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

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 50 https://schools.aglasem.com/6205

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

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: Pulsed: - 100% Duty Cycle - 20% Duty Cycle Effects: Pain/Stiffness/Spasm Effects: Pain/Stiffness/Spasm - Stimulation for Repair - Stimulation for Repair - Blood Flow - Blood Flow - Collagen Extensibility - Membrane Permeability - Macrophage Activity Indications: Indications: - Soft Tissue Repair - Soft Tissue Repair - Pain / Contracture - Pain / Scar Tissue - Trigger Points - Plantar Warts Considerations: Considerations: - Moving Sound Head - Stationary Sound Head 55 - 2-4 x size of ERA

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

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 oscillate and pulsate cell activity 58 https://www.sciencedirect.com/science/article/abs/pii/S092422441500179X

Deep Heat Ultrasound – Physics Terms and Parameters Acoustic Streaming: - Eddying of fluids at cell membranes. Change in Stable Cavitation Protein Ultrasound Alerted Cell Synthesis Mechanical Membrane Acoustic Effects Change in Streaming Blood Flow Change in Cell Changed Membrane Micro ‐ massage Collagen Transport 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 1 MHz High Freq = Shallow Low Freq = Deep Intensity Rate of Depth Rate of Depth W/cm2 ( ̊ C/min) ( ̊ C/min) 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 0.34 – 0.40 1.6cm 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 67 11. Documentation

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

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

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

Electrotherapy ES Current: ‐ The Flow of electrons from one electrical node to another. 74 https://www.researchgate.net/figure/Principle-of-glucose-extraction-by-reverse-iontophoresis_fig2_331349052

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 Low Frequency DC (No Frequency) High Cycles/Second Low Cycles/Second Constant ‐ Generally cause ‐ Generally cause ‐ Generally cause chemical neuromuscular change neuromuscular change change Different stimuli create different effects: Ultimately all Electric Stimulation (ES) works by Nerve Depolarization 76 https://accessphysiotherapy.mhmedical.com/content.aspx?bookid=465&sectionid=40195349

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

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

Electrotherapy ES Definitions: Strength-Duration Curve: In General: - Sensory Nerves = LOWER AMPLITUDES + Shorter Duration - Motor Nerves = HIGHER AMPLITUDES + Longer Duration 80 http://www.medicine.mcgill.ca/physio/vlab/other_exps/CAP/S-D.htm

Electrotherapy ES Definitions: Indications: - Muscle Spasm or Pain - Joint Effusion - Muscle Weakness or - Impaired ROM Reeducation - Idiopathic Scoliosis - Neuropathy - Labor Delivery Pain Control - Stress Incontinence - Fracture Healing & Pain - Shoulder Subluxation - Increased Circulation Contraindications: - Pacemaker - Phlebitis - Internal Electric Stim Device - Malignancy - Use over a carotid sinus - Pregnancy - Seizure Disorders - Arrhythmia 81

Electrotherapy ES Parameter Types: Monopolar Technique: - Small Electrode over Target Area - Large Dispersive Electrode Remote - Iontophoresis, edema https://www.medsourceusa.com/neuromuscular-stimulators/3356-ems-2c-pulsed-faradic-stimulator Bipolar Technique: - Two active electrodes over Target Area - Equal in size - Neuromuscular Facilitation, pain https://spinepains.com/electrode-therapy-the-history-and-benefits/ Quadripolar Technique: - Two electrodes from two separate stimulating circuits positioned so currents intersect - Interferential current https://accessphysiotherapy.mhmedical.com/content.aspx?bookid=465&sectionid=40195349 82

Electrotherapy ES Electrode Size Types: Small Electrodes Large Electrodes - Increased Current Density - Decreased Current Density - Increased Impedance - Decreased Impedance - Decreased Current Flow - Increased Current Flow Higher Risk of Tissue Damage 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 84 https://accessphysiotherapy.mhmedical.com/content.aspx?bookid=465&sectionid=40195349

Electrotherapy ES Treatment Parameters: Monophasic or Direct Current: (Galvanic Current) - Constant flow of electrons without interruption - Iontophoresis 85 https://accessphysiotherapy.mhmedical.com/content.aspx?bookid=465&sectionid=40195349

Electrotherapy ES Treatment Parameters: High Voltage Pulsed Current: (HVPC) - Twin-Peak, Monophasic Pulsed Current - Mimics DC without concerns of ionic build-up 86 https://fadavispt.mhmedical.com/content.aspx?bookid=1954&sectionid=146794726

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

Electrotherapy ES Treatment Parameters: Russian Current Indications   Medium frequency AC wave forms Strengthen healthy tissue (athletes) - (50pps – 50-200msec)  Contraindications Used for strengthening over  Over abdominal and pelvis in healthy muscle tissue leading to pregnancy increased contraction   Over hemorrhage Type of NMES and/or FES  Malignancy  Over anterior cervical area  Over electronic implants 88

Electrotherapy ES Treatment Parameters: Neuromuscular Electrical Stim (NMES) NMES and Functional Electric Parameters: Stim (FES) are the same with 20-40pps – on 6-10sec OFF computer assist 50-60sec Avoid fatigue (1:10) ‐ FES to promote function ‐ Treatment Time: 15 – 20 min (i.e. Dorsiflexion assist, swallowing) Used for maintaining ‐ strength (unproven) 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 92 https://www.researchgate.net/figure/Reverse-iontophoresis-principle-Cl-chloride-Na-sodium_fig3_24230871

Electrotherapy ES Treatment Parameters: Iontophoresis - Administer meds transcutaneously - Uses DC Stim (Opposites attract / Same repulse) - Use same polarity as drug to drive into skin 93 https://www.facebook.com/LBMBdz/posts/dont-panic-positive-is-anode-negative-is-cathode/1267956446642834/

Electrotherapy ES Treatment Parameters: Iontophoresis - Administer meds transcutaneously - Uses DC Stim (Opposites attract / Same repulse) - Use same polarity as drug to drive into skin 94 https://www.semanticscholar.org/paper/Electromotive-administration-of-topical-medications-Emmanuel-Jerremiah/613ee42cff855522ea2d79dfdbf2083113b082f0

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