Exam Prep

Clinical Indications

• wound care

• edema control

• aquatic exercise

• Superficial heating or cooling

Physical properties of water

• solvent

• resistance (viscosity)

• Hydrostatic pressure

• Buoyancy

• Thermodynamics

Solvent

Water is a a solvent since it can dissolve more substances than other liquid

makes it appropriate for cleaning wounds as it will dissolve and remove some contaminants and necrotic tissue

salt is often dissolved in the water to make saline

Resistance and Viscosity

Is the inherent friction present in liquid

provides resistance which occurs against the direction of motion of the body and increases relative to the speed of motion

Paddles and other devices are frequently used in water exercise to increase resistance

Hydrostatic Pressure

is the force that water exerts on the immersed body or body part and impacts the body equally from all directions at a given depth of immersion

(pascal’s law)

Buoyancy

is an upward thrust on the body against gravity

(since the human body is less dense than water it floats)

this helps decrease stress and compression on WBing strutures

Thermodynamics of water: Convection

Occurs with the movement within the water

caused by a mass movement of a larger number of molecules over a large distance

Thermodynamics of water: Conduction

occurs without movement: water touching the skin, caused by individual molecular collision

Thermodynamics of water: radiation

is the exchange of electromagnetic energy between the warmer surface of the body and the cooler surrounding air

Aquatics general: Temperature ranges

78.8-95 F general

78.8 - 82.4 for aerobic

71.6-78.8 for extreme aerobic

Time

aerobics start with max of 20 mins of max immersion (10 mins for people with CDV)

Aquatic Contraindications

• cardia failure/ unstable angina

• lung dysfunction

• PVD

• Hemorrhage risk

• kidney dx

• bleeding

• open wounds

• macerated wounds

• bowel incontinence

• tissue, skin infections

• infections that spread in water

• uncontrolled seizures, severe epilepsy

• confusion, impaired cognition

Aquatic Precautions

• fear of water

• impaired thermal sensation of the immersed area

• drunk

• limited strength, endurance, balance or ROM

• Bladder incontinence

• pregnancy

• poor thermal regulations

• neurologic disorders

• respiratory disorder

• cardiac dysfunction

Adverse effects

• drowning

  the pool should be equip with emergency equipment

• burning, fainting, bleeding

  increase risk due to hypotension when the body is immersed in warm water (watch HTN medications)

• hyponatremia

• infection

• aggravation of edema

• exacerbation of asthma

General Effects of aquatics: Edema

due to the hydrostatic pressure which results in changes in circulation and renal function

requires deep immersion

Cold water may also cause vasoconstriction and reduce vascular permeability

NO HOT WATER

MSK Effects

Get for strengthening

increase oxygen to the muscle and decrease muscle tone

increase in muscle strength

Cardiovascular

Increase venous return

decreases heart rate response with exercise

Respiratory Effects

Decrease Vital capacity

Increase work of breathing due to chest wall compression and increase circulation inn chest cavity

decrease exercise induced asthma (due to the humidity)

Renal Effects

Increase urine production due to increase renal blood flow, increase central blood volume and decrease of ADH hormones

Increase in sodium and potassium excretion

Types of exercise: Buoyancy Assisted

vertical movement from the water

Types of exercise: Buoyancy Supported

Horizontal movement with the vertical movement as the support

types of exercise: Buoyancy Resisted

Against the fluid

Types of exercise: Buoyancy super resisted

Against the fluid with resistance

Cleansing Effects

• Softens material

• exerts pressure

• debriding agent for exudate or necrotic tissue

• antimicrobial or surface additives may be used

Wound care considerations

• immersion (rarely used) vs non-immersion (Pulsed Lavage)

• any additives

• pain, particularly with debridement of burns

• negative pressure wound therapy (vacuum assisted)

Pulsed Lavage Suction

used to clean out, irrigate, and debride wounds via a pressurized, pulsed solution

will not destory granulation tissue

used to reduce contamination, remove debris and promote healing

Negative Pressure Wound Therapy

• helps reduce fluid

• draws the wound borders together

• stimulation of granulation tissue

• reduces chances of infections

Contraindications for NPWT

• necrotic tissue

• untreated osteomyelitis

• malignancy in the wound

• untreated malnutrition

• exposed vessels, nerves or organs

• noenteric and unexplored fistulas

Precautions for NPWT

• anticoagulant therapy

• difficult hemostasis

• confusion or disoriented

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