Modalities
Heat therapy (Thermotherapy)
Thermotherapy involves the application of heat to body tissues to increase circulation, metabolic rate, and tissue extensibility. It is commonly used to manage pain, muscle spasm, and joint stiffness in subacute and chronic conditions.
Types of thermotherapy:
Hot packs: Moist heat applied with hydrocollator packs wrapped in towelsParaffin wax baths : Commonly used for distal extremities (e.g., hands, feet)Fluidotherapy : Dry heat through suspended cellulose particlesShortwave diathermy: Deep heating through electromagnetic energy
Clinical indications:
Muscle spasm and guarding Joint stiffness and decreased ROM Chronic musculoskeletal pain Increased blood flow for tissue healing
Application parameters:
Hot packs: 15–20 minutes, use 6–8 towel layers to avoid burns
Paraffin: 10–15 minutes using dip-wrap method (5–10 dips)
Diathermy: Typically 20 minutes for deep heating effects
Contraindications:
Acute inflammation or bleeding Impaired sensation or mentation Malignancy in treatment area Deep vein thrombosis (DVT) Open wounds or infections
Cold therapy (cryotherapy)
Cryotherapy is the application of cold to reduce inflammation, pain, and muscle spasm, particularly in acute and post-surgical conditions
Types of cryotherapy:
Ice packs: Applied with a barrier for 10–15 minutesCold immersion baths: Typically 50–60°F (10–15°C), 10–15 minutesVapocoolant sprays: Used for muscle spasm, applied with 2–4 sweeps
Clinical indications:
Acute musculoskeletal injuries Edema control Spasticity management Localized pain relief
Contraindications:
Cold hypersensitivity or intolerance
Raynaud’s disease
Open or infected wounds
Peripheral vascular disease (PVD)
Therapeutic ultrasound (US)
Ultrasound uses high-frequency sound waves to produce thermal or non-thermal effects for tissue healing, pain reduction, and increased extensibility of soft tissues.
Clinical indications:
Chronic tendinopathies Ligament sprains and muscle strains Joint contractures Scar tissue management
Application parameters:
Frequency:
1 MHz: For deep tissue (up to 5 cm)
3 MHz: For superficial tissue (1–2 cm)
Duty cycle:
100% (Continuous): Thermal effects
20–50% (Pulsed): Non-thermal, acute phase
Intensity:
0.5–1.0 W/cm²: Superficial
1.0–2.0 W/cm²: Deep tissues
Duration:
5–10 minutes per treatment area
Contraindications:
Over malignant areas, reproductive organs
Over pacemakers, eyes, or carotid sinus
During pregnancy (lumbar/abdominal regions)
Electrical stimulation (E-stim)
E-Stim involves the use of electrical currents to stimulate nerve or muscle function for various therapeutic goals
Types and indications:
TENS (transcutaneous electrical nerve stimulation): Pain modulation via gate control theoryNMES (neuromuscular electrical stimulation): Muscle re-education, strengtheningHVPC (high-voltage pulsed current): Wound healing, edema control
Parameters:
TENS: 50–150 Hz, 50–80 µs, continuous mode
NMES: 35–50 Hz, 200–400 µs, 1:5 duty cycle
HVPC: 100–150 V, 50–100 Hz
Contraindications:
Cardiac pacemakers or defibrillators
Unstable arrhythmias
Thrombophlebitis or DVT
Pregnancy (abdomen/lumbar)
Traction
Mechanical traction is used to relieve pressure on the spinal structures and improve joint mobility.
Clinical indications:
Herniated discs Nerve root impingement Hypomobility or facet joint dysfunction
Parameters:
Cervical traction:
Initial force: 10–15 lbs
Maximum: 30 lbs
Angle: 15–20° flexion for lower cervical spine
Lumbar traction:
Force: 25–50% of body weight
Duration: 20–30 minutes
Contraindications:
Acute cervical or lumbar injuries
Spinal infections or malignancy
Hypermobility or instability
Severe osteoporosis
Infection control
Standard precautions
Standard precautions are the minimum infection prevention measures that apply to all patient care, regardless of suspected or confirmed infection status. These practices are essential to reduce the risk of transmission of microorganisms in healthcare settings.
Key components
Hand hygiene:
Wash hands with soap and water or use alcohol-based hand sanitizer before and after patient contact, before performing aseptic tasks, after exposure to bodily fluids, and after contact with patient surroundings
Use of personal protective equipment (PPE):
Gloves: Worn when anticipating contact with blood, body fluids, mucous membranes, or non-intact skin
Gowns: Worn to protect clothing and skin during procedures likely to generate splashes or sprays
Mask and Eye Protection: Worn if there is a risk of splash or spray to the face
Respiratory hygiene/cough etiquette:
Instruct symptomatic individuals to cover mouth/nose when coughing or sneezing and perform hand hygiene.
Equipment disinfection:
Clean and disinfect patient care equipment and surfaces between each use
Transmission-based precautions
These precautions are used in addition to standard precautions for patients who may be infected with pathogens spread by contact, droplet, or airborne routes.
Contact precautions
Examples: MRSA, C. difficile, VRE, Scabies Transmission: Direct contact with infected patients or contaminated surfaces
PPE:
Gloves and gown upon room entry. Dedicated patient equipment or thorough disinfection between uses.
Hand hygiene: Perform before and after patient contact.
Room Consideration: Private room preferred, or cohorting with patients with the same infection
Droplet precautions
Examples: Influenza, Mumps, Rubella, Pertussis Transmission: Large respiratory droplets (>5 microns) from coughing, sneezing, or talking
PPE:
Surgical mask within 3–6 feet of the patient. Eye protection if risk of splash or prolonged exposure.
Room Consideration: Private room; door may remain open
Airborne precautions
Examples: Tuberculosis, Measles, Varicella (Chickenpox) Transmission: Small airborne particles (<5 microns) suspended in the air
PPE:
N95 respirator or higher-level protection.
Room Consideration:
Patients should be placed in a negative pressure airborne infection isolation room
The room door must remain closed
Schedule immunocompromised or high-risk patients at times when traffic is minimal
Isolate or cohort patients known or suspected to be infected to prevent cross-contamination
*COVID-19 is airborne and droplet precautions combined.
Assistive and adaptive devices
Assistive and adaptive devices are essential tools that enhance a patient’s functional mobility, safety, and independence. They are used temporarily or long-term, depending on the patient’s diagnosis, recovery stage, or permanent impairments. This chapter covers the most common devices, including their types, fitting, indications, contraindications, usage in stair negotiation, and wheelchair prescription.
Types of assistive devices
Canes
Types:
Standard (Straight) Cane: For mild balance issuesQuad Cane : Offers a wider base of support; used for moderate balance deficits
Small-base quad cane (SBQC)
Large-base quad cane (LBQC)
Indications:
Minor balance impairments Hemiplegia (can be used on unaffected side)
Fitting:
Handle at wrist crease when standing upright Elbow flexed ~20–30°
Crutches
Types:
Axillary crutches: Temporary use; moderate to high support
Forearm (lofstrand) crutches: Long-term use; for patients with good trunk control
Indications:
NWB, PWB conditions Neurological or orthopedic impairments
Fitting:
Axillary: 2 inches below axilla, handgrip at wrist crease, 20–30° elbow flexion Forearm: Cuff 1–2 inches below olecranon
Walkers
Types:
Standard walker (SW): Maximum support, must lift to advance
Rolling walker (RW): Easier to use for patients with endurance/balance deficits
Platform walker: For patients unable to bear weight through the wrist/hand
Indications:
Severe balance/coordination issues Generalized weakness
Fitting:
Handles at wrist crease with 20–30° elbow flexion
Stair training and gait patterns with devices
Stair training principles
Up with the good, down with the bad. Ascend: Unaffected leg → assistive device + affected leg
Descend: Assistive device → affected leg → unaffected leg
Guarding:
Ascending stairs: Therapist stands behind the patient Descending stairs: Therapist stands in front
Gait patterns
2-point gait: One device and opposite leg move together – for FWB, balance issues3-point gait: Device(s) advance → non-weight-bearing leg swings → weight-bearing leg follows4-point gait : One device → opposite leg → other device → other leg – for maximum stabilitySwing-to/swing-through gait: Crutches move forward → both legs swing forward to or past them – for paraplegia or bilateral LE weakness
Fitting and measurement wheelchairs
Accurate fitting is critical to ensure safety, comfort, and effectiveness:
Wheelchairs:
Seat width: Widest point of hips + 2 inches Seat depth: Posterior buttocks to popliteal fold – 2 inches Seat height: Heel to popliteal fold + 2 inches (for footrests) Back height: Seat to inferior angle of scapula Armrest Height: Seat to bent elbow + 1 inch
Wheelchair types, modifications, and prescription
Types of wheelchairs
Standard wheelchair: Temporary use, self-propelled or assistedLightweight / ultra-lightweight: For active users or those with limited strengthReclining wheelchair: For patients with postural hypotension or poor trunk controlTilt-in-space wheelchair: Maintains hip/knee angle; ideal for spasticity or skin pressure managementPower wheelchair: Used when minimal upper limb strength is available (ALS, high SCI)
Common modifications
Anti-tippers: Prevent backward tippingLap belts: Enhance safetyElevating leg rests : For lower extremity edema or post-op recoveryPressure relief cushions : Prevent ulcers
Foam: Light and low-cost
Gel: Distributes pressure well
Air (Roho): Best for high-risk patients
Special populations
Hemiplegia: Lower seat height for propulsion using one leg
SCI (C6–C8): Lightweight manual wheelchair or power-assist
SCI (C5 or higher): Power chair with head/chin or sip-and-puff controls
Amputees: Rear axle moved posteriorly to improve stability
Bariatric Patients: Wider, reinforced frames
Safety, emergency response, and professional responsibilities
Emergency response procedures
Falls
Immediate action:
Stay with the patient; do not attempt to lift them alone. * * Assess the patient for consciousness, pain, bleeding, or signs of injury
If no serious injury is evident, assist them into a seated position
Notify appropriate medical personnel and document the incident
Prevention:
Use gait belts during ambulation
Remove environmental hazards (e.g., loose rugs, clutter).
Ensure proper footwear and assistive device use
Burns
Types: Thermal, chemical, electrical
Initial response:
Remove the source of the burn (e.g., hot packs, modality equipment)
For thermal burns, cool the area with lukewarm water—not ice
Cover with a sterile, non-adhesive dressing
Refer for further medical evaluation for moderate or severe burns
Document the cause and response
Equipment safety and maintenance
Regularly inspect all equipment (e.g., electrical stimulation units, treadmills, lifts).
Safety checks include:
Frayed cords or damaged plugs
Calibration and function of mechanical devices
Battery power for mobile units
Maintenance logs:
Keep updated records of routine inspections and servicing
Patient use safety:
Provide instruction and supervision during initial use of equipment
Ensure proper cleaning between patients to reduce infection risk
Cardiopulmonary resuscitation (CPR)
Basic life support (BLS) steps - adults:
Check responsiveness and call for help.
Call 911 and get an AED
Check breathing and pulse simultaneously.
If no pulse, start chest compressions:
Depth: At least 2 inches
Rate: 100–120 compressions/min
Ratio: 30 compressions : 2 breaths
Use AED as soon as available
Professional responsibilities in physical therapy
Ethics and jurisprudence
Core principles:
Autonomy: Respect the patient’s right to make their own decisions.
Beneficence: Always act in the patient’s best interest
Nonmaleficence: “Do no harm”—avoid interventions that cause unnecessary injury or suffering
Justice: Deliver care fairly and without discrimination
Veracity: Be honest in all interactions with patients and colleagues
Informed consent and confidentiality
Informed consent includes:
Explanation of diagnosis, proposed treatment, risks, and alternatives
Opportunity for questions
Voluntary agreement without coercion
HIPAA compliance:
Secure storage of records
Only share information with authorized personnel
Obtain consent before discussing patient info with third parties
Legal considerations
Negligence: Failure to provide standard care that results in harm
Malpractice: Professional misconduct or lack of skill leading to injury
Abandonment: Inappropriate discontinuation of care without proper notice or referral
Avoid by: Providing a transition plan, proper documentation, and clear communication
Supervision guidelines
PTA supervision:
PTA must follow the PT’s plan of care
PT must be available for consultation
Supervision laws vary by state; direct or general supervision may be required
PT aide supervision:
Aides may perform non-skilled tasks under direct supervision
Delegation and communication
Effective delegation:
Assign tasks based on the individual’s qualifications and legal scope
Ensure understanding of expectations
Monitor and provide feedback
Professional communication:
Maintain professionalism in all written and verbal exchanges
Use SBAR (Situation, Background, Assessment, Recommendation) for concise clinical updates
Research concepts and evidence-based practice
Levels of evidence
Understanding levels of evidence helps clinicians evaluate the strength of research when applying findings to practice:
Level 1a: Systematic reviews of randomized controlled trials (RCTs) Level 1b: Individual random control trials Level 2a: Cohort studies (prospective) Level 2b: Case-control studies (retrospective) Level 3: Case series or low-quality cohort and case-control studies Level 4: Expert opinion without critical appraisal
Study types and research designs
Descriptive: Case reports, case series
Analytical:
Observational: Cohort (prospective), case-control (retrospective), cross-sectional
Experimental: Random control trials (gold standard)
Qualitative: Thematic analysis, interviews, focus groups
Statistical concepts
P-values
A p-value < 0.05 typically indicates a statistically significant difference
A lower p-value suggests stronger evidence against the null hypothesis
Confidence intervals (CI)
A 95% CI means there’s a 95% chance the true value lies within that range
Narrow CI = more precise results; wide CI = more variability
Reliability and validity
Reliability: Consistency of a test (test-retest, interrater, intrarater)
Validity: Accuracy—does the tool measure what it’s intended to?
Construct validity , content validity , criterion validity .
Sensitivity, specificity, predictive values
Sensitivity: True positives – rules out a condition (SnNOUT)
Specificity: True negatives – rules in a condition (SpPIN)
Positive predictive value (PPV): Likelihood that a positive test is correct
Negative predictive value (NPV): Likelihood that a negative test is correct
Measurement scales
Nominal: Categories without order (e.g., gender, blood type)
Ordinal: Ordered categories (e.g., MMT grades, pain scale)
Interval: Equal intervals, no true zero (e.g., temperature)
Ratio: Equal intervals with a true zero (e.g., height, weight, time)
Hypothesis testing and data interpretation
Null hypothesis (H₀): No difference or relationship
Alternative hypothesis (H₁): A difference or relationship exists
Type I error (α): False positive
Type II error (β): False negative
Healthcare system and practice management
Reimbursement models
Medicare: Federal program for individuals >65 or with disabilities
Medicaid: State-run program for low-income individuals
HMO (Health Maintenance Organization): Requires PCP referral, lower cost
PPO (Preferred Provider Organization): More flexibility, higher premiums
Documentation standards
SOAP notes: Subjective, Objective, Assessment, Plan
ICD-10: Diagnosis coding
CPT codes: Billing for procedures
Documentation must be timely, accurate, legible, and support skilled care
Continuum of care
Acute care: Immediate medical care (hospital)
Subacute care: Less intensive than acute, but still requires skilled therapy
Outpatient rehab: For patients well enough to live at home
Home Health: Therapy provided in the patient’s home
Discharge planning and case management
Begins early in care
Factors include:
Patient’s home environment
Support system
Functional status
Need for durable medical equipment (DME)
Recommendations for follow-up services
Roles of Healthcare professionals
PT/OT/ST: Provide specialized rehabilitative care
Nurse: Monitor vital signs, administer medication
Physician: Medical diagnosis and overall treatment plan
Case manager: Coordinates discharge planning and resources
Social worker: Helps with psychosocial support and community resources
Environmental accessibility and the ADA
Americans with disabilities act (ADA) guidelines
Doorway width: Minimum 32 inches wide
Hallway width: Minimum 36 inches wide
Ramp slope: 1:12 (for every inch of rise, 12 inches of run)
Thresholds: ≤ ½ inch for easy wheelchair navigation
Bathroom access:
Grab bars: 33-36 inches high
Toilet seat height: 17-19 inches
Home and community modifications
Install ramps or stairlifts
Widen doorways
Lower countertops
Install grab bars and handheld showers
Workplace accommodations
Adjustable desks
Assistive tech (voice-to-text, screen readers)
Flexible work schedules
Accessible entrances and restrooms
Wheelchair accessibility features
Turning radius: At least 60 inches
Clear floor space: 30 x 48 inches minimum
Reach range:
High: Max 48 inches
Low: Min 15 inches
Accessible pathway: Free from obstacles, level, non-slip surface
