Biophysical Agents midterm

_____ responds to high intensity mechanical and thermal stimuli and conduct the signal very quickly which indicates the location of the stimulus and generates a withdrawal response. A. A-delta B. C fibers C. A-beta D. Histamine

A. A-delta

____ is described as sharp, stabbing, and prickling. Short lasting. A. A-delta B. C fibers C. A-beta D. Histamine

A. A-delta - Short lasting

______ refers to the decrease in analgesic effectiveness from repeated use if a given therapeutic method A. Analgesic tolerance B. Central sensitization C. Peripheral sensitization D. Central inhibition

A. Analgesic tolerance - Occurs through repeated stimulation of opioid receptors. The use of opioid meds repeatedly can result in analgesic tolerance due to repeated activation of these micro-opioid meds use and high freq TENS application - When we are deciding which freq of TENS applications to use, may need to consider pt's meds

How do you test the effectiveness of the modality?

Assesses the response of the patient post treatment to determine the effectiveness by utilizing the right outcome measures

Which of the following is a precaution for E-stim? A. Anterior thoracic region B. Areas of poor integrity C. Transcranially D. Pacemaker

B. Areas of poor integrity - All the others are CONTRAINDICATIONS

When would it be important to include a 1 or 2 second ramp down time during FES for gait? A. When the patient has spasticity B. When the patient has a foot slap C. When the device feels uncomfortable for the patient D. All of the above are correct

B. When the patient has a foot slap

The continuum of tissue conductivity and water content

Best to worst.

With muscle re-education we might select a 10 second muscle contraction. Because we need a rest in between contractions to replenish ATP creatine phosphate energy storage to the muscle, we might select a 50 second off time. As a result, our on/off ratio in this instance would be A. 10:50 B. 50:10 C. 1:5 D. 5:1

C. 1:5

If the burst frequency is 50 bursts per second, what is the pulse in each burst? A. 50 B. 100 C. 25 D. 75

C. 25

Which of the following is the PEAK amplitude allowable for iontophoresis with a direct current to prevent risk of burns. A. 10 mA B. 2 mA C. 4 mA D. 6 mA

C. 4 mA

If we have a pulse duration of 400 microseconds and an off time of 800 microseconds, then we would have a total time of 1200 microseconds. As a result the duty cycle would be.. A. 800 usec/ 1200 usec X 100 B. 1200 usec/ 800 usec X 100 C. 400 usec/ 1200 usec X 100 D. 800 usec/ 400 usec X 100

C. 400 usec/ 1200 usec X 100

_____ pain results from injury and/or disease causing potential or real tissue damage. Typically lasts less than 3 months. A. Chronic B. Referred C. Acute D. immediate

C. Acute - Associated with measurable changes - Biologically meaningful - Often associated with an actual physiological even such as infection, trauma, metabolic disorder, or degenerative changes - Superficial vs deep

_____ is the continuous flow of electrons in a bi-directional flow pattern, and the continuous flow changes direction AT LEAST once per second. A. Direct currents B. Indirect currents C. Alternating currents D. Pulsatile currents

C. Alternating currents

I focusing on muscle spasticity, there are 2 theories that exist that show a transient reduction in spastic muscles which of the following is NOT one of theories A. Applied to the antagonistic muscle with theoretical reciprocal inhibition B. Applied to the spastic muscle for fatigue C. Applied to the tight muscle for stretching

C. Applied to the tight muscle for stretching

_____ is a characteristic of chronic pain, and this refers to the neural signals within the CNS being amplified or hypersensitivity. A. Acute pain B. Chronic pain C. Central sensitization D. Referred pain

C. Central sensitization

Which of the following is INCORRECT in regards to sub-acute and chronic edema reduction A. Whether you elicit a twitch or contraction, ALWAYS add elevation whenever possible to assist in edema reduction B. Elevation also would be added with acute sensory-level E-STIM (HVPC) whenever possible C. Combining cryotherapy with twitch or contraction motor response will assist in edema reduction D. All of the above are correct

C. Combining cryotherapy with twitch or contraction motor response will assist in edema reduction - DO NOT combine cryotherapy with twitch or contraction motor response

With motor nerve conduction studies, we will be looking for a ______ to occur, which is recognized as the depolarization of all motor units underneath a specific electrode. A. M wave B. F wave C. Compound Muscle Action Potential (CAMP) D. H reflex

C. Compound Muscle Action Potential (CMAP) - Two electrodes are positioned on a distal muscle innervation by the nerve being tested. - Nerve is stimulated at various sites within the path from proximal to distal - The stimulation is incrementally increased until a maximal CMAP is generated - Active electrode is usually positioned closest to the motor point and the reference electrode positioned somewhere that no excitation occurs. - A third ground electrode is then used over a bony prominence of some soft. Two stimulation sites are required since there is no way to calculate the conduction across a NMJ.

Which of the following is TRUE in regards to acute edema. A. IFC has been shown to be an effective treatment for limiting the onset of swelling B. Evidence suggest that two 4 hour treatments (30-60 min apart) a day resulted in significant edema reduction C. Continuous application of HPVC for 3 to 4 hours was found to be even more effective in limiting edema formation D. All of the above are correct

C. Continuous application of HPVC for 3 to 4 hours was found to be even more effective in limiting edema formation - HVPC has been shown to be an effective treatment for limiting the onset of swelling only during the ACUTE period when vascular permeability is increased - Evidence suggest that four 30 min treatments (30-60 min apart) a day resulted in significant edema reduction

Which of the following electrode configuration is the BEST for delivering IFC? A. Bracketed B. Bilateral with distal points C. Crossed method D. Unilateral/ linear

C. Crossed method

Involvement of the CNS would be confirmed mostly through: A. NCS B. EMG C. Direct imaging D. SSEP

C. Direct imaging - A follow up with ENMG analysis might be warranted as an adjunct to rule out any presence of PNS involvement.

______ are nociceptive specific and receive input ONLY from peripheral nociceptors A. Peripheral sensitization B. Central sensitization C. High threshold neurons D. Wide dynamic range neurons

C. High threshold neurons

Which of the following is FALSE in regards to motor NCS findings? A. Latency values show the state of the myelin around the fastest conducting axons B. If latency value falls above the upper limit of normal, then it is considered slow C. Increase in latency = increase in NCV D. All of the above are correct

C. Increase in latency = increase in NCV is INCORRECT - Increase in latency = decrease in NCV - Since we know that myelin insulates the axon to enable current to be propagated faster and more efficiently, we can discern that if these values are abnormal, then we have some sort of a pathology going on in the area that was stimulated.

Which of the following electrode placements is MOST appropriate when treating medial knee pain that is concentrated in one area? A. Bipolar B. Monopolar C. Linear D. Quadripolar

C. Linear

Which of the following DOES NOT describe the conventional TENS mode: A. Most commonly used mode of TENS B. Frequency may be 80-110 Hz, with a short pulse duration of around 50-100 ms C. Low frequency and high intensity D. Preferentially activates A-Beta afferent fibers (non-painful sensory fibers) E. All of the above are correct

C. Low frequency and high intensity is INCORRECT - High frequency and low intensity

Which of the following is INCORRECT in regards to brief intense TENS mode: A. High frequency, duration, and intensity B. Freq (100-150 Hz), pulse duration (150-250 ms), and highest tolerable intensity the patient can do. C. Most commonly used TENS mode D. All of the above are correct

C. Most commonly used TENS mode - Not used often because it can be noxious or uncomfortable for pt. Can be successful method when other modes have been unsuccessful.

What type of nerve injury is likely after prolonged compression of the peroneal nerve resulting in chronic foot drop with no changes following frequent retesting? A. Neurapraxia B. Axonotmesis C. Neurotmesis D. Axonapraxia

C. Neurotmesis - The distinguishing factor between neurotmesis and axonotmesis is that there is usually no recovery with neurotmesis. In other words, with follow up testing over time, there would still be no improvement and surgical repair would be the only intervention possible as an attempt to recover the nerve integrity

What parameters would be MOST appropriate if you were to attempt to use NMES to decrease spasticity on the agonist (spastic) muscle? A. Pulse rate: 25 pps. Pulse duration: 100 usec B. Pulse rate: 30 pps. Pulse duration: 75 usec C. Pulse rate: 50 pps. Pulse duration: 400 usec D. Pulse rate: 5 pps. Pulse duration: 400 usec

C. Pulse rate: 50 pps. Pulse duration: 400 usec

____ electrode configurations are four electrodes of a single circuit that are on or over target tissue(s). Commonly used with pain modulation (TENS), IFC, and pre-mod A. Monopolar B. Bipolar C. Quadripolar D. Linear

C. Quadripolar

____ pain is typically easier to locate. ___ pain is is often more diffuse. A. Chronic; Acute B. Acute; Chronic C. Superficial; Deep D. Deep; Superficial

C. Superficial; Deep

A ____ is a series of pulses. One pulse after another is sequence. (waveform modulations) A. Ramp B. Modulation C. Train D. Burst

C. Train

______ is the degeneration of an axon after having been severed from the cell body, usually takes time to show up on EMG testing. A. Segmental demyelination B. ALS C. Wallerian degeneration D. CTS

C. Wallerian degeneration

If we have 100 pulses per second we would refer to that as having ______ when talking about IFC. A. 100 pps B. 50 beats C. 50 pps D. 100 beats

D. 100 beats - Our electrode placement selection is extremely important to have the needed interference in the tissue for the desired treatment effect

An appropriate range for muscle re-education is an on/off ratio of ____ depending on the condition. A. 1:5-1:9 B. 2:1-2:5 C. 2:5-2:9 D. 1:3-1:7

D. 1:3-1:7

Which of the following treatment parameters is MOST appropriate when using E-Stim for muscle strengthening? A. 75 pps, 200 usec, 1:1 on/off ratio, ramp up/down 2 sec 8 min 85% max contraction B. 75 pps, 200 usec, 1:5 on/off ratio, ramp up/down 2 sec 8 min 35% max contraction C. 50 pps, 200 usec, 1:5 on/off ratio, ramp up/down 2 sec 8 min 45% max contraction D. 50 pps, 200 usec, 1:5 on/off ratio, ramp up/down 2 sec 8 min 75% max contraction

D. 50 pps, 200 usec, 1:5 on/off ratio, ramp up/down 2 sec 8 min 75% max contraction

Patient presents with pain of unknown origin. Which of the following statements represents the MOST appropriate action? A. Educate the patient about correct posture B. Refer to MD for pain diagnosis C. Perform soft tissue mobilization D. Administer TENS

D. Administer TENS

Which of he following E-Stim would be used for pain? A. TENS unit B. IFC C. Pre-mod D. All of the above

D. All of the above

Central sensitization results in which of the following: A. Increase in responsiveness to noxious and non-noxious stimuli B. Increase in receptive fields C. Decrease in activation thresholds D. All of the above are correct E. Both A and B are correct

D. All of the above are correct

When providing E-Stim to patients with subacute or chronic edema, we need to be mindful of their A. Available ROM B. Involved healing constraints/ restrictions C. Tolerance levels D. All of the above are correct

D. All of the above are correct

Which of the following describes the acupuncture TENS mode: A. Low frequency and high intensity B. Non-painful sensory fibers being activated, muscle twitching/pulsing by activation of A-alpha motor neurons. C. Frequency < 10 Hz (usually 1-4Hz) with a longer pulse duration around 200 ms D. All of the above are correct

D. All of the above are correct

Which of the following is NOT a fundamental parameters for TENS A. Pulse frequency B. Pulse duration C. Amplitude D. All of the above are correct

D. All of the above are correct

Which of the following is a electrophysiological testing type of assessment technique: A. Nerve conduction study (NCS) B. Electromyography (EMG) C. Visual evoked potentials (VEPs) D. All of the above are correct

D. All of the above are correct - *Nerve conduction study (NCS), Electromyography (EMG)* , Visual evoked potentials (VEPs), Somatosensory-evoked potentials (SSEP), Brainstem auditory evoked potentials (BAEPs)

Calculation for the dosing of iontophoresis

Dosage (mA X min)= Current (mA) X Duration (min) - Current amplitude typically between 0.1-4mA - Typical dosages of iontophoresis range from 20-80 mAmin with current amplitudes ranging from 0.1 mA to 4 mA depending on patient tolerance and the current duration.

Edema that results from injury, trauma, or surgery can result in A. Pain B. Decreased ROM/ mobility C. Delays in return of strength D. Delays in return to functional and recreational activities E. All of the above are correct

E. All of the above are correct

Which of the following has iontophoresis been found to be effective when treating A. Inflammatory disorders B. Neuralgia C. Edema D. Scar tissue E. All of the above are correct

E. All of the above are correct

Which of the following is NOT a type of direct current (DC). A. Direct current (DC) B. Interrupted DC C. Reversed DC D. Interrupted reversed DC E. All of the above are types of DC

E. All of the above are types of DC - The current is on one side of the isoelectric line for > 1 sec before being either interrupted or reversed, or both.

Which of the following are nociceptors of the peripheral pain pathways? A. A-delta B. C fibers C. A-theta D. All of the above E. Both A and B

E. Both A and B - A delta: Small myelinated. Respond to mechanical and thermal stimuli. Become sensitized. - C fibers: Small unmyelinated. Respond to broad range of stimuli (polymodal)

A patient has sustained a CVA with R hemiparesis. He suffers from hypertonicity in the R biceps. You decide to use biofeedback to assist in decreasing tone. Which of the following applications would be appropriate? A. Biofeedback to the biceps with a low sensitivity B. Biofeedback to the biceps with high sensitivity C. Biofeedback to the triceps with high sensitivity D. Biofeedback to the triceps with low sensitivity E. Both A and D are correct

E. Both A and D are correct

Phase 1 Insertion (EMG procedures)

- 5 terms to indicate characteristics of neuronal activity: Normal, increased, sustained, decreased, or absent - Normal muscle membrane: brief electrical activation will occur as the needle is inserted, output should be relatively quiet. - Normal insertional activity should cease at about 500 msec. - Abnormal insertion: >500 = prolonged. Severe denervation abnormalities, insertional activity may continue. Chronic, absence of this activity during insertion.

Excitable vs non-excitable tissue classifications

- Excitable tissue: Nerves (-70 mV), muscle fibers (-90 mV), and cell membrane - Non excitable tissue: Bone, fascia, tendons, ligaments

The main difference between NMES and FES

- FES is NMES but with a function! activity that has specific intervention - NMES is used when a muscle contraction is desired form a muscle that has intact innervation.

M wave (CMAP)

- First wave that you will see on the computer readout and indicates the distal motor latency. - Represents the ability of the fastest conducting axon to conduct the signal to the NMJ, then passed the NMJ in order to stimulate the muscle to contract. - M wave is the "muscle" wave as it is the response of the orthodromic signal from the stimulation site to the muscle contraction.

Which of the following is an example of a pulsatile current. A. Iontophoresis B. TENS and NMES C. Russian D. All of the above are correct E. Both B and C are correct

E. Both B and C are correct - Examples: High volt pulsatile current, biphasic waveforms such as TENS and NMES, Russian stimulation (burst-modulating medium frequency alternating current), IFC (amplitude modulated alternating current), and functional electrical stimulation.

Beat (waveform modulations)

- Has to do with IFC. With IFC we are creating an amplitude modulated pulsatile current by taking 2 or more sine waves (alternating currents) that have different frequencies and interfering them in the tissue. - These sine waves of different frequencies go from being completely in phase with each other (*max beat amplitude*) to getting more and more out of phase with each other to where they are completely out of phase (*min beat amplitude* which starts and stops each pulse or beat)

Indications for Iontophoresis

- Inflammatory disorders - Pain - Neuralgia - Edema - Scar tissue - Acne

EMG outcomes

- Innervation integrity - Evidence of motor unit recovery - Findings of neuropathic or myopathic in nature - Localization of injury to specific patterns: Ex is injury consistent with anterior horn cells (ALS, polio), nerve root (tumor, HNP), plexus (stretch, compression), or NMJ (MG) disorders

True or False: Pulsatile currents have a higher risk of burns and direct currents are safest.

FALSE - Direct currents have a higher risk of burns and pulsatile currents are the safest. - This has to do with the average current! - Pulsatile currents: Even if the peak current is high, the average current is very low because of the interpulse interval time (where intensity is 0) and this allows for great clinical outcomes and decreased risk of burns. - Direct currents: The average current is great as it is on all the time at that amplitude.

The purpose of nerve conduction studies is the evaluate motor/ sensory nerve function to determine

- Involvement of PNS - Location of PNS involvement - Intensity of PNS involvement - Systemic/ localized involvement - Motor/ sensory involvements

Transcutaneous Electrical Nerve Stimulation (TENS)

- Method of activating nerve fibers using transcutaneous nerve stimulation, and does not refer to a type of electrical stimulation device. - Apply self-stick electrodes using various methods of electrode placement to the ski to stimulate or activate nerve fibers that essentially override painful stimuli going to the brain.

True or False: Treatment time of TENS should not go past 2 hours

FALSE - Don't go past 1 hr at a time to avoid or minimize ski irritation - After 30 min break, may re-apply

Documentation tips for TENS

- Mode of TENS - Current waveform and stimulator - Parameters - Electrode placement, size, type - Patient position - Treatment duration - Patient tolerance - Pre and post treatment pain assessment

Iontophoresis application

- Monopolar set up: 1 active electrode and 1 dispersive electrodes (Usually larger) - Recall spacing between pads - Select an ion - (I SAD): Dexamethasone (-) anti inflammatory; Lidocane (+) pain relief - Dispense medication on active pad - Attach the cathode/ anode depending on the polarity of the medication.

True or False: There is a good amount of evidence that supports the use of E-Stim for the enhancement of venous return, assistance in edema reduction, or lymphatic drainage compared to acute edema

FALSE - Limited literature and evidence.

True or False: Rather than looking at the location of the injury of nerve conduction (as we did with NCS), with EMG we are looking at the latency of nerve conduction

FALSE - Rather than looking at the latency of nerve conduction (as we did with NCS), with EMG we are looking at the location of the injury and the specific activity of the motor units underneath the electrode

True or False: The burst duration of medium frequency for muscle strengthening using the burst modulating alternating current devices is 4 milliseconds for Russian and 10 milliseconds for Aussie

FALSE - The burst duration of medium frequency devices is 10 milliseconds for Russian and 4 milliseconds for Aussie

True or False: For muscle strengthening using the burst modulating alternating current, the burst intensity should be less than 50% MVC because we want to see a contraction through the full ROM.

FALSE For muscle strengthening using the burst modulating alternating current, the burst intensity should be GREATER than 50% MVC because we want to see a contraction through the full ROM.

True or False: Burst train TENS mode is a combo of conventional TENS mode and Brief intense TENS mode

FALSE! - Combo of conventional and acupuncture

True or False: The main disadvantage toward the use of needle EMG is the electrical shock

False - The main disadvantage toward the use of needle EMG is of course the discomfort upon insertion and with muscle contraction

True or False: Every patient should just do ankle pumps or isometrics to reduce sub acute or chronic edema instead of E-Stim

False - Volitional contractions may still be impossible or insufficient due to the decreased muscle function, and this is why we may not just be able to have the patient perform either ankle or hand pumps, or isometric exercises.

True or False: The closer the electrodes are together, the deeper the current will travel between the two and will impact more deeper tissue.

False! - The closer the electrodes are together, the more superficial the current will travel between the two and will impact more superficial tissue. - The further the electrodes are apart, the deeper the electrical current will travel and thereby reach deeper tissues.

True or False: Acute pain is often associated with decreased muscle tone.

False! - Acute pain is often associated with INCREASED muscle tone - It can also cause changes in HR, BP, and even RR. Vitals should be measured

What is the gate control theory?

- Most commonly used theory to explain pain inhibition using therapeutic modalities - Theory proposes that stimulations of large diameter A-beta afferent fibers activates local inhibitory circuits in the dorsal horn of the spinal cord, thereby preventing nociceptive input from reaching the higher brain centers. - There are several therapeutic modalities that stimulate A-beta fibers, such as electrical stimulation and superficial heat

Electrophysiological testing (otherwise known as electroneuromyography) is used primarily to assess

Neuromuscular and bioelectrical activation in order to differentiate between normal and abnormal firing rate of muscles and nerves.

Sub-acute and chronic edema reduction

- Must elicit a motor response (twitch or submaximal contraction) that provides a form of retrograde effect that will in turn assist in controlling or reducing edema accumulation. - Sub acute stage: Seeking a comfortable twitch motor response as the involved tissue is newer to injury and we need to be careful about too much tissue loading. Area may be too swollen, or have too much inhibition to elicit a submaximal muscle contraction and have it be tolerable.

HVPC Acute edema parameters

- Negative polarity - Intensity: Sensory level (approx 10% below motor threshold) - Frequency: 100-125 pps - Pulse duration: 2-100 microseconds (usec) - Continuous - With cryotherapy (i.e: cold pack) - Electrodes surround Tx area

Equipment to conduct EMG

- No electrical stimulation involved - Needles - Computer/ computer software - Speakers

Phase 2 Rest (EMG procedures)

- Normal muscle will show no output, muscle will have returned to its electrically silent position when no contractions of muscle are produced.

Indications for those that need electrophysiological testing

- Numbness, tingling, pain in a sensory distribution of PNS - Weakness in a motor division of PNS injuries - Segmental demyelination: Detected by NCS - Axon degeneration: Detected by EMG

Phase 4 Maximal activation

- Observe the orderly recruitment of MUPs

On/off ratio (waveform modulation)

- On time: The time electrical current is delivered - Off time: The time there is no electrical current being delivered - On/off ratio is the on time relative to the off time

Measurements of MNCS

- Once the 2 sites are stimulated and the nerve conduction values are shown on the computer screen, a linear measurement is then taken between the proximal and distal sites. - When the MNCV is received, this is then compared to a chart with normal values corresponding to particular nerves - R: Reference electrode - G: Ground electrode - 1: indicates the site of the distal stimulation - 2: Indicates the proximal stimulation

Contraindications for TENS

- Over pregnant uterus - Electrical implants - Carotid sinus - Over damaged skin - Thrombosis - Thrombophlebitis - Hemorrhage - Over malignant tumors - Patients with impaired sensation or cognitive ability, and others

_____ is one of the most commonly used electrophysical agents used to relieve acute and chronic pain by healthcare professionals

Transcutaneous Electrical Nerve Stimulation (TENS)

Human body as a circuit True or False: The circuit needs to be completed by returning back through whatever amount of adipose tissue is present, back through the skin, and returned to the electrical stimulation device

True

Contraindications for E-stim with edema patients

- Over the trunk or heart region in patients with demand type pacemakers or ICDs - Over pelvic, abdominal, lumbar, or hip regions in pregnant women - Over the carotid bodies on the anterolateral neck between the SCM and trachea - Over a phrenic N or urinary bladder stimulators - Over areas of known peripheral vascular disease - Over the eyes or gonads - Over areas of active osteomyelitis - Over areas of hemorrhage

True or False The parameters for improving ROM need to focus on more of a robust muscle contraction in order to activate muscles involved in facilitating increased ROM

True

NMEW has the potential to increase muscle hypertrophy by..

- Overload principle - Increased neural adaptations (increased motor unit firing, increased synchronicity of motor unit firing)

Precautions to electrophsyiological testing

- Pacemakers (more relevant for NCS due to electrode use) - Anticoagulants (during needle EMG) - Blood transmittable diseases (during needle EMG)

Central Inhibition

- Pain is modulated by activation of descending inhibitory pathways projecting to spinal cord

Precautions for E-stim with edema patients

- Patients without intact sensation, compromised mental ability or lack of cognition, uncontrolled hyper or hypotension, irregular HR or rhythm - Over neoplasms (active or previous) - Compromised skin (except if treating for wound/ tissue repair), or tissue vulnerable to hemorrhage or hematoma

Duty cycle (waveform modulation)

- Percentage of on tome to the total time of the pulsatile current. - Don't always or often select the duty cycle on our equipment, however, it is automatically calculated by the setting of other parameters that we do select (pulse duration, pps, etc.)

True or False: Currents for pain modulation can be Symmetrical and asymmetrical biphasic pulsed

True

True or False: Gait control theory best describes the TENS unit

True

True or False: Motor unit is a motor nerve and all of the muscle fibers it innervates

True

True or False: Patient positioned with involved extremity elevated will help to decrease capillary hydrostatic pressure

True

True or False: The fact that we feel and experience pain is important as a means of protective sensation. When something hurts, it is our body's way of telling us something is not functioning correctly, or that movement should be avoided.

True

True or False: The larger the area to be treated the larger the electrode size

True

True or False: When an injury or surgery occurs, there is an increase in capillary permeability that results. This leads to plasma proteins, water, and leukocytes into the the interstitial space which is where we get swelling or edema

True

True or False: Motor nerve conduction study is usually the first portion of an electrophysiological test and will provide information regarding the integrity of the motor nerve and neuromuscular junction.

True - *Stimulating the nerve and recording the MUSCLE action!*

Amplitude and time dependent waveform characteristics

- Phase duration: Length of time 1 phase - 2 phases form 1 pulse - Pulse duration: Length of that pulse - Intra pulse interval: Length of time between each phase - Inter pulse interval: Length of time between each pulse - Amplitude: Measure of the magnitude of the current or voltage with respect to the baseline - Peak amplitude: Amplitude of each phase from 0 - Peak to peak amplitude: Amplitude from the peaks on the negative and positive sides of the isoelectric line

Direct currents

- Polarity: May be negative or positive for the determined time. - Units of measurement: Milliamperes (mA) and Microamperes (uA) - Current is used with iontophoresis applications and in the treatment of Bell's Palsy

Goals of the proliferation phase

- Primary goal: modalities are used to facilitate blood flow and enhance cellular activity to begin repair process - Introduce mild heating agents to aid in this

Goals of the maturation phase

- Primary goal: modalities that provide heat to deeper tissues to enhance the extensibility and organization of collagen to regain flexibility in the healing tissue may be possible adjuncts to Tx plan

Goals of the inflammation phase

- Primary goal: to minimize inflammation and expedite the healing process. Elevation. Gravitational forces. - Use of ice and compression

Sub-acute edema parameters

- Pulse frequency: 1-10 pps - Pulse duration: 100-600 usec - Constant (no on/off cycle; no ramping) - Waveforms (biphasic pulsatile current, or burst modulated alternating current - i.e; russian) - Electrodes placed over desired muscle groups (distal to proximal)

Chronic edema parameters

- Pulse frequency: 20-80 pps - Pulse duration: 100-600 usec - 1:1 on/off ratio - Waveforms (biphasic pulsatile current, or burst modulated alternating current - i.e; russian) - Electrodes placed over desired muscle groups (distal to proximal)

Parameters for strengthening the neurological population

- Pulse frequency: 30-100 pps (recall fatigue factor with increased rate) - Pulse duration: 100-800 usec - Pulse amplitude: Strong contraction (MMT - 4/5) - Ramp: 1-5 sec up/down (assist in decreasing spasticity and increase comfort) - Duty cycle: 1:3 or 1:5 - Tx duration: 10 contractions

Frequency waveform characteristic

- Pulses that are occurring in 1 sec - Pulsatile currents, typically refer to these a pulses per seconds (pps) - Alternating currents, you will see the terms cycles per second (cps) or Hertz (Hz)

Ramp or surge (waveform modulations)

- Ramp time can either be either ramp up or ramp down time. - Describes gradual or progressive increase or decrease in intensity to the designed peak amplitude/ intensity. - We do not want to have ramp up times longer than 4 seconds because this can alter the threshold for activation of the muscle, requiring a higher amplitude or intensity to contract the muscle.

Burst (waveform modulations)

- Refers to a pulsatile current in which a finite interval of alternating current is delivered at a specific frequency for a specified period of time (a series of consecutive pulses separated)

Pulsatile currents

- Refers to a unidirectional or bidirectional flow of electrons, or charged particles, that periodically cease for a short period before the next pulse. - Unidirectional and bidirectional pulses are very brief in duration. - Three pulsatile waveforms: monophasic, biphasic, and polyphasic

Rise time and Decay (fall time) waveform characteristic

- Rise time and decay are characteristics that give rise to the shape of the waveforms. - You typically do not set rise and decay times - Important to understand how waveforms are made to be different shapes - Rise time and decay time are gradual, gives shape of a triangle. Steepness can be more or less gradual which leads to different shapes of triangles - Rise was immediate (line would go straight up vertically), last a certain length of time, and then decay time is immediate (line going straight back down to 0), creates a waveform that has a rectangular shape.

Considerations when using NMES with neuro involved patients in the examination

- Screen for innervation, skin assessment, cognitive status, etc. - EMG screening as appropriate (to ensure full innervation is available)

Precautions for iontophoresis

- Sensation deficits, for example, need to be taken into consideration. - Patients with sensation deficits may still benefit from iontophoresis, but close monitoring is a good idea. - Cognitive deficits (depending on the extent) could be another grey area. - Cancer is another grey area and the physician would need to be consulted prior to application

Sensory Nerve Conduction Studies (SNCS)

- Similar procedure to that of MNCS but the stimulation will occur on the sensory nerve - SNAP is produced instead of CMAP - No NMJs that the sensory nerve has to transverse, thus only 1 stimulus needs to be provided - Sensory nerves propagate in both directions (orthodromically and antidromically) but the "Normal" direction will be toward the spinal cord compared to the orthodromic direction. - Sensory nerves will evoke a lower amplitude response than those seen with motor nerve conduction studies

H reflex (MNCS)

- Similar to the F wave - H reflex is a long loop reflex that measures the latency of the nerve after stimulating a Ia afferent neuron as opposed to recording and stimulating the motor neuron. - Same as the monosynaptic stretch reflex. - Can help identify radiculopathies

F wave (CMAP)

- Small action potential following the M wave with longer latencies as they are required to span the entire distance of the limb and then produces a small contraction of the muscle - Measures both the antidromic and orthodromic characteristic of the signal. - Since it takes longer for the contraction to occur, you will notice the lower amplitude of the F wave since it had to span both the proximal and distal directions of the limb is question

Monophasic pulsatile current

- Stay on one side of the isoelectric line as a result carry with them a net polarity (negative or positive) that we as clinicians get to select our equipment - High volt pulsatile current is an example of this that we use on wound care as well as acute swelling within the first 3 days (or 72 hours) after injury or surgery - By selecting a negative polarity we hope to discourage albumin (which carries a negative charge) from entering the interstitial space by having those like charges repel on another

Equipment used to conduct NCS

- Surface electrodes - Adjustable stimulation trigger - Computer/ computer software - Speakers

Muscle strengthening parameters: Pulsatile current

- Symmetrical or asymmetrical - Pulse freq: >30 pps - Pulse duration: highest possible to elicit desired result (>250 U sec) - Pulse intensity: Highest possible as tolerated by patient to achieve desired contraction (>50% MVC) - On/off ratio: 1:3 to 1:5 with on time up to 10 sec - Ramp time: 1-2 sec - Treatment time: 10 contractions (rest period, additional 10 contractions)

Currents for pain modulation

1. Amplitude modulated alternating current: - IFC - Amplitude modulated altering current that is created by interfering two sine waves of slightly different freq in the target tissue - Swing and sweep patterns and modes refer to the various ways in which to peak freq, and how long it stays at the lase or peak 2. Burst modulated alternating current: - Russian and Aussie currents

Match the following: 1. Cell body (soma): 2. Dendrite: 3. Axon: 4. Axon terminals: A. Receive information from adjacent cells via post synaptic neurons B. Project the information to another cell C. Central mass from which various dendrites extend D. The buds on the end of the axon that convey that information to the next cell

1. Cell body (soma): C. Central mass from which various dendrites extend 2. Dendrite: A. Receive information from adjacent cells via post synaptic neurons 3. Axon: B. Project the information to another cell 4. Axon terminals: D. The buds on the end of the axon that convey that information to the next cell

4 modes of TENS

1. Conventional TENS 2. Acupuncture TENS 3. Burst train TENS 4. Brief intense TENS

Neuron

- Each neuron contains multiple dendrites that receive information from other adjacent cells. - When an action potential occurs, the post synaptic neuron receives its information via the dendrites. - The soma then collects that information and conducts the signal via the "axon" to another cell.

Iontophoresis applications with direct currents

- A patient may have an electrode on the skin with a particular solution of medication (i.e; Dexamethasone). That medication carries with it a polarity (in the case of dexamethasone --> negative polarity), an the treatment time could last anywhere from 10 min + depending on the intensity. - This current is on continuously and for much longer than 1 sec (10+ min is a lot longer than 1 sec). - As a result, direct currents tend to have a greater risk of burns due to the continuous flow over longer periods of time

Patient positioning during therapeutic interventions

- Acute stage of healing: Affected body part should be placed in a position of the least amount of tissue stress (i.e; loose pack position). All other joints should be supported and the spine in neutral posture. - If swelling is already present or if an acute injury and there is a risk of edema formation, then elevation of the body part above the heart is recommended - Subacute or chronic stages of healing: Goal of the treatment must be considered (i.e: attempting to lengthen soft tissue and you choose a heat agent to increase tissue extensibility, then the tissue may need to be placed in a position of stretch.

Influential factors with NCV

- Age: Normal NCS velocity values are not achieved until age 7 (mature at age 18) - UE/LE injury: UE NCV tends to be faster than LE because arms are usually a little shorter than the legs so it requires less time for travel to the distal portion of UE. - Height/ limb length: Longer limbs have slower conduction velocities - Extremity temperature: Colder = slower conduction. (cryotherapy) - Anomalies with innervation patterns: everyone is wired differently with a unique neural pattern.

Overload principle with strengthening protocols

- Although the overload principle is vital to achieve a desired "strengthening" component, the neurological population is somewhat unique give the variability of injuries that are seen. - Striving for a general strengthening component is more desirable according to current literature. - Trying to reach apporx 4/5 from a MMT standpoint is desirable.

Applied to the spastic muscle for fatigue (Theories to decrease spasticity)

- Apply the electrode to the spastic biceps muscle to fatigue out the muscle.

Phase 3 Minimal activation (EMG procedures)

- Assess motor units with voluntary contractions (MUP)

Define atoms and ion

- Atoms: Composed of positive protons and negative electrons. - Ion: An atom or molecule that has gained or lost an electron.

Muscle strengthening parameters: Burst modulated alternating current

- Aussie current vs Russian - Burst freq: 50 bursts/sec - Burst duration: 10 milliseconds (russian), 4 milliseconds (Aussie) - On/off time: 10 on 50 off - Burst intensity: As high as needed to obtain desired contraction (within patient tolerance) - Duration: 10 contractions - Ramp: 1-2 seconds for contraction - Treatment time: 10 contractions

Contraindications of iontophoresis

- Avoiding the trunk or heart in individuals with demand type pacemakers - Pregnant woman - Cartoid bodies - Any type of neuro stimulators - Peripheral vascular disease including over areas of known thrombi - Over active osteomyelitis - Active hemorrhage.

Applied to the antagonistic muscle with theoretical reciprocal inhibition (Theories to decrease spasticity)

- Based off of a reciprocal inhibition theory whereby the electrodes are applied to the antagonistic muscle - Ex: Spasticity is noted in the biceps muscles following a stroke. Based on the firing of the muscle, these muscles become very short, causing the triceps to lengthen and become weak. By applying the electrodes to the triceps muscle, the theory is to increase the strength of those muscles and in turn cause a reciprocal inhibition of the spastic biceps muscle

E stim for ROM

- Burst modulated alternating current (Aussie, Russian), symmetrical, or balanced asymmetrical waveforms - Pulse frequency: 30-50 pps - Pulse duration: > 200 usec (up to 600) - On/off: 15 on 45 off OR 10 on 10 off - Tx time: 30-60 min - Tx freq: At least every other day

Diagnosis specific considerations when using NMES

- CVA: cognitive status, sensation, spasticity, HR, and BP - SCI: Autonomic dysreflexia sensation, orthopedic concerns, respiratory effects, pressure sores, and spasticity - CP/ PD: Implanted devices (ITB pump), neuro stimulants, and orthopedic co morbidities - MS: Spasticity, early fatigue, and cognitive status

Biphasic Pulsatile Current

- Can be symmetrical or asymmetrical - Can be balanced or unbalanced - Widely used because it can be used for any kind of a motor response (twitch or contraction) as well as depending on it's shape be used in the treatment of pain (TENS unit)

Waveform modulations

- Changes or adjustments in various waveform characteristics. - Sometimes we want waveforms to change and sometimes we don't - May be pre programmed setting on machine or may be manually modulated - We can modulate waveforms by changing the frequency (i.e; 4 pps to 25 pps), modulating the pulse direction (300 microseconds to 600 microseconds), or modulating the amplitude (intensity) of the current

Alternating currents

- Characteristics of a sine wave, and there is NO polarity effect as the positive and negative flow of currents cancel each other out - Units of measurement are typically in milliampers - One cycle is equal to 1 Hz such that 1,000 Hz equals 1,000 cycles per second. - Medium frequency currents are those that fall int eh range of 1,000-10,000 Hz (or cycles per second) - One cycle = shaded part of picture

Polyphasic pulsatile current

- Consist of many bidirectional phases that are symmetrical. - Russian stimulation is an example of this. Pulsatile current that has many cycles per second (2,500 Hz= 2,500 cycles per second)

Segmental demyelination (Nerve injuries detected by ENMG):

- Describes an abnormality along the course of an axon that is otherwise considered typical - Can usually be seen with general compression injuries to the nerves (i.e: CTS) - Best detected by NCS - Effects usually noted at "slowed: conduction velocity

Contraindications when using electrical stimulation

- Do NOT apply over the anterior thoracic region or the carotid sinus - Do NOT apply transcranially - Patients with demand pacemakers or any indwelling electrical devices - Do NOT apply over areas of severe peripheral vascular comprise such as thrombosis - Pregnant females (includes trunk and acupuncture points). NO E-STIM ANYWHERE FOR PREGNANT FEMALES (except for pain control during delivery)

Strength duration curve

- The microcurrent intensity which is sub threshold (or in other words below sensory level intensity). - It also illustrated the order with which these fibers are elicited, beginning with A-beta fibers, followed by motor fibers, A-Delta fibers, and then C fibers. - Denervated muscle requires higher amplitudes and requires the greatest duration. - Peripheral nerves are more excitable than intact muscle fibers or denervated muscles. - And different tissues have different potentials for excitation as shown on this strength-duration curve.

The mnemonic I SAD

- The mnemonic I SAD is a good way to recall the negatively charged medication. - In explanation, "SAD" is bad, or negative. And the " I SAD" stands for Iodine, Salicylates, Acetic acid, Dexamethasone. - All of the other medications used are positive (hyaluronidase, calcium chloride, magnesium sulfate, zinc oxide, lidocaine, and water).

FES for shoulder subluxation

- The premise behind FES for shoulder subluxation, is to activate the muscles surrounding the GH joint to improve joint approximation and to provide a more effective means to complete a function - The electrode placement for this is usually over the supraspinatus an posterior deltoid muscle

Therapeutic modalities

- Thermal: Heat and cold - Mechanical: Compression, traction, hydrotherapy - Acoustic: Ultrasound - Electromagnetic: Electrical stimulation, laser, light therapy, diathermy

Treatment duration for iontophoresis

- Treatment duration, we will take an example of a typical clinical treatment using the *maximum of 4 mA*. - If we want to be within the normal treatment range of 20-80 mA min, then the treatment time required would be between 5 to 20 minutes

The purpose of EMG biofeedback

- Used to increase muscle function and decrease pain - No electrical current delivered to the muscle - Feedback in this device can either facilitate or contribute to increased muscle activation, or inhibit muscle activity depending on the goal

Axon degeneration (Nerve injuries detected by ENMG):

- Usually takes a bit longer to manifest in individuals as opposed to segmental demyelination. - Best detected using needle electromyography. (EMG) - More severe forms of neural compression, neural ischemia, or trauma - Best to perform both NCS and EMG to obtain a complete picture of the problem

Precautions that we want to think about when using electrical stimulation

- Want to be careful when we place our electrodes over areas of high amounts of adipose when we are trying to achieve a motor response (like a twitch or a contraction) - It can be very difficult to get the electrical current to get to the target tissue because of the greater amount of higher resistance tissues (skin and adipose). As a result, it may be too uncomfortable to the patient - Inspecting areas for skin integrity when we are using E stim. When there are areas of poor skin integrity, this can lead to the application of E stim being uncomfortable.

Why do we have pain?

- When there is tissue damage (or potential for tissue damage), the stimulation of nociceptors sends signals through the PNS through the spinal cord and then to the brain. Those nociceptors responds chemical, mechanical or thermal stimuli. - Remember it is not until the signal reaches and is interpreted by the cortex, that the individual perceives the sensation of pain

Adverse effects of iontophoresis

- With direct current, we end up with a subsequent build up of charge, so if we increase the amplitude as high as it can go with a direct current, this can cause uncomfortable reactions resulting in chemical burns, tingling, itching, and/or redness.

3 methods for spasticity reduction

1. *Reciprocal inhibition*: Motor level estim on the antagonist to elicit a muscle contraction by means of reciprocal inhibition. Similar to muscle strengthening, but with decreased intensity due to nature of the situation. 2. *Fatigue os spastic muscle*: Motor level estim directly to the spastic agonist muscle in order to fatigue the muscle. In this case, we would want a high pulse frequency and lower on/off ratio to enhance fatigue. Increased frequency to predispose fatigue pending patient tolerance (50 pps) 3. *Sensory stimulation for habituation*: Sensory stimulation to the spastic muscle. Decreased on/off time to predispose fatigue 1:1-1:3

Laws of tissue excitation (factors affecting tissue excitation)

1. All or none law: If a stimulus to a nerve or muscle is greater than the threshold potential, all of the nerve or muscle fiber will respond. If the stimulus is below threshold, there is no response whatsoever. 2. The Du Bois-Reymond Law: Describes that there must be a sudden variation in the current flow, it allows us to avoid situations of accommodation with our patients (where they get accustomed to the stimulation and no longer continue to feel the current, or comfort is jeopardized by having to increase to a higher intensity to achieve the desired contraction). 3. Strength-Duration curve: Describes the relationship between the intensity and duration of an electrical stimulus on different types of excitable biological tissues

Characteristics of pulsatile currents

1. Amplitude and time dependent waveform characteristics 2. Frequency 3. Rise time 4. Decay time 5. Phase charge 6. Pulse charge 7. Average current

Define the following: 1. Electrical charge: 2. Voltage (E): 3. Current: 4. Amperage (I): 5. Coulombs: 6. Resistance (R) or Impedance: 7. Wattage (W): 8. Conductance:

1. Electrical charge: Loss or gain of electron 2. Voltage (E): Driving force that moves electrons and is a measure of potential energy. Units are Volts or millivolts. 3. Current: Movement of ions (or electrons) in response to a voltage force. Units of measurements Amperes or milliamperes 4. Amperage (I): Rate current/electrons flow past a point; 1 Ampere= 1 coulomb/sec 5. Coulombs: Quantity of elect. Charge: 1 coulomb @ 6.28x10^1 6. Resistance (R) or Impedance: When currents encounter biological tissues are met with resistance or impedance. Described by Ohm's law (I=V/R --> Current= voltage/ resistance) 7. Wattage (W): Watts= voltage X Ampere 8. Conductance: Some biological tissues are excellent conductors of electrical current, and others are considered to be more of an insulator.

Two basic concepts that underlie the use of iontophoresis

1. Electroporation: An increased in porosity of the skin as a result of electrical stimulation resulting in the easier penetration of ions 2. Electroosmosis: the movement of a solute in response to an applied electrical field.

Two main theories to support TENS (analgesic mechanism of TENS)

1. Gate control theory 2. Central inhibition

Two types of second order neurons in the central pain pathways

1. High threshold neurons: Nociceptive-specific receiving input from peripheral nociceptors only 2. Wide dynamic range neurons: Receive input from nociceptive and non-nociceptive primary afferent fibers - Both types become sensitized after injury

Normal healing process

1. Inflammation: Hemostasis, edema formation, pain. Cardinal signs: Red, heat, swelling, pain, & loss of function 2. Proliferation: Repairs the defect by laying down new tissue 3. Maturation/ Remodeling: Longest duration, rearranging of collagen matrix

Match the goals for using therapeutic modalities during the healing phases: 1. Inflammatory phase: 2. Proliferation phase: 3. Maturation phase: A. Enhance blood flow and cellular activity B. Reduce blood flow and decrease cellular metabolism to lessen the formation of edema C. Facilitate collagen maturation and organization

1. Inflammatory phase: B. Reduce blood flow and decrease cellular metabolism to lessen the formation of edema 2. Proliferation phase: A. Enhance blood flow and cellular activity 3. Maturation phase: C. Facilitate collagen maturation and organization

Match the following nerve injuries: 1. Neurapraxia: 2. Axonotmesis: 3. Neurotmesis: A. Axonal degeneration B. Local conduction block with no axon involvement C. Nerve pressure, stretching, inflammation resulting in some type of axonal involvement

1. Neurapraxia: B. Local conduction block with no axon involvement - Mildest form. - Ex: Sleeping on your arm for a long time 2. Axonotmesis: C. Nerve pressure, stretching, inflammation resulting in some type of axonal involvement. - Some level of Wallerian degeneration. - Connective tissue of neurons still intact. recovery possible 3. Neurotmesis: A. Axonal degeneration. - Damage to the connective tissue sheath around nerve - No recovery (surgical decompression needed)

Match the following: 1. Nociception: 2. Nociceptors: A. Process of encoding and processing noxious stimuli B. Sensory neurons; respond to chemical, mechanical, or thermal

1. Nociception: A. Process of encoding and processing noxious stimuli 2. Nociceptors: B. Nociceptors: Sensory neurons; respond to chemical, mechanical, or thermal

Match the following: 1. Orthodromic: 2. Antidromic: A. Conduction opposite of the normal direction to the anterior horn cells of the spinal cord, spinal cord then sends an action potential back towards the muscle and you see another smaller contraction. B. When the max intensity stimulus is given, the motor signal is conducted along the motor fibers in its "normal" direction towards the muscle, which causes a contraction. C. Contraction is seen on the nerve conduction screen as an M wave and measures the distal latency from the stimulus to the muscle D. The smaller contraction is called the F wave and measures distal latency in both the proximal and distal directions

1. Orthodromic: Both B and C - B. When the max intensity stimulus is given, the motor signal is conducted along the motor fibers in its "normal" direction towards the muscle, which causes a contraction. - C. Contraction is seen on the nerve conduction screen as an M wave and measures the distal latency from the stimulus to the muscle 2. Antidromic: Both A and D - A. Conduction opposite of the normal direction to the anterior horn cells of the spinal cord, spinal cord then sends an action potential back towards the muscle and you see another smaller contraction. - D. The smaller contraction is called the F wave and measures distal latency in both the proximal and distal directions

Match the 4 phases of an EMG procedure: 1. Phase 1: 2. Phase 2: 3. Phase 3: 4. Phase 4: A. Rest: Participant avoids contraction of the muscle B. Maximal activation: Max voluntary contraction C. Insertion: needle inserted into the muscle D. Minimal activation: minimal voluntary contraction of the muscle in question

1. Phase 1: C. Insertion: needle inserted into the muscle 2. Phase 2: A. Rest: Participant avoids contraction of the muscle 3. Phase 3: D. Minimal activation: minimal voluntary contraction of the muscle in question 4. Phase 4: B. Maximal activation: Max voluntary contraction

Match the following waveform characteristic: 1. Phase charge: 2. Pulse charge: 3. Average current: A. Sum of all the phase charges B. Charge within each phase (area under the curve in microcoulombs) 3. Absolute value of current per unit time

1. Phase charge: B. Charge within each phase (area under the curve in microcoulombs) 2. Pulse charge: A. Sum of all the phase charges 3. Average current: 3. Absolute value of current per unit time

Two types of circuits

1. Series circuit: Current will encounter a series of resistance 2. Parallel circuit: Current will follow the path of least resistance when there are multiple pathways for that current to travel

Voluntary recruitment vs Electrically induced recruitment

1. Voluntary recruitment: - Smaller to larger diameter motor units - "Helper" motor units during fatigue 2. Electrically induced recruitment: - Random generation of motor units - No modifications of firing frequency or intensity

Which of the following is TRUE in regards to NCS administration? A. Based on regulations set forth by each state B. Every state allows PTs to administer tests C. Whoever administers the NCS are able to use this for diagnosing a patient D. All of the above are correct

A. Based on regulations set forth by each state - Administration of NCSs are based on regulations set forth by each state - Most states allow PTs to administer the tests, but strictly prohibit them from making a medical diagnosis - Often, states will require a certification in electroneuromyography prior to administration by a licensed professional.

______ is defined as skeletal muscle assessment or monitoring that is used to affect future activation. A. Biofeedback B. Central sensitization C. Peripheral sensitization D. Gate control theory

A. Biofeedback

What would be the BEST current to use for a patient you want a motor response from (twitch or contraction). A. Biphasic pulsatile current B. Polyphasic pulsatile current C. Alternating current D. Direct current

A. Biphasic pulsatile current

What would be the BEST current to use for a patient who has pain. A. Biphasic pulsatile current B. Polyphasic pulsatile current C. Alternating current D. Direct current

A. Biphasic pulsatile current - TENS unit

Which of the following is the BEST electrode configuration when we have a target tissue of varying levels of stimulation? A. Bracketed method B. Bilateral with distal points C. Crossed method D. Unilateral/ linear

A. Bracketed method - Two channel 1 electrodes here could be placed over areas of similar levels of stimulation (motor points) and the two channel 2 electrodes could be placed over areas of a different level of stimulation (non motor points) - This configuration avoids the common predicament in the clinic where a patient feels some electrodes and not others as we dial up the intensity

____ pain persists beyond normal tissue healing time. Associated with structural/ functional changes in CNS and psychosocial issues. A. Chronic B. Referred C. Acute D. immediate

A. Chronic - Begins as acute pain, becomes persistent or recurrent - Often requires multi-modal approach - Central sensitization - Not as biologically meaningful as acute

Iontophoresis is unique in its use of _____ current to induce transmission of ions into the tissue to drive medications through. A. Direct B. Indirect C. Pulsatile D. Amplitude

A. Direct

A _____ current is the continuous flow of electrons in one direction (or one side of the isoelectric line) for 1 second or more. A. Direct currents B. Indirect currents C. Alternating currents D. Pulsatile currents

A. Direct currents

Which of the following is INCORRECT in regards to electrode placement (TENS): A. Distal to the painful areas B. Crossed around painful areas C. Along the path of a radicular pain patter stemming from nerve root D. All of the following are correct

A. Distal to the painful areas is INCORRECT - Directly on the painful areas

The second part of electrophysiological testing is the ____. This process is used in order to analyze the motor point without applying an external electrical stimulus A. EMG B. MNCS C. SNCS D. NCS

A. EMG - Most accurate tests will involve needle EMG. Very specific assessment of the motor units it penetrates. Decreased amount of surrounding noise.

______ refers to the activation of A-Beta afferent nerves (non-painful stimulus) the induce an inhibitory effect, or block, on the input from pain receptors (the A-delta and C fibers). A. Gate control theory B. Central sensitization C. Peripheral sensitization D. Central inhibition

A. Gate control theory - Brain interprets the non-painful stimulus coming from the TENS unit, rather than the painful stimulus, as it can only interpret one of the other. Non-painful stimulus blocks/overrides painful stimulus.

Which of the following is INCORRECT in regards to ramp time A. Ideal ramp up time is 5-6 seconds B. Too long of a ramp up time can alter the threshold for activation of the muscle C. Too long of a ramp up time may be uncomfortable D. Too long of a ramp up time can possibly decrease the total amount of current delivered to patient E. All of the above are correct

A. Ideal ramp up time is 5-6 seconds is INCORRECT - Ideal ramp up time is 2-4 seconds. Don't want it to be longer than 4 seconds

If a muscle activation or contraction is strong, then _____ sensitivity will be required to detect the activity in regards to biofeedback sensitivity A. Less B. More C. The same

A. Less

What would be the BEST current to use for a patient who has a wound injury or a patient who has acute swelling within the first 3 days after injury/surgery. A. Monophasic pulsatile current B. Polyphasic pulsatile current C. Alternating current D. Direct current

A. Monophasic pulsatile current

Because iontophoresis is usually administered using Direct current, a _____ electrode application is usually adopted whereby the active electrode is administering the medication, and the inactive electrode disperses the current A. Monopolar B. Bipolar C. Polypolar

A. Monopolar

____ electrode configurations are commonly used with pain modulation, iontophoresis, and tissue healing applications A. Monopolar B. Bipolar C. Quadripolar D. Linear

A. Monopolar - Always two poles (anode and cathode) that are required to make complete circuit. - Cathode is the electrode with greater concentration of negative ions or electrons. - Active electrode on a single circuit is on or over the target tissue and the inactive electrodes is on or over a nearby non-treatment area.

_____ is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. A. Pain B. Edema C. Muscle contractions D. Neurological re-education

A. Pain

With an injury ______ threshold of activation is lowered due to chemicals or substances that are released at the site of injury. A. Peripheral sensitization B. Central sensitization C. Acute pain D. Chronic pain

A. Peripheral sensitization

Which of the following electrode application is the MOST appropriate of electrodes when treating deeper structures? A. Place the electrodes farther apart B. Place the electrodes close together C. Place only one electrode on the patient D. Both B and C are correct

A. Place the electrodes farther apart

A patient has a R anterior inferior subluxation of the shoulder. Electrodes are positioned accordingly, however during stimulation, it seems that the electrode positioned on the posterior deltoid muscle is pulling the humerus too far posteriorly and the electrode positioned on the supraspinatus is not initiating enough movement of the humerus superiorly. How else might you modify your electrode settings to increase the stimulation of the supraspinatus? A. Placing a large electrode on the supraspinatus and a small electrode on the posterior deltoid B. Placing a small electrode on the supraspinatus and a large electrode on the posterior deltoid C. Increasing the pulse intensity and increasing the pulse duration D. Increasing the pulse intensity

A. Placing a large electrode on the supraspinatus and a small electrode on the posterior deltoid

______ causes faster transmission and allows for less physical space and energy of the action potential. A. Saltatory conduction B. Axon terminals C. Nodes of ranvier D. Action potential

A. Saltatory conduction - *Propagates the action potential (AP) down the axon at the Nodes of Ranvier.* - The myelin in between each node prevents the current from leaking out during the translation down the axon, essentially causing the stimulus to "jump" from node to node. - This is otherwise termed saltatory conduction and causes faster transmission and allows for less physical space and energy of the action potential.

Human body as a circuit: First encounter a ______ circuit where the current travels through the skin into the adipose tissue beneath the skin. A. Series circuit B. Parallel circuit

A. Series circuit - This is the ONLY pathway option that will get the current from the power source to our desired target tissue.

______ Electrode size should be used with higher current density and may be uncomfortable (TENS) A. Smaller B. Larger C. Medium

A. Smaller

_____ is considered the main pathway responsible for bringing painful input up to the higher brain centers A. Spinothalamic tract B. Anterior Lateral spinal tract C. Spinoreticular tract D. Dorsal Column-Medial Lemniscus tract

A. Spinothalamic tract

Patients spouse said that they cant help with transfers? Where does it go under A. Subjective B. Objective C. Assessment D. Plan

A. Subjective

A ______ motor response is in the sub acute phase of edema. A ____ motor response is in the chronic phase of edema. A. Twitch; Submaximal B. Submaximal; Maximal C. Submaximal; Twitch D. Twitch; Maximal

A. Twitch; Submaximal - Sub acute stage: Seeking a comfortable twitch motor response as the involved tissue is newer to injury - Chronic (>4 weeks): Submaximal contractions have been shown that 100% vessel occlusion occurs with 50% max volitional isometric contractions (MVIC). As a result, a submaximal and intermittent motor response will be sufficient in creating the retrograde pumping effect from distal to proximal

Electrode configuration that creates a "glove like" sensation of electrical stimulation intensity for a patient that is experiencing general pain along an extremity. A. Unilateral and overlapping with distal points B. Bilateral with distal points C. Crossed method D. Unilateral/ linear

A. Unilateral and overlapping with distal points

When documenting E-stim treatment in the medical records, the current frequency SHOULD be documented using which of the following units of measurements? A. pps B. V C. mA D. mS

A. pps

A patient has a R anterior inferior subluxation of the shoulder. Electrodes are positioned accordingly, however during stimulation, it seems that the electrode positioned on the posterior deltoid muscle is pulling the humerus too far posteriorly and the electrode positioned on the supraspinatus is not initiating enough movement of the humerus superiorly. Which of the following setting may be chosen to create increased amplitude on the anode balance with increased duration and decreased amplitude on the cathode. A. Symmetrical B. Asymmetrical C. Monopolar D. Bipolar

B. Asymmetrical - The graph on the left is a biphasic symmetrical waveform with equal amplitude whereas the graph on the right is an asymmetrical balanced biphasic graph with no build up of charge (as the area inside the triangle is = to the area inside the rectangle), but with a greater amplitude on the triangle as opposed to the rectangle.

Which of the following is INCORRECT in regards to muscle strengthening using the burst modulated alternating current. A. The main difference between russian and aussie is the carrier frequency B. Aussie current has a carrier frequency of 2500 Hz C. Russian current has a carrier frequency of 2500 Hz D. Russian frequency has been traditionally utilized E. All of the above are correct

B. Aussie current has a carrier frequency of 2500 Hz is INCORRECT - Aussie current freq = 1000Hz

A patient presents with bilateral neck pain at a certain level in the spine, and pain radiating down the left UE, which of the following electrode placements is the BEST option? A. Bracketed B. Bilateral with distal points C. Crossed method D. Unilateral/ linear

B. Bilateral with distal points

____ electrode configurations are both or all of the electrodes of a single circuit are on or over target tissue(s). Commonly used with pain modulation as well as with muscle contractions A. Monopolar B. Bipolar C. Quadripolar D. Linear

B. Bipolar

_____ are unmyelinated and conduct more slowly, responding to variety of stimuli: mechanical, thermal or chemical. Polymodal: multi-stimulus. A. A-delta B. C fibers C. A-beta D. Histamine

B. C fibers

_____ is described as dull, aching, and burning. A. A-delta B. C fibers C. A-beta D. Histamine

B. C fibers - Longer lasting

Painful stimulus (such as stepping on a tack while barefoot), and those painful fibers (A-delta and C fibers) synapse with a second order neurons in the dorsal horn of the spinal cord and painful impulses are transmitted up to the higher centers of the brain describes what? A. Peripheral sensitization B. Central sensitization C. Acute pain D. Chronic pain

B. Central sensitization

_______ results in increased responsiveness to noxious and non-noxious stimuli, increased receptive field, and decreased activation. A. Peripheral sensitization B. Central sensitization C. High threshold neurons D. Wide dynamic range neurons

B. Central sensitization

The Walkaide is a ______ E-Stim system used wirelessly to control the ankle during swing phase of gait to allow for increased dorsiflexion. A. NMES B. FES C. IFC D. Pre-mod

B. FES

A 79 year old female presents to outpatient rehabilitation services 6 weeks following a CVA with right hemiplegia. She complains of right shoulder pain working on functional upper extremity movements and has severe shoulder pain when practicing bed mobility activities such as rolling and scooting. On examination, it is observed that the humeral head is inferiorly displaced. Which of the following would be the MOST appropriate for her condition? A. Transcutaneous Electrical Nerve Stimulation (TENS) B. Functional Electrical Stimulation (FES) C. Short Wave Diathermy (SWD) D. Interferential Current (IFC) Stimulation

B. Functional Electrical Stimulation (FES) - Using FES to help elevate her shoulder will treat the displacement and ideally eliminate the source of pain.

Which of the following outcomes is MOST appropriate for determining the effectiveness after use of E-Stim to strengthen the triceps? A. Changes in ROM B. Functional improvement C. Pain reduction D. Reduction of stiffness

B. Functional improvement

Intensity/amplitude of e-stim be to a strong, but comfortable intensity. Should be _____ each day if tolerable in order to delay the onset of analgesic tolerance A. Decreased 15% B. Increased 10% C. Decreased 25% D. Increased 20%

B. Increased 10%

Which of the following is NOT a type of electrical current in electrotherapy A. Direct currents B. Indirect currents C. Alternating currents D. Pulsatile currents

B. Indirect currents

If an individual would like to decrease muscle muscle activation in order to reduce pain symptoms, this would provide _______ biofeedback A. Facilitated B. Inhibited C. Concurrent D. Pulsatile

B. Inhibited

______ Electrode size should be used with lower current densities and are typically more comfortable (TENS) A. Smaller B. Larger C. Medium

B. Larger

Which of the following is the correct calculation of MNCS: A. MNCV (m/sec)= Distance between distal/ proximal latency values B. MNCV (m/sec) = Distance between proximal/ distal latency values

B. MNCV (m/sec) = Distance between proximal/ distal latency values

"Naked spaces" or nodes of ranvier are condensed with ____ channels in order to propagate an action potential A. K+ B. Na+ C. Ca+ D. Cl-

B. Na+ - Myelin usually surrounds much of the axon with small spaces of "naked" interruptions allowing for propagation of the action potential. - These "naked spaces" are called nodes of ranvier where the action potential is essentially "refueled" with the action potential stimulus.

Human body as a circuit: Second encounter is a ___ circuit in the body, as the current encounters a variety of resistances (muscle, bone, blood, nerve, tissue, etc.) A. Series circuit B. Parallel circuit

B. Parallel circuit - The electrical flow of the current would most easily travel through blood, then nerve tissue, then muscle (in that order).

Russian stimulation is an example of which current? A. Biphasic pulsatile current B. Polyphasic pulsatile current C. Alternating current D. Direct current

B. Polyphasic pulsatile current

____ pain is pain at a site that is remote from the source. A. Chronic B. Referred C. Acute D. immediate

B. Referred - Convergence of various nociceptors on spinal nerve root - Central interpretation of afferent input

Which of the following is an example of performing biofeedback WITHOUT the use of a machine? A. Putting bubble wrap on the affected leg of someone who is on PWB restrictions B. Using interactive gaming device C. The Wii D. All of the above are correct E. Both B and C are correct

D. All of the above are correct - Bubble wrap: The audible pop of the "bubble" provides the patient with an auditory clue that too much weight is being placed through the limb - Wii/ interactive gaming device: Can allow the patient to understand how to grade balance reactions to gain points

Which of the following is NOT a correct electrode placement A. Dermatomes B. Myotomes C. Superficial peripheral nerves D. All of the above are correct

D. All of the above are correct - Dermatomes, myotomes, superficial peripheral nerves, motor points, trigger points, acupuncture points

How does Albumin play a significant role in edema? A. Most abundant plasma protein B. Has the greatest influence on osmotic pressure gradient at the capillary level C. Negatively charged plasma protein D. All of the above are correct

D. All of the above are correct - Negatively charged plasma protein, so as a result it can be affected by using high volt pulsatile current (HVPC) during this ACUTE timeframe. - We can set out HVPC polarity to negative, which would repel, and therefore discourage, the negatively charged albumin from coming out into the interstitial space as edema when vessel permeability is increased

_____ refers to activation of descending inhibitory pathways that project to the spinal cord. A. Gate control theory B. Central sensitization C. Peripheral sensitization D. Central inhibition

D. Central inhibition - Evidence that *low frequency* TENS activates micro-opioid (mu) receptors in the spinal cord and rostral ventromedial medullar (RVM) - *High frequency *TENS increases the concentration of beta endorphins in the bloodstream and activities delta opioid receptors in the dorsal horn.

Which of the following is NOT part of therapeutic modalities documentation. A. Position B. Intensity C. Duration D. Cognition E. All of the above are correct

D. Cognition - Documentation should include: Position, Intensity, Duration, Specific parameters, Tissue response, and Patient response

Which of the following applications of E-stim is MOST appropriate when treating acute edema? A. TENS B. LVPC C. MFAC D. HVPC

D. HVPC

Which of the following is used for treating/ preventing muscle atrophy? A. TENS unit B. IFC C. Pre-mod D. NMES

D. NMES - Used in order to obtain a skeletal muscle contraction of some sort. - Used to treat or prevent muscle atrophy that can develop due to surgical procedures, learned non-use atrophy, or other causes of general deconditioning

Which of the following is used for muscle contractions? A. TENS unit B. IFC C. Pre-mod D. NMES

D. NMES (Neuromuscular Electrical Stimulation)

Which of the following is INCORRECT in regards to biofeedback sensitivity: A. In order to train a patient with biofeedback, the muscles must be at least partially innervated B. Based on the max ability or muscle activation or "threshold" the biofeedback unit is set according to the goal of the intervention C. Once the patient reaches their inhibitory or facilitatory threshold target (set on the machine), audio or video feedback is provided D. Once the patient is able to increase or decrease volitional activity within the target threshold, the sensitivity of the device must remain the same in order for the patient to develop stamina

D. Once the patient is able to increase or decrease volitional activity within the target threshold, the sensitivity of the device must remain the same in order for the patient to develop stamina - Once the patient is able to increase or decrease volitional activity within the target threshold, the sensitivity of the device MAY BE MANIPULATED - Many machines provide different colored lights that allow the patient to see whether or not they have reached the goal. - An audible sound can also be inputted such that the patient hears the sound once they have reached the target threshold

_____ is the most commonly used current for clinicians, and it is the safest. A. Direct currents B. Indirect currents C. Alternating currents D. Pulsatile currents

D. Pulsatile currents

_____ is believed to be due to the convergence of various nociceptors on a common spinal nerve root of the spinal cord, and the brain interprets the sensory, or afferent input as coming from cutaneous structures. This occurs due to higher proportion of cutaneous afferent converging on second-order transmission. A. Acute pain B. Chronic pain C. Central sensitization D. Referred pain

D. Referred pain

A patient presents with right sided LBP at a certain level and radicular symptoms down the posterior R LE that ceases at the level of the knee. Which of the following is the BEST electrode configuration? A. Bracketed method B. Bilateral with distal points C. Crossed method D. Unilateral/ linear

D. Unilateral/ linear

_____ are receive input from nociceptive and non-nociceptive primary afferent fibers A. Peripheral sensitization B. Central sensitization C. High threshold neurons D. Wide dynamic range neurons

D. Wide dynamic range neurons

True or False: Nerve conduction velocity (NCV) is the speed at which an electrochemical impulse propagates down a neural pathway

True - By assessing this, we as PTs can determine if there is an underlying problem in the PNS and refer back to the MD if the findings are significant. - We can also begin to rationalize specific treatment protocols given the outcomes received with this test. - If there is a slowed conduction velocity within a sensory nerve pattern, we can determine the extent of the injury and attempt to localize the injury and use that to develop a plan of care for treatment.

True or False: Electrothermal effects can be created through heat as a product of kinetic energy of molecules from friction and vibration

True - These effects are more of a concern with direct currents than they are with alternating currents or pulsatile currents

True or False: As far as bone is concerned, the current does NOT go through bone, rather it goes AROUND.

True!

True or False: Where NCS tells information about the state of the myelin in regards to velocity and amplitude of nerve conduction, EMG provides information regarding the innervation integrity of a muscle.

True! - An EMG will help ascertain if the muscle is fully innervated, partially innervated, or denervated based on the output received on the computer screen. - Estimations have been made that even with a 50% loss of motor units, an individual is still able to complete two or three "normal" grade contractions, though with some complaints of fatigue. Without EMG, the localization of injury to specific motor units would not be able to be discerned.