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116 Cards in this Set
- Front
- Back
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Describe the inflammatory phase of healing
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It is the beginning of the healing process. Prepares the area for healing by protecting it, destroying foreign bodies (phagocytosis), vascular changes occur (histamines increases capillary permeability; increased blood flow, causing increased edema) and facilitating the fibroblastic phase.
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Purpose of phagocytosis in the cellular response is...
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...to destroy injury by-products (debris) through the venous & lymphatic systems.
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The purpose of immediate vasoconstriction following an injury is...
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...to prevent further bleeding & accumulation of fluids (edema) into the area.
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Why are platelets important in the inflammatory phase?
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Platelets help form a plug at the site of injury to reduce bleeding & repair the injured site.
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When does the inflammatory phase begin?
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Immediately after an injury
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How long does the fibroblastic phase last?
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4-6 weeks
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Granulation tissue consists of...
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Capillaries Collagen Fibroblasts |
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Why is tensile strength of the wound directly related to collagen synthesis?
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The more collagen fibers that are created (collagen synthesis), the stronger the wound will be. Increased tensile strength is needed to facilitate the maturation phase.
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Explain the role of Wolff's Law during the maturation phase
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Bone & tissue remodel due to physical demands placed on them by PT interventions during the maturation phase, causing them to realign along lines of tensile force to increase tensile strength. |
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Factors that impede healing
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* Age (takes longer to heal with age)
* Nutrition (does the body have the proper nutrients?) * Health (physically fit or couch potato?) * Vascular supply (poor circulation) * Edema (as long as swelling is present it will be hard to repair the tissue) * Corticosteroids (break down tissue) * Infection (makes it harder for the body to heal itself) * Muscle spasm (re-injury) * Humidity & climate for open wounds (takes longer to heal) |
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Signs of inflammation:
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* Redness
* Swelling * Heat * Pain * & sometimes a loss of function |
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Why is cryotherapy usually used after an acute injury?
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Reduce pain & control swelling
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RICE
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Rest Ice Compression Elevation |
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How long does the inflammatory phase usually last?
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1-6 days
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Goal of using modalities in the inflammatory phase...
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Control pain & limit swelling
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What type of exercises should the patient begin in the inflammatory phase?
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PROM & AROM
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During the fibroblastic phase the use of cold is often discontinued & heat is used. What clinical signs is used as a precautionary measure?
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Signs of inflammation (swelling, heat, redness, pain)
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Why would e-stim be used during the fibroblastic phase?
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To reduce pain & swelling
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Type of modality depends on...
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* Patient diagnosis (musculoskeletal injury: ice, etc.)
* Medical stability of the patient (pacemakers, cardiac issues: e-stim & whirlpools are contraindicated) * Goals for treatment (what modalities will facilitate the ability of the pt. to move towards those goals?) * Experience (are you trained in that modality?) * What is available? (some clinics won't have certain equipment--it's expensive) * Cognitive ability of patient (dementia, young, etc.) |
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Treatment Approaches
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* Dogmatic: based on research
* Psychological: based on how to approach pt. & review of the literature * Experimental: based on clinical experience All are involved |
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Responses to Physical Agents
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Observe & document before, during, & after treatment * Skin color: Be aware of color changes.* Skin condition: do a blanch test (pressing on the skin & looking for the return of color) this signifies if the tissue has impaired circulatory function or not. Mottling follows the application of heat & presents as spotty patches of redness & is a warning sign of overheating. |
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Palpable Observations
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* Muscle guarding & spasm: when muscles surrounding an injured area contract to prevent further damage or movement of the area. Can be voluntary or subconscious.
* Skin surface temp: assess patient's ability to determine hot & cold. Heat is a sign of inflammation. |
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Internal Microscopic Changes that compound pain:
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* Decreased circulation
* Decreased oxygen supply * Decreased lymphatic clearing * Decreased nutrient supply * Increased metabolism * Increased concentration of metabolites * Increased muscle fatigue * Inflammation & edema * |
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Stages of Proliferation (fibroblastic phase):
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* Epithelization
* Wound contraction * Collagen production |
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Effects of aging on the healing process
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Inflammatory phase: * Decreased & disrupted vascular supply* Decreased supply of nutrients * Decreased inflammation response * Decreased rate of capillary growth * Decreased metabolic response * Decreased migration & proliferation of cells * Delayed maturation of cells * Delayed wound contraction * Delayed collagen remodeling * Increased cross-linking of collagen (causing adhesions to form) |
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Sequence of events after injury:
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Inflammatory phase begins: * Vasoconstriction* Vasodilation * Clot formation * Phagocytosis * Epitheliazation * Collagen production * Wound contraction * Neovascularization * Collagen synthesis/lysis balance * Collagen fiber orientation (Wolff's Law) Injury healed |
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What is the definition of pain?
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An unpleasant sensory & emotional experience associated with actual or potential tissue damage. Pain is subjective, therefore is considered a symptom. |
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What is the purpose of pain?
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Warning that there is something wrong & can provoke a withdrawal response to avoid further injury.
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What is the definition of chronic pain?
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A persistent pan that does not respond to treatments, cause cannot be determined &/or lasts longer than 1 month beyond normal course.
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What is referred pain?
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Pain that does not follow a dermatome area & is localized to a specific area (we want to reduce the surrounding pain before addressing the local pain)
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Radiating pain...
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follows a dermatome
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What four assessments do pain profile tools attempt to measure?
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* Type of pain
* Intensity of pain * How it affects the pt.'s function * Psychosocial impact of pain |
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Describe a VAS (visual analog scale) and how it is used
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It is a quick & simple test completed by the patient to determine their pain level. It is usually a 10cm line that the patient marks for their corresponding pain level.
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What is the purpose of using pain charts?
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To objectify the pain
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What is the McGill Pain Questionnaire used for?
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Low back pain. Helps describe the type of pain & helps to identify what type of pain fiber is being activated, this tells us what modality is needed/best. |
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What four structures are most sensitive to damaging stimuli?
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* Periosteum & joint capsule
* Subchondral bone, tendons, & ligaments * Muscle & cortical bone * Synovium & articular cartilage |
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What is PT's objective in managing pain?
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Encourage the body to heal through exercise designs to progressively increase functional capacity & return to work & recreation as quickly & safely as possible.
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What is a nociceptor?
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A neuron that transmits pain signals
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Types of afferent peripheral fibers
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* Myelinated a-delta fibers: conducts impulses at a fast rate & evokes a sharp pain sensation that is well localized & has a short duration.
* A-beta fibers: pick up pleasant sensations. Stimulated by modalities to decrease pain to enable PT. Lasts from 15 min-a few hours. More intense the pain, the faster it will return. * Unmyelinated C fibers: conducts impulses at a slower rate & produces a longer lasting sensation that is not well localized. |
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Types of Nociceptors
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* High-threshold mechanoreceptor: responds to strong mechanical sensations (primarily pressure), carried on the a-delta fibers, described as "sharp, prickling" and is well localized.
* Mechanothermal nociceptor: responds to pressure & temperature (important in preventing serious injury), carried on the a-delta fibers, described as "sharp & prickling" and is well localized. * Polymodal nociceptor: responds to strong mechanical stimulation, noxious heat, irritant chemicals, carried on the C fibers, described as "dull, aching, burning" and is poorly localized. Chronic pain is carried on these fibers. |
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Systemic Reaction to Trauma/Pain
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* Increased heart rate
* Increased sweating * Expansion of airways * Dilation of pupils * Shunting of blood from the skin to muscles |
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Local Reaction to Trauma/Pain
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* Muscle spasm
* Edema * Release of endogenous opiates |
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What is the difference between afferent fibers & efferent fibers?
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Afferent fibers carry information TO the brain while efferent fibers carry information FROM the brain.
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What is the difference between first-order & second-order neurons?
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First order neurons transmit impulses from the sensory receptor to the dorsal horn while second order neurons transmit sensory messages from the dorsal horn to the brain.
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Gate Therory
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Is the theory that the spinal cord controls when a gait is open or closed. An open gate allows sensory information to be sent to the brain & a cold gait stops or changes the information sent to the brain. This can be done with modalities (stimulation of a-beta fibers--sense pleasure--to close the gate to the a-delta or C fibers).
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Endogenous opiate therory
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Endogenous opiates are naturally occurring pain killers found in the body (enkephalins: triggered by non-painful simuli, endorphins: released by intense pain or laughter or exercise, serotonin & dopamine: released by increasing pain)
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Modalities that are considered infrared...
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Hot packs, paraffin, whirlpool, cold packs, & infrared lamps. Infrared modalities are generally considered to be a superficial form of treatment. |
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Conduction
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Heat transfer through direct contact between materials with different temperatures
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Convection
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Transference of heat to a body by movement of air/matter/liquid around or past the body
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Radiation
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Transfers heat from a warmer source to a cooler source (i.e. the sun)
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Conversion
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Results when energy is transformed from one form to another (i.e. ultrasound)
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Temperature change depends on...
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* Temperature difference between thermal agent & treatment tissue
* Time of exposure to the thermal agent * Thermal conductivity of the treatment tissue * Intensity of the thermal agent |
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Cryotherapy is most effective in the _____ stage of healing.
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Acute
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What is the depth of penetration of infrared modalities?
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1cm
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What role does the hypothalamus play in increasing & decreasing circulation?
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With prolonged exposure to heat the hypothalamus will reflexively increase blood flow
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What are the three types of sensory receptors found in the subepithelial tissue?
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Cold Warm Pain |
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Pain & temperature are transmitted to the brain via the...
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spinothalamic tract
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Physiological Effects of Tissue Cooling
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* Cold is most beneficial with acute injures & is the initial treatment in musculoskeletal injuries
* Primary reason for using cold is to lower metabolism & the accumulation of metabolites * Also used to decrease pain, control swelling, & spasticity * Generally a person's size will determine how long the cold must be applied to achieve the therapeutic value. * The application of cold decreases cell permeability, decreases cellular metabolism, & decreases the accumulation of edema |
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What are two ways that cold reduces pain?
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Decreased nerve conduction & w/ the gate theory (opening one gateway closes another)
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CBAN
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Cold Burning Aching Numbness |
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What is the purpose of the Hunting Response?
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To prevent local tissue damage that may be caused by prolonged exposure to cold. The brain will sent blood to the area if it thinks there might be tissue damage, this can cause frost bite to occur. |
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What is a cryo-cuff & how is it used?
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A device that uses both cold & compression simultaneously. It has a sleeve & a container for chilled water. The sleeve provides compression while the cold water circulates from the container through the sleeve.
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What is cryokinetics & what is its purpose?
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A technique that combines cryotherapy with exercise. The purpose of cryokinetics is to numb the injured part to the point of analgesia & then work toward achieving normal ROM through progressive active exercise.
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Physiological Effects of Tissue Heating
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* Causes blood vessels to dilate which increases circulation
* Relaxes muscles * Decrease pain * Increases tissue extensibility |
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Why is heating beneficial in injuries with mild to moderate inflammation?
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It causes an increase in oxygen, antibodies, leukocytes (phagocytosis), and other nutrients to the area & allows for clearing metabolites. (Essentially restarts the inflammatory phase to facilitate healing)
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Consensual heat vasodilation (also known as reflex heating)
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Prolonged heating in a local area will cause vasodilation & increased blood flow will spread to remote areas, causing increased metabolism in the unheated area just distal to the area being heated.
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Primary goals of thermotherapy
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* Analgesia
* Nutrition * Reduction of edema * Removal of metabolites |
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Whirlpool temperature recommendations
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Upper extremity: 90-100 Lower extremity: 98-104 Full body: 98-102 |
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Why is cryotherapy used for pain reduction?
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A-beta & C fiber stimulation (Gate Theory)
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Why is cryotherapy used for muscle spasm reduction?
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Decreased muscle spindle activity (freezes the neurons)
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Why is cryotherapy used for inflammation/edema reduction?
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Decreased vascular responses (vasoconstriction)
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Why is cryotherapy used for hemorrhage containment?
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Decreased by minimizing effects of bleeding (slows blood viscosity)
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Physiologic responses to heat
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* Circulation is increased
* Muscle temperature is increase * Tissue temperature is increased * Spasms are relaxed |
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Paraffin Baths
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Composed of paraffin & mineral oil to treat the distal part of the extremities. Provides 6x more heat than water. Commonly used in chronic arthritis. Dip body part 6-8x, then wrap in plastic bag & covered by a towel/mitt. Treatment time is 20-30 mins. Temperature of paraffin is set at 126 (never exceed 135). |
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Physiological responses with paraffin
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* Increase in tissue temperature
* Pain relief * Thermal hyperthermia occurs * Moisturizes skin |
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Ultrasound
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Acoustic (sound) energy waves (vibrations of high frequency) that can may produce thermal or non-thermal physiologic effects.
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How US works
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The waves are produced by a piezoelectric crystal vibrating caused by alternating currents (A/C) and is transmitted through the transducer head
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A/C
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The expansion (+) and contraction (-) millions of times per second as electrical current passes through the crystal and causes the crystal to vibrate
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Attenuation
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LOSS OF ENERGY As the US beams travels through the tissues it will be absorbed or dispersed. This causes a transfer of energy. |
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Dispersion
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Loss of energy over time/space
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Reflection
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Energy waves bounce back (reflected) Can create standing waves
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Standing wave
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Reflected waves hitting new waves. This occurs if the head is held in one place for more than a few seconds & energy builds us resulting in unstable cavitation causing pain & potentially damaging/injuring the area.
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Refreaction
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Waves hitting at an angle
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Absorption
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Transfer of energy into heat (thermal effect)
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Acoustic impedence
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Denser substances offer more resistance which determines how much reflection occurs. Denser tissues will heat (absorb) quicker than tissues that have a lower density. Bone, tendons, & ligaments have a higher density & so will heat quickly. Muscles, adipose, & blood have a lower density & so will heat slower. |
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What two things determine the depth of penetration?
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The frequency of the US & the characteristics (density) of the tissue.
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ERA (Effective Radiating Area)
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Surface area that actually produces the sound wave. The size of the transducer does not equal the ERA. Ex: head is 3 cm & ERA is 2 This leads to a Nonuniformity of sound waves across the surface (beam) |
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BNR (Beam Nonuniformity Ratio)
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Measures the variability of intensity across the beam. The ratio represents the peak intensity present anywhere within the ERA & the average intensity over the entire ERA.
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Frequency
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Number of waves per second delivered. Determines the depth of penetration. Higher (3.3MHz) frequency results in more superficial penetration (use on smaller muscles). Lower (1MHz) frequency penetrates deeper (use on larger muscles) |
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Duty Cycle (Mode)
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Percentage of time the US is on. Continuous US produces energy 100% of the time. Pulsed US intensity is periodically interrupted. |
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20% duty cycle
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Provides no heat (non-thermal) Used to treat acute injury, edema & to facilitate healing. |
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50% duty cycle
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Mild heating (mild thermal, temp increase of 2) Used for chronic inflammation, pain, & trigger points. |
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100% duty cycle
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Vigorous heating (thermal, temp increase of 4) Used to stretch collagen, increase tissue extensibility, reduce stiffness, reduce pain, & increase blood flow. |
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Amplitude
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Describes the magnitude of vibration in a wave
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Power
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The amount of US energy in the beam
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Intensity
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energy (power) of the wave's amplitude being delivered per unit area. Measured as w/cm2 |
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Thermal Effects of US
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"A Stiff Spastic Penis Inflames & Extends because of Increased blood flow" * reduces joint Stiffness* reduction of muscle Spasm * decreases Pain * Inflammatory response to help decrease chronic Inflammation * increased Extensibility of collagen fibers * Increased blood flow |
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What is the primary advantage of using US for heating over other forms of heating?
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Because tissues high in collagen may be selectively heated to the therapeutic level without causing a significant temperature increase in adipose & skin.
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Contraindications of thermal US
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acute inflammation, active bone growth, pregnant (avoid low back & abdomen areas), cancer pts. currently undergoing radiation, TB infection (active), hemorrhagic conditions, impaired circulation (DVT), impaired sensation, impaired cognitive ability, pacemaker, implants (metal, etc.), and over eyes, reproductive organs & anterior neck
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Cavitation
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formation of gas-filled bubbles that expand & compress the tissue but do not implode
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Unstable cavitation
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occurs when gas-filled bubbles implode & collapse. This can occur because of high intensity, low frequency, &/or standing waves. Should be avoided! Can cause serious damage/injury. |
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Non-Thermal Effects
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* Micromassage
* increased Membrane permeability * increased Angiogenesis * Wound contraction * increased Capillary density * increased Plasmas & cells for repair (increased Phagocytosis) * increased Fibroblasts * Vasoconstriction & dilation of vessels |
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Frequency of Treatment
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Acute conditions required more frequent treatments over a shorter period of time (can be treated 1-2x daily) Chronic conditions require fewer treatments over a longer period of time (treated every other day) If no improvement is seen in 4-5 treatments US is usually discontinued. |
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Factors that determine the treatment time for ultrasound
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* Size of area being treated (2-3x the size of ERA)
* Intensity (higher the intensity, lower the treatment time) * Frequency (higher heats faster than lower) * Desired temperature increase (duty cycle) |
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Coupling Medium (US gel)
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A substance used to decrease impedance at the air-skin interface & facilitate the passage of US
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Coupling Methods
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Need to lubricate the skin Should absorb littler of the energy Correct viscosity (so it doesn't run off) No odor Should not stain clothing |
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Direct Contact
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Involves actual contact between the applicator & the skin w/ a sufficient amount of coupling between. Most effective application |
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Immersion Technique
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Useful if area being treated is small or irregular with bony prominences. Transducer should be held at distance of 1cm Need to increase intensity up to 50% (x1.5) |
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Bladder Technique
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Used when the body part cannot be immersed Not recommended |
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What is the "stretching window"
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The time period of vigorous heating when tissues undergo the greatest extensibility & elongation
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Bone Healing w/ US
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It has been shown that the application of US within the first 2 wks of post-fibular facture during the inflammatory & proliferative stages increases the rate of healing. It appears that the non-thermal effects of US are the most responsible for the accelerated bone healing. It is not recommended that US be applied to growing bone. |
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Pain Reduction w/ US
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Accomplished by elevating the threshold for activation of free nerve endings through thermal effects & the gate theory. Can create a counterirritant effects by increased nerve conduction. |
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Soft-Tissue healing & Joint Contracture w/ US
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US does not have an anti-inflammatory response, it is thought that US accelerates the inflammatory phase. Used to increase elasticity & decrease the viscosity of collagen fibers. US has been shown to increase mobility in a mature scar. Scar tissue can be softened in treated w/ US at an early stage. |
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Phonophoresis
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A technique in which US is used to enhance delivery of a selected medication into the tissues through the skin (absorption). Works by driving the medication through the skin & the increased vasodilation & increased permeability of the cell membranes absorbs the medication. Common medications are: hydrocortisone, dexamethasone, & lidocaine. 10% hydrocortisone cream is most commonly used. |
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Diathermy
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The application of high frequency electrical energy that is used to generate heat in body tissues as a result of the resistance of the tissue to the passage. Deep heating modality, but can be used for non-thermal effects. Patient sensation provides the basis for treatment. Two types: shortwave & microwave |
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Dosages for Diathermy
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Dose I: no sensation of heat Dose II: mild heating sensation Dose III: moderate heating sensation Dose IV: vigorous heating that is tolerable |
