal request for permission to proceed with the plan of care