Non-systems

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 towels
• Paraffin wax baths: Commonly used for distal extremities (e.g., hands, feet)
• Fluidotherapy: Dry heat through suspended cellulose particles
• Shortwave 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 minutes
• Cold immersion baths: Typically 50–60°F (10–15°C), 10–15 minutes
• Vapocoolant 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 theory
• NMES (neuromuscular electrical stimulation): Muscle re-education, strengthening
• HVPC (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 issues
  • Quad 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 issues
• 3-point gait: Device(s) advance → non-weight-bearing leg swings → weight-bearing leg follows
• 4-point gait: One device → opposite leg → other device → other leg – for maximum stability
• Swing-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 assisted
• Lightweight / ultra-lightweight: For active users or those with limited strength
• Reclining wheelchair: For patients with postural hypotension or poor trunk control
• Tilt-in-space wheelchair: Maintains hip/knee angle; ideal for spasticity or skin pressure management
• Power wheelchair: Used when minimal upper limb strength is available (ALS, high SCI)

Common modifications

• Anti-tippers: Prevent backward tipping
• Lap belts: Enhance safety
• Elevating leg rests: For lower extremity edema or post-op recovery
• Pressure 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:
  1. Check responsiveness and call for help.
  2. Call 911 and get an AED
  3. Check breathing and pulse simultaneously.
  4. If no pulse, start chest compressions:
     • Depth: At least 2 inches
     • Rate: 100–120 compressions/min
     • Ratio: 30 compressions : 2 breaths
  5. 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