NPTE Modalities and contraindications

Thermal modalities: increases

• cardiac output

• vasodilation

• Heart rate

• respiratory rate

• metabolic rate

Thermal modalities: decreases

• Muscle activity

• Blood pressure

• Blood to internal organs

• Blood flow to resting muscle

• Stroke volume

Cryotherapy: increases

• joint stiffness

• pain threshold

• muscle activation → shivering

Cryotherapy: decreases

• Collagen extensibility

• Blood flow

• Capillary permeability

• Local metabolism

• Spasticity → time with cold → 15-20 min

• Nerve conduction velocity → time with cold → 15-20 min

Temperature Settings: Hot

• Treatment temp: stored at 158-167 degrees Fahrenheit

• Treatment time: 20-30 minutes

• 6-8 layers of toweling

• hot pack peaks heat in first 5 minutes

  • have to check for burns in first 5 minutes

Temperature settings: cold

• Treatment temp: stored at 25 degrees Fahrenheit

• Treatment time: 10-20 minutes

• Can be applied every 1-2 hours

• Stages of cold (CBAAN)

  • Intense Cold

  • Burning

  • Aching

  • Analgesic

  • Numb

Superficial thermotherapy contraindications

• MC TIBIA

• Over an area of Malignancy

• Over an area of Compromised Circulation

• Thrombophlebitis

• Impaired sensation or mentation

• Bleeding or hemorrhage

• Infrared irradiation of the eyes

• Arterial disease

superficial cryotherapy contraindications

• Cold intolerance

  • cold hypersensitivity

  • cryoglobulinemia- can cause clotting/ ischemia

  • paroxysmal cold hemoglobinuria

  • raynaud phenomenon

• Over- regenerating peripheral nerves

• Circulatory compromise

ESTIM: Muscle Strengthening parameters

• Pulse frequency: 35-80 pps

• Pulse duration: 125-200 microseconds small m., 200-350 microseconds for large m.

• Amplitude: >10% of MVIC in injured, >50% MVIC in uninjured

• On: Off times and ratio: 6-10 sec on, 50-120 sec off, ratio of 1:5 initially

  • May reduce the off time with repeated treatment

• Ramp time: at least 2 seconds

• Treatment time: 10-20 minutes to produce 10-20 reps

• Times per day: Every 2-3 hours when awake

ESTIM: Muscle Re-education parameters

• Pulse frequency: 35-50 pps

• Pulse duration: 125-200 microseconds of small m., 200-350 microseconds for large m.

• Amplitude: Sufficient for functional activity (FES)

• On:Off times and ratio: Depends on functional activity

• Ramp time: At least 2 seconds

• Treatment time: Depends on functional activity

• Times per day: during Tx session

ESTIM: Muscle spasm reduction parameters

• Pulse frequency: 35-50 pps

• Pulse duration: 125-200 microseconds for small m., 200-350 microseconds for large m.

• Amplitude: to visible contraction

• On: Off times and ratio: 2-5 sec on, 2-5 sec off; = on:off times

• Ramp time: at least 1 second

• Treatment time: 10-30 min

• Times per day: every 2-3 hours until spasm relieved

ESTIM: Edema reduction using muscle pump parameters

• Pulse frequency: 35-50 pps

• Pulse duration: 125-200 microseconds for small m., 200-350 microseconds for large m.

• Amplitude: to visible contraction

• On: Off times and ratio: 2-5 sec on, 2-5 sec off; = on:off times

• Ramp time: at least 1 second

• Treatment time: 30 minutes

• Times per day: twice a day

Increasing patient comfort

• Ramp time: increase

• Pulse duration: decrease duration to decrease discomfort

• Electrode size and quality: increase size and stickiness

• Pulse frequency: increase

• On:Off time: increase off time

Electrical currents contraindications

• Pacemaker

• Unstable arrhythmias

• Carotid sinus

• Thrombosis or thrombophlebitis

• Near pregnant uterus

High-Voltage Pulsed Galvanic Current (HVPC): Negative

• Used to promote the healing of an inflamed or infected wound

• Electrode placed in (saline-soaked gauze) or around the wound area

• Waveform: HVPC

• Polarity: negative

• Pulse Frequency: 100-105 pps (think 100)

• Pulse Duration: Usually present for HVPC at 100 microseconds

• Amplitude: to comfortable tingling

• Treatment time: 45-60 minutes

High-Voltage Pulsed Galvanic Current (HVPC): Positive

• Positive electrode: used to promote healing of the wounds without inflammation

• Electrode is placed in (Saline soaked gauze) or around the wound area

• Waveform: HVPC

• Polarity: Positive

• Pulse Frequency: 100-105 pps (think 100)

• Pulse Duration: Usually present for HVPC at 100 microseconds

• Amplitude: to comfortable tingling

• Treatment time: 45-60 minutes

Iontophoresis: negative ions and what they are used for

• Hyperhidrosis → Water → neutral → Rx: tap water

• Scars → Iodine → (-) → Rx: Iodine

• Analgesic → Salicylate → (-) → Rx:Sodium salicylate

• Calcium deposits (Calcific tendonitis) → Rx: Acetate → (-) → Rx: Acetic acid

• MSK inflammation → Dexamethasone → (-) → Rx: Dexamethasone phosphate

• Think ISAD

Iontophoresis: positive ions and what they are used for

• Dermal Ulcers → Zinc → (+) → Zinc Oxide

• Analgesic → Lidocaine/ Xylocaine → (+) → Lidocaine/ Xylocaine

• Fungal Infections → Copper → (+) → Copper sulfate

• Edema reduction → Hyaluronidase → (+) → Wydase

• Muscle spasm → Calcium/ Magnesium → (+) → Calcium chloride/ Magnesium sulfate

Transcutaneous Electrical Nerve Stim (TENS): Acute pain (high rate)

• Type: Sensory stim

• Waveform: mono or biphasic pulsed

• Pulse frequency: 100 pps

• Pulse duration: 50-100 microseconds

• Amplitude: comfortable tingling

• Tx Duration: 20-30 min or during activities

Transcutaneous Electrical Nerve Stim (TENS): Acupuncture like (low rate)

• Type: Motor stimulation

• Waveform: Mono or biphasic pulsed

• Pulse frequency: <10 pps

• Pulse duration: >150 microseconds

• Amplitude: visible twitch

• Tx Duration: 20-45 min

Transcutaneous Electrical Nerve Stim (TENS): Brief intense

• Type: Motor stimulation

• Waveform: Mono or biphasic pulsed

• Pulse frequency: 100 pps

• Pulse duration: >150 microseconds

• Amplitude: strong muscle twitch

• Tx Duration: <15

Transcutaneous Electrical Nerve Stim (TENS): Noxious

• Type: Hyperstimulation

• Waveform: DC or monophasic

• Pulse frequency: High: 100 pps, Low: 1-5 pps

• Pulse duration: >250 microseconds up to 1 sec

• Amplitude: Highest tolerance/ painful stim

• Tx Duration: 30-60 sec per area

ultrasound characteristics

• Intensity- amount of energy delivered per unit area (W/cm2)

  • dependent on Tx goal

• Frequency- cycles per second (Hz,1 or 3 MHz)

  • 1- deep

  • 3- superficial

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

  • Pulsed or continuous

    • continuous → 100%, pulsed anything else

Ultrasound decision making

• Non-thermal → acute/ inflammatory phase, has a duty cycle, .5-1 W/cm2

• Thermal → chronic phase, is continuous,.5 W/cm2 (3Mhz), 1.5-2 W/cm2 (1Mhz)

• 5-10 min/ 2x ERA → size of sound head has to be ½ of the treatment area

Ultrasound Contraindications

• Malignancy

• Pacemaker

• Eyes

• Organs of reproduction or pregnancy

• Joint cement or plastic

• Central nervous system tissue

• Thrombophlebitis

Ultrasound- Hot spot

• Intensity/ depth too much

  • move sound head, 1.5 inches per second

  • add more gel

  • decrease intensity

  • change from 1 to 3 Mhz

  • Make sure Tx area is right size

  • Changed to pulsed ultrasound

EMG Biofeedback- initial parameters

• Sensitivity

  • The treatment for muscle relaxation requires low sensitivity

  • The treatment for muscle re-education requires high sensitivity

• Electrodes Placement

  • Closely placed- for muscle relaxation

  • Far apart- for muscle re-education

• Progress biofeedback = reverse parameters

  • sensitivity increases, electrodes far for relaxation

  • sensitivity decreases, electrodes close for facilitation

Lumbar traction

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

• Prone for posterior disc herniation (Extension DP)

• Supine: increase the intervertebral space of

  • L5-S1= 45-60 degrees of hip flexion

  • L3-L4= 75-90 degrees hip flexion

Cervical and Lumbar Traction Parameters

• Cervical

  • Joint distraction- 20-29 lbs (max)/ 7% BW

  • Disc protrusion/ muscle spasms/ elongation: 11-15 lbs

• Lumbar

  • Joint distraction- 50 lbs/ 50% BW

  • Disc protrusion/ muscle spasm/elongation: 25% BW

Mechanical Traction contraindication

• Joint hypermobility or instability

• Immobilization

• Peripheralization of s/s with traction

• Acute injury or inflammation

• Uncontrolled hypertension

Changes with Pregnancy

• Weight gain: 25-35lbs essential for baby nourishment

• MSK: postural changes → FWD head, kyphosis, increased lordosis, anterior pelvic tilt

  • postural stress continues even postpartum d/t lifting and carrying of baby

  • Tx: Postural education, stretching of tight muscles, and strengthening of weaker ones, pelvic stabilization exercises, pelvic tilts

• Blood pressure is low in first and second trimester and increases in 3rd trimester (both SBP and DBP), CO and Blood volume also increase

  • Supine lying can cause compression of inferior vena cava (after month 4). Decreases cardiac output and may cause supine hypotensive crisis

• Resting HR increases by 10-20 BPM

• Left Side Lying is considered the best, as it decreases compression of inferior vena cava, maxes out CO and decreases GERD as internal organs are relaxed and improves maternal and fetal circulation

Preeclampsia- Pregnancy

• Pregnancy-induced acute hypertension after the 20th week of gestation

• Increases in protein in urine, hyperreflexia, edema, headache, sudden weight gain seen

• A blood pressure reading more than 140/90 mmHg, second abnormal blood pressure reading four hours after the first confirms the Dx

• It is an Emergency

Pregnancy- contraindications to exercise

• Hemodynamically significant heart disease

• Restrictive lung disease

• Incompetent cervix: early dilation of the cervix before full term

• Vaginal bleeding, especially second or third trimester

• Placenta previa after 26 weeks gestation; placenta is located on the uterus position in which it may detach before the baby is delivered

• Preeclampsia or pregnancy-induced hypertension

• Rupture of membranes: loss of amniotic fluid before that onset of labor

• Premature labor: beginning before the 37th week of pregnancy

• Maternal type1 diabetes

• severe anemia

Tx: Diastasis Recti

• Dx: curl up with scaps off floor, > 2cm/ fingers = + diastasis rect

• 1-2 cm: no bracing, pelvic tilts, head lifts

• > 2 cm: abdominal bracing and head lifts → progress bracing/ headlifts/ PPT

• > 4cm: abdominal bracing and breathing exercises

• >6 cm: refer out

• Tx: Head lift → head lift w/ pelvic tilts

  • Perform all abdominal contractions w/ an exhalation to minimize intra-abdominal pressure