PTRS 705 MIDTERM STUDY GUIDE
PHYSICAL AGENTS TOPICS
ACOUSTIC SPECTRUM VS. ELECTROMAGNETIC SPECTRUM
 Acoustic spectrum includes: ultrasound and extracorporeal shock wave therapy
 Electromagnetic (visible light) spectrum: RED/LONG λ/LOW FREQUENCY ------------- VIOLET/SHORT λ/HIGH
FREQUENCY
 Characteristics of both spectrums:
 Their effect is produced when sufficient intense electrical or chemical forces are applied to a material
 Arndt-Schultz Principle = no reactions or changes can occur in the body tissues if the amount of energy
absorbed is insufficient to stimulate the absorbing tissues
 Radiation = energy traveling through space in multiple forms
 When radiations come in contact with various biological tissues, the velocity and direction of travel
are altered within the various types of tissues
CONCEPTS OF REFLECTION, REFRACTION, TRANSMISSION, AND ABSORPTION
 Reflection = to bounce off
 Refraction = to change direction
 Transmission = to penetrate
 Absorption = to be absorbed
CHARACTERISTICS OF WAVELENGTH
 Wavelength = distance from peak to peak
 All various types of radiations in the electromagnetic spectrum have a specific wavelength & frequency of vibration
that separates one region from another
 The longest wavelengths tend to have the greatest depths of penetration regardless of their frequencies
 Frequency = number of oscillations in one second (Hertz, Hz)
 Velocity = wavelength x frequency (~300 million m/s)
 Inverse relationship between energy absorption by a tissue & energy penetration to deeper layers
 Law of Grotthus-Draper = energy that is not absorbed by the superficial tissues will penetrate to deeper tissues
FACTORS AFFECTING PENETRATION
1. Tissue density
2. Tissue absorption rate (Grotthus-Draper)
3. Tissue interface – there is always refraction at each interface
4. Angle of physical agent to treatment area – ex. US head should be perpendicular to surface of body
 Cosine Law = the smaller the angle between the propagating ray & the right angle, the less radiation
reflected and the greater absorbed
5. Distance between the source of radiation and the surface of patient
 Inverse Square Law = the intensity of the radiation striking a particular surface varies inversely with the
square of the distance from the source
ELECTROMAGNETIC RADIATIONS
 Longer λ= greater penetration (heat formation)  INFRARED, DIATHERMY, E-STIM (beyond red)
 Shorter λ= produce chemical effects (healing characteristic)  UV RAYS, IONIZING RADIATION (beyond violet)
 As the density of the transmitting medium increases, the velocity of travel significantly decreases as a result of
refraction, reflection, or absorption by my the molecules in the medium
ACOUSTIC SPECTRUM
 Mechanical vibrations  depend on conduction through molecular collision
 The denser the medium, the greater the velocity
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Acoustic waves travel slower than electromagnetic radiation
Wavelengths of acoustic waves are considerably shorter than electromagnetic radiation  can penetrate deeper
because you can manipulate the frequency
Good for deep penetration because acoustic waves travel well in homogenous tissues (e.g. fat tissue)  US waves
can travel 5-13 cm deep
POMAS
1. Identify the PHASE of healing (inflammation, proliferation, maturation)
2. Decide on an OBJECTIVE (whether or not to address swelling, pain, strength, etc.)
3. Choose a MODALITY
4. Decide on APPLICATOR
5. Decide on SETTINGS
CASCADES OF HEALING
THREE PHASES OF HEALING
1. Inflammatory Phase (3-7 days)
o Main purpose = DEBRIS REMOVAL
o Stimulated due to a hypoxic state in the injured area
o Cellular response
→ Delivery of leukocytes and macrophages and exudate
→ Localize or dispose of injury by-products
→ Protective response
o Vascular reaction
→ Vascular spasm
→ Dilation and stasis
→ 24-36 hrs (clear the agent)
o Chemical mediators
→ Histamine and leucotaxin – increase cell permeability
→ Necrosin – phagocytic activity
o Platelet function
→ When collagen is exposed, platelets attach
o Clot formation
→ Thromboplastin is released by the cell
→ Conversion of prothrombin to thrombin
→ Conversion of fibrinogen to fibrin
→ Clots off the injury within 12 hrs and complete by 48 hrs after injury
→ Symptoms: pain, swelling, redness
2. Proliferative Phase (21-30 days)
o Main purposes = FIBROBLASTIC REPAIR and FILLING THE INJURY
o Begins within hours of the injury
o The hypoxia of inflammation triggers angiogenesis
o As the clot breaks down, granulation tissue will appear – fibroblasts, collagen, and capillaries
o Fibroblasts secrete extracellular matrix and encourage contraction
o Symptoms: pain and tenderness start to decrease, minimal residual swelling
3. Maturation Phase (up to years)
o Main purposes = REMODELING and STRENGTHENING
o Collagen rearrangement – apply stress to assist with aligning the fibers (Wolff’s Law)
o Strength only returns to about 80% original strength
o Symptoms: no pain, may have tenderness with end-range, weakness
 Chronic Inflammation
 Agent is not eliminated
 Leukocytes replaced with macrophages, lymphocytes, and plasma cells (metabolically active by-products)
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 Increased fibrogenesis
 Tissue damage
 NO TIME FRAME
Factors that slow down healing:
 Extent of injury (microtears due to overuse, macrotears due to acute trauma)
 Edema
 Hemorrhage
 Poor circulation
 Tissue separation – body heals fastest if the edges of the wound are approximated (unless it’s a deep
wound)
 Muscle spasm
 Atrophy
 Corticosteroids – stop inflammation
 Infections – increase exudates in interstitium
 Dehydration – need fluid to move waste
 Aging
 Malnutrition
Modality selection based on phase of healing:
 Inflammatory Phase – want to reduce swelling and pain
o FIRST CHOICE: Cryotherapy – ice, cold pack
o Compression
o E-stim – increase blood flow, stimulate contraction
o US – non-thermal US (pulse)  works best in inflammatory phase
o LASER – primarily works on chemical properties
 Proliferative Phase – want to reduce pain, increase ROM/strength
o FIRST CHOICE: Thermotherapy – hot pack
o Diathermy
o E-stim
o Compression
o US
 Maturation Phase – want to focus on ROM/strength
o Any, but deep heating works best (thermal US and diathermy) – add stress to the tissue too
 Chronic Inflammation
o Cryotherapy
o Thermotherapy
o Diathermy
PHYSIOLOGICAL EFFECT OF INFRARED MODALITIES
 Increase or decrease circulation (vasodilation/vasoconstriction)
 Stimulation of cutaneous sensory nerve endings causing analgesic effects
 Enhance the rate of healing – to return to function
TRANSMISSION OF HEAT
 Conduction = by direct contact of body with heat or cold modality (until equilibrium is reached)
 Convection = particles (air or water) move across the body, creating a temperature variation
 Radiation = transfer of heat from a warmer source to a cooler source through a conducting medium such as
infrared lamps transferring heat through air
 Conversion = changing of energy from one form to another
MECHANISMS OF HEAT TRANSFER BY MODALITY
CONDUCTION
CONVECTION
RADIATION
Ice massage
Hot whirlpool
Infrared lamps
CONVERSION
Ultrasound
Cold packs
Hydrocollator
Cold spray
Ice immersion
Contrast baths
Cryo-cuff
Cryokinetics
Paraffin bath
Cold whirlpool
*Fluidotherapy (for CRPS pts.)
LASER
UV light
Diathermy
*Not an infrared modality
INDICATIONS, CONTRAINDICATIONS, EFFECTS OF CRYOTHERAPY
 General info about cryotherapy:
 Greatest benefit in ACUTE injury
 Lowers the temperature in the injured area
 Reduces the metabolic rate
 Promotes vasoconstriction
 Reduces pain, spasms, and spastic conditions
 Decreases local neural activity
 Cryotherapy stages:
1. Cool
2. Burning/Stinging
3. Aching
4. Numb
INDICATIONS
CONTRAINDICATIONS
 Acute, Chronic pain (cold has a longer λ)  Impaired circulation (if you use cryotherapy,
make sure to document pulses)
 Acute swelling
 Peripheral vascular disease
 Myofascial trigger points
 Hypersensitivity to cold
 Muscle guarding, spasms
 Skin anesthesia (loss of sensation)
 Acute muscle/ligament sprain
 *Open wounds or skin conditions
 Acute contusion
 Infections (localization of waste products
 Bursitis
during cold therapy, then when the area
 Tenosynovitis
warms via vasodilatation, the waste
 Tendinitis
products may spread systemically)
 Delayed Onset Muscle Soreness (DOMS)
INDICATIONS, CONTRAINDICATIONS, EFFECTS OF THERMOTHERAPY
 General info about thermotherapy:
 Beneficial for SUBACUTE and CHRONIC conditions
 Raises temperature in the injured area
 Preferred treatment for pain and discomfort
 Promotes vasodilatation
 Increases metabolic rate
 Increases local neural activity
INDICATIONS
CONTRAINDICATIONS
 Subacute, Chronic pain
 Impaired circulation
 Subacute, Chronic inflammatory conditions  *Peripheral vascular disease
 Resolution of swelling/edema removal
 Skin anesthesia (loss of sensation)
 Myofascial trigger points
 *Open wounds or skin conditions
 Muscle guarding, spasms
 Acute musculoskeletal conditions
- Make sure to take extra care with pts. who have a thin
 Subacute muscle/ligament sprain
epidermis
 Subacute contusion
THERAPEUTIC USE OF INFRARED MODALITIES
 REMEMBER: stimulation can only occur if the amount of energy delivered and absorbed is sufficient (ArndtSchultz)
 GOAL: to deliver sufficient energy, in the best form & in the safest way, to stimulate the tissues to perform their
normal function
CPT CODES FOR CRYOTHERAPY AND THERMOTHERAPY
CPT
MODALITY
SERVICE/TIMED
97010
HMP/Cold Pack
N/A
97022
Whirlpool/Fluidotherapy Service – no time limit
97018
Paraffin
Service – no time limit
97034
Contrast Baths
Timed – at least 8 mins
97028
UV light
Service – no time limit
$$$$$$$$
Bundled – not reimbursed
$14
$6
$13
??
DOCUMENTATION OF INFRARED MODALITIES
 When documenting the use of a modality, must include:
1. Type of modality
2. Location of treatment
3. Parameters
4. Response to treatment
5. Treatment goal – related to function
CHARACTERISTICS OF DIATHERMY
 Thermal or non-thermal (chemical) effects
 Depth of penetration deeper than other infrared modalities
 Categorized as shortwave & microwave (not commercially used)
 Can heat a large area - ~12 cm deep
MICROWAVE (MWS)
SHORTWAVE (SWD)
1. Emits electromagnetic energy at a much higher
1. Three specific frequencies & corresponding λ:
frequency  915 MHz & 2450 MHz, 12 cm deep
- 13.56 MHz, 22 m
2. As frequency INCREASES, the penetration of energy
- 27.12 MHz, 11 m (MOST COMMON)
in the tissues DECREASES  provides a more
- 40.68 Mhz, 7 m
shallow tissue heating effect
2. Two models: continuous & pulsed (or hybrid)
3. Generate a stronger ELECTRICAL FIELD
3. Generate a stronger MAGNETIC FIELD
MOST COMMON DIATHERMY FREQUENCY  27.12 MHz (11 m λ)
ELECTROMAGNETIC RESONANCE
 Tuning = occurs when both the biological tissues (pt. circuit) and oscillating generator (device circuit) are oscillating
at the same frequency  always going to be some resistance
 Only with complete resonance can the electromagnetic energy be fully delivered to the tissues (rarely happens)
PHYSIOLOGICAL EFFECTS OF DIATHERMY
 Microwave (MWS)
 Much more localized heating effect than SWD
 Shortwave (SWD)
 Continuous = causes deep heating of soft tissues
 Pulsed = the delivery of radiation is interrupted for the purpose of inducing non-thermal (chemical)
physiological & therapeutic effects
INDICATIONS OF DIATHERMY
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INDICATIONS
Most effective modality for heating skeletal muscle
OA, RA, or traumatic arthritis
Strain or sprain
Acute or chronic bursitis
Traumatic injury to muscle, ligament, or tendon resulting in functional loss
Joint dislocation or subluxation
Treatment for a post surgical functional loss
Adhesive capsulitis
Joint contracture
Wound care
CPT CODE FOR DIATHERMY
CPT
MODALITY
97024 Shortwave/Microwave
SERVICE/TIMED
Service – no time limit
$$$$$$
$4.91
*Numbers to Know
Hydrocollator (heat) 170 degrees F
Hydrocollator (cold) 8 degrees F
COMPARISON OF MODALITIES
 Infrared modalities – based on electromagnetic spectrum
 Cryotherapy – longer λ, deeper penetration
 Thermotherapy
 Diathermy – longer λ than thermotherapy or cryotherapy, greater penetration
 NOTE: Focus on the temperature change needed for tissue change
 Cryotherapy  benefits occur around 57°F
 Thermotherapy  ideal is 38-40°C (above 45°C is dangerous  STOP THE HEAT)
 1° change – increases metabolism (hot packs)
 2-3° change – helps with pain (hot packs or paraffin)
 4° change – vigorous, collagen extension (US or diathermy)
 DEPTH OF PENETRATION INCREASES AS THE TEMPERATURE CHANGE INCREASES
GENERAL TIME FRAMES FOR APPLYING CRYOTHERAPY AND THERMOTHERAPY
 Heat – 20-30 min
 Cold – as long as it takes for pt. to get through the 4 stages (depends on body type); typically 10-20 min
LASER THERAPY
CONCEPTS OF COHERENCE, MONOCHROMACITY, AND COLLIMATION
 Coherence = same wavelength & in phase
 Monochromacity = same color (same as wavelength)
 Collimation = in parallel (minimal divergence)
LASER TYPES
 Main ones used in PT: gas lasers (He:Ne, 632 nm) and diode lasers (GaAS, 904 nm)
 High power  surgical laser produces heat & can cut tissue (>500 W)
 Low power  < 1 mW
LASER CLASSIFICATIONS
 Class I  infrared, GaAs
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Class II  all visible lasers
CLINICAL APPLICATIONS
 Largely UNKNOWN
 Pain (OA, 3/2009) – FDA approved but not clinically tested
 Wound Healing/Scar
 Immunological response
 Connective tissue stimulation (bone)
 Edema management (lymphedema, 11/2006)
(LIGHT) PENETRATION
 Depth of penetration depends on the type of laser (λ)
 HeNe laser absorbed in first 2-5 mm (for carpal tunnel , epicondylitis)  SUPERFICIAL
 GaAs laser absorbed in 1-2 cm  MORE DEPTH
 IR lasers can penetrate up to 13 cm  DEEPER
DOSAGE
 Measure in Joules : 1 J = 1 W/sec
 Energy density  J/cm2  average power
 Pulsed or continuous (at same output) – more energy with continuous
 Depends on:
1. Output of the laser (W)
2. Exposure time (sec)
3. Surface area of the LASER beam (cm2)
 Formula for how long to irradiate an area: TA = (E/P) X A
 TA = treatment time for a given area (sec)
 E = energy in J/cm2
 P = average power of the laser (W)
 A = beam area (cm2)
 ACUTE CONDITIONS  0.05 – 0.5 J/cm2
 CHRONIC CONDITION  0.5 – 3.0 J/cm2
CONTRAINDICATIONS
 Cancer – 1989 paper by FDA showed that tumors could be activated
 Do not shine in eyes
 Pregnancy or children
ULTRASOUND
ULTRASOUND  Inaudible, acoustic vibrations of high frequency that may produce either thermal or nonthermal
physiologic effects (18,000 Hz)
CHARACTERISTICS OF WAVES
 Frequency
 Period
 Amplitude
 Intensity
 Propagation Speed (Velocity)
 **Energy is transmitted through the vibration of molecules – displaced molecules follow the acoustic wave
LONGITUDINAL AND TRANSVERSE WAVES
LONGITUDINAL
TRANSVERSE
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Displacement is along the direction in which the wave 
travels
Areas of high density  compressions
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Areas of low density  rarefactions
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Travel in both solids and liquids
Ultrasound travels as a longitudinal wave in soft tissue
Displacement occurs perpendicular to the direction of
the wave
Travel only in solids
Ultrasound travels as a transverse wave when it
contacts bone
CONCEPTS OF FREQUENCY, PERIOD, AMPLITUE, INTENSITY, VELOCITY
 FREQUENCY
 How many cycles/second (Hz or MHz)
 Therapeutic US 0.75 - 3 MHz
 Frequency and shape of the wave are directly related
 Frequency and depth of penetration are inversely related  i.e. the lower the frequency, the deeper the
penetration
 PERIOD
 Time for one complete cycle
 Measured in seconds or microseconds
 AMPLITUDE
 Magnitude of vibration in a wave
 Gives indication of attenuation
 Decrease in energy intensity by: absorption OR dispersion and scattering
 INTENSITY
 Measure of the rate at which energy is delivered per unit area (W/cm2)
 Not to be confused with power, which is the amount of energy in the beam (W)
 VELOCITY
 Speed at which sound travels through a medium
 Denser and rigid materials demonstrate higher velocity: SOLID  LIQUID  GAS
 Soft tissue = 1540 m/s
 Compact bone = 4000 m/s
 Water = 1540 m/s (same as soft tissue because soft tissue is mainly made up of water)
ACOUSTIC IMPEDENCE  Determined by the product of the density of the material and speed of the sound within it
PIEZOELECTRIC EFFECT
 Definition: when an alternating electrical current generated at the same frequency as the crystal resonance is
passed through the piezoelectric crystal, the crystal will expand and contract or vibrate at the frequency of the
electrical oscillation thus generating ultrasound at a desired frequency
 Direct piezoelectric effect = generation of an electrical voltage across the crystal when it is compressed or
expanded
 Indirect/reverse piezoelectric effect = created when an alternating current moves through the crystal, producing
compression or expansion  TYPE USED TO GENERATE ULTRASOUND AT A DESIRED FREQUENCY
ERA (Effective Radiating Area)  total area of surface of transducer that actually produces the sound wave (~75%)
CHARACTERISTICS OF ULTRASOUND BEAM
 Spread = the entire beam measurement in the far field
 Divergence = measure of one side of beam to central axis in the far field
 Factors affecting divergence:
 Size of soundhead - smaller soundhead  increased divergence
 Frequency - smaller frequency  increased divergence
BNR (Beam Nonuniformity Ratio)
 Definition: ratio of the maximum point intensity to the average intensity across the transducer surface (ERA)
 Importance:
 The lower the BNR, the more uniform the output (less chance of hotspots)
 The speed and patient compliance during application
 The FDA requires that BNR be listed on ultrasound devices
 Allowed = 2:1 – 8:1 (anything above 6:1 or 7:1 significantly increases chance for hotspots)
 With a higher BNR, the pt. has a higher risk of getting injured (tissue damage) if the intensity is higher than
1.0 W/cm2
CONTINUOUS VERSUS PULSED ULTRASOUND
 Continuous = the intensity remains constant ( or 100% pulsed)
 Pulsed = the intensity is periodically interrupted
 Measured by the DUTY CYCLE
 20% pulsed  non-thermal effect
 50% pulsed  some thermal effect
 100% pulsed (continuous)  non-thermal effect if low intensity (0.1-0.5) is used, otherwise it is thermal
DUTY CYCLE EQUATION  (DURATION OF PULSE/PULSE PERIOD) X 100 = DUTY CYCLE (ex. 1 msec/5msec x 100 =
20%)
INTENSITY MEASURES
 Spatial-averaged (SA) intensity = intensity averaged over the area of the transducer (ERA)
 Temporal peak intensity = maximum intensity during the on period with pulsed ultrasound
 Spatial-averaged temporal peak (SATP) intensity = maximum intensity occurring in time of the spatially averaged
intensity (i.e. spatial average during a single pulse)  WHAT IS DOCUMENTED
 Spatial-averaged temporal-averaged (SATA) intensity = average intensity delivered in the ERA during a pulse
****THE OBJECTIVE OF ULTRASOUND****
 To provide the LOWEST INTENSITY of ultrasound energy at the HIGHEST FREQUENCY that will transmit the energy
to a specific tissue and achieve desired therapeutic effect.
PHYSIOLOGICAL EFFECTS, CONTRAINDICATIONS, AND INDICATIONS OF ULTRASOUND
 Thermal effects:
 Increase extensibility of collagen fibers
 Decrease in joint stiffness
 Reduction of muscle spasms
 Modulation of pain
 Increased blood flow
 Mild inflammatory response to reduce chronic edema
 Non-thermal effects:
 Cavitation = expansion and compression of gas-filled bubbles due to pressure changes
 Stable  the bubbles expand & contract in response to regularly repeated pressure changes over
many acoustic cycles (ONLY TYPE OF CAVITATION TO BRING ABOUT THERAPEUTIC BENEFIT)
 Unstable/transient  violent large excursions in bubble volume before implosion & collapse
occurs after only a few cycles (greater rarefaction than compression)
 Microstreaming = unidirectional movement of fluids along the boundaries of cell membranes
 Can produce changes in cell membrane permeability due to high viscous stresses  BAD!!
 If you overstress the cell, it will die
INDICATIONS
CONTRAINDICATIONS
 Soft tissue healing (non-thermal)
 DVTs
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Pitting edema (thermal)
Scar tissue & joint contracture management (thermal)
Chronic inflammation (non-thermal)
Bone healing (non-thermal)
Other treatments - ???
 Plantar wart treatment
 Absorption of calcium deposits
 Assessing stress fracture
 Pain reduction
 Placebo effects
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Decreased circulation (non-thermal probably OK)
Eye
Reproductive organs
Pregnancy
Pacemaker
Malignant tumor (thermal can increase blood supply
to the tumor)
Growth plates (can cause plate to fuse faster)
Plastic implants
Decreased sensation
MECHANISMS TO ACHIEVE EFFECTS
 Thermal effects
 Increase tissues to 40-45°C
 Increase tissues from baseline
 1°  increased metabolism/healing
 2-3°  decreased pain/muscle spasm
 4°  greater collagen extensibility & decreased joint stiffness
 Non-thermal effects
 0.1-0.5 W/cm2; continuous (100%); spatial-averaged temporal-averaged intensity
 1.0 W/cm2; 20% pulsed (duty cycle); temporal average intensity
Temp change per minute = Desired change of treatment Ex. 0.4 degree = 4 degree
------------------------------ ------------------------------------------- ---------1 minute
Duration of treatment
1 minute
x
X= 10 minutes
DIFFERENCE BETWEEN 1 MHz AND 3 MHz
 1 MHz  for deep tissue penetration (of 5 cm)
 3 MHz  for shallow tissue penetration (of 2 cm)
APPLICATION TECHNIQUES
 DIRECT APPLICATION
 Apply gel to skin surface & transducer
 IMMERSION TECHNIQUE
 Use for small or irregular areas
 Use a plastic, ceramic, or rubber basin
 Move transducer parallel to surface at a distance 0.5-1 cm
 Intensity should be increased for adequate heating (up to 50%)
 BLADDER TECHNIQUE
 If immersion is not suitable
 Gel should be added to both sides of the balloon/glove
INDICATIONS AND TECHNIQUE FOR PHONOPHORESIS
 Ultrasound is used to enhance delivery of selected medication into tissue
 Technique:
 Apply medication directly onto surface
 Apply gel for ultrasound treatment
 Can use direct or immersion technique
 Can use pulsed or continuous
 Pulsed  low spatial-averaged temporal peak intensity (decreased inflammation or pain)
 Continuous  to produce inflammatory response
COMBINATIONS OF MODALITIES
 Ultrasound and hot packs
 Additive heating effect
 Creates less dense medium, decreased penetration
 Ultrasound and cold packs
 Cold will increase the density of the tissue and improve thermal effects
 Recent studies have refuted this claim
 Ultrasound and electrical stimulation
 ****Well-documented and commonly used
CPT CODE FOR ULTRASOUND
CPT
SERVICE/TIMED
97035 Timed – at least 8 mins
$$$$$
$11.80/unit
DOCUMENTATION OF ULTRASOUND
 Record the specific parameters
 Frequency
 Spatial-averaged temporal peak intensity
 Pulsed or continuous
 Duty cycle (if pulsed)
 ERA
 Duration of treatment
 Number of treatments/week
 Non-thermal US is beneficial for inflammatory and proliferative phases of healing
 Thermal US is appropriate for the maturation phase
MASSAGE
EFFECTS OF MASSAGE
 PHYSIOLOGICAL
 Type of effects depends on stroke/technique
 Inhibitory/relaxing (slow, long, rotational strokes)  effleurage, petrissage
 Excitatory/stimulating (quick, short strokes)  percussion, friction, vibration, knuckling
 Inhibitory to voluntary mm  deep tendon pressure or stretch (Charlie horse, cramps)
 Reflex
 Stimulation of sensory receptors in the skin & superficial tissues  increase body awareness
 Mechanical
 Stretching, elongating, or mobilizing techniques
 Should perform after reflexive techniques
 REFLEXIVE
 Red flare or streak, arteriole dilation (BAD)
 Effects on capillaries in the skin  this is determined by the amount of pressure
- 1st a white reaction or blanching
- 2nd a red reaction or increase in local circulation (if not a local response, can indicate cellulitis)
**Keep in mind: massage done to only one area does not affect total body blood flow
 Red wheal (welt), release of histamines & prostaglandins (BAD)  should go away within 24 hrs
 Decrease in pain (NORMAL)  gate control vs. opiate
 Changes in chemicals in the blood flow (i.e. bicarbonates)  German studies
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 Increase of lymph flow  lymph system important in tissue nutrition, healing, & immunity by removing
metabolic waste & edema
MECHANICAL
 Deep work can be unpleasant & cause soreness
 On soft tissue
 Stretching tissue, increase in flexibility & length (passive stretch & traction techniques)
 Can break up or prevent fibrotic mm (X-fiber technique)  fibrotic cording in breast cancer
 Can increase muscle health through decreasing metabolic acids (lactic, uric), improving tissue
nutrition & enhancing waste exchange  can aid in ridding fatigue of mm
 Decreases scar tissue
 Effects on pulmonary system  percussion/tapotement strokes can loosen mucous plugs when combined
with postural drainage
 Local capillary dilation via splanchnic autonomic fibers
 Relaxation of voluntary muscle
 Sedation of pain stimuli (gate theory)
 Increase in skin temperature
INDICATIONS
 For edema of venous/lymph
 Garage Theory = if there is edema, always massage the proximal area first (because lymph dumps into
lymph nodes proximal to the edematic area & you need to clear them first)
 Promote wound healing  getting rid of metabolic byproducts
 To decrease/prevent adhesions  fibrotic scar tissue
 Pulmonary congestion
 To relax muscle or whole body
CONTRAINDICATIONS
 Edema from total system failure (i.e. CHF)
 Acute inflammatory edema
 Any area known or with suspected clot (DVT)
 Any site of known or suspected aneurysm
 Tumors (exception in terminal cases, massage can be used for comfort)
 Over open lesions, conditions that spread
 Abnormal abdominal mass
 Non-union fractures
 Graft sites
PRECAUTIONS
 Chronic fatigue syndrome – massage could increase fatigue
 Fracture sites – even ones that have been set
 Osteoporosis
 Hypersensitive to touch
 Diabetes mellitus – decreased sensation
 Complicated pregnancies
 High BP
 Asthma
 Alcoholism
 Psychiatric illness – never know how they will respond to initial touch
 Open lesions on pt.
 Children with shunts (ventriculoperitoneal) – take care with positioning (head elevated)
TERMINOLOGY
 Effleurage = long stroking, gliding movements following length of muscle (origin  insertion)
 Used to apply lubricant
 Begins and ends massage
 Accustoms patient to touch before deeper work
 PT can listen to hands & search for hot spots, edema, tightness, & other types of injury
 Petrissage = kneading, compress & release movements used to lift subcutaneous tissue up & off underlying
structures
 Applied uni or bi-manually with open “C” type position of the hand (no open fingers)
 Breaks up soft tissue tightness
 Friction = small circular strokes with deep pressure done with the thumb; linear strokes done with sides of hand,
finger tips, back of hand, or heel of hand
 Used to loosen/soften tight muscle tissue  breaks up adhesions
 X-fiber, rolling, wringing
 Tapotement = percussive strokes using alternating hands in rapid rhythmic motion
 Practitioners hand should be relaxed
 Tapping = striking with fingertips (on face)
 Hacking = striking with ulnar borders of hand
 Cupping = striking with curved (cupped) hands
 Pinchment = alternate pinching with thumb and index finger (for localized areas)
 Vibration = transmitting trembling motion from PT hands onto tissue
 Use after deep pressure of trigger point  increases circulation into the area
 Used for joints after deep stroking
**Flow of movement:
EFFLEURAGE  PETRISSAGE  FRICTION AND/OR TAPOTEMENT AND/OR VIBRATION  PETRISSAGE 
EFFLEURAGE
COMPONENTS OF MASSAGE
1. Lubricant
2. Draping
3. Positioning
4. Behavior of PT
 Remember to have a relaxed demeanor – puts pt. at ease
 Always be professional – avoid leading with fingertips
 Always inspect the area for skin condition before beginning
 Remember: the first touch should be done with respect, addressing the skin, not invading it
5. Preparation
 Pt. should remove as much clothing as is comfortable – all clothing removed for full body massage
6. Application
 Body mechanics – table height, hands relaxed, move from the hips and knees, knees bent, deep
breathing, avoid hyperextension of thumbs/fingers, do not lock elbows
 **Once beginning the massage, try not to break contact, gauge pressure carefully, never apply
pressure over the spinous processes, try to make transitional movements as smooth as possible
CPT CODES
97124 – Massage
97140 – Manual therapy/Trigger point
INTRODUCTION TO ELECTRICAL STIMULATION
GENERAL INDICATIONS FOR USING E-STIM
 Supplementation of functional activity
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Strengthening of muscle (atrophied muscle)
Reduction of acute pain
Reduction of chronic pain
GENERAL CONTRAINDICATIONS FOR USING E-STIM
 Pts. with an electronic demand-type cardiac pacemaker
 Over the carotid sinus
 Internally (may damage mucosal linings)
 Over the eyes
 Transcranially or in the upper cervical regions in pt. with history of CVA, TIA, or seizure
 Transthoracically (careful of heart)
 Over any area that would have a tendency to hemorrhage
 Over laryngeal or pharyngeal muscles
GENERAL SET-UP FOR E-STIM
 Clip excessive hair
 Use an alcohol prep to remove skin oils
 Apply a coupling agent (like US gel) to the skin under the electrode (unless electrode is pre-gelled)
 Place electrodes in such a way that the motor end plate is between the electrodes
 The motor end plate is generally found at the proximal third of the muscle
 Orient the electrodes in the direction of the muscle fibers
 For Russian e-stim, place the active electrode directly over the motor point
 Electrode placement is CRITICAL: “Electrode placement is probably one of the biggest causes of poor results from
electrotherapy.”
GENERAL INFORMATION ON CURRENT FLOW
 Current flow can be either unidirectional or bidirectional
 Types of current flow:
 Direct
o Unidirectional and continuous
o One second or longer
 Alternating
o Bidirectional
 Pulsatile
o Unidirectional or bidirectional (alternating polarities)
o Interrupted
o Milliseconds or less duration
PHASE- current flow in ONE direction for a finite period of time (i.e. one polarity)
 If phase duration is too short, there will be no action potential
PULSE- the time from the beginning to the end of an electrical event, even if the waveform leaves and returns to the
baseline several times (i.e. can be one or more polarities); may contain one or more phases
 Pulse duration = length of time the electrical flow is “on” (i.e. pulse width)
 Pulse rise time = the time it takes to reach peak intensity (i.e. ramp)
o Rapid rising pulses cause nerve depolarization
o Slow rising pulses cause nerve accommodation and an action potential is not elicited
- Good for muscle re-education with assisted contraction  with ramping, the shock of the current is
reduced, mimicking more of a functional control
CHARACTERISTICS OF WAVEFORMS
 Types of waveforms
 Square
 Sine
 Spike
 Monophasic vs. Biphasic
 Phase refers to the number of current flow switches per pulse
 Monophasic  polarity stays the same
 Biphasic  polarity switches two times
 Polyphasic  polarity switches multiple times
 Symmetrical vs. Asymmetrical
 Refers to the amount of time and amplitude of each phase of the pulse
 Symmetry  same time and amplitude
 Asymmetrical  either the time or the amplitude are different, or both are different
 Balanced vs. Unbalanced
 Refers to the amount of charge being delivered (i.e. the area “under” the waveform)
 Balanced  amount of charge is the same
 Unbalanced  amount of charge is different
FREQUENCY- number of pulses per unit of time
 Measured in pulses per second (pps) or beats per second (bps) for monophasic/pulsatile current (DC); cycles per
second (cps or Hz) for biphasic current (AC)
DUTY CYCLE- ratio of on time/total cycle time
 1:1 – fatigues muscle rapidly
 1:5 – less fatigue
 1:7 – no fatigue (passive muscle exercise)
ELECTRODE PLACEMENT AND SIZE
 Monopolar – one active electrode (DC)
 Bipolar – two active electrodes
 Quadripolar – four active electrodes
 Place the electrodes such that the motor point is between them (or the active electrode is over the motor point for
Russian)
 Electrode spacing:
 Make sure there is at least one “electrode width” between each electrode
 Current density is affected by spacing of the electrodes
o Closer together  more superficial current density
o Farther apart  deeper penetration of current density
 Electrode size:
 A small electrode can still deliver a lot of current to a localized area  will give the greatest effect to the
nerve or motor point (use a larger electrode farther from the treatment area for DC current)
 A large electrode disperses the current over a wider area
TERMS OF ELECTRICTY
 Electrical current = the flow of energy between two points
 Needs a voltage (electromotive force) and a conductor (material/tissue which allows free flow of energy)
 Two modality classifications:
1. Hi Volt – greater than 100-150 V
2. Low Volt – less than 100-150 V  MOST COMMON
 Ampere = the amount of current

AMPLITUDE- the intensity of the current ; Measured in millivolts (mV)
o Associated with the depth of penetration
 The deeper the penetration, the more muscle fiber recruitment possible
 Arndt-Schultz Principle – have to have sufficient stimulation to get the potential to its threshold point
CLINICAL APPLICATION OF ELECTRICITY
 Temperature
 Relationship: an increase in temperature increases resistance to current flow  need to either raise the
intensity of the e-stim to compensate OR put the hot pack on the pt. after completing e-stim treatment
 Applicability: preheating the treatment area may increase the comfort of the treatment, but it also
increases the resistance and the need for higher output intensities
 Length of circuit
 Relationship: greater the cross-sectional area of a path, the less resistance to current flow
 Applicability: nerves of larger diameter are depolarized before nerves of smaller diameter
 Material of the circuit
 Excitable tissues include: nerves, muscle fibers, blood cells, cell membranes
 Non-excitable tissues include: bone, cartilage, tendons, ligaments
CONDUCTION
 Conductors include: muscle, nerve, loose collagen, tendon, ligament
 Insulators include: fat, skin
 Poorest conductor = BONE
 Nerve conducts 6x faster than muscle, but is surrounded by a fat layer and sheath
RESISTANCE (R)
 Definition: relative opposition to movement of charged particles
 Skin thickness, level of hydration, skin cream all affect current flow in our clients
 The gel on the back of the electrode helps to reduce resistance
 Measure is ohms (Ω) with DC or impedence (Z) with AC
 Other factors affecting resistance:
 Material composition
 Length  greater length yields greater resistance
 Temperature  increased temperature = increased resistance
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
For a muscle contraction: lower frequency (20-40 Hz), longer duration (>300 μs)
For a sensory stimulation: higher frequency (80-120 Hz), shorter duration (50-300 μs)
TRICKS WITH AMPLITUDE MODULATION AND FREQUENCY MODULATION
 Accommodation = getting used to a feeling and diverting attention from it  adjust AM or FM to delay it
ELECTRODES
 Cations = positively charged atoms
 Anions = negatively charged atoms
 Cathode = negative terminal, attracts cations
 Negative pole (cathode) has a high concentration of electrons
 Anode = positive terminal , attracts anions
 Positive pole (anode) has a low concentration of electrons
ACTION POTENTIALS AND DEPOLARIZATION
 Each cell membrane has a voltage sensitivity permeability
 The voltage sensitivity permeability determines resting potential (inside = -70 mV, outside = -90 mV)
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Changes in the membrane permeability create an action potential resulting in depolarization
Depolarization normally occurs at the cathode (concentration of negative ions)
Shift in polarity (positive) due to Na+ influx
The cell will repolarize and restore its resting potential (K+ efflux)
Changes at the NMJ  cause the contraction of muscle
TYPES OF MUSCLE CONTRACTIONS
 Described according to the pulse width
 Twitch = 1 pps (low frequency)
 Treppe/summation = 10 pps
 Tetanus = 25-30 pps (most fibers will reach tetany by 50 pps)
 Initial tetany = 25-30 pps
 Mid tetany = 30-40 pps
 Full tetany = >40 pps
 300-600 ms pulse width for all of these
FIBER TYPES
A-alpha
Efferent to muscle (extrafusal) fibers
A-beta
Afferent from discriminative touch, pressure receptors
A-delta
Afferent from pain and temperature receptors (fast pain)
III
C
Afferent from pain receptors and free nerve endings (slow pain)
IV
 Axon myelination and diameter directly affect depolarization by e-stim
o A-alpha fibers are myelinated    C fibers are not myelinated
o Large diameter: A-alpha ↔ A-beta ↔ A-delta ↔ C : small diameter
GENERAL RULES TO REMEMBER FOR MUSCLE CONTRACTION
 Larger fibers have a lower threshold to depolarization from externally applied electrical current
 Large fibers offer less resistance to ion movement and therefore conduct action potentials faster
 Larger fibers will display conduction failure before smaller fibers in the presence of asphyxia/anoxia, compression,
and cold  more sensitive than smaller fibers to mechanical pressures
 Smaller fibers will display conduction failure before larger fibers in the presence of anesthetics or toxins
PHYSIOLOGIC VS. ELECTRICAL INDUCED MUSCLE CONTRACTION
VOLUNTARY
 Asynchronous firing
 Varied motor units: less fatigue
 First, small slow twitch fatigue resistant fibers, then large
 Graded movement depending on load
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ELECTRICAL INDUCED
Synchronous firing
Same motor units respond
Large fast twitch fibers
All or nothing, depending on intensity
FREQUENCY SELECTION FOR DESIRED OUTCOME
 Pain relief = 100 Hz
 Muscle contraction = 50-60 Hz
 Increased circulation (1:1 ratio for on/off time) = 1-50 Hz
 The higher the frequency (Hz) the more quickly the muscle will fatigue
GATE THEORY OF PAIN CONTROL
 Theory: stimulating bigger nerve fibers will override any signals coming from smaller ones through inhibitory
interneurons
 Since bigger nerves transmit impulses faster, they may elicit high frequency activation of the inhibitory
interneurons that “shut down” the firing of pain fibers
 This is good because our big nerve fibers are touch and our small nerve fibers are achy, dull pain

Two ways to close the “gate” on pain:
1. Block pain at the spinal cord level via inhibitory interneurons
2. Change activity at the brainstem level  activate the periaqueductal gray or Nucleus Raphae
IONTOPHORESIS
BASIC PRINCIPLES OF APPLICATION
 Electrical current causes topically applied ions to migrates TOWARDS the oppositely charged electrode and
AWAY FROM the similarly charged electrode
 Knowledge of a drug’s or ion’s polarity is critical for choosing the correct polarity of the electrode needed to drive
the drug into the underlying treatment area
DRUG POLARITY DRUG ELECTRODE
DISPERSIVE PAD
Negative (-)
Black (-) = CATHODE
Red (+) = ANODE
Positive (+)
Red (+) = ANODE
Black (-) = CATHODE
INDICATIONS FOR IONTOPHORESIS
 Frequently used for lateral epicondylitis, Achilles and patellar tendinitis, ITB syndrome, and CTS
 General indications:
 Pain
 Inflammation
 Edema
 Calcium deposits
 Hyperhydrosis
CONTRAINDICATIONS OF IONTOPHORESIS
 Near venous/arterial thrombosis or thrombophlebitis
 Over areas of impaired sensation
 Cardiac pacemakers (or any implant)
IONIC CHARACTERISTICS
 Current type = DC  required to provide polarity for drug “push”
 Cathode: alkaline reaction occurs, NaOH forms
 Anode: acidic reaction occurs, HCl forms
 Some commercial electrodes have built in buffering agents to help control ionic reactions
MEDICATIONS
 Dexamethasone (DSP) is the most commonly used steroid to treat inflammation
 DSP has a (-) polarity and must be placed under the cathode to drive it into the underlying target tissue
 A referral and medication prescription are required (must be specific)
 The simultaneous delivery of two medications under one electrode is popular, but is also controversial
 It is recommended that only one medication be delivered
 Iontophoresis is current limited, meaning if using two drugs at the same time, ionic competition can occur
(if the polarities between the two meds differ)
 Common medications used:
ION
SOURCE
POLARITY
INDICATIONS
%
Acetate
Acetic acid
(-)
Calcium deposits 2.5-5.0
Dexamethasone DexNa2PO3
(-)
Inflammation
0.4
Lidocaine
Lidocaine
(+)
Pain
5
Salicylate
NaSal
(-)
Inflammation
2
Water
(+/-)
Hyperhydrosis
NA
Zinc
ZnO2
(+)
Wounds
NA
FACTORS AFFECTING DRUG DELIVERY TO TARGET TISSUE
 Maximum depth of drug ion penetration has not been established
 Estimated to be 1 cm or less
 Skin thickness
 Thickness of subcutaneous tissues
 Muscle mass
 **Follow-up with treatment that increases circulation
TERMINOLOGY USED IN IONTOPHORESIS
 Current amplitude applied depends on:
 Pt. tolerance
 Polarity of delivery electrode (alkaline reactions more reactive with skin)
 Size of delivery electrode – large can take up to 4.0 mA
 Length of treatment
APPLICATION OF IONTOPHORESIS
 Set-up:
 Clip hair if needed
 Cleanse skin with alcohol wipe
 Apply electrode in monopolar arrangement
 Current type: DC
 Current amplitude: ≤4.0 mA
 Treatment duration: 10-40 min
 Dosage: 40-80 mA•min
 Polarity: delivery electrode and active ion should be the same
 Treatment frequency: 24-48 hr separation
 Total # of treatments: positive results should be obtained within 4-5 treatments
CURRENT PARAMETERS USED IN IONTOPHORESIS
 Any current dosage can be achieved by multiple amplitude-duration combinations
DOSAGE
AMPLITUDE DURATION
40 mA•min
2 mA
20 min
40 mA•min
3 mA
13.5 min
40 mA•min
4 mA
10 min
PRECAUTIONS OF IONTOPHORESIS
 Monitor the pt. closely during treatment, checking for a local or systemic reaction
 Minimize skin irritation
 Size of electrode – current density should not exceed 0.5 mA/cm2 if the cathode is used or 1.0 mA/cm2 if the anode
is used
CHEMICAL BURNS
 Most common problem associated with iontophoresis
 Occur because of the DC current, not the ion used in the drug
 Skin will appear pink and dry, irritated-looking
 Allow skin to heal  do not apply to the same area and change parameters to prevent future burns
 Can minimize the potential for burns by decreasing the current density:
 Increase the size of the electrode
 Decrease the current intensity
 Space the electrodes accordingly
 Change the electrode location between treatments
RUSSIAN ELECTRICAL STIMULATION
OBJECTIVE OF RUSSIAN
 Medium frequency goes deeper into the muscles to give a more intense contraction  Russian is only for muscle
strengthening
 GOAL: create a tetanic contraction
 Similar to NMES usage for muscle strengthening
CHARACTERISTICS OF RUSSIAN
 Type of NMES because the muscle is directly stimulated
 Considered “medium frequency”
 Polyphasic AC waveform (lots of modulation)
 Net physiologic effect:
 Independent of intrinsic number of pulses per burst
o Nerve/muscle membrane  EACH burst of pulses (Russian) is seen as a SINGLE PULSE
o Result = repeated delivery of bursts or beats of pulses induces motor nerve/motor unit
depolarizations and tetanic contractions
 Time modulation of continuous sine or square wave with carrier frequency of 2,500 pps
 Typical “Russian current” has a burst frequency of 50 bursts/second (50 pulses/burst)
 The “burst intervals” make the current intensity more tolerable, decrease tissue impedence, and increase the
number of motor units activated
 Fixed interburst and interpulse intervals
PARAMETERS OF RUSSIAN
 Pulse duration: 50-250 μs; may be sine or square wave
 Intensity: enough for desired muscle contraction without undue discomfort
 Polarity: irrelevant  because it is biphasic
 Current density: avoid too narrow  try to use larger electrodes that are farther apart
APPLICATION OF RUSSIAN
 Inter-electrode distance: not less than diameter of smallest electrode
 Electrode orientation: “line of pull”
 Electrode attachment: good coupling
 Location: electrodes over at least one motor point
 Sample treatment protocol: 10/50/10
 10 seconds on
 50 seconds off
 10 minute treatment session
TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS)
TENS
 Light weight units
 2 channels
 Variety of features depending on the unit
 ****GOLD STANDARD for acute pain management****
ELECTRODE LAYOUT
 Use electrodes of the same size for biphasic/AC or different sizes for monophasic/DC (smaller electrode over
treatment area)
 All electrodes are active so place accordingly:
 Bipolar – two active electrodes
 Quadripolar – four active electrodes; can cross channels (IFC) or have them parallel (NMES)
GATE CONTROL THEORY (discussed previously)
CENTRAL BIASING THEORY
 Stimulation of small fibers (C or pain fibers) for short time periods
 Peripheral sites
 Stimulation of descending neurons
 Closes the gate at the spinal cord level, affecting the transmission of pain
OPIATE PAIN CONTROL THEORY
 Release of enkephalin and endorphins
 Endorphins released from pituitary gland and hypothalamus into the CSF
CONTRAINDICATIONS OF TENS
 Cardiac pacemakers
 History of cardiac arrhythmias
 Phrenic or urinary bladder stimulators
 Deep brain stimulators
 Carotid sinus (scalene triangle)
 Temporal lobe
 Eyes
 Larynx locations
 Malignancy
 Superficial skin lesion
 Pelvic region in pregnant females
 Anxiety
LEVELS OF PAIN INHIBITION
 LEVEL 1 – periphery (subsensory)
 LEVEL 2 – occurs in dorsal horn (sensory)
 LEVEL 3 – involves hormonal system (motor)
 LEVEL 4 – involves brainstem sites and dorsolateral funiculus (noxious)
 LEVEL 5 – involves cortical area (placebo)
LEVEL 1 – SUBSENSORY LEVEL
 Microcurrent Electrical Nerve Stimulators (MENS)
 Can be beneficial for bone healing
 Peak amplitude below 1 mA, too low to stimulate either nerve or muscle
LEVEL 2 – SENSORY LEVEL
 Conventional TENS  most used and most studied (for acute pain)
 At or above the sensory threshold, but below motor threshold
 Mechanisms:
 Direct peripheral block of transmission
 Central inhibition of original gate-control theory
 Should not see a twitch in muscle, just “pins and needles” feeling (i.e. no muscle contraction)
 Indications for Conventional TENS:
 Any painful musculoskeletal condition
 Use with ice or heat
 Post-op management of pain
 Use when muscle contraction increases pain or is contraindicated  except when the pain increases
substantially
 Acute injuries
LEVEL 3 – MOTOR LEVEL
 Low-rate TENS  primarily used for subacute and chronic pain
 Pts. may describe pain as deep and throbbing
 Not as comfortable as sensory stimulation
 Visible muscle contraction
 Response is not immediate, but longer-lasting
 Mechanisms:
 Central inhibition of original gate-control theory
 Opiate Pain Theory (endorphin release)
 Indications for Motor TENS:
 Chronic pain
 Trigger points
 Muscle guarding
 FYI’s:
 Relief from 1-6 hrs
 Can use Conventional TENS first for rapid onset of relief and then apply low-rate Motor TENS
 Recommended to place electrodes in an area remote to pain site, but in same or related myotome
LEVEL 4 – NOXIOUS LEVEL
 Hyperstimulation TENS  seldom used
 Electrodes placed over painful site
 Brief treatment: 30-45 seconds
 Stimulation lasts for 1-6 hrs
 Daily treatments may reduce effectiveness (accommodation)
 Variable parameters
 OBJECTIVE: pt. to perceive stimulant as noxious
 Mechanism:
 Endorphin-mediated (Opiate Pain Theory)  release of endogenous opiates
 Central Biasing Theory
LEVEL 5 – PLACEBO LEVEL
 Well-documented
 Depends on pt.’s belief in the treatment
 Placebo effects are common in all treatments
BIOFEEDBACK
DEFINITION
 Information provided to the pt. about biologic function
 Common biofeedback instruments:
 Plethysmography  measures diameter; changes in volume or air (Rx: ED, respiration, relaxation)
 Electrogoniometry  measures joint angle (Rs: ROM)
 Electromyography  measure neuromuscular activity; MOST COMMON (Rx: stiffness, muscle retraining,
relaxation)
 ULTIMATE GOAL: encourage appropriate motor activity
BENEFITS OF BIOFEEDBACK
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Gives the pt. a lot of good, real-time info but forces the pt. to do the work on their own
Can be employed during functional tasks
Non-invasive
Fits better with the mechanisms of use-dependent plasticity and task-specific training than e-stim or bracing
DRAWBACKS OF BIOFEEDBACK
 People can become dependent on feedback  need to “wean” pts. off
 People seem to fall back into their old habits (i.e. poor retention)
 Research doesn’t strongly support it (difficult to quantify because of its subjectivity)
GAIN
 Definition: ratio of input to output
 High gain: 1x ↔ 10x ↔ 100x : Low gain
 Directly related to sensitivity/inversely related to threshold – if you increase the gain, you increase the sensitivity
(lower threshold); if you decrease the gain, you decrease the sensitivity (higher threshold)
 For severe muscle weakness  INCREASE THE GAIN
 For eliciting a bigger contraction or encouraging a maximal contraction  DECREASE THE GAIN
FREQUENCY
 Definition: how often activity is measured
 For minimal muscle activity  INCREASE THE SAMPLING FREQUENCY (to pick up any twitches)
 For muscle spasms  DECREASE THE SAMPLING FREQUENCY (to facilitate relaxation)
AREA
 Definition: size of area to be sampled
 To monitor more muscle units  INCREASE THE RECORDING AREA
 Two ways to modify the area of recording:
1. Size of electrodes
2. Distance between electrodes
GENERAL GUIDELINES FOR SUCCESS WITH BIOFEEDBACK
 The pt. needs to be cognitively aware enough to understand the feedback
 The pt. should have some volitional (voluntary) control of the muscle
 Make it functional!
NEUROMUSCULAR ELECTRICAL STIMULATION (NMES)
FACTS ABOUT NMES
 Also called Electrical Muscle Stimulation (EMS)
 Uses a biphasic current
 Purist Theory: the active electrode should be negative (placed distally) and positive electrode placed proximally
POTENTIAL USES FOR NMES
 Muscle dysfunction due to CNS lesion (CVA, spinal cord, TBI)
 Post-operative orthopedic – increase strength
 Disuse atrophy
 Peripheral nerve injuries ??
CONTRAINDICATIONS AND APPLICATION OF NMES
 Same as TENS
NMES OUTCOMES
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Muscle re-education
 Indication: muscle inhibition after surgery or injury (pain automatically causes muscle inhibition)
 Only a factor if neuromuscular mechanisms are intact – a totally deinervated muscle will NOT work by
NMES
 Increase sensory input to the muscle
 OBJECTIVE: to reestablish control
Edema reduction
 Indication: to duplicate regular muscle contractions to increase circulation through venous and lymphatics
(mimic muscle pump)
 Use with ice and elevation for best results
Contracture management
 Indication: increased ROM with prolonged stretching
Muscle strengthening
 Indication: increased force production
 Research: article on NMES for strengthening quadriceps femoris
o NMES makes sense compared with doing no exercises but voluntary exercises appear to be more
effective in most situations
o NMES may only be preferred over voluntary exercise for within-cast muscle training and perhaps
in specific situations where voluntary training does not receive sufficient pt. compliance
STIMULATION OF DEINERVATED MUSCLE
 THEORY: prevention of muscle atrophy, edema and venous stasis, and decreased degeneration
 E-stim has no effect on nerve regeneration
 Some studies suggest that it may interfere with nerve regeneration by traumatizing the deinervated muscle
 Not enough evidence to support the use of e-stim of deinervated muscle!
FUNCTIONAL ELECTRICAL STIMULATION
 Uses multiple channel stimulators to recruit muscles in a sequence to facilitate functional movement through a
microprocessor
 Current devices use surface electrodes  needle electrodes in research
 Clinical applications: CVA and SCI
MICROCURRENT ELECTRICAL STIMULATION
GENERAL INFO ABOUT MICROCURRENT
 Other names: Low Intensity Stimulation (LIS); formerly known as MENS
 Objectives:
 Simulate the “body’s current”
 Aid healing at the cellular level – for bone and wound healing
 Characteristics:
 Very low amplitude currents – most units <1 mA
 No activation of sensory nerve fibers
 Waveforms are rectangular, monophasic with periodic reversal of polarity
MENS/MES/LIS EFFECTS FOR WOUND HEALING
 Increases blood flow to wounded areas
 Increases cell proliferation, migration, and motility
 Increases DNA synthesis (promoted by polarity)
 Increases collagen synthesis
 Increases growth factor receptor levels
 Enhances electrical potential gradients of stimulated cells
MENS/MES/LIS EFFECTS FOR CHRONIC PAIN
 Approved by the FDA for “the symptomatic relief of chronic intractable pain and as an adjunctive treatment in the
management of post-surgical traumatic pain problems”
 No evidence for the measureable effectiveness of MENS (or any other electrotherapy) below sensory threshold to
decrease pain
INDICATIONS FOR LOW INTENSITY STIMULATION
 Wounds, such as skin ulcers
 Fractures – humerus, tibia, clavicle, radius, ulna, femur, fibula, MTs, MCs
 Healing post-surgical spinal fusion – Capacitive Coupling
 ***Bone healing
 Can be implanted or external
 Used when healing is delayed – 90 days w/o progress on serial x-ray (HCFA Medicare criteria) or 1 cm gap
or less on x-ray (CIGNA)
 Pts use for extended multiple daily periods
 Care is prescribed and monitored by physician – not by PT
HIGH VOLTAGE PULSED CURRENT (HVPC)
HVPC CHARACTERISTICS
 Twin-peaked, monophasic, pulsed current, DC
 High electromotive force (voltage): 150-500 V
 HVPC pulse duration = phase duration of both spikes: 100-200 μs, fixed duration
 Short stimulation periods: interpulse time is approx. 50x as long as stimulation time
 Interval between waves (one wave is twin-peaked) can be adjusted  i.e. pulse interval from one twin-spike to the
next twin-spike
 As the time decreases and spikes overlap, stronger stimulation is perceived
 Acid reaction under anode and alkaline reaction under cathode
 Output polarity constant during stimulation
 Pulse frequency: 1-200 pps
 Tissue impedance – HV encounters less capacitance; therefore, less impedance and more comfortable
INDICATIONS FOR HVPC
 Pain
 Edema
 Muscle weakness
 Wound management – GOLD STANDARD
CONTRAINDICATIONS OF HVPC
 Over neoplastic regions
 Heavy scarring
 Thick adipose tissue
 Extreme edema
 Osteomyelitis - has to be resolved prior to use because HVPC will mask it (with granulation tissue)
 Anterior cervical area
 Transthoracic region
 Transcranial area
 Pregnancy (over lumbar and abdomen)
 Hemorrhagic area
 Electronic implants
PHYSIOLOGIC EFFECTS OF HVPC
 Increased circulation
 Pain therapy
 Possibly via gate-control theory or by reducing spasm
 Muscle weakness  research shows its ineffective
 Dermal wounds
 Promotes healing by increasing “current of injury”, maintenance of polarity (GOLD STANDARD)
 Reduces soft-tissue edema
 Muscle pumping – increased with greater contraction strength and lower frequencies
 Studies suggest acutely “post-histamine microvessel leakiness” is reduced – retards edema formation
(cathode over injury site)
 Muscle spasm (similar to low-rate TENS)
PARAMETERS FOR VARIOUS HVPC USES
 ***Dermal wound therapy
 Polarity: anode at/near site (clean dermal wound should be negatively polarized)
 Frequency: arbitrary 30-200 pps
 Mode: continuous
 Amplitude: arbitrary 1-500 V, submotor
 Duration: arbitrary 10-60 min
 Pain therapy
 Frequency: arbitrary 1-200 pps
 Mode: continuous
 Amplitude: arbitrary 1-500 V
 Duration: arbitrary 10-20 min
 Edema/Spasm/Weakness
 Produce a tetanic muscle contraction
 Frequency: arbitrary 30-60 pps
 Mode: pulsed, on/off 1:5 or 1:3
 Amplitude: arbitrary 1-500 V
 Duration: arbitrary 5-30 min
PRECAUTIONS OF HVPC
 Chemical burn
 Excessive electrical density
o Intensity too high for size of the active electrode
o Direct metal contact
INTERFERENTIAL ELECTRICAL STIMULATION (IFC)
INTERFERENTIAL EFFECTS
 Physiologic effects:
 Set to depolarize peripheral sensory or motor fibers
 Therapeutic effects:
 Pain, urinary incontinence, blood flow/edema management, spasm reduction
INTERFERENTIAL CHARACTERISTICS
 Two channel stimulators
 AC current at 2000-5000 Hz
 Medium frequency decreases impendence at skin
 Deeper current flow
 Crossing quadripolar set-up:



 Currents from one electrode “interfere with” current from the other, resulting in “interference current”
with beat frequency equal to the difference between the two channels
 Each channel has its own frequency
 Example: Channel 1 = 3050, Channel 2 = 3000  BEAT FREQUENCY = 50
Beat frequency should be selected to correspond to the desired effect over the treatment area
 Pain = 80-150 bps
 Edema = 1-10 bps (muscle pump)
 Muscle rehab/strengthening = 20-50 bps
Premodulated IF estim = beat frequency and summation of currents occurs inside the machine (is a homogenous
medium vs. body tissues)
Methods of delivery:
1. Bipolar: 2 electrodes, 2 medium frequency currents (1 channel)  oval shaped field
2. Quadripolar (crossing): 4 electrodes, 2 unmodulated medium frequency sine currents (2 channels)
 Interference at level of treatment area
 “4 leaf clover” shaped field
3. Dual (not crossing), bipolar: 4 electrodes, 2 unmodulated medium frequency sine currents (2 channels)
 Interference area is much smaller
 Anecdotal decreased spasm
4. Quadripolar with vector scan: enlarge field
 Current amplitude of 1 circuit varies 50-100% of max, other circuit fixed at one amplitude
 Creates vector scan (field rotates)  circular shaped field of interferential current
INTERFERENTIAL DOSAGE
 Modes of delivery
 Constant  preset beat frequency or set by user
 Sweep  preset beat frequency range
 Carrier frequency preset by manufacturer
 Electrode placement – cover desired treatment area
 If doing IFC for pain, painful area should be located within the 4 electrodes
 If doing IFC for motor response, motor point should be located within the 4 electrodes
OVERVIEW OF E-STIM: WHEN TO USE WHAT
FOR STRENGTHENING:
 (1) NMES
 (2) IFC – quad set up (large muscle belly) or pre-mod (smaller/focused strengthening)
 (3) HVPC
 Russian  best to use for athletes strengthening (exaggerated, intense); AC, pulsed, burst
FOR PAIN (AND CREATING A MUSCLE CONTRACTION):
 Acute: Conventional TENS (AC)
 Acute: IFC (quad set up for large, pre-mod for smaller)
 Acute: HVPC
 GOAL FOR ACUTE = initiate gate-control theory
 Chronic: low-rate (motor) TENS or noxious TENS
 Chronic: HVPC
 Chronic: NMES
 GOAL FOR CHRONIC = fatigue muscle
FOR EDEMA:
 HVPC – pulsed DC
 NMES – AC, biphasic


IFC – interference
Ionto (steroid) – DC
FOR BONE HEALING:
 Micro – GOLD STANDARD  DC or AC
 Pulsed US
Wound Healing
Characteristics of Arterial and Venous Insufficiency Ulcers
Arterial Ulcers
Venous Ulcers
Location
Lower 1/3 of leg, toes, web spaces (distal toes, dorsal
foot, lateral malleolus)
Proximal to the medial malleolus
Appearance
Smooth edges, well defined; lack granulation tissue;
tend to be deep
Irregular shape; shallow
Pain
Severe
Mild to moderate
Pedal Pulses
Diminished or absent
Normal
Edema
Normal
Increased
Skin Temperature
Decreased
Normal
Tissue Changes
Thin and shiny; hair loss; yellow nails
Flaking, dry skin; brownish
discoloration
Miscellaneous
Leg elevation increases pain
Leg elevation lessens pain
The Wagner Ulcer Grade Classification Scale
Commonly used as an assessment instruction for the evaluation of diabetic foot ulcers
Grade
No open lesion but may possess pre-ulcerative lesions; healed ulcers; presence of bony deformity
0
Superficial ulcer not involving subcutaneous tissue
1
Deep ulcer with penetration through the subcutaneous tissue; potentially exposing bone, tendon, ligament, or
2
joint capsule
Deep ulcer with osteitis, abscess or osteomyelitis
3
Gangrene of digit
4
Gangrene of foot requiring disarticulation
5
Pressure Ulcer Staging
 Stage I
o An observable pressure related alteration of intact skin whose indicators as compared to an adjacent or
opposite area on the body may include changes in skin color, skin temperature, skin stiffness, or
sensation
 Stage II
o A partial-thickness skin loss that involves the epidermis and/or dermis. The ulcer is superficial and
presents clinically as an abrasion, a blister or a shallow crater.
 Stage III
o A full-thickness skin loss that involves damage or necrosis of subcutaneous tissue that may extend down
to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without
undermining adjacent tissue.
 Stage IV
o
A full-thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or
supporting structures (e.g. tendon, joint capsule)
Bony Prominences Associated with Pressure Injuries
Supine
Prone
Occiput
Forehead
Anterior portion of
Spine of the scapula
acromion process
Inferior angle of scapula
Anterior head of humerus
Vertebral spinous processes
Medial epicondyle of
humerus
Posterior iliac crest
Sacrum
Coccyx
Heel
Sternum
Side-lying
Ears
Lateral portion of acromion
process
Lateral head of humerus
Lateral epicondyle of
humerus
ASIS
Greater trochanter
Patella
Dorsum of foot
Head of fibula
Lateral malleolus
Medial malleolus
Sitting (chair)
Spine of the scapula
Vertebral spinous processes
Ischial tuberosities
Types of Dressings:
Hydrocolloids
 Consist of gel-forming polymers with a strong film or foam adhesive backing. Hydrocolloids absorb exudate
by swelling into a gel-like mass. The dressing does not attach to the actual wound itself and is instead anchored
to intact skin surrounding the wound.
 Advantages
o Provides a moist environment for wound healing
o Enables autolytic debridement
o Offers protection from microbial contamination
o Provides moderate absorption
o Does not requires a secondary dressing
o Provides a waterproof surface
 Disadvantages
o May traumatize surrounding intact skin upon removal
o May tend to roll in areas of excessive friction
o Cannot be used on infected wounds
Hydrogels
 Indications
o Hydrogels are commonly used on superficial and partial-thickness wounds (e.g. abrasions, blisters,
pressure ulcers) that have minimal drainage. Rather than absorb drainage, hydrogels are moisture
retentive.
 Advantages
o Provides a moist environment for wound healing
o Enables autolytic debridement
o May reduce pressure and diminish pain
o Can be used as a coupling agent for ultrasound
o Minimally adheres to wound
 Disadvantages
o Potential for dressings to dehydrate
o Cannot be used on wounds with significant drainage
o Typically requires a secondary dressing
Foam Dressings
 The dressings are hydrophilic at the wound contact surface and are hydrophobic on the outer surface. The
dressings allow exudates to be absorbed into the foam through the hydrophilic layer. .
 Indications
o
Used to provide protection over partial and full-thickness wounds with varying levels of exudate. They
can also be used as secondary dressings over amorphous hydrogels.
 Advantages
o Provides a moist environment for wound healing
o Available in adhesive and non-adhesive forms
o Provides prophylactic protection and cushioning
o Encourages autolytic debridement
o Provides moderate absorption
 Disadvantages
o May tend to roll in areas of excessive friction
o Adhesive form may traumatize periwound area upon removal
o Lack of transparency makes inspection of wound difficult
Transparent Film
 Film dressings are thin membranes. The dressings are permeable to vapor and oxygen, but are mostly
impermeable to bacteria and water.
 Indications
o Useful for superficial wounds (scalds, abrasions, lacerations) or partial-thickness wounds with minimal
drainage
 Advantages
o Provides a moist environment for wound healing
o Enables autolytic debridement
o Allows visualization of the wound
o Resistant to shearing and frictional forces
o Cost effective over time
 Disadvantages
o Excessive accumulation of exudates can result in periwound maceration
o Adhesive may traumatize periwound area upon removal
o Cannot be used on infected wounds
Gauze
 Indications
o Commonly used on infected or non-infected wounds of any size. The dressings can be used for wet-towet, wet-to-moist, or wet-to-dry debridement
 Advantages
o Readily available, cost effective dressings
o Can be used alone or in combo with other dressings or topical agents
o Can modify number of layers to accommodate for changing wound status
o Can be used on infected or uninfected wounds
 Disadvantages
o Has a tendency to adhere to wound bed
o Highly permeable and therefore requires frequent dressing changes (prolonged use decreases cost
effectiveness)
o Increased infection rate compared to occlusive dressings
Alginates
o Extracted from seaweed. Alginates are highly permeable and non-occlusive. As a result, they require a
secondary dressing.
o Indications
o Alginates are typically used on partial and full-thickness draining wounds such as pressure wounds or
venous insufficiency ulcers. Alginates are often used on infected wounds due to the likelihood of
excessive drainage
o Advantages
o High absorptive capacity
o Enables autolytic debridement
o Offers protection from microbial contamination
o Can be used on infected or uninfected wounds
o Non-adhering to wound
o
Disadvantages
o May require frequent dressing changes based on level of exudate
o Requires a secondary dressing
o Cannot be used on wounds with an exposed tendon, joint capsule, or bone
Wound Classification: Red-Yellow-Black System
Color
Wound description
Red
Pink granulation tissue
Yellow
Moist yellow slough
Black
Black, thick eschar firmly adhered
Goals
Protect wound; maintain moist
environment
Remove exudate and debris; absorb
drainage
Debride necrotic tissue
Selective Debridement
o Involves removing only nonviable tissues from a wound. Selective debridement is most often performed by
sharp debridement, enzymatic debridement, and autolytic debridement.
o Sharp Debridement
o Requires use of scalpel, scissors, and/or forceps to selectively remove devitalized tissues, foreign
materials or debris from a wound. Sharp debridement is most often used for wounds with large amounts
of thick, adherent, necrotic tissue; however, it is also used in the presence of cellulitis or sepsis. Sharp
debridement is the most expedient form of removing necrotic tissue. PTs are permitted to perform sharp
debridement in the majority of states.
o Enzymatic Debridement
o Refers to the topical application of enzymes to the surface of necrotic tissue. Enzymatic debridement
can be used on infected and non-infected wounds with necrotic tissue. This type of debridement may be
used in wounds that have not responded to autolytic debridement or in conjunction with other
debridement techniques. Enzymatic debridement can be slow to establish a clean wound bed and should
be discontinued after removal of devitalized tissues in order to avoid damage.
o Autolytic Debridement
o Refers to using the body’s own mechanisms to remove nonviable tissue. Common methods of autolytic
debridement include transparent films, hydrocolloids, hydrogels, and alginates. Autolytic debridement
results in a moist wound environment that permits rehydration of the necrotic tissue and eschar and
allows enzymes to digest the nonviable tissue. Autolytic debridement can be used with any amount of
necrotic tissue and is non-invasive and pain free. Patients and caregivers can be instructed to perform
autolytic debridement with relative ease; however, this type of debridement requires a longer period of
time for overall wound healing to occur. Autolytic debridement should not be performed on infected
wounds.
Non-selective Debridement
o Involves removing both viable and nonviable tissues from a wound. Non-selective debridement is often termed
‘mechanical’ and is most commonly performed by wet-to-dry dressings, wound irrigation, and hydrotherapy
(whirlpool).
o Wet-to-dry Dressings
o The application of a moistened gauze dressing placed in an area of necrotic tissue. The dressing is then
allowed to dry completely and is later removed along with the necrotic tissue that has adhered to the
gauze. Wet-to-dry dressings are most often used to debride wounds with moderate amounts of exudate
and necrotic tissue. This type of debridement should be used sparingly on wounds with both necrotic
and viable tissue since granulation tissue will be traumatized in the process. Removal of dry dressings
from granulation tissue may cause bleeding and be extremely painful.
o Wound Irrigation
o Removes necrotic tissue from the wound bed using pressurized fluid. Pulsatile lavage is an example of
wound irrigation that uses a pressured stream of irrigation solution. This type of debridement is most
desirable for wounds that are infected or have loose debris. Moist devices permit varying pressure
settings and provide suction for removal of the exudate and debris.
o
Hydrotherapy
o Most commonly employed using a whirlpool tank with agitation directed toward a wound that requires
debridement. This process results in the softening and loosening of adherent necrotic tissue. PTs must
be aware of the side effects of hydrotherapy such as dependent positioning of the lower extremities,
systemic effects such as a drop in bp, and maceration of surrounding skin.
Wound Terminology
o Abrasion: a wound that occurs from the scraping away of the surface layers of the skin, often as a result of
trauma
o Contusion: an injury in which the skin is not broken. The injury is characterized by pain, swelling, and
discoloration
o Hematoma: a swelling or mass of blood localized in an organ, space or tissue, usually caused by a break in a
blood vessel.
o Laceration: a wound or irregular tear of tissues that is often associated with trauma
o Penetrating wound: a wound that enters into the interior of an organ or cavity.
o Puncture: a wound that is made by a sharp pointed instrument or object by penetrating through the skin into
underlying tissues.
o Ulcer: a lesion on the surface of the skin or the surface of a mucous membrane, produced by the sloughing of
inflammatory, necrotic tissue.
Factors Influencing Wound Healing
o Age: decreased metabolism in older adults tends to decrease overall rate of wound healing
o Illness: compromised medical status such as cardiovascular disease may significantly delay healing. This often
results secondary to diminished oxygen and nutrients at the cellular level.
o Infection: an infected wound will impact essential activity associated with wound healing including fibroblast
activity, collagen synthesis, and phagocytosis.
o Lifestyle: regular physical activity results in increased circulation that enhances wound healing. Lifestyle
choices such as smoking negatively impacts wound healing by limiting the blood’s oxygen carrying capacity.
o Medications: Steroids, anti-inflammatory drugs, heparin, antineoplastic agents, and oral contraceptives.
Undesirable physiologic effects include delayed collagen synthesis, reduced blood supply, and decreased tensile
strength of connective tissues.
Exudate Classifications
o Serous: Presents as clear, light color with a thin, watery consistency. Serous exudate is considered to be normal
in a healthy healing wound.
o Sanguineous: Presents as red with a thin, watery consistency. Sanguineous exudate appears to be red due to the
presence of blood or may be brown if allowed to dehydrate. This type of exudate may be indicative of new
blood vessel growth or the disruption of blood vessels.
o Serosanguineous: Presents as light red or pink color with a thin, watery consistency. Serosanguineous exudate
can be normal in a healthy healing wound.
o Seropurulent: Presents as opaque, yellow or tan in color with a thin, watery consistency. Seropurulent exudate
may be an early warning sign of an impending infection.
o Purulent: Presents as yellow or green color with a thick, viscous consistency. Purulent exudate is generally an
indicator of wound infection.