Estim, Ultrasound, PNF, thermal, Massage, Traction

Contraindications for E stim

• Over venous/ arterio- thrombosis

• Pregnancy

• Demand a cardiac pacemaker,

• implanted defibrillator,

• unstable arrhythmia

• Over carotid Sinus

Precautions for E stim

• Cardiac disease

• Impaired sensation or mentation

• Maligency

• Skin Irritation/ open wound

• Iontophorsis

Adverse effects from e stim

• burns

• Skin irritation

• Pain

General therapeutic use for Estim

• muscle strengthening And reeducation

• Pain control

• Edema and inflammation

• Enhancing transdermal drug delivery

• Muscle spasm reduction

• Reducing joint contractures

• Minimizing disuse / atrophy

• Facilitating fracture healing

Capacitance

Is the ability of storing a charge and releasing it when needed. The higher the capacitance the longer before a response and the greater need for a higher amplitude/ and intensified. BODY TISSUE IS 10 x more

Impedance

Is the sum of Resistance and Capacitance and represents total opposition to current flow

• stratum Corneum represents the biggest resistance portion HOWEVER, if wet, sweaty

• Skin, bone and adipose all have high impedance

• nerve and muscle have low impedance

Current flow through tissue

Electric current will take the path of least resistance.

• High water content is the best conductor (bone, fat, tendon, fascia, ligament)

• Low water content

Relationship between temperature and current intensity

For every degree increase in skin temperature, the stimulation current was increased by 0.54 mA

Motor point

The place in a muscle where electrical stimulation will produce the greatest contraction with the least amount of electricity, usually the muscle belly

• when the active electrode, or cathode is over the motor point less current is required to excite the motor axon = muscle contraction

• Alternately stimulation to a non MP requires MORE current intensity which in turn could overly excite the sensory neurons to coney pain

Direct current/ Monophasic

Continuous, unidirectional current also called galvanic current

Can cause Base burns (base, Na+ build up) which is more caustic to the skin than and Acid (Cl-) burn

The cathode (-) pad may be increased in size to attempt to decrease the caustic reaction

Alternating current

Continuous, biphasic, alternating between negative and positive

Typically used for Pain and muscle contractions

Pulsed current

And AC + DC current that periodically ceases for a period of time

• biphasic or bidirectional

  • Symmetrical (and balanced) the most common pulsed used

  • Asymmetrical (and balanced)

  • Asymmetrical and unbalanced

• Monophasic or unidirectional (which stops the current for a period) called “high Volt”

Pulse current features: Phase

directional / polarity, the amount of time you are in that charge

Pulse current features: Pulse Duration

time that is going no mater the direction

• a longer one will stimulated more nerve fibers at the same intensity than a shorter pulse duration

Pulse Current Features: Pulse amplitude

the magnitude of the current os the INTENSITY

Pulse Current feature: Pulse Frequency:

Pulse per second PPS the number of cycles

• muscle twitches occurs less than 30 Hz

• tetanus contractions greater than 30 Hz

Current Modulation

Making it less likely for the brain to predict the pattern of the E stim (neural adaptation) change

Which are referred to Timing Modulations

• intensity

• Frequency

• Duration

• Ramp

• Timing

Polarity types Cathode

(- negative electrode) has the greatest number of electrons- active electrode

Cathode attract these cells

Used for early inflammation stage of healing because it can attract activate neutrophils, lymphocytes, platelets, mast cell, keratinocytes, and fibroblast

Polarity Types Anode

(+ positive electrode_) has the least number of active electrons = dispersive electrode

Anode Attract these cells

Proliferative: Attracts inactive neutrophils, macrophages and epidermal which can be used if necrosis without inflammation is present

Polarity effects

Chemical

• changes in pH

• Vasodilation

• Move opposite changed ion through the tissue Iontophoresis

Attraction of cells in the body

Current Density

The amount of charge per unit area, usually related to the size of the electrode. Density will be greater with a small electrode but also offers more resistance

Electrodes positioning

• the further apart the electrodes the deeper the current flow

• The closer they are more superficial the current flow

• Current density is highest where the electrodes meet the skin

Motor Point

The point in a muscle requiring the least amount of electrical current to contract

Amplitude

Another word for intensity

Galvanotaxis

The ability to attract appropriate callers to the area for healing

Sensory

The nerve type stimulated at a short duration and low amplitude

Placement of the cathode

Active electrode precisely overlies the motor point

Which electrode is closer to the wound for acute healing

Negative

Frequency is near used in estim

Hertz

Monophasic

Continuous unidirectional current

Electrode set up: Bipolar

electrodes same size, same current density

Electrode Set up: Monopolar

large dispersive (positive) and small active (negative) causing the small pad to have greater concentration

Electrode Set Up; Quadripolar

C. : 2 sets of bipolar electrodes (2 channels)

Electrode Placement for IFC

• interferential current uses a crossing pattern (DONT DO THIS ACROSS THE SPINE)

• 2 electrode signals of different frequencies and a Beat current is produced between

Indications for IFC

Acute pain

Chronic Pain

Muscle spasm

Premodulated

Estim with 2 medium frequency currents only needing 2 electrode

Strength Duration curve

• type of nerve determines amount of current (intensity/amplitude and pulse duration) required (threshold) for depolarization

• This relationship between amplitude/ intensity and pulse duration is the specific parameters and their applications regarding therapeutic use of e stim

Sensory High-Rate, Conventional

Waveform: biphasic

Frequency: 100-150 pps

Pulse Duration: 50-80ms

Amplitude: produce a comfortable sensation

Goal of TENS Sensory

Pain control

Mode of Action: Active non nociceptor A-Beta nerves to inhibit the transmission of nociceptive signals of the spinal cord

TENS Motor Low rate Opioid Release

Waveform: biphasic

Frequency: 2-10 pps

Pulse Duration: 100-200 ms, 200-300 ms

Amplitude: produce a small muscle contraction

Burst TENS

Waveform: biphasic

Frequency: preset 10 pps

Pulse Duration: 100-300 ms

Amplitude: produce a small contraction

Mode of Action: stimulate endogenous opioid relesase

TENS Motor Low rate and Burst Tens mode of action

Mode of Action: Active endogenous opioid production

High Volt Pulse Current (HVPC)

Waveform: Monophasic

Frequency: 150-500 pps

Pulse duration: <200 ms

Amplitude: comfortable sensory

Goal of HVPC

Mode of Action: Polarity of the electrode rings in or out of the cell

Goal: To help heal wounds, Infections, and Inflammation

IFC/Pre-modulated

Wavelength: Alternating current

Frequency: 100HZ

Pulse Duration: 1/200-1/500 msec

Amplitude: modulated low frequency of 2 medium frequency 2-4 Hz

Differences between ICF/ Pre modulated

ICF: has a beat frequency within the skin 100Hz

Pro Modulated: Beat frequency crosses in the machine

Both do opioid release, can target deeper tissue without the damage to the superficial structures

Iontophoresis

Wave length: Direct Current

Frequency: NA

Pulsed Duration: NA

Amplitude: to patients tolerance, no greater an 4 mA

Iontophoresis Mode of Action

Polarity of the electrode brings in or out of a desired cell.

Medication delivery

Muscle Strengthen Parameters

Pulsed Frequency: 35-80 pps

Pulse Duration: 125-200 Ms for small muscles, 200-350 Ms For large muscles

Amplitude: Less than 10% of injured muscle and <50% of the uninjured muscles

On: Off time: 6-10 sec on, 50-120 off (1:5 ratio)

Ramp time: at least 2 secs

Muscle reeducation protocol

Pulsed Frequency: 35-50 pps

Pulse Duration: 125-200 Ms for small muscles, 200-350 Ms For large muscles

Amplitude: Sufficient for functional activities

On: Off time: depends on the activity

Ramp time: at least 2 secs

Edema: reduction using a muscle pump, Muscle Spasm Protocol

Pulsed Frequency: 35-50 pps

Pulse Duration: 125-200 Ms for small muscles, 200-350 Ms For large muscles

Amplitude: to visible contraction

On: Off time: 2-5 sec on, 2-5 secs off (equal on:off times)

Ramp time: at least 2 secs

Current Density

Amount of charge per unit, relative to the size of the electrode

small electrode increases the density and resistance

Electrode positioning

Father apart the deeper the current will go

closer will make it go more superficial

current density increases when the electrode meet skin

Electrode set up: Bipolor

Electrodes same size, same amount of current

Electrode set up: Monipolor

a large positive and small negative (greater concentration

Sensory High-Rate, Conventional

Waveform: biphasic

Frequency: 100-150 pps

Pulse Duration: 50-80ms

Amplitude: produce a comfortable sensation

Goal of TENS Sensory

Pain control

Mode of Action: Active non nociceptor A-Beta nerves to inhibit the transmission of nociceptive signals of the spinal cord

TENS Motor Low rate Opioid Release

Waveform: biphasic

Frequency: 2-10 pps

Pulse Duration: 100-200 ms, 200-300 ms

Amplitude: produce a small muscle contraction

Tens Motor, Low Rate goal of therapy

Mode of Action: Active endogenous opioid production

Burst TENS

Waveform: biphasic

Frequency: preset 10 pps

Pulse Duration: 100-300 ms

Amplitude: produce a small contraction

Mode of Action: stimulate endogenous opioid relesase

Burst Tens

Mode of Action: Active endogenous opioid production

High Volt Pulse Current (HVPC)

Waveform: Monophasic

Frequency: 150-500 pps

Pulse duration: <200 ms

Amplitude: comfortable sensory

Goal of HVPC

Mode of Action: Polarity of the electrode rings in or out of the cell

Goal: To help heal wounds, Infections, and Inflammation

IFC/Pre-modulated

Wavelength: Alternating current

Frequency: 100HZ

Pulse Duration: 1/200-1/500 msec

Amplitude: modulated low frequency of 2 medium frequency 2-4 Hz

Differences between ICF/ Pre modulated

ICF: has a beat frequency within the skin 100Hz (uses 4 pads)

Pro Modulated: Beat frequency crosses in the machine (uses 2)

Both do opioid release, can target deeper tissue without the damage to the superficial structures

Iontophoresis

Wave length: Direct Current

Frequency: NA

Pulsed Duration: NA

Amplitude: to patients tolerance, no greater an 4 mA

Iontophoresis Mode of Action

Polarity of the electrode brings in or out of a desired cell.

Medication delivery

ultrasound can address

• soft tissue shortening

• Pain control

• Dermal ulcers, surgical skin incision

• Tendon and ligament injuries, fractures

• Carpal tunnel syndrome

Ultrasound

Is a typed of sound, and all forms of sound consist of waves that transmit energy by alternately compressing and rarefying material

Ultrasound contraindications

• cancer

• Pregnancy

• CNS tissue

• Joint cement or plastic

• Pacemaker

• DVTs

• Eyes

• Reproductive organs

Ultrasound precautions

• acute inflammation

• Epiphyseals

• Fractures

• Breast implants

Other Contraindication/ precautions

Areas of active bleeding

Areas of decreased temperature sensation (increased risk for burns)

Areas of decreased circulation

Infection

Over carotid sinus or cervical ganglia

Over the heart

Vascular insufficiency

Attenuated

Decrease in ultrasound intensity as ultrasound travel through the tissue

This effect is greater in denser tissues (more resistance) or acoustic impedance

Least reflecting / best absorbing

Ligament, tendons, fascia, joint capsule and scar tissue

Half depth

Is the depth of tissue at which the ultrasound intensity is ½ the applied intensity

ultrasound terminology: Compression

Created through compression (rarefaction of a wave)

(areas with increased density of molecules as ultrasound waves passed through it

ultrasound terminology: Rarefactions

are areas of decreased density of molecular

What is the mode of energy transfer using ultrasound

Conversion: electrical current produces kinetic (sound) wave through vibration

Physics of ultrasound

Ultrasound is generated by applying a high frequency, alternating electrical current to the crystal in the transducer

Alternating compression and rarefaction

Physics of ultrasound: attenuation

Is tissue frequency specific increases with collegen (protein) content and frequency of US

The higher the frequency the greater the loss or attention

Physics of ultrasound Cavitation

Is the formation, growth and pulsation of gas filled bubbles which expands and compression Due to ultrasonically induced pressure changes in the tissues

Types

Stable

Unstable

Physics of ultrasound Cavitation Types

Cavitations can altered the cell membrane

Types of cavitations

Unstable: can lead to standing waves and tissue damage: usually with high intensity, low frequency

Type of cavitations

Stable: used for therapeutic effects: have been proposed as a mechanism for the non-thermal therapeutic effects

Acoustic streaming

Steady circular flow of cellular fluids by ultrasound

Occurs as the gas bubbles set into oscillation by stable cavitations

The flow is larger in scale than that caused by micro streaming and is thought to alter cellular activity by transporting material to another area

Permeability to calcium and sodium ions: very important to the healing process

Acoustic micro streaming helps healing tissue by

• increase ping masking cell degranulation and release of chemical factor and histamine

• Promote macrophage responsiveness

• Increase rate of protein synthesis by fibroblast and tendocytes

• Low intensity can increase blood flow

Absorptions coefficient

The degree to which a material absorbs ultrasound: are tissue specific with the highest in collegen

Ultrasound Parameters: Frequency

MHz

1 MHz will go 3-5cm deep Which can reach deeper

3 MHz will go 1-3 cm deep: which can be more superficial

The depth in tissues higher in collagen content and areas with increased reflection levels is lower

Ultrasound Parameters: Duty cycles

The proportion of total treatment time the US is active

Continues vs pulsed: decided based on treatment goal, what do you want to accomplish

Ultrasound Parameters: duty cycle types

Pulsed: when high frequency alternating electrical current is delivered to the transducer for only a limited proportion of the treatment time

Non thermal 20% duty cycle pulsed (20% on and 80% off)

Ultrasound Parameters: Continuous

Is being the number of compression rarefactions delivered through out cycles per unit of time, express by cycle per sec and has a 100% duty cycle

Ultrasound Parameters: Intensity

The quantity of energy delivered per unit area

Reported as W/cm2 often refereed to as the spatial average intensity (SAI)

ERA

Is the area of the transducer from which at least 5% of teh peak ultrasound intensity radiates

Essentially the size of the area to which ultrasound is delivered and generally slightly smaller than the outside area of the treatment area

Ultrasound Parameters: Duration

Selected according

• Tx goal

• Size of the era

• Size of the treatment area

• Depth of penetration

5-10 mins for EACH area that is twice the size of the era not the size of the sound head

Chronic ultra sound treatment parameters

Impairment: soft tissue shortening

Effects of ultrasound: thermal

Duty cycle: 100%

Depth of problem:

• if depth problem is in between 1-2cm than ultrasound frequency: 3 MHz with and intensity of 0.5 W/cm2

• If depth problem is between less than 5 cm, ultrasound frequency play 1 MHz with an intensity of 1.5-2.0 W/cm2

Duration: 5-10 mins2 times ERA

Acute ultrasound parameters

Impairment: Delayed tissue healing, prolonged inflammation

Effects of ultrasound: Non thermal

Duty cycle: 20%

Depth of problem:

• if depth problem is in between 1-2cm than ultrasound frequency: 3 MHz with and intensity of 0.5 - 1.00 W/cm2

• If depth problem is between less than 5 cm, ultrasound frequency play 1 MHz with an intensity of 0.5- 1.00 W/cm2

Duration: 5-10 mins2 times ERA

Rule of ERA

Can’t go greater than 4x the ERA

Ultra sound coupling agents

Typically used to exclude air between the patient and the sound head

Apply the gel to the skin prior treatment

MAKE SURE THE US HEAD IS IN CONTACT WITH THE GEL AND SKIN BEFORE YOU TURN IT ON

Over a wound you would use a hydrogel sheet or semipermeable dressing

Therapeutic Effects of ultrasound Thermal

• soft tissue shortening from immobility, inactivity, or scarring, spasm

• Pain control via stimulation to the cutaneous thermal receptor increases soft tissue extensibaility and changes in the nervous conduction

• Healing of chronic wounds bring circulation to the area

• Carpal tunnel