12. Modalities

heat application increases

cardiac output

vasodilation

heart rate

respiratory rate

metabolic rate

heat application decreases

muscle activity

blood pressure

blood to internal organs

blood flow to resting muscle

stroke volume

cold application increases

joint stiffness

pain threshold

muscle activation (short duration cold application)

cold application decreases

collagen extensibility

blood flow (>15min)

capillary permeability

local metabolism

spasticity (Prolonged decreases muscle activity)

nerve conduction velocity

hot pack considerations

6-8 layers (4-6 layers for terry cloth)

20-30 minutes

158-167 degrees

ALWAYS WANT BLANCHING

peaks heat in first 5 min so check skin then

cold pack considerations

25 degrees F

10-20 minutes (for spasticity 15-20 minutes)

can be applied every 1-2 hours

stages of cold

CBAAN

intense cold

burning

aching

analgesic

numb

Superficial thermotherapy: contraindications

Over area of malignancy

Over area of compromised circulation

Thrombophlebitis

Impaired sensation or mentation

Bleeding or hemorrhage

Infrared irradiation of the eyes

Arterial disease

"MC TIBIA is HOT!!"

Superficial cryotherapy: contraindications

Cold intolerance

- Cold hypersensitivity

- Cryoglobulinemia - when proteins pull in the blood

- Paroxysmal cold hemoglobinuria - when hemoglobin is released in the urine

- Raynauds

Over regenerating peripheral nerves

Circulatory compromise

e-stim parameters for muscle strengthening/contractions

pulse frequency: 35-80pps

pulse duration: 125-200us for small muscles, 200-350us for large muscles

amplitude >10% MVIC in injured, >50% MVIC in uninjured

on off time: 6-10sec on, 50-120sec off, ratio 1:5 initially

ramp time: at least 2 sec

treatment time: 10-20 min for 10-20 contractions

times per day : every 2-3 hours awake

e-stim parameters for muscle reeducation

pulse frequency: 35-50pps

pulse duration: 125-200us for small muscles, 200-350us for large muscles

amplitude: sufficient for functional activity

on:off: depends on activity

ramp time: at least 2 sec

treatment time: depends on activity

times per day: NA

e-stim parameters for muscle spasms

pulse frequency: 35-50pps

pulse duration: 125-200us for small muscles, 200-350us for large muscles

amplitude: to visible contraction

on: off: 2-5 sec on, 2-5 sec off; equal on off times

ramp time: at least 1 sec

treatment: 10-30 min

times per day: every 2-3 hours until spasm is relieved

e-stim parameters for edema reduction using muscle pump

pulse frequency: 35-50pps

pulse duration: 125-200us for small muscles, 200-350us for large muscles

amplitude: to visible contraction

on:off: 2-5sec on, 2-5 sec off. equal on off times

ramp time: at least 1 sec

treatment time: 30 min

twice per day

pulse frequency

number of pulses per second

quick tapping, higher frequency = more comfortable

pulse duration

the actual time from the start of a pulse to the end of that pulse

longer pulse duration = more comfortable

whats the initial on off time ratio

1:5

ramp time

longer ramp = more comfortable

MVIC

max voluntary isometric contraction

How to increase patient comfort?

Ramp time - increase

Pulse duration - decrease duration to decrease discomfort (DDDD)

Electrode size and quality - big and sticky

Pulse frequency - increase

On:off time - increase off time

Estim currents: contraindications

PLEASE UNDERSTAND CURRENT THREATENS PREGNANCY

Pacemaker

Unstable arrhythmias

Carotid sinus

Thrombosis or thrombophlebitis

Near pregnant uterus - during no phase of pregnancy

HVPC - high voltage pulsed galvanic current (HVPC)

• Used to treat wounds

• Negative electrode = used to promote healing of the inflamed or infected wounds (think negative = bad so its an infected wound)

  • 100pps

  • 100 duration

  • amplitude - to produce comfortable tingling

  • 45-60min

  • 3-7d/week

• Positive electrode = used to promote healing of the wound without inflammation

  • 100pps

  • 100 duration

  • amplitude - to produce comfortable tingling

  • 45-60min

  • 3-7d/week

• electrodes placed in (saline soaked guaze so buffer) OR around the wound area

tissue healing inflammatory phase/infected treatment

wave form: HVPC

polarity: negative

pulse frequency: 100-105pps

pulse duration: usually preset to around 100us

amplitude: comfortable tingling

treatment time: 45-60 min

tissue healing proliferation phase/clean treatment

waveform: HVPC

polarity: positive

pulse frequency: 100-105pps

pulse duration: usually preset for HVPC at about 100us

amplitude: comfortable tingling

treatment time: 45-60 min

iontophoresis parameters

• measured in mA-min

• dosage = 40-80mA-min

• current amplitude = 1-4mA

• continuous direct current

• polarity should be set to ion solution

• 10-20 minutes

negative polarity for iontophoresis

ISAD

I - iodine → scars

S - salicylate → analgesic

A - acetate → calcium deposits

D - dexamethasone → musculoskeletal inflammation

EVERYTHING ELSE IS + (water can be both +/-)

hyperhydrosis

use tap water iontophoresis

positive polarity for iontophoresis

• zinc → dermal ulcers

• -caine → analgesic

• copper → fungal infections

• -ase → edema reductions

• calcium and magnesium sulface → muscle spasm

TENS for acute pain

type: sensory stim (HIGH RATE TENS; CONVENTIONAL TENS)

wave: biphasic or mono pulsed

pulse frequency: 100pps

pulse duration: 50-100usec

amplitude: comfortable tingling

duration: 20-30 minutes or during activities

TENS for chronic pain

type: motor stim (LOW RATE TENS; ACUPUNCTURE)

wave form: mono phasic or biphasic pulsed

pulse freq: <10pps

pulse duration: >150usec

amplitude: visible twitch

duration: 20-45 min

TENS brief intense

type: motor stim (COUNTER IRRITANT)

wave: monophasic or biphasic wave form

pulse freq: 100pps

pulse duration: >150usec

amp: strong muscle twitch

duration: < 15 min

TENS noxious stim

type: hyperstimulation (TRIGGER POINTS)

wave: DC or monophasic wave form

pulse freq: high: 100pps, low: 1-5pps

pulse duration: >250usec up to 1 sec

amp: highest tolerance/painful stimulus

duration: 30-60sec per area

US characteristics

Intensity :Amount of energy delivered per unit area (W/cm^2)

frequency: Cycles per second Hz, 1MHz or 3MHz

Superficial - 3

Deep - 1

Duty cycle = on time / (on time + off time)

Ultrasound: indirect vs direct coupling

• direct coupling agent (gel, lotion) should be applied to txt area and transducer before power is on; face of transducer is parallel to skin at 90 degree angle

• indirect coupling agent used on small, irregular shaped or unable to tolerate direct pressure from transducer; water immersion = body part of interest is in water and then transducer is parallel to treatment surface at a 0.5-3cm distance away from skin

pulsed or continuous ultrasound

Continuous has thermal effects pulsed does not

Example: 5 seconds on, 20 seconds off >> 5/25 >> 20% so this is a pulsed duty cycle and does not have thermal effects

Pulse is anything that is NOT 100%

ultrasound parameters in relation to acute/chronic injury

acute injury = pulsed (up to 3 weeks)

chronic injury = continuous (> 3 weeks)

ultrasound soft tissue shortening and chronic pain parameters

• thermal

• 100% duty cycle

• depth: 1-2cm → 3MHz frequency → 0.5W/cm^2 intensity

• depth: < or equal to 5cm → 1MHz frequency → 1.5-2.0W/cm^2 intensity

• 5-10min

delayed tissue healing prolonged inflammation US

• non thermal

• 20% or 50% duty cycle

• depth: 1-2cm → 3MHz

• depth: < or equal to 5cm → 1MHz

• 0.5-1.00W/cm^2 intensity

• 5-10 min

Ultrasound contraindication

Malignancy

Pacemaker

Eyes

Organs of reproduction or pregnancy

Joint cement or plastic

CNS tissue

Thrombophlebitis

^^ my poor exhausted old joints cant travel

ultrasound hot spots: ways to alter treatment response

• move sound head continuously 1.5in/second

• add more gel

• decrease intensity

• change frequency to 3MHz

• make sure txt area right size

• change pulsed US to non thermal

EMG biofeedback initial parameters

• muscle relaxation (inhibit; decrease spasm/muscle activity)

  • low sensitivity

  • closely placed

  • LOW AND CLOSE TO RELAX

• muscle re-education (activation; strenghtening; fascilitating; increase tone; address atrophy)

  • high sensitivity

  • electrodes far apart

• ***if pt made progress then for each one (relaxation or re-education) do the opposite for txt

lumbar traction positioning

• Supine position with pillow under knee - for intervertebral joints, facet joints, muscle elongation

• Prone for posterior disc herniation

• Places person in neutral or at least some extension

• Supine: increase intervertebral space of:

  • L5-S1 = 45-60 degrees hip flexion

  • L3-L4 = 75-90 degrees hip flexion

Joint distraction parameters in traction(cervical and lumbar)

• cervical

  • 20-29lbs(max)

  • 7% body weight

• lumbar

  • 50lbs

  • 50% body weight

cervical traction: angle of cervical spine for upper, middle, lower cervical regions

• upper cervical spine (C1-C2) = 0-5 degrees of flexion

• mid-cervical spine (C3-C4) =10-20 degrees of flexion

• lower cervical spine (C5-C7) = 25-35 degrees of flexion

Disc protrusion, muscle spasms, elongation parameters for traction (cervical and lumbar)

cervical - 11-15lb

• *should feel pull at base of skull

lumbar - 25% body weight

• initial treatment place pt in supine, knee extended, and sidebend trunk if it is a foramen issue on one side with 25% BW

Contraindications for traction

Joint hypermobility or instability

Immobilization

Peripheralization of symptoms with traction

Acute injury or inflammation

Uncontrolled hypertension

***H I P I H