Ultimate Review Pt. 3 Flashcards
emphysema
develops from a long history of chronic bronchitis. alveolar walls present with significant pathology and air spaces are permanently over inflated. pink puffers. expiration is difficult. characterized as centrilobular, panlobular or paraseptal. symptoms include: dyspnea, chronic cough, orthopnea, barrel chest, increased use of accessory muscles, and increased RR.
restrictive pulmonary disease
lungs fail to fully expand due to a weakened diaphragm, structural inability of chest wall to expand, and a decrease in elasticity of lung tissue. symptoms include: shortness of breath, persistent non-productive cough, increased RR. results in a decrease in all lung volumes.
tuberculosis
bacterial infection that is transmitted by airborne fashion (coughing, sneezing, speaking). lungs are primarily involved, however TB can occur in kidneys, lymph nodes, and meninges. lesions in the lungs can be seen with x ray. symptoms: fatigue, weight loss, loss of appetite, low grade fever, productive cough, chest discomfort, and dyspnea. treatment includes anti-tb drug therapy. prevention of TB through immunization is recommended for children.
pharmacological intervention for pulmonary management
bronchodilator agents, inhaled corticosteriod agents, mucolytic agents, expectorant agents, antiasthmatic agents. examples: albuterol, serevent, epnephrine, vanceril, flovent, decadron, mucosil, plumozyne, guafenesin, terpin hydrate, intal, tilade
transfers: levels of phys assistance
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independent
patient does not require any assistance to complete task
supervision
patient requires therapist to observe throughout completion of task
contact guard
patient requires therapist to maintain contact with patient to complete task. usually needed to assist of there is a loss of balance
min assist
patient requires 25% assist from therapist to complete task
mod assist
patient requires 50% assist from therapist to complete task
max assist
patient requires 75% assist from therapist to complete task
dependent
patient is unable to participate and therapist must provide all effort to perform task
3 person carry/lift
used to transfer patient from a stretcher to a bed or treatment plinth. 3 therapists carry patient in supine position. therapist at head usually gives commands.
2 person lift
used to transfer a patient btwn two surfaces of different heights or when transferring a patient to the floor.
dependent squat pivot transfer
used to transfer a patient who cannot stand independently, but can bear some weight thru the trunk and LEs. therapist should position patient at a 45 degree angle to the destination surface. patient places UEs on therapist’s shoulders, but should not pull on therapist’s neck. should position patient at edge of surface, hold patient around hips and under butt, block patients knees in order to avoid buckling. therapist should utilize momentum, straighten his or her legs and raise patient or allow patient to remain squatting, and pivot and slowly lower patient to destination surface.
sliding board transfer
used for a patient who has some sitting balance and some UE strength and can adequately follow directions. patient should be positioned at edge of w/c or bed and should lean to one side while placing one end of sliding board under proximal thigh. other end should be position on destination surface. use both arms to initiate a push up and scoot across board. therapist should guard in front of patient and assists as needed as patient performs a series of push ups across the board.
stand pivot transfer
used when a patient is able to stand and bear weight through one or both of LEs. must possess functional balance and ability to pivot.
wheelchair facts
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adult w/c specs:
seat width: 18 inches, set depth: 16 inches, seat height: 20 inches
hemi-height w/c
decreased seat height (17.5 inches) to allow for propulsion using the unaffected foot
rear wheel axles
can be positioned 2 inches posteriorly from normal for patients with amputations to increase the BOS and to compensate for diminished weight in front of w/c
reclining w/c
allow intermittent or constant reclined positioning
tilt-in-space w/c
allow for reclined position without losing required 90 degrees of knee flexion. entire chair reclines without any anatomical changes in positioning.
standard w/c measurements for proper fit
seat height/leg length: 19.5 to 20.5 inches. measure from user’s heel to popliteal fold and add 2 inches to allow clearance of foot rest.
seat depth
measure from user’s bottom along lateral thigh to popliteal fold, then subtract approx 2 inches to avoid pressure from front edge of seat against popliteal space. 16 inches average.
seat width
measure the widest aspect of user’s bottom or hips and add aprx 2 inches. will provide space for clothing and clearance of trochanters from armrest side panel. approx 18 inches is average.
back height
measure from seat of chair to floor of axilla with user’s shoulder flexed to 90 and then subtract 4 inches. this will allow final back height to be below inferior angles of scapula. 16-16 1/2 inches average.
armrest height
measure from seat of chair to olecranon process with user’s elbow flexed to 90 and then add one inch. average usually 9 inches above chair seat.
assistive devices
parallel bars, walkers, axillary crutches, lofstrand crutches, canes
parallel bars
proper fit includes bar height that allows for 20-25 degrees of elbow flexion while grasping bars approx four to six inches in front of body.
walker
can be used with all levels of weight bearing. should allow for 20-25 degrees of elbow flexion. used with 3 point gait pattern
axillary crutches
all levels of weight bearing, but requires higher coordination for proper use. 6 inches in front, two inches out (lateral) to patient. crutch height should be adjusted no greater than 3 finger widths from axilla. handgrip height should be adjusted to ulnar styloid process and allow for 20-25 degrees of elbow flexion while grasping.
lofstrand (forearm) crutches
20-25 degrees of elbow flexion while holding handgrips with crutches 6 inches in front and 2 inches lateral. arm cuff should be positioned 1 to 1 1/2 inches below olecranon process so it does not interfere with elbow flexion
cane
provides minimal stability and support during ambulation, mainly for balance.
NWB
non weight bearing
TTWB
toe touch weight bearing
PWB
partial weight bearing
WBAT
weight bearing as tolerated
FWB
full weight bearing
2 point gait
when patient uses 2 crutches or canes. moves left crutch forward while simultaneously advancing rt lower extremity ad vice versa.
3 point gait
walker or crutches. injured lower extremity may have decreased weight bearing. AD is advanced followed by injured LE and then uninjured LE. AD and each LE are considered separate points
4 point gait
each advancement of crutch or cane as well as LEs indicates a single point, used one at a time.
swing to gait
patient with bilateral trunk and or LE weakness uses crutches or a walker and advances LEs at the same time only to point of AD.
swing through
advances LEs thru AD
arterial line
monitoring device consisting of a catheter that is inserted into an artery and attached to an electronic monitoring system. used to measure blood pressure or obtain blood samples. considered more accurate than traditional measures of blood pressure and does not require repeated needle punctures
external catheter
applied over shaft of penis and is held in place by a padded strap or adhesive tape
foley catheter
indwelling urinary tract catheter that has a balloon attachment at one end. balloon which is filled with air or sterile water must be deflated before catheter can be removed
suprapubic catheter
indwelling urinary catheter that is surgically inserted directly into patient’s bladder. insertion of a suprapubic catheter is performed under general anesthesia
swan-ganz catheter
soft, flexible catheter that is inserted through a vein into pulmonary artery. used to provide continuous measurements of pulm artery pressure. can exercise with device but patient should avoid activities that increase pressure on injection site
intravenous system
consists of a sterile fluid source, pump, clamp, and catheter to insert into a vein. can be used to infuse fluids, electrolytes, nutrients, and medication. IV lines are most commonly inserted into superficial veins such as basilic, cephalic, or antecubital.
nasal cannula
tubing extends into patient’s nostrils approx 1 cm. oxgyen therapy can deliver up to 6 L of oxygen per min
nasogastric tube
plastic tube inserted thru a nostril that extends into stomach. commonly used for liquid feeding, medication administration or to remove gas from the stomach
oximeter
photoelectric device used to determine the oxygen saturation of blood. device is most commonly applied to finger or ear. often used to assess activity tolerance
indications for therapeutic modalities
inflammation and repair, pain, restriction in motion, and abnormal tone.
phases of tissue healing
inflammation (1-6 days), proliferative phase (day 3-day 20), maturation phase (day 9 - ongoing)
inflammation phase of tissue healing
occurs secondary to trauma or disease. required for healing to occur. presents with calor, rubor, tumor, dolor. clot formation and phagocytosis occur
proliferative phase
involves connective tissue and epithelial cells. epithelialization, collagen production, wound contracture, and neurovascularization occur
maturation phase
longest in duration, progression towards restoration of the prior function of injured tissues, collagen synthesis and lysis balance, collagen fiber orientation
keloid scar
can occur during healing process when collagen production greatly exceeds collagen lysis. extends beyond original boundaries of an injury and damages healthy tissues.
hypertrophic scar
can occur during healing process when collagen production greatly exceeds collagen lysis. will be raised, but remain within borders of original injury
principles of heat transfer
conduction, conversion, convection, evaporation, radiation
heat conduction
direct contact btwn 2 materials at different temperatures. ex: hot pack, paraffin, ice massage, cold pack
heat convection
air or water moving in a constant motion across body. ex: whirlpool
heat conversion
transfer of heat when nonthermal energy is absorbed into tissue and transformed into heat. ex: diathermy and ultrasound
heat evaporation
transfer of heat as a liquid absorbs energy and changes from to a vapor. ex: vapocoolant spray
heat radiation
direct transfer of heat from a radiation energy source of higher temperature to one of cooler temperature. directly absorbed without the need for a medium. ex: infrared lamp
cryotherapy
ex: ice massage, cold pack, cold bath, vapocoolant spray
cryotherapy’s therapeutic effects
initial decrease of blood flow to treated area, decreased temp, increase pain threshold, decrease metabolism, decrease edema, initial vasoconstriction, decrease nerve conduction velocity, decrease nerve conduction velocity, reduce spasticity of muscle, produce analgesic effects
cryotherapy’s indications
acute or chronic pain, myofascial pain syndrome, muscle spasm, bursitis, acute or subacute inflammation, musculoskeletal trauma, reduction of spasticity, tendonitis
cryotherapy contraindications
compromised circulation, peripheral vascular disease, ischemic tissue, cold hypersensitivity, raynaud’s phenomenon, cold urticaria, hypertension, infection, cryoglobinemia
stages of perceived symptoms during cryotherapy
intense cold within 3 mins, aching/burning sensation from 4-7 mins, anesthesia to analgesia from 8-15 mins, numbness from 15-30 mins
ice massage
5-10 min treatment time
cold pack
requires a temp of 23 degrees. apply cold pack wrapped in moistened towel to area for 15 mins. application may extend to 30 mins but requires observation every 10 minutes (for spasticity) can be applied every one to two hours for reduction of inflammation and pain control.
cold bath
used for immersion of distal extremities. water temp ranges from 55 to 64 degrees. immersed for 5 to 15 mins to attain desired effects
vapocoolant sprays
often used in conjunction with passive stretching. fluori-methane is a commonly used vapocollant spray that is typically applied from prox to distal muscle attachments.
superficial heating agents
fluidotherapy, hot pack, infrared lamp, paraffin
deep heating agents
diathermy, ultrasound (and phonopheresis)
heating therapeutic effects
increase temp, increase blood flow to area, decrease nerve conduction latency, vasodilation, increase muscle elasticity, increase collagen extensibility, decreases tone
heating indications
pain control, chronic inflammatory conditions, trigger point, tissue healing, muscle spasm, decreased ROM, densensitization
heating contraindications
circulatory impairment, area of malignancy, acute musculoskeletal trauma, bleeding, sensory impairment, thrombophlebities, arterial disease
fluidotherapy
container that circulates warm air and small cellulose particles. extremity is placed into container and dry heat is generated thru energy transferred by forced convection. promotes tissue healing and prevention of edema. body part should be placed into unit prior to turning machine on. temp should be set between 111-125 degrees. treatment time usually 20 minutes.
hot pack
effects include soft tissue healing, promoting relaxation, decreasing pain and stiffness. must be stored in hot water between 158-167 degrees. requires 6-8 towels around hot pack. require approx 20 minutes to achieve desire effects
infrared lamp (IR)
produces superficial heating of tissue through radiant heat. form of heating is usually limited to penetration of less than one to three millimeters. use is declining due to risk of burns during treatment. patient should be positioned approx 20 inches from source. 20 inches in distance should equal 20 minutes of treatment. as distance decreases, intensity will increase and time of total treatment should decrease.
paraffin wax
most commonly used superficial heating agent of distal extremities. temp should be between 113-126 degrees. dip patient’s hand and wrap with plastic bag with a towel around it to insulate and maintain heating for approx 15-20 mins.
diathermy
converts high frequency electromagnetic energy into therapeutic heat. produces vibration of molecules within a specific tissue, generates heat and elevates tissue temperature. main therapeutic effect is enhancement of soft tissue healing. can be delivered in continuous or pulsed mode. pulsed mode is usually used for thermal effects at 27.12 MHz.
contraindications for diathermy
low back, abdomen, pelvis of a pregnant woman, internal and external metal objects, eyes, malignant area, intrauterine device, cardiac pacemaker, pain and temp sensory deficits, moist wound dressing, testes, acute inflammation, ischemic tissue
diathermy parameters
inductive application: wrap coils around extremity that has been covered by a towel, place drum over treatment area. patient must remain in same position throughout treatment. treatment time varies from 15-30 mins.
ultrasound
common deep heating agent that transfers heat through conversion. elevates tissue temp to depths up to 5 cms, and uses inaudible acoustic mechanical vibrations of high frequency to produce thermal and nonthermal effects. crystal transducer converts electrical energy into sound.
ultrasound therapeutic effects
thermal: increase extensibility of collagen structure, decrease joint stiffness, pain relief, increase blood flow, decrease muscle spasm
ultrasound therapeutic effects (nonthermal)
nonthermal: stimulation of tissue regeneration, pain relief, soft tissue repair, increase blood flow,
indications for u/s
soft tissue repair, contracture, bone fracture, trigger point, dermal ulcer, scar tissue, pain, plantar wart, muscle spasm
contraindications for u/s
over eyes, over pregnant uterus, over cemented prosthetic joint, impaired circulation, impaired pain or temp sensory deficits, over heart, over testes, over epiphyseal areas in children, infection, over malignancy
u/s treatment parameters
place transducer over area before turning on machine (and gel already applied to head). move in small circular pattern over treatment area. maintain contact with skin and stay within treatment area. an area two to three times the size of the transducer typically requires a duration of five minutes of treatment. intensity for continuous u/s is normally set btwn .5 to 2 w/cm2 for thermal effects. pulsed u/s is normally set between .5 to .75 w/cm2 with a 20% duty cycle for nonthermal effects
BNR
beam nonuniformity ratio: ratio of intensity of highest peak to average intensity of all peaks. lower BNR, more favorable, since most patients will be less likely to experience hot spots and or discomfort during treatment. BNR values should range btwn 2:1 and 6:1, most devices often fall in 5:1 or 6:1 range.
ERA
effective radiating area. area of transducer that transmits u/s energy. always smaller than total size of transducer head.
acoustic cavitation
occurs as a result of acoustic energy generated by u/s that develops into microscopic bubbles causing cavities that surround soft tissues. the bubbles expand and contract.
2 types of cavitation that occur:
stable cavitation: microscopic bubbles increase and decrease in size but do not burst. triggers microsteaming. transient (unstable) cavitation: microscopic bubbles increase in size over multiple cycles and implode. this causes brief moments of local temperature ad pressure increases in area surrounding those bubbles. process should not occur during therapeutic u/s since intensities required are much higher than 3 w/cm2.
microsteaming
minute flow of fluid that takes place around vapor-filled bubbles that oscillate and pulsate
acoustic streaming
term for the consistent and circular flow of cellular fluids that results from u/s. responsible for altering cellular activity and the transport of fluids to different portions of the field.
phonophoresis
use of u/s for transdermal delivery of medication. u/s enhances the distribution of medication through the skin, provides a high concentration of the drug directly to the treatment site and avoids risks that may be involved with injection of medication. medications regularly used in phonophoresis include anti-inflammatory agents or analgesics. effective with both continuous and pulsed techniques.
hydrotherapy
the internal and external use of water in the treatment of disease. transfers heat thru conduction or convection and is administered in tanks of varying sizes. main therapeutic effects: wound care, unloading of weight, and reduction of edema.
buoyancy
(archmides): there is an upward force on body when immersed in water equal to amount of water that has been displaced by the body. ability to float in water results from the body possessing a specific gravity less than that of water.
hydrostatic pressure
water exerts pressure that is perpendicular to the body and increases in proportion with the depth of immersion
resistance
water molecules tend to attract to each other and provide resistance to movement of the body in the water. resistance by water increases in proportion to speed of motion.
specific gravity
computation for specific gravity of water is equal to 1. human body varies based on size and somatotype but typically has a specific gravity of less than 1 (average .974). therefore, a personal will generally float when fully submerged in water.
specific heat
measure of the ability of a fluid to store heat. calculated as amount of thermal energy required to increase fluid’s temp by one unit. water can store 4 times the heat as compared to air. water’s thermal conductivity is approx 25 times faster than air at the same temp.
total drag force
comprised of profile drag, wave drag and surface drag forces. is a hydromechanic force exerted on a person submerged in water that normally opposes the direction of the body’s motion.
therapeutic effects of hydrotherapy:
increase blood flow, increase core temp, relaxation, pain relief, vasodilation, decrease abnormal tone, wound/debridement
indications for hydrotherapy:
burn care, superficial heating or cooling, edema control, muscle strain, arthritis, desensitization of residual limb with contrast bath, pain management, wound care, decreased ROM, pool therapy/exercise, sprain, joint stiffness, muscle spasm/spasticity
contraindication for hydrotherapy:
peripheral vascular disease, gangrene, severe infection, urinary/fecal incontinence, advanced cardiov or pulm disease, buerger’s disease w/contrast bath, impaired circulation, renal infection, bleeding surface area, diminished sensation
types of hydrotherapy
extremity tank, lowboy tank, highboy tank, hubbard tank, therapeutic pool
treatment temps for water
32-79 degrees: acute inflammation of distal extremities, 79-92 degrees: exercise, 92-96: wound care, spasticity, 96-98: cardiopulmonary compromise, treatment of burns, 99-104: pain management, 104-110: chronic rheumatoid or osteoarthritis, increased ROM
treatment parameters for whirlpool
treatment time ranges from between 10 and 30 mins. select water temp based on diagnosis and goals and assist pt into comfortable position, monitor vital signs and level of comfort.
treatment parameters for pool therapy
general contraindications for superficial or deep heating, including incontinence, open areas, fear of water, confusion, and significant respiratory pathology. recommended populations for pool therapy include patients with arthritis, musculoskeletal injuries, neuro deficits, sci, cva, ms, and selected cardiopulmonary diagnoses. tank must be cleaned after each use with a disinfectant and antibacterial agent.
mechanical agent: traction
modality that applies mechanical forces to body to separate joint surfaces and decrease pressure. force can be applied manually by therapist or mechanically by a machine.
therapeutic effects of traction
joint distraction, soft tissue stretching, muscle relaxation, reduction of disk protrusion, joint mobility
indications for traction
nerve impingement, herniated or protruding disc, subacute joint inflammation, spondylolisthesis, joint hypomobility, paraspinal muscle spasm, degenerative joint disease, osteophyte formation
contraindications for traction
when motion is contraindicated, joint instability, tumor, pregnancy, acute inflammatory response, acute sprain, osteoporosis, fracture
treatment parameters for traction
treatment time is 5-20 mins. cervical: pt supine with approx 25-35 degrees of neck flexion, should start with a force btwn 10-15 lbs and progress to 7% of pt’s body weight as tolerated for separation of vertebrae. lumbar can be supine or prone, and should be set with a force of less than half body weight for initial treatment. traction force of 25-50 lbs is recommended when initiating mechanical lumbar traction. force of up to 50% of body weight is required for actual separation of the vertebrae.
compression
physical agent that applies a mechanical force to increase pressure on treated body part. works to keep venous and lymphatic flow from pooling into interstitial space. static compression utilizes bandaging and compression garments to shape residual limbs, control edema, prevent abnormal scar formation, and reduce risk of dvt. intermittent compression with a pneumatic device is used to reduce edema.
therapeutic effects of compression
control of peripheral edema, shaping of residual limb, management of scar formation, improve lymphatic and venous return, and prevention of DVT
indications for compression
lymphedema, new res limb, risk for DVT, edema, stasis ulcers, hypertrophic scarring
contraindications for compression
malignancy of treated area, DVT, unstable or acute fracture, heart failure, infection of treated area, pulm edema, circulatory obstruction
treatment parameters
therapist should measure girth and bp. therapist should set parameters based on desire effect. stockinette should be put over extremity and then compression sleeve. 3:1 ratio is generally used for on/off time with inflation btwn 40 to 100 seconds and deflation btwn 10-35 seconds. inflation pressure generally ranges from 30-80 mm Hg and should not exceed patient’s diastolic bp. treatment of upper extremities generally requires btwn 30 and 60 mm Hg of inflation pressure while treatment of LEs requires btwn 40 and 80 mm Hg of inflation pressure. treatment time varies for diagnosis, from 2-4 hours and is utilized from 3 x per week to 3 x per day. when treatment time is up, therapist should reassess extremity and remeasure girth and bp
UV: ultraviolet light
form of energy that is used therapeutically and absorbed one to two millimeters into the skin. divided into UV-A and UV-B, and UV-C. most effective use of UV is to treat skin disorders
therapeutic effects of UV
facilitate healing, exfoliation, Vit D production, increase pigmentation, tanning
indications for UV
acne, psoriasis, tetany, Vit D deficiency, chronic ulcer/wound, osteomalacia/rickets, sinusitis
contraindications for UV
photosensitive meds, lupus erythematosus, tb, herpes, renal or hepatic pathology, DM, pellagra
treatment parameters for UV
therapist must obtain a minimal erythemal dose before treatment (MED). this is the time of exposure needed to produce an area of mild redness btwn 8 and 24 hours after treatment. MED is tested by paper cutouts on forearm and therapist should wear goggles. squares on skin should be exposed in 15 sec increments for 15, 30, 45, 60 and 75 seconds and inspected after an 8 hr period to determine MED. treatment time should increase each consecutive treatment day since skin adapts to the UV exposure.
massage
manual therapeutic modality that produces physiologic effects through stroking, rubbing, and pressure.
effleurage
light in stroke and produces a reflexive response. performed at beginning and end of massage to allow patient to relax and should be directed towards the heart.
friction
incorporates small circular motion over a trigger point or muscle spasm. deep massage technique that penetrates into the depth of a muscle and attempts to reduce edema, loosen adhesions, and relieve muscle spasm. used with chronic inflammation or with overuse injuries
petrissage
kneading where muscle is squeezed and rolled under therapist’s hands. distal to proximal sequence of kneading over muscle. can be performed with 2 hands over larger muscle groups or with as few as two fingers over smaller muscles.
tapotement
provides stimulation through rapid and alternating movements such as tapping, hacking, cupping, and slapping. purpose is to enhance circulation and stimulate peripheral nerve endings
vibration
places hands or fingers firmly over area and uses a rapid shaking motion that causes vibration to treatment area. used primarily for relaxation.
therapeutic effects of massage
increases lymphatic circulation, removal of metabolic waste, decrease muscle atrophy, decrease anxiety and tension, facilitate healing, stimulate reflexive effects, reduction of edema, loosen adhesions, decrease muscle spasm
indications for massage
pain, decreased ROM, edema, adhesions, myositis, lactic acid excess, migraine, trigger point, muscle spasm and cramping, scar tissue, bursitis, tendonitis, intermittent claudication, raynaud’s syndrome
contraindications for massage
infection, arterioscelrosis, thrombus, cellulitis, acute injury, embolus, cancer.
electrotherapy
used for facilitation of skeletal muscle contraction, stimulation of denervated muscle, pain management, to retard muscle atrophy, osteogenesis, driving medications through the skin, and wound management
contraindications
cardiac pacemaker, patient with a bladder stimulator, over carotid sinus, seizure disorders, phlebitis, malignancy, over a pregnant uterus, cardiac arrhythmia, osteomyelitis
electrode configuration
techniques include: monopolar, bipolar, and quadripolar
monopolar
active (smaller) electrode is placed over target area. second dispersive electrode is placed at another site away from the target area. used for wounds, iontophoresis, and treatment of edema
bipolar
2 active electrodes are placed over target area. electrodes usually same size. used for muscle weakness, neuromuscular facilitation, spasms, and ROM
quadripolar
2 electrodes from 2 separate stimulating circuits are positioned so that the individual currents intersect with each other. utilized with interferential current.
electrode size
when using a smaller electrode it is particularly important to understand that since the current density is quite high compared to a larger electrode, the patient will be more susceptible to pain and potential tissue damage.
small electrodes
increased current density, increased impedance, decreased current flow
large electrodes
decreased current density, decreased impedance, increased current flow
estim indications
pain management, urinary incontinence, edema management, osteoarthritic pain, migraines
estim contraindication
malignancy, with all types of electrical implants, during first trimester of pregnancy, over lower abdomen/uterus during pregnancy, over anterior transcervical area
direct current
also known as galvanic, constant flow of electrons from anode to cathode without interruption. iontophoresis uses direct current
alternating current
polarity that changes from positive to negative with change in direction of current flow. biphasic, symmetrical or asymmetrical, and is a waveform that is sinusoidal in shape. used in muscle retraining, spasticity and stimulation of denervated muscle
interferential current
combines two high frequency alternating waveforms that are biphasic. used for deep muscle stimulation. attempts to reach deeper tissues using higher frequencies of each waveform along with overall shorter pulse widths. uses a frequency of 50-1250 pps and a pulse width of 50-150 microseconds for pain management; and a frequency of 20-50 pps and pulse width of 100-200 microseconds for muscle contractions
russian current
medium frequency polyphasic waveform. alternating current is produced in a 50 burst per second interval with a pulse width range of 50-200 microseconds, and an interburst interval of 10 milliseconds. type of NMES or FES and is believed to augment muscle strengthening by depolarizing both sensory and motor nerve fibers resulting in tetanic contractions that are painless and stronger than those made voluntarily by the patient. electrode should be placed parallel to muscle fibers along line of pull of muscle group.
russian stim parameters
average peak current amplitude of 100 mA, 50 bursts per second, with on/off time ration of 10/50. usually is done 10 evoked contractions with a 10 second contraction and a 50 second rest period between each of the 10 contractions.
NMES
neuromuscular electrical stimulation: used to facilitate skeletal muscle activity. stim of an innervated muscle occurs when an electrical stimulus of appropriate intensity and duration is administered to the corresponding peripheral nerve. commonly used to facilitate return of controlled functional muscular activity or to maintain postural alignment until recovery occurs.
NMES parameters
bipolar electrode placement over muscle. interrupted current is used with a range of 20-40 pulses per second an on time of 6-10 secs followed by off time of approx 50-60 secs. 15-20 mins for several times a day
TENS: transcutaneous electrical nerve stimulation
widely used for acute and chronic inflammation. main effects of TENS include pain relief through gate control theory. used for home use and is portable.
TENS contraindications
cardiac pacemakers, epilepsy, during 1st trimester
TENS Parameters
conventional, acupuncture like, pulse burst, and brief intense (high-intensity)
conventional TENS
frequency: 50-100 Hz, duration: 20-100 microseconds, amplitude: 10-30 mA
acupuncture like TENS
frequency: 1-4 Hz, 100-200 microseconds, amplitude: 30-80 mA
pulse burst
frequency: 70-100 Hz/burst, duration: 40-75 microseconds, amplitude: 30-60 mA
brief intense (high intensity)
frequency: 70-100 Hz/burst, duration: 150-200 microseconds, amplitude: 30-60 mA
TENS guidelines
electrodes may be placed on sites of nerve roots, trigger points, acupuncture sites or key points of pain and sensitivity. net polarity is normally equal to zero. if waveform is unbalanced, there will be an accumulation of charges that will lead to skin irritation under the electrodes. includes a pulse duration that can vary from 20-400 microseconds; pulse frequency that varies in range from 1-200 Hz, and current amplitude from .1-120 mA.
iontophoresis
process by which medications are induced through the skin into the body by means of continuous direct current electrical stimulation. medication is separated into ions based on the polarity of the current.
acidic/alkaline reaction
acidic reaction can cause hardening of skin. alkaline reaction can cause skin to soften over time.
buffering
technique used to stabilize the pH of skin during ionto by placing buffering agents into electrode pads that cover drug reservoir area within the electrode
electrolysis
decomposition of a compound that results from passing an electrical current through it
electron exchange
occurs during ionto where there is an exchange btwn ions within solutions and electrodes
redox reaction
decomposition of water when electrical current is passed through it. water will be reduced to a net accumulation of hydrogen ions (H+) under anode and hydroxyl ions (OH-) under the cathode.
iontophoresis parameters
pt should never lie on top of electrodes. unit should be set to continuous direct current. polarity must be set to same polarity as ion solution. ion solution should be massaged into treatment site or space within electrode. conductive surface area of the negative electrode (cathode) is twice the size of the conductive surface area of the positive electrode (anode) regardless of which on is the active electrode. active electrode must be placed over target area the the dispersive electrode should be placed as far as possible from active electrode. slowly increase intensity towards a max of five milliamperes. treatment should last 15-20 mins. additional time is required for treatment at an intensity of less than five milliamperes.
therapeutic ions and charge
positive charge: lidocaine, hydrocortisone, histamine, lithium, magnesium, zinc. negative charge: acetate, dexamethasone, salicylate, iodine, chlorine, tap water (+ and -)
hvpc
high voltage pulsed current: twin peak monophasic, pulsed current. produces high electromotive forces. has a phase duration of 5-20 microsecs (fixed in most machines), a short pulse duration that ranges btwn 100-200 microsecs, and voltage greater than 150V to a max of 500V. one large dispersive pad along with one, two or four active electrodes. active electrodes can be positive or negative in polarity based on treatment goals.
indications for hvpc
wound management, pain management, soft tissue edema, levator ani syndrome, muscle spasm, muscle weakness, bell’s palsy
contraindications for hvpc
cardiac pacemakers, over heavy scarring tissues, malignancy, pregnancy
hvpc parameters
secure one electrode over wound (using warm sterile gauze and sponge) and other over healthy skin a min of 5 cm from wound itself. polarity should be in reversal mode so that it allows for 50% of treatment with positive polarity. frequency is generally 30-200 pps, amplitude 1-500V, and duration of treatment from 10-60 mins per session. dermal wounds should be treated 5-7 days per week for best results
electromyography
science of evaluating motor units (anterior horn cell, axon, neuromuscular junctions and muscle fibers innervated by unit) through use of intramuscular needle electrodes or surface electrodes. potentials include abnormal: spontaneous and voluntary.
biofeedback
modality that uses an electromechanical device to provide visual and or auditory feedback. can be utilized to receive information related to motor performance, kinesthetic performance or physiological response. can measure peripheral skin temp, changes in blood volume thru vasodilation and vasoconstriction using finger phototransmission, sweat gland activity, and electrical activity during muscle contraction. electromyographic feedback is the most commonly used biofeedback modality in clinical setting.
biofeedback measures:
muscle activity, heart rate, balance, skin temp, bp, posture, abnormal mvmt, normal mvmt
types of feedback
myoelectric/electromyographic biofeedback, EMG-BF, position biofeedback, bp biofeedback, respiratory bioFB, sphincter control biofb, temp and blood flow bioFB, electroencephalographic bioFB
biofeedback therapeutic effects
muscle relaxation, improve muscle strength, decrease muscle spasm, neuromuscular control, decrease accessory muscle use, decrease pain
biofeedback indications
muscle spasm, pain, sci, urinary incontinence, improve neuromuscular control, muscle weakness, hemiplegia, cp, bowel incontinence, promote relaxation
biofeedback contraindications
any condition where muscle contraction is detrimental, skin irritation at electrode site
biofeedback treatment guidelines
2 active electrodes and 1 ground electrode in a bipolar arrangement best deletes “noise” (noise is any extraneous electrical activity not produced by the contraction of the muscle). surface electrodes with some form of conduction gel are required to adhere to prepared, clean skin. electrodes should be placed parallel to direction of the muscle fibers, set level of sensitivity on device relative to treatment goals: low level sensitivity settings for muscle re-education, high level sensitivity setting for relaxation
biofeedback treatment parameters
2 active electrodes should be placed parallel to muscle fibers and close to each other. reference or ground electrode can be placed anywhere on the body, but is often secured between 2 active electrodes. signals are transmitted to a differential amplifier and info is conveyed thru visual and audio feedback. for muscle re-education, should begin with pt performing a max muscle contraction. sensitivity of bfb unit should be set at a low sensitivity setting and adjusted so that the pt can perform reps at a ratio of 2/3rds of max muscle contraction. isometric contractions should continue for 6-10 secs with relaxation in btwn each contraction. treatment duration for a single muscle group is 5-10 mins. treatment for muscle relaxation requires a high sensitivity setting and a similar electrode placement with active electrodes initially positioned close to each other. as patient improves with relaxation, electrodes should be placed further apart and sensitivity setting increased. during this treatment, patient may also benefit from adjunct relaxation techniques such as imagery. treatment duration of 10-15 mins is usually adequate to attain relaxation.
gfci:
ground fault circuit interrupter: designed to cut off electrical supply to a piece of equipment if it detects any form of leakage or ground fault.
electrotherapy terms
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accommodation
an occurrence where a nerve and muscle membrane’s threshold for excitability increases secondary to a stimulation by a pulse that has a slow phase rise time. the quicker the rise time, the less the nerve can accommodate to the impulse.
alternating current (biphasic)
alternating current allows for the constant change in flow of ions
ampere
unit of measure used to describe rate of current
amplitude
magnitude of current. often labeled intensity or voltage.
anode
positively charged electrode that attracts negative ions
cathode
negatively charged electrode that attracts positive ions
biphasic
pulse that moves in one direction, returns to baseline, then in other direction and back to baseline again within a predetermined amount of time.
types of biphasic pulse
symmetrical: positive phase is identical to negative phase, asymmetrical: positive phase and negative phase are not identical in shape, balanced: positive phase’s electrical charge is equal to negative phase’s electrical charge, unbalanced: positive phase and negative phase do not have identical electrical charges
burst
interrupted group of pulses that are delivered in a finite series and a predetermined frequency
capacitance
property of an insulator that allows for the storage of energy when opposing surfaces of the insulator have an electrical potential difference
chronaxie
testing procedure used to measure amount of time required to produce a small muscle contraction at a particular intensity
conductance
ease at which a particular material will allow current flow (mho)
current
flow electrons from one place to another
direct current (monophasic)
constant unidirectional flow of ions. dependent on polarity
duration of stimulus/duration of rest
time period of stimulation and time period of rest btwn periods of stimulation.
duty cycle
percentage of time that electrical current is on in relation to entire treatment time.
electrical impedance
resistance of a tissue to electrical current
frequency
determines number of pulses delivered through each channel per second. often labeled “rate”
high volt current
characterized by a waveform greater than 150 volts with a short pulse duration. is intermittent and is used for deeper tissue penetration
impedance
property of a substance that provides resistance to flow of current by offering an alternate current
inductance
how easily a certain material will induce an electromotive force (emf) within a circuit
interpulse interval
period of time of electrical inactivity btwn each pulse, usually expressed in microsecs or millisecs
ion
positively or negatively charged atome
low volt current
waveform of less than 150 volts and is used for neuromuscular stimulation
monophasic
pulse that has either a positive or negative polarity and moves in only one direction from a zero baseline and returns to baseline within a predetermined amount of time
negative ion
gained one or more electrons and possesses a negative charge
ohm’s law
current of an electrical current. there is a direct proportional relationship btwn current and voltage and an indirect proportional relationship btwn current and resistance
positive ion
lost one or more electrons and possesses a positive charge
pulse
pulse is one individual waveform
pulse duration
amount of time that it takes to complete all phases of a single pulse. often labeled “pulse width”
pulsed current (interrupted)
allows for a non-continuous flow of either alternating or direct current with periods of no electrical activity
ramp
refers to number of seconds it takes for amplitude to gradually increase or decrease to the max value set by amplitude control
resistance
ability of a material to oppose the flow of ions through it
rheobase
minimal intensity used with a long current duration that produces a small muscle contraction
volt
unit of measure of electrical power or electromotive force
waveform
consistent pattern of a current measured on an oscilloscope
clinical application templates executive summaries
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achilles tendon rupture
usually one to two inches above tendinous insertion on calcaneous, greatest btwn 30-50 yrs of age, typically be unable to stand on their toes and tend to exhibit a positive Thompson test
adhesive capsulitis
occurs more in middle-aged population, greater incidence in women, arthrogram can assist with dx by detecting decreased volume of fluid within the joint capsule, ROM restriction typically in a capsular pattern (lateral rotation, abduction, medial rotation)
amyotrophic lateral sclerosis
risk is higher in males, usually occurs between 40-70, clinical presentation may include both upper and lower motorneuron involvement with weakness occurring in a distal to prox progression, average course of dx is 2-5 yrs with only 20-30% of patients surviving longer than five years
ankylosing spondylitis
systemic condition, inflammation of spine and larger peripheral joints, males greater risk btwn 20-40, presentation initially includes recurrent and insidious onset of back pain, morning stiffness, and impaired spinal extension
anterior cruciate ligament sprain
most commonly occurs during hyperflexion, rapid deceleration, hyperextension or landing in an unbalanced position, females involved in selected sports have higher ligament injury rates, approx 2/3 of time acl is completely torn, there is an associated meniscal tear
bicipital tendonitis
increased incidence of injury is associated with selected sports such as baseball pitching, swimming, rowing, gymnastics, and tennis; characterized by subjective reports of a deep ache directly in front and on top of the shoulder made worse with overhead activities or lifting, examination may reveal a positive speed’s test or yergason’s test
carpel tunnel syndrome
incidence is higher in females with most common age being from 35-55, muscle atrophy is often noted in abductor pollicis brevis muscle and later in the thenar muscles; electromyography studies, tinel’s sign, and phalen’s test can be used to assist with confirming diagnosis
cerebral palsy
spastic cp involves upper motor neuron damage; athetoid cp involves damage to cerebellum, cerebellar pathways or both; clinical presentation includes motor delays, abnormal muscle tone and motor control, reflex abnormalities, poor postural control, and balance impairments; mental retardation and epilepsy are present in 50-60% of children diagnosed with cp.
cva: cerebrovascular accident
types include ischemic (thrombus, embolus, lacunar) and hemorrhagic stroke (intracerebral, subdural, subarachnoid), left CVA may present with weakness or paralysis to rt side, impaired processing, heightened frustration, aphasia, dysphagia, and motor apraxia. right cva may present with weakness or paralysis to left side, poor attention span, impaired awareness and judgment, spatial deficits, memory deficits, emotional lability, and impulsive behavior
chf: congestive heart failure
etiologies include arrhythmia, pulm embolism, hypertension, valvular heart disease, myocarditis, unstable angina, renal failure, severe anemia;
cystic fibrosis
causes exocrine glands to overproduce thick mucus which causes subsequent obstruction, autosomal recessive genetic disorder located on long arm of chromosome seven, terminal disease but death age has increased to 32 yrs due to early detection and management
degenerative spondylolisthesis
caused by weakening of joints that allows for forward slippage of one vertebral segment on one below due to degenerative changes, most common site is L4/L5, william’s flexion exercises may be indicated to strengthen abs and reduce lumbar lordosis
diabetes mellitus (type 1)
insulin is functionally absent due to destruction of beta cells of pancreas; where insulin would normally be produced. starts in children ages 4 or older, adolescense. symptoms include polyuria, polydipsia, polyphagia, nausea, weight loss, fatigue, blurred vision, and dehydration
down syndrome
clinical presentation: hypotonia, flattened nasal bridge, simian line (palmar crease), epicanthal folds, enlargement of tongue and dd.
duchenne muscular dystrophy
x linked recessive trait manifesting in only male offspring while female offspring become carriers. waddling gait, prox muscle weakness, toe walking, pseudohypertrophy of calf and difficulty climbing stairs. rapid progression of this disease with inability to ambulate by ten to 12 yrs of age with death occurring as teenager or less frequently in the 20’s.
fibromyalgia
nonarticular rheumatic condition with pain caused by tender points within muscles, tendons, and ligaments. pain exists in all 4 quadrants of body and there is pain in at least 11 of 18 standardized tender point sites
full thickness burns
burn causes immediate cellular and tissue death and subsequent vascular destruction, eschar forms from necrotic cells and creates a dry and hard layer that requires debridement. absent sensation and pain due to destruction of free nerve endings
guillain barre syndrome
motor weakness in a distal to prox progression, sensory impairment, and possible respiratory paralysis. may be an autoimmune response to a previous respiratory infection, flu, immunization or surgery. patients usually have full recovery
huntingtons disease
chronic progressive genetic disorder that is fatal within 15 to 20 yrs after clinical manifestation. degeneration and atrophy of basal ganglia (stiatum) and cerebral cortex w/in brain. clinically presents with enlarged ventricles secondary to atrophy of basal ganglia, mental deterioration, speech disturbances and ataxic gait
juvenile rheumatoid arthritis
autoimmune disorder found in children less than 16 that occurs when immune cells mistakenly begin to attack the joints and organs causing local and systemic effects. girls more likely than boys. symptoms include joint swelling, pain, stiffness
lateral epicondylitis (tennis elbow)
inflammation or degenerative changes at common extensor tendon that attaches to lateral epicondyle of elbow. repeated overuse of wrist extensors. clinical symptoms include difficulty holding or gripping objects and insufficient forearm functional strength
integumentary system
consists of dermal and epidermal layers, air follicles, nails, sebaceous glands, sweat glands
dermis
true skin: well vascularized, elastic, flexible and tough.
epidermis
avascular, consists of outermost layer of skin
arterial insufficiency ulcers
occur secondary to ischemia from inadequate circulation of oxygenated blood often due to complicating factors such as atherosclerosis
venous insufficiency ulcers
occur secondary to inadequate functioning of the venous system resulting in inadequate circulation and eventual tissue damage and ulceration
pressure ulcer
decubitus ulcer: results from sustained or prolonged pressure at levels greater than the level of capillary pressure on the tissue
neuropathic ulcer
secondary complication usually associated with a combination of ischemia and neuropathy. most often associated with diabetes. frequently found on plantar surface of foot, often beneath the metatarsal heads. wound has good granulation tissue and little or no drainage. often do not report pain due to altered sensation
arterial ulcers
lower one third of leg, toes, web spaces. smooth edges, well defined, lack of granulation tissue, tend to be deep. severe pain, diminished or absent pedal pulses, normal edema, decreased skin temperature, thin and shiny tissue, hair loss, yellow nails. leg elevation increases pain.
venous ulcers
proximal to the medial malleolus, irregular shape, shallow, mild to moderate pain, normal pedal pulses, increased edema, normal skin temp, flaky, dry skin, leg elevation lessens pain
intervention for arterial insufficiency ulcer
cleansing the ulcer, rest, reducing risk factors, limb protection
intervention for venous insufficiency ulcer
cleansing the ulcer, compression to control edema
hydrocolloid dressing
gel forming polymer such as gelatin, pectin, and carboxymethylcellulose with a strong film or foam adhesive backing. absorb exudate by swelling into a gel like mass and vary from being occlusive to semi permeable. does not attach to actual wound itself and is instead anchored to intact skin surrounding the wound.
when to use hydrocolloids
useful for partial and full thickness wounds. can be effective with granular or necrotic wounds
advantages to hydrocolloids
moist environment for wound healing, enables autolytic debridement, offers protection from microbial contamination, provides moderate absorption, does not require a secondary dressing, provides a waterproof surface
disadvantages to hydrocolloids
may traumatize surrounding intact skin upon removal, may tend to roll in areas of excessive friction, cannot be used on infected wounds
hydrogels
consist of varying amounts of water and varying amounts of gel-forming materials such as glycerin, dressings are available in sheet form or amorphous form
when to use hydrogels
commonly used on superficial and partial thickness wounds (abrasions, blisters, pressure ulcers) that have minimal drainage. rather than absorb drainage, hydrogels are moisture retentive
advantages to hydrogels
provides a moist environment for wound healing, enables autolytic debridement, may reduce pressure and diminish pain, can be used as a coupling agent for ultrasound, minimally adheres to wound
disadvantages to hydrogels
potential for dressings to dehydrate, cannot be used on wounds with significant drainage, typically requires a secondary dressing
foam dressings
composed from a hydrophilic polyurethane base. hydrophilic at wound contact surface and are hydrophobic on the outer surface. allows exudates to be absorbed into the foam through the hydrophilic layer. most commonly available in sheets or pads with varying degrees of thickness.
when to use foam dressings
used to provide protection over partial and full thickness wounds with varying levels of exudate. can be used as secondary dressings over amorphous hydrogels
advantages to foam dressings
provides a moist environment for wound healing, available in adhesive and nonadhesive forms, provides prophylactic protection and cushioning, encourages autolytic debridement, provides moderate absorption
disadvantages to foam dressings
may tend to roll in areas of excessive friction, adhesive form may traumatize periwound area upon removal, lack of transparency makes inspection of wound difficult
transparent film
film dressings are thin membranes made from transparent polyurethane with water resistant adhesives. permeable to vapor and oxygen, but are mostly impermeable to bacteria and water. highly elastic, conform to a variety of body contours, and allow easy visual inspection of the wound since they are transparent.
when to use transparent films
useful for superficial wounds (scalds, abrasions, lacerations) or partial-thickness wounds with minimal drainage.
advantages to transparent films
provides a moist environment for wound healing, enables autolytic debridement, allows visualization of the wound, resistant to shearing and frictional forces, cost effective over time
disadvantages to transparent films
excessive accumulation of exudates can result in periwound maceration, adhesive may traumatize periwound area upon removal, cannot be used on infected wounds
gauze dressings
most readily available used in inpatient environment. commonly used on infected or non-infected wounds of any size. can be used for wet to wet, wet to moist, or wet to dry debridement. readily available and cost effective but has a tendency to adhere to wound bed. requires frequent dressing changes. increased infection rate compared to occlusive dressings
alginates
consist of calcium salt of alganic acid that is extracted from seaweed. highly permeable and non-occlusive. requires a secondary dressing. based on the interaction of calcium ions in the dressing and the sodium ions in the wound exudate.
when to use alginates
typically used on partial and full thickness draining wounds such as pressure wounds or venous insufficiency ulcers, often used on infected wounds due to likelihood excessive drainage.
advantages to alginates
high absorptive capacity, enables autolytic debridement, offers protection from microbial contamination, can be used on infected or uninfected wounds, non-adhering to wound
disadvantages to alginates
may require frequent dressing changes based on level of exudate, requires a secondary dressing, cannot be used on wound with an exposed tendon, joint capsule or bone
occlusion
refers to ability of a dressing to transmit moisture, vapor or gases from wound bed to atmosphere. truly occlusive substance would be completely impermeable, while a truly non-occlusive substance would be completely permeable.
most occlusive to non-occlusive
hydrocolloids, hydrogels, semi-permeable foam, semi-permeable film, impregnated gauze, alginates, and traditional gauze
most moisture retentive to least moisture retentive
alginates, semi-permeable foam, hydrocolloids, hydrogels, semi-permeable film
primary versus secondary dressing
primary - direct contact with wound. secondary - directly over primary dressing to provide protection, absorption, and/or occlusion
selective debridement
remove only nonviable tissue from a wound. selective debridement is most often performed by sharp debridement, enzymatic debridement, and autolytic debridement
red-yellow-black tissue
red: protect wound, maintain moist environment, yellow: moist yellow slough. debride necrotic tissue and absorb drainage. black: debride necrotic tissue.
sharp debridement
requires use of scalpel, scissors, and/or forceps to selectively remove devitalized tissues, foreign materials or debris from a wound. most often used for wounds with large amounts of thick, adherent, necrotic tissue, also for cellulitis or sepsis. most expedient form of removing necrotic tissue. PTs are permitted to perform sharp debridement in the majority of states.
enzymatic debridement
topical application of enzymes to surface of necrotic tissue. can be used on infected and non-infected wounds with necrotic tissue. may be used in wounds that have not responded to autolytic debridement or in conjunction with other debridement techniques. can be slow to establish a clean wound bed and should be discontinued after removal of devitalized tissues in order to avoid damage
autolytic debridement
using body’s own mechanisms to remove nonviable tissue. methods include transparent films, hydrocolloids, hydrogels and alginates. results in a moist wound environment that permits rehydration of the necrotic tissue and eschar and allows enzymes to digest the nonviable tissue. can be used with any amount of necrotic tissue and is non-invasive and pain free; however takes longer for wound healing to occur. should not be performed on infected wounds.
Revered
develops from a long history of chronic bronchitis. alveolar walls present with significant pathology and air spaces are permanently over inflated. pink puffers. expiration is difficult. characterized as centrilobular, panlobular or paraseptal. symptoms include: dyspnea, chronic cough, orthopnea, barrel chest, increased use of accessory muscles, and increased RR.
emphysema
Revered
lungs fail to fully expand due to a weakened diaphragm, structural inability of chest wall to expand, and a decrease in elasticity of lung tissue. symptoms include: shortness of breath, persistent non-productive cough, increased RR. results in a decrease in all lung volumes.
restrictive pulmonary disease
Revered
bacterial infection that is transmitted by airborne fashion (coughing, sneezing, speaking). lungs are primarily involved, however TB can occur in kidneys, lymph nodes, and meninges. lesions in the lungs can be seen with x ray. symptoms: fatigue, weight loss, loss of appetite, low grade fever, productive cough, chest discomfort, and dyspnea. treatment includes anti-tb drug therapy. prevention of TB through immunization is recommended for children.
tuberculosis
Revered
bronchodilator agents, inhaled corticosteriod agents, mucolytic agents, expectorant agents, antiasthmatic agents. examples: albuterol, serevent, epnephrine, vanceril, flovent, decadron, mucosil, plumozyne, guafenesin, terpin hydrate, intal, tilade
pharmacological intervention for pulmonary management
Revered
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transfers: levels of phys assistance
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patient does not require any assistance to complete task
independent
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patient requires therapist to observe throughout completion of task
supervision
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patient requires therapist to maintain contact with patient to complete task. usually needed to assist of there is a loss of balance
contact guard
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patient requires 25% assist from therapist to complete task
min assist
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patient requires 50% assist from therapist to complete task
mod assist
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patient requires 75% assist from therapist to complete task
max assist
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patient is unable to participate and therapist must provide all effort to perform task
dependent
Revered
used to transfer patient from a stretcher to a bed or treatment plinth. 3 therapists carry patient in supine position. therapist at head usually gives commands.
3 person carry/lift
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used to transfer a patient btwn two surfaces of different heights or when transferring a patient to the floor.
2 person lift
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used to transfer a patient who cannot stand independently, but can bear some weight thru the trunk and LEs. therapist should position patient at a 45 degree angle to the destination surface. patient places UEs on therapist’s shoulders, but should not pull on therapist’s neck. should position patient at edge of surface, hold patient around hips and under butt, block patients knees in order to avoid buckling. therapist should utilize momentum, straighten his or her legs and raise patient or allow patient to remain squatting, and pivot and slowly lower patient to destination surface.
dependent squat pivot transfer
Revered
used for a patient who has some sitting balance and some UE strength and can adequately follow directions. patient should be positioned at edge of w/c or bed and should lean to one side while placing one end of sliding board under proximal thigh. other end should be position on destination surface. use both arms to initiate a push up and scoot across board. therapist should guard in front of patient and assists as needed as patient performs a series of push ups across the board.
sliding board transfer
Revered
used when a patient is able to stand and bear weight through one or both of LEs. must possess functional balance and ability to pivot.
stand pivot transfer
Revered
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wheelchair facts
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seat width: 18 inches, set depth: 16 inches, seat height: 20 inches
adult w/c specs:
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decreased seat height (17.5 inches) to allow for propulsion using the unaffected foot
hemi-height w/c
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can be positioned 2 inches posteriorly from normal for patients with amputations to increase the BOS and to compensate for diminished weight in front of w/c
rear wheel axles
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allow intermittent or constant reclined positioning
reclining w/c
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allow for reclined position without losing required 90 degrees of knee flexion. entire chair reclines without any anatomical changes in positioning.
tilt-in-space w/c
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seat height/leg length: 19.5 to 20.5 inches. measure from user’s heel to popliteal fold and add 2 inches to allow clearance of foot rest.
standard w/c measurements for proper fit
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measure from user’s bottom along lateral thigh to popliteal fold, then subtract approx 2 inches to avoid pressure from front edge of seat against popliteal space. 16 inches average.
seat depth
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measure the widest aspect of user’s bottom or hips and add aprx 2 inches. will provide space for clothing and clearance of trochanters from armrest side panel. approx 18 inches is average.
seat width
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measure from seat of chair to floor of axilla with user’s shoulder flexed to 90 and then subtract 4 inches. this will allow final back height to be below inferior angles of scapula. 16-16 1/2 inches average.
back height
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measure from seat of chair to olecranon process with user’s elbow flexed to 90 and then add one inch. average usually 9 inches above chair seat.
armrest height
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parallel bars, walkers, axillary crutches, lofstrand crutches, canes
assistive devices
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proper fit includes bar height that allows for 20-25 degrees of elbow flexion while grasping bars approx four to six inches in front of body.
parallel bars
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can be used with all levels of weight bearing. should allow for 20-25 degrees of elbow flexion. used with 3 point gait pattern
walker
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all levels of weight bearing, but requires higher coordination for proper use. 6 inches in front, two inches out (lateral) to patient. crutch height should be adjusted no greater than 3 finger widths from axilla. handgrip height should be adjusted to ulnar styloid process and allow for 20-25 degrees of elbow flexion while grasping.
axillary crutches
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20-25 degrees of elbow flexion while holding handgrips with crutches 6 inches in front and 2 inches lateral. arm cuff should be positioned 1 to 1 1/2 inches below olecranon process so it does not interfere with elbow flexion
lofstrand (forearm) crutches
Revered
provides minimal stability and support during ambulation, mainly for balance.
cane
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non weight bearing
NWB
Revered
toe touch weight bearing
TTWB
Revered
partial weight bearing
PWB
Revered
weight bearing as tolerated
WBAT
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full weight bearing
FWB
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when patient uses 2 crutches or canes. moves left crutch forward while simultaneously advancing rt lower extremity ad vice versa.
2 point gait
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walker or crutches. injured lower extremity may have decreased weight bearing. AD is advanced followed by injured LE and then uninjured LE. AD and each LE are considered separate points
3 point gait
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each advancement of crutch or cane as well as LEs indicates a single point, used one at a time.
4 point gait
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patient with bilateral trunk and or LE weakness uses crutches or a walker and advances LEs at the same time only to point of AD.
swing to gait
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advances LEs thru AD
swing through
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monitoring device consisting of a catheter that is inserted into an artery and attached to an electronic monitoring system. used to measure blood pressure or obtain blood samples. considered more accurate than traditional measures of blood pressure and does not require repeated needle punctures
arterial line
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applied over shaft of penis and is held in place by a padded strap or adhesive tape
external catheter
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indwelling urinary tract catheter that has a balloon attachment at one end. balloon which is filled with air or sterile water must be deflated before catheter can be removed
foley catheter
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indwelling urinary catheter that is surgically inserted directly into patient’s bladder. insertion of a suprapubic catheter is performed under general anesthesia
suprapubic catheter
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soft, flexible catheter that is inserted through a vein into pulmonary artery. used to provide continuous measurements of pulm artery pressure. can exercise with device but patient should avoid activities that increase pressure on injection site
swan-ganz catheter
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consists of a sterile fluid source, pump, clamp, and catheter to insert into a vein. can be used to infuse fluids, electrolytes, nutrients, and medication. IV lines are most commonly inserted into superficial veins such as basilic, cephalic, or antecubital.
intravenous system
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tubing extends into patient’s nostrils approx 1 cm. oxgyen therapy can deliver up to 6 L of oxygen per min
nasal cannula
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plastic tube inserted thru a nostril that extends into stomach. commonly used for liquid feeding, medication administration or to remove gas from the stomach
nasogastric tube
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photoelectric device used to determine the oxygen saturation of blood. device is most commonly applied to finger or ear. often used to assess activity tolerance
oximeter
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inflammation and repair, pain, restriction in motion, and abnormal tone.
indications for therapeutic modalities
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inflammation (1-6 days), proliferative phase (day 3-day 20), maturation phase (day 9 - ongoing)
phases of tissue healing
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occurs secondary to trauma or disease. required for healing to occur. presents with calor, rubor, tumor, dolor. clot formation and phagocytosis occur
inflammation phase of tissue healing
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involves connective tissue and epithelial cells. epithelialization, collagen production, wound contracture, and neurovascularization occur
proliferative phase
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longest in duration, progression towards restoration of the prior function of injured tissues, collagen synthesis and lysis balance, collagen fiber orientation
maturation phase
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can occur during healing process when collagen production greatly exceeds collagen lysis. extends beyond original boundaries of an injury and damages healthy tissues.
keloid scar
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can occur during healing process when collagen production greatly exceeds collagen lysis. will be raised, but remain within borders of original injury
hypertrophic scar
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conduction, conversion, convection, evaporation, radiation
principles of heat transfer
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direct contact btwn 2 materials at different temperatures. ex: hot pack, paraffin, ice massage, cold pack
heat conduction
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air or water moving in a constant motion across body. ex: whirlpool
heat convection
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transfer of heat when nonthermal energy is absorbed into tissue and transformed into heat. ex: diathermy and ultrasound
heat conversion
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transfer of heat as a liquid absorbs energy and changes from to a vapor. ex: vapocoolant spray
heat evaporation
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direct transfer of heat from a radiation energy source of higher temperature to one of cooler temperature. directly absorbed without the need for a medium. ex: infrared lamp
heat radiation
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ex: ice massage, cold pack, cold bath, vapocoolant spray
cryotherapy
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initial decrease of blood flow to treated area, decreased temp, increase pain threshold, decrease metabolism, decrease edema, initial vasoconstriction, decrease nerve conduction velocity, decrease nerve conduction velocity, reduce spasticity of muscle, produce analgesic effects
cryotherapy’s therapeutic effects
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acute or chronic pain, myofascial pain syndrome, muscle spasm, bursitis, acute or subacute inflammation, musculoskeletal trauma, reduction of spasticity, tendonitis
cryotherapy’s indications
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compromised circulation, peripheral vascular disease, ischemic tissue, cold hypersensitivity, raynaud’s phenomenon, cold urticaria, hypertension, infection, cryoglobinemia
cryotherapy contraindications
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intense cold within 3 mins, aching/burning sensation from 4-7 mins, anesthesia to analgesia from 8-15 mins, numbness from 15-30 mins
stages of perceived symptoms during cryotherapy
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5-10 min treatment time
ice massage
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requires a temp of 23 degrees. apply cold pack wrapped in moistened towel to area for 15 mins. application may extend to 30 mins but requires observation every 10 minutes (for spasticity) can be applied every one to two hours for reduction of inflammation and pain control.
cold pack
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used for immersion of distal extremities. water temp ranges from 55 to 64 degrees. immersed for 5 to 15 mins to attain desired effects
cold bath
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often used in conjunction with passive stretching. fluori-methane is a commonly used vapocollant spray that is typically applied from prox to distal muscle attachments.
vapocoolant sprays
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fluidotherapy, hot pack, infrared lamp, paraffin
superficial heating agents
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diathermy, ultrasound (and phonopheresis)
deep heating agents
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increase temp, increase blood flow to area, decrease nerve conduction latency, vasodilation, increase muscle elasticity, increase collagen extensibility, decreases tone
heating therapeutic effects
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pain control, chronic inflammatory conditions, trigger point, tissue healing, muscle spasm, decreased ROM, densensitization
heating indications
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circulatory impairment, area of malignancy, acute musculoskeletal trauma, bleeding, sensory impairment, thrombophlebities, arterial disease
heating contraindications
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container that circulates warm air and small cellulose particles. extremity is placed into container and dry heat is generated thru energy transferred by forced convection. promotes tissue healing and prevention of edema. body part should be placed into unit prior to turning machine on. temp should be set between 111-125 degrees. treatment time usually 20 minutes.
fluidotherapy
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effects include soft tissue healing, promoting relaxation, decreasing pain and stiffness. must be stored in hot water between 158-167 degrees. requires 6-8 towels around hot pack. require approx 20 minutes to achieve desire effects
hot pack
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produces superficial heating of tissue through radiant heat. form of heating is usually limited to penetration of less than one to three millimeters. use is declining due to risk of burns during treatment. patient should be positioned approx 20 inches from source. 20 inches in distance should equal 20 minutes of treatment. as distance decreases, intensity will increase and time of total treatment should decrease.
infrared lamp (IR)
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most commonly used superficial heating agent of distal extremities. temp should be between 113-126 degrees. dip patient’s hand and wrap with plastic bag with a towel around it to insulate and maintain heating for approx 15-20 mins.
paraffin wax
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converts high frequency electromagnetic energy into therapeutic heat. produces vibration of molecules within a specific tissue, generates heat and elevates tissue temperature. main therapeutic effect is enhancement of soft tissue healing. can be delivered in continuous or pulsed mode. pulsed mode is usually used for thermal effects at 27.12 MHz.
diathermy
Revered
low back, abdomen, pelvis of a pregnant woman, internal and external metal objects, eyes, malignant area, intrauterine device, cardiac pacemaker, pain and temp sensory deficits, moist wound dressing, testes, acute inflammation, ischemic tissue
contraindications for diathermy
Revered
inductive application: wrap coils around extremity that has been covered by a towel, place drum over treatment area. patient must remain in same position throughout treatment. treatment time varies from 15-30 mins.
diathermy parameters
Revered
common deep heating agent that transfers heat through conversion. elevates tissue temp to depths up to 5 cms, and uses inaudible acoustic mechanical vibrations of high frequency to produce thermal and nonthermal effects. crystal transducer converts electrical energy into sound.
ultrasound
Revered
thermal: increase extensibility of collagen structure, decrease joint stiffness, pain relief, increase blood flow, decrease muscle spasm
ultrasound therapeutic effects
Revered
nonthermal: stimulation of tissue regeneration, pain relief, soft tissue repair, increase blood flow,
ultrasound therapeutic effects (nonthermal)
Revered
soft tissue repair, contracture, bone fracture, trigger point, dermal ulcer, scar tissue, pain, plantar wart, muscle spasm
indications for u/s
Revered
over eyes, over pregnant uterus, over cemented prosthetic joint, impaired circulation, impaired pain or temp sensory deficits, over heart, over testes, over epiphyseal areas in children, infection, over malignancy
contraindications for u/s
Revered
place transducer over area before turning on machine (and gel already applied to head). move in small circular pattern over treatment area. maintain contact with skin and stay within treatment area. an area two to three times the size of the transducer typically requires a duration of five minutes of treatment. intensity for continuous u/s is normally set btwn .5 to 2 w/cm2 for thermal effects. pulsed u/s is normally set between .5 to .75 w/cm2 with a 20% duty cycle for nonthermal effects
u/s treatment parameters
Revered
beam nonuniformity ratio: ratio of intensity of highest peak to average intensity of all peaks. lower BNR, more favorable, since most patients will be less likely to experience hot spots and or discomfort during treatment. BNR values should range btwn 2:1 and 6:1, most devices often fall in 5:1 or 6:1 range.
BNR
Revered
effective radiating area. area of transducer that transmits u/s energy. always smaller than total size of transducer head.
ERA
Revered
occurs as a result of acoustic energy generated by u/s that develops into microscopic bubbles causing cavities that surround soft tissues. the bubbles expand and contract.
acoustic cavitation
Revered
stable cavitation: microscopic bubbles increase and decrease in size but do not burst. triggers microsteaming. transient (unstable) cavitation: microscopic bubbles increase in size over multiple cycles and implode. this causes brief moments of local temperature ad pressure increases in area surrounding those bubbles. process should not occur during therapeutic u/s since intensities required are much higher than 3 w/cm2.
2 types of cavitation that occur:
Revered
minute flow of fluid that takes place around vapor-filled bubbles that oscillate and pulsate
microsteaming
Revered
term for the consistent and circular flow of cellular fluids that results from u/s. responsible for altering cellular activity and the transport of fluids to different portions of the field.
acoustic streaming
Revered
use of u/s for transdermal delivery of medication. u/s enhances the distribution of medication through the skin, provides a high concentration of the drug directly to the treatment site and avoids risks that may be involved with injection of medication. medications regularly used in phonophoresis include anti-inflammatory agents or analgesics. effective with both continuous and pulsed techniques.
phonophoresis
Revered
the internal and external use of water in the treatment of disease. transfers heat thru conduction or convection and is administered in tanks of varying sizes. main therapeutic effects: wound care, unloading of weight, and reduction of edema.
hydrotherapy
Revered
(archmides): there is an upward force on body when immersed in water equal to amount of water that has been displaced by the body. ability to float in water results from the body possessing a specific gravity less than that of water.
buoyancy
Revered
water exerts pressure that is perpendicular to the body and increases in proportion with the depth of immersion
hydrostatic pressure
Revered
water molecules tend to attract to each other and provide resistance to movement of the body in the water. resistance by water increases in proportion to speed of motion.
resistance
Revered
computation for specific gravity of water is equal to 1. human body varies based on size and somatotype but typically has a specific gravity of less than 1 (average .974). therefore, a personal will generally float when fully submerged in water.
specific gravity
Revered
measure of the ability of a fluid to store heat. calculated as amount of thermal energy required to increase fluid’s temp by one unit. water can store 4 times the heat as compared to air. water’s thermal conductivity is approx 25 times faster than air at the same temp.
specific heat
Revered
comprised of profile drag, wave drag and surface drag forces. is a hydromechanic force exerted on a person submerged in water that normally opposes the direction of the body’s motion.
total drag force
Revered
increase blood flow, increase core temp, relaxation, pain relief, vasodilation, decrease abnormal tone, wound/debridement
therapeutic effects of hydrotherapy:
Revered
burn care, superficial heating or cooling, edema control, muscle strain, arthritis, desensitization of residual limb with contrast bath, pain management, wound care, decreased ROM, pool therapy/exercise, sprain, joint stiffness, muscle spasm/spasticity
indications for hydrotherapy:
Revered
peripheral vascular disease, gangrene, severe infection, urinary/fecal incontinence, advanced cardiov or pulm disease, buerger’s disease w/contrast bath, impaired circulation, renal infection, bleeding surface area, diminished sensation
contraindication for hydrotherapy:
Revered
extremity tank, lowboy tank, highboy tank, hubbard tank, therapeutic pool
types of hydrotherapy
Revered
32-79 degrees: acute inflammation of distal extremities, 79-92 degrees: exercise, 92-96: wound care, spasticity, 96-98: cardiopulmonary compromise, treatment of burns, 99-104: pain management, 104-110: chronic rheumatoid or osteoarthritis, increased ROM
treatment temps for water
Revered
treatment time ranges from between 10 and 30 mins. select water temp based on diagnosis and goals and assist pt into comfortable position, monitor vital signs and level of comfort.
treatment parameters for whirlpool
Revered
general contraindications for superficial or deep heating, including incontinence, open areas, fear of water, confusion, and significant respiratory pathology. recommended populations for pool therapy include patients with arthritis, musculoskeletal injuries, neuro deficits, sci, cva, ms, and selected cardiopulmonary diagnoses. tank must be cleaned after each use with a disinfectant and antibacterial agent.
treatment parameters for pool therapy
Revered
modality that applies mechanical forces to body to separate joint surfaces and decrease pressure. force can be applied manually by therapist or mechanically by a machine.
mechanical agent: traction
Revered
joint distraction, soft tissue stretching, muscle relaxation, reduction of disk protrusion, joint mobility
therapeutic effects of traction
Revered
nerve impingement, herniated or protruding disc, subacute joint inflammation, spondylolisthesis, joint hypomobility, paraspinal muscle spasm, degenerative joint disease, osteophyte formation
indications for traction
Revered
when motion is contraindicated, joint instability, tumor, pregnancy, acute inflammatory response, acute sprain, osteoporosis, fracture
contraindications for traction
Revered
treatment time is 5-20 mins. cervical: pt supine with approx 25-35 degrees of neck flexion, should start with a force btwn 10-15 lbs and progress to 7% of pt’s body weight as tolerated for separation of vertebrae. lumbar can be supine or prone, and should be set with a force of less than half body weight for initial treatment. traction force of 25-50 lbs is recommended when initiating mechanical lumbar traction. force of up to 50% of body weight is required for actual separation of the vertebrae.
treatment parameters for traction
Revered
physical agent that applies a mechanical force to increase pressure on treated body part. works to keep venous and lymphatic flow from pooling into interstitial space. static compression utilizes bandaging and compression garments to shape residual limbs, control edema, prevent abnormal scar formation, and reduce risk of dvt. intermittent compression with a pneumatic device is used to reduce edema.
compression
Revered
control of peripheral edema, shaping of residual limb, management of scar formation, improve lymphatic and venous return, and prevention of DVT
therapeutic effects of compression
Revered
lymphedema, new res limb, risk for DVT, edema, stasis ulcers, hypertrophic scarring
indications for compression
Revered
malignancy of treated area, DVT, unstable or acute fracture, heart failure, infection of treated area, pulm edema, circulatory obstruction
contraindications for compression
Revered
therapist should measure girth and bp. therapist should set parameters based on desire effect. stockinette should be put over extremity and then compression sleeve. 3:1 ratio is generally used for on/off time with inflation btwn 40 to 100 seconds and deflation btwn 10-35 seconds. inflation pressure generally ranges from 30-80 mm Hg and should not exceed patient’s diastolic bp. treatment of upper extremities generally requires btwn 30 and 60 mm Hg of inflation pressure while treatment of LEs requires btwn 40 and 80 mm Hg of inflation pressure. treatment time varies for diagnosis, from 2-4 hours and is utilized from 3 x per week to 3 x per day. when treatment time is up, therapist should reassess extremity and remeasure girth and bp
treatment parameters
Revered
form of energy that is used therapeutically and absorbed one to two millimeters into the skin. divided into UV-A and UV-B, and UV-C. most effective use of UV is to treat skin disorders
UV: ultraviolet light
Revered
facilitate healing, exfoliation, Vit D production, increase pigmentation, tanning
therapeutic effects of UV
Revered
acne, psoriasis, tetany, Vit D deficiency, chronic ulcer/wound, osteomalacia/rickets, sinusitis
indications for UV
Revered
photosensitive meds, lupus erythematosus, tb, herpes, renal or hepatic pathology, DM, pellagra
contraindications for UV
Revered
therapist must obtain a minimal erythemal dose before treatment (MED). this is the time of exposure needed to produce an area of mild redness btwn 8 and 24 hours after treatment. MED is tested by paper cutouts on forearm and therapist should wear goggles. squares on skin should be exposed in 15 sec increments for 15, 30, 45, 60 and 75 seconds and inspected after an 8 hr period to determine MED. treatment time should increase each consecutive treatment day since skin adapts to the UV exposure.
treatment parameters for UV
Revered
manual therapeutic modality that produces physiologic effects through stroking, rubbing, and pressure.
massage
Revered
light in stroke and produces a reflexive response. performed at beginning and end of massage to allow patient to relax and should be directed towards the heart.
effleurage
Revered
incorporates small circular motion over a trigger point or muscle spasm. deep massage technique that penetrates into the depth of a muscle and attempts to reduce edema, loosen adhesions, and relieve muscle spasm. used with chronic inflammation or with overuse injuries
friction
Revered
kneading where muscle is squeezed and rolled under therapist’s hands. distal to proximal sequence of kneading over muscle. can be performed with 2 hands over larger muscle groups or with as few as two fingers over smaller muscles.
petrissage
Revered
provides stimulation through rapid and alternating movements such as tapping, hacking, cupping, and slapping. purpose is to enhance circulation and stimulate peripheral nerve endings
tapotement
Revered
places hands or fingers firmly over area and uses a rapid shaking motion that causes vibration to treatment area. used primarily for relaxation.
vibration
Revered
increases lymphatic circulation, removal of metabolic waste, decrease muscle atrophy, decrease anxiety and tension, facilitate healing, stimulate reflexive effects, reduction of edema, loosen adhesions, decrease muscle spasm
therapeutic effects of massage
Revered
pain, decreased ROM, edema, adhesions, myositis, lactic acid excess, migraine, trigger point, muscle spasm and cramping, scar tissue, bursitis, tendonitis, intermittent claudication, raynaud’s syndrome
indications for massage
Revered
infection, arterioscelrosis, thrombus, cellulitis, acute injury, embolus, cancer.
contraindications for massage
Revered
used for facilitation of skeletal muscle contraction, stimulation of denervated muscle, pain management, to retard muscle atrophy, osteogenesis, driving medications through the skin, and wound management
electrotherapy
Revered
cardiac pacemaker, patient with a bladder stimulator, over carotid sinus, seizure disorders, phlebitis, malignancy, over a pregnant uterus, cardiac arrhythmia, osteomyelitis
contraindications
Revered
techniques include: monopolar, bipolar, and quadripolar
electrode configuration
Revered
active (smaller) electrode is placed over target area. second dispersive electrode is placed at another site away from the target area. used for wounds, iontophoresis, and treatment of edema
monopolar
Revered
2 active electrodes are placed over target area. electrodes usually same size. used for muscle weakness, neuromuscular facilitation, spasms, and ROM
bipolar
Revered
2 electrodes from 2 separate stimulating circuits are positioned so that the individual currents intersect with each other. utilized with interferential current.
quadripolar
Revered
when using a smaller electrode it is particularly important to understand that since the current density is quite high compared to a larger electrode, the patient will be more susceptible to pain and potential tissue damage.
electrode size
Revered
increased current density, increased impedance, decreased current flow
small electrodes
Revered
decreased current density, decreased impedance, increased current flow
large electrodes
Revered
pain management, urinary incontinence, edema management, osteoarthritic pain, migraines
estim indications
Revered
malignancy, with all types of electrical implants, during first trimester of pregnancy, over lower abdomen/uterus during pregnancy, over anterior transcervical area
estim contraindication
Revered
also known as galvanic, constant flow of electrons from anode to cathode without interruption. iontophoresis uses direct current
direct current
Revered
polarity that changes from positive to negative with change in direction of current flow. biphasic, symmetrical or asymmetrical, and is a waveform that is sinusoidal in shape. used in muscle retraining, spasticity and stimulation of denervated muscle
alternating current
Revered
combines two high frequency alternating waveforms that are biphasic. used for deep muscle stimulation. attempts to reach deeper tissues using higher frequencies of each waveform along with overall shorter pulse widths. uses a frequency of 50-1250 pps and a pulse width of 50-150 microseconds for pain management; and a frequency of 20-50 pps and pulse width of 100-200 microseconds for muscle contractions
interferential current
Revered
medium frequency polyphasic waveform. alternating current is produced in a 50 burst per second interval with a pulse width range of 50-200 microseconds, and an interburst interval of 10 milliseconds. type of NMES or FES and is believed to augment muscle strengthening by depolarizing both sensory and motor nerve fibers resulting in tetanic contractions that are painless and stronger than those made voluntarily by the patient. electrode should be placed parallel to muscle fibers along line of pull of muscle group.
russian current
Revered
average peak current amplitude of 100 mA, 50 bursts per second, with on/off time ration of 10/50. usually is done 10 evoked contractions with a 10 second contraction and a 50 second rest period between each of the 10 contractions.
russian stim parameters
Revered
neuromuscular electrical stimulation: used to facilitate skeletal muscle activity. stim of an innervated muscle occurs when an electrical stimulus of appropriate intensity and duration is administered to the corresponding peripheral nerve. commonly used to facilitate return of controlled functional muscular activity or to maintain postural alignment until recovery occurs.
NMES
Revered
bipolar electrode placement over muscle. interrupted current is used with a range of 20-40 pulses per second an on time of 6-10 secs followed by off time of approx 50-60 secs. 15-20 mins for several times a day
NMES parameters
Revered
widely used for acute and chronic inflammation. main effects of TENS include pain relief through gate control theory. used for home use and is portable.
TENS: transcutaneous electrical nerve stimulation
Revered
cardiac pacemakers, epilepsy, during 1st trimester
TENS contraindications
Revered
conventional, acupuncture like, pulse burst, and brief intense (high-intensity)
TENS Parameters
Revered
frequency: 50-100 Hz, duration: 20-100 microseconds, amplitude: 10-30 mA
conventional TENS
Revered
frequency: 1-4 Hz, 100-200 microseconds, amplitude: 30-80 mA
acupuncture like TENS
Revered
frequency: 70-100 Hz/burst, duration: 40-75 microseconds, amplitude: 30-60 mA
pulse burst
Revered
frequency: 70-100 Hz/burst, duration: 150-200 microseconds, amplitude: 30-60 mA
brief intense (high intensity)
Revered
electrodes may be placed on sites of nerve roots, trigger points, acupuncture sites or key points of pain and sensitivity. net polarity is normally equal to zero. if waveform is unbalanced, there will be an accumulation of charges that will lead to skin irritation under the electrodes. includes a pulse duration that can vary from 20-400 microseconds; pulse frequency that varies in range from 1-200 Hz, and current amplitude from .1-120 mA.
TENS guidelines
Revered
process by which medications are induced through the skin into the body by means of continuous direct current electrical stimulation. medication is separated into ions based on the polarity of the current.
iontophoresis
Revered
acidic reaction can cause hardening of skin. alkaline reaction can cause skin to soften over time.
acidic/alkaline reaction
Revered
technique used to stabilize the pH of skin during ionto by placing buffering agents into electrode pads that cover drug reservoir area within the electrode
buffering
Revered
decomposition of a compound that results from passing an electrical current through it
electrolysis
Revered
occurs during ionto where there is an exchange btwn ions within solutions and electrodes
electron exchange
Revered
decomposition of water when electrical current is passed through it. water will be reduced to a net accumulation of hydrogen ions (H+) under anode and hydroxyl ions (OH-) under the cathode.
redox reaction
Revered
pt should never lie on top of electrodes. unit should be set to continuous direct current. polarity must be set to same polarity as ion solution. ion solution should be massaged into treatment site or space within electrode. conductive surface area of the negative electrode (cathode) is twice the size of the conductive surface area of the positive electrode (anode) regardless of which on is the active electrode. active electrode must be placed over target area the the dispersive electrode should be placed as far as possible from active electrode. slowly increase intensity towards a max of five milliamperes. treatment should last 15-20 mins. additional time is required for treatment at an intensity of less than five milliamperes.
iontophoresis parameters
Revered
positive charge: lidocaine, hydrocortisone, histamine, lithium, magnesium, zinc. negative charge: acetate, dexamethasone, salicylate, iodine, chlorine, tap water (+ and -)
therapeutic ions and charge
Revered
high voltage pulsed current: twin peak monophasic, pulsed current. produces high electromotive forces. has a phase duration of 5-20 microsecs (fixed in most machines), a short pulse duration that ranges btwn 100-200 microsecs, and voltage greater than 150V to a max of 500V. one large dispersive pad along with one, two or four active electrodes. active electrodes can be positive or negative in polarity based on treatment goals.
hvpc
Revered
wound management, pain management, soft tissue edema, levator ani syndrome, muscle spasm, muscle weakness, bell’s palsy
indications for hvpc
Revered
cardiac pacemakers, over heavy scarring tissues, malignancy, pregnancy
contraindications for hvpc
Revered
secure one electrode over wound (using warm sterile gauze and sponge) and other over healthy skin a min of 5 cm from wound itself. polarity should be in reversal mode so that it allows for 50% of treatment with positive polarity. frequency is generally 30-200 pps, amplitude 1-500V, and duration of treatment from 10-60 mins per session. dermal wounds should be treated 5-7 days per week for best results
hvpc parameters
Revered
science of evaluating motor units (anterior horn cell, axon, neuromuscular junctions and muscle fibers innervated by unit) through use of intramuscular needle electrodes or surface electrodes. potentials include abnormal: spontaneous and voluntary.
electromyography
Revered
modality that uses an electromechanical device to provide visual and or auditory feedback. can be utilized to receive information related to motor performance, kinesthetic performance or physiological response. can measure peripheral skin temp, changes in blood volume thru vasodilation and vasoconstriction using finger phototransmission, sweat gland activity, and electrical activity during muscle contraction. electromyographic feedback is the most commonly used biofeedback modality in clinical setting.
biofeedback
Revered
muscle activity, heart rate, balance, skin temp, bp, posture, abnormal mvmt, normal mvmt
biofeedback measures:
Revered
myoelectric/electromyographic biofeedback, EMG-BF, position biofeedback, bp biofeedback, respiratory bioFB, sphincter control biofb, temp and blood flow bioFB, electroencephalographic bioFB
types of feedback
Revered
muscle relaxation, improve muscle strength, decrease muscle spasm, neuromuscular control, decrease accessory muscle use, decrease pain
biofeedback therapeutic effects
Revered
muscle spasm, pain, sci, urinary incontinence, improve neuromuscular control, muscle weakness, hemiplegia, cp, bowel incontinence, promote relaxation
biofeedback indications
Revered
any condition where muscle contraction is detrimental, skin irritation at electrode site
biofeedback contraindications
Revered
2 active electrodes and 1 ground electrode in a bipolar arrangement best deletes “noise” (noise is any extraneous electrical activity not produced by the contraction of the muscle). surface electrodes with some form of conduction gel are required to adhere to prepared, clean skin. electrodes should be placed parallel to direction of the muscle fibers, set level of sensitivity on device relative to treatment goals: low level sensitivity settings for muscle re-education, high level sensitivity setting for relaxation
biofeedback treatment guidelines
Revered
2 active electrodes should be placed parallel to muscle fibers and close to each other. reference or ground electrode can be placed anywhere on the body, but is often secured between 2 active electrodes. signals are transmitted to a differential amplifier and info is conveyed thru visual and audio feedback. for muscle re-education, should begin with pt performing a max muscle contraction. sensitivity of bfb unit should be set at a low sensitivity setting and adjusted so that the pt can perform reps at a ratio of 2/3rds of max muscle contraction. isometric contractions should continue for 6-10 secs with relaxation in btwn each contraction. treatment duration for a single muscle group is 5-10 mins. treatment for muscle relaxation requires a high sensitivity setting and a similar electrode placement with active electrodes initially positioned close to each other. as patient improves with relaxation, electrodes should be placed further apart and sensitivity setting increased. during this treatment, patient may also benefit from adjunct relaxation techniques such as imagery. treatment duration of 10-15 mins is usually adequate to attain relaxation.
biofeedback treatment parameters
Revered
ground fault circuit interrupter: designed to cut off electrical supply to a piece of equipment if it detects any form of leakage or ground fault.
gfci:
Revered
…
electrotherapy terms
Revered
an occurrence where a nerve and muscle membrane’s threshold for excitability increases secondary to a stimulation by a pulse that has a slow phase rise time. the quicker the rise time, the less the nerve can accommodate to the impulse.
accommodation
Revered
alternating current allows for the constant change in flow of ions
alternating current (biphasic)
Revered
unit of measure used to describe rate of current
ampere
Revered
magnitude of current. often labeled intensity or voltage.
amplitude
Revered
positively charged electrode that attracts negative ions
anode
Revered
negatively charged electrode that attracts positive ions
cathode
Revered
pulse that moves in one direction, returns to baseline, then in other direction and back to baseline again within a predetermined amount of time.
biphasic
Revered
symmetrical: positive phase is identical to negative phase, asymmetrical: positive phase and negative phase are not identical in shape, balanced: positive phase’s electrical charge is equal to negative phase’s electrical charge, unbalanced: positive phase and negative phase do not have identical electrical charges
types of biphasic pulse
Revered
interrupted group of pulses that are delivered in a finite series and a predetermined frequency
burst
Revered
property of an insulator that allows for the storage of energy when opposing surfaces of the insulator have an electrical potential difference
capacitance
Revered
testing procedure used to measure amount of time required to produce a small muscle contraction at a particular intensity
chronaxie
Revered
ease at which a particular material will allow current flow (mho)
conductance
Revered
flow electrons from one place to another
current
Revered
constant unidirectional flow of ions. dependent on polarity
direct current (monophasic)
Revered
time period of stimulation and time period of rest btwn periods of stimulation.
duration of stimulus/duration of rest
Revered
percentage of time that electrical current is on in relation to entire treatment time.
duty cycle
Revered
resistance of a tissue to electrical current
electrical impedance
Revered
determines number of pulses delivered through each channel per second. often labeled “rate”
frequency
Revered
characterized by a waveform greater than 150 volts with a short pulse duration. is intermittent and is used for deeper tissue penetration
high volt current
Revered
property of a substance that provides resistance to flow of current by offering an alternate current
impedance
Revered
how easily a certain material will induce an electromotive force (emf) within a circuit
inductance
Revered
period of time of electrical inactivity btwn each pulse, usually expressed in microsecs or millisecs
interpulse interval
Revered
positively or negatively charged atome
ion
Revered
waveform of less than 150 volts and is used for neuromuscular stimulation
low volt current
Revered
pulse that has either a positive or negative polarity and moves in only one direction from a zero baseline and returns to baseline within a predetermined amount of time
monophasic
Revered
gained one or more electrons and possesses a negative charge
negative ion
Revered
current of an electrical current. there is a direct proportional relationship btwn current and voltage and an indirect proportional relationship btwn current and resistance
ohm’s law
Revered
lost one or more electrons and possesses a positive charge
positive ion
Revered
pulse is one individual waveform
pulse
Revered
amount of time that it takes to complete all phases of a single pulse. often labeled “pulse width”
pulse duration
Revered
allows for a non-continuous flow of either alternating or direct current with periods of no electrical activity
pulsed current (interrupted)
Revered
refers to number of seconds it takes for amplitude to gradually increase or decrease to the max value set by amplitude control
ramp
Revered
ability of a material to oppose the flow of ions through it
resistance
Revered
minimal intensity used with a long current duration that produces a small muscle contraction
rheobase
Revered
unit of measure of electrical power or electromotive force
volt
Revered
consistent pattern of a current measured on an oscilloscope
waveform
Revered
…
clinical application templates executive summaries
Revered
usually one to two inches above tendinous insertion on calcaneous, greatest btwn 30-50 yrs of age, typically be unable to stand on their toes and tend to exhibit a positive Thompson test
achilles tendon rupture
Revered
occurs more in middle-aged population, greater incidence in women, arthrogram can assist with dx by detecting decreased volume of fluid within the joint capsule, ROM restriction typically in a capsular pattern (lateral rotation, abduction, medial rotation)
adhesive capsulitis
Revered
risk is higher in males, usually occurs between 40-70, clinical presentation may include both upper and lower motorneuron involvement with weakness occurring in a distal to prox progression, average course of dx is 2-5 yrs with only 20-30% of patients surviving longer than five years
amyotrophic lateral sclerosis
Revered
systemic condition, inflammation of spine and larger peripheral joints, males greater risk btwn 20-40, presentation initially includes recurrent and insidious onset of back pain, morning stiffness, and impaired spinal extension
ankylosing spondylitis
Revered
most commonly occurs during hyperflexion, rapid deceleration, hyperextension or landing in an unbalanced position, females involved in selected sports have higher ligament injury rates, approx 2/3 of time acl is completely torn, there is an associated meniscal tear
anterior cruciate ligament sprain
Revered
increased incidence of injury is associated with selected sports such as baseball pitching, swimming, rowing, gymnastics, and tennis; characterized by subjective reports of a deep ache directly in front and on top of the shoulder made worse with overhead activities or lifting, examination may reveal a positive speed’s test or yergason’s test
bicipital tendonitis
Revered
incidence is higher in females with most common age being from 35-55, muscle atrophy is often noted in abductor pollicis brevis muscle and later in the thenar muscles; electromyography studies, tinel’s sign, and phalen’s test can be used to assist with confirming diagnosis
carpel tunnel syndrome
Revered
spastic cp involves upper motor neuron damage; athetoid cp involves damage to cerebellum, cerebellar pathways or both; clinical presentation includes motor delays, abnormal muscle tone and motor control, reflex abnormalities, poor postural control, and balance impairments; mental retardation and epilepsy are present in 50-60% of children diagnosed with cp.
cerebral palsy
Revered
types include ischemic (thrombus, embolus, lacunar) and hemorrhagic stroke (intracerebral, subdural, subarachnoid), left CVA may present with weakness or paralysis to rt side, impaired processing, heightened frustration, aphasia, dysphagia, and motor apraxia. right cva may present with weakness or paralysis to left side, poor attention span, impaired awareness and judgment, spatial deficits, memory deficits, emotional lability, and impulsive behavior
cva: cerebrovascular accident
Revered
etiologies include arrhythmia, pulm embolism, hypertension, valvular heart disease, myocarditis, unstable angina, renal failure, severe anemia;
chf: congestive heart failure
Revered
causes exocrine glands to overproduce thick mucus which causes subsequent obstruction, autosomal recessive genetic disorder located on long arm of chromosome seven, terminal disease but death age has increased to 32 yrs due to early detection and management
cystic fibrosis
Revered
caused by weakening of joints that allows for forward slippage of one vertebral segment on one below due to degenerative changes, most common site is L4/L5, william’s flexion exercises may be indicated to strengthen abs and reduce lumbar lordosis
degenerative spondylolisthesis
Revered
insulin is functionally absent due to destruction of beta cells of pancreas; where insulin would normally be produced. starts in children ages 4 or older, adolescense. symptoms include polyuria, polydipsia, polyphagia, nausea, weight loss, fatigue, blurred vision, and dehydration
diabetes mellitus (type 1)
Revered
clinical presentation: hypotonia, flattened nasal bridge, simian line (palmar crease), epicanthal folds, enlargement of tongue and dd.
down syndrome
Revered
x linked recessive trait manifesting in only male offspring while female offspring become carriers. waddling gait, prox muscle weakness, toe walking, pseudohypertrophy of calf and difficulty climbing stairs. rapid progression of this disease with inability to ambulate by ten to 12 yrs of age with death occurring as teenager or less frequently in the 20’s.
duchenne muscular dystrophy
Revered
nonarticular rheumatic condition with pain caused by tender points within muscles, tendons, and ligaments. pain exists in all 4 quadrants of body and there is pain in at least 11 of 18 standardized tender point sites
fibromyalgia
Revered
burn causes immediate cellular and tissue death and subsequent vascular destruction, eschar forms from necrotic cells and creates a dry and hard layer that requires debridement. absent sensation and pain due to destruction of free nerve endings
full thickness burns
Revered
motor weakness in a distal to prox progression, sensory impairment, and possible respiratory paralysis. may be an autoimmune response to a previous respiratory infection, flu, immunization or surgery. patients usually have full recovery
guillain barre syndrome
Revered
chronic progressive genetic disorder that is fatal within 15 to 20 yrs after clinical manifestation. degeneration and atrophy of basal ganglia (stiatum) and cerebral cortex w/in brain. clinically presents with enlarged ventricles secondary to atrophy of basal ganglia, mental deterioration, speech disturbances and ataxic gait
huntingtons disease
Revered
autoimmune disorder found in children less than 16 that occurs when immune cells mistakenly begin to attack the joints and organs causing local and systemic effects. girls more likely than boys. symptoms include joint swelling, pain, stiffness
juvenile rheumatoid arthritis
Revered
inflammation or degenerative changes at common extensor tendon that attaches to lateral epicondyle of elbow. repeated overuse of wrist extensors. clinical symptoms include difficulty holding or gripping objects and insufficient forearm functional strength
lateral epicondylitis (tennis elbow)
Revered
consists of dermal and epidermal layers, air follicles, nails, sebaceous glands, sweat glands
integumentary system
Revered
true skin: well vascularized, elastic, flexible and tough.
dermis
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avascular, consists of outermost layer of skin
epidermis
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occur secondary to ischemia from inadequate circulation of oxygenated blood often due to complicating factors such as atherosclerosis
arterial insufficiency ulcers
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occur secondary to inadequate functioning of the venous system resulting in inadequate circulation and eventual tissue damage and ulceration
venous insufficiency ulcers
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decubitus ulcer: results from sustained or prolonged pressure at levels greater than the level of capillary pressure on the tissue
pressure ulcer
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secondary complication usually associated with a combination of ischemia and neuropathy. most often associated with diabetes. frequently found on plantar surface of foot, often beneath the metatarsal heads. wound has good granulation tissue and little or no drainage. often do not report pain due to altered sensation
neuropathic ulcer
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lower one third of leg, toes, web spaces. smooth edges, well defined, lack of granulation tissue, tend to be deep. severe pain, diminished or absent pedal pulses, normal edema, decreased skin temperature, thin and shiny tissue, hair loss, yellow nails. leg elevation increases pain.
arterial ulcers
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proximal to the medial malleolus, irregular shape, shallow, mild to moderate pain, normal pedal pulses, increased edema, normal skin temp, flaky, dry skin, leg elevation lessens pain
venous ulcers
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cleansing the ulcer, rest, reducing risk factors, limb protection
intervention for arterial insufficiency ulcer
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cleansing the ulcer, compression to control edema
intervention for venous insufficiency ulcer
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gel forming polymer such as gelatin, pectin, and carboxymethylcellulose with a strong film or foam adhesive backing. absorb exudate by swelling into a gel like mass and vary from being occlusive to semi permeable. does not attach to actual wound itself and is instead anchored to intact skin surrounding the wound.
hydrocolloid dressing
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useful for partial and full thickness wounds. can be effective with granular or necrotic wounds
when to use hydrocolloids
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moist environment for wound healing, enables autolytic debridement, offers protection from microbial contamination, provides moderate absorption, does not require a secondary dressing, provides a waterproof surface
advantages to hydrocolloids
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may traumatize surrounding intact skin upon removal, may tend to roll in areas of excessive friction, cannot be used on infected wounds
disadvantages to hydrocolloids
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consist of varying amounts of water and varying amounts of gel-forming materials such as glycerin, dressings are available in sheet form or amorphous form
hydrogels
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commonly used on superficial and partial thickness wounds (abrasions, blisters, pressure ulcers) that have minimal drainage. rather than absorb drainage, hydrogels are moisture retentive
when to use hydrogels
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provides a moist environment for wound healing, enables autolytic debridement, may reduce pressure and diminish pain, can be used as a coupling agent for ultrasound, minimally adheres to wound
advantages to hydrogels
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potential for dressings to dehydrate, cannot be used on wounds with significant drainage, typically requires a secondary dressing
disadvantages to hydrogels
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composed from a hydrophilic polyurethane base. hydrophilic at wound contact surface and are hydrophobic on the outer surface. allows exudates to be absorbed into the foam through the hydrophilic layer. most commonly available in sheets or pads with varying degrees of thickness.
foam dressings
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used to provide protection over partial and full thickness wounds with varying levels of exudate. can be used as secondary dressings over amorphous hydrogels
when to use foam dressings
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provides a moist environment for wound healing, available in adhesive and nonadhesive forms, provides prophylactic protection and cushioning, encourages autolytic debridement, provides moderate absorption
advantages to foam dressings
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may tend to roll in areas of excessive friction, adhesive form may traumatize periwound area upon removal, lack of transparency makes inspection of wound difficult
disadvantages to foam dressings
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film dressings are thin membranes made from transparent polyurethane with water resistant adhesives. permeable to vapor and oxygen, but are mostly impermeable to bacteria and water. highly elastic, conform to a variety of body contours, and allow easy visual inspection of the wound since they are transparent.
transparent film
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useful for superficial wounds (scalds, abrasions, lacerations) or partial-thickness wounds with minimal drainage.
when to use transparent films
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provides a moist environment for wound healing, enables autolytic debridement, allows visualization of the wound, resistant to shearing and frictional forces, cost effective over time
advantages to transparent films
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excessive accumulation of exudates can result in periwound maceration, adhesive may traumatize periwound area upon removal, cannot be used on infected wounds
disadvantages to transparent films
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most readily available used in inpatient environment. commonly used on infected or non-infected wounds of any size. can be used for wet to wet, wet to moist, or wet to dry debridement. readily available and cost effective but has a tendency to adhere to wound bed. requires frequent dressing changes. increased infection rate compared to occlusive dressings
gauze dressings
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consist of calcium salt of alganic acid that is extracted from seaweed. highly permeable and non-occlusive. requires a secondary dressing. based on the interaction of calcium ions in the dressing and the sodium ions in the wound exudate.
alginates
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typically used on partial and full thickness draining wounds such as pressure wounds or venous insufficiency ulcers, often used on infected wounds due to likelihood excessive drainage.
when to use alginates
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high absorptive capacity, enables autolytic debridement, offers protection from microbial contamination, can be used on infected or uninfected wounds, non-adhering to wound
advantages to alginates
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may require frequent dressing changes based on level of exudate, requires a secondary dressing, cannot be used on wound with an exposed tendon, joint capsule or bone
disadvantages to alginates
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refers to ability of a dressing to transmit moisture, vapor or gases from wound bed to atmosphere. truly occlusive substance would be completely impermeable, while a truly non-occlusive substance would be completely permeable.
occlusion
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hydrocolloids, hydrogels, semi-permeable foam, semi-permeable film, impregnated gauze, alginates, and traditional gauze
most occlusive to non-occlusive
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alginates, semi-permeable foam, hydrocolloids, hydrogels, semi-permeable film
most moisture retentive to least moisture retentive
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primary - direct contact with wound. secondary - directly over primary dressing to provide protection, absorption, and/or occlusion
primary versus secondary dressing
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remove only nonviable tissue from a wound. selective debridement is most often performed by sharp debridement, enzymatic debridement, and autolytic debridement
selective debridement
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red: protect wound, maintain moist environment, yellow: moist yellow slough. debride necrotic tissue and absorb drainage. black: debride necrotic tissue.
red-yellow-black tissue
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requires use of scalpel, scissors, and/or forceps to selectively remove devitalized tissues, foreign materials or debris from a wound. most often used for wounds with large amounts of thick, adherent, necrotic tissue, also for cellulitis or sepsis. most expedient form of removing necrotic tissue. PTs are permitted to perform sharp debridement in the majority of states.
sharp debridement
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topical application of enzymes to surface of necrotic tissue. can be used on infected and non-infected wounds with necrotic tissue. may be used in wounds that have not responded to autolytic debridement or in conjunction with other debridement techniques. can be slow to establish a clean wound bed and should be discontinued after removal of devitalized tissues in order to avoid damage
enzymatic debridement
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using body’s own mechanisms to remove nonviable tissue. methods include transparent films, hydrocolloids, hydrogels and alginates. results in a moist wound environment that permits rehydration of the necrotic tissue and eschar and allows enzymes to digest the nonviable tissue. can be used with any amount of necrotic tissue and is non-invasive and pain free; however takes longer for wound healing to occur. should not be performed on infected wounds.
autolytic debridement
