Modalities Final study guide

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1 Modalities Final study guide Iontophoresis: The transdermal drug delivery of physiologically active ions through the use of a low voltage direct current.a method of local transfer (phoresis), or delivery of ionized (ionto) medicated & nonmedicated substances into the skin. The use of electrical current to promote the delivery of medications transcutaneously. Fxn/Basis: Negative charged ions being repelled away from the negative pole (cathode) & Positive charged ions being repelled away from the positive pole (anode). Therefore, a medication that is negative must be placed in the negative (cathode) delivery electrode. Ions travel through the skin via the sweat glands, sebaceous glands, & perhaps hair follicles and skin imperfections. Permeability of the skin is altered by the passage of the electric current across the skin. Info: Delivery or active electrode: the electrode that contains the medication. Non-delivery, return, or dispersive electrode: The other electrode of opposite polarity. Delivery or active electrode: the electrode that contains the medication. Non-delivery, return, or dispersive electrode: The other electrode of opposite polarity. Anode (+) Attracts negative ions Acid reaction Produces hydrochloric acid Hardens tissues Vasoconstriction Decreases nerve excitability Cathode (-) Attracts positive ions Alkaline reaction Produces sodium hydroxide Softens tissues Vasodilation Greater potential for burns Indication Superficial muscle, tendon, or bursae inflammation Pain relief Idiopathic hyperhidrosis Calcium deposits Reduce scar tissue sclerolytic agent Wound infections Gout RSD Herpes, Shingles Edema

2 Myofascial pain (TP) Dental areas Improve blood flow Dosage Simultaneous use of 2 drugs with opposing polarities: questionable effectiveness A reversal of polarity is required midway during the application to allow an even or balanced delivery of both drugs. At the end of the application, only a half dose of each drug is delivered to the soft tissues. Do not combine lidocaine & dexamethasone Once the desired dosage is set, the amplitude should be adjusted based upon patient comfort. Mild tingling is acceptable; an uncomfortable sensation requires lowering of the amplitude. Most devices will automatically set the duration of the treatment session based on the preset dosage & the amplitude. Although 40 ma mins dose can be delivered in 10 minutes with an amplitude of 4 ma, a longer duration with a lower amplitude will be less likely to cause skin irritation or burns. There is some evidence that a longer duration, lower amplitude dosage may be better for localized drug retention in the target tissue. Increase the potential for electrochemical burns so Caution due to: (use other modalitiesprior to ionto) 1. Altered pain perception via the Gate Theory. 2. Decreased skin impedance by softening of the skin. Treatment Parameters Amplitude: 1-4 ma Duration: determined by desired dosage & amplitude tolerance. (To prevent burns, try to keep the treatment under 20 minutes.) Frequency & number depends on the condition being treated & the medication used for treatment. Frequency: Usually every 2 days to allow for the skin to recover from the effects of the direct current. The number of treatments depends on the effectiveness or adverse effects of the treatments. 1. If the medication is effectively delivered to the target tissue & remains in or near the target tissue then beneficial effects should occur within a few treatments. 2. Discontinue if no benefits in 3-4 treatments Dosage Concentration Low concentrations (1-5%) Higher doses tend to increase interionic attraction & limit drug delivery. Depth of Drug Penetration:6 22 mm below skin Pain Relief Lidocaine: about 10 minutes Dexamethasone: immediate to 48 hours Medications Inflammation: Dexamethasone (-), anti-inflammatory Calcific tendonitis/myositis ossificans: Acetic Acid (-), decrease calcium deposits Soft tissue pain & inflammation: Lidocaine (+), local anesthetic effects Muscle & joint pains: Salicylates (-), analgesic & anti-inflammatory

3 Contraindications General electrical stimulation contraindications Allergies or sensitivities to medications Over recent scars or new skin; poor skin integrity (unless treating a wound) Areas lacking sensation In conjunction with other medications at the same time In the immediate area of metal implants, wire, staples, etc. Acute injury Safety Issues 1. Treatment area must have normal sensation Always concerned with potential of tissue burns when using a DC current due to acid & alkaline reactions within the tissue under the respective electrode. 2. Caution: When using medications with an anesthetic effect may alter pain perception (i.e. Lidocaine) 3. Greater potential for adverse tissue changes under the cathode (-) due to the 4. combination of alkaline reaction & softening of tissues. 5. Caution: When treating the face (clean make-up off) Advantages Precise local delivery Noninvasive Bypasses GI tract Bypasses liver No skin puncture No risk of infection Disadvantages Delivery limited to superficial tissue Professional help required for delivery More costly than oral ingestion: drug cost plus professional s fee

4 HVPC Definition: Percutaneous delivery of pulsed, twin-peak, monophasic pulses, each pulse having a very short phase duration of less than 200 microseconds, which employs a high-driving peak voltage, usually higher than 150 volts & up to 500 volts Biophysical Effects Increases rate of healing Decreases edema Increases production of ATP Increases protein/dna synthesis Bacteriostatic effect Increases cutaneous circulation Indications Necrotic/granulating infected or non-infected wounds Grade I IV Chronic wounds not responding to conservative treatment Acute edema Pain Residual or chronic muscle spasm Precautions Patients with impaired sensation Extensive torn tissue Hemorrhage Contraindications Over wound in the area of osteomyelitis arterial insufficiency ischemia Over areas containing chemical agents that contain metal ions (i.e. povidine-iodine) Excessive bleeding Demand type pacemakers Avoid transabdominal, transthoracic, transcranial or carotid sinus placement Pregnancy Parameters for Wounds: Pulsed monophasic with varied waveform Negative polarity: attracts macrophages to the area to get rid of necrotic tissue 50 pps, 150 volts (any intensity above 200 volts is not recommended) positive polarity :attracts fibroblastic activity to promote granulation pps, 100 volts Anti-Edema effect Caused by the repulsion, under the cathode (-), of negatively charged albumin proteins found in the blood. This causes a fluid shift and reduces edema at the electrode site. TX Parameters for Edema Reduction Amplitude: 10% below amplitude required for a muscle contraction Pulse Duration: usually fixed Pulse Frequency: 120 pps Polarity: Negative Mode: Continuous (no On time/off time Ratios) Electrode Placement: Immersion bath or surrounding the area Effects on Circulation Motor level stimulation is required to influence blood flow to the tissue. An electrically-induced muscle contraction increases metabolic activity within the muscle. This increase in metabolic activity increases oxygen & substrate needs in the muscle. Blood flow is increased to & within muscle to meet this oxygen & substrate demands. Contractions between 10 30% of MVIC produced a slight increase in blood flow. Increasing amplitudes that produced strong muscle contractions correlated with slight increases in blood flow. Pulse frequencies between pps, if at least 10% MVIC, increased blood flow. Advantages The only electrical stimulator proven to promote wound healing Can be applied to immobilized body part Highly versatile in function Disadvantages Cannot provide as strong contraction as low-volt stimulators (NMES)

5 Many units are not portable Sometimes trial & error is needed to determine the appropriate electrode polarity for wound healing Minimal Electrical Non-Invasive Stimulation (MENS). Microcurrent Electrical Therapy (MET) Electrical current applied at a subsensory level or very low sensory level. Delivered at less than one milliamp of current in the microamperage range. This type of electrical current will not excite peripheral nerves. Subsensory TENS Purpose: To create low voltage electrical fields at frequencies that mimic the bioelectric fields produced within the body to promote healing. Settings Monophasic; Biphasic DC & pulsed currents Amplitude: < 1 ua (1/1000 of 1mA; 1/1000 of typical TENS application) Frequency: 0.3 to 100 Hz Pulse duration: 1 to 500 msec (5000 microsec) Treat for 5-10 minutes; total treatment duration 30 minutes to 2 hours Move the probe so surrounding the area by treating every ½ inch for 10 seconds; NMES INDICATIONS Retardation of Disuse Atrophy Muscle Re-education Muscle Strengthening Functional Electrical Stimulation (FES) Increase in ROM Reduction of Edema (muscle pumping) Decrease Muscle Tone ( spasm ) Motor Unit: made up of an alpha motoneuron along with its axon & all the muscle fibers it innervates. Tetanic Contraction: a series of muscle twitches that will combine to form an evoked smooth fused tetanic muscle contraction similar to that of maximum voluntary contraction (MVC). On:Off Time Ratio: the time during which the muscle is electrically activated the time during which it is not Ramp-up & Ramp Down Times: the gradual build-up & relaxation Temporal Summation: The rate of discharge, or frequency, with which motor units are recruited during the process of muscle contraction. 1. A muscle fiber, like a nerve fiber, has a stimulus threshold. 2. A single AP would depolarize alpha motoneuron resulting in a single muscle fiber contraction or a twitch. But the alpha motoneuron or muscle fiber are usually activated by a series or train of AP s 4. An electrically stimulated muscle: AP train < 20 pps = a twitch AP train > 20 pps = fused tetany Spatial Summation :number of muscle fibers activated 1. The greater the number of alpha motoneurons activated, the greater the number of muscle fibers activated then the greater the force generated by the muscle. (increase the amplitude or pulse duration.) 3. Increases in either amplitude &/or pulse duration will increase the current density by increasing the pulse charge and the average current. This will result in a stronger sensory response, muscle contraction, & depolarization of deeper structures Muscle fxn factors that influence force production 1. Length-Tension Relationship 2.Concentric Force-Velocity Curve Induced muscle contractions Physiological 1. Small diameter, slow-twitch muscle fibers (Type I) are recruited first. 2. Contraction & recruitment are asynchronous to decrease fatigue. Electrical 1. Large diameter, fast-twitch muscle fibers (Type II) are recruited first. 2. Contraction & recruitment are synchronous, potential for fatigue based on pps.

6 Low Level E. Stim 1. Increased # mitochondria 2. Increased oxidative metabolic enzymes 3. Increased # of capillaries 4. Maximal Endurance Gains! High Level E. Stim 1. Short duration, high level contraction 2. Rapid fatigue onset 3. Maximal Strength Gains! To improve muscular Strength: Phosphagen System: Restoration: 70% complete in 30 seconds & 100% complete within 3-5 minutes. Therefore, the off time ratios during muscle re-education should be at least 30 seconds in duration to avoid excessive fatigue. Muscle contractions are > 5 seconds in duration. On time/off time ratios of 1:3 to 1:7 recommended. Isometric Programs Optimal training intensity for untrained individuals is a load > 50% MVIC. Maintain contraction 3-8 seconds; repeat 5-12 times. (Not > 15 minute Rx) Training should be at least 2 days/week. Optimal strength gains occur with a 5 day/week protocol. The effect of NMES on injured muscle By depolarizing alpha motoneurons, NMES causes muscles to involuntarily contract. After several repeated contractions, the CNS receives & processes afferent feedback from the muscle. This improves the patient s proprioceptive & visual sense of the motions. The patient begins to relearn the motions (re-education). As the patient gets stronger he/she must isometrically contract the muscles as much as possible during stimulation. Pulse Rate Twitch: 1-10 pps Contraction: > 20 pps Fatigue: > 50 pps Pulse Duration Small Muscles: microseconds Large Muscles: microseconds On/Off Time Ratio Strength: 1:3 to 1:7 (1:5 common) Fatigue: 1:1 to 1:3 Muscle Contraction Duration 3 8 seconds 10 seconds (greater fatigue potential) Number of Contractions/Session Strength: 5 12 Endurance: > 12 Fatigue: > 12 (with 1:1 to 1:3 on/off time ratio; 50 pps Electrode Location Place one electrode over the motor point & the other one on the opposite end of the muscle belly. Electrode Distance The greater the distance between the electrodes, the deeper the electrical current will travel into the tissue. The electrodes are too far apart. Therefore, decrease the electrode distance to achieve dorsiflexion only because it is a superficial muscle. Electrode Size The unit area of the electrode should be proportional in size to the target area to be treated. Electrode Position Muscle conducts current about four times better in the longitudinal direction of the fibers vs. the current traveling transversely across the fibers. This concept is especially important with NMES over a large muscle like the quadriceps. Precautions Over high adipose areas when a motor response is desired (may be too uncomfortable).

7 Over areas of poor skin integrity, unless would healing is desired. In an area of any condition that can be exacerbated by increased circulation. Contraindications Do not apply over the transthoracic region or the carotid sinus. Do not apply transcranially. Do not apply over areas of severe peripheral vascular compromise such as thrombosis. Patients with demand pacemakers. Pregnant females (includes trunk & acupuncture points LI4 & SP6). FES Sub-area of NMES Use electrically-induced muscle contraction to perform a functional activity. Enables motor function by replacing, or assisting, a patient s voluntary ability to execute or control the impaired functions. Common indications: gait training, scoliosis management, shoulder subluxation, & UE movement patterns, i.e. gripping. Baseline MMT: UE= 1/5; LE= 2/5 If this MMT baseline is lacking, precede with muscle re-education & strengthening. Reduction of Edema Submaximal motor response desired since 50% MVIC results in 100% blood vessel occlusion. Due to the potential for vessel occlusion, the motor response must be intermittent (cyclic). To enhance additional venous return or lymphatic drainage, the treatment area should be elevated. Parameter selection based upon available joint ROM, healing constraints, & patient tolerance. Russian Current Therapy:Protocol based on Kots series of experiments on athletes- found that the 10c/10s/50s protocol was the best protocol for achieving maximum strength gains without inducing significant muscle fatigue. Current defined as the time modulation, in the form of bursts of electrical pulses (or cycles), of a continuous alternating sine-wave current with a carrier frequency of 2500 cycles per second (cps). Training protocol: 10c/10s/50s 10 electrically evoked contractions (c) per training session Each contraction lasts 10 seconds Separated by a rest period of 50 seconds Duty Cycle: On/Off Time (1:5) Advantages 1. Can be applied to immobilized body part 2. Can supplement voluntary muscle contraction Disadvantage: Sometimes becomes a cure-all IFC Provide practitioners with another type of electrical current that can penetrate deeper into the layers of soft tissue with minimum discomfort or pain for the patients. You can achieve the stronger physiological effects of low frequency (<250 pps) electrical stimulation of muscle & nerve tissues without the associated painful side effects of such stimulation. Low: current output frequencies of less than 1000 Hz Medium: current output frequencies between 1001 and 10,000 Hz. Theory Usually uses two sinusoidal waves that interfere with each other to create a third current. Constructive interference: two sine waves of the same frequency in phase. (amplitude summation effect) Destructive interference: two sine waves of the same frequency are completely out of phase. (cancel each other out) If two waves are partially in phase, they will either have an additive effect or cancel each other out. A beat frequency is created. Beat Frequency The carrier frequencies of one or both circuits are programmable, so as to deliver low, amplitude-modulated frequency (AMF), or beat frequency. IFC in the range of beats per second (bps).

8 The beat frequency resulting from two carrier frequencies, one at 4000 cps and one at 4050 cps, is 50 bps. Utilizing a static interference pattern the maximum summated amplitude occurs at 45 degrees to the perpendicular lines extending between electrode pairs. Clinical Significance: When using interference current technique, one is not treating the area directly under the electrodes!! 100% amplitude modulation occurs at a 45 degree angle to the intersection of the two carrier frequencies in a homogeneous medium like water but The body is heterogeneous with regards to electrical conductivity, therefore the current intersection may not occur at the center of the two AC currents. Bipolar: this method is delivered using two electrodes applied over the target tissue. Pre-modulated: the electronic interference between the two medium-frequency sine-wave currents occurs at the level of the electronic circuitry within the device (not at the soft tissue level, as in the case with other methods). Quadripolar: the use of four (quadri-) electrodes, each pair of electrodes connected to its respective circuit of stimulation. True Interferential: the current interference occurs within the targeted soft tissues (as opposed to within the device). Generalizations IFC (True) does not treat under or between two electrodes therefore one must have a quadripolar electrode placement. Increase electrode distance to treat deeper tissues. Due to amplitude-modulated (beat) frequency (AMF), accommodation & habituation are not a concern. Tends to be a more comfortable waveform due to decreased skin impedance. Scan (sweep) to treat large diffuse areas of pain; Vector (scan) to treat local areas of pain. Wednesky Inhibition (nerve Block) Explains the analgesic effect of IFC. Successive depolarization occurs while the nerve is in the refractory period. Therefore repolarization is prevented and loss of excitation occurs. This causes the treatment area to feel numb-like Effects of IFC Primarily pain relief Some motor nerve stimulation (& associated muscular contraction) at higher amplitudes. Muscle spasm reduction Edema control (perhaps) Indications Acute pain Chronic pain Pain that covers a large area Muscle spasm Precautions Over high adipose areas when a motor response is desired (may be too uncomfortable) Over areas of poor skin integrity, unless wound healing is desired Impaired sensation Skin lesions (cuts, abrasions, new skin, recent scar tissue, etc.) Contraindications Patients with demand pacemakers Do not apply over the transthoracic region or the carotid sinus Do not apply transcranially Do not apply over areas of severe peripheral vascular compromise such as thrombosis Pregnant females (includes trunk & acupuncture points LI4 & SP6) Patients who are unable to provide clear & accurate feedback Advantages Stimulates tissues deeper than a TENS unit Larger coverage area than TENS Possibly more comfortable than a TENS Disadvantages Does not treat the cause of the pain May mask more serious problems

9 Few, if any, portable units are available Sometimes becomes a panacea Electrotherapy Electrotherapy Can be used for Pain Control Muscle Strengthening Edema Reduction Promotion of Tissue Repair Muscle Spasm Reduction Definitions Current: The movement of charged particles. Resistance: The opposition of current. Voltage: The potential for electrons to flow from a high concentration to a low concentration. Ohm s Law: Current in a conductor will vary in proportion to the voltage & will vary inversely to the resistance (I= V/R). Frequency (rate): the number of pulses per second (pps). Amplitude (intensity): the measure of the magnitude of the current or voltage. Pulse duration (width): the time elapsed from the beginning to the end of all the phases. Three basic types of Currents: Direct Current (DC): The continuous unidirectional flow of charged particles (electrons or ions) for at least 1 second. i.e. Iontophoresis, Denervated muscle Alternating Current (AC): The continuous bidirectional flow of charged particles. The change in direction of flow (positive or negative) occurs at least once every second. i.e pain control Pulsed Current:Better suited for short-duration applications of electrical current; most often used therapeutically. The brief unidirectional or bidirectional flow of electrons or ions separated by a brief period of no flow. Each pulse lasts only a few milliseconds or microseconds Phase and Pulse Charge Phase Charge: Is the charge within each phase. It is the area under the curve. Pulse Charge: The charge per pulse (cycle). For monophasic waveforms, the phase & pulse charge are equal. For biphasic waveforms, it is the sum of the two phases. The response of biologic tissues to PC is largely dependent upon the charge of each phase or pulse of a PC waveform. Modulation: A change in the characteristic of the waveform. This change occurs in the frequency, pulse duration, & amplitude of the current waveform.one or more of these can be modulated. Frequency (rate): Cyclic variations in the number of pulses per unit of time. Pulse Duration (width): Variations in the length of time for each pulse event. Amplitude (intensity): Variations in the peak amplitude of a series of pulses. Ramp or Surge: Cyclical, sequential increases or decreases in phase charge over time. Train: A continuous repetitive sequence of pulses or cycles. Burst: A pulsatile current in which a finite interval of AC is delivered at a specified frequency for a specified length of time, in the form of a series of pulses called bursts. On Time: The time duration during which a train of pulses or bursts is delivered in a therapeutic application. Off Time: The time duration between trains of pulses or bursts. On Time/Off Time Ratio: The relationship between the on time & the off time, i.e. 1:5 Duty Cycle: The percentage of on time to the total time the pulsatile current is on. Precautions Over high adipose areas when a motor response is desired (may be too uncomfortable). Over areas of poor skin integrity, unless wound healing is desired. In an area of any condition that can be exacerbated by increased circulation. Contraindications Patients with demand pacemakers. Do not apply over the transthoracic region or the carotid sinus. Do not apply transcranially. Do not apply over areas of severe vascular compromise such as thrombosis. Pregnant females (includes trunk & acupuncture points LI4 & SP6). Patients with indwelling stimulators, i.e. urinary bladder & phrenic nerve.

10 Tissue Classfiications Excitable tissues are directly influenced by an electric current. Examples include nerve & muscle fibers and cell membranes. Non-excitable tissues are influenced by electrical fields created by the current. Examples include bone, fascia, tendons, & ligaments. Factors Affecting Tissue Excitations Tissue Impedance Axon Size Nerve Tissue Depth Tissue Impedance The body is made up of tissues & fluids that each have a varying ability to conduct electrical current. The ability of tissue or fluid to conduct an electrical current is dependent upon its water & ion content. The greater the water & ion content, the greater the electrical conductivity of the tissue or fluid. Tissues with high water & ion content are good conductors & poor insulators (& vice versa). Blood>Nerve>Muscle>Tendon>Adipose>Epidermis>Bone Axon Size The larger the axon diameter the more easily the nerve will depolarize due to less internal resistance. Motor Nerve (alpha motoneuron) > Sensory Nerve (A beta) > Pain nerve (C fiber) Nerve Tissue Depth The closer the nerve is to the surface electrode, the greater the current density it receives. Therefore, a superficial sensory nerve will depolarize before a deeper motor nerve. It is a combination of axon size & nerve depth that influences the order in which the nerves depolarize. Typical order: Sensory Nerve > Motor Nerve > Pain Nerve Acupuncture Points Specific sites on the skin (called master points) that have decreased electrical impedance. Stimulation used to alleviate pain. Electrode Position Muscle conducts current about four times better in the longitudinal direction of the fibers vs. the current traveling transversely across the fibers. This concept is especially important with NMES over a large muscle like the quadriceps. Electrode Configuration Monopolar: One or more stimulating or the Active electrode are placed over the treatment area & a larger non-treating electrode or dispersive electrode is placed distant to the treatment area. Bipolar: All electrodes are of equal or near equal size are placed over the treatment area. Quadripolar: Electrodes from two circuits are positioned so that currents intersect or interfere with each other in the body tissue. TENS-Transcutaneous Electrical Nerve Stimulation: The passage of an electrical current through the skin via electrodes which results in: Depolarization of sensory and motor nerves A tingling or prickling sensation and muscle contraction. Purpose Control/relieve pain (analgesia) Treats the symptoms not the cause Reduce the amount of and dependency on medication, i.e. narcotics Provide the patient with a more active role in their pain management Increase functional movements and mobility with less discomfort Peripheral Nerves: Afferent Nerves (sensory): Electrical stimulation of A beta fibers. Efferent Nerves (motor) :Electrical stimulation of alpha motor fibers and A gamma motor fibers. Gate Control Theory: Stimulation of large-diameter afferent A beta fibers may block small-diameter afferent nocioceptive A delta and C fibers. Pulse Rate= 75 pps or greater

11 Pulse Duration= 125 microseconds Amplitude: sensory- strong but comfortable tingling Treatment Duration: minutes Treatment Area: bracket or over painful area with electrodes Analgesia Onset: almost immediately Duration of Analgesia: brief; stops when stimulation ends Enkephalin Release Model:Stimulation of the A beta fibers activates the release of enkephalin for quick pain relief. Pulse Rate: = pps Pulse Duration: = < 200 microseconds; may be as brief as microseconds Amplitude: sensory- strong but comfortable tingling Treatment Duration: minutes Treatment Area: bracket or over painful area with electrodes Analgesia Onset: almost immediately Duration of Analgesia: minutes post treatment Central Biasing Model: Brief intense stimulation of the A delta and C pain fibers to induce a descending pathway response. Pulse Rate= > 80 pps Pulse Duration= Should be as long as long as possible; not to exceed 10 mseconds (1000 microseconds) Amplitude: sensory Noxious but below a motor response Treatment Duration: 30 seconds to 1 minute Treatment Area: probe or single electrode over trigger or acupuncture point (s) Analgesia Onset: almost immediately Duration of Analgesia: minutes maximum post treatment Endorphin and Dynorphin Model: Intense stimulation of the A delta and C pain fibers to induce a descending pathway response (release of endogenous opioids). Pulse Rate= 1-4 pps (ideal); < 10 pps Pulse Duration= > 200 microseconds Amplitude: either a strong sensory response or a motor response Treatment Duration: minutes (time needed to release a neurohormone) Treatment Area: Sensory Response: bracket or over treatment area with electrodes. Motor twitch Response: surround area or focus electrodes on motor, trigger, and acupuncture points (many share same locale) Analgesia Onset: minutes Duration of Analgesia: about 4 hours post treatment TENS Waveforms Usually biphasic balanced and asymmetrical A balanced waveform has NO net polarity effect. Reduction of adverse skin reactions if the patient wears the unit for extended time periods. CONTRAINDICATIONS: PREGNANCY PACEMAKER Precautions: Decreased or absent sensation History of seizures Immature or confused patients Obesity Cancer Electrotherapy in close proximity to diathermy treatment Skin irritation or allergy to electrodes Conventional High-Rate Stimulation: Based on the Gate Theory/Enkephalin Release Model Acupuncture like, Low-rate Stimulation:Based on the Beta Endorphin Model Brief intense painful: Based on the Central Biasing Model/Beta Endorphin Model Electrode Location

12 Since the electrodes are transcutaneous, the location of the target tissue (s) must be determined. If the treatment goal is sensory stimulation, then place the electrodes closer together such as on trigger points and acupuncture points. But if the treatment goal is motor stimulation, place the electrodes further apart on a motor point. The location of pain is used to determine where to place the electrodes, i.e. nerve root pain that radiates in a given related dermatome or muscle pain in a given myotome. Use charts to determine location of dermatomes, myotomes, superficial peripheral nerves; motor, trigger, and acupuncture points; and auriculotherapy points. Electrode Orientation The following are different configurations that can be used: Bilateral with Distal Points Crossed Method Bracketed Method Unilateral/Linear Unilateral/Linear & Overlapping with Distal Points Parallel Electrode Attachment Must be secure to maintain proper density of current. Loosely attached electrodes will result in a higher density of current in the smaller remaining area of contact. May use tape to secure electrodes (even the self-adhesive type) depending upon the adherence of the electrode to the skin and the patient s level of activity. FROM MODALS EXAM 1 Inflammatory: 1-6 days Occurs in vascularized tissue Essential for tissue healing Regardless of the tissue damage, the inflammatory response is non specific (same pattern throughout the body) Brings phagocytes such as Neutrophils & Monocytes to the injured tissue Phagocytes destroy bacteria & get rid of dead and dying tissue so repair can begin Lasts between hours Complete within 2 weeks Cardinal Signs: Swelling (Tumor) Heat (Calor) Redness (Rubor) Pain (Dolor) Four Primary Responses Vascular

13 Cellular Hemostatic Immune The vascular reaction Vasoconstriction Vasodilation Edema formation The cellular reaction Platelets Neutrophils Monocytes/macrophages Lymphocytes Proliferation (or repair): 4-21 days Granulation tissue formation Re-epithelialization Wound contraction Subacute, repair and healing stage Removal of noxious stimuli Growth of capillary beds into area Collagen formation Fibrous healing aligns to stress Formation of granulation tissue Tissue is fragile Remodeling: 14 days Chronic Maturation of connective tissue Contracture of scar tissue Remodeling of scar Collagen continues to align with stress Tissue is sturdy Treatment for Vascular Response To offset filtration outward pressures (30-40 mmhg) 1. Compression Elastic wraps: 50% overlap & 50% stretch (40 mmhg) Garments: vary from mmhg Intermittent Pneumatic Compression (IPC) 2. Elevation:Above heart if possible Contraindications Presence of DVT Presence of PVD Presence of Arterial Insufficiency Pulmonary Edema CHF Dermatological Infections IPC First treatment pressure 40-50mmHg Maximum pressure NEVER to exceed Diastolic BP 10mmHg Treatment duration minutes Inflammatory Stage Healing process during this stage can also be facilitated by non-thermal ultrasound which alters the permeability of cell membranes to sodium and calcium ions Subacute, repair and healing stage May change from cold to heat Intermittent compression Electrical stimulation Chronic, Maturation Return patient to activity May initiate deep heating modalities (i.e. ultrasound)

14 Superficial heating less effective at this point PAIN Definition: The perception of an adverse or unpleasant sensation that originates from a specific region of the body Also associated with an emotional response Actual or potential tissue damage Warning signal so an appropriate behavioral response can occur Nociception: The reception of signals in the CNS evoked by activation of specialized sensory receptors that provide information about tissue damage.not all noxious stimuli that activate nocioceptors are necessarily experienced as pain. Acute Pain < 6 weeks in duration Easily localized Usually caused by an event (tissue damage by mechanical, chemical, or thermal agents) May cause an autonomic response (sweating, rapid breathing, increases in HR or BP) May result in hyperalgesia Usually responds to modalities especially electrical stimulation Chronic Pain Pain persists after healing is completed Difficult to localize No autonomic response Person may feel hopeless or depressed Somatic symptoms (loss of appetite, sleep disturbance) May want to limit modality use; avoid reinforcing a dependency Referred Pain: Pain perceived in an area of the body not related to the pathology. Radicular Pain: Irritation of nerve roots that cause pain over specific areas of the skin (dermatomes) and may be associated with specific spinal levels. Trigger Points:Hypersensitive areas within the soft tissue such as muscle, ligaments or fascia, that produce a predictable pain pattern. Pain Receptors Nocioceptors Free nerve endings located in the skin, viscera, cardiac, and skeletal muscle. They stimulate A-delta and C afferents Mechanical stress: sprain or strain Thermal: burns Chemical: prostaglandins Afferent neurons: conduct AP from the periphery toward the brain Efferent neurons: conduct AP from the brain toward the periphery 1. A Beta: Medium myelinated nerve fiber Cutaneous receptor Conduction velocity: meters/sec 2. A delta: Small myelinated nerve fiber Cutaneous nocioceptor Conduction velocity: 20 meters/sec Fast Pain ; brief, well-localized, matches pain stimuli 3. C fibers Small unmyelinated nerve fiber Located in the skin, ligaments, & muscle Conduction velocity: meters/sec Slow Pain ; poorly localized, aching, throbbing, non-specific Specificity Theory: The stimuli from each receptor propagates along specific pathways to and from the spinal cord to a center in the brain, where the stimuli is interpreted. Pattern Theory:The intensity and frequency of the AP propagation are interpreted by the brain. The AP coding determines how the sensation will be interpreted by the brain.

15 Gate Control Theory: A delta &/or C nerve fibers are stimulated due to tissue damage or irritation. (Neurotransmitter Substance P released) 1. The AP propagate along the first order neuron to the spinal cord. All fibers converge at the transmission cell (T cell). 2. The pain message synapses in the thalamus & travels to the postcentral gyrus, where interpretation occurs. 3. Remember pain does not occur until the sensory cortex can interpret it. 5. If it is modulated in ANY WAY, the pain sensation will be interpreted differently. 6. The effect of A beta fiber stimulation: a. The use of modalities stimulates the A beta fibers. b. The A beta fibers are larger axon & myelinated to a greater extent than the A delta & C fibers. As a result, the A beta fibers have a faster transmission rate than the pain fibers. Central Biasing Model 1. Stimulation of the A delta & C fibers stimulates the midbrain and the pons & medulla. 2. The midbrain sends impulses down to the dorsal lateral tracts which synapse with enkephalin interneurons. 3. Enkephalin inhibits pain. This model is activated during brief, intense stimuli. Pain reduction after acupressure & the electrical probe is attributed to this model. Endogenous Opiods Stimulation of the A delta & C fiber afferents stimulates the release of endogenous opiates. One such Opioid is Beta endorphin (BEP). TENS induced analgesia releases BEP from areas of the brain such as the periaqueductal gray. Dynorphin is also released from the brain. Therefore, its pain relief should last for several hours as opposed to several minutes (like a neurotransmitter). CRYOTHERAPY TRANSFER PRINCIPLE OF HEAT ENERGY :Heat Abstraction (cooling): Heat removed or lost from an object CONDUCTION CONVECTION EVAPORATION Magnitude of Tissue Temp change is Driven by the following factors: 1. Temperature Gradient Example: Cool Water Bath 2. Time of Exposure Skin temperature changes occur rapidly (Within 1 min) Example: Muscle temperature 3. Thermal Conductivity Efficiency of the tissue to conduct heat Muscle vs. Adipose 4. Type of Cooling Agent Ice Pack vs. Frozen gel pack Principles of Tissue Cooling Hemodynamic Effects:vasoconstriction Post-traumatic Edema & Inflammation:use of cold for the first hours after injury includes: 1. Vasoconstriction decreases hemorrhage which limits edema. 2. Less inflammation & pain. 3. A decrease in metabolic rate, and thus a decrease in secondary tissue hypoxia. Peripheral Nerve Effects: Cold decreases peripheral nerve conduction velocity & synaptic activity. 1. Increases the pain threshold 2. Nerves of various diameters & degrees of myelination have different sensitivities to cold stimuli, i.e. cat studies CAUTION With prolonged cold exposure, a condition called cold-induced nerve palsy may develop in peripheral nerves. Common areas include: Peroneal Nerve at the fibular head & Ulnar or Radial Nerve at the elbow. Neuromuscular Effects: Decreases spasticity from upper motoneuron lesions such as CVA, SCI, BI At least two mechanisms: 1. Reflexive decrease in gamma-motoneuron activity. 2. A decrease in muscle-spindle afferent fiber discharge by direct cooling.

16 Muscle Strength Effects: Short duration cryotherapy (5 minutes or less): McGown, 1967, cryotherapy can affect the ability of the muscle to generate tension. After 5 minutes of ice massage, the isometric quad strength increased post-test vs. pre-test. Possible explanations: 1. Increased blood flow to muscle 2. Psychological response 3. Increased motor nerve excitability With a prolonged duration ( 20 minutes), there was a decrease in isometric muscle strength BUT an increase over pre-rx values minutes post-rx.this increase in strength output continued for at least 3 hours post-rx. Hunting Response: This is a safety mechanism to prevent local tissue damage due to cold exposure. Activated when tissue cooled below 10 ºC (50 ºF) Fingers immersed in an ice bath had a decrease in skin temperature during the first 15 minutes followed by cyclical increases & decreases in skin temperature (vasodilation & vasoconstriction). Goals with Use of Cryotherapy 1. Limit edema 2. Reduce pain 3. Cause muscle relaxation 4. Reduce inflammatory response Patient s Physical Response Sensation Cycle (about 5 minutes) Coldness>Burning>Aching>Numbness Skin Color Changes Depends on skin tone Caucasian- redness or erythema African-American eggplant color or purple hue PRECAUTIONS 1. Hypertension 2. Complex Regional Pain Syndrome (CRPS) 3. Areas of decreased sensation 4. Decreased wound healing 5. Prolonged application 6. Psychological response Contraindications 1. Raynaud s Disease 2. Buerger s Disease 3. History of frostbite to the treatment area 4. History of problems with cold 5. Patient s with severe C-V or respiratory problems 6. Patient s with decreased circulation Cold immersion bath: Commonly used to treat acute injuries to bony and irregular areas of the distal extremities, i.e. hand Temperature: Upper extremity: F Lower extremity: F Concerns of a cold pressor effect in temperatures below 50 F THERMAL To increase tissue temperature within 1-3 cm depth: Moist heat packs Paraffin Fluidotherapy Warm whirlpool Microwaveable gel packs Air-activated heat wraps Electric heating pads To increase tissue temperature to within 1-5 cm depth Continuous-wave ultrasound

17 Continuous shortwave diathermy (CSWD) used to: Promote relaxation Reduce pain Increase blood flow Facilitate tissue healing Prepare stiff joints and tight muscles for exercise Thermal Conductivity:Heat flow through tissues varies with the type of tissue Changes in surface tissue temperature depends on the following factors: Intensity of the heat applied The time of heat exposure The thermal medium for surface heat (Product of thermal conductivity, density, & specific heat) Parafin Bath: F Usually a minute treatment Paraffin wax has a lower specific heat than water therefore it takes less thermal energy (joules) to raise the temperature of paraffin when compared with water=less chance of burns w/ paraffin wax treatment 2. Paraffin in the molten state surrounds irregular surfaces to allow an even distribution of heating It s commonly used to treat distal extremities, i.e. fingers, hands, wrist; ankle, foot & toes 3. Patient positioning issues: strongly recommended to treat bilateral hand conditions, i.e. RA 1. Painting On 2. Glove Method (aka Dip & Wrap) 3. Dip Immersion (aka Dip & Reimmerse) 4. Immersion Disadvantages 1. Effective for distal extremities only 2. Limits accessibility to treat other body parts effectively 3. No method of temperature control once applied 4. Heating lasts only 20 minutes 5. Passive intervention Moist Heat Pack Usually a canvas covered pack filled with hydrophilic silicate (looks like cement) Kept in a thermostatically controlled stainless steel container called a hydrocollator Typical water temperature ranges between F Reaches its maximum temperature in 6-8 minutes Variety of shapes & sizes: Advantages 1. Ease of preparation & application 2. Variety of shapes & sizes available 3. Treats larger areas, i.e. quads or hams 4. Moist, comfortable heat 5. Relatively inexpensive to purchase & replace Disadvantages: 1. No method of temperature control once applied 2. Does not readily conform to all body parts 3. Can be awkward to secure in place 4. Does not retain heat > 20 minutes 5. Passive intervention 6. May leak & then must be discarded Fluidotherapy A dry-heat modality that transfers heat energy by forced convection Contains finely divided cellulose particles (finely ground corn cob) The thermal conductivity & specific heat of the particles & air allow the temperature of the unit to be higher than that of water A significant factor in thermal therapy is skin temperature No thermal shock at entry Temperature & agitation can be varied Temperature ranges from F Lower temperatures for patients w/ predisposition to edema or who are beginning a program for desensitization

18 Agitation: usually on the medium setting or patient comfort; lower for patients with hypersensitivities Sub-acute or Chronic Conditions Desensitization (i.e. CRPS) Combination of heat & exercise desired Combination of heat & manual techniques desired Treatment to a distal bony extremity Sickle Cell Anemia Advantages 1. Easy & convenient to use 2. Temperature can be controlled 3. Agitation of dry particles can be controlled for comfort 4. Variety of unit sizes 5. Can easily perform exercises and/or PT can perform manual therapy 6. Dry, comfortable heat 7. Patient can tolerate higher temperatures 8. Desensitization Disadvantages 1. Relatively expensive to purchase 2. Claustrophobia 3. Some patients are intolerant to the dry particles 4. Only accommodates distal limbs 5. Open wounds must be dressed Effects of Heat Decreases pain Decreases muscle spasm Increases blood flow to the area Reddens the skin- vasodilation of skin blood vessels; release of histamine Can increase EDEMA if applied too soon post-injury Precautions Presence of deep vein thrombophlebitis (aka thrombosis) (DVT) Moderate to severe cases of peripheral vascular disease (PVD) Contraindications Areas of decreased and/or loss sensation Over burn scars Skin infections or open wounds areas Patients who cannot report heat sensations accurately i.e. dementia, confusion, CHI Presence of skin or lymphatic cancer Excessive HTN (160/90 mmhg) Hemophilia Long-term steroid therapy Over areas where liniments have been applied Wet vs. Dry Heat No clinical studies that prove efficacy of one versus the other in reaching functional goals Dry heat elevates surface temperature to a greater degree Moist heat elevates temperature to a slightly deeper level Contrast Baths Immersion of body parts in baths in which both warm & cold water temperatures are used alternately Primarily used for a vascular exercise causing alternate constriction & dilatation of the local blood vessels. This stimulates peripheral blood flow & helps to stimulate healing. Warm bath = F Cold bath = F Total treatment time = about 20 minutes Treatment may end in either hot or cold depending on the condition Indications 1. Impaired venous circulation & indolent ulcers 2. Subacute or chronic traumatic & inflammatory conditions (can be used during the transition period between cold & heat treatments) 3. Indurative edema 4. Sinus or congestive headaches applied to feet & hands to increase circulation

19 TRACTION Effects of Traction Separation of the vertebral bodies Combination of distraction & gliding of the facet joints Stretching of the ligaments & muscles Widening of the intervertebral foramen Straightening of the spinal curve Continuous: application using bars, pulleys, & weights in bed Used at home or an institutional setting Low weight, long duration Maintains immobilization during acute cervical or lumbar pain Mechanical Applied lying on a table by an electrical or mechanical device Duration: minutes Heavier forces Table splits Manual: Applied by hands Duration: seconds or a sudden thrust Positional Patient positioned to cause a longitudinal pull on the spinal structures Alleviates pressure on an entrapped spinal nerve & promotes paravertebral muscle relaxation Duration: determined by patient s response Positioned in side-lying with painful side up Auto:Combination mechanical table traction & self applied forces Gravity Assisted Applied to the lumbar spine Adjustable table tilts to vertical position Lower half of the body hangs free using gravity to provide the distraction Inversion: Patient s hang in an inverted position by boots/straps Gravity provides distraction force to the spine Physiological Effects Separate bony structures, vertebral bodies/facets Decompress impingement of peripheral nerve root Decrease or centralize intradiscal pressure Decompress the articular cartilage Decrease muscle hypertonicity

20 Transient Not segment specific Equals 0.5 for the human body lying on a mattress Therefore, it will require a force of ½ of the patient s body weight to move horizontally on a bed ½ the BW is below L3; Force: ½ x 0.5= ¼ BW lost in overcoming friction It will require >1/4 th body weight to cause distraction of lumbar spine Precautions Hypertension: take BP & pulse pre and post: observe response to traction Claustrophobia Traction Anxiety (includes restless/hyperactive) TMD: cervical traction (avoid chin strap) Pregnancy: cervical with caution due to ligamentous laxity Obesity Acute neck & back pain Mental disorientation History of spine surgery Children or frail elderly patients Exaggerated symptoms (i.e. litigation) Contraindications Known joint instability Osteoporosis (very old/frail patients) Spinal infection Spinal malignancy (instability common) Cord Compression Acute strain, sprain, or inflammation of the joints RA Aortic aneurysm Signs & symptoms of vertebral artery occlusion (cervical traction only) Following trauma if diagnosis has not r/o a spinal fracture, subluxation, or dislocation Cardiac or Respiratory problems Hiatal Hernia or reflux condition (GERD) Pregnancy- avoid LS traction Advantages Measurable degree of pull Greater intensity than manual Requires limited attendance May perform w/ hot or cold pack Disadvantages Not segment specific May be cumbersome to apply & adjust May aggravate condition Force (poundage/intensity) C1 - C2 = 10 pounds C3 - C4 = pounds C5 - C7 (or in sitting) = pounds Angle of pull: C1 C2 = 0 5 C3 C4 = C5 C7 = Duration (Based on the condition) HNP or muscle hypertonicity: Static: 5 8 minutes Prolonged Intermittent: 10 minutes; Hold 60 seconds, Rest 20 seconds (3:1 ratio) Stenosis, DDD, facet hypomobility, any joint condition, DJD Intermittent: minutes; 1:1 ratio i.e. Hold 20 seconds, Rest 20 seconds. ALWAYS observe for dizziness &/or headaches post treatment; patient must rest for 2-3 minutes (rebound effect/shift of CSF) post treatment Unilateral traction Protective scoliosis due to HNP A. If patient leans AWAY from the painful side: Lateral herniation

21 1. Traction pull same side as symptoms 2. Positional distraction: painful side up B. If patient leans TOWARD the painful side: Medial herniation 1. Traction pull on opposite side of symptoms 2. Positional distraction: painful side down Unilateral traction Protective Scoliosis due to HNP Regardless of the patient s protective scoliosis, the pull is from the convex side of the curve in order to maintain the positioning Lumbar Scoliosis due to Muscle Hypertonicity ( Spasm ) Traction pull is on the concave side of the curve The idea is to stretch out the muscle Static traction x 3 1/3 BW ULTRASOUND A form of inaudible acoustic or sound energy therefore it is inaudible Requires a medium deep heating They have two phases: Positive: molecules adjacent to the energy source are compressed together (condensations) Negative: the molecules in the same region disperse (rarefactions) Piezoelectricity: The phenomenon in which the crystal generates an electric voltage when mechanically compressed Reversed Piezoelectric Effect: If the crystal is expanded rather than compressed, a voltage of the opposite polarity is produced Frequency 3 MHz: target tissue up to 2.5 cm beneath the skin 1 MHz: target tissue up to 5 cm beneath the skin Two Types of Modes Continuous: US waves delivered as an uninterrupted stream Pulsed: US waves delivered with periodic intervals in which no energy is flowing Intensity: The strength of the US wave is determined by the quantity of energy produced by US transducer Common ranges W/cm² Effective Radiating Area (ERA) Area of the US beam as it exits the metal end plate The higher the ERA in relation to the transducer surface, the more efficiently the US can be delivered to the tissue Beam Nonuniformity Ratio (BNR) The ratio at the highest intensity (spatial peak intensity) found in the near field to the average intensity (spatial average intensity) hot spots ; be careful using high intensities BNR = 6:1 & US intensity= 1.0 W/cm² then the intensity range = 1-6 W/cm² (intensity x BNR = intensity range) Transmission: The wave is transmitted through the substance Absorption: Partially transmitted waves are absorbed by the tissue & turned into heat Acoustic Impedance: a material s ability to transmit sound; related to the molecular density & structure of the material