Modalities

Systemic and physiological effects of heat application: increases

cardiac output, vasodilation, heart rate, respiratory rate, metabolic rate

Systemic and physiological effects of heat application: decreases

muscle activity, blood pressure, blood to internal organs, blood flow to resting muscle, stroke volume

Systemic and physiological efficts of cold application: increases

joint stiffness, pain threshold, muscle activation

Systemic and physiological effects of cold application: decreases

collagen extensibility, blood flow, capillary permeability, local metabolism, spasticity, nerve conduction velocity

Hot pack temp settings

temp: 158-167 deg F

time: 20-30 min

6-8 towel layers

peak heat in first 5 min

Cold pack temp settings

temp: 25 deg F

time: 10-20 min

can be applied every 1-2 hrs

Stages of cold

CBAAN- 1) intense cold 2) burning 3) aching 4) analgesic 5) numb

Superficial thermotherapy: contraindications

MC TIBIA is fire- malignancy, compromised circulation, thrombophlebitis, impaired sensation or congnition, bleeding or hemorrhage, infrared irradition of the eyes, arterial disease

Superficial cyrotherapy: contraindications

cold intolerance (cold hypersensitivity, cryoglobulinemia, paroxysmal cold hemoglobinuria, Raynaud’s phenomenon), over regenerating peripheral nerves, circulatory compromise

ESTIM parameters: muscle strengthening (pulse frequency, duration, amplitude, on:off time, ramp time, treatment time, times per day)

frequency: 35-80pps

duration: 125-200us for small mm and 200-350us for large mm

amplitude: >10% of MVIC in injuried, >50% MVIC in uninjured

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

ramp: at least 2s

treatment time: 10-20 min

times per day: every 2-3 hrs during wake time

ESTIM parameters: Muscle Reeducation (pulse frequency, duration, amplitude, on:off time, ramp time, treatment time, times per day)

frequency: 35-50pps

duration: 125-200us for small mm and 200-350us for large mm

amplitude: sufficient for functional activity

on:off times: depends on functional activity

ramp time: at least 2 s

treatment time: depends on functional activity

ESTIM parameters: muscle spasm reeducation (pulse frequency, duration, amplitude, on:off times, ramp time, treatment time, times per day)

frequency: 35-50pps

duration: 125-200us for small mm and 200-350 for large mm

amplitude: to visible contraction

on:off times: equal on:off; 2-5s on: 2-5s off

ramp time: at least 1s

treatment time: 10-30 min

times per day: every 2-3 hrs until spasm relieves

ESTIM parameters: edema reduction using muscle pump (pulse frequency, duration,amplitude, on:off times, ramp time, treatment time, times per day)

frequency: 35-50pps

duration: 125-200us for small mm and 200-350 for large mm

amplitude: to visible contraction

on:off times: equal on:off; 2-5s on: 2-5s off

ramp time: at least 1s

treatment time: 30 min

times per day: twice a day

How to increase patient comfort (ramp time, pulse duration, electrode size and quality, pulse frequency, on:off time)

ramp time: inc, pulse duration: dec, electrode size and quality: bigger, sticky, fresh, pulse frequency: inc, on:off time: inc off time

Contraindications for ESTIM

“please understand currents threaten pregnancy”- pacemaker, unstable arrythmias, carotid sinus, thrombosis or thrombophlebitis, near pregnant uterus

negative v positive electrodes HVPC

neg: used to promote healing of the inflamed or infected wounds v pos: used to promote healing of the wounds without inflammation

HVPC parameters: tissue healing: inflammatory phase/ infected (waveform, polarity, pulse frequency, amplitude, treatment time)

waveform: HVPC

polarity: negative

frequency: 100-105 pps

amplitude: produce comfortable tingling

treatment time: 45-60 min

HVPC parameters: tissue healing: proliferation phase/clean (waveform, polarity, pulse frequency, amplitude, treatment time)

waveform: HVPC

polarity: positive

frequency: 100-105 pps

amplitude: to produce comfortable tingling

treatment time: 45-60 min

Iontophoresis: “ISAD” (polarity, indications, ions from medicine, and medicinal sources)

I: iodine, iodine, scars, -

S: salicylate, sodium salicylate, analgesic, -

A: acetate, acetic acid, calcium deposits, -

D: dexamethasone, dexamethasone phosphate, MSK inflammation, -

Iontophoresis: polarity and indications for water, zinc, lidocaine/xylocaine, copper, hyaluronidase, calcium magnesium

All are + polarity, water is neutral (+-)

water- hyperhidrosis

zinc- dermal ulcers

lidocaine/xylocaine- analgesic

copper- fungal infection

hyaluronidase- edema reduction

calcium magnesium- muscle spasm

TENS parameters: acute pain (high rate)- type, pulse freq, duration, amp, tx time

type: sensory stimulation

freq: 100pps

duration: 50-100usec

amp: comfortable tingling

tx time: 20-30min during functional activities

TENS parameters: acupuncture like (low rate)- type, pulse freq, duration, amplitude, tx time

type: motor stimulation

freq: <10pps

duration: >150usec

amp: visible twitch

tx time: 20-45 min

TENS parameters: brief intense- type, pulse freq, duration, amp, tx time

type: motor stimulation

freq: 100pps

duration: >150 usec

amp: strong mm twitch

tx time: <15 min

TENS parameters: noxious- type, freq, duration, amp, tx time

type: hyperstimulation

freq: High: 100pps Low: 1-5pps

duration: >250 usec up to 1s

amp: highest tolerance/ painful stimulus

tx duration: 30-60s per area

EMG biofeedback- initial parameters (high v low sensitivity and close v far apart electrodes)

low sensitivity- tx for mm relaxation

high sensitivity- tx for mm re-education

closely placed- mm relaxation

far apart- mm re-education

US- parameters (intensity, frequency, duty cycle)

intensity: amount of energy delivered per unit area (W/cm2), depends on tx goal

frequency: cycles per second (Hz, 1 or 3MHz)

duty cycle: on time/ (on time and off time), pulsed or continuous

US intensity: acute v chronic

acute: up to 3 wks- pulsed

chronic: >3 wks- continuous

US contraindications

“My poor exhausted old joints can’t travel”- malignancy, pacemaker, eyes, organs of reproduction or near pregnant uterus, joint cement or plastic, CNS tissue, thrombophlebitis

What is US hot spot and how should you address it initially?

burn of periosteum- add coupling agent/ gel, decrease depth, continuous> pulsed, move sound head, larger tx area, dec intensity

When to use supine positioning for lumbar traction.

intervertebral joints, facet joints, muscle elongation

When to use prone positioning for lumbar traction.

posterior disc herniation

How much hip flexion is recommended to increase intervertebral space of L5-S1?

45-60

How much hip flexion is recommended to increase intervertebral space of L3-L4?

75-90

cervical traction parameters: joint distraction

20-29lbs (max) or 7% of BW

cervical tractions parameters: disc protrusion, mm spasms, elongation

11-15 lbs

lumbar traction parameters: joint distraction

50lbs or 50% BW

lumbar traction parameters: disc protrusion, mm spasms, elongation

25% BW

Mechanical traction: contraindications

“HIPH”- joint Hypermobility, Immobilization, Peripheralization of s/s w/ traction, acute Injury or Inflammation, uncontrolled Hypertension