Physical Therapy Services

Physical therapists practice in a variety of settings: acute care hospitals, rehabilitation centers, skilled nursing facilities, convalescent homes, home health, schools, industry, sports clinics, pediatric facilities, and private practice.

The following is a quick reference to typical services (although not all inclusive) that are routinely provided by the physical therapist.

Physical Therapy Modalities

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  balneotherapy: medical use of spa pools and mineral baths particularly for arthritis therapy.

  
  
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  cervical traction: a means of separating the cervical vertebrae 1 to 2 mm to help relieve painful neck conditions or cervical radiculopathies; may be intermittent or continuous.

  
  
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  contrast baths: alternately exposing affected limb to warm and cool water for specified periods. This is a means of reducing swelling, diminishing pain, and improving joint ROM.

  
  
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  cryotherapy: use of low temperatures to decrease inflammation, decrease pain and spasm, promote vasoconstriction.

  
  
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  diathermy: electromagnetic waves with a specific wavelength (shortwave diathermy, microwave diathermy) used as a means of producing heat deep inside tissues.

  
  
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  electrical stimulation :

  
  
  
  
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    alternating current: sinusoidal or faradic; stimulates normally innervated muscles to relieve pain and relax muscle spasm.

    
    
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    galvanic: direct current used to stimulate denervated muscles and for ion transfer (iontophoresis).

    
    
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    high-voltage pulsed galvanic: to relieve pain and relax muscle spasm. Stimulates normally innervated muscles.

    
    
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    iontophoresis: the use of direct current to drive water-soluble ions through the skin. Dexamethasone and lidocaine (Xylocaine) are commonly used to treat acute and subacute localized inflammation and pain.

    
    
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    microamperage electrical nerve stimulation (MENS): microamperage current that is below patient’s threshold; to relieve pain.

    
    
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    transcutaneous electrical nerve stimulation (TENS): self-contained, modulated galvanic current (low voltage) that seems to block painful afferent nerve impulses. Helps to control pain so patient may exercise.

  
  
  
  
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  fluidotherapy: the use of forced warm air through a container holding fine cellulose particles to provide dry heat and exercise to upper and lower extremities. Both the temperature and the particle agitation can be controlled for edema and desensitization of hypersensitive area.

  
  
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  hot packs: silicone gel, clay, or other material in bags that can be heated to provide superficial heat for tissues.

  
  
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  Hubbard tank: a large full-body water tank used to assist in ROM and endurance exercise.

  
  
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  hydrostatic bed: essentially a waterbed that supports the patient for specific therapies.

  
  
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  hydrotherapy treatments: as commonly used today, immersion of affected limbs (sometimes including the trunk) in a tank of water at a specified temperature. The water may be moving (whirlpool). There are also tanks in which patients may sit (Lo-Boy) and in which they may be almost totally immersed (Hubbard tank). In a pool, the buoyancy of water can assist patients with partially paralyzed legs to walk. Some therapists refer to the Archimedes principle because the buoyancy in the water supports the weight, eliminates shock, and decreases the concern for need of balance.

  
  
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  interferential current: application of two medium-­frequency alternating currents that interfere with each other. Used for pain control and muscle stimulation.

  
  
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  intermittent compression: a boot or sleeve that encloses the leg or arm and is alternately pressurized with air and then deflated. The inflate-deflate action provides a pumping effect that reduces disabling edema. It is often prescribed for breast cancer patients after a mastectomy and for lymphedema that may result.

  
  
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  paraffin bath: a combination of wax and mineral oil at 126°F used as a means of heating the hands or feet.

  
  
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  phonophoresis: the use of ultrasound to drive molecules of medications through the skin to the underlying tissues.

  
  
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  rest, ice, compression, and elevation (RICE): for the initial treatment of an injury; the treatment of choice for acute musculoskeletal injuries that include sprains, strains, and hematomas.

  
  
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  traction: for low back pain; application of pelvic belt with caudad pull, which may be continuous or use greater force intermittently.

  
  
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  ultrasound: ultra-high-frequency sound waves that mechanically vibrate soft tissue. Secondary deep heat may develop according to method of application.

  
  
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  whirlpool: a form of hydrotherapy using fast moving water that is usually heated.

Physical Therapy Procedures

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  acupressure: sustained deep pressure over muscular trigger points.

  
  
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  aerobic exercises: exercises in which oxygen is inhaled at a rate sufficient for a continuous process of energy production for muscle contraction; the goal is to increase endurance required for long-distance running or after cardiac complications.

  
  
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  agility training: to improve balance and coordination; trains in the ability to make rapid changes in movement and direction.

  
  
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  anaerobic exercises: exercises in which the expenditure of energy is at a faster rate than that for which the muscles can function without a period of recovery before there is further exertion.

  
  
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  aquatic exercise: exercise performed in a pool or large hydrotherapy tank that uses the buoyancy of water.

  
  
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  closed chain exercise: exercise that occurs when the distal segment of an extremity is fixed, such as performing a squat, in which the foot is in contact with the ground. Motion can take place in all planes. Also called closed kinetic chain exercise.

  
  
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  Codman exercises: exercises for a stiff shoulder in which the patient is bent over at the waist (90 degrees) and the hand hangs like a pendulum toward the floor. A weight may be placed in the hand and the arm is then moved through various arcs to increase the ROM in that shoulder.

  
  
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  concentric contraction: muscle shortening with part moving in direction of muscle pull; also called positive work.

  
  
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  cross-training: a complex training regimen in which two or more sports or activities are combined into either a solitary or a cyclical program to exercise different muscle groups and to provide variety and protection from repetitive use syndromes.

  
  
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  DeLorme exercises: originally established on the basis of the 10 repetition maximum, which is the maximal amount of resistance a muscle can lift through full ROM exercises 10 times; the term is frequently interchanged with progressive resistive exercises, which are designed to build strength and increase endurance through graduated resistance for a prescribed number of repetitions.

  
  
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  eccentric contraction: muscle lengthening during contraction; strengthening exercises in which the external force overcomes the actively contracting muscle, forcing the muscle to lengthen. Also called negative work.

  
  
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  effleurage: a method of massage that uses a flowing motion with the hands over a tight muscle to relieve tightness.

  
  
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  endurance training: high-repetition exercise designed to give maximum endurance for repeated muscle contraction.

  
  
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  gait training: the use of parallel bars, crutches, walkers, and canes with specific instructions to the patient. Weight-bearing may be described as non–weight-bearing, partial weight-bearing, or full weight-bearing. Ambulation with crutches is often described as three-point gait, and with walker, four-point gait.

  
  
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  isokinetic exercises: constant velocity; strengthening exercises requiring special equipment in which there is an accommodating resistance, resulting in a maximal force against the contracting muscle throughout its full ROM. Can be used for the spine as well as the upper and lower extremities.

  
  
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  isometric exercises: muscle contraction without joint movement in which the resistance may be provided by a fixed object (wall, stabilized bar) or the antagonistic muscle group (flexors versus extensors); a muscle-strengthening exercise that does not impel muscle to work through its ROM; also called constant angle exercise and static exercise.

  
  
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  isotonic exercises: muscle contraction with movement of the joint through a specified ROM against a fixed amount of resistance; also called constant force exercise.

  
  
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  joint manipulation: any skilled manual technique applied to a joint that moves one particular surface in relation to another. Also referred to as Grade V joint mobilization in which there is a single high-velocity, low-amplitude thrust to a joint.

  
  
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  joint mobilization: skilled passive movements applied to joint surfaces to restore joint play and ROM or to treat pain. Intensity is graded I through IV, in which grades I and II address pain relief, and grades III and IV promote increased joint mobility.

  
  
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  joint play: involuntary movements of joint surfaces allowed by capsular elasticity that allow for normal, pain-free voluntary motion; also called accessory movement.

  
  
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  lumbar stabilization: exercise program to stabilize the torso by developing the corset muscles of the lumbar spine, particularly the abdominal muscles.

  
  
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  manual lymphatic drainage: a specialized form of manual therapy that mobilizes protein-rich fluid toward intact lymphatics to reduce edema.

  
  
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  manual therapy: any treatment in which hands are used to manipulate, massage, or mobilize a part of the body.

  
  
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  McConnell taping: the technique of specific taping to correct abnormal tilt, glide, and rotation of the patella in patients with patellofemoral disorders.

  
  
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  McKenzie method: rehabilitation program designed to relieve spinal and radicular extremity pain. Type of spinal exercises prescribed is patient specific and can be extension based, flexion based, or more complicated depending on the body position that relieves pain. These are repeated exercises in set of 10.

  
  
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  muscle energy technique: manual technique that uses active contraction of a patient’s muscle to correct joint dysfunction.

  
  
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  myofascial release: manual therapy technique that applies prolonged stretching to release restrictions in the muscle-fascia system.

  
  
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  open chain exercises: exercise that occurs when the distal segment of an extremity is free, such as performing a seated knee extension exercise. Non–weight-bearing and usually in one plane of motion; also called open kinetic chain exercises.

  
  
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  pétrissage: a massage maneuver similar to kneading.

  
  
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  prehensile: the use of the thumb opposing the hand to grasp an object. The term prehensile implies function in which the thumb can be placed in opposition to the object. An atavistic hand lacks that capacity.

  
  
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  pulley exercises: a rope-on-pulley system used to increase ROM of a joint or strengthen muscles; resistance can be applied by another limb or by weights.

  
  
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  range of motion (ROM) exercises: designed to maintain or increase the amount of movement in a joint. They may be one of the following:

  
  
  
  
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    passive ROM exercise: force is applied to bring about motion in a joint or joints by either a therapist or the patient, without any muscle function in these joints.

    
    
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    active-assistive ROM exercise: exercise performed by the patient but requiring assistance from a therapist, another extremity, or a mechanical device because of muscle weakness or pain.

    
    
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    active ROM exercise: exercise performed by patient without assistance or resistance; the therapist is only an instructor-observer.

  
  
  
  
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  resistive exercise table: commonly used for lower extremity problems, such as after knee surgery; resistance can be applied by weights (NK table in some locales) or by a graded hydraulic system.

  
  
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  spray and stretch: use of a vapocoolant, such as Fluori-Methane or ice, for treatment of trigger points in muscles. The vapocoolant is sprayed over a stretched muscle to increase ROM.

  
  
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  strength training: exercise directed to achieve the maximum capacity of a muscle to pull in a single effort.

  
  
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  Swiss ball exercises: use of an inflatable gymnastic ball with various movements for mobility, strength, balance, coordination, and stabilization of the spine and the extremities.

  
  
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  tapotement: a method of massage that involves percussion such as used in chest therapy.

  
  
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  therapeutic massage: soft tissue manipulation using techniques such as friction, stroking, and kneading to reduce muscle spasm and edema, stimulate circulation, and encourage relaxation. Also used to stretch scar tissue.

  
  
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  Williams exercises: for patients with low back pain; exercises are performed to open the lumbar intervertebral foramina and decrease the compression on the facet joints by flexing the lumbosacral spine, thereby stretching the extensors of the back and strengthening the abdominal muscles. Also called flexion ­exercises.

Tests and Measurements

Given that the circulation is intact, the major parameters in assessing the function of a limb are ROM, sensation, and strength. These can be tested directly by the application of forces to the muscle through the ROM of individual joint and stimuli to the skin. Muscle testing can be supplemented by electrodiagnostic modalities such as electromyography. In muscle testing, strength is graded by the following scale as assessed directly by the examiner. ROM is measured with a goniometer, an instrument that measures joint motion in degrees.

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  dynamometer: an instrument to measure muscle strength and its effects from exercise, such as a handgrip, which can be adjusted to test strength in different positions of grasp; or from a bicycle, which measures muscular, respiratory, and metabolic effects of exercise, recording directly from a pressure gauge; also called ergometer.

  
  
  
  
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    computerized isokinetic dynamometer: an apparatus that can be used to test and record the maximal strength of a muscle as it acts on a joint through a full ROM. The recording is used to evaluate the progress of a patient’s condition during recovery or to confirm the existence and extent of injury.

  
  
  
  
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  Institute of Sports Medicine and Athletic Trauma (ISMAT) muscle testing: manual assessment of muscle strength with a small, force-measuring device held by the examiner.

  
  
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  osteokinetic movement: movement that occurs between two bones, such as roll, glide, or spin.

Specific Occupational Therapist Interventions

Specific occupational therapy interventions include but are not limited to the following:

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  education and training in ADLs

  
  
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  administering and interpreting such tests as manual muscle and ROM

  
  
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  design, fabrication, and application of splints and other orthoses

  
  
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  developing perceptual-motor skills and sensory integrative functioning

  
  
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  restoration of hand functioning decreased by a disease process, after surgery, or by a traumatic event

  
  
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  instruction in work simplification, energy conservation, and use of proper body mechanics during activity for work, leisure, and daily living

  
  
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  guidance in the selection and use of adaptive equipment

  
  
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  therapeutic activities to enhance functional performance

  
  
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  prevocational evaluation and training and physical capacity evaluation

  
  
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  consultation concerning adaptation to home or work environments

Occupational Therapy Assessment

Services are provided to all age groups in a variety of settings, including hospitals, hand clinics, rehabilitation facilities, sheltered workshops, schools, extended care facilities, private homes, community agency clinics, and industrial settings.

Orthopaedists most frequently refer patients to occupational therapy for treatments of amputation, arthritis, soft tissue trauma, fractures, total joint replacement, sports injury, osteoporosis, elbow and shoulder arthroplasty, spinal cord injury, and chronic pain. One-fourth of AOTA’s more than 40,000 members work with orthopaedic patients.

Before intervention is provided, each potential patient’s or client’s case is screened to determine the need for occupational therapy. This is followed by evaluation, which consists of obtaining and interpreting data necessary for treatment, including that needed to plan for and document the evaluation process and treatment results. The occupational therapy evaluation includes assessment of functional abilities and deficits as related to the client’s needs.

Occupational Therapy Interventions

Occupational therapists are known for providing intervention that takes personal factors into account for each person. This client – centered approach allows clinicians to creatively target specific needs to further patient outcomes. This is especially important with patients who have a multitude of problems in different areas such as an orthopaedic patient who may have residual deficits from a neurologic event. Treatment refers to the use of specific activities or methods to promote, improve, or restore the performance of necessary functions, compensate for dysfunction, or minimize debilitation. The therapist plans for and documents treatment performance to show progression as well as where more intervention is needed. The following are categories of necessary functional activities treated in occupational therapy for orthopaedic problems:

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  activities of daily living (ADLs) and instrumental activities of daily living (IADLs): components of everyday activity, including self-care, work, and play or leisure activities. These may also be referred to as life skills or life tasks and consist of the following:

  
  
  
  
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    bathing: ability to obtain and use supplies and soap, rinse, and dry all body parts, maintain bathing position, transfer to and from bathing position, use adapted bathing equipment such as bath mitt, tub bench, grab bars, scrub brush, and so forth.

    
    
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    dressing: ability to select appropriate clothing; obtain clothing from storage area; dress and undress in sequential fashion; fasten and unfasten clothes and shoes; and don and doff appliances, for example, glasses, prostheses, or orthoses.

    
    
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    communication device use: ability to use equipment or systems to enhance or provide communication, such as writing equipment, telephones, computers, communication boards, call lights, emergency systems, braille writers, augmentative communication systems, and computers.

    
    
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    feeding and eating: ability to set up food, use appropriate regular or adapted utensils and tableware, and bring food or drink from table to mouth.

    
    
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    functional mobility: ability to move from one position or one place to another as in bed mobility, wheelchair mobility, transfers (bed, chair, tub, toilet, car), and functional ambulation with or without adaptive aids, driving, or use of public transportation.

    
    
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    personal hygiene and grooming: ability to obtain and use supplies to shave, apply and remove cosmetics, wash, comb, style, and brush hair, care for nails, care for skin, and apply deodorant.

    
    
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    toilet hygiene: ability to obtain and use supplies, clean self, and transfer to and from and maintain toileting position on bedpan, toilet, or commode.

    
    
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    current life activities: activities that include home, work, and play.

  
  
  
  
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  cognitive skills: necessary mental processes, including orientation, conceptualization and comprehension (concentration, attention span, memory), and cognitive integration (applying diverse knowledge to environmental situations, including ability to generalize and problem solve).

  
  
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  employment seeking and acquisition: vocational exploration, job acquisition, and timely and effective job performance.

  
  
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  home: includes home management tasks such as clothing care, cleaning, meal preparation and cleanup, household maintenance, care of others, and safety procedures. The latter is important in preventing falls in areas such as bathroom, kitchen, and stairs.

  
  
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  play or leisure: choosing and engaging in activities for amusement, relaxation, spontaneous enjoyment, or self-expression.

  
  
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  prevention and minimization of debilitation: refers to programs for persons with predisposition to disability, as well as for those who have already incurred a disability, and includes the following:

  
  
  
  
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    energy conservation: activity restriction, work simplification, time management, or organization of the environment to minimize energy output.

    
    
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    joint protection: procedures to minimize stress on joints, including use of proper body mechanics, avoidance of static or deforming postures, and avoidance of excess weight-bearing.

    
    
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    positioning: placement of body part in alignment to promote optimal functioning; or position of tasks and objects in a position to maximize performance.

  
  
  
  
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  sensorimotor skills: consist of performance patterns of sensory and motor behavior prerequisite to self-care, work, and play and leisure performance, such as:

  
  
  
  
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    •ROM

    
    
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    •gross and fine coordination

    
    
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    •muscle control

    
    
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    •coordination

    
    
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    •dexterity

    
    
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    •strength and endurance

    
    
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    •sensory awareness, including

    
    
    
    
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      tactile awareness

      
      
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      stereognosis

      
      
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      kinesthesia

      
      
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      proprioceptive awareness

    
    

  
  
  
  
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  therapeutic modifications: design or restructuring of the physical environment to assist self-care, work, and play and leisure performance through selecting, obtaining, fitting, and fabricating equipment, as well as instructing client, family, and staff in its proper use and care, including making minor repairs and modifications for correct fit, position, or use. Some categories of therapeutic adaptation are:

  
  
  
  
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    orthotics, splints, or slings: to relieve pain, maintain joint alignment, protect joint integrity, improve function, or decrease deformity.

    
    
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    dynamic splints: an orthotic device that achieves its effects by movement and force generated by the patient’s own musculature or external forces such as springs and rubber bands ( Fig. 12-1 ).

    
    

    
    

    
    

    

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