The Use and Application of Physical Agents and Modalities: Can be - - PowerPoint PPT Presentation

The Use and Application of Physical Agents and Modalities:

Can be used for: Physical Agent Modalities Certification (PAM) For Occupational Therapists and Certified Occupational Therapy Assistants

Kurt Gray, PT, DPT

1

What are Physical Agents or Modalities and what is their role in patient care?

Manual Therapy

• Soft tissue massage
• Mobilizations

(joint and soft tissue)

• Manipulations

Patient Education

• Body Mechanics
• Pain Relief
• Home Exercise Programs
• Wellness & Risk Reduction

Therapeutic Exercise

• Flexibility & Strengthening
• Neuro re-education
• Balance, Coordination
• Relaxation

Therapeutic Modalities

• Thermal
• Mechanical
• Acoustic
• Electromagnetic

Intervention Types 2

Physical Agents or Modalities:

• energy or material applied to achieve a physiologic goal

Can Include:

• Thermal (Heat & cold)
• Mechanical (water, pressure, sound)
• Electromagnetic (radiation, and electrical currents)

3

Clinical Applications of Physical Agents

• 1. Modulation of pain
• “Gate-control theory”
• 2. inflammation and facilitating tissue healing
• Inflammatory, proliferation, and maturation stages
• Inhibit inflammation?
• 3. Alteration of skeletal muscle performance
• ↑ strength, retraining, ↓ spasticity
• Blood flow restriction?
• ↑ tissue extensibility: flexibility and ROM

4

Modulation of Pain Neuroanatomy Afferent Towards the brain Sensory Efferent Toward the periphery Motor

Adapted From: https://www.getbodysmart.com/spinal‐cord/spinal‐nerve‐roots

5

Modulation of Pain Neuroanatomy Pain Receptors are specific to sensation

Meissner’s Corpuscles Light pressure Vibration Pacinian Corpuscles Deep pressure Ruffini Corpuscles Touch, Tension, Thermal Proprioception Merkel’s Corpuscles Light touch Pain Receptors Nociceptors Free Nerve endings

6

Modulation of Pain Neuroanatomy – Specific Nerve Fibers Carry Aβ: (Beta) – Fast Sensation

• Medium myelinated

cutaneous receptor Conduction velocity: 36-72 meters/second Sensation Aδ: (Delta) – Fast Pain

• Smaller myelinated

cutaneous nociceptor Conduction velocity: 20 meters/second “Fast Pain” Brief, well localized, specific C Fibers – Slow Pain

• Small unmyelinated
• Located in:

Skin Muscle Ligament Conduction velocity: 0.7 – 2 meters/second “Slow Pain” Poorly localized Aching, Non-specific 7

Modulation of Pain Neuroanatomy – Specific Nerve Fibers Carry: 8 Pain Gate Theory Model (Open Gait)

T-cell SG

Fast Fibers Slow Fibers

To Brain A-beta fibers A-delta fibers C-fibers

Modulation of Pain Neuroanatomy – Specific Nerve Fibers Carry: 9 Pain Gate Theory Model (Closed Gait)

T-cell SG

Fast Fibers Slow Fibers

To Brain A-beta fibers A-delta fibers C-fibers

Phases of Tissue Healing Hemostasis – Minutes to Hours Required for healing Due to trauma or disease Presents with: Calor, Rubor, Tumor, Dolor Clot formation Phagocytosis 10

Phases of Tissue Healing Inflammation – Day 1-6 Required for healing Due to trauma or disease Presents with: Calor, Rubor, Tumor, Dolor Clot formation Phagocytosis 1. Tissue damages cause increased blood flow 2. Permeable capillaries allow increased fluid and cells 11

Phases of Tissue Healing Inflammation – Day 1-6 Required for healing Due to trauma or disease Presents with: Calor, Rubor, Tumor, Dolor Clot formation Phagocytosis 3. Phagocytes migrate to inflammation 4. Phagocytes destroy bacteria 12

Phases of Tissue Healing Proliferative Phase – Day 3-20 Neovascular Epithelialization and Collagen production

• Most epithelial and collagen fibers (poorer quality)
• 1. Connective tissue production
• Increased Fibers
• Fragile Tissue
• 2. Epithelization
• Collagen
• Wound contracture
• Neovasculature

13

Phases of Tissue Healing Maturation Phase – Day 9-1year and beyond Progression towards normal Balance of collagen synthesis and collagen lysis

• 1. Collagen production/lysis
• Rebuilding – Stronger Tissue
• 2. Collagen reorientation
• 3. Scarring
• Collagen Production >> lysis
• Keloid Scar

(outside wound boundary)

• Hypertrophic Scar

(inside wound boundary) 14

Modulation of Pain Acute Pain 15

Modulation of Pain Chronic Pain 16

Modulation of Pain Referred Pain 17

Phases of Tissue Healing Name the Phase: 18

Phases of Tissue Healing Name the Phase: 19

Phases of Tissue Healing Name the Phase: 20

Phases of Tissue Healing Name the Phase: 21

Phases of Tissue Healing Name the Phase: 22

Phases of Tissue Healing Name the Phase: 23

Indications for Modalities: Alteration of skeletal muscle performance ↑ strength, retraining, ↓ spasticity ↑ tissue extensibility: flexibility and ROM Blood flow restriction

http://www.nobledrewalifoundation.com/russian-electrical-stimulation/ https://mtipt.com/blood-flow-restriction-bfr-training/

24

Inflammation and Healing Decision Tree

Inflammation?

What Type of Inflammation?

Acute

Not Recommended to Promote Healing

Chronic

What is Causal Agent? No Anti‐ Inflammatory Measures Needed Yes No 25

Choosing a Physical Agent Highest Priority PROMOTE HEALING

• Address Physical

Dysfunction

• Address Symptoms
• Patient Compliance

Partial assistance with the dysfunctions presented Address symptoms only (Pain) Lowest Priority 26

Categories of Physical Agents Category Types Clinical Examples Thermal Agents

Superficial Heating Agents Deep Heating Agents Cooling Agents Hot Packs, Paraffin Ultrasound, Diathermy Ice massage, Ice Packs

Mechanical Agents

Traction Compression Water Sound Mechanical Traction Elastic Bandage, Stockings, Compression Pumps Whirlpool Ultrasound

Electromagnetic Agents

Electromagnetic Waves or Fields Electric Currents Ultraviolet Light, Laser TENS, NMES, HVG Diathermy

27

Summary There are many different physical agents to available to use.

• Use sound rationale for choices.
• Consider indications, contraindications, precautions,

and patient preference. Assess the effectiveness of the physical agent.

• Evidence-Based Care
• Follow the “Highest Priority to Lowest Priority”

decision tree.

• Individualize your treatments.

28

Thermotherapy/Cryotherapy Primary principles of heat transfer Conduction Surface to surface Hot Pack, paraffin, ice Convection Moving air or water Whirlpool, Fluidotherapy Conversion Non-thermal energy to thermal Ultrasound Diathermy Evaporation Liquid to vapor Vapocoolant spray Radiation No medium Heat from radiation to a cooler temperature Infrared light, Ultraviolet light 29

Thermotherapy/Cryotherapy

Primary effects: Thermotherapy (Heat) Cryotherapy

• Reduce pain
• Increase tissue extensibility
• Increase circulation

Vasodilation

• Accelerate healing
• Decrease spasm
• Increase metabolic rate
• Vasoconstriction

Decrease blood flow

• Decrease temperature
• Decrease metabolism
• Decrease nerve conduction

Decrease pain Decrease spasticity

• Decrease edema

30

Thermotherapy/Cryotherapy

Contraindications: Thermotherapy (Heat) Cryotherapy

• DVT
• Recent Cancer
• Venous Insufficiency
• Altered sensation
• Over eyes
• Recent hemorrhage
• Impaired circulation
• PVD

Berger’s Disease Raynaud’s Syndrome

• Cold urticaria
• Hemoglobinuria
• Frostbite history

31

Thermotherapy/Cryotherapy

Precautions: Thermotherapy (Heat) Cryotherapy

• Acute Injury
• Pregnancy
• Impaired circulation
• Edema
• Exposed metal
• Topical creams
• Open wounds
• Over open wounds
• Hypertension
• Altered sensation

32

Thermotherapy/Cryotherapy

Applications: Thermotherapy (Heat) Cryotherapy

• Hot Packs
• Paraffin
• Fluidotherapy
• Infrared Lamps
• Cold Packs
• Ice Massage
• Ice Baths

Deep Heating Superficial Heating or Cooling

• Diathermy
• Ultrasound

33

Deep Heat

Diathermy – Conversion Therapy Heating by conversion of EM waves to heat

• Causes cellular vibration leading to increased

temperature Diathermy uses shortwave energy (27.12 MHz)

• Pulsed is non-thermal
• Continuous is thermal

Eddy currents cause friction that produce heat Preference for tissue with low impedance (Seeks Muscle) 34

35

Deep Heat

Diathermy – Conversion Therapy Eddy currents cause friction that produce heat Preference for tissue with low impedance (Seeks Muscle) Prefers:

• Wet, Ionic, Low Impedance Tissues
• Muscle
• Nerve
• Edema
• Hematoma
• Effusion

Deep Heat

Diathermy Heating by conversion of EM waves to heat

• Causes cellular vibration leading to increased

temperature Diathermy uses shortwave energy

• Pulsed is non-thermal
• Continuous is thermal

Capacitive or Electric Field Technique (Plate to Plate) 36

Deep Heat

Diathermy Heating by conversion of EM waves to heat

• Causes cellular vibration leading to increased temperature

Diathermy uses shortwave energy

• Pulsed is non-thermal
• Continuous is thermal

Inductive technique 37

Deep Heat

Diathermy Heating by conversion of EM waves to heat

• Causes cellular vibration leading to increased

temperature Diathermy uses shortwave energy

• Pulsed is non-thermal
• Continuous is thermal

Inductive technique 38

Deep Heat

Diathermy

Heating by conversion of EM waves to heat

• Causes cellular vibration leading to increased temperature

Diathermy uses shortwave energy: (27.12 MHz)

• Pulsed is non-thermal
• Continuous is thermal

Capacitive Technique (Plate to Plate) Inductive technique

39

Deep Heat

Diathermy Effects:

• Temperature & Metabolic Increase with Vasodilation
• Increased Collagen Extensibility
• Altered Cell Membrane Permeability
• Increased Nerve Conduction Velocity

Indications:

• Decreased Collagen Extensibility
• Pain, Muscle Guarding, DJD, Bursitis, Wounds
• Peripheral Nerve Regeneration
• Chronic Inflammation

Contraindications:

• Pregnancy, IUD, Testes, Eyes, Pacemaker, Metal Implants
• Malignancy
• Acute Inflammation/Moist Wound Dressing/PVD

40

Deep Heat

Diathermy

Treatment Parameters:

• Remove all metal
• Cover skin with dry cloth or towel
• 15 – 30 min

41

Deep Heat

Ultrasound (Ultrasound is a diathermy) – Conversion Therapy – Deep Heating

Heating by conversion of Ultrasonic Waves to produce

• Thermal Effects
• Non-Thermal Effects

Requires a coupling agent:

• Gel or lotion
• Water

Prefers:

• Dense Collagen-Based Tissues
• Ligament/Tendon/Fascia
• Joint Capsule
• Scar Tissue

42

Deep Heat

Ultrasound – Primary Parameters

1. Intensity (Similar to Volume)

• Higher Intensity -> Greater Effects

(Micro-massage & Temperature)

2. Duty Cycle (Pulsed or Constant)

• Pulsed = Non-Thermal but micro-massage effects
• Constant = Thermal with micro-massage effects

3. Frequency or Wavelength (Depth of Treatment)

• 1MHz (1.5mm wavelength) = Deep (up to 5 cm)
• 3MHz (0.5mm wavelength) = Superficial (<2 cm)
• 40,000 MHz = Wound Healing

43

Deep Heat

Ultrasound – Effects

Effects:

• Temperature & Metabolic Increase with Vasodilation
• Increased Collagen Extensibility
• Altered Cell Membrane Permeability
• Increased Nerve Conduction Velocity

44

Deep Heat

Ultrasound – Indications

Indications

• Decreased Collagen Extensibility
• Pain, Muscle Guarding, DJD, Bursitis, Wounds
• Peripheral Nerve Regeneration
• Chronic Inflammation

45

Deep Heat

Ultrasound – Contraindications

Contraindications:

• Pregnancy, IUD, Testes, Eyes, Pacemaker, Metal Implants
• Malignancy
• Acute Inflammation
• Over a healing fracture
• Over open epiphyseal plate
• PVD

46

Deep Heat

Ultrasound – Biophysical Effects:

Metabolic Changes: ( ↑ Metabolic Rate) Vascular Effects:

• Vasodilation:
• ↑ Axon Reflex
• ↑ Reflexes

Neuromuscular Effects:

• ↓ Pain and Muscle Spasms

Connective Tissue Effects:

• ↑ Elasticity and muscle flexibility
• ↓ Synovial fluid viscosity and accompanying joint stiffness

47

Deep Heat

Ultrasound – Purpose and Biophysical Effects:

Penetration

• Greatest of all heat modalities with significant heating 2

inches below the surface Absorption

• Greatest in high protein and dense tissues

48

Deep Heat

Ultrasound – Purpose and Biophysical Effects:

Penetration

• Greatest of all heat modalities with significant heating 2

inches below the surface Absorption

• Greatest in high protein and dense tissues

49

Deep Heat

Ultrasound – Purpose and Biophysical Effects:

Condensation (Compression)

• As sound waves travel through elastic medium tissues

(muscles and fat) they compress the molecules of the medium. Rarefaction

• As the sound wave reaches the elastic medium threshold the

compression is relaxed. The energy from condensation and rarefaction result in thermal and mechanical effects

https://schools.aglasem.com/6205

50

Deep Heat

Ultrasound – Purpose and Biophysical Effects:

Reflection

• Reflection is the “bouncing back” of wave energy as it moves

from one tissue to another. Refraction

• Refraction is the change in direction of wave energy as it

moves from one tissue to another. Because of reflection, heat is greatest at tissue interfaces 51

Deep Heat

Ultrasound – Purpose and Biophysical Effects:

http://www.planetoftunes.com/sound-audio-theory/sound-waveform-diagrams.html#.XgPncUdKg2w

52

Deep Heat

Ultrasound – Primary Parameters

1. Intensity (Similar to Volume)

• Higher Intensity -> Greater Effects

(Micro-massage & Temperature)

2. Duty Cycle (Pulsed or Constant)

• Pulsed = Non-Thermal but micro-massage effects
• Constant = Thermal with micro-massage effects

3. Frequency or Wavelength (Depth of Treatment)

• 1MHz (1.5mm wavelength) = Deep (up to 5 cm)
• 3MHz (0.5mm wavelength) = Superficial (<2 cm)
• 40,000 MHz = Wound Healing

53

Deep Heat

Ultrasound – Conversion Therapy – Deep Heating

• Ultrasound is a Diathermy

Continuous: Thermal

• 100% Duty Cycle
• 1MHz for Deeper tissues (up to 5 cm)
• 3 MHz for Superficial tissues (< 2 cm)

Pulsed: Non-Thermal

• 20% duty cycle (on 20% of the time)
• 1 MHz for Deeper tissues
• 3 MHz for Superficial tissues

54

Deep Heat

Ultrasound – THERMAL – vs – NON-THERMAL Thermal Non-Thermal Continuous:

• 100% Duty Cycle

Pulsed:

• 20% Duty Cycle

Effects: Pain/Stiffness/Spasm

• Stimulation for Repair
• Blood Flow
• Collagen Extensibility

Effects: Pain/Stiffness/Spasm

• Stimulation for Repair
• Blood Flow
• Membrane Permeability
• Macrophage Activity

Indications:

• Soft Tissue Repair
• Pain / Contracture
• Trigger Points

Indications:

• Soft Tissue Repair
• Pain / Scar Tissue
• Plantar Warts

Considerations:

• Moving Sound Head
• 2-4 x size of ERA

Considerations:

• Stationary Sound Head

55

Deep Heat

Ultrasound – Physics Terms and Parameters

Beam Nonuniformity Ratio: (BNR)

• Lower BNR = Higher Quality or more uniform wave form

Effective Radiating Area: (ERA)

• Area within sound head that produces Ultrasound

https://www.studyblue.com/notes/note/n/pta200-us/deck/13773832

56

Deep Heat

Ultrasound – Physics Terms and Parameters

Acoustic Cavitation:

• Energy enters fluid medium

Stable Cavitation:

• “Bubbles” on High Pressure side of wave

Transient Cavitation:

• “Bubbles” on Low Pressure side of wave

57

Deep Heat

Ultrasound – Physics Terms and Parameters

Acoustic Cavitation:

• “Bubbles” that form around a pulsating wave form
• Stable: Bubbles on High Pressure Microstreaming
• Transient: Bubbles on Low Pressure Implode No Effects

Cavitation Microstreaming Streaming Minute flow of fluid Circular flow of around bubbles that fluids that alter

• scillate and pulsate

cell activity

https://www.sciencedirect.com/science/article/abs/pii/S092422441500179X

58

Deep Heat

Ultrasound – Physics Terms and Parameters

Acoustic Streaming:

• Eddying of fluids at cell membranes.

Ultrasound Mechanical Effects Stable Cavitation Alerted Cell Membrane Change in Protein Synthesis Change in Blood Flow Changed Collagen Acoustic Streaming Change in Cell Membrane Transport Micro‐massage

Physical Factors Physiological Changes Therapeutic Effects

https://www.silabtec.com/en/general-principle-the-cavitation/

59

Deep Heat

Ultrasound – Physics Terms and Parameters

Therefore:

• CONSTANT ULTRASOUND - Thermal
• INTERMITTANT ULTRASOUND - Non-Thermal

60

Deep Heat

Ultrasound – Physics Terms and Parameters

Therefore:

• CONSTANT ULTRASOUND - Thermal
• Deep Heating with increased circulation + micro-massage to a

deeper tissue (Lumbar Spine)

• Duty Cycle 100% (Constant)
• Frequency 1 MHz (Low)
• Intensity 1.5 W/cm2 (High)
• Time

Documented as US @ 1.5W/cm2 x 5min @ 1MHz x 100% Duty Cycle

61

Deep Heat

Ultrasound – Physics Terms and Parameters

Therefore:

• INTERMITTANT ULTRASOUND - Non-Thermal
• No Heating with increased circulation + micro-massage to a

superficial tissue (Hand)

• Duty Cycle 20% (Low)
• Frequency 3 MHz (High)
• Intensity 0.8 W/cm2 (Low)
• Time

Documented as US @ 0.8W/cm2 x 5min @ 3MHz x 20% - 50% Duty Cycle

62

Deep Heat

Ultrasound – Constant vs Pulsed (% Duty Cycle)

• Beam Pattern
• ERA

63

Deep Heat

Ultrasound – Penetration 64

Deep Heat

Ultrasound – Penetration 3 MHz

High Freq = Shallow

1 MHz Low Freq = Deep

Intensity W/cm2 Rate of ( ̊C/min) Depth Rate of ( ̊C/min) Depth 0.5 0.30 – 0.31 0.8 cm 0.04 – 0.06 2.5 cm 1.0 0.58 0.16 1.5 0.82 – 0.96 0.31 – 0.34 2.0 1.30 – 1.50 1.6cm 0.34 – 0.40 5.0cm

65

Deep Heat

Ultrasound – Review

1. Intensity (Similar to Volume)

• Higher Intensity -> Greater Effects

(Micro-massage & Temperature)

2. Duty Cycle (Pulsed or Constant)

• Pulsed = Non-Thermal but micro-massage effects
• Constant = Thermal with micro-massage effects

3. Frequency or Wavelength (Depth of Treatment)

• 1MHz (1.5mm wavelength) = Deep (up to 5 cm)
• 3MHz (0.5mm wavelength) = Superficial (<2 cm)
• 40,000 MHz = Wound Healing

66

Deep Heat

Ultrasound – Instructions

• 1. Examine Patient - R/O Contraindications – Skin Check
• 2. Check Equipment – Calibrated
• 3. Position, Drape, Instruct Patient
• 4. Identify Treatment area/depth/type of tissue
• 5. Adjust settings (Frequency, Duty Cycle, Time, Intensity)
• 6. Apply Coupling Medium
• 7. Place sound head on coupling medium on skin
• 8. Adjust Intensity
• Keep SOUND HEAD MOVING
• Keep SOUND HEAD IN CONTACT WITH SKIN
• 9. Turn off and clean Sound Head
• 10. Skin Check
• 11. Documentation

67

Deep Heat

Ultrasound – Instructions

68

Deep Heat

Phonophoresis

Transdermal medication of medication using Ultrasound

• No invasion of the dermis

Indications

• Anti-inflammatory
• Anesthetic
• NSAID
• Steroid

Contraindications / Precautions

• As per Ultrasound
• As per medication

69

Deep Heat

Deep Heat: Diathermy vs Ultrasound

Diathermy is produced by three methods: (Therapeutic Diathermy)

• 1. Shortwave Diathermy
• 2. Ultrasound
• 3. Microwave Diathermy

SW Diathermy vs Ultrasound

• 1. Ultrasound: Treats smaller areas of dense collagen
• Ligaments, tendons, joint capsule
• 2. Diathermy: Treats larger areas in tissues with high fluid
• Muscles

Why do you choose one over the other? 70

Electrotherapy

Why do we use Electrotherapy?

• Pain reduction
• Muscle Re-Education
• Edema Prevention and Reduction
• Muscle Spasm Reduction
• Denervated muscle
• Medication administration (Iontophoresis)
• Wound Healing

71

https://www.painscience.com/articles/transcutaneous‐electrical‐stimulation.php

What is Electrotherapy:

The application of electrical stimulation via electrodes for a therapeutic purpose. As current flows through the body it can cause different physiological reactions. 72

Electrotherapy

ES Uses:

Alteration of cell function

• Pain control
• Alteration of skeletal muscle
• ↑ strength
• Muscle retraining,
• ↓ spasticity
• ↑ tissue extensibility: flexibility

and ROM

• Drug administration
• Edema control

https://doi.org/10.1093/ptj/82.4.354

73

Electrotherapy

ES Current: ‐ The Flow of electrons from one electrical node to another.

https://www.researchgate.net/figure/Principle-of-glucose-extraction-by-reverse-iontophoresis_fig2_331349052

74

Electrotherapy

The Effect of ES Current on Tissue Polarity: ‐ The when the flow of electrons reaches a threshold the cell depolarizes temporarily:

75

Electrotherapy

Electric Stimulation (ES) Definitions:

An electrical current: A flow of charged particles or electrons

High Frequency High Cycles/Second ‐ Generally cause neuromuscular change Low Frequency Low Cycles/Second ‐ Generally cause neuromuscular change DC (No Frequency) Constant ‐ Generally cause chemical change Different stimuli create different effects: Ultimately all Electric Stimulation (ES) works by Nerve Depolarization

https://accessphysiotherapy.mhmedical.com/content.aspx?bookid=465&sectionid=40195349

76

Electrotherapy

ES Definitions:

Nerve Depolarization:

• Nerve Resting Membrane Potential is Negative on Inside
• ES above threshold leads to Depolarization
• ACTION POTENTIAL (AP)
• Then the nerve returns to negative state (Repolarization)

77

Electrotherapy

ES Definitions:

Different nerves require different types & amounts of stimulation to produce an AP

• In general: Faster nerves need higher frequencies

https://accessphysiotherapy.mhmedical.com/content.aspx?bookid=465&sectionid=40195349

78

Electrotherapy

ES Definitions:

Strength-Duration Curve:

• In general, a stronger stimulus strength needs less time to

produce an AP

• RHEOBASE – The Minimum Current Amplitude that can

create an AP (LONG DURATION)

• CHRONAXIE – The Stimulus Duration required to produce

contraction at twice RHEOBASE (SHORT DURATION)

• Time needed to develop muscle contraction at any

intensity

http://www.medicine.mcgill.ca/physio/vlab/other_exps/CAP/S-D.htm

79

Electrotherapy

ES Definitions:

Strength-Duration Curve: In General:

• Sensory Nerves = LOWER AMPLITUDES + Shorter Duration
• Motor Nerves = HIGHER AMPLITUDES + Longer Duration

http://www.medicine.mcgill.ca/physio/vlab/other_exps/CAP/S-D.htm

80

Electrotherapy

ES Definitions:

Indications:

• Muscle Spasm or Pain
• Muscle Weakness or

Reeducation

• Neuropathy
• Stress Incontinence
• Shoulder Subluxation
• Joint Effusion
• Impaired ROM
• Idiopathic Scoliosis
• Labor Delivery Pain Control
• Fracture Healing & Pain
• Increased Circulation

Contraindications:

• Pacemaker
• Internal Electric Stim Device
• Use over a carotid sinus
• Seizure Disorders
• Phlebitis
• Malignancy
• Pregnancy
• Arrhythmia

81

Electrotherapy

ES Parameter Types:

Monopolar Technique:

• Small Electrode over Target Area
• Large Dispersive Electrode Remote
• Iontophoresis, edema

Bipolar Technique:

• Two active electrodes over Target Area
• Equal in size
• Neuromuscular Facilitation, pain

Quadripolar Technique:

• Two electrodes from two

separate stimulating circuits positioned so currents intersect

• Interferential current

https://www.medsourceusa.com/neuromuscular-stimulators/3356-ems-2c-pulsed-faradic-stimulator https://spinepains.com/electrode-therapy-the-history-and-benefits/ https://accessphysiotherapy.mhmedical.com/content.aspx?bookid=465&sectionid=40195349

82

Electrotherapy

ES Electrode Size Types:

Small Electrodes

• Increased Current Density
• Increased Impedance
• Decreased Current Flow

Higher Risk of Tissue Damage Large Electrodes

• Decreased Current Density
• Decreased Impedance
• Increased Current Flow

83

Electrotherapy

ES Treatment Parameters:

Biphasic or Alternating Current: (AC)

• Polarity changes from positive to negative
• Can be symmetrical or asymmetrical
• Used in muscle retraining, spasticity, stimulation of

denervated muscle

https://accessphysiotherapy.mhmedical.com/content.aspx?bookid=465&sectionid=40195349

84

Electrotherapy

ES Treatment Parameters:

Monophasic or Direct Current: (Galvanic Current)

• Constant flow of electrons without interruption
• Iontophoresis

https://accessphysiotherapy.mhmedical.com/content.aspx?bookid=465&sectionid=40195349

85

Electrotherapy

ES Treatment Parameters:

High Voltage Pulsed Current: (HVPC)

• Twin-Peak, Monophasic Pulsed Current
• Mimics DC without concerns of ionic build-up

https://fadavispt.mhmedical.com/content.aspx?bookid=1954&sectionid=146794726

86

Electrotherapy

ES Treatment Parameters:

Interferential Current: (IFC)

• Two high frequency waves
• Used for Deep Tissue Muscle
• 2-50pps + 100-200msec
• Used for Pain Control
• 50-120pps + 50-150msec

https://accessphysiotherapy.mhmedical.com/content.aspx?bookid=465&sectionid=40195349

87

Electrotherapy

ES Treatment Parameters:

Russian Current  Medium frequency AC wave forms

• (50pps – 50-200msec)

 Used for strengthening over healthy muscle tissue leading to increased contraction  Type of NMES and/or FES Indications  Strengthen healthy tissue (athletes) Contraindications  Over abdominal and pelvis in pregnancy  Over hemorrhage  Malignancy  Over anterior cervical area  Over electronic implants

88

Electrotherapy

ES Treatment Parameters:

Neuromuscular Electrical Stim (NMES) NMES and Functional Electric Stim (FES) are the same with computer assist ‐ FES to promote function (i.e. Dorsiflexion assist, swallowing) ‐ Used for maintaining strength (unproven) Parameters: 20-40pps – on 6-10sec OFF 50-60sec ‐ Avoid fatigue (1:10) Treatment Time: 15 – 20 min 89

Electrotherapy

ES Treatment Parameters:

Transcutaneous Electrical Nerve Stim (TENS) Used for pain (Acute & Chronic)

• Using Gate Control Theory - Uses endogenous Opiate Theory

Indications

• Pain: Post-op, labor, fractures, chronic, trigeminal, phantom
• For antiemetic effects
• Improved blood flow

Contraindications

• Pacemakers (Relative)
• Epilepsy
• Over uterus in pregnancy
• Over anterior trans-cervical area

90

Electrotherapy

ES Treatment Parameters:

Transcutaneous Electrical Nerve Stim (TENS) Used for pain (Acute & Chronic)

• Using Gate Control Theory - Uses endogenous Opiate Theory

Parameters:

• Monophasic pulsatile current or biphasic pulsatile current
• Wave forms can be spiked, rectangular or sinewave
• Place over nerve roots or trigger points
• Because pulsed, no net polarity change

91

Electrotherapy

ES Treatment Parameters:

Iontophoresis

• Administer meds transcutaneously
• Uses DC Stim (Opposites attract / Same repulse)
• Use same polarity as drug to drive into skin

https://www.researchgate.net/figure/Reverse-iontophoresis-principle-Cl-chloride-Na-sodium_fig3_24230871

92

Electrotherapy

ES Treatment Parameters:

Iontophoresis

• Administer meds transcutaneously
• Uses DC Stim (Opposites attract / Same repulse)
• Use same polarity as drug to drive into skin

https://www.facebook.com/LBMBdz/posts/dont-panic-positive-is-anode-negative-is-cathode/1267956446642834/

93

Electrotherapy

ES Treatment Parameters:

Iontophoresis

• Administer meds transcutaneously
• Uses DC Stim (Opposites attract / Same repulse)
• Use same polarity as drug to drive into skin

https://www.semanticscholar.org/paper/Electromotive-administration-of-topical-medications-Emmanuel-Jerremiah/613ee42cff855522ea2d79dfdbf2083113b082f0

94

Electrotherapy

ES Treatment Parameters:

Iontophoresis

• Administer meds transcutaneously
• Uses DC Stim (Opposites attract / Same repulse)
• Use same polarity as drug to drive into skin

95

Electrotherapy

ES Treatment Parameters:

Iontophoresis

• Administer meds transcutaneously
• Uses DC Stim (Opposites attract / Same repulse)
• Use same polarity as drug to drive into skin

So….

• If Dexamethasone is negatively charged:
• Under Negative Electrode
• If Hydrocortisone is positively charged:
• Under Negative Electrode
• If Tap Water for Hyperhidrosis:
• Equal time with both Positive and Negative Electrodes
• a

96

Electrotherapy

ES Treatment Parameters:

Iontophoresis Chemistry So….

• Using sterile water the positive node (Cathode) will draw the

negative (Anion) part of serous fluid (OH-)

• Hydroxide (OH-) is hydrophilic forming H302- in Aqueous
• Increasing fluid in the area
• Using sterile water the negative node (Anode) will draw the

positive (Cation) part of serous fluid (H+)

• Hydrogen (H+) is hydrophobic
• Decreasing fluid in the area (Anti-inflammatory)

97

Electrotherapy

ES Treatment Parameters:

Iontophoresis Chemistry So….

• If Dexamethasone is negatively charged:
• Under Negative Electrode
• If Hydrocortisone is positively charged:
• Under Negative Electrode
• If Tap Water for Hyperhidrosis:
• Equal time with both Positive and Negative Electrodes

98

Electrotherapy

ES Treatment Parameters:

Iontophoresis Reactions: Acidic Reaction: Sclerotic – Hardening skin Alkaline Reaction: Sclerotic – Softens skin Buffering: decrease acidic/alkaline reactions Electrolysis: Decomposition of drug with stim Electron Exchange: DC changes electron balance Redox Reaction: Water breakdown with stim into H+ at anode & OH- at cathode 99

Electrotherapy

ES Treatment Parameters:

• Iontophoresis Purpose and Effects:
• Used to introduce medicines locally rather than systemically
• Ion transfer is dependent on time and current flow
• Direct Current can cause Burns and/or ion imbalance

100

Electrotherapy

ES Treatment Parameters:

Iontophoresis Indications:

• Athlete's Foot
• Slow healing wounds
• Plantar warts
• Hyperhidrosis
• Lateral epicondylitis
• Infrapatellar tendonitis
• Plantar Fasciitis

101

Electrotherapy

ES Treatment Parameters:

Iontophoresis Contraindications:

• Contraindications of medicine
• Malignancies
• Disoriented patient
• Gravid uterus
• Anesthetic skin
• Scars
• Metal close to the skin
• Demand-inhibited pacemakers
• Implanted stimulators

102

Electrotherapy

ES Treatment Parameters:

Iontophoresis Precautions:

• Drug Allergies
• Skin reaction
• Local anesthetics may allow burns
• Discomfort from current
• Open wounds
• Edema
• Thick adipose tissue at location

103

Electrotherapy

ES Treatment Parameters:

Iontophoresis Instructions

• Follow Manufacturer’s Guidelines
• Assessment/Skin Inspection/Position patient

comfortably

• Clean Skin
• Apply medical solution to skin or electrode (As per

polarity: Cation to Anode)

• Place on skin with active electrode over desired

treatment area and dispersive electrode remotely

• Connect leads to current generator (if necessary)
• Direct Current is uncomfortable (NEVER Initiate,

terminate or Interrupt the current abruptly)

• Dosage is based on Milliampere-minutes current

density max is 0.5 mA/cm2

• Skin check and document

104

Electrotherapy

ES Treatment Parameters:

Iontophoresis Advantages Iontophoresis Disadvantages Treatment is noninvasive means

• f delivering a drug

Can develop skin reactions at electrode sites Provides means of localized drug delivery Direct current can produce burns Treatment is relatively painless compared to injection Actual drug dosage is difficult to determine Results can be seen quickly Can administer drugs without GI side effects Drugs not degraded in liver Constant level of drug can be maintained

105

Electrotherapy

ES Treatment Parameters:

High-Voltage Pulsed Current (HVPC)

• Twin-Peak, Monophasic Pulsed Current
• Phase duration is set in most machines at 5 – 20

microseconds and a pulse duration between 100-200 microseconds 106

Electrotherapy

ES Treatment Parameters:

High-Voltage Pulsed Current (HVPC)

• One large dispersive pad and 1,2, or 4 active electrodes (+/-)

Effects:

• Wound Healing by increased blood flow
• Increased pressure in tissues to exchange fluids at capillaries
• Increased Muscle strength
• Decreased pain

107

Electrotherapy

ES Treatment Parameters: High-Voltage Pulsed Current (HVPC)

Indications:

• Wound Management
• Muscle Spasm or Pain
• Joint Effusion

Contraindications

• Pacemaker
• Internal Electric Stim Device
• Use over a carotid sinus
• Seizure Disorders
• Phlebitis
• Malignancy
• Pregnancy
• Arrhythmia

108

Electrotherapy

ES Treatment Parameters: High-Voltage Pulsed Current (HVPC)

Parameters: One electrode over the wound with other over health tissue >5 cm away Polarity in reversal mode Leads to 50% treatment in positive/50% of treatment in negative

• (no ion build-up)

Frequency 30-200 pps, Amplitude 1-500V, 10-60 minutes of treatment 109

Electrotherapy

ES Parameters:

NMES PARAMETERS

Goal Pulse Freq Pulse Duration

Amplitude

(Strength) Duty Cycle On/Rest time Ramp Time

Treatment

Time Times per day

Muscle Strength 35-80 pps Note: 1pps = 1 Hz 150-200 microseconds Small Muscles 200-350 microseconds Large Muscles To > 10% of MVIC in injured >50% in uninjured 6-10 sec on 50-20 sec off (5:1 ratio) 2 sec or more 10-20 min Every 2-3 hours Muscle Reeducation 35-50 pps Sufficient to activity To activity-on when exerting effort-off with rest Activity Dependent NA – as tolerated (avoid fatigue) Muscle Spasm Reduction To contraction

To contraction then off/relax to create pumping action

1 sec or more 10-30 min Every 2-3 hours Edema 30 min 2X/day

110

Electrotherapy

ES Parameters:

ES For Pain Control:

Parameter Settings: Pulse Frequency Pulse Duration Amplitude Modulation (Freq or Duration) Treatment Time Mechanism of Action Conventional TENS 100 - 150pps

(1pps = 1hz)

50-80 ms To the production of tingling Use if available Can wear 24 hr/day Gaiting at the spinal cord Low Rate

Acupuncture- like

2 – 10 pps 200 – 300 ms To Visible

contraction

None 20 – 30 min Endorphin Release Burst 10 bursts (usually preset) 100 – 300 ms To Visible

contraction

None 20 - 30 min Endorphin Release

111

Electrotherapy

ES Parameters:

ES for Tissue Healing: Parameter Settings

Parameter settings

Waveform

Polarity Pulse Frequency Pulse Duration Amplitude Treatment Time Tissue Healing Phase:

Inflammatory Infected

High Volt Pulsed Current (HVPC) Negative 60-125 pps Usually preset for 40-100ms Produce a

comfortable

tingling 45-60min Tissue Healing Phase:

Proliferation

Clean Positive

112

Electrotherapy

ES Parameters:

ES for Iontophoresis: Goal Wavefor m Pulse Frequency Pulse Duration Amplitude Polarity Treatment Time Iontophoresis to deliver drug DC NA NA To patient tolerance no greater than 4mA Same as drug ion To produce a total of 40mA-min Positively Charged Drugs: (Driven by Anode) Negatively Charged Drugs: (Driven by Cathode) Lidocaine Hydrocortisone Histamine Lithium Magnesium Zinc Acetate Dexamethasone Salicylate Iodine Chlorine Tap water (Can be either + or -)

113

Electrotherapy

ES TERMS:

Accommodation Threshold for excitability increases (get “use to” stimulation) Alternating Current (AC or biphasic) Ionic movement shifts between positive and negative (no ion build-up) Ampere Measures RATE OF FLOW OF CURRENT Amplitude Magnitude of current (Voltage or Intensity) Anode Positive (+) Electrode - Attracts Negative (-) ions or Anions 114

Electrotherapy

ES TERMS:

Biphasic AC current Types: ‐ Symmetrical: Positive identical to negative phase ‐ Asymmetrical: ‐ Balanced: + Charge is = to - Charge ‐ Unbalanced: Burst A “Burst” of charges delivered at one time Capacitance Insulator that “HOLDS CHARGES” like a short-term battery Cathode Negative (-) Electrode - Attracts + ions

• r Cations

115

Electrotherapy

ES TERMS:

Chronaxie Measure of time to develop muscle contraction at any intensity Conductance Ease of electric movement Current Flow of electrons (Amplitude) Direct Current (DC or galvanic) Ionic movement in one direction (ion build-up) Duration of Stim/Rest On Time / to / Off Time Ratio Ratio changes change fatigue Duty Cycle On Time as related to whole treatment: 66% is on for 2/3 of treatment 116

Electrotherapy

ES TERMS:

Impedance Resistance to current flow Frequency Rate of pulses per second (also called rate) High-Volt >150V with short pulse duration – INTERMITTENT and DEEP PENETRATION - Used for Wound Care & PAIN Low-Volt <15V Used for muscle stim Ohm’s Law Voltage = Current x Resistance (V = IR) 117

Electrotherapy

ES TERMS:

Ramp Rate of increase in current strength or amplitude Resistance Resist current flow Rheobase Minimal current to create an ACTION POTENTIAL Volt Measure of Electrical Power 118

Name:_____________________________________ Ultrasound Supervision Treatment Log

Diagnosis Goals of Treatment Parameters and Settings Supervisor Signature 1.

Right Proximal Bicipital Tendonitis Tissue heating/Pain control/Edema

2.

Right Lateral Epicondylitis Pain/Edema

3.

Left carpal tunnel Edema control

4.

Left hand pain due to

• steoarthritis

Pain control

5.

Left adhesive capsulitis Tissue heating/Pain control/edema reduction

119

Name:_____________________________________ Electrotherapy Supervision Treatment Log

Diagnosis Goals of Treatment Parameters and Settings Supervisor Signature 1.

Right medial epicondylitis Pain control Edema reeducation

2.

Right Bicipital tendonitis (Proximal) Pain Control

3.

Burn on left forearm (palmar side) Tissue Healing Proliferative phase

4.

Muscle reeducation for wrist extension Edema Control

5.

Cervical spine pain Pain Control

120