Modalities Flashcards
E-Stim, Ultrasound, Laser, Thermo and Cyrotherapy
1
Q
List the goals and indications for E-Stim
A
- Pain modulation
- decrease muscle spasm
- improve ROM
- muscle re-education
- improve muscle strength/reduce atrophy
- wound healing
- edema reduction
- stimulate denervated muscle
2
Q
List some contraindications for E-Stim
A
- presence of pacemaker or electronic device (insulin pump) in patient
- never over:
- carotid artery
- thrombosis
- eyes
- phrenic nerve
- pelvis or low back of a pregnant woman
- never transcerebrally
- if there is bleeding or an infection
- over malignant tumors
- over pharyngeal or laryngeal muscles
- motor-level stimulation in conditions that prohibt motion
3
Q
List some precautions for E-Stim
A
- cardiac disease
- impaired mental status
- impaired sensation
- in areas of skin irritation or open wounds
- in patients with uncontrolled hypo/hypertension
- bleeding disorders
4
Q
Define polarity
A
net charge of object
cathode = net (-)
anode = net (+)
5
Q
define voltage
A
driving force that move electrons
force of attraction or repulsion (amplitude)
6
Q
define amperage/current
A
rate of flow of electrons
mesaured in milliamps (mA)
7
Q
what is Ohm’s Law?
A
I = V/R
current = voltage/resistance
(more resistance means greater voltage required to push the current through)
8
Q
List some biological sources of resistance to current
A
- skin
- hair
- fascia
- ligaments
- callus
- fat
- bone
- tendon
- scar
9
Q
what are some ways to reduce resistance at the skin?
A
- minimize air-electrode interface
- make sure there are no folds or gaps in the electrodes
- keep electrodes clean
- use electrodes on clean skin, minimize hair, oils, abrasions if possible
10
Q
List the different types of currents
A
- Monophasic
- Biphasic
- Direct current
- Alternating current
- Pulsed current
11
Q
what types of currents are unidirectional? bidirectional?
A
unidirectional = monophasic and direct current
bidirectional = biphasic and alternating current
pulsed can be both
12
Q
What are the unique features of a pulsed current?
A
this type of current will periodically cease for a short time period so it has:
a frequency
a pulse duration
an amplitude
13
Q
how do pulse currents influence the generation of AP differently than direct or alternating currents?
A
pulse currents allow for repolarization to occur (channels closing again) thus they can result in tetanic contractions
Direct and alternating currents do not allow for repolarization (the channels always remain open) thus they result in a single large contraction
14
Q
the higher the current the higher the _______
A
heat
also the greater risk for burns
15
Q
what are the effects of electrode size on stimulation?
A
different sizes result in different current densities
larger electrode = smaller current density/more tolerable
smaller electrode = larger current density/less tolerable
16
Q
what are 2 ways to increase current density?
A
- increase current
- decrease electode size
17
Q
what is the effect of increased current density on skin?
A
skin burn
avoid this by:
- removing resistance
- listen to pt’s perception
- use larger electrodes when possible
- always maintain good contact
- use appropriate coupling agent when appropriate
18
Q
List several electrode configurations
A
- monopolar
- bipolar
- quadripolar
19
Q
describe a monopolar electrode configuration
A
one small electrode over target area, and one large electrode placed over remote area (to complete the current)
method of choice when polarity matters
(wound healing, edema control, iontophoresis)
20
Q
describe a bipolar electrode configuration
A
both electrodes are of similar size and are placed over the target area
current bounces between two pads
used with any waveform except DC
21
Q
List some preferred uses for bipolar electrode configurations
A
- disuse atrophy
- neuromuscular facilitation
- ROM
- spasms
- circulatory disorders
22
Q
describe a quadripolar configuration
A
2 electrodes from 2 separate stimulating currents are positioned so that the individual currents intersect with each other (called IFC)
23
Q
how does the distance between electrodes influence current?
A
it influences the depth and course of current
further apart = deeper the current travels
recommended that the distance be at least one half the diameter of each electrode
24
Q
List some things to keep in mind when placing electrodes for motor stimulation
A
- place on region where the motor nerve is most easily excited
- typically at muscle belly or proximal 1/3 of muscle
- common mistake to place one electrode over the muscle belly and the other over a distal area w/o much muscle
- results in diminished response and increased discomfort
25
List several specific types of ES used for strengthenig
1. NMES (Neuromuscular E-Stim)
2. Russian (Burst Modulation)
3. FES (Functional E-Stim)
* more used to supplement orthotic devices
26
what are the goals for NMES?
1. atrophy treatment/prevention
2. stregthening
3. achieve synchronous firing/recruitment of motor units
27
What is Burst Modulation (Russian)?
variation of alternating current that is interrupted and delivered in short bursts
(AKA medium frequency burst alternating current)
most common form of NMES
28
List the typical parameters for Russian
1. Bipolar electrode placement
2. pulse width/duration = 150-200 µsec
3. pulse frequency = 50-70 pps
4. amplitude = max contraction/tolerance
5. On:Off time = varies dependent on use
* 10 sec on, 50 sec off is common for \>10 reps
6. Ramp = 1-5 secs up/down
7. Trx determination similar to that of TherEx prescription
29
List the parameters that are different in NMES from Russian
1. pulse width/duration = 200-800µsec
2. pulse frequency = 30-100 pps
30
List some generalizations with NMES parameters
1. if you want to continue to increase force output, need to increase amplitude during/between trxs
2. to decrease adapation and optimize strenghting with ES, increase current amplitude as often and as much as tolerated
3. the shorter the off time and longer the on time the greater the chance of fatigue
4. longer on time = greater decrease in force output over time
5. align electrodes parallel to muscle fiber, not transverse
6. use larger electrodes with bigger muscles
31
T/F: NMES has been shown to improve strength and function in patient's status post surgically
TRUE
32
T/F: Russian Current is more often used and more tolerable than NMES pulsed current
FALSE
it is more often used BUT
NMES produces less discomfort
33
what is the goal of FES?
this is a type of NMES in which e-stim is utilized as an alternative or supplement to orthotic devices or braces
34
T/F: the peripheral nerve does not have to be intact for FES to work
FALSE
must have an intact peripheral nerve
35
list 2 common uses for FES
1. shoulder subluxation
2. foot drop
36
List the types of E-Stim used in pain modulation
1. **Interferential Current (IFC)**
2. TENS
1. **Conventional (High Rate) transcutaneous E-Stim**
2. **Acupuncture-like (Low Rate) E-STIM**
3. Brief Intense TENS
4. Burst mode TENS
5. Hyperstimulation (point simulation) TENS
37
how is IFC characterized?
by crossing sinusoidal waves that interfere with one another to generate an amplitude-modulated beat frequency
38
define beat-frequency
(amplitude-modulate)
resultant frequency produced by the two frequencies going into and out of phase
39
describe the parameters for IFC
goal = pain reduction
1. quadripolar electrode setup
2. Wave form = alternating current amplitude modulated beats
3. pulse width/duration = 200-400 µsec
4. frequency = 10-150 pps
5. amplitude = strong but tolerable sensation
6. trx duration = 10-30 min
40
what are the unique effects of IFC treatment
sensory nerve fibers receive a lower amplitude stimulation than the area of tissue affected by vector
thus IFC is said to be more comfortable than equal amplitudes delivered by conventional means
41
List the parameters for High-rate (conventional) TENS
1. wave form = typically asymmetrical biphasic
2. current = continuous, pulsatile, or burst
3. pulse width/duration = 50-100 µsec
4. pulse rate/frequency = 50-80 pps
5. amplitude = comfortable tingling sensation, NO MUSCLE response
6. duration of trx = 10 min to several hours
7. onset of pain relief = relatively fast
8. duration of pain relief = temporary
42
how is the modulation of pain via High-rate TENS different from Low-rate TENS?
high-rate = gate control theory
low-rate = descending pathways release of endogenous opiates
43
List the parameters for Low-rate (acupuncture-like) TENS
1. wave form = typically asymmetrical biphasic
2. current = continous, pulsatile, or burst
3. pulse width/duration = 150-300 µsec
4. pulse rate/frequency = 1-5 pps
5. amplitude = strong, but comfortable rhythmic muscle twitch
6. duration of trx = 20-40 min
7. onset of pain relief = 20-40 min
8. duration of pain relief = long last \>1 hour
44
what is brief intense TENS used for?
used to provide rapid-onset, short term pain relief during painful procedures
(wound debridement, passive stretching, joint mobilizations)
45
List the parameters for brief intense TENS
1. wave form = typically asymmetrical biphasic
2. current = continuous, pulsatile, or burst
3. amplitude = patient's tolerance
4. pulse rate = 80-150 pps
5. pulse duration = 50-250 µsec
6. duration of trx = 15 min
7. onset of pain relief = relatively fast
8. duration of pain relief = temporary (30-60 min)
46
what is burst-mode TENS?
combines characteristics of both high and low rate TENS
stimulation of endogenous opiates, but current is more tolerable to patient than low-rate TENS
47
list the parameters of burst-mode TENS
1. wave form = typically asymmetrical biphasic
2. current = continous, pulsatile, or burst
3. amplitude = comfortable, intermittent paresthesia
4. pulse rate = 50-100 pps, delivered in packets or bursts 1-4 pps
5. pulse duration = 50-200 µsec
6. duration of trx = 20-30 min
7. onset of pain relief = 20-40 min
8. duration of pain relief = long lasting (hours)
48
what is hyperstimulation TENS?
also called point stimulation
noxiously stimulate trigger point or local area of pain such as tendonitis
49
list the parameters for hyperstimulation (point-stimulation) TENS
1. wave form = typically asymmetrical biphasic
2. current = continuous, pulsatile, or burst
3. amplitude = max tolerance (this should be uncomfortable)
4. pulse rate = 1-5 pps
5. pulse duration = 150-300 µsec
6. on/off cycle = 15-30 sec increments
7. duration of trx = generally 15-20 min, but can be longer
8. onset of pain relief = 20-40 min
9. duration of pain relief = long-lasting
50
what is amplitude modulation? what is it used for?
a method of modulating parameters of any type of TENS to prevent adaptation due to constant ES (alter frequency, intensity, or pulse duration by \>10%)
used to improve pt tolerance or limit adaptation
51
List the different types of E-Stim used for wound-healing
1. low-intensity DC (micro-current)
2. high-volt pulsed current (HVPC)
52
describe the general concept behind application of E-Stim in wound healing
intact skin surface is (-) with respect to deeper epidermal layers
injury to skin develops (+) potentials initially and (-) potentials during healing process
applying an electrical current (E-Stim) can draw in or stop cells from migrating to the injury site
53
List the general parameters for E-Stim used during wound-healing
1. current = monophasic
2. amplitude = comfortable tingling sensation, paresthesia, no muscle response
3. pulse rate = 50-200 pps
4. pulse duration = 20-100 µsec
5. mode = continuous
6. duration of trx = 20-60 min
7. current type = HVPC or continous low-volt DC
54
What type of E-Stim is used to trx inflammation
Iontophoresis
55
what is iontophoresis?
application of a continous DC to transport medicinal agents through the skin or mucous membrane for therapeutic purposes
need a prescription to apply medicine
56
list the parameters for Iontophoresis
1. wave form = DC
2. amplitude = max intensity 4-5 mA
3. electrode placement = anode and cathode placement will depend on charge of medicinal agent being utilized
57
What are other uses for E-Stim?
1. decrease muscle spasm
2. edema reduction
3. stimulation for denervated muscles
58
how does E-Stim decrease muscle spasms?
by altering the on/off time
results in muscle fatigue through tetantic contraction sustained for several minutes by continuous mode
59
how does E-Stim reduce edemas?
NMES resulting in stimulation/creation of the muscle pump action to increase lymph and venous flow
60
how can E-Stim impact denervated muscle?
must activate the sarcolemma
this requires a significantly higher amplitude and duration
majority of E-Stim units do not offer this
61
how is the use of E-Stim for denervated muscle controversial?
is it truly beneficial?
one theory = this retards the effects of disuse atrophy and shortens recovery time (good thing)
another theory = interferes with regenerating neuromuscular junction and subsequent re-innervation (thus it traumatizes hypersentive denervated muscles)
62
what are the 2 main components of an ultrasound?
1. Generator
2. Applicator
1. soundhead
2. piezoelectric crystal
63
what is the role of piezoelectric crystal in ultrasound?
expansion and compression of the crystal produces the sound waves
64
why is the beam from the ultrasound not uniform?
the crystal is not perfectly uniform which means it doesn't expand and contract uniformly resulting in nonuniformity of intensity of the beam
65
What does non-uniformity of the crystal make someone more prone to when ultrasound is applied?
Burns
66
define spatial peak intensity
power of beam at highest point of effective radiating area
67
define spatial average intensity
total power across the transducer head usually what is recorded for intensity during trx
68
define Beam non-uniformity ratio
ratio of spatial peak intensity to spatial average intensity
69
What occurs with absorption, refraction, and reflection in regards to ultrasound waves
* Absorption = the sound wave from the ultrasound is absorbed by tissue and transformed into thermal energy
* Refraction = ultrasound signal is deflected from a straight path and the angle of deflection is away from the transducer
* Reflection = ultrasound waves are deflected back towards the transducer
70
How is intensity of ultrasound measured and what does it represent?
* Expressed as W/cm2
* Represents the power of the ultrasonic energy/strength of the ultrasound wave
71
What is attenuation in regards to ultrasound?
reduction of acoustical energy as it passes through soft tissue
72
What tissue has the highest amount of attenuation in the body?
Bone
73
What are the two types of frequency of ultrasound?
3 MHz
1 MHz
74
how deep does 3 MHz penetrate and what area is primarily heating up?
~2.5 cm deep, this leads to greater heat production in superficial layers due to increase in scatter of sound waves in superficial tissues
75
how deep does 1 MHz penetrate and what area is heating up more?
~5 cm deep, heats deep layers due to less scatter in superficial tissue, thus more energy able to penetrate deeper
76
what is meant by duty cycle?
how often the ultrasound is on and off
77
Which duty cycle(s) are considered continuous/thermal which are considered pulsed/non-thermal?
* Continuous/thermal = US is applied at a constant energy level/duty cycle of 100%
* Pulsed/nonthermal = duty cycle range usually 5%-50%
78
List several proposed reasons to use ultrasound
1. Modulation of pain
2. Increase CT extensibility
3. Reduce muscle spasm
4. Increase tissue temperature
5. Increase blood flow
6. Facilitate healing
79
List ultrasound contraindications
1. Impaired circulation
2. Impaired cognitive function
3. Absent sensation
4. Cancer
5. Joint cement
6. Directly over plastic components
7. Over vital areas (brain, eyes, heart, ear, reproductive organs)
8. Pregnancy
80
List ultrasound precautions
1. Acute inflammation
2. Open epiphyseal plate
3. Healing fracture
4. Breast implants
81
What are the proposed impacts of thermal ultrasound?
1. Increased pain threshold
2. Increased collagen extensibility
3. Alteration of NCV
4. Increased enzymatic activity
5. Increased tissue perfusion
82
What should you do if someone complains about a “hot spot” or sudden strong ache with thermal ultrasound?
Reduce intensity or increase trx surface area
83
What are the proposed effects of non-thermal ultrasound can be explained by what 2 theories?
Cavitation theory
Acoustic streaming theory
84
what is the caviation theory for non-thermal ultrasound?
* Cavitation – alternating compression and expansion of small gas bubble in tissue fluids due to the mechanical pressure waves of the acoustic waves
* Stable – gas bubbles resonate w/o tissue damage, may be responsible for diffusional changes in cell membranes
* Unstable – severe collapse of gas bubbles during compression phase of pulsed US which can result in local tissue damage due to high temperatures
85
what is the acoustic streaming theory for non-thermal ultrasound?
* May produce the following to help accelerate tissue healing
* Alterations in cell membrane activity
* Increased cell wall permeability
* Increased intracellular calcium
* Increased macrophage response
* Increased protein synthesis
86
What should you document after using ultrasound?
1. Trx area
2. Patient position
3. Parameters
1. Frequency
2. Mode
3. Duty cycle
4. Intensity
5. Trx time
6. Transducer size
4. Outcome measure
1. Pain
2. Tenderness on palpation
3. Tenderness w/resisted motion
4. ROM
87
What is the difference between low level and high intensity lasers? Which is likely to burn you if you do not keep it moving?
* Low-level lasers = peak power equal or less than 500 mW
* High-intensity lasers = peak power greater than 500 mW
* More likely to burn if you don’t keep it moving
88
What are indications for laser use?
* Weak to moderate research showing laser beneficial in:
1. Carpal tunnel syndrome
2. Reducing pain and muscle spasm in pts w/fibromayalgia
3. Myofascial/trigger point disorders
4. Knee OA
5. RA
6. Migraine HA
7. Myofascial pain syndrome
8. Tennis elbow
89
What are contraindications to laser use?
1. Direct eye exposure
2. Pregnancy
3. Malignancy
4. Following acute injury where hemorrhage is possible or suspected
5. Open growth plates
6. Over the thyroid or other endocrine gland
90
What are the proposed physiological effects of laser?
1. ADP/RNA production within cells = improved mitochondrial function
2. Promotes collagen production – through mRNA production
3. Modulate inflammation – through interleukin and prostaglandin production
4. Inhibit bacterial growth of biological pathogens
5. Promotes vasodilation of microcirculation
6. Increased NCV
91
what are the 3 methods that heat/cold energy is transfered?
conduction
convection
radiation
92
List the goals of heat therapy
1. Decrease pain and stiffness
2. Alleviate muscle spasm
3. Increase ROM and tissue extensibility
4. Improve tissue healing by increasing blood flow
93
List the physiological effects of heat application on the body
1. dilation of arteries and arterioles to increase blood flow
2. increased capillary permeability
3. increased extensibility of collagen tissues
4. increase in metabolism rate
5. increased vasodilation leads to release of vasoactive agents
6. edema
7. reduced joint stiffness
8. decreased firing of muscle spindles and increased firing of GTO fibers reduces alpha motor neuron activity
9. pain inhibition (gate control theory)
94
List the contraindications for heat therapy
1. Acute inflammatory conditions
2. Absent sensation
3. DVT
4. Impaired cognitive function
5. Malignant tumor in area of application
6. Tendency toward hemorrhage
95
List precautions for heat therapy
1. Cardiac insufficiency
2. Edema
3. Decreased sensation
4. Decreased mentation
5. Impaired circulation
6. Impaired thermal regulation
7. Metal in trx area
8. Open wounds
9. Demyelinated nerves
96
Describe the general trx prep for heat and cold therapy
1. Treatment and expected sensations **must** be explained to patient
2. Place patient in position
3. Expose treatment area; drape properly
4. Leave call bell or signaling device with patient to alert PT of any adverse response
5. Check patient frequently especially during initial treatment
6. Dry and inspect skin at conclusion
7. Record response
97
how many towel layers are needed with a moist heat pack?
6-8
hydrocollator covers = 2 layers
98
how is heat transfered during paraffin wax trx?
conduction
99
what areas are typically trx with paraffin wax?
small joints like wrist and hand
100
List the various trx methods utilized during paraffin wax application
1. Glove (dip – wrap) – dip 5 to 6 times; wrap w/plastic than with towel
2. Immersion – suspended in wax
101
List contraindications for paraffin wax
1. Allergic rash
2. Open wounds
3. Recent scars
4. Skin infections
102
List precautions for whirlpool
1. Decreased sensation
2. Decreased cognition
3. Recent skin graft
103
List contraindications for whirlpool use
open wounds
104
List the goals of cold therapy
1. Decrease pain
2. Reduce inflammation or swelling
3. Alleviate muscle spasm
4. Reduce spasticity
5. Management in multiple sclerosis
6. Cyrostretch
105
List the physiologic effects of cold therapy
1. Used in acute trama
2. Decrease muscle spasm
3. Decrease NVC
4. Decreases pain/increase pain threshold
5. Decrease metabolism
6. Increase muscle strength
7. Increases joint stiffness
106
what is blanching due to cold therapy?
occurs in center of contact area due to vasoconstriction of skin capillaries; hyperemia around the edge of contact area in normal tissue due to a decreased rate of oxyhemoglobin dissociation
107
what is cold-induced vasodilation?
vasodilation following prolonged cold exposure (\>15 min). occurs mostly in the hands, feet, and face
108
ID an adverse reaction to cold therapy
* Histamine reaction
* Facial flush, puffiness eyelids, respiratory problems, in severe cases anaphylaxis with syncope
* Cold urticarial = erythema of the skin with wheal formation associated with severe itching due to histamine reaction
109
List the contraindications to cold therapy
1. Cold hypersensitivity (urticarial)
2. Cold intolerance
3. Cryoglobulinemia
4. Peripheral vascular disease
5. Severe impaired temperature sensation
6. Raynaud’s disease
7. Paroxysmal cold hemoglobinuria
8. Over regenerating, peripheral nerves
110
List precautions for cold therapy
1. Hypertension
2. Impaired temperature sensation
3. Open wound
4. Over superficial nerve
5. Cognitive changes
111
describe the technique utilized during ice massage
1. Ice formed by freezing water in paper cup
2. Applied to area no larger than 4x6 inches in slow overlapping circles or overlapping longitudinal strokes
3. Each stroke covering ½ of previous stroke circle
4. Continue until anesthesia achieved generally 5-10 minutes
5. Patient experience: cold, burning, aching, numbness
112
what types of injuries is ice massage generally used for?
small superficial injuries
tendonititis for superficial tendons
113
how is heat-transfered during vapo-coolant trx? what are the general goals of this trx?
evaporation
generally used to reduce muscle spasm and/or desensitize trigger points
114
how is heat transfered during a contrast bath?
what are the general goals of this technique?
conduction
produce vascular exercise through active vasodilation and vasoconstriction of blood vessels; may help with pain modulation
115
what are the 2 types of shortwave diathermy?
continuous
pulsed
116
what is the difference between continuous and pulsed shortwave diathermy?
* Continuous (thermal) – increases temperature in deeper structures
* Pulsed (nonthermal) – allows dissipation of heat during the off cycle and can result in other physiological/therapeutic benefits
117
describe the proposed effects of continuous shortwave diathermy
* Increased temperature to deep and superficial tissues
* Increased soft tissue extensibility
* Increased NCV
* Vasodilation
118
describe the effects of pulsed shortwave diathermy
* Increased microvascular perfusion
* Increased local tissue oxygenation
* Increased cell growth and phagocytosis (may help healing of wound and diabetic ulcers)
