Physical Agents/FES Flashcards
Name 9 types of physical agents that are used to produce therapeutic response in tissues:
- thermotherapy
- hydrotherapy
- Light therapy
- electrotherapy
- manual therapy
- pressure
- acupuncture
- iontophoresis
- phonophoresis
8 factors to consider when choosing therapeutic modality
- target tissue
- depth of heating or cooling desired
- intensity of heating or cooling desired
- body habitus
- comorbid conditions (arterial insufficiency)
- age (open epiphyses)
- sex (pregnant woman)
- specific features (metal implants, pacemaker, cold allergy)
6 elements of modality prescription
- indication/diagnosis
- modality
- location
- intensity - patient perception of thermal intensity
- Duration - 20-30 mins for most, 5-10mins per site for ultrasound
- Frequency - based on severity and clinical judgement
_____ is the transfer of thermal energy between two bodies in direct contact. Give example
Conduction (hot pack)
____ uses movement of a medium (water, air, blood) used to transport thermal energy. Give example
Convection - actual transfer of thermal energy ultimately by conduction. (whirlpool, fluidotherapy)
____is transformation of another form of energy to heat or could
Conversion (sound, electromagnetic) - ultrasound
_____ is emitted from any body whose surface temperature is above absolute zero (-273.15C or -459.67F)
Radiation (conversion)
Process of converting a liquid to a gas requiring thermal energy:
evaporation
Process of heat dissipation: For each 1g of water that evaporates from the body surface, approximately ____ of heat is lost
0.6 cal
5 hemodynamic effects of heat:
- increased blood flow and bleeding
- decreased chronic inflammation
- Increased acute inflammation
- Increased edema
- metabolic demand
3 neuromuscular effects of heat?
- Group 1a fiber firing rates increased (muscle spindle)
- Group 1b fiber firing rates increased (golgi tendon organ)
- Increased nerve conduction velocity
3 joint and connective tissue effects of Heat?
- increased tendon extensibility
- increased collegenase activity
- decreased joint stiffness
6 general uses for heat
- muscle relaxation
- chronic inflammation
- contracture
- arthritis
- pain (spinal, myofascial, neuromas, post herpetic neuralgia)
- musculoskeletal conductions (tendonitis, tenosynovitis, bursitis, capsulitis)
8 general precautions for use of heat:
- acute trauma or inflammation
- impaired circulation
- bleeding diatheses
- edema
- large scars
- impaired sensation
- malignancy
- cognitive or communication deficits that preclude reporting of pain
Define
superficial heat:
deep heat:
superficial 1-2cm
deep/diathermy >3-5cm
target tissues
Superficial heat:
Deep heat:
s: skin and subcutaneous
d: muscle, tendon, ligament, or bone
Goal of deep heat (diathermy)?
minimize skin and subcutaneous tissue while maximize heating of deeper tissues
Three methods of superficial heating:
conduction, convection, radiation
method of deep heating: Goal temp?
conversion (40-45C)
Uses for superficial heating?
OA, RA, Various pain syndromes, MSK conditions
Hot packs/heating pads
depth:
main mech of energy transfer:
superficial
conduction
Paraffin baths
depth:
mech:
superficial
conduction
fluidotherapy
depth:
mech:
superficial
convection
whirlpool baths
depth:
mech:
superficial
convection
radiant heat
depth
mech:
superficial
radiation
Ultrasound
depth:
mech:
deep
conversion
shortwave diathermy
depth:
mech:
deep
conversion
microwave
depth:
mech:
deep
conversion
Therapeutic temperature range:
for how long?
_____ temp for increased metabolism and associated effects
40-45C (104-114F)
3-30mins
43-45C for metab
In fluidotherapy, never use still water > _____ temp
46.1C (115F) - agitated water can be a little hotter due to insulating effects of bubbles
Never put whole body in water >_____F
100 degrees
for paraffin, do not use > ____ temp
54C
Hot packs:
1. immersed in tanks at _____ temp
2. applied:
3 treatment time?
4. depth:
5. temperature rise:
- 74.5C (166F)
- applied over several layers of insulating towels
- 30 mins
- 1-4cm
- 1.1 to 3.3 cm
patient should not lie on pack. more common cause of burns in PT
Heating pads:
1. two main types:
2. What is erythema ab igne?
- electric, circulating fluid
- repeated and prolonged skin exposure to heat noted after use of a variety of superficial heating modalities, reticular pigmentation and telangiectasia.
Paraffin baths:
1. Ratio of paraffin wax:mineral oil
2. Temp range (why tolerated)
3. Used in: (2)
4. Avoid in 2 areas
- 6-7:1 ratio of paraffin wax:mineral oil
- 52.2-54.4C (126-130F) (tolerated due to low heat conductivity of paraffin mixture)
- Scleroderma, RA (in conjunction with exercise)
- avoid in open wounds and infected areas
Name the 3 applications methods of paraffin baths:
- dipping: 7-12 dips followed by wrapping
- immersion: several dips to form thin glove, then immerse for 30 mins. Greatest temperature increase and duration
- Brushing: good for areas difficulty to immerse (fun for kids)
Fluidotherapy:
1. ____ heating. How?
2. 2 Advantages:
3. Range?
4. Pros:
5. Avoid:
- Convective - forced hot air and a bed of finely divided solid particles
- can control temperature and amount of agitation
- 46.1-48.9C typical
- massaging action, ROM freedom
- avoid infected wounds (cross-contamination)
Radiant heat: (infrared lamps)
1. Energy is emitted from:
2. produces heating by inducing:
3. change in temp at depth of 2cm:
- any substance with T>absolute zero
- inducing molecular vibration (luminous vs non-luminous)
- 1.3C rise at depth of 2cm
Radiant heat:
1. Determinants of intensity:
2. What is best angle of delivery?
- inverse square law: intensity of radiation varies inversely with square of distance from the source
15cm (4x intense)
30cm (x intense)
60cm (0.25x intense) - max radiation when source is perpendicular to the surface.
Radiant heat:
1. good for patients who:
2. Caveats: 4
- cannot tolerate weight of hot packs
- light sensitivity, skin drying, dermal photoaging, general heat precautions
Which finding is a relative contraindication to cryotherapy?
a. acute inflammation
b. pain
c. acute hematoma
d. impaired sensation
d impaired sensation
relative contraindications to cryotherapy: cold intolerance (decreased compliance, increased muscle guarding), Cryoglobulinemia (immune complex precipitation at lower temperature), Impaired sensation (tissue injury), cognitive deficits (tissue injury)
A 28 year old male firefighter sustained deep dermal berns across his lower face, neck, anterior chest, and shoulders. To help manage the formation of hypertrophic scars, you recommend:
a. corticosteroid injections directly into localized, early hypertrophic scars
b. compressiongarments to be worn 12 hours per day
c. topical silicone to areas of hypertrophic scars
d. ultrasound treatments with passive stretching
A corticosteroid injectiosn directly into localized early hypertrophic scars
When is the use of hyperbaric oxygen recommended for the treatment of diabetic foot ulcers?
a. as first-line treatment
b. if there are signs of infection
c. if standard treatment is ineffective
d. as prophylaxis after wound is healed
c
Repetitive transcranial magnetic stimulation (rTMS) of the motor cortex appears to have therapeutic value in treatment of:
a. fatigue
b. hypertension
c. stroke
d. seizure
c stroke
Which non-surgical treatment for carpal tunnel syndrome is shown to provide significant short-term benefit?
a. magnet therapy
b. laser therapy
c. therapeutic exercise
d. therapeutic ultrasound
d therapeutic ultrasound
Which is a deep heating modality?
a. fluidotherapy
b. paraffin bath
c. microwave
d infrared lamp
c microwave
Which is a form of conversion heating?
a. vaporant cooling spray
b. fluidotherapy
c. ice massge
d ultrasound
d
Which is a contraindication of ultrasound?
a: MSK pain
b: open epiphyses
c: chronic inflammation
d: chronic ankle sprain with edema
b
What prevents infrared radiation from heating deeper tissues?
a) insulating fat layer
b) reflection at skin surface
c) evaporation of sweat on skin
d) pain from heat intensity
a) insulating fat layer
Why would an infrared lamp often be more appropriate for heating an acute sprain than a hot pack?
a: it penetrates deeper
b: it is less likely to burn the patient
c: it is more comfortable (no pressure)
d: it has been shown to be more effective
c - it is more comfortable (no pressure)
What kind of heating is fluidotherapy?
a: convective
b: conversive
c: conduction
d: radiation
a: convection
Why is it necessary to use stroking technique in ultrasound applications?
a) to minimize the therapeutic effect in the ultrasound field
b) to minimize hot spots in the field
c) to avoid burns
d) to increase the acoustic impedance
b) to minimize hot spots in the field
Which is an absolute contraindication for shortwave diathermy?
a: low-grade malignancy, close to but not in the field
b: chronic inflammation
c: the patient being on anticoagulants such as warfarin
d: use of a cardiac pacemaker
d PM
When applying cryotherapy in the treatment of musculoskeletal disorders, which of the following events is NOT a contraindication to its use?
a: paroxysmal cold hemaglobinuria
b: impaired sensation
c: arterial insufficiency
d: spasticity
d spasticity
contraindications to cryotherapy include: paroxysmal cold hemoglobinuria, impaired sensation, arterial insufficiency, cold hypersensitivity, cryopathies, cold intolerance, cryotherapy-induced neuropraxia, raynaud disease
Which deep heat method recommends the use of protective eyewear to prevent the formation of cataracts?
a: ultrasound
b: short wave diathermy
c: fluidotherapy
d microwave diathermy
d microwave diathermy
Cooling can produce physiologic changes in the body. One of these changes is an increase in:
a: nerve conduction rate
b: stretch receptor sensitivity
c: elasticity of connective tissue
d: general sympathetic activity
d general sympathetic activity
____ is the use of high frequency acoustic energy (>20,000Hz) to produce effects in tissue:
Therapeutic ultrasound
Thermal effects are greatest at _____ in therapeutic ultrasound.
bone/muscle interface
acoustic energy absorbed –> molecular vibration –> heat production
In therapeutic ultrasound, temperatures up to ____ achieved in deep tissues (bone-muscle interface)
46C (114.8)
If deep heating is the goal, which is superior?
Ultrasound, then microwave or shortwave diathermy
- Describe the 3 non-thermal effects of ultrasound:
- may cause:
- minimized by:
(all may result in cellular damage and alteration of function)
- Cavitation:
- stable (bubbles)
- unstable (bubbles that grow and pop) platelet aggregation, tissue damage, cell death
(minimized by high frequency, low intensity pulsed mode) - Media motion
- acoustic (microstreaming)
- acoustic streaming - Standing waves
- focal heating at tissue interfaces
(minimized by stroking technique)
_____ is the process by which ultrasonic waves lose a proportion of their energy as they travel through tissue.
This increases as ____ increases.
Attenuation. increases as frequence increases
(1MHz signal would penetrate deeper than 3 MHz signal due to lower attenuation)
Attenuation of ultrasound can be caused by what 3 methods?
- Absorption (major cause of U/S attenuation)
- Beam Divergence
- Deflection (Reflection, refraction, scattering)
_____ is a measure of the resistance to the transmission of a sound wave
acoustic impedance (beam deflection0
High impedance mismatch between skin and air means that:
almost all of the ultrasound signal would be reflected if a coupling agent is not used.
Ideal coupling medium for ultrasound has acoustic impedance similar to ____.
Examples: 3)
tissue.
Degassed water
mineral oil
coupling gels
may be chosen based on cost and convenience
three techniques for ultrasound application:
- Stroking technique - most common, allows more even distribution over the site. Move applicator over 25cm2 (4in^2) area in a circular or longitudinal manner
- Standing technique - avoid due to potential for standing waves and the production of hot spots
- Pulsed: emission of brief bursts/pulses of ultrasound and interspersed with periods of silence. (results in less heating than continuous wave ultrasound. Emphasizes nonthermal effects)
5 indications for ultrasound
- degenerative arthritis and contracture - helps maintain prolonged stretch and increase ROM
- Bursitis
- Tendinitis (calcific)
- MSK pain
- subacute trauma
Many not well supported by EBM. interest in fracture healing, chronic wound healing.
Precautions for ultrasound (9)
- general heat precautions
- near brain, reproductive organs
- gravid or menstruating uterus
- near pacemaker
- near spine, laminectomy sites
- malignancy
- skeletal immaturity
- Arthroplasties?
- Methyl Methacrylate or high-density polyethyelene?
Ultrasound prescription:
Frequency:
Intensity:
Duration:
Pulsed vs continuous:
F: 0.8 - 1.1MHz; 3.0MHz (millions of cycles per second)
I:
- Most clinical use: 0.5-2.0 W/cm2
- Tendonitis/Bursitis Avg: 1.2-1.8 W/cm2
- Limit: 3 W/cm2 (WHO, IEC)
D: 5-10 mins per site
Pulsed requires additional parameters.
_____ is conversion of electromagnetic energy to thermal energy to produce deep muscle heating
Shortwave diathermy
Shortwave diathermy:
Depth:
Frequency:
Time:
Indications: 4
Conversion of electromagnetic energy to thermal energy to produce deep muscle heating
Depth: 4-5cm
Frequency: 27.12 MHz most common
(inductive or capacitive units)
20-30min treatment time
INdications:
1. chronic prostatitis
2. refractory PID
3. Myalgia
4. back spasms
Shortwave diathermy can be performed with what two devices? (when to use each)
- capacitive/condensor SWD - high temperature in water poor tissues (bone/fat) More effective for deeper joints
- Inductive coil SWD - high temperatures in water rich tissues (muscle/skin/blood). Indicated for heat to superficial muscles/joints with minimal superficial tissue.
5 precautions for shortwave diathermy
- general heat precautions
- Metal (jewelry, pacemakers, IUDs, surgical implants, DBS, etc)
- Contact lens
- gravid or menstruating uterus
- skeletal immaturity
____ is conversion of microwave electromagnetic energy to thermal energy.
microwave diathermy
Microwave diathermy
Frequency:
____ at a depth of 1-3 cm
Selectively heats _____
Eye protection needed due to risk of _____
INdications: (3)
915MHz and 2456 MHz approved
(lower frequency penetrates deeper)
41C at 1-3cm
Selectively heats fluid-filled cavities
Cataracts
Indications: superficial muscle and joint heating, speed hematoma resolution, local hyperthermia in cancer patients.
Microwave diathermy precautions (4)
- General heat precautions
- Metal implants
- skeletal immaturity
- avoid in fluid filled cavities (eyes, bullae, edematous tissue)
Heating depth for
Ultrasound:
Short wave diathermy:
Microwave diathermy:
8cm
4-5cm
1-4cm
3 hemodynamic effects of Cold
- immediate cutaneous vasoconstriction
- Delayed reactive vasodilatation
- decreases acute inflammation
7 neuromuscular effects of Cold
- decreased conduction velocity
- conduction block, axonal degeneration (prolonged exposure)
- decreased group 1a, 2, 1b firing rates
- decreased stretch reflex amplitudes
- increased maximal isometric strength
- decreased muscle fatigue
- decreased spasticity (temporarily)
three joint and connective tissue effects of cold
- increased joint stiffness
- decreased tendon extensibility
- decreased collagenase activity
6 general uses for Cryotherapy
- Acute trauma, injury (minimize edema, inflammation)
- Musculoskeletal conditions (symptomatic relief) - sprains strains, tendonitis, tenosynovitis, bursitis, capsulitis, arthritis, etc.
- myofascial pain
- following certain orthopaedic surgeries
- spasticity (mixed results)
- minor burns (emergency treatment)
general precautions for use of cryotherapy (6)
- cold intolerance
- cryotherapy - induced neuropraxiaa or axonotmesis
- arterial insufficiency
- cryopathies (cryoglobulinemia, paroxysmal cold hemoglobinuria, cold hypersensitivity, raynaud disease or phenomenon)
- Impaired sensation
- Cognitive or communication deficch:its that preclude reporting of pain
Cold packs
depth:
mech
superficial conduction
ice massage
depth:
mech:
superficial
Conduction
cold water immersion
depth:
mech:
superficial
Conduction
cryotherapy-compression units
depth:
mech:
superficial
conduction
Vapocoolant spray
depth:
mech:
superficial
evaporation
whirlpool baths
depth:
mech:
superficial
convection
three types of cold packs
- hydrocollator packs - skin cooled immediately, subcutaneous tissues within minutes. Muscle (2cm depth) cooled by 5C after 20 mins
- endothermic chemical gel packs
- ice packs
apply 20-30mins
cold water immersion is good for ____.
Temp:
Cons (2);
effective for
circumferential cooling of limbs
5-13C
uncomfortable/poorly tolerated
effective for localized burns due to rapid skin temperature reduction
____ are cuffs or boots through which cold water circulates and can be pneumatically compressed.
Indicated for:
Temp:
Pressure?
cryotherapy compression units - can be static or distal to prox
acute MSK injury with soft tissue swelling. some surgiers.
T 7.2C (45F)
up to 60mmHg
_____ is the external application of hot or cold water for the treatment of disease
hot or cold water for treatment of disease
4 main forms of hydrotherapy - what specifically do they treat and advantages
- whirlpool baths
- treat limb or localized lesion
- greater extremes of temperature tolerated without core body temp changes - hubbard tank
- whole body immersion
- decreases stress on bones/joints
- neutral temperatures prevent core temp fluctuations
- sodium hypochlorite commonly used in burn programs
- salt may be added to minimize fluid shifts for large wounds - shower cart
- contrast baths
Uses for hydrotherapy 3
- arthritis
- variety of MSK conditions
- cleansing and debridement of burns and other dermal injuries
Shower cart developed because:
Due to auto-contaminatino and cross-contamination with whirlpool bath and hubbard tanks
allows for gentle spray or shower hydrotherapy during mechanical debridement of large burns and other wounds under relatively sterile conditions
What are contrast baths? create what?
alternate immersion of distal limbs in hot and cold water. - cyclic vasoconstriction and vasodilation
30 min sessions
three uses for contrast baths:
- Rheum disease
- neuropathic pain
- chronic pain syndromes such as CRPS
Ultraviolet radiation traditionally used for:
Works by _____
Now almost exclusively ____
Adverse effects: 3
- treatment of skin ulcers
- increasing vasculariztion of wound margins
- dermatologic (>30 derm disorders including psoriasis)
- premature skin aging, skin cancer, cataracts
what is the minimal erythema dosage of ultravoilet radiation?
Initial 1-2 MED
Keep <5 MED
Need goggles to protect eyes
____ is the introduction of ions across biological membranes by means of direct electrical current.
iontophoresis
Iontophoresis is used for ____ or ____
transcutatneous systemic or local delivery of medicine to soft tissues (limits systemic absorption)
Iontophoresis is used in treatment fo localized inflammatory conductions in superficial tissues: (5)
- tendinitis
- epicondylitis
- arthritis
- plantar fasciitis
- myofascial pain
Name the 6 ionic medications, their charge, and effect
- Dexamethasone sodium phosphate, negative, anti-inflammatory (tendonitis, bursitis, enthesitis)
- Lidocaine, positive, analgesic
- Acetic Acid, negative, dissolves calcium depositis (calcific tendonitis)
- Calcium, positive, muscle relaxant
- magnesium, positive, muscle relaxant
- salicylates, negative, releaves joint and muscle pain
_____ is ultrasound used to facilititate transdermal migration of typically administered medications
phonophoresis (corticosteroids)
ultrasound coupling gel mixed with chemical substances to produce phonophoresis coupling agent
Uses for phonophoresis (12
- OA
- bursitis
- capsulitis
- tendonitis
- strains
- fasciitis,
- epicondylitis
- tenosynovitis
- contracture
- scar tissue
- neuromas
12 adhesions
Types of massage (4)
- stroking/effleurage
- compression/petrissage
- percussion/tapotement
- friction
Contraindications to massage (5)
- malignancy
- cellulitis
- lymphangitis
- recent bleeding
- DVT
Inferential current therapy able to deliver higher currents than _____.
May be useful in (3)
Precautions:
TENS
variety of MSK conditions, neurologic conditions, urinary incontinence
implanted stimulators, carotid sinus, open wounds, gravid uterus, DVT, insensate areas, near SWD
4 categories of Estim
- peripheral nervous system to induce muscle activation (Neuromuscular electrical stimulation/NMES)
- Central nervous system to induce activation
- central or peripheral nervous system to modulate sensory input (primarily to reduce pain)
- skin to induce wound healing
Neuromuscular estim can be used _____.
Requires: _____.
Best suited for _____.
Recruitment of motor units: ____.
May result in _____>
anywhere along axon of LMN
intact motor unit - threshold for muscle stimulation 100-1000x higher than for nerve fiber stimulation (not safe)
best suited for UMN disease (“all or none”)
Recruitment of motor units revers in order compared to normal physiologic excitation
May result in conversion of muscle fiber types
two types of neuromuscular estim:
- Therapeutic electrical stimulation (TES) - promotes neuro recovery, reduces pain. Repetitive stimulation applied to paralyzed muscles to minimize atrophy and maintain ROM. Benefits intended to persist after TES discontinued
- Functional electrical stimulation (FES) - functional benefits directly while estim is being delivered. Stimulation in a coordinated sequence to assist with functional tasks (ADLs, Transfers, ambulation)
Beneftis do not persist when stimulation discontinued
What is the recommended program for estim for post-stroke shoulder pain?
pathogenesis multifactoria. Estim to supraspinatus and posterior deltoid use for subluxation and pain (6hours/day x 6 weeks)
4other uses of NMES
- bladder - sacral nerve stimulation for effective micturition in suprasacral SCI
- Electroejaculation - electrical stimulation via rectal probe to collect semen in SCI
- Respiration - phrenic nerve pacing (PNP)
- Would healing (pressure ulcers)
____ is estim through intact skin taht aims to provide pain relief by secifically exciting peripheral nerves
transcutaneous nerve stimulation (TENs)
mechanisms of pain control in TENS units
placebo effect 30-35%
gate control theory
release of endogenouse opioids
Gate control theory
- stimulate large IA fibers (myelintated)
- this stimulated the substansia gelatinosa in the dorsal horn of the spinal cord
- This closes the gate
- Therefore C fibers (fine diameter) are not inhibited and can not send pain signal tot he thalamus via the spinal thalamic tract
- result, pain is not appreci5 INated by the thalamus
5 indications for TENs units:
- acute and chronic postop pain
- acute and chronic myofascial pin
- acute and chronic pain associated with MSK disorders and soft tissue injuries such as low ack pain, arthritis
- Neurologic pain: post-herpectic neuralgia, trigeminal neuralgia, peripheral n injuries
- residual limb and phantom limb pain
3 types of TENS stimulator types
- conventional - high frequency, low intensity stimulation
(most effective) - acupuncture - low frequency, high intensity
- pulse mode - high frequency stimulus at low frequency bursts
average 30=60mins at a tmie for 8 hours/day
10 contraindications for electrotherapy
- circulatory impairment
- stimulation over carotid sinus or heart (esp if pacemaker)
- pregnancy
- seizure
- fresh fracture
- active hemorrhage
- malignancy
- decreased sensation (risk of electrical burns)
- atrophic skin
- inability to report pain
